Workings of the Mind

As I wrote before, for the last 3 weeks I have been on an elective in Neurosurgery.  It's been a heady (hee hee) experience being back in the OR.  Learning SO much about neuroanatomy.  Since the beginning of the month, we have been on-call for spine, so I've also been getting quite the education about spinal lesions and learning how to read MRI's.

We've been rather busy due to "trauma season," and at times have affectionately nicknamed the Trauma ICU as "Turban City" since 90% of the patients are ours and have their heads wrapped following surgery or ventriculostomies.

During the last several weeks I've come to realize a few things:

 - drunk anything is bad.  It makes you drive carelessly and hit 70 year old grandmas who then bleed into their brains.  It makes you jump on the hood of a car that then drives away, and you fall and fracture your skull and then bleed into your brain.  It makes you jump off a porch causing you to break several bones in your spine which leave you with weakened legs and needing a urine bag because your bladder no longer works properly.

 - you can be hurt by the ones you love.  The guy whose name you tattooed on your shoulder can shoot you in the head and dump you by the side of the road.  The family of your boyfriend can object to your relationship and cause broken bones in your face and head.  Your drunk husband can roll over the car causing you to have massive brain injury and leaving you as helpless as your two young toddlers.

 - walking down the street is dangerous.  You can get shot at, run over, mugged, or just trip and fall.  All of which can land you on our service.  So is riding your bicycle, driving in a car, or flying in a plane.

 - I like opening and closing surgical cases more than the actual procedure.  I know, weird.  But there's something very satisfying about gaining the exposure, identifying the lesion, then trying to cosmetically close the wound.  While drilling and plating is interesting, once I've seen the anatomy I'm satisfied.  I know, weird.

 One more week then it's back to the E.D. for my final 11 shifts.  We're on a countdown of 30 more days until I move from coast to coast... I've got to start thinking of new names for my blog...

We Got Your Back--board

There's two ways to come into the E.D. at the County:  one is passing by the waiting room, and the other is coming up the back stairs and passing the hallway where the backboards are stacked.  Either way, I can get an idea of what's waiting for me inside the E.D.

Most of the time when we take someone off the backboard, they've been placed on it as a precaution following a fall or a traffic collision.  Sometimes there's blood on the boards.  Sometimes worse.

They all get brought here... to the back hallway.  Here they wait for Environmental Services to give them a good wipe down.  There's actually a separate stack for clean versus dirty.  The clean ones get picked up eventually by their respective EMS agencies so there is a constant ebb and flow to the stack.

Still, in general, it's a good indicator of how a day is going, or how the day has been.  Lots of boards means lots of traumas, and they slow the whole E.D. down, hold up resources, overwhelm the staff.

I make a conscious decision on most days - front entry and pass the waiting room to see what's coming;  back hallway and backboards to see what's been... it helps to prepare me for the shift ahead.

Theme Night

Talk to anyone working in the Emergency Department, and inevitably it seems that some days there's a theme running through the department.  Last night was "I Broke My Face" night.

36 year old who fell headfirst off of a balcony down to a sandy bottom below.  They thought they had a small scratch on their eyebrow.  They came to the emergency department because their eye swelled up and looked like a beet was growing out of their eye socket.  CT scan showed they broke their face.  They were  admitted for having pneumocephalus - "air in the skull."

20 year old who fell headfirst over the handlebars while biking with a friend.  Seems their front tire struck their friend's back tire.  No helmet.  Landed right on their face.  CT scan showed they broke their face.  The eye socket is made up of 4 walls.  They broke three of the four.  They got to go home with antibiotics and a follow-up with the facial trauma service.

25 year old that got mugged.  They were punched in the face and came in with a swollen cheek.  CT scan showed a broken cheek bone, otherwise known as the zygomatic arch.  Because it was broken in multiple places and pushed in, they most likely will need surgery.  I left that one at the end of my shift, so I will find out what happened to them when I go back.

40 year old that was drunk and crashed their car.  Since they weren't wearing their seat belt, the windshield stopped them from flying out of their car.  However, they broke the windshield with their face.  They broke their face in about 10 different places.  The facial trauma service was going to look at that one when I left.

I worked all Fourth of July weekend and kept expecting it to be a "Drunk and Disorderly" theme weekend, but surprisingly it wasn't.  However, the Trauma season is in full swing, so the hits will, literally, keep on coming.

A Week of Nights

So for the last two weeks, I have been looking forward to a leadership conference that I will be attending in Washington D.C. this week.  To make up for the fact that I would be gone for about 6 days during a non-vacation month, I had to squeeze in my required shifts into the rest of the time.  So, I just ended a string of 6 nights in a row.

Now, a 72 hour week is nothing compared to the sometimes 120 hour weeks I'd put in as a surgery resident. However, the last time I did something like that was over 3 years ago, so I was a little rusty.  Suffice it to say, there were a lot of patients seen during that time....

 - the "newlyweds" who came in concerned that an infection on one had spread to the other... it hadn't, but I was more concerned about the fact one of them had Hepatitis C.  Now, that's something that you don't want to be sharing...

 - why are the nicest patients always the sickest?  I had the status-post bone marrow transplant for leukemia who came in with a pulmonary embolism.  He and his wife were the nicest people.  She kept track of every doctor's appointment, lab result, medication schedule, and he showed an inward strength I can't begin to imagine.

 - on the opposite spectrum, I saw my share of 10 out of 10 abdominal/chest/back/etc. pains who are "allergic to everything except that di, dil, daldid, something d stuff.  Of course their pain is always something non-specific with random symptoms, and they have to have the full work-up and treatment... I did say "seriously?" once or twice as several I knew had multiple ED visits came in crying and writhing on the bed.  They just stopped for a second and said, "Well, maybe it's a 7 or 8.."

 - moving someone from the ambulance gurney to the hospital bed and seeing brains is never a good sign

 - I actually admitted a 10 year old for "severe constipation"... come on, parents, more leafy greens and water and less processed chicken nuggets and colas... make your kids run around instead of sitting in front of the Playstation... I can't tell you how many "rule out appendicitis" kids I see that turn out to be constipation

 - some things come in pairs:  I had a Martin and a Marvin both come in with the same wrist fracture on opposite arms, one from roller skating and one from skate boarding on the same night... wierd

 - we are not fast food, you can't come in, pick what you want off a menu and then leave if you don't want to finish your meal... also, if you're crying and writhing in the hallway and you've been waiting about an hour, I am still going to bypass you for the little old lady who's turning blue who just came in the door... keep screaming, I'm going to be just a little busy saving a life across the hallway

 - some people are crazy, literally.  I always wondered about mental illness.  I had to do an evaluation on a paranoid schizophrenic...  it was something like the scene in "Patch Adams" where Robin Williams fights the squirrels with his roommate... yeah, something like that...

Ok, I think I touched on the highlights.  I'll be blogging from the conference this week, so stay tuned!

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!

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.

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.

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.

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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, we 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 of 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 run 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 scrubs 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....

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...

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...

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!

Last Night at the County

Some of the cases from last night's revelry:

OD's - My two of the half dozen or so OD's we got last night were of unknown substances. One we think was methadone the other is a complete mystery.

GSW's - we got one last night but one shot was all it took to take the life of an 18 year old

Stabbings - mostly superficial wounds on the patients, but my patient's assailant decided stabbing wasn't enough. He was going to run over him with the car too. I think he's going to be lucky and wind up with some relatively minor injuries

Motorcycle crash - again, please don't take drugs and then think you can control a motorcycle. You'll end up with lots of broken bones in the trauma icu and the police placing you under arrest.

All this plus the chest pains, the abdominal pains, the shortness of breaths, and the eight or so patients signed out to me last night.

Have a great and safe Fourth! Stay out of the ED!! I don't want to meet you under those circumstances...

Dem Bones, Dem Bones...

So, I continue on the night ortho service. It was quite a week back following my wonderful time in New Orleans. I can't even begin to list all of the injuries I have seen so far, but suffice it to say that I have told my husband he's not allowed to pick up any powertools, chainsaws, table saws or use a lawnmower. He's not allowed to ride on a bike, in a car, or on a motorcycle. He's definitely not allowed on a horse. And, he can't go up or down any stairs, any ladders, and under no circumstances is he allowed up on the roof. Seriously, the world doesn't seem very dangerous until you're up all night tending to people's injuries.

Of course, I haven't even begun to list injuries caused by other people... gunshots and stabbings, assaults with hammers, baseball bats, and other metal objects.

I have had a lot of fun, for some odd reason, with amputations. I took off someone's finger this evening and then sewed their hand back together after an encounter they had with a table saw. I had another gentleman on Friday who caught his hand between a chain and the tailgate of a dump truck. It took me almost 2 hours to make his finger look like a finger again. Maybe it's the surgeon in me that keeps popping up. I get a lot of satisfaction in seeing something put back together and knowing that they are going to have a good result.

I have one more week left on this service then I start my elective. For anyone actually reading this, I am going to leave it as a surprise. Let's just say I will probably be doing some cutting... off to go do morning rounds... maybe if I figure out how to post from my iphone I will send tidbits during the next several shifts. It's hard to post because most nights I am too busy, and I spend 7 out of my 10 hours off between shifts sleeping. We'll see if the experiment works. Until then!

Ortho Flying ScutMonkey

For those who would like to know what a surgical rotation is really like, I would recommend The Underwear Drawer. Medical student turned cartoonist depicts the life of a medical student in a humerous fashion with a series of cartoons. Having been there, I can totally understand.

I started the first day of my rotation on the Orthopedic Surgery service at ECMC kinda like a medical student. I didn't know any of the patients, and I was pretty much following the Ortho residents around as we rushed from room to room. We took about 2 minutes per patient, and rounded on everyone on our list within about 30 minutes. I then spent the next 20 minutes helping to cast a patient with a broken ankle.

By the time we were done, I was wishing for some Advil and wondering if I would have time this rotation to start lifting weights at the gym. Seriously, this was a big guy, and I think his leg weighed 50 pounds. Because of the pain, he wasn't able to support the weight of his own leg, so I had to do the majority of the work.

Then we rushed downstairs to "run the board" which consisted of looking at films with the attendings from the previous evenings' consults. Then everyone took off for the O.R. Now, as many of you know, I spent 3 years as a surgical resident. I did an internship. My partner on the Ortho service is the Ortho intern. He carries "the Bomb."

"The Bomb" is the Ortho service pager. Anyone trying to get a hold of Ortho calls this pager. It goes off all the time. And, 75% of the calls are for patient scutwork. Scut is all the little tasks that go along with patient care - writing for medications, ordering tests, following up on tests, ordering labs, following up on labs, ordering xyz, following up on xyz, etc. If a patient has pain, they call "the Bomb." If a patient can't poop, they call "the Bomb."

As an E.D. resident, I carry the tradition set forth by my predecessors, that we DO NOT carry "the Bomb." However, from time to time, it becomes necessary to do so. I carried it this morning while the intern scrubbed in on a case with the promise that he would take it back when he was done. About 15 minutes into carrying it, I wanted to chuck it against the wall.

I was all too happy to give the pager back when the intern got out of surgery. We had a light early afternoon, and then I got called, by one of my colleagues, into the emergency department for a consult. I didn't leave for the rest of my shift as injury after injury started coming into the E.D. I got to do a tendon repair on someone's hand who got it smashed under a piece of machinery. The intern then splinted the patient's hand due to a bone fracture. Several other consults came in, but those got signed out to the oncoming night team.

Now it's time to go to sleep... 0430 comes much too soon... until tomorrow....

Slippin' and a Slidin'

Last night I started a string of nights at ECMC. Aside from my resolutions for my patients from a prior entry, I made my own resolution to not be so cynical of patients and expect the best. Kind of hard to do when you read some of the presenting complaints at the top of the patient forms, but I was going to make an effort. That lasted just about 1/2 way into my shift , and then I just gave up all hope... sigh.

Anyway, last night I drove to work in a freezing rain. It was just hovering about 33 degree F. We came into an almost empty board, at 7 p.m., and we had hopes of clearing it. Then came 11 p.m. All of that freezing rain turned to ice as the temps dropped down into the high 20's. Suddenly, there were sheets of black ice everywhere. And, then the fun began.

Four employees leaving the hospital slipped and fell in the parking lot. A police officer slipped and fell on the ice - broken leg. Another police officer crashed his car into a tree when he hit a patch of ice - concussion. A young man was carrying a porcelain toilet and it slipped out of his hands - he severed one of the major arteries to his hand and cut several tendons and an important nerve. He was going to surgery.

By 1 a.m. I counted 15 patients on the board, and 8 of them were ortho consults for fractures, dislocations, etc. And the night continued on steadily busy. One little 78 year old lady produced a similar film to the one I posted here. She'd slipped and fallen on her oxygen hosing. Her bone cut through her skin, so she was considered an open fracture necessitating immediate surgery. She was on the board to go to the O.R. when I was leaving this morning.

Well, ok. Time to head off for another shift. It's Monday, so there should be quite the crowd. Will let you know what I see tomorrow! Cheers!

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.