My Favorite Resident

I first met my My Favorite Resident at an ER barbecue during the start of his intern year.  It was during my very first conversation with My Favorite Resident that he asked me if I truly enjoyed working in the ED, or if my grades were just really bad and I needed something to salvage my med school application.

As you might imagine, our relationship only blossomed from there.

Actually, to be fair, his attitude over the years has improved significantly.  I even got to the point where I started to believe that he had changed for the better, until I decided to sit in on a particularly interesting EM grand rounds lecture last week.

Taking my seat next to some of the other residents I'm friends with, I nodded at My Favorite Resident as he walked in.  Turning to me, he asked: "What are you doing here?  Are you getting paid?  Or are you trying to suck up to the faculty?"

Looks like we're back to where we started.

Physician, Steal for Thyself

According to an article in USA Today, the family of a California police officer are charging that the emergency physician taking care of their father allowed him to die of a heart attack so the physician could steal the patient's Rolex watch.

Two nurses apparently noticed the watch was missing, and saw a watch bulge in the ER doc's pocket.  When approached by security, the doctor allegedly ran outside and threw the watch into the grass.

Way to lower my opinion of humanity, doc.

Press Ganey Be Damned

Pt: [looking up from her newspaper as her husband massaged her feet] "Excuse me, I need to urinate."

Me: "Okay, do you feel comfortable walking?  I can show you to the bathroom down the hall."

Pt: "No dear, I don't think there's any way I can walk that far." [She walked in to the ED without assistance]

Me: "Well, then, let me see if I can find you a bedpan."

Pt: "Absolutely not."

[I then spent the next ten minutes searching the department for our bedside commode, which the patient agreed to use only after a great deal of sighing and eye rolling.  After a dramatic imitation of a syncopal episode, she insisted that her husband and I help lift her]

Me: "I'll step out and give you some privacy."

Pt: "I'm going to need some water to help me go."  [I grab her a cup of water]

Pt: "No tea?  I always need tea with my water."

Me: "Sorry, no tea in the emergency department."

Pt: "Really?  I find that hard to believe."

Me: "Really." [icy glare]

Pt: "Well, I'll at least need this water microwaved then."

At that point, I turned to stare at the husband for a moment, pitying what his daily existence must be like, before walking out of the room.

Run-Around

Just got back from an excellent early fall afternoon run, which means two things: first, I will be an extremely good mood when I start my shift tonight, and second, I will be falling asleep approximately 30 minutes into it.

Dealer or No Dealer

I began to suspect that something was a little odd when I found random dollar bills stuffed in every nook and cranny of the patient's purse.  Singles, fives, fifties, and hundreds, wedged in between retail cards, receipts, and even in the lining of the badly worn fabric.

The patient, found initially unresponsive at the side of the road, insisted that we lock everything up.  The only problem: we weren't sure if we could find it all.  The cash was stuffed everywhere.

In total, almost a thousand dollars found mostly in small bills, 17 credit cards, and two recently-filled bottles of prescription pain medication missing far too many pills.  Initially, we were concerned about ingestion, but a negative tox screen quickly and unsurprisingly confirmed where all that money had likely come from.

This Week's Sign of the Apocalypse

Fully capable, discharged adult patient, throwing a Stage 5 temper tantrum in the waiting room, demanding that we call social work because his backpack is too heavy for him to carry.

I Don't Believe It

Apparently, no connection exists between a full moon and ER visits, but that's only if you're willing to believe "science."

I for one intend to stubbornly cling to my anecdotal evidence and insist that the phase of the moon can directly influence the number of people who flock to the ER.

Now if I only had a way to explain the insanity that occurs every other night of the month...

Late Night Musings

For those of  you who were wondering, a foley catheter balloon can hold roughly 300cc of air before it explodes, as confirmed by the remnants now found around the ambulance bay parking lot.

If You Like Piña Coladas

ERP from ER Stories just contributed his first guest post over at WhiteCoat's Call Room.  His story about intoxicated patients' seemingly miraculous ability to escape loss of life or limb reminded me of the hundreds of "drunk fall down" or "drunk vs. stairs" cases that roll through the trauma bay each year.

Up until today, I always believed there was some strange ability of alcohol to alter the gravitational constant of the universe in the immediate vicinity of those who consume it that contributed to the association between liquor and injury.

This week, however, I learned that I've had it all wrong.  Alcohol, it seems, actually prevents trauma... at least in certain cases.  According to the BBC, patients with EtOH on board appear less likely to die from brain trauma than teetotalers.  Experts believe that the right amount of booze can prevent secondary brain injury caused by swelling, in addition to the more well-known heart benefits.

Before we start stocking IV Smirnoff in the Pyxis, however, it's worth remembering that countless of other studies have linked alcohol and injury.  Just remember: everything in moderation.

One of Your Own

While reading Medic7's latest post about a fellow medic turned drug addict, I was reminded of the difficulty of treating "one your own."

Not too long ago, we received a radio patch alerting us to an incoming ingestion.  I prepped a critical care bed, making sure we had monitor leads, and EKG ready, and intubation equipment just in case.  EMTs arrived a few minutes later with a middle-aged woman, trashing on the stretcher and muttering incoherently.

Unlike most ingestions, however, she was wearing scrubs.  As we changed her into a gown, we found an ID badge from Another Hospital, where she worked as an RN.  

While the nurse tried to get blood and I connected the patient to the monitor, we listened as she cried about how busy her unit had been lately, and how she could no longer deal with the stress.  Knowing exactly what she was doing, she had taken a powerful combination of drugs, but thankfully had been found almost immediately.  Her stomach was pumped in the ER, and she was quickly admitted upstairs.

No suicide attempt is ever easy to deal with, but this one really hit home.

This is Terrifying

A gunman walks into a Chicago ER, fires a shot into the ceiling, and tells a tech that he killed his family.  Thankfully, the situation seems to have been resolved peacefully.  These kinds of incidents scare the crap out of me.

Strange Story

Came across this bizarre story of an ER nurse handcuffed by a Chicago police officer in the Chicago Sun-Times this morning.  According to the article, the charge nurse was placed in cuffs and sat in a police car for 45 minutes for refusing to draw blood on a DUI suspect until after he was "admitted to the hospital."  Only one side of the story is presented, and I would be interested to hear the officer's view of the incident.  It seems to me that more may have been going on.

Too Much Time on My Hands

I guess the amount of time people choose to waste in an ER waiting room will never cease to amaze me.  The other night, we had a patient present with a chief complaint of a small bruise to his arm after bumping into a table.  He showed up at 2330 and proceeded to wait three hours to be seen by a PA and discharged within five minutes.  

Lesson Learned

Here's what I experienced:

Working triage on a busy Saturday night, I called for the next person to sign in and watched a young guy drag himself up to the desk.  Obviously in a great deal of pain, he grimaced even while I placed the blood pressure cuff on his arm.  As I entered his information into the computer, he explained that he had kidney stones in the past, but this one felt like the biggest yet.  I handed him a urine cup, which dipped positive for blood when he returned it later, and watched him shuffle back to the waiting room.  Given the number of traumas and critical patients we had that night, it would be a few hours before he would be seen.

Here's what I later found out actually happened:

Looking for a fix, a young guy decided to score some narcs for the weekend by visiting a new ED for the first time.  Putting on a well-rehearsed act, he successfully conned an ED tech and triage nurse into believing that he was suffering from a bad kidney stone.  When handed a urine cup, he headed to the bathroom, pricked his finger, and dripped blood into the sample.  

Assured that it would be hours until his chart reached the top of the pile, he left the waiting room and drove over to Nearby Hospital, where he performed a similar routine.  There, he received a dose of IV pain meds and a script for narcs.  Mission accomplished, he returned to the Big City ED, claiming to have been outside on his cell phone when we called him up for re-evaluation.  

Once brought back, he received a second dose of IV pain meds for the evening, but this time decided not to wait for a script.  Rather, he attempted to rush out the door with his IV still in place.  When approached, he ripped out the lock and ran down the street.

Here's what I learned:

I was played, pure and simple.  I won't forget his face, and both the Big City and Nearby Hospital EDs are now wise to his act.  But there are plenty of other hospitals out there for him to scam.

It's sad when successful con artists push healthcare providers ever closer to cynicism, and increase the suspicion towards people in legitimate pain.  But it's sadder still to see the lengths addicts will go to get a fix, and to watch the destructive and all-consuming power addiction has over their lives.  I only hope he eventually gets the help he needs.

Scabies

 After hosing off our gentleman with scabies last night, I'm going to have psychosomatic itching for the next week.

The Drunk Dunk

We get a lot of EtOHers in the ED.  Some sing, some fight, and some poop their pants.  Last night, however, I witnessed my first patient drunk enough to dunk her head into a vomit-filled emesis basin while actively puking.  

Suffice it to say, I'd recommend she get a haircut.

I'll Have What She's Having

Judging by the number of patients demanding diet ginger ale last night, I'm guessing somebody must have spiked the whole batch of cans.  It seems like every couple minutes I had somebody yelling out to the hallway that they needed a refill.

In other news, I recently learned of a new medical video game called Emergency Room: Real Life Rescue.  Apparently you begin as a rookie EMT and work your way up using a variety of tools at your disposal to treat patients.  You can read more in this review.

Calm Before the Second Storm

Concerned that the swine flu (aka novel H1N1 influenza A virus) will return from its summer vacation with a vengeance, hospitals across the country are developing procedures designed to lighten the burden of worried well on their ERs.  

According to this article from the Washington Post, everyone from the federal government to the American College of Emergency Physicians is working on ways to stem the flood and keep the country's limited number of critical care beds free for those who truly need them.

Like most hospitals, we were swamped with patients at the height of the initial swine flu scare this spring.  Whether or not patients will elect to avoid the ER and remain home this time around remains to be seen.

Mortal Kombat

You know you're playing for keeps when an arm wrestling match ends up in an ER visit for three separate fractures.  Ouch.

Enough Already

I'm getting a little worn down by the senseless violence that's going on out there.  

We've had too many violent assaults recently - stab wound to the chest requiring a chest tube to drain the blood from the collapsed lung, stab wound to the belly requiring a trip to the OR, and one person stabbed at least seven times all over the body.  

And just last night, a guy who nearly bled out on scene from an arterial stab wound.  His crime?  Trying to break up a fight between two strangers.

24 More Hours

Thanks to the link from KeepBreathing, it seems that many were interested in the 24 hours USA Today spent in a Virginia ER.  The other day, I came across a similar article covering a day in the life of a New Zealand ER.  What caught my eye was the different types of presentations treated in both settings.  While the USA Today article focused on the ER in light of health care reform, it seems that the vast majority of patients down under arrive with what might be be considered more typical "emergencies."  

Also, be sure to check out some of the great photos.

Heeeee's Back

After a multi-month absence due to a rigorous touring schedule that took him to large and small ER venues across the region, Jack Daniels celebrated a triumphant homecoming to the Big City ED last night.  Rocking a new, shaggier haircut but still sporting that same winning personality that old and new fans have come to love, Jack invited me to orally remove fluids from his reproductive organ (albeit, in slightly more coarse language) when I attempted to check his finger stick.

Great to have him back.

Trauma Bay Tailgate

Now that college football has begun, I'm regretting heading into the ED on a Saturday afternoon.  ESPN's online game cast only goes so far.  If only there was a way to display today's games on the huge electronic patient board...

The Results Are In

I'm pleased to report that Second Shift: Stories from the ER is 100% TB-free according to its most recent PPD.

With the amount of hacking I've been exposed to lately, this is no small feat.  

As for the swine flu, however, we'll see what happens.

Ensemble Cast

While doctors and nurses may be the most visible members of the healthcare team both in the hospital and on TV shows, the fact is many more people contribute to a patient's ER experience.  Secretaries, registration folk, pharmacy techs, RT, and many others play critical and often unrecognized roles.

Our supply manager went on vacation last week, and it's one of those jobs that's easy to overlook when done properly, but impossible to miss when not done right.  Ordering the right amount any of the thousands of items we use every day is no small task.  An ER can be a pretty difficult place to operate if we've run out of blood tubes, or if we have to dig through fifty boxes of gloves to find a foley bag.  Hence, a quick shout-out to all the unsung staff that keep things running smoothly.

Extreme EM

From CNN, a brief video profile of the incredible work performed by military medical teams in Afghanistan:

Something in the Water

One spontaneous, atraumatic subarachnoid hemorrhage is unfortunate, but three in a single shift is just plain odd.  

There Goes My Appetite

While registering a patient at triage the other night, I knew I recognized the face but couldn't quite place him.  As I clipped the pulse ox monitor onto his finger, I finally broke down and asked him if we had met before.

He replied that made sandwiches at a popular food joint down the street from the hospital, where he'd just gotten off work.  It's a favorite spot for late-night snack runs by the ED staff, and a place I've visited many times myself.

Entering his name into the computer, I asked what brought him to the ED.

"Runny diarrhea for the past six days."

Looks like I'll be brown bagging it from now on.

24 Hours

USA Today recently published a piece covering 24 hours in a Virginia ER.  Check it out!

Time is Brain

Time from symptom onset to ED arrival: 60 minutes.

Time from ED arrival to CT scan: 10 minutes.

Time from ED arrival to tPA administration: 53 minutes.

Watching Grandma's right leg begin to move again: priceless.

Fool That I Am

You'd think I'd know by now that whenever I sign up for an extra shift, it ends up a hot mess.

Little did I realize that when I added my name to the overtime list that I was signing up for a Friday, on a full moon, at the beginning of a holiday weekend, early in the freshman drinking season.  Talk about the perfect storm.

Walking into the ED, I quickly discovered what I had gotten myself into when the stink of an EtOH-induced code brown laid siege to my nostrils.  Readying my trusty Lysol holster, I prepared for the worst as I began to take vitals at triage.  

Highlights included the patient whose heart rate soared to over 100 per his exercise HR monitor while out for a run, requesting that he be "checked out."  Young guy, no cardiac history, no CP/SOB.  Later, we had the woman who felt lightheaded all day.  When asked about the last time she ate, she replied "Yesterday.  I was too lazy to make anything today."  At least the guy high on PCP who jumped out through a second-story window while being chased by police actually required treatment.

After three more code browns as the night went on, and a parade of sloppy freshman, I swore off picking up any more extra time... at least until next week.

The Firefighter Will See You Now

"I joined the force to battle blazes, not to be an emergency room doctor," explains a Washington state firefighter.

While emergency departments have long played the role of primary care center, it seems that firefighters are now serving as mobile EDs.  A recent article from the New York Times profiles Engine Company 10, which receives 80% of their calls from medical emergencies.  It opens an interesting debate over whether fire trucks, which often have the fastest response times and carry EMTs, should be dispatched to medical calls.

This increase in medical calls, however, occurs while fire companies across the country are cutting back.  A few months ago I posted about a reduction in service by the city of Los Angeles.  Now the LA Times reports on a 3 year old who drown while the nearest fire truck was unavailable.

That Bites

When the health care debate becomes so heated that one protester bite off another's finger, I think it's time for everyone to take some ativan.

A Crappy Day

He had very shiny shoes.

Many of the med students who begin their ER rotations dress quite professionally, and this one was no exception.  Unfortunately, despite his attire, he clearly looked like he would rather be somewhere else.  Checking his watch, hugging the wall, and generally appearing less than pleased at being in the ED on a busy night, this med student was not having a good time.

One of our shared patients for the evening was an elderly man brought in for abdominal pain and altered mental status.  Entering the room to draw basic labs, I found the patient standing up and undergoing a neuro exam by the med student.  Realizing I forgot a tourniquet, I stepped out for a moment.

When I returned, it looked like someone set off a poop bomb.  In the few seconds I was out of the room, the patient had a bout of explosive diarrhea that seemed to hit every surface - the walls, the stretcher, and yes, even the med student.  

As he looked at me in horror, all I could think was that his once clean shoes would probably need to be re-shined.

Chilling

Debating abstract ethical dilemmas is one thing, but real-life medical decisions often have no easy answer, and can lead to devastating consequences.

You may recall the case of several health care providers accused of administering lethal doses of medication to patients in a flood-ravaged hospital in New Orleans during the chaotic period after Hurricane Katrina.  Last week, the New York Times Magazine published a detailed account of those terrible days, and the decisions made by physicians and nurses facing impossible choices.

Discussing the article in the ED this weekend led to some heated debate on about the nature of triage, euthanasia, and who should make decisions in disaster situations.  It's definitely worth a read.