Agraphia Medical Tragicomedy

Futile

It was a shitty day.

Some days are just like that.  Instead of humor and good outcomes, everything is pathos and tragedy.  Kind, sweet old ladies suddenly and unexpectedly die horribly painful deaths.  Young children are neglected by parents high on street drugs. An unexpected cancer diagnosis brings a grown man to tears.

In the midst of all this, TRAUMA CODE 1, coming by chopper.  A 50-something woman found out her husband was cheating on her and shot herself straight through the head.   For better or for worse the human body is resilient, so her heart was still beating when he found her in the bathtub.  Medics were clearly shaken by the scene when they arrived.

She rolled into the trauma bay a mess.  The room was abuzz with malignant energy.  Everyone knew something evil had happened here.

It was immediately apparent that she had no chance of survival; brain tissue was matted all over the trauma stretcher.  Traumas like this are formulaic.  Medics give report as a room full of physicians, nurses, and techs stand alert.  The patient is transferred over to the trauma bay stretcher, IV's are placed while an intern calls out a physical exam.  Clockwork.

A few minutes in her blood pressure started to drop, quickly.  It's a hallmark of severe brain injury and is usually easily managed if recognized early. Still, drops in blood pressure are a sign of badness, a portent omen of things to come.

"This is futile," said one of the trauma surgeons with a roll of his eyes, "she's fuckin' done."

Something in me snapped.  "There are still lives to be saved here," I snarled, "get your game face on or get out."

Everyone looked at me, taken aback.  I'm normally the champion for palliative and hospice care, and I'm a huge believer in one's right to die peacefully.  We physicians have a hubris about our capabilities that I find offputting; the human body is far smarter than we will ever be.

Quietly, I explained.   "She's got a pair of perfectly good kidneys, a liver, lungs, and a heart that can save the lives of several people today.  If she dies today, they do too."

After that the room silenced, and we got her to the ICU for stabilization.  She's on the transplant list pending final approval.  I hope that in her final moments she can help others, even if she couldn't help herself.

Some days are shitty. Hopefully there's a silver lining.

The Time Crunch

I sometimes fail to realize how busy I really am during residency.

Just today I was looking at my schedule and realized that I'm booked up for the next month and a half; not just working 80 hours a week, but editing articles for the EMRA magazine, writing research proposals, submitting a publication to an academic journal, giving lectures, starting a new academic blog (stay tuned, readers!) trying to write an EKG book with a cardiologist... the obligations just go on and on.

I'm happy, and I hope I'm doing good things for this world, but damn, am I busy! All you premeds, med students, and laypersons out there... it's not easy. Rewarding, yes. Fulfilling, yes. But easy? Think again.

Snuff

"I'm really anxious about this procedure," he said, "can't you just knock me out for it?"

He wasn't just anxious. His hands were trembling, the telltale shakes of the withdrawing alcoholic... perhaps a clue as to why he stumbled in the first place, shattering his ankle. The ankle was in bad shape - both fractured and dislocated - and needed to be fixed.

Setting this particular fracture is extremely painful, and he would need to be sedated heavily. The chronic alcohol use would complicate things, but he denied any other drugs except chew tobacco.

Airway equipment? Check. Monitoring equipment? Check. Orthopedic Surgeons? Check.

I start with a dose of Versed and Fentanyl and he goes glassy-eyed, until the orthopods start going at his foot like a pack of wild dogs to a hunk of meat. He starts howling and I quickly push more meds.

And then, something goes wrong. He starts gurgling and a thin, reedy trail of dark spittle traces down his cheek. The oxygen levels in his blood begin to fall, fast. My heart starts pounding. This isn't supposed to happen. This is never supposed to happen.

I reach for the breathing tube, pause, and think better of it. I check his mouth - pooled in the back of his throat is a copious amount of discolored saliva. He's drowning on his own spit. I've never seen this before, but he reeks of alcohol and nicotine.

I go back in for another look and suddenly it strikes me that there is something wrong with his lip. I swipe my finger between his gum line and promptly pull out a huge wad of dip. No wonder he was salivating like crazy. I've seen patients do some dumb shit, but this... well, this takes the cake.

They say nicotine kills. In this case, it almost did.

Defensive Medicine

Getting ready to enter a patient's room last week, I overheard her speaking loudly into her cell phone. A snippet of what she said appalled me.

"... uh huh, I am going to MILK this accident for money. Naw, I ain't hurt at all, I'll be home for dinner. We gonna get ourselves a fat check from this one..."

Walking through the door, it was as if a lightswitch had been thrown. Suddenly she was speaking in whispers, tears flowing from her eyes, with excruciating neck, back, side, arm, and head pain. She swore she was fainting in and out of consciousness.

I found out later that a city bus had been nicked by a car and all the bus occupants had taken the waaaaambulance to the ER, like sharks to blood, in search of lawsuit money.

A very good friend of mine was on the other end of something similar, so I have become hyperacute to the role my medical charting plays in the legal arena. As such, I've started practicing "defensive" medicine... or put another way, ensuring that I protect everyone involved in an accident - and not just my patient.

In this particular case, there was clearly nothing wrong with this woman. Written all over my chart is "no suspicion of serious injury" and "completely normal physical examination". I even went so far as to give her a work excuse note specifically stating that she could return to work the next day.

Of course, this isn't to say that some people involved in these incidents don't have real disease. But when neither the bus nor the car have any damage - and you're yammering into your phone about how the lawsuit is going to put food on the table - well, I simply don't like to see people taken advantage of.

Good luck suing the city with that chart, lady. It's bulletproof. I went ahead and quoted your cellphone conversation, too, as I suspect a direct quote of "I am going to MILK this accident for money. Naw, I ain't hurt at all" doesn't go over so well in a courtroom when you're filing for damages.

The Fear

ADULT TRAUMA CODE 1, FIVE MINUTES OUT BY AIR.

A young man was riding his motorcycle, swerved to miss a log in the road, and was flung headfirst into a concrete barrier. He was acting funny when the medics arrived on scene and quickly became so combative that they had to sedate him for safe transport to the hospital.

This is a telltale story for a head injury, and one that can be terrifying for the medic ground crew. It often takes multiple paramedics and firefighters to restrain these patients so that an IV can be placed and sedative medications can be given. In this case, he rapidly decompensated and required a breathing tube.

Intubation is not an easy procedure in the best of circumstances. Anatomically, the human airway is positioned above the esophagus, requiring specialized instrumentation to provide clean line of sight. The airway itself can be unbelievably hard to visualize; so much so that the field of emergency medicine has devoted entire lectures, conferences, and books to airway management.

The paramedic was unable to place an endotracheal tube; always a bad sign. He placed a specialized oxygen mask on the patient, flipped on his lights and sirens, and sped to the hospital as quickly as possible.

And thus, I find myself staring at the most difficult airway I've ever seen. The patient weighs about 280 pounds. His tongue is so swollen that I'm not even convinced I can get a laryngoscope past it. Vomit is everywhere, obscuring my view. Blood pressure is dropping, heart rate escalating. An entire trauma team is standing around with scalpels, waiting to cut into his neck in morbid anticipation of my failure.

Pause.

Always pause, gather yourself. Ten seconds to focus.

Primary airway equipment ready, the backup in case it goes wrong, the backup for the backup. The room goes quiet. All eyes on you. It's an odd feeling, holding a life in your hands. This man is not breathing and you need to help him. Fail and he dies.

Things speed up as you grab the laryngoscope. The surgeons crowd around the neck, like bloodthirsty sharks waiting to take bites of flesh. They know that if you can't get the tube in place, they'll need to slice down to the windpipe to place it directly. It's a last resort.

Primary equipment fails. You switch to secondary. It feels like minutes but only seconds have passed. Your arm is shaking; he's a big guy and it takes muscle to lift things into alignment.

Secondary equipment fails. The surgeons prepare for the cutting; a messy, bloody procedure that leaves a jagged scar. Voices rise, a chaotic, frantic cacophony. You grab your third and last option. Your mouth is dry, your heart pounding. Suddenly, a small view of the trachea.

Tube to my hand, please, I can see the airway.

The room goes silent. Someone puts the endotracheal tube in your hand and you place it gently in position. You straighten up and realize 20 people are watching you. Your hands are shaking from the adrenalin. He's alive.

A glance at the clock. Only 1 minute has elapsed.