Your ER Doc

Video Re-enactment of a Recent ER Visit

Your ER Doc — Tue, 01 Dec 2009 05:15:44 +0000

Large Clamp Please

Your ER Doc — Mon, 30 Nov 2009 00:40:32 +0000

Let’s face it, everything is funnier in the middle of the night. After about 5 cups of coffee, and no sleep you just get the giggles. On my last night shift, a favorite nursing supervisor was in charge, and I decided to have a little fun. I called her and asked if she knew where to find the Jass clamp.
“The what clamp?” she asked.
“The Jass clamp. J, A, S, S.” I said.
“Well what’s it for?”
“It’s for draining Lar abscesses.” I said. “The full name is Lar Jass clamp.”
“Okay, I’ll see if I can track it down.” she said.
Over the next hour, she searched every corner of the hospital, asking everyone if they had seen the Lar Jass clamp. She finally called me back and reported that she couldn’t find it anywhere.
“Can you slowly repeat what you are looking for?” I asked.
Slowly, she said, “The. Lar. Jass. Clamp.”

I couldn’t help laughing at that point, and understanding finally found her.
“Oh you’re going to get a large ass beatdown.” she said.

Naked Side Effects of Ambien

Your ER Doc — Thu, 12 Nov 2009 00:49:34 +0000

I believe this could be a new protocol for cardiac stress testing.
Recently on the late shift, the nurses on the telemetry unit were alerted to an elderly female patient who was having tachycardia. Her heart rate had been steady at around 80, but for no clear reason it accelerated to about 150 beats per minute. The charge nurse walked quickly over to investigate.
The patient noted that she had been having some insomnia, so she decided to read her romance novel. Suddenly, she had a very realistic hallucination.
“What did you see dear?” asked the nurse.
“Well, it was a very good looking man, who just walked into my room and asked where the grocery store was. And, he was . . . completely naked.” She admitted.
The nurse reassured the patient that it was nothing, and tucked her back into bed, and then chuckled her way back to the nurses station. A few minutes later while doing some charting, she was surprised to see another patient standing in front of the counter. It was a 40 year old man admitted for gallstones. He had been given a dose of Ambien for sleep about an hour before.
“Excuse me, can you show me where the grocery store is?” asked the man.
“I certainly can,” said the nurse, who then gently walked the sleepwalking (and completely naked) patient back to his room.

Worst construction accidents I have seen

Your ER Doc — Sun, 08 Nov 2009 05:53:41 +0000

I was attempting to build a deck today, pretending to be a handy guy, and as per my usual custom thinking about the worst construction accidents I have seen.

These are not just morbid ruminations of my darker side, but useful ways to avoid being hurt. Standing on a ladder while using a circular saw to cut off a piece of trim really gets the imagination going, because of the sheer number of different ways to lacerate, contuse, dismember, and abrade your body. For instance, I must remember to keep the ladder secure so I don’t tip over, breaking my wrist and impaling my face on a piece of rebar.

I can’t cut off a piece of lumber, and let it fall on my foot and then break my neck when I stumble in pain. Perhaps most importantly, I want to make sure I don’t position my body over a fence so that if I do fall off the ladder, I don’t straddle the fence and crush my testicles. Even when I’m finished using the circular saw, I must remember not to set it down while it’s running, so that it doesn’t run over my foot and amputate my toes. In fact, I’ve gotten so paranoid about all of these scenarios that sometimes I find myself just staring at my power tools, too afraid to pick them up.

Perhaps this is why the deck is unfinished after 6 months.

Opiate overuse and Michael Jackson: Time for the pendulum to swing back?

Your ER Doc — Mon, 13 Jul 2009 01:08:13 +0000

I was recently asked by a police officer why doctors prescribe so much opiate medication knowing full well that we are in the midst of an addiction crisis. Many people are hooked on opiates; pills, patches and injections, and the problem is getting worse. Anyone who works in the ER is aware of “drug seeking” patients who may not have a real medical problem, but repeatedly come into the ER seeking narcotics for various types of pain. The police officer sincerely wanted to know why doctors are so willing to prescribe high doses of opiates when the costs of addiction are so high, and this question has recently been brought into the spotlight with the death of Michael Jackson.

It’s a difficult question to answer, but I feel there are several sources of pressure put upon physicians to provide these medications. First, when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.

Additionally, physicians and hospitals are now obsessed with patient satisfaction. We are monitored constantly, at the level of the hospital, the ER and individual physician. When satisfaction goes up, physicians are rewarded, and when it goes down their very jobs may be at stake. If a doctor takes a “hard line” with opiate seeking patients, satisfaction numbers will predictably plummet. Not giving some patients the opiates that they want and expect will often times result in arguments, profanity, and calls and letters to administration.

Finally, pain is now considered by the medical establishment as the “new vital sign.” When patients present to the ER, they are asked to rate their pain 1 through 10, and then this number is followed all the way through discharge or admission. The implications with regard to opiate addicted patients can be profound. If a person states they have a 10/10 pain on arrival and it has not decreased whatsoever at discharge, the physician appears to be at best complacent, at worst sadistic.

For the above reasons, I believe the medical establishment is helping to fuel the opiate crisis in the US, and it is time to re-evaluate our expectations and our processes.

Michael Jackson die of a Heart Attack, or Cardiac Arrest?

Your ER Doc — Sun, 05 Jul 2009 16:46:09 +0000

I’ve been in the UK for the last 2 weeks, and over here many of the papers say he died of heart attack. However, in the United States, when you say “heart attack” that is the same as a myocardial infarction. This means that the coronary arteries get clogged up, and are unable to deliver oxygen and blood to the heart muscle. Cardiac arrest is when the heart stops beating, whatever the actual cause. In some people, cardiac arrest occurs from a heart attack, but it can also be due to medications, arrythmia, blood clots, trouble breathing, etc. When an autopsy is done, the pathologist will check for many different causes of cardiac arrest, including the possibility of drug and alcohol intoxication.

Diagnosis? You’re drunk.

Your ER Doc — Wed, 17 Jun 2009 02:29:57 +0000

A middle aged man recently drove to the ER looking to get some medical attention for a rash that he had for over a year. It was a bit unusual to come to the ER for a chronic rash, but I’ve seen stranger things for sure. The timing was stranger still, since it was about 2am. But let’s give him the benefit of the doubt, and assume he was just trying to come in when the ER wasn’t too crowded.

It wasn’t though–pretty much packed and full of cops who were there for a car crash and an assault. This turned out to be bad news for the man with the rash since he was completely drunk. He knew it was bad mojo when he pulled into the parking lot and saw all the squad cars. If his plan was to be inconspicuous, that didn’t work too well, because he drove in the wrong way on a one-way driveway. As calmly as possible, he tried to perform a casual 3-point U-turn. Unfortunately, he ended up on the curb, and nearly hit the ambulance entrance doors. This did not go unnoticed by our boys in blue, and the man was quickly arrested for DUI, his car was impounded, and he was given a notice to appear before the court. At that point, he should have just been glad he wasn’t going to spend the night at county jail, but he was pretty mad. He stomped over to register in the ER and demanded a blood alcohol level, since he “wasn’t even drunk!”

1 hour later and a measured blood alcohol level of 0.25, the man was ready for discharge.

“Well what’s my diagnosis?!” he demanded.

“Looks like you’re drunk, sir.”

Chelation therapy

Your ER Doc — Mon, 01 Jun 2009 19:10:45 +0000

Last week a physician colleague of mine mentioned that chelation therapy is a completely valid and useful treatment for coronary disease. He noted that there are countries where patients can’t even get bypass surgery unless they have been through chelation first.
Chelation therapy is when a substance, usually EDTA, is given in order to “sponge up” minerals and heavy metals that can cause inflammation, and perhaps contribute to coronary disease.
My recollection was that chelation therapy had never shown a benefit in clinical trials for coronary disease. My colleague said that there was plenty of good research out there that was beneficial, but that the drug companies, and cardiovascular disease establishment were squashing the data in order to maintain the status quo.
That’s quite an accusation. That would mean that thousands of doctors and scientists were engaged in a gigantic conspiracy to keep a valuable, and relatively inexpensive treatment from patients in order to make money through prescription medication, bypass surgery, angioplasty, etc. When you consider that coronary heart disease in the number one killer of men and women, and that many people suffer significant disability from it, this would be a conspiracy far more destructive than any genocide on record. It would make Pol Pot seem like a harmless old curmudgeon.
I decided to do a little research myself and eventually found myself on one of my favorite sites, Quackwatch.com, written by Saul Green, PhD. He has an excellent review of the chelation for vascular disease issue.
There have been some good studies done on chelation therapy, with no benefit shown. There also are a couple of large trials ongoing. There are no studies that show any significant benefit that I could find.
Now maybe Dr. Green has a garage full of Ferraris with bumperstickers that say “I love angioplasty” given to him by the American College of Cardiology, I’m not sure.
Or just perhaps there are some alternative practitioners making some claims (and a lot of money) that are based on marginal science. Hmm, that sounds familiar.

Gratitude

Your ER Doc — Fri, 15 May 2009 03:21:28 +0000

I think one of the fundamental desires of humans is to be appreciated. They want to do things that are important, they want to make an impact on other people, and they want acknowledgement for their efforts. I suspect ER doctors are no different, and many of them (including me) probably went into medicine to satisfy this desire.
Sometimes however, you don’t want to be thanked.
One such time was a few years ago, when I had a man in his early 60’s present to the ER with fevers, rash, and feeling crummy for a couple weeks. His symptoms were not adding up to a typical infection, so I ran some tests. Turns out he had acute leukemia. This was obviously terrible news, and I had to deliver it. The man was typically upset, but took the news with great composure. He then asked if he could go home.
I said, “No, you’ve got to be admitted for treatment, and you’ll probably be in the hospital for quite a while.” He needed induction chemotherapy, and he was going to have a tough time. He really didn’t want to be admitted to the hospital, because it turns out, he had cancelled his health insurance last year. He couldn’t afford the premiums anymore. He was hoping to make it to age 65, and get Medicare benefits, before he had any serious health problems. As the wheels were turning in his head, I came to realize that I had given him several pieces of bad news all at once. He was very ill, he could die, he was going to have a long and difficult hospital course, and he was going to lose all his money.
I checked on him several more times before he was admitted, and each time, he expressed his sincere appreciation and gratitude to me.
I wanted to say “For what? So I could give you the worst news of your life?”
Sometimes feeling appreciated is a shallow goal.

CDC Update

Your ER Doc — Mon, 04 May 2009 15:54:08 +0000

Avoid this type of activity