Happy Memorial Day

To all the men and women who gave their lives in service to their country, thank you.

Strong Work

While reading one of WhiteCoat's recent posts, I came across his use of the phrase "strong work," and chuckled. It's a common refrain in the Big City ED (used both sincerely and sarcastically), but whenever I use it outside the hospital, people look puzzled.

Glad to see we're not the only keepers of the sacred word.

You Think EMTALA is tough...

...try drawing the line between treating injured civilians and expending precious military resources in Afghanistan. The New York Times recounts the story of a 5 year old boy bitten by a snake in Helmand Province who managed to survive thanks to the US military. A fitting reminder this Memorial Day weekend to thank our men and women in uniform for their service.

Bad Boys Bad Boys, Whatcha Gonna Do?

The good news: With the number of police officers present in the ED last night to arrest/guard our unusually large population of felony-prone patients, the Big City Hospital was probably the safest location in the state for several hours. We estimated there was enough firepower in the department to repel a small battalion from attacking the ED.

The bad news: With the number of police officers present in the ED last night, I'm pretty sure the rest of the state was subject to mass looting and pillaging.

When I'm Sixty-Four

When I first started working in the ED, patients would frequently comment on how (inappropriately) young I looked. "What are you, 14" was a common refrain.

Today, over three years later, I can proudly state that a patient guessed that I was 17 years of age. Still well below the mark, but at least I appear to have aged the correct amount, and can almost pass as a high school graduate.

At the rate I'm going, I should finally look like an attending by the time I'm in my mid-sixties.

My Future Colleagues

Said the violently drunk college student as he was transferred off the EMS gurney: "I'm pre-med!"

Said the high girl as she trashed about the stretcher: "I'm a nursing student!"

Coming soon to a hospital near you!

Bizzaro ED

With my time in the Big City ED winding down and med school on the horizon, I recently took a trip to check out the institution that will soon be my new home for the next four years. (Spoiler alert: I had a great time!)

During the visit, I was able to shadow in their ED for a few hours. It's a beautiful facility, relatively new and much bigger than where I work now, but it felt like I had stepped into some sort of parallel universe. On one level, everything was the same - drunk patients were yelling, trauma patients were packaged for CT, the waiting room was full of patients anxious to be seen - but every little detail seemed different. Equipment was similar, but from other manufacturers, while protocols, uniforms, and even the local accent were all just a little bit off.

In any event, my next two years will be spent hitting the books, so these were nothing more than interesting observations. Knowing where to find a blood culture bottle is going to take a back seat to locating an obscure anatomical structure.

Still, it was great to peak into the future a bit, and realize that in just a few short months, my med school adventure will finally begin.

Apocalypse Now

Walking past the hospital this afternoon, I passed a gentleman relieving himself in public. Not behind a dumpster, not in some back alley, but literally while walking down the street. Letting it all hang out, apparently enjoying the summer breeze.

I think I just witnessed the end of civilization as we know it.

Suicide

Suicide is truly awful for all involved. Over the weekend, we took care of a patient who tried to end his life by jumping out a window several stories up. His attempt was not successful.

Instead of ending his life, he arrived in the ED with bilateral open tib-fib fractures, a closed pelvic fracture, several rib fractures, and multiple fractures up his spine.

He was in agony.

In the ED, where claims of suicidality are so often used an excuse to spend the night in a hospital bed or to seek attention, the temptation towards cynicism can be great. But for those who truly feel they have no other option than to end their own life, my heart breaks. Often, we're lucky, and ingestions can be managed and self-inflicted wounds repaired. But this gentleman, already clearly suffering, will now go on to endure an agonizing rehabilitation from which he will likely never recover.

Summer Breeze

I'm really going to miss the ER.

We had a very, very rare occurrence the other night: it was slow. As in, nobody in the waiting room. Nobody in the hallway. Empty rooms with nice, clean stretchers and nobody on them. So what did we do?

One of the nurses had his guitar, and we went outside and enjoyed the fresh air of a nice summer evening while listening to music in the ambulance bay. Maybe not everybody's idea of a good time, but for us, it was perfection.

Speaking of Helmets...

Wear one. Bicycle helmets have been shown to reduce the risk of head injuries by 88% and facial injuries by 65%, according to this article from the New York Times. Believe me, it's worth the investment.

Let Them Eat Cake

With my time in the ER rapidly approaching an end, some goodbyes have already begun. I've developed great relationships with patients and staff alike over the years, and I know I will be sad to leave.

Jose Cuervo, long one of my favorite chronic EtOHers, known equally for his slurred, off-tempo renditions of great 80s power ballads and his nearly 600 visits to the ED over the past few years, sadly has not graced us with his presence lately.

Earlier in the year, I had hoped he would reach the coveted 600 visit mark before my employment came to an end. To celebrate the occasion, I even planned to commission a cake in the shape of the hospital turkey sandwiches he so loves.

Whether he's back in jail or has simply migrated out of the Big City for a while remains to be seen, but it looks like Jose and I won't be able to have our cake and eat it, too.

Head Injury Month

As usual, nobody says it better than the folks at The Onion:

Nation's Bicyclists Remove Helmets For Head Injury Month

MAY 20, 2010 | ISSUE 46•20

CHICAGO—In celebration of concussions, cerebral contusions, and other forms of blunt head trauma, bicyclists across the country removed their protective helmets Monday for National Head Injury Month. "It is an honor for me to commemorate this wonderful, wonderful month," said NHIM organizer John Harris, who made the announcement while simultaneously riding his bike, blasting Danzig-era Misfits on his iPod, and veering wildly in and out of traffic. "It is an honor for me commemorate this wonderful, wonderful month." Cyclists observe National Head Injury Month each May, immediately following their recognition in April of Flailing Uncontrollably Through the Air Month.

Welcome to the ER

I've often thought of what kind of crazy old person I would like to become. Slightly dotty? Borderline offensive? Completely off my rocker?

Thanks to my 85 year old raging UTI patient from last night, I now have a new potential model.

Strong and combative enough that he needed to be restrained, we learned that his entire vocabulary consisted of only two words, shouted at the top of his lungs to anyone who passed by the stretcher, and they rhymed with "cluck you."

We briefly toyed with the idea of leaving him in the waiting room as our new greeter for drug seekers and fakeurs...

Happy EMS Week!

To all the EMTs and medics working on the front lines of emergency medicine, thank you and happy EMS week! We're fortunate to work with some great EMS professionals in the Big City ED, and I'm glad to know they're out there if I ever need them.

For those who haven't, be sure to check out Medic 22 and Ambulance Driver, two of my favorite EMS blogs!

(Also, I don't know if you're still out there EE, but I miss your blog!)

Balance

She came to the hospital to die in the ED. Concerns about inadequate pain management at the nursing home prompted family members to call 911 in her final hours, and EMS delivered her to the critical care area. With agonal respirations and a heart rate in the 30s, she was given medication to make her comfortable, and left to die with her family in peace.

In my experience, patients rarely die in the ED. The majority come in mostly or completely dead, some are stabilized long enough to make it to the unit or the OR, and a very small number truly die in front of you. I always remember the later. At least in this case the woman lived a long life, and died with family at the bedside, even if it was in a busy emergency department and not in the comfort of her home.

After a few years of working in emergency medicine, I still find these experiences among the most difficult to deal with. I know that she was not in pain, and that her family was present, but in an environment where we're always trying to "do something," simply standing by and letting nature take its course can leave me profoundly sad, even if it is the right thing to do.

Maybe it was some sort of karma when, later that same shift, I was asked to bring a very pregnant woman up to maternity. Already contracting and getting ready to pop, Mom smiled while Dad proudly shared the name of his soon-to-arrive firstborn son. I'm not a big, circle of life kind of guy, but it was a nice ending to a long day.

Man's Best Friend Redux

It's not every day your dog decides to bite your nipple off.

My distinctly non-medical family often questions why I would choose to pursue a career emergency medicine, and I usually reply that the ability to deliver statements like the above in a professional context plays a large role.

According to the patient, she was lying in bed, minding her own business when Snoopy decided leap out of nowhere and take a bite out of crime... or at least breast tissue.

She earned bonus points for bringing in the nipple, piercing and all, but sadly her hopes for reattachment were ultimately in vain.

Seniors

The weather is getting warmer, the sun is getting brighter, and graduation season is upon us. Before graduates don their caps and gowns, however, they generally all pass through some sort of Spring Concert/Class Day/Senior Week bacchanalia that inevitably leads a handful to pass through the ambulance bay doors.

The results typically range from the slightly amusing to the tragically trashy and the nearly intubated.

Over the weekend, however, amid the stream of 20-somethings pouring into the ED, a very inebriated septagenarian rolled in shouting obscenities.

Observed the triage RN: "Gives a whole new meaning to Senior Week."

Reasons Why I Love My Job

Walked into the ED the other night absentmindedly whistling the opening bars of the eminently catchy Your Love - "Josie's on a vacation far away..."

Both a doctor and a patient immediately responded by whistling the next part, "Come around and talk it over."

Hole in One

Golf balls: great for putting up ramps and through windmills, less great in the rectum.

Adding Insult to Injury

Sometimes in life, when it rains, it pours.

Take, for instance, the case of a patient who was discharged from our fast track area and promptly hit by a police car while crossing the street after leaving the hospital.

Back in the ER as a trauma patient only minutes after having his original minor problem fixed, he was lucky enough to avoid any significant injuries, but still managed to receive a ticket for jaywalking.

Truth or Dare

Pt: Is it true what they say about ER nurses?

RN: What's that?

Pt: That you're all wild and sleep around?

RN: ...

Man's Best Friend

I've said this before, but apparently the point bears repeating, so I'll say it again: Do not go up against a police dog.

You will lose.

Badly.

Every time.

Cool

Patient arrives in the ED with a non-cardiac related complaint. The nurse goes in and gets the story, the doctors go in and get the story, I go in and get some bloodwork, the patient waits for transport to take her for some imaging studies.

Patient returns from her scan, stating she "feels funny." While hooking her back up to the monitor, the alarms start ringing. Assuming that I'll find jagged green lines caused by artifact, I look up to see V-fib on the monitor, and look down to realize the patient is coding.

Yelling for help, I start compressions. Patient gets tubed, defibrillated, and shocked back into sinus tach. An ICU team arrives shortly thereafter with a cooling unit, dropping the patient's core temperature a few degrees.

Days later, I learn the patient walked out of the hospital with no deficits.

Not a bad day at the office.

Sorry... No We Can't

Patient who was npo while waiting for surgery: "If Obama can pass healthcare, you can get me some water!"

Do Not Pass Go

If for no other reason than the emergency department is an acute care medical facility and not a local watering hole, hospital policy states that intoxicated patients are not allowed visitors.

This remains the case even if one of the patients is "like, totally your best friend in the entire world" and you "just know that she'd, like, really feel better" if you were at her side.

It also remains the case even if, in addition to being a patient's bff, you proudly volunteer in the hospital once a month.

Leaving the hospital, going home, and returning to the ED with your volunteer polo shirt will not, I'm sorry to say, grant you any special privileges.

Put the Camera Phone Down

I'll concede that there is no sign in the emergency department that prohibits taking photos or videos with your cell phone.

There's also no sign in the ED prohibiting shooting people, but we don't allow that, either.

For those who may be unclear, let me spell it out - you cannot take photos of other patients during your ER visit. It violates patient privacy, it's creepy, and I'm guessing you wouldn't be too pleased if a video of you walking down the hallway with the back of your gown open showed up on YouTube.

A Mint Under Your Pillow

Not getting enough of your ER fix in the actual ER? Then travel to Australia where you can stay in the Daddy Long Legs hotel, complete with its own ER-themed room.

"As the name suggests, it has something of a hospital theme, with an X-ray cabinet on the walls and faux blood-spattered canvas curtains. A patient's gown is found hanging up, while the pillows have "Doctor" and "Nurse" written on them. The bathroom comes with a bedpan and a cabinet full of surgical tools."

Sounds more than a little creepy to me, to be perfectly honest.

Saturday Night's Alright for Fighting

Warm weather + weekend nights = trauma.

I mean, what better way is there to celebrate sunshine and warm breezes than by drunkenly pushing your baby daddy down the stairs, or seizing while riding your bike and falling on your head, or getting tazed by the cops while fleeing a robbery, or foolishly assaulting a bigger dude with his even bigger friends nearby, or sticking your fingers in the lawnmower?

My new idea for a public health intervention? Stick everyone in air conditioned rooms and just let them cool off.

Best Line of the Night

Intoxicated patient: "Wait, what time is it!?"

SS: "Almost 9 o'clock sir."

Pt: "Morning or night?"

SS: "Night."

Pt: "Shit... I hate it when this happens. I haven't accomplished anything today!"

What was he planning on, balancing his checkbook?

A Simple Request

Pt: "I got an awful lot of blood on my clothes in the accident. Any chance you could get them dry cleaned while I wait to be sutured?"