So, as I sit here I wonder...do I really have anything valuable to offer?  Is there any reason I should waste others time in reading this or the virtual ink to write it?  Well, I am honestly not sure and since this has become almost therapeutic sans couch or hourly rate I decide to really look deep, search for what has impacted me most of late.  

Well, I have a top three.  This is in  particular order.   These are all 3 life altering situations.  Strange, that they occurred in 2 days and to me they represent 3 very distinct situations that we could all find ourselves in.  That fact alone may be what scared me so much.  I hope that these recollections of the suffering endured by others will serve to do more than pass as therapy for me or a casual use of time for the reader.

#1.  A 4 year old otherwise healthy little girl comes in with her mom and dad for evaluation of abdominal pain.  She had been on an ATV driven by her older brother.  She, with the approval of her parents had been sitting in front of her 10 y/o brother who was driving the ATV.  Her brother hit a small tree with his right wheel causing the steering wheel to jerk to the right.  This resulted in the steering wheel hitting her in the right upper aspect of her abdomen.  No big deal.  Right ? Right.  Wrong.  I believed, hopeful person that I am, that despite the potential this beautiful bright eyed girl would be fine and that this was simply some expected discomfort that would pass.  

I was wrong.  This little girl had completely transected her liver was actively bleeding into her abdomen.  No time for watching or waiting.  The time lost in obtaining images at my little ER may have already been too much.  Angst and concern actively conveyed to both pediatric surgeons and parents.  Helicopters and electronic machines going beep rapidly attached.  Then as suddenly as the pt appeared she had gone.   Along with the grief racked parents that had accompanied her.  The same parents I had seen racked with guilt, eyes of the sobbing mother filled with emotional anguish.  

#2.  An 11 y/o boy who was a restrained front seat passenger when his mother swerved to avoid a deer thereby running off the road into a ditch.  Airbag deployed...check.  Seat belt working...check.  The patient walks in with his mom accompanied by the ambulance crew.  I saw him briefly from the corner of my eye (for a person prone to rash decisions and snap judgements that can be plenty) as he came in.  Shortly thereafter a nurse comes to get me.  After bidding me good day and with the requisite salutations completed she asked that I come see the patient toot de suite.  

I am juggling sick people, too many in fact, because with the changes in healthcare that is just how it goes.  ( healthcare, reimbursement, my take on the state of the union will come later)  In any event, I give the nurse a small measure of grief before remembering the old adage that nurses are my eyes and ears.   So, I am up and off to see him.  

Walking into the room I see the child on a bedside toilet.  He barely lifts his head to make eye contact with me.  When is the last time you saw any child comfortable in that type of position with anyone?  Much less a complete stranger in a foreign environment.   Walking into a thinly curtained room I see this pale child, half naked on a bedside commode who eventually looks up...and I immediately think Holy S*@t...I would prefer he never looked up so I could have continued to believe he was ok. Because this kid was a damn site from ok.  White, not like how you identify yourself on a voter card...but literally white...pale, drained of blood.   

Less than 24 hours preceeding I had come across a kid with a devastating injury (see case #1) and I was not about to let that happen again.   I immediately called Egleston.  AKA the cavalry.  I got the ER doc who immediately started with the requisite line of questioning.  "What is his 'crit' "? Uh...I don't know.  He just got here.  "What does his CT show"?  I haven't gotten it.  He rolled in 5 minutes ago.   "This kid is sick" I say.  He likely has a lacerated liver and I can't fix that so I am not trying to diagnose it.  After a few brief exchanges he relents saying "Ok, Ok, well get what you can and send it with him".   I take a deep breath, say thank you ( because it's alway appropriate) and go back to discussing the transfer of the patient with immunoglobulenemia and pulmonary fibrosis who has an oxygen saturation level of 58 or roughly that of a FISH.  Point is that it really is a little like a TV show for a few brief moments.  

By the time the helicopter arrives we have blood work and Cat Scans.  Blood work abnormal, check.  So what.  CT scan abnormal.  Holy S*@t.  The kid had ruptured his spleen and torn his liver.  He was also bleeding into his abdomen at an accelerated rate.  Hence his white appearance and my overwhelming fear he would die on my watch.  But tonight was not that night.  Knock on wood.  He left on a helicopter courtesy of Emory flight for a hastily arranged date with Hot lights and Cold steel.  AKA surgery. 

#3.  "I have a cough and it's keeping me from sleeping"  I ask the pratcically already answered question " Do you smoke"?  I ask because the treatment for a non smoker with a cough is dramatically different than for a pt who smokes with a cough.   Roughly speaking, a smoker gets treated with antibiotics because they can not fight off infections while non smokers do not unless they have clinical findings to suggest need of an antibiotic.  

Well, this patient had a chest Xray obtained based on the screening orders from a midlevel provider or physician assistant.  I had seen, examined and made the decision to discharge the patient before ever seeing the patient.  I checked the CXR as a matter of protocol, feeling that there were really no indications for having ordered it.  Unfortunately it was abnormal.  Not because of an infection, but because the Aorta ( which connects the heart to everything else) was widened to a concerning extent.  

So, I march back into the room and explain that this evaluation will take a little bit longer. I say "march" because when I am about to deliver news it really is a march of sorts.  I start to explain what I saw and what needs to happen and she says " so...am I going home"?  I simply say "well...lets get some tests and see what we find".  

3 hours and several conversations with her concerned fiancee later the results of her picture comes back.   It turns out that this 40 something yearold smoker has  a cough with bronchitis.  And an aorta which is about to burst.  Specifically it was greater than 7cm in width.  Normal is 3 or less.  Anything above 5 is a candidate for surgery due to risk of rupture.   I guess in hindsight I should have talked to her first, but I didn't.  My first call was to a thoracic surgeon who promptly accepted the patient for surgical repair that night.

So, I stroll back into the room and say "uh...so your pictures are back.  It looks like you have some other stuff going on.  The blood vessel from your heart is too wide and needs to fixed"  Cue the confused looks and vague stuttering responses.  Who wouldn't be confused.  You come in at 5pm for a cough and by 930 your leaving to have your chest cut open with death being a very real option. 

Lesson # 1.  Poor decisions, even those seemingly innocuous ones, can effect not only you, but your kids with devastating consequences.  

Lesson #2.  Even doing the right thing by your kids and the law does not necessarily guarantee your well being.  And that completely sucks. 

Lesson #3.  You never know what is coming.  So live your live your life.  Don't put off too much.  Enjoy the time you have.  I certainly have this holiday season.   God Bless.