Finale

Looking back, it's funny to realize that my interest in emergency medicine began with a flyer for an EMT certification course. In the years since pausing at that random campus bulletin board and thinking, Hey, that could be interesting, I've learned a lot, while simultaneously realizing how very little I know. But somewhere between taking care of trauma patients and listening to drunken renditions of '80s power ballads, I realized that this is what I want to do with my life.

And in just a few short weeks, through incredible good fortune and thanks to the support of my family and friends, I'll move even closer to that goal by starting medical school. Unfortunately, the trade off means that my time in the Big City ED, and the stories that came with it, must come to an end. I'm really going to miss the wonderful people I've worked with over the years.

I'm sure med school will produce one or two amusing stories of its own, which I may try to post from time to time. To everyone who has stopped by this blog, thanks for reading. It's been fun.

A Match Made in ER

She certainly was a keeper. Vomit covered hipster plaid shirt, mouth agape with spit/drool leaking out, glasses askew, head propped up with pillows to prevent falling into the emesis basin. A definite 10/10 hottie.

Which is totally why I wrote my number down on the nasal trumpet before inserting it through her nostril to help maintain her airway. That way when she sobers up tomorrow morning and pulls it out, she can call me, and our courtship can officially begin.

Rough Start

Watching the charge nurse running down the hallway, pushing a crash cart in one hand and yelling into a phone held in the other is never a good thing. Minutes after I had punched in, I followed the commotion to a cramped exam room, where an elderly patient who presented with shortness of breath had suddenly gone into cardiac arrest.

Crammed into possibly the smallest room in the department, we had senior resident at the head of the bed intubating, a tech on one side doing compressions, a nurse pushing meds, another nurse documenting, the attending shouting orders, another tech standing by to relieve compressions, respiratory elbowing through to set up a vent, an intern attempting to start a central line, and another nurse prepping drips.

The patient, who not an hour earlier had walked into the ER, was lying on the stretcher with clear plastic tubes sticking out of her mouth, both arms, and groin. The attending suspected a PE and ordered thrombolytics, which meant by my turn for compressions, blood spilled out of the ET tube, and splattered over my arms and face shield while RT suctioned. Shocked twice with no success.

An hour later she was pronounced, and, covered in blood and drenched in sweat, I shuffled out of the room with the rest of the team, listening to the patient's daughter sob in the chaplain's arms down the hall.

Not the best way to start a shift.

Sad, But True

Over the past five years, ER visits for prescription painkiller abuse is up 111% according to new figures from the CDC, as reported by Reuters. Oxycodone alone caused over 105,000 visits, an increase of 152% over the same period.

Clearly, there is no easy solution to this problem. Substance abuse problems destroy lives - a fact lived over and over again in ERs across the country. At the same time, painkiller abuse ties up ER beds and adds to healthcare costs. I don't have the answer, but hopefully there are people much smarter than I am working on this issue.

Magic Spray

Working at a Level 1 trauma center has introduced me to many kinds of life-saving equipment. The ER staff is quite versatile with rapid infusers, thoracotomy trays, and Glidescopes, among other things.

What we don't have is Magic Spray.

Magic Spray, for those who aren't glued to the World Cup every four years, is an apparently miraculous compound liberally applied to footballers following a seemingly agonizing injury. After rolling around in the fetal position in an attempt to draw a foul, the players are escorted off the field by medics who whip out their trusty aerosol cans and suddenly return mobility to the lame.

So here's my question: if it works for the fakeurs of elite international soccer, why don't we try it in the ER?

Pain in your knee for the past 10 years that you decided you could no longer handle at 0330 in a Saturday? Well, we're not going to prescribe you narcs, but if you step back here for a second and - don't tell anybody - we have a little something something that's all the rage among European athletes.

Then a quick spritz of ethyl chloride, or lidocaine, or norMAL SALine, or whatever, and send them on their way.

GOOOAAAALLLL!

Good Idea

Pt: "I've been feeling a little off for most of the day, and finally decided to get checked out. Better safe than sorry, you know?"

Turns out it was a pretty good idea. No chest pain, but EKG showed a MI and iStat troponin came back hugely positive. Rushed up to the cath lab and ended up doing pretty well.

There are plenty of BS complaints in the ED, and plenty of people who feel sheepish coming to the emergency room for what turns out to be a negative work-up. I wish there was a simple way to predict in advance what's emergent and what isn't, but cases like these prove that it really is better to be safe than sorry.

You Know How To Breathalyze, Don't You?

Just pucker your lips and blow.

At least that's how we tried to explain the process to the extremely intoxicated teenager who arrived in the ER covered in vomit over the weekend. Poking him with the straw, I asked him to blow out like he was blowing out a candle.

Eyes still mostly closed, head perked up a little, he affixed his lips to the straw, but rather than blowing out, he started sucking.

Hard.

Said the medic, "Not that kind of blow," as he continued to go to town.

I half expected the breathalyzer's LED screen to light up a smiley face as it got more action that night than any of the rest of us.

Extreme EM

From the New York Times, another article detailing the incredible job performed by Medevac teams operating in Afghanistan.

This Just In

BLACKHAWKS WIN!

Playing the Odds

Every so often, the stars align and I'm lucky enough to work with great nurses, great doctors, and great patients. Two out of three ain't bad, and even just one out of the three can usually get me through a shift. One of the things I love most about working in the ER is the variability, which, unfortunately, means every so often I'll get none of the three. And that can make for a very long 12 hours. When that happens, you suck it up and remember that things can only get better tomorrow.

Stomach Pumping

It may be ugly, but it's effective.

Using an Ewald tube, also known as stomach pumping, isn't all that common. For ingestion patients, activated charcoal or a nasogastric tube are much more popular options, at least in the Big City ED. But after ingesting a full bottle of Tylenol less than 30 minutes prior, our patient last night won herself the tube.

Actually two tubes, if you count the intubation. One of our veteran nurses recounted how stomach pumping on conscious patients was fairly common back when she first started. I'd prefer the etomidate and sux myself.

The Ewald tube resembles a clear plastic garden hose which is inserted through the mouth and advanced into the stomach. Even with the patient sedeated, it didn't look pleasant. Saline is rushed into the tube from a large bag suspended from the ceiling, filling the stomach with water, which gravity then drains out to an empty bag.

At least the pill fragments rushing through the tube looked much better in the bag than in her liver.

Trauma On Ice

Chicago Blackhawk Duncan Keith after losing 7 teeth in one game.

Not sure how many other rabid hockey fans there are out there, but with the Stanley Cup Finals now tied up, this article about hockey doctor stories is pretty timely. Not exactly stories from the emergency room, but close, and equally (if not more) awesome.

Known Unknowns

With just over two months to go, I'm getting pretty excited about starting med school this fall. Excited, and at times, a bit terrified. The sheer amount of knowledge I'll be expected to master, and the responsibilities that come with it, can feel pretty intimidating.

With those thoughts in mind, I have to thank one of our residents (we'll call him Roy G. Biv, MD) for allaying some of my fears. To be fair, Roy's a very smart guy, a very nice guy, and a good doctor. He just cannot function in the ED, which is unfortunate given that he is completing a residency in emergency medicine. Easily overwhelmed, Roy tends to get flustered quite easily.

So I'm assuming it was the stress of juggling multiple patients, and not temporary color blindness, that prompted him to open the IV cart, remove on of the blood tubes, walk over to me, place the tube in front of my face and ask:

"Is this a blue top tube?"

Yes, there are several colors of tubes to choose from, but we're not talking about a Crayola box of 120 crayons. I could have been a smartass and argued that it appeared to be more of a ciel or even robin egg blue, but instead I simply confirmed that the tube was, in fact, blue. As opposed to red, pink, green, light green, gray, or any of the other non-blue-colored tubes we use.

I may be terrified at how much I have to learn going into med school, but at least I have my colors down.

Tough Old Bird

"My pain? Try 20 out of 10, man. I stubbed my toe real bad!"

"I twisted my knee last month and it really hurts and I can't walk, so I decided to come in at 0300 because I lost my pain med prescription."

"I was in a minor fender bender 10 years ago that left me with chronic, debilitating, whole-body pain that only responds to Dilaudid."

Needless to say, we get statements like these all the time in the ED. And, sadly, over time they can make you a little skeptical about patients overstating their actual level of pain.

So imagine our surprise last night when a very poised older lady walked up to triage with an obviously dislocated shoulder and calmly asked if a doctor might take a look at it. Apparently she fell in the morning, but managed to finish packing her bags, board an airplane, fly to the Big City, and return to her home before deciding that she might need some fixing up.

When asked how bad her pain was, she replied, "Oh, not awful. I've had worse." She initially refused pain meds for the reduction, and didn't even wince as the intern tugged, pulled, and rotated her arm back into place.

Badass, Ma'am. Badass.

Oops

Well, it took me a few years, but I finally dropped my first blood tube and sent blood glass flying all over.

The slow clap initiated by my colleagues was a nice touch.

Looks like my plans to start juggling blood culture bottles to entertain waiting patients will be put on hold indefinitely.