Only sorta busy until the 16 EMS’s in an hour.
Ramblings of an Emergency Physician in Texas
I put a post up a few days ago about an NG tube that went poorly.
The post went just as badly as the tube (though with lesser consequences), and when I tried to fix it the new and improved WordPress rebelled. It refused to accept the change, and just got worse.
So, go read ImpactedNurse‘s post. And cringe.
I’ve internalized all the dogma of medicine, for good and bad.
When I was an EMT, green as a twig in an ER, I’d learned the basics: for any wound with hair employ the razor, and get the hair away from the laceration so the doc could do a good closure.
So, employment week 3, eyebrow lac? Shaved that sucker clean off. ED doc freaked out, and I learned some Dogma: don’t shave eyebrows, they don’t grow back. Heard it later, too. All the way through training, in fact.
Hmm. My now older-guy eyebrows would like to disagree…..
I shave my face, nearly daily. All the hair comes back. I have women in the home, who bemoan their razor-rituals. I see younguns with cuts deliberately made in their brows, with blithe unconcern they might be permanently bald there…
I’ve never, ever seen a person come in with one normal and one shorn-off brow, never. (I’ve seen people with shaven brows and penciled in, unlikely shaped, eyebrows but that’s an interesting choice).
So. Myth of EM? I think so. I seek the wisdom of the learned crowd.
Forwarded by a friend of his, and I have the authors’ express permission to run it.
Another amazing and emotional day yesterday. I try to write about things that impress me professionally, emotionally, and spiritually. Yesterday I was again impressed.
At 5:00 a.m., the Giant Voice (the base PA system) announced two incoming casualties. I reluctantly roused from my slumber and made my way to the E.R. On arrival, I found two victims of an accidental grenade explosion, one critically injured and one more stable. The critical patient had third degree burns to his face, neck and upper chest and severe penetrating abdominal injuries. He was in shock and was taken directly to the O.R. by the surgical team. The other had multiple burns, but fairly superficial. He also had eye injuries and he was essentially deaf from the blast, but he was stable. While the unstable patient was in surgery, my team and I evaluated and treated the stable patient, managed his eye injury (severe ocular contusion with corneal burns), CT’d him, cleaned and dressed his burns and expedited his helicopter evacuation to the ophthalmologist at the larger Bagram hospital (we don’t have one here).
The story of how the accident happened was initially unclear, but, when things settled a bit, my patient told me the following: He and the other soldier (both trained weapons specialists) had returned from a mission and were in the ammunition bunker, returning unused grenades and other weapons to the stock. One of the weapons they were handling was a “flash bang” grenade. These are the ones that they use as their team is initially entering a building by force. They toss it in and it explodes with a very bright light and very loud sound, designed to temporarily blind and deafen the people inside so that the soldiers can enter the building with the element of surprise. SWAT teams use these a lot. They’re not designed to kill.
He states that, as they were working, he heard a “click” noise, looked back and immediately saw that the pin had somehow popped out of one of the “flash bang” grenades that his buddy was holding. He looked up and saw a look of terror on his teammate’s face. My patient just had time to turn away as the grenade exploded. He was stunned and isn’t clear exactly what happened next, but somehow they were both loaded into vehicles and rushed to the hospital. From the pattern of the explosion on the severely injured patient who was holding the grenade, it appears that, in the brief instant he had to decide what to do, he made the decision to pull the explosive into his gut and take the force into his body. By doing so, he minimized the blast effect to the other soldier and to the stored ammunition inside the shed, preventing a possible catastrophic chain reaction of explosions. Faced with the split second decision to either toss the grenade into a corner and run, or take the blast himself to save the life of his friend and possibly others in the immediate area of the ammo shed, he chose to sacrifice himself.
In surgery, the severely injured troop had multiple severe abdominal, chest, and head injuries and burns. He required massive amounts of blood. Our little hospital keeps around 30-50 units of blood products available at any one time, but we were a bit low because of a lot of recent trauma activity. It was clear that if this soldier were to have any chance of survival, he would likely need more blood than we had in stock. In addition, we always have to be prepared for the next trauma activation (which, incidentally, came about four hours later, four patients from a Taliban attack on a civilian minivan, including a 14 year old boy, but that’s another story). After discussing this with the surgeons, the hospital commander made the decision to activate the “walking blood bank”.
The walking blood bank is something unique to the military. In the civilian medical world, blood is collected at donation sites and very carefully screened for infectious diseases such as HIV, hepatitis, and others. Then it is broken down into its various parts: red blood cells, platelets, and plasma. These are then separately packaged and stored for later use. The military does the same thing for routine blood use. However, in a combat emergency, we have the ability to short cut the process when we need blood immediately. Essentially, everyone in the military is “pre-screened” because we are all checked for HIV, hepatitis, etc. and given a million immunizations prior to deployment. We also have our blood typed and that information is printed on our dog tags and our military ID. We’re ready to donate and receive blood at any time.
The Giant Voice broadcast across to the base: “All O-positive soldiers report to the hospital immediately!” Our Utah medics, and others in the hospital, mobilized and immediately established impromtu “donation centers” in the outpatient clinic and the dental clinic. Within 10 minutes, they were taking blood from the first volunteers. Within 30 minutes nearly one hundred soldiers were lined up to donate for their fallen comrade. The line filled the clinic, the hallway, and went outside the door of the hospital, down around the corner of the building. All of these troops lined up look like they were waiting to get in a concert or a movie theater. As each precious, life-giving unit of blood was drawn from a troop, it was immediately taken around the corner to the operating room where it was infused, still warm, into the critically injured soldier on the table. Over the 4 hours of his surgery and attempted resuscitation, he received nearly forty units of whole blood taken directly from these donors, as well as banked blood and platelets, plasma, and other blood products. Tragically, the surgeons, despite herculean efforts, were unable to save him and the soldier was finally pronounced dead. The news hit everyone very hard. This incredible soldier, the accidental victim of a grenade malfunction, had died trying to prevent further injury to his fellow troops. He gave his life to protect them. In turn, those donating blood gave a very real part of themselves to try and save him. That is what soldiers do for each other.
Later, I witnessed the solemn and emotional completion to this story. The Army has a battlefield tradition called the “Hero Flight”. When a soldier dies, his body is flown home for a funeral with his (or her) family. The first step of this flight for this Hero was a helicopter ride from our base to the main air base at Bagram. A special ceremony was held as his body was moved from our morgue to the helicopter to begin his journey home.
At about 11:00 pm last night, Soldiers from the fallen soldier’s unit, the hospital, and from all over the base lined up in formation along the hundred yard route from the hospital to the helicopter pad. Everyone was dressed in full uniform; no shorts or tennis shoes.
I don’t know if I’ve ever mentioned it before, but we’re a “black out” base, which means no lights are allowed at night. This is to minimize us as a target at night. We all walk around with little tactical (very dim red or green) flashlights. It’s really dark here. So there we stood, silently and reverently in the darkness, two long columns of soldiers lining the route to the landing area, lit only by the stars in the brilliantly clear and quiet sky and a couple of glow sticks placed along the way. It occurred to me that many of the people standing in silent tribute last night had also given their blood to try and save the life of this soldier. Then, in complete darkness, two helicopters roared out of the night and landed, pulling up to the loading area, the wind from their rotors whipping the hair and faces of the silent line of troops. On cue, they simultaneously cut their engines and the rotors spun slowly to a halt. Into the ensuing silence the First Sergeant issued the command: “Task Force, Attention!”. We all came to attention, face forward, perfectly still. “Present Arms!”. Every soldier, all 250 or so of us, snaps and holds a salute as the body of the fallen soldier, draped in an American flag, is wheeled slowly between the two columns of troops and is placed reverently on the helicopter. “Order Arms!” We dropped our salutes, remaining at attention. The chaplain said a prayer for the soldier, for his family, and for his team, who must continue their work, their mission, without him. In the darkness, I heard soldiers, warriors, sniffling quietly as they suppressed their tears. Me too. As we were dismissed and silently began to depart, the two helicopters fired up their rotors and launched into the dark Afghan night, carrying the body of this young man home to his family.
It is difficult to describe the emotions this long day held for me. Many conflicting but very powerful feelings come to mind as I write. The tragedy of the accident. The heroism of this man’s selfless act protecting his fellow soldiers. The pride I had in my fellow docs and nurses who raced him into surgery and in our Utah medics who quickly and efficiently organized the blood donation operation. The amazement I felt as soldiers from all over the base, few of whom knew the injured troop, lined up to give blood without question. The disappointment when the soldier died despite everyone’s heroic efforts. The pride, respect, and honor of the silent Hero Flight ceremony as we paid our last respects to our brother in arms. A very dramatic, very sad, and very real day here at the War. I just wanted you to know about it. These kinds of things need to be shared.
It’s my pleasure to share this with you.
I was reminded of one of our particular curses the other day, reminded in the way we often are, when somebody reacts to what we do. Sometimes embarrassingly.
Yesterday, I was taking a history, and this was of a patient with a long, complex one. That much I knew from a quick perusal of the EMR prior to going into the room.
So, I and my scribe were there, along with the patient and their family member; because of the medical problems, the family member was giving the history. Family member was pleasant, knowledgeable, and good. Terrific history, and it was flowing. On point, not too many spurious details, and I was enjoying it.
One detail was “…so we went home Saturday…”, a totally innocent thing, pertinent to the history, correct, and natural. That’s when I looked at my watch.
“I’m sorry, I’m trying to be as brief as I can” said the historian, and I realized what I’d done: I’d given the universal signal for ‘you’re taking a long time’, inadvertently.
(What I was trying to do would be familiar to every ER doc, I was looking at my watch because it tells me what day it is: we usually have no idea what day it is. Work 24/7/365 a few years, and that whole ‘work week’ is something to be envied; most of us are at work because we have a shift, not because we have any idea of time otherwise…).
I immediately interrupted and apologized, telling them what I just told you, but in briefer form (“I was looking to see what today is…”), and life moved on.
It did have me make a mental note, though, to be more surreptitious in looking at my watch: my orientation to the calendar won’t change until I retire.
In my practice I try to apply some common sense, adopting a colleagues’ phrase “common things are common”.
This is particularly useful in the diagnosis of new problems that have eluded diagnosis, and I apply a lesson learned from a fellow resident (a PharmD before med school) who told me: new problems, ask about new meds.
So, if my patient has some new problem as part of the history (when did this start) I’ll follow up with ‘any new medications, or change in your meds, around then? (This is often fruitless despite the time investment to go through the meds, the list, then ‘when did that medication start’ conversations, but it’s time well spent).
Many times the reason the patient gets dizzy on standing is the new BP medication, or a BP med that has dehydration as a mechanism stacked onto decreased oral intake…
I’ve made a couple of good diagnoses recently, and it was directly because of questioning the timing of the new meds and the new symptoms, one patient with their second trip to the ED for an unexplained metabolic acidosis (who was taking a seizure med that said ‘metabolic acidosis’ as a known problem with it), so making the call to the pt’s doc for a re-admission and oh-by-the-way I believe the problem is this med that causes this problem. Nice way to have an admitting doc think you know what you’re doing…
Metformin causing diarrhea is a med-school diagnosis, so why it took the med student following me to make it I don’t know, but the patient and family were thrilled to have a reason for their debilitating symptoms. (Thanks, unnamed MS4!)
There are some others, but you get the message: temporally relating new meds then new symptoms, common things are common, and always question the medications.
has made my blog barren, joyless, and, well, dull.
It seems I’ve been working nonstop, and when I’ve had time to myself it’s been consumed with plans for my yearly MegaParty for our Scribes. It’ll be a good one (Seventh, for you counters). (Unless you’ve gotten an invitation, you’re welcome to throw your own party).
Work has drama, but it’s micro-political and therefore sounds whiny when I type it out. I’ll spare you. You’re welcome.
Our joint has started being very aggressive about Induced Hypothermia in resuscitated arrests, and I contributed to a success story, something that’s rare in medicine: a resuscitated arrest that left the hospital neurologically intact 1 week later. Anecdotal, I know, but still. I don’t know if I’ve had one of these before. I hope it’s a trend.
As for shootin’ stuff, I’ve had a self-imposed restriction on adding any new calibers of firearms, as at a certain point keeping up with all the different ammo types can be daunting, and expensive. That took care of itself recently when I was shooting my new 357Sig rounds through my Sigs with Barsto barrels (which I had just dropped in, and not had fitted by a gunsmith). I got talked into 357Sig rather than choosing it, but thought it deserved a good try.
That try had 6 failures to feed in 100 rounds, and said gear has been shelved. As I wasn’t crazy about it to start with the extra effort to make it work was easy to avoid.
Therefore, a new caliber opened up. I’ve never owned a .45, and that’ll change soon. I have my eye on the Springfield XD in 45, I’ve shot the range loaner and found it surprisingly likable and well-fitting for a non-Sig pistol (I’m mostly a Sig pistol snob), so different experiences pay off.
For those screaming at their screens that I need to get a 1911-style 45, rest assured I’ve shot several of them over the years, shot one recently, and, eh. I can shoot it, don’t like it, and you may now call me a Philistine.
Tomorrow I get to take another shooting-newbie out and teach him from zero, an experience I relish. So, good. Some play!
I’ve written about Scribes before, and I love ’em all.
I got an interesting email today that got me recommending my usual lament, that scribes “don’t get it” until they get ‘the buffer’, which I described as such:
[T]he one skill that makes a good scribe is a 2 to 3 sentence
brain buffer. That means, the ability to save in your head 2 or 3
whole sentences, then play it back to write down or act on.
Nearly everyone who starts wants to act on the first 6 words, starts
doing, and loses all that follows the first little bit.
So, there’s your key. Watch tv, listen to 3 sentences, mute the tv and
write them out. A little practice goes a long way.
I base this on watching 8 years of scribes train, progress, and move on, and my own personal experience as a medical student.
Repeat yourself enough as a practicing EM doc using scribes, and you notice when scribes ‘get it’, get that ability to hear everything you say and incorporate that into the record. And it’s the buffer that does it.
When I was in Med School I got that buffer, a life skill that serves me well to this day. We didn’t have a note service, or copies of the profs’ PowerPoints, we had paper, pens, and what we wrote down from the lecture. I wrote a lot, and fear of failure will stimulate the brain.
At my MS2 peak I had about a 5 sentence buffer, and I and my row-mates would be writing long after the lecture ended.
This ability to hear things and keep them in brain-RAM drove my then-new wife nuts; I could watch TV and ‘hear’ her, but when she would say “You didn’t hear a thing I said, did you…” I could very easily repeat her last sentence or two and answer her question. I still have some of it, though atrophy hits everything not exercised…
So, learn to listen, not just hear: there’s your key.
Emergency Medicine Excellence Award™
HealthGrades Identifies Hospitals Among the Top 5% for Emergency Medicine
HealthGrades is proud to announce that the first annual analysis of hospital emergency medicine programs found that the best-performing hospitals consistently outperformed all other hospitals for all eleven cohorts studied.
Neat, especially as Giant Community Hospital, where I humbly serve in the ED, is on the list. As we got the award, I will not question, or even investigate, the methodology…
Nice to be noticed.
But today, dear colleagues, it’s all better.
I’m thinking some calls to the toll-free number are in order.
The 2010 American College of Emergency Physicians’ Scientific Assembly is in Las Vegas this year.
I’ve registered, bought plane tickets and have a marker on a box under a bridge (but very near the convention site, so I’m good).
So, time for you EP’s to get in there and register, and, I’m going to blog it (unless ACEP gets a court order preventing it (they weren’t interested in me blogging for their house blog, so only time will tell…)).
Oh, as a service to my three ACEP readers I plan to get enough freebie pens from the exibitors to give one to each of you when I meet you.
Yeah, I’m a giver. Or a re-gifter. Whatever.
Recently, in the ED, I was seeing a patient who was left with something of a stammer/stutter after a prior stroke.
It was kind of a long history, and probably longer for the patient, who had to work very hard to be understood through their unwanted speech impediment.
Inexplicably, when I walked out of the room I started stuttering; I wasn’t trying to make light of the patients’ problem, and I had to stop talking for a few moments before I could speak in my normal cadence (and while in the patients’ room I was speaking normally as well). It was super-strange, like my brain heard the new cadence and said ‘oh, this is how we do it’. Awful.
It was embarrassing, and weird. Fortunately the patient didn’t hear it, and I apologized to the staff that did. I have no idea why my mouth/brain combo picked that anomaly to repeat. Strange.
Anyone else have this?
Wow, I’ve been promoted from crank to prominent critic!
A prominent critic of the process is Allen Roberts, MD, who blogs as Grunt Doc. http://gruntdoc.com. “I'm a proud member of ABEM,” he said. “I know they have this continuous certification thing going that has been forced on them by ABMS. And I understand the idea behind the yearly test [the Lifelong Learning and Self-Assessment].
I remain a critic of this Continuous certification, and find some of the responses to be laughable, but I’ll save that for another post.
(Are there any other critics of this, or is it really just me?)
Mess with the bull, you get the horn!
A picture is worth a thousand words. And some OMF surgery.
K2, the ‘legal marijuana’, has made it here.
I know that because my first patient with an adverse reaction to it came to see me in the ED.
Introductions are made, etc…
Me: Have you tried this before?
Pt: oh, yeah
Me: (wondering why a bad reaction now to something without a reaction before): anything different this time?
Pt: well, this was strawberry flavored, and it’s the first time I’ve tried that one.
Me: Aah. Stay away from the strawberry, then…
Yes, preventive medicine in the ED. It’s gratifying.