Tuesday, June 21, 2011

Another Night, A Few More Stories

There are a lot of annoying sounds in this world. The screech of fingernails on a blackboard. The thump thump thump of the three year old kicking your seatback in time to "It's a Small World" all the way to Florida. And the piercing wail of the EMS radio page an hour after midnight, just at the moment the ED is on the verge of being cleared out and the pillow...or at least a Jerry Springer rerun...beckons to your tousled head.

The call goes out on to an address on Castle Street for a middle-aged female with three months of vaginal bleeding. Several minutes later, we get report from the crew. The patient has only had vaginal bleeding for two months. So it's already 33% better.

Tonight's EMS squad pairs a man and a woman. I ask the distaff paramedic...who is also one of our Unit Clerks...for patient report. Specifically, I say "I've never had a vagina, so hopefully you can tell me why someone who has one that's been bleeding for two months would call an ambulance at 1:00 AM on a Friday night."

The paramedic smiles. "I suspect it has something to do with the alcohol."

Five minutes later, I'm in the room with both the patient and the vapors of her beverage of choice, so I ask. (I have to ask questions in the "why you're here NOW" category pretty often, so there's a set script here. Mine is not the best line. The best I've ever heard comes from my colleague Dr. John Prairie, who's version is, "And what MEDICAL EMERGENCY brings you to this LEVEL II TRAUMA CENTER this VERY NIGHT?")

"I know this is going to sound rude, and I don't mean it to, but what in particular brings you in to see us tonight after two months, instead of when it started or a month ago?"

"I was bleeding so much in the bathroom that they threw me out of the bar."

I finish my history, asking about past history, medications and allergies. "I'm on medications," she says. "For my fibromyalgia."

(I saw that one coming, but for some reason I can't explain just why. I know some people who think they have "Gaydar" or "Jewdar." Perhaps I have "Fibradar.")

Her exam is completely unremarkable...no bleeding to be found...and like many patients, it's going to take longer to do the paperwork then provide the needed care. So as I'm sitting down at the desk, I hear the nurse talking to the local domestic violence shelter.

"She wanted us to let you know she was here. Are her kids okay?"

Yep, she had left her kids at the domestic violence shelter to go out to a bar. And as the story emerges from the fog of war, apparently she's there because she has a stalker. Going to a bar is always a good way to shake them from your trail.

I go into Room 1 to see an older man who's been dizzy. As I start to ask him questions, his wife answers everything. This is another one of those situations where I've developed a standard script over the years. So I say, "Ma'am, I want your input, but I'd really like to hear from him how he's feeling, and then I'll want you to help fill in the gaps."

She blushed, and then the whole family started laughing. "I'm sorry. I always do that."

I asked the patient, "Do you ever get a word in edgewise?"

He shrugged. "Not often."

They seemed like nice people..fun people...so I decided to tell one of my stories. "You know, years ago I saw this little old couple when I was working in Florida. The guy was genuinely sick, but every time I asked him something, his wife would answer for him. And every now and then, when he would actually get out a word of his very own, she would put her hand on his head and say, "Shut up, Mohty. I'm tawkin to do dacotah."

They all laughed, so I figured I was on a roll. "She also wondered if I was Jewish, and if I was single. When she found out from the nurses that I was, she told me all about her granddaughter who was a college student and offerred me her phone number if I wanted to call."

I kept up the show for a good five minutes. Each laugh I got produced another joke or story. I was just on the verge of wrapping up my act by noting that I was there all week, and that you should tip the nurses and techs because they're working hard for you, when the patient finally piped up.

"Hey, doc...do I get to talk now?"

Two points for the patient.

We actually saved a life tonight. A lady came in with chest pain, as we're evalauting her she becomes unresponsive. She has no pulse and is not breathing. This is the kind of stuff we live for. Within moments she's getting ventilated with a mask, receiving CPR, and having sticky-backed pads placed on her chest to give her an electric shock. A few seconds later, voltage converts her heart rhythm from disorganized chaos to a normal rate with a bounding pulse and strong blood pressure. While the nurses prepare to start medication to stabilize her heart rhythm and control her pain, I step out of the room to call the cardiologist to take her to the cath lab. While I'm out of the room the patient's hearbeat again becomes unstable. By the time I run back to the room, the nurses have already given the needed shock and the patient is brought back to life once again. Total elapsed time of hands-on ER doc care: Fourteen minutes.

Another patient came in complaining of headache. She's had neck pain and headaches for years. She's been told the headaches are related to muscle tension, and she's had a compeletley negative workup, but she doesn't believe it. She wants them fixed now. She wants an MRI. I take her history, do her exam, write orders for pain medications, and check her response. I explain to her that in the ER, when the neurologic exam is stable we generally don't do MRI's. I explain it again. I painstakingly document the encounter and the areas of disagreement in the event that she chooses to bring it up the next day with adminsitration. Total hands-on ER doc care, not including observation time to watch for pain relief: Twenty-nine minutes.

I'm sure that says something about what actually constitutes an emergency, why saving lives takes seconds but risk management takes hours, patient expectations versus clinical realities, the problems with consumer-based health care, the silliness of a health care system that promotes equally silly behaviors, and the overall state of medical practice in America. But it's three in the morning, and I've got to see more chronic back pain and kids with runny noses who's crying is keeping up their parents and people who think they might have passed out yesterday but nobody was around to see it while I hope that someone else's grave misfortune will give me a purpose for being here.

I'll let you figure out the moral of the story, because honestly I'm just trying to make it to dawn.

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