Blissful Ignorance

Hey all! Blogging to ya from a remote tropical place where the sands are sugary white, the wind blows hard, and those little drinks with the colorful umbrellas never stop flowing. Being unemployed have never felt so relaxing. Truly this windsurfer's paradise. It's so awesome pulling off a duck jibe on a 65 liter board and a 4.0 sail. Rippin' it every day, man! The wind here is just unbelievable, steady and hard, while the water stay calm without the chops. But on the south side though, the waves breaks hard off the reefs. Oh man, perfect for wave sailing and surfing! Just visited the local ER, too, and they're hiring! Sweet! Tempting, but I haven't made a decision after the interview.

The internet connection here is slow and spotty.

I just checked Technorati and discovered that there's a healthy discussion here about one of my post. Unfortunately, many of these folks are non-medical and think that ambulance abuse is a rarity!

The Calling

My 8 y/o nephew interviewed me the other day as part of his homework assignment for school. He asked me the ultimate question, "Why did you become a doctor?" I didn't want to disappoint an impressionable child with the truth, so I gave him the usual inspirational answers about wanting to make a difference, helping people, saving lives, etc... But the truth is, I didn't know what else to do at the time so I went to med school.

My application to med school was impeccable, I must brag. I was the total package, clawed my way out of the housing projects of Crack City to graduate at the top of my high school, graduated summa cum laude in engineering from a prestigious university with internship experience through several internationally recognized companies. Even won a couple of national collegiate engineering design competitions, too. I proudly enumerated all of my proud academic achievements and accolades on the application, of course. I also included 2 U.S. patents with my name on them, earned from my work as an engineer for 3 years with a very well known company recognized worldwide as the premier leader in its field. Heck the company pretty much has a monopoly in the area, and still does. Thank goodness I had the foresight to max out my employee stock options at the time. Oh, I also aced the MCAT to boot. But my career in medicine almost never happened, as my first med school interview was a complete flop. And I only applied to one school.

I walked up and down the corridors of the MOB (medical office building) looking for his office. Tucked far in the back hallway corner, I finally spot the sign on his door, Dr. Weinstein.

"Good morning, sir..." I introduced myself cordially.

"You're 15 minutes early, Mr. Charity," he grumbled in a deep baritone voice. "Why don't you just wait outside until I review your file and I'll call you back in."

I peered furtively into his office as he closed the door. There wasn't anyone else in there. It wasn't as if he was interviewing another candidate or something. Then why the hell was this man making me stand outside the hallway like a stooge, I wondered to myself. And since when is showing up early for an interview, or anything for that matter, a detriment? Oh this guy was a hard ass! I could tell from the very get go.

Exactly 15 minutes later, not a second more or less, the door re-opened and he instructed immediately, "Have a seat, Mr. Charity."

I didn't even have an opportunity to speak my mind. It was that quick and short.

"You have very impressive credentials, Mr. Charity," he tossed my files onto his desk, propped up his feet and opened the conversation. "Your essays are very moving. Powerful, I must admit," he complimented, "You're a very good writer. And the letters of recommendations, very persuasive in your favor."

My confidence was quickly shattered, though, when he sat up and dropped the hammer, "So, why the hell are you here?"

"Excuse me, sir?" I replied dumbfoundedly after being completely stunned by his informality.

"Why the hell are you here?" he repeated crudely. "It looks to me like you already have a successful career in engineering. You shouldn't be in medicine, Mr. Charity."

"Sir, I want to be in medicine...."

"Let's not waste each other's time anymore, heh," he interrupted. "You don't belong in medicine, Mr. Charity. You were born an engineer. Go back."

With that he stood up and showed me the door.

(To be continued)

Insurance?

cc: "I think I'm pregnant again"

HPI: 22 y/o sexually active WF LMP "last month" c/o possible pregnancy. Denies pain. Denies vag. bleeding. Have not performed home pregnancy test.

ROS: 9 points ROS o/w neg.

PMHx: none
PSHx: none

POB/GynHx: G4P4Ao, all NSVD w/o complications, no STI's

PE: WDWN, AAOx4, NAD, ambulatory, drinking bottle of Sunkist soda.
HEENT: NCAT, EOMI, PERRLA, nonicteric
Neck: No LAD/mass/JVD/thyroidmegaly
CV: RRR, no m/r/g
Chest: CTAB no crackles/r/r/w
Abd: +BS, soft NT/ND, No HSM/masses. unable to palpate fundal ht.
GU/Pelvic: deferred since patient denies pain, VB or d/c
Back: No MT, no CVAT
Ext: 2+pulses throughout, no c/c/e
Skin: warm, dry, no obvious rashes
Neuro: grossly intact, no lateralizing signs, nonataxic gait.

Assessment: Young female requesting pregnancy test. LMP last month. Denies pain. Denies VB. PE benign. Abd. without pain on palp.

Plan/Dispo: Patient instructed to go to local pharmacy and get a home pregnancy test. If pregnant, f/u with her Gyn MD.

The above is the actual medical record documentation. The following is how things really transpired.

Me (after reading triage sheet and rolling my eyes): Hi, I'm Dr.____. I'm the doctor in charge of the EMERGENCY Department tonight. I see that you came by AMBULANCE. What was so bad that you had to call 9-1-1 at 3 AM to be rushed to the EMERGENCY ROOM by AMBULANCE? What is your MEDICAL EMERGENCY? What is your LIFE OR LIMB THREATENING problem??

Patient (clueless to the sarcasm): Oh, I think I'm pregnant again.

Me (thinking that this clueless girl still don't get it): You must be in a lot of pain or bleeding severely to come in by ambulance, huh?

Patient: No. I just didn't have a ride.

Me: So you're not having any pain or vaginal bleeding?

Patient: No, no pain. No bleeding.

Me: Did you take a home pregnancy test?

Patient: I didn't have one.

Me: You know they sell them at Walmart. They're open 24 hrs.

Patient: Well I couldn't go to Walmart in the middle of the night.

Me: So you took an ambulance?

Patient: Yeah, but my insurance will pay for it.

Me: Insurance? It says here that you've got Medicaid.

Patient: Yeah, that's my insurance.

Me: No, dear. Medicaid is not insurance.

Patient (quickly interupting me): Yes it is! That's my insurance!

Me: No, dear. Medicaid is not insurance. Medicaid is a government hand out! It's only called insurance if you're paying for it.

Patient: Well, what ever! Medicaid will pay for it.

Me: Good grief! You didn't have to take a $400 ambulance to the hospital for a simple pregnancy test.

Patient: But I didn't have a ride.

Me: You could have taken a cab. Surely you got $20 bucks for a cab. And those pregnancy tests are under $20 bucks at Walmart ya know. $400 bucks ambulance ride versus $20 bucks...You could have save us tax payers a lot of money, ya know.

Patient: My insurance will pay for the ambulance.

Me: Good grief! How many times do I have to tell you that Medicaid is not insurance? And it won't pay for nonemergent problems.

A quick 5 seconds physical exam. Push on the belly, no pain. Scribbled the discharge instructions and handed to patient to sign:

Go to local pharmacy and buy a home pregnancy test. Follow up with your medicaid assigned gynecologist if positive. If having pain or vaginally bleeding, return to ER.

Patient: So you're not gonna run a test to see if I'm pregnant?

Me: No, a possible pregnancy is not a medical EMERGENCY.

Patient: But my insurance will pay for it.

Me: Not if I don't order it. And even if I did order it, Medicaid...Oh never mind, just go to Walmart or any drug store and get yourself a home pregnancy test, alright. They're the same urine pregnancy test that we use in the hospital anyway, and it's much cheaper, too.

Patient (indignantly): So how am I gonna get home now? I got 4 kids at home.

Me: Well, you should have thought about that before you took an ambulance. Surely you didn't think that we would admit you to the hospital for a possible pregnancy, did you? Your kids are not at home by themselves are they?

Patient: You're a mean doctor!

Me: No I'm not! If I was, I wouldn't have ask about your kids. They're not home alone by themselves are they?

Patient: No, they're with a friend of mine.

Me: Alright. I'll see if the charge nurse can help you with a cab voucher home. There's also a cop here from your part of town. Maybe he can let you hitch a ride home in a while.

It's so frustrating trying to convince the local EMS folks to be not so fearful of litigation and have the balls to call their on line medical control and get a refusal to transport order for all these silly nonemergent problems.

Adden: I must issue an apology to all of my EMS brethens regarding the above statement. The problem is not with the heroic folks pounding the streets because they are only following orders and protocols established their chicken-shit administrators and medical directors who are the real ones fearful of lawsuits.

Another Quote of the Night

From the same charge nurse to hysterical patient with a stuffy nose whose chief complaint was "I can't breathe" -

"Ma'am, if you can talk, you can breathe...Ma'am, just calm down...Ma'am that hole in your mouth is bigger than the two holes in your nose! If you can talk, you can breathe!"

Crushing logic, isn't it?!!

Quote of the Night

Direct to you from last night's shift, wicked words of wisdom from Crack City ER's charge nurse to belligerent patient after polite attempts at diffusing a situation failed:

"Sir, as a nurse, I will clean your ass, I will wipe your ass, I will even stick my fingers up your ass. I will exhaust every effort to save your ass. BUT, I will NOT go so low as to kiss your ass. And rest assuredly, if you continue to piss me off, I will not hesitate to kick your ass! Now plant your ass down or I will take your temperature with my boot!"

Dereliction of Duty

It's May. My last month at Crack City so I'll try to blog as much as I can before figuring out my next move.

On some nights I'm just so sick and tired, so fed up with it all that I just wanna scream and ask, "AM I THE ONLY ONE WHO GIVES A SHIT AROUND HERE?"

Case in point, father of this 7 y/o little boy brings him into the ED last night reporting that his mother's boyfriend had beatened him black and blue with a belt, to which the mother did not deny. The couple had been divorced for a little over a year. On physical exam, the little boy had indeedly not been spared the rod at all. His buttocks and back were ecchymotic, black and blue with scattered scabbed marks from numerous whippings and beatings. It was unbelievable. Sort of reminded me of a scene right out of the TV mini-series Roots where LeVar Burton, portraying the main character Kunta Kinte, had been lashed repeatedly across the back. Yes, it was that gruesome.

The father had just picked up the little boy from his mother's house as he had court allotted time with the child on Fridays, Saturdays & Sundays. Upon giving the child a bath, he noticed the horrendous injuries and immediately called the mother, notifying her that he was bringing the child to our ED and will be filing charges. Poor kid was sleeping soundly when he arrived, whimpered a bit during the exam.

"It's OK, buddy. This is Annie, the nurse. And I'm Dr.____. We're just looking, alright. We want to help you get better."

His eyes were scared, not knowing how to react nor whom to trust.

Now the mother openly acknowledged that the boy had been "whupped" by her boyfriend, but defended the SOB over and over by giving a sob story of how rotten and misbehaved this kid had been. Reportedly this kid has ADHD, violent impulsive behavior, had tried to burn down the house several times in the past, once lit a fire in the classroom at school, is on Adderal, zoloft, tegretol, risperdal, and a bunch of other psych meds to control his behavior. Hell, the list of mood altering prescription drugs that this kid is on just boggles the mind. It is absolutely unconscionable and irresponsible for any physician to prescribe that many controlled substances and drugs to a child. That list was as long as those we typically see in debilitating elderly patients or those with end-staged renal disease on chronic hemodialysis.

Oh, how the mother sobbed like a squeaky violin trying to explain that the kid wouldn't go to bed even though it was 2 AM, screaming at the top of his voice, throwing things in the house, kept on wanting to watch TV, yada yadda yadda. So the boyfriend, whom she lived with, spared not the rod. Damn son of a bitch. He beated the kid to a pulp. Yet the mother still defended and condoned his actions.

Armed with this latest injury to his son, the father remarked, "I'll be gettin' custody now!"

In response to the father's threats, the mother began telling a disturbing story of alleged sexual abuse against the child by the father, how the father has a large collection of child pornography, watches it in front of this kid, etc...and was somehow able to ditch evidence of all of it during the divorce proceedings and investigations. I suppose that's how she got custody of the child and he has visitation rights?

God, I was so nauseated and sickened by it all...He said, she said...the child was the unfortunate victim and I was sadly caught in the middle trying to figure out whom to believe. I had mother and father moved to separate consultation rooms at each end of the ED and placed a hospital security guard at the child's bedside.

"Where the f*k is that motherf'er!!!" I suddenly heard the profuse profanity from the hallway. "I'm gonna kill him! I'm gonna kill him! Nobody beat up my kid like that and gets away with it. I'm gonna kill that son of a bitch!"

The repugnant boyfriend apparently had showed up. Pandemonium erupted in the ED as you can imagine. We had to tackle down the father to keep him from pouncing the boyfriend.

CCPD naturally had been contacted earlier and as soon as the two officers showed up, the boyfriend took off like a hot rabbit and ran out of the ED through the ambulance entrance. Did this guy have a previous criminal record? I asked myself. Or was he just scared shitless about getting arrested for being a child beater? Hell, we should've let the father of the kid kicked his ass.

Here's where things become even more sickening and frustrating. Children Protective Services was of no help at all. I personally spoke to the guy over the phone but it took him over 3 hours to show up. The dude was a completely useless imbecile. He spent 2 hours interviewing the father, the mother and the child without offering any helpful solution to the problem. I had expected him to take the child into state custody until pending further investigation, but he didn't.

"So, what're we gonna do with the kid?" I asked when he was all done.

"Umm, we're very familiar with this family. We've taken several reports on them before. You can send the little boy home with his mom," the imbecile replied.

"What?!!! Send him home with his mom?!!! But the guy who has been beating this child lives with her! I ain't sending this kid home with the mom. No way! You need to come up with a better solution than that."

"Well, I talked it over with my supervisor, and..."

You can understand why I started tuning out whatever the imbecile had to say afterward.

"Listen, the guy who has been beating up this kid is still out there. The mother lives with guy in his house for goodness sakes! What makes you think that he won't beat up this kid again?"

"The father already pressed charges and the police is looking for him."

"That's good to hear, but they haven't gotten him yet, have they? Did you missed the part about the mother and this kid living with this guy in his house? They got nowhere else to go. And from my discussion with her, it doesn't look like she intends to move out anytime soon. What's gonna happen after the police release him or if he post bail?"

"What makes you think he's gonna beat this kid again?"

"Fk! Did you see the horrendous wounds on the back of the kid? Have you seen it?! Hell, it's a chance that I'm not gonna take!"

"Well, the mother has legal custody of the kid and we can't send him home with his father."

"Man, you're completely hopeless and useless. Thanks-for-nothing! When you're driving home later, think about what you just did and see if you can live with it. You make me sick, man! You should be ashamed of yourself! Child Protective Services my ASS!"

It gets even worse. I had the pediatrician on call paged. And he, too, balked.

"Hey, Phil I got this little kid down here..." I explained the situation.

"What do you want me to do about it?" came his totally unexpected response. "If CPS isn't going to take this kid into custody, what am I going to do? There's no medical criteria for admission here. Medicaid won't allow it. I can't do a social admit and be an indefinite baby sitter."

WTF!!! I argued back and forth at length with this pediatrician about doing the right thing, being a child advocate, protecting a kid from getting abused...but DAMN, all to no avail! He was a wall. When did this pediatrician lose his compassion for children? I sadly wondered. When did this pediatrician's decisions become solely business based? No medical criteria for admission? Medicaid won't allow it? Shit! I ended our phone conversation with much needed words of impugnity.

"You're peds, Phil, you're not suppose to be this jaded. We're not suppose to punish a child for the stupidity of the parents, aren't we? Where's your love, Phil? Where IS your love? Have you lost it, man? Have you lost it?" I hung up not giving him an opportunity to mouth back at me.



Oh, it gets worse. Desperate, I called the psychiatrist on call, who agreed that this child should be admitted for his safety but wouldn't do it himself.

"I'm sorry I can't admit him. He's not..."

I started tuning out his psycho babble...

"It's psychosocial, man. It's all related. I can't believe that you guys are so willing to load him up with a bunch of psychotropic meds but won't admit him when it becomes inconvenient for you."

So then, I called the hospitalist on call, who commiserated with my situation but quickly pointed out, "Look, I'm not peds. My liability policy does not cover 7 years old kids. I'm sorry, man." Oh, my God!

Desperate again, I called the surgeon on call and tried the trauma-related angle. "It's a horrible situation, but what am I gonna do but consult the pediatrician and social services like you already did. I'm sorry, man."

I didn't want to resort to having to wake up the hospital's Chief of Pediatrics nor the President of the Medical Staff. It would have been pointless and useless anyway. They weren't on call for the night and wouldn't have answered the page anyway. So, I placed another phone call to the police to see if they have anything to offer...NADA. "We can't take him to juvies..." I don't want you to! I was hoping that they would know of some social services or shelter that would take the child in until things were sorted out.

Child Protective Services - Strike one
Pediatrician - Strike two
Psychiatrist - Strike three
Hospitalist - Strike 4
Surgeon - Strike 5
Police - Strike 6

AM I THE ONLY ONE WHO GIVES A SHIT ABOUT DOING THE RIGHT THING ANYMORE?

I ended up admitting this kid last night to my hyperbaric service, because I can. It's the only inpatient admitting privilege I have. It's just easier for me this way, and with so much less aggravation of having to argue back and forth with a bunch of derelicts. Not to admit this kid and release him to his dysfunctional and degenerate parents would have been a true dereliction of duty. I was raised by a military father never to shirk duty and honor. And I was not about to disappoint him.

This morning, the HBOT team was completely surprised and concerned about why a 7 years old kid is on our census list. "It's another one of Charity's social admits again," they complained. The kid's wounds do not meet HBOT criterias of course. The morning doc in my group wasn't too happy about having to round on this kid so I told everyone that I would personally round on him myself and take care of his disposition come Monday. I'm not sure yet what I'm gonna do or how to even disposition the kid. For now, I'm just glad that he has a safe place to sleep for the weekend. So far the nurses have informed that the kid has been very well behaved, a complete angel and not a problem at all. Not surprising how a little love and TLC goes a long way, I suppose. The only medication that I wrote for him is Motrin and Tylenol as needed for pain. No psych meds. A hospital security guard is posted at his bedside, of course. Funny how the hospital security folks are the only ones who understand the situation and have not complained at all about having to post a sitter with the kid 24/7. I just added them to my Christmas list for the year.

Tricks of the Trade

Our friendly blogosphere urologist Dr. Keagirl over at Urostream had this nice thing to say about us ER folks when she got called in to help with a difficult foley on a trauma patient. Grunt Doc thanked her for coming in on behalf of all of us ER guys.

One thing that has always puzzled me is...well here's the comment I left on her post with a little picture at the end:

Ditto, what Grunt Doc said.

I find that most urologists are very "ER friendly" and accomodating.

One of these days, I'm gonna have bribe one of them to show me some tricks of their trade in placing difficult foleys. Or at least get one drunk enough to reveal their secrets! Most of the time, the nurses have tried, at least over a dozen time with different size catheters. Then I get a crack at it with numerous attempts using different size catheters and coudets, from smallest to biggest as well... Firm grasp with the fist and pulling the penis straight up in the air toward the ceiling like we were taught during trauma rotation in med school, or angling it down toward the end of the bed, applying pressure at the prostate, pushing down against the bladder, some ativan, lots of KY and viscous lidocaine jelly, left handed, then right handed, then instructing the nurse, you grab I'll shove the catheter or, I grab you shove...and finally giving up myself after a few dozen exhaustive and frustrating tries. I then am forced to bow in humiliating defeat and have to place a consultation.

In comes happy-go-lucky, out-going urologist with the urology cart. One easy slip and it's in. Damn! Drives me nuts!!! Especially that smirk of triumph on their face afterwards every time. Oh yeah? We eased it up for ya!

I swear, it's a heavily guarded secret that they'll teach to no one else except one of their very own during some special secret session held only for urologists at some far and remote super secret locale where none of us mere non-urology mortals are allowed to know about or attend. I betcha anything that this is one of their esoteric board requirements for certification - How To Place Difficult Foleys And Make An ER Doc Look Like A Clown!

I knew it! I knew it! Look at the smirk on her face!

Look at her... gloating! ;-p

Toothache

"Hey Liz, could ya bring back the lady with the toothache?" I asked the triage nurse over the phone.

"Which one? There are several of them out here."

"The 68 years old one who just came in. Oh, please put her in Room 5 instead of the ENT room."

"Why, you know her?"

"Nah. Just a hunch."

"She told me she's been having the same toothache for 2 weeks. Room 5? You sure?"

"Yeah, Room 5."

"Okay...the other people who came in before her will be very mad..."



BOOYAH! Tombstones!

"How'd you know?" Liz asked.

"How many 68 years old li'l lady have you seen coming to the ER in the middle of the night for a toothache?" I answered.

"None," she replied.

Bingo! It was really a matter of knowing about the generation gap and using it to your advantage that made all the difference.

As an aside, I hate it when people with toothaches come to the ED. There's nothing meaningful that I can do for them. It's really a waste of my time. I'm not a dentist nor am I an oral surgeon. It's not that I can't do dental extractions and such, because I've rotated through the OMFS service during residency as an elective and spent 2 months pulling teeth, drilling, filling them, wiring jaw shut a la IMF for mandible fx, etc... I don't claim to be an expert in the field but I've done many of these dental procedures before. I just have no desire to do them again for obvious reasons, as well as liability issues. Plus we don't even have the proper equipments to do things, nor do I have the time to perform these elective procedures in a busy ED either. And far be it also for me to claim to be as capable as a dentist or an oral surgeon in performing these procedures.

For many of these toothachers, their problems are chronic and they are nuisant frequent fliers to the ED. They know that we do not and cannot perform dental procedures in the ED, and have no oral surgeons nor dentists on staff either. Yet, they still show up in droves every night, again and again.

"Look, I know that your teeth hurt, but there ain't no pain medication nor enough antibiotics in the world that'll ever solve your problem! You need to see a dentist or an oral surgeon, not me!"

If I see an odontogenic abscess, I'll be sympathetic and will give narcotic pain meds plus antibiotics without ever giving them much grief. But the vast majority of these toothachers who show up do not have an abscess nor any clinical signs of Ludwig's Angina. They just choose not to see a dentist, granted that many will cite limitted financial means as a reason why they can't see a dentist and cannot afford an upfront wallet biopsy when they are greeted by the receptionists at the dental clinics. But still, why come to me? I can't help ya with that either. You don't ask a plumber to do an electrician's job so why ask an ER doc to look at your rotting teeth?

Plus many of these toothachers are drug seekers.

"How long have your teeth been bothering you?"

"Just tonight." Or usually, "2 days."

C'mon, I ain't no idiot. Those rotten teeth, worn down to the nubbins at the gingival line, have only been giving you pain for just 2 days? Do these losers really think that we were born just yesterday? I was taught the 4 P's in caring for toothachers during residency...Pain pills, penicillin, and punt to clinics. These days I just punt. I'll offer them a dental block, but all of these drug seekers will refuse them citing fear of needles.

"Why can't you just give me some pain medication?"

"Because I don't want to. You'll just come back here again wanting more pain medications when you run out instead of going to see the dentist like you really need to."

"But I am gonna go see a dentist..."

"That's what you've said the multiple previous times we saw you in this ER. We keep records, you know."

"So how long does the numbing medication last?"

"A few hours."

"So what do I do when it wears off? Why can't you just give me some lortabs or vicodins?"

"So what will you do when the lortabs or vidocins wear off? Your logic is screwy."

I have this same screwy conversation every night on duty. What pisses me off even more is when they take an ambulance for their rotten teeth. That's why there's an obligatory 3 hrs. wait, at least, to be seen in my ED if you come in for a silly toothache. Longer, if you show up by ambulance.

"Damn it, these people take better care of their asses than they do their teeth!" an oral surgeon once whined to me.

"Wha d'ya mean, Greg?"

"I'll betcha that they'll wipe their ass after taking a dump every time, but do they brush their teeth every day?"

Hahahaha! LOL! He's got a really good point there!

Back to the EKG showing that the li'l old lady was having an acute MI (heart attack)...So how did I know that this old lady would have something bad? How did I know that she wasn't a routine toothacher. Experience. Elderly patients do not come to the ED in the middle of the night for stupid toothaches, as a general rule. It's just that simple. Plus, I've seen many with similar complaints of toothache over the years, only to find on exam that their teeth are fine or that they are edentulous or wearing dentures and having aginal equivalents of coronary ischemia. So when her name and age popped up on the computer screen after she triaged in for complaint of toothache, I had her brought back right away. I always keep my eyes on who's out it triage. Seen and heard too many triage horror stories not to pay attention.

This li'l old lady was a slight bit tachypneic and clammy after she was walked to the back from triage. One look at her teeth and I knew. Placed her on the monitor right away and saw the tombstoning ST-elevations. She was whizzed up to the cath lab and did fine. Her RCA was stented.

Logic

Drug seeking patient with chronic toothache returned to the ED claiming that someone had stolen his Lortab prescription generously written to him during the previous shift by one of our more easily persuaded/fooled physician in the group. I quickly looked in his halitotic mouth. Rotten molars worn down to the nubbins.

"I left it right there on the counter and someone stole it!" he claimed.

"Did they steal your Penicillin prescription, too?" I played along.

"No. I still got it right here."

"That's so terrible!" I empathized. "Some people, stealing other people's prescription like that, un-buh-lievable!"

"Yeah, can you give me another prescription?" he asked

"Why certainly! I'll write ya somethin' that they won't steal!" I answered accomodatingly and whipped out the prescription pad.

Rx: Motrin, 800mg
dsp: #10 (ten)
sig" 1 PO Q4h w/food prn

Hehehe. The guy was, needless to say, quite pissed and went ballistic. Couldn't stand the crushing logic. Had to be escorted out by hospital security.

Whar's the Bullit?

First the xrays, as usual. More later. No peeking by clicking on the xray. I'm too lazy to change the name of the file. It's one of those rare cases that ya don't see every day.

---------------------------------------------

"Hey, this ain't bad at all!" I commented as soon as I stepped into the ED to start my shift and noticed that the census board was rather "clean."

Marsha, a veteran ED charge nurse with over 30 years of experience hesitated not a bit in giving me a quick bop to the back of my head like my older brothers used to do. "Why'd you say summin' like that for?!!" she protested in a displeased but not too incensed tone of voice. "You done jinxed us all!"

"Hey, er..." I started stammering and rubbing the back of my head after realizing that I had violated one of the cardinal rule of the ED. "I didn't specifically refer to nothing," I argued back unconvincingly. "I was just saying things in general, you know, like life ain't bad at all. That kinda thing. It's a generic reference."

"Yeah, but we know what you meant. You done said it. You done jinxed us!"

"Man, you guys are too superstitious. That kinda thing has never worked for me anyway. I've always been the shit magnet, the black cloud, I get dumped on regardless of whether I say the word quiet or not. So there! I said it. QUIET. NOT BUSY. QUIET! QUIET! QUIET!"

"Oh God! He said the Q word. Hey everybody, Dr.___ just said the Q word!"

"Gee, thanks, Dr._____. You done jinxed us!" they groaned.

I shook my head and replied, "What-ever! I don't believe in that whole jinxing crap anyway. If that's the case, then I'm perpetually cursed because I can't even remember the last time we had an easy night here. I can't even remember the last time I was able to sit on my ass and finish a crossword puzzle or surf the internet like in the old days when I first started here. I can't even remember the last time I was able to take a short nap. Shit, on many nights, we get so busy, I even forget to go take a piss, much less eat something. It's like as soon as I show up, the ER gods said let the activated charcoal run and we get dumped on."

Just as soon as I ended that li'l whiny rant about placing patient care above even emptying our own bladders, Billy, one of the new nurses who got suckered into transferring from the SICU to work in the ED, came up to me and informed, "Hey, they need you on the radio. It's AirMed 1.

"Alright, here we go! Told y'all, he done jinxed us!"

"AirMed 1, this is CCMC med control, go 'head."

"Hey doc! AirMed 1. ETA to you in 20 minutes from Podunc County. 23 y/o male, GSW to the left flank. He's in hypovolemic shock. BP 70/palp. Sinus tachy at 150, O2 sat can't pick up but breath sounds are equal bilaterally. He's awake but diaphoretic and lethargic. 2 large bore IV's with fluids wide open on pressure bags. We're loadin' him up right now. Permission for RSI..."

"That's an affirmative! Etomidate and Sux per protocol. Go 'head and secure the airway. Make sure you check for end-tidal CO2. Pavulon as needed. Update us of any changes. CCMC out."

"Notify the OR, please," I went into Defcon mode. "Get Dr. Slasher on the phone. I want 4 units of O neg blood here now. Warm up the Level I infuser. Chest tube set up, suction..."

"See there, damn it, you done jinxed us!!! I can't believe you said that!"

We met the patient at the helipad. He didn't look spiffy at all, had that CD square look about him (circling drain, waiting for celestial discharge).

"4th and 5th bag of saline hanging, doc. Last BP 90 systolic, still tachy. His uncle shot him while climbing out of the bedroom window! S.O. (Sheriff Office) said that he'd been 'messin' with his ucle's wife!"

"Yup! That would explain Podunc's gene pool!" I couldn't contain the chuckling after hearing that comment from Marsha.

We rushed the patient into the trauma bay and proceeded to violate every orifice with our prying fingers and invasive tubes, while going rapidly through the primary and secondary survey of ATLS. Massive volume resuscitation was delivered with uncrossed match blood along with IVF pumped in by the Level I infuser at full speed.

"We're just waiting on The Slasher," said the OR crew hovering around waiting for the go 'head word to whiz the guy up to the OR.

Single GSW with entrance wound to the left flank, no exit, was all the injury that the guy had on full body exposure and log-rolling.

"Got your chest xray and KUB up!" announced the xray tech.

"Whar's the bullit?!" I kept on asking out loud after seeing both unremarkable xrays. "Whar's the bullet, whar's the bullet...No exit wound...Whar's the bullet?"

"Let's go lower," I then instructed the xray tech. How 'bout...."

"He's bradying down!" yelled Billy.

It was then that the answer became very clear. The guy's right leg and foot suddenly turned ominously purple and pulseless. Only the 2nd time in my career have I ever seen such a case. Here are some more views with the lateral:





Holy Shit! Single GSW to the left flank, no exit. How the hell did the bullet end up in his leg? There were no wounds in his leg.

A bullet embolus! The bullet penetrated the aorta and embolized to the popliteal artery of the leg causing a complete occlusion at the trifurcation.




"He's in V-fib!" yelled Billy again.

We shocked him into an idioventricular rhythm and gave a few rounds of Epi achieving a return to a sinus tachycardia. The rhythm then quickly degenerated again to a pulseless wide complex bradycardia.

"Let's cross-clamp the aorta and stop that bleeding. Set me up a thoracotomy tray!!"

--------------------------------------------

It was all anticlimatic from there, I'm afraid. Wide-complex bradycardia is an ominous sign in trauma resuscitation. My hope was to get his heart back to ROSC (pronounced rosky for Return of Spontaneous Circulation) with a pulse. And since he's young, hopefully would have a better fighting chance in the OR. I haphazzardly squirted betadine onto the left chest and threw some sterile towels onto the stretcher. Breached the parietal pleura with one firm, swift slash of the scalpel. Smooth, like cutting butter. After cranking the rib spreader, I dug my hands into the posterior thorax. All of the injuries seemed to be below the diaphragm as there was no blood at all in the chest. After locating the descending aorta, I quickly cross-clamped it. Just then, in come Dr. Slasher, young general surgeon extraordinaire.

"Looks like y'all started the party without me."

"Single GSW to the left flank, no exit. Look at where the bullet is on the xray," I pointed out and reported to The Slasher.

"Holy Embolism, Batman!"

Slasher snapped on sterile gloves and gave cardiac massage. I loaded up the needle and gave an amp of intracardiac epi. ROSC!

They whizzed him up to the OR, but his injuries were too extensive. Got the bowels, got the left kidney and penetrated the aorta just infrarenally. He made it out of the OR but died in the SICU a few hours later. Sad part of it all was that no family member or friends ever came to ask about him. I'm not a believer in getting jinxed or anything, but the night was just pure pandemonium and busy as hell afterward.