Tuesday, December 4, 2007

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.

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