Respect Your Elders

Walked into a patient's room last night to do an EKG, and found an elderly-looking female smiling pleasantly back at me.  I talked with her while I set up the machine, and despite seeming the slightest bit out of it, she ably held up her end of the conversation.  Taking a look at her ID band, I had trouble finding her birthdate.  Her name was clearly there, as was her medical record number and triage date, but the only other date on the band ended in '07.  After pausing for a second, I realized that was 1907, and that I was doing an EKG on a heart that had been beating for over a century.

When I checked in on her later, I caught her in the middle of trying to rip out her IV.  I tried negotiating with her, even arm wrestled for about 30 seconds, and then rapidly came to the conclusion that living to 101 years old gave her the right to do whatever the hell she wanted.  

Dynamic Duo

In the midst of all the new emergency medicine residents working their way through their first rotations in the ED, we must also endure the dreaded internal medicine residents coming down from the floors and struggling to keep their heads above water.  A few are great, most are mediocre, and some are just awful.

Last night, a relatively quiet Friday in the Big City, a tag team of medicine residents worked the hallway, forming a superhuman pair rivaling the likes of Batman and Robin, Starsky and Hutch, or, more accurately, Rocky and Bullwinkle.  

Deer In The Headlights, MD, made a triumphant reappearance after I had last worked with him a week ago.  Still sporting his sallow complexion and perpetually bug-eyed stare, Deer in the Headlights, MD, did his best to ensure no patient remained in the ER for anything less than three hours.  That patient who finished her contrast at the beginning of your shift still hasn't been scanned?  Deer in the Headlights, MD: "Oh, I just assumed somebody else put in the order for the CT...."

Joining Deer in the Headlights, MD, for the first time was Dr. Body Odor, a who apparently did not realize that Purell can replace handwashing, but not showering.  Whereas Deer in the Headlights would awkwardly avoid any contact with the ER staff and hide in the corners of the workstation, Dr. BO will eagerly stand next to you or peer over your shoulder in an attempt to make idle conversation.  

Maybe he could use his powers to drive some of Deer in the Headlights, MD's patients out of the ER?

Keep Your Friends Close

Ah, autumn: the changing of the seasons, the chill in the air, the hordes of college students returning to the Big City and drinking their way into the ER...

Scene: EMS delivers to our ambulance bay a young female strapped to a backboard, accompanied by FratBoyBoyfriend.  

Me:  "Hello ma'am.  I just need to check your vital signs while they get your registered."

Pt: "Aieeeeeeeeeee." [loud, high-pitched scream as she tries to rip off the collar]

Me:  "So, FratBoyBoyfriend, obviously too much drinking tonight.  Any drugs?"

FBB:  [grins, shrugs]

Pt:  "Aieeeeeeeeeeeeeeeee." [more ripping]

EMS: Strawberry Daquari here had a little too much tonight, so her 'friends' chose to drag, [lifts up blanket covering patient to reveal dirty, bloody scraped feet] yes drag, her to Local College health center, who then decided to send her your way.

FBB:  [grins, shrugs]

Pt:  "Aieeeeeeeeeeeeeeeeeeeeeeeeeeeeeee."

Best Chief Complaint Ever

Working at triage during a busy Thursday night.  Waiting room is packed, with patients languishing for several hours without being seen.  Stretchers line the hallways in our treatment areas, the trauma room is full, and everything is backed up.  I'm standing at the front desk, trying desperately to slow the constant surge of patients, when a young woman approaches me.  She sits in the chair and, over the sounds of crying and screaming, I ask her what brings her to the Emergency Department today.

Patient: "Well, I was wondering if you had those whitening strips, you know, for the teeth?"

Things That Make Me Sad

Most shifts are pretty routine combinations of patients who are decently sick or injured, and people who are completely full of it.  Very rarely, however, there are total tragedies that blow you away.  Case in point:

Two brothers arrive in the trauma bay a few minutes apart from each other after their car crashed into a telephone pole on a country road.  The older one came in first and was pretty much dead on arrival.  He was bleeding everywhere - out of his mouth, ears, and nose - and his skull was soft and pliable.  EMS delivered the younger brother, who was in much better shape, a few minutes later.

To make a long story short, the younger one was Spanish speaking only and without anyone in the US except his brother.  The two had been working here to send money to their family back home.  Social workers tried to call some of the kid's friends to support him before breaking the news of his brother's death, but being illegal immigrants, the friends were afraid to come in to the hospital.  Unable to reach any family in Mexico right away, social workers discovered that this young guy had lost his closest living relative and was suddenly alone in a country where he did not speak the language and had no one to comfort him.  Eventually, some of his friends arrived, but while all this was unfolding, I was in another room placing nasal tampons into the older brother's bruised and swollen face in an effort to stop the bleeding and make the body somewhat presentable.

Sometimes my job sucks.

Deja Vu All Over Again

Walking into work early yesterday for some day shift overtime.  On my way in I pass a liquor store, and who did I see staggering towards it but one of our most frequent recurring drunks.  Still clutching his belongings bag from when I had triaged him the night before, he was heading straight (more or less) for a refill.

When I arrived at work, I started placing bets for how quickly we'd see him again.  Surely by the end of my shift, but bets ranged from one to six hours, give or take.  I punched in, and started seeing patients in our critical care area.  Twenty minutes later, one the techs who was working out at triage comes over to inform me that Jack Daniels (let's call him) had just arrived via EMS in a backboard and collar.  Incredulous, I watched as he was wheeled over to our area after having been found after falling to the ground.  Apparently he wasn't able to get any booze from the store, and his alcohol level had dropped low enough for him to seize.  

Looking at the board, I saw that Jack's name was still listed in our drunk tank, where he'd been less than an hour before.  With nobody betting less than 60 minutes, I guess any proceeds should have gone to Jack.

On Top of the World

One of the more exciting parts of my job involves going to the helipad to receive patients transfered in by helicopter. Normally it's pretty cool - me and a security guard at the top of the hospital, wandering around the roof looking down at the city waiting for the chopper to arrive. It's best at night; pushing a stretcher up the ramp in darkness and steering it beside the helicopter while its blades are still spinning, unloading some injured patient, and rushing back down to the trauma room. Feels like a scene out of ER or M*A*S*H*.

I was working a hallway team last night when I heard the overhead page for an incoming helipad patient. On my way up to the roof, I learned that the patient was being transfered to our pediatric ICU. I'd never had a pediatric patient flown in before - usually we receive transfers to our cath lab or trauma room, but this time it was a very sick looking intubated seven year old. Lifting him onto our stretcher, I saw for the first time a passenger exit the helicopter as well. The boy's father looked distraught as he accompanied us down the elevator and past equally sick-looking children surrounded by machines in the PICU. He stood by helplessly as we transferred his son onto the PICU bed and teams of doctors and nurses descended to stabilize the boy. Bringing the helicopter crew back up to the roof, I realized that as much as I enjoy going up there, I hope I never have to receive another sick kid.

A Place for Everything Redux

Unlike my previous encounter with suicidal patients at triage, I had a sad experience last night.  Sitting at the desk around 3am, I watched a gentleman wander into the waiting room looking lost.  After I called out to ask if he needed to see a doctor, he stumbled over to the chair and sat down.  Appearing agitated, he told me without making eye contact that he felt like hurting himself.  I asked a nurse to come over and help me register the patient, but a moment later he stood up, started shaking his head, and stated that he did not want to be seen.  We tried unsuccessfully to convince him to stay, but the gentleman kept shaking his head and backing away.  Watching him walk back out to the street, I worried that this guy was truly in danger of hurting himself.  I'll probably never find out if he did.

I Can't Make This Stuff Up

A middle aged male comes in complaining of chest pain.  Brought back to our critical care area, he receives the million dollar workup.  I place him on a monitor, get an EKG and draw cardiac enzymes before they take him off for a chest x-ray.  Risk factors include hypertension, high cholesterol, smoking, and being slightly overweight.  After an hour or so, the patient is informed that he's being admitted upstairs for further evaluation, and suddenly becomes agitated.  Not at the wait, not that he's being admitted, not that chest pain might indicate something serious.  He starts ripping off the monitor cables and tugging at his IV after learning that he will be admitted to our cardiac ICU, where he had previously been restricted to a cardiac diet.  Placing a greater value on his cheeseburgers than his chest pain, the patient stormed out AMA.

Later last night I wandered over to triage, where a patient brought in by ambulance was getting registered at the desk.  Midway through talking with the nurse, he decides that he doesn't have a real complaint, does not want to be seen, and gets up to leave.  Pushing back the chair, he promptly drops to the ground and does the splits.  Jumping back up to his feet, he informs us that he has a drag show to get to, and struts out the waiting room door.

Staples: That Was Easy

For someone who wants to go into emergency medicine, working in a busy ER is a great experience. Not only do I get to see interesting and bizarre injuries, but I'm also learning how to interact with patients and gaining some hands-on experience with bandaging and splinting wounds, removing sutures, and drawing blood. I've learned how to start a foley, started a few IVs, and assisted with procedures like central lines and lumbar punctures. But every once in a while, I get to do something new, like put eight staples into a patient's head.

I was finishing an EKG on a patient last night when one of the nurses asked me to help out a surgeon in the trauma room. An older gentleman had fallen at home, and came in with a large scalp laceration that started at the top of his head and moved down almost to the eyebrow. I walked in to find his scalp peeled back over his head, leaving a decently large chunk of his skull exposed. The gentleman's son looked a little squeamish, but the patient seemed pretty relaxed. The surgeon handed me a pair of sterile gloves, and asked me to clean out the clots that had formed on the skin flaps with some gauze while she cauterized the tiny bleeding vessels. After going through several blood-soaked 4x4s, she brought the flaps together and handed me the staple gun. She explained how to point and shoot, and I started moving my way along the lac with the gun, putting in eight staples total.

Maybe I can try my hand at intubation next?

Phantom Trauma

Typical Monday last night: a full waiting room, stretchers lining the hallway, short on staffing, and plenty of minor traumas filling up our beds.  I worked in our chest pain unit for the first four hours of my shift, and then moved out to trauma for my last four, where my first patient was an obnoxious, loud, and uncooperative (surprise!) no helmet motorcyclist who crashed into a car and registered a BAC of .160 without even blowing into the straw.  Instead of the usual squirming, screaming and fighting associated with the dreaded rectal exam, he kept insisting that it simply wasn't necessary.  The resident stressed the importance of knowing if he was bleeding internally, to which the patient kept shouting, "I'll know!  I'll know!  I was in the military, I'll know!"  Later, he was afraid to enter the CT scanner.

With the trauma bay still full a couple hours later, the charge nurse came running in need of a bed right away.  Triage received a patch for a 17 year old female with slit wrists pulling up to our door.  Ripping a patient off the monitor, everyone scrambled to get ready: a fresh sheet was thrown on a bed, nurses grabbed intubation meds, the resident checked his airway kit, I had to bags of warmed lactated ringer's hanging and wheeled in the crash cart.  Within 60 seconds we had the room ready for a resuscitation and stood anxiously awaiting the patient.  After a couple minutes of waiting, we found out that the patient wasn't as serious as initially though, did not meet trauma criteria, and was brought to another area instead.  Ripping off our gowns, everyone shuffled out of the trauma bay, only to hear the page for yet another trauma, three minutes out.

You'll Shoot Your Eye Out

Eyes gross me out.  I've seen plenty of crazy stuff since I started working in the ED (cracked chests, exposed brain, intestines coming out of a self-inflicted stab wound), but eyes get to me.  When I was taking my EMT certification class, the pictures of bloody, punctured eyes with bits of metal sticking out of them made me want to hurl.  I have thankfully yet to see anything sticking out of anyone's eye in person, but I experienced an 8/10 on the gross-meter last night when I saw my first ruptured globe.  Apparently Dad was trying out Junior's remote-controlled car, driving it around the back yard when a pebble got drawn in by the tires and shot out the back... straight into Dad's eye.  

He wasn't even my patient; I was just passing by in the hallway and saw a group of people standing around a stretcher shining flashlights into a guy's face.  Curious to see what was happening, I peeked over the shoulders and found myself mesmerized by the red mess that was this poor guy's eye.  Unable to look away, I stood rooted to the spot, staring as the doctors examined the bloody eyeball before covering it up to wait for the ophthalmologists.  Grossed out, but excited about finally meeting my long-awaited optical nightmare, I nevertheless avoided rubbing my eyes for the next several hours.

Still, a ruptured globe isn't nearly as bad as this, which I doubt I'll ever be able to handle.

TGIF

Friday night in the Big City...

Two of our most familiar drunks (both coincidentally sharing the same first name) arrive within minutes of each other, bringing their combined total number of visits over the last few years up to nearly 400 taxpayer-funded sojourns.

Three dental pains in a row while I worked in our fast track area (they all managed to score some narcotics for the weekend).

One patient trying to steal equipment from the trauma room by opening up procedure trays, grabbing a pair of bolt cutters, and making a run for the front door.

Despite all these contenders, the award in the category of Best Use of the Emergency Room goes to...

Angry Suit-Wearing Dad, who drags his son into the friendly neighborhood Level I Trauma Center at 2am on a Saturday, marches up to the triage desk, demands that we remove his son's braces, and gets pissed off when told that there was a four to five hour wait to be seen, and that, lacking an on-call orthodontist anxiously awaiting orthodontic emergencies at 2am, we don't remove braces in the ER.

Maybe the Dad should try stealing some bolt cutters instead?

Couple of Wise Guys

A young male trauma patient arrives by ambulance and quickly endures the poking, prodding, and rapid-fire questioning that comprises the trauma assessment.  Docs are searching for injury, the nurse is getting a BP, and I'm drawing labs.  The patient is asked about any drug or alcohol use, and glibly states "a bunch of crack this morning."  Everyone pauses for a second, not surprised at the combination of drug use and trauma, but the frankness and ease of the admission.  Then the patient starts laughing and explains, "No I don't use drugs, but I bet you guys see a lot of that, right?"  For the rest of the assessment, this guy had everyone in hysterics, cracking jokes and asking questions, and making it one of the most laid back traumas I've ever been in.

Sadly, patients like that are the exceptions, not the norm.  On another day, we receive a patch for an MVC.  The patient arrives, and when asked the same questions about drug use, is much less forthcoming.  After several false starts, the story comes out: this gentleman bought come crack that afternoon, only to discover that it was "bad" crack and returned to the dealer to demand his money back.  Negotiation proved unsuccessful, so the patient attacked the dealer, only to be punched repeatedly in the head and chased back to his car, which, while speeding away, the patient crashed into a (thankfully empty) school building.

No joke.

Things That Get Me Mad

Number 1 on the list: parents who overdose in front of their kids.

Last winter I took care of a guy who felt "sad," and decided to take a bunch of pills at home.  EMS delivers him to our critical care area, where he's only semi-responsive.  Wife arrives with 8 year old son in tow because she can't find a sitter.  The kid is clearly terrified at being in a crowded ER at 11pm on a school night, but bravely tries to rationalize the situation by explaining to Mom that Dad's "just sleepy."  Then Dad proceeds to puke bright yellow vomit all over himself, sending the sobbing kid running out of the room in terror.  I don't care what people do in their free time, or how they choose to deal with their problems, but there's no excuse for dragging a child along with you.

Overdoses dominated the scene again last night, taking up the majority of our critical care beds during the first half of my shift.  Most of them were pretty straightforward - two bags of heroin instead of the usual one, celebrating a release from jail by drinking three bottles of Listerine - but one woman took ten of her Xanax and left it to her child to call 911 when he found her passed out at home.  Mom, with her Bride-of-Frankenstein hairdo and orange spray tan rubbing off on the sheets, took up a bed for the next several hours mumbling, half-asleep, that she was really cold and demanding more blankets while she snoozed.

Many Happy Returns

Returned to work last night after a long four-day weekend.  One of my first patients of the evening was an elderly female in severe respiratory distress brought from home by EMS after the daughter called 911.  Now, I'm no fan of nursing homes (one "accidentally" resuscitated my DNR grandmother), but this woman was clearly not getting the care she needed from her daughter.  Covered in feces, dehydrated, and wearing a urine-soaked gown, this poor old lady could barely breathe.  We cleaned and buffed her up before sending her upstairs, all while the daughter talked about how she used to be in the "medical profession."

Drug Seeking Asshole also celebrated my return by making a special guest appearance last night.  In our previous encounter, when he found that I could not in fact write him for Oxy, he wished that I'd go to the war and get killed in the first five minutes.  This time, he merely tried to spit at me whenever I passed by.

It felt good to be back.

A Place for Everything

In the pantheon of those claiming to be suicidal, we were recently graced by a superstar.  Discharged by our psych unit, she storms past the triage desk on her way out the door.  After yelling on her cell phone and failing to get anybody to come pick her up, she marches back up to the desk and announces, "I feel like killing myself."  One of the nurses politely but firmly informs her that she had been cleared and discharged by the psychiatrists, and therefore couldn't just go back to her room, but that she was welcome to sign in and start the process all over again.  Hearing this causes the drama queen to start sobbing hysterically.  After 30 seconds of theatrics without a response, the diva turns off the tears and marches out again while screaming obscenities.

Later in the evening, I'm sitting at the desk re-assessing patients still waiting to be see, and quickly recheck a gentleman's blood sugar.  As he returns to his seat, Drama Queen arrives for her second performance of the evening, and sits down in the chair in front of me.

DQ: "I feel... [sobs]... like killing myself."

Me: "Okay, let's get you regist-"

DQ: "If you don't let me back RIGHT THE FUCK NOW, I will slit my wrists and drop BURNING HOT COALS in to my arms!" [with emotion, arms thrashing wildly through the air]

Me [sotto voce]: "Would the coals cauterize the bleeding?"

Triage nurse [stage left, to the audience]: "I bet she'd drop them first."

When I failed to bring her back right the fuck away, she grabbed the glucometer box still sitting on the desk and hurled it at my head (I blocked it with my lightning fast reflexes).  Realizing that attacking staff doesn't gain you sympathy, and eyeing our geriatric security officers lumbering over from their desk, Drama Queen decided to take her final bow and leave for the evening, probably to debut her one woman act at another ER.

I now make sure to keep the glucometer underneath the desk when not in use.

In Case of Emergency

A completely appropriate use of 911 emergency services (though in this case, non-medical).

What Lies Beneath

Pulling an IV line is only slightly more complicated than it sounds: remove the tegaderm, apply some gauze, pull out the line, and tape the gauze.  No more than 30 seconds, tops.  Every once in a while, the gauze becomes blood-soaked, and simply gets replaced by another 3x3 and taped down again.  That's it.

The other day, a nurse asked me to pull the IV on a pleasant-looking older lady.  I removed the line, taped the gauze, and went back to work.  A minute later, the patient found me at the nurses' station and pointed at the gauze, which had a tiny red spot in the middle.  "It's still bleeding," she informs me.  No problem, I say, and tape down some new gauze.  A few minutes later she comes back and shows me the gauze, this time without any red spots, wanting it changed again.  When I ask her why, she tells me "she doesn't like knowing that there's blood underneath."  I add a third piece of gauze while the patient's nurse stands nearby trying not to laugh.  After the patient leaves, I turn to the nurse and mention that there's plenty of blood underneath the patient's skin.

Fearing an elective skin transplant, we hope she never finds out.

Just a Thought

In recent months, most US airlines have begun charging for checked and oversized baggage.  As a student who lives and studies 900 miles away from home, I hate these new policies and the effect they have on my travel budget.  That said, I think they should be applied to the ER right away.

As the name implies, an Emergency Room should ideally be used only in the event of an emergency.  An emergency, which is by definition unplanned.  An unplanned event, which does not involve premeditated packing.

Nevertheless, the number of people who seem to pack before coming to the ER amazes me, as does the volume of belongings that they bring.  A book, perhaps, and maybe a snack could be grabbed on the way out the door in anticipation for a long wait.  But two suitcases, a duffel bag, an oversized purse and three shopping bags should not accompany you to the Emergency Room.  And if they do, you should be charged a handling fee.  Just like airline passengers, ER patients should be allowed one personal item and one carry-on bag.  Anything else should merit a charge, with bags that cannot fit in the overhead bins costing double.

I've seen several instances of emergency room overcrowding caused by baggage, not bodies, but the most egregious example occurred a few months ago when a woman was unloaded by the ambulance with enough luggage for a six-day, seven-night stay.  Escorted by the bellhops, I mean paramedics, to the waiting room towards the beginning of my shift, she was still there eating a box lunch, flanked on either side by a mountain of bags, when I returned the next day.  Checking the list of triage sheets, I discovered that she had left without being seen.  Only she hadn't left - she was sitting there working on a tuna sandwich and a packet of crackers.  I know the economy is suffering and times are tough, but if someone's idea of a vacation includes an all-expenses-paid ride on the ambulance to the plush accommodations of a full waiting room, things must be worse than I thought.

Theme Night

Many shifts seem to revolve around certain themes.  Singing drunks, for example, often seem to come in sets of three.  Thursday night, my last in a string of working nine of the previous ten overnights, quickly became bloody airway night.  Compared to some people I work with, I usually don't have a black cloud in trauma, and was looking forward to an easy eight hours to end my long string of work and ease into a four day weekend.  That didn't happen.

My first trauma of the afternoon occurred early in the shift, when an older gentleman crashed into a telephone pole and rolled over his car.  The EMS patch reported intrusion into the vehicle and a head laceration.  When he arrived in the trauma bay, I was standing a the head of the bed ready to place him on the monitor.  As we transfer him to our stretcher, we notice the EMS gurney is soaked in a pool of blood.  Cutting off the dressing on his head reveals a huge section of his scalp avulsed, letting us see down to the skull.  As the resident begins an unsuccessful attempt at intubation, another full trauma rolls in to the next bed - a young female who'd been slashed over 20 times with a box cutter (mainly to her face and back) by an ex-coworker comes in screaming uncontrollably.  One of our new ED attendings successfully intubates the MVC, and then moves on to help tube the shrieking girl next door.

Bloody airway #3 was a (surprise!) no helmet motorcyclist with bilateral tib-fib fractures and a smell of alcohol about him (patient screaming: "Am I alive?!").  Another unsuccessful attempt at intubation results in a page for anesthesia to the trauma bay and the trauma attending ripping open a trach kit, holding a scalpel to the patient's throat before the ED attending convinces him to allow another, ultimately successful, attempt.  

Highlight of the evening: Trauma attending, getting impatient with his resident inserting a foley, yells out for him to grab the guy's dick, hold it up to the ceiling, and get the foley in.