I was back at St. D's and the signal event of the day was a medicine hack coming down to tell me about the guy I gave TPA to. He bled horribly into his brain. Argghhhh! Of course I found myself second guessing my decision and worrying over the medico-legal issues. Even though I think it was the only right thing to do, and even though I'm certain it fits the decribed standard of care, its demoralizing as hell to have a bad outcome. As for a lawsuit--what can be done? This meat head medcine doc was ;ecturing me on not giving TPA. Her reasoning was spurious, unsupported by the literature, and basically rooted in fear. But nevertheless she felt quite comfortable telling em to never give TPA again--not without a neurologist and a neurosurgeon on staff. What neurologists and neurosurgeons have to do with the desperate 3 hour window of action is unclear. She just wanted to have someone else on hand to tell her what to do--she's lost without her consults. I didn't punch her in the nose for her unwanted advice, but I certainly considered it. U-561

Last night I was at St.D's and had a close call. We had a young quadraplegic who came in with shortness of breath. He looked okay, but his chest XRay was terrible: total whiteout of the left hemithorax. We discussed intubation, but I pussy-footed around aand never really pushed it. He looked good and was doing fine on oxygen. But he was trending down. Not dramatically, but just incrementally his pulse ox dropped from the high nineties to the mid nineties to the low nineties and then he was at 88 and I had let myself get behind the curve on him. Still I wasn't too worried--we got ready to tube him. Then I considered his airway a little more closely: post trach, kind of an odd shaped jaw, etc. The PA asked if she could try the tube and I let her, but with misgivings. Things went badly right from the start. The PA was flailing from the start, the guys's pulse ox plummted to seventy within a dozen seconds, and then as we bagged him it dropped into the sixties. I went in and it was an absolute mess in this guy's oropharynx. No landmarks at all, just mucus, tissue, and odd dark shadows and crevices. I make a half hearted attempt, fail, and bail out to try again at bagging. Pulse ox in the thirties, dropping, and the guys getting bradycardic. We give atropine, and the RT askes if he can give it a shot. I assent and he muscles the tube down and in--it required some real force. At last we're saved. The pulse ox is up in the nineties ten second later and I'm off the hook. But, oh!, it was close. Hubris. U-561

At about 9:40 last night we had a guy come in with a stroke. He was young (64), in decent health, and had an absolute certain time of the event occuring: 9 o'clock on the dot. 9 o'clock when he said "Urgk!" and collapsed to the ground with loss of speech and total flacidity of his right and leg. In one way, it is the stroke presentation that I always fear and hope to avoid. All the factors he pressented with--exact recent time of event, good health prior to event, youth, and a sudden life destroying loss of speech and motor function--make him a good candidate for TPA. Which, in turn, puts me on the horns of a dilemma. Because TPA has the potential to reverse the effects of the stroke, but it also has the potential to cause bleeding--and while I can handle bleeding in the gut, I can not handle bleeding in the cerebrum. The risk is compounded by the fact that in the event of a good outcome (approx 12% chance) no one says a word, but in the event of a bad outcome (6% chance) some jackhole malpractice lawyer had 18 months to cull through all the possibly available medical history to find a single possible contra-indication that should have been ppicked up on by me in the rapidly closing 3 hour window of opportunity. I start the process by ordering a STAT CT Head (and calling the CT tech to make sure she gets the F'ing message) and starting the talk with the fiancee about TPA. Then I call the radiologist--except I don't because no one at NightHawk radiology is picking up the phone. Then I try to call this guy's PMD. Because it's a Saturday night at, now, 10:20 I get the entirely uninterested in being helpful on-call guy who, frankly, is not just useless but also a prick. A do a little more fruitless phone calling while I check the XRay (unreadable) and re-assess for any change in his neurologic function (none.) Eventually I get in touch with the guys kids. A son and daughter who live thousands of miles away. Well, does a pair of kids trump a 5 year fiancee in life and death proxy decision making? I agonize over this for a few minutes before the daughter announces that she has the durable power of attorney. Asking her to fax it to me seems a bit extreme, and to be honest I'm glad to have an unambiguous answer to what might have been a stick legal/ethical issue. The two kids really grill me about TPA, but they are obviously understanding the gravity of the situation and all their questions are very apt. All this time I'm wondering when, if ever, I'll get my CT report. The odds are against me because I happen to be waiting for another patient's CT that has taken the better part of 4 hours to be read. But all of a sudden the report come in and it is negative for bleed. Okay, I check the clock--11:40--and tell the kids I need a go-or-no-go directive. They say go, and I tell the nurse to draw up the TPA. We need 75 mg and in the ED MedSelect we have 2mg--enough for a embolic stroke in a 29 week preemie. Great. Pharmacy is called, a resident is dispatched, and at 11:58 we start the TPA bolus. So, we made the 3 hour deadline. I watch anxiously as the TPA runs in and really, theres nothing more boring than watching IV fluid run--even if there is the chance of a horrible intrecranial bleed in the cards. After an hour I am so relieved to be able to document that nothing has happened. Yes, yes, it would be nice to be able to say that I had helped this poor guy, but it is no exageration to say that my ability to pay the mortgage and feed my family may well depend on whether this guy bleeds. Malpractice is all about outcomes, not practices. I call his daughter to report the mixed news and then I go on with my night. Much ado about nothing it appears: the statistics show that if 12% of the time you get a good outcome, and 5% of the time you get a bad outcome, then over 80% of the time nothing really interesting happens. Because of the bad risk profile of TPA (1 in 20 bad outcome, limited time within which to act/gather information, etc.) a lot of ER docs just refuse to give it. Most of us look for excuses not to give it; I know I do. Part of it is the whole Primum Non Nocere thing--but that precept is often just a fig-leaf for moral cowardice. And, you carry higher medico-legal risk for acting than you do for finding an excuse not to act. My basic feeling is its a difficult, uncomfortable, risky thing to do--but that's the job I've chosen. Someone has to accept the risk, and every now and again it's going to be me. It's just shitty that that's how our malpractice system works. So, the punch line is that about 2 hours after the TPA the guy said "Yeah....", then "No." and, a little later he looked at the nurse angrily and said "Look!" So maybe we did a little good. In any event the nurse was relatively young and did a great job with this difficult case. Very good. U-561

Today at the Valley we had an internal disaster...which sounds awfully dramatic and, in this case, was. The power had gone out sometime in the morning and the back up generators had kicked in. But they weren't able to get the power back on and since the back up generators could go out and leave us with nothing (well, dim emergency lighting but nothing else) we couldn't operate as a real hospital. That meant no surgery and that meant closed for all ambulances and a sign on the ER door explaining: We are experiencing a major internal disaster.....yada-yada-yada....consider going elsewhere. The actual experience wasn't too bad--low patient volumes and a relaxed pace. Unfortunately the lab must have been thrown into total chaos because they reached new heights of impenetrable disorganization. Blood being lost two or three times (per patient!) and multi-hour long delays. Very anxiety provoking. Still, got out on time. U-561

Kind of a demoralizing day in the ER. Well, a demoralizing case. 24 year old guy comes in with some swelling on the right side of his neck. He saw a Fam Med doc about it 2 weeks ago and was told to go get a CT scan. Well, since he doesn't have any insurance this was not the most helpful advice. Predictably he did not get the CT scan and ended up coming in to the ER when things didn't get bettter. I have to admit, the neck did not look good. Obviously fuller on one side, and with multiple prominent palpable lumps that I could only assume were lymph nodes. I did some basic lab work, plus thyroid function tests, and ordered a CT of the neck with contrast. About an hour later the CT tech called to ask if I wanted him to go into the chest as well, because whatever the hell was growing in the guy's neck was extending into his mediasteinum, and thirty minutes after that the radiologist called me with bad news. This was probably Hodgkins lymphoma. Cancer. I gave him the news and he took it so well and so philosophically that I suspected he wasn't getting the whole picture. Still, I used the words cancer and chemotherapy so I felt comfortable I hadn't sugar coated it for him. His main concern was whether there were going to be any needles or scalpels in his neck ("Because i can't handle that, man!" said the guy with six square feet of tatoos on his body) and whether he could still work during the chemo. I called Family Medicine to see about the admission. Technically he wasn't really their responsibility, but a) their guy had seen him 2 weeks ago and failed to make the diagnosis and so there was some ass covering to be done and b) for God's sake--the kid has cancer. Aside from basic human decency there was also the really attractive opportunity to actually help someone. Most of what I do, and most of what they do, is little more than playing nursemaid to people deliberately destroying their helath over the course of many years. So rarely do we actually have the chance to help someone. And here it was--a 24 year old kid with no insurance and a new diagnosis of cancer. We could admit him, work him up, start the treatment, and since he was coming in through the ER, emergency MediCal would cover the expenses on admission as well. Family Medicine really did their part, but then Hem Onc was called in and her decision was that this could all be handled as an outpatient. Yeah, right. Technically, sure, I'm sure she's right. But come on--is that the BEST way to manage it? Surely not. But there we are--he'll be turfed out and left to fend for himself. Almost certainly he'll just be told to go to USC with his scary CT report and his giant neck and hope they can squeeze him into their schedule. As I told the FM resident--this is why I pay taxes. So our nation can pay to have this kid taken care of when he suddenly gets diagnosed with cancer. Not to support the economy of Mexico, not to imprison people who smoke pot, not to provide agricultural subsidies, etc., etc. But here, in the state that has the fifth largest economy in the world, we can't manage to provide decent care to a 24 year old father of 3 with a new diagnosis of cancer. How do they expect doctors to commit themselves to this system? The system is letting done its end of the deal. U-561

I had a career affirming patient today. Guy comes in with a blow to his head when he dropped a brick on it. He's pale as a sheet, almost passes out in triage and can barely keep his feet under him. I'm worried and pull out all the stops to get him a STAT CT Head. THe cut on his head is trivial, but the story is pretty dramatic: he was outside working on some sort of wall when a cinder block dropped about four feet and clocked him in the head. He spent an hour trying to control the bleeding and then drove in to the ER. CT is negative. I staple up his head and then his alcohol level comes back. 248. Over three times the legal limit! I hardly know what to say: I barely have the energy to do household projects cold sober. And....he drove himself in to the ER. I gave him a pretty good talking to and told him he would have to have someone pick him up for the ride home. Good, fine, okay....and three minutes later he was gone. I was sure he was driving home (and he lives about three blocks from me) so I called the local PD and gave them the story and his address. I thought they might be able to nail him for DUI on the way home. I usually don't get crazy about this sort of thing (incidental DUI discoveries) but come on!--248? That's not in the "one to many" range. About an hour and half later the guy calls me. His very sheepish and wants to explain. His wife was out of town so he was spending the day at his girlfirends when he dropped the brick on his head. His girlfriend drove him in, but he just wanted to keep it hush-hush. I'm sure the reason he's calling is because the cops knocked on his door and gave him a good scare. At least I can sleep tonight knowing that as long as guys like this exist I'll always have a job. U-561

Spent the day attending to the house. Put up the Christmas lights, cleaned the house a little. Tried to fix the power loss to our south facing wall. I think we may cancel our direct TV. It is just sucking up too much of my life. A stronger man would simply avoid over indulging in the boob tube, but that sort of minute by minute strength of character is not my strong suit. I'm better at the moment of decisiveness that sweeps aside temptation in the future. We'll see what the Bisvuit has to say about all this. I'm not advocating no TV--just limiting ourself to the 7 or eight free channels out there. We'll get a lot of what we like: Dancing with the Stars, American Idol, the Tonight Show, America's Next Top Model. We'll miss out on Ace of Cakes and............Sportscenter. U-561

Just got home from a shift in ER2 where I worked like a stevedore. It started with a near crisis intervention: the doc on before me was almost in tears over a difficult dispo and we needed to talk her off the ledge. Then I just dove in and started grinding the meat. A whole lot of nothing special. I felt like I was moving pretty fast, and I didn't have any real land mines explode on me. But I still had the feeling of being behind the ball. At 0200 I was in the awkward position of having the ER1 guy pick up a patient in MY waiting room. It didn't feel right at the time and at shift end I sorted through my charts to see if i really had been as busy as I felt. Lets see: 5....10....15.....20.....25...26...27! In a 9 hour shift?! 3 patients per hour and not a sore ankle or med refill amongst the bunch. That's earning the paycheck! The Biscuit is with the Marines this weekend, and she took the baby with her--which means I have a 36 hours of being blissfully alone. The mother-in-law is with her babysitting which is so, so nice. UCLA v. USc game today. Could be ugly. U-561