Sometimes You Need That Egyptian River

"This is Rescue 7,"said the paramedic's tremulous voice over the radio as his vehicle's siren wailed in the background.

"We are en route Code 3 to your facility with a 15 year-old female, gunshot wound lower abdomen. Pulse 120, BP 90 over 60, respirations 26. We have started two large bore IVs of Normal Saline and have 100% oxygen running by mask. ETA your location is five minutes."

Now this be badness.

It happened early in my civilian practice, before the hospital where I worked established itself as a Level I Trauma Center. An abdominal GSW mandates surgery. As the nurses set up the trauma room, I phoned the on-call general surgeon and gave him the news that he needed to leave his office full of patients and come immediately to take this young lady to the OR. He would arrive in 30 minutes. In the meantime I was on my own.

I gave the nurses a litany of STAT orders to be done as soon as our patient hit the door: "Complete blood count, chemistries, urinalysis, type and crossmatch for six - make that eight - units of blood. Foley catheter..."

The doors burst open as the paramedic team rolled through with our patient. She was a pretty caucasian female with long blond tresses. I quickly surmised that her usual complexion was probably less pallid than her currently white skin color. She'd clearly lost a significant amount of blood, which I could not see because it was inside her abdomen. So no telling how much. Undressing her quickly, we found a single entrance wound about two inches below her navel. We rolled her on her side to examine her back. No exit wound. And no telling where the missile had traveled once it entered her body. Rolling her back to supine, I noticed powder burns around the bullet hole.

I turned to the medics. "How did she get shot?"

"Appears to have been self-inflicted," they responded. A neighbor heard the shot and called 911. We found her in her bedroom. She had her father's handgun."

As I turned back to the patient, the nurses completed inserting a urinary catheter into her bladder. The drainage was red with blood. "Keep those IVs going wide open," I ordered. "And get me a central line setup. Any word on our surgeon yet?"

"On his way," replied a nurse.

I quickly started a central IV line in order to give her more fluids. Her vital signs had begun to stabilize, so at least we were matching her blood loss and keeping her intravascular volume steady. She would make it to the OR where our surgeon could definitively stop the bleeding and repair whatever organs were injured.

Another look at the girl's entry wound had me feeling her lower abdomen. Sure enough, a mass the size of a softball was palpable. (There was no such thing as ED ultrasound in those days.)

"The OR is ready and the surgeon is prepping," said the nurse.

"Good," I replied. "Tell them to call an obstetrician as well."

This pregnant teenager survived her internal injuries. The fetus whom she shot herself to kill did not fare as well.

NOT ONLY THE EGYPTIAN RIVER - Part One

"Eighteen year-old female c/o abdominal pain," read the Chief Complaint section on the emergency department treatment record that I picked up in the midst of a busy evening shift. The venue was John C. Lincoln Hospital in Phoenix, early in my civilian days of emergency medicine practice. I was not residency trained. None of us were, because EM residencies barely existed in those days. We gleaned our knowledge base mostly from the trusting patients who sought our care. I worked about 192 hours a month, single coverage. I saw a many women with abdominal pain, but never anyone like this lady, from whom I learned several valuable lessons.

Approaching the bedside I observed a young, very obese woman in obvious distress, holding both hands over her lower abdomen. In between her paroxysms of pain, I asked the usual questions intended to quickly identify any potentially life-threatening source of her abdominal pain. When first evaluating a patient, regardless of presentation, the emergency physician must immediately look for badness, especially treatable badness, and intervene appropriately if warranted.

Abdominal pain infrequently harbingers "badness" in the true emergency sense. Patients usually define "badness" differently, as in "I really hurt" or "I'm really scared." Because they came to the ED they expect us to do something about it NOW. They want relief. We want a diagnosis. This difference in perspective sometimes generates early conflict in the ED physician-patient relationship. Said conflict often leads to a different sort of "badness," and often makes the subsequent evaluation more difficult for both the physician and the patient.

In many cases of abdominal pain, we can initially rule out true badness by the history alone. My interview of this lady tweaked my badness sense, but did not raise the titer to alarming levels just yet:

Pain is crampy in nature, started four hours ago rather suddenly, gradually increased in intensity, no fever or chills, no nausea, vomiting, or diarrhea, no urinary symptoms, last menstrual period started this morning, and she's always been irregular.

Needing more information I went directly to a focused physical exam. I felt her massive doughy abdomen and did not elicit any areas of rigidity or point tenderness, so maybe no badness there after all. But then the exam findings suddenly changed. A large contractile mass rose up to meet my examining hands. Quickly palpating the mass, I noted it extended most of the way up her abdomen. As the contractile mass relaxed, I thought I felt a small arm or leg move under my fingers. I quickly reasoned the need for a more accurate history.

"Are these cramps regular," I asked. "Yes," she replied, "they come about every five minutes."

"And tell me again, when was you last period, and how heavy was it?" I asked.

"Just this morning, not heavy."

Finally the right question: "When was the prior period?"

"I don't remember," she said. "A few months ago maybe."

She denied she could be pregnant, but I pretty well knew better by that point. A quick speculum and manual vaginal exam confirmed that this woman was indeed in mid-labor well on her way to delivering a full term infant. A couple of hours later, with the help of our reluctant on-call obstetrician, she delivered a healthy baby. Proverbially, mom and baby both did well, at least by our ER definition of lacking badness.

Over the years I've sometimes thought about this lady, although not so much about the emergency department drama. This case taught me most of all about the role of denial in the human psyche. Somewhere deep in her mind this young unmarried woman must have known or at least suspected she was pregnant. But so terrible to her were the psychological consequences, that her mind simply yet elaborately blocked that fact from conscious thought – even once the inevitable process of childbirth began.

This learning case was ultimately not about emergency medicine, or obstetrics. The most valuable lesson learned here came from the realm of mental health: Denial is a powerful yet subtle human defense mechanism that can ultimately wreak great havoc in one's life, greater even than whatever the psyche fears from the inciting event.

This was the first such case in my early emergency practice. I would not be the last...

Old Dog Meets Best and Brightest

At least a third of the people in the room with me today were not even born when I attended my first ever Scientific Assembly of the American College of Emergency Physicians (ACEP) in 1975. That meeting was held in Las Vegas, which makes it all the more remarkable that I remember any of it.  (Can you say "Palomino"?)


At that time I had recently completed a surgical internship, and even more recently eschewed a promising neurosurgery residency to become one of those new "ER Docs" who limited their practice to the hospital "Emergency Room." I was one of about 5,000 early members of the College, all of whom were "second-career" emergency physicians like me. The specialty of emergency medicine was not yet recognized in the house of medicine (AMA), and the American Board of Emergency Medicine was merely a dream in the heads of the hardy pioneers who founded ACEP. They established the College to support the continuing medical education of us second career docs. In the absence of any formal body of knowledge or curriculum that was a daunting task.


Although details might vary from one ER Doc to the next in those days, my breadth of medical knowledge contained Swiss cheese-like holes that required rapid filling before I could safely treat emergency department patients while practicing (literally) this "newest specialty in medicine." I felt very comfortable diagnosing surgical or neurologic disease and managing victims of traumatic injury. But hand me an electrocardiogram, and I had difficulty knowing which end of the paper was up, let alone recognizing subtle indications of what nowadays is termed "acute coronary syndrome."


Over the ensuing years the College succeeded in winning support for the formal recognition of the specialty of emergency medicine by defining a body of knowledge and core content. The American Board of Emergency Medicine became a reality, and I eventually became not only a diplomate but an oral examiner. Training of emergency physicians progressed from the pick up games of those early ACEP meetings to a formal curriculum adroitly taught by ACGME-accredited residencies in emergency medicine. The specialty rapidly became so popular that positions in EM residencies were among the most sought after in the entire house of medicine. In those days we boasted that emergency medicine attracted the "best and brightest" graduates of the US medical education system.


My naval career gradually drew me away from the emergency department as I became more involved in executive and operational medicine. But recently I decided that my previously home-grown emergency medicine skills were long overdue for refreshment...a decision driven in no small part by approaching retirement from the Navy. So I signed up for and endured trans-Pacific travel in the very back of a JAL 777 to attend a course entitled, "Essentials of Emergency Medicine 2010" in San Francisco.


Wow! Talk about the best and brightest! The quality of evidence-based knowledge and education here blows me away. We're talking major leagues here, folks. Looking back on my early days as a leader in the specialty, I feel as if I'm awakening from a long sleep to find a dream come true. In those very early ACEP Scientific Assemblies we had to rely on educators from other specialties to teach us the various aspects of our "specialty in breadth." Those presenters were often irrelevant to ED practice, simply reflecting their own specialty perspective (or bias).


Today a cadre of emergency medicine superstars, most of them from one program as USC LA County, presented topic after topic, fully researched and developed to a depth of understanding and practical relevance to the emergency physician, and more importantly the ED patient, that we barely fathomed in those early days. These are indeed, in every sense of the term, the best and the brightest stars in the house of medicine. I must add that the audience, hailing from throughout the U.S., Canada, and abroad, contains many similar luminaries.


This experience moves me to extreme optimism about the quality of emergency care available to U.S. citizens and beyond, now forty plus years after those early visionaries of ACEP devoted their time and energies, sometimes against formidable opposition, to achieve that very end. Names like Wiegenstein, Mills, Rupke, Krome, Mangold, Rosen, Hannas, Haeck, Riggs, Podgorny and many others resonate deeply in my mind this evening. The best and brightest of today truly do stand on the shoulders of those bold-thinking, dedicated giants from the early days of our specialty.


For my own part, a highlight of my attendance at "Essentials" yesterday was the EKG session. Looking at the first of a series of practice EKGs, I recognized -- within mere seconds -- that I was holding it upside down. Now what was that cardiac rhythm...?

When I Half-Died

Heart rate of 12! I see it on the monitor just behind me.


MY heart rate! Not compatible with life!


My vision closes down, tunnel-like. I'm sinking through the operating table on which I lay, both arms stretch out and tied down, crucifixion style.


I need atropine.


The surgeon's voice, "Cough, Mike." I cough. I see the resulting blip on the monitor. Cough, cough, cough. Blip, blip, blip. To live, I must keep coughing.


Heart rate up to 30. Barely compatible with life, but I'm not sinking any more. I can talk.


"I need atropine!" I wonder how I can thump my own chest. But I can't move my arms. And now I descend again.


The voice, "Give him 0.04 milligrams of atropine." That's pre-anesthetic dose! Not good here.


"MORE atropine!" I demand in grave voice. "Half to one milligram!"


The voice, "Give him 0.5 milligrams of atropine IV."


I've stopped sinking. My vision is coming back. I'm lucid. I no longer need to run my own resuscitation. My heart rate is up to 60. I'm alive!


I remembered this story last night as a friend described his recent hernia repair. I recalled the time, now over 20 years ago in my pre-Navy days, when I tasted near-death while undergoing a similar procedure. I practiced emergency medicine at that hospital. I knew the anesthesia staff fairly well. Somewhat haughtily I reasoned that a surgeon could not kill me on the operating table if he tried, but an anesthesiologist could do so without half trying. Being an active triathlete at the time, I considered myself beyond healthy. So I eschewed general or even spinal anesthesia and elected to have the procedure under local anesthetic only.


The local didn't work so well. I was uncomfortable from the instant the knife hit my skin. When the surgeon manipulated the peritoneal sac, I experienced an intense vaso-vagal reaction. My vagus nerve reacted reflexively to the intense discomfort by slowing down my heart rate. My triathlon-trained resting pulse in the 40s left little margin, and hence my near-death experience. By my own choice, I was the only one in the room with recent training and experience in resuscitation. So I labored to fight off the impending darkness to direct my own life saving. 


"Physician, heal thyself."


Fortunately, it all worked out. A post-operative cardiac evaluation rendered the diagnosis of "Athlete's Heart Syndrome." I was pretty proud of that diagnosis at the time. Retrospectively, "Arrogant Doctor Syndrome" might have been more appropriate.


In spite of all the peri-operative dramatics, the hernia repair has held up just fine over the years. The surgeon, at least, knew to stay within his skill boundaries. Should the occasion for a repeat procedure occur any time in my life now, his former arrogant patient will most certainly trust his anesthesia colleagues to exercise their skills as well.


That particular emergency physician truly has no interest in healing himself again.

Sleepless in the Java Sea

I am no stranger to staying up all night.

I don't recall ever partying beyond the wee small hours. Not that it never happened. I just don't recall. I do remember once in med school waking up on the bathroom floor the morning after a party, but that was not technically partying all night since I was, in fact, unconscious. First and last time for that prototypical life experience. Ugh.

I pulled a few all-nighters writing papers or studying when I was in college and med school. As an English major I oddly got my best grades on those late night, last minute just-start-typing papers. Perhaps I write better when I don't have time to overedit myself. (See upcoming post on my "ScriptFrenzy" adventure.) In med school, however, my understanding and retention of complex scientific information always came out inversely proportional to the hours spent studying after midnight. I made it through medical school in spite of those last minute all night cram sessions, not because of them.


The vast majority of my sleepless nights occurred because I chose to be an emergency physician. Twenty-four/seven availability of immediate life-saving expertise is a fundamental aspect of that specialty. So, just as one who chooses a Navy career should expect some sea duty, an aspiring "ER Doc" should expect night duty. Unfortunately, there are exceptions to that rule in both professions, "sailors" who never go to sea (many, alas, are doctors) and emergency physicians who find a way to never pull a night shift. In either case, those outliers are neither to be respected nor emulated.


When I was young ER Doc in our specialty's salad days the current body of knowledge on circadian rhythm disruption was still developing. Not that I cared. Like my colleagues in that burgeoning specialty, I was a cocky young adrenalin junkie with testosterone to burn. Manfully we powered through strings of consecutive 12 - 14 hour night shifts, not only to meet the specialty's demands, but also to prove that we had the right stuff. One could not boast of being an ER Doc without first being tried in the crucible of human misery and tragedy that occurs more often after midnight: "Knife and Gun Club" trauma care, drug overdoses, poisonings, the full panoply of alcohol excess, long neglected end stage disease. These often afflicted the dregs of the human condition, desperately errant souls who ventured out only under cover of late darkness to end up in my ED and to keep me not only awake, but strangely professionally fulfilled.


Not all who sought this circadian-challenging profession succeeded. Arriving early one morning for my scheduled day shift after a new hire's first night, I came upon the distraught young physician sitting on the ambulance drive with his head cradled in his hands. In a nether-worldy voice he rasped, "I. Will. Never. Set. Foot. In. There. Again." He did not come back. I was only too happy to pick up my share of his night shifts for the remainder of the month.


Last night I pulled my first all-nighter in many a year. The need to synchronize activity with a distant higher headquarters required my presence at several teleconferences and briefs after midnight. Although many of my colleagues do this sort of thing from time to time, this week's activity involves most of the staff. "Just like a string of ED night shifts," I reasoned. "No problem. I'm a veteran."


Two unforeseen factors rendered this particular excursion into the wee-small hours less professionally satisfying than those ED shifts of yore. One is simply age. Those adrenalin-rushing, testosterone-burning night shifts occurred during my mid-thirties to mid-forties. (The variance, I hasten to add, is in recovery time not capacity.) The other, larger difference is the nature of the stimulus. Last night there were no airways to secure, no hemorrhage to control, no gastric tubes to place, no complex arrythmias to convert, no lacerations to sew. There were simply redundantly talking heads on giant VTC screens, and monosyllabic droning voices in my earpiece. I'm sure that the folks sitting around various remote conference tables, fully rested, fed, and caffeinated, found the lofty discussions stimulating. I probably would too under those conditions. But post-midnight to this grizzled old ED Doc they were as dull as dirt. Not complaining, just saying. Sure could have used a good trauma case at about 0300.

Well, I get to re-engage tonight, so I should probably get some rest. Unfortunately, someone just decided to take a grinder to the deck right over my pillow. So I'll go for a run on the deck instead. That should be good for an adrenalin surge.