Straight Talk from the Stanford ER

One Stop Shop

2008-05-06T13:53:00.000-07:00

I went into emergency medicine because I wanted to be able to help any person and do it anywhere. The field offered a body of knowledge I could use to help any patient that might enter the emergency department. Of course, it did not take long to realize how much my ED care relied upon other specialists, nurses, medical devices, and the vast resources of the hospital. In a neighboring blog Paul Auerbach describes medicine with far less resources as he has been doing for years in wilderness medicine. For me, I come closest to my initial goals of broad and independent care on the basketball court and through the questions posed by friends and family. It is those questions from family that are the most difficult and perplexing.

Largely because of the type of injuries pictured above my current gym bag now contains tape, splints, ice bags, hot packs, and bandages. The picture is my pinky after a jump shot gone wrong. I remember looking down and seeing my pinky pointing to left while my other fingers pointed straight ahead. Without thinking my normal hand reached out and straightened the finger while I gasped in disbelief. Luckily, the normal hand made the right decision by reducing the dislocation. It hurt, but at least the pain was somewhat mitigated by fulfilling my life's ambition, providing immediate medical care, and buddy taping my little finger to my ring finger.

Injuries as shown in the picture to the left require a higher level of care but one that I am still able to independently address. In this case, a rebound gone wrong, my eyebrow was split open by one of my ED attendings. It is for this reason that I have lidocaine, sutures, and a sterile laceration kit in my house. The truth is that I still needed some assistance to repair my orbit but the laceration kit is ready for a more accessible wound.

By far the most difficult cases I have ever encountered have been those posed by my immediate family. Surely, they think that I should be able to solve any medical problem they encounter. Unfortunately, the solvable problems such as a laceration, fracture, or pneumonia go directly to the ED and unanswerable questions are left for me.

For instance, my sister's boyfriend is 38, and two days ago noticed this bruise on his back. He has an improving pain located at the midline of his lower back and this rash, which has happened 5 times in the past in a similar distribution. He did not experience any trauma, and did not have any prior medical problems or associated symptoms.

Once I ruled out alien abduction I did not think he was in danger but I did not know the origin of his bruise. Since he was not going to seek further care based on my telephone estimation of his condition, I did feel obliged to verify that he was safe to heal on his own without a clear answer. To make sure I polled my dermatology colleagues who probably could post a similar blog about such alternate channel medical questions. The dermatologists did not have a confident explanation but believe that he was safe.

So far residency has given me some of the tools I hoped to obtain but it has also shown me that helping people is more complex than I originally believed.

Beyond Recognition

2008-04-02T14:21:00.000-07:00

She came to the Emergency Department, burned beyond recognition. She arrived in complete anonymity, and that is how she remains. I had just finished seeing a patient one early morning, when I heard the Paramedics enter the Emergency Room. I smelled her charred flesh, I heard her wheezing for every breath. This patient was supposed to be a "minor burn," as announced: they wheeled her past me, I saw her struggling for life, skin falling off of her face and hands.

She was homeless, and had caught on fire, we have no idea how, or why. Possibly a cooking stove, or camp fire. Her hair was a desiccated clump of char. The skin on her face was completely blistered and swollen. The skin on her hands and forearms dropped to the ground. She could hardly breathe, we started breathing for her.

We worked quickly to remove her clothing-parts of her back were blistered; these burns were more extensive than we had thought. We quickly began to think about how to best treat her. We worked to give her reprieve from the pain: we induced a coma, and started her on strong pain medication. We placed a tube in her throat to aid in her breathing: the back of her throat and vocal cords were singed black. She finally lay calm before us, unaware of the damage brewing beneath her seared skin.

Now that we had her airway secured, we could thoroughly assess her burns and try to stave off the other "burn nasties," as vocalized by the Chief Surgeon in charge of the burn unit that night: Dehydration, Swelling, and Infection. The skin holds water in the body. In order to estimate the amount of fluid she would need to maintain adequate oxygenation to the rest of her tissues, we had to characterize the extent of her burns: how much and how deep?

We quickly calculated the extent, or how much of her body surface area was burned by using the "Rule of 9's": the head and each arm is 9%, the chest and back are 18%, and each leg is 18%. Our patient had approximately 30-35% partial to full thickness burns of the face, head, back, arms and hands.

Next we characterized the depth of her burns. Instead of using the terms "First, Second, and Third Degree Burns," we now classify them according to their "thickness". Superficial burns involve the very top layer of skin only, and are usually red, like a sunburn. Partial Thickness burns involve the superficial and deeper fat layer of the skin, and are characterized by skin blistering. Full Thickness burns are burns through all layers of the skin to the muscle-these burns are the worst and are most prone to get infected and need skin grafting. They are usually white and without feeling. Our patient unfortunately had mostly partial and full thickness burns.

The fluid dripped from her fingers and arms, forming yellow pools around the bed. There was no skin to hold the liquid in her body. We acted quickly to replete her fluid loss by placing a large IV in her groin, and began giving her much needed fluid, and antibiotics.

After an hour we still had no answers as to where she came from, or what had happened to her. By this time her fingers and arms had become so swollen due to the massive amount of fluid we needed to give her just to keep her alive that she began to lose circulation to her fingers. We assisted the Burn Chief with performing an escharotomy: cutting through the thick fibrous scarring of the burns in order to relieve the pressure. Using electrocautery, we cut long, deep lines down her arms and fingers. The skin splayed open, oozing liquid.

Burns are one of the hardest injuries to cope with as an Emergency Room Physician. Not only do the victims suffer terribly from pain, and sometimes disfigurement, they also may have protracted recovery due to multiple skin grafts and infection. I visited our patient two weeks later in the burn unit. She lost her fingers, and part of her right arm. She has had no visitors. We still do not know her name. She remains on the ventilator, and infection has set in. We have been her only comfort, her only voice. The raw emotion of treating burn victims is extremely difficult to process. This patients’ situation is beyond comprehension.

She still lays in complete anonymity.

Shot in The Dark

2008-03-01T19:00:00.000-08:00

“There is a sniper out there,” the paramedics stated matter of factly as they wheeled our patient into the trauma bay. “This is Jose, he is 25 years old, he was walking to the store this evening when he heard a loud ‘pop’, and felt a sting on the left side of his neck. He is bleeding from a small puncture wound over the lateral portion of his neck, and there is noted swelling. He denies any airway compromise, his vital signs are stable, we have an IV established …we think he was struck by a pellet gun…this is the sniper’s 5th victim.” A pellet gun? Sniper? What is going on here? Apparently there is a vigilante perched in a window overlooking a busy San Francisco street corner. His targets? Drug dealers. He has taken matters into his own hands: shooting dubious drug dealers on the street corner in front of his apartment. He has shot 5 people so far, most have walked away-or walked to jail-with only welts, after the shooter alerted Police of their illegal business activities. The problem is, no one has any idea where he is, or when he will strike again. He remains elusive…investigators are waiting patiently for the next shooting. We have begun our own investigation in the Emergency Department: Jose’s healthy appearance and small wound may be concealing significant damage to large vessels in the neck.

Our first order of business is to ensure that Jose has no compromise of his airway. He had swelling over his neck, but he was able to speak clearly, and was breathing comfortably. We undressed him to locate any additional wounds-just the neck. We had no idea how close the shooter was to Jose: “I heard the shot come from above, a few seconds later I felt a sting,” Jose said. Below Jose’s left ear was a small puncture wound, no bigger than an eraser head, a small amount of blood oozed from the wound, surrounded by about 2 inches of swelling. “There is no way there is a pellet in there,” one of my colleagues stated…”most of these wounds are just tissue damage, you would be able to feel the pellet…look feel.” I felt the wound…he was right, no pellet. I just was not convinced. The investigation continues. Outside, “pop,” a sixth victim, a SFPD patrol car near the corner hears the shot, and notices a figure duck from a 3rd story window…

We need to find this pellet. Using my best sleuth hat, I set off to make certain that my colleague was right, or wrong, about that pellet. I had just the trick to find it.…like a detective searching for hidden clues, I turn to my most powerful instrument…behold, the mighty Ultrasound. Ultrasound, in its simplest terms is a device which emits sound waves, like sonar, into tissue. These waves are bounced back to the machine, and based on whether it is bone, blood, fat etc, an image is created. The machines are now smaller, more portable (about the size of a small brief case), more powerful, and are an essential piece of every Emergency Department physicians arsenal.

Just as a stethoscope gives us insight into the inner workings of the human body, the ultrasound machine is the “ultimate stethoscope for the 21st century, and has become our best investigative tool. We use it for every trauma victim in the Emergency Room, looking for any evidence of bleeding within the abdomen, collapsed lungs, or injury to solid organs. We use it to look for gallstones, for evidence of damage to the Aorta, and to evaluate pregnancies. We can look to see how well the heart is squeezing, or if it is surrounded by fluid. We have used it to diagnose pieces of glass and metal in the eye, to look for abscesses in the arm in order to drain them, and to find large blood vessels buried beneath the skin in order to start intra-venous fluids.

I place the ultrasound probe on Jose’s neck over the wound. I notice the tissue of the neck, and the great blood vessels pulsating beneath…no pellet. I think to myself, “he was shot from above…the pellet, if fired from a high powered gun would have traveled downward…and inch, an inch and a half?” I move the probe down….Eureka! Sitting less than 1 millimeter on top of Jose’s carotid artery is a bright shiny round pellet!

All trauma victims are “guilty until proven innocent of injuries.” Once again our ultrasound machine puts the questionable injury to the test. Jose had a Computed Tomography Angiography of his neck to ensure no damage to his Carotid artery. Luckily there was none. Unluckily for Jose, a father of 2, he just happened to be at the wrong place at the wrong time. He left the ER with a small souvenir of his visit with us. Meanwhile…the police knock on the third story window apartment door, a man answers, smoking a cigarette, in his boxer shorts….it is the “vigilante shooter.” He unexpectedly runs, and jumps out his third story window. Our next trauma victim is on his way.

Attack of the Zebras

2008-01-30T15:40:00.000-08:00

An 80 year old mentor, and Physician once told me, “being a good doctor is not understanding the typical presentation of uncommon disease, but rather the atypical presentation of common disease.” I have tried to keep these words close as I have journeyed through Medicine…but it is difficult. We naturally want to gravitate, especially in Emergency Medicine towards the “Zebras,” or those disease states which we feel will cause the patients the most harm, (even though they may not be that likely): “Sir, you say you are having chest pain, and it feels just like your heart burn? Well it could be…but it also could be a heart attack, an aortic dissection, a pulmonary embolism etc...” We as Emergency Physicians are trained to think this way; we do not want to miss a disastrous diagnosis. We need to watch for the Zebras while herding the common cow. (Forgive me for the coarse analogy.)

Mikey was a 4 year old boy, who was born with a hypoplastic left heart, a severe seizure disorder, and was found to be confused and disoriented one recent afternoon by his mother. In the pediatric Emergency Room at Stanford, we are used to seeing sick children, with many underlying complex diseases. Mikey was no exception. The left side of his heart, which pumps oxygenated blood to the rest of the body, failed to fully develop. He needed a series of open heart surgeries to correct the problem. In addition, Mikey had recently developed epilepsy, or seizures, which he needed to take medication for.

When the paramedics brought Mikey into the Emergency Department he seemed very sleepy-he was unable to keep his eyes open, and the only noise he would make was an occasional whimper. He would respond to a loud voice or a slight shake, but then...out again. Although his heart rate, oxygen saturation, and blood pressure were normal, I was obviously very worried about him: this was a child with a complex medical history-could this be a cardiac problem, was it neurologic? Did he have a seizure? His mother assured us that his “heart was great, he just saw the Cardiologist 2 weeks ago, and had an echo-he was given a clean bill of health.” She also informed us that he had been taking his seizure medications, but “he is acting like he did after his last seizure.” I asked if anyone had witnessed a seizure…”no,” she replied, “I work at home and was in my office all day, but the Nanny was with him all day…she sticks to him like glue…”

“She sticks to him like glue…” I kept reiterating in my head. What was going on with Mikey? I was fairly reassured that this was not a primary Cardiac, or Pulmonary problem-his vital signs and physical exam just did not fit this picture. We ordered a chest x-ray, and EKG to be sure. He MUST have had a seizure-I wanted to get a CT of this child’s head, and to check his Dilantin level (the medicine he was on for his seizures)…I queried the mother again…”Do you know if he hit his head recently? “, “No,” she replied. “Has he been sick recently?” “No,” she replied. Any vomiting, diarrhea, history of diabetes, fevers…”No, no, no, no…” The Zebras, hoards of them, were doing laps inside my head….

A moment of clarity broke through the shadowy dust of the dancing Zebras…my attending, intrigued by the case, asked me if “the child could have taken, or ingested any medication.” That is a great thought I remember thinking…the mother’s response…”the Nanny is on him like glue…” We give him his Dalantin, all of the medication in the house is up on our pantry shelf, he cannot reach it.” She assured us that there was no ingestion of any toxic or illicit substances…”the Nanny…you know,” she replied. “Why don’t you just send off a urine toxicology screen my attending implored…you never know…this is our job to find things like this you know…” I agreed to send one, in the off chance we might stagger across something…but meanwhile, back to this child having a full blown neurological problem…I need to call the neurologist now!

“Get the child to the CT scanner as soon as possible, and I will be down to look at him,” the neurologist replied. Meanwhile, Mikey was still lethargic, he could not even hold his head up, or keep his eyes open. Intermittent whimpers and shaking reminded one of the abnormal trouble this small person was going through.

An hour passes…the CT of the head is normal, the Chest x-Ray is normal, his EKG looks great. His labs are all normal, including the dilantin level. His urine is clean, no sign of infection anywhere…meanwhile Mikey sleeps, no sign of waking, or really doing anything child-like soon. “He had a seizure, and is still very post ictal (or dazed from the seizure),” was the final conclusion of the Neurologist. “We see this all of the time, if these kids have a big enough seizure, they can be out for a while. There is also the chance that he is still seizing…” We agreed to watch him for another hour, if he was not awake, we agreed to admit the child for more intensive monitoring….

An hour passes. Still no change; the incessant hum of a busy Emergency Department getting louder, as more kids get checked in. I page the neurologist to inform her about Mikey’s lack of change, I grab another chart while I wait her call. Just then I see my Attending, smiling from ear to ear, “Sean, did you check Mikey’s Urine Toxicology Screen?” she asks with a mischievous grin….ohhh that thing, I forgot…

In one of the few Perry Mason moments of discovery in my career as an Emergency Medicine Resident, I look up the Tox Screen: Opiates-NEGATIVE; Amphetamines-NEGATIVE; THC (Marijuana)-POSITIVE….whoa…POSITIVE?? Just then the mother appears…”I KNOW WHAT HAPPENED, I KNOW WHAT HAPPENED, come here quick….” The events were playing out too quickly. I enter the room-“The Nanny” is there, as well as the father, and the mother is holding what looks like a bag of cookies? “Mikey was playing in his father’s car, and found these, he ate the whole bag: 100% hash cookies, keep out of reach of children!” “His father has bad back pain, he buys these in San Francisco.”

Mikey was stoned out of his gourde. He was alone in his father’s car for up to 2 hours eating pot cookies. The Nanny admitted to cleaning clothes and talking on the phone. Mikey was admitted, and eventually returned to earth almost 6 hours later! It is so easy to focus on the Zebras, or look for the common presentations of rare disease when you must first consider the cow, or the strange presentations to an ordinary sickness. Ingestions of any kind in children are not rare. I wanted Mikey to show me his stripes with the words “hypoplastic heart,” or “Epilepsy,” but a good doctor shouldn’t always be chasing zebras.

Leap of Faith

2008-01-15T09:58:00.000-08:00

“Oh my God!” I exclaimed to my wife as we neared the restaurant. A nice day out with the family, driving to lunch, abruptly changed by our gruesome discovery. Our route had been rather fortuitous: I missed one turn, made another wrong turn, got stuck in traffic, then finally we neared the restaurant. I looked over casually…and there he lay, completely by happenstance: Half on, half off of the sidewalk, a body contorted in a grotesque manner, coughing up blood, gasping for breath. I was completely caught off guard.

My wife Megan was shocked by the tone in my voice…"LOOK next to the car,” She saw him-speechless. I jumped out of the car and ran to his side. People on the street seemed oblivious to his existence. A lady on her cell phone, steps over the gnarled man, covered in blood, not missing a beat, no notion of compassion, talking, “Yea Sue, I’ll work out tonight…”

Who was he, where did he come from? Was he struck by a car…no one…myself, my wife and a stranger dying on the street. I yelled for someone to call an ambulance-no answer…my wife dialed 911. I called again...”HELP!!” I am used to dealing with crisis situations, yet suddenly I felt like an alien in a strange world. I had taken for granted the amount of help, the controlled environment we have in the Emergency Department. Patients like this come to us “packaged,” with a story. This poor soul was shattered, without a story, and was dying in front of us.

I stabilized his neck, I could feel a pulse. Finally a man on the street runs to us…”what should I do he asked?” “Let’s get him on the sidewalk!” We eased him onto level surface. He was coughing up blood, it covered my hands. He was looking right at me, through me, gasping for air. I realized part of his leg lay a few feet from his body. I held his jaw outward to ensure he maintained a secure airway. My wife screamed, “The medics are on the way!”

Someone yelled “His name is Joe…” “Who in the hell said that?” I thought. I heard the sirens in the distance. “Joe it’s going to be ok,” I kept saying to the man, knowing damn well it was not-I had to try to comfort him. I had the man hold Joe’s head as we tore off his clothes…his chest was filled with broken ribs, his legs shattered…a lady states clearly, but matter of factly-“HE FELL” I looked up, a lady smoking a cigarette on the 4th floor, curlers in her hair, points up to a balcony on the 5th floor-empty. A crowd had gathered to gawk like a strange freak-show carnival. The lack of emotion or empathy from anyone was indescribable, almost inhumane. His injuries suddenly made sense.

Joe still had a pulse. I knew the fall had severely damaged his lungs, his breathing was slowing, his pulse getting fainter, weaker. I kept telling him to hold on. He stopped breathing, his eyes were now lifeless. This was the longest minute of my life. I had nothing to help this man breathe. I was not comfortable administering mouth-to mouth given the amount of blood covering us. His pulse then stopped…the Engine Company arrived.

Described as a “Traumatic Arrest”, or loss of pulses and breathing due to a significant traumatic injury, I knew this man had less than a 5% chance of survival…do we TRY to save him? These thoughts raced through my head as the fire engine rolled to a stop. He JUST loss his pulses not 30 seconds ago I thought to myself. “I’m an Emergency Medicine Resident at Stanford, he fell from the 5th floor, we just lost his pulse.” In Emergency Medicine, no matter how complicated the patient, it always helps me to take a step back, and remember the “ABC’s”: Airway, Breathing, and Circulation…right now we had none of them.

The firefighters administered oxygen and started forcing air into his lungs with a mask. Another started CPR and attempted to start an IV. The Paramedics arrived. I now was also in unfamiliar territory…I did not want to “step on anyone’s toes”, this environment is the Paramedics territory, I needed to take a “back seat,” and let them run the show. Luckily I knew one of the Paramedics from the ER. He prepared to intubate Joe, or place a tube through his vocal cords, and into his trachea, to secure his airway. “Sean, I cannot see a thing,” he stated as he struggled to place the tube, “do you want to give it a shot?” I suctioned his mouth, and took a look: there was still a lot of blood, but we were able to pass the tube into his lungs.

This experience was truly eye-opening, and raised many salient lessons and questions for me: Why was I so under prepared to aid in an emergency like this in the field? Had we done the right thing for this man? Did I do the right thing as a Physician? Why did Joe die alone?

I was vastly underprepared as a physician in the field to deal with an emergency like this. My cars are now stocked with at least gloves, and first aid kits. Even though his injuries proved to be fatal, I feel we gave him every chance to live. After talking with several of my attendings, I think I handled the situation correctly: Joe’s care was under the direction of the Palo Alto Fire Department. They ran the call perfectly and renewed my respect for what they do day after day for all of us. (Physicians and lay people are covered under “Good Samaritan” Laws in instances like this.) Lastly, I often think of Joe. I like to think my wife and I stumbled upon him to be able to comfort him in his last moments...he really was alone on the street. I do not think we will ever know the events surrounding his death. As the ambulance left for Stanford, a lady commented to me, “That was really great what you did for that man…” “That’s what we do for a living,” I replied. That felt pretty good.

Why?

2007-12-09T15:16:00.000-08:00

“We should have known he was dying,” my Attending said to me with a somber look on her face. “These young guys always fight you when they are getting ready to die,” and that’s exactly what Rodney did-he fought us. One minute the picture of perfect health, the next, gone-his only memory the steady beep of a heart monitor, a trail of blood leaving the trauma bay. Rodney died in the operating room.

“We can’t get him controlled,” the trauma nurse yelled as the young man, bucked, and sat upright on the gurney…” “What is his blood pressure?” I screamed, “It is stable in the 120s,” my surgical counter- part replied. Two nurses had to lie across him just to keep him still. He continued to buck, trying to sit up…”Rodney it’s OK, you are in the Emergency Room, you have been shot in the arm,” I tried to call him down. The paramedics had just called us 15 minutes ago-“a single gun-shot wound to the left upper arm, no other injuries, his vital signs are stable, we are working on an IV, we’ll be there in 5 minutes…”

It was my day to manage the trauma victims who arrived at the Emergency Department. I was going to treat Rodney with the same level of suspicion, and caution as I would any other trauma patient who comes into the Department: “Trauma patients are all guilty until proven innocent from an injury standpoint,” one of my mentors, and a great trauma surgeon, had once told me. Rodney was no exception.

When he arrived to the trauma bay, his left arm was covered in blood. He immediately was consumed by the trauma staff: taking his clothes off, working on IVs, getting warm blankets. We ensured that his airway was patent…”Rodney, I’m Doctor Donahue, do you know where you are right now?” “I’m at the hospital,” he replied in a calm, strong, yet frightened voice.” Next I turned to his breathing, I listened to his lungs-his right lung sounded muffled, but he was still moving air…”his breath sounds are diminished on the right, “ I yelled, “ can we get a chest x-ray now, and prep for a chest tube…” I could not piece it together, he had been shot in the left arm, apparently no other wounds. He had strong, fast pulse in all limbs, and he had a great blood pressure, but he was becoming increasingly more agitated. “Let’s make sure we have IV access on him,” I yelled.

“Where in the hell am I-let me go! LET ME GO!!” He swung wildly at one of the nurses. It had been just one minute; Rodney was changing in front of our eyes. He seemed almost like a caged animal. Was he on drugs? Did he have a head injury we did not know of? What was he trying to tell us? “Let’s quickly look for any other injuries I yelled.” My surgery colleague and I quickly assessed for any other wounds… only one wound to the left upper arm. I listened to his lungs again-this time I could not hear anything on his right side. The surgery Resident immediately prepped Rodney’s right chest for placement of a chest tube to evacuate any blood, or air which may have collapsed his lung. It was taking three nurses to hold him down-something was seriously wrong.

“Is that his pulse,” I asked in disbelief. His heart rate was now in the 30s…it had been 120 not fifteen seconds ago…”What is his blood pressure?” The trauma surgeon screamed….”we don’t have one,” a nurse replied. Rodney had stopped fighting us. “We need to open his chest,” the Trauma Surgeon commanded, “get me the thoracotomy tray!” In an instant the Surgery Resident had inserted a chest tube in Rodney’s right lung, and I assisted the Trauma Surgeon with the thoracotomy- a procedure to open the chest cavity, and to assess for injuries to the heart, aorta, and other great vessels. Over 2 Liters of blood spilled out from his right lung- mystified as to why Rodney continued to bleed, we struggled to decipher where the bullet had gone?

Once we had his chest cavity open, we discovered his heart was empty, there was no blood inside of the chambers, and it was barely squeezing. It was obvious he had bled a lot. The surgeon clamped the aorta below the heart in order to maintain blood pressure to the heart and brain…blood continued to pour out of his right chest, and from above his heart…”I can’t tell where this is coming from, I just can’t tell…” I can still hear ringing in my ears.

Rodney was whisked away to the Operating Room. He died 10 minutes later. The bullet had entered Rodney’s left chest cavity through his left shoulder, coursed behind his left collar bone, and major arteries on that side-somehow avoiding all major vital structures. It ultimately transected his right Carotid Artery before lodging in the deep muscles of his neck. He was bleeding to death in front of our eyes. In his own way he was telling us he was bleeding to death. I do not think we could have helped him any better. Frustrated and sad are the only words which come to mind. Standing in the trauma bay after he left I felt completely numb. The monitor made the only noise in the room.

Superman Sean

2007-12-06T23:53:00.000-08:00

I am using this title not only because I think Sean is one of my favorite and most impressive people to work with but also in an effort to instigate Sean into writing about his recent experience as a first responder to a trauma in downtown Palo Alto. In a sad turn of events, someone jumped from a building and landed right next to him. I'll leave that story for him. However, I do have my own story, similar to his that underscores how multidisciplinary and interdependent our medical system is.

Sean, myself, and most other emergency medicine physicians were attracted to our field because it offered a breadth of training that seemed widely applicable. I certainly wanted to be able to help any person in any situation instead of being constrained to reading CT scans or focusing on a specific organ system to do surgery. Sean even did a residency in family practice to before these three years of training. How much more broad can you be? (I suppose he can always do surgery next). It is probably this desire of mine that leaves me feeling helpless when I encounter a medical situation away from the hospital but find myself powerless without all those people and resources I normally work with--nurses, radiologists, technicians, subspecialists, CT scanners, ultrasounds, IV fluid, and medications.

The first time this angst struck home was in my last year as a medical student, after I finished my advanced cardiac life support class. That Saturday I ran a mock code on a patient with ventricular fibrillation and rushed to leave the class so I could go biking on Canada road. It was sunny and approaching noon when I started spinning my pedals on the 25 mile stretch. Of course, it seemed like half the world passed me at my max speed. One fifty year old man and his younger friend cruised by me on a slight incline. I was surprised to discover that older man on the ground just 2 minutes later. There was a circle around him and everyone seemed perplexed. Apparently, his younger friend was a chiropractor and had started chest compressions for a 30 seconds and stopped (today I'm still not sure why).

Since he was unresponsive and soon after I checked to discover that he also lacked pulses, I found myself in the same situation I had trained for just an hour earlier. The first step of calling for help was already complete so I moved on to getting someone to start chest compressions while I alternated with breaths.

It is worth taking a moment here to clarify that this is no longer the recommended procedure for BLS. A recent study lends evidence that breaths are not needed and 100 chest compressions for 2 minutes should be continued until EMS can respond.

That recommendation did not exist at the time so I did get a lot of saliva all over the place as I attempted rescue breathing. With the chest compressions he turned from blue to pink. Still, he had no pulses and there was nothing I could do. I knew he needed paddles to assess his rhythm and probably defibrillation, vasopressin, epinephrine, and more people to help with his care.

10 minutes later, and what seemed like an eternity, the paramedics did arrive to detect his ventricular fibrillation. The first shocks he received did not bring back his pulses and the rest of the care I missed I raced to Stanford to see what happened and he headed to another hospital never to be found by me.

As I said, the incident underscored the importance of our whole medical system, every person at the hospital, and all the resources we wield to make my training useful. Of course there is more we could do as a society as Sean touched on 2 posts ago.

For those physicians who strive to be as individually functional as possible there is still wilderness medicine. Another blogger here, Paul Auerbach, has written a textbook on medicine as it applies to remote environments. Maybe I'll start reading more of his blogs and until then I'll stay grateful for any hospital employee and even the pharmaceutical industry.

Anil

Coming Soon: the Trauma Center 1.2

2007-11-15T15:44:00.000-08:00

We'll be hosting the next issue of the Trauma Center here next Tuesday, November 20th. The Trauma Center is a new blog carnival covering all aspects of emergency medicine. To be included, please send an email to lshevchik at healthline dot com by 12 midnight PST Sunday, November 18th.

A Stroke of Luck

2007-11-12T10:58:00.000-08:00

Last night, John was enjoying dinner with his wife. Suddenly he dropped his fork, a pain seared through his head. His right arm went limp, he tried to talk, but only incomprehensible slurs emerged. John at just 55 years old had suffered a massive, debilitating stroke. When he arrived at the Emergency Room a team of doctors and nurses had to quickly calculate if John was a candidate for a specialized drug therapy which could reverse his symptoms. Saving a life is a team effort. Not only must Paramedics, Nurses, and Physicians work together in perfect harmony, in a race against time, to make the correct medical decisions, but families must place their trust in those caring for their loved ones as well. John and his family had to hold out hope that all was not lost.

Stroke is the leading cause of adult disability worldwide, and is the 3rd leading cause of death in the United States (1). Last year in this country, there were over 5 Million strokes among adults older than 20, and on the average, every 45 seconds someone has a stroke, and every 3 minutes someone dies of one (1). The symptoms can be far ranging from sudden onset of weakness of a particular part of the body, difficulty speaking, or vision loss, to numbness or dizziness. Approximately 80-89% of all strokes are caused by a blockage within the blood vessels of the brain (Ischemic Stroke), while 10-15% are caused by an actual ruptured blood vessel (Hemorrhagic Stroke) (2).

Sometimes we are able to “stack the deck” in our favor of lessening the damage from a stroke. Stanford University Medical Center is a nationally recognized Stroke Center and holds many of the cards needed for a positive outcome. A dedicated team of Neurologists and Nurses, known as the “Stroke Team”, Emergency Department personnel, and Paramedics must work in concert to not only properly diagnose, but to treat and manage individuals who may be suffering from a stroke. In my career as an Emergency Department Resident, I have never seen a higher level of teamwork, or corroboration amongst care providers, as when a caring for a stroke victim:

7:15 pm: John’s wife realized that something was drastically wrong, she dialed 911.

7:22 pm: Paramedics arrived at their home. They realized John was suffering a stroke. Their rapid response, and correct diagnosis, set in place the optimal chain of events to aid in his care.

7:40pm: The Paramedics called Stanford University Hospital and notified us of a “Stroke Code.” Immediately the Stroke Team was paged to the Emergency Department. The radiologist and technicians were immediately notified to have a CT scanner ready in order to obtain pictures of the patient’s brain. These pictures help determine if the sufferer is a candidate to receive certain life saving treatments. In perfect synchrony, all necessary Emergency Department personnel arrived at the currently vacant bed…

7:48 pm: John arrives in the Emergency Department. Within minutes the general diagnosis of stroke is confirmed, and he is whisked away to the CT scanner for a more detailed inspection. The Radiologist confirms that John did not suffer a bleeding stroke, but instead, a blockage in one of the major blood vessels of the brain.

8:00 pm: Because John’s symptoms were detected within 3 hours, and because of the nature of his stroke (Ischemic rather than Hemorrhagic ), he is deemed a candidate for tPA, or Tissue Plasminogen Activator, a potent clot buster- the only FDA approved drug for the treatment of Ischemic Stroke. We explained to John and his wife that approximately 6% of patients receiving tPA suffer bleeding into the brain, but there is a 30% or greater chance of a good neurological outcome after 3 months (3). These odds are a calculated risk, and both John and his wife are willing to take the risk and proceed with the medicine.

8:15 pm: After John is deemed stable enough to receive the drug, his treatment is started. His wife sits silently holding his flaccid right hand.

“I have never been so scared in my life,” John proclaimed. His words came out crystal clear. “My right hand still feels weak, and a little numb, but I think I’ll be able to work on my truck again!” He gave me a thumbs up. John was lucky. Less than 3-5 % of patients who present with his type of stroke are able to receive this drug for therapy (1). Unfortunately, most are beyond the 3 hour window, or are too unstable, and at a greater risk of having severe complications. The dedication, experience, and efficiency of every team member involved in John’s case played a crucial role in his recovery. “We never gave up hope,” his loving wife said, “we trusted you all knew what you were doing.”

REFERENCES:
1) Adams HP Jr, Del Zopo G, Alberts MJ, et al. American Heart Association; American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke. 2006.

2) Braunwald et al. Harrison’s Principles of Internal Medicine. 15th Edition. 2369-2371. McGraw Hill, New York City, NY 2001.

3) Bellolia F, Stead L et al. Stroke update 2007: Better Early Stroke Treatment (BEST). Emergency Medicine Practice . 2007; 9,8: 1-21.

Too Many Chefs

2007-11-06T23:47:00.000-08:00

I am now in Los Angeles visiting my sister and her newly born daughter. Immediately after work I drove straight for San Jose and Southwest Airlines to see the first new member in our small family. The stark transition of my last two hours in the emergency room to the joy and hope I immediately encountered in the delivery room has left my head spinning. The ER blog about boarding brings me back to those last two hours and keeps me thinking of how I can improve my care.

Stanford Hospital is currently modernizing and expanding components of its residencies because of the surge in its daily census that often reaches capacity. For us, in the the emergency department, this means patients that require an internal medicine team and hospital bed instead wait in the ED.

In my recent case I was signed out a "boarding" patient, awaiting a hospital bed, and followed by an internal medicine team. This 76 year old woman presented with dizziness, abdominal pain, and one episode of bloody stool. She had some abnormal laboratory values which included elevated markers of infection, but otherwise looked "good." By that I mean she seemed very safe for a floor bed and medical management without any emergent interventions such as colonoscopy or invasive procedures.

Now I see the danger of her ED stay being that though she is under our care the major thrust of her treatment is being managed by the admitting medicine team. This sets up a situation where we know less about her direction because communication is difficult to constantly update between the two groups. Also, each of us may feel a little too comfortable because there is someone else taking on responsibility for her care, and being too comfortable is alway dangerous.

Needless to say, her pressures dropped near the end of my shift and after 14 hours in the ED. We called the ICU, started central intravenous lines, and transfused her with blood and saline. Soon the surgeons also showed up concerned about ischemic bowel and took her to the operating room. Though I think we all worked well together to arrive at her best possible plan, it was at times difficult to determine who should be directing her care and who had the most current information about her.

There are certainly other problems with having patients managed long term in the ED related to work load and nursing but as a resident this issue looms the largest. Next time in the ED I will try to help these patients as if I am not only responsible for them in the ED but also as a de facto member of the medicine team, pushing them on issues of care and staying in the loop.

This patient did go to the operating room with the surgeons who looked inside her abdomen and did not find ischemic bowel and then did a colonoscopy that did not show any evidence of bleeding. Her low blood pressure was most likely due to an unknown infection progressing to sepsis.

The Trauma Center, 1.1

2007-11-06T13:32:00.000-08:00

Welcome to the inaugural issue of the Trauma Center, a blog carnival covering emergency medicine. I received an overwhelming number of submissions for our first time out and would like to thank everyone who sent in a submission. So without further ado, I bring you...

Fat Doctor gives us a crash course in Japanese in this moving post about the benefits and limitations of virtual critical care.

Our own Sean Donahue, DO shares his experience treating Frank, an uninsured patient, who is a frequent visitor to the Stanford Emergency Department.

"Boarding patients in the ER is a problem, a big problem," says ERnursery. Find out more in this insightful post.

Healthline blogger Dr. Nancy Brown describes how important it is to a family emergency plan in her post In Case of Emergency.

Alexandra shares her personal experience with a staph infection in 2006.

Do you know how to survive a wildfire? Healthline blogger Dr. Paul Auerbach tells us how in this informative post.

TherapyDoc at Everyone Needs Therapy separates fact from misconception in his post Borderline Personality Disorder and the DSM.

Natural disasters and other emergencies can be especially difficult for individuals with chronic illnesses. Healthline blogger and nurse JC Jones reminds diabetics to be prepared for emergencies.

Davex presents discusses many potential treatments for acne scars.

That's it for this time. The next issue of the Trauma Center will come out on Tuesday, November 20th. Thanks for your support.

Part II: Where Do We Go from Here?

2007-10-31T16:07:00.000-07:00

...I prescribed Frank a potent steroid cream to help with the inflammation, as well as a moisturizing cream, and wrote down strict instructions as to how to care for his diseased skin. We gave him a list of free clinics in the area where he could be followed for his condition. “Frank, these medicines will cost about $30 dollars, but should last you for a couple of months….” “Thanks Doc he replied,” and walked out the door...

Although Frank may represent one extreme in the continuum of those individuals without health insurance, his story no doubt raises many salient points regarding our current system. Maybe it is too difficult to enroll individuals like Frank in the Medicaid system. Perhaps he cannot receive insurance due to his “pre-existing condition (psoriasis),” which can be a lifetime problem, and viewed as an “expense” to an insurance carrier. What if Frank was not a U.S. citizen? These are all issues which hinder our ability to be able to provide healthcare to the uninsured.

To “fix” the current healthcare system in this country, we need to realistically address 5 areas:

1) 50% of the individuals eligible for governmental programs actually enroll (1). We need to make it easier to enroll all low-income individuals who qualify into an insurance program. From an Emergency Department perspective, this idea might include using computer kiosks in Emergency Departments where people can enroll while they wait. Furthermore the standards for enrolling “low income individuals” must also be “loosened”-one must not need in addition to income, children or be disabled to qualify.

2) Of the 40 million uninsured Americans, 10-15 % have jobs but are either not offered health insurance, or cannot afford it in the private market (1). Medical Savings Accounts, or MSAs, should be an acronym that every American knows, just like IRA or 401K. These tax free savings accounts should be established by every American as a way to supplement all of their health care needs. If catastrophic illness presents, these funds may provide a much needed cushion. Whether you spend the money or not, saving for your own healthcare needs puts the individual in charge of his or her own care. In addition to insuring individuals employed by smaller companies, small businesses must receive tax and other incentives as a way to not only afford, but offer quality insurance plans to their employees.

3) Individuals with “pre-existing conditions” including a diagnosis of cancer, high blood pressure, or psoriasis, must not be excluded from being able to have health insurance-plain and simple.

4) Number of uninsured immigrants in the United States: over 10 million (2) The number of immigrants in this country without health insurance, and who are provided medical care in emergency departments, labor units, and surgical suites is astronomical, and continues to grow every year (approximately 2 billion dollars per year in California alone!). No matter where you stand on immigration reform, these individuals will still need and will use the healthcare system. The question is…who will pay?

5) Can we force people who do not want health insurance to sign up? As stated earlier, between 15 and 20 million people could afford insurance, but have decided “I am young, and healthy-when am I going to ever need insurance?” The people I know who have this attitude always, without a doubt, concede that they wish they had spent that little extra money each month (even for more catastrophic care plans) after something really happened. This can make the difference between having to pay a $35,000 versus a $5,000 hospital bill.

At this point let me reiterate the conclusion from Part I of my essay: “A large portion of the uninsured will generally go on to find health insurance (even a low estimate is 10 million), and over 15 million people just opt not to buy insurance. That leaves by conservative standards 15 million people who truly need help purchasing insurance.” Employing the methods as outlined above have the potential to help over 15 million people find insurance.

So where do we go from here? We have the ability to provide everybody in this country the best medical care in the world, and in many aspects we already do. There is little doubt people will always need help obtaining health insurance, however, the common denominator in one’s ability to obtain quality healthcare is personal responsibility….

I saw Frank leaving the Emergency Department again 2 weeks ago-new prescriptions in hand…. “lost my last ones!” he exclaimed with a toothless smile. There is no health insurance plan in the world that would actually help an individual like Frank. The reality is that there are a lot of “Franks” out there using the Emergency Department day after day, and year after year. We can throw as much money as we want at the healthcare system to help cover the uninsured, but without personal responsibility for our own healthcare, the system will sink further into disrepair.

References:
1) State Coverage Initiatives, An Initiative of the Robert Wood Johnson Foundation, “Why are People Uninsured?” July 2004.

2) DeNavas-Walt C, Proctor B, Mills R. “Income, Poverty, and Health Insurance Coverage in the United States: 2004. Current Population Reports, Series P-60. Washington: US Government Printing Office. 2004

Where Do We Go from Here?

2007-10-14T10:52:00.000-07:00

Frank is an uninsured patient. I have seen him 4 times in the past 12 months for his chronic psoriasis-an autoimmune disorder which causes a thickening and irritation of the skin. His feet and hands are thick gloves of matted, cracked, peeling skin, which bleed and cause him a tremendous amount of pain. Even individuals with the best health insurance may have a difficult time dealing with this disease, which treatment may include UV light therapy, steroids, and creams to reduce the inflammation. Frank does not have access to therapy, except what we offer him in the Emergency Room*.

Every time I see Frank, the story usually goes something like this: “Frank your hands and feet look awful.” “I know Doc,” he usually replies. “Have you been using your steroid creams like we told you?” “No Doc, someone stole my prescriptions again.” “Where are you living now?” I usually ask. “Oh in the same hotel…” “Are you still drinking?” “You bet Doc,” he replies. I asked him why he is uninsured… “Can’t afford it Doc.” Frank divulges that his only current income is from social security and “a few odd jobs now and then.” The hospital works with him every time he visits the Emergency Department to enroll him in Medicaid, but his income is too high. Because of this problem Frank “just goes to other Emergency Rooms for prescriptions.”

We are the safety net for individuals like Frank. The Emergency Department has become the last bastion of hope, the primary care office, for many individuals lacking health insurance (approximately 30% of all Emergency Department visits are for Primary Care oriented problems-for both the insured and uninsured). I was always curious what happens to the bill Frank generates after he visits the Emergency Department, so I spoke to one of our hospital’s billing managers: “We send the bill to a viable address, and then we usually never get a response.” She told me that this particular hospital’s collection rate for individuals lacking health insurance is less than 10%. “What happens then? Do collection agencies go after these people,” I asked? “No, many do not have credit, and move around so much, it is very difficult to get them to pay.” An honest, straight to the point answer.

Aside from providing care to the uninsured in a private hospital setting, I have worked over the past 5 years in 3 major “County Hospitals,” meaning a facility which is owned and partially subsidized by the city and county in which it is located. The number of uninsured patients is usually much higher. I spent a month delivering babies at one County facility in Arizona while I was a Family Medicine Resident-90% of the 102 females I helped to deliver were either uninsured or of Immigrant status. In this situation, instead of the hospital “eating the bill, (well partially)” taxes pay the bill.

So I decided to do my research. I wanted to find out why the uninsured are uninsured. Who they are, what do they do, how can we help, and what needs to be changed:

-Number of Uninsured: approximately 40 million (1). This estimate varies widely from 25 million to 50 million and includes people who are both “chronically uninsured,” meaning for more than a year, and “transitionally uninsured,” those who will regain coverage (due to changing or gaining employment, or switching plans) within 6 months. The Congressional Budget Office estimates annually that 45-55% of the uninsured under the age of 65 (all individuals over 65 are eligible for Medicare) have health insurance within 4 months (2).

-Highest number of uninsured by race: Hispanics 32%, Blacks 19%, Asians 17% and Whites 15% make up the highest number of uninsured (3).

-Number of uninsured immigrants in the United States: over 10 million (4). There is no good estimate as to the number of immigrants who are uninsured. Census data usually includes all individuals living in the United States. The best estimate for the number of uninsured individuals who are immigrants, particularly those who are undocumented, is staggering: approximately 80-90% (4).

-Uninsured rates for low-income Americans (less than 100% Federal Poverty Level) vary greatly. Many may never qualify for Medicaid, or government assisted healthcare, if they are childless, or without disability. Most people are eligible for Medicaid, if they have children. On the opposite end of the spectrum, most states estimate that fewer than 50% of the individuals eligible for governmental programs actually enroll (5).

-Number of people who can afford health insurance and do not choose to participate in a plan: 15-20 million (6). Over 8 million people making between $50,000 and $75,000 did not buy health insurance in 2005. Likewise over 9 million people making more than $75,000 did not purchase health insurance that same year.

-Of the 40 million uninsured Americans, 10-15 % have jobs but are either not offered health insurance, or cannot afford it in the private market (6). Most are self employed, or ineligible for COBRA (Consolidated Omnibus Reconciliation Act) coverage: part-time, or working in a business with fewer than 20 people.

To me, these numbers are reassuring. A large portion of the uninsured will generally go on to find health insurance (even a low estimate is 10 million), and over 15 million people just opt not to buy insurance. That leaves by conservative standards 15 million people who truly need help purchasing insurance. We still are left wondering: “Where do we go from here?”

PART II to follow….

References:
1) The Kaiser Commission on Medicaid and the Uninsured. “Who are the Uninsured? A Consistent Profile Across National Surveys” August 2006
2) The Congressional Budget Office Economic and Budget Issue Brief. “How Many People Lack Health Insurance and For How Long?” May 2004.
3) DeNavas-Walt C, Proctor B, Mills R. “Income, Poverty, and Health Insurance Coverage in the United States: 2004. Current Population Reports, Series P-60. Washington: US Government Printing Office. 2004
4) DeNavas-Walt C, Proctor B, Lee CH. “Income, Poverty, and Health Insurance Coverage in the United States: 2005” The Census Bureau Report, Aug 2006
5) Remler, D et al. “What Other Programs Can Teach Us: Increasing Participation in Health Insurance Programs,” American Journal of Public Health, January 2003.
6) State Coverage Initiatives, An Initiative of the Robert Wood Johnson Foundation, “Why are People Uninsured?”

*(The Views expressed in this manuscript do not entirely represent those held by Stanford University Hospital and its employees. Hospitals mentioned in this manuscript are not affiliated directly with Stanford University Hospital, nor do events take place at Stanford University Hospital)

Thank You Grand Rounds 3.53

2007-09-25T14:18:00.001-07:00

Thank you Kevin M.D. for including D.O. Sean Donohue's What If... post in the fourth anniversary of Grand Rounds.

Another Ordinary Day

2007-09-06T13:58:00.000-07:00

“Doc this thing is stuck in my finger!” I was in the last hour of a 12 hour shift at Stanford University Hospital. Exhausted, I was hoping for a nice easy sliver, or laceration. As I looked down at Mr. J’s finger, I was shocked at what I saw: an Epinephrine Pen lodged in his thumb. Over the past 2 years at Stanford I have been mentally and physically training myself to be able to deal with any Emergency which might come through the Emergency Department doors. This encounter was a new one: trauma, heart attacks, strokes, coughs-you name it-these are givens in an emergency Resident Physicians repertoire, but an epinephrine Pen stuck in a finger? I gently tugged at the pen, “Good luck…” Mr. J replied.

Mr. J explained that he was prescribed the pen by his primary care doctor 3 days ago after he had an anaphylactic reaction to a wasp sting. He described quite perfectly the phenomenon of anaphylaxis: “My face and wind pipe swelled up like a puffer fish, and my blood pressure dropped like a rock.” The paramedics revived him with epinephrine-the drug which counters anaphylactic reactions. I like to think of anaphylaxis as an extreme way for the body to deal with a foreign substance: your blood vessels dilate and become leaky, allowing your body to release a plethora of substances to combat the toxin. People become covered in hives, airways swell, lungs and breathing become constricted, and the blood pressure can drop to extremely dangerous levels. Epinephrine works to combat the two most important aspects of this dangerous cascade: it constricts the blood vessels, and dilates the airways.

When I looked down at Mr. J’s finger I saw what I had feared: it was completely white and cold. He told me that it felt “numb” and that he had tried to pry the needle out with a pair of pliers but to no avail. Mr. J stated that he was at home, “showing my boy how to inject the medicine…I guess I had the wrong end pointed the wrong way.” Mr. J had grabbed the pen, and held it to his thigh. Pens like these are activated when a spring loaded needle is deploying after coming into contact with your skin. He had the pen turned around (as to not inject the medicine into his thigh), and accidentally pushed the spring, releasing the medicine and needle into his thumb.

I presented the case to my attending physician-who thankfully had “seen a few cases like this before.” “First we need to counteract the effects of the epinephrine on the thumb,” he said. “Slather the thumb with Nitroglycerine paste, this will allow the vessels to dilate.” “Then, call the pharmacy and have them send up 0.5 mg of injectable Phentolamine.” Phentolamine is a drug we can use to block the effects of Epinephrine.

After we obtained an x-ray (the needle was not stuck in the bone) we realized the needle had probably glanced off the bone, creating a barb on the end…no wonder we could not get it to budge. After numbing his finger we coated Mr. J’s finger with the Nitro-Paste, then injected the Phentolamine. Next with a pair of “ER Pliers” we were able to free the barb after a great deal of force. His finger “pinked up” over the next 5 minutes.

“I can’t believe I did this, I’m so stupid,” Mr. J. said over and over throughout the course of his treatment. I think he was being overtly harsh on himself-it seems like a very easy mistake to make. If it had not been for Mr. J’s mistake, I would not have learned how to treat the next person who comes in to the Emergency Room with an Epinephrine pen stuck in their finger. We have to be prepared to treat all comers-whether it’s in the first, or last hour of a busy day.

Thank You .Parallel Universes. for Grand Rounds 3.50

2007-09-04T11:39:00.000-07:00

Thank you .Parallel Universes. for including Sean Donohue's post Saving Lives in Grand Rounds 3.50.

Saving Lives

2007-08-22T21:39:00.000-07:00

I knew it was going to be a long night. It had to be. The blood still poured from his ear. I had been working nights in the Surgical Intensive Care Unit (SICU), and our new trauma patient had just come to the floor. As I sat with Patrick watching the blood pour in, and pour out, I thought about his choice, his life. Patrick had two choices, to hold on or to let go. He chose to let go, a decision which ended his life. I knew keeping him alive, in a strange sense would ultimately save others.

Patrick was just 18 years old and had jumped onto a moving train 2 hours earlier which he was trying to catch as it left the station. Stuck on the outside of the train, it gradually gained momentum, he had nowhere to go. In an instant, he was faced with the choice of a lifetime: to hold on, or to jump. The train picked up speed, the wind rushed through his hair, the noise became deafening. He chose to let go. Witnesses said that as the train left the station he landed on the platform on the back of his head.

I received the page that there was a "Trauma 99" arriving at Stanford University Medical Center by ambulance. A Trauma 99 is a designation for the most critical trauma patients. When I arrived at the trauma bay, Emergency Physicians were busy securing Patrick's airway- he had obvious facial and head trauma, and was bleeding profusely from his injuries. Amazingly, they were able to secure his airway by placing a tube in his mouth and into his lungs which enabled us to breathe for him.

In order to determine the extent of Patrick's injuries, he was rushed to a CT scanner. The damage from the fall was massive: he had completely broken through the base of his skull, severing the major artery which supplies blood to the brain. His brain was literally filled with blood. Blood continued to pour from his ear. The Neurosurgeons said there was nothing they could do for him. The injuries were too massive. His brain had taken a fatal blow.

Patrick, although unconscious, still had a very strong heart, and was in perfect physical condition. His mother later told me, "he had never been sick in his life." Everyone was deeply moved by what had transpired. This perfectly healthy young man-gone. At times like these there is always a feeling of hopelessness. There was nothing we could have done better or faster to save his life. Yet oddly enough our charge became to keep him alive…for one last conversation or remembrance, and so that he might save others. Patrick as it turns out was an organ donor.

The rest of the night we worked frantically to keep Patrick’s heart pumping, and to keep enough oxygen circulating to protect his organs. Having a son, I cannot imagine the pain, and horror of receiving the phone call Patrick’s parents received that evening. Your whole world would change in an instant. In order to say goodbye to their son, they had to drive five grueling hours. They pleaded that we keep him alive for them, and for others.

His blood pressure plummeted, blood continued to pump from his body faster than we could replace it. Vital clotting factors were missing, making it impossible for us to slow the bleeding. I had to use medications to keep his blood pressure elevated. We used one, then two, then three. The bleeding would not stop, his blood pressure steadily falling lower. After all had seemed lost, after 15 units of blood, 8 units of platelets, 6 units of plasma, and 7 hours of tireless work by the nurses and physicians, he stabilized. The organ donor network team arrived. We checked with the Neurosurgeons for reflexes which would show Patrick had brain activity…he did not. The ventilator made the only noise in the room. Patrick was declared brain dead at 8:00AM. Over the next 8 hours, his room was filled with a steady stream of specialists: Cardiologists, Pulmonologists, Nephrologists, Gastroenterologists, and Hepatologists all determining which organs would be suitable for donation.

In all, Patrick gave the gift of life to 4 people awaiting transplants-his lungs, liver, heart, and kidneys now exist, and work for others. Patrick’s parents arrived at the end of my shift. I gave my all and did my best to comfort them. I am a firm believer that on some level Patrick knew they were there with him. He passed soon after they arrived. His father sobbed, “my boy…my boy…” His mother asked, “Will Patrick get to help others?” I replied, “Yes.” She whispered through the tears, “Then he will live on.”

Thank You Eye on DNA for Grand Rounds at the Beach

2007-08-07T11:46:00.000-07:00

Thank you to Dr. Hsien-Hsien Lei and Eye on DNA for including Dr. Anil Menon's post "Drugs of Abuse" on Grand Rounds at the Beach.

What If.....

2007-07-31T21:36:00.000-07:00

The Emergency Department can be a very hazardous place to work. Over the course of one year I have seen random acts of violence, and have had friends exposed to various bodily fluids. I have seen a meal tray thrown at a nurse and unruly patients take swings at ER personnel, in fact one of my fellow residents was attacked and bitten by a patient in the hallway of a San Francisco hospital. Although physical threats are a reality, a more common threat to healthcare workers are from monsters smaller than 1 micron: Tuberculosis, Hepatitis A, B, C, and HIV. The Emergency Department can indeed be a very dangerous place to work-I personally experienced this fact 2 months ago.
Mr. R, was a 35 year-old who came into the Emergency Department one evening because he was having an extremely difficult time breathing. He was diagnosed with a horrific pneumonia. He could not speak more than 3 words at a time, he was covered in sweat, and his blood pressure was very low-he really needed our help. We placed a tube into his lungs to help him breath, and I took charge of inserting a large catheter into his Jugular Vein in order to rapidly administer fluid into his blood stream. This is a procedure that most Emergency Department Residents become very comfortable with after a year of working in the ER-but as I have learned, one must NEVER let his or her guard down when performing an invasive procedure. After I had inserted the catheter into his neck, I began anchoring it to his skin so that it would stay in place. In order to do this we use what looks like a sewing needle attached to a length of suture. The room was very hectic as we worked to save our patient.
In one instant, amidst the chaos, while standing at the head of the bed, and suturing the catheter in place I looked away to grab a scalpel-the needle pierced my glove and stuck into my index finger. These procedures can be very bloody-all I remember seeing was my blood covered hand, a blood covered needle. I immediately took my glove off, and saw what I had feared: blood oozing from a small puncture wound on the side of my finger.
After stabilizing the patient, I thoroughly irrigated my wound under water for 5 minutes. My mind was racing....what if Mr. R has HIV, or Hepatitis? Why does a seemingly young healthy 35 year old have such a terrible pneumonia? Is he immunocompromised, meaning is there a disease which we do not know about, such as HIV/AIDS which is shutting down his immune system? I tried to calm myself by thinking, "There is no way he has anything...", but the “what if’s” kept creeping in. Suddenly his world, his life, collided with mine.
Mr. R passed away 2 hours later in the intensive care unit from sepsis-or an overwhelming infection causing a dramatic loss of blood pressure, and respiratory failure. Per our hospital's protocol I was evaluated in the Emergency Department in order to determine my risk of exposure to Hepatitis, or HIV, diseases commonly transmitted through blood exposure. The whole scenario evolved so quickly. We simply had no answers: what was his lifestyle, did he use IV drugs, did he have Hepatitis or HIV? We needed to talk with the family to obtain their permission to run the necessary tests.
One of our Infectious Disease specialists talked with the family, and told them of the situation-they graciously agreed to allow us to check Mr. R for Hepatitis A, B, C, HIV, and a "Viral Load" which would quantify for us how much HIV Virus was in his system if indeed he had HIV. We also checked a CD4 count which is a rough estimate as to how well Mr. R's immune system was working (CD4 counts drop in the various stages of HIV infection). We worked with the Morgue to obtain the necessary blood work. Meanwhile, a family member informed us that Mr. R was homosexual. Although he was regularly tested for HIV with consistently negative results, my odds of being exposed to HIV were now much higher.
When dealing with exposures, and particularly needle-stick exposures, there are several key factors that come into play to determine if one needs to take prophylactic medication to prevent infection: 1) What is the probability that the patient has an infectious disease: what are their risk factors for Hepatitis and HIV, for example, IV drug use, a history of multiple blood transfusions, or sexual activities, and 2) What type of needle was the worker punctured with: was it hollow or solid, was it covered with blood, did it pass through gloves first? These are all factors which are additive and determine one's risk. Reassuringly, I was using a solid needle, although it was covered with blood, it did pass through a gloved hand first- all factors which lower the rate of transmission.
Based on the risk of exposure from this patient, I elected to start anti-retroviral therapy-or therapy to kill the HIV virus if it was circulating in my blood stream. I really sympathize with anyone who needs to take this medication-for any reason. After 2 days I became nauseous, and had horrible muscle aches-I felt hungry all of the time, yet I always wanted to vomit. I tried to stick it out for the full course, or at least until we had some answers.
Fortunately Mr. R did not have Hepatitis A, B or C. Unfortunately having to acquire an HIV test after he passed was not so easy-the sample of blood we obtained was unable to be tested....we will never know if he had HIV. We did discover that he passed from a common bacteria which causes pneumonia. I took the medicine for 2 weeks, I could not do it any longer because of the side effects. I will need to be regularly tested for HIV over the next year. Although I would not wish anyone to go through this experience-it really was eye opening.
An estimated 700,000 healthcare workers receive puncture wounds from needles every year. Studies have shown that the risk of transmission of HIV after receiving a needle stick from a person known to be infected with HIV is 0.3%. Conversely, the risk of contracting Hepatitis B or C, a much more likely virus to contract in a similar scenario, is upwards of 30% (if not vaccinated-all healthcare workers are required to have an up to date Hepatitis B Vaccination). Reflecting on my experience, I learned that one must always remain incredibly vigilant while working in the Emergency Department; the risk of exposure in real. I also learned that knowing the facts about exposures helps to quiet the “what if’s” in your head: sometimes the thing we fear the most is the least likely to happen to us.

Drugs of Abuse

2007-07-30T06:34:00.001-07:00

To pick up where my last post left off, I thought I would write about a more common case than LSD. That would be alcohol intoxication. SFGH's director of Emergency Medicine, Alan Gelb, noticed a decade by decade decline in LSD presentation to the ED but a consistent stream of alcohol related illness. Now that I look back at the past month at SFGH, I can hardly estimate the multitude of medical cases related to alcohol.

As a disclaimer, I don't want to get self righteous or moralize about the subject. I certainly have embarrassed myself on numerous occasions with too much alcohol--and on a suprisingly large number without alcohol for that matter. We all know about the dangers of drinking and driving--40% of motor vehicle fatalities. Having never had any close friends or family members in AA, it never hit me how destructive it can be on a regular basis until this month.

And this was the month to treat alcohol intoxication. It may be that there were a few holidays including July 4th or that it was particularly warm and festive in San Francisco this summer. Or it could be that 3/4 of Americans drink at any point in the year (coffee, milk and soft drinks are still more popular). On my way home from work over the past 2 years, I have stopped to help during one cardiac arrest and two motor vehicle collisions. This month, on one night, I stopped twice on the Stanford campus to see the flashing lights of an ambulance retrieve a drunken student.

Those students went to the Stanford ED with little intervention on my part beyond what the paramedics had already done. In a situation of acute intoxication morbidity is usually related to traumatic injury. Those students were able to talk so their airways were clear, and they were breathing without any signs of aspirating their vomit, and they had strong pulses, with no visible external trauma to their heads or bodies. Whoever was working in the ED probably put them on a gurney and waited for them to sober up until they could accurately deny any pain or injury and return home safely without hurting themselves or others. It is possible that they also received some IV fluid as well. Though it doesn't help with excretion or conversion to acetaldehyde, it does counter act the tachycardia and low blood pressure that some people get as a result of dehydration or decreased blood vessel tone.

Heavy chronic ethanol ingestion is usually more destructive because of its social impact and associated health problems. As high as 7% of our population can fall into the category of alcohol abuse. The health care costs have been estimated at 185 billion which seems to out weight the cardioprotective benefits of a daily red wine. Much like acute ingestion, a major concern is trauma and I have seen countless alcohol related injuries on any given day. More insidious in the chronic alcoholic is the complete dependence and withdrawal risks. Almost every other day I will see someone who has had a seizure after trying to quit drinking. These can be scary and life threatening and only treated with more alcohol or a benzodiazipine. Though I have not seen it yet, chronic alcoholics can become confused because of a thiamine deficiency and resultant neuronal dysfunction (sometimes this can be irreversible). Finally, I have also diagnosed a few head bleeds or subdural hematomas in chronic alcoholics. They tend to have more accidents, more brain atrophy so there is more room for the brain to move in the skull and veins to tear, and they often need to be admitted for these bleeds. Very often we will put these patients through the CT scanner.

Though I can remember great times drinking, it has been a sobering experience taking care of all the times that it didn't turn out so well.

Pandemonium

2007-07-11T15:33:00.000-07:00

"Fractals, fractals inside of fractals, and Asian doctors guarding the gates to eternity, little prisms, little prisms of gnomes, multicolored gnomes surrounding me, doctors with the keys, the key to eternity." I'll never forget those words that wished me goodbye as I left the hospital.
The launch of my second year as an EM resident began at San Francisco General Hospital and did so in relative peace. I began the day with trepidation and excitement and was surprised to arrive at an empty ED at 6am. Perched in the middle of SF's mission district, SFGH sees much of the city's traumatic injuries including penetrating trauma like gunshot wounds and stab wounds as well as many of the city's pedestrians that are too often hit by autos.

An empty ED is also scary because it will inevitably transform into a vortex. And on my first day it did. My friend, the mathematician, the one seeing fractals was about 20 years old, found in a park, shooting something as incoherent and intriguing as this when the police picked him up and transported him to SFGH. His voice was definitely the loudest in the cacophony at the end of my 12 hour shift. There were others, intoxicated, swearing at us and not happy to be in the ED. Also a the shouting in the trauma bay from an incident similar to the one I wrote about two blogs ago.

On my way home, having not seen the trajectory of his case, I wondered about what he might have ingested. My first thought was LSD or PCP because of the intensity with which he was fighting the cops and screaming about fractals.

LSD is a potent drug requiring only 1 microgram to have psychedelic effects. Usually a dose is distributed as blotter acid squares in 25 microgram proportions. If he did ingest acid he would not be near the lethal dose which requires 14,000 micrograms. Though his trip would not be pleasent because it usually lasts 12 hours, peaking in the first 4 hours, unlike mushrooms (psilocybin) that peaks in the first 30 minutes to 2 hours and wanes by 4-6 hours.
Still, his eyes were not as dilated as they usually are with LSD ingestion due to a sympathetic nervous system response. He didn't have the ataxia (uncoordinated), nystagmus (eye twitching) or increased secretions seen with PCP. At least his vital signs were normal, with a normal blood pressure, temperature, heart rate, and respiratory rate, so we felt more comfortable focusing on calming him down. After I left the hospital I was told that he needed four police officers to be restrained and sedative medications in voluminous quantities.

If a Tree Fell in a Forest...

2007-06-29T09:19:00.000-07:00

Mrs. B fell at her home 5 days ago. She was brought into the Emergency Department after a neighbor found her lying on the kitchen floor - she had failed to show for church bingo the night earlier - she had not missed that in 9 years! The paramedics brought her into room 13 on a gurney, she was still wearing her nightgown from the night of the incident. Mrs. B explained that she awoke the night of the fall to get a glass of water in the kitchen and tripped over a rug, landing on her right side. At this point she realized she was unable to get up. Mrs. B was rather overweight, and resorted to rolling on the floor to try to get from point A to B. Her first destination: the phone at the other end of the kitchen - once she arrived at the counter it rested on, she was unable to reach it. For the next 5 days she lay on the floor scooting around with what little strength she had in her legs. “I have one bad leg, so when I would try to scoot somewhere, I usually ended up going around in circles.” When she had to go to the bathroom she went. She resorted to eating dry rice from the lower floor cupboards. She had to ration water from her cats bowl - in fact they fought each other for it. It is truly amazing the personal tragedies people face on a daily basis - and many of us are completely unaware.
When she came into the Emergency Department you can imagine her condition: she was disheveled, covered in feces, urine, and was mildly hypothermic. We examined her thoroughly from head to toe and discovered that, fortunately, she did not injure herself from the fall. Now it is bad enough to be severely malnourished, dehydrated, and cold (each of these topics could be their own essay), but the real and much more sinister threat to her health was what was occurring deep in her muscle tissues, blood, and kidneys. After cleaning her, changing her clothes, and giving her warm blankets, we inserted a catheter into her bladder to help her urinate. She was too week to walk to the bathroom. After the catheter was inserted we were surprised to see what came out - a thick viscous maple syrup-like sludge began oozing into the tubing. Her body had begun to break itself down. After lying on the ground for 5 days, Mrs. B had crushed her muscles under her own weight. Her muscle tissue began to disintegrate - flooding her blood stream with toxic levels of muscle by-products, and clogging her kidneys.
Rhabdomyolysis (Rhabdo for short) is the term for the breakdown of muscle tissue leading to acute renal failure, or the inability to produce urine. The main building blocks of muscle - creatinine kinase, and myoglobin flood the blood stream and literally clog the kidneys with sludge. This event most often occurs after crush-type injuries (such as lying on a hard floor for 5 days), strenuous exercise (yes, we have seen this condition in people who start a new exercise regimen), electrical burns, and ingestion of certain chemicals. Growing up in Colorado Springs near the Air Force Academy, my father would tell me stories of treating soldiers who would march 50-100 miles a day during basic training. Many would come to see him the day after with severe muscle pain and coca-cola colored urine. Excessive myoglobin from the muscle turns the urine a dark coke-like color. They called it March Myoglobinuria, another name for rhabdomyolysis.
The diagnosis of rhabdomyolysis can be made both clinically (by the history you obtain from the patient), and by laboratory analysis (checking blood levels of creatinine kinase, and the urine for myoglobin). A normal creatinine kinase level in an adult is 20-170 International Units/Liter of blood. Mrs. B’s level was 20,000! That is the highest level I have ever seen. Her urine was flooded with myoglobin accounting for its dark color. Her condition was no doubt worsened by her dehydration. When treating rhabdo, you want to protect the kidneys as much as possible. Anticipating such a condition, we immediately began giving her intravenous fluids. In order to help clear excess creatinine kinase and myoglobin from her blood stream we administered a drug called Sodium Bicarbonate. This drug is a very strong base, and helps to alkalinize the urine (make it more basic versus acidic), thus helping the kidneys to clear the toxins (who figured this stuff out?!).
After 3 liters of intravenous fluid, and Bicarbonate, Mrs. B’s urine began to lighten, and flow more freely. Surprisingly the rest of Mrs. B’s lab values were normal. We admitted her to the hospital for continued hydration, and physical therapy to help with building her strength. I am never ceased to be amazed at our ability to treat any person, with any type of condition, no matter how obscure, that comes into the Emergency Department and that we as humans have figured out how to treat it. What is more amazing is that for 5 days Mrs. B lay alone, cold, and in dire need of help and we had no idea.

Another Late Night

2007-06-10T04:59:00.000-07:00

In the days following my last post I have worked successive night shifts. I even voluntarily switched into someone's night shift to keep my string together. Today is my first day off so I went to a party with my sister, a party that ended long ago, bringing me to my topic sentence. I can't sleep. As a result of last week's schedule only a raging party would have made me feel normal. Because I am a doctor I even have a label for my problem: shiftwork sleep disorder.

Definitely, there are downsides to my personal life that never occurred to me until this week. For example, being awake when everyone is asleep (though it does give me a chance to catch up on email and do some writing). And, being asleep when everyone is awake--I've seen less friends this week working 60 hours than working 90 hours in internal medicine. Also, there is the switch between nights and days that feels like a flight from New Delhi to San Francisco International Airport. That is a trip I wouldn't make on a weekly basis no matter how much I love my grandparents.

More importantly, shiftwork syndrome could potentially affect patient health if I don't manage it well. At least I'm in the right place to seek help. Our former residency director Rebecca Smith-Coggins has done several studies on the sleep habits of Emergency Physicians. In one such study she showed decreased performance during night shifts. After all, the accidents at Bhopal, Chernobyl, and Three-Mile Island all happened between 12am and 4am.

I could write a daily blog on the negative biologic cascade that may have led to these disasters but a good treatise already exists. In short, it comes down to not cooperating with our circadian rhythms which are programmed to operate on a more regular 23-26 hour cycle. Not only is our level of arousal associated with a regular pattern but so are gastric secretions, hormonal levels, sexual arousal, social behavior, anxiety, and metabolism. Circumventing the forces of nature is always a tricky endeavor. For this reason I try not to compound the problem by relying on pharmaceuticals as sleep aids.

One idea that rings true to me is the planned nap proposed by Dr. Smith-Coggins. Despite the fact that she showed an improvement in performance when this was implemented in her study, it just always seemed like a good idea at every job I've ever had. Other strategies include good sleep hygiene. That is, keep the bedroom for sleeping not work, follow regular habits around bedtime, reduce stress, and seek social support.

Don't get me wrong; I'm not trying to lament my life--I love emergency medicine. But sleep disturbances seem to be exponentially expanding from the invention of the light bulb to our rapidly expanding global economy. It is a health issue worth taking seriously.

Not Every Case is a Trauma

2007-06-01T18:05:00.000-07:00

It is 5:25 AM, Kaiser Emergency Department, and to my surprise I have time to write this blog. That means that all of our patients have been discharged--for a moment at least. This also illustrates that not everyone that comes through the door is a trauma. I thought it might be interesting to write a blog about a seemingly non-intense case to paint a more realistic picture of the emergency department. At least temporarily. It is just like the World Series of Poker that I always get caught up watching. Only the exciting hands make it to our television screen but the actual game is made in all the hands that are thrown away without any fanfare.

Today, a woman came to the ED with a chief complaint of elevated blood pressure. She checks her blood pressure every morning and it hovers around 130/90. But after a stressful day at work and having not checked it in the morning she visited a friend who also had a home blood pressure machine, checked her blood pressure, and was terrified to discover it had reached 170/100.

This case was an easy one for me. And, sometimes I look forward to those easy ones during a busy day. I think we all do.

Blood pressure rises with stress and anxiety. A one-time reading above baseline is nothing to get worked up about, and getting worked up about it just makes it go even higher. We only treat elevated blood pressure when it is also associated with other clinical problems such as stroke or vision changes. That usually doesn't result from one high reading. In fact Franklin Roosevelt was known to be travelling around the country with a blood pressure consistently above 250/150. There are long term consequences to this that require lifestyle changes and medical management but nothing we will do in the ED. The hard part was making the woman calmer. Her blood pressure did go down to 130/90. Now that's an effective treatment.