Monday, 9 April 2018

Compartment syndrome

NOTE: I realise I have not published any new posts in 4 weeks.  That is highly unusual for me, and I do not expect it to become a trend.  This was a combination of a dearth of interesting stories and a well-deserved holiday.  It turns out {redacted} is quite nice this time of year.

There are several absolute surgical emergencies in trauma.  These are operations which need to be done right now (or ideally 30 minutes ago) in order to save a life or limb.  Some are rather obvious:
  • active arterial bleeding
  • open skull fracture
  • intestines outside body
  • hole in heart
Some are decidedly less obvious:
  • bowel ischaemia (loss of blood supply to the intestine)
  • compartment syndrome
That last one is probably one you've never heard of, but it certainly belongs on the "Get To Theatre Now" list.  In short, the pressure inside a compartment (leg, arm, abdomen) rises higher than the systolic blood pressure, which then essentially chokes off the blood supply to the things in (and beyond) that body part.  Massive bleeding or swelling in the abdomen, for example, causes blood supply to the intestines and kidneys (among other things) to be cut off, leading to acute renal failure, bowel necrosis, and rapid death.  Injuries to the lower leg can cause swelling of the muscles in any of its four compartments, leading to muscle death, eventual limb death, and even more eventualler (that's a technical term), death.

Diagnosing lower extremity compartment syndrome is fairly straightforward despite its relative rarity.  As the swelling worsens and blood supply is gradually cut off, it presents with the 5 P's: Pain, Paraesthesia (decreased sensation), Pallor (paleness), Paralysis, Poikilothermia (inability to regulate temperature), and finally Pulselessness.  Anyone with a cold, insensate, paralysed, pulseless leg needs emergent surgery.  Now.  NOW.

NOW!

Unfortunately there is no medical treatment for compartment syndrome.  The only available recourse is to open the affected compartment to allow the contents room to swell and expand, thus re-establishing blood supply to the dying tissue.  Without it, the limb will die within a few hours, as will the patient not too long afterwards.

And Erik (not his real name™) had compartment syndrome (not his real diagnosis™).

I'll explain.

It was a rather slow day, though I made damned sure not to remind the Call Gods of this fact.  One of the nurses seemed not to give much of a fuck about the Call Gods, because out of nowhere I heard "Gee, it's been rather quiet today."

WHAT THE FUCK DID YOU JUST SAY?

Not five minutes later, the phone rang.  Of fucking course.  It was Outside Hospital (not its real name™) with a trauma consult.  Sigh.  These are rarely interesting, usually rib fractures after a car accident or facial fractures after an assault.  My ears seldom perk up when taking these consults.

"Hell Doctor Bastard, I'm calling from Outside Hospital.  I have a guy here with compartment syndrome I need to send over right away."

My ears perked up.  Something real?  On a slow day?  I waited for the story with bated breath.

"His name is Erik.  He is 29 years old, was struck by a car and was seen here earlier, but he looked ok so we sent him home.  He came back because of persistent pain in his left leg.  The leg is swollen and tight, and he needs to be decompressed."

Well now, this is some real trauma!  Huzzah!  But before the fanfare and sending troops to get him, I needed some additional information.

Me: Ok, does he still have a pulse {the pulse is usually the last thing to go}?
Her: Oh yes, it's normal.
Me: Well that's good.  How is his sensation and motor function?
Her: Normal.  He's been walking just fine.  Actually he said his pain is a little better today.
Me: ...
Her: Hello?
Me: Um, is the leg cold?
Her: No, it's warm.
Me: ...
Her: Hello?
Me: ...
Her: So can we send him over?
Me: ...
Her: Hello?
Me: This doesn't sound like compartment syndrome. At all.  He has a warm, sensate, normally functioning leg with a pulse?  And you said he was hit earlier today?
Her: Oh no, not today.  The accident was 16 days ago.
Me: It was . . . wait, WHAT?
Her: He said the swelling got worse, but it's been better the past two days. 
Me: ...
Her: So can I send him over?

WHAT. THE. FUCK.

The major problem was that I could not afford to say no.  If I told her to send this ridiculous-sounding bullshit consult home and he actually did have compartment syndrome, he would lose his leg and I would deserve to lose my licence.  So I grudgingly accepted the transfer (but not before thoroughly educating the emergency doc on what compartment syndrome actually is), knowing full well I would most likely be discharging him from my trauma bay 20 minutes after he arrived.

But I was wrong.  It was 15 minutes.

He walked into my trauma bay (yes, really) 5 hours later.  His leg was not cold, it was not tight, it had normal sensation, and it had a normal pulse.  In fact it was barely swollen at all.  And all his bruises were in their final stages of healing.

The good news was that the Call Gods must have taken pity on me, because they sent me nothing the entire rest of the evening.  Don't you worry though, they got their revenge next time.  But that's a story for another time.

41 comments:

  1. Hurts like crazy! First ED sent me home.said to tough it out..looked like cellulitis, see my md on Monday. Different ED a few hours later. My ortho was there by chance..he took one look and said 'I want her ready for surgery in 20 minutes, no more'. Still have 2 arms�� Though the one took a year to heal (collagen deficiency) and has RSDS..thank God for surgeons!!

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  2. Former CNN Space correspondent Miles O'Brien lost part of an arm to compartment syndrome. If I recall correctly, a flight case of reporting/video gear fell on his left forearm while he was stacking them. Went to hospital the next day and it had to be amputated.

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  3. Welcome back Doc, all rested for the next exciting episode of Doc Bastard : The Blog

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  4. Sounds like whoever sent him over needs a neurology consult.

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  5. Sounds like defensive medicine. You screw up your get sued for millions.



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  6. actually, I HAVE heard of it. haven't experienced it, directly, though. but I will make a point of keeping it in mind. sounds like one of those things where it might be useful to be able to tell the paramedic, "the patient's limb is tight, cold, insensate, and has no pulse."

    kind of like being able to tell the paramedic, "the patient's grip strength and facial expressions are asymmetrical."

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    1. Heck, you can get ACS when you lie down in a position that blocks a blood vessel for too long. It’s defensive medicine. That’s exactly what this ER doc did. He played dumb and passed the ball to Docbastard, and doc didn’t even know it. It’s an old ER trick.

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    2. and you really think this didn't get back to the outside hospital administration? and you don't think Doc had an inkling right around the "how is his sensation and motor function" question, Doc figured out outside doctor was being a bum?

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    3. Do you really believe that a surgeon like Docbastard would report this sort of thing to the administration? Good luck on that one. Not unless the other doctor was drunk, high on drugs, or highly incompetent. Go ahead and ask him. I triple and quadruple dare you.

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    4. I know in a for profit healthcare system, if nothing else they would get a bill for it.

      but it sounds to me like you have already asked, so I will just clarify it a bit.
      doc, when outside hospital does something like this, does it come back to them?

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    5. Yes, it gets back to them if it gets reported. Which I did.

      I hope you feel appropriately silly for making such an assumption, Anon. And if you think for one moment that I didn’t know exactly what the emergency doc was doing, then you made another bad assumption.

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    6. Docbastard, well, in that case, I would assume that you don’t practice here in the US. Because NO surgeon in the US would ever miss on the opportunity of getting the heir surgical consult.

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    7. and you're doubly silly for trying to sneak around the back to out Doc; because self respecting medical professionals in the US DO place their patients' health above their or their employers' income. not to imply that I know where Doc lives and works.

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    8. Like you’ve worked Medicine.

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    9. yeah, sure, I have absolutely no contact with the healthcare industry.

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    10. Having contact with them doesn’t make you a physician, Ken. Let’s be clear with that.

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    11. Anon - Your knowledge of surgeons and our attitudes is, as expected, lacking. None of my colleagues would have put up with this kind of bullshit without a complaint.

      That said, I neither know nor care what your problem is either with me or Ken. What I do know is that this pissing match you seem to be having in your head with both of us is officially over.

      I expect not to have to repeat myself.

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    12. No surgical consult.

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    13. When I was in Med School many years ago, we learned that Inadvertent or deliberate critical comments by one health care provider concerning another are dangerous. These encourage claims by reinforcing in the plaintiff’s or the plaintiff attorney’s mind that someone did something wrong, or that this case will put defendants at odds with one another and almost assuredly will guarantee a hefty settlement or judgment at trial. That’s why you’ll never find a doctor in the US criticizing another doctor.

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    14. Really? Cause i see and hear doctors criticizing each other all the time. Can ask the few doctor friends/aquaintences as I have specifically about it as well. I can assure you, that is completely false

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    15. I seriously doubt what you’re saying. Ethics, people. It is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician. It’s considered unprofessional conduct according to the American College of Physicians Ethics Manual.

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    16. You seem to have missed a very key clause at the end of that statement - “without substantial evidence”. Saying another doctor is an idiot is unethical. Criticising care when it has actually been inadequate is not.

      Surely you left that part out by accident, right? Surely you wouldn’t cherry pick on purpose, right?

      Here’s the part where you admit you’re wrong and move on.

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    17. Irrelevant.

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    18. so you're saying you've got a chip on your shoulder because you flunked out?

      just a guess.

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    19. Oooooh, I see. You consider the most salient part of the phrase irrelevant because you can’t admit you cherry picked it because it proves you wrong. Got it.

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    20. Never knew it was so easy to flunk out of Google University.
      Since clearly thats the only place thatd ever accept his bullshit

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  7. Your a surgeon with a blog. Not a blogger with...a surgeon...
    And doctors deserve vacations. Long as this isnt to often we wont fire you.
    Yes thats how this works.

    Also moment i saw outside hospital i knew the guys injury was a week or more ago

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    1. I would have said a blogger with a scalpel but that’s just me!

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    2. we just worry there has been an epidemic of common sense in the community of (redacted)

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    3. Ken you know thats nearly impossible dont be silly.

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    4. I can be as silly as I damned well please.

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    5. Speaking of damned silly...what do you think of Station 19, Ken?

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    6. I was yelling corrections at the screen before the opening credits.
      but it's not as bad as emergency 911 or whatever the title is.

      it's a soap opera first and a procedural second, but it gets something close to right, once in a while.

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    7. check that - this episode was even more soap opera and even less (correct) procedure. and that goes for both the fire AND the EMS side.

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    8. "From the producers of Grey's Anatomy"...Kind of what I expected. It's strangely nice to have people who actually KNOW what I'm watching is BS.

      Doc for Medical, you for fire/EMS, and another friend of mine who works for DoC (Let's talk OZ, shall we?). Thank you all!

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    9. or maybe I'm wrong, is it customary to use a BVM on the patient after they've spontaneously resumed breathing on their own after a field cricothyroidotomy because of inhaled glass fragments from exploding wine bottles?

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    10. Exploding wine bottles? Where do I sign up??

      My husband tore his bicep and it tore the vein in his arm that runs along the bicep, his arm swelled up and turned black.. We were in the ER for hours while they tried to control the bleeding, and had surgeons debating on surgery, and then they had to watch for compartment syndrome.. Took the bleeding a day to stop, I have the gnarly ass pictures some where..

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    11. same channel as Gray's Anatomy, since it is a spinoff. (and it's getting worse on the factchecking side)

      hope hubby is improving. been worried about you, you've been absent a while.

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    12. Blogger with a surge

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  8. I just found your blog, and it’s wonderful. I came across this post and thought “holy shit” my mom had that 18 months ago. Her left leg was swollen, she went to 2 hospitals in southern rd, they sent her home. By the time she went to the 3rd ER, I got a call (in Chicago), that the surgeon didn’t know if she’d make it. She did. With an open wound for a few months and a fail on the skin graft. She spent weeks crying on the phone to me about how she was so afraid to lose her life and how she needs to eat healthier. I’m truly worried, she’s 340 lbs and hasn’t yet begun to lose that weight. Each time she flies, it freaks me out. I’ve started going to the gym and changing my own life due to her issues. Anyway, it touched a note with me. Have a nice weekend. - heather

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