June 18th, 2009 by Bongi in Better Health Network, True Stories
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In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.
The guy had apparently fallen asleep next to his fire. When he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. Someone found him and brought him in late that night.
When I walked into casualties I could smell him. You can almost always smell the burn patients. I took a look. The one leg actually wasn’t too bad. It had an area of third degree wounds but they weren’t circumferential. I could deal with that later. The other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. This could not wait for later.
In third degree circumferential burns, the damaged skin becomes very tight. Constricting is actually a better description because unless it is released the taught skin will so constrict the leg’s bloodflow that if left untreated the patient’s leg will die. It is like a compartment syndrome only the entire leg is the compartment. Interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. That means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. You just cut the skin and as soon as you hit an area that the patient feels you’ve gone too far. If you do it right they will feel nothing. The longer you wait the higher the chance that he will lose his leg. I knew what I needed to do. I also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.
I asked for a blade and gathered my students around me. I sunk the knife through the dead skin and ran it down the length of the leg. The wound burst open as the pressure was released. The patient didn’t flinch. Quite a number of the students did. One excused herself and ran out. I think she might have been crying. Despite me telling them that it wasn’t painful and it was in the best interests of the patient to actually see it was more than most normal people could take.
When I wrote my last post and expressed a form of traumatic stress I found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. I was ok doing what that one student obviously thought was gruesome and bizarre because I was convinced it was in the best interests of the patient. When I did this procedure which, on the face of it, is so much more brutal than taking someone to shower, I was ok, but the shower incident was terrible for me. I ended up hoping the student didn’t see me as quite that monsterous. I also hoped she would get over the trauma I had inadvertently caused her.
June 8th, 2009 by Emergiblog in Better Health Network
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You walk into the unit, put down your backpack, fill your pocket with pen, scissors, and tape, sling the stethoscope over your neck, swipe your namebadge into the infernal timeclock and enter stage right.
It’s showtime!
Get the triage, hook up the monitor, grab the EKG, slam in the saline lock – grab the bloods in the process, hang a liter of normal saline, put up the side rails, hook the call bell to the side rail, throw on a warm blanket, medicate for fever and slam the chart in the “to-be-seen” rack.
Repeat x 30 over the next eight hours.
Feel like burnt toast, look like burnt toast, act like burnt toast.
*****
Where’s the patient?
You know, the person you just triaged, hooked, slammed, hydrated, side-railed, blanketed, medicated and lined up for evaluation?
Oh.
Did it ever occur to you that the reason you feel like burnt toast is because you are so focused on what you are doing you have lost sight of the “who” you are doing it to?
*****
Well, it occurred to me.
Because that is exactly what had happened.
Oh, my physical care was fine.
But I had stopped looking patients in the eye. I was spitting out standard responses instead of listening to what my patients were saying. I was expending the bare minimum of energy required to complete tasks.
I was doing; I wasn’t caring.
And I was burnt.
*****
But I discovered something.
And this is huge.
I was not focusing on tasks because I had burned out, I burned out because I had started focusing on tasks.
Let’s face it. The ER, while seemingly exciting to those outside the ambulance doors, can actually feel redundant to those of us who deal with the same issues every day. The same complaints. The same symptoms. Over and over and over.
So, what makes each case interesting? What makes each case unique?
The patient behind the story. The person under the symptoms.
Lose sight of the person and you lose sight of the profession. Lose sight of their humanity and you lose sight of your own. Lose sight of your own and you become a burnt shell.
*****
You would think that after three decades of this, I’d have figured this out by now.
I guess you never stop learning.
This time, my teachers were an elderly man with a DVT who talked to me about his time on the LAPD, back in the day.
And the young woman who described, quite vividly, how it felt to go from the pinnacle of health to the devastation of a cancer diagnosis, overnight.
Or the 18-month old who tucked their head under my chin and fell asleep as Mom described the terror of witnessing a first-time febrile seizure.
*****
Who would have guessed that sometimes patients are the cure for burn out and not the cause of burn out.
The patients didn’t change, they were always willing to talk.
All I had to do was stop and listen.
That simple.
Go figure.
*This blog post was originally published at Emergiblog*
June 3rd, 2009 by Emergiblog in Better Health Network
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FROM THE “BEST OF EMERGIBLOG” FILES, ORIGINALLY POSTED AUGUST 16, 2005, THIS WAS ONE OF THE VERY FIRST POSTS OF THE THEN BRAND-NEW EXPERIMENT KNOWN AS “EMERGIBLOG”
I never knew this game existed until I did a web search for the character! There are actually pristine, unopened Cherry Ames games on eBay.
No, I didn’t buy one. Seventy-five dollars is a wee bit too much to pay, although I did spend that much on a vintage Barbie outfit about ten years ago.
Hey, it came with the original shoes and Barbie fans know it’s all about the shoes!
(UPDATE 5/09: My co-worker gave me all of her Cherry Ames books – a complete set – and a copy of the game, in perfect condition!)
***********
Those who study human behavior should spend a shift in the emergency department.
The games played in the ER make the Olympics look like a tetherball tournament. Some of the participants are patients and some are staff. Some are gold-medalists in their specialty and some arrive a few feet short of a full balance beam.
Let’s take a look at “The Emergency Olympic Games”:
“The Suck-Up”
Usually the player is suffering from an acute lack of an opiate prescription for chronic pain symptoms with a nebulous origin for which they have not been evaluated by a doctor but they have an appointment with a specialist next week but they ran out of their Vicodin and they just cannot bear it.
Said patient is overwhelmingly complimentary to Team Nursing . The targeted nurse is SO much nicer than any other nurse anywhere in the whole world and gee, that other nurse was so rude they wish ALL nurses were just like you! These compliments are dispensed within 3.5 seconds of spotting the nurse, often making said RN feel an acute need for a shower.
The player realizes she is out of medal contention when the targeted nurse responds with, “Gee, thanks, but I just came in to get a Betadine swab….”
”Mean Medical Matchup”
This game is closely related to the Suck-Up, utilizing the same team.
Player has been evaluated by the ER doctor, who, having the audacity to disbelieve their story, has gone for the gold and verbalized his lack of belief to the patient. Bottom line: no prescription. The patient prepares for this event with the “Which Doctor is On Tonight?” drill, using a telephone to assess the playing field before engaging the opponent.
“Peek-a-Boo Bypass”
This event requires a large team that converges on the patient’s playing field soon after the patient’s arrival. Anyone can make the Peek-a-Boo team, although it is usually composed of family members and friends of many generations.
Upon arrival, Team Nursing announces the event rule: only two members of the Peek-a-Boo team on the field at a time. This is met with a courteous response and extraneous members go to the bench in the waiting room, where the goal is getting back onto the playing field without Team Nursing noticing. This is accomplished by one Peek-a-Boo team member returning to the patient at a time until the bedside number has quadrupled. Stealth and dexterity are assets to this goal. Occasionally Team Security will act as referee.
“The Two Guy Offense”
The preliminaries for this event take place off the Emergency Stadium grounds.
The player reports a spontaneous assault by Team Two Guys. The members of this team are always unknown to the patient and the initiation of contact always unprovoked.
The goal of Team Patient is to obtain care from Team Medical with minimal disclosure of the playbook. The involvement of Team Police is always declined as so as not to incur a penalty. Team Two Guys apparently has many expansion franchises.
“The Two Beer Defense”
Team Patient enters the arena via Team Paramedic, having received a report of “player down” on the sidelines of a local Team Seven-Eleven. Team Patient arrives supine on a movable gamepiece.
Upon arrival in ER Stadium, body fluids are released for assessment by Team Nursing who immediately take defensive positions. Performance-enhancing ETOH is suspected as the characterisic Odor Offense is noted. Team Medical waits for the Designated Cleaners and takes the field.
Minimal interaction takes place between the teams for many hours at which point Team Patient verbalizes that he only had “two beers”. Team Medical knows to multiply this number by 58. Team Patient is taken out of the medals race on a credibility technicality.
“The Decibel Debate”
Team Patient attempts to propel themselves off the bench and onto the playing field by increasing their verbal intensity. Team Nursing counters with internal auditory blocking mechanisms. The goal: Team Patient enters playing field at appropriate interval. Team Patient rarely medals in this event.
“The Titanic Panic”
Team Patient arrives, usually via Team Paramedic, complaining of numbness, chest pain, shortness of breath and near-syncope occurring at the preliminary event at Home Arena which involved a “Decibel Debate” with another member of Team Family.
The Peek-a-Boo team arrives to act as cheerleaders for the event. No medal is awarded, as the full cardiac work-up that ensues turns out to be negative. An Academy Award nomination, however, would be appropriate.
These are just some of the Emergency Olympic events to which I have a front row seat and perpetual season tickets!
*This blog post was originally published at Emergiblog*
May 17th, 2009 by Paul Auerbach, M.D. in Better Health Network
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When a healthcare provider takes care of a patient, he or she usually completes the episode by explaining something to the patient. For instance, if I treat a wound, before I leave the patient, I explain how to change the dressing, take care of the wounds, signs and symptoms of infection, how to take any suggested medications, when to return for a recheck, etc. But in thinking about how I make the communication, I don’t always write everything down for the patient, or even quiz the patient to determine if they comprehend what I have told them. Undoubtedly, some do not.
A recent study performed in the emergency department setting indicates that at least three quarters of patients do not fully understand the care that they have been given, or even comprehend when they do not understand their discharge instructions. Dr. Kirsten Engel and colleagues (Annals of Emergency Medicine 2009; 53:454-461) found that, “not only do the patients not understand the care instructions from their doctors, but the vast majority are also unaware that they have not fully understood what the doctor has told them.” One can always be critical of any study’s methodology – in this case it might have been more effective to include more patients and caregivers in the analysis – but even if the findings were not so dramatic, there is an important message in the results.
There are many reasons why a patient might not understand what has been accomplished for him. These include lack of an explanation, an explanation that exceeds the patient’s educational level (comprehension), language barrier, and distraction of the patient (by being ill, in pain, having altered consciousness, or other medical/social situation). Doctors are sometimes poor communicators, and are even caricatured as such. During a rescue situation, or when there are multiple victims, there may not be time to be a superb communicator. However, whenever possible, at least the basics should be covered, and this certainly applies to situations of medicine in the outdoors.
If the situation allows, take the time to explain what you are doing for/to your patient while you are doing it. This begins with preparing him or her for the event, particularly if it will be painful, like wound cleansing, manipulating an injured body part, realigning and splinting a broken bone, etc. After you have accomplished your medical intervention, if you need for the patient or anyone else to be responsible for assessing/monitoring the patient, then be very precise about what it is that is to be observed, how frequently to check on the patient, and whom to tell if there is a problem. Explain all medications, including purpose, doses, frequency of administration, and common side effects. To the extent possible, write everything down, so that the patient and other caregivers have a record of what they are supposed to do. If time allows and you have the patience for it, ask the patient and caregivers if they understand what you have told them, and ask them to repeat your advice and instructions. Do not assume that because you have told someone something one time in an awkward and rushed moment, that they heard and understood everything you said. “Medical speak” can be complicated or confusing, and what seems simple and logical to you may require more than a quick run-through. The time that you take to be clear, straightforward, and understood will pay large rewards later in terms of better patient outcomes and fewer problems down the road.
Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.
Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.
This post, Understanding Instructions, was originally published on
Healthine.com by Paul Auerbach, M.D..
May 14th, 2009 by GruntDoc in Better Health Network
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So typical a colleague remarked on it.
*This blog post was originally published at GruntDoc*
In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.
