What A Way To Go

Turns out those warnings to consult your doctor to make sure you're healthy enough for sexual activity featured at the end of those erectile dysfunction ads aren't included just to make teenage boys giggle.

EMS arrived in our critical care area over the weekend with a slightly older male who entered cardiac arrest while in the middle of intercourse with his wife. Thought we had him back for a moment, but ultimately they ended up calling it.

At least he died happy?

Good Samaritan

A drunk man failed in his noble attempt to resuscitate a dead possum on the side of the road. Nevertheless, I feel his efforts should be published as a case report in The New England Journal of Medicine.

Just When You Think You've Seen It All

Woman comes in via EMS after being found eating her own shit.

Bring On the Cavalry

The other night, security had just finished installing a new panic button at the triage desk and decided to test it. These buttons, placed in strategic spots throughout the ER, cause an automated voice to request immediate help at that particular location. When they go off, staff generally drop everything and run to aid a co-worker.

What security did not realize was that a large group of us were waiting to punch out on the other side of the waiting room doors. As soon as the panic alarm went off, a mob of roughly 20 scrub-clad individuals flooded the triage desk looking for trouble.

Said the patient registering with the nurse: "Damn."

Sad

Pleasant, polite, gracious... and ardently suicidal. It was a bizarre scene last night in Bed 4, as I made small talk with a middle-aged patient while irrigating lacerations and cleaning off dried blood.

In perfectly normal tones, the patient expressed disappointment that nobody he knew would sell him a gun, described his excitement at procuring a supply of razor blades, and lamented that fact that his slashing of his wrists and neck were not sufficient to end his life. We also discussed sports and the weather.

And while he appreciated that it was our job to patch him up and try to get him help, he sternly and rightly insisted that we had no idea about the depths of his depression, the profound sense of failure he felt, and his absolute conviction that death would be preferable to life.

It's heartbreaking to find a patient who feels they no longer have any options left. The doctors controlled the bleeding and sutured his lacerations, but he obviously needs a lot more help than that.

Wear Your Helmet

Vomit from a drunk teenager? Not a big deal.

Vomit from a drunk teenager who crashed his motorcycle, throwing his unprotected head against a guardrail, and ended up with several bleeds in his brain and a skull fracture? Big deal.

Wear. Your. Helmet.

Last Memory?

Witnessed cardiac arrest by a physician family member, with immediate CPR. Very short transport time to the hospital. Patient received 3 rounds of defibrillation while alternating between V-fib and PEA, but ultimately didn't make it.

The entire time, the MD family member was present. I can understand why a loved one, especially from the medical field, would want to be in the room during a code. I just don't think it's something I'd ever choose, having that be my last memory of someone. But hopefully it's a decision I'll never have to make.

Going to the Dogs

Everyone knows that you can be treated in the ER regardless of your ability to pay... even man's best friend. An injured dog made his way to a New Mexico ER over the weekend and walked into the department with blood on its nose and a puncture wound to its paw. Reminds me of an old ER episode where Dr. Greene was asked to treat a horse...

Serves Me Right

SS to practically deaf patient: "Does anything hurt you right now?"

Pt: "Huh?"

SS: "Do you have any PAIN?"

Pt: "What?"

SS: "HOW DO YOU FEEL?"

Pt: "With my hands."

ERs and Organs and Transplants, Oh My

Great article from the Washington Post that examines the complicated issues surrounding organ transplantation in this country. A Health and Human Services grant is funding a pilot program in two Pittsburgh hospitals to determine the feasibility and acceptability of transplanting organs from patients who die in the ED.

Personally, I favor a national opt-out policy for organ donation, as opposed to our current opt-in system. Until that change is made, however, I can understand the fear that some patients or family members have of physicians not working as hard to save the life of an organ donor. It seems that the Pittsburgh project has well-designed safeguards in place, but it will be interesting to see how the program unfolds.

Erin Go Bragh

St. Patrick's Day weekend: best spent outside the ER for both patients and staff alike.

Super User

The other day I posted a link to a Slate article that argued ER abuse was as big a problem as it has been presented. It went on to note that a small number of superusers stand out and make the problem appear worse than it is.

Last night was Chest Pain Jane's 21st visit in the past month. She had been seen at Another Hospital earlier that morning for the same pain. And the day before both at her primary care doctor, and the Big City ED. When I asked why she hadn't gone to her PCP again, she became suspicious and upset, and begged me not to call him.

Twenty-one visits in thirty days. All workups negative. It may not be the biggest contributor to the healthcare problem, but it certainly isn't helping.

From the Mouths of Babes

Pt: "I need my pills, man. I lost them or somebody stole them."

SS: "Who would steal your medicine, sir?"

Pt: "Oh, uh, it was a black kid, yeah some black kid. Or the EMTs."

SS: [skeptical stare]

Pt: "Yeah, well, I remember watching all the bottles spill out of my pants."

SS: "You keep your medication in your pants??"

Pt: "Can I have my dilaudid now?"

Much Ado About Nothing?

I haven't yet had the chance to check their figures, but an article Slate.com argues that most ER visits are not as unnecessary as we think. Perhaps the extreme examples of ER abuse that I regularly witness have left me biased.

Poor Guy

Sure, the smell was horrific. The combination of N95 mask, air freshener, peppermint neb treatment, and breathing through the mouth only when necessary didn't touch it.

I wouldn't call the situation pleasant: An older gentleman, his red, scaly legs had swollen to the size of tree trunks, and his feet were wrapped in what appeared to be petrified masking tape. His last reported bath was over a month ago. After an hour spent soaking and trying to cut through his makeshift bandages, we discovered the worst foot ulcers I have ever seen. His sugar was out of control, and as we changed him into a gown a fly escaped from his clothing.

In spite of all that, he was one of the nicest people I've ever encountered. Up until recently, he had family support in managing his multiple medical problems, but that resource no longer available, he had tried to do the best he could on his own. Obviously, it became too much for him to handle. Was he experiencing a life-threatening emergency? Not really, but after so many instances of feeling like I'm running in circles, here was a guy whose quality of life we could actually improve.

In spite of the odor, in spite of the puss and the drainage and fly buzzing overhead, it was a real pleasure taking care of him.

Drop in the Bucket

A patient admitted from the ED last week is now claiming that she had over $1000 dollars on her when she arrived, but that it was somehow gone by the time she made it upstairs. Now sadly, we do lose occasionally lose people's belongings in the ER, but no one who took care of her remembers seeing any money on her, nor was it documented on her personal property form.

At least when I was called in to talk with the manager about it, I could honestly say that $1000 really isn't going to put much of a dent in my med school bills. Now, had there been an extra $200,000 lying around, that might have been tempting.

When You Gotta Go

We have a "quiet room" in the ED that has some chairs, a bathroom, and an area for family members to see their loved one's body. Since people don't die in the ED that often (TV shows not withstanding), most of the time it isn't in use. Just like most of the time every other bathroom in the department isn't in use.

But last night, that wasn't the case. In urgent need for a loo, I popped in to the family room, only to find a middle-aged woman lying on a stretcher. Startled, bladder full, and caught off guard, I stopped and said excuse me.

Of course, being dead, she didn't seem to mind.

Full Moon Madness

The almost-a-full moon was out in force overnight, as absolute madness reigned in the ER.

It was a very long, very busy shift, and I am exhausted after dealing with patients peeing themselves, shitting themselves, screaming, barking, being restrained, and fighting their way through multiple doses of haldol all night long.

What do these people do for the rest of the month?

Extreme EM

From USA Today, an ER doctor reports on his experience providing care in Haiti.

Jinxing It

Nothing seems to stave off a good, messy trauma like preparing for a good, messy trauma.

Over the weekend we received a patch for an incoming stab wound to the neck. With the patient several minutes away, we had time to check suction, prep the airway bag, draw up intubation meds, and even have the tracheotomy tray ready. Of course, upon arrival, the patient's airway was intact and we discovered the knife had barely broken the skin.

Later in the night, EMS radioed in with a gun shot wound to the thorax. Setting up for chest tubes and breaking out the thoracotomy tray again seemed to ward off serious injuries, as the patient arrived relatively stable.

Obviously, the moral of the story is to never prepare, switch off the radio, and scramble around chaotically in a trauma grab bag every shift.

On a related note, it's really not a good idea to smoke illy/wet. I have no idea what kind of high it gives you, but it makes people do crazy things. Everyone knows PCP, but my illy/wet patients have been found dancing naked in the middle of the street, jumping out windows, or this weekend, trying to jam a butter knife into their necks. Pass on the grass, people.