I love meerkats. They are one of my favorite animals. Whenever I go to the zoo, I always have to check out the meerkat enclosure. I've been following Animal Planet's "Meerkat Manor" since it started. The fourth season is now on, and it's been a tumultuous roller coaster ride with a lot of hard truths about life on the Kalahari and many meerkat deaths. The saddest one so far has been this week's episode with the death of Flower.
She was the main momma and basically the whole series has been about her and her gang. Now she's dead, and I wonder about the direction of the series. Oh, the group will look for a new leader, and there will be many battles to be fought. But, the central figure always was Flower. I am sure her daughters will be figuring prominently as the season goes on... but, they're no Flower.
When I talk about the white board, I am referring to a large dry erase board where all the patient's information is placed. Every day at the beginning of the shift we stand in front of the board and talk about each patient listed. We hear about why they came in, what exams have been done, and what is left to do. As we "pick up" patients, we place our initials on the line at the end of the patient's information. That way, everyone knows who is responsible for that patient. A lot of interesting stories are told at the Big White Board. Sometimes the attending physicians question us about treatment plans or disease processes, so a lot of learning also happens at the Board.
Understand that this is a very large board. As I've said before, all 21 rooms are able to be listed on this. If you look real close, you can see that at 5 a.m. this morning, we had cleared out what had been a full board at 7 p.m. (19:00).
For privacy reasons you can't see the beginning of the board where names are placed. Next is the time they need vitals done. The big space is what's being done/been done, are they being admitted into the hospital or D/C'd (discharged). The next space is why they came to the ED (btw, SOB stands for Shortness of Breath, it usually is not a comment on someone's demeanor), and the final space is where we place our initials. You might see the nurses' names along the edge.
Like I said, we had cleared the board by around 5 this morning, so my senior allowed himself to be a guinea pig while I practiced my ultrasound skills. One of the benefits of this residency program is a strong foundation in ultrasound. He let me get the goop out and find his liver, heart, kidneys, spleen and bladder. This is all important when someone comes in that's had trauma.
A FAST exam (Focused Assessment by Sonography in Trauma) was developed to help determine if someone is bleeding internally. We can immediately see if someone needs to go straight to surgery or if they have lesser injuries that can be evaluated with some observation and other tests. We also have the benefit of immediately being able to assess for other diseases without having to wait for an ultrasound tech. Sometimes having advanced warning about a potentially life-threatening condition is well-warranted.
Officially, I have my ultrasound rotation in November, so I will save the technical aspects until then. Last night was just a nice introduction with some time, and a lean senior, which made finding the structures easier.
No real thoughts on my patients from last night. Most of them were pretty sick, and unfortunately, so many people fall through the cracks of the medical system. Preventative medicine should become a priority in our health care system and people need better access to health care.
I had a repeat patient who came back with pneumonia. I'd seen her the week prior and discharged her with a prescription for an antibiotic for her bronchitis. Her insurance wouldn't cover that antibiotic so she had to wait until morning to call her doctor's office. They didn't call her back. Two days later she was still waiting to hear from them, and her pharmacist was nice enough to give her antibiotics in a similar class as the one I had prescribed. Unfortunately, they did not have the same potency, and she did not get better and came back to the ED now with pneumonia.
Because an insurance company refused a $100 dollar prescription, they will now have to put out about $300 a day for her to be in the hospital, not to mention her labs, chest x-rays, transportation fees, etc. And, she's one of the luckier ones that actually has some insurance. Most of our patients don't have any, nor a regular physician. For all my banter about my patients, I really feel a national health plan for all workers might not be such a bad thing...
ok, no more politicking. I have the next 3 days off and then I stop being a vampire and return to the real world of working days. Maybe, I'll finally unpack all the boxes I've been skirting around in my bedroom... :D
For the last several nights, I've improved on my patient-managing skills, plus the ED has been super busy, and I have been seeing 12-15 patients a shift. Last night I saw 5. We just weren't busy. Oh, and out of superstition, you never use the Q Word (quiet) or the S Word (slow) in the ED or the ICU because if you say it, suddenly it won't be.
My patients last night were an interesting mix. Some thoughts:
- if you develop a skin boil and your grandmother tells you to put garlic on it because if garlic is good at helping prevent cancer it will probably kill whatever bad bugs are causing your infection, think twice about taking that piece of garlic and rubbing it in the wound, really (I had to stick a scalpel in it to drain out the pus)
- drunken male teens that get pounded on by bouncers at a club had to have done something to provoke the attack, and if you've been drinking all day and can't remember how you ended up with two guys showing you the door, still think you must have said something, probably, I don't care if you are a nice guy from Canada, I am sure the same rules apply there (I put 6 stitches on the L eyebrow and 3 stitches on the R eyebrow)
- little old ladies from nursing homes get directly admitted, do not pass go, do not collect $200
- exotic dancers face work hazards, I didn't know about all the falls some girls take "working the pole," if you fall off the pole and hit your head several times you might develop some back pain, or seizures, oh, and never accept drinks from customers, you don't know what might be in them
- and, finally, if you're over 60 and your girlfriend has already sent you to the hospital several times after an argument, might be time for a new girlfriend, or else you might end up like my final patient - with a broken rib leading to a collapsed lung (get a chest tube put in and admission to the hospital)
[on the soap box] seriously, domestic violence can happen to anyone, male or female at any age. I got Crisis Services involved with this patient. will he leave his girlfriend, probably not. will she hurt him again, statistically, probably. But, for now he's safe,admitted to the hospital.
Being in the ED is kinda like being in Vegas. There are no windows, few clocks, and it can be any time of day or night, you'd never know. I never thought about it until last night when I was examining a patient. When I came into work it was a very warm, sunny evening. This man was wearing a jacket.
Ok. I asked him to remove it so I could examine him. His shirt was wet. He had come in because he was short of breath. I asked if he was having a really hard time breathing and he said no. I asked if he was having any chest pain. Again, no. I said, "Your shirt is all wet." He looked at me as if I was the stupidest person in the world and said, "Yeah, it's raining like crazy out there."
If you've ever watched "ER" the pilot episode is kinda like that. Various characters at one point or another come to the ambulance doors or a window and ask, "When did it start (raining, snowing), etc...?" Seriously, we're in an isolated environment. The only acknowledgement of the passage of time is the changing roster of patients on the Big White Board.
Some thoughts on last night:
- there's a disease called Pica. It's when you eat unusual things. I had a patient who was attempting to kill himself by indirectly causing harm to himself. He took a boatload of cocaine to give himself a heart attack. All he managed to do was ruin his heart valve requiring surgery. He's swallowed razor blades, and other objects to cause blockages and infections. Last night he came in because he'd swallowed a toothbrush ten days prior. CT scan found it still lodged in his stomach. The tube of toothpaste had already passed through. Seriously. He's going to be scoped by the GI doctors. No blockage. One day out of prison. Try again.
- A mother was concerned because she came home and found her son asleep on the couch. Couldn't wake him up so she called 911. On the way to the hospital, he admitted to using a large amount of cocaine. He was having chest pain and having trouble breathing. Then he passed out again. When I talked to his mother she didn't seem very concerned. "He's been drinking with his friends for the last 2 days and hasn't slept. He's just sleepy. By the way, he's had like a cold. His nose is all runny. Can you check him out for that too?" When the 19 year old finally came to about 6 hours later, he admitted to me about the cocaine and heavy alcohol use. Sorry, mom, the sniffles is from the snorting. Stop the coke and that will all go away. Oh yeah, and he wasn't sleeping because he was on a high. But, I didn't say that. Mom doesn't know about the drugs, and I was not going to be the one to tell her. I did my duty and told the son about the dangers of cocaine use. We'll see.
- if you're going to get drunk, pass out at home, not in the middle of street. People are going to want to stop and help you. When they do, don't spit and throw punches. They'll just get mad and you'll wind up in restraints. Then, when you come into the ED we're going to put a face mask on you and give you drugs to calm you down. Then you're just going to tie up a bed for 8 hours while you sleep it off. Here, if the blood alcohol level is less than .350, the patient can be sent home when they're safe to. If it's above that, then they can be admitted to a special service to help them detox. Gets them out of our ED, frees up a bed. Keeps the board open for someone else.
OK, have to run off for another night of fun... oh yeah, and I got my first repeat customer. I admitted him on the 20th, he was discharged back to his nursing home yesterday, and came back again. Don't even get me started on nursing homes or keeping someone a full code. We've kinda covered that. So for now, the soap box stays put away.
So, I have a 48 hour break before my next shift. Just enough time to come home, take care of bills, clean the catbox, water the plants... the usual household tasks. And, since I work another set of nights, I am staying up all night so I don't break my sleep/wake cycles. TV at 3 in the morning is an interesting mix of really bad movies, info-mercials, and those strange shows that can only be shown at that time. Thank God for satellite. Not to mention my massive collection of DVD's.
The cats are happier. Especially Sofie. She's the girl. She's my little shadow. Wherever I am is where she has to be. On the couch, on the recliner, on the bed, in the bathroom, in the kitchen. If I sit, she sits next to me. If I am running around, she'll check out this or that in the room and then come crying and meowling until I pick her up and we settle down on a chair somewhere.
Ever wonder what cats think of us? I woke up this afternoon to see her face looking into my face as she took over half the pillow. When I called her name, she did the usual extension of the paw and laid it square on my nose. Does she see me as just some large big cat? Sometimes I wonder. But, not too long as she does a lazy roll on her back, and soon her purring lulls us both back to sleep.
I am too tired to do my usual diatribe about the events of the ED. Suffice it to say that the majority of the reports from the EMT's this evening started with the phrase: "Patient went out drinking tonight and then..."
- the patient drove into a tree and crashed headfirst through their front windshield. After all the work-up was complete, the patient was found to have only sustained a bloody nose (refer back to one of my previous posts for rule #1 for drinking and driving: drink enough and you won't get hurt)
- "several unknown assailants" (Two Dudes must be on vacation... again, refer to earlier posts) jumped on several of our patients causing a variety of injuries normally seen on boxers who are on the losing end of the prize match - the patient got into an altercation at a wedding leading to them being stabbed in the stomach, "really, it's just a flesh wound" lead to an exploration, and when 6 inches of the probe disappeared into the belly tissue, the patient was sent for emergency surgery
- the patients went out and rode their motorcycles which they subsequently crashed requiring the services of our Mercy Flight helicopters, the orthopedic surgeons, the neurosurgeons, and admittance into the trauma ICU
and, our favorite of the evening, of which, believe it or not we had two:
- the patient got into an altercation at a local bar, went outside to avoid a further dispute, and tripped off the curb...
what I want you to realize is that this person is lying FLAT on the bed... the two spots you see on the skin just below his pant's line would be just above the front of the ankle if the foot was in the normal position. And, like I said, we had TWO of these injuries tonight.
... that first step is a doozy!
So, last night was drug and alcohol night, and the majority of the patients followed the adage of the Coneheads and "consumed mass quantities." I was told that most of the local bars run specials on Thursday night and that the local college crowd gets a little rowdy.
I was also introduced to a new medical diagnostic clue: the Red Bag sign. That's when a patient is so drunk or high they're vomiting, so the EMS guys tie a red bag around their neck like a bib so the patient can vomit right into it and not mess up the nice clean ambulance. You pretty much know the diagnosis and the management as the patient is being wheeled in the door; red bag flopping, or sloshing, just a little as the case may be.
So, while one half of our patients were partying it up and getting rowdy (crashing cars, breaking windows, falling down stairs, knocking on neighbors doors and demanding to be let in to the point of being arrested and brought in by Buffalo PD, etc.) the other half of our patients were depressed and suicidal leading to a mixed bag of drug and alcohol combinations that were each a case study on how to treat overdoses. Some were just drug A. Some were drug A + alcohol. Some were drug A + B. And several were drugs A - F swallowed down with a good slug of vodka, or beer. Of course, if you're going to really try to make a statement, you might just be a murder suspect being chased by police through the woods and decide to stab yourself several times in the neck with a hunting knife. That'll show 'em.
And, speaking of cutting, I did have an 18 year old with cutting scars on her feet: one of which read, "I love you to DEATH" Seriously. Cut into the top of her feet. When I first went in to examine her, I thought she'd had some sort of accident. Then I noticed the scar lines seemed to be making some kind of pattern, which I soon understood to be words. Then I actually got to the point I could read the words. This on a girl who didn't want any blood work done because needles scared her. Uh, honey, you let someone CARVE into your skin with something most likely bigger and sharper than a needle. Hmmm...
As of the time I left, all of the overdose patients were still alive (some despite repeated attempts at offing themselves with drug cocktails), the drunks were detoxing (we usually just let them sleep it off, sometimes needing four point restraints for those that refuse to go to sleep peacefully), the crack and cocaine abusers who were developing paranoid delusions as the night went on were being sent to the psych side, and the drunken 18 year old was being picked up to be taken home by her parents with a stern warning by one of the other ED docs about the dangers of alcohol.
Red Bag Thursday night. The other must-see event.
Oh yeah, by the way, if you once burned the back of your throat while smoking crack cocaine to the extent that you needed to have a hole cut in your neck so that you could breathe, when you come back in complaining of a sore throat after you, uh, yes, wait for it, smoked crack cocaine again, we're gonna laugh at you. Really. Laugh and point. Mhmm.
