Before I could do the aforementioned highly anticipated rectal exam, I heard the sound of the trauma pagers going off (perfect timing! They sounded like angel's wings).
A male motorcycle rider in his 60's and the drunk who crossed lanes to hit him were both being brought in. We staked claim on the more equipped private trauma room and therefore got to take care of the motorcyclist.
The first steps in assessment when someone comes in to the ER (or really anytime you're assessing an emergent situation) are to look at the ABC's: Airway, Breathing, Circulation. Well, he was mumbling and had a (Thank God) full helmet on, so he had an airway and was breathing.
While we had him talking, we asked if he had pain anywhere. Well, my leg's bothering me. Yeah no kidding, I can see your bones sticking out of it. Of course I didn't say that out loud. But they were.
Overall, he seemed like he was in pretty good shape and he no internal bleeding that we could find. The only thing that worried us, besides the aforementioned bones sticking out of his leg, was that he kept asking what happened to him. I personally explained 4 times, and I think each of the nurses took several turns doing the same. "OH. Ok. Well, my leg is kinda bothering me." That's it? This guy must have had the pain tolerance of Valentina Vassilyeva.
The EMS team had called it an open tib-fib fracture, and we referred it to that for quite a while, until we got the X-rays. It was weird; there was no tibula or fibula fracture that we could see, but something wasn't quite right. Then on a different angle we could see it. Yikes. He had popped off the whole distal end of his femur and relocated it up a little higher in his leg. OOOHHHH.
The orthopod was already in the ER, so he started prepping for what we had to do next: Irrigate the hell out of the wound and try to relocate the leg as best we could before he went into surgery. (The OR team was currently tied up cleaning out my earlier patient with the acute abdomen). Irrigation is never particularly pretty, and since we were in the trauma bay with a big nasty wound it took on an even more rushed tone than usual. We doped the patient (but not too much b/c we didn't want to intubate) and started putting chucks (large disposable absorbent pads with plastic backing. I saw plenty of these in my nursing home days) under him, with a half-assed plan to funnel all the wound juice into a trash can. My glamorous job was to hold his leg up. Nothing like old man toes in your face at midnight to put you in a happy place.
Next came the saline. If you're doing a small wound you can use a syringe. If you're doing a large wound, sometimes all the docs do is grab a bag of saline, get a tube for it, and squeeze the bag directly. Always wear a mask with a face shield during something like this. The expertly designed chuck funnel didn't work (surprise) but I couldn't drop the guy's leg...so I stood there and watched while a big puddle of bloody saline slowly eased toward the side edge of the chuck before plopping at my feet. That was the first time my scrubs were soiled that night.
A wound like that looks like raw meat; it's amazing how the orthopods put something like that back together. Unfortunately, we had to put his leg back in line. He kept saying things like, "Watch my leg, it's a bit tender" and "I think my leg is hurt" (he couldn't remember why, but he picked up on the fact that somethin' weren't right). Since I was the tallest in the room (at least of disposable medical people who didn't have an MD behind their names), the orthopod made me stay on the job of holding up his leg while he worked it over.
I've mentioned before how much I like orthopedic injuries and manipulations. I couldn't leave, and I was standing on a stool surrounded by a puddle of bloody saline so I didn't feel like fainting was an option either. All I could do was zone out and do this forced quick breathing technique I've developed for any time I feel like I'm going to pass out or throw up. It's kind of like Lamaze, which makes sense because the time I use it most is when I have to watch someone give birth. Meanwhile the orthopod is working the guy's leg, pulling and shaping it like it's putty. Which, without proper bone structure, it kind of was. Deep breath, breathe ooooouuuuuuuuttt.
Then we wrapped a new quick-dry soft cast on it (man what I would give for a medical supply catalogue) and went to talk to his wife who had just gotten there.
I am probably done collecting dangerous hobbies. The more I see things like this, the less I feel inclined to ride a motorcycle, or a bike down a mountain, or talk smack in the car to that big jerk who can't drive.
I don't even know what happened to the drunk who hit him; he was in another room and out before I could see him.
Wednesday, November 4, 2009
Saturday, October 31, 2009
Radiology Means Never Having to Say "Rectal Exam"
My next patient that night in the ER was a middle-aged man who had started to bleed during his bowel movements. That's always a good time to work up.
He had actually just been in the hospital in October for an upper GI bleed, after which he supposedly quit all the hard living (IV drugs, drinking, smoking) he was doing that caused the bleed in the first place. I don't know if I was just hyper-enthused and idealistic after my last train-wreck patient actually turned out to be legit, but I really believe that he had quit all that stuff and was taking his meds. Another reason I can't be an ER doc (besides the fact that when we practice running codes, after 35 minutes everyone else is still pumping away and I'm like: "Well, it's just his time to go") is that I still remember the look on that guy's face as he was telling me his story and my heart sinks wondering if he has anyone left to care about him.
Anyway, from his story about what was currently happening, it was hard to tell where the bleed was. Hemorrhoids can give you blood in the toilet (try this: put 2 drops of red food coloring in your toilet bowl and see how red it turns. It doesn't take a lot of blood in the water for people to completely flip out.) Bright red blood ON stool means hemorrhoids or anal fissure, blood IN stool means it's internal, dark blood or stool means it's been digested. But briskly bleeding from from an upper GI source (bleeding ulcer for example) can go through so fast that it's still red. Bet you didn't want to know this much about bloody poop.
The moral of the story was, we needed to put a nasogastric tube and probably do a rectal exam. I was in favor of the NG tube first--if we got blood out of it, well hell it's an upper source and we were done! Seems like good cost-saving medicine to me. The attending wasn't having it. "You are going to have to do thousands of rectal exams in your life, you might as well get used to--wait, you are going into ER aren't you?" "No sir, I'm going into Radiology." I'm pretty sure he wanted to hit me for an instant right then. But then he just shook his head and laughed. I couldn't help myself. "Sir, radiology means never having to say "rectal exam"."
Lucky for me (I was going to do it for crying out loud, I just wanted to use logic about it), we had several traumas and acute patients come in, and the nurses never moved him to a private room (yeah, with H1N1 the ER is so crowded I had to interview him about his pooh in a room crowded with other patients), so by the time we were done, my shift was over. Yes, 7 hours later.
I pray I never have cause to go to the ER during flu season.
He had actually just been in the hospital in October for an upper GI bleed, after which he supposedly quit all the hard living (IV drugs, drinking, smoking) he was doing that caused the bleed in the first place. I don't know if I was just hyper-enthused and idealistic after my last train-wreck patient actually turned out to be legit, but I really believe that he had quit all that stuff and was taking his meds. Another reason I can't be an ER doc (besides the fact that when we practice running codes, after 35 minutes everyone else is still pumping away and I'm like: "Well, it's just his time to go") is that I still remember the look on that guy's face as he was telling me his story and my heart sinks wondering if he has anyone left to care about him.
Anyway, from his story about what was currently happening, it was hard to tell where the bleed was. Hemorrhoids can give you blood in the toilet (try this: put 2 drops of red food coloring in your toilet bowl and see how red it turns. It doesn't take a lot of blood in the water for people to completely flip out.) Bright red blood ON stool means hemorrhoids or anal fissure, blood IN stool means it's internal, dark blood or stool means it's been digested. But briskly bleeding from from an upper GI source (bleeding ulcer for example) can go through so fast that it's still red. Bet you didn't want to know this much about bloody poop.
The moral of the story was, we needed to put a nasogastric tube and probably do a rectal exam. I was in favor of the NG tube first--if we got blood out of it, well hell it's an upper source and we were done! Seems like good cost-saving medicine to me. The attending wasn't having it. "You are going to have to do thousands of rectal exams in your life, you might as well get used to--wait, you are going into ER aren't you?" "No sir, I'm going into Radiology." I'm pretty sure he wanted to hit me for an instant right then. But then he just shook his head and laughed. I couldn't help myself. "Sir, radiology means never having to say "rectal exam"."
Lucky for me (I was going to do it for crying out loud, I just wanted to use logic about it), we had several traumas and acute patients come in, and the nurses never moved him to a private room (yeah, with H1N1 the ER is so crowded I had to interview him about his pooh in a room crowded with other patients), so by the time we were done, my shift was over. Yes, 7 hours later.
I pray I never have cause to go to the ER during flu season.
Friday, October 30, 2009
Now THAT's constipation!
I spent another wild night in the ER Tuesday.
I had already put in a full day with more disaster lectures in the morning, then an afternoon crawling around in a confined space drill (more on that later), but at four pm I shook the rust and dirt out of my hair, changed into scrubs, and headed to the hospital.
The university has the only Level 1 trauma in the state, as well as being the catch-all hospital for everyone without insurance, including those without any documentation whatsoever.
My resident read a few charts and picked out out for me. Chief complaint: Abdominal pain. Which could be anything. There are so many organs in that area! Two patients could present with abdominal pain and one leave with pepto-bismol and the other leave with a baby.
I read over the lady's chart a little and in her words, she was here because, "Everything shut down on me." Alright, so that's not really helpful. When I went to talk to her, she was a TERRIBLE historian. And her story was so wild, I had no idea what to believe. She told me she hadn't had a bowel movement in eight weeks. ("Really ma'am? Eight weeks?") She told me she was mostly homeless. She had a miscarriage 10 years ago that was never "cleaned out" and now was the root of her problems. She was having difficulty urinating. She used to be a hhheeeavvvvy drinker (but of course, she wasn't anymore) She was full of pain and pressure. She had been kicked and beaten in the head while minding her own business in an area of town they call the War Zone (that one I believe, she had bruises all over her face--really made me look forward to the Fire Department Ride-Along I had scheduled the next night).
Basically, her story was wildly worthless. When you get something like that, from a person with altered mental status, you can try to take bits and pieces of the information and put it back together. Eight weeks without a bowel movement? Not hardly. Four days of abdominal pain, constipation, and difficulty urinating? Ok. The differential is huge: Does she have an ectopic pregnancy that burst? A ruptured appendix? Bowel obstruction from years of pelvic inflammatory disease? An STD? Did she get kicked in the abdomen during that beating and is she now bleeding? Or is she withdrawing from some drug? Or just being a whiner with indigestion?
I figured the best thing to do next would just be to put my hands on her abdomen and see if there was anything big going on. As soon as she lifted up her shirt I could see her abdomen looked distended. There is a difference between distended and fat. I don't know how exactly to describe it, partly I'd say it's the lack of a place to hide things. There is definitely a difference once you touch it. Her abdomen was hard and distended. And very painful. That's not a Chinese food baby. When I pressed down she hurt, but when I lifted my hand up quickly she nearly came up off the bed (rebound tenderness). I put my hands on both sides of her hips and rocked her back and forth. Ugly.
OH Crap. That was it for me in the physical exam part, I excused myself and got the resident. "So, whatcha got?" he asked, not really expecting much. "Eh, I don't want to be dramatic, but I think we have an acute abdomen." Acute abdomen means something terrible is going on in there. Blood, pus, gut juices, something has spilled out of its God-given container and into the peritoneal cavity. That equals an automatic trip to the OR.
But I'm just the medical student. And acute abdomens don't happen that often. So we went right back in there where he did a physical exam as well. When we came out of the room he said, "I don't mean to be dramatic, but I concur." The attending agreed and called surgery. We didn't scan her, and besides the basic labs (HIGH white blood cell count, slightly screwed up electryolytes, negative pregnancy test) we didn't need anything. No need for it; you can't medically treat an acute abdomen; nothing you give would clear the crap up anyway. She was going to the OR within half an hour.
"Well Allison, that's one hell of a case for your first patient here. Remember what she looked like; that's an acute abdomen and you won't see it often." The last I heard about the patient was from a general surgery resident who casually mentioned they had a complicated case going on with a woman whose belly was full of pus. That's a problem with the ER, especially just filling in shifts; you never really find out what happens.
My Mexican national patient died a few days after we brought him to the hospital. In some ways I'm surprised he lasted that long, but part of me still has the magical thought that if you make it through hell and arrive at the hospital alive, you're home free. It's still hard to understand that even if we know what's going on and have all the tools right there!, we can't always fix it.
I had already put in a full day with more disaster lectures in the morning, then an afternoon crawling around in a confined space drill (more on that later), but at four pm I shook the rust and dirt out of my hair, changed into scrubs, and headed to the hospital.
The university has the only Level 1 trauma in the state, as well as being the catch-all hospital for everyone without insurance, including those without any documentation whatsoever.
My resident read a few charts and picked out out for me. Chief complaint: Abdominal pain. Which could be anything. There are so many organs in that area! Two patients could present with abdominal pain and one leave with pepto-bismol and the other leave with a baby.
I read over the lady's chart a little and in her words, she was here because, "Everything shut down on me." Alright, so that's not really helpful. When I went to talk to her, she was a TERRIBLE historian. And her story was so wild, I had no idea what to believe. She told me she hadn't had a bowel movement in eight weeks. ("Really ma'am? Eight weeks?") She told me she was mostly homeless. She had a miscarriage 10 years ago that was never "cleaned out" and now was the root of her problems. She was having difficulty urinating. She used to be a hhheeeavvvvy drinker (but of course, she wasn't anymore) She was full of pain and pressure. She had been kicked and beaten in the head while minding her own business in an area of town they call the War Zone (that one I believe, she had bruises all over her face--really made me look forward to the Fire Department Ride-Along I had scheduled the next night).
Basically, her story was wildly worthless. When you get something like that, from a person with altered mental status, you can try to take bits and pieces of the information and put it back together. Eight weeks without a bowel movement? Not hardly. Four days of abdominal pain, constipation, and difficulty urinating? Ok. The differential is huge: Does she have an ectopic pregnancy that burst? A ruptured appendix? Bowel obstruction from years of pelvic inflammatory disease? An STD? Did she get kicked in the abdomen during that beating and is she now bleeding? Or is she withdrawing from some drug? Or just being a whiner with indigestion?
I figured the best thing to do next would just be to put my hands on her abdomen and see if there was anything big going on. As soon as she lifted up her shirt I could see her abdomen looked distended. There is a difference between distended and fat. I don't know how exactly to describe it, partly I'd say it's the lack of a place to hide things. There is definitely a difference once you touch it. Her abdomen was hard and distended. And very painful. That's not a Chinese food baby. When I pressed down she hurt, but when I lifted my hand up quickly she nearly came up off the bed (rebound tenderness). I put my hands on both sides of her hips and rocked her back and forth. Ugly.
OH Crap. That was it for me in the physical exam part, I excused myself and got the resident. "So, whatcha got?" he asked, not really expecting much. "Eh, I don't want to be dramatic, but I think we have an acute abdomen." Acute abdomen means something terrible is going on in there. Blood, pus, gut juices, something has spilled out of its God-given container and into the peritoneal cavity. That equals an automatic trip to the OR.
But I'm just the medical student. And acute abdomens don't happen that often. So we went right back in there where he did a physical exam as well. When we came out of the room he said, "I don't mean to be dramatic, but I concur." The attending agreed and called surgery. We didn't scan her, and besides the basic labs (HIGH white blood cell count, slightly screwed up electryolytes, negative pregnancy test) we didn't need anything. No need for it; you can't medically treat an acute abdomen; nothing you give would clear the crap up anyway. She was going to the OR within half an hour.
"Well Allison, that's one hell of a case for your first patient here. Remember what she looked like; that's an acute abdomen and you won't see it often." The last I heard about the patient was from a general surgery resident who casually mentioned they had a complicated case going on with a woman whose belly was full of pus. That's a problem with the ER, especially just filling in shifts; you never really find out what happens.
My Mexican national patient died a few days after we brought him to the hospital. In some ways I'm surprised he lasted that long, but part of me still has the magical thought that if you make it through hell and arrive at the hospital alive, you're home free. It's still hard to understand that even if we know what's going on and have all the tools right there!, we can't always fix it.
Sunday, October 25, 2009
The Spirit is Willing...
Apparently I am a legend around LifeGuard. I'm pretty sure there isn't a flight nurse, pilot, or paramedic in the state who hasn't heard about the medical student completely losing it on the flight to the point that she had to be medicated.
Friday afternoon we went over rope safety for a rappelling trip we're going to do Monday off some mountain in the Sandias. We spent the afternoon in the courtyard learning knots and "rappelling" off a 4 foot high walkway. The LifeGuard guys were training in one of the rooms in the building, and a handul looked out to see what was going on, saw me, and within a few minutes they'd ALL come out of various doors to see which one I was (which Keith, the flight paramedic, gladly assisted by pointing and saying, HI ALLISON! in the middle of the demonstration).
In spite of this, I had such an amazing time that I still wanted to go back up. I called the director of LifeGuard to see if she had any advice for new motion sickness regimen (Dramamine not being the ideal choice anymore) for my next flight. "Well, you got to see an interesting patient, didn't you?" Oh yeah, it was great. "You know honey, I think you should just let this one go." Alright, you have a point.
So no more flying for this girl, much to the relief of patient's mothers and to the chagrin of flight crews looking for a little fun.
Friday afternoon we went over rope safety for a rappelling trip we're going to do Monday off some mountain in the Sandias. We spent the afternoon in the courtyard learning knots and "rappelling" off a 4 foot high walkway. The LifeGuard guys were training in one of the rooms in the building, and a handul looked out to see what was going on, saw me, and within a few minutes they'd ALL come out of various doors to see which one I was (which Keith, the flight paramedic, gladly assisted by pointing and saying, HI ALLISON! in the middle of the demonstration).
In spite of this, I had such an amazing time that I still wanted to go back up. I called the director of LifeGuard to see if she had any advice for new motion sickness regimen (Dramamine not being the ideal choice anymore) for my next flight. "Well, you got to see an interesting patient, didn't you?" Oh yeah, it was great. "You know honey, I think you should just let this one go." Alright, you have a point.
So no more flying for this girl, much to the relief of patient's mothers and to the chagrin of flight crews looking for a little fun.
Wednesday, October 21, 2009
Maybe Flying Ain't For Me.
I have so much I could write about. But I'll start with the funniest first.
Last night, after a morning spent learning about bioterrorism (though apparently you don't have to leave New Mexico to get plague, hanta virus, tuleremia, and don't forget anthrax), and an afternoon crawling through a shaking, debris-filled semi in an Urban Search and Rescue earthquake recovery drill (definitely more about that later), I showed up to the fancy section of the ABQ airport where all the private flights, including the medical transport flights, take off.
Let me start off with the fact that these planes are awesome. It's like an ambulance in the air-ventilators, IV's, pharmacy cache, telemetry, all packaged with an ability to quickly load, secure, stabilize and monitor a patient through a flight. There were a lot of cool toys in that plane. The crew consists of pilot, flight paramedic, and flight nurse who all have a bit of a death wish if you ask me.
I had a 7p to 7a shift, which already made me a little nervous considering my swift detorioration after 10pm, but it was also a rare stormy night in Albuquerque (rare meaning the crap just hung around; it's still cloudy and rainy today!). I wasn't crazy about going up in a tiny airplane (it holds 5 people plus a patient) in dark stormy weather, but the flight nurse convinced me of the difference between helicopter rescues and planes which have ground support and fixed wings, plus the safety record of the pilot (he must have given that speech before). Alright, fine. I'm coming.
The first problem of the night was that I had been assured earlier that when I did my shift, I'd have enough lead time between getting a call and taking off to take my Dramamine. I used to pull whole caravans over on field trips when I was in elementary school. Anyway, the minute I got there they were already preparing to fly. The medicine makes me say crazy things, so I had really hoped for 30 minutes to drool quietly in a corner and come back to my senses in time to fly. No such luck. Plus, in the excitement of the weather and the rush to get off the ground I just forgot.
We flew to Truth or Consquences, NM to pick up a teenager who'd fallen off a moving car. She had a small subarachnoid bleed, and would probably just need observation, but we needed to move her to a facility with a neurosurgeon in house just in case. For some reason, El Paso was the closest place for her to go (guess they don't have a LifeGuard of their own). On the flight down there, we hit some storm-related turbulence. You don't know turbulence until you've been in a plane that small. That little thing shook like my old gifted education teacher when someone used the word "pregnant."
Anyway, I was not feeling awesome, but I really thought I could handle it. I haven't thrown up from motion sickness, well, ever that I can really remember. Maybe a few times, but it was long enough ago to give me a false sense of security. After we picked up the patient and her mom to head to El Paso though, we hit big time turbulence. I just wanted to die, but instead I turned to the flight nurse and simply said, "Basin time." I threw up and down. Repeatedly. For the whole rest of the hour flight. Fortunately, it was in a basin (if I feel a little sick and look at a toilet, I automatically throw up just by thinking of how dirty it probably is), but unfortunately, it was on a small plane. It was so pathetic that when we landed and loaded the teenager in the ambulance, her mom gave ME a comforting hug. The flight nurse said several times later that by looking that bad I actually took the mom's worry off her daughter and diffused the tension. She was much less worried about her comfortable medicated sleeping daughter after seeing me hurl repeatedly with tears streaming down my face (why does that happen when you throw up?) Thank you Drew, sure glad I could help.
While we were in El Paso (conversation excerpt--Pilot: We can fly over Mexican airspace, right? Paramedic: Who's going to shoot you, the imaginary Mexican Air Force? Pilot: You have a point. This will shave ten minutes off the trip!) the crew decided to go to Chico's Tacos on the border for some Mexican food. Having forgotten my ID at home, I didn't really want to go anywhere near the border, but it was my only chance to pick up some Dramamine. The restaurant was like a roller rink in smell and music selection; it was a little overwhelming. Especially since I was told to "Not act really white". Their idea to try some french fries was a spectacular failure, even thirty minutes after two Dramamine.
Once we got to the airport, they had joked about medicating me for the flight home. Then as we were walking across the tarmac, a call came to fly to another town, Demming, on our way home. A Mexican national who had spent two days wandering in the desert before a rancher found him and took him to border patrol (Really? Not a hospital? I'm sure that's in the Bible somewhere...). The man was in terrible shape. As soon as they agreed to take the flight, the nurse turned to me and said, "Zofran" (anti-nausea drug). Our choices were phenergan and Zofran. Phenergan can be given IM (intramuscularly--I was fine with getting shot at this point) but phenergan can give some people crazy reactions. We didn't need two people out of their mind on the plane, so Zofran was the logical choice. Unfortunately, you can't give Zofran IM, and you can't really give anything orally to someone who's puking....plus, by this time I was dehydrated. I really would have said yes to any idea they suggested.
So that's how I found myself in the back of a plane in the middle of the night flying to the edge of the US with an IV in my hand and a liter of saline hanging next to my head. I passed out pretty soon on the flight, whether it was from the meds or the hour I don't know, but I only woke up when we were on the ground and they were locking my IV.
The ER we went to was tiny, and packed. Mostly Hispanic patients; the signs were either bilingual or in Spanish. The room with out patient smelled horrible-if I hadn't already had two anti-emetics on board, things might have gotten uglier.
One look at that poor man and I knew he was in serious trouble. He was one of the worst patients I think I've ever seen. He was cachetic, with dried crusted sunburn on his face and ears, his lips were flaking off from dehydration, his eyes rolled around insensibly in his head unable to focus on anything. He had severe lactic acidosis--his muscles were breaking down because of the dehydration and exposure, his kidneys were failing, his liver enzymes were elevated. He was taking rapid, deep breaths, using all of his accessory muscles to try and clear some CO2 (a compensatory mechanism to rid the body of excess acid). He was out of it and moaning from pain. He had bag of O pos hanging and a positive fecal occult blood test, meaning he was losing blood out of his GI tract. Basically, everything in his body was going kaput. As he tried to move himself to our stretcher, his nose started to bleed.
Normal potassium in the blood is around 4 or 5. This man's was 8.3 Part was because of his acidosis, but a potassium this high in the blood, no matter the source, can cause fatal cardiac arrythmias. His CO2 level on arterial blood gas was 12 (normal is 40). As soon as he tired out (and he would), that was going to fail as a compensatory mechanism. I have never seen electrolytes as out of range as his.
Now that I'd been medicated, I rallied hard and was ready to go...at least while I was on my feet. We loaded him up and watched his breathing and O2 saturation. We gave him calcium gluconate to stabilize his heart and watched to see when we might have to intubate. It was a pretty uneventful flight, and it was around 3am by this time. I can't believe it, but I fell asleep sitting upright unsupported while leaning over the patient monitoring his vitals. Luckily the turbulence woke me up.
When we got back to Albuquerque, we loaded him up in the ambulance to take him to UNM hospital. When we got him out of the aircraft, I noticed blood flecked in his oxygen mask. That was new. In the ambulance he coughed and more blood came up. Crap.
He went straight to the MICU. I gave the patient report to the attending and we headed out to go back to LifeGuard headquarters. By this point I have dealt with two ambulance crews, an ER staff in Demming, MICU nurses and doctors at UNM and Border Patrol with an IV in my hand. One of the Abq crew said, "Hey, Erica needs to practice IVs, will you let her practice injections into it?" "Get your creepy eyes off me Erica, I've had enough for the night." (It got taken out in an elevator by the flight paramedic--don't know if that was much better than what she could have done.) You'd think we were done for the night, but I needed a flu shot, as did the flight nurse, so we said "What the hell?" and convinced a charge nurse to give us flu shots at 3:30am. By that time what was one more shot anyway? At least the IV was out.
On the drive back to HQ, they amused themselves by replaying the night. "You should have seen her give report Drew! She's all grown up!" "Oh Keith, she has just come so far. It seems like only yesterday she was throwing up in the back of the plane...oh wait, that WAS yesterday! HAHAHAHA!"
I went to sleep on a couch in the lounge around 4:30am after having a celebratory drumstick (celebratory because I could now hold food down).
I don't know if our patient made it or not. I'm pretty worried about his chances. I could write another blog on him. I also don't think I'll make another flight with LifeGuard. It was an amazing experience, but I can't fly with an IV every time. And I don't want to be another patient for the crew to deal with. This morning I've already received two emails from people who weren't there asking how I was doing. Lol word travels fast.
Last night, after a morning spent learning about bioterrorism (though apparently you don't have to leave New Mexico to get plague, hanta virus, tuleremia, and don't forget anthrax), and an afternoon crawling through a shaking, debris-filled semi in an Urban Search and Rescue earthquake recovery drill (definitely more about that later), I showed up to the fancy section of the ABQ airport where all the private flights, including the medical transport flights, take off.
Let me start off with the fact that these planes are awesome. It's like an ambulance in the air-ventilators, IV's, pharmacy cache, telemetry, all packaged with an ability to quickly load, secure, stabilize and monitor a patient through a flight. There were a lot of cool toys in that plane. The crew consists of pilot, flight paramedic, and flight nurse who all have a bit of a death wish if you ask me.
I had a 7p to 7a shift, which already made me a little nervous considering my swift detorioration after 10pm, but it was also a rare stormy night in Albuquerque (rare meaning the crap just hung around; it's still cloudy and rainy today!). I wasn't crazy about going up in a tiny airplane (it holds 5 people plus a patient) in dark stormy weather, but the flight nurse convinced me of the difference between helicopter rescues and planes which have ground support and fixed wings, plus the safety record of the pilot (he must have given that speech before). Alright, fine. I'm coming.
The first problem of the night was that I had been assured earlier that when I did my shift, I'd have enough lead time between getting a call and taking off to take my Dramamine. I used to pull whole caravans over on field trips when I was in elementary school. Anyway, the minute I got there they were already preparing to fly. The medicine makes me say crazy things, so I had really hoped for 30 minutes to drool quietly in a corner and come back to my senses in time to fly. No such luck. Plus, in the excitement of the weather and the rush to get off the ground I just forgot.
We flew to Truth or Consquences, NM to pick up a teenager who'd fallen off a moving car. She had a small subarachnoid bleed, and would probably just need observation, but we needed to move her to a facility with a neurosurgeon in house just in case. For some reason, El Paso was the closest place for her to go (guess they don't have a LifeGuard of their own). On the flight down there, we hit some storm-related turbulence. You don't know turbulence until you've been in a plane that small. That little thing shook like my old gifted education teacher when someone used the word "pregnant."
Anyway, I was not feeling awesome, but I really thought I could handle it. I haven't thrown up from motion sickness, well, ever that I can really remember. Maybe a few times, but it was long enough ago to give me a false sense of security. After we picked up the patient and her mom to head to El Paso though, we hit big time turbulence. I just wanted to die, but instead I turned to the flight nurse and simply said, "Basin time." I threw up and down. Repeatedly. For the whole rest of the hour flight. Fortunately, it was in a basin (if I feel a little sick and look at a toilet, I automatically throw up just by thinking of how dirty it probably is), but unfortunately, it was on a small plane. It was so pathetic that when we landed and loaded the teenager in the ambulance, her mom gave ME a comforting hug. The flight nurse said several times later that by looking that bad I actually took the mom's worry off her daughter and diffused the tension. She was much less worried about her comfortable medicated sleeping daughter after seeing me hurl repeatedly with tears streaming down my face (why does that happen when you throw up?) Thank you Drew, sure glad I could help.
While we were in El Paso (conversation excerpt--Pilot: We can fly over Mexican airspace, right? Paramedic: Who's going to shoot you, the imaginary Mexican Air Force? Pilot: You have a point. This will shave ten minutes off the trip!) the crew decided to go to Chico's Tacos on the border for some Mexican food. Having forgotten my ID at home, I didn't really want to go anywhere near the border, but it was my only chance to pick up some Dramamine. The restaurant was like a roller rink in smell and music selection; it was a little overwhelming. Especially since I was told to "Not act really white". Their idea to try some french fries was a spectacular failure, even thirty minutes after two Dramamine.
Once we got to the airport, they had joked about medicating me for the flight home. Then as we were walking across the tarmac, a call came to fly to another town, Demming, on our way home. A Mexican national who had spent two days wandering in the desert before a rancher found him and took him to border patrol (Really? Not a hospital? I'm sure that's in the Bible somewhere...). The man was in terrible shape. As soon as they agreed to take the flight, the nurse turned to me and said, "Zofran" (anti-nausea drug). Our choices were phenergan and Zofran. Phenergan can be given IM (intramuscularly--I was fine with getting shot at this point) but phenergan can give some people crazy reactions. We didn't need two people out of their mind on the plane, so Zofran was the logical choice. Unfortunately, you can't give Zofran IM, and you can't really give anything orally to someone who's puking....plus, by this time I was dehydrated. I really would have said yes to any idea they suggested.
So that's how I found myself in the back of a plane in the middle of the night flying to the edge of the US with an IV in my hand and a liter of saline hanging next to my head. I passed out pretty soon on the flight, whether it was from the meds or the hour I don't know, but I only woke up when we were on the ground and they were locking my IV.
The ER we went to was tiny, and packed. Mostly Hispanic patients; the signs were either bilingual or in Spanish. The room with out patient smelled horrible-if I hadn't already had two anti-emetics on board, things might have gotten uglier.
One look at that poor man and I knew he was in serious trouble. He was one of the worst patients I think I've ever seen. He was cachetic, with dried crusted sunburn on his face and ears, his lips were flaking off from dehydration, his eyes rolled around insensibly in his head unable to focus on anything. He had severe lactic acidosis--his muscles were breaking down because of the dehydration and exposure, his kidneys were failing, his liver enzymes were elevated. He was taking rapid, deep breaths, using all of his accessory muscles to try and clear some CO2 (a compensatory mechanism to rid the body of excess acid). He was out of it and moaning from pain. He had bag of O pos hanging and a positive fecal occult blood test, meaning he was losing blood out of his GI tract. Basically, everything in his body was going kaput. As he tried to move himself to our stretcher, his nose started to bleed.
Normal potassium in the blood is around 4 or 5. This man's was 8.3 Part was because of his acidosis, but a potassium this high in the blood, no matter the source, can cause fatal cardiac arrythmias. His CO2 level on arterial blood gas was 12 (normal is 40). As soon as he tired out (and he would), that was going to fail as a compensatory mechanism. I have never seen electrolytes as out of range as his.
Now that I'd been medicated, I rallied hard and was ready to go...at least while I was on my feet. We loaded him up and watched his breathing and O2 saturation. We gave him calcium gluconate to stabilize his heart and watched to see when we might have to intubate. It was a pretty uneventful flight, and it was around 3am by this time. I can't believe it, but I fell asleep sitting upright unsupported while leaning over the patient monitoring his vitals. Luckily the turbulence woke me up.
When we got back to Albuquerque, we loaded him up in the ambulance to take him to UNM hospital. When we got him out of the aircraft, I noticed blood flecked in his oxygen mask. That was new. In the ambulance he coughed and more blood came up. Crap.
He went straight to the MICU. I gave the patient report to the attending and we headed out to go back to LifeGuard headquarters. By this point I have dealt with two ambulance crews, an ER staff in Demming, MICU nurses and doctors at UNM and Border Patrol with an IV in my hand. One of the Abq crew said, "Hey, Erica needs to practice IVs, will you let her practice injections into it?" "Get your creepy eyes off me Erica, I've had enough for the night." (It got taken out in an elevator by the flight paramedic--don't know if that was much better than what she could have done.) You'd think we were done for the night, but I needed a flu shot, as did the flight nurse, so we said "What the hell?" and convinced a charge nurse to give us flu shots at 3:30am. By that time what was one more shot anyway? At least the IV was out.
On the drive back to HQ, they amused themselves by replaying the night. "You should have seen her give report Drew! She's all grown up!" "Oh Keith, she has just come so far. It seems like only yesterday she was throwing up in the back of the plane...oh wait, that WAS yesterday! HAHAHAHA!"
I went to sleep on a couch in the lounge around 4:30am after having a celebratory drumstick (celebratory because I could now hold food down).
I don't know if our patient made it or not. I'm pretty worried about his chances. I could write another blog on him. I also don't think I'll make another flight with LifeGuard. It was an amazing experience, but I can't fly with an IV every time. And I don't want to be another patient for the crew to deal with. This morning I've already received two emails from people who weren't there asking how I was doing. Lol word travels fast.
Friday, October 16, 2009
Wilder-nasty
The other day in my Disaster Medicine rotation we talked about wilderness medicine, which is just a fancy way of saying practicing medicine in austere conditions.
In the morning we listened to lectures on radiation and the consequences of accidental or intentional exposure. I'm not sure the lecturer really knew what level we were at because he asked, totally serious, if any of us had ever seen an X-ray before. So that was hard to get through.
The next lecture spoke about chemical exposure and warfare. My favorite line from the day: "When a person with cyanide poisoning vomits, their vomit is dangerous to you." I couldn't help but reply that I generally consider anybody else's vomit dangerous just as a general rule. "Well, their burps are dangerous to you too." he modified.
The afternoon was spent in the courtyard (it's 75 degrees and sunny most of the time) where the instructors recreated scenarios that might happen in unexpected places. For example, one of the docs just got back from lectures on wilderness medicine in Fiji. Several hours after he first got there another lecturer started bleeding profusely out of an unfortunate orifice. Yeah. So you can't just hold pressure until the bleeding stops. Another great story was a lady who slipped and fell on a walkway while running to get a picture. Her husband, an orthopedic surgeon, told everyone else gathered around concernedly that she was just prone to hysterics and that she really would stop screaming and get up. Well, she had a broken femur. Yeah. I wonder how they're doing now.
We did things like improvise cervical spine and back immobilizers, built a traction device for a femur fracture, and learned a few techniques for how to carry somebody back down the mountain if they can't walk.
Notice the Spanish Windlass below his foot. It's twisted in the straps to provide traction, pulling his theoretically broken femur and keeping it in alignment so the bones can't slide past each other and let a big hematoma sphere (basically a ball of blood in all the leg space-someone can bleed out internally from a femur fracture).
Cervical spine immobilization + handy leg-shoulder strap harness+ 2 dudes=one very uncomfortable ride down the mountain.
Two backpacks plus a walking pole and sleeping pad. I probably wouldn't try this with anyone over 60 pounds. Dang you Shook Ming.
Much less bulky femur traction device. Using a telescoping walking pole, a strap that originally held skis together, and the biggest carabiner I have ever seen.
Things I took away from this:
1. Don't hike with anyone you can't carry. Also, they need to be incredibly strong so they can carry you (you may remember my college rule of only dating those who could do a lap around a room with me in their arms. This is just good advice, mountain or no mountain). I'm thinking Chinese Acrobats are my best bet for future hiking partners.
2. It is very hard to improvise tape. All those people at the airport and on the mountain that had a strip of duct tape on their backpacks didn't just put it on there so they could find their bags at the baggage claim. Not that that's what I ever thought or anything.
3. I really should hike with hiking poles. Otherwise, if I ever break my femur I'm going to end up with a tree branch poking me the whole way down the mountain.
4. Also, a long rope. Crowd control during the hike, rope litter in case of emergency.
Those are all the lessons I can remember right now.
In the morning we listened to lectures on radiation and the consequences of accidental or intentional exposure. I'm not sure the lecturer really knew what level we were at because he asked, totally serious, if any of us had ever seen an X-ray before. So that was hard to get through.
The next lecture spoke about chemical exposure and warfare. My favorite line from the day: "When a person with cyanide poisoning vomits, their vomit is dangerous to you." I couldn't help but reply that I generally consider anybody else's vomit dangerous just as a general rule. "Well, their burps are dangerous to you too." he modified.
The afternoon was spent in the courtyard (it's 75 degrees and sunny most of the time) where the instructors recreated scenarios that might happen in unexpected places. For example, one of the docs just got back from lectures on wilderness medicine in Fiji. Several hours after he first got there another lecturer started bleeding profusely out of an unfortunate orifice. Yeah. So you can't just hold pressure until the bleeding stops. Another great story was a lady who slipped and fell on a walkway while running to get a picture. Her husband, an orthopedic surgeon, told everyone else gathered around concernedly that she was just prone to hysterics and that she really would stop screaming and get up. Well, she had a broken femur. Yeah. I wonder how they're doing now.We did things like improvise cervical spine and back immobilizers, built a traction device for a femur fracture, and learned a few techniques for how to carry somebody back down the mountain if they can't walk.
Notice the Spanish Windlass below his foot. It's twisted in the straps to provide traction, pulling his theoretically broken femur and keeping it in alignment so the bones can't slide past each other and let a big hematoma sphere (basically a ball of blood in all the leg space-someone can bleed out internally from a femur fracture).
Cervical spine immobilization + handy leg-shoulder strap harness+ 2 dudes=one very uncomfortable ride down the mountain.
Two backpacks plus a walking pole and sleeping pad. I probably wouldn't try this with anyone over 60 pounds. Dang you Shook Ming.
Much less bulky femur traction device. Using a telescoping walking pole, a strap that originally held skis together, and the biggest carabiner I have ever seen.Things I took away from this:
1. Don't hike with anyone you can't carry. Also, they need to be incredibly strong so they can carry you (you may remember my college rule of only dating those who could do a lap around a room with me in their arms. This is just good advice, mountain or no mountain). I'm thinking Chinese Acrobats are my best bet for future hiking partners.
2. It is very hard to improvise tape. All those people at the airport and on the mountain that had a strip of duct tape on their backpacks didn't just put it on there so they could find their bags at the baggage claim. Not that that's what I ever thought or anything.
3. I really should hike with hiking poles. Otherwise, if I ever break my femur I'm going to end up with a tree branch poking me the whole way down the mountain.
4. Also, a long rope. Crowd control during the hike, rope litter in case of emergency.
Those are all the lessons I can remember right now.
Wednesday, October 14, 2009
My 100th Post
In honor of this momentous occasion, I would like to open the floor to a reader with a good story.
Anyone who would like to guest post, possibly talking about how stupid you think doctors are to get back at my snarkiness, please comment or email me.
And now for my real post.
I'm in a disaster medicine rotation here in NM. You may wonder, why are you doing that when you want to be in Radiology? At least, that's what all the other medical students each asked me. They're going into emergency medicine of course.
Well, the long answer is, I wanted to check New Mexico out for residency, October has beautiful weather, when someone asks if there is a doctor in the house I'd still like to answer even if I'm only a picture doctor, I couldn't take another month of sitting behind three people trying to see a CT scan.
The short answer is, it's freakin cool.
Yesterday I listened to the head of NM's Urban Search and Rescue Team talk about going to New Orleans after Hurricane Katrina. She was one of the people on a boat floating around New Orleans cutting people out of their attics. She talked about why people might not have left before the storm, what was killing people in the first days after the hurricane..like it was blasted hot, and people were stuck in there attics. The US&R team had to stop rescue operations for 36 hours because people started shooting at the rescue boats. Really. The she showed pictures of the devastation, the flooding, and the four Porta-Potties that some firefighters with bolt cutters stole out of a construction site--the were the only ones there for 10 teams of 81 people.
By the way, did you know there's a regulation stating that you need to have a 20:1 person to toilet ratio in acute care settings like that? Who knew? But when the rest are under water, I guess there's nothing you can really do about that. We probably spent 20 minutes talking about the toilet situation (I did not know about the military field bucket system...something to read about).
I could have listened for hours. It's so fascinating to think about the different aspects of disaster preparedness and repsponse. I hope to have a lot more posts in the future as I learn more!
Anyone who would like to guest post, possibly talking about how stupid you think doctors are to get back at my snarkiness, please comment or email me.
And now for my real post.
I'm in a disaster medicine rotation here in NM. You may wonder, why are you doing that when you want to be in Radiology? At least, that's what all the other medical students each asked me. They're going into emergency medicine of course.
Well, the long answer is, I wanted to check New Mexico out for residency, October has beautiful weather, when someone asks if there is a doctor in the house I'd still like to answer even if I'm only a picture doctor, I couldn't take another month of sitting behind three people trying to see a CT scan.
The short answer is, it's freakin cool.
Yesterday I listened to the head of NM's Urban Search and Rescue Team talk about going to New Orleans after Hurricane Katrina. She was one of the people on a boat floating around New Orleans cutting people out of their attics. She talked about why people might not have left before the storm, what was killing people in the first days after the hurricane..like it was blasted hot, and people were stuck in there attics. The US&R team had to stop rescue operations for 36 hours because people started shooting at the rescue boats. Really. The she showed pictures of the devastation, the flooding, and the four Porta-Potties that some firefighters with bolt cutters stole out of a construction site--the were the only ones there for 10 teams of 81 people.
By the way, did you know there's a regulation stating that you need to have a 20:1 person to toilet ratio in acute care settings like that? Who knew? But when the rest are under water, I guess there's nothing you can really do about that. We probably spent 20 minutes talking about the toilet situation (I did not know about the military field bucket system...something to read about).
I could have listened for hours. It's so fascinating to think about the different aspects of disaster preparedness and repsponse. I hope to have a lot more posts in the future as I learn more!
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