Practice Pearls

This is a story of a patient from a year or so ago, while I still worked for my last employer.

A patient comes in because he has had increasing shortness of breath for about two weeks. He was walking down a small hill from where he parked his motorcycle and fell, tumbling down the small incline. He fell about 10 feet or so, he says. His vitals look fine. He is a bit of an overweight guy, typical 60-something man trying to recapture his youth by riding a Harley.

So I ordered a chest x-ray, started an IV, and did his intake paperwork. No doctor is signed on to his case yet. If the x-ray shows anything significant, the technician who takes it will normally give me a heads up. He didn’t in this case. The image of the x-ray came up on my computer, I took one look at it and immediately flagged down the first passing doctor and said, “Hey, I know that you’re busy and this isn’t your patient, but you need to see this now.” Here is what it looked like:

In case you don’t know what you are looking at, the dark section on the left is a relatively normal looking lung. The heart and trachea are supposed to be on the right side of the image and are being pushed into the other side by the large amount of blood that is collapsing his left lung (which appears on the right in this image). If you look closely at the film, you can see all of the structures that are supposed to be midline are being pushed over. This is called a hemothorax, and is a life-threatening medical emergency where a massive volume of blood rapidly accumulates in the pleural space (the area between the chest wall and the lung). This buildup compresses the lung and puts dangerous pressure on the main vein bringing blood to the heart (the vena cava) and the heart, leading to cardiovascular collapse, severe respiratory distress, and shock.

The doctor took one look at this and said “Holy shit! I’m signing up for him. Get me set up for a chest tube and some conscious sedation. Call respiratory and let’s get ready to send him to a trauma center.”

The patient had a rather chubby neck with a beard so it wasn’t readily apparent, but if you put the finger of one hand on his Adam’s apple, and a finger from the other hand in his sternal notch, you could see that his windpipe was deviating to the patient’s right. He was a good sport and didn’t even mind that I brought a couple of new nurses into the room to see what a tension hemothorax looked like. Of course, he had no lung sounds on the left, and his heart tones were distinctly muffled. His pulse pressure was a bit narrow.

There were not any other nurses or respiratory technicians available to help in time, so I grabbed a nursing assistant and the three of us (doctor, myself, and aide) rapidly initiated conscious sedation and inserted a chest tube. That’s a handful for one nurse and a doctor to handle (the nurses aid is pretty much there to hold this, and hand me that and isn’t much of a help)- I had to administer sedation, monitor and maintain his airway and breathing, and chart everything. For one nurse to do all of that without help is a major safety issue, and is one of the (many) reasons why I don’t work for that hospital any longer. That place is just understaffed to the point of compromising patient safety.

Once we got the tube in place, we sent him for a CT scan, and it turns out he had 4 ribs broken in two places- a classic flail chest. If you put your hands on his rib cage, you could feel the paradoxical motion of the chest wall. This is incredible, considering that he walked in to the ED and had been walking around like this for two weeks. The video below shows you what paradoxical motion looks like, but my patient’s wasn’t quite as pronounced as the video (and was located under his left armpit).

Anyhow, I pulled about 2 liters of blood from his chest cavity before we crimped off the tube because we didn’t want him losing too much blood. A helicopter came and took him to a trauma center, and the trauma surgeon was still pissed because we took out so much blood.

The patient made a full recovery.

A few of my readers have commented on how they enjoy practice pearls, so I thought I would go ahead and share a simple one. This particular pearl is not just for medical people, it will work quite well for those of you who are not in the medical profession. In the medical profession, a lot of time is spent training people in the latest, greatest technology- the newest medication, the latest technique, the wow factor, but sometimes, it is the old school method that works best. I recently had the chance to teach a young doctor this exact lesson.

Lacerations

We had a woman that entered the emergency room who had cut off the last quarter inch or so of the tip of her finger with a pair of scissors while attempting to cut open an Amazon package, of all things. In so doing, she had also managed to nick the artery, and blood was pulsing out of the end of her finger. She had the presence of mind to bring in what she thought was the tip of the finger (what she brought in wasn’t the finger) and she was attempting to control the bleeding herself, but wasn’t succeeding.

The doctor looked at it and suggested we perform a digital block and attempt to stitch off the artery and suture the wound closed. That was going to be a bear to do. Instead, I suggested that we try something a bit more old school. I took a large emesis basin, filled it with ice, a little water water, and a bottle of Providone. I told the woman to place her finger in the basin and keep it there until the cold became painful. This concoction does three things:

• The ice numbs the area
• the Providone cleans the wound (there is a risk of infection if you don’t)
• the ice also constricts blood vessels and is great at controlling bleeding

She spent about 15 minutes with her hand in that basin, and this stopped about 80% of the bleeding. I pulled her hand out, cleaned the finger with a couple of gauze pads (4×4), then had her hold one against the tip of her finger using her thumb. After about 5 minutes of that, we still had some bleeding, so I soaked a gauze pad with tranexamic acid (TXA) and placed it against the wound. That stopped the rest of the bleeding. I dressed the wound, and we sent her home.

Esophageal Varices

Just as you can get varicose veins in your legs, you can get them in your esophagus as a result of cirrhosis of the liver and the resulting portal hypertension. I was working in the ED one night when a patient began vomiting large amounts of blood. I’m not talking about what most people would think are large amounts of blood, but what a nurse who works in the ED thinks are large amounts of blood. It looked like this:

We were under the gun: if this bleeding didn’t stop, we were looking at a dead patient. I inserted an NG tube to suction out the blood, and the doctor and I came up with a plan. Using a piston syringe, I would push about 100 ml of ice water into the tube, let it sit for about 30 seconds, then suction it back out. I repeated this about 5 or 6 times, and each time, the amount of blood that came out with it was less. I was forced to stop after that 5th or 6th time, because the cold must have been irritating to her heart, as evidenced by the fact that she began having short runs of ventricular tachycardia. For that reason, anyone trying this, I would recommend placing the patient on a cardiac monitor and keeping a close eye on on their heart rhythm while doing this.

Ice- it’s quite useful in emergency medicine, but it isn’t used much any more in emergency medicine because it doesn’t have the sexy feel of the latest, greatest advances in medical technology, but it is still damned effective. Sometimes old school is still the best way to go.