Friday, December 4, 2009

You Choose the Story!

On rare occasions, people I work with will actually admit to reading my blog. (I suppose they don’t suffer enough in my direct presence, and so they need to suffer some more at home. Maybe they’re all Catholic. I'll have to check). Recently, someone asked me why most of the things I write are about the negative side of ED life.

It’s a good question, and if you read what I’ve written over the last few months you might get the impression that everyone who comes to the ED is either a drug-addled alcoholic, an irresponsible systematic abuser of government-sponsored health care, or has a terrible condition about which we can do absolutely nothing. And there’s always an avaricious attorney hovering by the exit trying to drum up business.

The simple fact is that this isn’t even close to the truth. The vast majority of patients who drift through the ED are genuinely nice people, and most of the time you can either make them feel better and let them go home, facilitate their admission into the hospital if needed, or at least reassure them that despite their pain or illness, nothing major is going on today. Every now and then you might even save a life. It does happen, you know. And Security does a very good job of confining attorneys to the far corner of the parking lot.

But I think the reason the “dark side” predominates in my writing is simply because we find that the more unique the situation, and the farther it lies from our own daily lives, the more interesting it can be. It’s a variation of the old adage that Dog Bites Man is not news, but Man Bites Dog is.

I’ll try to prove this to you with a brief example. Here are the stories of two patients who both came in last week within about a half hour of each other. In both cases, I’ll try to stick with a Joe Friday, “Just the facts, ma’am,” approach, and leave out any subjective information as best I can. At the end, you decide which one you’d like to know more about.

Case One: A 27 year old black female came to the ED complaining of vaginal bleeding. She had a LEEP procedure done two weeks ago and was doing fine until she felt a gush of water from between her legs while shopping at Wal-Mart and realized she was bleeding. (The LEEP is done to treat cervical dysplasia, abnormal cells on the surface of the female cervix that might lead to cancer.) The bleeding started about an hour prior to her arrival in the ED.

On exam, there was a large amount of blood in the vagina, and with effort we were able clear out the blood clots and identify the site of bleeding on the lower edge of the cervix. (Most likely what had happened is that in the healing process some tissue had sloughed off a small artery, causing the bleed.) After speaking with the gynecologist on-call, we were advised to try to apply some Monsell’s Solution (a topical anticoagulant) to the cervix to see if that would solve the problem. Unfortunately, the patient continued to bleed, so we called in a physician who was able to anesthetize the cervix and suture closed the blood vessel. No further bleeding was noted, and the patient was able to go home without incident.

Case Two: A 55 year old white female was brought in by ambulance complaining of head and rib pain. She said she had been having a few drinks (“Four Crown Royals”) with her boyfriend. They were riding home on his motorcycle when she said something he didn’t like about a mutual friend of theirs. He elbowed her in the ribs as she was hanging onto the back of the motorcycle. At the next stoplight, she hopped off the bike, and got a passerby to take her home. On her arrival at the home, he slammed her against a glass door, hitting her head and knocking it off the hinges. She then hit him in the face with a frying pan. The police had been called, but left “without doing anything.” She both drank and smoked on a regular basis.

The patient has been in a violent situation for at least three years, and the same boyfriend had hit her twice before, on one occasion breaking her ribs. She still had him in the home because she “can’t afford to evict him.” She was willing to talk to our case management staff about domestic violence resources in the community. She said she had a friend who she could stay with that night for safety.

Her exam showed her to be tender over the left side of the head and the lower right ribs. Her x-rays were all negative. Her alcohol level was one and a half times the legal limit. We gave her IV fluids, thiamine, and multivitamins (part of the standard treatment package for patients with chronic alcohol use, a combination known as a “banana bag” or a “rally pack”), and allowed her to rest quietly in the ED.

We were making arrangements to call her friend to take her home when we were asked to hold her until the police could come to arrest her. Turns out that whacking someone with a frying pan turns you into something called a “primary aggressor.” “He was big,” said the officer, “but she got him good.”

Now you tell me which story, once we add all the subjective layers to it…the sights, sounds, stream-of-consciousness recollections, and pop culture references…is bound to be more interesting? The one where we actually solved a problem and did a very nice lady some real good, or the one with motorcycles, Crown Royal, cops, and a frying pan?

Your honor, the defense rests.

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