Medical News

I had a few notable events happen in the ED this week.

• A man was brought in by EMS who was gorked out of his mind and was under arrest by the local gendarmes. He was tweaking hard. Unsurprising to anyone who saw him, his urine tested positive for amphetamines. It seems that he used some meth, beat up his elderly roommate, stole the roommate’s gun, and walked around the neighborhood firing off shots. I spoke with the first cop to arrive, and he told me that he ordered the man to drop the gun, and was only going to tell him once. To treat him, all I could do was give him 2mg of IV Ativan every hour to keep him calm. Two days later, he was still in the PCU and still feeling the effects of the meth.
• A woman came in with abdominal pain and symptoms that made me think she might have COVID. I tested her for it, and she did in fact have COVID. When the results of her abdominal CT came back, she had a large mass in the head of her pancreas that was consistent with cancer. There were also masses in her liver and lungs. The Dr and I had to tell her and her husband that she likely won’t live to see Christmas.
• A 95 year old woman came in after driving her car through the front of a store. She got the gas and brake pedals confused. In her defense, when she learned to drive, there was no brake pedal. All you did was say “Woah.”
• Had a 16 year old with mono, and another one who had spinal meningitis.
• A 30 year old jumped out of the car he was riding in and attacked a motorist in an apparent case of road rage. The target of his ire put the car in drive and ran over his ass. He became my patient, and it took up more than two hours of my time getting IVs, X-rays, giving pain meds, and all of the other things needed to treat an idiot with a blood alcohol of over 300 and a pair of broken legs. He is going to need surgery.
• We got a new director for the ED last month, and she announced that nothing would change. This week, she laid off 25 nurses. The very next day was my day off, and they called me at home to ask me to come in and work a 12 hour shift for overtime.

Posting has been and will be thin. I have a major project coming up that I need to work on.

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.”

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.

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.

Everybody talking about costs. I’m wondering how you end up so dehydrated you need 3 IV bags. https://t.co/zTW4t5qkWb

— Rangermonk (@rangermonk1) February 25, 2024

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.