Thursday, April 09, 2009

Tarheels Romp Through 'The Dance'

As my favorite basketball team was winning a game en route to the national title this is what I was doing. I have never seen overwhelming sepsis take a patient from me like this. This case would be a 'Grand Rounds' case at about any teaching hospital, but instead it happened in my little ER on a warm spring night.

When you let yourself get to 428 pounds as a 21 year old you have made some choices that will impact you for the rest of your life. In this case the impact was a sudden death in spite of everything we could do. We worked on her for about thirty minutes longer than the MECCA would have because we could. Academically speaking the last thirty minutes was futile. But we had met the family and we had seen the tears and we did not want to let her go even though we all knew.

When you become very ill and you have chosen to forgo health insurance you are in big trouble (in spite of EMTALA). Not only are you less able to see a physician when you first get ill, but just by me telling your story to a receiving facility over the phone it becomes obvious that you do not have insurance and the availability of ICU beds is mysteriously effected. The only cure for this is for the government to pass SUPEREMTALAHIPAA which will prohibit description of the patient in any way when transferring from one facility to another. Any information given might lead one to a correct inference about insured status. It will go like this...

ME: "I have a patient for you".
RECEIVING FACILITY: "Okay."

In all fairness the die was cast long before I saw this patient. She ignored her symptoms for too long and got to us a few hours too late and even the MECCA could not have saved her at this point. Her girth made central lines impossible even with ultrasound guidance. We could not even Doppler a femoral arterial pulse. And within a few hours it was all over, the last minute of CPR pictured here with 10 ER personnel trading turns trying to get enough blood out of her heart to perfuse her brain.

All of us in the room bit our nails to the nub as we watched all our interventions fail; gorillacillin IV, fluids wide open, pressors that would make you or me bleed inside our brains... dopamine, levophed, neosyneprhine, epi... failure. Then asystole, then PEA, and a dead heart on the ultrasound. No movement... not even the flutter of a valve, and all our puncture sites pouring blood while the extremities clotted off and she bled into her gut.

Go Tarheels. They were clearly the best team this year.


* picture altered from original

11 comments:

  1. just recently unsuccessfully coded a 660 lb. 33 y/o...same scenario you described What I remember is the 2 people trying hold up his abdomen to attempt a femoral line, sweat pouring off of them. Indigent with the only person interested in him was an equally indigent girlfriend. He couldn't fit in our morgue so he stayed in the room all night with the air conditioner on till the crematorium could get him in the a.m... I later found out he wouldn't fit into their "facility" either. I don't know the final disposition of his body.even in death his size worked against him.

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  2. About 5 minutes after the game I remembered that sports are over until Labor Day. Now what the hell am I gonna do with my time? Guess I'll go on a diet.

    GO 'Heels!

    Damn, I'm gonna miss that big ol' goofy white guy.

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  3. Posts like this remind me why it's a good idea to exercise.

    I'm off for a run docs. Sorry about your patient, 911.

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  4. This is the PSA that should be used in lieu of "eat the fruits and veggies." It is this scenario that scares the bejezuz out of people.

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  5. Dead bowel? Ascending cholangitis?

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  6. Whats all that white powder? Were you guys doing cocaine in the ED?

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  7. I think it's Talc from the gloves...leaves a telltale track of everywhere you've been touchin yourself...another good reason not to wear Scrubs outside the OR..

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  8. In the EMS days, we got toned out for a 40-ish 630 lb. DOA, not to work the pt, but to transport the body to the mortuary (nobody had transport big enough). We barely got the body in the truck and had to leave our bariatric stretcher in the funeral home since they didnt have a gurney big enough either.

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  9. I was reading a book that suggested people from Northern (colder) climes have a much larger tendancy to generate body fat, in order to keep warm. Transplant them to warmer areas, especially where there's an abundance of food, and it can be very difficult to keep the weight off, since there is a much stronger urge to eat, to prepare for cold weather.

    It still doesn't excuse people from letting themselves grow to 300+ lbs, but genetics can make self control much more difficult for some people.

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