Well, What DID you think was gonna happen?

Jay Leno had a rather amusing segment called "What Did You Think Was Going to Happen?". There was a video clip with a young man straddled between the front bumpers of two facing cars, with his, er, um...junk.... stationed directly over a lit bottle rocket. Predictably, the bottle rocket lodges in his jeans at Ground Zero; hilarious hijinks ensue. What Did You Think Was Going to Happen indeed.

I silently ask the same question of many of our ER patients. There is a great dearth of common sense out there. A vast wasteland devoid of both common sense and, frankly, any sense at all. Of course, the patient's own agenda frequently defies any kind of sense or even native intelligence. Many simply have no brains at all.

It never ceases to amaze me how frequently ignorance is eclipsed by galactic stupidity.

There is no cure for the common cold. Only bonedheads and the uninsured/free care/I'm never gonna pay my bill crowd anyway show up at the ER for antibiotics to cure said cold. Two nights in a row. One guy was seen twice in 24 hours because his pneumonia wasn't better after 1 dose of antibiotics; he wasn't worse, just not miraculously better. Dumbass.

As you know from previous posts, many days I feel like the Narcotics Elf who works with Dr. Santa Claus. We see the same people over and over and over. Sometimes they hit the right doc, sometimes they leave with nothing but their pud in their hands. These are the "Pitch 'til You Win" repeat offenders. One of our more routinely presenting frequent drug-seeking flyers has apparently pushed even Dr. Santa Claus over the edge.

She had been seen by Gil earlier in the day for her really bad (yawn) migraine. He went off the board and gave her Fioricet, which is an OK drug for migraines but which does absolutely nothing at all for someone who just wants their vicodin or percocet. "Vikes or perky Percs" as my colleague Kerry calls them.

Anyway, she sent in one of her frequent flier co-dependents to scout out which doc was working and was busted by Sheila, the secretary. "Oh", she said, "I just wanted to see if Dr. Santa Claus was here tonight; I thought I would just say hi". Sheila kicked her out and told her that she was trespassing unless she wanted to see the doctor. Riiiiight. Way to go Sheila, booting her out, quite rightly. Well, what did you think was going to happen?

Play along with me now as we delve into the world of
"What Did You THINK Was Gonna Happen?"

You may vote for the most stellar example.

1. For three months in a row, the same idiot has come to the ER requesting refills of his extensive list of psychiatric medicines. For three months in a row, we have refused. He couldn't seem to understand why the result was not different for month four.

2. One woman has refused to take her antihypertensives or antidiabetic meds in six months. She is five foot nothing and weighs over 300 pounds. She smokes about 2 packs of cigarettes a day; everytime she comes in she has grande mocha Frappucino and a charming new tatoo to show us. Is anybody shocked and appalled that her BP is Patent Pending/130? I certainly am not. She routinely refuses admission (and yes, we have had a psych eval done) and claims that with all of her other expenses she can't afford her meds. Maybe holding off on the tatoos and Frappucino's would help, but I doubt it.

3. One young man came in with back pain; I often look up the previous visits when the story doesn't quite match the way the patient behaves in triage. For example, they might whine about how tight the blood pressure cuff is when they are texting with 10/10 pain. Or, not realizing that we have a camera in several areas of the building, we often watch patients exit their vehicle and walk normally across the parking lot, only to turn on the drama once they hit the door. I never say anything though I often will comment to the doc that I had observed a normal gait before entering the department. Hence the "look up".

This particular young man has not been seen in about 10 months; prior to that he had been seen at least 8 times in two months with various pain related complaints. On the final visit, he was give a script for 15 Percocet by Dr. Santa Claus. The pharmacist called, concerned that the "1" had been changed to a "4", so it looked like Santa Claus had written him for 45 Percocet; it's just not done. Nor do we give out narcitic 'scripts with refills. With a different colored pen. The phamacist was instructed to tear the 'script up and advise the patient that tampering with prescriptions was against the law. Dr. Santa Claus was kind enough to document this fact in the patient's chart for future reference. He is lucky he was not arrested. You can imagine that the kid was pretty pissed that he did not get any narcotics this visit.

4. Here's one from the lazy EMS from my own town, who called on the land line to say that they were bringing a 23 year old who had taken an overdose of Zyprexa (used to treat schizophrenia and bipolar disorders). He had stable vital signs and seemed "OK". That was the report. Are you fucking kidding?

Um, no, you won't. For one thing, any overdose is presumed to be a suicidal attempt until proven otherwise, regardless if it was accidental, ESPECIALLY with a history of psychiatric issues. That means that the patient must be watched continuously to assure his safety until he is determinied to be safe. Or shipped off to inpatient treatment. That means a security watch, which we emphatically do not have. We also do not have any social workers available at our facility to do an evaluation. The physician instructed them to take the patient to the Mother Ship. Lazy, like I said, to presume to do otherwise.

5. We actually had a teenager come in with testicular pain, brought in by his father. This occurred after the teen had some physical contact with his girlfriend; apparently not enough. He was diagnosed with blue balls; Dr. Cripes said he had to give a little birds and bees lecture to the mortified teen. I thought the father should be the one who was mortified. Cripes was at a loss as to how to come up with a medical diagnosis for blue balls; Google to the rescue. It is called vasocongestion. Don't try this at home.

Alaska Tails

Sherry is safely back from her annual back-country paddling trip in Alaska. You may recall that last year, she had a real problem being stalked by grizzlies. Her husband subsequently failed to keep his word by purchasing, and learning to use, the necessary weapon that would ensure their safety.

Fortunately it was a remarkably griz-free adventure this year; except for the last day.

Sherry and her husband are dropped off by a bush plane, paddle to a certain point and then rendezvous with the pilot at a pre-determined time and place. This year, because her husband was doing some type of observation for the Park Service they were given a satellite phone (and a Jr. Ranger badge). This would serve to be a fortunate happenstance.

At the end of their trip, Sherry and her husband Dick were awaiting pickup on the appointed day by a small float plane; a little pond was to be the landing area. Sherry told her story:

"The wind was blowing a gale, and there was quite a bit of chop on this pond; it was relentless. These float planes have to land precisely, otherwise they would tip over and crash. The pilot made three or four passes, and I knew he wasn't going to be able to land. Sure enough, he called us on the sat phone and said there was no way. He has to come from two hours away, so he said he would come back the following day, and for us to call him at 6:30 AM to let him know about the wind conditions".

"I didn't sleep all night. The wind kept howling, and I was concerned that we would be stuck another day. It was so bad we had the tent tied to the gear bags so it wouldn't blow away. Finally, just about 6:00 AM the wind died down. Dick called the pilot who said he would arrive about 9:00. I was relieved and settled back in to get a couple of hours nap at least".

"At about 8:30 I got up, and Dick and I packed up the tent. We were pretty much out of food, but had a couple of granola bars so we pulled them out to eat while we sat on the gear bags and deflated canoe to wait for our ride. That's when we saw it: a giant grizzly. It was down at the end of the pond eating a caribou. Dick and I kept our eyes on the bear, but he seemed pretty engrossed in his breakfast and didn't seem to notice us".

"About this time, the wind picked up again with a vengeance. Now I was nervous, as if I wasn't when I spotted the bear. Maybe 10 minutes later we spotted the plane. I was thinking we were in some pretty serious trouble if he couldn't land, because the wind was gusting."

"The pilot had to come in low, right over the bear in order to land, so I know he realized we had a serious situation. The bear was pretty pissed off about it, too, roaring and waving a paw at the plane. The pilot tried to land, twice, a third time, then a fourth; each time the bear was roaring. I really didn't think we were going to get out of there; I had no idea how much fuel was available to burn on failed landing attempts, so I was feeling pretty desperate by this time. All I could imagine was spending another night with this really angry bear in our back yard".

"Finally, there was a lull in the wind; I had a feeling that this was going to be the last attempt. The plane came in so low I thought it was going to hit the bear, who was definitely not happy. At this point,the bear did something really odd; it THREW the caribou at the plane! I have never seen this before, nor had the pilot.

"The plane landed safely, loaded us in and we were on our way. The bear retrieved the caribou and continued with his meal, paying no attention to us at all. It was a great trip, but boy, was I glad to get out of there".

We are all happy to have Sherry home safely, but the phrase "when caribou fly" has become our new favorite saying.

We saw 24 patients last night. This, in a 6 bed ER with two nurses and one doc. Plus, the doc was Gil. Lord love the guy, but he is a cautious soul and we had some sick patients. Plus at least 6 dental paineurs, of which two left because the wait was at least 90 minutes. Can you imagine?

The campers from the several overnight camps kept coming. I don't know, perhaps it is the first time in a year many of these kids have been outdoors; they have fractured fingers, been stung by bees/mosquitoes/ spiders and one camp hamster (a campster?). As my son used to say, "ham comes from a hamster".

One day a week we offer a free walk-in blood pressure clinic. Not too many people use it, maybe a dozen or so. But for some of these crusty Yankee old-timers, it is perhaps a day out; and free to boot. One of the cranky old ladies never remembers to bring in her little booklet, so she gets a new one every week. We give these out gratis; I envision her house with about 3,000 little booklets, each with one or two blood pressures written in it. I seriously doubt that her PCP ever sees these readings. Or anybody. She is a little ritualistic, needing to sit for at least 5 minutes to "settle", then another 5 minutes to rummage around for the booklet she does not have. Several minutes are expended in divesting "only the left arm!!" from about 4 sweaters. Finally, she will squint up at me suspiciously and ask me who I am, and if I am new. We go through this every week. After taking her blood pressure and writing it in the new booklet I have provided, and she clucks and mumbles and frets her way back into her clothing, she is out the door, pushing a walker sporting 4 tennis balls in the legs.

Having your triage area tied up for 20 minutes on a free service: priceless.

One woman came in who just wants me to check her O2 saturation. Why? "I just had an asthma attack and if the reading is normal I don't want to be seen".

OOOOOOOOOOkay. We offer a 15% discount on ER co-pays that are paid right away; we take major credit cards even. But, you can't collect on this type of time-wasting activity which included informing the patient to return if she stopped breathing. Or whatever.

New Cathy emerged from an extended visit with one patient. "Well, she wanted to know if I had found Jesus, and I couldn't get out of the room; any suggestions for next time?".

"As the token atheist at a Catholic hospital, I am perhaps the last one to ask; I could give you some talking points from my perspective, but I doubt it would go over well", I said drily.

Gil says, "That happened to me once; the patient was jumpig up and down, waving his arms and yelling, "Praise Jesus! Praise Jesus!", so I just started jumping up and down yelling "Praise Jesus!" too. Then security took over".

"My son suggested that this might be an effective way to deal with telemarketers; I can just imagine. 'Hello, I am calling from XX Loan Corporation, are you interested in refinancing your home?'. 'Why no, but have you found Jesus?'. Could work pretty well", I said.

The hits just kept on coming. One little guy, I don't know how he managed this, fell off his bike and cut the soft palate in his mouth pretty badly. The rubber grip on the handle bar was mostly worn away, exposing much of the hollow metal edge, which wound up piercing the roof of his mouth. He was so scared, but did OK. It could have been so much worse.

The Last Patient of the night (whom we finally saw about midnight) was actually having an anxiety episode. She insisted that it was "overactive kidneys". I was too tired to pursue that she perhaps meant "overactive adrenal gland" that is located ON the kidney. The adrenal gland produces cortisol, a hormone that is important for several body functions, such as blood pressure regulation and release of insulin; it is also released in increased amounts in response to stress. Also, it is responsible for anxiety reactions, which is pretty much a "flight or flight response" gone haywire. That is tonight's science lesson, class.

Ativan helped, and she left with happy adrenal glands.

Summer Stuff

It has been a hot month. Even here in the arctic tundra it has been over 100 degrees some days. It is so hot the face of the Old Man of the Mountain would have slid off by now, if it had not already done so.

I hate the heat, there is nothing about it I like unless I am floating in water with a frosty drink in my hand. Can't eat, can't sleep, have no energy to do anything. Plus I stick to my leather sofa.

Mary, my kayaking buddy won't even go paddling if the temperature is any higher than about 93 since she doesn't do well in the heat either. Now she is being treated for Lyme disease since she discovered that pesky bulls-eye rash after a couple of days of fever.

If you have pets, and they tend to be outdoors a lot, ticks are a part of life. If I have fallen behind with the tick treatment for Tina, I can pick 7 or 8 of them off at a sitting. Tina loves it when I check her for ticks...she gets the most marvelous massages.

So I really don't get why people come to the ER to get a tick removed...and we get a lot of them, sometimes 3 or 4 per night. And these are ticks that I could basically pull out on my own in triage...but I won't, now, will I? Everyone pretty much gets treated for Lyme anyway, just to make the visit worthwhile.

One young man was brought in by an aunt; I suspect he had some sort of developmental delay. He was spending the summer working in the area.

Auntie had just returned with her nephew from her PCP; he had diagnosed his rash as heat rash. While not a classic bulls eye rash, the aunt was unsatisfied, and insisted we test him for Lyme.

Sure, no problem; and based on some of his other symptoms, Lyme was not completely out in left field. We treated him for Lyme anyway, something the PCP had not done. Several days later, the test came back positive. The kid was already being treated and everyone was happy.

We also get a lot of 'spider bites', 'allergic reaction to bee stings', and bug bites in general.

One mother brought in a 2 year old with "hives"; turns out there were about 30 mosquito bites, the poor kid looked miserable. Discharge instructions included "keep child away from mosquitoes". Ri-i-i-ght.

A 17 year old was brought by EMS with allergic reaction to a hornet sting; hives, swelling, itchy mouth, and epinephrine administered prior to her arrival. THIS, people, is the kind of thing that you SHOULD call 911 for. We watched her for a couple of hours while we waited for a parent to arrive. Nice kid, beautiful girl. A pleasure to care for.

Once the hornet sting was squared away, we get a very "interesting" 18 year old girl who "passed out" (at least twice) while lying down in the car on the way back from the beach. Huh huh. Her boyfriend came racing into the ambulance bay door; I was on the phone with Kerry at the time who had forgotten to tell me something when she left. I hung up on her and never did get back to her. Anyway, boyfriend looked to be about 35; scruffy; tattooed, body pierced and about the same age as her father, who was equally scruffy in appearance.

The young lady walked into the ER, albeit leaning heavily on the boyfriend. She lay down on the stretcher and immediately closed her eyes and pretended to be unconscious; I really hate that. Please don't waste my time and make me dig my knuckle into your sternum. We kicked out the rest of the young lady's fan club, started an IV and drew the appropriate labs (as well as a pregnancy test), all of which were entirely normal, of course. She complained and moaned about the IV so much I pulled it out and handed her a glass of water and told her to drink; I had long since lost interest in this "interesting" patient.

It must have been the heat that caused the co-worker of an 18 year old to pick him up and hurl him into a wall; a metal edged dry-wall wall. He had a 4 inch gash on his scalp which was easily fixed with about 11 staples. Gil of course asked him if he wanted the police notified. He did not, in part because it was a misunderstanding. Also, he had gotten up after being tossed around like a bean bag and clocked his assailant, splitting his lip. Gil jinxed us by joking that we would probably get the split lip as a patient, which we did. He didn't offer much information about the incident.

Hot weather brings out the nut bags; 95 degree heat is sure to inspire individuals to go to the ER with maladies they have suffered from for, oh, say 2 years. Like swelling in the head that was diagnosed as an infected hair follicle. The long list of psychiatric meds should have been a tip-off.

Cathy was taking care of a patient with chest pain, left over from day shift. We were waiting for an in patient bed assignment; yeah, that's not such a quick process. The day shift reported that the lady was on 2 1/2 pages of meds (never a good sign), had fibromyalgia (yawn) and a "mystery illness" that nobody could figure out (read: crayzee woman with vague nonsensical symptoms). This was confirmed when Cathy took her temperature, and it was a shade under 98.6. "That is usually a sign that something is seriously wrong!", the woman exclaimed. Clearly, with a laundry list of medical issues and drugs, and the dreaded mystery illness, it should have come as no surprise that she would obsess over a non-issue such as that.

Cathy had some insight. "You know, I read an article that it is no longer politically correct to call anyone a hypochondriac; they are individuals with 'heightened symptom awareness'. I blame the Internet".

" I think that it is a lot of non-medical people thinking up stupid names for garden-variety crayzee", I observed.

Yeah, it's gonna be hot again tomorrow.

CRNA and Cellulitis

In my youth, about the time that dinosaurs roamed the earth, I had a tendency to be intimidated if I had health care types for patients. Docs and nurses are not the best patients. For myself or my family, I don't (unless I am wearing scrubs) come right out and say I am a nurse with about 1000 years experience simply because it can be intimidating.

Case in point; my husband was admitted last year for a cellulitis in his hand. Since he was being discharged with the need to have IV antibiotics at home he required an IV change (yeah, that one: the one I had put in 2 days earlier). I gave the young nurse 2 tries, then I (nicely) bullied her into fetching me a warming pack and put the damn thing in myself. I really tried to stay out of her way but my husband is a hard stick; I was just looking out for him, not judging the nurse.

So a guy came in over the weekend with a pretty nasty infection; he would require IV antibiotics for a couple of doses, but could come to the ER for his medicine; hey, we're a full service ER.

As I looked over his arms for a suitable spot to place his IV, his wife helpfully shrieked, "You can't put it in that arm, that's the one with the infection!".

Um, ok. Gee ma'am, don't know what I would have done without that useless bit of information. I quickly intuited that she was some sort of health care person and she wanted me to know it.

In my experience, the degree of effort expended by an individual to inform me in some roundabout way that they are in health care:

a. is inversely proportional to their level of experience or years of practice

b. has no relation to the level of acuity said individual practices

c. is a clue that they are either a student or an LNA

or

d. just want me to know that while they may not be a kick-ass ER nurse like me, they are indeed a kick-ass school nurse, office nurse, camp nurse, etc.

Second case in point: the aforementioned unhelpful wife, once I had decided on my target vein and was moving in for the kill, asked, "will you put in a butterfly since he has to come back tomorrow? They are so much smaller".

This tells me that unhelpful wife is an idiot since a butterfly, while small and perhaps really useful for short term use (ie, minutes) under direct supervision is inappropriate for longer term use. People who exhibit health seeking behaviors such as migraneurs who capriciously use the ER for their chronic pain condition will often ask for a butterfly. I usually don't make an issue out of it, but explain that those are METAL needles which are not good for extended use. Then I promise to use a baby needle, usually inserting something like a 20 gauge. This is a good size stick and certainly not a baby sized needle unless the baby is a full grown adult. Which they are.

I decide to ignore unhelpful wife and address my comments to the patient who was being very quiet. I explained that the site I had chosen in the middle of his arm would not be as compromising to his lifestyle as one in the hand or the crook of his elbow.

"Oh, he knows all about it, he's a CRNA"

Ah. A nurse anesthetist. Cool. Scary damn specialty, though. Too much chemistry and opportunities for it all to go horribly, tragically wrong.

Mr. CRNA looked up at me and mused, "How am I going to work tomorrow?"

"Well, I'm pretty sure you have sick time; use it".

"Oh, he never takes any sick time", said unhelpful wife.

"Well, think about it, do you really want to go into the OR with this raging cellulitis? Hmmm? Is that a good idea?" I asked, hanging his bag of IV antibiotic.

"Guess not".

Unhelpful wife accurately intuited that I had lost interest in her and chose to regale me with tales of her horrible experiences in ER's. This not only bores me, but in most cases, this sort of discussion is about as tactful as telling me about the time you farted in church. It tells me a lot more about the kind of person you are than "scaring" me into believing you are an astute health care consumer or that you have any native intelligence at all.

To his credit, the CRNA patient was cool. Maybe he knew he was kind of screwed with that albatross of a wife.

"So, what what do you do for work?", I asked unhelpful wife, "are you a CRNA as well?". I knew she wanted me to ask. Really.

"Well, I work in dermatology".

"Wow, really, you're a dermatologist; that's great" I gushed, knowing damn well she was not. It is less than full disclosure, sort of like me saying I'm in MEDICINE; I work in the medical FIELD, but to say I work in medicine might lead one to believe that I was a physician. You can see my point, I'm sure.

Unhelpful wife squirmed noticibly and replied, "Oh no, I work in a dermatology OFFICE".

I moved in for the kill; "Oh, so what do you do there?"

"I'm a med tech, but I run the appointment desk".

Uh huh. Thought so.