Friday, April 4, 2014

Starting Line for Trauma Season




There is rarely a busier weekend in the University of Utah Emergency Department than Easter weekend. 

Warm weather means trauma season in the ER, and Easter weekend is the starting line—and it takes off in a full-on sprint. 

I wasn’t familiar with the Easter weekend phenomenon until my first year here.  I worked the Saturday of that Easter weekend and saw more severe injuries that day than I had seen in the previous month combined. 

“What’s going on today?” I asked one of the nurses. 

“It’s Easter weekend,” he said with a shrug.  “It’ always like this.” 

Over the years, I’ve learned more of the Easter weekend phenomenon.  In talking with the patients with broken arms, head injuries, lacerated spleens, and punctured lungs, I’ve come to realize a primary contributor to this weekend is the combination of ATVs, sand dunes, and alcohol—and the outcome is often not good. 

On Easter weekend, many individuals head for the Little Sahara Recreation Area, located about 2 hours southwest of Salt Lake City.  I’ve never been to the Little Sahara, but it sounds like a fun place—known for its miles of trails across the sand dunes and a 700-foot mountain of sand.  The site is so popular with ATV riders on Easter weekend that AirMed, our air transport service, stations a helicopter there and spends the entire weekend transporting individuals from the Little Sahara to the University of Utah Medical Center. 

And, of course, if you’re working in the ER on Easter weekend, you’re on the receiving end of those transports.

As a Level 1 trauma center, we’re equipped to handle any injury that comes our way—and those injuries range from bumps and bruises to severe head bleeds on Easter weekend. We have trauma surgeons, neurosurgeons, orthopedic surgeons, anesthesiologists, and ER doctors at the bedside when individuals with serious injuries arrive, and we have an operating room ready and waiting for these individuals if they need it.  Along with Intermountain Medical Center, the region’s only other Level 1 trauma center, we receive the most serious injuries from across the state, which can be both a blessing and a curse on this weekend. 

Since that first Easter weekend, I’ve come ready for subsequent Easter weekends.  I’ve had my running shoes on, my energy bars in my pockets, ready to be on my feet all day and handle whatever came my way.  I’ve had days where I’ve barely been able to leave the trauma rooms to try to catch up with the other patients in our ER.  It’s an exciting weekend, but certainly draining.

Which is why I won’t mind sitting out this Easter weekend.  By some stroke of luck, I wasn’t assigned a shift over that weekend.  Maybe some of the newer doctors volunteered to work, thinking that things would be nice and quiet as everyone left town for the holiday weekend.

They will learn.


Photo: freepublicdomainpictures.net


Tuesday, November 26, 2013

The Perils of Giving Thanks



(Listen to the podcast)

As we all gather to give thanks at Thanksgiving this week, it’s a great time to remember all that we have to be grateful for. And, as we’re giving thanks, we can also hopefully consider our gratitude that we’re not one of those who ends up in the ER on Thanksgiving—or shortly after—as a consequence of the activities associated with this holiday. 

Here are the top five perils of Thanksgiving, and the reasons we see people in the ER on this holiday:

1.  Fatter than a stuffed turkey.  Sure, there are perils to overeating, but these generally come in the form of some killer indigestion and the occasional nausea and vomiting. The real danger is for those who have congestive heart failure or fluid retention.  Thanksgiving food inevitably contains a good helping of salt: salted mashed potatoes, salted vegetables, salted stuffing, and salt on the turkey.  Salt means water retention, and for people who are trying to get water off their body by taking medication, it is often, unfortunately, a losing battle.  We often see people in the ER in the days following Thanksgiving with bloating and even difficulty breathing due to all of the fluid their body has retained, thanks to Thanksgiving’s salty foods.

2.  Sweeter than a candied yam.  Thanksgiving food not only has its share of salt, it also contains a healthy dose of carbs.  After all, who can pass up Grandma’s pumpkin pie?  And for patients with diabetes, they often tell me they just didn’t want to think about insulin, blood sugar levels, and carbs—they were with family, it was a time to celebrate the good times and memories, and they took in a little more than they were supposed to. Unfortunately, this can lead to serious consequences with blood sugar, and we tend to see several cases of significantly elevated blood sugar levels on the night of Thanksgiving and in the following days.

3.  Turkey Bowl bungles. The Turkey Bowl is an annual holiday tradition for many families.   The old guys get out there with the young guys and toss the football around.  And then things get a little competitive, the old guys overestimate their ability (or underestimate the growth of the young guys over the past year), and roll an ankle or break a forearm.  These injuries tend to start to roll into the ER around noon on Thanksgiving.  They inevitably result in a cell phone conversation between the old guy and the old guy’s wife in which I hear a not-so-happy discussion of the disruption of Thanksgiving dinner plans and “you’re not as young as you think you are.” 

4.  Over the river and through the woods to…the ER.  Thanksgiving is a unique holiday in that it’s one of two major holidays each year in which most people expect to be with their families.  But, unlike the Christmas holiday, people usually don’t take a day or two off before Thanksgiving.  In the West, in particular, this can mean long distances driving late at night—often in icy, snowy conditions—to make the trip after leaving work Wednesday evening.  Unfortunately, this combination of fatigue, late driving, ice, and speed often mean a trip to the ER rather than to grandmother’s house.   I always feel for the patients for whom I care in the ER, but these are some of the really difficult cases to see—calling a family to let them know their loved one won’t be making it to Thanksgiving dinner is tough. 

5.  Revenge of the turkey.  Occasionally, the Thanksgiving turkey gets its revenge on its consumers, and this often comes to those who shovel that Thanksgiving dinner down a little too quickly.  A big chunk of meat in the esophagus often just sits there, and once it’s there, there’s no getting any more turkey—or stuffing, mashed potatoes, or pie—down the food tube and into the stomach.  A person who suffers from the turkey’s revenge may try drinking some soda, which can sometimes relax the esophagus and loosen up that meat to allow it to pass, but this often mean a trip to the ER for a GI doctor to fish that food out.  As in Turkey Bowl injuries, these victims are also often male, often one of the “older guys,” and, once they’re freed from the turkey meat in their food tube, often seem on the losing end of a conversation of how they disrupted Thanksgiving dinner due to overestimating their own abilities. 

So here’s the real kicker with Thanksgiving. Sure, we see many of these cases roll into the ER on the day of Thanksgiving and in the days following.  But who wants to go to the ER on Thanksgiving?  And the next day is Black Friday—many people don’t want to miss those sales and the holiday shopping. Then it’s the weekend.  So Monday is when the salt overload, sugar overload, and rolled ankles all converge upon the ER in a perfect Thanksgiving storm.  

I’m not working in the ER on the Monday after Thanksgiving.  And that truly gives me something to be thankful for this year.  




Photo courtesy of publicdomainpictures.net



Thursday, October 17, 2013

Halloween in the ER



(Listen to the podcast here.)


It’s been a couple of years since I worked Halloween in the emergency department, but I’m scheduled to work October 31 this year.  In preparation for my impending Halloween in the ER, I’ve tried to anticipate what exactly I might encounter—and how I can be prepared for those things.

Werewolf Bites: I’ve never encountered a werewolf bite, but I’ve prepared for my Halloween shift by reviewing what I do when someone comes to the ER with the closest thing I can imagine to a werewolf bite: the bite of a large dog.  Of course, with dog bites, the first consideration is controlling the bleeding, then cleaning the wound and evaluating for the need for stitches.  With dogs, we always consider the possibility of rabies.  If the dog is a stray or its rabies status is unknown, we treat the patient with the rabies vaccine.  Infection is always a concern, and I typically start these patients on oral antibiotics to prevent any problems.  So if I run across a werewolf bite, I’m ordering up the rabies vaccines, administering a strong dose of antibiotics, and watching my back should my patient “transform” as I’m typing away at my computer.   

Vampire Bites: Vampires roam around as bats during daylight hours, and I’ve seen several occasions in which I’ve been concerned about possible bat bites.  Mind you, I’ve never actually seen someone who has been bitten by a bat (or a vampire, for that matter).  However, the US Centers for Disease Control recommends the rabies vaccine for anyone who even wakes up in the same room with a bat, and every case of a bat “bite” I’ve treated has fallen into this category.  Individuals and sometimes entire families have encountered a bat in the house and have come to the emergency department to receive the rabies vaccine, given the possibility they may have been bitten during their sleep but were not aware of the bite.  So vampire bites get the rabies vaccine, and the room lights stay on high to avoid any possible blood sucking in the ER (or any more blood sucking than we usually do with our copious blood draws).

Zombie Bites: The best comparison I’ve got for a zombie bite is the bite of a Komodo dragon.  I’ve never seen a person bitten by a zombie, nor by a Komodo dragon, but either bite is bad. And given the choice, I might opt for the zombie bite—at least that bite leaves you as the living dead, rather than just dead.  Komodo dragons are native to Indonesia, and they don’t kill their prey so much with force as with infection.  The bite of a Komodo dragon can lead to severe sepsis within hours and bring down its victim quickly.  So if I encounter an individual with the bite of a Komodo dragon, or a zombie, I’m giving them the strongest antibiotics I’ve got and admitting them to the hospital for intensive treatment. 

So have a great Halloween, and if you do happen upon an unfortunate encounter with a werewolf, vampire, or zombie, I’ll be ready and waiting!


Image courtesy of publicdomainpictures.net



Tuesday, October 1, 2013

Top 10 Reasons Hunters Visit the ER



(Check out the podcast here)

Hunting season is upon us!  Here are the top 10 (avoidable) reasons hunters find themselves in the ER:

1. Falls from cliffs and from tree stands.  

2.  Self-inflicted gunshot wounds.  We often see these in hunters cleaning their guns.

3.  ATV accidents. These are especially serious in those not wearing helmets.

4.  Burns with lighter fluid.  It's not uncommon for someone to spray lighter fluid on a fire, then that flame travels up the lighter fluid and the can explodes.

5.  Rabies.  Hunter gets bored, shoots at raccoon, raccoon gets angry and attacks hunter. It happens.

6.  Lightning strikes.  Carrying a metal rod (i.e. gun) in a lightning storm is not a great idea.  

7.  Carbon monoxide poisoning.  Weather gets cold, hunter puts the propane stove in the tent to stay warm, and this produces carbon monoxide.  

8.  Heart attacks. Hunting is often the most exercise a hunter gets over the course of a year.  It's not uncommon to have someone flown from the mountains with a heart attack after pursuing a deer.  

9.  Hypothermia.  It rains, hunters get wet, and with temperatures even in the 40s hunters can experience hypothermia and, on occasion, frostbite.

10.  Alcohol + any of the above=not good.  (Alcohol + guns, alcohol + ATVs, alcohol + raccoons...often just seems to compound the problem). 

Stay safe this season, and happy hunting!  


(Photo courtesy publicdomainpictures.net )



Friday, August 23, 2013

Back to School...and Not to the ER



(Listen here for the podcast)


Colleges across the country are starting up again soon, and with new students leaving home for the first time and students returning from summer break, ER visits by these college students are guaranteed to pick up again.  After 10 years of practice in emergency departments at hospitals affiliated with universities, I've seen my share of college students in the ER. Some of the reasons for college students' ER visits may be obvious, while some may not be quite so intuitive.  Here's my top 10 list for potentially preventable reasons that college students find themselves in the ER.     

1. The first one is an easy one: alcohol use.  Even if we didn't spend our college years in an Animal House-like fraternity scene, we know that drinking can often get out of hand with college students.  And it's not something to be taken lightly. It seems we see news stories each year of college students who have died from excessive alcohol intake. In my experience, students land in the ER after drinking too much at a party, and, when their friends can't awaken them, they call 9-1-1.  Our number one concern is making sure they don't vomit and then breathe this into their lungs--a significant risk when you're so unresponsive from alcohol use that we can't even awaken you.  And nobody wants a call to their parents at 2 am to tell them their child's in the ER after passing out at a party. 

2.  The next thing that land students in the ER is also sort of an obvious one: drug abuse. We occasionally see students in the ER after abusing prescription drugs like oxycodone and OxyContin. We also see quite a bit of methamphetamine abuse in the state of Utah.  In short, to avoid the ER, don't do drugs.  

Of course, there are some drugs students should take, and when they don't take those drugs, they might end up in the ER.  Students get away from home, they don't have their parents watching over them anymore, and they sometimes exercise that sense of independence to its full extent--and stop taking medications which have been prescribed to them for serious medical conditions.  In my experience, the medications students often stop taking are those prescribed for asthma, diabetes, or psychiatric illnesses, and, once off these medications, serious problems can ensue.  

3.  After a big win at a football game, students will often rush the field. In the process of racing down the stairs and trying to get onto the field, these students encounter the guardrails along the edge of the bleachers. And, in the midst of their enthusiasm, they try and leap over these guardrails, catching their legs on the railing and flipping forward, landing on their outstretched arms. With all that weight on their forearms, they often break one or both wrists. This is not a good situation to be in. Without getting into the specifics, it becomes very difficult to complete basic daily tasks at home if you have both arms in casts.  

4.  Of course, we all remember eating all sorts of questionable foods as college students. We may have seen something lying on the counter in our apartment or dorm room and figured it looked safe enough to eat. I see all sorts of students in the ER with symptoms of food poisoning, and they all report having ingested some questionable substance. Maybe it was the three-day-old pizza, the egg salad they thought their roommate's mom had dropped of last week--or was it last month?--or the bologna in the top drawer of the fridge that had been there since last semester.  Sometimes food is tough to come by as a college student, but opt for something that won't leave you regretting it while spending the night getting IV fluids in the ER.  

5.  The next issue that lands students in the ER is a very serious one, and something we see quite frequently. These are psychiatric illnesses. It's not unusual for individuals with schizophrenia to have their first “psychotic break”—hallucinations, delusions--as a college student and first receive this diagnosis of schizophrenia.  College students may face significant stress and have difficulty being away from home, which can lead to worsening symptoms of depression and, in some cases, even suicide attempts and overdoses. It’s important for college students to keep an eye on their friends to assure they're doing well. 

For those who might be having a difficult time, don't hesitate to seek help. College can be a difficult time of life, and there are plenty of resources available to help out in these situations. We've all been through some very tough times in our schooling, and there's no shame in looking for someone to talk with to get some help through these times.  Preventing an ER visit in these situations may not always be possible, but by getting help early for yourself or for friends in need, you're potentially avoiding a serious crisis down the road. 

6.  The next thing that often land students in the ER is various items which have been placed in various orifices. Again, I won't get into the details here of exactly what this involves. However, we do often hear from students that they slipped and fell on these items. As ER doctors and staff, we certainly know better. Nobody wants to end up in the operating room to have an item removed from a part of the body where it should not be, so, as a college student, you're best off just avoiding this altogether.

7.  We might think that because we live in the state of Utah that sexually-transmitted diseases may not be as big a deal as they might be elsewhere. This is something of a myth. We see many cases of gonorrhea and chlamydia in college-age students in our emergency department. These STDs can be very serious issues, particularly in women, where they can lead to future issues with childbirth and serious infections and, in some cases, even death. Just remember to be safe to avoid that ER visit.

8. Another common problem that sends college students to the ER is longboarding injuries. As we all know, college campuses can seem very large, and students may have to get from class to class very quickly. Unfortunately, in the process of moving between classes, accidents do occur.  Longboarders may travel at speeds of 30 miles per hour or more when going downhill, and trying to stop a longboard at that speed is next to impossible.  I've seen college longboarding injuries where students have collided with the back end of cars at stoplights and have even slid under cars.  Severe head injuries from longboarding injuries among students have even lead to deaths.  When using a longboard, remember that they move quickly and stop slowly, and when they collide with a vehicle, the vehicle always wins.  As with bikes, rollerblades, or anything else that moves, use a helmet.

9. Then, of course, there is caffeine.  I'll often see students in the ER who complain of their heart racing and, at times, feeling like they're going to pass out. We do an EKG and everything with their heart looks okay, and we watch them on a cardiac monitor for an hour or so to look for any abnormal heart rhythms. Then I ask them about their caffeine use, and I learn they've been throwing back an energy drink every hour for the past week.  "Were you drinking this much caffeine during the summer?" I ask. Of course not, they answer--they were sleeping in every day until 10, but have to get out of bed at 7 now for 8 am classes.  And stay out until 2 am with friends each night.  Try to get some sleep, cut back on the caffeine, and you'll potentially avoid the feeling that your heart is about to jump out of your chest.

10.  The final reason that college students end up in the ER is....finals. It always seems that as we’re approaching finals week, the number of ER visits among college students increases significantly. Most of the students complain of vague symptoms of abdominal pain and nausea, but on laboratory testing and in examining the patient, we don't really find much that seems to be wrong.  It’s certainly not my place to judge, but it is somewhat curious that nearly every one of the students asks for some sort of written excuse to allow them to schedule their finals for a later date. The best way to avoid this phenomenon, of course, is just to be prepared throughout the course of the semester so you don't feel obligated to go to the ER to avoid that pending final.

So if you're a new college student just starting out this semester, or you're heading back to college after summer break, here’s to a great semester. And let's hope we don't see you in the ER.



Photo by Jefferson liffey (Lifey College) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Thursday, July 11, 2013

Abscess Obsession



Some people just love to squeeze pimples. Now imagine a pimple that’s somewhere between one and 10 inches wide.  That’s an abscess.  And treating an abscess might be the most rewarding procedure in the ER.
                  
I recall with fondness the first abscess I treated as an emergency medicine intern.  Amy, the senior resident, offered to help.
                  
“Be sure to have a gown, gloves, and eye protection,” she counseled me beforehand.  “These things can be messy.”  Very sage advice.
                  
The abscess was on the upper leg of a man who had gone through this sort of thing before.  Some people may be more prone to developing abscesses, but sometimes they just happen: it may start with an ingrown hair, which develops an infection around it, and that infection just keeps growing.  It becomes a large, walled-off sea of pus.  I’ve seen abscesses which take up the entire upper leg.  The only way to treat them is to cut them open and drain the pus.
                  
I tried to numb up the abscess as well as I could.  That’s the difficult thing with abscesses: it’s just tough to really get them numb. I always tell patients this beforehand and prepare them for the worst.  In many cases I’ve had to sedate the patient in order to open the abscess.  All of that infection just seems to make the lidocaine less effective at providing much anesthesia to the area.
                  
We cleaned off the abscess as well as we could, but, as Amy astutely explained to me, treating an abscess “is not a sterile procedure.”  By definition, the abscess is full of pus and infection, so there’s no point in going through deliberate measures to try to create a completely “sterile field” like we would in an operating room or other procedures in the ER. 
                 
I felt on the abscess for the site with the most “fluctuance,” or where the skin seemed the thinnest and the pus nearest the surface.  I inserted the scalpel, not without a few groans from the patient, and the pus squirted out. 
                  
“Be sure to make a large incision,” Amy guided me.  The important thing with an abscess is not only to get the pus out, but to make sure it continues to drain over the coming week or so.  Depending on the size of the abscess, I always try to make the incision at least half the width of the abscess. 
                  
Amy then handed me the forceps.  “Dig around in there to open any pockets of infection.”  There’s something a little unnerving about taking a pair of forceps, inserting them into the abscess with the tip closed, then opening them to feel the tissue tear, opening new pockets of infection as the pus flows out.  Treating an abscess is not a delicate procedure.
                  
We washed the abscess copiously using a large syringe filled with water.  By the time we were done, the drapes we had placed under the patient’s leg were soaked with water, blood, and pus.  Amy was right about this being messy.
                  
I packed the abscess with sterile packing tape.  The idea is to keep everything open so that incision doesn’t heal over and the pus continues to drain.  We told the patient to come back in two days to have the abscess rechecked.  If it looked like the incision had healed open and would continue to drain without the need for packing, we could remove the packing at that time. If not, we would have to repack it to make sure it stayed open and was draining.
                  
“So that’s how you treat an abscess,” Amy summed up our experience.  “Fun, isn’t it?”  She was right. Abscesses usually are fun because you’re actually fixing something.  You’re not telling the patient to go see a specialist. You’re not sending off a bunch of labs.  You identify the problem, you cut it open, you drain it, and you send the patient on their way.
             
Since that first experience, I’ve seen patients with huge abscesses show up to the ER. 
                 
“I saw my doctor about it,” they tell me.  “They keep putting me on different antibiotics, but it just keeps getting worse.”  You look at their arm to see a bulging abscess just waiting to have a scalpel placed in it.  Generally, it’s the family friend who told them something like, “That looks like a big zit. You need to pop that.”  And they give up on the antibiotics and come to the ER for a second opinion.

Unfortunately, antibiotics don’t do a lot for abscesses.  They’re don't penetrate the capsule surrounding the pus, so they’re can't get in there actually get in there to treat the infection.  The best way to treat an abscess is to open it up and drain it.

In fact, there’s really not much of a role for antibiotics even after draining the abscess.  Even in this era of the “superbug” known as MRSA (methicillin-resistant staphylococcus aureus), which causes most abscesses we see, antibiotics don’t offer much.  If the patient has a bright red skin infection over the abscess, with that warmth and redness extending beyond the borders of the abscess, antibiotics may be helpful.  But for a simple abscess, the only real treatment is to cut open. 

So if you’ve got a big bulge on your arm that looks like a huge zit, don’t let the doctor just send you away with some antibiotics and tell you it will get better.  Demand they stick a scalpel in it.  It might be the most rewarding thing they do all day.  



(Image: Cone Tip Of Mayon Volcano by MALIZ ONG)




Monday, June 3, 2013

Motorcycle Helmets




“I always thought wearing a helmet on a motorcycle just meant you would have an open casket funeral instead of a closed casket funeral. I guess I was wrong.” 

The patient lay on a stretcher in the trauma bay.  He had come to us by ambulance after a motorcycle accident.  He worked as an EMT for the same ambulance service that had transported him from the accident.  And he wasn’t wearing a helmet. 

“My wife’s going to kill me…” he muttered.

He had been separated from his bike during the accident and had road rash up and down the right side of his body.  More importantly, we had found bleeding in his brain on the head CT we performed as part of his trauma evaluation. 

The good news was that his head injury would likely not require surgery, but he would have to stay in the hospital for observation and continued monitoring of the bleeding.  If he had been wearing a helmet, he likely would have walked out of the emergency department with just some scrapes and bruises. 

It’s not unusual for us to care for patients in motorcycle accidents who have severe head injuries and bleeding in the brain.  In some cases, these individuals may have been wearing a helmet, but, in most cases, they were not.  The state of Utah requires helmets only on motorcycle riders under the age of 18, so, for adults, the decision to wear a helmet is left to an individual’s discretion. 

Unfortunately, many bikers may think much as this individual thought—that if someone were to have a motorcycle accident, the accident would be so severe that it would be almost guaranteed to take their life, and the only purpose the helmet would severe would be to preserve their face for the funeral. 

Certainly, that’s not the case. 

We’ve seen quite a few motorcycle accidents over the past few weeks as the weather has warmed and people have gotten out on their bikes.  We’ve seen people with road rash, broken limbs, and lacerations.  And we’ve seen cases of severe head injuries.  In some of these cases, I think that a helmet could have made a difference. 

The reality of motorcycles, as most bikers accept, I think, is that there’s an inherent danger to riding a bike.  Per mile traveled, motorcycle crashes are 37 times more likely to result in death than car accidents.  In the majority of cases, head injuries are the cause of death.  Previous studies have shown that helmet use reduces that risk of death by at least 50%.   

A helmet, much like a seatbelt, doesn’t provide any guarantees, but it certainly stacks the odds a little more in a person’s favor.

So we’re not just talking about an open casket funeral.  Walking out of the ER with a few scrapes sure beats a night in the hospital, or in the operating room. 

And, as my patient noted, it sure beats the wrath of your spouse.



Source:  “Helmet Efficacy to Reduce Head Injury and Mortality in Motorcycle Crashes.”  J Trauma. 69(5):1101-1111, Nov 2010  https://www.east.org/tpg/MotorcycleHelmet.pdf

Photo: http://www.publicdomainpictures.net/view-image.php?image=5892&picture=motorcycle