Miscellany

I am sick. In hindsight, I have probably been ill all this week but I just put it off as tiredness, exhaustion or whathaveyou. A little nausea? Perhaps it was just stress. Cold sweats? Ditto. In any case, while at work two days ago I finally decided to make use of the abundant thermometers around the ER and voila! I had a fever. Which isn't surprising - I should probably be more surprised that I didn't catch anything from those sick kids sooner. In any case, I really have been feeling pretty awful - the nausea, cold sweats, dizziness and all-around rundown feeling is starting to get old pretty fast. And it's my vacation... I didn't plan on spending it like this!

I'vec been thinking lately about the fine line that sometimes divides life and death.

I came onto my shift a few days ago to a lot of drama. A young teenager had been out on his ATV. Unlike many young men, he had his helmet on and he was perfectly sober. It was a beautiful sunny day, the kind of day that I've come to think inspires lunacy in some of the denizens of this land in which the sun is a somewhat shy creature, prone even at the best of times to hiding coyly behind clouds. (More often, it tends to shroud itself in fog, snow and even hail). This young man was not similarly "sun-struck" - he was a perfectly sensible fellow, behaving responsibly - admirable considering he was just in his early teens.

In any case, someone else had unfortunately not been as socially responsible. This teen, while riding his ATV, had suffered a classic "clothesline" injury - someone had strung up a wire across two trees - as a joke? as a property marker? who knows? - and it had caught him straight across the neck. He was out in the woods when this happened, far away from any medical help, on his own. He knew that home was just a few minutes away by ATV - if he could get there. So this young man got back up on his ATV and, clutching his neck, managed somehow to get back home. His father - from whom those sensible, responsible genes must have been inherited - took one look and bundled him into the car and raced to the ER.

It had been a quiet day thus in the ER - coughs, colds, viral gastros and the like. That is, until the triage nurse looked up and saw a young teenaged boy clutching his neck staggering into our ER trailing blood behind him. He could hardly speak, and he was spitting up blood to boot. They got him into a bed, applied plenty of pressure to the wound, got the bleeding under control.

When I arrived at the pediatric ER, I found everyone in such a tizzy. Apparently, they had forgotten the cardinal rule of the ER - when the shit hits the fan, always take your own pulse first. Panic doesn't help anyone and it definitely doesn't get anything done...

In some ways, I understood their panic. The pediatric ER in this place is not staffed by emergency medicine physicians. It is staffed primarily by pediatricians who have no emergency medicine training, and by family physicians and general practitioners. 99% of the stuff that gets seen anyway does not qualify as an emergency, so this works for the most part. Unfortunately, every once in a while, a patient shows up who has suffered an injury/illness that is potentially life-threatening. This kid, for example, was an example of that.

In the adult world, the expectation is that the emergency physician will stabilise the patient and work the patient up if necessary before issuing a consultation (which makes sense because one should at the very least know who you are consulting which actually requires you to figure out what is wrong with a patient even if it is as simple as "surgical vs. nonsurgical"). This is generally - though not always - true. In the pediatric world in the place where I live, unfortunately, this was not the case.

High tracheal injuries (commonly seen in these clothesline injuries) compromise an airway. Establishing an airway is vital, obviously, if the airway is compromised. This kid had a laceration to his neck but he appeared to have missed his airway for the most part - the laceration was more off to the side. However, his hoarseness and the fact that he was spitting up blood were red flags. Intubating someone with a high tracheal injury runs the risk of tracheal transection and is a no-no. So if the shit hit the fan and he stopped breathing, that meant we would be committed to a surgical airway.

The nurses were scared; the attending physician was scared.

Scared is not a good thing to be.

"Listen," I said, "if he goes down the tubes I can cric him."

"You can?" they said.

"Yeah," I said, "I did the course."

A cric aka cricothyroidotomy is what you do when you can't intubate a patient and you need an emergent airway. I'd done the course and we'd practised on anesthetised pigs. It's a procedure you might see in Hollywood dramas - all you need, strictly speaking, is something sharp that cuts and something hollow - you find the right spot to cut into the airway and you jam in your hollow tube (a straw, Bic pen, etc...) You can then provide ventilation through that little tube. This, of course, is the Hollywood version - we tend to use scalpels and "cric tubes" instead of DIY materials. However, I actually personally know one physician who saved a life when he "cric'ed" a car-crash survivor before the paramedics arrived, using a pocketknife and a Bic pen. (Later, the man tried unsuccessfully to sue, arguing that he should have been allowed to die).

In any case, this revelation on my part that I was trained in crics seemed to settle everyone's nerves a little. It didn't settle mine since I was now on the hook for potentially having to do something that, in ER parlance, is done only when the situation has become so dire that you are pretty much needing a diaper while you shit yourself.

It also meant that I was then "assigned" to escort the teen everywhere - from the CT scanner to the X ray department, together with 2 nurses and a respiratory therapist. In my opinon, this was overkill especially considering that I brought neither a scalpel nor a cric tube with me on those trips, but ah well - c'est la vie. It did, however, mean that I also got to be by the bed when the ENT surgeon arrived to scope him - and the surgeon was so kind as to keep letting me peek down the scope to see the damage done, which was pretty awesome.

To cut a long story short - my teen escaped with his life by all of 1cm. 1cm - the width of your pinky fingernail.

And that's why I was reminded yet again of how there is such a fine line between life and death.

For this young man, that line was the thickness of 1cm. 1cm more to the left and he would have crushed or transected his airway. 1cm lower and he would have run the risk of severing the jugular or carotid. As it was, he had small lacerations to the airway, but nothing that required surgery. Nothing that required anything really. And his spine was fine - oftentimes, clothesline injuries also lead to broken necks (think of hanging, except in this case it's a horizontal force being applied not the vertical drop) and paralysis and death.

When the ENT surgeon looked up from the scope at last and announced that there would be no need for surgery and that he would recover just fine - although his voice might not be the same again and it might take a long time, he would be fine - the kid fought back tears of relief and his parents began to cry as well.

And I must admit that I too felt myself tear up. Because we lose so often, we lose lives and functionality and mobility when our patients die or end up paralysed and all of that - and this kid, he didn't end up losing anything. He kept his life, his mobility, he kept it all - and by 1 measly cm.

"I don't see people like you often," the ENT surgeon said. "Usually, you come in dead."

And we all laughed, including the parents - laughed with relief, laughed with that huge heaviness lifting off our hearts.

I know that good people die for others' stupidity and malice. I know that well. But lately, I find myself weary of seeing good people die, of seeing people die in front of me and being utterly helpless to stop it. It's one thing to witness a patient die from cancer - it's another thing entirely to watch them die choking on their blood, or unable to breathe, or to die because they made one mistake that day - perhaps they decided to go just that 10km faster, or have just that 1 more beer. It's those deaths that I see in the emergency room, not the types that have families surrounding the frail patient who has said his goodbyes, not the peaceful kinds - in the emergency department we watch the deaths of those who do not want to die, who are not ready to die, who rage against the dying of the light.

I think if that 1cm hadn't been there today, I don't know that I could go out there and keep doing what I do.

It's just been a long few months.