To Africa: "Road Traffic Accident Emergency"

Well, the past week has been more eventful than usual!

After a typical day at the hospital last week, I walked home around 4 pm with plans to read in the sun in the hammock or possibly fit in a quick workout before everyone else was home. Aparna had been in the operating room with a hysterectomy case that was pushing 5 hours, and she was starting to get sick, so I wasn't planning to wait for her to exercise. I changed into my running shorts and was sitting on the porch considering my next activity when Priyanka's phone rang. It was Aparna calling from the hospital. When Priyanka hung up the phone, she said there was a "road traffic accident emergency" in the Emergency Room. Not quite sure if that phone call was a request for help, I saw Priyanka starting to pull on her boots and realized that meant we were heading back to the hospital. I threw on my Chacos, waited for Molly to put her shoes on, and we started walking toward the hospital with Priyanka following behind. Her phone rang again and she ran up to hand it to me -- Aparna said that the RTA patient had an obvious head injury, his mouth was filled with blood, he wasn't breathing well, and asked what to do after they suctioned out the look. I suggested a jaw thrust, oral airway, and bagging if he wasn't protecting his airway. We picked up our pace, still at least 8-10 minutes from arriving at the hospital. About two minutes later, we saw the hospital's ambulance come careening down the dirt road toward us. The driver stopped in the middle of the road, let out two passengers and we loaded up into the van while the driver made a less than graceful 180 degree turn on the one lane road, taking advantage of a nearby yard. We tore down the dirt road with no regard to the ruts that plague the ground. I wasn't sure we were going to survive the drive without an RTA of our own. We pulled up to the ER entrance and ran into the resuscitation room to find Aparna and one of the COs at the head of the bed of a young man with a puddle of blood beneath his head, wearing a c-collar with a pelvic binder (i.e. a bed sheet tied around his hips) in place, and a splint (i.e. cardboard) applied to his deformed left femur. Sticking of the man's mouth was a laryngoscope and an endotracheal tube. His vitals flashed on the monitor at the bedside. -- heart rate 55, oxygen saturation 57%. Aparna attempted to intubate before we arrived but she was pretty sure she had the tube in the esophagus and had pulled it out. While trying to get some idea of what had already transpired, I grabbed a pair of gloves, squeezed between the head of the bed and the wall trying to avoid getting blood on my shorts or legs, and took a look with the laryngoscope. It wasn't the best view, but the airway was clear of blood, and I managed to get the endotracheal tube in place (which we could confirm only with listening to the chest and over the stomach). We tried to improve his oxygen saturation with bagging but the pulse oximeter continued to read low. I listened over his chest again and heard breath sounds with the bag assistance, but no heart sounds. We checked for a pulse, and came up empty. There was not any cardiac activity on ultrasound. Despite the efforts of the team, our patient was not going to survive. We debriefed for a few minutes after the trauma and identified many areas of improvement for trauma resuscitations here (especially following the ATLS algorithm beginning with "A" for airway). It was certainly a good lesson for the COs and nurses in how to work as a team and they astutely recognized areas for improvement and their need for practice/simulation with major traumas. Unfortunate outcome for the patient, but an important learning opportunity for the staff.

Less adrenaline provoking, but a new experience for me was assisting one of the EM/FM residents with placing a suprapubic catheter in a older man with urinary retention. A normal Foley (urethral) catheter was attempted several times without success, so we decided to place a suprapubic catheter. This is not something I do regularly at work, but I decided to go check on the resident during the procedure to see if I could help. He had already attempted once when I arrived at the procedure room and was unsuccessful. I suggested using ultrasound guidance for his second attempt -- we could now see the needle enter the bladder, and also confirm the catheter was in the bladder after insertion. The catheter seemed to be functional initially but later urine started to leak around the insertion site. We considered taking him to the OR to open the incision site more and actually look at the bladder and see if there was a way to better secure the catheter...but I'm not a surgeon, and Aparna was going to have to be the surgeon in charge of overseeing the resident and she doesn't usually operate on bladders, or on men...so we referred him out to a urologist. I felt a little out of place trying to assist someone in a procedure that I am not comfortable with, especially when it is being done with a technique that I would expect in an OR and not in a procedure room in the ER, but it was fun to do some creative problem solving in an environment where there is flexibility to do such.

Side note explanation for the random pictures below -- in honor of the upcoming Summer Olympics, we had our own "Sagam Olympics." Everyone chose an empire to represent (mine is the Ethiopian Empire) and an anthem (I chose "Roar" by Katy Perry) and we had an opening ceremony (which involved cooking Greek/Mediterranean food, slam poetry, and a parade of empires whilst carrying the "torch" -- an empty wine bottle with a candle sticking out of the top). Oh, and there were also glow sticks and glow in the dark face paint involved. Our first, and so far only event, in the Sagam Olympics was three on three tug of war. Aparna wore a shiny pink unitard straight out of an 80s jazzercise class. Enjoy!

Jeffrey, leading off the parade of empires

Molly, Aparna, Lance and Steve preparing the anthems for parade of empires (Lance chose "Pretty Fly for a White Guy", but the only version Aparna had was Weird Al's "Pretty Fly for a Rabbi"...we made it work)