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.

So?

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.

Sigh.

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.

Non-Compliance

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.

Twitter

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).

Communists

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.