obesity. viagra. heart attack. thrombolytics.

Last night in the ER...
....was very busy. And "busy" in a good way. Lots of codes and respiratory distress. Not so much "weak and dizzy" and "TMD (todo me duele)". The kind of night that reminds you why you chose emergency medicine as a specialty, and not primary care.

Anyhoo, there was this one guy...
A 36 yo morbidly obese Samoan man with a past medical history of diabetes, hypertension, and has lots of 'bad habits', was brought in by paramedics complaining of chest pain which started 10 minutes prior to the 911 call. He was sitting on the sofa watching reruns on TV when he suddenly felt a tightening in his chest. He got up to get a cup of water, and the pain got worse. Then he felt weak and lightheaded so he sat down on the nearest chair. He then called for his wife, and she took one look at him and called 911.

In the field EMS established a very tiny finger IV (because 'his veins could not be accessed secondary to excessive adipose tissue.' i.e. he was too fat). They gave him an aspirin, and after he denied using Viagra, a nitroglycerin sublingual. Immediately thereafter his blood pressure dropped from 150s systolic to low 80s. He became very diaphoretic (lots of sweating), and short of breath.

Upon ED arrival the patient was alert and oriented, but very agitated sitting upright on the gurney, in moderate/severe respiratory distress. He weighed about 450 pounds, and was extremely diaphoretic, and c/o worsening SOB. EKG could not be obtained by the paramedics because the stickers wouldn't stick to the body for all the sweat. Also, the patient was so agitated and anxious that a good reading couldn't be obtained even when the EKG leads were held in place by assistants.

In the ED we attempted to obtain an EKG...for over 20 minutes. We cannot make a diagnosis of acute MI requiring thrombolytics if we cannot obtain an EKG. Afterall, there are other deadly causes of chestpain, some of which absolutely cannot be treated with thrombolytics (or else you kill the patient). It's one thing for someone to die. It's another thing to kill them. So we worked to obtain that EKG...over, and over, and over, and over again.

During this time we worked to establish a better IV with ultrasound guidance. We worked to improve his oxygenation (from 90% on face mask to 95% on non-rebreather). We asked basic questions (allergies, past medical history, medications, *viagra use*). His bloodpressure continued to register in the low 80s (82/64 - narrow pulse pressure, with a heartrate of 120). Are you sure you don't take Viagra (or other 'viagra-like' drugs)? we asked again. He adamantly denies.

I'm so nervous at this point. Here I have a very sick patient, who I think I'm going to have to intubate. He's 450 pounds. His blood pressure sucks. And we can't get a frikin EKG. Agreed, he's likely having an MI...but what if it's an aortic dissection (which could be dissecting up to the origin of the cardiac vessels...causing the MI). On CXR it's possible that his mediastinum is widened. What if he has cardiac tamponade? (the cardiac silhouette is enlarged) I feel stuck without the EKG!!

Finally we get a very crappy EKG. The QRS complexes are very wide, and there are diffuse ST segment elevations. Hmmm....hyperkalemia? Pericarditis? Massive MI? Maybe....TCA toxicity? I give bicarb and fax the EKG to the cardiologist at home after explaining to her the clinical history. She agrees that it is consistent with hyperkalemia. We call the lab..."hey, we so *need* the results of the chemistry ASAP!! please!!" And push more bicarb. He seems to get a bit better. The QRS complexes narrow a bit. He admits to a questionable history of renal disease.

35 minutes have passed. Out of the window of thrombolytics. Now I'm going to have to justify to administrators (and those who wear suits) why I didn't push the thrombolytics in less than 30 minutes. For those that don't know, thrombolytics are very powerful clot busting drugs that have lots of potential deadly side effects. Afterall, they make the blood so "thin" and remove the ability of the blood to clot...and destroy existing clots...that brain bleeds and GI bleeds are not uncommon. And, again, if this guy had an aortic dissection or cardiac tamponade...or pericardities even...I'd kill him with this drug. My biggest source of stress was trying to mentally justify *not* giving this drug in 30 minutes or less (so my chart won't go to 'peer review', or whatever)...which is crazy being that I'm the doctor taking care of him, and arbitrary 'rules' shouldn't apply to individual patients. I should just focus on practicing best medicine, and not doing things simply to make it easier to 'explain' and 'justify' (to non-involved non-physicians analyzing *my* patient thru their retrospectoscopes) my actions after-the-fact. So I hesitate for a second, but proceed doing what I feel is good medicine...and continue trying to obtain EKG #2.

As we 'encourage' the patient to 'just "hold still for one minute," he starts blaming himself for being "so fat", not following his doctors advice...and how he deserves to die. He feels this is the end...

...all doctors know, it's never good when a patient says "I'm going to die." Especially when they're circling the drain.

Suddenly the monitor flickers, the heartrate speeds up, and the patient mumbles, "I don't feel well." Then he becomes altered. The monitors reveal v-tach...so I shock him. He wakes up with the shock. The monitor reveals sinus tach, and he's yells "what tha hell?!"" I breathe a sigh of relief. "Sir, I'm sorry, I had to shock you...your heart started having trouble."

Then it happens again. This time I warn him...."it looks like your heart is doing that thing again...I'm going to have to shock you again, I'm sorry."

"Bring it on Doc!!" he yells.

EKG #2 is obtained (finally)....and seems clear now that he's having an MI. So we get the 'thrombolytic box' out....and fax the 2nd EKG to the cardiologist. She agrees that thrombolytics may help (especially since everything we've been doing so far hasn't helped much....and the patient seems to be getting worse - with the whole v-tach/shock thing). I do a bedside ultrasound and there is no cardiac tamponade, and the heart motion....well, the heart is moving.

I suggest trying to get him to the cath lab instead of thrombolytics since this guy is in cardiogenic shock....and only a cath *may* save him. I was informed by the cardiologist that the cath table can only accommodate up to 350 pounds, so our patient couldn't go for cath. Thrombolytics are the only option for treatment of MI at this point. I ask her to come in to see the patient. She agrees. While she makes her way to the hospital, we obtain consent...and push the thrombolytics....

...30 seconds after the lytics are pushed into the IV, the patient becomes altered, agitated, and his breathing seems (more) labored. I think to myself, I'm just going to intubate him. All of his agitation isn't good for our treatment, but it's also not good for his heart. Additionally, he's nearly 500 pounds so a controlled intubation is preferable. I anticipate a very difficult airway because of his size, the severity of his medical problem, and the fact that he's in cardiogenic shock with frothy sputum coming up his airway.

I intubate him (despite the fat, and thru the pink froth). RT (respiratory therapy) secures the tube. And just then, he's in v-tach again. Before we charge the paddles he deteriorates into asystole. WTF? We'd already given the thrombolytics so I was hoping that this was the 'reperfusion rhythm.' But. It. Wasn't.

We started ACLS...and coded this guy. We got him back....kinda.

The cardiologist comes in and we agree the guy was in bad shape when he arrived. And the fact that he couldn't go to cath lab because of his weight....and the fact that (we later found out) he wasn't honest about his viagra use...and his multiple medical problems, bad habits, etc. made a bleak situation, worse.

In typical fashion, we coded this guy every 45 minutes or so...until he got a CCU bed (maybe 90 minutes later).

He made it to the CCU....and eventually started bleeding from every orifice (including his eyes and ears). It's like he was crying blood. That's what thrombolytics will do. Like most full arrests, he didn't live to hospital discharge.

Most doctors have memorable patients they think about for a long time after their encounter with them. This guy was one of mine.


The Hospital Credentialing Process Dog and Pony Show!!

So, I've been filling out multiple hospital applications lately. It's not uncommon for physicians to have hospital "privileges" at multiple hospitals, you know? And it's *crazy* what's involved in this process. Addressing this issue would be the perfect 'lifestyle, morale boosting, lovey dovey project' that our professional organizations could tackle, that will validate the membership fee (and PAC contributions) to those of us who are too busy to really get involved in the mundane, ever-changing politics of healthcare. Isn't that their purpose?

Okay, here's how it goes -

First you get this huge packet, maybe 70-100 pages of...who knows what. A piece of paper for everything...completely unnecessary and purely a hospital CYA. Read, sign, read, sign. They ask for accompanying documents, such as a CV, copies of your medical license, DEA, ACLS, PALS, board certification, diplomas, health clearance, etc.

There's a credentialing fee...which is a crock of shit. Aren't these people paid by the hospital to do this job? Why am I being charged a fee? Are other people charged a fee to apply for a job? The nurses....the techs? Everyone wants to be 'treated equal', yes? Where am I supposed to get this fee money? I have no money, hence the application for a *job*!! The fees range from $200 to over $500. Then, you want *me* to gather all the information....and pay the fee to boot?!! If I pay the fee....seems only right that you gather the information. Isn't that what I'm paying for?

The application - requires the standard info like name, address, etc. Then they ask for work history, educational history, and references. It's all on the CV. But they write "do not write see CV". Why not?!! Why ask for the damn thing? My CV has my work history, my references, contact info....all the basic stuff.

Then they ask you *again* (as if to catch you in a lie...as if you're that stupid), your work history....just to be sure there are no gaps. What they really want to know is if you've ever been committed to a psych hospital, or drug rehab...or otherwise MIA due to being "weak" or "crazy." It would be much easier to just write "I have never had a problem with drugs/alcohol, nor am I crazy" than to do this song and dance, that in the end proves nothing.

There's a sedation packet with a quiz...because this makes you "safe" to administer sedatives (can you feel the sarcasm?)

There's a core privileges packet, where you request which privileges you'd like. What the hell? I would like to do everything I'm trained to do, please. ACGME doesn't accredit residency programs, and ABEM doesn't allow one to graduate from a residency program, without showing competence with basic EM tasks. So, by being a graduate of an approved EM training program, I shouldn't have to pseudo-justify my competence in basic shit....like sedation, and ultrasound. Nor should I have to request privileges one by one. Even if I've never done a cric....I need permission to do one if needed. And if you tell me "no", how can I do my job? So...this packet could be eliminated if I'm an ER doc asking for ER privileges only.

Then there's a background check. Makes me wonder what is the Medical Board for, and why do I pay them almost $700 every other year if they can't vouch for me, and their 'blessing' isn't enough to practice medicine in my state's hospitals. It's insulting, and unnecessary.

References - are a joke. I give you 3 doctors....of the 100+ I know. So, what does that prove? Not that I'm a good doctor. Even the worst docs can find/pay 3 people to fill out a form. Then they call these 'references' (over and over and over again) and ask stuff like "would you say she's competent at LPs?" As if they'd know. They are not standing over me...ever...watching my LPs. ER docs don't stand over each other, and honestly have no idea what our colleague is doing 99% of the time.

Then there's the residency verification. Again, board certified should be sufficient to demonstrate my competence in my area of specialty. So why go thru contacting my residency program...and how long do they do that? I mean, my program director is an old guy already...

Then contacting every employer? I don't understand this either. Obviously, by the questions that are asked of them, there is that concern (again) of drug/alcohol use, and mental health issues. It's not like they're interested in "was she a good person....did she work hard?" Nope, the hospital doesn't care about that (the Group might, but they don't contact all prior employers). It's a CYA thing, again...no real value. Again, if I'm okay with the medical board, and my professional organization....board certified and a clean record (which is public and could easily be obtained by the medical office staff , which may begin to justify that $500 fee)...I should be okay to work (from the hospital's point of view).

I thought was ahead of the curve by saving all of my 'important documents' (LoR, malpractice certificates, employment letters, board scores, etc). Not. Get this...the information has to be "primary source information." This means, *they* have to contact someone other than you to get this information. (yep, crazy, I know). But, if they are unable to contact these people (people such as secretaries of departments to "confirm" you actually worked there, and weren't in rehab), they blame you: "I couldn't contact Doctor's Office up the street so we can't verify your credentials." Okay. I know I worked there. You're the one who wants "first hand proof." What the f*ck do you want me to do? You offer up the letter of recommendation from the medical director of that clinic. "Oh it's not addressed to us specifically....and we need to talk to him directly." Seems to me my letter is far more reliable than whomever you happen to get on the other end of the phone. Besides, I think he's probably dead by now....

Then there's the medical malpractice questionnaire. "Please list all of your malpractice carriers for the last 10 years." WTF? I could understand asking about any pending lawsuits...but even that doesn't concern the new job...until the outcome is known. We need a HIPAA for malpractice insurance companies (to protect us from the sharing of sensitive information which would be used to exclude us from being insurable. Afterall, isn't that the original intent of HIPAA? But we've allowed it to go as far as preventing us to obtain vital medical information from the PMD of our comatose patient...who cannot, and I repeat (to the person in charge of the pencils) *cannot* for the love of God, sign a authorization to release medical records right now!!) But I digress.

We have been successful in eliminating the ACLS/PALS/ATLS requirement for board certified ER docs. I mean, what the hell? I'm board certified as an emergency specialist, and you want a little red/white card saying I can complete an online open-book quiz...is that supposed to prove something?

Then they ask for your passport, social security card, drivers license, shoe size...and a strand of hair for DNA testing!!

The process takes a few hours of actual work time to complete...and that's if you have everything readily available at home. It's ridiculous!!

I'm all for interventions that contribute to actual improvement of safety or security. But many of these hoops are akin to the prohibition of lotion and chapstick on airplanes. It's just a hurdle that penalizes "good" people, and does nothing to increase safety or security. It serves to increase the cost of healthcare, and aggravates those of us who are on the front line.

I say, ACEP or AAEM should help us lowly grunt docs streamline this process. Maybe help us implement policies that will allow ABEM to be enough certification of our training and ability by virtue of being board certified. Our medmal should be private. The Medical Board issuance of a license should be sufficient to practice medicine in any hospital in the state. If I have a drug/alcohol problem that's significant to prevent secrecy, the Medical Board should know about it, and my licensure should be adjusted accordingly (understandably the Medical Board needs to be held accountable, which currently they are not). A CV should be sufficient to explain our professional lives (afterall, it's not like I'm writing something 'different' on the application. It's not more 'sacred' or 'accurate' because I write it twice...just more believable). And a 'central databank' would be excellent. One that could be referenced, and taken to be accurate by 'all the bullshit people who interfere with healthcare' (i.e. joint commissions, CMS, etc).


Here!! Here!!

The New ER Fad

The fad of the day in the ER is some form of Provider is triage, Rapid Medical Screening or whatever name admin can come up with. In their endless search to increase business we are now catering to the very business that is bankrupting us, the med-i-caid or indigent self-pay people that rarely pay their bill. Hospitals are dedicating rooms to prompt care to increase the speed at which we see the dental pain, back pain, cold symptoms crowd while the sicker people, who are having oh, say an emergency are still waiting in the lobby for a bed to open up.

Agreed!! and, I hear you too ER Murse:

The fundmental problem with Provider is Triage where the "Provider" is a midlevel is that the care is biased towards the low acuity patient. The midlevel does not categorize patients correctly in many cases. They get in over their heads when the main ED gets busy and tend to see patients they should not be seeing to help out rather than have the patient wait. Both Provider is Triage and Zero Wait ED's or Triage Bypass plans tend to get rid of an effective Triage systems and once beds are full +1 then there is frequently not an effective way to safetly priortize patients because Triage has been eliminated and the staff are assigned elsewhere. Then the system of prioritizing falls back to first come first serve with higher acuity patients in low acuity areas and low acuity patients in high acuity areas. Yes its a fad and a dangerous one.

Couldn't have said it better myself...


Have you heard? - Nasty Hotel Glasses

Thanks little brother for the link. I will certainly avoid...getting too comfortable in hotels. Especially cheap hotels!!


The Oral Exam Results...

"mic check....1-2-3"

"Is this thing on?"

"Excuse me, excuse me...may I have your attention please? From here on out, please refer to me as Dr. Backstage - diplomat of ABEM!!"

"Thank you, thank you very much!!"


I am finally a board CERTIFIED emergency medicine physician. I'm a SPECIALIST in something ya'll!!!

Yay for me...yay for my family...we all passed together!!!


Healthy toys - Consumer Action report released

Update: Very helpful websites (right at the top of my list as I do my Christmas shopping and such): www.HealthyToys.org, and Not Made in China. If you're buying anything for anyone that still plays with (childhood) toys...you should definitely educate yourself before slowly poisoning them...

...you might be surprised. Disney. Baby spoons. Hannah Montana = CONTAMINATED!! Probably you're not surprised. Why would you be? I'm not.

Contaminated, not just with lead, but arsenic, cadmium, mercury, etc. just as suspected. And, also as suspected, this shit isn't going to come of store shelves until dumb-asses quit buying it (or stores are held accountable via lawsuits and state/federal regulations). Do you really think that all that crap on store shelves is safe just because it hasn't been recalled? If it's made in China, it's shit...period.

Do a little investigating and draw your own conclusions. Then decide if you trust these assholes to *not* chronically poison your babies....rendering them stupid, cancerous, 'autistic', and "hyperactive." Makes you wonder if it's some sort of conspiracy, to destroy a generation of Americans...their minds, health, and ability to maintain their way of life. Would it surprise you? Just delve a bit farther and decide. Go on...