Welcome Back

After spending a wonderful week at home catching up with family and friends, I returned to the ER rested, refreshed, and ready to greet the sick and injured of the Big City.

Until a patient decided to spit in my face.

Now I've been working in the ED for a few years, and I've certainly been spit at many times. But this was the first well-formed spittle missile that made direct contact with my flesh just below the eye.

My knee-jerk reaction was a surprising amount of anger. Despite being a pretty non-violent individual, I truly wanted to jack the guy in the face. Here was a dood who picked a fight with the wrong crowd and lost badly, who then decided to take out his frustrations on the very people he turned to for help.

But unlike this patient, I controlled my impulses. I stepped away from the situation. I washed my face repeatedly. I went outside and checked my voicemail. And then I spent the rest of encounter treating him with the respect and dignity that he refused to show others.

Later in the night, one of the nurses showed me this, and I chuckled. Maybe I should become a surgeon?

Frequent Fliers

Their names may be different, but their stories are almost always the same. Every ER in the country has one, and most have several.

Today's Washington Post has a profile of one frequent flier from Washington, DC whose visits contribute to the estimated $32 billion wasted in non-urgent ER stays every year. It's a fantastic article and well worth a read.

Mix and Match

NewTech: "What the hell is that?"

Points to a white cloud floating in a urine cup that tested positive for large protein.

Second Shift: "Why, that's a little urine/semen cocktail your patient gave you."

Petty Theft

Cranky's encounter with supermarket larceny reminded me of the many people I've seen walk into the ER waiting room, only to grab a box of swine flu masks before turning around and walking out again.

Masks certainly aren't the only things I've witnessed patients try to lift from the ER. Other favorite include tissue boxes, wheelchairs, blankets and cordless phones.

But the winner in the category for best attempt at stealing ER goodies goes to trauma patient who opened the procedure tray cabinet, ripped open the sterile drapes and tried to walk out with a very large bolt cutter.

Not content with free medical care, it seems that certain patients feel entitled to parting gifts as well.

Happy Thanksgiving!

Many, many things to be grateful for this year, but once again topping the list is being home with friends and family today. And beating the guy dressed as a turkey in this morning's Turkey Trot.

Happy eating to excess!

On the Road Again

Road trip to State U today to pick up Brother Shift for the holiday. Happy Thanksgiving all!

Hot Water

Bathrooms are death traps.

Floors mats love to slide out from underneath their owners, toilets yearn to crush reproductive organs or trap other appendages, and now apparently the hot tub is just itching to finish us off.

The New York Times reports that an analysis of the National Electronic Injury Surveillance System revealed that hot tub-related emergency room visits skyrocketed from 2,549 in 1990 to over 6,600 in 2007.

Personally, I've never seen someone present with a hot tub-related complaint (presumably burns, water in the ears, or those dreaded pruney fingers), but rest assured that I will be hyper-vigilant about this issue from now on.

Punching Out

Preparing to fight my way through the battlefield of modern air travel this morning. I can't wait to brave the endless lines, strip down to my knickers at security, receive bruises and lacerations while fighting for the last inch of overhead storage space, and breath recycled H1N1-laden air as I fly home for the Thanksgiving holiday. Better have the trauma team on standby for when I land.

The Things They Carry

Discovered while cleaning up a room after a patient had been discharged: an aerosol spray can labeled "Apple Harvest Air Neutralizer Deodorant" that looked like it was made in the 1970s.

Unfortunately, when I dared to spritz a little in the room, I discovered that it smelled like it was made in the 1970s as well.

Are You Ready For Some Football?

Friends, food, and football this weekend. Throw in the fact that I've got some time off from the ED, and add a splash of EtOH, and life is good!

Mortality

KeepBreathing has a post up about how treating patients your own age can force you to confront your mortality.

Being one of the youngest working in the ER, most patients my age are lightweight college students puking in their stretchers. Recently, however, I took care of a woman only a year or two older than myself. Terminal Stage IV cancer. Beautiful, polite, and funny, she joked with her mother and the staff as we treated her for dehydration. The fact that she didn't even look sick made her diagnosis that much more shocking.

I firmly believe that no life is any more or less valuable than another, but there is something about a patient in what should be the prime of her life quickly dying from cancer that seems especially tragic.

Cancer sucks.

Trigger Happy

Dear X-ray tech,

When you announce that you're about to take an X-ray in Bed 2, and I'm on the other side of the curtain in Bed 3 yelling "Hold on!" as I empty a foley bag, please don't go ahead and shoot the film anyway.

I haven't made my babies yet, and I'd really prefer them not to glow in the dark.

Next time, if you'd like, I'll happily run out of the room with a white flag in one hand and a sloshing urinal in the other, shouting "Don't shoot... I surrender," if it will fulfill your trigger happy fantasies.

Just please don't irradiate my junk.

Sincerely yours,

Second Shift

A Sign of the Times

Courtesy of the New York Times - an unintended light bulb failure at what should read Elmhurst Emergency & Trauma Center:

A commentary on ER overcrowding?

Train Wrecks

When the sun goes down and the EtOHers start rolling in, the name of the game is getting them cleared to the drunk tank as quickly as possible. Last night, however, it seemed that each and every one of my patients was ready to start circling the drain.

Train Wreck #1 was a middle-aged EtOH all star who presented for nothing more than being found drunk on the street. He had a bit of a medical history, however, so the PA asked me to draw some basic labs. Turns out, in addition to being hammered, the patient also had positive troponin, low potassium, an elevated white count, uncontrolled diabetes, and renal failure. And a broken hand.

Train Wreck #2 also had a splash of EtOH on board, but would suddenly go from happily singing to dropping his head into his box lunch and going unresponsive. Another poorly controlled diabetic, his sugar would careen wildly from 180s following an amp of D50 down to 40 if he stopped sipping his orange juice.

Train Wreck #3 made his third EtOH-related visit in a 48 hour period at the beginning of my shift, got discharged, and returned as a heroin overdose by the end of my night. For whatever reason, treating ODs makes me really sad. Despite this, my patience was frayed as my last hour devolved into a constant game of reinserting the nasal trumpet the patient kept pulling out, and providing repeated sternal rubs to stimulate his oxygen saturation back into the 90s.

Next time I complain about straight drunks, I'll need to remember that it could always be worse.

Shock

It's one thing to read about shock in a textbook; it's another to see it unfold in front of you.

The other night a nurse and I were bringing a critical patient to CT scan to determine the extent of his internal bleeding. When we arrived, he was hooked up to two liters of fluid being squeezed in by pressure bags to keep his BP in the 120s, with a HR of 60.

One line needed to be D/Ced for IV contrast dye, and as the scan went on, I watched as the cuff recycled every 2 minutes to display an increasingly lower BP. With less volume to pump out, the heart tried to compensate by increasing the rate of its contractions.

By the time we returned to the area, both the pressure and HR were in the 90s. Thankfully, we had some O-negative waiting for us, and a surgeon ready to accompany the patient to the OR.

Nothing like the nerdy satisfaction of seeing physiology in action.

Coming Soon: Second Shift, MD!

Breaking news: Over the weekend I was accepted to one of my top choices for their medical school class of 2014!

It has been a long journey to reach this point. I am profoundly relieved, extraordinarily grateful, and still somewhat shocked that somebody thinks I have what it takes to be called "Doctor" in a little over four years from now.

I can't express how thankful I am to the many people in my life who helped me reach this point, nor how excited I am for this incredible opportunity. I know there is a long road ahead, but for the time being, I'm simply savoring the moment.

You Can't Make This Stuff Up

Wow and Wow.

Life in the ER, folks.

Trauma on Ice

Hockey tickets for this weekend!

Back in the day, I used to do EMS standby for hockey games. Now I just sit back, relax, and enjoy the trauma on ice.

You Can't Win Them All

During one particularly busy night (who am I kidding, they're all busy these days), with stretchers lining the hallway and our trauma bay full, EMS radioed in from the scene of a bad MVC with a report of three incoming traumatic cardiac arrests.

What's worse than scrambling to throw patients on portable monitors, playing bumper cars with stretchers to fill every last inch of hallway space, raiding unused monitor leads from exam rooms, spiking fluid bags and hurrying to change suction canisters before the patients arrive?

Finding out that all three were pronounced in the field. Three young kids already so far gone they didn't even make it to the hospital.

Save The Date

You know, I generally try to avoid posting personal information here. I mean, I'm actually kind of embarrassed... but I'm so excited I just have to tell people: I think I finally met the future Mrs. Second Shift.

I knew there was something there from the moment her pinpoint pupils met my gaze from across the ambulance bay. Staring at me through her sweaty, matted golden locks, I could hardly resist the chemistry between us. Listening to her lyrical sense of poetry cleverly employ words that rhymed with "duck," "itch," and "bunt," I realized that this was the one I could bring home to meet the family.

Her finely-manicured fingernails positively shined as she attempted to scratch anyone who came near her. Surrounded by the group of police officers who I hope will attend the wedding, I imagined that I was sliding a ring on her finger while I secured a restraint to her wrist. The spit mask placed over her head even resembled a delicately laced veil shimmering in the fluorescent lighting.

I think we'll try for a spring wedding.

It's The End of the World

Now that the novel-H1N1-pandemic-influenza-type-A-swine-flu-but-not-really-cuz-it's-not-from-pigs-but-apparently-your-cat-can-get-it virus is back from its summer vacation, the Big City ED is seeing its own share of low-grade hysteria.

Patients and visitors are strongly encouraged to wear masks while in the department to prevent transmission. The result? I've seen countless patients wearing masks upside-down, inside-out, covering their chins, covering their eyes, and in one memorable case covering a second mask.

There's also been a large spike in the number of patients presenting with flu-like symptoms, some real and others imagined. If you say you've been experiencing body aches, chills, and fatigue, and your temperature is 102.3˚ and your heart rate a bit tachy, odds are you have the flu.

If you storm the triage desk yelling that you had a 112˚ fever at home and need to be seen, odds are you're full of it. Or already dead.

The Need for AEDs

Last month, I posted an article about a man who died from cardiac arrest while riding a commuter train to Chicago. Like many people, I asked the question why Automated External Defibrillators - required on airplanes by federal law - aren't present on most trains. The Chicago Tribune is keeping attention on the issue, writing how Boston became the first major commuter line to install the life-saving devices on all its trains.

It's time for the rest of the country to follow their lead.

All In The Family

Despite the countless numbers of devoted and loving children, parents, siblings, family members, neighbors, friends and co-workers I've seen flock to the side of patients in the ED, it's always assholes who remain memorable.

Last night I took care of one elderly gentleman who was dropped off by family members at triage. When the left, we assumed they went to move their car, but instead they never came back. They left behind a confused, scared, and sick old man who spoke a language so rare that we did not have an interpreter readily available.

Later that evening, I took care of an older woman who had been stuck in the ED for most of the day. Finally ready for discharge, she gave me the phone number of her son and asked that I call him to drive her home. When I reached him, he told me that he had some "stuff to do" that night, and asked if we could just keep her in the ED until the morning.

I hope that when these two patients eventually die, they come back as ghosts and haunt the hell out of their ungrateful offspring.

No Surprise

Interesting, but not surprising, findings discussed on an LA Times blog today. The post reports on results published in a new study in the Archives of Internal Medicine that looked at ER utilization.

*The median wait time for ER patients increased from 22 minutes in 1997 to 33 minutes by 2006.

*The proportion of ER patients deemed to be suffering from a real medical emergency fell from 26.9% to 18.3% from 1997 to 2007.

*Per capita use of the ER was also up during the same period.

As previous reports have indicated, these numbers aren't driven simply by the uninsured, but stem from a general lack of access to primary care. Of course, I'd add the increasing public perception of the ER as a legitimate source of primary care to the list of casual factors.

Debating the merits of different financing schemes is great - and necessary - but until people have access to their own source of primary care, ER overcrowding will remain a serious problem.

Heads Up

A mind, as everyone knows, is a terrible thing to waste. That goes for the head, too.

Head Case #1 from this past weekend was a young teenager who decided to take a joyride down the highway at 90 mph in the wee hours of the morning. The medic's pictures from the scene - images of twisted metal that once belonged to Daddy's sports car wedged beneath a tractor trailer - clearly illustrated the two or three inches of space that hung between Junior and decapitation. That he survived with little more than a few bumps and scrapes is nothing short of a miracle.

Later in the weekend, two dudes accompanied their bro into the ER requesting sutures status post bar fight. A full two minutes after the nurse finished drawing labs on the patient, the entire department heard a powerful thud echo from the exam room. Turns out Bro #2 wasn't comfortable with the sight of blood and syncoped, landing head first on the hard tile floor.

But by far the best example of abusing one's noggin came from my patient who decided it would be a good idea to get some fresh air by sticking his head out the window of a moving automobile, just in time for his skull to make contact with very immobile traffic light.

Some people would do well to consider wearing helmets.

Fail

In my haste to cut through the clothing of a GSW victim, I sliced right through the IV tubing.

Carbon Monoxide Poisoning

Don't have a carbon monoxide detector for your house? Get one. And while you're at it, make sure to change the batteries in your smoke detectors.

Last year we had someone die from CO poisoning, last night we had an entire family hooked up to non-rebreathers after being exposed at home.

Symptoms of CO poisoning include dizziness and nausea - common complaints that may be mistaken for any number of illnesses. For more information, visit the CDC website.

ER Vocabulary Lesson

bold [bohld]

-adjective, -er, -est

1. not hesitating or fearful in the face of actual or possible danger or rebuff

2. showing your face again in the same ER where you drunkenly vomited and shat all over yourself to demand that the staff dig through the trash to locate the cell phone that you accidentally threw out along with your soiled clothing

Playing Possum

If I were trying to feign a mysterious medical condition to deflect responsibility from speeding through a red light and totaling another vehicle, I might be able to ignore the sternal rub. I seriously doubt that I could fake sleep through the 14g IV insertion. But I am certain that a 22g foley catheter (aka garden hose) inserted into my penis would make me jump off the stretcher.

Props to you, desperate fakeur, for merely flinching.

The Day After

What do you get when you thrown in a few vomit-covered superhero costumes, an aortic dissection, multiple "flu-like symptoms," real police officers passing by "naughty" ones, three septic patients arriving within minutes of each other, several gun shot wounds and stabbings, lots of chocolate, and a whole extra hour to enjoy it?

A special, 13 hour edition of Halloween on the night we gain an hour. Happy recovery!