Dr. Edwards

Several Days Before Christmas

/ Jordyn Redwood / Leave a comment

I’m pleased to host Frank Edwards, MD today as he writes about telling a family about the death of their loved one.

I have been in this position, unfortunately, as well. Sometimes, getting the feelings of a healthcare provider is hard to do. I think Frank has done it well with this poem.

It was a little after noon
when the drizzle began.

A truck skidded sideways on a bridge

and overturned.

The driver wasn’t hurt,

but underneath his truck

Lay a car,

roof caved flat,
the driver’s head crushed.

Before setting out,

she had firmly buckled her two young sons
in the back seat.

In the hospital

I examine them:
A few scratches from window glass
turned shrapnel.

They do not ask about their mother

who’d gone straight to the morgue.

Her husband,

at work,
was only told
there’d been a wreck,
his wife was hurt.
When he arrives
a silent nurse leads him
to the room we keep for these occasions.

How to do it?

Introduce yourself.

Not by first name–
use your title: doctor.
It’s pragmatically superfluous now,
the little good you did,
but this a time for shamans.

Start easy.

Your sons are fine,

Not hurt . . .
But I do not have good news about your wife
(Husband, mother, father, brother, sister, friend).
Then shut your mouth for about ten seconds,
sit, lean forward, take their hand,
allow them to poise,
their grief to ripen.

Do not proceed,

I repeat,
do not continue–
until you feel it yourself.

Only then

give the truth.
and do not be afraid
to use the word death.

And as the floor caves in–

sink with them.

*****************************************************************************

Frank Edwards was born and raised in Western New York. After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester. Along the way he earned an MFA in Writing at Warren Wilson College. He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

Check out Frank’s novel Final Mercy.

Aortic Injuries: Part II

/ Jordyn Redwood / Leave a comment

Dr. Edwards concludes his series on anuerysms today with a look at abdominal aneurysms.

The last blog in this series discussed problems with the upper (thoracic aorta) and how the condition known as a dissecting thoracic aorta can mimic heart attacks and be rapidly fatal if the wrong medication (a clot dissolving drug, for example) is given.  This time we’re looking at the abdominal section of the aorta.



www.health-news-blog.com

 By far the most common emergency condition involving the abdominal aorta involves a ruptured aneurysm. An aneurysm means a ballooning.  Abdominal aortic aneurysms, however, do not develop suddenly.  They rupture suddenly, but the underlying problem—the development of a large bulging section—occurs slowly over years.  We know that hypertension is a risk factor for this, but there are most likely hereditary factors as well.  Typically the aneurysm begins in a person’s forties, fifties, sixties or later, and is often present, usually undetected, for ten years or more before reaching the dimensions (usually greater than 4 cm in diameter) where sudden rupture may occur.    


Many, if not most, AAA’s remain asymptomatic and never rupture.   If a physician discovers one on physical exam or finds one incidentally in the course of performing an ultrasound or a CT scan for an unrelated condition and the AAA is less than 4cm, the patient can be followed by repeat ultrasounds every six months or so.  When and if the AAA reaches 4 cm, then consultation with a vascular surgeon is in order to consider a prophylactic graft procedure.

Unlike what happens with the thoracic aorta where a tear develops and blood channels inside the vessel wall, the AAA actually ruptures through the entire wall of the aorta and the patient can rapidly die from blood loss.  Time is very much of the essence.

The classic presentation of a ruptured AAA will be a patient in their seventies or eighties with a long standing history of hypertension who has the acute onset of severe lower back or possibly flank area pain which may or may not extend around to the front of the abdomen.  The pain is severe and a fair percentage of the time it is accompanied by a fainting episode and low blood pressure.  In some ways the pain mimics that of a kidney stone, though I have personally seen two patients with a ruptured AAA that came in complaining of feeling constipated. 

The diagnosis can be picked up by ultrasound or CT, but in a good number of cases, you can actually palpate a pulsatile mass in the abdomen.  Emergency providers must keep a high index of suspicion for the presence of a ruptured AAA in any elderly patient with abdominal pain.   If you don’t think about it, you can easily not consider it until the patient is crashing, and then it’s often too late.  In general, though, it must be said that the mortality rate is very high even if the physician does everything right.

****************************************************************************** 

Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

Aortic Injuries: Part I

/ Jordyn Redwood / Leave a comment
When Bad Things Happen to Great Vessels – Part I
Frank J. Edwards, MD
The aorta, as everyone knows, is a high-pressure, semi-elastic conduit coming off the heart’s left ventricle that arches downwards, dives through the diaphragm and courses through the abdomen into the pelvis, where it bifurcates into the iliac arteries.  Major arteries branch off throughout its long course supplying our vital structures with oxygen and nutrients.   The wall of the aorta has three layers under the microscope—a strong, fibrous outer layer, a muscular middle layer, and a relatively thin and delicate inner membrane. 
When something goes wrong with the aorta, it’s going to be a clinical nightmare.   Bullets and blades account for most traumatic injuries, but the aorta can rip when the heart is wrenched and twisted during the first seconds of a high velocity accident or fall.   Patients with traumatized aortas usually don’t make it to the hospital.  If they do, the challenge is not one of recognizing the problem—
But of fixing it . . . very quickly.
Non-traumatic aortic crises, however, can be surprising difficult to diagnose, and are just as potentially lethal.  Such patients may slip through triage looking like back strains, angina, kidney stones, strokes and even constipation.
The nature of non-traumatic aortic catastrophes will vary depending upon location, but fall into two general categories:  the thoracic aorta tends to suddenly dissect, while the abdominal aorta will gradually develop aneurysms that enlarge and eventually rupture.  Today we’ll look at thoracic aortic dissections, and next month the ruptured AAA (abdominal aortic aneurysm).



http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW025691



The thoracic aorta is that segment running from the heart to the diaphragm.  A dissection occurs when the inner lining develops a sudden, spontaneous tear, which can occur for a number of reasons, including long-standing high blood pressure, congenital connective tissue disorders like Marfan’s Syndrome, and the Ehlers-Danlos Syndrome.
The tear may occur close to the heart (the aortic root) or anywhere further along the vessel as it arches down.  Suddenly, all that blood pulsing out of the heart under high pressure has somewhere else to go, and because the toughest outer coating usually holds, it dissects a new channel between the inner and outer layers, and it does so with a vengeance, wrecking havoc along the way.
It can seep toward the heart and block the coronary arteries—giving heart attack symptoms—or it can compromise blood flow to the brain and resemble a stroke.  Not uncommonly it will dissect all the way down the length of the aorta into the pelvis and throttle blood flow to one of the iliac arteries, causing pain and numbness in a leg.  Furthermore, the outer layer may crack open and allow blood to gush out into the chest cavity.  We are talking serious badness anyway you slice the cake.
While a good number of patients with thoracic aortic dissections have severe upper back pain often described as “tearing” in nature, many don’t.  They may have only chest pain accompanied by EKG changes resembling a myocardial infarction, or they may have stroke-like neurologic deficits—up to and including coma—or they may have back-pain-plus-leg-numbness, or chest-pain-plus-arm-pain, or back-pain-and-chest pain, or . . .  you get the idea.  Chest x-ray alone won’t make the diagnosis, and neither will any single test except a contrast enhanced chest CT scan. 
This is what happened to the actor John Ritter.  He developed nausea and vomiting while on a set and went across the street to a very good medical center in L.A. where an EKG suggested he was having a heart attack.  The highly skilled cardiologist on duty ordered a blood thinner and Mr. Ritter died.  
Once in a while, thoracic dissections will “stabilize.”  The rent will seal, the dissection cease, and the patient may require only good blood pressure control.  But treatment usually falls to the thoracic surgeon, and the already high mortality rate rises the longer diagnosis is delayed.
 The stop watch has begun ticking before you even lay eyes on the patient.
 Emergency medicine providers must keep a high index of suspicion in anyone who complains of upper back pain or chest pain—and especially (here’s an excellent rule of thumb) if the patient has symptoms both above and below the diaphragm.  Next month—the equally dreaded “triple A.”
*****************************************************************************
Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

Sorting though Disaster: Triage and 9/11

/ Jordyn Redwood / Leave a comment
As a tribute to the upcoming ten year anniversary of 9/11, I thought it would be nice to have our resident ER doc write about triage.
Where were you on 9/11? Please, leave a comment today.
Most people over the age of twenty probably have some memory burned into their mind of the fire consuming the World Trade Towers and their ultimate collapse and destruction.
northernlight220
I had just flown in from Chicago the night before. I remember waking up to the incessant ringing of our phone. Tired from the previous night, I was adamant about letting the machine pick it up. It became clear after about five minutes of solid ringing that perhaps it was an emergency. I answered and a good friend of mine was on the other end blubbering, crying—nonsensical. I remember fragments of her words—“planes crashed” , “New York”, “Thank God you’re back!”–“Just turn on your TV!”
I think I sat on the couch watching the tragedy unfold for the next three days.
A good friend of mine was working as a nurse at the time of the attacks. She’d just gotten off the night shift and was getting settled into sleep when the events broke. Immediately, she hustled back out of her apartment to go back to the hospital.
Upon her arrival, they were setting up for multiple victims, beginning to formulate a plan of how they would triage the patients.
Here’s triage from the ED doctor’s perspective: Dr. Edwards.
Some extraordinarily difficult decisions have to be made when you’re dealing with a mass casualty situation. Unless you have unlimited resources to treat everyone, victims will have to be triaged.  Triage comes from the French verb trier–meaning to sort–and classically we think of three triage categories: 1) those victims so gravely injured they will not survive regardless of what you do; 2) those who can probably be saved if the right things are done quickly; and 3) those with lesser injuries who may be in distress but who can obviously wait (i.e., the walking wounded). 
 Battlefields have always been the crucible of innovations in trauma care, and indeed the modern concept of triage dates to the Napoleonic Wars of the late eighteenth and early nineteenth centuries.  The individual credited with inventing it (as well as field hospitals and fast-moving ambulances manned by trained individuals) was Dominique Jean Larrey, the French emperor’s surgeon-in-chief. 
 Partly in response to 9/11, disaster medicine is now an actual specialty unto itself, with post-graduate fellowships and board exams.  Because of this, triage grows into more of a science each year as we evolve ever more sophisticated rating scales based upon injuries and vital signs to help providers make those fateful decisions about whom they will race to save.  
 The person assigned to triage duty must be trained to rapidly differentiate hopeless cases from those who might be saved, Typically, that individual will attach a color-coded tag alerting the rest of the team to the patient’s category, and will also perform immediate life-saving maneuvers including the control of external bleeding, needle decompression of pneumothoraces (collapsed lungs), the insertion of mechanical airways, the initiation of field IV fluid resuscitation.  But more often primary triage involves deciding who must be transported to the hospital first. 
 When a mass casualty event occurs, hospitals switch into “disaster mode.”  Carefully worked out plans involving the assignment of crisis team roles and the mobilization of additional staff–all practiced in regular drills, lest we become complacent–are activated.  Hallways and lounges become triage and treatment areas.  Larrey would have been impressed.
***********************************************************************

Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

Drug Abuse in America: Part 1/3

/ Jordyn Redwood / Leave a comment

Dr. Edwards is here for his monthly post and I thought his topic of choice was very timely. He sent me a piece on dealing with chronic pain patients in the ED. This is a problem for every ED… including pediatrics.

In the past two years, I’ve been shocked by the number of chronic pain patients we are seeing in those under the age of 18. If you’re writing an in-depth novel with an ED worker in the center, this is one area of conflict you could explore.

How do we deal with these patients? Is there a component of drug addiction in this patient population? To say no for all cases would not be the truth either.

I think this trend bodes for some introspection on all of us. Here is Dr. Edwards post. On Wednesday and Friday this week I’m going to explore this topic more in depth and why there might be such an explosive prescription drug abuse problem in the US… and believe me… there is.

Desperately Seeking

Frank J. Edwards, MD

I hadn’t been practicing emergency medicine very long when I saw this particular patient, a thin woman in her mid-seventies wearing an old fashioned lace-collared evening gown.

“Doctor, I’ve passed another kidney stone,” she said.

My mind’s eye narrowed.  Was this a narcotic seeker?  Kidney stones are like white-hot ice picks thrust into one’s flank and violently twisted, over and over again.  Marine drill sergeants cry with kidney stones.  But there she sat smiling.  I was young.  Did she take me for an easy mark?

“Oh really,” I said.  “Are you looking for some medication, ma’am?”

“Heavens no,” she said.  “I thought you might like to see it.  I have these things all the time.”

“See it?”

Out of her cloth handbag, she fished a chunk of coarse roadbed gravel and plopped it in my hand.  Driving in the hospital entrance that muggy Sunday morning I had noticed a pile of similar stone.

“You can keep it if you like, doctor,” she said.

Since then, I’ve seen hundreds of patients feigning illnesses, but unlike the lady of the road gravel, they definitely want something more than the smidgeon of attention and sympathy she needed.   They may have headaches, back spasms, abdominal cramping or severe pelvic pain, but kidney stones do remain a common theme.  And, unlike her, they come in writhing and wincing.  When asked to give urine, they may prick their fingers and squeeze a drop of blood into the sample so the dipstick comes back positive. 

The typical drug seeker will have a genuine history of a disease characterized by recurrent episodes of agonizing pain.  Along with kidney stones, such conditions include migraine headaches, lumbar disc disease, fibromyalgia, inflammatory intestinal disorders (Crohn’s disease, for example), and pelvic problems such as endometriosis and interstitial cystitis.   Thanks to the powerfully addicting properties of the narcotics used to treat their pain, a handful gradually awaken in the labyrinth of Morpheus, from which escape is very hard.


These patients generate a swirl of negative emotions in healers.   You want to give everyone the benefit of the doubt, but you do not like the sense of being manipulated.  You do not want to reinforce their addiction, but on the other hand, you understand they are suffering.  You just do not really know how much of the suffering is physical pain and how much is . . . whatever.   And, Lord help the healer who pigeonholes a drug seeker and misses something disastrous.  Drug seekers get sick too.

So you examine them carefully and maybe run some tests, and you look for the usual clues.  Drug seekers often frequent many local EDs.  They’ve had multiple work-ups that never reveal anything new.  If you are blessed with the ability to look up records on the Internet (an innovation which can’t come too soon), you may discover they were in the ED at a hospital down the road just last week and neglected to mention it.   They are allergic to all the non-narcotic pain relief options and they know exactly which agent on the menu works best.  They demand the dose IV and require amounts that would kick most opiate virgins into a coma.
  
I know some healers who pretty much give in and give the drug seeker whatever he or she wants just to sweep them out quickly, and who may even discharge them with substantial prescriptions for more narcotics (a real mistake).  Other healers get angry and point to the door immediately.  Most of us are in the middle somewhere, but it is never a happy situation.  At some level, you feel like a drug dealer.  I assuage my conscience by counseling them on the dangers of secondary addiction, and try referring them to pain centers.  I’ve also stopped calling them drug seekers.  They are chronic pain patients until proven otherwise, which removes some of the tendency to pass judgment.

Regarding the danger of cynicism, not long ago, a doctor going off duty passed me a back-pain case.  His plan was to give this young man a single shot and send him packing in the hope he wouldn’t darken our doorway again.    The patient had admitted to visiting an urgent care center the day before and had furthermore confessed to heroin abuse in the past.

Slam dunk drug seeker, right?   Wait a minute.  How many of them volunteer a history of heroin abuse?  That’s either a pretty dumb drug seeker, or a rare instance of honesty.   I sat down and listened to his story, got a sense of his personality and observed the concern of his girl friend.  Then I re-examined him and ended up ordering a CT.  The next morning he had surgery for a severely herniated lumbar disc. 

Then, there are the true professional patients—few in number and slippery—who ply their ailments to score drugs for the street trade.   One patient I recall from many years ago made a circuit of EDs from Florida to Virginia.  He had a draining bone infection—chronic osteomyelitis of the tibia—from a motorcycle accident.  If he took his antibiotic, the wound would start to heal.  If he stopped taking his antibiotic, the wound would boil and drain pus.  He could literally shut it off and on like a faucet.

It was very hard to argue with such an ugly wound, and he reeled me in like a catfish on Valium.  Until I saw him again a few months later at an ED on the far end of North Carolina.  With a different name.

*****************************************************************************

Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.

   

Welcome Dr. Frank Edwards!

/ Jordyn Redwood / Leave a comment
I’m so pleased to announce a new monthly guest blogger to Redwood’s Medical Edge. Dr. Edwards is an emergency medicine physician and will be adding a wealth of information concerning adult ED medicine. I hope you’ll take the time to check out his medical thriller, Final Mercy. Welcome, Dr. Edwards!
Cracking Joints
Frank J. Edwards, MD
You’re coming down a set of steps and become distracted, or you’re jogging and don’t see the pothole, or you’re playing soccer, or maybe you’re strolling in the park at dusk, when suddenly an ankle you’ve always taken for granted painfully twists inward and you hear a snap.  Next morning, the outward (lateral) side of your ankle is swollen and bruised, and weight bearing is not a happy experience.  Surely, it is broken.  You even felt the crack.

Ankle injuries are among the most common presenting complaints to emergency departments and urgent care centers.   The ankle is a very flexible hinge-type joint, held together by ligaments and mainly designed to flex upwards and push downwards when we ambulate.  It also allows for inward and outward movements (inversion and eversion) and even some degree of rotation side to side.  Every joint has inherent weaknesses, and the ankle’s Achilles’ heel (so to speak) is excessive inversion.  In other words, it does not take much force to twist the ankle inwards beyond its structural limitations.  Reach down and check it out.   When this happens, the ligaments on the outside (lateral aspect) of the ankle will stretch and tear, or sometimes even rip off a sliver of bone.   By definition, this is a sprain.  However, given enough force, the same mechanism of injury can cause true fractures, sometimes even severe enough to require surgery.

The vast majority of ankle injuries, however, do not involve broken bones and are completely healed within a week.  The question is—when do you need an x-ray?  Fortunately, we have some good research to guide us, something called the Ottawa Ankle Rules (thank the cost-conscious Canadians for this one), which that allows us to predict the likelihood of fracture. 
Basically, the Ottawa Ankle Rules say that: 1) if the patient was able to bear weight right after the injury; 2) if there is no tenderness to pressure over the tip of the fibula (the bone running down the outside of the lower leg); 3) if there is no tenderness over the base of the fifth metatarsal (the outermost of the five long bones in the foot), and; 4) if the ankle is otherwise stable—the chance of a significant fracture is slight. 
When a patient meets these criteria, we can skip the x-ray for now.  Give the injured person a splint and crutches, and save tens of millions of health care dollars a year.  Many health care providers, however, are either unfamiliar with the rules or unwilling to disappoint a patient’s expectations that the visit is incomplete without some radiation.   Especially if the patient “heard it snap.”   However, in my years of ED experience, this sensation usually points toward a sprain.  It is like cracking your knuckles.
*******************************************************************************

Frank Edwards was born and raised in Western New York.  After serving as an Army helicopter pilot in Vietnam, he studied English and Chemistry at UNC Chapel Hill, then received an M.D. from the University of Rochester.  Along the way he earned an MFA in Writing at Warren Wilson College.  He continues to write, teach and practice emergency medicine. More information can be found at http://www.frankjedwards.com/.