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Lectures

Two days a week our residents at the Mecca receive several hours of lecture on Emergency Medicine and related topics. Lectures start at 0630 am and it doesn’t matter if you have been up 36 straight hours (or if it was after poker night)… it is still mandatory.

Yeah sure, gynecological ultrasound sounds like a fascinating topic… but when you’ve been up all night doing pelvic exams on 250lb women… well, let’s just say it’s easy to loose one’s focus. Here, one of the Mecca’s finest (who incidentally has missed lecture after one of the famous poker nights) sacrifices his body by suffering a nasty case of whiplash in an effort to improve his knowledge base.

Personal Items

There are times in the ER when I feel like I am asked to be Solomon… not necessarily in medical decision making but instead in social problems. These are dilemmas that I have no training for and no greater insight than any one else but yet I find myself recurrently thrust headlong into them as an unwilling yet helpless projectile. Some are cases in which I must determine who is telling the truth (if there is a truth), other times I am asked to decide to retain someone against their will for the greater good (if there is a greater good). Either way, it is always time consuming, frought with medico-legal consequences and ripe with frustration: the best part being, I never know if I did the right thing.

Cases in point:

A 72 year old man who lives alone was alert and oriented and denied complaints. He was brought to the ER by his daughter who said he was drinking too much and not caring for himself properly. She wanted him committed to a rehab facility and she precipitously left the ER after speaking with us. He says she just wanted to get in the house to get her dead mothers jewelry. His vitals and labs were normal.

A nurse reported to me that a middle-eastern man (who’s son is being treated in the ER) appeared to be inappropriately touching his 4 year old daughter in the room. There are no other signs of abuse. The man became insensed when I spoke with him about it and wanted to take both children out of the ER including his son who had not yet received care.


The staff in radiology overheard a technologist talking to her husband on the phone in an argument. She allegedly threatened to kill herself if he moved out of the home. They called security who brought her to the ER for treatment against her most vehement protests. Once there, she denied saying anything of the sort and was irate at the series of events, stating she was purposefully being embarassed and she became more belligerent by the minute… although not particularly psychotic.

A female patient was brought to the ER by police saying she could not remember anything, including her name. She refused all care and stated that she lied to police and really knew her name but refused to tell the ER staff any information citing her civil rights. Upon being called, the police stated she was not under arrest. She was intoxicated and verbally abusive to the staff but could ambulate without assistance.

I have found that the most important barrier to a successful conclusion in these types of cases is a lack of information. Usually with enough questioning, some other source of information, or just a little time I can make a decision that (at least) I can live with. With information being such a precious commodity I’ll take it anyway I can get it and in the last case the info came as I fumbled through the chart and noticed a page labeled “personal items”. On the paper was an inventory of patient’s possesions when she arrived. This particular list was as follows:

1- black sweat pants

1- cream/red sweater

1- blue shoe/ other foot in a cast

1- black leather coat

1- white shirt

1- Florida driver’s license with a photo of a person appearing different that the patient

1- black suitcase with a commercial flight attendants tag, (including still a different) name and address in Alaska

1- orange scarf used as a tie.

A simple call to Alaska revealed that the luggage had been stolen at the airport baggage terminal and inside the suitcase was the patient’s actual ID. Upon confronting the patient, she then became relatively docile, allowed a full exam and last I heard, she was explaining matters to the proper authorities.

I must have a been a good boy recently: that personal item list… it is NEVER placed on the chart.

PS- I shall be hauling ass from the plane to the luggage terminal from now on.

Slow News Day

From Associated Press

ALBANY, Ore. —  A 9-year-old boy who complained of an earache was a little surprised when the doctor told him that a pair of spiders had tried to make a home out of him.“They were walking on my eardrums,” said Jesse Courtney.

One of the spiders was still alive after the doctor flushed the fourth-grader’s left ear canal.

His mother, Diane Courtney, said her son insisted he kept hearing a faint popping in his ear — “like Rice Krispies” — before the earache sent them to the doctor.

Dr. David Irvine said it looked like the boy had something in his ear when he examined him, but he could not immediately identify it. So he irrigated the ear, and the first spider came out, dead. The other spider took a second dousing before it emerged, still alive. Both were about the size of a pencil eraser.

Irvine said it was a first for him as a physician. “It was the only time I ever pulled out an invertebrate,” he said.

Jesse was given the spiders — now both dead — as a souvenir. He has taken them to school and his mother has taken them to work.

“It was real interesting, ’cause, two spiders in my ear — what next?” Jesse said.

Funny, we see invertebrates in ears fairly frequently… so I’m not sure how this made the news, although TWO spiders is impressive. (-Trenchy)

Tattoo of The Day

This picture is of the upper arm of Veruca Salt, one of the alltime best nurses in the Mecca ER. I call her Veruca Salt because she looks like the adult version of the bratty little girl in Willy Wonka and the Chocolate Factory… that is, if she had grown up to be built like a brick shit-house.

The tattoo is script in elvish (you know, like Lord of The Rings) and I believe that it means “I am here to do whatever it takes to help you, unless you piss me off and then I will go Gandalf on your ass.”

Doctor May…

Disclaimer: These images are from the Senior ER Residents of the Mecca calendar which is as infamous around these parts for being contraband as it is for the “comedically sexy” poses. The picture credits go to Terra, the very persuasive nurse. She wanted me to make note that Doctor May was suppose to have spring flowers on the bed but all she had was roses…

Another note, I had thought about not publishing the rest of the pictures, but the residents enjoy your comments so much I have decided to finish out the year.

A Top 11 List…

The tradition continues. Today’s list could just have well been the Top 11 Things that piss us off in the ER but we realized that our attitude might be jaded a bit by PMS, (partner is menstruating syndrome) so we tweaked it.

The Top 11 Over-rated things in the ER… 

1. Rally Pack. (Listen. If someone drinks so much alcohol that they lack basic essential nutrition then pouring urine colored fluids into them is a waste. Give them a chewable Flintstone’s with thiamine, look them in the eye and ask them if their mother would be proud.)

2. Gastro-cult. (There is no way to obtain gastric fluid without causing some amount bleeding. Please, stop the insanity)

3. Oxygen in euoxemic patients. (chest pain, sickle cell crisis, hell some people get oxygen and we have abso-friggin-lutely no idea why… we didn’t order it. OK, we know… we will always do it and I know pneumothorax is another good exception, but we are still right… just as long as you all know.)

4. Pelvic X-Rays in Trauma (If it aint broke, don’t x-ray it… CAT SCAN IT!)

5. Blood Cultures in Community Aquired Pneumonia. (The data is solid. We are tired of it and if you Family Practice people ask for them again, feelings will get hurt.)

6. Tetanus/Diptheria toxoid. (What we NEED is Bordatella boosters. The only time we see risus sardonicus is when Trenchy writes an alimony check.)

7. Defasciculating dose of Norcuron in rapid sequence intubation. (Makes us feel like we remember BioChem… but we didn’t… and it is a waste of time.)

8. Sorbitol in Activated Charcoal. (Swallowed a quarter and need to get it back quick? Great, use sorbitol: otherwise it is bordering on malpractice.)

9. Lidocaine in Closed Head Injuries. (Lidocaine killed more people in cardiac usage than Cecil B. Demille, how in the hell did we think it would help here? Other than something to do while the succinylcholine is mixed up, that is.)

10. Rectal exam in trauma. (Uh, um… so we strap people flat to hard boards to prevent spinal injuries but then we have no quams about flopping them all over a stretcher to stick our reluctant fingers into their often surpised rectums… and for what, so we can guess that the prostate is high riding? then we put a foley catheter in ANYWAY… what is this? Advanced Torquemada Life Support? Oh, and why do we do it in women? Ridiculous!)

11. Fat Chick Cleavage. (OK, we know, this is not an entity that is isolated to the ER… although it is quite predominant in the mother’s of children who present with fever after  2am. It is simply that we here at Trenchdoc feel that FCC may be the most over-rated thing on the entire planet and we don’t want our readership to be fooled by all the new fangled grill enhancers out there. Listen. Gravity cannot be defied in the buff and by then it’s just too late.)

Dealing with Death

Medical school simply does not prepare us adequately to deal with the loved ones of those who die, particularly those who die suddenly. Or, maybe it does but there is so much other crap to digest that we just played golf on the days they went over that stuff. Either way, a great article on dealing with death can be found in this month’s Resident and Staff Physician . Check it out.

Yes, I still get Resident and Staff Physician. You think I can let a resident know ANYTHING that I don’t?

Un-uh.

Just Another Shift… By The Numbers

50- The milligrams of Haldol we gave.

4- The number of MRI’s that 1 resident ordered.

88- The heart rate of the gunshot victim just before we lost his pulse.

450- The weight (in pounds) of a patient that we could not find a ride home for.

4- The number of ambulance services that arrived, took one look at her and said “no way!”

2- The centimeters that a lung tumor has grown in a patient who never followed up with the oncologist I made an appointment with for him 3 months ago.

304- The alcohol level of the unresponsive, elderly lady that we intubated.

1- The number of mother’s who said, “why you need a cat scan of his head? His BODY was the thing that had the seizure!” It is also the number of psychotic female patients with the first name Christopher.

98- The room-air oxygen saturation of the patient with a pulmonary embolus.

8- The number of patients we saw with chest pain who thought they were having a heart attack.

0- The number of patients with a heart attack.

3- The number of patients that I sent to the Chest Pain Unit.

4- The number that had chest pain from smoking crack.

5- The number of calls it took to get Christopher into a psych unit.

2- The number of times that I had to explain that a “fracture” is the same thing as a “broke bone.” Also the number of patients that I suspect will soon have a new diagnosis of HIV.

91- The age of the lady who cut her arm off when her riding mower rolled over.

93- The age of her sister who summoned EMS after the accident.

6- The number of nurses who plan to quit soon.

 

An ER Ditty…

 

Much like Amadeus… this just came to me. It is to the tune of Stacy’s Mom has got it goin on.

J’aeQw’aan’s Mom has got it going on…

“he vomited once and has been fussin all night long”

J’aeQw’aan can’t you see, you don’t need a suppository

That would just be wro-oong,

We’ll tell your Mom when she’s off the phone.

Another Saturday Night- A Pictoral

Middle aged male; motorcycle vs. interstate median barrier… patient intermittently lost pulses in route.

Quickly evaluated in the trauma room, by almost too many people.

Intubated effectively… 1 problem fixed, 5 to go… next up, lack of right chest breath sounds.

His pulse weakens steadily. A chest tube is placed… with little results.

Pulse is lost. Ultrasound guided pericardiocentesis… a last ditch effort.

Apparently a mirror off the bike: found underneath the patient.