New life and near death in the ER (guest post by Steve)

Ahhh.  Now I feel at home.  I've mentioned before some of the challenges and differences that I've experienced while practicing medicine in New Zealand.  So many things have been different that it's taken me awhile to settle in.  I finally had a shift this week that made me feel right at home.  They can change the names of medications, doses, lab values, test ordering processes, etc., but they can't change crazy.  Crazy is crazy anywhere in the world.

The shift started off nice and quiet.  During handoff with the night docs, they told us about the patients that we would need to follow up on during the morning.  Chest pain rule-outs, weak and dizzies, patients waiting to be admitted to the floor, and a suicidal patient that had to be sedated overnight and was waiting for a crisis evaluation.  We settled in and started seeing some of the early morning patients that had begun to trickle in.  Before too long, it had picked up and we found ourselves busy with a variety of patients.  The EMS radio interrupted our pace with news that they were bringing in a 2-year-old in status epilepticus that had been seizing for 30-40 minutes.  Matt, another American, got prepped and waited for the patient to arrive.  It would prove to be a difficult case that would keep him, and several of the nursing staff, occupied for the next hour or so.

During this chaos, I witnessed an older gentleman yelling obscenities at a nurse and frantically pushing doors trying to get out of the emergency department.  I was told that he was the suicidal patient that had had to be chemically restrained overnight.  He apparently had woken up from his drug-induced coma and wanted out of the department now!  There were, of course, no security guards in sight.  I ran to help the nurse and see if we could calm the patient down and redirect him to his room.  We tried to reason with him, redirect him, offer bribes, and whisper sweet nothings.  He would have none of it.  He continued to scream at anyone in his way, demanding to leave and pounding on the doors.   I didn't want to sedate him again, because that would mean that crisis wouldn't be able to evaluate him for several more hours, but instructed the nurses to draw up meds just in case.  We finally found ourselves outside of a locked door at the end of the hallway leading to the waiting room.  After pounding on the door for a minute, he stopped, seemed to calm down, and turned around.  We hoped that maybe he was giving up and we could escort him back down the hallway to his room.  Little did I know it was just about to get interesting.

I should admit that I'm kind of a fight fan.  I've always enjoyed a good scrap, and maybe I stick my nose in a little close when things are starting to go down.  Someday, of course, that will eventually burn you.  Today was that day.  As I reached out to guide him by his arm down the hallway to his room, I was taken by surprise by his superhuman, cat-quick reflexes.  Before I could defend myself, he reached out, grabbed the ends of my stethoscope around my neck, crossed them, and pulled as hard as he could.  Time stopped.  It took me a second to process what was happening.  This older, pudgy, angry little man had me in a stethoscope necktie and was pulling for all he was worth.  I couldn't breathe.  As I stared at his glassy, bloodshot eyes bulging out of his angry little face, I felt angry at him, but sorry for him at the same time.  I tried wrapping my fingers underneath the stethoscope to give me some breathing room, but it was too tight.  Seconds that seemed like minutes passed as I tried to decide what to do.  I felt like my only option was to start swinging.  I pushed him into the corner and raised my fist, ready to bring down the hammer! (or at least the fly swatter).

But..., I..., hesitated.  Now, I've taken people down in the ED before, but throwing a punch just felt wrong, even if I couldn't breathe and was having my life flash before my eyes.  Maybe part of me thought that if I let him go just a little longer, maybe I would pass out and then get to go home early from my shift.  Unfortunately, my indecision was my decision.  After I pushed him into the corner, raised my fist and gave him my own bug-eyed, hypoxic stare, he loosened his grip.  I was able to extricate myself from his anaconda squeeze, but I still wanted to punch him.  I kept my hand raised for a moment, weighing how good it would feel to punch him in the mouth versus how bad it would look.  Reason finally won out, and I begrudgingly walked him back to his room.  I think he realized he had crossed the line, because he laid down on the bed, closed his eyes, and didn't move for the next hour.

I stood outside his room for a while, making sure he wasn't going to act up again, or maybe hoping for a redo.  As I stood there trying to get over my fightus interruptus, the EMS radio again blared to life.  They were bringing in a 28-year-old female with a distended, painful abdomen and low blood pressure.  Moments later, they arrived.  I walked into the room to see a young woman, lying on her side, writhing in pain.  She had been seen by her doctor that morning with severe abdominal pain, and a distended, tight abdomen.  He thought that something may have ruptured and that she needed to be seen by a surgeon.  She told us that she had had a period 3 weeks ago, and that she couldn't possibly be pregnant.  Now, I'm not an expert, but I've seen a pregnant woman once or twice, and this lady looked pregnant.  I asked her husband if she was pregnant, and he wouldn't say yes or no.  He just shook his head.

Trying to examine the patient was a challenge.  She wouldn't hold still, wouldn't let me palpate her abdomen, and writhed all over the bed as I tried to ultrasound her.  She seemed completely out of it, due to pain, drugs or emotional distress.  Very odd.  Even though I couldn't really see anything on the ultrasound due to her movement, I recognized that we had to treat her as if she was having a pregnancy-related emergency.  Nothing else could have caused this presentation.  We needed to see if she was delivering or hemorrhaging.  Attempting a pelvic exam was near impossible.  She had her legs crossed, and wouldn't lay on her back.  Again, very odd.  Finally, with enough nursing power, we rolled her on her back and performed a quick pelvic exam.  The baby's head was crowning.  Within a few moments, with the help of the OB resident who showed up just in time, the baby was delivered...full-term, healthy, pink, beautiful baby boy.  Crazy.  Mom didn't want to see or hold the baby.  Dad sat in the corner of the room and cried.  We cleaned them up, called social work, and sent them upstairs.

In the aftermath of the morning, I noticed people staring at my neck.  I had perfectly defined ligature marks on my neck.  I wish I would have snapped a photo for the scrapbook.  It's not everyday that you get to experience near death and new life all in one morning.