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.

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!

The Brain Box

Ok, so I am still rotating through the Medical Examiner's Office. The cases from the last couple of days have included several suicides and several mass traumas. We talked about how the patients that don't make it to the Emergency Department end up at the ME's office.

This is why I am doing this rotation. Nowhere else am I going to be able to be elbow deep in someone's chest looking for the traumatic aortic rupture, or holding someone's brain following the path of a bullet with my finger. (By the way, the pic is a Jello mold not a real brain.)

I wanted to quickly respond to some questions I received from Betty:
- The ME's office gets cases that warrant a forensic medical examinination as deemed by the County Coroner (there's a difference between coroner and medical examiner), and cases that fall under certain protocols - an unwitnessed death in a person who has not been under a doctor's care for a certain period of time, any death involving an inmate, an unexplained or unnatural death (murder, suicide, accident), deaths involving children or infants, and several other specific circumstances.

- We have a protocol sheet we follow in the E.D. and in the hospital when there's a death. We have to call the M.E.'s office, and they "sign-off" or take the case. If there is an autopsy that's not the same thing... a family can ask for an autopsy and that is performed by the hospital pathologist.

- I usually don't participate in autopsies, but I occasionally get to cut something or dissect an organ, and I get to touch most things after the official examination is done, which is a good thing because I am not a "spectator"

Tomorrow is an off day, so I will be back at the ME's on Thursday. Here's the case list from the last few days, including 3 suicides -
Homocide
MVC Fatality

Under Pressure

I never thought about the change that would happen in six months.

I just started my next rotation at Women and Children's Hospital. After almost two months working at ECMC, I think I was ready for the change. However, I didn't expect quite the change.

If you've been following my blog, you know that I have already done two rotations as an intern at WCHOB. And, despite the fact that I really don't like kids, I actually enjoyed them. It gave me a chance to do some preventative medicine - which I think is very important, a chance to teach - which I love to do, and, for the most part, I learned a lot about pediatric acute (and some not so acute) emergency medicine.

However, starting on Monday morning, I was the "senior" emergency medicine resident. Suddenly, it wasn't about "what does this child have?" it was about "how are you going to fix them?" Having not seen anyone under the age of 16 for the last 6 months, I really found myself rusty in my diagnostic skills, and with the added pressure of making more complex decisions about their health care, I was really at a loss my first shift.

What did not help was the fact that it was Monday. In January. At the height of RSV and flu season. And, I had an intern that had never been to WCHOB before. And, we started the morning with a trauma. A sixteen year old girl T-boned on her way to school at 45 mph. She ended up with a subdural hemorrhage. By the time we finished assessing her, we had four new patients on the board, and the fun was just starting.

I felt like an intern, trying to get used to the system again. Trying to manage the patients. Trying to just feel like I wasn't sinking. We got more residents in over the next 4 hours, but the whole system was just overloaded.

At one point we had all 26 rooms full. They opened another section of rooms (+6). And the waiting room had about 20 people waiting. The computers crashed, the nurses were surly as they were being pushed to their limits, and ambulances kept bringing people in.

We had the comic "E.R." moment when everyone was running around, a barely-breathing baby is brought into the back and starts being coded, the ambulance rolls in with another child turning blue despite ventilation, and the noise level rises to fever pitch. The baby is taken to another room so that the blue child can be rolled across the work station to the now vacant code room, and there's the rush and flurry of the respiratory therapists pushing ventilators as the radiology techs push around their giraffe-painted x-ray machines.

I left that night with 4 patients waiting to go to the Pediatric ICU (PICU), another 5 or waiting for admission, and a full board (20+) in the waiting room to be seen. You don't learn in that environment. You just try to survive and not let anyone else get hurt.

My next shift was a little better. At least I was able to think about my patients more. Review my disease processess. Come up with a plan before presenting to the attending. Not to mention, I actually knew the attendings. One of our complaints about WCHOB is that we're working with pediatric attendings who have completed a fellowship in Pediatric emergency medicine. We're guests in their house.

They've hired a whole group of new graduates, none of which I had worked with before. Not that it makes a whole lot of difference, but you get used to how an attending likes their work-up and presentation. You know who lets you fly and who keeps a close rein. I guess I could have almost called this posting "Out of my comfort zone."

Sigh. It was just the first two days. I work tonight (which is another problem, since we don't schedule our residents we get whatever schedule the pediatric chiefs come up with which doesn't always make sense or take into account shift time changes.) I know I will be able to get back into a rhythm. And, I know that by the end of the month, I will be a lot more comfortable with what I am doing in my new role.

Just in time to start my PICU month when the fun begins anew!

Until then, we'll see what interesting stories that don't involve coughs, colds, vomit, diarrhea and parents that should need a license before they're allowed to procreate we can come up with.

As for the video above. I like the way they combined two of my favorite shows "Grey's Anatomy" and "Scrubs" And, I like the song....

60 Hours

When I started my emergency medicine residency, I was told that all of our shifts are 12 hours long. Coming from a surgery residency where shifts can be 30 hours long, I was looking forward to the break. Having just spent the last five nights working a series of 12 hours shifts, I have realized that the hours add up pretty quickly.

While I can't write about everything that happened over the last 60 hours, I can hit the highlights. I have also found that the more tired I am, the more surly I become with patients. After a brief 18 hours to adjust from night shift to day shift, I was back at work this morning. My body was telling me that it was nighttime and I should be sleeping. Caffeine does wonders for the sleepy mind.

Anyway, what do I remember most about my last block of shifts:

- even pretty teenage girls from good families can be more troubled than you would think. I sewed up a 5 inch cut across her arm where she was "cutting" to hurt herself. It matched a series of other cuts that she had already put on her arm. This one was deeper than those, and I had to sew the wound closed in several layers and oversew a blood vessel that she had cut as well. Off to psych services, and probably alcohol rehab. She'd already lived more in 15 years than I had at 3o.

- the legend that people are more depressed around the holidays never showed more true than in this weekend after Thanksgiving. Our board shows the 20 rooms in the E.D. At least once per shift this weekend, there were 8 - 10 OD's, SIWL (self inflicted or suicidal ideation with laceration), rehab, depression, alcohol withdrawal, AMS (altered mental status), etc. on the board. It got so bad that I said that if I had to see one more suicidal patient or OD I was going to commit suicide. My senior actually called over to psych services to see if I could be committed for making a suicidal intent statement. They said yes, and that they would be more than happy to send security over to restrain me for a while. All in jest, but really... I was going crazy.

- there was a sale on car wrecks. Crash yours into someone else's and you both get seen for free!

- we had the first snowmobile accident of the year. No snow on the ground, he'd just had it tuned and wanted to hear it run... and it did, right into the building then flipped over on him. He had no injuries, luckily. We'll see how the rest of the season goes.

- for some reason, more stabbings are happening than shootings. They're a little hairier because you don't know just how far down the blade went. Bullets you worry about the path. Knives you're dealing with too many variables. We CT scan everyone. Oh, and marijuana is considered by some to be medicinal for post-traumatic stress following having been stabbed by your best friend who was high on "some pills" and thought you were suddenly out to get him. It's not.

- some attendings I get, some I just don't. Wonder what kind of attending I will be?

- even big strong 36 year olds die. Suddenly. We had one with a massive pulmonary embolism that died around 3 in the morning several nights ago. We worked hard to bring him back. Nothing would work. It affects the whole staff when something like that happens. Of course, I also had the 38 year old with end stage AIDS whose mother signed the "comfort measures" paperwork and then wouldn't let go of them. We all knew it was in the patient's best interest. I can't even begin to imagine the feeling of signing a paper that will limit the care your child receives. No matter the age, they are always your baby.

- which makes me salute all the mothers who brought their child to the ED for help and sat by their side while I explained what happens when you OD on soma, lortabs, alcohol, antidepressants; or while I sewed self-inflicted lac after lac; or who encouraged them to get help from Abuse Intervention Services because they "couldn't take it any more."

OK, it's late and I have one more shift before getting some time off... be happy! My ED patients have been so depressing lately.