Better Call Jack Bauer

Wolf Blitzer's Pandemicfest 2009 Swine Flu update: 

The World Health Organization has raised their pandemic alert to Level 5.  This stage indicates that human-to-human transmission of the virus is present in at least two countries in one WHO region, and calls for, among other things, Wolf Blitzer to move from a "serious" to "grave" delivery of all pandemic-related news.  It also means there will be 5 times as many people in the waiting room as during the previous alert level.

Move Along Folks

Every patient has a right to privacy, whether they act like they want it or not.  That includes the hot mess staging a meltdown in the triage bay, as she swears like a sailor and attacks the security officers with her nails while spitting at the tech taking her vitals.  So even if you're the very pleasant family members who I have enjoyed talking to while taking care of your sick elderly mother, I'm still going to ask you to stop gawking from the hallway.  This isn't TV, it's not a sideshow, and though you may roll your eyes as I ask you for a second time to return to your mother's room, remember that, despite her behavior, the patient at triage is entitled to the same standard of care as your mother.  Something tells me you wouldn't like if strangers started sticking their heads into Mom's room, so please, offer others the same courtesy.

Swine Flu Update

Despite Wolf Blitzer's Pandemicfest 2009, odds are you don't have swine flu.  Really.  

Ouch

Received a transfer from Another Hospital the other night, a (surprise!) no-helmet motorcyclist who was on the losing end of a collision with another vehicle at 45 mph.  Multiple facial and rib fractures, flail chest, splenic lac and head bleed.  One tube helping him breath and another draining the blood from his chest.  The worst part?  He was still fairly with it the entire time.  He could move his extremities (thankfully), squeeze your hand in response to questions, and motion when he was in pain.  I couldn't imagine being conscious in that condition and not being able to speak or open my eyes.

He's got a long recovery ahead.  Please, wear a helmet.

Sunday Afternoon Reading

A few interesting articles from the past couple days to enjoy on this beautiful spring Sunday:  

The first, from the LA Times, considers the role of Urgent Care centers in the context of ER overcrowding.  Are they helping to lessen the burden and clear space for the critically ill or injured, or are they simply siphoning off the "bread and butter" cases that help offset the millions of dollars ERs lose in uncompensated care?

Next, from Canada, a brief blurb about an ER in Nova Scotia that will be closed on Tuesdays in an effort to cut costs.  That's right, if you're planning on getting sick or shot, you better schedule accordingly.  Reminds me of road trips I've taken through some rural areas that had signs posted: "Emergency Medical Care available 8am-8pm."

And finally, from today's Chicago Tribune, an interesting profile of the night shift chaplain at a suburban hospital.

Enjoy the great weather!

Second Opinion

No abdominal pain, no cramping, no bleeding, no difficulty urinating.  Completely normal labs in the computer from a clinic visit the day before.  Vital signs stable.  Patient presents to triage at 0130:

CC: "I had an ultrasound yesterday at my OB/GYN and the doctor said my baby was a boy.  I want a second opinion."

ER Visits Up in Massachusetts

Despite mandating universal health insurance in 2006, Massachusetts experienced a 7% increase in ER visits from 2005-2007, according to this article from today's Boston Globe.  Nearly half of those visits were for conditions that did not require immediate care.  

While state officials want more years to collect data before drawing conclusions, Dr. Sandra Schneider of the American College of Emergency Physicians explains why insurance alone doesn't keep people out of the ER: "Just because you have insurance doesn't mean there's a [primary care] physician to see you."  

Several studies have shown that ER overcrowding is not solely caused by the uninsured, as many believe, but by patients who have insurance but cannot find or will not wait for an appointment with a primary care physician.  With PCPs forced to fill their schedules months in advance, and the common perception of the ER as a place to receive immediate primary care, it seems that ERs will continue to be swamped across the country regardless of whether or not we adopt universal health care.

Lost in Translation

Elderly patient delivered to the critical care area by EMS after collapsing in a shopping mall.  Confused and disoriented, he wasn't responding to questions or following commands appropriately upon arrival.  I got him hooked up to oxygen, placed on a portable monitor, and checked a finger stick while neuro was paged for a stat rule out CVA and CT was told to clear their table.  We were ready to scan him for a brain bleed when one of the doctors passing by pointed out that the patient was speaking Polish, not gibberish.  

A few nights ago, an older gentleman arrived in severe respiratory distress with a neighbor's son in tow to translate the rare African dialect that he spoke.  After a couple neb treatments relaxed his breathing, we brought out the state-of-the-art audio-visual translation doohickey that never works and spent half an hour wheeling the poor man up and down the hallways of the department in a futile search for a wireless signal.  Every time the translation service put us through to their expert, the screen would freeze and the call would cut off.  We ended up relying on the kid, even though it wasn't ideal.

Language barriers can be a big problem in medicine, especially in the ED.  While many situations are handled by simply muddling through, as this New York Times piece discusses, speaking the patient's language can sometimes mean the difference prepping tPA and giving an icepack to a visiting Polish grandpa who tripped at the mall.

Clean After Thyself

Dear MD,

Next time, if it wouldn't be too much trouble, could you kindly take the extra effort to dispose of the used stool guaiac card and used pair of gloves in the trash itself, rather than leaving them sitting on the counter approximately three inches from the trash?  Don't worry, I took care of all those sharps you left lying around without telling anyone, too.

Yours,

Second Shift

High Holiday

Even though 4/20 has come and gone, it appears that people remain committed to their observances.  Yet another young gentleman made his way dazed and confused into the ER last night, in a cold panic that "you know, those dudes" were trying to raise his blood pressure.  He could, of course, feel it rising to dangerous levels, and came to be checked out.  Recognizing that his BP of 126/78 put him in immediate danger of stroking out, the triage nurse brought him back for an hour or two of "therapeutic wait" spent staring at the brightly colored monitor.  After a while, he felt that his BP had "venished," and we pointed him in the direction of the exit.

Five minutes later, we got a call from radiology asking us if the stoner trying to find his way out of an X-ray room belonged to us.

Wii Wounded

I've been the stunned victim of a Wii controller to the face.  My dad pulled a muscle while Wii bowling.  It appears our Wii woes are not genetic, however.  The New York Times examines the growing epidemic of the Wii wounded from traumatic knee sprains to repetitive stress injuries.  Their umbrella term for this diverse array of morbidity: Nintendinitis. 

Though I have yet to see a Wii victim roll in to the ER, I'm sure it's only a matter of time...

Those Summer Nights

Let there be no doubt: summer is on its way.  Sure, it may not exactly be beach weather yet, but the steady rise in the number of shootings, stabbings, and (surprise!) no-helmet motorcycle accidents that heralds the arrival of warmer temperatures has begun once again.  Took care of one patient over the weekend who was shot while driving, and ended up crashing into a highway embankment.  One GSW to the abdomen, another to the chest.  Quickly tubed in the trauma bay, then run straight up to the OR.

Here's hoping it'll be a cold summer.

Love Me Doobie

Amidst the backdrop of pain and injury, GI bleeds and fungal infections, it can be truly heartwarming to watch the seeds of true love blossom in the ER.  Two young patients, both baked out of their minds, made that special connection while flirting from opposite ends of the hallway the other night.  Our young Romeo, waxing rhapsodic from his stretcher, sought to woo the object of his affection by repeatedly asking her for "her digits," promptly forgetting them, and asking again.  Our fair maiden, to her credit, never seemed to mind (or remember) that she was repeating herself.  

Throughout their courtship, I kept thinking back to that classic scene in the Princess Bride... "So treasure your wuv..."

I hope I'm invited to the wedding.

A Little Ditty

Got up early yesterday to review for a morning exam.  Went to work in the afternoon and ended up staying 16 hours to work a double (we were short staffed, and I'm in no position to refuse extra money).  After being awake for more than 24 hours straight, I managed to get some much needed sleep before rolling out of bed for class this afternoon.  Good training for med school and residency, bad plan for my sleep schedule.  

Now, I'm as big a John Mellencamp fan as the next guy, but I'll be perfectly honest here: if my neighbors keep up their full-volume, off-key, slurred rendition of "Jack & Diane" much further past midnight, I might soon be sending new patients to the ER.

Dress Code

Selected highlights from last night:

[Patient sitting on stretcher, surrounded by multiple belongings bags, searching through all his worldly possessions for the valuables he wants to lock up in the safe (you know, things like his pen, dinner receipt, and $0.87)]

Me: No sir, I'm not going to bring any of your valuables to the safe until you put some clothes back on.

[Drunk college student arrives s/p 70's night at a local bar, having been found vomiting on a telephone pole]

Pt: They're laughing at me!

RN: Of course they're laughing at you, your outfit is ridiculous!

Pt: No!  My pants are ridiculous!  But this shirts is awesome!  [pukes]

In Case You Were Wondering

You cannot commit suicide by drinking a glass of milk.  Even if you are lactose intolerant.  

It will, however, make you gassy.

Can't Buy My Love

One of the greatest risks you can take upon entering a patient's room for the first time is assuming the nature of their relationship to their visitor.  After a few early instances of removing my shoe to insert my foot into my oropharynx, I've learned to never make assumptions.  Nevertheless, my skeeve-o-meter registered a 10/10 the other night when I discovered that the stately older gentleman with salt and pepper hair and a striking resemblance to Larry King was not, in fact, the father of my 20 year old female patient.  She was complaining of abdominal pain while in the second trimester of her third pregnancy.  

She must have been glad to have such a supportive husband hovering over her.

Gross.

Stat Hydrocarbon Therapy

After dealing with two major traumas in my first 30 minutes over the weekend, I helped work on an unresponsive female transfered from a nursing home by EMS.  She arrived with weak and shallow respirations after being bagged en route, barely withdrawing to pain.  Unable to get a pulse ox, we prepared for a rapid intubation.  As the nurses started drawing up meds and the resident attempted to visualize the patient's cords, the charge nurse entered the room to help document.

Turning to the nurse who was in the middle of pushing etomidate, she wryly informed us that the patient next door was complaining of very dry lips, and was wondering why her nurse had not been by to give her some vaseline.

When Animals Attack

I've seen cat bites, dog bites, bat bites and fish bites.  I recently took care of a woman bitten by a horse - strange, but not completely unreasonable.  I'm afraid this woman, however, requires a bit more explanation.  It's a shame stupidity doesn't show up on a CT.

Around the House

The home can be a dangerous place.  So learned two of my patients from this past week after a pair off unfortunate accidents.  The first fell off the top step of a ladder while changing a light bulb, and landed himself in the trauma bay with an open tib-fib fracture.  The second was using a power saw on some wood in his garage.  Missed the 2x4, but hit his thigh, earning an 8 inch laceration that nearly hit bone.  Remember, safety first.

Ticket to Ride

Are hospitals passing off patients to their low-profit patients?  So asks the Chicago Tribune, which takes a look at the increasing practice of uninsured patients being sent to Cook County's ER.  

The Case for ER Reform

Imagine that you're sitting at home when you suddenly develop a condition that you believe warrants the emergency medical attention you can only find at a Level 1 Trauma Center.  You call 911, and an ambulance arrives to provide acute, pre-hospital care while transporting you to the ER.  Upon arrival, however, you find an overcrowded facility, with patients lining the hallways and staff constantly running from one patient to the next.  Triaged to the waiting room, you sit for nearly two hours without being seen, wondering if you have been forgotten.  When your name is finally called, a nurse brings you back to the treatment area, where you wait once more, this time on an uncomfortable stretcher, as people rush by you...

This was the experience of a patient of mine from the other night.  She was sitting at home when she developed a nose bleed lasting approximately 30 seconds.  After applying a bit of tissue, the bleeding stopped and did not resume again.  After calling 911, an ambulance transported her to the emergency department.  No pertinent medical history, no medications.  Vital signs normal, no other complaints.  No signs of trauma, no active bleeding.   When the PA taking care of her asked if she lived in a dry building, she replied "yes, that's what they asked me the last time the ambulance brought me here."  

Take Your Chances

You could hedge your bets, racing down a small road out in the boonies.  You could assume that you'll not only survive the crash, but still be alive when EMS finds your body 40 feet from the side of the road.  You could hope that the three fractured vertebrae diagnosed in the small town ER don't sever your spinal cord and leave you paralyzed.  And you can pray that you remain properly immobilized during your helicopter flight to the Big City ICU and arrive without any neuro deficits.

And every so often, you might just get lucky and beat the odds.

Or, you could wear your seat belt.    

Sewing Lessons

After several weeks of taking animals apart, I was finally able to put one back together again in my dissection lab this week.  Not the same as suturing in a chest tube, but still, it beats stitching up oranges...

Wasting Away Again

While not always the most charming of individuals, most of our regular EtOHers simply take up space in the hallways.  Most.  

One gentleman came in last night with a BAC in the upper 300s after being found on the ground.  Collared per EMS protocol, his scan was negative but his C-spine couldn't be cleared until he was sober.  Throughout the several hours he spent in the ED, he would frequently climb out of bed, rip off his collar (and his gown), and attempt to walk out of the department while tugging at his catheter.  As time passed he became more belligerent, screaming obscenities and yelling about the unpleasant things he did as a soldier in Vietnam.  Repeated doses of Ativan did little to help calm him down.

Later in the evening, a patient arrived in full-blown DTs.  I had seen people going through withdrawal before, but never this bad.  The patient was drenched in sweat, looking at us with a bug-eyed stare as he hallucinated and spoke gibberish.  Every so often he'd lay back in the stretcher, only to shoot up again seconds later, writhing so hard against the restraints that he looked like would rip his shoulders out of their sockets.  He had no idea where he was, nor could he tell us his name.  When we were finally able to bring him upstairs, we could hear screaming from down the hall as we transfered him over.  Turns out he was the third DT admission of the night.

Alcohol withdrawal is not fun thing to watch.  I'm sure it's far less fun to experience.

Recession Medicine

Took care of another victim of the recession the other night, a middle-aged women complaining of chest pain and difficulty breathing.  Despite a history of DVT and PE, she went off her Lovenox after losing her job and the health insurance that came with it.  Scans showed another PE, which was treated.  The last patient I had who went off her Lovenox ended up coding and dying shortly after arrival.  

From One Extreme to the Other

Sometimes, you just gotta love the comparisons.  Case in point:

Spent my first four hours the other night working in the purgatory that is Fast Track.  I go out to the waiting room to bring back a patient whose cc is "throat pain since the AM."  Great, throat swab, drink some fluids, get some rest, thanks for playing.  Simple dispo, right?  Unfortunately, this train wreck devolved into, "Oh, I also have this rash" and "I get headaches sometimes." Also, intense ankle pain (despite walking back to Fast Track and no signs of trauma).  To top it all off, the next patient I brought back had the same last name.  Turned out it was Mom, who also had some sniffles.  And who stole the Kleenex box when she left.

Thankfully, I was able to move out to trauma for the rest of the night.  Instead of the common cold, we got a mugging gone bad, where the unfortunate victim had struggled for the gun with his assailant and ended up being shot in the neck.  It could have been much worse - the bullet only grazed him - but he was also apparently pistol whipped several times in the head and had a small stab wound to the arm.  After dealing with people who game the system, it's nice to be able to actually help a patient who truly needs emergency care.

Pleasant Valley Sunday

Nothing beats a long run on a beautiful warm Sunday afternoon (except maybe antidepressants, but I'll let Nurse K and Happy Hospitalist fight that one out).  

With Levophed On the Side

While enjoying homemade turkey lasagna with some non-medical friends last night, one of them pointed out how turkey always left them tired after Thanksgiving.  "Yeah, it's that chemical...dobutamine I think," another explained.  

Now if we had dobutamine in every one of our turkey sandwiches in the ER, we'd probably have a lot more tachycardic patients in our midst.  If we had to choose a drug to lace our box lunches with, I'd start with a healthy serving of Ativan sauce before anything else.  Nerd that I am, I suggested that my friends might be thinking of tryptophan instead.

Nein!

I'm starting to think they just don't make 'em like they used to.  

I recently took care of an elderly German man who had the misfortune of falling while trying to board the bus.  He arrived via EMS with questionable LOC, large hematoma on the forehead, and a dislocated finger.  After a great deal of protest, he was eventually persuaded to accept some pain medication before the reduction, but vehemently refused a head CT.  ("Nein, zee problem is vit my finger!")

Despite the best effort of the resident and attending, he continued to refuse the scan.  Worried that he may be altered from the head injury, the docs insisted that he stay for several hours of observation instead.  Not happy, every few minutes he would pack up his lunch box, gather his newspapers, place his hat firmly on his head, and begin a slow march to the exit.  And every few minutes I would chase him down and ask him to return to his room.  After a few thwarted escape attempts, he grabbed my ID, wagged his finger at me, and stated: "I'm going to call zee newspapers and tell them that you, Second Shift, keep old people here against their will!"  I explained to him for the umpteenth time why we were concerned, and escorted him back to the stretcher.

At one point, the resident began to get fed up and told me to place him in restraints.  I turned her, and explained that if she wanted to shackle a stubborn 75 year old man to the bed, she was more than welcome to try, but there was no way on earth that I would do it for her.  My worthy adversary and I continued to spar for a couple more hours until his son arrived and finally took him home.

I'm keeping an eye out for my name in the papers.

In the Eye of the Beholder

In general, I have a very low tolerance for status dramaticus.  If a patient is brought in to the ER screaming and writhing in pain, and doesn't have a damn good story to back it up, we tend to assume BS.  Such was the case for my gentleman the other night, who arrived clutching his chest, rocking back and forth in the stretcher, all while pleading "Don't let me die!"  Normal EKG, negative cardiac enzymes, pain completely resolved with one GI cocktail.  Maybe if he had taken off the designer sunglasses at any point during his stay, the act would have been more convincing.

The same advice applied to the drunk vs. stairs that rolled in later that evening.  Sporting a broken pair of shades that were missing a lens, he emphatically informed me that there was no need to check his blood pressure, as he could feel that it was "seventy over one and a half."  Taking the patient at his word, I charted the BP and moved on.

The End

In the flood of valedictory articles that have appeared online over the past week to commemorate ER's final episode (airing tonight on NBC), several have commented on the many contributions the show has made over its 15 years.  The popularization of the steadicam and fast-paced medical jargon in TV dramas, an increased interest in emergency medicine residencies, and greater awareness of medical issues presented on the show have all been listed.

According to this article from the LA Times health blog, however, ER's lasting legacy might be screwing up a generation of medical education.  The article discusses a Canadian study that found medical dramas were the second most cited source of training for intubation skills, and that ER does it all wrong.  

As I watch ER for its entertainment and not its didactic value, I plan on enjoying tonight's finale.  Besides, I get more than enough evidence-based, real-world education from House.

A Day in the Life

Typical busy night last night - we were short staffed, the lab was backed up, and the waiting room was full of patients who had been there since morning.  It certainly didn't help that Nearby Hospital had lost power and we were receiving all their diversions.  Working in the critical care area, I was juggling three ICU patients and one little old lady who kept asking for a cup of water every five minutes.

Still, things didn't get bad until the strong winds outside blew the helicopter off the roof.  It made a crash landing in the middle of our ambulance bay, but we were thankfully able to get everyone out moments before it exploded in a massive fireball.  The patient they were transporting, however, was having a massive MI and required ten rounds of defibrillation and an open thoracotomy before we could stabilize him for the cath lab.

Later in the evening, I stepped outside for a moment to grab some fresh air, and was nearly run over by a car swerving into the ambulance bay.  Redirecting them around the still-burning hulk of the helicopter, I opened the rear door to find a woman in active labor.  With the baby crowning and no time to call for help, I was forced to deliver in the parking lot.  While tying off the umbilical cord with my shoe string, the mother suddenly lost her airway.  Lucky I still had my pen on me, as I used it to perform an emergency cricothyrotomy.

After getting Mom and Baby safely brought up to OB, I returned just in time to hear EMS patch from the scene of a crash involving a busload of hemophiliacs.  While prepping the trauma bay, I noticed we were out of medium gloves, and headed to the supply room to grab a fresh box.  Hot Doctor and Sexy Nurse were in there going at it again, forcing me to slide around them to reach the far shelf.  Once all the trauma patients were transfused and safely up to the ICU, I was finally able to grab my thirsty old lady her water and called it a night.