Saturday, October 15, 2011

Times when a history is helpful

I have been here for 4 yrs now and find histories (the patient telling you what they are feeling, how long they have been sick, what events led up to their illness, etc) quite frustrating.  It is often incomplete and has huge gaping holes that just don’t match up with what I find on examination of the patient.  (I do understand that it is hard to ask people who have no concept of time outside of when the sun goes up and goes down to tell you how long they have been sick.)  So despite everything I was taught in medical school and residency, I tend to ask very few questions and base most of what I do on my physical exam and whatever labs and xrays I might get.  This is usually enough to steer me in the right direction to get the pt back on the road to health, but not always.

Today, we could have used a little better history.  As walked outside the OPD building, I saw a crowd of people fighting over open window space to steal peeks inside the ER.  I go inside to see what has drawn the crowd and see a lady covered in blood laying on our middle ER table.  Bill, with blood all over his hands, is assisting Lash, one of our anesthesia guys, in trying to place a tube in this ladies mouth to help her breath.  Jim is working to bring the suction machine closer to assist the intubation process by removing all the blood from her mouth.  Becky is doing chest compressions because not only is she not breathing, but her heart is not pumping.

The guys who brought her in, told us she was hit by a car – so we were all thinking head injury and were working in that regard.  Once we started breathing for her through the tube, I was reassessing her heart when I noticed blood was running down her arm.  A further inspection revealed a 1 inch hold in her back, that was bleeding A LOT.  (For those of you who don’t know car accidents don’t usually cause this type of penetrating trauma, so once again our history failed us).  We quickly worked together to put a tube in her chest, get blood and another IV going, do a further assessment of other injuries, and kept doing CPR to try and get her back.  20 minutes later, we thought we were going to have to say sorry to the family, when the ultrasound revealed her heart was working again.  Praise God.  She wasn’t out of the woods, but this was a good sign. 
Someone else came and was able to give us a more accurate history that she was actually stabbed by the 2nd wife (her enemy wife) outside our station at a little market.  Her bleeding slowed down after the tube went in, her heart beat came back, she started breathing on her own, and things started going in the right direction as life saving blood was going into her.  Unfortunately, whatever vessel was tore and had bled initially started bleeding again as she seemed to be coming back to us.  Despite another valiant attempt to stop the bleeding and save her life, we were unable to do so and she passed away.  The instant we removed our hands from the body, the family was wailing and crying in the ER showing their grief at the loss of their loved one.  Jim asked if we could pray for them and they allowed us to have a time of prayer before the wailing restarted.    

Would an immediate accurate history have changed the outcome?  I doubt it, as we still had to try and do the ABCs, as we say in medicine, which is what we were working on with helping her breathe and getting her heart going.  However, an accurate history, every now and then, would be helpful.