No Pressure

"So the patient has been temporarily paralyzed by the drugs, and you're the one keeping them alive by squeezing air into their lungs...but...no pressure".

Gulp. 

I was holding the mask as tightly against her face as I could, sealing the rubber to her cheeks in the effort to keep highly oxygenated air from leaking out. Looking down at her from the head of the bed I saw the patient from a different vantage point, a place that made her look so vulnerable.

And she was vulnerable.

A few minutes prior to closing her eyes she had been nervously chatting and laughing away as we prepared her for surgery. The dose of propofol and the inhaled sedatives smoothed her face and left her body limp. Now we had injected medication into her intravenous line to paralyze her. Once her muscles were relaxed we could slide a tube down her throat and into the trachea, providing the means to ensure that her airway would remain open and her lungs could be well ventilated with oxygen during the surgery.

I removed the mask to prepare for the intubation. Her skin was pale, the freckles standing out now that the nervous blush had faded from her cheeks and neck. She was perfectly still and we were moving into action. 

It struck me then how explicitly patients trust their doctors and nurses. Of course I have always understood this as a general concept in healthcare but this was suddenly a much more concrete example. Patients literally put their lives in our hands on a daily basis.

Why have I never said to a patient, "Thank you for trusting me with your most precious possession"? Why has a patient never said to me, "Please do not be hurried, or harried, distracted or inattentive, because today you are responsible for my survival"?

I suppose these are silent agreements and understandings that we have in all of our patient interactions. Yet the fact that we don't outwardly acknowledge these understandings means that maybe we've forgotten that at the core, it is an honor to be in this role. I'm not so unrealistic to think that one is thankful when the bleep goes off for the 47th time on a Christmas eve night shift...but I hope that at the end of the day when I am bone tired and flopped-out on the couch in the call room I'll remember this, and take even just a tiny measure of satisfaction from the honor of responsibility. 

No pressure.

Tomorrow and Tomorrow...

It is moments like this that make me so happy that I am in medical school.

Engrossed

I don't know where to begin talking about "And the Band Played On" by Schiltz.

I've been wanting to read it since I had the unique opportunity to hear Dr. Paul Gallo speak 2 years ago at the University. Of course, I am only now beginning to grasp his role in the discovery of HIV and how he stood at the epicenter of an extraordinary time in medical science.

At the risk of sounding laughably naive, I never thought of how powerfully the politics of the time and society's value judgements facilitated the development of the AIDS epidemic. I hadn't considered the blatant discrimination displayed against gays by the lack of alarm and media coverage. How one of the first news stories to appear about the epidemic was only when a woman had contracted the disease...suddenly it was a story only when someone other than a homosexual man was sick. As I write this I shake my head at how stupid I sound. Of course politics and conservative beliefs played a huge role in the pathetic response by agencies like the CDC and the NIH. Of course. I just hadn't considered all these angles to the issue before.

But still, it boggles my mind. And it saddens me so deeply to learn how many lives could have been spared if only things had been handled more efficiently and more aggressively by people in power--from government agencies to gay leaders. I temper this statement only by saying that I know how easy it is to judge through the lens of the retrospectoscope.

And yet it is also enthralling to read about a time in medical science when clinicians and researchers were scrambling to put together this puzzle with seemingly random pieces. Some patients had toxoplasmosis, others had PCP, some thrush, many Kaposi's sarcoma...no wonder if took time for people to figure out this was one disease with so many faces. Even the concept of determining that it was an infectious disease...when many thought it came from a bad batch of 'poppers', inhaled nitrites.

I am just over half way through the book and already it has made me frustrated, angry, inspired, impressed and very, very sad. What would it have been like to be a nurse or doctor in San Fransisco in 1982 when we didn't know how the disease was transmitted? Let alone, what it would have been like to be a gay man in the same place at the same time? It is chilling to go there in one's mind.

I grew up knowing AIDS only as something famous people did fundraisers for, then as a rare disease I might encounter as a nurse, to a collection of the faces of AIDS patients I did care for. Then it was a complex subject I needed to memorize for the USMLE, and now to this...something I really know nothing about at all.

This book has certainly opened my eyes and heavied my heart.

Hurt So Good

Okay so I think it is safe to say I am officially hooked on adventure racing. 

I get by with a little help from my friends.

 Wow, that was a ridiculously good time! Where do I sign up for the next one?! Granted, the absolutely perfect weather yesterday has probably amplified my infatuation with the whole concept of thrashing my body for hours on end. I have to wait for official results but from the numbers last night it looks like I came in 9th for the women!! I was hoping to finish in 5h and so was really pleased with my time of 4:39.

Can't write a proper post right now as I am on a mission to buy some jam from a market I spotted yesterday after the race. I would have bought some at the time but I had no wallet on me...plus I probably looked like public health threat given the fact that I was leaving a trail of hay, seaweed, mud, and sweat in my wake.

Thanks much-ly for all the tweets, emails, and comments of support! I was having second thoughts about doing it all week so all those little nudges meant a lot.

For you data nerds: run, cycle, hike, evil cycle, ocean sprint/obs course*/run.

*And by 'obs course' I mean going over hay bales and running through tires, etc. not learning how to manage labor presentations. Whaaaaaaaaat...c'mon...medical people read this blog, someone might need clarification!!

Why My Roommate = Awesome

Today, while loading up my car with race gear, I found this stuck to the seat of my bike. If that isn't ridiculously sweet, I just don't know what is.

Last Ride

 

2 days ago was my last training ride before the Big Race this weekend. It was an absolutely beautiful evening, only marred by the screaming of my leg muscles. I think the photo does not do the steep climb justice so I am including a screen shot from my GPS so you can appreciate that it actually is a hill and not just a meandering, gentle walking path from the nursing home. 

Note the lack of 'flat bits'.

Tonight I went on a short run, and for the first time in a long time it felt good. I suppose that is the main bonus for me: having something to train for means I'll train. Because I have to admit, I am not really looking forward to the weekend. I'm doing this because I want to see if I can finish it, but I'd be much happier if it didn't involve 8h of driving and staying in a hotel alone for two days (oh and killing myself on a crazy multi-sport course that will probably take me about 5-6 hours!)

The biggest joy for me about the triathlon in June was the fact that most of my family was involved. It was so fantastic to come across the finish line to big hugs from my sister, sister-in-law, bro, bro-in-law, niece, and nephews! It just feels weird that I'll be finishing and high-fiving myself (before collapsing in a twitching mess).

And speaking of high fives...I would not like to high five my body for how has changed in the last 10 weeks. I found my measuring tape a few days ago and thought it'd be interesting to see if my measurements have changed since I kicked s*it into high gear. Granted, the last time I measured myself was about a week before I went on my Himalayan trip and I was in decent shape then but...

First disappointment: 4 inches gone from chest. Buh-bye.
Second disappointment: no inches gone from thighs or butt.

SERIOUSLY BODY? Seriously???

Great, so now I have the upper body of a 10 year old newspaper delivery boy, and the lower body of a middle-aged Greco-Roman wrestler. That is sub-awesome.

Um...do these vertical stripes make my thighs look big?

When One Eponym Suffers Another

The Oxford Handbook of Clinical Medicine is full of charming and hilarious little gems, usually tucked away in the depths of information overload. I would love to meet the authors of this sanity-saving handbook and shake all of their collective hands (while buying them beers).

Today I came across this entry which I felt the need to share:

In 1931, Buerger's* disease caused gangrene in the toes of Harvey Cushing**--the most cantankerous (and greatest) neurosurgeon ever. He had to be wheeled to the operating theatre to carry on his brilliant art (and to continue terrifying his assistants). He had to retire partially, whereupon his colleagues presented him with a magnificent silver cigarette box, containing 2000 cigarettes (to which he was addicted)--one for each brain tumor he had removed during his long career, so verifying the truth that although we owe everything to our teachers, we must eventually kill them to move out from under their shadow.

-Herman Hesse, Demain

And so there is your CME in obscure medical history for the day.  You're welcome. 

--

*Buerger's disease (thromboangitis obliterans) is smoking related inflammation of veins, nerves, and middle-sized arteries (which thrombose, causing gangerene). Cause is unknown. Stopping smoking is vital. Most patients are men. 

**Cushing's disease is bilateral adrenal hyperplasia from an ACTH-secreting pituitary adenoma. He also is known for Cushing's syndrome, and Cushing's triad...but I think we've learned enough for today.

An Unexpected Test--Part III

And then I remembered…I was supposed to phone Paul when I got down. What if he heard about the rescue or saw the helicopter and thought it was me. He knew I was heading up alone…and my bike! (Now I know it might sound like a crass thought to have in an emergency but that bike is worth more than my car and heaven knows I’d never be able to afford a replacement.)

I asked one of Tina’s friends to take over c-spine for me while I called Paul and checked on Maggie again. Paul was stunned when I told him the situation, and said he had started to wonder what had happened to me. He offered to help in any way he could. I wasn’t sure how long the elderly Irishman was going to be selling walking sticks and watching my bike, so I asked Paul if he’d pick it up for me and then collect me later once the ordeal was over. He was happy to do so and I could breathe a little easier.

I resumed my post after a short jog on unsteady legs in an effort to get my body temperature up again. Tina was oscillating between drowsy silence and angry outbursts directed at the cold. We were all starting to shiver. I couldn’t remember a time when I’d been that cold. I’ve been outside during winter in the Arctic circle but I was always appropriately dressed for that. My cold sweat and thin jacket were a bad combination and at times my hands and body started shaking to the point where I wondered how effective my c-spine stabilization was.

Finally we heard the reassuring buzz of the approaching helicopter. The fog was so thick that only the sound alerted us to its descent nearby. Tina began to cry out with relief. Our huddle, which consisted of Father Henry, two teens, the Swiss couple, and myself, looked around at each other with relief on our faces. Relief that soon turned to concern as we heard the noise change and then grow quieter and quieter. Tina soon realized the helicopter was gone and started to cry.

Twice more our rescuers tried to land unsuccessfully. Each time our hopes rose with the crescendo of its approach and fell further as it drifted away again. I was getting genuinely worried now about hypothermia, for all of us. How cold did it have to get before the injured ones really started getting into trouble? Our little circle got tighter and tighter. After the helicopters 3^rd failed attempt to land, another hiker coming down the mountain stopped to offer help. She immediately started pulling out extra pieces of clothing, hot coffee, and chocolate. She threw an extra coat over my shoulders and then sat behind me rubbing my back and arms in an effort to stop the shakes which were starting to take intermittent control of my body. As she pressed up against me she said, “I know I am getting into your personal space here, if I am annoying just tell me to go, but you really look like you need warming up…” I told her she was the farthest thing from annoying and that I was extremely grateful for the warmth she brought down with her.

Finally, the helicopter was able to drop a rescuer down nearby. Keith was a tall, stocky flight paramedic and he had with him two large bags filled with emergency medical supplies and outdoor protection gear. I gave him the best report I could from my initial surveys, and helped place a collar on Tina. We were able to wrap her in a thick, warm, bright orange emergency sack.  Soon many other rescuers were on the scene. I didn’t ever find out if they had arrived on foot or along with Keith when he was dropped off.  Someone, who I think was a doctor taking direction from Keith, took over c-spine. I asked the Swiss guy to pull my bent leg straight for me so I could stand.  My leg muscles had seized up and fallen asleep during the nearly three hours that I’d stayed almost motionless. It was a strange combination of sensations as I tried to negotiate the rocky terrain over to Maggie and the swarm of rescuers who surrounded her.  I knew the patients were in good hands and I suddenly felt like a supernumerary gawker. Where had all those bystanders come from? I approached Keith and told him I was planning to head down. He offered to give me a lift in the helicopter to the hospital. I thought for a moment how much I would love a spin down in the whirly bird but I felt like I needed to go sooner rather than later. He didn’t know how long the refueling would take and I didn’t know how much longer I could stay on the rocks. Not to mention that I’d long ago called Paul and told him ‘the helicopter is landing’ and then forgotten to update him with ‘and now it is gone’. He’d probably been waiting at the bottom for well over an hour.

I said goodbye to the rag-tag gang who I’d spent the afternoon with, wished the patients my best, and gave Keith my contact information.  Leaving the scene I took one last look at Maggie, getting rolled into the bright orange rescue blankets. The bruising on her face had started to look like raccoon eyes and I stiffened with the thought that maybe she did have a skull fracture after all…and that I hadn’t observed her close enough.  My next thought of course, was what could I have done differently if she was a skull fracture?

I started running down the mountain.

It felt so good to get moving again. My legs were rubbery and sore. Soon my body temperature started rising and the sweat started pouring. By the time I reached the bottom I was pulling off the extra layers and soaked again. I pulled open the door to the café at the bottom and spotted Paul reading at a table near the window. The teapot in front of him was empty. I sat down and began a litany of apologies for my lack of communication and keeping him waiting. He too apologized for the crazy afternoon of training that turned into a rescue off the mountain. He got up to buy me some tea and I went to the bathroom to wash my hands and face.

I looked like I’d been through the wars. Clothes damp from fog and perspiration, hair and eyes wild from the wind, lip cracked from nervous chewing. My attempts to make myself presentable to the café crowd were futile. I dried my face and hands with some toilet paper and went out to enjoy the hot tea and padded chair.

Epilogue

That evening, while I was driving home, Keith called to tell me they’d successfully airlifted one patient after the other, off Croagh Patrick. Maggie had gone second, and they’d left with her just after 1730h. He said both were stable and expected to do well. I thanked him for the call.

The next day Father Henry called me to say that Maggie had been released with a few stitches, and that Tina was expected to go home the next day. She had no broken bones, just a bad sprain, concussion, and a few head and facial cuts that required stitches. He thanked me profusely for my help. I felt somewhat sheepish because I didn’t really feel like I had done anything except stay with them. He told me that just being there and my reassurance that they weren’t doing anything to make the situation worse had been invaluable and extremely helpful.   

Two days ago I received a series of text messages from Tina, thanking me for my help, telling me how scared she was, and how she had been convinced that she was going to die.

I was very touched by the fact that all three people had endeavored to make contact with me and that they were so appreciative. It didn’t change the fact that I had felt helpless and useless during most of that afternoon on the mountain. But it was nice to think that in their eyes I’d made a difference.

I’d spent the 4h drive home going over the scenario in my head and thinking about all of the things that I should have done differently. I berated myself for things like not having thought of getting both of them off the cold ground right away, and not showing one of the people in Maggie’s group how to hold c-spine. All told, it was a very good learning experience. It showed me the power of reassurance, reminded me of my love for emergency situations, and reiterated the importance of never, ever, going out without a headlamp and an emergency blanket.

An Unexpected Test--Part II

I'd get to the girl, first I wanted to make sure Maggie was stable.

Maggie was well bundled up which made a quick primary survey almost impossible. I put my hands under her jacket and tried to feel along the bony aspect of the back of her neck. I pressed down on each vertebrae while asking if she was having any pain, numbness, or tingling. She said no.

I tried to move my fingers systematically around her skull feeling for any ridges, deformities, warm tangles of blood, boggy swelling. Nothing.

I quickly checked the pulse in her wrist—strong. That was a good sign, she had a decent blood pressure and wasn’t tachycardic, which meant she wasn’t going into shock (yet) from some hidden injury that was causing blood loss.

Maggie was alert and talking to me the whole time, she said one of the girls on the hike had lost control coming down too fast from the top. Maggie lunged after her, also losing her footing and going head first down the steep and rocky terrain. Now I was getting worried about this unknown girl and felt fairly certain that Maggie had no immediate threats to life or limb (despite my woefully brief and incomplete initial survey).  I asked the 3 young girls with her to try their best to keep each other warm, to continue talking to Maggie. I asked them to send someone over to me if she suddenly became confused, nauseated, or started complaining of numbness or tingling. 

I scurried over the slippery rocks to the second cluster of people, perched on the lateral aspect of the slope. A young girl was buried under a similar assortment of raingear and jackets, crying out in pain. Two of her teenaged friends were huddled against her, shivering in their thin hoodies and track pants. Her legs were splayed awkwardly but with no visible deformity, blood spattered the rocks near her feet. Under the hood of a green raincoat I could see that her hair was thickly matted to one side of her face with blood that appeared to have come from her scalp. Her cheek was also cut, just under the eye. She opened her eyes when I asked her to and told me she’d started coming down the mountain and couldn’t slow down, she didn’t know how she’d fallen or if she’d been knocked out.  Her pupils were of equal size, they constricted when she focused on my face, she knew where she was, and who she was there with.

Again I wrestled with the tangle of clothing trying to feel her neck and scalp. She said she had no neck pain but yelped whenever I touched her head, especially near her forehead. It seemed impossible to locate the cut as all the blood had dried in the lumpy nest of hair.  I looked in her ears and under her nose for blood or clear fluid that might indicate she had fractured her skull. Dry. She didn’t have the characteristic pattern of bruising associated with basal skull fractures, the bluish tinge behind the ear or black circles referred to as ‘raccoon eyes’.

I felt her wrist, trying to locate her pulse. As I measured her heart rate, which was fast but not worrisome, she complained of pain. I was reassured though, by the lack of a sickening crunch or odd angle to the joint, something I’d come across many times in the Whistler emergency department. I put my hands under her jacket, asking her to take deep breaths while I felt her chest rise and fall. Her rib cage felt stable and she said she had no troubles breathing. Good. She had a blood pressure and no breathing issues.  I felt her belly, tested the bones of her pelvis for pain or instability. She cried out in pain when I brought my hands down her left thigh and leg. I couldn’t feel any swelling or grinding under my pressure, the leg didn’t seem shortened but it was hard to tell and I didn’t want to move her limbs unnecessarily.

Somewhere in all of this I found out that the man with them was Father Henry, the priest who had been escorting a church group up the mountain, which is a famous pilgrimage for Catholics.  Maggie was the other leader of the group, which left him running back and forth between the two huddles, with one cell phone (and sometimes two) pressed to his face. 

It was during my assessment of Tina that I too started to shiver. Suddenly the combination of wind, fog, sweaty T-shirt, and stillness left me very cold and wishing I’d brought more clothes. I pulled on my damp wool shirt and windbreaker. Once I was crouched behind Tina with my hands along side her jaw and neck to stabilize her cervical spine, I realised that if I was that cold, the girls lying on the ground were in even bigger trouble.

At this point an athletic Swiss couple, each dressed in layers of hi-tech looking gear, arrived and offered extra coats to pile on the injured hikers. The woman pressed up against Tina’s legs, the man against her right side. Tina’s two friends took up positions on the left. A tall middle aged Scotsman came up and suggested we use his large backpack as something to put underneath Tina. 

I cringed with the realization that I should have thought of that ages ago.

CAcBCDE. Catastrophic bleed. Airway/c-spine. Breathing. Circulation. Disability. Environment. 

All of this had been drilled into me again only weeks ago at the Advanced Trauma in Community course I’d taken. Environment. As in, assess complications due to environment such as cold temperatures and adjust to protect against these dangers. 

And so there we were.  All of us freezing, worried, and wondering how long it would take for the mountain rescue crews to arrive, if they were sending a helicopter, and if the helicopter would even be able to land amidst the fog and wind.  I asked one of the girls to take over c-spine for me as I went back to check on Maggie. She was well bundled up and had a similar gathering surrounding her. The tall and quick thinking Scotsman and his wife were monitoring her. This gave me peace of mind over the nagging thought that I was ignoring one of the casualties. Maggie was still alert and oriented, nothing had changed since I had first assessed her. She said she was more worried about Tina than anything else. I tried to reassure her before running back to my post: holding on to Tina’s neck.

We heard ambulance sirens in the distance which gave us hope that help was soon to arrive, hopefully with blankets at least and and possibly stretchers.

“Wait!!!” I asked Matt, the teen to my left, to grab my nearby camelback.

“I had an emergency blanket in there this morning…did I leave it in or put it in my other pack?? Ohhh…” 

And then I remembered the brief conversation I had had with myself before heading off this morning. “I am only going on a road ride and a run, I am definitely not going to need my emergency blanket or my headlamp.”

Of course.  Dammit! We really could have used that emergency blanket now.  Tina was shivering uncontrollably to the point where her teeth chattered causing her to cry in frustration, “Get me OFF this mountain!!!! Where are they??”

We tried to calm her by talking about Justin Bieber, the hot blankets that awaited her, the exciting helicopter ride she was going to have…it distracted her for short periods of time. Father Henry would threaten to start singing if Tina went quiet for too long. This proved to be an effective technique for getting her to start talking again.

By now, over an hour had gone by since I arrived on the scene.  I thought about sending the teens down with one of the hikers who was offering to help. Were they going to get hypothermia while trying to keep their friend warm? Were we only creating more casualties by keeping them with us? What was the legality of sending minors down the mountain with strangers? What if we were up here until the middle of the night? I remembered only a couple of months ago a woman being stuck on Carrantuohill until 4am waiting to be stretchered off the mountain with a broken ankle.  At least now they could get down safely in the daylight. For the time being we decided to keep them with us. 

Surely mountain rescue was going to arrive any minute.