Unsure and Useful

A twenty year old was crashing and nothing fit the textbook.

Twenty years old. Brutal pain in one leg, and nothing to explain it.

Around 5 AM, early in my practice. Trauma call at Hoag. The ER wanted me to see him right away.

I examined the leg. A little mottled. That was it. Everywhere I touched he was in significant pain, way out of proportion to anything I could see. No broken skin. Compartments soft. No fever. Vitals normal. He was with it, just hurting.

Three add-on trauma cases that day.

After the first one I went to check on him. The hospitalist was at the bedside. He was moaning. Less coherent, but still interacting. His vitals starting to sag. The hospitalist wanted him in the ICU. I agreed.

After my second case I saw him in the ICU. Worse.

It didn't fit necrotizing fasciitis. It didn't fit compartment syndrome either. The indications weren't clear. I had to do something.

He wasn't coherent enough to consent. I called his mother. I told her I don't know exactly what's happening, but your son is very sick, and if I don't open up his leg I think he's going to die.

Held the last case. Rolled straight back.

I started with fasciotomies. Cloudy fluid everywhere, like dishwater, all through the fascia. Infected.

I extended the incisions down into the foot. Debrided. Then extended up toward the groin. The dishwater kept coming. Got close enough to wonder if I'd have to go into his abdomen, well outside where I usually worked.

I was already planning the approach. It stopped just below his pelvic crease. Long incisions on both sides, hip to foot.

The muscle underneath was healthy.

It was the weekend. No other surgeons operating. And no time to wait. Just me and a scrub tech. And a twenty year old running out of time.

I irrigated the leg thoroughly. Put the wound vacuums on. He went back to the ICU.

My partners picked it up after. The trauma surgeon did a couple more washouts and the closure. He followed up with my partner in the clinic.

Weeks later I was covering his clinic while he was out of town. The patient came in for his six week follow up. I introduced myself.

I'm Dr. Siljander. Covering for my partner today.

He heard my name and went still. Then slowly turned and looked at me.

You're him. You're the one who saved my life.

He shook my hand and held my eyes. Thank you for saving my life. I got the chills.

Patients had told me that before. After a hip or a knee. They meant it. But they weren't dying. This was a twenty year old who was crashing, no clear diagnosis, nobody around, and a phone call to his mother where I said he might die if I didn't go in.

And I went in.

This week, make the call before you feel ready. Wait until you are, and there's nothing left to be ready for. Go in.

The good thing is, you can be unsure and still be useful.

Good Thing Monday goes out every Monday. One story, one good thing.

Tell me your good thing this week. I read every one.