Sunday, September 23, 2007

Watch that first step....

I am too tired to do my usual diatribe about the events of the ED. Suffice it to say that the majority of the reports from the EMT's this evening started with the phrase: "Patient went out drinking tonight and then..."
- the patient drove into a tree and crashed headfirst through their front windshield. After all the work-up was complete, the patient was found to have only sustained a bloody nose (refer back to one of my previous posts for rule #1 for drinking and driving: drink enough and you won't get hurt)
- "several unknown assailants" (Two Dudes must be on vacation... again, refer to earlier posts) jumped on several of our patients causing a variety of injuries normally seen on boxers who are on the losing end of the prize match

- the patient got into an altercation at a wedding leading to them being stabbed in the stomach, "really, it's just a flesh wound" lead to an exploration, and when 6 inches of the probe disappeared into the belly tissue, the patient was sent for emergency surgery
- the patients went out and rode their motorcycles which they subsequently crashed requiring the services of our Mercy Flight helicopters, the orthopedic surgeons, the neurosurgeons, and admittance into the trauma ICU
and, our favorite of the evening, of which, believe it or not we had two:
- the patient got into an altercation at a local bar, went outside to avoid a further dispute, and tripped off the curb...

what I want you to realize is that this person is lying FLAT on the bed... the two spots you see on the skin just below his pant's line would be just above the front of the ankle if the foot was in the normal position. And, like I said, we had TWO of these injuries tonight.

... that first step is a doozy!

Friday, September 21, 2007

The Red Bag Sign...

So, last night was drug and alcohol night, and the majority of the patients followed the adage of the Coneheads and "consumed mass quantities."  I was told that most of the local bars run specials on Thursday night and that the local college crowd gets a little rowdy. 

I was also introduced to a new medical diagnostic clue:  the Red Bag sign.  That's when a patient is so drunk or high they're vomiting, so the EMS guys tie a red bag around their neck like a bib so the patient can vomit right into it and not mess up the nice clean ambulance.  You pretty much know the diagnosis and the management as the patient is being wheeled in the door; red bag flopping, or sloshing, just a little as the case may be.

So, while one half of our patients were partying it up and getting rowdy (crashing cars, breaking windows, falling down stairs, knocking on neighbors doors and demanding to be let in to the point of being arrested and brought in by Buffalo PD, etc.) the other half of our patients were depressed and suicidal leading to a mixed bag of drug and alcohol combinations that were each a case study on how to treat overdoses.  Some were just drug A.  Some were drug A + alcohol.  Some were drug A + B.  And several were drugs A - F swallowed down with a good slug of vodka, or beer.  Of course, if you're going to really try to make a statement, you might just be a murder suspect being chased by police through the woods and decide to stab yourself several times in the neck with a hunting knife.  That'll show 'em.

And, speaking of cutting, I did have an 18 year old with cutting scars on her feet:  one of which read, "I love you to DEATH"  Seriously.  Cut into the top of her feet.  When I first went in to examine her, I thought she'd had some sort of accident.  Then I noticed the scar lines seemed to be making some kind of pattern, which I soon understood to be words.  Then I actually got to the point I could read the words.  This on a girl who didn't want any blood work done because needles scared her.  Uh, honey, you let someone CARVE into your skin with something most likely bigger and sharper than a needle.  Hmmm...

As of the time I left, all of the overdose patients were still alive (some despite repeated attempts at offing themselves with drug cocktails), the drunks were detoxing (we usually just let them sleep it off, sometimes needing four point restraints for those that refuse to go to sleep peacefully), the crack and cocaine abusers who were developing paranoid delusions as the night went on were being sent to the psych side, and the drunken 18 year old was being picked up to be taken home by her parents with a stern warning by one of the other ED docs about the dangers of alcohol.

Red Bag Thursday night.  The other must-see event.

Oh yeah, by the way, if you once burned the back of your throat while smoking crack cocaine to the extent that you needed to have a hole cut in your neck so that you could breathe, when you come back in complaining of a sore throat after you, uh, yes, wait for it, smoked crack cocaine again, we're gonna laugh at you.  Really.  Laugh and point.  Mhmm.  

Thursday, September 20, 2007

First Shift, Late Night

Winston Churchill, the Social One, first greeter at the door.

So, I just got home, this morning, from my first "official shift" at ECMC.  I am scheduled for 4 days of nights, and if you've ever worked the night shift, you know the first day is a beast.  Your body is all out of sync.  You're tired, sleepy and grumpy even if you did manage to get a nap in the day before.  I loaded up on caffeine and sugar, courtesy of a Dunkin Donuts Vanilla Coolata which I picked up on my way in.  The buzz kept me going until around 3 in the morning when I finally hit the wall.  Then the barrage of patients kept me going until the end of shift at 7 this morning.

Just some thoughts on last night...

If you're going to start smoking... 7 is a good age to start.  Just start sneakin' em on the back porch of your grannies house with your school mates.  Keep up the habit until you're, oh say, 67.  Add "a couple of 40's" daily to that around your mid 50's and don't see a doctor despite knowing you have high blood pressure.  Come into the E.D. just about the time your blood pressure is 208/100 (btw: normal standard is about 120/60), and you're having problems standing up.  That should be just about right.

The old adage carries true even in Buffalo:  if a young male comes in beaten up, "Two Dudes" did it.  "Just mindin' my own bizness, doc, and these Two Dudes jumped outta their truck and beat on me."  There's a roving pair of hoodlums running rampant in every city in this country.  They're just Two Dudes looking to make some mischief.

If you're going to drink and drive, drink A LOT and you won't get hurt.  Drive that blood alcohol level to 0.446.  That's right, really high.  The legal drinking limit is 0.08 in most states.  For most people, 0.400 has them comatose.  Of course, you also have to remember to not wear your seatbelt and deactivate your airbags.  That way, when you ram head-on into that telephone pole and break the windshield, your body will be just loose enough to not sustain any injuries.  Well, ok, maybe a little injury like a slightly herniated disc in your neck.  No major structures around there anyway.  Nah, no problem.

When you're in the ED and you're asked if you have any medical conditions that might affect your care, say oh, if you're about to be zapped by a gazillion rads of energy from the CT scanner, please say you're pregnant.  That might affect how we manage your care.  Yeah.  That's right.  Just a little thing to remember.

When you're being sedated before a painful procedure, like setting a broken wrist, think of something pleasant and you'll remember that when you wake up.  I told my 15 year old male patient to think of somewhere fun and warm, when he woke up he told me he dreamt of candy and his bed at home.  Happy thoughts!

And, finally... didn't I mention I hate gyn exams... 'nuff said.

Monday, September 17, 2007

The Last Day of "Training"

I finished my last "training/orientation" shift this last Friday at ECMC.  It was a busy 10 hour day.  Officially, today is my start day, but somehow I managed to not be added to the schedule until Wednesday.  So, along with my two day weekend, I have an additional two days to do more personal things:  like unpack and finally stop living in the sea of boxes that has been my existence for the last 2 weeks.

I had several interesting patients on Friday.  One was an example of how a patient can be in the ED all day.  I first saw her at 08:30 and FINALLY discharged her at 18:45 (that's 6:45 p.m. in military time;  for some reason, it's also the language of doctors, along with the metric system, but don't get me started... )  Anyway, when I first saw her, I thought she should have several film studies along with her blood work.  My attending disagreed.  Several hours later, after I had asked to give the patient another liter of fluid since she was so dehydrated, the attending went to see the patient and came out to tell me they agreed with my initial assessment, and that I should order some films. The films showed some concern for bowel inflammation, so a CT scan was in order.  You have to drink contrast material to make an accurate diagnosis, and you can't have the CT scan until at least 40 minutes have passed to allow the contrast time to go through.  So you can see the additional length of time.  She was very polite about it, mostly I think because she said I was the nicest person she had ever encountered in the ED before.  Well, that's a given.. :D

The rest of my patients were a motley mix of:  a schizophrenic patient who had started walking into walls, a patient whose heart started beating in the 140's for no apparent reason, a patient who fell down the stairs and broke her foot (my first splint),  a patient with shortness of breath most likely from the "holes in my heart," and my first "trauma" a heroin addict "my last hit was 4 hours ago but I only drank one beer" who was hit by a car.  What you need to know is that drugs like heroin bind to the same pain receptors as morphine.  But, the high is SO MUCH more intense.  So much so that you actually, what I call, fry out the synapses.  So you need to give these patients HUGE amounts of narcotics to help keep their pain under control.  They get mad and belligerent at you because they're in pain, but then they're the ones who fried out their nerve endings.  So it goes...

Finally, I had my last patient that I picked up in the final hour of my shift.  I figured he wasn't going to take long, as his complaint on the board was "sore throat."  What he didn't tell me was that he was being worked up for stomach cancer.  And, his sore throat wasn't really sore throat but difficulty swallowing because food was taking a long time to go down.  Of course.  He has a big cancer blocking the entrance to his stomach, and food goes down slower as the passageway gets blocked.  All he wanted was some relief so he could enjoy eating something of substance, but even now he is barely able to swallow soup. 

This is the frustration.  That of a complete inability to help someone despite everything.  I could do nothing for this 70-something gentleman who was so calm and gentle in his demeanor.  I know he was sitting out in the waiting room for hours;  waiting his turn.  He didn't have an urgent complaint.  All my other patients definitely were more urgent than him, but I could almost see him sitting in chairs, smiling politely as other patients were called into the ED, and hours later finally getting his turn, only for me to tell him, "I'm sorry, there really isn't anything I can do." 

I didn't say that, of course.  Having been in surgery and having had an aunt who died of esophageal cancer, I knew what could be done for him.  The offer of a surgery to remove part of his stomach and esophagus and create a new path for food.  But, he is 70 and the complication rate is high.  He's already lost 30 pounds in 6 months.  He might be offered a feeding tube to bypass his stomach and give him some nutrition.  But, I more than most understand his complaint.  I enjoy food and can't imagine what it would be like to suddenly not be able to even enjoy something simple like soup.  Imagine a world with no more ribeyes!

But I digress.  His records showed pathology for a serious kind of stomach cancer.  Recent workup showed that it hadn't spread, but still.  There was nothing I could do for this gentle man.  I talked to my attending and informed him of the situation.  Theyrecommended some blood work to check the patient's level of hydration.  It was the end of my shift, and I signed him out to the oncoming resident.  But, before I left, I brought my patient a cold apple juice.  At least he could have one small pleasure as he waited for the results, and for the inevitable, "There's nothing else we can do right now."

Thursday, September 13, 2007

Trial by Fire

I did another "mini" 10 hour shift today at the main teaching hospital:  Buffalo General Hospital. 

I am going to get on my soapbox today and rant about another reason for my dislike of nursing homes.  Why?  One of my patients today was a nice, pleasantly confused almost 90 year old lady who's initial diagnosis was "ischemic fingers."  Ischemic = no blood supply, so I quickly went and saw her only to find that her purple-tinged fingertips quickly turned pink when I put my hands over hers and warmed them.  I waited to see if they would quickly return to purple, but they didn't.  I looked at her other hand.  Nothing significant.  I looked at her feet.  Perfectly fine.
She was unable to answer my question of why she had been sent, by ambulance mind you, to the hospital.  I got the number of the nursing home and called.  I was "connected" to the nursing supervisor's voice mail and left a message.  She never called back.  Finally, her granddaughter showed up saying she had received a message that her grandmother had been sent to the hospital with "blue hands" and needed "a vascular study" to determine why.  When she looked at her grandmother's hands, she said they weren't much different than usual.
My attending and I looked through my patient's paperwork.  No transfer note.  No current admission note.  Finally, one piece of paper stood out:  a patient progress note which stated that this a.m. the patient had "refused her medications and spit them out."  My attending stated that the patient was probably "dumped on us."  He said the staff most likely did not want to deal with her and sent her to the ED.  In the time it would take us to evaluate her, the nursing home staff would finish their shift, and she would most likely return when they were leaving for home.  Seriously?
I do have to admit, she was very well kempt and neater than some of the nursing home patients I have seen.  And, hergranddaughter seem to be actively involved and saw her on a regular basis.  But, just how annoying could an 89 year old be so that you'd send her out?  I almost thought my attending was being fascetious but he proceeded to give me his rant of nursing homes and this one in particular, so I am assured there must be some truth to this.
Anyway.  We drew the usual labs, took a chest ray and EKG to verify there wasn't anything unusual happening and sent her back.  Another learning experience for me.
Today I managed to see 6 patients:  the nursing home lady, a gentleman with an inflammed wrist - most likely gout, another drug reaction allergy, a gluteal (butt) abscess which I almost got to drain but which the surgery intern drained, a gentleman with a bladder infection and dehydration, and finally a very interesting case of a gentleman with kidney damage because of exposure to a high amount of gold who came in because of fevers.  He developed a number of complications because of the medications he was put on which I will have to research since I haven't heard or read about them since med school.  That's it!

Wednesday, September 12, 2007

There's a Reason I Wanted to Do Surgery

O.K. When I was deciding on my specialty in medical school, there were several criteria that I wanted to meet.  One had to do with working in or out of the hospital (I wanted in).  The next had to do with how much clinic I would have to do (little to none).  And, the final criteria had to do with gyn exams.  Hate them, hate doing them, some things in life I don't really want to see on anyone.

So when the time came to decide, surgery was a great fit.  I would be working in a hospital, I would have very little clinic, and, for the most part, very rarely would I ever have to do a gym exam.  And, so it's been for the last 4 years.  I did my last gyn exam as a 4th year medical student in May of 2003.  Until yesterday.....

My home for the next month.

On my very first shift, with my very first patient.  I saw the tag on the board, "Abdominal Pain."  No problem.  I was a surgery resident, and we are well versed in Abdominal pain.  As an Emergency Medicine resident, I walked in the room and met my patient who described a severe pain in her upper abdomen.  No problem.  "Oh yeah, Doc, by the way, the pain actually started in my lower abdomen, well pelvis actually, and now that I think about it, I had unprotected sex about the same time the pain started and could I be pregnant or have an STD?"  Major problem.

Suddenly, I felt like a medical student again.  I went to my chief resident to present the patient, and I had to admit it had been 4 years since I had done a gyn exam.  He was like, "No problem.  Grab the cart, grab some swabs, do a wet mount and I'll show you where the microscope is."   Um, "wet mount?"  I think I heard something about that during my OB/Gyn rotation in medical school, 3rd year...  So, I was walked through the procedure by my chief;  who, by the way, also had to help me with the microscope because I hadn't used one of those since 2nd year histology class.  Needless to say, it was not a very pleasant beginning.

Luckily, it was the only gyn exam of the day.  During the course of the next 9 hours I saw a total of 6 patients.  It doesn't sound like much considering some family practice doctors see 4 - 6 patients an hour.  But, you have to realize that in the Emergency Department a doctor may manage 4 - 5 patients an hour, and they all don't leave within fifteen minutes. 

For example, my first patient had to have a pregnancy test and an ultrasound (the culture swabs I obtained won't be ready for 2 days.)  So, she took about 2 hours from start to finish.  After my exam, I saw my next patient while I waited for patient #1's lab results and ultrasound results to come through.  Pt #2 was very sick and needed constant re-evaluation.  He ended up needing a chest x-ray, CT scan, multiple labs, a cardiac echo and would need admission to the ICU.  I saw him at the beginning of my second hour, it took 4 hours to get all of the labs and imaging studies done, and when I left 7 hours later, he was just being seen by the admitting service in the ICU.  While I was waiting on his work-up studies, I saw 4 more patients:  a musculoskeletal chest pain, a drug allergy reaction, a patient with fluid in one lung most likely from lung cancer, and a 20 something who woke up blind in one eye.  A nice mixed bag of patients.  Like I used to say in med school, "The ED is like a box of chocolates, you never know what you're going to get and some are just plain nuts."

So, this was my first day.  I know I will get better.  I know eventually I'll stop feeling like a medical student and start feeling like a doctor again.  I know soon I will be able to manage more than a patient or two an hour.  And, those gyn exams... I'll just have to take them one day at a time.

Friday, September 7, 2007

That funny smell

Just a random thought.... ever notice how your clothes take up the smell of the last place they were?  I've been unpacking my clothes today and hanging them in their new closet.  I am suddenly aware of a faint odor... not a bad one, just from my last house.  I also notice this when I unpack my suitcase after I've been on vacation.  Just a thought...

That and there's been too much death and despair on Meerkat Manor recently.... follow the CCdN Blog link to get recaps on the episodes...

Tuesday, September 4, 2007

The Hunt for Squirrels Begins

Well, I am in Buffalo.  For some reason, as I stood in the doorway of what had been my home for the last 14 months, this song came to mind.  I really was going to be sad to leave, but to paraphrase as I closed the door on this chapter of my life, I knew somewhere a window was opening....

Heart Hotels - Dan Fogelberg

Well there's too many windows
in this old hotel
And rooms filled with reckless pride
And the walls have grown sturdy
And the halls have worn well
But there is nobody living inside
Nobody living inside...

Gonna pull in the shutters
On this heart of mine
Roll up the carpets and pull
in the blinds
And retreat to the chambers that
I left behind
In hopes there still may be
Love left to find
Still may be love left to find.

Seek inspiration in daily affairs
Now you soul is in trouble
and requires repairs
And the voices you hear at the
top of the stairs
Are only echoes of unanswered prayers
Echoes of unanswered prayers.

Well there's too many windows
in this old hotel
And rooms filled with reckless pride
And the walls have grown sturdy
And the halls have worn well
But there is nobody living inside
Nobody living inside...

if you look closely at the horizon, you can see the outline of the Buffalo skyline