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.