Agraphia Medical Tragicomedy

24Aug/12Off

You Probably Should Quit Smoking

"Medic 5 calling ER.  We've got a patient who was... uh... smoking with his oxygen tank on.  It blew up in his face and now he's not breathing.  We'll be there in... uh... about 2 minutes.  He looks pretty bad."

Few things mobilize the ER staff quite as quickly as a bad accident.  So much of we see is routine chest pain, mild abdominal pain, and chronic migraines that a "real" emergency inevitably causes extra hands to materialize.  I immediately started getting set up for an advanced airway.  Burned face usually implies burned tongue, throat, and larynx - and although your face can accomodate a certain amount of swelling, swelling INSIDE the throat will close off an airway fast.  It's critically important to not only act fast, but before things get bad.

I was pleasantly surprised to find my training paid off.  This guy was the sickest person I've seen in about a week, but I knew exactly what to do.  Heart rate through the roof, blood pressure quickly circling the toilet, oxygen saturations less than 50%.  Calmly and quickly I intubated him - fast enough that the respiratory therapist, surprised, asked "already?" when I asked her to hook the patient up to the ventilator.  While intubating, I could see the ash trail down the bronchus, a telltale sign he was a smoker (alright, let's face it.  The guy needed to leave his oxygen cannula on at full blast to muster up enough breath to inhale his cigarettes.  That's olympic caliber dedication to tobacco right there).

That's when things went downhill.

The minute the paralytic wore off, he started squirming.  His blood pressure started rising.  110.  150.  210.  275.  The nurses started having trouble holding his arms down as he went to pull the breathing tube out.  Heart rate jumped into the 140's.

Knowing full well that too much sedative at one time could be a huge problem, I started carefully adding medications.  No response.  He kept trying to pull out my precious tube, the only thing keeping him alive at this point.  I gave him some more sedative, waited 5 minutes, and gave him more.  Still thrashing around, unconsciously reaching at the tube firmly lodged in his airway.  If I lost that, he was dead.

Suddenly, he crashed.   His blood pressure went from 275 to 75 in the blink of an eye.  Surely a mistake, I thought to myself.  I rechecked it, checked, and checked again.  It was real.  He was on the cusp of dying, and I could barely feel the pulse in his neck.

It's incredible how 4 years of medical school and 3 years of residency flash through your mind.  Over the next 15 minutes I started systematically checking for reasons why his blood pressure had dropped so rapidly.  Had the breathing tube been pushed in too far?  Pulled out?  Had his emphysema caused a rip in his lung, leading to a buildup of air?  Was our ventilator set wrong?  Did he have a sudden heart attack from the stress?  Had the sedatives all finally added up together?  Had his lungs filled with fluid from to the flames, suffering burns like his face?  The possibilities flew through my mind.

The nurses stood in silence while I pondered, carefully checking every tube, line, setting, and lab value.  A few threw out ideas.  I stood, thinking.

Finally having ruled everything out but over-sedation, I gave him a dose of medication to raise his blood pressure.  It worked like a charm, and I let myself relax a bit.  As he started to squirm again, one of the nurses asked if she should sedate him some more.  I gave her an icy glare.

It was only after he safely got on the chopper to the burn center that I realized how scary that situation really was.  I initially had no idea why his blood pressure dropped so rapidly, and I've never seen anything quite that dramatic before.  What's worse is that aside from burns to his face and his mouth, nothing else was wrong with him.  If he died?  I would have assumed it was something I did wrong.

Sure, if you really want to split hairs, he was a horrifically bad COPD patient with about 80 years of smoke and tar caked in his lungs, with countless other medical problems.  It's incredibly difficult to properly ventilate these people, and especially in the setting a huge fireball inhaled into his lungs, I suppose he was a setup for disaster.  Still and all, if he had died, I wouldn't have forgiven myself.  I sincerely hope all goes well for him at the burn center.  I've done what I can.

Can't prevent people from hurting themselves, though.  This field is exhausting sometimes.

30Jun/11Off

Big Fish In A Little Pond

And like that, a year has passed.

I'm officially a senior resident.  It may seem an arbitrary milestone - leave the hospital a second year resident, return as a senior - but the changes are easy to see.

During my shift today, I placed a central line in a matter of seconds; the first one I ever did took an hour and a half.  I casually transfused a trauma victim two pints of blood while on the phone with a consultant.  I coached a family through their mother's catastrophic brain bleed, answering their questions and initiating palliative care.  A man's heart stopped beating - twice - and I restarted it.  Another patient went into flash pulmonary edema and I prevented him from drowning in his own secretions.

It was a good day.  It's been a excellent year.  I'm excited to see what happens next... I love this job.

4Jan/11Off

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.

8) 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.