My stomach hurts. Sounds simple. The abdomen is full of hollow tubes with multilayer walls, lots of blood vessels, solid organs, and even reproductive structures. By convention, the abdomen is divided into four parts called quadrants, right upper and lower and left upper and lower. Any and all of the anatomical structures in the abdomen can go on the fritz and give one a belly ache. Constipation, nervous or acid stomach all sound benign but may represent a life threatening emergency.
The ER doc's investigation always begins with the most urgent and dangerous diagnosis: has an artery or vein sprung a leak. The body's main artery, the aorta, after exiting the heart and making a left handed loop descends south into the abdomen. It gives off branches to the liver, intestines, kidneys, spleen, spine and other stuff. The abdominal aorta itself is the number one concern as a source of vascular disaster causing abdominal pain.
Some causes of abdominal pain are described as colic. No, not the cranky baby type of colic. Biliary and renal colic can be the real 10/10 pain. Having stones or sludge exiting one's gall bladder can feel like a knife being twisting in the right upper quadrant of the abdomen. Kidney stones passing from the kidney to the bladder via the ureters is often described as stabbing, tearing pain in either flank or abdominal half. The tricky part for the ER staff is that the leaking aorta can feel just like a kidney stone. The former can kill in a matter of minutes, while the later justs make you wish you were dead, to end the horrific pain.
Problems involving the solid organs of the abdomen are usually more subtle in their presentation. Hepatitis, an infection of the liver, is heralded by dark urine, right upper quadrant pain and maybe even a resemblance to a lemon as you become jaundiced. Pyelonephritis, an infection of the kidney developes over time with flank ache, fever, chills, and nausea and vomiting. Enlargement of the spleen, which can accompany mononucleosis, causes a dull achy fullness in the left upper quadrant. Pancreatitis is especially unpleasant. The pancreas produces digestive enzymes that when carried by the pancreatic duct to the small intestine, aid in digestion of our food. The problem is that when damaged by infection, toxic exposure (often good old alcohol), vascular compromise or injury, those enzymes start digesting the pancreas itself.
A plumbers nightmare is the 10 meters or so of hollow tubing that include the stomach and small and large intestines. Coiled, full of trillions of bacteria, susceptible to inflammatory, vascular and infectious disease galore, all crammed into one's abdomen. Appendicitis, Crohn's disease, diverticulitis, colitis are all causes of mild to life threatening infections in the abdomen.
The complex meandering of the intestines can lead to blockages from twisting of adhesions (scar tissue, often from prior surgery to fix one of the diseases we have mentioned). There was nothing more humbling to your intrepid B.O.N.E.R. doc than being the victim of a bowel obstruction. Having the stuff that should come out my rectum backing up into my stomach and thence into a vomit bag, is miserable. This unpleasant experience can be temporarily treated by having a hard plastic tube rammed through a nostril, gagging you as the nurse passes this NG (nasogastric) tube into your stomach.
My stomach hurts. The differential diagnoses are seemingly without end. The clock is ticking. The patient is miserable. The stalwart ER doc, armed with his scanners, ultrasound machines, and hospital lab, takes a careful history, performs a thorough exam (sticking something into any available body opening that leads towards the abdomen), and tries to come up with the correct diagnosis and treatment.
Help!! Give your ER doc a hand by answering the usual questions concerning pain. When did it start? How has it progressed? What is the quality and intensity? Does the pain radiate and to where? Anything make the pain less or more intense? Any relation to the time of day or the eating of a meal?
Lots of anatomy, sometimes unpredictable pain patterns, time is critical. No problem, come to the ER with your bellyache.
Saturday, December 26, 2009
Friday, December 25, 2009
heart of the matter
Today will be the first of a series of postings pertaining to what is refered to as the chief or presenting complaint. First on our list of problems is chest pain. A common complaint and one that is fraught with potential disaster for the patient and the ER doc.
Let's start with the anatomy. To the ER doc the chest is bordered to the north by the nose and its southern extreme is the lower abdomen. The body's perception of the source of heart pain is unpredictable. The innards of the chest cavity are full of structures which when diseased or damaged can spell death and disability with little warning.
For everybody region or part, the conscientious ER doc begins his or her differential diagnoses with the vascular bits. The heart, arteries and veins are the most likely structures to kill the patient when their warranty expires. Heart attacks (myocardial infarction) are caused by blockages of the coronary arteries. These vessels supply the heart muscle with oxygen and nutrients. The aorta is the main artery in the body. All oxygenated blood leaving the left ventricle of the heart and heading to the rest of the body exits via the aorta. A dissection of the aorta is a ticking bomb which can kill in minutes if not detected and treated promptly.
Blood clots can also cause life threatening chest pain. Clots that form in the legs can break off travel through the right side of the heart and end up in the pulmonary (lung) arteries. A large clot can kill.
There are many other potentially lethal diseases that present as chest pain. Infections of the heart from viruses, bacteria and even parasites can lead to death. A collapsed lung, or lung infection are slower acting but still carry the potential for disaster.
Even the humble digestive tract, as it traverses the chest can blow a gasket and flood the chest cavity with bacterial laden, acidic stuff. Never mind the joys of acid reflux.
The difficulty for your caring ER doc is that the symptoms for any and all chest problems often overlap. Many a patient with a heart attack (MI) has complained of indigestion. For the fairer sex the symptoms of an MI may be even more subtle. Shortness of breath or even just increased fatigue may be the only symptom of an MI. Diabetics often have "silent MI's", heart attacks with no specific pain.
The triage nurse or EMT in the ambulance are the first line of defense. An EKG that is normal doesn't preclude an MI but can be helpful if it shows the specific patterns of acute damage to the heart muscle. Blood tests, x-rays, a good history and physical exam all contribute to the decision making process. To fully rule out an MI may take up to 8-9 hours, as the proteins that leak out of the injured heart muscle may take that long to show up on the blood tests.
MI, pulmonary embolus, aortic disection, collapsed lung, torn or ruptured esophagous, pneumonia, pleurisy, muscle strains, reflux, neuralgia... The list of diseases that present with chest pain goes on and and.
Help an old ER doc. Don't tell me at age 19 that you have heart pain and can't breath. Describe the location, quality (sharp, burning, pressure), onset, duration, and radiation (pain moving from chest to jaw) and level (0-10, no 20,50, or 1,000) when asked by the EMS, nurse, PA or doc. The triage process is not perfect but it allows the overworked ER staff to get to the sickest, most urgent patients first. Wait your turn. Our goal to relieve pain and suffering. We will get to every patient. The ER is not the deli counter at the supermarket. The order of arrival even if by ambulance is not the issue.
Don't smoke, exercise regularly, eat a low fat/cholesterol diet, see your doctor as recommended.
Let's start with the anatomy. To the ER doc the chest is bordered to the north by the nose and its southern extreme is the lower abdomen. The body's perception of the source of heart pain is unpredictable. The innards of the chest cavity are full of structures which when diseased or damaged can spell death and disability with little warning.
For everybody region or part, the conscientious ER doc begins his or her differential diagnoses with the vascular bits. The heart, arteries and veins are the most likely structures to kill the patient when their warranty expires. Heart attacks (myocardial infarction) are caused by blockages of the coronary arteries. These vessels supply the heart muscle with oxygen and nutrients. The aorta is the main artery in the body. All oxygenated blood leaving the left ventricle of the heart and heading to the rest of the body exits via the aorta. A dissection of the aorta is a ticking bomb which can kill in minutes if not detected and treated promptly.
Blood clots can also cause life threatening chest pain. Clots that form in the legs can break off travel through the right side of the heart and end up in the pulmonary (lung) arteries. A large clot can kill.
There are many other potentially lethal diseases that present as chest pain. Infections of the heart from viruses, bacteria and even parasites can lead to death. A collapsed lung, or lung infection are slower acting but still carry the potential for disaster.
Even the humble digestive tract, as it traverses the chest can blow a gasket and flood the chest cavity with bacterial laden, acidic stuff. Never mind the joys of acid reflux.
The difficulty for your caring ER doc is that the symptoms for any and all chest problems often overlap. Many a patient with a heart attack (MI) has complained of indigestion. For the fairer sex the symptoms of an MI may be even more subtle. Shortness of breath or even just increased fatigue may be the only symptom of an MI. Diabetics often have "silent MI's", heart attacks with no specific pain.
The triage nurse or EMT in the ambulance are the first line of defense. An EKG that is normal doesn't preclude an MI but can be helpful if it shows the specific patterns of acute damage to the heart muscle. Blood tests, x-rays, a good history and physical exam all contribute to the decision making process. To fully rule out an MI may take up to 8-9 hours, as the proteins that leak out of the injured heart muscle may take that long to show up on the blood tests.
MI, pulmonary embolus, aortic disection, collapsed lung, torn or ruptured esophagous, pneumonia, pleurisy, muscle strains, reflux, neuralgia... The list of diseases that present with chest pain goes on and and.
Help an old ER doc. Don't tell me at age 19 that you have heart pain and can't breath. Describe the location, quality (sharp, burning, pressure), onset, duration, and radiation (pain moving from chest to jaw) and level (0-10, no 20,50, or 1,000) when asked by the EMS, nurse, PA or doc. The triage process is not perfect but it allows the overworked ER staff to get to the sickest, most urgent patients first. Wait your turn. Our goal to relieve pain and suffering. We will get to every patient. The ER is not the deli counter at the supermarket. The order of arrival even if by ambulance is not the issue.
Don't smoke, exercise regularly, eat a low fat/cholesterol diet, see your doctor as recommended.
Thursday, December 17, 2009
christmas cheer?
Booze, hootch, brew, tea, aquavit, horse, smack, crack, crank, blow, Georgia Home Boy, special K, acid, meth, ice, X. Substance abuse is a never ending challenge and headache for ER docs. We have to deal with the chronic side effects of drug and alcohol use: liver disease, internal bleeding, dementia, and infections including HIV, hepatitis B and C and D, MRSA (a super bug), endocarditis (an invasive infection of the heart). Then there are the joys of withdrawal from drugs and alcohol, the vomiting, diarrhea, shaking, sweating, delirium and seizures. A user can die from chronic use, overdose and sudden cessation resulting in acute withdrawal. ER's also have to manage the collateral damage of drugs and alcohol, DUI's, child and spousal abuse and neglect.
The user rarely has health insurance, and often has been abandoned by the family that they lied to, stole from and abused. They arrive in the ER walking, by the police or by ambulance. Public intoxication is no longer treated by placement in the "drunk tank". The ER has become the repository for junkies, drunks and other users that society doesn't wish to acknowledge. Our local, state and national governments treat drug use criminally not as a disease. Billions are spent on ineffective attempts at stopping the manufacture, growing, distribution and sale of illegal substances. Little funding is left to treat the addict. Beds for alcohol and drug abuse are woefully inadequate for the number of people looking to get clean. Long term treatment programs and counseling are even less available. Volunteer groups on the AA or NA model are prolific but only effective after the acute withdrawal period has been completed.
The physiology of drug and alcohol dependency has been well studied and is well understood. There is good evidence that one's genetic make up may predispose someone to become addicted to alcohol or drugs. This is the basis of treating substance abuse as a disease, not a moral failing. The burden of care is enormous. Alcoholics and drug addicts are medical time bombs. The ER doc must diagnosis and treat the acute intoxication or withdrawal and find any underlying medical or surgical problem and treat those conditions. This must be accomplished on a patient who is often dirty, malodorous, physically and verbally assaultive to the people trying to care for them. Physical and chemical restrains are employed to help these patients despite themselves.
The mental health problems that frequently exist hand in hand with addiction will be the focus of a later blog. Suffice it to say that many alcohol and drug users are often self-medicating there depression, bipolar disorder or schizophrenia. Anyone out there think this is easy?
The drug seeker is a particularly nasty member of the substance abuse family. These patients usually start off as nice folks who are seriouly injured or have chronic pain conditions, such as arthritis, fibromyalgia or sickle cell disease. Their pain is treated with narcotic pain medications. The problem is that over time narcotics become less effective, requiring ever larger doses to maintain the same level of relief. The patient build tolerance to these drugs. They are less sedated by the medications. The patient finds that the more he or she demands the less their doctor returns his or her calls. The treating physician eventually "fires" the patient. Guess where they end up? Initially they are all sweetness and delight. They politely and tearfully relate their story of 10 over 10 pain in gory detail. When the doctor gets suspicious and hesitates or refuses the request for oxycontin 80 mg every 8 hours, Mr Hyde appears. You are insulted, threatened with both physical harm and legal actions. The drug seeker eventually realizes that his game is not working and makes a miraculous recovery from his chronic disability and storms out of the ER in a cloud of threats and obscenities.
For me the saddest part of abuse is the unintended victim. The drug addicted newborn is the most pitiable and innocent of the addicts' gifts to humankind. The thousands of people maimed and murdered by inpaired drivers often end up in the same ER as the drunk or addict who caused the accident. The families of the user haunt my psyche. They continue to love and care for the addict who makes their lives a nightmare. I am frustrated when the most I can offer is a list of detox facilities that have very long waiting lists.
So please, hark the heralds, enjoy Christmas, Kwanza, Hannukah, and the New Year. Drink slowly and in limited amounts. Have a designated driver or take a cab or public transportation. If you need alcohol or drugs to get through a family gathering, RSVP your regrets and spent the holiday volunteering in a shelter, soup kitchen, VA hospital, or nursing home. Christmas cheer is doing good by helping others not pounding down the eggnog.
The user rarely has health insurance, and often has been abandoned by the family that they lied to, stole from and abused. They arrive in the ER walking, by the police or by ambulance. Public intoxication is no longer treated by placement in the "drunk tank". The ER has become the repository for junkies, drunks and other users that society doesn't wish to acknowledge. Our local, state and national governments treat drug use criminally not as a disease. Billions are spent on ineffective attempts at stopping the manufacture, growing, distribution and sale of illegal substances. Little funding is left to treat the addict. Beds for alcohol and drug abuse are woefully inadequate for the number of people looking to get clean. Long term treatment programs and counseling are even less available. Volunteer groups on the AA or NA model are prolific but only effective after the acute withdrawal period has been completed.
The physiology of drug and alcohol dependency has been well studied and is well understood. There is good evidence that one's genetic make up may predispose someone to become addicted to alcohol or drugs. This is the basis of treating substance abuse as a disease, not a moral failing. The burden of care is enormous. Alcoholics and drug addicts are medical time bombs. The ER doc must diagnosis and treat the acute intoxication or withdrawal and find any underlying medical or surgical problem and treat those conditions. This must be accomplished on a patient who is often dirty, malodorous, physically and verbally assaultive to the people trying to care for them. Physical and chemical restrains are employed to help these patients despite themselves.
The mental health problems that frequently exist hand in hand with addiction will be the focus of a later blog. Suffice it to say that many alcohol and drug users are often self-medicating there depression, bipolar disorder or schizophrenia. Anyone out there think this is easy?
The drug seeker is a particularly nasty member of the substance abuse family. These patients usually start off as nice folks who are seriouly injured or have chronic pain conditions, such as arthritis, fibromyalgia or sickle cell disease. Their pain is treated with narcotic pain medications. The problem is that over time narcotics become less effective, requiring ever larger doses to maintain the same level of relief. The patient build tolerance to these drugs. They are less sedated by the medications. The patient finds that the more he or she demands the less their doctor returns his or her calls. The treating physician eventually "fires" the patient. Guess where they end up? Initially they are all sweetness and delight. They politely and tearfully relate their story of 10 over 10 pain in gory detail. When the doctor gets suspicious and hesitates or refuses the request for oxycontin 80 mg every 8 hours, Mr Hyde appears. You are insulted, threatened with both physical harm and legal actions. The drug seeker eventually realizes that his game is not working and makes a miraculous recovery from his chronic disability and storms out of the ER in a cloud of threats and obscenities.
For me the saddest part of abuse is the unintended victim. The drug addicted newborn is the most pitiable and innocent of the addicts' gifts to humankind. The thousands of people maimed and murdered by inpaired drivers often end up in the same ER as the drunk or addict who caused the accident. The families of the user haunt my psyche. They continue to love and care for the addict who makes their lives a nightmare. I am frustrated when the most I can offer is a list of detox facilities that have very long waiting lists.
So please, hark the heralds, enjoy Christmas, Kwanza, Hannukah, and the New Year. Drink slowly and in limited amounts. Have a designated driver or take a cab or public transportation. If you need alcohol or drugs to get through a family gathering, RSVP your regrets and spent the holiday volunteering in a shelter, soup kitchen, VA hospital, or nursing home. Christmas cheer is doing good by helping others not pounding down the eggnog.
Wednesday, December 16, 2009
to sleep, perchance to dream; revisiting nights
The letter N in B.O.N.E.R. doc stands for nocturnal. I and my brethren work the night shift in the ER. Most groups of ER docs have some type of advancing schedule. To cover the ER 24/7, the day is split into 2-5 shifts of varying lengths. One would work 1-2 weeks of the early shift and advance to the later shifts in sequence. My group has two docs who work only the night shifts, yours truly and my brother, Zorba. We cover all but 2-3 nights each month. I work my nights in blocks of three in a row. In between these shifts I try to sleep. If I am lucky I can sleep for 2-3 hours in the morning when I arrive home, and another 2-3 hours in the late afternoon before returning to the hospital. Nurses, techs, EMT's, paramedics, police, fire fighters, and others follow similar schedules. Night workers are sometimes paid a bonus for "volunteering" to work nights. Often the most junior members of an ER group get stuck with the majority of the nights, and as one ages, the number of nights is reduced.
The problem with working nights is circadian rythyms; no, not the noisy insects that hatch every 17 years. These variations in hormonal, neurological and even digestive activities are hard wired into all animals. Challenge them at the risk of disfunction and physiologic harm. The litany of side effects from impaired or inadequate sleep include heart attack, stroke, reflux, depression, increased risk of cancer and most disturbing, a shortening of one's life expectency. That's right, working nights shortens our lives. There is also the stress on a marriage and family life, when one spouse is either not home or trying to sleep when the other spouse is on the opposite schedule.
There are advantages to working nights. The most obvious is a lack of management supervision. Bosses sleep at night. Only the peons labor after 11:00 PM. This independence breeds a spirit of cooperation. An "us against the world" mentality. We become our own weird, cranky and chronically sleep deprived family. The day folk can't relate to our special needs. Black out blinds, white noise machines, strange eating habits, and an unnatural passion for coffee are some of the adaptations we employ to cope with sleeping during the day and being awake at night.
The real problem is that we constantly switch back and forth between the day world and the night world. I have just finished three nights working. I slept for 2 1/2 hours this morning, and am struggling to stay awake til 10:00 PM. I will probably sleep 8-9 hours. I actually set an alarm for 7:30 AM so that I can rejoin the sun people including my saintly wife and the rest of my family and friends.
Patients are unaware of circadian rythyms, to their detriment. Heart attacks, strokes and other medical disasters are most prevalent in the early morning hours, due to changes in levels of hormones in our bodies. The patient in severe respiratory distress at 6:00 AM is being cared for by doctors and nurses who are also at the low point of their physiological functioning. Night workers have a much higher rate of car accidents when driving home in the morning than the general public. You can't defeat mother nature.
The emergence of the ER as a 24 hour walk-in-clinic has made nights even more difficult for the B.O.N.E.R. doc. In my 30 years of night shifts I have gone from the occasional patient followed by games, crafts and even naps, to nonstop patients and a perpetually full bladder. A successful night is one in which the ER is less backed up when I leave, than when I arrived. Seeing someone with a minor back ache at the end of your shift, because the patient needs a note to stay out of work, sucks what little nugget of humanity remains at 6:00 AM.
So please, if you have an appointment that same day with your family doctor, don't come to the ER at 3:00 AM, for your one month of "fill in the complaint", because you just can't wait til 11:00 AM for your scheduled appointment.
Good night and pleasant dreams.....
The problem with working nights is circadian rythyms; no, not the noisy insects that hatch every 17 years. These variations in hormonal, neurological and even digestive activities are hard wired into all animals. Challenge them at the risk of disfunction and physiologic harm. The litany of side effects from impaired or inadequate sleep include heart attack, stroke, reflux, depression, increased risk of cancer and most disturbing, a shortening of one's life expectency. That's right, working nights shortens our lives. There is also the stress on a marriage and family life, when one spouse is either not home or trying to sleep when the other spouse is on the opposite schedule.
There are advantages to working nights. The most obvious is a lack of management supervision. Bosses sleep at night. Only the peons labor after 11:00 PM. This independence breeds a spirit of cooperation. An "us against the world" mentality. We become our own weird, cranky and chronically sleep deprived family. The day folk can't relate to our special needs. Black out blinds, white noise machines, strange eating habits, and an unnatural passion for coffee are some of the adaptations we employ to cope with sleeping during the day and being awake at night.
The real problem is that we constantly switch back and forth between the day world and the night world. I have just finished three nights working. I slept for 2 1/2 hours this morning, and am struggling to stay awake til 10:00 PM. I will probably sleep 8-9 hours. I actually set an alarm for 7:30 AM so that I can rejoin the sun people including my saintly wife and the rest of my family and friends.
Patients are unaware of circadian rythyms, to their detriment. Heart attacks, strokes and other medical disasters are most prevalent in the early morning hours, due to changes in levels of hormones in our bodies. The patient in severe respiratory distress at 6:00 AM is being cared for by doctors and nurses who are also at the low point of their physiological functioning. Night workers have a much higher rate of car accidents when driving home in the morning than the general public. You can't defeat mother nature.
The emergence of the ER as a 24 hour walk-in-clinic has made nights even more difficult for the B.O.N.E.R. doc. In my 30 years of night shifts I have gone from the occasional patient followed by games, crafts and even naps, to nonstop patients and a perpetually full bladder. A successful night is one in which the ER is less backed up when I leave, than when I arrived. Seeing someone with a minor back ache at the end of your shift, because the patient needs a note to stay out of work, sucks what little nugget of humanity remains at 6:00 AM.
So please, if you have an appointment that same day with your family doctor, don't come to the ER at 3:00 AM, for your one month of "fill in the complaint", because you just can't wait til 11:00 AM for your scheduled appointment.
Good night and pleasant dreams.....
Friday, December 11, 2009
doctor, teacher
In addition to an ER doc's daily task of treating and streeting the hordes of sick and injured patients that come through our door 24/7, we also have to be educators.
Todays young adults and children are the children and grandchildren of us "Boomers". Those of us who remember Ike, JFK, LBJ, Nam, MLK, etc were very aware that the world was competitive, and harsh. One needed to strive to succeed and sometimes just survive. We were taught to duck and cover because nuclear annihilation was a real possibility. Only the winners received trophies, the losers were admonished to try harder. When I applied to medical school in the early 70's only one in four applicants were accepted. 60,000 premeds for 15,000 first year spots.
Our progeny were raised with Mr Rogers telling them that they are special and unique. They were given trophies just for participating. They had far more distractions to entertain themselves. This has led to NCP's, non coping patients. They take an ambulance to the ER because they have the flu and don't feel well. Their child has a fever and they come to the ER so that we can give the child an antipyretic and give the parents reassurance. The constantly increasing number of ER visists is not just because of the population is getting older and sicker, but rather the lack of common sense and ability to cope with even minor discomfort. Yes I am aware of the lack of primary care, and other factors that also contribute to surge in ER usage.
So I teach. I instruct. I hand hold. "Fever is not a disease, it is how our body fights off infection.""Giving too little of both acetominophen and ibuprofen is less effective than giving the correct of dose of one or the other."
We are also morally and ethically obligated to teach the younger members of our ER team. PA's, nurses, ER techs, EMT's, paramedics and residents all can benefit from our experience and knowledge. Being a mentor to my colleagues, fresh their EM residencies has been one of the most rewarding aspects of my long career.
Lastly we need to be perpetual students. Medical knowledge doubles every five years. New technology, techniques, medications and diseases need to be assimilated into our aging brains. The fact that someone born at the time of rotary dial phones, TV's with black and white screens with 6 channels, and a stethoscope as the most useful medical instrument, now embraces the new, is difficult but necessary. Ultrasound, CT, MRI all need to be mastered. I use an electronic medical record, and am distressed when the system goes down and I have to resort to paper. This blog is testament to the imperative of "use it or lose it". Continue to grow intellectually and emotionally or become irrelevant.
Todays young adults and children are the children and grandchildren of us "Boomers". Those of us who remember Ike, JFK, LBJ, Nam, MLK, etc were very aware that the world was competitive, and harsh. One needed to strive to succeed and sometimes just survive. We were taught to duck and cover because nuclear annihilation was a real possibility. Only the winners received trophies, the losers were admonished to try harder. When I applied to medical school in the early 70's only one in four applicants were accepted. 60,000 premeds for 15,000 first year spots.
Our progeny were raised with Mr Rogers telling them that they are special and unique. They were given trophies just for participating. They had far more distractions to entertain themselves. This has led to NCP's, non coping patients. They take an ambulance to the ER because they have the flu and don't feel well. Their child has a fever and they come to the ER so that we can give the child an antipyretic and give the parents reassurance. The constantly increasing number of ER visists is not just because of the population is getting older and sicker, but rather the lack of common sense and ability to cope with even minor discomfort. Yes I am aware of the lack of primary care, and other factors that also contribute to surge in ER usage.
So I teach. I instruct. I hand hold. "Fever is not a disease, it is how our body fights off infection.""Giving too little of both acetominophen and ibuprofen is less effective than giving the correct of dose of one or the other."
We are also morally and ethically obligated to teach the younger members of our ER team. PA's, nurses, ER techs, EMT's, paramedics and residents all can benefit from our experience and knowledge. Being a mentor to my colleagues, fresh their EM residencies has been one of the most rewarding aspects of my long career.
Lastly we need to be perpetual students. Medical knowledge doubles every five years. New technology, techniques, medications and diseases need to be assimilated into our aging brains. The fact that someone born at the time of rotary dial phones, TV's with black and white screens with 6 channels, and a stethoscope as the most useful medical instrument, now embraces the new, is difficult but necessary. Ultrasound, CT, MRI all need to be mastered. I use an electronic medical record, and am distressed when the system goes down and I have to resort to paper. This blog is testament to the imperative of "use it or lose it". Continue to grow intellectually and emotionally or become irrelevant.
Thursday, December 3, 2009
bearer of bad news
ER docs often have to give bad news to patients and families. People die, they get injured, they develope potentially fatal diseases. In the dark ages of residency training, the 70's, we worked 36 hours on and 12 hours off. We made rounds with the senior residents and attendings and tried to learn how not to kill our patients. There was no training in how to handle death and dying. Yes I read Kubler Ross "On death and dying", but it didn't help. The old wisdom was to run the code behind closed doors and then to emerge with head hanging and say, "we did everything we could but your loved one died". The new paradigm is to have the family in the room. I accept this new approach but not with much enthusiasm. An experienced ER doctor knows by the circumstances of the arrest if the patient has any chance of survival and if so, with what, if any, degree of neurological recovery.
I was a witness to an unsuccessful cardiac arrest run by one of my younger partners. After the code was ended, a family member arrived who demonstrated a frequently seen behavior. The disbelieving loved one implores the deceased to wake up. Magical thinking? Frankensteinian reanimation? Early in my career I tried to resuscitate a 9 year old boy who had drowned. The nurses carefully cleaned up the detritus of the code and lovingly covered the body. Later, the father, an immigrant to the US arrived and after I told him the standard condolences and how hard we tried, he leaned over his son's body. Thinking that he was going to kiss his beloved child, I was rather taken aback when he scooped up the body, flung it over his shoulder and began jumping up and down. When I recovered enough to stop his bizarre behavior, the father told me that in his country, this was how you treated someone who drowned. Third world CPR. The father and I then shared a good cry over the boy's lifeless body.
The more challenging task of disclosure is to the patient who comes in for something he or she thinks is simple, a headache, a persistent cough, an annoying skin lesion, only to be told he has cancer. A patient who I saw recently came to the ER for cough and shortness of breath. Middle-aged and a smoker, I was thinking emphysema, chronic bronchitis, maybe even congestive heart failure. One chest x-ray, a chest CT, and some abnormal labs results proved that I would be giving a potentially terminal diagnosis to a fellow human being, who I had just met.
His Holiness John Paul II spoke of the dignity in the suffering of illness. I couldn't disagree more. I have run codes on patients who where dying on one or more terminal illnesses, but who the family or the family doctor had not made a DNR (do not resuscitate). Sometimes the problem is that the DNR paper work wasn't available. CPR is a degrading and brutal affair. Tubes are inserted into any available orifice, ribs and sternum crack like kindling with chest compressions, and the team tries to do their tasks without thinking to much about the dehumanization of the process. Years ago I treated an elderly man in congestive heart failure. His daughter was in the room. The patient was still a full code. I told this woman that the next step was entubation and placing her father on a ventilator. I asked if she thought her father would want to end his life on a machine. She told me to try and make her father comfortable but not to entubate or perform CPR. It was a relatively quiet night in the ER. It was shortly after my own father had died at home, with dignity, of cancer. I gave this gentleman some morphine and his daughter and held his hands and caressed his head as he took his last breaths. We both cried. I fulfilled my oath, Primum Non Nocere, first do no harm.
I was a witness to an unsuccessful cardiac arrest run by one of my younger partners. After the code was ended, a family member arrived who demonstrated a frequently seen behavior. The disbelieving loved one implores the deceased to wake up. Magical thinking? Frankensteinian reanimation? Early in my career I tried to resuscitate a 9 year old boy who had drowned. The nurses carefully cleaned up the detritus of the code and lovingly covered the body. Later, the father, an immigrant to the US arrived and after I told him the standard condolences and how hard we tried, he leaned over his son's body. Thinking that he was going to kiss his beloved child, I was rather taken aback when he scooped up the body, flung it over his shoulder and began jumping up and down. When I recovered enough to stop his bizarre behavior, the father told me that in his country, this was how you treated someone who drowned. Third world CPR. The father and I then shared a good cry over the boy's lifeless body.
The more challenging task of disclosure is to the patient who comes in for something he or she thinks is simple, a headache, a persistent cough, an annoying skin lesion, only to be told he has cancer. A patient who I saw recently came to the ER for cough and shortness of breath. Middle-aged and a smoker, I was thinking emphysema, chronic bronchitis, maybe even congestive heart failure. One chest x-ray, a chest CT, and some abnormal labs results proved that I would be giving a potentially terminal diagnosis to a fellow human being, who I had just met.
His Holiness John Paul II spoke of the dignity in the suffering of illness. I couldn't disagree more. I have run codes on patients who where dying on one or more terminal illnesses, but who the family or the family doctor had not made a DNR (do not resuscitate). Sometimes the problem is that the DNR paper work wasn't available. CPR is a degrading and brutal affair. Tubes are inserted into any available orifice, ribs and sternum crack like kindling with chest compressions, and the team tries to do their tasks without thinking to much about the dehumanization of the process. Years ago I treated an elderly man in congestive heart failure. His daughter was in the room. The patient was still a full code. I told this woman that the next step was entubation and placing her father on a ventilator. I asked if she thought her father would want to end his life on a machine. She told me to try and make her father comfortable but not to entubate or perform CPR. It was a relatively quiet night in the ER. It was shortly after my own father had died at home, with dignity, of cancer. I gave this gentleman some morphine and his daughter and held his hands and caressed his head as he took his last breaths. We both cried. I fulfilled my oath, Primum Non Nocere, first do no harm.
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