Full Moon Madness

Several studies have been published that find no correlation between the number of psych complaints presenting to the emergency department and whether or not there is a full moon.

I call BS.

Highlights from this week's full moon include:

*Pt complaining of being continuously awake for a 3-day sex binge. Combative and violent, he was placed in restraints and fought off multiple rounds of medication.

*Pt complaining of pain s/p inserting a foreign body into a cavity where it does not belong.

*Pt brought in spitting, trying to bite staff, screaming "I'm going to give you AIDS."

*Pt reading a large print bible down the hall from another patient who claimed to have stolen a rosary while drunk on dollar store mouthwash.

*Pt brought for eval by police after erratically operating her motorized wheelchair - scootering under the influence?

*Immodestly dressed patient found at a college underwear party with big, heaping chunks of vomit in her hair.

When I was little I wanted to be an astronaut when I grew up; now, working an 8 or 12 hour shift in the ER sometimes feels like visiting a completely different planet.

All Dressed Up and Nowhere To Go

Often, when a patient comes to the end of a long illness and is about to die, they seem sense that the end is near. As I triaged a lady brought in by EMS last night, she explained to me how she said goodbye to the nursing home for the last time as the EMTs wheeled her through the hallways. She sighed as she told me about seeing her dead husband, and how she was ready to be with him again. And although her eyes were sad and moist, she seemed at peace.

The only problem - she wasn't dying.

Brought in for an altered mental status workup, the patient had no other major medical problems apart from mild dementia.

It seemed a particularly cruel trick for the mind to convince itself that the end was near, and to live out the remainder of one's days convinced that each one was the last.

Little Shop of Horrors

Walking into a new shift in the ER, you never know what the night will bring you.

After arriving last night, I wandered into the trauma room to discover the result of "arm vs. industrial equipment." Normally these kinds of incidents result in what can effectively be described as ground beef, but in this case the machinery had removed the skin from the palm to the bicep, exposing a remarkably clean view of muscles, arteries, and tendons all doin' their thing.

Later in the evening, an unfortunate older gentleman arrived via EMS. The patient fell at home, where he lived alone, four days prior and had spent the intervening time unable to get up. Covered in his own excrement, it was the ferociously foul odor that finally tipped off a neighbor to call 911. The smell was so bad it even turned a few seasoned ER stomachs. Of course, tragedies like this have a way of occurring only to the nicest people, and the patient was remarkably pleasant while being thoroughly decontaminated.

And then of course there was the guy brought in by police after being found masturbating on the sidewalk.

Couldn't Have Said it Better Myself

Great column from the New York Times that echoes many of the sentiments shared by those working in an ER...

"But even people who have a personal physician are inclined to go to the emergency room when they have a bad sore throat or a persistent cough and are unable to reach their own doctor."

"Thus, you will not necessarily be taken in the order of arrival and you might have to wait a long time — even hours — to be seen by a doctor if your condition is not deemed serious by the triage nurse."

New funding for community health centers "to provide treatment - and, one would hope, preventive care" to patients who currently rely on the ER as their primary access to care.

The article goes on to list several conditions which should lead patients to seek emergency care, and includes a discussion of what to bring - and what to leave behind - when visiting the ER.

None of us in the ER enjoy a full waiting room, and if there were an infinite number of spots available in the department, we would bring everyone back right away. We do the best we can with limited resources, and until there are significant improvements made to the primary care infrastructure, long ER wait times will remain an unpleasant reality.

I'd Tap That

Over the weekend, I helped take care of a critically ill patient. Multi-organ system failure, hypotensive, GI bleeding out of both ends. Needless to say, she required multiple, serious interventions before she was even remotely stable enough to be transported to the ICU.

During the course of her treatment, an ultrasound revealed that she had fluid accumulating in the space around the heart, so I was able to watch a resident perform a pericardiocentesis. Basically, this involves sticking a needle into the patient's chest and drawing the fluid out into a syringe. The resident aspirated nearly 300cc of murky yellow fluid before he was done.

As I watched, I wondered, how could there be any better job? As an emergency physician, you splint fractures, manage airways, suture complicated lacerations, treat heart attacks and ingestions, and, oh yeah, once in a blue moon stick a needle into somebody's chest.

Is this an overly-rosy picture of the profession? Of course. Is the price of admission dealing with the drunks, punks, and skunks that occur with far greater frequency than the truly fascinating cases? Absolutely. But the sheer variety of skills required and of pathology encountered as an emergency physician is pretty impressive.

I've spent the past few years being the low man on the totem pole, catching glimpses into the world of EM while dodging bedpans and abusive patients. With med school around the corner, I can't wait to start moving closer to what I feel to be a pretty great way to earn a living.

How Not to Get a Blanket

Wondering how to make sure you never get that blanket you've been asking for? Just follow these quick, easy steps:

Step 1: Yell, loudly, "Hey asshole... get me a blanket!"

Step 2: Threaten to attack ER staff members if you ever encounter them outside the hospital.

Step 3: Shout louder, with an increased variety of obscenities, racial slurs, and disparaging remarks about sexual orientations.

Step 4: Throw the orange from your box lunch at a nurse while jumping off the stretcher.

That's all it takes! Simply stick to this patented, can't lose technique and you, too, can ensure that you won't receive a nice warm blanket.

We'll even throw in the restraints for free.

Be A Hero, Give Blood

Sure, the surgeons were able to save the life of last night's gunshot victim, but they couldn't have done it without the help of a blood donor. Donating your time to donate blood helps keep people alive. Please consider being a donor! Visit the American Red Cross website to learn more or find a blood drive near you.

Sorry Buddy

With EMS bringing in a woman with chest pain, I proceeded to move a stable patient who was waiting on transport out into the hallway to wait. Nobody likes having patients in the hallway, patients or staff, but it's a necessary evil when you have too many people seeking care and too few rooms.

As I pushed the stretcher, the patient looked up at me, and with a slightly accusatory, slightly pleading voice, stated: "I have really good insurance, you know."

I'm not sure of his intent. Did he think that was the secret password that would lead me to suddenly unlock the plush, VIP waiting area of the ER? That it granted him special access to some sort of executive elevator for bringing patients upstairs? That his insurance meant we'd do the EKG on the incoming women out in the hallway, or better yet, just send her somewhere else?

I explained to him that we treat everyone the same, regardless of insurance. He rolled his eyes.

When You Gotta Go

Finding time to void can seem all but impossible during particularly busy shifts in the ER, and so in many ways I empathize with the Full-Bladdered Ultrasound Tech. When you gotta go, you gotta go.

That said, probably not while you're in the middle of ultrasounding a seriously ill, probably septic patient. And certainly not when you leave the patient in a room which, for no rational reason whatsoever, locks automatically from the inside.

Imagine the charge nurse's delight while listening to the FBUT start off with, "So about that sick patient you sent over..."

On a related note, turns out the guys from maintenance are capable of getting a door off its hinges with the speed of a NASCAR pit crew when given the proper motivation.

Broken Hearts

The other night EMS arrived in the critical care area with an older male, witnessed arrest, defibrillated x 3 in the field. A crash intubation, several shocks, and multiple rounds of meds later, he was pronounced dead and we began cleaning up the body before bringing the family in.

After returning to triage, where I had been working before helping out with the code, I could still hear the heartbreaking sobs of the patient's loved ones. Not long after, the patient's wife arrived at the desk in a wheelchair, complaining of sharp chest pain in between tears.

Brought back to be placed on a monitor, an EKG revealed that she, too, was having a heart attack.

That Explains It

Why would anybody assume that a patient's inability to stand up, ambulate steadily, form a coherent, non-slurred sentence, or pass a breathalyzer indicates that he is drunk?

It was the shoes, not the booze.

My patient tonight coined a new classic: the "shoes made me do it" defense. The staggering, slurring, and sloshing about had nothing to do with the EtOH and everything to do with the allegedly faulty footwear.

Nike's new slogan: Just Drink It?

Oh, Baby

I'll admit that when I first started working in the ER a few years back, I envisioned opportunities to live out some of those dramatic scenes from the TV shows - cracking chests, climbing up on a moving stretcher to perform CPR, shouting "clear!" Infrequent though they may be, I have witnessed all of them at least once in between countless patients complaining of abdominal pains, med refils, or toe pain for the past 12 years.

Now, I can cross another ridiculous, "only in the ER" experience off my list.

Last night, as I was killing time by stocking an IV cart, I saw a nurse run towards the waiting room with our OB kit. My interest piqued, I followed him outside to discover a woman giving birth to her child in the backseat of a car idling in the parking lot.

With the engine running and a small crowd forming at the waiting room windows, a nurse crouched down and delivered the baby as more ER staff poured out into the lot. Having been one of the first to arrive, and thus close to the action, I was able to clamp the umbilical cord before both Mom and Baby were hoisted onto a stretcher and rushed inside.

Talk about a rush. Admittedly, I played a small role in the affair, but it nevertheless remains one of the coolest experiences I've ever been a part of. Happily, both Mom and Baby are doing well.

Needless to say, though, anything else that happened for the rest of the night was a bit of a let-down.

Don't Tase Me, Baaa... I Mean Bro

In the Big City ED, we come across a fair number of characters who have found themselves at the wrong end of a TASER. Most of the time the ED is just a pit stop to get the metal electrodes removed from the patient's skin before they continue on to jail.

While I can honestly say the idea never entered my head, some enquiring mind observed a similar situation and thought, "What if, instead of a patient, it was a sheep high on methamphetamines that got tased?"

Well, now science has provided an answer to that question. The journal Academic Emergency Medicine recently published an article in which high sheep (instead of humans) were tased to determine if the combination of electricity and meth would produce dangerous heart rhythms. Turns out the sheep were just fine... you know, except for being tased at the end of a bad trip.

Know what would be really cool? A combination TASER (to put you into V-tach) and defibrillator (to cardiovert you back to normal sinus). Maybe somebody will test that one out on crack-addicted bunnies.*

(*That's a joke, PETA)

For The Record

Working in the ER provides a lot of reasons to vent, and introduces you to many, shall we say, interesting characters.

Yet complain as we all might, ask most people who work in the ED and I think they'll tell you they at least secretly love their job. Lately I've crossed paths with some pretty wonderful individuals, and it served as a perfect reminder that it really can be a privilege to take care of patients. It only takes a few encounters like these to make all the abuse worth it.

Gym, Tolerance, Laundry

RoidRageRonnie rolls into the ER with a shoulder dislocation secondary to lifting mad weights with his bros in between tanning and laundry.

With the bros at the beside, he's all like, "Whatever bro, I was lifting mad weights. Nah, it doesn't hurt."

With the bros gone, he's all like, "Hey, you guys are gonna give me good shit right? I don't wanna feel it."

With a little versed and fentanyl on board, he's all like, "Give me the morphine, man. Don't let me feel it!!"

With a little more versed and fentanyl on board, he's all like, "That nurse is really pretty. Where's the morphine, man?"

With even more versed and fentanyl on board, he's sobbing, "DON'T LET ME DIE! I DON'T WANNA DIE! PLEASE DON'T LET ME DIIIIEEEEEE!"

With the help of our medical records, we're all like, "Oh he has a history of painkiller abuse. No wonder this is taking so long."

Finally, with the help of propofol, he's all like, "ZZZZzzzz."

With the shoulder reduced and his bros back, he's all like, "Whatever man, they just popped that shit back in."

Going Retro

I've encountered several patients in the ER who request specific medications by name, mostly of the narcotic variety. "I think it's called d-d-d-diluadid? It's the only thing that works for my chronic 20 out of 10 stubbed toe pain."

Last night, however, I took care of an older patient who had been boarding for several hours in the ER while waiting for an ICU bed to become available. Understandably agitated, he yell requests at the staff any time one of us entered the room. Towards the end of his stay, I was treated to a shout of "I CAN'T SLEEP BRING ME MY THORAZINE," and promptly thought of this...

Don't Drink and Drown

It's really not my intention to be a buzzkill, but the return of warmer weather means we're seeing a big increase in preventable visits to the ER.

Party all you want, just don't do it precipitously close to the edge of a body of water with friends too inebriated to get you out.

Deaths like this are just senseless and tragic.

Sweet, Sweet Irony

Patient approaches the triage desk complaining of heroin withdrawal. History of abusing benzos, narcotics, and pretty much anything else he could find.

The kicker? He was wearing a D.A.R.E. tee-shirt.

Cold and Dead

As the saying goes, you're not dead until you're warm and dead. Hence, the hour and a half mega-code last night, as the trauma team employed all its tricks while attempting to re-warm the victim of a boating accident.

Warm fluids through peripheral lines. Warm fluids through a central line. Warm fluids through bladder irrigation. Even (my first time seeing this), warm fluids pumped through an anterior chest tube to be drained by a posterior chest tube. With the patient's core temp continuing to drop (turns out he really was cold and dead), the surgeons brought him up to the OR for bypass, but without success. Despite our best efforts, he'd been down for too long before being rescued, and didn't make it.

On a related note, performing chest compressions for 1.5 hours (even with lots of people cycling in and out) is tough exercise!

The Great Escape

It's been a while since I last hated on nursing homes. Thankfully, this little jewel just came along.

Last night Sunrise Acres Seaside House Community Living Facility Home sent one of their residents to the ED. Their reason?

"Elopement risk."

We watched her for a few hours, she didn't escape, and then sent her back.

True Story

Did you hear the one about the patient with the live ammunition lodged in his head? No, seriously.

The New York Times reports on US military doctors in Afghanistan who removed a 14.5 millimeter high explosive round from the scalp of an Afghan soldier.

Wow.

Bring on the Caffeine

Busy is good. Just like in the ER, if I find that I have too much free time on my hands, I get bored easily. But I've been juggling a lot lately, all good things, and as a result am operating a bit of a sleep debt.

Long day ahead + followed by another night shift = caffeine drip with prn bolus.

It's Not What You Think

A few weeks back, I took care of an older lady who was quite vocal about her displeasure with the care she received in the ED. Sent by her doctor for an evaluation by one of our neurologists, the patient was not happy to learn that the neuro resident was covering the entire hospital, and that she was nowhere near the top of his list. As her wait dragged over several hours, she was eventually moved into the hallway to make room for incoming patients.

Throughout her visit, as I checked on her several times, she became increasingly upset. She explained to me that she had chosen her career over having a family, had earned a great deal of money, and did not feel she deserved to be subjected to the realities of an over-crowded urban emergency room. "I know it's all those people without insurance," she told me, "that are causing me to wait. It just isn't right."

Despite my explanations that, as a major trauma center, we treat anyone who walks through the door, and that most of our patients are in fact insured, she continued to cast disparaging looks at her fellow patients, imply that her wealth entitled her to better care, and mutter about the uninsured.

Well, next time she comes back I'll have some numbers to back up my claims. According to a study published last month, 60% of frequent ER users (the 8% of ER patients who account for 28% of ER visits) are enrolled in Medicare or Medicaid. Only 2% of uninsured adults visit the ER four or more times per year, states the article.

So take that, Mrs. Howell. Turns out those dirty, sick, injured masses you wouldn't deign to share the hallway with are in fact just like you - insured, working individuals who simply can't get an appointment with their regular doctor or are told to get a work-up in the ER.

Insurance doesn't equal access.

Thanks, But No Thanks

Dear (surprise!) No-Helmet Motorcyclist,

I appreciate the thought, really. As a soon-to-be medical student (still can't quite to believe that I'll be starting in just a few months), I love seeing all that I can in the ER before hitting the books for the next two years. And bloody, messy scalp avulsions never get old. So I do appreciate your consideration as I stare into the gaping wound that was once the back of your head, watching the surgeons attempt to suture and staple together the jagged ends of what little flesh remains.

But honestly, I've seen more than my fair share over the past few years. So if it's all the same to you, I'd rather you just wore a helmet next time. Sure, the scratches on the plastic won't be as impressive to show off as your wicked cool scars, but hey - just think of all those brain cells you'll save!

Sincerely yours,

SS

Grandma

Grandma #1, loudly, as we removed her shirt to place her into a hospital gown: "Easy with my tits a-holes!"

Grandma #2, loudly, as she drunkenly kicked a police officer in the chest while being transfered to a stretcher: "I'm gonna F@&% you up!"

Where's the bar of soap when you need it?

Triage Highlights

Direct quotes are often the best way to convey a patient's chief complaint. Case in point: "I ain't got no money for a pregnancy test."

* * *

Need directions to the ER? Call our main number. Do not call to schedule an ambulance to pick you up, to inquire about a patient's medical status, or my personal favorite, call from out of state because you realized that the medication you just took expired two days ago and you're worried you might be dying.

* * *

What you see if what you get. This may come as a surprise, but we do not have a secret stash of vending machines hidden in the waiting room. I know you may prefer a particular brand of soft drink, but sadly, the Big City hospital has apparently contracted with a rival company. This fact will not change no matter how many times you ask.

A Day in the Life

Typical busy night last night - we were short staffed, the lab was backed up, and the waiting room was full of patients who had been there since morning. It certainly didn't help that Nearby Hospital had lost power and we were receiving all their diversions. Working in the critical care area, I was juggling three ICU patients and one little old lady who kept asking for a cup of water every five minutes.

Still, things didn't get bad until the strong winds outside blew the helicopter off the roof. It made a crash landing in the middle of our ambulance bay, but we were thankfully able to get everyone out moments before it exploded in a massive fireball. The patient they were transporting, however, was having a massive MI and required ten rounds of defibrillation and an open thoracotomy before we could stabilize him for the cath lab.

Later in the evening, I stepped outside for a moment to grab some fresh air, and was nearly run over by a car swerving into the ambulance bay. Redirecting them around the still-burning hulk of the helicopter, I opened the rear door to find a woman in active labor. With the baby crowning and no time to call for help, I was forced to deliver in the parking lot. While tying off the umbilical cord with my shoe string, the mother suddenly lost her airway. Lucky I still had my pen on me, as I used it to perform an emergency cricothyrotomy.

After getting Mom and Baby safely brought up to OB, I returned just in time to hear EMS patch from the scene of a crash involving a busload of hemophiliacs. While prepping the trauma bay, I noticed we were out of medium gloves, and headed to the supply room to grab a fresh box. Hot Doctor and Sexy Nurse were in there going at it again, forcing me to slide around them to reach the far shelf. Once all the trauma patients were transfused and safely up to the ICU, I was finally able to grab my thirsty old lady her water and called it a night.

Originally posted April 1, 2009.