If a Tree Fell in a Forest...

Mrs. B fell at her home 5 days ago. She was brought into the Emergency Department after a neighbor found her lying on the kitchen floor - she had failed to show for church bingo the night earlier - she had not missed that in 9 years! The paramedics brought her into room 13 on a gurney, she was still wearing her nightgown from the night of the incident. Mrs. B explained that she awoke the night of the fall to get a glass of water in the kitchen and tripped over a rug, landing on her right side. At this point she realized she was unable to get up. Mrs. B was rather overweight, and resorted to rolling on the floor to try to get from point A to B. Her first destination: the phone at the other end of the kitchen - once she arrived at the counter it rested on, she was unable to reach it. For the next 5 days she lay on the floor scooting around with what little strength she had in her legs. “I have one bad leg, so when I would try to scoot somewhere, I usually ended up going around in circles.” When she had to go to the bathroom she went. She resorted to eating dry rice from the lower floor cupboards. She had to ration water from her cats bowl - in fact they fought each other for it. It is truly amazing the personal tragedies people face on a daily basis - and many of us are completely unaware.
When she came into the Emergency Department you can imagine her condition: she was disheveled, covered in feces, urine, and was mildly hypothermic. We examined her thoroughly from head to toe and discovered that, fortunately, she did not injure herself from the fall. Now it is bad enough to be severely malnourished, dehydrated, and cold (each of these topics could be their own essay), but the real and much more sinister threat to her health was what was occurring deep in her muscle tissues, blood, and kidneys. After cleaning her, changing her clothes, and giving her warm blankets, we inserted a catheter into her bladder to help her urinate. She was too week to walk to the bathroom. After the catheter was inserted we were surprised to see what came out - a thick viscous maple syrup-like sludge began oozing into the tubing. Her body had begun to break itself down. After lying on the ground for 5 days, Mrs. B had crushed her muscles under her own weight. Her muscle tissue began to disintegrate - flooding her blood stream with toxic levels of muscle by-products, and clogging her kidneys.
Rhabdomyolysis (Rhabdo for short) is the term for the breakdown of muscle tissue leading to acute renal failure, or the inability to produce urine. The main building blocks of muscle - creatinine kinase, and myoglobin flood the blood stream and literally clog the kidneys with sludge. This event most often occurs after crush-type injuries (such as lying on a hard floor for 5 days), strenuous exercise (yes, we have seen this condition in people who start a new exercise regimen), electrical burns, and ingestion of certain chemicals. Growing up in Colorado Springs near the Air Force Academy, my father would tell me stories of treating soldiers who would march 50-100 miles a day during basic training. Many would come to see him the day after with severe muscle pain and coca-cola colored urine. Excessive myoglobin from the muscle turns the urine a dark coke-like color. They called it March Myoglobinuria, another name for rhabdomyolysis.
The diagnosis of rhabdomyolysis can be made both clinically (by the history you obtain from the patient), and by laboratory analysis (checking blood levels of creatinine kinase, and the urine for myoglobin). A normal creatinine kinase level in an adult is 20-170 International Units/Liter of blood. Mrs. B’s level was 20,000! That is the highest level I have ever seen. Her urine was flooded with myoglobin accounting for its dark color. Her condition was no doubt worsened by her dehydration. When treating rhabdo, you want to protect the kidneys as much as possible. Anticipating such a condition, we immediately began giving her intravenous fluids. In order to help clear excess creatinine kinase and myoglobin from her blood stream we administered a drug called Sodium Bicarbonate. This drug is a very strong base, and helps to alkalinize the urine (make it more basic versus acidic), thus helping the kidneys to clear the toxins (who figured this stuff out?!).
After 3 liters of intravenous fluid, and Bicarbonate, Mrs. B’s urine began to lighten, and flow more freely. Surprisingly the rest of Mrs. B’s lab values were normal. We admitted her to the hospital for continued hydration, and physical therapy to help with building her strength. I am never ceased to be amazed at our ability to treat any person, with any type of condition, no matter how obscure, that comes into the Emergency Department and that we as humans have figured out how to treat it. What is more amazing is that for 5 days Mrs. B lay alone, cold, and in dire need of help and we had no idea.

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Another Late Night

In the days following my last post I have worked successive night shifts. I even voluntarily switched into someone's night shift to keep my string together. Today is my first day off so I went to a party with my sister, a party that ended long ago, bringing me to my topic sentence. I can't sleep. As a result of last week's schedule only a raging party would have made me feel normal. Because I am a doctor I even have a label for my problem: shiftwork sleep disorder.

Definitely, there are downsides to my personal life that never occurred to me until this week. For example, being awake when everyone is asleep (though it does give me a chance to catch up on email and do some writing). And, being asleep when everyone is awake--I've seen less friends this week working 60 hours than working 90 hours in internal medicine. Also, there is the switch between nights and days that feels like a flight from New Delhi to San Francisco International Airport. That is a trip I wouldn't make on a weekly basis no matter how much I love my grandparents.

More importantly, shiftwork syndrome could potentially affect patient health if I don't manage it well. At least I'm in the right place to seek help. Our former residency director Rebecca Smith-Coggins has done several studies on the sleep habits of Emergency Physicians. In one such study she showed decreased performance during night shifts. After all, the accidents at Bhopal, Chernobyl, and Three-Mile Island all happened between 12am and 4am.

I could write a daily blog on the negative biologic cascade that may have led to these disasters but a good treatise already exists. In short, it comes down to not cooperating with our circadian rhythms which are programmed to operate on a more regular 23-26 hour cycle. Not only is our level of arousal associated with a regular pattern but so are gastric secretions, hormonal levels, sexual arousal, social behavior, anxiety, and metabolism. Circumventing the forces of nature is always a tricky endeavor. For this reason I try not to compound the problem by relying on pharmaceuticals as sleep aids.

One idea that rings true to me is the planned nap proposed by Dr. Smith-Coggins. Despite the fact that she showed an improvement in performance when this was implemented in her study, it just always seemed like a good idea at every job I've ever had. Other strategies include good sleep hygiene. That is, keep the bedroom for sleeping not work, follow regular habits around bedtime, reduce stress, and seek social support.

Don't get me wrong; I'm not trying to lament my life--I love emergency medicine. But sleep disturbances seem to be exponentially expanding from the invention of the light bulb to our rapidly expanding global economy. It is a health issue worth taking seriously.

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Not Every Case is a Trauma

Today, a woman came to the ED with a chief complaint of elevated blood pressure. She checks her blood pressure every morning and it hovers around 130/90. But after a stressful day at work and having not checked it in the morning she visited a friend who also had a home blood pressure machine, checked her blood pressure, and was terrified to discover it had reached 170/100.

This case was an easy one for me. And, sometimes I look forward to those easy ones during a busy day. I think we all do.

Blood pressure rises with stress and anxiety. A one-time reading above baseline is nothing to get worked up about, and getting worked up about it just makes it go even higher. We only treat elevated blood pressure when it is also associated with other clinical problems such as stroke or vision changes. That usually doesn't result from one high reading. In fact Franklin Roosevelt was known to be travelling around the country with a blood pressure consistently above 250/150. There are long term consequences to this that require lifestyle changes and medical management but nothing we will do in the ED. The hard part was making the woman calmer. Her blood pressure did go down to 130/90. Now that's an effective treatment.

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