Medical News

Mammals, or humans in particular as it relates to this post, need to exchange gases. We take in oxygen and get rid of carbon dioxide. The process that we use to do that is breathing. There are two components to that process: ventilation, and respiration.

Ventilation is the mechanical process of moving air (or other gases) into and out of the lungs. Ventilation requires a functioning respiratory drive (provided by the CNS and portions of the PNS), an intact and functioning chest wall, the airways, and lung tissue that is functioning properly. Being a mechanical process, there are things that can affect it: physical blockages of the airway through trauma, inflammation, or even a failure to maintain open air passages because of dysfunction in the nervous system.

Respiration is the actual exchange of gases, first across the alveolar membranes, then into the blood, into the tissues of the body, then back to the blood and across the alveolar membranes to be expelled from the body. This process depends upon the relative pressures of the gases involved. Things like partial pressure, electrochemical gradient, pH, and other factors play a huge role in the moving of gases into and out of the lungs.

Entire textbooks are written on how this process works, so this limited post won’t be an exhaustive treatise on the function of the respiratory system. I want to mention mechanical ventilation and why intubating a patient and placing them on a ventilator is so important.

There are times when a patient’s respiration doesn’t function as it should. Perhaps the process of gas exchange has been disrupted because another gas has more affinity for the chemical reactions that are taking place, as is the case with hemoglobin’s stronger affinity for carbon monoxide than oxygen. Maybe the pH of the blood is shifting, causing gas exchange in the alveoli to cease. There are a lot of reasons why this can stop working as it should, and these can be addressed through multiple means. The simplest of these is simply putting a nasal cannula in place to deliver oxygen at a slightly higher partial pressure. Still, there are times when these tricks don’t work and respiration breaks down.

Once the breakdown in the processes of ventilation and respiration take place, a person will begin to struggle to breathe. The work of breathing increases, and the patient has to put in more and more effort to get a breath. This is extremely tiring. Sooner or later, the person becomes too exhausted to breathe, and slips into what is called respiratory failure. When this sets in, there are again numerous things that can be done to assist the person in breathing. BiPAP and CPAP are two ways to do this. However, if these measures don’t work, or if the person can’t breathe on their own, then someone or something has to breathe for them.

In the short term, a device called a bag valve mask allows medical personnel to breathe for the patient, but this isn’t a long term solution, nor is it very useful for delivering higher levels of pressure to the gases involved.

Ultimately, a person who is not breathing well on their own will wind up with a tube down their throat and a machine called a ventilator doing their breathing for them. This can be done because the person can’t keep their airways open when they are unconscious, like during surgery. It can be done because they have significant damage to the nervous system, for example a broken neck has damaged their phrenic nerve, are simply too tired to breathe, like during an asthma attack, and for a host of other reasons.

Here is a recent, real-life example. Steve is a known IV drug user who was found in his backyard by EMS. He is breathing with grunting, low volume respirations that are clearly ineffective. EMS tried giving him Narcan, but it had no effect, so they began ventilating him with a bag valve mask. Since he still had a gag reflex, they were unable to intubate the patient.

The doctor in the emergency room decides that he needs to be intubated and placed on a ventilator because he is simply incapable of maintaining and protecting his own airway. The staff gives him etomidate to sedate him, rocuronium to paralyze him, then the doctor inserts the tube before a respiratory therapist places him on a ventilator. The process is fast, taking less than 5 minutes.

The drugs used to place the tube will wear off in just a few minutes, so the patient needs to be sedated to keep him from fighting against the ventilator. Drugs like Versed, Propofol, Ketamine, and Fentanyl are used to keep the patient sedated. Of course, those drugs cause side effects that must also be dealt with. It becomes a delicate process of keep the patient sedated to the correct level while also maintaining the other parameters, as well as dealing with the drug overdose and the issues that it caused.

In the above case, the patient had rhabdomyolysis, liver failure, kidney failure, and a host of other issues that had to be dealt with. Dealing with those issues takes time, but unless a patient is breathing, time is what you don’t have. Ventilation buys you that time to deal with it.

There are COVID (as well as influenza and pneumonia) who get intubated to this day. Some make it, some do not. It’s not the ventilation that kills those patients, it’s the sepsis and the immune system’s response to it that kills them. In some patients’ cases, ventilation does more harm than good, but overall, mechanical ventilation is a process that saves thousands of lives per year.

It’s been a busy few days. I was at work one day last week, and we were simply overloaded with patients. In our 100 bed ED, we at one point had more than 220 patients. The waiting room saw every seat full, and some people were standing. Wait times were more than 6 hours for some people to even get a room inside of the department. I wound up working for 15 hours, and even then they asked if I could stay the rest of the night. When I pointed out that I still had to work the next morning, they asked if I could come in 4 hours early. I told them that I needed to get SOME sleep, so then they asked if I could come in 2 hours early. I agreed.

When I went in the next day, having only had time for 5 hours’ sleep, a shower, and a change of clothes, the backlog had been taken care of. My first patient of the day was a septic man who had a sore on his abdomen, and didn’t realize that he had a blood sugar of over 500. His A1C was 12.7, and he didn’t even know that he was diabetic.

My second patient was a 60 year old woman that had begun speaking gibberish the night before. The family let he go to bed. When she woke up the next morning and was still doing it, they decided that bringing her in was a good idea. We did all of the stroke assessments initially couldn’t find anything. Still, because of the delay, she was not a candidate for clot busters, so we did an angiogram of her head.

While we were waiting for the results, a new family member came in and began yelling at me, wanting to know why we weren’t doing a bunch of ridiculous stuff that she thought needed to be done. I guess her extensive Google search had recommended a bunch of things that she wanted us to do. I explained to her all of the things that we were doing, but she kept on making requests and went so far as to begin flagging down every hospital employee she saw to make these demands. She started getting really loud and mouthy. I finally had to tell her to wait in the patient’s room or I would have to call security. She came unglued at that point and said she wanted to speak to my supervisor so she could have me fired.

I know you would never guess that she was an Amish Canadian from Norway.

The patient eventually was transferred to another facility for brain surgery to fix the extensive blood clot that was found, but since the delay of over 12 hours meant that there was a lot of dead brain tissue there, her inability to walk or speak is likely permanent, and that’s on the family.

That mess was followed by a parade of people with sepsis, some diabetics, and a host of other issues. One diabetic had an A1C that was over 14, meaning that it was off the chart. He claimed to me that he always follows his diet and always takes his medication. Of course, he is lying. He doesn’t need to lie to me, it’s his feet, eyes, and life that he is playing with, not mine.

Every patient that I had wanted to argue and tell me that I didn’t know what I was talking about. Keep relying on doctor google and see what happens. As for me, all it does is keep me employed.

Or alternatively titled: Why I Don’t Watch TV.

Nearly every medical show irritates the piss out of me. That’s why I can’t watch those shows.

Chicago Med doesn’t appear to have any nurses- the doctors do everything.
I saw one show where there was a car accident near the hospital and the doctors ran down the street to the scene, snatched the extrication tools from the firefighters’ hands, and extricated the patient from the car.

This is how it works-

• the patient comes in and is triaged by the nursing triage team.
• The patient is taken to an ED bed. The nurse assigned to that bed conducts the initial assessment and orders some basic tests, and maybe even a few medications.
• The doctor reviews the patient’s chart and orders some additional tests and more medicine.
• Then we wait for the results if testing and imaging
• More medications are ordered and the patient is either admitted or discharged

The doctor may appear to see the patient at any point in this process, or may not. There are times when the patient may not even see the doctor until hours after they arrived. It doesn’t mean that the provider isn’t evaluating you- it means that some maladies don’t require him to physically be in the room for most of it.

Not so on TV. On television, the doctors are waiting outside for the ambulance, then they run into the ED with the patient, frantically shouting orders. People see this, and when they come into the hospital are shocked and angered that it doesn’t work like that.

I get at least one patient each day who asks: “So when is the doctor going to come see me? I’ve been waiting for an hour.” In reality, the doctor and I have been in constant contact, you have an IV, blood has been drawn, a CT scan was ordered and done, you have received three or four medications, and we are awaiting the results of all of that testing. It’s remarkably efficient, fast, and maximizes the wise use of everyone’s time.

Even shows about EMS and firefighters is nothing close to reality. I once watched a show where a paramedic needed to deliver a shock to a patient in cardiac arrest, but the patient was lying in a puddle of water. He then placed the paddles on the patient’s chest (paddles are largely a relic of the past) did a handstand on those paddles to get out of the water, and shocked the patient.

I can’t tell you how many times someone has said to me: “Why aren’t you doing X? It always works on Greys Anatomy/Chicago Fire/Rescue 911.” People watch this stuff and think that it’s a documentary.

The few times that my wife tried to get me to watch shows that cover topics in which I have some knowledge, I spent the entire time rolling my eyes and making comments. She doesn’t watch them while I am around any more.

The only thing that all of those shows get right is that there are tons of people who work together that are having romantic affairs. Every hospital seems to have a doctor or two who enjoys diddling the nursing staff, and there are plenty of young nurses fresh out of school who think that they are going to bag themselves a doctor husband, not realizing that they are the fourth or fifth nurse he has bedded this year.

At this point, I just assume that every show on TV is BS. Then there are the people who Google their symptoms or malady and want to know why we aren’t doing what Google recommends, but that is another topic entirely.

Hospitals have a hurricane plan in Florida. The employees of the hospital are split into two teams: Team A, and Team B. Team A reports to work about six hours before the storm begins and remains at work until the storm has passed. Team A is divided into a day and a night shift, and they sleep in unused rooms of the hospital for the duration. Team B reports to work once the storm has passed, and works shift work until the hospital returns to normal operation. Team B gets to go home when they are not actually working.

There are benefits to both teams. Team A gets paid for the entire time they are there, and even though the rate of pay is lower while you are sleeping, you ARE still getting paid to sleep. Even when Team A is actually working, there isn’t really much work to do, as no one comes into the emergency department during the storm. During Hurricane Milton, there were 98 nurses on Team A, and they had a total of 12 patients.

Team B gets to go home when their shift is over, but your home may not have power, and the hospital is usually really busy. You definitely earn your money. There are no mid shifts on the hurricane teams- there is only Day shift (7 am to 7 pm) and Night shift (7 pm to 7 am).

The team you are on is up to you. In March of each year, they ask everyone what team they would like to be on for that hurricane season. I would rather be home caring for my wife during the storm, so I always select team B.

Team A reported to work at 7 am on Wednesday. They stayed at work until Friday morning at 7 am. That’s when Team B came in. I was on Team B days for Hurricane Milton. I was assigned to the Red zone, and I got the three lowest numbered rooms: room 4, 5, and 6. Since they are the lowest numbered rooms, you have two jobs- you support the nurse assigned to the three trauma rooms and take care of the sickest patients.

Let me tell you, there was a lot of sick people in the aftermath of Milton. On day one, every sedentary 50-something year old man who was trying to clear storm debris found out whether or not his heart was healthy. I had a parade of middle aged men who reported the same complaints- “I was working outside, cleaning up, when all of a sudden, I got dizzy, cold, and broke out in a sweat, then my chest and left arm started hurting.”

I sent half a dozen patients to the PCU on day one. I was slammed with unstable cardiac patients with high troponin levels who had to be Heparinized. The very first patient of the day had been clearing storm debris and felt tired, so went inside the house to lie down. There was a generator running in the garage. When the wife went inside, she found him lying on the floor, gasping like a fish. He didn’t make it. His CO levels in his blood weren’t really elevated, so it looks like a heart attack from exertion. Hurricane related death.

I went home exhausted, got home at about 8 o’clock, and was in bed asleep by 8:45.

Then came day two. That day was stroke and sepsis day, on top of the heart attacks. Some of the high points:

• I had one patient who was on four different drugs for the heart attack she was having, and I took her to the ICU with a central line, heparin, amiodarone, and pressors running. I was glad to get rid of her, she was taking a lot of effort to care for.
• Then there was the nursing home patient who pulled out his G tube during the hurricane.
• There was a woman who came in complaining of a headache, dizziness, and vomiting since Wednesday night. At first I wondered why triage sent her to my rooms, but they must have had a hunch. Her head CT showed a large area of infarct (dead brain) in the rear of her brain. She had a stroke during the hurricane, but didn’t come in until it was to late to give her TPA. The damage is permanent.
• A guy who was working in his yard when his 4 pit bulls who were overstimulated from all of the activity decided to use him as a chew toy. He had over 40 puncture wounds, including his cheek being ripped open to the point where you could see his teeth while his mouth was closed. They also tore off his right ear, and tore a 3 inch gash in his right thigh. The man’s brother came in an hour later to tell my patient that he had shot all 4 dogs because he couldn’t get them under control.

Most of the day, our 100 room department had only 30 or 40 patients. So, at 3:30, admin decided to send a quarter of the nursing staff home to save money. I took over one of the trauma rooms, so that I had Trauma 3, 4, 5, and 6 as my rooms. At 4 o’clock, all hell broke loose. I went from having 2 patients to having 4 in less than 15 minutes- with one of them being my sickest of the day:

A woman who was in septic shock that came to me unresponsive with a Lactic acid level of 3.4 and a white blood count of 24. Her blood pressure kept dropping- at one point to as low as 72/50. Her rectal temperature was 96.4 degF. Cold sepsis as it is called, is a very ominous sign. Patients in cold sepsis are frequently on death’s door, especially when they have a low blood pressure. She got three IV lines, 3 liters of lactated ringers, as well as the antibiotics Vancomycin and Rocephin.

I got her stabilized, but then she started shitting watery diarrhea every 5 minutes. I had to stay late to help night shift clean her up. I also earned points with the night shift by inserting the Flexi Seal for them. If you don’t know what that is, it’s a plastic tube you stick up a person’s ass, and it directs fecal matter into a bag. Ah, the glamorous side of nursing that no one tells you about.

So I got home from day two at about 9 pm, and was in bed by 9:30. I slept in on Sunday.

That’s it for my work journey from Hurricane Milton.

Day One

I was working in the red zone when a patient came in and went into cardiac arrest in the lobby. I went to the trauma room, and was put in charge of the code cart. That means you draw up the medications, run the defibrillator, and deliver shocks as needed. You don’t usually look at the patient, as you are busy with other things. When I did look over, I realized that the patient was the 30-something year old son of an old friend. The last time I saw the kid, he was still in high school. The entire time we worked him, his wife was in the room. We had offered to take her to wait in the chapel, but she refused to leave the room. When the charting nurse said, “Time of death, 6:17” the wife let out the most anguished scream. It was something that you felt all the way to your soul. I spoke with his father, who told me that parents aren’t supposed to bury their kids, and asked me in anguish what he was supposed to do next. It’s much harder to stay detached when it is someone you have known since he was born. I had trouble sleeping that night because of it, and woke up at 3 am before staring at the clock for an hour and a half. I wound up only getting about four hours of sleep, not nearly enough after a day like that.

There was the man who lived in a group home because he was mentally retarded. He came in with stomach pains, but couldn’t tell us what was wrong because he is mostly non-verbal. It turns out that the group home served him refried beans the night before, and he needed to take a gassy deuce.

Day Two

Day two saw me assigned to the green zone because I think that they were feeling sorry for me from the previous day. That day was rough because I was sleep deprived. A woman was angry because her teenaged daughter was diagnosed with COVID, and we were sending her home with instructions to take Tylenol. The woman wanted us to write her a prescription for the Tylenol so Medicaid would pay for it, because she didn’t want to pay for it herself. So of course we did, gotta have those Press-Ganey scores to get paid under the Obamacare rules, you know. Your tax dollars at work.

Day Three

I was in triage for day three. A guy came in complaining of abdominal pain. Said he hadn’t seen a doctor about it. Then I pulled his chart, and an alert came up that he had just been seen at another hospital 30 minutes away. He was just discharged 35 minutes before for the same problem. He said in response, “Yeah, but they didn’t give me what I want.” He has been seen 14 times in one ED or another over the past three months. But we can’t say no, thanks to EMTALA. So again, your tax dollars at work.

I slept in this morning, then went to a local eatery for some chicken fried steak and eggs breakfast. I paid extra for onions in my hashbrowns. Now I have to get prepped for our next hurricane, set to arrive on Tuesday. So this is all of the posting you get today.

The left is claiming that a woman who died after she elected to get an abortion is the fault of Republicans. Amber Thurman died while she was getting an emergency D&C that was needed because she took an abortion pill and had a reaction that caused a large amount of hemorrhaging. The timeline is telling:

Thurman discovered she was pregnant with twins in the summer of 2022. She made the decision to kill her unborn child after she had moved out of her family’s home into a gated apartment complex and had plans to enroll in nursing school. A child would have spoiled those plans, so the most convenient thing that she could do was kill the inconvenience.

Thurman had wanted a surgical abortion in her home state, but at nine weeks she sought care at a clinic in North Carolina. The clinic gave her mifepristone and misoprostol, otherwise known as an “abortion pill.”

After taking the pills, Thurman experienced cramping, but her condition worsened over several days with vomiting and heavy bleeding. She was transported to Piedmont Henry Hospital in Stockbridge, Georgia, on the evening of August 18, where doctors discovered she had not expelled all the fetal tissue from her body.

She died during the surgery that followed. Georgia’s maternal mortality review committee, which includes 10 doctors, concluded that there was a “good chance” that Thurman’s death could likely have been prevented if the D&C had been provided earlier.

Maybe, but then again, maybe not. There is no way to be certain. What caused this woman’s death is not a delay in surgical intervention. What caused her death is that she took an abortion pill, but that doesn’t fit the narrative that the left wants to portray.

About a year ago, I had something similar happen when a woman who had taken an abortion pill came in complaining of vaginal bleeding at two in the morning. Over the next hour, I had to give her 2 liters of saline, a unit of fresh frozen plasma, four units of packed red blood cells, and a unit of platelets. All together, that adds up to about 4 liters of fluids- or roughly her entire blood volume. That’s when the on call surgical team came in and took her for her emergency D&C.

There is a price to pay for taking these drugs, and they are much higher risk than the left wants you to believe that they are.

This past week was a busy one in the ED. We are seeing a lot more cases of COVID as of late. I was working in “fast track” one day, which is where our minor illnesses go. I saw six different patients who were positive for COVID. None of them were serious enough to be admitted, and were sent home with instructions to get lots of fluids, rest, and take OTC medications to control symptoms. So we are seeing lots of COVID patients, but none of them are seriously ill.

If you want to know more about how emergency medicine is done, read on. If that doesn’t interest you, then there will be other posts.

The ED is organized chaos. There is a lot that goes into a large emergency room that is seeing hundreds of patients a day. How this is accomplished is that the ED is divided up into zones, each color coded to indicate the acuity of the patients within it.

Gray Zone

Gray is not really a treatment zone. This is where patients are checked in and triaged. The gray nurses decide which treatment zone a patient will be sent to. It’s staffed with two technicians, two nurses, and a registration clerk. Security is also here, because this is where people decide to be assholes. If the ED is really busy, a doctor and an additional nurse (called the pit nurse) get assigned here and began treating the easiest cases out of two exam rooms (called the pit) in gray. The idea of the pit is for people with simple requests like toothaches, wound rechecks, and medication refill requests be treated and discharged within 30 minutes of arriving.

Green Zone

The “Green” zone, also called Fast track, is a subunit of the ED and is entirely made up of patients who the triage unit believes can be treated and discharged in less than two hours. Fast track itself contains three sections:

• Treatment. This area consists of 12 rooms staffed by two or three nurses. The nurses here are usually nurses who are still learning how the ED works. It’s a great area for nurses new to the ED to develop the skills and workflow that makes the ED more difficult and challenging than some other units. The idea of this area is to get the patient assessed, treated, and discharged in less than two hours. The team nursing concept is used in this section, so nurses see a lot of patients in a very fast paced environment. It isn’t unusual for a nurse to see 30 or 40 patients in a 12 hour shift.
• If the patient is not really ill, but we are waiting for some test like the results of a CT scan or some lab work that will take a bit of time, they are moved to RPZ (Results Pending Zone) to await a further clinical decision. RPZ is like purgatory, where a patient waits for the results of those tests to see if they will be discharged or admitted. The patients here have received medication and have been assessed and found to be stable. RPZ is staffed by a single nurse and can contain as many as 12 patients awaiting results, who sit in reclining chairs and watch TV while they wait. There are two rooms here that are used so that the providers can talk privately to patients to discuss lab results.
• Holding. This area is for those times when triage got it wrong, and the patient will be there for longer than two hours. Things like blood administration, medications than take awhile, or patients waiting for an inpatient room on one of the hospital floors. Holding is three rooms, staffed by a single nurse. When I am in fast track, I am usually (but not always) the holding nurse.

Fast track moves a lot of patients through it, over 150 patients a day. The cases are usually mild: toothaches, STI’s, lacerations requiring stitches, FLU like symptoms, and other mild illnesses go here. For that reason, this section sees more COVID cases than any other zone. If the pediatric patient load decreases to the point where they close pediatrics, the children go here for treatment. If patient load drops further, fast track gets closed at either 11pm or 1am. There is one charge nurse that is assigned to both green and purple together.

Purple Zone

Across the hall from green is the purple zone, or pediatrics. It is exactly what it sounds like. It consists of 8 rooms and a pediatric triage room. This zone is staffed by 3 nurses. This is a secure unit that is located behind locked doors. When the ED is especially busy with pediatrics, the gray nurses will send pediatric patients to a separate waiting room so they don’t have to be seated next to the druggies and other people in the gray zone waiting room.

If there aren’t enough pediatric patients, this zone gets closed at 9pm, and pediatric patients go either to the red, orange, or green zone. It’s rare for them to go anywhere other than green, as kids usually aren’t all that ill.

Yellow/Blue Zone

This zone is called “subacute” but it usually is anything but that. With a name like subacute, you would think that this area has patients with complaints that aren’t that serious, but you would be wrong. Some nasty stuff happens in here, and I swear that some of the rooms in this area are located on top of an Indian burial ground or something, because they seem to be cursed. If Red/Orange is full, then any other high acuity patients who come in wind up in Yellow or blue. This area contains 36 rooms that are staffed by 9 to 12 nurses, a charge nurse, and 1 or 2 technicians.

Red/Orange Zone

This zone is called acute care. The patients who are deemed to be the sickest come here. If EMS brings in a patient in cardiac arrest, they come here. Severe respiratory distress comes here. This unit contains 36 rooms that are staffed by 14 nurses, a charge nurse, 3 paramedics, a respiratory therapist, 3 patient care technicians, a clerk, and a lab technician. Three of the rooms are called trauma rooms and are kept empty as much as possible. The most unstable patients are initially put in them, stabilized, and then moved to other treatment rooms as soon as possible. Additionally, there is a room that can be accessed through a decon shower room, and a psychiatric room that is the classic “rubber room,” but thanks to a court case from another hospital deeming that to be inhumane, that room is no longer used for that purpose.

Other staff

Staffing for providers varies, but there can be as many as 6 doctors, a pharmacist, and 2 midlevel providers (Nurse Practitioner or Physician Assistant) in this ED. Also included here are 2 pharmacy technicians, some transporters to move patients around, and two janitors for cleaning rooms. There is also Xray and CT, which are staffed by another 6 technicians, and the lab which is staffed with 4 more technicians, as well as the radiologist who is offsite, but interprets all of the imaging that is done.

So there you have it- a 100 room Emergency Department that, when fully staffed, contains 10 providers, 40 nurses, 20 or so technicians, and 8 to 10 other personnel.

And yeah, this is a filler post, with most of the content written for the day when I needed a post but didn’t feel like writing that morning. (To be honest, it’s because I am out mowing the lawn and doing other honeydew chores this morning.)