What a weekend

It's been about a week since I updated this blog because it has been a rough week. I worked seven out of the last eight days, so I was TIRED. But I did see a lot of shit.

First, there was this 26 year old kid who was really drunk the night before; he was running down the street -- actually after partying it up at the bar over which I LIVE -- and he tripped and fell down at enough of a weird angle onto his hip -- hard enough to *dislocate* it. OUCH. Just looking at him made me cringe -- his left hip was out of its anatomical position, leg rotated outwards and about six inches shorter than the other one. Ewwwwww....

So together with my friend from orthopedics, we had to reduce it. Or rather, we tried to. This patient was as big as an ox, and he confessed to us that after he fell and dislocated his hip, it hurt so bad that he started doing lines of coke on the STREET to numb the pain. There are multiple problems with that "solution," one of which is to counteract centrally-depressive agents. Thus, his heart rate and consciousness sailed through our attempts to sedate him enough to put his hip back in place. I pushed 24 mg of Versed and 200 micrograms of Fentanyl on this guy and it only made him slightly sleepy. Usually, an adult dose is 4 mg of Versed, and at 10 mg, you start to worry about the patient maintaining their airway.

On attempts 2 - 4, we tried another agent called Propofol. It's a milky white general anesthetic (we call it Milk of Amnesia) that's very quick-on quick-off -- it lasts about five minutes, so it's a favorite for short procedural sedations. Only problem is, it has a narrow therapeutic profile, so just a hint too much and they quit breathing. The easy part about that is that you only need to bag the patient for about sixty seconds before it wears off and they start breathing on their own again. And the usual induction dose for total anesthesia in the operating room is about 40 or 50 mg for a generic 70-kg adult.

I pushed a total of 170mg on this guy and still nothing except mild drowsiness. He said he had only three lines of coke, but there's no way I believe that. He finally had to go to the operating room for general anesthesia because nothing was touching him in the ER.

Then the trauma phone rang. We got advance notification that an adult male had a generalized seizure but was no longer seizing, he was just post-ictal and kind of "out of it." "He's fine," said the EMS guy that called in advance, "his vital signs are stable." Okay, great.

When we get advance trauma notification, we usually call the whole trauma team and everyone runs into the trauma room in advance, put on gowns and gloves and faceshields and is waiting for the patient to arrive. But since the EMS field guys told me that the post-seizure dude was fine and "just a little out of it," I felt no need to call the troops poste haste.

So the ambulance arrived and the fourth-year resident met them out in triage. All of a sudden I heard him yell across the ER: "HE NEEDS AN AIRWAY GO TO THE TRAUMA SLOT RIGHT NOW!!!" I don't even remember what I was doing at that moment, I just remember running at full speed to the trauma room.

When I got there, I saw the patient completely BLUE, not breathing, vomit chunks around his mouth. Now, the party line is that you protect yourself first, so no matter what is going on, you must put on a gown and gloves and facemask first before you touch the patient. But this guy -- and a big ol' 250-lb dude he was -- was not breathing and God knows for how long. So, rightly or wrongly, I didn't put on a gown or facemask, and luckily I was already wearing gloves. I just reached over for the intubation blade and tube and thought, "this guy is so big with a huge neck, and he vomited everywhere and it's going to be a difficult intubation, but please God let this tube go in." In one look and pass, it went in. Whew.

Meanwhile, I could overhear the fourth-year having words with the EMS field guys. (Why the hell would you call and say "oh he's fine??!!" HE'S NOT BREATHING!)

I went back to the ER where I still had some relatively sick patients who needed my attention:

-- a gentleman who had no history of a seizure disorder who had suddenly seized in the triage bay (but thank God HIS airway was never an issue)

-- an interesting hematologic case where this woman was spontaneously bleeding from her gums. The normal platelet count is between 150K and 450K, and this woman had only 9K. Below 15K, you're at risk for spontaneous intracranial hemorrhage. I had to transfuse her a unit of platelets and blood. As it turned out, she had aplastic anemia -- massive underproduction of all cell lines -- she had very little platelets, red blood cels and white blood cells. (A later work-up and bone marrow biopsy by the heme-onc inpatient team confirmed she had aplastic anemia, most likely as a result with previous infection from parvovirus and Dengue fever when she traveled abroad -- a known and feared complication from a usually somewhat benign virus.)

I don't remember when I got to finally wrap up and go home, but that evening's hot shower felt very, very good.