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I do have an interesting case, basic and not a lot of flair, as I am working my shift tonight in a single coverage ED with a 17,000-patient volume with periodic PA coverage. We were busy up until about 3am when things are starting to run together, just getting my last patient out of the ED, except my 18-year-old who ingested 10gms of tylenol and just finished his 15,000mg of “Acetadote” awaiting psyche eval. I figure if I could just get 1/2 hour, maybe even a 45-minute power nap, I would be good. Two phone calls later, I look at my watch after tossing and turning (for no good reason, except it’s not my bed and I’m not at home), and it’s 3:30. I am finally feeling like I could doze off and suddenly a knock on my door and it’s Tim from Cardiopulmonary who says “…we’re intubating in the unit, do you want the Glidescope?” and I said yes, grab it. As I am walking back to the ED to tell them the plan, I get a little history, “…he was admitted at 5pm with respiratory problems and he’s a full code!” I arrive to our 4-bed unit, 2 nurses, a clerk, a tech and Tim from Cardio are there. They tell me he was on the floor, originally on BiPAP in the ED but “weaned off” to go to the floor on Telemetry. He was found by the tech to have a temp of 33 C, HR 30′s, BP 50/30 and a SaO2 of 60%. He was moved to the unit and the hospitalist on call from home (1 hour away) said “…intubate him, give him fluids and call the ER doc…” in that order, I am told. I arrive to find a pale, very diaphoretic and cachetic eldery male with agonal respirations. He was on BiPAP, barely moving any air, still hypoxic, hypotensive and unresponsive. The nurse yells to me his wife is on her way, he’s a DNR in our computer, but she is the “Durable Power of Attorney” and wants everything possible done, except “…unless it is going to prolong his suffering and he’s not going to get better….” Of course I have the crystal ball to determine that.

I made the “executive decision” to give fluids, atropine, increase O2 and NOT intubate. The wife arrives shortly thereafter, she rushes to the bedside, teary-eyed, to hold his hand. She sees he is not responsive to her and his vitals on the monitor are “in the toilet” (a medical term of course). I tell her I thought this was a terminal event and he was not going to recover (.but who gave me the crystal ball). I did sneak in 2 rounds of atropine, a little diluted epi, a liter of NS with no response. She tells me he has really deteriorated over the past several weeks to months. He stopped eating 6 weeks ago, was hospitalized twice for pneumonia and never has really been the same and was sent to our local skilled nursing facility. Because he was found hypoxic with an altered LOC he was sent to the ER and admitted a few hours before I arrived. By now, their 2 pastors arrived (not at the same time of course) and the wife wanted me to explain what was going on. Just as I finished telling the first pastor, the second arrives and so I repeat it. She again asked if I thought there was anything that could be done. And of course I said no; “it’s between he and the man upstairs,” but I will make sure he is comfortable and not suffering.

I bounce back and forth between the ED and the ICU over the next hour. Now a little after 5am his HR is 20′s, BP 30/20, SaO2 is still hanging on at 97% but he’s still on BiPAP. I return at 5:30am, HR single digits, BP still 32/20 (obviously from several minutes ago). I ask to stop the BiPAP, HR 0, and I ask to turn the monitor off. I go through my normal routine and pronounce him at 0535, 10 minutes before writing this sentence. As I offer my condolences, the wife crying, gives me a hug and says , “thank you,” the pastors shake my hand; I ask if there is anything I can do, or if they have any questions I can answer. I tell them the nurse will have certain questions, the state of Michigan mandate we call “Gift of Life” and funeral home, etc. The nurse tells me, “thank you, I wish they all went like this!”

Now the punch line. It is well published that the last 6 months of life utilizes the highest percentage of health care dollars, also, that ED docs are expected to participate in comfort or palliative care in the ED, with increasing frequency. While ED patient volume is increasing, there are the same number of ED beds and staff, decreasing reimbursements (ie, we all are expected to work harder, more stress with less compensation). We are expected to maintain an excellent attitude to keep our Press Ganey scores up and improve our “…likelihood to recommend,” keep patients happy so they don’t sue us, while all along optimizing patient safety and quality of care. This while spending quality time at home with family and somewhere in there getting enough sleep before our first night shift and thereafter.

Now that I have reiterated the obvious to all of us, this is what we do day (or night) in and day out. I am going to ask yet one more thing of all of us. We are on the front lines and are responsible for a significant expenditure of health care dollars. We spend billions of dollars on defensive medicine and doing what is “expected” versus what we “should” be doing. I do have a strict adage, “…no one should ever die alone or in pain!” I was all ready to intubate my 82-year-old cachetic dying pneumonia patient ( and believe me, I am all about procedures) and even though he was initially a full code, it just wasn’t the “right” thing to do. After seeing both my parents die a similar death; one at a tertiary care center in Los Angeles and my father at home; it was just nice to have someone there who “cared.” This is what I think society wants at end of life, not to suffer, and someone there who cares. I think if we explain to families, DPOAs, etc, what we do to prolong the inevitable they would opt not to do it. That being said, there is definitely a fine line sometimes at end of life. What is “terminal” and what is not may be difficult. But after almost 20 years of doing this, I think we have a pretty good idea. Sir William Osler had it right too, and it still applies!

I would ask that we be cognizant not only about the health care dollars we spend not only at end of life but every day, and after quality of life has passed that we emphasize the “quality of Death.” We as physicians can impact the cost of health care the most by using our judgment of what we expend at end of life and before. This should be a judgment made by the family and physician at the bedside (not at home on the phone). And if this takes us out of the ER and into the ICU then so be it! If we are the only physicians in house then it is incumbent on us to be there for the patient and their family. Our government is doomed to fail (even more), if health care spending is not controlled, and we can control it on our terms and not theirs!

We as physicians are blessed to be in the position we are in. We have a lot of influence on everything. We should use that influence to benefit every aspect of our lives and the lives of others.

Harold K. Moores, MD, FACEP

Please send your stories to Tracy Napper (tnapper@acep.org) today!

The night after Christmas day was a busy day in the department.  We had already slogged our way through a stream of what seemed like endless patients when Triage alerted the team of a potentially sick patient. “They are coming straight over to the Acute Care side now, and they are turning blue!” With this information, my interest was instantly piqued. 

The patient rolled quickly across the ED into a bed via wheelchair.  I half-jogged to the room to find a young patient, in no apparent distress. A quick glance up at her monitor revealed normal vital signs, normal oxygen saturations on room air.  Hmmm. “What brings you in today?” I started. “My mom told me to come in tonight. She said, I don’t look right and that my face and hands look blue. I feel fine.” It was only then that I was able to see the subtle, but easily recognizable blue hue around her mouth, lips, and her fingertips. 

 My first thought was, this girl is cyanotic. She sure is. And with the involvement of her face and lips, she has central cyanosis. From what? But, she has normal oxygen saturations, heart rate, and blood pressure. A quick listen to her chest revealed no murmur and no extraneous lung sounds. Hmmm. Very interesting.

 I turned my attention to her hands. Closer inspection revealed the subtle blue hue to primarily be located on her fingertips. I squeeze her fingertip to assess her capillary refill, and it was normal. However, when blanched, her fingertip remained slightly blue. 

 ”I don’t know why this is happening to me, I feel fine. I’m a little freaked out right now because everybody looked very worried in triage,” she said anxiously. At this point, she looked very nervous, drumming her fingers on her leg, tapping her foot. I looked at her hands again. She was wringing them, tapping her fingers on her leg, rubbing them together, then back again, drumming her jeans. Her dark blue, denim jeans. 

 ”Did you get some new jeans for Christmas?” I asked. “Yeah….,” she replied, looking very confused. I took an alcohol swab out of the drawer, ripped open the package, and wiped one of her fingertips. I showed her the results. Her face now turned a beet red. “I’m so embarrassed,” she said putting her hands up to her mouth. “It’s a rare disorder, but a very curable case,” I teased. 

 It’s not every shift you catch a “zebra” like Blue Jean Pseudo-Cyanosis. But when you do, it reminds you why you love this job, even during the holidays.

 Jeremy Webb, PGY3

Wake Forest Baptist Health. Winston Salem, NC

Please send your stories to Tracy Napper (tnapper@acep.org) today!

War Stories
John Bibb, MD, FACEP
Do you know the difference between a fairy tale and a sea story as told by sailors? A fairy tale starts out, “Once upon a time…”; a sea story starts out , “Now this is no s*!%….”

So this did not happen when I was on duty. Not everything that goes wrong does so when I am on duty. A female patient who was in her 30s comes in with a complaint of lower abdominal pain. She is seen by the emergency physician who sends off a gram stain of the cervical secretions to the laboratory. The lab calls back and says we see gram negative intracellular diplococci consistent with gonorrhea. The patient is informed of her diagnosis. She says, “Is that right? Please send in my husband George.” The patient confronts her husband with the diagnosis and so George confesses about his extramarital endeavors. Then the lab calls back and states that they over decolorized the slide and that their initial reading is in error.

Oops.

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By John Newcomb, MD, FACEP

I am a fifty-five-year-old physician trained in family practice working as an emergency physician in a high-volume rural emergency department. This is my story.

Ever since I can remember, I have wanted to do something that would allow me to help people. My mother told me I should be a dentist. After being rejected by numerous first responder organizations, I resolved myself to enrolling in college. After one year of college, I received a call from one of the ambulance companies with an offer of employment. Despite a budding career in academia, with a stellar 2.0 GPA, I made the sacrifice and left college and took to the streets, literally. My credentials for being a medic were a standard Red Cross First Aid course, a CPR card, and a “willingness to learn.” At the tender age of eighteen I was assigned to patient care while my older, more experienced partner was assigned to the important job of driving the truck!

I served on the ambulance for three years. Little did I know I was living in the beginning of the end of the dark ages in EMS. I was an EMT but I was treated as a TGT (Throw and Go Technician). I had the privilege of taking the first AHA ACLS course ever. No mannequins for us. We practiced our intubation skills on anesthetized patients in the OR. I still feel badly about what happened to that man’s frontal incisors. I took some solace in the fact that lives would be saved and pre-hospital care advanced by the experience; too bad though, he once had a nice smile. It was a time of the esophageal airway tube, mast trousers, and calcium gluconate with its legendary mythical powers of bringing the dead back to life. I particularly miss the passing of the “pre-cordial thump.” Maybe it’s just nostalgia, but it saddens me when I think how emergency care professionals training today will never know the exhilaration one felt when you could literally beat the life into someone.

Today, I am the Medical Director and Chairman of a rural ED with an annual volume of nearly 50,000. I serve on most of the major committees of my hospital and committees that govern the hospital system. Recently, I served as Co-Chair for the Workforce Section of ACEP and as Section Councilor for two consecutive years. I am board certified in family medicine, but this July I celebrated 21 years as an emergency physician.

So much talk today revolves around who is qualified to practice emergency medicine. I recall a time when the idea of paramedics was first introduced. ED nurses saw it as a threat to their position. When mid-level providers were beginning practice, physicians felt threatened. Now I ask you, how would we care for our patients today if it weren’t for paramedics and mid-level providers? Throughout my life I have seen a lot of changes in EMS, but turf battles seem to remain the one constant.

Maybe it’s in my position as medical director, or maybe it’s just because of my experience, but most likely my perspective is the result of both. As emergency physicians, we have been given a tremendous opportunity, and I believe a great privilege, to care for the sick and injured among us. I stress teamwork in my ED. Every member of the department is responsible for the needs of every patient and every member is responsible for making every other member the best they can be. This attitude extends to the registrars and to the ambulance personnel. Despite my commitment to teamwork, from time to time, I still have to resist the urge to give somebody a good “thumping.”

There is a shortage of nurses and physicians to staff our nation’s EDs at a time when volume and acuity are increasing. The turnover of staff makes the task even more challenging. We frequently do not have inpatient beds, we do not always have the specialty care our patients need or the most appropriate diagnostic or therapeutic equipment available. We go to our jobs everyday under the threat of the next terror attack and knowing the next pandemic is inevitable. Because of the high pace, and lack of readily available resources, I lean on my experience more each day to help me to be as efficient as possible. Today there is no place for turf battles in America’s EDs. Our patients and our country can’t afford it. In addition to caring for our patients, everyone will be better served if we look for ways to take care of our own and lift each other up.

To summarize, I’ve learned a couple of things from my life’s journey in EMS. Change is inevitable and usually for the good. Teamwork is essential to providing the best patient outcomes. Experience should not be underestimated. Finally, always consider a mother’s advice.