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.

Loo Humour

In keeping with today's unintended theme of "Random British Shit," I respectfully submit the following article from the BBC.

Yes, a British dude did have to be transported to the hospital by ambulance while still attached to the steel toilet that some hooligan had covered in super glue.

According to the ambulance service spokeman, the patient "appeared to be none the worse for his ordeal other than being somewhat understandably embarrassed."  Indeed.

Hat tip to a friend of mine, not only for discovering the article, but for knowing that it's exactly the sort of thing I'd find hilarious.

Oh Heavens

Somebody page Ortho...

Med Student Blues

I came across an article written in the New York Times a couple days ago that looked at burnout among medical students.  I found it a little disconcerting since I start applying this spring, and with an extra year tacked on for my masters, I'm apparently looking at five years ripe with primo burnout potential.

The discussion about losing empathy especially peaked my interest.  Obviously the ER is not a hand-holding, pillow-fluffing environment, but I wonder if starting out here puts me on a fast track to cynicism?  I love working in the ER, and right now can't see myself doing anything but Emergency Medicine.  I enjoy the unpredictability, I'm excited to be part of the fast saves, and I love (no matter how much I complain here) the wide variety of people that pass through.  But at the same time, you can only take care of so many drunks and manipulative drug addicts before you start to get jaded.

Still, my focus will be on getting into a school before I start worrying about burning out.  In the meantime, however, it's stories like these that make me pretty sure it's going to be worth it.