Tuesday, December 30, 2008
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.
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.
Monday, December 29, 2008
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.
Sunday, December 28, 2008
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?
Friday, December 26, 2008
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.
Wednesday, December 24, 2008
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!
Tuesday, December 23, 2008
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.
Monday, December 22, 2008
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."
Sunday, December 21, 2008
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.
Saturday, December 20, 2008
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.
Friday, December 19, 2008
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.
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.
Thursday, December 18, 2008
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.
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.
Wednesday, December 17, 2008
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.
Tuesday, December 16, 2008
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.
Monday, December 15, 2008
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.
Sunday, December 14, 2008
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.
Saturday, December 13, 2008
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.
Friday, December 12, 2008
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.
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.
Thursday, December 11, 2008
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.
Wednesday, December 10, 2008
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.
Tuesday, December 9, 2008
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.
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.
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.
Monday, December 8, 2008
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.
Sunday, December 7, 2008
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.
Saturday, December 6, 2008
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.
Friday, December 5, 2008
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.
Thursday, December 4, 2008
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.
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."
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.
Wednesday, December 3, 2008
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.
Tuesday, December 2, 2008
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.
Monday, December 1, 2008
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!