Friday, March 4, 2011

Dispatches from the Front

A few thoughts to share from a Midwestern night shift:

I had always assumed that the grocery business was relatively safe. And even if there were some jobs within the supermarket that might be more prone to injury than others, I never would have put the dairy staff in this category. (We are intentionally ignoring the perennial concern about fingertips in the deli slicer, and in doing so get to avoid making a strained analogy between sandwiches of tongue and hoagies of digits. Although I will note that two decades ago I sewed back on the pad of a finger lost at Gates and Sons BBQ in KC, and for the next twelve months gratitude upgraded my Beef on Bread to a Beef and a Half.)

Last night I sewed up the thumb of a young woman who had been injured by eggs. Well, maybe not the eggs themselves, but by the knife she was using to cut open a box of eggs. The funny thing is that this wasn’t her first ovolaceration. Two weeks ago she had cut her face when the knife hit a snag in the box and flew up against her cheek. Which made filling out her workplace accident report quite fun in trying to resist the urge to put under the heading of work restrictions, “May Open Egg Beaters Only.” Which is an urge I may, or may not have, given in to. Only Worker's Comp knows for sure.


Two ambulances are called to a domestic disturbance. During the spat, one of the protagonists had a seizure. Watching the seizure, a second combatant had an anxiety attack.

The first patient came to ER and promptly demonstrated her seizure. She tensed up her whole body, holding her limbs rigid and trembling while producing a constant, undulating moan. She did, however, follow me around the bed with her eyes when I entered the room. You can’t do that with a seizure. So I told her it was okay to stop, and she did so immediately, letting out a large sigh as she slumped back into the bed.

The second patient was unresponsive. She was so unresponsive that when the nurse began to do a sternal rub, she immediately opened her eyes and said, “Stop doing that!” In conversation, both the patient and her boyfriend recalled that while she had been unconscious at home, she had full recall of the paramedics talking to her and rubbing on her chest. “It hurt!’ she noted. You can’t do that if you’re unconscious. (For the record, a sternal rub is not as nice as it sounds. There’s no rhythmic caress with Vapo-Rub and a nice warm, fuzzy feeling. It’s driving your knuckles into the heart of the breastbone, a painful maneuver sure to provoke some kind of response. And if there’s truly no response, there’s a real problem.)

What happened at home is that the first patient, a middle-aged female homeowner, got into an argument with the second patient’s boyfriend. The second patient’s boyfriend is also the first patient‘s daughter’s not-yet-divorced husband. The son-in-law and his girlfriend are currently living rent free in his mother-in-law's home. She's upset because they don’t pay rent and eat all her food, and the fight was a result of her attempt to evict them while they were all sitting together watching a movie. Police were called when soda cans and laptop computers began to fly through the air.

The nurse and I agreed this was a Jerry Springer moment, and we’ve decided that a good side business would be to start an ED based Jerry Springer Talent Search. For a finder’s fee, we’ll drop the names of potential guests to the Springer production staff. Could pay off a few credit cards faster than spit, for in our line of work there’s a virtually inexhaustible supply of material.

Honestly, you can’t make this stuff up.


One of the tricks of working at night is getting medication for patients when there’s no 24 hour pharmacy in town. You can write a prescription, but after 9 PM (6 on the weekends) there’s no way for the patient to get it filled until the following day. The hospital inpatient pharmacy does not want to be (and in fairness, probably should not be) in the business of filling outpatient prescriptions. So there’s this stopgap scheme where we can put a sticker on a sandwich baggie and dispense enough medication to get the patient through until the next morning when the pharmacies reopen.

Occasionally, this requires a bit of math as you try to determine if you need to give the patient one or two doses of medicine to help them through the night. Last evening, it was also a reminder that working in a small town ER has its benefits. So when I was trying to figure out if I needed to give a patient a second dose of narcotic pain medication, I was told not to worry about it. The nurses knew he'd just get another dose from his mother.


There was a call from an outlying ED about a patient who had swallowed a prickle. These are the little burrs that stick to your shoes and socks when you walk through an ungroomed field or a path through the woods. Anyway, she had apparently tried to pluck one off a mitten by nipping it with her teeth, and then swallowed it by accident.

There’s something about the atmosphere in the ER that resolves certain medical problems. Mostly this happens with children, whose fever of 134 degrees, gasping for breath, and inability to drink without barfing immediately disappears once they get within The Healing Walls of Health. (More than likely, it’s because the Tylenol has kicked in, popsicles are tastier than Pedialyte, and the cool night air has eased the cough. But there’s still enough voodoo in medicine that I’m willing to attribute some magic to the ethers.) Which is why, after a two hour drive in the dead of night, the patient arrived, coughed twice in the lobby, and promptly hacked up a slimy, mucus-encrusted plant burr. Treatment consistend of placing it in a specimen container, affixing a label inscribed “Mr. Prickly,” and taken home for display.


An example of how the health care system works…or doesn’t…and of the Law of Unintended Consequences:

A patient came in early in the day with seizures. To get the seizures to stop, she required the use of multiple medications. Her seizures were not new…they had been fully evaluated, and she had been under the care of a neurologist, and she was already on medications. And it was known that when she had a seizure, she had a prolonged “post-ictal” state. (This is the presence of an altered level of consciousness that follows a seizure, a phase of lethargy and slowness of thought that clears over time.) Most people are back up to speed in 1-2 hours after a seizure; in her case, it had been noted that it often took twelve hours or more.

For the patient’s comfort and to keep the ED bed open, it made sense for the patient to be admitted to the main hospital to watch for resolution of her lethargy and confusion. We spoke with the admitting physician on call, who determined that if the patient had a neurologic problem, he was uncomfortable caring for her without neurologic consultation. Unfortunately, there was no neurologist available on call, so we would need to find someplace else for her to go. We found a referral facility willing to accept the patient, but could only gain her acceptance if she needed admission to the ICU. So half the battle won.

Normally she’d take the hop down the interstate to the next big city by ground. However, of the four ambulances in the county, two were broken and the other two needed to be kept in the service area. So the only way to get the patient to the referral center was by plane. It took time for the plane to arrive, for the patient to taken from the ED to the airport, to be flown to the referral center, and to be unloaded at the airport and taken to the hospital. And of course, by the time she arrived at her final destination, she was already starting to wake up, and everyone looked kind of silly.

I tell this story not to blame anyone. Taken in isolation, each piece of the story makes perfect sense. The patient should not be subject to 12 hours in the ED, and admission was clearly warranted. You shouldn’t force any physician to care for a patient when they’re uncomfortable with that level of care, so the patient needed to be transferred someplace. You can’t take needed EMS units out of a community, so other transport resources need to be utilized. And things take time, and time changes things. Two wrongs don’t make a right, but in this case multiple rights surely added up to a wrong. But that’s health care in America.


It was a good night. Never too busy, patients pretty straightforward. Got to sleep in the wee small hours and didn’t wake up ‘til sunrise. And it’s the kind of shift you dread when you leave at 7 AM, because you know that the Law of Averages means you’ll pay for it tomorrow.

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