Mostly Dead...

Man in his late 70's is rushed back to the trauma room complaining of chest pain. History of MI and CABG (open heart surgery). He's diaphoretic, pale, and does not look good. Blood pressure's in the 70's with a HR in the 30's. Complete A-V block on the monitor. EKG shows inferior wall MI. We start pacing him, get him aspirin, and await the chest x-ray. With the pacer, BP's improved to 130/80 range. His chest x-ray looks good, we don't have a cath lab at this hospital, so we call the transferring facility and helicopter, start lytics and heparin. He's in a paced rhythm, stable blood pressure, tolerating the pacer well at about 20 mA with good capture.

Gradually, his pressure starts to drop. 110's....90's...80's...70's....nothing. Electrical activity on the monitor, no pulse. We start CPR, open up the fluids. I turn around to talk to the wife, as the patient had requested "no life support" (whatever that means). I get the sense that what he had really wanted was to not be on a ventilator for the rest of his life, so I explain to her that this may reversible if we can get him to the cath lab, and that this is probably worth a round of CPR. She agrees, so we continue. After a couple of minutes, recheck the pulse...still nothing. Push epi and continue CPR. We intubate him. Couple of more minutes and we get a pressure. A good pressure. Funky wide-complex rhythm bordering on V-tach, which is either epi effect (for non-medical folks still reading--you can pump epinephrine into a dead heart and make it beat for a few minutes until the drug wears off...bad) or reperfusion rhythm (a rhythm frequently induced by lytics that resolves on its own...good). But still...it's a good blood pressure. A few more minutes and more narrow complexes...things are looking good.

In the meantime, the helicopter has arrived. They're getting him ready for transport when his pressure starts to drop again. He arrests again. We start CPR and I again turn to the wife. At this point, she's not as enthusiastic about things and we decide to stop efforts. The code is called. Nurse pushes epinephrine. There is some dispute (in her mind) about whether she heard the code being called and pushed epinephrine anyway. In any case, I glare at her and ask her to turn off the monitor so the wife doesn't have to sit and watch her dead husband's heart beat for the next 5 minutes. Our nursing coordinator takes the wife into another room so that we can "clean up things in the room".

For the next few minutes, we watch the heart predictably start to beat, with palpable pulses. He occasionally takes a breath here and there, but nothing that you wouldn't expect from the epinephrine. I leave the room to discuss things with the family and contact the receiving facility. Soon, the nurse interrupts me, "Doctor, can I borrow you for a minute?". As I come into the room, she says "this patient's not dying". We turn back on the monitor to see that he still has a funky rhythm but a pretty good pressure. He's also breathing on his own. Problem is, the coroner's been called, the transfer's been cancelled, the helicopter's gone, and the code has been called. This guy's been dead, not once, but twice. This HAS to be the epi. It WILL wear off. And anyway, the wife asked us to stop resuscitative efforts. We all agree to turn off the monitor and try to delay the family from seeing the body for a little longer.

To make a long story short, over the next 30 minutes, this guy continues to "stabilize". Now he's breathing regularly, albeit with a tube in his throat. He's making purposeful movements. "Sir, can you hold up two fingers?" He holds up two fingers. "Do you want this tube out of your throat?" He nods. This guy is alive and functioning. He has a good BP. He's in sinus rhythm off of the pacer--best rhythm he's been in yet. I haven't seen the cath report yet, but I do know he made it to the facility without any problems.

A true resuscitation.

Being a believer most of the time, with the occasional moment of doubt, I have to wax metaphysical here and wonder what God's role is in all of this. Before I was in medicine, I used to think of death as being this black-or-white thing, and when it's time to go, God takes you. There are plenty of medical folks who think this way--the flight nurse was helping to comfort the wife and said to her, "He's just got somewhere else to be now"--a very sensitive way of putting it that she seemed to really appreciate.

So what happened here? Did God just come down and say, "it's time" only to come a few minutes later with "well, maybe not"? And then only to change His mind two more times?

Or did Billy Crystal have it right all along?

More on pain...

The surest and most reliable sign of a wuss is the statement "I have a high tolerance for pain."

Seekers

The other day, I had a patient who hasn't quite reached our platinum frequent flyer status, but is steadily working her way up. About 20 visits over the last year. In with a headache today. Same headache she had two days ago when she was here. Told to follow up with PCP yesterday, who of course was impossible to get a hold of with that one call she made at 4:30 pm, so alas, it's Saturday, and the pain is unbearable.

I hadn't as yet had the pleasure of her acquaintance, so after our meeting, I offer her a shot for the pain (in my mind = benadryl + compazine). She asks for specifics (d#%! it...), and I find out this isn't what she had in mind:

"Yesterday, I got 2 mg of dilaudid and 50 mg of vistaril. Give me that and I'll be out of here in ten minutes."

I've treated plenty of sicklers who wanted to write their own orders, so the specific request wasn't too surprising; it was the offer that got my attention. This lady was speaking my language. Give me this, I'll cut your throughput, increase your patient flow, help your patient satisfaction scores. An administrator in patient's clothing.

I'm still fairly new out of residency, so I'm still sorting out how I'm going to treat the seekers. I used to think the answer was pretty simple until a patient I can recall in residency. Woman with HA, known frequent flyer in the neighboring town 30 minutes away. Called the ambulance from the ER (those of you in the hood won't be that surprised by this) for transport to our facility. Staff at said hospital alerted us of her impending arrival. When I get to her, I'm ready. Give her a shot of Benadryl. No effect (gasp!). Just wait, it will kick in (grinning inside...). Shot of compazine. "I'm allergic to compazine". "That's why I gave you the Benadryl--you'll make it."

Anyway, we did this little dance for a good hour or two before my attending steps in and reminds me that she's been here for two hours and I haven't done a thing for her. Wants me to give her what she's asking for. The idealist in me is going, "but...but..." "But nothing...treat her and move on."

Now I would write this guy off, but he was one of the best attendings in our residency. Always kept his cool, kept the department moving, and a great guy to work with. Nothing ever really seemed to get to him, a stark contrast to the slew of burned-out malcontents we usually had to work with.

So I'm finding myself increasingly following his advice. The battle just isn't worth it. I got into it with one of the nurses the other day who was irritated that I was giving this guy with back pain a morphine shot. "But he's here all the time!" Quick check to the records to see that "all the time" meant about every other week, and that with EVERY visit, the doc had done the toradol/flexeril/norflex thing, likely tying up a bed and a nurse for an hour, only to give him his drug at the end.

Why not just start at the endpoint? I don't KNOW the guy's not in pain. And even if he's seeking drugs, every other week ain't bad. Give him his drug, and save the battles for the platinum club.

The pain scale

A word of advice: if you're asked to rate your pain on a scale of 1 to 10, choose a number between 1 and 10. 11 is not between 1 and 10. Neither is 15. I know you're trying to communicate to me the urgency of your headache. I know you're trying to impress upon me just how bad it hurts. But in reality, it's all I can do to not roll my eyes at you (or stab this 18-gauge needle into your leg and ask you where your pain is now...between 1 and 10). And the triage nurse, the registration clerk, the tech, and everyone else who treats you are all thinking the same thing.

Forgive what I'm sure you'll perceive as a lack of compassion, but every day we see people with severed limbs, broken femurs, or jagged rocks passing through their urinary tract, who all manage to pick a number between 1 and 10. And they rarely pick 10.

Oh...and it helps if we don't have to wake you up to pick your number.

I hate the pain scale.

The power of an apology

I recently treated two college freshman who had concocted this homemade brew of nutmeg and poppy seeds. The reason for the poppy seeds is fairly obvious, but the addition of the nutmeg puzzled me a little. Until I called Poison Control and found out that nutmeg has fairly potent anticholinergic properties--tachycardia, dry mouth, vomiting, hallucinations---aaahhh...that's it--hallucinations. Our two little scientists had come up with a brand new concoction that was totally legal and available at your local grocery store.

Well, since the safety of this brew hasn't been as well established as some of the more commonly used drugs we see all the time (crack, meth, marijuana, etc), we were obligated to give these guys charcoal, which they inevitably vomited all over the place (why didn't I put in an NG tube???) For non-medical folks, charcoal vomiting creates a mess that no commercial stain remover is designed to clean up. This mess then tied up not one, but both of our night nurses for a good hour. We then had to call the social worker to come see them in the middle of the night and arrange for their ICU admission.

The thing that makes this story unique (besides the novel use of nutmeg) is that towards the end of this, one of them tells me "I'm really sorry about all of this." Huh? You're sorry? I was speechless. Sure, patients have said this before, but it's usually the little old lady who's so sorry to be bugging everyone about this, but she's concerned about this tearing sensation in her chest that turns out to be an aortic dissection. It's never the people that really should be sorry.

But you know what? The two words "I'm sorry" made everything--the charcoal mess, the tired social worker, the ICU admission--a little better for everyone. I guess it's because we've all done really stupid things in our lives, things that create bigger problems than a little mess on the floor. Thank goodness for the words, "I'm sorry."

Last night, I discovered the world of medblogs, and now I'm hooked. (Thank you internet, for stealing yet another day of my life.) Some of my favorites:

M.D.O.D. www.docsontheweb.blogspot.com
Musings of a Highly Trained Monkey www.highlytrainedmonkey.blogspot.com
Scalpel or Sword www.scalpelorsword.com

It got me wondering about what I'm writing this for, who I'm writing it to, etc. The idea of writing a medblog is appealing in a sense. I could use an outlet for venting--try as she might, my wife just doesn't always get it. I also work in a single-coverage ER for the most part, and I sort of miss having other docs to talk to. On the other hand, I spend enough time at work, that when I get home, medicine is often the last thing I want to think or talk about.

I want to write about what I'm thinking, which more often than not is not related to medicine, and may or may not be all that interesting. I would love for my friends to stop by and read a few posts, but most of my friends aren't in the medical field and aren't the blogging type, if there is such a thing. And with such a lack of direction, I'm not sure I can count on any consistent audience of strangers out there.

So, I guess I'm settling on this blog being for me. Well, me and that faceless stranger I'm talking to in these posts who always cares what I have to say, no matter the subject, and is intensely interested.

For anyone else who happens to wander by this blog, deal with it.

Oh...and feel free to leave a comment...

Tired

Just finishing a week of 12's--2 nights followed by three days. As any ER doctor knows, a 12-hour is really a 13-hour shift by the time things get all wrapped up. So, it's a 65-hour week. I used to pull those all the time in residency--I'm getting soft.

I'm not so much tired as I am annoyed. For me, annoyance with patients is my first sign of burnout, a sign that I need a break. I caught myself several times getting bored as the patient is talking to me, wondering in my head, "why in the world are they telling me this? Do they really think I care? Why on earth is this relevant?" Which is sort of dangerous, because on more than one occasion, a patient has volunteered a detail I never would have asked about that's been the key to their diagnosis. The problem is, for every one of those facts that saves your butt, you have to wade through 20 ramblings about a patient's tingling sensation in their left pinky.

It's flu season, which adds to the fatigue. Besides having to listen to the same constellation of symptoms over and over (and over...), I end up having to tell them that despite the fact that they're absolutely miserable, there's really nothing I can do that they can't do for themselves by a quick walk through the pharmacy. And even after my lengthy explanation that their illness is due to a virus, they inevitably ask, "Are you going to write me for something?" Yes, "something" means an antibiotic.

Did you hear a word of what I just said? YOU DON'T NEED AN ANTIBIOTIC. I don't care if your doctor gives you a Z-pack whenever you get this. You could take a pack of jelly beans and get better just as quickly. Here...I'll even put them in a pill bottle for you.

As you can tell, I'm not very good at the kind doctor comforting thing. It's actually much more tiring to me telling 20 people they're fine (without ticking them off) than treating 20 MI's. Wow...it's really a good thing I switched residencies.

Good news, I have a good week ahead. Only two shifts. Such is the beauty of 12's.