I am now working in a community emergency Department. This emergency department is in a rough part of an inner city community and it happens to be extraordinarily busy. Every time I show up for a shift, there are at least 7 ambulances in the parking lot 40 patients in the waiting room and all 36 patient rooms are full. The minute I hit the door it is "go time" and it seems that for the next 12 hours I am constantly running from room to room fixing this, fixing that, doing a lumbar puncture here, and intubating somebody there, doing an incision and drainage here, and repairing a laceration there.
I like this emergency department because it is in a community type setting therefore when I have to call a specialist it is usually a private physician at home and not a resident in house. These private physicians at home on call are usually paid to be on call and happy to be busy or to get business. Compared to a full academic emergency department, when I call a specialist like a surgeon, I am usually calling an in-house resident physician who is not paid any extra for the extra work I am about to give him or her. So you can imagine the difference in the environment when working in a community emergency department as compared to an academic emergency department.
For example, one time in the community emergency department I had a young patient who was suffering from an apparent appendicitis. I called the private surgeon who was on call at his home being paid to be on-call as well as being paid to perform surgeries. I remember calling him at 2 in the morning and saying hi Dr. sorry to call you so early in the morning but I have a young patient here who has what I believe to be appendicitis. There was a pause on the other end of the phone and I was preparing for a verbal beat down or some sort of explanation as to why I should call a different specialty because that is the normal response in an academic emergency department when I'm calling resident specialists. However, in this case because I was in the community emergency department the private surgeon responded with; thank you for calling me I appreciate the business, do you think this is appendicitis? I answered, yes the patients symptoms seem pretty classic for appendicitis. He stated, great I will be in in 5 minutes don't worry about getting a CT scan that sounds like classic appendicitis I will take care of the patient please let the family know I am on my way. By the way what do you want on your pizza. Thank you for calling me I appreciate all you guys do.
Needless to say there are some differences in working in an emergency department in a academic center versus a community center. This post however is not about the politics or differences of academic medicine versus community medicine! This post is simply a post about a man who knew better who should not have tried to be a Hero.
This man was in his 30's and had a great job as an accountant for a big city firm. He was educated and had a wife a 3 young children. He had been out with his friends watching a football game and drinking and upon returning to his home at about 5 in the morning he was approached by a person wearing a hat and a mask pulled over his hat. The individual stated "empty your pockets you are being robbed". Somewhat intoxicated and somewhat scared the young accountant started to put his hands towards his pockets to empty out his pockets and give the items to the thief, when he noticed that that thief was not paying attention. Foolishly the young accountant decided to take this opportunity and punch the burglar in the face. The burglar was obviously not expecting this punch, and dropped to the ground when he was punched.
The accountant felt like a superstar as the adrenaline pumped through his veins. Suddenly however, the account felt someone or something jump onto his back and take him to the ground. A wrestling match ensued with the second burglar and eventually the accountant was able to break free and escaped to his house. He walked into his house to find his wife and young children waking up for the morning and days' activities. To their astonishment they saw their father bleeding profusely. His wife started to scream and the children soon started screaming as well, she ran and grabbed a towel as the accountant began to try to find and see where he was bleeding from. It became evidently apparent that he was bleeding from his arm as there was an 8 inch gash on his forearm. Blood was pouring out all over their entry way floors. Fortunately his wife had her wits about her self and sent her children off to their bedrooms. She wrapped a towel around her husband's bleeding arm and demanded him into the car so she could drive him to the emergency department. This young smart, wise accountant didn't want to make a fuss and stated "it is fine just put a Band-Aid on it, I do not need to go to the emergency department." Fortunately, the wife knew the limitations of her husband's common sense and she ignored his statement and forced him into the car and brought him to the emergency department.
The nurse approached me and said "doctor you have a patient in room 13 that needs to be seen immediately, he is bleeding profusely and may have lost a lot of blood I think he needs to be seen sooner rather than later!" Great! I thought to myself what has this person done at 5:00 AM? I scrambled to room 13 to find a surprisingly well dressed well kept individual with a towel saturated in blood wrapped around his forearm. I also noticed a young wife sitting in a chair frantically making phone calls to make arrangements for her children to be taken to school and to their various activities as well as calling her work and his work to explain why they would not be there today. I introduced myself to both of them and told them I would need to take a look at the wound. I peeled back the blood soaked washcloth to expose a gapping laceration, I asked the patient; "Do you remember when your last tetanus shot was?" He smiled obviously getting my humor and I said that actually this is the least of our concerns at this point let's stop this bleeding first!
The police arrived shortly after I began to fix this laceration. After what seemed to be an hour or 2 of meticulous stitching, a full 3 layer closure, was required to completely fix this laceration and stop the bleeding. Ultimately, the patient had an excellent outcome, but will have to followup with hand surgery and potentially have physical therapy and maybe further interventions. However he was very fortunate to have come to the emergency department quickly and have his laceration fully repaired.
I asked him "how much money would you have lost if you had just given the thief your wallet and other items. He calculated if he would have given the thief everything it would have cost him maybe $500.00 - $800.00 if the thief got his cell phone as well. He actually only had $100.00 cash on his person at the time and the rest of the estimated costs were losing his wallet,and cell phone and costs associated with replacing his credit cards and getting a new licenses etc. Remember this man was an accountant so he thought long and hard about what giving in would have cost him. He was proud that his macho super powers had saved him up to $800.00. While he boasted about this great savings his wife rolled her eyes in the background and I asked him if mugging loses could be declared on taxes.
I politely asked him if he was done with his accounting estimation of the savings he had achieved by punching his attacker and not giving up his belongings. He said, "I think I calculated all the savings." I pointed out and asked what the costs were for missing 2-3 days of work for himself and for his wife. His wife chimed in and reminded him that his $300 new leather jacket now had a 12 inch cut and the arm and could now be deemed worthless unless leather vests make a comeback. His wife also reminded him that his children will need some form of therapy after seeing their father pouring blood from his extremity all over the house. She then started to calculate the cost of cleaning the carpet or replacing the carpet and wood floors. She also noted that there was blood spilled all over their car and the cleaning that would cost money as well not to mention all the other stained clothes he was wearing and she was wearing and finally she reminded him of the medical costs associated with this type of injury. I kept silent during this exchange.
I decided it was in my best interest at this point to remain quiet and not explain how physical therapy and possible hand surgery and further doctor visits as well as medications, and medical supplies would add up to significant costs and it would have just been about 1% of the full cost to just have turned over his wallet with $100.00 in it. I did point out he was lucky that the stab wound missed a major artery by about 1 cm or we would also have to ad in the cost of a funeral into the equation of costs vs savings. I mentioned this in the upmost professional way possible and we all had a laugh but he got my point.
Lesson: Do not be a hero!
Lesson Learned?: The last thing the patient said to me after hours of sewing his arm up after thanking me was : "Hey doc you should have seen the face on the other guy, I knocked him out and he definitely will remember my punch when he wakes up!"
Lesson Learned? = NO
Thursday, November 3, 2011
Tuesday, October 18, 2011
ICU Cricothyrotomy
I know that I have not posted on this block for quite some time. let's just say lipase, residency, family, tragedy, and a multiple flurry of other things have taken my time.
However, I have a time of great stories and medical adventures of residency that have occurred and would make great posts for my blog I just need to get caught up.
I wanted to post an experience that occurred while I was working in a medical surgical ICU. as a senior resident working in the ICU can be very stressful. In the ICU the patients are very sick often on the edge of deaths door and overnight You are the only doctor available to take care of these patients. In addition to this responsibility you are also required to respond to all code blues except for ones in the emergency department. CODE BLUES l are pronounced over the intercom as "CODE BLUE room 747" or whatever the room number is and as the ICU resident I would drop everything I was doing and literally run to the room because it meant a patient was crashing or dying. So lets just I was on call every third night and all of those calls were exciting and in no sleep occurred.
On one night I had an amazing experience where a young patient who had just recently been extubated (taken of a ventilator) who had multiple medical problems and was very sick, stopped breathing. I was immediately called to the room and the patients 's 02% was in the low 30% range which is very low and if prolonged for even a short period of time can cause severe brain injury if not death. this individual was a family man with a wife and young children and ultimately although sick should have ultimately recovered and returned to his normal life.
Upon entering the room I saw the patient's vital signs and it became very clear to me that I had to make a quick decision on how I would manage this patient. I was the only doctor there in the room a 2:00am but I had several very experienced nurses and respiratory techs to help and to lean on. As I entered the room the charge nurse said "thank heavens he is an ER doc, he'll know what to do!" which of course added to the pressure. I grabbed my intubation kit and tried to visualize the airway, without success. I grabbed a glidescope which is a fiberoptic video intubation machine that makes intubating easier on difficult airway cases. I had no luck with the glidescope either. Every second that passed = brain cells dying.
I remained very calm although on the inside I was about to pass out. I yelled out "cric kit stat!" The respiratory therapist said with a gasp "doctor, don't you need an attending physician to do a surgical airway?" I politely said "if we wait for an attending to show up, this father of 3 will be dead." The cric kit was produced and I immediately made my incision at the appropriate landmarks and found a very scarred and hard trachea as this patine had been trach'ed in the past for different medical problems. However I was able to cut through the trachea and get my gloved finger into the hole so that I would not lose the incision. I had to cut to make the hole larger and then was able to insert a tracy tube.
Immediately the thatch tube fogged with condensation of the patient's air. ALmost immediately the beeping alarms silenced and the patient regained consciousness and his vital signs returned to normal. I finished suturing the tube into place and hooked it up to the ventilator. Right about at this time an attending anesthesiologist entered the room and audibly gasped. He said "doctor wil you please note that this procedure was started prior to my arrival?" I replied "yes I will note that it was started and completed prior to your arrival." He smiled at my subtle humor and looked over my work. He examined the patients airway and said "there was no way to get this patient's airway other than what you did, nice call." Of course, this made me feel better about the decision to do the surgical airway. In looking back at the documentation this time from when I entered the room to the point where I was cutting was 38 seconds and old records showed the last time he was intubated in an OR setting it took 45 minutes with a fiberoptic scope because his airway was so scarred and difficult to get a tube through. In that setting they were breathing for him so they could take the time and it was non emergent. My setting was a little different.
I called the family at 3am and they all came in and verified that he was at his normal mental status and it did not appear that he suffered any brain damage. I told them the entire story and they were very grateful. I explained that their had to be other forces at work because everything works out perfectly and I said "I am a good doctor but not that good" and we all laughed.
The patient was discharged from the hospital 5 days later with a trach that would be removed in 3 - 4 months but he was alive and at his normal healthy mental status. Even now the experience seems like a surreal dream. Fortunately it went well. I love this job.
This is not a picture of the patient and it is a picture of cricothyrotomy procedure done on a cadaver. You can tell as there is no blood. This procedure in "real life" is very bloody and you have to make sure it is venous blood not arterial blood as the carotid arteries are close in proximity and if cut will cause horrendous outcomes and bleeding out of control. It is never good to cut an artery on accident.
During my case there was lots of venous blood which I expected and fortunately no arterial bleeding.
I am truly fortunate that this case went well as they often do not and can end in death or other bad outcomes. I also am lucky that I have the privilege of doing this line of work. I love going to work.
However, I have a time of great stories and medical adventures of residency that have occurred and would make great posts for my blog I just need to get caught up.
I wanted to post an experience that occurred while I was working in a medical surgical ICU. as a senior resident working in the ICU can be very stressful. In the ICU the patients are very sick often on the edge of deaths door and overnight You are the only doctor available to take care of these patients. In addition to this responsibility you are also required to respond to all code blues except for ones in the emergency department. CODE BLUES l are pronounced over the intercom as "CODE BLUE room 747" or whatever the room number is and as the ICU resident I would drop everything I was doing and literally run to the room because it meant a patient was crashing or dying. So lets just I was on call every third night and all of those calls were exciting and in no sleep occurred.
On one night I had an amazing experience where a young patient who had just recently been extubated (taken of a ventilator) who had multiple medical problems and was very sick, stopped breathing. I was immediately called to the room and the patients 's 02% was in the low 30% range which is very low and if prolonged for even a short period of time can cause severe brain injury if not death. this individual was a family man with a wife and young children and ultimately although sick should have ultimately recovered and returned to his normal life.
Upon entering the room I saw the patient's vital signs and it became very clear to me that I had to make a quick decision on how I would manage this patient. I was the only doctor there in the room a 2:00am but I had several very experienced nurses and respiratory techs to help and to lean on. As I entered the room the charge nurse said "thank heavens he is an ER doc, he'll know what to do!" which of course added to the pressure. I grabbed my intubation kit and tried to visualize the airway, without success. I grabbed a glidescope which is a fiberoptic video intubation machine that makes intubating easier on difficult airway cases. I had no luck with the glidescope either. Every second that passed = brain cells dying.
I remained very calm although on the inside I was about to pass out. I yelled out "cric kit stat!" The respiratory therapist said with a gasp "doctor, don't you need an attending physician to do a surgical airway?" I politely said "if we wait for an attending to show up, this father of 3 will be dead." The cric kit was produced and I immediately made my incision at the appropriate landmarks and found a very scarred and hard trachea as this patine had been trach'ed in the past for different medical problems. However I was able to cut through the trachea and get my gloved finger into the hole so that I would not lose the incision. I had to cut to make the hole larger and then was able to insert a tracy tube.
Immediately the thatch tube fogged with condensation of the patient's air. ALmost immediately the beeping alarms silenced and the patient regained consciousness and his vital signs returned to normal. I finished suturing the tube into place and hooked it up to the ventilator. Right about at this time an attending anesthesiologist entered the room and audibly gasped. He said "doctor wil you please note that this procedure was started prior to my arrival?" I replied "yes I will note that it was started and completed prior to your arrival." He smiled at my subtle humor and looked over my work. He examined the patients airway and said "there was no way to get this patient's airway other than what you did, nice call." Of course, this made me feel better about the decision to do the surgical airway. In looking back at the documentation this time from when I entered the room to the point where I was cutting was 38 seconds and old records showed the last time he was intubated in an OR setting it took 45 minutes with a fiberoptic scope because his airway was so scarred and difficult to get a tube through. In that setting they were breathing for him so they could take the time and it was non emergent. My setting was a little different.
I called the family at 3am and they all came in and verified that he was at his normal mental status and it did not appear that he suffered any brain damage. I told them the entire story and they were very grateful. I explained that their had to be other forces at work because everything works out perfectly and I said "I am a good doctor but not that good" and we all laughed.
The patient was discharged from the hospital 5 days later with a trach that would be removed in 3 - 4 months but he was alive and at his normal healthy mental status. Even now the experience seems like a surreal dream. Fortunately it went well. I love this job.
During my case there was lots of venous blood which I expected and fortunately no arterial bleeding.
I am truly fortunate that this case went well as they often do not and can end in death or other bad outcomes. I also am lucky that I have the privilege of doing this line of work. I love going to work.
Friday, September 23, 2011
Long time, ICU
I just finished a long month at a inner city ICU as a senior resident. While there I saw many many sick, sick patients. I could probably create 100+ dedicated posts just to multiple interesting cases that I had while being a senior resident.
A relatively newer common phenomenon that's occurring in the United States today is that the hospitals are becoming so increasingly busy that the ERs are packed full and the ICU and other hospital beds are full and so the sick patients pile on in the emergency room and have to be boarded in the hallways and ultimately stay in the ER for several hours or even days.
As part of all Emergency Medicine training we spend several months working ICUs as junior residents and as senior residents. This past month was my first month in an ICU as a "senior resident". That means that I had the ultimate responsibility for managing the unit. Never fear I had lots of back up, a fellow in critical care at home and an attending physician trained in critical care who was also at home. During the day everyone on the team was there but at night often times it was me and the nurses and a bunch of sick patients with more arriving at all hours. At times it was a little overwhelming but exciting, challenging and fun. I learned more in that month than I could have learned in 1 year of didactic course work.
I want to share one very interesting case that I had while working as the senior resident on the ICU. So one evening when I was on call I was on the floor helping the nurses in putting in orders for 20 different very sick patients we had in the ICU. I was called to one of the rooms because a patient had become bradycardic, with a heart rate in the low 20s. As I entered the room I asked the nurse to prepare some medications and begin to treat the patient. Right in front of my eyes I saw the patient's heart rate completely stop and he flat lined on the monitor.
Immediately we began CPR and resuscitation protocol. I noted that the patient's stomach had become increasingly distended. This patient actually had a feeding tube that was directly connected to his stomach through his abdomen. As I watched his stomach become more and more distended I realized that this was the cause of his problems.
I quickly grabbed some suction tubing and connected it to the wall suction device on one and and then connected the other end to the patient's feeding tube and immediately the distention of the patient's abdomen begin to decrease and the patient took a large breath and his heart beat came back, he was alive. He is still alive and doing well. It was a fortunate save and luckily I saw the stomach / abdomen distention. Air was entering his abdomen and causing the diaphragm to distend which was pushing on his heart / aorta causing the heart to go into abnormal rhythm. As soon as the pressure was decreased and released the heart rate returned to normal. This patient would have certainly died had the pressure continued to build. Fortunately we only had to do 1 round of CPR before fixing the problem. The CPR itself kept the patient alive while his heart was not functioning.
This is a 15 minute look into the ICU. I was there for a total of 20,000 + minutes so you can imagine the stories I have to tell.
A relatively newer common phenomenon that's occurring in the United States today is that the hospitals are becoming so increasingly busy that the ERs are packed full and the ICU and other hospital beds are full and so the sick patients pile on in the emergency room and have to be boarded in the hallways and ultimately stay in the ER for several hours or even days.
As part of all Emergency Medicine training we spend several months working ICUs as junior residents and as senior residents. This past month was my first month in an ICU as a "senior resident". That means that I had the ultimate responsibility for managing the unit. Never fear I had lots of back up, a fellow in critical care at home and an attending physician trained in critical care who was also at home. During the day everyone on the team was there but at night often times it was me and the nurses and a bunch of sick patients with more arriving at all hours. At times it was a little overwhelming but exciting, challenging and fun. I learned more in that month than I could have learned in 1 year of didactic course work.
I want to share one very interesting case that I had while working as the senior resident on the ICU. So one evening when I was on call I was on the floor helping the nurses in putting in orders for 20 different very sick patients we had in the ICU. I was called to one of the rooms because a patient had become bradycardic, with a heart rate in the low 20s. As I entered the room I asked the nurse to prepare some medications and begin to treat the patient. Right in front of my eyes I saw the patient's heart rate completely stop and he flat lined on the monitor.
Immediately we began CPR and resuscitation protocol. I noted that the patient's stomach had become increasingly distended. This patient actually had a feeding tube that was directly connected to his stomach through his abdomen. As I watched his stomach become more and more distended I realized that this was the cause of his problems.
I quickly grabbed some suction tubing and connected it to the wall suction device on one and and then connected the other end to the patient's feeding tube and immediately the distention of the patient's abdomen begin to decrease and the patient took a large breath and his heart beat came back, he was alive. He is still alive and doing well. It was a fortunate save and luckily I saw the stomach / abdomen distention. Air was entering his abdomen and causing the diaphragm to distend which was pushing on his heart / aorta causing the heart to go into abnormal rhythm. As soon as the pressure was decreased and released the heart rate returned to normal. This patient would have certainly died had the pressure continued to build. Fortunately we only had to do 1 round of CPR before fixing the problem. The CPR itself kept the patient alive while his heart was not functioning.
This is a 15 minute look into the ICU. I was there for a total of 20,000 + minutes so you can imagine the stories I have to tell.
Monday, April 25, 2011
Nasal Foreign Body: Up your nose and around the corner.
I am back in an inner-city emergency department. And it's been a while since I have posted anything to my blog. Life has been a little crazy. But as Aerosmith once said back in the early 80s "I'm back in the saddle again".
This emergency department is in the heart of an inner-city and what some would call a knife and gun club. That means that there are gunshot wound victims knife stabbing victims and people who suffer all forms of trauma abuse and other accidents. I will have to catch you up later on a lot of the details nevertheless I have seen some amazing cases during this rotation so far.
On a lighter note the other night while working at 2:00 in the morning a very sweet nice little five-year-old girl presented to the emergency department with her father with a chief complaint of a foreign body in her nose. That is just medical mumbo-jumbo for she got something stuck up her nose. As I entered the exam room and saw this cute scared little five-year-old girl who thought for sure she was going to get some sort of a shot. I couldn't help but think of how scared she was and how concerned her father was not sure if he was concerned or mad or maybe a little of both.
I asked the patient how she got something stuck up her nose or what was stuck up her nose to which she replied with big alligator tears in her eyes I don't know and I don't know, which is a fairly typical response. I was able to further question her and explain that she was not in any trouble that I was there to help her and that we see these these things all the time with not just kids but also with adults. After making a few more jokes and getting her to laugh she finally admitted that she was playing with some toys and accidentally put a plastic bead up her nose.
I was able to take a very small tiny balloon catheter, after anesthetizing her nose and slide the balloon catheter pass what appeared to be a black bead and inflate the balloon. Then ever so gently I pulled back on the catheter bringing with it the small black ball that she had somehow put up her nose. Everybody in the room clapped and cheered. This was a very rewarding case. I immediately proclaimed "Popsicle stat" and the nurse magically appeared with an orange popsicle (the patient's favorite flavor) and all was well at three in the morning for this five-year-old girl and her father.
I love my job.
This emergency department is in the heart of an inner-city and what some would call a knife and gun club. That means that there are gunshot wound victims knife stabbing victims and people who suffer all forms of trauma abuse and other accidents. I will have to catch you up later on a lot of the details nevertheless I have seen some amazing cases during this rotation so far.
On a lighter note the other night while working at 2:00 in the morning a very sweet nice little five-year-old girl presented to the emergency department with her father with a chief complaint of a foreign body in her nose. That is just medical mumbo-jumbo for she got something stuck up her nose. As I entered the exam room and saw this cute scared little five-year-old girl who thought for sure she was going to get some sort of a shot. I couldn't help but think of how scared she was and how concerned her father was not sure if he was concerned or mad or maybe a little of both.
I asked the patient how she got something stuck up her nose or what was stuck up her nose to which she replied with big alligator tears in her eyes I don't know and I don't know, which is a fairly typical response. I was able to further question her and explain that she was not in any trouble that I was there to help her and that we see these these things all the time with not just kids but also with adults. After making a few more jokes and getting her to laugh she finally admitted that she was playing with some toys and accidentally put a plastic bead up her nose.
I was able to take a very small tiny balloon catheter, after anesthetizing her nose and slide the balloon catheter pass what appeared to be a black bead and inflate the balloon. Then ever so gently I pulled back on the catheter bringing with it the small black ball that she had somehow put up her nose. Everybody in the room clapped and cheered. This was a very rewarding case. I immediately proclaimed "Popsicle stat" and the nurse magically appeared with an orange popsicle (the patient's favorite flavor) and all was well at three in the morning for this five-year-old girl and her father.
I love my job.
Thursday, February 24, 2011
Suicide, Tantrum or Just Stupid?
Beep, Beep, fuss, beep....... "Hi this is Doctor ___, what do you have?" "Hey Doc, we have a 22 year old male who od'ed on xanax and drank some liquid dishwasher detergent." "What are his vital signs? Is he alert and protecting his airway?" I ask. "Yes he is stable and protecting his airway. His vitals are HR 98, RR 24 and BP is 134/92, he is alert and oriented x 3." they scream back over the radio. "Great, what is your eta? If he starts to crash let us know." I said. "Thanks Doc, we are 10 minutes out."
It was 2 in the morning and we had 4 sets of paramedics on their way in with a variety of sick and not so sick patients. I continued taking care of the patients I already had and waited for this toxic ingestion to arrive. About 10 minutes later I heard a bunch of yelling and screaming coming from the paramedic bay as my toxic patient arrived, yelling and screaming at everyone. One profanity after another came flying out as he made sure to insult everyone his eyes came in contact with. As the paramedics rolled him by I looked up to see how sick my new patient was and I yelled, "take him to room 3, in case I have to intubate him." They obliged and looked like all they wanted to do was drop off this maniac and get out of the ER as fast as possible.
I made my way over to room 3 and started examining the patient as they hooked him up to all the monitors in room 3 and he started told us the story be he was just yelling and obviously agitated. He told me to F+&*& off and attempted to spit on me. This was not the first nor the last time a patient who I was trying to care for tried to spit on me, so I was prepared and dodged the spit like a champion bull fighter. I quickly assessed the situation and fortunately his much calmer girlfriend was there and could tell us what happened and what she saw.
As it turned out he had been on a bender and had "eaten" (her words) all the xanax in the house, which was not enough to kill him. He was only looking to get high but when he found out they were out of xanax he became irate and decided to drink some Cascade, about 2 cups in her estimation. He immediately started throwing up at home and she thought most of it had come back up. I quickly completed my exam and noted that his throat was irritated and also that his teeth were particularly shiny and had no streaks.
I had one of the medical students call poison control to get any further recommendations for treatment and I started a some treatments and stabilized the patient. I saw a few other patients when I was called back by the nurse because "Mr. Clean" (her words) had started to cough up / vomit blood. I made my way to room 3 prepared to intubate our patient but he look ok and was ventilating nicely. He looked like he was withdrawing from xanax / other benzos. I gave some medication too help prevent a full fledged withdrawal with seizures and other horrible symptoms.
Finally poison control called back and I was paged to take the call. I explained what I had done so far; which tests I had orders, and the interventions / treatments I had started. The doctor on the other end of the line, said "perfect, you did not even need to call us, great job!" I told him thanks and explained I needed to document his recommendations for liability reasons and he chuckled and replied with "smart, very smart, cover all your bases." He also let me know what to watch for and what to expect.
Fortunately my patient had not consumed enough of Casacade to cause major problems that would be permanent. He did however burn his throat, mouth and esophagus. He also had aspirated some into his lungs. I explained to him and his family and girlfriend that he would be admitted into the hospital. At this point the patient was calmed down and ready to talk. It sounded like this whole event was a tantrum and not a suicide attempt. I called for a 24 hour sitter anyway just incase. I was able to make some phone calls for social work to see him the next day and talk to him about getting into rehab.
This was 1 patient of the 24 I saw that night. While I was caring for him I had 6 other patients in rooms that I was responsible for as well. What I night. I love what I do, it never gets old and when you think you have seen it all, the doors come flying open and a new adventure begins. You can't make this stuff up, real life better than fiction.
The thing about emergency medicine is that you get to do a little bit of everything. You do some minor surgeries / procedures, OB/GYN, psychiatry, orthopedics, dentistry, urology, neurology, GI, cardiology, ophthalmology, dermatology, pediatrics, toxicology, radiology, anesthesiology, primary care and so much more. Often you do all of these within the same shift. Perfect for ADD / ADHD.
Good times.
It was 2 in the morning and we had 4 sets of paramedics on their way in with a variety of sick and not so sick patients. I continued taking care of the patients I already had and waited for this toxic ingestion to arrive. About 10 minutes later I heard a bunch of yelling and screaming coming from the paramedic bay as my toxic patient arrived, yelling and screaming at everyone. One profanity after another came flying out as he made sure to insult everyone his eyes came in contact with. As the paramedics rolled him by I looked up to see how sick my new patient was and I yelled, "take him to room 3, in case I have to intubate him." They obliged and looked like all they wanted to do was drop off this maniac and get out of the ER as fast as possible.
I made my way over to room 3 and started examining the patient as they hooked him up to all the monitors in room 3 and he started told us the story be he was just yelling and obviously agitated. He told me to F+&*& off and attempted to spit on me. This was not the first nor the last time a patient who I was trying to care for tried to spit on me, so I was prepared and dodged the spit like a champion bull fighter. I quickly assessed the situation and fortunately his much calmer girlfriend was there and could tell us what happened and what she saw.
As it turned out he had been on a bender and had "eaten" (her words) all the xanax in the house, which was not enough to kill him. He was only looking to get high but when he found out they were out of xanax he became irate and decided to drink some Cascade, about 2 cups in her estimation. He immediately started throwing up at home and she thought most of it had come back up. I quickly completed my exam and noted that his throat was irritated and also that his teeth were particularly shiny and had no streaks.
I had one of the medical students call poison control to get any further recommendations for treatment and I started a some treatments and stabilized the patient. I saw a few other patients when I was called back by the nurse because "Mr. Clean" (her words) had started to cough up / vomit blood. I made my way to room 3 prepared to intubate our patient but he look ok and was ventilating nicely. He looked like he was withdrawing from xanax / other benzos. I gave some medication too help prevent a full fledged withdrawal with seizures and other horrible symptoms.
Finally poison control called back and I was paged to take the call. I explained what I had done so far; which tests I had orders, and the interventions / treatments I had started. The doctor on the other end of the line, said "perfect, you did not even need to call us, great job!" I told him thanks and explained I needed to document his recommendations for liability reasons and he chuckled and replied with "smart, very smart, cover all your bases." He also let me know what to watch for and what to expect.
Fortunately my patient had not consumed enough of Casacade to cause major problems that would be permanent. He did however burn his throat, mouth and esophagus. He also had aspirated some into his lungs. I explained to him and his family and girlfriend that he would be admitted into the hospital. At this point the patient was calmed down and ready to talk. It sounded like this whole event was a tantrum and not a suicide attempt. I called for a 24 hour sitter anyway just incase. I was able to make some phone calls for social work to see him the next day and talk to him about getting into rehab.
This was 1 patient of the 24 I saw that night. While I was caring for him I had 6 other patients in rooms that I was responsible for as well. What I night. I love what I do, it never gets old and when you think you have seen it all, the doors come flying open and a new adventure begins. You can't make this stuff up, real life better than fiction.
The thing about emergency medicine is that you get to do a little bit of everything. You do some minor surgeries / procedures, OB/GYN, psychiatry, orthopedics, dentistry, urology, neurology, GI, cardiology, ophthalmology, dermatology, pediatrics, toxicology, radiology, anesthesiology, primary care and so much more. Often you do all of these within the same shift. Perfect for ADD / ADHD.
Good times.
Monday, February 21, 2011
Tough Cases in the ER
I am on emergency medicine in a urban trauma one center and I'm working 12 hour shifts. I work 7 PM to 7 AM for 7 AM to 7 PM. It feels good to be back in my element, my home. This is a scratch that this is a busy emergency department and receive lots of very sick patients tonight
I had an interesting patient the other night. This was a 34 -year-old African-American male with HIV-positive, ESRD (End Stage Renal Disease, and a rip roaring case of pneumonia with a recent pulmonary embolism (PE). He was recently in our ICU unit for pneumonia he was discharged last week and this morning woke up with worsening shortness of breath. He decided to come into the emergency department because of his worsening symptoms when I enter the room I immediately knew this was a sick patient. He was talking just fine but his blood pressure was low and he was having a difficult time getting his oxygen. So I decided to work this individual up for sepsis. I ordered the appropriate labs and films and imaging and I looked at some of his old records.
He had a low CD4 count which is bad for someone’s immune system. He had moved from HIV+ to full-blown AIDS. His low blood pressure continued to plummet. I started him on IV fluid, bolus to bolster his blood pressure. His blood pressure started to come up but it was not high enough, so I decided I was going to put a central line in for better access. I started a medication that helps maintain blood pressure. This medication, seemed to help him and he remained stable in the emergency department.
We got his chest x-ray back and it showed a worsening left-sided lower lobe pneumonia. He was discharged last week with pneumonia and today it was worsening which probably explained his worsening shortness of breath and symptoms. His discharge x-rays were much improved from today’s x-ray. I was fairly certain he was improving and after he was discharged he continued to improve but then started to get worse. He was a very sick individual and needed to be placed back in the ICU.
So I called the ICU doctor to let them know about this patient. This patient needed a central venous line. This is a catheter that is placed into a major vessel like the internal jugular carotid to give better access for medications and fluids. Placement of a central line is bread and butter of emergency medicine. We place them all the time. The ICU senior resident came down because she wanted to learn how to do a central line. She asked me if I would show / teach her. I said yes. We started to do a central line. We had to avoid doing a central line on the right internal jugular which is where we normally like to do it, because this patient had dialysis catheter on the right. This meant we had to place the central line on the left. I begin to show the senior resident how to do the central line. We were both in our sterile gowns and she was having difficulty getting in the vessel. After several attempts I asked if I could show her personally and do central line. I proceeded to show her how to get a central line in the femoral. I was able to get the vessel. However when I advanced the wire it became difficult to advance, so I stopped. This could have been due to a clot in the vessel, my attending tried a couple of times but was unsuccessful.
The patient’s blood pressure had significantly improved and he was maintaining his vitals. We decided to get him up to the unit and place the line later if he needed that level of access. The patient was talking and he said he felt fine and thanked us as he was transferred up to the ICU. He was checked into the unit and was stable.
A little while later I heard a code RRT (Rapid Response Team) called to the ICU and I had a feeling it was for this patient. It turned out that he was talking on the phone when he just suddenly slumped over. He was found to be in a-systole (essentially dead). He was revived 3 times before finally died. He most likely had a big pulmonary embolism. He most like would have died from his worsening pneumonia given his near zero CD4 count.
Ultimately I was able to follow up on this patient and it turns out the he had a large saddle pulmonary embolism in his pulmonary arteries that came from a DVT (deep venous thrombosis) in his lower extremities.
These cases rock your world every time.
Saturday, January 15, 2011
Trauma Surgery Rotation
It is January 10, 2011. Today I started a new rotation which I am fairly excited about, but it will be a difficult rotation. The rotation is trauma. Some people might ask; “isn't everything you do trauma?” and that's a good question. Trauma is its own sub-specialty within emergency medicine and within surgery. Many hospitals are Level 1 trauma centers. That means that they are equipped and have the personnel to handle any kind of trauma, the most severe trauma and there are trauma Level 2 centers which do not handle all of the major traumas, but can still handle fairly significant trauma and then it drops off from there to trauma Level 3, etc., on to minor. What is a Level 1 trauma center? Well, that means you have a trauma service that is there on call 24 hours a day, you have neurosurgery available 24 hours a day, and you have an emergency department with a trauma center and it can handle and treat blunt force trauma, penetrating trauma, gunshot wounds, fire burns, and the sickest of sick trauma patients. The Level 1 centers will also have a surgical ICU (SICU) where the patient can be treated and managed following the trauma and the surgery required to fix the trauma.
I am at a Level 1 trauma center in an urban setting. As you can imagine we get some very severe trauma cases on a daily basis. Today I started my rotation by showing up on the surgical floor at 4:30 in the morning to meet the trauma team and I was assigned four patients who were already admitted to manage. So in addition to that taking care of trauma patients who are recovering in the SICU, I also have the responsibilities is to respond to all the Code Greens in the hospital. Code Green is an announcement that there is a trauma case that is coming to the hospital or already at the hospital. “Attention, will the trauma team please report to the trauma bay” is the announcement made throughout the hospital. The announcement is heard by everyone through the overhead paging systems. Each of the members of the trauma team also receive a text page through their pagers. I will go along with the rest of the trauma team down to the emergency department to wait for a trauma that's coming in and help treat the patient once they do get there.
Today was a particularly busy day. We had I think eight Code Greens. Several were pedestrian versus automobile, so someone was hit by a car and you can imagine that the injuries are severe, the car always wins, and so it was an interesting day and plus I had a gunshot wound to the leg and someone who fell and fractured their skull. There's all kinds of trauma patients that come in. So once we go down to the emergency room and manage the patient. Basically that entails securing the airway, if they need intubation I'll intubate them, doing an ultrasound FAST exam to check for any internal bleeding. We fully inspect the patient, cut their clothes off and look for any wounds or deformed extremities or cuts, lacerations, and do a general assessment of what's wrong with the patient. Then do all the imaging, X‑rays, CT, whatever's required to look for any fractures, particularly spinal injuries, and then we also repair any lacerations. Then if the patient has the kind of wounds that would require immediate surgery they are whisked off to the operating room where whatever the necessary surgery is to be done. So they either go into surgery or if surgery's not required then they go to the trauma surgery service floor where we continue to manage them as a trauma team until they are better, go home, or transferred to another service for whatever reason. So right now we have 15‑plus patients on our service plus whatever comes in overnight tonight, so it's very busy and tomorrow I'm on call, so that will be a long day but certainly an interesting day. I'm sure I'll learn a lot. So I'll be on this service for the next month and I take call every third night so the hours will be extraordinarily long. It should be fun though and I imagine I will learn a lot and it is a good adrenalin rush to treat the trauma patient.
Tuesday, January 4, 2011
Pediatric Emergency Medicine
Wow, here I am at the end of another rotation and I have even written one post about it yet. I have a few more shifts so I better get crackin'.
I am on Peds/EM rotation which is doing shifts at 2 different Emergency Departments that have dedicated Pediatric Emergency Centers. Across America in most hospitals the emergency department sees all patients whether adult, child or infant. EM physicians are trained to see all of these patients. I would say that on any given ED shift I see 20 - 40% of all the patients I see are pediatric. So far this year I have seen lots of kids on my various rotations.
However everyone gets a little tense whenever we have a really sick child that presents. I feel like we can always use more pediatric training. My residency gives us several dedicated pediatric emergency rotations. This month I have been doing shifts at 2 different pediatric emergency departments. I show up for my shift and only see sick kids the entire shift. It has been great for my training and learning to solely focus on pediatric emergencies and illnesses.
I have seen a lot of sick kids and some not so sick kids that had very worried parents. In pediatric populations you almost have 3 patients per room, the child and the parents. Often you have grandparents as well.
There is a fellowship offered after completing a residency in EM that allows you to further specialize in just pediatrics. It is 2 years. Not a lot of doctors choose to do this fellowship because most ED's do not have a separate emergency department just for kids.
This rotation has been a great learning experience so far. I will post some of the cases.
I am on Peds/EM rotation which is doing shifts at 2 different Emergency Departments that have dedicated Pediatric Emergency Centers. Across America in most hospitals the emergency department sees all patients whether adult, child or infant. EM physicians are trained to see all of these patients. I would say that on any given ED shift I see 20 - 40% of all the patients I see are pediatric. So far this year I have seen lots of kids on my various rotations.
However everyone gets a little tense whenever we have a really sick child that presents. I feel like we can always use more pediatric training. My residency gives us several dedicated pediatric emergency rotations. This month I have been doing shifts at 2 different pediatric emergency departments. I show up for my shift and only see sick kids the entire shift. It has been great for my training and learning to solely focus on pediatric emergencies and illnesses.
I have seen a lot of sick kids and some not so sick kids that had very worried parents. In pediatric populations you almost have 3 patients per room, the child and the parents. Often you have grandparents as well.
There is a fellowship offered after completing a residency in EM that allows you to further specialize in just pediatrics. It is 2 years. Not a lot of doctors choose to do this fellowship because most ED's do not have a separate emergency department just for kids.
This rotation has been a great learning experience so far. I will post some of the cases.
Subscribe to:
Posts (Atom)