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!