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Late on April 21, 2006 I received a call from my son’s cell phone; it was not him, it was a social worker at the University of Michigan’s ED who picked up Alex’s phone and hit redial. “Do you have a son named Alex? He’s been in a bad car accident, can you come right down?” Countless times I have been on the other side of that phone call. I always imagined what it must be like to receive it; now I know. As emergency physicians we try to never tell someone over the phone that their loved one has died. Get the family to the ED first. This knowledge served to increase the fear and anxiety that Marion and I felt rushing to get up, rushing to the hospital and brings tears to my eyes just in the recollection. When we got to the ED a number of the attendings and students recognized me and their discomfort was palpable as they themselves seemed to vicariously feel what it was like to be on the other side. We found Alex intubated and on a ventilator. By then his injuries had started to be catalogued: Intracranial bleed, diffuse axonal shearing, fractured C3, sinus and orbital floor fractures, blood loss from major scalp and facial lacerations. Alex was having decerebrate posturing which seemed to increase as time went by.
Talk with the neurosurgery resident of a ventriculostomy was put on hold when Alex seemed to show some subtle improvements but I could not stop myself from thinking about how I could possibly cope when they ask me for organ donation signatures. Twenty years of hopes and dreams seemed to be shattered. During the next two days in the trauma ICU we dealt with a steady stream of grieving friends and an uninjured, responsible, teenage driver who sobbed and cried by Alex’s bedside for almost 24 hours before we insisted he leave to get rest. The second night Alex showed some purposeful movement and then the next morning, he woke up. Completely. He was extubated, pulled his own feeding tube, sat up, and demanded to go home. The following morning he was indeed discharged, not from the ICU, but from the hospital. He walked the two blocks to the car himself. Decerebrate to walking home in less than three days! Now at home, I cannot minimize his discomfort as he contends with bruises and broken bones and the inevitable feeling of self sorrow, but…my God…he can feel!
My family and my son were astoundingly lucky, to the point of giving meaning to the word “miracle.” I was able to see and feel what we as providers do from the perspective of our patients and their families.
Used with permission by EPMB.
Charles Grassie, MD
June 2013 is up and running. Short and sweet, you can access it here!
-ED Crowding is associated with increased mortality, costs, and inpatient length of stay
-Characteristics of high performing hospitals on ED quality markers
-Physician email and phone contact after visits increases satisfaction
-Impact of Computerized Provider Order Entry in the ED
-Administrator views on barriers and opportunities to Palliative Care in the ED
-Improving Palliative Care in the ED – Notes from the early adopters
-Disaster triage – what method is best?
Email us at firstname.lastname@example.org, let us know what you think.
The American College of Emergency Physicians is set to undertake a new editorial direction for our monthly news magazine, ACEP News, which coincides with a new publishing contract with Wiley Periodicals Inc. beginning in 2014.
Kevin Klauer, DO, EDJ, FACEP will take over as medical editor-in-chief in January 2014, helping to set the tone and editorial direction of the publication. In June, Dr. Klauer will resign as editor-in-chief of Emergency Physicians Monthly, a position he has held since 2008.
Robert Solomon, MD, FACEP, ACEP News’ current medical editor, has served in this role for almost eight years. Under his leadership, the magazine has grown from a small, insider newsletter to a robust and trusted source of up-to-date clinical information, valued articles on practice trends, and entertaining features on emergency physicians worldwide. Dr. Solomon will continue as ACEP News’ medical editor through December 2013.
ACEP would like to thank Dr. Solomon for his tireless dedication and the progress he has helped ACEP achieve with ACEP News.
Dr. Klauer will bring a new voice to ACEP News that will resonate with the 31,000 ACEP members and additional 8,000 emergency physicians who read the publication each month. He has a following in the emergency medicine community, where he is a respected, popular and dynamic faculty member at emergency medicine educational conferences. He will augment the current 21-member ACEP News Editorial Advisory Board with different perspectives and additional columnists.
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About two years ago, we had a lady come in with vague complaints who began to be hypotensive and tachycardic. Despite all interventions, her pressure continued to deteriorate until she actually went into PEA. Extensive resuscitative measures were carried out by myself and fortunately I was supported by a fellow in cardiology. After all measures were determined to be unsuccessful, the patient was pronounced dead. While discussing the case in an adjacent cubicle, the nurse noted that the patient on the monitor began to manifest an appropriate sinus rhythm and there was a pulse. More fluid was given and the patient who had spontaneously resuscitated herself was admitted to the floor. I later learned that the same scenario re-enacted on the floor where she lost her blood pressure and then her pulse and was once again pronounced dead. Amazingly the same event reoccurred, i.e., the patient developed a spontaneous pulse and respiration and was eventually discharged within several days.
What was very surprising about this case is that about two weeks after the incident, the patient walked into the emergency department, introduced herself to me and thanked me for helping resuscitate her and then told me that “I could hear everything you people were talking about and when you pronounced me dead.” She had no animosity, was not upset, and merely was pointing out a fact. That was a very chilling incident in my life and reminded me that my wife has repeatedly told me over the years that “hearing is the last to go.”
Bruce Janiak, MD
Dr. Krome graduated from the Wayne State University surgery residency in 1969 and was assigned staff-oversight responsibility for the Detroit General Hospital emergency room – a position that became necessary after the 1967 Detroit riots.
By the early 1970s, Dr. Krome had begun to develop an emergency physician staff that practiced exclusively in emergency medicine and the emergency department had become a formal part of the hospital’s administrative structure.
In 1971, he joined ACEP and ultimately became a life member. In 1972, he was chosen editor in chief of JACEP, which became Annals of Emergency Medicine in January 1980, due to the strong credibility established by the publication under Dr. Krome’s guidance.
He served as ACEP President from 1976-77 and was presented the John G. Wiegenstein Leadership Award in 1979 for effectively promoting excellence in emergency medicine education.
Dr. Krome was on the team that successfully negotiated recognition for emergency medicine as a specialty in 1979, and chaired the Test Committee appointed to develop the first certification exam. As an active chapter member, he served as a councillor from Michigan for nine years.
A decade after he was president, Dr. Krome received the John D. Mills Outstanding Contribution to Emergency Medicine Award in 1987 for his exemplary long-term contribution to both ACEP and the specialty.
Long after completing his tenure as an elected College leader, Dr. Krome continued to be diligent in striving for increased legitimacy of the specialty through expanding the body of research. His contributions to the Blue Ribbon Commission on the Future of Emergency Medicine and his commitment to Annals of Emergency Medicine has had lasting effects on emergency medicine, as has his work as a teacher and mentor of emergency physicians.
In addition to being a past president of ACEP, he was also a past president of the American Board of Emergency Medicine (ABEM).
He was the first recipient in 1983 of the Michigan ACEP chapter’s Meritorious Service Award, which was then named in his honor. He also published a book, “The Floaters’ Log,” about his emergency department experiences.
He served as chief of the division of emergency medicine at Wayne State University, Detroit, MI, as well as chief of emergency medicine at William Beaumont Hospital, Royal Oak, MI. He attracted many to the field, and mentored many physicians who have since achieved professional prominence.
In 2008, he was named one of ACEP’s Heroes of Emergency Medicine, and reported that his favorite saying was that he receives the greatest joy from seeing his students achieve successes even greater than his.
Contributions in his memory may be sent to the Emergency Medicine Foundation, PO Box 619911, Dallas TX 75261-9911 or online at www.emfoundation.org/donate.
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More than a decade ago, I was working in a suburban ED when a mother and daughter
were brought in at about 10 a.m. from a motor vehicle accident. The daughter was fine, the mother (immobilized on a back board) at first blush seemed fine to paramedics and triage. Vital signs were initially normal. It was quiet in the department and I immediately walked in to see her. She grabbed my hand, looked me in the eyes with terror, and died, all in the length of time that it took to write these few sentences. This was a young woman in her thirties with a young daughter. This was not acceptable. I had to literally peel her fingers off of my hand so that I could begin the interventions. Technically, everything went smoothly but she was definitively dead from the outset. Having watched her die squeezing my hand, I went the extra mile and opened her chest, cross clamped her aorta, performed open cardiac massage. These were desperate measures that everyone would recognize as futile in a blunt trauma; I had neither the skill of a thoracic surgeon nor the backup for such efforts. But I could not stand by without trying everything possible to undo what fate had dealt. This is not a happy story; the dead remained dead. And I was emotionally wrought from having to deal with such an unexpected outcome which had stretched my abilities to no avail. Now the really difficult part began. I had to talk to the nine-year-old daughter, the same age as my own son. As it turned out, this was her stepmother; the child’s biological mother had previously died in an automobile accident in which she had also been a passenger. Her father had been incapacitated in an industrial accident a few years previously, another patient with which I was very familiar. Her aunt and uncle were with her by then and after a brief conversation with them, we elected that I would deliver the bad news. “NO, I wanted her to see me grow up!” I was stunned not just by the volume of her scream but by the apparent maturity of it. She wanted to visit with her mother’s dead, and now mutilated, body. How can I permit that? Who am I to prevent that? I can hardly describe the grieving that we all did at the cruel blow that fate had dealt this poor child. This day will be etched in my memory for the rest of my life. Life went on and in the ED, patients kept coming; eventually I had to put on my game face and go back to work. Some sick people, but mostly people with routine problems, had filled up the department. None of them were privy to the tragedy that had just transpired a few yards from them; they were concerned with their own legitimate issues. I had to put it all aside rapidly; further grieving would have to be on my own time. Two days later, I was again working the morning shift when the triage nurse summoned me to the front desk. There the very same nine-year-old girl stood waiting to give me flowers. She had stopped by on her way to her stepmother’s funeral to personally deliver them.
Several years ago I came across a human interest article in the local newspaper. There was the same child now graduated from high school, having grown up with her grandparents. All the memories flooded back to me.
Used with permission by EPMB.
Charles Grassie, MD
May Annals of EM Audio is up and running. Highlights:
-Variability in ICU admits for minor ICH – who’s right?
-Canadian and New Orleans Head CT rules in Tunisia: a clear winner…
-Where should AEDs be placed for highest yield?
-90-day mortality after ED discharge for Atrial fibrillation
-Copeptin to improve single-troponin sensitivity?
-Searching for Pediatric UTI: how aggressive should we be?
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Virtual PEM is an extensive digital library of presentations from the 2013 Pediatric Emergency Medicine Assembly. With financial support from PEPID, ACEP is offering the entire meeting -17.5 hours of educational content on your own schedule and in the comfort of your home or office or while traveling, anywhere you can get an internet connection. Watch presenters’ slides while listening to fully synchronized audio as if you were actually attending each session. Learn what you need, satisfy your CME requirements, “go to” the sessions you couldn’t see live. Check out Virtual Advanced PEM.
April Audio Summary is posted! Click here (see the left side of the page) to listen to a summary of Aprils’ Annals of EM. Highlights:
-Clinical decision aid derivation for ALTEs: which babies are safe for discharge?
-Head injuries in children with VP shunts
-Access to specialty care through the ED
-Video laryngoscopy, a panoply
-Major problem with the NHAMCS database
-Symptoms as a predictor of emergency visits among cancer patients
-Ultrasound for peripheral IVs: is the data robust?
-Video capsule endoscopy for UGIB in the ED
-Black widow antivenin: a RCT!
-Dabigatran and warfarin bleeding complications in the ED
Email us any time at firstname.lastname@example.org, and tune in every month for more.
Please send your stories to Tracy Napper (email@example.com) today!
When I was working at the Toledo hospital many years ago, we had a patient who came in extremis. She was an elderly female who basically presented as altered mental status. As I began the workup and checked her airway, a person identifying himself as her son admonished me to not do much for mom because she does not wish “to be resuscitated.” Since I didn’t know who he was or what his authority was, I continued with the evaluation and of course checked her blood sugar which was very low. Upon receiving 1 ampule of D50, the patient became awake, alert and in no distress and the son disappeared as soon as possible. I learned later that the son had attempted to terminate his mother by overdosing her on her own insulin. I never heard whether the son who ran away from the emergency department was ever arrested but that certainly left me suspicious of the motives of relatives.
Bruce Janiak, MD