Thursday, August 7, 2008

The Burned Girl

A couple of night ago I was on call in the OR. I got a call from the shock/trauma room that they needed my assistance. A fifty something John Doe was brought in after being beaten in his own home. One look was enough to see this was an odd case. This man had been literally tortured. The odd thing was that all his bruises were several days old. From the shape of the bruising, we deduced that he had been forced to remain on all fours while he was whipped with what we assumed was a belt (some of the bruises had the shape of a buckle). He had massive subcutaneous emphysema (air under the skin) from his neck to his groin. This indicated that there was a puncture of the airway. Because he was agitated and was unable to cooperate I anesthetized and ventilated him. After a total body CT we transferred him to the ICU. A bronchoscopy and esophagoscopy were performed with no findings. Odd.
Later that night, the ENT doctor called with a bit of panic in her voice. A year old infant with post tonsillectomy bleeding was being rushed to the OR. This did not sound good. We prepared the pediatric equipment and received the child at the entrance to the OR. He was completely pale including his lips. He was unconscious and his fontanelle was sunken. All this indicated that he was in severe shock because of massive blood loss.
Post tonsillectomy bleeding is not an uncommon complication and is considered one of the classic problems of anesthesia and is almost always included in the oral board exam. The dilemma is how to induce anesthesia to optimally prevent aspiration of blood into the lungs. Like many problems in anesthesia there is no right answer. The individual technique is probably less important (even though the discussions of proper technique sometimes deteriorate to the verge of fisticuffs) than the overall approach to an emergency situation. I agree with Dr. Keamy, who blogs on The Ether Way who writes:
"Judgment in anesthesia, as in all of life, takes unusual forms. While you might think that drug selection/technique are the essence of anesthesia judgment, I believe after thirty years that these choices matter rather less than we think. I am reminded of old studies of psychotherapy that concluded that good therapeutic outcomes correlated with individual therapists more than theoretical "schools" of therapy; that talk therapy is personal. So, perhaps surprisingly, is anesthesia."
We rushed the baby into OR 7. Luckily the pediatricians had put in an IV line. We induced anesthesia. I put the laryngoscope in the mouth and for a split second glimpsed the vocal cords and then everything went red. The oral cavity filled with blood. I asked for large bore suction (which we had prepared beforehand) to be put into the mouth. The blood was flowing freely, but I could see the vocal cords. I pushed the endotracheal tube through and moved aside so that the ENT could get in there and stop the bleed with electrical cautery. We gave blood through the IV and put in a central venous line in the femoral vein. Color returned to the baby's lips although he was still quite pale. Still asleep and mechanically ventilated I transferred the child to the Pediatric ICU.
Yesterday I had a chance to do a good-deed-for-the-day. I went to pediatrics to anesthetize a 4 year old girl for a change of bandages. This poor child had played with matches and her dress had caught fire causing severe burns from her ears to her ankles. She had been hospitalized for close to two months, much of that time in intensive care. Dressing changes are done almost every day and are excruciatingly painful, hence necessitating anesthesia. Thus, I had anesthetized her often in the ICU. This was the first time I saw her on the Peds ward. For the first time I noticed that her hair was matted, and her fingernails had grown quite long. I asked the nurses about this and they said that the mother refused to shampoo her hair and trim her nails and had demanded that it be done under anesthesia. They went on to describe how the family had raised the ire of the staff by complaining about everything and everyone. I could understand, the staff works very hard under difficult conditions to provide the best care possible and it is frustrating to hear nothing but complaints from the family. I pointed out that the parents probably don't know how to deal with the guilt about what had happened and vented their frustration on the staff. This is unfortunate, I told them, but the bottom line is that we are here for the girl and we won't "cure" the parents of their guilt and their poor manners. Besides, I continued, you work so hard to keep her bandages fresh and clean, but all is for naught with such grimy fingernails. The microbial garden growing there is a constant source of infection. I'll give you another 10 minutes of anesthesia and you make her pretty. Such rapier sharp logic apparently made sense. At the end of the procedure, the little girl had nice clean bandages, an expert manicure and clean scented hair. While I was writing the anesthesia note in the chart, the nurses came and told me that the mother thanked them. I thought to myself, "perhaps there is a cure for poor manners"

1 comment:

Ken said...

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