Wednesday, February 01, 2012
Eschars form at surgical sites, burn sites... they are scabs, deep ones, and sometimes when they fall off they start bleeding by pulling away the edge of a vein or an artery to which they are adhered.
The classic case for ER docs is the 'post tonsillectomy bleed'.... usually with kids... its seven days out from surgery and the scab pops off and BOOM, bright red pulsatile bleeding occurs and you better be ready with a good airway team because time is of the essence. It's always a trip to the OR for cautery or whatever the ENT docs are doing these days.
So this happened to me. In all seriousness, I won't be very specific, all my surgeons and docs did a great job, I'm not trying to nail anyone, I just had an infrequent but known post -op complication of massive bleeding after a small eschar popped off a high pressure vessel up in my oro-naso-retro-supra pharyngeal area. I survived and am doing well and there's only the remotest chance it will happen again in the next two weeks so I'm feeling pretty relaxed. PTSD much?
Rather than tell the story bit by bit I thought it would be more interesting to ask what would have happened to me if I were not an ER doctor who knew, the instant this thing popped, just what to do. See, I don't live near any MECCA and my local hospital had no one on call the night this thing went. But I knew all of this and was able to game the system.
Because of EMTALA, the life saving care I needed a few days ago was only available an hour away by helicopter. Our local hospital, now completely incapable of taking care of any surgical emergency after hours (and most surgical emergencies during operating hours) has simply become a way-station, picking the low hanging fruit of sick medical patients with insurance.
The complicated cases must go away because the specialists have gone away and they have gone away because they don't appreciate working for free more than twenty or thirty times a year.
Knowing this and while spewing vast amounts of bright red blood into my sink, I was able to instruct my life-partner (and ex-girlfriend) to say to the 911 operator "My husband is bleeding out.... We need an ambulance now.... the hospital needs to have trauma blood ready to transfuse.... Medic-Flight needs to be called now...." And then she pulled out the doctor card when the high school graduate on the other end of the line started asking things like, "...is the bleeding more or less than a teaspoonfull????"
Then she was able to speak directly with the local ER attending who knew me and knew this was the real deal and ALSO knew immediately that I had to be flown away as soon as possible.
And the local ER was great. They started tanking me with blood and, miraculously, the bleeding had slowed to a trickle, so at this point I was feeling very dizzy, but very good about my chances of making it to where they cold actually fix me. And obtw, JCAHO, your mandatory questions did get asked and were somehow just as important as the real issue at hand, and so for you JCAHO, I answered that I DO NOT feel safe at home, that I was NOT suicidal but, in fact, HOMICIDAL, and that I had lots and lots of guns in the house. Still waiting for the safety benefits of this mandatory JCAHO shit to accrue to me. Waiting..... Hmm, maybe those questions are worthless wastes of time.
Anyhoo. The Medic-flight crew wanted me to sit very still as they got me down to the place that still does complicated stuff. If that miraculous little clot were to dislodge then they were going to turn into a flying blood fountain with the flight medics desperately trying to get an airway in me at 4500 feet with me choking on my own blood. One of the nice things of this excursion was that my hero-clot stood his ground. Way to go Hercules!
Down at the place where they still do medicine and surgery that is hard I was a fairly routine case. The attending surgeon peaked in at one point and the Chief Resident and third year resident fixed me up. Nice work ladies and gentlemen. Really great.
And hey, anesthesia guys, I was just there last week and you fell for the "I'm allergic to succinylcholine" line again! It paralyzes me dudes! Every time! Glad you thought it was funny too. Oh, and nurse in the second ER, sorry about the "you guys don't have a Foley big enough for me" comment, but I was feeling it a bit, you know, realizing, I was probably not going to die.
So here I am. Walking around gingerly, trying not to sneeze or cough. Waiting for the chances of this popping off again to go close enough to zero to go back to my normal routine, and thanking God that I'm typing this, and wondering, just a bit, what would have happened if I did not know exactly what was happening to me when it happened, did not call ahead and get everybody from EMS to local ER to Medic-flight prepped for what was coming, and did not get lucky with a good weather night for helicopter transport AND get lucky with the availability of a bird.
In other words, what if I was Joe Schmoe? Joe would probably be dead, and he would probably be dead due to EMTALA. And we are trying to turn the whole deal into the 'model' built from the worst piece of medical legislation ever passed in this country.
But to end on a positive. Seeing what I used to do full-time through the eyes of a truly emergent patient made me proud to have been a part. You Medics and Nurses and Docs who continue to do this.... you are simply the best. I am proud to have played on your team. RW, you are a saint.