Word on Corzine Was Unnaturally Upbeat

By Marie McCullough, The Philadelphia Inquirer

Apr. 20–Cooper University Hospital trauma physicians face not only the challenge of saving New Jersey’s critically injured governor, but also of updating the public in a way that doesn’t sound too technical or terrifying.

So far, the doctors — and the governor’s staff — have erred on the side of vagueness and optimism.

A week ago, Gov. Corzine’s aide Anthony Coley said the governor would be able to resume his duties in "a week or so" — despite multiple and serious fractures suffered in the accident. Cooper trauma chief Steve Ross said he hoped the governor could be weaned from the ventilator "over the course of the next few days."

But today, the governor remains on a ventilator, his chest cavity full of tubes. Two drain blood and other body fluids; two more drip in an anesthetic to reduce his need for intravenous narcotic painkillers.

So how scary is the governor’s condition? It’s clearly not as rosy as the public was told last week.

In answer to a reporter’s question, Ross acknowledged that Corzine may have a "flail chest." This occurs when multiple ribs and sometimes the breastbone are so badly fractured that part of the chest cage is separated from the chest wall. This broken section can’t help with lung expansion during breathing.

A flail chest also indicates that the lungs have been badly bruised. The extent of lung injury largely determines the need for a ventilator.

"To get those fractures, you need enough force. And 99.9 percent of the time, you’re going to bruise the lungs," said Paul Kolecki, an emergency medicine physician at Thomas Jefferson University Hospital. "It makes sense because he’s been on the ventilator for a week."

Corzine’s doctors have said he has "injuries to his lungs," but that the ventilator is needed both because his fractures make breathing too painful and narcotic painkillers have suppressed his breathing.

Severe lung bruising "can lead to pneumonia, diffuse lung injury, and adult respiratory distress," Kolecki said.

Respiratory distress, which is fatal about half the time, is characterized by excessive fluid in the lungs, leading to respiratory failure.

Cooper physicians said chest tubes were placed to drain fluid "around" the governor’s lungs, and that these have had "no effect on his lung function."

All of the invasive tubes and devices that are providing life support also increase the risk of infection and dangerous blood clots.

Corzine is on a mild blood-thinner to prevent clots, his doctors said, but the blood thinner complicated the use of the anesthetic. Putting the anesthetic directly into the governor’s spine would have been more effective than into his chest, but "you run the risk of causing a bleed near that spine and paralysis," Cooper anesthesia chief Michael Goldberg said during Wednesday’s press briefing.

Getting the governor off the ventilator as soon as possible is vital, experts say.

"Because mechanical ventilation can have life-threatening complications, it should be discontinued at the earliest possible time," wrote Chicago pulmonary critical care specialist Martin J. Tobin in a 2001 journal article.

However, weaning a patient too quickly can lead respiratory distress severe enough to force them back onto the vent.

Vent patients should take 16 to 30 breaths a minute, with the machine intermittently forcing a breath if the patient does not spontaneously breathe.

On Wednesday, Corzine was drawing 16 breaths — eight with the vent, and six on his own, his doctors said.

Vincente Gracias, chief of surgical critical care at the University of Pennsylvania School of Medicine, said patients need to be able to draw 20 relatively deep breaths per minute on their own to go without a vent.

"Generally, you hope for three to five days" to remove the vent, he said. "If that doesn’t happen, the next goal is the 10- to 14-day mark. That’s when you start thinking, ‘This is going to be a long-term problem.’"

Contact Marie McCullough at 215-854-2720 or mmccullough@phillynews.com.

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Copyright (c) 2007, The Philadelphia Inquirer

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