Wednesday, April 28, 2004

Haven't been able to post due to the very busy weekend on call, operating until 6PM Monday, and full office yesterday. I cleared my day to allow for a deposition this morning which took all of thirty minutes. Let me tell you about my weekend...

FRIDAY: Got a call from a local hospital about a patient who was kicked in the neck and their CT scanner was broken. "Can we send them to you for a CT?", they ask. "If it is negative can I send them back?", I reply. "Well, our ENT surgeon is out of town...blah,blah,blah..", is the response. Patient arrives and I find that the referring physician had neglected to mention that the assault was FIVE DAYS AGO. Patient also has what they themselves describe as a "major nerve problem". CT was negative. We discharged them ASAP since I am not a "nerve problem" doctor.

Another patient came in with a bleeding pseudoaneurysm from an A-V graft in their upper arm. This is caused by the dialysis personnel sticking the same place on the graft every time which leads to weakness in the graft material. Eventually it thins out so much that it bleeds. A lot. I took this patient to the OR and excised the pseudoaneurysm an placed an interposition graft. This patient also had secondary hyperparathyroidism which resulted in calcification of his graft. I had to punch holes in his old graft with a 22 gauge needle just to be able to pass my suture through. This graft had so many things wrong with it that the likelihood of thrombosis was high. Turned out that it did on Saturday.

Diabetic comes in with a "bump near his anus". Turned out it was a perineal abscess the size of a golf ball. Finally got to bed at 2am

SATURDAY: Early morning call for a cyclist struck by a vehicle. Intoxicated. Claims he's a "stunt man". Since the resident found a smear of blood on rectal, had to do a rigid sigmoidoscopy. Found nothing but hemorrhoids. GI scoped him few days later and found a polyp. Later that morning a stab wound to the flank arrived. CT showed no major injury so they were watched for awhile in the ED and then sent home. Placed a difficult dialysis catheter, and finished rounds and consults at about 5:30 pm, and slept until 11 pm when I woke up and had supper. Fell back to sleep...

SUNDAY: Only to be awakened by a call from another referral hospital at 1 am. Old guy stabbed in the chest. Had a hemothorax with about 800cc's of blood. Couldn't get an airway. Lifesaving maneuver performed by placement of a cricothyrotomy using a #5 ET tube. It's difficult to ventilate and oxygenate a 350 pound man through a soda straw. Shortly after arrival I took him to the OR for an emergent trach. Whenever I would place retractors to better see inferiorly, It would cause his O2 sat to drop. Finally got a extra-long trach in place. This was one of those situations where time seemed to stand still, but when I finished the case I discovered that the procedure had only taken 30 minutes.

About the same time another hospital calls....
Dr. X: I have a blah blah year old man stabbed in the anterior right upper quadrant...
Me: You don't have a general surgeon to handle this?
Dr. X: No, we only have surgeons available during daytime hours (I wish I had that job!)
Me: Was he stabbed above or below the costal margin?
Dr. X: Well, um, ahh, lets see... At this time I resist the temptation to ask if Dr. X had even examined the patient. I am not reassured by his answer. It gets even worse.
Dr. X: The patient just returned from CT.
Me: Why did you get a CT?
Dr. X : To determine the extent of injury....
Me: Well if it is negative that means you won't need to send him, correct?
Dr. X: Well, ah no, I think we will still need to send him.....
As this conversation was going nowhere, I gave in and accepted the transfer. When he arrived he had a 5mm puncture site in his RUQ. Given that Dr. X told me the knife was described a "foot long" unless he was stabbed with an epee injury was unlikely. Discharged Monday.

Man stabbed and slashed with a boxcutter by his wife. Multiple wounds with one on the flexor surface of the wrist actively bleeding from the distal ulnar artery. Given that finding the artery was ligated. Palmar arch found to be intact by doppler. Discharged Monday.

Placed a dialysis catheter in the psuedoaneurysm patient from Friday.

Call from the ED at the Hospital of the Sisters of Blessed Confusion about a "painful recurrent hernia". How long has the patient known about the recurrence? Oh it just happened , I am told. The ER guy hadn't even tried to reduce it with or without drugs. Please try, I ask, and give me a call back. They give him some pain medicine and get it reduced. I go see the guy and he tells me the hernia has been present for about a year. Come see me in the office...scheduled for surgery this Friday.

MVC with multiple facial, extremity, and intra-oral lacerations. The on call facial trauma physician was resigning from staff at the end of the month and refused to come in so I put his face back together. Discharged Monday.

Young woman in MVC with open hand fracture. Almost avulsed her thumb. She lost so much blood from this that she required 2 units of packed cells to stabilize her BP. Transferred to orthopedics Monday.

Young man stabbed and beaten. Right pneumothorax. That makes five stabbings so far.

MONDAY: 1am man fleeing from police on a motorcycle. Crashes bike. Some concern of a shooting. What looks like an entry wound over his left iliac spine. Also with hypotension, an open elbow fracture and a 20mm Hg difference in leg pressures. To the OR found to have a renal vein avulsion, splenic and liver lacerations. Out come the spleen and kidney. On-table angiography reveals no arterial injury. Pelvic fracture underlying puncture site. No evidence of shooting found. Required a good deal of blood products and fluid. Became cold, acidotic, and coagulopathic. So just like this guy he gets himself one of those open abdomens. I plan to take him back for second look today. By this time the magnificent hour of 7am arrived and I was free....
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