Emergency Medicine orientation

"Sometimes the facial structures are traumatized, complicating the intubation. Although, it is a lot easier to get the jaw and tongue out of the way when they are disconnected."

"You want to make sure the NG tube is not in the lungs; it can't really decompress the stomach from there."

"He came in with a skeleton of a finger, no flesh, and said 'fix me.' Well, sorry dude, you're f*cked. There's no saving that finger. Degloving injuries require amputation."

"In Europe, not everyone who goes into a trauma bay gets a rectal, but here we log roll everyone and do a rectal exam. The surgeons love it."

Body Surface Area

While gchatting (ostensibly studying neurology) a friend sent me a news story (from the science section?!) detailing how much skin a woman should show to maximize attractiveness to nearby men.

Methods: This was an observational study in which the authors used percentages of the body to determine the amount of exposed skin. Each arm was 10%, each leg 15% and the torso 50%. They they counted how many times each woman was approached. Neither the men or the women knew they were being studied.

Results: Women showing more or less than 40% exposed skin were approached less frequently.

Conclusion: Women showing less than 40% sent "prude" signals and women showing more sent "whore, adulteress" signals.

My immediate reaction was not "what a stupid thing to study" or "how can they claim to know what the men were thinking" or even "how does the methodology account for the possibility that the 40% women just happened to be the hottest regardless of clothing".

No, my reaction was: they got the body percentages wrong! Commonly used body surface area percentages for estimating burn injury are shown in the picture.

picture from UofM burn website: http://www.traumaburn.org/referring/fluid.shtml

Big trauma

A class one rolled in with the survival flight paramedics; he had been broad-sided in a MVC. He looked to be in surprising good shape: unstable pelvis and dehydrated, but good vitals, responsive pupils and moving all four extremities. The CT scan, however, told a different story and he went up to the OR emergently: 3 perforations in his bowels, multiple pelvic fractures (with bleeding) and an aortic dissection. He went straight from OR to IR to BICU... we'll see how he does.

Yet more trauma

It started off well. I was studying in a coffeeshop when my trauma pager went off. It's silly, but I felt a little cool reading the page out to my friend and booking it out of there.

"Class 2 M, Go cart vs truck, blunt, 115/78, not intubated, unk GCS, ETA 8 min"

It turned out the patient was pretty much ok - just a closed tib/fib fracture. He had been transferred to our hospital mostly because of questionable change in mental status, which it became quickly clear was not the case.

On my way back to my car to drive home and contine studying (well, doing write-ups on clinic patients) the pager goes off again (in front of more people!).

"Class 1, M, ATV vs tree, blunt, 123/80, intubated, GCS 3, ETA 10 mins."

It turned out ATV vs tree was actually fell-off-the-back-of-moving-pickup-truck. For those non-medical folk, GCS of 3 is very bad. It's a scale of 3-15 based on eye opening, movement and vocalization. A 3 means you have none of the above. He displayed from priapism (look it up if you don't know), indicating decreased sympathetic tone. On CT he had an impressive skull fracture and significant uncal herniation.

While eating a delayed dinner, the pager again beeps.

"Class 2, M, dirt bike accident, GCS 15, not int, in ER"

Five minutes later...

"Adult, class 2, motorcycle accident, left ankle lac, 148/68, HR 118, GCS 15, ETA 5mins"

More trauma pages

The trauma pager has beeped a few more times and I've seen multiple bike vs. car and a falling off a 30 foot ladder. Think chest tubes, intubation, consults with a neurosurgeon and lot of leg fractures. Any thoughts I had of becoming a bicyclist are definitely out. Mostly I just watch the trauma team in action, but occasionally I get to do things like put a gown on the person, stabilize the neck while rolling him.. small things of that nature.

I've also had two more gen med clinics. Yesterday's was particularly cool because Dr. K went in and did the appointment (without me), then sent me in to try my hand (observed by Dr. P). I asked my questions, did a limited physical exam and then explained what I thought it was and attempted to address the patients concerns and questions. Upon debrief with Dr. K and Dr. P... I got it RIGHT! I successfully diagnosed a real patient based only on information I gathered myself in real time. I have to admit, that felt really really good.

There was a second ego boost later in the day when the M4 on trauma rotation was quizzing the M3s on surgery about thoracotomy and pneumothorax. M3s didn't have a clue (and I knew all the answers, but kept my mouth shut because no one likes a show off). The current M3 class has been running around patting themselves on the back for their record-breaking board scores (their average was the highest at UofM ever), but they are being outdone by lowly little M2s in the trauma bay.

Caught

Rounds just ended. I did fine on the first half where we are walking from room to room. Even saw a man with 27% of his body surface burned by a bbq. Also saw a compartment syndrome fasciotomy on the anteriolateral lower leg. THEN we went to the conference room and went through another hour of patients just talking.... talking in a dim room... sitting down... after I'd been up all night... I REALLY tried to hold it together.

The trauma surgeon who was in the trauma bay over the weekend walks out of the room with me.

"Looks like your coffee is wearing off. Fighting a losing battle there."

And now I'm completely ashamed. Ashamed and embarrassed. And still really sleepy.

First pages

This weekend brought the first liver transplant since I started taking anesthesia call and the first trauma page on my trauma block.

For anesthesia, my friend J was on call of the intra-op samples (I'm jealous) but I've been going in to the surgical ICU every day to take blood from the arterial line and urine from the Foley for processing. I'm sure there will eventually be a liver on my watch and I'll get to go into the OR.

For trauma, I booked it down to the trauma bays to watch the team take care of a young adult with an open tib-fib fracture from a motorcycle accident. I was hoping July 4th would be a heavy trauma weekend, but so far - not so much. Let's hope it gets busier over the next two weeks.

Ok, so I realise that my hoping for livers and trauma requires that people get sick and that it makes me a tad bit of a bad person. But really, these things are going to happen; I just want them to happen here (as opposed to in OH or some other place that I am not).