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.

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....

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...

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...

Another Month Did and Done

Well, it's Sunday. Officially, the last day of the module, and the last day of the medical year. Tomorrow morning I start as a senior resident in the Emergency Department. Fifteen more months and I will be done. I am going to put a counter on the sideline to count down the days.

After the excitement and interesting tales from this last rotation and the two months of Orthopedics before this, my husband was telling me that I was going back to the usual "boring stuff." I reminded him that I would be doing this "boring stuff" for the rest of my career; unless, of course, he lets me return to surgery and be a resident for another three years. By the groans and threats of moving to live in an RV on a beach in Florida I take it he is about ready for this to be over too.

My last case at the ME's office on Friday was a sad tale of a massive thunderstorm and downpour, a car out of control and hitting the curb at about 75 mph, jumping the curb and over a about a 3 foot wall and slamming into a church. The driver had major trauma to his head and lower legs. His passenger died.

Again, while I can't discuss the specific findings, I can say that this was the most trauma I had ever seen on one person. That the driver survived at all is incredible. I was in amazement throughout the entire post-mortem exam. I couldn't even begin to think of what I would do had this patient come into the emergency department. Where to even start. But, this is one of the reasons I did this rotation. To make you think about the traumas. To make you understand more fully the traumas. And, to realize that there are some things that can't be fixed.

What I'll be missing tomorrow: a second child has died of the H1N1 flu virus. We had been following her condition very closely throughout the last week. And, a victim of a train accident has died. I heard the radio call out when he was first injured and was amazed that he survived to make it to ECMC. I heard about his progress in the ICU. They will probably be posted tomorrow. With tongue in cheek, this just goes to show that even at the ME's office, life goes on.

Accidents Do Happen

So, I have been working on the orthopedic service, and I am seeing a lot of trauma. Today was a day of accidents of one sort or another:

20-something who drank and drove his his car right into the back of a semi. He had a nasty scalp laceration which was fixed by one of the E.D. medical students. I was there because of his broken hand. We casted it and sent him on his merry, albeit under arrest for DUI, way.

40-something who likes to get high and is already on disability for a prior back injury (that's you and me paying for him to stay home and toke up, but I digress), who was fixing a golf cart on a lift. Said cart was in gear when he started it up and it fell off the lift and fell on his leg breaking it. You might remember the backward foot from one of my earlier posts. His leg looked like this but because the lower part of his leg was broken in half. We splinted it, and he was on his way to surgery when I left.

60-something female who was making a shelf. She was using a circular saw to cut some wood. She says she "looked away for just a second." You can guess what happened. Although she properly wrapped and iced her cut fingers, there would be no reattachment for her. The fingers would not survive. We cleaned what remained of her first 2 fingers on her hand and oversewed the exposed bone. She had a great attitude and was already asking when she would be able to go back to work. I'll see if I can follow up with her next week in clinic to see how she's healing, and doing.

That was today... Tuesday we had a patient who crossed the median and ran head on into another car. They're still alive in the ICU but have a broken knee and ankle on one side and a broken leg on the other side; plus, a broken pelvis, broken insides, etc. We'll see how they do.

Back to work tomorrow, and I am on 24 hour hospital call over the weekend. With nice weather headed our way, it's definitely going to be the start of the trauma season... eek!

p.s. click on the picture to see the animation