Archive for category TheCentralLine.org
I think we’ve all experienced what I like to call “case envy.” Or even sometimes, “shift envy.” You come on and your colleague immediately starts telling you about the interesting case, or the polytrauma, or the fantastic save/diagnosis/procedure that they just completed.
“Hey, bud, I just performed an open thoracotomy, cross-clamped the aorta and threw in a central line just after performing a cric while I was watching this guy’s aorta rupture during my ultrasound of his belly during which we lost pulses. Sorry about the rest of the mess here in the ED, but those three pelvics and a disempaction might yield something interesting… Enjoy your shift!”
I sometimes hear the story and wonder what I might have done. Would I have handled things the same way? Is that the diagnostic approach I would have followed? Would I even have considered things the same way? Why don’t I ever get the cool cases…?
In residency, we had one colleague who was the perpetual “Black Cloud.” Now, they got to see a lot of cool stuff. However, you didn’t want to follow them because you knew it was going to be chaos in the ED when you arrived. And, if you came before them, you knew the last part of your shift was going to start going to pot about an hour before the end of it.
So maybe it’s not so bad being a bit of a white cloud… but still… I think we all like to have a little something that gets the juices flowing, the mind working, a bit of “yeah for me” moment… After all, that’s why we got into Emergency Medicine… at least for me… how about you?
Sometimes I have a hard time trying to separate fact from fiction; especially when patients start giving me a back story to explain why they haven’t had follow up for a medical problem, or how their narcotics got stolen/lost/misplaced, etc. I sometimes think, seriously? Is that really how bad your life is? Come on…
I know times are hard for a lot of people, but when you’re a 30-something, insulin-dependent, right AKA with non-healing wounds who social work bent over backward following your last admission to get you a clean place to live, home health care visits and arranged for a primary care physician so that you could regularly get medical care and, more importantly, your prescriptions, it’s poor form to miss appointments and get dropped from the practice.
Yes, I know it’s easy to get kicked out of your place within a month for having a dog which wasn’t allowed in the first place and which you acquired AFTER you moved in. What home isn’t complete without a loving pet? And, since you couldn’t afford a place before because of your limited SSI, I am sure adding vet bills, dog feed, and vaccinations to your budget will be no problem at all. And, sure, having a significant other who doesn’t work and who smokes despite the no-smoking policy of the building management is a problem especially when they’re not supposed to be on the property either. Yes, darn those apartment landlords and their stupid rules.
Now, I understand that you had previously been living in your car and had been lucky to have a nice place to live, but why couldn’t you drive that car to the appointment again? I’m sorry, you’re now having to live in it again… is it in working order? How did you get here again? What? It’s a legitimate question since you came 20 miles out of your way from your hometown to our E.D. Sure, yes, well, you’re in luck, we have no beds and are having to send all of our admissions north to our sister hospital. So, you’ll be closer to, um, home… and, besides, those social workers already know you and have done all of the leg work already, so there’s that too.
Then there’s the “I need a drug refill because my meds were stolen after I moved out from the last place I was in.” My answer is simply “drugs and scripts are like money, if you lose it, it’s gone and there’s no replacing it.” Besides, we have pain contracts with the local primary care M.D.’s, and they say, “No.” I still get some interesting stories, though, of backpacks being left “for just a second,” or of drugs disappearing “while I was taking a nap” or of pills in a lockbox in someone else’s house that mysteriously disappear when the person with the key leaves the house to go out to get some smokes. My favorite is the “I left them at my ex’s house, and now I can’t get them back.” “Did you file a police report?” “Well, um, yeah.” “Ok, let me talk to the police department and confirm the report number.” “Yeah, well, um.” “So, which police officer was it again..?” “Um, well, yeah it’s kinda like this…”
Mark Twain once said, “Truth is stranger than fiction, but it is because Fiction is obliged to stick to possibilities; Truth isn’t.” Twain must have worked in an E.D.
I can handle the abusive drunks. I can handle the tweekers who are “talkin’ to the devil.” I can handle the annoying drug seekers who are being seen for their weekly “dental pain” fix. But what I can’t seem to handle are the “walk in the door with my dead baby” parents.
I understand this was baby number 8 or 9. I know you can’t remember which since you don’t have custody of any of your other children, and sure, that makes it harder to keep track. And, yeah, she was only 2 months old; you hadn’t quite gotten used to having her around. She still hadn’t quite fit into the household routine.
Now, I know, she was a great baby because she slept through the night. And, yeah, who hasn’t put their baby to bed and then not checked on them for 15 hours. As long as they’re not crying, they’re fine, right? Yes, yes, I understand it was quite the family party and no one woke up before noon… or one… or two in the afternoon. I’m sure the baby was safe and sound on the bed with her full bottle from last night.
As for medical care, sure, being weighed once at the WIC office and being told that she’s “nice and healthy” is exactly the same as being seen by a pediatrician. It’s almost as good as getting vaccinated. I know that you’re busy and just couldn’t quite get in to have her seen at the pediatrician’s office, but I am sure all of your child’s health needs were met during that visit so you could get your much-earned government support.
Now, I have to let you know that I will be calling the local police, the coroner’s office, and Child Protective Services. They’re going to be asking a lot of questions. And, I know several of the maternity nurses are going to want some answers, too, when they find out that the “meth-addicted, breeds like a rabbit, that CPS was told about” at the time of your child’s birth is now bringing back that same child in not quite the same condition as when she left.
But seriously now, I don’t mind doing a peri-mortem exam in the E.D. with the coroner’s official. I’ve done physical exams on lots of two month olds. Granted, they are not usually wearing wet, soiled onesies. They usually aren’t stone cold with obvious lividity set in. They generally are not brought in wrapped in foul, cigarette and eau de dog scented blankets. But, I am a professional. I can maintain a clinical distance while performing my duties.
I am good at my job. And, I can make it through the end of my shift. And, through the next shift. That is… until I finally get home… until the night goes quiet… until I start to wonder what good I am doing at all… until I try to go to sleep with your daughter’s half open eyes and opened mouth still burnt in my brain as if asking me silently, “why?”
I know that the holidays can get really depressing for a lot of people, but I had three patients over the weekend that really got me depressed because of their situations. I always said that I would never make a good psychiatrist because I would tend to internalize and identify with my patients, and so that’s why I enjoyed surgery so much. There’s quite a bit of distancing that happens when you’re behind a mask looking at a square of skin.
As an E.D. doc, though, we’re up close and personal with a lot of our patients, so it’s back to internalizing and not having the luxury of a sterile sheet between you and your patient.
Patient One crashed their car. They are homeless, so their car is like their home. Everything they own is in there. They had just gotten kicked out of one “fleabag” motel and were on their way to find something better along the coast when they lost control on a curve. Now, all they have is the clothes on their backs. Well, actually in a hospital bag because they were stripped down to a hospital gown when they arrived. They’re bruised and battered and slightly torn. And, they have no one and no where to go. I can discharge them because, luckily, they didn’t suffer any major injuries. But, they have nothing. So they get admitted. Social Work and Discharge Planning can figure out what to do with them in the morning.
They used to have a life, and friends, and a home. But then they were forced to take early retirement from their work. They lost their home and their social network. They can’t afford housing on a fixed income. So they roam… in their car… from place to place.
Patient Two had a nice home, and a wife. Then their wife died and a part of them died too. So they turned to alcohol to help deal with the pain. Soon their nice home deteriorated as did their health. They have a neighbor who checks on them from time to time. Their neighbor brings them in whenever things get too bad. Patient Two can’t see their PCP because they have an outstanding bill, so the E.D. becomes their PCP. Diabetes out of control again? Yep. Bad cellulitis on your legs again? Yep. Anything new? Yep, pressure ulcers on my bottom from not getting up out of my chair for the last three days because my legs felt too bad. Am I going to be admitted? Yep.
Patient Three has a psych history. They’ve been in and out of the system their entire life which is only 50+ years long so far. They have the look of a 90 year old man. A neighbor stopped by because they hadn’t seen them for a few days and found them looking slightly worse than usual. Not eating or drinking. Somehow, though, they continue to smoke despite the rattling cough in their lungs. How the cigarette paper doesn’t just rip their Sahara Desert dry and cracked lips to shreds is beyond me. Must be the warm stale beer that somehow is within reach. Another admission for “Failure to Thrive.” It’s the least I can do.
Three hots and cot… at least for tonight… at least for today…
A year ago I was in Vegas attending ACEP SA and looking forward to starting my new career as an attending physician. Now I am an attending physician looking forward to attending ACEP SA in San Francisco. It’s been quite the year, with a LOT of things learned along the way…
- With a good supporting staff you can run two codes at the same time.
- It’s never easy when a patient dies… it’s even harder when they come back to life after you’ve pronounced them.
- Suddenly the painful bread and butter patients become your bread and butter.
- Nights and weekends, you’re the central line, intubation and OB specialist.
- Draining an abscess is still satisfying.
- I hate dictating.
- I realized one day about six months in, that I will probably be here to see some of my pediatric patients grow up, some of my elderly frequent fliers die, and I will end up with some “private” patients.
- The surgeon who yelled at you one day will be the one who comes in and places a chest tube and central line for you the next when you’ve got a major trauma and a full board and growing rack.
- The Darwin Awards exist for a reason as exemplified by the girl with the C2 unstable fracture that left AMA because I wouldn’t “schedule” her a neurosurgery appointment and who “had too much to do” to be transferred to the other hospital up the road. She ended up driving herself about 2 hours later to the hospital and couldn’t be taken to surgery until later that night because she’d stopped at McDonald’s for a full meal… while wearing her C-collar at least…
- Really sick peds patients still scare me.
- Necessity really is the Mother of Invention
A year ago when I became an attending at this small rural hospital, I posted a blog about being thrown into the water not sure if I would sink or swim. A year later, I think I’ve mastered dog-paddling; this next year I will probably be learning some simple strokes. Just keep swimmin’ Just keep swimmin’… I look forward to seeing you in San Fran!!
Thank you, Mom, for finding a really fantastic, funny, insightful reminder about what it’s like to be a patient in today’s health care system from Andy Borowitz, from The Moth Podcast. Everyone should take the 15 minutes to listen.moth-podcast-169-andy-borowitz.mp3
After seeing your fifth or sixth toothache of the day with severe dental caries, you begin to think that everyone smokes meth. After talking to your third or fourth 20-something who’s on disability for their “chronic pain,” you start to wonder who’s actually working in the community. When your second or third morbidly obese child comes from one of the outlying towns, you wonder about the strength of the local gene pool.
I’ve sometimes left the E.D. at night worrying about the people in my new community. While this community doesn’t have the Knife and Gun Club I left behind in the city where I trained, I feel like the perceived social environment may be more insidious. But, like I said, I have a skewed view.
Then one day I had an epiphany as I drove the main street of this small town. Even though it seems like we see half the town in one day in the E.D., it’s actually a very small percentage of the people who live here. The people who come through the E.D. aren’t the people I see working in the grocery store, delivering the mail, running the gas station, etc. Ok, well, sometimes those people do get hurt too, but they aren’t the chronic back pains, chronic dental pains, chronic anythings. They are the people with the emergencies. They are the people who I got into Emergency Medicine for… and somedays that thought is enough to keep me going through one more shift.
It’s a new year so I’m going to let you in on a little secret… I stress about every post I place here. I sweat and I struggle. I write, delete, write, edit, delete, write, delete, delete, delete, then finally come up with something resembling a post which is worthy of a professional, medical website. So that is why I post so infrequently.
Sure, at first I tried to condition myself to posting once a week. I was a new senior resident, about to graduate; I had a lot to talk about. Then, as the year progressed, time became a factor. I was in the middle of interviewing, finishing requirements, and thinking about moving my brood cross-country which entailed packing and moving the accumulation of 13 years’ of stuff and memories. Then, once I got settled, I did have some fodder for posts being a new attending and everything. But now, it’s back to the sweating…
See, I’m going to let you in on another secret…. I’m just a simple country E.D. doc. I’m not an academic. I’m not a politico. I just go to work and take care of patients in my little corner of the world. And, I write about those encounters; cases that make you stop and think a bit, patients that are a reminder that we are linked by common themes, and those particular cases that teach you that there is still so much more to learn.
This is what I write about. And, I’m ok with that. I hope you are, too….
I’m finishing the week here in Bonita Springs, attending the NAEMSP conference. Boy, do I have some work to be done in my area. And, along with that I am sure some new themes for future blog posts.
The internet has fundamentally changed the way we understand and interact with the world: not just as physicians, but in our daily lives; however medicine (especially academic medicine) still lives in the dark ages. The ways of old are starting to show signs of wear, that this is beginning to change. And as things in the age of information move at an ever more-rapid pace, I think the changes will be here before we know it. I, for one, welcome our new data overlords.
The medical journal was initially created as a forum: a way to publicly share information with your colleagues, and get credit for the discovery. Say you wanted to tell the world of a new surgical technique. Or a new drug that you’ve discovered to help your patients. You could discuss it with a few colleagues in the hospital. But if you think you’re really onto something — something that really might be great and really might help not just your patients, but everyone’s — you’ve got to spread the word. And that’s how the journals started. Not with research, but with physician opinions and approaches and case reports and “Hey look what I found out”s. If you go back to the early publications of the New England Journal of Medicine — which now allows you to search from their archives from 1812 on – you can see some pretty cool stuff. Punch in your favorite subject and you’re transported back in time to when physicians like you were still trying to figure out what the hell was going on with this patient, instead of the biochemical cytokine pathway of today. It’s pretty incredible.
So here’s my first point: look how we share information today (and honestly, we’re just getting started): Twitter, Facebook, emails, blogs, text messages, Google, Wikipedia. Sure sure, we still share some very important information through medical journals, but they simply can’t keep up. Hundreds of new medical journals are launched every year, for everyone’s own sub-sub-specialty out there. Yet the hunger for publication and knowledge continues to grow. Let’s just consider the case report, for example. Imagine you’re staffing a hospital in the late 70s/early 80s in New York, or San Francisco, or Los Angeles, and you find these small crops of patients with really, really weird infections. You scratch your head, dig in a little deeper, and publish what you’re finding in the New England Journal of Medicine in the December 10, 1981 edition. Four months later, several replies are published: it’s marijuana use; no no, it’s the amyl nitrates that the gay men are using; of course not, it’s the CMV they’ve been exposed to; no, you’re wrong, this is something entirely new we’ve never seen before. It’s an absolutely fascinating read of the natural course of HIV’s research pattern, but one that I imagine would be very different today (and will be different when the next HIV/AIDS-like disease hits):
Okay okay, so fine, that’s just case reports. And medicine and science and the scientific method evolved, and It Was Good, and then medical journals became the place to publish research. Big trials. Lots of money. Which brings me to my second, unforunate point: peer review is not all it’s cracked up to be. Some concerning data (ironically, yes, published in the journals):
- Association of Funding and Conclusions in Randomized Drug Trials, JAMA 2003: if your randomized trial was funded by Pharma, it was 5.3 times more likely to recommend the experimental drug than if it was funded by a non-profit organization.
- Undisclosed Changes in Outcomes in Randomized Controlled Trials: An Observational Study, Annals of Family Medicine, 2009: In 31% of randomized controlled trials, the primary outcome had been changed (without disclosure) after the trial had been submitted to the clinicaltrials.gov database.
- Females may be less likely to get papers accepted.
- When you blind reviewers to information about the author, they are less biased in their acceptance of abstracts.
Now, I’m not saying that peer review should be discarded, or that journals should cease to exist, or that we should throw the baby out with the bathwater. I am, saying, however, that I think there’s room for another option, using the internet, social networks, and crowdsourcing. (NB: In this topic I am building on existing ideas from Chris Nickson/LITFL’s Time to Publish Then Filter? and The Wisdom of Crown Review which also references these BMJ and Annals of EM opinion pieces.) I agree with Chris: I don’t know exactly what form this should take, but something like an academic Twitter (Trip Database’s TILT?) might not be a bad start. I hate to make this all a popularity contest (mostly because I lost those so vigorously in high school), but the cream typically rises to the top when something is put to the crowds. (But sadly, not always. Okay, at least, the academic crowds.)
Or perhaps it’s meta-reviews of the data. It’s online Critical Care Journal Clubs, or it’s a rating system to articles with ratings from colleagues you like and trust (and who know the literature better than you) like Leon Gussow’s 5/5 Skull and Crossbones at his Toxicology blog. Or podcasts reviewing a single topic. I’m not sure if it’s centralized. Who knows. Someone will build it and get it right (maybe me?) and we’ll go from there.
And all these great online links and resources lead me to my final point: “academic” works cannot and should not be limited to the length of one’s search in Pubmed as author. Yes yes, I’m suggesting the beginning of an academic new world order, and should be burned at the stake for such heresy (especially since I’m going into academics). But “publish or perish” should not simply mean “get your name in a journal.” Academics is the pursuit of knowledge, the pursuit of teaching and education. Case in point: Rob Reardon, narrator of so many of those fantastic ultrasound videos that I’m forever loving, is a well-published article in the journal world as well. But I guarantee you this: the amount of education that Rob has produced on his website — and that people have learned from — already exceeds the amount of whole-world educational impact of his Pubmed career. It’s simply exposure from the internet versus exposure through one journal.
Like-minded people (frequently education-minded, tech-oriented like myself) are doing this all over the web. They’re frequently (but not always) affiliated with some sort of academic place — be it an official medical school or simply an area where residents rotate — and do it because they enjoy it. And none of it would make it into a journal article. It’s too short, or too fast, or too digital, or simply too practical — but yet clearly useful. And it should be valid and appropriate academic work, recognized by our peers. (Let the crowds do the peer-reviewing of these publications if they like. Don’t like one of Rob’s videos, or disagree with him on something he says? Leave a comment or send a message on Twitter for all the world to see.)
There is a huge, huge volume of really high-quality learning on the web, especially in Emergency Medicine (much of which I’ve documented here), and it’s only becoming better.
Journals are here to stay — and I welcome them. They provide an important resource to develop and publish research and trials, and are still the biggest forum available to spread one’s medical ideas. But at the same time, there is content and ideas and a wealth of knowledge and information-sharing going on that is occuring not in sequence — but in parallel with them. Information that is simply out of the realm and scope of the journals and old-fashioned peer review. We are starting to develop the tools to share this information, and I look forward to where the next 10 years take us. (Hopefully to at least a modicum of technologic advancement in the snail’s pace at which medicine frequently changes.)
A baby died today; a very small infant. One minute I’m excited by the end of my overnight shift quickly approaching, and the next I am hearing the words you never want to hear come over the radio, “En route to home for infant not breathing.” I think the whole ED staff stopped for a minute waiting for the next report.
Then we begin to organize. Prepare a room, grab the pediatric resuscitation cart, where’s the Broselow tape, get respiratory alerted. The on-coming attending arrives, and I tell him what is going on.
The next report comes over the radio, “Attempted intubation, bagging via BVM, chest compressions ongoing, no IV access. Five minutes out.” Ok. Grab the ultrasound, do we have the right sized needle for the EZ IO, call an overhead infant code.
The infant arrives. One, two, three, gently over to the gurney. Let’s take a look. Intubation attempted. Ultrasound shows no cardiac activity. Temperature is 31 rectally. The parents are hovering expectantly, holding onto each other tightly, watching our every move. The other attending and I look at each other. We know there is no hope. We try to make our attempted resuscitation last as long as possible for the sake of the parents. But soon the staff understands our motions. We take one last look with the ultrasound. Silent snow.
We turn to the parents. They have a sense of what they’re going to be told before a word is even said. They look around at us and our staff and see our eyes looking down, looking sad, tearing up and looking at them wordlessly. Cries of anguish fill the ED. The infant is gently wrapped and the parents are brought to the bedside. We file silently out to give them their last moments with their child.
I go to dictate my last patient’s chart, stopping to hug the nurse who stepped into my work area to “get it together” before heading back out to the other waiting patient in the E.D. She apologizes, and I tell her it’s ok to show her emotion. She starts to shake as tears run down both of our cheeks. She quickly recovers and steps out. I take a deep breath, dial the familiar number, and begin my dictation.