kaos...

some nights just bring it... The ebb and flow of an Emergency Department can be one of the most complex things to predict. Just when you feel that you have things settled, ambulances pour into the ER and line the halls with patients strapped to plastic backboards.
They form a captive group that watches you simultaneously as you rush around and try to move the patients piling up in the waiting room. Abdominal Pain. Chest Pain. Trouble Breathing. And then, interspersed, the Headache that's been constant for over a year. I see a girl who describes a head pressure who was shot with a BB at age 9... she is concerned that the BB is sinking into her skull and causing brain damage.

Just when I feel that I've gotten everyone off of their backboard and I can finally run to the bathroom, a fresh wave of ambulance patients wash into the ER. A young pregnant girl involved in an assault is placed across from the nurses station. I look over to find her screaming and carrying on. Apparently she was pistol whipped. I can not imagine why..."When the hell am i gonna get seen... i'm pregnant. i've been waiting and i'm in pain. awww hell. i knew i shouldn't have come here. i'm in pain. i've got an open wound and ya'll just letting me sit here. i need pain medicine. and i'm pregnant! i need to call an ambulance. ya'll can't handle this shit! these mutha f#%@$ know i'm in pain and they just walkin' around. i need pain medicine. no one's been in to clean my sh%#. i need pain medicine! i've got a head injury and an open wound! i need pain medicine..."

the chant is incessant. but i'm working as hard as I can. I ask a nurse to take her some ice for her head. 4 left to see. She has a 3cm L eyebrow laceration. I move faster. She continues yelling. The belligerence is starting to concern other patients. I call the patient advocate. 3 left to see. Continued yelling. Cursewords hurled through the air. I contemplate calling security. No change.

"Ma'am, we are doing the best we can and I am going to come and see you soon. Please do not yell as we have children and other patients in the ED. I promise I am doing everything I can to get to you but we have a lot of critically ill patients tonight." 2 left to see. She was quiet for a few minutes, but begins to get up and pace in the room. The yelling starts again and then she finds the call button. I think to myself, "now i'm going to stop rushing".

By the time I see her, there is no more bleeding. She waited just over an hour to be seen. The wound is a sharp, linear laceration along her L eyebrow. I explain that I am going to take my time to minimize the scarring and perform a good repair. I explain she'll have a scar but that is she stays out of the sun, the scarring will be minimal. I tell her I've got good hands. And then, almost instantly, she begins to cry. I don't mean a few tears, I mean bawling. In the middle of choked tears and snot running down her face, she apologizes. A garbled "I'm sorry for this..." escapes her. It was as if the thorn had smoothly been plucked from the lion's paw. She cooperated and we finished the repair. She thanked me. And then I discharged her.

These nights teach me that patience is a virtue that I have to cultivate... I am not here to judge. After all, we are all, only human...

its not a tumor...

Before I could sit down last night, the loudspeaker crackled overhead asking for "KEG to Trauma 1". With fresh legs, I jumped. I moved quicker than expected and took the hallway in a few quick strides. Two weeks off from the ER leaves each synapse exploding with double-shots of neurotransmitter. As I walked through the ED, its prep time. Images of tragic trauma victims strobe through my mind. In those precious few seconds, I've learned to feed off the past. I instinctively conjure the worst cases I've seen, for there is nothing scarier than the unknown...

I push open double doors to find a pale, confused, twenty nine year old. His startled eyes were staring into the bright trauma bay lights, pupils as wide as shiny black peacoat buttons. Awake and no one home... and all I could think was 'bad'... severe head injury, intracranial hemorrhage, tumor, anticholinergic toxidrome. When you're holding a hammer, everything looks like a nail.
One of the nurses says something about a history of inoperable brain tumor. As I quickly examined him I called out for a stat head CT. "Let's get him to scan in 3 minutes".

I made my way back into the thick of the ED. A few more had trickled in and I jumped right in. Postcoital headaches, a bevy of unexplained abdominal pain, new onset congestive heart failures, and of course, a host of unexplained chest pains. As I circled back to Trauma 1, I saw that the room was empty. Good. He was in CT.

"Dr. Patel to CT"

I ran to radiology. There are few times when ER docs run. Getting paged to radiology is always bad. As I walked in, I found him, mouth frothing, with arms and legs rhythmically shaking. I immediately turned his head, laced the oxygen cannula under his nose, and called out for some ativan. In my relatively short career, I've already seen enough bad to know this was going to be bad. He rolled through the scanner and we hustled him back to the main ED. A few moments later, I cautiously opened up the PACS to bring up his images. Family just showed up.

I wondered how I would break the bad news. As I scrolled through the images, I saw the angry mass lodged in his left frontal lobe. As I was reviewing the CT, his friend ambushed the nurses station and started apologizing. "I'm sorry I took so long... I had to park the car. We were driving and he started shaking in the car and foaming at the mouth. I think he had a seizure...He hasn't been taking his medicine for the last 3 days..."

Its okay. You're right. He's had a seizure. But the tumor looks unchanged. No bleeding in the brain. In my line of work, I love being wrong...