Sing a Song of Sixpence

Wow

Fri, 31 Oct 2008 20:55:31 GMT

I have the best freaking nurses in the whole entire world.

the south shall rise again! (or something)

Tue, 28 Oct 2008 21:10:52 GMT

Brief ED post, no need for editing - nothing gross:

The next chart in the rack is Duncan Weisner, an 18 year old with chest pain. He's got no medical history, no relevant family history, no real risk factors. I don't know what's going on but I figure before I go into the room that he's not dying of a heart attack.

In the room there is a chunky young guy clutching his chest. He's hooked up to a monitor which shows an extremely normal heart rhythm. The nurses have put the EKG on the counter and it could not be more normal. Duncan has an equally out of shape friend with him who limps painfully around the bed, holding a half eaten bag of Doritos and winces visibly as he sits down.

"What's going on, Mr. Weisner?" I ask.
"I think I'm having a heart attack," he gasps. He does look miserable but I'm not convinced he is having a heart attack.
"Well, tell me the story of your pain. When did this start?"
"Cooper and me," he gestures towards his friend, "we're trying to get in shape. We're going to join the army so we want to get in shape." City X donates a lot of young men and women to the armed forces. It is the only way out for many people - and there is possibly a smaller likelihood of being shot in a foreign country than there is on the streets of City X. I see a lot of vets in my ED and a lot of very sad parents but I don't think I've ever seen people attempting to get into the army before.
"It's great that you're trying to get into shape. When did the pain start?"
"Well we rented this DVD that was supposed to be like basic training and, shit man, that shit is hard core. We were running and doing crunches and stuff. We must have done like, a million crunches and a million push ups and a million squats. Maybe more. But we're going to get in shape!"
"Did the pain start when you were exercising?"
"Nah. We both finished and then we had a couple of 40s. We deserved them after that shit. And when I woke up this morning I was having a heart attack."
"Hmm," I say, and do a physical exam.

Mr. Weisner needs to lose about 50 lbs but his heart has a regular rate and rhythm with no murmurs, rubs, or gallops; his lungs are clear. He's got mild diffuse tenderness in his quadraceps , hamstrings, gastrocs, deltoids, biceps, triceps and impressive tenderness along both sides of his anterior chest wall. I diagnose him with acute inflammation of his pectoral muscles from doing way too many push-ups. He is mortified. Cooper teases him. I mention that Cooper is limping and perhaps shouldn't throw stones. Mr. Weisner laughs uproariously and Cooper retreats into his bag of Doritos.

"So what motivated you to join the army now?" I'm killing time while I finish up my charting. This guy was brought back as an emergent patient and I need to get him out quickly to free up the monitored bed for someone who might actually be having a heart attack. The question agitates my patient.
"This country is a bunch of pansies who don't know how to fight. We're willing to go and kill a bunch of Arabs, but we won't stand up for our own people!" This confuses me.
"Do you mean the situation in Afghanistan?"
"No! They're just another bunch of towel heads. I don't even know what the fuck we're doing there, that Osama guy has moved on by now. I'm talking about America. America is being attacked and nobody is doing nothing."
"Um," I say.
"Yeah, we used to have a cold war and everybody was all nuts about it but now we have a hot war and nobody cares."
"Ah," I say.
"See?" Cooper says, heatedly, "She doesn't care either!" He turns addresses me directly, "I don't know what is wrong with you people!" I'm not sure what part of being a short, four-eyed, overeducated female he means by "you people," but regardless, I've been called worse.
"Lady," says Mr. Weisner, grabbing my wrist and then remembering who I am and releasing it as if he had been burned, "I mean doctor. Doctor, the Russians invaded Georgia. My grandma is from Georgia. Don't you care?!"

I discharge Mr. Weisner with a prescription for Ibuprofen and orders to ramp up more slowly on his exercise plan.
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and, yes, this is a compilation of multiple patients. This seems to be a common misperception.

One more reason to vote

Thu, 23 Oct 2008 19:47:24 GMT

http://www.benjerry.com/features/i_voted/

I give all my patients a prescription to vote. I don't care who they vote for but they have to vote. They don't like this but they don't like a lot of the other things I give them prescriptions for either...and this is easier than taking a pill 4 times a day for 10 days.

3 weeks of pain was worth it

Tue, 23 Sep 2008 19:51:03 GMT

I am going to be first author in a JAMA article in the 10/22 health of the nation issue.

For those of you not in medicine/academia, this is a super big deal. Unimaginably big.

And it is basically unheard of for someone's first paper to be published there.

I am very, very happy. I could not be happier unless someone gifted me with a whole lot more sleep.

Appearances can be deceiving (II)

Thu, 21 Aug 2008 17:01:04 GMT

Continuation of the previous post.....

I go to meet the two Misses Browns and Mr. Durcan. Cooper stops me with some lab results, the chest pains ruled out and can go home, the COPDer is feeling better and moving more air and can go home. Shawn stops me with some new charts. A chest pain, might actually be something; a swollen hot knee; a kidney stone; a pregnant bleeder. Fine, fine, fine. He knows what to do. He goes and does it. I quickly see the new patients, most of these I'm content to stick my head in the door, introduce myself, and move on. The only ones I'm worried about are the Browns and Durcan.
    I finally reach Brown #1. The room stinks of urine. Ms. Brown has manage to completely tangle herself in her bed clothes is flailing helplessly. I straighten her out.
    "Oh, thank you. Thank you so much, dear. Aren't you a pretty thing. And so young to be a nurse!"
    "You flatter me, Ms. Brown. I'm not patient enough to be a nurse. I'm your doctor. How are you feeling?"
    "A doctor?! Oh my! That's wonderful! It is just wonderful what you young ladies can do these days. Little girls now can grow up to be anything, it's fabulous. Don't you think so?"
    "It's fabulous, I love my job. Now, how are you feeling?" I smile at her. This must be Ida S. Ms. Brown grabs my hand and squeezes it.
    "Are you angry with me for calling you a nurse? I am sorry. I forget sometimes that woman can be anything these days. They can be race car drivers or doctors or, or, anything at all. In my day you could be a mommy or a nurse or a teacher and we didn't know anything else. Now you can be anything. Men, too! There's a young man on my street, he wears a skirt. Have you ever seen that? A man in a skirt! Well! But he seems perfectly nice and he shovels my walk in the winter and I got used to him wearing a skirt. It would look odd to me now if I saw him in pants."
    "Ms Brown, do you hurt anywhere?"
    "Oh, all over sweetie. I always do. It's my rheumatiz. But I can't complain, can't complain." She pats my hand and grins. I grin back, it is hard not to.
    "Do you know why your family brought you in today?"
    "Oh, they worry. Or maybe they were mad at me. Where are they? Where did Vergie go?" She sounds a little panicked, I squeeze her hand.
    "I'm not quite sure, but we have a telephone number and we're trying to get a hold of them to get them back. Ms Brown, can you tell me, why are you here today?"
    "Why am I where, honey?"
    "Why are you here? Here in the hospital?"
    "Oh, well, I certainly don't know. You're the nurse. I'm sure you can figure it out."
    Oy.
    My physical exam on Ida S. tells me nothing. She's old, she has a scar that indicates she had a c-section and one that might have been for a gall bladder. Her lungs are mildly junky, but it sounds more like a long term smoker than a big pneumonia. Nothing else particularly exciting. I'll wait for the lab work. I go to see the next Ms. Brown. This room also stinks of urine. She is also as billed. I see someone has put 4 point restraints on her, which means she attacked staff or tried to hurt herself.
    "Go away!" she yells as I enter the room, "I don't want any!"
    "Hi Ms Brown," I say, "I'm your doctor. Don't want any what?"
    "Don't want any of your lip, that's for sure. "I'm your doctor" Well, whoop dee doo. Good for you. What do you want, a cookie?"
    "Do you hurt anywhere?"
    "Take these offa me!"
    "Do you know why the paramedics thought you ought to come in today?" The run sheet says that they were called because she was stark naked in a parking lot screaming at a parking meter for looking at her with lust in its eyes.
    "Because they're a bunch of miserable pigfuckers who hate Negroes. You're a pigfucker, too." She attempts to evade my exam but I persevere. She has some mild tenderness over her lower abdomen. Maybe. Otherwise it is a completely benign exam. She has a long jagged scar on her abdomen and another on her arm. Both very old.
    "How did you get these scars, Ms. Brown."
    "I killed someone who looked like you." She grins. I do not grin back.
    Shawn is right, I will have no problem telling Ms. Ida S and Ms. Ida E apart.

    Mr. Durcan looks like crap. When I was in medical school some attending told me that the only thing you needed to know to be an okay ED doctor was who had outeritis and who had interitis - who could go home and who should stay. Mr. Durcan might not have had enteritis but he certainly had interitis. Hydrate and home was not an option for this guy. I didn't know what was wrong with him yet, but he looked sick. Really, really sick. He certainly looked dehydrated but I didn't like his breathing, either. He was taking deep rapid breaths that made me think his body was trying hard to blow off CO2. His entire belly was tender, but nothing that made me think he needed to be rushed to surgery. His lungs were clear, his heart rate was faster now than it had been in triage. His tongue looked like it had spent three weeks in the desert. I sniffed.
    "You don't want to do that, doc. I keep puking. I can't smell too good."
    It wasn't vomit I was smelling, it was something fruity and chemical. Some people compare the smell to an apple. Some people say it smells more like acetone. If this were a healthy 20 year old with food poisoning, it would just mean they hadn't manage to take in any carbohydrates in many hours. With Mr. Durcan's diabetes, I think it means he is in diabetic ketoacidosis, a potentially life threatening condition.
    "Did you check your sugar before you came in today?" I ask him.
    "I tried to, but my machine is broke."
    "Oh no! When did your machine break?"
    Mr. Durcan grimaces, "Just in the last day or two. It always worked great before this but now whenever I check my sugar it just says "Hi!" It's nice that it is being friendly and all, but I don't want a greeting, I want a number. Sometimes I think these smart machines aren't so smart."
    I tell him we'll look into it and go off to ask Mr. Durcan's nurse for a finger stick glucose reading. One should have been done either in triage or when he hit the room but I can't find it on the chart. Ellen, the nurse taking care of him is very sweet but is a recent nursing graduate and I've noticed a couple of things that have gotten dropped. I have to be just a tad more vigilant about her patients. I don't think his machine was giving him an amicable salutation. I'm pretty sure it was saying "HI!" the only way a machine can say "this is too high to read" on a three digit display. It probably says LO! below a certain number as well. That doesn't mean the machine is suddenly saying "Look! See what we have here!" It's saying the blood glucose is too low to read. Most machines top out at 500, if Mr. Durcan's sugar is that high or higher, he'll need an insulin drip and an ICU bed.

    I tell Shawn that I've seen his patients and agree with his plans for dispo. Malina presents another patient, equally sloppily. She thinks this guy has a viral upper respiratory infection. I go to see him. He has a viral upper respiratory infection. I probe and I press to find something that Malina has missed but she's right, this is a mostly healthy 29 year old guy who takes meds for anxiety and depression who is here with a straightforward cold. That's good. I feel comfortable with her seeing healthy patients with cough, cold, and congestion. As long as she doesn't actually see anyone sick, she can't mess up. I tell her I agree with her assessment and I appreciated her coming up with a broad differential. Usually my differential for mild congestion, sore throat, and a fever of 101.5 doesn't include plague, legionnaire's disease, Tularemia, or Q-Fever but I'd rather have her coming up with some differential than none. I have the distinct feeling that Malina spent more time thinking up things to impress me on the differential than she spend seeing the patient but I have no factual basis for that and try to squash the thought.

    Some of the labs are coming back on the two Ms. Browns. Ida E. has a white blood count of 26 with a marked left shift, she has bands and segmented forms in her blood - signs of her body trying desperately to crank out more white blood cells to fight an infection. She's mildly acidotic, which makes me worry that she's in full sepsis. Before I have time to verbalize the thought Shawn says that he's worried about her anion gap and has sent off a lactate level to make sure she isn't in full sepsis. He is a very good doctor. I would be comfortable with him taking care of anyone I know. We don't have a source for the infection yet, I'm guessing it's in her urine because old people tend to get very sick very quickly with urosepsis but we can't rule out something bad in her guts or spinal fluid yet. Her chest Xray shows no free air in her abdomen, which is reassuring but not 100% definitive. I discuss this with Shawn, he says that he's waiting for her urine to come back. If her urine is clean, he'll do a spinal tap, if her tap is clean we'll CT her abdomen. Shawn tells me that Ida E's blood pressure is starting to drop and her heart rate is remaining high. He's told the nurses to start another IV and to start flooding her with fluids in addition to starting two very broad spectrum antibiotics. I like this plan.

    Ida S is more of a mystery. Her blood count is unremarkable, a little anemic but no more than a lot of older women. No signs of infection. Her electrolytes are mostly normal. Her liver enzymes are elevated, why I don't know, but they're only about twice normal - not particularly impressive. Her urine is clean. I check with her nurse. She's still, as Shawn puts it, wacked. Her nurse says she's drowsy but easily arousible, sweet but completely confused, very talkative.
    "What do you think?" I ask Shawn. I yawn, it's time for more caffeine.
    "Well, this could be her baseline, but family brought her in for not acting right. So, we'll assume this is all new." I wish Malina was here to hear him say that, "After I saw her labs I went back, got her up and walked her. Ida S can barely walk, she's got this really wide based gait and she's totally ataxic. That room stank of pee. So she is wet, wobbly, and wacky - I think we have to consider normal pressure hydrocephalus. And I think we still have to consider viral meningitis or encephalitis because sometimes you can have a normal white count and have a positive tap." We both make a face. I hate torturing a sweet old lady, but we don't have a source and we do have an altered patient.
    "I think we have to." I say, reluctantly. Both of those diagnoses make sense. Both require a tap and if it crosses your mind to get an LP, you probably should get one.
    "I think so too. She's on the skinny side, it won't be hard."
    Shawn orders a CT on Ida S and asks the nurse to set up for an LP. We quickly talk through the rest of his open patients. The chest pain will stay be admitted as an unstable angina, a tap of the swollen knee has determined that it is gout and not an infection so the guy is going to go home on standard gout medicines, the kidney stone went home with a strainer and pain medicines, the pregnant woman has what we call an "inevitable abortion." There is still a 6 week embryo in her uterus but there is nothing modern medicine can do to stop her from miscarrying. He grabs another stack of patients to see while I check on Mr. Durcan's labs. I'd really be drowning if Shawn weren't here.

    Mr. Durcan is sick. Sick sick. I stand up and catch the charge nurse's eye.
    "Cooper, can you start trying to find an ICU bed for Durcan? He's your top priority right now."
    "Did you see his finger stick? Ellen did it a little bit ago. It just read high. Is his real glucose done yet?"
    I check the labs, everything is back but that. "No, it looks like they're still diluting it."
    These labs are ugly. It looks like Mr. Durcan has an infection...somewhere. I don't remember his lungs being particularly impressive, it could be in his urine. It could even be a viral gastro-y thing that would make Malina happy. But in addition to and probably because of the infection, Edward Durcan has gone into full DKA. His body has run out of insulin and because of this, even though his blood is full of glucose the cells of his body are not receiving enough fuel to produce energy. All of his body has gone into starvation mode which starts the breakdown of triglycerides into free fatty acids (FFAs) so his body can start gluconeogenisis, another pathway to make energy for the cells. His body has started to metabolize protein and fat to produce a source of energy and the FFAs are metabolized into strong organic acids known as ketones. In normal life, small amounts of ketones are used as energy in the peripheral tissue. Mr. Durcan's body thinks it is starving, though, and doesn't use the circulating ketones. The increase production and decreased use of the ketones leads to his blood and body become steadily more acidotic. due to the starvation state of the cells, the ketones are not used. An increase in ketone production and a decrease in peripheral cell use lead to metabolic acidosis. A normal blood pH is 7.4, his is 7.01. A normal bicarbonate level is in the upper 20s, his is 14. The beta hydroxy butyrate, the test we use to screen for ketones, should be zero; Mr. Durcan's is 87.
    As I stare at the screen in horror, the glucose comes back: 653.
    "Cooper! 653!"
    "Eh, that's not that high."
    "That's just because you've been seeing a lot of HONK. I'd rather he have a sugar of 1200 than the rest of the shit I'm seeing on his labs. Could you please page Malina to the doctors' desk?" I haven't the foggiest idea where she is and this is her patient. She should be at least as scared as I am. HONK is hyperosmolar non-ketotic illness, you see it a lot in non-insulin dependent diabetics. As our patient population gets fatter we see more of it. It is also life threatening, just less quickly so than DKA. And, Cooper's right, I've seen a lot of sugars over 900. But 653 is scary when you're looking at blood this acidotic. I use the back of a prescription pad to figure out his corrected sodium. Because of the way we measure the electrolytes, the huge glucose load gives us incorrect values. In DKA, the potassium will look much higher than it is and the sodium will look much lower. Malina slouches around the corner.
    "Hey, what did you think of Mr. Durcan's labs?"
    "Oh, are they back?"
    I take a deep breath. If I just wanted to manage all the patients myself I wouldn't have gone into academia, but Malina's lack of involvement is getting on my last nerve. "They are; why don't you take a look and see what you think?"
    Malina glances at the computer, sees all the red panic values and takes a better look.
    "I think he's in DKA."
    "He is. This is not someone you can hydrate and send home. But we do have to hydrate him, what do you want to give?" I hand her the chart. She needs to write her own orders or she'll never remember what we ordered and why.
    "Two liters of normal saline." That's a pretty safe answer for most adults who aren't on dialysis and who don't have congestive heart failure.
    "That's a reasonable place to start and then reassess. His fluid deficit is likely much higher so don't be surprised if we end up giving four or more liters down here in the ED. What about his potassium, do you want to do anything about that?" Malina writes on the chart and then looks back at the computer.
    "6.7?! That's really high! We should get an EKG and then start....wait. Potassium is abnormally elevated in DKA, it's going to fall as we give him insulin and shove the extracellular potassium back into the cells." She glares at me through narrowed eyes, "You're trying to trick me!"
    "Not at all, I'm asking you to interpret your patient's lab values. I would still get an EKG so that if there are potassium related changes you can keep an eye on them, but I agree, do not try to lower that. You're going to end up chasing your own tail. We'll probably end up repleting him in a couple of hours anyhow. What about the sodium?"
    Unsurprisingly Malina does not know how to do the sodium correction that tells us that the low sodium we see now will actually normalize as his glucose comes down. I show her how to do it and then point her to a web page that will do it for her if she enters in the right values.
    "So we're going to hydrate and track his ins and outs, and watch his potassium closely. But what drug do we want to give to fix this?"
    "Insulin." Malina does everything but roll her eyes at the inanity of the question.
    "Right. And how much do we want to start with?"
    "One unit per kilo per hour." She says it confidently.
    "Right, and...wait. Say that again."
    "One unit per kilo per hour insulin drip." I can't believe this.
    "One unit per kilo per hour?"
    "Yup! you'd switch the fluid over to something with dextrose when his sugar gets around 300 or less and then...." I interrupt.
    "Malina! It is 0.1 units/kilo/hr. Not one. 0.1. You're off by a factor of ten. 1 unit per kilo per hour would kill somebody. Think of how much insulin that is! We write sliding scale insulin dosing starting at 2 and maxing out at 12. For a normal sized guy, you're talking about 70 units!"
    "I meant point one. I'm just tired." She did not. She meant one. She hadn't a clue that she was giving me a potentially lethal dosing.
    "Even in the middle of the night, you have to have dosing right. Even when you've been up for two days, you have to have dosing right. I'm sorry you're tired but that kind of mistake could kill someone." I notice that she has another chart in her lap, "Is that a new patient?"
    "Yeah, I'm not ready to present them yet, I'm still getting the history and physical."
    "May I see it?" She hands it over as she continues to write the orders we've discussed on Durcan's chart. Alicia Rose Bradley is a 6 week baby girl brought in for congestion. Her vital signs are normal. This is a good patient for Malina. I hand it back, "Tell me about her when you're ready. I want Durcan to go up to an ICU ASAP so start making some phone calls once those orders are in. You're going to need to talk to his doc, the covering ICU attending, and the ICU resident on call. We also need to check a repeat set of electrolytes every 2 hours and a repeat glucose every hour while he's down here."
    "I know!" Dealing with Malina is like dealing with a hostile adolescent. I've met hostile adolescents I've liked more. At this point I think there are probably many hostile adolescents who could do a better job of pretending to be a doctor. The fact that she has an MD after name scares the crap out of me.

    Shawn is charting, pretending not to hear our conversation, waiting to talk to me. He gives me the update. Eeeeevil Ida has a huge urinary tract infection and an elevated lactate. She is truly septic and will be going to an ICU step down bed. Shawn tells me that he's also talked to the ICU resident because while she doesn't currently meet full ICU criteria he thinks she might crash and burn later on tonight or some time later this morning and wants everyone to be aware she exists.
    "I love that plan. Any idea how long until we get a bed for her? She gives me the creeps."
    "All the telemetry beds are full, if she gets more stable I'll switch her to a general, if she gets sicker I'll switch her to a unit. Until that happens, we've got her for a while."
    "What about Ida S?"
    "Smiling Ida continues to be a mystery. Her CT shows normal age related change, nothing scary. She was sweet about the tap, but it was harder than I thought it might be because she even has some trunkal ataxia. She just sways, I was feeling seasick trying to keep up with her! I thought my NPH idea was brilliant but her tap had a normal opening pressure, no signs of NPH. The lab results weren't back the last time I checked, but if they're negative, I'm running out of ideas."
    I check the labs. The CSF is back. It's negative. It's actually what is known as a "champagne tap" - no red cells, no white cells, nothing but spinal fluid.
    "Nice job. Now what?"
    "I don't know."
    Shawn and I sit in companionable baffled silence trying to figure out what makes smiling Ida so goofy.
    "Let's go look at her again," I suggest. Ida E is sedate now, out of her restraints. Her blood pressures is still low on the monitor and I suggest upping her fluids and perhaps starting a central line. Shawn agrees. Ida E now looks just like a very sick old woman. You'd never know how monstrous she was. We peer into room 14. Ida S. is singing to herself and occasionally laughing. She is smiling and charming even though there is no longer anyone there to appreciated it. She's taken her teeth out and her singing is both atonal and nearly completely without consonants. She does indeed sway side to side as she sits in bed. I don't get it. I'm missing something huge. I think of the things we've ruled out so far and other things that might cause this bizarre constellation of behaviors.
    The other shoe finally drops. I turn to Shawn,
    "I'm going to send one more blood test. I think I know what's wrong."
    "Well that makes one of us." He grimaces. "I feel so dumb! Gah! I can't believe I have one year left and then I have to be an attending. What would I do if my grandma started acting like this? 'Well, Ma, I know you sent me to four years of college and four years of medical school and four years of residency, but I haven't a clue what's wrong with her. Sorry!' That's going to go over well!"
    I grin and write the lab order I want on her chart, "Shawn, I could be wrong. I don't know your grandmother. But I don't think this is going to happen to her. We'll get that lab test back and you tell me if I'm right." I suddenly realize that Malina is standing at my elbow, waiting for me to notice her. I don't know how long she's been there. "Yes, Malina?" For the first time this evening she doesn't look sullen, she looks...worried. And that worries me.
    "Uh, the baby? The one you sent me to see? The one in room 19?"
    "Yes?"
    "Uh. She's not breathing."

FUCK!

    I run, Shawn runs, Malina trails behind us, if she's talking I'm not paying attention. I yell for nurses and a crash cart. The distance between room 14 and room 19 seems impossibly long. In room 19 there are two young parents, looking down at an unmoving lump on the bed. I knock dad out of the way as I get to the bed. Alicia Rose is still and blue and ... dead. She has no heart beat and no respirations. There is nothing set up in the room. No monitor, no infant face mask, nothing. I think the parents are talking to me but I don't hear them. I grab Alicia Rose and do something I've never done before in 10 years of medicine: true mouth to mouth. I've run hundreds of codes, I've intubated, used bag valve masks, done chest compressions, but I've never physically breathed into a patient's mouth. It is terrifyingly intimate to have our lives connected this way. She is still warm and smells like a baby although she is floppy and unresponsive in my arms. Breathe in through my nose, breathe out into her. My hands work instinctively, I've done plenty of chest compressions on plenty of infants, that's not the hard part here. Breathe in through my nose, breathe out into her. It only takes the volume of air in my mouth to fill her entire lungs. I've never before understood before how tiny infants are, how fragile. Breathe in through my nose, breathe out into her. Alicia suddenly twists in my arms and makes a squawking noise and then a good solid bellow, with her next inhale she goes from blue to pink and bellows again.
    My world, which had narrowed down to just Alicia Rose suddenly refills with noise, the room is packed. The parents are crying in one corner, Malina is standing in the opposite corner looking blank, the rest of the room is filled with nurses, techs, a crash cart, the respiratory therapist, everyone I could possibly want. Cooper is on his pocket phone demanding a bed in the pediatric ICU. Two nurses take the baby from me and hook her up to the monitor, another swiftly and competently inserts an IV and starts to draw blood. I try to talk and make a sound that isn't a word but might be a sob. I take a breath and try again,
    "Shawn, I'm going to want a cbc, chem 7, ekg, chest xray, cath urine for culture, and we're going to need a spinal tap on this one, too. Start some broad spectrum antibiotics and I'll take care of the PICU." Our social worker has shown up, Cooper must have called her, and is talking to the parents. I'll let her do her thing, I'm too shaken up to talk to anyone right now. I keep thinking about the feel of the lifeless baby in my arms and her mouth under my mouth. We'll see how she turns out, I don't know how long she was down without oxygen or a heart beat, but the fact that Alicia Rose is now screaming at the top of her lungs and trying to wiggle out of the monitor leads is a good sign. Babies are resilient. I don't know why this one was dead for a while. Could be a breathing problem, could be a heart problem, could be that we just saw SIDS in action. That's not something I'm going to be able to figure out in the ED but I can make sure it isn't an infectious process or a huge heart problem and get her upstairs to the people who can figure it out. I call the PICU, the primary care doctor, the covering resident for the PICU.
    "Hey!" It's Malina, sullen again, in my face, "Why did you just give the procedure on my patient to Shawn? That was my LP to do!" I do not brain her with the phone in my hand. She should count herself lucky.
    "Malina, what does ABC stand for?" She looks confused and mistrustful. This is probably another trick I'm pulling on her,
    "Airway, breathing, circulation."
    "Yes. Exactly. It is not attending, breathing, circulation. You're a doctor. If there is someone not breathing you make them breathe, you keep them alive. And if you are the only one there, you shout for help and get other people to help you. That's not emergency medicine, that's what you should have learned in a CPR class somewhere. You never, never leave someone who isn't breathing to get help."
    "The parents were right there, I didn't want to scare them!"
    "I think, given the fact that the baby was blue and not breathing, they were already pretty scared. And, if they weren't, it was a great time for someone to be scared and the first someone should have been you!" I realize my voice had been steadily rising during this tirade. I think it is poor form to yell at the residents in public. It doesn't help them learn and it scares the patients who can hear the yelling. I lower my voice, "Go check on Mr. Durcan, see how he's doing, make sure all those phone calls are made. I'll see you back at the doctors' station."

    I walk out the doors of the ED and sit on the curb, taking deep breaths of the early morning air. In an hour or so the sun would rise. In an hour or so my shift would be over and I would get to go home and not sleep; how much brain damage did Alicia Rose sustain? I think about the tiny volume of air it took to fill her lungs and the way she smelled and I shudder.
    "Hey, are you a nurse? I'm worried about my auntie" A young man was trying to get my attention.
    "No, actually, I'm one of the doctors. The nurses are inside."
    "Hey, that's cool. My auntie is real sick, I came as quickly as I could."
    "I'm sure she'll appreciate it, that was nice of you." Talking to someone else makes me feel more normal. I'm slipping back into my doctor-persona and it is an enormous relief.
    "Nothing I could do would be too nice. She's old but she's awesome. She's in charge of breakfast every day the food kitchen down on Van Buren. She's in her 80s and she still cooks breakfast for 20, 30, sometimes 40 people every morning. She's just the nicest lady you can imagine. She half raised my mom. I can't think of any time in my life she hasn't been there. I can't believe she's sick. I've never even seen her in a bad mood."
    "Who is your auntie?"
    "Ms. Ida Brown. Is she going to be okay?" I debate telling him what I think is wrong with his aunt, I decide that until the lab test confirms my suspicion there is no reason to burden him with it.
    "Yeah, we're waiting for one more test to come back, but I'm pretty sure she'll be better soon."
    "Oh, that is so good to hear. When I told my mom she started a telephone prayer line going for her at the church. My mom said "The good Lord won't take Ida, she's too nice. She's helped too many people. He needs her to continue His work on earth."
    "She's obviously really important to you. That's great. We were frustrated last night when we couldn't reach anybody." He looks confused,
    "Well, how would you know who to call?"
    "We didn't! The telephone number in the chart seemed to be disconnected and we had no other leads."
    "The paramedics gave you a telephone number? Was it to their boss or something?" I stare at him in growing dismay, "I just found out came home from work, I work swing shift, see? I came home and Ms. Lucy up the block said that auntie was acting crazy and had been taken to the hospital by paramedics."
    Crap. Best just to be honest.
    "We actually have two patients with similar names. What's your auntie's middle name?" He looks at me like I'm crazy.
    "Middle name? I have no clue. I didn't even know she had a middle name. So you were telling me about the wrong patient? What about my auntie?"
    "Does your auntie have any identifying marks on her?"
    "Oh you mean her big scars? She's got a huge one on her arm and then another one on her belly. Is that what you are talking about?"
    "Yeah...." I am about to tell him about Ida E's urosepsis but he keeps talking right over me.
    "She's real proud of those scars. She got between a little kid and a police dog in 1964 in Birmingham. She says they're her badge of courage. 'I wasn't brave enough to sit at the counter, I wasn't even brave enough to go on the marches, but when push came to shove and someone was going to be hurt I discovered that I was brave enough to do what I had to do.' That's what she told me when I was a little kid. My auntie is something special. Is she going to be okay?"
    Eeeeeeeevil Ida.
    "You're aunt is really sick. She had an infection in her urine and it spread to her blood. We've got her on a bunch of medicines and we're going to admit her to a monitored bed so we can keep a close eye on her overnight. She'll probably be fine, but she's older and she's really sick so we're worried about her." The young man gives me a hand up off the curb.
    "Don't worry, doctor. She'll be just fine. Ms. Ida is way too nice for the Good Lord to let her die."
    I'm a miserable pigfucker and can't deny it.

    Cooper meets me at the door with an expression like thunder on his face.
    "We've got trouble,"
    "What kind of trouble?"
    "The "please hope to god that no one calls the papers and that you and I survive to work in another ED somewhere far, far away" kind of trouble. I'm so sorry," I've never seen Cooper loose his cool before, I'm not liking it now, "I told you this wouldn't happen and it did."
    "Cooper, don't worry about it. There is no way you could have predicted that baby's apnea. She had totally normal vital signs when she hit the door. Ideally the code would have been started sooner, but at this point we just have to hope for a good outcome." Cooper looks like he might be sick,
    "No. Not the baby. Mr. Durcan."
    I stop walking and look at him. There is a beat of silence. Unbelievably, my night just got worse.
    "What about Mr. Durcan?"
    "Ellen's a recent graduate and didn't know that she should go to you with questions about orders. I should have had her under supervision for another week or so, I guess."
    "Cooper, just tell me what the fuck happened to Mr. Durcan." The story came out.
    Mr. Durcan weighs about 200 pounds, Malina estimated that to be about 90 kilos, a reasonable estimation. She had then written for 1unit/kg/hr of insulin. Not 0.1. One. Whole. Unit. Ellen had questioned the order. "I've never given 90 units of insulin an hour before. Are you sure that's right?" Malina not only pulled some "I'm the doctor, you're the nurse, you do what I say" shit but also told Ellen that the two of us had discussed the orders and that this was specifically what I wanted. So Ellen ordered a 90unit/hr insulin drip from pharmacy who, in yet another systems error, had sent it up with out any question. Ellen hooked up the drip and Mr. Durcan had gotten some 140 units of insulin before his sugar was checked.
    Crap.

    Shawn is still seeing patients like a madman, the only saving grace of this night. Given how little I've actually managed to accomplish, the department would be a complete logjam except for his actions. Alicia Rose has gone upstairs to the PICU. Ms Ida E. Brown has continued to get worse and is now on a medicine to keep her blood pressure up. Shawn has changed her bed to a full ICU bed. If she continues to deteriorate we'll have to intubate her. He still calls her Evil Ida, I don't have the energy to correct him. Ms Ida S. Brown is getting more sleepy, that doesn't surprise me. He wants to know if we should consider intubation, I tell him to keep an eye on her but I thought she'd be fine. I explain what has happened to Mr. Durcan and tell Shawn to keep seeing patients while I do damage control. I start fluids that have sugar in them on him. I put in a 2nd IV line so we can draw frequent blood checks. I have a long talk with Mr. Durcan. When things go wrong I think it is crucial for patients to know it. Secrecy doesn't help anyone. I tell him that we gave him much too much of the right medication and now the sugar level in his blood is falling too quickly. It's hard to explain why I wanted his sugar lowered slowly and not quickly; osmotic forces are a hard thing to explain at any time of the day, let alone at 5 in the morning to someone who doesn't have a high school education. I talk about the salts and sugars in his blood falling too quickly, about cells swelling, about the risk of parts of his brain being affected. He pats my hand and tells me I worry too much, that he feels fine, that he knows I'm taking good care of him. Why do people have so much faith in us? I file an incident report. I call Risk Management and have a long and painful conversation with them. I call the patient advocate and fill her in on the situation. I dictate a long addendum to his written ED chart. I call the ICU attending and update him on the situation and sit patiently and quietly while he chews me out and tells me how terrible the ED is and suggests that we should shoot our patients at the front door since it would be quicker and more humane than the care we provide. I check back on Mr. Durcan, he is unchanged.

    Then I go and do what I have been putting off: find Malina. I make sure we're in as private a place as possible when we walk, I don't think I can keep from raising my voice. I manage to corner her in the X-ray reading room.
    "Sorry," she says, looking sullen.
    "Malina, I told you what dose to write and you still wrote the wrong dose. You ordered a potentially lethal dose of medicine on a patient. You overrode the safety check in place when you didn't take the nurses query seriously. 'Sorry' isn't sufficient here. Seppuku might not be sufficient. You don't seem to be aware of the severity of this error."
    "Well, yeah. It was bad. And I'm sorry. And it won't happen again, but I just checked in on him like fifteen minutes ago and he was fine."
    "Brain damage and organ failure from osmotic shifts can take up to 72 hours to manifest. I don't really care what he looks like right now. I'm worried about what he's going to look like when he leaves the hospital."
    "Oh. Well, I'll call the ICU at the start of my shift tomorrow and find out how he is." Like this is some kind of favor to me, like this is going above and beyond anything that could reasonably be expected of her. I've had enough.
    "No. You won't. Because you're not coming in tomorrow. And you're going home right now. I won't have you in my ED. You endanger patient safety and I want you out of here." Malina is so shocked that she forgets to look sullen and resentful. She now looks surprised and resentful.
    "But I've got 45 minutes left in the shift!"
    "I don't care how long you have, you're going home. Now. And you're not coming back tomorrow. Two patients almost died tonight because of your actions, either or both of them might still have horrible long term sequelae. I can not accept that kind of risk while I'm in charge of this ED. I'll call your program director this morning and tell her exactly why I don't feel safe having you in my ED."
    "I know why you're doing this!" Malina is crying and shrill,
    "I hope so. I'm doing this because you put patients' lives at risk and are unsafe to be practicing medicine."
    "Whatever! That's bullshit and you know it." She is screeching at the top of her lungs, I'm pretty sure the entire ED can hear her through the door, "You hate the thought that there could be another female doctor practicing on your turf. You think I'm a potential threat to you and you're determined to keep me in my place." I have a hard time not laughing
    "Malina, we've already determined you're a threat. But not to me. Now leave." I walk back into the bright light of the ED and don't look behind me.

    A quick splash of water on my face and another cold diet coke and I feel almost human again. Not having Malina in the department is like having an enormous weight lifted off my back. Shawn is waiting for me at the doctors' desk. I sign a bunch of his charts and check on the few patients he has left. I tell him that he is the only reason there isn't rioting in the waiting room right now.
    "The nurses say you just fired Malina."
    "I don't have the power to fire her. I did throw her out of the ED and tell her not to come back."
    "Holy crap! That's amazing."
    "No, it's depressing. If you want to see something amazing, check out smiling Ida's lab value." Shawn checks and his jaw literally drops. It is very satisfying.
    "260!"
    "Yup!"
    "Many, many hours after she hit the door!"
    "Yup! So, was I wrong? Is your grandma going to come down with the same thing?"
    "Gram? Hell no! Not in a million years. But how did you know?"
    "I took a step back and went through the causes of altered mental status in my head. We had ruled out sepsis, which was my first thought, and NPH and encephalitis, which were also excellent thoughts. I wanted the two Ida's to be similar, since they certainly had similar presentations and we got snowed because of that. When I took the patient out of the picture and just looked at the symptoms it became more clear. We have a confused, hyperverbose, inappropriate patient who is incontinent of urine with a wide based gait and trunkal ataxia. We have a woman whose liver enzymes are elevated for unclear reasons. We have someone whose family dropped her off with a positive taillight sign - they're obviously not real worried."
    "Oh god. I'm so stupid."
    "No! No, you're not, at all. I was totally going down the wrong path myself. If she had presented at a different time than the other Ida maybe we would have seen it earlier but I think it's just hard when you're dealing with a sweet little old lady."
    "But when you put it all together it is so obvious."
    "Only in hindsight. Really, you're fine Shawn. I love working with you. Stop beating yourself up."
    "But we see it all the freaking time! How could I have missed the fact that she was drunk?!"

    The day attending picks that moment to walk in.
    "If the most interesting patient you have to talk about is some drunk, you must have had a pretty quiet night." He pauses. Looks around. "Weren't you supposed to have another resident on with you?"

    I call Malina's residency director when I get home. I tell her that I don't care whether the program fails her out or not but she is never allowed back in my ED when I am working. The residency director tells me to calm down. The conversation goes downhill from there. I then call the PICU. Alicia Rose looks great, has breastfed several times since I last saw her, nobody yet has an idea why she lost her breathing and heart rate. So far she seems neurologically intact, she'll have several more days in the hospital, dozens of more tests scheduled, and we may not know the end result for years. But for right now she seems to be okay. And for right now, that has to be good enough for me.

It takes me a long, long time to fall asleep.

Thanks to Dr. Memory who told me how to improve my formatting and to all the lovely people who wrote comforting/encouraging things after my last cranky post. I'm still sleep deprived, so if you see any huge typos/editing errors let me know and I'll fix them.

Appearances can be deceiving (I)

Thu, 21 Aug 2008 16:58:20 GMT

Remember: all patients and staff are compilations. Behind a cut as usual for length and grossness. Broken into two parts because LJ doesn't like the length of my posts

    Tonight's going to be good. I can just feel it. I am caught up on sleep, I am properly caffeinated, I've even managed to get some laundry done and see the sun today. I've gotten a prime space in the parking lot, Cooper is my charge nurse and he is awesome, and the first person I see when I get to the doctor's station is Shawn - a senior resident who is excellent. I'm actually trying to recruit him to work at Hospital X when he graduates. It's going to be a good night.
    "Hey!" Shawn says, we work well together and he is as happy to see me as I am to see him, "The outgoing attending is caught up in a trauma that won't live and won't die. He's been in their for an hour, can I staff a bunch of nothingburgers with you and get the department moving?"
    You can see why I like him.
    I crack open an fresh diet coke and listen to his stories. A couple of cocaine chest pains - they'll be straightforward four hour rule-outs and home; a woman who came in with belly pain but probably just wanted a pregnancy test and an ultrasound since the pain magically went away following these interventions, that's fine, I'm glad she'll be getting prenatal care from here on out; a big time smoker here with another COPD exacerbation; a chronic alcoholic here to go to the sobering house - the same way he did 2 days ago and 2 days before that and 2 days before that, it's a 36 hour stay and considerably nicer than the shelter. Shawn says the sobering house laughed when he called. They suggested just having a cab on call to the ED every two days until the weather cools off and the guy can go back to sleeping on the street. Shawn and I agree that it would save a lot of time and phone calls. I go off to see the patients, they're as billed. All straightforward, none particularly exciting. One of the cocaine chest pains has enough risk factors and enough of a cardiac history that I suggest we might keep her overnight to see a cardiologist in the morning. She's not excited by that plan, I ask her to think about it. I'm not going to push her on this one, the thing that would help her heart the most is if she stopped smoking crack and she isn't ready to do that yet. Until she makes that change there isn't a whole lot that a cardiologist can help her with.
    "Why does this keep happening to me, doc?" Mr. Edin, the COPD patient asks plaintively around his albuterol nebulizer, "I've cut way down on my smoking." I check his chart. He has cut down an impressive amount, he's decreased his daily cigarette intake by 1/3. Which is great, except in his case it means that he's gone from 3 packs a day to 2 packs a day, which would still be two packs a day more than his lungs can take.
    "Well, Mr. Edin, you've been smoking for about 50 years. Most of that time you smoked three to four packs a day. Let's call it three packs. That gives you an 150 pack-year history of smoking. You're doing the right thing by cutting down, but your lungs have already sustained a lot of damage. That doesn't disappear overnight."
    My general feeling is that the guy is 72 years old, he's already on home oxygen, and besides the risk of blowing himself up from smoking on oxygen there isn't a lot of point in him quitting. Even if he stopped smoking tomorrow, he'll die of his pre-existing lung disease or his vascular disease (also secondary to his smoking history) long before his lungs remodel and he actually gets any of the benefits of quitting. Other than that whole not blowing himself up. Someday I'll have enough courage to a patient that; as it is, I applaud his efforts to quit and tell him to keep it up, that I know it's hard.
    I know Mr. Agresti, the alcoholic, well. He knows me. We chat about his bum back and his ungrateful children, he tells me that this time he is serious, he really wants to quit. He told me that last week, too. I hope of that one of these times he means it and I hope that when he actually does means it someone takes him seriously.

    When I get back to the desk the trauma has gone up to the surgical ICU and the other attending is ready to sign out. Shawn has been busy dispositioning people and there isn't much left from the previous shift. I tell him to go home. I tell Shawn that all the people he told about look fine, he tells me about an upper respiratory infection and a nasty STD.
    "Is it just you and me tonight? Let's crank through patients and if it gets a little slower in the middle of the night I can go through some oral boards questions with you." The oral boards don't test medical knowledge so much as how well you can take the oral boards. It is a totally artificial scenario, practice is key. Shawn looks uncomfortable.
    "It's sort of just you and me."
    "Sort of? How does that work?"
    "Well, it's you, me, and Malina."
    "What?!" I thought Malina was gone. As far as I knew, she had failed every rotation last year. Maybe my night wasn't going to be so great.
    "Yeah, it's going to be a long night." The other residents were sick of picking up her slack.
    "I'm confused, why is she still here? The rumor had it that she was out of the program."
    "Yeah, well," Shawn picked up the next two charts in the rack, "She was supposed to be out but then she started claiming discrimination. Based on what I don't know, ankle size, hair length, something, and the administration said she could have one more chance. She's repeating the year, she didn't advance and she's officially on probation. But now that she's on probation, nobody wants to fail her because then it will be their fault that she's out. It sucks. Some of the attendings just need to grow some balls." He suddenly remembers that he is talking to an attending and that I am remarkably unlikely to grow balls. "Um, ah, what I meant was..."
    "Or ovaries. Or something. I get it. Don't let her slow you down tonight, you keep cranking on patients. If the nurses come to you with problems about her patients, send them to me, it isn't your problem. It's my job to make sure she doesn't kill anybody."
    Shawn noted agreement and took off with the two charts, still obviously mortified about his previous comment. I wasn't hurt or offended by it and I didn't disagree.

I go to see the next patient, a 23 year old woman with the chief complaint "DFO." In medical school they teach you that the chief complaint is literally what the patient is complaining of in his or her own words. "I feel like an elephant is sitting on my chest," "I feel woozy," "I passed out." In the real world the chief complaint is how the triage nurse interprets the patient's complaint. "Chest pain," "Dizziness," or in this case "Done Fell Out." I'm not sure whether it is a idiom that is specific to city X, but the first time I heard a patient use it I asked "Fell out of what?" and the whole room erupted into laughter. "I done fell out" means that the patient fainted or passed out or had a seizure and is such a common expression that it is charted as "DFO." The other chief complaint that I hadn't encountered before I started working at Hospital X was "WADAO." That's "weak and dizzy all over" and is a catch all for "I just don't feel good but can't explain how."
    The 23 year old DFO was a thin, tired appearing woman still looking a little woozy. No previous history was listed on the chart. I introduce myself and shake her hand, noting the dark circles under her eyes; she looks like she is at the end of her rope. She is mildly tachycardic, and mildly orthostatic but otherwise has a normal exam. Her finger-stick glucose in triage was 47 which is low enough to make her pass out. Given all of that I write for her to receive two liters of fluid with some sugar in it and sit down to chat. I probe for anything unusual. She's not diabetic, she's not pregnant, she has no history of seizures, there is no history of sudden death at a young age in her family, she denies using drugs or alcohol. She does have two children of her own and is raising a four year old niece since her sister is in jail and the kid's father isn't in the picture. Three kids under six would make anyone exhausted but most moms don't pass out. I ask her if she has any idea why she fell out. She thinks for a while, avoiding my eyes. I can't figure out whether she is deciding if she can confide in me or if she is coming up with some lie she thinks will be plausible. I wait.
    "Can you pass out from not eating?" she finally asks.
    "You can. Why aren't you eating?" There is another long pause.
    "I'm not asking for charity!" Ah. Not anorexia.
    "I didn't think you were." Another pause.
    "Well, it's the 28th."
    "It just turned into the 29th. Go on."
    "Well, I work at..." she names a clothing store in the mall in the failing suburbs of City X, "they pay good, you know. I don't need welfare. And they say another 18 months and I'll make assistant manager and then I'll make even more. But I got three kids, y'know. And I've got my truck which still has payments and that's due on the 15th. I get paid on the 31st. Rent is due on the 1st. The store is 20 miles away, sometimes late in the month it gets hard. If I don't go to work I don't get paid, so if it comes down to gas or food..." there is another pause.
    "That's just food for me, you know. The kids always eat. I'll hook before they go hungry. I got powdered milk and enough cereal for 9 more bowls; the little one doesn't eat a lot for breakfast so some of the bowls can be sort of small. I've got peanut butter and two loaves of bread at home. That's 36 pieces of bread. Two loaves, 36 pieces. Each sandwich has two pieces. I've got enough until the 31st. I haven't run out yet. I'm careful. They're not going to go hungry."
    "What about you?" I ask, gently.
    "It's the 29th. I get paid on the 31st. I'll be okay."
    "You weren't okay today. If you passed out when you were driving, your kids could lose their mom."
    "This doesn't happen when I'm driving. This only ever happens when I stand for a long time or when I go from sitting to standing. I told Maria not to bring me but she wouldn't listen. I bet she thought I was going to sue the store or something."
    "So this has happened before?"
    "Sometimes at the end of the month, things get hard. I told you. It all depends on gas prices, you know? Last year wasn't much of a problem. Eighteen months I'll probably get a raise. This is just a temporary thing. Gas can't keep going up forever, right?"
    This isn't the first time I've heard this story and it won't be the last. I'm hearing it more often these days. Unlike my patient, I think gas prices will continue to rise. This winter is going to be ugly. People are going to have to choose between food, rent, heat, and gas. There is no public transportation in City X and last year, when oil prices were lower, the state fund to pay for heating for low income people ran out before Christmas. I am dreading the first cold snap.
    I suggest food stamps. She is irate.
    "I don't need charity! I work hard, I've always had a job. I'm not a 'welfare mom,'" she spits the words out, "I'm not a bum. People always say "go to a food pantry, go get food stamps." That's bullshit, you know? I work at a fucking full time job. I have my neighbor watch my kids so I can work and be a role model and shit. I don't want my kids to think it's okay to sit at home and watch TV and have the government give you something for nothing. I don't want a hand out. We're going to be fine. I'm going to be fine. It's just gas prices right now, you know?"
    I know.
    I tell her we're going to hydrate her, re-check her sugar, make sure she isn't orthostatic, give her a sandwich and get her on her way. She tells me she doesn't want charity. I tell her the sandwich is standard for anyone who comes in with low blood sugar. That's true. I write for the nurse to put two sandwiches on her tray, that's not standard but if one happens to go home in her pocket it wouldn't be a bad thing. Is it charity if I'm trying to prevent a return visit to the ED for the same problem? I tell her to talk with billing and they'll arrange a payment plan to cover the cost of the visit. Our billing department is so happy to get anything at all that they're very flexible. If you can do 5 or 10 dollars a week they're usually okay with it. Unfortunately for my patient, an extra $5 a week isn't affordable and we both know that. I close the door before she starts to cry.
    My diet coke is quickly going warm and flat but I take a long swallow and think about how lucky I am.

    Shawn comes up, I still haven't seen Malina.
    "You're going to hate this. I've got room 14 and 15. Room 14 is an 85 year old African American woman brought in by family for "not acting right." Family has left. We've got no history, no meds, no nothing. The phone number they left doesn't work. She can't tell me anything, she's totally wacked."
    "Okay, so?"
    "Room 15 is an 85 year old African American woman brought in by EMS for "not acting right." EMS has gone. We've got no history, no meds, no contact number. And, you've guessed it, she's totally wacked."
    "You're right. I hate it."
    "No, wait. It gets better. Room 14 is Ida Brown. Room 15 is Ida Brown."
    "You're shitting me. Cooper!" I holler for the charge nurse, this is ridiculous.
    "Nope, room 14 is Ida S. Brown; room 15 is Ida E. Brown."
    "That's a nightmare. I'm never going to keep them straight. Nobody is going to keep them straight. Cooper!" Cooper materializes, looking frazzled.
    "Room 14, Ida Brown; Room 15, Ida Brown? Are you trying to kill me?"
    "We needed monitored rooms, they were the last two left. You're pretty safe on the nursing side, they're in two different cores." I've never quite gotten the nursing cores, they are groups of rooms that are tended by the same team of nurses. The back, non monitored rooms tend to get less acute patients, the front rooms get more acute patients, the trauma bays get dying patients. The nurses get cores that contain some of each (except for the less experienced nurses who mainly manage the back hallway until they've been there for a while). I can never keep track of which rooms are in which cores. Having room 14 and 15 be in different cores will definitely cut down on the name confusing but it will still be a problem for the clerks, the lab, xray, and -worst of all- me and Shawn.
    "Could you please put big "NAME ALERT" stickers all over their charts? 14 is E, 15 is S."
    "No!" Shawn jumps in, "14 is S, 15 is E."
    Crap, I'm totally hosed.
    "I'll just look it up myself. We'll take care of this, you take care of everything else, don't stress. You guys are doing fine. We're only 6 down in the waiting room and 2 of them are prompt care patients. We're tight on monitored beds upstairs but plenty of ICUs and generals."
"Great. I'll make sure that I only admit sick and not sick people, no one in the middle." I give him a grin.
"Your intern, though, she's a little scary." Cooper has seen a lot of residents come and go. For him to think someone is scary, they have to be really, really scary.
"Yeah. She's not an intern and we're very aware. Don't let her kill anyone."
"Don't worry," Cooper says, "The nurses have your back. We won't let her hurt anybody." Cooper disappears. He's a great charge nurse. He never loses his cool and the department runs smoothly when he is here.
    "Help me out, Shawn, how am I going to tell these two babes apart?"
    "It's pretty easy once you meet them. Ida S is smilely. She's wacked but nice. She kept patting my hand and telling me she felt terrible for not being able to remember her medicines or her history. Ida E is evil. She wouldn't answer any questions, it was just one constant stream of abuse. She knows some cuss words that I didn't know. S is for sssssssmilely. E is for eeeeeevil. 14 S, 15E. They're easy to keep straight once you've met them."

    E for evil, s for smiley. I think I can handle that. I see Malina out of the corner of my eye,
    "Malina! did you have anyone you need to present?" Given that I've been here for close to two hours and I haven't seen her see a single patient this seems a reasonable question. Shawn suddenly makes himself scarce. Malina gives me the evil eye and flounces into a chair.
    "Yeah, I've got Edward Durcan in room 2, some minor history nothing really pertinent to this illness. Yesterday he started vomiting, today he's still vomiting, having a hard time keeping down liquids, and feels a too weak and dizzy to walk so he came here. He's got straightforward gastro. My plan is hydrate and home."
    That seems like a reasonable plan. Except that I trust Cooper much more than I trust Malina and he wouldn't have put a straightforward gastro into room 2. I lean over and take the chart from her.
    I'm not quite sure what past medical history Malina would consider pertinent to this illness, but Edward Durcan turns out to be a 78 year old ex-alcoholic on a list of medicines as long as my arm with a previous medical history that includes pancreatitis, multiple prior abdominal surgeries, several MIs, poorly controlled high blood pressure, diabetes requiring oral and IV medications, and mildly impared renal function, He's also tachycardic and mildly hypotensive, could be dehydration could be something more serious.
    "That's a start. Can you expand your differential diagnosis for me?"
    "Well, he could have viral gastro or, I guess, some bacterial endotoxin. If he had been on antibiotics recently he might have c. diff, but that is usually more diarrhea and less vomiting."
    "I have a hard time calling anything gastro that doesn't include some diarrhea. Gastro is usually shorthand for gastroenteritis and I'm failing to see a enteritic component here. So lets take that diagnosis entirely off the table. What else could this be?"
    There is a pause. I'm not sure if Malina is thinking or just wishing she were somewhere else.
    "Food poisoning?"
    There are now three more charts in the rack; it is too late at night and too crowded in here for me to want to spend hours on the Socratic method with a resident with a bad attitude and a worse track record.
    "You can do better than that. You have to do better than that. It is our job to think of things that could be life threatening. A lot of things can be life threatening to a 78 year old with this kind of history. This could be aspirin toxicity, a heart attack, a diabetic crisis, a cerebellar stroke, a small bowel obstruction, urosepsis, gut ischemia, gastroparesis, pancreatitis or a new presentation of cancer. Old people sometimes present weirdly, this could be a perforated viscous or an aneurysm. Your differential has to include the most deadly things and the most likely things. Old people keep us humble, they can be really sick and not look it, they can look really sick but their body hasn't read the same textbooks we learn from and they don't present straightforwardly. It's our job to assume they are sick and their job to prove they're well. We shouldn't assume that someone is well until he or she proves to be sick."
    "Okay." says Malina, unenthusiastically.
    She sits there. I sit there. I want to shake her. I think that is probably against some rule somewhere. We sit. Another chart goes into the rack.
    "So, what do you want to do now?"
    "I'd check back to see if my hydration made him feel better. If it did, I think he can probably go home and follow up with his primary care doctor."
ARGH! Did she not listen to anything I said? I try not to raise my or act as impatient as I feel.
    "Malina, I just told you that it is our job to think of the worst possible things this could be and make sure that none of those things exist before we decide the patient is well. Do you think your plan does that?"
    "I guess not."
    "So what do you want to do?"
    Malina finally decides to start some labs, check an EKG, and an abdominal film for free air or obstruction. I remind her to check an aspirin level, she adds it on sullenly. I remind her to get a urinanalysis and urine culture. She grinds her teeth and checks the box. I'm a little unclear why she is fighting so hard to stay in a program where she so obviously hates what she does. Maybe it is just Hospital X or just overnight shifts. Maybe she is Ms. Mary Sunshine in the other hospitals she rotates through and is a truly lovely person at 4 in the afternoon. Maybe. If all the other attendings see what I see and aren't failing her, they really do need to grow some balls. Or ovaries. Or whatever. By not failing her they are putting patients in jeopardy and compromising department flow. I failed her the last time we worked together, I would have no qualms whatsoever about failing her this time as well.

Continued in the next post...

stop the presses!

Tue, 05 Aug 2008 17:47:51 GMT

Hubbell FA et al, Functional status and financial barriers to medical care among the poor. Southern Medical Journal. May 1990, 83(5), 548-550

In the results and conclusion section:

"...patients who experienced financial barriers tended to be poorer."

Thanks for clearing that up, Dr. Hubbell. I was under the misguided notion that people with financial barriers were rich.

obviously a bored housewife

Mon, 30 Jun 2008 21:13:52 GMT

It's been brutal at Hospital X. The nurses are short staffed and this is hitting the overnight shift particularly hard. We've got float and agency nurses who are perfectly nice people, but the ED at 3am is a bizarre place and the world's best nurse in the family practice clinic can be frustrated to tears -or screams- in the ED. We're so short staffed that the ED has become a complete log jam. There are open beds upstairs but we can't spare a single nurse or tech to move patients with ready beds from the ED to the floor because otherwise the unstable patients in the ED will die. This is definitely suboptimal but I've been too tired to do much more than keep my head down and see more patients.

I'm in a ghastly stretch of five overnight shifts followed by a DOMA (I get out of the hospital for my day off at 8am following an overnight shift and am due back at 6am the following morning for day shift; doma = "Day Off, My Ass") and 5 day shifts. I'm going to be fairly crispy by the end. I've told my boss twice in the last week that I have had it, that this is it, that there is no way I'm coming back. Both times he said that he was terribly sorry to hear that and could I pick up an extra shift. Both times I said yes, of course.

Last night we had an acute MI that went to cath lab, an acute stroke in a 34 year old mother of 3, a horrible trauma (car fell on a guy and burst into flames), two gun shots, a stabbing, an unstable GI bleeder, a rape victim who had been set on fire, and all the usual other stuff we see. Oh, wait. Maybe that was the night before. I think last night was the leaking aortic aneurysm, the crazy woman who stabbed herself repeatedly in the abdomen with a arm-long sliver of window glass and managed to hit every organ in her body, the young woman who appeared to have been beaten and raped but wouldn't talk and was in the middle of multisystem organ failure, and the 5 year old who inhaled a plastic something and required a surgical airway. It's all sort of running together now. The City X cops who were supposed to be guarding a murderer who had run in front of a car left to get us food because we were so overwhelmed. The murderer was intubated, he wasn't going anywhere.

There was another riot by another family. The victim was drunk, high, and going 100mph the wrong way on the freeway without his seatbelt. The semitruck did everything possible to get out of his way but it wasn't enough. The guy went through the windshield and was stuck, a la "Signs," between his car and the semi; the highway needed to be shut down to get in an ECHO truck to extricate the guy . Unbelievably, he was still alive when he got to the ED. In addition to me, 2 residents, the trauma surgeon, the surgical PA, and half the nurses in the department did everything we could for over hour before we pronounced him. The deceased family did not take this well. We were accused of not doing anything to try and save his life, of being happy he was dead, of wanting him dead for spare parts. I had to walk away before I lost my temper. Multiple family members ended up handcuffed after threatening the police officers who were attempting to de-escalate the situation. I heard about that later, I was already taking care of other people.

This morning, when I left the ED 3 hours past the end of my shift, it was grey and raining. Perfect sleeping weather. The non verbal woman still bothered me, I hope I didn't miss anything on her. I slept -sort of- until hot sun on my pillow woke me up and I realize that the jackhammer in my head does not mean I had a great time last night but that there is construction outside my window. I look out. The neighbors both sides of me have suddenly decided to have work done; I hate them with the passion of ten thousand fiery suns. I'm too tired to sustain that so if quickly fades into grumpy annoyance. I try to go back to sleep but it doesn't work. I get up, do some laundry, unload and reload the dishwasher, make some food for dinner (or breakfast or whatever the one meal a day I end up eating when I work overnights is called). Normal stuff, but I feel like I am moving through mud. I'm so tired that thinking hurts.

I open the door to get mail and see that part of the construction crew belonging to the house on the right is lounging against the hood of my car. I know I should say something, but I'm just too tired. I stand there on the porch in my bathrobe in the afternoon sun and stare at him. He stares back.

"Nice time to wake up, Lady!" he calls derisively, "Maybe you should get a job!"

I close to the door, realize I have still not gotten the mail, and trudge up the stairs. Maybe I can get another hour of nap in before I have to be back in Hospital X. As I drift off - despite of the sun, the heat, the jackhammers- I realize that today is June 30th; we'll have brand spanking new, fresh out of medical school interns tomorrow.

When I finally sleep, I have nightmares.

not everybody wants universal health care

Wed, 25 Jun 2008 17:11:08 GMT

Link goes to video. I cried with laughter.

Awesome Hyperbole

Mon, 05 May 2008 16:25:45 GMT

From a piece in Eating Liberally called "How the War on Drugs take Horticultural Hostages" comes this fantastic /ridiculous bit of over-the-top food politics rhetoric:

"...diabetics outnumber crackheads in the U.S. by a big fat margin, but the corn cartel’s got carte blanche to fill us (and our gas tanks) with their Beltway-blessed by-products. So U.S. drug policies focus more on coke addicts than Coke addicts, despite the fact that soda’s the more abused substance."

Horticultural Hostages
Beltway-blessed by-products
coke addicts vs. Coke addicts

Having nothing to do with whether or not I agree with it, this purple prose needs to be read loudly from a pulpit by a fire and brimstone preacher with a thick southern accent.

Sheer AWESOMENESS!

Lolcavore

Thu, 24 Apr 2008 22:43:52 GMT

Extra Fig points if you know who Jessica Prentice is.
Hat tip to seriouseats

Not all nights are fun.

Fri, 11 Apr 2008 21:31:08 GMT

Sometimes I have a good time in the ED, sometimes I don't. This was one of those times.

As usual, all patients and staff are fully anonimized, some are composites. Also per usual, this is behind a cut for length and grossness.

Tonight sucks. It just sucks.

The HVAC can't decide whether it is winter or summer and alternates between blasts of heat and blasts of cold. The next hospital over has gone on diversion and we are swamped with ambulances that should have gone there. Ralph, one of my least favorite charge nurses is on and we alternate between having 4 empty rooms and no new patients in the rack to having 4 full hallway beds and 8 patients in the rack to be seen. Since the waiting room is consistently full, I think this is a flow issue. I could be wrong; I’ve never tried to be a charge nurse, I never want to be a charge nurse, but it seems like other charges keep the influx and outflux of patients more steady. The last time I attempted to talk to Ralph about flow I got my head handed to me and suddenly all the paperwork mysteriously went missing on my patients. It’s not worth it to bring it up tonight. I’m just going to keep slogging through patients and hope that it slows down enough that I can make a dent in the waiting room.

I’ve got three residents. They’re all useless. Well, actually I have 2. I started out with three but Adi was 38 weeks pregnant and contracting so strongly you could see her scrubs ripple. At 38 weeks the kid would probably be fine but I have enough chaos tonight without having to do an emergent delivery; I told her to go home and hydrate. She made a couple of half-hearted protestations that she was fine and then ran for the door. I’ve got a medicine resident who has spent the last 45 minutes putting a cast on a guy’s arm. Before that she spent an hour and a half getting a history from a lady with chest pain. I don’t think she’s going to see five patients in her 8 hour shift. Adam is my 4^th year resident. A 4^th year resident should be like another attending. He should half my work load. Instead, I’m babysitting this guy. Initially I treated him the way I treat most 4^th years: fix it and tell me before you sent them home. He presented a woman with incisional pain who wanted a refill on her narcs. Adam suggested that she might be gaining tolerance/getting addicted but said that he had refilled her ‘scripts and planned to send her back to her surgeon. Since this woman was 10 days past major surgery I thought narc seeking doubtful. I went to check her out and she had frank pus draining from her incision. Adam said he thought it was granulation (healing) tissue. I don’t think he looked under the bandage. Now I’m double checking all of his orders and all of his patients since I don’t trust him worth a damn.

Worst, the machine is out of diet coke and the coffee machine in the security office is broken.

Tonight just sucks.

“We’re getting a fat guy in respiratory distress.” Ralph says loudly in my ear. I think he likes to see me jump. Given that Ralph left svelt 80 or more pounds ago, I don’t think he should be throwing any stones.

“Okay.” I say. I’m not excited.

“No, you don’t get it,” Ralph is wildly gesticulating to nurses and giving conflicting orders, “He’s really fat. Really, really fat.”

I bite,

“How fat?”

“The paramedics called a crane.”

“Seriously?”

“Seriously. They’re gonna move him on a flat bed truck.”

“Tell me you’re kidding.”

“No kidding.”

“Okay, let’s get the Big Boy Bed to the trauma bay and get anesthesia down here.” The BBB isn’t a pejorative, it’s a brand name. It’s a bed that is wider than normal, able to bear more weight than normal, and has special hydraulics to make placing a larger person in the bed and positioning them easier. The last time I tried to intubate a 600 pounder I realized I need to work out a lot more. This guy sounds like he is more than 600 pounds. I definitely want airway back up.

“I can’t.” Ralph looks like he is guiding in airplanes with his arms. Nobody is paying any attention to him which is causing him to gesticulate ever more furiously.

“What do you mean you can’t?”

“I’ve already called anesthesia, but we don’t have a Big Boy Bed.”

“Yes we do, it’s in the hallway by the morgue.”

“Not anymore. JCAHO came to visit and said it wasn’t up to code so we got rid of it about a week ago.” I close my eyes. Yes, the bed was a ten years old. Yes, there may have been some rust on it. We all know we need a new Big Boy but Hospital X doesn’t have any money to buy a newer bed. The good inspectors from the Joint Commission have patient safety at heart but now they have gone and screwed me. I think hard, what are we going to do with this guy? Right, we have a new foregut surgery unit.

“Alright. Call the bariatric service. Have them send down a bari bed ASAP. Move out the bed from trauma bay B, it’s the largest bay. Put it in there. How far out are they?”

“I don’t know. How long does it take to move someone on a crane?”

“Tell them to call us with updates.”

I peek my head in on my other patients. Everything is going smoothly. A couple of them are waiting on labs, two are waiting on CTs, four are waiting for beds upstairs.

The overhead speaker blares: “ATTENDING TO THE PARKING LOT! ATTENDING TO THE PARKING LOT!” I run.

The flat bed is pulling into the parking lot with a police escort. There are 6 paramedics on the truck and a mountain of flesh. CPR seems to be in progress. It’s hard to tell from the ground. The police are setting up Klieg lights. Security runs out and starts putting up truck skids – those are the ramps you attach to the back of trucks so you can wheel boxes in or out of the truck.

“Whaddaya got?” I yell at the paramedics.

“We’ve got nothing!” they yell back.

“Vitals?”

“No vitals! We can’t find a pulse…but we couldn’t find a pulse when he was talking to us and he probably had one then. He might have one now, we don’t know.”

“Pressure?”

“You’re funny, doc. We don’t have a cuff anywhere near big enough. Our “Large Adult” doesn’t fit around his ankles. We do know he’s not breathing. He used to be but he’s not now. But he was blue when we got there with a sat of 60 on the monitor and he’s blue now with a sat of 60. No IVs, we couldn’t find a vein. No tube, two of us couldn’t get his mouth open.”

He’s dead. The guy is dead. But the paramedics can’t pronounce most deaths (decapitation, obvious decay, complete immolation - yes. Recent death where there is any question, no) and I can’t pronounce him until I can evaluate him.

The truck skids are up. The paramedics jump down. I’m about to yell at the one who is supposed to be bagging the guy but then I realize that there is no way to bag and get him off the truck at the same time. The patient is on a large black tarp.

“One, two, three, Heave!” One of the paramedics is in charge of making sure the patient’s head doesn’t hit the pavement. All the rest of the paramedics are pulling on the tarp. Nothing happens. The security guards run up. They grab the tarp.

“One, two, three, HEAVE!” Nothing happens. This is a nightmare. The patient isn’t being oxygenated, there is no CPR in progress, and he’s not moving off the truck. On the other hand, I’m pretty sure he’s dead so it doesn’t make that much of a difference. I don’t have any good ideas so I keep my mouth shut. Ralph is next to me,

“Is the bari bed in place?”

“No.”

“What?! Why not?”

“All the bari beds are full of bariatric patients.”

“Where am I supposed to put this dude?”

Ralph shrugs. Great.

All the male nurses and techs are pulling the tarp. There are 12 people on the tarp now. It (and my patient) starts to slide down the ramp slowly. Then faster. And faster. I now see that this was a really a bad idea. The crowd (for now there is a crowd, I’m not sure there is anyone left in the department. I see a couple of patients gawking and make note. If they’re well enough to leave their bed to stare at the circus they are well enough to go home.) screams and backs up. The nurses, security guys, and paramedics are now desperately dragging the tarp in the opposite direction but the momentum is unstoppable. The patient, whose name I still don’t know, runs over a paramedic’s foot left unwisely on the truck skid. There is a loud snap and a louder scream as the midfoot breaks.

“Don’t make him sit in the waiting room.” I mutter to Ralph.

My patient bowls into the paramedic assigned to catch the head. The paramedic is a superstar and does not let the head hit the ground. He is pushed flat under the patient, ending up an enormous pillow underneath my patients head and upper chest but he doesn’t let the head hit. He deserves a medal.

One of the techs starts doing CPR. He’s our biggest tech. An ex college football player. I’m not sure he’s actually moving the chest wall. Someone else starts bagging the patient, trying to force air into his lungs

“There’s a lot of resistance!”

Well, yeah. That could mean he’s full of fluid. That could mean that he has something stuck in his throat. It could also mean that his chest wall weighs 200 lbs.

I listen. I hear no breath sounds. I hear no heart sounds. But I’m surrounded by pandemonium and I’m not sure I’d hear anything if we were in a quiet room. That’s a lot of flesh to listen through.

“I need a 8-0 tube!” Someone pushes one into my hand as a nurse announces she’s got an IV. My nurses are freaking awesome. An IV on a pulseless morbidly obese guy is amazing. Another nurse announces she’s got a 2^nd. But I don’t know what drugs to give unless I know what heart rhythm he has and I’m not going to worry about the heart rhythm until I have a secure airway. ABC. Airway, Breathing, Circulation. Right now we don’t have any of the three so I’m going to start at the top.

I attempt to put the laryngescope into his mouth. It slides in easily enough but I can’t move his jaw. I pull harder. Nothing. I look for anesthesia. Nothing. Crap. I give the laryngescope to someone (a nurse? A tech? I don’t know, I’m not looking) in front of me me and tell them to pull down as hard as they can. The mouth opens a crack, not enough for a tube, barely enough for me to get my fingers in.

I drop the tube, it’s useless to me.

“I need a 7-0 tube!” One is handed to me.

I shove the tube down the guy’s right nostril and guide it between my fingers in the back of his throat. This is totally blind. I hope I’m going into the trachea, I’ve got about a 50/50 chance.

I’m showered with chunky orange vomit fountaining out of the tube. Apparently I missed the trachea. A chunk of vomit slides down the side of my neck, under my scrubs, and into my bra.

“I need a 7-0 tube!” I get a third tube. Now that I know where one hole is, I can make sure this tube goes into the other. I jam the tube down the guy’s left nostril and, using my fingers guide it away from the first tube and into the trachea. Someone starts bagging. There is no chest rise. CPR continues but I’m not sure we’re actually compressing his chest. This sucks.

The nurses have rolled two of our crash carts into the parking lot along with a portable monitor. While I was getting drenched in vomit they were busy hooking up the patient to the monitor. There is movement on the line on the screen. Maybe. That might be a really low voltage rhythm, hidden by inches of flesh or it could be electrical noise and a flat line.

“Can you turn up the gain?”

“Nope,” Brenda cracks her gum, “Not on this monitor.”

The gods hate me.

The futile bagging continues. The futile CPR continues. I shine a light in the patient’s eyes. They don’t respond.

“Let’s call this. Time of death…”

“I’m not going to let you call it.” says Ralph.

“Ralph, he’s got no spontaneous resps, no heart beat, no pressure, and his eyes are fixed.”

“You can’t hear a heartbeat because he’s too fat. We can’t get a pressure because he’s too fat. He’s in respiratory arrest, not dead.”

I can’t believe I’m having this conversation. The patient is dead when I say they’re dead, “He’s dead, Ralph.”

“We’re not calling this in the parking lot! We’re going to get him inside and hook him up and call it when we actually know what’s going on.”

My hair is plastered to my neck with vomit. Whatever. It’s not like we’re going to make the guy more dead. I’m not willing to fight about it.

“Fine. Let’s get this show on the road.”

I’m unconvinced I see a rhythm so I ask for epi. CPR and bagging stop, again, while people attempt to lift the tarp onto a bed. 12 people could pull him down a ramp. It takes 17 men to pick up the tarp and put it on the bed. This is a regular Stryker stretcher. They have a 700 lb limit. The hydraulics fail; a wheel cracks. CPR resumes, bagging resumes. I ask for more epi. I don’t have a whole lot else to offer.

Ten people pull the unwheelable stretcher into the trauma bay. I hook him up to the monitor and stare at the unhelpful, possibly wavy line.

“Can you turn up the gain?”

“That’s up as high as it will go.”

I think it is nothing. It might be fine v-fib. If it is v-fib it is a shockable rhythm. We shock him. Nothing happens. This doesn’t particularly surprise me. I think that the rhythm probably isn’t v-fib and, even if it were, there is well documented literature that the morbidly obese can only be internally shocked since not enough electricity reaches the heart from external shocks.

I pull over the ultrasounds and look at the guy’s heart. I get nothing but fat. I change probes, change depth, finally see it. It’s the size of a large cantaloupe melon and not moving at all. I pronounce him. I thank everybody for their hard work. I take a blanket from the cabinet and rub most of the vomit off my face, hair, and neck. I finally do a full physical examination. The sides of his feet are oozing sores, the flesh had cracked open from the weight on them. He has more sores on his butt and on his shoulder. Any pressure point when he was standing, lying, or sitting had degraded under his body’s weight. The fat of his abdomen hangs nearly to his knees, or would if he were standing up. Lying down it overlaps both sides of the stryker bed. The lower aspect was a mottled purple with multiple oozing wounds – it was so far away from blood supply that the flesh was starting to die. His fingers have no visible knuckles. The fat of his stomach appears to have eaten his penis and testicles. I’m unable to find either although I do locate a pit in the fat that appears to be draining urine. I, of course, find this pit when I discover warm urine dripping onto my leg. I have no idea how old he is. I’m guessing 50s.

“I am never going to eat another cookie.” I mutter to myself.

“Oh, please,” says Ralph, “This is the first time I’ve felt skinny in years. His family is waiting in the family room.”

“What happened to anesthesia?”

“They came when you were in the parking lot. They said that they couldn’t do anything until he was inside and to call them when he was. I figured it wasn’t worth calling them after you pronounced him.”

“I have some special knowledge of how to intubate someone on pavement that they lack?”

“Hey,” Ralph shrugs, “I’m just the messenger.”

I grab somebody else’s white coat off the coat hooks. I stopped wearing white coats my 2^nd year of residency. They’re hot, they get in the way, and if my patients complain that I’m not wearing one then they’re probably not sick enough to be in the ED. White coats do, however, provide excellent vomit coverage. The one I chose is huge. The shoulders come down half way to my elbows. There is somebody else’s name on the front that I try to hide with my ID tag. I couldn’t look less professional if I tried, but I figure it’s better than going to see a family covered in their deceased family member’s vomit. I realize I still don’t know the dead guy’s name. This better be the right family. I’ve announced deaths to the wrong family before and it is horrible.

Four people sit in the family room; they are various degrees of normal-plump. Shit. If they were really fat I’d be more comfortable assuming they were my patient’s family.

“How is Jimmy?” an older woman accosts me, “That crane didn’t hurt him, did it?” Okay, right family.

“I’m so sorry.” I take her hand and look her in the eye. “We did everything we possibly could but Jimmy’s heart and lungs stopped working. We tried medicines, we tried shocking his heart, but we failed. I’m so sorry. Jimmy is dead.” She dissolves into tears. Usually I hug family members. I do not think it would be comforting to be smushed against my vomity bosom. I pat her hand.

“We’re…” she sobs and starts over, “We were planning his 30^th birthday. He’s going to be 30 next week. Why did he die? Why? Why?”

Thirty?! You’ve got to be kidding, he was younger than I am.

“Well,” I pause. He died because he was fat. He had just as much a lethal eating disorder as any anorexic. But how do I say that politely?

“We may never know exactly why he died, but the more weight you have the harder it is for your lungs to move air and your heart to pump blood. I think, and this is only my guess, that one or the other of them tired out.”

“But why? He was my baby! He was only 29! He had his whole life ahead of him! He had everything to live for!” I pat her hand more. “He’s always been a big boy, but it never kept him back. He had plenty of friends over the computer. He was perfectly healthy!”

My jaw drops but before I have a chance to respond to this bizarre statement the loudspeaker blares,

“ATTENDED NEEDED IN THE TRAUMA BAY! ATTENDING NEEDED IN THE TRAUMA BAY STAT!”

“I’m so sorry,” I say again and run.

Bay B still has Jimmy. I’m not sure how the morgue is going to get him out of here or where they are going to put him when they do. Bay A now has a screaming someone and a lot of blood. A LOT of blood.

I grab a pair of gloves, throw the white coat on a hook, and take a look. In the bed is a young woman, covered in blood. She is thrashing and screaming obscenities. The screaming has a burbling sound that I don’t like.

“What’s going on?” I ask the paramedic. I don’t know his name but I recognize his face. He always seems to bring me the worst things.

“We got called for a domestic dispute. This is what we found. This is Maria, she’s 26, and that’s all we know since she’s not being real helpful. We think the guy attacked her with a knife, she’s got a bunch of slashes and a bunch of stabs. She’s a wild woman, though, I think she’s high on something. We got IV access and got a turban on head wound but that’s it. She was swinging and spitting and there wasn’t much we could do.”

Maria is still swinging and kicking and spitting and swearing. She is practically levitating off the bed in her drug fueled rage. The nurses are grabbing at her, dancing back as she kicks and swears and blood flies everywhere.

“I’m impressed you could get an IV at all.”

I go to the head of the bed.

“Maria, I’m the doctor. We want to help you. Can you calm down so we can take a good look at you, get you out of pain, and get all this bleeding stopped?”

Maria swivels her head back to look at me, causing her turban –the pressure dressing on her head- to fall off. She has an arterial bleed on her scalp and a deep knife wound that obviously bagged the facial nerve. The pulse from the artery promply hits my chest, soaking my scrub top with blood. I use my left hand to slam the dressing back on, with my right I search for tape to secure it. Half of her face droops like she’s had a stroke, the other half is distorted with anger, pain, and whatever cocktail of drugs she’s taken.

“Don’t touch me, bitch! Cunt! Bitch! You deserve this, not me. Don’t look at me that way. You’re not any better than me.” She twists up the half of her mouth that works and spits. I dodge but still get hit on my ear and in my hair. Tonight is just not a good night for bodily fluids.

Ralph leaps in and puts a wadded up gown over her mouth with more force than I feel is necessary. I think he likes exerting power over patients to an unhealthy extent. He yells in her ear that she is not to spit. She attempts to bite through the gag. He pushes harder. I call for security to help restrain her. That’s not what I want to do. She’s already been hurt tonight and the last thing she needs is a bunch of people to tie her down, but I can’t even examine her at this point. If she were hurt less badly then I could throw everybody out, attempt to calm her down verbally, give her some time to calm herself down, but her oxygen saturation is low, her heart rate is fast, and her blood pressure is low.

Security arrives at the same time that I decide that my holding pressure on her head is not the best use of my time. I call for a skin stapler and throw in three staples to hold that wound closed for the moment. She’s still oozing but not spurting. She is so wild that I can’t tell if she felt the staples or not.

While security ties her into four points, I take a look at her. She’s got slices all over her fingers and forearms, one of them caught a big vein which is bleeding steadily. I ask a nurse to put a dressing on it until I can get over there. Then she has the cut on the left side of her head, the one on the left side of her face, one on her left neck with an alarming amount of swelling, one on the top of her left shoulder, her right shoulder has dark red pressure marks on it, two on the side of her left chest one of which is bubbling air, and one beneath the ribs on her left side. That’s all I can see from the head of the bed.

I’m a doctor, not a police officer, but to me it looks like whoever attacked her started from in front and she tried to block the knife with her hands. After that the assaulter grabbed her right shoulder and proceeded to stab a lot with his or her right hand on Maria’s left side. She’s lucky she isn’t dead. With a neck wound, two chest wounds, and an abdominal one that may have hit her spleen or bowels she still may end up that way.

“Has trauma been notified? We need to class this out.” One of the nurses goes to page trauma. I ask for 2 liters of warmed saline and to start crossmatching her blood. I also ask for intubation drugs. I’m guessing she has a pneumothorax, maybe a hemo-pneumo, but I’m actually more worried about her neck wound. There are a lot of large, scary, important structures in the neck that can bleed a lot. I don’t want to lose her airway due to neck swelling. I tell her we’re going to give her some drugs to make her sleepy so I can help her breathe. She looks at me with hate in her eyes, still trying to bite through the gag.

“It’s about fucking time.” Ralph grumbles. “No wonder some one tried to stab her. What a SPOS.” Sub-human piece of shit. I choose to think of Maria as A. a victim and B. very high. Ralph chooses to think of her as sub-human. We all pick the frame through which we view our patients.

It is crazy in the trauma bay. Jimmy takes up a lot of room. Security is hanging around gawking at both Jimmy and Maria. I’m afraid she’s going to do herself serious injury. I try not to use physical restraints. I prefer behavioral redirection or chemical alteration of behavior, but there are times when restraints are necessary. Security has her strapped down in four points, one arm up, one arm down. If you keep both arms up the patient can suffocate. There isn’t much give in the padded straps. This tiny lady, maybe 5’2” and 110 pounds, is finding every millimeter of give she can. She arches off the bed like someone with end stage tetanus, touching the bed only with her heels and her head and then goes into another spasm of attempting to hit, kick, bite, spit on, or head butt whatever comes near her. It is actually very impressive. I’m guessing PCP or a PCP analog. When I was in medical school I saw a guy on PCP stand up with a hospital stretcher strapped to his back. If Maria was any bigger or stronger she’d probably do the same. To get the medicines into her IV requires all the nurses we have. One lies over her stomach, one holds down her thighs, one holds her feet, Ralph still has her head, one nurse holds each arm, and one pushes the medicines.

As the medicines take effect she relaxes and lies still. I intubate her with minimal difficulty although the swelling I noted on the outside of her neck is beginning to show on the inside. Trauma shows up. Usually I like to do my own chest tubes and all that other fun stuff but today I’m perfectly happy to hand over the patient to them. I just want to change my scrubs at this point. They’re stiff and sticky with drying blood and vomit.

Bert, the trauma PA, tells me they are taking her emergently to the OR to explore her neck wound and then sniffs.

“Did she puke?”

“No,” I say angrily, “That’s me. The guy in bay B puked and I’m wearing it.”

“That sucks. Hey, how fat is that guy?”

“My medical opinion? Very fat.”

“I think he’s more than 900. We had a 900 pounder in the unit for a while. He died, of course, but I don’t think he was as big as this guy.”

I mumble something, retrieve my vomit-hiding white coat, and go off to find scrubs. I don’t really care. 800, 900, 1200, he’s dead and I’ve got vomit in my bra.

I’m stopped before I can get to the scrub machine by Adam.

“Hey, where have you been? I’ve got a bunch to staff with you.” He sniffs, “Do you smell something?”

“Yes. I smell something. I’m covered in dead guy vomit. Let’s make this quick so I can change that.”

Adam takes a step backward. He tells me about a bunch of cases. Nothing seems terribly wrong. He’s being a little over cautious since the woman with the draining abdominal wound, but I would rather have over cautious than cocky. He’s got a couple of chest pain patients that are waiting for labs, a couple of belly pain patients one of whom is waiting for labs, one of whom is waiting for CT; and a prisoner with a tooth abscess that he anethestized and drained. He’s already got the discharge paperwork done on that guy so I go to see him first.

I see something is wrong the moment I get to the door. The patient is on his front moaning and writhing on the bed. That doesn’t look like a fixed abscess, maybe something abdominal. A kidney stone? What would make somebody writhe like that? What the hell did Adam do to this guy?

“Hey,” I say, striding into the room, “What’s going…”

The patient flips over in bed; I have just enough time to notice that his fly is undone and take a step backwards before I am hit with a stream of ejaculate. Without the step backwards it would have caught me square in the face; as it is the warm goo hits me mid chest and promptly runs under my scrubs. The prisoner cackles, displaying his rotting teeth. I’ve just discovered there is something worse than having vomit in my bra. Maria’s drying blood is sticky against my stomach. The semen smells remarkably bad.

The prison guard giggles. I take a deep breath.

“I’m the senior supervising doctor. I understand that you have a tooth that’s hurting you?” I know my tone is cold; I’m not sure what look I have on my face but the prisoner is no longer cackling and the prison guard isn’t giggling, either.

“Oh.” The prison guard stands up, “Oh, hey, lady. We didn’t know you were the doctor….”

I cut him off, “And that would have been acceptable for someone who wasn’t a doctor?” The prison guard looks away, angry and guilty that I called him on his bad behavior. I could probably write this up, get him in trouble, get the prisoner charged with one more crime but it’s just not worth it. I don’t have the time or the energy.

I look in the guy’s mouth. The abscess is no longer fluctuant. He’s going to get more of them unless he has a bunch of teeth pulled. I tell them this. I tell him that we’re sending him back with antibiotics and some pain control medicine and that he needs to see the prison dentist.

The prison guard winks at me conspiratorially, “He’ll get pain control when he can control himself.” I turn on him, angrier by the minute.

“I don’t want you withholding his pain medicines or losing the prescription because you’re embarrassed that I find your behavior despicable. That’s not going to make me think better of you. All my patients deserve to be treated well, even the ones who don’t behave well.” I walk out of the room. I hear the prison guard say,

“Frigid bitch. That’s probably the closest she’s been to a guy’s dick in a decade. You did her a favor, bro.” The prisoner cackles in agreement.

Did I mention that tonight sucks?

Ralph accosts me in the hallway to tell me that the department is backing up and I have to dispo some people. I tell Adam that the guy can go back to prison. My medicine resident is eating dinner and looking at shoes on Zappos. I tell her that lunch hour is over and that she needs to see some patients. She tells me she is nearly done and that this is the first break she has taken. I tell her that we don’t get breaks in the ED and that she needs to see some patients. I give her the chart of the paramedic with the broken foot. She tells me that she has already put on one cast today and that it isn’t helpful to her as a medicine person to learn to put casts on. I reach over and closer her browser window and tell her to see the paramedic now. The body substance smell of my scrubs wafts towards her as I lean over, she looks at me startled. She sees my expression and leaps up with as much alacrity as I have seen her use today. She takes the paramedics chart. She actually takes a 2^nd chart and flees the doctor’s area.

I check on my patients, get one of them admitted, send one of them home. I have the nurse explain the discharge paperwork since I don’t think it would be helpful for the anxious 45 year old who was convinced that he was having a heart attack but was instead having an anxiety attack talk to a vomit, semen, urine, blood, and spit covered doctor. I go to get scrubs.

“ATTENDING NEEDED IN THE TRAUMA BAY! ATTENDING NEEDED IN THE TRAUMA BAY!”

I go running. The paramedics are unloading a patient onto my stretcher, CPR is in progress. Something is wrong about the way the patient’s chest is moving.

“What have we got, guys?”

“Jumper. Jumped from a 9^th floor parking garage. We got two IVs in place and a tube but no heart beat. I think there were some brains in his throat.”

I look at the guy. He’s dead. His head is open and brain is exposed. His hands, forearms and upper arms are shattered. The reason CPR looks weird is that all of his ribs and his sternum are broken.

“Hold CPR!” I listen. Nothing. Nothing on the monitor. No breath sounds. I pronounce him. That was easy. If you need a spatula to get the guy to the hospital there isn’t much we can do.

“Is his family here?” I ask the paramedics. They tell me that the police called the family when they found the guy. Ralph tells me that they’ve showed up. He says there are a lot of them.

He wasn’t kidding. There must be ten people in the family room.

“How is he? What happened to Derrick? How is my baby?” An older woman to my right grabs at me. I tell her that her son had fallen from a great height and sustained massive fatal injuries. I’m so sorry but there was nothing we could do, Derrick was dead.

“Don’t you say that! You wash your mouth! You’re lying….AEEEEIIIE!” Derrick’s mom throws herself to the ground screaming, crying, ripping her clothing. The two women next to her do the same. There is a noise behind me and I have just enough time to realize that I have stupidly turned so my back is towards most of the room before a thundering horde of relatives starts pummeling me with their fists. They get in a couple of good kicks, too.

In medical school we learned that this was an “aberrant grief reaction.” In city X it isn’t so aberrant. I saw a co-worker get his jaw broken when the 22 year old wife of a stabbing victim cold-cocked him. A week ago a family became so violent in their grief that the police in the hospital had to use tear gas. That’s never good for the asthma patients.

A chair goes sailing over my head and breaks the wall. We just repaired this room from the last family that acted this way. They don’t actually want to hurt me. They’re also busy punching each other and the walls. When my mom was informed that my dad died she swallowed hard and started making lists of who we needed to call and what sort of food we needed to have on hand for visitors – a restrained, stiff upper lip, hard core New England approach to deep grief. Where I grew up, that was pretty normal. In city X it would mean that she didn’t care. If anyone acted the way my patient’s families act where I grew up they’d probably be arrested and/or committed. Here this violent display along with the wailing and rolling on the ground is just how families display their grief.

The family rushes out the door of the family room to continue their grieving in the hallway. All in all they get in six or seven solid hits to my upper back and neck and a couple of kicks to the back of my legs; nothing serious. They don’t really know how to punch and, like I said, they’re not trying to hurt anyone. It still isn’t fun to be hit.

I take a couple of deep breaths and wiggle my shoulders to make sure they’re okay. They’re okay. The social worker shows up,

“What happened in here? It sounded like a mob!”

“A family took news of a death poorly.” My shoulders are okay but I’m going to be sore tomorrow.

“Are you okay?”

“I’ll be fine. Just some bruises.” The social worker nods, unsurprised that I might have bruises, and goes off to find the family members. I do a final wiggle of my shoulders and –at long last- accomplish my mission of making it to the scrub machine.

Which is broken.

The usually green light blinks red and the machine won’t take my card. ERROR 493e the display reads, CALL SUPPLIER. I kick the machine. The error message doesn’t change. I kick it again.

“What the hell are you doing, doc?” Bert has snuck up behind me. “The nurses told me that you got walloped. You look completely ridiculous in that coat. You okay?”

“I am not fucking okay!” Bert takes a step back, I’m not sure if it’s my yelling or my stench. “I’ve had two deaths, I had to physically restrain a woman who was cut to pieces, I can’t get ten minutes to see my not-dead patients so I can actually dispo them and move some meat, I got two shit-for-brains waste-of-air residents who aren’t helping, there is no caffeine in this hospital, I am currently wearing FIVE of the seven bodily fluids, I’ve got vomit in my bra, and the fucking, goddamn, piece of shit scrub machine is broken!”

Bert thinks for a moment.

“I came to tell you that your sliced up lady is going to live. The plan is to sew up her bowel, there’s a small splenic laceration but it will stop on its’ own. We’ve reinflated her lung, and she’s already gone and come back from angio for her carotid injury. I think, however, that it is more important to tell you I can get you some scrubs from the OR.”

“Really?”

“Really.” That’s the best news I’ve heard all night. I feel like crying.

“And I’ve got some caffeine gum,” Bert offers me two pieces. I cram them into my mouth. I know, biochemically, that the caffeine will take 30 minutes to kick in but I feel better already

“And you know what else will make you feel better?”

“A vacation in Hawaii?”

“Nah, you’d be bored. You should hit something.”

“I just kicked the scrub machine.”

“You’ll feel better if you hit something.”

“Bert, that’s the dumbest idea I’ve heard all night.” I mentally annotate that to be the second dumbest idea I’ve heard all night, the first being pulling a apneic fat guy off a flat bed on a tarp, “I’m not going to punch a wall, I’ll end up with a boxer’s fracture and I’ll never hear the end of it. I’m not going to punch a pillow because we don’t have any. I’m not going to punch a bed because they’re all full of patients. And I’m not going to punch a patient because, tempting as that is right now, it’s just wrong.”

“You should punch me.”

“I’m not going to punch you.”

“No, really. Punch me. It will make you feel better.” I work in the craziest place in the universe. Bert offers his shoulder. I hit it.

“Oh for God’s sake. Really punch me. Like you mean it.”

I consider it. I take a step back and punch him. Really, really punch him, as hard as I can. And it feels good.

“See, don’t you feel better?”

“Maybe. Can I punch you again to make sure?” Bert takes a step back and rubs his shoulder theatrically.

“Not tonight. You hit pretty good for a pansy-assed liberal.”

“Doc! Where the hell have you been? I’ve been looking all over for you!” Ralph wheezes up the hallway. Bert give me a grin,

“I’ll be back with those scrubs ASAP.”

“Do you know Mary Harrington?” Ralph is shaking a chart in my face.

“Maybe, it sounds like one of Adam’s patients. I don’t think I’ve been in to see her yet.”

“Well I think you should go and see her. Adam didn’t do a pregnancy test; she just got back from her abdominal CT scan and wants to know if it hurt her 8 week fetus. Why she didn’t ask before she went, I don’t know, but she didn’t and now she’s going to have a baby with three heads.” Not exactly. Ralph likes to be dramatic, but it still isn’t good.

“I’ll take care of it.”

“And your guy in room 10 with heartburn just ruled in for an acute MI. He’s got a troponin of 7. But we made him feel a lot better so now he wants to go home.”

“Okay. Anything else?”

“Edna Redwine, room 14?”

“I know her. Little old lady, belly pain.”

“Yeah. She’s got a white count of 26, a lactate of 12, and she’s just dumped her pressure to 70/30.”

I start giving Ralph verbal orders which he reluctantly takes as we walk back to the ED. I’m going to get clean scrubs. The semen has glued the chunk of vomit in place under my bra which is actually a lot less uncomfortable. I’ve had caffeine.

“Housekeeping is so fucking useless in this hospital,” says Ralph, firmly convinced that everyone except for him is completely incompetent, “I mean, what is that god-awful smell?”

I look at the clock. Five more hours until my relief comes, I think I can make it.

My apologies for the ugly formatting. Apparently LJ does not like it when I copy and paste from Word; if anyone has any bright ideas of how to avoid this, please let me know

A bunch of bizarre stuff happens in this post. I promise that while I anonimize, make composites of similar patients, and re-arrange time for better flow I do not make anything up. Working at Hospital X I don't have to.

Once More With Feeling

Tue, 11 Mar 2008 14:22:57 GMT

A spontaneous food court musical, courtesy of the always fantastic Improv Everywhere

American Gods

Mon, 03 Mar 2008 22:00:56 GMT

If you haven't read it, you should.
If you have read it, it's probably worth reading again.

And, hey, free book!

Browse Inside this book

Get this for your site

You can read the entire thing for free. Thanks, Neil Gaiman!

Oh dear

Fri, 29 Feb 2008 20:09:19 GMT

My post yesterday was not supposed to mean "statins are bad, people who take them are stupid and doctors who prescribe them are stupider." It was supposed to be "few physicians use NNT in their prescribing practices and it's important" and "important outcomes are death/disability, not a arbitrary number" along with a component of "few medicines are good or necessary for every single person, it is a complex decision."

Let me clarify: Statins are standard of care and will decrease your risk of death for people with multiple risk factors who have had a heart attack. If you haven't had a heart attack and you have few risk factors it is a decision you have to make with your doctor...and your doctor should know about NNT.

I chose to write about statins because the article I linked to referenced them - it seemed easiest to follow. I could have written a very similar post (with different numbers) about oral hypoglycemics, glycoprotein 2b/3a inhibitors, different types of blood thinners for different conditions, or many other types of medication. It was the methodology I was pointing out, not the medicine. All of those are good medicines for some people and they all have risks and benefits.

For some medicines there is a very clear "right" answer for the majority of people. Aspirin after heart attacks is one. Albuterol for asthma is another. Antibiotics for bacterial infections are a third. Safe, effective, NNT<<NNH, and the good outcome is much much better than the bad outcome. (There are always exceptions - like those who are truly allergic.)

Most medicines are not that clear cut. A lot of medicines are prescribed to treat a number (cholesterol, BP, blood sugar, etc) and may not change the outcomes that are actually important (heat attack, death, loss of vision, stroke, etc). Medicines like these should be carefully explained. Taking a statin to prevent a 1:100 or 1:250 or 1:500 chance of a heart attack may make total sense to some people. For other people, they may prefer to avoid the hassle and expense of taking a medicine and bet that they'll be that 99:100 or the 499:500 for whom the statin may not protect against heart attack. (BTW, another point that I think was unclear from yesterday's post - some people will get their heart attack whether or not they take the statin. About 3/100 people with high cholesterol and high BP will have a heart attack in the next 3 years. If all 100 people take a statin, only 2 of them will have a heart attack in the next 3 years. One heart attack was prevented. The two people who had heart attacks were in the group that the statin had no effect...unless they were negative effects.)

Some academic institutions are starting to do this with diabetes care. When physicians are discussing with their patients the pros and cons of the medicines they might be start taking they show them cards with 100 smiley faces on them. The majority are color A and neutral faced. Some of them are color B and sad faced. Some of them are color C and happy faced . The doctor says something like "This is 100 people who are taking drug X. The A faces are people that the medicine neither helps nor hurts. the B faces are people who get side effects that may include blah blah blah. The C faces are people who get result X (fewer heart attacks, decreased death, increased functioning, whatever). We don't know which one of these faces you will be. On this other medicine..." and they'll show a different card. This seems like a good system to me but it only works with motivated patients and motivated doctors and enough time to flip through some cards.

So, to everyone I confused, please accept my apologies.

Number Needed to Treat

Thu, 28 Feb 2008 15:01:52 GMT

Do you play the lottery? Do you gamble? I've got a great gamble for you.

You pick 99 of your closest friends. You each put in $3000. and you wait three years. At that point in time 15 of you will win.... (what's behind door number 1?)....difficulty thinking, difficulty getting an erection, chronic diarrhea, and/or chronic muscle pain. One of you will get what is behind door number 2....that lucky person will not have a heart attack he (and it probably is a he) otherwise would have. Oh, and BTW, there is a 20% chance that the heart attack would have killed him and an 80% chance that it would be much more minor.

Okay, the line forms to the left.
Hello?
<crickets chirping>

13 million Americans choose to take that gamble. That's 130,000 heart attacks prevented! Yay! That's nearly 2 million people with chronic diarrhea, cognitive impairment, aching muscles, and inability to have sex....Yay? That's $39,000,000,000.00 to prevent those 130,000 heart attacks.

That's the difference between "Statins reduce the risk of heart attack by 36% in patients with multiple risk factors for heart disease" and the number needed to treat (NNT) analysis. That's the difference between an overall decrease of heart attack risk and YOUR PERSONAL risk or gain from the medicine.

The NNT (in the case of statins it is somewhere between 100 and infinity - you need to treat at least 100 people before you get one person who benefits) and NNH (number needed to harm - in the case of statins it is 7. You need to treat 7 people before one has adverse side effects) are really hard concepts to explain especially when drug companies are spending millions of dollars to make you (and your doctor) think you need their drugs.

This article does a really great job of explaining this concept.

Running the numbers

Mon, 25 Feb 2008 19:01:36 GMT

I know, I know. You want ED posts. I promise there will be more.

In the meantime, take a look at Chris Jordan's work. I found it beautiful and horrifying.

Another day of anger

Thu, 07 Feb 2008 16:25:34 GMT

My phone records are my business. What's on my computer is my business. I'm not going to hand over the keys to my house; I have a similar lack of desire to hand over the passwords to my computer.

There is nothing illegal on my computer, but there are things that I do not want to share with random people. Like financial information. And, equally if not more importantly, confidential patient information. I can cancel bank accounts and credit cards. I can't give another person back their privacy.

A short rant on misguided policy

Wed, 06 Feb 2008 16:02:55 GMT

Last month the Michigan Secretary of State stopped giving driver's licenses to immigrants. They interpreted an opinion by the state Attorney General to mean that people who are legal visa holders but not permanent residents should not be granted licenses. They can keep their country of origin license until it expires but then they can not get a new one from the state of Michigan.

I think many peoples' reaction will be "Yay! now we don't have to worry about terrorists driving car bombs into Michigan stadium." or "That makes sense, everybody knows that dirty {insert random country here} can't drive." I don't think that most people consider the effect this will have on people from other countries who are:

Medical residents doing their training in Michigan hospitals (statistically likely to stay and continue taking care of either rural or inner city Michigan residents).

Graduate and undergraduate students at the University of Michigan

Post-doctorates and visiting professors here for two or more years.

Engineers working with Michigan auto manufacturers.

I know people in medicine or academia from South Korea, England, Germany, Belarus, Ghana, and Canada who will be affected by this change. Some of them are thinking of giving up their positions and/or returning to their home country due to the difficulties of doing their job with this restriction. They have told me about other professionals who were planning on coming to Michigan and have now changed their plans.

A policy which drives professionals out of a state with a faltering economy seems remarkably poorly thought out.

A policy which is so pointlessly biased just makes me mad.

Food that should not be

Tue, 29 Jan 2008 21:55:21 GMT

Cheeseburger in a can.

bleaurgh!

Why? Why? Why?

hat tip (I guess. Although I think I was happier before I knew about this) to Serious Eats.

Twas the night before Christmas....

Sun, 06 Jan 2008 01:11:10 GMT

There’s been some concern expressed by LJ readers recently about confidentiality given the specifics I put into my posts. I’m thrilled that people worry about that - too many of my colleagues don’t. Please remember that all patients and co-workers in my posts are fully anonymized (most are amalgams) and all shifts are composites. The sole exception is the post about the veteran where I got the patient’s consent to use her name and her story.

My apology for the long delay in posting. I have several half written posts backed up from the summer but graduate school is taking much more of my time and my brain than I anticipated.

As usual, this is behind a cut for length and possible grossness. Without further ado:

Hospital X has a separate pediatric emergency department that’s open for about half the day; it closes for the night about the same time I usually show up to work. It’s fun – I get to take care of people who haven’t been broken by eating fast food for 40 years. It’s terrible – kids who die are a lot harder for me to take.

I took a couple of weeks off from working in the ED so I could concentrate on my finals. With all my shifts clustered at the end of the month combined with the holiday scheduling, I’m working more non-night shifts than usual. I hate day shifts - getting up at 4am just sucks. Evening shifts are fun, it’s busy and there are tons of residents to help and to teach. The peds shifts, however, are the best. It’s a weird swing shift but the nurses are great, there’s usually a PA and a resident to help out, and I can often fix the patients’ problems.

Tonight, however, is dead. For most of the major holidays, Christmas especially, people stay home unless they are really, really sick or really, really lonely. I’ve got two residents and a PA and we’re sitting around doing nothing. In New York City, where I did most of my training, the staff who worked on Christmas were Jews, Muslims, Hindus, Buddhists, Wiccans, and people who hated their families. City X doesn’t have that kind of diversity but nurses get double time and a half for working holidays and the doctors split the holidays on a rotating basis so no one is bitter about being there. It’s fairly festive and, currently, extremely boring.

Tinsel is draped over the monitors. Tinny, almost inaudible, Christmas music plays over the PA system. Trays of cookies and candies cover every possible countertop. There’s one from each ambulance company, one from the police department, one from the fire department; there’s even one from the disposal company who take our dead bodies from the ED to the morgue. The nurses used to do that, but new regulations came out and now we contract with some company. It’s a little weird, but I’m enjoying the cannolis they sent and can’t complain too much.

I haven’t seen a patient by myself all day. I’m sorting through my backlog of charts, trying to get everything signed before the new year. The two residents are each seeing about one patient an hour. They haven’t yet started squabbling about who gets to see the next patient but I think it’s only a matter of time. One of the residents is a family practice resident originally from Belarus. The other resident is doing a med-peds combined residency and is originally from Russia. They are not talking to each other for complicated political reasons. I don’t really care but it does cut down on the amount of social chatting that often takes place on a slow shift.

Anya, from Russia, is currently sewing up a laceration on a six year old who was squabbling with his twin over who got to…I don’t know. Something involving a new toy now taken away, possibly permanently, by the totally frustrated mother. Voinov, from Belarus, is closing up the hand of a four year old who grabbed a glass ornament. These are the most exciting patients we’ve seen all day. I check in on both their sewing jobs, they’re doing fine. The four year old is totally numb but throwing a fit because she needs to be still for the sewing. The six year old is crying and saying that it’s entirely his brother’s fault and it’s not fair. He’s far more upset about the loss of his toy than the cut on his arm.

The PA, Paula, tells me about a vomiting kid - gastroenteritis versus too much Christmas candy. He’s fine. We’ll let him go home as soon as he can hold down a popsicle. There’s a lot of gastro going around; ‘tis the season.

The nurses are playing some twisty word game on the computer.
“Ravine,” I say. “Raven. Rave. Vine. Nave. Nare.”
“Nare isn’t a word,” says Becca, a fat, placid, middle aged woman who is fantastic with kids and could get a working IV on a turnip.
“Sure it is. It’s a nostril.”
“The game says it isn’t a word.”
“The game is stupid.”
“Nah, it just hasn’t gone to medical school and learned words for body parts that already have perfectly good names.” I can’t argue with that one.
“Fine. Ran. Van. Ire.”
“Quit that,” says Becca without rancor, “You’re going faster than I can type.”

Anya finishes sewing and sends the six year old, still blaming his brother, home. She checks in on her only other patient, an asthmatic with an asthma flare –probably from being at grandma’s house, she smokes like a chimney. After a couple of breathing treatments the kid’s wheezes have resolved. I listen and agree. Grandma tells me that she’s only smoking in her bed room and in the kitchen where there is a fan. She’s holding herself to two packs a day while her grand-daughter is visiting. She really wants to believe that the asthma flare is from playing in the snow. It’s not, but this isn’t a battle I’m going to win tonight. The kid is only there for four days. I tell mom to take my patient on walks, to the mall, to the movies, get her out of the house as much as possible. We send her back to grandma’s smoky house with a prescription for a new inhaler and a steroid burst.

I check back on Voinov. He’s slow at baseline and this repair is taking forever. The four year old has worn her self out crying and is sleeping comfortably as he labors over her hand. Most of the lacerations are shallow and able to be closed with glue and steri-strips but there is a deep jagged cut through the web between her thumb and index finger that required both deep and surface stitches. He’s putting in tiny, precise stitches that a vascular surgeon would be proud of. It looks beautiful, is entirely unnecessary, and if the ED were busy would get us painful behind on seeing more acute patients. But, I remind myself, the ED isn’t busy tonight, he’s making these parents very happy, and he’s not an ED doc. I praise him on his stitching and suggest a way of closing the end of the laceration so that there’s not a raised bit at the end. I give the parents standard hand laceration instruction and tell them they can go home as soon as he’s done.

When I get back to the doctor’s station Paula is shopping for her daughter on line. Paula is 5’4” and American-normal - which is to say plump. Her husband, a paramedic, is shorter than I am, which is really, really short. Her daughter, through some weird gene sorting, is well over six feet tall and has a 40 inch inseam. I have heard endlessly about the difficulty in buying her pants. Anya is reading her email. The nurses are still playing the twisty word game.

“Hang, chin, chain, gain, nag, hag, can.” I say.
“Quit that,” says Becca.
“Goddamn it,” says Paula, “These look great but they only go up to a 38.”
I eat another cannoli, they’re starting to make me feel a little sick.

Voinov discharges his patient and comes back to the doctors’ station. He looks at Anya reading her email and ostentatiously pulls out his thick textbook on pediatrics. I look at the clock. Four hours left until the end of their shifts.

“You know what?” I say, they both look up. Anya sees what Voinov is doing, turns red, and quickly closes her email. “There’s no one here. There’s no one in the kids’ waiting room. There’s no one in kids’ triage. It’s Christmas Eve. Go home.”

“Really?” says Voinov. I know he has a wife and two small children at home.
“Really.” I say. He stands up and starts gathering his things.
“I will stay,” says Anya. “I am happy to learn. I am happy to work.” Voinov looks stricken.
“Anya, go home. I know you’re happy to work. You’ll be happier at home. Go. Consider it a Christmas present.” She hesitates. Voinov hovers, undecided. I turn away and open my email. There is a moment’s silence and they both leave.

The tension leaves the department. The nurses turn up the Christmas music. Suze reaches into her bag. Suze is hot. Speaking as a straight woman, she is smoking hot. She is also an unflappable trauma nurse and has been known to give patients money out of her pocket to get a taxi home but what she is best known for is her hotness.

“Look! I’ve got pictures from my last vacation!” Well, okay. She’s mostly known for her hotness and her vacations to nude resorts where everyone is good looking and there’s a lot of sex. The pictures are always interesting. These are no exception. The nurses and I pass them back and forth. I’m surprised that there aren’t more sunburns given all the tender flesh that is exposed. We all comment on flaws on the people who look like (very naked) models to make ourselves feel better. I decide not to have another cannoli.

The gastroenteritis kid goes home. Another gastroenteritis kid comes in. Paula continues to search for pants. A chestnut burn to a finger comes in. That’s not some medical term, she burned it on a chestnut. It’s nothing. I send her home. I finish my charts. I haven’t seen the bottom of my chart box for months, it feels as good as getting a present.

    “TAP!” yells Becca. That’s not a hard word to get, I’m not impressed. Suddenly I’m being hugged from behind; the shirt is rough, the body hard. Really, really hard. Like metal.
    “Tap!” I yell. I turn around and Officer Stapszynski hands me a steaming hot latte. That man certainly knows how to make me happy.
    “How did you know it was me?”
    “Your vest. No one else hugs me encased in Kevlar.”

Stapczynski, called Tap, is our favorite police officers. Hospital X has two police officers twenty four hours a day in the department. They’re not just for show, our patients are often more dangerous than the unarmed hospital security force can handle. More importantly, and certainly more commonly, if a patient who is struck by a car, shot, or stabbed is reported to be in “critical” critical condition the officers in the department immediately order an investigation started. It saves a lot of time in a city as violent as City X. It also occasionally means that when a frequent violent offender or suspected cop-killer comes in struck by a car, shot, or stabbed that they are reported to be “stable.” The label doesn’t change the care we give the patient; it does change the police response to their injury. I’ve never done this - even knowing that it happens makes me feel squicky inside, but it happens. My colleagues tell me that in a few more years I’ll be doing it too. I hope not.

Many of the police officers hang out in the x-ray reading room, drinking coffee, listening to their radio, and wishing they were somewhere else. Tap hangs out in the department, knows our names and our passions (hence the latte), flirts outrageously with all the women, and entertains the men with stories of guns and violence. He splits his time between the SWAT team and working in the hospital and is one of the few officers who volunteer to do this. Most of them find it boring, Tap says that he finds its heartening and inspiring to watch us working so hard to fix people. He says that in the rest of his job he gets to threaten people and hurt people and very occasionally save people but he never gets to try and fix anybody.

Tap grew up in City X and remembers it when it was prosperous. He has an unshakeable belief that the city will come back, that something will step in to the void left when the big companies pulled out, that the current poverty and violence is just a temporary down swing. I think he’s delusional, I hope he’s right.

I’m glad he’s here tonight, it cuts the monotony. He pulls Becca away from the word game and dances with her to “Rocking Around the Christmas Tree” and refuses to look at Suze’s pictures because he says it will make his uniform ill-fitting. He does, however, give her a backrub that turns her into a puddle of nurse. I don’t think most people know that he’s a single parent and has a severely mentally handicapped daughter.

The second gastroenteritis kid goes home. We have no one for a little bit. I get sick of the word game, excuse myself, and cross over the adult side. The attending there has his feet up on the desk and is twirling his pen. One of the residents is watching You-tube videos; the other one is trying to teach the medical student how to twirl her pen.

“I was going to offer to help out since we’re under control on the other side, but it looks like you’ve got all the help you need.”
    John, the adult attending, stops twirling his pen and points it at me, “We had an exciting one earlier. Some lady choked on a marshmallow. It wouldn’t come up, it wouldn’t go down, we couldn’t get a tube past it.”
            “What did you do?”
            “Took it out with McGill forceps. See?” He tosses me a denture container, in it is a wet marshmallow. I have no idea why he kept it or what he’s going to do with it. Some things are better not to ask. I toss it back,
            “No thanks, I’ve already had a lot of cannollis. Did she do okay?”
            “From the disposal company? Aren’t they great? Yeah, she was fine, went home no problem.”
            I pull up a chair, “Anything else interesting?”
            “Acute anaphylaxis. Woman with a severe seafood allergy just couldn’t resist the seafood dip. I thought she had bought it.” Bought it, meaning died. “Tongue swelling, wheezing, total body hives so I couldn’t see her eyes. A little epinephrine, some steroids, some benadryl, she turned out okay. Kinda disappointing. That was the most excitement we had all day.”
            “What an idiot!”
John grins toothily,
             “It gets better. Take a look at this.” He pulls up her visit record on the computer. Dec 24, 2007 Anaphylaxis, Treat and Release. Dec 24, 2006 Anaphylaxis, Treat and Release. Dec 24, 2005 Anaphylaxis, Treat and Release. Dec 24, 2004 Anaphylaxis, Treat and Release…
            “Holy cow! That must be some good seafood dip.”
            “A whole knew meaning to ‘it’s to die for.’ If you look at the times, each visit she stays a little longer, one of these days she’ll be boxed.” Boxed, as in put in a coffin. We’ve got a lot of euphemisms.
            “I wonder if something else is going on. Did you prescribe her an epi pen?”
            “Of course.” John looks offended.
            “I bet everyone else she has seen did too. And she never uses it. Near death is a great way to get a lot of attention.”
            “Huh. Maybe.” I want to go on more but John had stopped paying attention. He likes to treat sick patients, not to think about them. That’s okay, I can talk about sick patients as well as anyone,
            “Let me tell you my favorite Christmas story.” I put my feet up on the desk, mirroring his stance.
            “I was a resident, working in on the trauma service. It was Christmas day. We get called down to a stabbing in the ED. As we’re running down my pager goes off again, we’re being called down to a bad burn in the ED.
            “It turns out to be a husband-wife Christmas combo. He insulted her ham, she stabbed him with the carving fork, got his lung, his liver, and his heart. We had to do a pericardiocentesis in the ED before he went to the OR. But, anyhow, after being stabbed Hubby picked up the candles and threw them at Wifey, her nylon shirt went up like a roman candle and promptly encased her in the equivalent of napalm.”
            “Wow,” John says
            “Yeah. Good times.”
            “He die?”
            “Nah, they both lived. We kept them at either end of the trauma ward. One night when the woman was extubated” Off her breathing machine and breathing on her own, “and the guy was still intubated, she went down the hall and tried to kill him again. Good thing those things alarm when they’re unhooked.”
            “Wow, that’s awesome.”
            “You know what the moral of that story is?”
            “No idea.”
            “Don’t ever insult your wife’s cooking.” John throws his pen at me and misses.

I hang around for a little while; they are slightly busier than the kid’s side but not much. I mention that I sent my residents home. The residents look up hopefully. John glares but agrees they’re not doing much of anything. They look at me gratefully as they start to pack up their stuff. That’s me, spreading Christmas cheer. My work done, I return to the pediatric ED.

Paula runs up, “Guess what?”
My adrenaline starts pumping, “We’ve got a sick one? You should have called me!” All the attendings carry pocket phones for that reason. I walk quickly in her direction; she looks like I’m an idiot.
“No, I found a store on-line, that sells pants with up to 44 inch inseam! It’s in New Zealand, they must be taller there.”

Oh. That’s less exciting for me although it’s obviously made her night. There are a few new patients that she tells me about after filling me in on the pants situation: A pair of 9 month old twins with gastro, their parents glassy-eyed from lack of sleep. I tell mom that she has baby poop on her shirt; she tells me she’s just happy she got it out of her hair. I suggest they reschedule celebrating Christmas for after the kids are well. Dad tells me that after the amount of bodily contents he’s seen today he may never celebrate Christmas again. There’s also a small facial laceration from an over excited Christmas puppy. Paula can handle all of these. I let her do her thing.

I check the clock. 2 hours left. This night is crawling. I like to be busy and I like to see sick people. I didn’t go into this to sit around. I check my email again. No new messages. I check all my favorite web sites again, nothing has been updated. I play the word game with Becca.

“Cwm!”
                “What? There’s no O!”
                “No, it’s ‘c-w-m,’ it’s just pronounced coom.” Becca gives me a baleful look but enters it. The computer rejects it.
                “What? That’s a perfectly good word! It means valley.”
                “Only in crazy doctor-speak.”
                “Actually, it’s from the Welsh.”

“Whatever.” Becca enters ‘mic;’ the computer accepts it.
“What’s mic?”
“Not mick, mike. Like a microphone.”
“That’s not a word, that’s an abbreviation.”
“It obviously more of a word than that crazy Welsh thing.” I hate this game.

Paula tells me that the twins are actually going to have to be admitted. They’re both pretty dehydrated. I take a careful look at them and agree. Paula examines their arms and legs; their tiny veins are flat from lack of fluid. She suggests calling IV team. I suggest Becca. She gets the invisible veins without a problem, the kids barely notice the poke. I’m telling you, that woman could get a flowing IV into a rock. Which, I guess, mitigates the fact that she thinks ‘mic’ is an acceptable word. The kid with the laceration is sewn up and goes home. I tell Paula to go home too. She doesn’t give me any argument.

One hour left. I’ll play computer Boggle instead of the twisty word game with the inadequate vocabulary. I announce this loudly.

            “C’mon doc, you’re getting cranky.” Tap puts a comforting arm around my shoulders and walks me down the hallway. “Let’s get you more coffee. Have you eaten anything today besides Christmas cookies and coffee?”
           “You sound like my mom. Next you’ll be telling me to wear a sweater.”
            “That’s a no. Okay, I’ve got an orange in my bag; I’ll share it with you.”
            “I put milk in my coffee, that’s protein – right?”
            “I’m not going to argue science with you, but if you don’t eat the orange I’ll charge you with obstructing an officer of the law.” I am unable to keep from laughing. Tap is great. I let him lead me away.

We walk down the hallway and get bad burnt coffee from the paramedics who sit immediately inside the double doors to the ambulance bay. Tap produces the orange. I eat it. I feel a little less cranky. We hang out and chat with the paramedics. Their night is as dead as ours.
        “Usually you get a couple of sick ones, today we’ve got nothing,” one of the paramedics says dolefully.
I tell my Christmas trauma burn story again. Everybody loves it. It’s the best story I’ve got.
            The doleful paramedic perks up, “What’s that?”
            A car fishtails wildly as it comes in, screeching around the corner.
            “Ooh!” says a second paramedic, “Maybe it’s a woman in labor. That looks like how about-to-be dads drive. I love Christmas babies.”

Hmm. I don’t mind delivering babies in the ED. I hate delivering them in the back seats of cars, especially in the cold. I decide that since I’m technically the pediatric attending and the mom would be an adult patient I’ll let the other attending deliver if we can’t get the woman out of the car. Hey, nobody said I was nice.

The car careens to a stop outside the double doors. The driver exits the car like he was shot from a rocket,
“This is going to be great. Dads get so excited!” The paramedic next to me is practically bouncing up and down. The driver takes off at a dead sprint away from the hospital as fast as his legs will carry him.
“What the….?” I leave the paramedic wondering as I run for the double doors putting on exam gloves. I don’t know what it is either, but it’s nothing good.

I can hear screaming before I reach the car. I open the door, three people and lots of blood.
            “Oh my god! Oh my god! I’ve been shot! I’ve been fucking shot!” screams a wide eye girl in the far corner of the back seat. And when I say girl, it doesn’t mean woman. It means girl. She can’t be older than 14.
            “I need gurneys, lifting help, nurses!” I bellow. “I need help NOW! Call Trauma, we’ve got gun shots! Get nurses in the trauma bay!” I turn back to the car
            “I’m the doctor, we’re going to help. How old are you?”
             “Oh my god! I’ve been shot!” If she can talk she’s not dying right now.
            “How OLD are you?” I yell
            “Eighteen!” she lies, unconvincingly, “I’ve been shot! OWWWWWWW!” Crap. This is my problem. I take a better look at the other people in the car, they are all my problem. I don’t think a single one of them is older than 16.

People run out the door, almost gleefully. This is what everyone has been waiting for. Nurses and techs scoop the patients on to wheeled gurneys and we all run for the trauma bays. 2 gunshot teenagers. Wow. What a way to end a dull night.

A horn blares as we reach the double doors and I turn around to see a second car slam into the rear end of the first one. The air bags deploy. The driver and the front passenger leap out and open the rear doors. There is continuous screaming from the back seat. I yell,
“I need more help out here!”
The two uninjured front seaters are each dragging a bleeding person from the back seat.
“Help! My friend’s been shot!” one of them yells.
They step into the light of the ambulance door, they’re teenagers. Oh fuck, fuck, fuck. I am so sorry that I was bored. It’s that old adage, be careful what you wish for.

A screech of tires tells me a third car is pulling in. I run for the trauma bay. I can’t help anyone out here.

Inside is pandemonium. John is yelling because the nurses have moved his drunk driver and his heart attack out of the trauma bay. I tune him out. The three kids we’ve already got on stretchers are screaming, the friends of the next two are yelling. We’ve got three trauma bay slots with monitors and equipment. I’ve got, currently, 5 wounded teens. I don’t know how wounded they are. I don’t know what is in the third car, I don’t know if there are going to be more cars.

            “Suze, set up triage in the hallway, don’t put anyone in the trauma room who isn’t critical. Becca, I want all of these kids to have two large bore IVs.” I turn to one of our nurse extern who is supposed to be on the adult side but is standing in the hallway ogling the mess, I read her name off of her id, “Marjorie, do you have trauma shears? If not, find someone who does. I want all of these patients totally exposed. Nothing left on.” Bullets bounce. They bounce off hard things outside the body, the bounce off hard things inside the body. Everybody I know has been burned at least once by leaping to treat the obvious wound on the front and missing the deadly wound on the back or side. It’s certainly happened to me. I try to ensure it won’t happen again.
            “In the hallway?” Marjorie squeaks”
            “In the hallway, right fucking now.”
Overhead I can hear one of the adult nurses announcing the arriving patients over the trauma activation system.
            “We have 5 level two traumas in the trauma bay now, GSW, all other information unknown at this time. Correction we have 7 level two traumas in the trauma bay at this time.”
Seven? Oh, right. The other car. They must still be bringing them in.
            “Correction, we have 9 level two traumas in the trauma bay at this time.”
Nine? I’ve never taken care of nine gunshots at one time. Four was my previous best. I am so sorry I sent the residents and Paula home. I am so, so, so, so sorry.

The hallway is getting crowded and loud. These are friends and, apparently, prostitutes of our patients. There are some eye popping outfits. I order everyone who is not bleeding down the hallway to the family waiting room. The crowd ignores me. A woman –girl, I correct my self, twenty at the most, pushes her way in front of me. She is wearing a red vinyl bustier, blue fishnet thigh-highs, and a black mini skirt. She must be very cold. In her four inch heels she towers over me.
            “Look,” she says, “That asshole owes me twenty five dollars and I don’t care what’s wrong with him or who you are, I’m not leaving until I get my money.”
            “You need to go to the waiting room.”
            “I said. I’m. Not. Leaving.” She jabs me in the sternum with a 2 inch airbrushed nail to emphasize her point. Tap steps in front of my in all of his uniformed, kevlar’d glory.
            “And I said, You. Are. Going.” It turns out that she could move amazingly quickly in those heels, she was down the hall in a flash. Tap goes back to trying to figure out what happened, I go back to trying to treat patients.

So far there is a lot of blood and a lot of non-limb-threatening extremity injuries. One of the guys in the first car was shot through the eye. Nothing for me to do there, he was beyond my care when he showed up. One guy was shot through the knee, I’m worried about injury to the big artery that runs behind the knee. I ask somebody, whoever is near me, to move him to the trauma bay and grab the ultrasound so I can check for flow. One of the girls has been shot in the butt. No exit wound. She is screaming with pain and fear. The bullet could be in the fat and muscle of her butt or it could be her pelvis or abdomen. Like I said, bullets bounce around. I ask for her to be moved to the trauma bay and to shoot 1 view xrays of her chest, abdomen, and pelvis so I can figure out roughly where that sucker is.

Screaming is normal, screaming is good. Screaming is exactly what I would do if I were shot. My next patient, however, has blood pouring from a graze on his shoulder, a through and through wound on his upper arm, an entrance with no exit on his calf and he is talking intently into his cell phone.
            “Damn, man, I’ve been shot again! It was Jerome and his guys. You’ve got to tell DeAngelo that…”
            I grab his cellphone. No putting out hits on people in my ED. “Sorry, no cellphones in the hospital. You know the rules.”
            He glares at me balefully, “Fuck you, bitch. Gimme my fucking phone.” He lunges forward with his good arm. I jump back.
            “That’s Doctor Bitch to you and if you reach for me one more time I will make sure you are last in line to get pain meds. With you and my friends all here, it could be a pretty long line.
            “They ain’t my friends.” But he lies back and lets me examine him. I wouldn’t actually withhold pain medicine; I’m perfectly happy not to have him know that.

There’s an adult victim of the shooting in the trauma bay being taken care of by John. He happened to be an innocent bystander (or, in this case, driver) who passed by what appears to be a gang war. From the brief glace I got of him, he’ll probably die. I’m not sure whether the gang members in City X have remarkably bad aim or don’t actually aim to kill but I can count on one hand the number of deaths I’ve seen from a gang shooting. If you or I were shot, we’d be seriously injured or dead. These kids, as my last patient so vividly demonstrated, live to shoot each other another day.

Our social worker is trying to get contact information from the nine victims. We’re allowed to provide emergency care to stabilize them but we’re technically not allowed to treat them without their parents consent. So far the oldest one I’ve talked to has been 17; the youngest, 14. To treat them in the absence of a parent or legal guardian we have to petition the court for guardianship. It happens, probably once or twice a month, but it’s a huge hassle, delays treatment, and I’m not even sure the court is open until after Christmas.

Trauma has shown up. I tell them what I have. That I’m worried about the leg on one kid, the whereabouts of the bullet in the girl and that I have a couple of extremity fractures from bullets. They’re totally not interested as they whisk the dying adult up to the OR to see if they can stop his bleeding and figure out how many things in his abdomen were damaged.

The nurses bring in another teenager bleeding from his nose and mouth and sit him in the hall way.
            “Another gun shot?”
            “No, he was hit the face with a bottle. I think that there’s going to be a riot.”
            “In the family waiting room?”
The nurse laughs at how far behind I am on what is happening.
            “No, Tap cleared out the waiting room because there was a lot of pushing and shoving and yelling. He sent them all outside. They called their friends and they called their friends and now we’ve got two hundred angry teenagers outside the door.”
            “Aw, crap.” I turn to the boy who was hit, “How old are you?”
            “Eighteen, he says indistinctly around a mouthful of broken teeth. Score!
            “Take him over to the adult side; I’ve got my hands full here.”

The bullet on the girl who was shot in the butt appears to be in her belly. I can’t feel under her skin. Her vital signs are stable and her pain is controlled so I write orders to crossmatch her blood, send her to CT, and call the trauma PA to remind them of her. My ultrasound of the leg is inconclusive and I can’t get a good feeling for what is going on. The toes on that foot are freezing cold…but so are the toes on the non-shot leg. Whatever footwear he was wearing wasn’t appropriate for December.

Suze and Becca have formed order out of chaos. Every one of the patients has had two IVs placed, prophylactic antibiotics -bullets track the skin bacteria to the inside of the body- and tetanus updates, and everyone has had pain control. Even more remarkably, all of the 10 patients have had face sheets drawn up that have their medical history, current medicines, and allergies listed on them. My life is much better than it was 10 minutes ago. My nurses are amazing.

             “Doc! We need you in room 18.” I run. Suze doesn’t say they need me unless they really need me. It’s a thin teenager, struggling to breathe.
           “What’s this?” I ask the nurses, the patient obviously can’t tell me anything.
            “Asthmatic, got maced.”
            “What?”
            “Doc, where have you been? There’s a riot outside. They’re flipping cars and throwing bottles. City X police are here. They’re trying to break up the crowd but it’s not working well.”

I’ve been examining the patient while we’re talking. He’s not doing well. He’s really, really not doing well and his oxygen saturation is dropping. I don’t want to intubate him, asthmatic don’t do well with intubation.
“Okay, I want him on continuous albuterol with atrovent in the first dose. Give him 125 of Solumedrol right now. I want two grams of magnesium given over two minutes and I want him to have anaphylaxis dose epinephrine. And get me the pediatric ICU.” I turn to my patient,
“I don’t want you to talk right now, just listen to me. Your job is to get your breathing under control. I know it’s really hard right now but I want you to count while you breathe. Right now you’re breathing really fast, one in, one out. I want you to try and slow it down. Start small. Go for one count in and two counts out. And when you’re good at that, do two counts in and three counts out. Keep your breathing out longer than you’re breathing in because with your asthma you are trapping air into your lungs.”

I can see that he’s trying. That’s all I can ask. If he gets worse I’ve got a couple more tricks up my sleeve, but asthma patients can crash and die on you. It’s interesting to me that I get 9 gun shot patients and the patient who is most likely to die isn’t one of them. I go and check on the rest of my patients. The butt-shot girl went to the OR. The formal ultrasound on the boy who was shot in the knee looks like there is some vessel injury. I admit him to vascular surgery so they can continue to do checks on his leg and surgery if necessary. Two kids are going to be admitted for complex fractures caused by bullets. Everyone else is going to go home. Amazing.

There is a lot of paper work. I finish it up about three hours after the end of my shift. The asthma kid went up to the ICU on continuous albuterol. He was doing better but not out of the woods. The girl is out of the OR, the bullet hit her bowel and one of her ovaries but she’s going to live. The adult bystander died during surgery.

I tell the adult attending I’m leaving and that I have no patients to sign over to him. A porter is washing the blood off the floors and the walls in the hallway where we were triaging. I thank her for her work and wish her a merry Christmas.

Tap is off duty and a an officer I haven’t worked with before has replaced him. She says its safe to go outside without looking up from her computer screen.

The parking lot, usually dark, is lit by portable klieg lights and four police SUVs still watch over it. The rioters flipped one car and broke the windows of the security booth. Other than that, there isn’t much obvious damage. I drive home. I need to be back here in 8 hours. One hour home, one hour back, a half hour for showering and eating, 5 and a half hours of sleep. I’ll be fine.

The next morning my local paper reports a Christmas miracle: a local girl’s cat survived being put through the washer and drier. It reports that a town in Texas which doesn’t usually see snow got snow for Christmas. It says nothing about the shooting, the death, or the riot in City X. I don’t know if that is because it’s so common it’s not worth reporting –although nine pediatric shooting in one evening certainly isn’t common in my experience- or whether the rest of the world just doesn’t know or care that X is falling apart.

I put on my scrubs and head into the snow to go to work.

The very model of a psychopharmacologist

Mon, 19 Nov 2007 17:44:07 GMT

I do realize that I need to get out more but as a lover of G&S and a big geek I thought this was worth seeing

Healthy as a Horse

Tue, 06 Nov 2007 23:12:19 GMT

Graduate school is officially Kicking. My. Ass.

Medical school is mostly just memorization. It's tons of hard work, but it's really just mostly memorization. Graduate school requires a lot of in depth analysis which requires me to dust off neurons that haven't seen the light of day in decades. Add that into being a full time research fellow and attending in an ED and it doesn't leave a whole lot of time for blogging. I have three longer posts half written and will get them up as soon as possible...which may not be soon.

But this happened on a recent shift and was too good not

    Ms. Turner's family obviously didn't believe in speed limits since they beat the lights-and-sirens ambulance to Hospital X. I lost count of all the family members after 10 or twelve people asked if Sadie was going to be okay. I hadn't the foggiest idea what her prognosis was since Sadie had not yet arrived and banished the hordes of Turners to the family waiting room. I asked Sadie's husband to wait. I could get some information from him while we were waiting for the paramedics. He looked miserable, shrunken inside his suit, twisting his hat between his hands.

    "Does Ms. Turner have any medical problems?" I ask
    "No, no," Mr. Turner said. "She's as healthy as a horse. Always has been."
    "Does she take any medicines?"
    "I don't rightly know." He thinks about it for a moment, "I expect not."
    "Is she allergic to any medicines?"
    "She's real allergic to ragweed and cats. She gets all stuffy."
    "When did you last see her acting like herself?"
    "About a half hour ago. She was washing up after dinner and then went to go watch some TV. I came in a little while later and she....she wasn't breathing." Mr. Turner's eyes fill up with tears.

    The paramedics thunder down the hallway. They've obviously managed to intubate Ms. Turner and it doesn't look like they are having any problems oxygenating her with bag.

    "Sadie!" Mr. Turner cries. I ask him to wait on the chair in the hallway just until we get her off the paramedics gurney and into a hospital gown.

    The paramedics tell me that they found Ms Turner on the couch, her family had rolled her off her face. She appears to have lost control of both her bowels and her bladder and the paramedics relate that she has bite marks on her tongue. Seems like she had a seizure. She's got a steady heartbeat and a good blood pressure, she's just not breathing on her own. I listen to make sure the endotracheal tube is actually in her lungs then step outside the room while the nurses and the paramedics clean Ms. Turner before putting her into a gown.

    "Mr. Turner, Sadie is very sick but right now the paramedics have her stabilized. Her heart is okay and her blood pressure is okay, but she's still not breathing so we have a machine breathing for her. It looks like she may have had a seizure. Has she ever had a seizure before?"
    "No, no. She's always healthy."
    "Does she drink alcohol or use any illegal drugs?"
    "No! Never! Nothing like that!"

    The nurse sticks her head out of the room and asks me to come in. I reassure Mr. Turner that I'll be back in a minute.

    Carrie, Ms. Turner's nurse, bears a disturbing resemblance to Paris Hilton. She is an excellent nurse, but the resemblance is off putting. Carrie cracks her gum and tilts her head to our patient,
    "I thought you said she didn't have any medical problems."
    "That's what her husband said."
    "Then what's that?"
    Ms. Turner is now naked, the tech is washing stool off of her legs; that's not what Carrie brought me in here to see. On Ms. Turner's left arm there is a huge vessel, the size of a sausage with a palpable thrill when you touch it. It's a fistula, an artificial vessel made by sewing together a vein and an artery so the patient can get dialysis. Ms. Turner also has a large scar on her abdomen and, in her lower abdomen, there is a palpable lump. Carrie tells me what she thinks it is. I agree. I look at the latest set of vitals and step out of the room.

    "Mr. Turner?"
    "Is Sadie all right?" I put a hand on his shoulder to comfort him.
    "She's no different. Still very sick but not in any danger right now. As soon as they get her cleaned up and we get some of the people out of the room you can go in and give her a hug. I thought you said she was healthy."
    "She was. Always healthy, my Sadie was."
    "Uh." I'm not quite sure how to proceed. Mr. Turner is not an old man. He does not look like he is demented or senile. Did this possibly happen before they met each other?
    "Uh, Mr. Turner. Sadie has a scar on her abdomen and a lump that I can feel in her belly."
    "Well, yeah. That's her kidney."
    "Her kidney?"
    "Ayup. She had a kidney transplant and that's where they put her new kidney." Which is exactly what Carrie and I thought, but someone who required dialysis and a kidney transplant is hardly 'as healthy as a horse.'
    "Why did Sadie need a kidney transplant, Mr. Turner?"
    Mr. Turner looks at me disbelievingly.
    "Why did she need a transplant?"
    "Yeah. Why did Sadie need a transplant?"
    He obviously thinks I'm a total idiot.
    "Because her kidneys weren't working good, that's why." Well, of course. I should have known.

    I give it another couple of tries. Mr. Turner denies her having high blood pressure or diabetes and still can't recall her taking any medicines. As a transplant recipient she should be on several, some of which can cause seizures. The nurses come out and tell me that Sadie's all clean. I follow Mr. Turner into the room do a complete and detailed exam and then write orders. The exam has some very abnormal neurologic findings but it could be anything. Uremia from her transplant shutting down, infection, drug overdose, stroke, bleed in her head from trauma, anything. I send off every lab in the book and order a head CT. I give an extremely brief update to the entire extended Turner clan and see my other patients.

    Sadie Turner's labs come back. Normal. All normal. Her transplanted kidney is actually functioning remarkably well. No signs of infection. No intoxication, illegal drugs, or abnormal levels of drugs she might be taking. She goes off for her head CT. I walk Mr. Turner back to the family waiting room and give another update. The Turner family is shocked that this could happen, she's always so healthy.

    No, no, no, they say to all my questions. No seizures, ever. No head trauma in the past. No mild head trauma within the last week. I ask them if anyone knows why her kidneys failed.
    "I think it was high blood." says one Turner.
    "Nah. You always get that wrong," says another Turner, "It was high sugar."
    A third, elderly Turner, shakes her head and stamps her cane on the floor, "None of you know nothing. Her kidneys were just messed up. They just was. Just 'cause. And that's the way it was, wasn't it, Jake"
    "Yes'm." says Mr. Turner, obediently.

    My pocket phone rings, it's the radiology tech. I excuse myself from the Turners and walk towards CT, talking as I go.
    "Doc, what's this lady's story?"
    "We don't really know. Apparently she was her usual self earlier this evening and then was found on the couch apneic. It looks like she had a seizure."
    "What are you looking for on this scan?"
    "Just about anything abnormal, Joe. A bleed, stroke, anything."
    "Well, we've got something abnormal. You better come and see this."

    I look at the CT. I call my residents to look at the CT. Joe calls other radiology techs to come look at the CT. It is very impressive. At least now I've got a good reason for her to seize. I walk back to the Turners.

    I ask them again. Any history of trauma? Any strange past history? Any seizures before? Any headaches? Any trouble with vision?
    No, no, no, no, no, nothing. I ask Mr. Turner to come with me. A woman who I hadn't seen before stands up as well.
    "That's my Momma. I want to hear anything you have to say." I introduce myself to Ms. Turner's daughter and escort them both out of the room.

    We stand in the hallway, there's no where else to go.
    "I didn't want to say this in front of the entire family because if they don't know it might be because she didn't want them to know. There's no easy way to tell you this, but Ms. Turner," I pause, trying to think of there is a better way to put this. I don't think there is. They watch me, expectantly.
    "Ms. Turner has a bullet in her brain."
    "She do?" Her husband doesn't look so much surprised as thoughtful. "Aww...that's right. I recollect now. Yeah. I think so. Unhunh. Unhunh. Yes, she do."
    Ms. Turner's daughter slams her hand down on the side rail "Shoot! That's right! Momma WAS shot! Yes, she was. Right in the head. Right in the middle. The doctors said that bullet was never going to come out." She stopped and turned wide eyes to me, "It hasn't come out, has it?"
    I reassure them that it hasn't come out.
    "I guess that's good. They said that it wasn't. I was real surprised to hear that she was here tonight. Momma's always been healthy."
    "Well," I said, unable to restrain myself any longer, "Except for that kidney transplant." Both the Turners nodded in agreement.
    "Ayup, that's right."
    "And," I couldn't help adding, "The bullet in her brain."
    "Yes ma'am," the younger Ms. Turner says emphatically and without a trace of irony, "Except for her kidney transplant and the bullet in her brain and maybe one or two other things, my Momma is as healthy as a horse."

Sigh. Only at Hospital X.
I could make this stuff up but, luckily, I don't have to.

check, please!

Tue, 09 Oct 2007 23:26:45 GMT

Scene: A pretentious restaurant in an expensive hotel. The sort where all the food is named after local sights and a salad costs $17.

Waiter: Ohhh...you're in town for one of the conventions!

Me: (Looking down and realizing I've forgotten to take off my dorky name badge that says INVITED SPEAKER) Yes. I'm here with the American College of Emergency Physicians.

Waiter: So you're a nurse?

Bad statistics, bad journalism, lots of press

Tue, 02 Oct 2007 20:38:52 GMT

Last Wednesday hordes of people started asking me if I had read the New York Times that day.

Of course I had! Wednesday has the dining section. There was an interesting note on fondue and yodeling and I was sad to note that the Vendy awards were coming up and I would miss them again, but the people who were asking didn't care about street food or yodeling, they cared about happiness. I thought that yodeling and happiness were tightly linked but what my friends and coworkers were concerned about was that the NYT said that men were happier than women.

I read it and said "That's a load of hogwash!"

But I kept getting irate emails from upset women discovering that they weren't as happy as they thought they were and men gloating about being so happy.

Maybe I missed something. So I followed the link to the paper referenced in the article and slogged (well, okay, skimmed) through 42 pages of economics.

What did I think at the end? "Wow. That was a really cool statistical trick to make something out of nothing!"

Which can be paraphrased as "That's a load of hogwash!"

But it is hard to explain on the fly what an ordered probit model is or how a paper entitled the Paradox of Declining Female Happiness doesn't actually prove that female happiness is declining or why it is that statistics hold true for BIG groups of people but are nearly meaningless when applied to any individual. And after trying to explain one or more of those concepts to dozens of people I gave up.

But, thanks to tlatoani, I now know that there are other people who think "That's a load of hogwash!" and are far more articulate than I am.

Everybody should go to Language Log and read the posts about this article. They do a great job of explaining why this research doesn't mean that men are happier than women.

I think that Stevenson, Wolfers, and Kruegers are brilliant - most economists toil in obscurity; they are making popular press headlines and getting Dugg.

I think David Leonhardt should be given a huge raise by his bosses. He has the 7th most email NYT story of the last 30 days and is being quoted all over the web.

Finally, I think that both "He's happier, she's less so" and the concept of a happiness gap is a load of hogwash.