A day in the ED

I trailed two hours behind skriehma after the shift today because I relieved some more of my piano cravings in the empty administrative building on this beautiful Saturday morning. Oh did I mention that they actually had that beautiful piano tuned a week ago? I've been coming earlier before shifts a couple of times now to play.

On the way back I was toying with the idea of giving you all an "accurate" impression of this day in the ED by presenting today's patients of mine to you. The reason why I hesitated to "just do it (tm)" is that someone might construe my disclosing patient information, even if completely anonymous, as a HIPAA (Health Insurance Portability and Accountability Act) violation. I then decided that I could just change and/or switch a few details, making these patients "fictional", since some of their data is intentionally wronged, but not in a way that would alter the impression you're supposed to get from this ED day. When I then saw what skriehma wrote, I wondered why I even care so much about patient confidentiality. Anyway, here we go.

So where do I begin. Maybe with the most prominent patient, comparing her with skriehma's college girls (by the way, he apparently failed to get any numbers from them!) was one of the running-gags among some residents and skriehma's attending. She was a 42y/o F c/o (complaining of) constant, sharp pain to both knees and what she describes as "cracking" sounds when she moves x1d (times[=since,for] one day). +pain down the entire length of her spine, +leg swelling x1wk, +bed sores, +abd. pain, +SOB (shortness of breath), +obstipation x3d, +occipital HA (headache) x3h. She described the pain with a severity of 10/10 (=excruciating), smiling and laughing while she was talking to me. She also had 6 Smirnoff Ice today. Oh, did I mention she weighed 367 pounds? I had to "help" her get into and out of bed several times today. She also complained of some odor down below, she explained that she cannot reach down there to wipe herself after going for a number 2. I didn't dare to wonder about a number 1. Her PMH (past medical history) was significant for asthma, HTN (hypertension) and, needless to say, gross obesity. Her PSH (past surgical history) consisted of one CS (caesarean section) in '86. Her Meds were Vitamins and Iron, Benadryl (diphenhydramine) to go to sleep, Motrin (ibuprofen) prn (when needed) and albuterol prn. She admitted to one pack year of tobacco use and regular EtOH (ethanol) abuse. Oh and cocaine this morning with her sister. One of the two residents on my side scolded me for getting all this history from her, since attention was exactly what she was looking for. And she was right. Numerous times after that I heard the sweet sound of "Honey!" - and when I didn't react - "Doctor!" from her corner, until I had to go there, the residents looking at me with a mixture of amusement and pity. She usually wanted "some more pain medication!" or to be turned off of her bed sores or to help me move her legs on or off the bed. Our management with this lady was to give her the warm bed she was looking for, some weak pain meds (Toradol[ketorolac] and Tylenol[acetaminophen a.k.a. paracetamol], not the morphine she demanded) and a chest x-ray to keep her occupied (the official excuse was to look for edema, since she had been treated for leg edema before). We later attempted to discharge her, but she refused to leave and nobody wanted to fight a 367-pound-woman at the time. She may still be there.

Enough of her, the next patient was a more pleasant 53y/o M c/o acute onset of abdominal and chest pain with n/v (nausea and vomiting) x1 + diarrhea x1 at the same time. He was diaphoretic and short of breath when it happened and at that point I asked for cardiac risk factors, which he all denied, but slipped him for an EKG and drew his blood for cardiac enzymes anyway. If there's one thing I've learned it's that you cannot walk into an American ED and mention "chest pain" if you don't want them to work you up to rule out MI (myocardial infarction). Naturally, you also get a chest x-ray. Just say "chest pain" and before you can say "AMA" people will have drawn your blood, attach electrodes and shoot gamma radiation through your chest. This guy had no diabetes, no hypertension, no hypercholesterolemia, no family history of thrombembolic events, didn't smoke, the chest pain was anything but typical MI. But if I hadn't started the cardiac workup the attending would have ripped me to pieces. The best (/worst) thing about it is that if you claim your chest pain started less than six hours ago, they will also draw blood again six hours later for a second set of cardiac enzymes (CK, CK-MB, Troponin-I) - just in case the event was too recent for the markers to show yet. So by mentioning some chest discomfort while throwing up, this guy essentially bought himself a minimum of 8 hours in our ED (half an hour for triage, history and until the line is in, 6-hour-wait for the second set, one hour for the lab to get the results ready and at least another half hour for us to look at him and discharge the patient). He was still there when I left.

I don't remember the exact order of things, but I think around this time came a double-notification, one trauma alert and one code, the head trauma was handled by skriehma's side, the 73y/o M with PEA (pulseless electrical activity) was brought to us. He had obvious AOB (alcohol on breath), but we never found out why he arrested and ended the code after about 20 minutes of unsucessful resuscitation attempts. There were a couple more trauma alerts, I don't remember them all. There was one pediatric GSW (gun shot wound), one guy beaten up with sticks, one guy just with fists but his face actually looked worse and possibly more that I don't remember during the course of the night.

The next patient I actually saw was a 10y/o boy BIBEMS&NYPD (brought in by emergency medical service and cops) after threatening his brother with razor blades, then running away from mom, drawing a box cutter (one of these knives that come out of the hilt and retract) in a stand-off with the cops (people die doing that). This little boy either had some serious balls or was incredibly stupid. I tend to suspect the latter. The cops reenacted to me how the boy was standing a few yards away from them in a wide stance and reached for his back pocket, producing the box cutter. If he were not the four-foot youngster he is, he would probably either be riddled with bullets or already in jail. The cops were very adamant in asking me to put restraints on the boy (that was actually before I heard the story) and I did suggest this to the resident but he agreed that the boy was very pleasant and cooperative right now and we felt we could handle a 10-year-old. The cops said "allright, but we warned you, if he gets hold of a needle or a scalpel .." and then announced that they would leave soon, depriving us of their protection. I talked to the boy, he told me he ran away because he was under the impression his mom preferred his brother over him (hence probably also the razorblade-thing), he did take the box cutter to "defend against people, there are weird people out there, you know" but denies wanting to use it against cops. He had no medical condition except some pain in the wrists from being restrained, so all that was left to do was to call for a psych consult. Mom had left with her other kids already anyway. The boy was currently being treated with Concerta (methylphenidate) for ADHD, this stimulating medication may well have contributed to his outburst.

Next was a 19y/o M who had had an unpleasant encounter with a baseball bat in the hands of someone who didn't like him. Among my first questions was whether the police was involved, he denied and didn't want them to be. It's always good to see the system works .. anyway, he had some bruises to the back but appeared in NAD (no apparent distress), no cp (chest pain), SOB (shortness of breath), ap (abdominal pain) or n/v. He had AOB (alcohol on breath) and whisperingly admitted to weed and dust (PCP). No PMH or PSH, meds were just Tylenol prn and, again whisperingly, SSIs once in a while. The tenderness I found on physical exam was not very impressive, I slipped him for x-rays but since radiology was taking hours to get him he signed out AMA later on.

Then there was this 45y/o F BIBEMS that didn't complain of anything except being handcuffed and brought to the ED. In a very coherent and intelligible way she asserted that she stood in front of a building trying to light a cigarette, with her car being on the opposite side of the street, when police "converged on her", handcuffed her and "threw" her "into the back of an ambulance". I talked to her before her chart was prepared by the clerk, so I had neither the EMS report nor the ability to check her history in the computer (for lack of her ID-number) when she explained to me that she was a nurse in another hospital, had no physical complaints and felt it was unlawful to bring her here against her will. The only thing that made me disagree with her was that she really didn't offer any explanation for the handcuffs and the transport to the ED. She started to become upset with me for not agreeing that she should leave now and kept asking me what the heck I was waiting for - "the chart with the EMS report" didn't seem answer enough for her. Eventually one of the two residents on my side who recognized the patient intervened, mumbled the word "psych" to me and tried to stall the patient further. When eventually the chart was ready, sure enough, there were several PSY admissions in the computer and luckily the psychiatrist was still in the ED for one of the several consults we kept him busy with tonight.

At about 6am I started seeing my last patient for the night, a 38y/o M BIBEMS s/p (status post) being assaulted and "asked for" money out on the street. He had obviously taken several blows to the head and reported of kicking to his left side, this all having happened 30 mins before. He denied any dizzyness, cp, SOB, ap and n/v. He had no PMH but a PSH of donating his left kidney to his mother in March of this year. Even though there was just some rather mild rib tenderness on physical exam, there was some blood and protein in his urine when I dipped it, so I sent the urine up for analysis and in accordance with the attending slipped him for an abdominal CT, the goal obviously being to prevent him from losing his other kidney at all costs. I also dragged the guy over to ED2 for a visual acuity exam but his vision was 20/30 b/l (bilateral) despite some bruising under his right eye.

The (wannabe-?)"nurse" had meanwhile been sedated with haldol and ativan IM which made her cooperative (read: drowsy) enough for us to start an IV on her, she was going to be admitted. Pretty soon after that, at 7am, rounds started and we signed out the patients that we hadn't managed to discharge yet out to the day shift.

After that skriehma and I had breakfast and then I went up to play some piano. Now I'm back home and skriehma is sleeping already .. again .. getting ready for the next night shift, later today, a Saturday night.