E.D. Rollercoaster Ride

One day you're rushing around like crazy, getting slammed on all sides, and the next night you're sitting around discussing the death of Princess Diana, hypothetical situations necessitating "opening and packing" trauma patients, socialist medicine, and Latin phrases.  Of course, the first one most physicians learn is "Primum non nocerum" - First do no harm. 

In our case, my attending gave me several Post-it notes with the letters "FOS" on them.  Usually, FOS means "Full of S*&#" most often referring to a CT scan or abdominal x-ray showing copious amounts of, well, S*&#.  But, in this case, my attending was referring to himself being, "Full of Science."  He gave them to me with the understanding that I could stick one to his white coat if I felt he was giving me too much information from the medical literature which had nothing to do with the current patient's condition.  It's a medical/science thing so maybe not funny to you, but seriously laugh a minute to us.

As you can guess, the patient load was low.  I think the first 3 patients I saw, I went in, evaluated them, determined there was really nothing to do with them, and we sent them on their way with reassurance that they were fine and needed nothing further.  My fourth patient had a migraine, so I gave them some medication, they felt better, and off they went.  My next 2 patients kept me busy with labs and such until about 3 in the morning when there were no more patients waiting, and my attending said I could leave.  So I did.

I had that evening free and this evening free.  In case you're paying attention to the time, this is now Tuesday morning.  Because I am trying to keep my Vampire hours and my internal clock set appropriately, I am keeping myself awake for as long as I can.  Then I'll take a "nap" for several hours before doing this all over again.  I go back to work on Wednesday night for the next three nights, and then, believe it or not, I am done with this rotation.  My next is anesthesia which will be sort of like the free for all that ultrasound was except with needles and breathing tubes.

Since the two more complicated patients were rather boring, I won't bore you with their details.  Suffice it to say that sometimes I miss working at a place like Brigham and Women's in Boston.  I miss havingthe ability to perform whatever procedure is deemed necessary.  The challenge of rural medicine is making due with what you have and being able to stabilize patients given your resources.  Which is where the conversation about "opening and packing" came in.

Princess Diana officially died of a tear in her pulmonary vein leading to her bleeding out into her chest.  Had she been in the U.S. her likelihood of survival would have been higher given that EMS units here follow the edict of "Scoop and Run."  Serious patients aren't managed in the field, they are brought to a hospital for more definitive care.  Not so in France.  They try to stabilize in the field.  According to official reports, it took almost 2 hours for her to be brought in to the hospital because the ambulance crew first tried to stabilize her in the field and then actually stopped en route to the hospital when her blood pressure fell.

My discussion with my attending had to do with "cracking the chest" and then trying to temporarily repair the damage so that the patient would survive transport to ECMC which is the closest major trauma center.  In trauma surgery sometimes you open a patient with massive bleeding and just pack everything off and then go back in later when you have the patient more stable.  It's called "Damage Control" surgery.  You just hope to get the patient through the physiological processes that happen after major trauma so that they can survive the surgery that will actually repair the physical damage.

So too in the rural E.D. setting.  I guess you can think about it like a M*A*S*H setting.  You don't do anything fancy.  That comes later.  Keeping the patient alive long enough to be ultimately repaired is the goal.  Anyway, we had a lively discussion of scenarios and possible means of repair.  He had a lot of war stories to tell, and I can appreciate the need to work within your abilities and resources.

As for my cancer patient from the day before, they pulled out 550 cc of fluid from her lung, and it looked much improved on chest x-ray today.  If you remember the bottles from some of my prior entries, it would be a 1/2 liter;  about the amount of one of those bottles.  She still has some fluid there and will probably need that tapped at some later time.

Tags: M*A*S*H, ECMC trauma, damage control, Princess Diana