Tuesday, March 15, 2011

Interlude, Part The Second

Another bad day. Bad for me, worse for others.

I had an unusual case yesterday, wherein a 21 year old lad presented with severe lower limb muscle spasm, and turned out to have bilateral fractured femoral necks; without significant trauma.

Yes, I'm stumped, too.

the first was a young man, in his 60s, previously well, in cardiac arrest. He had had a colonoscopy the previous day, and returned home without complication; after a few hours at home, he developed severe lower abdominal pain, cramping and colicky, although the notes document that this passed when he opened his bowels and passed flatus.

The notes document that he was symptom free when seen in the ED. He examined normally, and was discharged. Then she couldn't wake him this morning.

By the time he got to us, the Ambos had been working hard for an hour. They couldn't intubate, and I could see why. His jaw was clamped shut, clamped so hard, he'd bitten through his tongue. I couldn't get it to budge a millimetre. Looking down from the head end, I could see my colleagues struggling to straighten his legs out.

No dice.

There's usually only one reason why someone in cardiac arrest has muscle rigidity: rigor mortis. The poor soul had been down for several hours before even the Ambos were on scene, I'd say. We tried, and we tried, but he remained stubbornly in asystole, and his blood gases were those of a dead man.

His wife was utterly unprepared; she pleaded with me to do something, oblivious to my gentle suggestion that he had, in fact, died in the night, and that at best, with a downtime of 90 minutes, even if I could convince his heart to beat, his brain would never recover.

But I couldn't convince his heart to beat.

I knew the accusation would come; she couldn't help it: "He was here last night! Why didn't you see it?"

I had no answer, could barely look her in the eye.

...the second, another young man, found in a collapsed state. Known to be a fitter, prone to slow recovery, he looked post-ictal, but was too slow to come round. He gradually developed some focal signs, his right side becoming tense, spastic and useless, his conscious level ebbing away.

The diagnosis of a prolonged post-ictal phase began to ebb away. CT confirmed what we had all thought: a sizeable intra-cranial haemorrhage. Neurosurgery wasted no time in pronouncing no hope for meaningful recovery. They did offer to take him, to try a ventricular drain, but stressed this would be to prolong duration of life, not improve the quality of that life.

As we pulled the tube, and placed him on his side, I'm left to reflect: two sets of lives ruined, and not even lunchtime. Difficult to put a spring in my step today.


night tech said...

2 causes of non-traumatic bilateral NOF fracture that we can exclude with quick and dirty Labs would be
hypocalcemia (source to be determined by further investigation) and multiple myeloma.

Would need a bit more Hx to go any deeper? Epilepsy? Parathyroid insufficiency? Meds?

But yeah, weird.

As for the shitty day...
don't let it bring you down.

Very few people have the strength to do what you do in the ER. I hide behind the machines in my lab and crank out numbers, you do the hard work caring for the patients and their families.

Take care of yourself first :)


safaris in tanzania said...

Truly life of a life man.. Congratulations for your endeavor to save lives. We appreciate your work and efforts always. I wonder how the world would be without docs.