Archives for July 2010

A Letter from Afghanistan

Forwarded by a friend of his, and I have the authors’ express permission to run it.

Hey Gang,

Another amazing and emotional day yesterday. I try to write about things that impress me professionally, emotionally, and spiritually. Yesterday I was again impressed.

At 5:00 a.m., the Giant Voice (the base PA system) announced two incoming casualties. I reluctantly roused from my slumber and made my way to the E.R. On arrival, I found two victims of an accidental grenade explosion, one critically injured and one more stable. The critical patient had third degree burns to his face, neck and upper chest and severe penetrating abdominal injuries. He was in shock and was taken directly to the O.R. by the surgical team. The other had multiple burns, but fairly superficial. He also had eye injuries and he was essentially deaf from the blast, but he was stable. While the unstable patient was in surgery, my team and I evaluated and treated the stable patient, managed his eye injury (severe ocular contusion with corneal burns), CT’d him, cleaned and dressed his burns and expedited his helicopter evacuation to the ophthalmologist at the larger Bagram hospital (we don’t have one here).

The story of how the accident happened was initially unclear, but, when things settled a bit, my patient told me the following: He and the other soldier (both trained weapons specialists) had returned from a mission and were in the ammunition bunker, returning unused grenades and other weapons to the stock. One of the weapons they were handling was a “flash bang” grenade. These are the ones that they use as their team is initially entering a building by force. They toss it in and it explodes with a very bright light and very loud sound, designed to temporarily blind and deafen the people inside so that the soldiers can enter the building with the element of surprise. SWAT teams use these a lot. They’re not designed to kill.

He states that, as they were working, he heard a “click” noise, looked back and immediately saw that the pin had somehow popped out of one of the “flash bang” grenades that his buddy was holding. He looked up and saw a look of terror on his teammate’s face. My patient just had time to turn away as the grenade exploded. He was stunned and isn’t clear exactly what happened next, but somehow they were both loaded into vehicles and rushed to the hospital. From the pattern of the explosion on the severely injured patient who was holding the grenade, it appears that, in the brief instant he had to decide what to do, he made the decision to pull the explosive into his gut and take the force into his body. By doing so, he minimized the blast effect to the other soldier and to the stored ammunition inside the shed, preventing a possible catastrophic chain reaction of explosions. Faced with the split second decision to either toss the grenade into a corner and run, or take the blast himself to save the life of his friend and possibly others in the immediate area of the ammo shed, he chose to sacrifice himself.

In surgery, the severely injured troop had multiple severe abdominal, chest, and head injuries and burns. He required massive amounts of blood. Our little hospital keeps around 30-50 units of blood products available at any one time, but we were a bit low because of a lot of recent trauma activity. It was clear that if this soldier were to have any chance of survival, he would likely need more blood than we had in stock. In addition, we always have to be prepared for the next trauma activation (which, incidentally, came about four hours later, four patients from a Taliban attack on a civilian minivan, including a 14 year old boy, but that’s another story). After discussing this with the surgeons, the hospital commander made the decision to activate the “walking blood bank”.

The walking blood bank is something unique to the military. In the civilian medical world, blood is collected at donation sites and very carefully screened for infectious diseases such as HIV, hepatitis, and others. Then it is broken down into its various parts: red blood cells, platelets, and plasma. These are then separately packaged and stored for later use. The military does the same thing for routine blood use. However, in a combat emergency, we have the ability to short cut the process when we need blood immediately. Essentially, everyone in the military is “pre-screened” because we are all checked for HIV, hepatitis, etc. and given a million immunizations prior to deployment. We also have our blood typed and that information is printed on our dog tags and our military ID. We’re ready to donate and receive blood at any time.

The Giant Voice broadcast across to the base: “All O-positive soldiers report to the hospital immediately!” Our Utah medics, and others in the hospital, mobilized and immediately established impromtu “donation centers” in the outpatient clinic and the dental clinic. Within 10 minutes, they were taking blood from the first volunteers. Within 30 minutes nearly one hundred soldiers were lined up to donate for their fallen comrade. The line filled the clinic, the hallway, and went outside the door of the hospital, down around the corner of the building.  All of these troops lined up look like they were waiting to get in a concert or a movie theater. As each precious, life-giving unit of blood was drawn from a troop, it was immediately taken around the corner to the operating room where it was infused, still warm, into the critically injured soldier on the table.  Over the 4 hours of his surgery and attempted resuscitation, he received nearly forty units of whole blood taken directly from these donors, as well as banked blood and platelets, plasma, and other blood products. Tragically, the surgeons, despite herculean efforts, were unable to save him and the soldier was finally pronounced dead. The news hit everyone very hard. This incredible soldier, the accidental victim of a grenade malfunction, had died trying to prevent further injury to his fellow troops. He gave his life to protect them. In turn, those donating blood gave a very real part of themselves to try and save him. That is what soldiers do for each other.

Later, I witnessed the solemn and emotional completion to this story. The Army has a battlefield tradition called the “Hero Flight”. When a soldier dies, his body is flown home for a funeral with his (or her) family. The first step of this flight for this Hero was a helicopter ride from our base to the main air base at Bagram. A special ceremony was held as his body was moved from our morgue to the helicopter to begin his journey home.

At about 11:00 pm last night, Soldiers from the fallen soldier’s unit, the hospital, and from all over the base lined up in formation along the hundred yard route from the hospital to the helicopter pad. Everyone was dressed in full uniform; no shorts or tennis shoes.

I don’t know if I’ve ever mentioned it before, but we’re a “black out” base, which means no lights are allowed at night. This is to minimize us as a target at night. We all walk around with little tactical (very dim red or green) flashlights. It’s really dark here.  So there we stood, silently and reverently in the darkness, two long columns of soldiers lining the route to the landing area, lit only by the stars in the brilliantly clear and quiet sky and a couple of glow sticks placed along the way. It occurred to me that many of the people standing in silent tribute last night had also given their blood to try and save the life of this soldier. Then, in complete darkness, two helicopters roared out of the night and landed, pulling up to the loading area, the wind from their rotors whipping the hair and faces of the silent line of troops. On cue, they simultaneously cut their engines and the rotors spun slowly to a halt. Into the ensuing silence the First Sergeant issued the command: “Task Force, Attention!”. We all came to attention, face forward, perfectly still. “Present Arms!”. Every soldier, all 250 or so of us, snaps and holds a salute as the body of the fallen soldier, draped in an American flag, is wheeled slowly between the two columns of troops and is placed reverently on the helicopter. “Order Arms!” We dropped our salutes, remaining at attention. The chaplain said a prayer for the soldier, for his family, and for his team, who must continue their work, their mission, without him. In the darkness, I heard soldiers, warriors, sniffling quietly as they suppressed their tears. Me too. As we were dismissed and silently began to depart, the two helicopters fired up their rotors and launched into the dark Afghan night, carrying the body of this young man home to his family.

It is difficult to describe the emotions this long day held for me. Many conflicting but very powerful feelings come to mind as I write. The tragedy of the accident. The heroism of this man’s selfless act protecting his fellow soldiers. The pride I had in my fellow docs and nurses who raced him into surgery and in our Utah medics who quickly and efficiently organized the blood donation operation. The amazement I felt as soldiers from all over the base, few of whom knew the injured troop, lined up to give blood without question. The disappointment when the soldier died despite everyone’s heroic efforts. The pride, respect, and honor of the silent Hero Flight ceremony as we paid our last respects to our brother in arms. A very dramatic, very sad, and very real day here at the War. I just wanted you to know about it. These kinds of things need to be shared.



It’s my pleasure to share this with you.

How to Answer a Nurses’ Questions: Funniest thing you’ll see this week

Via A Cartoon Guide to Becoming a Doctor comes this bit of Genius: How to Answer Nurses’ Questions: An Algorithm for New Interns.

Go, read, laugh.  You’ll enjoy it.

Via DocRob

Dang. Still not perfect.

All Emergency Docs fear the “hey, remember that patient…” conversation with a colleague. It’s hardly ever ego-stroking news.

I had one of those tonight. “Hey, remember the patient…” and, yes I did. Yes, I missed something. The patient wasn’t harmed, and my excellent colleague took care of the problem, just wanted me to know. That the patient will be fine was reassuring, if not exculpating.

I appreciated that my colleague told me. Having been on both sides of that conversation, it’s uncomfortable for the sender as well as the receiver. Also, the knowledge will help me slightly tweak one aspect of my care. (If the vagueness of this bugs you, it bugs me, too. Thank a room full of lawyers).

So: Not Perfect. I’ve never professed to be, and frankly don’t hope to be, as that’s a setup for failure and disappointment. I have in my sights a somewhat lower goal: do the best I can, and make as few mistakes as possible. People are human, and make mistakes. Doctors are human. Do the math.

Doctor Charles is having a Poetry Contest

And it’s not just any old contest, there’s $500 up for grabs. Here’s Doctor Charles’ contest page.

I’m disqualified, as the only poetry I even remotely like is the bawdy limerick. Non-medical.

Best of luck to you poets!

Yikes! Last minute bailout

via @AndyLevy on Twitter…

FWIW, an F-18 costs (according to the Internet tubes) between 28-58 Million dollars.

video via Ace

ER Waits meet truth in advertizing

ER Fail – FAIL Blog: Epic Fail Funny Pictures and Funny Videos of Owned, Pwned and Fail Moments.


M.D.O.D.: Must Be a Brit

M.D.O.D.: Must Be a Brit.

Hahah.  Funny video!  Orthopedist vs. Anesthesiologists…

OSHA Faults Hospital for Workplace Violence Violations – News – Campus Safety Magazine

DANBURY, Conn. — The Occupational Safety and Health Administration (OSHA) has cited Danbury Hospital for failing to provide its employees with sufficient protection against workplace violence. The hospital has been fined $6,300.

The announcement comes on the heels of the March 2010 attack, when nurse Andy Hull was shot three times by 86-year-old Stanley Lupienski, a patient at the hospital.

via OSHA Faults Hospital for Workplace Violence Violations – News – Campus Safety Magazine.

Yes, $6,300 isn’t much money, I agree.  But, I’d imagine,  it’s not good for admin careers…

One of the ER Doc curses

I was reminded of one of our particular curses the other day, reminded in the way we often are, when somebody reacts to what we do. Sometimes embarrassingly.

Yesterday, I was taking a history, and this was of a patient with a long, complex one. That much I knew from a quick perusal of the EMR prior to going into the room.

So, I and my scribe were there, along with the patient and their family member; because of the medical problems, the family member was giving the history. Family member was pleasant, knowledgeable, and good. Terrific history, and it was flowing. On point, not too many spurious details, and I was enjoying it.

One detail was “…so we went home Saturday…”, a totally innocent thing, pertinent to the history, correct, and natural. That’s when I looked at my watch.

“I’m sorry, I’m trying to be as brief as I can” said the historian, and I realized what I’d done: I’d given the universal signal for ‘you’re taking a long time’, inadvertently.

(What I was trying to do would be familiar to every ER doc, I was looking at my watch because it tells me what day it is: we usually have no idea what day it is. Work 24/7/365 a few years, and that whole ‘work week’ is something to be envied; most of us are at work because we have a shift, not because we have any idea of time otherwise…).

I immediately interrupted and apologized, telling them what I just told you, but in briefer form (“I was looking to see what today is…”), and life moved on.

It did have me make a mental note, though, to be more surreptitious in looking at my watch: my orientation to the calendar won’t change until I retire.

Movin’ Meat: Here we go again

Movin’ Meat: Here we go again.

Shadowfax’s group is hiring.

I skimmed it, but it looks like there’s some treadmill choreography they’re teaching new grads now…  Things change.

Physician in Whistle-Blower Case Charged by Texas Medical Board

July 15, 2010 — The Texas Medical Board (TMB) has charged a family physician at the center of a nationally publicized whistle-blower case involving 2 nurses with poor medical judgment, nontherapeutic prescribing, failure to maintain adequate records, overbilling, witness intimidation, and other violations.

via Physician in Whistle-Blower Case Charged by Texas Medical Board.

Some follow-up / karma from the Kermit / Winkler County Nursing prosecution.

Thanks to CardioNP!

Question the Meds

In my practice I try to apply some common sense, adopting a colleagues’ phrase “common things are common”.

This is particularly useful in the diagnosis of new problems that have eluded diagnosis, and I apply a lesson learned from a fellow resident (a PharmD before med school) who told me: new problems, ask about new meds.

So, if my patient has some new problem as part of the history (when did this start) I’ll follow up with ‘any new medications, or change in your meds, around then? (This is often fruitless despite the time investment to go through the meds, the list, then ‘when did that medication start’ conversations, but it’s time well spent).

Many times the reason the patient gets dizzy on standing is the new BP medication, or a BP med that has dehydration as a mechanism stacked onto decreased oral intake…

I’ve made a couple of good diagnoses recently, and it was directly because of questioning the timing of the new meds and the new symptoms, one patient with their second trip to the ED for an unexplained metabolic acidosis (who was taking a seizure med that said ‘metabolic acidosis’ as a known problem with it), so making the call to the pt’s doc for a re-admission and oh-by-the-way I believe the problem is this med that causes this problem. Nice way to have an admitting doc think you know what you’re doing…

Metformin causing diarrhea is a med-school diagnosis, so why it took the med student following me to make it I don’t know, but the patient and family were thrilled to have a reason for their debilitating symptoms. (Thanks, unnamed MS4!)

There are some others, but you get the message: temporally relating new meds then new symptoms, common things are common, and always question the medications.

other things amanzi: grand rounds on south african shores.

other things amanzi: grand rounds on south african shores..

Grand Rounds!

I must talk a good game

I took another total-newbie to the pistol range the other day, a place I go to quite a bit and feel comfortable with. I like taking novice shooters out: it’s a skill I think everyone should at least be able to perform (if not like it, I’m not saying everyone should love it) and many continue, citing their positive early experiences.

I try my best to instill safety (x3) and fun. Everyone enjoys their first trip to shoot with me so far, and I’ve taken several. I like this.

We start with a single action .22 pistol I bought from Kim DuToit a long time ago, and progress as the shooter gets comfortable. Next is a Ruger .22 automatic, then a 9mm, .40 (both Sigs), then to cap the experience some shots through a Desert Eagle in 44 Mag. (It’s a long story, I wasn’t looking for it, it found me).

Adding to this range session was my latest acquisition, a .45 Springfield XD-45. After the novitiate was comfortably independently shooting the 9mm, I started getting to know the .45, and it’s fine. More than fine, it shoots like I want it to, and well. More on this someday.

(Like most people who go to the range with some frequency, I also watch all the shooters on the line and get a feel for how they handle their weapons, how they shoot generally, with an eye for when I need to get myself and my shooters off the line. This day, no real worries, except for That Guy. TG was shooting some very big calibers from pistols, and was reliably hitting the back wall. That and he’s not a safety hazard to others were the best that could be said). (The lady getting the lesson would easily qualify for her CHL, and good for her).

We’re shooting for an hour and a half or so, with a decent amount of the gentle instruction needed, the very occasional safety thing (thumbs on autos are most common), and life is very good. I have some Zombie Targets to keep shooters having fun (be honest, shooting round dots on paper gets boring), and I’m having some fun emptying/testing new mags on one of the zombies from the new XD. (Zombie Steve didn’t make it).

So, we’re packing up, and That Guy turned and asked me “Do you have a card”? (I froze; I’ve never been asked this on a range, several times in the ED, but I have learned to expect that.) “Uh, no..?” I lamely replied, and TG confessed “I’ve bought these guns and can’t hit anything, I need some lessons”. Aah, I have an answer for you: this range has a couple of good instructors, so as tactfully as I could I recommended he contact the ranges’ instruction staff.

Made me feel good, though. Maybe I should do some instruction. Wouldn’t replace my day job, though…

My Medical Museum Contest: Meet The Winner!

We’re happy to announce that Adam Simone, who took us on a tour of the Warren Anatomical Museum in Boston, is the winner and will be taking home a brand new Apple iPad. Adam is a graduate student in Biotechnology and Management out of Carnegie Mellon University and is interning at a medical technology consulting firm.

via My Medical Museum Contest: Meet The Winner!.

Oops, missed this announcement, but better late than never?