Grandma got run over by a reindeer

One of my least favorite things about the holiday season is the grandma phenomenon. The grandkids live far away and only see her on Christmas and Easter. So it's been awhile. Did I mention she's 80 years old and in a nursing home? So the family gets together for Christmas and the grandkids realize that grandma's old! "Grandma doesn't look so hot, does she?" " Grandma, you look so much older than last time I saw you (8 months ago)! We had better get you to the hospital!"

I have no problems seeing Grandma and even running what are likely unnecessary tests to make everyone happy. Chances are, grandma is a little bit dehydrated. Aren't we all? But if grandma has no complaints, I don't want to keep her in the hospital. And the family usually wants me to. "Can't you find a reason to admit her?" I try to explain the risks of hospital-acquired infections and deconditioning on someone who really isn't sick, but it is rarely successful. The families usually refuse to take grandma home, so what can I do? They feel better because they swooped in to rescue this poor old lady and now they can relax and enjoy the rest of Christmas without the shadow of the woman they once knew sitting quietly in the corner.

Holiday cheer!

I told my husband that I am responsible for baking a treat for our annual holiday party, held during the shift on Christmas Eve day (12/24). Because it's an Emergency Department, there is no time that everyone can be off, and there always needs to be a crew working the holidays. He reminded me of the first time he visited for an on-shift party. It was my birthday, I was working, and the nurses had a surprise party for me in our back room. They called my husband and invited him to come. There were sandwiches, salads, chips, cookies and a cake. They had decorated the room as much as they could. It was so sweet. We were all chowing down when my husband came in. Now, he loves to eat, but had a hard time. We don't have a bunch of extra tables in the ED, so we set everything up on gurneys. With tablecloths of course! It doesn't bother me at all to eat food from a stretcher where someone may have had a boil lanced, a pelvic exam or CPR, but apparently, some people are squeamish!

There but for fortune

Despite my usual ranting about my patients' ridiculousness, I usually just feel bad for them. Some of them lead lives I can't even imagine. And when I see their children, I get this feeling that they will be stuck in the same rut. I was so privileged growing up middle class with educated parents who expected a lot from me. So many of these kids have parents who are just kids themselves!

In any case, last week I had a "there but for fortune" patient. The medics brought in a forty year old woman as a "code" (meaning dead, basically). She had a history of drug use and depression and her boyfriend found her unresponsive in the house. Instead of calling 911, he decided she was just drunk and threw her in the shower. When that didn't work, he called the medics, who found her in asystole (flatline). They decided to try to resuscitate her anyway, which never works from asystole. Anyway, they brought her in and one of the EMTs remarked, "We pulled a dead body from the basement of the same house last year around this time!" My god. It made me think about how lucky I am that I never got into alcohol or drugs and that I am married to a man who wouldn't assume that my blue, unresponsive, not breathing body was just intoxicated!! We were unsuccessful in reviving her. The boyfriend never showed up at the hospital and we couldn't get in touch with her mother. Like many of my patients, her emergency contact had a phone number listed, but it was out of service. We asked the police to look for the mom, but as of 7 hours later, when I left for the day, no one had come. Can you imagine dying in your own house and no one showing up? Horrific.

Sleepless

It's 5am and I've been awake for two hours obsessing about my patients. And that's one of the downsides of being an Emergency Physician- they're really not MY patients. Except for the few patients who routinely visit the ED, either because of lack of a family doctor or surplus of chronic diseases, most of the patients I see are unfamiliar to me. I don't have a file with each person's medical history, medications and allergies, and the patients often don't know their own information. We don't do the same kinds of testing from the ED that one can do from a primary care office. Most tests and procedures need to be scheduled ahead of time, but patients walk in with the expectation that anything they need done can be done right away. After all, it's a hospital. I saw one woman the other day who asked me if she could get a hysterectomy (which she pronounced hystamectomy) that day, since she was already there.

But back to why I can't sleep. I saw a patient the other day who had chronic nausea and had a fairly substantial workup for it. She was scheduled for a special test as an outpatient the next day, but called her doctor that morning and said she was still nauseaus. He told her to come to the ED to be admitted. I can't admit someone for nausea. To top it off, it was her third visit to the ED in 48 hours for the same thing. I never order this particular test that she was scheduled for. It's just not something that we order, since it is not an emergency test. But I called radiology and they were able to fit her in that morning. I was so proud of myself and felt like I was doing a real service for this woman. The test was read as normal. I called her doctor who asked about a specific portion of it. When I spoke to the radiologist, he told me that I had to order that other part specifically or they didn't do it, and that now it was too late. Now the patient and her specialist are furious at me. What can I do? She'll get it again as an outpatient like she should have the first time. But I hate when people are mad at me.

I've become less obsessive over the years of my practice, but I have many nights awake thinking about what I could have or should have done, despite the fact that it usually doesn't make any difference in patient outcome. I guess that the day I stop worrying, I should quit medicine, because I will have stopped caring.

Why are you here?

I'm sure I'm a pleasure to be with, but it still doesn't explain why some people choose to visit the Emergency Department. I find myself listening to patients' chief complaints and asking questions, eventually asking the biggie: But why are you here? Case in point- a man with end-stage AIDS came in to the ED by ambulance at 4am. Fever? No. Weakness? No. Vomiting? No. He couldn't sleep. He took a sleeping pill, but still couldn't sleep. And I found myself asking the question that I try to avoid, "But why are you here?" And when I say "here", I mean the Emergency Department. What is it that you want me to do? This is not an emergency. Most nights, I don't sleep. An inconvenience, yes. An annoyance, again yes. But an emergency? Most definitely not. I offered to hit him on the head with a frying pan.

Another patient came to the ED recently with two years of abdominal pain. TWO YEARS! She'd seen multiple specialists, had invasive procedures and surgery and still had pain. Nothing had changed. So why are you here???? She told me she "couldn't take it any more". Again, what did she want me to do? Amputate her...abdomen? Not something I'm credentialled for. But I offered any way.

There is no life-fixer-upper magic pill or injection in the emergency department, folks.

Anxiety attack

No one would argue with the statement that life is stressful. Money, relationships, health issues, all conspire together to make living a daily challenge. And I can understand feeling overwhelmed and anxious. I often feel that way! Insomnia, weight gain, snapping at my family- they are all manifestations of anxiety. But it would never occur to me to go to the hospital for it! Last week at work, a 21 year old man was practically carried in by his mother because he was having an anxiety attack, complete with hyperventilation, carpopedal spasm and crying. Carpopedal spasm is spasm of the hands and feel that occurs when you hyperventilate. Breathing too fast upsets the balance of calcium in the muscle and the dominant muscle forces of the extremities clench. In any case, this 21 year old was sobbing. His chief complaint, according to his mother, was that "he gives his heart away too easily". He laid in the stretcher, covered in tears, with mucous pouring out of his nose. He couldn't get it together to use a kleenex, so his mommy sat by his bed and wiped his face. Now, I've had my heart broken, but it never occured to me that the hospital might fix it! What did they want that the emergency department could provide? Drugs? Couples counselling? I couldn't put him in the waiting room, because he was such a mess. So people who were actually sick, not just sad, waited for a bed, while he cried. As a naturally sympathetic person, I tried my best to make him feel better, but it was hard even for me. I did my best, but my instict was to shake him by the shoulders, look him in the eye, and tell him that life doesn't get any easier. We need to learn to deal with life's disappointments if we don't want our hands to be permanently stuck in spasm.