The Hospital that I work at is a county hospital, meaning that it is primarily funded by the taxpayers and Medicare/Medicaid. In other words, patients pay if they can, but if they can't, that's ok too. The Hospital served nearly 500,000 patients in 2006 (including 81,000 in the ER). Of these, only about one-third were able to pay with commercial or private insurance, and 12% were unable to pay at all. What this means, at least for the ER, is that many of our clients come from severely underserved populations, including the poor, the homeless, and the addicted. These are the folks for whom our Emergency Medicine services are the only kind of primary care they receive.

An interesting case I saw recently was a 29 y/o female who, due to chronic IV drug use, looked like she was about 15 years older. She presented with massive opened abscesses to both arms, which were extremely painful and draining copious amounts of foul-smelling pus, or "purulent discharge," in medical terms. (To see an early-stage closed abscess, click here. To see a later-stage opened abscess, click here.)

I overheard one of the nurses say that the patient used about 6 grams of heroin daily. (Slight tangent: I'm not sure if I believe this. 6 grams daily is a tremendous amount, even for a seasoned junkie. Currently, the purest heroin can cost over $100 per gram.)

Anyway, this case led me to do a little research on the cause and formation of drug abscesses, which typically result from using dirty needles when shooting up. An infection starts brewing under the skin, creating a pocket of pus. Left untreated, the infection will spread, destroying the surrounding tissue, including the overlying skin. At this point, the abscess has opened. Treatment for small or shallow abscesses includes antibiotics, plus a debridement of the abscess itself followed by daily gauze packings and dressing changes. Treatment for large abscesses, like those of the woman I saw, could be amputation.

In my research on this topic, I came across King County's "Harm Reduction" website. (Incidentally, this page is the first that appears if you Google "drug abscess"). If you are not familiar with this, harm reduction is the theory instead of criminalizing a certain behavior, the general population is better served by providing the resources to make that behavior safer. In drug terms, harm reduction programs generally consist of needle exchanges, distribution of clean supplies like new cotton balls, spoons and alcohol pads, and information about the safest ways to use drugs. Naturally, these programs are strongly criticized, as it can appear that they are supporting or condoning drug use.

My position: neither theory is perfect. The government's War on Drugs is problematic, and has been largely unsuccessful in reducing overall drug use (this is a topic for another day). And while harm reduction programs may make IV drug use safer, I believe that it's not the only solution, and emphasis must also be placed on helping addicts get off drugs.

What do you think?

So I've been doing this EMT job for about two months now, and so far it has been about 90% routine (transporting old folks between nursing homes and hospitals, etc.), 8% exciting (car accidents, major trauma, etc.), and 2% "Oh shit." I'll tell you about the 2% here.

STORY ONE
Nearing the end of our shift, we're dispatched code-red (priority, with lights and sirens) to assist with a possible overdose. Police, fire, and paramedics are already on-scene. In a case like this, the paramedics evaluate the patient and determine how sick he/she is. Sick patients are taken by the Fire Dept. paramedics (advanced life support, or ALS), not-so-sick patients are taken by us, the private ambulance companies (basic life support, or BLS). Let me repeat for emphasis: paramedics, who have much more traning than EMTs, evaluate the patient and determine whether they need ALS or BLS en-route to the hospital. Truly sick patients should not be transported by BLS, because we have neither the training nor the equipment to keep them stable.

We arrive at a private residence and go inside, where we find a bunch of cops and medics circled around a female in her mid-forties, who is ranting and raving at everyone in Russian and broken English. The report we got from the medics was that the woman had emptied 7 bottles' worth of various prescription meds into a Tupperware and started tossing back handfuls of them, washing it all down with swigs of vodka. Nobody knew how many pills she actually took, nor did we know what all of them were, as some of the bottles were labelled in Russian. We did know that one of the meds was amitryptiline, an antidepressant, and this was the one that made the paramedics nervous.

With the help of her Russian-speaking neighbor, we finally convinced her that she needed to go to the hospital. Because she was still shouting at us, the medics were confident enough to let her be transported BLS by us. We loaded her up into our ambulance, and one of the paramedics and myself attempted to get her vital signs before we left. It was while we were doing this that she started getting much more sluggish. It soon became obvious that whatever drugs she had taken were starting to kick in, and I started wondering if maybe she should be taken by the medics instead. By the time we were ready to leave, she had become completely unresponsive. The medics told us to take her anyway.

The entire time we were flying towards the hospital, the patient got worse and worse. She became completely unresponsive even to painful stimuli (grinding a knuckle into the sternum, pinching the earlobe), she lost her gag reflex (tested by touching the back of her mouth with a tongue depressor), her pupils were pinpoint and fixed, and she lost her muscular reflexes (a cool medic trick tested by holding the arm up above the face and dropping it; people with this reflex will not let their arms hit them in the face). Her breathing became labored. She did not vomit, and while this was nice for me, this was bad for her as it meant whatever she had taken stayed inside her body.

Things I was watching out for:
- A slowing of her breathing, or a reduced tidal volume. She would then need me to help her breathe, using a bag-valve-mask setup. This uses a big rubber bulb connected to compressed oxygen that I squeeze to drive oxygen into her lungs through a mask.
- Vomiting, which would require me to suction her airway to reduce the risk of her aspirating (inhaling) the vomit.
- Bradycardia, or a slowing of her heart rate. Not much I can do for this, except for start chest compressions if her heart rate drops below 40 beats per minute.

As it was, we got to the hospital before I had to do any of these things. They ended up intubating her (putting a tube into her trachea and having a machine breathe for her) and doing a gastric lavage (removing her stomach contents and flushing her stomach with many liters of saline).

When we opened the back doors of the ambulance, her friend was there and asked, "Is she dead yet?" Apparently, she's tried this before :)

Story Two soon to come...

--From PostSecret

I think I'm a bit susceptible to OCD myself. I had a period when I was younger where I would check every lightswitch and outlet in the house to make sure there were no bad connections that could start a fire. I did this several times a day, frequently waking up in a sweat, terrified the house was burning down. Today, I no longer have that particular fear (thankfully, considering the house I'm living in now is over ninety years old, and probably retains some of the original wiring... they did have electricity back then, right?). My new thing is feeling crippling waves of guilt every time I eat something remotely unhealthy. Note that this does not prevent me from eating something unhealthy, but just prevents me from enjoying it. Cheers!

Best quote of the day, overheard at the airport in Chicago: "I've got to get away from this football on TV. I can't stand this crap anymore. It reminds me of my ex-husband."

Just finished watching one of my favorite episodes of Scrubs, called My Philosophy, from Season 2. The episode's finale features a Broadway-like rendition of Colin Hay's Waiting for My Real Life to Begin, performed in perfect harmony by the cast and guest star Jill Tracy. Her character is in need of a replacement heart valve, and earlier in the episode, when J.D. asks her what she thinks death is like, she replies that she hopes it's like a big Broadway play, where "you go out with a real flourish." The finale takes place in one of J.D.'s imagination sequences, where Tracy's dying character gets her wish and assumes the lead in her own musical. But what makes it so impressive is how well it also ties up the rest of the episode. Some of Hay's lyrics fit pretty well with what happened in the episode, and when they do, the appropriate character has his or her chance in the spotlight to sing the part.


I love smart TV.

Day One

My first post. This blog will describe what happens to me as I pursue my dream job. It will be a record of my experiences, my people, and my ups and downs. You will see a lot of this last one. My dream is to become a physician.

I will be writing a lot about the two main facets of my life right now: the application process to medical school, and my new job. When I write about the former, feel free to skim. Look for big news, but don't expect anything thrilling. I'm not. But I should have a lot of interesting things to say about my new job, as I've just been hired as a medical assistant for the best ER around.

In a nod to the ways of modern medicine, identifying information will be limited. My hospital is not really called The House, but that's we'll call it for now. You don't need to know what it's called to read about what goes on there. You don't need to know the names of my coworkers or my bosses, and you really don't need to know the names of my patients.

My patients. Wow. Not mine in the sense that I make big decisions about their healthcare, but mine in the sense that I'm working around them, with them, and on them. This new responsibility is both exciting and scary at the same time. Today, we learned how to restrain patients, run lab tests, and draw blood, among other things. Not a big deal to some of you I'm sure, but I can't believe I'm actually doing this. Unreal.

Next week I fly to Rochester, NY to interview at the U. of Rochester. My first and only interview so far. Also exciting and scary.

This week at The House has been all orientation, and I've got two more days to go. After that, I have about ten one-on-one shifts with my preceptor until I'm ready to be let loose on my own. All these 0700 mornings are wearing me out.

I know this blog will be primarily friends and family, but I hope you enjoy it. I hope you look forward to new posts, and I hope I can keep them coming. Lord knows there will be enough to talk about!