Tattoos

If your body is covered in tattoos I am going to have very little sympathy for you when I give you an injection of local anesthetic. If you then complain about how much it hurts I just plain old don't know what to think. If in the course of me fixing your small finger laceration you remark to me, in the presence of your son, that you have tattoos "from my scalp to my pecker" then you get your story told on my blog. He did, in fact, have a tattoo on his scalp and on his penis. He evidently tried to tattoo his own scrotum but had to stop as it was too painful. I really couldn't make this stuff up.

Meet the Country's Next Serial Killer

One of the red flags for anti social behavior including murder, mayhem, basically anything bad you can think of is animal abuse. Also, a history of sexual abuse is a red flag. I think I just met Lucifer.

Brought to me by the local police tonight was a young man who has been bounced around from family to foster care. Recently he threatened to kill his current caregivers. Also, he was caught in the act of beastiality and no further details are necessary.

He had the eerily calm demeanor of someone who had absolutely nothing wrong with them and had absolutely no shame. I put him on a mental health hold and sent him for inpatient psychiatric evaluation. The kid did not even have the decency to be a drug addict or boozer... at least then one might rationalize the behavior as substance abuse related. Very scary. Very evil. Unfortunately for us, he will probably not be held very long as he is definitely not psychotic or schizophrenic. Scary.

Dulce et Decorum est Pro Patria Mori

I had the privelege of attending a memorial service on base today for some of our country's finest warriors who were killed in action. I couldn't help but think of the anti-war poem that I studied in 8th grade English- click the above title to read it. I don't enjoy death or war but I'm also not a pacifist and I love and respect our men and women in uniform. I have never liked that poem. I think it's too simple... too pat.

I was in the military for four years and I had it easy. I squeaked in between conflicts and managed to stay stateside for my tour. I currently live in a military town and the losses here are particularly hard felt, but there is no shortage of grim determination either.

It's an interesting thing to be in what could pass for the set of a patriotic hollywood movie (do they still make them?). That's what if felt like today. I did not know these gentlemen who had been killed. Listening to the service it was obvious that they had gone down in a blaze of glory, fighting the enemy, and, ultimately, dying as a result.

For someone in a generation that missed, for the most part, these kind of sacrifices it's just very humbling to see. While I was listening to the Chaplain, the Commanding Officer, and the friends offer eulogies, I had to ask myself if I could have done what these guys did. I don't think I will ever know.

Some may say that there is an element of heroism in the practice of medicine. I would disagree. I think it is an honorable profession, don't mistake me, and I'm proud to be a physician. However, there really is something unique about being a warrior. In no other profession does one chose to literally become a target, hopefully a lethal one, for the greater good. In no other profession does death seek you specifically. It takes a special individual to realize this and to choose it anyway.

The M-16s with bayonets stuck in the ground, the Kevlar helmets, the tears, the roll-call, the rifle shots, and the playing of 'Taps'. I see death all the time but this was different. This was sacrifice, this was a choice, this was heroic, this was important, and I will not forget.

Crystal

At four in the morning I met a patient with stab wounds to his left arm and axilla (armpit). They were mostly superficial but the one on the posterior aspect of his axilla was well into the fat and needed deep sutures. Also, one of the superficial lacerations on his arm went right through a tattoo which read, “Crystal”.

It turns out that this young man, a construction worker, had a girlfriend named Crystal. Crystal had a sister named Melanie, and this gentleman had set the sister up with one of his buddies from work. The only problem with this was that Melanie had an admirer who lived next door to my patient. This admirer had lost a leg some years ago in a motorcycle accident and spent his time, according to my patient, drinking and smoking and hobbling around on a single crutch.

When the somewhat drunk foursome came home the admirer was waiting. My patient was not expecting to be beaten with a broken crutch by a hobbling drunk. But he was. To his credit, he did not fight back, and had a few lacerations as a result. I did manage to reconnect the letters in the tattoo to spell 'Crystal' once again. Ah, love.

Skinny

One night at our city hospital a scrawny, hippie-looking dude was brought in by police. He was about twenty years old. He was cuffed to the gurney. It was, perhaps, 20 degrees outside, and the streets were covered with snow and ice. I have no idea what this guy was arrested for, but he didn’t want to go to jail. Typically, with patients who are flight risks we take their clothes. I was standing at the nurse’s station surveying my domain when I saw a naked guy running for the doors. Somehow this little dude had slipped his cuffs and bolted. He made it out onto the streets with his package flopping in the breeze and a couple of stunned paramedics looking at him from the ambulance bay. The police were called immediately and in 10 minutes this guy was assisted back to his room wrapped in a blanket and shivering like nobody’s business. Evidently he was not hard to find. The cuffs were applied more tightly.

The JCAHO Shakedown

JCAHO (commonly referred to as 'JAY-CO') is an onganization that has us by the short hairs. It is a prime example of good intentions evolving into micromanagement and unintended consequences. I could take the time to educate myself about the organization that has it's nose in every hospital nook and cranny across the fruited plain but I'm really not interested because I can't change things and have to live for now with the JCAHO reality which is this.

JCAHO provides accreditations to hospitals that allow them to continue to operate with a ''clean bill of health''. Without JCAHO accreditation your hospital is a pariah and funding and reimbursement dry up until you toe the line. I'm sure they do some good work but the following are examples of the absurdity that we deal with everyday in the Emergency Deparmtment.

JCAHO has established 'core measures' for all emergency departments, one of which is that we must draw blood cultures on all pneumonia patients. Never mind that the literature does not supoprt this as helpful in standard cases of pneumonia, never mind that blood cultures add hundreds of dollars to patient's bills, we have to do them because if we don't our 'core measures' score will not be good and we can't advertise complete compliance with the JCAHO standard.

If I am Joe Shmo and have never heard of JCAHO and don't read the New England Journal of Medicine then I damn well want the hospital I go to to be JCAHO compliant. Why wouldn't I? They know, don't they? Well, no.

JCAHO progressively has taken decision making away from doctors and nurses and made much of what we do redundant and 'by the book'... the blood culture example being just one of many. Are the rule makers at JCAHO doctors? I don't know, but I do know that most physicians who work for JCAHO no longer practice medicine themselves. Now here's the real shit.

Because of JCAHO we can not have food in the ED. We have to leave the ED to eat. Probably, I think, the hygeinic concerns might be outweighed a little bit by having staff out of the ED for even short periods of time. Also, I now have to push certain drugs myself. The nurse is not allowed to even if I order it. The ridiculous result is that I have to futz around with IV lines and have the nurse show me where and how to push these medicines. Does this make sense? A nurse, specifically trained to start IV's, do assessments, and push medicines is suddenly restricted so that I, with very little training in the above, have to stand with a nurse at my side and push the plunger at the nurse's direction.

I hate JCAHO.

Know What I'm Sayin'?

There is no "know what I'm sayin'?" better way, "know what I'm sayin'?", to make me think you are an idiot, "know what I'm sayin'?", than to answer "know what I'm sayin'?", to every question I ask you, "know what I'm sayin'?".

I'll Never Know

Emergency Physicians are sometimes derided as ''cookbook'' doctors unable to think much beyond the ''ABC''s (airway, breathing, and circulation). This is the order in which we address a critical patient... We secure the airway, then check and remedy any breathing problems, and then address circulatory inadequacies or problems.

There's truth to this "cookbook" criticism. We all tend to be big picture people with relatively short attention spans and near manic energy levels. We are confident people, some outwardly so, some not, sometimes with reason, sometimes not. A friend of mine put it this way, as an Emergency Physician one is "often wrong but never in doubt".

All I would say to my colleagues who do not do emergent care of patients is that when someone is dying then the Airway-Breathing-Circulation mantra will save your ass and your patient's life. I had a patient two days ago that I will always think about. This person had terrible underlying diseases and had a respiratory arrest in the field.

My paramedics intubated the patient in the field and thought they had a good tube. My respiratory tech didn't think so and I wasn't sure either so I pulled the tube and retubed him. Meanwhile he was in asystole, generally a non-survivable rhythm, and was purple from the chest up. I wondered though if it was because the paramedics had been blowing air into his stomach, and I went on with the code. The IV lines blew and I had to put a central line in his pulseless left groin. I got it in a minute or two and we slammed him with epinephrine, atropine, and fluids.

ABC. Ten minutes into the code and we were making no headway. When I tubed him I got a small bit of color change in the CO2 detector which was about right because of his down time, and I heard breath sounds over the apices of the lungs. Disturbingly, and ten minutes into the code, I thought I also heard bubbling over the stomach which would indicate a bad tube.

I pulled the tube again and put a third in. Futile care probably from the minute he went down in the field but damn it, three minutes later we had his heart back and an hour later he went to the unit with a good pressure. Total CPR/code time? About an hour. Chances of the brain being alive. Near zero. Pupils? Really big and not reacting to light.

ABC. ABC. Was the tube good? Was it dislodged during the code by the jostling or the NG tube? What could I have done differently? I could have used an esophageal detector device. We have no rescue airway equipment yet in our small ED. I could have done a cricothyrotomy to verify the tube. I could have etc... The point is that I thought "A" was taken care of and it may not have been. Ultimately in this case, shit rolls uphill. If it was a bad tube it was my fault even if I did "B" "C" and all the rest perfectly. If "A" is bad the patient dies, it's just that simple and that's where an Emergency Physician can not fail.

Assuming his first and second tubes were bad, did we cause his death. No. He had smoked himself to three heart attacks and had been ''sick'', according to the family for two days refusing to see his physician. The paramedics said that his last words before collapsing were ''no hospital''. Could he have had a meaningful survival with everything done correctly from the start. Perhaps, though I will never know. He had care withdrawn per the family's wishes as he was felt to have severe anoxic brain damage. That last tube was good and if a post mortem is done the pathologist will find it right where it should be. I will never know if the first two were. I will not crawl into a bottle of Jack Daniels over this but I will learn from it. ABC.

One's Mind Wanders

A man died on the surgical floor the other day. I took the call to run the code and it went on and on and on. We did not succeed in resuscitating him.

During the code we went through most of the Advanced Cardiac Life Support (ACLS) algorithms but to no avail. We performed CPR for almost an hour (not a one person job), and there were nursing students in the room. This was a great learning opportunity for them so we had every one of them take their turn learning the proper CPR technique.

Now I was not the only male in the room but I didn't dare make eye contact with any of the others. You see, it just so happened that these particular students were all young and female and fit. All of them were a bit small too so they had to get up on the bed and straddle the patient in order to create enough downward force to compress this gentleman's chest.

It was a bit disconcerting for me and I couldn't really watch them (I let the senior nurse in the room advise them of their technical skills or flaws). Out of the corner of my eye though, between looking at the monitor, repeating the cardiac ultrasound, and ordering medicines I noticed a strange picture.

There's just no nice way to say this but if I had been looking in the window and hadn't seen the patient or the other 10 people in the room I would have been forced to conclude that a lucky patient was getting quite special treatment. I say this to my shame, but in retrospect it encapsulates how many times humor, death, life, and sex do a strange little dance every day in the world of medicine.