Monday, July 29, 2013

Level one trauma: A Story of a Broken Heart: in 3 parts Part One: Preop What’s the story? 53 year old male, level one trauma. Single car MVA, unconscious. Intubated at scene, CPR in progress. Part Two: IntraOp Chaotic scene. Setting up in OR 17. Laying out drugs, intravenous lines, Belmont rapid infuser, getting room warm. Patient rolls into room on stretcher, ER team ventilating via ambu bag, monitor at the foot of the bed. Bilateral chest tubes in place, blood on pressure bags infusing through antecubital IVs. Lead anesthesiologist: “What’s the story?” ER nurse: “53 year old male, level one trauma. Single car MVA, unconscious. Intubated at scene. No known allergies. Came to ER with chest injury, no known head trauma, but unconscious, intubated, pupils reactive. Had a baseline dysrhythmia, unknown type. CPR initiated in transit. In ER, initial rhythm was non-perfusing V-tach, shocked into sinus tach, CPR continued as BP remained low. Widened mediastinum, chest tubes and pericardiocentesis performed. Pressure stabilized, but requiring massive transfusion.” Lead anesthesiologist: “So he’s bleeding out?” ER: “Basically. Something tore in his heart. Pressures came up with chest tube placement and pericardiocentesis. Still low, but perfusing as long as we keep the tank full.” Moving patient over to OR table, watching the lines, endotracheal tube, C-collar. Delegating anes team to transfer the monitors, one line at a time. Lead anes: “Can someone get a blood gas? Any other history? Where’s the surgeon?” Surgeon, directing prep as he scrubs: “we need to open the chest. “ “Roger that! If we can’t stop the bleeding, we’ll just empty the blood bank. Working on a MAC cordis now.” Taking off C-collar, keeping head neutral. Directing anes team: “Try giving him some anesthesia. He’s gotta be in a lot of pain.” “ Got the neck line, hook up the Belmont. How much blood do we have?” Circulator: “We’ve got two more units of type O from ER, type and cross pending.” “May be time for some permissive hypotension. ABG results are OK..ish. Anemic, Oxygenation OK, pH moderate metabolic acidosis.” Surgeon getting exposure. “There’s a lot of scarring around his heart. Any previous surgeries?” “None known. Some childhood stuff.” “No anesthetic onboard, he still can’t tolerate it. He’s gotta be in a lot of pain. “ “There’s some constriction around his heart. That band of stiffness just cut into his heart. That’s what’s causing the bleeding. Need to free up the rest of the constriction and patch the hole. Surgeon: “I can’t get good access”. To the scrub nurse “Can you reach in and lift the heart a little?” Anes “It’s making him a bit tachy, dropping his pressure, but he’s tolerating it” Surgeon: “patch in, bleeding should be decreasing.” Anes “ Seems so. Patient stabilizing. Belmont only at 20 ml/min now. Gotta keep him from getting cold, then he’ll die from coagulopathy. Need some followup ABGs.” Surgeon: “Does he have any family?” Circulator: “Chart says he’s married, but separated. 2 kids, grown, not living at home. He lives alone.” Part Three: PostOp Family and friends: “What’s the prognosis?” The team: “He’s still very ill. He had an old injury to his heart, some kind of constriction, a scarring in a band, and when the crash happened, his heart slammed into that and it cut a hole in his heart. We patched it, and either the patch will hold, and he’ll grow into it and recover or he’ll get cold and die. Or the patch could rupture and he’ll die. The constriction was probably causing him problems for years, but he wasn’t aware of it.” Family and friends : “What can we do?” “Hold his hand, talk to him, keep him warm. He’s aware, even if he’s not responding. He’s lucky. Most people don’t get a second chance. He’s got blood flowing to places that haven’t seen good flow in years. That in and of itself can induce some instability. There doesn’t appear to be any brain damage. If he recovers, he should be better than before. His heart is in a proper rhythm, and the constrictions that limited him before are gone. I’m really amazed that he did all he did with that limited blood flow.”

Tuesday, January 04, 2011

Red Cross


Sunday, January 02, 2011

4call


3call


test calengooicon


Wednesday, September 22, 2010

Still resting

just trying to reactivate accts.

Wednesday, February 11, 2009

I'm not gone

just resting....

Wednesday, November 12, 2008

Wither Freedom?

The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries. W. Churchill...
Except I don't expect those in power will share the misery.

We contend for a nation to tax itself into prosperity is like a man standing in a bucket and trying to lift himself up by the handle.

Thursday, May 25, 2006

"Magic" foods

There seems to me to be a major disorder of thought out there. People think that eating "special" foods will cure all their ills. It's not just the "eat grapefruit" diets, eat protein diets, etc. that I'm thinking of. It's the idea that the quantity doesn't matter. If I eat 90 calories of sugery crap, I'll get fatter than if I eat 100 calories of nutrious fruit. UNTRUE. Calories are calories.