MVC

I am sitting in a car dealership having a headlight replaced. Being a fine piece of German engineering, the bulb will cost $209 plus labor. I have been told that the bumper assembly must be entered to replace this Xenon bulb. The car I drive is 10 years old. It is a squat, unsexy wagon. It's appeal is safety. "Bruno" weighs in at 4000 + pounds, is all wheel drive, has front and side airbags and has a manual transmission. Driving to and from the ER earlier this week during a blizzard, reinforced one of the reasons I drive this vehicle. The main purpose of owning 2 tons of car is to allow me to survive an MVC (motor vehicle collision).



My ER is a level 3 trauma center. Weather permitting, an MVC patient having life threatening injuries, may be sent to one of the level 1 trauma center 30 miles from my area by helicopter. Most occupants of a car crash are brought to the regional level 3 hospital. The patients arrive on a board with a cervical collar in place. ALS (advanced life support) is rarely needed for victims of motor vehicle trauma. New evidence has supported the concept of scoop and run versus the ALS, stay and play. Thankfully automotive design has made cars, trucks, and vans safer for their occupants in a MVC.



When a patient from an MVC arrives in the ER, the nurses, doctors, techs and PA's do a primary assessment. Vital signs, airway, breathing and cardiovascular are rapidly performed. Pertinent information as to the patients medications, allergies, past medical and surgical history and last food and drink ingestion. An examination of the patient from head to toes will guide the ER staff in determining what labs, radiographic and other diagnostic tests need to be necessary. FAST examination (an ultrasound of the abdomen) may be done quickly and without moving the patient. A trauma surgeon may be called in or the patient may be stabilized for urgent transport to a higher level trauma center.

The most seriously injured patients from an MVC are those that are ejected from the vehicle. The single most important tool for survival is to wear a seat and shoulder belt. The details of the accident such as speed, area of impact, and rollover may give clues as to the type of injuries that the patients will have. Prolonged extrication times are also important as internal injuries with ongoing blood loss must be addressed as soon as possible.

There are strong guidelines as to the type of seat and its position for protecting babies and children in motor vehicles. Parents must use the correct seat type for the age and weight of their child. Belts and straps must be applied as recommended by the device and car manufacturer.

Winter is here. Snow, ice, wind make driving a challenge. Take your time. Appropriate speed is determined by the weather and road conditions, not the speed limit. Wear your seat belt. Protect your children. Maintain your car with winter tires, lots of window washer fluid and proper air pressure in your tires. If there is a storm advisory, stay home. Don't drive unless you have to. Bruno, my trusty tank, will get me to the ER. I will be there with my coworkers, ready to care for the victims of MVC's

SAD

S.A.D is an acronym for seasonal affective disorder. This used to be referred to as the winter blues. Short days, long nights, cold, windy and snowy conditions make some feel blue. My beautiful wife will inevitably tell me that we must go somewhere warm and sunny during the long winters of the Northeast.

The holidays are also a source of winter depression. The joy and festive mood of the Christmas season reminds us of the loved ones who are not with us. Military personnel serving in war zones or on distant bases, family in far off cities, towns and foreign countries, and family and friends who have passed leave us bereft and aching.

The economy has idled millions of our fellow citizens. The number of Americans who have had their homes foreclosed is staggering. What parent wouldn't feel depressed when faced with a Christmas among strangers and no presents for their children.

I want to cure the winter blues. Isn't that what a physician is trained and sworn to do? SAD is treatable. Special whole spectrum lights can affect the parts of the brain that cause the sadness and lack of energy associated with SAD. In severe cases antidepressant medications may be prescribed and are usually effective.

In the ER, the number of psychiatric patients often increases around Christmas and New Year's. The staff provides a warm bed, food, a TV for entertainment and medications for our depressed, schizophrenic, bipolar, substance abusing patients. Their stay in the ER is prolonged because of the dearth of beds in the psychiatric hospitals.

To my gentle readers, I would make a request. Spread the joy of the holiday. Be kind to all you encounter. Donate food, clothes, toys and money. Volunteering costs you only some time and yet yields great rewards for the recipients and the givers. Be sensitive to those who are feeling the void of a missing loved one. Kind words, a hug if appropriate, and prayers if one is so motivated.

My wife and I will spend Christmas eve with family. Tomorrow we will visit my nonagenarian mother in the nursing home. "It's a wonderful life" is on TV tomorrow night. We will sit together, speak the dialogue along with Jimmy Steward and Donna Reed, and cry at the ending.

Merry Chistmas. Feliz Navidad. Chung Mung Giang Sinh. Boas Festose Feliz Ano Novo. Kala Christouyenna. Joyeux Noel. Soursdey Noel. Buone Feste Natalizie.

Peace on Earth!

Seven days til Christmas

Tis the week before Christmas and all through my mind,
Visions of moms with their kids; complaints of all kind:
Sniffles and coughs, fever and chills,
Spitting up, pooping, bumps and spills,
Swallowing toys, batteries, and herbage,
Infants and toddlers will eat any garbage.

The plants of the season give me concerns,
Mistletoe, poinsettias and even house ferns,
All can injure if chewed or ingested.

Holly especially is one to be detested:
20 berries to a child is a dose that may kill,
Vomiting, gasping, seizing; this is not a drill.

Take care with toys that have been painted,
With lead and cadmium, they could be tainted.

Sleds, skate, skis and snow boards make great presents,
Add a helmet for the young and even the parents.

Safety for my patients keeps me awake,
Thin ice may cause drowning for wee ones who skate.

Low temperature, wet and wind: frost bite is a real peril,
Layers of clothes, hats, scarves, mittens; warm winter apparel.

Hot toddies, egg nog and drinks for the season,
None for children and with good reason,

Alcohol is a poison even in small doses,
Take care of the partiers with curious noses.

But you'll hear me proclaim ere my words fade from sight,
Have a safe Christmas and to all a good night.

Fit to be Tied

Fit, spell, seizure, epilepsy, ictus are all terms that denote a seizure. Let's start with a definition. A seizure is a sudden neurological event caused by an abnormal excessive discharge of a group of neurons in the brain. The disease, epilepsy is recurrent seizures due to a chronic underlying process. Seizures are grossly divided into generalized and partial (focal).

Simple partial seizures do not lead to alterations in consciousness. The patient may have motor, sensory, automatic or psychic symptoms. Complex partial seizures include alteration in consciousness in addition to automatisms such as lip smacking, chewing, aimless walking or other complex motor activities.

Generalized seizures are either grand mal (tonic-clonic) or petit mal (absence). Have I ever mentioned that the French were the pioneers in neurology?

Grand mal seizures always present with a loss of consciousness and posture control. During the tonic phase there are marked contraction of muscles. Teeth clenching may lead to oral trauma and bleeding. The clonic phase of the seizure demonstrates rhythmic jerking of the body. There is usually a loss of control of the bladder and sometimes the bowels. A person having a grand mal seizure is not swallowing his tongue. One should not try and force anything into the patient's mouth. First aid is to remove any objects around the victim that they might cause injury and if possible to turn them onto their side.

Absence seizures are best described as a sudden brief impairment of consciousness without a loss of posture control. The typical petit mal seizure is 5-10 seconds of staring with minor motor twitching. The danger is that a petit mal seizure occurring while driving or performing any dangerous task could be disastrous.

Focal seizures involve only part on the body. Sometimes a single limb or side of the face, or more commonly a half of the body. Focal seizures are caused by anatomical abnormalities on the side of the brain opposite the side where the seizure activity is noted.

Some clonic movements may also be seen with many forms of syncope. Cardiac arrhythmias, vasovagal syncope, hyperventilation syncope may all show brief muscle twitching. In the ER psychogenic or pseudoseizures are part of the differential diagnosis in the seizure work up. Often patients with a true seizure disorder will have pseudoseizures. The lack of respiratory muscle involvement, the stylized movements and the lack of a postictal period of confusion and lethargy help to separate the psychogenic from the true seizure.

Seizures are often idiopathic, that is that there is no known cause. Genetics do play some role in idiopathic seizures. Tumors of the brain or metastatic tumors from other cancers, vascular anomalies such as AVM's (arteriovenous malformations), strokes and trauma to the brain are all anatomical causes of seizures. Many medications and abusable substances lower the seizure threshold and may lead to seizures. Isoniazid for tuberculosis, alkylating agents for chemotherapy, antimalarials (chloroquine and mefloquine), antipsychotics, antidepressants, alcohol, speed, cocaine, PCP, and methylphenidate are just some of drugs that may cause seizures.

In the patient with known epilepsy, a recurrent seizure work up will include an examination for any evidence of brain injury, infections, electrolyte abnormalities, and blood levels of the anticonvulsants that are prescribed for the patient. A drug and alcohol panel may also be done. Missed doses or simply stopping their medications are most often the cause of the recurrent seizure.

A first time seizure in an afebrile child or adult will lead to a more comprehensive work up. Besides blood and urine tests and a detailed history and physical exam, some type of imaging study will be performed. A CT or MRI of the head is part of the initial examination. An EEG will be done as soon as possible. Neurologists prefer that the patient not be started on an anticonvulsant until the EEG has been done. The ER doc must strongly admonish the patient that he or she is not to drive, operate machinery or engage in dangerous activities (scuba diving, climbing ladders, skiing, etc) until cleared by the neurologist. Seizures with fever especially in an adult may indicate a CNS infection such as meningitis or encephalitis and an LP will need to be performed.

Simple febrile seizures are a fairly common ER occurrence. In children from 3 months to 5 years, a seizure that is generalized, lasts less than 5 minutes and is accompanied by a fever is the usual presentation. The work up will depend on the individual patient's history and physical examination and height of the fever. About 80% of children who have a simple febrile seizure will not have any additional seizures. The EEG and use of anticonvulsants is rarely needed except for the 20% who return in the future with second or third febrile seizures. First aid as mentioned earlier is to protect the child from injury and to turn him on his side.

A newborn having a seizure, with or without fever, will be more aggressively evaluated with CT and LP almost always being part on the examination. Birth trauma and neonatal infection are the most common etiology of seizures in this patient population.

Status epilepticus is a life or death emergency in the patient with seizures. Status is the term used to describe a patient who has multiple seizure without a return to full consciousness or a patient who has continuous seizure activity. Untreated, status epilepticus will cause permanent injury to the brain or death. A recent patient of mine illustrates the difficulty in management of this condition.

The patient was man in his 60's who had had a hemorrhagic stroke in the past. He had a craniotomy to remove accumulated blood and was taking anticonvulsants. The injury to his brain had been on the left side. He presented to the ER with the paramedics and had been given IV lorazepam. This medication is a benzodiazepine and is a rapidly effective anticonvulsant. The patient was still having seizure activity involving the right side of his face and his right arm and leg. Blood tests and a CT did not show any obvious cause of his continued seizure activity. The patient was endotracheally entubated to protect his airway and multiple doses of ativan were given. He was given a loading dose of phenytoin, an additional anticonvulsant and paralytics to stop the motor activity. I arranged for urgent transfer to a tertiary care hospital as even when paralyzed the seizure activity of the brain could still be occurring. He needed continuous EEG monitoring. As he was about to be transferred I noticed a subtle twitching of his right eyelids. My parting shot was a loading dose on phenobarbital, a potent anticonvulsant.

Seizures are a frightening experience for the patient, their family and friends and even the bystanders who witness the ictus (from the Latin, meaning to strike). Historically, people with epilepsy were considered possessed. Exorcisms, trephinations (holes drilled into the skull) were perpetrated against these unfortunate patients. The psychic pronouncements of individuals with simple partial seizures may have been the basis for the oracles of mythology. As enlightened humans we should recognize that epilepsy in all its manifestations is diagnosable and treatable. There is no room in the 21st century for stigmatizing patients with epilepsy.

Knowledge leads to understanding.

Due Date

This epistle is dedicated to a dear friend. She is a great ER nurse who recently "caught" a baby.



Docs, nurses, cops, and EMT's don't deliver babies. Women deliver babies. Everyone else involved just helps. The hospital where I "live" has a busy OB service. More than 3,000 babies a year enter this troubled world from within our doors. Highly trained labor and delivery nurses and special care nursery staff along with obstetricians, anesthesiologists and pediatricians all work hard to ensure a safe and healthy outcome for mother and child.



Occasionally the delivery occurs in the ER. ER docs and nurses are trained, have the appropriate equipment and are ably backed up by the L&D and nursery pros. Deliveries in the community are the responsibility of police, firemen, and EMS personnel. The mother and child arrive in the ER and stop only if not stable enough for transport upstairs.



A recent episode highlights an unusual OB and neonatal case. The call was for a precipitous delivery in an apartment. The mother was OK but the baby was reported to be blue. The night ER staff was ready with a warming stand, and all the equipment for entubation and resuscitation of the newborn. The baby arrived crying lustily. His face was blue but the rest of his body was pink. He had good muscle tone and good respiratory efforts. His oxygen saturation was 100%. The blue face was caused by bruising from his too rapid descend through the birth canal. His mother's use of cocaine was probably a factor in his hasty entrance.



The twilight zone of deliveries resides in the cars that drive up to the ER entrance with a usually male driver yelling that his wife/girlfriend is having the baby in the car. In my 30+ years of ER experience, I have done 2 "auto" deliveries.



The first was in a small car. It was February and the ambient temperature of 20 degrees (F). The delivery was easy. The cold was the problem. Being a much younger "world's oldest ER doc", I placed the baby on the mother's stomach, wrapped both in a blanket and lifted them up in my arms and rushed into the ER. All went well for mother and baby.



My second drive-up delivery was very different. My "old" friend (the nurse to whom this blog is dedicated) ran out to the minivan in response to the husband's cries for help. A rather large woman of about 110 Kg was lying on the passenger's seat that was in the reclined position. The mother's feet were up on the dash and between her legs the nurse saw two tiny feet dangling from the vagina. The nurse's calls for help were clearly heard in the ER core as she yelled my name. I grabbed some gloves and went through the ER waiting room to the minivan. An obstetrician (who no longer works at our hospital) arrived almost at the same time.



A breech delivery is when any part of the lower half of the baby leads the way down the birth canal. This unfortunate mother was scheduled to have an elective Cesarean section at 8:00 AM that day for an ultrasound proven breech presentation. I was faced with a double footling breech delivery. Most emergency medicine residencies give little training in the management of abnormal deliveries. Ultrasound has decreased the unexpected brow, breech, or shoulder presentations. The OB doc who met me at the minivan offered only the advice that I should get the mother upstairs and then turned and reentered the hospital.



There was no way to safely lift and transport this woman from the van to the ER. My mind and hands recalled a single leg and full breech delivery that I had done while on my obstetrical rotation, during my EM residency back in the seventies. I probed and brought out the upper arm and then the lower arm and finally the baby's head. I clamped and cut the umbilical cord and rushed the baby into the ER. The mother followed soon there after. The baby had a broken clavicle but was otherwise perfectly healthy.



My nurse-friend and I were shaken by this close call. My partners all commented that they had never seen any type of breech delivery and were relieved that I (not they) had been working that night. The nurse shared with me that she had nightmares about this case. The what ifs were hard to digest. I slept well that morning, after my shift ended and I arrived home. Being OCD, I brushed up on all less than normal deliveries with a very old textbook from my medical school collection.



There is nothing more satisfying to anyone who works in health care than being part of a delivery. The birth of another human being is awe inspiring. It was a privilege to have had the opportunity to assist these 2 women. My dear friend currently works in the ER of a tertiary care hospital that handles most complicated OB cases in our region. Her occasional per diem shift in my ER and our friendship keep us connected. The case of the double footling breech is our special bond.

GGB redux

One of my earliest blogs was about falls in the elderly and the subsequent ER visits from the injuries suffered. I bloviated about the neurological, cardiac and pharmacological issues that led to these all too frequent events.

A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.

Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".

After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.

The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.

I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.

One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.

There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.

The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.

Resquiescat in pace

RIP. As a new member of the medical staff of my hospital in the early 80's, I needed advise and guidance. A smiling pediatrician welcomed me to Local General Hospital. Dr M worked in a large multispecialty group practice. He later started his own office with his wife who managed the practice. Children from his practice would arrive in the ER after a phone call from M. The information would often include insights into the dynamics of the family. Having M's friendship and confidence was greatly appreciated by a naive ER doc.

I was privileged to be Dr M's personal ER doc. He and his beloved wife honored me by their confidence in my abilities. When my nephews needed a new pediatrician, Dr M welcomed them into his "family" of patients. Eight days ago M made his last visit to the ER. He had suffered a cardiac arrest at home. Despite CPR by his wife and the best efforts of EMS, ER and intensivists at our hospital, Dr M died on Halloween morning.

A memorial service was held this morning. I had worked the past three nights and grabbed two hours of sleep. A shower and my best dark suit made me presentable to say goodbye to my friend. The church was packed with colleagues, family, friends and patients. The receiving line at the wake last night began forming an hour before the viewing began. A reading from "Winnie the Pooh" was given by one of M's son. His other son who joined his office 5 years ago, read a pertinent passage from the New Testament. The CEO of our hospital gave a deeply felt and moving eulogy. A life long friend added a eulogy that gave insight into M's personal life.

What is the measure of a man? Dr M was a loving husband and father. Friend, mentor, care giver, teacher. He served as president of the medical staff, member of the board of trustees, and tirelessly raised the profile and brought in donations for the hospital. The loss of this extraordinary man will be felt by everyone who was embraced by his warmth and humanity.

The epitaph for Dr M is what he told my sister-in-law and the parents of all his kids, "take him home and love him".