Merry Christmas Eve

I haven't posted in awhile b/c I've been off service for a month. Nothing interesting during that time really. But now I'm back in the ER doing a stretch of nights during the Christmas season. As usual, there's no shortage of craziness. Let's see.....

Last night:

An inmate from Riker's came to the ER with the chief complaint of "penis pain." His only past medical history was schizophrenia. So I gulped some coffee and went to interview him. Or I tried to, rather. He was so floridly psychotic that I couldn't -- no one could -- have a conversation with him. I felt very sorry for him -- schizophrenia is a horrible disease. He honestly could not distinguish between what is real and what is not; he was having constant auditory hallucinations. Basically, he said that he had been impregnated by aliens and that he would soon give birth to exactly 500 male-only babies that would emerge from his penis. However, they were all going to be premature and die. The only way that he could stop that from happening -- according to the aliens that were speaking to him and only him -- was to constantly masturbate so that the babies would stay inside.

And masturbate he did. Over the previous four days, he said he had been masturbating NONSTOP -- and based on what I saw, I believed him. I pulled back his sheet, and he penis was raw, skin was denuded, bleeding, and the area around the head of the penis was so swollen (the size of a small baseball), it was choking off the blood supply to the head of the penis (a condition called paraphimosis), and the head was starting to rot, pus was coming out.

"Don't touch it," he said. "You will make me give birth to my babies and I can't have that happen yet." And with that, he swatted me away and started to jerk off.

I briefly thought about admitting him to the ob/gyn service but thought that it might be frowned upon.

Anyway, I had to have his accompanying officers handcuff both hands to the stretcher to prevent him from masturbating. He cried, begged and pleaded with me to let his babies live. I made one futile attempt at reasoning with him, then admitted him to the urology, started him on antibiotics and he had to go to the OR. It took the staff psychiatrist less than five minutes to declare him legally incompetent and without capacity.

-----

Next up: a twenty year old kid who was out drinking with friends. They were walking back to Penn Station (ostensibly to go back to Jersey) when they came upon construction scaffolding. Mr. Stupid Drunk decided to grab onto the scaffolding and swing from it. The scaffolding crashed down on his head and down he went, lost consciousness for about five minutes, according to his friends.

He arrived fine, talking, no abnormalities on exam, no cuts, abrasions or lacerations anywhere. He was still drunk, and we CT'd his head. I was quite surprised -- he had a fairly large subarachnoid hemorrhage and was bleeding into his brain. In fact, the neurosurgeon had to come down and see if he needed to go to the OR (he didn't). But his status changed from stable to critical, so we had to make sure this belligerent drunk was calm, stayed in bed and didn't move.

Naturally he did the opposite of that. He was loud, obnoxious, and was trying to leave, saying his mom was going to be SO MAD.

So we strapped him down and then he said he was going to piss in his pants. It's the holidays, so we're understaffed -- there were no nurses aides to help him pee, and I couldn't allow him to get out of bed. So I did what I had to do -- unzipped him and held his wee-wee in place while he peed in a portable urinal. This is what I paid $200K for -- to go to med school and learn how to help someone pee. I'm sure my parents are so proud.

Well, his mother DID show up and she WAS pissed. I explained to her the seriousness of the situation, and she said, "I'm going to beat him silly when he sobers up."

"You can hit him anywhere except the head," I told her.

-----

Then the trauma phone (a/k/a batphone) rings. Someone hit by a car, but vitals were stable. I felt so terrible for this poor guy -- his car stalled, he was changing a tire, and another came by and swiped him. His right leg was almost 100% sheared off at the knee, and the other leg was crushed. Just in time for the holidays, too. As of this writing, the surgeons are still trying to put his leg back together.

-----

Another dude made a second trip to the ER in as many days for the same problem: left arm pain. He was here yesterday according to his previous chart, and he was x-rayed. After the films were negative, he was discharged with pain meds and follow up. In the intervening time, however, his arm became markedly more painful and now swollen from shoulder to fingertip. Looking at him, he was very thin, pale, cachetic and sickly-looking. On further history, it turns out that he had been losing massive amounts of weight and felt tired and lethargic all the time.

It's said that if you come back to the ER for the same complaint, you'd better fish some more. So I drew bloodwork on him and sent it off to the lab. There's not much in the differential diagnosis of unilateral upper extremity swelling, and in the absence of trauma, something much more sinister is going on. He was slightly tachycardic, so I gave him some fluids and pain medicine in the IV thinking that his pain was causing his fast heartrate.

The the lab called: his white blood cell count was 52 (normal is up to 12), and his d-dimer, or measure of blood coagulability, was sky high. And then, all of a sudden, his heart rate jumped to the 160s, but his blood pressure was stable. He was now in rapid atrial fibrillation with rapid ventricular response. It was a confusing clinical picture with many different symptoms: arm pain, swelling, high white count, rapid heart rate, now in atrial fibrillation.

Sir William Osler was a famous physician from the 1800s who came up with a general rule: if there are multiple complaints, the overwhelming chance is that there is one unifying diagnosis rather that multiple, discrete ones.

So what could this guy have? I wondered.

Think, think, think:

A *very* high white count

Hypercoagulable state

Thin, cachectic, unusual weight loss

Arm pain and swelling

Sinus tachycardia

Now in atrial fibrillation

One diagnosis.

Cancer.

It could only be cancer causing a blood clot and pulmonary embolism. Blood and bone marrow cancers cause your white cell count to skyrocket to those types of numbers. Cancer causes you to be hypercoagulable and get blood clots in your great vessels. Sinus tachycardia is the most-associated heart rate/rhythm with malignant pulmonary embolism. Atrial fibrillation is the second most common.

And as it turned out, his arm swelling was in fact the initial presenation of his lymphoma, and he had a fairly large blood clot in his arm and one in his lung.

-----

Back at it tonight.

Orifice Day

Today there was an unusual amount of foreign bodies to be retrieved.

Patient 1: a young woman who stuck a kitchen sponge inside her vagina and couldn't get it out. I took a look, and sure enough, a small piece of sponge was there, lodged near the cervix. I didn't ask why it was there -- I never do. One, I don't care why; two, who am I to judge? Three, the question gives the appearance of judgment, and I don't want to make the patient uncomfortable. The closest I ever came to asking "why?" was when during a routine pelvic exam, I found a leaf inside a patient's vagina. I simply held it up and said, "Did you know this was in there?" "Nope," was all she said. And that was that.

Patient 2: Another foreign body in vagina. This was acutely more painful. A young woman was using a vibrator in the shape of a penis, and the head BROKE OFF and got lodged. (No, it was not still vibrating.) But it had electrical parts to it. Danger, Will Robinson. I had to give her valium to get her to relax so that I could pull it out with forceps. Unless it's infected, I always offer to let the patient keep whatever I retrieve. "No thanks," she said, "and my boyfriend is totally going to get an ass-kicking now, this was his idea, you know." Go girl.

Patient 3: 94 year old dear woman with a big ol' protruding belly. She was almost completely deaf and she was shouting as if everyone else was too.

"I HAVEN'T SHIT IN TWO WEEKS," she yelled.

I thought that if I whispered, she would get the hint. "Really?"

"WHAT? YOU HAVE TO SPEAK UP SONNY, I CAN'T HEAR A WORD YOU'RE SAYING."

Now we were shouting at each other for the whole ER to hear.

"WHEN WAS YOUR LAST BOWEL MOVEMENT?"

"I SAID TWO WEEKS AGO."

"REALLY? FOURTEEN DAYS?"

"SINCE ONE WEEK IS MADE UP OF SEVEN DAYS, THAT WOULD BE A 'YES'."

Sharp as a tack, old as dirt.

"LET ME DO A RECTAL EXAM AND SEE IF THERE'S ANYTHING THERE. YOUR BELLY COULD BE SWOLLEN FOR A DIFFERENT, MORE SERIOUS REASON."

"DO YOUR THING, DOC."

So I have an aide hold her onto her side, and I glove up, put some lube on my finger (don't ever forget to do that part), and poke a finger in. Gobs of doo doo greeted me. And when that happens, you know what you have to do: manually disimpact. It is my least favorite thing to do, but it's THE most gratifying thing for a patient, hands down. They always heave a HUGE sigh and say "THANK YOU!!!" after it's all said and done. So with two fingers, I'm shoveling out turd after turd. It was disgusting. And I found out that this procedure has a higher billing rate than either CPR or intubation, can you believe it? I told the aide helping me: "I spent $150,000 to go to medical school to learn how to shovel shit. That's some bang for your buck." But here's the really twisted part: after collecting it all, I weighed it on a scale, just out of sheer curiosity. OVER FOUR POUNDS.

Patient 4: Prisoner came with police escort who said he swallowed a ring. And though I said I never ask why someone shoves something up their butt, I *do* ask why they swallow stuff.

"Cuz someone would steal it from me if they saw it on my finger. It's gold with a diamond in it."

I'm sure he wasn't lying about someone wanting to steal it in the joint.

X-ray confirmation: a ring in the rectum. So I gloved up and fished it out. Fake gold, fake diamond. I gave it back and said he should find a better place to hide it.

Orifice Day

Today there was an unusual amount of foreign bodies to be retrieved.

Patient 1: a young woman who stuck a kitchen sponge inside her vagina and couldn't get it out. I took a look, and sure enough, a small piece of sponge was there, lodged near the cervix. I didn't ask why it was there -- I never do. One, I don't care why; two, who am I to judge? Three, the question gives the appearance of judgment, and I don't want to make the patient uncomfortable. The closest I ever came to asking "why?" was when during a routine pelvic exam, I found a leaf inside a patient's vagina. I simply held it up and said, "Did you know this was in there?" "Nope," was all she said. And that was that.

Patient 2: Another foreign body in vagina. This was acutely more painful. A young woman was using a vibrator in the shape of a penis, and the head BROKE OFF and got lodged. (No, it was not still vibrating.) But it had electrical parts to it. Danger, Will Robinson. I had to give her valium to get her to relax so that I could pull it out with forceps. Unless it's infected, I always offer to let the patient keep whatever I retrieve. "No thanks," she said, "and my boyfriend is totally going to get an ass-kicking now, this was his idea, you know." Go girl.

Patient 3: 94 year old dear woman with a big ol' protruding belly. She was almost completely deaf and she was shouting as if everyone else was too.

"I HAVEN'T SHIT IN TWO WEEKS," she yelled.

I thought that if I whispered, she would get the hint. "Really?"

"WHAT? YOU HAVE TO SPEAK UP SONNY, I CAN'T HEAR A WORD YOU'RE SAYING."

Now we were shouting at each other for the whole ER to hear.

"WHEN WAS YOUR LAST BOWEL MOVEMENT?"

"I SAID TWO WEEKS AGO."

"REALLY? FOURTEEN DAYS?"

"SINCE ONE WEEK IS MADE UP OF SEVEN DAYS, THAT WOULD BE A 'YES'."

Sharp as a tack, old as dirt.

"LET ME DO A RECTAL EXAM AND SEE IF THERE'S ANYTHING THERE. YOUR BELLY COULD BE SWOLLEN FOR A DIFFERENT, MORE SERIOUS REASON."

"DO YOUR THING, DOC."

So I have an aide hold her onto her side, and I glove up, put some lube on my finger (don't ever forget to do that part), and poke a finger in. Gobs of doo doo greeted me. And when that happens, you know what you have to do: manually disimpact. It is my least favorite thing to do, but it's THE most gratifying thing for a patient, hands down. They always heave a HUGE sigh and say "THANK YOU!!!" after it's all said and done. So with two fingers, I'm shoveling out turd after turd. It was disgusting. And I found out that this procedure has a higher billing rate than either CPR or intubation, can you believe it? I told the aide helping me: "I spent $150,000 to go to medical school to learn how to shovel shit. That's some bang for your buck." But here's the really twisted part: after collecting it all, I weighed it on a scale, just out of sheer curiosity. OVER FOUR POUNDS.

Patient 4: Prisoner came with police escort who said he swallowed a ring. And though I said I never ask why someone shoves something up their butt, I *do* ask why they swallow stuff.

"Cuz someone would steal it from me if they saw it on my finger. It's gold with a diamond in it."

I'm sure he wasn't lying about someone wanting to steal it in the joint.

X-ray confirmation: a ring in the rectum. So I gloved up and fished it out. Fake gold, fake diamond. I gave it back and said he should find a better place to hide it.

The Nursing Scuffle Shuffle

Last night, a Chinese woman who spoke no English came with several relatives to the ER. It was obvious that something was wrong with her left ankle. It was deformed, swollen, blue and purple. My immediate guess was that she had some type of accident and fractured her ankle.

I got her on a stretcher and used the translator phone to determine that my assumption was correct -- she was a bit elderly, was walking to dinner, tripped in a pothole, and down she went. She said it didn't hurt that badly. I told her I was going to give her some pain medicine, and she declined -- she said, via the translator, that she just didn't want any medicine right now. Fine, I said, let me know when you do.

Five minutes later, the nurse Sandy came up to me and asked why I was letting this old lady sit around and cry in pain.

First of all, let me tell you about Sandy -- she's one of the old guards of this old hospital, and has been around for a long, long time. Today was her last day, and she was retiring. Bottom line: she's nasty, has a terrible attitude, is awful to patients and to doctors, and often fails to carry out orders in a timely fashion. In addition, she's loud, obnoxious, and universally unpopular except to her contingent of other old-guard bad-attitude nurses that are her friends. For some reason, many people are afraid of her. They don't want to get into an argument, they don't want confrontation with her, they simply just want to avoid her altogether.

One time, she had (finally) done an EKG on a patient who was triaged for chest pain. An hour after that EKG was done, the patient's clinical picture had changed, and he was having active chest pain. I asked Sandy to do a repeat EKG on the patient, and she cocked her neck to one side, put her hand on her hip, raised one eyebrow and said, "what for?"

"Because his clinical picture is changing. He is now having worsening...."

And she rolled her eyes and walked off (but did the EKG). No matter how you slice and dice it, that was just RUDE. And very few things make me more upset than being rude and wrong at the same time with an air of superiority about it.

"Just let it go," said my attending who saw that exchange. "She's getting the EKG."

That's the problem. Everyone lets it go. Sometimes I guess I do too, but I was not in the mood for it that night. So I ran right up to Sandy after she did the EKG (and I made sure it was benign) and said, "Look, you can ask any question you want to, I'm fine with that. But what I'm not fine with is when you walk away during the answer. If you don't want to know the answer, don't ask. You KNOW that was rude and there's no excuse for that."

She said nothing, but I know she knew I was right.

So back to this particular story (and I'm still getting riled just recollecting the events).

"Why are you letting this poor lady sit there and cry in pain?? Give her something!"

"Sandy, I JUST got off the translator phone with her and she refused ANY pain medication. Now that the situation has obviously changed since she's crying, I'm happy to reassess her and give her anything she wants to control the pain."

Not good enough for Sandy. She said, "I mean, for goodness sake," and her voice is rising and patients and their families are noticing, "you give any fucking alcoholic in here as much morphine as they want, but you won't give a lady with a broken ankle any fucking morphine? That's bullshit! But what do I know?? YOU'RE the doctor, right?"

"First of all, did you hear anything I just said? Second, if you don't think I'm treating a patient's pain appropriately, you say, 'hey doc, I think your patient is having worsening pain, can you re-assess her or give her more medicine?' Third, I think we can all agree that there is NO need for that kind of language in any setting, much less in an ER in front of patients, families, nurses and doctors. That is completely inappropriate and out of line and you know it. I'll deal with you later but right now I'm going back to the patient."

So I doped up the patient with plenty of vicodin and went back to Sandy.

"Come here, Sandy, I want you to hear this." I had her stand in front of me while I picked up the phone and called the Director of Nursing. While the phone was ringing, I said, "Sandy, I want you to hear exactly word for word what I'm telling Lorrie, that way you can tell her if anything I'm saying to her is inaccurate in any way."

So I told Lorrie exactly what happened. She came downstairs in less than one minute.

"Sandy, is this true?" she asked.

No answer.

"Sandy. Is what he's saying true? Did that happen? Did you say those things?"

"Yes I did."

"Go home."

Call me an asshole, but I got her sent home the day of her retirement before her retirement party. I don't regret any of it, and different doctors and nurses alike who witnessed this whole event kept saying that more people should have spoken up to her and combatted her bullying much, much sooner. And that's exactly how she's been acting to many people over the years -- like a bully. I wish her the best in her next endeavor whatever it may be, but I sure hope it's in an administrative role inside a cubicle.

Brief political foray

It's no secret I'm quite left of center, but not, say, Berkeley left. Just slightly.

I couldn't be happier about the midterms for the most part. Frank Rich got it right -- this was the rise of the moderates. Most Americans are quite centrist in their views, and they were sick of the GOP being beholden and hostage to ultra-right wing political cronies and undue influence. No better was this illustrated than in South Dakota, where most republican voters struck down the sweeping anti-abortion law ever seen since Roe v. Wade. It, like government under Bush, went too far, and voters finally recognized that. And they came to see an old axiom come to life: absolute power corrupts. GOP control of the presidency and legislature was, in the past 8 years, a slap in the face of the Constitutional framers. Make no mistake -- a vast majority of the voters said that this vote was about national issues and a referendum on Bush. And it was a stinging rebuke of the presidency and his perceived incompetency on national and international issues. Let the moderates rise.

But -- did anyone else notice that the former darling of the right wing Ann Coulter was conspicuously absent from the entire political landscape during the midterms? What happened to her?

Let's hope bipartisanship can work -- and that the new in-power in-vogue Democrats can put populism on par with ideology.

Gunfight at the OK Corral

It's ten minutes before my shift ends and the trauma phone rings.

Shit.

Oh hey, whaddya know? My compatriot Anthony arrived ten minutes early for his shift. "No worries, Fletchy, you go home, I'll just start early and take this one coming in." Bless you, Anthony!

The notification: 24 year old male, gunshot victim, bullet apparently lodged in his arm, bone in pieces, open fracture, no other injuries, vitals stable. Easy enough. Make sure there's no other injuries and off he goes to the OR. I decided to peek in before leaving.

True enough, the EMS personnel bring him in, and he's one mad as hell mutha. A quick survey revealed no other injuries, and Anthony was standing at the head of the bed helping to run the trauma. Gross sight -- the bone in his forarm was splintered into pieces and sticking out of the skin, like a piece of old wood that broke off. Ewwww, I thought. Then, I was just about to leave when the paramedic says, "The other guy will be here in five minutes."

Huh? Other guy?

"Yeah, there was another guy shot at the scene, he got shot in the chest but I think his vitals are stable."

"You *think*?"

"I dunno. I just picked up this one who got shot in the arm; I just heard about the other one coming over the radio."

I looked over at Anthony. He tilted his head towards me and gave me that knowing, sympathetic look: I know, I'm sorry. I can't break away from this one, you have to help run the other one coming. Sigh. What was I going to do, leave? At least I had a second to make a phone call and let my friends know I wouldn't be joining them for dinner. Sometimes I lose perspective about what it is that I do, so the following conversation is a little funny now that I recollect it:

Me: "Sorry guys, I can't make dinner."

Them: "Why not?"

Me: "Sigh," I'm moping and pouting. "Somebody got shot in the chest and I have to help."

Them: "Ummm....I think the *rest* of us think that's a good excuse. Why are you even on the phone right now?"

That was really selfish, right? But it made me laugh.

Anyway, I set up everything in anticipation of a traumatic intubation, and then the EMS guys burst in the room with a young, skinny little thing who is scared shitless. "I GOT SHOT!" was all he could say, over and over. At least he was speaking. No inubation needed. And his vitals were stable. But no sign of a gunshot wound in the chest.

However, when we surveyed him and rolled him over, we saw a bullet hole over his left scapula. But no exit wound. The bullet was still there inside him, somewhere. Most of us thought that it was stuck in the bone or left lung, so we stabilized him and put in IVs and drew blood while the tech took a chest xray.

Twenty feet away, the other trauma was still going on. The two victims then saw each other and -- wouldn't you know it -- they were the two shooting at each other.

"MUTHAFUCKA! YOU AIN'T DEAD MUTHAFUCKA??!! YOU FINNA BE!"

Great. Just great. At least they were both talking, despite the fact they were riddled with bulletholes.

"BITCH ASS YOU WILL DIE WHEN I GET OUT OF HERE MUTHAFUCKA!!"

"FUCK YOU!"

"FUCK YOU PUNK!"

The first one was wheeled out and to the O.R. We rolled the second over and did our primary survey. Part of the survey is to stick a well-lubed finger in the ass to make sure there's no hidden rectal injury or bleeding that would indicate an intra-abdominal wound. So the surgery resident split his asscheeks apart and out popped two bags of crack and a bag of weed.

Later, I had to explain the anatomy of all this to the NYPD detective who showed up. ("No no, it wasn't IN his ass per se, it was in his asscrack proper. Get it? Not in his assHOLE, but trapped in his assCRACK.")

So the chest xray got done and there it was: the bullet. Lodged in the right lung. But he got shot in the left scapula. As it turns out, the bullet was deflected off the left scapula (it IS a very thick piece of bone), traversed his midline, somehow avoided the mediastinum and great vessels in the thoracic cavity (lucky dude), and ended up in the right lung. So he had a blood-filled left lung that collapsed (hemothorax) and a punctured right lung that collapsed (pneumothorax). But he had enough reserve lung capacity to breathe somewhat normally. However, he would need bilateral chest tubes.

So my friend Tran from surgery took the left side and I took the right side. We gently sedated the patient and gave him lots of morphine. Tran and I poked large holes in his chest from the side with the BMKs (short for what we call Big Mother Kelly Clamps) -- POW -- you can actually hear when you poke into the lung cavity. Blood poured out from Tran's side with the hemothorax, and a WHOOSH of air rushed out from my side with the pneumothorax. We slid the tubes in (Tran beat me, he finished first), tied them off, his lungs were nice and re-inflated, and off to the CT scanner he went. I just hoped that they would remember to put him and the other assailant in different rooms when they were done.

I collected the bags of crack and weed, handed them over to the NYPD, washed up, changed scrubs, threw the bloody ones away, and headed home since I missed dinner.

I did, however, get to flip on the TV for a minute and watch as Nellie Oleson (LOVE HER) tormented Laura. Then off to bed, too tired for food.

What a weekend

It's been about a week since I updated this blog because it has been a rough week. I worked seven out of the last eight days, so I was TIRED. But I did see a lot of shit.

First, there was this 26 year old kid who was really drunk the night before; he was running down the street -- actually after partying it up at the bar over which I LIVE -- and he tripped and fell down at enough of a weird angle onto his hip -- hard enough to *dislocate* it. OUCH. Just looking at him made me cringe -- his left hip was out of its anatomical position, leg rotated outwards and about six inches shorter than the other one. Ewwwwww....

So together with my friend from orthopedics, we had to reduce it. Or rather, we tried to. This patient was as big as an ox, and he confessed to us that after he fell and dislocated his hip, it hurt so bad that he started doing lines of coke on the STREET to numb the pain. There are multiple problems with that "solution," one of which is to counteract centrally-depressive agents. Thus, his heart rate and consciousness sailed through our attempts to sedate him enough to put his hip back in place. I pushed 24 mg of Versed and 200 micrograms of Fentanyl on this guy and it only made him slightly sleepy. Usually, an adult dose is 4 mg of Versed, and at 10 mg, you start to worry about the patient maintaining their airway.

On attempts 2 - 4, we tried another agent called Propofol. It's a milky white general anesthetic (we call it Milk of Amnesia) that's very quick-on quick-off -- it lasts about five minutes, so it's a favorite for short procedural sedations. Only problem is, it has a narrow therapeutic profile, so just a hint too much and they quit breathing. The easy part about that is that you only need to bag the patient for about sixty seconds before it wears off and they start breathing on their own again. And the usual induction dose for total anesthesia in the operating room is about 40 or 50 mg for a generic 70-kg adult.

I pushed a total of 170mg on this guy and still nothing except mild drowsiness. He said he had only three lines of coke, but there's no way I believe that. He finally had to go to the operating room for general anesthesia because nothing was touching him in the ER.

Then the trauma phone rang. We got advance notification that an adult male had a generalized seizure but was no longer seizing, he was just post-ictal and kind of "out of it." "He's fine," said the EMS guy that called in advance, "his vital signs are stable." Okay, great.

When we get advance trauma notification, we usually call the whole trauma team and everyone runs into the trauma room in advance, put on gowns and gloves and faceshields and is waiting for the patient to arrive. But since the EMS field guys told me that the post-seizure dude was fine and "just a little out of it," I felt no need to call the troops poste haste.

So the ambulance arrived and the fourth-year resident met them out in triage. All of a sudden I heard him yell across the ER: "HE NEEDS AN AIRWAY GO TO THE TRAUMA SLOT RIGHT NOW!!!" I don't even remember what I was doing at that moment, I just remember running at full speed to the trauma room.

When I got there, I saw the patient completely BLUE, not breathing, vomit chunks around his mouth. Now, the party line is that you protect yourself first, so no matter what is going on, you must put on a gown and gloves and facemask first before you touch the patient. But this guy -- and a big ol' 250-lb dude he was -- was not breathing and God knows for how long. So, rightly or wrongly, I didn't put on a gown or facemask, and luckily I was already wearing gloves. I just reached over for the intubation blade and tube and thought, "this guy is so big with a huge neck, and he vomited everywhere and it's going to be a difficult intubation, but please God let this tube go in." In one look and pass, it went in. Whew.

Meanwhile, I could overhear the fourth-year having words with the EMS field guys. (Why the hell would you call and say "oh he's fine??!!" HE'S NOT BREATHING!)

I went back to the ER where I still had some relatively sick patients who needed my attention:

-- a gentleman who had no history of a seizure disorder who had suddenly seized in the triage bay (but thank God HIS airway was never an issue)

-- an interesting hematologic case where this woman was spontaneously bleeding from her gums. The normal platelet count is between 150K and 450K, and this woman had only 9K. Below 15K, you're at risk for spontaneous intracranial hemorrhage. I had to transfuse her a unit of platelets and blood. As it turned out, she had aplastic anemia -- massive underproduction of all cell lines -- she had very little platelets, red blood cels and white blood cells. (A later work-up and bone marrow biopsy by the heme-onc inpatient team confirmed she had aplastic anemia, most likely as a result with previous infection from parvovirus and Dengue fever when she traveled abroad -- a known and feared complication from a usually somewhat benign virus.)

I don't remember when I got to finally wrap up and go home, but that evening's hot shower felt very, very good.

Entry 22

The other night a trauma was called in advance by EMS. All I knew was that an 80-something year old man was coming who fell for unknown reasons and had a head injury, but vitals stable.

EMS brought him into the trauma slot and he was talking and moving about (thus, quick ABCs were okay -- airway patent, breathing okay, circulation okay), but not making any sense, perseverating about his address. That was all he could say over and over: "I live at 100 spring street. I live at 100 spring street." Big bandage on his head put there by EMS. I unwrapped it to get a look at what was under there. It was bad, but I've seen worse -- a semicircular laceration about 10 centimeters in length, but the galea was exposed and you could see the bony white color of the skull underneath. A quick exam around the wound failed to show any depressed fracture that I could see. As protocol, I wrapped it back up with a compression dressing (someone will suture it later, first priority is stabilization, not cosmetic repair), he needed to go for his head and neck ct to make sure he didn't break anything. He had an altered mental status though, he couldn't tell me his name or where he was, only that he lived at 100 spring street for the last 50 years. I bet his rent control in soho now was, like, fifty bucks.

The trauma intern packed him up and escorted him to CT. The studies were all clean -- no intracranial bleeding, no skull fracture, no cervical spine fracture or dislocation, chest xray normal. His only apparent injury was the gash on his head. Good news for him.

It used to be the case that in our hospital, the protocol was that should any trauma case come in, no matter what injuries the patient does or does not have, it was an automatic admission to the trauma service and they were responsible for the ultimate disposition, treatment and discharge of the patient. I don't know how or when this next step started, but for some reason, within the last year or so, there's now an unwritten "policy" that was seemingly forced by the surgery team that if, after all radiology studies (CTs, xrays, etc) are negative, the patient is considered "de-trauma-slotted" and goes back to the ER as OUR patient for observation and discharge. "We're really busy," they said.

We're not?

I've been on the trauma service -- there are ten times as many active patients in the ED as there are on the trauma service. But whatever. I'm not that confrontational. I rather understand -- on a case-by-case basis, if it's very simple and requires no operative intervention, fine, I'm happy to have that patient babysat in the ER until they're ready to leave.

But I got pissed off in this case.

"Hey," said the surgery intern -- who's been a doctor for all of three months now -- "all his scans were totally clean, he's going to be de-slotted and coming back."

I felt a little affronted. "Is this your particular decision?"

"The whole team's." [Codespeak for "I don't want to tell you, but it has to be a united front so we can push this patient back to you."]

"I know this is way above you," I snapped back coldly at him. "I need to talk to your senior." But I thought ahead: "Can I see your patient list first?" Like I thought -- a total of seven patients on the trauma service, three under the "to discharge in a.m." column, no one slated for the O.R. Nice try.

So I paged the senior resident. "Jasmine," I said, "your intern is attempting to de-slot Mr. X."

"Yeah? His scans were negative."

"Have you talked to the patient yet?"

"I checked in on him."

"Was he alert and oriented to you?"

"I didn't specifically ask." She could tell I was trying to corner her -- appropriately so -- and before I could again speak, she said, in a not-too-friendly-tone, "LOOK, all his studies are negative, he just needs to be observed and then discharged, that's what happens in a de-slot."

"Are you kidding me? I know some cases are clear -- but he's not a 20 year old who fell down, and I know he's not going to the OR, BUT, he IS over EIGHTY years old, we don't know the mechanism of his injury -- did he trip and fall? Or did he syncopize or have a cardiac event and pass out and hit his head? He's on aspirin and coumadin, AND we all smelled alcohol on him, so he's got three really good reasons to have ineffective platelets, PLUS he has altered mental status and can only tell me his address, not even his name or date or where he is. What about any of that says this-is-okay-to-watch-and-discharge to YOU?"

"Well YOU can re-scan his head if you need to, we are VERY busy."

"About that -- your signout sheet has seven patients on it, three of whom are about to be discharged. We currently have 32 active patients in the ED with more in triage right now."

"His studies were all negative."

"And back we circle. He can't stay here in the ED. Have your intern babysit him."

"Why can't he sit in your ED with a monitor and you discharge him in the morning when he's better?"

Was I talking to a hole in the wall? Time for the trump card.

"Jasmine -- I don't know that he IS dischargeable. I think at this point I should bump it up to your attending and call him at 3am to see if he thinks this guy is stable to be discharged like YOU think he is."

"FORGET IT. WE'LL ACCEPT HIM." Click.

It's not her choice anyway since we have admitting privileges.


AAAARRRRGGGHHH. I just needed to vent about this one. I am no stranger to being on the losing side of a debate about the best thing for a patient, but this seemed totally obvious to me, and I just thought they were being lazy. I generally have a fine relationship with the surgeons but every once in awhile we have to have a spat like this. Incidentally, the patient continued to have altered mental status and had two more head CTs in the next 24 hours, both of which were negative for any pathology or slow bleed. For some reason, he became mentally "fine" and "with it" again later on and was discharged, but not until over 30 hours after presentation -- way too long to sit in the ER.

Entry 21

I'm just going to start calling the titles by entry numbers since I've run out of creative ways to say "same shit, different day."

Not such a bad day at the hospital. Right now I have a few shifts at the private hospital a few blocks up the road from the other one we rotate at. It's four blocks away but a world apart. This private hospital is very much populated by Upper East Side types. I'm not kidding -- when I ask a patient about their prior surgical histories, more often than not they lie right to my face and say, "none" when I can see their eyebrows stretched up to their temples while the rest of their face looks windswept and micro-dermabrasioned down to reddened dermis. Sometimes they're honest with me about the plastic surgery (how many 74 year olds look like they're 40, after all?), but the forgotten-about turkey neck always gives it away. Gobble gobble.

Anyways, the patients here are very different than the ones at the other hospital. These tend to be wealthy, have a SLEW of private doctors ("My primary care doc is doctor x, my cardiologist is doctor y, my ENT is doctor z, my rheumatologist is doctor a, and my dermatologist is doctor b."). The good part about that is that when they end up in the ED, it's usually for something rather acute and serious that their primary couldn't handle.

The bad part is that they're also very high maintenance and almost all of them have M.E.S. -- what we call "Malignant Entitlement Syndrome." For some reason, many -- not all -- think they're the ONLY patient in the ER and deserve your undivided attention at all times. I try to defuse this from the get-go by initially telling them that they will likely have at least a 4-6 hour stay in total, so it's best just to grab the New York Times (or anything not produced by Rupert Murdoch) and sit back and wait.

I actually had a patient write me up to my supervisor for the following exchange (which I still don't regret and don't apologize for because I was honest and nice and made no bones about it):

Patient: Doctor, I've been here for two hours and haven't had my x-ray yet.

Me: Well, like we discussed, I didn't think you needed one for your knee because there's no clinical indication for it -- you say it hurts, and I believe that, but you didn't fall on it, twist it, injure it, and it's not swollen or tender to the touch. Xrays are good for visualizing bony problems, and I just don't think there's one there. I only ordered one because you repeatedly asked for it despite my judgment and explanation as to why you don't need it.

Patient: Well I think it's outrageous that I have to wait two hours for an xray.

Me: I do too, but xrays are triaged according to severity, so someone who has an actual suspected fracture, even if they come in after you, will have to go ahead of you. I'm sure you know this isn't a first-come-first-serve model.

Patient: I'm aware of that, but you know, my husband -- who is a big CEO -- is waiting for me.

[The name drop had to come sooner or later.]

Me: Your husband isn't the patient.

Patient: Yes but I have to get going.

Me: In here, everyone is equal, CEO or non-CEO. And like I said, I'm happy to discharge you without an xray. I know that you also have a private orthopedist, so I'd be happy to have you see him during a scheduled appointment that will probably be more amenable to your schedule.

Patient: LOOK. I JUST WANT THIS XRAY.

Me: Alright, time to level with you -- look around you and think about where you are -- you are in the middle of the biggest city in North America, in one of the busiest ERs in the entire country and probably in the Western Hemisphere. You're just going to have to wait until the five people who are here with KNOWN fractures receive THEIR xrays. If you don't want to wait, this is not a prison, and you are free to go. I am quite frankly asking you to think about those five other people right now and not just yourself.

Patient: Fine, goodbye.

And off she left, walked out with zero abnormalities in her gait.

Just to check, I looked to see in our computer system if she received an xray (it's linked up to her private orthopedists' since he's affiliated with our hospital).

The official report:

"No fracture or dislocation. No swelling or effusion. No history of trauma. Normal knee xray."

I don't believe in coddling people who don't need to be coddled. I don't believe in engaging in someone's dramatics for the sake of drama. On the other hand, I know I could be less bitchy in certain situations. I guess that's why someone wrote a letter about me. JUST SO YOU KNOW, however, I DO receive nice letters too. :)

more from the front lines

Yesterday was that rare good shift: everything seemed to work out. Not too many patients (and it was a Monday!), I was supervising good, hardworking students, and I had good cases. Additionally, I didn't get into one single argument with another resident.

My first patient was a sick guy admitted from the GI clinic. Massive cirrhosis from drinking too much. His liver is scarred down to a nubbin, and his belly is filled with fluid. And it's infected. I get the pleasure of sticking an angiocath into his tummy and I drained THREE LITERS of nasty yellow fluid out of there then start some antiobiotics. I even left a stopcock in his belly so that the admitting team could turn it "on" and drain more as needed. Remember kids, one drink a day keeps the doctor away, but twenty a day will keep the doctor at your bedside sticking needles into your gut while you wait for a liver transplant.

Another lady had DKA (diabetic ketoacidosis). She was short and squat, and her family brought her in b/c she was acting "confused." Not herself, they tell me. What does that mean?

Oh wait, wait -- this is good -- the news is on in the background and Marc Foley -- one of the legions of GOP hippocrites (he was the leader of the Center for Missing and Exploited Children) -- his lawyer just came on and said that the bastard was himself molested by the clergy and thus it's not his fault. Give me a fucking break. It's long been time to clean house -- and senate.

Anyways, this lady had a blood sugar of 750. 750! Normal is 70 to 100. No wonder she was confused -- her blood was like maple syrup. When it's that high, in insulin-dependent diabetics, your body actually goes into "starvation-like" mode. It can't process the sugar as fuel because it has no insulin to bring it into cells, so the body starts breaking down fats for energy and the waste byproduct is ketones. (I guess I did learn a little something in biochem.) Her ketone level in her blood (acetone) and urine were through the roof, and when you walked into her area, her it smelled "fruity." Really. That's b/c the ketones are rather volatile and are excreted into the air when she breathes. It smells like juicy fruit -- not altogether unpleasant, actually.

You know, the literal translation of "diabetes mellitus" means "sugar in the urine." And that's how apothecaries in the renaissance diagnosed it -- by tasting their patients' urine. Yuck. Technically, though, unless you've got a raging UTI, urine is a sterile fluid.

Anyway, DKA is a true medical emergency. This lady was ketotic, acidotic, and had mental status changes. Electrolytes are all fucked up. Potassium too low, bicarbonate WAY too low, pH too low, sodium too low, sugar too high, renal function compromised. The calculations get a bit complicated, but I started an insulin drip on her to closer her anion gap acidosis, and normally you're supposed to flood these patients with fluids to bring the osmolality down, but of course she also had congestive heart failure, which means her heart wouldn't properly pump all of those fluids properly and it would just get backed up in her lungs. And her chest xray showed them to be layered with fluid already. What to do? I doubled the insulin infusion and gave her some potassium.

An hour later her sugar was down to 306 and she was a new woman. Dangerous condition though, that DKA. Needs close monitoring, so off to the ICU she went.

Trauma came in. Some dude completely wasted. At 3pm. Hit and run, awful. The EMTs brought him in to the trauma slot. Face is bashed in a ton of places. Uh-oh, this could be another horrible intubation. He comes in writhing around, spitting up blood, not speaking. Again, all eyes boring into me to secure the airway.

This was disgusting -- I put the intubation blade into his mouth, lift up, and his jaw falls into pieces around the blade. The skin is intact, but I could feel and hear the crunching and grinding of his jawbone pieces. Suction suction suction. All I see is blood. Suction suction suction.

"WELL?" says somebody, impatience mixed with acute anxiety. I have no idea who said that -- there are ten docs in the room, three nurses, ten med students, five volunteers, some police, EMTs and firemen.

His O2 sat IS still 100% you know, I'm thinking, I *do* have more than five seconds to secure this airway. Fuck off whoever said that.

I see it -- vocal cords. Tube goes in. Whew!

Then as everyone else moves in, vomit starts projecting out of the breathing tube. (Seven years into medicine and I STILL can't stomach vomit.)

"YOU TUBED HIS STOMACH," shouted another unknown.

"NO I DIDN'T," I shouted back. "The tube went THROUGH THE CORDS, I SAW IT. I'm sure he aspirated his own vomit in the field. JUST WAIT TILL I SUCTION IT OUT BEFORE YOU GO PULLING OUT HIS AIRWAY."

So I stick a suction catheter into his tube and down into his lungs, suck back chunks of his lunch -- and a lot of vodka -- and sure enough, the O2 sat goes up, I can auscultate breath sounds with my stethoscope, and the end-tidal CO2 detector says I'm in.

Tube in, IV's in, BP stable, heartrate fine, orthopedics is pointing out that his shinbone is sticking out of his shin, off to the OR he goes.

Again: paperwork, talk to the NYPD who always has the same question ("Is he going to die? Cuz then it's a homicide and it's different paperwork for us, you know"), me always with the same answer ("I have no idea, we all have to wait until he actually lives or actually dies, the OR holding area is on 11, go up there and speak with the surgeons when they're done.").

No resting. The ER is still full of people. I eat a Jolly Rancher that's been sitting in my pocket for two days just for the sugar.

I start treating and booting people out rather quickly:

Broken collar bone -- closed fracture, treatment is a sling and send for follow up

Bilateral lower extremity edema with history of liver failure -- subacute, chronic, nothing we can do here, probably needs med adjustments, send to his primary care MD

Cellulitis -- antibiotics, discharge

Hedge fund jockey with three days of bad diarrhea after some bad Mexican food -- gastroenterities, ride it out, it's a virus, can't do anything about it, discharge

Bad cellulitis and homelessness -- no way to ensure compliance and follow up, has to be admitted for IV antibiotics

Another hyperglycemia -- urine ketones negative, no gap acidosis, not DKA, give fluids, insulin, sugar comes down, discharge

Pneumonia -- antibiotics, admit

COPD exacerbation -- combivent inhalation treatments, another, another, another, finally he's feeling fine, he can go home

Ohmigod someone brought cookies, I take two, time to go home.

I don't care how tired I am, I will not touch my bed or 600-thread count Egyptian cotton sheets without showering first. Too tired to eat, I'll do that in the morning.

back at it

haven't updated this blog since JUNE 2006. what can i say, i lost some motivation. second year is REALLY tough in my program, and every second i had away from the hospital was one i wanted to cherish and NOT think about work, which meant no blogging.

but now i'm back. I started third year, and I have to say, it's so much better. Two hours less per shift. At 18 shifts per month still, that works out to be 36 hours less per month. That's an entire full-time workweek for most Americans.

Thus, I have more free time. Plus, as a third year, I get to cherry pick the good patients. The PGY1s and 2s have to see just about everyone on their boards, but I get to float and pick off the good patients that are interesting. "Sickies and quickes," we call them -- third years get to take care of the critically ill and those that are very easy to boot out the door with nothing because there's nothing wrong with them. Thus, when i see "vaginal bleeding," "abdominal pain x 2 weeks," or -- my favorite -- "constipation," I grin and think, that has intern written all over it.

So third year is much better, and I'm happier. Still many frustrations, but it's better. The big thing about third year is that we're the resident responsible for the airway during traumas. That can be quite scary. Last month, I went to intubate someone who got shot in the neck. This guy was dying in front of our eyes -- we could see his heartrate, respirations, oxgenation and blood pressure drop precipitously and regularly on the monitor. I put the intubation blade in and it looked like a tomato exploded in his throat. No vocal cords. Couldn't make out any anatomy. Blood everywhere.

This moment is a lot of pressure. Airway is the very first thing that must be established before anything else can take place. Hence, all eyes are on me -- all the other residents, surgeons, EMTs, firemen, cops, etc., who are in the trauma resuscitation room all have eyes boring into me waiting for me to secure an airway before they can move in.

No time to pussyfoot around with this guy. No second chances. No excuses. No maybes. No repeat intubation attemps. Everyone's waiting, and he's dying.

One look into his throat. Blood everywhere. Tissue everywhere. Stop.

"No discernible anatomy secondary to traumatic wound, no cords visualized, everything's completely distorted, you have to cric him right now."

(cric -- pronounced "cryke" -- equals cricothyroidotomy, or just cutting a hole in his throat and putting a breathing tube in that way.)

No time for questions, not even an "are you sure?" The surgery senior swoops in, scalpel in hand, one deep cut into the throat, he holds the hole open, I put in a breathing tube.

Vitals come back.

My scrubs are see-through with sweat. Then mounds of paperwork and interviews with the NYPD and detectives. Sigh.