Saturday Snippet - The joys of emergency room medicine

 

J. Paul Waymack has penned a very entertaining memoir of his experiences as a medical student and, later, a trauma surgeon.  He calls it "Well, Doc, It Seemed Like a Good Idea At The Time!".

The blurb reads:

In 1976, Paul Waymack began chronicling his experience as a third-year medical student, and for the next 20 years, he kept a journal filled with crazy stories of unusual patients, maladies, and international espionage. Some of them, he’s the first to admit, seem unbelievable--like chasing a naked patient around the ER parking lot in the middle of the night . . . or constructing a horse sling for a 700-pound patient . . . or treating a patient who swallowed a cigarette lighter . . . or serving as a major in the U.S. Army Medical Corps during the Cold War, on orders of the president and with a KGB agent hot on his tail in the Soviet Union. In his wildest dreams, Dr. Waymack could never have imagined most of what he experienced as a doctor, but these stories are all true. He couldn’t have made them up if he tried.

Here's a sample from his early years in the field.

On my first day as a brand-new third-year medical student on rotation in the emergency room at Riverside Hospital, I cheerfully introduced myself to the ER director, the intern, the nurses, the receptionist, and anybody else I passed. Although I was just a medical student, I had the self-assurance and buoyancy of a promising doctor, and I was eager to meet the staff and get to work.

The director showed me the doctors’ lounge. It was located right in the middle of the ER, and doctors retreated there to read charts, write notes, review X-rays, make phone calls, eat, and drink coffee. One wall was lined with bookcases filled with various medical textbooks. A refrigerator, coffee maker, and other odds and ends filled another wall. Windows took up most of a third wall, providing a lovely view of the parking lot, and the final wall displayed the X-ray viewing boxes. You’ve seen those on TV: rectangular boxes with bright lights in the back. You put the X-ray film on the box, turn on the light, and thoughtfully squint at the film.

When I entered the lounge, I noticed a film hanging on one of the viewing boxes; next to it was an index card with some printing. Immediately, I understood what it was. Or thought I did.

I’d seen these at school: view boxes with hanging X-ray film and an attached index card with the patient’s symptoms. Med students would look at the X-ray, review the listed symptoms on the card, and come up with a diagnosis. A week later, the correct diagnosis would be listed, and a new X-ray and history would be up on the box.

I walked over to the unlit X-ray and read the index card:

Patient complained he couldn’t sleep at night. The light kept him awake.

I was puzzled. I knew many diseases could cause insomnia, but the thing about the light confused me. If the light kept the patient awake, why didn’t he just turn it off? As I mentally scanned the list of diagnoses that might fit, I determined that a tumor inside the patient’s brain must be affecting his optic nerves. I therefore expected to see some form of skull X-ray when I turned on the light behind the box.

Instead, to my surprise an X-ray of an abdomen appeared. I recognized the features: bottom parts of lungs and heart, upper thighs, and almost everything in between. I could see a faint outline of the kidneys and liver, plus a number of bones far more distinctive than the less visible internal organs.

It took me a few seconds to review these standard anatomical features, for my attention was focused on something else: something in the patient’s rectum that—even to my inexperienced eyes—didn’t belong there. A crystal-clear image of a metal flashlight showed up on the X-ray. You could see not just the outer metal shell, but also the light bulb, the on/off switch, the batteries, even the wires. It was one of the most memorable X-ray images I would ever see in my career.

For a minute, I just stood there looking at it intently. I had seen a lot of X-rays as a med student—scans that showed cancers, pneumonia, kidney stones, bowel obstructions, and seemingly endless other types of pathology. But I had never seen anything like this. Eventually, the intern on call for the ER noticed me standing there, staring slack-jawed with what I can only imagine was a look of complete bewilderment. He walked over and stood next to me in front of the X-ray.

“Kinda funny, isn’t it?” he said. “Especially the part about the light keeping him awake.”

I didn’t respond immediately.

“It’s a flashlight,” I said.

“Yeah.” The intern nodded, pursing his lips as he examined the X-ray.

“It’s in the patient’s rectum.”

He looked at me and smiled. “Yeah, we see this,” he said nonchalantly, as if to say, Don’t worry, you’ll get used to it.

After staring at the bizarre X-ray for a while, I was wondering what to do next when the ER director walked back into the lounge, pointed at me and said curtly, “You. There’s a patient in Room 8. Go examine him.”

I didn’t bother to ask why.

“Yes sir,” I responded briskly, and headed for Room 8.

As I walked down the hallway, my self-assurance started to diminish. My heart pounded, my breathing increased, anxiety nearly overwhelmed me, and I began to perspire profusely. This was what I had been training for the past six years—four years of college and the first two years of medical school. I was about to walk into a room and see a patient, take a history from him, perform a physical exam, then come up with a diagnosis and plan for him. I was about to see a patient who would likely think I was a doctor—unless I messed up badly.

As I stood outside the door to Room 8, I made sure my tie was correctly knotted and its point was directly above my belt buckle. I straightened my white jacket and combed my hair. Satisfied that I looked like a doctor, I confidently entered the room.

Lying on a gurney was a man about 6’6” and 250 pounds—mostly muscle, from what I could tell. I was so nervous and focused on acting like a doctor that I failed to notice that all four appendages were in full leather restraints lashed tightly to the side railings on the gurney. The patient was almost completely immobilized.

Even if I had noticed the restraints, I was so inexperienced that I wouldn’t have comprehended what they implied. At this point in my budding career, however, I apparently lacked both experience and common sense.

I cleared my throat.

“Good morning, sir. I’m Paul Waymack.”

We’d been told that while we were still medical students, we could not introduce ourselves as Doctor. If we gave our first and last names while wearing a white lab coat, however, patients would usually assume we were, in fact, doctors.

“What seems to be the trouble?”

My voice was louder and higher than normal due to my extreme nervousness; it probably hadn’t sounded like that since puberty. I was embarrassed by the sound of my voice and feared it had conveyed my inexperience and anxiety. I worried the patient would sense the apprehension in my voice and ask if I was really a doctor—one of the worst things you could say to a third-year med student.

The patient, however, said nothing. In fact, he appeared to not even notice I had entered the room.

I quickly contemplated the patient’s strange lack of a response. Why is he ignoring me? I wondered. Did he already realize I’m only a med student? What gave me away so quickly? Anxiety and self-doubt crept in.

Then the light went on—Aha! I quickly wrote down on my clipboard, “patient’s hearing severely impaired.” I smiled, pleased, as I looked down at this notation. Five seconds into my career as a student-physician, and already I had identified an abnormal physical finding!

Flushed with the confidence of having just obtained what I considered a diagnostic coup, I now felt my heart and breathing slow down. Instinctively, I stuck my chest out a bit and cocked my head slightly to the side. I may not have been a doctor yet, but I suddenly believed that strong evidence already showed I was going to be very good at it.

I walked up to the head of the gurney and drew close to the patient’s ear. He continued to ignore me as his eyes wandered aimlessly about in the general direction of the ceiling.

“SIR, WHAT SEEMS TO BE THE TROUBLE?” I said in a very loud, authoritative voice.

This time I got a response from the patient, though it was not the one I had expected. Instead of hearing a description of his problems, I was greeted with a bloodcurdling scream. He then struggled forcefully to sit up. As he yanked on the leather restraints, he began to bend one of the metal railings on the gurney and lunged at me, yelling unintelligibly. It was as though Dr. Frankenstein’s monster had suddenly come to life, and I was the doctor who had put him there.

My upright and cocky posturing ended instantly. My body was halfway to the fetal position before I regained control, and my pulse increased by at least twenty beats a minute. I backed out of the room as quickly as possible with my eyes constantly focused on the patient in case he broke free. Without thinking, I shouted the number-one most used expression of med students who realize they are in over their heads:

“I’ll go get the doctor!”

With that, I left the room and headed back towards the doctors’ lounge at a brisk pace. By the time I got there, my jacket was no longer straight and I had loosened my tie and unbuttoned the top button of my shirt.

I found the ER director sipping a cup of coffee and reading some document in his lap. I glanced at him, relieved that he apparently didn’t see me enter the lounge. But as soon as I sat down, without removing his eyes from his reading material, he asked the question that’s guaranteed to cause anxiety in new third-year medical students.

“So, Doctor. What do you think your patient has?” He wasn’t exactly smirking, but I knew sarcasm when I heard it.

Only then did it occur to me that I hadn’t accomplished every doctor’s primary objective: come up with a possible diagnosis. In fact, in my hurried efforts to exit Room 8 with my life intact, I had failed to take any medical history or perform any physical examination of the patient. All I knew was that the patient seemed to be hard of hearing, insane, and preternaturally strong. My mind raced for a diagnosis that would fit those symptoms.

Fortunately, I did not know too many diagnoses at that time, which shortened the amount of time required to contemplate each one. Among the diagnoses I knew was drug abuse.

“Maybe he’s on drugs, like amphetamines?” I offered.

The director smiled. “Well that’s possible, considering his bizarre behavior, but what about all the perspiring he’s doing?”

Perspiring? I thought, stunned. I was the one doing all the perspiring!

 “Huh?” I responded uncertainly.

The director finally looked up from the paper in his lap and chuckled. Not a good sign.

“With all the perspiration, wouldn’t delirium tremors be a more likely diagnosis?” he quizzed.

I paused for a few seconds, trying to appear as though I were thoughtfully contemplating this possibility.

“Oh, yes,” I responded casually. “Of course you’re correct. DTs is a more likely diagnosis.”

“Indeed,” he said drily. He then reviewed the consequences of taking alcohol away from addicts.

“DTs include hallucinations, loss of touch with reality, plus many physiologic changes including a rapid pulse and a lot of perspiring,” he explained, like a professor patiently lecturing to a class of first-year students. “If not treated, patients can sometimes die from it.”

As I listened to him, I vaguely remembered learning about DTs as a second-year. Now that I had actually seen a patient with DTs—especially someone who looked as if he used to play defensive tackle for the Green Bay Packers—I was never going to forget it again.

“So… how do you treat those patients?” I asked the director.

He shrugged.

“Oh, you give them IV fluids to replace what they lose from perspiration, and vitamins—since a lot of these patients have vitamin deficiency due to a diet that has consisted solely of gin and vodka.”

My mind remained focused on the patient’s wild behavior.

“Yes, but how do you keep them from—well, from attacking us?”

He smiled. “Oh, you give them Librium,” he explained. “Twenty-five milligram shots until they calm down.”

That was the first drug for which I ever learned the exact dosage—and I never forgot it. By the end of that month, I had also learned that when you work in the ER, you use a great deal of Librium.

I spent the next half-hour reading about DTs, then went off to see a series of sore throats, backaches, and flu cases. These were the kinds of maladies I had expected to see in practice, before the third year of medical school kicked me into reality. But it wasn’t long before there were more cases in which patients had been injured doing really stupid things. I wondered how long the craziness would last, and when sanity would return.

One of the nice things about the rotation at Riverside Hospital was that we were never pressured to see patients or stay long hours at the hospital, but were allowed to set our own pace. It was the only rotation with such a schedule for third-year students. I was excited to take advantage of the free time, though, so I ended up staying in the ER until very late. The first night was no exception. I didn’t start heading back to my apartment until 11:00 p.m., after the night-shift intern had taken over for his daytime counterpart.

Unfortunately—or fortunately, from the night-shift intern’s point of view—it was just at 11:00 when a patient arrived, yelling and screaming as the ambulance crew brought him into the unit. I decided to hang around for a few minutes, since it seemed likely the patient had DTs, and I now knew a lot about those. If that was the case, I could impress everyone on the night shift with my new knowledge, and the intern would, hopefully, give me an outstanding grade on my performance.

As the nurse and intern tried to control the patient, I reached over and touched the skin on the patient’s extended arm, looking for perspiration. Upon palpating his skin, however, I found it to be very dry. I determined that this patient was not having DTs; he was merely crazy from amphetamines. Damn, I thought. With that, I decided to call it a day and head on back to the apartment.

Meanwhile, the intern and nurse seemed to succeed at least partially in quieting the patient.

The experienced nurse clearly knew what to do next. “Full leather restraints?” she asked. “The usual 25 mg of Librium?”

The intern shook his head.

“That won’t be necessary,” he responded brusquely. “Just get him out of his clothes and into a gown, then send him up to the Psych ward. Let them worry about him.”

The nurse derisively looked at the cocky intern and rolled her eyes. Convinced that I could learn nothing more from this patient, I went back to the doctor’s lounge to pick up the textbook and other items I had brought in that morning. The intern followed me into the lounge, where he began writing an admission note for the patient. The note included orders on how the patient was to be treated: how often to take his vital signs, what to feed him, and what medications to give him.

I wished the intern a good night and was about to leave when the nurse ran into the lounge.

“He just ran off into the parking lot!” she gasped, glaring at the intern. She didn’t have to add, “I told you so!”

As we looked out the lounge window, we could see him running past one of the parking lot lights. He was stark naked—the nurse had just managed to get his clothes off before he bolted for freedom.

The intern looked at me and barked, “Come on, we’ve got to catch him!”

We both ran out the ER doors into the parking lot, chasing after the drug addict. An orderly soon joined us in our unscheduled late-night calisthenics. I knew I had forgotten some things from my first two years of med school, but I was fairly certain none of my professors had ever mentioned catching crazy naked patients in the middle of the night.

The parking lot was enormous, and it was very dark. That guy sure can run fast, I thought breathlessly. We spent ten minutes chasing him as he ran between, around, and sometimes over the tops of parked cars. As we ran after him, the intern would holler things such as, “Cut him off at the Pontiac!” Now, that was the type of order I had never dreamed I would be receiving from interns.

Finally, we cornered and tackled him. The patient laid face down on the pavement, shouting and struggling. Trying fiercely to restrain him, I was sitting on his upper back with my knees gripping his head, while the intern was sitting on the back of his thighs, trying not to touch the patient’s naked butt that stuck up between us. We looked like we were trying to ride a bull in tandem. Never having been taught how to deal with this situation, I turned around and was about to ask the intern, Now what? But when I noticed the uncertain look on his face, I figured we were both clueless.

At that moment in the darkened parking lot, two legs in very white stockings suddenly appeared. The nurse stood over us, smirking.

“So, do you want him to have the Librium?” she asked the intern.

“Uh, yes,” he sheepishly answered. “Twenty-five milligrams.”

With that confirmation, the nurse pulled out a syringe and a vial of Librium. She drew up the Librium into the syringe, then bent down between the intern and me and wiped the patient’s buttock with an alcohol swab. She calmly stabbed it with the syringe, then left to get a gurney.

As the intern and I sat on the patient, waiting for the Librium to take effect, I couldn’t resist asking a question. As nonjudgmentally as possible, I asked the intern, “Why did you tell the nurse to not restrain him or give him Librium?”

The intern contemplated that for a few seconds and then said, “Well, at the time it seemed like a reasonable decision.”

About ten minutes later, the patient calmed down. The orderly brought out a gurney, the nurse placed a gown on the now-mellow patient, and the orderly wheeled the patient up to the Psych ward.

At this point, I noticed my trousers and white jacket were no longer clean and my shirttail was hanging outside my trousers. After tucking in my shirt and brushing off as much of the dirt from the parking lot as I could, I headed to my apartment.

As I drove, I reflected on what a bizarre day it had been. I figured I would probably practice medicine for well over ten thousand days during my medical career, and yet it would be nearly impossible for any of those subsequent days to be as bizarre as this first day. What are the odds, I thought in amazement, that of all the days I will practice medicine, the most insane will be the first!

I continued believing this for about nine more hours—until the second day in the ER began as strangely as the first had ended.

Things only get worse from there!

Peter