"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

Multi-Tasking

Finally, got a real night shift.

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

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

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

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

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.

/sermon.

Gauze

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

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.

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.

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.

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.

Rant

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.

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.

Shaken or Stirred?

When James Bond says how he wants his martinis, both choices are refined, the choice is a test of internal character, of dashing charm. In the ED, though, it never seems to work out that way...

Part 1: 'Stirred'

A middle eastern fellow comes in complaining of 'twitching' and a funny feeling in his chest, and, sitting on the gurney, shakes his extremities violently and spasmodically, going red in the face. He still responds, asking, 'what is it, what is it' that makes him do this between episodes, and even throws up a couple times. He gets pads, monitors, a non-rebreather, and serum and urine tox.

History reveals that he's had 3 full-size Red Bulls that morning alone (it's about 10:30). He also says 'someone blew smoke in his face' and he didn't know what it was, right before he started jerking all the time. Riiight. U Tox comes back with...hmmm...cannabinoids. I go to tell him and have to excuse his father and older brother; his mother, covered head to toe in a hijab (they're Jordanian) doesn't speak English and just looks at me with a smile while I tell her son he's a pothead (which he denies, must have been that guy blowing smoke at him) and it doesn't mix with Red Bull. His father wants to know if he's doing drugs. I said, "I can't tell you, but as a father, you should parent him as you would based on your own impressions". The dood (thanks Nurse K) denied any pot use. Right.

Part 2: 'Shaken'

I'm walking down the hallway minding my own business when an uptight lady standing next to a gurney says, 'Are you an attending?' then before I answer, says 'I'm doctor so-and-so from the Children's hospital ICU, and I need to talk to you right now.' The Children's hospital is adjoining ours, and corridors connect us. She then gives me sign out about this guy who started having 'a seizure' in the cafeteria of Children's. Later the nurses said she was totally rude and I wish that I had told her something about EMTALA violations (since he was on Children's premesis) but I didn't. The guy is still shaking all over but looking at us.

'Sir, can you hear me?' He can. 'Can you stop?' He can. Sweet! Cured.

I start examining him briefly and tell him we're going to get a few tests--and he refuses blood draw. My staff comes in, and says--'Hi, Howard. We're not going to play these games today, OK? You give us blood and let us evaluate you, or you leave now'.

Howard starts shaking again, this time on his feet--miraculous how he can do that--then pretends to fall. Refuses blood draws. He gets put in a wheelchair, and says, 'I'm going right back to the cafeteria to have a seizure!' 'Go ahead', the attending says. He starts shaking in his chair again. 'Knock it off, Howard', says the tech, and he does. To myself, I'm thinking, did that ICU doc even look at this guy? Probably not. Way too old.

So the ED shaken or stirred question, not so glamorous. But way, way more fun.