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




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.

Set-Up For Success

Normally, intubating children produces angst because we're worried if we miss, but overall they tend to be straightforward as long as you do a few simple things. For young kids, you should have their ear at the level of their anterior shoulder, perhaps put a towel under their shoulder to compensate for their giant heeds, use a straight blade, look up, and you're home free.

So when the anesthesiologist brings in a wee laddie in a crib in traction, meaning their legs are up in the air, their chin is slouched into their chest, there's no way to approach them straight from above like we normally do, and then he says, "let's intubate him on the crib", and, "I normally don't use a paralytic", that's an awesome set up. Sterling. Perfect.

We ended up using a paralytic. Then I got it the second time. Gives me a lot of respect for paramedics intubating with less than ideal conditions, including in cars, in fields, and so on. However, when you have time, it seems silly to me not to use every advantage the first time, every time. Ironic, since usually the anesthesiologists call us cowboys, not the other way around.


Healthcare Reform

Sigh. I guess it's time to finally say something about this circus. About this distraction. About healthcare 'reform'.

The biggest thing I can say is that we're missing the point completely. The death panel debate is inane and shockingly uninformed and offensive, but it's really a shell game in front of closed-door deals that signal the true agenda of this bill and 'reform': window dressing for business as usual.

Obama, for all his rhetoric, looks to have sold the public down the river in order to mollify the big contributors, including for-profit hospitals, the insurance agency, and big pharma. How can I say this? Well, it seems obvious that he's agreed to limit contributions from the big players as covered by the NY Times and others. Now, conveniently the dialogue has shifted to co-ops instead of a public option; the 'death panel' idea has been dropped. The talk is about taxing health benefits, requiring people to buy insurance, and avoiding forcing drug companies into concessions on what they charge Medicare, all in the name of 'personal freedom'. These are all shifts away from what he said on the campaign trail, and away from meaningful reform.

The real show is going on behind closed doors. And if you're not outraged at that as a citizen you're missing the point. The big dogs are off making the real deal while we're busy yelling at each other like morons in 'town hall meetings'.

The real discussion needs to occur about the possibility of a single-payer, government run system. Unfortunately, with so much money and profit wrapped up in both politics and all aspects of media, it'll never happen. Does that help me as a doctor? Sort of. I'll keep making a higher salary, but I'll also be little more than a profit engine for corporations providing health care struggling to actually take care of patients. We'll still have uneven distribution of outcomes based on socioeconomic status, the CEOs of insurance companies and pharmaceutical companies and hospitals will still make enormous profits, and the president will get his speech. But, overall, very, very little will actually change except you'll be forced to buy crappy insurance.

What actually needs to happen is to get the monied interests out of the back conference rooms of the white house, and out of congress, and out of politics. When John Adams made his way to the continental congress before we were even a country, he had to do it for free, and he had to close down his law practice to do it. He did it because he loved his country, not for the bennies (which, for current congressmen and women, includes a great health care plan. Notice how they're not talking about giving that up). It's all about campaign finance reform and lobby reform, not health insurance.

Life-saving skills

Stuff that saves people is cool. We can all accept that. The things that really save people, though, are usually not what we expect. Helicopter transport, hypothermia with a cool machine that self-regulates, ICU care, monitors that beep and whistle, recombinant clotting factors that cost more than an SUV per ounce, those save people, right?

Um, maybe; but things that actually do are often eerily simple. Good chest compressions. Needles in the mid-clavicular line. And airway management--with a mask and a chin lift.

Terrifyingly recently, anesthesiologists would do a suprising number of cases without intubation and without a machine, just bagging the patient with an ambu bag. You breathe for the patient, literally.

On peds anesthesia this week, the best cases were the ear tubes, becuase for five minutes or so it'd just be me and the bag and the patient not breathing. This skill, as much as intubation, saves lives. Just a bag. No big fiber-optic scope, no fancy stainless steel LED-lit laryngoscope or, as my trauma surgeon called it, 'dog and pony show'.

It's all well and good to talk about lifting the jaw up into the mask with your pinkie, ring and middle finger spread from behind the jaw to the chin, but like any motor memory task, it takes time to learn it. Once you do, there's no feeling like holding the jaw up, squeezing the bag, and watching that little chest rise just enough to avoid inflating the stomach while still giving them oxygen. And to think we walk around normally breathing without even thinking about it. Want to manage a person's airway? Learn to bag. Don't know what to do with a failed airway? Learn to bag. Save a life.


FMOE: What do I do with this rhythm?

Gimme an M! Gimme an A! Gimme a G! What's that spell? That's right, the electrolyte that's also a code drug. Let's hear it for magnesium. 1 to 2 grams IV like, stat.

And for all the med students out there? Want an obscure cause of Torsdes? Try cardiac sarcoidosis. We had a woman with a strip like the above who we loaded with mag after a self-limited run who had just been diagnosed with sarcoidosis. The cardiac MRI was negative, unfortunately for science, but fortunately for her.

Rat Poison

He finishes dinner with his wife, the first they've had in weeks as he's recovered from hospitalization. Both feel better. Renewed. Maybe a bit hopeful. His balance isn't what it used to be, he's still tired, unsteady at times. Weaker than he was. She finishes the dishes while he, complaining of being tired, heads for bed upstairs.

On the third step, he remembers something and, naturally, turns to go back down. His balance, though. Not what it used to be. He falls the three steps, foreward into the foyer. And weak; doesn't catch himself. His nose bleeds. And bleeds. Bleeds even after she holds pressure and calls 911, bleeds to the hospital. Bleeds with anterior packing.

By the time he stops bleeding with a postieror pack, he's intubated; mental status, airway protection, and all that. Multiple facial fractures are found. He's admitted to the ICU for a hopefully swift recovery. Opacity at the base of his lung is watched; perhaps he breathed blood. Hard to say.

By day 3 or 4, it's not hard to say. The lung fills in, the tube stays after the packing does. He spikes fevers. He doesn't wake up. Now 4 to 5 days without nutrition, fractured, infected, a tired body, issues layering on each other.

His wife knows that he wouldn't want all of this. Wouldn't want the tracheostomy, the feeding tube, the supportive care to see if he comes out of it. That's were we were. Stuck. Or, not stuck, because the family was sure of his wishes, and all of them agreed.

The Navy man who drove the boats for the landing on Guadalcanal had care withdrawn on the 4th of July. How terrible, you may opine. How macabre. But. The monitors were shut off. The tubes removed. His sons and daughter were there. His wife was there. They held his yellowed, bruised cool hands. Draped in a home blanket. They spoke to him, and we shut the door and the curtains, watching the monitor still on outside slow, and become more and more shallow until they stopped.

This is the situation the supposed 'death panels' were for. It was as good a death as we could offer for a good man. No bureaucrat showed up and told us we had to let grandpa die, nor would they if we had kept the 'death panels'. The family happened to know what he wanted, and because of that, we could let him go. What if they had been gone? What if they had disagreed? Weeks and months could pass, hooked up to machines and tubes, sustained, exactly as he didn't want to be maintained.

It's terrible when anyone dies. It's worse when they are treated with guesses as to their wishes. No one deserves guesses like that. The family is often asked to 'guess' what they might have wanted. Imagine, having to feel as though your decision will either end the person's life or lead to a full code and then the end of their life, not knowing if they wanted to leave quietly, or fighting to the last.



The concept of burnout isn't new; the pre-game is brownout, and it feels like it sounds. There's no crack, no explosion, no drama. Just a slow fade. The exams of patients get a bit shorter, the reliance on data higher because it's emotionally easier to look at a scan or a lab. The morning is harder.

Empathy starts to slip and is replaced by pity and sarcasm. Families aren't comforted or updated as often. It's not terminal. Your work doesn't slip to poor, just from excellent to good, or good enough.

Time to leave the ICU. Time to leave the one long hallway lined with an ever-changing but remarkably similar parade of random victims, the drug dealer next to the teenage model UN attendee struck by the drunk driver. Time to leave the purring ventilators and whispering pumps and step into the sunlight. Three days. Thirty-six hours, give or take. Not that I'm counting.

I am not who I was.


Strike One

Sorry to all for the long layoff. It's been unavoidable on the ICU, which has been a 'rich' learning environment to say the least.

We had a summer weekend night at the beginning of the month not too far outside the normal with fifteen or so traumas that came in, one of whom was a three hundered pound diabetic with hip fractures and rib fractures and a blood sugar of 850. She got blood in the truama bay because she was tachycardic and no pne could feel her pulses; after the resuscitation, she went to thr OR for an open femur. I was at the head of the bed in case there was an airway issue. In retrospect, it's hard to see the detail we could've caught to avoid amputating her leg three days later.

In the ICU, she kept failing to meet her resuscitation goals; too acidotic, not enough urine output, poor perfusion and cold extremities all around, remained intubated. She made all of us uneasy but we didn't quite know why, and we scratched our heads every morning and every afternoon and tinkered with her drips and fluids.

She gradually accrued orthopedic splints and rods sticking out of her leg and pelvis and arterial lines and venous lines and tubes, and on the morning of the third day the nurse said hey her foot looks dusky and it's really cold. The attending looked at it and agreed; she was going to the OR again and we told the ortho docs that the nureses were worried about her foot and that she had no pulse we could find but didn't call vascular specifically.

She came back four or five hours later and they said, you should call vascular, we can't find a pulse. By the time vascular came her foot had been cold for eight or nine hours and they, shocker, said nothing to do. An angio showed loss of the popliteal artery, which supplies the whole lower leg, just above the knee.

The amputation rate for injuries like this eight or more hours out is 86%. Even within six, the rate is about 20% if there is a femur injury. After we found out I remember sitting on the toilet in the room becuase it was the only place to sit and looking at her now purple toes sticking out of the splint. That may have been why she kept missing her goals all along. The reasons to miss the injury were legion, yet sitting there staring at her dead toes they all sounded like excuses.

That's the other part of the whole cost debate. Becuase of those purple toes I'll be more likely to order angios for the rest of my life, but not to somehow line my own pockets and not to avoid lawsuits. To avoid purple toes.



In the midst of the busiest call night in memory, I stand for twenty minutes, still, and watch the end of a baseball game.

I hold pressure to the wound that has soaked the bedsheet and is drying from the outside in. It soaked his shirt before he arrived. My hand protests and numbs after I wedge my elbow against the bed.

I have stacks of consults to finish. The pagers hum, heedless of each other, while I hold pressure, unable to answer. Traumas are stacked in rooms to go upstairs. Ribs, open legs, head injuries. Splintered livers. The detritus of a sticky summer night. Scanned, diagnosed, improved, ready to move.

I try to switch hands but position dictates my left is better, so I switch back. The chief had held pressure before me but she was too busy. Go get someone to do this, she said. This is what he needs. He needs a human being to hold pressure for thirty minutes.

Thirty minutes. From 9:25 to 9:55 PM on a weekend night in June, after the summer heat has arrived.

I ask for the med student first. He is too busy learning, I am told. My own staff tells me this, an attending who has taught me how to read EKGs, how to diagnose vertigo. My own staff who should be on my side except this month I am an interloper, I am a surgeon, I am an other, a 'consultant'. Get a tech.

I go and talk to the charge nurse, perhaps even more important than the staff physician. She is washing a bed. I do not take that as a good omen. I need help, I say. Someone needs to hold pressure on this poor man's wound, and right now the overnight chief of trauma surgery, the grand poobah of weekend nights, is holding pressure. She laughs a short laugh. We have no help, she says. They are too busy. She does not recognize my so-called authority. I am but a mendicant.

I return. I will hold it, I say to the chief. Perhaps you would like to argue our cause. She leaves, the curtain rustles. The nurse, who is giving an IV medication over the course of ten minutes, cannot leave her post, either. We are together. The patient is silent. He watches the game.

The bleeding stops. The bandage is taped. The patient is treated. Anyone could have held it there. The choice of who holds the gauze, though. That is how I know where power lies, and where it does not.

And what was gained? The patient was treated. A task was completed that the charge nurse, the staff doctor, the chief of surgery, and the medical student did not want to complete. Will this matter, I wonder. Will it matter that I did that task rather than order someone to do so? I could have, with my authority, so-called. But authority and power are not the same.

Photo Credit


A New Era

This is the first post from a phone I've ever written, and that sure is amazing if you think about it. Of course, the fact that I think it's amazing rather than normal tells you what a dinosaur I really am. Pretty soon my phone will intubate my patients and place central lines while it brews my coffee. Perhaps now I will actually be able to post again, busy as we are on truma. Sorry to all for the layoff.

We sent a lady wothy of buckeye surgeon, another blogger on the sidebar, to the OR today for a small bowel obstruction, and now I get what the surgical emegency is all about. Her belly was like a drum. Fourteen prior surgeries. Tiny little lady with a buddha belly, criss-crossed with scars that she clutched with both hands, fluid pouring out of her NG tube. She would surely be vomiting up a storm without it. I guess those surgeon-type people do some good after all.



Here's a knee-slapper. What if the very Harley that you rode to traumatic brain injury land without a helmet also technically kept you from qualifying for federal insurance to pay for the nursing home you needed? What if it made you 'over assets' because it was so nice on paper, but really was a twisted heap of metal that no one had officially listed as totaled yet?



Trauma Time

Photo Credit

Last day of cardiology call; starting trauma surgery tomorrow.

An article about South Africa's hosting of the 2010 World Cup made me think about the context of penetrating trauma. Johannesberg in particular is an infamous center for trauma research, and one of the most dangerous places in the world, prompting all the concerns about tourists visiting.

Looking around, it certainly seems that the risk of getting shot or stabbed is, ahem, not quite equal. The rates where I train are in the neighborhood of 20 per 100,000 or so, putting us outside the top 25 most dangerous cities in the US in favor of places like Detroit and Compton; on a country averaged rate, though, it puts us between Puerto Rico and Kasakhstan, which is not great. With a stated death rate from intentional trauma of 20, we get more than a gunshot wound a day on average (they do tend to come in groups).

Of course, it gets worse; South Africa has a rate of 38 per 100,000, as high as almost 50 in the last decade. Iraq wins--or loses, whichever. But that's an active war zone; the one that makes me wonder in this list is Jamaica, which people run off to all the time. Imagine if Apple tourism started selling getaway packages to Iraq.

These statistics face the same problems as any public health measure. Any country with a functioning public health system will do a better job of tracking statistics, and the statistics in Sierra Leone or Somalia are likely not quite reliable, whereas ours should be quite reliable. I'm guessing the rates in countries like Somalia, Angola, or Colombia are unreliable to say the least. I'm not sure how a country with no infrastructure deals with such a trauma load, except as depicted in the pictures linked above from Somalia.

According to the Boston Globe article with the photo above, Somalia has lost 17,000 civilians to trauma in the last 2.5 years, or 6,800 a year; if the population is counted right, that's a death rate of 680 a year from penetrating trauma. 680! Makes that picture above seem a bit more poignant. Makes me think I'll take trauma more seriously. Makes me happy I'm not in Somalia. Makes me just overall confused about the state of the world and what we're missing on a daily basis if we don't go looking for it. Imagine the apocolypse we would be filling our airwaves with if our penetrating trauma death rate was thirty times greater than it is now. And yet, it's happening. Just not here.


That's The Difference Between Us...

Rotating on cardiology, I've had the opportunity to see some of the, ahem, differences in how we approach patients. It was accentuated this morning when my staff said, 'your notes are so ER', which I took as a compliment--she said that because my entire written plan in the daily progress note was 'pt to CABG tomorrow'. I hadn't commented that we were replacing the potassium at the low end of normal, keeping the patient on a cardiac diet, monitoring the patient on telemetry, and so on. I just wanted to say what was happening and how they were leaving. Well, what more is really needed?

Although EM grew from medicine or surgery based on which hospital was covering the ED in the sixties and seventies, I would argue that we are now our own full-grown speciality. We're hyper and have the attention span of a caffeinated meerkat compared to the other services, we're the only ones to seriously consider things like toxicology, we think about disposition like no one else, but the real, real difference is one of mindset, and it all goes back to the teaching I got as a 4th year medical student.

My attending said, what do you think is happening, and, at the same time, what are you doing? You're in the ED, buddy, dispo is everything, and you can't sit there and scratch your head forever. 18 in the waiting room, let's go.

We 'diagnose' our patients, although that's a loose term and really an ED diagnosis is more like, are you going to die a) 5 minutes ago b) in the next 5 minutes c) maybe in the next few hours d) in the next 30 days or e) someday, but I don't know when and I bet you'll see another doctor before you do therefore relieving my liability.

If the answer is a or b, then we're at our best, and we DO diagnose to the extent of determining the pathophysiology of the shock present and the subtypes of life-threatening presentations we see, including poly-terrible situations like the 85 year old who either had a heart attack and hit a tree or hit a tree and had a heart attack.

If the answer is c or d, then our 'diagnosis' is not really a diagnosis but rather risk stratification for really bad things that might lead you to be in category a or b. Yes you have chest pain and it might be mantle-cell lymphoma (which if I weren't on a medicine service I wouldn't even know was a disease) but really what I care about is how likely are you to die soon? This is really, really tough and I'm still learning it. It's hard. And it always presents patients that don't fit the mold.

Medicine, god love them, and by that I mean internal medicine, is a vital adjunct to Emergency Medicine. They take all the patients in category c and d that we risk stratify to scary or at least a little bit scary and then they do something called rounding, which involves terribly long and inexorable walking conversations about patients to agonizing detail. They address changes of less than 5% in electrolyte levels over the course of days; they draw crazy tests like trans-thyretin antibodies, ceruloplasmin levels, anti-double stranded DNA antibody tests, dexamethasone supression tests, and so on and on. They get really excited by complicated patients with multi-system disease that affects multiple organ systems and they love the unifying diagnosis that ties all of this together.

This drives me bonkers. I can't concentrate. I pray for lines and codes and then feel bad because that means patients are sick. I go talk to the crazy withdrawing person because it reminds me of the ED.

A discussion the other day epitomized this divide. I wanted to start our sarcoid patient on steroids because we knew she had sarcoid and probably she had cardiac and GI sarcoid and she felt sick, so why not give her steroids and see if she feels better? What am I doing for this patient?

The med resident, who's very good, was all, we don't know for sure that it's cardiac sarcoid.


Well, what are we treating then?

Um, sick person? Hope she feels better?

But that's undisciplined, she meant to say; that's untidy, that's not targeted therapy.


I love them because I admit to them. I'll stick to my version of diagnosis, though. Not sure what the point of this post was, other than to say, we all have a place, and the best way is to figure out how we complement each other.

Thank You

When my girls see the flag outside the window, they go, 'look, the flag!' and they both burst into song: "it's a grand old flag, it's a high-flying flag..." through all the verses.

Happy Memorial Day, and thanks to all of those who put their lives on the line for all of us. Your service is appreciated, your sacrifices noticed.


Um, Silly?

When I admit a patient, I ask them what they are taking. The nurse asks them what they are taking, and the pharmacist does, too. In the ED (happy, WhiteCoat?) we have a little section where we can mark their medications and enter new ones.

Then, when they go upstairs, I copy the medications from a computer onto an order sheet by hand with a ball point pen, making sure to press hard so it goes through the carbon paper. I then copy it again, still by hand, into a history and physical. Three lists and counting.

I then am supposed to copy it onto the daily progress note by hand with doses and frequencies every day even though we round with a pharmacist with a computer (who, you guessed it, has access to the computer list). I don't do this out of protest. Four lists, and counting.

When the patient gets transferred from the ICU to the floor, or from one floor unit to another, there is a transfer medication list that also gets copied onto a triplicate paper order sheet with a ball point pen, because there is no way to just, oh I dunno, transfer the list. So that's five and counting if there's a transfer.

Upon discharge, the nurse prints a form that has their before admission meds and their inpatient meds as well as a new place to write discharge meds, so we'll call that six. The nurse is then supposed to copy, by hand, that list onto another so-called 'RN discharge'. That's seven. I then dicatate, hopefully from one of these reliable lists, into a discharge summary that is on a different system and not automatically correlated with anything. We'll call that eight.

Eight medication lists for every hospital admission, seven if there's no discharge or transfer. If someone comes out of the ICU and then transfers at all it's up to nine. They all live in different spots. There is no automated updating except at that first step, when there's an EMR.

I know White Coat just posted about a place that uninstalled it's EMR because, admittedly, garbage in is garbage out. But what is garbage copied eight different times, with lists as long as 30? That's, hmmm, 240 chances for error. All in the name of reducing errors.

And we chide our patients for not knowing what medications they're on. We probably don't know, either.

Gassed Out

I have any number of ideas about what to write but I am truly spent, good hearts. I am browning out. It's slower than burnout. I walk slower. The coffee isn't as good at 5 am in a nurse's unit as it is at 7 am on a beautiful morning on the patio with the kids. The iPod works but I get tired of walking the hospital stairs as my only workout, and listening to lectures while filling out forms as my only mental stimulation.

It could be worse, mind you. I have my health. We have running water, plumbing, heat, and food. There's no nearby war. I haven't lost my job or my house. But...

All of us on the current service have our own short-timer's calendar. Somehow we're all looking forward to the 20th because the 20th seems a manageable amount of days away from the end of the month, but that's only half-time, and then it's on to another month of call and scut, then another.

I'm tired of having my family and my relationship come 5th of 5 on the priority list so we can walk around and discuss oral versus IV magnesium supplementation and when to make so-and-so NPO for the cath I won't see except to document normal pedal pulses four hours after return.

This isn't a sarcastic hate the world post, a lot of patients are decent and I'll try to post about them, it's just that I'm 'all done', thanks, as my son would say. All done.


Jaded, Redux

A confidante noted that I've gotten sarcastic. It's a weakness of mine, brought out by paperwork, long hours, and stress. On the way in from the parking garage, though, the birds were chirping, the sun was shining, and the helicopter landed right overhead, which, call me crazy, has always reminded me why I love this job.

Intern year, I will yet conquer thee and remain at least somewhat compassionate. But thanks for the reminder, I need it.


Pearls Before Swine

Which is more--twenty or thirty thousand, or fifty-nine?

The first is the approximate number of deaths over the last few years, per year, from 'influenza and pneumonia', one of the top ten killers in the country. The second, of course, is the number of deaths from the virus formerly known as swine flu, now known as H1N1 flu, which, though unreported, is also the antigen configuration that makes up a goodly portion of the seasonal flu. Now, I'm no public health guru, I'm just a simple resident. Somehow, though, those numbers call recent calls for global action into question just a tad.

We all love a crisis. Me more than most, apparently, since I picked a job where 'crisis' is part of the daily routine. We're good at it; we can pick a discrete enemy to fight.

I must say, though, that the reaction to this pandemic has been just a trifle ludicrous. Fifty-nine deaths? Really? Schools closed, flights diverted, billions of dollars, for fifty-nine deaths?

Not to mention the ED overload with people spreading whatever other gunk they had to each other in order to get tested for swine flu. Awesome. Sterling.

The public health departments actually did the job they were supposed to. They performed surveillance on a new threat and quickly tried to characterize it's mortality rate and epidemiologic characteristics. This work has to, by nature, be paranoid. It's the job of those of us watching and interpreting to avoid mass hysteria, and in this, we failed. I blame mostly the media, frankly, and Joe Biden for good measure as a proxy for elected leaders.

Oh, there's a new virus? Let's cover it for ten minutes of every hour of every day for weeks on end, close schools with no cases, and generally freak out as if the world is ending and make sure people know it COULD HAPPEN TO YOU AT ANY SECOND, especially if you happen to have Mexicans in your neighborhood or even in your time zone. Oh, wait, that's all of us.

Where are all these people for the ongoing threats we have to face on a daily basis? Where's the call for clean water worldwide? Where's the call for increased flu vaccination coverage, which is almost always woefully abysmal? Where's the call to stop diarrhea? Where's the call to actually, shock, have a helmet law or make drunk driving illegal to reduce accidents (no, it really isn't illegal, first time, in some midwestern states. It's a citation). Hmmm, must be too busy spraying down the playground equipment with powerful cleansing agents, because that will somehow stop the kids from sneezing on each other when they come back.

Seriously. Hissy-fit extraordinaire.


We have a guy right now that's got it all figured out. He has heart failure, and some sort of cardiomyopathy that keeps his heart from pumping well, and in order to treat this, we need to help him remove more fluid than he takes in, preferably rather quickly so he can re-equilabrate. Simple, right? So why does he roam the halls at night drinking tons of water from outside his room and stealing other people's food?

On the surface, it would seem mad, but deep down it displays the hallmarks not of madness but of mad genius. Each time someone tells him to be compliant, he says, oh, yes, I know, bless you, I'll do better. And then each night he goes and drinks more. A styrofoam cup filled with hospital ice here, someone's leftover milk carton there.

You see, if he's in the hospital, he has free TV, a comfortable bed with housekeeping, a nurse to help him take care of everything, and he gets to stay away from work because he has a decompensation of a serious medical problem. It's a five-star hotel with a craftmatic adjustable bed and an on-demand minibar of narcs.

The team this morning noted, accurately, that even if we discharge him he'll be back in the ED in a couple days 'feeling puffy' and wanting admission, so if we kick him out, he just becomes a problem a few days later for someone else.

Where's our out? Here's the mad genius part. He never openly defies anyone, and he never asks to leave. He says he wants to get better. This takes away the option of letting him leave against medical advice, one out for a troublesome patient. But he doesn't want to leave.

He's always pleasant to the attending and usually to the resident, and always agrees that his health is important, and that he has to save his urine so we can measure it and comply with the fluid restrictions ordered. Thus, we have no options we normally have with a defiant patient. We have no way to restrain or sedate him, or put a catheter in him to measure the urine output he refuses to save. We literally cannot force someone to get treatment unless it's an 'emergency', which, currently, it's not. Further insight can be gained through his one persistent request: a disability letter so he can get out of work. He knows the hospital gig is limited, even in the current climate. He has to have a long-term retirement plan. He's found the gravy train, and it's us. He's playing us. The team knows it.

Our system, for all it's good intention, facilitates this cycle. He has to be seen if he comes back to the ED even if we kick him out. We know if he leaves he'll just drink, do cocaine, and eat salty foods until he 'decompensates' again. I suggest a sitter to make sure he stays in his room, and I'm told that we don't have the staffing for it, because apparently it's better to just have him in the hospital for an endless amount of time. He's totally non-compliant but pleasant, thus we continue, night after night, him wandering the halls undoing everything done during the day. He's been here for almost 2 weeks, and another hospital before that, working on getting his disability in air-condintioned comfort, with top notch nursing staff and a team of dedicated doctors.

It's good to know that if we kicked him out and he got really sick again, there would be a wealth of potential legal advocates to represent his interests. It's great to know that our system supports this poor gentleman in such dire need. God bless America.



As you can see by my sidebar, I'm not too sure about what to do with Twitter. My phone is too old to work with it, and me sending updates would be mind-numbingly boring, i.e., going to work, coming home from work, going to work, eating, and so on. If anything actually interesting is going on, I'd better not be twittering, but standing somewhere trying not to pee my pants, remaining outwardly calm, and running the ACLS algorigthms best I know how. So for now, I'm going to try and set a record for longest time between Twitter posts. If I ever get a new phone and a life, we'll see. Sorry. New post below.

Too Many Acronyms

AF w/RVR + AS.

One of our staff calls up from the ED to the floor (gag) where I have to work for three more long weeks with an 'interesting case'. A fib with RVR is common; my first week, we had, like, seven of them, old people with underachieving, scatter-brained atria fibrillating away and ventricles that responded too quickly, leading to usually mild badness like relative hypotension, shortness of breath, weakness, and so on. This one, though...

He came in as a trauma, having fallen off of his bike. EMS did CPR for 'a minute or two' with a stated GCS of 4 initially, and then 9. He was hypotensive with an irregularly irregular pulse, and a harsh, mechanical murmur over the right and left chest. He had old, old fistulas on his right arm for dialysis.

Now A fib doesn't seem so benign. The irregularity keeps the ventricles from being able to pump well; first, they're chaotic, and second, they lose the 'atrial kick' that is often needed to fill them. This gentleman's murmur sounded like aortic stenosis, adding one more problem; the same ventricle that lost it's sidekick atrium also has to push against a tiny, hardened valve.

He comes to the ICU with a rate of 150 or so, and a pressure of 70/48. He won't answer me. He won't open his eyes. He won't do anything. He also doesn't respond to pain. But he's breathing. Thank goodness my ED staff from the department had warned me that he's got mental retardation, too; and thank goodness his mom was there to tell me that he hates hospitals, and ignores everyone. If I hold his eyes open, he looks at me. Cautiously, I decide that he's wide awake, just faking it. Usually this doesn't bother me to assume, but when his pressure is now, hmm, 72/50, it makes me nervous.

What to do? He gets a fluid bolus. He gets pads put on. Now I'm stuck. If I give him too much fluid, that floppy heart pushing against the valve will get filled like a water balloon and lose it's strength from being stretched. The rhythm I can try to fix with a shock, but I don't know if he has a clot in there that could shoot up into his scon-box and infarct a bunch of brain. Even if I shock him, he has a fixed outflow obstruction from the valve--a class of problems that can cause shock because blood is blocked. Other similar lesions include massive PEs, and tension pneumothorax, although the obstructing mechanisms are vastly different. He has two IVs, so we just watch him. Watch him, and worry.

I start explaining to his mother how he'll probably need surgery, and he yells 'no!' from the bed, then 'no, no, no!' just to make sure. Ironically, he looks strikingly like a bald Dustin Hoffman, making the comparison to Rain Man complete. I feel much better with my retarded, hypotensive, irregularly irregular, stenotic, and syncopal patient who is now vociferously negative. Thank you for your lack of cooperation, sir. Keep it up.

Review his labs; the EKG is irregularly irregular but no ST elevations; the chest x-ray, unfortunately, has a hugely wide mediastinum, but 'no!' is also the answer to my inquiry about chest pain, so perhaps this can wait. His troponin is 0.5, which is elevated but not yet in the NSTEMI territory (that is, he doesn't have a heart attack, yet).

As the Fat Man says, the delivery of good medical care is to do as much nothing as possible. So we do nothing. We watch. We wait. And at 7 am, when the team arrives, and the post-call sigh of relief occurs, my retarded, stenotic, hypotensive, irregular, contrarian friend is in a regular rhythm (on his own), has a pressure of 94/62, and still shouts 'no!' whenever surgery is mentioned, now opening his eyes and sticking out his bottom lip to make the point. More to come. I want to see that valve when it gets hacked out (he NEEDS it).



The old demented Lithuanian is upset because I wanted to get an EKG for his heart block and bradycardia. He gets upset. He gets ornery. He raises his voice.

'Ah, you,' he says, 'you're a communist, aren't you?'

'You forgot your Red Star.' 'Where are we?' I ask.

'Where are we? Hah! You know! Where are we!?' OK, so it wasn't the most delicate way to ask about orientation. I think I know where he is; thirty years ago, in some Gulag. It dawns on me that this may be very real for him, and the EKG pads, Lord knows what he thinks those are.

I go sit next to him. 'How can I make this easier for you?' I ask, since he's been roaming the halls, and since we can't give haldol to someone in heart block.

'I don't have to talk to you,' he says. 'You're nothing.' It makes me wonder about his story. But since I don't have my Red Star with me, I suppose I can't very well interrogate him.


Like Butter

So far, I've had three really sick people this month--one sepsis, one status, and one angioedema. At the end of each, the staff has said it went smoothly. The last one even said, 'from my perspective, that was like butter'.

Which reinforces my sense that, if an Emergency Doc knows exactly what's wrong with you and knows exactly what to do, you're a sick, sick puppy.

All those other folks that confuse the heck out of me with wierd shooting pains in their foot and some shortness of breath and a headache and oh, yeah, I'm sleepy--nothing too terrible seems to happen to them.


"Then You'll Get One Case..."

Staff and I were sitting at the tracking board when a new patient popped up, that I signed up for. The chief complaint was 'allergic reaction'.

"That should worry you," he said. "You'll get all these people with rashes and minor stuff and you might get cavalier, and then you'll get one that's true anaphylaxis, or true angioedema, and from then on that chief complaint will cause a lot of sphincter tone." We walk to the room.

He draws back the curtain and the lady's lips are HUGE, both of them. He turns and says to the nurse, benadryl, cimetidine, and solumedrol, please...no audible stridor but she is uncomfortable, worried.

0.4 mg of epinephrine, 1:1000, IM, is given. The language phone reveals nothing--no known allergies, no medications, no recent changes. Her hands are swollen, as well, and she has hives on her chest. No wheezing. Still no stridor. At the end of the phone call with the translator, through which she has said nothing as her cousin translates because she can't talk, she says, 'my throat feels tight'.

She is wheeled back to the trauma bay, where we do all our airways and lines, nurses hurrying, which is often a great predictor of how sick someone is. Surgery is there with three other traumas but the trauma chief is very intent on this lady. Another predictor of how sick someone is.

I am tempted to ask if this is a 'learner airway', but it's assumed that I will take it. I've seen her posterior pharynx, it's not swollen, she's young, it should be easy, but the impact of lips the thickness of two fingers across each is daunting. The trauma chief has the cric kit and is gowned.

Etomidate, sux, and I walk the mac blade down the center of the tongue, posterior pharynx, epiglottis, and a grade I view of the cords at which point I know she's safe because if I can't get it someone will, then the tube is passed gently, and she's truly safe. All over but the sedation, and the workup. No labs ever drawn. Under it all, she was an easy airway--which means we did it at the right time.

These are rare. I remember those prophetic words--you'll get cavalier, and then you'll have one...


Poor Predictors

There are probably plenty of healthy people out there who don't take medications and don't see doctors. If, however, this is you, and you end up in the ED, and you're over the age when people normally start taking meds and seeing the doctor--say, forty--then these are bad signs.

Any other major medical problems? No? Any medications? No? Next question, always--do you see a doctor regularly or are you just in denial?

Alternative health nuts would say the western system is based on ilness not health blah blah dangerous medications blah spirit healing and so on, and for some, sure. If it works, great. But...

If you come in with a smoking history, painful lumps in your groin, axilla, and on your shoulder, and you have a cough, and you've lost twenty pounds since february, and you wake up soaking the sheets...sorry, dude. Giant, metastatic lung cancer for you. Now granted, lung cancer has no accepted screening. But maybe, just maybe, a family doc actively trying to get him to quit smoking might've made a difference. I sure didn't--outside of delivering the news as compassionately as I could.

He has a nine month old daughter. Damn, damn, damn. Add not smoking to helmets, please.

And to highlight why we get so paranoid--he had been to two EDs prior to this, and had never gotten a chest x-ray. Of course, he hadn't had four weeks of illness at that point, either. The last doc ALWAYS looks the smartest, but they have the easiest job. Catching it on the first go round? Now that's genius.


A Stye? Oh, wait, a hordeolum...That's an Emergency!

If you come in at 01:30 by ambulance into our ED with two months of eye pain that you just couldn't take anymore with no redness/swelling/discharge/eyeballpain/changesinvision/headache/fever/chills/nausea/vomiting and bumps on both eyelids that you haven't tried anything for, well, OK...no, please, tell your son who just got home from work that he doesn't have to come get you because we can call you a cab right after we dispense your tube of erythromycin ointment. Sure, no problem.

Oh, no, don't worry, we won't bill you for the cab or the ambulance ride or the visit or the eval or the ointment or the tissues. No, no. Thanks, taxpayers. You got this one.

Six shifts, I lasted, before I got mad about misuse of the ED. Not too bad. And remember, folks...85% of patients believe they have a true emergency, even if only 5% of MDs think so.


Super Bowl

There are a few people that lay claim to the airway in medicine. EM docs are a big one, and we usually spar with anesthesia. Paramedics handle tubes in the field in many systems, and then ICU docs are a third. Before my last airway, I had done anesthesia tubes, and ICU tubes, but the ED tube--that's a different ballgame. One of our lecturers calls it the 'super bowl' of airways.

When I heard that the first time, I thought it was a bit over the top, until I had a truly sick airway.

Sixty-something obese, small-jawed alcoholic with a bicarb of 3, Kussmall respirations, yet somehow still oriented, needs a tube. We positioned him ear to sternal notch as we were supposed to. First pass, and I saw cords but the mouth was tiny and I couldn't pass the tube. Terrible feeling. Someone holding pressure on the trachea was also less than ideal, moving it while I was looking--but still.

Bag with a nasal airway. Staff takes a look, 2nd pass with a bougie, tubes him blind and blood sprays out the tube all over (yay for gowns and masks!) and no color change. We place a King LT to bag him back up from the low nineties, which is not too bad, but he was dropping. "This is exciting", says my staff, who is a sharp, smart young doc we all love to work with.

Third staff comes in and looks, all smiles, like he's at the coffee shop chatting about donuts. Next pass, bougie again, downsize the blade to a 3 because the airway is anterior--always changing something, and this time bougie through cords visualized and the tube passes. More blood and no breath sounds on the left, so pull the tube back.

All good.

This was my first ED tube but not my first tube; a previous post talked about my anesthesia rotation where I was up to 13, then I had an ICU month with 6 and hit them all, so I was at 78% first pass success and about ten in a row on the trot, which is to say, nowhere near proficient, but not a total newbie. But this one was terrible. Sick, sick, sick. I see now why they call it the super bowl of airways. I see now why my attending said when I was setting up, 'got your bougie?', and 'got your King LT?' Up to 1% of ED airways are not tube-able. That's a lot. Many, many more are like this...badness. And it will go down as a procedure with no hypoxia, no hypotension, and no perceived adverse event.


I Say, Leave the Darn Thing Alone

The teaching about nailbed injuries is that if you have a crush injury or any sort of injury involving the proximal matrix of the nail it has to be removed, the matrix, or nailbed, repaired, and the nail replaced to keep the matrix open for the new nail. The worry is subungual hematomas.

A pregnant lady came in who had cut her nail and fingertip with a breadknife. She was on lovenox because it was a high-risk pregnancy. She had a linear laceration through her nail but it was three quarters of the way towards the tip. My staff indicated we should explore the nail bed and pry the nail up to see if there was damage underneath it.

I did that; her finger was numb, so I pryed up the end of the nail and it started bleeding like crazy. Surprise, surprise. Before, there was no visible hematoma, no bleeding from the nail. But the nailbed is so friable in a normal person, let alone someone anticoagulated, that it's a mess to reveal. This lady did have a laceration; I had to trim off maybe 3-4 millimeters of her nail to get to it, and then we repaired it with absorbable sutures.

But, before we started messing with it, it was FINE. According to Tintanelli, nailbed repair is required for open fracture underneath, disruption of the proximal matrix, and subungual hematoma. Some recent lectures on EM podcasts have disputed the subungual hematoma thing; the others I buy. Otherwise, I say LEAVE THE NAILBED ALONE. It bleeds, I don't think it helps proximally. Thoughts?

Oh--to take the nail off, gently dissect along the bed from the front with drivers, grip and pull away from the matrix along the axis of the finger, then repair, then suture the nail back in place through the nail itself with simple or matress sutures.



Buddhism has this concept of transitions, or bardos, transitions between one state and the next. When a practitioner is prepared, they can be opportunities for enlightenment; for the unprepared, they can be terrifying. Buddhism captures the same fears and opportunities many religions do about death, just in a different framework. The picture is the 'big buddha' on Lantau island off of Hong Kong, which I saw in college--although my favorite was the tiny stone buddha in an alleyway in Kathmandu.

When I saw those buddhas and read about bardos I had never seen people die. From my perspective they really do withdraw; wikipedia above describes all these stages of the bardo of death--final breath, lucidity after the final breath, then the space until the next life. I feel as though my whole service right now is in that state--some stage on their way out. Three brain-dead patients between yesterday and today, two donating organs, preserved for now. I joked I was the angel of death. Now, I think not so much. That's too stereotyped, co-opted by the halloween crowd. Bardos are more my style. They're more real, too. Death can be terrifying, but maybe, if we prepare ourselves, it might be a transition to something else? I hope?


Old School

When my hands ache from four central lines and an arterial line, and I laugh inappropriately at the MRSA swab on the brain dead 20-year old overdose admission because I'm too tired to care about hiding my derision...

When my boss tells me to go upstairs and talk to the overdose girl's family and it's just me and two parents who have lost a daughter and the nurse...

When it gets to be one in the morning and I haven't even started my documentation for the three afternoon transfers...

When these shifts come along, they make us doctors.


For The Love of God, Wear a HELMET

Natasha Richardson's death is tragic and sad. No one is prepared for such an event, and the mysteries surrouding her case have prompted a rash of articles on traumatic brain injury on CNN and in the New York Times.

With the exception, finally, of this article on CNN, which actually advises people to wear helmets, gasp, everyone has been discussing imaging and neurosurgery. It was noted that the initial hospital didn't have an MRI scanner, as if that would've been used. It was noted that she could've had a carotid or vertebral artery dissection that would've required special imaging, and then 'months' in the NICU, as if the best imaging and the best critical care was what she was missing. Perhaps she needed a craniotomy, or better yet, a hemicraniectomy where half her skull was removed. Then, in a one-liner at the bottom of the article, we get, 'it might've helped to wear a helmet'. Maybe.

The autopsy report showed an epidural hematoma according to the AP. The ONLY WAY to get an epidural hematoma is by TRAUMA. Not some rare neck artery dissection, not some wierd syndrome, or Moya Moya, or an aneurysm.

I have some bad news for the public. If you get this injury, we can do virtually nothing to reverse the damage to your actual grey matter if it has already occured. Yes, you can get a CT scan and then a hole in your skull or your skull removed and we can reverse any coagulopathy and we can monitor you in a beautiful ICU and control your blood pressure to within strict parameters and monitor your blood sugar and correct your electrolytes and prevent clots and use new, fancy drugs, and protect your airway and eat for you and pee for you and poop for you and then give you the best in long, slow, painful rehabilitation...

Or you can WEAR A HELMET!!!

This post does not in any way disrespect the tragedy that befell Ms. Richardson. But, why, by all that is holy, in that aftermath, wouldn't you advise people to wear helmets strongly? Another ABC article starts with a debate over whether acute care would've made a difference, and on page 3 says, well, she should wear a helmet but 'there's little evidence' that a helmet would've helped. Well, shoot, let me go out and conduct a randomized controlled trial on helmet use. We'll put half our people in helmets, half not, and then ram them all into a snowbank and see what happens. Heaven forbid we advise safety precautions before we have 'good evidence'.

Everyone should wear helmets. They're warm, they're stylish, they have ports for headphones, and, contrary to some asinine contentions on CNN and other major media outlets, they don't restrict your peripheral vision or encourage reckless skiing. Please. Please. Wear one.


End of Life Care

I morbidly joke, usually on my ICU months, that when my time has come, I'm taking my morphine and going on a long hike.

The way we treat end of life care in this country bespeaks a discomfort with death that is bad for the dying. My jokes aside, ICU patients are often there for unexpected catastrophes: muggings, subarachnoid hemorrhages like time bombs in people's skulls, car accidents. That these people are alive is a medical achievement of high order.

However, as Buckeye Surgeon notes, the return on our investment is somewhat less than miraculous. After these catastrophes, despite our ability to image the smallest blood vessels in the brain, and measure a gazillion-and-one physiologic parameters, we rarely are able to restore full or even almost full function. As a pediatrician I was shadowing once said to a patient, 'we can fix some things, but if you fall on your head or neck, we can't always fix it'.

For families, this presents a problem. Some don't care; they bring the social security benefits form in for their comatose relative to 'sign' with an X so they can collect a check. Others are in the ICU room for days and days, monitoring tiny changes in progress. My wife blinked. My mom moved her toe when the doctor yelled in her ear.

I think we need a frank discussion in our society that makes it OK to transition to comfort cares. Hospice docs have long held that allowing a failing body to expire on its own is more comfortable than prolonging life. Gradually failing lungs raise CO2 levels and essentially sedate the dying patient. Procedures to monitor ICU patients, on the other hand, are often painful--bladder catheters, arterial catheters, needles, ventilators.

Don't get me wrong--these are life-saving advances. But when it becomes clear that the prognosis is poor, it should be easier to say, 'enough'. We need to face death and accept it, not hide it behind sliding glass doors and curtains.


Damn it all

Just had to intubate the Marlboro man, in room 3. Stubborn bastard wouldn't keep his sats up. Second time in a week.

This tube didn't feel like saving a life, it felt like ending it. He'll never come off the vent.



Room 1 is an 84-year old stroke, clotted off her whole left carotid. We had to place a central line. Her BP is supposed to be like, 220.

Room 2 is a forty-something with c-spine surgery that lead to fulminant meningitis on the ventilator.

Room 3 is a COPD-er who is breathing 30-40 and dropping his saturations to the low nineties on BiPAP who we are giving one last shot at breathing because if we tube him he will never breathe without help again.

Room 4 is an intubated subarachnoid hemorrhage who moves her feet, sometimes, and blinks.

Room 5 got tPA today and was bleeding from her IV, her ET tube, her NG tube, and her eyeballs when she arrived. Her blood pressure is supposed to be low. Pray I don't mix room 1 and 5 up.

Room 7 is a poor guy who got mugged for three dollars after his car skidded into a ditch and the person who offered to help him beat him up. He only moves half his body.

Room 8 is bleeding from her tracheostomy, has renal failure, and can't move because she's been here so long. She's having trouble breathing.

I'm the only white coat here.

Only six more hours until the others return.

Only five hours, fifty-nine minutes until the others return.

And so on.



The EMS call comes over the phone to us in the ED, ambulance in the field needs assistance. 5 month old, found down, not breathing for an unknown time, be advised CPR in progress. 1 round of epi through an intraosseous line, asystole is the presenting heart rhythm.

The three of us--intern, senior resident who answered the phone, and pediatric EM staff--calm down when we hear the story. This is not a rush, not a challenge, not a moment to shine. This is a moment to let death quietly come in. The chance of success bringing back a dead baby with no heart activity is near zero, and the chance of having a baby recognizable as a baby who smiles and coos is even smaller than that. But we are in a quiet, carpeted control room, not in a cramped ambulance performing CPR on a tiny infant with family looking on. It's easy for us to assess the situation at a distance. Easy for us to be 'objective'.

More details are relayed--impaired status at baseline, crack mom, baby now living with grandma who wants everything done. 2 rounds of epi, aystole in three leads. Intubation fails. Bagging, doing compressions. As I listen, the paramedics relay updates in brief chunks of speech with long pauses.

The senior resident asks for signs of lividity or prolonged downtime. A long pause. We're dealing with an african-american baby, hard to tell, comes the answer. One sign of lividity is pooling of blood by gravity, which is easier to see in a caucasian baby, but that's not why they answer that way.

Third round of epi. Asysto--wait, one beat. Another beat. Long pauses.

The pediatric staff puts her hand to the bridge of her nose, squeezing. I hate the third round of epi, she says. You can get a beat from a stone with enough epi, the senior resident says.

Ask them if there's a pulse. Cajole them. Push them to call off their efforts, it's the right thing to do. We're in the carpeted room. The situation is clear to us. We're not the ones compressing the tiny chest, feeling the ribs recoil, suctioning out the mouth, bagging, watching the limbs jump with the compressions. We're not the ones willing return of circulation. Not the ones chasing the fairy tale ending.

No pulse. Asystole. Stop.


I Will Never Diagnose Constipation

I will never diagnose constipation. I will never diagnose gastroenteritis. You have abdominal pain. You have nausea and vomiting. I may have to diagnose viral syndrome, due to the overwhelming crush of well-appearing sniffly children, but I draw the line after that.

To say 'constipation' or 'gastroenteritis' is to say 'there is no chance that you have badness currently occurring'. That is NOT how I have learned to think. This was reinforced a few days ago.

A 14-yo boy w/hx of constipation written suggestively in the nursing notes comes in with RLQ pain for only 2 hours that came on suddenly. I went to see him. His story was correct in sequence for an appy--pain first, central migrating to RLQ, with nausea. One tiny loose stool that did not relieve the pain. His exam was correct; he was tender maximally over McBurney's point, the magic spot for the appy. There was one more detail; there was something behind his eyes that told me he was sick. This is not scientific. It isn't always there. When it is, I have found it very reliable.

I went to staff the patient, told the story, and the attending, who is quite good, said, if you told a surgeon this story, they would laugh at you. No way appendicitis starts and progresses in only 2 hours. But, you're right, he's hooked us with his exam.

We tried a KUB which showed some stool. We tried a fleets enema, and it initially seemed to work. I actually filled out the paperwork for constipation before I went back in to re-examine him on my own, because the nurse said it made him feel better. Just before I went in, my staff went in, and came out. His exam was unchanged. CT showed a 1 cm dilated appendix with peri-appendiceal fat stranding (inflammation) and I called surgery for an acute appy, put in a line, gave him some morphine.

Constipation is a sign and a symptom, not a diagnosis. Yes, there are LOLs who come in with impaction, but it is due to something--inactivity, opioids, or, scary terrible inflammation in the gut that is waiting to kill them.

Gastroenteritis and constipation are dangerous, dangerous diagnoses--moreso becuase they are so common, and usually we will get away with these diagnoses if we are confident, or maybe foolhardy, enough to use them. The author of RENT, 3 days before he died in his apartment of a ruptured aortic aneurysm, was diagnosed with gastroenteritis. Is that common? No, or people would be dying in droves. But COMMON isn't what I'm looking for. I'm looking for 'zebras', what we call rare diseases. For a medicine doc or a pediatrician, that's usually some obscure genetic disorder. I look for enormous zebras with big teeth waiting to kill you--the aortic dissection, the coronary artery aneurysm from KD, the inferior MI that shows up as weakness.

It felt good to be right about this kid. He got helped. But how many have I sent? How many will I send? Only paranoia can save me from the abyss.


At the program I train with, we are required to do EMS ride-alongs, and we have the option to do helicopter medicine. I am all in on the flying, but I learned the most real-world perspective from two or three ride-alongs. EMS folks live in a different world than anyone else. They take the fight to save the patient from themselves into the erstwhile lair of the patient themselves, and all their crack-addled neighbors.

Imagine intubating on the kitchen floor while your partner stomps the roaches to keep them from crawling into your field of view. Or starting an IV in a moving truck.

ER docs do good. But we work as a team. Next time EMS rolls in, whether they've done a banner job or not, I think we should keep in mind where they were and what they do on a daily basis. Coffee's always around for y'all, you do good work.

Why this post? Good new EMS blog here.

Respect the SS

Sickle-cell anemia comes in a couple of forms, but in general SC disease is more trait-like, and SS disease is more severe, with pain crises, strokes at young ages, autoinfarction of the spleen, and so on. So, typically we're more careful with SS patients than with others.

A 13 year old girl with SS comes in with a sore throat for about six hours and feeling a bit tired. She has friends who have strep. Her exam isn't scary; she does have a fever, and a bit of a fast heart rate (116), but otherwise, her throat isn't bad, she's not in respiratory distress, she's appropriately alert. This is not like a normal crisis. She's having absolutely no chest pain or shortness of breath. Her neuro exam is normal. By protocol we sent off CBC, reticulocyte count, and blood cultures, but only by protocol.

Her anemia was so profound that her count of new blood cells being created in order to make up for her losses was almost higher than her blood count. Her hematocrit was 18 (normal is above 35) and her reticulocyte count was 17 (normal is, like 2). Oh, and her O2 saturation was 80.

We only got an oxygen saturation because she had sickle cell disease.

This kid scared me good. Respect the SS disease. She looked fine! No respiratory distress! Yes, she had a murmur--but a hematocrit of 18?!? And a pulse ox of 80%?!?

Oh, by the way, the strep was negative.


Is a Missing Lip an Emergency Condition?

The medblogs are buzzing about University of Chicago's decision to treat a boy attacked by a pitbull without surgery.

Shadowfax has posted multiple times, most recently here; WhiteCoat has picked up on it here; and Scalpel has replied with a vigorous, bracingly conservative ripost here.

These three and others have framed the question as an EMTALA violation; is this a patient dump, or not? Is it illegal, or not? I'm more interested in how it framed the plight of modern EDs. I don't think, from what I've read, that there was an EMTALA violation. The boy was 'treated', and although his cosmetic outcome may well have been better, according to Dr. Grevious (no joke) once mom carted him across Chicago for immediate surgery, I think UCMC has a case.

More interestingly, the question is how can overwhelmed EDs possibly respond to crushing patient loads, the loss of subspecialty coverage, the mandate to see any and all regardless of pay, and all of this increasing as more and more EDs close and the federal government that forces us to see everyone subsidizes less and less? This on top of California's recent court decision that legally prevents EM groups from seeking additional compensation for services rendered from the patient. From our perspective, what exactly are we supposed to do? Chicago was trying to dispo out people who don't need emergency care. That's OK with me; tons of people abuse the ED although they are overall the minority. I think they picked a horrible time to do it with this kid--but, then, maybe they did it on purpose. No plastics available? Fine. No subspecialty care? Fine. America, this is what you get from us, they are (possibly) saying. You get the care you pay for. And when co-pays in the ED are zero, medicare reduces payments towards zero, states disallow collection of fees, we all end up with...well, zero happy stakeholders.

It's easy for me to say I care about cosmesis and wound outcomes and I'll fix a lot. I didn't see the kid, it might well have been beyond me, and besides, I work in a pediatric ED sometimes with triple attending coverage and three or four residents for twenty rooms, and we still have visit times up around four or five hours. I can see UCMC's side, easy--even if I also feel for that poor kid who couldn't get his lip sewn after he was a chew toy for a pit bull. If we can't take care of that, we're in trouble. Maybe UCMC is just pointing that out to society.

Undue Influence?

Thought this was a great shot. On anesthesia at the VA, one of the retiring PAs brought in his pen mug from his office and these were my top choices for classics. Interesting how long big pharma has been plying MDs with free pens--not that we should be interested, it seems like we could afford our own pens. I still don't understand why MDs are interested in these. The trip to Hawaii I understand.

I've taken an oath here to avoid pharma influence. So far it's been easy. The county where I went to medical school outlawed drug reps, and my residency program has a policy of not taking any money or gifts from pharma. Just wait for the community, right?

I think the Versed pen is my favorite. I was tempted to take it, I admit.



This is a rant. Fair warning.

OK. Reasons NOT to bring your kid into the spanking new high-quality 20 bed pediatric only ED with 6 resuscitation rooms and triple attending coverage.

Number 1. My kid's foot jerks in his sleep sometimes. I videotaped it. It happens, like, every five minutes. He keeps sleeping but he, oh my GOD, like rolls over. I brought him in here, not so you ED docs could look at him because you don't know what seizures are, but so he could get an MRI and a STAT Neurology consult (I didn't tell her that was an oxymoron). Yes he has a fever. Yes he has a cold. Yes he's 18 months. So, A, that's not a seizure, it's sleep myoclonus, and B, even if it were a seizure and it were generalized, even up to 3 or four minutes, it would be a febrile seizure and he wouldn't need an MR. Let's say you're right and he is having focal seizures, just for the sake of argument; if that were the case, he has a fever so I have to 1, CT him, which is radiation which you don't want, and 2,tap him which you obviously won't like if it bothers you that his itty bitty widdle foot twitches in his sleep. Honestly. I'm not trying to deprive you of your God-given right to a stat MR for sleep myoclonus. I'm trying to avoid giving your kid leukemia (now thought to be perhaps as high as 1 in 1000 for early CT exposure). Sigh.

Number 2. My otherwise well kid really didn't sleep well last night and he has a runny nose. Guess what? My kid didn't sleep last night either, because despite stripping at the door and sprinting to the bathroom to wash my hands, I still am covered with stinky-germ-goo from people like you and all my kids, my wife, and I, are sick. I still came to work. My kid is at home. He woke up ten times too. My wife, who feels sick, is at home taking care of three sick kids so I can have the joy of telling you it's a virus and you should, like, suction his nose and let him rest. Christ.

Number 3. On to annoying primary docs (many are good, I'm not yelling at them). My patient is totally fine, but she has a bump on the back of her leg that doesn't hurt at all. She fell a MONTH ago on her shin and couldn't walk for a day and now is better. She has NO feverchillseasybruisinglossofappetitenauseavomitingdiarrheacoughheadachemalaise. You, smart PMD, told this poor lady and her two kids to come DIRECTLY to the ED for EMERGENCY hematology consult and EMERGENCY orthopedic consult. Apparently small, painless, barely noticeable calf bumps are outside the scope of practice for this particular generalist pediatrician.

Number 4, a special shout out to the receptionist. Thank you, oh thank you, for telling the chronic abdominal pain patient who, to their credit, is not requesting drugs or mega work-up, to come DIRECTLY to the EMERGENCY DEPARTMENT (so named because it is for emergencies, not clinic visits) so that we EM docs can arrange for your doctor to see you in the ED because he's over at the hospital today. Please, please don't tell the patient they can be seen in clinic by one of the doc's colleagues. Please, please don't tell them to make an appointment, God forbid, tomorrow when the doc is back in clinic. No, no. Send them directly here. I'll see them right after the runny nose, the calf bump, and the jerking foot kid.


Airway Tip O' The Day

A colleague on flight had a horrendous trip the other day to a blast site. One victim was talking, had normal vital signs, but was hoarse and covered in black soot from the neck up due to the blast.

An indication for a tube if ever there was one; it had only been sixty minutes or so from the time of the blast and already she was unable to pass a tube a full size smaller than needed, and saved his life with a rescue device instead (a King LT). Which leads to the airway tip o' the day.

A bougie is a long, flexible plastic thingee used to find the trachea by feel and by the bend at its end, over which you can then pass a tube. Usually I think of it as a means to improve an airway with a bad view. She had a great view; he was just too swollen.

The tip is to use a bougie even with a great view in the setting of airway edema; if you can't pass a tube over the bougie, leave it in place, go one size down, continuing until you pass something.

Of course, this being the great frozen north, it was seven degrees where she was trying to intubate without the windchill, so the bougie probably would've snapped. The O2 tubing had already frozen. Sweet. Can't wait to start flying.


GCS of Seven

Most kids aren't that sick in the ED. Some are downright well. After working there for a while, you're sicker than most of them because they've given you GI junk and URI junk and maybe some rash junk, too.

When they ARE sick, good God, it's scary. We had an ambulance call, not a trauma call, come in the other day, of a 3 year old, head versus TV, and 'altered'.

To prepare in my head, though I would never be the one to do it as an Intern, I reviewed RSI doses--0.2 mg/kg etomidate, 2 mg/kg succinylcholine, estimate for a 3 year old about 15 Kg, so 3 mg and 30 mg.

He came in moaning, not in a C-collar, his right arm flexed, eyes closed. GCS? 1 for eyes, 3 for pediatric moaning, 3 for flexion posture--seven. Needed a tube.

We took him into the trauma bay, and held C-spine precautions while I realized I didn't know how to work the C-collars we have at children's because I've never done it. Having never done a peds trauma resuscitation, I was sort of useless--I could hold the bag on and do the ATLS algorithm in my head, but so what?

IV in 2 minutes, intubated in 5, CT scanner in 10. Pretty good. The kids are so small and everyone is so intense, pediatric traumas are frenetic. Everyone is close together. The sphincter tone in the room is incredible.

His CT scan showed a skull fracture and air all over, with 2 mm of midline shift. Hopefully he'll do better.

That's Peds EM this month--95% BS snot and wheezing or their leg looks funny but doesn't hurt, and 5% holy crap.


I'm Sorry, Man

The picture here is from the first page of Beowulf--not the CGI version that was produced with Angelina Jolie but the oldest surviving piece of English literature. It's a testament to how important words are, and for how long we've struggled as people to get our meaning across.

Imagine, then, not being able to find your words. Imagine speaking in truncated sentences, stopping in the middle, fumbling. This is a finding called non-fluent aphasia. Sudden onset of speech difficulty is often listed as 'slurred speech' in stroke education, but that is actually dysarthria and comes from loss of control of the muscles of the mouth and tongue to some extent. Aphasia is a stroke that somehow involves the higher cortical functions of language, and patients literally cannot find the words they need.

A gentleman came in with this last week. It had first happened in Mexico, on vacation, and then resolved somewhat; it had returned four hours before arrival and it was his only presenting symptom. Histories like this make me sad. It was no doubt what he had. There was an upside--he had very few deficits. But imagine not being able to find words anymore.

Imagine being mute not from some physical ailment but from literally not being able to get to that word or phrase that is dying to come out. It happens to all of us (ironically, for me the other day when I was trying to remember the word 'dysarthria')--but this is different. He stopped in the middle of almost every sentence, and he made grammatical mistakes normally heard in an ESL class.

His main question? When can I go back to work? He worked in business, had meetings all day. Not soon, dude. Not soon.