Workplace Violence

Ten Out of Ten has a great post up about a sad, but all-too-true reality of working in the ED: the violent patient.

The LA Times also calls attention to this issue, reporting that 25% of ED nurses surveyed reported experiencing physical violence more than 20 times in the past 3 years, while almost 20% reported experiencing verbal abuse more than 200 times in the same period.

Just the other week we had a patient arrive tied down to an EMS stretcher.  Status post assault, his face looked like a swollen pumpkin, multiple bruises covered his body, and footprints could be clearly seen on his back.  As we transferred him over, I couldn't help but feel sorry for the kid; this was obviously the work of multiple assailants.

Yet as he fought with the staff, throwing punches while screaming obscenities and racial slurs, I could begin to imagine how he managed to incite a brawl.  For trying to hold his arm still as a nurse searched for IV access, I received two punches myself, and another when we transferred him to the CT scanner.  Like Ten out of Ten's patient, he eventually needed to be intubated for his safety and ours.

Sometimes it's a thankless job, but somebody's got to do it!

How To Save a Life

"I did the thing whatever lifeguards do whenever you drown and can't breathe anymore.  That's what I did, but only three times and then he started to breathe.  Then I knew he wasn't dead."

So explains 7 year old Kenny Bagby, who saved his brother's life by performing CPR he learned from reading a Boy Scout manual.

Are you CPR certified?  One class could help you save the life of someone you love.  To find a CPR course near you, try calling your local fire department, or search for an American Heart Association class here.

Who's Calling, Please?

"Anybody have a patient over at CT scan?" the secretary called out to the workstation as staff mulled about.

"I think I do," mumbled a nurse distractedly as she charted.

"She's seizing."

That's certainly one way to jolt people into action.  I ran with the nurse over to radiology, while another nurse hustled over to the Pyxis to grab meds.  We found her unresponsive by the time we arrived, and I bagged her as we rushed her back to the trauma bay.  After a slightly frenzied couple of minutes we had her intubated, placed on a portable monitor, and back on her way to the scanner.  Turned out she had a massive bleed in her brain.

Never a dull moment.

Feast or Famine

Complain as I might when we're busy, the only thing worse is hanging around with nothing to do.

Over the weekend, a patient presented to triage with thoughts of jumping off a bridge.  With no one-to-one sitters available from the pool, my job for three hours was to make sure he did not succeed.  I always feel bad for psych patients who must endure the noise and commotion of a busy ED that isn't particularly well suited for their care, and I try to do the best I can to keep these patients comfortable.  Nevertheless, sitting is my least favorite part of the job.

It didn't help that once again we were getting slammed with traumas, and I was unable to help out.  As MDs, nurses, and techs ran from room to room trying to stay on top of things, one gentleman parked in the hallway noticed my obvious lack of movement and commented, "Everyone else is so busy.  How come you just sit there?"

Thanks for rubbing it in, dude.

My Mistake

Walked into an exam room to do an EKG on a new patient, and as I placed the leads I asked if she was having any chest pain.

"Oh yes," she replied, "in my stomach."

Trying to clarify that, I asked if she was having pain in her chest in addition to the stomach pain.

Pointing to her stomach, she explained, "Yes, real sharp chest pains, right here in my stomach."

"In her stomach," echoed the son, nodding gravely.

"So you're having chest pain," I asked while pointing to my chest, "in your stomach" as I moved my finger to my abdomen.  Trying a different approach, I decided to ask if she was having any stomach pain.

"Oh no dear," she replied, puzzled at my confusion.  "Just in my chest."

Bad Omen?

Lately I've found myself needing some extra cash to help support my education habit, so I've been applying to whatever scholarships I can find.  Today I received login information via email for an online application.

Should I be concerned that the first two letters of my assigned password are FU?

Take It Off

It's not often that an attending asks me to take off my shirt.  Proud as I may be of my emaciated runner's physique, a summer spent under the fluorescent lighting of the ED does not a bronzed Abercrombie model make me.  Thus, I was a little taken aback when the question was posed yesterday, and wondered if I had become the unwitting participant in some sort of sexual harassment training.

It turned out that a kids summer camp was making a field trip to the Big City ED, and the doc needed a volunteer to undergo an ultrasound demonstration.  More than happy to strip in the support of education, I headed over to the trauma bay and hopped on the stretcher.  Listening to the oohs and ahhs as the attending narrated a tour through my liver, gall bladder, and lungs, I noticed a pause once she switched to the cardiac probe.

As my heart valves opened and closed on the monitor, the attending leaned towards me and asked in a slightly concerned and doubtful tone if I was an athlete.  With a resting pulse in the 40s, I reassured her that my bradycardia was perfectly normal.

Apparently I have the running down, it's just the physique part I have to work on.

They Boy Who Cried Opiate Abuse

While I may not agree with a patient's choice to abuse drugs, I respect that it is their choice to make.  Like any decision, however, it should be made with full knowledge of the consequences.

For one of my patients last night, this meant that there was very little we could do to control his pain.  After a long history of heroin addiction and buying oxy off the street, his body had developed an impressive tolerance to narcotics.  When it finally came time to reduce a very painful-looking dislocation, even 100 of propofol (now forever known as the Michael Jackson drug) couldn't put him out.

It was sad to watch that after years of chasing highs, when this guy needed the drugs the most, they couldn't help.

What's the Worst That Could Happen?

Both Arizona and Tennessee now allow patrons to carry concealed weapons in bars.  I don't have wildly passionate views on either side of the gun debate, but I'm thinking this might not be the best idea.  Don't worry though, the new law prohibits customers who conceal their weapons from drinking in the bar.  Since nobody under the age of 21 has ever been served alcohol at a bar, either, I'm sure this stipulation will be equally well-enforced.

I might as well go prepare the trauma bay now...

Second Shift Turns One Year Old!

Today is my blogging birthday!  Many thanks to everyone who has taken the time to stop by or post a comment over the past year.  It's been a lot of fun sharing my misadventures in the ED, and I hope you've at at least some fun reading about them!

Gross Anatomy

A couple years ago a friend gave me an anatomy coloring book as a gift.  The pictures do a great job of showing where various body parts should be, but after the past few nights in the trauma bay, I think I might start coloring where they could end up.

One (surprise!) no-helmet motorcyclist forgot that the ankle bone is supposed to be connected to the leg bone, at least in principle.  After losing control of his bike and careening into a telephone pole, he ended up in the trauma bay with a massive deformity to his left ankle.  X-ray later revealed that he had broke both his tibia and fibula; essentially his foot had broken off the rest of his body.  A little piece of one of the fractured bones even poked through the skin.  Needless to say, he was admitted upstairs for surgery.

Second Shift's Revised Anatomy Coloring Book will also correct the impression that both legs are supposed to be the same length.  Not so when a nasty car crash causes an even nastier leg fracture that seems to shorten one leg.  On this page, children will have the option to color in the Steinman pin (a metal rod drilled through the leg near the knee to hang weights used to maintain traction).

Finally, we took care of a gentleman last night who got drunk, drove his ATV into a ditch out in the boonies, and spent hours wandering the woods with a pretty significant scalp avulsion before he was eventually found.  Transfered to our trauma bay from Another Hospital, he was still drunk enough to not comprehend that a chunk of his skull was now exposed for the world to see.  I think for that page I'll just take a red crayon and scribble all over the head.

Once again, I hope my black cloud passes!

Black Cloud

Trauma gods, I know not how I offended thee, but I humbly ask for a respite from the raging storm of MVCs, assaults, falling off docks and hitting heads on boats, ATV accidents, (surprise!) no-helmet motorcyclist crashes, stabbings, jumping out of windows and landing on concrete instead of pools, and GSWs that rains upon the Big City ED only on nights when I am assigned to work the trauma bay; I'm wet enough from the sweat of wearing those plastic trauma gowns all weekend.  Seriously, you know it's bad when I show up to work and everyone groans that we're going to get slammed for the next 12 hours!

Flu Wars II: The Pig Strikes Back

While Wolf Blitzer's Pandemicfest 2009 enjoys a brief summer vacation, the piggy flu continues to circulate down in the Southern Hemisphere.  During its absence, it's good to see that health officials are planning for its return.  In the weeks following the outbreak, the Big City ED, like EDs across the country, was hit hard with worried well.  I'd be interested to see if the plan to direct flu screening to other venues would prove effective, or if people will continue to present to their local ER no matter what.  Time will tell.

Always Check the Label

Noticing a crowd forming around the triage desk in the wee hours this weekend, I wandered over to discover that a grateful patient had dropped off a gift basket to thank us for the care he received.  Since the only thing ER staff love more than food is free food, I elbowed my way through the crowd of techs, RNs, MDs, security officers, registration folk and probably one or two undercover patients to feast upon the assorted cheeses, nuts, crackers and meats that lay beneath the shredded plastic wrap.  Sadly, by the time I arrived all that remained in the wicker basket were crumbs and a crumpled blue bow.  

As I turned to mope my way back to my patients, one of the nurses examined a cracker box and discovered her snacks had expired in 2004, thus begging the question: was this the regifting of a grateful but slightly confused senior citizen, or the clever scheme of a vengeful former patient bent on poisoning us all?  We'll never know.

Go (In)Directly To Jail

People will do all sorts of crazy things to try to avoid going to jail.

Fake seizures are a popular but predictable option.  The act ranges from half-hearted shivering, to full-blown convulsions to be followed by status dramaticus.  While peeing your pants to simulate incontinence may merit an A for effort, it's rarely convincing and just leaves you in wet undies.

Also common is "incarceritis," the mysterious constellation of symptoms including sudden onset severe chest pain, sudden onset severe abdominal pain, or sudden onset severe crying "I need to see a doctor."

While these acts may buy patients a couple hours in the ER, they almost always end up with a quick return to jail.  Last night, however, one prisoner/patient was so determined to avoid spending the night in the slammer, he banged his head violently against the door of the ambulance as he was escorted to the hospital and ended up with a small skull fracture.  He ended up buying himself a night in the hospital - in police custody of course - only to end up in jail as soon as he was discharged.  

NKDA

Like WhiteCoat and Nurse K, I've had my own share of interesting "allergies" described by patients in the ER.  Responses range from the legitimate (like shellfish, which could indicate an allergy to contrast dye), to the out-of-context ("Yes ma'am, we'll be sure to hold off on giving you any IV pollen this evening), to the slightly suspicious ("feathers").  

Last night, when taking a care of a trauma patient, I asked if he had any known allergies to drugs or medications.  

His response: "fruit."  

Now, even though that's not something we normally keep in the Pyxis, I decided to indulge him and ask what kind of fruit.  

His response: "all fruit."

I'm pretty sure that qualifies as NKDA.

Be A Hero

In the ER, we rely on donated blood to help save lives.  Someone in the US needs blood every two seconds, but only 5% of people donate, according to the American Red Cross.  Looking for a way to do some good this summer?  If you're eligible, please consider making an appointment to donate blood.  Give blood, give life.

For more information, please visit the American Red Cross website.

Safety First

After seeing far too many fingers lost this summer from hands being stuck where they don't belong, I was glad to learn that my patient last night decided not to clear out his jammed paper shredder with his fingers.

Using a knife, however, didn't end up being a much better choice.

Wait for It

As we were getting slammed with trauma all weekend (leave it to the nice weather to bring out the violent assaults), EMS radioed in with the following patch:

"Big City ED, we're approximately three minutes out with a 27 year old male, multiple gunshot wounds to the chest.."

"Great," I muttered as I turned to prep the trauma room for yet another GSW.

"...from a BB gun.  One of them may have broken skin."

Very funny guys.

Grin and Bear It

We put up with a lot in the ER, and most of the time we accept it as part of the job.  People who come to us are sick, in pain, confused, scared, often on a wide variety of medications or drugs, and they need help.  And that's what were there for.  It may not always be a pleasant encounter, but a certain amount of abuse comes with the job.

What's never excusable, however, is assaulting a healthcare provider.  I understand that you may be worried about your friend, but shoving one nurse and punching another while they're trying to assess the patient is not only inappropriate, it's criminal.  One visitor recently became violent at triage, and ended being arrested for violent and threatening behavior.  We put up with a lot, but that's crossing the line.

Chain Reaction

Sometimes, when you're flossing, your gums might start to bleed a little.  And for some people, the sight of blood makes them gag.  The gag reflex could cause a brief episode of tachycardia.  In a some cases this might trigger a bit of a panic attack, and if you're asthmatic, this could lead to a full-blown asthma attack.

So I guess the lesson for my patient receiving a neb treatment in bed 4 is clearly to stop flossing.

The Birds and The Bees

Honesty is always the best policy for a patient in the ER, especially at triage.  The nurse needs a complete and accurate understanding of the patient's problem in order to triage them appropriately.

That said, the young woman who presented with abdominal pain following intercourse probably could have skipped over the protracted and extremely detailed description of her experience while her mother stood by her side nodding.

Time to Get a Bike

Took care of a unlicensed 16 year old who decided to take Dad's car for a midnight joyride and ended up ejected from the vehicle after crashing head-on with a telephone pole.  Heavy front end damage to the vehicle, which quickly caught fire.  Positive loss of consciousness for the kid, who thankfully did not.  Remarkably he ended up with few serious injuries after a mechanism that could have easily killed him.

I have a younger cousin who is learning to drive this summer, and it's stories like these that scare the crap out of me.

Fast Track

Clearly in a hurry and having more important things to do, a young gentleman approached me as I worked triage the other night.

Pt: "Yo dude, I got stuff to do.  Can you just give me a note for work saying I was seen here?"

Me: "No... we can't give you a work note until you've been seen by a doctor."

Pt: "But I gotta miss some days, these hemmorrhoids are killing me man."

Me: "I'm sorry sir, but if you want a note a doctor needs to see you."

Pt: "Can I just show you?"  

He then proceeded to turn around, loosen his belt, unzip his pants and begin to pull them down in the middle of the waiting room before I could yell at him to stop.

He never did get his note.

Pastoral Care

Working the Monday after a long holiday weekend, and a full moon no less, was not a smart idea.  The ED, which has already been approaching record levels of overcrowding over the past few weeks, was once again bursting at the seams with everything from knee pain for the past 12 years to multiple trauma victims.

At one point, as I was standing in the triage bay trying to grab vitals on the line of ambulance patients that stretched out the doors, a disheveled young guy with a bright yellow tie and a thick black book tried to squeeze his way past the crowd of techs, RNs, and EMTs.  I recognized him as one of the new chaplain interns who had been paged to the ER multiple times over the past few hours for every major trauma that rolled in.  Looking down at the patient in front of him, a young woman strapped to a backboard after her car was T-boned by truck running a red light, he turned to me with pleading eyes and asked, "This isn't another major trauma, is it?"  I told him no, that she would only be a minor trauma.

His response: "Oh, thank Jesus."

Holiday Planning

All in all we managed to get through the holiday weekend in pretty good shape, and without any major incidents.  Despite working in a windowless department, though, it was amazing how we could tell exactly what was going on outside...

1500: Family and guests begin to arrive for BBQ.

[ER: Evening shift begins to arrive and munch on the food everyone brought in]

1800: Grandma has a little too much sun, falls faint.

[ER: First wave of dehydrated syncopal episodes arrive en masse]

1930: Aunt Becky, slightly buzzed, slices her hand while cutting a hot dog bun.

[ER: First wave of EtOH-related injuries trickle in]

2000: Grandpa trips while walking on the patio.

[ER: Second wave of older patients arrives, most with broken arms]

2100:  Fireworks!

[ER: Staff rushes up to the roof to watch fireworks!]

2105:  Ouch!

[ER: Staff rushes back down to start treating firework injuries]

2130: Fireworks over, Uncle Billy decides to give his no-good brother-in-law a piece of his mind.

[ER: First wave of assaults shows up]

2300: Junior gets behind the wheel, drives into a telephone pole, slams head into windshield, decides to flee the scene on foot.

[ER: First wave of scalp avulsions, rib fractures, clavicle fractures, and MVCs begin to arrive in police custody]

0100: Nothing says Happy Independence Day like a little coke, right?

[ER: Enter the ODs, stage left]

0230: Dudes start looking at other dudes the wrong way.

[ER: Clear the trauma bay for the GSWs]

After 0300 things started to calm down, and we could safely return to the snacking. 

Happy 4th of July

Remember: fingers and fireworks don't mix.

Awaiting the [Amublance's] Red Glare

I'm working all 4th of July weekend.  

Don't come visit me.  

Enjoy the fireworks, have a great time, and be safe!

Here We Go Again

Last week I took care of a lovely woman whose husband turned to me, face etched in mock concern as he asked, "We managed to squeeze in her illness before all those new doctors start, right?"  

By now the first of July has come and gone, hopefully without a nationwide spike in mortality attributed to the crop of new doctors beginning their intern year.  While it's true that people are routinely cautioned to never get sick in July, less they fall victim to some woefully inexperienced junior MD, it's also true that interns do operate under supervision.  Last July 1st the attending pulled all the staff aside, and in a lowered voice and explained that if anything, anything, the interns ordered seemed odd, to come straight to her.

So don't worry patients, your treatment won't hurt the new doctors a bit.  I'm crossing my fingers and wishing them good luck.  Remember, everybody's got to start somewhere.

ERs in the News

Patients say their top concern is not how long they spend in the ER waiting room, but rather how well they were kept informed of delays, according to the results of a Press Ganey survey and reported by the Chicago Sun-Times.  Rounding out the top concerns were how well the staff cared for the patient, and pain control.  Not surprisingly, patient satisfaction decreased as waiting time increased.

Patients can expect to see those wait times keep climbing, however, as the number of trauma patients spikes during the summer months, according to the Chicago Tribune.  One suburban Chicago ER has compiled a top ten list - including reminders to wear helmets and seatbelts - of ways to stay out of the ER this summer.

They Say It's Your Birthday

Sometimes, amid all the craziness of working in a trauma center, it's nice to take a quick from the madness and have some fun.  Last night, one of the residents received a surprise birthday celebration, ER style.

After one of our treatment areas closed for the night, we served cake from a stretcher by slicing it with tongue depressors, ate M&Ms from sterile bowls, and drank Coke from medicine cups.  Dorky, yes, but still lots of fun.