Thursday, May 15, 2008

Nasty, Brutish and Short

On call in the mobile ICU. We get a call to join CPR in progress on a 6 year old. The feeling is always different when we know a child is involved. Not that it's more urgent but there is always more tension and more emotion. We arrive and a one EMT is performing chest compressions and another is breathing the child by mask. I examine the child who clearly has some birth defects, the pupils are dilated, the prognosis is grim. I could easily order rescusitation stopped. But I ask my team to continue and institute advanced life support techniques. I have three reasons: 1. I always make the effort until I receive the patient's medical history. 2. It's always more difficult emotionally for the team to "lose" a child. 3. CPR in children is relatively uncommon and it provides the younger members of the team valuable experience. While the paramedic and EMT's were working under my supervision, the family handed me a very organized notebook with all the child's medical documentation. To my surprise, the child was a bedouin adopted by a jewish family. He was born with an impossible constellation of birth defects: Microcephaly (a small brain), meningocoele, blindness, severe psychomotor retardation, obstructive sleep apnea and by the scars on his abdomen, had several operations. This family took in the child in an attempt to relieve the burden on his impoverished relatives. The daughter of the woman who adopted him told me what a miserable existence the child had. Looking at the deformed child reminded me of Hobbes' most famous quote: "life is solitary, poor, nasty, brutish and short". After 20 minutes of advanced life support with no response, I directed the team to cease and pronounced the child dead. Despite the outcome I thanked the team for their effort. I'm satisfied that this team will do well perhaps with another patient who has a chance at life.
Later that day we rendevouz with an ambulance from one of the outlying communities. A 65 year old gentleman with chest pain the first time in his life. We transfer him to our vehicle. I tell the paramedic and the student to make a mental note of the clinical picture. "This is as classic as it gets", I told them. We obtained an EKG which screamed MI (myocardial infarct). Time is of the essence. On route we administer drugs and I call the Cardiac ICU. This is where the advantage of hospital doctors in the mobile ICU is apparent. We've all worked with each other for years and trust each other's opinions. In addition, I'm an ACLS (Advanced Cardiac Life Support) instructor, so all the cardiologists know and respect me (hard won respect I assure you). I described the patient and the EKG and asked that we bring straight to cardiology and bypass the ER. The cardiologist said, "I'll do you one better, bring him straight of to the cath lab." This decision was critical because during myocardial infarction, saving time means saving heart muscle. We arrive at the hospital and go straight to the cath lab, I flash the EKG to the cardiologist who gets excited, a chance for a save.
Later that day we visit the ICCU. The right coronary artery was completely blocked. A stent was placed and a followup echocardiogram showed almost no residual dysfunction of the heart.


Anonymous said...

I hope you realize you saved this gentlmen's life.


Lioness said...

Oh your mum is so brilliant! And you did, and it must feel tremendous.

I wish you were closer to give me a series of quick cardiology lessons, I'll graduate soon and know next to nothing abt the heart?? It's not sobering, it's terrifying! Honestly, our school is so bent upon making us memorise pages and pages of material we'll never have use for and cheese making and such that we don't even have time to properly study what is important. It's criminal.

Dragonfly said...

There can be such juxtapositions in a day of work as a doctor.

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