This is Dr. Slicy dictating…

Chief complaint: Fall

HPI:
This is an elderly white male who per EMS had fallen earlier this evening.  This apparently happened just outside of the “King’s Bar.”  Witnesses on scene stated he had complained of severe pain after “a great fall” though has difficulty siting exactly where his pain is, stating “it hurts everywhere.”  Of note, the patient is extremely morbidly obese.  He had been sitting on a tall wall where this happened for unknown reasons.  After he collided with the ground he has poor recollection of events, however witnesses stated that several men came out of the bar and attempted to get him back together, though they were unsuccessful.  The witnesses also mentioned that the men from the bar also had some equine assistance in this manner as well, though I am suspicious for intoxication vs. poor recollection pertaining to this.

PMH: negative     PSH:  negative   Social: denies alcohol/drug use

Physical Exam:
General: Extremely morbidly obese man lacking several key components of his body

ED Course:
Unfortunately, despite the effort of the men and possibly equine assistance, this person had obvious signs of death and despite our best efforts, he was pronounced scrambled  dead shortly after arrival.

…A friend of mine thought it would be funny if I put a Nursery Rhyme into dictation form. 

The incredible lack of logic makes kids hilarious.  I’m jealous.  I want to be able to do this crap and get away with it as well.

My friend has a little 4 year old, or maybe 5, or possibly 3, I’m not good with kids, since mines only 5 months.

He’s old enough to talk and walk, so good enough.  I’ll call my friend Mega-milk, since he drinks that crap.

Child: “Dad!  Dad!  Daaaaaad!”
Megamilk: “Just a minute,”
Child: “DAAAAAAD!”
Megamilk: (sigh), Yes?
Child:  “IT’S TIME TO R-R-R-ROCK AND ROLL!” (and then the child runs off screaming).

There was no music.  There was no mention of rock and roll nor of anything even tangentially related to his statement.  He had never done this before.  Why?  Why do this?  No idea, but it ruled.

My buddy in residency?  Yeah, he was Batman for 5 months.  That was his name.  Not Dad.  Not Father.  Not anything related to parenting.  Just Batman.  Such as:

“Batman can I have Cherios for breakfast?”
“Batman can I watch cartoons this morning?”
“Batman I don’t want to go to bed yet”

No reason.  He just called him Batman for 5 months.  No reason.  No exception.  He was Batman.

Don’t you wish you could do that and get away with it?

I do.

Is it crazy to envy the insane?

Man, time for bed.

A friend of mine asked if I ever got scared at work, which I responded that I did pretty much everyday.  However, when you know the patients very intimately, it becomes a bit more terrifying.

Here’s a few examples where I did not get too scared.  Sometimes in the ER you have to take the story of your patients with a grain of salt.  During exciting moments, people tend to lose track of time and space.  This must be expected, and is completely understandable.

Your child had a seizure?  OK, sure, please explain what you saw, perhaps it was a seizure, perhaps not.  Oh, your child was waving her hand at one of her friends and she waved her hand really fast for a minute while giggling?  Yes, my suspicion is that it might not have been a seizure after all.

You had multiple episodes of vomiting all day?  OK, how many?  None?  Oh, you were nauseous today after drinking yesterday?  OK, well, what did you take to help for your nausea?  Vodka?  Really?  Vodka?  How did that work out for you?  Oh, the vodka did not seem to settle your stomach, weird, well, lets see if we can help.

I realize this makes me sound condescending, which it certainly would be if I were making these stories up and they were not true…

However, more recently I did have a scary occurrence with a set of parents.  The parents were my brother and sister in law and the patient was my niece.  They said she had a high fever.  In the ER a “high” fever can mean anything from a fever of 99.1 to much higher.  However, when my sister in law took my nieces temperature and the thermometer read 106, this caused a bit of concern.  I’m not sure the precise temperature at which the brain turns into a warm bag of oatmeal, but 106 is enough to scare me.

I did what any trained doctor would do, I wet myself.  Then changed my shorts.  After changing said shorts we rechecked the temperature again.  They had a skin thermometer (you put in on the forehead then drag it to the temple, I’m not sure how accurate it really is, but 106 give or take a degree still is toasty) Still high.  Fortunately, after finding out the dosing they had been using for her fever it was discovered that she actually could have a significantly larger dose of Tylenol and Motrin.  Despite her very high temp, she really looked quite good and did not have that many symptoms.  To make a long story short, her temperature came down and she perked up and looked great a short time later.  She did great and made a full recovery as most kids do, mostly miffed that mom and dad kept her from doing all the crazy things a little kid wants to do when they are sick but don’t realize it.

On a separate note, I tried to find a good image on google images for a fever, and then I found this awesome pic of a fire-breathing giant robot baby.  I love google images.

 This is how hot her fever was…

Still, 106.  That’s hot.  Anyone seen a temp higher?

A typical night shift in the ER (details changed to protect me from the HIPAA-police).

A hallway full of people with varying levels of alcohol, each with similar colorful phrases to yell at the nurses, mostly rhyming with “trucking stitch.”

Several young children brought in for fevers.  Tonight, all of them went home with diagnosis varying from viral illness, to upper respiratory illness, to otitis media.  My intervention with all of them was limited to Motrin.

Then, in a flash,  the night became much scarier, when the Priority one phone rang.  I rushed over to answer it and plugged my other ear to listen for the story from the EMS.  Apparently a ninety-two year old man had been found at the nursing home unconscious.  By unconscious, I mean not breathing and also without a heartbeat.  In medical terms, this is described as “bad.”

Per the EMS, whenever this happens the nursing staff there are required to start CPR and notify EMS.  This struck me as quite odd, since usually (especially at nursing homes) patients often have advanced directives as to whether or not they are to be resuscitated or not.  My suspicion is that this information may have not been 100% accurate, but in the ER, working with incomplete information is the norm.

The EMS did a fantastic job.  They intubated (put a breathing tube) into the patient, started an IV, and began CPR.  The man remained unresponsive and unconscious, but his heart beat and blood pressure did return as well.  They also had limited information.  How long was this man down?  What past medical problems?  What medications does he take?  In such situations they do not have time to take a full history, they start CPR and bring the patient to us.

In transit, the gentleman coded again, meaning his heart stopped beating (again) and his blood pressure decreased to zero.  His breathing stopped as well, but he was already intubated, thus the EMS were already breathing for him.  Again they gave more epinephrine, atropine, and other strong medications, and again the patients heart began beating. 

The patient came into the ER trauma bay and the staff immediately began attaching wires, IV line, and all of the apparatus so that we could evaluate him.  Our knowledge of the patient was obviously the same as the EMS.  On arrival he had a very weak, thready pulse.  I called to our ICU physician and described the case while the nurses continued to attach devices. 

The nurses continuously monitored the patient and found his heart had stopped yet again.  We re-started CPR a third time, continuing with chest compressions, more STRONG IV medications, as well as defibrillating the gentleman when his cardiac rhythm showed Ventricular Tachycardia.  We continued to try to “save” this man for quite a while.  I did a bedside ultrasound on him, when I looked at his heart, it had no movement at all.  He was finally pronounced dead.

Here comes the hard question.  Was it better that we tried everything in our power to attempt to save this 92 year-old gentleman, or would it have been better to let him die peacefully in his sleep? 

I do not attempt to know the answer to this question.  I have seen some very spry 92 year olds, as well as some people that are in their 60′s that have end stage dementia, that no nothing of their surroundings and just live only because they have IV sites that keep them alive.

I have seen how destructive and invasive CPR can be, and how rarely it is effective.  That being said, I have seen people brought back from the brink of death.  Rarely.  Very rarely.

I know more than one EMS worker who actually has a tattoo on their chest that reads DNR, which means “Do Not Rescusitate.”  An interesting decision from an individual who often is required to rescusitate many patients.

Currently, in the US I am required to do everything in my power to save anyone and everyone that walks through the doors of my ER.  In cases like this, I must definately try my best to save the patients life, until I have found that my efforts are futile.  Personally, I find such interactions frustrating.

Every person must draw their own line.  If this patient had a clear order for a “Do Not Rescusitate” maybe he would have died peacefully in his sleep.  Maybe that’s the answer, or at least part of the answer.  Every person in the US has to fill out an order what they want done if they require CPR every 10 years. 

I don’t know what the answer is, nor what the future of US medicine holds, but I think it all starts with asking the right questions.

For me, these are some of the right questions:

How much should individuals be accountable for their own health?  Overweight, Smokers, Alcoholics, Drug-users vs. healthy, active?

What age determines you to be elderly, or is it how healthy you are?  Should you be declared a DNR once your health has deteriorated past a certain likelihood of meaningful recovery?

Will it take a nationwide shift in our approach to medicine as a whole to change for the better, or can the current system continue indefinately?

I visited my brother’s cottage last weekend.  Beautiful sunny weather, warm water, and lots of beach time made the trip yet another reminder that I love the lake.  Nearly everyone had a fantastic time while there… except.

Catherine.

That is my 1.5 year old niece. 

She did not mind having her new, younger cousin around.  She did not mind having her at the table.  She did not mind sharing her toys.  She did not even mind Samantha being the center of attention for much of the time.  She also did not mind if my brother (her daddy) held Samantha.

What she did mind was when her mommy held Samantha.

Whenever she saw this, the retribution was swift and terrible.  Tears, screaming, and complete meltdown occurred mere seconds after seeing mom holding another baby.  As soon as mommy got rid of the other baby, all was well… for everyone.  As soon as mom picked up Samantha, well, it made that girl from the exorcist seem like Rainbow Brite. 

I thought that Catherine did not hold a grudge.  She even learned Samantha’s name, sort of.  She would call her “Mantha.”  We even thought at first she was getting over her anger at mommy holding “Mantha.”  That was until she recited her ABCs.

“A, B, C, D, E, F – Mantha!” 

Ah, children, jealousy runs deem in thy veins.

The Chore at the time     Level of Scariness 
High School                   Caterpillar  
College                          Mosquito
Grad School                  Stingy wasp
Medical School             Grumpy Troll         
Residency                      Fire-breathing dragon
Working doctor             Tightrope walking with dragon circling
Moonlighting alone         Getting kicked in the nuts by a Grumpy troll while tightrope
                                       walking, with a dragon burning the line.

What is the scariest position you have ever been in?  Have you ever been in a situation where many people depended on you if the SPLOUTS hit the fan?  I just got back from moonlighting.  For the un-moon-enlightened, that is when a doc goes to a different hospital in need to pick up a few shifts.

What made this experience interesting, by which I mean wet-my-pants scary, is that when I worked my shifts there, I was the only doctor in the hospital.  Did you read that last part?  I don’t think you read it loudly enough, so let me e-scream it at you, I was THE ONLY DOCTOR IN THE HOSPITAL!  Sorry, didn’t mean to bust your eardrums.  But that’s intimidating. 

I’ll get to the big finish now so that I can end with ranting and whining, which is more fun for me.  Nothing bad happened.  No one died and no heroics were necessary.  However, I spoke with the Emergency Room director.  He had been there 15 years and remained a very Sharp, intelligent, jovial fellow who did not show the stress of having the responsibility of the entire community weighing him down like a beached whale carcass of responsibility.

He did say, though, that he has had several code blues upstairs in the hospital, several babies that delivered, and multiple critical patients where he’s the only doc.  Intimidating.  If something goes wrong, well, just keep trying because you’re the only person to fix it.  Got a patient that you can not intubate?  Well, you can’t call down anesthesia to do that for you, and surgery is not nearby to come in to do a quick tracheostomy, it is all you baby!  Intimidating.

AAAAAH!!!

That being said, it was a quite small community, so they could not afford to have in-hospital doctors all of the time to cover for the “just in case this might happen.”  Thus the ER doctor has to do it all.  And he does.  Though, that is one of the reason ER doctors go into ER.  We like to help people in situations where you are the one who has to do it all (sometimes for the simple reason that you are the only one).

Scary.  Intimidating.  Fun.

So a buddy of mine wanted to know where the name “Slicy” came from, I don’t remember writing about it, but if I did, I can do it again for giggles. 

No, it is not from anything medical.  I wish.  That would be way cooler.  You know, like I had to do an emergency chest tube for a tension pneumothorax and no one could find a scalpel so I had to slice open a chest with my giant Bowie knife that I keep strapped to my thigh.  Sorry, didn’t happen.

What did happen was that I used to work at a pizza place.  Yes, I was your mild mannered pizza delivery boy.  I did a fine job cleaning up the place, but my bosses didn’t like me so they shot me into Space… wait, that was Mystery Science Theater 3000.  Sorry, my memories are a bit muddled.  Let me scan blankly into space to try to remember again… ah, there’s the memory, filed under “hilariously horrible things I’ve done to people by accident.”  You’d think that file wouldn’t be so large, oh well.

So one day at work, the manager, we’ll call her Petunia, brought in a giant foam pizza slice outfit.  It was hideous.  It had huge pieces of mushrooms and gross looking sausage on it, as well as some mutant pepperoni.  I loved it instantly.  Unsurprisingly, I was one of the more energetic and outgoing workers.  Thus, I was determined to be the new pizza slice.

As soon as I saw the thing, I knew it needed a name.  I instantly dubbed myself “Slicy” as soon as I put on the monstrosity.  No one else called it Slicy, though I continued to refer to myself by this name.  Well, no one called it Slicy… until…

It was a fine afternoon.  The birds were singing in the summer sun as they glided overhead to celebrate being alive.  People drove by and shouted obscenities at the moron in a pizza slice outfit while I ran/waved/yelled happy messages back.  Being in a giant foam suit in the sweltering heat screaming at people to come eat pizza for a few hours is actually not as much fun as you might think.

Now, don’t get me wrong.  At times it was kind of fun.  However, I do want to state outright, that I had NO INTENTION of causing harm to any other human being, I was just trying to do my job.

Anyways.  I was running up and down the sidewalk.  Cars would honk and people would ride their bikes and smile at the annoying Slicy inviting them in for a piece.  Then I saw a couple of bikers riding by.  Granted, a giant pizza slice can be a bit intimidating, so they did give me wide berth.  However, I think they thought I was anamatronic or something.  Again, I did not try to cause harm, it’s just not my nature…

So as the couple of bikers passed, the first biker was transfixed by all of the pizza Slicy goodness as he passed.  Sensing interest, I yelled (encouragingly) to the fellow passing me on the bike, while I stepped towards him.  As he continued to ride on, he became incapable to look away.  I had somehow hypnotized him with all my Slicy goodness.  Helplessly trapped in my pizza goodness stare, I watched as he slowly drifted right.  Farther and farther, as if in slow motion, he drifted towards the three foot high stone wall until the inevitable occurred.  The crash was dramatic, though no significant injury occurred.  The man sprawled all over the stone wall yelled a few times, but retreated in fear/agony as the giant pizza tried to run over to assist him. 

As I went into the building, trying to hang my giant foam crust of a head in shame, my coworkers cheered for Slicy, the terror of the pizza place.  I never wore the suit again, but somewhere deep inside, I still have a special place in my heart for Slicy.  Thus, to this very day, call it hubris, call in sentimentality, call it idiocy, I keep the name.  I used to have a picture of me in the costume, regretably, I could not find it.

Man.  Anyone else craving pizza?

Me too.

Oh, I googled “Slicy” and found the following game, not bad eh?

* * * “This is Paramedic741, we have a multiple stabbing victim coming in, be there in less than 2 minutes” * * * *

Sorry to interrupt you sir, but you are in the Emergency Room right now.  Yes I do realize that it is probably a VERY important cell phone call that you are having right now.  I am sure that your girlfriend wants to know what the inside of the ambulance looks like, and also that some idiot doctor really is pestering you right now.

I apologize for my irrational behavior, but could you please at least let me know how many times you were stabbed?  Oh, it was five times?  Ok, thank you.  Please continue with your important call, I will patiently wait while you continue to bleed all over the floor.  I am sure discussing which bars you went to last night is infinitely more important than finding out if any vital organs were sliced open.  You’re right, I am being a prick for interrupting you. 

Yipes!  Yes, you are right.  It is completely Fu*#(@&*  malpractice for us to try to put an IV in you.  We would not want to accidentally give you some IV fluid and maybe give you life-saving medication.  Yes, please continue to test message all of your friends instead of answering any of our questions.  I understand, you have a very busy life, and at 3:50am many people want to be woken up so they can get that important information. 

Interesting perspective.  Though I don’t agree that the nurse is a F*$@ing B*#%, thank you for screaming it at the top of your lungs.  I’m sure the family with the sick children next door appreciate your perspective.  These new people are from the surgery team, they have to evaluate you as well.  No, I’m sure they won’t interupt your busy schedule of swearing, peeing on the floor (despite the urinal literally 5 inches from your hand) and texting on your phone. 

Sir!  SIR!  Please refrain from taking a swing at our staff.  Though you were no where close to hitting them, likely since you are amazingly drunk and uncoordinated, we try to refrain from punching people in here.  Thank you.

No.  I actually think that leaving the ER right now to go outside and have a cigarrette is a bad idea.  Sometimes, when people get stabbed several times, that is actually a bad thing.  Yes, I know, I am a stuck up F*#@.  I do have crazy demands.  Again sorry for the inconvienience.  We would like to run a few tests though.  Yes, I know that you ARE SURE nothing is wrong.

Oh, guess what.  Somehow, despite your extensive medical training, you were actually wrong.  It turns out that you actually do have serious medical problems after being stabbed multiple times.  What’s that?  Ah, I see.  Yes, you are right, I just ran all of those test since I am greedy.  Even though you informed me several times that you are not going to pay for any of this Sh*#, and I am sure you won’t, that is my main reason for ordering all of the test.  By some weird cooincidence we managed to keep you alive and find serious problems though.

You are going to have to be admitted to the hospital overnight.  Yes, we are all F&#*ing A&&holes.  It is unreasonable for us to admit you to the hospital and not let you smoke while you are on oxygen and not let you go back to the bars draging your intestines behind you.  No, we don’t let you drink vodka in the hospital.  We’re kind of jerks that way. 

Sorry for the inconvienience.  
 

For a while I have been trying to explain what a baby is like.  Other people have described having one a form of brainwashing.  You wake up at random intervals repeatedly to perform trivial tasks.  Or, actually, sometimes to perform no task at all.  Sometimes you get to sleep 3 hours, sometimes 20 minutes.  There is no way to tell.  If you don’t get up the punishment will be swift and severe.  Not only that, but it’s only going to prolong your agony and increase the time that you must stay awake and miserable. 

Want to have a kid yet?

On the plus side, the kid grows out of this stage, and I am quite pleased to announce that Sam has actually slept for over 4 hours straight.  This may not sound like much to you without children, but those of you with children I can feel you nodding your heads to my weary triumph.

Also on the plus side, when your little peanut smiles at you, it makes it all worth it.  At least that’s what I keep telling myself over and over.

Back to the point at hand.  I was trying to figure out what a baby is like.  I am somewhat surprised it took me this long, but after a quick discussion with my friend, we’ll call him Superman, I realize that babies are just like the amazingly drunk people.  Let’s take a look at the facts.

WHY BABIES ARE LIKE DRUNKS.

1.  Both babies and drunks will puke anywhere, including on you.  Both of them will do so with a smile and without an apology.

2.  Both are needy.  They are certain, without a single doubt, that they are the most important creature that has ever been put on the earth.  They know what they want (baby = milk!   Drunk = Booze/sammich!) and they want it now!

3.  Both will pee at any given time, even if they have just peed 3 minutes ago.  Also, they have no problem peeing on the floor, even if you leave a perfectly good container right next to them.

4.  They speak the exact same language.  Truth be told the drunks are much more long-winded, but it is the same language.  (Me:  Good morning Sam!  Her: blblblaah!  Ah-gah!  Ble-ble-ble.  And when I speak to my daughter it is nearly the same)

5.  They can both poop everywhere, which may shock and disgust you, but you still have to deal with it.

6.  All you want to do is keep them quiet, and you will do just about anything to make it happen.

7.  They are incredibly unstable on their feet, while at the same time seem to seek out dangerous places to hurt themselves.

8.  Screams at maximum volume despite social situation.

9.  If either gets even a slight bump on the head, you get worried that they might have an intracranial bleed.

10.  They will both cry.  For no reason.

Though, to my baby’s credit, she does smell much better than any of the drunks I have taken care of.  Even during a dirty diaper change.  However, I’m told this changes when we start adding solid food.  Thus, she gets breast milk till she’s potty trained.

Ever looked directly into a laser for 45 seconds while smelling your own eyeball flesh burning?  Really?  Me too!

I officially went under the knife.  Well, actually there was no knife, only lasers.  I got LASIK.  Now, I’m invincible.  Well, maybe that’s a little far, but it is cool to wake up in the middle of the night and be able to read the alarm clock.  But I’m sure you’re wondering what LASIK is all about, lets go on a journey together to make you less dumb.  But, let me make it sound waaay scarier than it is so that you think I’m a stud.

First, a bunch of drops are put in your eyes so that you can’t feel anything.  These drops burn.  Suck it up and quit whining.  This will be the total of your anesthesia for the procedure.  Thus, I suggest you make sure those drops get in, otherwise the whole laser in the eyes thing might sting a bit.

The doctor then puts super-mega-suction cups on your eye so that it stays in place.  This may seem trivial, but it is the reason that I have two horrible subconjunctival hematomas on my eyes even 10 days after the procedure.

    I should have clicked on red-eye reduction…

Then, they make a flap in your outer eyeball with a laser.  Think of it as a trap-door on the surface of your eye that they flip open to get the next laser better access.  They make a large “C” on your eye and literally flip that flap to the side.  Mmm, tasty.

Next, they ZAP the be-juju-bees out of your eye.  You are supposed to stare at a red dot while they are doing this, but they just cut open a friggin’ eyeball flap so you really can’t see a darn thing anyways.  The opthomologist will calmly reassure you that the burning eye smell will go away with time and that everything is going great.  Just keep staring at the giant red blur, er, I mean the small red dot.  Don’t worry about the fact that if you glance even one millimeter to either side you will surely be blinded forever.  Fortunately they have the super-suction to prevent you from looking around.

Now, for  a split second, you can actually see a clear, tiny red dot, which is cool.

Then they repeat the process for the other eye.

Then you leave and the doc looks at your eyes under a scope to be sure he didn’t just accidentally make eyeball pudding.

Then you go home and sleep for 4 hours, crying like a little girl.  There is a slight burning pain, but mostly you cry since your eyes just got cut open and that’s the normal response.

Now you go back to the doctor.

Guess what… at that 4 hour later appointment my eyes were 20/20.  Cool.

The only part that was slightly less cool was wearing sunglasses the entire next day at work.  Also, they have a guard you wear at night (also glasses).  So I got this procedure to get rid of glasses, and now I have to wear EXTRA-DORKY glasses to remind me why I got it done in the first place.