11.25.2004

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

11.21.2004

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?

No.

Any past medical history?

I'm not sure.

When did this start?

I think yesterday.

Do you drink alcohol?

No.

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?

Beer.

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?

No.

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?

No.

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.

Heroin?

I'm not no drug addict doctor.

Have you ever had surgery?

No.

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?

No.

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.

Okay.

11.20.2004

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.

11.19.2004

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.