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23 December 2008

Bookends

Ok, so I had to work a shift at Buffalo General yesterday. It's one of the least favorite places for us to work because the system issues drive us crazy. To admit a patient takes a minimum of two phone calls. Most of the time it's three or four. And, the patients are generally sicker, have more medical problems, and can change on a dime.

I call this entry "Bookends" because during my las
t two shifts, yesterday at "the General" and the prior one at ECMC, it seems my shift started and ended with similar cases....

I walked into the E.D. at the start of my ECMC shift on Saturday and was immediately directed by my attending to follow the incoming ambulance crew into Trauma One. We walked in to find a 70 year old gentleman with known dementia who had decided around 4 in the morning that he wanted a coffee from a local drive thru called Tim Horton's. The only problem with that is: 1 - it was 4 in the morning, 2 - he didn't take a coat, 3 - we had just had the season's highest snowfall in the days before, and 4 - had he wanted his usual frappacino he would have walked just a block down the road, but he turned in the opposite direction to the Tim Horton's located about 10 miles away.

He was found only about a block and half aw
ay from his home, but he had been out in the snow for several hours. He came in with frostbite to his hands and feet. His body temperature... 87.5 degrees F! Now, normal is 98.6 degrees. You begin to have heart arrythmias at around 91 or 92. The fact that he was actually talking to us, albeit just repeating over and over that he was cold, was a miracle.

We quickly stripped him down and placed him on top
of and under warming blankets. We placed a catheter in his bladder to put in warm saline internally. I placed a central line so that warm saline could be infused as well. He was admitted to the burn center so that they could treat his hands and feet. I will check on his progress when I go back in tomorrow.

From there, the rest of the day flew by in a flurry of the usual sta
ndard fare of patients. About 45 minutes before the end of the shift, I was trying to wrap up my patients for the day when one of the EMT's asked me to triage a patient they were bringing in. It was a 40 something known opioid addict who was found in a snow drift.

I quickly directed them to Trauma Four where we learned that the patient had started throwing up after being given Narcan which is a reversal drug
for opioid overdoses. When they were clearing his throat with suction, they noticed what looked like a gumball in the back of his throat. They couldn't remove it, so I quickly intubated him for a potential threatened airway. We didn't see a gumball, but there was a lot of irritated tissue and a foreign mass seen on CT. I'll find out what happened to him as well tomorrow.

Cookie break:

So, I ended up working late. I had the next day off and then went to work at Buff General yesterday. One of the first patients we saw in the morning was a 65 year old gentleman who had gone outside to shovel the overnight snow. His wife saw him collapse and immediately called 911. Within two minutes BFD arrived and started CPR which continued until he got to the hospital.

My senior and I went into the room, and I immediately took over and continued CPR. We worked on him for about 30 minutes while family started arriving. Unfortunately, we weren't able to get him back although we tho
ught we had several times. My senior went to talk to the family, and I went back to work on the rest of my patients.

At the end of the day, after admitting a 43 year old who didn't want to comprehend that he'd had a heart attack and would have to, OMG, stop smoking and drinking and take medication for, um, the rest of his life because he'd had, oh yeah, A HEART ATTACK, I was signing out my patients to the on-coming seni
or when one of the patients that I'd had started having heart arrythmias.

I walked over with my attending and watched on the monitor as my patient's heart rhythm changed from something regular to something completely scary. His wife was just telling me that his AICD (automatic defibrillator) had just gone off. My patient was commenting that he'd been napping and had just had a rude awakening when all of a sudden he went into a deadly rhythm known as ventricular fibrillation. His heart started beating with no coordination at all.


We immediately gave him several external shocks as his AICD started firing off as well. Then he went into asystole, no heart activity at all. We started CPR and worked on him for about 10 minutes pushing a number of different drugs. He was intubated and we were able to get his heart rate stabilized and beating regularly. His pacemaker kicked in at that point and kept him going as well. I stayed late and placed a central line in him and watched as they took him up to the MICU.

I can see how far I've come, but I know there's still a long way for
me to go. It's back to the County for me for the next two days. We'll see what kind of gifts Santa, via the EMT's, brings me for Christmas.







21 December 2008

Getting Out of the "Big" House

The view from the ambulance ramp just after it started snowing. You can't see the trees and houses just across the drive.

I think at some
point I might have mentioned that we see a lot of the prison population at ECMC. One of the reasons being that we are the tertiary care center for a number of facilities. The other being that we have a very progressive telemedicine program which is connected to all of the correctional facilities in the state of New York.

We had a severe weather day on Friday when lots of snow (9 - 12 inches) was expected to fall over the course of about 12 hours. All of the schools were closed, and a lot of staff came in prepared to not be able to leave that night. The drive in was easy, but I had to spend about 20 minutes getting snow off my car (especially the 6 inches piled on the windshield) when I made the drive home 13 hours later. Luckily, I have a Jeep with 4 wheel drive and just rode over that foot and a half of snow piled up in front of it.

We kept expecting that it was going to be a light day. The snow started about 0900 and around noon, we were informed that there was a "no drive" directive out. However, we kept getting patients... mostly from the correctional facilities.
The complaints were legitimate enough that they warranted being seen, but not so critical that they needed to be seen "today."


Of course, one of the questions I always get asked when I can't provide a service on demand, such as a referral to a surgeon for an elective procedure, is "Is it because I'm wearing an orange jumpsuit?" I look at them, I look at the corrections' officer who is with them, then I look back at them and answer with a resounding, exasperated, "no!"

We never ask anything about our inmate patients. A lot of times, I am sure I don't want to know. I've treated lots of "accidental" falls that have resulted in broken noses, broken ribs, lot of cuts that need suturing, etc. I've treated STD's that have occurred. We have the frequent flyers who use their prior heart attack, asthma, HIV+ status, or seizure history to get out of jail for a while. We had one inmate with a psych history who was treated "Hannibal Lector" style since he was Hep C, HIV+ and liked to occasional spit and bite, or try to cause a needle stick incident when he was being treated.

Which reminds me: it's hard to get a physical exam on a patient wearing full jumpsuit with wrist and ankle cuffs attached to chains which are also wrapped around their midsection. But, for the most part, the CO's know what to do and start getting the pertinent body part ready for us to examine.

We also get a lot of new arrests. They either have just been arrested and have sudden chest pain or difficulty breathing and need a medical eval prior to being taken to jail. We've had the ones who made it to booking and then suddenly developed symptoms. We've had the hunger strikes, unwitnessed seizures, mysteriously injured jail-bound patients. I even had the patient with two days' nausea and vomiting that I had to now inform that she was pregnant. Bummer.

On Friday, all of the inmates were cleared and sent back to their respective facilities. A few looked disappointed that we couldn't admit them and get them out and into the real world... at least for a few more hours.




18 December 2008

Takotsubo Troubles

There's a medical condition in the literature known as Takotsubo Cardiomyopathy. It's basically broken heart cardiomyopathy where extreme grief or stress can actually lead to heart failure. It's been well documented in elderly widows who have chest pain or pressure at some point after losing their spouses. One of my favorite shows, "Scrubs," actually had the diagnosis as one of their story lines.



I think I might have written about the multitude of OD's we were seeing in the days following Thanksgiving (60 Hours), but lately it's seemed like I'm seeing a lot of depressed patients who come into the E.D. just for some companionship, or to have someone to talk to for a while. I did have two women who came in that made me think of Takotsubo's.

The first was a woman whose chief complaint was: chest pain. About 2 minutes after I started talking to her, I realized that her heartache was more of the emotional kind than the physical kind. She made a comment about all the "pressures" in her life at this time. When I pressed about them, she started crying and told me about how her fiance had died the year before, and how the holidays had always been a very special time for the both of them. They had been together for 8 years. She had family she wasn't really close to, and he had no one. They had each other.

She told me how she had seen him die right in front of her in a freak accident. One minute they were walking along, joking and laughing; the next, he had fallen down an embankment and died as a result of the fall. They had just gotten engaged and had not even gotten around to setting a date. I still had to work her up as a potential Acute Coronary Syndrome, but I ended up discharging her home with follow-up to counseling and psychiatry.

The second little lady came in this evening as I was trying to wrap things up at the end of my shift. Her chief complaint was "weakness." As I talked to her, she had some very non-specific symptoms: some nausea but no vomiting, some general feelings of "just being sick," and a feeling in her stomach that wasn't pain, and wasn't related to anything else. When I pushed her on it, she stated that she thought she might be lonely.

She lives in Senior Apartments. She doesn't like seeing ambulances coming and going at all hours. She's proud of her children and their accomplishments but calls them "work a holics" who don't have time to visit. She says her apartment is by the lake, but too much moisture which makes her bones ache. She said just being in the E.D. made her feel better. She told me that her physician told her that "loneliness will make you sick" and maybe that's all that is going on with her now.

When I signed her out at the end of my shift, I brought up Takotsubo's. My colleagues chuckled, but I'll think of this scene in "Scrubs" as I go to bed tonight; lying on a bed surrounded by three warm and purring kitties. Charles Schultz in "Peanuts" once said that "Happiness is a warm puppy." Too bad I can't write a prescription for a box of kittens or a warm puppy.

16 December 2008

Frequent Flyers

One of the things I don't think I've talked about in previous posts are the frequent flyers we get in the E.D. It seems like every E.D. has it's cast of known patients. Most of them, unfortunately, are either alcoholics brought in every several days by EMS after another drinking binge. Or they are the chronic drug seekers. Or patients with chronic back pain or sickle cell disease who need a shot of dilaudid to make it through to their next doctor's appointment.

A lot of ECMC's frequent flyers get greeted with a, "So, what's it going to take to get you out of the E.D. today, Johnny?" Sometimes, the discharge paperw
ork is written at the same time as the dilaudid with a side of zofran order. Of course, we always worry about the possibility that one time a more serious problem is going to be missed.

I have been working at ECMC for the last two days. Along with the sundry assortment of the usual chest pains, shortness of breaths, etc, I have had a number of repeat customers. I don't mind seeing patients again, mostly to see that they have done better. However, I begin to obsess over what I might have missed the first time. Then, I begin to question the patients' true motives for returning to the E.D. Then I begin to get callous about these patients and wonder what exactly it will take to get them out of the E.D.

Of course, the management of the patient then has to be filtered through the attendings' own biases. Some attendings are of the treat and release type. Others make the patients go through a bit of bargaining before giving them their requested drug of choice. Still there are those that subject the patient to a new round of tests and queries, exhausting all diagnostic possibilities before resorting to giving the patient what they came in for. Finally, a patient might get admitted for "pain management."

One of my attendings today was more of the, "I have pain, they should be able to deal with theirs" variety. Made for quick turn arounds today.

Anyway, tomorrow is Grand Rounds Wednesday, then a stretch of three days before the weekend. We'll see what the weekend brings...!

14 December 2008

California Dreamin'

I was going to call this blog entry "Ventura Highway" but I figured that not a lot of people would get the significance, other than the song by America. For some reason, during most of my trip back home to California this past week, I had that song running through my mind. Well, that and the title of this blog entry, "California Dreamin" which is another great song by the Mamas and Papas.

It's funny, but it seems that these last several trips home over the last several months have taken on a very nostalgic feel. Maybe because I'm returning to places I have been to over and over again. Maybe because I am sharing the travels with my new husband and my mother. My husband has ne
ver traveled in California, and my old places are new to him. My mother and I spend most of the road talking about this adventure, or that restaurant. How my uncle did this on one trip, or how we stopped for a picnic between those trees on another.

During this week, we did the day trip up north of Santa Barbara to a little Danish settlement of Solvang. The buildings are reminiscent of towns in Denmark. There are lots of shops that sell Danish imports; great restaurants that sell Danish fare, and now the more popular wine bars with tastings. Lot of local wineries, so some great samplings to be had.

The other thing that Solvang is famous for is its baked goods, especially its butter cookies. Tins and tubs of butter cookies. You can see them right now during the holidays when those paper-wrapped goodies are on every counter in the hospital. Darn blue tins.

The other part of the trip that I always enjoy is seeing the ocean again. They say that the Pacific has a memory, and I have a lot of memories of the Pacific. Especially driving along PCH (Pacific Coast Highway, Hwy 1). We pulled off the road in Malibu on our way back to catch the sunset. For a few brief moments we sat in silence watching the last of the days' final rays reach across the water.

A sailboat made its way across the waters. As darkness fell, we pulled back on the road and continued our way home.

The rest of the week was filled with Christmas shopping with my mother, family affairs, and a lot of just plain old relaxing and lazing around the house. Not to mention eating just about all of my favorites while I was in town. Tomorrow back to the reality of the Emergency Department. Albeit, a bit more refreshed. More optimistic. Ready to carry forth.

Oh, and I lucked out just a bit: my upcoming rotation is a split month between the ED's at ECMC and Buffalo General, however, due to scheduling, I will only be doing two shifts at the General and the rest of my shifts at ECMC including Christmas Eve and Christmas Day. Sucks to work the holidays, but I anticipate a much pleasanter environment. We'll see!
















04 December 2008

60 Hours

When I started my emergency medicine residency, I was told that all of our shifts are 12 hours long. Coming from a surgery residency where shifts can be 30 hours long, I was looking forward to the break. Having just spent the last five nights working a series of 12 hours shifts, I have realized that the hours add up pretty quickly.

While I can't write about everything that happened over the last 60 hours, I can hit the highlights. I have also found that the more tired I am, the more surly I become with patients. After a brief 18 hours to adjust from night shift to day shift, I was back at work this morning. My body was telling me that it was nighttime and I should be sleeping. Caffeine does wonders for the sleepy mind.

Anyway, what do I remember most about my last block of shifts:

- even pretty teenage girls from good families can be more troubled than you would think. I sewed up a 5 inch cut across her arm where she was "cutting" to hurt herself. It matched a series of other cuts that she had already put on her arm. This one was deeper than those, and I had to sew the wound closed in several layers and oversew a blood vessel that she had cut as well. Off to psych services, and probably alcohol rehab. She'd already lived more in 15 years than I had at 3o.

- the legend that people are more depressed around the holidays never showed more true than in this weekend after Thanksgiving. Our board shows the 20 rooms in the E.D. At least once per shift this weekend, there were 8 - 10 OD's, SIWL (self inflicted or suicidal ideation with laceration), rehab, depression, alcohol withdrawal, AMS (altered mental status), etc. on the board. It got so bad that I said that if I had to see one more suicidal patient or OD I was going to commit suicide. My senior actually called over to psych services to see if I could be committed for making a suicidal intent statement. They said yes, and that they would be more than happy to send security over to restrain me for a while. All in jest, but really... I was going crazy.

- there was a sale on car wrecks. Crash yours into someone else's and you both get seen for free!

- we had the first snowmobile accident of the year. No snow on the ground, he'd just had it tuned and wanted to hear it run... and it did, right into the building then flipped over on him. He had no injuries, luckily. We'll see how the rest of the season goes.

- for some reason, more stabbings are happening than shootings. They're a little hairier because you don't know just how far down the blade went. Bullets you worry about the path. Knives you're dealing with too many variables. We CT scan everyone. Oh, and marijuana is considered by some to be medicinal for post-traumatic stress following having been stabbed by your best friend who was high on "some pills" and thought you were suddenly out to get him. It's not.

- some attendings I get, some I just don't. Wonder what kind of attending I will be?

- even big strong 36 year olds die. Suddenly. We had one with a massive pulmonary embolism that died around 3 in the morning several nights ago. We worked hard to bring him back. Nothing would work. It affects the whole staff when something like that happens. Of course, I also had the 38 year old with end stage AIDS whose mother signed the "comfort measures" paperwork and then wouldn't let go of them. We all knew it was in the patient's best interest. I can't even begin to imagine the feeling of signing a paper that will limit the care your child receives. No matter the age, they are always your baby.

- which makes me salute all the mothers who brought their child to the ED for help and sat by their side while I explained what happens when you OD on soma, lortabs, alcohol, antidepressants; or while I sewed self-inflicted lac after lac; or who encouraged them to get help from Abuse Intervention Services because they "couldn't take it any more."

OK, it's late and I have one more shift before getting some time off... be happy! My ED patients have been so depressing lately.