When I was called to see the patient after a motorcycle accident I expected the worst. The patient sustained a thoracic spine injury with cord transsection at T5 level as well as significant chest wall injury on the right side.

Multiple ribs were broken; some with a significant displacement (see the upper image above). Managing patients with a significant chest wall trauma could be a nightmare. Pain control is only one of the challenges.

Mechanics of the respiratory mechanism is impaired. Patients often are unable to take a deep breath and fully expand their lungs. Clearance of the secretions is a concern as well. Many patients with severe chest wall injury succumb to pneumonia and respiratory failure.

To facilitate pulmonary clearance, improve pain control and pulmonary mechanics chest wall stabilization has become a practical option. The technique of realigning and stabilizing ribs with metal plates is yet to be widely adopted. I have witnessed on multiple occasions that the patients with a stabilized chest do better and recover faster then the patients treated conservatively.

I was surprised to see that the patient was, actually, doing Ok from the respiratory standpoint. He was describing that he could feel his whole right side of the chest shifting when he was being moved. Besides that, pain was not a major issue and his respiratory status, otherwise, was stable.

The explanation for this surprising “wellness” was not in any way satisfying. He also sustained a severe spine injury with cord transsection at T5 level. His sensory level was just below his nipples. The patient simply could not feel the pain from the chest injury.

In no way I can call it even a mixed blessing. Most of us would likely take severe pain over being paralyzed.

It did make me think, nevertheless, about the importance of pain control in these trauma patients. Huge doses of narcotics are often unable to control the discomfort. Epidural analgesia is frequently employed to alleviate the pain. Some centers even utilize pain control techniques like intercostal blocks to achieve analgesia.

This is the most unusual and bizarre cancer case I have ever seen.

69 year old female with no previous medical history presented to her gynecologist with vaginal bleeding. Pelvic ultrasound reveled an abnormal endometrial thickening. Endometrial biopsy confirmed the diagnosis of endometrial cancer.

The patient underwent uneventful laparoscopic hysterectomy and salpingo-oophorectomy. The post-op pathology revealed a surprise – in addition to the endometrial cancer the patient also had grade 1 ovarian papillary serous carcinoma.

A PET scan revealed areas of increased intake in the pelvis. Very shortly after the first surgery she underwent exploratory laparotomy and restaging including pelvic/periaortic lymphadenectomy, omentectomy and multiple biopsies. The final pathology – no cancer, just reactive changes after the first procedure.

Five weeks later the patient gets readmitted with abdominal distention and a sepsis like picture. CT abdomen/pelvis showed multiple abdominal and pelvic masses. CT chest shows multiple pulmonary nodules (see the images above). Broad spectrum IV antibiotics started. The patient was getting progressively worse.

The biggest question was: what were we dealing with? It would be unlikely for stage 1 endometrial or ovarian cancer to progress so rapidly just a few weeks after a complete restaging.

Some reports in the medical literature indicate that a laparoscopic approach for hysterectomy could promote retrograde dissemination of the cancer cells through the fallopian tubes into the peritoneal cavity. These concerns were not substantiated in the bigger studies.

The patient was taken back to OR for an exploratory laparotomy. Intraoperative findings – abdomen and pelvis are packed with cancer. The preliminary pathology – high grade sarcoma. The biopsy specimens were sent to New York to a sarcoma specialist.

The patient continued to deteriorate and Hospice care was initiated.

All the pathology slides beginning with the first surgery are going to be re-looked at and reviewed again. Regardless of what the final pathological diagnosis is, this is the most explosive presentation of cancer I have ever seen.

Dealing with an incurable illness or terminal condition is an inevitable reality of the practice of Medicine. Not uncommonly, especially in the Intensive Care Unit, we care for the patient with no chance for recovery and survival. Keeping that patient comfortable and allowing him or her to die with dignity becomes the priority of care.

Occasionally, I hear requests from the family members of the dying patient – “Can you give her a little something to…you know…make her comfortable and let her pass away quickly?”

Keeping the terminal patient comfortable is the purpose of comfort care. Facilitating or hastening death is considered unethical or even illegal. Physician assisted suicide or euthanasia is illegal in most states.

In theory, comfort care is quite different from euthanasia. Keeping the patient comfortable and letting the nature take its course is at the core of palliative care approach. Yet, the line between keeping comfortable and facilitating death is often blurry.

The same medications used to control pain and discomfort, primarily opioid analgesics and sedatives, could be used to “help” the patient to stop breathing. The concept of terminal sedation assumes death as an outcome of the intervention.

There are no standards regarding the amounts of medication that could be given for the purpose of comfort before it could be considered a “lethal dose”. Patients on chronic opioids, like many cancer patients, may develop tolerance to the medication and require very significant doses just to control the pain. In contrast, it might not require a lot to stop the breathing of an 89 year old with bad kidneys.

As one transplant surgeon in California found out, it is possible to get in trouble for trying to keep the patient comfortable before death.

Dr. Hootan Roozrokh was accused of hastening the patient’s death by administering large amounts of Morphine and Ativan. The incident took place in November of 2006. The prosecutors alleged that Dr. Roozrokh was hastening the patient’s death to harvest his organs for donation. Subsequently the doctor was acquitted of all charges. His defense was able to prove to the jury that the medications were administered to keep the patient comfortable.

The patient in the above incident had been on opioid analgesics and likely was tolerant to the effects of those drugs. It was very reasonable to assume that he required seemingly exuberant doses of Morphine just to control his pain and discomfort.

This case indicates that there could be a very thin line between what we consider terminal sedation and euthanasia. The purpose is clearly different – keeping comfortable vs. hastening death. Yet, in clinical practice, it is more of a continuum or spectrum of actions and outcomes. Often, it’s not all that difficult to cross that line.

According to the four seasons of trauma – summer is a motorcycle season. I am “fortunate” enough to live in a state with no mandatory helmet law. It is nice to know that my personal freedom of not protecting myself with a helmet is protected.

I do not ride a bike. I live on the opposite side of this issue – I treat patients in the trauma ICU. Not surprisingly, with the onset of warm weather we have had an influx of motorcycle trauma patients. A very recent encounter made me think about the helmet law, personal safety and the role of society to care for the trauma patients.

19 year old girl was admitted as a trauma patient with multiple orthopedic injuries including pelvic fractures and fractures of her lower extremities. The patient did not sustain any head injury and was neurologically intact. Her boyfriend let her use his helmet when they were getting on the bike. The boyfriend was pronounced “dead on arrival” due to an overwhelming head injury. Is it possible the he gave her a generous “gift of life” by letting her use his helmet?

This is an isolated encounter, though. It has a significant emotional burden, yet, speaking in scientific terms, is not "statistically significant”. One unfortunate death is not a “representative sample”. To find more meaningful data I delved into Ovid database to find the most recent scientific evidence. I was using terms “helmet” and “head injury” to narrow down my search results.

There was no lack of data. Multiple and multiple studies have shown that helmets do save lives and prevent severe head injuries. The evidence is simply overwhelming. One study found that helmets were 37% effective in preventing death and 65% effective in preventing brain injury.

It seems puzzling to me that we have a universal seatbelts law, yet only 21 states in the Union have a mandatory helmet law. You do not need to conduct a study to figure out that riding a motorcycle is far more dangerous than driving a car – there is no metal shell around you body, there are no restraints, either. Indeed, the federal government estimates that motorcycle deaths are about 35 times that for automobiles per mile traveled.

So, if motorcycle helmets save lives, why there is no uniform mandatory helmet law? Like many things in America, this is more a political than a policy question. In 1995 Congress lifted federal sanctions against states with no helmet law. Congress just could not stand the pressure of anti-helmet lobbyists.

One could argue that personal freedom and the freedom of choice prevailed in this case. What about common sense? If wearing a helmet is good for and not wearing one can kill you, we should see more motorcycle related deaths, right? The study conducted in Pennsylvania showed just that.

The Pennsylvania motorcycle helmet law was repealed in 2003. The helmet use among riders in crashes decreased from 82% to 58%. Head injury deaths increased 66%; non-head injury deaths increased by 25%. Motorcycle related head injury hospitalizations increased 78% compared with 28% for non-head injury hospitalizations.

It begs the question – what’s more important – the personal freedom of being stupid or the benefit for society as a whole from the decreased burden of motorcycle related head injuries?

For the purpose of keeping the post short the issue of the socioeconomic burden of the motorcycle related head injuries and helmet law will be explored in Part 2 of this post. Stay tuned.

With the advancement in healthcare and technology we are able to greatly extend the life expectancy of the population. For the healthcare provider that means that more elderly patients and patients with multiple chronic medical conditions are being admitted to the hospital. Some “complex” patients require a multidisciplinary approach with the involvement of multiple consultants.

As a primary attending physician for the patient you often have to deal with contradictory or even conflicting opinions from your consultants.

Sometimes, the decisions are pretty easy. For example, the patient who underwent a recent cardiac catheterization with the placement of a drug eluting coronary stent is being admitted with a massive gastrointestinal bleeding. The bleeding source is a gastric ulcer with a visible vessel. The gastroenterologist requested to stop Aspirin and Plavix that were given to the patient after the cardiac procedure. The cardiologist insists on resuming both medications as soon as possible to protect the coronary stent from clotting. Your role is to negotiate with the consultants the appropriate timeframe for resuming both medications. The timing will depend on the patient’s condition and the absence of further bleeding.

In other cases the management decisions might not be so clear-cut. A very recent encounter made me think about the contradictions in medical practice.

67 year old female presented with dizziness, nausea, left sided weakness and difficulty speaking. The clinical diagnosis of brainstem stroke was confirmed be the findings on the brain MRI. (See upper image above with the arrow indicating the site of the stroke in the right pons).

MRA (MR angiography) demonstrated a very tortuous right vertebral artery with significantly limited flow (black arrows on the bottom image above). The left vertebral artery was normal (white arrow on the same image).

The consulting neurologist suspected vertebral artery dissection as a possible cause of the vessel occlusion leading to stroke. The patient was started on anticoagulation, Heparin infusion, per the neurologist’s recommendations.

On Monday morning a different neurologist saw the patient and made completely different recommendations. According to the second neurologist, this was unlikely to be a dissection, but rather an anatomic variability in the size of the vertebral arteries. The Heparin infusion was stopped and the patient was started on Aspirin.

You are the primary attending physician and it is your responsibility to ensure that the patient gets the best treatment for her condition. The most important question to ask yourself is: if the change in medical management compromises the patient’s safety and health.

The review of the literature revealed that yes, indeed, the patients with a suspected vertebral artery dissection are often being treated with anticoagulation. Several favorable outcomes were reported in the literature. Yet, there are no randomized studies available to confirm the benefit of this therapy for the patient with the vertebral artery dissection.

Considering somewhat equivocal results of the imaging study (dissection vs. anatomical variation) and the absence of firm evidence to support the use of anticoagulation, the decision was made to change the medical management according to the rounding neurologist.

There are two questions to consider while navigating the path of contradictory medical opinions. Number one is always what would be safer for the patient – do no harm first. Number two is what would offer more benefit for the patient. The second question is often harder to answer. That is why we consult specialists in the first place.

It is estimated that nearly 325,000 people in the US die each year from a cardiac arrest. That means that cardiac arrest kills one person every two minutes. It is also estimated that nearly 200,000 cardiac arrests occur while the patient is being treated in the hospital – in-hospital cardiac arrest.

It has been demonstrated in experimental studies that female hormones, primarily estrogen and progesterone, exhibit a neuroprotective effect in animal models of global hypoxic-ischemic injury, stroke and traumatic brain injury.

So, does it mean that female patients, who naturally have higher levels of these hormones, do better after cardiac arrest?

A study by Topjian et al. attempts to answer this question. The authors of this study looked at the survival after an in-hospital cardiac arrest in two groups of patients. Female patients 15-44 years old were compared to the male patients of the same age. Females older than 56 years were compared to the males of the same age group.

The authors hypothesized that female patients of child bearing age will have a significantly higher levels of estrogen and progesterone compared to the male subjects of the similar age. This difference in hormone composition would dissipate after the menopause. Women older than 56 years would not have this advantage over older men. Women between 45 to 55 years were intentionally excluded from this study. The variability of hormonal composition in the perimenopausal period could potentially skew the results.

The findings of this study were quite revealing. After adjusting for confounding conditions, women of child bearing age (15 to 44 years) were more likely to survive to hospital discharge after a cardiac arrest than men in the same age group. Also, younger women had a more favorable neurological recovery compared to men.

In contrast, there was no difference in survival and recovery between men and women older than 56 years.

The authors concluded that administration of female sex hormones might improve the survival after a cardiac arrest. It is unclear if these hormones would have a similar effect in men. No clinical studies investigating the effect of female sex hormones after cardiac arrest have been published.

Interestingly, the improvement in survival exceeded that of any recently introduced advance in health care and treatment after cardiac arrest.

The treatment approach for the victims of cardiac arrest is unlikely to change based on the results of the single study. More evidence is needed before it can be introduced into the clinical practice. Yet, it does sound promising.