Friday, December 18, 2009

Not All Survive

Chris Henry , the Cincinnatti Bengal wide receiver died this week when he was thrown from the bed of a pick up truck. This is such a common mechanism of injury that the American College of Surgeons uses it as a teaching scenario for its trauma life support course. The body was not designed to be thrown at high speed. The force of landing breaks bones, especially the pelvis, causing significant internal bleeding. The brain can rattle in hte skull causing bleeding and swelling. Sometimes people can be resuscitated and survive. Unfortunately, for some patients Mr. Henry, death happens. Even well conditioned athletes who are accustomed to being hit on the football field can’t withstand the damage caused by ejection from a moving vehicle. In trauma resuscitation, much emphasis is placed on keeping the patient alive until they can get to a trauma center. Medical personnel focus on keeping the lungs and heart working while at the same time, trying to find obvious sources of bleeding and prevent further blood loss. In major trauma, people die early because of disastrous head injury or shock due to blood loss. Deaths that occur later may be due to a variety of reasons: delayed swelling of the brain, lung failure, multiple organs that stop working because of prolonged low blood pressure or infection. While there have been great advances in trauma care and survival rates are much better than in the past (much has been learned from the military experience), some injuries are not survivable, no matter how much technology is used.

More than a Minor Concussion

Technology has been helpful in understanding brain injury and concussion. Fortunately, or unfortunately, the quality of brain imaging has advanced to the point that small areas of damage can now be seen on CT or MRI, where in the past they would have been missed. Sometimes the information doesn’t make a difference in patient care but sometimes it might be a life saver. Todd Hays, hopeful for his fourth Olympic bobsled team crashed this week in Germany and though he only complained of a little dizziness and had a slight concussion, the CT scan of his brain showed a tiny area of bleeding. Clinically, it had no effect on his brain function, but it was enough to disqualify him from going down a bobsled run at 80mph and withstanding significant G force to the brain.

In the past, a tiny amount of blood might have been missed on CT, but the use of TPA, a clot busting drug to treat stroke changed all that. In a stroke situation, a blood vessel in the brain gets clogged with a blood clot preventing blood from getting to brain tissue. That part of the brain turns off and so does the part of the body it controls. TPA can dissolve the clot and reinstitute blood flow to the brain tissue. However, it would be a disaster to give TPA to patient who is already bleeding; it would make the bleeding much worse. When TPA became a possibility, the settings on CT scanners changed from taking a picture of the brain every centimeter (10mm) to taking one every half centimeter (5mm). Five slices an inch finds more small bleeds than 2 every inch. For Todd Hayes those extra slices were able to find the tiny amount of blood that ended his career. It didn’t change what happened to the care he received for this concussion since the amount of bleeding wasn’t enough to cause swelling ion the brain or require surgery, but it made the risk of competing just too high.

The Nose Job

It should be called the Italian nose job and should remind us that there are different ways of doing things depending upon where you live. Italian Prime Minister Silvio Berlusconi was hit in the face by a marble souvenir of the Milan cathedral. It cut his face, broke his nose and knocked out two teeth. In the US that would mean as trip to the ER, repair of the damage and discharge to recover at home. In Italy, Mr. Berulsconi was admitted to the hospital for a few days of recuperation. Often people present to the ER with nose injuries. Since it protrudes from the face, the nose often leads and gets damaged. Unfortunately, there is little to be done acutely with a nasal injury. The initial assessment often deals with making certain the bones of the midface that support the eyes are intact and to make certain brain injury didn’t occur, remembering that the face is the front part of the skull and is also responsible for protecting the brain. If just the nose is damaged, o definitive care is delayed for 3 or 4 days. Once the swelling of the injury resolves, an otolaryngologist or ENT doctor, can evaluate the cosmetics of the face and decide whether the bones are damaged and need to be fixed. This is routinely done under local anesthetic in the office. Xrays are not usually needed in the ER but one complication that the physician may want to look for is a septal hematoma, a blood clot that forms on the cartilage of the nose. It’s rarely present but easy to find when the doc looks into the nose and sees a big swelling. It’s also an easy fix by lancing it with a scalpel.

A Special Doctor

Finally, the saga of Dr. Antony Galea brings up the question of credentials and licensing. If he travelled to Florida to treat Tiger Woods with enhanced platelet therapy, it would reasonable to expect that he has a license to practice in the state.

Licensing is the purview of each state and province. Except for military physicians caring for service members, a doctor needs to apply for a separate license in each state prior to seeing patients. Advertising oneself as a specialist demands that the doctor actually be a specialist. The American Board of Medical Specialties authorizes a variety of boards to confer specialist certification for example in surgery, obstetrics or psychiatry. T oobtain the specialist designation requires years of residency training after medical school, passing tests, continuing yearly medical education and recertification exams. Some physicians are sub-specialists and even more further training and testing. Sports medicine specialization can occur after an orthopedic residency for those who will operate on injuries, but emergency physicians, family physicians and pediatricians can also become sports specialists.

While the press may label Dr. Galea as a sports medicine specialist, the College of Physicians and Surgeons of Ontario list no specialty for him. A medical license and specialty designation help the community know that a physician has developed some minimal competence to care for patients. Calling a physician a specialist should mean something special.

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