"Let grief be your sister, she will whether or not"

The paramedics call to base for support for a PNB, which is run-of-the-mill, two or three times a shift. Either they have brought the patient back, or they want to stop, or they want to keep going, and they need our OK.

They called from the middle of a basketball court, doing CPR in the center circle on the son, cousin, and uncle of the well-dressed audience, watching and holding each other. A twenty-year old who collapsed stone-cold dead between the second and third free throw, falling backwards.

Round three of the typical three is already done when they call, asking for transport, for continuation; reaching for the refuge of hope that drugs like bicarb and lidocaine after amiodarone represent, some extra tool to throw at death when you're not ready to give up yet.

Everyone there did everything right. The coach started CPR, the EMT basic delivered one shock before the paramedics got there, they placed a combitube rather than an ET tube and ran the show. IV was placed on arrival. By the time they called me, though, it had been almost thirty minutes. Move to the rig. Move to the rig, out of the gym, away from the people all around. I ask one or two times, are you comfortable going 1099. Negative, they say. The mom is with us in the rig. OK, then. Come to the hospital.

The team knows this is theatre, to some extent. That doesn't mean we try any less hard, or that our compressions are too shallow, or that we breathe at the wrong rate. It means as soon as he rolls in, CPR still going, sadness rises in place of hope.

At the head, I see his fixed and dilated pupils; the c-collar in place because he fell backwards and maybe it's trauma, I take off, because it's not trauma, it's a heart that got too big for itself. With the first pulse check the tube is placed and confirmed. We do three rounds of drugs, CPR all the time, switching every two minutes, stomach decompressed. I can see mom ten feet from the foot, being held, eyes fixed on her son that an hour ago was running up and down the court. Not prowling the street selling drugs, not driving drunk, not stabbed by some dude while minding his own business; not doing the things so many of our other visitors do.

Our staff gives the warning shot. I'm going to tell mom it's not going well, he says, and one more round.

The nurse keeps the alarms off. Only the sound of 100 a minute compressions and 10 a minute bag-valve-mask ventilation. It's a soft sound. Rhythmic. The sound of our best tool, our best way to keep someone alive in the short term. The sound of failure.

We stop. A door shuts for the others in the room and mom drops to the floor, wailing and gasping for air. We help her to a cot to support the weight she cannot support herself. She breathes underwater, eyes on nothing.

There is no question of why. I know why this happened, the story is the classic presentation of this. No, there's no 'why'. There's just the next patient, and a sensation over the back of the head as if a window were just opened on a winter's evening, as the stickers are taken off and our patient is covered with clean white blankets.

Holy Crap It's Been ForEVER

...since I last posted. Sorry!

I've been at ACEP and looking for jobs and generally trying to live life while also remodeling a flooded basement and just being a resident. Somehow that interferes with posting. I'll try to post the best nuggets from the conference as I go through all the syllabi.

A large, large man came in the second to last shift before I flew out with chest pain. He was a mountain. Chest pain, of course, is our most common complaint, so I went in to talk to him without thinking much about the differential.

Where do you have pain?

Right here, he says, indicating his ICD which is so new he has only a partially healed surgical scar over it.

Did something happen to it?

Well, yes, my girlfriend punched me in the implantable cardioverter-defibrillator (ICD), two times. Like, hard. And I think it went off and now it hurts.

Um, OK. I walk back out of the room and pull out the algorithm for people punched in the ICD by their girlfriend, which we have filed right behind the STEMI protocol. Interestingly, all pathways end with 'get a new girlfriend'. And, admit them to the hospital for an ICD interrogation and cardiac rule-out. You never know. Maybe he was having ischemia at the same time he got punched twice in the ICD. God I love my job. The hardest part was not laughing. I think I actually did. I think I might have also told him to get a new girlfriend, a vital part of my patient education.

A What Scratched You?

I officially have a new favorite chief complaint by ambulance. Mouse scratch.

Paged out as such, I didn't know what to expect but at 3 am I was ready for the worst...not really. I was ready for what I got.

There were tons of mice in my house, one ran over the covers or over the bed, I freaked out, and while I was scrubbing myself down with alcohol solution and soap my leg stung and I noticed this tiny l'il scratch about 5 cm long that barely broke the skin. Oh yeah, I'm wearing a finger splint with a sharp edge on it. But I was worried it was the mouse that got me and maybe I need rabies or tetanus.

Um, tetanus OK. Rabies no. More importantly, since it's three in the morning and you're the only to be seen, how many mice exactly?

Mice on the curtains, mice in the kitchen, in the closet, in the bedroom, kids screamin', can't do their homework, traps out catch ten at a time. OK, so, um, you don't really need me. You need some dude with bad chemicals that has to wear rubber gloves that'll fix your problem. Needing a tetanus shot is, well, the least of your very disturbing, disgusting worries.

Third world at home, folks. Third world at home. Instead of the taxpayers picking up the am-boo-lance ride, perhaps we should pay for the exterminator.

FYI, CDC tetanus recs: booster if more than five years from past tetanus booster. Immune globulin for those who have not received their normal immunizations, or who are unknown. So-called 'clean, minor wounds' can wait up to 10 years and should never get immune globulin, but I rarely see that happening.

CDC recs for rabies are more compliated. First, what animal. If a dog, cat, or ferret--i.e., pets--no treatment is needed unless the pet is thought to be rabid, so if you have the pet, you can watch it. If wild--i.e., scary furry critters like racoons, skunks, foxes, or, notably, bats--immunize as below. If livestock, call public health. Gerbils are probably OK.

Treatment is irrigation with povidone-iodine or the like, rabies immune globulin at the site of the wound AND at a distant site if you can't infiltrate all of it, in addition to the rabies vaccine at 0, 3, 7, 14, and 28 days, in the shoulder, not in the tummy like I was afraid of when I was a kid. Apparently according to another blogger this just changed with ACIP but not with CDC; perhaps we'll be able to skip the last dose.

photo credit

Multi-Tasking

Finally, got a real night shift.

At one point, I was gowned up holding direct pressure on a spurting radial artery wound after some dude had punched his way through a window. My headset (yes, we wear headsets, and they're only slightly metrosexual) goes off asking me to come to the trauma bay to supervise an airway as we do for any trauma during our second year. I get someone to take over for me and walk down towards the bay, talking on the phone to hand surgery. I don't even know the name of the radial artery bleed, only the room, since I walked in on the heels of EMS. I re-gown for the airway, check the tube and end-tidal CO2, manage vent settings, and while I'm placing an OG tube the radiologist calls me, also on my headset, to tell me about a new cerebellar stroke found on the patient right next to the radial artery bleed.

Despite myself, I smile. This is EM. I realize deep down that it all makes sense. It was the right choice.

Also ran my first PNB over the EMS radio and tubed a drunk lady with a huge laceration of her posterior while wading through the headaches and abdominal pains and two decompensated cirrhotics.

picture credit, an interesting blog on communication found by an image search for 'multitasking'.

Life-saving skills

Stuff that saves people is cool. We can all accept that. The things that really save people, though, are usually not what we expect. Helicopter transport, hypothermia with a cool machine that self-regulates, ICU care, monitors that beep and whistle, recombinant clotting factors that cost more than an SUV per ounce, those save people, right?

Um, maybe; but things that actually do are often eerily simple. Good chest compressions. Needles in the mid-clavicular line. And airway management--with a mask and a chin lift.

Terrifyingly recently, anesthesiologists would do a suprising number of cases without intubation and without a machine, just bagging the patient with an ambu bag. You breathe for the patient, literally.

On peds anesthesia this week, the best cases were the ear tubes, becuase for five minutes or so it'd just be me and the bag and the patient not breathing. This skill, as much as intubation, saves lives. Just a bag. No big fiber-optic scope, no fancy stainless steel LED-lit laryngoscope or, as my trauma surgeon called it, 'dog and pony show'.

It's all well and good to talk about lifting the jaw up into the mask with your pinkie, ring and middle finger spread from behind the jaw to the chin, but like any motor memory task, it takes time to learn it. Once you do, there's no feeling like holding the jaw up, squeezing the bag, and watching that little chest rise just enough to avoid inflating the stomach while still giving them oxygen. And to think we walk around normally breathing without even thinking about it. Want to manage a person's airway? Learn to bag. Don't know what to do with a failed airway? Learn to bag. Save a life.

/sermon.

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