Philip Greenspun’s Weblog

The second week of EM. As soon as I put my bags down for the second shift (2:00 PM to 10:00 PM) at the physician/nurses station, a code blue is called over the loudspeaker – “Code Blue, Triage.” My PYG3 resident, a 30-year-old mountain biking enthusiast yearning for his upcoming Montana life after graduation in a few short months, waves for me to join as several residents, nurses, and attendings briskly walk over to triage.

A 70-year-old obese female is lying on the floor surrounded by six people. Two are taking turns performing chest compressions. A resident is attempting to ventilate the patient with an Ambu Bag manual resuscitator. We get the patient onto a stretcher, and cart her off to one of our rooms. The ED is divided into a trauma section, triage, a sick section, an observation unit, and a healthier section. Once she is on a bed in the sick section, an attending and her resident prepare to intubate.

The attending hands a GlideScope, a video-assisted laryngoscope to the resident.  Unlike a traditional direct laryngoscope that allows only the intubator to see what is happening, with the GlideScope both the attending and resident can see what’s in front of the scope, The resident then inserts the blade and visualizes the cords, but struggles to get the ETT (endotracheal tube) through the vocal cords. They are tight. He asks for a “boogie,” a long thin bright blue bendable plastic tube that he is able to pass through the vocal cords. He takes the laryngoscope out, threads the ETT over the boogie, and pushes the ETT forward aggressively. The attending asks, “Are you in?” He responds, “Yes, I feel the tube gliding over the [tracheal] rings.” The attending agrees, “I feel you too,” as she removes her hands from the neck.

The respiratory therapist (RT) hands us the tubing connected to the ventilator. Every tube  at initial intubation is hooked in series with an end-tidal CO2 colorimeter. If the ETT is correctly in the trachea (i.e., not in the esophagus) carbon dioxide on exhalation will change the color confirming correct placement. While this is going on, another attending and resident are “dropping lines” including a central venous catheter and arterial line.

We learn that a granddaughter brought the patient after she had trouble breathing with wheezing. The daughter said, “She was just in the hospital for a COPD exacerbation two months ago.” The patient was coding for 20 minutes. My attending asks if the family would like to come in during the code to watch. (Afterwards, she says there is evidence that the family seeing the end-of-life code is helpful for the grieving process.) The granddaughter, daughter, and son-in-law take one step into the room and begin sobbing. They step out after a few minutes. On the next pulse check, the patient is still in asystole. My attending asks if anyone has any other thoughts. “We’ve ruled out other reversible causes of arrest.” After a short pause with silence, she announces, “Time of death – 15:25.” There is a quick debrief afterwards, and then everyone scatters. I help the two nurses get the patient presentable for the family to come into the room for one last farewell. The charge nurse can tell this is my first code. “Oh sweetie, thanks. We cannot forget to clean their bottom.” The other nurse chuckles, “Post-mortem shits. Nothing quite like it.”

Immediately after this a mother brings in her 20-year-old daughter, a bone-thin IV drug user with uncontrolled type 1 diabetes who presents for weakness and confusion. She is found to be in diabetic ketoacidosis (DKA) and is septic from likely bacteremia. She is tachypnic (breathing fast) and becoming more lethargic. The attending states, “We need to intubate her now.” The attending and resident let me intubate the patient. The resident instructs the charge nurse to grab an induction agent and paralytic. We first pre-oxygenate the patient by placing a non rebreather (breathing mask) over her mouth. After two minutes, the attending tells the nurse to push the sedation followed by the paralytic. 

The resident hands me the GlideScope. “Watch the teeth! It’s not a rotation motion, it’s a lift up to the crease between the wall and ceiling.” I struggle with the motion, being too timid. The attending pulls my hands to the sky, supporting the entire weight of her head and neck off the table, pulling into view the vocal cords (pretty much a perfect view… she is an easy intubation). I guide the ETT through the vocal cords. Once through, the RT blows up the balloon. Once intubated, the RT connects her to the mechanical ventilator. 

After a few minutes, the nurse comes out to the station saying the patient is now hypotensive (low blood pressure). The attending asks, “How much fluid has she gotten?” The resident says, “She’s gotten two liters, and she is a tiny skinny lady.” My resident turns to me, “Would you like to place a central line?” I exclaim, “Yes.”. “If you can grab all the right stuff, it’s yours.” I speed off towards “Walmart”, the ED stockroom. I grab a central line kit, sterile ultrasound probe cover, enough suture to weave a sweater, and several pairs of sterile gloves. The resident jokes, “Not bad.” While I was off, he had already grabbed everything we needed. “Let’s get started, the hardest part is positioning everything.”

After we place the patient in Trendelenburg, we open up the kit on a stand. I put a sterile gown on with my resident’s help, and then my gloves. He does it all by himself. We prep the patient. The nurse hands us the ultrasound and we are ready. Okay, show me the internal jugular. I grab the ultrasound and scan up and down the neck. “It’s the plump vessel, next to the pulsing carotid.” I push down with the ultrasound probe, thereby compressing the internal jugular (IJ) vein. “Notice how the IJ nearly compresses on inhalation. She is quite hypovolemic.” The resident hands me all the tools in the right order. I insert the access needle into the IJ under ultrasound-guidance. “Don’t freak out when blood squirts back at you. Hold steady. I’ll hand you everything. We both will freak out if it is pulsatile (indicating we hit the carotid and not the IJ)” Once I get blood return, he hands me the guidewire that I thread through the needle. “Look at the ectopy on tele!” (when the guidewire knocks around in the atrium it can cause aberrant heart beats.) I communicate, “It’s threading easily.” I take the needle out, and he hands me the dilator followed by the flushed catheter. The catheter goes in smoothly, I suture it in place. I struggle placing a sterile covering, a fancy plastic lining that goes over to try to prevent infections. “I’ll do that, this is our signature for nurses.” 

As we walk out, the resident shares, “One of my best friends has type 1 diabetes. I’ve noticed that type 1 diabetics are either extremely health conscious and disciplined, or are complete wrecks and die of massive heart attacks in the 40s.”

I leave exhausted, but am too excited to fall asleep. Type-A Anita has been active on Facebook. She writes about a New York City article citing the rise in divorce rates: “I’m glad the divorce rate is higher. You want to know why the divorce rate was so low back in the Day? It’s because your grandmother did not feel safe to leave the relationship. It means women feel empowered now to leave their shitty husbands because they are not dependent on any man. #StandUp”

[Editor: Type-A Anita is on track to make $400,000 per year in ob-gyn and her fiancé (now husband) is in a much less lucrative career. If she is unwise enough to settle in one of the states that awards alimony, in about 15 years we might find that her opinion on this topic changes…]

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Beers and burgers with Sarcastic Samantha. Mischievous Mary unexpectedly joins midway. She recounts walking away from her Tinder date without introducing herself to the young man because he showed up to the restaurant  in an undisclosed wheelchair.

[Editor: It would appear that the medical school’s heavy investment in diversity and inclusion education is not reaching everyone.]

The rest of the book: http://fifthchance.com/MedicalSchool2020

It’s May and we’re back from an uneventful week of vacation.

Emergency medicine rotation, 12 shifts in 30 days. I am one of the first medical students in my class to complete EM. One quarter of the class completes EM clerkship during the third year; the remaining wait for the fourth.

I begin at 7:00 am in the simulation center with the EM clerkship director, a toxicologist. He gives us an overview of the ED. “We have a mantra in EM: “Anyone, anything, anytime. You will see a bit of everything on your shifts. EM docs are a master of none, but a jack of all trades.” He continues:  “All of you have done internal medicine rotation already. I am sure you have the impression that the ED consults everyone. In fact, we discharge over 70 percent of the patients from the ED.” Emergency Medicine changed overnight when EMTALA passed in the 1980s. “This requires emergency rooms to screen and stabilize all patients that come in regardless of insurance or ability to pay.”

He explains that the ED risk stratifies patients and recommends we all become familiar with PERL rules, Nexus criteria versus the Canadian criteria for cervical spine clearance, and the HEART pathway and OTTAWA rules. 

After this introduction, my six classmates and I head over to the first simulation room. The room is similar to the trauma bay in the hospital with a mannequin on the bed, various screens showing vital signs and fully stocked closets with e.g., endotracheal airways and chest tubes. The first simulation day is focused on ACLS, and management of various cardiac arrhythmias. The EM clerkship director, and two simulation staff (a former medic and a former ED nurse) step out into the viewing section behind an opaque glass window. We hear them over the loudspeaker giving the simulation introduction. Then the EM clerkship director gets into character: “Ugggh, I don’t feel so good.” We begin to ask questions and request tests. “Can we get an EKG?” The staff put up various EKGs and we are supposed to respond by treating the arrhythmia, whether that is to shock the patient (synchronized cardioversion versus defibrillation) or administer medications. 

My first shift is slow and the 34-year-old PGY2 resident has plenty of time to teach. Before medical school, she worked for 5-years as an operations engineer. (EM residency is a three-year training, the majority do not go on to fellowship training). The attending’s high level of trust in her is evidenced by the fact that she manages 10 beds by herself and updates the attending on any admissions. We have a COPD exacerbation from a nursing home and an uncontrolled type 1 diabetic in DKA. My resident starts the patient on her preferred protocol (K+ and insulin drip) and then updates the attending. The attending discusses his view of bolus versus drip only, as he prefers bolus. “It’s your patient, your move.” We have a patient transferred about 150 miles from an outside hospital due to a stable GI bleed. I do not understand what hospital would transfer this patient. He doesn’t even need a blood transfusion. His only comorbidity is well-controlled type 2 diabetes and hypertension. The PGY2 summarizes the situation: “He was driven all this way for a digital rectal exam.” She continues, “He has supplemental insurance, so I’ll offer to keep him under observation. We might catch something to flip him into inpatient and get him an EGD and colonoscopy. But he frankly should be discharged and sent for elective outpatient colonoscopy. I feel bad for the guy and the wife who is driving here now.”

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Brewery outing with classmates and pups. Lanky Luke and Sarcastic Samantha are training their puppy, however she only listens to Samantha because Luke is always working on his internal medicine rotation.

The rest of the book: http://fifthchance.com/MedicalSchool2020

During our morning session on multiple sclerosis, a stroke alert is called. The clerkship director and I walk over to the ED. A 66-year-old female is presenting for left-sided weakness (arm more than leg), but there is no facial droop. Her husband explains she was normal when they went to bed, but when they woke up at 7:30 am, she “just wasn’t right”. She has already gotten the imaging workup, but there is nothing to be done because she is well outside the 3-4.5-hour window for TPA (tissue plasminogen activator) and this is not a large infarct. (Even if we did know the time from initial event, she has been on oral anticoagulants for atrial fibrillation. These are difficult to reverse and a contraindication to TPA.) We put in admission orders to optimize her recovery, including blood pressure and sugar control. We also order an MRI to diagnose and prognosticate the extent of the infarct. The attending cancels some of the orders placed by the ED and the psychiatry PGY2 resident. “This is the tyranny of the order set [default groups within Epic, intended to save time and typing]! Why order a carotid duplex when we just got a better picture of it with the CTA already performed? We are just wasting hospital resources and Medicare dollars.”

[Editor: The hospital CFO may not consider it a “waste” when Medicare dollars are transferred to the hospital…]

We arrive at the Situation Room, a narrow office crammed with two computers and an old couch. The clerkship director, resident, and I hang out here until the next stroke alert. I am pimped on the types of strokes. I fail miserably, citing only two of the common sites of brain bleeds. There are two main types of strokes: intracerebral hemorrhage (ICH, brain bleed, rarely lethal) and ischemic (occlusion of an artery, potentially fatal due to increased intracranial pressure). This neurologist gave a great lecture on strokes during second year, so I pull up the slides on Blackboard and then UpToDate each topic for more information. A common cause of ICH is hypertension due to cocaine and meth use among the young and poorly controlled chronic conditions among the elderly. ICH can also be caused by anticoagulants and Alzheimer’s (amyloid angiopathy). “You can quickly figure out what is the cause by the location of the bleed. Hypertension is a deep brain bleed, in the basal ganglia, thalamus, pons, or cerebellum. Dementia patients bleed into the cortex.”

He asks me, “What kind of workup would you do for the patient we just saw in the ED?” I answer, “Well, she is out of the window for TPA, and not a candidate for endovascular therapies [clot in proximal artery].” I recommend ordering an echocardiogram, carotid duplex, and EKG. “Right, we need to rule out the preventable causes of ischemic strokes” These include cardioembolism (a result of, for example, atrial fibrillation, an infected heart valve from iv drug use, or a ventricular thrombus after a heart attack), carotid stenosis, and a patent foramen ovale or hole in the heart, that can allow a clot to pass from the venous circulation into systemic circulation). We check Epic and see that the MRI images are available, though without a radiologist’s read yet. He points out a small infarct in her posterior limb of the internal capsule. Nothing to do.

(I followed up with her over the next several days and her condition was unchanged. She’ll have a permanent limp and some arm weakness, but can live independently.)

We get a stroke alert for a 76-year-old diabetic female who had a breast cancer lumpectomy one year ago. Her husband reports returning from grocery shopping to find that she was slurring words and unable to walk. He promptly called 911 so we’re probably seeing her about two hours after the onset. Her blood pressure is 215/100, too high for TPA, so she’s on a nicardipine drip in hopes of bringing it down. The neurologist calmly examines her with standard techniques (“follow my hand with your gaze”) and some of his own design (“close your eyes and tell me what you feel” as he hands her objects such as a key or lighter). She has a left facial droop, dysarthria (speech disorder due to muscle weakness), right gaze preference, and a left hemianopsia (blindness). Like most of our stroke admits, she gets a CT perfusion scan (five minutes and reimbursed at $12,000 by Medicare) to see if she is a candidate for endovascular intervention, i.e., clearing out a plumbing clog with a drain snake. Her scan is among the 10 percent that suggest endovascular intervention: proximal (closer to the heart) clot surrounded by potentially viable tissue. Her clog is in the middle cerebral artery (MCA, the main artery of the brain).

She is carted off to the endovascular suite. I call Straight-Shooter Sally, who did not get to see an endovascular procedure on her week of stroke service. We meet up in the Interventional Radiology suite; endovascular procedures are split between interventional radiology and interventional neurology. We’re both excited, but the neurologist doesn’t say anything during the 45-minute procedure. “Well that was useless,” says Sally. We follow up with the patient the next day and she has almost no symptoms, except mild weakness in her right wrist.

(It seems obvious that cleaning out the pipes would work, but there are no good clinical trials to support the anecdotal evidence. A lot of patients who get endovascular therapy would likely have recovered on their own.)

During the 4:00 pm debrief in the “Situation Room”, I ask if all stroke patients should get a $12,000 CT perfusion scan. “It depends whom you ask,” responds my attending. “The people who designed our current protocols say, ‘Yes.’ But they mostly are not neurologists. Medicare doesn’t understand the purpose of the CT perfusion scan. Two out of three scans that they pay for are unnecessary in my opinion. Only a small percentage of strokes are amenable to endovascular therapy. And we are not an institution at the cutting edge doing research on other indications. There is no excuse except laziness and dipping into a free pot of gold.” I ask about the VAN score to screen for patients for a large proximal clot. If a patient does not have focal weakness and one of the following: Visual disturbance, Aphasia, or hemi-Neglect, it is extremely unlikely to be a large proximal clot amenable to endovascular therapy. My attending doesn’t disagree with the VAN system, but thinks it adds little to an experienced neurologist’s judgment. “Stroke centers are graded by the door-to-needle time [time to get a stroke patient administered TPA]. The ED is so focused on taking the thought out of medicine with protocols.” He noted that every stroke patient now goes through the same steps: (1) non-contrast CT brain to rule out brain bleed, (2) CT angiogram to look for a clot, and (3) CT perfusion scan to evaluate salvageable brain tissue. “Though lucrative, most of this is unnecessary and doesn’t change management. CMS hasn’t investigated us yet, but I hope they do.”

In his opinion, what would help more patients at a tiny fraction of the cost is simply speeding up radiology. “During nights and weekends we don’t have in-house radiologists. We use teleradiologists who are contracted to get back to us within 30 minutes. We need a 5-minute look at brain anatomy, but they take the full 30 minutes to give us a detailed report so that they can’t be sued for missing something. We get a report on spine, teeth, lungs, etc. The ED can’t read images, so the stroke patient is sitting there for 30 minutes without any therapy. A good  neurologist reads his or her own films and a brave one will make the call without a radiologist.”

[Editor: Smaller hospitals are unable to do either the CT perfusion scans or the endovascular intervention (“thrombectomy”), so our near-octogenarian Presidential candidates might not want to spend too much romancing voters in small towns. See “A Breakthrough Stroke Treatment Can Save Lives—If It’s Available” (WSJ, February 6, 2018).]

Statistics for the week… Study: 7 hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with live music. Mischievous Mary has already started looking for visiting away electives in cardiothoracic surgery.

The rest of the book: http://fifthchance.com/MedicalSchool2020