I'm in charge of the pencils, December 27, 2004

Does your job have a pencil monitor?

You know the person...the most insignificant non-contributor...unionized...low/no skilled laborer in the entire building, who's given a title? And you best believe that they take that little title and run.

For instance, the PA who thinks they can read a head CT better than a board certifed, (5-year residency trained) radiologist. "The radiologist reading says there are hypodensities in the occipital region consistent with mass vs. infection, but I don't agree, it looks normal to me." What? As if it matters what it looks like to you.

Or the tech who (very reluctantly) comes over to the ER to shoot an xray on a kid who was hit by a car. "I don't think you need to be doing all these xrays."

See, that's the problem, "you're thinking," we don't pay you to think, (or wonder). They didn't hire you because you have such great ideas, or extensive problem solving skills. You get the order, you bring your machine, you position the patient, and you shoot the xray...that's it.

Ms. Clerk, you mind handing me a pencil?

"A pencil? Well you have to get clearance from administration in order to get a pencil."

What? Why?

"Because I need to see the blue permission form, or I ain't givin you no pencil."

That's not a policy, you can't do that...just make up rules like that.

"Yes I can, I'm in charge of the pencils."


Should they close King? December 10, 2004

King is a mirage. You have standing here a building masquerading as a hospital. People come here (rightfully) expecting help, but the "hospital" is unable to provide even the most basic care. Is it better to have no hospital, forcing people to go to USC or Harbor; or is it better to have a pseudohospital, where they come, but cannot receive the care they need?

Radiology. If there is no radiologist, mechanisms are put into place to deal with that issue. Either the ER docs read films, and/or you have teleradiology. You need not get approval from a radiologist if there is none in house. BUT, because *on paper* King has radiologists 24/7, it's policy to get their approval for CT scans and such. So, what this means is...by pretending to have radiologists, no one can ever get CT approval. And if a tech is being humane, and does the study despite this fact...there's no one to read it. The ER doctors aren't allowed to read them...and there is no alternative. But, if they were to just call a duck a duck, and state the obvious...admit that there are no radiologists...care could actually be improved. But they don't want anyone to know...so the outcome is, delay in care, and bad outcomes.

Trauma. There are no surgeons. How can you have a trauma center without surgeons?

Pediatrics. No pediatric surgeons, no pediatric ICU nurses...how can you say you're equipped to handle sick kids?

OB. There's one delivery room.

Pharmacy. There's no way to rapidly get drugs to the ER. The list goes on and on.

You bring your child to the ER for a cough. The lady next to you in the bed has active multi-drug resistant TB...and we all know this. She's not isolated because there are no critical isolation rooms. So, you and your child come in with the flu, and leave with TB.

If a hospital cannot perform basic tasks...all of society is at risk, afterall you work with these sick people (with ER acquired TB) and your children go to school with these people.

Security. If there is no security that can actually restrain violent patients (and thereby protect everyone in the ER), that is a worse situation than not having an ER. Again, innocent people in the ER, just wanting to see a doctor...but end up seeing the man next to their 9 year old daughter jacking off.

Having King is like having a gun that on occasion shoots backwards. How is having an unpredictable weapon better than not having one at all??

Having *no* hospital is better than having an unstable, incompetent hospital. Like the gun that shoots backwards...eventually it will kill you.


Doctor, can I have a bedpan? November 25, 2004

In life limits have to be set. Doctoring is no exception.

One person cannot do all...and believe you me, I cannot (nor will I try to) be a nurse, a social worker, an orderly, and a doctor...all at the same time. If I attempt this impossible mission, I will fail every task. So, I've long decided that I'm going to be the best *doctor* I can be...for the patients that *I'm* responsible for. There are millions of patients in the United States alone, and I can only truly handle those relatively few I actually establish some sort of relationship with. Afterall, it wouldn't be fair to *my* patients if I try to be "super doctor" and pick up the slack of other physicians, nurses, etc. I, honestly, wouldn't want *my* doctor trying to do too much either...because then I wouldn't get good care.

The unfortunate thing is, when you work at a place where the nurses aren't required (or allowed) to perform nursing duties, people suffer.

"Sure, I'll get you a bedpan." But if you need help *using* the bedpan...I'll have to go get your nurse


The History. November 21, 2004

50 year old lady walks in to our ER.

I'm having a little bit of spotting from my rectum.

Any belly pain, diarrhea, vomiting?


Any past medical history?

I'm not sure.

When did this start?

I think yesterday.

Do you drink alcohol?


Have you ever?

Well, a long time ago.

When's the last time you had an alcoholic beverage?

What do you mean?

When's the last time you drank any liquor?

Hmmmm....well....sheesh...I haven't had a drink since...last night?

I thought you said you don't drink.

Not today.

What do you drink...when you drink?


How many 12 packs do you go thru in a day?

Shit doc, I don't drink that much! I might get thru one 12 pack at the most.

One the weekends too?

Well...I might go thru 2 or 3 12 packs on Friday.

Do you smoke?


Do you do any drugs?

Heeeellllll naw!!! I don't mess with no drugs.

Do you smoke weed?

Oh yeah.

Do you do crack?

No. Not ever?


Never ever? Never even tried the stuff?

Well, I've tried it before.

When was the last time you *tried* a little?

I got a little bit from my daughter this morning.

What about IV drugs?

Oh no.


I'm not no drug addict doctor.

Have you ever had surgery?


What's this (big ass) scar on your belly?

Oh, that...I think that's when I had my baby?

Umm...no, try again?

Maybe it was my appendix...aw, I don't know, they took out something.

Okay, have you ever had this bleeding before?


Anything else wrong?

Yeah, I have this headache sometimes...and my vision gets blurry in my right eye. Oh, and my knee sometimes makes this clicking sound...what do you think that is?

I don't know, but today we'll just address your rectal bleeding.



This stuff really works, November 20, 2004

I had the opportunity to be a true senior resident a couple of months ago.

The patient was a 70ish year-old AA female, found down at home, pulseless and apneic. Rhythm was PEA, EMS started ACLS and brought her to King. I was the blue side senior, so I went to the critical area to help out. The critical area was full, and the juniors were overwhelmed. The first rhythm was PEA...gave epi and atropine. Then v-tach. We shocked her twice. Now sinus tach...for a second, then back to v-tach. Charge the paddles...

...paramedics provide some additional history. ESRD, HTN, DM, among other things. Meds include a beta-blocker, but no digoxin. Okay, lets give the patient bicarb and calcium chloride. Epi, CPR, check pulse. Is that a pulse??

A very weak carotid pulse is palpated. Check BP. 60/p. Hmmm, let's go ahead and start a dopamine infusion. What's the HR? 52. Let's try transcutaneous pacing. Pads on chest, set the machine...and...it works!! BP 110/59, HR at a perfect 60 bpm. The TC pacemaker isn't going to hold, perhaps we'll set up for a transvenous, just in case. Anterior approach to the internal jugular (avoid the carotid artery)...insert cordis catherter, perfectly. Now we have great access for CVP, and TV pacing. Call CCU...and wait.

A-line (that I also placed) indicates the BP is dropping. Now the TC pacemaker isn't capturing. Grab the attending, Dr. Salem. Get the TV pacer...we float it to the appropriate place in the right ventricle. Instantly, her BP is back up to normal limits...her radial pulse is strong, and her HR is at 60 again.

Wow, this stuff really works.


What do you mean, you don't have racemic epi? November 19, 2004

The run: Rescue 257 calls King base notifying and requesting online direction from us for a 4 year old little boy, with a history of asthma and recent URI, in moderate to severe respiratory distress for 15 minutes. Thru the phone I can hear the boy with loud stridor. RA257 stated that they were 4 minutes from King (an EDAP - emergency department approved for pediatrics), and 10 minutes from Harbor (a PCCC - pediatric critical care center). With this child is such distress, and being that the paramedics cannot (within the scope of their practice) intubate children...I direct them to bring the child to King. Children decompensate quickly, and the extra 6 minutes to get to Harbor may become very significant.

They arrive at King, about 3 minutes later. This child looked like shit. He was sitting upright on the paramedic gurney, drooling, grunting, retracting, pale, and with loud respirations. We immediately set up for intubation...but hope we don't have to. Once we intubate him, it'll be a long hard process of getting him extubated. We get further history from the paramedics and the mother. Turns out the kid's story sounds like croup - cold, seal-like cough. Treatment, racemic epinepherine and dexamethasone...and that's it. Most kids turn right around immediately, and (get this) go home. So, we call respiratory therapist stat to the ER, and request the nurse to give an albuterol mist in the meantime, plus dexamethasone. I stay in the critical area to supervise/assist the junior residents.

So, RT (respiratory therapy) comes down right away. I ask him to give the kid the racemic epi. His response "they decided they want everything to go thru the pharmacy and nursing." What, you've got to be kidding?? Didn't the Times say that those departments were the two most incompetent departments, with most of the high profile mishaps directly related to them??

So, now we have to write an order...find someone (who, I don't know...*I* can't go) to go to the pharmacy and pick up the epi. They can't read the time, or the numeral "2" is too squiggly, or whatever...the doctor needs to rewrite it. It takes (count them) 30 minutes to get this first line drug. This poor child is here, gasping for breath, vomiting, grunting, waiting for this drug...and all we could do as doctors is wait for him to decompensate enough to intubate. So, while we wait I ask the nurse for the albuterol. Wouldn't you know, it's lock in the "suremed" vending machine. And in order to get the drug out of the machine, you need the patients ID number. But, he doesn't have one, now does he? And he won't have one until the ident people come down and get his insurance information. In the meantime, we all look at each other...with our hands completely tied. We ask RA257 to go out to their rig and get more albuterol...so at least we're doing something.

Do you realize, that for 30 minutes we did no more for this child than they did in the field.

That extra 6 minutes it would have taken to get to Harbor suddenly didn't seem so significant.


Now What?

I'm so...unclear. I've graduated from residency, and I'm feeling unclear. I guess this is what new college grads must feel...but I'm feeling it about 10 years later. So far my path has been laid out for me. Highschool, college, med school, residency...and then the job would just come, I thought. Actually, I didn't think about it - finishing residency - much because it was so far into the future...a concept I couldn't quite grasp. But here I am. And as happy as I am to have completed this leg of life's journey...I can't help but to feel a bit anxious about the next. Especially since, I have no idea what I want to do.

I've completed my training in emergency medicine. But, I'm pretty sure I don't want to work in ERs for the rest of my career...or even now, really. I'm afraid of medicine, honestly. I'm afraid of making a mistake...of too much work...and lack of free time. Free time is what I counted on as a doctor. The ability to work a few days, make great money, and have time to develop other aspects of my life. And I'm still counting on that time...actually, even moreso after this long journey. Working at an HMO doesn't appeal to me. Eventhough the malpractice issue is not as great...there's the bureaucracy (rules and paperwork), the "efficiency" (meaning speed and inadequate workups), and the boredom (same place, same thing). True they have the benefits...provided they stay in business for the rest of my life. And, true they have the job security. But...you work 40hr/week...and make less than you would working other places. Honestly, 40hrs/week is too much work. Especially for work to be *work*.

My plan was to...relax for a few months. We have money saved and I have marketable skills. But, now I realize (now that I've had a minute to really think about something other than medicine) that I have to do something soon. Also, I realize that eventhough I may "get a job," will it permit me to even see my family? Will it be just like residency all over again. And when does that phase end?

I have an MD, what do I want to do with it? Sometimes I question whether or not I made the right choice in choosing this path. But I quickly reassure myself that I have...by thinking about many, many instances where my choice was reaffirmed. Even doing emergency medicine seems like it was right on the path of where I'm supposed to be. So...I must be on the right track. But, now what?

Urgent care will allow me to maintain my energy - both physically, and emotionally. Less liability, less pressure...less stress. I'll study and pass my boards...afterall, I am EM trained, may as well study and take one more test.

Fellowship? Maybe. EMS is what seems logical. But...I don't know. More training...to do what? Public policy...sounds fun. But how?

Time will tell, and soon I will have a clearer picture...


Night Shift.

Just completed a stint of night shifts. Man!! I didn't think I'd make it...

As an intern I actually enjoyed the night shift. It was more peaceful, less busy. The adminstrators weren't around interrupting your patient care activities. And the "extra" people hanging out were all at home. Studies were completed faster...and xrays were more accessible. Even the staff seemed closer, more family-like.

But now...I hate nights. I'm tired during my shift, and during my "off" time. I never get good sleep...and therefore have a headache. And, I miss the activites of daily living. I miss my family...I miss the sunshine. I feel like I miss days of my life.

What a difference a day (and a good *night's* sleep) makes. Today I feel great. No nausea, no vomiting, able to tolerate POs. I have a healthy mental disposition. And I have no HA or cramps.

I have 3 night shifts this upcoming month, one shift from 6p-2a, and finish the residency with 7 *final* night shifts in June. I think I'll be able to pull myself thru the final stint knowing it's my last week at the Kingdom as a resident.


Onward to the ED

There are endless stories about King. Stories of triumph and success...but more commonly stories of failure, incompetence, and frustration. Let's start with last night.

I arrived for my shift at a quarter to seven pm. Got a feel for the department, and was happy to be back after a 2 month hiatus. I had two good interns, two good juniors, and a medical student...nice sized team. My sign-out was from a colleague, Dr. Ray, who initially was pissed at me, but was mature enough to *move on* once the issue was resolved. He's easily frazzled, and utterly frustrated by the workings of the Kingdom. He was made to stay an extra 6 months because of academic probation (meaning he pissed off the wrong people), and is very jaded, cynical, and ready to graduate. Anyway, it was a complete disaster, his sign out. I don't necessary make judgments about people based on the sign-out (as many other residents do). I feel like we all have bad days...sometimes it's just fucking busy...or your interns suck, or you're just tired. Whatever. This is what I signed up for...bring it on!!

So I get this sign out.
Ms. Ava, 50 yo hispanic, alcoholic female who presented c/o RUQ pain with N/V for 1 day after an ETOH binge of 2 days. Patient reeks of alcohol, but is not completely intoxicated. Her PMH is significant for DM (diabetes), HTN (hypertension), leukemia (in remission), and ALD (alcoholic liver disease). Dr. Ray's sign out was: drunk, probably pancreatitis, maybe cholecystitis, pending ultrasound and labs. She had been given a banana bag, phenergan, and ativan. We continued our rounds.

Then there was a lady, Ms. Marin. 55 yo obese AA woman with h/o HTN, CAD (coronary artery disease), with a c/c of sudden CP (chest pain) with SOB. Signed out first set of cardiac enzymes negative, pending CT chest.

CT chest? Any leg swelling? No. Any PE risk factors (other than obesity/sedentary)? No. Why the CT? Well, she had an Aa gradient of 33. Why did you get an ABG? Because of the history. Okay, so your suspicion is low for PE? Yes. (But obviously high enough to request chest CT). Moving on.

Mr. UK. 88 yo man (unsure of his country of origin, unsure of the language he speaks, unsure of his history, or even his chief complaint). Basically, there's this old guy, has some belly pain. The son said something about liver lesions (?septic emboli). He was here not long ago...but of course there's no record to be found. This guy has a temp of 101, a white count of 20K with a left shift. Did I mention he was 88 y/o? So...he was in the process of a complete re-workup. R/o (rule-out) septic emboli (from where? no one knows). R/o sepsis, r/o...basically everything.

Then there was Ms. Flores. 30ish y/o female with headache. H/O toxoplasmosis (what the hell??) and retinal necrosis, being treated. Okaaayyyy. Now with headache, white count of 15K, and no source. Signed out pending HCT (head CT), and then LP.

Let's not fail to mention these were the 4 most notable patients...the entire ER was full...all signout. About 23 patients total...for me!! With the above 4 being the most "interesting." The critical area is full. And there are no ICU beds in the hospital. Bruce was the CT tech (more about him later) so no one was going to get scanned before 11pm.

Let me run thru what happened to the patients. Ms Ava turned out to be tachycardic (rapid heart rate) in the 120s (which wasn't mentioned on rounds). Her labs came back (4 hours after they were requested) with a low bicarb. UA had ketones. What was her sugar I asked the nurse...no one knew. No accu check since early afternoon. Recheck and measured, about 300. Medical student draws ABG. Patient is in DKA (diabetic ketoacidosis). What?? It took 8 hours to discover she was in DKA?? For the record, her ultrasound and CT abd/pelvis were both negative. ETOH level was 69.

Ms. Marin had a right PA PE!! What?! MICU consulted. Let me say, however, it took until 5am to get that chest CT...10 hours after the sign out. What kind of place allows a PE sit undiagnosed therefore untreated, for 12 hours??!!

Mr. UK...well we never found out what his problem was. But it took until 5am to get the CT of the abdomen, and surgery won't come see the patient until the CT is done. So at 7am he was signed out by me to the oncoming team, pending medicine admission. No closer to the diagnosis.

Turned out Ms. Flores had clean CSF, and we discharged her right at 7am, 12 hours later...because that's when we got the CSF results.

Then there's this cleaning guy, who's rude and seems bitter because he doesn't speak English. He never says "hi" but humiliates folks in Spanish, as if most of us English speakers don't know enough Spanish to understand that's he's being rude. So he's machine dusting the ER floor...at 4am. Full ER, dust flying everywhere...with his mask on. *I* don't have a mask, the patients don't have masks...and they are the ones who are compromised. Finally, after the air was full of dirty ER floor dust particles, next to this 2 year old asthmatic, and the lady with the PE...I called the supervisor, and asked him to stop. Since the doctors have no power in a place like this, with their strong union...I begged them to stop.

I have a suggestion for the hospital. How about, instead of paying this guy whatever he's making to aggravate doctors and patients in the ER, why not hire...lets say...a NURSE so we can move some of these patients out of the ER and up to their beds. We have patients that stay in th ER, waiting for an ICU bed for 16 days!! Count them, 32 shifts!! How about...another CT tech, so we can get that CT chest in less than 12 hours. Oh, because this guy is union, and therefore cannot ever be fired. So, lets teach him English, and then his new job becomes interpretation...so we can talk to our patients. Pay him more for a service that's more necessary...he keeps his job, everyone wins...and most importantly, the union is happy.

Let's not forget about the crazy guy who beat up my intern. This guy comes in thru triage...for *nothing.* He says, I have these little bug bites on my legs. We look, he has 2 pimples, on on his thigh, and one on the opposite inner knee. He's been waiting...obviously, because he's not sick. So they bring him back...and the first clue that he's fuckin crazy is, he refuses to sit down. When patient's don't cooperate with a simple request without a reason, something is wrong. And I don't waste my time. If he's not sick, he can wait or cooperate...period. So he waited, and waited, until the intern got around to seeing him. Things seemed to be going okay...until the guy hauled off and hit the intern, in the head, and swung again and again. We called security, and they decided there were more important things going on. Finally they show up 5 minutes later...

...we'll he's here because he's sick...you want us to arrest him???

Hell yeah, get his ass outta my ER!! (GOMER) It's not okay to hit the doctor, and if you do, you go to jail, period!! Being drunk, crazy, mad, high, or otherwise, is no excuse to commit violent crimes. And if it's not okay in the street, it's not okay in the hospital. If he's sick and needs care, he can get it from jail...under the watchful eye of the police. And once he's "better" it can be decided what the reprecussions should be considering the circumstances. But loose, violent, in the ER isn't an option. We have a duty to protect ourselves (for our families), and to protect our other patients and staff. Hitting my intern, and staying, is not an option. So, reluctantly, they handcuff him, and take him to jail.


Lastly, let me tell you about a couple of positive experiences. One child, 2 y/o, BIBM (brought in by mom) c/o left arm pain. Child was protecting the hand, holding it prone, flexed, close to the body. No h/o trauma. On exam no swelling or bruising. Hmm, nursemaid's elbow. So I hyperpronated...no response. (So much for ACEP lecture). Then (for the first time) I supinated/flexed, and reduced the elbow. Felt the pop...wha'la, all better. The child left as my best friend. Even taught the mom and dad how to do it, just in case it happens again. Very satisfying. And, then there was a young man with TMJ. Made the diagnosis easily after my ENT rotation...and they went home happy. Finally, the febrile seizure 10 mo old, came in twice in 14 hours. Baby had a cold, and mom wasn't giving enough Tylenol/Motrin...nothing more. But, if you come to the ER...be prepared to get stuck, poked, and prodded...even when it may not be necessary. So this kid gets the full septic w/u (which is of course negative). But obviously the LP really upset the mom...but later she thanked us, knowing that her child didn't have meningitis. And when the baby appeared normal (moving all extremities and such) after the procedure, she was relieved. I saw her checking the baby's feet and legs...standing the baby. Poor mom.

Well, I'm post shift...so I'm gonna end this here for today. Long night over...typical day at the Kingdom.