A tough nut in the ED

Last evening, working the 2-10 pm shift, I caught three ambulances with sick patients in the midst of a very busy shift. The first two were almost on top of each other. Just happened I was being shadowed by an intern who was literally in his first day in the ED as one of our FP (family practice) residents.

First, ambulance coming code 3 (lights and sirens) with a 7 year old seizing for 25 minutes, no better after of 10 mg Valium per rectum per protocol from the paramedics. Ativan 1mg IV (intravenous) once, twice, three times and starting Dilantin and intubating and midazolam drip started and the kid was still seizing. The CT scanner breaks. More Ativan. Still seizing. Temperature goes up. Start phenobarbital and after half a phenobarbital load and more benzodiazepines, he finally stops seizing.

As I am confirming placement of the ET (endotracheal tube) on the 7 year old in status epilepticus, ambulance brings (code 3) a 30-something man who was found hanging by an electric cord and shoe strings 5 inches above the bedroom floor. His wife had talked to him 15 minutes before. He had started a popular, well advertised prescription antidepresssant a couple of weeks before. I intubate him and although the lateral cervical spine xrays looked okay, as I said, the CT scanner was down and for all I knew his neck was broken. His pupils responded sluggishly, and he had some posturing as the sedatives wore off. He was never responsive. Likely a very bad anoxic brain injury had already happened.

At the same time, I had two old ladies with chest pain, a man with dysuria who turned out to have a K=6.7 (a high potassium) and a bicarb of 10, two drunk patients with head lacs (did I mention the CT was down?), and the PAs (physician assistants) were busting at the seams. Two people with headaches (the worst in their life), and I can’t even remember what else…

In this context, in comes and ambulance with a bipolar gentleman who stopped his meds two weeks prior. The day before he decided to end it all. He took two steak knives and stabbed them into the sides of his eyes, into his head, up to the hilt. When that did nothing more than give him a bad headache and double vision, he took the largest, sharpest knife in the kitchen (the EMTs brought all blood stained knives) and cut off the skin of his scrotum and one of his testicles. He stamps the testicle flat on the kitchen floor and lies down to die. Later that afternoon he wakes up and, surprised to be alive, he figures he should have said goodbye to his apartment manager, so he finds him to do so. The apartment manager called 911. The paramedics estimated 2 liters of blood was left on the floor. His hematocric agreed. The testicle was not worth bringing, they said.

Thanks to the big urban medical center that accepted transfer of the seizing child and thanks to the big, local, pastoral, private university medical center that accepted the two suicide attempt patients. Helicopters were landing and taking off outside like we were a MASH. The new intern was scarred for life.

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