Best Of | Agraphia

10Jul/1111

Megacode

She rolled in to Resuscitation Bay One an ashen grey, the tired paramedic straddling the stretcher doing chest compressions. Sweat poured down his brow and arms. They had been at this for an hour en route to our hospital on dark, twisty back roads. She was just shy of 90 years old.

She died for the first time at home while washing the dishes; her husband heard a plate shatter and found her dead on the floor. He started CPR while calling 911 and valiantly kept doing chest compressions until the medics arrived. They jump-started her heart with a defibrillator, but she died for the second and third times on the way to us.

There is a hue about truly dead people - an aura, almost. Extremities pale and mottled, lips colorless. When she arrived the other physician and I shared a knowing glance. This would not end well for her. She was long gone already, but her wishes were to "have everything done". So, we started doing everything.

It is a peculiar feeling, cracking someone's ribs while doing CPR. The heart is simply a series of one-way valves; by doing chest compressions blood is forced out of the heart to the rest of the body. Unfortunately generating that much pressure is often too much for osteoporotic, elderly bones to handle. The result is a *snap* as ribs break from the force. It feels like torture.

Broken ribs are unbelievably sharp. Chest compressions generate inward force, and so the bones rip and tear the lungs, causing air to leak out. With nowhere to go, eventually the air pressure deflates the lungs. The solution is to "decompress" the pulmonary cavity with large bore needles stabbed directly though the chest wall.

As her heart began to fibrillate we began to shock it with 200 joules of electricity, over and over, in an attempt to regain a normal rhythm. Caustic medications were pushed through her IV's to try to stabilize and restart the heart muscle. None of it worked, of course, but she wanted everything done.

In ACLS training this is referred to as a Megacode - a code situation where every therapy and every algorithm is used. It's purely for training purposes; you never survive these extensive measures.

She briefly regained a pulse and then died for the fourth and final time, with a tube in her trachea and esophagus, every rib broken, a needle in each side of her chest, IVs in each arm, special intravascular devices to each groin, and a catheter up her urethra.

I wish I could bestow my entire medical knowledge on patients and families before they ask to have "everything done". They cannot possibly understand what they ask me to do to the ones they love.

Tagged as: coding, cpr, death & dying, futile care, heroic measures, shockable rhythm 11 Comments

8Feb/117

FULL CODE!!!!

Last week a man was rolled in to the ER, although I hesitate to call him a man. He looked more like a mummy; lips shriveled, eyes sunken, arms and legs even wrapped in gauze to cover his numerous decubitus ulcers. He had suffered complete and total anoxic brain injury months earlier; there was nothing left of him but a physical husk. Every single physician and nurse dropped what they were doing to stare incredulously as he was wheeled by. He was death incarnate.

The medics, with a wry smile, handed me his chart from the nursing home. Handwritten, on a single blank sheet on top of the chart was a family member's scrawl, underlined three times and followed by a plethora of exclamations.

FULL CODE!!!!

It became quickly apparent that he was much sicker than his chronic state of nearly-dead. Heart rate was up, blood pressure was down. We sat around for a moment, twiddling our thumbs. He was clearly going to die no matter what we did. The "right" thing to do from a legal standpoint was to rush him up to the ICU, flood his system with antibiotics, take him to the operating room to slice out all of the decaying flesh, and pound him with fluids.

The "right" thing to do from a medical and humane perspective, however, was to let him go. I would add "peacefully", but that opportunity was lost months before when we stabbed a breathing tube through his neck, shoved a foley up his urethra, a catheter up his rectum, and a feeding tube through his stomach in the name of Good Medicine. So, instead, I pulled the family aside to talk about end-of-life care. I wish I could say it went well.

"I'm sorry to tell you this, but there are two ways he can die tonight," I said quietly, "peacefully, with morphine to make it painless and comfortable, or with the ICU physicians cracking ribs during CPR, pushing painful medications through his veins, and shoving you out of the way during his last moments so he can't be with his family."

The daughter looked at me with a distasteful look. "Well, we goin' home, so it's between him and God now," she scoffed, "so y'all better do everything for him. I got faith he'll pull through. Here's my phone number in case anything happens. If it's busy jest call back later."

And so, he went to the ICU. Predictably, his heart stopped beating, ribs were broken during CPR, needles were stabbed into any remaining veins, and no loved ones were with him when he died. The phone was busy. They stopped by the hospital late the next morning with a bag of Dunkin Donuts to sign the paperwork.

Is there a moral here? I'm not really sure. I suppose I can only speak for myself when I say - vehemently - that I would never want to go that way.

Tagged as: coding, cpr, death & dying, heroic measures, idealorealistic dissociation, shockable rhythm, uninvolved families 7 Comments

4Jan/119

10 Things That Make A Great Emergency Doc

I got asked this question at a dinner party the other night: "What's the difference between emergency physicians and other doctors?"

It took me a moment. I haven't had to answer that question since interviewing for residency, back when I had only spent two months as a medical student rotating through the field. I think I've got some better answers and perspective now. So, for all you aspiring premeds out there , or for laypeople interested in just what makes an ER doc tick...

1) You have to have passion for what you do.
This is true for every medical specialty, but moreso in emergency. A 10 hour shift will run you ragged and exhausted. It's only because I love it that I leave my shifts in a good mood. I helped a couple people, saw some cool things, and sure I'm tired... but at the end of the day I did good work.

2) You have to be willing to roll with the punches.
Usually figuratively. Sometimes literally. Things will be thrown at you that you would never expect. Multicar pileup on the freeway? You bet all those patients are coming to you at the exact same time. Guy found unresponsive in the snow? Yup, take him to the ER. And somewhere in there, a heart attack will sneak on through. Naturally they all arrive without any medical records.

3) You have to love interacting with people.
The emergency department thrives on teamwork. If you're not a people person, or you can't take criticism, you're dead in the water. You live and die by your nurses, techs, and consultants. Plus, you've got all of 5 minutes to meet a patient you've never seen before, shake their hand, and gain their trust so you can figure out what's wrong with them.

4) You can't be offended easily.
Consultants hate being called by the ER. Yeah, they're "on call", but I assure you nobody likes to be woken up at 3 AM. You'll be questioned on your medical judgement, you'll be ridiculed, and you need to understand that the other person is just tired. They simply don't want to see the patient if they don't have to.

5) You need to be quick on your toes ...
Slow people don't typically enjoy emergency medicine. If you don't like the idea that multiple new patients could show up at any time and need to be seen quickly, you may want to consider a specialty where you have time to be methodical, triple-dot your i's, and extra-cross your t's.

6) ... and good with your hands.
You hear this about any field that performs procedures. You will do so many procedures in emergency medicine that you will stop counting - and you will be grateful that you like to work with your hands. Some people simply don't enjoy this.

7) You need to accept your limitations.
You will never be a cardiologist, nor a neurosurgeon, nor a radiation oncologist, so you will not understand everything that they do. You will, however, know about 70% of what they do, which is just enough to babysit patients until the specialist comes.

You have to keep an open mind.
Our patients can be very hard to deal with. Suicide attempt by swallowing one tylenol. Alcoholic presents for acute missing sandwich and stat hot shower. Drug seeker needs dilaaa... dilauudaaa... dilaudid, is that it? The earlier you learn these people truly need help - referral to detox centers, shelters and social work, the easier your life will be. Otherwise you will turn into a cold shell of a person, always suspecting someone is trying to get the best of you.

9) You've gotta enjoy a bit of chaos.
For some, fun is a nice round of golf with the chaps. For us, fun is when the ED goes batshit - every patient wants something, every nurse, tech and doc is overworked, yet somehow you're keeping it together. It's trench medicine. It's the front lines of the American Health Care Debacle System. Exhilarating, isn't it?

10) You should be proud of what you do.
The unwashed masses are cast against the shores of the department and you take all comers. You don't ask insurance status. You don't ask if they can pay. No, you treat meningitis, fatal arrhythmias, broken bones, and bring people back from the brink. Why? Because it's the right thing to do.

Tagged as: advantages in ER, badass, chaos, good mood 9 Comments

29Jul/105

Psych Is Scary

3AM, and the all-too-familiar beeping starts. I awake to the dull amber glow of my pager. Call the nurse for bed 29, please.

"Zac... we have a patient who is scaring us and we need you to come see him." I rub the sand out of my eyes and stumble out of bed.

It's quiet in the hospital, but there is an ominous tone hanging over the night. Wind whips past windows and the rain has been coming in bursts. The nursing station is silent except for the gentle beeping of the monitors. The lights are dimmed in the ICU, except for Robert's room, bed 29. He's a psych patient who landed himself here by driving full-bore into a concrete median. He's been in and out of consciousness since day one.

I walk down the darkened hallway and towards his room. Eerie noises emanate as I get closer; a mixture of wails and shrieks. It's Robert.

Nurses stand back against the cabinets, and I see Robert lying in his bed, ripping and tearing at his restraints. A thin line of spittle hangs down his mouth and a small trickle of blood trails from where he has chafed at the wrist cuffs. He's hurting himself. He moans like a caged animal.

"Robert, it's the doctor, just coming to check on you..." I stammer, but his eyes are wild and rolled in the back of his head. The rain starts to pick up outside of the room, first brisk and then torrential. I don't want to be in the room alone with him, but the nurses file out now that I'm here.

He mumbles something, eyes darting around the room.

"I can't hear you, Robert, please speak up." He meets my eyes for one brief moment, lucid, and motions me over. Slowly, I advance. I'm keenly aware of the darkened hallway behind me. This feels like something out of a horror movie and I have the distinct sensation that something is there. I glance over my back. I'm being silly, it's nobody. The hairs on the back of my neck crawl anyway.

Nervous, I lean in. "Robert, I can't understand you. You're speaking nonsense." He grunts some more. I edge closer.

Suddenly, he sits bolt upright, his face inches from mine. I jump back, startled. Panting, sweat beading off his brow, his arms are cords of muscle as he fights the restraints.

Robert's head starts turning, slowly, staring straight forward, breath fetid. A slow, terrifying grin spreads across his face as he fixes his gaze to mine, his cracked yellowing teeth in a rictus of madness. Slowly, his head tilts, his bloodshot eyes boring into me. The patter of rain is the only sound in the room. And then he speaks, his voice deep, hoarse, and gutteral.

"Look... out... the WINDOW!"

Panicked, I spin around as a single bolt of lightning illuminates the room. A shadow flits across the glass - no, it must be my imagination - but my heart is pounding. The rain traces lazy rivulets down the window. I turn back quickly, but Robert, spent, is lying back in bed, breathing softly, eyes closed. The room is silent again except for the rain.

Filed under: Best Of, Medicine 5 Comments

2Jul/108

End Of An Era

And like that, it's finished. No fanfare, no awards. Walk out of the hospital one day an intern, return the next a resident.

My parents called to ask if it felt any different. To my surprise, I answered, "yes... it kind of does."

Countless books have been written about intern year. Every physician gets a bit misty-eyed when thinking back to the nascent, formative moments of their career. Medical students peer forward, trying to pierce that impenetrable veil of transition from student to doctor.

The difference between an intern and a fourth year medical student is simply the M.D. behind their name. But, of course, that's everything. Someone has accredited an intern to make decisions about patient care. An order for a CT scan will result in the same scan, no matter whether an intern, resident, or attending authorized it, but no medical student can give that order.

Exactly one year ago, on my first night on call as an intern, I got a call from a nurse for the simplest of things. "Doctor," she said, "your patient in bed six has a fever of 102.4, and there is no Tylenol ordered. Can I give him some?"

I panicked. Tylenol is the oldest of drugs. Parents give it to their kids like candy. There are elixer, flavor, chew tab, and extra strength variants. It has countless brand names across the world. I was a doctor now, and I should know the answer. Just a simple Tylenol order. And yet.

In a patient with liver failure, Tylenol can be lethal. The primary team didn't think there were going to be any problems with this patient overnight, and suddenly I was presented with a fever. Fevers in the hospital setting are often the harbinger of massive bacterial infections, lethal blood clots, wound infections, sepsis from urinary tract infections, and so on. A simple order for Tylenol... well, it's not so simple.

I sprung out of bed, hair mussed, wild eyed, heart racing. The patient was sleeping, but I woke him up and grilled him for 10 minutes to make sure he felt alright. Gruffly he responded, "well, I was doing just fine until you woke me up!" I pored over the chart, trying to comprehend his care, his underlying pathology. He was postoperative from an appendectomy. Nervously, I reasoned that his fevers were from atelectasis, a common and benign cause of postop fevers, and ordered the tylenol.

What if I was wrong? What if it was infection? What if lying in the bed had caused clots to form in his legs, rocketing off and wedging themselves in his lungs? I went back to my call room and laid awake for hours, exhausted, the dim blue glow of the computer suffusing the room with bits of the electronic medical record.

In the morning, I called the primary team to let them know I had given tylenol to their patient overnight. "Cool, man, thanks, he probably just had atelectasis," said the resident. In a single moment, a night of agony validated and dismissed.

I soon learned that with experience, confidence builds. With every mistake identified, every correct decision confirmed, I grew as a physician. 4,000 hours spent in the hospital, 80 hours a week, 50 weeks a year. Bathed in the milieu of medicine day in, day out.

And at the end of it, one step up the ladder. One layer of supervision, peeled away. One more level of scrubs asking me the questions. One year of training down.

I saw a new intern walking into the hospital on her first day as a doctor this morning, uncomfortable in her starched new white coat, the hospital logo emblazoned proudly on her sleeve. She kept grabbing at the pockets, adjusting her stethoscope, buttoning and unbuttoning, checking her pens. Nervous, but deathly afraid to show it. I remember that feeling well.

"Morning!" I greeted her, cheerfully, "You excited?"

"Yeah..." she allowed.

"It's going to be a fantastic year, " I assured her. "Come find me if you have any questions."

Tagged as: good mood, growing up 8 Comments

16Jan/106

This Mortal Coil

I remember all my first deaths.

The very first was our cadaver in medical school. As first year medical students, we shuffled quietly into anatomy lab, nervous giggles escaping pockets among the crowd. Lying cold, still, aseptic, was our body. Charlie. It's an unsettling feeling, laying hands on a dead body. There is a quiet dignity about death, a final stillness that is unmistakeable. I remember stainless steel tables with stainless steel scalpels, and the subtle scent of formaldehyde barely masked by the cloying smell of wintergreen. My hands shook violently as I made the first incision.

The second was the first death I ever witnessed in person. Surprisingly, it took until my 4th year of medical school, on an ER rotation in Seattle. He was an elderly gentleman who had shot himself in the head after downing a 5th of vodka when his wife divorced him. His features were barely recognizable with all the damage. He was intubated, paralyzed, and barely had a pulse on arrival. CPR continued only for 5 minutes before he was pronounced dead; somewhat of an afterthought. The only thing keeping his heart beating until he reached the hospital were the massive doses of epinepherine circulating in his bloodstream. I remember being sorry for him, but not devastated - he was already DOA.

Last night, my patient died.

The page came: ADULT TRAUMA CODE ONE FIVE MINUTES OUT BY AIR

I sprinted downstairs and into the trauma room, a sea of faces greeting me. My favorite nurses, our best physicians, waiting. These are the most capable people I know. They were ready - I prepared myself for the survey. As the trauma intern, it's my job to perform the whole physical examination in front of everyone and call out significant findings. All we knew is that the patient was a 70-ish woman in a car accident.

The medics rolled the stretcher in, and instantly the mood changed; suddenly silent and tense as we saw how bad off she really was. For a second, the only sound was her quiet wailing, "Oh, Lord. Oh, Lordy, my arm hurts. Please, my arm hurts so badly..."

The moment ground to a halt. I remember utter quiet as the seconds ticked by, as long as minutes. Her forearm had three joints where it should only have two...

Silently, I took in the damage. Horrific, tenting fracture to the left forearm. Right wrist splayed off to the side, every bone in her hand likely shattered. Right ankle sideways. Left shin with shards of bone sticking out the front. Amazingly, she was still talking and protecting her airway, the first thing ever said in a trauma assessment.

So I spoke.

"Airway... is currently intact."

Time sped up, sounds and colors rushing in to fill the void. What once was silence and stillness was bedlam and cacophany. Everyone talking. Everything moving. I was lost in the exam, hoping against hope that if I could just find the one thing that was wrong, I could save her. But there was too much.

Broken bones were quickly realigned, blood lost was quickly replaced, but we were waging a war against death and we were losing. For every vein that we accessed, another collapsed. For every unit of blood given, she bled two more. I was struck for a moment by how beautiful it was, all of these people working in harmony to try to save one life. Grim faces and furrowed brows desperate to help this stranger. People at their best.

Blood pressure started dropping. I had my hand on her pulse and felt it ebbing away, slowly, surely, towards that final quiet stillness. I remember at one point looking up at the clock and realizing an hour and ten minutes had elapsed. There was the chill, certain realization that nothing would stop this woman from dying. My fingers felt her pulse getting weaker. Slower. Fading. A few minutes later, she was dead. Everyone shuffled out of the trauma bay until it was just me and her. I was struck by how cold she was. Like Charlie.

And then the page came: PEDIATRIC TRAUMA CODE ONE 6 MINUTES OUT BY AIR

Off to save a life, this time.

Tagged as: chaos, coding, cpr, death & dying, heroic measures, shockable rhythm 6 Comments

1Jan/104

Cold

"Hey, brotha. I need help. Look, I'm not gonna shit you, I'm an alcoholic. I'm homeless. I've got back pain. You can help me, you're a doctor. I need Ativan so I don't go into DT's and some Percocet for my pain. Please, brotha, I lay myself at your feet."

Before me lies an emaciated husk of a man, frost-bitten, his bleach-blonde hair pulled into dirty dreadlocks. The room reeks of alcohol, the tang of shitty beer lying uncomfortably in the air. His bloodshot eyes track me as I walk over to examine him.

This was my first introduction to our resident frequent flier. He's famous; every ER doc in the city has treated him for everything from alcohol withdrawal to blood infections. Among other things, he's an asshole, a florid alcoholic, and an abuser of the system (a news article estimated his ambulance rides, ER visits, and ICU stays costing the taxpayer more than $10 million).

Unsurprisingly, my exam is unremarkable. It's freezing out, and the ER is a refuge for a few hours from the biting cold and the unforgiving streets. I prepare myself for his discharge, and give him his papers.

"Your exam is normal today. I can't find a reason that your back hurts. I'm sending you home."

"Fuck you, man. I can already tell, I can't change your mind. I know your type. Yea, I'll fuckin' go. You know how cold it is outside? Yea, I'll fuckin' go. I'll go, you privileged sumbitch. You have no idea what it's like to be homeless."

He leaves without much fuss. A nurse claps me on the back for handling him well. She thinks my no-nonsense attitude approach will serve me well as an ER doc. All the same, a small voice in the back of my head wonders if I should have been more compassionate.

The rest of the shift goes uneventfully, and as I drive home, I notice it's cold out, cold enough to freeze the windshield on my car. I run inside my heated house and crack a beer. Life is good.

"You have no idea..."

Out of guilt, I throw on a sweater and my overcoat, and shuffle outside. It is bitingly cold; I start shivering instantly. The stars are frigid, beautiful, and unforgiving, the moon austere behind a single veil of cloud. He was only wearing a sweater and some thin pants when I discharged him. He must be freezing right now. I last all of 5 minutes; my teeth chatter so hard I fear I'll break the enamel. I rush inside, the warmth enveloping me like an old friend.

Tagged as: drug seekers, rough day 4 Comments

23Oct/097

Trapped and Free

4:55 AM, and I was dragging. My 12th day straight in the hospital, leaving a string of three call nights behind me with one left to go. Twenty patients to see before grand rounds at 7AM.

My knee has been hurting. I suspect it's from the miles and miles I've been putting on my body 14 hours a day, 90 hours a week, running around the hospital. I've been taking the stairs everywhere in an attempt to remain in better shape, but this morning it was too much. No coffee yet and too little sleep. I gave in and took the elevator from the 3rd to the 11th floor.

I leaned back in exhaustion against the side of the elevator, eyes closed. It whirred into life, and I let the tug of gravity pull me to the ground. The elevator reached the top floor and *dinged* quietly. I stirred, mentally preparing to start rounds.

And then, the door made a few feeble attempts to open, and quit. Servos whined to a halt. I was stuck in the elevator.

Funny, how things can change. Any other time I would immediately panic. What if I have to go to the bathroom? What if the cable breaks? What if the call button doesn't work? What if I can never get out?

Instead, pure, unabashed relief washed over me. I couldn't work while trapped in the elevator.

Zac, why haven't you finished rounds yet? The situation played out in my mind, There's so much to do today! We have to get on it!

Sorry sir, I quietly replied, I'm physically trapped in the elevator on the 11th floor, there's really not much I can do from here.

Well, I suppose you've got an excuse then. Take the day off.

I sat there for a few minutes, relishing the solitude. I planned out my entire day of rest, mapping out every delicious hour I would spend in each corner. Perhaps I'd take a nap right in the middle of the floor. I smiled. It was going to be a good day.

Then the elevator *dinged* softly again, and my hopes sank as I traveled back down. The door opened on the third floor. A tech stared at me in surprise, papers stuffed in my pockets, hair askew, sitting on the floor of the elevator.

"You alright, man?" he asked.

"Not really", I responded. I stood up, knee hurting, as I limped off towards the stairs.

Tagged as: apathy, burnout, fatigue, rough day 7 Comments

30Sep/094

The Endless Tide Of Unwashed Humanity

Faceless children throng through the doors of the Peds ER; parents, illnesses, charts all flowing into one feverish, runny-nosed amalgamation.

The waiting room is full of these kids. Anyone who didn't have the flu before, does now. It takes 7 hours to be seen, plenty of time for snotty hands to wipe all over the tables, the chairs, the playthings.

I vaguely listen to my voice on autopilot, droning on about the benefits of motrin and tyenol for fevers. I'm surprised to hear myself lose patience with a particularly insistent mother who wants her daughter hospitalized for a fever of 101.3 and a cough. Her kid is fine. She won't take no for an answer. We get security to escort her out.

This isn't fun. At one point I see 8 children in a row who I diagnose with the cold. The monotony is broken by a child with a cut on his finger, but he starts screaming the second I enter the room. We have to sedate him before I can sew it up. He hates me for it, and his mom judges my repair every step of the way. I look too young, she explains. My next 5 patients all have the cold. Nothing about this is enjoyable or fulfilling.

The shift ends with a whimper, as we finally clear out the waiting room 15 minutes before I'm scheduled to leave. My last patient is a kid with a cough. I send him home with tylenol for the fevers. The parents can't believe they waited eight hours for me to tell them that. I can't believe they did either.

Tagged as: apathy, chaos, idealorealistic dissociation, peds 4 Comments

27Jul/096

Fitting the Stereotype

I treated a guy a few days ago for the "worst lower back pain of his life". This is a surprisingly common occurrence for emergency doctors, and I must admit that I immediately wrote him off. Mohawk, neonazi tattoos, bad teeth, nasty attitude.

I went through the song and dance, pretending to care about his "back pain after twisting it the wrong way". I've heard this story so many times, from so many drug seekers, that is has competely lost its luster. Immediately I informed him that I was not comfortable prescribing narcotic medications.

"But I'm allergic to tylenol, aspirin, and advil!" he decried, "Please, doctor, it hurts so bad. Can't you give me something else? Nobody can help me but you..."

Even a couple of years into hearing these complaints I still cringe a little on the inside while I put on the hard, callous exterior. "I'm not going to prescribe you any narcotics today, sir."

But what if I'm wrong? What if he's truly in pain and I'm just being stubborn? He was barely able to sit up from the bed without wincing in pain when I examined him. Every small touch sent him into paroxysms of agony. I discharged him with an anti-inflammatory I hoped he wouldn't recognize the name of.

Two days later I was walking back from the cafeteria and saw him strutting down the hall towards the urgent care with a heavy backpack on, no evidence of the "extreme pain" he had 2 days earlier. The doctor covering urgent care called me when he came in 10 minutes later for an inability to walk.

Nobody likes to be made a fool of, which I suspect is part of the reason Emergency Physicians undertreat pain. I follow up many of my patients in the hospital (did my suspected heart attack actually have one?), but I never follow up on suspected drug seekers. Why? Because I don't want to turn cynical earlier than I have to.

Tagged as: cynicism, drug seekers 6 Comments

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