Friday, February 16, 2018

Patients never cease to confound

During a recent shift in minor care (44 patient in 10 hours...Ugh!)

Complaints (as written by the patient)

Coold - Cold or URI

Trought - Throat pain or pharyngitis

Left (then scribbled out), right (something unreadable scribbled out) shoulder

Constipal - Constipation

Absest - Abscess (?Incest, obsessed?)

Absens seizurs -

Urinary and progressive agressive behavior -

I had one patient today that was seeming named after a Laptop computer.

Tuesday, January 30, 2018

Re-posting: Reflections on the effects of Medicaid from another Emergency Medicine Colleague

The link below is a Op-Ed on the effects of Medicaid, from the perspective of another Emergency Medicine Colleague.  It is re-posted here without his expressed permission, but I do also recommend his blog at  However, every word of it is true and echoes some of  my own personal experiences in emergency medicine over the past 19 years.

Fixes:  Probably none, as many of those involved  share the traits of ignorance, entitlement, and apathy.  Society for many of these people, exists only to serve them, and we dare not ask them to lift a finger in order to improve their situation, as the latter might have a negative impact patient satisfaction scores (God forbid).


  • Continue to provider excellent care services and thoroughly document the encounter. Above all, be courteous.  
  • Encourage the use of primary care by increasing Medicaid provider reimbursements and dropping the co-pay for the primary care visits.
  • Institute a co-pay for non-emergent ED visits.  Having a co-pay does not violate EMTALA. Nor does discharging a patient with a well-documented non-emergency medical condition to follow-up with the primary care provider.
  • Stop writing prescriptions for OTC meds.  
  • Never tell anyone that they're clogging up the ER with minor issues, abusing the EMS system by using it as a taxi, or that they could buy the OTC medicine for less than the cost of the pack of cigarettes in their pocket.  
Just a few thoughts.

Johnston Medical Center ER Vignette Survey – January 29-30, 2018

On January 29-30, 2018, I performed a brief survey of the medical staff, nursing staff, and other ancillary staff during the night shift in the ED.  Each staff member was given the survey document below, and asked to consider the vignette below for a minute or so and then to write what they thought the most likely problem(s) could be.    With the exception of answering a question about ability to ambulate, (the patient could ambulate) No additional information was provided about the patient.

A total of 31 personnel were surveyed.

Surveys were provided to staff, who were asked not to discuss their responses with other  personnel. On returning the surveys,  the participants, in addition to their answers, indicated only their credential  (MD, PA, RN, etc.)   The purpose of the survey was not disclosed to participants.


Patient is a 24-year-old female who presents to an urgent care facility for evaluation of right lower extremity pain.  8 days previously the patient had been struck on the right medial calf by a pallet full of heavy photographic equipment.   Patient has pain and swelling to the leg with worsening since onset.

Past history:  No significant medical issues

Medications: NuvaRing contraception

Vital signs: Assume normal

Exam:  Extensive bruising and tenderness to the right medial calf and pain to the ankle

Survey Question:  What is your prime concern(s) in this patient?         

Survey Responses from thirty (30) licensed / certified personnel surveyed, were as follows, listed by each discipline: 

MD (ER) – DVTs
MD (ER) – DVT, Compartment syndrome

PA-C  (ER) – DVT
PA-C (ER) – DVT, Compartment syndrome
PA Student – DVT, Compartment syndrome

FNP (IM) - DVT, Compartment Syndrome, Hematoma, Vascular compromise
RN – DVT, fracture
RN – Compartment syndrome
RN – DVT, Foreign body (if open wound)
RN – DVT, fracture
LPN – DVT, fracture

RCP – DVT, Compartment syndrome,  Necrotizing fasciitis
RCP – DVT, fracture
EMT-Intermediate – DVT
EMT-Paramedic – DVT

96.8%    (30/31)                  Recognized risk for DVT               
19.4%    (6/31)                    Recognized risk for Compartment syndrome 
12.9%    (4/31)                    Recognized risk of Fracture
9.7 %     (3/31)                    Recognized risk for other conditions (Hematoma, Infection, Vascular) 

DVT Risk Identified by provider groups:
100%      Medicine Group:             MD, PA-C, PA-S, Personnel
 94%       Nursing Group:               FNP, RN, LPN Personnel

100%      Ancillary Personnel:       RCP, EMT Personnel

Tuesday, January 23, 2018

Advances in Trauma Care: Lessons from the Wars in Iraq and Afghanistan

While I was in Afghanistan (2014-2015), I researched and wrote an article regarding the advances in trauma care that have resulted in our wars in Iraq and Afghanistan.  I intended to publish this in Advance for PA's and NP's when I came home, but neglected to pursue submission due to other priorities and my inability to contact Mike at Merion Publishing.   I'm going to post the article here on my blog site, if for nothing else than to show I did actually write it and maybe someone will still get some practical benefit.   I would also like to point out that some of these lessons were instrumental in the phenomenal work of the Trauma staff in Las Vegas who were able to save many lives in the 2017 mass shooting there.

Lessons from the Battlefield: Damage Control Surgery, Resuscitation and

Tranexamic Acid (TXA) in Trauma Care

Roger S. Best, EMPA-C, MPAS

If anything beneficial has ever come from modern warfare, it has been the improvements in the survival rate of severely injured combat casualties.  These benefits eventually ring down to traumatically injured patients in the civilian world.  The wars in Iraq and Afghanistan have brought several major advances in trauma care1: damage-control surgery (DCS), damage-control resuscitation (DCR), and the use Transexamic acid (TXA) in patients with massive hemorrhage. This article addresses these modalities, beginning with damage control surgery.

The concept of DCS2,3 has been evolving since the 1990’s, but with lessons learned during the wars in Iraq and Afghanistan, the concept and practice of damage-control surgery has rapidly advanced in the war-time theater.  These practices are now gaining acceptance in civilian trauma care settings as well.  In DCS, patients are initially evaluated and receive any indicated emergent life-saving interventions (LSIs), i.e. definitive airway management, thoracostomy, initial resuscitation for hypovolemia, etc.  Once these have been performed, the patient is then taken to the operating suite for initial surgical interventions that are specifically designed to: 1) control hemorrhage; 2) prevent or mitigate contamination, and 3) protect the patient from further injury.

It is now well-established that trauma patients surviving their initial injuries are more likely to die from severe metabolic derangements than from the failure to complete the surgical repair(s) of their injuries.  These derangements, referred to as the “lethal triad,” include coagulopathies, which impair hemorrhage control, hypothermia and metabolic acidosis.* Once these derangements are established, their management becomes problematic. Ironically, prolonged surgical procedures to complete repairs of injuries are major contributors to these derangements and to the corresponding increase in delayed patient mortality.  This realization requires a shift in the surgical mindset, where conventional surgical wisdom dictated that surgery is best provided as a single definitive procedure to one of staged surgical intervention(s).

Our collective wartime experience now shows that the best patient outcomes result from initial life-saving interventions, followed by abbreviated, staged surgical procedures, particularly laparotomy, to control hemorrhage, prevent further contamination and protect the patient from further injury.  Once these initial goals are accomplished, the patient is then transferred to the intensive care setting for management of coagulopathy, hypothermia and metabolic acidosis.  Once the patient’s physiologic condition has been optimized, they can be returned to the OR for completion of surgical care.  Best practices in trauma care now dictate a continuum of staged surgical interventions, interspersed with ICU care in order to optimize the patient’s medical condition between interventions.

Damage Control Resuscitation (DCR)3,4, is emergent medical care provided to treat or mitigate the impact of coagulopathies, hypothermia and metabolic acidosis, either in concert with DCS, or while the patient is awaiting surgical intervention.  The initial, and most important aspect of DCR, is to optimize the control of hemorrhage.  Death from hemorrhage accounts for 30-45% of trauma deaths, but paradoxically is the most preventable cause of death among combat casualties. 
In contrast to previous approaches initially using direct pressure, elevation and proximal arterial pressure points for the control severe bleeding, the methods best proven for the control of potentially life threatening hemorrhage should be limited to direct pressure to compressible bleeding sites, the use of hemostatic dressings, and the effective use of tourniquets.

Direct pressure remains the mainstay of initial hemorrhage control measures. Hemostasis can be achieved quickly with a compressible wound.  Hemostatic dressings used in conjunction with pressure are highly effective.  In cases where an extremity injury results in severe bleeding and these techniques will not quickly bring this under control, then proximal application of a tourniquet is the intervention of choice. In the wartime experience, the use of tourniquets have shown several advantages, where the prehospital time is under six (6) hours, including:

·         Improved hemorrhage control
·         Decreased incidence of shock
·         Improved survival
·         Acceptably low rate of tourniquet-related complications

Non-traditional tourniquets (junctional tourniquets) have also been developed and have shown success in controlling hemorrhage from typically non-compressible sites, such as the iliac and axillary arteries5.  In areas of hemorrhage where bleeding is occurring from inaccessible sites, i.e. Pelvic fractures, non-compressible injuries not amenable to tourniquet application, therapies such as pelvic binders and also hemostatic dressings (i.e. Combat Gauze) have shown some benefit.  Ultimately, the goal of using more aggressive methods of hemorrhage control are intended to reduce the need for massive transfusion and address the resultant risk of coagulopathy.

Predictive indicators of the need for transfusion therapy include penetrating injuries to the trunk, systemic hypotension (SBP<90 and="" core="" hg="" hypothermia="" mm="">36°C or 96°F).  However, data from the National Trauma Data Bank has shown increased mortality with SBP of <110 10mm="" 4.8="" a="" abnormalities.="" absent="" altered="" are="" as="" at="" base="" begin="" combination="" deaths="" deficits="" defined="" drop="" early="" every="" following="" for="" heart-rate="" helpful="" heralding="" hg.="" hg="" hypotension="" identifying="" in="" increase="" injured="" is="" laboratory="" loss="" massive="" mental="" mm="" nbsp="" o:p="" of="" onset="" or="" patients="" perfusion="" pulse="" radial="" requiring="" sbp.="" sbp="" sbps="" severely="" status="" studies="" the="" therapy.="" this="" tissue="" transfusion="" trauma="" variability="" weak="" with="">

·         Base deficit > 6 or pH < 7.25
·         INR > 1.5
·         Hemoglobin <11 hematocrit="" o:p="" or="">

Even with what would have previously been considered “stable” levels of SBP (90-118 mm/hg), the insidious onset of the shock state can be seen in the increasing base deficit, declining pH, declining H&H values, and the early onset of coagulopathy. 

The next component of DCR is the prevention of hypothermia, which increases the risk of life-threatening hemorrhage and associated mortality, with a death rate of 100% in severe cases.  Strategies to combat the incidence and degree of hypothermia in the prehospital setting by focusing on hemorrhage control, limiting the amount of clothing removed, instituting passive warming techniques such as the use of wool, solar and warming blankets and the infusions warmed IV fluids.  Passive and active anti-hypothermic measures should be continued in the emergency and intensive care settings.

The final component of DCR is the management of hypotension, transfusion considerations and the mitigation of metabolic derangements.  Ideally, the goal would be to address all of these derangements simultaneously.  In prehospital settings, or at facilities where appropriate surgical services are not readily available, consideration should be given to “hypotensive resuscitation” in selected cases.

In hypotensive resuscitation, aggressive hemorrhage control of active bleeding is the focus, along with vascular access and conservative intravenous fluid administration, while a lower-then-normal SBP is permitted.  The intention is to avoid rebleeding and dilutional coagulopathy until surgical control of hemorrhage can be accomplished. This approach uses the body’s natural coagulation cascade, vascular spasm secondary to injury, and a degree is hypotension (SBP <90 1="" 2="" a="" and="" animal="" are="" b="" be="" beneficial:="" by="" care.="" cases="" clearly="" cns="" combat="" controlled="" current="" delayed="" felt="" field="" further="" hemorrhage="" hg="" hospitals="" however="" hypotension="" hypotensive="" immediately="" in="" indicated="" is="" mitigate="" mm="" nbsp="" non-compressible="" not="" of="" only="" operations="" operative="" or="" patient="" permissive="" practices="" quickly="" reaching="" reflects="" resuscitation="" s="" situations="" studies="" support="" surgical="" taken="" teams="" the="" there="" to="" trauma="" two="" war="" well-supported="" where="" will="" with="" zones.="">6
or in cases of impending vascular collapse. 

Where hypotensive resuscitation is not indicated, intravenous therapy may be instituted to support circulation.  Traditionally, crystalloid solutions such and normal saline (NS) or lactated ringer’s solution (LR) have been used for initial resuscitation.  In animal studies of these fluids in the treatment of traumatic shock, NS was shown to contribute to metabolic acidosis and worsening coagulopathy, whereas this was not observed using LR. Theoretically, either fluid in significant volume (>20 mL/kg) may result in dilutional coagulopathy, and while LR has been shown to be superior in animal models for trauma resuscitation, neither fluid is ideal and the administration of greater than 20 mL/kg is of dubious benefit.  Colloidal solutions, such as HES (Hetastarch) also contribute to dilutional coagulopathy, but has the added disadvantage of impairing the plasma activity of von Willebrand factor7.  These effects would make such solutions undesirable for resuscitation in the setting of continuing hemorrhage.

Vasopressor agents, though widely used in medical shock states, are generally eschewed in the case of acute hemorrhagic shock.   However, an exception may be the use of low-dose vasopressin, which apparently becomes deficient in advanced stages of hemorrhagic shock.  Theoretically, vasopressin may lower overall resuscitation volumes is hemorrhagic shock, reducing morbidity and mortality, but there are currently no studies to support its use.  Promising studies thus have shown enhanced survival from lethal hemorrhage in porcine subjects8 and reduced fluid resuscitation volumes in human subjects. More extensive human trials are planned involving the use of vasopressin in trauma.
The resuscitation fluids of choice for hemorrhagic shock include whole blood, or combination blood component therapy.  Whole blood has the advantage of volume replacement with an equivalent oxygen-carrying substitute, while concomitantly addressing coagulation deficiencies.  In the absence of whole blood, component therapy at a 1:6:6* ratio of platelets, PRBCs and fresh-frozen plasma respectively is the currently preferred option until patient stabilization has been obtained9.
*Concentrated platelets are equivalent to the number of platelets contain in 6 units of whole blood.  Administration of a unit of concentrated platelets per 6 units of PRBCs and FFP is equal to a blood component transfusion ratio of 1:1:1.

Massive transfusion is generally considered as the administration of 10 or more units of blood within a 24-hour period.  During massive transfusion, the patient will need to be under continuous surveillance for associated transfusion-related complications, including potential hyperkalemia and hypocalcemia, and treated accordingly10.

In patients who receive massive transfusion therapy, the early use of Transexamic acid (TXA) has been shown to improve survival11.  TXA is an Antifibrinolytic agent that exerts a protective effect against the onset of coagulopathies (i.e. DIC). Studies using TXA in the setting of combat trauma have demonstrated improvements in long-term patient survival, despite higher injury severity scores in TXA-treated casualties requiring massive transfusion if TXA is administered within 3 hours following an injury12.

Advances in the care of trauma victims continue to evolve from our dynamic experiences with combat casualties.   Simply getting the patient into the surgical suite is no longer the gold standard of care, but rather a part of a balanced multi-disciplinary approach that includes life-saving pre-hospital and emergency department therapies, staged surgical interventions, and intensive care optimization that will provide more substantial reductions in mortality and morbidity than seen previous decades.

1. Howell SJ. Advances in trauma care: a quiet revolution. British Journal of    Anaesthesia (2014) 113 (2): 201-202
2.       Wyrzykowski AD, Feliciano DV: Trauma damage control. In Trauma. 6th edition. 2008: 851-870. OpenURL
3.       Lenhart MK., Savitsky E., Eastridge B., Combat Casualty Care: Lessons Learned from OEF and OIF. Office of the Surgeon General, U.S. Army. Borden Institute, Fort Detrick MD. 2014.
4.    McLamb CM, MacGoey P, Navarro, AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. British Journal of Anaesthesia; (2014) 113 (2): 242-249.
5.       Kotwal, Russ S., et al. Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines–Proposed Change 13-03. Journal of Special Operations Medicine; 13.4 (2013): 85-93.
6.  Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. Journal of Neurotrauma 2007; 24 (1 Supplement): S7-13.
7.       Treib J, Haass A, Pindur G. Coagulation disorders caused by hydroxyethyl starch. Thromb Haemost; 1997; 78(3): 974-983.
8.       Karl H. Stadlbauer, M.D., Horst G. Wagner-Berger, M.D., et al. Vasopressin, but Not Fluid Resuscitation, Enhances Survival in a Liver Trauma Model with Uncontrolled and Otherwise Lethal Hemorrhagic Shock in Pigs. Anesthesiology; 2003; 98: 699–704
9.       Ho AM, Dion PW, Cheng CA, et al. A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Canadian Journal of Surgery 2005; 48(6): 470-478.
10.   Kristen C. Sihler, MD, MS; Lena M. Napolitano, MD. Complications of Massive Transfusion. Chest; 2010; 137(1): 209-220.
11.   Rappold JFPusateri AE. Tranexamic acid in remote damage control resuscitation. Transfusion. 2013 Jan; 53 (Supplement 1): 96S-99S.
12.   Olldashi F, Kerci M, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomised controlled trial. The Lancet 2011; 377 (9771) 

Roger Scott Best, EMPA-C, MPAS
Emergency Medicine Physician Assistant
Bagram Air Field, Afghanistan - Providing medical services in support of 401st Army Field Support Brigade

Lives in Garner, North Carolina.

Thursday, September 29, 2016

NCCPA Wakes Up. Could somebody please shake the AAPA too?

NCCPA Responds to PA Concerns with Change to CME Requirements

At its meeting last weekend, the NCCPA Board of Directors responded to concerns from PAs and to a new analysis regarding the availability of self-assessment and PI-CME activities and reached a decision to relax the self-assessment and PI-CME requirements introduced with the new 10-year certification maintenance process.

Effective immediately, self-assessment CME and PI-CME are no longer required. However, in recognition of the value of these very interactive types of CME, NCCPA will weight those types of CME more heavily, awarding extra credit for these now optional types of CME.

Dear Colleagues:

From my perspective, this is a good adjustment and at least SOME evidence that our organizations actually listen to what we clinicians say to them.  I changed over to the 10 years cycle after my last (third) PANRE in October 2015.  In reviewing all the CME changes attached to the new cycle, I frankly couldn't discern anything that would make this a better process. The explanations of what constituted what, I found confusing.  It should like PI CME would be some collaborative process targeted to enhance the clinician's knowledge and skills in his/her practice setting, and that SA CME was simple that, self-assessment.  

Despite looking at the NCCPA site through it's changes over the past couple of years, a decent explanation of this I could not find.  That these have now been removed, serves to simplify the process for PA's who have been using a proven, flexible  and appropriate CME and re-certification process that has been in place for their entire career.  It wasn't broken, it didn't need to be "fixed" and now the failed "fix" has finally (and properly) been retired.  That's good, because it wasn't a good model to begin with.  

A major issue that I have with the NCCPA release on this subject if that the NCCPA is giving "extra credit" to the PI and SA programs it has previously approved / endorsed.  

"To encourage PAs to continue to pursue self-assessment activities, NCCPA will award 50% additional credit for all activities designated for self-assessment Category 1 CME credit (i.e., a self-assessment activity worth 10 credits will be converted to 15 credits by NCCPA). Also, the first 20 PI-CME credits logged during every two-year cycle will be doubled when logged with NCCPA."

I am not sure that the NCCPA can properly give Category I credit in excess of the number of hours for which that activity has been approved by the accrediting body.  If the AMA approves a program for 12 hours of Category I CME, then NCCPA can't simply give you six extra credits.  NCCPA is not an accrediting CME provider. It is a certifying body.  This policy might suggest that NCCPA somehow benefits from PA's purchasing these products.  Hopefully that's not the case, but certainly no stretch to see that as a real possibility.

AAPA and NCCPA need to work more cooperatively.  Ever since NCCPA stopped allowing PA's to log CME free through AAPA, there has been a running "pissing match" between the two organizations over one thing of another.  It's no wonder that may of my colleagues no longer maintain membership in the AAPA.  I am back and forth on the issue, mainly because there are few tangible benefits provided for us here in the trenches.  I have never seen a decent public service ad regarding PA's in my 20 years and people still ask me regularly about what PA's do.  The only recognition AAPA has provided is for the DFAAPA folks, mostly those involved in the politics of the profession.  You practice a couple of decades, train PA students, publish now and then, gain a specialty credential, that won't net you anything. Frankly I kinda roll my eyes at AAPA on that.  I think everyone certified PA member of the AAPA should be a FAAPA. The argument against this was that it wasn't like a "fellow" of a physician group, like FACS, FACEP, etc. Well, neither is DFAAPA.  I guess it makes some people feel special.  Certainly not the rest of us though.  

I'll give the NCCPA it's due on finally making specialty recognition happen after the AAPA turned a blind eye and deaf ear to AAPA members on the subject for years.  NCCPA used a great model that preserved the "generalist" credential along the way.  NCCPA kicking the mandatory SI and PI to the curb was another good decision.  Frankly, the "old method" allowed much more of the flexibility PA's need.  Hopefully, they won't try to further complicate the process.  PANCE - PANRE works just fine, places us at the top of chain in terms of maintaining currency and competence among health provider groups in the US.  My state doesn't require me to be NCCPA certified to maintain a license.  I like to have it, but if they muck about too much, I would NCCPA like a hot rock at then end of my current cycle.

AAPA's getting huffed up about the NCCPA and suggesting that they might seek an alternate certification model would be a disastrous move for out profession. That could lead to a fragmentation of our profession and bickering arguments about whose certification was valid or whether one was "better" that the other. I would hate to see us moving down the same road as our physician colleagues and their perpetual bickering about Board Certification. "My certification path is better than your certification path."  I can already see some of that affecting relationships among APN's.  We simply don't need that type of divisive rhetoric in our profession. PAs should always stand together.  Let the plethora of titled "doctors," argue, while we focus on providing the best possible care to our patients.

Let's try to get together on finding the most effective ways to train, certify and support some of the best and most dedicated medical care providers the U.S. has seen in the last 50 years (2017 is coming). It's either that or the possibility of letting our profession degenerate into something akin to the sad state of the 2016 Presidential Election.


R. Scott Best, PA-C

Tuesday, January 27, 2015

Injecting a Little Humor, with just a little seriousness

I'm sorry to be so sporadic in posting, but here at Bagram Air Field, there is always something to occupy my time.  My wife ran across a funny video and sent the link to me. I enjoyed it and found a second.  Both are posted for your review, and both reflect some of the frustrations we have as practitioners of emergency medicine.

Patient satisfaction.  I like people and I like practicing medicine.  However, part of the job is often to tell people things that they don't want to hear, and of course, even under the best of circumstances, you will not be able to please everyone.  Finally, doing whatever is takes to please someone, may result in a bad outcome.  Basic psychology shows us that when people are under stress, are unhappy, etc. they will often project those negative feelings towards those around them.  Our job, is not to make people happy, but to practice good medicine.  If we can make them happy at the same time, that's good, but at the core...providing good medical care always take precedence.  Administrative types and former health care personnel-turned-"suits" don't seem to get this concept.  Probably because their are dollar signs attached, which often impairs both ethics and common sense. Then again, they either never provided care, or took a desk job because they were never very good at it.

In any case, please enjoy the video (Credited of course to sure to visit the site):

My boss is CEO

Drug-seeking...have I said enough on this subject.  Probably, but these guys actually sing about it...something I would not subject you to myself.  Mo tune would be something more like, "NO!" then "I don't know how many times I can tell you No!" generally followed by a discharge, or in the case of the blatant drug-seeker for resale purposes, an introduction to a nice police officer is my approach.

Once...a patient came in with a dicey pain complaint...of course it was 10/10, but he sat cool as a cucumber requesting "PERCs" (ask for them by name), and of course an injection of dilaudid.  We wasn't from the area, but rather was staying some friends in SC (very far South of my ER) and when asked what he was doing up here, he said that he had gone up to VA to visit some other friends and his back started hurting on the way back.  He apparently was driving himself.  Oh...and of course, he listed allergies to every medication that he didn't want or couldn't sell.  Sound familiar?  I looked him up on the controlled substances registry...this was for my state only, but is showed that over the past 3-4 days, he had been visiting various facilities within a 20-30 minute drive of my ER and had received multiple prescriptions for opiates.  I guess he was taking the long way back to SC.  I placed a phone call.

About 20 minutes later, I went back to the patient's room.  I told him what I had found out, told him I wasn't going to give him any medication, either in the ER or by prescription.  I then introduced him to some nice officers, who arrested him and carried him from the ER in handcuffs right through the waiting room.  I'm sure my customer feedback would have been less than ideal.

The reality today is that more Americans die now from prescription pain medicine abuse than from heroin and cocaine combined.  Many that aren't just abusing their medications and diverting it for sale on the illegal market, and much of ER prescriptions for opiates is helping fuel these deaths and illegal diversions.  So much for serious talk...enjoy the video.  This was also on KevinMD, but I snagged it from a repost.

We are never, never, ever...

Like Reagan said...just say "NO!" to drugs.  

Tuesday, September 10, 2013

Rough Day at Work

I had a rough day at work recently.  I was in the ER doing my usual thing, seeing the routine things we see in the ER, plus a chest pain, asthma, altered mental status, etc.  Afternoon rolled around and we got a call about an EMS unit that had responded to an MVA (motor vehicle accident).  We were informed that they were on the way with a pediatric trauma code.

EMS called with a history of a child that had been hit by a truck after getting off of her school bus.  The bus was stopped, signs out, door open. The little girl bounced out of the bus and started across the street when she was struck by a large truck speeding past the stopped school bus. 

The little girl had no vital signs on the arrival of the first unit, but they instituted resuscitation attempts anyway and rushed her in to the ED.  Resuscitation and transport were futile, and the attending physician that day pronounced her dead almost as fast at she was moved to the treatment room stretcher.  The sheer force of an 18-wheeled tractor-trailer vs. the frail body of a 6-year old child obliterated any hope that she would have survived.

I saw the bus driver later.  She was, naturally, very badly shaken by the incident. I listened as she recounted, in excruciating detail, the split-second event that took the life of the little girl, and forever impacted the life of this driver, the child's grandmother who watched this tragedy occur from their yard, the child's other family members and likely some of the horrified students that watching from the bus.  I knew that she, and many others, would likely suffer from some level of PTSD.  The driver herself, returned to the ER within 48 hours with an MI.  I myself pondered how I would feel if such a thing were to happen with own little girl stepping off her bus and couldn't even imagine it.

I love you Victoria.