Simulate This

Interesting article about medical simulation in this week's New York Times. I've seen and even had the chance to practice on some of these state-of-the-art dummies, and I have to say it's a pretty cool experience. I'm hoping that there will be plenty of opportunities to use this technology in med school.

However, as the column points out, it's one thing to intubate a plastic dummy. It's quite another to tube the combative, uncooperative patient trashing in the stretcher while high out of his mind.

A Piece of Advice

IF you break into somebody's home with the intent to steal things and

IF you realize police are responding and even

IF you decide to make your escape by jumping out of a glass window,

I still wouldn't pick a fight with the police dog. You will lose every time.

Looking for a way to avoid multiple lacerations, a few broken bones, and a trip to the OR to wash dog bacteria out of your knee? Don't burgle.

If a Body Catch a Body Comin' Through The Rye

Don't ever tell anybody anything. If you do, you start missing everybody.

J.D. Salinger, the reclusive author of my favorite novel of all time, passed away today at age 91. He was a gifted writer. He really was.

Deal or No Deal

I've heard EtOHers made some pretty outlandish claims over the years - "I'm best friends with the President of the United States," "I can kick your ass," "I'm not drunk."

But one particularly vocal intoxicated patient from the other night insisted that he had $5,000 on him and that he would use it to pay for an early discharge.

He really did have a wad of cash to use as a visual aide in support of his boasting, but when I went to check his vital signs, I noted with great disappointment that it was made mostly of singles.

It's a real shame, too. I gotta pay for med school somehow.

Counter-Strike 3: Counter Strike With a Vengeance

Unleashing, with righteous fury, an amp of D50 all over a nurse's scrubs is the nuclear option after a series of ice cubes aerial bombardments targeted down the back of your neck as you sit, innocently, at the computer.

Counter-Strike 2: Strike Harder

Four saline flushes, bundled together with tape, make a potent and portable retaliatory weapon against a nurse who sprays a flush in your ear.

Counter-Strike

A saline flush squirted at a nurse's chest is a proportionate response after she draws on your hand with a marker while you chart.

Late Night Musings

She was one of the nicest patients I've had the pleasure to take care of in a long time. During the course of her visit, we chatted about her life, her past jobs, my job, and how busy the ER has been lately. She was engaging, kind, friendly, and a serenely pleasant human being.

Who happened to be stricken with a degenerative chronic condition that left her unable to care for herself. Distressed by her worsening state, and disappointed at the poor quality of care she was receiving at her facility, she made some statements that she did not mean, which necessitated an evaluation from our psychiatrists. Yet throughout her protracted wait, she was never anything but patient, nor did she ever have anything but positive things to say.

I've taken care of sick patients before. Formerly high-functioning adults who had their lives stolen from them by the ravages of crippling, devastating diseases. But for whatever reason, this particular patient shook me, saddened me, angered me. No one deserves to be sick or to die, but her particular situation left me rattled for long after we parted ways.

Odds are that we'll never cross paths again, and that our encounter will fade from her memory, and ultimately mine. But for the time being at least, I find my thoughts returning to her, imagining what her daily existence is like, and ruminating how there's really nothing that I or anyone else can do for her. Maybe that's why I find myself attracted to emergency medicine - you do what you can for those you can help and pass along those that you can't.

But every so often that really doesn't feel good enough.

Nursing Home Fail

[Serene older lady arrives in the triage bay, sitting comfortably in an ambulance stretcher holding a roll of toilet paper.]

EMT: This young lady is here for an uncontrollable nose bleed.

RN: I don't see any blood.

EMT: You can't see the large clots she's passing? The endless stream of blood? That's why the nursing home called 911.

Pt: I noticed a spot of blood on the toilet paper when I blew my nose.

RN: Is that Charmin?

She Can't Take Much More, Captain

The Big City ED has been crazy over the past few days. The hospital has no empty beds, other facilites are sending us their diversion, and our waiting room is packed. And believe it or not, we don't like that.

There are few more beautiful, precious, and rare sights on this earth than an empty waiting room. Yet some patients seem to believe that we deliberately keep it full because we like to be yelled at.

We don't.

If we say that the ER is full, it is. Once you get back and you see the stretchers lining the hallways, every room occupied, and some patients even being treated in wheelchairs, you'll see for yourselves. If we say the hospital is full, it is. Note the intubated ICU players waiting hours in the ER for somebody to be moved (or code) upstairs. If we say that we wish there was something we could do, we do. Several of us have proposed getting some shovels and 2x4s and expanding the ER ourselves.

And if we say that we don't appreciate your nasty tone, we don't. We are honestly doing our best to bring each and every person in the waiting room back as quickly as possible, but sometimes the cough or laceration or even severe abdominal pain is going to have to wait, and wait for a while.

It sucks, we know.

But to paraphrase the USS Enterprise Chief Engineer Montgomery Scott, we're giving you all she's got.

You Win Some, You Lose Some

A few kind words can go a long way in the emergency department.

Last night, as I was pulling out a patient's IV, a family member turned to me and told me I should consider becoming a doctor. "You have a great way of interacting with people," he told me, "you really seem to care."

Whether the fact that both he and the patient were absolutely stark-raving mad cancels out that statement, I have yet to decide.

Still flush with the warm and fuzzy feeling of a compliment, later in the evening I moved on to an intoxicated patient who told me I "could be really mean sometimes."

Oh well, I guess it was a wash.

Table for One

I know this is a sentiment shared by pretty much anyone who has worked in the ER, but doctors who promise their patients that they will either have a bed "reserved" for them, or promise to meet them in the ER should be punched in the face. They're lying to you, patients. Please take it out on them, not us.

Why I Hate Answering Phones

A very popular game in the ER involves seeing who can sit next to a ringing phone the longest without picking it up. Usually I'm very good at this game, but last night I made the mistake of trying to answer several phone calls.

Call #1. Exceptionally loud, high-pitched beeping of a fax being sent directly to my ear lobe.

Call #2. Very muffled, largely incomprehensible voice calling from what I can only imagine to be a combination busy train station/jackhammer testing facility. "Hello hello let me speak hello to doctor taking care of my daughter hello." Sure, let me put you on hold for a moment...

Call #3. "Hello! Hello they just put me on hold hello can I speak to doctor?"

Call #4. Some doc calling about a patient I spent several minutes searching for among the various patient tracking boards in the department, asking different nurses and secretaries about, only to find out they had been discharged hours ago.

Call #5. Another eardrum-piercing fax.

Call #6. "Hi is this 7th floor North medical step-down unit overflow?"

Call #7. [dial tone]

It's going to be a while before I try answering again.

I'm a Big Boy Look What I Can Do...

Medicine Resident Working in the ED: [saccharine sing-songy voice] "Hi there, kiddo. Hey, can you do me a favor?"

SS: [already not liking where this is going] "Sure, what do you need."

MD: "Do you know how to take a patient's blood pressure?"

[Nearby ED resident and nurse start to chuckle]

SS: "Yeah... I think I can handle that."

MD: "Oh, and the other vital signs, too!?"

SS: "Pretty sure I can manage."

MD: "Oh goody goody. Could you check Orth-o-STATIC vital signs on a patient for me? Do you know how to do those?"

[ER resident pretends to drink from water bottle to stifle laugh, chokes on water.]

SS: "I'll do my best."

For the rest of the night, any requests made by the ER doc or nurse came in that same, high-pitch babytalk voice. Medicine Resident was even more impressed when I proved I could walk, talk, chew gum, and get accepted to medical school at the same time.

Suicide is Not Painless

Of all the terrible cases to make their way into the ED, suicides are among the most tragic to deal with.

Over the weekend I took care of a gentleman who decided to take his own life. Found by EMS in his home, the patient had a shopping bag full of prescription pill bottles, whose contented he had poured into an empty milk gallon. He swallowed nearly all of them.

By the time I started taking care of him, he looked sick.* Eyes half open, he was either shivering from his hypothermia or seizing from his completely FUBAR lab values. Diaphoretic, he had soaked through his gown and sheets. We managed to get him up to the ICU without incident, but he coded and died within half an hour of arrival.

Suicide is terrible. For the patient, for their family and friends, and certainly for those of us in the ER.

*ER sick - aka ready to die.

The "Right Stuff"

Great article from the New York Times this week about re-thinking the seemingly all-important MCAT. Like every other pre-med, I suffered through months of flash cards, prep books, and practice exams with the fear that a bad score would tank my application.

Given the wide range of pre-med backgrounds, some sort of objective measure is necessary, so I don't believe the test will be going away in the foreseeable future. That said, I know people with incredibly high MCAT scores who I wouldn't want anywhere near me in a white coat

Testing how people respond to stress and how conscientious they are to others in addition to their mastery of organic chemistry seems like a promising direction. I have no doubt that, if this kind of test is adopted, a whole industry based on "coaching" agreeableness and openness will crop up. But it does speak to the recognition that there's more to medicine than the memorization of different SN2 reactions.

How Original

Congratulations, Jim Beam. In the relatively brief but illustrious history of American emergency medicine, you are the first patient in any hospital ever (a tribute to your cleverness, no doubt), to conceive to call 911 from the emergency room.

We, the staff of the Big City ED, who entered our professions in the hopes of preserving life and limb, in conjunction with 911 Emergency Services, who felt called to a similarly noble purpose, truly appreciate both your wit and charm.

I'd also like to give you mad props for correctly discerning that the reason I asked security to restrain you was not, as I publicly claimed, because you threw a large and heavy object at my face, but my secret and deep-seated racially-motivated bigotry.

How Could I Possibly Misunderstand You?

During a particularly hectic shift...

MD: "Can you find me a [what I heard as] SANtimeter measure?"

SS: "I'm sorry, I don't know what that is."

MD: [looking at me like I'm dumber than dirt] "A SANtimeter measure."

SS: [scratching head] "SANtimeter... SANti... CENTimeter? A centimeter measure? You want a measuring tape?"

MD: rolling eyes "Yes."

Next time she wants something, I think we'll have better luck playing Charades.

Strokes Waiting to Happen

Four patients over the course of a twelve hour shift last night with blood pressures in the 200s over 100s.

All of them were diagnosed with hypertension, and none of them were taking their meds. Two had diabetes, three were obese. Individually, these are all major risk factors, but when combined they put you at an increased risk for a wide range of bad outcomes.

Another one of my patients was a teenager who had already experienced a CVA.

I know from personal experience how difficult, annoying, and expensive taking daily prescriptions can be. Recovering from a stroke would be worse. Please, especially if you have high blood pressure, take your meds!

Grab and Go vs. Stay and Play?

Interesting article out of Baltimore this morning that discusses the benefits of spinal immobilization. It cites a study that concluded victims of penetrating trauma were twice as likely to die if they were boarded and collared than those who were not, an effect attributed to the delay in transport to the hospital. I'm sure EMS bloggers will have more to say on the subject, but it just goes to show you that policy and protocols are always evolving.

Good Grief

Sometimes the general air of incompetence becomes too much to handle.

Ultrasound tech called the ER because the patient we sent still had pants on. Rather than pull them down for the scan (or, even more brazen, ask the patient to do it himself), I needed to cross the hospital to perform the 5 second task.

Our ER Xray called Charge because an empty stretcher had been parked so that it partially blocked their entrance. Could they move it themselves? Of course not.

The floors either don't have room, and refuse to take report as we're up to our necks in patients, or complain because we send them two patients in a 45 minute period. Transport can't move anyone because they only have two people and both are on break.

Working in the ER is hard enough with the overcrowding, under staffing, broken equipment, and nonstop surge of patients. Dealing with piss poor attitudes from the rest of the hospital certainly doesn't make it any easier.

Heal the Sick

SS: "Do you have a primary care physician, sir?"

Johnny Walker (gracing our presence after his recent release from jail): "Jesus."

SS: "Oh. Where are his offices located?"

JW: "Upstairs."

You may be a chronic EtOHer and repeat offender, Johnny, but you are a clever son of a gun.

Tighty Whities

After chuckling at KeepBreathing's post about his tough guy patient sporting lacy leopard print knickers, I headed to work last night. While striping the sheets off an empty stretcher, I found a plastic shopping bag buried under the blankets. I opened the bag to discover a brand new, still sealed 4 pack of underwear that the patient had left behind. Maybe they were a gift for KB's dude?

Small Favors

This lingering, weeks-long sinus congestion has given me few reasons to celebrate lately. Yet while changing the sheets of a patient with a GI bleed four times in a one hour period last night, I was extremely grateful my sense of smell was severely compromised.

To Be Real

While making my rounds to vital my patients at the beginning of my shift last night, I came across an older, slightly unkempt-looking gentleman who struggled with opening the box lunch container. I helped him pop open the plastic, and as I checked his blood pressure, he asked me in a weary voice if I knew when he could go home. He had asked at least three different people, he told me while shaking his head sadly, but no one had given him an answer.

I told him that it was change of shift, but that as soon as the nurses finished giving report I'd find out what the plan was. I also grabbed him a blanket and a pillow to make him more comfortable. As I turned to leave, he grabbed my hand and thanked me for being "a real person." Patting myself on the back for providing good patient care, I felt happy to be a "real person" who treated my patients with respect and tried not to let them get lost in the shuffle.

It was only during my next encounter with the gentleman that I realized that the patient had a history of psych issues, and thought that 50% of the population were aliens.

Thank You For Choosing the Big City ED

Arrived in the ED before the start of my shift last night, and before I had even taken off my gloves, let alone punched in, I received my first F@$% YOU of the night from the charming gentlemen sporting 4-point restraints and the striking scent of eau de stale urine.

Thirty seconds or less from arrival? I'd say that's a new record for me!

Poker Face

Pt's young child: "Eeewww, Mommy, he's got spots on his pants! Did you pee your pants?!"

[Looking down at my scrub pants, whose undried water splashes were the result of vigorous hand-washing consistent with the hospital's hand hygiene best practices, with a mixture of chagrin and amusement]

Second Shift: "No."

Bad Romance

The other night, in the middle of a particularly chaotic shift, an attending asked me to pull the IV on a patient awaiting discharge. Grabbing some tape and gauze, I found the patient (not one that I had been taking care of) parked on a stretcher in the hallway.

"Hi Ma'am, my name's Second Shift, I'm one of the techs. The doctor asked me to pull your IV out so we can get you out of here and on your way home." Rather than expressing the look of relief that usually accompanies discharge, the patient instead reacted as if I had told her that I hate both puppies and rainbows.

Now, patients generally don't bring their A-game to the ER*. They're sick, scared, high, or hurt, and often frustrated about being stuck in a place they had not planned on visiting. Working in the ED, all the madness and morbidity is part of our daily routine, and at times it can become easy to forget the patient's perspective.

Nevertheless, while the patient inferred that "get you out of here" meant that I would be rolling her to the ambulance bay and pushing her into oncoming traffic, that's certainly not what I intended to imply. The patient became slightly agitated, demanding to know what doctor had decided to "throw her to the curb" and why "no one had told her anything." Despite multiple attempts at explaining the doctor was printing discharge instructions and on his way to explain her diagnosis, she would not calm down.

In retrospect, was my word choice overly-casual? Perhaps. Could it simply have been the last straw in what apparently had been a long an unsatisfying ER visit? Probably. Do I think the situation was a bit of an over-reaction? Yes. Should I be more on guard when approaching patients that aren't mine? Definitely.

I generally develop good relationships with my patients, so this episode was more surprising than anything else. I suppose I should be more careful in how I phrase things. In the meantime, though, I won't be expecting any gold stars from Press Ganey.

*The notable exception, of course, being the drug seekers, fakeurs, and people who literally have nothing better to do with their time than chill in the waiting room. They always give one hundred and ten percent.

Bottoms Up

I'll be the first to admit that there are plenty of stories of me making a fool of myself in the ER.

Back when I first started as a volunteer EMT, there were also a handful of embarrassing mishaps. I still cringe when I remember how I nearly fumbled a backboard with a patient strapped to it.

But at least I never planted my bum over a patient's face like this medic...

A New Record

I've seen more than a few lightweights drink their way into the ER, and I've babysat many of them as they sobered up in the drunk tank.

With the cold weather in full blast, it's not uncommon for patients to spend most of the night sobering up where it's warm.

But this weekend was my first experience triaging a drunk kid around 0100 (careful to avoid the vomit remnants in his stubble), only to find him still mostly out of it when I returned the next afternoon.

Spending 16 hours sobering up on a stretcher in a hallway is certainly one way to ring in the new year.

Auld Lang Syne

Happy New Year everyone! Many thanks to everyone who visited this blog over the past year. I wish everyone a wonderful 2010, and good luck on those resolutions!