Have Jeep Will Travel

I think I've mentioned before that I love my Jeep.

I had the day off so I decided to go for a drive and went down to the beach.

There's a couple of places to pull out and then you get views like this.

However, trying to leave I soon ended up like this...

And, then I had to wait for my hubby to come get me out... 

but then we took the Jeep to a little more user-friendly area.

I still love my Jeep.... but I might have to think about investing in some knobby tires...

Trail-Blazing

As you know, I've bought a house on 25 acres.  Twenty-five acres of almost untouched wilderness.  There's a front five acres that hasn't been touched in 16 years.  The only thing going through it are the myriad of deer trails cutting through the trees.  Until today.

About a week or so ago I actually bought a chainsaw.  In 30 minutes I went from medical maven to Chainsaw 101 novice.  I spent that time with the Husqvarna salesman who talked to me about horsepower, torque, blade length and what kind of chain to use with what kind of wood.  I haven't turned it on, but today my husband did.

We spent the afternoon when I got off my work shift clearing a path on the Front Five;  enlarging one of those deer trails.  He went ahead cutting limbs and small trees, and I followed behind, pulling the branches and tossing them into areas we had designated for the foliage.  Then we got to an area with a large clearing.  That's when I got to work.

I used the weed-eater to clear the brush and greens from around the bases of small trees then my hubby cut them down.  We then made several large piles with the thought of coming back with a "Bush Hog" and getting all the underbrush in the open areas trimmed down.  Of course, we can always just put a fence around everything and get those goats we've been talking about... 

The Rainmaker

A while back I talked about the difference between Black Clouds and White Clouds in medicine.  Seriously, since becoming an attending, I have become the Sh*& magnet in the E.D.   Today was a prime example of why I should not be allowed in the building without some sort of hazard warning for the staff.

The morning started like any other Saturday.  Random cases that could have waited until Monday, or who had waited all week to be seen came in.  Nothing serious.  The patient with the stuck end of a cotton swab in their ear was about as exciting as it got.  I got it out and saved the day.  Yeah for me.

Then about the time we were thinking about lunch, we heard a call go out on the radio about a motorcycle crash south of us.  We heard the paramedic give report to the closest hospital letting them know they would be by-passing them and coming to us.  It didn't sound too bad, just some shoulder pain.  We waited for contact from the ambulance.

While we waited, the E.D. slowly started filling up with random patients that were a little more complicated and needed some sort of work-up (labs, x-rays, etc.) before they could be dispo'd (a decision made regarding admission versus outpatient treatment.)  Then finally the call came across that in 30 minutes the patient would be arriving.  Vital signs were stable, and we still didn't get a sense of an overly critical patient.

When the ambulance was 10 minutes out, they called again.  We had one of the trauma rooms ready.  However, at about the same time another ambulance had gone out for a cardiac arrest, and we were waiting for further information from them.  And then my lunch arrived, but that's just another example of bad timing. (and, no, I didn't get to eat this one either.)

The motorcycle crash arrived, and it quickly became obvious that this person would need to be intubated and placed on a ventilator.  I was just listening to heart and lung sounds and feeling the disconcerting sensation of severely broken ribs and a crushed sternum when the cardiac arrest arrived in the next room.  For the next 45 minutes I stood in between the two rooms and simultaneously ran a cardiac arrest and a trauma resuscitation.

Seriously.  The monologue went something like this:
Cardiac Arrest (CA):  continue CPR, hook them up to the monitor and let's see what we have
Trauma Resuscitation (TR): get X-ray in here for a STAT portable chest and pelvis
CA: that's V-fib, let's shock 'em
TR: someone hold c-spine and help the radiology tech, plus we need another IV line started
CA: still V-fib, shock again
TR:  start getting the RSI (rapid sequence intubation) meds together and get a vent
CA: continue CPR and let's get a vent ready in here
TR: sats are dropping let's get ready to intubate
CA (from the other side of the curtain while intubating TR): yes, push epi and continue compressions
TR: intubation done, I need to see that first x-ray and we're going to need a second one for ETT placement
CA: ok, it's been almost 90 minutes is everyone OK with calling the code? Time of death is ___
[went to go look at TR chest film]
TR: mediastinum looks a little wide and pelvis definitely looks widened, we need CT's of everything from head to toe, call CT and let's get going, meanwhile I'm going to do a FAST exam... excuse me..?  The CA has a heartbeat???!!???
CA:  ok, we have a heartbeat, and we have a pulse let's push some atropine and get the patient back on the monitor... (20 minutes later)... Time of death is _____,  I'm going to go talk to the family
TR:  when are you going to CT?

I walked out of the trauma rooms and the E.D. had all but imploded on itself with every room full and about 6 charts in the "waiting to be seen" chart rack.  I quickly looked at the CT scans of the trauma patient and knew that they would need a chest tube and a central line.  I called for reinforcements from surgery and another E.D. physician to help with the deluge.

After I placed a central line to help with the need for blood products, the surgeon arrived to place a chest tube, and we started to get the official radiology reports.  The patient had internal bleeding and would need to go to the OR.  The surgery team was called in while I received report of yet another motorcycle crash coming to us within the half-hour.

The trauma was rushed off to surgery for some internal bleeding and intestinal injury then transferred to the trauma center at UCDavis for their other multitude of injuries.  I discharged some of the patients that had been in the E.D. at the start of all this, admitted some others, evaluated the newly arrived trauma, and started sewing back a hand ripped apart by a great dane.  My colleague showed up and started seeing some of the longer waiting patients, and we cleared the board just about the time it was my end of shift.

I was munching on a cold lunch and dictating my stack of charts when a cardiac arrest rolled in the door... help with CPR?  Sure, I think I can handle that.

I'll March My Band Out...

So, sometimes you have to toot your own horn.



There's a lot of little victories we win from day to day.  They can be as simple as making it out of bed in the morning, to not losing it when the coffee girl gets it wrong again, to saving a life and being the hero.  Of course, in Emergency Medicine, you save a life and then go on to the cough, runny nose, year long history of headache suddenly worse tonight... there's no fanfare, no applause, no big Broadway number. And, we're ok with that.

But, sometimes... just sometimes you want to yell from the rooftops, "Hey! World! Look at what I did today!" So that's what I'm doing with two stories from the E.D. No congratulatory applause needed, but statues in my honor will be accepted.

Just a note, this is going to run a little longer than my usual posts so you might want to grab a cool beverage.  Champagne toast in my honor... aww... now you're making me blush...

You know I dread Mondays;  in general, the busiest days in the E.D.  So I was mentally preparing myself and starting the day off with the usual cafeteria fare and a coffee.  It was just before the start of shift, and I ran into the Nursing Supervisor who gave me the head's up that a patient in the ICU was not doing well and might need to be intubated (put on a ventilator). He said he would let me know as sometimes the anesthesiologists handled the intubations, and there should be someone free.

I went back to the E.D. and made sure I had the GlideScope at the ready since typically ICU patients are harder to intubate, and I wanted to make sure I had all my tools ready.  Sure enough, about 10 minutes later I was called to the ICU.  It was explained to me that the patient was very sick from a simple infection gone horribly bad and not only needed to be put on the ventilator but also needed a central line.

The patient was on a CPAP machine that was helping their breathing but was quickly tiring and needed to be put on the ventilator.  A central line is like an IV except it is much bigger and can deliver fluids and medications rapidly.  It's usually placed in one of the larger veins of the neck or just under the collar bone.  Sometimes it's put into the femoral vein in the groin.  We have been putting them into the neck vein using ultrasound so we can visualize the needle going in which is much safer.

So, anyway, the patient is on the CPAP doing ok for the time being, so I decided to do the central line first.  I got all of my equipment in order and the last thing we did was lay the patient flat so it would be easy to put in the central line.  I was dressed in a sterile gown and was just about to insert the needle when the nurse noticed that the patient's oxygen status was dropping.  So we tossed everything off the patient, and I got into intubation mode.

Intubation involves timing medications to relax and paralyze the patient and then using a laryngoscope to lift the jaw and see the vocal cords.  Only when I took my first look there was nothing to see.  I adjusted the scope and looked again, still nothing.  Understand that while this is going on the patient is not getting oxygen to their lungs and this patient had no reserve and starting dropping their saturations again.  I pulled out and we "bagged" the patient to get their oxygen saturation back up again, and I grabbed the GlideScope which I had brought with me, thankfully, from the E.D.

I got back into position and took a look with the GlideScope... nothing... Everyone's eyes were glued to the small screen.  I made a few adjustments and suddenly there were the vocal cords!  I think we had all been holding our collective breaths about that time, but suddenly it was the like that cave scene in "Raiders of the Lost Ark" where all the walls start to collapse around you.  I quickly put the endotracheal tube in and watched in almost horror as the tube pushed the vocal cords further and further away.  I had the EMT standing next to me grab the stylet supporting the tube, and I pushed harder.  We all watched the screen as the balloon on the tube slid through the vocal cords, then we let out a breath and got to the business of securing the tube.

Not even catching my own breath, I re-gloved and gowned and quickly put in the central line that I had been working on.  We got the patient's oxygen saturations back up to an acceptable level.  The primary physician ordered antibiotics and fluids now that we had the central line to be able to manage all the different fluids, and I ordered a STAT chest x-ray so that we could confirm placement of the breathing tube.  I grabbed the GlideScope and headed back to the E.D.  An hour had passed, and I would be seeing my first patient... back pain, really?  I think I can handle it.

My second story will be much quicker...  I had just finished intubating a young man involved in a roll-over car crash (who ended up having a brain injury and would be later transferred to a neurosurgeon) when we got the call that three victims of another roll-over car crash were on their way in with one patient also having a head injury.  I quickly reviewed the labs and films on the first victim when the second victim was at the back door.  We got him into the other trauma room, and I repeated all the instructions to my respiratory tech who was getting very familiar with the routine.

Two trauma intubations within 45 minutes of each other.  Two more car crash victims to add to the already full Emergency Department.  Yup, got it.

"I'm gonna live and live NOW!
Get what I want, I know how!
One roll for the whole shebang!
One throw that bell will go clang,
Eye on the target and wham,
One shot, one gun shot and bam!
Listen here, World, here I am... !"