10.12.2005

Killer King

This guy comes in as a code yellow, secondary to multiple GSWs to the head. We jump thru all the hoops, and do the million dollar trauma activation. He's a teenager. Upon arrival his brain tissue is on the back board. His pupils are fixed and dilated. He arrests a couple of days later in the TICU (trauma ICU).

His family blames us....*us*...for his death.

"You guys killed him!! Killer King, killer King"

Look asshole, maybe you should be pissed-off at the guy who...pointed the gun at your brother, and pulled the trigger. That's who 'killed him.'

Geez.

It's not hard to have a high death toll when your patients arrive to your front door already dead!! Maybe "Killer Compton" is more accurate.

5.28.2005

Someone you know

The paramedic run:

"This is rescue 257, on the scene with a middle aged Hispanic male with multiple GSWs (gun shot wounds) to the chest and abdomen. There is also a GSW to the left neck, left arm, and left buttock. The patient is agitated, but awake. Vitals are - BP 90 palpated, HR is 120, and his respirations are about 40, shallow. His skin is cool and clammy. We've established 2 large bore IVs. He's on oxygen NRB (non-rebreather). We have him in full spinal immobilization. You are our closest trauma center with an ETA of about 5 minutes."

5 minutes later this guy arrives as described. He is fighting, agitated, and altered. His respirations are weak/shallow, and breaths sounds on the left are diminished. His BP is low, and HR is fast (indicating shock).

We intubate him. Give him fluids. And undress him to see where the holes are. Since there are multple GSWs in the left chest....he needs a chest tube. Guess who gets to put it in??!! With no surgery residents to compete....we get to do everything.

I put in my first, unsupervised chest tube successfully on this guy. Before I have a chance to check the position via CXR, he is taken to the OR.

Later, maybe 2 hours later, I get a call from my mother. Hey, Marco (friend of the family) was just shot and taken to King.

Me: "I don't think so, we've only had one guy come in so far, and I got to put in the chest tube." with a sense of pride: yay for me!!

Her: "I'm sure he's there, I think he's in the OR"

Me: "Wait a minute....you mean my chest tube guy was Marco? No WAY!!"

It's such a trip when someone you know...comes into the ED as a trauma patient!!

1.30.2005

Code 9

It's been a long time...I'm ashamed to say. I had a month of vacation...and essentially "vacationed" from everything...apparently. I even had plans to study for the inservice...but it's not easy to stay motivated with the current environment of the hospital.

I had an opportnunity to read MDresident's blog...and I must say, I agree with most of it. Especially as it applies to the Kingom. Specifically:

Tuesday, December 28: Mandating Retarded Policy

MLK is back in the news today. This time for supposed failures of the Code 9 Policy by the psychiatric facility...an event that occurs a few times every day. ("Code 9" refers to a situation where "aggressive behavior is likely to occur"...)

The Federal government in all their wisdom wants all confrontations that occur in a hospital to be non-violent and wants to minimize the use of restraints unreasonably. Its great to have bureaucrats telling you how to handle violent patients when they're sitting behind a desk some 3,000 miles away and not the ones dealing with these situations on a daily basis.

Basically, the county safety police have been using such devices as the taser to subdue aggressive psychiatric patients ...a "no, no" in the eyes of regulators. So CMS (Medicare & Medicaid) has threatened to pull funding ...possibly shutting down the hospital permanently.

One of the patients was tasered occur on my shift. This approximately 6'4" 270 lbs guy was actively psychotic with religious preoccupations. After being brought into the hospital he became a little more agitated and got up out of his chair and proceed to snatch a baby out of the hands of a woman. Staff promptly wrestled the baby away from the man and called security. When security arrived, he became more defiant and the officers opted to use a taser on the man so as to avoid physical violence and trauma. ...The most interesting aspect of this was when the man got hit with the taser...he proceed to convulse on the floor while constantly repeating "Thank you Jesus, Thank you Jesus." Wow...that was something!

Afterwards, the man was actually much better. I'm sure he didn't feel that great (he did avoid a bunch of people jumping on top of him), but then again he was more lucid and actually seemed like he was no longer in his psychotic state ..probably most likely due to Vitamin H--Haldol. The only other alternative would have been for 4 officers to jump in and risk getting a punch or a bite or worse..and why should they take that risk? One thing for sure ...there is no way that I want to jump in and try and handle a psychotic 270 pound man! Unfortunately, the federal government has mandated that this is now my new job--to jump in and take on violent patients twice the size of me ...awesome.

Determining the appropriate response level will always be viewed retrospectively as a failure. For instance, if the man injured or killed the baby, we would be up shits creek. If a taser was used, then it was excessive force. Its a no win situation...you are always wrong in the eyes of regulators or lawyers. That is what these policies eventually state. Great job!

I have seen some crazy stuff. We once had a 6'6" 300+ lbs guy with COPD and Pickwickian Obstructive Sleep Apnea wake up in an extremely agitated state. He ripped out of his soft restraint, pulled out his endotracheal tube, got up out of bed, went over to the next bed and tried to KILL the patient next to him which was a patient on a ventilator also for respiratory failure by strangulation. This guy was totally CO2 narcotic. Three ED residents in the vicinity saw this and ran over to tackle this man. During the skirmish the man toppled and hit the sink ..breaking it clean off the wall! Unbelievable... The patient subsequently improved from his hypercapnia (elevated CO2) and was actually the nicest guy possible ...completely shocked that he attempted to kill someone in his altered state.

In another event, a patient on PCP overcame a police officer and socked him right in the face, knocking him out cold, and then proceed to try and assault other people. Thankfully there was an ED resident that actually did kick boxing in the past who took this guy down with a choke hold.

In the past few years, about 4 residents have been assaulted...one punched in the face just 2 months ago. So my question is: "Who is the federal government trying to protect?" The regulation of every aspect of our job and virtually every aspect about our profession is verging on the ridiculous.

The next time we get a violent 300 pound patient in the ED ...I think I'll call up that 130 pound pencil-pushing policy-promulgating bureaucrat to come take the guy down using those great non-violence tactics ...I'd love to see that.


The policy may just as well read "Doctors are now to jump off highrises in the event of thunderstorms..." It ain't happ'n!! They can fire me first...and I can take my health, and my medical license, and get another job.

I wonder why these people attempt to implement policy that's not going to work. Why bother?? For CMS? What's the point? So when we get a code 9, and no one does a got damn thing...resulting in injury or death...the policymakers are scratching their heads asking "what happened?"