At the End of the Day...

I haven't written about a day in the E.D. for a while, so I thought I would blog tonight about my shift today.  Just another day in my world.  For some, this was no ordinary day...

So, I started my shift at 0700, taking over from one of my colleagues and picking up about 10 patients right off the bat.  While I sent off my rotating resident and medical student to pick up a couple of the new patients that were waiting to be seen, I went to look at the lacerations on a stabbing patient that I had picked up on sign out.  My colleague hadn't been able to sew the wounds because they had been waiting for a few more films to come back, but by sign-out the patient was ready to have their wounds fixed.

I looked at the 4 inch cut to the face and the inch long wounds to the arm and back, and I knew that I would be sewing for a while.  When you're the senior, you're not just in charge of your patients, but you're also responsible for the flow of the department (what's coming in and what's going out and where).  So, I knew that I couldn't just leisurely tie myself up in one patient's room.  I had to think about what could potentially happen.

I stepped out to gather my supplies and went and saw a new patient coming in complaining of back pain.  She'd had recent back surgery and was having post-operative pain.  I wrote for some medications after some discussion with my attending and continued gathering my suture supplies.  About that time an elderly patient that had fallen down the stairs came in.

There was some concern because the patient was on blood thinners, and she had hit her head.  I did her exam, did a FAST exam and wrote order for the multitude of CAT scans I would be getting on her.  I then went to go start stitching my patient's face.  It took me about 30 minutes to get his face sewn up.  In the middle of my stitching, nurses would come in from time to time to ask about orders for patients.  At one point near the end, the nurse taking care of my elderly fall lady came to tell me that the patient wasn't as alert as she had previously been.  I told her to rush her to CAT scan.

I finished the patient's face and went out to see what had happened while I was gone.  The patient tracking board was filling up with patients, and I quickly went and saw another senior who had passed out in church, and one of our sickle cell frequent fliers.  I put in orders then went back and quickly spent about 5 minutes sewing up the laceration on my patient's arm.  Two lacerations down and one to go.  As I was putting in the last stitch, the nurse for my fall patient came in to tell me that the patient had bleeding in the brain.

I went out and told the charge nurse that we needed to move the patient to a trauma room.  I paged out the trauma team, and I put out a call to the neurosurgeon.  I wrote some order discharging a couple of the patients that I had been signed out that morning and answered returned phone calls.  I got the medical student started on sewing the last wound on my stabbing patient.  He got the first stitch in about the time I heard my name paged to the trauma room.

I went and found that the fall patient had an even worse neurological exam and would need to be intubated.  I went to find my attending as I grabbed the airway box and went to the room.  My attending told me to wait because he didn't feel there had been much of a change, and he wanted the neurosurgeon to get a good exam.  I went back to my medical student and got him through another stitch.  I got called back out of the room to talk to the family of the fall patient.  I explained about the head bleed and how I might have to put a breathing tube in.  They understood, and I went back to the stabbing victim.

One more stitch and I was called back to the fall patient.  She'd just vomited everywhere.  I told my attending I was intubating.  I got the breathing tube in and went to tell the family I had just done so.  They were very upset asking how the patient was going to do.  I couldn't answer them, but elderly patients who fall down the stairs and bleed into their brains don't often do well.  Another stitch with the medical student plus one or two I quickly threw in to move things along, and we were done.  By this time it was close to 1 p.m.  Where had the morning gone?

My fall patient went to the ICU, and I discharged (finally) the stabbing victim.  I picked up a nursing home patient brought in for altered mental status and another patient with swelling in their lower extremities.  After discussing the cases with the attending, I placed my orders and sent the resident to lunch.  I quickly saw a prisoner with a hand injury from a fight in the jail and placed orders for films.

My swollen patient ended up needing a cat scan, and for some reason it took 2 hours to get a head CT on my altered mental status patient during which time I sent the prisoner back to his cell and sent the medical student off to lunch.  I grabbed a quick salad myself (still doing the raw food thing) while I saw a pseudoseizure (nee big faker) and a patient bleeding from just about every orifice.  Oh, and a short of breath pregnant patient who did a whole lot of cocaine.

By this time it was after 5:30 p.m.  I got a neurology consult on the big faker, um, seizure patient, and I started ordering blood products for the bleeder.  My cocaine patient settled down, and I picked up a patient that had lost their battle with a table saw.  Almost missing - one pinky.  I called orthopedics.

Around this time I was cleaning house.  I got my big faker patient admitted, my swollen patient admitted, and my bleeding patient admitted.  We got word about this time that my fall patient had suffered a major bleed and now had a ton of blood in her head.  This was not going to end well.

Seven p.m. and my colleague returned.  We signed out our patients to her, and I spent about another hour doing paperwork and getting my altered mental status patient admitted and got my cocaine patient information about her reproductive choices.  While morally I oppose abortion, a cocaine and alcohol addicted patient whose three children are in the custody of her parents probably should have the option.  I don't condone it, but at time I think of it as a necessary evil.

Anyway, I signed out the cocaine patient because her heart rate was still irregular and my almost missing pinky patient because ortho was busy with a dislocated knee that had rolled in the door just at change of shift.  Tiredly, I packed my belongings and made my way home.  Vacation started the minute I left the hospital.  After another "usual" day in the E.D., I really need it.

For those reading on Facebook, my original blog site is buffalosquirrels.blogspot.com and I also blog for the American College of Emergency Physician's (ACEP's) website thecentralline.org

La Comedie Tragique

So I have worked a couple of more shifts in the E.D. at WCHOB, and now I am on a string of swing shifts of a sort. My sleep schedule is a bit off, so I don't know whether to stay awake or sleep in. I've been doing a little bit of both.

Anyway, there was a fair bit of drama going on during my last shift. Some of it funny. Some of it sad. Hence, the title of my blog entry today. I'll share just a few of the scenes from today's episode of "Drama: Life in the E.D."

4 year old girl. Chief complaint: bloody stools. Seems this girl was sent from her pediatrician's office with several days' history of diarrhea. Over the last two, mom had noticed bright red blood in the stools. She took her to her pediatrician who immediately sent her to the E.D. I did a thorough exam as I ran through all the possible causes in my head. When I did the rectal exam, I thought, "Now this is strange."

Now, I've done lots of rectals (not something I admit readily in public). I've seen blood in its many forms before. This wasn't blood. I didn't want to say anything until I did a hemocult card. We put a small sample on the card, and then add developer. If there's blood, it turns a dark blue color. This didn't. I still didn't say anything. The parents were looking at me expectantly. I just said, "I don't think this is blood." There were two sighs of relief. I told them to hang on a second.

I grabbed another hemocult card and brought it back into the room. Mom had collected several samples. It looked red all right, just not blood red. I put some on the other card. Again, negative. I went out to tell my attending. We looked at the sample. We looked at the card. Dad wasn't convinced so I did it again with another sample. Still negative. "Do you believe 2 out of 3?" I asked him. He smiled and said, "Yes."

Now, onto the mystery of the red poops. I asked about foods. I asked about drinks. I asked about new pills or the antibiotics the patient was taking for a recent ear infection. Anything that could have a red color dye. The mom kept answering, "No, no, no..." Then her face changed, and she smiled. Vitamins. They had just changed vitamins a few days before, about the same time the patient had started having diarrhea. All the patient liked to take were the red ones. Mystery solved. Discharged to home.

9 month old patient. Chief complaint: ? seizure. Seems the little girl had been sick over the course of the day. She felt flushed and warm to the grandmother that was taking care of her. Because it was so cold, they had wrapped the child in heavy blankets. At some point she became stiff/limp, and the grandmother got scared. They ran the child to the bath and splashed cold water all over her. She recovered, and they brought her into the E.D.

I worked her up for a febrile seizure and felt that it was from an upper respiratory infection she had been developing during the day. I was talking to the Mom and Grandmom, and they started to tell me how the reason she'd been bundled so warmly had been because the landlord was not responding to calls to fix the heater. They had been using space heaters and turning on the oven to keep the apartment warm.

I found out that we can admit children to the hospital for social or welfare reasons. We were concerned about sending a baby back out into an apartment with no heat on a night when temperatures were going to reach the single digits. However, the family told me that they had somehow managed to get the heater working again in the time they were in the E.D. (about 5 hours or so), and the Grandmom told me that she would have taken the baby home with her if that hadn't been the case. We called their pediatrician and arranged for follow-up. Discharged to home.

10 year old. Chief complaint: rash ? chicken pox. Nowadays, with the chicken pox vaccination, we're seeing less of chicken pox. I had asked if all the immunizations were up to date, which the mother assured me they were. I asked about sick contacts. I asked about other kids at school being sick. No, no. I looked at the "rash." I asked if anyone else had it.

The mother turned to an older daughter, and she showed me her lesions. I asked about family pets. A rabbit. I asked about other people's pets. Some new puppies at a friend's house. The family looked at me as if I was strange. How can a pet give you chicken pox? I said I would be right back.

I went out of the room. My attending asked me, "So, is it chicken pox?" I said, "No, bed bugs." I described the characteristic "triple bite" pattern. He went to go look while I typed up the discharge information, and a sheet about treating insect bites. At least they don't have to get rid of their rabbit. Discharge to home.

The final case: I came on shift, and one of the pediatric residents came up to me and asked me how I would proceed on a case she had. It was a 13 year old girl with abdominal pain. The pregnancy test had come back positive, and the girl had vehemently denied being sexually active. I asked if she had talked about other possible circumstances which would allow the meeting of sperm and egg, and the resident said, no she hadn't asked.

I asked if she had done an ultrasound. She asked, "We can do that?" I told her that as E.D. residents we always put an ultrasound on anything we want a quick and easy answer for. I offered to do it for her. She said, "Yes." So I went into the room and introduced myself. I told them I was just looking to see if there were any obvious abnormalities.

The mother kept joking, albeit with more worry than laughter in her voice, about finding babies and how there had better not be any. The daughter kept saying, "No way" and then asking me if I was seeing anything abnormal. I told her that I didn't see anything abnormal, and that her resident still might want to do a more formal ultrasound. We got back the blood pregnancy test that confirmed there was a pregnancy. The number of the count was low, so too small for me to even see the beginnings of what is known as a gestational sac.

As the shift progressed, I asked the peds resident what had happened. Before sending the girl to ultrasound for a formal scan, she had told the girl that she was pregnant. The girl started crying and then admitted that she had a 16 year old boyfriend, and that they'd been having sex for 2 years. Something about the thought of an 11 year old girl having sex left me unsettled for some reason. I tried to think back to when I was 11; boys were still icky annoyances.

There was no badness on ultrasound (meaning no ectopic), and after OB-Gyn came down for a consult (pelvic and mom finding out the diagnosis) the patient was discharged to follow-up with her pediatrician and to get a prescription for chemical pregnancy termination. I won't discuss my thoughts on that issue, but suffice it to say that given what I see from day to day, I think it's the right decision for all involved. Sigh.

Time to get ready for another shift. Seriously, I am hoping to see something more interesting than colds and diarrhea. When is the RSV season over...?