A Drunk Pilot?

Right now I’m working several overnight shifts, so I work from like 10:00 at night until 7:00 the next morning roughly.  Sometimes it’s 9:00 until 8:00 the next morning or 9:00 the next morning, but anyways, last night I had a shift.  This was Saturday, overnight, October 30 and so in the early Halloween morning.  I arrived at the hospital for my shift, I wasn’t sure how busy it would be.  Generally Saturday nights are pretty busy at this emergency department with all kinds of things, car accidents, traumas, headaches, fights, heart attacks, strokes, lacerations, you know, everything you can imagine comes rolling in and on top of the usual given that it’s a holiday or day before a holiday where people go out and become exceedingly inebriated, I was prepared for just about anything. Parties, public drunkenness always increases what we are going to see in the emergency department.  

 I got to the hospital, and it was kind of busy, not super busy, but it started off with a unpleasant case which was a rape and when somebody is raped and presents to the emergency department, there is something called a rape kit, which is a actually a legal document.  It’s a kit that once it’s opened, has to be kept with the same person the entire time until it’s handed off to the detectives.  So, it’s always a difficult handful of these I’ve had to deal with and treat and basically it is a very unpleasant experience for everyone involved, but particularly obviously, the victim and so you try to be extra sensitive and not have them repeat their stories a bunch of times.  But you also have to do quite a few invasive things and procedures to document and collect evidence.  I won’t go into all the details because I’ll try to keep this a somewhat pleasant blog, but there’s no way to keep this pleasant. 

Anyways, the rape kits tend to take a long time and are complicated. The data has to be gathered, clothing, specimens and fluid and all this has to be documented a certain way and then handled in a way that you can then turn it over to the detectives at the end and so that was a tough case to start with, and then throughout the night I had various different cases, some complex, some not so complex, and ended up seeing quite a few patients.

I had  a gentleman that presented, originally I was told it was a pilot, who had been beat up.  When I went in to the room to examine the patient, it turns out it was a drunk person dressed up as a pilot at a bar who had fallen over, become injured and had several lacerations on his face that needed to be sewn up.  So, it was quite humorous and a lot of the staff thought that this poor pilot’s been attacked, but in reality it was a drunk individual dressed as a pilot who had not been attacked, but had actually fallen over on his face and broke his nose and cut up his face.  So, he was rather unpleasant, belligerent, intoxicated and I calmed him down and convinced him to let me suture his laceration closed and get the proper imaging studies and make sure he didn’t have a head bleed or anything like that, so that was kind of our more humorous case.

Often times in the emergency department the people you are treating are inebriated or intoxicated on some substance.  They don’t want to be there and they are rude.  They’ll try to spit on you, try to hit you, try to attack you, yell and scream at everybody and generally make everybody’s night a little more miserable.  You’re trying to help them and trying to fix their wounds or illnesses and it’s definitely not very appreciated.  In fact, you often have to be careful or you’ll catch a fist yourself or be kicked or spit on or whatever, so that case was a little bit humorous though because everybody was worried about his pilot that turned out to be really just a drunk bum dressed as a pilot in the spirit of Halloween.  So that case was interesting. 

So this is a small sampling of just a couple of interesting cases from the night.  I had several.  I am on overnight the next several nights so I’m sure I’ll have more stories to tell and to share, but in the meantime, be safe, don’t drink, don’t do drugs, don’t eat too much and wear a helmet and wear your seat belts and be safe.

Another ED shift, Intubations, Lacerations,

I had another shift at the community emergency department in the urban setting.  This morning I worked early morning until, I guess, kind of early in the evening.  A 10 hour shift.  I started off the day with the first patient who was an individual who had a head laceration that was bleeding; she lost lots of blood.  The scalp has a lot of vessels that feed blood to it, so when the scalp is cut it tends to bleed profusely. This laceration required me to irrigate the wound, clean and explore the wound. I had to make sure there’s no foreign bodies in the wound and then make sure that I could clean the wound and close it properly. This laceration was on the back of the patient's head.  I decided to use staples and I put 4 staples in the scalp to close the wound.  The patient had fallen and hit her head and had lost quite a bit of blood so we kept her for a while and ran some labs to make sure that she hadn’t bled too much.

I was in the middle of caring for the 1st patient when I got pulled out to run to  Resuscitation Room 1 where we had a nursing home patient who was found to be nonresponsive and brought in by paramedics.  I got in there and his vital signs looked fairly stable but he was having some difficulty breathing and getting the proper levels of oxygen.  So, ultimately, the decision was made by myself and the attending to intubate the patient so I went through the process of getting the proper medications and the equipment ready to intubate the patient so he could be hooked up to a ventilator, which is always a flurry of excitement and commotion.  So, fortunately, this was a less difficult intubation for me or, maybe I’m getting better at it or possibly he was just an easier patient. Regardless, I was able to intubate him without any problem and get him hooked up to the ventilator settings. Once he was stable enough, we sent him down for CT, we had noticed while we were examining him that he did have what looked to be like a shunt under his scalp in the skull area.  We didn’t have much of a history from the paramedics or the nursing home so like a lot of times we are sort of going on what we can find on the patient and he was nonresponsive so we figured he was having some increased intracranial pressure from something related to a shunt in his head, we sent him down to CT scan.  He, in fact, did have a shunt and it did look like to me that his left side lateral ventricle was enlarged but it’s hard to guess because we didn’t have a previous study to look at and compare. Ultimately, this patient went to the ICU. I had to page neurosurgery and explain the details of his case and convince them that this patient was worthy of being seen by them and they came down to the ED and actually saw him in the emergency department, which is often rare so I must have done a good job convincing them to come down.  

Neurosurgeons are extraordinarily busy and don’t like to be bothered and can be kind of rude or seemed bothered over the phone but I had all the information that they needed so when I called them they were not annoyed with me and came down.  Those were two of the patients that I had today.  I could continue on and on and tell you about all 20 of the patients but I’m trying to pick and choose some of the more interesting cases.  

 I did have a run of the mill kidney stone patients and I also had a patient I diagnosed with  or gallbladder disease.  I did a bedside ultrasound and found a gallstone in her gallbladder and I admitted her for a cholecystectomy.  She’ll probably have the surgery tomorrow.  So, anyways, it was a good day, long and tiring day.  That’s how the emergency department can be.  It’s just a non‑stop, running, running, you never know what’s going to come through the door and I guess, maybe , that’s what I like about it.  Anyways, have a good day.

Emergency medicine in an urban community emergency department

I have started a new rotation! I am working at an Emergency Department in a community / urban setting. Today my Emergency medicine shift at urban community emergency department was extremely busy.  So I had several patients today that were very interesting in nature.  It started early in the morning and it was busy right when I got there.  

First patient was an anaphylactic shock for a bumble bee sting to the hand that required some sub q epinephrine to prevent worsening of the anaphylaxis.  I had another patient, I'm not going to tell about all of them, but this patient had a panic attack, he was a young male who had recently quit smoking marijuana, he was kind of having a paranoid / panic attack.  I also had a family who had some stomach gastroenteritis and vomiting, stomach pain, and diarrhea. I had a four-person automobile accident trauma brought in by paramedics.  The driver was a 23-year-old female who had been driving her nieces and nephews.  There was total of four in the car going, I don't know, she was traveling at about 60 miles an hour, ran into another car then bounced off the median.  All of them were in seat belts and remarkably all of them were fine.  The driver was the worst injured.  She lost some blood due to a large laceration on her forehead that was about 6 centimeters in length, and a laceration on her nasal bridge.  The forehead laceration required four 4-0 vicryl sutures that I buried the knots to bring the forehead laceration together, and then I threw about eight 6.0 ethicon nylon sutures to close the forehead wound and additional sutures were needed for her nasal bridge laceration as well.  Fortunately for her all of her CT scans of her head and neck and chest and pelvis were unremarkable, no abdominal perforations or head bleeds or broken bones.  We also did several X-rays and there were no broken bones but she was pretty shaken up.  A 10-year-old, a 5-year-old and a 2-year-old in the car as well who also had various injuries but nothing life threatening.

I had a gentleman who came in, an older gentleman with an acute attack of gout which required a procedure.  I had to put a needle into his knee to tap I delicately inserted a needle into the joint space and was able to get the fluid out so I could send it to the lab. The lab was able to analyze it and it came back and it turned out to be a flare up gout rather than a septic knee.  I also had a couple patients, that were not too interesting, just an alcohol intoxication and a drug overdose that both needed medical attention. 

A lady came in with severe mouth /  tooth pain.  She had a dental abscess and had been turned away from five dentists' offices because of her diabetes and hypertension.  I was able to examine her and determine that in fact she did have a tooth that has essentially decayed down to the root and really needed to be pulled but she had an abscess and some severe 10 out of 10 pain.  I was able to give her I.V. pain medication in addition to a nerve block in her mouth to block the pain that was causing her to almost become suicidal so she got a regional nerve block in her mouth and a nerve block around the tooth and abscess itself which helped her tremendously.  So this was a crazy shift where I saw at least 15 patients with varying ranges of acuity from pretty moderate/mild to near life threatening.  

That was the day in this urban community emergency department.  This particular emergency department does not have other residencies so as an emergency physician in residency, I get to do most of the procedures whether it's an incision and drainage of an abscess or a vaginal issue that needs to be taken care of, we don't call the other specialties, we just do most of the procedures and handle it ourselves.  So that was my day and I am sticking to it! We will see how tomorrow goes. It will be just as busy and probably just as crazy. It is just how Emergency Medicine goes, and I happen to love it. 

On Call Postpartum Hemorrhage management

The other night I was on call overnight and had an amazingly busy, scary, enlightening and highly educational night. I should have known I was up for a crazy call night when during sign out at the beginning of my call I was paged to the floor where a woman who had just recently delivered was hemorrhaging out. I quickly ran to the patient's room to find a panicked nurse and an even more panicked husband to see blood flooding out of the patients vagina. I would have to say that OB is probably one of the more bloody specialties. It seems like I am constantly changing my scrubs as they get drenched in blood . 

I immediately assessed the situation and realized that this had to be postpartum hemorrhage due to uterine atony or a laceration that had re-opened. I decided to go with the bimanual uterine massage because as I examined the patients abdomen I could tell that the uterus was in fact atonic, which means the uterus has failed to retract to its normal size and remains stretched out. This leads to massive hemorrhage and actual can cause maternal demise if not treated quickly.

Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute hemorrhage. Clinically, 75-80% of postpartum hemorrhages are due to uterine atony.

I place my whole hand into the vagina until I reached the uterus and squeezed down on it while using my other hand to squeeze the uterus by pushing on the patient's abdomen. You essentially mash the uterus between your hands on the inside and on the outside. This is painful for the patient and has to be performed quickly to reduce the risk of death. This procedure is effective and can dramatically reduce the bleeding and get the uterus to regain its tonicity. 

Fortunately this procedure worked and the massive hemorrhage began to subside as I continued to massage the uterus. I was sweating but remained calm which in turn calmed the family and the patient. I uttered out a few orders for the nurse to hang some medications and lactated ringers in addition to calling for some labs to determine how much blood was lost. These labs helped determine whether we needed to transfuse the patient.

Ultimately the patient did not need a transfusion and following the uterine massage I found a laceration that was up on the vaginal wall that needed further suturing. Most of the bleeding had stopped due to the uterine massage and the medications and I was able to stop the remaining trickle by repairing the laceration.

This was the start of my 24 hour call and I was only 1 hour in to my shift. I knew the night was going to be a blast. I love this job.

More to come….