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23 December 2009

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.

06 December 2009

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!




25 November 2009

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...

22 November 2009

Bang Your Head

Ok, so it's been a while.... Funny how some shifts just seem to have a theme.  Last night I found out all the different ways that someone could suffer a head injury.  It made for an eventful but tedious shift, and also kept the CT scanner burning away.  I think we all had radiation exposure since 80 percent of the patients that came in from 11 p.m. onward needed a head and face CT.
There was:
 - drunk, fell down and smashed head on concrete 
 - drunk, tripped and fell down hitting face forward on concrete
 - drunk, minding own business, and got whacked on head with metal pipe
 - drunk, minding own business, and got slammed on head with baseball bat
 - drunk, jumped into middle of fight and got hit on head and face with beer bottles
 - doing cocaine and got hit by several people's fists across the face
 - got drunk, drove without a seatbelt, crashed into several cars, jumped out and ran for about a mile from police that were chasing them, then needed an ambulance for a minor injury and ended up unresponsive with a breathing tube in the E.D.


and then there was the:

 - out with family and suddenly collapsed.  This patient had a massive brain bleed and ended up dying in the emergency room before the end of my shift.  They most likely had a brain aneurysm that ruptured and that was it.


The rest of the patients I had ended up being everything from a cracked skull to facial bruising, and I put the medical student to good use stapling and suturing all the various lacerations.  This, of course, kept me free to move onto ordering the next CT.



29 October 2009

What Did I Just Say?

I have a friend who works as a transcriptionist.  She blogs and occasionally talks about her work.  However, she talks about the business side of her work:  how much she makes per line, how she can’t understand what the doctor is saying, how she has to undergo QI, etc.  One thing she’s never mentioned is if she ever takes the time to think about what she’s transcribing.

I’m currently on rotation with a group that dictates their H&P’s along with their assessments and plans.  After a day or two of dictation (which by the way I hate to do because I can’t stand the sound of my own voice) I started to wonder if transcriptionists laugh at some of the content in dictations or if they’re like mailmen who deliver postcards without reading the back.  I know I sometimes chuckle when I get the transcribed note back to sign for the chart… especially when I read things like:

“Patient states they have been constipated for a whole month.”

“87 year old patient states she fell off a chair while painting her ceiling.  She states her bridge club was coming over and didn’t want them to see a brown water spot that was on it.”

“Patient states that she has vomited several times.  The last emesis looked like blood, or it could have been the cranberry juice she had been drinking just prior.”

“Patient denies any alcohol, tobacco or drug use, except for the occasional marijuana use whenever her son is in town.”

“Patient states he thought his abscess was due to an ingrown hair, so he shaved off his all the hair in his axilla thinking it would go away.”

“Patient presents asking for Tamiflu because “there’s a lot of sick people hanging around the grocery store.”"

Did I really dictate that…?  Yep, patients say the funniest things…

p.s. ;) Betty this is for you...


15 October 2009

A Cowboy Needs a Horse



I never thought much about our “regulars” until I came back from vacation to find that one of them had died.  We’ll call him “the Cowboy.”

I met him when I was an intern.  He was the anginal patient with known severe coronary disease who had suffered from alcohol abuse for many years.  He would come in from time to time;  usually drunk, complaining of chest pain.  We would run some cursory labs and an EKG, let him sober up,  and then send him on his way.

As the months passed, he would start to come in more and more frequently;  trademark hat and boots in place as the ambulance gurney brought him in.  He had developed cardiomyopathy somewhere along the way and had an AICD placed.  He started coming in complaining of it firing frequently and chest pain.  He would be admitted and usually signed out AMA after a day or two.

Over the last 6 months, he was an almost weekly visitor to the downtown hospital, but then we started seeing him at the county hospital where we also have shifts.  The Cowboy started becoming one of those “repeater” patients that become annoying.  You’d see his name on the triage board, sigh, and then go in and ask, “Seriously, Cowboy, what is it today?”

About 3 months ago, though, he really started declining.  His prior history of medical non-compliance and signing out AMA was making it difficult to get him admitted even when his heart failure was severely affecting his health.  Somehow, we would convince the attending that he really did need to be admitted, and true to form, the Cowboy would get diuresed, refills on his nitro, and then sign-out AMA or abscond yet again.

Recently, though, on one of my admissions, I convinced him that he needed to stay for evaluation by the cardiac surgeons who had wanted to take him to surgery during the previous admission.  He agreed only to be told that his disease was so severe that only a specialized center like the Cleveland Clinic might consider his case.  He told me this about a week later when I saw him, yet again.

As soon as he saw me he said, “Wait a minute.  Before you say anything I did stay, and this is what they told me…”  As I was ordering his now routine chest x-ray, EKG, POC troponins and BNP, I looked at the Discharge Summary from his most prior admission.  The angio said it all.  He had severe disease of his left main, LAD and circumflex.  His right was open about 80%.  Basically, the Cowboy was surviving on one coronary artery.

He lived alone and didn’t have much family support.  He was practically homeless.  There was not going to be a life-saving trip to Cleveland.  We all knew he didn’t have long.  During my first shift back I was told that he had presented in fulminant pulmonary edema.  One of my colleagues intubated him, but there was nothing else that could be done, and he died.

I tried to think back to the last time I saw him.  Did I even pick up the chart, or did I leave it to one of the interns?  Did I make conversation with him?  Was I polite to him the last time I treated him or was he just one of the “regulars” who is quickly “treated and streeted” to make room for the “real” patients?  I really can’t remember now, but I know that he’s a patient I won’t soon forget.

So, ride on, Cowboy.  Keep riding;  riding, along.

13 October 2009

Play to the End

I was thinking a lot today about a post I wrote some time last year in which I talked about a "good day to die."  The patient that prompted me to remember this was my last patient of the day.  Having just come back from 11 glorious days off, it was very hard to try to get back into the rhythm of things.  

Just at the last hour, we suddenly got a Mercy flight.  The report was a patient who had suffered a stroke.  As the helicopter landed, we began to learn more about our new patient.  They were in their 90's and had traveled with friends to a casino about 4 hours away from home.

While at the casino, they had felt suddenly ill and began to exhibit signs of a stroke (* I'll give a quick easy way to remember these at the end.)  EMS was called and the patient was transferred to us.  Unfortunately, they had suffered a severe bleed into their brain and their prognosis is grim at best.

Later, as I thought about this patient, I felt they'd had their "good day to die."  Or, at least, what I would consider a good day:  a trip with friends, gambling, probably a good buffet lunch, dressed to the nines... in their 90's.  Keep partying on, brother, keep partying on...!



Think

F - face - is one side drooping?

A - arms - are you not able to hold one of them up?

S - speech - is the speech garbled or slurred?

T - time is brain,  get to a hospital as soon as possible

!!!

11 October 2009

Weary Road Traveler

Ok, so we missed our flight due to delays in San Francisco, and we had to spend the last 7 hours at the airport.  Suffice it to say, it's been a looonnng 7 hours.  And, we still have another 2 hours to go.  Eeek!

I've been sitting here for the last several hours watching the droves of humanity walk to and fro, and I've come up with a few thoughts based on my own travel experiences.


  - Wear something comfortable and practical.  Low rise jeans that have to be constantly hitched up and short shorts that show everyone whether or not you've waxed recently do not make for comfortable clothing.  Me, I prefer the loose velour-type pants.  More stylish than sweats and more comfortable than jeans.  Scrubs will work in a pinch, but people keep asking if you're on your way to surgery somewhere.


 - Along that line, wear comfortable shoes.  Those three-inch wooden wedge heels look awesome with that studded denim mini, but when you fall over running to your gate, it's not going to be a pretty site.  Me, I like the slip-on tennis shoe.  Comfy and you can sprint like a track star when you need to.



 - I see a lot of people wearing the "I bought it at the airport" pashmina.  Now, while some may say they're not really still in style, I think there's nothing better than having something warm to wrap around your shoulders on a cold flight.  And, that's a good thing considering the scarcity, or high cost, of in-flight blankets lately.



 - Next, the travel bag.  Now while I am not a fan of the cat-covered "I bought it at the airport" tapestry bag on wheels, I can understand the attraction.  It's light.  It rolls.  It doubles as a floor mat for your feet.  No, really.  Anything small on wheels is all you should be taking on a plane.  Except for a tote... you can never have enough tote bags.


 - Or, for that matter, over the shoulder bags.  I have several in different colors, and I always travel with one.  Except for this trip I went with a tote.  Two actually.  Three if you count my handbag, but it's a Coach and I wanted to look stylish for my interviews.  But, I digress.  The shoulder bag provides plenty of pockets for your ID, pens, travel documents, cell phone, etc.  And, it can be unisexually stylish.  Well, except for this one, it's got horses on it.



Finally, the ultimate travel need:



 - the neck pillow.  The softer the better.  And, since I tend to like to sleep all through my flight, mine gets plenty of use.  Along with my face mask and slippers which I got in a travel pack with the pillow.  Did I mention I bought them at the airport Brookstone?

10 October 2009

Interesting Road Sites

You never know what you are going to find when you drive willy-nilly along the road.  We were in no hurry as we made our way down the Oregon coastline, so we took the time to stop at various beaches, pull-outs and memorial plaques along the way.  Here's a few of our finds today:
 
I love sand dollars.  I collect them whenever I can.  We walked this whole stretch of beach and I did not find one intact sand dollar.  So I am bringing home a whole mess of partials for my collection.  Some interesting facts about sand dollars can be found here.


We stopped to take a picture of the marvelous ocean view and overshot the turn-off by several yards, but luckily there was a smaller turn-off which we were able to pull into.  As I was stepping around looking for the perfect spot, we came across this plaque on the ground.  I Googled the name and came across a few facts.  Here are two links telling the story of this local hang glider.
 
This is a monument in Depoe Bay memorializing two fishermen, Roy Bower and Jack Chambers, who went out to rescue another boat that was in distress and lost their lives.  The town honors all of the lost in their annual "Fleet of Flowers" which is held on Memorial Day every year.  Something about the quote (who is quoted I cannot say) really got to me, so I end with it here.

"It is not true. Life is not slain by death. The vast, immortal sea shall have her own, shall garner to her this expiring breath, shall reap where she has sown."


09 October 2009

Recurrent Thought


My DH and I made our way through Mount Rainier National Forest today as we worked our way across the Cascades back toward the Pacific.



As we drove, for some reason the words of Thoreau passed through my thoughts several times;  especially as we walked through the Grove of the Patriarchs.

Here are the words and some of my pics:
 

"I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived."


07 October 2009

On the Road...

Just a few quick thoughts as my DH and I make our way around the Pacific Northwest...

I love Victorians


Purple never comes out in pics


I love the beach... any beach


I like helicopters... my husband, not so much


I really love bears, and Black Bear Diners


Sometimes you just have to do what your DH is into


My favorite time of the day is still early morning


Even crippled horses by the roadside have a certain beauty


Take the scenic road, you never know where it might lead


You can find simple beauty in unusual places


I thank God at the end of the day for allowing me to do all the things that I have been able to do in my life... And for allowing me to enjoy the splendor of nature.

03 October 2009

Strangers on a Plane


Did you ever get the talkity talk seat mate while traveling?  I have been post 24 hour call or have just come off several night shifts in a row the most recent times I have traveled, so I have basically fallen asleep from just before take off to just before landing.  I have become conditioned to waking up the minute my ears start sensing pressure changes in the cabin.  Seriously, my ears start to pop, I wake up, the captain gets on the loud speaker and announces we're on final approach.  Sleeping is the only way to travel.  Wake up and you're in a whole new place.



However, I have been traveling with my husband lately, and we've been meeting a series of gabby travelers during our journeys.  We had the "Name Dropper" who talked loudly and passionately all the way from Chicago to Los Angeles about her friend's wedding, who was going to be at her friend's wedding, the Who's Who who would be at the wedding and how they were all connected to this other Who's Who, etc.  This is one of those times I am glad cell phones are not allowed to be used during flights.


We met "The Local" who spent the entire trip talking about local restaurants and hotels and recommending places we visit.  She was not discouraged at all by fact that we would only be in town for a day and continued to regale us with stories of places she had been 15 years before which she felt would probably still be open and as wonderful as she remembered them to be.  All this while pouring liquor from the two small bottles she brought on the 50 minute flight into her soda.


I am sure there will be more as we make our way across the Pacific Northwest... at least it's better than getting that baby who cries the whole trip... or is it?

29 September 2009

Hitting the Road...

I feel like I have been neglecting this blog a bit.  Ok, I admit I have.  But, things have been so crazy, and I just finished a three day battle with a cold.  Maybe the flu... eek!  I did have the fevers and everything.  But, anyway.
I am headed out on the interview trail to the Pacific Northwest.  I am carrying my computer with me, so I promise to post lots of pretty pictures and tales of my adventures along the way.  I have 5 interviews scheduled, so hopefully I will find the perfect spot in which to begin my career.  'Cause, let's face it, it's about time I actually started working for a living, right?

See you on the other side!  Au revoir!  Bon Voyage!

19 September 2009

And, the Countdown Continues....


Along the side of my blog site you may have noticed the countdown graphic... slowly working its way down... down... down... Today it slipped below 365!
Next month I go for several interviews.
Let the final year begin!
 

13 September 2009

Safety Dance

I am training to be an Emergency Medicine physician, but sometimes I wonder how I would do in an actual emergency. I mean, I can run a trauma or cardiac arrest code without much problem on my own turf. But, how would I hand a situation at 36,000 feet?

Obviously, most of us won’t be faced with a situation like Wallace who relieved a tension pneumothorax with a wire hanger, a catheter and a bottle of brandy. However, I would like to think I could handle something reasonably simple. A bump on the head from a piece of falling luggage?

The British Medical Journal in 2000 ran an article listing the top 10 medical emergencies as: chest pain, collapse, asthma, head injury, psychiatric problems, abdominal problems, diabetes, allergic reactions, and OB-Gyn emergencies. Since 1986, most airlines carry an AED, and most also carry oxygen and some basic medical supplies. A study in 2008 by USA Today stated that three overseas airlines and only one US airline seem to do more than carry the minimum medical equipment.

Of course, I didn’t think about what could potential be in this particular aircraft’s safety kit as I sat watching the other passengers start to board the airplane: the morbidly obese person who was wiping sweat off their face as they hurried aboard, the obviously pregnant woman who was pacing around the waiting area, the barrel-chested passenger who looked as if they couldn’t wait to land to be able to pull out their cigarette pack and take their next drag, the laughing out loud been-at-the-airport-bar-during-their-layover pair, and the other 50 or so ticking time bombs of potentially unknown medical problems.

Armed with my medical knowledge and last year’s ACEP presentation “101 Uses for a Safety Pin and Duct Tape” I boarded, thinking in my head, “Surely you can’t be serious?” “I am serious, and don’t call me Shirley.”

05 September 2009

Why I Love Firetrucks


They're big.
They're red.
They're shiny.
They make lots of noise.
And the firemen inside are always nice.

I probably wrote a poem similar to this when I was in first grade, and our class visited the fire house located right next door to our grade school. I thought it was cool that the firemen got to live in a big house and had a pole to slide down. Plus, they helped people, and I thought that was the best thing of all; helping people. Because that's what it's all about!

Today myself and a group of residents spent the day with the gentlemen of BNIA (Buffalo Niagara International Airport) Fire and Rescue. Along with learning about their day to day operations, it was nice to become familiar with some of the people we work with. As part of our EMS and SMART responsibilities, we respond to airport alerts. These get sent out whenever a plane is having a problem, mechanical usually. Code 1 is for less than 5 passengers. Code 2 is for more than 5 passengers, Code 3 is plane down. We had one Code 3 last year which everyone has heard about. No more of those please.

Here are some pics from the day, enjoy! And wave at your local firemen when they go by!

04 September 2009

Vampire Nights

I haven't been blogging as I worked a series of 5 days followed by an overnight shift, late morning with Grand Rounds, night off and then another overnight shift. I'm just a wee bit tired. My mind has barely mastered the concept of "upright" much less "typing a coherent thought."

One of the thoughts that came to me last night as I was walking the empty hallways of the hospital is how eerie a familiar place can suddenly seem. We occasionally have to leave the E.D. which is located in the basement of the hospital and go up to the second floor to inject a patient who is getting a CT scan with IV contrast. We do this because there is a small possibility that the IV line will infiltrate, or spill its contents into the surrounding skin, during the injection phase of the scan. This is bad. You can get a very nasty skin necrosis with this.

During the day, there are plenty of radiologists around to do the injection, but in the middle of the night, there's only a radiology tech running the scanner, so we get called up. As I walked the empty hallway heading toward the back of the radiology department, I started wondering about all those scenes in horror movies. You know, the one where the unsuspecting person is casually walking along when the scary music starts playing. There might be a sudden soft squeak. Or the sound of a breath. The person stops and looks around. Then walks a little more quickly. The music begins to rise. The person starts to walk faster. That kind of a thing.

I guess I was thinking of scary stuff because we'd had a patient come in with their own little stuff of horror movies. Seems the patient had been sleeping when they felt something near their ear. In their sleep they reached out and felt something warm and furry. They suddenly woke and grabbed it with two hands and ran to the bathroom.

They called out to their father sleeping in the next room. When he turned the light on, the patient realized they were holding a live bat in their hands! The father shot the bat with a BB gun, and they came into the E.D. with the bat in a baggie. The patient needed to start on rabies vaccinations because the bat had actually scratched their ear.

The bat was placed on ice in a container for the Health Department to come and pick up. One of the clerks called it her "pet" since it spent the majority of the morning sitting on her desk, and she had to keep renewing the ice supply. We had quite a laugh at sign out, and everyone had to go look at the bat.

I tell you, we can't make this stuff up...

p.s. a shout-out to one of our attendings, Dr. Jehle (yay-lah) who made the local media following a multi-car pile-up. I was at the General that night so my buddies at the County and Children's suffered through the multiple traumas.

Main story
His story

28 August 2009

My Brilliant Feat

So, today was not a good day to be elderly and male in my E.D. Besides having someone die (came in as a cardiac arrest), I had two other gentlemen come in who most likely have some form of metastatic cancer, both of whom are married, one of whom takes care of his wife who has Alzheimer's. He is 75.

I've been blogging for over two years now, and I recently had the opportunity to apply to blog to the American College of Emergency Physicians Blog site The Central Line. I am happy to report, I was accepted, and I will start posting some thoughts there as well.

This site however will continue to be my main blog despite my new-found fame and increase in readership from 4 to 6. (I love you Ladies, Betty, Julia, Lisa and Claudia!!) I will post the link from today's post on The Central Line (my second, so don't think you missed anything.)

Happy reading! My Brilliant Feat

23 August 2009

Blood on My Scrubs

I can't say I've honestly thought about what happens to my scrubs throughout the course of my medical career. Until last night. I don't know why I had this surreal moment in the middle of a trauma code. I was handing a chest tube to one of the surgery residents to place in this patient's chest, and I looked down to step back as a puddle of blood had formed on the floor.

I noticed the blood spattered on my scrubs, and my first thought was, "Darn, I don't have a clean pair and it's the middle of the shift." Then, I started thinking about all the bloody, vomited on, amniotic-fluid covered scrubs I have worn during my medical training.

In medical school, most of the scrubs worn in the anatomy labs were new, bought excitedly in anticipation of starting your medical training. By the end of the year, w
e had a mass burning of these soiled clothes that had spent countless hours, literally elbow-deep at times, working to understand and learn the intricacies of the human body. I threw my shoes out too.

In your third year when you start your clinical rotation, you grabbed scrubs whenever you could. The residents had access to the scrubs machines and some hospitals had a general pile. We didn't have access to the machines so you stocked up when you could. Sometimes your scrubs got soiled midshift, and you had to have some kind of backup. I kept an extra pair in my "on-call bag." So, by the end o
f your medical school training you had this mixed bag of scrubs sporting the "not to leave the premises" or "property of" imprinting from the various hospitals.

These became a badge of honor in a way when I started my internship. You'd go to work in your home scrubs some nights on call. Everyone would look at your scrubs and say, "Oh, you worked there?" or "Oh, do you know so and so at that hospital?" We had access to the scrub machines there when we had to go to the OR, but you were only allotted 3 sets at a time. Sometimes you just didn't have time to r
un to the machine (or most likely the machine was empty), so it was more convenient to always have a pile of scrubs in your locker. We learned ingenious ways of getting more scrubs (including timing your visit to the locker room when the filler of the scrub machine was loading the machine... "Geesh, I don't have my card right now and I've got to get to the OR, can you help me out?") so that you had quite the surplus too by the end of the year.

Of course, the bloody, messed up ones went into the dirty bin. So all the s
crubs you kept were nice and clean. At this point in my life, I have a pile of scrubs from all the places I've been. Most of them are blue in some shade or other. Some are what I call OR green. I have a cool teal green pair from a hospital in Rhode Island where we went on a transplant run while I was in Boston. We had to wear their scrubs to go to the OR for the harvest, and we didn't change out on our way home since time is of the essence in transplants.

But, when I became an Emergency Medicine resident, we didn't get scrubs. So we all had to go back to grabbing them when we could while on other off-service rotations.

Last year, our residency bought us these cool black "Ninja" scrubs.
I don't like to think about what collection of body fluids accumulates on my shoes and the bottom of my scrubs by the end of the night. And, like last night, you can't help but get something on you.

Because we got a limited amount, they go right in the dirty bin when I get home. They get washed with the super-extra strength detergent after an Oxy-Clean soak. You just don't know what's hiding on them....



17 August 2009

Lowered Expectations



(**Warning: venting today... warning! warning! warning! High pressure release! warning! warning! warning!)

And, I had such high expectations for today because we started off with three patients on the board...

I have goals for the year. Every day I strive to improve my efficiency. Every day I set a goal that I will succeed in learning one new thing about a disease process. Every day I will treat my patients with the honor and dignity due to a member of the human race. Today I failed miserably on the last.

I went to a private Catholic parochial school. Somewhere around 5th or 6th grade we were visiting neighboring churches (Lutheran, Methodist, Jewish, etc.) to learn about the similarities and differences in our faiths. At the Jewish temple, the rabbi asked us what the worst word in the world was. My naive brain could only come up with one or two words that are tame compared to some of the words used on network TV these days.

Then the rabbi told us that "weird" was the worst word in the world. He said we should never call anyone "weird." Just because someone does something in their culture or faith that you don't doesn't make them any less deserving of respect. This started my understanding of the idea of tolerance. I never forgot that.

My husband feels that the word "stupid" is the worst thing you can call a person. It implies, to him, that you are the lowest, most ignorant being on the planet. Worse than "retarded" because "retards don't know any better." When you're stupid you have brains, you just can't use them. You are, in a way, "low class" and uneducated.

Unfortunately, my first round of patients this morning were seriously stupid. And, then they just got weird. So much so to the point that I got very frustrated this morning with what I was doing during my shift. And, to add to the mess, there was a situation with a sick patient that was signed out to me from the night before that just pushed me over the edge.

I was lamenting, in part, to an unsympathetic ear who told me that I needed to lower my expectations. Once I did that, they said, I would be able to survive my shifts in Emergency Medicine. Seriously? Really? Seriously? I'm about a year from starting my career and you're telling me this?

I went off in need of a break. I considered my options: try to match in surgery, take a year off and do a fellowship, move to Mexico and be a beach-side doc-in-the-box catering to tourists, get a new career, maybe something in retail or truck driving.

I pictured myself at a town hall meeting standing up and saying, "You know, instead of spending my hard-earned tax dollars on taking over medicine with a potentially corrupt and inexperienced socialistic government Health Czar, why don't you take those billions of dollars and educate people on the importance of preventative medicine, on seeing your doctor on a regular basis, on taking medication as directed, on not cutting off your cast every two weeks because you think it smells and you want a new one, on not treating the emergency department like a drive-through that will provide services on your time schedule? How about that? Why don't you tax them for taking up valuable time in the E.D. and wasting, oh yeah, again, my small resident's salary tax dollars? Instead of Hope and Change how about Personal Responsibility and a sense of agape (ἀγάπη)?" Huh? I can't hear you....!

At what point should I expect nothing of my fellow human beings? My colleagues in medicine? I was very surly. I was thinking I would like nothing more than to pack it all up and go home. Start again in the morning.

Anyway, my foul mood might have continued had my attending not come around the corner at this point and, seeing me, started singing, "Don't go changing... to try and please me..." in the most honest and sincere voice I think I've ever heard out of him. I had to smile and then laugh. I was still snickering to myself as I continued to work my way through the flood of patients that came in this afternoon.

Somehow, it didn't seem so bad after that....

Early in our relationship my husband and I discussed an email that was circulating around the web at that time. It had to do with a man who went home every night and touched the tree that stood just outside his door. One day a neighbor asked about his ritual. He said that the tree was their "Problem Tree." Before walking in the door, any problems from the day were "hung on the tree." The neighbor asked what happened when he left in the morning. The man answered that somehow the problems never seemed to be there.

We made a promise to leave any problems "hanging outside" and not bring them in. Tomorrow I will wake up and head into my shift. There will be a clean slate and anything from today will not be carried forward. Sure lessons will be learned, but I will again try to achieve my goals, especially the one that can be restated simply as, "Love thy neighbor." Lord, love it, but it's hard sometimes...

15 August 2009

Hot in the City



We've had a lot of shootings over the last several days. I have been working the night shift, so it's always very difficult to post because I am often too tired in the morning when I get home, and then I am usually in a rush out the door when I head off for the next shift. I do manage to sneak in a quick post from time to time.

Anyway, onto the shootings. I worked the overnight shift at the county hospital on Tuesday night, and we had three unrelated shootings, plus a couple of stabbings, plus the token rollover... and a whole lot of drunks. I was in the middle of dealing with several different patients that I received on sign-out (some things are never what they seem) when a patient comes running in the door saying "I got shot in the face, don't let me die."

I took a look and saw the wound on his face. A larger caliber round and his face would have been an empty hole. A couple of inches further back, and I wouldn't been seeing this patient as they would have been either an organ donor or in the morgue. He was the lucky one that night. The bullet scratched just under his eye and ended up stopping and breaking his nose. Oh yeah, the bullet fragments are still there. He's going to need to have those removed at some point. That night, though, just some fancy stitching by the facial trauma resident and a referral to specialty clinic to fix his nose.

While I was finishing getting him settled I was told by the charge nurse that another shooting victim was coming in. This time, multiple wounds in the extremities and torso. We got the trauma team notified and I waited in the room as they were brought in. He lost his pulse as he was brought in the door. There was no saving him. I had to tell his family members. I worried about retaliatory shootings.

I kept working the shift. In the early morning hours we got another victim. This one had multiple bullet holes and a fracture in an arm and a leg. Not to mention the bullets that went into their abdomen. They went to the O.R. They survived.

Thursday night I went back to work at the General, and there was a large security presence in the area in front of the E.D. Now, at the county when there's a shooting, we get a strong police presence, so it's no big deal to see the ambulance ramp shut down to traffic. Just not used to seeing it at the General. But, that evening there had been a shooting that resulted in a death of a member of the community. Their family along with many neighbors were all there and had just gotten news of the death when I pulled up trying to get in for my shift.

I made my way through the crying, screaming people holding onto one another and demanding to be let into the E.D. to be with their loved one. Security let me through as several people tried to push their way through. They were held back.

Today I worked a day shift. I had a GSW (gun shot wound) to the legs in the morning, and a GSW to the abdomen in the evening. Kinda like book ends. Both were in the process of an attempted robbery. Both were taken to surgery. Both will most likely survive.

Some say people are going a little crazy from the heat. The heat wave is supposed to continue through the weekend. I wonder what tomorrow's going to bring...

10 August 2009

Chronic Pains

My primary diagnosis for many of my patients last night was "Acute on Chronic _____." I don't know what it was about last night, but a lot of people just couldn't face waiting until Monday a.m. to see their PMD's. Of course, a percentage of my patients don't have PMD's (that's Primary Medical Doctor) and come to the E.D. to get their primary care; as well as a couple of shots of Dilaudid or Lortab.

The local media discussed one such patient who is a daily visitor to the E.D.; mostly at ECMC, but we see him on occasion at BGH. Last night, I got several more of the "regulars" who decided to come in. I also got the "I've been admitted multiple times and left because I didn't feel like staying around any more" group; patients who regularly need to be admitted because they have legitimate medical problems (like one patient who is daily killing heart cells because he refuses to stay in the hospital long enough for surgery to be done) but who have worn out their welcomes with the medical staff.

I did get a couple of emergencies: a gentleman who started having a GI bleed and also a heart attack, a new onset diabetic who was initially thought to be having a stroke because he had been having strange symptoms for over a week, another known diabetic who suddenly started having problems when they couldn't keep any food down, and a another lady who was rapidly filling up with fluid to the point she couldn't breathe any more.

But it's those chronic pain people that drive us crazy. Now, I have said many times that I have never had a broken bone, and I have never been shot, but I can imagine that it would hurt... badly. But when you're told to not eat fatty foods because you have gallstones and it's going to hurt if you do, and then you go out and have the cholesterol special at your favorite fast food joint, I can't quite draw enough sympathy. Oh yeah, and the first words out of the patient's mouth were, "I have Chronic Pain Syndrome so the usual dose of pain meds doesn't work for me."

Sigh. I am all about being a patient advocate. I threatened my "killing my heart cells" patient with "if I see you back in the E.D. without a new hole having been cut in your chest, I will do it myself." Seriously, I just spent 10 minutes on the phone presenting a case arguing how they had already been cleared for surgery, this time they "promised" that they would stay and not leave AMA (against medical advice), and they really should be given one more chance.

Maybe I am too hopeful. Maybe I believe in people too much. Or, maybe I am playing a similar game, the one played in "The House of God" known as a Turf... or as we call it, the Dispo. Luckily, our Dispos don't bounce, oh wait... yes they do.


06 August 2009

Number Two

So, I started writing down my little musings two years ago when I found out I was leaving the very cosmopolitan Twin Cities and moving to Buffalo. Before interviewing for my current residency spot I only knew a few things about Buffalo: the song "Shuffle Off to Buffalo" from the movie "42nd Street," Buffalo wings, the song "Buffalo Stance" by Neneh Cherry, "The Dominator" Dominik Hasek who played for the Buffalo Sabres, and, of course, the song title of my blog, "Buffalo Girls Won't You Come Out Tonight" which I first heard in the movie "It's a Wonderful Life."

I can now say that I know a few more things mostly involving the Assassination of President McKinley at the Pan-American Expo held in Buffalo in 1901. Mostly because our program is facinated with the fact that the on-call M.D. was an OB-Gyn and that the President was operated on at the exposition fair grounds instead of being brought to Buffalo General.

Anyway...

Thanks for following along with me during this time. From my original post on the original blog, "Do They Have Squirrels in Buffalo?" which was posted, originally, on AOL's Community Site. A year later I was starting my second year of residency. Somewhere we made the transition to Blogger, and I changed the name to Buffalo Squirrels. Since then, I've started two other sites: My Paper Cuts and This Squirrel's a-Quiltin' to show off my more creative side and new-found hobby.

Wow... thanks for reading along. Thanks for being with me (D from the start who told me, yes, there were squirrels in Buffalo) on this incredible journey. I wonder what my new title will be in another year... another two years... and where we'll all be? Are you just excited at the prospect? I know I am.

02 August 2009

30 Days of [BLANK], actually now 29 Days of [BLANK]

Although I've been working a lot, I haven't had the energy to write in my blog. Most of the stories I think I have told before, or so it seems, and the most exciting thing rumbling the E.D. is the constant undercurrent of discussion relating to the socialization of medical care. Now, I am not going to get on my soap box and declare my position about this... if you've read my blog long enough I think I've talked about what needs to be fixed.

Instead, I am going to discuss my 30 Day Plan. I was reading "Pioneer Woman" which is a fabulous blog site. She posted a link which lead to a link, where I followed another link to a blog called "Room 704" in which the discussion was about how a habit can be formed by doing something repetitively for 30 days. The author challenged their readers to do something for 30 days.

So, since I know I will never make it to the gym every day for 30 days, given my schedule, I made the following plan: drink more water, drink less diet soda and eat a salad or greens every day. I was also thinking of renewing my Pledge to Be Veg for 30 days, but I knew I would already be cheating today since we had a Surf and Turf BBQ, the key words being Surf and Turf. Oh well, I can start tomorrow and carry over into the next month.

Now, I challenge you! What new habit are you going to form over the next 30 days?? Thirty days of: yoga? taking an hour to read a real book instead of watching tv? prayer or meditation? speaking to one person a day who you don't know? showing affection to your spouse or loved one in a way you don't normally do?

p.s. speaking of which, I can give an example of this from my own life. I came from a family that really didn't express emotions. Hugs, kisses, not really common. I always say I learned to hug in college because we just didn't do that in my family. Around the time I was about to start medical school, I read somewhere that you should always say, "I love you" to people you care about because you never know if it's the last time you're going to say it.

I can honestly say I wasn't brave enough at first. Express emotion to my mother? Are you kidding? Then one day I was leaving for a trip of some sort, and I was talking to her on the phone telling her I would call when I arrived. Just before I hung up, I said, "I love you, Mom, talk to you soon." Silence. I could tell she was stunned. After a short time when I sure she was going to mutter something quick and hang up, she said quietly, "Love you, too."

I started saying it after every conversation on the phone and just before leaving home after a visit. The hugs came much later, but now she's quick to say it if I haven't just before we hang up. It took a little longer with my uncle who was always the father in my life. I still am glad I was able to say it to him the last time we spoke which was a few weeks before he died. At least I said it, and he knew.

That's one habit, I am not going to break.