Law #3: Emergency Medicine Provider Rules

1.  People will die


2.  I cannot save everyone


3.  It does not matter who you are or what you have done, I will go through hell to break rules 1 & 2


The IV pole and the inverted organ

This happened a few days ago…


I had a patient who was brought in by her boyfriend.  The boyfriend did not stay, did not help her into the ER.  Just dropped her off and left.  This is always a good sign.  She was a 30 year with the complaint of vomiting and pseudoseizures.  Yes, she complained of having pseudo-seizures.  It is funny that so many people will look up on the web and self diagnosis their cold or stubbed toe as some terminal disease but then you have people who have a diagnosis of pseudo-seizures and are super proud of it.  They never look up what it really means.

I went into the room, she was laying there, holding on to 2 stuff animals as if they were her children.  It was hard to get a history out of her.  But she has been having pseudo-seizures more frequently and vomiting off and on for the past day.  Her exam was normal.  So I ordered some tests and told her I would be back once I got them back.

Off to the next room,  the chief complaint was:  I have been off my meds and my privates growing inside me.  Going into the room, I have to clear the mandatory stuff on all psych patients.  “Do you want to kill yourself or anyone else?” “No”.  “Are you hearing any voices or seeing things that aren’t there?” “No more than normal when I get off my meds.”  Fair enough, I thought.  “Are the voices telling you anything bad?” “No.”  The guy was able to tell me his meds that he was supposed to be on.  I had no problem refilling them.  Now for the other complaint.  “So your private parts are growing inside you?”  “Yes” he responded with no sign of emotion.  “Ok, I need to take a look.”  As the patient is starting to pull down his pants so I can do the exam, I am trying to prepare myself for anything. From a completely normal exam to his privates being completely cut off.  I did my exam.  “Everything looks normal.”  I told him.  He then responded, “It is supposed to be longer” – pointing at his penis.  “I can’t fix that.” I replied and left the room.

While doing his chart, I look up over the counter and see an IV pole moving down the hall.  I stand up and see that there is a patient crawling on the floor pushing the pole.  The patient can’t crawl real fast because her legs (still has sweat pants on) keep getting caught up in her gown that is dragging the floor.  A nurse is already on the way to help her.  The patient then proceeds to kick and try to bite the nurse because the patient does not want to get out of the floor.  I then notice that it is my pseudo-seizure patient.  I quickly looked at her chart and everything was back and normal – surprising!!  By that time, they had put the patient back in the bed.  I went in and informed everything checks out. I then asked, “Why were you crawling in the floor, pushing the iv pole??”  She replied with a straight face, “Because he wanted a ride”.  I then looked down the IV pole, and at the bottom was a stuff bear sitting on the base of the IV pole.  “So your bear wanted a ride on the IV pole?”  “Yep.”  Amazing.

Oh the super bowl

As I start back with the blog, one of the easiest ways is going to be sharing what I experienced on shift to give you an idea of what happened during the shift.


So I missed the Super Bowl because of having to man the ED.  But it seems like I did not miss much any way.  With the super bowl, you can expect a few things.  Usually the ED is slower during the game because people are watching the game and then you get rushed after it is over.  The other occurrence is kinda like if you have ever gone to Walmart during the Super Bowl.  I have, and it was the best time ever.  No one is there! You basically get the entire store to yourself.  I think some patients have the same idea about the ED instead of walmart.  Maybe they just came from Walmart or they are going back once done in the ED.  But we get these people (more than normal) with issues that have been going on for months or for only 2 minutes.  Like:  my kid has had a cough or fever for 15 minutes, or I have this tooth pain that has been going on for awhile.  With awhile being defined as any time period greater than 6 months. I am surprised we did not get any suicidal people because Denver got crushed.

Now onto the usual patients:

1) “I cut my leg guy”:

This guy comes in with I cut my leg.  He is on permanent disability because he has chronic back pain.  He daily medication list is the picture below.  The numbers beside the meds is how many he takes a day.  That is enough to knock most of us out for a week.  Because he is on permanent disability he does not work.  Instead he does motocross races and works his farm.  Tonight he came in because he was cutting up a tree stump with a circular saw.  Missed the stump and got his leg.  So what part of his daily activities makes him seem disabled. Hmm…


2) “I have a CIA transceiver in my belly”:

With all the NSA spying and keeping our phone records, the CIA must be getting annoyed that they are not getting any press.  So they are now putting transceivers in the bellies of my patients.  This one must not have been tuned right and the volume on to loud, because he came in so we could adjust the setting and turn it down because it was keeping him up at night.

3) “I punched out my step dad”:

Well this kid got into a fist fight with his step dad and hurt his fist.  Another happy family.  This is not even the main part of this story.  The kid and mom were discharged from the ED.  He only bruised his hands.  They walked out into the waiting room and then started yelling and cursing because he was not rolled out in wheelchair.  You need a wheelchair for a bruised hand? Come on.  While screaming and yelling about how mistreated they were, they made some phone calls to see if someone could come pick them up.  They need a ride because they came by ambulance for a bruised hand.  Well, no one could come get them.  In mid scream, they turn to the triage nurse and asked in the nicest voice if we could pay for their cab ride home because they had “no money”. Wow how things change when you need something.  The charge nurse had a soft heart and arranged for the cab.  While waiting for the cab, the patient and mom were able to go to the cafeteria and buy a large meal for each of them. Funny how money can appear when not 5 minutes before you had no money.

4) “I might be having a heart attack, but I want to go home’:

I am telling this story because I respect this guy more than any of my other patients I had tonight.  He was an elderly (in his 80s) gentlemen that had chest pain.  He lives  in a nursing home and they sent him in to get evaluated.  He had had heart attacks in the past.  The workup was normal. But because of the pain and risk factors, I wanted to admit him.  When I told him this, he politely declined the the admission.  Here is what he told me.  “I am old.  I live in a nursing home.  I do not want to be resuscitated. I do not want a lot of tests to be done.  If I die, I die.  It might be my time and I am ready.”  I have a lot of respect for this man.  I feel his reasoning is sound.  I hope to have the same courage and peace when I am in his shoes.

Law #2

I actually stole this from someone else. I cannot remember who. But it is a great truth of the Emergency Room.


Law #2:  I will always have a job as long as there is testosterone and alcohol.

almost 18 months

It is hard to believe that it has almost been 18 months since my last post.  Now, I am back.  The main reason I had not posted in a long time was because I had moved into more a administration role.  I know.. I stepped over to the dark side and became a suit.  Well, I got out of that job about 6 months ago and I am back in the pit.  So stories and wisdom are coming at me from every direction.  So I am ready to step back into the dirty rooms of the house of god.  There is much more to come.

Loving free healthcare

Patient came into the ER yesterday. Chief complaint was bilateral heel pain. I saw the chart – based on the chief the complaint, I ordered bilateral heel xrays. They showed bilateral small heel spurs. I brought the patient back to my bed to be a quick in and out. I started getting the history from the patient.

"What brings you into the ER? Tell me the story."
"My heels hurts."
"Ok, how long have your heels hurts?"
"About 4 months." (no expression on the patient’s face)
"4 months??? So what changed today that made you come into the ER?"
– The patient just stares at me like why would you ask that question. So I rephrased the question.
"Why after 4 months is this an emergency today?"
"Well, I got laid off 1 1/2 months ago and since I did not have a job to go to I thought I would just come in and get it checked out."
"This is the same old pain you have been having – no change?"
"Yep" the patient says with a grin.

I finish the exam. Yep, heel spurs.

"I will give you some pain medications to go home with, but you will need to follow up with podiatry to get further care."
"What?!?! That is all you are going to do for me? You mean I have to now get an appointment somewhere else."
"Yes. That is all I CAN do for you."

The patient got up and left unhappy. Nothing like having free healthcare so that people can come into the ER like it is just a 24 hour walk-in clinic. As more people get insurance under the new legislation and no change in number of primary care providers, this will happen more and more. This will take up more man hours in the ER and thus delay care for patients who really need to be in the ER. I can’t wait.

Lucky save

So last night I was working at the local trauma center, we get the call "Trauma Code – 5 minutes". Trauma code means that the patient is basically dead or almost dead and it is due to some sort of trauma. Not knowing exactly what is coming in, we headed to the trauma bay. Gloved and waiting, we here that it was a GSW (gun shot wound). Patient is rushed into the trauma bay by the paramedics. On initial exam, the patient is unresponsive and lifeless. He has no pulse. The patient has multiple holes in both side of his groin. We immediately intubate the patient. The trauma team opens the chest. Nothing. Fluids are pouring in and central line is placed. We gave epinephrine and then atropine. Now the patient has a pulse. I quickly placed the ultrasound probe on the abdomen to make sure there was no free fluid. Nothing. Blood is started. We now have bleeding from the holes in the groin. The patient was rushed to the operating room. He survived the surgery and was moved to the ICU.

This patient was lucky. The patient was lucky he was not found just a few minutes later. Lucky it did not take longer to get to the hospital. Lucky we were able to resuscitate the patient. It is rare thing that a trauma code survives. It is usually a futile exercise. But we do not play odds when it comes to patient care. In the ER, we always go all out on everyone no matter what their chances because occasionally we all get lucky and a life is saved.