An excerpt from The Healing Connection: A Partnership for Your Health.
The blood spurt was alarming though because it therefore indicated that the pressure in the venous system had to be sky high in order to shoot a column of blood in such a continuous arc over my right shoulder.
So, I repeated the process in the exact same spot and angle and confirmed, when I removed the syringe the second time, that the flow of blood was truly not bright red and also was obviously not pulsatile. I didn’t even bother to get an actual central venous pressure measurement, choosing to rely on my initial visual measurement of, “Way too high!” So, this meant that something was obstructing the outflow of blood from the heart causing a backup into the veins, thus causing the patient’s low blood pressure.
The next correct step in this situation is to perform a pericardiocentesis procedure (needle drainage of the blood from around the heart). So, I re-positioned myself down just above his waist on his right side and I was again methodically inserting a much longer but somewhat narrower bore needle beneath his sternum, in this case aiming for his left shoulder. This is yet again a blind technique but is assisted somewhat by the fact that you can attach an EKG wire to the metal needle which will show you what’s called an “injury pattern” on the EKG machine when you touch the cardiac muscle, which you are trying to stop short of.
In this case, I hadn’t even seen the requisite “one” of these procedures, but it had been described to me and I’d reviewed the steps from time to time. I did have the advantage of having punctured the heart on purpose with needles on multiple occasions but never in a truly live person (in my 1980-1981 internship days it was not unusual in the last stages of a cardiac resuscitation effort to inject an ampule of epinephrine directly into the heart to try to restart it, before declaring the patient dead, which was the only result I’d ever seen following that technique). The difference here was that this unfortunate guy was fully awake although subdued to some degree by his elevated alcohol level and by staff who were holding him down by the shoulders. But at this exact moment with the needle already inserted about halfway down its length, he raised his head to look down at what I was doing, and yelled his first and only question of the night, “Are you f#%king enjoying yourself?”
I restrained myself from the response that I wanted to yell back which was, “Hell no, I’m not enjoying myself, I’ve never done this before.” So no, we did not have the opportunity to form a cordial relationship! Long story short, I did manage to withdraw a large syringe full of blood from what I presumed to be the pericardial space, since his blood pressure then improved following that, and I had not seen any injury pattern on the EKG lead. He did survive his transport to a downtown trauma hospital where I subsequently learned that indeed he had blood in his pericardial space as well as an unusual form of dissection of his superior vena cava (separation of the layers of the blood vessel wall of the largest vein in the body), just above the heart which was blocking the return of blood flow. Both injuries thus compromised his cardiac output and caused the sky-high central venous pressure.
This patient’s life was truly saved by the cardiothoracic surgeons who took care of him in the trauma hospital, but I feel that our care of him kept him alive long enough to get there. I say our care because in the ED we are, of course, reliant upon the continual assistance of our nursing, EMS, and ancillary staff colleagues, as we all consider emergency medicine to be more or less a “team sport.”
Throughout my work career I have been a JAFERD (just another f#cking emergency room doctor) as we in EM call ourselves. We do this in a mostly faux self-deprecating, proud, and partially bitter way to acknowledge that’s how we were thought of when we first entered the house of medicine as a specialty back in the late 1970s and early 1980s. At that time, to our colleagues in other specialties, we were mostly just a source of annoyance with phone calls for consultations in the middle of the night, the wee hours of the morning, or in the middle of busy office hours.
We have also been described as seeing “the most interesting fifteen minutes of all specialties.” It shouldn’t be too hard then to imagine that we are often on tenuous novel grounds, sometimes seeing things for the very first time with patients “trying to die on us.” The hardest times are when those threats are of clearly premature deaths. So yes, there is a steady process of inurement to the reality that we can’t always succeed in staving off death or suffering, and we learn to settle on seeking satisfaction in doing what we can to the best of our abilities and limitations and setting aside our emotions in order to function. When we succeed in managing a difficult case or successfully finishing an extremely busy shift without incident, we temporarily reach the more elevated status of BAFERD (bad ass f#cking emergency room doctor). This MVA case on Halloween was one of several moments in my career where I felt that I had briefly reached that BAFERD status.
After all was said and done, I had indeed “kind of enjoyed” the whole process. I could only more fully relive the pleasure of the challenge in retrospect, once I knew of his positive outcome. So yes, I guess you could say I “kinda loved” emergency medicine, especially those moments when I could relieve a patient’s suffering or sustain their health.
Drew Remignanti is an emergency physician and author of The Healing Connection: A Partnership for Your Health.
