Excuse me, I believe you have my crack pipe...

I think the fine citizens of inner-city Atlanta are conspiring to make me miss it even more than I thought I would….Last night was a banner night in the ER. What was funniest was that for once, all the weird patients didn't come to me…they ALL went to one hideously unlucky internal medicine intern rotating in the ER this month. Poor thing, all she wants to do is take care of hypertension and diabetes, and she gets multiple patients who are seriously crazy even by Grady standards. For starters, her first patient was having psychosis with delusions of grandeur (just what it sounds like), and would not respond to you unless you addressed her as "Goddess Johnson (name slightly changed for privacy, but not much - she seriously insisted on being called "Goddess.")." Patient #2 was (at least he said he was, though he WAS schizophrenic, so you kind of have to take everything with a grain of salt) a head of the KKK, and stated that everyone in the ER was of such low intelligence that it was not even worthwhile to speak to us. What made this even funnier is that that the intern is Jewish, so she was like, "Great, wait till he gets around to reading my name tag!" Thankfully, she has an awesome sense of humor, so we had many a good laugh at the nurse's station about all of her patients last night. I don't remember another ER shift where I've laughed so much. Another of her cadre of patients was a person with hepatic encephalopathy (one can get quite loopy with excess amounts of ammonia in the brain!) who kept coming out of his room and entertaining the nurse's station with various antics. Lastly, a discharged patient inadvertently left their crack pipe on their bed….Apparently this a not-uncommon finding at Grady, and most of them have the audacity (unless they're too strung out on crack at the time, of course) to come back and claim their property….I'm going to miss this place….

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Tijuana Police Have Guns Confiscated, Issued Slingshots

TIJUANA, Mexico — The police department has issued about 60 slingshots to officers in the violent border city of Tijuana, where soldiers confiscated police weapons two weeks ago on allegations of collusion with drug traffickers.
Municipal police spokesman Fernando Bojorquez said Monday that the slingshots, along with bags of ballbearings, were given to officers patrolling areas of the city visited by tourists.
Tijuana's police force of 2,000 officers has been without guns since Jan. 5, but some patrol alongside armed state police.
President Felipe Calderon sent 3,300 soldiers and federal police to Tijuana at the beginning of January to hunt down drug gangs. The soldiers swept police stations and took officers' guns for inspection amid allegations by federal investigators that a corrupt network of officers supports smugglers who traffic drugs into the U.S. The weapons are still being checked.
About 100 police demonstrated outside Tijuana town hall on Monday demanding the return of their guns. "The arms are our tools for work," said officer Juan Manuel Nieves. "Do they want more police to be killed?"

More than 300 people were slain in Tijuana last year including 13 police officers.

A little trip down memory lane.....

Today started out late in med-school terms - we didn't have lecture until 9am, so I had time to run to my favorite Midtown breakfast spot, Einstein's Bagels. I noticed something I'm sure they've had forever, but I'd never seen there before - the Martinelli's apple juice that comes in the little round bottle shaped like an apple! I remember this being SUCH a favorite thing when I was little.... I also remember them being a lot bigger than they seem now, but I digress.....

I remember we used to go to this not-quite-mom-and-pop-but-not-exactly-a-chain grocery store in Sacramento called Corti Brothers (sort of a precursor to the trendy places like Whole Foods we have today I think), and for whatever reason I associate that store with the Martinelli's apple juice apple bottles. It's not there anymore - I think it's a chain drugstore or something equally lacking in character, but I can't really even remember when it closed. I also remember they had excellent bread stick samples, that we could get while we waited at the deli. I know this post will be of absolutely no interest to anyone but me, but it was a neat little side-trip to memory lane this morning, finding something I didn't even know I missed.

Best Chief Complaint Ever!

On my last ER shift (better known as the "projectile pus day"), I had my favorite chief complaint EVER. It was: "abdominal pain s/p (status post = after) eating a large amount of butter beans and pig tails."

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For those of you not from the South, butter beans are lima beans. And down here, apparently they are occasionally consumed in such large quantities that they cause abdominal pain (read: gas) severe enough to drive patients to the ER. In this ER, we round at every shift change, and so the offgoing resident was presenting this lady, in all her housecoat-and-hair-curlers glory, and when he said "butter beans and pigtails," we were all kind of looking at each other with puzzled expressions. Only a few of the group were from the South, and so when they realized that we all thought "pig tails" were some kind of breakfast pastry or the like, they said, "NO, they're actually the tails of the pig. She was eating actual pig tails!!" Then there was a collective, "Ohhhhh...." Apparently this is a combination not unknown to the Grady ER, so all when we had given her some fluids and proved that she could tolerate PO liquids (liquids by mouth), we let her go. She was the cutest thing - she had her walker with her, and she called it "Old Bessie."

Never Again

I think the title of this post was said by somebody famous (I'm going to get irate emails from various people for not knowing who said this, I know!) about what the Nazis did to the Jews after WWII....I am using it in reference to an event that happened yesterday in the ER.

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Background: When you go to I&D (incision & drainage) an abscess, it is important to remember that the contents are under pressure (that's why they're so painful!), and that's why you're supposed to be very careful when doing this....When you stick in the needle that shoots in the numbing medicine, you leave a hole that pus sometimes uses to escape. So that is Hazard #1. Hazard #2 is the fact that an abscess is basically a lump of necrotic tissue and pus, and it smells like nothing else. It's comparable to GI bleed smell, for those of you with medical backgrounds...It is truly awful, and everyone in the vicinity will know you are doing an I&D as soon as you make the incision. Hazard #3 is simply that, should you NOT have released some of the pressure with the needle sticks while numbing the patient up, be ready for Vesuvius when you make the incision across the dome of the abscess. So because of the aforementioned hazards, one should probably always put a gown, a hat, and most definitely a face mask with a splashguard on it on when doing an I&D. But we in the medical field are fairly lazy, and after doing a few of these with no Vesuvius-like eruptions, I was getting lazy as well about gowning up. Thank God I DID have a face mask on though....

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So to move on to the events of yesterday...I was I&Ding a large abscess on a patient's jaw, and as I take out my syringe with the numbing medicine in it, I see a stream of pus, flying straight toward my face as if in slow motion. Yes, pus can move in slo-mo. That is why I am SO thankful I was wearing a mask and splash shield!!!!! I would have loved to see my expression, though as I couldn't, I have to imagine it looked something like JD and Turk, below:

For those of you who know how OCD I am, you can only imagine how disgusted I was. I just turned to the nurses and said, "Exactly how much pus am I wearing right now?" because I couldn't see below my face shield and I really didn't want to look. I had it ALL over my shirt....And of course I still had to pack the wound, so I couldn't just run & change. And in true Grady fashion, no one would go get me clean scrubs. (In a community hospital, the nurses would've actually sympathized with me and would've had scrubs waiting before I had even finished the procedure - ahhhh sometimes I miss community hospitals!) Of course I got misdirected to where I could get scrubs, so for the next 20 minutes I was wandering around the hospital, smelling like an abscess, trying to find where I could get clean scrubs.

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So here is what I will be wearing the next time I suit up to I&D an abscess:

And as to doing an I&D again in just a mask and gloves, I say, Never again!

Okay, Okay, so I spoke too soon!

I've done 3 shifts in the ER now, and while I'm exhausted, I'm having a good time (still would never do ER though!). Except for a few select ER nurses with the perpetual panties-in-a-bunch, most of them are really great, although slow....It's not unusual for your lab orders to sit on the chart, for no particular reason, for 3 hours or so....I don't know why - they have more nurses here than I've seen anywhere else...It's just that most of them don't seem to do a heck of a lot. I've taken to starting all my own IVs and drawing my labs, which is a great skill to have at Grady. I also made the happy discovery that even if your patient is 10th on the radiology list, if you just wheel them over and dump them in the radiology prep area, they tend to take them, without seeming to realize that they're out of order....It's great!

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So far, I've had a new diagnosis of a brain tumor, I've gotten to see a patient with a recurrent pituitary adenoma (with all the classical symptoms/signs except she didn't have bitemporal hemianopsia, which I was kind of disappointed about), and I've gotten to see a bunch of cool things all related to crack use. Who would've thought crack could be so fun? And educational! What has suprised me is how sick 99% of the patients are here - and even on the "slow" side. (The ER is divided into two zones - the Blue Zone, which is the medical, i.e. "slow" side, and the Red Zone, which is the trauma/surgery side and tends to have much sicker patients). I've only had 1 social visit, which was a homeless guy who just wanted to get out of the rain for a bit. So we got him some dry clothes and a sandwich, and he hung out in the asthma treatment room for the night. I almost like it more than a community hospital - there you see a lot more psych-induced problems...I thought there'd be more of that in a county hospital, but apparently not.
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On another note, they gave us yet ANOTHER assignment - a tedious bore of a group project of which I will spare you the details. I was sorely tempted to raise my hand and ask when our TIPS reports were going to be due (If you haven't heard of TIPS reports, you need to watch "Office Space.").

The Most Ridiculous ER Rotation....Ever!!!

I never thought anything could take away my joy of being in the ghetto of all ghettos, but something has. I had orientation for my ER rotation this am, and it was ridiculous. We have to take 3 - count em - 3 tests, just for EMORY! That doesn't count the other one I have to take for my school, all in the same week, and coincidentally, the same week I just signed up to take my Boards!!!! Aaaauuugghh! And one of the tests is an OSCE!! (For the non med students, an OSCE is an "Objective Structured Clinical Exam" which is where you have the fake patient and someone is in another room marking you off for things you forget to ask/do. They're the single most tedious/stressful thing in med school, and what's more, they're basically just practice to ensure we don't fail the clinical skills part of our boards, which ALL of the students rotating in ER this month have already taken!!!) So we're being graded on something that is a practice test for a test we've already taken....Go figure...Then there is literally no end to the paperwork they want us to fill out for each shift...In addition to all the paperwork we have to do to take care of patients!!

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I am about to have an aneurysm. Seriously.