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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!