September 22, 2007 | Leave a Comment
Consider two separate rooms in the same Emergency Department. In one lies a young man who has been shot in the chest and arrived in full cardiac arrest with the paramedics frantically giving CPR. Red frothy bubbles come out of the gaping hole over his heart whenever the bag attached to his endotracheal tube is squeezed. A Full court press ensues and the trauma bay fills with interested bystanders watching the action as the patient is prepped for an emergent thoracotomy; a procedure where the chest is cut open to expose the heart and allow the repair of any obvious holes (as well as manual compression of the left ventricle to circulate blood).
In another room sits a sixteen-year-old girl, two weeks out from a tonsillectomy, with an emesis basin by her mouth and over which she has coughed or vomitted enough blood to cover the front of her dress. The room is empty except for the Emergency Physician, the nurse, and the anxious family.
Which case is more important? Surely the gunshot wound in the trauma bay is getting the most attention. It is an exciting case after all. It has everything one could possibly want. Blood, gore, violence, the cops, good guys, bad guys, and a young man whose life is hanging by such a fine thread that the Emergency Physician who is not in any way, shape or form a trained cardiothoracic surgeons is preparing to make a very large hole in a chest to perform rudimentary open-heart surgery. This is the stuff of which legends are made.
“Say, Bob, remember that chest we cracked last month. Man. What a mess that was!”
The young girl in the other room? It’s just a post-tonsillectomy hemorrhage. Not exactly riveting stuff but I submit that this girl is the more important of the two cases. The guy in the trauma bay, after all, is dead and not likely to improve. He’s been shot through the heart or a great vessel and has been without oxygen to his brain for all but the first minute (the time it takes for his heart to pump most of his blood onto the street) of the last official twenty minutes of his life. There is probably nothing left upstairs to save even if circulation is restored. There is literally nothing to lose so everything possible is done and the trauma bay hums with frenzied activity even though the chances of even restoring spontaneous circulation with an emergent thoracotomy in a patient who arrives without vital signs is less than one percent. And only a small fraction of that less-than-one-percent ever leave the ICU except feet first for that last ride to the basement.
And yet this kind of thing defines Emergency Medicine as a specialty. The sixteen-year-old girl? How many of you contemplating Emergency Medicine as a career have ever though about this kind of patient? She seems pretty mundane and yet a patient like this is in mortal danger unless something is done and done quickly.
Everybody knows what to do in an exciting trauma. Big Things. Big Procedures. Lines, tubes, fluids, ventilators. Futile but extremely gratifying. How many of you have even considered how you’d handle a frightened sixteen-year-old rapidly bleeding to death and periodically vomitting another half-pint or two of blood. And no, it’s not as easy as you think. The girl could die. She’s sixteen. She isn’t supposed to die just yet. It’s just a tonsillectomy for which her otolaryngologist humorously prescribed ice-cream to make her throat feel better. If you let her die how will you explain it to the family?
“We did everything we could…I’m sorry,” doesn’t quite cut it in this case.
The moral? Emergency Medicine is not what you think. For every major trauma you are going to see a hundred garden-variety gastrointestinal bleeds, overdoses, strokes, heart attacks, ectopic pregnacies, sepsis and a large variety of other potentially life-threatening presentations. These will be woven into a day mostly spent dealing with relatively minor stuff like vague abdominal pain, headaches, and whatever complaint can be used to access the bounty of The Man. That’s just the way it is.
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