A. McGyver, MD

Sorry I haven't posted in a while, but I have been a li'l busy with keeping my New Year resolution to spend more time with my family, as well as training for the 2008 Boston Marathon. I did pretty decent in this past Disney marathon. Haven't ran a full marathon in a very long time, but I've been keeping up, logging about 2-5 miles at least once a week over the years. My time was respectable, at least for this old geezer anyway. The exhausting experience made me realize how out of shape and what a complete slug I've let myself deteriorated to over the years. So my goal is to run in the 2008 Boston Marathon. I've ran in several other marathons over the years but never the grandest of them all in Boston. I've already qualified for my age group, but I'm in no shape to run by this April. So I'm training "Eye of the Tiger" hard this year. My aim to run in at least 2 other marathons by next year until the Boston rolls around again so I can post a respectable time against the rest of the hard core crowd, of which I'm certainly not one of.

There have also been a few other things going on that have occupied my attention as well. A very close and dear friend just died a little over a week ago. He was my age and was a Catholic priest. He collapsed while celebrating Mass at a small chapel in a remote 3rd world country. Hemorrhagic CVA...sad and tragic. He was a kind, loving man who dedicated his life to God and affirmed it with the many charitable organizations that he had devoted his life to. He visited us at least once a year and baptized my daughter a few years back. I don't ever recall him complaining of headaches nor does he have a history of hypertension. God works in mysterious ways, I suppose, though I am still shock that someone so filled with vitality, so young (only in his 40's, as I), so noble...Why?

Then there's that frivolous malpractice suit that I'm fighting. Met with the lawyers several times since the beginning of this year. We're fighting the case all the way, no settling! It's completely ridiculous and groundless. As you can see, I have too many things on my plate at this time to keep up with the blog, but I'll try. The posts will be sparse from now on, I'm afraid.

On to the new story.

A. McGyver, MD

Has anyone ever ran a code up on the floor in the middle of the night? If you have, then you'll agree with me that majority of times the experience is frustrating, if not frightening. Perhaps it's because these floor nurses haven't been in enough code situations so they easily get flustered? Unlike the cracked crew that I've trained and am accustomed to in the ED, of course. As a current member of the Crack City Medical Center's Code Blue Committee, it kills me that whenever I run up to the floor for a code, it's usually a cluster f'k. The committee has made numerous attempts to educate and improve the situation but nothing has seemed to work. Next meeting, I'm going to propose surprise mock codes/drills.

"Code Blue, Room 546...Code Blue, Room 546...." the hospital operator blared across the intercom system.

"Hell, that's gotta wake every patient in the hospital up at 3 AM!" I commented out loud as I started jogging down the hallway.

Seconds later, my code beeper began chirping loudly as well.

"Why the hell do they have to blast it that loud?" asked one of my nurse. "It's freakin' 3 AM!"

"Well, apparently not too long ago there was a Code Blue that not everyone responded to because it wasn't heard over the intercom. And many people were not wearing their code beepers!" I answered as I was privy to such secrets, being a member of the Code Blue Committee and all.

Upon my entry into the room, there were, as usual, too many freakin' people in that tiny confined space just standing around either rubber necking, twiddlin' their thumbs or gossiping. I had ran all the way from the ground floor of the hospital, up the many stairwells and down the many hallways, finally to Rm. 546 of the 5th floor...yet, much to my dismay, the patient hadn't even been placed on the monitor yet! The 2 respiratory therapists who had gotten there before I did were bagging the patient, one sealing the mask tightly around the face of the patient while the other one bagged. One nurse was providing chest compressions while the other dozen or so people around in the room were...hell, I don't know what the heck they were doing, but amidst the chaos, they weren't doing anything useful, nor helpful, that's for sure. Not even on the monitor! That just KILLS me!!!! These folks are supposed to be ACLS certified, too! ARGHHH!!!!!

So as usual, I literally had to point fingers to each person and assign tasks.

"You! Go get the crash cart! You! Go grab the patient's chart and read me his MAR list, last labs, and allergies! You, bag the patient so one of the respiratory therapist can load me up an 8.0 ET tube and MAC 4 blade. You...Who's his nurse??... What happened?...What's he admitted for?..."

"Stop compression, please," I asked while checking for a femoral pulse and confirmed that there was indeed one. Weak and tachy but it was there. "Alright, let's hook him up on the monitor!"

The patient was a thin 66 y/o man with numerous chronic medical problems who had been admitted from the VA nursing home for a pneumonia. He was unresponsive and apneic, but he was in sinus tachycardia on the monitor. His blood pressure was only 60/palp. As I checked for breath sounds with bag-valved-mask ventilation provided by the RT, I discovered that he had subcutaneous emphysema in the left anterior chest wall. The nurse sealing the mask over the patient face was having a great deal of difficulty providing a tight seal despite an oral airway. I also noticed that the RT was having difficulty bagging the patient as well.

"Is he tight?" I asked the RT.

"Yeah, I'm having difficulty bagging him."

I tried listening for breath sounds but the cacophony in the room made it impossible.

"Quiet!" I yelled out loud. "Could someone turn off the air conditioner! It's too noisy in here to hear anything!"

I knew right away that he had a tension pneumothorax. Didn't really need to verify it with auscultating for breath sounds, except to confirm which side the pneumothorax was on. What else could have cause SQ air, tracheal deviation, and difficulty with ventilation in a patient who's hypoxic, cyanotic, tachycardic, hypotensive and looking like he's circling the drain?

I rummaged through the crash cart looking for a 14 or 16 gauge Jelco, none were in there. DAmn!

"He's got a pneumo!" I relayed out loud. "Someone get me a chest tube tray! I need a 14 or 16 Jelco cath now!"

"What size chest tube do you want?"

"I don't care, whatever we have up here!"

"We'll have to run and get it from central supply or the OR," answered the House Supervisor.

"Wha??!!!" I asked incredulously, knowing that in the middle of a weekend night there is never anyone in Central Supply and the OR crew ain't around to get me what I need right away. WTF!!!! The patient will die in a matter of minutes unless I decompress the chest immediately to relieve the tension pneumothorax and re-expand his lung. He ain't got no stinkin' time for someone to run to the OR supply room or Central Supply to hunt for a chest tube tray and a chest tube!!! What a cluster Fk this situation was turning out to be!!!

"You mean to tell me we don't have a chest tube tray up here? Can I get a 14 or 16 gauge Jelco then?!"

"We don't have that size on the floor."

WTF, again!!!! Why the hell doesn't the crash cart have a 14 or 16g angiocath???!!!! And why the hell isn't a chest tube in there as well? Who's stocking these damn crash carts because these instruments, by protocol, are supposed to be in there!

Damn it, time to improvise and McGyver things, once again!

"How about Betadine? Surely y'all have gotta have betadine up here!" I said sarcastically.

"Someone please grab me a pair of sterile glove, at least 8.0!"

I ripped open a central line kit from the crash cart and jabbed the big needle into chest of the patient to decompress the pneumo as much as possible.

One of the techs threw me a glove in sterile paper wrapping.

"What the hell is this?" I asked in disbelief. It was only one glove. Not a pair, but one glove. "Just one?"

"That's the only kind of sterile glove we have up here. I'll get you another one if you want a whole pair."

WTF!!!!

"I need a Foley kit, STAT!" I screamed. "Surely there's enough Foley caths on this floor to drain the lake outside!" I mocked aloud and shook my head.

Everyone in the room including the House Supervisor gave me a funny look when I asked for the Foley kit, but the message was relayed out loud to the folks standing outside of the room. "Foley, stat!!! Foley stat!!!"

"What size do you want?"

.....Oh Lord....could it get any worse?

"I don't care what size, just bring me a Foley kit!"

"Uhmm, what's a Foley cath gonna do for a tension pneumo?" the House Supervisor finally asked.

"It's not for his bladder," I rolled my eyes at her.

"Oh...OH,..OOHH!" she snickered slowly and finally caught on.

I suppose they all have never heard a Foley kit being called for stat during a code before, but they were about to learn how we used to do it at my old stomping ground during residency when Gotham Medical Center was so under budgeted that it couldn't afford to stock enough chest tubes to handle all the traumas.

Straight up Old School! The central line kit had the scalpel and a suture with a straight needle. The Foley kit had the sterile gloves, betadine, as well as a big sterile tubing that can be cut and improvised into a chest tube. Using the sterile scalpel from the central line kit, I cut off approximately 2 feet of the clear tubing and made several quick wedge cuts to create some holes along the sides. Voila! A functioning chest tube! The patient was a very thin man, as I mentioned, and poking a hole bluntly into his thorax with my finger wasn't much of a problem after I had made an incision with the scalpel down to the intercostal muscles, just anterior to the midaxillary line and lateral to the nipple. As soon as I enter the thorax, a loud rush of air blew out like a deflating tire due to the extreme pressure build up. Immediately, the patient's blood pressure improved and he was much easier to bag. I intubated him right afterward as he was still unresponsive. Saved his life. This just happened last Sunday night. He was extubated this morning and is doing well, I've been told.

So, if you ever need to slap in a chest tube in an emergent situation where there are none available, remember the central line and Foley kits. Will work just as well. Tricks of the trade, practical pearls, if you will. I'm proud to claim that I came up with that trick years ago during my residency when we had to make do with what we got. That's what I love most about Emergency Medicine, you must think fast on your feet, improvise and adapt to the situation, McGyver things every now and then. Whatever it takes to save a life.

Bet many of you didn't know that McGyver's first name was Angus, did ya?

Eagle Eye

First the xrays, as usual:

Story later after I have some time. I'm not sure what caliber that bullet is. We rarely ever see small caliber GSW in Crack City. Usually there's a big ol' slug. Look at where the bullet is and you can probably guess how he presented clinically. Single GSW, entrance at base of the occiput. No exit.

PART II
You could say that the dude fully deserved what was coming to him. But then again, who could ever wish such an atrocious injury on anyone? Perhaps too extreme for poetic justice?

He robbed a local convenient store owned by a simple immigrant family. It's your typical Mom & Pop, junior store off the main highway selling the usual items of cigarettes, beers, sodas, candies, chips, etc... He shot the owner of the store in the head and unloaded a few more rounds into the chest to ensure the kill. He thought that he had safely absconded with the money in the cash register but it wasn't to be. Unbeknownst to this scumbag that for most immigrants, a business is a truly a family venture. The owner of the store had 2 sons that help out every day after school with the usual chores of restocking items on the shelves, picking up the trash, cleaning the store, etc... The 10 yrs. old boy pulled his 8 yrs. old brother into the back room and hid inside a broom closet when shots rang out. The thug ran out of the store thinking that he had gotten away with it when suddenly, POW! He was gunned down. The dude was found lying face down in the middle of the street when the cops arrived.



"A single shot," the police officer told me. Right to the back of the head at the base of the skull posteriorly. "It was well over 100 yards away, doc! Dropped him like a sack of potatoes!"

The 10 yrs. old boy had taken his father's hand gun hidden under the counter and fired at the robber with deadly aim from that great of a distance. He pulled the trigger only once. One round! One, single round! Holy cow! A hundred yards! A whole football field. HOLY COW! Talk about a bullet with your name on it. No wonder that it was a small caliber slug lodged in the neck of the scumbag. Scumbags only carry big guns as a rule around these parts.

The dude was brought into our ED in full C-collar and spinal board immobilization. He was wide awake and breathing rapidly on his own. But he had complete right hemiparesis. Couldn't move damn thing on the right side of his body from the neck on down!

Blog you later. Just woke up and continued this story quickly. Got to get ready for another night shift. Next entry, will post CT of his neck and discussions on the pathophysiology of the rare Brown Sequard syndrome. This is only the second time that I've seen a pure Brown Sequard syndrome.

Part III
Here are some CT's of the lesion:


I didn't really have to order any CT's because he was already hemiparetic and the xray clearly showed a C3 lamina fx. But while awaiting the neurosurgeon's arrival to the ED, what the heck. The CT showed that both C2 and C3 (that's the 2nd and 3rd cervical vertebrae for you non-medspeak folks) were involved.


The CT below showed that involvement at C3 was worse than C2.



It wasn't too clear by the above CT's whether or not the spinal canal was involved, but clinically the dude had the classic Brown-Sequard syndrome. What's a little puzzling was that he was able to breathe completely on his own. Though tachypneic, he was not hypoxic on room air. 3-4-5 keeps you alive...I guess it was because he only had lateral hemisection and not complete transection of the spinal cord.

Brown Sequard Syndrome

Charles Edouard Brown-Séquard (1817-1894) was a prolific researcher and writer, publishing over 577 papers during his lifetime. However, it was his findings on lateral hemisection of the spinal cord that the famous eponym was derived. In 1849, he first published the syndrome consisting of ipsilateral paralysis and hyperesthesia with loss of pain and temperature sensation in the contralateral limb, based on numerous animal experiments and collected human cases with autopsy confirmation.

Interestingly, many nations claim him as their own, he was the son of an American sea captain and a French woman, living in a British territory. He was born at Port Louis, Mauritius, on the April 8, 1817. He himself always desired to be looked upon as a British subject. He studied in the US, France, as well as the UK. He described this injury which resulted from caning knives in Mauritius, a common mechanism of this injury as originally described in the nineteenth century was a stab wound with a long caning knife.

The Brown-Sequard Syndrome is classically defined as an incomplete lesion of the spinal cord characterized by:

--Ipsilateral loss of motor function and dorsal column function (light touch, proprioception, vibratory sense)

--Contralateral loss of pain and temperature sensation

And the deficits usually begin two levels below the injury.



To finish the story on the scumbag dude, he was taken to the OR emergently for C2-C3 laminectomies.

"Charity, did you give him solumedrol yet?" inquired the neurosurgeon.

"Well, sir... (in deference to his seniority. He's as old as dirt pushing 70-something yrs old. But gotta respect him for still doing what he does, taking ER calls in the middle of the night. As old as he is, though, he can still run with the best of them. He may limp a little bit, but he can hold his own and is still among the elite, I tell ya!), Well sir, it's your call since you're taking the guy to the OR, but the current literature really does not support the use of high dose steroids for penetrating spinal cord injury."

"Are ya gonna believe what you read or are you gonna believe my years of experience dealing with these thing?"

Hehehe. Old school! Old fart! "Hey, Russ (charge nurse), Dr. Crany has some verbal orders for ya."

The scumbag had very little improvement post laminectomies. He was able to regain some sensation and was able to wiggle his toes and fingers, I've been told. However, he is still unable to oppose gravity nor regain any meaningful functional capability.

Final Commentary
What's a post without a little commentary at the end, huh? So the scumbag robbed a store and killed the owner with a gun at point blank. Poetically, while trying to flee the scene of the crime, he was gunned down over 100 yds away by the 10 yrs old son of the store owner with a single gun shot to the back of the neck leaving him permanently paralyzed. I cannot possibly imagine the horrific psychologic damage that has been done to this kid and his 8 yrs. old brother. It's incredibly disheartening.

So now what happens to the scumbag? What becomes of him? Who's going to pay his medical bills?

Why certainly it's always us, the good taxpaying people, who always get shafted in the end! I've seen this same scenario happen too many times in my career. This scumbag will never fork up a single penny to pay for his medical bills. And what's even more sickening is that he'll probably never be prosecuted, nor ever have to face a jail sentence for his heinous crime. Why??? Because doing so would entail that our justice system must shell out the big $,$$$,$$$ to cover his medical costs, hospitalizations, medications, rehab, long term care, etc...Eventually he'll end up applying for disability, which he is certain to get, of course, because of the hemiparesis. In the end, the good taxpaying people are b-fk'ed again and again. ONLY IN AMERICA!!!! ONLY IN AMERICA!!!!

Hey, thanks to the 30+ people who voted for me as Best Medical Weblog 2006 and Best New Medical Weblog 2006. I am flabberghasted and appreciate your kind thoughts. However, it's truly undeserved. My blog holds no altruistic endeavors nor has any benevolent intentions. It's just me mouthing off in an anonymous forum to release the stress of my job. I have no literary dreams and my grammar is atrocious! My grade school English teachers are probably shaking their heads and quaking in their graves right about now. Still, I can't believe that so many of you tune in on a daily basis to follow the silliness and diatribes that I post on here. Thank you kindly, my friends and loyal readers, for allowing me to let off some steam. Thank you for helping me to better cope with the stressors of my job. But most of all, thank you for not letting me lose sight and focus of what medicine should be all about.

Having said that, the next Gripe Day 2007 entry will be filled with comments of people telling me what a complete jerk I am.

An Eye For An Eye

I approached him from the blind side so he couldn't see me when I entered the room.

"The doc is here, Mr. Cochran," introduced the nurse.

"Can't see out of left eye" read the chief complaint on the chart.

Mr. Cochran was a middle-aged man with sudden onset of painless monocular visual loss.

"Hi, sir, I'm Dr.____(common surname). What happenned to you?"

"All of the sudden I became blind out of my left eye, doc. Can't see a damn thing!"

"How long ago did this happen?"

"About 2 and a half hours, I thought it would go away but it didn't so I'm here. Am I having a stroke?"

I go on through the routine questions and review of systems. No other neurodeficits. No bulbar symptoms. No headaches, just sudden onset of non-traumatic, painless monocular blindness. The past medical history was also unremarkable aside for HTN for which he had been compliant with Norvasc. No history of MS.

"Have you ever had syphillis?"

"No. Heavens, no!" he sounded irate but puzzled.

"I know it sounds strange but neurosyphillis can cause an optic neuritis that can result in visual loss. It's a rare disorder these days but just thought I'd ask to be thorough."

Now come the social history...No smoking, no illicit drug use, no alcohol abuse. He denied it all...

"What do you do for a living?" I asked, already knowing the answer.

"I'm an attorney," he proudly responded. "You've probably seen my ads on the highways."

"Yes, yes. A fair settlement is no accident." (That billboard slogan is plastered all over Crack City)

"Yeah, I'm a personal injury lawyer. I have no problems telling doctors that. I get better care that way, actually. Makes you guys more careful around me."

"Yes, I know you very well, Mr. Cochran. You were the plaintiff attorney accusing me of being a baby killer, remember?!"

Pausing briefly to let him absorb the full irony of the situation, I continued, "As to being more careful around you, all that means is that you'll have a bigger medical bill because of all the unnecessary tests and consultations, but I personally treat everyone the same regardless of the circumstances."

Disclaimer - The names have been changed to protect...well, me from HIPAA. This patient was not THE famous Johnnie Cochran (October 2, 1937 – March 29, 2005), of course.

After realizing who I was, he muttered, "That was a long time ago, doc! You're not gonna hold that against me are you? The hospital settled and we dropped the case against you, as I recall."

"C'mon, you guys dropped the case against me because there WAS NO case and I refused to settle!" (See Lawsuit #4) Hold it against you?? Hold it against you?? You KNOW deep down that I wasn't responsible for that little boy's death. YOU KNOW IT!"

"Hey, a man's gotta make a living somehow."

This guy was truly pond scum. That's all he had to say? A man's gotta make a living somehow? The enormous stress and torment he put me through all these years labelling me a baby killer, and that's all he had to say? What a conceited, heartless asshole! Representing the parents of the deceased child, the li'l weasel sued the pediatricians, the health department, the hospital, and me. He spent all of that time and money and finally settled with the hospital for a lousy 10 grand. The 2 pediatricians and the health department all settled for an undisclosed amount of money. I was the only one who refused to settle. My attorney fees and such racked up over $40,000. And here's this son of a bitch in my ED seeking care for his sudden visual loss! Oh joy! Oh joy! That's the nice thing about working in the ED on weekend nights exclusively. Eventually, everyone in town will come through because nothing else is open, all the clinics are closed. Don't screw with me, because one of these days you'll need my help on a weekend night when no one else is around! A cop gave me a speeding ticket once for driving 47 in a 35 mph zone, but that's a whole 'nother story for another blog.

"Water under the bridge," I said to the weasel. "Let's get back to your eye and find out what's wrong with it."

"You know, doc. It's just business." He persisted in trying to explain himself.

"Let's not dwell on the past, Mr. Cochran," I interjected. "Your eye is what's important now."

He shut his yap up afterwards and behaved like an obedient puppy.

"Now, let's see....Are you taking any medications such as Viagra, Cialis or Levitra for erectile dysfunction?"

"What does that have to do with anything?!!" came his incensed outburst.

"Well, there have been published reports of sudden visual loss due to these drugs. You want me to be thorough now, don't you? So I gotta ask. Just doin' my job and being, as you say, more careful around you, sir. Do you have erectile dysfunction and are you on any of these drugs?" I persisted.

Hehehe. I silently giggled. Got the bastard all squirmy and riled up! hehehe. I felt like a lawyer grilling a scumbag criminal on the stand. Sscwheeeet!!!

"I haven't taken Viagra in over 6 months," he mumbled.

I scribbled "ED, not taken viagra in over 6 months" on the chart and silently giggled some more. Hehehehe.

I looked on the cardiac monitor, he was in A-fib but the rate was controlled. I quickly checked the order box for an EKG.

"It looks like you have an abnormal heart beat. You're in atrial fibrillation. Do you have a history of a-fib?"

"I had it a long time ago but it went away. I had a nuclear stress test 2 years ago and it was normal."

"Sir, is there anything else, any other medical problems that you're not telling us? You're not very forthcoming about things. You said only high blood pressure earlier and now we find out about atrial fibrillation and that you've been on viagra? Is there anything else you're witholding? You said you don't drink alcohol much, but I can smell it on you. Have you been celebrating and drinking more than usual over these holidays? Because excessive alcohol drinking can cause atrial fibrillation, what we call a Holiday Heart Syndrome."

"Yeah, I drank a little bit more than usual this past week. It's the holiday season, as you said. I did drink more than I should have. Some champagne, some martini. It's New Year Eve. But I don't consider myself an alcoholic, if that's what you're getting at. I don't drink every day."

His visual acuity was horrendous. He couldn't even see the big E on the Snellen chart. He had no head ache, no pain, and a normal Sed. Rate, thus ruling out Temporal Arteritis. His head CT was also unremarkable. His neurologic exam was also unremarkable. The slit lamp exam was unremarkable without fluorescein uptake. On tonometry, his IOP was borderline at 19, 19, and 20 on 3 separate readings, the same as the unaffected eye. On fundoscopic exam, his optic disk was pale. The cherry spot was there. He had all the classic findings of Central Retinal Artery Occlusion.


I instructed him to apply pressure and massage his left eye while we started him on acetazolemide. He was given an aspirin and was started on heparin after his head CT came back negative. His labs also showed renal insufficiency with a creatinine of 2.1, that I suspect is chronic. The RPR was still pending.

"Am I having a stroke, doc?"

"No sir. But Mr. C., we don't have a whole lot of time left," I explained to the man. "We must initiate treatment immediately because you have about 6 hours from the onset of symptoms until you become permanently blind in that eye. You have Central Retinal Artery Occlusion and it's likely due to an embolic phenomenon, a blood clot in the retinal artery of your eye. You're throwing clots because of untreated atrial fibrillation. From what you've told me, we're at about the 4 hours mark from the onset of your symptoms. We've got about a little over 2 hrs left to do everything we can to salvage things and prevent more damage to your eye and preserve whatever vision you may still have left. I've consulted an opthalmologist to come and see you. You'll probably need to have an anterior chamber paracentesis done. That entails a small needle in your eye to withdraw some fluid from the anterior chamber to decrease the intraocular pressure of your eye so that the clot can pass. I can do that, but I prefer that the opthalmologist examine your eyes first. I've already consulted the internist on call to admit you to the hospital since you do not have a primary care doctor. I've already arranged for you to get hyperbaric oxygen therapy...Hyperbaric oxygent therapy is...and we also need to consider giving you tPA, a clot buster....You also have some kidney failure, which I suspect may be chronic...."

I overwhelmed him with so much information all at once that he became like any other patient in situations of extremis. "I trust your judgement, doctor," he said quietly, "And if it means anything, no I do not think that you or anyone sued was responsible for the death of that child. I'm sorry."

Wow! There is hope for pond scum, after all. Finally some closure, for what it's worth, to a malpractice case that has plagued my psyche for years, kept me pissed off and awake many a nights as I tossed and turned. As to this attorney, his prognosis is poor in terms of regaining full vision in that eye. After his first round of HBOT, he is now able to see, but still very blurry. At least he's able to count fingers when raised up before him, whereas he was completely blind in that eye before.

Lost in Translation

"Hey Charity! Do you habla?"

"Yeah, I habla."

"Go into Room 8 with me and...I got an illegal alien..."

"...Man, you really need to learn how to habla, Mark. Ya can't work in an ER these days without knowing how to habla."

....So we walked into the room.....

"OK, tell him I gotta suture his face and ask him when his last tetanus was."

Me, grabbing sterile towel from lac tray...."Hey man, pick up your head."

Dude picked up his head for me to slide the towel underneath. "Busted!!!" I laughed.

"He don't need no stinkin' translator!" I told Mark and left the room.