A girl 18 weeks pregnant came in with something trivial.

Me: (During the pelvic exam) “Ok, everything looks normal.  Do you want to know if it’s a boy or a girl?”

A 19 year old guy about to get a shot was nervously flipping channels on the TV in the room.  He was too freaked out to notice what he stopped on.

Me: “Oh, so you’re a big Murder She Wrote fan?”

A woman came to the ER with one month of belly pain, a complaint I would normally find irritating.  Pain for a month hardly seems like an emergency, now does it?  Don’t you know emergency rooms are for emergencies?  (Of course everyone knows that ER’s are mostly for non-emergencies, yet ER staff love to conjure up mini-bafflement/outrage tizzies for particularly egregious complaints, I guess to allow for some form of masochistic release.)

But this lady was somewhat different than the typical something-wrong-x-1-month-er.  For one, I liked her almost immediately.  She was affable and seemed reasonable, two characteristics so rarely found in tandem amongst my patients, which conspired to melt through my inherent pessimistic frostiness over such a complaint.  As she augmented her description by sitting up and placing her hands over an unusual area to hurt, I was struck by a discreet moment of clairvoyance.  It was less a thought and more as if someone briefly took control of me, dimming the surrounding din then playing for me my pre-recorded voice inside my head, confident and clear so that I could not possibly miss the message, “something is horribly wrong with this woman.”

I was only allowed a second or two on this omnipotent perch, in the blink of an eye I was once again relegated to collecting data on associated symptoms and social history.  Though the premonition’s prospective weight was not that of its retrospective cousin, it was impressive enough that I found an excuse to scan without a second thought.  I wouldn’t have been shocked if it came back normal since time blunts and allows for second guessing.  Still, I was not surprised in the least to read of her now newly-diagnosed metastatic cancer within the CT report.

I made sure this nice woman was taken care of, then bumbled through the rest of my shift, ensconced in ambiguity, the dizziness probably just inner ear, the chest pain probably not cardiac, the headache probably just a migraine, the fever probably just a virus.

I don’t want to talk about vaccines and autism for the same reason I don’t feel like standing up and repeatedly smacking my head against the wall.  I would, however, like to pass along the following information about the H1N1 flu vaccine and mercury.

There are three different companies that make H1N1 (swine flu) flu shots.  Of those only one, Sanofi Pasteur, has a shot FDA approved for kids less than 4 years old.  Sanofi Pasteur makes three different H1N1 flu shots, one of which is FDA approved for kids older than 3, the other two are approved for kids all the way down to 6 months.

Of the 2 Sanofi Pasteur shots approved for kids older than 6 months:

-one is a 0.25 mL prefilled syringe (an individually packaged shot) which contains no mercury
-one is a 5.0 mL multidose vial (a bottle of vaccine that 10 shots can be drawn out of) which contains 25 micrograms of mercury per shot.

A mercury free H1N1 vaccine is out there for your kiddo if you are so inclined, don’t let any fear mongers tell you otherwise.

CDC website — scroll to the table near the bottom if you want to see for yourself

1. See next toddler with flu-like symptoms.

2. Try to figure out if the mom will only be satisfied by a flu test.

2a. If no, she just wants my opinion:
-It’s swine flu
-Discharge home
-Diagnosis: Swine flu, clinical
-Treatment: Motrin and tylenol; no one has any liquid tamiflu and it’s too expensive anyway

2b. If yes, I don’t care about your opinion I want a test go to 3.

3. Test for flu

3a. If negative:
-Good news!  It’s not swine flu!  It’s some other virus.
-Discharge home
-Diagnosis: Swine flu, test false negative
-Treatment: Motrin and tylenol; no one has any liquid tamiflu and it’s too expensive anyway

3b. If positive:
-Good news!  We know what’s wrong.  It’s swine flu.
-Discharge home
-Diagnosis: Swine flu, I mean it was proven by a test
-Treatment: Motrin and tylenol; no one has any liquid tamiflu and it’s too expensive anyway

4. Go to 1.

At least not literally.  Figuratively I’m still not sure.  I have some things I’d like to write about, but life can change and I’m just finding it harder and harder to come up with the chunks of time I need to post.  Hopefully it’s just a sabbatical.  Thank you all for your nice comments and concern.

Me: Now that you’re pregnant, you should stop smoking.

Patient: I’ve been smoking for 12 years, and I don’t plan on stopping now.

Me: (Pause) Wait, you’ve been smoking since 2nd grade?

I haven’t seen very many people die.  Instead it’s people who’ve already died and then are brought to the ER (usually still dead), or people who are about to die that we prop up long enough to die in the ICU, or people that die just a minute before I get to them in response to their code blue.  Of those that actually manage to die in the ER, most are lined and tubed and monitored so that their death is observed not on their person but rather in an aseptic collection of downward trending numbers oblivious to our resuscitative efforts.

But then I saw a 103 year old man who actually looked fine but turned out to be in complete heart block.  And then some time later his heart rate jumped from 40 to 190 and now he was in V-tach.  He still looked fine so I just stood somewhat mesmerized by his sine wave waiting for the nurse to come back with the amiodarone.

And then abruptly his sine wave became a flat line.  He had a Do Not Resuscitate order in the chart so I didn’t.  Instead I just watched him.  For a few long seconds his countenance seemed to defy his condition.  But then his eyes rolled back in his head, and his color began to change from pale to red to dusky blue.  His mouth kind of drew in on itself in a manner wholly unnatural with life.  I asked his son if he wanted to say goodbye and he did so I led him to the bedside and everyone else including myself out of his room.

But I continued to eavesdrop from the remote heart monitoring station.  And I saw a blip in his flat line, then another, and soon his heart was beating again, more normal than when he arrived.  I headed back to his room to find him eerily well appearing, as if the last few minutes had abruptly been erased.

Like I said, I haven’t seen very many people die.

The ambulance pulled up and two medics hopped out, which was unusual since I wasn’t at work.  From my kitchen window I had seen them drive past my house to the next door neighbor’s, a nice enough couple that I share a fence but little else with as they are more than twice my age.  I thought about going over to see if I could help, but other than being in the way I add nothing to a medic’s prehospital interventions, not to mention I was literally heading out the door for work and I figured I’d just see them there.

I saw him soon thereafter, and shook his hand, and told all his family the next time we get together let’s do it someplace besides the ER since that always lightens the mood with people you only kind of know.  As I started my assessment it soon became clear that he had something VERY BAD.  I ordered a series of tests to show the BAD and quantify how VERY, placing some calls to make sure they were done as soon as possible

A bystander might wonder how an ER can be so devoid of empathy, how we can be unaffected by and in fact make light of disease and suffering and death.  The reason is that it’s impersonal, that we interact with you but don’t know you, that the fact of the matter is unless something is particularly tragic some sort of an interpersonal connection is necessary to conjure up grief.  It’s the difference between reading an AP story of another soldier’s death, then watching a sit-down interview with his decimated wife and kids.

I’ve been cognizant of my emotional detachment for some time now, but never really appreciated its benefits until I worked without it.  I’ve taken care of friends and acquaintances before, but always for some relatively minor ailment.  But now here was my neighbor, and his VERY BAD findings.  No longer was I able to run the department expertly, only adequately, since I was spending far too much time perseverating on him.  He had a few different treatment options, his accompanying co-morbidities causing each choice to carry a substantial countering risk.  I second guessed myself far longer than I normally would, continually revisited and reupdated his family, and had a persistant underlying sense of unease and jitteriness — all because I had a small but legitimate fear that he would tip over some ill-defined physiologic precipice and die in front of me, his house becoming my permanent reminder of his family’s grief, my house turning into a monument of failure and shortcoming to his widow.

Finally he was gone from the ER, as stable as possible, and at least if something happened now I’d be off the hook for it.  As it was, he went on to make a full recovery.  He now credits me for saving his life, and while my emotional side is plenty willing to soak that up, my more insistant logical side knows his diagnosis couldn’t have been more obvious, that sometimes a patient’s fate is set, one way or the other, regardless of this or that treatment thrown at them, that as an ER doc it doesn’t feel like you’ve done anything extraordinary unless you, well, do something extraordinary — certainly not just see over some case that anyone, save for a complete hack, would be unable to bungle.

Still, I’m so glad you’re ok neighbor, for both you and for me.  Next time we get together let’s do it someplace besides the ER.

Timeless advice: don’t run with scissors, don’t swim after eating, don’t drunkenly stagger out of a pawn shop and onto an interstate feeder road.  Especially if it lands you squarely in the crosshairs of a barreling tow truck.

To the driver who had glanced down at his radio, it was as if he had materialized out of thin air.  The story almost ended here, someguy to share the same fate as the flattened critters on the truck’s grille.  Only in retrospect was it clear that he was far too mean to die so easily.  Instead, the driver instinctively smashed the brake and yanked on the wheel, the front end seemingly just whistling by, but the side mirror smacking him flush on the shoulder, spinning him around, then the passing rear bumper catching him just below the knee.

Undeterred, someguy got up and resumed his staggering, although this time minus a chunk of his leg.  Police and EMS quickly arrived on scene, and someguy wanted no part of an ER evaluation but he was in no position to refuse, being drunk and high and whatever else, and so our paths crossed.

I examined him, cautiously, unsettled by his lability: he was laughing hysterically one minute, sobbing the next, then vicious the next.  The exam was about as revealing as a nun-of-the-month calendar — all I took away from it was that this guy was hit by a freaking tow truck and needed to be CAT scanned from head to pelvis.

But then the blood pressure cuff started inflating, and it was as if the cuff had become white-hot too.  Someguy, in an impressive burst of insanity, sat bolt upright, screamed, ripped off the cuff, ripped off his neck brace, ripped off his gown, and ripped out his IV, splattering drops of blood across the wall.

Clearly he needed to be restrained, for his safety and ours.  We did the usual thing, one person for each extremity, and I took my place at the head of the bed to keep his neck bones immobilized.  He fought the leather restraints, thrashing dangerously, so I slipped my fingers under his jaw and applied upward pressure, a move that typically elicits submission.  Not this time though, it was as if he was impervious to pain.  And then, suddenly, he managed to wrench an arm free and pow/pow punched me twice in the face.

I felt no pain, it didn’t hurt until later.  Instead shock and a primal rage that spread internally like a reservoir through a crumbling dam pleading and empowering me to retaliate but I didn’t, fortunately, I just grimly dug deeper into his jaw until finally that arm like the rest of him was tied up.

I went back to reassess a few minutes later, composed, since I am scary good at setting aside emotions to deal with the task at hand.  The nurse stood by with the haldol and ativan as I explained to someguy how important it was to get the scans, that he could have life threatening injuries for all I knew.  He looked at me wild-eyed and said as crudely as you can imagine that he’d never allow it to happen.  Immediately, I saw in my mind’s eye an image of the CT scanner, with the tech and nurses struggling to hold him down, and then returning to reality I looked at the nurse and asked her to put the haldol and ativan away.

Enough was enough.  I decided to sedate him far deeper, to a level that would require intubation and mechanical ventilation.  Reflecting on the decision while getting things ready I found myself more apprehensive than usual: there is always risk involved in taking over someone’s airway and here I didn’t have a “hard” indication like being unable to adequately breathe or clear secretions.  But here we were an hour and a half into his ER visit and I had yet to even be able to assess if he had any sort of internal injury, not to mention he was consuming the majority of resources available in the ER, so that he was compromising not just his care but the rest of the patients as well.

We gave him the intubating meds and his oxygen levels almost immediately plummeted.  Normally they’ll hold steady for 3-5 minutes or so, but his metabolic rate was ramped up so crazy high from all the stuff he was on that his body was chewing through oxygen like crop-deprived locusts through a field.  I hastily stuck the laryngoscope in his mouth and his vocal cords politely dropped into view.  ”Gimme that tube” I said, quickly easing it down his throat, the monitor voicing approval with some happier-pitched beeping.  Finally, blissfully, his care became routine, he went quietly through the scanner, and in fact he did have some internal injuries that were treated without incident.

Sometimes alcohol turns people into a-holes, and sometimes a-holes just happen to be drunk; this guy went on to reveal himself as the latter.  Not that it matters.  No matter how base, or irresponsible, or dangerous you might be I’m stuck with you.  How I feel about being the nation’s safety net is a whole other post, for this one it is suffice to say that holding the rope at times can literally leave a mark.