Pain Control in the Elderly

An elderly gentleman presented to the ER with severe upper back pain. He had fallen at home two weeks before this visit, but he reported his pain was only mild until awakening him from sleep that night. Initial X-rays after the injury were reportedly negative.

He was alert and ambulatory but in moderate distress from his pain, which was midscapular and worse with movement. He denied chest pain, shortness of breath, fever, vomiting, or neurological deficits. He was markedly kyphotic and mildly tender over the upper spine, with muscle spasm and tenderness to the paraspinal muscles as well. Vital signs, distal pulses and neurologic exam were normal.

After obtaining an ECG and IV access, a chest X-ray was performed which revealed a severe mid thoracic vertebral compression fracture.

I began by giving 2 mg of morphine intravenously every 5 minutes, to a total dose of 10 mg. Subsequently two additional 5 mg doses were required, as well as 15 mg of Toradol. He never became sedated, confused, or hypotensive, and his pain was completely controlled. He refused inpatient admission, and was not very receptive to the concept of percutaneous vertebroplasty, although I strongly recommended that he at least consider it.

I discharge such patients with oral morphine immediate release tablets so that the daily morphine dose required for pain control can be determined. After a couple of days, an extended-release narcotic can be added to provide more continuous pain control without the need for frequent dosing. If the patient's renal function can tolerate NSAIDS and there are no other contraindications, then an anti-inflammatory such as ibuprofen or naproxen is added as well. Discussion of potential side effects, including dizziness, constipation, and delirium is mandatory. I recommend early initiation of stool softeners and close followup.

Drinking yourself to death

An unfortunate young man presented with 12 hours of severe upper abdominal pain and vomiting. He was quite obese but otherwise without medical history. He initially admitted to only occasional alcohol use, although he later confessed to consuming around 20 drinks per weekend, with a lesser degree of daily use. He reported one similar episode of pain a month before which had responded to antacids.

He was afebrile, tachycardic to about 120, actively vomiting, and moderately tender over the upper abdomen. His WBC was 24,000, and his amylase and lipase were markedly elevated (around 10 times normal). His serum glucose level was 220, his LDH was 750, and his transaminases were around 100 with normal bilirubin. His triglycerides were 1300, and his blood was notably lipemic. His CT scan revealed marked pancreatic edema with impressive surrounding inflammatory changes and peripancreatic fluid collections. There were no gallstones, pseudocysts, hemorrhage, or other abnormalities seen on the study.

Because of the rapid progression of his illness and his high Ranson score suggesting the potential for serious complications, he was admitted to the ICU. The following day, he became hypoxemic requiring intubation, and he developed acute renal failure and mild rhabdomyolysis. His serum calcium was 6.0, his creatinine had increased from 1.4 to 3.0, and the predicted mortality for this 26 year old man was well over 50%.

Acute pancreatitis can be a killer.

And in this case, it was. RIP.

Gig 'em Aggies!

Texas A&M 12
UT 7

AUSTIN, Texas (AP) -- Stephen McGee had taken so many hard hits, he was throwing up. But yard by yard, McGee and the Texas A&M Aggies were pounding out six years of frustration in their rivalry with Texas.

With a stingy defense and two long scoring drives in the first and fourth quarters, the Aggies finally got past the Longhorns with a 12-7 victory Friday that they hope signals their return to prominence in the Big 12.

McGee, battered by the heat and the beating he was taking while running the option, punched in the winning touchdown with an 8-yard run with 2:32 to play.

"I looked those guys in the eye," in the huddle, McGee said. "And if I can't do it, I don't expect them to do it."

The Aggies churned out 244 yards on the ground against the nation's top rush defense. They snapped a six-game losing streak to the Longhorns and won in Austin for the first time since 1994.

Happy Thanksgiving Everyone!

Thanksgiving is going to be wonderful this year. Right now it's 65 degrees and sunny, and we're getting ready for a big family feast. I love Fall in Texas. I do have to work all weekend, but who cares? It's Turkey Time!

So what are you thankful for?

I'm thankful for my parents, to whom I owe everything.

For my wife, for staying with me all these years.

For my children, for just being.

For my health, which despite the occasional minor glitch has been thankfully wonderful.

For my friends, both old and new, who continue to share their lives with me.

For my good fortune, which has somehow always prevailed over its opponent, eventually.

For the ability to help others, which the creator has blessed me with.

Happy Thanksgiving!

UPDATE: Everyone takes pictures of the turkey. I take pictures of the cookies!

A Letter to an Angry Patient

Dear Mrs. D'Ramatica:

I'm sorry you were upset with your experience in our Emergency Department. I try my best to make sure that everyone is satisfied, but inevitably patients with unrealistic expectations are going to be disappointed.

As soon as I walked into the room, I could tell that you were expecting to be admitted to the hospital. I've seen those overnight bags sitting shyly in the corner before, and I know fully well what they represent. When you said that you just couldn't take the pain anymore and that your family had told you to go check yourself into the hospital, of course it should have been clear to me that you expected to be admitted. And it was.

I'm certain that you think much less of me than you do of your personal physician. After all, he gave you a compact disc with your MRI pictures on it and told you to "go see a back doctor." There is something wrong with your back, he told you, and you need to see someone about it. Missing that appointment on Friday was a bad idea, however, and so you ended up in my ER.

When you reflect upon our interaction, remember that your doctor (who you probably still adore) didn't actually tell you what was wrong with your back, or what a "back doctor" could do about it.

Apparently, he didn't even bother to have anyone look at the MRI to interpret the study, because when I hand-carried the disc to personally go over your images with the radiologist on call for the ER (which he interpreted without charge to you, by the way), we found that there was nothing much wrong at all. Particularly nothing that required surgical intervention.

"How can that be?" you wondered. "It hurts so much!"

I doubt that you will remember my detailed explanation of back injuries and their rehabilitation, the rationale of medical treatment and the indications for surgical management. All you will remember is that I didn't admit you to the hospital. You won't appreciate that instead of telling you to go see a "back doctor," I actually spoke with one at midnight and personally arranged an appointment on an urgent basis during a short holiday week.

When you eventually discover that neither the "back doctor" nor your own doctor are going to prescribe you the same quality of powerful narcotics that I did, I hope you send me a Christmas card thanking me for doing everything that I possibly could to make you feel better. You might send one to our patient relations department as well, commending me for taking the extra effort to help you. I know you didn't really mean the awful things you said about me on your way out.

Thanks in advance, and best wishes for a quick recovery,

Your ER doc

Unbelievable

A 60 year old gentleman presented to the ER with shortness of breath which he described as "gasping for air," intermittent palpitations, and a vague heaviness in his chest of about 3 hours duration. His symptoms had resolved by the time he arrived in the ER, and his vital signs and ECG on arrival were normal. Fortunately, he already had an established Cardiologist at our facility. Once the initial set of cardiac enzymes came back negative, I asked the unit secretary to call him. For admission, of course.

The patient had been worked up extensively in the past for paroxysmal atrial fibrillation, and his cardiac catheterization two years ago at another facility reportedly showed normal coronary arteries. Nonetheless, it seemed like a straightforward admission, particularly at 4 am. Hardly anyone is awake enough, hardheaded enough, or foolish enough to argue against such an admission at 4 am. So I thought.

"I have a 60 year old man with chest pain" is usually all you have to say, and it's a done deal. That is the presentation that is considered the most slam-dunk of all admissions. The no-brainer. The Best Possible Patient for an ER doc to ever have: a level 5 with a cookie-cutter workup and no controversy except "does he need the ICU or can he go to telemetry?" So I expected.

Instead, I received a 10 minute lecture from a Cardiologist about the evaluation of chest pain in the Emergency Department. At 4 am.

"You drew cardiac enzymes? Why would you do THAT? You don't think he's having an infarction do you? DO YOU? What do you think the warranty should be on a normal heart catheterization? You guys draw way too many enzymes!!!!!!!!"

"Not everyone with chest pain is having an infarction. Don't you ever THINK? Aren't you a doctor? Don't you ever try to figure out what else they might have? A robot could just draw enzymes and admit everyone to the chest pain unit."

And so on. As I sipped my coffee and listened to his rant, I wondered how many Cafe Grandes he had already consumed this morning to get him so agitated.

"What is it going to take to make you comfortable that he can go home?" he asked.

"An observation bed and a negative stress test," I offered hopefully.

"Well, I'm not going to do that. I just cathed him. He's probably just having intermittent arrhythmias. Call his electrophysiologist and see if he wants to adjust his medication. Is the patient comfortable going home?"

I didn't know. The thought never crossed my mind to even ask him.

The electrophysiologist didn't want to adjust the medications. The patient decided to follow the recommendation of his Cardiologist. I offered to find another Cardiologist to admit him, but the patient declined. He felt better.

I felt worse.

Preparation is the Key to Success

If I have a motto, this would be it. It's based upon Sir William Osler's quote "The best preparation for tomorrow is to do today's work supremely well."

Unfortunately, I didn't follow my own guideline so well this time. What could have been a simple laceration repair became a difficult misadventure.

A toddler between 2 and 3 years old had ran into the corner of a table, cutting his eyelid. I gained his trust enough to have him laying peacefully on the stretcher so that I could clean his wound. His small cut was scabbed up with dried blood, and I wasn't certain if he would require suturing or not. After the uneventful cleaning, his laceration appeared to be a perfect candidate for Dermabond. Unfortunately, I hadn't brought it into the room with me.

"Pardon me, I'll be right back."

By the time I returned to the room, the quiet gentle child had transformed into a demonic thrashing screaming maniac, far beyond the possibility of verbal reassurance. I had lost my chance.

I know better than that too.

A Holiday of Sorts

I can't ever recall a shift such as the one I had last night. We were busy, sure...it was Monday after all. But all of the radiology studies were negative:

No fractures.
No pneumonias.
No CHFers.
No bowel obstructions.

I didn't even order a CT scan all night long. On anybody.

All of the abdominal pains were seemingly benign and easily controlled with only one dose of medication. The back pains were all of the acute variety. All of the vomiters stopped vomiting. All of the WBC's were well within normal range. One lady did have a positive troponin, but she was going to be admitted anyway. Nobody was whiny, not even the kiddos.

I even got two hours sleep on a stretcher after clearing out the ER by 5 am. That never happens.

The Nighthawk

I'm the night guy. For the last 5 years or so, I have worked exclusively nightshifts in the Emergency Department. I prefer the graveyard shift, the all-nighter, as opposed to the midshift that ends well before dawn. I initially gravitated to this shift for many reasons:

1) I found a particular cadre of nurses that I considered to be outstanding, and they happened to work nights. I arranged my schedule to work with that group. My enjoyment of this profession and the success with which I am able to accomplish it depend more upon my nurses than any other factor. Night nurses rock.

2) With a typical nightshift, we start off busy and it gradually slows down toward the morning. With a typical day shift, it starts off slow and is busiest at the end of a shift. In this respect, night shifts are more physiologic. Of course some examples of either shift are busy from start to finish, or hardly busy at all.

3) It's often easier to get things done at night. There are less administrative types running around bothering us. We can bend the rules to our liking. The lab and x-ray departments can be faster without the crush of "routine studies" that occur during the day (although this is staffing-dependent).

4) The ambient noise level is less at night. This is partly why night staff tends to be less neurotic than day staff, I suspect.

5) I've always been more of a night person anyway. It's always been easier for me to stay up late than to get up early.

6) I had difficulty adapting to staggered shifts. At times, I would "hit the wall" in the middle of the night and have to take a brief nap at the nurse's station desk. A couple of times I recall almost nodding off taking a patient's history at 4 am. It was routine for me to fall asleep at the wheel literally dozens of times (per trip!) on the way home from work, and I looked forward to stoplights as an opportunity to grab a minute or two of sleep. I adjusted my schedule to try to maximize my ability to stay awake at work and on the road. Later, I was diagnosed with obstructive sleep apnea and shift work sleep disorder, and the treatment has changed my life for the better.

7) In any job, I think it's a good idea to make oneself indispensable, or at least to have useful qualities that distinguish you from your peers. There is always going to be a spot on the schedule for a guy who will happily work the graveyard shift. More about this in a later post.

My circadian rhythm is now totally backwards from most people's: the time of day that I am most awake, and most hungry, is about 2 am. I prefer to sleep from 10 am to 4 pm, and I don't really wake up completely until about 7 pm. But now I'm wide awake for my entire shift. The problem is adjusting to off days.

Is it better to stay up all day and then try to sleep the next night or stay on my preferred sleep schedule? If I try to stay up all day, I am going to be dead tired and miserable all afternoon. If I'm going to have any meaningful interactions with my fellow humans, I've found it's best to try to take a short nap in the afternoon and then try to get on a regular sleep schedule. Otherwise I'll just sit up on the computer all night, by myself. At least it's quiet.

Recently, a couple of my partners have chosen the dark path as well, which makes it easier to trade shifts when necessary. Once the daytime guys start getting spoiled by not having to do as many nights, it's like pulling teeth to get them to work a night shift for you. As I mentioned, being a nighthawk is good for one's job security.

The Worst Thing

It's usually a casual acquaintance or a stranger who asks, for some reason. As soon as someone discovers what I do for a living, they immediately want to know "what is the worst thing you have seen?" I'll be buying milk at the corner gas station or getting my oil changed at Jiffy Lube, wearing my scrubs from the night before. "Are you a doctor?" they ask.

Yup.

"What do you do?"

I'm an ER doc.

"An ear doc?"

No. Emergency Medicine. I'm an Emergency Medicine Physician.

"Wow. I bet you see some crazy shit."

Yup, I smile. Or maybe it's a grimace, because I know what is coming next.

I can't really tell them the worst thing I have ever seen, because it is so horrible that it almost makes me cry just to think about it. Tears are welling up even as I type this. I honestly recommend that you stop reading now and don't give in to your curiosity.

We see so many tragedies in this profession, is one really any worse than the other? Traumatic amputations, burns, drownings, sudden deaths, brain tumors, rapes, suicides....they are all emotionally difficult. But it's the children that are always the hardest for me.

I was a scared and clueless third year medical student doing my first rotation in the ER when the paramedics brought her in. I think she was probably 8 or 9 years old. Her father went into her room that morning to find only an open window. She was finally discovered late in the afternoon, discarded in a roadside ditch with her throat sliced all the way across, somehow missing the major blood vessels but lacerating her trachea. The sight of her breathing through her gaping neck wound and the realization that someone could be that evil were shocking enough, but the memory of that muddy shivering young girl covered with what appeared to be a million ant bites all over her body haunts me to this day. The bravest person I have ever seen, she never cried.

To ask such a question of a mere acquaintance as cavalierly as one might ask about my favorite restaurant is really a bit more personal than either of us expects from a polite conversation across a counter.

The Smooth Shift

No two shifts in the ER are the same, obviously. That's partly what makes it fun. Some shifts can be monotonous, with a few patients just trickling in throughout the night. I'd much rather be busy.

Then there is the shift where the ER is packed and overflowing. Every single Monday is like that, for whatever reason, but any other night might be the same. I like to come a little early and walk through triage on my way in to work so that I can get an immediate feel for the situation. Maybe I'll try to clear someone off a backboard, or fast track a patient or two. If there are several ambulances in the bay and patients are spilling outside and lined up on stretchers in the hallway, I can be sure that I will be running hard from start to finish. Or if it's not busy, I'll just chat with the police officers for a few minutes.

Sometimes, but not always, the first patient you see sets the tone for the rest of the night, so I try to choose that patient carefully. If nobody is crashing, I'll try to see someone who has been in the department for the longest time. That way I can be the good guy. When they complain about the wait, I can tell them "sorry, I just got here, and you are the first patient I came to see." That often diffuses their anger a bit. They will still complain in their Press-Ganey survey though..

Some nights, fate intervenes to make everything more difficult. Maybe we are understaffed, or the nurses aren't as motivated, or maybe the lab or X-ray department is having problems. Perhaps the patients' problems are more complex, or the on-call physicians don't call back promptly when paged. Sometimes we will page an on-call physician for over an hour without a response. Usually in that case, the call schedule might be incorrect, or a physician is on call who doesn't usually take call for this hospital. Some patients require 3 or 4 different calls; the dialysis patient with pneumonia and elevated cardiac enzymes, for example. Perhaps the consultant will want us to add another test or three that we haven't done yet, to delay the inevitable admission. Of course, the hospital is usually full as well, so the ER gets backed up and everyone is grumpy. On a bad night, all of these things usually happen at once.

But other nights, when everything is running smoothly, the shift is almost effortless. When all of the components are working together as they should, it is a lot more fun. The shift is over before you know it, and it's hard to even remember any specific patients because they were so easy to take care of. On nights like that, it seems that all of your initial diagnoses are correct, and all of your procedures and interventions are succesful. The patients respond well to treatment, do not require multiple re-evaluations or re-medication, and the flow is smooth. When patients come in at the same rate we can move them out, then everyone is pretty happy.

Model Train or Artistic Masterpiece?

This is simply amazing. Thanks to Rodger for posting the videos. Part I gives some background and a general overview, and Part II shows some of the engineering behind the system. Even if you are not a fan of model trains, the attention to detail in this work of art is worth a look.

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Watch Part II

Mixed Nuts

It's that time of year again. The first crop of mixed nuts showed up in the grocery store today. As I examined the bag and anticipated the woody deliciousness inside, an elderly lady came up behind me.

"I bet these have been in the freezer since last year" the wise old sage said to me disapprovingly. "It's too early for nuts."

I thought about it for a second, and said "I'll bet you're right," and sheepishly put them back. But as I passed by the display a second time, I found I could not resist. I snuck the bag into my basket, half expecting a ruler to sting the back of my hand. But she was admiring some candles nearby. I slithered off to the meat aisle, satisfied with my clean escape.

"You get them anyway didn't you!" There she was, thankfully sans ruler. She'd snuck up behind me while I was investigating the ribeyes. I was busted.

"I couldn't help myself. They just look so good."

And they were.