Needle Sticks and Scapel Injuries

I've been stuck by a sharp object twice in my medical career. The first time, I was doing a lumbar puncture, aka spinal tap, on a 3 week old neonate for a complete septic workup. I had everything prepped and had the long spinal needle in my right thumb and middle finger. As I was turning to ask the assistant something, I poked myself at the tip of the index finger. Fortunately, the needle was clean and I had not even began the procedure. I washed up immediately and was not concerned about infection or tetany (I had my tetanus shot 2 years ago)

Recently, I was about to place a chest tube on a patient.

I prepped the skin and injected generous amounts of lidocaine into the tissue. I made a small incision with my scalpel above T4 level along the anterior axillary line and placed the bloody scapel on the sterile drape over the mayo stand.

I turned to grab the Kelly's and instead stabbed myself with the scalpel on my right thumb through the latex glove. Blood oozed immediately into the glove and yet I felt no pain.

My attending told me, "Sam, wash your hands like you've never washed them before." Luckily, the surgical residents were right next to me and took over the procedure. We didn't know too much about this patient, so it was frightening to consider that I could become infected with HIV, Hep B, Hep C, or other bugs.

Although, I've taken care of several staff with needle exposures, I'd never personally really felt the fear of the unknown. A rapid HIV test was ordered on the patient, along with Hep B and Hep C testing. The wait felt like it took forever and I was offered a triple combination of HIV antiviral medications. Should I take them? I pondered as I looked over the CDC recommendations:

As you can see above, I am in the "Source HIV status unknown" and "More severe injury type." CDC does not generally recommend taking PEP. However, I opted to take one dose now, as its most effective in the first 1-2hrs, plus I got some Zofran ODT to prevent nausea/vomiting.

Overall, everything turned out OK for me (pending studies). I gained several insights about needle sticks during this encounter:

1) Although the risk is very low, it's mind-boggling freaky to be faced with the diseases that can change your life.

2) During procedures and traumas, it's particularly important to SLOW down and be aware of each and every sharp object on the table.

3) Percutaneous injuries are very common in the hospital. Even with all the safety mechanisms, more automatic methods need to be created to prevent them.

For example, in the central line kits, there is Styrofoam piece designed to temporarily place needles into.

My suggestion: Please place one in the chest tube kit!

Seven Lessons Learned from Ambulance Ride Alongs

I am on EMS this month as part of my residency training. This includes time with police, firefighters, 911 operators, and ambulance crews. Today, you will gain from my experiences with hanging out with an AMR ambulance team.

1. Be nice to the EMTs/Paramedics. They determine who comes to your ER. Typically, patients can request which hospital to go to. However, if a patient is clueless about where they want to go, the ambulance crew will decide for them. Otherwise, they will bring all indigent vomiting/diarrhea patients to you.

2. Listen to EMS providers. Sometimes the ride to the hospital takes a while, and there is a paramedic in the back talking to the patient for a solid 15-30 minutes. They ask a lot of questions and can give you a significant amount of history.

3. Teach an EMT/Paramedic something each time you meet one. A lot of these guys/gals are eager to learn. Because they are truly the "front-line" they can help you with diagnosing critical situations.

4. Give free food. It's tough being out on the road. EMS providers don't get as many perks as police officers or firefighters, but definitely deserve props for the work they do in the community. In my opinion, they are truly unrecognized heroes.

5. Help them access a place to sit for paperwork. Documentation is a necessary evil in the practice of medicine. It's much easier to sit in a non-moving site to finish up charting on paper and computer.

6. Give them feedback. If you see an EMS provider and recall a patient they brought in previously, tell them about what happened during the ER stay. A lot of paramedics and EMTs remain in the dark about the ultimate outcome of the patient they bring in.

7. Don't sweat IV access. It's challenging to get an IV on patients, and even more difficult in the back of a vehicle bouncing along the roads. If they don't get an IV, please give them a little slack.

Overall, we have to respect them. Listen and teach. They have a lot of information to give and are willing to learn.

Easy Ocular Application of Fluoroscein

Below is a Blog Post in Tricks of the Trade that I helped write. Thanks Dr. Lin!

Trick of the Trade: Easy ocular application of fluoroscein

Gently instilling a fluorescein drop into a patient's eye requires that the patient keep his/her eye still. What do you do for a patient who can't quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).

A 14-month old male is brought into the Emergency Department by his mother because he is rubbing his eye and inconsolably crying. You suspect a corneal abrasion or foreign body and decide to quickly evaluate his cornea using the fluorescein stain. Using the method below, you’ll be able to perform the exam with little discomfort to the patient.

1. You will need a small vial of saline (left) and a fluorescein strip in packaging (right).


2. Open only one end of the fluorescein strip package.

3. Insert saline flush vial into the package.


4. Flush saline in and out of the packaging several times until the fluid in the bottle turns yellow.

5. Now that the saline vial contains fluorescein, use the container like an eye dropper.


Pearls to consider:

• Defects in the corneal epithelium will appear green under the light.
  
• Beware that mucus can also stain green. If you aren’t sure which is which, ask the patient to blink. The mucus will move, but the defects won’t.
  
• Remove contact lens before this exam, because they can become permanently stained (perhaps a cool Halloween trick for next year?).
• Pseudomonas easily grows in fluorescein dye, so never reuse or share dye.

Crystal Meth: Multiple Pictures are Worth a Million Words

Healthcare Cost Reduction Idea

If a person requires dialylsis for end stage renal disease and are unable to pay for it, the patient can get Medicare to fund the dialysis.

"The cost of kidney dialysis averages about $44,000 per year per patient, using 1993 figures. The average cost for the transplant patients in our study, including the transplant surgery and medical care for the first year following surgery was $89,939. After the first year, costs for the transplant patients averaged $16,043; mostly for medications to prevent rejection.

http://www.umm.edu/news/releases/kidcost.htm

I wonder if it'd be better to open up a market for kidney transplants.

Why Medical Students Stay Up During Call

Med Student: Dr. Bausch, I've got several hours more work to do tonight, and you don't. How come you're always going to sleep, and I'm always staying awake?

Roy Bausch: Simple. You're a mathemetician, right? Now, I get paid a fixed salary by the BMS, no matter how many hours I'm awake. You pay a fixed tuition to BMS, no matter how many hours you're awake. Therefore, the more I sleep, the more I earn per waking hour, and the more you stay awake, the less you pay per waking hour. Got it?

~House of God by Samuel Shem, MD

Top 20 Tips for Intern Year

1. When ordering a test or taking any action on a patient, ask your self the question, “Why am I doing this?” If it doesn’t change the patient’s outcome, reconsider your plan.

2. Evolve your communication skills to the maximum. Keep your attendings, senior residents, nurses, patients, and patient’s families up to date on the plan.

3. Ask questions when you don’t know the answer. Its okay to ask the nurse and even the actual patient, “What do you think is going on?”

4. When you’re on call overnight and sleeping in your plush intern bunk bed, and a nurse calls you about a patient with abdominal pain, chest pain, or difficulty breathing, get out of bed & go to see them ASAP.

5. If a diabetic patient comes in with nausea and vomiting with no chest pain or SOB, still consider Acute Coronary Syndrome (ACS) in your differential.

6. If someone yells at you or criticizes you, ignore the instinctual reaction of defending your position. Simply state, “Sorry. Mea culpa. It won’t happen again.” Even if it was not your fault.

7. Be nice to nurses, BUT don’t always listen to them.

8. Teach something to a medical student, nurse, PA, a junior resident at any free moment. Spend the additional 2 minutes to P.I.M.P. Doctor comes from the Latin word, doctoris, which means teacher.

9. If you say you are going to be somewhere, or promise to do something, follow through. If you can’t, let them know as soon as you realize it.

10. Be generous with pain meds. It’s better to give narcotics to fakers than to have a person in really bad pain. In trauma patients, consider fast acting fentanyl 1 mcg/kg

11. Do the things that scare you and see the patients that you find challenging. Be aware of your backups in case you suck. Feel the fear, and do it anyway.

12. Try not to hook up with co-workers, nurses, med techs, etc.

13. Exercise regularly.

14. During vacation weeks, go somewhere that requires a flight. You’ll come back much more refreshed. Also, don’t request vacations in the first week of a rotation, you might be lost when you come back.

15. When calling a consult, be sure to know the patient. Then introduce yourself by name. Verify that it is the correct service. Ask for their name. Ask how they are doing today. Begin with, “This consult is for…” and tell them the rest. End the conversation with, ‘Do you have any other questions about this consult?”

16. Try not to call bogus consults. You will recognize them after you’ve been an intern for that service.

17. If you have an infant who is crying, inconsolable, and everything else is normal, get the lidocaine eye drops. It just might be a corneal ulcer.

18. In the ED, ask the patient, “What made you decide to come in TONIGHT?” and if it’s a chronic problem, “What does your primary medical doctor think about this?”

19. If it doesn’t make sense to you, question your attendings and senior residents in a diplomatic way. They are human and make mistakes too.

20. Forgive yourself for the mistakes b/c you will absolutely make them. Just learn from each. James Allen wrote, “Circumstances don’t make a man, they reveal him”

If you're thinking about EM, consider this:

"They never exam the patient.

Those ER docs miss everything.

Why don't you see the patient first, then call me?

It's 3:30AM, do you really need this consult now?

Order the MRI, then let me know if anything shows up.

Didn't you realize you needed EKG on all diabetic patients?

Ovarian torsion? Ultrasound is terrible at detecting that.

So what are you going to specialize in after you are done with ER?

Trauma surgeon: Call Anesthesia, we need an airway STAT!

How could they have missed the septic knee, inferior MI, AAA, etc?"

EM is a young specialty, and we need to develop a thick skin.

It's the ultimate fishbowl, and everyone questions your decisions on Monday.

Bring it on.

My Hero is Mel Herbert from EM Rap

This week, I went to the Cal/ACEP meeting in La Quinta Resort near Palm Springs. This place was AMAZING to say the least - over 50 hot tubs, about 20 pools, and most importantly, some amazing lectures over EM.

My favorite speaker was Dr. Mel Herbert...

"Mel Herbert, MD, is an award-winning educator and full-time member of the faculty at the Los Angeles County / USC Medical Center Emergency Medicine Residency. Mel's talent at producing EM:RAP is a natural extension of his gift for teaching. Within the past few years, he's received the UCLA "Chairman's Teaching Award" and the "Golden Stogie" Award, the Cal/ACEP Education Award, the Emergency Medicine Residents Award for Teaching Excellence, and Honorable Mention for ACEP's Outstanding Speaker of the Year Award." ~ EMRAP

Here's a picture that a good friend and I got with him as he was departing. Woohoo!

Society of Critical Care Medicine

I'm taking a course from the Society of Critical Care Medicine. I did not take an elective in the ICU during medical school, so my first TRUE experience will be on the PICU in July. This course was actually pretty helpful in reviewing the basics of ICU. Some tips I learned:

Always start with the ABCs.

Tachypnea is an omnious sign of sickness. Evaluate thoroughly

When a nurse calls you on call and tells you about a patient with dyspnea, get up, standup.

Rocuronium (a non-depolarizing agent) has an antidote - Sugammadex! I don't thinks it's been approved by the FDA yet.

Intubate starting from pt's right mouth and sweep the tongue. Have someone give you Sellick and the fish hook. Then use BURP myself and have another person hold it when i visualize cords.

Use the bougie as a tube exchanger.

Winter's formula: 1.5*HCO3 + 8 +/- 2

For every 10mmHg change in PCO2, there is a 0.8 change in pH.

Propofol can cause falsely elevated Pulse oximetry saturations.

After finishing up the Day 1 of the course, I went and hung out with surgical interns. Yes, they are normal people too. Good times.

p.s. Who knows how to calculate the delta-delta? Care to share?

My application essay for Cal/ACEP Rep for 2009

“Given one well-trained physician of the highest type, he will do better work for a thousand people than ten specialists.”

~ William James Mayo, M.D.

Emergency medicine is the youngest and most diverse medical specialty. We can reassure patients about H1N1 virus and their home BP measurement of 160/90, while detecting a pneumothorax on ultrasound and placing a chest tube on the trauma patient. If we choose to, we can become certified experts in pediatrics, toxicology, sports medicine, high altitude, & deep sea diving.

Because of this broad training, we have the ability to speak the language of every specialty: Monteggia’s fracture, Stanford Type A dissections, retinal detachments, retrograde urethrogram, Brugada syndrome, and ectopic pregnancy are words that even our astrocytes retain. Moreover, the ED is truly the front door to the hospital. Putting these factors together, I believe emergency physicians are uniquely poised to transform from the newbie to the "big dog" at the head of the medical community.

Our field has numerous strengths, yet there are many challenges. For example, we are legally responsible to see every patient regardless of ability to pay. Ironically, there is no funding set aside to pay for these visits. Upon graduation, some residents will work at an hourly wage for a healthcare corporation, while administrators skim heavy “management” fees off the top. Naturally, we need leaders who can represent Emergency Medicine in the political, medical, and business world.

My calling is to be the doctor with a business toolbox to represent physicians in these crucial areas. Today, I ask for your vote to begin my path towards making a difference not only for our patients, but also for you. Thank you. http://dr.samko.googlepages.com/

Swine Flu

I've been working the 6pm-4am shift for the past four nights at the County. The patient wait times are getting longer and we are hitting record numbers of patients seen. I attribute it to fears of Swine Flu.

The symptoms of swine flu aka H1N1 virus are:

Fever, cough, sore throat, rhinorrhea, body aches, headaches, and sometimes nausea/vomiting/diarrhea. (Essentially, your normal flu symptoms)

We get especially concerned if the patient has come from Mexico, San Diego, or the Imperial County in the past week or if the patient has been in contact with some from these areas in the past 7 days.

If the person has exhibited symptoms for less than 48 hours, I prescribe an antiviral. Turns out the cost is $92.99 bucks for Tamiflu (oseltamivir) or $63.99 for Relenza (zanamivir). *Epocrates

But here's the rub: a lot of my patients don't have insurance or have federally funded/state funded health insurance.

How the hell are they going to pay for it?

What I like about Emergency Medicine

1. Variety - Every day is different. Some days there are trends. It can be pediatric patients with fevers one day, then women with vag bleeding another. I lose attention easily sometimes so it helps to see different types of patients.

2. Ultrasound - I'm really enjoying portable ultrasound to make diagnoses. I've used the PROBE to find retinal detachment, gallstones, AAAs, vascular access, pneumothorax, and free fluid in the abdomen after traumas. My favorite u/s exam is the eye because it so clear. The hardest exam for me is cardiac. Here's an excellent website on ultrasound.

3. Progressiveness - Since EM is the newest specialty, I believe our specialty has the ability to flex and bend to changes. For example, Ketamine and Propofol in combination for Keto-Fol! There's a lot of room for growth and debate on what should be done in the ED.

4. Shift work -I don't mind the transition between mornings, nights, and days. It's cool to stay awake after an overnight shift and hang out at Starbucks seeing morning people when it's nearly bedtime for me.

5. The smells - Just kidding;)