Emergency Medicine (EM) Residency

Don't Be A Hero

2011-11-03T14:02:00.000-07:00

I am now working in a community emergency Department. This emergency department however is in a rough part of an inner city community and it happens to be extraordinarily busy. Every time I show up for a shift, there are at least 7 ambulances in the parking lot 40 patients in the waiting room and all 36 patient rooms are full. The minute I hit the door it is go time and it seems that for the next 12 hours and constantly running from room to room fixing this fixing that doing a lumbar puncture here intubating somebody there, doing an incision and drainage here, repairing a laceration there.

I like to this emergency department because it is in a community type setting therefore when I have to call a specialist he is usually a private physician at home and calling and not a resident in house to call. These private physicians at home but a call are usually paid to be on call and happy to be busy or to get business. Compared to a full academic emergency department, when I call a specialist like a surgeon, I am usually calling an in-house resident physician who is not paid any extra for the extra work him about to give him or her. So you can imagine the difference in the environment when working in a community emergency Department as compared to an academic emergency department.

For example, one time in the community emergency Department I had a young patient who was suffering from an apparent appendicitis. I called the private surgeon who was on call at his home being paid to the on-call as well as paid to perform surgeries. I remember calling him at 2 in the morning and saying hi Dr. sorry to Pages so early in the morning by to have a young patient here and has what I believe to be appendicitis. There is a positive the other end of the phone and I was preparing for a verbal beat down or some sort of explanation as to why I should call a different specialty because that is the normal response in an academic emergency department when I'm calling resident specialists. However, in this case because I was in the community emergency Department the private surgeon responded with; thank you for calling me I appreciate the business, do you think this is appendicitis? I answered, he had seems pretty classic for appendicitis. He stated, great I will be in in 5 minutes don't worry about getting a CT scan that sounds like a classic appendicitis I will take care of the patient please let the family know I am on my way. By the way what do you want on your pizza. Thank you for calling me I appreciate.

Needless to say there are some differences in working in an emergency department in a academic center versus a community center. This post however is not about the politics or differences of academic medicine versus community medicine! This post is simply a post about a man who knew better who should not have tried to be a Hero.

This man was in is 30's and had a great job as an accountant for a big city firm. He was educated and had a wife a 3 young children. he had been out with his friends watching a football game and drinking and upon returning to his home at about 5 in the morning he was approached by a person wearing a hat and he can't be pulled over his hat. The individual stated anterior pockets here being robbed. Somewhat intoxicated and somewhat scared young accountant started to put his hands towards his pockets to empty out his pockets to give the items to the thief, when he noticed that that thief was not paying attention. Foolishly the young accountant decided to take this opportunity and punch the burglar in the face. The burglar was obviously not expecting this punch, and dropped to the ground when he was punched.

The accountant felt like a superstar as the adrenaline pumped through his veins. Suddenly however, the account in felt someone or something jump onto his back and take him to the ground. A wrestling match ensued with the second burglar and eventually the accountant was able to break free and escaped to his house. He walked into his house to find his wife and young children waking up for the morning and days' activities. To their astonishment they saw their father bleeding profusely. His wife started to scream and the children soon started screaming as well, she ran and grabbed a towel as the accountant began to try to find and see where he was bleeding from. It became evidently apparent that he was bleeding from his arm as there was an 8 inch gash on his forearm. Blood was pouring out all over their entry way floors. Fortunately his wife had her wits about her self and sent her children off to their bedrooms. She wrapped a towel around her husband's bleeding arm and demanded him into the car so she could drive him to the emergency department. This young smart, wise accountant didn't want to make a fuss and stated "it is fine just put a Band-Aid on it, I do not need to go to the emergency department." Fortunately, the wife knew the limitations of her husband's common sense and she ignored his statement and forced him into the car and brought him to the emergency department.

The nurse approached me and said "doctor you have a patient in room 13 that needs to be seen immediately, he is bleeding profusely and may have lost a lot of blood I think he needs to be seen sooner rather than later!" Great! I thought to myself what has this person done at 5:00 AM? I scrambled to room 13 to find a surprisingly well dressed well kept individual with a towel saturated in blood wrapped around his forearm. I also noticed a young wife sitting in a chair frantically making phone calls to make arrangements for her children to be taken to school and to their various activities as well as calling her work and his work to explain why they would not be there today. I introduced myself to both of them and told them I would need to take a look at the wound. I peeled back the blood soaked washcloth to expose a gapping laceration, I asked the patient; "Do you remember when your last tetanus shot was?" He smiled obviously getting my humor and I said that actually this is the least of our concerns at this point let's stop this bleeding first!

The police arrived shortly after I began to fix this laceration. After what seemed to be an hour or 2 of meticulous stitching, a full 3 layer closure, was required to completely fix this laceration and stop the bleeding. Ultimately, the patient had an excellent outcome, but will have to followup with hand surgery and potentially have physical therapy and maybe further interventions. However he was very fortunate to have come to the emergency department quickly and have his laceration fully repaired.

I asked him "how much money would you have lost if you had just given the thief your wallet and other items. He calculated if he would have given the thief everything it would have cost him maybe $500.00 - $800.00 if the thief got his cell phone as well. He actually only had $100.00 cash on his person at the time and the rest of the estimated costs were losing his wallet,and cell phone and costs associated with replacing his credit cards and getting a new licenses etc. Remember this man was an accountant so he thought long and hard about what giving in would have cost him. He was proud that his macho super powers had saved him up to $800.00. While he boasted about this great savings his wife rolled her eyes in the background and I asked him if mugging loses could be declared on taxes.

I politely asked him if he was done with his accounting estimation of the savings he had achieved by punching his attacker and not giving up his belongings. He said, "I think I calculated all the savings." I pointed out and asked what the costs were for missing 2-3 days of work for himself and for his wife. His wife chimed in and reminded him that his $300 new leather jacket now had a 12 inch cut and the arm and could now be deemed worthless unless leather vests make a comeback. His wife also reminded him that his children will need some form of therapy after seeing their father pouring blood from his extremity all over the house. She then started to calculate the cost of cleaning the carpet or replacing the carpet and wood floors. She also noted that there was blood spilled all over their car and the cleaning that would cost money as well not to mention all the other stained clothes he was wearing and she was wearing and finally she reminded him of the medical costs associated with this type of injury. I kept silent during this exchange.

I decided it was in my best interest at this point to remain quiet and not explain how physical therapy and possible hand surgery and further doctor visits as well as medications, and medical supplies would add up to significant costs and it would have just been about 1% of the full cost to just have turned over his wallet with $100.00 in it. I did point out he was licks that the stabbing wound missed a major artery my about 1 cm or we would also have to ad in the cost of a funeral into the equation of costs vs savings. I mentioned this in the upmost professional way possible and we all had a laugh but he got my point.

Lesson: Do not be a hero!

Lesson Learned?: The last thing the patient said to me after hours of sewing his arm up after thanking me was : "Hey doc you should have seen the face on the other guy, I knocked him out and he definitely will remember my punch when he wakes up!"

Lesson Learned? = NO

ICU Cricothyrotomy

2011-10-18T16:18:00.000-07:00

I know that I have not posted on this block for quite some time. let's just say lipase, residency, family, tragedy, and a multiple flurry of other things have taken my time.

However, I have a time of great stories and medical adventures of residency that have occurred and would make great posts for my blog I just need to get caught up.

I wanted to post an experience that occurred while I was working in a medical surgical ICU. as a senior resident working in the ICU can be very stressful. In the ICU the patients are very sick often on the edge of deaths door and overnight You are the only doctor available to take care of these patients. In addition to this responsibility you are also required to respond to all code blues except for ones in the emergency department. CODE BLUES l are pronounced over the intercom as "CODE BLUE room 747" or whatever the room number is and as the ICU resident I would drop everything I was doing and literally run to the room because it meant a patient was crashing or dying. So lets just I was on call every third night and all of those calls were exciting and in no sleep occurred.

On one night I had an amazing experience where a young patient who had just recently been extubated (taken of a ventilator) who had multiple medical problems and was very sick, stopped breathing. I was immediately called to the room and the patients 's 02% was in the low 30% range which is very low and if prolonged for even a short period of time can cause severe brain injury if not death. this individual was a family man with a wife and young children and ultimately although sick should have ultimately recovered and returned to his normal life.

Upon entering the room I saw the patient's vital signs and it became very clear to me that I had to make a quick decision on how I would manage this patient. I was the only doctor there in the room a 2:00am but I had several very experienced nurses and respiratory techs to help and to lean on. As I entered the room the charge nurse said "thank heavens he is an ER doc, he'll know what to do!" which of course added to the pressure. I grabbed my intubation kit and tried to visualize the airway, without success. I grabbed a glidescope which is a fiberoptic video intubation machine that makes intubating easier on difficult airway cases. I had no luck with the glidescope either. Every second that passed = brain cells dying.

I remained very calm although on the inside I was about to pass out. I yelled out "cric kit stat!" The respiratory therapist said with a gasp "doctor, don't you need an attending physician to do a surgical airway?" I politely said "if we wait for an attending to show up, this father of 3 will be dead." The cric kit was produced and I immediately made my incision at the appropriate landmarks and found a very scarred and hard trachea as this patine had been trach'ed in the past for different medical problems. However I was able to cut through the trachea and get my gloved finger into the hole so that I would not lose the incision. I had to cut to make the hole larger and then was able to insert a tracy tube.

Immediately the thatch tube fogged with condensation of the patient's air. ALmost immediately the beeping alarms silenced and the patient regained consciousness and his vital signs returned to normal. I finished suturing the tube into place and hooked it up to the ventilator. Right about at this time an attending anesthesiologist entered the room and audibly gasped. He said "doctor wil you please note that this procedure was started prior to my arrival?" I replied "yes I will note that it was started and completed prior to your arrival." He smiled at my subtle humor and looked over my work. He examined the patients airway and said "there was no way to get this patient's airway other than what you did, nice call." Of course, this made me feel better about the decision to do the surgical airway. In looking back at the documentation this time from when I entered the room to the point where I was cutting was 38 seconds and old records showed the last time he was intubated in an OR setting it took 45 minutes with a fiberoptic scope because his airway was so scarred and difficult to get a tube through. In that setting they were breathing for him so they could take the time and it was non emergent. My setting was a little different.

I called the family at 3am and they all came in and verified that he was at his normal mental status and it did not appear that he suffered any brain damage. I told them the entire story and they were very grateful. I explained that their had to be other forces at work because everything works out perfectly and I said "I am a good doctor but not that good" and we all laughed.

The patient was discharged from the hospital 5 days later with a trach that would be removed in 3 - 4 months but he was alive and at his normal healthy mental status. Even now the experience seems like a surreal dream. Fortunately it went well. I love this job.

This is not a picture of the patient and it is a picture of cricothyrotomy procedure done on a cadaver. You can tell as there is no blood. This procedure in "real life" is very bloody and you have to make sure it is venous blood not arterial blood as the carotid arteries are close in proximity and if cut will cause horrendous outcomes and bleeding out of control. It is never good to cut an artery on accident.

During my case there was lots of venous blood which I expected and fortunately no arterial bleeding.

I am truly fortunate that this case went well as they often do not and can end in death or other bad outcomes. I also am lucky that I have the privilege of doing this line of work. I love going to work.

Long time, ICU

2011-09-23T15:53:00.000-07:00

I just finished a long month at a inner city ICU as a senior resident. While there I saw many many sick, sick patients. I could probably create 100+ dedicated posts just to multiple interesting cases that I had while being a senior resident.

A relatively newer common phenomenon that's occurring in the United States today is that the hospitals are becoming so increasingly busy that the ERs are packed full and the ICU and other hospital beds are full and so the sick patients pile on in the emergency room and have to be boarded in the hallways and ultimately stay in the ER for several hours or even days.

As part of all Emergency Medicine training we spend several months working ICUs as junior residents and as senior residents. This past month was my first month in an ICU as a "senior resident". That means that I had the ultimate responsibility for managing the unit. Never fear I had lots of back up, a fellow in critical care at home and an attending physician trained in critical care who was also at home. During the day everyone on the team was there but at night often times it was me and the nurses and a bunch of sick patients with more arriving at all hours. At times it was a little overwhelming but exciting, challenging and fun. I learned more in that month than I could have learned in 1 year of didactic course work.

I want to share one very interesting case that I had while working as the senior resident on the ICU. So one evening when I was on call I was on the floor helping the nurses in putting in orders for 20 different very sick patients we had in the ICU. I was called to one of the rooms because a patient had become bradycardic, with a heart rate in the low 20s. As I entered the room I asked the nurse to prepare some medications and begin to treat the patient. Right in front of my eyes I saw the patient's heart rate completely stop and he flat lined on the monitor.

Immediately we began CPR and resuscitation protocol. I noted that the patient's stomach had become increasingly distended. This patient actually had a feeding tube that was directly connected to his stomach through his abdomen. As I watched his stomach become more and more distended I realized that this was the cause of his problems.

I quickly grabbed some suction tubing and connected it to the wall suction device on one and and then connected the other end to the patient's feeding tube and immediately the distention of the patient's abdomen begin to decrease and the patient took a large breath and his heart beat came back, he was alive. He is still alive and doing well. It was a fortunate save and luckily I saw the stomach / abdomen distention. Air was entering his abdomen and causing the diaphragm to distend which was pushing on his heart / aorta causing the heart to go into abnormal rhythm. As soon as the pressure was decreased and released the heart rate returned to normal. This patient would have certainly died had the pressure continued to build. Fortunately we only had to do 1 round of CPR before fixing the problem. The CPR itself kept the patient alive while his heart was not functioning.

This is a 15 minute look into the ICU. I was there for a total of 20,000 + minutes so you can imagine the stories I have to tell.

Nasal Foreign Body: Up your nose and around the corner.

2011-04-25T14:21:00.000-07:00

I am back in an inner-city emergency department. And it's been a while since I have posted anything to my blog. Life has been a little crazy. But as Aerosmith once said back in the early 80s "I'm back in the saddle again".

This emergency department is in the heart of an inner-city and what some would call a knife and gun club. That means that there are gunshot wound victims knife stabbing victims and people who suffer all forms of trauma abuse and other accidents. I will have to catch you up later on a lot of the details nevertheless I have seen some amazing cases during this rotation so far.

On a lighter note the other night while working at 2:00 in the morning a very sweet nice little five-year-old girl presented to the emergency department with her father with a chief complaint of a foreign body in her nose. That is just medical mumbo-jumbo for she got something stuck up her nose. As I entered the exam room and saw this cute scared little five-year-old girl who thought for sure she was going to get some sort of a shot. I couldn't help but think of how scared she was and how concerned her father was not sure if he was concerned or mad or maybe a little of both.

I asked the patient how she got something stuck up her nose or what was stuck up her nose to which she replied with big alligator tears in her eyes I don't know and I don't know, which is a fairly typical response. I was able to further question her and explain that she was not in any trouble that I was there to help her and that we see these these things all the time with not just kids but also with adults. After making a few more jokes and getting her to laugh she finally admitted that she was playing with some toys and accidentally put a plastic bead up her nose.

I was able to take a very small tiny balloon catheter, after anesthetizing her nose and slide the balloon catheter pass what appeared to be a black bead and inflate the balloon. Then ever so gently I pulled back on the catheter bringing with it the small black ball that she had somehow put up her nose. Everybody in the room clapped and cheered. This was a very rewarding case. I immediately proclaimed "Popsicle stat" and the nurse magically appeared with an orange popsicle (the patient's favorite flavor) and all was well at three in the morning for this five-year-old girl and her father.

I love my job.

Suicide, Tantrum or Just Stupid?

2011-02-24T15:15:00.000-08:00

Beep, Beep, fuss, beep....... "Hi this is Doctor ___, what do you have?" "Hey Doc, we have a 22 year old male who od'ed on xanax and drank some liquid dishwasher detergent." "What are his vital signs? Is he alert and protecting his airway?" I ask. "Yes he is stable and protecting his airway. His vitals are HR 98, RR 24 and BP is 134/92, he is alert and oriented x 3." they scream back over the radio. "Great, what is your eta? If he starts to crash let us know." I said. "Thanks Doc, we are 10 minutes out."

It was 2 in the morning and we had 4 sets of paramedics on their way in with a variety of sick and not so sick patients. I continued taking care of the patients I already had and waited for this toxic ingestion to arrive. About 10 minutes later I heard a bunch of yelling and screaming coming from the paramedic bay as my toxic patient arrived, yelling and screaming at everyone. One profanity after another came flying out as he made sure to insult everyone his eyes came in contact with. As the paramedics rolled him by I looked up to see how sick my new patient was and I yelled, "take him to room 3, in case I have to intubate him." They obliged and looked like all they wanted to do was drop off this maniac and get out of the ER as fast as possible.

I made my way over to room 3 and started examining the patient as they hooked him up to all the monitors in room 3 and he started told us the story be he was just yelling and obviously agitated. He told me to F+&*& off and attempted to spit on me. This was not the first nor the last time a patient who I was trying to care for tried to spit on me, so I was prepared and dodged the spit like a champion bull fighter. I quickly assessed the situation and fortunately his much calmer girlfriend was there and could tell us what happened and what she saw.

As it turned out he had been on a bender and had "eaten" (her words) all the xanax in the house, which was not enough to kill him. He was only looking to get high but when he found out they were out of xanax he became irate and decided to drink some Cascade, about 2 cups in her estimation. He immediately started throwing up at home and she thought most of it had come back up. I quickly completed my exam and noted that his throat was irritated and also that his teeth were particularly shiny and had no streaks.

I had one of the medical students call poison control to get any further recommendations for treatment and I started a some treatments and stabilized the patient. I saw a few other patients when I was called back by the nurse because "Mr. Clean" (her words) had started to cough up / vomit blood. I made my way to room 3 prepared to intubate our patient but he look ok and was ventilating nicely. He looked like he was withdrawing from xanax / other benzos. I gave some medication too help prevent a full fledged withdrawal with seizures and other horrible symptoms.

Finally poison control called back and I was paged to take the call. I explained what I had done so far; which tests I had orders, and the interventions / treatments I had started. The doctor on the other end of the line, said "perfect, you did not even need to call us, great job!" I told him thanks and explained I needed to document his recommendations for liability reasons and he chuckled and replied with "smart, very smart, cover all your bases." He also let me know what to watch for and what to expect.

Fortunately my patient had not consumed enough of Casacade to cause major problems that would be permanent. He did however burn his throat, mouth and esophagus. He also had aspirated some into his lungs. I explained to him and his family and girlfriend that he would be admitted into the hospital. At this point the patient was calmed down and ready to talk. It sounded like this whole event was a tantrum and not a suicide attempt. I called for a 24 hour sitter anyway just incase. I was able to make some phone calls for social work to see him the next day and talk to him about getting into rehab.

This was 1 patient of the 24 I saw that night. While I was caring for him I had 6 other patients in rooms that I was responsible for as well. What I night. I love what I do, it never gets old and when you think you have seen it all, the doors come flying open and a new adventure begins. You can't make this stuff up, real life better than fiction.

The thing about emergency medicine is that you get to do a little bit of everything. You do some minor surgeries / procedures, OB/GYN, psychiatry, orthopedics, dentistry, urology, neurology, GI, cardiology, ophthalmology, dermatology, pediatrics, toxicology, radiology, anesthesiology, primary care and so much more. Often you do all of these within the same shift. Perfect for ADD / ADHD.

Good times.

Tough Cases in the ER

2011-02-21T16:48:00.000-08:00

I am on emergency medicine in a urban trauma one center and I'm working 12 hour shifts. I work 7 PM to 7 AM for 7 AM to 7 PM. It feels good to be back in my element, my home. This is a scratch that this is a busy emergency department and receive lots of very sick patients tonight

I had an interesting patient the other night. This was a 34 -year-old African-American male with HIV-positive, ESRD (End Stage Renal Disease, and a rip roaring case of pneumonia with a recent pulmonary embolism (PE). He was recently in our ICU unit for pneumonia he was discharged last week and this morning woke up with worsening shortness of breath. He decided to come into the emergency department because of his worsening symptoms when I enter the room I immediately knew this was a sick patient. He was talking just fine but his blood pressure was low and he was having a difficult time getting his oxygen. So I decided to work this individual up for sepsis. I ordered the appropriate labs and films and imaging and I looked at some of his old records.

He had a low CD4 count which is bad for someone’s immune system. He had moved from HIV+ to full-blown AIDS. His low blood pressure continued to plummet. I started him on IV fluid, bolus to bolster his blood pressure. His blood pressure started to come up but it was not high enough, so I decided I was going to put a central line in for better access. I started a medication that helps maintain blood pressure. This medication, seemed to help him and he remained stable in the emergency department.

We got his chest x-ray back and it showed a worsening left-sided lower lobe pneumonia. He was discharged last week with pneumonia and today it was worsening which probably explained his worsening shortness of breath and symptoms. His discharge x-rays were much improved from today’s x-ray. I was fairly certain he was improving and after he was discharged he continued to improve but then started to get worse. He was a very sick individual and needed to be placed back in the ICU.

So I called the ICU doctor to let them know about this patient. This patient needed a central venous line. This is a catheter that is placed into a major vessel like the internal jugular carotid to give better access for medications and fluids. Placement of a central line is bread and butter of emergency medicine. We place them all the time. The ICU senior resident came down because she wanted to learn how to do a central line. She asked me if I would show / teach her. I said yes. We started to do a central line. We had to avoid doing a central line on the right internal jugular which is where we normally like to do it, because this patient had dialysis catheter on the right. This meant we had to place the central line on the left. I begin to show the senior resident how to do the central line. We were both in our sterile gowns and she was having difficulty getting in the vessel. After several attempts I asked if I could show her personally and do central line. I proceeded to show her how to get a central line in the femoral. I was able to get the vessel. However when I advanced the wire it became difficult to advance, so I stopped. This could have been due to a clot in the vessel, my attending tried a couple of times but was unsuccessful.

The patient’s blood pressure had significantly improved and he was maintaining his vitals. We decided to get him up to the unit and place the line later if he needed that level of access. The patient was talking and he said he felt fine and thanked us as he was transferred up to the ICU. He was checked into the unit and was stable.

A little while later I heard a code RRT (Rapid Response Team) called to the ICU and I had a feeling it was for this patient. It turned out that he was talking on the phone when he just suddenly slumped over. He was found to be in a-systole (essentially dead). He was revived 3 times before finally died. He most likely had a big pulmonary embolism. He most like would have died from his worsening pneumonia given his near zero CD4 count.

Ultimately I was able to follow up on this patient and it turns out the he had a large saddle pulmonary embolism in his pulmonary arteries that came from a DVT (deep venous thrombosis) in his lower extremities.

These cases rock your world every time.

Trauma Surgery Rotation

2011-01-15T19:43:00.000-08:00

It is January 10, 2011. Today I started a new rotation which I am fairly excited about, but it will be a difficult rotation. The rotation is trauma. Some people might ask; “isn't everything you do trauma?” and that's a good question. Trauma is its own sub-specialty within emergency medicine and within surgery. Many hospitals are Level 1 trauma centers. That means that they are equipped and have the personnel to handle any kind of trauma, the most severe trauma and there are trauma Level 2 centers which do not handle all of the major traumas, but can still handle fairly significant trauma and then it drops off from there to trauma Level 3, etc., on to minor. What is a Level 1 trauma center? Well, that means you have a trauma service that is there on call 24 hours a day, you have neurosurgery available 24 hours a day, and you have an emergency department with a trauma center and it can handle and treat blunt force trauma, penetrating trauma, gunshot wounds, fire burns, and the sickest of sick trauma patients. The Level 1 centers will also have a surgical ICU (SICU) where the patient can be treated and managed following the trauma and the surgery required to fix the trauma.

I am at a Level 1 trauma center in an urban setting. As you can imagine we get some very severe trauma cases on a daily basis. Today I started my rotation by showing up on the surgical floor at 4:30 in the morning to meet the trauma team and I was assigned four patients who were already admitted to manage. So in addition to that taking care of trauma patients who are recovering in the SICU, I also have the responsibilities is to respond to all the Code Greens in the hospital. Code Green is an announcement that there is a trauma case that is coming to the hospital or already at the hospital. “Attention, will the trauma team please report to the trauma bay” is the announcement made throughout the hospital. The announcement is heard by everyone through the overhead paging systems. Each of the members of the trauma team also receive a text page through their pagers. I will go along with the rest of the trauma team down to the emergency department to wait for a trauma that's coming in and help treat the patient once they do get there.

Today was a particularly busy day. We had I think eight Code Greens. Several were pedestrian versus automobile, so someone was hit by a car and you can imagine that the injuries are severe, the car always wins, and so it was an interesting day and plus I had a gunshot wound to the leg and someone who fell and fractured their skull. There's all kinds of trauma patients that come in. So once we go down to the emergency room and manage the patient. Basically that entails securing the airway, if they need intubation I'll intubate them, doing an ultrasound FAST exam to check for any internal bleeding. We fully inspect the patient, cut their clothes off and look for any wounds or deformed extremities or cuts, lacerations, and do a general assessment of what's wrong with the patient. Then do all the imaging, X‑rays, CT, whatever's required to look for any fractures, particularly spinal injuries, and then we also repair any lacerations. Then if the patient has the kind of wounds that would require immediate surgery they are whisked off to the operating room where whatever the necessary surgery is to be done. So they either go into surgery or if surgery's not required then they go to the trauma surgery service floor where we continue to manage them as a trauma team until they are better, go home, or transferred to another service for whatever reason. So right now we have 15‑plus patients on our service plus whatever comes in overnight tonight, so it's very busy and tomorrow I'm on call, so that will be a long day but certainly an interesting day. I'm sure I'll learn a lot. So I'll be on this service for the next month and I take call every third night so the hours will be extraordinarily long. It should be fun though and I imagine I will learn a lot and it is a good adrenalin rush to treat the trauma patient.

Pediatric Emergency Medicine

2011-01-04T15:14:00.000-08:00

Wow, here I am at the end of another rotation and I have even written one post about it yet. I have a few more shifts so I better get crackin'.

I am on Peds/EM rotation which is doing shifts at 2 different Emergency Departments that have dedicated Pediatric Emergency Centers. Across America in most hospitals the emergency department sees all patients whether adult, child or infant. EM physicians are trained to see all of these patients. I would say that on any given ED shift I see 20 - 40% of all the patients I see are pediatric. So far this year I have seen lots of kids on my various rotations.

However everyone gets a little tense whenever we have a really sick child that presents. I feel like we can always use more pediatric training. My residency gives us several dedicated pediatric emergency rotations. This month I have been doing shifts at 2 different pediatric emergency departments. I show up for my shift and only see sick kids the entire shift. It has been great for my training and learning to solely focus on pediatric emergencies and illnesses.

I have seen a lot of sick kids and some not so sick kids that had very worried parents. In pediatric populations you almost have 3 patients per room, the child and the parents. Often you have grandparents as well.

There is a fellowship offered after completing a residency in EM that allows you to further specialize in just pediatrics. It is 2 years. Not a lot of doctors choose to do this fellowship because most ED's do not have a separate emergency department just for kids.

This rotation has been a great learning experience so far. I will post some of the cases.

Flash

2010-12-15T15:03:00.001-08:00

Unless you love your life will flash by..

Another Night of Call, ICU

2010-12-13T13:52:00.000-08:00

These are the details of one night, one call in the Medical ICU. I happened to be on call overnight for the Medical ICU and my day started about 4:00 in the morning. I arrived to round on some of my patients that I had been following in the ICU. I think I had three or four patients that I was following, all relatively sick. One patient with advanced end stage metastatic cancer.

Another patient who was on a ventilator with end stage liver disease, alcoholism, portal hypertension and bleeding varices which are veins on the esophagus near the stomach and the esophagus where they meet and those have a tendency to bleed and they bleed profusely and patients often bleed out and die. Then I had another patient who was for all intents and purposes brain dead on full life support while family was trying to determine what they should do or if they should do anything to prolong the patient’s existence. There was no way to really prolong life because the patient wasn’t that brain dead, and then I had another patient who was there on a ventilator who had had acute respiratory failure and the complications that go along with that.

So I was rounding on those patients and seeing how they did and adjusting medications, adjusting vent settings and gathering data from the night before, and so my day started at 4:00 in the morning in rounding on those patients, and throughout the day, like from 4:00 in the morning until 5:00 at night I continued to manage those patients, take care of those patients and other patients that we had on the unit which entailed calling specialists, again changing medications, ordering different imaging tests or different diagnostic tests on the patient. Around 5:00 I began to take calls so at about 13 hours into my day I start taking calls, so all the other residents and physicians go home for dinner. I stayed and for the night and I stayed at the hospital on the ICU and begin to take call.

The night started rather swell. I didn’t have a lot of calls to begin with as far as admitting new patients. Mostly just calls on the patients who were already on the floor, from the nurses maybe asking me to come and examine the patient because they looked they were getting worse or questions about can we give the patient this kind of medication, or oh, the patient’s blood pressure is low and it’s time for their blood pressure medication. Should we hold the medication and these kind of things, and those kind of not swell enough to where I could go to bed and not busy enough where I felt like I was hurried and running around.

Then about 8:00 at night, shortly after a shift change of the nurses, they change at 7:00 at night, things really started getting crazy. So like I don’t know if it was my lucky day but the ER was extraordinarily busy and patients who were already on the floor seemed to be getting sick and we had a lot of open beds in the ICU and the patients just started coming one after another. I had, now when you’re on the ICU those beds are held for very, very sick patients, but as the hospital fills up and all the other floors become full, you still have beds at the ICU that are available, often times you might fill those beds with what we call Kelly boarding patients. So these are patients who may not normally be full fledged ICU but need to be monitored for heart problems or potential heart problems and the floor telemetry where they normally go is full and you start getting boarding patients and I started to get some of these kind of patients so the telemetry unit filled up pretty quick, and telemetry unit is a unit that monitors the heart constantly.

Of course on the ICU we monitor the heart constantly but we’re also monitoring other things. So my first patient was a patient who had been sober for several years. Decided to start drinking again. Went on a bender and was found unconscious in the street. Brought into the emergency department and began vomiting copious amounts of blood, coffee ground emesis and because he was losing blood very quickly he began to bleed out in the ED. They stabilized the patient and gave the patient blood. Got him kind of maintained safe level and then transferred him up to me in the ICU where I continued the management, giving more blood and actually put in a central line in the patient, and right as I was admitting that patient, got another patient who had a third degree AV block which is an emergency. The heart is blocked and the patient in need of temporary pacing for their heart so they can get a full pacemaker, and so that entailed, I got the patient up on the floor and put in a central line or I put in a line to the internal carotid artery and fed that catheter if you will down right down about to the heart, just into the heart, and it was a triple lumen catheter and I called cardiology fellow then came over once I had the line in and we put in an intravenous pacer. So it’s a little heart pacemaker that is temporary. It would get in through the catheter I put in and into the heart and then pace the heart, and these are always tenuous situations because a patient’s heart is to the point where it can give out at any moment and until you get that line in and the pacing in you’re kind of on pins and needles because the pacing pads that you have on are not the greatest pacing pads and really it’s touch and go, so it’s kind of a very careful hurried insertion of a line and getting the pacer and so I paged the fellow. Let him know I was starting the central line. Got the line in. He showed up and together he let me put the transvenous pacer in and we got that patient stabilized and it seemed while I was doing that two more patients started coming to the floor and so it was like this for several hours. Just like a crazy busy night.

On top of that I had several of the patients who were already there have problems and needing attention and was getting called by the nurses at all times. So the night just continued to go and by the time I was able to actually take a moment to breath and go to the bathroom, I looked at the clock and realized it was 4:00 in the morning. So I had been there a full 24 hours at that point, and had two more patients coming up. So by the time I finished my call at nearly 7:00 in the morning I had admitted nine patients overnight as a load as far as the covering the ICU and I couldn’t even count how many other orders or things I did to manage the existing patients. I was beat. I think it was a record; an intern admitting nine patients overnight in the ICU and several procedures. Nobody died and it was a successful night from that standpoint. Many patients got better, but about 7:00 I finished my call and the other physicians started coming in, and I went back to managing the patients that I was directly in charge of, and rounding with the attending physician and the morning went on with managing just my patients and also signing out or telling the other physicians coming in about the patients I admitted and who would take those patients, the nine patients I admitted, and all in all that took me up until about noon or so, and then I was post-call and able to leave. So that was by far the most busy night I’ve ever had. It was go, go, go, very sick patients, lots of procedures and not a lot of downtime so it was kind of a crazy night.

So obviously I’m not going into all of the nine patients that I admitted but needless to say they were very sick and so quite an experience and when I finished I felt pretty good that oh, gee, I can handle these very sick patients and I was fortunate and lucky enough that I was able to avoid any disasters or near disasters and got through the night, but I do not want another night like that to occur ever again if possible but I’m sure it will, and that was my call in the ICU.

Critical Care Medicine Life in the MICU

2010-11-20T15:14:00.001-08:00

Today I was working in the medical ICU again in the urban hospital, the Inner City Urban Hospital. I arrived there about 4:30 in the morning and the on-call senior resident was slammed. The whole unit looked like it was hit by a tornado; and so right as I got there, plenty early to help out, I received a bonus in the form of a very sick patient who had been transferred over from another unit without any information about her. So this was an inter hospital and inter department transfer. A dying, crashing patient.

Normally when I am not on call, I get there at 4:30 or so; 4:00, sometimes 5:00, whatever, and my job is to take current patients that we are already managing from days before. I am not responsible for new admissions when I am not on call. I start to see these patients in the morning and work on their current problems and treatments. Generally the person who was on call, particularly at 4:30 in the morning, is responsible for admitting those patients and later in the day we will help with new admissions. This was above and beyond my duties, but they had had a rough night, so the senior resident said, "Aw please take this patient in Room XYZ and she's very sick". And I said, "Well, what can you tell me about the patient". She said, "Aw nothing. They just dumped her here. I'm not sure who it is." That is how my day began. I went into the room to see a elderly lady, probably 91 years old, with extremely low blood pressure, you know, 50/palpable, meaning I couldn't get the diastolic. You know, normally 120/80 is normal. This lady was 50/who knows what. So diagnosis, or differential diagnosis in that kind of a scenario often includes sepsis or cardiogenic shock and there's a couple of other things that can cause that kind of presentation. Often with elderly patients, particularly who had come from a nursing home, sepsis is high up on my list for diagnosis. I looked at some of the medications that were running and from the department that had transferred her over to me, it became apparent that they thought this patient must be septic because of the treatments they were using.

However, this patient didn't look like a typical septic patient. It seemed like something else was going on. So I immediately began to assess the patient and examine the patient and found some notes about the patient and tried to sort out what was going on, but in the meantime, the patient was awake and her gag reflex was protected, meaning she wasn't about to lose her airway. So my first and foremost priority was covered and I did not need to intubate her to protect her airwaiy; but she was sick nonetheless and I needed to get her blood pressure up. I noticed she also had congestive heart failure. I did not want to slam her with IV fluids because you can essentially drown a patient who has congestive heart failure if you give them too much fluid.

My options were to give her pressors, which are medications that help your heart and vascular system move blood. I did an EKG, a chest X-ray, started some fluids very carefully and started her on medications, which brought her blood pressure up. That bought me some time. I started some antibiotics, in case there was some sepsis going on, and then I started to look at the patient's care to kind of see what was going on and basically the story was this was a "semi healthy" patient, but we weren't sure if she had dementia or not, who was transferred to our hospital from another hospital a few days ago; I think on Sunday, where she had presented to their emergency department for something we call altered mental status, confusion, and they admitted her and then realized the scope of her treatment that was required was beyond their hospital abilities and so they transferred her over to our hospital.

Initially she was on a general medical floor and then as she progressed to get sicker and sicker, at 3:00 in the morning, they decided to transfer her over to the ICU, and shortly thereafter I came into her life.

It's kind of like detective work to a certain degree. I just started reading her charts and notes and found some family members' numbers. I ordered a bunch of labs. As some of her labs are came back my suspicions were confirmed that this was not sepsis nor was it necessarily cardiogenic shock. I noted she had coronary artery disease and congestive heart failure and that was bout it. So I ultimately got a hold of some of her family members and had to talk to them about do not resuscitate, do not intubate and update them on their mother's situation, and I was able to find out that on Saturday night they were with her and she was fine, not confused at all. Then Sunday she started to get kind of tired and confused and that's when they decided to bring her to the other hospital. This information shed some light on what was going on and I was able to ask them about some of her past medical history.

As the day went on, her hold on life was tenuous at best. She was hanging on by a thread and I kept having to manage her medications to kind of keep her from crashing and ultimately, by late afternoon of balancing her medication, we never had to intubate her, but by giving her some forced oxygen, she was able to start turning around. Finally I did a 2-D echocardiogram, which is like an ultrasound of the heart, and was able to determine that she has pulmonary hypertension and basically a pretty bad heart, and so that gave us an idea of what was going on. It turned out it was a multifactorial combination of things that was causing her, to be sick and she's not out of the woods, but she is much more stable tonight than she was this morning when I inherited her. It will be interesting to see how she does over the next few days. In talking to her family, she is full code, meaning they want us to resuscitate, they want us to intubate if necessary.

This patient was one of the five patients that I was in charge of taking care of today. She took a lot of time because she was very sick. These are the kind of patients you take care of in the ICU. Another exciting day in the medical ICU.

ICU Medicine (MICU) The sickest of the sick

2010-11-18T18:53:00.000-08:00

It is the middle of November, and I have started a new rotation. I am now working in an inner-city Medical ICU, it is called MICU. These kind of rotations are always slightly horrendous because the hours are extraordinarily long, the patient pathology and acuity is extraordinarily complex, and it's just all around an intense experience. You're dealing with the sickest of sick patients with the worst of the worst diseases and often they are dying, so how this rotation works is generally I report at 4:30 or 5:00 in the morning to the Medical ICU floor and pick up anywhere from three to four patients for that day; some of them might be patients I've been following from the day before, some of them might be brand new patients that came in overnight, some of them might be patients that somebody else was following the day before. Essentially I go in and examine each of these patients and check with the nurse who was there overnight with them about any new events or new complaints, and I write up a note that kind of explains what is going on with the patient and their disease, processes, and any new findings like laboratory findings, vital signs. A lot of these patients are on breathing machines or respirators/ventilators, and I might have to adjust the ventilators depending on the labs that have returned whether the patient is acidotic or alkalotic, and I have to check all of the sites where they have tubes or catheters placed and look for any signs of infection or other problems. So, I do this. It takes a couple hours and so by 7:00 or so, I present to the senior residents my findings and what I found and then they kind of go from there and present to the attending physicians kind of the course of the patient's evaluation and treatment and then we meet and then while they're doing that I continue to write my notes for the day which unlike emergency medicine notes, tend to be very long and elaborate, small volume novels written about every aspect of the patient's treatment and care. So this takes a little bit and somewhere around I don't know 10:00 or so in the morning while I'm in the middle of this, we meet with the attending physicians and round on the patients; all of the patients on the ICU.

This particular ICU has 16 beds, and there's generally three or four interns and two seniors and so we have the patients divided up and then we go and see each of the patients with the attendings or the physician who's in charge. We get quizzed and grilled about their condition and differential diagnoses and what could be going on and what medications should we start or what settings should we do or what kind of imaging studies do we need or labs, etc., etc., and we might be rated about the course of treatment or evaluation, and we look at any films like X‑rays, CT scans that have recently been done and we're asked and grilled about the findings, and so we look at the X‑ray and attending physician will say okay what is this here, what causes this finding, where is the catheter or central line on this X‑ray or whatever, and so you kind of have the whole pain there while the attending physician grills you and might say well what kind of bacteria can cause this pathology, and okay well what kind of antibiotics are best for this pathology, and you may know the answers, you may not.

The supervising physician will keep going until he stumps you no matter what, so this takes an extraordinary long period of time and you kind of go through and everyone takes their turn getting abused and then once that is done, three or four hours later into the afternoon and you go back over the patients that you were managing and examine them again, writing more notes on them, and you might change any course of therapy or add therapy depending on recommendations from the attending physician, and oftentimes, many of his recommendations are why don't you get infectious disease involved or pulmonology involved or nephrology or cardiology depending on the illness the patient has, and so you spend the afternoon tracking down the various specialist and telling them about the patient and asking them to see the patient and following up on different things. So as this goes on, somewhere around 5:00 or 6:00 at night, everything is finished up, and you're allowed to leave. So you get there at 4:00-4:30, leave 6:00 sometimes 7:00 and then every fourth or fifth night you have the pleasure of being on call, so when you are on call, you come in that day at the same time 4:00-5:00, and you follow the same schedule I just explained. However, at about 5:00, 5:30-6:00 when everyone else is starting to leave, you take sign-out which is where the physicians taking care of the patients that you are directly in charge of will update you on their condition and what kind of things are going to happen overnight or what you should look for, what you should treat and then they leave. Now, generally there's two physicians on call; a senior resident and junior resident like myself, but instead of covering 14 beds, we're covering 28 beds because we also cover while we're on call the floor that is right next to the Medical ICU which is the progressive CCU or progressive Cardiology Care Unit, so there's 14 beds there with patients who have severe coronary or cardiac illness and so overnight as a junior resident you are covering the PCCU or the Cardiac Care Unit which are all patients you are unfamiliar with because you've been working the days over on the other ICU. So, that's kind of how it goes, and so when you're on call, you stay and you get there at 4:00 in the morning, and you stay all the way through the day, through the evening taking new admissions and putting in orders for patients that need stuff, coding patients, or you're running CPR or announcing patients dead or whatever may occur overnight, and like I said admitting all the new patients that come in overnight, and this basically keeps you up all night so the next morning, 24 hours later at 4:00 or 5:00 when the team comes back, you start the day like you would any other day picking up new patients and examining them, write notes on them, and the difference is you stay until about 11:00 the next day, and you do presenting to the attending physician and then once 11:00 or noon hits, you are free to go and then you go home, go to sleep, and start all over the next day.

This is how the ICU works. In addition to my daily responsibilities, I do call every few days for the CCU. I started the rotation this week and it's my fourth day on the ICU. I have had one call so far and a whole bunch of interesting cases and very, very sick patients. You may be asking yourself why does an emergency medicine physician, need ICU training? Given the current disaster of emergency room crowding we end up housing some of these patients for a long period of time so not only do we have to know how to stabilize the very sick patients, get them on the breathing machine (ventilator) but we also have to know how to continue to manage these patients because these patients will not actually leave the emergency department for even up to a day and so while they're in the emergency department, as our patients as an emergency physician, we have to know how to continue to manage their critical illness before they get up to the ICU, so it's great training but it's a different flavor of medicine. It is important as an ED physician that you have good ICU training.

Emergency Medicine, Orthopedic cases

2010-11-13T19:37:00.000-08:00

A couple of days ago I had another shift at the community emergency department in an urban setting and it was a busy day. I saw 17 patients in about a 9-hour shift and I saw all kinds of patients. The day went by in a whirlwind because I was busy, busy, busy. I had a couple interesting orthopedic cases. Oftentimes we see these things in the emergency department and treat them and send them home and they may or may not need any follow up after an accident.

I had a gentleman who was hit by a car. This emergency department, although in a community, is tucked off on a very busy road and oftentimes we get motor vehicle collisions or MVCs or MVAs for motor vehicle accidents and this one was pedestrian versus car or car versus pedestrian, however you would like to say it, and usually it’s not difficult to figure out who’s going to win in that kind of a confrontation. The car wins every time. This gentleman was crossing the road and was struck by a car going maybe 20 miles an hour and had his leg run over and was rather fortunate considering the circumstances. He was brought in by an ambulance and when I went to examine him it became very clear that his main injury complaint was his right foot and ankle, and when I examined him I quickly saw that his right foot was twisted in the wrong direction, and that’s where most of his pain was coming from.

I examined him completely from head to toe for other injuries that may not be apparent at first and when I found no other injuries, I returned to examine the right ankle and foot and it was an unstable injury. So I sent him to X‑ray. I gave him some pain medication first and then sent him to X‑ray and when he returned it was clear he had fractured his tibia and fibia, and also had another fracture in his ankle and so his foot was completely unstable and could pretty much turn it any direction. I did not have any doubt there were fractures but we needed the X-ray images to fully diagnose the damage. The fractures needed to be reduced. I sedated him and reduced the fracture and put it in a splint and because of the nature of the injury, and it was unstable, he definitely is going to need surgery to repair the broken bones. Through the reduction procedure we were able to get it more stable and reduced it back to where it needed to be and into a cast until he can get a surgery.

The other case I had was a postal service worker who goes and delivers mail door to door by foot, and he came around a corner and three mad lunatic dogs, as he described them, charged him and he sprayed them and they continued to charge him as he ran backwards, and there was an incline in the yard that he didn’t see as he was going backwards and he fell back and landed on an outstretched wrist. He fractured his wrist in two places. He had a radial and an ulnar fracture and he was in a lot of pain. This was a stable fracture and we gave him significant amounts of pain medication to ease his pain, and then after we got an X‑ray that showed these fractures it needed to be reduced or set. We gave him some conscious sedation and waited until he was significant unaware of his surroundings and reduced the wrist to get it back in its place and he will not need an operation, just a cast and he should heal just fine.

In the emergency department we see orthopedic injuries all the time. These are just a couple from one of my shifts that I treated in the emergency department.

Suicide by Tylenol

2010-11-09T18:26:00.000-08:00

What happens when you decide to take several hundred Tylenol in an attempt to kill yourself? You think about that for a little bit. Well, let me tell you. Generally, you're going to end up dead or a very painful and excruciating terrible death or you are going to end up with a ruined liver needing a liver transplant on the transplant list and suffering and if you get a liver, well, you might live, but your life will never be normal again and if you don't get a liver you'll die like in the first scenario. So faced with in this past emergency medicine shift I worked, a young individual and presented after swallowing several hundred Tylenol and he was found vomiting and next to the toilet by his family and there was an empty Tylenol bottle and they only can assume he took the whole thing. It was a sad tragic case, so, what do we do. Well, the first thing we do is when the patient gets there, we make sure the patient is stable and then back in the day they used to try to make the patient vomit. They also used to try to do gastric lavage (pump the stomach) to flush your stomach. That's no longer the usual approach any longer. c

There is an antidote to Tylenol poisoning, it's called N-Acetyl Cysteine. We make sure that the patient is currently stable, not losing their airway or seizing or in some other form of immediate life threatening catastrophe. Usually, on presentation, they're just sick. We assess their vital signs run some labs to test their liver function and measure their Tylenol level and we also do a tox screen to measure other drugs including aspirin, that they may have taken, we can start to gauge how real the Tylenol or acetaminophen overdose is. N-Acetyl Cysteine basically prevents the Tylenol from being metabolized into a toxin that kills your liver and so then you can get rid of the remaining Tylenol without metabolizing it into a poison. Sometimes a person really does a job like this individual did, even with the greatest medical care and quick medical care, sometimes will not save the patient. Sometimes you can't beat the suicide attempt that the patient attempted and in this case unfortunately this patient had done such a number on himself and even with the antidote he died before our eyes and was successful in his suicide attempt.

Suicide is never an easy case to manage and the sad part is dealing with the family after the fact and those that are left behind. That's probably even harder than dealing with the patient themselves, so Tylenol is not the answer.

Febrile Seizure, partial seizure and Lumbar Puncture (LP)

2010-11-05T11:30:00.000-07:00

It was about 2:00 in the morning when I was typing my notes on the night shift for a patient that had presented with chest pain. I was doing the usual workup to rule out a heart attack when I heard the radio go off and the paramedics and EMS say that they were bringing in a 3‑year-old boy with fever who may have had a seizure in the night. I barely even heard it. It was kind of almost in my subconscious as I typed away about my patient with chest pain. In fact looking back I think it was more like my subconscious heard it. I continued to ponder about my patient wondering if he in fact was having a heart attack or maybe it was anxiety or some other kind of chest pain, costochondritis, another form of chest wall tenderness, pneumonia . It could have been a whole bunch of explanations for his chest pain and I didn't have his EKG back and was thinking to myself about how I was going to move forward with his management.

About 20 minutes later and a couple patients later I happened to be coming out of an exam room and the paramedics were there in the entryway with the 3-year-old child on their gurney and two young adults that looked like they must have been the parents and two older adults who looked like they must be grandparents and the child was on the gurney screaming and crying obviously in discomfort. I looked up barely to even notice the patient as I had two or three other critically ill patients and the paramedics said hey doc, what room should I take her to. So, I motioned to them to take him over to one of the side rooms and let the family know I'd be in there in a minute and I told the nurse, to start getting the patient hooked up to monitors, etc. I thought to myself "oh this is going to be another febrile seizure", not a big deal. We see these all the time. I entered into my office room to continue to chart on another patient. There was something about the child's cry or maybe it was the parents' faces I thought to myself, you know I better go and see this patient, this 3-year-old boy real quick and see what's going on. I went in there and he looked uncomfortable and he looked "sick" and his parents were definitely scared but the parents are always scared. I went over to the boy and looked at him to see if he was postictal and he did not look right to me. I continued to talk to the parents and the nurses were scurrying around to get the orders that I had put in for the patient, getting a temperature, hooking the child up to the heart monitor and getting an IV access, etc., etc. As I explained to the parents what a febrile seizure is and the nurse says to me "doctor, this kid's temperature is 105". I said okay, give a Tylenol rectal suppository stat and at this point the mom was starting to cry and I put my hand on her shoulder and explained to her that we're going to take care of her child and just as I was explaining this the nurse yelled out, "hey doctor, pulse rate is 280".

I stopped mid-sentence with the mother and immediately went to the patient's side to begin further examination and looking at the patient, immediately noticed that the patient was having some kind of a seizure, not a toniclonic seizure where the patient is unconscious and their entire body is shaking all over but this looked like a partial seizure to me, where the patient appeared to be awake. Both of his legs were stiff and plantar flexed and his right arm was contracted almost like he was having a stroke. The parents could tell by the look on my face that this was a little bit more serious than I had originally thought and I had the nurses move the patient over to the trauma bay so we could prepare to intubate the child and further manage the child.

The nurses took the patient to one of the resuscitation rooms and I explained to the parents what was going on and what I planed on doing to treat their child's illness. Once over in the other room my attending physician finally came in and I was preparing to intubate the child and I was giving medications to stop the seizures. It's always difficult when you have a sick child. You have to remember the pediatric doses and all the treatments are slightly more complicated because you are dealing with a much smaller patient. Everyone is on their toes when you have an innocent child suffering, it just creates a slightly more intense atmosphere. I let the parents and the grandparents stay in the room the entire time. They stood at the child's side and comforted him while what must have seemed like a ball of confusion whirled around them. So, we gave the child medication. We called respiratory down and prepared to intubate the child. After two rounds of medication I was able to get the child's seizures to break. I was able to get the child's temperature from 105 down to 101 and ultimately was able to intubate the child and it is no small task to intubate a small child, especially with the parents and grandparents in the room and get the child hooked up to the ventilator and we were able to do a spinal tap and start antibiotics and then get on the phone with a pediatric ICU hospital and have the patient transferred over where they had the facilities (pediatric ICU) to continue the long term treatment for the patient.

I have not yet heard what the pathology was in this case. I think that the child had meningitis or some other infection causing these high temperatures leading to the seizures. However these seizures where not like the typical febrile seizures, so there may have been additional pathology going on with this child. He was healthy without any problems up until this point and hopefully he will return to his normal healthy state but you can't be sure. I will follow up with this case to see what ultimately happened. Hopefully his parents quick response and our quick medical management prevented any longterm deficits from occurring. We did everything we could in a quick fashion; stopped the seizures by bringing the fever down and giving anti-seizure medications, we performed a spinal tap to diagnose meningitis if in fact he had meningitis, we started broad spectrum antibiotics to cover for infections including meningitis, protected his airway by intubating him and finally we got him to a pediatric hospital where he could receive further care and evaluation.

The overnight shifts in the emergency department.

2010-11-03T22:06:00.000-07:00

I would have to say that I like the overnight shifts. There are many reasons why I like these shifts. The administrators are missing in action, they only work from 9:00 - 5:00. It is a "when the cat is away" situation. Also the patients that come in to the ED are often interesting individuals. You still get all the life threatening illnesses but sprinkled in with the real emergencies are these fantastic characters that come out of the woodwork. You really can't make up these stories. It is a "real life is stranger than fiction" situation.

The other night I had an interesting patient. She drove herself to the ED on her hovearound scooter that was paid for by her public aid money, also known as tax dollars. This was a lady in her late 40's that weighed about 380 - 400 lbs and had been smoking since she was 9 years old. She was on disability and received disability funds. She assured me that she in fact had her last cigarette on her 3:00am scooter ride into the emergency department. Never mind that she asked if she could go out for a smoke 30 minutes later.

I asked the patient what her life threatening emergency was and she explained that she "felt winded"and could not fall asleep. She did not have any immediate life threatening emergencies but because she came to the ED we had to work her up and make sure there was nothing acutely going on. She demanded meals, drinks, warm blankets and something for her pain. I explained that chain smoking for 40 years can make anyone winded and that large consumption of nicotine and red bull will make it difficult to fall asleep. After running some tests and lab work and making sure she was not having an emergency I discharged her and she reluctantly went back to her scooter chained to a tree in the parking lot and rode home.

Although this case is pretty sad on so many levels, it makes the night shift a little more interesting.

A Drunk Pilot?

2010-10-31T14:27:00.000-07:00

Right now I’m working several overnight shifts, so I work from like 10:00 at night until 7:00 the next morning roughly. Sometimes it’s 9:00 until 8:00 the next morning or 9:00 the next morning, but anyways, last night I had a shift. This was Saturday, overnight, October 30 and so in the early Halloween morning. I arrived at the hospital for my shift, I wasn’t sure how busy it would be. Generally Saturday nights are pretty busy at this emergency department with all kinds of things, car accidents, traumas, headaches, fights, heart attacks, strokes, lacerations, you know, everything you can imagine comes rolling in and on top of the usual given that it’s a holiday or day before a holiday where people go out and become exceedingly inebriated, I was prepared for just about anything. Parties, public drunkenness always increases what we are going to see in the emergency department.

I got to the hospital, and it was kind of busy, not super busy, but it started off with a unpleasant case which was a rape and when somebody is raped and presents to the emergency department, there is something called a rape kit, which is a actually a legal document. It’s a kit that once it’s opened, has to be kept with the same person the entire time until it’s handed off to the detectives. So, it’s always a difficult handful of these I’ve had to deal with and treat and basically it is a very unpleasant experience for everyone involved, but particularly obviously, the victim and so you try to be extra sensitive and not have them repeat their stories a bunch of times. But you also have to do quite a few invasive things and procedures to document and collect evidence. I won’t go into all the details because I’ll try to keep this a somewhat pleasant blog, but there’s no way to keep this pleasant.

Anyways, the rape kits tend to take a long time and are complicated. The data has to be gathered, clothing, specimens and fluid and all this has to be documented a certain way and then handled in a way that you can then turn it over to the detectives at the end and so that was a tough case to start with, and then throughout the night I had various different cases, some complex, some not so complex, and ended up seeing quite a few patients.

I had a gentleman that presented, originally I was told it was a pilot, who had been beat up. When I went in to the room to examine the patient, it turns out it was a drunk person dressed up as a pilot at a bar who had fallen over, become injured and had several lacerations on his face that needed to be sewn up. So, it was quite humorous and a lot of the staff thought that this poor pilot’s been attacked, but in reality it was a drunk individual dressed as a pilot who had not been attacked, but had actually fallen over on his face and broke his nose and cut up his face. So, he was rather unpleasant, belligerent, intoxicated and I calmed him down and convinced him to let me suture his laceration closed and get the proper imaging studies and make sure he didn’t have a head bleed or anything like that, so that was kind of our more humorous case.

Often times in the emergency department the people you are treating are inebriated or intoxicated on some substance. They don’t want to be there and they are rude. They’ll try to spit on you, try to hit you, try to attack you, yell and scream at everybody and generally make everybody’s night a little more miserable. You’re trying to help them and trying to fix their wounds or illnesses and it’s definitely not very appreciated. In fact, you often have to be careful or you’ll catch a fist yourself or be kicked or spit on or whatever, so that case was a little bit humorous though because everybody was worried about his pilot that turned out to be really just a drunk bum dressed as a pilot in the spirit of Halloween. So that case was interesting.

So this is a small sampling of just a couple of interesting cases from the night. I had several. I am on overnight the next several nights so I’m sure I’ll have more stories to tell and to share, but in the meantime, be safe, don’t drink, don’t do drugs, don’t eat too much and wear a helmet and wear your seat belts and be safe.

Another ED shift, Intubations, Lacerations,

2010-10-26T15:00:00.000-07:00

I had another shift at the community emergency department in the urban setting. This morning I worked early morning until, I guess, kind of early in the evening. A 10 hour shift. I started off the day with the first patient who was an individual who had a head laceration that was bleeding; she lost lots of blood. The scalp has a lot of vessels that feed blood to it, so when the scalp is cut it tends to bleed profusely. This laceration required me to irrigate the wound, clean and explore the wound. I had to make sure there’s no foreign bodies in the wound and then make sure that I could clean the wound and close it properly. This laceration was on the back of the patient's head. I decided to use staples and I put 4 staples in the scalp to close the wound. The patient had fallen and hit her head and had lost quite a bit of blood so we kept her for a while and ran some labs to make sure that she hadn’t bled too much.

I was in the middle of caring for the 1st patient when I got pulled out to run to Resuscitation Room 1 where we had a nursing home patient who was found to be nonresponsive and brought in by paramedics. I got in there and his vital signs looked fairly stable but he was having some difficulty breathing and getting the proper levels of oxygen. So, ultimately, the decision was made by myself and the attending to intubate the patient so I went through the process of getting the proper medications and the equipment ready to intubate the patient so he could be hooked up to a ventilator, which is always a flurry of excitement and commotion. So, fortunately, this was a less difficult intubation for me or, maybe I’m getting better at it or possibly he was just an easier patient. Regardless, I was able to intubate him without any problem and get him hooked up to the ventilator settings. Once he was stable enough, we sent him down for CT, we had noticed while we were examining him that he did have what looked to be like a shunt under his scalp in the skull area. We didn’t have much of a history from the paramedics or the nursing home so like a lot of times we are sort of going on what we can find on the patient and he was nonresponsive so we figured he was having some increased intracranial pressure from something related to a shunt in his head, we sent him down to CT scan. He, in fact, did have a shunt and it did look like to me that his left side lateral ventricle was enlarged but it’s hard to guess because we didn’t have a previous study to look at and compare. Ultimately, this patient went to the ICU. I had to page neurosurgery and explain the details of his case and convince them that this patient was worthy of being seen by them and they came down to the ED and actually saw him in the emergency department, which is often rare so I must have done a good job convincing them to come down.

Neurosurgeons are extraordinarily busy and don’t like to be bothered and can be kind of rude or seemed bothered over the phone but I had all the information that they needed so when I called them they were not annoyed with me and came down. Those were two of the patients that I had today. I could continue on and on and tell you about all 20 of the patients but I’m trying to pick and choose some of the more interesting cases.

I did have a run of the mill kidney stone patients and I also had a patient I diagnosed with or gallbladder disease. I did a bedside ultrasound and found a gallstone in her gallbladder and I admitted her for a cholecystectomy. She’ll probably have the surgery tomorrow. So, anyways, it was a good day, long and tiring day. That’s how the emergency department can be. It’s just a non‑stop, running, running, you never know what’s going to come through the door and I guess, maybe , that’s what I like about it. Anyways, have a good day.

Emergency medicine in an urban community emergency department

2010-10-25T15:45:00.000-07:00

I have started a new rotation! I am working at an Emergency Department in a community / urban setting. Today my Emergency medicine shift at urban community emergency department was extremely busy. So I had several patients today that were very interesting in nature. It started early in the morning and it was busy right when I got there.

First patient was an anaphylactic shock for a bumble bee sting to the hand that required some sub q epinephrine to prevent worsening of the anaphylaxis. I had another patient, I'm not going to tell about all of them, but this patient had a panic attack, he was a young male who had recently quit smoking marijuana, he was kind of having a paranoid / panic attack. I also had a family who had some stomach gastroenteritis and vomiting, stomach pain, and diarrhea. I had a four-person automobile accident trauma brought in by paramedics. The driver was a 23-year-old female who had been driving her nieces and nephews. There was total of four in the car going, I don't know, she was traveling at about 60 miles an hour, ran into another car then bounced off the median. All of them were in seat belts and remarkably all of them were fine. The driver was the worst injured. She lost some blood due to a large laceration on her forehead that was about 6 centimeters in length, and a laceration on her nasal bridge. The forehead laceration required four 4-0 vicryl sutures that I buried the knots to bring the forehead laceration together, and then I threw about eight 6.0 ethicon nylon sutures to close the forehead wound and additional sutures were needed for her nasal bridge laceration as well. Fortunately for her all of her CT scans of her head and neck and chest and pelvis were unremarkable, no abdominal perforations or head bleeds or broken bones. We also did several X-rays and there were no broken bones but she was pretty shaken up. A 10-year-old, a 5-year-old and a 2-year-old in the car as well who also had various injuries but nothing life threatening.

I had a gentleman who came in, an older gentleman with an acute attack of gout which required a procedure. I had to put a needle into his knee to tap I delicately inserted a needle into the joint space and was able to get the fluid out so I could send it to the lab. The lab was able to analyze it and it came back and it turned out to be a flare up gout rather than a septic knee. I also had a couple patients, that were not too interesting, just an alcohol intoxication and a drug overdose that both needed medical attention.

A lady came in with severe mouth / tooth pain. She had a dental abscess and had been turned away from five dentists' offices because of her diabetes and hypertension. I was able to examine her and determine that in fact she did have a tooth that has essentially decayed down to the root and really needed to be pulled but she had an abscess and some severe 10 out of 10 pain. I was able to give her I.V. pain medication in addition to a nerve block in her mouth to block the pain that was causing her to almost become suicidal so she got a regional nerve block in her mouth and a nerve block around the tooth and abscess itself which helped her tremendously. So this was a crazy shift where I saw at least 15 patients with varying ranges of acuity from pretty moderate/mild to near life threatening.

That was the day in this urban community emergency department. This particular emergency department does not have other residencies so as an emergency physician in residency, I get to do most of the procedures whether it's an incision and drainage of an abscess or a vaginal issue that needs to be taken care of, we don't call the other specialties, we just do most of the procedures and handle it ourselves. So that was my day and I am sticking to it! We will see how tomorrow goes. It will be just as busy and probably just as crazy. It is just how Emergency Medicine goes, and I happen to love it.

On Call Postpartum Hemorrhage management

2010-10-11T20:00:00.000-07:00

The other night I was on call overnight and had an amazingly busy, scary, enlightening and highly educational night. I should have known I was up for a crazy call night when during sign out at the beginning of my call I was paged to the floor where a woman who had just recently delivered was hemorrhaging out. I quickly ran to the patient's room to find a panicked nurse and an even more panicked husband to see blood flooding out of the patients vagina. I would have to say that OB is probably one of the more bloody specialties. It seems like I am constantly changing my scrubs as they get drenched in blood .

I immediately assessed the situation and realized that this had to be postpartum hemorrhage due to uterine atony or a laceration that had re-opened. I decided to go with the bimanual uterine massage because as I examined the patients abdomen I could tell that the uterus was in fact atonic, which means the uterus has failed to retract to its normal size and remains stretched out. This leads to massive hemorrhage and actual can cause maternal demise if not treated quickly.

Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute hemorrhage. Clinically, 75-80% of postpartum hemorrhages are due to uterine atony.

I place my whole hand into the vagina until I reached the uterus and squeezed down on it while using my other hand to squeeze the uterus by pushing on the patient's abdomen. You essentially mash the uterus between your hands on the inside and on the outside. This is painful for the patient and has to be performed quickly to reduce the risk of death. This procedure is effective and can dramatically reduce the bleeding and get the uterus to regain its tonicity.

Fortunately this procedure worked and the massive hemorrhage began to subside as I continued to massage the uterus. I was sweating but remained calm which in turn calmed the family and the patient. I uttered out a few orders for the nurse to hang some medications and lactated ringers in addition to calling for some labs to determine how much blood was lost. These labs helped determine whether we needed to transfuse the patient.

Ultimately the patient did not need a transfusion and following the uterine massage I found a laceration that was up on the vaginal wall that needed further suturing. Most of the bleeding had stopped due to the uterine massage and the medications and I was able to stop the remaining trickle by repairing the laceration.

This was the start of my 24 hour call and I was only 1 hour in to my shift. I knew the night was going to be a blast. I love this job.

More to come….

Babies babies everywhere NSVD and a nuchal chord

2010-09-26T20:14:00.000-07:00

I had my first night of call on the OB/GYN service the other day. I actually had a blast. I covered the MBU (Mother Baby Unit) and Triage as well as L&D (labor and delivery). I had a Medical student, junior resident and a senior resident to help cover everything except the MBU, that was all mine. If I do my job well as the on call intern then the junior OB resident and especially the senior OB should not have to do much and they can have a more relaxing night. The more I can do and cover and the better I do it the less they have to do.

It was a crazy night to say the least. I am only 1 week into this rotation so I am still learning all the little details of how the OB service works. For example; how do they like their notes written, how to use their computer system, what medications do they like to use etc. These are all little details that you have to learn at the beginning of each rotation and this makes you less efficient at the start of the rotation. I felt like I pretty much had all the details, tasks, protocols down going into the call which was nice.

I told the other residents that I was ready to rock & roll, and they were relieved. Some residents like to try and avoid the work which makes the other residents work harder. They were great with me taking over and using them for help as needed. They were there for me and I learned so much during that 30 hour shift. I delivered 4 babies over night. All 4 were NSVD = normal spontaneous vaginal delivery. It was great. One delivery was fairly difficult with and required maneuvers and techniques that were great to get to perform and get that much closer to mastering these techniques. I had one baby with a nuchal chord which is when the umbilical cord is wrapped around the neck. You have to move quick and be looking for this complication so you can quickly reduce it. I found it right away and immediately reduced the cord which decreased the risk of hypoxia for the infant. I was thrilled when this baby had APGAR scores of 10 at 1 minute and 10 at 5 minutes!

I also delivered a baby of a lesbian couple which was an interesting / fun social situation. They were great and both actively involved. I delivered the baby and almost asked the more masculine girl "Hey dad do you want to cut the umbilical chord?" However, I caught myself before saying anything and simply just asked her if she wanted to cut the chord and her response was great; "HELL yeah doc!"

OB/GYN as an Emergency Medicine Doctor

2010-09-21T20:32:00.000-07:00

I started a new rotation this week. I am on OB/Gyn. Many ask why do you have to do an OB/Gyn rotation / training as an EM resident? Well, we see a whole bunch of OB/Gyn in the ED. Nearly every shift in the ED I have several patients "OB/Gyn" chief complaints like (not an all inclusive list); vaginal bleeding during 1st trimester, STD complaints, yeast infections, UTI's, rape, abnormal vaginal bleeding, pre-eclampsia, preterm labor, full term labor, fetal demise, pregnancy related complaints, etc.

It is crucial to be proficient at pelvic exams (speculum and bi-manual). Although it is not as common as it once was there is still several deliveries done in the ED by the EM physician every year. As part of my training I have to show proficiency in OB/Gyn management common in the ED. I have to deliver a enough babies to graduate and become board certified. Obviously we are not required or expected to be on the same level as OB/Gyn physicians but we do need to handle the emergency type OB/Gyn complaints.

Many STD's are more commonly diagnosed in the ED than in an OB's office in certain areas. There are some OB/Gyn complaints that ED physicians will see more often than OB/Gyn physicians given the current use of the emergency department. When the complaints are beyond the ED physician's skill set OB/Gyn will be consulted. Every attempt will be made to have the delivering mother deliver in the Labor and Delivery department when possible but this does not always occur.

Finally EM doctors will see lots of emergency traumas, illnesses and disease states that happen to pregnant patients. If a pregnant patient has a seizure they are brought to the ER. Anyways this is why we spend a good amount of time doing OB/gyn training during our residency. I want to be clear that EM doctors are not the experts when it comes to OB/Gyn. Certainly our skill set in this area is not near their level of expertise.

Today was a great day. I delivered 2 babies. One was fairly complicated and the other was fairly straight forward. Both were vaginal deliveries. It is always a great feeling to share that moment with a happy couple when they bring a healthy child into the world and when you deliver it their gratitude and thanks is always a great reminder of why I love my job.

Radiology, Fractures and the ER

2010-09-15T09:43:00.001-07:00

I have heard people say, "The ER doctors missed my broken arm (fill in whatever bone you want, like nose, finger, ribs, etc) on the Xray and when I went to my doctor he saw the fracture clearly." How does this happen? A patient comes into the ED with a "chief complaint" like "I got punched in the face". The ER doctors will assess the situation and make sure there is no life ending injuries or limb loss threatening injuries. Part of this process will include imaging studies like Xray depending on what the doctor is looking for related to the injuries.

The patient gets wheeled to the Radiology department where the image studies are completed. The ER doctor will look at the Xray or whatever imaging study is completed while he / she awaits for an official read from the Radiologist. The Radiologists are highly specialized in reading these images. Often the ER doctors can read the images themselves before the official read is completed but even then they will still often wait for the Radiolgist's read to confirm the diagnosis. In the end, the Radiologist is making the call usually which is really who you want making the official call.

Often times when a person fractures a bone and it is not an obvious fracture, like a compound open fracture or a complete separation bone fracture, picking up a subtle fracture on an Xray in the first 24 - 48 hours can be impossible. The swelling and the inflammation will make it difficult if not impossible to see many fractures that occur. In these cases the doctor will read the Xray and wait for the radiology read as well which will be ambiguous because t radiologist can't see if there is a fracture at this point either, then explain to the patient that there may be a fracture and that follow up with their doctor is recommended after 3 - 7 days or so depending on the injury. If the doctor has a high suspicion for a fracture but it can't be verified by the Xray he/she may say I think that you have a fracture and here is the treatment plan.

ER doctors do not like to put a full cast on in the ER right after an acute fracture. Often the swelling has not stopped yet and so if the ER doc puts a full cast rather than a splint on the fracture and the swelling continues under the cast, the patient is at great risk for compartment syndrome or essentially swelling to the point where damage occurs in the area that is casted because there is no where for the swelling to go. So you will almost always get a temporary cast / splint in the ER and then have follow up with Orthopedics for a full cast once the swelling has subsided in 5 - 14 days depending on the fracture. Usually a good ER doctor will set the fracture and splint the area, give good pain control and care instructions with a referral for a full cast once the swelling has subsided. The patient will then go to the Orthopedic doctor where they will Xray the area again and make sure the fracture is healing properly and then put a full cast on if needed.

As you can see, even a simple fracture is not so straight forward in medicine. Nothing is simple given our current environment but there usually is an explanation for why things are done certain ways. The main problem is that most of these doctors do not communicate these things well to their patients so the patients have no idea what has happened. Even if the ER doctor does communicate well to the patient, they inevitably only recall about 10% of what they were told. They come in and are told "the Xray did not show a fracture... and here is a splint... follow up with Dr. Ortho in 1 week." They go to Dr. Ortho who then takes an Xray and says "You have a fracture..... and now I will put a cast on!" The patient says "The ER said it was not fractured....." Dr. Ortho says "they do not know what they are talking about.... it is clearly fractured so here is your cast, and your bill.."

By the way I am doing Radiology and Anesthesia this month, hence the quip about radiology. I think that the Radiologists are great!

Intubation

2010-09-07T23:18:00.000-07:00

All specialties in medicine like to claim their turf and mark their territory. The cardiologists, no doubt are the gurus of the EKG and managing chronic heart disease. The Nephrologists own the kidney, dialysis etc. Surgeons, often think they own everything but they do own the surgical procedures, no questions about that. Emergency doctors have to know all of these things but are not the best at many but do have a few areas they own.

Resuscitation (running codes), airway management and other acute medical emergencies are what EM doctors like to claim as their expertise. Airway management can sometimes be a turf war or a battle with Anesthesia. Anesthesiologists intubate (manage the airway) everyday. Every surgery that requires general anesthesia requires the patient to be intubated and it is the Anesthesiologists who do this day in and day out. This is done under a nice peaceful controlled environment with lots of time and the patients are stable and usually the intubation is nothing more than routine.

In the emergency department the Emergency doctors do intubations as well, but these are Rapid Sequence Intubations (RSI). It is a different game all together. These are critically ill patients who are often crashing and the airway must be managed and protected very quickly in a high pressure atmosphere. This type of intubation or airway management is what Emergency Physicians like to claim as their turf. There usually is not much argument or turf battles when it comes to Rapid Sequence Intubations. Funny, no other specialty is trying to steal or take this procedure from the EM docs.

Anyways this is a brief introduction to intubations or airway management as I am currently on an anesthesiology rotation right now and doing several intubations / day. The boring peaceful, relaxed kind that Anesthesiologists are no doubt the masters. I am learning a lot and there is no better way to fine tune my intubation skills than to intubate lots of patients. I have had to do a good number of Rapid Sequence Intubations while on EM rotations but not enough to fell super comfortable, so this rotations is the perfect tool to get my technique and motor skills where they need to be for intubating.

Moving Flesh

2010-09-02T23:03:00.000-07:00

It was a hot Saturday afternoon and I was working an extremely busy 12 hour shift. I was in the middle of my shift and had not stopped. The wait for patients to be seen had crept up to about 4 hours. The ICU was full and our ED was full We were starting to board patients in the hallways and up against walls. It was a little crazy. In the middle of all of the nonsense patients backing up the ED we had our real emergencies coming in at a nonstop pace. Gunshot wound, Stabbing, Myocardial Infarction (MI), Motor Vehicle Accidents (MVA), Stokes, etc.

I was charting on a patient I had seen and trying to catch up on some of my documentation when I smelled an unpleasantly familiar foul odor in the air. I immediately knew someone was rotting. Flesh that is rotting has a very distinct smell. So I looked around my shoulder and noticed a patient on gurney boarded in the middle of the ED. There was no room in the inn. She was older and it looked like she had some family with her. She did not look acutely ill from where I was sitting. I decided to investigate and make sure she was not a ticking time bomb waiting to expire.

As I made my way to the patient the smell became even stronger and I noted that her foot was wrapped in gauze all the way up to just below the knee. I knew that I needed to unwrap the bandage, but I also knew that upon unwrapping the wound would unleash an odor potent enough to induce vomiting in staff and other patients that had not acquired the ability to coexist with such potent odors. It would have been an unpleasant thing to do and or inflict upon those in the ED minding their own business.

I went over to the Charge Nurse and explained that I needed to take a look at this patients leg but that I needed to do it in a room where the smell could be somewhat contained. She agreed and quickly pulled a patient complaining of an "itchy hand" out of a room and gave the room to my patient. I went into the room and continued to speak with the patient and the family to get a proper history and perform a physical exam. I was excited to see what was behind curtain number 1. I put on my gloves and began to slowly unwrap the gauze bandage and immediately the odor became 10 times more apparent. I looked up the the patient's son was vomiting into the sink but the daughter was holding strong and only gaging. The nurse had to excuse himself from the room. I continued to reveal the wound. Once I had the entire bandage removed it was clear to see that this was a serious wound. She had gangrenous flesh and an open wound with exposed bone from the middle of the shin down to her foot.

I noticed that the wound was "sparkling" in certain places so I moved in closer. I noticed a rippling motion within the wound. The daughter said "why is the flesh moving?" I reached into the wound and pulled out a maggot and removed some of the dead flesh only to reveal several maggots enjoying their lunch. I explained / showed the daughter the maggots and the rotting flesh. I cut away much of the dead flesh and cleaned the wound. I could not appreciate any pulses. The lower leg was unsalvageable and would need to be amputated.

I did all the cultures and lab work and started some powerful antibiotics. The patient was admitted and later taken to the OR for a below the knee amputation. She was fortunate that she had not become septic.