Rat Poison

He finishes dinner with his wife, the first they've had in weeks as he's recovered from hospitalization. Both feel better. Renewed. Maybe a bit hopeful. His balance isn't what it used to be, he's still tired, unsteady at times. Weaker than he was. She finishes the dishes while he, complaining of being tired, heads for bed upstairs.

On the third step, he remembers something and, naturally, turns to go back down. His balance, though. Not what it used to be. He falls the three steps, foreward into the foyer. And weak; doesn't catch himself. His nose bleeds. And bleeds. Bleeds even after she holds pressure and calls 911, bleeds to the hospital. Bleeds with anterior packing.

By the time he stops bleeding with a postieror pack, he's intubated; mental status, airway protection, and all that. Multiple facial fractures are found. He's admitted to the ICU for a hopefully swift recovery. Opacity at the base of his lung is watched; perhaps he breathed blood. Hard to say.

By day 3 or 4, it's not hard to say. The lung fills in, the tube stays after the packing does. He spikes fevers. He doesn't wake up. Now 4 to 5 days without nutrition, fractured, infected, a tired body, issues layering on each other.

His wife knows that he wouldn't want all of this. Wouldn't want the tracheostomy, the feeding tube, the supportive care to see if he comes out of it. That's were we were. Stuck. Or, not stuck, because the family was sure of his wishes, and all of them agreed.

The Navy man who drove the boats for the landing on Guadalcanal had care withdrawn on the 4th of July. How terrible, you may opine. How macabre. But. The monitors were shut off. The tubes removed. His sons and daughter were there. His wife was there. They held his yellowed, bruised cool hands. Draped in a home blanket. They spoke to him, and we shut the door and the curtains, watching the monitor still on outside slow, and become more and more shallow until they stopped.

This is the situation the supposed 'death panels' were for. It was as good a death as we could offer for a good man. No bureaucrat showed up and told us we had to let grandpa die, nor would they if we had kept the 'death panels'. The family happened to know what he wanted, and because of that, we could let him go. What if they had been gone? What if they had disagreed? Weeks and months could pass, hooked up to machines and tubes, sustained, exactly as he didn't want to be maintained.

It's terrible when anyone dies. It's worse when they are treated with guesses as to their wishes. No one deserves guesses like that. The family is often asked to 'guess' what they might have wanted. Imagine, having to feel as though your decision will either end the person's life or lead to a full code and then the end of their life, not knowing if they wanted to leave quietly, or fighting to the last.

Gauze

In the midst of the busiest call night in memory, I stand for twenty minutes, still, and watch the end of a baseball game.

I hold pressure to the wound that has soaked the bedsheet and is drying from the outside in. It soaked his shirt before he arrived. My hand protests and numbs after I wedge my elbow against the bed.

I have stacks of consults to finish. The pagers hum, heedless of each other, while I hold pressure, unable to answer. Traumas are stacked in rooms to go upstairs. Ribs, open legs, head injuries. Splintered livers. The detritus of a sticky summer night. Scanned, diagnosed, improved, ready to move.

I try to switch hands but position dictates my left is better, so I switch back. The chief had held pressure before me but she was too busy. Go get someone to do this, she said. This is what he needs. He needs a human being to hold pressure for thirty minutes.

Thirty minutes. From 9:25 to 9:55 PM on a weekend night in June, after the summer heat has arrived.

I ask for the med student first. He is too busy learning, I am told. My own staff tells me this, an attending who has taught me how to read EKGs, how to diagnose vertigo. My own staff who should be on my side except this month I am an interloper, I am a surgeon, I am an other, a 'consultant'. Get a tech.

I go and talk to the charge nurse, perhaps even more important than the staff physician. She is washing a bed. I do not take that as a good omen. I need help, I say. Someone needs to hold pressure on this poor man's wound, and right now the overnight chief of trauma surgery, the grand poobah of weekend nights, is holding pressure. She laughs a short laugh. We have no help, she says. They are too busy. She does not recognize my so-called authority. I am but a mendicant.

I return. I will hold it, I say to the chief. Perhaps you would like to argue our cause. She leaves, the curtain rustles. The nurse, who is giving an IV medication over the course of ten minutes, cannot leave her post, either. We are together. The patient is silent. He watches the game.

The bleeding stops. The bandage is taped. The patient is treated. Anyone could have held it there. The choice of who holds the gauze, though. That is how I know where power lies, and where it does not.

And what was gained? The patient was treated. A task was completed that the charge nurse, the staff doctor, the chief of surgery, and the medical student did not want to complete. Will this matter, I wonder. Will it matter that I did that task rather than order someone to do so? I could have, with my authority, so-called. But authority and power are not the same.

Photo Credit

Irony

Here's a knee-slapper. What if the very Harley that you rode to traumatic brain injury land without a helmet also technically kept you from qualifying for federal insurance to pay for the nursing home you needed? What if it made you 'over assets' because it was so nice on paper, but really was a twisted heap of metal that no one had officially listed as totaled yet?

Hmmmm.

Trauma Time

Photo Credit

Last day of cardiology call; starting trauma surgery tomorrow.

An article about South Africa's hosting of the 2010 World Cup made me think about the context of penetrating trauma. Johannesberg in particular is an infamous center for trauma research, and one of the most dangerous places in the world, prompting all the concerns about tourists visiting.

Looking around, it certainly seems that the risk of getting shot or stabbed is, ahem, not quite equal. The rates where I train are in the neighborhood of 20 per 100,000 or so, putting us outside the top 25 most dangerous cities in the US in favor of places like Detroit and Compton; on a country averaged rate, though, it puts us between Puerto Rico and Kasakhstan, which is not great. With a stated death rate from intentional trauma of 20, we get more than a gunshot wound a day on average (they do tend to come in groups).

Of course, it gets worse; South Africa has a rate of 38 per 100,000, as high as almost 50 in the last decade. Iraq wins--or loses, whichever. But that's an active war zone; the one that makes me wonder in this list is Jamaica, which people run off to all the time. Imagine if Apple tourism started selling getaway packages to Iraq.

These statistics face the same problems as any public health measure. Any country with a functioning public health system will do a better job of tracking statistics, and the statistics in Sierra Leone or Somalia are likely not quite reliable, whereas ours should be quite reliable. I'm guessing the rates in countries like Somalia, Angola, or Colombia are unreliable to say the least. I'm not sure how a country with no infrastructure deals with such a trauma load, except as depicted in the pictures linked above from Somalia.

According to the Boston Globe article with the photo above, Somalia has lost 17,000 civilians to trauma in the last 2.5 years, or 6,800 a year; if the population is counted right, that's a death rate of 680 a year from penetrating trauma. 680! Makes that picture above seem a bit more poignant. Makes me think I'll take trauma more seriously. Makes me happy I'm not in Somalia. Makes me just overall confused about the state of the world and what we're missing on a daily basis if we don't go looking for it. Imagine the apocolypse we would be filling our airwaves with if our penetrating trauma death rate was thirty times greater than it is now. And yet, it's happening. Just not here.

GCS of Seven

Most kids aren't that sick in the ED. Some are downright well. After working there for a while, you're sicker than most of them because they've given you GI junk and URI junk and maybe some rash junk, too.

When they ARE sick, good God, it's scary. We had an ambulance call, not a trauma call, come in the other day, of a 3 year old, head versus TV, and 'altered'.

To prepare in my head, though I would never be the one to do it as an Intern, I reviewed RSI doses--0.2 mg/kg etomidate, 2 mg/kg succinylcholine, estimate for a 3 year old about 15 Kg, so 3 mg and 30 mg.

He came in moaning, not in a C-collar, his right arm flexed, eyes closed. GCS? 1 for eyes, 3 for pediatric moaning, 3 for flexion posture--seven. Needed a tube.

We took him into the trauma bay, and held C-spine precautions while I realized I didn't know how to work the C-collars we have at children's because I've never done it. Having never done a peds trauma resuscitation, I was sort of useless--I could hold the bag on and do the ATLS algorithm in my head, but so what?

IV in 2 minutes, intubated in 5, CT scanner in 10. Pretty good. The kids are so small and everyone is so intense, pediatric traumas are frenetic. Everyone is close together. The sphincter tone in the room is incredible.

His CT scan showed a skull fracture and air all over, with 2 mm of midline shift. Hopefully he'll do better.

That's Peds EM this month--95% BS snot and wheezing or their leg looks funny but doesn't hurt, and 5% holy crap.

White Cloud

I'm hoping that in writing this I will tempt the fates enough to bring me an admission. I'm a white cloud right now, and I'm stuck on call blogging rather than working. Now, this might seem like a bit of a crazy request; but when my wife is home in bed taking care of three kids, I kind of want my time away to be, oh, I don't know, somehow productive.

The first time I realized that I was actually superstitious was an overnight trauma call. We had seen a penetrating chest wound that didn't survive, a car accident that included a whole family that did, and a five-hundered pound Amyand's hernia, which occurs when a Meckel's diverticulum incarcerates into a hernia sack and then ruptures, causing necrosis and serious badness if not removed. Even the chief, who was amazingly resiliant, was exhausted, breaking between stitches to roll his shoulders back and look at the ceiling. As we finished up the case, I said, 'well, at least it's quiet now, right?'

He looked at me as only med students can be looked at, for we have yet to learn the ways of doctoring that matter. Never, ever, ever, tempt the fates, for they will deliver. We had three more traumas not thirty minutes later, just in time to push morning rounds back by hours. I couldn't feel my feet. And while that night was the night that helped me pick my speciality, I was tired and I wanted to go home. I had made myself into a typhoon cloud.

In contrast, here on my medicine rotation, I'm a white cloud on a breezy blue-sky day, footloose and fancy-free. Life I love you...all is groooovy.

The concept of white and black clouds, well, it's not official until I've actually been the responsible one on call. We'll see yet what my true colors are. Perhaps fate, just like attendings, doesn't really care too much what medical students say. Here's to being productive.

The Dark Side of Those Souvenier Mugs

You know those mugs people buy from tourist locations with etched scenes of the St. Louis arch, or the Statue of Liberty? Those are etched with hydrofluoric acid, which is my new favorite type of burn. It's perfect for an ER doc--bad and treatable, so it combines toxicology with trauma.

The below is a picture of an HFA burn, which doesn't present as pictured initially. Just like pain out of proportion with exam is a marker for mesenteric ischemia, pain out of proportion with burn is a marker for HFA burns. Why? The fluoride ions diffuse through the skin easily and proceed to precipitate out with calcium and magnesium ions, destroying deep tissue; the consumption is so marked that patients can present with hypocalcemia and hypomagnesemia.

Treatment is to give the acid what it wants; calcium gluconate to the skin, which attracts the fluoride ions and causes a precipitate. That's the white crust seen above--vigorous application of calcium gluconate jelly every hour created a calcium salt on the skin. It also was replaced intravenously and intraarterially in the above case.

Medicine is 'fun' (since I can't use fun without quotes when talking about someone getting their hand burned off) when you have recognizable symptom complex with a clear antidote.

Of course, I haven't actually seen such a patient. My only hope is to file the knowledge away and hope it is still recall-able when I do see it.

Genius Parade, part 1

At first he just laid on the backboard, stabilized. Two giant styrofoam logs on either side of his head helped keep him from moving.

Perhaps we should've left him there. He refused to tell his story. How did you get that 3 cm gash on the back of your head? Did someone jump you? No answers.

Try a bit of cajoling, which, of course, he doesn't respond to, being a young, drunk male. Where are you? What's your name? No response.

Normally, I suppose petulance works well to control your situation, but in an ER it's more likely to get you intubated, which I told him. He winked at me. Like, you understand, don't you? I can't tell the police what was happening.

Despite myself, my response at that point showed how old I really am. No, I don't understand you, genius. What the hell are you thinking exactly?

Restraints came next, eventually, as he got less and less cooperative and started to insult nurses, doctors, guards.

After we spun his head (CT) and found nothing, it was time to fix the laceration. It was a Y-shaped laceration with relatively clean lines that I could re-approximate well. Having done a few scalp repairs, I was hoping to try for a good result with a stitch at the Y that re-approximated the three angles loosely; Y-shaped lacs are notorious for losing blood flow at the middle of the Y since there is often a tearing force involved.

So that's where my head was. How can I technically approach this problem to get the best result for the patient, with regards to infection prevention and cosmesis?

His head wasn't at the same point. Just to get him turned over we had two security guards holding the limbs out of restraints. As soon as I started to irrigate, he started moving his head around, shaking it. To truly irrigate a wound the minimum amount is probably on the order of a 1/2 liter or so of tap water or saline. That didn't happen.

And my plans of stitching didn't happen, either. Once the wound was tolerably prepared, I asked him if he'd allow me to fix it, and he said, 'you do what you have to do, but as soon as you start, I'm going to go like this'--and he shook his head violently back and forth.

Now I'm less worried about him than us. There were four people in the room trying their best to help this genius, and the time it would take to suture him wasn't feasible. So he got staples. Less than 30 seconds, and his wound was closed. There was a touch of satisfaction that I would be lying to deny in stapling his head. 30 seconds was about all we had as someone had to hold his head down, and his free arm.

During the time we were screwing around trying to take care of genius no. 1, there were probably about 15 other patients that came into the ED and needed help, including a couple cardiac arrhythmias, a woman on the edge of sepsis, little kids that were really sick in the middle of the night.

Re-reading this post, I can see my writing is a bit choppy and odd. Probably because I'm still suffering from counter-transference--that is, strong feelings that arise in a provider in response to a patient that should, ideally, be put to the side. Not always so easy to do.

Perhaps I'm younger than I think, and still too close to the time in my life when I made my own stupid decisions. He certainly made it difficult to help him. Perhaps I'm not the most patient person by nature. Or, perhaps I was starting to be aware of everything going on in the ED that needed attention.

I'm still sorting this one through. What are the consequences of helping everyone? Can you make a judgment on how deserving someone is of help? If so, how?

In the meantime, I'll try to be less of an idiot, if only for the sake of others.

Wear Your Seatbelts

A classmate recently had a roll-over accident and sent out a mass e-mail reminding people to wear their seatbelts with pictures of his car.

I prefer to remember a couple of patients. It would start with a funny feeling, and then the pager would go off; a text page. Level 1, 24-yo unbelted ejected driver high-speed MVA, GCS 3. Then some vitals, unstable. His arrival is busy, scrubs, x-ray lead, and gowns blur around him, while I remember his head, bright red from across the room. His scalp is bleeding. His nose is bleeding. His ears are bleeding. He bleeds around his intubation. The blood pools in the antihelical fossa of his ear as it drains out of the canal. Blood, blood, blood. We take a stapler to the scalp, which is the trauma way of treating a minor injury. One can only imagine what his brain looks like. I clean the blood from his nose for a while, then stop. There are bigger problems.

Or, in rehab, another young man, recovering from an unbelted ejection from his car. He had been on his way home from picking up his brother upon return from Iraq. It's not hard to imagine, and indeed forgive, the idea of stopping for a few beers. Now, months after his injury, he can't speak, walk, or remember three objects you tell him to remember for more than five minutes.

So yes, wear your seatbelt. Put your children in their car seats. All the king's horses, all the king's men.

Intro

I guess I probably fell in love with the trauma bay when I had my hands in a man's chest, his heart in my hands, squeezing blood through him.

Before he showed up, the trauma attending gave us an into...listen up, this man's coming in with a penetrating trauma to his chest, we're going to do what we can to establish an airway but we need to be ready to open his chest here in the ED...and so on. The worry was tamponade, a stab wound that involved the pericardium, or the sac around the heart; if it fills with fluid, the heart can't beat and the patient dies.

The gurney came in and, since I haven't been in that many traumas, I saw chaos ensue. Four nurses and doctors around the head, two more on the left side of his chest, two on either side of his groin, one at his feet, with nurses and radiology techs in the room as well as paramedics at the door of the bay, yelling what they found at the scene. In a less serious trauma, the medical student (me) has the job of recording the physical exam, which is set in a trauma. In this case, we never got past attempts to revive him.

An ED thoracotomy is performed by incising along the fourth intercostal space, creating an incision along the patient's side about at the nipple line. The ribs spread enough to fit your hands into the chest. The trauma attending and the trauma chief, a fourth-year resident, did this; I saw the initial bloom of sub-Q fat with the incision, but to this day it stands visually how little bleeding there was. The chest was opened, tongues of lung pressed back, and the pericardium, pearlescent, was seen. The chief made an incision, still with little to no bleeding, in the sac, and the attending, urgently voicing instructions all the time, had his hands around the heart.

At the same time, the two docs at the groin and a nurse at either arm were trying desperately to find a line. Finally, a flight nurse at the head, whose job was not finding an IV line, said he was trying at the EJ (the external jugular), and within less than a minute he had an IV line and two large heaters holding blood and fluid were opened to try and give volume back to the patient. With volume, the attending and the chief could start direct cardiac massage, squeezing the heart to distribute the blood; the hope was that the residual electrical activity the heart had, called PEA, or pulseless electical activity, could be shocked into a rhythm. They pulled out internal paddles, like the defibrillators used on TV but designed differently, silver disks that fitted around the heart.

The pace was fantastically fast to my eyes, but the attending probably knew how futile it was from the start. He had the presence of mind to ask where I was, and I had fortunately had the presence of mind to put on a pair of sterile gloves and step towards the center. He pulled me up and showed me where to put my hands, inside the pericardium which was amazingly stiff and resistant to stretch, and around the heart which felt like a tensed muscle but was squeezable, and with flat hands on either side, I squeezed blood out of the heart, trying to stay at the 100 beats a minute set by CPR training.

He died. He was likely dead on arrival, in retrospect. I looked for the article in the newspaper the next day, and he had been stabbed almost 15 minutes before he arrived. More telling, he had a stab wound in his leg which squirted blood after the tourniquet was removed, probably from blood given during the resuscitation attempt. Although he came billed as a stab wound to the chest, the one in his thigh may well have been the one that troubled him more.

So that's why I'm an M3 in Madison considering EM as a career. More to come.