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Pinning Down the 'Death by Crushing' Legend

By Douglas Page,  1998

Urban legends are the crab grass in the lawn of medicine. They're impossible to stamp out, can be found growing everywhere, often even in emergency departments. Although no EP cares to admit to it publicly, some urban medical legends, in fact, may originate in the ED.

Four ingredients are necessary to make an instant urban legend, according to a folklore FAQ put together on the world wide web by Peter van der Linden and Terry Chan.

First, it must appear mysteriously and spread spontaneously; second, it must contain elements of humor and/or horror; third, it must make a good story; and fourth, it does not have to be false.

Most urban legends, of course, are false, or doubtful at best. Examples of false legends include the legend that nurses remove flowers from hospital rooms every night because flowers consume oxygen and oxygen is good for healing. Or that ear lobe repair is booming in New York City because thieves snatch earrings from women; that there is a flourishing body-part black market; that cell phones cause brain cancer; or that arc welders can fuse their contact lens to their cornea.

Some legends, though, have just enough truth in them to lend a sufficient degree of credibility to seduce the indiscriminate, providing grist for retelling - sometimes even by medical professionals. The death by crushing legend is an example.

In this legend someone is crushed by a commuter train, and the person's smashed internal organ's fall apart once the crushing object is lifted. The legend holds that the person is conscious and coherent while pinned under the train but dies immediately once the pressure is removed because his internal organs spontaneously disintegrate.

In the book "Emergency Doctor" by Edward Ziegler in cooperation with Lewis R. Goldfrank, MD (Ballantine Books, New York 1987, ISBN0-345-35664-0), a case is presented where a crane fell on a New York City women, crushing her legs beneath the object. "Both of her legs were pinned at a point 10 inches above the knees between an edge of the giant machine and the crumbled sidewalk," the book states. "As the crane came to rest, her right leg seemed to be almost severed and her left leg severely crushed."

As in most death by crushing urban legends, the woman remained perfectly lucid and was surprisingly calm, displaying an air of detachment that the authors describe as "tremendously impressive". "Hello, doctor," she is said to have responded when Dr. Goldfrank approached, indicating she was in command of her faculties and in a mood of calm resignation.

While waiting for crews to remove the crane Dr. Goldfrank remained with the patient. He stated her pulse and respiration looked surprisingly good. "My gravest concern now was turning to the moment when we got her free of the weight. Lactic acid builds up - a natural breakdown product of the body's own glucose metabolism with limited oxygen - in the compromised part of the lower extremities. This toxin when liberated to the systemic blood supply could cause complications, such as severe acidosis and shock. We planned to enclose her extremities in medical anti-shock trousers as soon as she was free, to support her mangled legs and to minimize both bleeding and the lactic acid problem."

In this case the woman survived. In the legend, patients such as this woman, perish from organ disintegration once the crushing object is removed. The phenomena may refer to a condition called rhabdomyolysis (also known as 'melting muscles'), a disorder involving injury to the kidney caused by toxic effects of the contents of muscle cells.

When the skeletal muscle is damaged, myoglobin is released into the bloodstream. Myoglobin is thought to occlude the structures of the kidney, causing damage such as acute tubular necrosis or kidney failure. Myoglobin breaks down into potentially toxic compounds, which can also cause kidney failure. Necrotic (dead tissue) skeletal muscle may cause massive fluid shifts from the bloodstream into the muscle, reducing the relative fluid volume of the body, leading to shock and reduced blood flow to the kidneys.

The disorder affects about one out of 10,000 persons of any age, sex or race. Rhabdomyolysis was first reported in 1881, in the German literature, but the major clinical sequelae were described by Bywaters ("Crush injuries with impairment of renal function", British Medical Journal, 1941;1:427) during the Blitz of London. The condition may occur after trauma; ischemia (including acute myocardial ischemia); excessive exertion from marathon running or calisthenics; bacteria and viral sepsis; electrical burns; injuries related to heat or cold; prolonged muscle compression as often seen in the unconscious state after alcohol or drug intoxication; seizures; hypokalemia; and shock.

The pathophysiology of rhabdomyolysis is uncertain, though it is thought to revolve around the fact that when extracellular calcium ions are transported into and accumulate within muscle cells, cell destruction can quickly follow, mediated by several mechanisms including the release of phospholipase-type enzymes. When muscle cells are destroyed, myoglobin and other intracellar components are released.

The condition, then, is one of toxic effect. Organs do not disintegrate.


Comments? Questions? Corrections? Assignments? douglaspage@earthlink.net
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