The Final Countdown - Day 3 of 5

A quote by Emerson states: "To finish the moment, to find the journey's end in every step of the road, to live the greatest number of good hours, is Wisdom."

As many of you know, I'm probably at my happiest when I'm traveling. Just the thought of that next voyage or road trip keeps my mind wandering to what next adventure am I going to have? Will I be going someplace familiar, or will I be going someplace new to explore?  Who will I meet along the way? What new places will I find to eat, and how many photos am I going to take? 

Alas, with the new travel restrictions, I really don't have a travel plan until I start working my new job somewhere in the Mid West. To be honest, I'm not quite sure where actually since licensing is up in the air. And, travel for work really isn't a journey. It's more like commuting. Don't get me wrong, I love to fly. I love to check out new places. But it loses some of its luster when it's for work, because, well, you're going to work. Still, I love to sit and people watch at the airport. I create scenarios for some of the people I see. Mostly I can't wait to get to the end of the trip just to be done with the getting there. Certainly not as exciting as heading out for vacation, but for the time being it will have to do.

Anyway, today was a crazy day. It's not like I saw a lot of patients because, even though there were a lot of patients, we can't bring people back to a room when there aren't any because the rooms are full of other people... 

 - people like my meth addict who came back again but this time stayed long enough for me to actually evaluate their wound, give them antibiotics and actually ask them to come back again so that we can try to get social work to help get them the resources they need to keep their foot from getting so infected it would have to be amputated.

 - people like my really bad pneumonia that had to be intubated. Once, again, please have the discussion with your family members about your final wishes. And, while I appreciated that they had a Living Will, it wasn't very clear about CPR versus no CPR, or being on a ventilator. Sure I can say I think it's possible they might come off the vent once the pneumonia is clear, but I can't guarantee it. I wasn't not hopeful for this patient, but I can't promise that they won't need to be on it long term. We'll see how they do.

 - people like my 60-something, meth'd up patient who dislocated their hip... again... somehow "in their sleep..." my back and hip are feeling the effects of yorking on that leg "Captain Morgan style" and getting it back into place. That actually was a "yeah for me" kind of moment because initially a colleague attempted to reduce it and didn't... and I did... yeah, that's right, I did it, 5ft 1in me who had to practically climb on the bed... pat on the back for me.

- people like the transfer from the smaller hospital that needed hemodialysis which they don't do in the smaller hospital, the three psych patients who are in the midst of their varied psychoses and either suicidal, severely depressed, or floridly psychotic... at least I was entertained by their Cardi B impression... they received a clap for that...

And, speaking of entertainment, we had two police take downs this morning. One was drunk and decided that they weren't going to cooperate with a legal blood draw. The second was another of our repeat customers who decided they were bored of sitting in the waiting room and did some kind of substance then proceeded to act crazily which then required three police officers to take them down and away to jail. Funny thing: this patient has a pretty serious heart infection from their IV drug use but keeps leaving the hospital to... shoot up drugs... then returns because somewhere in their brain they know they need IV antibiotics... but the last time they were successfully treated was while they were in jail because they actually got their full course of antibiotics. Fancy that.

- I had the usual chest pains, the falling down, the miscarriage, and, I'm sure a couple I'm forgetting... probably because my head is thinking I should be thinking about the Pacific Ocean and sipping a piña colada on the deck of a ship... 

But, for a while I'm not sure what I'll be imagining other than I've got two more shifts then six weeks to contemplate... and plan... because I never stop planning for that next big adventure... 

The Final Countdown - Day 2 of 5

And, so it's come to this...

A tent just outside of the ED to help contain the flood of

sick, maybe sick and worried well.

And, just when I thought I just had to make it through

3 more shifts and escape from all this craziness...

So, now I have a whole month off to sit and ponder my future.

Well, according to my DH, not actually sit, but pack

and start getting ready for a cross country move a little sooner than expected.

Without any massages or facials or body wraps... sigh... 

Hey, at least, all of our suitcases were packed.

Now we can just load those up and be ready to go...

anywhere...

But, for the next three days, it'll just be more of:

- known drunk comes back in... drumroll... drunk; seriously, I just saw you yesterday

- known infection comes back in with infection after leaving the hospital to go do meth;

surprisingly, not the same one as yesterday, although the one from yesterday did come back too,

they just left because they weren't being see fast enough

and that's because my nurses, in full hazard gear, were swabbing noses and throats

out in people's cars... the ones that met criteria... there were a lot that didn't...

anyway...

- saw a kid with a viral infection

- saw another kid with pink eye

- saw an elderly person that's been on chronic pain meds and switched over to suboxone by their primary care doc and wasn't handling the switch very well

- there was a pneumonia

- there was a stroke

- there was a mystery diagnosis solved by one of my internal medicine colleagues because 

they see stuff we never see

- there was an allergic reaction that came in covered in hives

- and there was the patient that was seen a couple of days prior, had a negative

work-up, came back because they left before they were given discharge instructions 

and were actually feeling better but still wanted to know what was wrong with them

because Google told them that they might have a "blood clot" that "migrated from between their shoulder blades to their pectoralis muscle" and made them cough... I tried to explain to them that

yeah, that's not how that works... and they told me I didn't understand because I hadn't heard the "whole story" at which point I heard every small detail of their life from sleeping on the floor,

to taking their kids to school, to having something to eat, then taking a nap, then the "blood clots" migration from back to front and now gone, and how they were sure it was a "heart attack" because they felt their heart "exploding into pieces" that one time they were in a meth-induced haze

and how they've had many "undiagnosed heart attacks" because they felt that way 

several times... that was when my head exploded...

when I walked out of the room I was imagining myself on a long ocean cruise... 

which is now not to be... sigh...

Let's all pray together as we wash our hands that soon "this too shall pass"

The Final Countdown - Day 1 of 5

So about 9 years, 5 months and a week ago I started as an attending

at a small hospital in Northern California.

This is how it went.

Today I started the last of 5 shifts that I will be working

at the slightly bigger sister hospital.

This is how today went:

cardiac arrest came in, after about 30 minutes of CPR and putting in a breathing tube

we got back pulses... then I had to stop the ventilator because we found out the patient had a DNR (do not resuscitate) and the family member let us know that they had wished to not have anything done,

so that was a little frustrating

during that time, a patient came in with a really low blood pressure and fast heart beat,

hung some IVF and some pressor medications and got them under control,

admission to the ICU

then I had to clean up the mass of patients that had come in while I was working on the cardiac arrest and patient with low heart beat

they included:

  - a chronic drunk who was drunk again and needed a room to sleep it off

 - poison oak allergic reaction

 - patient with shingles

 - patient with problem with their ostomy

 - a chronic meth user that left the hospital to smoke meth and was now returning

because their infected foot somehow did not magically get better without 

antibiotics and wound care, not to mention running on it barefoot in the woods

while high on meth

 - an elderly couple both with dementia that went on a joy ride and ended up driving down

an embankment

- a patient who passed out and hit their head and who could now not move their leg

AND

I had to manage the patients signed out to me by my colleague in the morning

which included:

- an appy

 - a pregnant appy

- a car crash victim with abnormal vitals

and a couple of people who didn't like their lives any more

so needed psychiatric help 

AND

in the midst of all this a code was called on the hospital floor

and I had to run upstairs and put a breathing tube in that patient

while they were doing CPR...

... the patient later coded again in the ICU and didn't make it...

AND

not to mention a lot of phone calls where we had to triage and decide

which patients actually needed COVID testing... OMG

The one bright spot in my day was a visit from a patient

who'd had a serious brain infection which had to be transferred down to 

the big city children's hospital where they underwent

brain, eye and sinus surgery,

IV antibiotics,

physical therapy to help them be able to walk and move

their right side again

and here they are a month later looking

bright and a lot healthier than the day I saw them...

this is them:

I hope he does amazing things... 

*photo posted with permission*

NaBloPoMo - Day 18 - Seriously...?

I haven't watched "Grey's Anatomy" in the longest time, 

but one of the taglines from the show that I remember vividly

was "seriously..?"

It covered everything from boy problems, to work problems, to all general life problems.

Often, when I pick up a chart in the ED, I read the presenting complaint of

(what the patient came into the ED for) and immediately go "seriously?"

Others, I go in and interview the patient then walk out and go... "seriously?"

Still others are given the benefit of the doubt, worked up,

found to have, um, something like meth or cocaine in their system,

to which I say, "Seriously...?"

I really wish I could say it to the patient...

As in,

"Seriously..? You came in concerned that you were having a stroke because

you "couldn't think straight," or couldn't "find the right words,"

and your head and your body hurts and you're not sure why...

Well, let's see... your CT of the head was negative...

your EKG, labs, vitals are all normal...

oh, but let's focus on that drug test:

positive for cocaine

positive for methamphetamines

positive for benzodiazepines

positive for methadone (which you're not prescribed, by the way)

and you wonder why you alternatively:

don't feel right...

have been really tired...

can't seem to focus...

etc...

Seriously...?

People wonder why health care costs are so high...

I think it's in part because of all the patients like this I see on a daily basis...

Today it was like this for three different patients...

All different genders and age ranges...

I can't discount you're not having some physical symptoms which are bothering you,

but if you had initially just been a little honest about your social habits

I probably could have avoided about $5000 worth of a work-up.

Don't do drugs, seriously...

And, especially, don't do uppers which you then take downers for

which leads to more uppers, then downers, then uppers, etc, ad nauseum...

I wish we did have levels instead of just positive/negative for drugs

because I think some patients have perfected the meth/heroin ratio...

However, combining uppers and downers can 

lead to a potentially lethal combination...

Then there's the "what's this on my body...?"

Seriously, you came in for that...?

#297 to 264 - Z is for Zombie Apocalypse

Thank you for visiting my blog throughout this month.

I hope that some of you will stay and continue to follow

my blog throughout the rest of the year.

Although this month I focused on fun things

like travel and photography,

at the heart of it all, I am a doctor...

in the Emergency Department...

working in areas with high levels of

drug abuse,

homelessness,

unemployment,

and poor education.

There's a lot of trauma and drama

some of which I write about here.

I share stories and pictures when I can,

but I do work in a rural area some of the time,

so it's hard to keep HIPPA-compliant and

still give a complete story... 

Nevertheless, I do write a lot about my own experiences

and feelings.

And my beliefs on the importance of taking responsibility

for your health and that of others.

So I write about those things as well.

As for the Zombie Apocalypse..?

Well, methamphetamine abuse is high in the areas where I work.

If I could just videotape the patients that come in high on meth,

or the medical problems that meth brings

I'd have hours of tape to share to hopefully

keep someone from going down that road.

You can Google "meth mouth," "meth skin,"

"the faces of meth" to see what I see every day.

People prostitute themselves for meth.

They steal whatever they can for meth.

They come to the ED for drugs that they can then trade for meth.

I had a patient tell me yesterday that they lost their medical insurance

so they couldn't see their doctor for their chronic pain condition

so they were "self-treating" with meth.

I know they were going to take whatever prescription 

I wrote them and sell it.

Irony is, because they were homeless with no ID, the pharmacy

called to tell me they couldn't fill the script.

And, because of the effects on the brain, there's no

reasoning with these patients.

They don't understand that methamphetamines will lead to being tired

or weak or shaky because the effects are like running a marathon, full out,

without important things like eating or keeping hydrated.

They don't understand that the "worms under the skin" that they see or feel

are because of the effects on the nervous system.

So they pick at their skin to the point of causing bleeding

which leads to scarring and, worse yet, infection.

Which can lead to sepsis, possible amputation and sometimes death.

Pain management is a huge issue with these patients

as meth has fried out all of their pain receptors so now

pain which to you and I might be handled with a Tylenol now

requires large amounts of narcotics.

Don't even get me started on the dental problems...

Whew!  I thought we needed a nice pastoral scene from

the little chunk of Earth I call home...

Chickens and geese, I write about them too....

Hope to see you again soon...!

p.s. In July I do a birthday iPod shuffle where I write the whole month

about songs on my iPod, and I participate in NaBloPoMo in November

Day 26 - Warning Labels

Most people know that they shouldn't drink and drive...

but they do.

Most people should know that they shouldn't use 

certain prescribed medications and drive...

but they do.

And we see the aftermath all the time in the

Emergency Department.

Or, I should say, all that remains from the aftermath;

because those that die immediately in that

rollover,

head on collision,

auto versus pedestrian,

or other accident

never make it to the ED.

We hear about them later in the news,

from family that come to the ED looking for their loved ones,

from the police officer, sheriff's officer, CHP officer, paramedic

or worse when they survive the accident, 

but then are pronounced in the ED because they are

too broken to be fixed.

But the DUI offender...?

They're rarely injured seriously.

There's a saying that there's a god that protects

drunks and small children, 

and never is that more truly realized than in the ED.

Sorry your ankle hurts "really bad,"

but that combination of methamphetamines and norcos

which caused you to cross the center line

should hold you over while you're being processed in jail

for the deaths of those grandparents who were just

traveling to see family.

I know your head hurts.

Bummer that the alcohol you used to wash down

the benzos you have for anxiety can't help that.

I'm sure the family of the child I'm flying out to a trauma center

understand that you needed to "just run out for some cigarettes."

I'm sure they're thinking of several ways to help you

stop smoking... permanently.

The nurses and I realize you think you need your

next dose of pain medications early for your broken wrist

by the endless pushing of the call button with your

good wrist which is, by the way, handcuffed to the bed,

but we're a little busy over here trying

to keep the teen you hit on their bicycle alive

because they've now got more tubes in them than a

1950's television, and the bleeding isn't stopping.

Would you like to make a donation?

Oh, no, sorry, the blood alcohol level is a little

too high, and the cocaine surge probably would be a bad thing.

Yes, back/tooth/arm/leg/stomach/neck pain can be very bad.

Here's your prescriptions for ibuprofen and norco.

Make sure you read the warning label, don't use alcohol

and don't drive or use heavy machinery...

any questions?

#575 - F is for Frenetic

Momma told me there'd be days like this...

Here's an example of the kind of day I DON'T like to have in the E.D...

My shift started at 0800, there were already 5 patients on the board,

4 of which my colleague signed out to me waiting for lab or xray results.

The patients I saw today:

 - patient who swallowed an entire bottle of herbal supplement after confusing it with a bottle of 5 Hour Energy Drink

 - leg pain for a week, worse today

 - I Didn't Know I was Pregnant show candidate who came in about 7 months pregnant and using meth

- patient with facial lac after a fall out of their wheelchair

- psych patient off their meds who ran out the door twice, and brought back by police once

- patient who passed out while getting out of their trailer

 - strep throat

- skin infection

- patient who passed out while doing chair exercises with their senior group

 - asthma attack

 - migraine headache

- hair coloring on beard gone awry

- dental infection

- alcohol intoxication, passed out in front of the local market

- cough for several months

- chronic headache who could only be treated with demerol which we haven't had in the ED for years

- tick bite brought in because "we didn't get it all out"

- end of life hospice patient

- patient who was second in line to be seen, but left because after waiting 30 minutes they couldn't wait any longer for the CT they knew "they just had to have" for the belly pain that had been going on for several weeks

- appendicitis

- eye irritation

- panic attack

- alcohol intoxication hit in head by spouse with head laceration that then cussed us out and ran out the door

- skin infection

- febrile illness in transplant patient

I left out identifiers like sex... the pregnant person you can figure out.

I left out much of some of the back story because this is a small town

after all, and everyone knows everyone's business as it is...

These all came in within a 12 hours period and kept my ED busy

the entire time...

Let's now even talk about how many charts I have yet to do...

NaBloPoMo Day 12 - Having Kids

Third of the way through... woohoo...!!

I don't often write about child abuse and my thoughts on population control (like a manditory "Depo-Provera vaccination" for all teen girls), but some shifts just get you more than others.  There's a quote I think of often when shifts like this happen.  It's from the movie "Parenthood" with Steve Martin and Keanu Reeves.  Keanu's character is a soon-to-be young father, and he says, "You know, Mrs. Buckman, you need a license to buy a dog, to drive a car - hell, you even need a license to catch a fish.  But they'll let any butt-reaming asshole be a father."

Last night was about parents, who under the influence of various substances, probably weren't as attentive to their children as they should be, and the children are the ones who suffered... head injuries... intracranial bleeds... etc.  There's a lot of people recently calling for drug testing of welfare recipients.  Last night should have been about the drug testing as a qualification for parenthood.

I don't know that I've ever written about this before, but when I went to adopt my cat Winston I had to go through a long and lengthy process.  I adopted him from the Chicago AntiCruelty Society.  I had a rather lengthy application to fill out which included my needing to list my place of employment, provide a pay stub, present proof from my landlord allowing me to have pets in my apartment, etc.  I also had to have an interview which discussed everything from my work schedule, prior pet owning experiences, disciplinary tactics, and only then was I allowed to look at the kittens.  Much different from prior experiences of "pick one out of the box and let's go."

While doing my residency in Buffalo, we'd get a lot of patient with multiple children.  Sure, each one was that much more state support entering the household.  While I don't agree with the selective abortions and infanticide heard from China, their One Child Policy that encourages single children and punishes multiple births might be a consideration.  Along with mandatory drug testing, because seriously, how can you enjoy your child when your mind is clouded with methamphetamines... pot... methadone... alcohol... a combination of all or any of the above....?  I find it to be the ultimate in selfishness... which is the exact opposite of what you should be when you decide to bring another life into the world.