Monday, April 28, 2008

April Showers

Heavy spring rain showers pummeled the flowers outside. I love all of the color, but the sickeningly soapy-sweet smell of hibiscus is a little overwhelming when I open the door.

Thursday, April 24, 2008

Checks and Balances

"So this was part of a check-off thing tonight, right?" he said, with the last word said with a hopeful lilt.

"Yeah, they've been wanting to meet you for several months now, and I had been blowing them off. But now it's done," I answered.



Army Guy and I were leaving from a dinner with some co-workers and friends. I am still really impressed with AG. He's willing to try new things, and puts up with meeting my friends and co-workers... even the annoying ones. And he shows a lot more restraint in annoying situations than I would if I had training in hand-to-hand combat!

I have told him that he doesn't have to hang out with my friends or even like them, but so far he's been really good in social situations. Even better, is that everyone seems to like him! Maybe I have just dated socially-inept people in the past, but typically I either couldn't even get ex-boyfriends to go out socially with my friends or the few encounters we had were always awkward.

While I pride myself on being pretty independent, it is nice having someone to do things with, talk to at the end of the day, and who pretty much instantly makes you happy just to be around them.

Sunday, April 20, 2008

Bright, Sunshiney Days

Spring is definitely here...

-The daffodils Ru helped me plant last fall are blooming, with tulips on the way.
-Red-breasted robins chirp and flutter from one green branch to the next.

Bright-colored petals are competing for pollination, animals are competing for attention from the opposite sex, and local teens/young adults loiter outside-- ending stupid arguments with violence and gunfire.

Thursday, April 17, 2008

Rooty Tooty Fresh N' Fruity

What does the name Emergency Department mean to you? A place to go for help when you are sick or injured? How about a place to go for breakfast? As it turns out, that's really all one of my recent patients was looking for.

She was a hand-off patient, meaning that another person initially saw her, and transfered her to me at shift change. The story was that she had just been discharged from the hospital the day before and was back with more pain. It was her typical sickle cell pain. No chest pain, no difficulty breathing, no fever. So the other resident treated her pain, gave her some IV fluids, etc. Sick sicklers we work up with labs and imaging, those with pain crises we treat and if we're unsuccessful at controlling their pain, they get admitted to the pain service for PCA pumps, and other meds we're not willing to administer willy-nilly in the ED.

So, I was a good little resident and immediately re-assessed the patient after signout. Her pain was a little better, but she said that she usually gets better pain relief when the morphine is pushed, rather than run in with fluids in a drip. Fine, second dose: IV push, followed by another liter of fluid.

In the meantime, the breakfast cart arrived in the department. Breakfast trays had been ordered for all of the overnight psych patients and nursing home guests that for whatever reason couldn't be moved out of the department overnight due to placement issues. Typically, we don't feed our patients as oftentimes they are not around for more than a few hours, are potential surgical candidates, or are in acute distress and can't actually swallow anything safely.

It is not "three hots and a cot", people.

So the sickler requests breakfast. Fine. Since the cafeteria was actually up and running by this point, a nice, hot breakfast arrived at her stretcher in less than 30 minutes. That's pretty damn good. During that 30 minutes, she pressed her call button no less than three times to demand fruit punch, more fruit punch WITH ICE, etc. from her poor nurse who was also managing an overdose-patient, a cardiac patient, and I think an asthmatic, all with multiple orders and monitoring tasks to keep up with.

Finally, the tray arrives. The call bell for Room 19 immediately starts beeping. Soon afterwards, the charge nurse comes up to me, and said that the patient was upset that there wasn't any meat on her breakfast tray.

She said, "This ain't no breakfast-- there's no meat in here! I've gotta have bacon or sausage, or I'm just going to go home."

That was the best news I had heard yet.

So, I go back to the room and tell the patient that I hear she's feeling better and ready to go home. She says "Yeah, my pain's all better, I just want to finish my breakfast." So we discuss follow-up plans with her hematologist to discuss chronic pain management.

The unsatisfactory breakfast? Steaming-hot cheese omlet, 2 pancakes with maple syrup, and hot coffee with cream and sugar. (I think I'd crammed a pre-smashed protein bar into my pie-hole that morning on the drive in, so I was seriously eyeballing her breakfast.)

Patients like this always frustrate me. I think her nurse should have set out a tip jar. They stroll in and out of the department frequently, and have been in so many times that they come with all sorts of crazy demands and expectations. Occasionally, they present really sick, but like the boy who cried, "Wolf", when you see someone multiple times every month it's hard to take their complaints seriously.

Often, it seems to be the patients who aren't paying for our services with co-pays or insurance premiums that try to glean as much out of the hospital as they can. I wonder how this works with countries with socialized medicine. Surely they still have the frequent-fliers, mainly drug-seekers, but do they have patients that are just as demanding, or do people abuse socialized medicine less?

Tuesday, April 15, 2008

The Stuff of Genius...

I never said I was smart. I was supposed to go for a long run after work today. However, things got crazy midway through the afternoon, and I never got a chance to eat anything for lunch. So, instead of just sticking it out, I decided to head home, wolf down some oatmeal cookies and gatorade and then go for a run. Apparently, nothing spells bricks in your tummy like oatmeal cookies. And that's how my 9-mile run went to 1 mile with 2 miles of walking. Argh.

Tuesday, April 08, 2008

Spring, Sprang, Sprung

On my way off to work on Sunday, I noticed the crocus were blooming in the front yard. I guess Spring this year isn't so far behind last year, it just has seemed like such a looonnng winter. It's been in the 60's for the past three days, a drastic change from the snowflakes that were still falling last week.

Yesterday, I went for a run out by the lake. The ice had finally all melted away, there weren't any boats out, but there were a few ducks testing the water. The bare trees looked funny in the bright light... naked and exposed, huddling next to each other.

Today I finally turned the heat off, and have several windows cracked open. It feels good to air out the house.

I had a few days off last week, and when I went back to work the other day, I was shocked to find out that a teenager I had admitted a few nights before had died suddenly on the floor. She'd had heart and lung problems her entire life and had been leading a relatively normal life when she started coughing up blood. When I saw her, she was completely stable, and she got admitted for more formal testing. Everything was done correctly-- specialists were called in early and responded quickly, and I don't think that there was anything that we could have done differently.

While death and bad outcomes aren't all that uncommon, I guess I just have high expectations for stable patients that get admitted. Emergency medicine is high-pressure, but generally you can lump patients into just a few categories: those that go home, those that get admitted and then go home, and those that you just can't fix. I think that I have been brooding about this case because we all thought that this child would do so well. I had to really push the parents to allow her to even stay to get evaluated.

Thursday, April 03, 2008

I Wanna Be Sedated

I haven't updated for a while, although it has not been for lack of material. Things have been busy in the Peds ED. It seems like every shift is clogged up with sedations. Like I have said before, I like kids-- I just don't particularly like dealing with their parents.

The other day, I got called over the intercom to go into Room 7 for uncontrolled bleeding. I wasn't quite sure what to expect. When I walked into the room, I saw a relatively calm toddler seated on the bed with blood oozing through the dressing on his head. His mother was pacing back and forth uttering all sorts of obscenities while her "friend" sat in a rocking chair by the child's stretcher, shoveling Doritos into her mouth.

The situation? Rottweiler vs. Toddler

As I unwrapped his head, I couldn't get a good view of the oozing wound. He had a second laceration on the top of his head that went down to the skull, and there was an odd flat spot on his head. I notice an orange crumb fall on the sheet and and look up to realize Mom's friend is eating her chips over my patient's bleeding head. I am already annoyed.

I tightly wrap up my patient's head injury, fill out consent forms and personally take him to the CT scanner. He's only 4, and there's a good chance he won't hold still for the scan. Mom is still doing nothing to comfort her child (unless swearing is the equivalent of a lullaby at home), so I hold him in my arms, and place his turbaned head in the headrest of the CT scanner. One of our nurses gave him a stuffed dinosaur, and as we wrap him up burrito-style for the scan, I place the dino on his little chest so he has something to look at while the machine buzzes around his head.

Luckily, the scan's clean... no skull fractures. I pick boy and dino back up and back to room we go, where he gets hooked up to the monitor, and we start pushing the sedatives (midazolam, atropine, and ketamine in the Peds ED). His eyes spin and "Mom" laughs at the drunken expression on his face. She doesn't want to stay for the repair, and I kick Dorito-muncher out of the room.

His cuts are deep, extending through the galea down to the skull. The bleeding has finally stopped with the pressure dressing. My attending and I are deep into repairing the wounds when random Ortho resident walks in, and goes, "Wow, what layer are you guys at?"

"That would be skull," I answer, tapping the hard surface with my suture needle.

"Shouldn't ENT be doing this?" he asks. (Ear, Nose, and Throat Surgery is the substitute for plastics at my hospital.)

"Why would two strong, independent women need ENT?" I answer, gesturing at my attending. Who let this guy in here? He's about as helpful as Dorito-woman!

He says something about another patient to my attending and ducks out.

Several absorbable sutures and staples later, the wounds are all closed. Luckily for the kid, his injuries were all in the scalp area. Although he will have some huge scars, there's not a mark on his face. "Mom" finally returns a bit more calm. They don't exactly seem to be the most reliable at follow-up, so I go over wound care and antibiotic coverage three times with them. We also gave him IV antibiotics. "Mom" still has done nothing to comfort her son, and Dorito-woman interjects some helpful anecdote about something she saw on TV.

I was ready for my own chemical-induced nap by the time they left, and had to exchange white coats as mine now had blood all over the shoulder. I think that The Ramones said it best.