Evidence-Based Medicine

Came across this paper while doing some reading for class...great medical/nerd humor.  Anyone interested in serving the control group?  The rest of the paper is equally amusing:

Smith and Pell, "Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials," British Medical Journal 2003, 327: 1459-1461.

Hotel ER

Scene: Chronic EtOHer Jim Beam comes in from the cold and marches up to the triage desk on a busy Friday night.

Me: What's going on tonight, Jim?  

[Good evening, sir, are you checking in?]

JB: I gah dis pain in mah knee.  

[Yes, I'd like a room please.]

Me: How long has that been going on?  

[How long were you planning to stay with us?]

JB: 'Bout 10 years.  

[About 10 years.]

Me: Really?  

[Very good sir.]

JB: Shit man, it's cold outside.  

[Yes, I've frequented this establishment before and found it to my liking.]

Me: Alright, I'll get you a blanket and a box lunch while you sleep it off.  

[We'll make sure all the usual amenities are in order]

JB: I godda be somwhere in dah morning.

[I have an important business meeting tomorrow morning.]

Me: I'll make sure our concierge places a wake-up call promptly at 7am.

Great Anatomy

No, that's not the backwards X-ray from Scrubs, it's the (Google-obtained) chest film of a patient with dextrocardia, an autosomal recessive condition that leads to the heart being located on the right side instead of the left.  The ER can be an incredible place to learn, especially when I'm working with some of the more awesome residents who don't mind taking the time to teach even a lowly ER tech.  One gave me the tipoff on a young patient with the dextrocardia the other night, showing me his X-ray and letting me listen to heart sounds coming from the right side.  As an added bonus, I heard my first heart murmur while listening.  Pretty cool.

Cure-all Clinics?

Interesting news out of Salt Lake City (how often do you hear that phrase?), where the Utah state senate is considering a proposal to build new clinics in an effort to divert non-emergent patients - 60% of visits according to one estimate - from overcrowded ERs.  

The concept of using clinics to help ease the burden isn't new, but it is interesting.  Several months ago, the Washington Post published an in-depth article about Michelle Obama's role in a program that attempted to dissuade patients from using the ER as a source of primary care and directing them to neighborhood clinics instead.  Politics aside, it seems like a great idea on paper: redirecting the non-critical to more appropriate settings while freeing up ER beds for those with life-threatening emergencies and saving millions in healthcare costs.  Critics, however, maintain that the program is merely a way for the University of Chicago Medical Center "to save money and reduce costs by serving fewer poor people without health insurance."  

It raises the question: what role should the ER play in our healthcare system?  Since EMTALA, emergency rooms have come to be seen as offering "free" care for anyone who walks through the door.  If a hospital attempts to redirect patients without insurance to local clinics, should they be seen as trying to provide more appropriate primary care or as dumping patients who can't pay?

And The Challenger...

It's common parlance in the ER to succinctly summarize the mechanism of injury like you're advertising a prize fight; Car vs. Truck, Drunk vs. Stairs, Big Dude vs. Bigger Dude.  Last night, despite a valiant effort on behalf of the underdog, a scrappy contender from the driveway down the street, I had to step in and declare a winner in the much-anticipated Man vs. Snowblower showdown.  I'll let you guess who won the prize of two severed fingers.

We Have a Pulse

My laptop was just discharged from the Apple ICU and has returned home after a few successful transplant procedures.  Goodbye inconvenience of trudging to the computer lab and welcome back inconvenience of wasting time on the internet!

In Other News

The internets inform me that George Clooney will be returning as Dr. Ross sometime during this last season of ER. I am somewhat ashamed to admit that I have kept watching the show on and off over the years even as the quality plummeted, but it's good to see that some of the actors from the good old days are helping give the aging series a nice send off.

The Long and Winding Road II

Blogging from the computer lab (especially on a PC) just doesn't have the same feel to it, so I apologize for weak posts as I continue to wait for the return of my laptop.

Meanwhile, the process of applying to medical school is officially underway. The most recent hurdle involves writing a personal statement for the pre-med counselors to use in their evaluation of my application. I'm trying desperately to refrain from the whole "I want to be a doctor because I want to help people and save the world" shtick, but it can be toughto avoid speaking in cliches. Should I be brutally honest and say that I like the blood and guts, and want to crack chests perform difficult intubations for a living*?



*Even though that comprises approximately 1% of the time, the rest being spent on patients with knee pain for the past 10 years.

When Nature Calls

When you gotta go, you gotta go. I get it. Especially when you're piss drunk. Sure I'll grab you a urinal. I'll wheel you into the empty trauma bay so you can relieve yourself in private. I'll even get you that free box lunch you've been asking for all night. All I ask in return is that you actually use the urinal, and that you don't aim your pecker at the cart we use to store procedure trays. I know urine is sterile, but I guarantee you wouldn't like it if we used a tinkled-upon thoracotomy kit to crack your chest open should the need arise.

Foreign Body Airway Obstruction

I thought of EE's Young Teeny-bopper Student as I worked triage last night. Middle age gentleman ran up to the desk with hysterical wife in tow, who explained that her husband had started choking on a piece of steak while they were eating out. A physician on scene performed the Heimlich maneuver and then recommended the guy head to the ER to get checked out. Upon arrival, he stood hunched over the desk, still having difficulty breathing. As the nurse registered the patient and I began to get a set of vital signs, the gentleman suddenly vomited all over the desk, finally expelling the offending bit of meat.

He then plopped himself into the chair, wiped off his mouth, and proclaimed "that felt good."

Update

While the original plan called for keeping my computer overnight for observation, its worsening course necessitated a transfer to a major referral center and potentially a week-long stay in their ICU.  With the new semester starting to pick up, this is becoming a huge inconvenience.  I'm just hoping it pulls through.

In other news, the Big City Hospital recently upgraded the sliding glass doors at its main entrance.  No longer motion-sensitive, they now require pushing a button to open (in an effort to prevent cold air from rushing in any time someone passes by I guess).  Of course, the result has been no less than three head-on collisions by yours truly as I boldly strode into the glass, expecting the doors to woosh open at my presence.  Should only take about 20 more embarrassing incidents like these before I'm conditioned to push the damn button.

Woes

Fortuitously-timed computer issues are (hopefully temporarily) limiting my access to the internets and have thus prevented a rant about a fairly nasty incident at work recently.  Suffice it to say that my long-held delusion that everyone in the ER looks out for each other has been revealed as such, and the importance of covering one's ass reaffirmed.  

Lesson learned.

How Low Can You Go?

Beeping monitor alarms are the elevator muzak of the ER: always playing, often ignored after the first refrain.  I've seen many patients impressively hold up their end of the conversation while the monitor read V-tach, and a few patients in actual V-tach without the monitor seeming to notice.  Nevertheless, the beat goes on and I often find myself silencing the alarm from the central monitor on the massively hypertensive patient who hasn't taken his medications for the past two months.  The other night, as I went to silence yet another shrill alarm, I noticed the patient had a heart rate in the low 40s that would brady down to the low 30s every few seconds.  I turned to the nurse, who was already aware, and she said for whatever reason the doc was okay with that.  An elderly fall victim with a heart rate in the 30s would make me a little uncomfortable, but what do I know?

Warm and Dead

As the saying goes, you're not dead until you're warm and dead.  I've seen at least one pretty extreme example to lend support to this claim.  Given the recent string of frigid temperatures, and the miraculous survival of those US Airways passengers after crashing in near-freezing waters, hypothermia has been in the headlines lately.  Here's a Scientific American interview with an ER doc published yesterday on what happens when your patient is an ice cube.

Quote of the Night

Scene: 20-something year old punk, high out of his mind and sporting a deep stab wound to the left thigh, refuses to cooperate during a trauma exam. 

MD: "Do you have any pain - stop moving! - do you have any pain when I push here?"

Pt: "Yo, man, what's with all these questions?  Can't we have an intellectual conversation or something?"

At which point we stopped the exam, brought some coffee shop chairs into the trauma bay, and began to discuss themes of fatherhood and identity in James Joyce's Ulysses. 

Almost a Patient

Nothing like nearly getting plowed over by an SUV to get the blood pressure up.  Just got back from a run where some asshole driver ran a red light and came within inches of a slamdunk vehicular manslaughter conviction.  As I've often mentioned to my friends, I have no desire to be in the ER unless I'm getting paid, and thankfully avoided becoming a patient this afternoon.  

Remember: red means stop.

The Weather Outside is Frightful

Temperatures well below freezing and sub-zero windchills have descended over most of the country, and the Big City is no exception.  My past few shifts have seen a big increase in the number of patients requiring rewarming, many with core temps in the low 90s.  In yet another example of the vicious cycle started by the economic collapse, government funding and private donations to local homeless shelters have started to dry up, forcing people to risk freezing to death outside and eventually making their way to the ED.

One of my least favorite aspects of the cold is the need to cut off trauma patients' clothing.  When someone arrives in a c-collar, we often have little choice but to cut off their shirts so they can be examined for other injuries.  Pants I'll always try to slide off, but if we can't ease the bulky sweater or turtleneck over the head, I feel awful having to cut through what may be that person's only warm clothing.  

Bribery

Perhaps to climb up in the Press Ganey rankings, a Virginia network of hospitals recently announced that it will provide written letters of apology and a free movie ticket to patients who were not seen or did not have treatment started within 30 minutes of arrival.  During busy nights in the Big City ED, there's no way we could turn over the entire waiting room population and get everyone back in 30 minutes, so I'm curious what "being seen" actually means.  Drawing labs and ordering X-rays from triage, which we do?  Or having a provider come out, look at a patient, and say "see you in three hours?"

On a side note, I propose an alternate plan: offer free movie tickets to patients with bogus complaints if they leave.  I'm not trying to dissuade patients with actual emergencies or even perceived ones to avoid the ER, simply the "knee pain for the past 10 years" or "my doctor's office won't open until tomorrow morning" or "I need a refill for my allergy prescription" variety.  EMTALA aside, wouldn't our health care costs plummet if we simply handed them two free passes to Bride Wars or something like that?  It might even save Hollywood from a bailout.

What We Do

Many thanks to Kim at Emergiblog for her post on the role of the ER tech.  I know we may not contribute a whole lot in the way of life-saving, but the ER tech is often the first to enter the patient's room to help transfer the patient and the last to leave after pulling the IV.  We grab blankets for the patients, draw labs and get EKGs for busy nurses, assist doctors with procedures and find whatever it is they're looking for.  In the big scheme of things, these are often simple tasks, but I enjoy what I do, learn a lot doing it, and often have a small but significant impact on an patient's care.

Oh Baby

Two extremely pregnant Moms-to-be were rushed in over my last couple shifts, bringing me close (but no cigar) to witnessing my first ER birth.  As far as I know, it hasn't happened in the nearly two years that I've worked in the Big City ED, but nurses who have been there longer say that they've seen a handful.

Mom #1 waddled into a wheelchair before being pushed up to triage in active labor, contractions two minutes apart.  Her water hadn't broken yet, so they had me wheel up her to Maternity.  I'm a runner with good endurance but weak hand-eye coordination, so I was immensely relieved that I didn't have to catch anything in that elevator ride.

Mom #2 showed up at our back door on an ambulance stretcher in very active labor, and was quickly pulled into an empty room to see if she was crowning.  One of the nurses grabbed the emergency delivery kit, but they ended up running her upstairs to deliver as well.

Two moments of excitement that helped break up the string of frozen EtOHers and slip-sliding MVCs over the weekend.  I hope both new families are doing well!

Vacation's Over

Back to school means the lazy days of break are no longer, replaced with 0800 classes and far too little sleep.  My last semester as an undergraduate began this morning, and between class, work, and research it's going to be busy.  But busy is good, right?

Presumed Consent

In the ED, we can be real jerks sometimes.  I mean, we get a patient with a blueish tinge, really working hard to move air, who has a history of intubation for asthma attacks, and we have the nerve to not only refuse to let him go home, but give him neb treatments as well.  And then, just to piss him off, we started an IV to draw labs and push more medication to help him breathe.  Where do we get off?  Come on, all this guy was trying to do was get some sleep, but EMS had to show up and drag him down to the ER for no good reason.  We know those pinpoint pupils are how his eyes always look when he's sleepy, but we still gave him Narcan anyway, just because we can.

Overflow

Summer brings the GSWs and the (suprise!) no helmet motorcyclists, with autumn comes the sloppy freshman requiring intubation after their first drink, and winter belongs to the psych patients.

The post-holiday blues have arrived in full swing.  Our pysch unit is booked through June, the hallways are packed, and of course there's not a pool sitter to be found.  Some of the cases are absolutely tragic, like the father who lost his only daughter the day after Christmas and no longer has the will to live without her.  Some, of the "I took three Xanax and now I want to die" variety, are frustrating.  Others, like the little old lady who sits alone with a pleading look and politely explains that can't stop thinking about hurting herself, are just plain sad.  They're the kinds of cases I have the most trouble dealing with, and it's made all the worse knowing that the chaos of the ER is probably the worst environment for these patients to be stuck in.  In a couple weeks it'll all die down, but in the meantime it's rough for everyone.

How May I Take Your Order?

Me: "We're not trying to kill you Ma'am"

Pt: "Oh yes you is.  Nobody brought me dinner.  I haven't eaten in two days.  Bring me a steak before I starve to death."

[Grab a turkey sandwich box lunch] 

Pt: "Don't bring me that juice shit.  That shit's nasty.  I don't like that juice.  I want the ginger ale.  Cheap bastards used to have the good ginger ale, but now it's that cheap shit but hell I'll drink it.  Bring me a pillow too I gots pain in my coccyx."

Sign of the Times

Walked into work last night for my first shift back after a long vacation, and who was there to great me but Jose Cuervo, sporting his very own c-collar after getting drunk and falling down.  With the amount of wasted CT scan radiation that head has been exposed to, it's amazing it doesn't glow in the dark.  

My eight hours in our critical care area were spent dealing with some pretty sick patients, but the worst was a 65 year old male with 10/10 crushing chest pain.  Rushed in by EMS from his home, the gentleman experienced sudden onset of pain as the sheriff arrived to evict him and his wife from their home.  According to the wife, her husband had worked for the same company for over 30 years, but lost his pension when the economy began to tank.  Their savings finally ran out and they could no longer afford to pay their bills.  

EKG showed he was having an MI so we ran him up to the cath lab, saving his life while burying him with medical bills plunging him further into financial hell.

Meanwhile, Jose Cuervo returned to the ambulance bay three hours after he had been discharged, where he could be seen through the glass doors downing another bottle of Listerine before staggering into the waiting room.

Kentucky Fried Chest Pain

Resolution #2 for the new year: eat healthier.  Shouldn't be terribly difficult as long as I avoid the example of some of my patients.  Or maybe I should just page Surgeon General Gupta for some wellness advice.

Not too long ago I took care of a middle-aged male complaining of severe chest pain.  His EKG was normal and first set of enzymes negative, however the guy was a walking risk factor: an obese, diabetic smoker with hypertension, high cholesterol and a family history of heart disease.  While waiting in our short-term observation unit for serial enzymes, his family asked if they could bring him some food.  I pointed them in the direction of the cafeteria, with the reminder to hold off on anything with caffeine, as he would likely get a stress test in the morning.  A short time later I walked into his room to check vitals and found that his family had delivered a jumbo bucket of Kentucky Fried Chicken for him to munch on and an extra large Coke to guzzle.  As I stood dumbfounded, he looked at me while chewing, and with little bits of chicken flying out of his mouth asked "It's okay if I snack in here, right?"

Tomorrow Never Knows

I came across an interesting commentary on ED overcrowding yesterday in the current issue of the journal Academic Emergency Medicine.   Rather than focusing on the danger to patients and pressure on staff, the authors consider a different angle that I hadn't considered - the effect on medical education.  As the article makes clear, harried emergency physicians dealing with hallways full of patients do not find themselves in an ideal environment for teaching: "As we spend more time discussing diversion with charge nurses, and less time teaching students and residents, we wonder if we are doing a disservice to the doctors (and patients) of tomorrow....Could I really teach the student the subtleties of the abdominal exam on that fully clothed patient in the hallway?"  

Of course multi-tasking and prioritizing in hectic situations are core skills of emergency medicine, and no one would argue that an ER will ever be free of distraction.  Part of the difficulty in studying this problem involves establishing metrics for overcrowding and education in the first place.  But what remains clear is that continuing to push emergency departments beyond capacity will produce negative outcomes not just in the short term for those patients stuck on stretchers or out in the waiting room, but far into the future as well.

-J Fischer et al., "Overcrowding: Harming the Patients of Tomorrow?" Academic Emergency Medicine, 16(1): 56-60, January 2009.

Another Way to Die

Continued channel surfing has introduced me to commercials for series called 1000 Ways to Die.  I have yet to see an episode, but the clips online have potential.  One part Untold Stories of the ER cheesy re-enactments, one part Darwin Awards, and a dash of House-inspired CGI anatomy, it has all the makings of must see TV.  I recommend the tale of the drunk, gun-toting rattlesnake victims.  

Yummy

A thoracic cake.

Now that looks appetizing!  (Courtesy of The Happy Hospitalist)

Heal Thyself

Resolution #1 for when I head back to work in a few days: be less clumsy.

Normally I'm not too bad, but I've had my fair share of bumping into IV poles, playing bumper cars with stretchers, or juggling vacutainers.  A while back I was checking lab results on the computer when I saw an elderly man walking to the bathroom syncope and hit his head on a crash cart as he fell.  Rushing over with several nurses and a doc, we found him with a nice forehead lac and a newly forming hematoma.  I ran to grab a backboard and c-collar but, former track star that I am, accelerated right into a parked stretcher and won myself a massive bruise on my thigh for the next several days.  I limped back with the goods, and after a negative head CT and a couple stitches, the patient was right as rain.

My blue and black souvenir reminded me of my favorite phrase from first chapter of my EMT text: "An injured EMT is of no use to anybody."

Happy New Year

Welcome 2009!  Hopefully everyone has finished their banana bags by now and is off to make progress on those resolutions!