A few weeks ago I blogged about now being able to save everyone. I wrote about it after I had signed up for a "simple" back pain that ended up dissecting his aorta from the arch down to his iliacs. Yesterday I came to the realization that not only can you not save everyone, but not everyone can be helped either.
Yesterday I signed up for a patient with a chief complaint stating, "General complaint." These complaints are always interesting, the "Lets make a deal" of the emergency room, because you never know what you're going to get when you open the door. Usually it's a young male with penile discharge that was too embarrassed to tell the female triage nurse about his recent escapades.
I walked in the room yesterday and saw I young male unable to sit still. Every one of his extremities jerking, almost violently, in a random pattern. I look at him with his arms and legs flailing all around as he and his wife told me his story. He was diagnosed with an unknown movement disorder two years prior. He was initially started on one medication regiment that significantly improved his dystonic jerks, but later was recommended to try another regiment to see if it would it further improve his symptoms. Not only did it not improve, but when he return to the initial medication regiment that had provided relief, it no longer helped.
I asked him why he came in to the ED yesterday as this had been ongoing for two years and he had a nuerologist.
"I'm tired of it all, " he replied. "I just wanted to see if you all could help."
Looking at this poor fellow reminded me of the news story/youtube video of the chearleader that developed a dystonic reaction supposedly after receiving the flu vaccine. http://www.youtube.com/watch?v=cEN5KGwNGeo
This guy had seen numerous primary physicians, numerous neruologist and even medical doctors at the state level. I'd like to think that I'm not a stupid person, but I fill pretty confident that I'm not going to think of anything that hasn't already been pondered.
The only truly beneficial option, although not practical for obvious reasons, was to RSI the guy so at least he could get some sleep for a while. Alternatively, I told him to start taking benadryl 50mg every 6 hours and started him on some Cogentin telling him to see his neurologist again this week.
I felt really bad for the guy, but in the end I'm an emergency medicine doctor, and he needs help I can't provide. Hopefully he find some who can help.
Wednesday, March 31, 2010
Saturday, March 27, 2010
Healthcare
Well, it happened. For better or for worse our leaders passed a landmark healthcare bill last week. I'm not going to sit here and rant about whether or not I think this is a good or bad thing for our country, but I will provide my two cents about what I believe the impact on emergency medicine will be.
I believe the impact will be two fold: initially positive, yet progressively negative as time progresses. Currently, federal law (i.e., EMTALA) requires the emergency department to provide care to everyone, regardless of insurance. So it only begs to reason that if this bill is going to provide insurance coverage to 35 million additional Americans, less patients will present as self pay ( aka: good luck getting reimbursed). Using elementary math, more patients in the ED with insurance equates to more payouts.
One could argue that there are numerous negatives to this plan. I'm going to argue that this bill does nothing to address the shortage of primary care physicians which I believe is one of the largest problems with our current healthcare system. As an ED doc, why do I care you ask? As the shortage of primary care docs in this country grows, so does the amount of primary care I have to put up with in the emergency department.
The common cold.
Lost medications.
Poor glycemic control.
Depression.
Those are just a handful of daily complaints I have in the emergency department. None of which are emergencies. I predict that as more and more people receive insurance, intuitively there will be an increase in people seeking care. Instead of waiting three, four or even five weeks to see a primary care physician, they'll just jump in the car and come to the ED. "Why not, I have insurance now," they'll say.
Technically according to my first paragraph this wouldn't necessarily be a bad thing; however it would inevitably worsen ED overcrowding. About once every couple of years I here about a patient dying in the lobby of an emergency department as he or she was waiting to be seen. Incidences like that, albeit rare, do represent consequences to ED overcrowding, and the prevalance of these negative consequences under this new system I believe are destined to rise.
Then again, I'm just an intern, and this is a very simplistic view of a very complicated matter. Time will tell how it all plays out.
I believe the impact will be two fold: initially positive, yet progressively negative as time progresses. Currently, federal law (i.e., EMTALA) requires the emergency department to provide care to everyone, regardless of insurance. So it only begs to reason that if this bill is going to provide insurance coverage to 35 million additional Americans, less patients will present as self pay ( aka: good luck getting reimbursed). Using elementary math, more patients in the ED with insurance equates to more payouts.
One could argue that there are numerous negatives to this plan. I'm going to argue that this bill does nothing to address the shortage of primary care physicians which I believe is one of the largest problems with our current healthcare system. As an ED doc, why do I care you ask? As the shortage of primary care docs in this country grows, so does the amount of primary care I have to put up with in the emergency department.
The common cold.
Lost medications.
Poor glycemic control.
Depression.
Those are just a handful of daily complaints I have in the emergency department. None of which are emergencies. I predict that as more and more people receive insurance, intuitively there will be an increase in people seeking care. Instead of waiting three, four or even five weeks to see a primary care physician, they'll just jump in the car and come to the ED. "Why not, I have insurance now," they'll say.
Technically according to my first paragraph this wouldn't necessarily be a bad thing; however it would inevitably worsen ED overcrowding. About once every couple of years I here about a patient dying in the lobby of an emergency department as he or she was waiting to be seen. Incidences like that, albeit rare, do represent consequences to ED overcrowding, and the prevalance of these negative consequences under this new system I believe are destined to rise.
Then again, I'm just an intern, and this is a very simplistic view of a very complicated matter. Time will tell how it all plays out.
Tuesday, March 23, 2010
Ultrasound
I'm fortunate in my residency program to have a handful of attendings that are extremely proficient in using the ultraound for various procedures in the ED. The ultrasound has recently gained a lot of popularity in the department for its practicality. Most seasoned physicians have at least taken a CME course or two to learn how to do a pretty accurate F.A.S.T. exam in trauma bays, but now there are entire fellowship programs devoted to its use.
We had this huge woman present today in DKA. She had ketones in her blood and urine and her blood glucose was around 800. Initially, none of the nurses were able to get a line on her so I strolled in the room with the ultrasound machine. I took one look and popped in an IV. The peripheral line was a temporizing measure as I got everything I would need for a central line. Using the ultrasound I took one look at her neck, found her IJ, and with one stick, got the line. If you look at the new data floating around that shows the decrease in complication rates with ultrasounds guided central lines, some would say it is malpractice to attempt CVLs without it.
The lesson of the day: the ultrasound machine is your friend. It takes practice, especially in using it for peripheral IVs, but it is absolutely worth it. I've used the machine for the following: scanning for aneurysms, gall stones, comparing kidneys for hydronephrosis, looking for pericardial effusions, and evaluating for ectopic pregnancy.
It is a great tool for the ED doc to have in his arsenal.
We had this huge woman present today in DKA. She had ketones in her blood and urine and her blood glucose was around 800. Initially, none of the nurses were able to get a line on her so I strolled in the room with the ultrasound machine. I took one look and popped in an IV. The peripheral line was a temporizing measure as I got everything I would need for a central line. Using the ultrasound I took one look at her neck, found her IJ, and with one stick, got the line. If you look at the new data floating around that shows the decrease in complication rates with ultrasounds guided central lines, some would say it is malpractice to attempt CVLs without it.
The lesson of the day: the ultrasound machine is your friend. It takes practice, especially in using it for peripheral IVs, but it is absolutely worth it. I've used the machine for the following: scanning for aneurysms, gall stones, comparing kidneys for hydronephrosis, looking for pericardial effusions, and evaluating for ectopic pregnancy.
It is a great tool for the ED doc to have in his arsenal.
Sunday, March 21, 2010
The night train
I haven't posted as mush recently. I've been working a lot of nights and its tough to keep something like this up. Briefly, one of our regulars came in last night. Only this time she was coding. Found down by EMS, she arrived intubated and actively receiving chest compressions.
She was young (in her 40s). Always came in with pancreatitis because she couldn't stay away from the alcohol. She was actually one of our more pleasant regulars. I felt sorry for her in some way. She wasn't addicted to narcotics, just alcohol. She only came to the ED because her habit caused her pancreas to flare up.
She died last night. It was her thirteenth visit this year. How unlucky.
I'll be back on days soon. Better blogs will return...
She was young (in her 40s). Always came in with pancreatitis because she couldn't stay away from the alcohol. She was actually one of our more pleasant regulars. I felt sorry for her in some way. She wasn't addicted to narcotics, just alcohol. She only came to the ED because her habit caused her pancreas to flare up.
She died last night. It was her thirteenth visit this year. How unlucky.
I'll be back on days soon. Better blogs will return...
Friday, March 12, 2010
Crying Wolf
A guy came in to the ED last week. He also came in three days ago and again last night. I've only been doing this for about 10 months now, but I'm already starting to recognize some of our regular customers. He uses different chief complaints every time only to mask the real reason for his routine visits: he is homeless and has nothing better to do. Last night's chief complaint was back pain. He says it started four days ago which, oddly enough, was before his last visit three days prior in which back pain was not mentioned.
There was nothing special about the circumstances of his pain: no falls, no recent trauma, and his vitals were stable. I rely on vitals often when someone is complaining of pain. If they are in the room saying this is the worst pain of there life with a heart rate of 68, I'm always a little suspicious about their "pain". As was the case with this guy tonight: severe pain with normal vitals. I gave him a shot of dilaudid IM and was going to reevaluate. Twenty minutes later he was asleep.
I went back in to reevaluate about an hour later and told him I was going to be sending him home soon. He said I had done nothing for his pain. I didn't buy it, but feeling generous I gave him a script for some percocets and told him to follow up with the free clinic in the coming days. He reluctantly agreed.
I got a page from one of my friends who was working the day shift today. The patient came back in with bilateral pulmonary embolisms.
Shit.
Sure I feel bad for sending this guy out with blood clots in his lungs. Could I have done more of a work-up on him? Sure. Should I have? I don't think so. Some people will argue a D-dimer maybe, but I've seen too many false negative even in low risk patients for me to put any credibility in that test (my apologies to Wells and his criteria). Also, you can't Ct scan everyone. Especially those who have spend years abusing the system.
So the guy ended up being put on anti-coagulants and he'll be fine. At least until he comes back tomorrow...
There was nothing special about the circumstances of his pain: no falls, no recent trauma, and his vitals were stable. I rely on vitals often when someone is complaining of pain. If they are in the room saying this is the worst pain of there life with a heart rate of 68, I'm always a little suspicious about their "pain". As was the case with this guy tonight: severe pain with normal vitals. I gave him a shot of dilaudid IM and was going to reevaluate. Twenty minutes later he was asleep.
I went back in to reevaluate about an hour later and told him I was going to be sending him home soon. He said I had done nothing for his pain. I didn't buy it, but feeling generous I gave him a script for some percocets and told him to follow up with the free clinic in the coming days. He reluctantly agreed.
I got a page from one of my friends who was working the day shift today. The patient came back in with bilateral pulmonary embolisms.
Shit.
Sure I feel bad for sending this guy out with blood clots in his lungs. Could I have done more of a work-up on him? Sure. Should I have? I don't think so. Some people will argue a D-dimer maybe, but I've seen too many false negative even in low risk patients for me to put any credibility in that test (my apologies to Wells and his criteria). Also, you can't Ct scan everyone. Especially those who have spend years abusing the system.
So the guy ended up being put on anti-coagulants and he'll be fine. At least until he comes back tomorrow...
Monday, March 8, 2010
Can't save everyone
Last night I signed up for a back pain. I had about five other active patients at the time so I figured a back pain wouldn't hinder me too much. I walked in to the room just as EMS was leaving. I heard them mention to the nurses that they had given him 75 mics of fentanyl, 4 mg of morhpine and 4 mg of zofran. I could tell this guy was really uncomfortable. He was diaphoretic and his blood pressure was 225/115. I ordered 1 mg of dilaudid and 10 mg of hydralazine (his pulse was 65). We waited a few minutes, cycled the pressure and saw no change. This guy was in his 30s so I looked at his wife and asked if he did any drugs. She looked at her husband and then looked at me with remorse. She didn't say anything, but her eyes had YES written all over them.
The patient then began to say he felt the pain tearing up his back. I looked at the monitor and saw a once normal heart rate now beating at 150 bmp. The patient grabbed his chest, and then he took his last breath.
I couldn't believe it. This guy's presentation was so classic it was surreal. I blogged a few weeks ago about how useless pneumonics and "classic presentations" were in real-world medicine, and then this guy classically dissects his aorta right in front of me. Of course we started ACLS on the guy, but it was useless. While chest compressions were being performed, one of the other residents grabbed the ultrasound machine and placed the probe on his abdomen. We all saw the dissection clearly.
I went to talk to his wife as she had been escorted out of the room while all this was going on. She looked at my face, and with tears in her eyes I knew that she knew there was no good news coming. I was blunt but compassionate when I explained the circumstances of her husband's death. I concluded with saying "despite out bests efforts, your husband died today." I find there is no substitute for the "D" word. If you say "he passed away" or "he didn't make it" a patient will, for one reason or another, maintain the faintest bit of hope that there is chance for their loved one. Death is death, clear, and unmistakable.
The patient then began to say he felt the pain tearing up his back. I looked at the monitor and saw a once normal heart rate now beating at 150 bmp. The patient grabbed his chest, and then he took his last breath.
I couldn't believe it. This guy's presentation was so classic it was surreal. I blogged a few weeks ago about how useless pneumonics and "classic presentations" were in real-world medicine, and then this guy classically dissects his aorta right in front of me. Of course we started ACLS on the guy, but it was useless. While chest compressions were being performed, one of the other residents grabbed the ultrasound machine and placed the probe on his abdomen. We all saw the dissection clearly.
I went to talk to his wife as she had been escorted out of the room while all this was going on. She looked at my face, and with tears in her eyes I knew that she knew there was no good news coming. I was blunt but compassionate when I explained the circumstances of her husband's death. I concluded with saying "despite out bests efforts, your husband died today." I find there is no substitute for the "D" word. If you say "he passed away" or "he didn't make it" a patient will, for one reason or another, maintain the faintest bit of hope that there is chance for their loved one. Death is death, clear, and unmistakable.
Sunday, March 7, 2010
The Panic Button
Last night around 3 in the morning everything seemed to be winding down when suddenly we heard shouts erupting from the lobby. I looked around the corner to peer through the doors that lead in to the waiting area. There is a small square of glass on each of these locked doors that allow us to see through. Not only are they locked, but everyone in the ED lobby has to walk through metal detectors before they can enter. (Believe me, I don't practice in "gangsta-land", we just play it safe). I looked through the glass just in time to see a cop come out of nowhere and slam one of the guys causing trouble straight to the ground, and then the place really went crazy.
"PRESS THE BUTTON!!, " I heard one of the nurses say. That's a great idea I thought to myself. It was comforting to know that we had a panic button around for everyone's protection. Then I was a little disheartened when I realized I had no idea where the panic button was.
"PRESS THE BUTTON!!," I shouted to someone else in the hopes that person knew where the button was. Within minutes a storm of hospital and city police had filled the lobby. I was actually impressed at how quickly they responded. I'm usually picking fun at them as they crawl around campus on those stupid segways.
In the end no one was seriously injured. The bad thing was everyone involved in the brawl checked in to be evaluated. I know at some point they will all be claiming police brutality. It was funny to see one cop manhandle one dude to the ground. He slammed his face on the floor and held it there with his hand.
"Bite my hand and I will jack you up!," I heard him say. Pretty funny stuff.
Anyway, lesson of the day: know where the panic button is.
"PRESS THE BUTTON!!, " I heard one of the nurses say. That's a great idea I thought to myself. It was comforting to know that we had a panic button around for everyone's protection. Then I was a little disheartened when I realized I had no idea where the panic button was.
"PRESS THE BUTTON!!," I shouted to someone else in the hopes that person knew where the button was. Within minutes a storm of hospital and city police had filled the lobby. I was actually impressed at how quickly they responded. I'm usually picking fun at them as they crawl around campus on those stupid segways.
In the end no one was seriously injured. The bad thing was everyone involved in the brawl checked in to be evaluated. I know at some point they will all be claiming police brutality. It was funny to see one cop manhandle one dude to the ground. He slammed his face on the floor and held it there with his hand.
"Bite my hand and I will jack you up!," I heard him say. Pretty funny stuff.
Anyway, lesson of the day: know where the panic button is.
Friday, March 5, 2010
Baby, it is cold outside.
The other day a young guy came in by EMS. They said they found him down outside a bar and beat up. So that, in and of itself, is normally not that big of a deal; however, that night it had been snowing. This guy was as white as a ghost, and had a rectal temp of 30 degrees Celsius (moderately severe hypothermia).
The EMS had appropriately removed his clothes so when he came in to the trauma bay we placed him under the bair hugger. We got an IV, started some warmed IV fluids, gave him some warmed humidified 02, and I tried to get a central line. The guy was shivering so much I turned his leg in to swiss cheese before I got flashback. Nevertheless, I got the line and we really started pumping so fluids in him.
So the moral of the story today: if you're going to go out drinking, don't follow the binge by getting your butt kicked. And if your going to get your butt kicked, don't let it happen in a back alley in sub-freezing temperatures.
So I've been working nights lately, and I have a quite a few ahead of me. I'll get back to updating the blog more regularly soon.
The EMS had appropriately removed his clothes so when he came in to the trauma bay we placed him under the bair hugger. We got an IV, started some warmed IV fluids, gave him some warmed humidified 02, and I tried to get a central line. The guy was shivering so much I turned his leg in to swiss cheese before I got flashback. Nevertheless, I got the line and we really started pumping so fluids in him.
So the moral of the story today: if you're going to go out drinking, don't follow the binge by getting your butt kicked. And if your going to get your butt kicked, don't let it happen in a back alley in sub-freezing temperatures.
So I've been working nights lately, and I have a quite a few ahead of me. I'll get back to updating the blog more regularly soon.
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