The nurses rocked in the ER. I'm glad I eventually bought them all junk food and strawberries as a way of saying thanks. I never took vitals. I ACE wrapped only when I wanted to. Suture trays were set up for me in advance. I gave one shot in 6 weeks. They collected and cleaned up urine and spilled urine...it was plush. It was such a well-oiled machine that for me to disrupt the system by trying to help out, would create an inefficiency. And, I was busy doing other important things, I rationalize, like diagnosing Lower Back Pain Not Otherwise Specified.

In the prison, I will be the triage nurse, medical assistant, charge nurse, clerk, and PA student. In addition to the history, physical and charting we'll be doing all the vitals, medications, scheduling of patients, transporting of patients to rooms, EKGs....I might put in a few hours at the cafeteria making mashed potatoes so I can round out my curriculum vitae.

I am pretty excited about this diversification of duties, actually. Lots of procedures to be done here, like toenail removals and cryotherapy. I had a 30 second patient encounter today that involved simply having the patient stick his arm through the small latched window from the suicidal isolation room so I could inject his deltoid with some medicine. It felt a little funny. No introductions, no eye contact. Just grab that deltoid, poke it, and walk away.

Great to be home in sunny Portland with the wife and puppy. I hope this 6 weeks goes by nice and slow!

Prison Medicine Day One

This is going to be interesting.

In some ways, there will be a lot for me learn, coming "from the street". Like how to unlock and lock every door you go through all day.

In other ways, it will be more of the same. For example, a pus-filled abscess in prison looks just like a pus-filled abscess on Whidbey Island. Patients hurt and they don't want to.

It's a lot quieter in prison, though. Everybody is very calm so far. We'll see how long that lasts.

Clean & Free

Closing in on the end. With 2 days off before my last 2 shifts and feeling a bit of island fever, I had to get to the mainland. I don't really like being surrounded by water, unless I can be immersed in the liquid, not just look at it.



























So I went to Forks, WA. Fellow PA-S and blogger is rotating there, and assured me that there would be room on the floor for me to sleep. Outside of town, at the end of the road, is La Push, Home of the Quilete Indians and a consistent wave (and rain and cold and supposedly lots of sharks).

Tuesday afternoon conditions were nice. Calm, glassy, small waves. As I paddled out, 3 guys got out and left. Solo session in an unknown locale.

After a few hours, I drove into town to watch JW play softball. He is playing for "Clean and Free" a local AA team. (No, not AA, like "double A" farm team). They played well against Subway's team. At one point, JW did a head first slide into second base, exposing both his base running prowess and his "sensitive parts" to the crowd (and the gravelly dirt). Despite the efforts, they lost (by a lot). Suprisingly, Jake was the only one wearing a Clean & Free jersey in the bar afterwards where we shared a pitcher of beer.

Wednesday early morning session at La Push was rainy and cold, but provided fun waves. And again, solo. After an hour or so, another surfer paddled out. He said he was suprised to see me out here alone, and that he would never paddle out solo. And while, as a professional courtesy, the name of the specific fish goes unmentioned while our legs dangle below our surfboards, it is assumed that the reason that people don't come out here alone is that......they actually aren't alone. Many "landlords" occupy this area. A sea lion pokes his head out of the water and stares at me from about 20 feet away. A few fish jump here and there. The other surfer catches a wave to the beach and walks back to his car. The rain pounds on my wetsuit. My legs dangle in the dark water. My heart beats. The sea lion poke his head back up, curious to see what I am going to do. I catch the next wave in. I was ready to get out anyway, I tell myself.

Numbness

Hotel Suite Scene "Dirty Rotten Scoundrels" - Watch the best video clips here

Numbness.
Everybody is numb, if you ask. Bursitis? Numb. Ankle sprain? Totally numb. Strep throat? If I asked, they would say numb. Just like everybody that feels sick, when asked will say, "Yes, I've had chills", every injured person says "Yes, I have numbness." Numb, numb, numb. It doesn't mean anything, if everybody is numb.

Bug Bites and Paragliders

There are 2 young docs in the ER that perpetually seem flustered. When it is busy, they spend more time grumbling then working. They sit in front of the computer and shuffle through the patients they have yet to see, like they are shuffling their poker hand around to see if they can make a straight out of nothing. The hand they were dealt was a full house, but that is a losing hand unless you can empty it.

I show up at noon yesterday and start picking up patients. Young Doc is rushing about tending to a new CVA and a hypotensive patient with positve FAST exam. She says in a slightly condescending manner, "I'll see the sick patients and when I'm done you can tell me about bug bites." I skip the bug bites in room 13, and go straight for the diarrhea in room 9 as a subtle stand against PA pigeon holing. I figured the diarrhea had a bigger, albeit stickier, work up and a more complicated differential, so when young doc was done saving lives she could see the bug bites.

The only lesson from the diarrhea experience was one I have known for years: avoid the Jack in the Box chain. Something is just not right with that place.

Later in the evening, with the Young Doc phasing out and the Old Doc taking command, we found a rhythm in the busy hive that is the ER. Old Doc understands that I my job here is not to see just "Fast Track" patients and support the doctors as they see the "criticals". If they want to hire a PA to do that, fine. As a student, we see whoever. Including Paragliding accidents.

57 yo handle bar mustachioed paraglider stalled 15 feet above his landing and dropped flat on his back onto rocks, with a bounce. +Loss of conciousness, complaining of back pain, epistaxis. Attributes the fact that he doesn't know the month, date, or what he had for breakfast to "I'm and Artist." Friends dragged him off the beach and drove him to the ER. Actually, If they had called 911, there would have been other people in the room besides me and the nurse. But they didn't and I was in charge.

CT head, c-spine, t-spine, chest x-ray.....long story short he had a burst fracture of T4, which was a fortunate diagnosis for the mechanism of injury. He walked out with a boatload of pain meds (and stool softeners).

I have no problem seeing the simple stuff. It feels good, in fact, to bounce from room to room and feel like you have a grasp on what is going on. But because I am paying to work here, not vice versa, I'll take the liberty to see the bug bites and the paragliders.

BONUS QUIZ: What medication did I prescribe for the paraglider that will be administered intra-nasally? First person to comment with the right answer wins a prize!

More Baseball Medicine Talk

I should retire right now while batting 1.000 with ABGs.
Respiratory therapist missed twice, so my preceptor said "Let's let the PA student try".
I've stuck lots of veins. Jabbing a needle into somebody's radial artery has a different feel.
Straight in. Helps when the patient is comatose.
One for One. This high batting average will not last. Unless I refuse to step up to the plate again.

Mirror Image

Room 13: 15 yo male, lip laceration.
Sign me up. This is not like a high rise hotel that skips from floor 12 to 14 to avoid the unluckiest number. We are proud of our room 13. Being in the "Fast Track" area, it tends to get the unlucky patients that did unlucky things like "stepped on a nail" or "slipped on a boat". Not quite enough to get you into the trauma bay but enough to get you into Old 13. This happens to be where most of my suturing has taken place, so if you consider having a young PA student who believes in Trial & Error learning, pass needle and thread through your wound to be unlucky then it's the perfect room for you.

As soon as I made eye contact with the 15 year old, I knew I recognized him. He was me, about 17 years ago. He looked like me. He talked like me. OK, well he didn't talk like me, because his upper lip was swollen to the size of an orange slice and curled upward to the ceiling in a strange way. When he told me about the baseball he took to the face, I instantly was taken back to when I was hit by the ball. The stunned, starry, buzzing face that comes from only a hardball to the face is a feeling that isn't easily forgotten. Your ears ring. The temperature rises 10 degrees. The other kids look at you funny. The blood trickling onto your shirt....

When he told me it was a grounder, a bad hop, I knew that he also played second base, like I did. Although I never had stitches for any baseball related trauma, I felt this guy's pain, more so than any boating injury, birdfeeder mishap, or bronchitis so far. I was there with him, taking bad hops, bad throws, bad pitches. I felt the sting.

After deciding that the laceration did not cross the vermillion border, and thus not a plastic surgery case, I placed 8 stitches in his upper lip. I denied his mother's request to incorporate the lower lip into this set of sutures, despite her insistence that it would make for a quieter summer.

His summer is starting with a fat lip, but summer break when you are 15 cannot be ruined by such a minor insult. He has plans. He asked me if he could work tomorrow, and when he said he was a bagger/stockboy at the local grocery store, I almost laughed out loud. Again, almost two decades ago there I am: Bagging groceries at my local store, playing baseball, getting smacked in the face. All day we run around crossing paths with hundreds of people. Once in a while, one of them has the ability to take us back to the same burning pain we've experienced, as well as the same youthful joy that we've relished in.

Clinical Equations

Dog's Paw + Child's Foot + Jump = Puncture Wound + Antibiotics + Animal Control

Slippery Ladder + Bucket of Wood Stain/Pain Thinner + Open Mouth = Belly Pain

Semen + Blood = Anxiety

Garage Door + Head = Disorientation

Third Story Window + Broken Screen + 12 yo Girl + Gravity = Stick Impaled in Arm Only!

House, MD Watching x (dizzy,syncope,abdominal pain,toothache,finger twitching) = Strange Jungle Disease, according to patient

12 oz can of Mountain Dew x 12 per day = Renal Pelvocaliectasis = My Kidneys Hate Me.

Child + Tylenol Bottle as Toy + Mom taking Nap = Red stains on mouth, shirt, carpet + Several Hours in Emergency Room



A few recent pics:

Woke up this morning with enough wind that I thought maybe, just maybe there’d be some junky but surfable waves at Fort Ebey. With this wishful thinking,a surf check is born. Things needed for a proper morning surf check include:

•Coffee (The lady at Miriam’s in Coupeville starts making my Americano when I walk in the door.)
•Your surfboard in case it looks like Waikiki.
•A plan for what to do when it looks like Lake Erie.

Flat. Flatter than Lake Erie. My backup plan is set into motion: Drive to Cananda. Multiple motives exist for this trip:

•The other day, while assessing a patient’s mental status, I asked, among other things, for the name of the President. He said, “well, I am from Canada, so that’s not a fair question.” Granted, this man didn’t know his own address or what month it was so I could’ve stopped right there. But because the request of naming government leaders was already out there, I only thought it fair to reword with a more Canadian friendly question. Who’s the Prime Minister of Canada, then? As soon as I asked it, I realized I didn’t know the answer to my own question. How alert and oriented does that make me? He said something like Stephen Harper, and to me that sounded more like a basketball player, so I considered him delusional and had him admitted. I decided then and there that I needed to go North for a visit.

•I am a _____ and driving somewhere just to drive there, never sounds like a bad idea. My surname actually translates to Of the Rose, which is a nod to the compass rose that has been utilized throughout my bloodline.

•In a future rotation I will be within driving distance of Old Mexico, and the more International I can make these rotations seem, the better it will look on my résumé.

•I hadn’t been treated like a terrorist in a while, so I was due for good border crossing.

A piece of advice for anybody going to the big C, eh? N, eh? D, eh? is to actually look at a map and at least pick out one town to tell the bulletproof vest wearing Canadian Border Cop that that is where you are going. All I really had was “I am here to visit.” He needed specifics and I just froze. It doesn’t help that a surfboard bag and a body bag are very similar in appearance, especially when being brought across international boundaries by an unshaven, unshowered man on Wednesday morning. They took my driver’s license, my passport, my cell phone and my car keys and told me to wait inside. I felt like a vulnerable ER patient, forced to wear nothing but a cheap open-backed gown, and told to sit in a small room and wait to be told your fate.

After a short-lived visit with our northern neighbors, I found out that the US Border Patrol also frowned on me “just taking a quick trip” to Canada. I even rehearsed my statement while in line. But once the questioning began of why exactly I came up here, by myself, on a Wednesday, in a van, for a few short hours….I just couldn’t convince them of my aforementioned motives. Oh, and apparently a surfboard bag looks just as much like a body bag in the southbound lanes as it did to the Canucks guarding the northbound route. Once again, keys, passport, wait inside with the other miscreants. Why are my palms sweating trying to innocently make passage to my own motherland?

Maybe both the Canadian and US Border Patrols have successfully convinced me that, yes that was a stupid thing to do on a Wednesday morning. It’s like they had seen my To Do List…Let’s see, laundry, phone calls, pay that bill, read up on Huntington’s Disease…..look at all this stuff you should be doing, Mr. DuRoss, you don’t deserve to make some willy nilly flight of fancy to another country, with all these other things going on….

I spent more time in Customs than I did in Canada. I didn’t even learn anything about the leader of the Canadian Government. But, I made it back to Whidbey Island without any latex gloves being broken out, so I consider that a small victory. Next time, I’m leaving the body bag at home. Actually, the next time will likely be a Mexican border crossing, so the surfboard will be coming along. I guess next time I just need a better story to go along with it.

More Heard from the Herd

"I've got an apple stuck in my throat," says the drooling lady.

"I pushed the Walk Button," repeats the pedestrian who doesn't remember being hit by and flipped up and over the sedan.

"I've been in the Navy for 25 years, I know how to tie a square knot," says the unimpressed sailor as he watches me sew his soup can laceration.

"If you can get my potassium to 2.5, I'll be doing calisthenics in the hallway," says the emaciated and weak lady who was admitted last week with a K+ of 1.6 (nl = 3.5-5)

"I called 911 again," says the same lady with a toothache from last week.

"Attackacardia," reads the chief complaint, filled out by our registrar, referring to the patient's rapid heart rate.

"The blackberry bushes were losing for a while," says the frustrated and wounded fighter of the oh-so-tasty yet oh-so overgrowingly annoying berry when his new weapon of choice, gas-powered hedge trimmers, turned against him by opening the skin on his left knee.

Halftime Show

Diverse stories, not-so diverse ethnicity.

Top 10 Diagnoses
	079.99 - UNSPECIFIED VIRAL INFECTION
	847.2 - SPRAIN/STRAIN LUMBAR REGION
	599.0 - URINARY TRACT INFECTION UNSPEC
	786.50 - UNSPEC CHEST PAIN
	682.2 - CELLULITIS/ABSCESS TRUNK
	292.0 - DRUG WITHDRAWAL
	461.9 - UNS ACUTE SINUSITIS
	466.0 - ACUTE BRONCHITIS
	682.6 - CELLULITIS/ABSCESS LEG EX FOOT
	780.2 - SYNCOPE AND COLLAPSE

Despite such diverse stories, it still often boils down to back pain, viruses, pee pain, drugs, and "bug bites".

high pressure

Speaking of stories, here's a guy who can spin a yarn:

Me: Was there an initial injury or event that occurred, causing you this low back pain?

Guy: (abbreviated for brevity) You know those water slides? The ones where you go through the tunnel? Well, I used to be a lot fatter than I am now (He's still pretty obese). I was going down the slide and I got wedged in the tube and I was stuck. It was near the bottom of the slide. All this water started building up behind me and the pressure finally built up enough to shoot me through. But it was so much pressure that it shot me through the little pool at the bottom and onto the concrete.

Me: Wow.

Me: Any recent injury to cause this recent worsening of the pain?

Guy: Well, I was bending over to turn off this outdoor faucet....that kinda hurt.....but 2 days ago my new propane tank for my BBQ exploded. I was sent flying into the air and did a corkscrew and landed on my back. (To his credit, his face is red and his eyebrows are scorched off)

Me: Wow.

Guy: You know those big green freeway signs? I used to have to scrap those in California. And I was cutting one down with this big torch and a huge flaming hot ball of steel landed on my chest and I wasn't wearing a shirt, let me show you the scar. (Looks better than a cigarette burn)

Note: This patient has been awarded by my preceptor a Lifetime Achievement Award for Creativity and Originality with the Waterslide Story, that he had also heard a few months ago.
Th prize for this prestigious award includes a no-questions-asked Percocet upon arrival to the ER, and a free IM shot of Dilaudid with Phenergan before you leave. Quite an honor!

From the parking lot of the closed public library, where I just finished entering Typhon patients from yesterday. There are just so many stories here. I don't have to try very hard. It's just a constant flow from one room to the next, walking out of one wild history into the next heartbreaking tale. It'd be impossible to make this stuff up.

29 yo F on the island for great grandmas birthday party decides to go on a Meth, alcohol, and prescription narcotic binge for 4 days. Disappears from family. Re-injures her already broken and casted foot sometime during the bender.

24 yo M in Seattle came down to parking garage to see his wife being attacked from behind. He runs up and punches the guy in the back of the head once, causing the assailant to run, but also his fifth metatarsal to break. Bad enough for surgery. I truly believed this story, although I may sound gullible. Maybe he just was drunk and punched a wall, felt silly and made up a hero story.

85 yo M Nausea/Vomiting........troponin = 97.54! Classic huge heart attack with no chest pain, no SOB, no nothing. Highest troponin that any of the docs had seen.

61 yo F Nausea/Vomiting after drinking 1 too many margaritas....develops headache and dizzyness whiles discharge instructions are being written. Head CT = Huge head bleed = Helicopter to Seattle.

No real theme last night other than it seemed like a good night to stay on ones toes.

The Awristocrats of Whidbey Island

After some jet setting down to Portland and thoroughly enjoying my mainland time, it was back to the island for me. Left the big city at 6am, battled Sea-Tac traffic squirming in my sweaty leather seat of my no AC-working Mazda as the blazing sun was reminding me that a Noon O'clock start in the ER was going to be a push. A ferry ride full of Euros later, I made it to the ER w/ 3 minutes to spare.

Apparently, a thunder storm hit Portland when I left. But I entered my own storm, of a nature previously not witnessed. It was the Great Wrist Storm of 2009. While brief, it was intense, and in a matter of 2 hours, we were in a deluge of displaced carpals, distal ulnas, and comminuted radii. We had 8 wrist injuries in this time. That is a lot for a 13 bed ER on an island of only 10,000 wrists. (and remember all except the saltiest of sailors up here, have two each)

11 yo boy fell skatebording
9 yo boy fell walking backwards
72 yo lady fell while slipping on a rock
10 yo boy tackled at school
19 yo girl wrist vs. knife in a brownie pan incident
17 yo guy boxer's fracture
44 yo I don't even know what happened to her (I can only keep up for so long)
18 yo wrist vs brick (that happened to be on the ground which happened to be adjacent to a trampoline which happens to be bouncy and happens to toss children and adults off with very little discrimination)

When I walked into the Fast Track area, there was a guy on the left with a right wrist injury and a guy on the right with a left wrist injury. I was hearing words like Monteggia and Galeazzi being thrown around. I heard at least 4 providers provide mnemonics for remembering the carpal bones. When the clouds cleared and last wrist was discharged, we surveyed the damage: We ran out of air splints. We're down to the 8 inch ACE wraps. Ortho is still on hold for that one guy. But we never ran out of Vicodin. No, we will never run out of Vicodin.

Library is closing. I went to an Ultrasound training session today, so almost normal hours for me. Now they are kicking me out, so gotta run back into the Internetless world. Miss you all!

Heard from the Herd

"I punched a chandelier," says the meth smoker.

"It hurts so bad that when I dropped a banana on it, I screamed. Then when I dropped a cassette tape on it, I screamed again," says the lady who fell off a ladder.

"I am Paul, what's your name?" asks the 50 y.o. man that didn't remember me coming into his room 5 minutes ago, let alone what year it is, who the President is, or what he had for breakfast. (New symptom today, no trauma, no drugs, no head bleed after CT)

"I got a bug bite," says almost everybody with MRSA.

"I got MRSA," says everybody who has a bug bite.

"Your next pizza is on me," says the pizzerria owner after I sew his finger.

"I called 911," says the lady with tooth pain.

"It's healing up well," says the toothless son of a 160 pack year history (4 ppd x 40 years) smoker who fell asleep on the couch with a ciggie in his mouth, as he (the son) rubs the oozing wound with his bare finger. "We came in because he's constipated."

"It's not erysipelas," says the hospitalist to the PA student who thought he was pretty cool for diagnosing erysipelas in the ER, thus crushing the 4 minutes of fame and glory that he had been basking in before the hospitalist came in.

"I hate chandeliers," declares the meth smoker, clarifying exactly why he punched it.

The Lamest ER Visit Thus Far

I've got a rash.
Where is it?
Right there on my foot.
That? (3-4 red dots on dorsal aspect of right foot...initial impression: not very impressive contact dermatitis vs. even less impressive poison ivy)
Yes.
How?
I don't know.
Been seen?
Yes, I have Benadryl, Hydrocortisone cream, and prednisone from my doctor.
Is it working?
Yes.
OK.
I might need to be off work so I can air it out and I work around electricity and if I don't have a boot on my right foot then I am not grounded and......I might just explode spontaneously....
I see. Goodbye.
I was not this curt. But I wanted to be. This guy is a Navy man. Active Duty. Defending our country. I think there are some vets out there that would like to kick this guy in the mouth with their gangrenous trench foot to give him something real to complain about. Wow.

Can you tell the honeymoon is over?
A little tired of the "Stay Late-Look Great - Rah Rah Rah" thing. I am scheduled an hour earlier than the "middle doc". I get run ragged by the day shift. They leave, and the night shift comes in fresh. I stay later than the "middle doc". Just enough time to sleep and enter Typhon data before work again. I am actually enjoying it immensely, and don't mean to moan about a few extra hours. But when your foot itches, and is getting much better with the 3 medicines you have been taking, and you drive up to the hospital with a big red EMERGENCY sign.....just remember that there might be somebody inside that has worked five 13 hour days and will still be professional and empathetic but only because they have to be.