Agraphia Medical Tragicomedy

The Fear

ADULT TRAUMA CODE 1, FIVE MINUTES OUT BY AIR.

A young man was riding his motorcycle, swerved to miss a log in the road, and was flung headfirst into a concrete barrier. He was acting funny when the medics arrived on scene and quickly became so combative that they had to sedate him for safe transport to the hospital.

This is a telltale story for a head injury, and one that can be terrifying for the medic ground crew. It often takes multiple paramedics and firefighters to restrain these patients so that an IV can be placed and sedative medications can be given. In this case, he rapidly decompensated and required a breathing tube.

Intubation is not an easy procedure in the best of circumstances. Anatomically, the human airway is positioned above the esophagus, requiring specialized instrumentation to provide clean line of sight. The airway itself can be unbelievably hard to visualize; so much so that the field of emergency medicine has devoted entire lectures, conferences, and books to airway management.

The paramedic was unable to place an endotracheal tube; always a bad sign. He placed a specialized oxygen mask on the patient, flipped on his lights and sirens, and sped to the hospital as quickly as possible.

And thus, I find myself staring at the most difficult airway I've ever seen. The patient weighs about 280 pounds. His tongue is so swollen that I'm not even convinced I can get a laryngoscope past it. Vomit is everywhere, obscuring my view. Blood pressure is dropping, heart rate escalating. An entire trauma team is standing around with scalpels, waiting to cut into his neck in morbid anticipation of my failure.

Pause.

Always pause, gather yourself. Ten seconds to focus.

Primary airway equipment ready, the backup in case it goes wrong, the backup for the backup. The room goes quiet. All eyes on you. It's an odd feeling, holding a life in your hands. This man is not breathing and you need to help him. Fail and he dies.

Things speed up as you grab the laryngoscope. The surgeons crowd around the neck, like bloodthirsty sharks waiting to take bites of flesh. They know that if you can't get the tube in place, they'll need to slice down to the windpipe to place it directly. It's a last resort.

Primary equipment fails. You switch to secondary. It feels like minutes but only seconds have passed. Your arm is shaking; he's a big guy and it takes muscle to lift things into alignment.

Secondary equipment fails. The surgeons prepare for the cutting; a messy, bloody procedure that leaves a jagged scar. Voices rise, a chaotic, frantic cacophony. You grab your third and last option. Your mouth is dry, your heart pounding. Suddenly, a small view of the trachea.

Tube to my hand, please, I can see the airway.

The room goes silent. Someone puts the endotracheal tube in your hand and you place it gently in position. You straighten up and realize 20 people are watching you. Your hands are shaking from the adrenalin. He's alive.

A glance at the clock. Only 1 minute has elapsed.

Benefits

I've been driving around my new city for a year and a half now. At some point my car's registration lapsed, and I never quite got around to getting it taken care of. That's not to say I didn't try; I actually drove to the DMV once and was paged back to the hospital for an urgent consult. I got my emissions test 3 times in a row... and then got too busy to follow through with the actual registration. My mom keeps hounding me to just get it done, but somehow timing never seems right. Every time I see a cop on the road my blood freezes a bit.

Driving home from an ER shift tonight I noticed a cop tailing me. I pulled in to my neighborhood; seconds later the awful sight of sirens. You never realize how bright police lights are until they flood your mirrors at night. A flashlight in the face and my heart started racing like a jackhammer.

"Do you know why I pulled you over?"
"Not sure, officer. I believe I was following the speed limit."
"Your registration is out of date. Any good reason you couldn't get it taken care of?"
I paused a moment. I'm a terrible liar, so the truth came out. "Honestly, officer... I'm a resident at the hospital. I've got no excuse other than I've had no time to get my car fixed up."

He took my license and expired registration back to his cruiser. I stewed. A few minutes later - an eternity - he walked back.

"Dr. Zac?" he said, "That you?"
"Yeah."
"Hey, man, you were really nice to me when we brought in a prisoner a few months ago. More than most of the docs in the ER. I'll tell you what; I cut you a break this time, you keep doing what you do. Get your car registered within the month and you're good to go."

Relief flooded my system. I don't believe in perks of the job, but I suppose this time it was karma. I forsee a trip to the DMV in my exceptionally near future.

8 patients

And just when you think you've gotten into the swing of things...

It's been a quiet night. Nary a peep out of the frequent fliers. The department is a ghost town, nurses are tidying up loose ends. The calm before the storm.

Then the calls come. Trauma Code 1... times three. Ten minutes out by helicopter. Ears perk up. Medics coming to rooms 8, 14, 17, and 18. Rumblings of dissatisfaction begin. Overdose transfer to room 4. Audible anxiety from the staff.

We gear up. There are only three of us physicians. The attending heads to one room, the senior resident to a second. I take the third. And then the fourth. And fifth, and sixth, until my head is spinning. Everyone is sick, everyone needs attention, and everyone is just slightly too complicated. It's 4 AM on Christmas eve and Santa has dropped a few presents off for us early.

It's times like these when you just put your head down and run with it. I go from taking care of three patients to eight in the space of a few minutes. And so things get missed; a patient has a blood pressure of 220/100 - dangerously high - but I see him before the nurses do, so I don't hear about the abnormal result. A man is found by the side of the road, complaining of back pain and reeking of booze and weed. He doesn't really remember how he got there; in my rush to get him to the CT scanner for traumatic injuries I forget to draw an alcohol level. A woman who took half a bottle of klonopin turns out to also have an occult pneumonia, but is so altered she can't tell me she has trouble breathing.

Thankfully, I catch a breather an hour later. The intricacies become clear, and I dot my i's and cross the t's, correcting blood pressures and sugars. But still. Emergency medicine would be easy if you had only one patient and the luxury of infinite time to work them up. In reality, shit seems to hit the fan at the most inopportune moments.

I'm starting to understand why we physicians refer to our jobs as a "practice". We're always learning. Always striving to be better. I'm getting there.

Is Your Refrigerator Running?

Last night I was in the middle of calling a consult to one of our hospitalists. We've been friends since intern year, so it's always fun to have her as my admitting doc.

"What's up, Jenn? How've you been? Got a guy down here who needs your TLC."

"Hey, Zac! I'd be happy to fix him up. What's the situation?"

"Well," I said, "he's otherwise pretty healthy, but he's got this terrible pneumonia, he'll need some big gun antibio--"

At that moment, I trailed off. From the far hall I heard a crescendoing wail. Every doctor, nurse, and patient in the department turned their heads to stare in unison.

"I said don't touch me YOU BASTAAAAARDS!!!"

My jaw dropped. Sure enough, one of my psychotic patients was sprinting around the emergency department, buck naked, hair trailing behind her like a demented Venus, security guards frantically trying to stop her.

I heard Jenn laughing over the phone. "Your patient, I assume? You'd better go catch her! I'll make you a deal: I'll take care of the pneumonia if you promise not to admit crazy cat lady."

I chuckled, and promised I'd do my best. It's a good job - at least it's always entertaining!

Holding My Ground

Someone today threatened the lives of my coworkers.

He was a wanted man, and the sheriff had been clued in to his presence in the emergency department by his terrified wife. The nurse who brought him in from triage felt something "off" about him and notified security. At the sight of their badges he tried to bolt, thrusting his hand into his pocket as if to grab a gun.

They slammed him into the wall and he elbowed one out of the way, trying to pull something out of his pocket. When fully restrained, an unsheathed bowie knife slipped from his outstretched hand. The knife was cursorily kicked away as he was wrestled to a gurney.

He finally calmed down enough for me to evaluate him. I did my duty as his doctor and checked him over for signs of illness. Apparently he had ingested some 40 tylenol, a ton of cocaine, and some PCP as a suicide attempt a few hours prior. I drew some bloodwork and started him on treatment for tylenol overdose. At the sight of the needle he started screaming obscenities and thrashing about in his bed. At some point a nurse got kicked. The restraints went on.

It's difficult when medicine and law intersect. Every part of me was screaming "THIS IS A BAD MAN", except for a tiny doctor voice in the background saying "he also overdosed on tylenol." And so, I did my job, treating him carefully, cutting no corners in the process.

A while later I heard a ruckus outside of his room. The nursing manager was mentioning big words like "QA" and "patient satisfaction", and was demanding that his restraints be lifted.

It's rare that I take a stand against my higher-ups, as usually they have good reasons for their requests. This time, on the other hand? Nobody threatens my friends, and fists and feet can be lethal weapons in a person high on PCP and crack.

"Ma'am," I said, "this man pulled a knife on our security guards and kicked a nurse in the arm. I don't care what 'patient satisfaction' measures or 'quality assurance' protocols you think I'm violating. He is a threat to staff and he leaves this ER in police custody and cuffs, or onto a hospital floor with 4 point restraints and an escort."

She was a bit taken aback, but I think she got the point loud and clear. Staff safety comes first. On that point I will never budge.

A Modest Proposal

This is a guest post I wrote for The Brio Reporter - I'm the healthcare correspondant. See my previous post for them here.

The system is broken.

We've heard it over and over again, shouted from pundits, over radio and TV, inked across the blogosphere. "Where," we cry, "do all the healthcare dollars go?"

I can tell you, because I've spent them. Millions and millions. The most expensive piece of equipment in all of medicine, as they say, is the doctor's pen.

There's a particular problem with American health care, which is that the cost of everything is removed from the equation. I'm taking care of an 80 year-old, morbidly obese woman in the ICU in multi-organ failure right now. Her hospital bill so far? Upwards of $400,000. Match her against a group of similarly-ill people and her expected mortality is 95%. It's an underestimate.

We keep tacking on more and more therapies since nothing makes her better. There are 10 or so consulting physicians on board, all who believe her survival to be impossible.  Yet, the husband wants us to "do everything". I told him a month ago we were fighting a losing battle. He didn't want to hear it. Instead I've spent almost a half-million dollars with futile therapies, buffering my risk against a lawsuit by acquiescing to the family's demands. Will she die? Absolutely. Has the money we've spent been a waste? Absolutely.

It's easy to take the bird's-eye view and place blame. "Why on earth," you scoff, "would you even consider spending $400,000 on an obese 80-year-old who has a 95% expected mortality?" It's an excellent question, and the answer is mired in medicolegal quagmire.

It's a problem deep rooted in the American psyche. We don't want to be told that anything is impossible. As such, we look for a solution to every problem, without recognizing that some problems cannot be fixed. There is an adage: "just because you can doesn't mean you should." This has been forgotten in modern medicine.

With our ever aging, ever fattening, ever sickening population we need to take a big step back from the precipice. Parents cannot afford antibiotics for their children, diabetics cannot afford their blood sugar medicines, and yet our ICUs are overpopulated with critically ill patients with no chance of survival. Oncologists are prescribing rounds and rounds of expensive chemotherapy for terminally ill cancer patients with 5% expected 5 year lifespans. Nephrologists are dialyzing people with failed kidneys who are not transplant candidates.

Why? Because no doctor ever says "I'm sorry, that treatment is too expensive, and the money could be better used elsewhere." Nor would patients want them to. And so my belief is that the decision needs to be taken away from doctors and patients; we physicians have proven that we cannot police ourselves.

It all boils down to one fundamental truth:  the money we spend on futile care is gone forever.  The amount of money in the system is finite, and this becomes more apparent every day.

Here is my modest proposal.

1) Establish a set of "covered" illnesses. Diabetics should get their blood sugar medications for free. Why? Because they should never have to choose between a rent check and insulin. This directly increases the number of hospitalizations for diabetic complications, and increases the total cost to the system.

2) Establish an algorithm for "non-covered" illnesses. Take insurance out of the equation. My 80-year-old, morbidly obese patient with multisystem organ failure?  Every single physician who saw her believed her case to be futile. Just because she has insurance doesn't mean we should be wasting $400,000. That money could be better spent - no, must be better spent. There are children dying.

3) Generate a firm "no" for certain treatments. Pancreatic cancer is a devastating and incurable illness; survival is typically 3-6 months with a 5-year survival of 5%. Why spend hundreds of thousands of dollars on a treatment we know won't work when that money is needed elsewhere? That said, favor the young. Premature babies cost a lot but also have the highest potential benefit.

4) Adopt a 3-strikes-you're-out policy. Cocaine users who present to the Emergency Department for chest pain should not have those visits comped by the public. Same goes for the alcoholic brought in for withdrawal symptoms, the hypertensive who doesn't take his meds, and the drug seeker looking for a narcotics fix.

5) Fund the system by taxes on high-risk behaviors. Any food containing HFCS, all tobacco products, and all alcohol should contribute a direct proportion of their earnings to the healthcare system they are overburdening.  I support your right to eat at McDonalds every day.  I also support my right to not be affected by your decision.

The system is broken.  Without any oversight we have created a massively expensive healthcare monster that prioritizes all the wrong things.  If we have any hope of providing the best care for everyone - without bankrupting our country - we need to make some very tough decisions.

The debate is not how to fix it, but when.  All of our lives hang in the balance.

But it huuuuuurts!

Tonight I took care of one of the most difficult patients I've seen yet.

Typically drug-seekers are a straightforward bunch.  ER docs have very fine noses for seekers; I like to think I can spot them within 30 seconds of entering a room.  A confirmatory exam of the medical record usually reveals multiple visits in the past for "knee pain" or "back pain", always with the same story.

"Well, you see, I have chronic back pain, but I'm VERY CAREFUL to stick to the pain contract I have with my primary physician, you see, but today my doctor was out of town, and it's the day I'm supposed to renew my vicodin, and so I called but they told me I had to come to the ER, so now I'm here and in pain and all I need is a 3 day supply and then I can get to my doctor's office on Monday, you see..."

Drug seekers always speak in run-on sentences.  The nice thing is that once they've been called out, they're usually pretty good about going home.  Or, at least, to the next ER in their rotation.

This woman was different, though; she was mentally retarded.

I've never actually seen an intellectually challenged drug seeker before.  The problem was, no matter how many times I told her she wasn't getting pain meds, she just kept asking.  Our conversation went something like this:

"I want vicodins for my tummy pains."

"Ma'am, you're constipated, which is what is causing the pain, and if I give you vicodin it will make it worse."

"But it huuuuuuurts!"

"I know, you need a laxative."

"It huuuuuurts and I need viiiiiiicodins!"

"No, you need a laxative."

"I need viiiicodins, you don't even knoooooow!"

"I do know, because I am your doctor, and I am telling you what you need is a laxative."

"No I need viiiiiiicodins!"

"We're getting nowhere, are we..."

I felt awful, because I honestly didn't know what else to say.  The worst part was, her narcotics addiction truly was causing her constipation - and therefore her pain - and I could not make her understand.

In the end I had to call security to escort her out; there was no other way to get her to physically leave the room.  It left a horrible, sour taste in my mouth.  I've kicked drug seekers out before and felt a slight twinge of Schadenfreude, but never have I needed security to boot someone out who doesn't understand why.

Just Hanging Out

After a shift the other night, a few of us emergency residents went to go grab a beer.  We've gotten much less interesting lately; last year we would have elaborate dinner parties, hiking trips out to the local mountains, you name it.  Nowadays we try to muster the energy to pour back a cold one before we pass out in our beds.  The news was playing in the bar.

"... multicar pileup on the freeway today," intoned the news announcer, "all 12 injured taken to the local trauma center where we anxiously await news of their health."

I turned to one of the other residents, who was watching the newscast with vague interest in between sips of his drink.

"Anybody hurt?" I asked.

"One broken humerus and some whiplash, is all," he said.

"That's good," I nodded, "Trauma ICU's already pretty full."

"Yep."

We sat, news blaring, and took another sip of beer in silence.