They were a happy couple in their 70s, traveling every summer as they had done since their grandchildren were first born. Finally feeling like they had finished raising their own children the couple enjoyed a carefree, low-budget retirement by driving their VW van to National Parks during the summertime.

After a sleepless night of indigestion, he wanted to take it easy that day. They took their van up over the summit of the national park and remarked on the wildflowers in bloom, the wildlife, the birds, the amazing pine scented air.

She took photos of him picking flowers for her, candid shots of him daydreaming in the mountain air. A bystander took a photo of the couple in front of the “Lava Cliffs” sign. He had brought a santa hat with him and they planned to send out the photo for their annual Christmas Card.

They were still so much in love.

I met him in the back of their van, he was cold and blue and gasping for air. She was frantic. “I didn’t know how to call for help,” she told me as she clasped her pink cell phone in her fists. She was hyperventilating.

I sat her down in a private room while the medics dragged him out of the van and put him on a gurney. I felt helpless when I saw him. We went through the routine, checked vital signs, started CPR, secured the airway, gave all the right drugs at the right times in the right order.

“Stop CPR,” I ordered as I squirted some ultrasound gel on his chest.

A faint flicker of cardiac activity showed on my screen.

“Resume CPR.”

The flight crew had arrived and the entire group of us went through our algorithms once more.

“Is there anything we havn’t tried?” I asked. No answer from my staff.

A baby cried in the room next door. I asked the clerk to escort the family only a curtain away back into the waiting room.

“Stop CPR. Time of death…” I announced.

I didn’t mind any of that…the teamwork, the drugs, the hustle and urgency of it all. It makes me feel important, gives me a space to occupy for a period of time. It’s the part that comes afterwards that I dread.

…

She was all alone in an instant. She still hadn’t show him all the photos she had taken that day. Her children were half a country away with their own children. He was simply gone.

I tried to console her by telling her that he went quickly, probably didn’t feel any pain, and had an amazing last day of his life in a place that he loved with the woman he adored.

Several hours later, she left with a smile on her face. She simply got back into her van, gave us a quiet ‘Thank You’ for all that we had done and drove away, alone in the van.

My emptiness pales in comparison to hers.  I can’t imagine what she must be going through.  I hope she’s safe and decided to drive back home to see her grandchildren.  I know they miss her when she’s gone for the summer.

I did a double take…yes, it was a clown, sitting in a wheelchair. A Pink curly wig donned his head and billowing teal pants with red and pink polka dots spilled through the spokes of the wheels.

He sat staring straight ahead. The droop on one side of his face pulled his make-up over to one side and made his painted red nose even more prominent. But it didn’t make me laugh.

I quickly examined the clown from head to toe and added some new parts to my neurologic examination.

“Raise your eyebrows for me,” I said.

His rainbow painted eyebrows tilted his whole forehead to his left as he struggled get them up.

“Show me all your teeth.”

The cognitive dissonance between a clown with rotten teeth and halitosis augmented the irony of his presense.

A short thin bobbing woman who resembled a toothpick came skipping down the hallway. Her bright orange wig somehow made me smile and she thrust her hand out to introduce herself.

“I’m Jellybean,” she squeaked. “How is Riggles doing? The rest of the group will be here shortly”

“Hi Jellybean, I’m Doc Shazam,” I replied. The words that came out of my mouth were, “It looks like Riggles has had a stroke.” But inside my head I was thinking, “A whole group of clowns arriving in our ER will make everyone happy.”

I’ve learned to emotionally separate myself from the personal details of my sickest patients, but internally, this seemed ot me to be a step too far. As I put in the alarm for a stroke alert, I was smiling inside at the thought of a hallway filled with bobbing, squeaking, smiling, polka-dotted, wig topped, red-nosed adults in Urban Blight Memorial.

I forgot that people who live in this community still reach out to their neighbors. Ghetto Clowns. Nice.

This is not a trick post…talk me out of it, please…

Once upon a midnight dreary
There I pondered, weak and weary
About a hound named Lola
Covered with bumps of curious lore.

When all at once I heard a knockin’
Lee-Ann cried, “Shazam! This dog is Talking,
About an oozing bloody mass that’s
Spewing pus upon her fur!”

Then the puss soaked, slimy rustling of each fur
Sickened me-left with a queezy feeling never felt before
My Soul grew stronger, hesitating then no longer
“L-A I will help you ferry, and in the process make more merry
The journey to the vet, to ensure the health of the ‘lords pet
Route 8 and nothing more,

Now Dasher, Now Dancer, Now Prancer, Now Vixen.
On Comet, On Cupid, On Doner, On Blitzen.
Grab a cat leash, your pal Shazam and jump in the CRV
Wait we do and patiently.

We arrived upon the clinic so dark
and pounded on the door,
“bark, bark!”
The entrance swung open slowly
and creaked a lonely sound.

We entered, females three,
Lee-Ann, Lola and me.
And lamented that there were only
two humans to laugh out loud.

When suddnely the door swung open,
“CARL!!!” Shazam shouted with emotion.
The waiting room got quiet and all eyes
darted from the floor.

On the road they had phoned, explained and bemoaned
and dreams of ice cream roused him twisting turning speeding toward them
Deep in the darkness came a beac’n not without a certain reak’n
Eat n’ Park!! was the source to spurn this man upon his course
surrounded by “smiley” faces awaiting patiently his bounty
Twas 3 shakes. Who could ask for more?

Text at 11, replies of fright,
“a leaky bassett hound you say?”, not such a delight
but how, but when, but why, you might ask?
no explanation given, just focus on the task
poor lola the bassett, she can barely see
but rest assured in better hands she could not be….

Upon his arrival, barging through the doggy door
There erupted from a patron a heartfelt gutsy roar
Joyous their reunion, cold and creamy their communion
cheery banter filled the air , those around tried not to stare
who are these interlopers disturbing their morbid lair.
Shakes by Jamaal and nothing more

Deep in the darkness, the talk turned to canines, cycling, appendix, cogs
lawyers, patrons, friends, hats and puss filled dogs
A feline hit by a car, and a Husky too drugged to walk far
amidst the downcast faces surrounding them in these morbid places
They found laughter and sun- the clock steadily approached one
350$. Nothing more

Some of the files that were deleted had the directory string

“C:\Temp\Patcher\Patcher1048\PBSLocalizedStrings\PBSLocalization\es_ES\PBS.zdct 5.88KB”

There were hundreds of these…what the heck are they?

So I googled “patcher”, and got millions of hits.

Then I googled “patcher1048″ and got ZERO hits.  That’s right, zero.

So try googling “Patcher1048″.

If I’m lucky, I’ll be the only result.  I wonder how many people search for patcher1048?

I sighed.  I always want patients and family to understand what is happening, but sometimes I feel like i explain the same thing over & over again (because I do, most of the time).  But this time the questions were different.

“I need you to be frank with me,” her son stated solemnly, but peacefully at the same time.  I actually felt soothed by being in the room with the woman whose blood pressure was 88 systolic and her pulse ox was 85%.  “Is my mother in imminent danger of dying?” he asked.

I wasn’t quite sure how to answer his question, so I probed further in to why he was asking.

She was a “no code”, “Do Not Intubate”, “Do Not Resucitate”, etc.  Generally, I know what that means, but far more important than what boxes are checked on the “DNR” form is what the patient wants from their quality of life.  I feel that it is the onus of the physician and healthcare team to determine what “boxes” to check, based on the patient’s and family’s stated wishes for end of life.

After discussing his mother’s quality of life, I gave him my recommendations.  I didn’t feel comfortable withdrawing all care until he had the opportunity to talk to his sister in North Carolina, and to talk to his mother’s physician.  While I was flattered that he asked for my opinion, I explained to him, “I’ve only known you and your mother for less than two hours.  I don’t feel comfortable telling you stop all treatment right now, but I will give you my advice about what you should do tonight.”

I suggested that we continue fluids, antibiotics and humidified oxygen through the night to maintain her present state of health, and possibly improve it.  This evening he could discuss the case with his sister and in the morning talk about it with his mothers physician. I told him that there was nothing that we were doing tonight that could not easily be stopped in the morning and this would give him and his sister time to discuss her care.

Was it a cop out on my part?  I don’t think so.  I’ve recommended to families that they stop all treatment in the past, especially when it’s clear what the patient’s wishes are.  I wasn’t certain that this lady would die tonight if all treatment were stopped…I was pretty sure she would linger for days to weeks, getting progressively worse every day.  I wanted him to at least enjoy her company for one more night.

She said to her son just as I was leaving, “Matthew…I’m not very good company right now.  Why don’t you go home.”  Matthew didn’t seem to mind just sitting there in his mother’s room.  Enjoying her quiet serenity one last time.

Matthew didn’t mind it at all, and neither did I.  It was better than the bike race would have been.

I felt bad for the little old guy, but was more irritated at the nursing home staff.  There is a misconception that all they have to do is fill out the committment papers, and it’s a done deal…the patient gets admitted to the psych hospital against their will.

It’s basically the same as putting someone in prison, and has legal ramifications that are similar.

The problem was, that this wasn’t a psychiatric problem, it was a medical problem and a social one.  His aggressive behavior is part of his dementia.  Couple that with an ex-boxer resident walking into his room, and sure enough, he’ll fight back.

I declined the involuntary committment and sent the patient back with instructions that the staff is required to keep other residents from wandering into his room.  I mean, it’s the only right he has left…his right to privacy.

The distal tendons popped into view easily by simply extending all of his fingers flat against the table. They popped out like little white worms and just sat there.  That was easy.  The hard part was findign the proximal ends.  I gently dissected the tissue back towards his wrist, grasping the overlying skin & fat in forceps then cutting the skin with a scalpel.

I was shocked when I saw a small whitish object hiding under the retinaculum.  I quickly grasped it with forceps and pulled it out, placed a stich through it and kept it in sight.  I tugged on it and his forearm twitched.  We proceeded to suture the 3rd distal and proximal tendons together.  While it wasn’t the prettiest knot, it was functional, and what’s even more important, his finger worked again!

THen I set off to find the 4th & 5th tendons.  I had luck in only finding the smallest proximal tendon and I’m assuming it was the 5th.  So I placed sutures through both the 4th & 5th distal tendons and sewed them to the 5th distal tendon.

In the end, I had a pretty three sided laceration…one side formed by the machete, and the other two formed by me looking for the proximal tendons.  I pulled the two sides up and placed a red rubber catheter drain in the lac, and we created an ulnar gutter splint for him.

We fed both he and his brother dinner (tortillas, rice & beans) and the two set off towards home.  We offered them a place to stay for the night, but they insisted on walking back home, 5 hours, in the dark.

The boy came back to the clinic 5 days later, after we were gone, to see the nurse.  We received an email from her saying that the wound looked good, non-infected, and she removed the drain.

Hopefully in 6 months he’ll come back to the clinic to show us how well his fingers are working.  It wasn’t the best tendon repair, but it was the best one he could get at the time.

Everytime I go there, I learn more, come back & study more and am better prepared.  I can’t wait for my next machete wound in Hondura!

This is when I met him for the first time.

“Doc Shazam, we need you.  We have a  machete injury…” said the 3rd year resident.

While minor trauma and fractures is run of the mill for me, the family practice docs that typically staff the medical clinic in the rural mountain village seem to find relief with my presence whenever the presenting complaint is trauma.  So a machete laceration that is right up my alley is gladly referred to me by the other docs.

This was the first machete injury I’d seen on this particular trip. Usually we have at least a handful.  It makes me wonder what the villagers do the other 48 weeks out of the year when there is no physician present, let alone an ER physician who is happy to poke around in tendons and muscles and such.

I had prepared myself for this patient’s visit more than a year in advance.  18 months ago, during my last trip to the mountains of Honduras, I had seena  similar case.  A young man with a machete laceration, this one due to carelessness, and not a snake, had lost the use of his index finger. I performed a gentle and timid exploration for a proximal tendon without success.

Upon returning home I consulted with my uncle, an orthopedic surgeon with over 40 years of practice.  He’s very familiar with my global antics, even from before I went to medical school. I’ve asked him about the very situation I was now facing.  Having never done an extensor tendon exploration or repair during my residency and subsequent clinical practice, I have since visualized the exploration I would do and the repair that would be needed.

When these boys and men have no other recourse aside from what they find at our clinic, how can I go wrong but to do an exploration, with the worst possible scenario that they recieve a sterile incision (due to my exploration) and leave with an injury no worse than when they came (only cleaner)

So the senior resident, 2 months away from starting her sports medicine fellowship and I began an exploration in anticipation of an extnesor tendon repair.  Others were skeptical…”Are you going ot try and repair that?” they asked.  “Why don’t you just send him down the mountain?” another questioned.

I knew that sending him down the mountain was an expensive proposition.  First of all, he had no money for the ride down in the pickup truck.  It would have to be gathered from the group of us, or deducted form the health committee funds, which are limited considering a clinic visit is the equivalent of 50 cents, which sometimes covers a family of six or more.  THis boy had no money at all.

Had I been assured that once down the mountain he would be able to see and follow up with an orthopedic surgeon, I would have given the $20-$40 dollars it cost to take an “emergency” ride down the mountain in one of the three pickup trucks in town.  (More than a months wage for many people).  But i knew that once he was in the Emergency Room in El Progresso, and had sat there for many hours, all he would get was a few superficial stitches in the skin, and he’d have lost the use of his left hand for good.

That was not an acceptable alternative for me.  So, betadine in hand, bandana on head, and LED headlamp in place, I began my exploration for the extensor tendons of his 3rd, 4th and 5th digits on his left hand…

A fifteen year old farmer leaned over in the beating sun, swinging his machete in his right hand while gathering ripe corn with his left.  His 10 year old brother picked up the ears that had fallen to the muddy ground.  The older boy suddenly felt a cool touch on the back of his neck…followed by a slick sensation running down his left arm.

With an automatic reaction fueled by terror, the poisonous snake was killed with one swift  swing of his machete.  His left hand began spurting blood from the deep laceration left by the machete.  The snake was dead, but he could no longer move the last three fingers of his left hand.

The younger boy ran to the edge of the field yelling for the other workers.  The older boy stumbled down the hillside corn rows in shock, cradling his left hand across his chest.  One of the older men doused the bleeding hand in gasoline to prevent infection and wrapped his hand in a towel.

With no choice but to maintain composure, the two boys began the five hour trek to our clinic where I met them for the first time.

…to be continued…