Conflicted

It's a strange feeling to have. Wanting to be correct about a diagnosis and trying to balance that with wanting nothing to be wrong with your patient. Often this is simply not a problem. If someone comes in near death from a heart attack or a stroke or from trauma these thoughts don't occur as everything is as black and white as it gets in medicine. Sometimes, though, I am the first person to see the puzzle, and I want to solve it with dash and style.

Case in point. Last night I took care of an individual with very vague complaints... "My back hurts, my foot Hurts, my tummy hurts" etc... The one thing he couldn't fake was his obviously tender and distended abdomen. I felt, after my exam, that his abdominal pain was from urinary retention and sure enough, after passing a foley catheter into his bladder, he diuresed over a liter and a half of urine (and felt much better). While doing this, however, he lost control of his bowels. I say this not for shock, but to add a clue to the diagnosis... He had urinary retention and fecal incontinence. He also had strange and varying pain complaints that could not be put together in a neat diagnosis. Except! Except for something like Multiple Sclerosis (click ''conflicted'' above for more information).

Multiple Sclerosis is rarely diagnosed in the ED and I was sure after further examination, thought, and research that this gentleman had it. He also had, by my exam, weakness in his foot flexor and extensor muscles making him almost a "classic" case.

I did all the preliminary stuff in the ED including a spinal tap and admitted the nice man after a good talk about MS and other possible diagnoses (I had only vague guesses). Today when I found out that his MRI of the brain was NORMAL and that other etiologies were being considered did I feel disappointment? Is that what it was? Maybe. And there's the conflict. I should have been happy but my pride was a bit affected. I wanted to make the ''zebra'' diagnosis and be the smart guy. I think it's a very human feeling but not necessarily a good one.

Two Sad Deaths

Mr. Brown weighed 650 pounds. He was 39. I have no idea how or when he gave up on life but he did. He died an undignified death the other day with his family and his pulmonologist deciding that the point of medical futility had been reached. I had miraculously managed to get his heart beating again after he arrested on the floor. Correction, me and an anesthesiologist and about 15 nurses. He "lived" another two days on a ventilator before the endotracheal tube was removed and he ceased to breathe. Really he suffocated. He was too weak to expand his massive chest. He was broken.

Mrs. Gilroy was also 39. She married a soldier and moved to this country from Thailand some years ago. She had a child. She got divorced. She lived alone. She had squamous cell carcinoma at the base of her tongue. I'm sure she smoked but it doesn't matter; she may have just been dealt the ace of spades in her chromosomes. She came into the ED with hemoptysis... coughing up blood. She was in the middle of chemotherapy and radiation therapy and she was unstable. Her heart rate was 150 and her blood pressure was in the toilet. She also had no platelets and so she couldn't clot to stop her bleeding. I told her in the ED that I needed to intubate her to save her life. She had been intubated before and when I told her I saw her give up. Her shoulders slumped and her face fell and I imagine she resigned herself to her fate. I almost couldn't get the tube in because of the distortion of the posterior pharnyx from the cancer. I knew she was going to die, I just didn't know how soon. I went to check on her yesterday and the ICU nurse told me she had died in the night. She never came off the tube. I don't even know if she had adequate sedation on the vent because the ICU nurses told me she was quite aware. She died alone and unable to speak, with all of us trying desperately to help but none of us able to. All in all a sobering week in the department.

How Does a Bomb Kill You?

If you click the link above you will be directed to a very fine report from Hell from Abu Musab Al-Zarqawi. Perhaps if he had turned his talents to composing rap lyrics he might not have had to kill to become famous? Through my laughter I remembered a presentation I attended during my residency about blast injuries and I thought it might be interesting to consider how people actually die in an explosion.

The primary cause of death in an explosion in overpressure in the bariatric-susceptible organs. The blast creates a huge pressure differential in the air which ruptures lung tissue and air filled intestinal tissue in a thousand different places. Death follows for those who are not literally blown to bits by respiratory failure, bleeding, or traumatic brain injury. Those in close but not lethal proximity to the blast will often have ruptured eardrums. Think of it like a firecracker exploding next to a balloon... the balloon pops.

If the blast does not destroy the respiratory mechanism there are a host of other problems an explosion creates for its victim. "Secondary" blast effects kill many... these include objects propelled into the victim by the blast or conversely, the victim propelled into an immovable object by the blast ("tertiary" injuries).

It sounds from reports like Abu Musab Al-Zarqawi survived the initial blast. I have heard it said, and must agree, that it is somehow satisfying to know that the last thing this murderer saw was a United States Soldier. RIH.

Wham-Bam

Had one of those days today.

At about 4 pm we had a shitstorm. My partner took a patient with an immeasurable blood pressure who was bleeding out his butt and needed to be intubated and transfused emergently.

I got tagged almost right after that for a patient who was already at our door with EMS who was coding. He was dead on arrival and we tried for a few minutes but when I saw with the ultrasound that he was truly in asystole and I also saw the 2 or three feet of garden hose that some enterprising vascular surgeon had used to connect his inferior aorta to his failed femoral arteries I decided that he had less than a zero percent chance of any meaningful recovery and I pronounced him dead.

As I was pronouncing this guy I got tagged again for a 50'ish dude having a huge anterior wall MI. He went to the cath lab within 20 minutes after all manner of meds and drips and hurried explanations of risks and benefits and likelihoods.

Then the winds died and all I had to deal with was a woman with neck pain for a month.

The "Hymen" Maneuver

I went in to speak with the family of a man who was severely ill and on a ventilator in the department. The patient's sister was in the family room and I introduced myself and asked, "Tell me what happened."

She said that her brother had "fallen-out" and that she called 911. She added that she started CPR and, "Just like the lady told me I did the 'hymen maneuver' with all my strength".

Horses are Strong Animals

If you can avoid it, don't get kicked in the face by a horse. Luckily the human face is a lot like an aluminum can. If you smash it it will collapse in stages.

A very nice gentleman walked behind his horse at the wrong time the other day. He came in to the ED completely F'ed up with his lower lip shredded and unable to move his jaw. I knew looking at him that he had multiple mid-face fractures. Our institution does not have the latest CT technology and I didn't want to scan him if we were going to have to send him to the trauma center anyway. I opted for the plain films first which, strangely enough, did not show any fractures. I didn't believe what I was not seeing and I asked our radiologist to look at them as well. We agreed to do a CT scan, and there they were, this poor guy had fractured from his mid-face extending into his hard palate. I sent him to the specialist down the road and he was probably heading for the OR for a relatively complicated procedure.

The frustrating thing about this case for me is that we have group of Oral-Maxillofacial surgeons right down the road from us but they gave up their hospital privileges and will not talk with us. Why? Turns out they don't like being forced to work for free. Priveleges at the hospital mean call at the hospital which means non paying patients etc... I don't blame them.