Babies babies everywhere NSVD and a nuchal chord

I had my first night of call on the OB/GYN service the other day. I actually had a blast. I covered the MBU  (Mother Baby Unit) and Triage as well as L&D (labor and delivery). I had a Medical student, junior resident and a senior resident to help cover everything except the MBU, that was all mine. If I do my job well as the on call intern then the junior OB resident and especially the senior OB should not have to do much and they can have a more relaxing night. The more I can do and cover and the better I do it the less they have to do.

It was a crazy night to say the least. I am only 1 week into this rotation so I am still learning all the little details of how the OB service works. For example; how do they like their notes written, how to use their computer system, what medications do they like to use etc. These are all little details that you have to learn at the beginning of each rotation and this makes you less efficient at the start of the rotation. I felt like I pretty much had all the details, tasks, protocols down going into the call which was nice.

I told the other residents that I was ready to rock & roll, and they were relieved. Some residents like to try and avoid the work which makes the other residents work harder. They were great with me taking over and using them for help as needed. They were there for me and I learned so much during that 30 hour shift. I delivered 4 babies over night. All 4 were NSVD = normal spontaneous vaginal delivery. It was great. One delivery was fairly difficult with and required maneuvers and techniques that were great to get to perform and get that much closer to mastering these techniques. I had one baby with a nuchal chord which is when the umbilical cord is wrapped around the neck. You have to move quick and be looking for this complication so you can quickly reduce it. I found it right away and immediately reduced the cord which decreased the risk of hypoxia for the infant. I was thrilled when this baby had APGAR scores of 10 at 1 minute and 10 at 5 minutes!

I also delivered a baby of a lesbian couple which was an interesting / fun social situation. They were great and both actively involved. I delivered the baby and almost asked the more masculine girl "Hey dad do you want to cut the umbilical chord?" However, I caught myself before saying anything and simply just asked her if she wanted to cut the chord and her response was great; "HELL yeah doc!"

OB/GYN as an Emergency Medicine Doctor

I started a new rotation this week. I am on OB/Gyn. Many ask why do you have to do an OB/Gyn rotation / training as an EM resident? Well, we see a whole bunch of OB/Gyn in the ED. Nearly every shift in the ED I have several patients "OB/Gyn" chief complaints like (not an all inclusive list); vaginal bleeding during 1st trimester, STD complaints, yeast infections, UTI's, rape, abnormal vaginal bleeding, pre-eclampsia, preterm labor, full term labor, fetal demise, pregnancy related complaints, etc.

It is crucial to be proficient at pelvic exams (speculum and bi-manual). Although it is not as common as it once was there is still several deliveries done in the ED by the EM physician every year. As part of my training I have to show proficiency in OB/Gyn management common in the ED. I have to deliver a enough babies to graduate and become board certified. Obviously we are not required or expected to be on the same level as OB/Gyn physicians but we do need to handle the emergency type OB/Gyn complaints.

Many STD's are more commonly diagnosed in the ED than in an OB's office in certain areas. There are some OB/Gyn complaints that ED physicians will see more often than OB/Gyn physicians given the current use of the emergency department. When the complaints are beyond the ED physician's skill set OB/Gyn will be consulted. Every attempt will be made to have the delivering mother deliver in the Labor and Delivery department when possible but this does not always occur.

Finally EM doctors will see lots of emergency traumas, illnesses and disease states that happen to pregnant patients. If  a pregnant patient has a seizure they are brought to the ER. Anyways this is why we spend a good amount of time doing OB/gyn training during our residency. I want to be clear that EM doctors are not the experts when it comes to OB/Gyn. Certainly our skill set in this area is not near their level of expertise.

Today was a great day. I delivered 2 babies. One was fairly complicated and the other was fairly straight forward. Both were vaginal deliveries. It is always a great feeling to share that moment with a happy couple when they bring a healthy child into the world and when you deliver it their gratitude and thanks is always a great reminder of why I love my job.

Radiology, Fractures and the ER

I have heard people say, "The ER doctors missed my broken arm (fill in whatever bone you want, like nose, finger, ribs, etc) on the Xray and when I went to my doctor he saw the fracture clearly." How does this happen? A patient comes into the ED with a "chief complaint" like "I got punched in the face". The ER doctors will assess the situation and make sure there is no life ending injuries or limb loss threatening injuries. Part of this process will include imaging studies like Xray depending on what the doctor is looking for related to the injuries.

The patient gets wheeled to the Radiology department where the image studies are completed. The ER doctor will look at the Xray or whatever imaging study is completed while he / she awaits for an official read from the Radiologist. The Radiologists are highly specialized in reading these images. Often the ER doctors can read the images themselves before the official read is completed but even then they will still often wait for the Radiolgist's read to confirm the diagnosis. In the end, the Radiologist is making the call usually which is really who you want making the official call.

Often times when a person fractures a bone and it is not an obvious fracture, like a compound open fracture or a complete separation bone fracture, picking up a subtle fracture on an Xray in the first 24 - 48 hours can be impossible. The swelling and the inflammation will make it difficult if not impossible to see many fractures that occur. In these cases the doctor will read the Xray and wait for the radiology read as well which will be ambiguous because t radiologist can't see if there is a fracture at this point either, then explain to the patient that there may be a fracture and that follow up with their doctor is recommended after 3 - 7 days or so depending on the injury. If the doctor has a high suspicion for a fracture but it can't be verified by the Xray he/she may say I think that you have a fracture and here is the treatment plan.

ER doctors do not like to put a full cast on in the ER right after an acute fracture. Often the swelling has not stopped yet and so if the ER doc puts a full cast rather than a splint on the fracture and the swelling continues under the cast, the patient is at great risk for compartment syndrome or essentially swelling to the point where damage occurs in the area that is casted because there is no where for the swelling to go. So you will almost always get a temporary cast / splint in the ER and then have follow up with Orthopedics for a full cast once the swelling has subsided in 5 - 14 days depending on the fracture. Usually a good ER doctor will set the fracture and splint the area, give good pain control and care instructions with a referral for a full cast once the swelling has subsided. The patient will then go to the Orthopedic doctor where they will Xray the area again and make sure the fracture is healing properly and then put a full cast on if needed.

As you can see, even a simple fracture is not so straight forward in medicine. Nothing is simple given our current environment but there usually is an explanation for why things are done certain ways. The main problem is that most of these doctors do not communicate these things well to their patients so the patients have no idea what has happened. Even if the ER doctor does communicate well to the patient, they inevitably only recall about 10% of what they were told. They come in and are told "the Xray did not show a fracture... and here is a splint... follow up with Dr. Ortho in 1 week." They go to Dr. Ortho who then takes an Xray and says "You have a fracture..... and now I will put a cast on!" The patient says "The ER said it was not fractured....." Dr. Ortho says "they do not know what they are talking about.... it is clearly fractured so here is your cast, and your bill.."

By the way I am doing Radiology and Anesthesia this month, hence the quip about radiology. I think that the Radiologists are great!

Intubation

All specialties in medicine like to claim their turf and mark their territory. The cardiologists, no doubt are the gurus of the EKG and managing chronic heart disease. The Nephrologists own the kidney, dialysis etc. Surgeons, often think they own everything but they do own the surgical procedures, no questions about that. Emergency doctors have to know all of these things but are not the best at many but do have a few areas they own.

Resuscitation (running codes), airway management and other acute medical emergencies are what EM doctors like to claim as their expertise. Airway management can sometimes be a turf war or a battle with Anesthesia. Anesthesiologists intubate (manage the airway) everyday. Every surgery that requires general anesthesia requires the patient to be intubated and it is the Anesthesiologists who do this day in and day out. This is done under a nice peaceful controlled environment with lots of time and the patients are stable and usually the intubation is nothing more than routine.

In the emergency department the Emergency doctors do intubations as well, but these are Rapid Sequence Intubations (RSI). It is a different game all together. These are critically ill patients who are often crashing and the airway must be managed and protected very quickly in a high pressure atmosphere. This type of intubation or airway management is what Emergency Physicians like to claim as their turf. There usually is not much argument or turf battles when it comes to Rapid Sequence Intubations. Funny, no other specialty is trying to steal or take this procedure from the EM docs.

Anyways this is a brief  introduction to intubations or airway management as I am currently on an anesthesiology rotation right now and doing several intubations / day. The boring peaceful, relaxed kind that Anesthesiologists are no doubt the masters. I am learning a lot and there is no better way to fine tune my intubation skills than to intubate lots of patients. I have had to do a good number of Rapid Sequence Intubations while on EM rotations but not enough to fell super comfortable, so this rotations is the perfect tool to get my technique and motor skills where they need to be for intubating.

Moving Flesh

It was a hot Saturday afternoon and I was working an extremely busy 12 hour shift. I was in the middle of my shift and had not stopped. The wait for patients to be seen had crept up to about 4 hours. The ICU was full and our ED was full We were starting to board patients in the hallways and up against walls. It was a little crazy. In the middle of all of the nonsense patients backing up the ED we had our real emergencies coming in at a nonstop pace. Gunshot wound, Stabbing, Myocardial Infarction (MI), Motor Vehicle Accidents (MVA), Stokes, etc.

I was charting on a patient I had seen and trying to catch up on some of my documentation when I smelled an unpleasantly familiar foul odor in the air. I immediately knew someone was rotting. Flesh that is rotting has a very distinct smell. So I looked around my shoulder and noticed a patient on gurney boarded in the middle of the ED. There was no room in the inn. She was older and it looked like she had some family with her. She did not look acutely ill from where I was sitting. I decided to investigate and make sure she was not a ticking time bomb waiting to expire.

As I made my way to the patient the smell became even stronger and I noted that her foot was wrapped in gauze all the way up to just below the knee. I knew that I needed to unwrap the bandage, but I also knew that upon unwrapping the wound would unleash an odor potent enough to induce vomiting in staff and other patients that had not acquired the ability to coexist with such potent odors. It would have been an unpleasant thing to do and or inflict upon those in the ED minding their own business.

I went over to the Charge Nurse and explained that I needed to take a look at this patients leg but that I needed to do it in a room where the smell could be somewhat contained. She agreed and quickly pulled a patient complaining of an "itchy hand" out of a room and gave the room to my patient. I went into the room and continued to speak with the patient and the family to get a proper history and perform a physical exam. I was excited to see what was behind curtain number 1. I put on my gloves and began to slowly unwrap the gauze bandage and immediately the odor became 10 times more apparent. I looked up the the patient's son was vomiting into the sink but the daughter was holding strong and only gaging. The nurse had to excuse himself from the room. I continued to reveal the wound. Once I had the entire bandage removed it was clear to see that this was a serious wound. She had gangrenous flesh and an open wound with exposed bone from the middle of the shin down to her foot.

I noticed that the wound was "sparkling" in certain places so I moved in closer. I noticed a rippling motion within the wound. The daughter said "why is the flesh moving?" I reached into the wound and pulled out a maggot and removed some of the dead flesh only to reveal several maggots enjoying their lunch. I explained / showed the daughter the maggots and the rotting flesh. I cut away much of the dead flesh and cleaned the wound. I could not appreciate any pulses. The lower leg was unsalvageable and would need to be amputated.

I did all the cultures and lab work and started some powerful antibiotics. The patient was admitted and later taken to the OR for a below the knee amputation. She was fortunate that she had not become septic.