The Most Widely Used Anti-Depressant

May 4, 2009

Oh, how this video summarizes the case of so many ER patients.

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No, We Don’t Need to Land in Scotland!

May 2, 2009
Fish or chicken? Should've had the pasta.

Fish or chicken? Should've had the pasta.

As I had mentioned before, I am on vacation for the next couple of weeks. I thought I would be getting away from the stupidity of swine flu (now called H1N1 flu to protect pork sales), but it looks like I landed right in the middle of stoopid yesterday.

I’m on an international flight and heading towards Europe. Mid-way through the flight I see a crowd gather near one of the galleys and then a frantic sounding flight attendant gets on the mic and calls for one of her associates. I figured it was likely a medical emergency of some sort and followed the hurried attendant.

At the galley, I find a young man laying on the floor breathing O2 through a mask with two disoriented looking passengers fiddling with him. I tell them that I am an ER doc and they tell me that they are paramedics from Europe. The story is that this guy got up to go to the bathroom and became presyncopal (almost fainted) and called for help. I ask the scared looking flight attendant for the medical kit so I can assess this guy.

Now of course, everyone is worried about one thing – SWINE FLU. I can read their scared minds … “Oh no! We’re all gonna get swine flu and die horrible deaths!”. But when I assess the patient, after pushing the very eager, overly wound up paramedics away, my first question is, “How much have you had to drink?” Previous experience with airline medical emergencies has taught me that, just like on the ground, alcohol factors into a lot of emergencies.

After establishing the fact that he didn’t have half a cart of Jack Daniels, my next set of questions focuses on flu symptoms (fever, nausea/vomiting, body aches, fatigue, cough, runny nose, etc.). He was only nauseated, likely from the near fainting. No medical history, on no medications.  Then I hear one of the paramedics talking with the flight attendant about an emergency landing in Scotland and I get really peeved.

Dealing with the totally awesome EMS personnel in the States, I get used to them understanding chain of command and knowing when to defer. I imagine that many EMS personnel in Europe are also the same, so not sure what was up with these jackers. I tell the flight purser that I am the medical doctor in charge and that an emergency landing is not necessary at this point in time and that everyone should chill. Too many cooks in the kitchen.

Getting back to the sick person, I observe another flight attendant trying to put the leads from the automatic defibrillator (AED) on the patient – one on the stomach and the other near the right shoulder. It was like doing a code on the floor – total cluster. I was totally expecting to see the “paramedics” preparing to inject this poor guy with some epinephrine or something.

So, what was the sick guy’s story? He was majorly sleep deprived (typical for many people preparing for international travel), been staying awake on lots of caffeine and probably not having enough fluids to replace all the ones he was urinating out. Add to that, the chicken meal he ate on board.

The AED shows a very temporary sinus bradycardia (slow heart beat) at about 40. While I was checking his blood pressure, it went back up to normal between 65-72. I think it was because he was overhearing the “paramedics” from Hell discussing totally inappropriate interventions. His blood pressure turned out to be 110/70. My team of boners tried to get a blood sugar and failed. But by this time, the guy was saying he was feeling better and wanting to sit up. His “fight or flight” response was probably in high gear overhearing the things being said.

Catastrophe averted for the moment. I told the sick guy to contact me directly if he started to feel woozy again and to avoid the “paramedics” at all costs. The flight attendants were thankful for the man’s quick recovery and for services provided.

In the last hour of the flight though, I was heading up near the sick guy’s seat and see his wife standing and looking concerned. He was feeling woozy again and luckily I arrived at the right time (read – before Beavis and Butthead). I had him lie down and put his feet up. Checked his pulse and it was regular at about 65. He was very nauseated again. To avert another medical emergency landing, I went to the head purser and told her that the guy was stable and not to be worried. I would stay with him until we landed and inform her of any changes.

Within minutes, the guy was feeling and looking back to normal – a good sign that he was likely dehydrated and getting vasovagal. A few nice passengers near-by offered to move so that he could lay down across four seats. Beavis and Butthead arrived soon enough with an O2 tank (incorrectly set-up). Once again, they by-passed me to tell the captain to land ASAP. I think one of them was trying to impress one of the attendants or something.

Just before we landed, sick guy vomited up his chicken. I was sitting right in front of him and immediately after I asked him if after vomiting he felt better or worse. Although it’s not so evidence-based, I have found over the years that with food-borne illnesses (commonly called “food poisoning”) that people generally feel better immediately after vomiting – likely because of the reduced toxin load in their stomach. On the other hand, vomiting from flu syndromes usually results in a person feeling even worse and more fatigued. Maybe it was the chicken after all?

We arrived to our destination after a hurried landing and had to wait on board until this country’s EMS came on board to load up the patient and take him to the airport medical facility. I gave report to the ER doctor that accompanied the team and gave my new friend (sick guy) some farewell advice and a good-bye. My advice was get some IV fluids and some rest. After he was gone, I had to reassure several passengers that there was no flu threat and that they should all be ok.

That is, unless they had the chicken. Glad I ate the pasta.


Nude Psychiatry

April 28, 2009
Shirt and shorts required.

Shirt and shorts required.

I had this patient come in for a fall this weekend – seems like everyone was falling for some reason. He was in his sixties and had recently lost his job as a marital counselor because the foundation he worked for lost 1.5 million dollars in the Bernie Madoff scandal. Till that point, he had been sober for eight years, but the news was too much for him. So he went to the bar and got hammered.

Came home totally stinking drunk, and freshly unemployed to boot, so his wife said she had enough of him and told him to get out. So the marriage counselor was having marriage problems and not approaching them in the way that he probably advised others to do (at least I hope not).

Since this poor soul had fallen while drunk, the nurse asked him to get into a gown so that I could check him for injuries from the fall. I walk in and find a pleasant gentleman sitting on one of the chairs in the room. As we get into the physical exam, he tells me about some bruises and abrasions he suffered from the fall and proceeds to lift up the gown to show me his abdomen.

He didn’t tell me though that under that gown, he was totally naked. Just naked and casually sitting on a chair reading a magazine. Personally, I don’t prefer that any of my skin touches anything in an ER patient room.  But he, on the other hand, didn’t seem to mind plopping his naked genitals (i.e., free-birding) right down on that cloth lined (read absorbent) chair that others before him had bled, vomited, urinated and God knows what else on before. Either that or he really trusts generic hospital brand Lysol.

This reminded me of a patient we had a few months back in our psych room. She was about 50 and depressed. One of my colleagues went in to see her and being that it is the psych room, it is monitored on CC TV. As he was interviewing her, I noticed from my peripheral vision that she was successively taking off her clothes. Right down until she was totally naked and just sitting there answering his questions. It was a most unusual site to behold.

I mentioned this encounter to one of my other colleagues who is a serious triathlete. He told me that this was nothing compared to the guy that visually tortured him for months when he used to go swimming at the YMCA. This guy used to strip down to nothing but his socks and shoes and spend a good half hour riding the air-dyne (fan bike) in full view of all to behold. Not a nice image.

So, all-in-all, not sure if these are just nudists who happened to need to come in to the ER or what? But there is no doubt that we sometimes get to see way more of our patients than we ever intended to – and in most of these cases, have to live with the nightmares.


Internet Date Goes Horribly Wrong

April 23, 2009

You're hot An interesting thing happened last weekend. My own Romeo and Juliette … from Hell that is.  We had two patients come in from a car accident by EMS. Here is their story; a story that deserves a movie deal, or at least a Saturday Night Live skit.

John and Peggy.

John, a portly 275lb, unemployed alcoholic was looking for love. But unfortunately, love wasn’t look back in his direction. So he tried the internet. Peggy, an equally portly 255lb, gainfully employed assistant manager was having trouble finding the right man and also thought to try her luck on the internet. It was a match made in heaven, or at least in Heaven-Hill.

Their love on-line seemed to blossom, until they could hold themselves back no longer and just had to meet. John unfortunately had a suspended license (damn DUI’s), so Peggy would have to go and pick him up. They decided to go someplace exotic, someplace intriguing, a place where they could look deep into each other’s eyes and hear one another’s sweet words. They decided to go to a bar.

At the bar, they drank and drank. Maybe they imagined that the alcohol would make them appear more enticing (ahh, the famed beer goggle).

They hoped for the arrows of Cupid to pierce deeply into their hearts, but instead they discovered that the alcohol only brought on the spear of Ares (Roman god of war). Their arguments led them to decide that maybe it was best to go home. But Peggy was nice enough to at least drive the drunk and stupid John home.  John, alcohol having removed his ever so thin veil of “niceness”, told Peggy she needed to take a certain route to get him home.

Peggy, on the other hand, thought that John’s liquor was talking instead of his “brain”, and she decided to take another road to get him back to his hometown. I guess her route would have eventually gotten him home if they had driven long enough in such a great circle, but we will never know the answer to that intriguing question. Why?

Because poor John became so angry at his dear Peggy on their way home, that he decided to grab the steering wheel at 50 mph and spin it around. He apparently thought that this would be a good idea and help put her on the “right road” as he tells it. Unfortunately for our dear couple, the car rolled and landed in a ditch awaiting the fine men and women of EMS.

Upon arriving, EMS immediately recognized that they were in the middle of a love nest and decided to transport our  Romeo and Juliette together in the same ambulance. Although it sounded to everyone else like they were arguing and blaming each other, as well as calling each other @$%&*# and the ever-endearing ?*&$%#!, I’m sure that this was just John and Peggy’s own special love code. We on the other hand in the ED had to give them separate rooms. That didn’t stop them from yelling at each other across the hall though. Oh no, love like that just can’t be stopped.

They were both drunk – John weighing in at an alcohol level of .31 and Peggy (the driver) coming in a close second with a .20. State Police was present to give them citations by which they could immortalize their first date. Who knows, maybe they may even consider tying the knot when they show up for their court date. Although some may see Peggy losing her license for drinking and driving as a tragedy, my sentimental side sees it as an opportunity for them to take long, romantic walks along the highway together.

At the end of it all, it turns out that even though John was chomping at the bit to leave and get out of his spine precautions, the poor soul had suffered a broken neck. Yep, a good old C2 fracture. It would be a wonderful reminder of his first date with Peggy. Peggy would only end up with a few scrapes and bruises to remind her of their first meeting though. Ahh, a first date to remember. Just hope I’m not around for their next one!

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* Note – a case like this illustrates the great importance of radiographically clearing a C-spine when you are dealing with an intoxicated patient. Don’t be misled by their lack of pain and get a good radiographic exam.


On Death and Dying: The Grieving Tray

April 22, 2009

 

I think that all doctors would agree that of all of the moments we get trained for, the one that can be the most difficult is when telling a family member that their loved one has passed away. It’s hard to find the right words, especially when speaking to someone that, in many cases, you have known for less than a few hours at best.

 

Not so long ago though, I had accepted an assignment at a new hospital and was still getting my bearings. I had become used to the culture of the South where usually I made sure my back was covered before I informed families of bad news as they were known to sometimes attack me in their misguided grief (they usually apologized later). This though was a different part of the US.

 

Enter Mr. W from the nursing home. This patient was 66 years old and had suffered through many medical problems in his life. He was a double above the knee amputee who was coming because of lethargy and abdominal pain. When I went in to see the patient, he looked ashen and was very lethargic. His abdomen was very distended and had the distinctive tin sound of a bowel obstruction when I listened. So, I ordered blood tests and an x-ray. He didn’t last long in x-ray as when they tried to lay him down he groaned and started retching. So, the x-ray staff brought him back and requested we maybe put a tube in his belly (NG) to prevent him from barfing all over the place when he got flat.

 

“Reasonable enough”, I thought, so I asked the nurse who was taking care of this patient to come with me and we would get this done together and hopefully soon because he wasn’t looking so good. The nurse passed the tube as I tried to coach the patient and when it was hooked up to suction, suddenly the patient stopped moving and his color paled a little bit. I almost wondered if we had passed it into his lungs, but it sounded like it was in the right place. We stood there for a moment considering whether the old timer had just taken his last breath. It was an interesting moment in my career – no urgency, no fear on my part for some reason.

 

Then I said to the nurse, “Hey, if this guy’s not a DNR (do not resuscitate) then we should probably call a code.” Some of you may be thinking, “Wow, that’s kind of a nonchalant attitude isn’t it”, and I wouldn’t blame you because it really did seem as if time was passing a little slow. We went out and were told that he did in fact have a medical directive and so we had done the right thing. That’s when things began to get interesting …

 

A call was promptly put out to family. A message was left for his wife, but we did succeed in getting a hold of his son. We told him that he should probably come to the hospital immediately as his father was very sick and may not survive. His answer?

 

Well, there’ll be no love lost there I tell ya.” And then he hung up. Hmmm.

 

I then asked the nurses where they usually have the doctor tell the family the bad news. They said that there was indeed a family room and they would go ahead and getting the grieving tray ready. “Grieving tray?”, I asked. The grieving tray was a special at this kind hospital – loaded with cookies, fruits, pie, tea and soft drinks – to help grieving families with their overwhelming emotions. I thought that was nice, but then one of the nurses told me, “Yeah, they usually never touch it, so then we get it after they’re gone and can snack on it.” Ahhh, the ever practical mind of the ER staff.

 

So, I got busy with some other patients and about 45 minutes later, I’m called out to the nurse’s station to meet with the deceased man’s wife. I ask the nurses where I can go (assuming they understood that I meant I wanted to go to the family room) and they told me to go to the end of the ER in the last room. As I’m walking with the woman, I’m at a loss of what to say and just trying to get her to where we can sit down so that I can break the news to her. I get to the last room and pull open the curtain only to find the dead man lying there! Doh!

 

The woman pushes past me to go to his side – still not knowing if he’s dead. Meanwhile, I’m desperately thinking what to say to her and how to handle this awkward situation (and how much I wanted to strangle the nurse who sent me down here!). As the woman stands – oddly enough at a distance – by the bed, she asks in a confused voice,

 

Is he dead?”

 

Damn it! Have to think fast …

 

Yes ma’am, actually your husband did pass away just before you arrived. I’m sorry that you had to learn this way, but we did try everything we possibly could …”

 

She didn’t seem to be listening though. I was thinking that maybe I should get her a chair or something. Was she going to pass out? Suddenly, the single most amazing thing I have ever seen in a dead patient’s room happened next.

 

The woman leaned over her husband’s face, looked at him directly and then asked out loud,

 

I wonder if he’s in Hell right now.”

 

Overwhelmed with relief that she wasn’t pissed at the lack of a proper introduction, and at the same time by my disbelief at what I had just witnessed, I blurted out anything I could to keep from laughing. “Ma’am, there seemed to have been some confusion over his medical directive. Did he in fact have one?”

 

The disbelief continued in her next statement.

 

You know, I have no idea. But if you woulda asked me, I woulda told ya to let the bastard die.”

 

Ok, what do you say to that? Before things got any stranger, I excused myself and told her that I would give her some time alone and that if she wanted anything to drink that the grieving tray was there for her – although in her case, I guess it may have been more appropriately called a party platter. As I stepped out, I silently wondered if she was going to slap him, spit on him or even worse, get out a knife and carve her initials into his chest.

 

Turns out, after some further research, that this man had been a wife-beater and a terrible father to his children. He had lived a life of hurting everyone in his family which explained the interesting reaction of his whole family to his death. For me though, it is a case I will never forget,

 

And by the way, the cookies were good.

 

 


Made With Love

April 20, 2009

Since we were just on the topic of nutrition a few days ago, I thought I would share an interesting true story with you from our ER. It is among the many reasons that I usually prefer to cook my own food.

As it turns out, a patient’s daughter brought some cupcakes to the hospital once as a way to say thanks to the staff for having cared for one of her loved ones. She was so very appreciative of their heroic efforts and decided to cook them an ever so special recipe. As everyone was digging in and fully enjoying their treats, someone remarked, “these are soooo good. And moist! What’s your secret?”

Before I get to the secret ingredient though, let me impart some wisdom that was taught to me. One of my teachers once told me that in ancient times, scholars used to say that 90% of ignorance is bliss. In other words, getting all the details usually ruins most of life’s pleasures. Most of the time, it is just best to enjoy what you have and not ask too many questions.

So, back to the secret ingredient … the patient’s daughter was so visibly happy with all of the complements and beamed out proudly, “I used my own breast milk!” Needless to say, we now only accept packaged food products.

On a similar note, hope you find this little video from failblog. org as fun and “interesting” as I did:


Training Video: How to Get Sued

April 19, 2009

I visited a new friend’s blog yesterday and saw this video and had to share it with those of you who may not have seen it yet. I’m sure EMS will totally love it too. There’s always someone out there who either makes us look awesome or like total idiots. Enjoy!