And What Brings You In Tonight?

Courtesy of my brother, here's a link to an online game requiring you to guess the top 20 reasons for ER visits.  I'm ashamed to admit that I could only get 10 of them, an embarrassment I blame on differences in terminology, and their failure to include reasons like "drug-seeking," "knee pain for the past 10 years," and "nothing better to do."

Virtually the Same

There's a good chance that if and when I finally become a med student, some of the first patients I learn on could be plastic, not people.  Simulation is the new big thing in medical education, and the residents and med students who train in the Big City ED have all had chances to practice everything from intubation to running a code on some pretty sophisticated dummies.  

I'm a big fan of technology, and I'm excited to experience one of these simulators first hand.  I wonder, though, about what might be lost in the process.  An op-ed from last Friday's New York Times felt the need to defend the time-honored practice of anatomy lab from the encroachment of digital dissection.  Citing dramatic improvements in imaging technology and the high costs of preparing cadavers for thousands of med students each year, some institutions are trying to replace scalpels with computer mice.  I was reminded of this piece when I came across an article on CNN.com today that discussed how medical students in London are examining patients in a virtual hospital using the online environment Second Life.

The potential for technology to improve medicine is huge, but as Nurse K points out, by no means a sure thing.  And for all the advantages that are gained, there are still costs when you remember that medicine is very much a hands-on art.  As the op-ed author wrote: "The dissection of cadavers also gives young doctors an appreciation for the wonders of the human body in a way no virtual image can match.  It is awe-inspiring to hold a human heart in one's hands, to appreciate its fragility, intricacy and strength."

Why?

She was a young female brought in to the ER by police.  Uncooperative and combative, she had to be restrained to prevent her from leaving.  In between profanity-laced tirades and repeated attempts to spit at staff who approached her, she would start whimpering and accuse us of trying to hurt her baby by placing her in restraints.

Obviously pregnant, she stated she was midway through her second trimester.  

She also reported trying to kill her baby by ingesting large amounts of heroin and crack.

The sad thing was, she meant it.  She'd been brought in a handful of times over the past few weeks, high out of her mind in an effort to end her pregnancy.  She had been talked to, offered help, had options explained.  And yet she continued to poison herself and her baby.

5,000

Second Shift had its 5,000th visitor today.  That's extremely small potatoes compared to most other bloggers, but still kind of a fun milestone.  Thanks to everyone who stops by - I hope you enjoy.

Act Now

While I'm busy wrapping up my final papers before graduation, the senior residents are all counting down their final remaining shifts.  They're a great group, and we'll miss having them around next year.  There's one in particular, however, that I don't want to see go.  I'm always unsuccessfully trying to bargain my way into trying procedures - maybe an easy intubation here, a quick central line there - but one of the seniors promised to talk me through a chest tube last summer.  The only catch: I needed to find a patient willing to consent.  Anyone willing to volunteer to help further my hands-on education?

The Few, The Proud, The Decent Human Beings

It's easy to post about the crazy, combative, and uncooperative patients that frequent the ER; less common are the posts about great patients who are a pleasure to take care of.  Keep Breathing just wrote on this, and I thought I'd echo him.

One of my patients this week was a delightful older woman.  I greatly enjoyed talking with her as I stopped in her room to grab and EKG, draw bloods, or help her to the bathroom.  She was polite, funny, engaging, and very understanding about delays in finding her a bed upstairs.  Clearly she was also a wonderful mother, as her children that waited by her bedside shared those same characteristics.  I know it sounds cliche to say this, but patients like her really are the ones who make dealing with all the other crap worth it.  (Crap like the guy on PCP just down the hall from her, who broke through the restraints and needed to be placed in handcuffs and police custody)

The Bad News Continues

While the furor over the University of Chicago Medical Center's controversial policy to redirect patients from its Emergency Room has died down over the past couple weeks, the beleaguered ER is once again generating some bad press.

According to this article from WBBM's website, the federal government is threatening to strip the hospital's Medicare certification after a patient died in their waiting room last month.  Allegedly, the 78 year old arrived around 12:30pm and waited for several hours without being triaged.  A report states that the patient was later found apneic and in rigor mortis.  UCMC has suspended two RNs and issued a statement that proper policies were in place but procedures were not followed.

Nice Try

Random Hallway Pt: "Excuse me, I lost $30 in that room behind you when I was seen here last month."

Me: "I'm pretty sure it's gone by now, Ma'am."

Random Hallway Pt: "Can you call my doctor or social work or somebody and have them reimburse me?"

Me: [Blank stare]

Come to think of it, I lost about $160,000 of med school tuition money in room 6 two weeks ago.  I wonder if social work can cut a check to pay me back?

Final Countdown

The second-to-last episode of ER airs tonight on NBC.  I've watched it off and on over the past 15 years, and it's hard to believe the show is finally coming to an end.  The quality has certainly faded, but I've really enjoyed the cameos by many of the old characters over the past few episodes.  After it ends, where will I turn to see doctors using the old-style paddles to shock asystole while screaming "Clear"?

Kids These Days

Took care of two patients last night who weren't old enough to legally purchase alcohol but were nevertheless addicted to heroin.  One I've treated in the past, and I know he's had a pretty rough life.  The other I'd never seen before, but couldn't help but overhear the screaming match that occurred when her mom arrived at the bedside.  Both of them had been in and out of rehab, and were cruising down a pretty bad path.

The only point of amusement in either episode came from the second kid, who was only semi-responsive upon arrival.  All we had to do was say the word "Narcan" and she'd suddenly perk up, open her eyes, and stammer "No Narcan... no Narcan."  So, naturally, whenever we needed to interact with her for the rest of the evening, we'd step in the room and yell "Narcan" to get her attention.  It even worked long distance, when yelled from across the nursing station.  Now that's a powerful drug.

Episode IV

Today I came across a recent news article that I now share as part of my continuing series, "Man vs. Toilet."  

When I first started blogging several months ago, I could not have anticipated that humanity's epic struggle against the porcelain throne of doom would provide such a rich source of material, but it seems that this truly global struggle shows no sign of stopping.  Previously, I recounted the story of an unfortunate man who misplaced his penis between the bowl and the seat, to disastrous effect.  Before that, it was the tale of the Frenchman getting his arm stuck in a train toilet while trying to receive his dropped cell phone.  He was preceded by the unlucky Brit transported to the ER whilst superglued to the loo.

This latest chapter revolves around a two year old from central New York who was brought to a local fire station with a plastic potty stuck on his head.

"In 29 years, I've seen a lot of things, but this was definitely a first," said First Deputy Chief Gary Vincitore.  "He just put it over his head and pulled."  The child was successfully cut free from the toilet, and became yet another victim of loathsome latrine violence.

Checklist

Things you should bring with you to the Emergency Room:

*Insurance card

*A list of your medications

*Contact information for your primary physician

Things you can safely leave behind:

*Your ziplock baggie of dog food that you refuse to release from your ironclad grip

I'm Looking Through You

No, that's not the complex 3D folding structure of some newly-discovered protein.  It's the CT scan of a 6-piece chicken McNugget meal from McDonald's.  Today's Science Times has a great article on the work of a an artist-turned-medical student, as well as a slide show containing some very cool images of everything from a Barbie Doll to an iPhone.  

March Madness

Most people watching the NCAA tournament want to relax, maybe drink a beer, and enjoy some basketball.  That was the plan for one of my patients from yesterday, until he became the victim of a violent home invasion.  The guy was sitting on his couch, getting ready to watch the game with his son, when he heard someone moving around in the next room.  Dad managed to push his child out of the way before the home invader opened fire.

Instead of grabbing snacks at halftime, he was lying on a stretcher in the trauma bay awaiting the results of a head CT.  No GSWs, thankfully, but a series of nasty bruises covered his face where he had been pistol whipped several times.  The son managed to call 911 despite being shaken up pretty badly, but the burglar had fled by the time police arrived.

I don't know if it's the economy that's driving people to pull stuff like this or what, but it's a crazy world out there.

Suspicious Minds

While sitting at the computer waiting for lab results to come back, I was approached by a little old lady with white hair and pearls who hesitantly informed us of her belief that a patient in bathroom was smoking crack.

Typical for the ED staff, our subsequent conversation revolved not around how Annie Addict managed to smuggle her stash past security, but just how exactly June Cleaver knew what smoking crack looked like.  

Get Back

Home from my brief adventure in Another Country, where I narrowly escaped death from E. coli water, roaming packs of probably rabid dogs, MDR-TB exposure (pending PPD) and amphetamine-fueled traffic to perform some ultimately insignificant but nevertheless rewarding work. 

Returned to the Big City to find temperatures just as cold as when I left and only three voicemails from short-staffed charge nurses asking me to come in.  My first shift back from vacations are always disasters, and I can't wait to see what this week has in store. 

In other news, duty free is the best thing in the world.

Leaving on a Jet Plane

Happy early St. Patrick´s Day! I´m off to Another Country for the week, regular blogging to start up again when I return. I'm sure all the EtOHers will miss me...

Friday the 13th

Never was very superstitious before I started working in the ED, now I know I'm lucky to have tonight off.  Avoid those black cats and broken mirrors everyone!

Public Service Announcement

For anyone planning on getting high on PCP this weekend, remember to lock your windows.  While the third floor may not be as high as you are, it's still a lot further from the ground than you think.

And no, you can't actually fly.

Cancer Sucks

We get a good number of cancer patients passing through the ED, many of them in the later stages of their disease.  I've watched family members and friends go through it, and it's horrible.  Sometimes, however, even worse than the patients who are septic, altered, unresponsive, or consumed with pain are the ones who still look like they should be completely healthy.  I took care of a relatively young woman recently who was pretty far advanced, but still cheerful and friendly.  Surrounded by friends and family, she tried not to wince while I searched for her last remaining veins, never complained about being poked and prodded, and smiled and joked with the staff as she answered our questions.  I hated the fact that instead of being out and living her life, she was stuck in an ER bed rattling off a long list of ineffective meds that she was on.  The doctors tried to control her pain more effectively, but beyond that there was nothing we could do for her.  It sucks.

Twenty Questions

MD: "How often do you smoke?"

Pt: "Whenever I drink."

MD: "How often do you drink?"

Pt: "Only when I go out."

MD: "...and how often do you do that?"

Pt: "Do what?"

MD: bangs head into wall

Full Moon

Seems like everyone was getting a jump on the upcoming full moon last night.

Seven minor traumas in two hours were punctuated with the shrieks of little old man who whined in an unnaturally high-pitched voiced about the tingling feeling he was experiencing.  He was later joined by a woman who communicated only by singing.  Throw in the dude high on illy who kept repeating his name over and over, and we were on our way to having the next one-hit wonder.

Other highlights of the evening included watching a drunk stagger up to the board and erase the "No" of the "No Food" reminder next to his name (nice try my friend), drawing blood on the gentleman complaining of chest pain for the past 10 years (who was not actually having an MI... phew!), helping splint the dude whose boat engine fell on his ankle, and keeping an eye on SI patient who wanted to rent a guillotine to finish the job (do they come with a safety deposit?).  

While all this was going on, the clocks on our computers kept randomly changing in and out of daylight savings time.

 

Yeah, I'm pretty sure the full moon came early.

Spring Ahead

Snow is melting, clocks have jumped ahead an hour (don't forget), and warm temperatures are making a special guest appearance this weekend.  Taking advantage of the temporary heat wave with a long run through the streets of the Big City yesterday afternoon, I crossed paths with one of our regular patients while waiting for the light to change.  He did a brief double take before I ran off again, but I'm pretty sure he recognized me.  It's happened a few times, making eye contact on the street or at the supermarket, and it can be a little awkward.  Thankfully, however, I have yet to run into a crazy or violent patient (or anyone I've ever had to put into restraints) and I hope I never do.

On a side note, I've worked the night we lose an hour in the past, but never the night we fall back.  I wonder what happens for documentation purposes - can you chart a medication order at 0215 and then a reassessment at 0205 when the clock resets itself?

Everybody Was Kung Fu Fighting

Police found him high on PCP performing "karate" alone in the middle of the street.

Now that is why we have restraints.

Balloon Man

What is it that makes people decide to use the ER?  Some call 911 at the first sign of a mild cough, a handful decide after 10 year of knee pain that they simply can no longer take it, and others with legitimate and obvious medical problems nevertheless avoid medical treatment at all costs.

The other night I was working in our critical care area when a patient arrived via EMS looking like a poorly-drawn cartoon character.  Massive swelling from edema from the neck down to the toes.  Basically, he was a human Michelin Man.  Hypertensive to the tune of 270/140s, CHF, SOB.  Of course, he had prescribed meds for all his underlying conditions, but he hadn't taken them for months because he didn't like doctors.

Unfortunately, it got worse for the poor gentleman.  To get a urine sample, the nurse tried to insert a foley.  After a few tries, the doc attempted.  Then urology.  Turns out he was so swollen, even they couldn't get it in, and left the guy moaning in a blood-soaked gown.  Probably didn't improve his opinion of doctors very much.

For so many of these kinds of patients, I often wonder at what point they realize that they have a problem.  Many times it's family members who call 911, but if I were blown up like a balloon, I might try to do something about it.  

Two Words

Mullet wig.

That's right friends, for those of you who thought that business in the front and party in the back was a dream limited only to a lucky few with non-receeding hairlines, think again.  Now those who would struggle with even a comb-over can look exactly like Bono circa 1984!

I love ER patients.

Pulitzer Prize

If only there was a category for triage notes:

"This is Jose Cuervo's 389th visit to this Emergency Department in the past 4 years, and his 3rd in the last 24 hours.  +Slurred speech and unsteady gate, FS normal, BAC .390.  He has no complaint and breath smells of Listerine."

Birds may fly south for the winter, but the chronic EtOHers simply flock to the ER.

In (and Out) Like a Lion

Managed to survive Winter's surprise March sneak attack, though the crashed truck I passed on my way to class and the parade of ambulance sirens heard echoing throughout the Big City made me glad I wasn't at work tonight.  In addition to being besieged by snow, I still have two more midterms and a lab report, recommendation letters to solicit, and financial aid stuff to figure out within the next week.  

Still, it could be worse.  According to this article, a Russian dude who bet two ladies that he could endure a twelve-hour Viagra-fueled play date failed to collect his cash after succumbing to a heart attack upon completion of his effort.  What a way to go.

Call Me Dr. Doogie

"Are you old enough to work here?"

"Have you graduated high school?"

"You look like you're 13."

My apparently youthful experience, while probably something to appreciate later in life, has led to a certain amount of frustration working in the ED.  Yes I'm old enough to work and I have in fact graduated high school.

And I'm at least 14, thank you very much.

Now I can empathize with what poor Doogie Howser must have gone through...

I Hate Lice

For Dr. Jones, it was snakes.  For me, it's lice.

Working at triage the other night, I had just finished hooking a patient up to the BP cuff and pulse ox and was starting to write his name on a wrist band when the nurse registering the guy started squealing and pushed her chair back away from the desk.  Following her pointed finger to the patient's arm, I leaned in closer to she what was so excited about, then immediately jumped back myself as I noticed several little white critters inching their way along the black backdrop of the BP cuff.

Asking him if he knew he had lice prompted the response, "Oh sure, I have 'em all the time."

Totally skeeved, we covered ourselves head to toe in plastic, dragged him to the Hazmat room and showered him off after placing his clothes in a double-lined plastic bag.  We then returned to the triage desk and wiped down every single surface.

I could feel my skin crawling for the next six hours.

I hate lice.