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.