7.26.2009

Strike One

Sorry to all for the long layoff. It's been unavoidable on the ICU, which has been a 'rich' learning environment to say the least.

We had a summer weekend night at the beginning of the month not too far outside the normal with fifteen or so traumas that came in, one of whom was a three hundered pound diabetic with hip fractures and rib fractures and a blood sugar of 850. She got blood in the truama bay because she was tachycardic and no pne could feel her pulses; after the resuscitation, she went to thr OR for an open femur. I was at the head of the bed in case there was an airway issue. In retrospect, it's hard to see the detail we could've caught to avoid amputating her leg three days later.

In the ICU, she kept failing to meet her resuscitation goals; too acidotic, not enough urine output, poor perfusion and cold extremities all around, remained intubated. She made all of us uneasy but we didn't quite know why, and we scratched our heads every morning and every afternoon and tinkered with her drips and fluids.

She gradually accrued orthopedic splints and rods sticking out of her leg and pelvis and arterial lines and venous lines and tubes, and on the morning of the third day the nurse said hey her foot looks dusky and it's really cold. The attending looked at it and agreed; she was going to the OR again and we told the ortho docs that the nureses were worried about her foot and that she had no pulse we could find but didn't call vascular specifically.

She came back four or five hours later and they said, you should call vascular, we can't find a pulse. By the time vascular came her foot had been cold for eight or nine hours and they, shocker, said nothing to do. An angio showed loss of the popliteal artery, which supplies the whole lower leg, just above the knee.

The amputation rate for injuries like this eight or more hours out is 86%. Even within six, the rate is about 20% if there is a femur injury. After we found out I remember sitting on the toilet in the room becuase it was the only place to sit and looking at her now purple toes sticking out of the splint. That may have been why she kept missing her goals all along. The reasons to miss the injury were legion, yet sitting there staring at her dead toes they all sounded like excuses.

That's the other part of the whole cost debate. Becuase of those purple toes I'll be more likely to order angios for the rest of my life, but not to somehow line my own pockets and not to avoid lawsuits. To avoid purple toes.

5 comments:

Anonymous said...

It sounds weird to say that she "failed" her resuscitation goals, all for things that were out of her control.

One of my friends was told that he "failed" chemo. What a nasty way to put it.

Maybe medicine failed her?

tyro said...

Your comment helps me see how that language is pejorative. We don't think of it as the patient's failure, but our own; the use of the word 'fail' for the patient betrays our bias in medicine that, when critically ill, the patient is not part of the healing process. Rather, somehow our therapy has not worked. If I say that a critically ill trauma patient is 'not meeting his or her resuscitation goals' it's not a knock on the patient but a hint to the team that we're missing something. I do see your point, though.

DHS said...

No ultrasound machine with doppler? much quicker than a formal angio, and as an EM resident you should be able to do one by the bedside.

tyro said...

Only one of us does bedside U/S well enough to look for DVT, let alone running the artery with ultrasound, but we're, to be honest, a bit behind on our use of ultrasound. Doppler alone, sure, but that is not reliable to rule out an arterial injury; it would help rule it in if I had no doppler signal. Dopplers were wierd in this patient, they would come and go in all extremities as she went in and out of shock.

tyro said...
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