Saturday, April 24, 2010

A Really Bad Day

It was a bad day to start with. That being said, it’s also true that the definition of bad is relative. For most patients, a trip to the ED means it’s automatically a bad day (although for a surprising number of folks, a trip to the ED is a chance to get out of the house and socialize, or get under cover and grab a quick meal). From the view of those of us who work in there, every day starts out as simply “a day” and has nowhere to go but down. This is because of the well-known ED Rule that says using terms like “good” or “slow” to describe your workday provides an instant kiss of death to the rest of your shift, virtually guaranteeing that within the next six minutes a bus carrying the Finnish Methadone Clinic Tour Group will fall off a bridge into the Halifax River. None of them will speak English, and all of them will have pain.

So while most every day is a bad day, there are certainly variations on the theme. There are days that we label as bad for fear of the Gods of Nordic Tour Buses, and then there are the days when things are genuinely nuts, and not in the pleasant, Roger Rabbit sort of way. And that day was one of those days, too many patients with too many complaints who want to give you too much information about each of them, and very little I could do about any of it. They were lined up deep in the waiting room, and the harder you worked to get patients out the door the more you got punished for it, as within moments another one was shoveled into the mix. It was a day when it would have paid to have no work ethic, to keep the patients waiting, and make your own life easier because at least the beds would be full and they couldn’t give you any more. It was, as the phrase goes, not the kind of day I’d signed up for.

In the middle of all this, the radio tells us we’ll be receiving a “Trauma Alert.” Our hospital is a Trauma Center, and injured patients are selectively directed here based on specific criteria. For example, a penetrating injury to the chest or head meets trauma criteria, as do a combination of other lesser factors such as age and mechanism of injury that suggest potentially serious problems. A “Trauma Alert” notification swings the entire ED into action. Specialists are called, nurses are reassigned, x-ray techs descend upon us, respiratory therapy appears from…well, wherever they hide, the lab comes down to run “on-the-spot” testing, a chaplain drops by (actual chaplain joke: “Take two tablets…of commandments…and call me in the morning”), and if you’re lucky during the daytime even a low-level administrator will show up to peek around the corner to say helpful things like, “Oooooh,” and, “That looks bad, “ and, “Yuck,” and, “Why aren’t you moving any faster? Revenues are down and the patient turnaround time is too long.”

(One quick story about a recent Trauma Alert. About a month ago, EMS called to let us know they were bringing us a patient with a self-inflicted gunshot wound to the chest. This is usually not a good thing, so we were quite surprised to hear the patient talking quite animatedly over the paramedic’s radio report. She kept up the conversation on her arrival. “Please!” she cried out to anyone who would listen. “It’s all been a misunderstanding!”

We never did figure out what the misunderstanding was. What we did learn was that she had shot herself at home. This wasn’t known, however, until she drove to a gas station about eight miles down the highway. It was there that the attendant saw a woman pumping gas, quite unconcerned with the large quantity of blood upon her shirt. He rightly called the police, who traced the license plate on the car to the patient’s address. They arrived at her home, found a loaded gun lying across the bed, and were in the process of searching the house for a body when she pulled up in the now topped-off Ford.

In the end, she had an entrance wound over the left breast with an exit over the left flank area; x-ray showed free air in the abdomen, indicating that a gas filled cavity, like the stomach or intestines, have been torn open and air has leaked out. She went to the operating room, had her bowel repaired, and went home a few days later to presumably resume her obession with petrol and firearms. And we all learned a valuable lesson: If you’re going to shoot yourself, make sure the car is filled up first.)

The patient arrived by helicopter, and he turned out to be a middle aged male described by the flight medic as a “well-known transient” in the western part of our county. (I’m not sure gramatically how you can be a “well-known transient,” but there it is). He had been whacked by a car at a high rate of speed while trying to cross the street under the influence of an intoxicating beverage. He was initially unresponsive on the scene, but had now woken up and was complaining mostly of pain in his left chest and hand. On exam, the most notable injuries were in his hand. The bloodied tip of the little finger was hanging on by a thin flap of skin, and there was crepitus (the crunchy sound you feel when the sharp edges of a broken bone move against each other) throughout the rest of his mangled left hand. It was quite a sight, to be sure. But clinically, his most important injury was to his chest, where I found few breath sounds and lots of crepitus from broken ribs. He also had subcutaneous crepitus, which is a separate crunchy feeling, like Rice Krispies or tapioca buried beneath the skin, which results from a communication between the subcutaneous tissue and a gas-filled cavity of the body. The overall picture suggested that the patient had multiple fractured ribs with a punctured lung and free air in the chest cavity, a condition known as a pneumothorax. This is a true emergency, for if the air continues to accumulate within the chest cavity it may eventually build up enough pressure to compress the lungs, preventing oxygenation of the blood, and eventually compress upon the heart so it can’t pump effectively. This condition (a “tension pneumothorax”) is an immediate threat to life, and so once a pneumothorax is suspected the goal is to prevent this lethal complication. There are a couple of ways to deal with this situation, but the best one is to place a tube to draw off blood and air from within the chest, allowing the lung to re-expand and relieving pressure on the other organs if the chest.

I had previously called the trauma surgeon to let him know that the patient was coming. He was stuck in the operating room, but could break away as needed. I called again to tell him what’s going on now that the patient has been seen and assessed. He agreed that we needed a chest tube, and asked if I’d be comfortable doing so.

Comfortable? I’m an EMERGENCY PHYSICIAN, by jingo. Residency-trained, board-certified, battle tested. Able to move from a STD to a heart attack in the blink of an eye. Able to clean up all the messes that happen when the doctor’s office says, “We can’t work you in today. You’d better go to the ER.” Able to get yelled at by lesser physicians at 3 AM and still able to have steak and beer for breakfast. I can keep ANYBODY alive for at least a half hour. Plus, I had seen one done on television a few weeks back and videotaped the episode, so I had a pretty good idea of what to do. (That one was a joke. I don’t do a chest tube every week, but often enough that it’s not an intellectual leap. But with patients who’ve already shown a sense of fun, it’s interesting to tell that to family members before you do a procedure and watch their reaction. It’s also fun when you walk into a room and the patient says, “Are you the doctor?” to reply, “No, but I stayed at Holiday Inn Express last night.” Yet I digress.)

Here’s what you do to put in a chest tube. You have someone grab the patient’s arm and pull it above their head. You do this in the unresponsive patient to get it out of your way. You do this in the awake patient because as soon as you start, they’re going to try to hit you. Chest tubes are not fun for anyone.

You numb up the skin and the tissue underneath as best you can, take a blade, and make an incision down from the middle of the armpit about halfway down the chest. You use a clamp to help spread the wound and scissors to cut through the different tissue layers…subcutaneous fat, fascia, muscle, ore fascia…until you’ve exposed the chest wall. Using a VERY large clamp, you find the top edge of a rib and drive the clamp through the chest wall. It’s tough work…there’s nothing elegant about it…and the chest was designed not to let anything in. It takes force, real force. You know it, the patient feels it, and everyone around you hears it. When the clamp goes in, there’s a loud POP, and out comes a rush of air.

You follow the course of the clamp with your finger and put your digit in the hole to keep it open. With your finger in place, you guide a large plastic tube up to an inch in diameter through the hole. When thumb goes in and hits a pocket of blood, you do a version of the “Fluid Dance.” The Fluid Dance occurs when fluid under pressure…blood in this case…spurts out after the pressure is released. You try to jump out of the way of the bodily cascade while keeping hold of the tube so it doesn’t fall out. Not making the leap is how people lose shoes (and why my work shoes are $12.00 gray Velcro sneakers from Wal-Mart.)

Once in, the tube is connected to a suction drain, and you sew up the wound and secure the tube. This takes longer for me than for others. I’m not a surgeon, and it takes me a while to tie knots, although they’re awfully pretty when they’re done. I remember feeling like my glove got nicked by some scissors while I was sewing him up…whether the assistant cutting suture for me got me or my finger was just in the wrong place, I don’t know…but I didn’t think anything of it until I took off my gloves to wash my hands and found there was blood on my skin under the latex. I was even more surprised to find that, after washing my hands, the blood was still there. Turns out it was my blood coming from a cut on the tip of my left index finger.

I would imagine that a century ago, if a surgeon nicked their finger there might have been some collegial snickering about the “butterfingers” in their midst, but probably not much was thought about it. These days, however, when we know so much more about blood-borne pathogens, and specifically about HIV and hepatitis, a cut on the finger becomes a major league issue. Still there was some hope that the situation might be defused. My finger hurt enough already. I didn’t want it all to get worse.

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The first thing you do after an exposure is ask the patient if they’ve had an HIV test or are positive for hepatitis. There is a formal, quiet, confidential counseling process that’s supposed to go on, but this is not like an HIV test on a concerned citizen. This is the guy I’m saving from himself, the guy who gives nothing to society except some revenue to the liquor store where he buys his drinks. I’m paying for it with my own taxpayer dollars, knowing full well that when he sobers up watching late-night television and finds that his chest tube hurts, he can pick up the phone(“Morgan & Morgan. For the People.” ) and sue me for pain and suffering. I did this for him, put myself, my career, my family at risk for what?

The more I thought about it, the angrier I got. (Still am, to be honest about it.) Patient confidentiality be dammed. So I shouted across the room “Hey, man, you ever get tested for HIV? You know, the virus that causes AIDS?”

After a moment, he yelled back a no. Halfway there.

“How about hepatitis?”

“Yeah, I got Hep C.”

Lovely. Just flippin’ lovely.

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Of course, what happened to me did not bring the ED to a halt. Instead,the patients who were already in the ED were even more upset because the trauma patient had interrupted their care. And since I had worked hard and discharged four patients in the twenty minutes before I was pulled away to care for Transient Tim, the rooms had been filled back up by patients who were upset because they had been PROMISED by the hospital marketing department that it was a “No-Wait ED” and they couldn’t figure out why they were still waiting, let alone that it was the other hospital in town with that advertisement.

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The formal process that we follow is outlined in the “exposure packet,” a ubiquitous manila envelope that will rule you life for the next six months. The process begins with testing of both myself and the source patient for HIV and hepatitis. I also begin a take a “cocktail” of HIV medications until the blood results come back. You have to sign a consent to take the medications. In medicine, you generally sign a consent only when thing have the potential to go wrong. Very wrong.

My blood was drawn for baseline testing. I had my typical panic attack when approached with the needle, but I’m getting better about it…my “down time” afterwards is now only 20 minutes, which is an improvement over the 45 minutes it took last year to stop hyperventilating after I needed an IV. One of our nurses was kind enough to run up the pharmacy to get my meds. Took the first dose then and there, the next in 12 hours, 3 AM. It just kept getting better.

(I have a question for pharmaceutical companies. The doses of this stuff are in milligrams. A tablet of Kaletra has 250mg of total medication, or a quarter of a gram. A gram is a 1/454 of a pound. A tablet of Kaletra, then, has 0.00055 pounds of actual medicine in it. So why are the tablets so big? Is it just some psychological thing so we can say to ourselves, “YES! I TOOK A PILL!” I’m so tired of gagging my way though the medicines, and I’m only a few days done. But I have a much better understanding of non-compliance. Bleeccch.)

The following day I checked in with employee health on the test results. The patient was exactly as advertised. No HIV, no hepatitis B, positive for hepatitis C. I was negative for everything, a fact which I can attribute to clean living, high moral standards, regular intake of fruits and vegetables, and not having anywhere near as many adventures as I probably could have along the way. The next step was to talk with the local HIV consultant who helps the hospital with exposures. Very bright guy, very good at what he does, and I was hoping that he would pat me on the head, reassure me, and send me on my happy way. No such luck. Because the source patient is considered high-risk for HIV, and he might be positive for the virus but within the 6 week window after infection where his test might still be negative. The safest thing for me to do is go ahead and finish out a 28 day course of my HIV cocktail, give it two weeks, and then recheck my HIV titer to make certain there’s no signs of infection. (This also means six weeks of celibacy. This would have been a lot easier to do when I was single, and when there were no opportunities in the pipeline. If there were, you could always defer under the guise of “I don’t want to rush this,” or “We should know each other better,” which usually had the effect of making things even better when the hold was released. Now that I’m married with reasonable access to relations, it’s going to be a lot more difficult to do.) And while the transmission rate of hepatitis C is less than 3% with a blood exposure, it was advised that I get follow-up testing at 6 weeks, 12 weeks, and 6 months just to make sure. (Hepatitis C is fortuitously not transmitted through normal “relations,” for which several parts of me are very glad.)

As I write this, I’m four days into my HIV prophylaxis. I’m not having the most common side effects of these medicines, which are nausea and vomiting. I’m just not hungry, and everything tastes metallic. The only thing I want to eat is plain white rice and nothing else, so that I’ll probably die of pellagra before any virus has a shot at me. I’m also totally wiped out, sleeping 12 or 14 hours a day, which may be the meds or, admittedly, may be psychosomatic. This week I go for my first follow-up appointment with the HIV/hepatitis specialist, and it also turns out my hepatitis B antibodies are undetectable, which means I need to go back for another series of vaccines. I’m already marking my upcoming blood draw panic attacks on the calendar.

And all of this for someone who doesn’t give a damn about anyone or anything, who will continue to abuse the hospitality of a giving society. The thrill of putting in a chest tube, or even of potentially saving a life, doesn’t even come close to making up the anger I feel. And if I’m honest about it, I’m also mad at myself. I could have easily asked the surgeon to do the tube. The guy probably would have done fine until the he could have gotten free of the OR. But it’s what I was trained to do, so I did it. And look what happened.

Today, while I’m eating rice and choking down tablets, if you ask me if a career in medicine is worth it, the answer would be no. I would tell any aspiring physician to use your smarts, run off to Wall Street, rape the system for a decade or so, retire, and then do whatever you really want to do. (Mine involves some combination of travel, fruity drinks, and The Florida Keys.)

In a week when my helping someone else has led to nothing but disaster, I’ve got nothing left for medicine. It happens whenever I’m like this, feeling used or abused by a patient or the health care system and getting nothing in return. The desire get back into the ED will come back in a day or so. It always does. But each time it does, there’s just a little less caring, a little less compassion, and little less sense of making a positive difference in someone’s life. And sadly, that makes me a little bit less of a physician.

4 comments:

  1. Ewww. That is a bad day. Hang in there buddy!
    Come back to Kansas.....
    Viki

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  2. Dave Morehead RNMay 16, 2010 at 9:42 AM

    Dear Dr. Rodenberg, I hope that you see this, i don't know if you check your comments or not. I have had the PRIVLEDGE and HONOUR to work by your side for over a year now, on the occasions when the schedule allows it. I noticed a change in your usual chipper self about two months ago. Now I know why. What a story and let me tell you I am the first to say I am sorry. And the funny thing is that if this was an upstanding, hard working member of society, who had a car accident or some such trauma that was NOT his fault from drinking or smoking crack, and if he would have said I am sorry afterwards, it probably would have made chocking down those pills bearable. The problem is that this is a piece of human filth that has never and never will care about any other human being on this planet besides himself. Yet we both are required to save him. And neither of us would call a code "slowly" if he would have coded. God bless you and your dedication, even if jaded beyond belief at times. Your a great physician and you do write the best H&P's in the ER. Oh yeah now I FINALLY know what the deal is with those shoes! That has bugged me since March 2009 when I started at Halifax. Great web site BTW. I will probably check it daily for the rest of my life or until you stop writing it. Thanks. Whether you know it or not you are an inspiration and a true role model for me and many of the other nurses. And thanks for listening to us!

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  3. Dave, thanks so much for the kind comments. The blog is my outlet, and I plan on keeping it up for a long, long time. See you around the Halifax ranch!

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