Callous

The EMS call comes over the phone to us in the ED, ambulance in the field needs assistance. 5 month old, found down, not breathing for an unknown time, be advised CPR in progress. 1 round of epi through an intraosseous line, asystole is the presenting heart rhythm.

The three of us--intern, senior resident who answered the phone, and pediatric EM staff--calm down when we hear the story. This is not a rush, not a challenge, not a moment to shine. This is a moment to let death quietly come in. The chance of success bringing back a dead baby with no heart activity is near zero, and the chance of having a baby recognizable as a baby who smiles and coos is even smaller than that. But we are in a quiet, carpeted control room, not in a cramped ambulance performing CPR on a tiny infant with family looking on. It's easy for us to assess the situation at a distance. Easy for us to be 'objective'.

More details are relayed--impaired status at baseline, crack mom, baby now living with grandma who wants everything done. 2 rounds of epi, aystole in three leads. Intubation fails. Bagging, doing compressions. As I listen, the paramedics relay updates in brief chunks of speech with long pauses.

The senior resident asks for signs of lividity or prolonged downtime. A long pause. We're dealing with an african-american baby, hard to tell, comes the answer. One sign of lividity is pooling of blood by gravity, which is easier to see in a caucasian baby, but that's not why they answer that way.

Third round of epi. Asysto--wait, one beat. Another beat. Long pauses.

The pediatric staff puts her hand to the bridge of her nose, squeezing. I hate the third round of epi, she says. You can get a beat from a stone with enough epi, the senior resident says.

Ask them if there's a pulse. Cajole them. Push them to call off their efforts, it's the right thing to do. We're in the carpeted room. The situation is clear to us. We're not the ones compressing the tiny chest, feeling the ribs recoil, suctioning out the mouth, bagging, watching the limbs jump with the compressions. We're not the ones willing return of circulation. Not the ones chasing the fairy tale ending.

No pulse. Asystole. Stop.

Heroes

At the program I train with, we are required to do EMS ride-alongs, and we have the option to do helicopter medicine. I am all in on the flying, but I learned the most real-world perspective from two or three ride-alongs. EMS folks live in a different world than anyone else. They take the fight to save the patient from themselves into the erstwhile lair of the patient themselves, and all their crack-addled neighbors.

Imagine intubating on the kitchen floor while your partner stomps the roaches to keep them from crawling into your field of view. Or starting an IV in a moving truck.

ER docs do good. But we work as a team. Next time EMS rolls in, whether they've done a banner job or not, I think we should keep in mind where they were and what they do on a daily basis. Coffee's always around for y'all, you do good work.

Why this post? Good new EMS blog here.

Airway Tip O' The Day

A colleague on flight had a horrendous trip the other day to a blast site. One victim was talking, had normal vital signs, but was hoarse and covered in black soot from the neck up due to the blast.

An indication for a tube if ever there was one; it had only been sixty minutes or so from the time of the blast and already she was unable to pass a tube a full size smaller than needed, and saved his life with a rescue device instead (a King LT). Which leads to the airway tip o' the day.

A bougie is a long, flexible plastic thingee used to find the trachea by feel and by the bend at its end, over which you can then pass a tube. Usually I think of it as a means to improve an airway with a bad view. She had a great view; he was just too swollen.

The tip is to use a bougie even with a great view in the setting of airway edema; if you can't pass a tube over the bougie, leave it in place, go one size down, continuing until you pass something.

Of course, this being the great frozen north, it was seven degrees where she was trying to intubate without the windchill, so the bougie probably would've snapped. The O2 tubing had already frozen. Sweet. Can't wait to start flying.

MedFlight Tribute Page

UW Health has posted a tribute page where anyone can post remembrances, here. It also contains a link to the page itself to read what others have submitted. Thanks to commentators here and to those from around the country who have sent their condolences.

Dear God, No. No, no, no!

At the risk of losing anonymity, I have to post the passing of one of those docs I most admire, one of the best I've worked with or seen, who will truly be missed. There was a crash last night, just to the west of La Crosse, Wisconsin; one of UW Madison's EC-135 copters went down with few details known yet. As of what I've heard now, there were three crew members lost.

It's covered in this article in the Wisconsin State Journal. I didn't know the other two crew members, who will be sorely missed as everyone I've ever interacted with has been pure class at Med Flight. Dr. Bean was a leading light to me, a mentor, an example of what I want to be. He was a doctor and a teacher I will sorely miss.

The best way I can think to memorialize Dr. Bean is to tell stories about him. He helped me see that EM was the field for me. I never saw him treat anyone badly, patient or colleague. When he talked to a patient, he sat down as if he had all the time in the world for them, but damn if he didn't know how to run trauma, and how to run a department. As with so many EM docs, he was also the local EMS director. At conferences with other services, his was the honest question, the insightful comment, always in the spirit of increasing cooperation, coordinating.

My fourth year rotation on EM was awesome. Dr. Bean would regularly 'hold court' after shifts, even those that ended in the middle of the night. My best memory of teaching in the ED was at 3 am after a 4-1 shift. Patients were all 'purple' (admitted) or 'green' (discharged). The Intern, who was awesome too, decided to run a session on airways because he had just been re-taught. He took me into one of the trauma bays and we picked tubes, discussed doses. The other intern came in and joined in. Dr. Bean came last, and the first thing he did was listen to the interns teaching me. Then, he ran cases for at least half an hour. What induction drug, what dose, what are you worried about. 'If you're worried,' he said, 'take out a pen and write your doses on the gurney while they're bringing the patient in. Better to take the time to be sure than get the dose wrong. Believe me, we all get rattled sometimes.' He said that, but I never saw him be rattled. More than the teaching points, which I loved, I noticed that this attending was there, two and half hours after his shift, teaching. And I also noticed that he carried himself as an example. Confident, not arrogant.

He also took the time to do the little things right. Wound exploration was a great example. It's not enough to clean the wound; explore, look for tendon injury. He would take time to discuss the proper tension on a nailbed repair, for example, along with suture choice. His attention to detail was impressive, and it pointed out that even though we're generalists, that shouldn't prevent us from taking pride in our work.

My father-in-law said, 'not all those that die, deserve to.' Amen to that. So the next time you're drinking, raise one for these folks. The next time you have a moment, make it a moment of silence. I sure will. I'll be lucky if I'm half the doc Dr. Bean was, but I'm damn sure going to try.

I'll try and keep up announcements, if any on this topic.

Bookends

The final week of my 3rd year, I scrubbed in on a hysterectomy for a 500 pound woman. I commented before the case that I had also seen her every morning for my entire internal medicine rotation, prompting my attending to comment to the patient, in the OR, that 'you're almost like a bookend' for my first year of clinical training.

Morbidly obese patients seem to make fantastic bookends. This final month of my clinical 4th year, that same woman is in the ICU with sepsis. Again. And, we had another patient admitted who was over 500 pounds, because he had fallen three times in the last week, and couldn't get up each time. His chief complaint was knee pain. Hmmmm.

As this article in the NY Times illustrates, fire departments and EMS providers around the country are buying 'bariatric' stretchers and 'bariatric' ambulances. Picture here courtesy Stryker on the NY Times website, so I may have to take it down.

Our attending commented that he doesn't think that this type of obesity is common, and that the obesity epidemic is more comprised of the just-barely-obese; I beg to differ. I've seen more morbidly obese patients than I have pancreatitis patients, or hepatitis patients, or AIDS patients (even in Milwaukee), or colon cancer patients.

When I say morbidly obese, it does get, well, morbid. As in, 'suggesting the horror of death and decay', here. It's hard to describe the reaction to someone of this size when they are sick. In my experiences, these patients could not perform any routine hygeine, and were sometimes incontinent not due to any urinary defect but due to an inability to reach the bathroom. One woman died of urosepsis from an indwelling catheter she used for this problem. She died because she couldn't get up and go to the bathroom. Their skin folds were so deep and extensive that they would become infected with yeast, which would allow the entry of bacteria, which often led to sepsis via panniculitis, or infection of the panus, the word for overlying fat rolls. They often had chronic ulcers, which again led to sepsis. And when they were intubated they couldn't breathe because the fat was too heavy for the lungs to expand properly.

The woman above, when she started to recover, didn't want to leave. She was the first patient where I was taught the trick of pushing down on someone's abdomen while listening, thereby hiding the fact that you were testing for pain. I pushed down the stethoscope; nothing. I pushed with my hands; Oh God, terrible pain, 10/10, doc, I can't stand it. I assume that the hospital nursing care was superior to the in-home care she had to receive.

Mountains of illness, geological formations of pestilence, people encased in double or triple the amount of pure protoplasm they should have, decay, stench. I don't describe this to be judgemental; obviously, these patients had reached an apex of obesity beyond that of the occasional trip to McDonald's and a failure to eat enough leafy greens. Everything was more difficult. Rolling them in the OR took five people instead of three. They didn't fit on the gurneys. The instruments weren't long enough. Their tissue died more easily because fat is poorly vascularized. And so on.

An epidemic, indeed. Bookends of illness against which I often feel helpless at the sheer enormity of it all.