All right, welcome back everyone to Emergency minute. This is episode number two for the year. Toughest cases of my career. I want to thank everyone for tuning in last time to cold weather emergencies. Now, I do apologize for not being able to do the scheduled show with Dr. Lewis for CPR and DNR. Both of us have been trying to run the ER. I got influenza, then he got influenza after. We just really couldn't get our schedules aligned. Have no fear, the show must go on. We will do the CPR and DNR show. That's a fact. It's just going to be a matter of trying to align our schedules so that we can do this the right way.
Today's show features some of the toughest cases in my career
So today's a brief episode of a discussion of some of the toughest cases in my career. One of the more frequent questions I get asked is, what is the craziest thing you've ever seen? What's the funniest thing you've ever seen? And these are things that are always hard to answer. But today we're going to talk about some of the toughest cases of my career. Now, today's show is being brought to you by the good people of travel fans. Yes, that is my new company, and we're sponsoring today's episode. What we do is we basically tell you all of the secrets that you can't find online. So be sure to check them out on any social media platform. At travel fans, we're on TikTok, Instagram, Facebook, and YouTube. We do reviews of high end resorts, and we also give those secrets that you just really won't be able to find anywhere online unless you really get down into the weeds of something like TripAdvisor. And it's just going to take a lot of time and energy. So just follow us. On social media, you also see a lot of funny things about really cool vacations and some really nice pictures of vacations, some videos, and some things about day drinking, which is always fun. So before we get into these cases, I'm going to walk through the cases, really in no particular order, but I will lead up to the final case, which is by far and away the toughest of my career, so you don't want to miss that.
How do you define tough? I mean, we deal with things every day
Before we get started. This is something, no matter how I do this podcast, there are just simply too many cases to count that are tough. I have tough cases every day. And then how do you define tough? I mean, we deal with things all the time that are rough, kids that are dying, trauma. Those types of things, of course, are hard, but we also deal with challenges, like dealing with asshole hospitalists and surgeons that swear at us and dealing with medical professionals who aren't very professional at all and sometimes, just quite frankly, aren't very good at their jobs. And so we have to be patient advocates because we know or think what's best, for them and which path to take. But then there's tough cases, like socially. Like, we have homeless people. We can't just throw them outside and say, good luck. We have patients that come back into the ER, like, every three days. So there's a lot of ways to define the word tough. And today, I think what I'll discuss are some of the cases that were not necessarily physically tough on me, but definitely mentally tough. And so that's kind of hard to talk about. And again, no matter, I cannot do any justice to the stuff that we actually see. I never forget my beautiful neighbor John, who said to me one time, he's like, yeah, but how many times you actually deal with death? And I'm like, well, like, every day? He's like, no way. And, yeah, we do. We deal with just absolute horror. Stuff that people don't realize goes on around them, because most people are out living their lives and don't have to go to the ER. But people that do go to the ER, there's, like a subculture of people that we see, and I don't really know where they live, but we seem to find them. So we do see these things. We see a car accident, for example, where one person will die, but the other one lives. That's always difficult. Or one person comes to us from a major trauma, and the other one gets flown to the trauma center, and sometimes that person dies there. And we know these things, and it's always about, how do we deliver that message to the person that's here? Should we deliver that message to the person that's here? We've even had cases where both parents were killed and then the child survives. Yeah, I've had that. That's actually happened. So, yeah, I mean, we talk about violent crimes. That's not as common in a small community hospital where I spend the majority of my time. But quite frankly, the violent crimes are the easiest ones to take care of. We have the knife and gun club. We just need to see where the bullet is or where the stab wound is, where did it exit, and then really address the diagnosis and the treatment based on that. It's often the blunt traumas where you're in a car accident and you're going 70 miles an hour and you go into a wall. Those are often more difficult because we have a much larger area that we have to assess and potentially treat. So those a lot of times are more difficult.
Small community hospital has very limited resources for treating trauma patients
So let's talk about case number one. So, case number one is a family that was driving through the state of Ohio that really didn't know where the hell they were going. I think they were going to, like, cedar point or something along those lines. And one of my biggest fears along these country roads out here, are these pathways where you have this intersection where if someone doesn't see that there is a stop sign, you're talking about someone going in one direction, 50, 60, 70 miles an hour, and someone going in a different direction at a 90 degree angle. And if those two things collide, you're going to have a big problem. These country roads are great because there's really not a lot of traffic. So I can get to and from work quickly, but are terrifying from a trauma standpoint, because if someone misses a red light or if someone passes out at the wheel and goes left of center and you're in a head on collision going 70 miles an hour, these country roads can be some pretty devastating car accidents. So in this particular case, we had the entire family of four that came in as traumas. Now, one of the things about being a physician in a small community hospital is you have to be a real doctor. Now, what does that mean? Well, if you're in a major trauma and you happen to be in a bigger city, Cleveland, Akron, Toledo, et cetera, chances are you're going to be taken to a trauma center where there's an entire team of people that can come down and help you, which is great, by the way. But when you're in a small community hospital, a lot of times you have to be a real doctor. You have to be able to take care of a lot of patients very quickly with very limited resources. Now, in my primary hospital, we do have surgical backup and a great trauma program, so I'm lucky in that regard. But I think for this particular case, this one was several years ago. This was before the trauma program. All right, so what happened? So this was a roughly 60 miles an hour car collision that took place, just, as I said, in what we call T bone fashion, meaning two cars hit each other in a 90 degree way. And so we ended up taking care of the mom, the dad and the two kids. Now, for this particular accident, this was a high speed collision. Everybody, thankfully, was wearing their seatbelts plug. Make sure you wear your seatbelts. That's how you survive these things. And ultimately was very difficult because we had four patients at once and it was myself and another pa. I think we may have had a second Pa at that time as well. So my job, obviously, is I have to see kind of everyone to kind of make sure who is the sickest patient, who needs the most amount of help? Who may need the least amount of help. And the parents were okay. They were a little bit banged up, but they looked like they were doing all right. It was really this eight year old boy that was struggling. And so he obviously had a head injury. He had some bruising and small laceration. He was very nauseous. He kind of kept asking the same questions over and over again. What happened? Where are we? And, oh, you were in a car accident. You're okay. You're here at the hospital. And three minutes later he's just like, well, where are we? And you're like, you're at the hospital. We just kind of told you this. And it's just this repetitive questioning that we often see with head injuries. So I'm checking on this child, obviously doing a full trauma exam, in the meantime, trying to bounce into another room while I have the PA checking on the other two folks. And so they're assessing them as well. And then the nurses come back to me and Dr. Parente, you need to come into this room. And now this eight year old that previously had obviously this head injury and was kind of asking the same questions. Well, now, at this point, he was less responsive and he actually had some seizure activity. So anyone that's in healthcare knows if you hit your head hard enough that you start having seizures, that's not a good day. And if it happens right after the fact, we see that's pretty commonly like, you see somebody that falls and hits their head really hard on the basketball floor and then they have like a brief seizure, something along those lines. We do see that, but this is a more dangerous situation where we call it like a lucid interval where the patient seems to be doing okay, kind of asking some same questions. We obviously see signs of trauma, but at the end of the day. Then they start having neurological symptoms, such as seizure, or they change their mental status. They become less responsive of things like that. So at this point, the only way to properly evaluate this child and stabilize things would be to intubate this child. And for those of you that aren't in the medical field, intubate means put a tube down their throat, put them on life support so that you can make sure they're getting enough oxygen. You can control things. You can control their vital signs, you can control their airway, make sure that that's secure. A lot of times, these head injury patients will start to vomit. You don't want vomited going down into the lungs, because then obviously, you'll have aspiration. All right, so we go to set up for the intubation of this child. Now, keep in mind, ah, I'm still a human being. I'm not just a robot. I have an eight year old son at the time of this accident. And so, obviously, my son looks an awful lot like the kid that I'm about to intubate. And so I'm putting all the medications ready. I'm, putting all my emotions to the side, because you really don't have time to process this when it's happening. And I remember putting the medications in the IV with the nurses and getting ready to intubate this child. The seizure activity stopped as we were giving the medication, which is not uncommon, because those medications do stop seizures. And about ready to put the tube down the throat, and I'll never forget that. Down the side of the child's face streams a tear. And that one really hit me hard because it was obviously an eight year old. I had an eight year old boy at home as well. I didn't really know what was going to happen to his mom and dad. I hadn't even seen his sister yet. He was obviously sick enough that he became less responsive. And we worry about people stop breathing. Intracranial hemorrhage, which is bleeding inside the brain, things like that. And here is this cute little kid that was just involved in this car accident, and he's just got this tear streaming down the side of his face. Don't think I'll ever forget that one. That one definitely hit me hard. The good news is that we did fly him to a level one trauma center, and my understanding is he woke up later that day or the next day, was doing well. They took the tube out, and he basically just had a really severe concussion, but overall did well. And, I'm very thankful for that. But I don't think I'll ever forget that, because, look, prior to being a father, being a doctor was a lot easier. Because it's not to say I didn't care when I took care of someone, especially a kid, that had something happen to them that was horrible. Of course I cared. But it's just a different level when you're a father, especially when it kind of hits close to home. And in this case, I'll never forget that eight year old with the tear streaming down his face.
Second case involved a man who was shot in the chest by police
All right, second case is another rural hospital case where I am the only physician there. Single, small community hospital. The physician assistant had actually just left the building, and it was close to midnight. Now we get this call that there's GSW, gunshot wound coming in, and the story sort of evolves that this 20 ish or 30 ish year old male was basically charging towards a police officer when he was shot because he was wielding a big knife, a knife that he had actually just used to fillet his mother's arm. And there had been some type of altercation at the house, so the police were called to the scene. Because of the domestic disturbance, this man had apparently taken a swipe at his mother and fillet open her arm. And then the police arrived, and obviously, he starts charging the police officer with this knife, so they had to shoot him. So we had a GSW to the chest, and it was in the right side of the chest. Now, keep in mind, I'm, one person, and now I have to see the mother, whose arm is fillet open, the perp who basically was shot in the chest and not doing well. And then I even had to see the police officer because that was part of their protocol. So, unfortunately, he had to wait the longest because I had to try to save the guy that he just shot. So obviously, the mother went to the back burner. Thank God the PA actually caught wind of all this, like, as they were walking out the door or maybe even in the car, I'm not even sure. They turned around, came back in, and thank God they took care of the mother, who needed a pretty extensive repair of the forearm. So that left me to take care of the perpetrator. And this guy was about as sick as you can get. Whenever you get shot in your chest, obviously, a lot of things can happen. The first and foremost is we worry about collapse of your lung that can obviously stop your breathing and impact your ability to survive. The other things we worry about bleeding and things like that. So the first thing that we did for this particular situation. Again, we did stabilize this patient by putting in a tube, endotrachial tube, which is putting the tube down the throat to breathe for this patient. So that was sort of step one. But I knew, obviously, the patient had a chest wound in the right side. And given the location of where this wound was, you just know that there's what's called a pneumothorax. you can sort of see it clinically by listening to breath sounds, things like that, and just the location, it was just probably about the third rib space down. So this is somebody that obviously is going to need what's called a chest tube. So that was step two. Step two is to put in a chest tube into this patient, meaning we put a tube in the side of the chest to allow the lung to reexpand. Now, that serves two purposes. One, obviously, you have to have a reexpanded lung in order to appropriately breathe. But the second thing it does is it serves as a bit of an escape for any blood that has collected in the chest. If you hit any of the main arteries, which in this case, he probably did, although not the main artery like your aorta or pulmonary artery, because if those get clipped by a bullet or a knife, there's about a 98% to 99% chance you're going to be dead either at the scene or shortly after arriving at the hospital. So I put the tube in the side of the chest, and lo and behold, his lung expanded, so he was breathing a lot better on the ventilator. And then the second thing we did with that was hook it up to suction. So we're suctioning all this blood out of his chest, and there was quite a bit of blood. At this point, he did have his pressure dropping. So we were giving trauma blood and at the same time activating for a level one trauma and a helicopter lifelight to come help us to get this patient to a higher level of care, because this is definitely not a patient who's going to be staying in a community hospital. So I'll never forget that case, because, number one, it's kind of crazy with, charging a police officer with a weapon and being taken down. And within 20 minutes, I had that patient intubated, had a chest, who pulled out the side. And then the last thing I did was, put in what's called a trauma line or a Cortis, where you basically have this large IV, but it's in the groin or in the neck that allows you to give a large amount of volume, very quickly. It's sort of a life saving device. So I put one of those in as well, because we actually gave all of the blood in the hospital to this patient. We actually ran out of blood. That's how much blood we gave him. And what's crazy about this is that the guy ended up walking out of the level one trauma center, like, three days later, was fine, everything was taken care of, and lung re expanded, and he actually did just fine, from what I understand, after the fact, to become a contributing member of society, hopefully.
Case number three is a horrible case that really impacted me in residency
Case number three is a horrible case that really impacted me when I was in residency. So this was a long time ago, but I'll never forget it because, of course, it was Christmas Eve, and on Christmas Eve, they brought us a six month old baby. And this six month old was a full arrest. So a full arrest means that there's no breathing and the heart isn't working either. So this is, again, that situation where you have less than 5% chance of survival. We'd like to think it's higher because it's a child, and we're going to work as hard as humanly possible to try to bring this child back. But it turns out that this child was co sleeping with mom on the couch for Christmas Eve. And lo and behold, mom rolls over, smothers baby, doesn't realize it because mom's sleeping too. Mom's probably tired. And then all of a sudden, we have a dead six month old. So I will never forget that. We did everything in our power from obviously giving epinephrine, which is sort of the adrenaline that try to get the heart started up again. We had the tube down the throat to breathe for the child did all the things we normally do, but at the end of the day, this child did die. And a lot of sad things here. Obviously, anytime a child dies, it really hits us hard. It's really hard to go on at that time. And obviously, you have to tell the parents, which is horrific. this mom was pretty much in shock, just almost like stone faced, just could not possibly believe what was happening. And it didn't help that it was on Christmas Eve. Not that it would have been any easier on any other day of the year, but you guys get what I'm saying.
36% of SIDS patients were co-sleeping according to a recent study
So let me take this as an opportunity to give you a little bit of statistics and some studies surrounding co sleeping or bed sharing is the new word that they like to use. As many as 40% to 76% of parents participate in co sleeping. On some level, this is not recommended. This is not a good thing, guys. This is how people die. I've had four in my career, dead babies because of co sleeping. According to a recent study, 36% of SIDS patients were co sleeping. Another study demonstrated nearly 50%. So, what are some risk factors for SIDS? Well, if you have the baby sleeping prone, which means butt up in the air, that doubles your risk. So it's just not smart. And I know I'm a father. I've got three kids, and I swear to God, they always sleep better when they were on their stomach. But this is what doubles your chances of SIDS. Your chances are still low, but they're double what they should be. Bed sharing, obviously, is one of the biggest single risk factors out there. And then blankets or other bed accessories in with a newborn, not a good idea. What does reduce your risk? Well, breastfeeding, for one, and then sleeping on his or her back. And strangely enough, pacifiers are some of the things that can reduce the likelihood of death and likelihood of, SIDs. So, long term co sleeping can also lead to things like memory loss, fatigue, depression, low energy, and obesity. So it basically sounds like marriage. Just kidding, honey. I just had to make a joke. I have to try to be funny here once in a while, otherwise people aren't going to listen. So there you go.
Case number four involves a patient who came to see ER with headaches
All right, let's talk about case number four while we're mulling over the reasons why we're not going to ever co sleep again. Case number four is a 35 year old patient that came to see me who was having headaches. Now, we see this all the time in the ER and kind of triage who may be dangerous and what they're telling us and who had maybe a dangerous injury. Do we do a CAT scan? Do we not? Is there something else going on? The vast majority of people that present to, ers with headaches, they're just having a headache and migraine or tension or stress or what have you, we treat them, they go home, we all live happily ever after, and everything's great. That's the vast majority of ER visits that involve headaches. Now, once in a while, we see awful things. We see aneurysms, we see brain tumors, we see strokes, we see intracranial hemorrhage, which is bleeding inside your brain. We see, very rarely, meningitis. That's not very common at all. And so we see these things in the Er, and we typically see the worst of the worst. And this one particular case hit me hard, and I think it was because I was 35 years old. And this guy came to see me and he was been having headaches, and he kind of said, well, I think my vision is just a little bit off. Like, nothing crazy, but definitely enough that made me say, like, hm, this is maybe more than a headache. And look, I always tell this to students. We're in the business of ruling out in the ER, we have to rule out the bad stuff. And that doesn't mean every single person gets a CT. We also have to be judicious with our use of resources. But if someone has headaches and they have some type of neurologic symptom, then at that point we have to get the CAT scan. And I'll never forget looking at that CAT scan. That was absolutely horrible. The entire brain was just littered with tumors. So this guy had either just horrible brain cancer, which is unlikely, or he had cancer somewhere else in his body and it had spread to the brain, and his brain was just absolutely loaded with cancer. And I'll never forget this, because you have to tell them at this point, there's no way around it. A lot of times we'll get something like, oh, there's a mass in the belly, or, hey, you got a mass on your lung. And we kind of know it's cancer, but we can't say that because it's not like a biopsy or something. But we can kind of carefully craft our message to the patient. Like, look, this could be cancer. I'm concerned about it. You can kind of soften that language a little bit. But in a case like this, where the brain is just riddled with tumors, there's no easy way to say this. Like, you have cancer in your brain and it doesn't look good. And I'll never forget talking to him. And he literally looked at me and said, well, doc, appreciate your time. Thank you for taking care of me. I'm going to go home now. And I was like, just blown away. I was like, whoa, whoa, hold on, hold on. We can treat you. You got to see a neurosurgeon. We got to get you plugged in with an oncologist. Like, you're probably going to need chemotherapy, you may need radiation. You got a lot of work ahead of you here. And he's like, no, I'm good. Time to go home right now. I'm leaving. And got up and walked out of the bed, out of the ER, and I never saw him again. Crazy, crazy story. Live every day to the fullest because tomorrow is never promised.
Case number five is in reference to a case that I had again in residency
Case number five is in reference to a case that I had again back in residency. I don't want to talk too long about it because it is in the podcast interesting cases in my career from last year. So you can really hear a lot more detail about that case. But nonetheless, it is one of the toughest cases of my career. And it's strangely funny if you have, like, a morbid sense of humor. This patient comes in that was basically stabbed to death by his fiance and started to arrest in front of us in the trauma bay. It was on New Year's Eve again. So it's strangely if you have a real dark sense of humor. Here you are on New Year's Eve. And the thing about this case that sticks out to me was we had to put in tubes in the chest, and we had to crack the chest open because the heart had stopped. We had the senior surgical resident sitting on top of the bed, squeezing the heart, contracting the heart for this patient because the heart had stopped and were rolling by families that were waiting in hallways because the place was on fire and so busy that there was no other place to put people and their families. It was all over the place. And I'll never forget the look on their eyes as we're wheeling by going to the or to try to save this person's life. Just complete shock and awe and just disbelief of what they were seeing, only to turn the corner, having the pressurized blood that was being infused, that cord unfortunately got caught and ripped open and started spraying blood like Carrie, the horror movie Carrie, all over the hallway. It was crazy. And then we're on the elevator, and ding. As soon as the elevator dings, we're on the second floor to go to the OR. Happy new year, everybody. I'll never forget that one. That was one of the craziest cases of my career. And I don't think I enjoyed talking to the housekeeper on the way back when I said, hey, can clean, up on aisle, too. There's blood all over the hallway. We probably need to get that cleaned up. So, again, that was kind of a crazy one, but I'll never forget that one either.
One of the toughest cases in my career involved a pediatric suicide
All right, and the final case, which is without question the toughest case in my career, I'm not going to talk about details because it involved a pediatric suicide. And out of respect for the family, I still have a connection with this family. And for all I know, they may be listening right now, but I will tell you how this impacts a physician. You have to block out emotional trauma during the situation because you have to function in that moment to try to give that person the best chance of survival, and we have to execute in that environment, which is easier said than done. And one of the things always gets asked to me is, why do these residencies, why do these guys work so hard? Why do they work them 80 hours a week? Why do they have them m stay up for 24 hours? Well, I would ask the same thing of our military that have boot camp. Why do they put them through hell? It's because they need to be able to function in a very high stress environment at a high level, and that's exactly what we do as well. So we are trained to block out this emotional trauma in these situations. Oftentimes, we may even look emotionless at times and have this large wall build up. We use medical terms like pediatric suicide, so it allows us to keep that case outside of our wall rather than saying what really happened, which is a sweet, innocent child that died, and that's much more triggering from an emotional standpoint. And what's worse is, after taking care of a child, or any death, but specifically a child, you have to take care of this tragedy. There's no relief. We don't get to go home. We don't get to do it. We still have to talk to the family, which is horrific. And then two of the toughest things we do, taking care of the dying child and their families, only to be followed by returning to work. And what does that look like? Well, the ER doesn't stop. So now I'm running around like a madman, talking to pissed off patients and families that now they've been waiting an extra 20 minutes, 40, 60 minutes, maybe even an hour or two, and they may not realize what just happened. And quite frankly, I've had patients that did realize what happened, and some people are just assholes, and, they just want their service, and they want it right now, and they want their back pain taken care of. And it's like, sorry, we just coded a child for the last 2 hours. I'm sorry that you're here waiting for your percocet. So we do have to deal with this, and I've referenced this before on multiple other shows where air traffic controllers, obviously a very high stress environment, if they have a, tragedy occurred or even a near tragedy, they're immediately pulled out of service. Well, for me, if I have a tragedy at noon, well, I have seven more hours in my shift, and there's no relief in sight. So it's just a different way. It's a different level of sort of emotional strength in order to kind of get through something like that and much less talk to these families that have just dealt with the worst tragedy imaginable. So I'm glad there is this sort of movement where people are talking more about mental health, not just like athletes and things like that, but this is very real. This is real for physicians, this is real for patients and for families. And you always put this on the outside, like, suicide is not going to impact me because I'm tough, I'm strong. I can get through this. But everybody has a breaking point. And you think that you know somebody, but you really don't necessarily know what they're going through. And especially with kids, you never think that this happens in kids, but unfortunately, we see it all the time in the ER now. Yes, most kids survive. They take pills or they cut themselves or they do something else. That's more of a suicidal gesture that allows us to sort of intervene, save them, get them the help that they need and they deserve. But in certain cases, yeah, I mean, kids can actually pull the trigger or whatever it may be that ends their life, and it is truly, truly tragic. So check on your friends, your families, your loved ones, even your kids. The suicide hotline is simply nine eight eight from your phone anywhere in the United States. And that could be the difference in somebody's life or your own life. So, as always, I do try to end the show on a positive note, which is nearly impossible after talking through a case like that. However, for every horrible case we deal with, there are others where we get a chance to make a difference. We get a chance to save a life where we see a close call and we prevent something from happening. These are truly life saving interventions and actions by an incredible group of people that do amazing work. I don't know, maybe that should be my next show. Maybe my next show could be like, these are some of the crazy situations that we've been in and some of the saved lives we've seen. I don't know what your thoughts are on that. Let me know at social media, Dr. J. Parente. Or you can message me through my drjprente.com, so in conclusion, that's all I got for you guys today. Remember to join us next time if we can ever get our schedules aligned with myself and Dr. Lewis, CPR and DNR. Boy, there's a lot of misinformation surrounding that. I want to wish everybody a happy St. Paddy's day. Coming up, one of my favorite days of the year. And as always, peace, love and happiness to everyone. Out there. Cheers, everyone