Anybody Have a Pen?

Christmas may have come and gone, but there's still one shopping day left until a self-imposed ban on pharmaceutical company knick knacks goes into effect on January 1st.  The ubiquitous free pens, clip boards, and note pads will go the way of Polaroid film and no longer be found strewn about the ER.  To commemorate their passing, here's a blog dedicated to showing off the wide variety of pharma bling.  I'm especially fond of the Toprol Swiss Army knife.

Mixed Drinks

As we're all swigging champange tomorrow night in celebration of the New Year, be sure not to follow it with an Antabuse chaser.  A few months ago we had a chronic drinker who imbibed while on the medication designed to treat alcoholism, and experienced a nasty reaction with a heart rate in the 130s, low BP, altered mental status and vomiting so severe that he required intubation to protect his airway.  Doesn't sound like my idea of a good time.

And speaking of bad times, I've yet to understand occasional drunks in the ER.  Our regulars, I know, see the ER as their second home and many are operating under the "three hots and a cot" philosophy.  I get people who push their limits, end up overdoing it, and learn their lesson after a night in the ER (though I still think it's the result of bad friends not looking out for each other).  What I don't get is the group that decides to get violently drunk every couple months.  They don't like coming in, and we certainly don't like having them take up space, so nobody wins.  

Channel Surfing

I'll admit that I haven't been the most productive member of society over the past several days as I've partaken in multiple TV marathons while enjoying my break from school.  And while I've become good friends with the remote control, I have yet to feel the need to take it with me when I leave the house.

One patient from a couple weeks ago, however, insisted on the companionship of her clicker as EMS brought her from home to the ER.  An older woman with altered mental status, she arrived with the remote clenched firmly in her left hand, where it remained for the duration of her visit.  Try as we might to get her to let go, she held on to the damn thing with the jaws of life.  Parked in the hallway, she continued to press the channel button while muttering to herself, and brought the remote with her to X-ray and even the bathroom.

I figure it'll only take one or two more days on the couch before I'm in the same state.

Helping Hands

Our ED is lucky to have some great volunteers who pitch in and help things run as close to smoothly as possible in the Big City.  In thanks to them, here's a profile of a ER volunteer from White Plains, NY.

Think for Yourself

Each of our exam rooms used to have telephones mounted on the wall for patient use.  They have since been removed out of concerns that suicidal patients might try to hang themselves with the cord.  In their place, we were given three or four phones that we can plug into each room's jack.  They lasted almost an entire week before being broken, and now every time a patient needs to use a phone (not an unreasonable request), we have to beg, borrow, and steal one of the cordless units.  

Meanwhile, suction tubing, monitor cables, oxygen tubing, and bedsheets remain in the room, ripe with potential use.  Nevermind the fact that suicidal patients are directly observed by a staff member, or that rooms upstairs keep their phones in place.  Who comes up with these decisions?

Say No To Drugs

Earlier this week, Nurse K wrote about the sad reality of hard-core drug addictions destroying people's lives, and reminded me of a patient from several months ago.  She was in her late teens or early twenties, but looked at least 50.  Her thinning hair still had some hints of blond, but was mostly grayish-tinged.  Receding gums left her with a toothy smile and track marks lined her arms, but her most distinguishing feature was a large patch of necrotic tissue on her arm - a failed graft that fell victim to skin popping.  Impossible to know what in her life turned her to drugs, but certain to say that they were rapidly killing her.  She appeared in the ER several times over a two week period, and then stopped coming in.  Whether she finally ODed or simply moved on to another hospital I couldn't say, but it's terrible to watch people killing themselves before your eyes.  

White Christmas

I first knew the holidays were approaching when Jose Cuervo substituted signing his standard slurred rendition of "Don't Stop Believing" with "Feliz Navidad" at triage.  Now that I'm home with our tree lit up and snow falling outside the window, I know they've arrived.  Merry Christmas everyone!

I'll Be Home for Christmas

Every so often, it's nice to score one for the home team.  A couple weeks ago I was working trauma when I saw a nurse grab a defibrillator and run to a patient's bedside.  I followed and found a middle-aged male with PEA on the monitor who had come in for an unrelated complaint but suddenly went into arrest.  I immediately relived the nurse doing compressions and brought him up to a rate of 112 (humming "Stayin' Alive" of course), while she grabbed drugs from the crash cart.  We did a round of CPR and meds while the resident intubated the patient, then paused for a rhythm check, saw V-fib on the monitor and shocked him into rapid A-fib.  

It was one of those rare examples where everything went right.  Witnessed, in-hospital arrest followed by rapid defibrillation.  Everyone from the attending down to me worked seamlessly together, doing exactly what needed to be done without wasted effort.  It was one of the smoothest-run codes I've ever been in, and I learned just before I left for break that the patient had left the hospital and was doing well.  

For another perspective on codes from someone concerned with more than just adequate compressions, go check out Shadowfax's recent post and his link to Happy Hospitalist.

Silent Night

Keepbreathing posted about the quiet lull that seems to settle in a hospital before the rush of the holidays arrives in full swing.  For me, there's nothing eerier than an empty ER.  Every so often, we shut down one half of the department after midnight so the floors can be waxed.  It's like a scene from some apocalyptic movie: empty chairs with sweatshirts still thrown over them, computer screens still lit with no one to look at them, treatment rooms with monitors beeping but no stretchers.  Just seems unnatural for the hallways to be devoid of parked stretchers and a steady stream of organized chaos.

And that's part of the problem.  While ER abuse and overcrowding are dangerous but well-discussed problems, this article points to liability they pose for disaster preparedness.  According to the piece, more than half of Southern California's hospitals are on diversion at least 20% of the time, and up to 75% of teaching hospitals are either at or over capacity in their EDs at any given moment.  Persistent bed shortages and packed ERs severely limit a hospital's surge capacity in the event of a large-scale emergency, adding yet another pressing reason to reform the state of emergency care.  As one industry observer states, "If Southern California's hospitals can't handle patient inflow even during the course off a normal day, I have grave doubts about how the region would do in a disaster scenario."

All I Want for Christmas

Dear Santa Claus,

I have been an extra good ER tech this year, and this Christmas I would like a brand new running watch.  My current one still keeps the time, but its buttons do not work, and it will randomly reset the timer during a run.  This is very frustrating.

I will use my current watch at work only, instead of bringing it home to run with.  This will give the bonus gift of not transporting more MRSA of the ER.

Merry Christmas,

Second Shift

Disturbing Trends

Just in time for the end of final exams comes this sobering article in the New York Times announcing that 25% of US medical students graduate at least $200,000 in debt.  The explosion in costs just within the past 10 years is amazing.  And people wonder why no one's going into primary care.

The median cost of attending your state medical school is $44,390, and private schools average $62,243 per year.  That translates to a whole bunch of shifts in the ER once I return to the Big City after a couple weeks at home.  

Let It Snow

Snowball fights are much more fun than studying for my last exam tomorrow.  And the chorus of ambulance sirens makes me glad I'm not working tonight.  Drive safely everyone.

Stocking Stuffer

Still looking for last minute gift ideas for that hip alcoholic who carries an iPod in one hand and a bottle of Listerine in the other?  Well stop your search, because the Chicago Tribune has found the perfect solution: an iPod breathalyzer.

But wait, there's more!  Not only does the $79 iBreath set off an alarm if you blow over 0.08, but it also comes with a built-in FM transmitter.  Says the founder of the company that makes the device, "We figured, OK, if it's only a breathalyzer, the chances are this thing is coming off the iPod and sitting in the drawer."  BUT, "if we put in the FM transmitter, they might keep it on there."  Neato!

He goes on to say that kids "don't listen to their parents, but they listen to their iPods."  Promise?  If I gave an iPod with a looped recording of me yelling "stop drinking" to every drunk who came in, would we suddenly have a lot more space in our hallways?

The president of Mothers Against Drunk Driving has an alternate suggestion to relying on the iBreath to tell you if you can drive: "There's no need to risk hurting yourself or other innocent people when you can simply plan ahead."  A (free) designated driver instead of an expensive gadget?  How lame.

...It Pours

As the yin to Wednesday's yang, last night's shift saw the oddballs replaced with some pretty critical patients that started to arrive just as I tried to grab dinner.  

Topping the list was a major trauma: single passenger MVC rollover with ejection from the vehicle.  Bilateral open tib-fib fractures and a nasty forearm fracture.  While rolling the patient to examine the back, I attempted to stabilize the arm above and below the injury, but could still feel bone fragments shifting from within (cool experience, but sucked for the patient).  Difficult airway prompted an emergency page to anesthesia and the cracking open of a trach kit, but our ED attending managed to get the tube after the resident was unsuccessful (my second near miss of getting to see a trach in the past few months).  A nasty-looking scalp lac exposed the skull for all to see before being quickly closed with a staple gun.  Poor guy went straight from CT to the OR and eventually the ICU, where he'll probably remain for the foreseeable future.

As soon as we finished packaging the MVC for his trip upstairs, an elderly woman with a massive GI bleed was rushed into our critical care area.  Within minutes her stretcher was steeped in a pool of blood, resulting in opening of the O-neg fridge and a quick run up to the blood bank for type-specific.  Managed to get her upstairs as well before the string of three minor MVCs and one dropped cheerleader rolled in back to back.  

I eventually made it to dinner three hours later.

When it Rains...

One bizarre patient early in the shift usually sets the tone for the rest of the night, and yesterday was no exception.  

Crazy Chest Pain Guy was getting triaged right as I walked in.  Crazy Chest Pain Guy is crazy, and apparently has a lot of chest pain (to the tune of several hundred negative workups over the past few years).  Crazy Chest Pain Guy will sit in a bed for hours, smacking his lips, and repeating, "Yup, it hurts real bad" until he goes home.

From that point on I knew I was doomed.  My first actual patient was Flat Affect Girl, a young woman who came in for a twisted ankle.  No history according to her chart, but she seemed totally spaced out and more than a little off.  Could have been the result of Overbearing Mother, who hovered over me every time I entered the room, asked me about everything I was doing, and then repeated was I said to her daughter in a sing-songy voice.

Next on the list was a demented old woman in the hallway tugging at her catheter and trying to climb out of the stretcher.  Nothing's better for a laugh than when I put on my super-polite voice and try to calm her down, fluff her pillow, and tuck in her blankets while everyone's watching, only to have her scream "Go to Hell" as I walk away.

And finally,

Foul-Smelling Patient.  I've had plenty of stinky ones in the past, and I'm an expert at breathing through my mouth to avoid wafting the fumes emanating from unwashed patients' folds, but this one was so bad that as soon as I finished the EKG and left the room, I had to immediately step outside for some fresh air.  No joke, my eyes were watering. 

Fluid Balance

Took advantage of a brief lull in the action last night to run down the street and grab some coffee.  On my way out the waiting room doors, I passed by one of our recently discharged patients staggering down the sidewalk, clutching his plastic belongings bag.  He had only advanced a few feet by the time I returned, and as I sipped my caffeine before heading back in, I had the treat of watching him relieve himself all over the wall of the hospital.  Just another satisfied customer I guess.

Unidentified Male

Patch came in for a traumatic cardiac arrest, unknown downtime.  EMS arrived shortly thereafter, delivering a middle-aged male with paramedics performing knowingly futile compressions.  I helped transfer him to our stretcher before attaching leads to the pale body.  Fingers were too cold for the sat probe to get a reading, monitor showed asystole on two leads.  Pupils fixed and dilated.  Ultrasound revealed no cardiac activity.  The trauma team pronounced him, and everyone left the room while a nurse and I stayed behind to clean up the body.

He had been found underneath a third floor balcony; when we removed the collar his head rolled around independently from the rest of his neck below the break.  Remarkably there didn't seem to be any other injuries.  

No ID on the body, no family followed him in.  Never learned what happened.

Public Service Bumper Sticker

Did a double-take on my way into a final this morning as I passed by a car parked on the side of the street.  Prominently plastered across the rear fender was a large bumper sticker that in lieu of the typical political names or band logos instead displayed "VRE KILLS" and a local phone number.  I didn't have time to write down the number, and the car was gone by the time I finished, but you can bet the next time it drives by I'm going to call in.  

Holiday Cheer

We had our own minor Miracle on 34th Street the other night when a patient's son went out of his way to thank the staff who treated his mother.  I was in the middle of drawing blood cultures on a sweet older lady when the son walked in, looked at my ID badge, and said "Second Shift, I'm going out to buy coffee for everyone who's taking care of my mom, would you like some?"  

Of course my initial reaction was to assume this was a clever attempt to poison me and I politely refused.  But lo and behold a little while later he returned to the nurses station with several cups of coffee for the staff.  After his mother was discharged he came around once more and thanked every member of the patient care team.  Maybe it was the holidays or maybe he was just an unusually nice guy, but little acts of kindness like that almost restore my faith in humanity.

No Work Note For You

Tired of being overrun with non-emergent complaints, one Georgia ER has decided to direct the sub-acute population to less expensive options and attempt to "teach people when they should or shouldn't use the emergency room."  To counteract the increasing number of people turning to their local ER as a means of free primary care, Culquitt Regional Medical Center now asks non-emergent patients to prove they have insurance or the ability to pay. 

While something certainly needs to be done to stop people from seeking emergency treatment for toothaches or prescription refills, I'm curious to see how this policy will play out under EMTALA.  It's thanks in part to the unfunded federal mandate that we have so many people seeking free ER care in the first place, but because of EMTALA we can't turn them away.  Will patients be asked about their ability to pay after receiving the medical screening exam?  How long will it take for a lawyer to strike after a patient triaged as non-emergent crashes on their way to the clinic down the street?  It won't take long to find out.

Lunar Lunacy

I never used to be superstitious before working in the ED, but now I know better.  Tonight's a full moon on a Friday night and, what's more, it will appear 14% larger and 30% brighter than any full moon this year.  That's almost enough to make me glad I'm stuck studying for a Saturday morning final.  Good luck to everyone working tonight.

Take it Like a Man

Took care of 29 year old male complaining of a 9/10 headache last night.  This dude was obviously in agony, but refused narcotic pain medication each time it was offered.  Fine by me, but refusing the good stuff didn't prevent him from using his cell phone to place several calls to his mother from his treatment room.  Every 20 minutes or so I'd get a call from the secretary saying the guy's mother was calling the ER demanding to know why her son was in pain, but every time we'd offer meds he wouldn't take anything stronger than Tylenol.  

If you want to act tough that's cool, but don't expect us to buy it if you cry to Mommy every time we leave the room.

Fly the Friendly Skies

If I ever go into cardiac arrest while in flight, I certainly hope it's in the back of medical helicopter.  While waiting for a patient to be airlifted to our cath lab, we received a call from the chopper informing us that the patient had started coding mid-flight.  Rushing a code cart and meds up to the helipad with a couple of nurses, I got to run out onto the roof in the middle of the night to unload the patient with the rotors still spinning.  By the time they touched down, they had shocked him back into sinus, and we headed straight to the cath lab.

Every time they come through, I'm always really impressed with the flight crew.  About a year ago, one of the nurses from our department left to become a flight nurse, and described the incredible amount of knowledge they need to possess before they leave the ground.  The team usually consists of an RN and paramedic, with one or both also certified as a Respiratory Therapist.  Working highly independently in cramped spaces with critically ill patients several hundred feet in the air sounds like a pretty cool way to make a living.

Final Exams

As I'm trapped in he library studying for upcoming exams, it's at least comforting to know that my grades should (hopefully) look much better than the C+ average given by the American College of Emergency Physicians 2009 national report card.  WhiteCoat has a link to the report, including a rather grim breakdown assessing why we aren't doing so hot.

This Week's Sign of the Apocalypse

First it was that idiot Plaxico Burress who shot himself in the leg when his own handgun slipped down his pants.  Now the Chicago Tribune reports that Bulls guard Derrick Rose required 10 stitches to his forearm after he rolled onto a knife he was using to eat an apple in bed.  In the ER, we have a hard enough time keeping a straight face when regular people do stupid shit like this to themselves.  I can't imagine what we'd do if a professional athlete with a multi-million dollar salary ever rolled in.

Investigative Journalism

It seems that most major news outlets are on a continuing cycle to "re-break" the news that emergency departments across the country are dangerously overcrowded.  Just in the past week, both the Wall Street Journal and the New York Times published articles (here and here) on this painfully obvious fact of life for our current system.

It's the same song heard countless times before; ERs are overcrowded and short-staffed, uninsured and under-insured patients are abusing the ER as a source of primary care, while even those with insurance are forced to sit in waiting rooms because they can't get an appointment with the dwindling number of overworked and underpaid primary care physicians.  The Times article throws in the contradiction that many ERs are being pushed even further beyond the breaking point by those who can no longer afford health care costs in light of the recession, while other ERs are emptying out as struggling individuals avoid seeking treatment to prevent devastating medical bills.

Unfortunately, though the problem is exceedingly well-defined, no one (including myself) seems to have a convincing solution.  And until that changes, we can expect to see these same articles again and again.

The Unusual Suspects

Unusually slow Monday night ripe with unusually interesting patients.  It all started shortly after I arrived, when I saw two nurses running over to a bedside in the critical care area.  That's never a good sign, so I followed and discovered a patient's wife had syncoped while waiting with her husband.  Grabbing a stretcher, I helped hoist her off the ground and into trendelenberg before checking a set of vitals - heart rate in the low 40s, good pressure but clammy skin.  We had a pair of his and hers stretchers parked next to each other until she got back on her feet.

Later, I had the chance to watch my first thoracentesis as a resident stuck a long needle into a patient's back under the guidance of ultrasound to drain fluid off the pleural space.  Parked in the next room over was a woman who had been hearing things roll around in her head for the past month, and finally decided she could no longer take the noise.  While trying to ignore her, I went to do an EKG on an older gentleman, and when I rolled up his pant legs to place the limb leads, noticed his legs were completely blue-black.  Learned later that it was caused by a reaction to the antibiotic minocyclin.  Rounded out the evening by playing charades to communicate with a stroke patient as a screaming drug seeker serenaded the department.  All in all, not a bad night.

I'm Sorry, I Thought You Were Crazy

While making my rounds to update vitals the other night, I opened a curtain to find a middle-aged woman sitting on the stretcher, waving her arms frantically and speaking very rapidly in a shrill voice.  Glancing around to be sure, I realized that she was talking to herself.  That's not unusual for many of our patients, so I introduced myself and reached towards her arm with the blood pressure cuff.  Looking annoyed, she waved me away, pointed to the tiny Bluetooth headset in her ear and quickly explained that her husband (the real patient) was in the bathroom before returning to the heated conversation.

Thank the Stork

Some expectant mothers with nothing better to do on a Friday night may chose to pass the time by sitting nearly 5 hours in a crowded ER waiting room with a chief complaint of "I think I'm pregnant."  In addition to missing her period, Mom claimed she could feel her HGC levels rising, although none of the pregnancy tests she bought seemed to concur.  Nor had they worked for the ten previous pregnancies she claimed to have gone through this year (what do I know, I'm no math major).  When our pregnancy test reached the same conclusion and nothing showed up on her ultrasound, she promised us she'd come back next week when she was further along.

Meanwhile, some expectant fathers celebrate with a cigar, while others learn that their girlfriends are pregnant and decide to get drunk, smoke some illy (pot soaked in formaldehyde), and stab themselves in the leg.

To each their own.

Gargled, Not Stirred

The sophisticated gentleman knows that the epitome of class lies not just in showing up to the ED drunk on Listerine and high on benzos, but in generously bringing an unopened bottle of dollar store mouthwash to share with the staff.

At least his breath smelled better than the rest of him.  I love Friday nights.

Hit and Run

There are few crimes more cowardly and despicable than a hit and run.  We had a bad one last night while I was working trauma - an 18 year old kid plowed over as she was crossing the street.

It was pretty ugly.  EMS patched in early for an unresponsive pedestrian stuck.  Severe facial trauma, unable to intubate in the field.  We prepped for a difficult airway, breaking out the trach kit and a couple other serious-looking airway toys that I've never seen used.  Patient rolled in a few minutes later, face covered in blood.  The resident managed to tube her on the second attempt, fixing one problem before moving on to multiple others.  Examination revealed multiple lacs and abrasions and an open tib fib fracture.  The blood in the foley bag wasn't a good sign, either.

After bringing the kid over to CT, I watched as the trauma surgeons identified multiple rib fractures, a ruptured bladder, a splenic laceration and a couple small bleeds in the brain.  Confident at least that she would survive, they predicted an extremely long and difficult recovery.

I walked past the crowd of friends and family that had gathered in the waiting room on my way out for the night.  While the kid lay in an ICU bed hooked up to a ventilator, the jackass who put her there was still roaming free.

Ice Ice Baby

When the American Heart Association changed the CPR guidelines in 2005, they recommended cooling victims of cardiac arrest to 32-34˚C for 12-24 hours in an effort to limit brain damage due to oxygen deprivation.  Anecdotally at least, it appears that this policy has been slow to catch on, as we currently do not cool cardiac arrest patients in our ED, and neither do any of the several ambulance services that feed into us.

That may all begin to change, as a front page article from the New York Times this morning reports that starting January 1st, ambulances in New York City will bypass closer hospitals to deliver patients in cardiac arrest to EDs with cooling therapy.  The article cites some impressive statistics, namely that 55% of patients who were cooled down experienced moderate or no brain damage, compared to 39% who received normal treatment.

I'll be interested to see how outcomes differ after this policy goes into effect, and whether it will change the prevailing view that simply getting to any ED as quickly as possible is of primary importance and become a new standard of care.  In the meantime, however, it might be wise to start throwing some saline bags into the freezer.

UPDATE: The Chicago Tribune reports on a "Slurpee" method of cooling patients... maybe we won't need the saline after all.

Head Bone's Connected to the...

From time to time I help teach at the EMT class that I took when I was getting certified a few years ago.  I enjoy teaching, and it's fun to show people how to splint an arm or figure out how to strap someone into the rarely-used KED.  If tonight's class was any indication, however, the current crop of future life savers needs a little remedial education.

Highlights from my stint as a practice patient include:

A student attempting to assess my lung sounds by placing the stethoscope over my shoulder blades.

A student attempting to check my pulse by placing their two fingers on the middle of my forearm.

A student attempting to assist my (regular and adequate) ventilation with a BVM because "a little oxygen never hurt."

And finally...

Getting my blood pressure checked by having the cuff inflated to 250 and then left on while the student fumbled with getting the stethoscope under the cluff, then looked at the dial for another minute or so without deflating the pressure, and finally announcing "120 over 80" as I ripped the cuff off my tingling arm before it turned black and died.

Night Shift

Working nights for the first time this summer exposed me to the different world that exists after midnight.  Here's a cool look at some of the other people who work the night shift from the lens of a New York Times photographer.

How to Empty a Waiting Room

In the event that a patient comes in with some sort of contamination, our ED has a Hazmat room that prevides a separate entrance to the department.  I've seen it used a couple times to shower off the occasional chemical spill, but it also stores equipment to set up a massive decontamination tent out in the ambulance bay.

A couple weeks ago, I went through a Hazmat training session to learn how to don the spacesuits - the paper jumpsuits with the rubber boots, portable air filters, and plastic hood that gets fogged up every time you breath.  Aside from sleeping through an hourlong monologue on radiation safety from some hospital administrator, it was actually pretty cool to try on the suits and walk around - though hopefully I'll never have to wear them in a real event.

As the group of us lumbered around the conference room feeling like we were on the moon, we realized that we had discovered a foolproof way to empty the waiting room chairs: stroll out the back, peek in through the windows from outside the ED in the suits, maybe with some yellow caution tape in hand, and time how long it takes for the stampede to make it out the front door.  

Every overcrowded Monday since, I've been sorely tempted to suit up, grab a stopwatch, and find out.

Teachable Moment

While working another princess shift last night (the calm before the storm of final exams), EMS delivered a middle-aged male complaining of shortness of breath.  History of CHF and hypertension, with a room air sat of 92% and a systolic in the 190s.  

Legs were incredibly swollen from fluid retention, and combined with his obesity and shortness of breath, he was finding it difficult to take even a few steps.  Perhaps unsurprisingly, the patient did not have a regular doctor, missed his clinic appointments, and was non-compliant with his medications, which he hadn't taken in a week.  As I got him on the monitor, ran an EKG, and tried to find a vein, he lamented that "they" wouldn't give him "the weight loss surgery."

Later he promised that if he "lived through the night," he'd start to take better care of himself.  Hopefully a visit to the ER will scare him into taking better care of himself, but I'm not holding my breath.  All the weight loss surgery in the world won't make a difference if he keeps eating salty food and doesn't take his meds.  It makes me wonder, though, if patients like these aren't getting enough education about their serious health problems, or if they truly just don't get it and think that by ignoring their chronic conditions they'll simply go away.  

Open Season

Flu season is upon us, and with it comes the endless tide of nausea and vomiting, aches and pains, coughs and sniffles.  It'll be nasal swabs for everyone over the next few months, and stocking up on Purell might not be a bad idea.  In the Big City ED we know it's coming.  We're ready.  Bring it.

One of my patients yesterday decided to change things up a bit and try to throw us off our game.  After a week of coming in each day complaining of nausea, she chose to stop in on a Sunday afternoon because she no longer felt fluish, and believed that such a sudden change "needed to be checked out."  I think the chief complaint read something along the lines of "I feel healthy."

In related news, Google now tracks the spread of flu outbreaks by looking for clusters of people searching for for terms like "flu symptoms" at the same time and place (as reported by the New York Times a couple weeks ago).  The search engine expects that it will be able to estimate flu activity up to two weeks faster than traditional systems.  I'll be interested to see how well their data correlates to the CDC's.

Happy handwashing everyone!

Satisfaction Guaranteed

After more than a week away from the madness, it felt good to be back, even if it was only for a princess shift on an easy Sunday.  Still, even on a slow day, you can always learn something.

Lesson of the day: While wearing a condom "80% of the time" is a commendable statistic, it leaves the other 20% to explain the blood in your semen and pain when you urinate.

Flying

When I first started flying back and forth between home and school a few years ago I loved air travel.  I like airports, love watching people coming and going, and enjoy flying.  As anyone who has flown recently knows, however, these days the entire process seems designed to drive you mad.  My flight this morning was late, overcrowded, and overflowing with people trying to stuff all their belongings in carry-ons to avoid checked baggage fees.  That I could handle.  The family sitting next to me I could not.

Stuck on the runway for half an hour before takeoff, Mom, Dad and Junior complained constantly about the size of the plane, the wait, and the seemingly pervasive smell of urine.  (Having smelled more than enough urine to last a lifetime, perhaps I was just desensitized, but no one else seemed to smell it, either.)  After harassing the flight attendant, the trio decided to pull out their cell phones and complain to family members.  Even after the pilot announced that we were clear to take off and ordered electronics to be shut off, my delightful seat neighbors continued to chat away.  Finally forced to stow the phones, Junior pulled out a Gameboy as we taxied to the runway, but lost one of the batteries.  Unbuckling himself from the seat, he started crawling around the cabin floor while his mother laughed.  The flight attendant screamed as she saw him on the floor, so loudly in fact that the pilot jammed the breaks.  Confronted by the flight attendant, the mother continued to laugh away the incident before starting to yell.  I was shocked they weren't arrested.  But with Junior finally strapped in, we were able to take off without further incident.  

People are unbelievable.  I've come to expect such behavior in the ER, but I don't want to deal with it in the "real world."  

Come Together

Back home with friends and a loving, healthy family for the first time in almost sixth months - I'm thankful for many things this year, but this tops the list.  

(A close second, however, is another victory over the guy dressed as a turkey at this year's Turkey Trot.)

Happy Thanksgiving!

Your Mother Should Know

When you were little, did your mother warn you about sitting too close to the television?  As this article proves, mother knows best.

As I discussed yesterday, the ER can be a dangerous place.  A Texas woman learned that lesson the hard way when a 19-inch television fell on her in an ER waiting room in 2006.  Now she's suing the hospital for damages related to physical disfigurement, physical pain and mental anguish, in addition to her medical bills.  

It's all just further ammunition for Mom to scoot you back from the TV: it could ruin your eyesight or fall out of the wall and land on you.  

All You Need Is Love

Violence in the emergency department is an unfortunate but common occurrence, especially in the urban setting in which I work.  I've been involved in more than a few scuffles in my time at the Big City ED, but we benefit from having a full-time contingent of security officers in the department.  From reading other ER blogs, I realize that's a resource not available to all.

Nevertheless, we see more than our fair share of violent patients, some dangerously so.  Yesterday's post over at Detroit Receiving EM (a great educational blog - the vast majority is way over my head, but it gives me a ton of topics to read up on) made the excellent point that in no other setting would such behavior be tolerated, yet in the ER it remains a fact of life.

Two points in particular caught my interest.  First, that their ED has metal detectors (ours does not), and second, the recognition that "frontline staff (nurses and PCAs, mostly) receive the brunt" of violent patients.  We had two instances this summer in which staff members were put in danger.  Thankfully no one was hurt, but I remember wondering at the time, if a patient ever threatened the safety of a physician instead of an ER tech, would we have metal detectors in the waiting room?

Obviously, given the nature of the work, the ER will never be violence-free.  Despite that fact, I have always felt very safe at work, especially knowing that everyone in the department looks out for each other.  Still, it's an issue worth thinking about.  [Side note: I wholeheartedly agree with the post that offering a sandwich can help diffuse a tense situation - it's worked for me many times]

Let's! Go! EMS!

Maybe it was the single-digit wind chills, the nearly nonexistent tailgate, the three missed field goals or the multiple fumbles, but the quality of football was a little weak this Saturday.  So weak, in fact, that the highlight of the game had nothing to do with the action on the field.

Somewhere between our QB getting sacked and yet another incomplete pass, my attention drifted over to the equally-underperforming cheerleaders on the sidelines, who were in the middle of some complicated formation that involved throwing people up in the air.  Unfortunately, like many of our receivers, they had a little problem with catching.

From the stands, it looked like her leg took the brunt of the fall, but I found myself calling the play-by-play of spinal immobilization to my friends as EMS boarded and collared her before taking her away.  

The cheerleaders didn't throw anything for the rest of the game.  The football team should have followed their lead.

On Diversion

Closed to incoming patients this weekend - heading off to the Big Game today and then catching a plane home first thing tomorrow morning.  Looking forward to a week of R&R, catching up with family, and nobody no strangers trying to piss/spit/vomit on me.

[Update: thanks to KeepBreathing for inspiring that important clarification]

Game On

Highs in the upper 30s and below-freezing wind chills can only mean one thing: hockey season is finally upon us.  While I'm looking forward to the last football game of the season tomorrow, my true love will always be trauma on ice.

Watching a victorious home opener last weekend reminded of one of my all-time favorite patients.  I work as a volunteer EMT for Big City University, covering mainly club and varsity sporting events.  On standby at a game last winter with my partner and a PA from the ED, we were approached by a cop who said he had someone who needed help.  Curious, as we had just finished a conversation about how we never had real patients while covering varsity hockey (club at least can be a litter rougher around the edges), we followed the officer to the patient.

Turned out to be an 8 year old kid decked out in his very own Big City University hockey jersey looking very angry about missing the action.  General impression was unremarkable until Dad revealed that Junior was suffering from a nasty splinter courtesy of the wooden bleachers.  Slightly embarrassed, I explained that we didn't carry tweezers in our gear, and the PA realized that he didn't either.  Unwilling to let our fan suffer, however, he ran out to his truck and brought back a suture kit.  Offering me the tweezers from the kit, I was able to perform my first successful splinterectomy before returning to watch another home team victory. 

Extreme EM

The ER can be an intense environment - juggling critically ill patients and performing life-saving interventions in high stress situations - but imagine dealing with the rib-breaking coughs, frostbite, and high-altitude retinal hemorrhage that present when you practice emergency medicine at 18,000 feet above sea level.

It's all part of the job as described in this great article about the Everest Base Camp Medical Clinic, which treats its patients on the highest mountain in the world.  

"I was really concerned that Joe might not make it through the night.  They'd brought him down through the Khumbu Icefall - more than 7,000 feet - to our medical clinic at Everest base camp.  His face was blue, each breath was a struggle, and he was drowning in his own blood," says Luanne Freer, describing a patient treated at the clinic she founded in 2003.

As a runner who grew up in the flat plains of the Midwest, anything steeper than a small hill seems mountainous to me.  I can't even imagine what it must be like to be saving lives 3 miles off the ground.

The Long and Winding Road

An extremely rare phenomenon occurred in the trauma room last night: a motorcyclist was brought in by EMS after getting struck by a car.  The catch?  He was actually wearing a helmet.

Over the course of the summer, unhelmeted motorcyclists were nearly a daily occurrence.  Maybe he was just wearing it to keep his head warm now that the brutal cold has settled in (continuing to ride a motorcycle in this weather is crazy in itself), but regardless of the reason, we were all pleasantly surprised to see it.  So much so apparently, that the patient ended up getting annoyed at the number of people congratulating him for wearing the helmet.

In other news, I had my first registration meeting yesterday for students applying to med school in the upcoming cycle.  A little nerve-wracking, but also exciting.  Terrifying, however, is the average cost just to apply: $5,000.  It's going to be an interesting year...

Things That Get Me Mad (II)

I understand that crack heads will demand gourmet room service, drunks will try to piss on me, and that people will treat their bodies like crap and expect us to put them back together again.  It's the simple truth that, in the ED, we treat everyone who walks in the door.  I knew what I was getting into when I started, and no one is forcing me to work in the trenches.  

What still gets me, however, is when someone's self-destructive behavior affects another.  I could care less that my guy in bed 9 overdosed on methadone for the third time this month.  But when the ED is full, and we have an 88 year old gentleman dying of colon cancer forced to be treated in the hallway, I get pissed.  Methadone guy couldn't be pulled out because he would brady down to the low 40s and drop his sats every time he nodded off, and thus needed a monitored bed.  With every other room occupied by patients who could also not be pulled out, my cancer guy was simply out of luck until we finally were able to move a patient upstairs. 

It didn't help that as my perfectly polite and understanding gentleman suffered in the hall, Methadone guy ripped his IV out after receiving a Narcan eye-opener.  At least his nurse took the time to explain the "two for one" rule: for every IV the patient removed, two more larger gauge lines would be put in as replacements.  Nothing like bilateral 16s in either hand and the threat of a 14 to encourage compliance.

Winter Reminder

It's finally starting to get pretty cold here in the Big City, and with the falling temperatures comes a reminder about home safety.

I had an EMT student following me around the other night, and as the hours went on I kept hoping something interesting would come in to show him.  (I remembered my ED observation time from EMT class, where the most exciting thing I saw was an old guy falling off a step ladder.)  Just before he was set to leave, we received a patch for an incoming code.  I brought him into the trauma room and had him help me lay out the body bag, hang a couple liters of LR, and make sure the defibrillator was at the bedside.  He seemed pretty excited when I told him he could do compressions.

Unfortunately, the patient barely made it off the ambulance stretcher before he was pronounced.  No electrical activity on the monitor, ultrasound showed no cardiac movement, and he had been down for at least 45 minutes.  EMS said he had been found unresponsive on the basement couch by the wife shortly after she returned home.  He was only in his early 50s.  

Read in the news the next morning that the death was caused by carbon monoxide poisoning from a faulty home furnace.  Scary how easily that can happen, and tragic that he died so young.  Now that people are starting to turn on their heat, it would be a good idea to buy some CO detectors.

Beware Pizza Guys Bearing Gifts

Few things make the ED staff happier than food.  When I first started working nights, I was amazed at the explosion of munchies that occurred after the day shift left.  Homemade brownies, chips and salsa, Chinese takeout, my customary order of mozzarella sticks at midnight - all the necessary ingredients to keep people fueled into early hours of the morning.  The one thing better than food?  Free food.

On those rare but happy occasions, word quickly spreads throughout the ED.  Whispered revelations of "food in the conference room" inevitably sets off a parade of scrubs in a walk-run shuffle down the hall, causing a momentary mass exodus from the patient care areas.  We had one such stampede the other night, and I was lucky enough to arrive in time to claim two still-warm slices of pizza.  Savoring the greasy goodness and momentary relief from my screaming drug seeker, I asked who we had to thank for their generosity, but nobody knew where the pies had come from.

One of the other techs looked up from his plate and suggested, "Probably some former patient trying to poison all of us."  Everyone laughed, then stopped suddenly and scanned the room, waiting for the first person to drop dead.

Bad Idea

Scene: A 50-something year old patient with emphysema and chronic bronchitis lingers around the workstation, waiting for discharge paperwork after an hour or so of continuous neb treatments allowed him to narrowly avoid intubation.

Pt: "Yo, can I go grab a smoke while I wait?"

Attending, Resident, Nurse, and Me: "NO!"

Happy Holidays

Hot off the news wire, a statistic that literally had me laughing out loud...

"Impregnable packaging has incited such frustration among consumers that an industry term has been coined for it - "wrap rage."  It has sent about 6,000 Americans each year to emergency rooms with injuries caused by trying to pry, stab and cut open their purchases, according to the Consumer Product Safety Commission."

The number of trauma patients usually drops off during the winter, but I'll be on the lookout for an increase in wrap rage injuries over the next couple months...

Direct Pressure

Running up to triage with a blood-soaked rag covering a body part is good way to skip the line.  It won't necessarily get you brought back right away - we have plenty of people with impressive lacs wait to get sutured - but if you remove the rag and bright red blood spurts into the air, you'll quickly win yourself quite a bit of attention.

Situations like those, while rare, are why I always keep the triage desk drawers stocked.  As soon as I saw the pulsing red rainbow arcing over the desk, I grabbed a wad of 4x4s from the drawer and clamped down on the arm.  A nurse ran over a wheelchair, and we rushed him to the trauma room with my hands still locked around his arm.  It wasn't until a large BP cuff was over-inflated above my hands that my brief career as a human tourniquet ended.  

Word to the wise: when playing poker with an unsavory crowd, try to avoid cheating the dude with the knife.

Hitting the Books

With the last big round of problem sets and exams for the semester occurring this week, I've pretty much been living in the library.  Since misery loves company, it's nice to know that at least one of my patients is probably hitting the books just as hard.

EMS delivered her to the critical care area after she seized during a police traffic stop.  She "seized" again while being triaged, and appeared confused by the time she got to us.  A nervous-looking intern was thinking of intubating her when our beloved, grizzled charge nurse walked in with the registration paperwork, took a look at the patient, and barked "Before you fake your next seizure, read a better book."  The patient dropped the act, I laughed, and the intern's jaw hung open in amazement.  

Brilliant Idea

Great article this morning in the New York Times that talks about a 24-hour clinic designed to catch people who might otherwise end up in the emergency room because of a non-emergent condition that occurred during their physician's off hours.

The article notes that an estimated 60% of ER patients could (ie should) be treated in a physician's office.  Perhaps if this model really takes off, we might begin to reverse the trend of overcrowding ERs.  But with posted warnings that clinic staff do not have access to narcotics, I'm not going to hold my breath.

Thank You

To the self-described old navy man who referred to me as "corpsman" and asked me to point him to the head,

To the young female army officer who answered every trauma assessment question with a "yes ma'am" or "no sir,"

To the techs, nurses, PAs/APRNs and doctors in our ED who have served in the armed forces, including one currently deployed in Iraq,

And to my grandfathers,

Thank you for your service and your sacrifice.

TV Timeout

Nurse K's post about the precious but rare night shifts without patients reminded me of one such shift this summer.  I was surfing the internet in a beautifully empty critical care area around 3am when I noticed that my entire half of the ER seemed completely deserted.  Aside from the drunk sleeping in the hallway and the other one or two patients waiting for lab results, there was a single nurse checking her email and a resident catching up on charting.  

Curious to find the rest of our staff, I wandered out to triage, where I found every waiting room chair filled with nurses, techs, security and cleaning staff, residents and the attending all gathered beneath the TV watching the Olympics.  Amazed that there was not a single patient waiting to be seen, I grabbed a seat, put my feet up, and watched Michael Phelps set another world record half a world away.  

Not enough to make up for every other insanely busy night overflowing with patients, but close.

Manic Monday

Patch came in for an uncooperative ingestion, prompting a welcoming party of several nurses, techs, and security officers waiting in the ambulance bay with restraints already tied to the stretcher.  Anticipating some PCP-ed out muscle head ready to rip the ED off its foundations, we were instead met with a short, middle-aged, slightly pudgy guy with a gigantic grin on his face.

As the triage nurse assessed the patient, her questions were met with a high-pitched, singsongy voice and a perpetually bug-eyed stare.

RN: "Sir, do you know where you are?"

Pt: "Of course!  I'm at Big City ED!  I LOVE YOU GUYS!"

RN: "Do you feel like hurting yourself or others?"

Pt: "No!  You guys are the greatest!  I LOVE YOU!"

RN: "What's bothering you right now?"

Pt: "NOTHING!  I feel FANTASTIC!"

With that much love for the ED staff, we knew he had to be on some pretty good stuff, so we weren't surprised when his tests came back positive for GHB.  Figures it would take a self-induced date rape drug for anyone to be happy to see us.

The Plot Thickens

There are some nights in the ED where it feels like more of our efforts are spent on figuring out a patient's story than actually treating the conditions that brought them to us.  

Working trauma last night, I listened in as EMS patched for an incoming older male patient with several abrasions and lacerations.  Only after he arrived in the ambulance bay did we learn that, in addition to the bumps and scrapes, he had been found unresponsive by the side of the road, and was currently confused an unable to follow commands.  Since those are generally considered bad signs, Mystery Man was triaged as a minor trauma and brought to our trauma bay.  As the ED resident began his survey, he discovered that Mystery Man had a GCS of 8, sluggish pupils, and weak, shallow respirations.  Quickly upgraded to a major trauma, he was intubated while an NG tube and foley cath were inserted before he was placed on a ventilator and rushed up to the ICU.  After we got him upstairs, we could only wonder what happened to him - assault, thrown from a car, fall resulting from a seizure?  EMS had nothing, and police were investigating.

Meanwhile, a case of less mysterious origin was unfolding out in the hallway.  A young female arrived from lockup in police custody complaining of sudden onset, crushing 10/10 chest pain and a stomach ache.  And tingling in her foot.  And jaw pain.  I bet her elbow even hurt when the weather changed.  With a normal EKG and negative cardiac and abdominal labs, however, she was diagnosed with acute incarceritis secondary to jaw pain status-post ass-whooping, and discharged back to jail.

Searching for an update on Mystery Man's status later in the night, I learned from the trauma team that his altered mental status, labored breathing, and sluggish gaze were the result of nothing more than being really, really drunk (BAC .390).  He was subsequently extubated and allowed to sleep it off.

Mysteries solved.

Patient Tips

Just returned from an eventful Friday night in the Big City ED, and thought I'd share some brief words of advice to any potential patients out there:

If you feel the need to shout "I'm not crazy" in a repeated loop using a variety of different fake accents while being triaged, we might just go out on a limb and guess that you're not telling the truth.

In other news, many thanks to EE for causing an explosion in my traffic.  I checked sitemeter when I got back, and was forced to make sure that I, too, was not in fact crazy and reading the numbers wrong.  New visitors: I hope you enjoy!

Epidemic Outbreak

It appears that our friends across the pond are having trouble keeping their various body parts unstuck from public toilets.  First it was the British guy getting his rear end superglued to a toilet seat and needing to be transported to the hospital with the loo still attached.

Now I find out that just a couple weeks ago, a French dude dropped his cell phone in the toilet of a high-speed train, and got his arm stuck  in la toilette while attempting to retrieve it.  The TGV trains, as the BBC ably reports, "are equipped with a powerful suction system."

The train was delayed for two hours while firefighters cut through the plumbing in order to transport the man to the hospital with his arm still stuck in the toilet.

Treating patients attached to toilets?  For European ER docs, c'est la vie.

Emergency Medicine Goes to the Movies

Experienced one of those rare, "oh shit" moments during a shift last week when a patient unexpectedly coded while being evaluated in one of our regular treatment rooms for a non-cardiac complaint.  The resident walked in the room to check on the 60ish year old gentleman, and assumed that the flat line on the monitor was caused by disconnected monitor leads.  It wasn't.

He ended up receiving CPR, meds, and three shocks at the bedside after a small army of docs, nurses and techs rushed into the already cramped space.  He regained a pulse long enough for us to transfer him to the trauma bay in one of those very rare, made-for-TV moments.  Running down the hallway alongside the stretcher, I was pushing the still-attached defibrillator while another nurse dragged the crash cart and the resident bagged the patient.  (It's a guaranteed method for clearing the hallways).  By the time we reached trauma he was pulseless again, and received a lightning fast intubation before three more rounds of defibrillation and compressions left him stable enough to be rushed up to the ICU, where he kept on living at least through the end of my shift.  Definitely an unexpected curveball to shake up an otherwise quiet night.

I was reminded of this event while watching the most recent James Bond movie, Casino Royale, the other night in anticipation for next Friday's release of the newest 007 flim.  In one of the more ridiculous scenes, a poisoned Bond staggers out to his car to self-administer his very own AED, but ends up passing out before he can connect the pads.  The beautiful Bond Girl arrives in the nick of time, and manages to shock him back to life despite the ominous flatline monotone heard in the background.  Medically inaccurate?  Yes.  But if only real life were like the movies. 

Time Flies

Well, I've reached the 100 post mark on what was originally intended to be a way to keep track of amusing ER stories from over the summer, but has since grown into a surprisingly enjoyable mini-hobby.  Even more surprising, however, is that there seems to be a small handful of people who actually read this from time to time (emphasis on small).  If you're one of that silent majority, I'd be interested to hear your questions/comments/concerns/pleas for me to shut up.  Otherwise, it's back to studying, and we'll see if I can make it to 200 posts...

Handicap Accessible

Some patients are like the living room couch - reach into the folds and it's anybody's guess as to what you might find.  Loose change, gum wrappers, half-eaten candy bar?  You never know.

I'd heard the urban legends of obese patients with unopened Twinkies found in their jowls.  I've even seen patients get off the stretcher to go home and find nickels and dimes left on the sheets.  But I never anticipated my own, almost Indiana Jones-level discovery.

Working a hallway team the other night, a PA asked if I could help roll an obese patient whose back needed to be examined.  I tried to reach across the patient and pulled them towards me as best I could.  Starring off into space while waiting for the PA to finish his exam, I heard an unexpected "pthwack."  I looked back at the PA, who was holding the rectangular handicap parking placard he had just peeled out from the patient's skin folds.

Our eyes met, drifted back to stare at the unexpected surprise, and then without breaking face, we finished the exam in silence.  Saying nothing, the PA left the placard on the counter as we left.

The End of the Beginning

During a particularly busy night this summer, with everyone running around in organized chaos as we were getting slammed with back to back traumas and had patients filling every available hallway space, a well-dressed doctor called in for a consult tiptoed his way through the department with a look of disgust on his face and declared to a nearby med student, "Thank God I don't work here."

Today, after two very long years of campaigning, we will elect a new president, and one way or another it will bring an end (however briefly) to attack ads, robocalls, and screaming pundits.  Like many who thought the campaign would never finish, there's the temptation to sit back and simply thank God that it's over.  Politics may be a messy business, but no matter how chaotic the process may be, we should be thankful for the freedom to elect our leaders.  So, no matter which candidate you support, I hope you exercise that freedom and make sure to vote.

Happy Election Day!

Death of a Salesman

By his own account, Willy Lowman (as we'll call him) was your typical high school jock.  Athletically inclined, he was a solid performer on the football and baseball teams.  Friendly and outgoing, his ability to make friends made him a natural networker.  From high school he went on to college, where majored in business with a minor in frat parties.  After graduation he started a career in sales, where he used his charm and charisma to make connections and land the big contracts.  He drove a fancy car, lived in a big house, had a growing family.

Willy told me this as he cracked jokes and asked me about my family.  Searching for personal connections, Willy was ever the salesman, even after downing shot after shot after shot before getting behind the wheel and flipping over his beloved car.  In between recollections of his past slipped admissions of previous binges, prior accidents, failed rehab attempts, and alcoholic family members.  He lamented how he tried to hide his problem from his three young kids, and how it became increasingly difficult as they grew older.  He worried that his wife would pack up and leave.  And he cried, when he learned that his license was being taken away, over the loss of his car and the end of his life as a salesman.  

Easy as it is to complain about drunks overcrowding the ER, it's tough to learn the individual stories and see first hand how alcoholism can destroy people's lives.