What If.....

The Emergency Department can be a very hazardous place to work. Over the course of one year I have seen random acts of violence, and have had friends exposed to various bodily fluids. I have seen a meal tray thrown at a nurse and unruly patients take swings at ER personnel, in fact one of my fellow residents was attacked and bitten by a patient in the hallway of a San Francisco hospital. Although physical threats are a reality, a more common threat to healthcare workers are from monsters smaller than 1 micron: Tuberculosis, Hepatitis A, B, C, and HIV. The Emergency Department can indeed be a very dangerous place to work-I personally experienced this fact 2 months ago.
Mr. R, was a 35 year-old who came into the Emergency Department one evening because he was having an extremely difficult time breathing. He was diagnosed with a horrific pneumonia. He could not speak more than 3 words at a time, he was covered in sweat, and his blood pressure was very low-he really needed our help. We placed a tube into his lungs to help him breath, and I took charge of inserting a large catheter into his Jugular Vein in order to rapidly administer fluid into his blood stream. This is a procedure that most Emergency Department Residents become very comfortable with after a year of working in the ER-but as I have learned, one must NEVER let his or her guard down when performing an invasive procedure. After I had inserted the catheter into his neck, I began anchoring it to his skin so that it would stay in place. In order to do this we use what looks like a sewing needle attached to a length of suture. The room was very hectic as we worked to save our patient.
In one instant, amidst the chaos, while standing at the head of the bed, and suturing the catheter in place I looked away to grab a scalpel-the needle pierced my glove and stuck into my index finger. These procedures can be very bloody-all I remember seeing was my blood covered hand, a blood covered needle. I immediately took my glove off, and saw what I had feared: blood oozing from a small puncture wound on the side of my finger.
After stabilizing the patient, I thoroughly irrigated my wound under water for 5 minutes. My mind was racing....what if Mr. R has HIV, or Hepatitis? Why does a seemingly young healthy 35 year old have such a terrible pneumonia? Is he immunocompromised, meaning is there a disease which we do not know about, such as HIV/AIDS which is shutting down his immune system? I tried to calm myself by thinking, "There is no way he has anything...", but the “what if’s” kept creeping in. Suddenly his world, his life, collided with mine.
Mr. R passed away 2 hours later in the intensive care unit from sepsis-or an overwhelming infection causing a dramatic loss of blood pressure, and respiratory failure. Per our hospital's protocol I was evaluated in the Emergency Department in order to determine my risk of exposure to Hepatitis, or HIV, diseases commonly transmitted through blood exposure. The whole scenario evolved so quickly. We simply had no answers: what was his lifestyle, did he use IV drugs, did he have Hepatitis or HIV? We needed to talk with the family to obtain their permission to run the necessary tests.
One of our Infectious Disease specialists talked with the family, and told them of the situation-they graciously agreed to allow us to check Mr. R for Hepatitis A, B, C, HIV, and a "Viral Load" which would quantify for us how much HIV Virus was in his system if indeed he had HIV. We also checked a CD4 count which is a rough estimate as to how well Mr. R's immune system was working (CD4 counts drop in the various stages of HIV infection). We worked with the Morgue to obtain the necessary blood work. Meanwhile, a family member informed us that Mr. R was homosexual. Although he was regularly tested for HIV with consistently negative results, my odds of being exposed to HIV were now much higher.
When dealing with exposures, and particularly needle-stick exposures, there are several key factors that come into play to determine if one needs to take prophylactic medication to prevent infection: 1) What is the probability that the patient has an infectious disease: what are their risk factors for Hepatitis and HIV, for example, IV drug use, a history of multiple blood transfusions, or sexual activities, and 2) What type of needle was the worker punctured with: was it hollow or solid, was it covered with blood, did it pass through gloves first? These are all factors which are additive and determine one's risk. Reassuringly, I was using a solid needle, although it was covered with blood, it did pass through a gloved hand first- all factors which lower the rate of transmission.
Based on the risk of exposure from this patient, I elected to start anti-retroviral therapy-or therapy to kill the HIV virus if it was circulating in my blood stream. I really sympathize with anyone who needs to take this medication-for any reason. After 2 days I became nauseous, and had horrible muscle aches-I felt hungry all of the time, yet I always wanted to vomit. I tried to stick it out for the full course, or at least until we had some answers.
Fortunately Mr. R did not have Hepatitis A, B or C. Unfortunately having to acquire an HIV test after he passed was not so easy-the sample of blood we obtained was unable to be tested....we will never know if he had HIV. We did discover that he passed from a common bacteria which causes pneumonia. I took the medicine for 2 weeks, I could not do it any longer because of the side effects. I will need to be regularly tested for HIV over the next year. Although I would not wish anyone to go through this experience-it really was eye opening.
An estimated 700,000 healthcare workers receive puncture wounds from needles every year. Studies have shown that the risk of transmission of HIV after receiving a needle stick from a person known to be infected with HIV is 0.3%. Conversely, the risk of contracting Hepatitis B or C, a much more likely virus to contract in a similar scenario, is upwards of 30% (if not vaccinated-all healthcare workers are required to have an up to date Hepatitis B Vaccination). Reflecting on my experience, I learned that one must always remain incredibly vigilant while working in the Emergency Department; the risk of exposure in real. I also learned that knowing the facts about exposures helps to quiet the “what if’s” in your head: sometimes the thing we fear the most is the least likely to happen to us.

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Drugs of Abuse

To pick up where my last post left off, I thought I would write about a more common case than LSD. That would be alcohol intoxication. SFGH's director of Emergency Medicine, Alan Gelb, noticed a decade by decade decline in LSD presentation to the ED but a consistent stream of alcohol related illness. Now that I look back at the past month at SFGH, I can hardly estimate the multitude of medical cases related to alcohol.

As a disclaimer, I don't want to get self righteous or moralize about the subject. I certainly have embarrassed myself on numerous occasions with too much alcohol--and on a suprisingly large number without alcohol for that matter. We all know about the dangers of drinking and driving--40% of motor vehicle fatalities. Having never had any close friends or family members in AA, it never hit me how destructive it can be on a regular basis until this month.

And this was the month to treat alcohol intoxication. It may be that there were a few holidays including July 4th or that it was particularly warm and festive in San Francisco this summer. Or it could be that 3/4 of Americans drink at any point in the year (coffee, milk and soft drinks are still more popular). On my way home from work over the past 2 years, I have stopped to help during one cardiac arrest and two motor vehicle collisions. This month, on one night, I stopped twice on the Stanford campus to see the flashing lights of an ambulance retrieve a drunken student.

Those students went to the Stanford ED with little intervention on my part beyond what the paramedics had already done. In a situation of acute intoxication morbidity is usually related to traumatic injury. Those students were able to talk so their airways were clear, and they were breathing without any signs of aspirating their vomit, and they had strong pulses, with no visible external trauma to their heads or bodies. Whoever was working in the ED probably put them on a gurney and waited for them to sober up until they could accurately deny any pain or injury and return home safely without hurting themselves or others. It is possible that they also received some IV fluid as well. Though it doesn't help with excretion or conversion to acetaldehyde, it does counter act the tachycardia and low blood pressure that some people get as a result of dehydration or decreased blood vessel tone.

Heavy chronic ethanol ingestion is usually more destructive because of its social impact and associated health problems. As high as 7% of our population can fall into the category of alcohol abuse. The health care costs have been estimated at 185 billion which seems to out weight the cardioprotective benefits of a daily red wine. Much like acute ingestion, a major concern is trauma and I have seen countless alcohol related injuries on any given day. More insidious in the chronic alcoholic is the complete dependence and withdrawal risks. Almost every other day I will see someone who has had a seizure after trying to quit drinking. These can be scary and life threatening and only treated with more alcohol or a benzodiazipine. Though I have not seen it yet, chronic alcoholics can become confused because of a thiamine deficiency and resultant neuronal dysfunction (sometimes this can be irreversible). Finally, I have also diagnosed a few head bleeds or subdural hematomas in chronic alcoholics. They tend to have more accidents, more brain atrophy so there is more room for the brain to move in the skull and veins to tear, and they often need to be admitted for these bleeds. Very often we will put these patients through the CT scanner.

Though I can remember great times drinking, it has been a sobering experience taking care of all the times that it didn't turn out so well.

Labels: alcohol, alcohol abuse, emergency medicine, intoxication

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Pandemonium

"Fractals, fractals inside of fractals, and Asian doctors guarding the gates to eternity, little prisms, little prisms of gnomes, multicolored gnomes surrounding me, doctors with the keys, the key to eternity." I'll never forget those words that wished me goodbye as I left the hospital.
The launch of my second year as an EM resident began at San Francisco General Hospital and did so in relative peace. I began the day with trepidation and excitement and was surprised to arrive at an empty ED at 6am. Perched in the middle of SF's mission district, SFGH sees much of the city's traumatic injuries including penetrating trauma like gunshot wounds and stab wounds as well as many of the city's pedestrians that are too often hit by autos.

An empty ED is also scary because it will inevitably transform into a vortex. And on my first day it did. My friend, the mathematician, the one seeing fractals was about 20 years old, found in a park, shooting something as incoherent and intriguing as this when the police picked him up and transported him to SFGH. His voice was definitely the loudest in the cacophony at the end of my 12 hour shift. There were others, intoxicated, swearing at us and not happy to be in the ED. Also a the shouting in the trauma bay from an incident similar to the one I wrote about two blogs ago.

On my way home, having not seen the trajectory of his case, I wondered about what he might have ingested. My first thought was LSD or PCP because of the intensity with which he was fighting the cops and screaming about fractals.

LSD is a potent drug requiring only 1 microgram to have psychedelic effects. Usually a dose is distributed as blotter acid squares in 25 microgram proportions. If he did ingest acid he would not be near the lethal dose which requires 14,000 micrograms. Though his trip would not be pleasent because it usually lasts 12 hours, peaking in the first 4 hours, unlike mushrooms (psilocybin) that peaks in the first 30 minutes to 2 hours and wanes by 4-6 hours.
Still, his eyes were not as dilated as they usually are with LSD ingestion due to a sympathetic nervous system response. He didn't have the ataxia (uncoordinated), nystagmus (eye twitching) or increased secretions seen with PCP. At least his vital signs were normal, with a normal blood pressure, temperature, heart rate, and respiratory rate, so we felt more comfortable focusing on calming him down. After I left the hospital I was told that he needed four police officers to be restrained and sedative medications in voluminous quantities.

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