Happy Halloween!

Have fun, stay safe!

Haunted ER

Reaching to remove the patient's tourniquet late one night, I paused for a moment as the lights began to flicker. Next came the sudden BANG of the fire doors slamming shut in unison, only to be followed by the slow creaking sound as the opened themselves up again. Fluorescent lighting tubes sizzled as the continued to flicker, monitor alarms rang loudly before suddenly silencing and going blank, fire doors opened and closed themselves at will...

Had the ghosts of patients past come back to haunt the ER, as my patient suggested?

Either that, or engineering was testing the backup generators.

Besides, we're already haunted by prior patients - we just call them frequent fliers, not ghosts.

ER Chainsaw Massacre

The metallic, buzzing sound of a chainsaw about to butcher us to death would probably sound more terrifying if its imitation wasn't slurred. Or occasionally interrupted by a gurgle of vomit.

"Chainsaw Killer," as one of our occasional EtOHers likes to be called, can be easily identified from triage by the buzzing noise he insists on making throughout his visit.

"I'm the Chainsaw Killer bitches," he'll scream, followed by a prolonged "Bzzzzzzzzzzzz" and dramatically accompanied by flailing arms.

After a few moments he'll tire out, nod off and begin to drool. But at random moments throughout the night (ideally when some new volunteer passes by his stretcher), he'll spring upright and repeat a chorus of "I'm the Chainsaw Killer bitches... BzzzZZzzzzzZzzz."

Whether or not he'd be able to operate a real chainsaw, let alone stand up straight, is open to debate.

Dr. Lurch

He's creepy and he's kooky, mysogynistic and spooky, he's all together ooky, he's... My Favorite Resident.

He lurks, he eavesdrops on conversations, and he breathes heavily while standing behind you.  I'll be he even sleeps suspended from the ceiling upside down.

Yet despite his past misdeed, no antics by My Favorite Resident have endeared him to the staff as much as his recent comments about Halloween costumes.  While a bunch of us were discussing an upcoming ER costume party, My Favorite Resident worked himself into the conversation by describing what kind of sexy nurse outfits the females in the group should wear.  Nobody laughed, a few people frowned at him, but My Favorite Resident kept describing his fantasy costumes until the attending finally had to pull him aside and tell him to knock it off.

What a creep.

Trick or Treat

Sometimes it feels like every night in the ER is Halloween.

Wearing her way-too-tight shirt costume, a patient walked up to triage:

Pt: "I feel weak and dizzy."

RN: "When was the last time you had anything to eat?"

Pt: "Yesterday."

RN: "Why so long ago?"

Pt: "I was too lazy to make anything."

RN: (eye role)

The patient was given a box lunch, which she dropped in her extra large purse, and promptly walked out of the waiting room.

Maybe we should just leave a bowl of candy on our doorstep?

Things That Go Bump In The Night Shift

As I wrote around this time last year, the emergency room can be a scary place.  Pale, listless creatures roam the hallways after midnight looking for blood, everyone's concerned about the undead, and no one in their right mind wants to work on a full moon.

To celebrate the upcoming holiday, I'll use the next few days to share some Halloween-themed stories from the Big City ED.  Because in the words of one patient, "this isn't a hospital, it's a zoo."  

A haunted zoo.

Change of Plans

Husband and wife for over 30 years, their original plan for the evening involved dinner reservations and concert tickets.

Instead, he ended up spending the night at her bedside, watching his intubated wife wait for admission after being flown in from Another Hospital following the onset of a massive hemmorhagic stroke.

I can't imagine what it must be like to have your life change so completely, so quickly.

Bummer Dude

I offered the drunk, frat boy freshman five whole dollars for his bro-tastic sweater vest, but my offer was sadly declined.

True Story

Pt: "Don't worry, I understand.  I heard there were a lot of trauma patients tonight; you guys gotta take care of them first.  I know you'll get to me as soon as you can."

Me: (Stunned silence)

While no patient in the ER is more important than any other, some are more critical, and traumas always get first dibs on things like CT scans.  To have a patient not only understand that, but endorse the idea while waiting patiently on a busy night left me speechless.  

Getting in the Spirit

Halloween must be just around the corner if one of our more unsavory frequent fliers has switched from his standard repertoire of profane insults hurled at the staff, to attaching the slightly more festive moniker of "Witch Doctor" to anyone who attempts to treat him.  I kinda like the sound of that.

Perhaps I should direct my energies to Voodoo, instead of allopathic, medicine instead.

Drop the Hemostat and Nobody Gets Hurt

Only in the ER.  According to this article, an ER nurse reported a Michigan man to the police for allegedly stealing a hemostat that he claimed to be borrowing to trim his nose hair.  When the police arrived, they discovered that this wasn't the miscreant's first brush with the law; he was picked up for an outstanding warrant.

Reminds me of the time when a dude try to steal our bolt cutters from the trauma bay.  Except he didn't want to use them on his nose hair.  And we just made him put them back.  And apologize.

My First Intubation!

...was on a plastic dummy.  To be fair, it was a very expensive, high-tech plastic dummy.  That I also defibrillated and cardioverted.  But the intubation was definitely my favorite.

Never mind that its teeth were pretty banged up in the process.  Or that his vocal cords would have been torn to shreds.  It may have been a rocky start, but I have a long way to go before I'll be trying it for real.  And after multiple attempts, I now have a better appreciation for why Ten Out of Ten decided to start lifting weights.  It was a fun experience, and one that re-affirmed my hope to go into emergency medicine.

Cold Snap

I think Old Man Winter's surprise, pre-season sneak attack froze my brain cell and lulled me into a false sense of security.  Naively, I believed that the sudden arctic burst might encourage people to stay huddled around the fireplace, sipping homemade hot cocoa while playing delightful parlor games in the presence of friends and family rather than heading outside to crash their motorcycles and shoot each other.

Of course, I was wrong.

While cooling temperatures generally lead to an increase in social and psychiatric complaints and a slight drop in the number of traumas, this weekend bucked the trend.  One (surprise!) no-helmet motorcyclist arrived in traumatic cardiac arrest and was already too far gone.  A second MCC victim arrived with a nasty forehead hematoma and amnesia.  One drug deal gone bad led to three gun shot wounds the chest, while an altercation outside a club resulted in a mere single GSW to the foot.

At least the second motorcyclist had on gloves and a proper winter jacket, if not a helmet.  Otherwise he may have caught a cold.

Fail

While changing a little old lady for the fourth time in a shift, I got a little dollop of poop on my arm.

Cooties CPR

So it appears CNN is really trying to push Sanjay Gupta's new book by publishing related articles under the auspices of "news," but nevertheless it leads to some interesting stories.  Like this one, of a woman who survived cardiac arrest thanks to prompt CPR and hypothermia.  The article calls attention to the newer lay rescuer guidelines, "cooties CPR," that no longer require rescue breathing in an effort to emphasize the importance of strong, continuous chest compressions.  Yet another reminder that if you aren't CPR certified, you should be!

Toothache

My tooth hurts.  Especially when I drink cold beverages.

I will suck it up.  I will try to ignore it and hope it goes away.  Worst case, I will wait until I head back home next month and make an appointment with my dentist.

I will not use this as an excuse to head to the ER at 0300 and demand narcotic pain medication.

Though I'm sure it would help.

Chill Out

Just in time for the cool fall weather to hit the Big City, this interesting article comes out about why we put our cardiac arrest survivors on ice, so to speak.  You're not dead until you're warm and dead!

Dichotomy

It was really cool.

EMS called in a major trauma, and arrived minutes later with a critical patient.  A severe motor vehicle collision with prolonged extrication resulted in an almost complete arm amputation and significant blood loss on scene.

It had all the makings of one of those rare, made-for-TV moments.  The humerus, broken in half, had its jagged edges separated by several inches as both ends of the bone poked out of bloody messes of muscle and tissue joined only by a thin stretch of intact skin.  Blood hung from the rapid infuser, and the emergency transfusion protocol was initiated.  Kneeling at the head of the bed, I held c-spine while the attending struggled to pass a bougie.  Trauma surgeons doused the patient in betadine before inserting a femoral line.  With a pressure barely holding in the 70s, we ran the stretcher through the department and up the elevator to the OR.

Returning to the trauma bay to clean up, my scrubs sprinkled with blood, I was amped up on adrenaline for the rest of the night.

* * *

It was really tragic.

Only a year or two younger than me, she was on her way to pick up some friends from a party when a drunk driver slammed into her car at 70mph.  From the moment she arrived in the trauma bay, we all knew it didn't look good.  

Her body was cut and bruised, but it was the bloody stump of an arm barely dangling from her shoulder that made everyone worry.  The black and red of exposed flesh contrasted with the ghostly pale coloring of her skin.  Kneeling at the head of the bed, my face only inches from hers, I could see the dried blood caked in her blonde hair and listened to her moaning while we waited for the nurses to draw up paralytic medication.  With her pressure dangerously low, we rushed her up to surgery, wondering how long she would last on the table.

Sadly, it wasn't long.

* * *

The wannabe ER doc inside me eagerly took in the gross anatomy of the amputation, the practiced ease of the emergency interventions, and the calm and deliberate manner in which the team worked to stabilize the patient.  Truly bad traumas like this one are relatively uncommon, and after working in the ED for a few years now, I rarely feel my heart racing like I did here.  Excited as I was in the moment, however, I was crushed to learn about the story behind the patient, and later that she didn't make it.  I felt guilty for getting pumped up by the gore factor.  I try hard not to let the adrenaline junkie take over, but sometimes it's a difficult balance to strike.

Planes, Trains, and Defibrillators

Should Automated External Defibrillators - portable devices designed to be used by the general public to "shock" somebody in cardiac arrest - be required on trains?  That's the question being asked after a Chicago-area man died from a heart attack while commuting to work this week.  AEDs, as they are known, have been required on airplanes since 2001, and are becoming increasingly common in public areas like shopping malls and sports stadiums.  

Though survival rates for cardiac arrest are pretty dismal, early CPR and early defibrillation are simple and effective interventions.  Are you CPR/AED certified?  Check out the American Heart Association website to learn how to save a life!

One Thousand and One Uses

Alcohol-based hand gels, while omnipresent these days as our last best hope against Wolf Blitzer's Pandemicfest 2009, have long been popular in the ER.  Among patients and staff, Purell keeps our hands clean; among certain EtOHers, it keeps them buzzed.

But now we can add another use... hair gel.  I just learned that one of our nurses keeps her hair spikey by liberally applying a spritz of Purell and running her hands through her hair multiple times a night.  Is there nothing this magical substance can't do?

Time To Cut Back

If anyone who walks into your exam room gets an instant headache and probably lung cancer just from the secondhand smoke clinging to your clothes, and immediately runs outside to get some ambulance exhaust-laden air that seems fresh by comparison, then it just may be time to reduce your number of packs per day.

Remedial Media

The media plays an important role in shaping public health concerns.  Earlier this spring, intense news coverage of the H1N1 flu outbreak prompted scores of mostly worried well to rush to the hospital and overwhelm their local emergency department.  

According to a study presented at this week's ACEP conference in Boston, a similar effect was observed following the death of actress Natasha Richardson.  The authors looked at 19 EDs across New York and New Jersey, and found a 73% increase in the number of patients presenting with head trauma in the days following the event.  

A few weeks ago, the Medscape Emergency Medicine blog asked "Will the Media Screw Emergency Departments Again on H1N1," which is a valid question.  The medical community relies on the media to convey important health information to the public, but the balance between responsible reporting and sensationalizing can make a big difference in the waiting room.

BAMF

Hypoxic patient with severe facial trauma and difficult anatomy.  Who you gonna call?  The Anesthesia BAMF.

In the Big City ED, our docs are pros at airway management.  So good, in fact, that I've only ever seen them call for help a handful of times over the past few years.  But when they can't get the tube, the Anesthesia BAMF swoops in with the save.

Sporting their signature surgical caps and standard, unflappable demeanor, the Anesthesia BAMF always arrives instantaneously, armed with any number of toys from their bag of tricks.  Sometimes it's a simple bougie, while other times the Glidescope makes an appearance.  My favorite is the Upsher laryngoscope, mainly because it makes the Anesthesia BAMF look like she's visualizing the cords with a sniper rifle.

Whatever their device of choice, the Anesthesia BAMF always gets the tube, gives the ED docs a knowing nod and a consoling "that was a tricky one," before packing up their equipment and riding off into the sunset.

Late Night Musings

Ever wonder what the highly-trained, professional life savers of a busy ER do during the wee hours of a rare slow night?

Well, while others may be planning for pandemic flu or some other looming public health threat, we in the ER focus on a more pressing yet under-studied issue of disaster preparedness. 

Zombies.

That's right, those cannibalistic, brain-hungry undead drones who might at any moment rise up against us.  Swine flu?  Get a mask, wash your hands.  But zombies?  Bet your hospital doesn't have a incident plan for that.

Starting around 0230 the other night, the whole ED staff from attending to tech grew embroiled in a heated debate about best practices for a potential zombie apocalypse.  How could we ensure the physical security of the department?  How long could we live off the hospital turkey sandwiches?  Would a laryngoscope prove an effective close range weapon against a recently-deceased patient lusting for your brain?

While a summary of our findings probably won't make its way into the Annals of Emergency Medicine anytime soon, rest assured that the committed professionals of the emergency department are working 24/7 to keep you safe.

Note To Self

Failing to turn off your alarm clock after working a 16 hour double shift is not a smart plan.

Good For a Laugh

I finally broke down and watched the premier of the new NBC show Trauma online yesterday.  All I can say is, in addition being the best new comedy show of the season, the program serves an educational mission as well by educating TV viewers once more how not to perform effective chest compressions.

Nursing Home Fail

I generally try to avoid hating on nursing homes, mainly because they are easy targets.  Most are understaffed and underfunded, struggle with a high degree of turnover, and try to do the best they can regardless.  That said, one did "accidentally" resuscitate my grandmother, despite her DNR status.

Nevertheless, when the patient's nursing home report includes the words "sent to ER for probable urinal tract infection," I knew I couldn't resist mentioning it here.

Big Kid

The patient had done it again.  A little drunk, a little high, this time he stumbled down the stairs and ended up with a unhappy deformity to his left leg.  Xray confirmed a fracture, which was splinted in the ED and mostly likely would require surgery.  Luckily, the still dazed and confused patient had a long-suffering family member present to schedule a visit at the ortho clinic, inquire about discharge care instructions, arrange a ride home, and locate the nearest 24 hour pharmacy.

It's a real shame when a 12 year old is forced to be more mature than his parent.