Cocaine, nosebleeds, and snakebites: lessons learned in a hurry and not forgotten.


Is cocaine the thing that you need,

When it comes to a nose that would bleed?

     Would some other med

    Do the same job instead?

It depends on the books that you read.

I did my residency in Wyoming.  Thirty years ago, I had a license and when I had a free weekend I could work where doctors needed help.  Most places paid fifteen dollars an hour; a seventy-two hour weekend could generate a lot of cash for a young man who had just finished twenty-one years of student poverty.  I soon found that the value of the learning experience exceeded the importance of the money.

In a large state with very few people, before the Internet, I found the pressure of dealing with medical problems outside my experience stimulated me to read, learn, and retain. 

Once, the ER where I was moonlighting got a call about a person who’d been bitten by a snake and would arrive within five minutes.  I had never seen a case of snakebite, but I went to the bookshelf, pulled down Rosen’s two volume Emergency Medicine, and read as fast as I could.  I looked up; no patient, but I had another minute before arrival.  I pulled down Harrison’s Principles of Internal Medicine and read what it had to say about snakebite.  The patient now three minutes late, I took a breath and started plowing through the books at hand.  Twenty minutes later, amazed at how much I’d learned in so short a time, I went to lunch.  The patient never arrived.

When confronted with a frightening nosebleed, Emergency Medicine provided me with a chapter that shines as a paragon of what medical writing should be: a review of the anatomy and physiology, elements of history and physical, proven techniques, and pitfalls, in a concise ten pages.

I faced an epidemic of nosebleeds at the Indian Health Service hospital where I worked fresh out of residency.  I could never determine if my hospital alone or if the area IHS hospitals in general had had their supplies of cocaine removed, nor for what reason.  I knew, for sure, that when I was confronted with the only legitimate use of the medication, nosebleeds, or epistaxis, I couldn’t get my hands on the drug of choice. 

We made do with 2% Lidocaine with epinephrine.  For a year and a half I saw a minimum of two major nosebleeds a week.  Most were the common variety, where the bleeding comes from the front part of the nose, but we also saw the terrifying bleeding from the back part of the nose.  I remember calling up the consultant in the big city at the other end of the highway and saying, “The patient has my best anterior (front) and posterior (back) nose packing job and he’s still bleeding, I’m afraid you’re going to end up ligating (tying off) his external carotid artery.”

“Nah,” he replied, “I haven’t had to do that for ten years.”

He called me the next day and said, “I had to tie off the external carotid.”

My experience with nose bleeds has stood me in good stead ever since, and yesterday I took care of two patients with that problem.  For one, I simply pinched the soft part of the nose shut for five minutes, and the bleeding stopped.  When I looked at the middle part of the nose, I found diffuse redness. 

The dry air in Barrow gets worse in the winter, and noses desiccate and bleed; most of those patients don’t need anything more than a little bit of Vaseline a couple of times a day.

When I looked at the other patient I found a snake-like varicose vein, the origin of the bleeding, about the length of an eyelash.  Numbing the area the way I’d learned in New Mexico, I touched bleeder with a silver nitrate stick for three seconds.  The nitric acid from the stick created a burn, and the vein stopped functioning as a blood vessel. It won’t bleed again.

It hurt like the dickens.  The Lidocaine hadn’t done its job as anesthetic, not like cocaine.

Advertisements

Tags: , , , , , , , , , , , , , ,

One Response to “Cocaine, nosebleeds, and snakebites: lessons learned in a hurry and not forgotten.”

  1. DAVE STERLING Says:

    Steve – as usual, you articulate your experiences in very good fashion. As with you, I am learning from what you have to say, but if they can’t fix it with a debit or a credit, them I am out in left field. But I do have a common sense approach to taking care of common medical problems. Marty Zucker used to ask me what medical school I had attended when I would tell him what I thought that he had to do. My answer was always the same “a better school than you went to”. I am not sure that he appreciated my humor, but I thought there was a certain amount of truth to what I said. My dad always said that all it took to get along in the world was good common sense. But as I got older I realized that common sense is not so common.

    We are getting some blowing snow right now. More blowing than snow. Temperature is going down to minus 9 tomorrow. I hardly notice the weather because I am putting in long hours in the office. Not only that but I bought an insulated coat at Menards a few weeks ago for the grand price of $20 (and with a hood) which keeps me warm in the coldest weather. It might even do the job if I were in Alaska.

    Irv Givot told me that CBS did not make a minyan a week ago at Shabbat services. I don’t know about this past week. We have to recruit more Jews or go out and get a few more that we can convert. I have been reading a book (and only one more chapter to go) by a Lubavitcher rabbi who talks about how God affects our lives, whether we understand or realize how that takes place. It is not a religious book, but his message is that we should open our minds and understand the connection between humankind and our creator. He illustrates what he says, and it does make sense.

    DAVE

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s


%d bloggers like this: