Wednesday, October 31, 2007
Happy Halloween!!
Beer meter: zero
Another short shift Wednesday. Today, most of the patients stayed away. Maybe they were busy filling their goodie bags with treats. I don't know. All I do know is I was actually able to think about my patients and their conditions today. Not too busy at all.
Instead of my usual diatribe, and the lack of anything new and interesting patient-wise (by the way, the patient with the possible pseudocyst in his pancreas did have one, woohoo on me for my ability to read "badness" on a CT scan) I will include a link to someone else's diatribe, which funny enough sounds something like my own... but it isn't.... but it could be...
http://www.craigslist.org/about/best/sfo/301345524.html
Monday, October 29, 2007
It's Just Another Manic Monday
Beer meter: 
Ok, so the floodgates opened yet again. The E.D. was FULL of patients and about 50% of them were chest pain patients. And, it seemed like all of the other E.D.'s were full and sending us their patients. There's been news that several E.D.'s in the area will be closing, and that just means more congestion for the E.D.'s that remain open.
Politics aside, my patients for today:
Chest pain - admit with pneumonia - coming in and making demands is not a good way to make friends in the E.D. I love hearing the "why I am not compliant with my medication" stories about how awful their doctors are and how they never give them their prescriptions when they need them; and then, when I call their doctors to admit them, I hear the other side of the story, how the patients don't come into clinic for follow-up appointments, or how they call saying they've "run out of all of their medications and need them refilled today." For some reason I believe their doctor's side. Don't know why, just a gut feeling.
Shortness of breath - admit with COPD exacerbation - COPD = emphysema. Somehow I don't care if you're 92 going to turn 93 tomorrow. You really shouldn't smoke... still. Maybe that's the reason you need to wear oxygen... no smoking with that on, or you'll go up in flames.
Shortness of breath - discharge with upper respiratory infection - I don't care what the bottle says, if it smells like horse liniment it probably isn't something you should take to "clear out your chest congestion."
Abdominal pain - admit with small bowel obstruction - cancer sucks when it happens to really nice people. What sucks even more is being a doctor who can look at a CT scan and go "oh crap that's a BIG tumor." When I was at in medical school, one of my attendings used to make the comment, "All he needs is a script for a cane pole and a six pack" meaning a patient had cancer with no hope. There's always hope, but looking at my patient's CT, I wondered if he'd even have time to hook the worm.
Chest pain - admit to chest pain center - seriously, stop doing the cocaine and the chest pain will stop. Or your heart will. Either or, the pain will be gone.
Abdominal pain - probably will be admitted with a pancreatic pseudocyst - if you're told you have pancreatitis and to not drink and you chose to block out the pancreatitis part and still drink, when you come back again with abdominal pain and you tell me you don't know why, I am going to find out. Electronic medical records are a great thing.
Chest pain and abdominal pain - most likely going to be discharged with nothing wrong except for the fact you haven't been able to get your methadone for the last four days so you're coming to the E.D. for your fix. Oh, and when I ask for significant medical history, telling me you're biologically a man who now dresses like a woman is important so I don't look silly/stupid in front of the nurses when I ask for a urine pregnancy test.
Day off tomorrow. I'm on a strange day on/day off/switch over to the night shift thing for the next week.
Ok, so the floodgates opened yet again. The E.D. was FULL of patients and about 50% of them were chest pain patients. And, it seemed like all of the other E.D.'s were full and sending us their patients. There's been news that several E.D.'s in the area will be closing, and that just means more congestion for the E.D.'s that remain open.
Politics aside, my patients for today:
Chest pain - admit with pneumonia - coming in and making demands is not a good way to make friends in the E.D. I love hearing the "why I am not compliant with my medication" stories about how awful their doctors are and how they never give them their prescriptions when they need them; and then, when I call their doctors to admit them, I hear the other side of the story, how the patients don't come into clinic for follow-up appointments, or how they call saying they've "run out of all of their medications and need them refilled today." For some reason I believe their doctor's side. Don't know why, just a gut feeling.
Shortness of breath - admit with COPD exacerbation - COPD = emphysema. Somehow I don't care if you're 92 going to turn 93 tomorrow. You really shouldn't smoke... still. Maybe that's the reason you need to wear oxygen... no smoking with that on, or you'll go up in flames.
Shortness of breath - discharge with upper respiratory infection - I don't care what the bottle says, if it smells like horse liniment it probably isn't something you should take to "clear out your chest congestion."
Abdominal pain - admit with small bowel obstruction - cancer sucks when it happens to really nice people. What sucks even more is being a doctor who can look at a CT scan and go "oh crap that's a BIG tumor." When I was at in medical school, one of my attendings used to make the comment, "All he needs is a script for a cane pole and a six pack" meaning a patient had cancer with no hope. There's always hope, but looking at my patient's CT, I wondered if he'd even have time to hook the worm.
Chest pain - admit to chest pain center - seriously, stop doing the cocaine and the chest pain will stop. Or your heart will. Either or, the pain will be gone.
Abdominal pain - probably will be admitted with a pancreatic pseudocyst - if you're told you have pancreatitis and to not drink and you chose to block out the pancreatitis part and still drink, when you come back again with abdominal pain and you tell me you don't know why, I am going to find out. Electronic medical records are a great thing.
Chest pain and abdominal pain - most likely going to be discharged with nothing wrong except for the fact you haven't been able to get your methadone for the last four days so you're coming to the E.D. for your fix. Oh, and when I ask for significant medical history, telling me you're biologically a man who now dresses like a woman is important so I don't look silly/stupid in front of the nurses when I ask for a urine pregnancy test.
Day off tomorrow. I'm on a strange day on/day off/switch over to the night shift thing for the next week.
Sunday, October 28, 2007
Wastin' away again...
Funny how when you have several days off, you make all kinds of plans about how you're going to spend your time. I was certain I was going to finally unpack completely, do loads of laundry, organize (and pay) all of my bills, and a number of assorted other household tasks. How much of this did I do....? Not much.
I did clear out the pile of bottles and glasses surrounding my easy chair in the living room. And, I put all the shoes that had accumulated in my living room into a pile at the foot of the stairs. I managed to empty out a few trash cans and made a trip to the dumpster. And, that's about it.
Honestly, I don't know where the time goes. Granted, sleeping in until 10, 11 or even, eek, 12 every single day hasn't helped. But I finally feel more rested. Three days of sitting around, a cat in the lap, remote in one hand and computer mouse in the other, and I feel refreshed. Ready for work again in the morning.
Too bad I can't work from home. When I was working in Boston, one of my co-workers nicknamed me "the Empress." In the ICU at BWH, there's a work area on 8C surrounded by glass and you can stand and see the entire ICU from it. The monitors were hung on a wall just above everything, so you could quickly look up and see any one patient's monitor.
One night I was working the night shift, and he had come over to chat with me. As we sat, several nurses came up to me and told me about their patient's current condition. I could literally remain seated, look over at monitors and type orders into the computer without much effort. From that, he teased me that if I set things up just right I could do all my work from home. I said, give me a computer and enough video monitors and I could rule the world. So he started calling me the Empress.
Hence, the idea of telemedicine. Of course, I'll be able to tell you more about it next month when I do the rotation. Should be interesting... Now I must sleep. Morning will come soon, and with it another set of challenging patients in the E.D.
I did clear out the pile of bottles and glasses surrounding my easy chair in the living room. And, I put all the shoes that had accumulated in my living room into a pile at the foot of the stairs. I managed to empty out a few trash cans and made a trip to the dumpster. And, that's about it.
Honestly, I don't know where the time goes. Granted, sleeping in until 10, 11 or even, eek, 12 every single day hasn't helped. But I finally feel more rested. Three days of sitting around, a cat in the lap, remote in one hand and computer mouse in the other, and I feel refreshed. Ready for work again in the morning.
Too bad I can't work from home. When I was working in Boston, one of my co-workers nicknamed me "the Empress." In the ICU at BWH, there's a work area on 8C surrounded by glass and you can stand and see the entire ICU from it. The monitors were hung on a wall just above everything, so you could quickly look up and see any one patient's monitor.
One night I was working the night shift, and he had come over to chat with me. As we sat, several nurses came up to me and told me about their patient's current condition. I could literally remain seated, look over at monitors and type orders into the computer without much effort. From that, he teased me that if I set things up just right I could do all my work from home. I said, give me a computer and enough video monitors and I could rule the world. So he started calling me the Empress.
Hence, the idea of telemedicine. Of course, I'll be able to tell you more about it next month when I do the rotation. Should be interesting... Now I must sleep. Morning will come soon, and with it another set of challenging patients in the E.D.
Wednesday, October 24, 2007
Short shift Wednesday
Beer rating for today:
Every Wednesday we have several morning meetings. First, we all meet in our individual classes (interns, second year residents, and third year residents) and discuss selected chapters in our Emergency Medicine textbook for an hour. It helps to correlate the science aspect with the clinic aspects of our jobs. Then we have Grand Rounds for about 3 hours. Grand Rounds consists of several lectures, usually themed together, with occasional guest speakers. We then might discuss a clinical case as presented by one of our colleagues (my presentation will be in May '08) or discuss some clinical scenarios.
Our shifts on Wednesdays then don't start until 1400 (2 p.m.). We work until 2100 (9 p.m.). The night shift then comes in and works 2100 - 0700. So, instead of a 12 hour shift, we work shorter shifts on Wednesdays which makes it nice because things just seem to go by a little faster.
My patients this afternoon:
- 80 something with diarrhea for a week = get admitted for dehydration and weakness
- 70 something with abdominal pain = get admitted for pain control of your underlying colon and pancreatic cancer (and, I might just add, cancer patients in my book get all the drugs they want)
- 20 something with chest pain = get admitted for observation in chest pain center
- 50 something passing out after a fall = still getting worked up when I left, but I worry when I read that the patient can't be placed in a normal shelter because he's listed as a "sexual predator" which makes living in most locations difficult
- 70 something with swollen hands = still being evaluated to make sure he's not going into heart failure, he just wanted to eat the same things he ate in the hospital so that his hands won't be swollen
- screaming 50 year old who I was asked to see because she only understood Spanish = would not listen to me when I tried to explain that I don't arrange for housing, I can only take care of her medical needs. From my conversation with the social worker, she's been thrown out of every local shelter around for being annoying and demanding.
Finally, we were signing out patients at shift change (where the on-coming residents take over our patients that are still being evaluated) when one of our own, a resident, was brought in by EMS. I think he was more embarrassed at having to be brought in than by what actually happened to him, but then he's got nothing to fear... we take good care of our own.
Every Wednesday we have several morning meetings. First, we all meet in our individual classes (interns, second year residents, and third year residents) and discuss selected chapters in our Emergency Medicine textbook for an hour. It helps to correlate the science aspect with the clinic aspects of our jobs. Then we have Grand Rounds for about 3 hours. Grand Rounds consists of several lectures, usually themed together, with occasional guest speakers. We then might discuss a clinical case as presented by one of our colleagues (my presentation will be in May '08) or discuss some clinical scenarios.
Our shifts on Wednesdays then don't start until 1400 (2 p.m.). We work until 2100 (9 p.m.). The night shift then comes in and works 2100 - 0700. So, instead of a 12 hour shift, we work shorter shifts on Wednesdays which makes it nice because things just seem to go by a little faster.
My patients this afternoon:
- 80 something with diarrhea for a week = get admitted for dehydration and weakness
- 70 something with abdominal pain = get admitted for pain control of your underlying colon and pancreatic cancer (and, I might just add, cancer patients in my book get all the drugs they want)
- 20 something with chest pain = get admitted for observation in chest pain center
- 50 something passing out after a fall = still getting worked up when I left, but I worry when I read that the patient can't be placed in a normal shelter because he's listed as a "sexual predator" which makes living in most locations difficult
- 70 something with swollen hands = still being evaluated to make sure he's not going into heart failure, he just wanted to eat the same things he ate in the hospital so that his hands won't be swollen
- screaming 50 year old who I was asked to see because she only understood Spanish = would not listen to me when I tried to explain that I don't arrange for housing, I can only take care of her medical needs. From my conversation with the social worker, she's been thrown out of every local shelter around for being annoying and demanding.
Finally, we were signing out patients at shift change (where the on-coming residents take over our patients that are still being evaluated) when one of our own, a resident, was brought in by EMS. I think he was more embarrassed at having to be brought in than by what actually happened to him, but then he's got nothing to fear... we take good care of our own.
Monday, October 22, 2007
Seriously...!?!?!?!
Ok, so I finally finished a five day run of 12 hour day shifts. During this time, I have developed a grading system based on how my day was. It's the beer system. The more beers I feel I have to drink to get over my day, the worse the day has been.
Let us begin:
Yesterday: 1 beer
Today: 3 beers
A lot has been written about emergency departments in this country being used as centers of primary care. That's not what they're intended to be. We are not Fast Food Medicine. We don't take the place of establishing care with a primary physician. But still, sooo many patients come to the E.D. for basic medical care.
Like today. I don't know who opened the floodgates, but just about every patient I saw started their monologue with "I've had XYZ problem for the last week/three weeks/month/two months/six months." As my eyes slowly started rolling upwards and flitting at the top of my head, I would ask, "And, what was different today that made you come in?"
Seriously.
I know I bag a lot on some of the patients that I see, but I think that comes with working in this environment day in and day out.
Some patients I can sympathize with... most are indigent, living in shelters, they don't have a primary care physician and can't get to clinics, etc. on a regular basis. So they don't come in until they are in dire straits.
Shelters are starting to get ready for winter... by closing their doors. Supposedly they are "refurbishing" to be able to handle the increased numbers that will soon be arriving. So, the E.D. gets a lot of those people who are just looking for a place to sleep and be safe for a while. We even had one person ask, "If I say I am suicidal, can I get a room?"
A lot of people know how to beat the system. If you walk into the E.D.,chances are you will be triaged (sorted according to medical severity) and then sent to chairs to wait your turn. If you call an ambulance, you will be wheeled into the E.D. on a stretcher and most likely get a room somewhat faster. So, therefore, we get a HUGE volume of ambulance patients. But, on days like today, sometimes they get evaluated and sent to sit in chairs... and, they're usually not happy about it.
So then they get to know all the buzzwords that guarantee that they will get a bed sooner rather than later: words like chest pain, shortness of breath, chest pain and shortness of breath, substernal chest pain that radiates to my neck and arm. Really, sometimes it's like listening to a case from one of our medical textbooks. The patients get very savvy about using some medical terminology that will assure that they will be seen expediently. Then, once they're in a room, they start saying, "Oh, yeah, by the way, can you check my...." AND, "how about some pain meds and a box lunch?" Yes, they know we have a supply of sandwiches and milk kept in the E.D. refrigerator. They even know what kind of juices or sodas we keep.
So, we run lots of expensive (and sometimes unnecessary tests) because legally we can get sued if it's noticed that a patient came in complaining of something that wasn't addressed on their chart. Yes, folks, your tax dollars at work.
Officially, I have a day off tomorrow. I have a 1/2 hour meeting in the morning that will eat up about 2 hours of my time, but I am off, finally... now where did I put that six pack...?
Let us begin:
Yesterday: 1 beer
Today: 3 beers
A lot has been written about emergency departments in this country being used as centers of primary care. That's not what they're intended to be. We are not Fast Food Medicine. We don't take the place of establishing care with a primary physician. But still, sooo many patients come to the E.D. for basic medical care.
Like today. I don't know who opened the floodgates, but just about every patient I saw started their monologue with "I've had XYZ problem for the last week/three weeks/month/two months/six months." As my eyes slowly started rolling upwards and flitting at the top of my head, I would ask, "And, what was different today that made you come in?"
Seriously.
I know I bag a lot on some of the patients that I see, but I think that comes with working in this environment day in and day out.
Some patients I can sympathize with... most are indigent, living in shelters, they don't have a primary care physician and can't get to clinics, etc. on a regular basis. So they don't come in until they are in dire straits.
Shelters are starting to get ready for winter... by closing their doors. Supposedly they are "refurbishing" to be able to handle the increased numbers that will soon be arriving. So, the E.D. gets a lot of those people who are just looking for a place to sleep and be safe for a while. We even had one person ask, "If I say I am suicidal, can I get a room?"
A lot of people know how to beat the system. If you walk into the E.D.,chances are you will be triaged (sorted according to medical severity) and then sent to chairs to wait your turn. If you call an ambulance, you will be wheeled into the E.D. on a stretcher and most likely get a room somewhat faster. So, therefore, we get a HUGE volume of ambulance patients. But, on days like today, sometimes they get evaluated and sent to sit in chairs... and, they're usually not happy about it.
So then they get to know all the buzzwords that guarantee that they will get a bed sooner rather than later: words like chest pain, shortness of breath, chest pain and shortness of breath, substernal chest pain that radiates to my neck and arm. Really, sometimes it's like listening to a case from one of our medical textbooks. The patients get very savvy about using some medical terminology that will assure that they will be seen expediently. Then, once they're in a room, they start saying, "Oh, yeah, by the way, can you check my...." AND, "how about some pain meds and a box lunch?" Yes, they know we have a supply of sandwiches and milk kept in the E.D. refrigerator. They even know what kind of juices or sodas we keep.
So, we run lots of expensive (and sometimes unnecessary tests) because legally we can get sued if it's noticed that a patient came in complaining of something that wasn't addressed on their chart. Yes, folks, your tax dollars at work.
Officially, I have a day off tomorrow. I have a 1/2 hour meeting in the morning that will eat up about 2 hours of my time, but I am off, finally... now where did I put that six pack...?
Saturday, October 20, 2007
The Bigger They are the Harder They Fall
I saw a fair number of patients today. It was actually not as stressful as it's seemed the last two days. I think it has to do with the attendings and the patient load. Both "lightened up" a bit today giving us some breathing room for the patients we did have... and they were a very interesting mix indeed.
For a moment, I actually thought "Crash and Burn" would be a better title, but the two most memorable patients during this shift were of the, shall I say, larger portion of the population. And, experience shows that when they crash, they crash hard.
The first came in with a pulmonary embolism. She went from a "oh I'm having a little trouble breathing" to dropping her blood pressure, her pulse and needing to be rushed to the ICU. We later heard that she needed to have a breathing tube placed. An anticoagulant was started to help with the massive blood clot in her lungs and she started vomiting blood. We don't expect that she will do well. Luckily, in some ways, her entire family was always around and at her bedside.
The second came in having been found by a neighbor collapsed in his apartment. He was dirty and unkempt as he might have been down at least a day, maybe two. He didn't have any power in his apartment. We don't know why. He was minimally responsive when the EMT's brought him in the door. He was able to answer my questions after some oxygen and fluid. Then he crashed. It's hard to put a breathing tube in someone who is overweight. The angles are all wrong, and it's hard to see the breathing tube go in the right place. We have a new fiber optic scope that makes things easier, and the intubation seemed to go well, until he started vomiting blood all over, blocking the view and leading to a feeling of general badness. He started to drop his blood pressure, and we started ordering blood products. I don't know that he'll do well. He is alone. No family, no one to contact. Just a concerned neighbor without whom he probably would have died alone in his apartment.
I had a lot of headache patients today:
- assault - hit in head three times with a fist - CT scan neg.
- blunt force trauma - hit in head by falling window - CT scan neg.
- carbon monoxide poisoning - if you're in a house that smells like gas, don't wait two days before calling the gas company. Open the windows and get out. - get put on 100% oxygen for 3 hours
For a moment, I actually thought "Crash and Burn" would be a better title, but the two most memorable patients during this shift were of the, shall I say, larger portion of the population. And, experience shows that when they crash, they crash hard.
The first came in with a pulmonary embolism. She went from a "oh I'm having a little trouble breathing" to dropping her blood pressure, her pulse and needing to be rushed to the ICU. We later heard that she needed to have a breathing tube placed. An anticoagulant was started to help with the massive blood clot in her lungs and she started vomiting blood. We don't expect that she will do well. Luckily, in some ways, her entire family was always around and at her bedside.
The second came in having been found by a neighbor collapsed in his apartment. He was dirty and unkempt as he might have been down at least a day, maybe two. He didn't have any power in his apartment. We don't know why. He was minimally responsive when the EMT's brought him in the door. He was able to answer my questions after some oxygen and fluid. Then he crashed. It's hard to put a breathing tube in someone who is overweight. The angles are all wrong, and it's hard to see the breathing tube go in the right place. We have a new fiber optic scope that makes things easier, and the intubation seemed to go well, until he started vomiting blood all over, blocking the view and leading to a feeling of general badness. He started to drop his blood pressure, and we started ordering blood products. I don't know that he'll do well. He is alone. No family, no one to contact. Just a concerned neighbor without whom he probably would have died alone in his apartment.
I had a lot of headache patients today:
- assault - hit in head three times with a fist - CT scan neg.
- blunt force trauma - hit in head by falling window - CT scan neg.
- carbon monoxide poisoning - if you're in a house that smells like gas, don't wait two days before calling the gas company. Open the windows and get out. - get put on 100% oxygen for 3 hours
Friday, October 19, 2007
Irregular Rhythms
So, I just finished my 2nd day shift at my new rotation of BGH. There's been sort of a common theme over the last 2 days: chest pain and heart irregularities. Of course, I also have the abdominal pains, the SOB's (shortness of breath, remember?), the back pains, etc. It seems like I see a lot more real medicine patients here. So much so that this morning I was convinced I was working a primary care clinic.
But onto the good stuff:
Chest pain central: we've have several STEMI's (ST elevation myocardial infarctions) = think major heart attack you're going to die unless we open up that clogged artery. The hospital is known as a chest pain center, so we get admissions from all over the surrounding area. Some patients get stabilized at their closest E.D. and then sent to us. Some come in the door "hot" meaning they're in the midst of a massive M.I. Our "door to balloon" time is about less than 45 minutes. We had a 38 minute run yesterday. Balloon means angioplasty means opening clogged artery with a balloon and then usually stent placement. Very exciting stuff.
We've also had a rash of NSTEMI's (non-STEMI's) which is chest pain not currently showing signs of having a heart attack but at risk for a heart attack. They go to our chest pain center where they're observed for a day or so, given a stress test and then discharged. I've actually admitted about 5 patients to our observation unit. We're filling up the beds.
The one exciting patient we had came in with heart rate of 15. That's right: 15. AND she was awake and talking to us. We couldn't even measure a blood pressure on her because you need a certain heart beat to be able to maintain an adequate blood pressure. Again, she was awake and talking to us. Very impressive, and very scary to have to work-up. We finally got her heart rate up to about 50 and some semblance of a blood pressure. At one point we had external pacemaker pads on her just in case we were going to need to pace her from the outside. Just an FYI - getting "mini" shocks to keep her heart going would not be fun... for anyone.
And, speaking of shocks, my last patient today had an AICD (Automatic Internal Cardiac Defibrillator) placed yesterday. If his heart goes into a lethal rhythm, the defibrillator will go off and give him a shock.
Unfortunately, as he was making his way to his car having been discharged from the hospital, his AICD fired off. He described the sensation as "being hit in the chest with a sledgehammer," and it happened five times. He's been admitted to have his AICD evaluated. They can actually put a monitor over it and read out why it fired off and run diagnostics on it. Cool stuff.
Some other random, non-cardiac (heart) thoughts:
- the emergency department does not work like a drive thru; you can't just come in, expect to be seen immediately, have your tests completed in under an hour and go home. Don't come to the E.D. if you "have plans." It's not like going to the doctor's office. They see one patient at a time, I see 5-6 (so far, I'll get better). Your two weeks of leg pain that has to be seen and evaluated right now falls below my other 4 patients with the chest pains, breathing problems and abdominal pains needing surgery. So, it's gonna take a while. You waited two weeks, what's another 2 hours. Go out and smoke while you're waiting. It'll help pass the time and clog up what's left of your leg's blood supply which is probably the reason you have the leg pain now.
- drug seekers come in all shapes and sizes. Even "sweet little old ladies" become raging, um, monsters when they're jonesing for another vicodin/percocet/lortab/etc.
- did I mention I'm getting really good at rectals? Don't ask....
But onto the good stuff:
Chest pain central: we've have several STEMI's (ST elevation myocardial infarctions) = think major heart attack you're going to die unless we open up that clogged artery. The hospital is known as a chest pain center, so we get admissions from all over the surrounding area. Some patients get stabilized at their closest E.D. and then sent to us. Some come in the door "hot" meaning they're in the midst of a massive M.I. Our "door to balloon" time is about less than 45 minutes. We had a 38 minute run yesterday. Balloon means angioplasty means opening clogged artery with a balloon and then usually stent placement. Very exciting stuff.
We've also had a rash of NSTEMI's (non-STEMI's) which is chest pain not currently showing signs of having a heart attack but at risk for a heart attack. They go to our chest pain center where they're observed for a day or so, given a stress test and then discharged. I've actually admitted about 5 patients to our observation unit. We're filling up the beds.
The one exciting patient we had came in with heart rate of 15. That's right: 15. AND she was awake and talking to us. We couldn't even measure a blood pressure on her because you need a certain heart beat to be able to maintain an adequate blood pressure. Again, she was awake and talking to us. Very impressive, and very scary to have to work-up. We finally got her heart rate up to about 50 and some semblance of a blood pressure. At one point we had external pacemaker pads on her just in case we were going to need to pace her from the outside. Just an FYI - getting "mini" shocks to keep her heart going would not be fun... for anyone.
And, speaking of shocks, my last patient today had an AICD (Automatic Internal Cardiac Defibrillator) placed yesterday. If his heart goes into a lethal rhythm, the defibrillator will go off and give him a shock.
Unfortunately, as he was making his way to his car having been discharged from the hospital, his AICD fired off. He described the sensation as "being hit in the chest with a sledgehammer," and it happened five times. He's been admitted to have his AICD evaluated. They can actually put a monitor over it and read out why it fired off and run diagnostics on it. Cool stuff.
Some other random, non-cardiac (heart) thoughts:
- the emergency department does not work like a drive thru; you can't just come in, expect to be seen immediately, have your tests completed in under an hour and go home. Don't come to the E.D. if you "have plans." It's not like going to the doctor's office. They see one patient at a time, I see 5-6 (so far, I'll get better). Your two weeks of leg pain that has to be seen and evaluated right now falls below my other 4 patients with the chest pains, breathing problems and abdominal pains needing surgery. So, it's gonna take a while. You waited two weeks, what's another 2 hours. Go out and smoke while you're waiting. It'll help pass the time and clog up what's left of your leg's blood supply which is probably the reason you have the leg pain now.
- drug seekers come in all shapes and sizes. Even "sweet little old ladies" become raging, um, monsters when they're jonesing for another vicodin/percocet/lortab/etc.
- did I mention I'm getting really good at rectals? Don't ask....
Wednesday, October 17, 2007
A clean white slate
I don't know what happened, but I wrote an entry yesterday morning about my first day/night albeit shift at Buffalo General Hospital. The entry disappeared into the subether of the web. It really was a good blog entry full of witticisms, observations, and general blathering since I had been on all night and was trying to keep myself awake to "reset" my internal clock.
Suffice it to say, this is the electronic white board at BGH E.D. This is a clean white board which occurred around 0530 yesterday morning and lasted all of 2 minutes. My patients were not as colorful as the ones at ECMC except for one of my last ones involved in a domestic dispute which was rapidly drawing out into a She Said, He Said. More later as I am late for my meeting and upset about losing an entry... Hmm...
Tuesday, October 16, 2007
A clean white slate
A new place... BGH Emergency Department
A new board....
actually a very fancy flat screen connected to the main computer. Instead of dry erase, we log onto the computer and place our name next to the patient's name and information.
As you can see here, it's empty. This lasted for all of about 2 minutes around 0530 this morning. I grabbed the picture quickly. Same kind of layout, 21 rooms and about 8 hallway beds labeled alphabetically. The cool thing is when labs are completed or radiological studies are done, they pop up next to your patient's name on the screen. No more continually checking back, you can see immediately what's been completed.
No real drama last night in the E.D. After fumbling around for about two hours trying to learn the system, searching for patient's charts, finding out where labs go, etc, I finally started feeling like I was getting back into a groove. Luckily the patients cooperated and we hit a lull around 2 in the morning.
Most of my patients last night were of the garden variety medical problem that really needs addressing. Several chest pains were directly admitted to our cardiac observation unit. My nausea and vomiting patients got drugs and were able to be sent home. The chronic pain users got a dose or two to carry them through to their next doctor's appointment (or E.D. visit, hey, I'm not that naive), and my sick guy with cancer got scanned and pain relief then got sent home.
My one interesting patient of the night came in as a head injury. All traumas go to ECMC, but this patient refused to go there so she came to us. She was involved in a domestic dispute where her former boyfriend hit her across the head and back with a cane, actually reportedly breaking the cane in half. She ended up with a clean CT (no bleeding, no fracture) and no bony injuries. That's not to say she won't be hurting for several days to come from her muscle and skin injuries.
While we were arranging for her to get home, it came out that this "boyfriend" has tried several times to hurt her and her family including: several other assaults, turning and leaving the gas on in the apartment so that the family would all die, stalking her and accosting her at her home, and other various sundry offenses. The police were called to escort her home, and Crisis Services was called. It seems they were familiar with her assailant when his name was mentioned because HE showed up at ECMC last night claiming that he had been a victim of domestic abuse. The Crisis Counselor had actually taken a report from him.
Who's to say what the real story is? We only get a part of the story... and to be honest, sometimes it's better not knowing. There'll always be another patient, another story... but not for 2 more days. I have 48 hours to reset my clock and turn back into a day person again.
A new board....
actually a very fancy flat screen connected to the main computer. Instead of dry erase, we log onto the computer and place our name next to the patient's name and information.
As you can see here, it's empty. This lasted for all of about 2 minutes around 0530 this morning. I grabbed the picture quickly. Same kind of layout, 21 rooms and about 8 hallway beds labeled alphabetically. The cool thing is when labs are completed or radiological studies are done, they pop up next to your patient's name on the screen. No more continually checking back, you can see immediately what's been completed.
No real drama last night in the E.D. After fumbling around for about two hours trying to learn the system, searching for patient's charts, finding out where labs go, etc, I finally started feeling like I was getting back into a groove. Luckily the patients cooperated and we hit a lull around 2 in the morning.
Most of my patients last night were of the garden variety medical problem that really needs addressing. Several chest pains were directly admitted to our cardiac observation unit. My nausea and vomiting patients got drugs and were able to be sent home. The chronic pain users got a dose or two to carry them through to their next doctor's appointment (or E.D. visit, hey, I'm not that naive), and my sick guy with cancer got scanned and pain relief then got sent home.
My one interesting patient of the night came in as a head injury. All traumas go to ECMC, but this patient refused to go there so she came to us. She was involved in a domestic dispute where her former boyfriend hit her across the head and back with a cane, actually reportedly breaking the cane in half. She ended up with a clean CT (no bleeding, no fracture) and no bony injuries. That's not to say she won't be hurting for several days to come from her muscle and skin injuries.
While we were arranging for her to get home, it came out that this "boyfriend" has tried several times to hurt her and her family including: several other assaults, turning and leaving the gas on in the apartment so that the family would all die, stalking her and accosting her at her home, and other various sundry offenses. The police were called to escort her home, and Crisis Services was called. It seems they were familiar with her assailant when his name was mentioned because HE showed up at ECMC last night claiming that he had been a victim of domestic abuse. The Crisis Counselor had actually taken a report from him.
Who's to say what the real story is? We only get a part of the story... and to be honest, sometimes it's better not knowing. There'll always be another patient, another story... but not for 2 more days. I have 48 hours to reset my clock and turn back into a day person again.
Monday, October 15, 2007
Sunrise, Sunset
Well, I lived through it. My first official month as an EM resident. 33 more to go. As I drove away from work this morning, I actually thought, "I'm gonna miss it (the ECMC E.D.), just a little." It's sort of like being back in medical school. You just start to get comfortable in a rotation, then it's time to shift again.
Last night wasn't too bad. I had a period of about 3 hours where I had one patient on the board, and they were basically sleeping in the E.D. waiting for a bed upstairs. I did get to do a trauma on my own. A 25 foot fall from a tree stand while hunting will knock the wind out of you. Not to mention breaking a couple of ribs, your arm, some important parts of your neck bones. Yep.
One major event that made me miss my trauma days was a double stabbing. You stab me, I stab you and we both end up in the E.D. There's a bit of excitement in running down the corridor with your hand covering someone's gushing wound and going right into the O.R. Last night I stood back and watched them rush by. I had a finger to sew back together. My patient would be leaving via the front door; not the morgue door like the trauma patient.
So this morning I sat for a second in the warmth of my car and watched the sun rise. Pondered my choices in life. Reflected on what might have been. But, to be honest, I am looking forward to what will be. Every day I pick up on something new to study, something I want to be better at doing, another skill I want to perfect.
And sometimes, yep just sometimes, I get a patient that says "Thank you" and really appreciates that I took the time to help them. And, that, more than anything makes me want to continue on where I am, what I am doing, this life I am living.
Last night wasn't too bad. I had a period of about 3 hours where I had one patient on the board, and they were basically sleeping in the E.D. waiting for a bed upstairs. I did get to do a trauma on my own. A 25 foot fall from a tree stand while hunting will knock the wind out of you. Not to mention breaking a couple of ribs, your arm, some important parts of your neck bones. Yep.
One major event that made me miss my trauma days was a double stabbing. You stab me, I stab you and we both end up in the E.D. There's a bit of excitement in running down the corridor with your hand covering someone's gushing wound and going right into the O.R. Last night I stood back and watched them rush by. I had a finger to sew back together. My patient would be leaving via the front door; not the morgue door like the trauma patient.
So this morning I sat for a second in the warmth of my car and watched the sun rise. Pondered my choices in life. Reflected on what might have been. But, to be honest, I am looking forward to what will be. Every day I pick up on something new to study, something I want to be better at doing, another skill I want to perfect.
And sometimes, yep just sometimes, I get a patient that says "Thank you" and really appreciates that I took the time to help them. And, that, more than anything makes me want to continue on where I am, what I am doing, this life I am living.
Sunday, October 14, 2007
When the party's over
I didn't realize that here in Buffalo the bars don't close until 4 in the morning. When working trauma in Minnesota, usually the carnage started around 2:30 in the morning as the drunks started driving home, the fights broke out, the revelers went home to continue their partying, etc. Here it's much later and last night was a good example of what can happen when the party ends and the fun begins... for us at least.
We'd actually had a good night. Most of the board was clear, and the few patients waiting around were mostly surgery or ortho patients waiting to go to the OR, their room or to have something or other splinted. This was at 0200. Then at 0400 the floodgates, or bar doors, opened.
Within 30 minutes we had:
- drunk brother and sister who needed to be brought in because they were passed out after a university party. The sister when asked if she knew where she was answered with the name of her grammar school.
- guy thrown through plate glass window who luckily was too drunk to realize that his right arm was hanging on, almost literally, by skin and bone. That's going to need a LOT of stitches.
- teenager doing "flaming shots" that forgot to blow out the shot or didn't drink fast enough causing 2nd degree burns to his face and hand. I myself prefer the Lamborghini they serve at the Black Angus near my hometown. Dark green and flaming, you have to drink fast or else your straw will melt.
- two people involved in a drive-by shooting. One was running and got shot in the legs having almost exactly the same injuries as the patient from last night. I saw a 19 year old with a gun shot to the arm. Some more souvenirs to add to their collections.
- two assault victims one of which I saw. He got jumped and beaten up, escaped, then went to find the people that beat him up, and got beaten up again. I hope my colleague had a steady hand while sewing up his eyelid. Some dangerous territory there. I actually assisted the medical student with suturing the other victim's chin. He wouldn't stop talking theentire time, and I kept telling him if he didn't want a crooked scar he'd have to stop. He didn't, but my own obsessiveness made sure he's going to have smallest scar possible.
- And, finally one or two MVC's. Nothing serious.
The other thing I didn't know is that beer can be served at 0800 in the morning. I'll just say that Pano's, which I've mentioned before has good food, really has a nice-priced breakfast. And, after all, nothing goes better than a Molson with steak and eggs at eight in the morning after working the night shift... at least, so I've heard... :D
We'd actually had a good night. Most of the board was clear, and the few patients waiting around were mostly surgery or ortho patients waiting to go to the OR, their room or to have something or other splinted. This was at 0200. Then at 0400 the floodgates, or bar doors, opened.
Within 30 minutes we had:
- drunk brother and sister who needed to be brought in because they were passed out after a university party. The sister when asked if she knew where she was answered with the name of her grammar school.
- guy thrown through plate glass window who luckily was too drunk to realize that his right arm was hanging on, almost literally, by skin and bone. That's going to need a LOT of stitches.
- teenager doing "flaming shots" that forgot to blow out the shot or didn't drink fast enough causing 2nd degree burns to his face and hand. I myself prefer the Lamborghini they serve at the Black Angus near my hometown. Dark green and flaming, you have to drink fast or else your straw will melt.
- two people involved in a drive-by shooting. One was running and got shot in the legs having almost exactly the same injuries as the patient from last night. I saw a 19 year old with a gun shot to the arm. Some more souvenirs to add to their collections.
- two assault victims one of which I saw. He got jumped and beaten up, escaped, then went to find the people that beat him up, and got beaten up again. I hope my colleague had a steady hand while sewing up his eyelid. Some dangerous territory there. I actually assisted the medical student with suturing the other victim's chin. He wouldn't stop talking theentire time, and I kept telling him if he didn't want a crooked scar he'd have to stop. He didn't, but my own obsessiveness made sure he's going to have smallest scar possible.
- And, finally one or two MVC's. Nothing serious.
The other thing I didn't know is that beer can be served at 0800 in the morning. I'll just say that Pano's, which I've mentioned before has good food, really has a nice-priced breakfast. And, after all, nothing goes better than a Molson with steak and eggs at eight in the morning after working the night shift... at least, so I've heard... :D
Saturday, October 13, 2007
The Shhh (quiet) Night
Surprisingly... not too bad. One of the best shifts so far in terms of not being completely overwhelmed and feeling like I could spend some time really focusing on patient care... not that watching drunks "sleep it off" is very challenging, but there's always something that can be learned from each patient.
Such as:
- if you're going to take a bunch of muscle relaxers and some benzo's (anti-anxiety meds) to start off your weekend, you really shouldn't drive too soon after taking them. If you think "they're not going to hit until I get home," think again. They're going to hit while you're driving home. Maybe stopping at the McDonald's to get that Big Mac won't help, because that just means you took them on an empty stomach, and they're going to work just that much sooner. And, if you're high on this combination and decide to eat that Big Mac while driving you just might end up hitting several cars causing a chain reaction that results in not just you coming to the E.D. but 4 other people coming to the E.D. too. And, I won't feel bad that you, darn-it, starred the window of your Bronco because in some ways you're like the drunk driver. The more intoxicated you are, the less damage you'll do to yourself. No stitches for you. Can't say the same for the rest of the carnage you left behind.
- if you think that banging your head in your holding cell while you're in hand cuffs for public intoxication and causing a laceration is going to get you out of jail, it will. But just long enough for me to put 5 stitches in your head so the nice officers can take you right back to jail. And, I did learn a lot about the officers that brought you in as they started comparing scars while I sewed up your newest one.
- the LOLNAD and gomere rule still applies, get directly admitted, do not pass go, do not collect $200.
- it's O.K. to come to the E.D. with hemorrhoids. We won't laugh. It's better than coming in with a foreign body up there that we have to fish out, pry out, um, get out as best as we can. Just remember: fiber in the diet is good thing.
- A B-52 in the E.D. is NOT a fun drink nor an 80's band. It's a mix of Benadryl, Haldol and Ativan (50mg/5mg/2mg) that is going to make you sleep for a very, very long time. When you wake up, you'll no longer be the obnoxious and boisterous 17 year old who is totally drunk, you'll be the obnoxious and boisterous 17 year old in the psych holding facility because you've been off your meds and started physically abusing your mother and sister. However, don't worry. When you tell your mother, "I promise I'll be a good boy this time, really, I promise" she'll spring you free, again. Because she just can't stand to see her baby crying and upset. Provided she's been taking her own psych meds and can handle you coming back home that is.
- Pelvics are no fun for anyone. I'll make you a deal: you stop having sex and I'll stop doing pelvics. Deal? Anyone?
- Guys walking to/from their gramma's (or church) are gonna get shot. Every time. "Two Dudes" are just waitin' to do it. You walkin', they watchin' and someone's gonna get shot. In this case, in one leg and out, then in the other leg and almost out. You can feel it just under the skin. That's going to be with you probably for the rest of your life. Yep. We don't take them out. They stay with you forever. Just a little souvenir.
- Inmates (we see a lot of them) are hard to do physical exams on. For the most part they have wrist, waist and ankle shackles. And the CO's (correction officers) don't like to take them off unless they have to, which, come on, you're bringing in a patient for a medical evaluation. They should be just like everyone else. Strip down to your skivvies, put on a hospital gown, handcuff them to the bed and let us do our job. Now, I do realize that some inmates might be dangerous, and it's a matter of safety, but most of the prisoners I see come in could probably outrun their CO's even in ankle shackles or they're so debilitated that the weight of the shackles probably isn't helping their medical condition any.
That's about it for my night... nap time and back again tonight... we'll see what the next shift has in store.
Such as:
- if you're going to take a bunch of muscle relaxers and some benzo's (anti-anxiety meds) to start off your weekend, you really shouldn't drive too soon after taking them. If you think "they're not going to hit until I get home," think again. They're going to hit while you're driving home. Maybe stopping at the McDonald's to get that Big Mac won't help, because that just means you took them on an empty stomach, and they're going to work just that much sooner. And, if you're high on this combination and decide to eat that Big Mac while driving you just might end up hitting several cars causing a chain reaction that results in not just you coming to the E.D. but 4 other people coming to the E.D. too. And, I won't feel bad that you, darn-it, starred the window of your Bronco because in some ways you're like the drunk driver. The more intoxicated you are, the less damage you'll do to yourself. No stitches for you. Can't say the same for the rest of the carnage you left behind.
- if you think that banging your head in your holding cell while you're in hand cuffs for public intoxication and causing a laceration is going to get you out of jail, it will. But just long enough for me to put 5 stitches in your head so the nice officers can take you right back to jail. And, I did learn a lot about the officers that brought you in as they started comparing scars while I sewed up your newest one.
- the LOLNAD and gomere rule still applies, get directly admitted, do not pass go, do not collect $200.
- it's O.K. to come to the E.D. with hemorrhoids. We won't laugh. It's better than coming in with a foreign body up there that we have to fish out, pry out, um, get out as best as we can. Just remember: fiber in the diet is good thing.
- A B-52 in the E.D. is NOT a fun drink nor an 80's band. It's a mix of Benadryl, Haldol and Ativan (50mg/5mg/2mg) that is going to make you sleep for a very, very long time. When you wake up, you'll no longer be the obnoxious and boisterous 17 year old who is totally drunk, you'll be the obnoxious and boisterous 17 year old in the psych holding facility because you've been off your meds and started physically abusing your mother and sister. However, don't worry. When you tell your mother, "I promise I'll be a good boy this time, really, I promise" she'll spring you free, again. Because she just can't stand to see her baby crying and upset. Provided she's been taking her own psych meds and can handle you coming back home that is.
- Pelvics are no fun for anyone. I'll make you a deal: you stop having sex and I'll stop doing pelvics. Deal? Anyone?
- Guys walking to/from their gramma's (or church) are gonna get shot. Every time. "Two Dudes" are just waitin' to do it. You walkin', they watchin' and someone's gonna get shot. In this case, in one leg and out, then in the other leg and almost out. You can feel it just under the skin. That's going to be with you probably for the rest of your life. Yep. We don't take them out. They stay with you forever. Just a little souvenir.
- Inmates (we see a lot of them) are hard to do physical exams on. For the most part they have wrist, waist and ankle shackles. And the CO's (correction officers) don't like to take them off unless they have to, which, come on, you're bringing in a patient for a medical evaluation. They should be just like everyone else. Strip down to your skivvies, put on a hospital gown, handcuff them to the bed and let us do our job. Now, I do realize that some inmates might be dangerous, and it's a matter of safety, but most of the prisoners I see come in could probably outrun their CO's even in ankle shackles or they're so debilitated that the weight of the shackles probably isn't helping their medical condition any.
That's about it for my night... nap time and back again tonight... we'll see what the next shift has in store.
Thursday, October 11, 2007
Three Nights, Three Tales
I am in the middle of 36 hours off before I have to go back for my last 3 nights at ECMC. After the pain of the prior shift, I had a day off to transition back to night shift. Like I said before, that first night back was a killer. I was falling asleep during our morning meeting and doing everything I could to stay awake while driving back home. Now I am just staying awake to the keep the whole night/day rhythm going so I can work the next set of nights.
But I digress... let's talk about the themes and patients from the last several nights shall we...?
Of Gomeres and LOLNADs: In the "House of God," a GOMER is defined as "Get Out of My Emergency Room" usually referring to a nursing home patient. A female gomer was affectionately called a gomere. Also, when we write our physical exams, we describe a patient's state which is usually NAD = no apparent distress. In the "House of God," they refer to a LOLNAD which is a "Little Old Lady in No Apparent Distress." I had a night of gomeres and LOLNADs.
You've read my diatribes on the local nursing homes, so enough said there. I had several patients who came in, and when I asked what brought them to the E.D. they had no idea. Smiling LOLNADs. No idea why they were there. Nope, didn't hurt anywhere, didn't remember having a pain anywhere, just told they needed to come to the E.D., packed onto an ambulance and sent over.
Twenty pages into the photocopied stack of papers sent with them from the nursing home I was finally able to figure out that they'd had some abnormal (lab, vital sign, cough, episode of throwing up, etc.) and had been sent over for evaluation. Most likely because some doctor was called multiple times and finally said, "Just send them to be evaluated."
Unfortunately, ambulances just deliver, they don't pick up. AND, the van to the nursing homes doesn't start until, oh, 07:30. So, my gomeres that show up around 9 p.m. and get worked up and are ready for discharge around midnight have to spend the night at the hospital because unless a family member comes to get them (been hung up on several times at that suggestionso I don't even bother any more), they are going to be spending the night.
Primary care medicine night: I always ask patients if they have a primary care doctor who follows them for their general medical management. Most of the time it's because a patient is going to need to be admitted, and I need to know which service to admit them to. The other night it was because almost all of my patients, and those of my fellow residents were coming in for primary care issues.
I knew as soon as I walked into the room, heard the presenting complaint and asked, "How long has this been going on?" that if the patient answered greater than two months it was going to be tedious, very tedious. And, unsatisfactory. I would do the complete work-up, probably not come up with a diagnosis, and end up referring them to who...? A primary care doctor: their own or a referral to the medicine clinic who will eventually sort things out and manage the patients care. As they should. Not me. Them.
Musta been a full moon: Last night was crazy night. Crazy patient night. We all had them. We're used to the drunks, the druggies, the confused gomers and gomeres. But, last night it was the schizos, the psychos, and everything in between.
There's a medical condition called Munchausen's where patients make themselves sick so that they'll get attention. And, there's a condition, pseudocyesis, where patients want to be pregnant so badly that they'll actually be able to stop their periods, gain weight, start making milk, etc. I had a patient last night that seemed to have both.
A police officer brought in a woman who had been found at a bar drunk after her family reported her missing. The report stated that she was 8 1/2 months' pregnant and had missed going to her ob-gyn appointment. No one knew where she was. When she was found by police just a few blocks from her home, she stated that she had gone to her ob's that morning, had been told that her baby died, delivered the baby and had left. There was concern that she may have done something to the baby, or had delivered out of the hospital.
I asked the officer if he was sure there actually was a baby. Supposedly her sister and several other family members were under the impression that she was. The baby was presumed to be due next week. They were all worried about her mental state since she had previously lost another baby close to term. She even had a tattoo on her left breast in honor of it.
Well, long story short. Pregnancy test was negative. No baby for at least a month. The more we investigated (I even put an ultrasound probe on her) the more upset she got. She was the victim. Feel sorry for her. Lost another baby and didn't go home. No, she went to a bar to drink and figure out what she was going to do because she didn't want to disappoint her husband and family.
When I told the police officer, he was dumbfounded. He stayed around to help escort her over to our psychiatric intake center because she was not going easily. He was still shaking his head as he was leaving. He was even more amazed that the husband was still under the delusion that his wife had been pregnant. When I asked if the husband hadn't found out, I was told no. Telling him would be in violation of HIPAA rights which if you didn't know are the protection of patient privacy laws which you're informed of whenever you see a doctor.
So he's in oblivion, and she's in the looney bin. My attending is still snickering because I was concerned about a baby that never was. No wonder House is so cynical. "Everybody lies."
But I digress... let's talk about the themes and patients from the last several nights shall we...?
Of Gomeres and LOLNADs: In the "House of God," a GOMER is defined as "Get Out of My Emergency Room" usually referring to a nursing home patient. A female gomer was affectionately called a gomere. Also, when we write our physical exams, we describe a patient's state which is usually NAD = no apparent distress. In the "House of God," they refer to a LOLNAD which is a "Little Old Lady in No Apparent Distress." I had a night of gomeres and LOLNADs.
You've read my diatribes on the local nursing homes, so enough said there. I had several patients who came in, and when I asked what brought them to the E.D. they had no idea. Smiling LOLNADs. No idea why they were there. Nope, didn't hurt anywhere, didn't remember having a pain anywhere, just told they needed to come to the E.D., packed onto an ambulance and sent over.
Twenty pages into the photocopied stack of papers sent with them from the nursing home I was finally able to figure out that they'd had some abnormal (lab, vital sign, cough, episode of throwing up, etc.) and had been sent over for evaluation. Most likely because some doctor was called multiple times and finally said, "Just send them to be evaluated."
Unfortunately, ambulances just deliver, they don't pick up. AND, the van to the nursing homes doesn't start until, oh, 07:30. So, my gomeres that show up around 9 p.m. and get worked up and are ready for discharge around midnight have to spend the night at the hospital because unless a family member comes to get them (been hung up on several times at that suggestionso I don't even bother any more), they are going to be spending the night.
Primary care medicine night: I always ask patients if they have a primary care doctor who follows them for their general medical management. Most of the time it's because a patient is going to need to be admitted, and I need to know which service to admit them to. The other night it was because almost all of my patients, and those of my fellow residents were coming in for primary care issues.
I knew as soon as I walked into the room, heard the presenting complaint and asked, "How long has this been going on?" that if the patient answered greater than two months it was going to be tedious, very tedious. And, unsatisfactory. I would do the complete work-up, probably not come up with a diagnosis, and end up referring them to who...? A primary care doctor: their own or a referral to the medicine clinic who will eventually sort things out and manage the patients care. As they should. Not me. Them.
Musta been a full moon: Last night was crazy night. Crazy patient night. We all had them. We're used to the drunks, the druggies, the confused gomers and gomeres. But, last night it was the schizos, the psychos, and everything in between.
There's a medical condition called Munchausen's where patients make themselves sick so that they'll get attention. And, there's a condition, pseudocyesis, where patients want to be pregnant so badly that they'll actually be able to stop their periods, gain weight, start making milk, etc. I had a patient last night that seemed to have both.
A police officer brought in a woman who had been found at a bar drunk after her family reported her missing. The report stated that she was 8 1/2 months' pregnant and had missed going to her ob-gyn appointment. No one knew where she was. When she was found by police just a few blocks from her home, she stated that she had gone to her ob's that morning, had been told that her baby died, delivered the baby and had left. There was concern that she may have done something to the baby, or had delivered out of the hospital.
I asked the officer if he was sure there actually was a baby. Supposedly her sister and several other family members were under the impression that she was. The baby was presumed to be due next week. They were all worried about her mental state since she had previously lost another baby close to term. She even had a tattoo on her left breast in honor of it.
Well, long story short. Pregnancy test was negative. No baby for at least a month. The more we investigated (I even put an ultrasound probe on her) the more upset she got. She was the victim. Feel sorry for her. Lost another baby and didn't go home. No, she went to a bar to drink and figure out what she was going to do because she didn't want to disappoint her husband and family.
When I told the police officer, he was dumbfounded. He stayed around to help escort her over to our psychiatric intake center because she was not going easily. He was still shaking his head as he was leaving. He was even more amazed that the husband was still under the delusion that his wife had been pregnant. When I asked if the husband hadn't found out, I was told no. Telling him would be in violation of HIPAA rights which if you didn't know are the protection of patient privacy laws which you're informed of whenever you see a doctor.
So he's in oblivion, and she's in the looney bin. My attending is still snickering because I was concerned about a baby that never was. No wonder House is so cynical. "Everybody lies."
Sunday, October 7, 2007
You go on with your bad self...
While in medical school, I read the book "The House of God." It's the story of an intern and his first year. There's a line in that book about how sometimes patients "can hurt you back."
When my friends and I graduated from medical school and started our internships, we all had a day where we began to question our decision about being in our chosen residency. Then as time went on you found your footing and settled in. Yesterday, I had another of those "internship" moments.
Somewhere between the patient who came in with multiple bug bites, the transvestite high on crack and meth, the frequent flyer who called 911 from the emergency room when she didn't get a second dose of narcotic medications, the young ATV accident patient who had a seizure after flying over the handlebars, and the patient with a gunshot wound to the arm who had encountered "Three Dudes" I found myself alone running a resuscitation code on a patient.
After we got the heart beating again, the patient proceeded to "code" three more times. When the family arrived we were in the middle of the third code. I had them taken to the quiet room where I was going to go talk to them about stopping the chest compressions. I was in the middle of trying to get them to understand that most likely their family member wasn't going to live when my attending walked in the room, basically asked if a decision had been made about stopping care and to let us know as soon as it was, and then walked out of the room. The family fell apart. What should have been a peaceful discussion turned into a chaos of emotions. I think that's when I had my "what am I doing here" moment and lost it.
There was something in the air yesterday. One of the attendings told me to "go enjoy a cocktail" after the day that I'd had. By the time I finally finished up an hour and a half after my shift should have ended, my senior was leaving too. They told me they were impressed at how I handled the coding patient and family. They were about to step in, but then just thought "you got it, go on with your bad self." And that's why you step back, suck it in, and go on. Like in the book, you can't let the patients get to you.
When my friends and I graduated from medical school and started our internships, we all had a day where we began to question our decision about being in our chosen residency. Then as time went on you found your footing and settled in. Yesterday, I had another of those "internship" moments.
Somewhere between the patient who came in with multiple bug bites, the transvestite high on crack and meth, the frequent flyer who called 911 from the emergency room when she didn't get a second dose of narcotic medications, the young ATV accident patient who had a seizure after flying over the handlebars, and the patient with a gunshot wound to the arm who had encountered "Three Dudes" I found myself alone running a resuscitation code on a patient.
After we got the heart beating again, the patient proceeded to "code" three more times. When the family arrived we were in the middle of the third code. I had them taken to the quiet room where I was going to go talk to them about stopping the chest compressions. I was in the middle of trying to get them to understand that most likely their family member wasn't going to live when my attending walked in the room, basically asked if a decision had been made about stopping care and to let us know as soon as it was, and then walked out of the room. The family fell apart. What should have been a peaceful discussion turned into a chaos of emotions. I think that's when I had my "what am I doing here" moment and lost it.
There was something in the air yesterday. One of the attendings told me to "go enjoy a cocktail" after the day that I'd had. By the time I finally finished up an hour and a half after my shift should have ended, my senior was leaving too. They told me they were impressed at how I handled the coding patient and family. They were about to step in, but then just thought "you got it, go on with your bad self." And that's why you step back, suck it in, and go on. Like in the book, you can't let the patients get to you.
Friday, October 5, 2007
A sea of gurneys
Today was such a busy day... at one point we had all 21 patient rooms full, plus the 6 fast track rooms, 3 people in wheelchairs waiting in the hallways, 6 people in gurneys waiting at the entrance, and Lord knows how many people in the waiting room. And to think I was optimistic at the beginning of my day... 0700
On the soapbox: if you're going to lie to me, the police, the EMS workers, the nurse, etc about what happened to you last night, make the lie a really good one... but make sure you tell the same lie to everyone or else we'll know you're lying. Also, don't make it so that I actually care or worry about you at the beginning, because by the end when you're calling your pimp/boyfriend who beat the crap out of you last night to the point you lost consciousness and for which you're now refusing medical treatment to come get you, I'm not going to hesitate to have you sign out AMA (against medical advice) just so that you'll leave. Really. Harsh I know, but seriously...
Off the soapbox: little old ladies who have nothing better to do than sit around an ED all day getting pain medication and being fed box lunches make sure you come in early in the morning when the ED is generally less busy so you'll get into a room you can occupy all day. Make sure that your presenting complaint is something vague but still serious enough to warrant a full work-up. Lots of tests means lots of time spent sitting and waiting around. After all, the worse thing you'll have to endure is having an IV put in when you first get there.
On the soapbox: the local nursing home sucks. When a patient is unresponsive and turning blue, a nebulizer treatment is not going to help them. Instead, wait another two hours and then try the nebulizer treatment again. Then call an ambulance, not 911, just the ambulance because with that extra time you can collect the patient's medical records from 1997 to send over. Not that I could use anything relevant to what's happening now. Luckily, the hypoxia isn't going to be the cause of death. No, that would be the massive infection this patient has from a bowel infection that's probably been going on for the last 2 weeks which made them unresponsive in the first place. At least they had a Health Care Proxy who agreed to make the patient DNR/DNI. They understood that the patient would not want their suffering prolonged. About the only positive in this case.
Off the soapbox: if you come in having had a heart attack in the past and the pain is exactly the same, I can call your cardiologist who is going to admit you directly and I don't have to do much work... nope, not much.
On the soapbox: if you know that you have bleeding ulcers because you've already pickled your liver into cirrhosis, go ahead and have another drink. Like 1/2 a pint of vodka. This time when you suddenly pass out, bang your head on the sidewalk and give yourself a nice head bleed, you might just gently fall off to sleep.... and not wake up. Or you'll be brought into the ED vomiting up blood and requiring blood transfusions. Oh, and the crack you smoke won't help your situation either. Might actually hinder some of our care. Yeah. Really.
Off the soapbox: even though I am in the ED I still get to stick big long needles into people's bellies and drain off fluid (ascites). Then I get to proudly showcase all your fluid... all 5 liters of it on the counter... woohoo!
each bottle = 1L, 4L = 1 gallon, 1 gallon of fluid weighs 8#, so I took off almost 10 pounds of fluid from this patient.
End of shift: 2100 = 9 p.m.
On the soapbox: if you're going to lie to me, the police, the EMS workers, the nurse, etc about what happened to you last night, make the lie a really good one... but make sure you tell the same lie to everyone or else we'll know you're lying. Also, don't make it so that I actually care or worry about you at the beginning, because by the end when you're calling your pimp/boyfriend who beat the crap out of you last night to the point you lost consciousness and for which you're now refusing medical treatment to come get you, I'm not going to hesitate to have you sign out AMA (against medical advice) just so that you'll leave. Really. Harsh I know, but seriously...
Off the soapbox: little old ladies who have nothing better to do than sit around an ED all day getting pain medication and being fed box lunches make sure you come in early in the morning when the ED is generally less busy so you'll get into a room you can occupy all day. Make sure that your presenting complaint is something vague but still serious enough to warrant a full work-up. Lots of tests means lots of time spent sitting and waiting around. After all, the worse thing you'll have to endure is having an IV put in when you first get there.
On the soapbox: the local nursing home sucks. When a patient is unresponsive and turning blue, a nebulizer treatment is not going to help them. Instead, wait another two hours and then try the nebulizer treatment again. Then call an ambulance, not 911, just the ambulance because with that extra time you can collect the patient's medical records from 1997 to send over. Not that I could use anything relevant to what's happening now. Luckily, the hypoxia isn't going to be the cause of death. No, that would be the massive infection this patient has from a bowel infection that's probably been going on for the last 2 weeks which made them unresponsive in the first place. At least they had a Health Care Proxy who agreed to make the patient DNR/DNI. They understood that the patient would not want their suffering prolonged. About the only positive in this case.
Off the soapbox: if you come in having had a heart attack in the past and the pain is exactly the same, I can call your cardiologist who is going to admit you directly and I don't have to do much work... nope, not much.
On the soapbox: if you know that you have bleeding ulcers because you've already pickled your liver into cirrhosis, go ahead and have another drink. Like 1/2 a pint of vodka. This time when you suddenly pass out, bang your head on the sidewalk and give yourself a nice head bleed, you might just gently fall off to sleep.... and not wake up. Or you'll be brought into the ED vomiting up blood and requiring blood transfusions. Oh, and the crack you smoke won't help your situation either. Might actually hinder some of our care. Yeah. Really.
Off the soapbox: even though I am in the ED I still get to stick big long needles into people's bellies and drain off fluid (ascites). Then I get to proudly showcase all your fluid... all 5 liters of it on the counter... woohoo!
each bottle = 1L, 4L = 1 gallon, 1 gallon of fluid weighs 8#, so I took off almost 10 pounds of fluid from this patient.
End of shift: 2100 = 9 p.m.
Thursday, October 4, 2007
Learning to keep up...
Today I had a bit of a trial by fire. I had been plugging along, seeing my patients. We were busy but not overly so. Then the bottom fell out of the E.D. At least for me.
I had about 2 more hours left in my shift. I picked up first one patient and then another within about 15 minutes. I had to finish discharging another patient and then I was finally able to focus on my two new patients. I was in the process of writing orders, etc on these two when I got called to another patient's room for an intubation.
Now intubation means putting in a breathing tube; a skill I am required (and very excited) to learn. It wasn't my patient, but the attending felt I should have the chance to try putting one in, and I wasn't about to argue.
So I went into the room. Confident in my lack of knowledge. Of course, I'd done anesthesia in medical school. I think I remember intubating 2 or 3 patients during my time on the service. But, I hadn't intubated anything except for mannequins for the last 4 years. Oh, and a ferret and rabbit during an airway workshop when I was a surgery resident.
Under the guidance of my attending and the senior resident I went through the steps for intubation... when I was ready, I inserted the blade, lifted the epiglottis (covers your windpipe when you swallow so you don't choke on food) and looked for the vocal cords that are the "doors of the windpipe." I lifted, lifted and suddenly, there they were! Insert the breathing tube, check for a color change on a gauge meaning I was in the right place, and viola!
Of course, all the orders following intubation were left to me, and I still hadn't written my notes on my other 2 patients from about 45 minutes prior. I was about to sit and start writing my notes when suddenly 2 traumas came in at the same time, and I was told to go in and assess one of them. Now, I had 4 patients all of whom needed notes, orders, etc.
It took me an extra hour after my shift officially ended to finish cleaning up and signing out.
In my 13 hour shift I saw:
left-sided pain - discharge to home, most likely muscle strain "oh yeah, I use crack cocaine"
abdominal pain - discharge to home, diverticulosis "great lady, former school teacher"
motor vehicle crash, rear ended - discharge to home, muscle strain "what kind of fun drugs are you giving me for the pain?"
abdominal pain - discharge to home, ovarian cyst
burn to arm - discharge to home, silver sulfadene to wound
chest pain - admit to medicine service, heart attack "last I checked in February I weighed 650 pounds but I think I've probably lost a few pounds since then"
weakness - most likely admit with a need for blood transfusions "I know I've seen you before"
heroin withdrawal - most likely admit for detox "I can't keep living the way I'm living" $40/day habit
shortness of breath - discharge to home, "I saw my primary physician in the office and he said to come here to make sure I wasn't having a heart attack"
weak and dizzy - admit to cardiology service, atrial fibrillation (heart arrhythmia) causing his low blood pressure
motor vehicle crash, T-boned - pelvic fracture will be admitted for sure
The patient I intubated was found wandering around a store not making any sense. By the time she came into the emergency department she was unresponsive. We intubated her for her own safety. I'll have to wait to follow up and see why she was not making sense....
I had about 2 more hours left in my shift. I picked up first one patient and then another within about 15 minutes. I had to finish discharging another patient and then I was finally able to focus on my two new patients. I was in the process of writing orders, etc on these two when I got called to another patient's room for an intubation.
Now intubation means putting in a breathing tube; a skill I am required (and very excited) to learn. It wasn't my patient, but the attending felt I should have the chance to try putting one in, and I wasn't about to argue.
So I went into the room. Confident in my lack of knowledge. Of course, I'd done anesthesia in medical school. I think I remember intubating 2 or 3 patients during my time on the service. But, I hadn't intubated anything except for mannequins for the last 4 years. Oh, and a ferret and rabbit during an airway workshop when I was a surgery resident.
Under the guidance of my attending and the senior resident I went through the steps for intubation... when I was ready, I inserted the blade, lifted the epiglottis (covers your windpipe when you swallow so you don't choke on food) and looked for the vocal cords that are the "doors of the windpipe." I lifted, lifted and suddenly, there they were! Insert the breathing tube, check for a color change on a gauge meaning I was in the right place, and viola!
Of course, all the orders following intubation were left to me, and I still hadn't written my notes on my other 2 patients from about 45 minutes prior. I was about to sit and start writing my notes when suddenly 2 traumas came in at the same time, and I was told to go in and assess one of them. Now, I had 4 patients all of whom needed notes, orders, etc.
It took me an extra hour after my shift officially ended to finish cleaning up and signing out.
In my 13 hour shift I saw:
left-sided pain - discharge to home, most likely muscle strain "oh yeah, I use crack cocaine"
abdominal pain - discharge to home, diverticulosis "great lady, former school teacher"
motor vehicle crash, rear ended - discharge to home, muscle strain "what kind of fun drugs are you giving me for the pain?"
abdominal pain - discharge to home, ovarian cyst
burn to arm - discharge to home, silver sulfadene to wound
chest pain - admit to medicine service, heart attack "last I checked in February I weighed 650 pounds but I think I've probably lost a few pounds since then"
weakness - most likely admit with a need for blood transfusions "I know I've seen you before"
heroin withdrawal - most likely admit for detox "I can't keep living the way I'm living" $40/day habit
shortness of breath - discharge to home, "I saw my primary physician in the office and he said to come here to make sure I wasn't having a heart attack"
weak and dizzy - admit to cardiology service, atrial fibrillation (heart arrhythmia) causing his low blood pressure
motor vehicle crash, T-boned - pelvic fracture will be admitted for sure
The patient I intubated was found wandering around a store not making any sense. By the time she came into the emergency department she was unresponsive. We intubated her for her own safety. I'll have to wait to follow up and see why she was not making sense....
Wednesday, October 3, 2007
The Constipated Board
For the most part, I don't mind emergency medicine and the fact that I see patients for a limited amount of time. I do what I hope is the best I can for them, and they move on. As part of my training, we actually do follow up on some of our patients to see how they've done. Most of the time, however, we hear about certain patients from our colleagues on different services.
I found out this morning that one of the patients from the MVC yesterday died after surgery. Their injuries were just too extensive. So unfortunate because it seemed like a very nice family. My patient was admitted with multiple rib fractures. Physically, they will be probably recover in time. The heartache of losing their spouse will probably take a lot longer, if ever.
I officially saw a total of 3 patients during my 7 hour shift today (this doesn't count my involvement in several traumas and answering the telemedicine video link which I'll talk more about in a couple of months when I formally do the rotation). Why such a short shift you might ask...? We have meetings every Wednesday morning, so our shifts start just a little later than usual. However, the main reason was the "constipated big white board." Medicine service was overwhelmed, and patients that need to be admitted cannot go upstairs without admission orders. Since the Medicine service was behind, it pushed us behind. No patients going out of the E.D. means no patients coming into the E.D. Which meant, no new patients to see until my old ones cleared out.
However, traumas stop for no one....
So, some random thoughts on today...
Spurting open wound in the arm caused by your also-homeless, been-living-in-a-storage-unit-with-no-running-water girlfriend during an alcohol-induced domestic argument with a "Dollar Store steak knife" = go directly to O.R.
Brand new horse labeled as "skittish" should not be ridden until you get to know each other better, and when you're wearing something more protective than a tank top, shorts and sandals. Attempt to ride = pelvic fracture after you get thrown and kicked.
Being knocked unconscious after a football tackle and then not knowing where you are for several minutes = head CT. I don't care if you "feel a ton better now" and just want to get back to your cell and lie down. Think of it as a "get out of jail for a little while so you don't risk dying from a massive head bleed" card courtesy of me.
You, your spouse, and 50 cats living in feces and urine for months on end = dirty litter box smelling patients confined in the E.D. until they get admitted to the floor
I found out this morning that one of the patients from the MVC yesterday died after surgery. Their injuries were just too extensive. So unfortunate because it seemed like a very nice family. My patient was admitted with multiple rib fractures. Physically, they will be probably recover in time. The heartache of losing their spouse will probably take a lot longer, if ever.
I officially saw a total of 3 patients during my 7 hour shift today (this doesn't count my involvement in several traumas and answering the telemedicine video link which I'll talk more about in a couple of months when I formally do the rotation). Why such a short shift you might ask...? We have meetings every Wednesday morning, so our shifts start just a little later than usual. However, the main reason was the "constipated big white board." Medicine service was overwhelmed, and patients that need to be admitted cannot go upstairs without admission orders. Since the Medicine service was behind, it pushed us behind. No patients going out of the E.D. means no patients coming into the E.D. Which meant, no new patients to see until my old ones cleared out.
However, traumas stop for no one....
So, some random thoughts on today...
Spurting open wound in the arm caused by your also-homeless, been-living-in-a-storage-unit-with-no-running-water girlfriend during an alcohol-induced domestic argument with a "Dollar Store steak knife" = go directly to O.R.
Brand new horse labeled as "skittish" should not be ridden until you get to know each other better, and when you're wearing something more protective than a tank top, shorts and sandals. Attempt to ride = pelvic fracture after you get thrown and kicked.
Being knocked unconscious after a football tackle and then not knowing where you are for several minutes = head CT. I don't care if you "feel a ton better now" and just want to get back to your cell and lie down. Think of it as a "get out of jail for a little while so you don't risk dying from a massive head bleed" card courtesy of me.
You, your spouse, and 50 cats living in feces and urine for months on end = dirty litter box smelling patients confined in the E.D. until they get admitted to the floor
Tuesday, October 2, 2007
A moment in time...
It's always amazing to me how quickly things can change. In a single moment things can go from calm to chaotic and people's lives are changed forever.
I had been working the day shift in the ED, and I had three patients I was following that were just waiting for some results so that I could send them home. The ED was busy, but there were enough residents and PA's to cover them all and not be overwhelmed. Then everything changed.
I was standing at the board waiting for one of my patients to come back from getting a chest x-ray when my senior rushed past me and said we were getting five accident victims from a multi-car vehicle collision (note, they are MVC's (motor vehicle collisions) not MVA's (motor vehicle accidents) since in the ED we don't believe that anything is an accident, it's always someone's fault).
I grabbed some gloves and got to the first trauma room as the EMT's were bringing in the first stretcher. We started to assess that patient when another set of EMT's were wheeling past the door with another stretcher calling out that the patient was not responding. Suddenly, everyone rushed into that room, and I was left alone assessing the patient I had. I was examining my patient when another patient was brought into the ED, and I was told to pack my patient up and move to another room.
So I disconnected all the monitors and grabbed my patient's bed and wheeled him to another room. The other patient was quickly put into the trauma room, and promptly needed a breathing tube. My patient ended up needing basically a CT scan from his head to his knees and plain x-ray films of everything in between.
Once I had finally finished a complete evaluation, about an hour later, I was able to get back to my three waiting patients and try to get them discharged. When I left at the end of my shift, my patient from the MVC was still waiting to get his CT scan. I'll find out tomorrow what it found.
He was driving along. Probably on his way home since this was late afternoon. The patient who took his place in the trauma room was high on something, leading the police on a high speed chase. One of the cars involved in the chase hit my patient and his passenger who ended up intubated and rushed to the operating room. We'll see if they even survive.
Two other, less serious patients were brought in from the same chain of accidents. One was being discharged as we were leaving. I don't know anything about the other one.
A moment in time when someone decided to run, someone decided to chase, and someone got caught in the middle. And, all ended up in our ED.
I had been working the day shift in the ED, and I had three patients I was following that were just waiting for some results so that I could send them home. The ED was busy, but there were enough residents and PA's to cover them all and not be overwhelmed. Then everything changed.
I was standing at the board waiting for one of my patients to come back from getting a chest x-ray when my senior rushed past me and said we were getting five accident victims from a multi-car vehicle collision (note, they are MVC's (motor vehicle collisions) not MVA's (motor vehicle accidents) since in the ED we don't believe that anything is an accident, it's always someone's fault).
I grabbed some gloves and got to the first trauma room as the EMT's were bringing in the first stretcher. We started to assess that patient when another set of EMT's were wheeling past the door with another stretcher calling out that the patient was not responding. Suddenly, everyone rushed into that room, and I was left alone assessing the patient I had. I was examining my patient when another patient was brought into the ED, and I was told to pack my patient up and move to another room.
So I disconnected all the monitors and grabbed my patient's bed and wheeled him to another room. The other patient was quickly put into the trauma room, and promptly needed a breathing tube. My patient ended up needing basically a CT scan from his head to his knees and plain x-ray films of everything in between.
Once I had finally finished a complete evaluation, about an hour later, I was able to get back to my three waiting patients and try to get them discharged. When I left at the end of my shift, my patient from the MVC was still waiting to get his CT scan. I'll find out tomorrow what it found.
He was driving along. Probably on his way home since this was late afternoon. The patient who took his place in the trauma room was high on something, leading the police on a high speed chase. One of the cars involved in the chase hit my patient and his passenger who ended up intubated and rushed to the operating room. We'll see if they even survive.
Two other, less serious patients were brought in from the same chain of accidents. One was being discharged as we were leaving. I don't know anything about the other one.
A moment in time when someone decided to run, someone decided to chase, and someone got caught in the middle. And, all ended up in our ED.
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