It's beginning to look a lot like Christmas. Depression hits hard this time of year and suicides and idiotic drunk behavior abounds. Even more depressing are the tragedies that befall families when they gather together.

Take for example, Grandpa Henry who had decided that his city slicker grandchildren would love to have a tree house at grandpa's home when they visited beautiful arborous Knoxville, Tennessee. Grandpa Henry was busy cutting away smaller branches from this fabulous fort he was creating when the branch he was standing on gave way and he came plummeting to the ground by the grace of gravity. On his way down he was cushioned by multiple large branches that were to buttress his darlings' refuge. These branches caused multple bruises, but may have contributed to the devestating spinal cord injury or it may have been the hard ground below, I don't know.

What I do know, is that Grandpa Henry has suffered a devastating C5-C6 distraction injury (upper spinal cord injury) and upon transfer to our trauma bay was guppy breathing. Once you take out the nerve supply to the diaphragm, breathing becomes quite difficult. He was able to move only his right arm from the shoulder and the rest of him was as floppy as a marienet with cut strings. So Grandpa got intubated and a CT scan of his cervical spine confirmed his findings and got added to the list of educational Cspine films I have in the back of mind to show interns.

In my ICU Grandpa started developing neurogenic shock. His nerve supply that maintains the tone to his blood vessels became shot with his injury and just like his arms and legs, his blood vessels have become floppy and so his blood pressure began falling. So we started him on blood pressure medications, vasopressors.

Now don't be fooled, meanwhile the ICU is hopping... Grandpa Henery is so NOT my only patient. We actually have a young man who was in a motor cycle accident and ruptured his colon in his accident, another gentleman has had to have his colon transplanted and turned into a bladder conduit due to radiation cystitis and is having a difficult postoperative course, yet another gentleman is the Jehovah's Witness who would consent to surgery for his hip but not to blood transfusions.

So Jehovah (which is probably a very rude and sacriligious way to view him) had lost about a liter of blood in surgery and postoperatively his hematocrit was 16.6 (hematocrit is a percentage of red blood cells in your circulating plasma - normal is 40, our transfusion trigger is 24). His anesthesiologist for the case was very concerned about this critical hematocrit and despite Jehovah's vitals being near normal (BP 107/51 and HR 90), he demanded that the patient be placed under my care in the ICU.

Frustrated, cause really what can I offer a man who's primary need is a blood transfusion?, I gave up a highly needed ICU bed for Jehovah. As Jehovah was wheeled into the ICU our nursing staff explained to him why he was surrounded by patients with tubes and geegaws - his doctors were afraid he'd die from his severe anemia. He requested the paperwork to get his transfusion. Great. I was so glad that I got to do admission and discharge paperwork for a transfusion that he could have got intraoperatively or in recovery in addition to taking care of 30 other critically ill patients.

So I ignore poor Jehovah for the rest of the night, I've got so many other problems/patients, and my shift has been over since 6pm and its now 11pm. But who can keep track of time when Mr. Henton has become unresponsive and needs to be intubated, and Grandpa Henry needs a central line for his vasopressors, and we have to set the Motorcycle Kid up for an exploratory laparotomy?

I finally trudge home at midnight and thank Allah that I've moved literally 3 minutes from the hospital. I shower, prepare my Morbidity and Mortality presentations and lay down when Shanon calls me and tells me she needs another central line in Grandpa Henry, can I come in early and help. Sure, I'm on my way...

I'm finishing up my central line and suturing it in place, when Jo - a crotechety nurse who openly scorns the 'kid' residents comes ambling up to the bedside. "Miss Emma (don't ask me why she calls me Emma), are you 'here'? (asking if I was taking over Shanon's shift as the resident responsible for all concerns of the ICU patients)".

"What can I do for you, Jo?" I ask very politely, looking up from my needle work. To be quite honest, Jo scares me just a little and I'm quite in awe that she trusts me with her patients. "My little man, who got all the blood last night, has low blood pressure. His systolic is in the 70s"

Aware that Jehovah ran low blood pressures his entire hospital stay, I ask for a more precise number: "What is his mean pressure?" I locate my blade and nick the end of the of the suture.

"Why would you ask that? Its low" Jo replies tartly.

"I'll be right there Jo"

"Thank you"

I place a sterile dressing over the precious central line and walk over to Jehovah. Indeed his systolic blood pressure is 77 and his mean is 53. I place my hand on Jehovah's shoulder to make sure he is rousable (confusion and lethargy being some of the earliest manifestations of poor blood circulation to the brain)- "Good morning sir"

Jehovah woke right up. He looks me up and down.

"How are you feeling sir."

"Just fine."

"You look a lot better than when you came in last night." He had been as white as corpse for the lack of a more appropriate similie.

"You are a Muslim" he accuses in return.

"Yes sir, I am" I respond with amusement. Apparently enough blood is circulating through his brain for him to percieve what many in East Tennessee don't. (Remind me to tell you about the respiratory therapist who thought I was 'protestant')

"You believe in Allah" he further accuses.

"Yes sir. Allah is another name for God."

"God states Himself that His only name is Yahweh. It says so right in the Bible."

"Yes sir."

"Than why do you worship Allah?"

I recycle his blood pressure and it reads: 107/73.

"Jo, your patient's blood pressure is cured" I call out.

I now have one more strategy to treat hypotension...

and the day continued as before...