Random ER thoughts from the week

Friday, April 20, 2018

Random ER thoughts for the week

Carrie Underwood makes her new face debut months after falling, lacerating her face and needing a significant repair. There a couple teaching points.t:

  • The only reason to repair a wound is for its cosmetic results. Every cut will heal eventually.
  • The primary concern when caring for any wound is to prevent infection and make certain that the structures underneath the cut, like tendons, arteries and nerves, aren’t damaged.
  • Scars take time to mature. The timeline starts first with a raised,r ed healing ridge, followed by gradual flattening of the scar, and finally weathering and whitening. It may take 6 months or longer for the final outcome to be realized.

Justice Sonia Sotomayer falls at home and fractures her humeral head, the ball part of the shoulder joint. The fracture often heals on its own with a sling, but the bigger question we ask, especially of older people who fall, is why did the fall happen? Was it a trip on a rug or did the patient pass out and then fall.

Passing out is never normal and can be due to a variety of reasons and it takes detective work to find the cause.

  • Was it low blood sugar (hypoglycemia)? This is one of the complications of medications (including insulin) used to treat diabetics and the Justice has had hypoglycemic events in the past.
  • Was it dehydration or anemia (low red blood cell count)
  • How about a heart rhythm disorder, where the electrical system made the heart beat two fast or too slow?
  • Maybe a seizure?
  • And sometimes it’s normal physiology that runs amok, like a vasovagal episode where the vagus nerve is stimulated and causes the heart rate to slow and blood vessels to dilate, temporarily decreasing blood supply to the brain.

The fracture is a consequence of the fall and taking care of a broken bone is easy. The most important job in in the ER is to understand the why of the injury.


Kevin Love of the Cleveland Cavaliers hurts his hand and damages a ligament in his thumb, most likely the ulnar collateral ligament, which is responsible for keeping the thumb in place as it is used to grasp.

  • A completely torn ligament is a third-degree sprain and would require surgery for repair.
  • Fortunately for Mr. Love, his is not that severe and he is able to continue to play.
  • But injured ligaments can’t do their job as well and a partially torn ligament can completely rupture in the near future
  • With a sprained UCL, it’s tough to pinch the thumb and index together and make a powerful fist.
  • UCL tears are also known as Gamekeeper’s Thumb or Skier’s Thumb.


Minnesota Wild Zach Parise is done for the playoffs after fracturing his sternum or breastbone. It sounds like a terrible injury and it takes significant force as a direct blow for this to happen. Most often it’s in car wrecks or during sports.

  • Sternal fractures can be associated with other injuries and it’s important to look for those, including lung and rib damage.
  • While the heart sits right behind the sternum, it is usually not damaged An EKG is often done, looking for abnormalities that might be associated with a bruising of the myocardium (heart muscle).
  • The treatment is all about pain control so that the victim can take deep breaths and keep the lungs expanded.
  • Unfortunately, the healing time is measured in months not days and Mr. Parise is done till next season.


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when you have to wait

Sunday, April 8, 2018

There is no word to describe the photo. Three survivors of the bus wreck that killed 14 of their Humboldt junior hockey teammates and their coach, holding hands while waiting to be helicoptered to a larger hospital in Saskatoon. Did they know that so many had died? Did they see the bodies, or did somebody tell them while they lay on the stretchers in the hospital? And who was that somebody? Who was there to help them hold hands while they waited. Teenagers with no family at their bedside.

Every hospital is required to have disaster drills that includes triage at the front end, sorting victims, and then making certain the hospital staff shows up at their designated spot. Like a life boat drill on a boat, once everybody gets to their spot, it’s over, everybody congratulates themselves on a drill well done and the day goes on. There is no part of the drill that involves breaking news to three teenagers about their friends and who lived and who died. And there is no drill that looks after those who cared for the victims.

Looking after patients who are extremely ill or injured is why most people work in the ER, providing critical care and making a difference in the first few minutes is what defines emergency medicine. There is a ying-yang to the adrenaline rush that comes during a patient resuscitation. Win the battle, the patient survives and the team celebration can last for the rest of the shift; lose and the patient dies, but there is no time for remorse or grief. The family now needs care and there is a waiting room full of patients, all waiting, some not so patiently. Winning makes it easier to deal with a frustrated waiting room but losing makes it much harder.

When the ambulance radio goes off with a trauma notification, everybody’s ears perk up. The trauma nurses hand off their patients to others to ready for battle in the resuscitation room. The ER docs try to plan care for their other patients when they will be drawn away to look after the soon to be arriving victim. The team gathers (lab, x-ray, respiratory therapy, pharmacy) and starts to prepare. But in the back of their minds, they want to know…where is the ambulance coming from… how old is the victim… and where is my family? Just checking.

Even with the best of care, some people die. Bodies are too damaged or too diseased, and death may be declared quickly, or it may take hours of care. The options for people at the bedside to process the unexpected death are limited. One can pretend that the victim wasn’t a real person becoming numb to events, or they may not be able to let go and disconnect the death they have just witnessed from their own life. When it’s a child who dies, it can sometime become overwhelming for the staff. The ability to pause for a few minutes and process what just happened is an important need for hospital workers, but that never gets practiced in a drill and not commonly in the real world. Time for reflection rarely happens because of the pressure to see a continuously filling waiting room.

Patients and family get frustrated when they have to wait, especially when they don’t know why. Newer hospital architectural designs insulate the waiting and treatment areas. In older buildings, people could see ambulances arriving, staff running to meet them and the noise of the care provided. Now, sitting in a quiet waiting room, the patient can only imagine doctors and nurses staff working at a leisurely pace with the urgency that they expect.

After a busy shift, and a less than polite patient or two, the ER staff have been known to gripe over a beer…the time to pause sometimes comes later than it should…and say things that they never would in front of a patient.

  • Can you believe the guy who complained that he had to wait for two hours? Doesn’t he have a clue?
  • We’re sorry that you had to but be glad that we thought you could wait. It means that somebody else was more damaged.
  • You had to wait because the doc was looking after a teenage trauma victim, and even though we did everything that we could for 45 minutes, he died.
  • The nurse and the doc had to tell family and sit with them until the chaplain came. The nurse stayed behind to talk about organ donation, while the doc talked to medical examiner and then had to go in back to change scrubs and coat because of blood contamination.
  • Meanwhile, housekeeping had to clean up the mess in the room. Central supply and pharmacy had to come down and restock so it would be ready for the next trauma patient.
  • So yeah, you had to wait and you’ll be seen when the doctors, nurses, techs and everybody else who makes the ER run, gets their heads together about what just happened because they have feelings and emotions too.
  • Welcome to the ER. now do you want to fill out your satisfaction survey?

By the way, there are three boys holding hands waiting for a helicopter, and somebody has to tell them that their teammates and coach are dead.


image: mirror.co.uk


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