It’s that time again….

This summer I spent more time playing outdoors and less time blogging indoors. Well, I did do other stuff indoors, like work, and I have a few other projects going on, but I didn’t get to include as many stories of fishing & biking as I have in the past.

Today I packed up my car and my bikes, and said a round of good-byes, and after a quick trip to central Colorado, will return tomorrow, pick up my kitties & drive back east for the winter. I’m always sad this time of year, the air is just cooling off, the tourists are gone (and so is the need for my services), and the aspens have just a tiny hint of yellow.

See you next year, Rockies!

The Butcher’s Silver Skin – Part 3

With the bleeding finally controlled and an adequate view of the gory injury, I took a few deep breaths and finally stood up straight. I stretched my shoulders back with hands still held in front of me, between head & waist, in sterile fashion. My collar bones cracked on each side.

For the first time I looked the butcher in the face and smiled…of course, he couldn’t see me behind my mask.

“How do feel?” I asked.

“I feel fine, a paper cut hurts worse than this,” he replied.

I started to give him a tour of the damage he had caused to his forearm.

“See this whitish rope? That’s palmarus longus, a tendon that attaches to your palm. You don’t really need it and I can’t find the other end anyway. You’ll do fine without it.”

As if in disbelief, he opened and closed his fingers again. Yep, they were still working.

“What’s more concerning is the muscle fascia. You’ve cut that completely open and your forearm muscles are bulging out,” I continued to explain.

I grabbed one edge of the silvery, tough membrane and pulled it away from the fat and muscle so he could see it.

“Is that like the silver skin on a cut of meat?” he asked.

“Yes, it’s exactly the same thing,” I said.

“You’re right, that stuff is tough, it’s really hard to get off, isn’t it.”

“Yes, and that’s good news and bad news for you.” I went on to explain how it was easily sewn back together because it was so tough. But because of it’s inelasticity, the likelyhood of dangerous swelling in his forearm was high. If I sewed it together and the muscles continued to swell, he could lose circulation and require subesquent surgery.

I was torn on whether or not to tack it loosly together and allow for swelling, or to sew it tight and try to return normal functioning to his forearm.

Finally, the surgeon arrived. He looked over the bloody scene and confirmed my gut instinct, which was to sew it up tight using a “baseball” stitch. The surgeon grabbed a pair of sterile gloves, picked up some instruments and stood on the other side of my table. He began to pull tissue layers out from the mess, clarifying my view. As I started to run a continuous stitch, he followed me, meaning he held my suture tight as I tied each subesquent one. The sewing went rapidly and at the other end, the entire muscle compartment was back in one piece.

THe patient opened and closed his hand several times, marveling at the odd sensations in his forearm. Not numb, not tingly, not painful, just strange, like a tightness in his arm.

The surgeon stepped out and I finished the repair with an additional layer of stures and finally a row of staples up his forearm.

The other arm had additional cuts, not nearly as bad, but also closed with a row of staples. The butcher was proud of his frankenstein appearance, but his wife was horrified.

I gave them both all the warning signs of compartment syndrome, and insisted that he spend the next 2 days with his arms above his head. Partly in jest, but also to emphasize the importance of minimizing the swelling.

Later that week I went to his restaruant. He was still at home recuperating, but I had the most amazing beef brisket I’ve ever tasted. The butcher truly knows his craft.

Silver Skin: Part 2

I put on the face shield and plastic gown that I had set aside earlier. The paramedics all gathered round me as I gently unwound the bright red, blood-soaked dressing on his forearm. I had a wad of 4×4 gauze pads in my left hand as I slowly peeled away the last layer covering the wound. Blood quickly pooled in a large oblong defect on the underside of the butcher’s forearm. I pressed the gauze directly over the wound a peeked under each corner to try and identify the bleeding vessel. It was not large, wherever it was, because the blood was not spurting, but it’s rapid spilling from the unseeen vessel told me that this was arterial bleeding, and not a vein.

The medic to my right placed a blood pressure cuff on the man’s upper arm and inflated it to 160 mmHg, higher than his systolic blood pressure on arrival. I peeked again and this time was able to see two distinct bleeding arterioles from the subcutaneous fatty layer that had been exposed.

I asked for suction. As the medicl held the suction tip directly over the vessel, the escaping blood was immediately removed from the area. No pooling, and perfect visualization of the tiny artery. With my left hand still holding direct pressure on the 2nd site, I quicly tied a figure 8 suture around artery #1. Success. The medic was pleased and so was I. Still aware that I had placed a blood pressure tourniquet, I moved quickly to the next vessel. Lifting the gauze, I again saw a small bleeding artery. The medic moved the suction over the second culprit and the process was repeated with success.

I now had a beautiful bloodless field and could clearly see the damage he had done to the muscles of his forearm. The nurse slowly lowered the pressure in the cuff and as he did so, another bleeding artery sprang open. We repeated the entire process a third time, then slowly lowered the cuff again. as the cuff deflated completely we waited for more bleeding arteries to spring open, but none did. I finally had the bleeding adequately controlled. Although my surgeon hadn’t shown up yet, I was feeling just a bit more in control.

His forearm now laid at rest, the meaty muscles ruptured out of their fascia and rope like, shiny white tendons sliding back and forth gracefully as I had him open & close his hand.

…part 3 to come shortly… (this writing stuff is hard work!)

The Butcher’s Silver Skin

On days like this, my job is awesome…but it can stink if you are the patient. The radio call was for an injury that was “down to bone”, created by broken glass. “…bleeding won’t stop…” said the dispatcher. Sirens blare and quickly vanish as the ambulances race away from the hospital to the scene.

Twenty minutes later they are back on their way to the hospital, “non-emergent”. I breath a sign of relief. I was wondering how long I would need to leave the suture ties if I had to tie off a radial or brachial artery. Non-emergent means the medics don’t think he’s bleeding to death, and it’s probably not as bad is the bystanders thought.

When the patient rolls in, I see that one dressing is soaked in bright red blood. Not the kind of blood from a minor injury that stopped bleeding 30 imnutes ago, the kind of blood from an injury that is still losing blood.

I have the surgeon paged as I have no clue what I’m about to uncover…

Read more tomorrow…sorry, gotta get ready for work!

I’d like to thank all the people…

I’d like to thank all the people…

I’ve been nominated for an award by Rocky Mountain Medic, one of my favorite literary bloggers. I have a special place in my heart for EMS blogs by nature of my specialty, emergency medicine.

Here is what he has to say about my blog:

A doc with his ear to the gorund. Great stories. I love going to his site. Plus, he’s from the Rockies.

Short, but sweet. Thank you Rocky Mountain Medic. The medics that climb/hike/kayak/bike together blog together! A commenter on his blog did correct the fact that I’m a she, not a he!

Here is an explanation of the award:

“This award should make you reflect on five bloggers who have been an encouragement, a source of love, impacted you in some way, and have been a Godly example to you. Five Bloggers who when you reflect on them you get a sense of pride and joyโ€ฆ of knowing them and being blessed by them.โ€
Here are the rules for this one:

1. Copy this post (meaning the rules).
2. Reflect on five bloggers and write a least a paragraph about each one.
3. Make sure you link this post so others can read it and the rules.
4. Go leave your chosen bloggers a comment and let them know theyโ€™ve been given the award.
5. Put the award icon on your site.

So…here are my five:

1) Grunt Doc
Grunt Doc is a practicing ER doc that I wish I worked with side by side, day by day. He seems to have a balanced sense of who he is and the proper place for emergency medicine in today’s modern world. That last sentence may not make sense if you are not an ER doc, but I hope it makes sense to Grunt Doc. Although I discovered him after I started my own blog, I am motivated and encouraged by his bravery in not hiding his true identity and his consistency in posting over the past several years. I was honored to be a co-blogger with him on the former Lingual Nerve Group Blog project. Plus I think it’s cute that his aunts and other relatives leave comments on his personal posts. ๐Ÿ˜‰

2) Mandarin Designs
How can one find love in short posts about CSS tricks? Well, just visit the site to find out. We connected long ago in blogosphere time, and the hostess of Mandarin designs continues to share her discoveries with us as well as hosting a nice quilt of blog friends from time to time. It appears she has not blogged in about a year, but the site is worth a visit. thanks for your loyal years of visiting as well. ๐Ÿ™‚

3) Padgett Business Services
OK, this one sounds really weird. An accountant? This guy’s passion for life, adventure and self-discovery is conveyed through his original posts on the blog section of his accounting web site. Take This Post for example about a warehouse filled with sawdust…

4) Hermes
The blog is long gone, due to beurocracy at Hermes’ home institution. Victor, of Hermes, had one of the most introspective and artistic writing styles of the medical blogosphere that I ever encountered. For a short period of time, I had the pleasure of co-blogging with him at Lingual Nerve, a group medical blog that has since dissolved. However many of my formative experiences during my residency were shaped by the introspection and intersection of life and medicine that we used to read about on Hermes. Hermes is Dead. Long live Hermes.

5) All the rest. (too many to name…you know who you are)
Is this a cheat? Just as the initial mission statement of my blog involved finding a notable patient interaction during each day of my residency, my early blogging experiences were formed and strengthed by the strong bond of the initial “inner circle” of medical bloggers that I felt I was part of. I was proud to discover half a dozen or so blogs when I was first starting out, and quickly saw expansion into many subspecialties of medicine. While I initially turned down many opportunies for exposure, due to privacy reasons, I still feel that Mr. Hassle’s Long Underpant’s and Doc Shazam (my pseudonym) were part of a strong foundation for the medical blogging niche that exists today. Thanks to everyone.

And thanks again to Rocky Mountain Medic for the Initial Nomination.


Comments welcomed.