EMERGENCIES

The Man Who Was Folded in Half and the Man Who Couldn’t Be Folded

Two stories about getting bent

His right foot lay limply on his left shoulder. His left foot rested on his right shoulder.

We knew he was coming in because the paramedic radio has squawked “farming accident, adult male with stable vital signs” or words to that effect.

Deep into my career as an Emergency Physician I’d seen some crazy shit, but my first glimpse of the man twisted my mind a bit, quite a bit actually.

He only occupied half the paramedic gurney’s length because …

He. Was. Folded. In. Half.

Dressed in now-shredded farm worker blue jeans and a tee shirt, the man was folded in half from just below the pelvis. Remarkably he uttered not a sound as he stared upward, seemingly pain free.

As we gently transferred him to our bed, the paramedics gave their report.

A Spanish-speaking male of approximately 40 years of age. Run over by some kind of farm equipment. We’ve got pictures if you want to see the gear. Found in the position he is now. Transported that way. One IV in and flowing. Stable vital signs. No complaint of pain.

I’m seeing all I want to right now I thought. The farm gear that did this is immaterial.

We spoke to the man through an interpreter and got the rest of his nearly nonexistent medical history. We confirmed that he was in minimal discomfort. A quick check of his body from the waist up revealed no additional trauma, an intact airway, clear lungs, a steady heartbeat and no signs of life-ending abdominal injury.

We consented him for “procedural sedation” after explaining our proposed treatment plan. A second IV was started. Oxygen was applied. A substantial slug of opioid pain medication was given followed by propofol for deep sedation.

And. Then. We. Just. Straightened. Him. Out.

We did the left leg first since it lay atop the right. As a tech stabilized the patient’s pelvis, I held his left ankle firmly, and, keeping his leg at length, rotated it 180 degrees until it lay flat on the gurney, toes skyward. Then we did the same with the right leg.

Mindful of the numerous shards of shattered bone that must have been present in each leg, we checked for pulses before and after the procedure. Thankfully, they remained intact.

And, as I said once, but it bears repeating,

We just straightened him out.

It was that simple.

And then my mind untwisted a bit.

“Doc, he’s stiff as a board.”

Sometimes the medics get ahead of themselves and say what they consider to be the most interesting info first rather than what I’d prefer to hear, the ABC’s. That’s Airway, Breathing and Circulation. In short, is the patient’s heart beating and is he breathing? That’s what I need to know first, but I understand.

That was particularly true as an Emergency Medicine trainee, fresh out of medical school.

But, as was said to me then “Doc, he’s stiff as a board.”

“His name’s in the nursing home paperwork, but he’s in his eighties. Fever and a decline in mental status for a day or so, according to the nurses there.”

“He’s non-responsive to voice and sternal rub. Respiratory rate of 36, and shallow. Heart rate in the 140’s with a thready pulse. BP of 80. Feels hot.”

Then all of a sudden, this feverish, old, critically ill man is mine. I’m in charge.

As I step up to the bedside to begin my assessment I notice that my patient’s weight, in pounds, roughly matches his age. He stares blankly up at the ceiling as though looking into an abyss, one only he can see the far edge of. He’s wearing a flimsy hospital gown so examining him is easy. As I do so, I call out orders to the two nurses and the assisting tech.

“Two liters of IV saline wide open” (to support and improve his marginal blood pressure)

“A rectal temp when you can and 1,000 milligrams of rectal tylenol.”

“High-flow oxygen by face mask.”

“High-dose, hard-core antibiotics (details long forgotten), to howitzer whatever infection within 100 yards exists that is taking this man out before our eyes.”

All this while I do a quick head-to-toe.

I confirm that my patient is truly out of it. After yelling in his ear gets no response, I place my knuckles on his sternum and grind down. There’s not a flicker of a reaction, no grunt, groan, word or motion. He continues to stare into the abyss.

He’s not quite guppy-breathing, but he’s close. Regular but shallow and far too fast, especially too fast for an old sick guy to maintain for too much longer. I make a mental note he’ll need an artificial airway, and soon, and I alert the team to set me up to provide it.

His heart is racing, struggling to keep up with his dehydration, infection, fever and increased metabolic demands. For now it’s succeeding, but it may soon need help. Thankfully, there are no extra heart sounds, just the normal lub dub lub dub, over and over. No heart murmurs signaling potential infection showering from his heart valves to the rest of the body.

His lungs are clear, so likely no pneumonia.

The abdomen is scaphoid, hollowed out from weight loss and wasting, but there are normal bowel sounds and the thin muscles beneath my hands aren’t involuntarily rigid, the classic reaction to pus. There may be further investigations to do in the belly, but my first glance tells me the source of sepsis isn’t there.

His skin is clear. Hot and dusty dry, but clear. Skin and soft tissue infection seems not to be the problem.

As part of the evaluation a urinary catheter is inserted. I watch as scant dark yellow urine trickles into the catheter and down into the bag. It’s clear, not cloudy, not rotten pineapple juice, the odor and turbidity of which would signal likely infection.

So what IS killing this man?

What about the rigidity that was all the rage when he rolled in? The stiffness that so captivated the medics?

I move the man’s limbs about and they are somewhat stiff but not fixed in place. Seems as expected for a senior citizen.

I again approach the head of his bed, the place where my head-to-toe survey began.

Cupping the back of the patient’s head, I attempt to flex his neck. But, instead of flexion, I get lift. My roughly 80-pound patient comes clean off the bed so that only his heels remain in place, pressed to the sheets. His body doesn’t sag.

As initially described, he’s stiff as a board.

It’s meningitis.

As I call for a lumbar puncture tray, the patient is rolled onto his side and readied for the procedure. My burly assistant holds the man and attempts to flex his spine, especially the lumbar area. It is frankly impossible. Flexion here would make it easier to slip a needle into the space it needs to go to gather cerebrospinal fluid, the presumed source of deadly infection, but not a degree of bend is forthcoming.

Thankfully, my needle finds its way where it needs to go and there a satisfying tactile “pop” as the tip breaches the dura mater housing the spinal cord, nerves, and cerebrospinal fluid. Fluid begins to flow.

But it is GREEN! and MURKY!

It should be pale and clear.

An hour later my patient is dead.

He arrived stiff, unable to be flexed, even a single degree.

He exited bent, bent by forces far behind his control and well beyond mine.