Snowstorm!

... I would like to thank this snowstorm... for keeping the ER quiet... and only creating a few Saturday night drunks instead of a ton (although the one I'm taking care of is particularly vomit-y)

ER entrance, midnight.

And The Moral of the Story...

So, last night in the Cornell ER was a steady stream of interesting cases, notifications (EMS giving us a heads-up they are coming in with someone sick) and some unfortunate events.

There was the woman who tripped at a holiday party she was hosting. Turned out that she hadn't tripped -- she had had a massive stroke. Apparently there was some debate at the party as to whether she was just stunned from her fall or actually had something seriously wrong. One of the woman's friends basically said "I don't care what all of you think, I'm calling 911." Minutes are brain with strokes. The patient had tPA (the clotbuster drug) on board within 1 1/2 hours of onset of symptoms. For those of you who are non-medical, that's damn good. I later overheard the friend on the phone with other partygoers saying "See? I told you!! I saved her life tonight!" The patient's future is still very unknown (strokes are horrible and take months before a prognosis can be made), but that friend drew a line in the sand and as a result the patient has the best possible chance of making a meaningful recovery she could have.

Later in the evening a horrible case came in. A car pulled into the hospital circle and two young guys helped a third unconscious, pulseless guy out of the car, yelling for help. We brought him straight in only knowing that the patient had told his friends that he was having an "allergic reaction." Immediate CPR was started and the patient was asystolic (flatline). We worked on him for half an hour before calling it. It didn't make sense that this very young professional could present after an allergic reaction without any signs of cardiac activity. He never had a pulse, never had anything other than asystole... it was erie, strange and confusing. Young healthy people's hearts don't just stop. And he was young and healthy.

You work longer and harder on the younger patients for a number of reasons. There's the obvious -- the patient has so much left to life. There 's anothe reason, their hearts are more resillient. Let me explain: There was a heartbreaking arrest a few weeks ago in the hospital. A young, previously healthy person arrested on the main units. Every medical resident in the hospital that night assisted with that code. They coded her for two hours and eventually lost the patient. Why? Because they kept getting her back and loosing her again. This is how you expect young person arrests to be. Horrible, full of hope that gets dashed over and over again. I was in one on my surgery rotation. We kept getting a heartbeat back and we would all take a deep breath and feel the pulse... strong... strong... not as strong... moderate... weaker... gone... fuck! Start compressions!

Back to our guy from last night... he never did what I'm talking about. He was the same age as the other examples I gave, but his heart never gave an inkling. Maybe that was the most confusing part. It just didn't fit and it was hard. What were we missing? What was the silver bullet that would make this guy's heart wake up? We threw every drug we had at him -- nada.

Over the hours following his arrest, more of the story of the events of the night came to light. He had severe food allergies. He was at a holiday party for work and started to have an allergic reaction. People wanted to call 911, but the patient wouldn't let them. He and a friend went trekking across the campus of the facility to go to his locker in search of an Epi pen. None to be had. Then back to his office -- maybe it was there. Nope. They decided to drive him to the hospital but the car was in the 3rd sub-basement. The patient got in the back, his two friends in the front. At this point, the patient stopped responding to his friends. They drove... but they didn't know where the hospital was. It took them 10-15 minutes to find us. The rest, some might say, is history.

No one is to blame for any of the events in any of the examples here. The young man's friends lifted him and carried him bodily into the ER for help. They yelled encouragement to him from the other side of the curtain. The older woman at the party had significant slurred speech seeming like confusion.

The lesson is that one of the hardest thing to do is to stand up to your friends. To go against the group decision or against your friend's own decision. To be the "bad guy" who caused embarrasment by calling 911 for "nothing." It might not be nothing. Forget all that "do what is right" bullshit -- I think it is nearly impossible to live a completely morally just life. I would say, if you're scared, do what will make you un-scared -- whatever that may be, I find that it usually involves getting backup.

Happy Thanksgiving!

Happy Thanksgiving, everyone!

I find myself in Philadelphia with Rob's family for the second year -- something which I enjoy very much. It's always fun to be with someone in their "native habitat"... in Rob's case, this consists of his mother (who has a special place in my heart for putting me up last year for an entire month), the younger bro and lots of family friends. Thanksgiving this year was a big event consisting of 13 people around one giant table in one tiny dining room. The food didn't fit (never does) so it lived on a separate buffet table. There was a wide smattering of ages from high school, college, us 20-somethings, some 30-somethings and, of course, the parentals who were actually the significant minority!

All in all, yummy, warm, excellent wine selections (thank you, Rob) and then a nice long lie-down on the living room floor in an attempt to digest. Good time =).

The gang...
Nan, Lucas, Ryan, Angela, Marcelle, Alex, Nora, Danielle, and Jeff
in line for the buffet =).

Vacation, Part Deux

Where did I last leave off... oh yeah, in DC, at G's. DC was great -- Genevieve and I went to the National Opera Trunk sale and got great halloween costumes (see bottom of page).

Chicago was tons of fun -- Aileen was slaving away in MICU (ugh) but still managed to take me to FlatTop -- one of my FAVORITE restaurants of all time! FlatTop seriously needs to come to NYC... I say this when they only just arrived in downtown Chicago. Aileen took me to the new location in the Loop that has only been open for a few months.
Ashley took care of me for the rest of my chicago stay, including super yummy oysters at Shaw's Crab House -- live music, fab seafood. Overall, the dinner (with two glasses of wine each, and dessert) was incredibly reasonable!! Not something you would expect from a restaurant just off the Loop, valet out front and the after-work-suits piling in. We opted for the significantly more casual Raw Bar half of the restaurant due to the jeans we were wearing and LOVED it!

From Chicago, I jetted off to Seattle to visit Dave and Katie. Katie and I spent the day bumming around Seattle with a trip to one of my favorite stores ever -- Fireworks, and then the Seattle Mystery Book Shop which is wall-to-wall, floor-to-ceiling Mystery Novels. Katie was in heaven.

The highlight of the stay was definatley dinner at the Purple Cafe and Wine Bar with Dave, Katie and Nolan!! It was great to see Nolan -- who I hadn't seen in literally 5 years! The four of us caught up, tasted through a bunch of wines and had a fabulous dinner.

I highly recommend the restaurant -- it is a new favorite of mine in Seattle! The wines are great, the food is delicious, but the also have a sense of humor. The wine list opens with "The Book says "the apple tempted eve."... our book says "it must have been the grape."" The entire list is covered with little jokes. I still know next to nothing about wine, but we ordered a few fleets of which each fleet definately had one "looser" wine and one major "winner" wine.

Of the "Bullfighter" flight of 100% spanish wines (we ordered it as a tribute to the absent Rob), Atalya Amansa 2007 was the winner. From the "Pino Noir" fleet, the Erste & Neue Kellerei "Mezzan" 2007 from the sudtirol-alto region of Italy was the clear winner. Rob wrinkled his nose when he heard that, but it was the best of the bunch!

Returning to NYC and work kindof sucked. It was so great to see everyone, but time flies. I'll leave you with a Halloween picture displaying the awesome Kimono costome I picked up with Genevieve in DC!

Rob, Me, Elena and Alex on Halloween.

Enjoying NYC once again...

Took a while, but I finally got back around to enjoying NYC -- or just enjoying everything in general. I just finished a month on the Acute Care Surgery service at Columbia Presbyterian Hospital. I learnt a lot, I worked hard, did 30-hour call (horrible) and actually had a good time. The Surgery residents at Columbia are a fantastic group of people and I had the tremendous help of someone who has helped generations of NYP EM residents survive surgery -- Voula, the acute care surgery service PA. If most PAs are worth their weight in Gold, Voula is worth her weight in Platinum. phew!

First, there were the 3rd row seats in the endzone at the Eagles game in Philly...
I was going to go SCUBA diving during this time off, but that all fell through, mostly due to the fault of annoying bosses and failure of appropriate planning. Oh well. That's why I live in NYC and can salvage! Then there was taking Deka to the dog park (she was spade and forbidden to run for a month). She was so excited, she ran laps for the first 15 minutes. Deka is now 9 months old!!!

Thursday found me at Carnegie hall with Elena to hear Hayden's "The Seasons" -- a piece I was completely unfamiliar with. Turns out that Hayden drew significant inspiration from Handel's Messiah for this work and it was really beautiful! Full orchestra, full choir, soprano, tenor and bass soloists. Each "season" was unique. Spring was calm and pretty, Summer was a little weird because it had a sad feeling to it, however Fall was fantastic with the "hunt" and the french horns going bells up and balls out crazy and Winter was full of BIG choral stuff with a necessarily rousing finish.

All of this was followed by a weekend in DC w/ my college roommate, Genevieve and her husband, Bren which included a stop by the National Opera Company's Trunk Sale where they were selling old costumes -- both G and I walked away with kickass halloween costumes from Madame Butterfly (Bren stayed home).

Now I'm in Chi-town visiting Aileen and Ashley. Irony of ironies, it's actually warmer here than in NYC (as in, 53 instead of 48, but I'll take it). From here I go to Seattle to see Dave and Katie for the first time in almost a year and a half!

..More pictures later. I kindof forgot my camera charger, so I'm taking pics VERY sparingly. oops.

NEJM does it again!

So, I'm browsing, killing time (on vacation, I might add) and decide to see what's doing on the NEJM website. I get there and the top story on the website is this: Interactive Medical Case- A Bloody Mystery.

Wait... interactive?? So I click the link and guess what? This is FABULOUS! There is a reason why the NEJM is considered the preeminent medical journal and innovations like this are it. This is a case, presented in pieces (the usual horrible puns apply) with frequent breaks where you "order" lab tests and "create" a differential diagnosis then reassess and "order" more tests/treatments. There are charts, tables, MOVIES, images. Even better, this isn't the "one correct answer" format. It's the "which 5 of these 15 potential diagnoses could this patient have?" There also isn't any sort of giant ERROR buzzer, either. You choose your answers, the green checks and red "x"-es appear and you read an explanation of the answer.

Did I mention the excellent explanations? Sometimes a little too helpful before you click on your answers, but that's what learning is about, right?

NEJM is famous for its long-established "Case Records of the Massacchuttes General Hospital" in which docs get to read a round-table discussion of a complicated case with a number of experts weighing in. Very valuable -- med students everywhere are told to read it -- but its dry and complicated as hell to follow. They literally transcribe the round-table discussion verbatim. I feel that this new interactive case format accomplishes the same goal but I actually learn becuase I'm participating and actually care (I admit it... I don't like to get questions wrong).

Overall, two thumbs up.

While I'm at it, I'm going to put in a one-line plug for the NEJM "Image Challenge" on the website. This shows pictures of pathology -- anything from photographs, radiology, microscopy, gel electrophoresis...etc. You pick the answer from the multiple choice on the side and get told right/wrong. Quick, visual recognition, great for keeping your brain plugged in on overnight where you have to stay awake but don't have the energy for more than a mouse-click.

Could Hawai'i be generalized?

There is an article in this weekend’s NY Times that I found very interesting. It’s about the healthcare system in Hawaii – and how GOOD it is! The authors cite that Hawaiians live longer than any other state in the union and they they are generally healthier. The doubters among us say “no shit, Sherlock. It’s BEAUTIFUL all the time!!” However, there were some more intriguing tidbits in the article that made me wonder. Hawaii has the highest rate of breast cancer in the US, however, they have the fewest DEATHS from the disease of any state. Hawaii has the highest percentage of insured in the US and the lowest Medicare costs (possibly again contributable to that whole tropical paradise thing).

But really, the least number of uninsured? Massachuttess has the next lowest number of uninsured at 20%. Hawaii’s uninsured # is 10%. What’s going on? There is a law in Hawaii that every employee who works a minimum of 20 hours per week must have health insurance. Sure, there are people who try to circumvent the systems, employers making sure their employees only work 17 hours per week so that they don’t have to pay insurance, but generally the plans are cheap, no deductible, widely accepted and easily suffice for your average fairly healthy tropical paradise inhabitant.

I was puttering along this article until I hit the section where they start talking about the ERs in Hawaii. The author interviewed an ER doc who spends part of his year in LA and part in Hawaii. He described the Hawaii ER experience as “greased lightning.” Nationally, there are 400 ER visists/1,000 people annually. In Hawaii, that number is 200/1,000 people – half the national average. Again, you could make the tropical paradise argument, but Hawaii is not without its dangers. Anywhere there are highways, there are high-speed car wrecks. Just because the live in paradise doesn’t mean that Hawaiians don’t suffer from heart disease, asthma (highest rate in the US), COPD. Not to mention the kind of trouble the “touristas” can get themselves into with the vast number of adventurous activities available in Hawaii – there’s surfing, jellyfish, climbing, diving, parasailing, base jumping, heat stroke… all recipes for tourists ending up in the ER.

So why is this mystery ER doc saying that Hawaii’s ERs are “greased lightning”? The theory proposed by the article is that there is much better access to family care practitioners and general primary care docs, so patients go to their doctors for all the minor stuff rather than to the ER. i.e.—appropriate use of the primary care physician and the ER. This is something that I am continuously advocating as the root of our healthcare crisis—lack of access to primary care. I also always say that this is not going to be fixed without a massive expansion of our clinic system. The system as it is right now is at its breaking point on all fronts. This is the point at which Rob jumped into to play devil’s advocate.

What is the ratio of primary care physicians to population in Honolulu vs. NYC or Philadelphia? Barring that, what is the population difference? What kinds of numbers is each hospital on Hawaii serving in beds per population vs a NYC hospital? How many insured use the ER vs. primary care for minor complaints? How sick ARE these people in Hawaii (tropical paradise argument again)?

I’ll have to do more research and get back to those valid questions. For now, it appears that the spin on the NYTimes article agrees with my personal opinions – we need more primary care!

Hawaii’s system is not without problems. A number of the hospitals, especially on the outer islands, are failing. The rate of uninsured is increasing due to the current economy and the system is not built to handle the uninsured right now – it is a system built to handle almost 100% insured. It is interesting to wonder if the resources and the finances will be able to withstand what is to come. Also this whole “greased lightning” thing… I can’t see it. Maybe an entirely decompressed healthcare system works. I just don’t know.

Puppy Update!!

My parents are still gladly suffering through "ridgeback puppyhood" with Deka, who is now 8 months old! Rob and I went over for some sukiyaki the other night (and some furrball time).

Sukiyaki = the best food EVER. Japanese mish-mosh of yumminess.


Back to the nonexistent point... I was really impreesed with how Dek is doing! She is obeying commands and actually didn't eat a single scrap off of hte knee-height coffee table! The whole point is to just share some pics to the pets! =).

Sashi looking regal as ever :) (and begging for food)

The not-so-small-anymore baby looking somwhat sad at having to be good.

Felix finally figured out a way to hide and still be pet --
the pup can't see him, but we can!

Oscar is more brave...venturing all the way out to the couch.

The Tale of A3

I've been working night for almost a week now. I like working nights -- I prefer the patient population and the structure (starts out busy, tapers off) and by about 2am, whoever is coming in is genuinely sick. That being said, there can be nights like last night (I slept!) or there can be nights like what is now being called "A3 night" among the residents.

I walked into shift. The ER was packed, the rack had 3 or 4 charts in it, the signout was clean (fortunately!) and I picked up the first chart -- 50 year old guy with syncope. groan.
(translation of above for my non-medical friends: there were 3 or 4 patients to be seen, signout is patient handoff from one doc to another at the end of shift so that care continues and being "clean" means that there isn't much to do on the patients who are being transferred.)

Syncope (fainting) is the presenting complaint for 1-3% of annual ER visits nationwide. There are over 112 million ER visits per year according to the CDC, making syncope account for up to 3.3 million ER visist per year. As a comparison, "chest pain" accounts for approximately 6 million visits per year. So yeah, syncope is common. Of pateints complaining of syncope, only 34% get admitted to the hospital and, of those only about half actually get diagnosed with a cause for their syncope -- this doesn't take into account the patients who complain of syncope and then upon further questioning turn out to have had "near-syncope", aka- lightheadedness. I couldn't find a number for how many patients fall into that category, but I promise you it is a LOT.

Back to the "Tale of A3"... I'm looking at my guy, who is sitting up, awake, alert, telling me he feels kindof silly for being in the ER. I haven't laid hands on him yet-- we're still in the talking phase -- his monitor looks good, EKG normal, normal heart rate, normal blood pressure, normal oxygen content, but first thing I notice is, "wow, this guy's story sounds like he really did loose consciousness!" He doesn't have any medical problems, no medications, no allergies, no ciagaretts, no alcohol, no drugs, nada. I ask if he felt anything funny before passing out and he looks at me and says "You know doc, I'm kindof feeling it right now. A headrush thing..." aaaaand he's unconsicous. I look at the monitor and he is asystolic!!!! Heart NOT beating. Well fuck.

I call for help, sternal rub him to wake him up, I'm about to lay him out and start chest compressions when he wakes back up! He was out for about 5 seconds -- by the time the rest of the ER staff arrives they're looking at me like I'm crazy because his heart is beating and the patient is like, "I can't believe I passed out again!!" This episode made number 3 for the day.

He does it a fourth time about 20 minutes later, this time while the nurse is with me. Everyone sees that one. We need cardiology and we need them 5 minutes ago. I go directly to the top and page the SENIOR fellow (this is kindof ballsy for an intern) "ED STAT"... I didn't even leave a phone number. (later he told me he thought that the page was hillarious) But he appeared in about 2 minutes, so it had the desired effect.

Recap: I have a patient who is going periodically flatline on me, crash cart is OPEN at beside, code meds are already drawn up into syringes, the senior cards fellow has no clue what is causing this becuase the guy's EKG looks like it could be in a textbook under "normal," and the patient is looking at all of us like we're crazy 'cause he feels fine.

He can't be moved from the ER becuase what if he goes asystolic and this time doesn't spontaneously recover. It's too dangerous for him to be being wheeled down a hospital hallway when that happens. But he NEEDS to be in the cardiology intensive care unit.

The decision is made that we need to put in a pacemaker in the emergency room to take over triggering heartbeats when he heart pauses. It's simple -- we thread electrical wires through a vein in the patient's neck into their heart. However, before we can do that... the patient's heartrate starts to slow to the 20's. We're all thinking, "here he goes again!" Nope. This time, he has a seizure! (actually, "seizure-like activity"... medical technicality) and afterwards he is vomiting, confused and has zero short term memory. We went from conversing with and intelligent, cognizant guy to: "wha? who're you?" "I've been passing out? NO WAY! SERIOUSLY? duuuuude." "Why is my wife here?" "Wha? who're you?" ... repeat. He couldn't follow commands any more because he couldn't remember them and he was vomiting on top of that. The decision was made to intubate the patient to protect him from inhaling vomit in his confusion.

After that, things went much more smoothly. He had another episode of asystole while I was placing the pacemaker (I got to put in a transvenous pacemaker!!!! SO COOL!), but otherwise, things were ok. He went up to the Cardiac Internsive Care Unit where he got a multi-million dollar workup, a permanent pacemaker was surgically placed and he was discharged after 4 days -- the cardiologists still had no clue why his heart was stopping.

That was the first 4 hours of my shift. Cleanup takes an hour (the room looks like a hurricaine hit it). Next up in A3 was a ruptured ectopic pregnancy who got rushed to the Operating Room in about 20 minutes flat. We were able to diagnose her rapidly with a life-threatening condition and get her to help. Later, the Ob/Gyn came down and told us that she had over 3 liters of blood in her belly and they were able to successfully stop the hemorrhage. Yowzer.

Clean the room again (antoher hour becuase it looks like another hurricaine hit it after the ecotpic -- running around to get IVs, blood, fluids, ultraosound, yada yada.) and a little old lady comes in. Another syncope. Moderate language barrier and no one around who speaks Mandarin, so the story is fuzzy, but it sounds like she's having seizures. However, she's sitting in bed looking all cute and normal. Ok, chill out, we'll get Neurology. Neuro's evaluation gets interrupted becuase a stroke rolls in, whatever, she's fine.

All the docs are chilling back in the doctor's room, we're tired, it's been crazy, things are finally settled, the stroke is in the MRI and it's 6am. The overhead comes, "doctor needed in A3." again!?!?! Yep, little old chinese lady is having a seizure. Well, at least that's confirmed. She's gonna be admitted to Neurology. However, her seizure isn't breaking despite medications. Takes about 20 minutes, but we finally get the seizure to break and once again, the room looks like a tornado hit it. The nurse is begging us not to put any more patients in her room and just let her finish the last hour of her shift in peace!

Fortunately, that is exactly what happened. =)

I leave in the morning, sun is up, it's a hot August day and I look around -- it's weird to be outside. Every once in a while we get a gift. A reminder of why we spend our days and nights inside with beeping machines, no windows, drunks, crazies, the smattering of rediculous complains, disgruntled people and admitting residents who resent that you are making more work for them. The story above is why. This is what I do. And this is why I do it. Damn straight.

Rachmoninov

So, friends both new and old have begun calling, E-mailing and texting to find out if I am still alive! I am -- no fears. However, I am currently working in the Medical Intensive Care Unit, which is occupying more than a significant portion of my life.

I was originally going to talk about my experiences there over the past few weeks -- especially last night when I was on 24-hour call. I shocked my first cardiac arrest (and brought him back!), watched the 3rd year medicine resident perform a procedure that currently takes me about 20 minutes in about 30 seconds flat in a crash situation... and much more. Crazy, amazing 24 hours of my life.

However, sitting here in my living room listening to Rachmoninov's 2nd Piano Concerto on my formidable and kickass stereo system, I realized that I have talked about many things on this blog, but am yet to mention a final HUGE aspect of my life -- music.

I grew up in a home where we didn't leave the TV on -- we left the CDs playing. Continuously. Beethoven would be blasting on the first floor, Mahler on the second and some version of whatever was popular at the time on the third (my room). Every day when I came home from school I had to do my homework (like every kid), clean my room (never did that) and practice both Flute and Piano. At my peak in high school, I was playing the flute at least 6 hours a day between rehearsals and practicing. Without enough time to practice at home, I would practice at school during lunch and my other free periods. I was in literally every musical group in my high school (except for Jazz Band) -- and there were quite a few! I also spent a full 10 years from the age of 12 to 22 first in local youth orchestras and then in the non-music-major orchestra during college.

Music brought me to lifelong friends, took me all over Europe, brought me skill and accomplishment -- brought me solace.

Medical School threatened to kill all that.

During the first months of medical school I left music. I thought I needed to focus -- work harder than ever. After a few months of wondering why I hated my life so much I called my parents -- could we get my keyboard from Grandma's in Florida? Something in my voice must have told them I was in dire straights. Without hesitation or questionning I had the keyboard in my dorm room within a week. My mood improved immensely with playing. I had learned something valuable -- music wasn't something I did. It was my sanity.

I resumed flute lessons with my long-time teacher of now over a decade -- Mr. Jones. Maybe even more so than the playing, Mr. Jones became a rock for me during medical school and now during residency. Having no connections to the medical world, I could go to him every weekly and vent my frustrations (a lot of "look what medicine DID to me this week!") and he would be outraged, threated to lock me in my apartment when I needed to study more and generally kick my butt my drilling the music for a hour so I couldn't think of my frustrations.

Now I practice on my off days (which are rare), struggle to go to the Philharmonic as much as possible and usually listen to my iPod in the hospital in the morning while reviewing the computer for overnight events on my patients. It is not the satisfaction I used to get from playing an orchestra, but it is a compromise for now.

Enjoying NYC

Announcement: I have *officially* completed my first month of residency!! (only 46 more to go, as my Residency Director likes to point out...).

Over the past month I have done some cool stuff (I pushed tPA on a patient!! my med peeps will know what that means. It was very anticlimactic, but cool nevertheless). I have had lots of lectures and educational time as the program eases us into reality. I have made mistakes but fortunately haven't harmed anyone. One huge thing is that I have been talked to a LOT about how HARD intern year is and how important it is that I make the most of my free time.

Being that I am more than a bit of a homebody, this could present a problem. When I am busy and working hard, I am much more inclined to just drop dead at home when I have a day off. My seniors and attendings, however, are telling me that such behavior will lead to a never-ending spiral that ends in hating life. Or something along those lines.

So, I decided to start out strong and have been really enjoying myself during my free days (of which I have had 4.) and Rob has been a tremendous help in working towards this goal.

First off, there 4th of July, when I showed for a shift I wasn't supposed to be working. My salvage: a day on a beach in the Hamptons with Ted (Rob's old roommate) and his family and, ofcourse, Rob. I even took the midnight train back to NYC and had that song "Just a small town girl, livin' in the lonely world... took the midnight train going aaaany-where..." stuck in my head for the two hour ride back. The day was, in a word, fabulous.

Then there was last Sunday, when I hung out with friends on Saturday night at a wine tasting, slept until 11:30, went to fancy-schmantzy brunch at Sarabeth's with friends, discovered that Rob and I in a Barnes and Noble is a recipie for spending WAY too much money and then ended up down at Battery Park looking out at NY Harbor and reading for the afternoon.

This weekend I actually had BOTH days off (amazing!) and I've met new people, gone to brunch x2, took Sashi and Deka to the park, spent the day at Coney Island and am now in the process of cooking some genuine russian dumplings from Brighton Beach. Again, so great!

I think I need to keep this up. (Here's hoping I can!)

Back into puppyness...

It's been a while since I wrote about the antics of my parents' new puppy, Deka. She is now 5 months old and is just barely starting to show some signs of calming down... sometimes.

My mother recently convinced me to go with her to Deka's dog training class. The puppy decided to buck and whine every time another dog was getting attention that she wasn't. She sits like an angel (my mother had taught her that when she was 10 weeks old). The "no jumping" training was a complete and utter failure. The best, however, was the "come" training.

For this exercise, the trainer stands on one end of the room attempting to hold the dog (usually an easy job... until you separate Deka from my mother, and then you have a bucking, whining, crazed 60lbs of muscle) and the owner stands at the other. When the dog is released, the owner calls the dog and tries to get the dog to come to them. The other dogs looked like this...

Deka, however, looked like this...(That's Deka a few weeks ago at the doggy park.)

She went careening across the room at a FULL SPRINT, crashed into my mother at full tilt, bounced off, shook herself off, spun around a few times and promptly sat to receive her treats. Not only that, but she did it three times! The whole thing was hillarious, but I think the funniest part was the absolutley careening into my mother each time rather than stopping BEFORE knocking her owner over.

I'll leave you with a few more Deka at the doggy park shots.

Yeah, this last one is Deka sniffing the butt of a Great Dane. So funny.

What makes a Trauma Center?

Numerous recent conversations with friends of mine have brought me to seek an answer to the question, "What makes a trauma center?" I run into this all the time because Columbia is a Level II Trauma center while Cornell is a Level I Trauma center. What do these different designations mean?

The concept of the "trauma center" began in the 1960's in either Baltimore, MD (Ever heard of the hospital called the Shock Trauma Center? yeah.) or Chicago, IL (Cook County, the hospital that the TV Show ER is about). These are facilities who are equipped to handle any form of trauma care or complication 24 hours a day without delay in care.

What do the levels mean?

Level I: 24-hour in-house trauma surgeons and anesthesiologists as well as rapidly available (at Cornell, that means <10 onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://www.myds.com.au/img/game/Trauma-Center--Under-the-Knife-1.jpg">es. In addition, Level I's must be conducting active scientific research into trauma care, be involved in trauma education (ie- have a trauma fellowship) and be able to and willing to act as a referral center for neighboring regions. You might be thinking this is extremely expensive. It's even more expensive than you are imagining, I promise you.

Level II: must have 24-hour availability of all the required specialties, but they do NOT have to have training programs in all the specialties. In addition, they are not required to be conducting ongoing research into trauma care.

Level III: does not have 24-hour access to all the required specialties. However, they DO have the facilities required for emergency management, critical care and general surgery for simple trauma patients. These are generally smaller community hospitals without all the specialties that may be required, such as neurosurgery or hand surgery.

Level IV: Their job is to asses, stabilize, and transfer to a higher level center. So, Columbia is a huge hospital with residencies in everything under the sun, so why is it level II? There are a number of resons. First, no super passionate trauma surgeon. Second, the ER is literally in a DIFFERENT BUILDING from the rest of the hospital. Little bit of logistical stupidity. It is just too far from the ER to transfer an unstable, hemmorrhaging trauma patient to the operating room. (lots of famous trauma centers, like Shock Trauma, have a Trauma operating room literally adjacent to the Emergency Room. The patient is moved about 20 feet to get into the OR). Third, lack of trauma research. Fourth, lack of a full cohort of trauma-specialized staff.

That is all going to change. Dr. Maruzio Miglietta is a recent addition to the Columbia Presbyterian surgical staff. He is a trauma surgeon who has trained at every big name in Trauma that exists. The guy's resume is mind-blowing. He is dedicated to increasing the level to Trauma care at Columbia by first building staff and then getting the funds to remedy the physical and logistical issues that prevent Columbia from becoming Level I. His vision for Columbia will require increased staff, development of a Trauma fellowship, resesarch (which he is already conducting) and construction to change the layout of the ER to make it more trauma-friendly. The construction is already planned -- the Columbia ER is embarking on a renovation project that will renew the facilities from top to bottom.

I, for one, am very excited about this prospect. Columbia is in a high-trauma neighborhood of New York City and yet, we don't see many traumas due to our Level II status. A recent fire on the Columbia hospital campus sent three injured trauma patients to Harlem Hospital!! How embarassing. Hopefully, under Dr. Miglietta's direction, all that will change.

Tale of the missing patient...

Rob is encouraging me to collect "Tales from the ER"... and felt that this one deserved to be told.

Recently, I had a lost patient. Columbia's ER, while one of the largest in NYC (second or third) is really not that big when it comes down to it. Four rectangular patient areas connected in a line with short hallways in-between.

I sent the patient to ER x-ray expecting him to be back in about 15 minutes. His admitting doctors show up and, no patient! I direct them to x-ray. No patient. Radiology claimed they had sent him back. His wife was standing at my area's nurses' station without her husband.

Radiology didn't have him (the patient was stretcher-bound). In fact, his stretcher was still in x-ray with no patient on it. Multiple loops through every area of the ER did not reveal my missing patient. Overhead announcing his name and asking him to return yielded nothing. The surgery residents admitting him were extremely kind in trying to help my search, however they had no idea what the patient looked like! It is triply hard to find a patient in an ER if you don't know what they look like without walking patient to patient and taking names. As a result I was running around the ER with a team of surgeons trailing after me for an hour.

It should be pointed out here that (said in a snooty voice), "doctors don't run." However, we do walk damn fast.

The search expanded into the main hospital hallways around the ER. Maybe my stretcher-bound patient had wandered out... somehow. Security was notified and everyone was radioed the patients description (he looked like 90% of the patients at Columbia).

Finally, when me and my entourage made our fifth run through the ER, the patient is miraculously sitting in his assigned slot, in a wheelchair, looking definitely worse for the wear. Where had he been? CT on the 6th floor of the main hospital! Someone had taken the wrong patient from x-ray OUT of the ER and across the street and up to the 6th floor. Who takes an emergency room patient out of the emergency room!?!?! (point #2: the ER has it's own CT scanner INSIDE the ER. There is no need to patients to go to main CT in the hospital.)

The lesson for budding young doctors out there? Tell your patient the plan! I had told my patient, in detail: "You're going to x-ray. When you come back, you are going to drink contrast liquid. 2 hours after that, you are going to get at CT scan." If I hadn't, he wouldn't have put up such a fight in the main hospital CT (apparently, he caused a bit of a scene). The patient himself knew that he was lost and got himself returned to the ER. I just ran (read: walked briskly) around like a chicken without a head trailing a team of Transplant surgeons.

Intubation workshop

I knew there was a reason I wanted to come to this program. They held an intubation workshop for the interns (formal advanced airway training is during second year, but they want us to at least have a clue). We walked into the room and rather than intubation supplies, the first thing we saw were splinting supplies.

(To catch my non-medical colleagues up, to intubate someone is to put a tube down their throat so that you can hook them up to a breathing machine. It is a definitive airway for patients who can't breathe on their own. No breathing = no life, so, it's important. Splinting is applying a strip of plaster cast to stabilize a part of the body and then wrapping in an ACE bandage.)

What the hell does applying a cast have to do with intubating a patient?
The pictures below illustrate what happens if you move your wrist to rock the blade back and forth... you knock out your patient's front teeth. Yet that doesn't stop most young doctors because the more natural thing to do when you can't see is to rock your wrist. BAD. You're supposed to pull UP towards the far corner of the ceiling as in the second picture.













So, how did we look while trying to do this?

Yeah EM interns!... No opportunity for wrist movement this way. (I am totally the shortest person in my class by far... Joyce, Edozie, Debbie, me, Rishi).

The thing is, this is BRILLIANT! I have been to many intubation workshops before. During Anesthesia as a third year medical student, Emergency Medicine three times (one on each rotation) as a fourth year medical student, ACLS this year, and yet I NEVER GOT IT RIGHT. This time it was easy as pie. Two seconds and I had a perfect view (you have to view the vocal cords and watch the tube pass between them, otherwise you're just going to end up ventilating the patient's esophagus, which lies right behind the airway) and in another 2 seconds, I had an airway. 5 previous intubation classes and all anyone had to do was put a cast on my wrist. So impressive.

First Shift

So, I had my first shift as an "offical" ER doctor last night. Let's just say, if I wasn't used to people calling me "Dr. Hamburg" before, I am now! However, I still feel like a total fraud. Walking into the busy ER at noon to start my 12 hours, I made the conscious decision to go slow, be thorough and not make mistakes. It didn't matter how full the rack of patients to be seen got, I wasn't going to let it pressure me.

Fortunately for me, it was a relatively calm day for Columbia Presbyterian (meaning that, instead of patients lining every inch of space inside the curtains and stretchers end to end along every single wall and solid structure, there were two patients to a curtain and stretchers occupying every other hallway space).

My "welcome to a new world" wake-up call came about 5 minutes into my shift after I had seen my first patient. I wanted to order Morphine to help her with her pain, but I know that I'm not allowed to prescribe medications... or so I thought. I asked my attending to sign off on my Morphine order and he said, "You're a doctor now. This is the LAST order I will ever sign for you." whoa. (Turns out that in the ER, I am writing med orders under the auspices of the hospital and therefore am allowed to prescribe medications.)

I made it through the shift without too much stress, managed to see 4 patients (I was reassured that this was normal for a first shift), got mistaken for a nurse about a hundred times (the ER was literally 79 degrees and therefore the white coat got ditched in about 30 seconds), learned the names of 4 nurses and one unit clerk (I feel that is an accomplishment), managed one barely stable patient who continuously threatened to tank on me (just to keep the adrenaline level up), signed about 100 orders "Dr. Hamburg" and prescribed narcotics to my pain patient like nobody's business all the while desperately trying to not chew my nails with nervousness that I would overdose her.

Damn I love my job.

Chicago Urban Health Initiative

Do you know what has been happening at the University of Chicago ER? No? Time you found out about the University of Chicago Urban Health Initiative (UHI).

Originally designed in 2005 as a community outreach program created to educate the South Side community about what healthcare options were available to them and how to decide when/when not to go to the Emergency Department. By the end of 2008, U of C still had the longest wait times in the country and the highest percentage of patients who left without being seen (something considered very bad in the emergency med world).

Surveys conducted at the U of C estimated that 40% of its 80,000 annual ER visits were non-emergent and did not require the services of the emergency department. When the economy really decided to tank, U of C decided to “up the ante,” so to speak. They announced that they were changing their method of triage by putting MDs in the triage area to asses need for emergency room resources. Those patients deemed non-emergent would be sent to a network of “20 community health centers and more than 60 UCMC doctors” as well as 2 participating local community hospitals for care. (hmmm… 30,000 patients… 60 physicians. That math does NOT work). The medical community swallowed this lump with difficulty and something doctors love to do called “watchful waiting.”

In February of 2009, on the heels of the above announcement, the University of Chicago hospital announced it was going to be firing 5% of its staff AND cutting down Emergency Room resources, mostly in terms of decreased numbers of inpatient beds available to the Emergency department. This coming from the hospital with one of the highest frequencies of ER boarding times up to 72 hours! Both the Chairman of Medicine and the Chairman of Emergency Medicine resigned to protest this announcement, causing BIG headlines. This was when I first learned about what was going on in Chicago. The protests worked. The hospital still fired staff, but they did not cut emergency room resources. As a result of the media attention, the UHI has come under severe scrutiny.

Has anyone died from these changes in routing strategies? No. Are the clinics complaining or the other hospitals involved protesting? No. The media drudged up one story of a 12-year-old boy who was bitten on the face by a pit bull and was sent to Cook County for surgery from the U of C ER… Of course, if you look at the date of the incident, it occurred before UHI became more strict and before the Feb ’09 announcement. In many ways, that makes the story of the boy worse (he’s fine, by the way), but not the fault of UHI.

The American College of Emergency Physicians (ACEP) rapidly came up with a statement condemning UHI’s policy of turning away non-emergency patients, stating that it was “dangerously close” to violating the Emergency Medical Labor and Treatment Act (EMTALA) of 1986 which states that all hospitals receiving government assistance (everyone) are required to provide treatment for all individuals seeing emergency medical care, regardless of insurance or immigration status. HOWEVER, it IS legal to transfer a patient from one emergency room to a clinic, another hospital or a government-run system. This clause was originally intended for transfer to better care (eg- a hospital without a cath lab can transfer a patient having a heart attack to a hospital with the ability to perform cardiac catheterization and open the blocked vessel). U of C is using a broader definition. This month, Representative Bobby Rush is calling upon congress to conduct an investigation into the UHI, specifically to determine if the Emergency Department is “patient dumping” under the auspices of the UHI – a practice specifically forbidden by EMTALA.

Emergency physicians I have talked to fall mostly on the side of disagreeing with UHI, but not for the reason you might expect. There is a fabulous editorial on the ACEP website by Dr. David F. Baehren (takes a while to load) that really illustrates the difficult position emergency physicians are currently in. On the one hand, our specialty was developed to treat the critically ill or injured. To provide life-saving treatment immediately without consideration to cost, insurance status, nationality, social status or anything else. What we have become is the one and only safety net for a broken medical system – a net that is stretched to breaking point. The actions at the University of Chicago may be the first rope in the safety net breaking. We, the emergency physicians, need help. Time for the other medical professions to step up and save us.

I essentially see the U of C’s UHI and an attempt to build a primary care network in South Side Chicago. I believe that such a network – a cooperative relationship where primary care physicians and clinics support our nation’s emergency rooms by increasing in number, making their presence known and encouraging appropriate utilization of medical resources can make a huge difference in our nation's healthcare. A strong network, where the Emergency Room physician can say “this stubbed toe can be treated by your clinic, I’ve called them and they will see you at 2pm.” And the clinic can say “Your shortness of breath is very concerning, We’ve called the Emergency Room and they have a bed for you and are sending an ambulance to get you.” Is what we NEED! Emergency physicians I have talked to about UHI are concerned about it because they worry that the network is too weak (only 38% of patients referred out end up going to 2 or more clinic visits). They worry about patients slipping through the cracks and about someone making a mistake.

As much as we suffer being the nation’s medical “safety net,” emergency physicians also take a certain amount of pride in our role as the dutch boy with his finger in the dam. There is fear that the changes taking place at the University of Chicago could become widespread in the wrong ways and thus leave the poor and uninsured without anywhere to receive treatment. This is a bastardization of the goals of UHI. Nevertheless, it is a valid concern that needs to be closely monitored.