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 last 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 away 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 standard 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 thought 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 senior 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.