The other night, we had a serious trauma patient come in. She was eighteen-years-old and crashed her car off the freeway into a ditch. She was unconscious and severely injured. The whole team moved together to try to save her. I helped an emergency medicine resident pass a breathing tube as the surgeons put in IVs, gave her blood and stabilized her for CT scan and the ICU. I read in the paper two days later that she had passed away. This is what the floor looked like in the trauma room after she left:

“Housekeeping to the Trauma Room” is a pretty common page heard overhead.

When a rape is reported somewhere in our county, police investigate and, if they think a forensic rape exam is indicated, the patient is brought to our emergency department for that exam. The victim is not seen by our emergency physician unless some issue comes up that the specially trained Sexual Assault Response Team (SART) nurse is not able to deal with.

Recently, while the SART nurse was doing the exam, the patient said that being raped had made her suicidal and, when she got back home, she was going to kill herself.

This information was passed to me and I went to talk with her. She was emotionally upset, as you can imagine. She admitted to saying she was going to kill herself but she had just said it because she was upset, not because she was going to follow through on the threat. She just wanted to go home.

This put me in a tough position. By law, if I think patients are suicidal, I have to place them on a psychiatric hold and get them to our psychiatric emergency room for help. If I don’t do so, I have broken the law. This also offers a challenging moral dilemma. If I sent such a person home and she did kill herself, I would certainly be at fault and would feel terrible about it.

We see people all the time who come in on a hold with clear documentation of suicidal behavior who totally deny it once they get to the emergency department. They either change their minds or they lie because they just don’t want to be on a hold. Was this patient like them or was she really just upset and misunderstood by the SART nurse? I had to decide whether to believe that she had just said something that she didn’t mean and let her go home or put her on a hold and send her to emergency psychiatry.

After talking to her for quite a while, I told her I was obliged, under law, to send her to psychiatry to get her help that would not be available if she just went home. When I told her that, she pleaded and begged to be allowed to go home. When that didn’t work, she went ballistic and started hollering and screaming that she was just going to leave.

When she went off, the staff called security. Soon, three big guys in blue uniforms were standing at the door of her room, which only made her more hysterical.

You can imagine how bad I felt. First, she is raped, which is horrible. Now, instead of the calm, understanding environment we try to provide victims of rape, we are threatening to tie her down to a gurney with leather restraints. It made me feel really bad, though I recognized I made the right decision, given the circumstances presented.

Fortunately, she quieted down and went peacefully off to talk with the psychiatrist. When she got there, she was calm and cooperative. She told the psychiatrist she felt safe and was glad she was there. She acknowledged she really needed help.

I was just looking back at my last few posts. They are pretty sad. I decided to share this with you as it lifts my heart a bit.

This is a letter that was mailed to our department from a patient. I think it speaks for itself:

To the Emergency Room Staff of The Medical Center

My name is John Smith. I was a patient at your hospital the night of July 4^th, 2008. I am writing this letter to apologize for my verbal and physical abuse to the members of the staff working that night. I have to admit that I do not remember much of what happened that night due to being extremely intoxicated. I am told that I made threats to kill and that I was spitting on staff members. I cannot capture with words how sorry I am for saying those hurtful things and spitting on people that were only trying to help me. I am extremely embarrassed about my behavior and will be paying for it for a long time to come. You guys have a hard enough job as it is and the last thing you need is some drunk kid making that job even harder. I obviously was having a problem with my drinking and it turned me into a person that I never want to be. I have a long road to recovery ahead of me. I understand that forgiveness might be out of the question for some of you, but I hope that in time you can find it in your heart to forgive me. I would never knowingly want to hurt anyone that is trying to help me and feel a great amount of shame for acting as I did. I just want to say sorry and thank you, thank you for helping somebody who needed it whether they knew it or not.

If you look at all the great cookies recipes I have shared on this blog, you might get the idea I am an expert and alway make perfect cookies. Not so. Thursday, I had a cookie catastrophe. I took the recipe for Chewy Oatmeal Cherry Toffee Chocolate Chip Crisps. I made them exactly by the recipe except that I substituted three cups of cooked quinoa (left over from cookies from two weeks ago) for the oats. The original cookies needed to be flattened a bit before cooking. These spread out and ran together, almost forming a sheet cake. Even when I let them cook long enough that they were dark brown, they were still soft. When I scraped them off of the parchment with a spatula, they came off like putty or clay. I put them in a big Tupperware in the refrigerator where they formed one, big, amorphous blob. There they sit, teasing me with the challenge of coming up with something to do with it. I quickly made up a batch of Tad’s Oatmeal Chocolate Chip Cookies to take to the hospital.

Lesson learned: you can’t just substitute quinoa for oats.

I just hired a PR guy to help me promote my cookies. Here is what I am going to put on every bag of cookies I make from now on:

The Art of the Cookie

Begin with a baker’s soul. Seek the finest ingredients. Explore nature’s infinite variety of flavors and textures – crunchy, sweet, rich… oh, and chocolate.

Entertain inspirations. Embrace decadent cravings. Reward yourself. Open…Taste…Delight.

Actually, I got this off a package of Pepperidge Farms cookies someone left lying around the emergency department. Who the heck writes stuff like this?

We see a lot of methamphetamine-crazed people in our emergency department. One such guy came in the other night. He was in his twenties and was so crazy he had to be held down by multiple staff, police and medics. He was sweating profusely and his stringy hair was in his face. His heart was racing, he was thrashing and he was hollering, though the only word you could understand started with “F.”

He got our usual treatment: leather restraints on all extremities, sedatives, and a close evaluation to make sure nothing else was going on.

All such patients are assigned a “sitter.” This is a staff member who has no other responsibility than to watch the patient to make sure he is safe. When I went back a few minutes later to check on the patient, the room reeked of stinky feet and the poor sitter was stuck there, unable to leave the room. The patient’s shoes and socks were so bad, they had been taken off and sealed inside double plastic bags. I am sure that helped, but his bare feet were also very stinky so the room was no less unpleasant.

I recommended the sitter place plastic bags over the patient’s feet and tape them around his ankles. This he did, with great result in clearing up the air. I couldn’t resist the temptation to take a picture.

A 28-year-old man came in with his mother complaining of chest and abdominal pain after drinking a whole bottle of Fireball Whisky on an empty stomach.  I had never heard of this sweet, cinnamon-flavored alcoholic drink but got the rundown from Xavier, the millennial physician assistant with whom I was working.

As I understand it, Fireball is not really whiskey at all but a cheap liquor that tastes like Red Hots. I understand it is looked down upon by serious consumers of whiskey. The fact that he drank the whole bottle, at home, alone, caused the young staff carrying for him to scorn him, behind his back, of course. The response seemed to be somewhere between, “What did you expect?” and “You deserve it.”

After talking with him and examining him, I was comfortable that he did just have a stomachache caused by his imprudent ingestion. I reassured him and told him I was going to have the nurse come bring him some medicine to make him feel better before he went home.

“Is it natural?”

“I’m sorry?”

“Does the medicine you’re going to give me come from natural sources?” he clarified.

“It comes from a big pharmaceutical factory. There is no reason to expect that anything we might give you here would be ‘natural,’” I answered.

This upset him and he told me he was astounded that we would offer anyone medicine without knowing about the origin of its ingredients.

I then pointed out the irony that someone would drink a whole bottle of Fireball Whisky, which is clearly not natural, yet refuse medication offered by a doctor because it was not “natural.”

“What are you getting at?” he asked.

At this point, his mother piped in, trying to help him understand. He turned, shook his finger at her and told her to stay out of his business. Their conversation quickly turned into an argument and I walked out the door.

I ordered his Maalox, in case he changed his mind about taking something “natural,” and processed his discharge papers.

While doing my emergency medicine training, I worked in a hospital in Slidell, Louisiana. There, I helped care for a middle-aged woman who was passing through town when she, her young adult son and his wife stopped in town for lunch. Coming out of the restaurant, the lady fell and injured her ankle. X-rays showed a fracture so I splinted her leg, got her some crutches and gave her a dose of pain medicine. She was discharged with a prescription for more pain medicine and instructions to follow up with her doctor in Mississippi. We helped her get into the back seat of the car and prop up her leg. Off they went.

About four hours later, the nurse came to me to ask for help. The lady’s son was there, asking if we could give his mother another dose of pain medicine to help her get home, where they could fill her prescription. It had been my impression that they were headed straight home when they left the emergency department, so I was really puzzled as to where they had been.

It took a while for me to get the clear picture of what had happened and it is still hard to even believe. Rather than head north on I-10, which would have had them in Mississippi within a few minutes, they went south. Thirty-seven miles later, they had crossed the causeway over Lake Pontchartrain and arrived in New Orleans. There, I-10 turns west. When they got to Baton Rouge, 81 miles later, they finally recognized they were going the wrong way. They turned around and by the time they got back to Slidell, the lady’s pain medication had worn off and her ankle was killing her so they stopped in for her next dose.

Going south instead of north on the interstate could happen to anyone. But how could someone drive, in broad daylight, on a 24-mile bridge over a lake, through a major metropolitan area and continue for another hour and half before recognizing that he was heading the wrong direction?

I told you that story in order to tell you this one:

A 53-year-old woman was taken by ambulance to the emergency department in San Jose, California. She had been found driving the wrong way, at 2:00 in the morning, on a freeway going through town. The highway patrol felt she had a medical problem so they sent her to the hospital rather than take her to jail.

The lady was primarily Russian speaking so her broken English and accent made it a bit hard to understand her. In addition, she had schizophrenia. This made it hard to figure out what part of her story was real and what part was a result of her mental illness. So, her story didn’t seem to make any sense and it took quite a while to understand just what had happened to her.

She lived in Yuba City with her brother and elderly mother. Yuba City is about forty-five miles north of Sacramento. The day before, she had driven to Sacramento to visit her brother who was a patient at the UC Davis Medical Center.

After her visit, she had headed west and south for 120 miles to San Jose rather than drive the 45 miles north back to Yuba City.

By the time she got to San Jose, she recognized she was lost. She got scared when she saw the low fuel light go on in her car. Then, “a spirit” appeared in her car and did something to the car. She ended up on the wrong side of the freeway because of the presence of the spirit. That is when she was discovered by highway patrol.

Since she had no medical problems, she sat in the emergency department until the social worker arrived in the morning. The social worker was the one who finally was able to make sense of the whole story. She called the brother, still in the hospital, who confirmed the patient had left there the day before. She called the mother and talked with a sheriff deputy who had been called by the family to help find the lady when she didn’t return to Yuba City after visiting her brother. Her family was very relieved to find that she was alive and well in San Jose.

The woman was obviously not in any condition to drive home. Since her brother was in the hospital and her mother didn’t drive, the patient was put in an ambulance and sent back on the three-hour drive to Yuba City. The car was towed home and the department of motor vehicles was advised of a need to reconsider her driving privileges.

It seems like I have so many drunk stories that one might think this is a blog about drunks. Oh well, here are some more.

Drunk 1

My patient was a twenty-one-year-old who was excessively drunk. The medics pointed out that she had “pathmarks” on her forearm. These, I was informed, indicated how many drinks she had consumed. Sure enough, on her left forearm were hash marks: three groups of four connected by a cross hashes then two singles. Seventeen drinks. Marked and worn, I assume, as a badge of honor. How much honor is there in becoming unconscious and barfing all over yourself? At least I added a new term to my vocabulary: pathmarks.

Drunk 2

A fifteen-year-old went to the mall with her friends. I don’t know exactly what happened at the mall (or, wherever she really went,) but she arrived in our emergency department about midnight so poisoned from alcohol that she had to have a breathing tube placed in her windpipe and be put on a ventilator to breathe for her. She went to pediatric intensive care where she still was the following night. As I have mentioned many times, the blood alcohol level to be legally drunk in our fair state is 80. Hers was 659. I have seen above 700 a few times but never in a kid. Amazing. Kids (and adults) do the dumbest things.

Drunk 3

Most of my drunk stories are sad or amusing. This was truly horrible: A fifteen-year-old girl went drinking after school with friends. She got so drunk she passed out and didn’t remember what happened to her. She was later found, bleeding and in pain, with lacerations in her vagina from having been raped. That was really terrible to take care of.

Emergency department staff deal with a lot of stressful situations. We kind of get used to it, after a while, so most of it doesn’t get to us. Only rarely is something so emotionally traumatic that it really rocks the whole department and each staff member personally. Let me tell you about what I think if one of the most stressful things we encounter in our job.

As I was walking in for my shift, there was a huge commotion going on in Room 6A. I quickly learned they were trying to resuscitate a nine-month old baby boy who had been found unresponsive at home by family members.

I put down my ice chest and Timbuk2 bag and slipped in to see if there was something I could do to help. It is hard for me to adequately describe what was going on. This is as stressful a situation as arises in the emergency department. A baby is dead or trying to die. Everyone is doing everything possible to save a little life with so much potential. Every thing that needs to be done on such a little thing is more difficult than in most adults. IVs are hard to start. The breathing tube is hard to get into such a little windpipe. CPR is difficult to do correctly. It is really challenging and the stress brings appropriate emotions to the surface.

At the bedside were two emergency physicians, an emergency medicine resident (specialist in training,) and two pediatricians. In addition, there were nurses, emergency department technicians, clerks, radiology technicians, and other curious staff. At one point, I counted thirty-two people in the room. I then walked out into the hall and counted sixteen more there, mostly cops and paramedics. You can imagine what a crazy scene that is and that nothing else was going on in any other part of the emergency department.

The team worked well together but, in spite of all of their efforts, there was no response and no signs of life. The resuscitative efforts were ended. That left the emergency physicians with the painful job of telling the family their baby was dead, which is one of the hardest things we ever have to do.

After the shift ended, those caring for the baby had a debriefing session where they could talk about things a bit and make sure everyone was OK. Since we almost never find that necessary, this illustrates how unusual and stressful a baby’s death is for us in the emergency department.

In deaths that are obviously from natural causes, we encourage family members to come see the patient before the body is carried off to the morgue. But in situations like this, there is always the suspicion of non-accidental death so the police treat everything like a crime scene. They won’t let any family members near the baby. That makes it really hard for the family and also for staff to start to come to a resolution. It is really tough.