At the End of the Day...

I haven't written about a day in the E.D. for a while, so I thought I would blog tonight about my shift today.  Just another day in my world.  For some, this was no ordinary day...

So, I started my shift at 0700, taking over from one of my colleagues and picking up about 10 patients right off the bat.  While I sent off my rotating resident and medical student to pick up a couple of the new patients that were waiting to be seen, I went to look at the lacerations on a stabbing patient that I had picked up on sign out.  My colleague hadn't been able to sew the wounds because they had been waiting for a few more films to come back, but by sign-out the patient was ready to have their wounds fixed.

I looked at the 4 inch cut to the face and the inch long wounds to the arm and back, and I knew that I would be sewing for a while.  When you're the senior, you're not just in charge of your patients, but you're also responsible for the flow of the department (what's coming in and what's going out and where).  So, I knew that I couldn't just leisurely tie myself up in one patient's room.  I had to think about what could potentially happen.

I stepped out to gather my supplies and went and saw a new patient coming in complaining of back pain.  She'd had recent back surgery and was having post-operative pain.  I wrote for some medications after some discussion with my attending and continued gathering my suture supplies.  About that time an elderly patient that had fallen down the stairs came in.

There was some concern because the patient was on blood thinners, and she had hit her head.  I did her exam, did a FAST exam and wrote order for the multitude of CAT scans I would be getting on her.  I then went to go start stitching my patient's face.  It took me about 30 minutes to get his face sewn up.  In the middle of my stitching, nurses would come in from time to time to ask about orders for patients.  At one point near the end, the nurse taking care of my elderly fall lady came to tell me that the patient wasn't as alert as she had previously been.  I told her to rush her to CAT scan.

I finished the patient's face and went out to see what had happened while I was gone.  The patient tracking board was filling up with patients, and I quickly went and saw another senior who had passed out in church, and one of our sickle cell frequent fliers.  I put in orders then went back and quickly spent about 5 minutes sewing up the laceration on my patient's arm.  Two lacerations down and one to go.  As I was putting in the last stitch, the nurse for my fall patient came in to tell me that the patient had bleeding in the brain.

I went out and told the charge nurse that we needed to move the patient to a trauma room.  I paged out the trauma team, and I put out a call to the neurosurgeon.  I wrote some order discharging a couple of the patients that I had been signed out that morning and answered returned phone calls.  I got the medical student started on sewing the last wound on my stabbing patient.  He got the first stitch in about the time I heard my name paged to the trauma room.

I went and found that the fall patient had an even worse neurological exam and would need to be intubated.  I went to find my attending as I grabbed the airway box and went to the room.  My attending told me to wait because he didn't feel there had been much of a change, and he wanted the neurosurgeon to get a good exam.  I went back to my medical student and got him through another stitch.  I got called back out of the room to talk to the family of the fall patient.  I explained about the head bleed and how I might have to put a breathing tube in.  They understood, and I went back to the stabbing victim.

One more stitch and I was called back to the fall patient.  She'd just vomited everywhere.  I told my attending I was intubating.  I got the breathing tube in and went to tell the family I had just done so.  They were very upset asking how the patient was going to do.  I couldn't answer them, but elderly patients who fall down the stairs and bleed into their brains don't often do well.  Another stitch with the medical student plus one or two I quickly threw in to move things along, and we were done.  By this time it was close to 1 p.m.  Where had the morning gone?

My fall patient went to the ICU, and I discharged (finally) the stabbing victim.  I picked up a nursing home patient brought in for altered mental status and another patient with swelling in their lower extremities.  After discussing the cases with the attending, I placed my orders and sent the resident to lunch.  I quickly saw a prisoner with a hand injury from a fight in the jail and placed orders for films.

My swollen patient ended up needing a cat scan, and for some reason it took 2 hours to get a head CT on my altered mental status patient during which time I sent the prisoner back to his cell and sent the medical student off to lunch.  I grabbed a quick salad myself (still doing the raw food thing) while I saw a pseudoseizure (nee big faker) and a patient bleeding from just about every orifice.  Oh, and a short of breath pregnant patient who did a whole lot of cocaine.

By this time it was after 5:30 p.m.  I got a neurology consult on the big faker, um, seizure patient, and I started ordering blood products for the bleeder.  My cocaine patient settled down, and I picked up a patient that had lost their battle with a table saw.  Almost missing - one pinky.  I called orthopedics.

Around this time I was cleaning house.  I got my big faker patient admitted, my swollen patient admitted, and my bleeding patient admitted.  We got word about this time that my fall patient had suffered a major bleed and now had a ton of blood in her head.  This was not going to end well.

Seven p.m. and my colleague returned.  We signed out our patients to her, and I spent about another hour doing paperwork and getting my altered mental status patient admitted and got my cocaine patient information about her reproductive choices.  While morally I oppose abortion, a cocaine and alcohol addicted patient whose three children are in the custody of her parents probably should have the option.  I don't condone it, but at time I think of it as a necessary evil.

Anyway, I signed out the cocaine patient because her heart rate was still irregular and my almost missing pinky patient because ortho was busy with a dislocated knee that had rolled in the door just at change of shift.  Tiredly, I packed my belongings and made my way home.  Vacation started the minute I left the hospital.  After another "usual" day in the E.D., I really need it.

For those reading on Facebook, my original blog site is buffalosquirrels.blogspot.com and I also blog for the American College of Emergency Physician's (ACEP's) website thecentralline.org

It's the Journey and the Destination...

So, today it's official... I signed my contract, and in a couple of weeks we're going to take a second trip to Humboldt County to begin looking at housing.  Earlier this week, I got an email from a friend coordinating our 25th high school reunion.  How far I've come.


My plan when I graduated from high school:  graduate with a degree in civil engineering, meet my future husband, start a career, have three kids (2 boys and a girl), and build the cities of the future.


Five years later when I graduated from college with a degree in Photojournalism my plan was:  get a job as a reporter, try to get a job as a foreign journalist, meet someone and think about marriage later when I've gotten the wanderlust out of my system.


About five years later when I turned 30, I thought I could probably safely die and feel as though I had led a rich life.  I had been traveling across country to train in Washington D.C. for a demographic researcher position in Mexico City.  I lived in Mexico City for a year and met an amazing group of people.  I had traveled to Europe and Australia, and I had seen parts of the country that I never thought I would.  And, despite some dire odds against me, I actually got accepted to medical school.  Marriage and family was a distant memory... I had things to do.


I don't know that I had much of a plan going to medical school other than to actually graduate. I originally went in with the intention of doing emergency medicine, however when I did my fourth year elective I hated it.  How could anyone possibly want to work with people who did not take care of themselves?  Why did all the cool traumas go to surgery?  Was it too late to change my mind?


I found out it wasn't which is how I ended up doing three years of surgery.  Over that time, though, I found I missed the patient contact.  I missed teaching my patients.  After taking a year off, I went back to emergency medicine.  I got married.  I have three children of the furry kind;  a boy and two girls.  And, now, I have just taken the next step.  We're actually going to be "settling down."  Wow.


It definitely wasn't the destination, but the journey that has brought me to this point.  I can stop and think about several points in my life where a decision I made definitely changed the course of my life.  They're the "what ifs" that everyone has faced from time to time.  I'll ponder them in another post.... might even base a story on them.  But for now, I will relish in the fact that I'm just about to reach my next destination... I don't think it's the final one.  Ask me again in five years...

Real World Lessons

Thank you for all the comments on the Raw Food way of life that I started at the end of last year.  I thought I would take some time to answer some questions:


1.  To the left is the book that got me started.  It's really a gourmet raw food cookbook, but the authors took the time to research the science behind the Raw Food lifestyle.  In that it was great.  Practically, I can't find most of the ingredients that are listed (although the book has a great resource index at the back), but I am sure that once we move back to the land of fruits and nuts that is Northern California I know we will have a coop nearby and a ton of fresh locally grown produce from the farmer's markets.


2.  No, I don't eat raw meat.  We're not eating any animals at this time.  We are doing about 85% raw at this time because I can't quite give up cheese (Wisconsin raw Monterey Jack, yum) and my hubby needs his cream for his coffee (definitely not raw on both accounts) not to mention we will occasionally eat eggs (soon to be our own;  home-grown from our own chickens).


3.  The best website I have found is this one by Esme Stevens which has a lot of practical advice for newbies.  I also consult the Raw Food Community site and also the Raw Way site.  There are tons of other sites out there for recipe ideas.  Also, I have been collecting some site for finding deals on many of the staples:  nuts, dehydrators, etc.


4.  What do I miss?  At this point over 2 months into it, seriously not much.  I always said I couldn't be a vegetarian because I couldn't give up ribeyes.  Now they don't taste the same (not to mention the assault on my GI system).  Bread - almost like I can taste the processing.  Pasta - it just doesn't have a fresh taste.  There's something about the crisp clean crunchy taste of fresh foods.  After this time, some days I am starving for a big salad, other days I just want a shake.  We've learned to be very creative with different ingredients.  Oh, but I do miss warm things... you're not allowed to cook anything.  But I have popped my Manna bread into the dehydrator from time to time.


5.  How can you go out?  You get creative.  I've eaten a lot of salads with oil and vinegar.  I have eaten grilled vegetables.  And, I allow myself one meal a week that is not completely raw.  I talked on my last blog post about some of the foods I enjoy.  I recently went on a trip to Phoenix for a medical conference and took my bag of dried fruit and nuts for snacks.  I was able to pick appropriate foods, and one night I indulged in some awesome soft corn carne asada tacos .


6.  "I don't know how you do it" - I don't know either, but it took a lot of discipline.  The first week was the hardest.  It does take a certain amount of prep time to get everything together.  You go to the grocery store more often, and spend a little more money, because everything is fresh.  But, after the first week of drinking water instead of Diet Coke, skipping the grill and heading to the salad bar at work, bypassing all my favorite fast food and take out places, I started to feel better.  I noticed I was sleeping better, felt more rested when I woke up, and didn't have a mid-afternoon post-lunch sleepy feeling.  Not to mention the weight loss benefits I talked about before.  Now, I am adding some exercise to my routine keeping the idea of running a five K and wearing a swimsuit by summertime as a goal to achieve.


Not that I expect to convert everyone to the Raw Food lifestyle, in fact the authors of the Raw Food Raw World book have a goal of 80% raw for most people, but I do hope this has helped to encourage you to make some lifestyle changes that will keep you out of my E.D. :) Not to mention help keep you around as my friends for just a little longer.  An easy way to get into a healthier way of eating is to do the "Pledge to be Veg" which I did last year, and which really got me thinking about what I was eating.  Good luck!


p.s. for those on Facebook, these notes are imported from my blogsite:  buffalosquirrels.blogspot.com

In the Raw for 2010

 

Ok, so for the last month and a half I have been doing the "Raw Food Diet." No, I don't eat raw meat.  It's a vegetarian-based, nee vegan, way of eating that believes in the principle that cooking food destroys valuable enzymes necessary for the digestion of the food, and also decreases the valuable vitamins and nutritional value of the food.  So, I've been eating a lot of cold food lately.
I am happy to admit, about 12 pounds off later, that I am feeling better and definitely seeing the results of a healthier way of living.  Not that it's been easy.  It took a lot, a LOT, of discipline to not nibble on any of the yummy Christmas goodies that were brought to the hospital and laid out for everyone to enjoy.  I sort of miss my daily Diet Coke.  And, I haven't had a Starbuck's Caramel Macchiato since before Halloween.
I have to plan my meals, and the biggest problem I had in the beginning was keeping my sugar levels up. I would get shaky right around 10 or 11 in the morning, and I realized that I could no longer go without eating something substantial in the morning.  Now I pretty much nibble all day long.
I also spend a little more at the grocery store.  But I enjoy seeing the different colors of the foods I am buying... from the deep greens of the romaine lettuce and zucchinis to the reds of the radishes and radicchio, the yellows and oranges of the peppers, oranges and bananas.  I got a box of avocados from my uncle in California for Christmas and am teaching my Southern DH (who had never seen an avocado before he met me) how to peel and prepare them.
I drink a ton of water, and I am learning how to be more creative when it comes to preparing food.
Now, I have to admit, I have a fondness for the lamb hummus from a place called Falafel Bar, and I have been known to eat a piece of chicken here and there.  But, my treat is one meal a week, and to be honest, I don't miss it if I don't have it.
So, my resolutions for the new year:
 - to continue my raw food healthy habits
 - to study and read more journal articles
 - to finally get better on my snowboard
 - to pet a cheetah
 - to finish at least 2 of the UFO's (that's unfinished projects) in my quilting stash
 - and to make it to church more often and thank God for the wonderful gifts of family, friends, and health He has bestowed on me this year.


My best wishes for your new year... what are your resolutions?

Voices Carry

Along with those patients we see during our shifts, there’s a group of patients we never see…. the ones on the other end of the Medical Direction line.  At the hospitals we rotate through, there are the “Bat Phones” -  the phones on which pre-hospital care providers call us for, well, medical direction.  It’s actually red at one of the hospitals.  Cool.

Interns, not allowed to touch the Bat Phones.  Junior residents, encouraged to field calls.  Us seniors, we’re on it most of the time.  I’ve given orders for medications, orders to keep a patient home, orders to have a patient sign off AMA.  And, I’ve given the order to pronounce a patient in the field.

I don’t think about those too much.  Usually it’s an elderly patient, found down after EMS was called to a home for a welfare check.  “Lividity?”  Yes.  “Cold with no signs of life?”  Yes.  Ok to pronounce.
I did have one funny situation where I was told the patient was “obviously dead” however they still were showing a sinus rythmn at 60.  Pacemaker.  I told the EMT’s to get a big magnet, and/or to make sure that anyone that was going to be handling the body knew about the pacemaker.  Wouldn’t want anyone to get an unpleasant  jolt.

During my overnight shift, though, I had the hardest medical direction yet – pronouncing victims of a house fire.  I got the first call about 3 in the morning.  I could hear the sadness in the usually jovial EMT’s voice, “thirty-something year old found in a burning house;  soot around their face and mouth.  No signs of life.  Asystole on three leads.”  I didn’t know what to say.  How long had they been in the house?  “Unknown.  Found by first responders to the scene.  Fire had just shown up.”  I put them on hold.

Now, I’ve asked my attending about some complicated scenarios that I’ve been faced with.  Early on it had to mostly do with medications during in-the-field resuscitations.  But, last night, I felt I needed his advice.  I told him the scenario.  He too paused for a moment and asked the same question I had asked, “how long?”  We both knew too long.  I gave the order to pronounce.

Saddened by this, I went back to the bustle of the E.D.  Then about 20 minutes later the Bat Phone rang again.  It was the same EMT sounding even more morose.  “I have two more, doc.  Twelve and about 15 years old.  Pulled out by Fire just a few minutes ago.  Soot on the face and asystole on three leads.”  In my head I calculated 4 – 6 mintes for brain damage to start and they had been in the house already longer than the first victim.  Kids have a smaller reserve.  I gave the order to pronounce.

My attending walked over to where I had been on the phone, documenting what I was hearing.  He read over my shoulder.  He walked away quietly.  I hung up the phone and placed the run sheet in its place;  suddenly feeling as though I had pronounced that family in the E.D. instead of from a distance.  I had lost three patients in 30 minutes.

I gathered myself and went to pick up another chart.  As I walked to the patient’s room I glanced at the Bat Phone, wondering when it would ring again, and what my next patient would be.

Isn't Sunday a Day of Rest...?

So I knew things were going to be bad when I woke up late for work this morning.  I was able to grab a pair of clean scrubs and run out the door.  All I could think about was getting sign out from the night team and heading downstairs to get a cup of coffee.  Little did I know...  I rushed to get to work quickly.  Made it in the door just at 0700, change of shift.  Before I even had a chance to take off my coat, the senior from the night shift told me that there were three victims from a house fire coming in;  one was a child and unresponsive and the other was an adult in respiratory distress.

I quickly took off my outer coat, grabbed my lab coat and stethoscope, figured out who my junior resident was going to be and got ready.  We got the adult patient first.  They were not responding coherently, so the decision was made to put a breathing tube in.  I left my junior resident to handle that while I took off to the next room as the child was being brought in.

She was brought in barely conscious but breathing.  She had soot around her nose, and we knew she probably had inhalation injuries.  We quickly made the decision to intubate her, and I put a breathing tube in.  We got her stabilized and started arranging transport to Children's Hospital.  We had no names for either of the patients, so we would just have to wait to name our little Jane Doe.

About this time, a third victim from the fire was brought in.  We asked if they had a little girl.  They immediately started crying but could not give us a name.  Carbon monoxide poisoning from a fire can make you goofy and delirious which they were.  They became argumentative and refusing treatment, but it quickly became apparent that they were not breathing well and would quickly be needing to be intubated.

After a quick sign-out from the night team that had patiently waited while we stabilized the fire victims, I talked to the patient who was starting to complain of a sore throat.  I told them what I was about to do and got some feeling that they understood.  We sedated the patient and placed the breathing tube... three patients intubated and it wasn't even 0930.

Somewhere around here time started to speed up.  I know from time to time I asked if it was Sunday and was anyone going downstairs for coffee.  Seriously, it was a cold snowy day.  A Sunday.  Why were we so busy?

Things that also happened during my shift, sometimes at the same time or right after each other:

 - alcoholic who vomited a liter and half of blood and needed a blood transfusion and admission to the ICU

  - a patient who heard voiced telling them to stab themselves in the chest, so they did, and then ate kitty litter in an attempt to kill themselves, they also needed a breathing tube

 - a possible stroke that turned out to be worsening heart and kidney failure

 - a teenager shot while driving with a friend "minding their own business" who initially went to Children's and then needed to be transfered to us

 - a teenager who decided to drink and drive and had a head-on collision with another vehicle;  they and their passenger forgot to wear their seatbelts and both had head injuries

 - an older driver who should have known better and drove while under the influence.  They had a head-on collision too, with a tree.  Again, no seatbelt.  Again, major face trauma

 - a very sick elderly patient that was transferred from another hospital and brought in by the helicopter.  I'll have to see if they're still alive when I go in tomorrow

 - another patient "minding their own business" who was stopping at a convenience store and was shot;  they came in just at the end of my shift which just about rounded out my day.  I will find out in the morning what the extent of their injuries were.

Wow.  What a Sunday.  And, tomorrow is Monday;  traditionally the busiest day of the week.  I better get to sleep early and double set my alarms... I think being late starts the day off on the wrong foot... yeah, we'll blame it on that!

When Art Imitates Life, Exactly

One of my colleagues posted this on Facebook, and I am sad to say I am sure someone stood outside the Emergency Department room while I interviewed a patient.... seriously....




Today a mother presented with her teenage son and said she wanted him tested for the Swine Flu and a prescription for Tamiflu. When informed that we don't routinely test for the flu and that Tamiflu was only for those at high risk showing symptoms (which her son was not), she told my attending she wanted to speak to his supervisor. When he informed her he was the senior medical staff, she told him that she was in the medical profession (a secretary at a nursing home) and no one was going to fool her like they did everyone else, and that she wanted a second opinion. He told her she could check her son back in and be seen again. But, she had a 50/50 chance of seeing him again.

She then stated she wanted to talk to a supervisor, and she demanded a second opinion. She saw the nursing supervisor who advised her to go to her child's pediatrician which just happened to be at the pediatric clinic across the street. When my attending called over to warn them that she was coming over, he was told that she had already been there and that they had told her the same thing. Last we heard, she was on her way to get a third opinion...