Chaos and Control

During Residency there was a concept that we were taught that has really stuck with me. We push some really powerful medications and perform some risky procedures on a daily basis and, under the wrong hands, any of them can be a murder weapon. The phrase “murder weapon” is said tongue in cheek to teach us that the things we sometimes try to do to our patients can lead to their untimely death. The idea is that we shouldn’t let these interventions become so routine that we overlook the small but real potential for harm that they possess, and should actively seek to ensure their safety. The part of the Hippocratic oath that most people can recite off the top of their head states “First, do no harm” and all doctors across all specialities try to never be the source of harm. I had a case recently that reminded me of those lessons and reminded me of how close to chaos we can be even when we think everything is under control.

Chaos is, in a word, exactly how this case started. I get a call from my frantic Charge Nurse that in 3 minutes an EMS crew is arriving with an elderly man who has had continuous seizures for the last 20 minutes despite multiple medications. No vitals, no information about their respiratory status, no additional information available. I assemble my crew, handing out duties, laying out our plan of action for both the best and worst case scenario. We are fully prepared for anything between a patient in cardiac arrest to someone who can wave to us from the stretcher as he rolls in, in just under 3 minutes.

What arrives is someone who is decidedly in the middle of those two clinical pictures. Sick but safe, I would say. He is breathing on his own, his vitals are stable, but he is unresponsive to any stimulation, verbal, physical, and most importantly painful. Once he is moved from the EMS stretcher to the bed, a whirlwind of activity starts. This tiny moment in medicine is one of my favorites. It’s truly a moment of Zen. The team has a singular focus and, when done correctly, work perfectly to gather information and prepare the patient for whatever might be needed. Multi tasking would be a massive understatement. I’m receiving the report from EMS while the nurses call out vital signs and I visually asses the patient. Within another three minutes, all of the following has happened: I have checked the patient’s pupils, established that there is no gag reflex, calculated a GCS score, estimated the patient’s weight and told the nurses the weight based doses we will need if we need to intubate, established that while the patient can spontaneously move all 4 extremities, there is little coordinated response to even severely painful stimulation. There are also no obvious outward signs of continued seizures, and I’ve also taken a quick look inside the patient’s mouth and neck to assess for the possibility of a difficult intubation and listened to his heart and lungs for obvious abnormalities. Meanwhile the nurses have established additional IV access, hooked the patient up to the monitors, obtained another set of vitals including blood sugar, drawn up the medications we need if he seizes or if we decide to intubate, and sent a preliminary set of lab work to the lab for testing. Anti seizure medication is already on the way from pharmacy and respiratory therapy is on standby for definitive control of the airway should it be needed. I’ve listed all of this to illustrate that even though things started chaotically, the team was well prepared and the situation was now under control. Sick but safe, like I said.

From here on out things went as well as you could ask for. He did not seize again and his vitals remained stable. Given his complete lack of response to external stimulation, he was intubated to protect his airway and facilitate treatment. He received fluids and anti-seizure medications. Lab work was as expected and he went and had a CT scan and a chest X-ray without a hitch. We later gained some additional details regarding this patient’s history. Turns out that the patient not only had a history of epilepsy, but was also currently in rehab for alcohol and cocaine abuse, things which can independently cause seizures during their withdrawal phase. While reviewing his results in anticipation for an ICU admission, I received a call from the radiologist. He stated that while there were no definitive abnormalities on his CT scan, there was an area in his brain that did not appear normal. He said that this area could represent “possible neoplasm (tumor) versus cerebritis (inflammation) versus infarction (stroke).” Any of these could also potentially be the cause of his presentation. He recommended an MRI and said he would be willing to approve calling in the on-call technicians to have this done ASAP. This patient came late at night and all MRIs at this time require a team to be called in - sometimes a difficult obstacle to clear. I discussed each of the possibilities with the radiologist and after walking down each of those paths I decided that it would not change the patient’s management in the acute phase and that we would forgo this test for the time being. He was satisfied with my reasoning and happy to not have to wake the techs for this case. I rarely decline additional studies when they are requested by the radiologist, but in this case it may have been the best decision I have ever made. After discussion with the ICU the patient was admitted, my shift ended, and I went home.

Cruising through old charts a few days later, I saw his name pop up on my computer. Even though as ED physicians our role is stabilization of these patients with definitive management being deferred to the other hospital teams, we frequently follow up on our patients to see how things went after they left our care. I remembered his case well and thought I would look up his MRI to see what the study eventually revealed. I clicked through his imaging and stopped dead in my tracks. There have been many times I’ve been left speechless at work, but it does not usually happen days afterwards. I felt chills down my spine, and a wave of relief and disbelief crashed over me.

The patient never got the MRI. Some of his routine imaging showed an incidental finding: Bullet fragments. This by itself is not very surprising. CT scans to get a better idea of what we were dealing with delivered the bad news: one of the bullet fragments was lodged in his left internal carotid artery. That’s the big one, the one you don’t want to touch. Had I ordered an MRI and he had gone there on an emergent basis, there was a very real chance that the fragments could have damaged the vessel and killed him on the spot. There is no remedying an injury like that and if it had happened, it would have been fatal without a doubt. There was no indication that this patient had this old fragment in their body, no family or friend to tip us off. Patients do routinely get dental X-rays to check for metal in their mouth, but this would not have been seen on that. It was also too high up to be seen on a routine chest X-ray. It was a perfect miss. I was inches away from having the MRI as my murder weapon, and the thought of that brutal act of negligence was making me dizzy in my seat. I still can’t stop thinking about it. Outwardly it was a perfectly executed case, but even with the best of intentions and plans, there was a very real risk of death at my hands.

I try to keep these cases as a mental catalogue to learn from, as an active guard against complacency or arrogance. We use powerful tools every day, and manipulate physiology to improve the health of our patients, but there is always an element that is not under our control. Remembering that is both nerve wrecking and relieving. At the end of the day, it is always someone’s time to die, but at the same time you need to constantly check and recheck to make sure you are doing the right thing for your patients. And even after you’ve done everything you can, things can still go horribly wrong. Maybe I should re-evaluate that whole “sick but safe” thing.

Smell Series: Melena

Melena is the most beautiful name for one of the most disgusting things in medicine. It rolls off the tongue with a certain grace, and if you didn't know better you'd think it was the name of your co-worker's daughter. What it really is, is a technical term for what happens to old blood in new poop: the iron in the blood rusts, and turns from bright red to maroon to a tarry black color. This distinction, between black blood and red blood, is pretty important for physicians and helps us judge the challenge we face in caring for patients who come with bleeding from where the sun don't shine. When the blood we see is "Tarry Black" in color, it has three things:

1. A beautiful name

2. An unforgettable appearance

3. A characteristic smell

Additionally, when the patient comes in looking not much better than a steaming pile of shit, it has one more thing: Our undivided attention.

Melena can be a process that has been ongoing for several months or a warning sign of impending disaster. Therefore its presence in a patient is always more important in context than in isolation. Still, patients don't usually walk into rooms with a sample of poop for us to examine, and many don't think it's worth mentioning that they've had this problem for the last several weeks, in these cases, it can be the smell that saves the day.

The smell of melena is one that everyone in the ER knows well. Not just the physicians, but the nurses, techs, and probably even the registration personnel. The reason for this is that blood in the GI tract is cathartic, and tends to cause a pretty significant diarrhea. So the techs and nurses have to clean it up often, and the stench hangs around for the registration personnel to appreciate afterwards. It's an inky smell, calling it "aged blood" would be appropriate. I've heard people describe it as having a "farm animal" quality, which is also accurate. Luckily it smells more blood than poop, but there's still plenty of poop. Here is the score breakdown

Prevalence: 7 Out of 10. Any busy ER will see this almost daily. As mentioned earlier, the process can be prolonged, occurring over weeks and months, or a rapid process that is acutely life-threatening. The people whom the smell clings to can be spotted as "sick" a mile away and usually brought in immediately. Multiple episodes of this tarry black magic make the air heavy with its presence.

Strength: 8 Out of 10. The smell is horrible, but it is hugely beneficial that it lingers the way it does. I don't want to personally witness the bowel movement, but when the patient comes in an hour afterwards and I can smell it before they can tell me their name, I'm happy to be clued into what's going on sooner rather than later.

Affect on Appetite: 8 Out of 10. If you were raised in a barn alongside farm animals, you'll probably be okay. Anyone else will have a reaction. I've seen gagging, crying, anger at being assaulted with the smell, and a look of hopelessness. The smell will hit anyone in the room and beyond. It can take out an entire hallway. It can make nearby patients request a discharge home.

Prognostic Value: 9 out of 10. Truth be told, rectal bleeding is a very common phenomenon, and the most frequent culprits are self-limited and not dangerous. Most patients who look stable, have had minor bleeding, and are capable of following up with a specialist can go home. IF this smell is present, the likelihood of them matching the above description is almost zero. If someone comes in with abdominal pain, regardless of age, and this is what I smell, they have an uphill battle to convince me that they can go home. It is the only redeeming quality of this smell because so many times patients will simply withhold their GI troubles from us.

Final Score: 32/40

Out of Mind, Out of Sight

*This post contains graphic imagery that is not suitable for everyone, the image is attached at the bottom, please take appropriate discretion*

    I trained at a level 1 trauma center, and it did not take very long until I felt that I was "immune" to the types of things that would make others gag. Severed limbs, traumatic injuries, and gushing blood did not bother me in the slightest. Over time your training overpowers your natural responses and you approach these situations in a calculated manner. It's the only way, I was taught, to do the job because sitting and pondering the implications means you're not useful to your patient. I understand and agree with this notion in the majority of situations, and was happy to adopt it into my practice. Of course, if you've been reading this blog, you've noticed a certain pattern. Experience has continuously taught me that you'll never truly "see it all" and there are still cases that can rattle you. This story is regarding one of those cases. 

    First, I want to set the backdrop for this story. Let me start by explaining that when I started medical school, I matriculated with the intention of becoming an ophthalmologist. To acclimate myself to this future, I spent roughly 150 hours shadowing an ophthalmologist in the OR and in the clinic. So, as early as medical school, I was no stranger to surgical exploration and manipulation of the human eye. I had seen numerous traumatic injuries and was accustomed to the visceral reaction seeing a damaged eye produces. With that in mind, understand that this case and the context in which it occurred was enough to floor me for the remainder of my shift and beyond.

    Secondly, in the Emergency Department, strange things arrive at night. It is known, expected, and probably welcomed,honestly. The night-crew is a hardened set of veterans who, above all, get the job done. This case was no different and was a classic middle of the night  "drop in". We were prepared, but we were not prepared.

    Actually, the night was exceptionally busy, and I hadn't really had any time at all to think thoughts or feel feelings. My mind was running in bullet points and I was jumping from task to task  with as much efficiency as I could manage. I remember asking a nurse if she could accompany me for an exam and she said she needed some time. I told her I could be ready in 3,8,12, or 20 minutes, and whenever she was ready I would switch the order of things I had to do to accommodate her. This was that type of night. 

    So, like every other patient I had seen that night, I did not bother to fully read the documentation before I went in to investigate. This patient was a transfer from another facility, and had I read the documentation, I would have been introduced to this case in parts, lessening the shock. 

    EMS had wordlessly unloaded the patient from the stretcher onto the bed by the time I arrived. The patient had a bandage on his head but seemed otherwise content. Young, still dressed in street clothes, and in no apparent distress. What gives? My instincts were at odds with each other. On the one hand, he did not have the tell-tale signs of a chronically ill patient with an impending catastrophe, but on the other, there were subtle clues towards the magnitude of what was unfolding.  

    Whatever, no one has time for these mysteries and I began rattling off my introductions and open ended questions. How do you feel? Okay. Are you hurting anywhere? My eye. This was getting nowhere fast so I started to unwrap the bandages while I redirected the patient towards the salient points of his history. How did you hurt your eye? My hand. The conventional portion of the interview ended here because as he said this I had uncovered his injury. 

    This gentleman was young, about 30. He was very appropriate, tired as he should be because it was the middle of the night. He  gave off the same vibe that a child has when they approach you to confess doing something they shouldn't have. The shuffling, roundabout answers you get when they know you won't be pleased with their response. Over the course of the last several months, he had started to exhibit strange behavior. He recognized it as such himself, but kept on with it. He recognized that he was having auditory hallucinations and over time they started to gain power over him. The hallucinations demanded actions from him and he eventually relented. In this particular case, he had been convinced that his right eye was guilty of "lusting" and he felt that God was commanding him to remove it. He decided to use his hand and crush his eyeball in an effort to rip it out of his face. He was largely successful. Over the course of the medical transport, he regained lucidity and was fully aware of his situation. He would never see out of that eye again, and in fact, required surgery to complete the evacuation. He also understood that he had a serious problem on his hands, and from this point forward he would be struggling against these internal forces. I've attached a picture of this encounter, but the photograph does not fully recreate the horror of the situation. 

    We often describe accidents, injuries, or wrongful deaths as tragedies, which they are, because they rob someone of a family member, a career, or a future. This case was a tragedy in a slightly different manner in the sense that the victim was the architect of his own loss. He was blameless of course. This particular story is especially disturbing because it is troubling from every angle: the implications of a debilitating psychiatric condition, the horror of self-inflicted mutilation, and the loss of one of the most meaningful ways of interacting with the world. I think this is why it hit me like a brick wall, forcing me to reflect on it. It was a classic case of the insanity we sometimes see in the Emergency Department but will never truly be accustomed to.

Smell Series: Diabetic Ketoacidosis

    Most "diagnostic" smells are such that they are obvious to the clinician but largely unknown to the patient. The general public may have heard of some common serious illnesses, but they don't have a smell to match the condition in their mind. The smell of Diabetic Ketoacidosis (DKA) is an exception to this rule in that many of our patients come in stating "I could smell it, so I came before I could feel it". Other times, they have become so sick that they are unable to reason their way to a diagnosis even when the smell is overwhelming. 

    DKA is a serious diagnosis, an almost automatic ICU admission in the vast majority of the cases. Even with treatment, outcomes can be devastating, so any help in getting the diagnosis early and starting treatment as quickly as possible is welcomed. It represents the extreme end of the spectrum for patients who are diabetic. The smell is characteristic, and aside from a few rare imitators, is largely found only in patients who have DKA.

    You may detect this smell as soon as you open the door to a patient's room, or only once you've gotten close enough to examine them. This roughly approximates the severity of their case. It is a musty, sweet odor. It is not a bad smell, per se, but its association with death is well engrained in our minds. The patient's skin exudes this smell, and it pours out of their mouth with every word. It smells a bit like sugar-free, fruit flavored gum or nail polish remover. The diagnostic giveaway in adult patients is that they have a prior history of diabetes, but in children who are presenting with this condition for the first time, that information may not be available. Thus, the smell demands a quick evaluation for the presence of this very serious condition. 

Prevalence: 8 out of 10. Any busy emergency department will see these cases on a daily basis and any pediatric ICU will have multiple cases of this concurrently. These patients are sick and know that outside of a hospital they cannot survive

Strength: 6 out of 10. As mentioned previously, it is variable given the length of time the patient has been in DKA. But it is largely unmistakable and the sicker the patient, the harder it is to ignore. 

Effect on Appetite: 2 out of 10. Of all the smells a human body produces, this is the least noxious. The smell of the ketones in the breath is from the same group of compounds used to make perfumes. This smell is more likely to take your appetite due to your concern for the patient's well-being.

Prognostic Value: 9 out of 10. This smell is a harbinger of death for diabetic patients. The majority of these cases will end in death if untreated, and many will die even if aggressively treated. Even though it has a sickly sweet flavor, the implications of it can be sobering.

Final Score: 25/40

Smell Series: Clostridium Difficile Colitis

    Any good clinician will accept data from the patient in any form they can get. Direct questioning, interviewing the family, and thoughtful observation are as valuable as any lab test. Of course embracing the smells of the room is part of this data set. The smell of Clostridium Difficile Colitis is immediately recognizable, but at the same time out of place. It’s a smell that does not seem organic, its character is different from any other smell produced by the human body. If you’ve read the book Dreamcatcher, it smells the way I imagine the parasitic alien fungus does. It’s a deep, inky smell, that dominates over the other smells in the room. It is not diluted by the smell of sweat or urine that often accompanies chronically ill patients. It carries strong notes of ether and organic chemicals that remind me of my time in the lab as an undergrad student. I’ve heard it described as sweet by other providers, which is not a word I’ve ever used to describe fecal matter, but I understand it. It’s a smell I’ve learned to trust, which is its only redeeming quality. Let’s break down the ratings

    Prevalence: 4 out of 10. This is a weekly smell in my experience. Found more frequently in patients who’ve recently been discharged or have been languishing at a nursing home for just a little too long. 

    Strength: 6 out of 10. When it comes to bad smells, this is perfect. It’s strong, immediately detectable when entering the room, but not clingy. A good hand wash with soap and water and the smell stays basically in the room. It does not stay on your clothes. It lingers in the background of the room after the patient has given a sample like music in a hotel lobby. 

    Effect on appetite: 2 out of 10. This smell, as mentioned previously, does not smell organic. It’s not like any other body fluid and therefore it doesn’t have a strong association with food. Think of its affect on appetite like the affect a bad smelling household cleaner would have on appetite. No long term damage. 

    Prognostic Value: 8 out of 10. If a smell can have a redeeming quality, it is this. I can walk into a room and smell this smell and we have a plan for the patient as I’m introducing myself. You cannot accidentally have this smell, it strongly correlated with the presence of Clostridium Difficile Colitis. It can be a debilitating infection, but embracing this smell can give you a head start in resuscitating these severely ill patients. 

Total Score: 20/40