"Crump"

(not a typo of crumpets)

You get all kinds of odd words and phrases when you let scientists and doctors name things without strict oversight. One of my favorites is “bleb”. It’s the visual equivalent of an onomatopoeia. A bleb is when a cell membrane (or any other membrane for that matter) goes “bleb” and sticks out a little nubbin like a cat sticking their tongue out. This term was created by some lab gremlins with microscopes that watched cells go “bleb” and they got the official name in the published paper before anyone in admin or marketing got a word in edgewise. One of my favorites of these terms from medicine is “crump”. I do not know the providence of the term, nor do I remember where, when, or from whom I first heard it, but it is a particularly illustrative word.

To “crump” is to go off the end of a cliff in terms of presentation of illness. It’s when a patient that was doing well, or at least okay-ish, just heckin’ tanks. Their vital signs stop being worrying and start being terrifying, the patient will look like they just flopped headfirst onto death’s door, and it can be quite the cause for alarm sometimes.

For an example, I was scampering around doing my regular duties as an ER tech in the children’s hospital when we get a call from an urgent care saying that they’re sending us a kiddo that doesn’t look great. They aren’t sending the patient by ambulance because they’re mostly fine…-ish, but they need more of a workup than the urgent care can do. So, our charge takes report, and we make a note to expect a kiddo with a bit of a high fever that is feeling pretty crummy.

They showed up in the lobby and got moved into a room fairly quickly by ER standards. It sounded like the kid was having a rough go of it with a nasty virus, but their vital signs were mostly okay. A little feverish, a little tachy, breathing a little fast—all to be expected with a viral illness. One of the mid-level providers with a couple decades of experience signed up for the patient. She had quite competently dealt with much worse than this before, and no need to add more to the already overwhelmed ER physicians’ plates. So, she reviews the notes and looks at the labs that the urgent care had already done, and went to go examine the patient.

Now, normally, for Caucasians, you expect them to be a sort of peachy color, maybe a bit pink or flushed red if they have a fever. What you don’t expect is a sort of yellow-ashy grey. It had only been a few minutes since the nurse had gotten the last set of relatively okay vitals, but that was enough time for the kiddo to fall off the proverbial cliff. The kiddo had well and truly crumped.

The mid-level provider snags me as I’m walking by and promptly re-tasks me with bringing the patient to the resuscitation bay while she runs and grabs a physician and a few more nurses. What followed was the usual chaos that tends to occupy the resuscitation bay while nurses and ER techs scrambled to get an IV started and get blood for labs, because this quite obviously was not a run of the mill viral cold.

The physician, a normally calm, jovial man with a kind voice and a dry wit was the one running this code. When the nurses had tried and failed to get an IV started to get blood work for labs, he stepped in giving orders and instructions in a calm, stern tone. I was new to this role, but not new to him as I had previously been his scribe. Despite my short tenure in the role of ER tech, he picked me out and ordered me over to assist with getting a femoral line.

The nurses were having trouble getting an IV because the kiddo’s blood pressure had dropped and they were fairly dehydrated to begin with, but the physician needed those labs literally as soon as possible. In ERs, veins are typically the domain of nurses, and arteries are the domain of physicians, just because of the risk involved with sticking needles into actively pulsating blood vessels.

In contrast to the difficulties with the IV, the physician had me position the patient appropriately then swiftly and deftly slid the needle neatly into the femoral artery in one smooth movement. A nurse was tasked with getting the tubes of blood needed for the labs, and I was tasked with holding pressure over the femoral artery the second the needle had been removed because arteries can’t be used to deliver fluids or meds. It was an odd place to be, in the center of the chaos, doing nothing besides holding pressure to prevent bleeding while the cacophony continued on around myself and the patient.

By this point the physician had completed his assessment and had left to place orders for the labs to be run, medications to be given, and a STAT transfer to the PICU. Eventually, the nurses got the IV in and started the ordered fluids and medicine, and the kiddo was already looking just a little bit pinker.

I didn’t do very much for this case; I was mostly just an extra pair of hands for the physician and the patient transporter, but it was a very valuable lesson. Speaking to the physician later that night, I asked him what kinds of signs I should look for to find out whether a patient is about to crump or if they’re going to stay stable. He didn’t really have an answer for me, because there isn’t really an answer for that except to see thousands of patients and observe which ones crump and which ones don’t.

Medical school involves a lot of reading, a lot of lectures, labs, and memorization, but all that really is, is the foundations for building your heuristics as a physician. So, years or decades from now, when I’ll have been a physician longer than most medical students have been alive, maybe I’ll be able to figure out which patients are going to crump before they actually do so; but in the meantime, I’m just going to have to watch, listen, learn, examine, and frequently recheck my patients until I can sort the ones that are just generally feeling kind of miserable from the crumpers.