Trauma on Ice

USA-Canada gold medal game today. Very glad I'm not working, though I may have to sign in for a heart attack depending on how close the game is...

Dark Horse

In a shocking upset, Sweet Caroline surpassed all expectations as she staggered through her victory lap after winning Best Performance in the Amateur EtOHer event tonight. Fending off surprisingly weak challengers Sweatervest, Snot Rocket, and Ashtray, all lightweight members of Team Frat-tastic, Sweet Caroline sobbed her way to the finish by breathalyzing a whopping 0.165.

Somebody must have been seriously watering down the drinks tonight.

*Bangs Head On Desk*

Pt: "I have a rash."

RN: "Any new foods or medications lately? Have you had this before?"

Pt: "Look, it's not like I've been shot or anything, there's no need to ask me all these questions."

RN: "Ma'am, we need to ask you these questions to figure out how to treat you..."

Pt: "I'm not answering any more questions."

* * *

Pt: "Dude, I've been waiting for hours bro and my asthma is real bad."

SS: "Yes sir, it says here that we called you twice but you didn't answer."

Pt: "Yeah, but I was outside smoking across the street. You should have come found me!"

* * *

Pt: "I have pain in my shoulder and I need an MRI."

RN: "Who said you need an MRI?"

Pt: "My doctor said I need one but he hasn't scheduled it yet."

RN: "Okay... that sounds like something you should speak to your doctor about. It's not an emergency, so there's not much we can do for you here."

Pt: "I'm here because I want to order my MRI. Can't you just give me one?"

Karma?

Now, I would never go so far as to say a patient deserves an injury based on their behavior.

But, when you are so belligerent - screaming, swearing, spitting, throwing punches, threatening to kill staff - after your own motorized wheelchair decided to run you over after you fell out of it at home, I'm thinking karma just may have played a role.

Less Extreme EM

Far from the vistas of Whistler and it's state-of-the-art mobile medical clinic, Vancouver ERs are seeing a spike in patients with injuries that aren't caused by rocketing down a ski slope too quickly. According to the Vancouver Sun, St. Paul's hospital treated 200 more patients than usual this week, mainly due to alcohol and alcohol-fueled assaults.

I can only imagine what might happen should Team Canada win gold in hockey.

Ten Minutes Or Less

Patients in the ER often complain to me about their extended waits for things like specialist consultations or imaging procedures. In those situations, I try to explain that we are at our best when you are at your worst. Despite its de facto role as a primary care center in today's world, the ER remains designed to handle life-threatening emergencies.

We proved that last night when EMS brought in a middle-aged female shot in the abdomen during a home invasion. In the span of nine minutes from when she rolled through the door, the team placed two IVs, hung a unit of uncrossmatched blood, intubated the patient, checked her body from head to toe for other injuries, had her placed on a portable monitor and vent, and rolling up to the OR.

Those are the patients that don't wait, while the ones with abdominal pain for six months do.

It's unfortunate to be in either category, but despite the waiting, I would still hope to be in the later.

There's An App for That

ER waiting times, increasingly found on highway billboards and hospital websites, are now coming to an iPhone near you. A new app created by hospitals in Connecticut gives waiting times and directions to two emergencies rooms in the state. As one member of ACEP points out, the concern with these types of programs is that seriously ill patients may see long wait times and travel to a farther hospital, not realizing that emergent cases will always be seen first.

Extreme EM

Olympic athletes injured during their events don't need to leave the beautiful views of Whistler to receive state of the art care. The Whistler Polyclinic provides everything from ultrasound to CT scans and MRI.

Should an athlete require more intensive care and weather conditions prevent an airlift out, the mobile medical unit can treat up to 12 patients and has the staffing and equipment necessary to conduct surgery on site.

Pretty cool.

In Which I Become an ER Patient

Halfway through a 12 hour shift in the critical care area over the weekend, EMS arrived with a very sick-looking male in cardiac arrest. As the full complement of a resuscitation team flooded the room, I grabbed a stool and took over compressions.

With elbows locked and my head staring down at the patient, I had an aerial view of the nasty brown secretions exploding out of the patient's mouth as the resident attempted intubation. Closing my eyes, I continued compressions while a nurse ran up behind me to slip a face shield over my ear. I turned, gratefully, as she reached the mask across my face and then *BAM*.

Accidentally letting go of the elastic, she snapped the band straight into my eyeball. I continued with one-eyed compressions until another tech relieved me, and then staggered away still seeing (very blurry) stars.

Per policy, I had to sign in for a workplace injury and proceeded to check my own vitals and register myself in the computer. Got my name on the board, my own chart, and a (thankfully) very brief workout. Turns out I have a nice corneal abrasion, for which I did not receive a single dose of narcotic pain medication nor a box lunch.

Can't wait until I get my Press Ganey survey!

Father Knows Best

In an urban ED, we see a lot of problems associated with substance use. It can be particularly tough when arguments between parents and their children over drug use get out of hand, and someone ends up in the hospital.

Last night, however, the fight was over the drugs themselves. It seems both Dad and Junior really wanted that illy, and neither remembered their lessons on sharing.

Junior ended up winning by pushing Dad out of a moving vehicle.

I think they both could use a timeout.

Do You Want To Know A Secret?

The New York Times health blog has a post up on "7 Secrets of the Emergency Room," which links to more so-called secrets in Reader's Digest.

Most people pass through the ER at some point in the lives, either as a patient or with a patient, so I'm all for educating the public about what to expect.

I am a little nonplussed, however, when several of these tips amount to "don't lie" and "be nice," especially to the people who are working to keep you alive.

Those aren't secrets - it's called common sense.

A Drop in the Bucket

One of my patients last night was an elderly female sent from her SNF for altered mental status. While she waited for a bed to open up on the floors, I heard her crying and went to check on her.

There she sat, sobbing, as she unburdened how much she hated living at the facility, how she feared speaking about her poor treatment for fear of retribution from the staff, how she missed being able to take care of herself, and how she had no friends or family to come visit her.

The standard "we're going to take good care of you," or "it won't be long until they bring you up to a more comfortable bed" platitudes couldn't stand up to that.

So instead I sat and listened to her. And when she stopped and asked if she could have some extra oranges from another box lunch, I grabbed some. I even got her to laugh for a moment as we joked about the food.

But it wasn't long until forgot it all and started crying again.

It sounds terrible, but one of the reasons I think I find myself attracted to emergency medicine is the (relatively) quick patient turnover. Following complicated patients over long periods takes a special kin of person - cases like these are just too heart wrenching.

Bad Moon Rising

Right now, under the Physician Services for Indigents Program, LA county reimburses doctors a whopping 27% of estimated fees for the patients' first three days of care at private hospitals. On Tuesday, county supervisors voted to slash that rate to 17%, according to the LA Times.

"Financing at that level to pay doctors for 24/7 lifesaving emergency care is an insult to the doctors and a further threat to the already-fraying hospital emergency care safety net upon which we all depend," states one supervisor who says he voted for the decrease to prevent a complete loss of funding.

These cuts are prompting fears that emergency departments will be forced to close, and that emergency physicians will flee the state, leaving patients with nowhere to turn.

A lot of press has been dedicated to the shortage of primary care physicians lately. With comparatively low reimbursement in the face of staggering medical school costs, fewer med students are entering primary care than ever before (and as a soon-to-be med student facing hundreds of thousands of dollars in loans, I understand that pressure). A lack of primary care has contributed in large part to our healthcare problems, and forced countless patients to seek treatment in overcrowded emergency departments.

With reimbursement cuts for emergency physicians on the horizon, where will patients have left to turn?

ER Olympics: The Triage Thunderdome

In true Olympic spirit, we of the Big City ED spent the wee hours last night devising a more compelling triage process. In the current system, a patient approaches the desk, explains their complaint, gets their vital signs checked, and is either immediately brought back for treatment or sent to the waiting room.

Clearly, we need more tests of bravery, skill, and endurance.

Under our new proposed guidelines, the following events will be added to the process:

1) A wheel chair race through a course littered with waiting room chairs, used emesis basins, and the random piles of the four or five suitcases certain patients feel the need to bring with them to the ER.

2) A floor exercise, set to music, that utilizes gymnastic skill to most expressively convey a fake seizure.

3) Some sort of parallel bars routine using the stretcher rails.

And finally...

4) A team relay that requires one patient to fill an uncapped urine cup in the bathroom, then hand off the cup as your team races opponents to the triage desk. Least amount of spillage wins.

Now if we could only get Bob Costas to host it...

True Story

While searching for an EKG machine last night, I was stopped dead in my tracks after realizing that a patient's cell phone ringtone was the theme from Doogie Howser. Epic awesomeness.

It went a little something like this...

Extreme EM

From TIME magazine, a photo essay from a Medevac unit tells stories of the brave women and men working to save lives on the front lines of Afghanistan.

Another Day at the Office

Arrived in the ED this weekend and immediately did a double-take as a man in full clown makeup and a patient gown carried his urine specimen cup back to his stretcher.

Shortly thereafter, two guys who had been electrocuted while doing some rewiring arrived in the trauma bay, one with scorched holes in his underwear where the electricity shot through his body.

Of course, being the weekend, it didn't take long for the parade of intoxicated patients to arrive, some spitting and throwing punches.

After helping place one in restraints, I turned around to see a psych patient sprinting down the back hallway trying to escape. His IV ripped out, blood spilled from his hand and trailed in a stream behind him.

Perhaps he was set off by broken fire alarms that went off three times in twenty minutes.

But the greatest fiasco of the evening?

For a terrifying few minutes, we were out of toilet paper.

I Have a Fever...

...and the only prescription is more Olympics. Speed skating and ski jump were great yesterday, and I can't wait for hockey and curling to start!

Winter Reminders

Can't believe it's taken this long for someone to pull an ER winter classic, but last night I saw my first snow blower vs. finger of the season. I have yet to see a finger win. Don't get me wrong - it's pretty cool to watch a doc file down the bone so the skin flaps can be sutured together, but far less cool if it's your own digit being whittled.

And while we're on the topic of winter safety tips, don't forget to check the batteries on (or purchase) your carbon monoxide detectors!

Jersey Shore Chic

Mad props to the visitor of the patient in Bed 5 last night. Despite the cold, despite the snow, this guy was willing to make the ultimate sacrifice to race to the ED as quickly as possible.

That's right, after a full day of gym/tan/laundry, this studly family member rushed to put on his designer jeans, stylish jacket, and gold chains, hastily gelled his hair, and flew out the door without even noticing he had forgotten his shirt.

What were a couple frosted chest hairs when compared to the seconds wasted by covering up his pectorals?

We in the ED salute you, Walking Around Shirtless in the Emergency Room With Your Jacket Unbuttoned In The Middle of Winter Guy. If only Snooki were in Bed 6...

Keep Still!

It seems like common sense to me, but apparently there's a subset of the population that doesn't realize the importance of keeping your arm still when someone has a needle in it.

KeepBreathing has a post up that reminded me of a patient from a while back. After delicately inserting a 25g butterfly into what I swear was his last functional vein, I could only watch in horror as the patient decided to wave his hand wildly to convey his point while speaking with the doctor. Butterflies in the hand may be painful, but I'd much rather have that than an IV inserted in my neck.

Please, if someone has a sharp pointed object inserted into your flesh, do us both a favor and don't move!

Nursing Home Fail

After grabbing a set of vital signs on the pleasant but confused nursing home patient who had just arrived in the ED, I found her chart to document. Glancing at the inter-facility transfer form, I discovered the reason she had been taken from her room, put in an ambulance, and driven across the city in the middle of the night.

The patient, according to the form, was an "elopement risk."

In the ED we work up altered mental status. We work up UTIs. We work up chest pain and shortness of breath.

How exactly did they want us to work up "elopement risk?" Watch her for an hour and make sure she didn't run away?

I Can't Get No Satisfaction

Like many hospitals throughout the country, the Big City Hospital is feeling the pinch of the recession and doing everything it can to improve patient satisfaction in the hopes of retaining its customer base. Down in the ED, we've seen a variety of new initiatives designed to lower waiting times and facilitate rapid dispositions.

Armed with this renewed zeal of customer service, one of the RNs approached a patient who beckoned from the hallway. "Look man," the patient implored, "you guys gotta let me go. I've got a really important meeting to make."

At 0130.

The RN politely explained that while we do everything in our power to send patients home in a timely manner, the fact that the patient was currently dependent on Ativan to prevent his alcohol withdrawal seizures limited our ability to comply with his request.

Stressing the high quality of the crack he was scheduled to purchase, the patient again repeated his desire to be discharged.

Later in the morning, we received a call from the nurse taking care of him after he was admitted to the floor. In yet another effort to secure a rapid discharge, the patient was offering to reduce the amount of time spent waiting for the elevator by insisting that he would simply jump out the window to score his crack.

For our inability to assent to his treatment demands, I'll bet we receive low marks on his patient satisfaction survey.

Are You Ready For Some Commercials?

I'll admit that I'm rooting more for great commercials than either team today, but I hope everyone has a great Superbowl Sunday. Be safe!

There Will Be Blood

Today, countless people are alive thanks in part to a stranger's choice to donate blood. Want to save a life? Visit the American Red Cross website and find a blood drive near you.

Spoiler Alert

Psych Pt: "YOU are going to DIE! We are ALL going to DIE."

SS: "You're absolutely correct. What's your name?"

Pt: "I am Death. I am the Grim Reaper!"

SS: "Which one is it?"

Pt: "Er, Death. No, Grim Reap... DeathGrimReaper! YOU are going to DIE!"

You Spin My Head Right Round, Right Round

Pt: "I was seen her in the ER last week for this problem, but they told me it wasn't a medical emergency and that I should follow up with my primary care doctor. So I made an appointment, but they told me I couldn't be seen for a month. I managed to get in when somebody canceled, but my doctor told me I would need to be treated by a specialist. I had that appointment today, but he told me that I needed blood work and a CT scan, so he told me to go to the ER to get them."

Something about this system almost seems wasteful and inefficient.

A Code in the Night

For the first time in what felt like a very while, there were no patients waiting to be seen at 0330.

My carts fully stocked and the trauma bay empty, I took advantage of the rare downtime to catch up on some readings for class. A nurse at the computer next to me shopped for some new shoes online, a resident and a med student huddled around an EKG looking for ischemic changes, and the sound of some large fans could be heard as the maintenance guys waxed the floors in the back hallway. Even the drunk bigot in the room farthest from the nursing station had finally fallen asleep.

And then the radio crackled for an incoming cardiac arrest four minutes out. A minute later, EMS arrived with a mid-30s male undergoing CPR. Journal articles, Ebay, CNN.com and EKGs were all set aside as the critical care area filled with more staff than was necessary. Nurses started more lines and drew up resuscitation medications, I grabbed the defibrillator pads (does anybody but House use the paddles anymore?), respiratory bagged, and the senior resident checked suction before intubating the patient. We cycled through a few rounds of compressions and meds, giving the med student a chance to practice real-life CPR, but there was nothing on the monitor, no cardiac activity on ultrasound, and no pulse without compressions. We continued long enough for the intern to be guided through a central line insertion, but with nothing left to try, time of death was called at 0352. Unwitnessed arrest, with no information on medical history.

Talking with some non-medical friends the other day reminded me of the emotional and dramatic portrayal of codes on television. In reality, life rarely imitates art. We all took notice of the patient's age, and felt bad that he died so young. We all felt terrible watching the patient's loved ones cry as the chaplain led them to the family room. But then we went back to work.

After cleaning up the body, I stuck around to replace the suction canister, grab a new ambu bag, and throw some new saline flushes in the IV cart. Gradually people drifted back to whatever they were doing beforehand, and resumed the countdown to morning.

Blast From the Past

Having grown up several hundred miles from the Big City, it's really only the occasional drunk student that I recognize in the ED. Last night, however, I had to do a double-take as I realized one of my freshman year chemistry professors had sat down to be triaged for a minor laceration. This guy was a fantastic teacher, and very well-liked by his students.

I don't know what scared him more - that a former student of his was now participating in his medical care, or how overly enthusiastic I must have seemed to him. Either way, it was clear he had absolutely no idea who I was. Regardless, it was still great to see him.

There's a First Time For Everything

I've seen patients vomit in the sink.

I've seen patients pee in the sink.

But I've never seen a patient shit in the sink. Until now.

Do people do this kind of thing in their homes? I really wonder what it is about the hospital, or the ER specifically, that people feel gives them license to act in such seriously strange ways.

The best part was the patient's reaction after I turned to him in shocked recognition and asked if he had, in fact, just shat in the sink.

Pt: "Yeah."

At least he didn't deny it.