If I Had A Nickel

Now, never having tried illy myself, I cannot speak from personal experience about its effects.  But repeated encounters with formaldehyde-laced marijuana aficionados have left me to wonder if it's the drug itself that causes people to run down the street naked, or if people who like to run down the street naked simply use illy more often than the general population.  In either case, a nickel for every crazed, would-be Roger Bannister who ended up in the ER would make me a very rich man indeed.

That's The Way I Like It

"Big City ED, be advised that our patient has entered cardiac arrest and we are coding him en route."  So much for the abdominal pain that they had previously radioed about.

As I moved to the trauma bay to throw a body bag over the stretcher, I thought that if there was ever a good time to code, it would be a witnessed arrest in the back of a ALS ambulance only minutes away a major trauma center.  Unlike the majority of coding patients who arrive already dead or close to it, this guy had a fighting chance, and we knew it.

The triage nurse had the ambulance bay doors open and the attending stood outside, waiting.  I primed some fluids, resuscitation meds were drawn up, Respiratory was paged and the defibrillator stood charged and ready.

As the ambulance peeled in with sirens wailing, the rear doors opened to reveal a second attempt at intubation underway.  Unable to get the tube, the medics ran the stretcher to the trauma bay while doing one-handed compressions.  

Clothes were cut, leads placed, a second line started and the airway secured.  Nurses pushed rounds of meds while techs cycled through compressions and the attending calmly called out orders.  After the third defib, the patient regained his pulse.  An ICU team arrived with a cooling unit to induce hypothermia, and not more than 20 minutes after arrival the patient was on his way upstairs.

Talk about a rush.  Job well done, all.

Now Here's a New One

Looking for a more convenient way to schedule your trips to the ER?  For those whose perception of an emergency varies with the wait time, one Albany hospital is offering a service that allows potential patients to text message the ER to see how long they'll wait.  What's next, offering appointments? 

Stroke Blues

Took care of two patients recently who had suffered strokes in the past and were living with significant deficits.  One gentleman, who I recognized from a few previous trips over the years, could communicate fairly effectively but slurred his words, making them difficult to understand.  I could see the frustration in his eyes as a group of us gathered around him struggled to comprehend what he was saying.  I hate that feeling of impotence that comes with dealing with stroke patients who have clear wishes that I am unable to understand or help them with.

The second patient was an older lady who experience a much more severe stroke that left her unable to communicate or move her left side.  There was little I could do to make her more comfortable beyond propping her up with some pillows and stopping by every so often to wipe off the drool that had spilled down her neck.

No real moral of the story here, just the frustration of dealing with patients that I can't help.  And a reminder to learn and recognize the warning symptoms of a stroke.  Calling 911 immediately and arriving at the hospital within 3 hours of symptom onset can make you eligible for tPA, a powerful clot-busting drug that may reduce long-term disability for some stroke patients.  If you or a loved one start experiencing stroke symptoms, never wait to call 911!

Spoiler Alert

Turns out that the EKG, cardiac enzymes, and chest xray were all normal on the patient presenting with chest pain two days after breast enhancement surgery.  

Memorial Day

If you're lucky enough to be spending the holiday enjoying warm weather and BBQs with friends and family, I hope we all also take the time to remember the sacrifices of the brave men and women who have given their lives in service to this country.  To all the members of our armed forces - past, present, and future - thank you.

Just What I Needed

Walked into a patient's room last night to help start the workup, and she immediately opened with "Doctor, I'd like you to meet my son."  After explaining that I was the tech, and still many years of education and many more loans away from an MD, I proceeded to hook her up to the monitor, run an EKG, and draw a set of cultures.

An hour or so later, as I was getting her packaged to go upstairs, she grabbed my hand, smiled, and said, "Don't worry honey, you're going to make it."  After struggling a bit lately over the whole med school application process, it was a perfectly-timed and gratuitously nice thing to say.  It's amazing how a few kind words can put you in a good mood for the rest of the night.

Happy National EMS Week

I just learned that we're in the middle of National EMS week.  Thanks to all the skilled EMTs and Paramedics who work on the front lines of medicine, saving lives every day!

Good Day Sunshine

Due to a scheduling mixup, I worked a rare day shift yesterday and was quickly reminded why I overwhelmingly prefer nights.  During those precious sunlit hours, the hospital is just too crowded.  We can get just as swamped on nights as the days, but there are less people to bump into.  Yesterday there were so many visitors, consultants, private docs, med students, nursing students, and supply people milling about that I had trouble moving without bumping into someone.  At night I can run from the ER to the blood bank and back without seeing a single person.  

I'll stick to my nights.

Only The Good Die Young

One of the hardest parts of my job is watching people my age or even younger literally killing themselves before my eyes.  Working in the ER has opened my eyes to wide variety of challenges that I was fortunate enough to never deal with growing up, and it can be heartbreaking to see the consequences.

I've taken care of teenagers who have already developed pancreatitis and young kids whose drug addictions have caused their hair to thin, their gums to recede and their eyes to seemingly sink into their face as they stare back at you blankly.  Girls whose number of pregnancies nearly equal their ages.  Kids murdered while perpetuating the cycle of gang violence, and innocent victims of it.

And just last night a patient not much older than I in multiple organ failure after his drug addiction finally succeeded in ruining his life.  Admitted upstairs for emergent dialysis, he was still too high to comprehend that his damaged body was killing him from the inside out.  

With graduation season in full bloom and clips of commencement speeches and caps being tossed in the air showing up on the evening news, it's sad to see those whose aborted futures ended before they ever really began.

Law & Order

I know how difficult situations involving drug-seeking patients can be, but I'm not sure that arresting patients for trespassing is the right solution.

Smells Like Teen Spirit

Sure medical shows provide the sights of pulsing arterial wounds or checked chests and the sound of the ominous flatline monotone heard in the background, but no TV drama can accurately portray the rich cornucopia of olfactory insults that pervade the ER.

This premium blend of distinct aromas combines the subtle essence of raging urosepsis with the heavy tang of a massive GI bleed.  The breath of an EtOHer drunk on Listerine adds a touch of mint, while often competing with the scent of stale urine.  Meanwhile, the heavy, moist essence of unwashed body odor can easily be complemented by a splash of fresh vomit (which itself can be spiced with corn chowder to taste).  Add in my guy from the other night who reeked of hot dogs and you've got the next fragrance sensation that we'll call L'eau d'ER.

While it's not uncommon for smells such as these to drive people out of the ER, I'd never heard of odor alone bringing people in until I came across this article from the LA Times, in which seven people are said to have sought hospital care after opening a refrigerator filled with rotting food.  Smells a little fishy to me.

Speaking of Fast Track...

Here's an article from the Chicago Tribune looking at the growth of Urgent Care centers in Illinois.  

Highway To the Danger Zone

Highlights of a recent shift:

Car vs. Truck, Motorcycle vs. Tree, Fingers vs. Snowblower.  All par for the course.  After last night, however, I can now add "Motorized Supermarket Power Scooter vs. Curb" to my roster of trauma matchups.  Thank goodness it didn't cause a multi-scooter pileup.

Dude was sitting out on his porch, doing some early summer grilling when the neighbor's dog broke through the fence and took a nibble on his foot.  Irrigated the small puncture wound, started on rabies prophylaxis just in case.  As I wrapped the foot, Dude told me to "bandage it up good" and "use extra gauze" so it would look impressive when he threatened to sue his neighbor.

Throw in a handful of people who "lost" their prescriptions for narcotic pain medication, and you have another shift in Fast Track. 

The Sound of Silence

Despite all the talk about creating a quiet, peaceful healing environment, the ED is loud.  Beeping monitors, shrill alarms, slamming IV cart drawers and the perpetual game of bumper cars as stretchers navigate the hallway all do their best to ensure no patient has a chance to nod off.  In our observation area, however, we do try to keep the doors closed and the lights dimmed for patients to rest while waiting for serial enzymes or whatever tests they require.

Working back there last night however, I thought I was in the middle of a construction site.  To borrow a phrase from National Lampoon's Christmas Vacation, it sounded like a dump truck driving through a nitroglycerin plant.  Somebody must have been doing ductwork or maybe rearranging things on the floor above, but quite honestly I thought there was a jackhammer about to burst through the ceiling.  For a good hour the patients and I debated whether there was a tank doing doughnuts on the second floor or two elephants trying to get lucky.  Either way, the noise eventually abated and were left with the regular soothing tones of the ER instead.

Waiting

To the 90 pound elderly man whose eyes would no longer open and whose legs could not uncross, whose skin tore whenever it was touched, whose veins were gone and whose pressure would not climb out of the 70s, and to his family assembled at the bedside, waiting, I'm truly sorry there was nothing more we could do.

Before He Cheats

With final exams finishing up for the semester, it can be a stressful time.  Get caught cheating, however, and life suddenly becomes a whole lot worse.  So learned one student, who presented to the ED with a cc of depression and possible suicidal ideation after being caught in the act.  Nothing like being threatened with expulsion on the eve of graduation to ruin a beautiful spring day.  I don't think any ED work note is going to help get out of this mess.

Thank You, Come Again

Over the weekend I took care of a patient who had the misfortune of falling off a ladder and breaking his arm.  It wasn't a bad break, but it did require splinting.  Unfortunately, even though Wolf Blizter's Pandemicfest 2009 seems to have subsided, the ED was still full to the brim and the gentleman was forced to wait (patiently) for some time.  I apologized for the delay as I was finally able to hand him his paperwork, which he gratefully took and made his way out to the waiting room.

Ten minutes later, I heard an overhead page for an incoming trauma, and arrived in the trauma bay to see EMS transferring the same patient over to our stretcher.  Turns out he was crossing the street a few blocks from the hospital and was struck by a car that had run a red light.  Once again, his injuries were minor, but given how backed up everything was, he was forced to wait for another couple hours.  Walking him out to the waiting room for a second time late that evening, I asked if he was planning on completing a hat trick.  

His response: "Over my dead body."

Child-Proof

Child-proof homes have plastic plugs to cover electrical outlets, locks for cabinets, and little gates at the top of the stairs.  These features are designed to protect children, whose awareness of danger and sense of mortality is not yet developed, from hurting themselves.

I propose a similar plan for EtOHers, whose perception of risk is equally compromised.  Instead of the collapsable gates at the tops of the stairs, however, I envision ones regulated by a breathalyzer.  After taking care of my probably 2,352th "EtOH vs. Stairs" trauma patient last night, I think all staircases should now require proof of sobriety before allowing people to use them.  It could save millions!

Bed 4

As I've said before, I never used to be superstitious before I started working in the ED, but these days I'm pretty sure Bed 4 is cursed.  I don't know if somebody wheeled a stretcher under a ladder or broke a mirror or strangled a black cat or whatever in there, but it seems that any patient brought back to that unlucky spot has an elevated risk of going septic and coding.

I took care of no less than three truly sick (as in the ER definition of sick, not "I've had sniffles since the AM," but "very likely to die in the next few minutes") patients in Bed 4 last night.  Two of them coded, and the other dropped her pressure and required a rapid intubation, central line, gallons of fluid and every drip known to man before getting her up to the ICU.  And that was just in one shift.  I don't know why a black cloud hangs over that room, but I do know that if I'm ever a patient, it's not where I'll want to be treated.

Give Blood. Give Life.

We had a bloody mess of a trauma last night - a victim of multiple GSWs.  Last week, an elderly patient with a massive GI bleed required an emergency transfusion in the ED.  Both survived thanks in part to a ready supply of donated blood.  Every two seconds someone in the United States needs blood.  Want to save a life?  Please consider being a donor.

Who Are You?

A bit of advice for anyone thinking of ending up in the trauma bay - don't wear your favorite pair of jeans.  Cutting off a patient's clothes is one of the first steps of the trauma protocol.  While doctors are completing their primary survey, the nurse is getting a line and the tech is getting the patient on the monitor, somebody in the back is generally digging through the shredded pants to find a wallet.  You can learn a lot about a person by what they keep in their pockets.

For an unconscious patient, finding a driver's license may be our only way to ID them.  Some people carry a list of emergency phone numbers in their wallet, others a blood donor card with their blood type on it.  

The best wallets are the overstuffed receptacles of every scrap of paper ever received by the patient.  Digging through to find any cash that needs to be locked up, I've come across dinner receipts from 10 years prior, lotto tickets, business cards, pictures of family, and multiple sets of fake IDs.  Discount membership cards reveal where a patient shops.  Does the patient smoke?  Check the pockets for a lighter.  Drink?  I've come across a couple flasks.  Sometimes the shoes - stained and caked in mud, or shiny and polished - can offer clues to the patient's occupation.

And don't even get me started about the underwear.

My favorites, though, are the unexpected discoveries.  Three bottles of oxy buried in the bottom of a purse, for example.  Knives ranging from Swiss Army to machete size.  The occasional brass knuckles or crack pipe. Or, like a gentleman from the other night, $4500 in small-denomination bills found in his left pajama pocket.  

I wonder why my pockets say about me?

Life In The Fast Lane

For those among us who thought that ER wasn't nearly melodramatic enough, NBC is seeking to satisfy our cravings with a new drama this fall: Trauma.  Featuring all the fireballs, sparks, miraculous CPR saves, and female paramedics with unbuttoned uniform tops that you would expect from a self-described "high octane medical drama," Trauma promises to realistically portray the day-to-day routine of an urban EMS crew. 

As far as I can tell, this isn't a joke.  

We Can Work It Out

ERP has a funny story up about the woes of dealing with Fast Track patients that reminded me of a similar incident from a while ago.  

While working with an excellent PA, I brought back an elderly gentleman with a minor hand laceration who had been stuck waiting for over an hour.  When the PA introduced herself, the patient immediately asked if there was a male provider available.  After grudgingly agreeing to be cared for by a woman, he became dismayed to learn that she was "just a PA" and demanded that we call a private plastic surgeon friend of his to come in to the ER and suture the 2cm lac.  After waiting for 45 minutes with no response to our call, he then gave us the number of a second plastic surgeon friend to call.  When that failed to work, he wanted Plastic Surgery paged, and when they refused to see him, he finally agreed to be treated by "just a PA."  

After several hours of waiting, he was stitched up in five minutes.  On his way out, he thanked the PA for doing "an excellent job."

Keep Your Eye On The Ball

Among the few lessons I remember from the disastrous experience that was childhood baseball is the importance of keeping your eye on the ball.  In my case, this training point meant nothing, as I could stare at the ball through a laser-guided scope and still not hit the broad side of a barn (thankfully hand-eye coordination is not required for running).  

One little Little Leaguer recently followed that rule a little too closely when he was struck in the eye by a fastball, and rather than taking his base, took an ambulance to the trauma bay.  Massive swelling and an orbital fracture later, he was not a happy camper.  He was still waiting for an optho consult by the time I left, so I can only hope that his vision won't be permanently damaged and he can continue on his path to the Major League.  Or he could always join cross-country.

The Look

Tied up with a handful of big workup patients the other night - grabbing EKGs, orthostatics, blood/urine cultures and the like for a good two hours back to back - I managed to avoid entering room 9.  The report I received on the patient consisted mainly of "he's a handful," but the nurse seemed to have everything under control.  

While I caught up on charting later in the evening, I saw the nurse step out of the room with the Look - that unique, slightly flushed, wide-eyed expression of bemusement, exasperation, and a slight tinge of horror.  She turned to me and asked if I might try to get a repeat set of labs on the patient.  Knowing how important it can be to take a break from certain patients from time to time, I happily obliged, only to emerge several minutes later with the Look etched firmly on my face as well.

As I walked out of the room 9, I noticed a patient in the hallway who nodded at me and smiled.  "I'm an RN from Another Hospital," she explained,"and I recognize that Look.  Every person who has walked out of that room has it.  Hang in there."

Some things are universal.

Hunkered Down

My semi-annual migration to library has begun, where I will remain entrenched for the next several days finishing off papers and preparing for exams.  I'm thinking of surrounding my cubicle with HEPA air filters and bathing in Purell each morning before donning my swine flu mask and hunting down anyone who sneezes from amid the bookshelves.

Oh, and after several days of Wolf Blitzer's Pandemicfest 2009, CNN.com now reports (shockingly), that ERs across the country are being swamped with worried well.  Thanks Wolf.

Drive Through Emergency Medicine

Even before Wolf Blitzer's Pandemicfest 2009 launched stampedes to local ERs, waiting times in emergency departments across the country were already painfully long.  As the system continues to be weighed down by newly uninsured victims of the recession, ER closures, inpatient bed reductions and any of the other challenges facing health care, the backlog of patients will only increase.

Fed up with waiting?  You could follow the example of a North Dakota man, who overdosed on prescription medication and, while naked, crashed his pickup truck into an ER waiting room (thankfully no one was hurt).  Sure he was arrested, but that's one guaranteed method for jumping to the front of the line.