ER: concluding with bubbles

Well, in the end I know this program is somewhere I want to do my residency. I feel like i know these people and this place so well that I could function here.  But when I left this rotation, I had to take a 30 question quiz that I did not do well on.

However, I did see this amazing case. Something great to remember them by.  It was a rare slow day in the ER and I was desperate to see something anything, because being idle means I have to think about that stupid quiz and what that'll mean for my chances getting in here. So finally EMS calls and reports they are bringing in a patient from an unknown trauma with unknown injuries. This report is... at the very least vague and unusual. So I decide, I'm going to take this case with the resident.

44yo M comes in on a stretcher,  he is awake and has blood on his head. EMS still doesn't know his story or what happened, they picked up from an apartment building. They couldn't find blood or heavy objects or any clues.  So we go all out, like back in my days of trauma service, priority #1: find out what happened.  We get whole body xrays, CT of the brain, STAT blood work, and begin cutting off clothes and asking questions.  The patient answers questions, but he seems not to remember what happened or who called EMS, and he also seems a bit off.  Either he's had a significant head injury or he is mentally delayed. Everyone is rushing around listening to patients heart and lungs, looking at lab work and xrays, when I do something that nobody has really done yet.  I touch the patient.  Just on his shoulder, skin to glove. I meant it to get his attention to ask more questions, but something is off.... his skin feels strange. I put my other hand on his chest, then quickly run my hands down his arms, abdomen, and legs.  Its everywhere. What is this?  I call the resident, feeling stupid because I can't explain what i feel.  It feels like bubbles, like that plastic bubble wrap you put in packages, only the bubbles move when i push on them.  The resident looks at me like I grew a second head, but since he's been working with me for a year now, he does something I don't expect.  He believes me.

He gets into the room and starts feeling the patient, yep he feels it too. Soon he calls the nurse and everyone outside looking at grey swirls of brain tissue on CT to get in here. The patient is being gently mauled by hands feeling all over his skin. and sure enough the CT shows it: MASSIVE airpockets all throughout his body.  They aren't just under his skin like we thought, they are between his muscles, around his heart, around his fat cells, and even in some organs.

This case was just so crazy, that i did steal this very illegal CT photo for you.  Its the actual guy.  Now subcutaneous air pockets can happen in patients who perforate a lung or intestine. But usually its located only in one area. The amount of pressure it takes to put air in our tissues is vast. Air outside of the GI tract or lungs is called "free air" and always a warning that the person will be on the operating table within hours. It is often the first and only indicator of something life threatening. But even the surgeons stared at this guy in awe. There were no holes in any organs they could find, but the air was everywhere. They couldn't take him to surgery because we didn't know where it was all coming from. The first theory was that it might be from a rare condition called Boerhaave's syndrome, which is a rupture or complete tearing of the esophagus.  This is life threatening and is rather rare.  The problem is we couldn't find the tear in the esophagus with the CT.  So, basically nobody knew what to do with him.

While the trauma surgeons were calling every specialist in the hopsital looking for possible other answers, we as ER were trying to come up with a way to fix his symptoms. He had no head injury and no fractures. Besides there air and abnormal but confusing lab results we had nothing to go off of. Usually for air in the body we cut a hole to let it out, but  making tiny incisions in the skin whereever there was a bubble was just assinine, he wouldn't have skin left!  So in the end we admitted him, put in chest tubes to relieve air around his heart and lungs, left a tiny air in the middle of his belly and admitted him. The surgeons told us they would be doing special studies that day to see the esophagus and make sure that wasn't the cause.  And they took him upstairs.  I never did find out what it was.... as is the true spirit of ER. :)  What a send off.... i got to conclude my month with bubbles.