Baby It's Cold Outside

We have had a few patients with cold weather injuries recently that seemed to be post worthy.

A few details are changed to protect the innocent.

# 1 Come On In, The Water's Fine
We had a patient that had been drinking for much of the night with friends.  Apparently they were not using the "Buddy System" and our patient was noted to be missing when the bar closed up for the night.  A search ensued resulting in the police being called to help find the missing individual.  Eventually they were found in or next to a nearby creek, soaking wet, and confused.  At the hospital the patients core temp was 31C (87.8* F).  As a little refresher your supposed to be around 37 C (98.6* F).  The alcohol level greater 3.5x the legal limit & additional drugs in his system probably had a role in this.


# 2 Trashday
After drinking well into the early morning patient # 2 came to the realization that was trashday.  Quick, out the door they went, trash in hand.  Hurrying back to grab the screen door before it shut and locked, they grabbed the handle and in a quick movement pulled the door back, striking themselves in the head.  This knocked them off the porch and into the snow.  By the time they were able to get back to the door it had closed and locked.  No problem grab the key from your pocket, right??? ---- Wrong, in their haste they had neglected to put on any clothes (well unless you count the underware and socks).  No pockets, no key, no one inside.
After trying the neighbors (who weren't home) the patient decided to just sit down on the porch and wait for someone else to come home. Fortunately passing motorists called the police to alert them of a half naked person hanging around the neighborhood. 
Unfortunately they had already been out long enough to get 2* frostbite to their feet and had already started to blister. 
Long term they should be fine but I bet that they might hide a key under the mat, just in case.

# 3 Walking in a Winter Wonderland

After being locked out of their apartment patient # 3 wasn't sure what to do.  Ask the landlord for an extra key? Find a neighbor?  Break into your apartment?  - apparently that didn't cross the mind of our patient.  Sadly they had a mental illness and had stopped taking their medication/  Rational thoughts were in short supply.  Instead they spent 2-3 days & nights enjoying winter up close and personal.  When found they were hypothermic and had had pretty significant 2 & 3rd degree frostbite to their extremities.  Not the worst I've seen but pretty tragic for a person that already has alot of health problems to deal with.

So when your headed out, remember to bundle up, and take your keys with you!

I wish I were an oscar meyer weiner

Having fun at the Henry Ford.

Merry Christmas

I thought this was a cute picture of Marin. If only she was this angelic all of the time.

I hope that all of you have a wonderful Christmas & that you are able to feel the love the Savior has for you.

Domestic Violence

I am betting that most of you don't need arrows for this CTscan.

This patient was the victim of domestic violence.
The skull fractures you see are the result of being attacked and struck in the head with a tool.
The patient was unresponsive when we got them.

Amazingly the patient recovered after surgery and did not have any major deficits from this injury.

R Colectomy

This colon was causing problems & had to come out!

M5 Has Arrived!

Maxwell Price Ethington
Born: Sept, 23 2009
7lbs. 7oz. 20in.

Mom & Baby are doing great. More pictures & info later.

Lending a Hand

We had an interesting case the other day of a person that attempted to injure themselves. Their intent was to kill themselves by bloodloss. To facilitate this they used a razor blade around the entire circumfrence of their wrist. When this failed to get the intended effect they stepped up their effort using a steak knife then a reciprocating saw and finally a circular saw. Amazingly the patient had injured many tendons & vessels, and lost a significant amount of blood but our plastic surgeon was able to repair things enough that the patient will likely keep the hand.

It was a bizarre & sad injury but looks to have a good outcome.

Musca Domestica Infestation

I had another first not to long ago, that I think you may find interesting &/or revolting.

I almost hate to bring it up since it makes it sound like I work in some third world hospital. But it is too good so I'll share it.

One of our patients was in an ICU and had been on a ventilator for several days, one morning when the nurses were doing their oral care they noticed something moving. Upon closer inspection there were many things moving - maggots. Yes you read that correctly, maggots.

Apparently this happens periodically in the hospital, all it takes is one fly and 24 hrs to get maggots. Still it is pretty gross to consider.

In the end, the patient wasn't too worse for the wear, a little oral chlorhexadine scrub down and the problem was solved.

Just thought I'd share this new experience with all of you.

Happy B-Day Marin

Keeping w/ tradition we went to Red Robin to celebrate Marin's B-day (a little early, it is next week) She loved the free ice cream! Wish you could all be here with us.

They only do that on TV shows (until today)

I am sure that you have seen those shows like ER & House where they do all sorts of surgeries right there in the room rather than the operating room. I have always told Melissa and anyone else who asks that that is all TV.

Occasionally we might do a thoracotomy (opening someone's chest so you can get to their heart/lungs or great vessels) in the ER but in we don't open up the abdomen unless we are in the OR, or at least I had never been at work when it had been done.

Recently however we had a patient who could not be ventilated very well because his abdomen was getting too swollen and distended pusshing back on his lungs so they would not inflate well. The patient was unstable for a few other reasons and wasn't really able to be moved to the OR at that time so we got a bovie (electrocautary) set from the operating room, brought it to the bedside in intensive care and opened up the abdomen right there. (This is just an internet picture, but it looked about the same)

It was pretty interesting and the ICU nurses had some pretty big eyes.

So, I guess that some of that TV stuff is true after all.

Case Study: Dumpster Injuries

OK I know it has been a long time since I have posted -

Unfortunately my workplace blocked "blogger" from our internet, limiting the time I have to post little snippets.  Additionally it has been really busy, it is "trauma season" after all.

I felt that a patient I had recently deserved a little mention however since it is a pretty unique (at least for me) patient & presentation. 

Chief Complaint: 24 yo with vertebral (back) fracture & foot pain.

History of the Present Illness: Patient is a homeless heroin addict who was asleep in a dumpster.  The patient was unaware that the following morning was garbage day and was woken by the dumpster being emptied in to the garbage truck. He was "rescued" when the garbage man heard his cries / screams for help. (He did manage to grab his needle / supply before he toppled out).

Past Medical History: Multiple Abcesses, Necrotizing fascitis (spreading skin infection), Hepatitis, early liver failure, Kidney damage, No IV access (currently administering his "medications" into his buttocks.

Past Surgery History:  Extensive debridement of skin from his infections. Etc.

Allergies: None
Meds:   Heroin 2-3 grams / daily;  Dilaudid 24mg at a time for fun,  Oxycontin as much as he can get,  Methadone 120mg / day (when he is in rehab), a variety of other "recreational pharmacuticals"

Exam: Back pain, Foot pain, malnourished, unshowered for probably weeks, offensive smell.  No obvious lice, (not examined for body lice).  Multiple scars.  No IV access - Patinet has blown /scarred every vein from the neck to his toes. (including jugulars).  Enlarged Liver & Spleen secondary to hepatitis/liver damage.

Overall plan.... Back Brace, Psych Consult, Attempt to avoid withdrawal & provide pain control.

Anyway it was pretty interesting for me and I thought it might interest you too!

Trust Me - I am an Expert!

Some of you know that I have been going with our Scout troop to work on our Rifle Shooting Merit Badge for the last few weeks. We did a NRA course.

It has been alot of fun and surprisingly to me I did fairly well. I met the qualifications for "Expert" Status in NRA program.

It sounds alot more impressive than it is, we were only using .22's at targets about 50 feet away. Still it was pretty fun and I figured I'd post a blog entry to brag about it a bit.

Paraplegic Snowmobiling - No pain, No Gain

Here is an entertaining trauma story for all of you.

We had a patient who was paraplegic (paralyzed from the waist down) from a previous injury.  This patient enjoys winter sports and wasn't going to let his handicap keep him from enjoying all of the snow we have gotten recently. 

He convinced his friends to bungee cord him to his snowmobile and they were happy to oblige.  At some point the patient fell off or almost fell off - his legs were caught and he ended up breaking one of his femurs.    This is a femur fracture similar to the one our patient had.    Of course he didn't realize it at the time because as you recall he is paralyzed from the waist down.  After another four (yes 4) hours of snowmobiling he wasn't feeling to well (because of blood loss into the femur around the fracture site and the mild low blood pressure that resulted) so he came into the ER for evaluation. 

He had to have surgery to stabilize the fracture.

Anyway I just thought that this was too unique of a case to not share it.

Chief Complaint: " I can't see "

Here is a regular CXR - for comparison.

An individual presented to the ER with the main complaint being " I can't see".

Stroke, Tumor, Retinal detachment - there are a few possibilities for this condition.
This patient had an interesting cause.

Here is what happened.

The patient had fallen several days prior to their vision loss (possibly a week before). Unknown to them (or possibly ignored by them) they had broken some ribs and punctured their lung. The air leaking out of there lung had steadily leaked out of the chest and into the space between the ribs / muscle and the skin (an area typically full of fat) called the Subcutaneous (SubQ) layer of tissue.

As the air continued to leak out it tracked up and down that subQ tissue plane until it had eventually caused swelling in their eyelids to the point where he could not open them any longer, hence his chief complaint. They had air literally from the top of their head to their toes. They felt kind of crinkly / crunchy when we touched them.

Obviously there are a few questions here like -- did you not notice that you were swelling up like a balloon. Very bizarre. In any case the patient recovered fully.

I have examples of subcutaneous emphysema above to illustrate the situation.

When good valves go bad!

As most of you who know me already know, my mom had to have surgery this week to replace her mitral valve. The mitral valve is one of four valves in the heart. (See picture 1)

Her valve was damaged by rhumatic fever as a child and had gotten progressivly thickened and scarred to the point where it was not allowing much blood past it. (Picture 2 is a valve with sclerosis from rhumatic disease)

After several years of progressing fatigue she and her physicians elected to replace it.

On Dec 5th, she had a new valve made out of bovine (cow) tissue placed. It was done minimally invasive meaning she didn't have to have a sternotomy, (they went through her right ribcage), but it is still pretty painful. (Picture 3 shows the approach and you can see the valve at the 11 oclock position)

In any case, she seems to be doing well for now and should be out of the ICU tonight.

Thanks to all of you for your prayers and concern.