22 September 2011

Violation of Dogma

I've recently been studying a lot for my upcoming recertification exam for  the Emergency Medicine boards. This actually may be why you have noticed me posing more than usual -- I have a clear and discrete task that I am supposed to be doing, which really encourages procrastination. But anyhoo, it has given me an opportunity to re-acquaint myself with all of the dogma we were taught in ER residency, and horrible amounts of mind-numbing trivia: deferoxamine is the antidote for iron overdoses, Brugada syndrome is a sodium channelopathy primarily affecting southeast Asian males, lymphogranuloma venerium is a rare STD caused by chlamydia.

Ugh. somebody please kill me. I hate this trivia SO MUCH that I'm half tempted just to show up and take the test cold. I'd probably pass. But it's a really high-stakes test and if I were to fail it would be expensive and embarrassing and would have unpleasant professional consequences. So I am going to make 100% certain that I will pass and that means reminding myself what the difference is between a Monteggia and Galeazzi fracture even though in the real world you just call ortho and tell them "Bone broke. Come fix."

It's not all bad, though, in that I have had the opportunity to refresh my memory about some uncommon stuff that you just DO NOT want to miss, because even though it's rare, if you miss it Something Bad will happen to a patient. Like, well, Brudaga syndrome, which is associated with unpleasant cases of sudden death. And since people not dying is kind of my raison d'etre, that's a fun and satisfying thing to review. In fact, it makes me kind of frustrated with my clinical practice. Where's all the pathology? I haven't seen a AAA in years. That's just not fair.

So I was particularly satisfied when I recently saw a kid with a classic You Do NOT Want To Miss This presentation. A 9-year old who presented 24 hours after a non-displaced midshaft tibia fracture from a bike accident. He had only mild pain at first, which is why the presentation was delayed. But over time the pain got worse and worse and finally the parents, perhaps a bit belatedly, decided to bring him into the little rural hospital where we sometimes work.

The fracture was spectacularly unimpressive. Sure, midshaft tibia is a bad place, but it was barely more than a hairline and it was completely non-displaced, in perfact anatomic position, and well-stabilized by the intact fibula. But the leg ... was a sight to behold. A skinny little fellow, his left leg was maybe three inches in diameter, but his right calf was about as big as my own. And tight as a drum. Bingo -- compartment syndrome.

That is when there is some swelling in an extremity which causes the pressure in the muscular compartments to be so high the muscle is deprived of blood and dies. And the patient is left with a non-functional limb. Don't miss this, and don't screw this up. Especially in an athletic nine-year-old. I wasn't sure this was compartment syndrome, mind you, but it was a really concerning presentation, with pain out of proportion to the fracture, progressively increasing pain, and severe pain with passive movement of the toes.

The management of compartment syndrome is clear: You stick a big Stryker needle in to measure the pressures, and if elevated, orthos fillets open the limb to restore blood flow. Ghastly, but it works. Only problem was that at this little hospital, there was only one ortho guy (since his partner got deployed to Afghanistan) and he does not like taking care of any pediatric stuff beyond the really simple cases. This is not simple. Also, I have never even seen let alone utilized a Stryker needle. So I called the local regional children's hospital and got their orthopedics resident on the phone.

The resident was a real piece of work who proceeded to abuse me because he thought my ortho guy was lazy and/or incompetent and was dumping work onto him, and he accepted the case in transfer only after reading me the riot act about how this was a surgical emergency and I needed to measure the pressures immediately and release the compartments immediately and I was endangering the child's leg by delaying care with an unnecessary transfer. I'm good at ignoring that sort of thing, thanked him for accepting the transfer, and got off the phone. In my heart, I felt that the kid would not need a fasciotomy, but I was not going to be the one to make that call. We had the kid downtown within the hour.

At the end of my shift I called the ER at the children's hospital and got the ER resident who was taking care of the kid. She was quite pleasant, and informed me that the kid had been splinted and would be admitted for observation. So, he didn't go to the OR, then, I thought. "What were his compartment pressures?" I asked. I was unsurprised to hear that ortho had not even checked the pressures. They just had examined the patient, somehow performed a visual/tactile/olfactory measurement of the pressures and decided it was fine. It must be wonderful to be a specialist and have that sort of godlike sensory powers.

I see this all the time, and it blows my mind. I was half-tempted to call the resident back and call him on the line of BS he had given me. I know that would have been pointless, but so tempting. The thing, though, is that this is what I mean when I talk about how real-world medicine differs from textbook medicine, like the case of the hangman's fracture the neurosurgeon wanted to send home.

I'm going to assume that the ortho guys at Children's were competent, and that they didn't just screw up. Possible, but they are specialists and pretty sharp. When I first spoke to the resident, he recited chapter and verse of the textbook at me, just as I would have to a medical student I was instructing (though I would have been nicer). But the real world is not black and white, and judgement is all about gauging the shades of gray and that involves instinct and experience.

See, I've never seen a true compartment syndrome, largely because I see the fractures on day one, before it has had time to develop. I palpated the kid's leg, and it was frighteningly tight, but there was some give there, just a bit. Maybe that was enough to tell an experienced ortho attending that it was not worth sticking the needle in. I don't know how it turned out, whether the kid went to the OR or not. The lesson, though, for budding ER residents out there is this: know the dogma, respect it, but don't be too insistent on it. There are cases where it needs to be followed and cases where it may not. The trick is to know the difference, or to get the patient to the right person to make the call.


  1. Perfusion Is Good9/22/2011 11:57 AM

    Olfactory measurment of pressure is very impressive indeed ;)

  2. ER tip from a Bendy Person:
    Treat anyone with Ehlers Danlos Syndrome (of any type), or Benign Joint Hypermobility syndrome as though they had Marfan's if they come in with chest pain. We are all at nearly equal risk for Aortic Dissection. Doesn't matter what age or sex either, the collagen in our bodies is faulty.

  3. And remember that undisplaced tibia fractures are actually at higher risk of compartment syndrome because the compartments are still intact, where a significantly displaced fracture has often violated the compartmental spaces allowing some degree of relief of pressure.

  4. Recently had a car fall on my arm, got compartment syndrome and a fasciotomy to boot. I can tell you first hand, movement of the fingers, and the sheer amount of pain is terrifying. I was curled into a ball on the cot crying, I'd ran out of screams after the first hour of being trapped under the car. I'll never fully use my arm agian, and it took me 18 hours to get into surgery due to the injury not presenting itself immediately, but my arm was saved. In all my years on the truck, I'd never seen compartment syndrome truely, I'd suspected it. But looking back now, it was pretty easy to diagnose once it showed itself. My arm turned bright red, fingers had barely any cap refill(5+ seconds) and the pain was completely out of control. Glad you sent him to Children's, they sent me to the regional trauma center for it.

  5. I know what you mean. 90% of the math I took in college I do not use in my life as a computer programmer. Really I just use algebra II. That's it. I'm doing business apps, not rocket science or orbital dynamics.


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