June 27th is my 34th wedding anniversary. It is also the 39th anniversary of the day I met my wife. The summer of 71 at a coed camp in New England was extraordinary for the waterfront counselors. Three marriages ensued from relationships that began that summer. I was a 19 year old, soon to be college sophomore, when I met this cute girl who was entering her senior year in high school. Besides being cute, she was funny, smart and told me to go f--- myself at one point during that summer. I was smitten.
Five years later, one month after she graduated from college, we were wed. I was in my fourth year in medical school. Our honeymoon was delayed until the next spring, after my graduation. Internship, residency and my bride's master degree occupied our early married life. We were fortunate to have supportive families, who all got along well.
We purchased our first home with help from her grandmother in 1980. Careers and actually spending time together led to misunderstanding and a short separation. Our dogs brought us together. Life continued with triumphs and tragedies. The weird hours and pressures of the ER were constant stressors. Having children was not to be part of our marriage. We became the world's best uncle and aunt (according to our youngest nephew). My wife pursued a second career as a attorney.
Joys and sorrows were shared. Our love continued to grow. Best friends, partners,and lovers, we enjoyed being parents to a number of beloved akitas. My cousin, an advertising executive, gave my beloved her current sobriquet, "an exotic woman of indeterminate age".
We now face new challenges and problems. Our own future, and the need to be supportive of our dear parents must be addressed. As "senior" members of our respective professional groups, we now mentor young colleagues, even as we ponder our own longevity.
The world's oldest ER doc is a lucky man. I have wonderful nurses, doctors, PA's, aides, techs, and clerical staff in my ER. My family is loving and near by. Best of all, I have my wife by my side. June 27, 2010 is our 34th anniversary. It's a wonderful life.
Saturday, June 26, 2010
Friday, June 25, 2010
The big C
The disease that we all fear, cancer. ER docs treat cancer patients frequently. At the hospital where I work, there is a very active cancer center. Side effects of radiation and chemotherapy include vomiting, dehydration, and infections. Our oncologists and primary care doctors send cancer patients to the ER for treatment and possible admission.
On occasion, I have made the diagnosis of cancer in a patient who came to the ER for a seemingly unrelated problem. Chronic coughs, vomiting and diarrhea, abdominal pains, headaches, seizures, strokes, skin lesions, nose bleeds, and fevers may all be the first presenting symptoms of cancer. In my thirty years of ER practice I have diagnosed leukemia, brain tumors, melanoma and other skin cancers, lung cancer, breast cancer, ovarian cancer and oral cancer.
The diagnosis is usually a surprise to me and devastating to the patient and his or her family. As a resident during the late 70's, I examined a 27 year old woman for the presenting complaint of a "breast infection". This young mother of three was 6 months postpartum. Her left breast was hard with a pebbly feel known as peau d'orange. The nipple was retracted and I easily palpated several hard lymph nodes in the left axilla (armpit). There was no doubt that she had advanced breast cancer. She was only a couple of years older than me. Her mother accompanied her and was watching the patient's children. Being young and very inexperienced, I blurted out the diagnosis and told her I would set up for her to see a surgeon. When she started crying I offered my sympathies and almost ran out of the room.
Recently I examined a woman in her 60's who presented after a syncopal episode. She had a sudden unexplained loss of consciousness. I ordered the usual labs, EKG and head CT. She was very lethargic and her speech was slurred. The CT showed a large mass with some bleeding. There was swelling of the brain. A malignant brain tumor in a healthy woman who "fainted". I arranged for transfer to a major teaching hospital. The family and I spoke at length of the diagnosis. I offered a sympathetic and encouraging message. In my advanced years, I also cried along with the family.
A toddler with frequent nose bleeds is usually caused by vigorous use of the child's index finger in his nostril. The beautiful little boy on the stretcher looked too pale and I noticed petechiae and bruises. My worst fears were confirmed when his CBC showed ALL (acute lymphocytic leukemia). The child was transferred to a pediatric hospital. The cure rate for this form of cancer is excellent, but knowing what he and his family would have to endure gave me nightmares for weeks after.
A smoker with a chronic cough is a common complaint in the ER. The usual diagnosis is bronchitis or pneumonia. On a number of occasions I have viewed the x-ray and found a lesion that looked like lung cancer. The word cancer comes from the Latin and means crab. The central body and the "legs" of the crab are an apt description of the shape of a lung cancer on a chest x-ray. Despite the warnings on every pack of cigarettes, the addictive power of nicotine traps the smoker. In each case, I try to be honest but offer hope and sympathy.
Ovarian cancer is too often diagnosed only after it has become advanced. Chronic pelvic or lower abdominal pain is sometimes seen in the ER. An ultrasound or CT may make the diagnosis. A sore testicle or a lump in the testicle may turn out to be testicular cancer. ER docs must keep these diagnoses in the differential of patients with pelvic or scrotal complaints.
Radiation and chemotherapy can impair a cancer patient's immune system and lead to life threatening infections. A cancer patient with a fever is a call to action. Cultures are obtained from the patient's blood, urine, stool, sputum, throat, skin lesions; a chest x-ray is done; and the patient is given broad spectrum antibiotics. Although this is ER medicine by the numbers, it is imperative to remember the anxiety and emotional well being of the patient and family.
We all have friends or family members who have cancer or who have died from cancer. Some of us are currently being evaluated or treated for cancer. Walk, bike, swim etc "athons" are held to raise funds for cancer research for "the cure". I would urge my readers to keep current on the latest research. Cancer is a complex disease. Early diagnosis and preventive behavior are still our best hope. Get recommended screenings, don't smoke, eat a healthy diet, keep your weight down and know your family history of cancer.
Having a strong faith, keeping a optimistic outlook, laughing, and being active are all helpful in dealing with a personal diagnosis and treatment of any cancer. Friends and family are vital in the battle. We are all mortal. My father died of renal cell carcinoma. When he received the diagnosis and grim prognosis, his comment to me was "at least I know what I will die from". He was in hospice care at the end. He died at home with his family at his bedside. I hope I can face my mortality with such grace and strength.
On occasion, I have made the diagnosis of cancer in a patient who came to the ER for a seemingly unrelated problem. Chronic coughs, vomiting and diarrhea, abdominal pains, headaches, seizures, strokes, skin lesions, nose bleeds, and fevers may all be the first presenting symptoms of cancer. In my thirty years of ER practice I have diagnosed leukemia, brain tumors, melanoma and other skin cancers, lung cancer, breast cancer, ovarian cancer and oral cancer.
The diagnosis is usually a surprise to me and devastating to the patient and his or her family. As a resident during the late 70's, I examined a 27 year old woman for the presenting complaint of a "breast infection". This young mother of three was 6 months postpartum. Her left breast was hard with a pebbly feel known as peau d'orange. The nipple was retracted and I easily palpated several hard lymph nodes in the left axilla (armpit). There was no doubt that she had advanced breast cancer. She was only a couple of years older than me. Her mother accompanied her and was watching the patient's children. Being young and very inexperienced, I blurted out the diagnosis and told her I would set up for her to see a surgeon. When she started crying I offered my sympathies and almost ran out of the room.
Recently I examined a woman in her 60's who presented after a syncopal episode. She had a sudden unexplained loss of consciousness. I ordered the usual labs, EKG and head CT. She was very lethargic and her speech was slurred. The CT showed a large mass with some bleeding. There was swelling of the brain. A malignant brain tumor in a healthy woman who "fainted". I arranged for transfer to a major teaching hospital. The family and I spoke at length of the diagnosis. I offered a sympathetic and encouraging message. In my advanced years, I also cried along with the family.
A toddler with frequent nose bleeds is usually caused by vigorous use of the child's index finger in his nostril. The beautiful little boy on the stretcher looked too pale and I noticed petechiae and bruises. My worst fears were confirmed when his CBC showed ALL (acute lymphocytic leukemia). The child was transferred to a pediatric hospital. The cure rate for this form of cancer is excellent, but knowing what he and his family would have to endure gave me nightmares for weeks after.
A smoker with a chronic cough is a common complaint in the ER. The usual diagnosis is bronchitis or pneumonia. On a number of occasions I have viewed the x-ray and found a lesion that looked like lung cancer. The word cancer comes from the Latin and means crab. The central body and the "legs" of the crab are an apt description of the shape of a lung cancer on a chest x-ray. Despite the warnings on every pack of cigarettes, the addictive power of nicotine traps the smoker. In each case, I try to be honest but offer hope and sympathy.
Ovarian cancer is too often diagnosed only after it has become advanced. Chronic pelvic or lower abdominal pain is sometimes seen in the ER. An ultrasound or CT may make the diagnosis. A sore testicle or a lump in the testicle may turn out to be testicular cancer. ER docs must keep these diagnoses in the differential of patients with pelvic or scrotal complaints.
Radiation and chemotherapy can impair a cancer patient's immune system and lead to life threatening infections. A cancer patient with a fever is a call to action. Cultures are obtained from the patient's blood, urine, stool, sputum, throat, skin lesions; a chest x-ray is done; and the patient is given broad spectrum antibiotics. Although this is ER medicine by the numbers, it is imperative to remember the anxiety and emotional well being of the patient and family.
We all have friends or family members who have cancer or who have died from cancer. Some of us are currently being evaluated or treated for cancer. Walk, bike, swim etc "athons" are held to raise funds for cancer research for "the cure". I would urge my readers to keep current on the latest research. Cancer is a complex disease. Early diagnosis and preventive behavior are still our best hope. Get recommended screenings, don't smoke, eat a healthy diet, keep your weight down and know your family history of cancer.
Having a strong faith, keeping a optimistic outlook, laughing, and being active are all helpful in dealing with a personal diagnosis and treatment of any cancer. Friends and family are vital in the battle. We are all mortal. My father died of renal cell carcinoma. When he received the diagnosis and grim prognosis, his comment to me was "at least I know what I will die from". He was in hospice care at the end. He died at home with his family at his bedside. I hope I can face my mortality with such grace and strength.
Saturday, June 19, 2010
Men
Tomorrow is Father's day. My reminisces about my father and his death at age 78, stimulated my creative juices. Men are brought up to be strong and uncomplaining. My father was a medic in WW2. He let an old GP suture my chin when I was 4 years old with only an ice cube application for anesthesia. He admonished to be a "man". I stifled my tears and made my father proud.
This denial of pain can lead to increased morbidity and mortality for men. I waited 5 days before seeking medical attention with increasing right lower quadrant abdominal pain. A 40 year old physician being berated by his attorney wife that RLQ pain could be appendicitis. When I was finally diagnosed with appendicitis, my surgeon was confronted with a large appendiceal abscess. The subsequent scar tissue and adhesions that developed from this abscess have led to 3 surgeries for bowel obstruction and the resection of 1 foot of my ileum. Chronic intestinal dysfunction is the legacy of my stubbornness.
Men die of myocardial infarction in large numbers because of this same attitude. Chest pain is dismissed as indigestion. Poor dietary habits, smoking, excessive drinking, and lack of exercise are rife in the male ER population. That "beer belly" is metabolically active fat that predisposes men to coronary artery events. Many male patients pridefully tell me that they don't go to the doctor. Interventions that could extend their life and improve their health are neglected.
Those of us who are fortunate to have a loving partner pushing us through the ER door, may get timely treatment. Our children may also shame us into getting medical attention. The changes in our life style are relatively simple to enumerate but difficult to initiate and maintain.
Eat healthy. No fried foods. Smaller portions. Limit salt intake. Eat fruits and vegetables. Limit your intake of caffeine and alcohol. STOP SMOKING. Begin a regular exercise program. Walk the stairs. Park further away from the store. Play a sport. Take a multiple vitamin and mineral supplement.
ED (erectile dysfunction) and lazy, slow or few "boys". Infertility in men is an increasing problem. Sperm counts and motility issues are related to multiple health and environmental factors. Excessive body fat increases levels of estrogen. Lack of exercise leads to sluggish circulation and promotes atherosclerosis (hardening of the arteries). Wearing tight clothing increases the temperature in the scrotum and impairs sperm formation. Obesity often leads to diabetes and hypertension. Both diseases are major factors in ED.
Men need to pay attention to their bodies. We tend to gain 10 lbs per decade after age 20. Increased urination may be related to elevated blood sugar and or an enlarging prostate gland. Numbness, weakness, headaches, and chest pains should not be ignored. Find a primary care doctor and get a thorough exam. Know your cholesterol level, blood pressure and BMI (body mass index, a measure of obesity).
Er docs often refer to the immature, dangerous and often times felonious actions of young men as acute testosterone poisoning. Drunk driving, binge drinking, drunken brawls, drug abuse, domestic violence, reckless behavior all lead to ER visits for the male patient or their victims. Alcohol and drug use, hazing and sexual assault are all too common on college campuses. We fathers, grandfathers, godfathers, older brothers, and uncles need to set a good example for our boys. Actions speak louder than words. I remind my nephews that I will always love them. Even if they get into trouble, I will never abandon them. They are also told that they will have to pay the financial, legal and health costs of their indiscretion's.
From a Darwinian perspective, men are only needed to procreate. That may be true for most species but human males have the chance to contribute to our families, and communities in much more significant ways. Be a caring and attentive father. Cherish your life's partner. Be good sons, brothers, and uncles. Mentor younger men at work, houses of worship, and in your community. Good health and a longer, happier life can be achieved with knowledge and determination.
Happy Father's Day
This denial of pain can lead to increased morbidity and mortality for men. I waited 5 days before seeking medical attention with increasing right lower quadrant abdominal pain. A 40 year old physician being berated by his attorney wife that RLQ pain could be appendicitis. When I was finally diagnosed with appendicitis, my surgeon was confronted with a large appendiceal abscess. The subsequent scar tissue and adhesions that developed from this abscess have led to 3 surgeries for bowel obstruction and the resection of 1 foot of my ileum. Chronic intestinal dysfunction is the legacy of my stubbornness.
Men die of myocardial infarction in large numbers because of this same attitude. Chest pain is dismissed as indigestion. Poor dietary habits, smoking, excessive drinking, and lack of exercise are rife in the male ER population. That "beer belly" is metabolically active fat that predisposes men to coronary artery events. Many male patients pridefully tell me that they don't go to the doctor. Interventions that could extend their life and improve their health are neglected.
Those of us who are fortunate to have a loving partner pushing us through the ER door, may get timely treatment. Our children may also shame us into getting medical attention. The changes in our life style are relatively simple to enumerate but difficult to initiate and maintain.
Eat healthy. No fried foods. Smaller portions. Limit salt intake. Eat fruits and vegetables. Limit your intake of caffeine and alcohol. STOP SMOKING. Begin a regular exercise program. Walk the stairs. Park further away from the store. Play a sport. Take a multiple vitamin and mineral supplement.
ED (erectile dysfunction) and lazy, slow or few "boys". Infertility in men is an increasing problem. Sperm counts and motility issues are related to multiple health and environmental factors. Excessive body fat increases levels of estrogen. Lack of exercise leads to sluggish circulation and promotes atherosclerosis (hardening of the arteries). Wearing tight clothing increases the temperature in the scrotum and impairs sperm formation. Obesity often leads to diabetes and hypertension. Both diseases are major factors in ED.
Men need to pay attention to their bodies. We tend to gain 10 lbs per decade after age 20. Increased urination may be related to elevated blood sugar and or an enlarging prostate gland. Numbness, weakness, headaches, and chest pains should not be ignored. Find a primary care doctor and get a thorough exam. Know your cholesterol level, blood pressure and BMI (body mass index, a measure of obesity).
Er docs often refer to the immature, dangerous and often times felonious actions of young men as acute testosterone poisoning. Drunk driving, binge drinking, drunken brawls, drug abuse, domestic violence, reckless behavior all lead to ER visits for the male patient or their victims. Alcohol and drug use, hazing and sexual assault are all too common on college campuses. We fathers, grandfathers, godfathers, older brothers, and uncles need to set a good example for our boys. Actions speak louder than words. I remind my nephews that I will always love them. Even if they get into trouble, I will never abandon them. They are also told that they will have to pay the financial, legal and health costs of their indiscretion's.
From a Darwinian perspective, men are only needed to procreate. That may be true for most species but human males have the chance to contribute to our families, and communities in much more significant ways. Be a caring and attentive father. Cherish your life's partner. Be good sons, brothers, and uncles. Mentor younger men at work, houses of worship, and in your community. Good health and a longer, happier life can be achieved with knowledge and determination.
Happy Father's Day
Saturday, June 12, 2010
Consciousness
I am parked in what my wife refers to as the Big Chair. She purchased this comfortable recliner as a birthday present for me last year. I picked the design, she chose the color. It is situated 2 meters from a large screen, high def TV. The USA vs England world cup match is today's feature. Four minutes into the match and we are losing 1-0. What does this have to do with consciousness? Multitasking. Can the human brain perform two functions simultaneously? Is the human brain distinct from the human mind? This is Descartes (I think therefore I am) and Nietzsche (god is dead) vs functional MRI.
As the world's oldest ER doc, I have had many opportunities to contemplate the great philosophical issues of the late twentieth and early twenty first centuries. Nurture vs nature is played out in the ER every night. A recent teenage patient was brought in by the police on an involuntary commitment. He was aggressive, abusing drugs and averse to getting any treatment. His mother was controlling, inflexible, and exhibited her own psychiatric pathology.
The young man required physical and chemical restraints to protect the ER staff from his violent attempts at escape. He was eventually placed in a psychiatric facility after more than 36 hours in the ER. My impression was that he was doomed at birth. Genetically he was handed the roots of mental illness. The environment of his home sealed the deal. Nature and nurture ganging up on this young man.
The genetic basis of mental illness and the environmental factors that increase the risk of development of mental disease have been well documented if not absolutely proven. Sociobiologists say that we are born with instincts and behavior imprinted in our genes. The environment in which we are raised may bring out the better traits, or the antisocial traits. When I treat a child for vomiting and the parent(s) are feeding the tyke cheese puffs, this construct seems all too accurate.
Mental illness, obesity, substance abuse, criminality, diabetes, and cardiovascular disease are all major players in the ER patient population. As my patients are often accompanied by family members, I get to see the genetic roots as well as the environmental enhancers of these conditions. My 27 years at the same hospital have allowed me to be the Jane Goodall of ER patients. Generations of patients from the same family with teenage births, low intelligence, and frequent ER visits make me feel like an anthropologist.
What is consciousness? Function MRI can demonstrate the sections of the brain that are active with viewing certain pictures, listening to sounds, voices and music and performing certain tasks. There is no separate consciousness. Mind=brain. Multitasking as practiced by my youngest nephew is an illusion. One cannot text, be on Facebook and study for school simultaneously. The USA vs England match is at the interval. I saw the goals only in replay because my brain was focused on this blog. Scribo ergo sum.
As the world's oldest ER doc, I have had many opportunities to contemplate the great philosophical issues of the late twentieth and early twenty first centuries. Nurture vs nature is played out in the ER every night. A recent teenage patient was brought in by the police on an involuntary commitment. He was aggressive, abusing drugs and averse to getting any treatment. His mother was controlling, inflexible, and exhibited her own psychiatric pathology.
The young man required physical and chemical restraints to protect the ER staff from his violent attempts at escape. He was eventually placed in a psychiatric facility after more than 36 hours in the ER. My impression was that he was doomed at birth. Genetically he was handed the roots of mental illness. The environment of his home sealed the deal. Nature and nurture ganging up on this young man.
The genetic basis of mental illness and the environmental factors that increase the risk of development of mental disease have been well documented if not absolutely proven. Sociobiologists say that we are born with instincts and behavior imprinted in our genes. The environment in which we are raised may bring out the better traits, or the antisocial traits. When I treat a child for vomiting and the parent(s) are feeding the tyke cheese puffs, this construct seems all too accurate.
Mental illness, obesity, substance abuse, criminality, diabetes, and cardiovascular disease are all major players in the ER patient population. As my patients are often accompanied by family members, I get to see the genetic roots as well as the environmental enhancers of these conditions. My 27 years at the same hospital have allowed me to be the Jane Goodall of ER patients. Generations of patients from the same family with teenage births, low intelligence, and frequent ER visits make me feel like an anthropologist.
What is consciousness? Function MRI can demonstrate the sections of the brain that are active with viewing certain pictures, listening to sounds, voices and music and performing certain tasks. There is no separate consciousness. Mind=brain. Multitasking as practiced by my youngest nephew is an illusion. One cannot text, be on Facebook and study for school simultaneously. The USA vs England match is at the interval. I saw the goals only in replay because my brain was focused on this blog. Scribo ergo sum.
Friday, June 11, 2010
Burn, baby, burn!
Burns are devastating injuries. They leave physical and psychic scars on the victims. ER staff are often traumatized when they care for patients with burns. Two patients with burns from a MVA, when the contents of a truck exploded, were brought to the ER this week. My young partners expertly cared for these patients and expedited their transfer to regional burn centers.
Thermal injuries can be caused by hot liquids, direct flame, electricity, or hot air. Infrared and ultraviolet rays can burn exposed skin, i.e. a sunburn. Burns are roughly divided into superficial, partial thickness and full thickness.
Superficial burns damage the upper layers of the skin but to not reach the deeper levels. A sunburn or mild scald are examples of superficial burns. The treatment is cool compresses. Topical creams containing aloe are popular and may give some comfort. NSAID's such as ibuprofen are usually adequate for pain control.
Partial thickness burns cause damage to the deeper layers of the skin and subcutaneous tissues. Blistering of the skin is often evident. These burns are very painful. Infection is likely and prophylaxis for tetanus should be given. Careful handling, removal of dead tissue, and burn dressings are used by the ER and burn center team. Fluid loss can be significant. IV fluids are often given to maintain adequate blood pressure and urine output.
Full thickness burns are usually painless. The skin and subcutaneous tissues including the sensory nerves have been destroyed. Muscle, tendon and even bone may be exposed. The treatment requires skin grafting. These burns must be treated at burn centers. The recovery is prolonged and painful. Physical therapy is a must, to recover use of burned limbs and to prevent contractures.
Electrical burns are especially difficult to treat. The external signs of the burn may be minimal. The deeper structures including muscles, nerves, and blood vessels may be severely burned without initial evidence on the surface. Cardiac complications, when the electrical current crosses the chest, are common. The voltage and duration of contact are important in determining the extent of the injuries
The area of the body surface that is burned is a critical factor in the prognosis and treatment of burns. ER staff use formulas to calculate the percentage of body surface burned. The degree of burn is also measured. Fluid resuscitation is guided by these measurements.
The burned patients airway is a critical part of the ER doc's priorities. Burns of the upper body or any burns from superheated gases may damage the upper airway and cause swelling and blockage of the airway. Endotracheal entubation, cricothyrotomy or tracheostomy may be necessary.
Deep burns that involve the neck, trunk or limbs may cause constriction of these structures. Blood flow and or respiration may be impeded. An escharotomy is the required treatment ASAP.
Escharotomy is the incising of the burnt and contracted tissue to restore blood flow or allow the chest to expand.
Early in my career I treated a homeless man who had lighter fluid squirted on his legs and been "lit up" by unknown assailants. He arrived in the ER with full thickness burns from his lower abdomen to his feet. His genitals had been burned off and he had no pulses in either leg. An inexperienced surgeon was present as the "trauma" surgeon. I pointed out that the patient needed escharotomies of both legs and a cystostomy to gain access to his bladder. The surgeon froze. He knew what had to be done but told me that he had never done either procedure solo. My emergency medicine residency was at a hospital with a large burn center. I did what I had been trained to do. Long incisions, fully through the eschar on both sides of each leg, rapidly and thankfully restored circulation. I placed a suprapubic catheter and got good urine flow. The patient was transferred to a burn center but died of his injuries a few days later.
No witty comments in this blog. I still cringe at the smell of burned flesh. ER staff are all too human. We are deeply effected by the suffering of our patients. Be careful. We are ready and able to care for the victims of burns.
Thermal injuries can be caused by hot liquids, direct flame, electricity, or hot air. Infrared and ultraviolet rays can burn exposed skin, i.e. a sunburn. Burns are roughly divided into superficial, partial thickness and full thickness.
Superficial burns damage the upper layers of the skin but to not reach the deeper levels. A sunburn or mild scald are examples of superficial burns. The treatment is cool compresses. Topical creams containing aloe are popular and may give some comfort. NSAID's such as ibuprofen are usually adequate for pain control.
Partial thickness burns cause damage to the deeper layers of the skin and subcutaneous tissues. Blistering of the skin is often evident. These burns are very painful. Infection is likely and prophylaxis for tetanus should be given. Careful handling, removal of dead tissue, and burn dressings are used by the ER and burn center team. Fluid loss can be significant. IV fluids are often given to maintain adequate blood pressure and urine output.
Full thickness burns are usually painless. The skin and subcutaneous tissues including the sensory nerves have been destroyed. Muscle, tendon and even bone may be exposed. The treatment requires skin grafting. These burns must be treated at burn centers. The recovery is prolonged and painful. Physical therapy is a must, to recover use of burned limbs and to prevent contractures.
Electrical burns are especially difficult to treat. The external signs of the burn may be minimal. The deeper structures including muscles, nerves, and blood vessels may be severely burned without initial evidence on the surface. Cardiac complications, when the electrical current crosses the chest, are common. The voltage and duration of contact are important in determining the extent of the injuries
The area of the body surface that is burned is a critical factor in the prognosis and treatment of burns. ER staff use formulas to calculate the percentage of body surface burned. The degree of burn is also measured. Fluid resuscitation is guided by these measurements.
The burned patients airway is a critical part of the ER doc's priorities. Burns of the upper body or any burns from superheated gases may damage the upper airway and cause swelling and blockage of the airway. Endotracheal entubation, cricothyrotomy or tracheostomy may be necessary.
Deep burns that involve the neck, trunk or limbs may cause constriction of these structures. Blood flow and or respiration may be impeded. An escharotomy is the required treatment ASAP.
Escharotomy is the incising of the burnt and contracted tissue to restore blood flow or allow the chest to expand.
Early in my career I treated a homeless man who had lighter fluid squirted on his legs and been "lit up" by unknown assailants. He arrived in the ER with full thickness burns from his lower abdomen to his feet. His genitals had been burned off and he had no pulses in either leg. An inexperienced surgeon was present as the "trauma" surgeon. I pointed out that the patient needed escharotomies of both legs and a cystostomy to gain access to his bladder. The surgeon froze. He knew what had to be done but told me that he had never done either procedure solo. My emergency medicine residency was at a hospital with a large burn center. I did what I had been trained to do. Long incisions, fully through the eschar on both sides of each leg, rapidly and thankfully restored circulation. I placed a suprapubic catheter and got good urine flow. The patient was transferred to a burn center but died of his injuries a few days later.
No witty comments in this blog. I still cringe at the smell of burned flesh. ER staff are all too human. We are deeply effected by the suffering of our patients. Be careful. We are ready and able to care for the victims of burns.
Sunday, June 6, 2010
post vacation blues
My wife and I had a wonderful vacation in sometimes sunny California during the last 2 weeks of May. We drove the Pacific Coast highway, visited the Hearst Castle, hiked in Muir woods, sampled wines in Sonoma, and enjoyed San Francisco. We were privileged to attend the graduation of our youngest niece, as she received her doctorate from Berkeley. Fun times, good food, fine wines, and 2 weeks with my best friend; a great vacation.
My wife is never completely on vacation. Her trusty I-phone was given a daily workout. Being an ER doc, when not at the hospital, I am free of any work obligations. I did keep in touch with Robin, my PA. I took more than 500 digital pictures and generally acted like a typical tourist.
My trained diagnostic visioscope is never turned off. I note gait disorders, Parkinsonian tremors and head titubations, orthopedic injuries and signs of cardiopulmonary distress. I even encountered a bipolar, hypomanic woman sitting behind me on the return flight. Observing and noting physical and mental illness is ingrained in me. People watching and bird watching are two of my avocations.
As I flew home with the "chatty" woman behind me, I was reminded of my only other trip to California. In 1988 I attended a wilderness medicine conference in the Sierra Mountains. It had very little relevance to the practice of emergency medicine in a city in the Northeast, but my wife and I enjoyed Lake Tahoe and hiking in the Sierras. During the flight home from that conference, the head flight attendant asked if there were any physicians on the 747. There were 3 docs, an obstectrician, an orthopedic surgeon and a much younger "world's oldest ER doc". An elderly passenger was having difficulty breathing, so I was elected to provide care. Airlines have made significant strides in the equipment carried on planes. In 1988 I was lucky to find a cheap stethoscope and a blood pressure cuff.
The woman had a slightly elevated blood pressure and a few rales at her lung bases. She denied chest pain and felt much better with oxygen. The flight engineer came back to where I was treating the woman (pre 9/11) and asked me if the plane needed to make an emergency landing. It took me a minute to fully comprehend that the flight crew would follow my recommendations. The woman felt better. I stayed with her until the plane landed at our scheduled destination, and I handed her over to EMS personnel. The flight attendants gave my wife and I a bottle of champagne (domestic) as we deplaned. I also received a letter from the CEO of the airline, thanking me for my efforts.
Resuming my usual schedule, I worked the Memorial Day weekend. Issues in my wife's business have required her to work nonstop since we got home. We are ready for another vacation.
My wife is never completely on vacation. Her trusty I-phone was given a daily workout. Being an ER doc, when not at the hospital, I am free of any work obligations. I did keep in touch with Robin, my PA. I took more than 500 digital pictures and generally acted like a typical tourist.
My trained diagnostic visioscope is never turned off. I note gait disorders, Parkinsonian tremors and head titubations, orthopedic injuries and signs of cardiopulmonary distress. I even encountered a bipolar, hypomanic woman sitting behind me on the return flight. Observing and noting physical and mental illness is ingrained in me. People watching and bird watching are two of my avocations.
As I flew home with the "chatty" woman behind me, I was reminded of my only other trip to California. In 1988 I attended a wilderness medicine conference in the Sierra Mountains. It had very little relevance to the practice of emergency medicine in a city in the Northeast, but my wife and I enjoyed Lake Tahoe and hiking in the Sierras. During the flight home from that conference, the head flight attendant asked if there were any physicians on the 747. There were 3 docs, an obstectrician, an orthopedic surgeon and a much younger "world's oldest ER doc". An elderly passenger was having difficulty breathing, so I was elected to provide care. Airlines have made significant strides in the equipment carried on planes. In 1988 I was lucky to find a cheap stethoscope and a blood pressure cuff.
The woman had a slightly elevated blood pressure and a few rales at her lung bases. She denied chest pain and felt much better with oxygen. The flight engineer came back to where I was treating the woman (pre 9/11) and asked me if the plane needed to make an emergency landing. It took me a minute to fully comprehend that the flight crew would follow my recommendations. The woman felt better. I stayed with her until the plane landed at our scheduled destination, and I handed her over to EMS personnel. The flight attendants gave my wife and I a bottle of champagne (domestic) as we deplaned. I also received a letter from the CEO of the airline, thanking me for my efforts.
Resuming my usual schedule, I worked the Memorial Day weekend. Issues in my wife's business have required her to work nonstop since we got home. We are ready for another vacation.
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