Tragic Accident

Our entire community was devastated last week by an airplane accident that took the lives of ten individuals from our area. One pilot and nine medical personnel were killed when the plane they used to fly to remote clinics went down shortly after takeoff on Friday night. I was friends with several of those who were on board, but especially with the physician assistant, Dave Goddard. I had just worked with him while he took an extra shift at the ER last week. The PA who usually worked had a to take the day off and Dave took her shift. This is just one example of what a good guy he was. While he was in the ER I got to see him work up an especially difficult abdominal pain case. Dave, even though he now works primarily in Dermatology, had a vast amount of experience in medicine. Watching him take the history and do the physical was another pearl for me to add to my medical training. You couldn't have done a more thorough and complete exam if you had been reading from a textbook! A fantastic example of a good PA! He was very good to me, always giving me journals to read, guiding me through medical procedures, and above all, offering good advice and help.

These were, all of them, great individuals who will be sorely missed. Our thoughts and prayers go to their friends and families.

So, thought I'd share this with you all since I thought it was important. When I went in for my post rotation exam/paper/chew out session at school I was thinking things weren't going to go well. I'd been at Girl's Camp for three days with Mindy, as their designated medic, and hadn't studied as much as I should have. I also hadn't started my Surgery report (basically a History and Physical, commonly known as an H&P). So, amid helping cook, babysitting Beauden, and removing the odd splinter and taping some ankles, I got to study and write a 6 page H&P. Now the Surgery exam was supposed to be a killer. More people had failed Surgery than any other elective besides Emergency Medicine. So I was NERVOUS! I get up on the day of the exam at 3am, and drive off the mountain in the dark, headed to Sin City. After a last minute review (I know, I know, it was a cramming session, but I'm optimistic), I took the exam, and turned in my papers. I got my results from the exam back that afternoon: 84%, Fifth overall highest score in the class! WAHOO!!!

Then, a week later, I get an e-mail from the program director personally. This usually isn't good news. The last time I got a personal e-mail from her it was because I had failed my H&P and to redo it and pass or fail the rotation. Well, this time, it was to ask me if the school could use my paper as an example for the next class before they go on rotations. And NOT as a BAD example either! I'd gotten a 97%! WAHOO again!!!

Boy, next time I go to my end of rotation blood bath (which is what many of us call end of rotation exams) I'm going to go to Girl's Camp with some Stake for a few days so I get some a little extra divine help on my assignments! Note to self: magnify your calling...and you're wife's.

-Bart

How drunk are you?

So, we have this game…well, it’s kind of a sick game, where we bet on what someone’s blood alcohol level (BAC) is going to be. Those of your in law enforcement will probably be old pros at this one. If it’s a first timer that no one has seen before then we’re all pretty much shooting in the dark. But, if it’s a frequent flyer to the ER and you’ve got a track record as to how well tuned their liver is, you can usually guess within about 20 or 30 points.

Now a BAC of 80 mg/dL is equivalent of a 0.08 g/dL on a breathalyzer test used by departments of public safety for DUIs. In the medical paradigm we don’t use the decimal, just a number between 1 and whatever. So, a BAC of 80 means you’re to drunk to drive. Actually at 40 you’re technically drunk. Above 200 is considered toxic. But I’ve seen folks who are over 400 who can still walk and talk! Now those are some REALLY super charged livers! Livers who are screaming cirrhosis death chants, but who for now are really operating at amazing levels. So this little gal comes in the other night, claiming a head injury while incarcerated the day before. She is as coherent, alert, and oriented as the Stake President with abdominal pain in Trauma Bay 9. But I think MY BAC was probably 40 just from being in the same room as her! When asked about the strong (and I mean STRONG) smell of alcohol on her breath, she states one of the conditions of her probation is to abstain from all forms of the evils of booze, and that the smell is simply Mtn. Dew…now I know that there are a lot of different flavored soft drinks, but, last I knew Mtn Dew didn’t make a flavor named Jack Daniels! So we start taking guess on her BAC: My guess was 130. Not even close:278 baby! One of the nurses guessed 280! Yeah, this girl was a regular at the Emergency Room. You might remember the 15 year old I saw a while back who was comatose with a BAC of 330? Not little miss 278, her liver was a Formula One Alcohol Processing Machine…On it’s way to an implosion! She didn’t get any drugs for her headache either.

Pretty wild night tonight. Three subdural hematomas, one of whom was LifeFlighted north in a hurry, a little girl with tetanus of all things, and a strangulated hernia that I got to take to the operating room, and be first assist in taking out an eight inch necrotic section of his bowel. He should do well though: No diabetes, No hypertension, no infection. Man, as much as I love the ER, I miss surgery a lot!

Well, time to go to beddy bye! Let me know how all of you are doing!

Love,

Bartman

Bleeders

So, had another good one in the ER tonight. Very nice lady, cleaning some dishes, decides that the inside of a cheap glass was dirty, and goes ahead and makes it the most expensive piece of crystal she owns by breaking it and slicing a huge gash into her hand. So when I check it, you can tell there's arterial blood in there and you have to find it's source. I open up the wound, and YEP, IT'S A SPURTER!!! 5 feet across the ER bay, all over my arms, the bed, the patient's pants, and the floor! After grabbing a hemostat and clamping it off, I look for other bleeders. Nothing a little vitamin P (otherwise known as Pressure) can't take care of, and we're off to the stitches! Tricky part about stitching an arteriole (small artery) closed is; 1) getting all the way around it, and 2) not slicing through it with your suture material. Now, I was taught that you can't bleed to death from a hand laceration...but this one would have been a good candidate. You can't sew someone up with bleeding inside the wound or you're looking at a huge hematoma, clots breaking lose and heading to important areas-like the lungs, and a probable lawsuit. So after I sew her bleeder off, it's time to wait to see if you missed anything. Now this takes a while, especially important when you've got five other patients waiting to be seen. But to do it right, you've got to settle down and make sure you get the bleeding stopped. Looking good, two more internal and seven external mattress sutures and it looks MUCH MUCH better. The biggest challenge after getting the bleeding controlled was to keep the patient from seeing the blood sprayed all over the ER bay, and keeping her mind off the pool of red stuff her hand is lying in. Looked good afterward though, and the doc (once again my surgeon buddy) said it looked "beautiful." I almost cried.

BLEECH! The milk I stole from the ER is sour!

After I was done it looked like I'd been in a bar fight, which was good since my next patient wanted a prescription for ephedra, most likely for cooking meth. I told him no, ephedra isn't the best thing for your asthma, and gave him albuterol and theophylline instead. He wasn't happy, but hey, you gonna argue with a guy who's got blood splattered all over him? He took off AMA (against medical advice) before we could give him his scripts. Good luck meth boy.

-Bartman

Emergency Room

Officially saved my first life tonight. Well technically it was morning. Got to run a chest tube on a guy who had been successfully resuscitated (a rare event), and then had a pneumothorax (a condition where the lung collapses as air is pushed into the space between the lung and the chest wall, resulting in respiratory distress). The doc asked if I had done any of these, I responded that I had (although only in my head, but I'd practiced it many times), so he said "I trust you, call me if you have any problems." And I was off to the races!

Now to be fair, the doc did come back in after I had started the tube in (after prepping the area, making the incision, and inserting the tube) and began the time honored tradition of yelling at you while you're trying to do something so that you REALLY have to concentrate. "Don't use that!", "Don't let that come out!", "That needle isn't going to stay!", "Who the **** taught you to do sutures?" (he taught me of course, but I wasn't going to bring that up). Etc, etc. So, sweat dripping down my nose, two medics, a respiratory therapist, two nurses, and one screaming doc looking on, I successfully inserted an 8 inch Aarow chest decompression device above the fourth rib and into the pleural space. After removing about 200 cc of free air we put on the Heimlich reverse flow device and the patient was much more comfortable. The chest X-ray showed a successfully placed chest tube and a fully expanded lung. YAHOO!!! One down, thousands to go! One of my other docs said I probably saved a guy with a pulmonary emoboli in February, but that was more the nurses doing. This one was my first solo. Feels good, hope the patient makes it, he was very very sick. The rest of the evening/morning was relatively uneventful; asthma, facial laceration, constipation (those are always fun), middle ear infections x 2, and a couple of fevers.

The doc let me go early since I'd done a good job, and he told me before I left he was proud of me. That was the second highlight of my evening. Had to put that online before I went to bed tonight. Take care all, hope I don't see you this month, at least at work! Hate seeing people I know in the ER, gives me the chills!

Love to all,

-Bartman