This unfortunate gentleman was stopped at a checkpoint by ANA soliders. They wanted him to give one of the soliders a ride and the guy refused, so they shot him. He came in in bad shape. They put a chest tube in which drained at least 400cc of blood immediately (as you can see he has a hemothorax on chest xray) and he died of hemorrhage within an hour of arriving. They poured tons of fluid and blood into him, but his low blood pressure eventually went away. They do not have a cardiothoracic surgeon, so not a lot they can do. I was not there for this event, but I heard the story as we rounded on his grandson, who was in the back seat. The bullet went through his grandfather and hit the young boy in the shoulder. Fortunately it was just a flesh wound, but a sad story.

S I, Q III, T III

So I get a call from one of the ANA docs asking me to see a pt. He states he is a young guy with tachycardia and it won't go away, so he wants my help. A month or two ago, we had a young guy with AVNRT(arrhythmia), so I was thinking it was something like that. When I show up I could tell this was not going to be what I was expecting. There is a 24 y/o male in obvious respiratory distress, pulse oxygenation (little thing that goes on your finger) is 88% on a face mask (not good) and his heart rate is 120. The doc states he is treating him for pneumonia for the past 36 hours (it was a three day holiday weekend), and tries to communicates that also in his differential diagnosis is pulmonary edema(fluid in the lungs) and pulmonary embolism (clot in the pulmonary arteries). I was a little confused because I thought he was trying to communicate that the patient was getting better, ie: his heart rate was now only 120, and it was 180 the day prior, his hypoxia and respiratory status are better. The patient told me he felt better too. So I look at his chest xray, which was not that bad, and if I looked hard, could kinda see a pneumonia, but nothing overt that could explain his hypoxia (low oxygenation). I also look at his EKG because after all, the whole reason he called me in was for tachycardia. There is an incomplete RBBB, and some other "odd" changes, but at first I wasn't sure why, I just knew things didn't add up. So I asked the pt why he came in, he said, I have been short of breath for 6 days, coughing up small amounts of blood and I passed out the day I came in. As soon as he mentioned the blood and passing out I knew it was going to be something bad. I listen to his lungs and they were unfortunately clear... I knew immediately he had a pulmonary embolism. I look at his legs and the right one is red and swollen. We immediately treated him with lovenox. We decided not use thrombolytics (tears up the clot in his lung) because his blood pressure was stable and once we sat him up, his oxygen sat came up to low 90s. The patient did well for the first 10 days, came off oxygen, heart rate in the 80s.....until very early one morning he decided to get up and walk to the bathroom, which we had warned him not too do, and he passed out. I get woken up to come to the hospital, but they coded him for about 20 or 30 minutes and he was dead by the time I got there. I told them not to feel bad, there was nothing they could have done.

In hind-sight, the interesting thing about his EKG is that he had an S wave in lead I, Q in lead III and abnormal T wave in III, which fits the classic but rarely seen EKG pattern for pulmonary embolism.

Saved from iatrogenia twice!!

I get a call at 530 PM tonight from an ANA doc stating that, in fragmented English, a guy has a bad heart, intubated and they need help. I was thinking some old guy was having a heart attack or heart failure. To my surprise the guy was in his early 20s. At first glance his vitals were stable, so I knew I had time to quiz the ANA docs before intervening. (Story goes: he was playing volleyball when he suddenly passed out. He was brought to the spanish hospital down the street. All they did was intubate him and transfer. No labs no EGK no xrays). I asked what they (ANA) had done, and they said nothing. So I instructed them to examine the patient. I examined him after the duty doc was done and immediately noticed that the left side of his lung had no breath sounds. I asked him to listen again because he said the exam was initially normal. After a second listen he noticed there were no breath sounds on the left. So we moved the tube back 3 or 4 cm back. On re-examine breath sounds were normal bilaterally. Then we spent about 5 minutes discussing the differential, while the nurse obtained an EKG. All he could come up with was seizure, which is true. I told him most likely is arrhthymia. His EKG is above. In short, I think the guy has WPW - an unfortunate conduction pathway in his heart. Since our resources are limited, I went to find a cardiology textbook to look for alternative long term treatments, since we do not have first line treatment (ablation and other anti-arrhythmic medicines). When I came back, I noticed the labs were done. His pH was 7 and CO2 was 100!!!! normal is 7.4 and CO2 of 40. Of course no one looked at the labs!!! I told them to repeat it STAT while I tried to figure out what was going on. The ventilator was acting wierd. Tidal volume (measured breath the machine gives the patient) going from 0 to 1200 cc (it was set for 400). Repeat blood gas was still horrible. So I told the doc to get another machine while I manually bag the patient. Well, there was no resistance while trying to "bag" the patient, so I knew that the tube somehow came out. either I did not inflate the cuff enough or the cuff had a leak. In a very commanding tone, I tell everyone to grab me the intubation kit and get meds ready. I pull out the tube and lower the head of the bed and try to put a mask on his face to hand bag him. It was difficult because he was fighting me. I figure since he is fighting me, he can probably breath on his own. We repeat a blood gas and it improved dramatically, still slightly abnormal, but not nearly as bad. Guess I had to just relieve the obstruction in his throat. It was good learning for all. Still not exactly sure about long term treatment. I emailed a cardiology friend of mine with the options available to us to see what he would do.

Guess How Many Afghans in the Truck?

There were about 20+ afghans walking down the street, when all the sudden a truck pulled up and honked it's horn. They all started running down the street piling into the vehicle. Bushey and I did not think they would all fit but our interpreters had no doubt they would all fit. In fact, they said there was room enough for them!

First Helicopter Ride

Took a trip down south last week to Shindand. There is an Army surgical team there, who sends me a lot of transfers. So I figured I would stop and say hi. Had a great time. Took my first helicopter ride, smoked some cigars with the nurse anesthetist, ate good italian food, got licked by the bomb squad dogs and worked out. Life was grand. Hope all is well with you guys back home, see you soon!

Shigalicious

My friend sent this picture from Hawaii. Thought it was great, given one of my nicknames is shiggy.

Advanced Leukemia

This 32 y/o gentleman presented with fatigue, cough and fevers. He had a white count of 160,ooo!!! As you can see by the outline on his belly, his spleen and liver are very big. He also had enlarged lymph nodes in his neck. As you can see by the second picture, he is very anemic, hemoglobin 4.1. He stated he started noticing symptoms and swelling in his neck for maybe 8-12 months. I am not exactly sure, but by his blood smear my best guess is CLL(chronic lymphocytic leukemia), which is unusual at his age. I was guessing CML(chronic myelogenous leukemia). We sent him to Kabul for definitive treatment. Not sure how he is doing, as we have no way of tracking patients in this country.

Deep Doo Doo

This gentleman was injured in an IED (road-side bomb) blast. He was transfered to us in the middle of the night. The story I got was that he had some broken ribs and missing teeth. When he arrived, the ANA physician stated in broken english that he had 2 chest tubes, was on the ventilator and had no blood pressure. We were able to resuscitate him and for the first time in this hospital, started vasopressors (which he had to mix ourselves. Since I have never actually mixed it up myself, I had to look it up in a book). It was a great case, especially since I was able to give a mini-lecture on vasopressors, indications, bad side effects, etc.. The patient actually did well for the next few days, and we were just waiting for him to wake up so we could extubate him. Well.....that morning on rounds, I happened to comment about the chest tube, and asked if it was high. I am embarrassed to say, I have very little experience with chest tubes management and do not recall ever putting one in. The surgeons said yes and that they would pull it back a bit. That was HUGE mistake. The next morning I come in and the patient is on pressors, had been bolused 2L of fluids and is hypoxic (not oxygenating well) on 100% O2. I get worried and asked the overnight doc what he did, which was nothing except try to treat his low blood pressure and hypoxia, but did nothing to try to find out why. I tell them to get a chest xray now and the bottom CXR comes back first ( do not know why it loaded the pics in reverse order). I tell them I think he has pneumothorax, and that this radiograph is called the "deep sulcus sign". I had seen this once during a medical jeopardy morning report my first or second year. I wasn't exactly sure, but I was fairly certain. What happens is, when the patient lies on their back, instead of the air rising to the top of the chest and pushing the lung towards the middle of the chest, the air rises to the top and pushes the lung downward, but the lung markings go all the way out to the chest wall on an AP view so you can get fooled. You would have to take a lateral view to see the smooshing of the lung. But, what you do get is pushing down of the diaphragm, thus called the "deep sulcus sign". The reason this patient developed the pneumothroax (actually tension pneumothorax) was because when they pulled back the chest tube, the proximal port was no longer inside the chest wall and instead between the tissue, causing in essence an air leak. The top CXR is after insertion of the new chest tube. As you can see the tension pneumothorax is worse. Again because the proximal port is not inside the chest wall. You can also see abundant air between the skin and muscle, which shows up as black between 2 white stripes. Needless to say this patient died around 5PM that day, (the patient was practically coding hours before I stepped in the door, and we resuscitated him no less than 5 times in a 6 hour time period) . It was a hard lesson to learn, but I actually got about 20+ people to attend the mortality conference on this patient (the most that has ever attended). We discussed this xray finding, chest tube management (something I did not know too much about prior to this), and the need to diagnose and not just treat symptoms.

Bedside brain debridement

The story goes on this unfortunate gentleman is that he got up in the middle of the night and shot 4 of his ANP buddies. Then he jumped into his truck and hit a barricade and thus suffered bad head trauma (yes, there is exposed brain matter). One died, and 3 were critical. Now the 3 are doing well, but this guy is essentially dead, expect that we are keeping him alive on the ventilator and his heart works fine. The next day, rumor has it that these 4 tried to force themselves upon him and he retaliated by shooting them. Not sure which story to believe. The only reason I am not advocating to take this guy off the vent is that he has a lot of electrolyte and acid-base abnormalities which I am using as teaching points. His sodium is 179 and potassium is 2 (we caused this by giving him a bunch of mannitol for the past two days without checking labs). Our lab machine broke the day after he came in, the day we started the mannitol (draws a lot of water out of the cell and eventually you pee it out). I was surprised we started the mannitol because they asked me how much mannitol they should give him and I told them it was not a good idea. On this day, the decided to do a bedside debridement of his skull.

This young gentleman came in with dyspnea(problems breathing), duh!! The top xray shows a huge pleural effusion with compressed lung. The post-thoracentesis (sucking fluid out of the chest) chest xray shows a decreased effusion, but the lung is still pretty collapsed. They brought this patient and his xrays the day after. I was surprised the guy looked as good as he did with his lung still the way it was. Also surprised they did not put a chest tube in when the lung did not re-expand.

Then they decided to re-tap his lung. Of course there techniques were non-sterile, but even more surprising is that they stuck a needle in his chest without doing an exam to see where the fluid ends/begins. Of course, it is hard to miss the fluid, but normally we examine the pt first. When I tried to explain this they just blew me off. Then I told the patient to let us know if he has any pain or problems breathing(they stuck the needle very deep and I was worried they would hit his lung). The doc responded, "if we tell our patients that, then they will all complain of pain". It was such a ridiculous statement, I couldn't respond. Oh well, inshala!!

It snowed on Sunday, day before superbowl here. It was great! Obviously not too cold because the snow melted as soon as it hit the ground. It continued to snow through the superbowl which was at 330 in the morning on Monday. We had a little party at our office. It was a lot of fun except when Peyton through an interception with 4 minutes to go. I was pretty upset the whole rest of the day. Oh well, life eventually goes on.

LTJG Bushey Demonstrating how to use a spirometery machine

I found out that had a spirometry machine! This aides us to diagnosis different types of lung disease by taking a deep breath in and then blowing it all out. Anyways, we have diagnoses someone with severe COPD and tracheal stenosis in the last 2 or 3 weeks. I took photos of how to use the machine step-by-step, with the help of Mike, so that I can give a power point presentation how to use it. Then I plan to give a lecture to the docs how to interpret. Anyways, I thought it was pretty cool that they had a hand-held spirometry machine. Unfortunately can't do lung volumes, but I will take what I can get. We also got $100K worth of endoscopy equipment that nobody really knows how to use. I am planning on going to Kabul in March to work with an American GI doc to learn how to put it together, clean and maintain it, besides doing the endoscopy part. Then teaching the Afghans? We will see how that works out.

P90X - 90 days and counting

So as you all know, I had a friend join me in my P90X journey. Well, I now got Mike (the OR nurse I work with) to join also. Funny, but true story. I got them to let me take a "before" pic of them in the office. So, we locked the door and they took their shirts off so I could take the pic. Although I am very tempted to post it, I promised not to until the 90 days is finished. Well as they are getting dressed, an Italian solider tries to walk in. So we let them in, but John is tucking his shirt in and his pant's button is undone, and Mike is buttoning up his shirt and I have a camera in my hand. Very awkward moment! I hope you find this as funny as we did. We could not stop laughing and the Italian solider did not look amused.

Tachycardia anyone?

There was a 30y/o solider admitted for trauma, with broken humerus. He had been there about 24 hours and they decided to take him to the OR (same day as they did the bedside procedure on the post below this one). As they wheel him back and hook him up to the monitor they notice his heart rate is 200! So they appropriately wheel to the ICU and call Dr. Habib. I happened to walk by and notice them hooking up an EKG to a "new" pt in ICU. When I realized what happened, I asked if he noticed his heart beating fast and how long this had been happening. He stated yes, and it had been happening since last night constantly, no other symptoms. He then went on to say he has had this on and off again for a year. Of course no one got an EKG last night, it probably was never reported. Also, no one ever got a pre-op chest xray (CXR), but an xray of the bone. Prior to them hooking him up to an EKG or monitor in the ICU, I started to examine him. At first I thought he had afib because his pulse was irregular, but when I saw the monitor, I felt it again, and realized that his pulse disappeared everytime he breathed in! The first thing I thought was this guy had been in an MVA and maybe had tamponade, but he looked too good. His heart sounds were kinda distant, but not that bad. The rest of his exam was normal, no signs of heart failure. He converted back to normal sinus rhythmn (Second EKG) after 5mg of iv metoprolol (works on the heart to slow it down). His CXR showed a large heart. We did a quick ultrasound of his heart to make sure there was no fluid, which there was not. I told Dr. Habib, I thought this might have been AVNRT and he might have a tachycardia induced cardiomyopathy. I am trying to get in touch with the Italian docs and see if they have a cardiologist who could teach us how to do a good bedside echo, we have the equipment. For my fellow medicine friends, I am interested in what you think of the EKGs and CXR (keep in mind it is an AP, not a PA) but we did redo a PA and lat CXR the next day and it shows an enlarged heart without evidence of CHF. You can post your thoughts under this post. Thanks! To be honest, it has been a while since I have thought about some of this stuff, and I do not feel all that competent anymore, so I appreciate your input.

Another OR case done at the bedside

Unfortunately these pics loaded backwards. But going from the bottom, an ANA solider was brought in after being shot by Taliban presumably. As you can tell his fibula, the smaller of the two bones in his leg, is shattered and he has fragments in his leg. The next pic is the docs doing a bedside exploration for the fragments, using local anesthesia!!!! Mike and I walked in on this procedure and were floored. We tried to tell them stop and go to the OR, but they were already started and had no intention of stopping. I suggested pain meds, but they said no, he is not in any pain, as he lies there crying for mercy. After about 15 minutes of them fishing around, and make several inscisions, Mike suggested bring the C-arm over (it is real time xray machine) to get better views. I went over to hold the guys hand because he looked like he needed someone to just care. Today, the day after the procedure, he came up and thanked me, saying he will pray for me everday. The last picture is of the bullet fragments. Another exciting day at the office!

Didn't your mother tell you not to stand behind an RPG?

This poor solider came in two days after our other burn victims. He was hit by the back-blast of an RPG (rocket propelled grenade). When asked how it happened, the story he gives it that they were attacked by Taliban, but more than likely someone either shot it off by accident (accidental discharge is very common around here) or his buddies were playing around trying to hit a bird or something and he happened to be behind it. He is recovering nicely.

This unfortunate gentleman was involved in a diesel tanker fire. He and his friend were brought in late in the afternoon a few days ago. His friend had 75% of his body burned, but he only had about 25-30%. They both came in intubated, but only his friend was on a ventilator. I insisted several times they put him on a ventilator, but they stated, "he is breathing fine on his own, see." I could not believe it. If I had my camera, I would have taken a picture because it is so unbelievable. The one gentleman died early that morning, which I was not surprised, he was in very bad shape. But the tube was out the next morning on this gentleman. When I asked what happened, they stated he pulled it out in the middle of the night. I thought about giving them a straw to breath through and ask how it feels, but I didn't have one on hand. This pic is of them doing dressing changes. He is actually doing good, eating on his own, drinking ensure through a plastic tube because he can't open his mouth very much. I tried to give them praise by saying good job on intubating any and every patient with facial burns, but then STRESSED that they also need to sedate and ventilate the pt. Not sure how much got through as, I also stressed that they needed frequent lab draws that first night they came in, but there were no labs until midmorning the next day. There is no reprecussion for being lazy here. People frequently do not show up for work without any negative effects.

On a good note though, we are continuing the M&M conference and it will be run by Afghan doctors. The next one will be this Sunday on the burn patient that died. I am to review the chart with two doctors tomorrow morning to see what could have been done better. Although I could name 5 things at first glance, we will probably only focus on one, maybe two. Another good note, I have got them to do a system that now has the lab and nurses reporting abnormal lab values in less than an hour!!! Instead of the next day if anyone even cared to look at the labs. It may not seem like much, but that is a huge victory. Praise God!!

This is Mike (OR nurse mentor for the ANA). We are the two clinical medicine mentors at this regional hospital. There are 4 regional hospitals, we are in the west. He is Navy, and will pin on O-3 in a few months.

This patient is a 20-something ANA solider who presented with dysuria (pain with urination), and urinary retention. On ultrasound he had a 5.3cm stone. They took it out the next day. I put the top picture in for you to closely observe the one surgeon's ungloved hand touching sterile instruments!! My partner, who is an OR nurse mentor (Mike), had a kinipshit!! They thought it was funny, but he did not.

Below is the picture of the stone.

Gastroenteritis, are you kidding me?

This 65 year old man presented 14 hours after having constant nausea and vomiting. By the way he passed out last night also. They show me the EKG and want to treat him for gastroenteritis with a PPI (stomach acid suppressor) and antibiotics. This is one of those times you have take a few deep breaths before you start to speak. For those who don't look at EKGs, this is a classic EKG of someone having a heart attack. Despite my best attempts, they did not want to listen to what I had to say. Luckily, I invited an Italian cardiologist to come give a lecture that morning on EKGs (kinda ironic, huh). He walked into the discussion and backed me up. Thank God!!

Top: Sunrise at Camp Stone in the tower. Beautiful!!

Bottom: My room. As you can see, the walls are not that high.

My First Intubation

No problem!! Afghans don't have a lot of redundant tissue.

This unfortunate gentleman arrived at our hospital 10 days ago. He was a civilian hit by another civilian. He was initially taken to the Spanish hospital where they did internal fixation of his badly broken left arm and leg. He also had a 7 x 4 cm subdural hematoma with step-off fracture, but no evidence of herniation when he was transferred. He self extubated about 4 days ago and actually is doing well besides that his leg is necrotic (dead tissue). Today they did a BEDSIDE debriedement without pain medicaiton (that is until I suggested it). On the bottom pic you can see them cutting nonviable tissue. The top pic you can see his bone and plate. I have had a feeling for the past three days that his leg will need to come off. I know there are other options in the states, but I fear his infection will no longer be contained by the antibiotics and he will die of sepsis. We will see what they do. When I ask about amputation, they ignore me, I think because no one knows how to do them?

One of the Navy Chiefs decided he was going to give me a Marine style haircut. It definitely reminds me of my uncle Neil's hair when I was a child. Personally I do not like it, but too late now.

What's wrong with this picture?

The story the ANA solider tells is that he was cleaning his weapon when it "accidentally" discharged, bounced off the wall and into his chest. The lateral does not show up that well as real life, but needless to say it is not at the periphery. I would say it is pretty close to his heart or SVC. He walked out of the hospital a few days later with the bullet still in him. Inshalla!

Extubate?? Really??

This is the CXR of an "enemy" patient who had been shot in the right chest wall and therefore has a hemopneumothorax on that side, and had ESBL K. pneumo on top of that, therefore his left side is all whited-out. On the day this CXR was shot, they wanted to extubate him (take the breathing tube) despite him being on max ventilator settings. The chief surgeon put him on CPAP of 5. Obviously it did not work.