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. 

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.

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.

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.

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.

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.

Flash

Unless you love your life will flash by..