Saturday, January 3, 2015

Corpsman Chronicles I: Angles of Mercey

What is the difference between a sea story and a fairy tale? A fairy tail begins, "Once upon a time..." A sea story begins, "This is no $#!+..."

Well, this is no $#!+...
When the father walked into the ER with his son, I saw at a glance that the kid was very sick. He was pale as a ghost, trembling, and hunched over. He was a junior high kid, probably 12 or 13 years old, skinny and gangly, just starting his growth spurt.

I pegged dad as an enlisted guy, probably an E-6, probably an aviation rating, probably a wrench turner over at AIMD. I was pretty sure I'd seen him around.

I intercepted the pair before they reached the check in desk and whisked them toward the treatment room. I glanced at the clock for a start time and wrote 1540 on the back of my hand. I motioned to a couple of underemployed junior corpsmen, signaling one to start the paperwork and the other to get a set of vitals.

I introduced myself and shook hands with dad. "What's going on?"

As we eased the kid down onto a gurney and dad brought me up to speed. The boy had been speared playing touch football during PE class about two hours earlier. The PE teacher thought he'd just had the wind knocked out of him, and the school nurse decided to park him on the cot in her office for the last 90 minutes of the day. When dad picked him up he'd been in quite a bit of pain and was very shaky and weak. They'd come directly to the clinic from school.

Neither dad nor the kid were worried. I was. The boy looked shocky to me, and a blow to the belly could mean an organ injury and internal bleeding. He'd walked in under his own power, so that was good, and he hadn't cratered in the two hours since the injury, so that was good, too, but he looked rough as hell.

The clinic at Naval Air Station Oceana had a very good ER and was certified as a Level IV trauma center, but it was not a hospital. It had labs and x-ray and all the tools and skilled personnel needed to assess and stabilize trauma cases, but no ability to perform surgery or provide inpatient care. Our job was to stabilize trauma cases and quickly transport them to the appropriate major hospital for definitive care.

As HN Patel scribbled madly on the ER form and HA Gross took vital signs, I continued to assess and examine the boy. He was alert and oriented and in moderate distress from pain. He was pale but his skin was warm and not clammy. His belly, however, was rock hard, abdominal muscles rigid and "guarding" the belly in response to injury.

"B/P 60 over 30," said Gross, "pulse 130."

Yep, the kid was shocky. He was reasonably stable at the moment but he was almost certainly bleeding on the inside. Maybe not a lot, but some. My guess was a contused or lacerated spleen. We were going to have to get him to a hospital and a surgeon. I didn't really need to see a lot more, but I wanted to get some lab work to get a better feel for what was going on. A complete blood count and urinalysis would tell me how much and how fast he was bleeding.

"Okay, Bud," I said to the kid. "It looks like you've probably hurt your spleen."
Wikimedia commons. Abdominal organs.

"It's a little organ here in the left side of your belly and it's kind of fragile. Tends to bleed a lot when it's injured. What we're going to do is get some lab work and start an IV, then we'll drive you over to Virginia Beach General so a belly doc can take a look at you. First let's get a urine sample. Do you think you can walk into the head here and pee in a cup for me?"

"Sure," said the kid. We eased him up and he wobbled into the bathroom a few feet away. I watched closely as he moved, continuing to assess his condition. I could have collected the sample while he lay on the gurney, (something the ER nurse would have demanded, had she not been terribly busy with a major bureaucratic project) but having him get up and walk was a quick and dirty tilt test to see how shocky he really was. I hovered close to catch him if necessary. He moved pretty slowly, mostly because of the pain, but didn't show any signs of lightheadedness, and that was another reasonably good sign.

I sent Patel to get the ambulance crew spooled up and had Gross go fetch the ER doc, Lieutenant Commander Benny Beanpole (alias). Benny was a career navy doc. He was a General Practitioner Flight Surgeon who had been trained in trauma. He generally saw sick call but along with all the other physicians at the clinic he took a turn working in the ER.

As I jotted down my SOAP notes on the ER chart, HM3 Diaz, the duty ambulance driver, stuck her head around the corner. "Where we goin', Mikey?"

"VA Beach (pronounced, in this context, 'VAH-beech'). Thirteen year-old male, belly trauma, pretty shocky. You're probably gonna roll pretty quick."

"Roger that," she said, and dashed off to collect her EMT attendant as the boy came out of the head, clutching a pee cup half filled with dark red liquid.

His face told me that the bloody urine had scared him. It scared dad, too, and the pair shared a concerned look. It surprised the hell out of me, though it shouldn't have. Damn. Probably not the spleen, then, more likely a kidney, maybe ureter, maybe bladder. Maybe all three.

Wikimedia commons. Human urinary system: 2. Kidney, 3. Renal pelvis, 4.Ureter, 5. Urinary bladder, 6. Urethra. 7. Adrenal gland Vessels: 8. Renal artery and vein, 9. Inferior vena cava, 10. Abdominal aorta, 11. Common iliac artery and vein With transparency: 12. Liver, 13. Large intestine, 14.Pelvis.

Almost certainly a more serious injury than a bruised spleen. The red liquid in that cup made me want to get this kid to a surgeon most rikki-tik.

"Okay, Bud," I said, taking the cup and guiding him back onto the gurney. "Time for an IV, then we're gonna give you an ambulance ride to the hospital." As I prepared to start the IV, I explained what we were doing and why, being both explicit about the seriousness of the injury and upbeat and confident about what was going to happen. Father and son relaxed.

As I was starting the IV, Benny Parks breezed in, asked a couple of questions, and palpated the boy's belly.

"We're going to send you to Virginia Beach General," he said...

Five minutes later the ambulance was pulling out for the short trip to VA Beach. "Thanks, Doc!" yelled dad as he sprinted for his car.

I glanced at the clock. 1605.

A week later the boy was back in the ER, this time with both mom and dad. He was still hunched over, but he looked a lot better and had a big smile on his face. Mom and dad were smiling too.

"Hi Doc," said dad. "You were right. They had to remove his kidney."

"Show him your stitches," said mom.

The boy lifted his tee shirt and proudly showed off a sutured surgical incision.

"They treat you okay over there?" I asked.

"Yessir," said the boy.

Mom dug into her purse and pulled out a card. "I don't know what else to say but thank you. Thank you so much." Her face clouded up and tears began to flow as she gave me a fierce hug.

"Hey," I said, "that's what they pay me for, right?"

After they'd gone I opened the card and passed it around.

The ER nurse snorted at the coarse handwriting and misspellings.

Me, I was fine with Angle of Mercey.

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