Great case at St.D's! The PA brought back this EKG on a guy who had come in with abdominal pain, probably mid to late sixties. Because it was abdominal pain he was a lower priority EKG and it had taken an hour to get it. Son of a gun, but he had tall broad ST segments in the inferior leads and reciprocal changed in V1 and V2. Acute inferior MI! I put in for Cath lab and as I'm waiting to hear from them this woman calls out "Help--there's something wrong with my husband!" I run over. New patient. Laying in the gurney, eyes open, teth bared, clenched hands held up towards his neck and a stricken look on his purpling face. Monitor? Coarse V-fib! Holy shit--he must have just dropped out! I yell "Code in C!" and I go for the pre-cordial thump. I haul back and punch the guy as hard as I can. In the text books they have images of a very dignified fellow in a white coat thumping his palm on the patient's chest, but I can't believe that technique gets any sort of discharge so I go with a clenched fist hammered into the sternum. Except I missed and punched this poor guy right in his gut. Shit, I reloaded and fired again and this time nailed him right on target--2 centimeters bove the Xiphoid process, mid sternum. The team arrives, the wife flees the room, and I yell "Paddles first! Paddles first!" I start doing CPR. Our top gun nurse is on and we are a smooth team. The pads go on the chest and we defibrilate. Nothing. More CPR while the machine charges and we fire again. Got him--QRS's on the monitor and in seconds he's awake and fighting us. Minutes later he's relxed and I'm chatting with the family. Then off to cath lab. Good, good, God damn Emergency Medicine! U-561

Today I was better. I felt good and on top of the patients. I still hit the ER Call doc pretty hard but a) they were legit, b) I went out of my way to spare him whenever possible and c) he takes call 4 out of every 7 days--he's going to get a lot of pain in his life. I don't know if he has an alimony or a girlfriend or an ego to pay tribute to, but something is flogging this guy. Regardless, I had some interesting cases: a knee cellulitis, a pair of interesting overdoses (one recreational, one suicidal) a surprise 8mm renal stone, a respiratory failure. Not too hard. I got put a half hour early and got home to the Biscuit on time. Prior to me leaving, however, we had a plane crash. Yes--an airplane crash. Really. Local airport, 11 o'clock at night, a little private plane crashed and we got a pair of burns. One was a horrible burn--young girl who is in desperate straits. I was off and the night guy was handling it. Even so, I was around and had to force myself not to interfere with his management. I would have done it differently. It's odd and, also, nice to find myself thinking not, "Thank God he's on....", but "I could be doing this better..." It's good to be confident. U-561

Last night I definitely did not have my A-game. I was mediocre. Lot's of patients with unclear dispos and a sense of flailing about. Fortunately, nobody was too sick and nothing untoward happened. We had an odd case a few days ago--a kid got a barbeque fork through the elbow. I yanked it out (after suitable pre-amblle and preparation) and billed for foreign body removal. I also gave a little talk about EM to a group of high school kids. One of those summer camps that caters to the dreams of aspiring professionals and their deep-pocketed parents. I may have overdone it a liittle, but the kids loved it. This year it was pro-bono work, but I think I made a sufficiently strong impression that next year I can make a case for being paid for my services next year. I've got an animal work coming up--miserable 7 shifts in the next eight days. U-561

Mercifully I've had a long stretch off. I'm sure I have a pneumonia--I haven't been that sick in a long time. Still recovering--I can make it through the day without collapsing, but walking uphill leaves me gasping for breath. Apparently I'm getting old. Today the U.S. got whallopped in the World Cup. Really poor play. Dismaying. U-561

Bizzarely I am writing from work. It's 0330 and the place is dead. I've seen five or six patients, but none in the last two hours. A unique experience. Quite pleasant. The staff fell into a conversation about child abuse and molestation--one of our nurses works with the victims. I checked Megan's law for abusers near my house and the list is long enough to be disturbing. Though I guess having even one name on the list is disturbing enough. Hopefully we won't get a early morning rush. U-561

Had a good shift. Coming off the shift before I home and got to bed at 9 am and laid in bed worrying I wouldn't be able to sleep. I knew I needed to be up by 4 to make it to St.D's for my night shift so I decided on the following: if I was still laying in bed awake at 10am I'd take fifty of benadryl and a couple of ounces of Maker's Mark and just put myself down for the count. Fortunately the last thing I remember seeing on the clock was 9:49...and then I was out. Unfortunately, the next thing I saw was 1:13. Some Jehova's Witnesses the Biscuit had befriended (Woe unto them!) came knocking on the door. I was awake and when I laid back in bed I realized that it was gone--that precious window of opportunity has passed and I would not sleep again. Twelve hour night shift, Saturday, St.D ghetto, and I was going to has three and half hours of sleep. I braced myself for the pain to come. It began horribly--Willie G. was on the day shift signing out to me. This lazy sack of crap is one of the old guard at St.D's who bankrupted the ED, demoralized the entire department, drove the hourly to $100 an hour and basically drove the F'ing car off the cliff. I hate coming on after him because there is always a load of patients waiting to be seen that he somehow just hasn't been able to get to. Lazy shit! He makes me fucking sick! How he can have the balls to speak to me after he pulls one of his little fairy princess disappearing acts I can not fathom. The only answer is that he has no honor. He's one of those vile little people who have no pride and no integrity and who worm their way through life with shit eating smiles and greasy little hands and a thousand excuses for every occasion. When I come on to relieve Bearie the patients are seen, the dispos are in and the rack is clear: Bearie owns his ED and he takes care of his shit. Which is why I admire Bearie and why I wouldn't cross the road to piss on Willie G if he were on fire. So, I saw seven patients in my first hour and was only one patient behind by 7pm. The resident who was on (Yes, the G had a 3RD YEAR ER RESIDENT WORKING WITH HIM--2 ER DOCS IN THE THE 14 BED ED!!--AND HE STILL LEFT SIX OF THE 12 FILLED BEDS FOR ME TO SEE!!!) didn't do shit for that hour. It's not her fault--I got to know her when the G finally left and she's strong, hard working, competent. She worked hard for me. With Willie she got sucked down into his sick little world of hateful inadequacy and probably wasted an hour of patiwent care time learning about how to differentiate Hemophilia A from Hemohilia B using only a sheet of newspaper, a tallow candle stub, and a common pocket knife. He's a cancer. Then, bizarrely, a good friend from residency called because he knew I was on and he was bringing in his relative with a psychotic break. She got the cadillac treatment and I'm pretty happy with the care I gave and got for her. Psych issues are so delicate and so delicate. And right at 5am (11 hours deep in the shift) we got a full arrest. Guy got up to go to the bathroom and just dropped dead in front of his wife. Medics brought him in and I'll be damned if we didn't get a pulse, a perfusing pressure, and a pulse ox of 100%. Pulled his pH back to 7.16.....and I think we were headed towards even better. His BP was just hanging on when I left at 7--he was in the 80's on max'd Dopa and a little Levophed--but I felt I had managed him pretty well. Bed soon. One night shift to go and the Biscuit gets home tonight. U-561.

Somehow I picked up some bug in Hawaii. God willing it's not Avain Flu. It's nothing serious, but I'm coming into a three day run of night shifts and that is a grim grim prospect. Last night I went in for my evening shift at the Valley. I felt bad. My hope was for a quiet night and on a Thursday there was a chance, albeit slim, of having one a quiet night. Mercifully, I did have a good night. Part of this was the slow pace (until 8pm when it got ugly, but by then the shift was almost over) and part of it was that I had a decent resident. I had in the back of my mind the fear that we'd get a code; it's the sort of situation where you want to be at your best and I knew I wasn't. We did, of course, get a code. A guy went down and the medics were called. Typical FUBAR bullshit where the time on scene goes on and on and on and brain and heart slowly dies. He got to us with the tube in and a wide complex slow rhythm but no pulses. We pile it on. He has an internal defibrillator which periodically fires--this is incredibly unnerving the first time it happens. We're doing compressions, runnign through ACLS and suddenly the guy jerks off the gurney, his hand sweeps up and grabs a nurse and the guy on his chest screams like a girl and falls off his stool. We push it to the point of futility. The family arrives. I send the nurse to see if they want to witness the resuscitation. This is the new little fad in Emergency Medicine--very au courant and forward thinking. It promotoes "closure" and "helps the grieving process" and "de-mystifies the medical process" and "decreases the barrier between physician and patient" etc. Only the surgeons have the courage to openly oppose it on the grounds that it is bad for the patient. That argument is, I firmly believe, true--and this "family presence" movement is all part of the trend of serving the family and not the patient. A wise trend--families sue, call administrators, complain to their friends, and as a rule dead men don't--but a shitty way for medicine to be practiced. That argument aside--and Oh, I wish organized Emergency Medicine had the confidence and courgae of the surgeons to enter the debate in a meaningful way--this guy was dead and with that reality established, a llittle theatrics may help with the grieving process and obtaining closure, etc. The poor little wife is wheeled in with some friends. We do CPR, push meds, check pulses and I, for one, am acutely aware of the sensation of playing at being a TV doc. I do the ultrasound of the static heart routine, call it, express my condolensces (sp?) and ask the nurse to call me if the family has any questions. Rest of the night passes without too much pain. I get some good sleep and I think I'll be allright for the night shifts. U-561