To provide a fuller education, our curriculum should occasionally bend from the scientific and technical and include matters of the heart. This is a case from the early 1990s, a time in this fair land when ultrasound was not part of emergency practice, when RSI was still a relatively fresh concept, when the treatment of shock was non-systematic, and when consultation was a matter of pleading on the telephone.
Another Short(ish) Story
An apartment dweller in a not very nice part of town heard a thump at his door, and found an emaciated, nearly naked man lying in the hallway, moaning but unable to speak. EMS was called, and found him to be hypotensive, tachycardic, and tachypneic. Bystanders reported that they thought he lived in the building, and that he was a heavy drinker. No one knew his name. Pulse ox did not register. Finger stick glucose was 89.
On exam he was uncommunicative, but regarded with his eyes when stimulated. His extremities were covered with bruises and abrasions of various ages, and he had what appeared to be crusted, coffee-ground material on his tongue, lips, face, and covering his chest, abdomen and underpants. He had thready pulses, a cool clammy periphery, six-second capillary refill, increased work of breathing, rhonchorous breath sounds, flat neck veins, distant heart sounds and a non-distended abdomen. He was observed to move all four extremities and to have equal, reactive pupils and facial symmetry, but no other neurologic exam could be done. His rectal exam showed darkish, heme-positive stool in the vault, but no frank melena or blood, and no evidence of blood external to his anus. He smelled, his hair and beard were matted, he was filthy and undernourished.
VS: p 144, r 22, bp 76/palpated, O2 sat unobtainable, GCS 10 (M5V2E3), T 94.6.
IV access was obtained, and crystalloid resuscitation was initiated. He was intubated by RSI. In this dark, bygone era, induction was performed with midazolam and fentanyl at embarrassingly low doses, and post-intubation sedation was an uncommon practice. Nonetheless, his pressure tanked, but responded slowly to volume. EKG showed sinus tach, CXR showed upper lobe infiltrates felt to represent aspiration, labs showed anemia, an AKI, metabolic acidosis, a total CK of 2000, and elevated transaminases but no coagulopathy. PRBCs were hung and after 2 units, his systolic pressure was 92 and his pulse 122. He received thiamine and a rally-pack.
With a fairly obvious diagnosis of an upper GI bleed, likely variceal, GI was called. He was too sick to go to the endoscopy center, and the MICU was full, so they came to the SRU and scoped him. His EGD showed 100 mL of coffee-ground material in his stomach, and mild gastritis, but no varices or ulcers, and no obvious pathology to explain his hemodynamics. While a lower GI bleed was possible, this was felt to be unlikely. Sepsis deserved consideration, and he was cultured and initiated on antibiotics.
He did not stabilize, and his pressures continued to drop. About this time, I could finally go to the reading room (no computer images in this decade) and look at his CXR. A mildly-displaced, left ninth rib fracture was noted. The patient was rushed to the CT scanner and found to have a moderate amount of intraperitoneal fluid. Trauma was called. The attending responded, and I presented the case and my concerns about a possible splenic injury to him at the bedside.
Now, this was also an era where the relationship between the ED and the trauma service was at its absolute nadir. The particular trauma attending responding (who long ago moved on to another institution far, far away) was a primary architect of this friction. He angrily stated that this was “a typical ED dump…you don’t know how to take care of this guy and just want to make it our problem.” I asked him to perform a DPL, the standard at the time, and he refused, stating that the patient was obviously septic and just had ascites. We argued loudly in the SRU. In frustration, I grabbed a 35 cc syringe, a spinal needle and some betadine and, after prepping the midline hypogastrium, inserted the needle and drew back pure blood. I handed him the syringe and suggested that the patient had hemoperitoneum.
The patient went to the OR and had a splenectomy for a punctured spleen. Later that day the patient was identified and a family member (sister) arrived. I explained the situation to her and she stood up, began pounding on my chest, and with spittle flying in my face yelled, “God damn you! Why didn’t you just let him go!” The patient and had a long, rocky, month-long ICU course complicated by DTs and pneumonia. Eventually, I lost track of him. The trauma surgeon never spoke to me about him again.
On a morning B-pod shift a middle-aged man from a SNF was placed in room 23 with a presenting complaint of hypoxia. He had mildly increased work of breathing and rales at his right base. He was stable, with a room-air sat of 94%. Toward the end of the encounter, he said, “You don’t remember me, do you.” I agreed, I didn’t. He then said, “I remember you…you didn’t give up on me.” Recognition struck me like a hammer, and we both choked up to the point where we couldn’t talk for several minutes. He explained that he was aware of his surroundings during his entire ED course. He experienced his endoscopy. He overheard my argument with the surgeon. He felt the bite of the needle when I did my poor man’s DPL. All of it. Holy smokes.
I asked him about his life – it wasn’t great – but he was sober, clean, fed, sheltered, well cared for, and he had friends. Unsurprisingly, he was estranged from his sister.
I think about him all the time. Especially when confronted with patients whose health has been destroyed by substance abuse, where one might uncharitably say that it is a self-inflicted wound. Also when I encounter patients who are markedly less lucky that I am in their social circumstances. And also when I see people that, in an even further bygone era, might have been described as "wretched".
In Hebrews (I believe Chapter 13, verse 2) there is an admonition that, depending on the translation, basically states, “Show love to strangers…you might just be entertaining angels.” Folk tales from many traditions repeat the theme of wretched, unattractive strangers that are actually powerful spirits, who request help at the door of a fortunate person. If the opportunity to show grace is denied, awful consequences follow, the metaphoric imperilment of one’s soul.
My patient that day was an angel who invited me to be a better version of myself. That day I accepted the invitation, advocated for someone who couldn’t advocate for himself, and protected a stranger from an indifferent universe. I’m afraid I don’t always meet this standard. But I try, and the memory of this man keeps me trying.
P.S. There is only a tangential airway connection in this tale, and it is this: Don’t assume that your patients, whether induced, sedated or whatever, can’t hear what your saying at their bedside. Keep the discussions kind, caring, and as professional as possible.
I.C. Cordes is written by Steven Carleton, MD PhD, Professor of Emergency Medicine, University of Cincinnati Department of Emergency Medicine and instructor of airway education at the Airway Course.