Black Radishes & Honey

Fantastic writing from Dr. Charles, highlighted in last week’s Grand Rounds. An exerpt:

And then suddenly there was a noise from within, like the flapping of bats’ wings. I held onto the stethoscope that dangled from my neck like a crucifix, hoping that it would offer me some protection against her foul beasts.

Flight 024

Flight 024, however, was an adventure. I’m not sure how the patient made out just yet, but at least he survived to the hospital and beyond admission.

This was a callout for an 80 year old man whose tractor rolled over an embankment by his house into the creek below. He was pinned underneath for about 45 minutes. Thankfully, he was not in the water, but he might as well have been because his clothing was absolutely soaked.

We flew pretty far north and landed at a firehouse. We carried our litter and bags to the waiting ambulance, opened the back door and it was…empty! Huh? We climbed in, loading our litter onto the empty litter in teh back, and the driver took us up the road apiece, mabye 5 miles or so. He then turned up a narrow snowy drive into the woods, parking on a wooden bridge over a creek. It was as close as we could get to the scene.

The patient had just been extricated and was in the back of the next ambulance up the driveway. When we arrived, the only thing on scene medics had time to do was put him in a c-collar and give him some O2s. I was a little thrown off because normally by the time we arrive, they have the patient bundled & packed, IV access started, fluids running, the works. This guy was fresh out of the snow bank.

He was having trouble breathing, but was awake and could talk to us. Minimal signs of external trauma. I was relieved. He didn’t need a tube just yet, at least not down his trachea. The medic got IV access and delivered 100mcg of fentanyl. We got his wet pants off & covered him as best we could. The quarters were too cramped to get him off of his soaking wet longunderwear, flannel shirt & bulky jacket that he lay on top of. FOrtuneatly, that was my only regret on this run, that we brought him back with wet clothes still somewhat attached. We put hotpacks around his groin and underarms, covered him with dry blankets, cranked up the heat and got him back to the waiting helicopter, loaded him and brought him to the trauma bay.

He ended up getting bilateral chest tubes, but I think he avoided intubation. In retrospect, I think it’s worth the small amount of extra time it would take to lift or roll him and get the clothes off. Less dry clothing is much, much better than more wet clothing.

Flight 025

I don’t really want to write about this, but it’s probably good for you to hear about it, and probably good for me to write about it. It’s the kind of case that we all have nightmares about, wonder if we’ll know what to do when the time comes, wonder if we’ll forget everything that we’ve learned. It was the kind of case that makes me feel like all those years of school and training were worth something, even though we couldn’t save his life. At least we knew how to try.

Yesterday, around noon, we were dispatched to the site of a construction accident. Actually, the landing site was at a prison because it was the closest safe place to land the helicopter. In the back of the ambulance, lying on the stretcher, was a young man with obvious difficulty breathing. He was taking huge gasps of air, but his chest wasn’t moving. Instead, his belly was going up and down, up and down. He had dried blood around his mouth and nose, and every exhalation was accompanied by little sputters of blood from his mouth. He had been crushed underneath a several ton slab of concrete while unloading it from a trailer bed…imagine getting one of those highway “jersey barriers” dropped on top of you from five feet in the air. Somehow, he managed to crawl free on his own.

He needed to be intubated and fast. My intern did an excellent job of getting the tube in the trachea, considering all the blood that was building up in his throat. Just as we had him packaged up to transport to the back of the helicopter, his heart rate started to drop. We verified tube placement again, and suctioned frank blood from the tube. There was so much blood that it was just pouring out of the tube and clogging up our bag mask filter. His neck turned purple, and subcutaneous air filled his neck and upper chest. I put a needle through his chest wall into his lung space and more blood poured out. We put a second needle in the lateral wall with even more frank blood. By this time, I tried to feel his trachea, and it was deviated…the first time I’ve ever felt trachea deviation. We popped his left chest as well and a huge rush of air came out. He continued his bradycardic demise despite atropine & epinephrine. We began CPR. He went into ventricular fibrillation. We shocked at 200 Joules. We shocked at 300 Joules. He finally had a heart rate, and we jumped on the opportunity to get him transported to teh helicopter. His distant, and only hope was to cut his chest open and start clamping major blood vessels, or even his entire left lung.

While en route to the hospital, he began to brady down again. Atropine. Epinephrine. FLuids. Heart rate of 30. I began CPR in the cramped quarters of the helicopter where I didnt even have enough room to get my elbow over my wrist for my one handed compressions. It was while I was doing CPR that my staff doc finally came over the radio for report. I conveyed his dire situation in rhythm with my compressions. My stomach started to hurt…partly from nausea, but also because of the awkward position of giving CPR. The medic took over for me. We paused to check his rhythm and he was back in VFib. Time to shock again. THankfully the ambulances defibrillation pads were compatible with our defibrillator. We charged right up to 360 joules and presed the button and … no shock. CRAP. Now he’s charged with enough energy to put any of us in vfib, and the machine won’t discharge. Again, in cramped quarters, the medic leans over and presses a few buttons. We see the patient’s body jerk and the paddles are finally discharged. Safe to touch him again.

He’s back in an ideoventricular rhythm and we continue CPR. All the while, the flight nurse has been suctioning his tube and has about another liter of blood. he’s gotten four liters of fluid by now. We finally land on the roof, transport to teh trauma team who’s awaiting with two chest tube kits and a thoracotomy tray.

By the time we arrive, however, he has no signs of life. Heart rate of 20 with no pulse. CPR initiated almost 45 minutes ago. Blunt cardiac arrest…nearly no chance of survival, even with immediated surgical intervention. He was pronounced dead.

Everyone was notably distraught. Mostly because he was so young, but partly because of the gore and the hopelessness of it all. I was crushed, so was my intern. We went over and over the case wondering what we could have done differently, or better. No one faulted us at all, everyone agreed that with such massive trauma, even with immediate surgical intervention, the chances would have been slim.

I spoke with his supervisors at the scene, they were clearly very upset. A burly, rugged man wearing Carhart overalls and a hardhat with tears in his eyes. I asked him for details about the accident, but no one saw it. i asked him to describe the concrete beam, he guessed it weighed 20,000 pounds. It was 4 feet wide, 8 inches thick and 20 feet long.

This morning, I saw my intern again. He had nightmares last night. So did I. AFter I got home, I noticed the spot of blood on my shoes. I’m surprised there wasn’t more on me considering how much blood poured from every hole we made in him. For some reason, the blood doesn’t bother me. It actually makes me feel good about myself. We did all the right things and it just wasn’t enough. Maybe the next time the medics we worked with have to pop a chest, they’ll make a difference. Maybe having seen it and done it this time will help the next guy they treat.

Nothing is ever simple…

At our hospital, a tertiary, no quaternary referral center, nothing is ever simple. As I continue my effors to thrust “D” to the top of my patient assessment list, I am thrilled to pick up charts with a quick disposition. For example…

HIVES. Easy. As I scribble the script for prednisone & benedryl on my way to the room, I eye the patient whose hair is falling out, badana in place, whose husband has to tell me her story because the astrocytoma in her brain is eating away at her memory…Make that decadron instead of prednisone…

VOMITING. Great, we’ve seen a ton of gastroenteritis. Fluids, phenergan. Hmm. Well, there’s that shunt in his brain to consider as well…

FEVER, COUGH, CHEST PAIN. Ahh yes, a simple case of pneumonia if I ever heard of one. Oh…the Cleveland Clinic? Your transplant doctor. Uh huh… Two lungs, really?

Nothing is ever simple.

Flight 023

I was the physician on-scene to pronounce this man dead. At first glance, it appeared that the car had hit a telephone pole. There was an indentation of about 5-6 feet in the front end of the car, displacing the engine completely. The car lay at teh bottom of a small embankment at the intersecion of the railroad tracks and the road. I looked around to see the pole that he had hit, and felt my stomach sink when I realized that he had hit a train instead. The train of course, was nowhere to be found. A black coal train, crossign the road at 2AM…he may have never even seen it. He was only about a mile from home too.

Saturday, January 15, 11 a.m.

Gotham County Fatal Crash

A Gotham County man died after his car collided with a train early Saturday morning. Police said the John Doe, 28, of Kryptonville, failed to yield to a train on Route 99 around 2 A.M.. His car was hit by a Norfolk Southern Train. Officials said Doe died at the scene. Police said the train’s engineer apparently didn’t know he hit anything, and the train continued to it’s destination.