Wednesday, 12 July 2017

Actively dying

I have a confession: most of the patients I see are not actively dying, and I'm not a superhero.  I'm sure that will come as a shock and disappointment for some of you, but I cannot sustain this facade any longer.  But sadly it's true; the vast majority of the victims I see in my trauma bay are lightly injured at most, and some are completely uninjured (other than their pride, perhaps).  Car accidents, falls, assaults, even gunshot wounds and stabbings - most of the people I see are sent home from the trauma bay without even spending a night in hospital.  Those are the people I don't write about, because who the hell wants to read that dreck.

On the other hand, there are some who come in dead and stay dead.  Despite my best efforts and plenty of practice, my resurrection skills remain poor.

And THEN there are the ones at death's door.  These are the ones we feel really good about, the ones we talk about over coffee the next morning, the ones I write about.  They are the patients that give me pause, that make me stop and think, "NOW THIS is why I went into trauma."  They are the ones who make the commitment, the loss of time with my family, and the sleep deprivation totally worth it.  These are the "Great Saves".

Bosley (not his real name™) was a Great Save.  Except that I didn't save him.

"Hey Doc, if you didn't save him, why are you writing someone else's story?  Isn't that even more arrogant than usual for you?"

Didn't your mother ever tell you what happens when you make assumptions?  Something about U and umptions.  I don't remember.

Anyway, the story we got from the ambulance crew as Bosley was en route was strange enough, but it only got stranger after he hit the door.  We were told that Bosley was the driver of a car that ran into a building, which happened to be a chemist/apothecary/pharmacy/drug store.  Coincidence?  Perhaps, but perhaps not.

Hm.  Strange things are afoot.

By the time the ambulance got to us about 10 minutes later (just before midnight), Bosley was awake and talking, though something was definitely off.  I couldn't tell exactly what it was, but he just Didn't Look Right.  The medics were acting rather cavalier, however, clearly playing off the whole "trauma" thing as nonsense.

"Hey there everyone, this is Bosley.  He's 72, healthy, never sees a doctor.  He was on his way to the drug store tonight to pick up some medicine for a stomach ache when he hit the wall of the building, low speed, basically no damage.  But he lost consciousness, so with that and his age, we made him a trauma.  No sign of trauma on him, though.  Probably just fell asleep at the wheel, right Doc?" he concluded with a grin.

No.  A quick glance at Bosley told me that was not right.  Though he was awake he looked awfully pale, and he was a bit sweaty despite it not being very warm.  When he was hooked up to the monitor, however, his vitals were all completely fine - heart rate of 71, blood pressure 121/70, oxygen saturation 98% on room air.

Hmm.

The nurses started disrobing him and asking his medical history.  He had no medical problems, no prior surgeries, took no medicines on a daily basis, no allergies, doesn't drink, smokes 1-2 packs of cigarettes a day since he was 17.  Hasn't seen a doctor in 45 or 50 years.  I started my cursory secondary survey, trying to find any body part that hurt.  His head was fine, neck was fine, chest was fine, arms and legs were fine.  But when I pushed on his abdomen, I got a bit of a grunt in return.

Hmmm.

I asked him how much it hurt when I pushed, and he replied, "Not that much, Doc.  But it's been hurting me all day.  That's why I was going to get some medicine, to try to settle my stomach.  It hurts in my back, too."

Hmmmm.

"And I passed out in the parking lot.  That's why I crashed."

Hmmmmm.

Unfortunately it was right about this time when we got two walk-in stabbing victims.  Well, that's not exactly true.  Only one of them walked in, while the other had CPR in progress.  I didn't get a chance to examine Bosley more carefully like I usually do, but I glanced at his monitor as I rushed out to try to save the dead patient and saw that his blood pressure was steady at 120/75 and his heart rate was 68.

Good, I thought.  He's stable.  His CT scans should be done by the time the dead guy finishes dying.

It took me about 20 minutes to discover that the dead guy was dead because the knife had created a big hole in his left pulmonary artery (which is generally regarded as a Very Bad Thing), and as soon as I pronounced him dead I ambled over to the CT scanner to look at Bosley's scan.  The tech flashed through the pictures quickly, and something caught my eye.

WHAT THE FUCK IS THAT IN THE MIDDLE OF HIS ABDOMEN??

I took control of the computer's mouse and scrolled through at a more human pace, and what greeted me was a huge (and I mean FUCKING HUGE) abdominal aortic aneurysm.
Not actually Bosley's huge fucking AAA
It doesn't take a radiologist to see THAT LOOKS BAD.  That huge white thing in the middle of the abdomen is an abdominal aortic aneurysm.  In layman's terms, the main artery that supplies blood to the entire body was dilated to approximately 5 times its normal diameter, and it was surrounded by blood that had leaked out of a hole.

Let me repeat that in case the gravity hadn't set in: the aorta had a big fucking hole in it and was leaking.

Bosley didn't know it, but he was actually in danger of dying at any second.  He was literally a figurative time bomb that could literally explode at any moment.  Literally.

And just in case you think I'm being hyperbolous (why the hell isn't "hyperbolous" a word?), I grabbed the radiologist and dragged him over to the screen.  This was his exact reaction:
Oh.  OH!  Oh, oh wow.  Oh, uh that's bad.  That's really bad.  That's a ruptured AAA with a huge retroperitoneal haematoma.  He needs to be in theatre.  Wow.  Just make sure you MOVE HIM REALLY CAREFULLY.
The aneurysm had nothing whatsoever to do with the car accident but rather had been slowly growing over several decades and was related to his smoking and untreated high blood pressure and general lack of medical care over 70+ years.

Eighty two seconds later (I counted) I was on the phone with the cardiovascular surgeon on call, and 29 minutes after that (you're damned right I counted), he was standing next to me looking at the scan, and Bosley was waiting for him in front of the operating theatre.

His aortic aneurysm repair was completed about 4 hours later just as I was finishing an exploratory laparotomy and right colon repair for yet another stabbing victim that came in about two hours after Bosley did (of course).  He stayed in hospital for about 2 weeks before going home with several new prescriptions for high blood pressure and diabetes, none of which I suspect he will take.

It was a great save, it just wasn't mine.  Actually now that I think about it, Bosley's car accident saved his life.  If he hadn't crashed and had simply passed out at home, his neighbours would have probably found him dead on his floor several days later.

Well, I must be off as it's time for my resurrection practice.  Now was that wave the left hand twice and then pronate the right while incanting, or . . .

Shit.

34 comments:

  1. The correct diagnosis isn't always the obvious one. Case in point. I'd had a slight stitch in my side and a persistant cough for most of the day, and finally come mid-evening, after returning from a stroll, I began to feel light-headed and weak. My first thought was heat exhaustion (it had been a toasty day), and my wife helped put me under a shower. After about five minutes with no change (I've had HE before), I realized it might be something bigger, and the stitch had become a more general chest pain, focused on the left side. So off to the ER we go. They focused on the cough, and asked me (though coughing had become excruciating) to cough up a sample while they developed the chest x-ray. After painfully getting a clearish glob to come up, I hear "Nope, definitely not pneumonia. You have a collapsed lung." Nobody thought it was anything beyond an over-reactive patient with a chest cold. Ha!

    At least I know what that feels like should it repeat down the road.

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  2. Sorry to go OT, but look at the last comment on the NRO latest on Jahi.
    http://www.nationalreview.com/corner/449351/jahi-mcmath-alive

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    1. While this is very interesting, it does not belong here. Please keep comments on topic. Thanks.

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  3. The author of that piece is a lawyer with the Discovery Institute, a mock-science creationist outfit of ill repute.

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    1. I have witnessed, up close and personal (across the table at a birthday party), death from rupture of an abdominal aortic aneurysm. Alarming, but didn't seem like a bad way to go.

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  4. So Doc, you don't do AAA repairs? Not to say that you don't have mad skills already. I just thought trauma surgeons were trained to do everything except brain surgery, organ transplants & c-sections.

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    1. Not his scope of practice.

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    2. No I don't. I can repair an aorta that's been injured (if the patient is still alive, which they usually aren't), but replacing a segment of aorta is outside my area of expertise. Fortunately.

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    3. Can you perform a c-section?

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    4. I can, but I'd prefer not to.

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  5. Let's see 72 yrs old. He's lucky his case was surgical. Here in the US, if his case was medical, he'd be a perfect candidate for passive and active form of euthanasia. Get that morphine drip going. If his blood pressure drops we can always blame the patient for his previous smoking history habit. No harm. No foul. Euthanasia. A very common occurrence in hospitals today except they don't call it that.

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    1. If you're in the USA, way to go on a false way to portray America. If you're not, you're misinformed.

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    2. I see it all the time. An 80 yr old latina female gets admitted to ICU for mild pneumonia. Alert + Awake + able to communicate. No dyspnea or tachypnea. History of hypertension controlled by Lopressor. Patient on Medicaid. VSS normal. O2 Sat 96% on R/A. Family speaks no English. She received sedation during the night. She also received erythromycin. The next day she was non-responsive appeared to be in shock with her BP dropping. ABG showed acidosis (metabolic). Kusmaul respiration. She was intubated and placed on mechanical ventilation. Comatose. The attending physician then persuaded the family to make her a no code (DNR) since she was no longer responding to treatments. To make her comfortable the doctor order morphine drip and a couple of hours later she was dead. Now for the big error this MD made. Can you spot them?

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    3. Pt. was in diabetic ketoacidosis or impending renal failure. The E-mycin stressed severely compromised kidney function.

      The morphine drip potentiated the beta mediated vaso dilatation of Lopressor.

      Perhaps "mild pneumonia" was pain from renal colic seeing as how pt. was not dyspnic.

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    4. 1. No history of diabetes. Kussmaul breathing is also associated with severe metabolic acidosis (shock) not just DKA. 2. Morphine to relieve distress associated with Kussmaul breathing but the effects can also cause low BP and hypotension. It was necessary for the MD to get the DNR orders first before starting morphin. Mild pneumonia confirmed via CXR.

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    5. Very interesting, I'm just an old nurse.It's always fun to learn something. Back in the day, Kussmaul = DKA.

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  6. "The aneurysm had nothing whatsoever to do with the car accident"

    That's my be true but only in a limited sense - the converse may not be true. The car accident may have definitely been a result of the leak, some hypotension/hypoperfusion of the brain and not driving too well with a clouded consciousness. The aneurysm hadn't exploded so he may have gotten some partial tamponade which is why he didn't die at the scene. It's not uncommon to see nonspecific symptoms that are not easy to explain before one of those explodes. That's why they are sometimes hard to diagnose before they blow

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    1. Yes indeed, the accident was directly caused by the aneurysm rupturing and the subsequent haemorrhage.

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  7. well, technically, since you were the one who got everything under way, you still get partial credit for the save.

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    1. I agree - you identified the issue and made the arrangements to have it fixed. Obviously the fixing is important but your handling got him to the theatre alive, which sounds like it was no small feat! The cardio' surgeon might be the best in the world but a minute or two with no aorta would put our Bosley beyond the help of anyone.

      Ugi

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  8. My husband had an ultrasound twice by his cardiologist to check for a abdominal aneurism. He is overweight and smoked for over 50 years. Finally quit after retiring. I hear wheezing at times but he denies he has a problem.

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  9. You're still my imaginary superhero. :)

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  10. It's interesting, and slightly worrying, just how much damage your internal organs can sustain without you feeling *that* bad. I managed to lose 90% of kidney function over a period of a few weeks; until the later stages the main symptom was my cycle-to-work times getting unaccountably worse. Plus, a BP of 220/200 gave no obvious symptoms..

    And a friend at work managed a large lung tumor with brain secondaries with only a slight headache. It's enough to make you paranoid..

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    1. story from a coworker of a coworker of HIS who went into the doctor for stomach pain. said they sent him to a surgeon, who opened him up, took one look, stapled him closed, and told him, "if you don't have a will, you should write one. if you don't have a pen, I'll loan you one."

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    2. A lady I knew from church went to the doctor because she thought she had kidney stones. Surgeon found it was stage 4 overran cancer. She died less than a week later.

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    3. my grandmother survived breast cancer at the end of the 70s. a few years later, she developed hip pain, and her doctor diagnosed it as bursitis.
      in the late 80s, she slipped on their front step, and broke her hip - when they opened her up to pin it together, they found it was bone cancer - and there wasn't enough bone left to pin together. she held on long enough to celebrate their 50th wedding anniversary, and died a few months after.
      my grandfather married his next door neighbor (who had been recently widowed, herself) about a year after, and it is probably what kept him alive.

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  11. My father always tells me to never go to a doctor that has been in practice for more than 40 years. They tend to be lazy with a big attitude and hates questions. He says young doctors are better.

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    1. I think young doctors are smart, yet arrogant. I think old doctors are a bit set in their ways but not afraid to admit they made a mistake. I'd take old over young any day.

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    2. and the ones in the middle are either arrogant AND set in their ways, or smart and not afraid to learn.

      the challenge is finding the latter.

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  12. Well... I have CMT and just thought A, I was seriously losing my mind or B, CMT was progressing faster than the rate I ever expected, but after many falls, more often than expected it was the double vision that took me to the ER to be diagnosed with a brain tumor. In a very bad place. I think we all 'ride it out' thinking sure it'll get better! Before we know we have to do something about it.

    CMT is short for Charcot-Marie-Tooth disease. I have type 4C.

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  13. I'm not a superhero. <<< Let me gues. An aversion to wearing underoos on the outside and not having the legs to rock tights?

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    1. For the record, I look fantastic in tights. Probably.

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