Just Not Right

They say that you need about 10,000 reps of anything to be an 'expert'. Average US residents in EM, then, graduate slightly less than that; even assuming we are rockstars, 3-4 years of training, up to 2000 hours a year, 2.0 patients per hour--which would be crazy busy--we only see, at best, 8,000 patients. Thus, a learning curve still exists.

I had a neurology attending describe partial status epilepticus my second year of residency by standing at the foot of the bed and staring at the patient. She almost seemed to test the air for a whiff of the electrical storm in the patient's cranium. Seemed like an eternity; no exam, just observation. Finally, she said, 'yep. Seizing'. I scoffed, internally, of course. But the EEG, as the greyhairs and nohairs reading the post have already surmised, was positive. She later explained that you eventually just get a feel for who is seizing or not, and that her decision is primarily made when she walks into a room based on her gestalt. Malcolm Gladwell talks about this phenomenon as 'thin-slicing', the contribution of our automatic intelligence. In EM, it's as big a part of our job as any other, and usually represents the sick/not sick decision point, but it's developed only over time.

I've had two cases recently where my 'thin-slice' impression was the right one. In the first one, a 74 yo M presented by ambulance with altered mental status; per EMS, he had a witnessed syncopal episode in the yard while drinking with seizure-like activity and persistent altered mental status, minimal trauma from the fall, and no other associated symptoms. Normal pre-hospital sugar. The paramedics stated, 'he has a history of seizures' as well as alcohol problems. Actually, they said, 'pt has a history of seizures and is post-ictal, and he was drunk too'. Hmmmm. Perhaps; a lot to unpack there. If he's post-ictal, that doesn't help me; prolonged post-ictal states can be a sign of status epilepticus, or a representation that it wasn't a seizure at all.

His exam was odd; his GCS was about 12 with confused speech, eye opening to voice, and localization, but he seemed to favor his right side. Sugar was again normal and a focused airway exam revealed an intact gag. I watched him for about 15 minutes, and he improved, consistent with a post-ictal state, so was sent for CT.

Of course, it was no post-ictal state, but a spontaneous ICH. He declined again and was intubated. In retrospect, though, this was not a surprise; at the foot of the bed he already didn't 'smell' post-ictal. Think of how many post-seizure patients we see; this is a very typical patient, usually a brief or non-existent work-up, maybe a load of AED, and discharge. But the persistent altered patient...time to think a bit more. You can use the AEIOU TIPS pneumonic, standing for alcohol, endocrine causes (hypoglycemia), infection, opiates, uremia, trauma, intracranial causes, poisoning, or stroke; but the pneumonic can represent a trap of sorts. Some require more prioritization than others and vastly different treatments. Unless you give IV dextrose, narcan, ceftriaxone, and charcoal via NG after LP and intubation to every altered patient, more work is needed to get to the bottom of it. Start with the sick/not sick question; if you think they're sick in your gut, get to the bottom of it.

Photo Credit

Tweet

Frequent Flyer

As he's moved over to the stretcher, he complains of chest pain 'just like his past MI'. Sweet! Admit! says my inside voice. To be perfectly honest, at 3 in the morning, the rest of the history is window dressing. Hypertensive. Then he adds on. On dialysis, missed the last 'couple'. And he fell down nine stairs, with a bump on the head. And he's on coumadin due to a prior PE.

I was already done, now I'm even more so; when I go to his chart to look at his history, though, the true story emerges. Every four days, he has a discharge summary; each one essentially the same. Came to ED, needed dialysis, admitted, dialyzed, sent home.

These are the people that are eventually easier to just buy an apartment and a social worker for. Each of these visits gets billed out, each time labs are drawn, IV meds given. Reminds me of someone getting their liver eaten and then pushing a rock up a hill...

Pellet Gun

Normally they don't hurt this much; even birdshot is more of a nuisance, really, than true pain. I saw one guy with about thirty pellets in the side of his face and chest who didn't really need more than a dose of pain medicine. So I'm taken aback that he's sweating and arching before I even push on his belly. The sweat and penetrating trauma don't go together well. Heart rate's over 120--but it's just a bb. Can't be that bad, right?

He had come in with mom through front triage, and the nurses, bless them, had already labeled her hysterical. One nurse says 'she doesn't think we're doing enough to take care of them'. Ok, fine, but...'I think the bb is still in there', mom says, worried. She didn't see what happened and the patient is not in the mood. So, look for other witnesses--his friend. The bb gun, or air rifle, was really close when it went off. Like, really close. Neither one thought it was loaded. Mom pushes around the tiny dimple of exposed, red, subcutaneous tissue through the center of the wound in the lower stomach. 'I could feel it', she says, 'and now it's gone'. Has anyone seen the bb? No?

I can't feel it either, so x-ray it is; on the lateral abdominal film, it's deep, and there's that subtle rim of free air on the decubitus film. It's just a bb! That no one found because it's deep to the intestines. Away he goes, stable, luckily.

Moms certainly do go after those who harm their little ones at times, and yes, they can be hard to deal with. But if mom says she 'feels the bb', maybe that's because she carried this 14 year old boy inside for 10 months and nursed him for years, and can 'feel' the bb through the layers of fat, muscle, and peritoneum. So if she's worried, I'm worried.

Pellet and air guns have a muzzle velocity at times as great as a hunting rifle. The energy is low because of the low mass of the pellet or bb, but in this case, it wasn't the energy--it was the penetration.

No, I Won't Do It.

There's this article, by some dude from Detroit called Rivers, perhaps you've heard of it--some weirdness about "Early Goal Directed Therapy" and some "Surviving Sepsis" type thing. Anyway, the upshot is that anyone who is septic--that is, has signs of a severe, overwhelming infection--should be aggressively resuscitated with tons of fluids, invasive monitoring, antibiotics, pressors, transfusion if needed, preferably (according to the original article) with expensive, slick-looking catheters. The kinds of catheters BMW would make if they were in the medical supply business. The kinds of catheters the resident gets yelled at for breaking.

This idea has saved a lot of lives, with interventions, and also with increased screening. However, the catheters have downsides; even the Toyota versions rather than the BMW versions are invasive. There's a big needle, and a wire, and it's stuck in a big vein, usually next to an artery, just above the lung. So, bad stuff can happen, and it's not like a Swedish Massage, either.

This seventy-eight, looks ninety-eight lady is brought in from the nursing home in her bathrobe because she's 'not acting right'. Of course, she's non-verbal at baseline, and lays on her side until someone turns her. Her legs are atrophied and contractured up so they no longer straighten. Her skin is taught like parchment. She looks at nothing, just generally up; one could imagine she looks to her eventual home. She doesn't moan or wail or complain--there's not enough left, I don't think. And yet, she's a so-called 'full code'--that is, we, as the medical establishment, should do everything to save her life, including push on her chest and break her ribs to force blood up to her damaged brain, put a tube in her throat, and stick her with needles.

Well, I'm sorry, family that can't accept the loss of your loved one that happened years ago with the first stroke, I'm not doing it.

I'm not going to lay her in a position where her head slopes down to make the vein bigger, clean her neck, and stick a long hollow needle in her neck. Do you know why? Because she's going to cry out, and try to move her atrophied, useless limbs towards me under the drape. Or worse yet, not even move. And I can't explain to her what we're doing. I can't tell her that there are risks to this but we should do it to bring her back to her baseline, because she can't respond at her baseline.

Those of us on the front lines are learning when to say no. No, this poor lady in the twilight doesn't need to be harpooned. She's going away gently already. The central line doesn't beat back time, or raise the veil.

In The Scanner...

They have to bring the CT bed all the way out from the scanner to reveal a foot-long rubberized platform; I consider standing on it for a second, then straddle it. The oximeter beeps. This chubby nine-year old breathes shallowly, eyes closed. The tool box is open beside us.

One of the RTs starts bagging for me; I've seen him multiple times, a large, happy presence at the head of the bed with great confidence that's infectious. Then we push drugs and thank you dear lord the clean, pink, kid-beautiful cords pop into view for the tube, and I've just tubed in the CT scanner. I breathe at the same time he does.

It's a maxim in Emergency Medicine that you never send anyone to the scanner that's unstable, because they die. The worst words you can year overhead aren't 'code 4', but 'MD to the CT scanner', because that means you've inadvertently caused someone to crash (or, at least, that's how it feels). This kid was hit in the head by the side window of a car driving by his school, and had been asking for his mom in spanish for about twenty minutes; he was sleepy enough for me to follow him down the hall, through three sets of double doors, and to sit in the CT control room, so I was there when his pulse ox was suddenly 86%. I'm pretty sure my staff walked into the control room just as I was passing the tube, and he looked a little pale when I updated him. Everything's under control. No problems. Just a bit of reversible hypoxemia. For both of us, since I didn't breathe the whole time.

He ended up not having much of anything; probably a bad concussion. Lucky, for all of us. Beware that scanner down the hall.

I'm Back

Time to come back. It's been along time away. Years, in fact. Got caught up in survival, and forgot how to talk about what we're doing. I graduated. Found a job. And the stories got even stranger. Plus, I got discovered; so, I had to change my name, and in today's climate, it was a scary thing, I'll tell you, to get discovered. So, I assume if you're reading this you're either bored, or you're a Chinese spam company trying to sell me some sort of Nigerian bank stock deal. Welcome in the first case, Ni hao in the second. Read on. And check back for the best of the urban, suburban, inane, and sublime.

Dirty

Normally, when a patient says, "Thank you, Dr. Novitius, you're a great doctor", one would expect a swell of pride. Instead, I am cheap and hollow. Almost embarrassed. I consider not taking her outstretched hand for a second. The reason for that, dear reader, is the script I have just handed her.
I had seen the prior notes. She has all the markers. She has an underlying, painful diagnosis. She has recurrent pain for which I have no good long-term treatment. But, oh, do I have a great short-term treatment. A short-term treatment that ensures repeat business. That sweet, sweet nectar known as 'dee-luadid'. Ask for it by name at your local emergency department.
She has pain contracts. She has pain clinics. She splits them; those 'bad' doctors who don't listen to her, that she has fired in the past. Perhaps she fired them in order to redress the power imbalance, to make it feel less like they're the dealer and she's the mark. Her GI doctor, of course, has deferred to PMD, and she says the PMD has told her to come to the ED for pain control. This may, or may not, be true. Either way, she's here.
I have nine other patients in process. A huge stroke, intubated in the trauma bay. A small, real stroke, in a nice grandmother of a colleague. A dislocated lens. A sodium of 117. A short-of-breath dialysis patient with a pressure of 220/110, wheezing. My pant leg is covered in urine from a spilled urinal that, thankfully, was dilute and not infected. This woman needs to go.
I don't fight the good fight. I cave. I write the script, for a small amount. She requests the methadone, and thankfully I do not have the special license for that. I'm her dealer. And, I've essentially ensured she'll return.
For the same reason that I caved and wrote the prescription, I shake her hand. Head down, I excuse myself from the private room, noting how easily she moves around, how her voice is clear and she shows no sign of distress. I try to mentally wash my hands and move on.
We're creating a new epidemic of drug abuse, and shifting people from street drugs to our own supply. Certainly, in some ways that's safer than before; but I don't remember them talking about this feeling, this dirtiness, when they reminded me a gazillion times in medical school to track the patient's pain on a ten-point scale and always address their pain to the point that a number from 1 to 10 is supposed to rival their heart rate, temperature, or pulse oximetry in importance. Imagine that. Pain is treated on a par with oxygen.

Wait Time

She breathes quietly under the sterile sheet, her breath fogging the plastic window they have provided. Her neck is a pale blue from the chlorhexidine. The white line is prepped and my arms are folded, chin down in a wide-based waiting stance I learned in the OR as a student. I breathe, too, to avoid pacing to the door of the ICU room.

Outside the fellow is waiting for another consultant to call him back and see if we should place a central line for plasma exchange. He told me to place the line, let me prep, then decided that we should call them. Now we're waiting, silent. I think about small talk but she's under a sheet and it seems too odd.

It's already been an odd line; I tried a subclavian and missed, which is not unusual, but then felt a pulse under the collarbone, which is, and the monitor started alarming, saying 'v tach' which it says for anything it can't describe. It's a bit like a bad hunting dog that way. But I can't tell and the attempt doesn't feel right so I stop, confirm she didn't have a heart about to stop by talking to her, confirm she has that pulse under her collarbone on both sides, and decide to use ultrasound instead on her neck.

She's a mom with eight kids so she knows hospitals and she knows pain and she's stoic but I wonder what she's thinking. The plasma exchange is for her kidneys; kidneys that are stopping from accumulated bacterial toxin secreted into her from their hideout in her colon. Perhaps made worse by the antibiotics and anti-diarrheal medication she got at the outside hospital.

We wait some more. How stupid, this training system. How preposterous. I can't move until he says so. Six years of medical training and I'm a puppy on a leash to a supervising cricital care fellow who can't decide by himself if he wants to put in a central line or not. He also continued her antibiotics, which we shouldn't have done. And forgot to call nephrology that night. At least he didn't re-start her anti-diarrheal.

The reason not to treat and not to stop the diarrhea comes from the suicidal tendancies of the bacteria. As they die, they release all their toxin, worsening the problem. The diarrhea, as uncomfortable as it is, allows at least some of the toxin to escape.

It's partly my own fault. I'm off my home turf, in theICU, so I'm less likely to actually speak up, but often as a resident you have to choose--do I stick up for this or just shut up and pass on the bad decision? The reason for me to pass on the bad decision is, well, I might be wrong; but that's happening less, and now my thoughts are more likely to be at least substantiated somewhere. The other reason is that even if you are right, some of our teachers are set in their ways, and they may just continue anyway even if you're right. Then you just get yelled at for no benefit.

So I wait. ICUs have their own background music. Chimes, and bells. The alarm for a heart rhythm that will kill in minutes is the same as if a sticker monitoring the patient falls off, so to listen to these alerts is useless. Just let them lull you to sleep.

Finally the OK is given. The line is placed. Dark blood easily filling a syringe in the neck is gratifying, meaning I'm in the right place, not the oh-crap-pull-the-needle-out-and-hold-pressure-and-hope-she-doesn't-stroke-or-bleedout-place. Dressings placed, dated. Line confirmed. Checklists completed. Dressing off. Head of bed up. Now if only we didn't have people getting in our way, we could maybe get some work done.

Sugar

I don't know what the role of hypoglycemia in resuscitation is; all I know for sure is that both patients I've taken care of with an initial FSG reading of 'lo' that had an associated cardiac arrest didn't survive, even if the problem was addressed. Ideas? Maybe there's something to candy, after all.

"Let grief be your sister, she will whether or not"

The paramedics call to base for support for a PNB, which is run-of-the-mill, two or three times a shift. Either they have brought the patient back, or they want to stop, or they want to keep going, and they need our OK.

They called from the middle of a basketball court, doing CPR in the center circle on the son, cousin, and uncle of the well-dressed audience, watching and holding each other. A twenty-year old who collapsed stone-cold dead between the second and third free throw, falling backwards.

Round three of the typical three is already done when they call, asking for transport, for continuation; reaching for the refuge of hope that drugs like bicarb and lidocaine after amiodarone represent, some extra tool to throw at death when you're not ready to give up yet.

Everyone there did everything right. The coach started CPR, the EMT basic delivered one shock before the paramedics got there, they placed a combitube rather than an ET tube and ran the show. IV was placed on arrival. By the time they called me, though, it had been almost thirty minutes. Move to the rig. Move to the rig, out of the gym, away from the people all around. I ask one or two times, are you comfortable going 1099. Negative, they say. The mom is with us in the rig. OK, then. Come to the hospital.

The team knows this is theatre, to some extent. That doesn't mean we try any less hard, or that our compressions are too shallow, or that we breathe at the wrong rate. It means as soon as he rolls in, CPR still going, sadness rises in place of hope.

At the head, I see his fixed and dilated pupils; the c-collar in place because he fell backwards and maybe it's trauma, I take off, because it's not trauma, it's a heart that got too big for itself. With the first pulse check the tube is placed and confirmed. We do three rounds of drugs, CPR all the time, switching every two minutes, stomach decompressed. I can see mom ten feet from the foot, being held, eyes fixed on her son that an hour ago was running up and down the court. Not prowling the street selling drugs, not driving drunk, not stabbed by some dude while minding his own business; not doing the things so many of our other visitors do.

Our staff gives the warning shot. I'm going to tell mom it's not going well, he says, and one more round.

The nurse keeps the alarms off. Only the sound of 100 a minute compressions and 10 a minute bag-valve-mask ventilation. It's a soft sound. Rhythmic. The sound of our best tool, our best way to keep someone alive in the short term. The sound of failure.

We stop. A door shuts for the others in the room and mom drops to the floor, wailing and gasping for air. We help her to a cot to support the weight she cannot support herself. She breathes underwater, eyes on nothing.

There is no question of why. I know why this happened, the story is the classic presentation of this. No, there's no 'why'. There's just the next patient, and a sensation over the back of the head as if a window were just opened on a winter's evening, as the stickers are taken off and our patient is covered with clean white blankets.

Holy Crap It's Been ForEVER

...since I last posted. Sorry!

I've been at ACEP and looking for jobs and generally trying to live life while also remodeling a flooded basement and just being a resident. Somehow that interferes with posting. I'll try to post the best nuggets from the conference as I go through all the syllabi.

A large, large man came in the second to last shift before I flew out with chest pain. He was a mountain. Chest pain, of course, is our most common complaint, so I went in to talk to him without thinking much about the differential.

Where do you have pain?

Right here, he says, indicating his ICD which is so new he has only a partially healed surgical scar over it.

Did something happen to it?

Well, yes, my girlfriend punched me in the implantable cardioverter-defibrillator (ICD), two times. Like, hard. And I think it went off and now it hurts.

Um, OK. I walk back out of the room and pull out the algorithm for people punched in the ICD by their girlfriend, which we have filed right behind the STEMI protocol. Interestingly, all pathways end with 'get a new girlfriend'. And, admit them to the hospital for an ICD interrogation and cardiac rule-out. You never know. Maybe he was having ischemia at the same time he got punched twice in the ICD. God I love my job. The hardest part was not laughing. I think I actually did. I think I might have also told him to get a new girlfriend, a vital part of my patient education.

A What Scratched You?

I officially have a new favorite chief complaint by ambulance. Mouse scratch.

Paged out as such, I didn't know what to expect but at 3 am I was ready for the worst...not really. I was ready for what I got.

There were tons of mice in my house, one ran over the covers or over the bed, I freaked out, and while I was scrubbing myself down with alcohol solution and soap my leg stung and I noticed this tiny l'il scratch about 5 cm long that barely broke the skin. Oh yeah, I'm wearing a finger splint with a sharp edge on it. But I was worried it was the mouse that got me and maybe I need rabies or tetanus.

Um, tetanus OK. Rabies no. More importantly, since it's three in the morning and you're the only to be seen, how many mice exactly?

Mice on the curtains, mice in the kitchen, in the closet, in the bedroom, kids screamin', can't do their homework, traps out catch ten at a time. OK, so, um, you don't really need me. You need some dude with bad chemicals that has to wear rubber gloves that'll fix your problem. Needing a tetanus shot is, well, the least of your very disturbing, disgusting worries.

Third world at home, folks. Third world at home. Instead of the taxpayers picking up the am-boo-lance ride, perhaps we should pay for the exterminator.

FYI, CDC tetanus recs: booster if more than five years from past tetanus booster. Immune globulin for those who have not received their normal immunizations, or who are unknown. So-called 'clean, minor wounds' can wait up to 10 years and should never get immune globulin, but I rarely see that happening.

CDC recs for rabies are more compliated. First, what animal. If a dog, cat, or ferret--i.e., pets--no treatment is needed unless the pet is thought to be rabid, so if you have the pet, you can watch it. If wild--i.e., scary furry critters like racoons, skunks, foxes, or, notably, bats--immunize as below. If livestock, call public health. Gerbils are probably OK.

Treatment is irrigation with povidone-iodine or the like, rabies immune globulin at the site of the wound AND at a distant site if you can't infiltrate all of it, in addition to the rabies vaccine at 0, 3, 7, 14, and 28 days, in the shoulder, not in the tummy like I was afraid of when I was a kid. Apparently according to another blogger this just changed with ACIP but not with CDC; perhaps we'll be able to skip the last dose.

photo credit

Thanks

Multi-Tasking

Finally, got a real night shift.

At one point, I was gowned up holding direct pressure on a spurting radial artery wound after some dude had punched his way through a window. My headset (yes, we wear headsets, and they're only slightly metrosexual) goes off asking me to come to the trauma bay to supervise an airway as we do for any trauma during our second year. I get someone to take over for me and walk down towards the bay, talking on the phone to hand surgery. I don't even know the name of the radial artery bleed, only the room, since I walked in on the heels of EMS. I re-gown for the airway, check the tube and end-tidal CO2, manage vent settings, and while I'm placing an OG tube the radiologist calls me, also on my headset, to tell me about a new cerebellar stroke found on the patient right next to the radial artery bleed.

Despite myself, I smile. This is EM. I realize deep down that it all makes sense. It was the right choice.

Also ran my first PNB over the EMS radio and tubed a drunk lady with a huge laceration of her posterior while wading through the headaches and abdominal pains and two decompensated cirrhotics.

picture credit, an interesting blog on communication found by an image search for 'multitasking'.

Why My Daughters Are Going to Have the HPV Vaccine Strongly Suggested To Them

A beautiful little cherub sits on the stretcher. Not as cute as my kids, of course, but close. She's reading to herself. Groomed. Haircut is stylish. She's a vision of Nordic charm. Then you ask her how she likes her book. 'Good', she says, 'it's called Who Rang the Doorbell'. Hmmm. Voice is all raspy and soft. I can barely hear her.

That's because she's had genital warts lasered or chopped off her larynx like sixty gajillion times (aka, once every four to six weeks for a year or two). How did she get them? Her mom had asymptomatic HPV at the time of her vaginal delivery that was either missed or tested for and not caught. Now this little girl has to come in and get put under general anesthesia all the time. Today she has re-growth that's 'not too bad' according to the ENT doc. The clusters of new HPV growth are only occluding about 30% of her tracheal opening after six weeks. You can't even see her vocal cords anymore. Her larynx is a tube of scar tissue and virus. There's enough bleeding and swelling after the treatments that she's been hypoxic a few times from acute obstruction, and of course, if she didn't have the surgeries the virus would just keep growing until it blocked her airway and she died.

Compare that to some local injection reactions from the vaccine. Damn those pharmaceutical companies coercing young women into getting a shot just for profit, and forcing their immoral opinions on our young women.