Costs of the Obesity Epidemic

Just came across this video from CNN.com, which reports that Kansas patients weighing over 350lbs will see their cost of riding an ambulance nearly double to over $1000 per trip.  Lifting and transporting obese patients can be dangerous, both for the ambulance crew and the patient.  As the obesity epidemic continues, there's going to be an increase in need for these kinds of specialized equipment to safely accommodate heavier patients.

A Last Goodbye

Codes are messy affairs.  The patient often lies naked on the stretcher, surrounded by strangers as nurses twist arms searching for IV access and a resident suctions secretions while trying to force a tube down the patient's throat.  The brown stains of betadine may dye the patient's skin as a central line is inserted through the groin, and blobs of ultrasound gel are smeared over the chest while a prodding probe checks for cardiac motion.  Monitor alarms ring, ribs crack under the weight of compressions, and a layer of empty plastic wrappings, used flushes, and medication caps builds on the floor.

In short, it's not something I would like to watch a loved one go through.  Like many healthcare providers, I have reservations about bringing family members into a code situation.  In a 2006 paper published in Circulation, less than half of urban emergency department personnel surveyed felt that family presence during resuscitation attempts was appropriate.  Yet other studies have found that family members who were allowed to watch report a stronger sense of closure, an improved grieving process, and greater confidence that everything possible was done. 

My doubts over this practice were called into question recently, when the attending allowed the son of a patient in cardiac arrest to stay while we coded his mother.  For thirty minutes he cried silently with a chaplain, watching.  His mother received CPR, medication, and defibrillation, and was eventually brought back long enough to squeeze her son's hand as he whispered in her ear.  Sadly, her heart soon stopped again, and further attempts at resuscitation were unsuccessful.  

Am I glad this mother had one last chance to communicate with her son?  Absolutely.  Would I want the same opportunity myself?  I honestly don't know.  It's a decision I hope I'll never have to make.

Summer Casualties

Summer has arrived with a vengeance it seems, if this past weekend is any indication.

One gentleman was setting up lawn chairs in the backyard for a BBQ and somehow managed to receive a deep and painful-looking inch and a half gash along his thumb.  Another, more serious set of lacs were caused by a malicious convertible top that left several cuts requiring stitches.  Throw in a couple facial lacerations from softball and bicycle injuries and we were down several suture sets by the end of the weekend.

The worst, however, was a poor young guy who made the mistake of reaching too close to the lawnmower, and ended up having to lose the tips to two of his fingers.

Have fun out there, but remember safety first!

Extreme EM

Here's a short article from a few days ago detailing the dangerous and impressive work of combat medics currently treating injured civilians in Afghanistan.  Many thanks to our brave men and women in uniform!

Party On

We've had some pretty impressive characters fight for their right to party over the past several days.

The first was a young woman found passed out in the bathroom of a club.  Despite her pinpoint pupils, BAC of .270, and vomit-covered dress, she persistently mumbled her demands for the ambulance to take her back to the dance floor.

Meanwhile, Johnny Walker set a new record for three separate visits to the ED within a 12-hour period.  Discharged at the very beginning of my shift, he returned around two hours later in police custody.  Not drunk enough for us to keep him, he was cut loose, only to stumble in once again before the end of my night.

By far the most dedicated, however, was the woman who was not only walking at talking with a BAC of .416, but made a coherent phone call to her husband to make sure he had "plenty of beer" available for when she got home.

Thanks CNN

How many people do you think will read this article and now start demanding to see the charge nurse or the attending or the hospital administrator or the patient advocate after waiting for 15 minutes?

Or, my personal favorite, "try to drop a big name, like say you're friends with the president of the hospital."

Seriously?

Useful Education

Given the explosion of healthcare policy debates everywhere from the editorial pages to the Senate floor (not to mention medblogs), Slate.com raises a great point: why aren't medical students being required to learn more about the field they are training to enter?  Says one student quoted in article, "People I graduated with couldn't tell you the difference between Medicare and Medicaid."  Obviously the primary focus of med school remains medicine, but requiring at least a course on policy issues seems like a reasonable way to fill an important knowledge gap.

Here's To You Mrs. Robinson

A Would-Be Anne Bancroft: "Oh, aren't you handsome!  You should get out of medicine, with a face like that you should be in the movies.  I'm serious.  Don't worry dear, I'm 76, I'm not trying to seduce you!"

How flattering.  Of course, to make a claim like that she had to have a little dementia... or a head injury.

She had both.  

Medicine it is, I suppose.

Things That Get Me Mad (III)

With the department pretty backed up, I started re-vitaling patients in the waiting room while working triage last night.  I called up a young pregnant women with abdominal pain who had been waiting for just over an hour.

As I laid out my vacutainers and reached for a butterfly, she asked why she had not yet been brought back, and I explained that the department was very busy, there weren't any open beds, we bringing people back as fast as possible, etc.

Pt: "If my baby dies while I'm still waiting, who I get to sue?"

The Compressionator

Here's an interesting little article on one of those new-fangled, automatic CPR doohickies that's just been adopted by a fire service out in California.  I've see a couple different types of these devices make their way through the Big City ED, and they're pretty impressive, if not a little scary.  They seem like a great way to ensure adequate depth and rate of compressions, while freeing up a medic's hands for other vital tasks and generally looking like they'll snap the patient in half.

I completely agree with the medic quoted in the article when he says he could get a pulse on a rock with one of these things!

Family Matters

Bed 1 was a 79 year old incontinent female transfered from a facility for altered mental status.  Her pressure in the 70s, and oxygen sat not much higher without a non-rebreather mask, she required a central line and fluids squeezed in by pressure bags while waiting for a bed upstairs.

Bed 3 was a 57 year old mother of two who called 911 after feeling short of breath.  CT scan revealed a PE, in addition to newly-discovered advanced lung cancer.

The diabetic with a sugar of 620 in Bed 2 had to be pulled out on a portable monitor to make room for an 82 year old male, delirious with sepsis.  Moaning constantly, his dry brittle skin cracked in our hands and he howled in pain while we searched for non-existent veins.

And they each had family - a husband of over 50 years, children, a crying wife - standing at the bedside.  For the patients I can at least clean them up, change the sheets, turn them off their bed sores.  It doesn't mean much in the long run, but it is something.  For the family, though, there's really nothing I can do or say.  

Mother Knows Best

RN: "Sir, I need your name to get you registered."

Joe Cool: [mumble mumble groan]

RN: "Sir, what's bothering you today?"

Joe Cool: [mumble mumble groan]

After a few more rounds of twenty questions, we managed to decipher that the 28 year old male waiting to be triaged on a busy Sunday afternoon in the Big City ED was complaining of nausea and vomiting since the AM.  With the hospital full and nothing but slow dispos in the back, he was told that the wait was several hours.  I drew basic labs from the waiting room to help speed things along, and all his results came back normal.  Sometime later, Mrs. Cool marched up to triage.

Mrs. Cool: "Why hasn't my son been seen!?  What's taking so long?  He's DYING!"

RN: "Ma'am, we're extremely busy today.  Your son has been triaged and we'll take him back as soon as we can.  There are still several people ahead of him."

Mrs. Cool: "I don't care about those other people!  My son needs to be seen now! He's DYING and you people don't care!"

This exchange continued for several minutes, and after much huffing and puffing, Mrs. Cool stormed off muttering about how she was going to sue us all.  She continued to shoot us dirty looks from the waiting room, where she had Joe Cool spread across several chairs, covered under various jackets.  It appeared she was gently fanning him with a magazine.

A few hours later, after he had been brought back, I asked the PA taking care of him what the story was.

Apparently, Joe Cool had a bit too much to drink last night, and presented to the Level I trauma center with a hysterical mother because he was a little hungover.

Happy Father's Day

To all the dads and granddads out there, I hope you have a great day!  

(Even though the dad who recently decided to show his fatherly devotion to his 20-something year old daughter by crawling on to the stretcher to lay next to her may have gone just a little beyond the call of duty...)

Oil and (Fire)Water

To the Listerine Julip and Purelltini that may eventually be included in Second Shift's ED Cocktail Guide, I can now add Canola Oil, straight up.  Maybe it's actually a good chaser, maybe the patient got the bottles confused, but regardless of the reason, we treated an slightly intoxicated individual while assuring them that quarter bottle of oil they downed would not prove fatal.

Cheers!

Stay Cool

I've written in the past that at least anecdotally, the number of assaults/GSWs/stabbings seems to increase during the warm summer months.  Now there's some data to back that up.  

Once again, here's hoping that it's a cool, safe summer for everyone out there.

Can You Hear Me Now?

Several of my friends have or are planning to enter Teach for America and spend two years teaching children in underserved districts across the country.  I tell them that I greatly admire their dedication, especially since I doubt that I would ever have the patience to constantly repeat myself while trying to keep rambunctious kids in line.

And then I remembered where I work.

Last night there was a woman so engrossed in her phone call and so unwilling to simply step out into the waiting room that she broke the sliding ambulance bay doors ajar not once, not twice, but three separate times before we threatened to have security come talk to her.  Sternly told to take her call elsewhere, she took a few steps toward the waiting room, and then did an about face back toward the ambulance bay.

It'll be detention for a week for that one.

Finding a Balance

From the New York Times, another great column by surgeon Pauline Chen.  In it, she discusses the importance of balancing the rigorous dedication needed to pursue a career in medicine with taking time for oneself.  Good advice!

Droplet Precautions

Though Wolf Blitzer's Pandemicfest 2009 seems to have been toned down in recent weeks, neither the H1N1 swine flu virus nor its associated hysteria have gone away.  In the Big City ED, like other EDs across the country I would imagine, we have strict protocols about testing and isolating suspected cases.  In most instances, regular droplet precautions suffice.  

Despite being given a mask after presenting with flu-like symptoms, however, a recent patient decided that better protection could be provided by simply wearing winter clothes.  

Yes, because in the middle of June, nothing will keep those piggy germs away better than a ski jacket, wool hat, and a thick scarf.  In fact, I think I read that in the most recent issue of JAMA.

At Least You're Honest

You know what, I actually appreciated it when the middle-aged man presenting to triage for some dull aching status post surgery 12 years ago opened with, "This really isn't an emergency, but..."  Glad we were on the same page there.

Something Doesn't Add Up

If you're a 45 year old patient presenting to triage with your 38 year old "daughter" while traveling through the Big City from "out of town" with a sudden flair up of "extreme pain" that nevertheless allows you to walk, talk, chew gum, chat on your phone, and make threats against the safety of the ED staff when they question how you "lost" your prescription pain medication and why your "primary doctor" wouldn't have a phone number that we could use to contact him, somebody might just become the slightest bit curious about the veracity of your story.  I'm just sayin'.

Speaking of Anatomy...

More than half of Britons surveyed could not point out the location of the human heart on a diagram, according to this article from CNN.  Even more failed to identify the shape of the lungs.  Meanwhile, KeepBreathing just posted about patient who had no idea what an artery was.

It's not like we're talking about finding Qatar on a map or anything - this is basic health education.  It's great that the healthcare debate is addressing cost and insurance issues, but it should be equally important for people to possess at least a rudimentary understanding of their bodies in order to take ownership of their health.

Trauma Lessons

Solid performance in the blood and guts department from over the weekend.

One honest-to-goodness actually helmeted motorcyclist took a nasty spill out on the highway.  Head remained nicely unscathed, but the rest of his arms, legs, and a good chunk of the torso sported some pretty serious road rash.  

Lesson: Helmet good, pants and leather even better.

A bicyclist who took a wrong turn on the bike path found himself at the bottom of the ditch with a managed leg.  Got to watch the orthopods power drill a steel rod through the patient's leg from which they would later hang weights to maintain traction.

Lesson: Propofol can be a wonderful thing.

And finally...

While doing some painting up on a ladder, a woman reached too far and ended up on the floor with an unbelievable lac running along her lower leg.  Basically, it looked like the skin was just split open, revealing all the tissue, muscle, bone, and tendons for all to see.

Lesson: Anatomy is awesome, especially when you can see the tendons moving as the foot wiggles.

Creature Comforts

Me: "No, I'm sorry sir.  I'm afraid we don't have the ability to Tivo shows you're missing while waiting to be admitted."

Summer in the City

After walking into a madhouse yesterday afternoon, the department had all but cleared out shortly after midnight.  Turning to caffeine to keep me going for the remaining hours of my shift, a nurse and I made the mistake of remarking how bored we were getting.

Within half and hour, we had been slammed with four new patients to our critical care area, three trauma victims from a bad MVC rollover with ejection, and the return of two EtOHers who had just been discharged at the beginning of my shift.  Not to mention the word of a code in progress out in the field, which sent us scrambling to throw a bag on a stretcher, hang some fluids, draw up meds, grab the defibrillator, all only to find out it was sent to another hospital.

At least we were no longer bored - by the next time I looked at my watch, it was time to go home.

In Which I Nearly Burn Down My House

I like to think I'm pretty good at my job.  I know where the random pieces of equipment are hidden away, I usually relate well with patients, and I'm not bad with tough sticks.  

I cannot, however, cook.

Now that I'm off the meal plan for the summer, I'm trying to broaden my culinary repertoire beyond dry pasta and frozen dinners.  Tonight's attempt at making brats on the stove produced charred nuggets of meat that resulted in an inadvertent test of my smoke detector's batteries.  At least nobody called 911.

If anybody out there knows some simple, idiot-proof recipes that might expand my palate while keeping me out of the ER, please feel free to share!  

Hello [Co-Worker]

One of the reasons I love working in the ED is the strong sense of teamwork.  From the techs and the secretaries, to the security and custodial staff, to the nurses, mid-levels, and physicians, we're all on the same team and in the words of Ben Franklin, must all hang together or surely hang separately.  And for that reason, along with most of the staff, I make it a greet staff by name as I pass them in the halls.  It's not a big deal, but it's a nice gesture.

Which is why I felt like an arse today when I learned that I've been calling someone the wrong name all along.  She works in another part of the hospital, only passing through the ED occasionally, I still feel like an idiot.  To be fair, she never once corrected me, but in a way that almost makes it worse.

Oh well, looks like I'll never be a politician.

Dodge, Dip, Dive, Duck, and Dodge

In retrospect, my spider-sense should have started tingling the moment I spied that full urinal perched precariously atop that slanted garbage can lid.  Blissfully unaware, however, I continued to search for a vein until I heard the plunk of impact with the floor, and turned just in time to dodge the oncoming golden wave.

Later in the evening, I was in the room as a combative patient tore out his IV and started waving his bleeding hand at anyone who approached him.  Managed to get out of that one without a speck on my scrubs.

But it was only when I kicked the chair back from the triage desk as the patient began emptying his stomach contents over his registration paperwork that I started to consider myself unusually lucky for the night.

That is, until I tripped on the sidewalk on my way home and wiped out in front of the hospital's main entrance.  Oh well, you can't win them all.

The Children Are the Future

Took care of a teenager over the weekend who blew a .450 on the breathalyzer with minimal effort.  I'd surely be dead or at least intubated at that level, but this champ was not only maintaining his airway, but also managed to put together a coherent string of obscenities every time we touched him.

I wanted to take him down the hall for a glimpse into the future.  In another room, we had a jaundiced patient going through a terrible withdrawal.  Full-blown DTs, hallucinations, incontinent, ammonia levels sky-high from liver failure.  It's hard enough watching the destructive power of EtOH abuse ruin the lives of adults, but seeing kids head down the same path is terrible.

You Want Fries With That?

Charge nurse brought back a very pleasant and polite middle-aged patient with a minor complaint.  Appeared perfectly normal in every way.

Walking into his room to check his vitals, however, I was met with the overwhelming smell of hot dogs.

I guess nobody's perfect.

Ain't It The Truth

Since paying for Showtime won't be making it into the budget anytime soon, my only chance for catching its new show Nurse Jackie will be finding episodes online buying the DVD.  In the meantime, however, the ad campaign I see posted on billboards all over the Big City makes me chuckle every time.

The image: Edie Falco holding a syringe.  The catchphrase: "Life if full of little pricks."

Worsening Course

EMS delivered our umpteenth (surprise!) no-helmet motorcyclist of the summer last night.  He sustained fairly minor road rash and a small forehead hematoma after a low-speed collision with a guardrail.  He arrived alert, but slightly confused, and joked with the staff throughout the trauma assessment.  At first glance he looked like he just might be able to walk out with a reasonably speedy dispo.

As he waited for the previous trauma patient to get off the CT table, however, he began to complain of a new-onset headache.  While I was hooking him back up to the monitor after his scan, he started feeling nauseous.  Waiting for the read on the CT, his confusion worsened and he soon started vomiting.  

Survey says brain bleed, as confirmed by the scan.  Instead of cruising off to that BBQ, he was admitted to an ICU bed.

Just wear a helmet.  Please.

Heartbreaking

Elderly female patient arrived via EMS uncooperative and combative.  Alternating between swearing, sobbing, and swinging at the staff, she insisted on leaving and repeatedly tried to jump off the stretcher.  Heavy EtOH on board.

She had been diagnosed with terminal cancer three days prior.

She lived alone, and no friends or family followed her in.

After several failed attempts at calming her down, one of the doctors asked that she be restrained to prevent injury to herself or others, but there was no way that I was going to be the one to shackle this poor lady to the bed.  I offered to sit with her instead, and kept her from jumping off the bed.  After an hour or so she calmed down and eventually fell asleep.

Cancer sucks.

You Give Love a Bad Name

Occupational hazard though it may be, even a gangbanger understands that getting shot will generally put a damper on one's evening.  Lucky for my young friend last night, however, his was only a flesh wound, and judging by the scars found upon exam, he'd been through the drill before.  Sticking to the tough guy routine, he waited impatiently to be discharged after we patched him up.

Unfortunately, in this digital age word travels fast, and whether alerted through Twitter, MySpace, Facebook or regular old-fashioned text messaging, a large contingent of worried friends began to assemble in the waiting room.  

After the docs finished their initial exam, the greeter stepped into the trauma bay and asked the patient if she could send a Briana in to see him.  The patient shurgged, and the greeter smiled while asking which one he'd like to see first.

Suddenly, bravado gone, a look of shocked recognition appeared on his face.

Turns out that, despite the savings from being able to buy faux-diamond-studded name necklaces in bulk, simultaneously dating three women with the same name is not actually a good idea.

In the end, the gun shot wound really was the least of his worries that night.  Remember, hell hath no fury...

Reservation Confirmed

If KeepBreathing ever retires from RT, I think he could find fulfillment with a new career as an ER concierge.  After my post this weekend about a service that allows patients to text message the ER to learn about wait times in advance, I stumbled across an article on InQuickER, a service that provides reservations for the Emergency Room.

Now I understand the pressure for hospitals to reduce their wait times and keep patients happy, but I'm going to have to side with Dr. Arthur Kellerman, a professor of emergency medicine at Emory University, when he says "if you're well enough to call and plug in a 10am time to be seen, why are you going to the emergency department and not your primary care physician?"  The very real, very dangerous problem of ER overcrowding is never going to be solved as long as people continue to see the ER as a point of primary care.  Any serious attempt at healthcare reform needs to address this and improve access to PCPs (and not PCP).

So what do you think KB, are you ready to start scheduling appointments?

Special Delivery

As I've written about in the past, my general philosophy is that if you can get yourself into a car to be driven to the ER, you can get yourself out.  Nine times out of ten, when I'm asked to break my back lifting someone out of the passenger seat, I see the same person skipping out of waiting room once they have their discharge papers in hand.

So it was with my standard level of skepticism that I pushed a stretcher out to the large SUV idling outside the main entrance to the ER to help a gentleman lift his mother.  Instead of opening the side door as expected, however, the son popped open the trunk and revealed a makeshift bed of pillows resting over the folded-down chairs.  Lying atop the cushioning was an older woman covered in blankets, paralyzed from the neck down.  Not your typical mode of transportation for a quadriplegic, but effective nonetheless.

With a few extra set of hands, we managed to hoist the patient onto a draw sheet and slide her easily onto the waiting stretcher.  

Of course, the whole thing would have gone a lot more smoothly if we didn't have to fend off the four cats that accompanied the woman along for the ride.