How do you translate ‘miscarriage’?

It’s been an emotional week in the ER for me.

First I had a difficult patient who was brought in from nursing home in police custody. He has a rep around the city for being a bit combative and somewhat dangerous, so no new nursing home would take him in the city. He finally got placed out in the suburbs. He really was a nice guy once you learned how to talk to him. I don’t think it helped that he was a good 6’5 and 330. It broke my heart to see him cry when we told him we were having a hard time finding a place for him. I bought him a Pepsi… you woulda thought it was Christmas in March.

Then we had a girl who tried to kill herself by taking a bunch of Vicodin. She was trying to work to help her family out and still go to school, but her grades were slipping. She couldn’t handle the responsibility and the inevitable disappointment from her family. Broke my heart to see her cry like that. And her dad never showed up either.

The other night was the worst. Woman came in with some spotting that had worsened into heavier bleeding. She was about 4-5 weeks pregnant and had a positive pregnancy test at her OB’s office a week or so ago. She really wanted to keep this baby. I did the pelvic exam and her cervix was open… and there was a significant amount of blood coming through. It’s hard enough telling a woman she’s having a miscarriage. It’s even worse when you don’t share the language and you have to have a friend interpret for you. It’s hard to provide empathy and sympathy through a translator. All the friend kept asking was “Is there anything you can do? Can’t you do something?” It was already done though and the blood test confirmed it.

This job is starting to tax me emotionally.

Which may not be a bad thing.  I find myself becoming more invested in the emotional well being of my patients.  It’s a bit different than the jaded outlooks of some of my older colleagues and our attendings.  I worry that the transformation is inevitable.  Or are we just talking tough when we’re not surrounded by the curtains and walls of a patient’s room?  I’d like to hope it’s the latter, but I think for many it’s the former.  I know not everyone has the ability to separate various patient experiences from each other.  The bad experience with one patient too often allows itself to seep into many of your other patient relationships.  I see it more often with the overdoses and psych patients.  People seem to have lost their empathy for their fellow man.

I think the best we can do for our patients is try to not and judge their choices and decisions until we’ve lived their lives and truly had to deal with their stresses and demons.  It’s quite a Pollyanna world view, but if I stopped caring about the people my patient’s are then I’m not much more than a science detective.  If I wanted that, I could have just stayed in the lab.

And no one really wants to be in the lab all day.

Any day you almost call DCFS is not a good day

I think that ranks up there with one of the most difficult discussions I’ve ever had to have in the ER. To say that emotions were raw would be an understatement.

The triage nurse rushed a young girl about 2 years old into the peds ER with her mom right behind them. The child was a little lethargic and drowsy but looked like she was starting to come around. The story from mom is that she went to take a nap and left her daughter in front of the TV after putting on Dora.

When she woke up she found 2 of her new bottles of pills (an anti-depressant and an anti-anxiety medication) open and spilled on the bathroom floor. Initially she told us that they were brand new bottles and she hadn’t taken any yet. She claimed her daughter only took one of each. We called Poison Control and talked to the toxicologists and put mom on the phone with the tox folks and then had her talk to our PharmD as well.

In the interim, the step dad showed up and introduces himself as Dr. So&So. We talk with him to see if he can add much to the story, but he wasn’t home at the time. During all of this the child continues to look better, but after talking with Poison Control and our PharmD the mom changes her story and says she’s not sure how many pills were in the bottle because she did take some and never really counted to see how many were left.

After discussing things at length with the toxicologists from Poison Control and getting initial blood work, we go to talk to the family and let them know that we need to admit the child for observation in the PICU (Pediatric Intensive Care Unit) step-down section. The mom argues that she doesn’t want her to be admitted, that her daughter is back to her normal self and they’re going to take her home. Incredibly, the father Dr. So&So agrees with her. Turns out Dr. isn’t an MD but a PhD in psychology.  He tries to argue that they can bring the child home and he can watch her because he’s a doctor, and if there are any problems they’ll bring her back.

We explain to them that this idea was not safe in the least and that their daughter ingested some very dangerous medications. Even though she’s looking well now at this point, the two medications have different pharmacokinetics (meaning they reach peak activity at different times) and she could quickly become drowsy again, possibly worse than before.

Unfortunately, it went to shit when one of the other residents stepped in to try and help convince them and something she said set the mom off. She never mentioned DCFS specifically or said “we’ll have to take your daughter away”. From what I can recall, she said something to the effect that “We need to admit your child, with or without your consent.” The (pretend) Dr. Dad says “Well, we’ll just sign out AMA (against medical advice)” which is something you can normally do unless it’s thought that your actions are going to harm another person.

The mom flipped out at this point and started screaming at the top of her lungs at everyone. She flipped off the other resident and told her that if she ever had to see her face again she would sue the hospital and then yelled over and over “GET OUT OF OUR ROOM, GET OUT OF OUR ROOM”. She then tried to convince us that she was a wonderful mother who was with her daughter “24 hours a day, 7 days a week.” Except when she’s taking a nap and her daughter is getting into her pills.

Thankfully the attending and I were able to get the situation under control and we were able to convince the family why it was important for us to just keep her overnight so we could make sure she’d be okay. We assured them they’d be able to stay with her and that no one wanted to call DCFS as this clearly wasn’t intentional and wasn’t part of a pattern of any abuse that we could see. Things went okay after that, we just kept the other resident away from the family and rushed to get them a bed in PICU step-down.

This wasn’t my first interaction with a potential DCFS scenario. I’ve had a couple others but in one, one of the parents was clearly abusing the child and in the other, another healthcare facility had called DCFS due to a misunderstanding about a child’s ongoing chronic illness that caused her to be emaciated.

But I’ve never seen so many of my colleagues actively shaken and disturbed. We’ve all dealt with angry families and volatile patients who have attempted to harm our staff. But this wasn’t different. It was a more emotional and psychological trauma… maybe more so than a death of a loved one. I imagine the death of a young child might affect a family in the same way, but I thankfully haven’t experienced that yet.

I just wanted to give some thanks to any DCFS or social workers out there. I have no idea how you get up everyday and do you job. I couldn’t do it, but I’m glad you can.

Some Thoughts on Fighting Death

I was planning on making a post about these cases even before the debate about the NFL players and their search and rescue. I just wasn’t sure what aspect I wanted to talk about. I know people find the life and death things that we do to be very exciting, but there’s only so much to be gained from relating a story. I think sometimes it’s much more beneficial to discuss the ethics related.

The last week in the ER has been a little rough for everyone. We had back to back days with a number of very sick patients. More than a couple ended up intubated and admitted to the MICU (Medical Intensive Care Unit where we take care of critically ill patients). Some didn’t make it all the way upstairs.

One woman was brought to us by Chicago EMS. She had been at a nearby clinic waiting for a long scheduled follow-up appointment when she collapsed in the waiting room. She was a cancer patient, likely terminally ill. As she arrived one of the paramedics was straddling her on the gurney given chest compressions for CPR. She had been intubated in the clinic office and they were breathing for her through the tube. We took over chest compressions and breathing and hooked her up to our monitors. She had no electrical cardiac activity, which was confirmed when I ultrasounded her heart. We started giving medications that would hopefully make her heart more receptible to our CPR efforts.

After a few minutes we stopped and checked the monitor. She now had electrical activity, but the heart wasn’t beating as she had no pulses. We continued CPR while placing a central venous line in her thigh so we could run high volume fluids into vascular system. After a few more minutes we again stopped to check the monitor. She was in ventricular fibrillation. Normally this is a very dangerous rhythm but for someone who a few minutes earlier had no cardiac activity whatsoever it was actually a good sign.

We shocked her twice and he regained her pulses. I checked her heart on ultrasound and it was beating normally with no fluid around the heart (a good sign). We called the MICU service to come and see the patient and we started IV medications to keep her blood pressure up and prevent her heart from going into a dangerous arrhythmia. As they were reviewing the patient’s course with us in the ED, she again lost her pulses and cardiac activity. We started CPR again and again pushed IV medications to try and restart her heart. The MICU service went back upstairs and asked us to call them in the unlikely event that we got her back.

They weren’t being callous when they said this. First of all, it’s an extremely rare event that we are able to resuscitate someone back to life when they come to us in asystole (no electrical activity in the heart). To get them back and then lose it again, makes it very very unlikely especially in someone with terminal cancer. However, after another 5 minutes of CPR we got her heart to restart. We started giving her blood transfusions as we found out her blood count was very, very low. She eventually made it upstairs to the MICU.

The other patient was an elderly gentlemen with a known aortic aneurysm. This is a condition where the aorta (the large artery that feeds blood to your entire body through various branches) develops a ballooning of its wall. It can continue to grow and eventually rupture which will lead very quickly to death. People with aneurysms of the aorta are evaluated every 6-12 months to see if their aneurysms are growing at all. If they grow past a certain size or over a certain rate, then surgery is done to replace the aneurysm with a graft.

The patient came in with abdominal pain, which is quite common in people with aneurysms. However, when he was evaluated by one of the senior residents he wasn’t doing well: he was mentally altered and was having difficulty breathing. We moved him into the resuscitation room and began taking measures to hopefully protect him. As we placed a central line and evaluated to see if he’d need to be intubated, we noticed his belly start to distend. We grabbed ultrasound and tried to look for blood leaking into his belly. We couldn’t see any but still had high suspicion that his aneurysm had ruptured. We called surgery to come and see him. In the meantime we decided to intubate. He eventually lost the pulse in his L thigh although his R was still strong. This was more evidence that his aneurysm was either quickly growing and about to rupture or had already ruptured. During surgery’s evaluation, we noticed some strange activity on the heart monitor. We did another EKG… he was having an acute heart attack. We called cardiology and he was taken to the cath lab so that they could attempt to relieve any blockage in his heart vessels.

In woman who went to the ICU eventually was taken off life support by her family. Even though we had her heart working, her brain and likely been deprived of oxygen too long and serial neuro exams demonstrated that she had almost no chance of meaningful recovery. The family elected after 2 or 3 days to allow her to die in peace.

The man who went to the cath lab, also died. He was on the table in the cath lab when he coded. I don’t know the specifics of what happened so I won’t guess too much other than to say, he was probably bleeding from his aneurysm into his belly. The heart attack likely wasn’t from any blockage, but from the fact that there was no blood to feed the heart as it was pouring into the belly. His family was extremely anxious (as any family would be) and we kept them as informed as we could during our resuscitation efforts in the ER and as we waited for surgery and cardiology to evaluate the patient and eventually bring him to the cath lab.

In both instances, the staff felt that we had done just about everything we could have in our power to prevent death. If we had both cases again, we’d likely do everything the same. There was nothing we could have done to prevent an aneurysm from rupturing and no medication could have prevented a sick heart from going into and out of dangerous arrhythmias other than what we were already giving. It’s hard for physicians to realize that sometimes when you do everything you can, people still die in front of you. As hard as it is for us, we realize it’s even harder for the families.

I’ve been in resuscitations where we worked for almost an hour… well beyond the amount of time we should have. When you explain to families that you did everything you could, they demand that we keep trying. At some point though the chance of a meaningful recovery is too slim and we have many other sick patients that demand our care. I don’t know that it’s fair or accurate to draw an analogy between the Coast Guard and the NFL players lost at sea, but it makes sense to me in what I do. I’m by no means a search and rescue expert. I do have a pretty good idea of how long someone could reasonably survive at sea as both a physician and a brother to a Navy Lt and Naval diver. If they say they did every reasonable thing they could then at some point you have to accept that.

I’m not arguing it should be easy and that if it was my family I’d take it well. But having been on that same side as the Coast Guard, I know how difficult it is to accept defeat and failure. It may look as if they’re giving up because of race or another factor. But I can almost guarantee you that they would much rather keep looking and be able to give the families the bodies of their loved ones. None of us are looking to fail at the basic responsibilities of our jobs. I obviously can’t speak for all of them, but I’ve known a few people in military search and rescue. They’re likely taking this hard. Clearly, not as hard as the families, but this isn’t the outcome that any of them would have desired.

Hopefully all of the deceased and their loved ones can find peace through time and understanding.

Trauma Call is Kicking my Ass right now

A veritable pantheon of medical delights from my most recent call:

The day started off with a brilliant bang: 20 something Hispanic gentleman with stab wounds to the back of his neck, shoulder and lower deltoid. The neck wound was so deep we could see the 11th cranial nerve and probe to one of his vertebrae and the shoulder would was so deep we’re afraid the knife might have entered the joint capsule.

Then some brilliant individual thought it’d be a grand idea to go joyriding on the Kennedy while intoxicated on his way back from the club. Hit some ice, skidded and flipped his car going 60+. He had a good 10-12 cm lac across his brow.

Our final winner for the day was later in the afternoon who somehow flipped out of his bed at the nursing home after getting Ativan and Haldol the night before and cracked his second cervical vertebrae. This is basically the one that lets you turn your head left and right. He cracked it in HALF. Normally, I’d feel bad but this dude decided he didn’t want to listen to us and kept trying to move his head and sit up. It’s a miracle he didn’t sever his fucking cord and buy himself an intubation.

Friday was equally bad starting at 5am:

High speed accident on the Kennedy, but driver was restrained. Somehow when his car crashed his L hand got caught up and he “degloved” the skin on his middle 3 fingers. He basically boned out the end bone in his middle finger (or as I like to say “he popped out the distal phalanx of his 3rd digit”). It was literally missing. No one knows where it went. Surprisingly he didn’t have much else in the way of injury and he had good sensation intact, but we were worried about him losing blood flow to those de-skinned fingers to he got transferred to Loyola where they have slightly better micro-vascular hand surgeons.

Next guy was a bit of a sad case. One of our OB/GYN attendings was crossing the street near his house to get on the Blue Line to go to O’Hare and he tried to run the 6 lanes across Irving Park road. That didn’t work out to well. He got slammed by a hit n run driver. He came in and was completely altered. He got intubated and was in slightly bad shape. My ultrasound exam for trauma showed some possible blood around the liver. CT showed 3 different bleeds in the brain and kidney fracture and possible liver lac. Good thing we decided to intubate when he came in.

Last was a young lady who wasn’t even initially a trauma activation. She came via ambulance to the ER as a regular status-post MVC (motor vehicle collision). But one of my colleagues started talking to her and thought she would rate an activation, ran it by me, and I agreed so off to the trauma bay she went. She was going 60+ down the Kennedy when a car suddenly spun into her and she spun into the wall and all her airbags deployed. Her L arm looked banged up, but all the x-rays were negative and she was in and out in 36 hours. Lucky girl. Could have been much worse.

People really need to be more careful in the winter.  Thankfully no DOAs… yet.

Oral Sex can be hazardous to your health

From one of my attendings via email while working at another ER in the city:

he presenting complaint was “sore throat”.

the patient was very up front about what happened: 38yo female with past medical history significant for daily alcohol use (she was drunk at noon when i saw her) complaining of sore throat since the night before. while performing oral sex on her fiance, she felt a sudden sharp pain and started “bleeding like my period” from her mouth and nose. she kept spitting the blood out and it subsided about 20mins later. she then went to sleep. when she woke up in the morning, she noted severe throat pain and could not turn her head due to the pain.

vitals were normal. exam, aside from a subtle soft tissue abnormality in the posterior oropharynx (ed note: basically where your mouth meets your throat) and her resistance of essentially all head/neck movement, was unremarkable. CBC (ed note: complete blood count measure your white cells, red cells, etc) was normal, except for her platelets of 55k (ed note: this is very low and makes you more susceptible to bleeding). pain meds did nothing, in fact her pain was getting worse. that’s when i got the plain films (ed note: aka x-rays). broad-spectrum antibiotics and a CT scan rapidly followed. attached are some images from her ct.

she had free air from the base of the skull down into the mediastinum (ed note: middle of the inside of your chest/thorax inbetween the lungs). there was fluid as well, but no abscess (ed note: abscess is a pocket of infection that can be extremely dangerous). she started having worsening pain and started retching. her next stop was the ICU (intensive care unit). i don’t have follow-up yet but ENT (Ear Nose and Throat Surgery) planned to observe her initially given that, at the time, her airway was fine and there was no abscess.

bummer of a hummer indeed…

That may be the greatst email I’ve ever recieved.  Just a bit of background in case your lost, as I’ve sent this to several non-medical friends and they were a bit confused by the significance of the story.  Many alcoholics can develop severe thinning of their esophagus from chronic vomiting.  Because of the thinning it’s quite easy for them to tear their esophagus during an episode of retching.  We even have a name for it in medicine: a Mallory-Weiss tear.  Once the esophagus is torn, it obviously will bleed like a stuck pig, which is often not good as most alcoholics have low platelet counts like our patient above.  A platelet count of around 50K is pretty low and can lead to poor clotting of blood, which will cause excessive bleeding.

The other thing that can happen is that a torn esophagus will allow air into places it shouldn’t go.  The danger of this is that air irritates the body and causes exceptional pain and swelling when it tracks into undesired areas.  This frequently happens in the abdomen when a stomach ulcer perforates through the wall of the stomach.  Air then tracks into the stomach and causes very severe pain.  We consider air in the abdomen a surgical emergency and air found in any other part of the body where it shouldn’t be is also an emergency.

The other danger in tearing part of your GI tract open is that there’s a lot of bacterial flora that hang out naturally in the GI tract.  That bacteria can track along with the air to places it shouldn’t be.  They can collect and make a walled-off area of infectiona and inflammation called an abscess.  Our patient here didn’t have one but we worry a great deal about that, because abscesses can lead quickly to sepsis.  Sepsis is a state of extreme badness.  The body is overwhelmed by bacterial infection that is now in the bloodstream.  As your body attempts to fight this overwhelming infection, your immune cells are pouring out special proteins and enzymes to help recruit other cells to kill off bacteria.   Some of these proteins cause very high fever and can often raise your heart rate and drop your blood pressure to very dangerous levels.  When that happens we call it ‘septic shock’.

Fortunately, that didn’t happen above, likely because it had been caught relatively early, but if left alone it would have been a very likely outcome.  She was pretty lucky in the long run.

This is a pretty unique story though.  There’s no case reports in the medical literature of any patient ever having an esophageal rupture/tear after performing oral sex.  The CTs and X-rays are pretty impressive also, but to an untrained eye they don’t look like too much so I won’t bore you with them here.  My attending is hoping to have this published in a journal or at least present the case at a few conferences in the upcoming year.  If that happens I’ll be sure to link to them.

Stay safe out there folks.

Expect some new posts next week

I’m queing some good stuff up as sort of a return to posting.  I’ve been stuck on internal medicine rotations for the last three months and it’s been a bit busier than emergency medicine.  Not as high acuity of patients but we work longer hours… around 80 a week, give or take.

As Christmas is coming up, I’m going to try to post once a day on the run up to Christmas.  Think of it as a Medical 12 Days of Christmas.  I’m also working Christmas Eve and Christmas Day in the ER this year so we might have some stories from that.

I’ve got some good things in the pipe though.  Hope you enjoy them.  And also let’s hope I don’t take another 2-3 month break from blogging anytime soon.

I can officially say I save lives now

This was written a few days ago while I was on call.  I’d changed the phrasing but I like the way it reads now.   Enjoy:

I was finishing up some work about a half hour ago and checking scores on the day’s games when “Number 1 Emergency – Adult, 687 East” came out across the PA system. I was already on the 6th floor so I ran to the other side and as I spied the room with all the activity I went to see if they needed another set of hands. The 3rd year senior resident had me run to find a central line kit. As I came back, he found out that the patient had a portacath for her chemotherapy (the patient was on the Oncology service, while the senior resident was in the Intensive Care Unit). A portacath is just as good as a central line, so there was no reason to put one in. I locked eyes with another intern to see if she needed any help. She asked me to rotate in on CPR. I jumped in and got to work, crushing this poor woman’s small, fragile rib cage. I’m always worried about crushing someone’s chest, even more so this time. I guess it was apparent to the senior because he told me to press harder.

In the middle of my 2 minutes of chest compressions we were giving epinepherine, a drug that increases blood pressure which helps push more blood to the brain and stimulates the heart to start beating again. We also give atropine, a drug which blocks any slowing input to the heart. At some point, I was asked to stop compressions so they could check for a spontaneous heart rate. Suddenly a relatively normal heart rhythm appeared, almost from nowhere, on the monitor and it began to chirp away. Her blood pressure came up and she had a palpable pulse again.

We found out that she was an oncology patient who had her esophagus and stomach scoped earlier today by the GI service. Shortly before we arrived, she had suddenly vomited and then lost consciousness. Fortunately, an anesthesiology resident was around and she was quickly intubated to help with her breathing and protect her airway from any further vomitus from traveling down into her lungs.

One of the 2nd year residents placed an arterial line in the large artery in the thigh, so that we can get second to second monitoring of her actual blood pressure. It’s much more precise than relying on a blood pressure cuff. We ordered several lab tests to check her heart enzymes and blood gas and to check for infection. She’ll get several high potency antibiotics to help protect against the likely pneumonia she’ll develop from aspirating vomitus into her lungs.

Honestly, she’s a pretty sick lady and might not make it much longer no matter what else we do tonight. I don’t say that to sound defeatist… I say it because it’s the truth. We can’t pat ourselves too hard on the back for this one. I’m glad we’re giving her a fighting chance and I hope that she pulls out of it. But at least when my wife or parents ask “Did you save any lives today?” I can say “Yeah… actually I did.”

I won’t lie… it’s pretty damn cool.

It’s the thing that feels like a wet noodle

I know I promised this story a long time ago and never got around to telling it. 

It was around 2am and a call came over telemetry that a young black male in his mid 20s was coming in with several stab wounds to his chest and unlike the young 15 year old in the other story he was already unstable: unconscious, extremely low blood pressure, bad heart rate. Everyone immediately got nervous and excited: there are very few indications to open up someone’s chest in the ER. One is penetrating chest wounds and hemodynamically unstable. But even then you don’t just go around cracking chests, it has to be within a certain amount of time and you have to have a reasonable chance at bringing them back. Most people go their entire residency and many their entire career without performing a thoracotomy or even seeing one performed. 

Everything happened fast. The trauma team swept down from their call rooms. The ER attending and senior resident mentioned to the trauma surgery attending that this seemed like a likely thoracotomy since he was initially stable when the paramedics arrived on scene and then started crashing en route. She wasn’t thrilled but said we could discuss it depending on how things progressed. We set up to run a full code. 

The patient comes in and everyone in the ER was there: two ER attendings, senior resident, the intern (me), trauma attending, the three trauma residents, 4 or 5 nurses, 5 techs, two pharmacologists, 2 radiology techs, 2 or 3 respiratory techs, the police, and the CFD paramedics. To say we had too many people would be an understatement, but everyone went to work. Thankfully the young man was already intubated when he arrived thanks to the great CFD paramedics. The techs got to work getting his clothes off, starting peripheral IVs, drawing blood, attaching heart monitors, performing chest compressions, etc. I tried to help them as best as I could. Since our work as ER physicians in traumas are mostly relegated to maintaining the airway and he was already intubated, my senior resident was helping the trauma surgeons explore the wounds. The trauma intern/junior went to work trying to establish a central line in the L thigh. 

The heart monitor showed minimal activity so they decided to open the chest and take a look at the heart and the aorta. The trauma senior and my senior poured a ton of iodine over the chest, gowned and gloved, opened a thoracotomy tray and made a giant incision along the top of the 4th rib. They opened it up stuck their hands in, grabbed a rib spreader and cranked it open. They exposed the heart and checked for any mechanical activity. Nothing. So they started internal cardiac massage. Essentially, you hold the heart in both hands and gently massage it to help it pump the blood. While one was doing that the other reached into the chest to see how the aorta was doing. “Feel for a long, big wet noodle. Normally it’d be thick but his heart isn’t beating properly so it’s not as full.” They found it and crossed-clamped it. 

In the mean time, the trauma intern was struggling with the central line in the thigh and couldn’t get it to thread. The whole process would be a waste if we didn’t have central access to the heart, so my two attendings took the drill and threaded two IV lines into the bilateral tibias (the bigger bone in the lower leg). Those are known as interosseous lines. You can pour just as much fluid into the bones as you can into the venous system and it goes to the heart pretty quickly. We started pouring in IV fluids and giving cardiac drugs. 

I went outside the trauma bay, back to the main ER to check on our other patients. There was one or two nurses out there; thankfully everything was ok. As I’m checking on some labs and xrays, a tech comes running out and says: they have a heart rate. I rush back in and sure enough the kid’s heart was beating again. My senior resident told me later that he was performing cardiac massage when the heart just started beating on it’s own. I can only imagine what that felt like. The trauma surgeons took him to the OR. 

I couldn’t believe it. It’s not often that we get someone back. Real life isn’t like House or ER where you do everything the right way and patient’s magically come back to life. Most of the time, when you get to that point, you’re already in big trouble. It’s very rare that you do a thoracotomy and get someone’s heart back. It seemed like a miracle. 

I found out a few hours later that he had lost his heart rhythm again just as they were about to begin surgery in the OR. He was shocked 7 or 8 times with the internal paddles and given several rounds of cardiac drugs but he had lost too much blood and there wasn’t anything more anyone could do. 

I always feel conflicted when I tell stories like this one. At the time it was both nerve racking and exciting to be in that room and watch people gently pull a heart from a chest and start massaging it. It was thrilling but it all seemed surreal for the patient. Almost like he wasn’t a real person we were working on, but another simulation. And then his heart started beating again and it all became real. I wasn’t involved when the surgeons spoke with the family. I can’t imagine how they felt when they were told that we momentarily had his heart beating again but that we ultimately weren’t able to save him. Were they angry that we put him through all that? Were they thankful that we did everything we could and had him back if only briefly? I don’t know, but I feel bad being as geeked and excited as I was. Maybe I’d feel better if the overall outcome was better. 

I don’t know.

Learning from your mistakes

Some days you walk in to the ER at 7am shift change and it’s an absolute mess. Usually this happens on Saturday mornings. People love to wil’ out on Friday nights. But when you walk in at 7am and the two senior resident’s who were supposed to leave at 5am are still there? That’s a bad sign. 

Everyone was crowded into one room with a 15 year old kid who was brought in by ambulance at about 3am. He was drunk and had gotten stomped out. I never found out where or why, but he was in pretty bad shape. He had been slowly decompensating over the last hour. He had 2 stab wounds to the back that were initially deemed to be superficial; they were explored and didn’t appear to be deep. But he was becoming more and more mentally altered. We attempted to have him transferred to a pediatric trauma center but they wouldn’t take him because he was drunk and “posed a danger to our other patients”. 

About 5 minutes after walking in he began talking incoherently and we decided to intubate him (stick a tube down his throat to help him breathe). Normally, 15 year olds are easy to intubate, but because he got stomped out, we had him in a neck collar and on a backboard. We couldn’t really manipulate his neck until we had insured he hadn’t injured his spinal column. Thankfully I wasn’t pegged to put the tube in. I was just asked to keep his head in alignment since we have to remove the neck collar to intubate. It went relatively well. 

The CT chest came back and showed bilateral hemopneumothoraces — in English that means that his lungs were collapsed from air and blood leaking into the space surrounding the lungs. He needed chest tubes on both sides of the chest to remove the blood and air and allow his lungs to re-expand. And needle decompression on both sides because some of the air was likely due to a traumatic lung injury. 

After that was taken care of, one of the senior residents signed out a few of his patients to me. They all needed follow up of various CTs — one was in a car accident and needed a spine CT to rule out injury, another was having severe abdominal pain and needed a CT to rule out appendicitis, and a third needed a chest CT to rule out blood clots in the lungs. I told him I’d follow up on everyone and disposition them appropriately. 

While everyone else was taking care of the 15 year old, I went to try and clean up the rest of the ER. I saw the 18 year old brother of the 15 year old (also drunk and post stomping out) who had his 3 front teeth knocked out. He was in a bit of pain and needed a head CT to insure there was no other injury. I also picked up a leg laceration in room 1 and a possible rectal bleed in another room. I went to see the guy with the leg lac first so the nurses and techs could get it cleaned up for me while I went to see the guy with rectal bleeding. It was a busy night like I said earlier, and he had been waiting for about 4 hours. Someone had wrapped his calf in gauze and as I unravelled it it was clear that except for the outer 2 or 3 wrappings it was soaked through with bright red blood. Now that’s not good. When I had unwrapped it fully the injury was still bleeding and rather steadily. It seemed like it was rhythmically gushing although it wasn’t spurting or pumping like most arterial bleeds do. 

I called a nurse and tech in and had them get together a compressive dressing while one of them put some serious pressure on the leg. I went to grab an available attending. One was helping a senior resident place the chest tubes in the 15 year old and the other was seeing other patients who had been waiting for 4 hours overnight. I went back to check on this guy with the likely arterial bleed. I had them remove the gauze. Luckily I have decent reflexes and was able to side step the spurt of arterial blood that flew across the room. I ran to grab the attending and had them move the patient to a different room. I checked his x-rays and he had two nice pieces of glass sitting somewhat deep in his leg. Apparently he had come home from the bars with his girlfriend and had slipped and fell onto a wine glass. The stem of the glass ended up stabbing him in the leg. Just unlucky as hell. 

We ordered a CT angiogram of the leg which allows us to look at the vasculature and see which artery is injured and how badly. While all this was going on the CT scan of the spine for the patient who was in an MVC came back and was read as having no fractures, dislocations or other abnormalities by the radiologist. I put a note on the board saying “CT negative, home soon???” to remind myself to discuss it with the attending covering the case, who was currently still helping to put the chest tubes and decompress the 15 year old. 

The CT angiogram came back and showed that the artery was injured but not completed severed and there was still blood flow in the lower leg which is excellent considering the nature of the injury. I called the vascular surgeon on call, explained the situation and asked him to come in. I made a follow up call to the dentist on call to have them come and check my 18 year old with the knocked out teeth. His CT head was normal and I just needed a dentist to determine what else we needed to do with the teeth. 

As I was making these calls, the attending taking care of the 15 year old came out and asked what had happened to the guy in the car accident. I said that the CT was negative but I hadn’t had a chance to check on him. He said “Well he’s off the board… where did he go??” The nurse then popped up and said “The note in the computer said CT negative, home soon?, so I checked on him. He had discharge paperwork and scripts in his chart so I checked him out, he had no pain, so I sent him home.” I explained that the senior resident who signed out to me had done the paperwork before he left but that the patient shouldn’t have been discharged until being seen by the attending. The nurse maintained everything was fine, but the attending was about to have a break down and kill someone. Apparently the last time he saw the patient, he had still been complaining of neck pain and tenderness, which even with a normal CT spine can be indicative of an occult fracture. I apologized profusely and offered to pull the chart so I could call the patient at home and have him come back to the ER for a re-eval. The attending said he’d think about it. 

After all of this went down, I went to check on the patient with the arterial leg bleed. His pain was well controlled and he was feeling better. He needed to use the bathroom so I told him to walk slowly and carefully. Not 2 minutes later I hear a yell. As he turned the corner he began re-bleeding in his leg. Blood was pouring down his leg now as he hobbled back from the bathroom. We got him back on the bed, flipped him upside down and started pouring IV fluids into him. We were still waiting on blood from the blood bank. The trauma surgeon showed up and asked what the hell happened. I said “He needed to use the bathroom and I told him it was ok to walk. It was my mistake, it didn’t occur to me at the time that he shouldn’t walk.” She looked at me, looked at my attending and said “Well at least he’s smart enough to know he screwed up.” I spent the next 20 minutes applying pressure and trying to get a compressive dressing to stop the bleeding. Just as we had that accomplished, the OR called down for him to go up. I apologized for letting him use the bathroom and he said “Apologize for what? I sat in the waiting room for 4 hours before anyone saw me. You were the first person to see me and figured out what was going on. You made a small mistake, no one died. We live and learn, right? ”

The attending for the MVC found me the next day and apologized for flipping out on me. He said that the guy would have likely gone home anyway and after talking to the nurse some more it seemed like the patient really wasn’t in pain any longer. I apologized again and said that in the future I’d make sure to better communicate our plan with the nurses, especially with a patient who was signed out and already had discharge paper work in his chart. As for the guy with the leg bleed, they repaired the artery but he needs another operation in a month for some further repair. 

As far as mistakes go, these weren’t the worst, but that doesn’t really matter to me. A mistake is a mistake. To me both cases illustrated the need to run things by my attendings. I felt like I was handling everything pretty well that day and it just never occurred to me that I shouldn’t let an arterial injury walk to the bathroom. Thinking about it now, it seems obvious. At the time though, his pain was well controlled and he wasn’t bleeding. He was in good spirits and just wanted to take a piss. What could be the harm in that? Apparently much more than I had imagined. Which is why residency is here and why we have attendings backing us up. 

And not that I ever entertained the idea that I was perfect, but that day really helped to emphasize how easy it is to make mistakes in this job. Most mistakes don’t jeopardize lives, but they can add uneccessary pain and suffering. Thankfully my patient was understanding about the entire situation, but it doesn’t make it any easier when you go back over it in your mind.

14 Hour Days Aren’t Conducive to Blogging

But I’ve only got a few more days of this brutal rotation left and then an easier month working with Emergency Medical Services.  I’ve been saving some stories up and plan on expanding on some things I’ve posted elsewhere.  I can promise a story about a thoracotomy hopefully tomorrow or in the next few days.  Sorry again, but look at it this way.  The quieter I am now, likely means more good tales later.