I knew he was dying the moment he came in and I watched him slowly die. I was called to the bedside on three different occasions to evaluate a man with shortness of breath. The first time, he got a stat duoneb and got better. The second time, he was hypotensive. We put in central lines and started dopamine. A stat cardiology echo showed something flopping around in his right atrium and ventricle. Was it a clot? A ruptured cord? The third time was after his massive PE had reared its ugly head once more. This time I didn’t leave the room until he was dead.
We intubated him and he became bradycardic. His sats were in the 80s. It was really inevitable and everyone in the room knew it. His wife was at home, she can’t drive at night. We told her that he was very sick and might die. She said, “I knew he was sick, I told him to go to the hospital sooner.” We could squeeze all the oxygen into his lungs that we wanted, but that wasn’t going to get rid of the clot in his pulmonary arteries. Cardiology considered doing thrombectomy. The whole time we watched his heart rate slow. We all knew he was dying, and all we could do was go through the motions of a bradycardic arrest, which was of course followed by a PEA arrest. Occasional episodes of asystole prompted rounds of CPR. I even put in an external jugular 16 guage IV…his femoral veins were full of clot and the meds just wouldn’t flow. SO that was it. We gave up after about 40 minutes of CPR, Epi, Atropine, Fluids and more. Four attending physicians…ER, Cardiology, Cardiothoracic Surgeon, Invasive Cardiologist, all standing at bedside helpless.
Tetanus is a rare but deadly disease with only about 40 cases seen per year in the US. THis year, 2 cases came through our emergency department, both seen by the same resident, a colleague of mine. Think about those odds. less than 1 case per state per year, and my classmate has seen 2 cases in one year. What did those cases have in common? As with all tetanus cases, lack of immunity. Immunity comes from immunization, as in Tetanus booster shots every 10 years or sooner for a dirty wound. The schedule also differs depending on whether or not you’ve ever had your original series of three primary vaccinations as a child (or adult).
So why did our ED see 5% of all the tetanus cases in the US this past year? The high concentration of Amish in the area also means a high number of unvaccinated children.
On another note, Americans over the age of 60 are at SEVEN times greater risk of tetanus than those less than sixty. Why? Lack of booster immunizations. The CDC states that
“Every contact with the health-care system, particularly among older adults and IDUs, should be used to review and update vaccination status as needed.”
I gave out three tetanus boosters today, and inquired about many, many more. The emergency department is a prime location for screening for outdated tetanus boosters. The majority of the time, in fact EVERY time until today, patients are happy to get their booster sensing on some level how imporant it is.
SO I was a little shocked when I asked a man in his 70s when his last tetanus booster was. “Back when I was in the Army,” he said, which was over 30 years ago. “How about if we give you a booster today?” “No thanks, I’ll be OK,” he replied.
Well, fortunately, thanks to a litte EBM (Evidenced Based Medicine) knowledge…which just means that I was paying attention in lecture one day…I was able to inform him that the majority of tetanus cases in teh US are in people over the age of 60 due to lack of booster immunization. It described my patient exactly. He was more than happy to wait for one after hearing this.
Well, the holiday frozen turkey toe and foot injuries were not as numerous as I had imagined they would be. Only one real frozen turkey injury. But plenty of other holiday traumas…
1 Finger laceration while washing dishe
1 Toe Nail avulsion while moving deceased relatives belongings out of a nursing home
2 pediatric facial & head injuries from playing with cousins
2 fractured metacarpals (both on the same hand) from go cart riding
1 (and only one) dental pain
1 pediatric fever
1 arthritis pain
1 very needy, tearful, chronic ankle pain. (why tonight?)
It was the kind of game you love to watch. Two conference rivals, battering one another, trading leads througout the game. We get a field goal, they get a touchdown, we get a touchdown, they get another, finally we score again. There are less than three minutes left in the game when we sack their quarterback in the end zone…Safety! Two more points, further sealing the pending victory by the good guys.
I’m hiding in an empty patient room, watching the last two minutes of a great game, most of which I’ve missed because I’ve been seeing patients in the ED, and it’s been busy. THen I hear overhead, “Adult code team, emergency department…adult code team, emergency department.” The first thought that comes to mind isn’t “GREAT, another life to save!”, but instead, “CRAP, I’m going to miss the end of the game…I’ve only gotten to see one play”
Moments later, an ambulance rolls in the door with a man in his 60s, found down by local police. Paramedics responded, cut his clothes off, put pads on his chest and found him in ventricular fibrillation. He got shocked 3 times, got some drugs, loaded in the ambulance and arrived at our door. Before he even got off the stretcher onto our bed, he got shocked again. My collegues and me are doing what we’ve been trained to do! He’s back in a narrow complex rhythm after the fourth shock, we hang an antiarrythmic drip, get a 12 lead EKG and a chest x-ray. IV access isn’t working so we put in a femoral line. Everything seems to be running smoothly. He’s intubated, he’s got a blood pressure (albiet low), his heart is beating, he’s not having an acute MI based on the EKG, we’ve shocked him four times and he’s in a narrow complex rhythm. The resuscitation bay starts to spin its wheels. Can somebody get me a …, where’s the …, are we ready to …, it gradually becomes more chaotic and disorganized when it had been running so well. What’s wrong? What’s happening?
The problem was, what we did worked! We performed a resuscitation for man found in cardiac arrest, and now he’s breathing and his heart is beating again…none of teh ACLS courses teach you what to do next. We all scratched our heads and decided the best next move was to transfer him to the ICU. Our job here was done.
Submit your nominations at Echo Journal
Looking through my archives, I used to write pretty interesting stuff. Lately, not so interesting, huh? I won’t be offended if you don’t nominate me, but you should head over to echo journal and check it out.
On the other hand, if there were a nomination for Best Medical Bird Blog, I’d expect at least a mention!