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.

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.

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.

Sophomore Stories

I thought I would take my time tonight and post some comments on my second year of residency. Last year I wrote a post on my original blog "Do They Have Squirrels in Buffalo?" wrapping up my first year. So here we go through the second year:

Essentially, I started off my second year in July as an "unofficial, but acting in the capacity of" second year. Since I was hired late in the medical year, I still owed another month of internship. But, in essence I was acting as a second year. I spent the majority of the month getting ready for all the activities of second year, such as taking ATLS (advance trauma life support), a base station course (where we learn to give medical direction to EMS providers, learning about Mercy Flight, and learning to drive real fast in our SMART (specialized medical assistance team) vehicles, while at the same time dealing with summertime pediatric dramas. Oh, and I became a vegetarian "For the Animals!" in a 30 day pledge.

The next month I was on my EMS (Emergency Medical Services) rotation. I spent my time with firefighters, doing several runs with the EMT supervisors, and I got to fly in a helicopter for the first time with Mercy Flight. The other part of this rotation is being the resident for the local Poison Control Center. Whenever there's a drug overdose, we get called. We then call our attending who guides us through the correct treatment for all the drug overdoses we're going to face as E.D. physicians. It's learning through experience.

The next month had me reliving life as a surgical resident. During your second year of surgery, you spend a great deal of time in the ICU. Emergency medicine residents spend a month in the trauma ICU at ECMC. It was fun going back to the pimping, and the early morning rounds. I really enjoy the ICU and had for a time considered a fellowship (an extra time after residency for more advanced training) in critical care. But, I think by the end of the month, I really did look forward to getting back to the E.D. and did not regret my change in careers at all.

The next month was spent learning about ophthalmology, dentistry and radiology. Mornings were spent with the dentists learning to provide anesthesia to the mouth, and afternoons were spent looking in people's eyes. Not a very exciting month, but a nice 9 - 5 kind of month with weekends off and no call. I did get to work a Buffalo Bills' game providing medical support to the fans in one of the clinics at the stadium, so not an overall bad month.

Of course, October is when we made the move from J-land to, for the most part, Blogger. I had been chosen as the representative to the national residency organization (EMRA), and I was able to attend my first national conference back in my old stomping grounds of Chicago. I then spent the next month working at one of the suburban hospitals in the area. I learned a lot, and I got a new pair of shoes!

My next rotation took me back to the drama that is ECMC. I know I have mentioned several times that most of us really enjoy our rotations there. The system is a lot easier to deal with, and the patients are a lot less medically critical. So, let's see, what happened...? Thanksgiving came and went. I continued to be a vegetarian. I worked 5 days straight and had some interesting tales to tell. I went home to California for an early holiday.

I then did the "Swing Month" which is not as exciting as it sounds. Basically, we split our time between ECMC and Buffalo General. I spent 15 of my shifts at ECMC and 2 shifts at Buffalo General. Sounds about evenly split. Oh, yeah, and snow came to Buffalo and started the winter off with a bang. Christmas came and went, and I made you all take the Resolutions for New Year's Oath.

I then started my official second year rotation at the Children's Hospital and tried the best that I could not to catch the RSV and other bugs children were flocking to the E.D. with at the time. I failed miserably and took it into my next rotation in the Pediatric ICU where I spent a great deal of time writing notes, and not so much time doing anything else.

Of course, I must take a moment to remember the 50 who died when Flight 3407 crashed on final approach to Buffalo Niagara International Airport. I was on scene as a member of SMART providing support for the workers who had the dangerous task of removing the wreckage as others worked to collect their remains.

My husband and I celebrated our first wedding anniversary at a great little B&B in Pennsylvania near Gettysburg. We then spent the next couple of days exploring the battlefields (mostly on the Confederate side since my hubby is a Son of the South), followed by a trip to Lancaster where my interest in quilting began to develop. Who knew it would blossom into a new hobby?

I finished my rotation at Buffalo General and spent my vacation that month in Florida visiting the Everglades and the Florida Keys. A very nice way to take a break from things medical which was good because my next two months were going to be purely hellishish.

The Ortho Service: two months of pure immersion into orthopedic surgery. You spend two weeks on the Hand Service working in the clinic and going to the O.R. Then you spend five days on the service, take a 24 hour call, and then another 5 days on the service. After that marathon 2 weeks you flip over to nights and become a vampire for a month. I learned to set a lot of broken bones, and I learned to sew a lot of messed up hands and feet. I learned how to complete an amputation. I did get to go to the second national conference in New Orleans which broke up the month very nicely. And, I was already used to staying up during the night which played into the festivities nicely.

My final month was spent as an elective in the Medical Examiner's office, and I have shared a lot of the tales and stories which were encountered during my month there. It was a light relaxing month, and I even had time to do some additional ride along time with Buffalo's Finest on Rescue 1, and to provide back-up in the SMART car.

Wow, what a year. This year, I will spend 90% of my time in the emergency departments of Buffalo General, ECMC, and Women and Children's hospitals. I do have spend one more month, a "make up month" which is a carry over from my second year at the suburban hospital again. I'll be looking for a real job this first part of the year. By the time 2010 begins, I will be looking forward to my graduation, my new job, and a new and exciting chapter in my life... Hope we all make it there together, and thanks for being here for the journey!

The Defenseless Ones

Something I thought about today that isn't usually discussed is the problem of Elder Abuse. Now, while most people think about physical violence when they hear abuse, you don't often think of other ways in which the elderly are taken advantage of. I had a case today that kept me late and which turned into a very disturbing story.

Again, while I cannot discuss the particulars of the case because this will now be a criminal investigation, I can say that a moment of kindness offered by a stranger turned into a break-in and physical abuse on the elder person. To add insult to injury, the attacker portrayed a health care worker "acting concerned" about the elder when they somehow managed to call 911 and police arrived.

The elder was then transported as having Altered Mental Status and ended up in the ED. Meanwhile, the stranger and their accomplices ransacked and stole from this elder person. Luckily, a concerned neighbor was able to get a license plate, and the suspects are being tracked. But this poor person had to suffer some humiliation with no one believing them, not to mention the losses suffered in their home, and probably some loss of faith in humanity. I was in shock as I was told the story. If I get an update I will post it.

Unfortunately, we often see some form or other of elder abuse. Usually neglect, sometimes by families that mean well, but are just not prepared to handle the demands of a frail aging person with multiple medical problems. Or by the hands of those in the nursing homes to which they are entrusted. I haven't written about some of the more horrific stories I've heard and seen. I've had a patient I've called Adult Protective Services for due to concern their fracture was inflicted by a staff member.

As for the rest of the day...

I spent the morning cleaning up from a multivehicle accident that resulted in the death of a Buffalo police officer.

I then had a patient come in with a steak knife sticking out of their belly. The driver and passenger of a motorcycle crash who both needed trauma work-ups. An overdose who needed to be intubated upon arrival. And assorted other crazy patients that each took up their own space of time.

Tomorrow it's back to the fun at the County. What a way to spend the weekend!

p.s. you can link to the National Council on Elder Abuse by clicking on the purple ribbon.

Passing Time

I had a few minutes so I thought I would jot down a few brief thoughts from the last two overnight shifts I worked. One at the County and one at the General....

The Canadian Healthcare system sucks. Just because you have healthcare doesn't guarantee that you have access to everything. I could have an illegal migrant farm worker walk into the E.D. with a severed thumb, and he would have a hand surgeon evaluating his thumb and most likely reattaching it within a few hours. A Canadian citizen cut his thumb and was transferred to a receiving hospital who then spent the next 6 hours looking for an orthopedist who might consider operating on his hand. They then spent the next 2 hours calling U.S. hospitals to find a hand surgeon willing to take the case. He then spent another 2 hours trying to get transportation arranged across the border. We had accepted him to the County, but by then it was too late. He will have to do his work sans his thumb.

Psych patients drive me crazy. While I can go along with some delusions, it's the scarily quiet ones that freak me out. Questions that go unanswered. Or a question that is answered, "well the last time I felt like this I went totally crazy and ...." Ok, stepping away from the patient before they, "...." on me.

Why do people insist on driving while under the influence of anything? It just isn't safe to take 2 sleeping pills, chase them down with alcohol, and then decide you're hungry and NEED to get something to eat right now. Ride your bike, no. Walk, no wait. Just stay home and sleep.

Patients with pica are weird. We got this patient who likes to swallow things like pens and markers. Not sure if it meets the technical diagnosis of pica but close enough. The GI fellow told me they have scoped this patient multiple times and pulled out a variety of objects. He told me that they have several patients known for all the items they've swallowed. Also, we had to get psych involved because this patient can't be trusted in their room. Last time they were admitted they unscrewed the screws on their bed and swallowed those while waiting for their upper GI scope. So, they got a 1 to 1 sitter.

Um, weenises come in all shapes and sizes. Just saying. We put in a lot of foleys for traumas. Not judging, just noticing.

How come patients who come into the E.D. complaining of pain never take anything at home for it? And, why do they all seem to know that "that stuff that started with a d... dil-something, that they put in my IV, that works really well." One of my colleagues argued that we should have a Lortab dispenser in the waiting room because it would cut down on the number of patients we would actually have to see.

Why is it I can go to work for 12 hours having to shake my hand all day because my carpal tunnel is acting up and I'm having ulnar neuropathies (my ring and pinkie finger are falling asleep), but you need a work note and a prescription for Lortab (see could have used a dispenser here) because the toe you stubbed 3 weeks ago is "really bothering you" and you just can't handle your six hour shift sitting down and answering phones?

I really wish we had a Room Nine. When I was in medical school, the E.D. at Froedert had a back room where the drunks, inmates and psych patients were held. It was Room Nine. There was a seperate area with a few shower benches and a drain in the middle. "It puts the lotion on the skin or else it gets the hose again." Actually, no, but they did have a power hose for unruly patients. And, if someone had an accident, or on-purpose soilage, clean-up was a snap. About the time I graduated, the room had been converted as part of an observation area for 23 hours' admissions, but during that first year doing tag-a-longs in the E.D., it was the site for some very interesting patient encounters. We could use a Room Nine in our E.D.'s at times.

Did I mention I like polite patients? The ones that say, "no problem, I know you're very busy" and "thank you, I appreciate every thing you did for me tonight." On some nights, they're the bright spot of my night.... except for a messy trauma of course. Again, it's not that I want you to get hurt... I just want to be there when you do.

I have several days off to recharge. Teaching a procedures class in the morning and then hopefully some sailing. A dinner party on Thursday night. Then it's work the weekend. Till then, stay safe out there!

Traumarama Thursday Night

So I started my first night of three at the County last night, and from the onset to the end of my 12 hour shift, it was one trauma after another. Actually, one trauma with another because they seemed to come in pairs. Now, I love traumas, don't get me wrong, it's just that sometimes having to work with different departments, ie. surgery, can be very frustrating. Especially when you come from different systems where departments actually get along and run real trauma codes, ie. U of Minn.

This is so not U of Minn.

Anyway, here is how my night went...
1900 get sign out from the day team. I pick up nine patients that are left over. Three are already admitted, and the rest are waiting for consults, lab results, etc. Sign out takes about 15 - 20 minutes, and about the time we are done and everyone is leaving, I get word from the charge nurse that Mercy Flight is en route with an MVC (motor vehicle collision). I sigh because I am working with a rotator (an internal medicine resident) and a medical student.

This means that my night is going to be twice as busy since, as a rule, the off-service rotators don't have the same, um, sense of urgency that we, Emergency medicine residents, do. And, there's a great quote passed along the medical tradition that says something to the effect of, "give me a medical student that will only double my work and I will jump for joy." I also had a physician's assistant and one of the new interns, so there was going to be enough fun for everyone.

So about 1930, Mercy Flight brings in SUV versus semi. The semi won. However, you have to admire the semi driver who saw the SUV about to hit him, watched the impact, then jumped out of their cab to help the person get out of their car. Luckily, no major injuries, and the driver of the SUV stayed overnight for observation.

About the time that I finished this evaluation, EMT's arrive with Gear Wheel Flew into Face. The eye is involved, so GWFiF goes into a room and I get ophthalmology and ENT involved because there is going to be some serious damage, and a lot of fine sewing involved.

I work on one or two of my sign-out patients, deal with a surly (I would use harsher language, but I don't have the parental control warning on this blog) surgical chief who will be the bane of my existence for the rest of the night, give someone procedural sedation for a dislocated shoulder, and start to write up the trauma patient when I get word from the charge nurse that an ambulance is en route with a partial amputation and low blood pressure.

I get to the trauma room, and we get Motorcycle versus car. The patient's lower leg is hanging on by a few tissues, and we make plans for the patient to go to the O.R.; of course, after a couple of units of blood and stabililization. I am just putting up the orders from this patient when a patient I had heard about earlier, Bike versus Tree, rolls in the door. They were transferred from another hospital when the patient started dropping their blood pressure and complaining of chest pain. We get them into another trauma room (we have four) and start their work up.

By now it's about midnight. Somehow I have managed to dispo (disposition meaning getting someone admitted or discharged) my signout patients and I pick up a non-trauma MVC. I get them pain meds, order spine films, and go talk to an alcoholic who just got out of rehab two weeks ago and started drinking the day they got out. I explain that there is no room in our rehab program and tell them to go back to their initial contact. I always write on the disharge instructions, "only use alcohol in moderation." While I can write "stop smoking" I am not allowed to tell someone to stop using drugs or stop drinking. Fancy that. Drug abusers get, "only use medications or narcotics as prescribed by a physician."

I stop in the middle of things to help out the intern with an assault victim that is bleeding profusely from their head. After finally getting his pain under control long enough for him to allow us to start to work on his head, I walk the intern through stopping bleeders with a figure 8 stitch and then get them started on a double layer closure. I leave them to finish the suturing and close the skin with staples. Now, where was that chart I put down...?

My BVT goes for further evaluation by the cardiologists for a possible heart injury (after I had to intubate them for dropping oxygenation saturations) which clears the back room just in time for Struck by Car While Getting Beer at the Corner Market. The patient was clipped by the mirror of the car, fell to the ground, and didn't break the 40 they were carrying. We start the work-up, but the patient will most likely be sleeping it off in a room until they are sober enough to be released.

It's about 0330 and one of the ER techs runs downstairs and gets me a coffee. I take a sip or two and then go to the trauma room for T Boned While Leaving Sleepover. The trauma team is activated yet again, and I am handing in orders for this patient when Lost Control of Motorcycle rolls in. We meet this person and see two obvious leg fractures. They will end up having about 3 other fractures which are found during the course of the work-up.

I sit to write my notes. It's getting close to 0600, and I pick up some more patients as the medical student and the rotator seem to be satisfied with managing their one patient for the final hour (did that sound catty?). I get "went to concert and got kicked in the head." I give them something for their headache and order a CT scan. (Excuse me while I clean my name badge. There seems to be some blood on it. I wonder from whom?) Then I get "my gout is acting up" which I give pain meds to, write a script and their discharge paperwork. At 15 minutes to 0700, I go and see "Chest Pain since Yesterday," and I put in their orders to get them started for the next resident.

I sign out 4 of my patients from the overnight, and I discharge T Boned because they had been cleared by surgery. I head to my car and drink the last of my now-cold coffee and head off to sleep. Another shift begins tonight. I can't wait!