Where Trauma Meets Tragedy

“Full Trauma Now.” The words blare across the emergency department. There is a rush towards the trauma bay – stretchers, x-ray technicians, nurses, medical students, residents, attending physicians. We dress in our protective gear – plastic blue gowns, gray gloves, face masks, blue marshmallow hats. And we wait. “Have you heard the story?” One nurse whispers to another.

“It sounds bad…car vs. tree, I think, or maybe bike vs. tree, I’m not exactly sure…” She tilts her head up, as if trying to grasp the story from thin air.

One of the technicians pipes up, “GCS 4 in the field. Not intubated.”

A nearby resident raises an eyebrow, “Really? They haven’t intubated yet?” He gets his equipment ready – suction, tube, blade. Everything is in order.

And we wait.

Minutes go by.

A nervous, hushed wave of conversation ripples across the room. The hum of stretcher wheels fast approaches, or perhaps we are only imagining it. The air is thick with anticipation.

This is the trauma bay. The small, rectangular room where life meets death. But I have rarely seen a death here. Because we have become so skilled at keeping people alive, we are often able to stabilize patients for just enough time to whisk them away to the operating room or the intensive care unit. Even so, this is the room where a sudden life change is first realized, observed, and recorded. This is where it all begins. A bay – it is not a fitting term, really. Bright red airway bags, big computer screens, beeping monitors, life-saving carts, stretchers, fluorescent lighting. And there is no peace here. It is not a bay – more of an ocean, with unseen waves, trade winds, thunder, lightning strikes.

I have watched many patients meet their fate here. And yesterday, for one, the tears welled up. I know exactly how to hold them back – have become an expert, in fact, at letting them come just far enough to the brim of my lashes, so that if I smile it almost looks as though they are a twinkle and not a tear. Have I begun to feel again, after these years of blocking everything out? Perhaps. I was pleased to discover them – quite unexpected, I might add. Incredible that after all this time the tear ducts still function in the old, familiar way. A miracle, really.

As I watch this woman’s tragedy unfold in front of my eyes, I realize that she will not make it. I look at her, I look at the CT scan, and I know – with certainty. I no longer have the naïve hope of a medical student. I no longer need to look to my attending for confirmation. I almost wish I did. I glimpse the family at her bedside. Children, grandchildren, sister. I watch them weep. Their eyes are wide – too much hope, I think. I want to brace them for what lies ahead. But I know that would be impossible. A shock is not absorbed, or even felt, at first. It just is. It glares you in the face.

This is my last day as a second year resident. How the time has gone by. How much has changed. Children, grandchildren, sister. I watch them weep. And for a moment, I let myself remember what it feels like to be one of them. I, in my white coat, with too much knowledge for my own good. I, the doctor. No more or less powerful than they are, when it comes down to it. I put myself in their shoes. Slip them on my feet, feel the worn leather, tap them on the white floors, now splattered with blood. I watch them weep. And I feel something – not as much for her, but for them. For all the trials they will face in the coming hours, for all the tears they will shed, for their loss.

They loved her so much, didn’t they?

Another day, another summer…

Heat rises from the sidewalks of the city. Backyard grills appear again. Sun dresses, outside tables, kites, picnic baskets, bike riding. The world welcomes us to summer. In the hospital, it is a time of great change. All of us – residents, fellows, medical students – are moving on in our journey. Over a period of a few weeks, we will be “promoted” to new positions in the hospital. Some of us – those who have completed their training – will be leaving, to become attending physicians at last.

The emergency room, windowless and air-conditioned, feels the heat of summer in our patients. Sunburns, carbon monoxide exposure from boats, firework injuries, fractures from playing sports, dehydration, heat exhaustion, and the list of summer maladies goes on. And so it is with the seasons of emergency medicine.

Here are some important words of advice, for those of us want to enjoy our summers and avoid the emergency department.

1. Wear sunscreen. This applies to people of all ages. Do not let the urge to get a beautiful tan quickly take over here. Use at least SPF 15, preferably 30 to 45. Wear baseball caps and sunglasses. Protect yourself from those rays which will wrinkle your skin, penetrate the epithelial layer, damage cells, and increase your risk of skin cancer.

2. Drink water. Lots. And look for signs that you may need more water – darkened urine, decreased urine output, increased thirst, decreased skin turgor, dry mouth, light-headedness, or lethargy.

3. Be aware of running boats, and avoid swimming in these areas. Refer to a CDC report from 2004 for more information, Carbon Monoxide Poisonings Resulting from Open Air Exposures to Operating Motorboats.

4. Do not operate equipment while drinking alcohol. This includes boats, lawn mowers, grills. Some studies have estimated that 6 to 45% of injuries that present to the emergency department are alcohol-related cases. Refer to a World Health Organization project website, Alcohol and injuries, for more information.

5. If you ride a motorcycle, wear a helmet at all times. Wear protective gear. Do not ride after drinking alcohol. Be careful on the roads. Do not ride in the dark if at all possible.

6. In the summer heat, invest in air conditioning. Approximately 400 people die in the United States per year of heat stroke, which is defined as a core body temperature that rises above 40C. Refer to an excellent review article published in the New England Journal of Medicine in 2002 , Heat Stroke.

These tips only touch the surface – but they are related to some of the most common, and devastating, injuries that we see in the emergency department. So cool off, be responsible, enjoy the summer, and avoid the emergency department if you can!

Coming to a close…

As the first half of residency nears an end, I recall this year – with all of its trials and tribulations. There were days when I walked through the ominous double doors of the hospital’s front entrance and wondered if I would ever emerge from them again – and if I did, how changed I might be. There were days when I was so frustrated to look down at my pale blue uniform and realize that the blueness had penetrated me, coursed through my veins, made me sad. There were days when I was angry to be in the hospital and not home. And there were days I was grateful to be here, honored to care for my patients with compassion and concern. This place has grown on me, and it has challenged my perspectives on healing, illness, and hope.

As I glance out the windows at a stone garden where a little girl in a hospital gown throws a ball to her father, I wonder if residency is a process that will encourage me to close the doors of the hospital, inch by inch, never to return again, or if it is a process that will allow me to re-open the doors, ever so slowly, as I recover from the hours that I have spent here healing patients.

The sun shines bright, and rain pours down outside. Clouds linger in the distance. The rain is gray but sparkles. The greatest paradox. A beaming smile curled with doubt at the edges. Eyes wide and bright through tears. Hope high in the midst of devastation. Expect the worse, hope for the best. Residency is not unlike a downpour in sunshine – and I, drenched but warm, through it all, have reached the peak of this mountain and am now ready to trek down the other side. Unchartered territory, slippery at times, but less daunting – and less exhausting – than the ascent. This I can do.

We are entering into a transition time in the hospital. As July approaches, the new interns – with fear and enthusiasm that now amaze me, although I was one of them only 24 months ago – are entering the realm of the hospital for the first time as doctors. A momentous occasion. But as I gaze at them, I realize that an insurmountable barrier has formed between us. How can I tell them what to expect? How can I explain to them how they will change in these coming years, how they will be challenged, and how hard they will be pushed – emotionally, physically, and intellectually? No words or experiences will do this journey justice. It is very much an individual journey – shaped by our unique encounters with patients, physicians, and one another.

Earlier this year, I used to approach my drive to the hospital with dread. But now I approach my drive to the hospital with a sense of wonder. I understand, sadly, that I will not be able to save everyone who rolls through the doors. But I am confident that I will be able to make a difference in the lives of my patients. I am confident that I will work to help people heal – and even to alter the course of their lives.

The sun shines on a downpour. Tears, regrets, the past trickle down into the drains. The grayness of the world is lessened by these rays, which boldly penetrate a place where they are unexpected, but where their warmth – and persistence – are always welcome.

Hiccups: A Medical Conundrum

Hiccups are a common annoyance. Most of the time they are a benign, self-limited condition that resolve on their own. Some of the time, however, they can become a persistent, chronic problem and, in these cases, might indicate a more serious underlying pathology. There are many theories about the pathophysiology of persistent hiccups – from problems with the central and peripheral nervous systems to post-operative diaphragmatic irritation to metabolic derangements. Psychogenic and idiopathic hiccups are other alternatives. There are also several theories about the pathophysiology of self-limited hiccups, but none are well-established. These include gastric distention, alcohol ingestion, smoking, ingestion of particular foods, ingestion of foods at the extremes of temperature, exposure of the body to a rapid temperature change, stress, and heightened emotions.

And the cure? Well, as with so many things in medicine, there is none. There are several laymen’s approaches to arresting hiccups that are often used by patients before seeking medical care, some of which rely on pharyngeal stimulation or interference with the normal respiratory cycle. These include: sipping ice water, gargling with water, biting a lemon, drinking water upside down, drinking water from the far side of a glass, a teaspoon of vinegar, a teaspoon of honey, and holding one’s breath. The list goes on. A letter to the editor, Granulated Sugar as Treatment for Hiccups in Conscious Patients, published in 1971 in the New England Journal of Medicine advocated for the use of one teaspoon of white granulated sugar, swallowed “dry.”

The medical anecdotes are not well-studied, but chlorpromazine – an antipsychotic – is perhaps the most widely accepted agent for the treatment of persistent hiccups. Metaclopramide may also demonstrate some benefit.

For patients with persistent hiccups, the inconvenience – and annoyance – can become unbearable. Hiccups can ultimately lead to weight loss or difficulty sleeping and thus have an impact on people’s lives. As we continue to advance our medical knowledge and skills, perhaps we should look back at one of the simple, familiar, age-old problem which remains very much a medical mystery.

For the residents…

Only today did I realize that after almost two full years of residency, I have not yet acknowledged one of my greatest sources of support – my co-residents. They have stumbled along this path, by my side, step by step, over the years. They have celebrated, and grieved, and learned alongside me. They are the pillars that hold me up when I am ready to fall. They have demonstrated to me, time and time again, that if they can do it, so can I. They have scaled this mountain with me, pulling me along when I began to lag. Without co-residents, this journey would be impossible. They inspire me to be a better doctor, a better teacher, a better student – every day. And I go to my limits for them – work-up a patient at the end of the shift only so that it will be easier for them when they come on, call a consult so that they will not have to deal with the inconvenience.

Residency is about caring for patients, but it is also about caring for one another – volunteering to work extra time when a colleague’s baby is sick, or when someone needs to get to a graduation or a wedding on time. I cannot imagine this journey without them. And as I venture into year three, when we will be transferring patient care from our hands into the hands of one of our co-residents, this bond only becomes stronger.

More on trauma tomorrow, but for today, a thank you to the residents – my support, my vitality, and my strength through this minefield of residency.

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