Excuse me, Doctor, but did you wash your hands?

After last night’s shift in the ER, my hands feel like sandpaper. It’s due to the amount of hand washing I do – before and after every patient, and sometimes in between patients - “just because” (in the ER we come in contact with some very interesting “stuff”).

It turns out that one of the most important measures healthcare workers can implement to stop the spread of disease and save lives is to establish a careful, consistent practice of washing their hands “religiously” between patients. While this may be intuitive, it is an unfortunate fact that the hand washing habit is not as “ingrained” as we’d like. In fact, it appears that health care providers only comply with strict hand washing about 40-60% of the time.

Our hospital, like many others is mounting a campaign to educate and remind all our patient care providers of the importance of hand hygiene. In the ER, we have sinks all around and have placed alcohol gel hand cleaner dispensers strategically throughout our clinical areas. A study published in the Journal of the American Medical Association* a few years ago confirmed that proper use of these hand cleaners is just as effective in reducing the risk of spreading infection as traditional scrubbing with soap and water.

So, for my readers, here’s the point: If you find yourself in an ER (or even in your private physician’s office), you should feel empowered to politely ask all your care providers (doctors, nurses, technicians, etc.) if they have just washed their hands. Even though I’m good about my hand washing habits, I’m now trying to develop the practice of doing it right in front of patients as I walk into their room and introduce myself – so patients and their loved ones know I care about their safety and health.

Well, time to go put some more lotion on my hands…

Stay alert and stay safe.

- Dr. Bob

* Parienti J J, Thibon P, Heller R, et al: Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. JAMA 2002;288:722-727.

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It's Not Just in the History Books!

When most people hear the term “whooping cough,” they think of some historical disease that plagued settlers crossing the prairies in their covered wagons. Well, whooping cough, or, more correctly, pertussis, is “alive and well,” and making a comeback. I had a case in our Pediatric ER yesterday - a sweet 2 month old baby who came in with a bad cough and periods during which she would stop breathing for several seconds – a syndrome we call “ALTE” (Apparently Life Threatening Events) in newborns. Sure enough, her tests were positive for pertussis and she was admitted to the Pediatric Intensive Care Unit for monitoring and treatment. She should do fine.

So, what do we need to know about pertussis? It is caused by a bacterium, Bordetella pertussis, and it is spread person-to-person by coughing. Most of us are vaccinated against it as children with our “baby shots,” but immunity fades within a few years of our last immunization, and this has a lot to do with its current rising incidence. While there were just 7000 cases reported in the U.S. in 2001, in 2004 there were 19,000 cases.

Pertussis is very contagious – as many as 80-90% of household members will get the disease if someone at home brings it in. The incubation period is about a week. Then the cough starts (along with other mild symptoms that suggest a “cold”). The cough is mild at first (and this is when folks are most contagious), but gradually gets more severe until it reaches the paroxysmal stage which is characterized by fits of coughing, often ending with vomiting and the classic “whoop.” Unfortunately, the cough often lasts about 10 weeks, even with treatment – thus, the term “hundred day cough” used to describe pertussis. Even the convalescent stage is prolonged, as it can take weeks to months for the cough to completely go away.

Small children (under about 6 months) are at risk of apnea (or cessation of breathing), pneumonia and death. The disease is rarely fatal to older children or adults, but weeks to months of severe coughing is nothing “to sneeze at.” Many older kids and adults have less severe courses, which is good for them, but they may be unknowingly spreading the disease into the community.

The health departments in our states keep a close watch out for this disease, and, when it is discovered in the community, physicians report it to the authorities so that warnings can be sent out. We generally suspect the disease in people who have had coughs for more than a couple of weeks. We have tests for the disease, though they’re less than perfect. If the disease is picked up, the recommendation is to begin antibiotic “prophylaxis” (generally with 5 days of antibiotics such as azithromycin) to all close-contacts (at home, the work place, school, etc.) in order to try to prevent its spread. Antibiotic treatment of those who have actually contracted pertussis helps to limit spread, but doesn’t do much to shorten the course of the illness.

For more information, check out the CDC web site at: http://www.cdc.gov/doc.do/id/0900f3ec80228696

That little 2 month old girl I saw in the ER yesterday sure was cute, but I have a colleague who contracted pertussis last year from a patient in our Peds ER. It was not a pretty thing. And, one of our nurses was telling me last night how she broke a couple ribs from her pertussis cough a few years ago. I think I’ll go take my antibiotic now…

Stay alert and stay safe.
- Dr. Bob

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Last Night in the ER

There is so much that I love about the practice of Emergency Medicine, and very little that I truly despise and would change if I could. Last night, however, I had one of the fortunately rare cases that causes me to ever-so-briefly stop and re-consider my career choice.

This case involved a young woman (I'll call her "Christine") who had been riding on the back of a motorcycle driven by her boyfriend. He lost control and “laid the bike down” at a high rate of speed. No other vehicles were apparently involved. As the motorcycle slid across the harsh pavement, Christine suffered a complete amputation of her left leg above the knee and a severe crushing of her pelvis. Her rapid blood loss sent her quickly into shock. The rescue personnel (including our amazing Life Flight helicopter crew) responded quickly and began immediate resuscitative care. Unfortunately, she was in a relatively remote location when the accident occurred, but the flight crew packaged her and got her to us as quickly as possible.

As Christine was brought into our ER trauma room, she was amazingly awake and alert, and very lucid. She was frightened and in a lot of pain, suffering from both psychological and physiological shock. We moved quickly to assess and treat her injuries, and as the physician in charge of the initial resuscitation, I tried to calm her and reassure her. It was clear that she was very severely injured and would be going through major interventions in an effort to save her life. I, therefore, made the decision to sedate her, temporarily paralyze her and to take over control of her airway and breathing (a procedure termed "Rapid Sequence Intubation" or "RSI") in an effort to reduce her pain and to put her lungs and respiratory muscles at rest, thereby easing some of the work her heart needed to do. As I was about to put her to sleep, I bent over and gently spoke into her ear, “We’re going to take good care of you.”

Taking control of Christine's airway and breathing went flawlessly, and we rapidly poured blood into her veins in an effort to replace what she’d lost on the pavement and into her broken pelvis. We then moved her as quickly as possible to the operating room for care by our trauma and orthopedic surgeons. She was, however, still in shock as she was moved out of the ER.

A few hours later (and, for me, many ER patients later), the trauma surgeon came down to the ER to give me the very sad news that Christine had died in the OR. Her injuries and her shock were just too severe. I had just a few moments to pause and reflect before moving on to the next ER patient who needed our care.

We deal with death regularly in the ER, and every ER doc learns to deal with it in his/her own special way. I like to think that I have a healthy approach to dealing with patients at the end of life, and I feel that I am pretty good at helping family members and loved ones work through the initial phase of dealing with their loss. In Christine's case, however, there was no family for me to speak with, and the only “loved one” was her boyfriend who had been driving the motorcycle. His injuries were much more minor, and he’ll eventually make a full physical recovery. I’m not sure what his ultimate emotional injuries, scars and recovery will be however.

So, the part of Emergency Medicine that I truly despise? It’s those times when I bend over and whisper into the ear of a very sick or badly injured patient, “We’re going to take good care of you,” and, despite all my best efforts and the efforts of the very talented people with whom I work, those turn out to be the last words that person hears in this life...

Stay alert and stay safe.
- Dr. Bob

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Plugging the Dike... Stopping that Nose Bleed

Nose bleeds are common, especially in the cooler months of the year when we are relying on artificial heat sources to keep us warm… and dry out our mucus membranes! They’re also common in those who have a habit of “picking their nose” (common in children and more than a few “closet” adult “pickers”). There is a very nice array of blood vessels in the front part of the nose, lining the septum (the cartilaginous tissue inside the middle of the nose). Those vessels are designed to help heat and moisten the air we breathe in. But when that air is especially dry, the membranes over the vessels can become dehydrated and cracked, setting the stage for nose bleeds.

If you develop a nose bleed, don’t panic. Just find a comfortable place to sit for a few minutes--preferably somewhere where you can see a clock or a watch. Pinch your nose at its tip, at the point just below where the bone ends and the soft part (cartilage) begins. Pinch firmly with your thumb and forefinger and hold it. Hold it for 10 straight minutes, and no peeking. You’re allowing a clot to form, and if you get impatient and peek too soon, you’ll pull that clot off the blood vessel and have to start all over again. There’s no advantage to cool compresses on the forehead or the back of the neck--unless they feel good and help you to relax. It may help for you to lean slightly forward to keep blood from draining down the back of your throat. Swallowed blood can make you nauseated.

If, after 10 minutes of constant direct pressure, the bleeding continues, keep up the pressure and head to the ER for evaluation. If you are taking medications that affect your blood’s clotting abilities (eg, aspirin, coumadin, Plavix, Aggrenox), you are more likely to need professional help to get the bleeding stopped. In the ER, the physician will try to identify the precise site of bleeding and stop it (using topically applied agents and possibly chemical cautery or a nasal balloon or pack to keep pressure on the site). In rare cases, the bleeding is coming from a site farther back in the nose, and this will require more specialized care, including possibly an evaluation by an Ear, Nose & Throat specialist (ENT).

If you have hypertension, once the bleeding is stopped, get your blood pressure checked, though the relationship between high blood pressure and nosebleeds remains pretty speculative, unless the blood pressure is very high.

To prevent nosebleeds, stay well hydrated--drink plenty of water and non-caffeine/non-alcoholic fluids during the day. Consider using a humidifier in your home if your air is particularly dry. You can also apply just a spot of petroleum jelly (e.g., Vaseline) to the inside of your nasal septum (the tissue in the middle) with the just the tip of your little finger. And, most importantly, if you’re a “nose picker”… just say “No”.

Stay alert and stay safe.

- Dr. Bob

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Chest Pain? Don't Wait!

Why is it that, on a regular basis in the ER, I see very intelligent patients with chest pain that clearly could be a “heart attack” wait at home for hours before they come in to see me? I suppose there must be some degree of denial of their symptoms. “If I ignore the pain and don’t go to the hospital, it can’t be my heart…” On an intellectual level, this clearly doesn’t make sense, but I see it almost every day, and this is too bad, because, with a heart attack or a stroke (a “brain attack” – more on that another day!), “time is tissue”… Every minute wasted before getting to definitive care (either a cardiac catheterization or use of a “clot busting” drug), allows more heart muscle to go starved of oxygen and die. This means a weaker pump and a shorter life expectancy.

So, if you develop chest pain, especially if it feels like a heaviness or pressure sensation, or like an unfamiliar “indigestion” you should seek prompt medical attention. Other worrisome signs that it might be your heart include onset with or shortly after exertion, associated shortness of breath, nausea or sweating, and movement or radiation of the pain into the neck, jaw, back, shoulder or arm (either side).

Steps to take:

• immediately find a place to rest
• loosen any constrictive clothing
• call 911 right away and request an ambulance (they’ll arrive with the equipment needed to begin managing a heart attack, though you still need to get to the hospital for the definitive treatment)
• take an aspirin (if you’re not allergic to it)… best: chew and swallow 2 baby aspirins
• try to stay calm… to slow your heart rate and reduce how hard it must pump

I’d be remiss if I didn’t, in closing, throw out those familiar “ounce of prevention” tips – eat healthy, exercise, don’t smoke, keep high blood pressure and/or diabetes under control, and watch your cholesterol.

But, most importantly, if you have worrisome symptoms, don’t wait!... get yourself promptly to the ER!

Stay alert and stay safe.

- Dr. Bob

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Should I stop?

Suddenly, traffic slows to a crawl just when you're late for an appointment. And then you see why -- up ahead there's a mangled mess of metal and plastic that used to be two automobiles. People are obviously hurt, and as you look around, you are horrified to note that there are none of the comforting flashing red lights of emergency vehicles yet on the scene... Should you stop?

For most people, thankfully, the answer to that is, "I HAVE to! I have to try to help!" but there are important considerations that must go through your mind when you decide to try to help out with an accident on the roadway.

Some things to consider:

- Can you see emergency response vehicles on the road, headed to the accident? If so, you should leave the situation to the professionals.

- Has anyone called 911? If not, do so immediately and explain who you are, where you are, what is going on, and what help you think is needed (eg., police, ambulance, fire, utilities). Stay on the line until the 911 dispatcher tells you it's OK to hang up.

- Are you trained to help?

• If you have never taken a basic first aid course, then I strongly suggest signing up for a class. This can be done quickly and easily through the American Red Cross, or, if you're especially motivated, you might sign up for an evening EMT (emergency medical technician) class through a local college -- they're a lot of fun, and it was an EMT class that got me first interested in a career in Emergency Medicine!

- Is it safe to stop, based on the location of the accident and position of the vehicles?

• If possible, you should pull your vehicle safely off the road and out of traffic
• You should consider positioning your vehicle - with its flashers blinking - a safe distance from the accident so that it acts as a warning to other vehicles and gives you some protection as you render care. If you choose to do this, get all occupants in your vehicle out and to a safe location away from traffic.
• Do you have small children in your vehicle? If so, you can't render care at a scene and keep an appropriate eye on your kids -- best to let others help.
• Survey the scene... and here's the MOST important part -- look for any hazards that might not be immediately obvious BEFORE you proceed. Obviously, moving traffic is a huge risk, but also, is there fuel on the road? Sharp glass and metal? How about downed power lines? If there are downed power lines in proximity to the vehicle, do NOT approach the vehicle. Warn the occupants to stay inside the vehicle until professional help arrives. They are pretty well protected inside the vehicle by the insulating properties of the tires, as long as they don't try to get out and touch any part of the exterior of the vehicle.

- Do you have equipment/supplies with which to render aid? Everyone should have a first aid kit in their vehicle. The contents of such a kit is a topic for a future blog!

- Have other people stopped to help? If so, seek out whomever seems to be running things -- probably the person who has been quickly identified as the one with the most training or experience.

• Check in with that person and let him/her know that you're willing to help and what you are trained to do.

- If you decide or are asked to direct traffic, be sure you are highly visible (have a flashlight in your car for use at night) and stay out of the actual path of vehicles. Position yourself a safe distance before the accident to give those passing through time to slow down before they reach the scene.

• If you plan to place road flares, you should know how to light them, how to keep them from rolling away, how to extinguish them if necessary, and how to assess whether they are safe to use (no risk of igniting fuel, grass, etc.). Better yet, have in your vehicle high visibility emergency reflectors that can be used more safely.
  

A lot to think about, but we owe it to ourselves to consider these issues BEFORE we come across that next major accident. Again, once we have prepared for the emergency, it ceases to be an emergency.

Stay alert and stay safe.
- Dr. Bob

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A Little Background

As I begin my journey with you via "Straight Talk from the ER", I thought it appropriate to tell you a little about my background so you'll know a bit about the experiences from whence I'll be speaking. I was raised on the east coast, educated in the public school system, and went to college at Virginia Military Institute, receiving the Hughes Trophy in 1979 as the top Army ROTC graduate in the nation. I then went to medical school at the Medical College of Virginia, graduating in 1983. I discovered early on in medical school that I had a passion for Emergency Medicine. So, during my cherished free time from school, I volunteered as an advanced Emergency Medical Technician for a local rescue squad. My wonderful wife who worked hard to support us during med school also got excited about emergency care. She got her EMT certification and we teamed up on the ambulance -- with her driving and me in the back working on patients. That made for some interesting tales around the dinner table!

After med school, I did my residency in Emergency Medicine at Akron City Hospital in Ohio. That afforded me a great opportunity to learn about adult and pediatric Emergency Medicine. I trained not only at Akron City Hospital, but also at St. Thomas Hospital and at Akron Children's Hospital, and I got to spend 2 months working at the Maryland Institute of Emergency Medical Services Systems -- better known as "Baltimore Shock Trauma". After completing my residency, I went into the Army and served for 4 years at Brooke Army Medical Center in San Antonio. Both of my children (a daughter and a son) were born in San Antonio, and I will always be jealous of their status as native Texans!

While at BAMC I got to "cut my teeth" as an attending Emergency Physician seeing lots of traumatized and critically ill patients. BAMC also gave me the opportunity to get back into an interest I had had for a long time but had to put "on hold" during my education years -- snakes. I had a very "tolerant" commanding officer, and he allowed me to collect and keep all sorts of snakes in my office outside of the hospital... an office that soon became fondly known as "the pit" -- the only room on post that the housekeeping staff refused to clean!

After my 4 years at BAMC I made the difficult decision to leave the Army and pursue a career in civilian academic Emergency Medicine. I was hired into a faculty position at Vanderbilt University by my dear friend Dr. Paul Auerbach (author of Medicine for the Outdoors). While at "Vandy," I developed their now-very-successful residency program. After about a year there, however, I was recruited by Dr. Auerbach to move to Stanford University Medical Center. Paul had taken the Chief of Emergency Medicine position at Stanford and he offered me the chance to be his Associate Chief at one of the nation's top medical centers. It was an offer too good to pass up, so I moved my family to the west coast. After a few great years at Stanford, Paul decided to pursue other career opportunities, and I was promoted to Chief of Emergency Medicine at Stanford. I've now been here for 15 years.

During my time at Stanford, I have had the pleasure of leading a phenomenally talented group of physicians and nurses in the Emergency Department. We have a very successful and highly competitive residency training program in Emergency Medicine, and it is my distinct pleasure to participate in the training of future Emergency Physicians. I have been able to pursue my research interests and to develop special expertise in subspecialty areas of Emergency Medicine -- venomous bites and stings (snakes, spiders, scorpions, etc.), wilderness medicine, and tactical medicine.

After the tragic events of September 11, 2001, I felt a deep desire to find some way to give back to those who are charged with protecting our freedom. In order to do that, I became involved with the Santa Clara County Sheriff's Emergency Response Team as a tactical physician and reserve deputy. In that role, I provide medical support to our team members and civilians involved in law enforcement operations. It has been a very rewarding experience. Wanting to learn more about law enforcement, in 2004, I was given the opportunity by Stanford University to take a 7 month sabbatical to attend the police academy. I graduated in March of 2005 at the top of my class... not bad for a 47 year old man! Attending the police academy was, I guess, my version of a "mid-life crisis." It was either that or buy a fast sports car, and my wife felt that the police academy would be safer!

I have also become very interested in disaster medicine and am now an active member of an Urban Search and Rescue Team, California Task Force 3. My wife has also continued her parallel interests with me and is now an American Red Cross Disaster Response Volunteer (and served faithfully in Baton Rouge, LA after Katrina).

My eclectic background and experiences (Emergency Medicine, teaching, snakebites, wilderness medicine, the military, law enforcement, pre-hospital care, disaster medicine, etc.) have made life interesting to say the least, and, I believe, they put me in an excellent position to author a site that will be interesting and educational. So, to those of you who check in on a regular basis, I look forward to looking into the vast realm of Emergency Medicine together!
Stay alert and stay safe.

- Dr. Bob

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