The column this week is written about events that generate pride in our emergency medical services.  At the same time, there is disappointment in why these services are sometimes needed.  When  I  was a kid and not  doing  as  well as  my  father  thought  I  should,  he  would  tell me, “If  you  are going  to  play  lumber jack,  you  have  to  carry  your  end  of  the  log.”  That  admonition  has  application  as  below.

    The story begins with a gentleman doing his normal activities.  As he was straining slightly doing a home improvement, he had the sudden onset of severe pain in his abdomen. The pain was disabling.  He immediately stopped what he was doing  and returned inside the house with some difficulty.  On arrival there, he laid down on the kitchen floor because of the severity of his pain.  An ambulance was called and properly transported him to the hospital with all of the appropriate precautions.  Step 1: Compliments to the ambulance crew; they carried their end of the log.

    On arrival at the hospital, the nurse practitioner recognized very quickly that the gentleman had a severe medical problem.  She suspected that he might have a bleeding abdominal aortic aneurysm based simply on his history.  Appropriate attention to his pain and stabilization was carried out.  She then called to transfer him to St. Mary’s Hospital in Pierre.  Step 2:  She carried her end of the log.

    The AMR Ambulance Service from Pierre was summoned to pick him up arriving very promptly.  He was transported with great haste to St. Mary’s Hospital in stable condition with the appropriate precautions being taken in route.  Step 3:  The AMR Ambulance Service carried their end of the log.

    On arrival at St. Mary’s Hospital, word had already been received regarding the nature of the gentleman’s problem.  The first and most immediate need was to clearly diagnose the cause of the gentleman’s abdominal pain.  A CAT scan of his abdomen was done within minutes and the appropriate diagnosis of a ruptured abdominal aortic aneurysm was made.  Step 4:  The radiology department and the excellent technicians who work there with Dr.’s Barry Monfore  and  Kelly Krizan, the radiologists, carried their end of the log.

    An abdominal aortic aneurysm can be described as a bubble that occurs on the major blood vessel that carries blood to the abdomen and the legs.  This bubble represents a weakening in the wall of the vessel. Eventually, it may rupture and the person can bleed to death on the inside of their abdomen.  The only treatment is surgical and the patient usually requires many, many units of blood to transfuse and replace the blood loss that  has occurred.  If possible this type of surgery is best done in hospitals the size of Rapid  City Regional Hospital.  If urgently needed, the surgery could have been done at St. Mary’s Hospital in Pierre, but there is an extra strain upon the system with the need for  blood and post operative intensive care.  Thus, the next step was to decide if the gentleman needed to have the aneurysm fixed immediately in Pierre or would it be safer to transfer him to the Rapid City Regional Hospital.  At this point, the most important step in care was to lower this gentleman’s blood pressure so that the force causing bleeding was decreased.  This was done, and blood replacement provided as he had already bled approximately 50% of his total blood volume into the back of his abdomen.  It was elected to have him transferred to Rapid City Regional Hospital for definitive surgery and post operative care.  Within three hours,
the airplane had arrived and transferred him to Rapid City Regional Hospital for further surgical intervention.  Step 5:  The healthcare professionals at St. Mary’s Hospital in Pierre, South Dakota, carried their end of the log.

    It  is  hard  enough  to  care  for a case  like  this  in the hospital.  Doing it in an airplane is a tricky business.  Step 6:  High compliments to the Rapid City  Air  Ambulance  Service who delivered him  to Rapid City Regional Hospital in stable condition.  They  carried  their  end  of  the log.

    On arrival in Rapid City, he was taken directly to the hospital where a vascular surgeon carried out the repair of his abdominal aortic aneurysm.  He was out of the operating room by 11:00 pm, almost exactly 12 hours after his initial bleeding had begun. The aneurysm was repaired and his condition stabilized.  Step 7:  The surgeon carried her end of the log.

    The post operative course would predictably be difficult.  Managing fluid balance, blood replacement, prevention of infection, provision of nutrition, and re-establishing physical capabilities such as walking are all very difficult problems in somebody who has undergone an ordeal such as this.  All of those aspects of care are in process as recovery continues.  Step 8:  Rapid City Regional Hospital carried their end of the log.

    But now comes the disappointment.  This gentleman had known for many years that he had an abdominal aortic aneurysm.  He knew that he had high blood pressure and he knew that he had high blood cholesterol.  He had been prescribed medications for the blood pressure and the cholesterol.  He had been advised to discontinue his cigarette
habit.  Smoking cigarettes is the best single predictor of an abdominal aortic aneurysm.  I can say that in my 40 years in the practice of medicine, I have never seen an abdominal aortic aneurysm in a non smoking individual and I have seem many aneurysms.  He had been advised of this but continued his cigarette habit.

    This gentleman had not sought medical attention in the year and a half prior to his aneurysm bursting.  His medications had run out and he neglected to return to the clinic to have a renewal on his medications.  Thus his blood pressure was uncontrolled and as anyone can predict, too much pressure in a pipe is going to burst it.  That is what happened to this gentleman.  Step 9:  I don’t think this patient carried his end of the log.  By God’s grace, there were enough other people carrying their part of the log so that he survived this ordeal.  Even in the best of hands and  ideal conditions, a ruptured abdominal aortic aneurysm  is 90% fatal.  Only 10 out of every 100 people that have a ruptured abdominal aortic aneurysm survive.

    Our psychology books describe “denial” as a defense mechanism we use to cope with things that we don’t like or do not want to deal with..  I am reminded of the very first surgical patient that I ever had as a junior medical student clear back in 1963.  She had a cancer on her breast that was the size of an apple.  It had ulcerated through the skin and was oozing serum and pus onto her clothing.  She had put up with this for almost a full year and eventually came to the doctor to get some medicine to put on the sore on her breast.  Her breast cancer was diagnosed and she came into the hospital to have it surgically addressed.  As a naïve medical student, I asked her how long the sore had been present on her breast.  She replied that it had been there since spring.  It was now November.  I asked why she had waited so long before she came to the doctor.  She replied that she was afraid that it was a cancer.  In her mind if she simply denied the existence of the cancer, it didn’t exist.  As the psychology books will tell you, denial is not a very good defense mechanism.  It  seems that this would be the same tactic utilized by our gentleman today with the abdominal aortic aneurysm.  If he simply denied that there was a problem, as far as he was concerned there wasn’t one.  Until it burst.

    And so I pose the question that is the title of this article.   In regard to the maintenance of your health and well-being, who is going to carry your end of the log?
This and other articles are available at www.macpierre.com.