Shiloh County Medical Center - Emergency Department

[Chris07 10]

Shiloh County Medical Center

 

Edited January 15, 2020 by Chris07

[R. Dunne]

*It isn't much long after I hang the calcium chloride that we pull into County's ER. I move my drip to the IV pole on the stretcher and switch oxygen over to the portable. A quick visual once over makes sure no lines or wires will snag and we pull her out. As we walk in the door, I'm met by some staff at the front ambulance reception.*

'Hey, we have the 80 year old hyperk we called in about. What room.'

[Dr. C. Grant]

*I'm sitting at my computer at the nurse's station in Resus, looking over a chest XRay for a patient in ER North. The resident physician is standing over me.*

'Looks good. You can send her home.' I say to him. 'Alright. I'm gonig to send her with Tessalon Pearls and PCP follow-up.' he tells me.

'Yeah. That's fine.' I say.

I see an ambulance crew coming into ambulance triage. I can hear a nurse point them to Resus 5. As I'm about to get up and go see what this patient is about, a first year resident comes up to me.

'Hey. Dr. Grant I got one for you.' the resident tells me, ready to give me the lo-down on his patient.

*I maximize my Microsoft Word document on the computer. I have a running list of patients and pertinent info on there to help me keep people straight in my mind.*

'Whachya got?' I say ready to type.

'32 year old female with history of menorrhagia presenting with shortness of breath and chest pain for the past few hours. No alleviating factors, but made worse with deep inspiration. She says pain i localized around the fourth/fifth rib at around the costochondral border. She's on OCPs, but denies edema, calf pain, prolonged immobility, surgeries or trauma...'

*I type while listening*

'...she doesn't have any hemoptysis or anything like that either. Her blood pressure is normal but her heart rate is 108. On physical I'm able to reproduce her pain with palpating the 4th-5th costochondral junction. Her lungs are clear. EKG shows sinus tach. Calves are non-tender.'

*He hands me the EKG. I look at it, sign & date it.*

'What do you want to do for her?' I ask.

'I got a troponin running to rule out cardiac. I can't PERC her out because she's new on OCPs and her heart rate....'

'Oh. She just started taking OCPs?' I ask.

'Yeah....sorry...she started 2 weeks ago to control menstrual bleeding.' the resident replies.

'Any family history of anything?' I ask

'No. Nothing.' he replies.

'Ok...so what are we doing?' I ask again.

'Troponin, CBC, CMP, Chest XRay. EKG we got done already...' he starts.

'Are you concerned about a PE?' I ask.

'Definitely. I say we just D-Dimer her. I think she's relatively low risk, and I think this really fits a costochondritis picture more than anything.' he answers.

'I think so, but we have to make sure. She's got a few risk factors here so we can't really sit on it. If the dimer's positive then we'll have to CTA her.' I say in response. 'Make sure to get a urine pregnancy too.' I say.

'Okay. Sounds good.' the resident says as he walks away.

I can see the ambulance crew just transferred their patient over to the bed in Resus 5. One of my residents is already in the room listening to the report from EMS. I get up and walk over to the room. They have just finished up the report. I catch the paramedic on the way out of the room as I'm about to enter. 

'What do you guys have?' I ask quickly.

 

[R. Dunne]

*We're directed over to resus 5 and I do a quick once over, protecting the slack on my IO as we move her over. I speak quickly, giving a quick rundown of the patient to one of the docs and the nurse. I step out of the room once I've given my report - I know I'm going to have a shit ton of paperwork when this is all over with. Once I step out of the room, Dr. Grant stops by me on the way into the room, asking what we've got.*

'Hey Doc. We have an approximately 80 year old who presented with difficulty breathing and altered loc. History of ESRD, diabetes, and COPD. Hasn't been to dialysis in several weeks. She is hypoglycemic, tachypneic, bradycardic with a sine wave presentation, and hypertensive. I left a last set with the nurse in there. Significant edema in upper extremities, and it's noticeable in her trunk as well. I have an IO in her left humeral head, with calcium chloride running. I was able to improve work of breathing with a neb, and got her sats up. Anything else you need from me?'

[Dr. C. Grant]

*My eyebrow furrows*
”Where is she coming from? Home?” I ask perplexed. 
“Why has she not been going to dialysis?“ I ask.

[R. Dunne]

'She's coming from a nursing home, family says she's been refusing to go.'

*I glance at my clipboard, at the notes I hastily scrawled.*

[Dr. C. Grant]

*I shake my head*

'That's unreal.' I say amazed.
'Any family come with you guys? What's her baseline mental status?' I ask

As I get my answer I start walking into the room, and stop before entering.

'What was the sugar you got?' I ask.

After I get my reply, I thank Dunne and walk into the room.

Edited February 19, 2020 by Chris07

[R. Dunne]

*I look back up at the doc as he asks just a couple more follow up questions.*

'Family says she's normally pretty with it. They should be here shortly, they were following. We were only able to get a bgl of low. I did give glucagon - it did improve her mentation somewhat, temporarily.'

*I nod at Dr. Grant as he walks into the room and I realize I'm still gloved up. I shake my head at myself and take them off, tossing my clipboard on the unmade stretcher and rubbing my eyes with both hands. I sigh, and grab several cavi wipes to begin cleaning all of the equipment up. I'll work on this report later.*

[Dr. C. Grant]

I walk in to find the resident doing a physical exam. The nurse is trying to get an IV. Behind me two more nurses come in, one of them with the EKG cart.

*I walk up to the patient, trying to stay out of the way of everyone working*

'Hey there. I'm Dr. Grant, can you hear me?' I say loudly looking at the patient. She mumbles. She looks out of it. She doesn't seem to be breathing too well. I look up at the monitor:

Pulse Ox is fluctuating between 89% and 90%. The blood pressure comes back 211/124. Heart rate is 58.

I grab her shoulder and give a good squeeze to try and get a response. I say: 'Are you there?' as I give her shoulder a good squeeze.

She lets out a little moan and moves her arm a bit and looks over at me slowly. I can see puffiness to her face and eyes.

'There we go.' I say.

'Can you tell me your name?' I ask her loudly. She mumbles something unintelligible.

She's altered.

'Why haven't you been going to dialysis?' I ask loudly as I pull out my stethoscope and start listening to her lungs. She doesn't reply, but I can hear her lungs are full of fluid.

I listen to her heart and hear a small murmmur and S3 heart sound.

'She's completely fluid overloaded' the resident says over to me. 'Look at this.'

I look down at the patient's arm. He pushes his finger into her arm and then removes his finger. A depression of where his finger was remains in the skin.

'Jeez' I say softly. 

'Okay, everyone, stop what you're doing while I get this EKG.' a nurse says. I walk over to the EKG cart and take a peak at the screen. It's full blown sine waves.

'I'd say her potassium's a tad high.' the resident says as he looks at the EKG screen. 'I'd say she's pushing a potassium of 9 to 10'

'Pfft. I bet it's higher.' I say in reply.

The EKG is captured and starts printing.

'Doctors...you guys want Calcium?' one of the nurses asks as she gets an IV in place.

'Yeah. Lets do a 1000 of Calcium Chloride' the resident replies.

'...and lets give her an amp of D50 and 20 units of insulin.' the resident says.

'What's the sugar?' he asks.

'89' on of the nurses says out loud.

'Make sure you watch her sugar. If you need to just give her another amp of D50.' I say over to the resident. 'I'd rather get her sugar a little high than bottom her out. We can always give her more insulin.'

'Yeah....what do you think about a nitro drip?' he asks me.

'It can't hurt. I mean she's so fluid overloaded I'm not sure how much it'll work. She needs dialysis is what she needs.' I say looking over at him.

'Yeah.' he agrees.

With oxygen her Pulse Ox increases to 94%.

'She's working to breathe too.' I say to the resident.

'Yeah. I really don't want to have to intubate her.' he tells me.

'We may have to.' I say to him. 

Nurses and techs are drawing blood and prepping medications.

'Make sure we get nephrology rolling.' I say over to the resident. He goes over to a phone in the room and sends out a page to nephrology.

Edited February 19, 2020 by Chris07

[Dr. C. Grant]

*I sit at my computer at the nurses' station review some residents' patient care notes and signing off on them*

'Dr. Grant.' I hear from behind me. I look, and it's one of the residents under me this shift.

'What's up?' I ask, continuing to read the computer screen.

'You know my septic abdominal pain patient?' he asks.

I immediately recall the one. She's incredibly sick, with what I can almost guarantee is a ruptured appendicitis, although the CT scan was inconclusive. Not good for a 22 year old girl.

'Yeah. Did you call surgery?' I ask.

'Yeah, I talked to Dr. Moss and he....'

'Wait, Dr. Moss? You talked to Dr. Moss?' I interrupt.

Dr. Moss is the assistant chief of surgery. A Harvard man, well published, well accomplished, full of himself, and quite the A-Hole.

'Yeah...he refused to accept her.'

'Are you serious?' I say looking up from my computer screen and looking directly into the resident's eyes.

'Did he even come down to see her?' I ask.

'No. He said it was a GYN problem and to call the proper people next time.'

'Did you relay your exam findings?' I ask

'Of course, but he wouldn't hear it. I tried arguing with him but he just told me to mind my place and hung up.'

'Woah...woah...woah....You argued with Dr. Moss?' I ask shocked.

'Yeah, I mean I'm trying to advocate for my deathly ill patient, and he won't even send a resident to come see her.' he tries to explain.

'No. Man, you don't argue with attendings. Ever. If you have an issue with an attending, you come to me. I'll argue with them, because that's MY job. ESPECIALLY Dr. Moss. Okay?' I say sternly.

*The phone rings in the background as a clerk answers it*

'Yeah, I'm sorry. I just let my emotions get the best of me.'

'What did you say to him?' I ask curiously.

'Well...'

*I'm interrupted by the clerk*

'Dr. Grant. Dr. Moss on line 2' she says.

'Well that didn't take long.' I say as I pick up the phone.

'Hello Dr. Moss' I say pleasantly.

'YOU NEED TO TEACH YOUR RESIDENTS SOME MANNERS.' he shouts to me.

'Well Dr. Moss, what seems to be the problem?' I say as pleasantly as possible.

'ONE OF YOUR DAMN RESIDENTS, DOCTOR....DOCTOR HARRIS OR SOMETHING JUST HAD THE NERVE TO QUESTION MY ABILITY TO BE A PHYSICIAN.'

'Well I'm sorry to...'

'I EXPLICITLY TOLD HIM THAT HIS PATIENT WAS NOT A SURGERY PATIENT BUT TO REFER HER TO GYNECOLOGY, AND HE TOLD ME THAT IF I WAS HALF THE PHYSICIAN I THOUGHT I WAS I'D AT LEAST COME DOWN AND LAY EYES ON HER.'

'Oh...well Dr. Moss I...'

'WHAT THE HELL DO YOU DO DOWN THERE IN THE ER? ALLOWING YOUR RESIDENTS TO TALK TO ATTENDINGS LIKE THAT? DON'T YOU TEACH THEM ANYTHING? MY RESIDENTS AT LEAST KNOW HOW TO SHOW SOME RESPECT.'

'Dr. Moss, I apologize. I've spoken to the resident about it already. He was just trying to advocate for his patient and let emotions get in the way. He's sorry, I'm sorry, it won't happen again.'

'WELL IT BEST NOT'

'...but given the circumstances, perhaps he wasn't all that far off base?'

'EXCUSE ME?'

'Dr. Moss, this patient is clearly a surgical patient. She septic and peritoneal. Febrile at 103, her blood pressure is low, her white cells are through the roof, I think it would be prudent to at least have a resident come down to look at her.' I try and explain calmly.

'Are you a surgeon now Dr. Grant? The CT scan is doesn't show anything. Your resident said she has multiple sexual partners and doesn't use protection. That sounds more like Pelvic Inflammatory disease to me. Therefore its a GYN issue, not surgical.'

'With all due respect, I've never seen PID present this way. Look, all I'm saying is she at least deserves someone to come down and lay eyes on her.' I say trying to be diplomatic.

'Listen. My service is bursting at the seems. I have no one to spare. The CT is clear, the girl works as a whore, she's got PID, not my problem.'

*I'm disgusted by what I hear. I'm getting mad.*

'Are you honestly refusing to see this surgical consult?' I ask.

'YES. SHE IS NOT A SURGICAL PATIENT.' he says getting frustrated at me.

'So you're going to make that determination without even seeing her? What kind of physician are you?'

*What the hell am I saying. Do I know who I'm talking to?*

'ARE YOU QUESTIONING MY ABILITIES?'

'No. There's no question. It's just that even the medical student I sent in to see this patient believes she has appendicitis. The fact that you refuse to even accept the possibility is more than enough evidence of your abilities. Apparently the student and resident have more sense about them.'

'YOU WATCH YOURSELF...'

'No. Perhaps it's better she not be seen by your service. Perhaps she'll get better care elsewhere....where...you know...they'll actually come down and see her before the write her off to die.'

*I hang up the phone*

*I take a few deep breaths*

What the fuck did I just do? Did I really just tell off the assistant chief of surgery?
I'm numb.

*I look up and notice that the room is completely silent. A few nurses, the clerk, and the resident are all just staring at me in disbelief. My resident's jaw is wide open.*

I snap out of my daze as the room starts to move again.

*I pick up the phone and start to dial*

'Yes. Page Dr. [Director of the ER] for Dr. Grant at x2302 stat'

*I hang up the phone*

'We need to get someone to see this girl.'

[Bling Bling]

Bling bling come into the er wit da chess pain. i smoked a lotta crack today. "HELP, I GOT DA CHESS PAINS, MY NAME BLING BLING" I yell in da er. I need some dat help.

dis da 2nd time i come to da hopspidal. furst time i aint get no help

[Dr. C. Grant]

I hear Bling Bling make a commotion out in the ambulance entrance. Security is starting to descend on him. Everyone rolls their eyes. We all know Bling Bling. His statements are false. He was just here 8 hours ago sober. He's taken another hit since then, so now he's back.

Wonderful.

Security starts to haul Bling Bling out of the door.

'Hold on. You can let him go. Stick him in Resus 7.'

'Isn't that room broken?'

'Isn't Bling Bling broken?' I mutter to myself.

'Stick him in Resus 7 and do the workup on him.'

Security starts to lead him to his room. As he passes I ask him a very important question:

'You want turkey or ham sandwich today Bling Bling?'

Edited February 25, 2020 by Chris07

[B. Hunn]

I briskly stride down the hallway to the room, my holistic physician said to make sure I walk with more of a purpose. No one escapes not getting registered in this hospital. No one. 

 

"WHO DID WE JUST STICK IN ROOM 7. HE NEEDS TO BE REGISTERED BEFORE HE CAN BE TREATED." I yell at the doctor. Stupid doctors don't understand that paperwork comes first. 

[Dr. C. Grant]

"WHO DID WE JUST STICK IN ROOM 7. HE NEEDS TO BE REGISTERED BEFORE HE CAN BE TREATED."

'He came in the ambulance entrance, and I thought it best to get him in a room before he starts being...you know...Bling Bling' I say.

*I'm pretty over it today already, especially after yelling at the assistant chief of surgery.*

'Well, he's in room 7. Now that you're here we can register him so we can evaluate his chest pain.' I say walking away.

I got to the computer and rename Room 7 to: "Hotel Bling Bling"

Edited February 26, 2020 by Chris07

[Bling Bling]

I just did buncha crak. dey dont know doe cause dey not dat smart. imma get me a sammich ann runn oudda here. bud if i get my sammich dey get da 5 start review on da yelpes.

[B. Hunn]

I go into room 7, no one escapes my hospital without registration, I am the wall that stands between chaos and order. 

 

"SIR WHAT'S YOUR NAME?"

[Bling Bling]

"MY NAME IS SIR REGINALD JERIMIIAH SMITH DA THIRD, JUST LOOK AT MY ID OR MY KNIGHTHOOD PAPERWORK YOU BICH"

[B. Hunn]

"SIR IF YOU KEEP CALLING ME THAT YOU'RE NOT GETTING TREATED. YOU NEED TO WORK WITH ME SO THAT WE CAN GET YOU TREATED, OKAY"

I am the thin line that holds this place together. The grease in the gears. With fingers swift as a sparrow I type in his information. Surprisingly the information he game me is accurate. I look down at my nails and realize that I'm going to need a mani soon. 

 

"CAN YOU CONFIRM YOUR DATE OF BIRTH AND ADDRESS SIR?"

[Bling Bling]

"I SEENT YOU LOOKIN AT YO FINGURS LIKE YOU GONNA NEED A MANI, BICH WHALES LIKE YOU DONT NEED A MANI. AND I AINT GOT NO HOME. BUT IF IT DID 13415 SEASHORE DRIVE, CAUSE I HAD A MANSHIN ON DA BEACH. BICH."

[B. Hunn]

"WHAT'S YOUR BIRTHDAY???????"

[Bling Bling]

"MAH BIRDAY IS DA SAME AS YO MOMS. 3/22/55"

 

[T. Murdoch]

*As we near the ER, I snatch up the mic to the HEAR radio.*

"County ER, county ER, County Medic 1, emergent traffic."

"Medic 1."

"We're en route emergent traffic, ETA 10 minutes, 89 year old female that is post arrest. Indeterminate downtime, was in PEA. Two rounds ACLS and ROSC. We've got a OPA in, bagging her 10 per minute. End tidal 40. Sinus brady on the monitor with sine waves at about 45. Calcium gluconate drip going in a 16 gauge EJ. IO access to the left numeral head with a dopamine drip at 15 mikes per kilo per minute. Pressure 54/32. Patient reportedly missed several dialysis appointments. We'll see you in ten."

*I hang the microphone back up and sit next to the patient, watching the monitor and debating giving atropine or letting the dopamine work. Just a short minute later, we're pulling up at County. We get the patient unloaded and I walk in, guiding the foot of the stretcher.*

'Where we going with the ROSC?'

[C. Conway]

*Leaning up against the wall behind the Resus Nurse Station I devour my bologna sandwich for lunch.  Not doing anything cause fuck it, I'm on break.  Sure there's a crackhead in 7 and EMS is bringing in another patient but I ain't going to do shit unless I'm told.  I wanna enjoy my sandwich.*

[Dr. C. Grant]

'Chris. You told off Dick Moss. The man plays golf with the chief of staff every Wednesday afternoon for christ sake. How was he not going to find out?' The director of the ER asks.

*I've just been told that the Chief of Staff heard about my little exchange with Dr. Moss, the assistant chief of surgery a little while ago. He's not too thrilled.*

'I mean what was I supposed to do? The man is writing that poor girl off to die. I'm just trying to fight for her, because God knows, nobody else will for her.' I start.

'Look, I get it, but you can't lose it like that, especially with Dick Moss. You know this.' he explains to me.

'He called her a whore. Did you hear that part?' I ask the director. He remains silent.

'This girl, cast out by everyone she knows because she got hooked on drugs, had to support herself by prostituting.' I start.

'...I know...maybe not the best way to solve her situation, but what does it matter? To him, she just some hooker, not worth his time, so he tries to pawn her off on someone else. This is a COUNTY hospital. We take care of all comers here.' I say vigorously while trying to keep my voice down.

'Look I get it, and God knows I agree with you, but you can't let emotion get ahold of you like that. You're a leader down here. You need to keep a cool head and solve the problem.' he says trying to calm me down.

*I sigh and take a deep breath, calming me down.*

'It's just not right. You know how he treats the residents and even us attendings. He's unprofessional. No one likes to call him.' I say trying to remain calm.

'Verbally insulting him over the phone isn't exactly a model of professionalism either. Next time, just take it. Just put on a smile and take it. When you hang up, call me and we'll get it sorted out.' he replies to me.

I remain silent. There is a long pause.

'How is she doing?' he asks to break the silence.

'Not good. She's hypotensive now, altered and on pressors. For all the storm that came with it, at least we got him to come down and see her. The resident and Moss are in there right now seeing her.' I say to him.

We gaze down into ER North where I see Dr. Moss and his resident come out of the patient's room. Dr. Moss sees me in the distance and gives me a dirty look and walks out of the ER. His resident walks over to us.

'Hey, Dr. Grant. You're right, she's incredibly sick. We're going to run her up to surgery right now and do an ex-lap on her...it probably is the appendix, but she's incredibly septic. It's going to be risky.' he tells me.

An intense sense of relief comes over me. At least my fight had some purpose. 

'Thanks for coming down.' I tell him.

'No problem.' he says as he walks off back to the patient's room where surgery staff are pulling her out of her room.

'If this goes to M&M, I can bet my career I'm throwing Moss under the bus.' I say angered that his arrogance lead to this woman's illness becoming so much worse.

'Chris. You were right. Just let it go. It's done, you won, let's move on with our day, now.' the ER director says patting me on the shoulder.

*I take another deep breath*

'Ok.' I say calmly.

'You alright?' he asks me.

'Yeah.' I say look at him in the eyes sincerely.

I see an ambulance crew bringing in a patient. It looks serious. They are heading into Resus 1.

'Looks like it's getting busy, so I'll leave you to your work.' he says as he leaves.

Also, seeing the ambulance crew coming in, a resident gets up from his computer and heads to Resus 1 along with some nurses. We enter the large open room together and hear EMS' report on their patient.

 

 

[Dr. J. Thompson]

*I look up from my computer as an ambulance crew rolls through the door. I see that the patient still has a Lucas device attached and has a couple drips going. This must be the ROSC patient. As the medic asks where he's taking her, I point to Resus 1 as I get up.*

'Let's get her in One. What's the story?'

*I walk into the room with a nurse, putting on a pair of gloves as the EMS crew brings the patient in and gets her transferred over. We get the Lucas device over and the nurse runs a set of vitals on the patient.*

'89 year old female, dialysis patient. Hasn't been to dialysis in around a week. No damn DNR, of course. Call came in as a med alarm with heavy breathing heard on the line. We made entry and found her unresponsive and apneic. She was in PEA with strong sine waves showing. We've done three rounds of ACLS, started a calcium drip, gave bicarb, and have now started her on dope. She's in a sinus brady, still has some sine wave activity, and her pressure is shit. 50s over 30s. And as you can see, she is intubated.'

*I nod.*

'OK, let's get an ECG, someone call respiratory, let's draw labs. CBC, BMP, CMP, troponin. Murdoch, was family behind y'all?'