Friday, November 16, 2007
not one single word
sometimes the patient is in no condition to lie for himself. then it is important that others lie for him.
i was working in a private casualty unit to make extra money during my surgery training. (don't tell the prof. it was strictly forbidden. one day i'll post about the time i got caught.) it was some ridiculous hour. i was catching a nap when i was rudely awakened. the sister said an ambulance was expected to arrive in about 5 minutes with a possible epilepsy patient. i dragged myself out of bed. a medical case! absolutely wonderful. and at this time of the morning. just the thing to warm a budding surgeon's heart.
i stumbled into resus just as the ambulance crew came casually strolling in with the patient. they told us they had been called to fetch the guy from work where his colleagues said he simply collapsed. they didn't know why. something was wrong. he was restless. he was also pale. i felt his pulse. it was thready and fast. very fast. he had no drip up. being surgically minded, i thought that if i didn't know better i would say he was bled out. fortunately the ambulance crew could tell me that his colleagues at work told them that he had been working in a dairy cold storage facility when he simply collapsed. i asked if there had been convulsions. they didn't know. meanwhile one of the sisters was getting a blood pressure. 80 over 30 didn't fit with epilepsy. a quick glucose test was normal. the only alternative was cardiogenic shock from myocardial infarction or some exotic dysrhythm. but once again, it didn't fit. the patient was black. (white south africans have about the highest incident of ischaemic heart disease in the world, but south african blacks don't have much of it at all.) then it happened. the patient, now gasping for every breath looked at me and said,
"help me doctor! i'm dying!"
if you've been in medicine for a while you'll know that most times, the reason a patient says he is about to die is because he is in fact about to die. i believed him. my blood went cold. it just didn't fit. i wanted to tell him we'd do everything we could (although i still had no idea what i was capable of doing for him). in a reassuring way, i placed my hand on his chest. with every breath i could feel bones grinding against each other. i pulled my hand back in shock. he had broken ribs!!! epilepsy or cardiogenic shock or some heart problem does not cause broken ribs!! this was trauma! this was surgical! i jumped into action.
at that moment, the patient breathed one terminal gasp and promptly stopped breathing. for good measure his heart stopped beating too. nice bloody epilepsy, this, i thought. i delegated one sister to start cpr and another two to get iv access as i moved to the head to get airway control. the sister pumping the chest immediately stopped.
"everything is crunching under my hands" she said. what could be done? circulation is fairly important for survival, so i told her to continue. at this stage i was intubating. as i inserted the laryngoscope, fresh bright red blood came frothing directly out of his trachea. the trachea was also way over to the right. i shouted for someone to prepare an intercostal drain and slid the et tube in. the sister was fast. by the time i moved around to the left flank, the set was ready. i stabbed the blade into the chest. there was a gush of old dark blood. i shoved the tube quickly between the ribs into the pleural space. immediately one bottle filled with blood.
we consolidated. the patient was on a ventilator. two lines were running full tilt. with a touch of adrenalin, the heart started beating again (although i think the removal of the tension hemothorax also had a part in that). we got emergency blood going and got x-rays. we also called the thoracic surgeon.
the x-rays showed the worst disruption of the thoracic cavity i have ever seen, before and since. every rib on the left was broken and the fractured surfaces were about 5cm from each other. this basically meant there was a tear of the lung from top to bottom which was about 5cm deep. i gingerly reflected that that would explain the constant stream of blood draining from the intercostal drain.
as could be expected, the patient decompensated again. this time there was no bringing him back. when the thoracic surgeon arrived, the patient was already dead.
as usually happens, the story did come out. what the patient and his colleagues didn't know was that the cold storage facility where they worked had closed circuit tv. this was probably to prevent night staff from stealing. or maybe to prevent them from racing around on a fork lift chasing each other. yes, dear readers, that is what they were doing when one of them lost control of the fork lift and drove into my patient, crushing him up against a pole. they figured they were in trouble already, so it seems they decided the depth didn't really matter. if you are going to be in crap for messing with the machinery at night and for killing your colleague, then why not lie also to really confound any chances of the paramedics and the doctors to try to save his life. go figure.