With Much Thanksgiving

I have a lot to be thankful for this year.

I hope that the Holiday finds you healthy and with loved ones.

-K

Dinner and a Movie

"Don't worry, about dinner tonight, I'm bringing it down." he said.

"Are you sure? I was just going to heat up some leftovers."

"We can have the leftovers if you don't like what I bring." he countered.

At this point, I was baffled. AG can make a mean pork chop, so I don't doubt that he can cook, and to keep the leftovers handy didn't sound too promising. I had no idea what he could be talking about.

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An hour later, we stood in my kitchen. I watched expectantly as steam hissed out of a small, cardboard box. AG had brought down MRE's (Meal Ready to Eat) for the both of us. Mine was BBQ pork, with clam chowder and a piece of lemon poppyseed pound cake.

The olive green packets didn't look very impressive. Neither did the clear green bag with a white piece of styrofoam in it. The instructions were to add some water and prop the bag "on a rock or something" and showed a handy illustration with the bag tipped, supported at an angle by a "something". I also had a plastic flask which I dumped water and powder into to make my lime green energy drink. Both packets also came with a single serving of coffee, matches, salt, sugar, creamer packets, AG had a mini-tabasco sauce, and napkins that double as toilet paper.

I was pleasantly surprised.

The BBQ pork came with two compressed pieces of wheat bread, cheese spread, and BBQ sauce. The flattened bread and cake products were kind of weird texture-wise, but they didn't taste bad. And the sandwich was filling, I couldn't even finish my meal. (This was probably a good thing because AG says that 1 MRE has a full day's calories packed into it.)

I got a little impatient waiting for the soup to heat up, so it was kind of lukewarm, but it was really hearty, with big chunks of meat. AG's meal was chicken noodle soup that scalded my tongue (guess he's not the impatient one of the two of us!), an energy bar, chocolate shake, and a full package of peanut M&M's.

Apparently, there are about 30 different flavors, and I'm told the Vegetarian Omlet option is the absolute worst. When the guys eat together, there's a great deal of bartering cheese spread for peanut butter, and that sort of thing. It's also not cool to dig through the supply box and pick the meal of your choice.

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As for the movie, we sat down to watch "High Fidelity" and I was promptly asleep in 20 minutes curled up next to AG on the couch. Not a bad date.

Dear Starbucks,

I am almost ashamed to admit how much I enjoy your Gingerbread Latte. However, what I do NOT enjoy is at the very end of it, I always somehow nearly gag myself with the last sip when something solid and chunky hits the back of my throat. Tonight I actually bit down on a piece of it, and I'm just guessing here, but it was semi-crunchy and I think that it may have been an honest-to-God actual piece of ginger, or maybe a clove?

ARE YOU TRYING TO MAKE ME BARF?

There should not be chunks of anything at the bottom of one's coffee, particularly when they have paid over $4 for said coffee! So please, please, please lose the chunks. I would like to just order a latte and not sound like a prima donna when I ask the barista to get me a Grande-Skinny-Gingerbread-Latte-No-Whip with all of the SH!T hand-strained out of it.

Thank you,


-K

Busted!

This year I have been moonlighting at one of the community ED's nearby. It's a different type of patient mix-- most of the patients are insured, and maybe it's all in my head, but they seem to be more polite, and actually follow-up with their private physicians. I typically work a shift or two a month for extra money. I don't want to miss any time that I could be spending with AG before he deploys, and to be honest, I really don't want to give up too many of my days off.

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Anyway, the other night, working at two different hospitals came in handy. I was working with my friend, M, and I grabbed the next chart and walked into the room. It was a young woman who was complaining of bilateral knee pain, and told the nurse that she hadn't been able to walk for the past 3 days. When I walked in, I was surprised to recognize the girlfriend of one of my patient's that I had seen the night before in my base hospital. I remembered her because he was there for a big, long rule-out appendicitis workup and she proceeded to hound the nursing staff constantly and paced back and forth across the department making phone calls (and demanding we feed said boyfriend immediately, despite his reported pain and vomiting, once it turned out that he didn't have appendicitis).

So, I called her on it, and she said she hid the difficulty walking the night before because she was concerned about her boyfriend. Fine. I asked her how she got to the hospital that night because when thinking about pain meds, you typically don't want to give a bunch of narcotics to someone who is about to drive home. That's when she said that she walked to the hospital. ???

Hmm, so I now I have someone who wants narcotics (allergic to ibuprofen, and acetaminophen "doesn't work") for an injury that doesn't make any sense. So, I gave her a shot of an anti-inflammatory that she'd never heard of, and sent her on her way. Reportedly, she'd had months of intermittent pains, no trauma/fall, and a normal physical exam, which to me means no need to waste any time with x-rays/imaging.

Just before she walked out to the waiting room, I ask her how the boyfriend's doing, and she says, "His belly doesn't hurt no more, now it's his teeth."

Hmm...

I sit down next to M, and see what he's up to. Wouldn't you know it, he's right in the middle of writing a prescription for narcotics for a young male with dental pain! I tell him the story, and mention how the guy just got discharged from our ED with narcotics the night before.

So, we both walk back to the guy's room, and I just stand there silently while M grills him for not telling him about the prescription he'd just gotten the night before. He doesn't deny anything, and just sheepishly says that he never filled the first one, but that he still has it at home. M tells him to go fill the first script because we're not giving him anything tonight, and out the door he slinks.

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I am sure that this happens all the time, but as I typically work just in one location, I don't see it that much. With electronic tracking, we now can easily look up just how many times someone's been in our department and what they've been given, so it's easy to tell if they have prematurely run out of their pain meds. However, there's no way to link between hospitals, so we can't really tell just how much someone's trying to abuse the system. This couple will probably still continue their quests for meds, but hopefully it will be to hospitals 3, 4, and 5 instead of the two I'm at.

Missing (parts of) Persons

I get a lot of work-related emails. Most of it is just instant-delete type junk, but this one made me laugh:

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EM Residents and Faculty,

Need your help with an issue here, digits with no owners....

Since August 2008 we have had three separate cases where finger tips or most of a thumb were found unlabeled on trays or in drawers in a bag. The most recent was yesterday. It is impossible for us to track what providers may have been involved in these cases as specimens were unlabeled. I have attached some hospital polices that address this, but I think _______ from pathology sums it up nicely that if the resident is in doubt, put the specimen in a container, label it with patient's name and MR# and send it down to pathology with a requisition. We'd appreciate your help, I'll be sending a reminder to the orthopedic residents as well.

Thanks

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So, I don't know who has been leaving dismembered body parts laying around (or worse yet, shoving them in a drawer?), but it is kind of brings up some funny imagery of body parts just lying around everywhere in random drawers.

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Recently, I saw a prisoner who got one of his front teeth knocked out when he was punched in the face. He tried to put it back in himself, but when he woke up the next morning, he found his tooth lying on his pillow.

By this point, the tooth was no longer salvageable. We put it in a specimen cup and asked him if he'd like to keep it. He said yes, at which point the guards interjected and said that he couldn't take it back to jail with him. We asked if they could store it for him with his personal belongings, and were given a line about there not being enough storage space in the jail.

I had thought about sending his tooth to the lab to have them identify it, just for the kick of seeing a label on the computer that said Incisor; likely human, but in the end, the thing just got red bagged.

dFwMP

Last night, I happened to glance down the hallway and there they were-- gleaming, copper-colored calf boots with a good 5-inch heel. They belonged to a young woman, and how she managed to walk in them I will never know, but it reminded me of a couple of strange cases that I had recently. In the Emergency Department, it sometimes seems like patients seem to come in clusters with the same injury. One shift it is asthma-day, the next is heart-failure day, etc.

The other week, I had two bizarre high-heel related injuries. The first was a young woman who got clubbed in the face by a stiletto. She had a D-shaped laceration present just below her eye. A few centimeters different, and she would have been like that guy in whatever horror flick that was dies after a stiletto to the eyeball by a crazy stalker woman.

The very next night, I had a 30's male come in with an eye injury. He had a lot of bruising and swelling just under his left eyebrow. He also had some loss of his peripheral vision, and his pupils were asymmetric, and the one on the left was not quite round like it should be. Into the CT scanner he went, and there was no bleed. Ophthomology came and saw him and diagnosed him with an iris sphincter tear. As for how he injured his eye, it turned out that it happened in a strip club. Apparently, he was sitting too close to the stage, and when one of the "dancers" swung around the pole, she ended up hitting him with her heel. As you can imagine, there was a lot of chuckling about his mechanism of injury.

So maybe instead of calling them FMP's, we should call them "Don't F With Me Pumps".

Step Away from the Computer

If you are taking the time to read this, I hope that you have already taken the time to vote today. Ok, it may be for selfish reasons, but I hope that most Americans are out there voting and glued to the television today-- that way they're not coming into the Emergency Department with their sore throats and belly pain of six months that must be fixed post-haste (come in all you want after midnight tonight!).

We don't have televisions in our department. I think it would be interesting to do a survey of departments across the country and see if there's any spike in visits at the places that do equip each room with a TV on days like today.

Like a lot of people, I'm sick of this two-year marathon of campaigning, but at least I made a decision at the end of it all. Part of me is secretly hoping that my candidate loses, so if things don't turn around, I can continue with my shrug and "Don't look at me, I didn't vote for him!" mutterings.

Sadly, I went to my local Starbucks to claim my free cup of election-day coffee, only to discover that they had gone out of business, and I refuse to go to the ones downtown where you have to pay for parking!

This morning, all I had to do (after finding my unmarked, unadvertised voting site) was state my name and sign somewhat similarly to the old signature they had on file. No goverment ID, no recitation of a DOB or SSN, nothing. Maybe someday we can actually learn how to tally votes without any questions of validity, but unless there's a landslide today, I predict weeks of arguing to follow.

Um, yeah...

It's been a while since I've written anything here, and it is not for lack of activity. Today is day 14 since I have worked a shift in the Emergency Department. Two weeks ago, Army Guy and I packed up my Saturn and drove off to Ohio to spend a week with his family and high school friends. (AG's car threw a fit and decided to throw a piston while he was driving down the other weekend, which ultimately led to selling it to an "auto recycler" and the decision to rent a car until he deploys.) I had never met any of them before, and was nervous-- although mostly about if I would make a good first impression with the family's 20 year-old Sheltie. The week flew by though, and it turns out that AG and I actually like each other enough to survive long car rides!

This past week, we went to Chicago to attend the American College of Emergency Physician's annual assembly. It is basically four days of death-by-powerpoint followed by late-night drinking/dining with one's co-workers. My program pays for each senior resident to attend because it is also a good networking opportunity for residents to look for job openings across the country. AG was also able to go with me, so he spent the days exploring Chicago and then we would meet up each evening. The last night we managed to squeeze in a date night and went to see "The Brothers Karamosov" at Looking Glass Theatre. The stage itself was pretty small, but the performance blew us away, as we usually go to local community/college theater.

Halloween ended up being pretty quiet. We passed out candy to the local trick-or-treaters, and then went to see a local production of "Dracula", which turned out to be in a church basement of all places! It didn't quite compare with the professional theater company, but it still was a fun way to spend the evening.

So, it's been a busy couple of weeks, and I am not exactly looking forward to my shift tomorrow!

Alaskan Picture Pages

I extended my time in Alaska to include a week of vacation. "The Phoenix" came up and joined me, and we spent a week cramming in as many activities as possible.

The first day we went on a bear-viewing tour. We chartered a small float plane and went to a nearby bay where we could safely view the bears from a boat.

Mama grizzly bear fishing for her two cubs:

I wouldn't want to be a salmon!

These two Spring cubs made all sorts of loud whiny, grunty sounds for more fish:

Smaller, adult male grizzly:

Black bears look small and cuddly by comparison:

I think this eagle was hoping for some leftover fish:

We spent a few days in Denali National Park, doing some hiking and white water rafting. We didn't have very much time for hiking, so we took the park shuttle as far as we could to the Savage River and walked around. Denali, by far, had the some of the best scenery. I had hoped to see caribou, moose, and dall sheep, but it didn't pan out. Mount McKinley is only visible a handful of days every month, so we didn't get to see it during our time there. Oh well, more incentive to return for a longer stay next time.

Fall looks entirely different on the tundra:

Me, looking carefree:

Marmot!

This is a ptarmigan, which I think must mean "tastes like chicken" in native tongue. One of our fellow tourists tried to convince us that it was a golden eagle. We just smiled and nodded.

After that, it was on to Seward Peninsula via the Alaskan Railroad (which has great views, but is a REALLY slow trip, so I was glad we took the motorcoach back!). We spent a couple of days on on Fox island at a fairly secluded hotel, where we dined on salmon, kayaked on the ocean, and took advantage of their personal chef.

The next day, we went on a wildlife-viewing day cruise. Highlights included spotting some whales and watching a glacier calve.

I think this sea lion was also on vacation:



Flirty otter:

Mama and baby whale:

It was difficult to go back to work, and I still have tons of photos to sort through, but I'm glad I went, and feel like I took pretty good advantage of the time that I had in Alaska. It's such a huge state, that there's no way to cover everything in one visit, and for some of the things that I wanted to see (Northern Lights), you really have to check it out at different times of the year. August was a great time to go though, as there was still plenty of daylight and tourist season was tapering down, so a lot of places that we went weren't as crowded.

Alaska, Part 2

More pictures from my recent Alaskan trip:

Pink salmon, about to die after spawning.

Silver salmon, hung out to dry in one of the villages.

I went fishing (for the first time EVER), while I was doing a four-day village stay to do annual check-ups and medication renewals. I didn't actually catch anything, but by the end of a couple hours, I was no longer casting into the weeds. The best part of it was that on the way out to the fishing spot, we saw a lynx swim across the river and there were a couple of bald eagles that flew by.

There was a seafood processing plant in town, where you could buy a pound of Alaskan Red King crab for pretty reasonable prices. It was even cheaper to buy the live ones, however there just wasn't a pot big enough for a full crab in the apartment and I was a little squeamish about chopping up crab guts. These suckers were spiky, but from now on, I will probably associate watching the Summer Olympics with sitting down with a pile of fresh steamed crab legs and butter.

Tundra geese:



I really wanted to get a good picture of a musk ox, but even with my larger lens, this guy turned and stared me down from about 200 yards, so I opted for a non-gored liver and a distance shot.

Ready-to-pick fresh blueberries.

As for the actual month of medicine, I delivered three babies (ok, one of them popped out before I could get my gloves on). It was actually a primary care/family practice rotation, so a lot of time was spent seeing people in the outpatient clinic while covering any emergencies. I did do several flight transports, including one harrowing one where the patient was in hypovolemic shock, and we had no blood products with us, and were down to our last 500 cc of fluid on the airplane. It was nerve-wracking to just watch someone's blood pressure fall, with nothing to do but hope to get them to the hospital (and operating room) before they arrested. Another of my patients had a heart attack, but he was transferred quickly and did well.

I worked a ton of hours for those four weeks, but it was interesting to see how patient management has to be adjusted to the resources that are available. I also learned to advocate aggressively for my patients, dealing with unknown specialists over the phone to get them what they needed. It was a good month, but I don't have any intentions of returning... at least not for work.

Alaska, Part 1

I am not sure I can summarize the whole 4-week rotation and vacation in just a few entries, but I am going to try. My rotation was through the Indian Health Service, and it took several months of filling out paperwork and waiting for a temporary resident permit to get the thing set up. I chose to go to Alaska, partly because some residents the year before me had gone there and had a great time, and partly because I had been hearing about locum tenems options for a while and had wanted to check it out.

I went to a small city made famous during the Gold Rush of the 1800s (I'm avoiding mentioning the name directly to avoid Google hits.), and getting there from here was somewhat awkward. In particular, it involved a 6-hour layover in Anchorage and sleeping on a bench outside the bathroom with my luggage since apparently there's a law against checking luggage more than 4 hours in advance!

The next morning, I was met by a hospital employee at the airport, who thankfully took me to my apartment, which turned out to be well-furnished and very conveniently located down the street from the hospital. Walking around town that first day, I was shocked to see that gas was priced at $5.39/gallon (apparently it gets delivered once a year, so the price doesn't fluctuate daily like back home) and a gallon of milk was over $7.

The first day at the hospital was spent giving a urine sample for drug testing (which seemed kind of silly because why run the risk of having to eliminate free labor?) followed by a maddeningly-long 1.5 hour session (not exaggerating) of fingerprinting. After that, I was free to roam around town.

The next day, I was pretty much thrown right into the mix of things. The majority of my work involved seeing patients in the outpatient clinic. Sometimes they would schedule me for patients, but typically I just saw walk-in's. The hospital did have an ER, but it literally was a room, not a department, with two beds. I was given a pager, and had my first 24-hour call the second day of work and pretty much every 4th night after that.

On-call duties included village phone calls. The hospital doctors are responsible for overseeing the treatment plans of health aides in fifteen different villages. Typically, all day long, health aides are faxing in notes of what patients they have been seeing throughout the day. Then, whomever is on call, spends the whole afternoon returning phone calls and guiding treatment for patients that you just hear about on the phone. Most of it is pretty standard stuff-- earaches, sore throats, etc. Health aides have a few months of training, and then they follow instructions from a systems-based state-approved book to diagnose and treat patients. The ones that have been doing it for years are pretty good.

When the health aides get stumped, they sometimes take a picture of the problem and send it online through a special program where the physician can then view it and discuss it with them. Luckily, mail/delivery planes go to most of the villages once or twice daily, so really sick people can be sent in to the outpatient clinic to be evaluated in person. If someone is urgently sick, then a MedEvac flight team is sent directly out to the village. Depending on the person's severity of illness, they either are brought in to the local hospital, or directly to Anchorage.

Shifts on-call could be interesting. Typically, the x-ray tech, pharmacist, and the lab tech would go home around 7pm, so you had to decide if whatever you wanted to work up was really worth waking someone up at home to get the x-ray shot or blood drawn. Most of the time, unless someone had something acute like chest pain, you would splint the sprained ankle and have them come back in the morning. The hospital did not have a CT scanner, and during my orientation, I was told that we only had 4 units of blood to work with in the whole hospital. Pretty much, unless you wanted to admit someone for something like a basic vaginal delivery or pneumonia, most people got stabilized and shipped to Anchorage. It was an interesting way to practice for four weeks.

That first week, it was about 40 and cloudy on most days, but I still spent as much time as I could walking around. Prospectors on the beach hand-pan for gold, and the more ambitious souls have smaller dredging operations.

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I met a prospector named Jessie, who showed me the gold he had spent all day hand-panning on the beach. It didn't look all that impressive-- almost like a large lump of pigeon droppings. Carefully, he folded the foil containing his gold as a lit cigarette balanced between his fingertips and he turned on a small propane stove.

As the gold dried, it became more shiny, and was more coarse-grained than the sand. He talked about how many colors per pan made for a good day's work and said that he had learned his skills from Tattooed Don, who had learned from Blueberry John, who had been "panning theses beaches since before any of these dredges were ever here."

Jessie poured the gold flakes into a small glass vial. He said it was 12-hours worth of work and 3/4 of an ounce, for which he should b e able to make about $700. (I briefly wondered why I went to med school, when apparently you can just sift gold off the beach.)

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That first weekend, I also went on a park ranger guided hike on the tundra where she pointed out a lot of the wildflowers. We had to cross a stream barefoot, and it was cold enough to make me nauseous. The size of the town and the way everyone knew each other's business was pretty comparable to my hometown back in Arizona, but the environment was a big change in environment for this Desert Rat...

Oops

Missed a couple of numbers:

32. Calculators so that I don't have to rely on my math/counting abilities

48. Three-Paycheck months (happens twice a year if you get paid every 2 wks)

100 Things

I have been home for about a week now, and it's taken me a little time to get back into old routines. I spent five weeks in Alaska (four of it working, and 1 of it playing). A few days since I have been back were spent catching up on sleep and mail, and then diving back into busy night shifts.

There are a ton of pictures to sort through, and stories to tell, but I am glad to be home. I'm going to follow a lead from Chris, and list 100 things I'm grateful for (in no particular order).

1. Family

2. Army Guy

3. Friends who will let you drag them around at crazy hours for a week and still speak to you.

4. Friends who will wake up their new spouse before the sun is up to meet you for coffee at the airport during a layover.

5. That it gets dark here before 1 am

6. Alarm clock-free mornings

7. Surprise dinners waiting for me in the fridge when I get home from work

8. Anchorage bus drivers that will mail a forgotten cell phone back to you across the country

9. Antibiotic eye drops (don't ask)

10. Microwaves that don't explode when you nuke a fork... uh, twice

11. Air conditioning

12. Summer breezes when the A/C stops working

13. High-speed Internet

14. A stable job

15. Online banking accessible anywhere

16. Coffee!!!

17. DVR

18. ... and cable

19. Worn-in sneakers

20. Scrubs so I don't have to bother with getting dressed

21. Supportive co-workers

22. Knowledgeable and efficient nurses

23. Shady trees

24. Having a roof over my head

25. Alarm system

26. Perennial flowers

27. Smooth intubations

28. Unexpected happy outcomes

29. Cruise control

30. Non-exorbitant dairy/produce prices ($7/gallon of milk, $5/avocado!)

31. iTunes/iPod

33. No cavities at the dentist!

34. Quiet time to read a book

35. Picking fresh blueberries from the Alaskan tundra

36. Digital cameras

37. Nights on-call when the pager didn't go off for a few hours

38. Lightning bugs

39. Reliable transportation

40. Deadlines to push myself harder

41. Finished races

42. Friendly faces at work

43. Vacation time

44. Mint-chocolate chip ice cream

45. Female predecessors who paved the way for me in the workplace

46. Soldiers

47. Freedom of speech

49. Hand-written letters

50. Laughter

51. A finished book chapter revision

52. Freedom of religion

53. A warm hand to hold

54. Afternoon naps

55. That I live in a society that wants to take care of its elderly, disabled, and women with children

56. Opportunity

57. Rediscovering old friends

58. Free time

59. Benefiting from the creativity of others... art, music, theater, movies, comedy shows

60. Ability to travel

61. Good health

62. Optimism

63. Ability to vote and participate in government

64. Ability to have input in my work schedule

65. Ability to work overtime

66. Room to improve in my cooking skills

67. Rainy days

68. Parents that valued education

69. Tree-lined neighborhood

70. Long walks around the lake

71. Tiny details in snowflakes


72. Teachers that challenged me

73. Patients that trust me

74. Mexican hot chocolate (it's cinnamon-y!)

75. Long soaks in bubble baths

76. Foot massages

77. Post-shift bar trips

78. Long highway drives with the radio blaring

79. Running into someone I've helped in the community

80. The comics section in the newspaper

81. Learning more about other people's life experiences through blogs/comments

82. Covered parking

83. Waterproof hiking boots

84. Hours-long phone calls to de-stress with my buddy

85. That first "welcome-back" hug with a loved one

86. First-time "I Love You" and I guess the ones since then, too!

87. Starry nights and trying to find constellations

88. Campfires and s'mores

89. The way time seems to help me forget bad memories

90. My work ethic

91. My stall tactics

92. The way sumac turns impossibly-red in Fall

93. Twinkly Christmas lights

94. Memories of my grandparents

95. Daydreams

96. A future to look forward to

97. The smell of fresh-cut grass

98. My sense of humor

99. There are significantly less mosquitoes here than in Alaska

100. TO BE HOME!!!

Northern Exposure

I am off to catch a flight today and start a new adventure. The plan was to get a lot of entries done before I left and take advantage of Blogger's scheduled posting options, but of course that didn't happen. I don't know what my internet capabilities will be, so there probably won't be any updates for a while. Let's just say the next five weeks will include working without a CT scanner, Air medical transport flights, and meeting up with "The Phoenix" for bear viewing, hiking and kayaking!

Striking Out

Thankfully, with July has come the end of the workplace softball season. I think we actually ended up forfeiting the last two games due to lack of interest. Unlike the record number of injuries last year (my eye, a broken nose, and a broken HAND) for slow-pitch softball, this year's injuries were pretty tame. One of my co-workers dislocated his knee, and another one strained an already bad shoulder, but that was pretty much it.

I was somehow elected team catcher again, despite any actual talent. I did wear a mask at all games as Army Guy declared there would be no dating in public if I managed to bang up my face again. Unfortunately, due to scheduling difficulties, I was available to play almost every single game.

Most of the games were mercy-ruled. We did actually win one game, but it was because the other team had to forfeit when one of their teammates had a seizure as she was standing at first base. At the time of the forfeit, they were already creaming us 6-0 in spite of already taking an automatic out in the lineup for not having enough female players.

A few of us have suggested that next year, we just meet weekly for beer, and forget about this whole softball mess beforehand. Maybe we'll have a bowling team, or better yet, darts-- that would at least make for more interesting injuries!

Rockband

Every now and then, unique opportunities present themselves at work. This past weekend I helped staff an all-day rock concert. We worked for free (I'm sure someone got paid somewhere, but it wasn't me!), keeping the air-conditioned first-aid building a revolving door of heavily-tattooed drunk punks walking in and out. It was a rock/alternative concert, so naturally there was an all-day mosh pit that kept us busy. Paramedics on ATVs regularly brought in the vomiting and wounded.

For the most part, the patients were all drunk. There's nothing more annoying than telling a drunken fool to hold still while you stitch up their ungrateful face with a portable spotlight in a garage for lighting.

ME: "You need stitches."

DRUNK DUDE/CHICK: "I don't want stitches."

ME: "Well then, you can walk out and tomorrow wonder why your face is such a mess."

DD/C: "Fine, put them in. Ow! OW!!!! OWWWW!!!!!! I F***'N HATE GETTING STITCHES!!!"

ME: "Shut up, that was just the betadine."

There were a few serious injuries-- someone got run over by a car and another landed on his head and may have had a neck fracture. Most of the stuff was pretty simple. Our only capabilities were starting IVs and suturing. We were supposed to have been supplied with some Tylenol and Motrin, but ended up not having anything other than nebulizers for asthmatics and antiemetics. Oh well. Anyone with a loss of consciousness, possible fractures, or vague complaints that couldn't be evaluated got shipped out. A full-term pregnant woman came in actively contracting, but she wasn't actively delivering, so we shipped her out, too.

There were 12,000 concert attendants and I think we treated 78 patients. There's a formula for figuring out how many medical providers are needed to cover large-scale events. It's a pretty rough guideline though, because there's no way to really plan for large-scale pandemonium, like when a stage collapses on people or there's a fire/chemical exposure. Our coverage was exellent, and the day was relaxed enough that we took turns walking around the grounds and enjoying the bands. A mid-concert rain shower made for a lot of mud, but kept the temperature cool enough that despite all-day beer guzzling at an outdoor venue, we didn't see too much dehydration.

I stuck close to my attending on breaks because he was well-known to all of the security guys. They let us up right in front of the stage. We were behind the security guard barrier, so it was hilarious watching them catch crowd surfers all night long, and release them back to the masses. I can't imagine the workout from grabbing drunk adults and setting them down safely on the ground hour after hour.

I took these pictures with my cellphone, so they're pretty crappy, but you get the idea.

The music was great, so it made dealing with all of the drunk people worth it. The headliners were Shinedown, Seether, and Three Days Grace. We people-watched from in front of the stage for some of Shinedown and most of Three Days Grace's performance. I could hear most of Seether's songs from standing outside the medical station. Luckily, even drunk people wait through good music to seek medical treatment.

Three Days Grace:

More Three Days Grace:

I think I saw more than enough tattoos and belly flab to get me through the next year. There were a few young women who needed assistance from security getting their shirts and bikini tops back on. I gave my single guy buddy a hard time for missing out on the concert! It was entertaining just watching random shoes and water bottles flying though the air of the crowd.

Short Visit

My parents were in town last week for a quick visit. They took a large detour to come here on their way to the annual family reunion. We spent the few days I had off work exploring and driving around. They also met Army Guy for the first time. I hadn't seen them since Christmas, and I'm not sure when the next time I will fly back home will be. It was good to see them, but hectic working my shifts around their stay. Luckily, they are low-maintenance folks that are just as content to explore bookstores in my neighborhood and spend days lounging around my house reading.

Sympathy for the Devil

The other day, an EMS crew dumped a guy on one of our trauma stretchers. He was on a backboard, so we did the usual stuff as far as stripping him down, looking for injuries and asking him a whole bunch of questions. I can always get a bit of a hint from EMS about the patient. If the patient's been difficult, they pretty much transfer them over and take off before you can get any questions in. If the patient's injuries are interesting, or if they like the patient, they tend to stick around through our initial assessment and x-rays. This was clearly a case of dump-and-run.

This guy was a motorcyclist that rear-ended a stopped vehicle and went flying over the handlebars. He was wearing a helmet, and supposedly stood up and was walking around on scene, but now was complaining of some rib pain and difficulty breathing. As we were checking him out, his main concern was that we didn't cut up his black leather vest. Fine.

So, I continued looking for injuries. There wasn't a mark on him, but he had an interesting collection of tattoos. On one arm was an Irish flag with swastikas, on the other side big letters (in Old English script) that said, "Death to the Queen!" I felt the need to ask him which queen was out of his favor... apparently it's the one in England. He countered with a series of questions about my heritage, and I would have loved to tell him I was English, but my last name kind of gives away my background.

We continue on with the questioning, and there's not any telling marks on his body for injury. His chest x-ray in the trauma bay is negative, but he's complaining of a lot of pain, so we get him ready for a catscan. At this point, he tells me that he doesn't want to be given any blood because "It's against my religion." His vitals are stable, so I tell him that I don't think that's going to be an issue.

One of the nurses asks him if he's a Jehovah's Witness, and he says, "No, I'm a devil worshipper." This causes one of our nurses to cock an eyebrow and reflexively make the sign of the cross across his chest. "And I don't want any salt, either," snarls the patient.

Drip.... drip... drip..

"I don't plan on giving you any salt." I tell him.

Drip.... drip... drip..

"Saline, I mean, I don't want anything with salt in it," he adds.

Drip.... drip... drip..

"What's wrong with a little salt? The only reason it's in the saline is to make it more balanced with the electrolytes in your blood. If I put water into your veins, it would leach out all of your electrolytes and make you very sick," I try to rationalize.

Drip.... drip... drip..

"I don't care. Salt is used in Christian ceremonies like baptisms and weddings, and I can't have any of it in my body. I don't ever eat it, and I don't want any saline!" he protests.

Drip.... drip... drip..

"Ok sir, if you don't want the saline, I can stop it, but I should probably let you know that it's been running since the medic put that IV in your arm, and you've gotten almost a full liter of the stuff."

"WAAAAAAAHHHHHH!!!! TURN! IT! OFF!!!! WAAAAAAAAAAAAHHHHHHH!!!!!!!!!!!" he screamed, and started thrashing around.

So the fluids got turned off. The rest of his time was pretty uneventful. CT scans were negative for any fractures or pnemothoraces and he went home. His blood pressure and heart rate stayed within normal range, so he didn't need any more fluid or blood products and he went home. One of his matching vest-wearing buddies showed up for moral support, and before he went home, a Hispanic woman showed up with his 6 year-old son. With all the swastikas, I was kind of surprised that the guy spoke a little Spanish and would have a minority taking care of his child. I always find it odd that people that are obviously born and raised in this country still carry around predjudices from generations ago (Ireland vs England). Then again, since I don't have any tattoos, I always have the expectation that if you are willing to have something permanently scored onto your flesh, that it has some meaning for you, and I suppose that is not necessarily true, either.

Two Years in the Making

Every fall I have added new bulbs to the existing ones slumbering in the flowerbeds around my house. I often forget where and what I have buried. For the past year, there have been prominent green leaves next to the front steps. I could not remember what kind of flower they were, but given the size of the leaves, I had great expectations.

A few weeks ago, giant iris blooms appeared out of nowhere that were so heavy that the stalks tipped over to the ground. I guess it takes two years to make an iris, but I think that they are worth the wait.

Humble Pie

It has been a rough week for me procedure-wise. The other day I saw a septic patient. He had a fever, diarrhea, a heart-rate twice normal, and a soft blood pressure. So, we did all of the usual things, and then I got called to his room because there was a problem getting IV access. No problem-- time to put in a central line (an IV placed into one of the larger veins in the body- internal jugular, subclavian, or femoral veins). I didn't want to access his neck because he'd been shot there recently and there was a lot of scar tissue, a retained bullet and bone fragments. I didn't want to access his groin because of the diarrhea issue and with him being paraplegic it seemed like it would be easily contaminated. So, I settled on the chest. The needle connected with the vein and I had no problems floating the catheter in over the wire. However, when I went to check the ports, I drew back air instead of blood. Uh-oh.


At this point, the patient's father came in the room and said that central lines wouldn't work on his son (which doesn't make sense) and that he would have to have a PICC line (large catheter placed into one of the arm veins). So, we abandoned the procedure, and called for the PICC team.


And that's when the patient decompensated. He went from a heart rate of 120 to 160 to 200. The monitors get very angry when one's heart rate is 200... that's a whole lot of beeping! I had already had a sinking feeling about my failed procedure, but this just confirmed it. A quick portable x-ray showed it all: the patient now had a pneumothorax.


There was no time to wait for a PICC line. This guy needed fluids, antibiotics and was heading towards needing a pressor. Quickly, I put in a femoral line while the ICU was called. The ICU resident automatically called the cardiothoracic surgeon and that's how I ended up creating business for my least-favorite surgeon. The treatment for a pneumothorax is to put in a chest tube to decompress the air and reinflate the dropped lung. I'm capable of doing a chest tube on my own, but by that point surgery was involved and it was too late to uninvolve them.

I talked to the patient and his father and let them know what had happened. Apparently, the exact same situation had happened when a subclavian was attempted when the patient was shot several months ago. My attending was pretty cool about the whole thing, shrugging it off with "Well, they say you haven't done enough subclavians if you haven't dropped a lung." However, I think I am going to be more than a little gun shy about doing them in the future. As for the patient, he did well and went home a few days later.

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And then there was the patient that walked out of an ICU against medical advice a few days ago. The nurse called me immediately into her room and there I found a heavy older woman only able to speak 2-words at a time. She said the other hospital called her at home and told her to come in immediately or else they would send the police to her home to escort her to the hospital. (This story doesn't quite make sense because the patient appeared to be completely capable of decision-making to me, but that was her story.)

Anyway, the woman was in respiratory failure and had asthma and COPD. Not a good combo. She refused any IVs, and said she had a DNR (Do Not Resuscitate order) "somewhere" and did not want to be intubated. So now I have a patient in respiratory failure that's tying my hands behind my back as far as letting me help her.

We started breathing treatments. She had already taken oral steroids at home.

She got worse.

She agreed to let me give her one shot of something, so we drew up some terbutaline.

She got worse.

She agreed to an IV finally, and medication-wise I threw everything I could think of at her.

She got worse.

We tried non-invasive ventilation.

She got worse.

Finally, she said she wanted to be put to sleep. I confirmed that she meant she wanted a breathing tube, and to be put on the ventilator. I then called her neighbor and made sure there was someone to take care of her dog. Apparently, that was why she left the other hospital in the first place and didn't want to come in today.

We set up for intubation. She was difficult, but the tube passed easily, good color change, breath sounds. Fine. Before we could confirm it with a chest x-ray she desats and turns purple. I pulled the tube, but now I can't get it back again. I can see just a hint of where I need to put the tube but it's not going in. I try to use a different tool, but it doesn't work either. Finally, a colleague steps in and is able to get it. The patient went off to the ICU. She got extubated two days later, and is still in-house, but at least she's been moved out of the unit.

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So it hasn't been the greatest of weeks. Two big blows to my confidence. Everyone has bad days, but it is kind of poor timing as I am about to start working part-time at another hospital without an attending to be my safety net.