Healing Touch

There are certain cases that are such a joy to treat in the emergency department. One of those cases is called Nurse Maid's elbow. The reason it is a joy to treat is that you can take away the pain and restore the patient's pain free status. Ultimately the patients are very happy with their doctor. This usually occurs when a young child is tugged by the hand and causes a type of elbow joint dislocation. It can be very painful and only occurs in younger children because of their specific anatomy allows for this type of dislocation. Older children and adults have different shaped bones making this type of injury unlikely.

I had a young patient brought in by the parents. They were shopping at a big department store and the father was holding hands with the child and they were looking at some ornaments on a tree. The child was trying to grab some of the ornaments off the tree and the father tugged the child away from the tree. The parents heard a popping sound and their child began crying out in excruciating pain. The parents were scared and the father felt guilty.

I entered the room and the crying child began to cry even more and shouted out to me "go away, go away, go away now!" The parents were embarrassed and told the child to not be rude. Then the child blurted out "you are stupid!!" I smiled and carefully approached the child and explained the diagnosis to the parents and eased their concerns and fears. I also explained the cure / maneuver to reduce the injury and relieve the pain. The father while holding the screaming child gave me the indication to proceed with the maneuver and I took the child's arm and moved it in a fashion that restored its proper position. It takes a lot of force and the child usually screeches even louder but only for a second or two and then slumps in relief as the pain subsides. I performed the maneuver successfully.

You relief and thankfulness was palpable and auditory as the parents verbalized their thanks. I told them to wait for five minutes or so and that I would return to make sure that the arm / elbow was back to normal and check to see if there was any nerve damage from the injury which can occur in some occasions. I returned and completed the proper examination of the child's arm and all of the neuro functions were intact and appeared to be normal. The child was smiling and happy playing with a toy and the parents were beaming with a sense of relief.

I explained that the nurse would be in shortly to discharge them and then turned to leave the room when the child said "doctor, I am sorry I said you were stupid" I kneeled down to the child's so we were looking at each other eye to eye and said "I understand that you were in a lot of pain and scared. Thank you for apologizing that makes me feel so much better and now my feelings are not hurt anymore." The child smiled and said "thank you." Then as I left the room the mother stood up and before I knew it she gave me a big embrace and said "thanks for fixing our little baby and thanks for not ruining a teaching opportunity by telling our child that it was ok to call you stupid."

I smiled and said "thanks" Now I can fix your child but your husband needs more help than I can offer so you are going to have to fix him." We all laughed, especially the husband as he confirmed my diagnosis. I said to the mother "don't worry about it, my wife has the same task with me and it is a life long process to fix a husband." We shook hands and I left the room. I walked towards the room of my next patient, a 55 year old man with chest pain and I smiled and thought to myself "I love this job!"

This is why doctors have certain diseases or problems they like to treat or fix.

Time of Death

Most people I imagine do not think about the concept of "time of death". While working in the emergency department you have to have this "time" in the back of your mind at all times. Immediate death is what we are trying to prevent in the emergency department which is a different approach than many other fields of medicine.

This week I have had the sorrow of having to declare the time of death on 2 patients. The patients keep coming and you must keep working. Often you do not even have time to reflect on the whole process of declaring someone dead until well after your shift while lying in bed or while driving home and then a flood of emotions enter your mind. You work like crazy to save a patient who is dying and you when that effort fails, you declare the time of death. This is just a technicality that society requires doctors to do. It is not like the patient actually died at the exact time the doctor declared the time the death. Often we do not know when exactly or technically the patient has died.

This week I had an older individual that had a heart attack right in front of all of his family visiting for Thanksgiving. We could not save him. He most likely died well before his arrival to the emergency department even though he arrived to us with a weak pulse it is hard to say that he was actually still living. We gave it every effort. My other patient was a young patient involved in a motor vehicle accident and that was a tough case. It was especially difficulty telling the family that they just lost their child. Again we tried everything to save the patient but finally I had to declare the time of death.

All in a days work...... I guess.

Another EM Rotation Done

I finished up another rotation in emergency medicine. This time I worked at a large government hospital where no one has to pay for any care. It was an extremely frustrating experience to say the least. There was so much "red tape" and "hoops" to jump through that it was nearly impossible to practice good medicine. The supplies and equipment were sub par and non existent. The excuse was always "we do not have the funding". The technology and equipment that was there was outdated and not comparable to any modern hospital. The employees complete lack of desire and motivation to do any work made treating patients difficult. Emergency medicine is certainly a team sport and when a large portion of the team does not care enough to put any effort in, you can imagine how inefficient the process becomes.

I am glad that I did my rotation here because it confirmed that this is not the kind of program that I would want to train at for residency. The average wait for patients to be seen by a doctor was often more than 18 hours. Once the patient was seen by the doctor it seemed that the entire goal was to do the least amount of work possible and then get the patient out of the ED to be someone else's problem. Then the patient was shuffled around by the other services in the hospital. It was truly unbelievable. I think anyone who is a proponent of socialized medicine in America should come and witness the disaster that is called medical care at government hospitals. Even when the doctors at these hospitals are top notch as many of them are, they are handicapped by the ancillary services that are inefficient or even worthless.

For example we had a patient that we needed to get a test done immediately so that we could make the correct diagnosis and start the proper treatment. Without the test we could not begin treatment or it would be dangerous for the patient. I make the call to the department that handles the test and I explained that we needed the test ASAP. They responded that they were on a mandatory break and could not perform the test at that time. I begged and further pleaded my case only to be hung up on. Ultimately this case turned out ok because I was able to work around the given test but it certainly delayed treatment. This kind of scenario is a daily frustration and many times the end results are not favorable.

Also this hospital is hemorrhaging money and continuing to use up tax dollars to provide subpar services. The medical system is in need of fixing but the idea that the government can somehow run it seems unlikely given my many experiences working at multiple government hospitals. I certainly do not claim to have the perfect solution but I think the solution should not include anything that resembles the VA and County hospitals that are scattered throughout the USA. The patients do not pay with money but they do pay and it can be far more costly than any amount of money.

Great Night

I like working overnight. There is a certain buzz in the air from midnight into the early hours of the morning. None of the administrative heads are there so the staff seems a little more laid back and not on edge. It is less formal. The individuals that work nights are also a little more interesting so all the nurses and ancillary staff have a different vibe. I like the night.

Last night I worked from 11:00 pm to 8:00 am and my most interesting case was a 54 y/o alcoholic male who was found on the street in a pool of blood. After cleaning him up and looking for the source of the blood we were able to determine that it was coming from his GI tract. Ultimately he became fatigued with his breathing and I watched as he struggled know that we were going to have to intubate him.

I was able to go to the head of the bed and with the senior resident helping I intubated the patient. First you pre-oxygenate the patient by giving 100% oxygen. This helps his body build up reserves so that he won't crash while you are trying to get the breathing tube in and he is getting no oxygen. Then you administer a few medications to paralyze and knock the patient out. Once the patient is out you use an instrument to expose the airway through the mouth. Once you see the vocal cords you know you are there. You slip the tube between the cords and push it down the trachea. Once in place you supply oxygen and listen to both lung fields to make sure you are in the correct place. You also check placement with a chest xray.

Following successful intubation the patient is hooked up to a ventilator and remains in a sedated state while the various health problems are addressed and hopefully fixed so that the patient can be weened from the ventilator. Intubation can be a stressful procedure because the clock is ticking and many times due to anatomy or other factors it can be difficult to find and get an airway. While you are attempting to intubate the patient is not receiving oxygen so you have to be quick. There are also a handful of complications that can occur as well which also add to the stress of the procedure.

I love it. It was a great night. The patient lived.

How many pillows do you sleep on?

A 51 y/o African American female presented with shortness of breath. She had noticed that about 1 week ago it became difficult to do anything without becoming winded or worn out. She thought that maybe it was asthma or something. Tonight it had become worse and she was starting to have chest pain as well so her husband drove her to the hospital.

I entered her room and looked at her propped up on several pillows and struggling to get oxygen. She was an obese women who claimed to have no past illnesses. She was not taking any medications. Either she was very healthy or had not been to her doctor in a long time. I worried that she may be having a myocardial infarction and ordered an EKG.

I asked her if she found that she woke up in the night and felt like she could not breath. SHe said "How did you know?" She was waking up 2 - 4 times a night and would stand by the open window to catch her breath. I examined her legs and she had pitting edema. I asked her how many pillows she was sleeping on. She told me she sleeps on 4 pillows to prop herself up.

Her EKG came back unremarkable and her cardiac enzymes were negative which suggested that she was not having an MI. We ultimately determined that she had congestive heart failure (CHF) and admitted her to observe her and pull some of the excess fluid out of her. I explained to her and her husband what CHF was and how we treat it. I then admitted her to the hospital and talked with the hospitalist who would manage her for the next day or so.

CHF patients suffer from their heart just not cutting it anymore and they become congested has fluid backs up into the lungs. This makes it difficult to breath and they often have to prop themselves up on several pillows when they sleep to get enough oxygen. If they lay flat on their back their lungs become more congested due to gravity making it even harder to breath. Often a classic diagnostic question will be "How many pillows do you sleep on?" There are a few different ways to treat CHF all of which entail helping the heart to better do its job.

18 hours, for what?

I have had some interesting cases this week in the ED. The first case was a 33 year old female who came in to the ER with complaint of a rapid onset of shortness of breath and cough. She described it as not being able to breath and that she was sure she was going to die to the triage nurse. The nurse measure her oxygen saturation and determined that the patient was not in immediate danger of expiring. In fact her oxygen levels were normal. SHe was sent to the waiting room to wait her turn with the other non-emergent emergencies.

She waited 18 hours to see me. The ER was completely out of control with multiple emergencies and non-emergent cases so the wait was extra long. I look in the computer to read about her case and then make my way to the bed 47 to she how she was breathing. The patient was in no acute distress and seemed to be fine. I asked about her shortness of breath and her cough. She said "oh doc it is really bad! I can't even breathe. I listened and fully examined her and there seemed to be nothing wrong. She asked me "hey doc did you run a pregnancy test on me?" I explained that it was common procedure to run a pregnancy test on every women of childbearing age, she was obviously aware of this procedure. I told her that her pregnancy test was negative and she immediately stood up and began removing her gown and putting her street cloths back on.

I asked her what she was doing and she said that her cough was gone and that she felt all better. She was on her way out when I said "you know that you can buy a pregnancy test for a few dollars and not have to wait 18 hours for the results." She did not reply and headed for the exit.