Tuesday, December 13, 2005

Chalk another one up for the ER- Wait, I have to vomit first

Its moments like these that made me want to become a doctor in the first place. The strange thing about all this is how these rare moments happen whenever I’m doing my ER rotations. Strange, because I find I am able to spend very little time with patients, much less than I would as an internist, and yet there are these little sparkles of light. Maybe this is what draws emergency physicians to their specialty. Although, I’m betting it’s the fact that they get to intubate.

I’ll set the stage. It’s five in the afternoon and I’m preparing to draw blood on one of my patients when the receptionist pages overhead “Medical notification is HERE!”. Normally, a notification is announced minutes in advance thus notifying the physicians of the severity of a particular case that is on its way to the Emergency department. This notification was slightly late.

Suddenly, I see a young girl; about 26 years old, being wheeled towards the back while Emergency technicians are trying to give her oxygen with a bag. She is not moving any air. I can’t hear any breath sounds. No time to react. We establish a line and she is intubated almost immediately.

After the intubation a careful exam still reveals clear breath sounds, no wheezing, normal peak pressures on the ventilator. While before the intubation this was likely a case of horrible asthma, it doesn’t seem to be the case now.

A further probe into her past reveals this patient suffering of a condition called paradoxical vocal cord movement. A cause was not yet found but is probably psychiatric in nature.

She is extubated one hour later.

Now she begins to wheeze heavily and we re-assess our initial impression.

She spends the next four hours wheezing heavily, looking like she needs to be re-intubated. But, all the blood gases and the monitor shows she is oxygenating perfectly. I think I may be going on too much about this case but here’s why I decided to write about it.

Before my shift was about to end I went to check on her. Having looked to me like she was tiring I decided to attempt another blood gas. While I was obtaining the test I started asking her about her life.

“I have four kids” she said.
“Four kids?” I answered, surprised. “If I had four kids I would be here getting intubated every night”. She laughed.
“Where’s your husband?”
“At home with the kids”
“How are things at home?”
“They’re great she answered” She was calming down. No more wheezing.
“Are you sure?” I continued.

And she nodded. We continued our conversation. I was trying to make as many jokes as I could, this was definitely working.

Within two minutes even the non-rebreather was off, the legs were crossed and we were having a nice little chat. No more wheezing.

“What causes this I asked her?” She didn’t know. She’s been to therapy, is on medication and still she’s been intubated five times. We talked for a while, no wheezing, no intubation, no blood gas. Just words. She began to breath normally because we were talking.

I went home happy that night. And that’s why I became a doctor.