Wednesday, August 11, 2010

The Decisions We Make

It had been a high-speed motor-vehicle accident. One car. A twenty-something male driver without passengers. No seat belt. And now, this same driver had no movement from his waist down and no sensations below his mid-abdomen.

According to bystanders, he had been driving his sedan dangerously fast, some estimates of nearly 100 m.p.h., before losing control. The car veered off the roadway to the right, flipping mid-air before smacking head-on into a magnificent tree. It was unclear if the driver had been thrown from the vehicle or eased out of it by witnesses at the scene.

The prehospital call came from an experienced paramedic who's shallow, rapid breathing and abbreviated sentences clearly defined the dire circumstances of this patient. "We are bringing you a male patient, approximate age twenty, involved in a single-car MVC (motor vehicle collision). The patient's vital signs are stable. He has no, I repeat--no, leg movements and cannot feel us touching him on his abdomen." The paramedic took a deep breath before she continued. "The patient also has priaprism."

"Is the patient talking?" the charge nurse taking the radio call asked.

"If it weren't for the forehead laceration and his neurological deficits, you wouldn't even know this guy was in an accident," came the reply.

From this short conversation, we were able to garner some very important information. One, the patient had an obvious spinal cord injury. With his leg weakness and loss of sensation below the abdomen, we could assume that the level was somewhere in the thoracic or lumbar area. Two, his vital signs were stable, which went against an injury above T6. A spinal cord injury above this area can result in neurogenic shock, where the patient may exhibit extremely unstable hypotension and bradycardia. The paramedic had told us the patient's vital signs were stable. And three, this patient had priaprism--a persistant erection that, in this circumstance, was indicative of a spinal cord injury.

It was not sounding good for this patient.

We prepared the trauma room for this patient's impending arrival. He was being flown directly to our facility from the scene of the accident, about an hour away by car. Just minutes by chopper. A trauma alert was called, which ensured that the CT scanner was vacant and ready, that the trauma team would respond and work hand-in-hand with our ER team, that respiratory therapists would bring a ventilator and intubation trays, and that all other services were placed on high-alert to immediately respond as needed.

Within minutes, the chopper landed on our parking garage rooftop and the patient was rushed into our department, Trauma Room 18. Surpisingly, just as the paramedic has described, he did not appear to be acutely ill or injured upon first impressions.

He had sandy brown hair with matted bangs from the clotted blood of his forehead injury. His eyes were brown and frightened. He was covered in pale gray blankets, monitors and wires poking out from different angles. He was on a transport board with a hard supportive neck collar wrapped tightly in place to prevent him from moving his head.

Our eyes met. I walked up to the head of the bed as the nurses began obtaining new vital signs and my ER resident and the trauma doctor began their exams. "Hey, buddy," I said, bending down and talking calmly into his ear, "everybody in this room is going to be working hard to help you with your injuries. You are going to be getting poked and prodded and asked a million and one questions, but you have to bear with us. Okay?" He nodded at my words. After a moment's hesitation, he spoke, his voice soft, quiet, disheartened.

"Can somebody call my mom and dad and let them know where I am and what happened?"

"Of course," I assured him, calling in our case manager to his bedside to get a phone number. "We'll talk to them and let them know that you are here in our ER."

I performed my exam, first checking to make sure that his vital signs were stable. They were. I listened to his heart and lungs. All was normal. I palpated his abdomen, impressed by the horizontal line of xxx's that the flight paramedic had drawn across his abdomen to show the loss of sensation below. I did a motor strength test of his arms, which were strong and without deficit, and his legs, which were thick and heavy and without movement. It is quite disconcerting to have a young, healthy, strong patient lay in bed and not be able to move his legs at your command. I held his legs in the air, six inches from the cot, and told the patient to hold them there when I let go. They dropped with a thud. I pinched his great toes, we poked his feet with a clean pin, and still, nothing. He had absent reflexes of both legs.

Finally, my ER resident gained my attention by clearing his throat. He was standing at this patient's right side, lifting the gray sheets from the patient's torso. Sadly, he was showing me the patient's priaprism.

I can assure you that, of all of the telltale signs of sustaining a bad injury, priaprism is one of the worst. You can get priaprism from many various causes (sickle cell disease, medications, etc.), but when it happens hand-in-hand with trauma and some form of paralysis, the results are usually not favorable. Hell, the results are devastating, pure and simple.

I went back to the head of this patient's bed to speak to him. I explained all our clinical results on exam, and told him he would be going to the CT scan immediately. He nodded, wiped a tear from his right eye, and spoke. "My parents are going to kill me."

This patient returned from CT scan with the devastating results that we were expecting. He had sustained a vertebral fracture in his mid-thoracic region that had transected his spinal cord, cutting off all nerve innervation to the rest of the body below that area of injury.

Damn it all.

Neurosurgery was called, the OR was placed on standby, and the patient was emergently transferred to our ICU. Although we could do nothing about the permanence of the complete transection of his spinal cord, this patient would need surgery to stabilize his vertebral fractures. He had a long road ahead of him.

Imagine being this patient's mother and father. Imagine that phone call that came their way at 2 a.m. It is every parent's worst nightmare. Imagine driving an hour to arrive at a hospital you are not familiar with, only to find out that your child has just become a permanent paraplegic. How do you survive such devastation?

You raised a son, giving him your best through his formative years, wishing for all of the world's best offerings to come his way. Unfortunately, due to some poor decision-making, he wrecked his car, becoming an instant paraplegic. That little boy who jumped on his bed after bedtime stories, that young teenager who ran and played ball with the family dog until both passed out from sheer exhaustion, and that brave high-school graduate who walked sheepishly across the graduation stage just a few short years ago--that life would remain in the past, all those dreams and hopes tidied and packaged into the box of life's disappointments.

To be visited time and time again.

Ironically, as I wrote this post last night on my back deck, several medical helicopters flew overhead, I'm sure following their path along the lake's edge towards our hospital. I can only hope all was well...As always, big thanks for reading. See you soon.


The Hopeful Elephant said...

I wish, with all of my heart, that more physicians viewed life and it's sacredness---and the quality of life---as much as you do. I truly think the world would be a better place.

That poor kid worrying about his parents being mad rather than worrying about the fact that life as he knew it was over....heartbreaking. :(

rlbates said...


Kate said...

No. His parent's are not going to kill him. They are going to be grateful over and over and over again that he is simply alive.

Katie Axelson said...

What a way to start my morning, thanks, Jim.

When I was in high school, we had four or five youth involved in MVCs in a six month span. Some were poor decisions, some were avoidable, some were alcohol-related... all were devastating. I didn't know anyone personally, but they all shook my world.

I was in an accident in October. Two cars tried to occupy the same spot at once, and I saw the whole thing unfold. As a passenger, there wasn't anything I could do, only so many times I could say, "Jess, he doesn't see us." She never heard me. Both cars were totaled but all of the people were uninjured. I'm ten-times more adamant about seat-belt use now, and I have resolved myself to forever be a backseat driver: I'd rather be annoying than in a crushed car.

There's a billboard on my way to work that shows a sign in a rear view mirror reading, "Let's go out for ice cream after you paralyze us." I don't think I'll ever see that billboard in the same way again. I wish there was a way for young drivers to read a testimony like this.

<>< Katie

AtYourCervix said...

Thank you for showing such compassion!

CharityVL said...

This brought me to tears. It can happen at any anyone. Thanks for the reminder.

J-Quell'n said...

Damn. A sobering reminder of how life can change in an instant.

Anonymous said...

His parents will be glad he's alive. We lost my 32 year old cousin last summer to a head injury from a car accident. The only good thing to come out of it is we donated his organs and now others live on.

Empress Bee (of the high sea) said...

how tragic. i feel so bad for the whole family. just the thought of that call makes me have chills. truly heartbreaking.


Rositta said...

There have been many bad decisions made by young men in this part of the world recently leading to serious injuries and death. It has always been thus and always will be. I was always my worst fear raising a son but I guess you just have to trust them at some point to make good decisions, what else can you do. Tearjerker post my friend...ciao

Anonymous said...

This is a very sad story but this kid's life is far from over. He can recover and go on to live a full, happy life because he has good upper body strength and an intact brain. I'm not saying he definitely will but he certainly can.
-whitecap nurse

Tiffany said...

As always such a great post jim!!

This post made me wanna reach through the computer screen and hold this kids hand and be there to comfort him. I was in an accident last summer (although nothing as bad as this kids') and I remember being sooo scared and guilty and shock and all these emotions. I recently just got my "N" (one step under a full licence in my province) and was driving my parents car, when I wasnt paying full attention, ran through a Red light and teboned a car turning left that was clearing the intersection. Luckily everyone was ok (considering their car flipped and they were in a convertible, with the top down, THANK GOD THEY WERE WEARING THEIR SEATBELTS) But we were all taken to hospital to get checked out. I remember being soo frieghtened and shocked, and I just had whiplash and a broken arm. I couldnt even imagine finding out that I was paralyzed. Like Kate said, his parents will just be happy that he is alive. I also thought my parents were going to kill me (how the hell was i gonna get outta that one--"hey mom and dad, sorry i ran through a red, oh and btw, it was your car")but they were just thankful i was ok. Although, a week after the accident I definately got "the lecture" lol.

I commend you for being the voice of calm for the guy, I can gaurantee you that even though it probably didnt seem like much, the fact that you were calm and compassionate probably made him a little at ease.
Again, great post, and keep up the great work!!

Amanda-medic said...

i'm reading this after pronouncing a gentleman on a motorcycle who ran into an SUV this morning at an intersection. Puts a tear in my eye thinking about being the one who bears the weight of delivering that news. And even more sad is that these things seem to keep happening when people are so close to home.
In some ways that boy is lucky, but in other ways he has a lot more challenges to face that are based on one split second decision.
Thanks for sharing this. :)

Unknown said...
This comment has been removed by the author.
Unknown said...

Sorry for the deleted comment! I thought it didn't work so I emailed it...then saw that google was just kidding about the "comment too large" thing apparently. I didn't want the longgg comment to drive people insane so I deleted it.

Thank you so much for this story, and for opening my eyes to the potentially dangerous decisions I've been making.

Rogue Medic said...

You smoothly included information about the proper assessment of possible spinal cord injuries. The marking of the line of sensation and others, that may remain with readers long after they may think they have forgotten about this. Nicely done.

Sara said...

My uncle became a quadraplegic after a fall from a tree 25 years ago. He was deer hunting, and there was a problem with his safety harness. My cousins, now adults, were four and six years old. Incredible how much can change so fast.

coulrophobic agnostic said...

Damn. Though I normally don't feel huge amounts of sympathy for reckless drivers, it makes me so sad that so many people get hurt, often for NO good reason beyond poor decision making.

Just so POINTLESS. But thank god he still can use his arms, his head, speak, breathe on his own, feed himself. As bad as it was, it could have been a lot worse.

Why do these injuries cause priapism?

Annemiek said...

So terribly sad! His and his family's life is changed forever. I hope to never experience anything like that. Some decisions can ruin a life.

Karen said...

I hope this boy has the courage to make the best of his life while paralyzed. Sad, sad situation.

soulful sepulcher said...

Of course, while reading I hoped the end result was not going to be permanent that way.

When I was 16 and in a head on collision (red light runner hit my car)the paramedics turned their sirens off when they approached the scene, telling my mom they assumed it was a fatal scene. I was tossed all over the car like a rag doll, according to witnesses. I, to this day have no memory from that accident except for the medic's face who asked me what my phone number was to call my mom...multiple injuries, ripped apart knee, head trauma, I was able to say the number. For a month after that, I repeated the same day and date when asked as I recovered, it took 3 months to bend my knee again.

I was alive. I did not have a seatbelt on, and have worn one ever since.

As an adult, I had a friend lose her teen son to speeding and not buckled up, as he was ejected from the car via the window when he hit a telephone pole.

After my car accident I attended a teen bible study that summer. The young pastor said, to watch ourselves, in all areas, as to "don't become another statistic in the newspaper".

I told that to my kids as they learned to drive, and I'll tell it to anyone reading here. Life, is more fragile that it appears. Fleeting. The young man in this story is alive, and hopefully happy, though life not as expected, it's the same for all of in the moment.

Have Myelin? said...

Life changes on a dime but at least he has life. And no... his parents won't be mad at him, they'll be grateful he's alive.

Anonymous said...

Gut-wrenching, yes, but am I the only voice saying "thank goodness his reckless driving didn't kill some innocent family instead of just injuring him?" I hate to sound callous, but he made the poor choices that led to his injury; by 20-something we all know what can happen when we are acting stupid. Usually it's innocent bystanders who pay the price -- this time it was the instigator who did. A terrible, heavy price, but one that was not unexpected. My sympathies are much more on the side of the many innocents who die each day, killed by drunk, sleepy, or reckless drivers like that young man.

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Calamity Bird said...

How awful. And amazing, how suddenly everything can change. May he and his family get through this and adjust with love, patience and strength.

New reader here, directed to your blog by a friend. I have to resist the temptation to sit and read all the back posts in one long night! Your good humor and obvious compassion for people really shine through.

As a medical transcriptionist, I have an odd sort of window into people's lives myself. I have laughed over some of the (no permanent damage!) things people have gotten themselves into, and felt my heart break for others, but I never meet them. I have known physicians for years - their names, their voices, their ups and downs, sleepy ones and impatient ones, self-important ones and kind ones - who don't know that I exist (beyond that they must know there is *some*one out there listening to them!) You, sir, sound like one of the good ones. I'll bet you're even kind to the MTs.

...but you misspelled "priapism". (I'm sorry! It was making my MT reflexes twitch!)