Sometimes theres that one patient I see that makes me realize how far modern medicine has come. This week I reflected on one of those patients. A previously healthy, young, female was a restrained passenger in a motor vehicle collision that was taken initially to Kings County hospital. She presented with, intra and extra peritoneal bladder rupture, pelvic hematoma, dissected hypogastric artery, splenal rupture, C7 right pedicle to facet fracture, L2/L4 transverse process fracture, left 2nd rib fracture, right 3-5 rib fracture, pelvic ring disruption, bilateral acetabular fracture, hip dislocation, left iliac wing fracure, zone 2 sacral ala fracture, left superior and inferior ramus fractures, and right inferior ramus fracture. Doesnt sound too good and as one orthopedic resident said, "She had a bad day." But, the crazy thing is she is expected to make a full recovery. It will be a long recovery, but she will get better. This particular patient came to the unit after three days at Kings County where they dealt with the immediate soft tissue and organ injuries. When she arrived, she was heavily, heavily sedated, largely unresponsive, and very beat up looking to say the least. But checking in on her two weeks later, her internal injuries are largely healed, she has completed the big orthopedic repairs (although she will need several more smaller surgeries and revisions along the way), she is awake, chatty, and ready to leave the SICU for a regular floor. In another week or two, she will probably be able to leave for a rehab center. Its absolutely amazing to see the progress in severe traumas like this. However, its also so crazy that in comparison to the full recoveries I have seen in patients like this, sometimes just one seemingly simple problem is absolutely ruinous.
Last week I talked about the young 30s female patient who suffered from a huge intracranial bleed and was left brain dead, possibly from some assault (they never could determine if it was a assault or not so police werent involved. She was transferred to Neuro ICU where she remains brain dead on full life support), well this week the same exact case happened again. It doesnt matter how many times I could see this injury, its so tragic every time. Another young 30s female was found unresponsive by her husband at 3am. She presented at the ER GCS 4 and was found to have a massive cerebral hemorrhage from what looked like a burst aneurysm. She was young, healthy, had no prior health problems but this aneurysm had slowly been growing in her brain undetected until it burst. She was taken for an emergency craniotomy and evacuation of the clot, but even though she was taken for surgery not even an hour after being found, it was too late. She is completely brain dead. In principal it is a simple problem: an aneurysm burst and the brain bled and became swollen. Its a contained problem in one area in contract to an extreme trauma patient, but it is so fast acting, so deadly, and so tragic. Just watching the family was heart breaking. Sadly, her tragedy became a rare learning experience for me as I was able to observe start to finish the process of stabilizing her, testing and declaring brain death, the discussions for organ donation, and finally the organ donation process. Its relieving that some hope will come from her death, but seeing these two young patients in one week is just so tragic.
Dealing with patients unable to control their temperature, like a brain dead patient, or a patient with an uncontrollably high fever has introduced me to what the nurses claim is their favorite machine: the Arctic Sun. The Arctic Sun employs pads with cold water lines running through it to bring a patients fever down and maintain a target temperature. Its a favorite due to its extreme ease of use, simple feedback, its ability to "talk" to you or at least display a large user friendly touch screen, its quiet, and its efficacy. Apparently it was also developed "By a nurse. Not some engineer" as the nurses gladly told me. Hence the importance of a real clinical immersion. Without seeing, and dare I say doing, we are lost in our little lab worlds and come out with designs that clinicians wind up hating for one reason or another. One new device Ive been seeing that needs improvement are naso-gastric feeding tubes. These tubes come in a variety of shapes and sizes. The SICU favorite being the Dobhoff tube, a thing, flexible tube, with a weighted end that makes placement much easier that larger stiffer predecessors. However, the problem with this and any feeding tube is coiling upon insertion. There are three "trouble" junctions: where the throat meets the nose, the epiglottis, and the epigastric junction. Get the tube smoothly past these areas and its a success. But the tubes tend to coil up upon hitting an area of resistance. Tubes can wind up in bronchii, too deep, too shallow, twisted so they are obstructed, and the only surefire way to prove placement is an xray after insertion which is a second procedure, another dose of radiation, and another cost. It also can delay care since you may have to drop the tube again hours later if you find out when xray finally arrives its misplaced; you cant feed the patient until the tube is verified. Im not quite sure how to find that balance between stiff and flexible to inhibit coiling or how to weight it correctly, but it definitely needs improvement.
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