Tuesday, June 24, 2014

Opioid Overdose in the Emergency Department

Image via Shutterstock
I had just finished introducing myself to the resident when the EMTs wheeled in a patient on a stretcher. The patient’s face was completely pale and expressionless and his eyes were closed; his hair looked disheveled and unwashed. He wore tattered jeans, a soiled white t-shirt with holes, and white sneakers with untied shoelaces. His age, according to the EMTs, was 34, but he looked as if he were 50, with a sagging face and prominent wrinkles that no 34-year-old should have.

Other than this, we knew nothing about him. An anonymous person had called 911 and reported that this gentleman was “not awake.” This is not uncommon, as many folks who get into gunfights or use drugs do not want to be caught by police, and associate the medical profession with the law. As further contribution to our complete ignorance, the unconscious patient could not tell us what had happened.

Moreover, he was apneic, which means his breathing rate was dangerously slow. Without adequate oxygen intake, his heart and brain would perish. As I wrote about in my post on running a trauma code, one of the most important aspects of a patient’s care in the ED is the airway — physicians ensure that the system that takes in oxygen works. With diminished breathing, this patient needed oxygen. Thus, the ED resident rushed to set up tools for intubation: sticking a tube down the patient’s throat to provide a space for oxygen entry.

When a patient like this comes into the ED — unconscious with no clear history — the ED physicians give the patient a few basic drugs that can save his life. These therapies target the most common causes of AMS (altered mental status) or total lack of consciousness. One therapy is glucose or sugar administration. Hypoglycemia (low blood sugar) can affect a person’s mental status. The brain primarily uses glucose for its processes; without glucose, it starves, leading to unconsciousness. One of the other therapies is naloxone, also known as narcan. Naloxone is an opioid antagonist, a term that describes its inhibitory actions at opioid receptors in the nervous system. Opioid agonists include drugs like morphine and heroin that cause sedation and respiratory depression. Naloxone acts quickly to reverse these effects in patients who overdose on opioids.

A fellow student and I watched as the attending physician injected a dose of naloxone into the patient’s IV. The patient shot up in bed, trembling, sweating, and breathing rapidly, his eyes wide open. That’s the catch with the agonist and antagonist relationship: because their effects oppose each other, their manifestations also oppose each other. While opioids sedate, naloxone stimulates. The patient screamed at the nurses and physicians and threatened them. He hurled expletives at the healthcare staff and swung his arms at the nurses while demanding to leave the hospital, as spittle flew from his mouth.

The reason, as the attending ED physician explained to the patient, that they kept him in the hospital is that naloxone has a very short life in the body’s system and wears off in about an hour. But some opioids can be long-acting; ergo, this patient could become dangerously sedated again once the naloxone wore off. And he could not, given his mental status, make individual decisions for himself. The patient continued to thrash around until a police officer from another part of the ED came over. Not surprisingly, the patient calmed down.

Watching this elicits mixed emotions. What if this person did become more violent? Would I actually need, physically, to defend myself from this drugged individual — a man who clearly has little sense of what is and is not reckless and harmful? And then there’s sympathy; how unfortunate that such a young person could fall into a life of drugs. Further, what will his fate be? Will he ever give up using drugs? I also could not help but find it humorous that as soon as the police officer came into the room, the patient calmed down. The law and its enforcers have a potent effect, indeed. Lastly, this was an incredible physiologic feat of saving someone’s life using a drug with an antagonistic molecular construction — another wonder of modern medicine to put on the list of scientific achievements.

We may soon witness scenes like this in a more public sphere. The wonder that is naloxone is currently being distributed to police officers in big cities to use on people overdosing on opioids, according to The New York Times. The same thing is happening in New Jersey, too. Government agencies are responding to a rapid increase in the use of opioids: “Gov. Andrew M. Cuomo committed state money to get naloxone into the hands of emergency medical workers across New York, saying the heroin epidemic in the state was worse than that seen in the 1970s, and the problem is growing.” Of course, this is not going to rid us of addiction, but it will certainly save lives. And as the New York City Health Commissioner noted of naloxone, “It’s really quite miraculous. Anyone who’s ever reversed an overdose will never forget it. People wake up.”

Monday, June 16, 2014

Running a Trauma Code in the ED

Hospital image via Shutterstock
The paramedics flying the patient in by helicopter called the Emergency Department charge nurse and described the patient: a 40-year-old male in a construction accident with deep lacerations (wounds) to the left leg. The moment between the paramedics’ call and arrival was only a few minutes.

During this time, the ED notified the trauma surgery team that a patient may need surgical care and classified the trauma as level 1 (a level 2 trauma is less urgent). As the ED notified the trauma surgery team, the ED nurses and an ED resident prepared the trauma bay, which is just a larger patient room in the ED. They kept IV fluids at the ready; the blood bank prepared to get the patient blood; the resident placed an intubation kit at the stretcher side (if the patient is unconscious and cannot breathe on his or her own, the resident places a tube down the patient’s throat in order to get oxygen into the lungs); an oxygen mask was set to deliver oxygen; we medical students placed blankets at the bedside; and everyone put on gowns, masks, and gloves. The whole scene was chaotic, not least because of the sheer number of people involved: multiple nurses, an ED resident, a general surgery resident and/or an acute care surgery fellow, a trauma surgery intern, a pharmacist, medical students, and an x-ray technician to take immediate imaging if needed.

As the paramedics rushed the patient in on a stretcher (yes, just like in the movies), they recapped the patient presentation for the healthcare team and provided slightly more detail about the mechanism of injury. A construction worker accidentally dropped a chainsaw onto his leg. The metal edges of the saw cut through the patient’s left shin and thigh.

I don’t usually find blood upsetting. During surgery, I had no problem in the operating room watching the surgeons explore bowel or try to stop bleeding from a severed artery. Objectively, I comprehend that it is gruesome, but it doesn’t induce an intense visceral reaction. However, this particular event was absolutely disturbing. The metal blades cut the left shin so deeply that only half of the bottom leg was attached to the knee. The tibia and fibula bones jutted out of the skin over large, severed arteries and veins. Muscle and tissue clung to the leg by a few strands of skin as blood seeped from the wound. On the upper thigh, the damage was less intense — the saw tore through the quadriceps and the lateral leg muscles. Some of the superficial muscle hung off the wound, which bled much less severely. This sounds horrible, but the sight of this, akin to some kind of horror movie, was not so affecting until one pairs it with the fact that this patient was conscious.

His screams were charged with fear and intense pain, while he lay in a completely strange place with no family and no shortage of doctors and nurses and paramedics aggressively intruding on his personal space. I thought of this passage from Tolstoy’s The Death of Ivan Ilyich: the screaming “was so terrible that one could not hear it through two closed doors without horror.... ‘Oh! Oh! Oh!’ he cried in various intonations. He had begun by screaming ‘I won’t!’ and continued screaming on the letter ‘O.’” For this person to experience all this commotion and pain while also realizing the possibility of losing his leg must have been overwhelming.

But the struggle to provide medical care went on and the trauma assessment began. The upper-level surgery resident stood at the foot of the patient’s bed directing the healthcare team and the ED resident stood at the head of the stretcher making sure the patient could breathe. The nurses, meanwhile, confirmed that two IVs (one in each arm vein) were in place and working so that they could deliver blood, fluids, and pain medication as needed. The upper-level trauma surgery resident began with the primary survey, which identifies life-threatening injuries to the patient. For instance, an injury to the patient’s throat or mouth that prevents the patient from breathing is an immediate concern. The resident scrutinized the vital signs and quickly assessed for other urgent issues: airway (is the patient’s mouth clear from obstruction?), breathing, circulation (major blood loss), disability/neurological issues, exposures to toxins/environmental control. We frequently use the mnemonic ABCDE to remember this. The nurses completely stripped the patient of his clothing during this examination, for the sake of thoroughness.

If the patient is not on the verge of dying, the trauma surgery resident begins a secondary survey and fastidiously examines the patient head to toe for other, perhaps less urgent, signs of bruising, bleeding, or anatomical abnormalities caused by trauma to bones or tissue. The hospital staff roll the patient onto his or her side in order to get a clear view of the back and buttocks. The surgical intern usually performs this part of the exam, hollering out any abnormal findings to a nurse who stands outside the room, documenting the patient’s injuries to a computer. The resident also performs a FAST exam (Focused Assessment with Sonography for Trauma), where he or she uses ultrasound imaging to search for blood within certain parts of the abdomen, chest, and pelvis. It is a quick and effective way to assess whether a patient is bleeding internally and needs immediate surgery.

The healthcare team did a secondary survey as the patient continued to groan and scream. Because of the severity of the injuries to different systems, the trauma surgeons, orthopedic surgeons, and vascular surgeons all came to assess what kind of surgery this patient needed. After a quick huddle with the attending physicians, the nurses wheeled the patient straight to the OR, never to be seen or heard from by me again. The one aspect of this patient’s prognosis that I do know is that the surgeons thought they could save this patient’s leg and its function, which is demonstrative of the miraculousness of modern medicine.
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In the early seventeenth century the great English poet, cleric, and lawyer John Donne reflected upon sickness and health in a book called Devotions upon Emergent Occasions, after battling illness himself. In it, he wrote that “we study health, and we deliberate upon our meats, and drink, and air, and exercises, and we hew and we polish every stone that goes to that building; and so our health is a long and a regular work: but in a minute a cannon batters all, overthrows all, demolishes all....” There is nothing quite like a trauma to reinforce Donne’s observation about how fragile our condition remains; being struck by a car or being in a construction accident shoves us off the tenuous tightrope of health on which we walk. Here, a healthy patient in the prime of his life was nearly destroyed by poor fortune.

This is also an example of losing track of a patient’s outcome, which is so common in medical school and residency. I’ll never know his whole story — as I’ve written, this is something that contributes to cynicism in medicine.

And another thought on this trauma: a Chinese proverb states that “no man is a good doctor who has never been sick himself.” This certainly sounds right. How can one understand a patient until experiencing his pain? I disagree, though. We know that many who see other people in pain experience pain themselves. But further, the power of human empathy can be surprisingly vast. True that nurses, students, and doctors may not directly feel the pain of a sharp metal edge slicing through flesh, but can we not comprehend the horror of this? Can we not, in an admission of never wanting something like this to happen to us, experience in a small way the terror of such an event? An empathetic emotional response is enough to prime healthcare workers to take great care of a patient. The potential problem in medicine, then, is not what the Chinese Proverb suggests. The possible outcome is that when we see people like this every day, the once-astonishing horror becomes treated as a daily experience.

Thursday, June 5, 2014

How the ED (Emergency Department) Works


Ambulance image via Shutterstock
The Emergency Department is one of the most active and exciting parts of the hospital because it is the hospital’s sieve. The ED physician determines whether an injury or complaint is life-threatening or not and then treats or admits the patient to the hospital if necessary. Someone usually comes in by ambulance or private vehicle with a general complaint — referred to as the chief complaint — such as “stomach pain,” “chest pain,” “leg pain,” or “shortness of breath.”

But occasionally, the first assessment of this chief complaint begins outside of the emergency room. Paramedics or emergency medical technicians who bring the patient in by ambulance identify someone clearly in need of medical attention. Outside of the hospital they take the patient’s blood pressure, heart rate, breathing rate, and temperature (collectively known as vital signs). These measurements indicate the seriousness of the situation. For example, if a patient looks pale and sweaty, and his blood pressure is 80/40 (extremely low), this indicates the need for emergency treatment. However, if a patient calls for an ambulance but has normal vital signs and looks healthy, then he can wait a bit longer for medical care, and the ambulance does not rush to the hospital.

When the patient arrives in the emergency room, he will see a similar setup at many different institutions (I can testify to this because of my days spent as an emergency medical technician in New York City, where I saw the emergency rooms of many hospitals). The doctors and nurses sit at an open station with computers in the center of the circular or semi-circular room. The patient beds stand on the outer edges of the circle in small slots separated from each other by curtains and, in some cases, by an actual wall. Usually, a patient is hooked up to a machine that continually takes vital signs and projects them onto a screen facing the doctors and nurses.

Once the nurses bring a new patient back to a bed, the resident physician assigned to that bed asks one of the medical students to go see the patient. We have ten minutes to interview the patient about the chief complaint and do a focused physical exam, which means we only ask about and examine bodily systems that relate to the chief complaint. If a patient has chest pain, we do not ask about or examine the foot.

Difficulties abound with this assignment. First, some patients come to the ED and want to have all their problems taken care of, which is impossible to do in a short period of time. Additionally, the ED is only meant to handle emergencies. Someone who has a broken leg, for example, may also want to talk about a muscle sprain in his shoulder — but a sprain is far less concerning and does not need immediate attention. Second, some patients want to have a long conversation with a medical student or physician. They may feel lonely at home, or have a difficult social situation, or just want to chat. And while we must listen to the patient, these conversations may be irrelevant to the chief complaint. Moreover, other patients with life-threatening problems arrive regularly and need an ED doctor more urgently. Finally, some patients come seeking pain medications because of an addiction, or some may malinger (faking an illness for some type of secondary gain, like getting out of school or criminal prosecution).

Dealing with these kinds of patients is integral to the art of medicine in the ED. The methods we were taught in first and second year about how to manage disease and what questions to ask tend to dissolve when dealing with human beings who have different motivations for coming in to the ED. We need to understand those motivations and, occasionally, quickly work around them in order to address a patient’s life-threatening illness.

After we see and examine the patient, we tell the resident what we think the diagnosis is and what lab tests or imaging we want to get. The resident then sees the patient briefly and tells the attending physician his or her plan for the patient. The attending finalizes the plan for the patient and the resident executes it. All this might be clearer with an example from my own experience.

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During one of my shifts, a patient presented to the ED with severe back pain. He could not sit still, and cried out every few seconds. He squirmed on the stretcher, moving his legs up and down, tearing sheets off the bed and clenching his hands to his chest while grimacing. Watching someone in pain is extremely difficult and can even cause the observer to feel pain. And there is no question that I felt incredibly sympathetic for this man — so much so that I didn’t want to disturb him by asking him questions and examining him.

This is another difficulty in the field of medicine. We need to perform certain exam maneuvers or tests even though they cause the patient pain and frustration. But it can be so difficult to bring oneself, especially in the student role, to swallow that difficulty and foist the necessary exam onto the patient. How could I bear to push on and examine this man’s back when I knew this would cause immense discomfort? With difficulty, I continued the interview and briefly palpated the spot on his back that hurt.

Once I finished the interview, I thought about a differential diagnosis. A differential diagnosis is a list of possible diagnoses for the patient given the signs and symptoms the patient is presenting with, usually listed from the most likely to least likely. This gentleman with left lower back pain, for instance, had a differential diagnosis list as follows:

1. Kidney stones
2. Herniated disc
3. Pulled muscle
4. Kidney infection (pyelonephritis)
5. Spinal abscess
6. Appendicitis

This list may not be complete, but it gives a sense of the kind of approach a physician takes to a medical issue. And as the physician questions the patient, the list changes. A doctor might ask if this particular patient had his appendix removed. If the answer is yes, then appendicitis comes off the list. A practitioner uses interview questions and physical exam maneuvers to narrow the list down to one or two very likely diagnoses.

As for labs or imaging tests, these are only done to rule out or in diagnoses after narrowing down the list of possibilities with an interview and physical exam. This man most likely had a kidney stone, as his presentation of severe back pain with an inability to sit still is a classic demonstration of this pathology. Therefore, a urinalysis (examination of the urine) or CT scan (an imaging study to look for the stone) was integral to the diagnosis.

After deciding on this, I presented the patient to the resident. Across the field of medicine, medical students, residents, and attending physicians present patients to each other in a standard format with an ordered listing of information. This information includes the age of the patient, history of the chief complaint, relevant past medical history, physical exam findings, and a plan for the patient’s care. This gives all medical professionals a concise, relevant, and standardized summary of the situation. In this case, for example, I might present the patient to the resident by saying this:

“Mr. B is a 44 year old caucasian male with a relevant past medical history of previous kidney stones, here today with a chief complaint of severe back pain. The pain began five hours ago while showering with no apparent preceding incident. The pain is only better when the patient brings his knees up to his stomach but otherwise remains severe. The pain is sharp and unilateral on the left side and does not radiate anywhere. The patient took ibuprofen earlier, but that has not helped. He reports no blood in the urine, no difficulty urinating and no change in bowel movements. On physical exam, the patient is extremely tender to palpation on his left flank but the exam is otherwise normal. My differential diagnosis includes kidney stones, pyelonephritis, herniated disc, pulled muscle, spinal abscess, and appendicitis. I’d like to get a urinalysis and CT scan of the kidneys, ureters, and bladder, and give the patient morphine for pain.”

That’s not a perfect presentation (and at the time mine was far less comprehensive), but it is the kind of formatted presentation that doctors look for when they see a patient who has severe back pain.

If the ED attending physician is unsure of what is going on or how to treat the problem, the resident usually calls a consult. If the patient is bipolar, for example, the ED resident calls a psychiatrist to see the patient in the ED and possibly admit the patient to the psychiatric ward in the hospital. If the patient presents with a stroke, the resident calls a neurologist, who treats and admits the patient to the stroke service. While emergency medicine physicians are excellent at figuring out what might be going on and whether it is serious, and while they are meant to know a little bit about everything, they don’t know as much about specific problems as a specialist in that field. Therefore, it is not the ED physician’s job to treat everything neurological, psychiatric, or cardiac in nature. It is the ED physician’s job to determine who needs to see which specialist physician, and to treat those urgent problems that they can treat.