Happy New Year

This year, as usual, I am on call. This is usual because most of my colleagues are Russian immigrants who have a passion for partying and celebration. Since the Jewish holidays are more important to me I don't mind being on call.

I remember a while back, I was on call in the MADA's Mobile ICU. Surprisingly, there were no traffic accidents due to the superb efforts of our men/women in blue. They were at every main intersection and the areas with a high saturation of pubs to prevent drunks from driving. Hopefully this year will be the same.

Unfortunately, there were not enough police to be inside the pubs. We were dispatched to a pub where a fight had occurred. Into the ambulance entered a huge Russian who wreaked of a nauseating combination of alcohol, blood, vomit, urine and feces. It was truely an attractive sight. He was also the proud owner of five extra holes that the Creator of the Universe had not intended. He had multiple stab wounds. Since he was conscious, I asked him what happened:

A ------- (ethnicity deleted) had hit on his wife. Since he had to protect her honor, he began arguing with the ------- (ethnicity deleted) who promptly bared a knife and exhibited his turkey carving skills to the assembled drunken partiers. Luckily for our patient, the -----(ethnicity deleted) was as inebriated as he, so that his trusty sabre only caused flesh wounds. Now, having seen the wife, who was almost as large as our patient and not as drunk, I came to the conclusion that she probably could have handled the lout herself.

I asked the gentleman if he learned something from this experience. He squinted at me completely uncomprehendingly (is that even a word?). I said, "When a -----(ethnicity deleted) hits on your wife, let her deal with him, and you just head for cover."

Fortunately for me, he didn't understand the joke.

Happy, and safe New Year to all.

I too was called to serve

I am reposting the following from a previous (to remain nameless) site. This was prompted by a flurry of comments to a Treppenwitz post called "Exploding Myths". The comment by Lisa Goldman disturbed me because it implied that the "mainstream" lives in Tel Aviv and environs. Tel Avivans live in a bubble of sorts and often see the rest of the country as some bucolic backwater. The following was posted during a period of pain and upheaval for the country and reflects my own state of mind at the time. Rereading the post, I haven't changed my feelings on the subjects presented:

I too was called up. I serve in the reserves in two capacities: I command a Forward Surgical Team and I'm an ATLS (Advanced Trauma Life Support) instructor. It was in the latter capacity that I was assigned to train medical units heading up north at the National Medical Simulation Center. Since there aren't enough physicians that treat trauma on a daily basis (surgeons and anesthesiologists mainly) to serve in all the medical units in the army, the medical corps provides an ATLS course for all military doctors (both career and reserves). In addition, we provide the course for all civilian doctors who specialize in surgical specialties. The implication is this: those doctors in the non-trauma related specialties must provide treatment to the wounded.
My personal dilemma is always the same. Where can I better serve the country? Obviously, my experience treating trauma victims both in the OR and intensive care would bear fruition on the front lines. On the other hand, I couldn't possibly be in more than one place at one time. So perhaps imparting my knowledge and experience to doctors who will be called up anyway to serve at the front is more effective. I don't know if there is a correct answer.
The last two weeks we gave intensive training sessions to as many doctors and medics as possible. Using a very sophisticated simulator we could recreate battle injuries using computerized manikins that respond to treatments and procedures. After each scenario, which was video taped, we reviewed the teams' performance and offered constructive criticism. I was struck by one thing: None of the doctors or medics exhibited any misgivings about joining the combat troops (at least not outwardly). The only misgivings that were expressed were those of non-trauma doctors as to their own level of experience: was it enough to help the wounded they were about to treat? Except for one cardiothoracic surgeon with an over inflated ego, all the doctors and medics were very appreciative of any wisdom I could impart to them.
This dedication to professionalism was shared by both career army physicians and reservists alike. I imagine that the tenaciousness of the combat troops and their dedication to our country will be well served by such doctors. I, like many others, have noticed that the combat units are populated disproportionately by soldier/citizens from the periphery. The Tel-Aviv Yuppies, the high tech sector (aka technoweenies), the economic elite are all under-represented in these units. I despise them and their religious pursuit of money. I find their lack of communal consciousness pathetic. I served as a tank commander during my compulsory service and in the reserves until I was transferred to the medical corps during med school. As an armored battalion physician, I addressed my medics with the claim that those who serve in the reserves are not "suckers" but the country's real elite, and they should be proud of serving. I don't know that I ever convinced any of the soldiers under my command of anything but that I truly believe in this credo.
It may be too early for pointing fingers; however at the very least I feel that the soldiers and officers that do all the hard work have been betrayed by the top brass and the self serving politicians. I think Olmert ( the Prime Minister) should take his spineless politics elsewhere, and Halutz (former Chief of Staff) is invited to spread his wings and fly away, they are both utter failures at what they do and don't deserve to lead the fine men an women who are the salt of the earth in this country. Peretz (former Defense Minister) is just pathetic. If I have insulted anyone, so be it.

Post Script: I invite the reader to make note of what happened to our "leaders" in the past 15 months.

The New Math

I'm on call in the OR. The list of urgent and emergent surgeries gets longer and longer. As the day wears on, the anesthesiologists and the OR nurses become weary.

I don't even remember the first operation of the day. At 2:45 AM we finish the last operation. I write out orders to the recovery room nurse for pain medication and send the junior resident to get some rest. I stay to write out the log of the cases that were done on call. At 3 AM my beeper jars my senses. The supervising nurse in the OR informs me that the surgeons are rushing up with a trauma victim from Gaza.

I call the junior resident and tell him to prepare OR 5 for an emergency operation. The surgeons burst in with the patient. It is a Palestinian with a gunshot wound to the abdomen. He underwent an initial emergency surgery in Gaza, but because of ongoing bleeding, the hospital there requested transfer to Soroka for further treatment.

We often get referrals from Gaza, so this was not unusual. The circumstances surrounding the incident were unclear, but the victim was not shot by Israeli soldiers. We assumed that he was injured during infighting among Palestinian factions.

We transferred the young man to the operating table, he was barely conscious, he was cold, and his pulse was barely palpable: all hallmarks of severe hemorrhagic shock.

As the surgeons opened up the abdomen the extent of his injuries was appalling. The bullet entered the right lung, passed through the diaphragm shredding the liver, part of the small bowel and the right kidney finally lodging in the pelvis. Our surgeons admired the Gazan surgeons’ work. They had resected most of the liver, the small bowel and removed the damaged kidney. They anastomosed (connected) the stomach to the stump of the bowel. The sutures were perfect. These guys definitely know how to sew.

Unfortunately, their post-op treatment is less optimal and the patient continued to bleed because of consumption of clotting factors. Although the surgeons urged me to infuse blood, I started with plasma in order to replenish the clotting factors. The only documentation we received described the surgical procedure performed. There was no information as to which blood products the victim received. My instincts were right, the oozing stopped and then I started to infuse blood. The patient’s blood pressure stabilized but remained low. We transferred the patient to the Intensive Care Unit. By the time we were finished, it was 7 AM. Time to sign out.

These “on calls” are killing me. They are becoming harder and harder. Operating through the night has become the rule rather than the exception. Maybe it's the caseload which has become endless, or maybe I'm getting older, or maybe it's both. I go home feeling like I'm observing the world from inside an aquarium.

At the bus stop someone asks me a question, his voice sounds like it's emanating from a tape recorder with low batteries. I haven't the foggiest idea what he wants from me. He points to his wrist. Assuming he wants to know what time it is, I say "7:20."

Apparently I was right because he turns away. I hook up my ears to my MP3 player and try my best to ignore the world. At home, I shower and collapse in bed.

A few days later, I'm assigned to the ICU. Amazing, the patient is still alive, barely. How he survived to the initial surgery is a mystery. How he made it this far is unfathomable. He is sedated, mechanically ventilated, and since his remaining kidney has shut down, is on hemofiltration (a machine that replaces the kidney temporarily). His blood pressure is still low. The doctor finishing his on-call rattles off the vital stats and relates that the patient underwent a "second look" operation to make sure he didn't rebleed.

One of the doctors is a Gazan who tells us the circumstances surrounding the injury. It turns out that the patient was at a wedding. As is customary, shots were fired in the air in celebration. Either someone missed the air in the sky and hit the air in the young man's lung, or it was a bullet finishing its steep trajectory that fell on the unsuspecting victim. Not that it matters to him, but it seems a pretty stupid reason for getting shot.

Ruminating on the case, I became enlightened as to how the "new math" is done in Gaza. I'm reminded of Milo Minderbinder, a character from my favorite book "Catch-22." The character is a mess officer during WW II who turns the war into a lucrative business. He buys eggs at a high price and sells at a low price and still manages to make a profit in a dizzying transfer of goods all over the Mediterranean. This Gazan did the same thing, except with his life.

Bear with me: He was born with nine lives. He used up 11 of them. He still has 2 left. Sounds surreal? You betcha! Surreal is how he survived such a horrendous injury




Post Script: Unfortunately, the patient succumbed to his wounds. This is not only tragic, but frustrating because of all the effort expended to try to save him.

Sunspots

It must be the sunspots. There is no other explanation. I've had so many arguments with co-workers this past week that it must be the sunspot activity affecting everybody. Everyone, that is, except me. It couldn't possibly be because I was on call three days out of the last five. It couldn't be because I was tired and cranky. When I analyzed the situations while soaking in the hot tub after the last on call, I saw that I was absolutely right in all of the situations.

It started when I was on call in the OR. Close to midnight, we were alerted that a helicopter was evacuating a seriously injured soldier who was unconscious and mechanically ventilated. It was a tragic accident. The soldier serving in the armored corps had his head crushed between the breech of the cannon and the roof of the turret. Having served as a tank commander during my compulsory service I knew that this was a rare but terrible consequence of mechanical malfunction, human error, or both. Getting a limb caught in the cannon mechanism was not a rare accident in older tanks. The newer tanks have a failsafe system to prevent this from happening. Something must have gone terribly wrong.

When the helicopter landed I asked my colleagues in the ICU to send someone down to the trauma room because I couldn't leave the OR. I was supervising an inexperienced junior resident who couldn't be left alone. The doctor sent down is a woman we call "the chicken" because she's afraid of her own shadow. It never ceases to amaze me that some doctors don't know their own limitations. She should never have been an anesthesiologist. Sure, she can anesthetize any routine case, but when things get complicated or the patient's condition deteriorates she loses her head. As soon as she got to the trauma room she called me to help intubate. I asked her why intubation was necessary since the patient received an emergency tracheotomy in the field. I asked her what the soldier's condition was, she couldn't tell me. She hadn't even examined the patient herself! I told her that I couldn't come down there myself but I would send her another anesthesiologist from the delivery room to help her. She apparently was not satisfied with this solution and complained to the senior on call in the ICU. The senior was dragged into the general hysteria and she immediately began to shout at me and insult me that I was irresponsible. She also threatened to file a complaint with the chief of the department. I told her she could go right ahead, I was standing by my decision. The doctor I was sending to help is very competent and has even more experience than me in airway management. Besides, if anything adverse happens to the patient currently in the OR, the question will not be IF they fry my testicles, but whether they will be fried in olive oil or butter. Anyway, after lots of frantic telephone conversations and shouting and histrionics and soap opera antics, the doctor in the trauma room finally checked the patient herself and found that he was adequately ventilated and stable. In other words false alarm! A few moments later the senior in the ICU called to tell me that the patient was stable and that there was no need to send another doctor to help out. God forbid she should apologize.

The arguments, mostly stupid, and I remind you that I was justified in all of them, despite being very tired and cranky, just kept happening.

The best and final argument occurred when I was on call in the ICU. I managed to insult a professor of pediatric infectious diseases who is also the director of the bacteriology lab. For some silly reason, any time we need the lab services while on call we need his permission to call the lab tech in. The lab tech, incidentally, is paid to come in when necessary during on calls. So his esteemed highness needed to know all the details of the sample that was sent to the lab. The sample was taken a day before in the OR so I hadn't actually seen it. He insisted on knowing if the sample was obtained on a swab or stored in a sterile cup. I just couldn't figure out why this was so important to him. He chewed me out for not having that critical information. (Later I realized that he just HAD to know because: if the sample is on a swab, then it must first be cultured and then gram stained the next day and viewed in a microscope. If the sample is in a cup then it can be stained and viewed the same day. In other words he wanted to determine if he had to come in the same day or the next day to look into the microscope.) I was getting flustered with his incessant interrogation and I was needed on the ward. I finally told him that I didn't need any favors and hung up.

Well, his royal highness, the Grand Poopah of all Professordom was mortally insulted. He called back VERY angry. I would like to mention that I have a history of insulting higher ups. Even during my compulsory service in the army I somehow had a knack of insulting full colonels and brigadier generals. That I was never punished shows that I have more luck than brains. I tried to apologize, but his holiness wouldn't let me get a word in edgewise. He was adamant that he should educate me in how to be polite to jerks with over inflated egos. He kept telling me not to hang up, that he had just a little more to tell me. Finally, his tirade ended and I could get back to treating the patients in the ICU. For about one millionth of a nanosecond, I entertained the odd idea of actually apologizing face to face. But in a calmer moment, I realized that the one who behaved badly was the esteemed professor of poor etiquette. He's not the first professor I've encountered who causes Emily Post to rotate in her grave. I guess the title inflates the ego and ablates the etiquette gland.

It'll be a cold day in hell before I give that jack-of-all-asses the satisfaction.

It's the sunspot activity I tell ya, it just has to be.

Young at Heart

Some patients just surprise in many ways. On call in the ICU, again. The surgeons call to ask that I admit one of their patients. The gentleman, an elderly Russian immigrant, was suffering from rapid atrial fibrillation (a chaotic rhythm where the atria beat quickly and the ventricles do what they can to keep up) that wasn't responding to treatment. He was originally admitted for an emergency operation due to a perforation of the colon, which complicated a routine colonoscopy (that's where a gastroenterologist views the inside of one's guts with a fiber-optic scope looking for polyps, tumors and the like). The odd thing was that the man was walking around with this perforation for three days before going to the ER. This must be a tough guy. I have observed that people who ate the soles of shoes in Stalingrad are not easily phased. He may have been there during that awful period in history.

Our opinion was that the rhythm disturbance was a stress response to the intrabdominal infection (which is what happens when intestinal contents leak out and slosh around freely in the abdominal cavity). So before transfer to the ICU, we requested (we meaning my boss, the ICU chief and I) that the surgeons take another look in the abdomen to make sure that there were no remnants of colonic contents still around. After the operation we received him in stable condition but with ongoing atrial fibrillation.

I started a drip of an anti-arrhythmic and asked the other doctor on call to put in a central venous line while I went up to surgery to see another patient. When I left, the patient's blood pressure was 140/70, pretty good considering.

When I returned, the blood pressure was 80/60. In response to my query, the other doctor explained that the patient began to wake up from the anesthetic, so she administered a small amount of an IV anesthetic so that he wouldn't suffer during the procedure. This caused his blood pressure to drop. I quickly injected phenylephrine to boost the blood pressure but it continued to drop. I called for the defibrillator; in the several seconds it took to reach the patient's beside, the pressure had dropped to 40/15 - this is considered incompatible with life.

But then again, life is full of surprises.

Grabbing the paddles, I give the order to set the defibrillator at 100 Joules synchronized. Shouting "clear," I administered the electrical shock to the patient's chest and the rhythm converted to normal sinus rhythm. Yes, sports fans, we have a save! Except, that the blood pressure remained low. So we infused a vasopressor to get the pressure up. A few hours later our patient was weaned from both the vasopressor and mechanical ventilation. However, he had one more surprise up his sleeve.

While the nurses were changing his position (in order to prevent pressure sores which can develop only after 2 hours of immobility), the patient complained of pain, so we gave a couple of milligrams of morphine. A few minutes later, the patient became obtunded, with slow labored breathing. The fairly small dose of morphine had depressed his respiratory center. We had to reintubate and ventilate him, again. I administered a different anesthetic this time for the intubation (putting a breathing tube into the trachea). This anesthetic is known for preserving blood pressure, yet, again, his pressure dropped.

Again we gave him a drip of a vasopressor. A couple of hours later he was fully awake and alert with a stable blood pressure and mechanically ventilated through the tube. And, get this, he was actually flirting with the nurses! He must have been a real ladies' man in his youth.

Eventually we weaned him from mechanical ventilation. He looked and acted as if he had just returned from a stroll in the park. This guy is indestructible.

Stupid Mistakes

This too is an old post from a defunct (for all intents and purposes) site. It is as relevant today as ever. Especially because I've just finished a run of 3 on calls in 5 days. It's very fatiguing as one might imagine. In the middle of all this was the tragic death of a young armored corps soldier which left me numb. This in itself deserves a post which I promise as soon as I get some rest. In the mean time I offer this:

Lately I've treated patients who were severely injured. That's nothing new. The common denominator of these patients was that the cause of their injuries was, for lack of a better term: stupid mistakes.

The first two I call the copper robbers (bear with me). They also might be called tweedle dum and tweedle dumber. These two numbskulls steal copper wire. Not that they need the money: they live in a moshav - one is a soldier and the other just finished his service. They are cousins. They are probably bored and were looking for some excitement. So, they went out looking for copper wire to steal. They found some. However, to their discomfort, the wire just happened to be connected to electricity, of the high voltage variety. The result: 40% and 60% burns. The treatment: multiple operations for skin grafts and a lot of pain.

The next victim: Legs of steel. An army doctor, a friend and student of mine. He was to provide medical support for some mission. This means hours of boredom sitting in the ambulance waiting for the signal to return to base if there are no wounded to treat. I imagine he got out to stretch his legs and take a breather. Unfortunately, he was on the main route in that particular area (just a wide dirt road) on a moonless night, when a Hummer with the headlights off for some reason, came round the bend and struck him. Why was he on the road, why was the Hummer hurtling down with the headlights off? Who knows? The result: head trauma, fractured ribs, legs, lung contusion, lots of pain. Probably a long period of rehabilitation, and maybe permanent disability. And for what? For a stupid mistake.

The last victim rattled me the most. A multi-car pile up. Three cars, 9 injured. 7 adults with mild injuries. But two children severely injured. A two year old girl who died of her injuries. A 12 year old whose scarred face will greet him in the mirror for the rest of his life. I was on call in Magen David Adom. The first ambulance on the scene evacuated him to my team in the mobile ICU. The sight was gruesome, deep gashes in his scalp and left cheek. The left side of the upper jaw was missing - it just wasn't there. Blood everywhere. He was semi conscious. Fearing aspiration of blood and gastric contents into the lungs, I sedated the boy and attempted intubation of the trachea (placing a breathing tube into the windpipe). This was plan A. Even with a suction catheter evacuating the blood from the airway, I couldn't visualize the vocal cords. Ventilating him with a mask and bag was just barely adequate, lots of air was escaping through the laceration in his left cheek. I decided to perform an emergency cricothyroidotomy. This was plan B. A relatively simple procedure in adults, it is trickier in children because the surface anatomy is less obvious. I added more sedation and made the incision in his neck to expose the cricothyroid membrane through which I might introduce a breathing tube. I wasn't able to pass the guide through. With his oxygen saturation dropping fast, I needed a plan C immediately, if not sooner! I instructed one medic to obstruct the hole I made in the trachea with a finger. I took a thick gauze pad and held the boy's cheek closed and with the same hand pressed the mask to his mouth and nose. I emptied the breathing bag into his lungs. A lot of air was leaking out, but I was able to improve his oxygenation. We loaded the stretcher onto the ambulance and raced to the ER. There, the anesthesiologists took over for me, my hands were tired at this point, and were able to intubate. After hours of surgery, the boy was transferred to the pediatric ICU in stable condition. The result of this accident: terrible damage to the bones and skin of the face requiring multiple operations in the future. No plastic surgery will ever erase the physical and emotional scars. All could have been avoided had the children been properly restrained with seat belts. (The children were the only passengers not wearing seat belts, and I remind you that all the adults emerged with only minor injuries because they were wearing seat belts). The parents will forever be burdened with guilt. Such a seemingly minor oversight, yet such catastrophic consequences.

The last few nights I fall asleep with the images of that accident. I replay the scenario over and over, this time I succeed in the intubation, another time I succeed in performing the cricothyroidotomy. Every time I scream at the parents, "why didn't you fasten their seatbelts?"

I've been staring at the screen for the past hour. I have no pithy summation. What can I write? Some stupid cliche like: "an ounce of prevention..."? I just feel drained. Darn it! I implore anyone reading this to drive carefully, and fasten everybody's seat belt, and don't talk on the cell phone while driving and stop making stupid thoughtless mistakes! I really don't need the aggravation.