One of those families

Most families are very nice and appropriately concerned for their loved one. But sometimes you get a family that is unhappy with everything. The second you walk in the door there are problems. "We don't like this...We don't like that...We don't know anything...We don't know why this...We want this...We need that, or else..." Sometimes there truly is a reason for all the gripes. Recently we had a patient that was transferred from another hospital, and the transferring hospital made a whole bunch of promises about what and how we were going to do things, some of which were not even possible. I was under fire the second I walked in the door. Then, as I listened more, I also realized many of the problems actually occurred at the other hospital. Wounds weren't cleaned there, there was a delay in treatment there, they were "forced" to transfer from there...and that carried over to us. "Why haven't we been seen by so-and-so? That team didn't even know about us until this morning. Why hasn't he been to surgery?" After a good hour of explanations and troubleshooting, we started to see eye-to-eye.

Fresh off that family, I got a new one. Not a transfer this time, though. They don't want these surgeons, they don't want residents, and they want everything NOW. Although I consider myself very good with patients and families, I have learned there are some cases where you can never make a family happy. You can't make enough accommodations, say enough nice things, jump through enough hoops to make them happy. Maybe some people are just predisposed to being angry everywhere they go. Maybe it's the stress of the situation that makes them think with cloudy reason. Maybe they had a prior experience that makes them go into attack-mode. I'm sure there are a whole host of explanations, but it definitely makes caring for that patient so much more difficult. Irregardless though, I still try my darnedest to make them happy, even if I never to. I can't say it doesn't make me not want to trade them in for a a nice family though.

trauma in the elderly

I love old people. I always have, but in my nursing career I chose trauma (because obviously I love that, too). So naturally, when I started working this job in trauma, I've been interested in trends of trauma in the elderly. I started taking this interest serious enough that I looked into ways of getting more involved with the elderly and investigate data our hospital. The data I gathered is what I presented at the AANP conference last year and then submitted an article on, also. Well, it appears my interest in trauma in the elderly is catching on at my hospital. One of our fellows did a presentation on trauma in the elderly and everybody wanted me to be there. As long as I am working that day, I try to go to conference every week, so really I would have been there anyway. But it occurred to me that my interest in this topic must be well-known, or it wouldn't be that important I be there.

Anyways, I, of course, found the presentation very interesting. One thing that I found very interesting was regarding head trauma. Now, I know I did a relatively recent blog about head bleeds, so it's going to look like I have big thing for head bleeds. I don't really have a specific interest in it; it's more because head bleeds are a common sequela of trauma. And this injury is very much seen in the elderly. There is usually a lot of discussion about elderly being on anti-coagulants (like coumadin, plavix, etc.) and its associated risk for head bleeds. But not all elderly that get a head bleed from trauma are on anti-coagulants (although, yes, it is more likely when they are taking those meds). But, it is also more common for elderly overall to get a head injury compared to their younger counterparts.

Ah, so here comes the part I find interesting. I guess I had just never connected the dots, but as we age we lose cortical brain volume. Most of us probably know that, or least knew that at one point. There is a 15-20% reduction between the 5th and 10th decade of life, such that the elderly brain only occupies 82% of the cranial vault (whereas it's 92% for younger brains). Above is a normal head CT, but with obvious volume loss. But while the brain shrinks, the dura remains adherent to the skull, increasing the subdural space and the tension on vessels (parasagital and branching veins). Studies show elderly are 3 times more at risk for a subdrual hematoma (SDH) and now it makes sense why that type specifically!

compartment syndrome

I always think abdominal compartment syndrome in an interesting phenomenon. We haven't had a case of it for a very long time, and it seems to be pretty rare from my experience, but still interesting. What made me think of it was a recent patient that thought he had compartment syndrome of his leg. Although compartment syndrome is well recognized in the extremities, this guy DID NOT have it. I'm not sure if someone told he has or may get it when he first came in, but his leg was a soft as could be. Nonetheless, he got me thinking about it and how it can also occur in the abdomen.

Compartment syndrome occurs when there is increased pressure within a fixed compartment that is usually limited by bone and/or fascia. In the abdomen, the result of this is organ dysfunction, such as decreased urine output from decreased renal perfusion or respiratory distress from decreased tidal volumes. It may seem a little strange to think of the abdomen as a fixed compartment. An extremity presents a clearer picture because its ability to distend is pretty limited. But even the abdomen will reach an endpoint in its ability to distend, as the picture above shows.

The abdomen can be at risk for compartment syndrome in an acute setting from an internal source such as intraperitoneal hemorrhage, an external factor that limits the belly from distending such as debris or structures crushing the patient, or even large volume resuscitation. An example of a chronic cause would be ascites from cirrhosis.

The key to resolving the sequela is to remove the pressure. This can be done by removing the external source or draining the internal source. Although patients with chronic ascites often undergo paracentesis (get "tapped"), this is probably not the best solution for someone who came in as a trauma patient. Most likely there is extensive internal bleeding, and merely draining the blood will not solve the problem. This would be a clear indication for going to the OR for an ex-lap to find the source of bleeding and repair it. But if there's that much blood, in some ways the pressure may be tamponading the source. In which case, once the belly opens, surgery could be quite tenuous and possibly a time when a patient "bleeds out."