Medical News

Stories From the ED

A young adult woman comes to the ED, having been brought there by her mother for having abnormal behavior. Displaying many of the classic signs of mental illness, she is obviously having a mental health crisis. The mother even said that she woke up in the middle of the night with her daughter standing over her with a large knife in her hand. The doctor considered her to be a threat to her own or someone else’s safety, and subsequently signed the Baker Act paperwork.

As I always do, I am explaining to the young lady that she is being held on an involuntary 72 hour psychiatric hold. I am trying to explain the rules to her- she can’t wear her own clothes, can’t have any of her possessions with her, she will be searched, and she can’t go home.

As I am doing that, the mother keeps hovering and trying to talk to her. The girl keeps trying to negotiate and delay: begging her mother to take her home, asking to go to the bathroom, and looking over my shoulder at the exit, obviously planning an escape. The mother keeps insisting that the girl can’t change clothes with me in the room, needs to be permitted to use the bathroom without a male present, kept blathering on about the woman’s rights, and said that she wanted to “take it all back” and sign her daughter out. I explained that it doesn’t work like that. Legally, once the doctor signs that order, the only person who can cancel it is a psychologist, and that is after the patient is examined by that psychologist. The doctor who signed the order can’t even rescind it.

After over an hour of trying to deal with this, I finally told the mother that she needed to be quiet for a minute so I could do my job. She replied with: “Wow! You’re rude.” I called security to come over so we would have someone that is wearing a body camera there for backup. Then I told the mother: “This is how it’s going to be: Your daughter, my patient, needs to be supervised and has to be within sight of a staff member at all times for her own safety. She doesn’t get to decide who or how that is going to happen, as that is all done according to state law and hospital policy. She is going to take her clothes off and put on these paper clothes voluntarily, or I am going to cut her clothes off and dress her by force. If she resists, I will sedate her. If you continue to impede my ability to provide patient care, I will have you removed. This isn’t a debate, it isn’t a negotiation, and this isn’t a courtroom. That’s how it’s going to be. You can either let me do my job in caring for your daughter and I will allow you to stay, or you can keep getting in the way and I will ask you to leave.”

The patient continued to argue and resist, so I gave her 10mg of Haldol after which we got her dressed in the paper gown, and put her down for her nappy nap. I put a hospital employee in her room as a safety sitter. Mom filed a complaint, and when the charge nurse came over to talk to me about it, she said, “I was waiting for you to have enough of that. You were more patient than I would have been.”

By Divemedic, ago

I Should Know Better

News6 in Orlando has their panties in a twist over 17 people statewide who died after being sedated in Florida over the past decade. Every time I try to comment on an article on this website, it gets censored for violating community standards, because lefties have to be protected from facts.

You have a violent psychotic person that is a danger to themselves and everyone around them. Now explain how you get that violent person under control. There are only a few ways to stop someone who is out of their minds in a violent rampage:

  • You can shoot them.
  • You can sedate them.
  • You can beat them into submission.

Which of those is the least likely to cause lasting harm? The ones who died are being killed because they are using some sort of illegal drug, whose effects can’t be predicted because criminal drug dealers can’t be bothered with things like quality control. The drug user, who already likely has mental issues BEFORE becoming an addict, then becomes violent, delusional, and psychotic.

So an EMS crew administers a sedative. Those sedatives are safe and effective, and get used thousands of times every day in the state of Florida without incident. (Just yesterday, I gave Versed to a 5 year old. She did fine, and all that happened to her was she took a nap) The problem here is that the sedative interacts with the unknown substances that the violent drug abuser is using, and the results are unpredictable, and sadly, sometimes fatal.

Of course they are given without consent. A person who is out of their minds while under the influence of drugs can’t legally give consent, any more than a person in cardiac arrest can. That statement is enough for me to realize that this entire article is clickbait.

Just yesterday, I gave Narcan, Fentanyl, Versed, Morphine, and Dilaudid to patients- some of them without consent. They all lived, because most of them weren’t drug fueled psychotics.

By Divemedic, ago

Complaint

I recently had a complaint made against me at work, which is a rare occurrence. This was a 50 year old woman with a history of diabetes who came in because she had an open wound on her ass. We were admitting her because it was a diabetic sore. When you admit a patient, it takes a couple of hours to secure them a bed and send them upstairs.

She had an A1C of 12.6, meaning that her AVERAGE blood sugar level is 315. At that level, your blood gets thicker, meaning that it can’t perfuse as well, and as a result she had already had one leg amputated. She just isn’t managing her diabetes.

After six hours in the ED, we managed to get her blood sugar down to “only” 177, and had been refusing to feed her because her sugar when she came in was over 400. When I told her she couldn’t eat, she said she would fix that, and took some of her insulin when I wasn’t looking, which caused her blood sugar to drop into the 40’s. Then we had to give her an ampule of dextrose, and it really complicated her care.

She was upset with me that we were sending her upstairs without “fixing the problem” that she came in for. I told her that her problem was caused by her not managing her diabetes, and that continuing to eat sugary foods and not taking her medication would mean losing other body parts, and would eventually kill her. This wound was not something we could “fix” in the ED, and would require a stay in the hospital with specialized wound care nurses working on the wound, and with her constantly trying to eat sweets, it likely would never completely heal.

So she complained about me for being rude. My boss agreed with me, and told me that sometimes people don’t want to hear the truth that they need to hear.

By Divemedic, ago

Lies

The left is ramping up their propaganda for election season.

Of course, that isn’t the price of insulin. Not even close. I give people Insulin in the ED every single day. Here is the cost: less than $40, and that is for a 30 day supply. That includes Novalog, Lantus, and others. The cost is slightly more than a dollar a day, which is nowhere near the $1,300 a month being claimed.

Even if a drug was more than a person can afford, all they have to do is go to the ED. The hospital will give it to them while they are a patient.

The entire post above is a lie. It didn’t happen, or at least not the way that the person creating it wants you to believe that it happened, and that’s before we get into how a restaurant manager only made $35k a year.

I had to left align this picture.

By Divemedic, ago

At Work

At work this week, a couple of noteworthy patients.

The first was a woman who brought in her year old baby because the baby had a purple spot on her tongue and about a dozen red spots on her body, just isolated 1mm red dots. The baby’s tongue looked just like this:

This is called purpura, and the ones on the skin are called petechiae. It can be genetic, or can be triggered by a virus that causes the immune system to misbehave and attack the patient’s blood. So I went to go tell the doctor, who ordered a blood test. Sure enough, the baby’s platelet count was 3,000. It should be between 150,000 to 450,000.

The disease is called thrombocytopenia. It can be caused by a number of different things, this will require more testing. No matter what, it isn’t going to be good news. We transferred the baby to a children’s hospital.

The second one was a fine example of how people abuse the system. A woman came in telling me that she had called in sick to work so her and her boyfriend could spend the day smoking weed. She had no medical complaints, but wanted a doctor’s note for work so she wouldn’t get fired for calling in again.

We ( the nurses and doctors) were offended, but the doctor wrote her note. Why? Because payment rates for the hospital for all patients are set by satisfaction scores, according to Obamacare.

On the business front, we began showing the rental finally. There have been two people by to look at it, but no one has put in an application yet.

By Divemedic, ago

My Answer

Let’s say that you go to the ED with a complaint that could be an infection. The team is going to evaluate you to see if you meet sepsis criteria. I posted about that back in August right here on this blog. If the patient meets sepsis criteria, the nurse will enter a standardized set of orders for tests. Those tests include tests for lactic acid, a CBC, CMP, and if appropriate, COVID/Flu tests, urinalysis, and other tests. If the patient has a lactic acid level of 2.0 or more, they are going to get IV fluids. Lots of them, like 30mL per kilogram of body weight. If you weigh 100kg, that means 3 liters of fluid. The lactic acid level will be checked and rechecked until the level is below 2.0.

So think about this when you consider the cost:

  • The triage nurse and their team briefly evaluates you and assigns you to the appropriate nurse.
  • You then become one of the 3 or 4 patients that nurse is caring for. You get a full evaluation, including an EKG, an IV line, along with blood and urine tests. This nurse has years of education and years or even decades more experience.
  • The lab team then runs the tests, the X-ray team shoots your pictures, a radiologist reviews them and sends the results to your nurse.
  • The ED physician evaluates all of that information and, in cooperation with your nurse comes up with the treatment plan. Then he orders the medications.
  • The pharmacy reviews the patient’s previous medications, condition, and the ordered medication to ensure that this is a safe course of medicine, then releases it.
  • The nurse then triple checks everything and gives the medicine.

In all, a visit to the ED involves no fewer than 12 specially trained medical personnel, who perform tests and treatment across no fewer than 9 different specialties. Each of those people is college educated from a 2 year degree to full on doctors. Most of them have a decade or more of experience. That doesn’t count all of the other people involved from the hospital’s chief nursing officer, the administrative people, janitors, security, and others involved in running a large business.

Now consider that Americans demand flawless health care on a 24/7 schedule, and want to be seen and leaving the hospital in less than 3 hours. Sometimes, we actually meet that deadline. Most of the time, we come close, but there are too many patients there for too many silly complaints. I had a patient this week who came in for constipation and was demanding to know why we were so understaffed that he had to wait an hour and a half to see the doctor.

So if you want to know why it costs $10k for an ED visit, that’s why. The old saying is that all businesses offer one of three services:

  • Good
  • Fast
  • Cheap

You can only get two- if it is cheap and fast, it won’t be good. If it is good and cheap, it won’t be fast. If it is good and fast, it won’t be cheap.

We as a nation demand good and fast. That means it won’t be cheap. On top of it, the patients want to be pampered like they are in a day spa. My patients are frequently more concerned with what I am going to feed them than they are in the quality of their care. They expect to be cured in an hour for a problem that has been years in the making: you are a long term smoker, a diabetic, are 100 pounds overweight, and have high blood pressure, then expect to come in and be cured of your shortness of breath in an hour so you can make it to half priced wing and beer night at your local watering hole. Then you blame the health care personnel when it takes too long.

Another of my patients came in and the first thing he said to me is that he wanted a sandwich followed by a cup of coffee brought to him every hour. I told him that I was holding him without anything by mouth at least until we were done evaluating him, so he demanded to see my boss. When the boss told him the same thing, he told us that we were inhumane for denying him food, then stormed out.

That’s my rant.

By Divemedic, ago

Non-Issue

The left thinks that they have a smoking gun because the White House medical unit ordered thousands of narcotic pills during the Trump Presidency, and the Pentagon says that they were not tracked very well. It isn’t smoking, nor is it a gun.

The White House Medical unit maintains a health clinic for all of the staff members of the White House, the Naval Observatory, Air Force 1 and 2, as well as assisting the Secret Service in setting up and maintaining emergency trauma centers everywhere their protectees go. The office also maintains fully stocked pharmacies at the White House, Naval Observatory, Old Executive Office Building, and aboard Air Force 1. There are 1800 staff members of the White House alone. The WHMU also provides emergency coverage for more than 1.5 million annual visitors to the White House and guests of the President, as well as national and international Heads-of-State and diplomats when they are in Washington, DC. So the amounts ordered aren’t really that remarkable.

The same doctor has been assigned to the WHMU since1995, and has been its director since 2000- more than 24 years. He is an Air Force Brigadier General by the name of Richard Tubb.

As an ED nurse, I see between 10 and 30 patients a day, most days. On any given day, I give controlled substances like Fentanyl, Dilaudid, Morphine, Norco, Xanax, Valium, Versed, and others a dozen or more times per day, and I am not filling prescriptions like a pharmacy, I am personally administering them.

The difference here is that our medical staff at the hospital have a pharmacist who checks every medical order for safety. The doctor writes the order, the pharmacist checks to make sure it is safe, then releases it. The nurse retrieves it from the automated dispenser, then administers it to the patient after also checking to make sure it’s a safe and appropriate medication. That’s right- at least three different people check to make sure it’s safe.

Not so in the WHMU. The providers are directly administering the medications without a pharmacist or nurse backstopping them. This makes errors more likely, but it doesn’t mean that the drugs are being abused.

The fact that some drugs weren’t well maintained doesn’t mean that Trump or someone on his staff was abusing them, it just means that government workers, being immune from fines for not tracking narcotics or lawsuits from improperly dosing or prescribing them don’t bother to do so. They track their controlled medications like law enforcement tracks their firearms. That is to say, not very well.

By Divemedic, ago

Stupidity

A woman is claiming that her child’s Easy Bake Oven gave her family carbon monoxide poisoning. This is why people shouldn’t use Google to self diagnose medical problems. The Easy Bake oven uses a lightbulb to generate heat. There is no open flame, thus no combustion. Since carbon monoxide is a product of incomplete combustion, this isn’t the culprit.

The second issue here is that a pulse oximeter allegedly showed 89 percent. This is not caused by CO for technical reasons. See, a pulse oximeter works because hemoglobin that is bound to another molecule absorbs certain frequencies of red light, while hemoglobin that is not bound to another molecule does not. The pulse oximeter shines two frequencies of red light through the body, and measures how much one is absorbed over the other. The result is used to calculate the proportion of bound hemoglobin versus unbound that is passing through the beam.

Carbon monoxide poisoning is caused because CO binds to hemoglobin 200 times more readily than does oxygen. This causes the hemoglobin to form carboxyhemoglobin, which absorbs that red light as readily as oxyhemoglobin, which is formed when oxygen binds to hemoglobin. This means that the pulse oximeter will show the same number whether it is carboxyhemoglobin or oxyhemoglobin. This phenomenon is called the pulse oximetry gap and makes a pulse oximeter useless for diagnosing CO poisoning.

There is a linear decline in O2Hb (oxyhemoglobin) saturation as COHb (carboxyhemoglobin) saturation increases. This decline is not detected by pulse oximetry, which therefore overestimates O2Hb saturation in patients with increased COHb levels. The pulse oximetry gap increases with higher levels of COHb and approximates the COHb level. In patients with possible CO poisoning, pulse oximetry must be considered unreliable and interpreted with caution until the COHb level has been measured. [Bozeman WP, Myers RAM, Barish RA: Confirmation of the pulse oximetry gap in carbon monoxide poisoning. Ann Emerg Med November 1997;30:608-611.]

The fire department found no signs of CO in the apartment, but the couple claims that this was due to the oven having been unplugged 8 hours before.

This entire story is stupidity, and newspapers should be sued for publishing garbage like this with no corroboration other than some moron’s Google search. If you are going to make a claim like this, at least do a little research. Layers of editorial research my hairy ass.

Because I am getting used to providing evidence based resources:

Barker SJ, Tremper KK, The effect of carbon monoxide inhalation on pulse oximetry and transcutaneous PO2. Anesthesiology. 1987; 66: 677-679Gonzalez A

Buckley RG, Aks SE, Eshom JL, et al. The pulse oximetry gap in carbon monoxide intoxication. Ann Emerg Med. 1994; 24: 252-255

Gomez-Arnau J, Pensado A, Carboxyhemoglobin and pulse oximetry.Anesthesiology. 1990; 73: 57

By Divemedic, ago

Ventilation

The lungs are the organ that allows oxygen to enter the body and carbon dioxide to leave the body. They accomplish this by permitting gas to enter small sacs called alveoli. These sacs allow the exchange of gas across their membrane. The alveoli stay open through the use of a surfactant. In an infection, it can travel to the lungs and cause a potentially fatal condition called acute respiratory distress syndrome (ARDS). In ARDS, the alveoli fill with a fluid that is essentially pus, which diminishes the lungs’ ability to provide vital organs with enough oxygen. There are ways that we can fight that.

If the patient is conscious and able to keep their own airway open, we can put them on CPAP or BiPAP, which is a mask that pressurizes the air that the person is breathing. This extra pressure forces the fluid out of the alveoli and back into the bloodstream. If a person can’t maintain their own airway, they will be intubated and placed on a ventilator. That ventilator will provide pressurized oxygen, and this is called PEEP. You can see it at work here, where a mechanical ventilator is working on a set of pig lungs as a demonstration:

As doctors have gained more experience treating patients with COVID-19, they’ve found that many can avoid ventilation—or do better while on ventilators—when they are turned over to lie on their stomachs. This is called prone positioning, or proning. Because of how the lungs are positioned, this lets you use parts of your lungs that aren’t being used when you are on your back, because it reduces pressure from the heart and diaphragm on the lungs, which allows them to inflate more easily.

If we are talking about emergency intubations (IOW not for procedural reasons), the only people who get intubated and placed on a vent are really sick. People colloquially refer to this as “being on life support.” Anyone can tell you that a person who isn’t adequately breathing on their own is pretty sick. So, for starters, anyone who is being intubated is a pretty sick puppy.

The most common complications in COVID-19 infections are bilateral pneumonia which may progressed to ARDS, sepsis and septic shock, acute kidney injury and others such as acute cardiac injury, coagulopathy, hyponatremia (low sodium levels in the blood) and acidosis (blood Ph too low). Complications are more likely in serious sickness versus non-extreme illness.

On top of that, there are risks for mechanical ventilation: overinflating the lungs, oxygen toxicity, and other issues are possible complications. These complications are more likely in people with ARDS, diabetes, high blood pressure, chronic heart or lung disease, and obesity all are at higher risk of complications from mechanical ventilation. You will recall that these same risk factors also make a patient more susceptible to COVID.

If your COVID infection is bad enough that it is collapsing your alveoli, you likely have problems with other organs as well- specifically the liver, heart, and kidneys. Remember- the same cytokine storm that is damaging the lungs is also damaging other organs as well. This can cause the development of something called MODS (multiple organ dysfunction syndrome). What causes about 20% of COVID deaths is MODS, and is not due to the use of a ventilator. Three quarters of the people who developed MODS already had underlying problems like kidney or heart disease, diabetes, or were morbidly obese.

The simple fact is that we in health care are using other methods for treating low blood oxygen caused by COVID, such as high flow devices (up to 60 liters of oxygen per minute) to try and delay or put off the need to mechanically ventilate a patient, but once you are sick enough from COVID to need a ventilator, you are really sick and your likelihood for surviving is low.

By Divemedic, ago