The ER v SomeGuy

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.

 

Hope You Didn’t Have Dinner Plans

How to quickly land a spot in a psych hospital: complain all wild-eyed, while rocking back and forth, that a cactus is trying to have sex with you.  I didn’t ask anymore questions, because I knew everything I needed to know.

 

I Am So Dejected

I spent 20 or so uncomfortable minutes arguing back and forth with the on-call cardiologist trying to get a straightforward chest pain patient admitted.  New onset chest pain in a man in his 40’s that radiates up to his jaw and down his left arm, throwing multiple PVC’s, with pain relieved by nitro needs to come in.  What is the debate here?  How can you possibly argue to send this patient home??

Back and forth and back and forth with new patient charts steadily being ka-clonked in the to-be-seen rack.  Finally after enough time passed it was clear we were at an impasse since neither one of us were able convince the other to do what we wanted.  Except it’s not really an impasse, I always hold the upper hand here if I so choose and I did, finally listing his options as admitting the patient or coming in to the ER to evaluate and personally discharge, end of discussion.

He said fine he’d admit then ended with an insult, but oh well right back at you plus I got what I wanted and what was right for the patient.  But the whole incident left me really dejected.  It’s deflating to have to fight tooth and nail for what should be effortless.  This kind of interaction comes with a price, and now it’s going to be awkward seeing this guy or calling him to admit future patients.  I’ve had a run of shifts with burnout-worthy incidents and I can tell I need to get away from the ER for awhile.

Funny how circumstances can conspire to warp your priorities.  Nothing would be more satisfying than finding out this guy went on to have a heart attack so I could forever keep that troponin of 5 tucked away in my back pocket, a pretty sweet arbitrator for any future disputes.

 

Seriously, Beepers?

When I was 8 my dad started carrying a beeper.  He sported this hefty little technological wonder like a temperamental off-kilter belt buckle, its random screechings resulting in a little panic and a lot of off-switch fumbling, the messages I guess usually from God telling him no he didn’t have to stick out the entire sermon.

Now naturally I get a little misty-eyed reminiscing about gadgets from back in the day.  Oregon Trail (dysentery!) and Number Munchers (Troggles!) on the computer lab’s Apple IIc’s.  Mike Tyson’s Punch Out (King Hippo!) on the original Nintendo.  My battery and tape eating Walkman.  My Casio keyboard (Greensleeves!).

Of course I can’t miss you if you won’t go away.  There’s not a doctor I know without a cell phone, and so naturally when I need to speak with one we dial their, um, beeper.  Wait, what?

It usually goes like this: I tell the clerk we need to page so-and-so.  She calls their answering service (answering service! madness!!) at which time it’s 50/50 the clerk gets put on hold.  Eventually the clerk kindly asks the answering service person to make the doctor’s beeper beep.  They call back at random times, or not at all, some beepers it seems have to be dialed twice before beeping.  I’m held completely at the mercy of the system, unless I just absolutely truly require an immediate response, in which case I simply head off to the bathroom.

It’s not that I don’t get it.  Beepers are a buffer, a way for doctors to protect themselves from their patients, the floor nurses, pharmacies, etc.  For a doc to doc conversation though, how about offering up your cell phone number for me to call or text?  There are hundreds of time sucks in the ER.  Me wondering if your beeper has beeped shouldn’t be one of them.

 

Proposition Disposition

Residency: This kid has a supracondylar fracture, page ortho to come down.

Community: This kid has a supracondylar fracture.  Let’s see here now, there’s the hospital ortho group and the community ortho group and I happen to know it’s the community group’s night to take call.  There are three of them, one will see supracondylar’s but the other two “don’t feel comfortable” and always ask us to arrange follow up with the pediatric orthopedic surgeons in the referral city down the road.  I walk over to the call schedule and slowly look to see which one is on, muttering “please be supracondylar guy please be supracondylar guy” so I can be done with this patient but “damn!” it’s a worthless non-supracondylar guy whose name comes up on the list.

Ok then.  I go through the chart to see what kind of insurance this kid has, since any kind of insurance means paging the pediatric orthopedic surgeon to arrange out-patient followup, but no insurance means transferring them to the big city ER, the exact details of why it is this way still fuzzy to me but somehow someway I’m told that some amount of money is recovered by the pediatric orthopods if the patients are funneled to them through their affiliated ER.

This particular kid happens to be uninsured so I call the big city ER and usually they say fine but I must have a new guy or something who is unaware of the arrangement because I get a lot of resistance: he asks me “why can’t your orthopods take care of a simple supracondylar fracture” and I say “I don’t know, because they ‘don’t feel comfortable’” and then he says “well didn’t they go through an ortho residency?” and I say “look all I can tell you is what they’ve told me” and then he plays his trump card and says “well did they even come in and see the patient?” and I sigh and say “no they just looked at the xray from home” and then he gets uppity and says “well they need to at least personally evaluate the patient” and hangs up as I’m trying to just explain that there is already a system in place not to mention we both know the orthopod doesn’t really need to come in I mean it’s not some complicated HIV/dialysis/heart failure/septic patient or anything it’s just a healthy kid for crying out loud and he’s seen the film and I told him the fracture was closed and neurovascularly intact and that’s all there is to know but the big city ER guy probably thinks I’m trying to dump an uninsured patient on his overwhelmed ER and of course they are uninsured but the truth of the matter is it’s not a dump our orthopod doesn’t manage any supracondylars insured or not and I sure don’t care whether or not they have insurance and I don’t care where they go, I just want someone to take this patient off my hands because I have 14 others to worry about and a packed waiting room myself.

So now I’m left to decide whether to call the big city pediatric orthopod to see if I can get him to call the big city ER to tell this guy to go ahead and accept the patient in transfer or call my community orthopod to come in and evaluate the patient and I decide to call the local guy since that’s what the big city ER guy is asking for and because he’ll probably call back faster than the out of town guy and let’s not forget to mention if this board certified orthopedist would just take care of freaking non-displaced uncomplicated bread-and-butter supracondylar fractures I wouldn’t be wasting all of this time.  I decide to walk over to triage and announce to the nurse that while I’ll continue to see straightforward chest and abdominal pain, I am finding more and more that I just “don’t feel comfortable” with dizziness and ask her to refer those patients on south.  Unfortunately she doesn’t take me seriously.

The local guy calls back and I explain the situation to him and he agrees to come in.  He evaluates the patient, calls the big city ER, and the patient is accepted for transfer.  We fill out lots and lots (and lots) of paperwork, print out the xrays, call for nursing report, call for an ambulance, and finally the patient is loaded up and on his way to the next ER.

In residency you learn how to diagnose a supracondylar fracture.  Out in the community you learn how to disposition it.

 

Oh Yeah

So I worked today and realized all along that it was July 1st, but totally forgot about the significance of July 1st until just now.  This is the day 2nd year med students start clinical rotations, senior med students become interns, interns become residents, residents become fellows or attendings.  I’ve had plenty of angst brought on by this day in the not-to-distant past, I love that it’s just another day now.  I’ve had enough of new challenges going through the medical education wringer, for now I’m content to be content.

 

Venus and Mars

The hospital’s electronic medical record recently underwent some major upgrades, new code written and uploaded, allowing administration to inch ever closer to their singular goal of making my head explode once and for all as the computers are clunkier, buggier, and more sluggish than ever.

Anyhoo, the cosmetic changes to the interface include a colored backdrop for patient names, the previous generic white now shaded blue for boys and pink for girls.  Although I’d never picked up on this before , the new cotton candy colored screens make it strikingly obvious that the female patients substantially outnumber the males, I’d guess by about 2 to 1.

Why is this I wonder, other than my devastatingly good looks?  Women outlive men by a substantial margin, shouldn’t they be healthier than men and therefore have fewer ER visits?

Then again, women’s reproductive parts are fraught with complications.  Women get pregnant far more often, it’s rare not to see at least a patient or two per shift with some sort of pregnancy issue whether it be cramping, bleeding, nausea, or acute ultrasound deficiency.  The number of women showing up with discharge or painful urination dwarfs their male counterparts.  Ovaries are much more prone to painful problems than testicles.  Tampons and IUD strings get lost.  All in all I’ve learned it’s much riskier being a female.  And that I should have been an accountant.

But men have gender specific diseases too, like trauma, they being far more likely to mangle themselves in various creative ways as compared to women.  The root of the ER gender disparity then, I submit, is found not in the pelvis, but instead laying north within the gray and white matter between the ears.

Women are far more prone to somatization, the process of anxiety or stress manifesting itself as a physical symptom.  Women seem to be wired in such a way that their negative emotions lead directly to chest pains, or abdominal pain, or shortness of breath, or headaches, or diarrhea, or weakness, or dizziness far more often than in men.  The discomfort is real, but the root cause is not physiologic but instead psychosomatic.

And then, women are not only more likely to develop symptoms, but they are more likely to do something about them.  Men prefer to put their heads in the sand, dealing with disease in the same way they handle the homeless guy asking for spare change at a stoplight: by looking the other way and hoping it moves on.  Women are far more proactive, their threshold for seeking medical evaluation significantly lower.  It’s never the husband who drags his unwilling macho wife to the ER to be checked out for this or that.

This is all about populations of course and cannot be applied to individuals — there are plenty of guys who show up with anxiety-induced chest pain scared they’re having a heart attack.  But taken as a whole, and applied over thousands of patient interactions, these differences between the sexes have over time have become more and more apparent to me.  And it’s a factor in what the bulk of emergency medicine is in this country: it’s not about taking care of actual emergencies, it’s about offering reassurance that there isn’t one.

 

Highly Scientific

Q: What is the proper amount of time to observe a drunk?

A: It depends on when your shift ends.

 

How Patients Are Admitted

Nice Old Patient: “Dr. 10/10, is there any way you can please keep me overnight?”

Me: “Well, I think we have enough here that that’s reasonable.”

Nice Old Patient: “Oh what a relief!  Will you be taking care of me?”

Me: “Oh no, they don’t let me out of the basement.  I’ll discuss your symptoms with one of our hospital specialists, who will take care of you from here on out.”

Nice Old Patient: “Wonderful thank you very much.”

Me: (leaves room, now thinking) Hmmm, let’s see, who’s on…uh oh Dr. Wornout.

Me: Boy, he used to be great back when he first came to town and made deals with a bunch of the local doctors to admit their patients for them.  He just had a handful of fully funded admissions a day, and the hospitalist was left to admit everyone else.  Gosh he was so nice and pleasant then.

Me: Then for some reason the hospitalist left, and Dr. Wornout took over admitting everybody.  Now he’s mean and surly for some reason, and all he ever does is complain about how many admissions he’s had and how many patients he’s managing upstairs and how he’s so overworked.  He’ll try to wiggle out of this for sure.

Me: Of course he is too busy, it’s too much for one doctor to try to admit all these patients, manage them on the floor, and discharge them home.  Not my fault he won’t hire extra help though.

Me: (looks at watch) 6:40pm.  Hmmm.  Dr. Wornout gets off at 7pm, and his partner Dr. Crosscover takes over.  He doesn’t care about admissions, all he does is give admitting orders to the nurse over the phone from home.  Dr. Wornout’s the one who’ll have to actually take care of him when he gets back tomorrow morning.

Me: (to clerk): “Will you page Dr. Crosscover for an admission in 25 minutes?”

A heartwarming story, I know.

 

My Day In Court

A malpractice claim is not the only way to end up in court.

I happened to be on the night a toddler was brought broken to our ER essentially dead from abuse, a case that was horrific for all of us that futilely tried to stave off the inevitable.  An investigation dug up even more grisly details, and eventually the perpetrator was brought to trial.

The day I was called to take the stand I put on a suit I hadn’t worn since a funeral, which seemed appropriate.  I arrived at the courthouse and took a seat outside the courtroom to wait my turn to testify.  I sat alone flipping through a stray Newsweek wishing my stomach would stop churning.  I was really nervous although about what I’m not sure — I had already met previously with the prosecutors to go over the case and the questions they would ask.  I guess it was just the gravity and the formality of the proceedings, knowing that all eyes would be on me and that all my answers would be permanently recorded, worrying some about how my answers would come across and more from the uncertainty that hung over the questions I might get in cross-examination.  Maybe at some point in my career I’ll get used to providing testimony, but for now it’s all new and I found myself way out of my comfort zone.

Then they opened the door and called me in.  I walked up to the stand and faced the jury and raised my right hand and said I’d tell the whole truth.  I sat down, my stupid stomach on spin cycle by now, and for a split second I had trouble answering just where it was that I went to med school.  But gradually I settled down and soon it was just a conversation, albeit with a lot of spectators, about what happened in the ER that night.

The defense just had a couple of easy questions, I think through my own self-centered take on the proceedings it was easy to forget that I wasn’t the one on trial.  Then for me it was over and I walked out to my car relieved to be just some guy again.

The drive home gave me a chance to reflect.  Some of the questions they asked bounced around in my head, and like I always do I picked apart my answers and wished I had said it this way instead of that, replaying the altered, new-and-improved dialogue again and again in my mind as if doing so would make the changes real.

But mostly I thought about that little kid, and life, and why is it that some children are born with love overflowing and others destined to savagely die.  And those kind of thoughts stir up dormant emotions, because no matter how grizzled and cynical this job makes you, some things still pierce through.  I wonder if time really does heal all wounds — this one just seems to scab over, rebleeding every time it’s picked at.

But I’m not much of a thinker, and by the time I got home I was ready to start forgetting.  I got a beer from the fridge and turned on a mindless baseball game, appreciating the sanctuary of my home, insulated from all the monsters.