Archive for July, 2012
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.
We’re up and running for July. Highlights:
-Barriers to care in Medicaid vs privately insured patients
-Care Coordination in the ED, a systematic review of existing data
-A novel biomarker for detecting appendicitis in children?
-The Canadian Triage Scale
-Differentiating benign early repolarization and STEMI
-High frequency ED users
-More, more, more!
Email any time at email@example.com,
David and Ashley
Please email your story to Tracy Napper at firstname.lastname@example.org
A Piece of Humble Pie
It was not just another day in the trauma resuscitation area at our tertiary referral center. We had just received a call from dispatch that a cardiac arrest was on its imminent arrival from a close scene. As the second year resident, I was in charge of the resuscitation and I assembled my team. Unlike other medical resuscitations where it’s just you as the only resident on hand, a cardiac arrest meant all-hands-on-deck. I quickly called my fellow residents working in the department and gave them all distinct tasks. The intern had the airway with the other second year as their backup. The senior resident would work on vascular access. I stood outside the resuscitation bay waiting for the electronic doors to automatically open and tried to gather my thoughts. I knew how to run a code and could recite ACLS with my eyes closed, but I just felt this cardiac arrest would be different.
The automatic doors flew open and I was glad I was wearing a face mask to hide the fact that my jaw had just dropped. The patient received one-handed chest compressions as a paramedic walked briskly next to the EMS stretcher. The patient was easily over 500 pounds. I started to assist with chest compressions as I realized the petite female paramedic was barely making an indentation in his chest, let alone anything adequate for perfusion. I began to listen to EMS’ history as I continued compressions to the metronome in my head. They had been called to the patient’s house by his mother and found him seated/propped against the couch on the floor tachypneic and diaphoretic. He reportedly walked to the ambulance and subsequently collapsed in the rear of the truck. He became bradycardic and then went into a pulseless, non-shockable rhythm.
As I continued my chest compressions the patient was moved to the hospital stretcher–sort of. Even though there were no less than six people transferring this patient from the EMS stretcher, his lifeless body only made it halfway, then his girth abruptly pushed the entire mattress askew. After some quick maneuvering (and more help) the emergency department resuscitation began. The airway was difficult so an LMA was placed. Vascular access was also formidable, so an IO was placed by an emergency medicine resident who was rotating on orthopedics. Talk about all hands on deck! Although our efforts were valiant, the patient never had return of spontaneous circulation and was declared dead. Following the customary thank you to all who had participated, questions started swirling. What happened to this patient? Who had more answers?
After allowing me to gather my thoughts, our social worker approached me and asked me to speak to the patient’s mother in the family waiting room. But there was a catch, she knew nothing. She was not even aware the patient had collapsed, let alone had just been pronounced dead after arriving lifeless to the emergency department. You can go through lectures in medical school on “How to break bad news” or receive a “pep talk” from your attending, but telling a family member their loved one is dead is one of the most difficult aspects of residency.
I started with the customary, “What do you know about ____’s condition?” His mother began to paint the picture of a normally healthy obese male who had just been discharged two or three days ago from another hospital for pneumonia and called her that morning saying he did not feel well. When she arrived to his home, she found him in the same position that EMS reported. After she had finished with her description and sequence of events her eyebrows raised and she gave me that look like, “Is my son okay?” I shot a quick glance to the social worker and she slowly nodded her head as if cajoling me to tell her. I did. Aside from the normal shock and denial, the patient’s mother said something that will stick with me for my entire career. ”But his father is a doctor here and he is upstairs right now. We have to tell him.” The social worker let out a gasp and gathered his name so she could try and bring him down to the family waiting room. The patient’s father was an internal medicine faculty member who was still rounding on the floors above the emergency department with his residents.
When he arrived and saw his wife, he knew something was inexplicably wrong. Before I could tell him the news, his wife broke down and began sobbing. She kept on saying, “He’s gone, he’s gone, he’s gone!” As the patient’s father attempted to find his bearings and make sense of his wife’s sorrows, I stepped in to tell him the news. He asked for details, and I gave him what I could. He thanked me and began the grieving process with his wife.
Who could be prepared for something like this? I have two small children myself, and placing myself in the shoes of that physician, that father, was a real eye-opener. These are the servings of humble pie that life and emergency medicine can hand you. When I got home from that shift, my daughter was watching the Lion King. I sat next to her and held her hand as I started to reflect on the day and how that experience (now in the past) would affect me and mold my career. I “zoned” back in to the movie, and heard wisdom as only Disney can bestow, “The Past Can Hurt, But The Way I See It You Can Either Run From It or Learn From It.” ~Rafiki
Brandon R. Allen, MD
University of Florida-Shands Emergency Medicine Chief Resident