Agraphia Medical Tragicomedy

7Jan/1410

Righteous outrage

I came across this blog post recently by a retired surgical chair who is pretty upset with a court case about an emergency physician.

Here's the short and outraged version: a man is found during a routine traffic stop to have marijuana in the car. He's taken to jail, doesn't comply with the officer's questions, then barricades himself in the interview room. They proceed to violate all of his 4th amendment rights by strip searching him, but don't find anything. Then they cart him off to the Emergency Department for a forcible cavity search. They have an ER doctor who has done a few rectal exams for them before, so he decides to aid the police, and follows their orders. He's unsuccessful, so he sedates the guy against his will, intubates, and puts him on the ventilator all for a rectal exam ... then the doc pulls a 5.7 gram rock of crack cocaine out of his rectum, and turns it over as evidence.

People are demonizing the physician for forcing this poor man to undergo a "warrantless search" and being a "tool of law enforcement." What I find so frustrating is how quickly people decry the actions of this emergency doc - and assume that law enforcement was just out to make an unconstitutional bust. In my mind, this is a medical case, not a legal one.

Why? Because here's how I can retell the story. Bear with me for just a moment, and assume that the doctor and the police are good people trying to do the right thing. Also, read the actual court case.

A man is pulled over with expired tags. He consents to a search of his car, but his passenger, Felix Booker, is really bugging out and making the officer nervous. The officer actually recognizes Booker; he's taken drug-deal quantities of marijuana from him before. The officer finds marijuana and a "powdery substance" in the car and brings Booker in. At this point, this guy really starts losing it. He barricades himself in the interview room - not a normal thing to do - and starts acting crazier and crazier. There are several physical altercations with police. He keeps clenching his buttocks and trying to use his hands to stuff something further up his rectum. What he's doing is so obvious that the officers actually re-cuff him with his hands in front so he can't reach in back. They strip search him and see a string hanging out. In conjunction with the white powder in the car, they figure this might be a medical emergency.

So, imagine you're Dr. LaPaglia. Police bring you a guy that is acting so crazy he's naked and strapped to a chair, and the officers tell you they brought him in on a drug bust with $1,700 in cash in his pocket. They found a white powder in the car, and now he keeps trying to reach around to shove something further up his rectum. Remember - it is not normal for someone to be so agitated that you have to strap them down. Most normal people calmly and politely ask you to take the restraints off and apologize for all the confusion.

Booker is acting crazy enough you suspect it's either cocaine or PCP in his rectum. Who knows, maybe he's been dipping wet or doing bath salts. The concern is, if he's a known drug dealer, has a bunch of cocaine stuffed in his rectum and he's already this agitated, his baggie may have ripped and now is leaking high-grade cocaine directly into his GI tract. Just like a lot of Emergency Medicine, you cannot know what it is until you take it out; it's Schrödinger's baggie. Then the cops tell you there is a string hanging from his rectum. It's pretty clear you need to get it out.

Your patient actually agrees to let you do a rectal exam, but even after giving him 10mcg of Versed you can't retrieve the baggie - which you now know is there because you can feel it - and the only real way to get it past his anal sphincter is to paralyze him. Is this a medical emergency? Absolutely. If it leaks and he dies, it is your fault. This is a classic toxicology scenario, and that baggie might be a ticking time bomb. So, you sedate and paralyze him, pull the baggie out and... sure enough, you pull out a 5.7 gram rock of crack cocaine. Congratulations, you're a hero! You just saved this man's life. Then you get hit with a lawsuit.

Now, I don't know which version of the story is correct. I'm sure there is truth to both. From what I can tell, the court ruling is still in appeals. I don't have the benefit of seeing the medical record. That said, I have been in situations similar to this more times than I can count. People do drugs, and some people do so many drugs that we need to intubate them for the staff's safety and for their own. We don't like to do it, but I have seen people tear through bed restraints, spit HIV+ and HepC+ bloody saliva at nurses and police, and bash their heads against the wall until they bleed. I've been kicked and punched. We routinely find knives and guns in our metal detectors. If you don't think it's scary to deal with someone who is high on cocaine/PCP/wet/bath salts in the ED, you have never been in the situation. It is one of the few things that still makes me nervous.

It is really easy to armchair quarterback this story and to get all upset about how this man's rights were violated. A lot of the court brief centers around Booker's "consent" to the rectal exam but not to the intubation. This is a very difficult, murky area, especially in the heat of the moment. To the best of my knowledge, if the patient is altered, they no longer are capable of refusing consent. You as their physician must act in their best interest. It seems to me that there was no other way of getting the cocaine out of this guy, and that the doctor had enough reasonable suspicion that it was medically indicated.

Not having been there in the moment, I really can't say. On the flip side, if that cocaine was left in Booker and Dr. LaPaglia refused to do the rectal exam - and Booker died in police custody from a cocaine overdose - well, then there would be an entirely different court case.

And there would be a whole lot of fingers pointing at Dr. LaPaglia then.

26Jul/116

The Grind

Being an ER doctor isn't all fun and games.  Well, it's usually fun, and mostly games, but really we're at the mercy of the city and its drunk and dying denizens.  When two trauma 1's roll through the door at the same time, a scattering of chest pains and GI bleeders are still waiting to be seen in the back rooms, and the hallways are filled to the brim with gurneys... well, my heart rate starts to rise.

I enter autopilot, and start doing what I loathe the most - overtesting. It's what emergency physicians refer to as "moving the meat."  It's a term I hate, but when there are multiple patients needing to be seen - any of whom could be dying - and the department is bedlam, it starts to make sense.

Chest pain?  Check.  How long?  Describe it for me.  Risk factors for cardiac disease.  Labs, chest x-ray, pain control, next room.  In and out the door in a couple minutes.  Scribble on the chart, "typical chest pain story, patient appears well and in no acute distress, check labs.  EKG nondiagnostic, will evaluate xray for pathology and admit for observation."

It becomes formulaic at this point.  Patients with abdominal pain get "belly labs" and a CT.  Headaches get compazine/benadryl/decadron and probably a CT & spinal tap.  Traumas get "trauma labs" and a $15,000 full body CT scan to search for any hint of bleeding - it exposes them to approximately half the radiation experienced by survivors of Hiroshima.

My normally friendly bedside manner goes out the window.  I'll usually introduce myself, "Hi, I'm Doctor Zac and I apologize for being brief.  Unfortunately an SUV just overturned on the highway and they'll be arriving in 5 minutes, so I just wanted to pop in and see how you were doing."

I never yell, but I can be brusque.  Before residency, I would have never imagined myself to be the type to say "I'm sorry, I don't have time for you right now,"  but it happens.  At least I always say "I'm sorry" first.

I suppose it's part of being a feast-or-famine specialty.  We don't have the luxury of scheduling our patients.  It still leaves an unpleasant taste in my mouth when I don't feel like I can care for people the way they need to be cared for.  Especially when it means spending thousands of dollars of their money that I know they don't have, and delivering enough radiation to possibly cause cancer down the road.

4Jan/1112

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.

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.

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.