Necrotizing Fasciitis!! or maybe just Cellulitis…

“Nec Fasc” is one of those diagnoses in medicine that makes surgeons sweat bullets, ER docs pump antibiotics like firehoses, and sends interns screaming into phones to set up emergency surgery STAT.  We had a patient where this was a concern, he’d let it go due to the fact he was sooo close to finishing Hellweek as part of his SEAL training- and he made it!  But like most guys I’ve seen from this training, they are so cut up, beat down, and pushed so far past their limits you just have to sit back in awe at what they’ve done to their bodies.  Stress fracture?  That’s nothing!  Pneumonia?  Who cares!  Keep going!

Anyway, I got a few key pointers about telling the difference between nec fasc and cellulitis.  These are just things someone educated me about, I didn’t pull this from the 7th edition of a textbook or a randomized controlled double blinded study,  so take it for what it is.  Cellulitis is MUCH less concerning, though also usually requires hospital admission with antibiotics and can also be devastating in the long run.  So here were a couple physical exam pointers that can either raise your blood pressure or calm those 4 AM frayed nerves:

1.)  Erythema:  Present with both, but in nec fasc the infection in the fascial plane spreads faster than the erythema above it.  Therefore, patients often complain of pain beyond the erythematous border.  In cellulitis, pain is typically only present over the affected skin.

2.) Palpation: If there’s crepitus, think nec fasc.  I’ve felt crepitus before (from a botched chest tube placement) and it seriously feels like there’s crinkled cellophane just below the surface of the skin.  Others have described it as rice krispies, which is also close.  It actually feels like popping and snapping when you press down!  Lack of crepitus doesn’t rule out nec fasc though- it can still be an emergency situation if all you feel is the classic hot, swollen, painful skin.  Remember it depends on the organism causing the infection…

3.) Vital signs: Tachycardia may be the only change.  Especially in young, healthy patients (like in the military population) their body can compensate for infection for quite a while.. until a sudden crash that was unanticipated lands them in the ICU.  On exam, patients can appear to be doing well, but don’t let that fool you!  All that “badness” growing at exponential rates will hit a threshold the body can’t handle… and then you’re dealing with full blown Shock.  No thanks.  Watch your vitals carefully!

4.) Labs: Obviously infection will make your white count go up.  However, in the experience of most residents I’ve spoken with, ned fasc will raise it dramatically and usually above 35.  Of course, it depends on the time of presentation and immune status of the patient but if the lab starts calling you with critical values, that might be a sign that something critical is happening.

With the SEAL I saw, when I evaluated him in the emergency room, I drew a line at where the erythematous border was though he was already receiving antibiotics.  Being on ortho, I was there to rule out compartment syndrome (due to pain out of proportion to exam) but I quickly ruled that out since the skin was pretty soft.  Surgery decided to take him to the OR, where I saw him 1.5 hours later and was astounded at how far past my markings the erythema had progressed!  He had alredy received about 5 different IV antibiotics and still the infection was advancing.  In some places, it was almost an inch.  Holy smoke Batman!!!

The surgeon made an elliptical incision over where some new petechiae had shown up on the skin, often being a clue as to where the worst underlying infection may be.  I heard him teaching the resident that (only read on if you’re a surgeon or have a strong stomach) …. if it’s nec fasc, expect “dishwater discharge” when making the incision.  When palpating the fascia, run your finger up and down the incised areas and if it’s intact, that’s good.  If it breaks apart as you push, that’s bad.  That’s when you being the unzipping process and debride, debride, debride.  Then drink a couple RedBulls and Rockstars because you’re not going to get any sleep on the frequent post-op checks.

My patient did not have nec fasc, in case you’re wondering.  They just did the 2 elliptical incisions, packed and left them open, and kept pumping him full of antibiotics and fluids.  Phew

 

Dirtbikes cause fractures: Pelvis and Scapula

This is the second call I’ve gotten about fractures and dirtbikes.  The first was someone I saw who raced up a sand dune only to find the back was not there.. and he fell 20 feet onto his bike, fracturing his pelvis- which is a hard thing to do!

Today I saw a scapular fracture, it was a guy who went over his handlebars and now can’t raise his arm above his shoulder.  Apparently this is expected after fracturing your scapula.  Treatment for a fracture that’s still relatively lined up (non displaced) is to just keep it in a sling for a few weeks, but keep flexing the elbow so as not to lose muscle tone or develop any other disuse symptoms.  After 3 weeks, having someone move the shoulder (passive range of motion) should help regain strength in the shoulder.

Surgical indications are if the fracture is displaced, involves the articulation with the humerus, and some coracoid process fractures.  As I got sent home sick today and am miserably typing from my couch and don’t have the energy to look in my Handbook of Fractures, I can add more later.  Right now I’m going to blow my nose and take a nap instead.

…. The only thing I thought to add is that I’d like to try dirtbiking some day.  Seriously, no sarcasm!  I accidentally got my ninja on some sand, it freaked me out for a sec when it fishtailed and I worried about how junky my chain would get but if I had a dirtbike I bet you could take some badass curves and the lack of roadrash would be a plus!

 

On call- Fractures! Compartment syndrome!

The fun thing about being on call is when you realize you don’t care that this patient has kept you from getting sleep, it’s the coolest case ever!

We had a patient come in just as my resident and I had tidyed everything up, seen and written notes on 3 broken arms, done our post-op checks, and had already said “goodnight, hope we get some sleep..”  Just as we were exiting the elevator, the emergency room number pops up     But when I saw the X-ray, that frowny face turned into a smiley face!!  (Did I mention I love trauma?)

It was a fracture known as “comminuted” because there were a bunch of fracture lines creating multiple pieces of bone . Because the limb was turned at an obviously weird angle, we gave a mix of fentanyl and propofol for pain control, brought in the fluoro machine ( live x ray vision!) and had our plaster splint on standby.  Then we pulled on it to straighten it out, which is known as reducing the bone.  Given the past reductions I’d seen, I expected to have to really tug hard to get the pieces back together. Instead, it moved almost too well!  I guess when you have bones in that many pieces you don’t have to force it.

The only thing is, I recently saw a patient who had a lot of muscle taken out of his leg after a fracture that led to “compartment syndrome.”  When this happens, the swelling gets so bad that you cut off blood supply to a bundle of muscles within that compartment.  The fascia and skin create an almost tourniquet-like effect and the muscle can die within 24 hours.  Because this new case was so severe and had so much swelling, I was really, really worried that this fracture might progress also.  On admission I placed orders for neurovascular checks every 2 hours to make sure there were still pulses and sensation beyond the fracture site but still went to sleep biting my nails…

So, I learned a little bit and was able to expand my knowledge on the classic compartment syndrome’s “pain, pallor, pulselessness, parasthesia, and pain out of proportion”  Though the compartments were really tense from all the swelling, it wasn’t compartment syndrome.  I hear it’s pretty obvious when you find compartment syndrome on physical exam (the leg/arm will feel like a block of wood.  Really!) But it’s scary nonetheless when you see such a severe fracture with so much swelling!  I’m glad I had someone there to tell me NOT to do a fasciotomy, if I was in the middle of Afghanistan on my own and this happened to one of my marines….I still would have waited but I’m just glad everything turned out ok today

… 1 week later…. After I left post-call, I heard that they did end up taking this patient to do a fasciotomy, but no muscle tissue seems to have been compromised.  Compartment syndrome is a clinical diagnosis, though you can use a Stryker compartment pressure machine to get actual numbers.  This is used more in exercise-induced compartment syndrome because patients will occasionally consent to having long needles inserted into their muscles for this kind of evaluation.

 

Things I learned today

As I no longer eat dinner with the nuclear family and have the question put to me by my parents “so, how was school today?  What did you learn?”  I thought it might be a fun experiment to post something to that effect on this blog.  Today was a learning-filled day, here are a few:

1.)  Blummensaat’s line: A radiographic landmark of the knee at 30 degrees flexion, a line drawn at the distal femur’s cortical line that should extend out inferior to the inferior border of the patella.  If the line intersects the patella (and the insall-salvati ratio is less than 1.0) you suspect patella baja, and thus a quadriceps muscle rupture.

2.) Anyone who tells a hospital-admitted marine recruit (who has never gone through MC training himself)  anything to the effect of “Do you want a straw?  Suck it up!” is a complete tool.  TOOL.  Just because you’re a pudgy navy officer doesn’t mean you should be a jackass to an injured recruit.  Please, I saw you almost die at the end of a 1.5 mile run….

3.) Knowing I can easily find parking within 1 block of a downtown bar with my motorcycle has greatly improved my outlook on socializing downtown.  MUCH less anxiety about the anticipation of frustration with parking and circling and fighting over pavement and scoping and tailing people down the street and shelling out $20 because of a Padres game and etc.

 

Senioritis

Now in my last full month of medical school, I am finding it easy to deal with my lack of motivation. When I started my clerkships a year and a half ago, I worked my ass off. I kept working my ass off all year… and along with my fellow classmates, discovered through the joy of standardized evaluations that practically no one notices. Sadly, this is the way it tends to be and so you discover how to work less and yet learn the same amount.

My rotation now is awesome and I’ve learned a ton (which is mostly stuff I’ve learned and forgot!) I know for a fact that once I start my intern year I’ll be jump-started into being a workhorse again and much more responsibility will be placed on me. Knowing that, it’s validation for spending my free time between patients searching for cheap flights to Europe, sending messages through Facebook, or even posting this blog. Oh, bless the person who put Mozilla on the hospital computers…. Fourth year rocks!

Amendment:  I felt kinda guilty being almost too honest and telling it like it is about how fourth year goes, but I now have to rephrase that no one notices… after reviewing my fourth year grades, it seems like people do notice!  Maybe only now on more close-knit rotations where you get daily interaction with attendings and they know you want to be there (versus doing required clerkships!)  Someone once told me in college that if you’re not getting good grades your senior year, you picked the wrong major.  If I apply that to medical school, then I’m right where I should be.

 

iBuenas Noticias!

The only times I ever wake up before my alarm clock goes off are the nights I am super stressed out. So when I woke up a full half hour early this Wednesday, I wasn’t surprised… it was possible I might find out where I would match!!

There are 2 air force med students here in Bolivia staying at the house who got an email Tuesday night announcing the list would be out at 5:30 AM CST. I didn’t get an email like this from the Navy, but had heard a rumor (through Facebook, no less) that we might find out at 9 or 10 AM. That morning, I sat at the kitchen table watching the other students nervously fidgeting and clicking “update” on their email every 4 seconds. Finally the list was up, they were on their feet scanning the pages, and “YESSSS!” they screamed in unison. But I had to wait until later…

As we had to work in a rural clinic that day, we drove out 2-3 hours into the Bolivian rainforest and saw patients who came in from the nearby pueblos. When clinic was over, a few of us drove an hour to the nearest internet cafe in Buena Vista, Bolivia. Just off the town square is this tiny, hot, steamy room filled with local boys playing video games. After getting a computer, opening my email, and initially missing the GME-1 email amidst the junk I received, the match list was slowly…slowly..slowly downloading. Then it aborted and an error message popped up in spanish.

With my heart pounding and hands shaking, I actually consider opening up Facebook to read the messages on my wall which may actually tell me where I’ll be next year. A little girl in the cafe tries to peer around at the screen as I’m unconsiously saying “Oh my gosh… oh my gosh…” as I’m wringing my hands with nervousness and sweat is dripping down my neck.

Deferring to Plan B, I log onto the Navy GME-1 site and enter the password. The page slowly begins to load…the circle at the right top hand of the screen swirling away… and just as someone behind me offers a suggestion, a list of names with locations pop up. I gasp and hear nothing else as I punch the down arrow quickly but scanning carefully so not to misread the “Crawford, Leslie….” that should scroll up any second. Before I have time to register that next to my name reads “… Transitional Year, San Diego” I am already out of my dirty red plastic chair, screaming and literally jumping up and down.

The other med students and doctors from the clinic high-five me, give me hugs, as I see the street vendors gaping at me through the open garage-type door. Later I was told that one of them asked our clinic coordinator

“What’s going on? I just about had a heart attack!”

“Good news from home.” she responded.

“Oh! Is she having a baby?”

I am totally oblivious to this as I’m grinning and still jumping up and down and realize that I’m so happy I can cry… and I did tear up a bit! I am soooooo sooooo lucky!!! Barely catching my breath, I compose myself enough to sit down and see where my friends matched, write off a few quick emails before my computer time runs out, and then call my parents with my phone card.

The rest of the day I spent glowing and squealing with disbelief about how awesome this is and how lucky I am that I actually matched in my first choice!!! Then the other med students and I toasted with some Cuban rum and coke (a.k.a. Cuba Libre) and watched telenovelas. Though I wish I could have spent it in the USA so as to be able to call friends and family and celebrate properly, the knowledge alone that I will be moving to San Diego next year made it one of the happiest days I have ever had in med school.

 

The Great Dismal Swamp

Now I’m across the country in Portsmouth, Virginia. The Great Dismal Swamp is one of the best things ever out here! It’s an old highway that was converted into a running/biking/horseback riding trail next to this huge swamp preserve. When I initially flew in last Monday, I figured out pretty fast that the hospital seems to be about all there is to see in Portsmouth. I also didn’t know where to run (at this point, I still haven’t explored Norfolk or Virginia Beach) but then I got some advice to run at this Dismal Swamp place. Though it’s kind of a drive, it’s worth it!

I have to admit that my running schedule suffers from a serious lack of consistency on my part. I’m being lazy!! Also, any time I run more than 10 miles my left calf starts to tighten up. I’m halfway between allowing it to rest and giving in to my procrastinatoriness. But I just signed up to run the Fleet Week 1/2 Marathon this weekend so I know I have to run that at least. Not fast, but it will be nice to run with refreshments along the way!! (the dismal swamp has noooo water fountains…the only downside)

At the hospital, I’m working in the emergency room which is awesome!! I’ve worked a few evening shifts so far and have seen some cool stuff, worked with awesome residents and attendings. I have to say, it is very different than working in a westside Chicago ER… no walk in gunshot wounds yet The pressure’s getting a little more heated with additional interviews and letters of recommendation and the selection process getting started. I’ll be matched in 2 months! TWO MONTHS AND I KNOW MY DESTINY! Well, 2 months and 3-5 days… I’m not nervous or anything…. of course not….!!!!

I had a few days off and drove up to Bethesda and saw some friends up there, which was wayyy cool. We had lunch at Fogo de Chao and then went to the Spy Museum. We had some drinks while watching the Yankees lose, and as everyone had to work the next day I just walked around downtown D.C. on my own until Nilsa got done with work and we went over to Georgetown for dinner. But I had to drive back for conferences and lectures today, plus I’m starting night shifts tomorrow. Gotta go stock up on Red Bull…

p.s. download the new radiohead album. it is awesome!!

 

Little nigglepoo

When I set out to run my 17 mile this week (which I pushed back for time constraints and also for having to skip some weekday runs) I had a tightness set in again in my left calf around mile 4. I was sooooooo mad!!! This run was out on Coronado, following the path up north that runs around the peninsula. I tried slowing down and stretching, which allowed me to run back to base and finish 9 miles. Then I ended up not running at all for 4 days because things got so busy as I was leaving San Diego. But today I ran an easy 3 mile and didn’t feel that nigglepoo whatsoever so I’m feeling optimistic about doing a long run tomorrow. My goal is to do 13 miles, then continue on if my calf is up to it.

Otherwise, I’m now in Chicago and missing San Diego!! Last night I was at a house party in Wrigleyville and with the Cubs winning something or other, fireworks were going off and everyone was blaring their horns. It definitely reminded me that I am now back here and conversations revolve around the Bears versus the Chargers, Cubs or White Sox versus Padres, getting to the Lake versus the beach. Also, I don’t know how I forgot how bad traffic in Chicago is, but I managed to and that made me love San Diego “rush hour” even more!! Plus, parking is just terrible here compared to San Diego… in suburbs, downtown, and Wrigleyville alike!

I’m flying out again to Virginia Beach on Monday for my emergency rotation at the the Navy hospital in Portsmouth. So, this weekend for me is just trying to fill out reimbursement paperwork, opening a month’s worth of mail, and walking around town while my car is in the shop. Fun fun fun

See, we can have fun in the hospital too! I had to wear that khaki uniform every day. And this is my resident, who graduated from Loyola too! That was a super fun rotation… Go Red Team!!

This is a few of us at an italian restaurant in the Gaslamp district. It was called Acqua 2 or something. It was yummy!  And sitting across from me is my girl Nilsa, who’s Puerto Rican and a kick ass salsa dancer

This was taken while driving over the Coronado bridge at dawn, looking out over to the 32nd street base. The USS Mercy is one of the ships to the back (although you can’t really see it with this lighting!)

 

Still in love!

I love San Diego.

I love being in the Navy.

I love being a sub intern.

So yes, my life is totally awesome right now!!  It’s crazy to think that this might actually be my future.  After 3 years of being around people who I have to explain my career decisions to, I am now surrounded by people who not only understand it, but support it and can give me invaluable advice.  The people I’ve met here are awesome.  The stories I’ve heard are awesome.  How many people in your field have gotten to practice all over the world?  Fly with the Blue Angels? Treat Navy SEALS?  It’s sooo cool!!  Oh, and the SEALS are staying at my base on Coronado and just got done with Hell Week.  Apparently that movie G.I. Jane is the closest to accurate!

Plus I’ve been having fun with the other med students, getting around San Diego and Coronado and going to restaurants, clubs, beaches, chilling out on the patio with a beer, etc.  One downside is that I’m staying in a dorm-style room with just a microwave to cook with.  And having to wear my khaki uniform everyday.  Today I had to park far away from the hospital and had to return salutes all over the place.  It’s kind of an inner groan to see a uniform walk towards you, since you have to squint at their rank from a distance and figure out if you salute first or if they’re supposed to salute you.  Since I’m an officer, and a majority of the Navy is enlisted, most of them salute me.  But when I was walking along and a huge group of Marines was getting out of a van right as I walked past…that was interesting.

As for internship interviews, I’ve had 3 so far and they were awesome.  I had to wear the Navy summer whites, the uniform you’ve probably seen in Top Gun.  They’re still stressful in that you need to have a CV and personal statement ready and you’re looking to impress.  But I think they went well!!!  The only downside is that the selection process in the Navy is undergoing a big change and everything is in transition and although it used to be like the NFL draft, the new system is so complicated I’m just crossing my fingers and praying.

As for my marathon training, I’ve done the long runs of a 15 last week and an 11 this past Tuesday, which was actually harder than the 15!  During the week I really only have 1 or 2 days to do an additional day.  Plus I’m keeping my social life a bit more active than my running life at the moment   I’m heading up to Ridgeland this weekend and will probably do some hiking, and I’m scheduled for a 17 miler on Sunday.  Though I was nervous about the 15 and did fine, I’m still a little nervous about the 17!  Not sure why, I guess I’m just not as familiar with all the routes and am constantly worried about getting water along the way, which is what makes the Mission Bay trail a great place to run.  And I’m hoping I’m getting the mileage right, I’m just running the mileage x10 minutes and assume that’s the full distance.  I probably should get a GPS thing…I should look into that.

This is a photo I stole that shows the bay, the bridge is going over to Coronado Island where I’m staying (to the right) and San Diego is to the left, with all those ships being privately owned.  But I thought it was pretty

 

LOVE San Diego. L-O-V-E.

So I flew into San Diego last Monday just in time to spend a couple hours on Mission beach/Pacific beach amidst the bikini-clad tan body crowd of college students and get a little bit of time in the waves before starting my rotation at the Navy Medical Center Balboa.  I’m doing a medicine rotation, basically acting as a sub-intern and taking care of active duty Navy people and their families.  It’s sooo nice to finally be working in this hospital!!  I’ve been wanting to work here as I’d heard great things and want to do my internship here but hadn’t actually seen the place.  The days can get long but my team is super cool and the nurses are friendly.  Everyone here is so polite and helpful!!  The only weird thing is I have to wear my uniform and do the saluting thing when I’m outside.  Thankfully you don’t have to do that indoors.

I’ve had the chance to do a couple things in San Diego like visit Coronado island and go out with other medical students for dinner and such.  Last night I went to the Gaslamp district for sushi (excellent!) although parking was a nightmare (much like Chicago).  Then we went over to a jazz bar in Pacific Beach called Turquoise which was really cool.  We walked along the beach at night and ran into some bums so that was fun!

But I’m here to work and hopefully make a good impression.  My running has kept up pretty well, I’m running on the boardwalk alongside the beach, which is incredible.  Last night I watched the instant the sun dipped below the horizon over the ocean while on mile 5 and the people lined up to watch the sunset applauded all in that moment.  I’m on call today so can’t do my cross training, which I think will consist mainly of jumping in the waves or surfing if I get the chance.  Tomorrow is my long 15-miler which I plan to run around Mission Bay after watching the Bears game.  If I survive I’ll let you know!

And by the way, I LOVE SAN DIEGO.

here’s a photo from my half last weekend!