More Bad Press for UChicago

From page 3 of this morning's Wall Street Journal, an article about a plan by UCMC to reduce their number of ER beds that has led two physicians to resign in protest.  

"The current plans to cut our bed number further will make it more likely that only the poorest of the poor will be waiting prolonged hours for care, longer than will be safe," wrote one of the physicians.

The hospital also plans to close a general medicine unit and an ICU, placing further strain on the remaining ER beds and increasing patient boarding.

Yet another sign of the times.

A Tale of Two Gunshots

After receiving a call for shots fired, EMS responded to find a young male found lying in the street in a pool of blood.  Their early patch meant that the trauma team, ER docs, three nurses and two techs were waiting at the beside, the rapid infuser was primed, and X-ray and respiratory were standing by upon their arrival to the trauma bay.  Barely conscious, the patient was pale and had a last reported pressure in the 60s.  The mob descended on the guy before the medics had even transferred him to our stretcher, but it only took one quick look by the trauma attending to call everyone off and redline him upstairs.  I threw on a portable monitor while another tech held the elevator, and we rushed him up to the OR with a resident holding pressure on the leg.

Contrast that with the guy from last night: high out of his mind and status-post ass-kicking.  Several bruises and small lacs to the face drew everyone's attention while I cut off the guys jeans and discovered a through-and-through GSW to the thigh.  I tipped off the resident, who proceeded to ask the patient if he knew he had been shot.  The response: "Nah, dude, really?" 

No Flash Photography

Wisconsin nurses accused of taking photographs of an X-ray of a patient who presented to the ER with an object in his rectum and posting the image on the internet have been fired, and their case forwarded to the FBI to investigate HIPPA violations, according to this article linked from CNN.com.  A good opportunity to remind everyone of the disclaimer appearing at the bottom of the page.

Internal Dilemma

So on the one hand, my patient was probably taught to share at a young age.  Odds are he was also instructed to cover his mouth when coughing.  I understand his dilemma, struggling between two deeply-ingrained life lessons, but in the case of pneumonia, I'm really going to have to side with covering your mouth.  I'm sure a profound sense of generosity motivated him to cough directly into the face of anyone who came near him, but the rest of us are fine without pneumonia of our own.  In fact, I was so inspired by his example that I decided to share one of our masks, and tell him I'd call security if he took it off.

Which One is Not Like The Other?

Checked the board at the beginning of my shift last night to take stock of my patients:

CP, AP, SOB, AP+, restless legs, stroke, minor MVC.

(translations: chest pain, abdominal pain, shortness of breath, abd pain - pregnant).

Now restless leg syndrome is a legit condition, but seeing up on the board along surrounded by those other complaints definitely gave me a chuckle.  With four exams spaced out over the next week, I'm hoping that all the right answers stand out just as clearly.

Code Flu

It's called the common cold (google.com/flutrends).

After eight agonizing hours spent working in Fast Track and witnessing a nearly unbroken string of "upper respiratory tract infection" dispositions, I have decided that the Big City ED needs to implement a Code Flu protocol.

Upon presentation to the Emergency Department, patients between the ages of 18 and 65 must undergo rapid screening to assess whether symptoms (cough x 1, sneezing, fussiness >5/10, being sleepy, runny nose lasting longer than 2 minutes, general achiness, wanting to skip school/work) warrant activation of a Code Flu Protocol.  If any of the above criteria are met, the triage nurse, in consultation with the Charge Nurse, will instruct the secretary to overhead page Code Flu with a D2C (door to couch) goal of 5 minutes.

The Code Flu Protocol requires:

*Patients will be brought back to a comfy couch to be evaluated by an emergency physician.  

*Trauma Nurse will provide a heated blanket to the patient on the comfy couch.

*Respiratory will be paged for a stat portable humidifier.

*Pharmacy Tech will deliver a pre-mixed bag of IV chicken soup.

*ICU Code Team will rapidly respond with sterile tissues and high-dose antihistimine.

*Mom will be paged to take the patient's temperature and provide prn reassurance.

*Upon stabilization, and with approval of the attending physician, IT Services may modify the cardiac monitor to display daytime television.

I think it's going to be a roaring success.

When I'm Nintey-Four

I'd like to say that a patient experiencing "senile agitation" came after me with their cane like in the picture above, but that would be a lie.

He used his walker.

And while we certainly didn't break out the thorazine to calm him down, he did require some coaxing before relenting in his quest to trample me to death using his gray plastic mobility device with the hollowed-out tennis ball booties.  I've encountered a broad spectrum of elderly patients in my time in the ED, running the gamut from the senile to the serene, violent to vivacious, and more than one inappropriately flirtatious.  Although part of me fears that I'll grown into the potty-mouthed old codger who hurtles obscenities and used Kleenex at the ER staff with reckless abandon, I'd much rather become the crazy grandpa who can't stop laughing while telling dirty jokes.  I'll probably end up somewhere in between.

(Check out more ridiculous old ads here)

Really?

I apologize in advance for being crass, but to those who don't know, pretty much every surface in the ER have come in contact with fluids at some point, and we're not talking normal saline.  From the flu victim with projectile vomit to the drunk shooting golden arches in every direction, it's all been done before.  And I've come to expect it.  At work.  But when I come home after a night out to find stupid sots relieving themselves on the staircase of the building where I live, I become justifiably perturbed.  Seriously hooligans, find a bush or something.

Rough Night

Long shift last night, with two tough cases:

The first was an 88 year old women from an ECF brought in for difficulty breathing per the staff. She had a room air sat of 82% upon arrival that managed to climb up to the low 90s with a non-rebreather.  Blind and unable to speak, she was barely conscious and unable to straighten out her legs in the bed.  Probable pneumonia, labs came back showing severe dehydration, and echo revealed an EF of 10%.  Her daughter followed her in, and stood at the bedside for hours reading to her mother and stroking her hair.  With her DNR, there was little we could do but wait for a bed upstairs.

The second was a 45 year old male who collapsed while playing basketball at the gym.  Brought in by paramedics in full arrest, we coded him for 30 minutes without success.  At one point we thought we got a pulse back, but a quick check on the ultrasound showed no cardiac activity.  Several members of his family rushed to ER, and we could hear their crying from the family room for hours.

Two very tough ways to go, but at least both we lucky enough to have loving families nearby.

Paying the Bills

So I've been getting a lot of mail from the Air Force and the Navy lately offering to pay for medical school.  Free books and tuition, a monthly stipend and a hefty signing bonus are obviously attractive selling points in this economy, but I don't know how I feel about the service commitment.  I'm already looking at a minimum of nine more years of education, would I be willing to tack on another four years of obligation after that?  Sure it would be a great experience, a chance to serve my country, and hopefully a way to see the world, but I wonder how it would affect my career and plans to have a family.  Something to keep thinking about, but I guess I should focus on applying and getting into schools first.

The Story Continues

More interesting news out of Chicago this afternoon, as the American College of Emergency Physicians spoke out against the University of Chicago Medical Center's controversial new plan to redirect patients out of their emergency room.  According to the Tribune, the ACEP said the hospital is "failing in its obligation to treat emergency patients" and is "dangerously close to patient dumping" and violating EMTALA.  They go on to describe the new program as an effort to "cherry pick" richer patients.  

When I first heard about the policy, I wondered how long it would take for a bad outcome to occur, and shortly thereafter Shadowfax wrote about UCMC turning away a child whose face had been mauled by a pit bull.  We'll see how long this program lasts.

Going to the Birds

I know there's been a lot of gloom and doom talk about rising health care costs, lost insurance, and ER closures, but today's Chicago Tribune shows that the situation is far worse than I thought.

The Bird Emergency Room (yes, as in an ER for birds) is facing financial collapse.

Winter weather damage has burdened the avian trauma center with thousands of dollars in repair costs at a time when donations are drying up, leaving our injured winged friends with nowhere to turn.  Dawn Keller, a wildlife rescuer, would triage her patients, place IVs, and even use a coffee stirrer to suction blood from an ailing bird's mouth, but is now fighting to keep her ER from closing its doors.

Oh the humanity!

Who's On First?

Somebody must have put crazy pills in the drinking water last night:

Pt: "I need to call my daughter, can you get me a phone?"

Me: "Sure, is it a local call?"

Pt: "No, long distance."

Me: "Okay, I need to get a code from the secretary if it's not area code 555."

Pt: "No, it's 555."

Me: "So it's local."

Pt: "No, long distance."

Me: [Sigh]

Dude Wearing Designer Sunglasses Despite Being Inside on a Cloudy Day: "These alarms are driving me crazy, turn them off or I'm leaving!"

Me: "Sir, if you stop moving around and pulling the leads off, the monitor won't beep."

DWDSDBIOACD: "I can't stop moving until the alarms stop!"

Sick Drunk Guy: "Get me some water!"

Me: "Sir, you can't have anything by mouth."

Sick Drunk Guy: "How 'bout Johnny Walker?"

Do-It-Yourself Medicine

In the midst of the economic meltdown, overburdened ERs continue to serve as an unintended safety net.  Since hospitals are required by law to provide emergency care regardless of a patient's ability to pay, many individuals who have lost their jobs or seen their health insurance evaporate in recent months turn to the ER as their only place to see a doctor.  Some reports have shown increases in ER use by the newly-uninsured, while others anticipate brewing storm as (mainly older) patients with complex and expensive illnesses forgo prescription medications or necessary procedures to save money today, but end up needing more expensive emergency care when they decompensate in the future.  

The New York Times recently took a look at a group of 20-somethings, dubbed "invincibles," who are forced to make some difficult choices about their health care: "They borrow leftover prescription drugs from friends, attempt to self-diagnose ailments online, stretch their diabetes and asthma medicines for as long as possible and set their own broken bones" because "when emergencies strike, they can rarely afford the bills that follow."  Unlike their older relatives, these younger adults are not eligible for Medicare and make too much to qualify for Medicaid but not enough to afford private insurance.  As these tough times continue, expect to see more and more people lined up outside the ER.

Mmm Mmm Good

Took care of an absolutely delightful older lady the other night who had the misfortune of falling at home while eating dinner.  Still very high functioning, she described how she slipped on a rug while cleaning her empty soup bowl.  EMS delivered her to us with an obvious and painful-looking shoulder dislocation, and though she winced mightily while being transfered to our stretcher, she seemed more concerned that her hair wasn't done and she wasn't "dressed properly" to leave the house (I don't know if she was comforted or shocked when told that many of our patients come in with no clothing at all).

I helped get her settled while the nurse went to grab some morphine to take the edge off the pain and the resident explained how he would try to reduce the shoulder.  I had just finished hooking her up to the monitor when the nurse returned to push the pain meds.  The patient smiled and was in the middle of thanking all of us for taking care of her when she promptly began to vomit all over the nurse who was charting at the bedside.  

This wasn't just a little spitup, either - we're talking serious, projectile vomit aimed squarely at the nurse's chest that continued to erupt over the stretcher as the heavy, moist odor of warm soup tinged with bile quickly filled the room.  The resident and I couldn't contain our laughter as the nurse turned to the mortified little old lady and, wiping little yellow chunks off her scrubs, asked "Corn chowder tonight?"

Priorities

The other night, I was working in the critical care area with an awesome team of nurses and Doctor Robert when a middle-aged patient unexpectedly stopped breathing and lost their pulse.  We started coding the guy, working on him for over 45 minutes until we had him somewhat stabilized.  As I'm compressing away on the patient's chest, you know, trying to keep him perfused, Doctor Robert tells me to "lighten up" with the compressions for fear of breaking a rib.  Now I know that a broken rib could potentially cause internal injuries, but lowly tech that I am, I assumed the patient would rather be alive with rib fracture than dead with all bones intact.

I should also mention that this was all going down at shift change, and that within seconds of the oncoming attending's arrival, Doctor Robert gave a 30-second report and hit the road.

Entitlement Reform

The other day, an otherwise healthy young guy accidently gave himself a half centimeter lac on the hand while slicing food at home and decided to do what any other sane, rational person would do in the same situation:

He called 911, had an ambulance deliver him to the Level I Trauma Center, waited an hour to be seen in Fast Track, refused to let the PA treat him, demanded a plastic surgeon suture the "wound," and waited another hour for the consult to arrive.

The plastics resident gave him some Dermabond and sent him on his way.

Drink Plenty of Fluids, Don't Call

Things we can do in the ER:

*Put a tube down your throat to keep you breathing.

*Shock your heart back to life.

*Stick a needle in your chest to re-inflate your lung.

*Splint a broken bone, suture lacerations.

Things we canNOT do in the ER:

*Cure the common cold.

*Make the flu go away.

*Care that you've had "horribly bad sniffles for like four hours man!"

Theme Songs

So I've often debated possible theme songs for the ER with people at work.  Past ideas have included "Welcome to the Jungle" for triage, "Life in the Fast Lane" for Urgent Care, and "Stayin' Alive" or "Another One Bites the Dust" for the trauma bay.

Today, however, I learn from the internets that Rihanna is collaborating on a new song entitled "Emergency Room" with the lyrics:

"Let me see you try to live without me/Now where's your heartbeat?/Flat line on the EKG."

I think we have our winner.

Triage in the time of Recession

A few days ago I mentioned a plan started by Michelle Obama at the University of Chicago Medical Center to shift non-critical patients away from the ER and towards local primary care clinics.  This policy appears to have expanded according to an article in the Chicago Tribune this morning that discusses a new triage system designed to transfer patients to other hospitals.  While it unfortunately does not go into specifics, the article explains that, with up to 40% of their visits inappropriate for the ER, the hospital cannot cope with continued high costs and non-paying patients in the current economy.  

This should be an interesting story to follow.  How long before somebody brings an EMTALA claim?  With the new program worsen relations with local residents?  Will programs such as these finally change the perception that the ER is the place to go for primary care?

How To Save a Life

We had a pretty bad trauma a while back - a young guy shot in the chest by a stray bullet -  and one of the things that helped him survive was having enough donated blood in the blood bank to initiate a massive transfusion protocol.  Every two seconds somebody in the United States needs blood, but only 5% of eligible donors choose to give according to the American Red Cross.  Want to save a life?  Donate blood.

But I Gotta Go...

Some days you can't catch a break - Keep Breathing has a post up illustrating how impossible it can be to sneak even a quick snack on during a busy shift.  I would offer that the only thing worse than a steadily declining blood sugar at work is an increasingly full bladder.  I can't tell you the number of times I've asked someone to keep an ear open while I try to make quick trip to the bathroom, only to hear a page for two major traumas at the back door.  There's nothing worse than drawing labs on a patient while doing the "I can't hold it much longer" dance.

I Scream, You Scream

Quote of the night:

Me: "I know the doctors said you can't have anything by mouth, but no ma'am, I'm afraid the pharmacy does not stock IV ice cream."

Pt: "Damn."

Hold Me Tight

While I'm often lucky enough to work with a team that will let me get some hands-on experience and take the time to teach me, I'm still the low man on the totem pole and occasionally get dealt the less-than-stimulating tasks of sitting with psychiatric patients, cleaning off Scabies Guy, or serving as a human pressure dressing.

The other night a middle-aged dialysis patient came in with a bleeding fistula.  I've seen plenty of fistulas before, but this one was bleeding so heavily that it soaked through every dressing we applied in a matter of seconds, resulting in a good 45 minutes of me applying direct pressure while waiting for the consult to arrive.  Even though I was tightly clamping down on the arm, the force of the blood pumping through was enough to push my hand back.  Luckily, the gentleman was a nice guy and we made small talk to pass the time while making sure he didn't bleed out.

Two of Us

Nobody told me it was two for one night in the ER yesterday, but the pairwise arrivals throughout the evening eventually tipped me off.

EMS started off the shift by delivering Statler and Waldorf, a couple of nursing home residents involved in a kerfuffle in the dinner line who were sent to the ER to be evaluated for "altered mental status."

Next to arrive were Cheech and Chong - one high out of his mind and complaining of [for the record, invisible] bumps on his skin, the other merely dazed and confused.

Around 2am, Joanie and Chaci strolled up to triage desk and explained they had both been in a car accident.  When asked how long ago, they replied around midnight... two days ago.

And finally...

Two drunks were dragged in by the police - one having pissed his jeans while the other, lacking any clothing whatsoever, tried to draw pants onto his birthday suit with a black magic marker.

Doctor Robert

If you're a drug addict with a long and documented history of cocaine overdose and narcotic-seeking behavior, I suggest you schedule your visit when Doctor Robert is working.  As the Beatles said, if you're down he'll pick you up - especially if you demand IV dilaudid for your "chest pain" while threatening to leave.  Most of our other MDs will gladly show you the door, but Doctor Robert?  Well, well, well he'll make you.

It's All Too Much

Just as I'm starting to think about what schools to apply to and how to write my personal statement, Kevin MD writes that 21% of medical students are depressed.  I'm heading into the application process with eyes wide open after talking to several med students, and fully expect the next several years of my life to full of studying and stress.  That said, I'm usually a pretty happy guy and don't want to end up a depressed, miserable burnout with a white coat.  

Maybe it's the fact that a quarter of US medical students graduate with over $200,000 in debt.  Now that's depressing.

Hello, Goodbye

She was a 78 year old female rushed in by EMS from home with her middle-aged son in tow.  Complaining of shortness of breath, she had a history of prior stroke, and had been recently discharged from the hospital after having an MI two weeks ago.  She got the works - EKG, monitor, labs, O2, and was kept under a close eye while we waited for results to come back.  Within a few minutes, however, she bradyed down and lost her pulse, and we started coding her.  After CPR, meds, and defibrillation, we got her back, and the doc asked me to show her son to the family room.

Finding him talking to a nurse in the hallway, I asked him to follow me, but instead he handed me a piece of paper with his cell phone number on it.  "I gotta go," he insisted, "I don't like driving in the snow so I want to get my car back before it starts coming down again."  The nurse and I explained that his mother was extremely sick and that her heart had stopped, but he told us he had "things to do," and to just to "stick his number in her chart" before walking out.

I returned to the beside and ran an EKG that showed a massive ST segment elevation, while ultrasound revealed an ejection fraction of 10%.  I helped bring her up to the cath lab, but that's the last I know.  Whether the son ever found the time to come back I couldn't say.

It Just Keeps Getting Better

The bathroom can be a dangerous place; wet floors, sliding bathmats and slippery showers are all just itching to finish you off, but they pale in comparison to that ultimate death trap - the toilet.  

I've posted on the diabolical machinations those pernicious pieces of plumbing peril have undertaken to ensnare their victims.  I recall a night this summer when no less than five elderly patients came in after falling off their toilet seats.  One Florida resident, however, appears to have fallen victim to the latest escalation of toilet-on-human violence:

"A man who stopped in at the DeLand police station to use the public restroom was injured when a loose toilet seat shifted, smashing his penis, police said."

In a police station no less!  But wait, there's more:

"It was painful.  I was quite traumatized when it happened... I am 250 pounds.  Imagine that, that's all my weight pushing on that."

This unfortunate gentleman, who suffered a bruise and broken skin, goes on to say that he is not the litigious type, but that a lawsuit (against the toilet?) has not been ruled out.  The article concludes with a note that reader comments have been disabled.  That is not the case here.

If I Needed Someone

Working in the critical care area the other night, I had just finished drawing a set of blood cultures when I heard the resident cry for help from behind a curtain.  Running over with one of the nurses, we found her alone, gowned and masked standing over a patient draped in a sterile field, midway through inserting a central line on a septic older woman.  Monitor showed a heart rate in the 30s, and the patient had suddenly stopped breathing.  Stuck with the gidewire still sticking out of the patient's neck, the resident rushed to complete the procedure while the rest of us moved in to help.

It happened to be a night when I was lucky enough to be working with the A-Team.  In what felt like an hour, but documentation later proved to be a total of five minutes, the resident finished the line, I bagged the patient, nurses grabbed and pushed a couple rounds of meds, the secretary paged respiratory, the patient got tubed and her heart rate and O2 sat started climbing up to happier numbers.  

It's amazing to see how smoothly a serious situation can go when you've got a great team that's used to working with each other.  I definitely have my Fantasy ER team lined up if I'm ever a patient.

Respiratory Distress

James Harrison's 100 yard interception return in the Superbowl yesterday appeared to leave him a bit winded.  After the play, they had a brief shot of him on the sidelines enjoying some well-deserved oxygen via non-rebreather.  As a skinny distance runner, I can only imagine what it must be like for a linebacker to huff it from end zone to end zone.  

Janie's Got a Gun

While generally not a good idea to provoke your significant other, it's especially true is she's a gun-toting Annie Oakley with excellent aim.  Such was the lesson learned by one of our patients the other night after being rushed from home by EMS with his brachial artery pierced by a well-placed bullet.  Strong work by the medics, who found him with significant blood loss on scene, but quickly got pressure on the wound and brought him up to a systolic in the 100s with fluids.  Needless to say, he was taken straight up to the OR while the wife was taken into custody.