04/13/13

Saving King

Killing King

The time is the 4th of April 1968, a cool Spring evening close on six pm. The place is a predominantly black neighborhood on the south edge of downtown Memphis, Tennessee. An area of run-down homes and low incomes. At 450 Mulberry Street there sits a small, modestly upscale boarding establishment, the Lorraine Motel. It is two stories and there is a pool, installed by the motel’s long time owner, Mr. Walter Bailey. The motel is popular among black musicians who frequent the nearby Stax Records. Over the years these have included Ray Charles, Lionel Hampton, Aretha Franklin, Ethel Waters, and Otis Redding before his death the year before.

Across the street and beyond a small brushy knoll is a two-story brick rooming house. 422 Main Street. On the second floor of this shoddy establishment, at the window of a small bathroom, a man named James Earl Ray waits with a 30.06 rifle. Ray has a clear view of the Lorraine Motel, of room 306 on the second floor.

It is one minute after six in the evening and, in the time it takes a bullet to fly the length of the knoll, everything changes.

Martin Luther King, 39 years old, has already survived one assassination attempt. Ten years earlier, on September 20th, 1958, a deranged black woman with the bewitched name of Izola Curr plunged a steel letter opener into his chest—his sternum actually—while he was holding a book signing at a Harlem bookstore. Three hours of emergency surgery at Harlem Hospital saved his life. The blade missed his aorta by a hair’s breath.

He will not be nearly so lucky this time…

 

In all of American history, surely one of the most atrocious acts of gun violence took place on the evening of April 4, 1968. No less a personage than George Wallace, the avowed segregationist, called the shot that rang out at 6:01 pm in Memphis, Tennessee “a senseless, regrettable act.” President Lyndon Johnson canceled an important trip to Hawaii—he had been scheduled to meet with his military commanders about strategy in Vietnam—upon learning of King’s death.

Over 100 American cities erupted into rioting on the news of what this single gunshot wrought: the stilling of the greatest single voice in the American civil rights movement, the Rev. Dr. Martin Luther King, Jr.

These facts are well known and not in dispute: King was shot at 6:01 pm and was pronounced dead at 7:05 pm at St. Joseph’s Hospital after a failed attempt at open cardiac massage. He was 39 years old.

According to King biographer Taylor Branch (At Canaan’s Edge: America in the King Years, 1965-68), King was standing on the balcony outside room 306 on the second floor of the Lorraine Motel when Jesse Jackson hollered up to him: “Doc, you remember Ben Branch?” King replied “Oh yes, he’s my man.” King then said, “Ben, make sure you play ‘Precious Lord, Take My Hand,’ in the meeting tonight. Play it real pretty.”

Ben Branch replied “Okay, Doc, I will.”

There was no reply.

King had spoken his last words, and in the words of biographer Taylor Branch, time on the balcony had turned lethal and King’s sojourn on earth went blank.

But did it? Did it do so immediately? Was King doomed the moment that bullet crashed through him? Is there any action that might have saved his life as he lay supine on that balcony. Bleeding profusely from a wound to his right jaw and neck? He wasn’t pronounced dead for 64 minutes. Was he, in fact, alive during that time? Was there ever a chance he could have been saved by the relatively crude trauma care of 1968? And how about today? If King was shot in 2013, might he survive?

The answers to these questions and more are interesting and worth pursueing. They illustrate, if nothing more, how far trauma care has come in the forty-five years since that fateful night. Based on a close reading of eyewitness reports, the autopsy filing, the 1978 House Select Committee on Assassinations’ investigation into the assassination of Martin Luther King, and other sources, I have put together a creative but nonfictitious account of the efforts to save Dr. King’s life in the 64 minutes that followed his shooting.

This is an intense, no holds barred look at what transpired in 1968, and an equally intense account of what might occur under similar circumstances today. If you have any interest in medicine, surgery, the drama of the emergency room, or trauma in general, you won’t want to miss this.

SAVING KING is about one of life’s harder moments. Available now for the Amazon Kindle. Just 99¢ & you can touch a piece of history.

Killing King

Click on the book image to buy for 99¢ for the Amazon Kindle

Now that’s damn interesting!

04/2/13

The Golden Hour

 

The Golden Hour

GoldenHourMore a concept than an actuality, the golden hour was devised in the early days of trauma research and is credited to Dr. R Adams Crowley, widely considered the father of trauma surgery. 

It is clear that the earlier a severely injured patient is brought to definitive therapy, the better the outcome. Once an injury occurs, the clock can be said to start running as regards additional, or secondary, injury. Blood is lost, breathing may be compromised, open cuts and abrasions invite infection, and internal injuries may lead to the loss of the normal internal milieu—by which is meant the normal physiologic environment. For example, rupture of the colon will spill fecal matter into the space around the intestines (the peritoneal cavity), potentially leading to peritonitis (a life threatening infection of the abdominal cavity). A crush injury to the arm or leg might lead to buildup of waste products in the local tissues (surrounding skin, fat, and especially muscle) if the blood flow is compromised. This waste buildup, a toxic stew, leads to further damage.

In another example, injury to the kidneys not only leads to bleeding (which can be severe since the kidneys are so well vascularized) but also to the spillage of urine. Rupture of the stomach can spill caustic digestive juices, including hydrochloric acid (leading to chemical burns and decomposition) into the abdominal cavity. Rupture of a lung can produce pneumothorax, wherein the lung collapses and is no longer effective at oxygenating the blood, with obvious ramifications. A tension pneumothorax, wherein each inhaled breath leads to progressive overinflation of the chest with resultant compression of the heart, is especially dangerous and often immediately life-threatening.

All of these entities and many more are likely to make their appearance in the first minutes or several hours after injury. In addition, once shock sets in, damage is progressive and ongoing. Shock has many definitions, the common denominator of which is a situation in which the tissues of the body are inadequately supplied with oxygen. It may come about as a result of circulatory collapse from loss of blood, a damaged heart no longer capable of pumping (as in heart attack), or perhaps from an absence of adequate oxygen in the blood (damaged lung, choking) or the environment (drowning, asphyxia, etc). The list goes on. 

The idea behind the golden hour is simply this: the sooner a patient gets to definitive medical care, the better. Definitive medical care is generally defined, in modern parlance, as a skilled trauma center with quick access to appropriate specialists, which might include neurosurgeons, trauma surgeons, orthopedic surgeons, critical care specialists, anesthesiologists, and imaging resources such as CT, MRI, etc. Note that this criteria often suggests a patient should be taken to the nearest trauma center and not the nearest hospital. This, in fact, is true and has lead to the modern system of designated trauma centers in most cities and regions of the United States.

Despite the term, it has come to be recognized that there is likely not an increased mortality after 60 minutes. The concept is a general one, in that there is increased mortality with increasing time after injury, whether it be 60 minutes or three hours. The term golden hour is a good one though, in that it continues to emphasize the importance of getting a severely injured patient to definitive care as quickly as possible. It also emphasizes prehospital care by EMTs, paramedics, etc. The concept, in practice, has saved countless lives, whether it be on the streets of inner city America—or the battlefields of Iraq and Afghanistan.

 

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03/19/13

The ABCs of Trauma

THE ABCs

The problem with head injuries is that much of the damage has already occurred when the patient arrives at the hospital. This primary injury, that is, the injury which occurs at the time of the accident and perhaps in the several minutes that follow, is not generally something that can be prevented except by primary prevention orod thru skullf the accident itself or through public health measures (such as teaching people not to dive head first into shallow water, or designing automobile steering wheel columns so that they collapse in a collision rather than impale the driver through his/her chest—indeed, such impaling was a common cause of death in the cars of the 1960’s and before).

Everything that happens after the initial few moments of an accident can be modified or affected by first responders, EMT’s, paramedics, nurses, and physicians. The goal of these folks is to reduce any subsequent injury, the so-called secondary injury. Indeed, prevention of secondary injury is the holy grail of the trauma system generally, and, in the case of head injuries, the neurosurgeon in particular.

What exactly does this mean?

Here’s an example. Let’s say a little boy climbs a tree, as little boys will. Unfortuantely, this little boy, call him Billy, takes a tumble and falls twenty feet or so to the ground. Billy’s sister, call her Jane, sees the whole thing and rushes to his side. Billy is unconscious, maybe he’s breathing and maybe he isn’t. Maybe his neck is broken. Perhaps he has a punctured lung. His leg is skewed something awful, so that’s probably broken too. And who can say whether or not Billy has internal injuries—a ruptured spleen, torn intestine, etc.

Now, all of these things constitute primary injuries. Everything Jane does from here on out will result in some degree of secondary injury. Some actions will lessen it, others might make things worse.

If his neck is broken, moving it could result in paralysis. This is secondary injury. Even if he is paralyzed, moving his neck could make the paralysis worse.

What about that broken leg? Is there a pulse in the foot? If not, every minute that passes without restoring the pulse results in potential injury to the muscles, nerves, sinew, etc of the leg. This too is secondary injury.

What if Billy is bleeding? If he is bleeding profusely, it must be controlled (stopped) immediately, or Billy won’t make it. Thus, one of the first things a first responder must do is look for and control bleeding. But it’s not the first.

It’s not the first because controlling bleeding in somebody who is not breathing makes little sense. You can win the battle and lose the war in such a moment.

It’s all very confusing at first, but there is an order to these things. Everyone, from trained first responders up the line to trauma surgeons, are taught to follow the ABCs of trauma care:

A—Airway, B—Breathing, C—Circulation, in that order.

A quick glance will often tell if a patient is breathing. If he is, the airway (mouth, throat, treachea) must be reasonably clear, if not check first that the airway is not clogged with teeth, blood, dirt, vomit, etc. These things will need to be removed if they are present. Once clear, does he breathe? Could be the lungs are damaged, or the chest compromised in some way (a punctured lung, for example). Some of these things can be treated on the spot, others less so. Finally, if the patient is breathing, is he circulating blood? Are his fingers and lips blue? Is he bleeding? Profusely?

These are the things which kill immediately or at least very quickly. Of course, the experienced responder does these things more or less simultaneously, followed by a more thorough survey of the patient. It’s all a work in progress though, with reassessment after reassessment after reassessment until the patient gets to a higher level of care.

Then the real fight to prevent secondary injury begins. More on that another time.

03/3/13

“Then, sir, you will go as a corpse.”

“Then, sir, you will go as a corpse.”

425px-Edward_VIIWhen Queen Victoria died in 1901 after more than 50 years on the throne of England, her  59 year old son Edward succeeded her. He was set to be crowned King Edward VII on June 26, 1902.

Twelve days before this, on June 14, 1902, the future king developed abdominal pain. He was examined by the physician-in-ordinary to the King (they have such wonderful titles in Great Britain), Sir Francis Laking. Edward worsened over several days and by the 18th Sir Frederick Treves was sent for. Treves was, at the time, the most famous and best known surgeon in London. 

Treves is known by many today as the physician who rescued John Merrick, the so-called Elephant Man, from his appalling life as an exhibit in a circus sideshow. This story was popularized in the movie The Elephant Man, in which Anthony Hopkins played the doctor.

Treves had originally gained famed by performing the first appendectomy in England in 1888. Appendicitis was a deadly disease at the time, and remained so for much of the first two decades of the twentieth century. At the time of Edward’s illness, surgery was usually considered only as a last resort.

Edward appeared to improve for several days, even traveling to London from Windsor on Monday, June 23rd and hosting a large dinner party for coronation guests. But that night he took a dramatic turn for the worse and by the following morning it was apparent to Treves and the other attending physicians that an operation was necessary to secure the King’s life. 

The King refused, not wishing to delay the coronation. It was at this point Treves uttered his now famous words, “then, sir, you will go as a corpse.”

The operation was carried out by Treves at 12:30 pm on June 24th, 1902. Lord Joseph Lister, who had discovered antisepsis and ushered in the era of antispetic surgery (which eventually made modern day aseptic surgery possible), was among those in attendance. The operation was carried out in a room at Buckingham Palace. 

Interestingly, the appendix itself was not removed, probably because it was too scarred in to mobilize easily. Instead, the pus pocket surrounding it was entered and drained through the front of the abdomen (today this is a routine part of treating any abscess—incision and drainage to the outside). The King recovered uneventfully, though it is said Treves did not leave his bedside for seven long sleepless days and nights.

Treves was made a Baron, among many other honors, and appendix surgery finally ascended to its rightful place in the British surgical lexicon. 

Ironically, Treves own daughter died of appendicitis.

Frederick Treves

Frederick Treves