Another one

This is another wild and crazy image from the radiology department. This comes from a patient who had a collapsed vertebral body in the thoracic spine. The patient had previously had surgery to repair an aortic aneurysm - the dotted circle is a cross-section of the prosthetic aortic graft. The big grey thing in front of the dotted white circle is the heart.



The needle enters the collapsed vertebral body. We took samples to look for evidence of infection or tumor. In this case, the bone was not so much a sheet of bone as a bunch of bony fragments held loosely together with inflammatory tissue, so it was easy to get the needle through. Had the bone been more solid, we would have used a bigger needle and a mallet.

You can see the spinal cord unusually well - it is the darker area within the lighter area of the spinal canal, looking almost like an eye. This is not what the spinal cord normally looks like on a CT; usually the spinal cord and the fluid surrounding it are nearly identical in color. But, this patient had a myelogram prior to the procedure, in which we do a spinal tap and inject material that shows up well on x-rays. Thus, on this image we get a really good shot of the spinal cord.

Some guys have all the luck

This 19-year old man was "minding his own business" when he heard four gunshots and felt sharp pain across the front of his chest. He saw some small wounds on either side of his chest, and drove himself to the hospital.

His blood pressure and pulse remained normal. He had no trouble breathing.

A CT of his chest showed the following:



The dark spots across the front of his chest are specks of air in his pectoralis major muscles. There were skin defects at the upper right and left chest, but no other injuries. Basically, the bullet did the following, missing everything else important:

Knife and Gun Club

When I am working in the Emergency Department, I see the CT scans and X-rays of nearly every injury that comes into the hospital. I am getting really discouraged by the superabundance of some specific injuries:

1. Gunshot wounds to the spine. Way too many teenagers and young adults are forever paralyzed from the neck or mid-chest down as a result of careless or, more likely, malicious people shooting them. I'm not sure what these patients were doing to induce others to shoot them, and I really don't care that much. Although I am sure that a significant proportion of those who are shot were engaged in illegal activities at or shortly before the time they were shot, it doesn't make me feel any better about these patients whose lives are now infinitely harder than they would otherwise have been.
   
   To wit, they will, for the rest of their lives, have no bowel or bladder control. They will need surgery to enable them to put catheters into their own bladders or to divert their urine into a hole on their abdomen so that it can be collected in a bag. They will either need surgery to divert their feces into a colostomy or will need their diapers changed for the rest of their lives.
   
   Of course, they also will be unable to move independently for the rest of their lives.
   
   I am further disgusted that these patients are now wards of the state. You and I, the taxpayers, are and will be paying for the lifelong care of these patients - for both the cost of their surgeries and the salaries of those who change their diapers and roll them around in bed. It sickens me that these patients are only unable to care for themselves because some other person made a rash and/or evil decision to pull the trigger of a gun.
   
   
2. Gunshot wounds in general. Way too many people get shot around here. Gunshot wounds are devastating injuries, shattering bones and organs alike, and causing all kinds of mayhem. While many people survive their injuries, those who get shot in the head tend not to.
   
   
3. Motorcycle accidents. These are a touchy subject for many motorcycle aficionados, but let's get real - every day I see horrible injuries sustained by people who are doing innocuous things on a motorcycle. For example, this man was riding his motorcycle at 10 miles per hour.
   
   
   
   He got clipped by a car, which shattered his left foot. He had to have his leg amputated below the knee.
   
   No matter whose fault it is, a motorcycle accident will always leave the motorcyclist in a world of hurt.
   
   
4. Lung Cancer. This is another subject that gets me somewhat upset. Way, way too many people are dying early because of smoking and its deleterious effects. Take, for example, this woman. An ordinary chest CT would have lungs on both sides of the chest, with the heart on the patient's left.
   
   This woman's heart has been displaced into the right side of the chest by this enormous aggressive mass that replaces pretty much her entire left lung.
   
   
   
   It is also making its way out of the chest cavity by bulging out between the ribs. What a crummy way to die.
   
   
   

Anyway, those are four of the most preventable problems in our society, and we see far too much of them. I wish, like Alma, that I could cry repentance with the voice of thunder, that all men everywhere might repent, that there might not be more sorrow upon all the face of the earth.

EtOH

After an experience I had the other day, my conviction that alcohol is not for the body and not good for man is much stronger.

I was reading CT scans from the emergency room, and a young man came in who had been backed over by a slow-moving car. His pelvis was smashed to smithereens, and he suffered facial fractures.

I was chatting with some of my associates about how he could have sustained such an injury, when it occurred to me to ask if his blood alcohol level had been measured when he came to the ER. It was twice the legal driving limit. I am sanguine that the blood alcohol level of the driver that backed over him was also quite high.

The next patient was a man who had fallen off his bicycle while attempting to get on it. Passersby noticed that he was struggling to get up and summoned the police, who brought him to the hospital. His alcohol level was 4 times the legal limit.

The next patient had been assaulted and stabbed. He was also drunk.

For the next several patients, I inquired as to the alcohol level of the patient. Every one of them had been too drunk to legally drive when they arrived in the emergency room - meaning that their blood alcohol level when they were injured was even higher.

Now, there could be a number of confounding factors in this sample; perhaps the emergency room has a lower threshold for ordering CT scans on drunk patients because the physical exam is less reliable, or maybe it was random chance. However, it is clear based on my experience that being drunk is a risk factor for being irradiated if you go to the emergency department. I would also suggest that, based on the mechanisms of the injuries I described above, being drunk is a risk factor for being injured.

So unless you want me to see some really embarrassing pictures of your insides, it's best not to drink alcohol in Sacramento or its environs.

Guns and coumadin don't mix

This is a patient who came in after reportedly shooting himself in the forehead with a 25-caliber handgun. He was reportedly taking coumadin, an agent that is used to keep the blood from clotting.


Incredibly, when he arrived in the emergency room he was alert and conversant with the ER staff. They saw the entrance wound on his forehead, but couldn't find an exit wound.

The first image they took was an x-ray of the skull.



The white thing just at the level of the nose is the bullet. The little arrow on the forehead is a marker that the emergency room put on the patient to show where the entrance wound was. It also shows the skull fracture that ensued from the bullet wound.

When he became unresponsive, they rushed the patient to the CT scanner to get a better idea of what was going on in his head. This is what they found initially on the "scout radiograph" - the initial image they take to plan where they will take "slices" with the CT scanner.





This is a side view of the skull. Again, the dot on the forehead shows where the bullet entered the head. The bright thing in about the middle of the head is the bullet, which is embedded in the soft tissues at the back of the patient's mouth. The dark oblong shapes in the middle of the head should not be there - those are indicative of air within the space that should be filled with brain or cerebrospinal fluid.




This is a slice through the patient's head at the level of the forehead sloping back just above the ears. The black dots throughout the head are collections of air that are moving around within his shattered skull. The white rounded area near the top of the image is clot and blood within the brain, marking the path the bullet took as it went down through his forehead, through his nasal cavity, and down into the soft tissues at the back of his mouth.





This image shows the exact path that the bullet took. It is a side view through the head showing the wound (at the upper left of the image) with the bone fragments traveling diagonally downward until you get to the bullet (the bright rectangle at the bottom center of the image).

Suffice to say, this was a non-survivable injury and the patient soon succumbed to increased intracranial pressure - probably from bleeding into the space that should be holding his brain. Gross!

So much stuff!

I came home from work the other day and started unloading the pockets of my scrubs onto the kitchen counter. My wife stared as I pulled out more and more things - it was reminiscent of the scene from Mary Poppins when Julie Andrews starts pulling potted plants and hat stands out of her carpet bag. Eventually, my wife shook her head and said, walking away, "you need a purse."

This is a picture of the things I carry on my person at all times. Clockwise from the top: my radiation badge (essentially a piece of Kodak film that gets tested every three months to see how much radiation I have been exposed to), my keys, my ID badge, my wallet, my cell phone, my pager, my little pre-inked stamper to put my name and ID number on orders that I write, and my car keys. In the middle are my iPod and pen.

If you think you are having a bad day...

This is one of a number of images of a patient that I saw in the emergency room the other day. That is, I saw the images. I did not actually see the patient, and I am kind of glad.

This 22-year old man allowed a homeless man to stay at his house. The patient had a disagreement with his guest - I have a sneaking suspicion that alcohol was involved in the disagreement, as the patient's blood alcohol level was twice the legal driving limit when he arrived at the hospital - but regardless of the cause, the homeless man shot the patient at close range with a small-caliber weapon. The patient presented complaining of being unable to see.

The attached image is from his CT scan. The marked circles are the approximate locations of his eyeballs; the arrow shows the path of the bullet. He had no injuries to his brain, but both eyeballs were shattered and full of air, blood, and bits of bone and metal.



Surgery revealed irreparable posterior eyeball lacerations with protruding tissue and multiple metallic fragments inside both eyeballs.

Whenever you feel like you are having a bad day, just remember that it could be worse - you could be this guy. I shudder to even look at these images.

The world of barium

Double contrast barium enemas, I have decided, are among the most innately beautiful of the radiology studies we do. A colleague and I were discussing how some of these studies are nice enough to hang on the wall. See the following: