until a student of medicine shows me it’s unusual…

We have (mostly) non-EM studs rotate through our ED on their sometimes mandatory, sometimes killing a month elective ED tour. There is little reason for EM destined students to rotate in our place, as we don’t have a residency and we’re not part of the club of EM residency directors ( i.e. letter of rec writers). So, usually not EM hard chargers. Nothing wrong with that, but they’re not my cuppa tea.

Today’s lesson: shoulder reduction for the non-EM Stud, and for me in What We Do Isn’t Usual.

As is our norm, after a thorough Hx, PE, Xrays and Time Out, was in on a 2 doc reduction; One does the sedation, one the reduction. I don’t typically have students follow me: I don’t dislike the students, but I don’t have them. Personal preference.

Today, a shoulder reduction. My colleagues’ student. Not destined for a life in the ED (already matched, not in a remotely EM specialty). My colleague is on the sedation, and I’m on the reduction. I, after discussing the technique, in my presence and under my direction, allowed the stud the first attempt at reduction after sedation. No go. Good effort, not enough muscle.

Second attempt was mine, and when we got the happy “clunk” (with the accompanying interesting sound), I was happy but the Stud wasn’t. While not actively vomiting, the Stud wasn’t uber-happy. At all. Wide eyed, in fact. Unpleasantly surprised, in reality.

After a period both the patient and the Stud recovered. One with a shoulder that’ll work, and one with an appreciation for what it takes to reduce a dislocated shoulder.

And I got the indirect lesson, that what I do isn’t common, and is actually a skill.

Students teach, too.

Thank you for the lesson.

Update 2-17-11: Not a stroke, thank goodness, but a stroke mimic, a complex migraine:

LOS ANGELES — A TV reporter who lapsed into gibberish during a live shot outside the Grammys suffered a migraine, her doctors said Thursday.

KCBS-TV reporter Serene Branson was doing a stand-up Sunday outside the Staples Center where the award show was held when her speech became incoherent. The station quickly cut away, and she was examined by paramedics and recovered at home.

Branson’s incoherence fueled Internet speculation that she suffered an on-air stroke. But doctors at the University of California, Los Angeles where she went to get a brain scan and blood work done ruled it out.

I’m glad for her. The smart move is to assume this is a stroke until proven it’s not, and I’m glad it wasn’t.

Original Post:

The site I found this on assumed it was on-air jitters, and called it ‘the flub heard ’round the world‘.

Except it’s not a flub. This is one way a stroke can present (watch the video, it’s short and unforgettable):
I cannot suppress the autoplay, and for that reason the video and the rest of the post is below the fold. Apologies.
[Read more...]

I have experience with this, from both sides. Both involve hand-washing. Still, a clean story.

Washing of hands is the right thing to do for health-care providers, between seeing patients, for infection control reasons. And, I’ve gotten ‘the letter’ from a VP charged with signing them, citing me for not washing my hands between patients.

Except, I did. This is the problem with observational medicine.

Several years ago I saw a patient at the end of an irregularly-shaped hall, which has an alcove area at the end. There are alcohol dispensers there, I used them on the way in and out of a patient interaction there. That wasn’t enough for the observer: she veritably gloated ‘I got you’, meaning she got me not washing my hands into/out of a patients’ room. (I’m not perfect, nobody is, and I’ve probably botched this somewhere, but not here; I knew she was there, but didn’t think she was dense. I was wrong). I pointed out there are dispensers out of her vision, to no avail. I got the letter from the VP who hasn’t touched a patient in a decade, and oh well.

I think of this sometimes, as my ED’s Fast Track was not designed, more just cobbled together from available space and good intentions. The resulting arrangement has the doc station less than an arms’ breadth from the primary patient restroom. To say this affords ample opportunity for totally unavoidable observational medicine is an understatement. Trust me, we’d love to avoid it, but that’s not an option.

We’d love for the count from fully audible flush to door opening ot be, oh, a 6 count: long enough to reach the sink, run some water over the hands, then hit the door. (Problem: we cannot hear the water run in the sink, or it’s never happened, so we prefer to think we cannot hear it). Yeah, it’s Usain Bolt speed, but that’s preferable to the alternative, no washing. And yet, speed like that is hard to believe from the general ED public.  It doesn’t happen. Flush, door open within a 4 count. Nobody dries their hands on their pants, like, you know…people in a hurry.

So, given my experience, I’m forced to accept the alternative: people clearly wash their hands, then flush, then exit the bathroom with super-dry hands. Yes, it goes against everything I know about humans and the behavior, but then so does the majority of the ED population.

It’s the trouble with observation in medicine.  It’s unreliable.

(In case you’re slow, this isn’t an indictment of my patients, it’s about hand washing observation and its limitations). (I might not be the clever writer I imagine).

I like lacs (lacerations).  It’s bread and butter in EM, and it’s a way to demonstrably help a patient immediately and visibly.

Visibly is where the tattoos come in. While I don’t have any skin art, many of my patients do. It’s interesting how many lacerations go through my patients’ tats.

While with the USMC in Okinawa, a patient went through a window. Whether he jumped or was pushed was a point of contention, but that mattered not to me. What did matter was the roughly 2 foot long, razor-straight laceration of an upper-through-to-lower arm, going through an ornate tattoo.

Due to the natural stretch of skin (Langhers’ lines) when skin is cut it doesn’t fall one side to another like a steak, but will ‘spring’ into different directions…. which makes deciding what to tie to what a little complicated.

Unless there’s a picture embedded into the skin. Then, it’s a relatively easy ‘connect the dots’, putting the picture back together.

I spent the better part of a couple of hours doing my best, and in the end even the patient was happy with the result. He did say that he’d get it touched up after it healed… (Someone educate me here, how do scars take tattoo dye)?

Yes, lacs happen, and we try to make the resulting closure first functional and then as cosmetic as we can. The tats make it a lot more interesting.

In case you wondered what was required to diagnose, and how to treat potentially successfully, rabies.  This is from the place that had a neurologically intact survivor (some damage but functional, which beats the norm).

The Milwaukee Rabies Protocol (.pdf)

via Notes from Dr. RW

One in two emergency care doctors will suffer a burnout during their career, according to a survey of French physicians, published online in Emergency Medicine Journal. The research was funded in part by the NEXT NURSES’ EXIT STUDY (‘Sustaining working ability in the nursing profession – investigation of premature departure from work’) project, which received more than EUR 2 million under the ‘Quality of life and management of living resources’ Programme of the EU’s Fifth Framework Programme (FP5).

…

The responses showed that the prevalence of burnout was high, with 1 in 2 emergency care doctors identified as suffering from it, compared with more than 4 out of 10 of the representative sample. Physicians had the highest burnout rate in the two age groups, between 35 and 44 and between 45 and 54.

via Balkans.com Business News : One in two emergency care doctors will suffer a burnout during their career.

Expectedly, it’s International…

…another in a series.

“You know that patient you saw yesterday?” was how the conversation started.

I did remember, it’s not often I Find the Pony, diagnostically.  A good case, which from my aspect means I had to think, act, and make things happen. Yesterday I was quite pleased with myself.

Now the ‘do you remember’ intro. Never good. Never.

A colleague tells me how the patient I saw yesterday (and made a couple of good, if odd-to-present-at-the-same-time diagnoses) died while getting an x-ray study, in the ED, when one set of their symptoms returned. (Sorry for the vagueness, thank a room full of lawyers who are afraid of their shadows and have rubber sheets).

Darn. The day before, the patient was doing well, thanks to a good diagnosis and getting the right people to buy in and act. And now my patient is dead, from one of the same diagnoses.

Lifetime death rate: 100%. I do what I can, we all do.

But 100% is an absolute. Sorry.

If you’ve ever had one or 10 too many drinks at a bar, you’re probably familiar with this scenario: a drunk guy stumbles past you, spills a beer all over you, and you get angry. You’re convinced he did it on purpose, and you start fuming. According to a new study in Personality and Social Psychology Bulletin, you’ve probably fallen victim to one of the many side effects of booze: assuming that others’ actions are intentional.

via Drunks More Likely to Think You’re a Jerk | Wired Science | Wired.com.

That explains why the intoxicated patient in the ED is very often the disruptive one who gets way out of proportion angry with the very simple rules / requests in any ED.

Now, if they had a cure, or IV Insight, we’d be all set…