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ER FAQ 5.00, Section 6: Medical Questions (6/8)


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ER FAQ 5.00: Medical Questions


MeMiceElfAnI Productions Copyright 1997-99 by Mike Sugimoto; content cannot
be used without expressed written permission of the author.


Last Updated: 11/27/98 by Mike "phloem" Sugimoto and Rose "MotherFAQer"
Cooper [Note: this section was re-written _entirely_ by Mike, but since I
like seeing my name in lights...]


 SECTION SIX: MEDICAL QUESTIONS
 Putting the 'duh' in meduhcine

[Please note: For the purposes of this section of the FAQ, the terms "ER"
and "ED" should not be considered to be interchangeable. "ER" is a TV show.
"ED" is an abbreviation for a specialized part of a hospital known as an
emergency department, designed for the care of acutely ill and injured
patients. With that out of the way, let's begin.]


 6.1  How realistic is "ER"?

     The question that gets asked the most about ER when it comes to medicine
is, "How realistic is the show compared to real hospitals?" Like most things
in life, you'll get a different answer depending on who you ask -- I'll tell
you it's not that realistic, and other people may disagree with that
assessment. So right off the bat, I'll give a really short answer and say the
show isn't too grounded in reality, and if you don't want to hear why I say
that, you can skip down to the next answer and tune into TLC's excellent
series "Trauma: Life in the ER," which I strongly recommend for anyone who
wants to see what it's really like out there.

     But I'll try and say a few (hah) words about it anyway.

     The long answer depends on how you want to score them. ER and its
producers get high marks for accurate presentation of diseases and injuries
(although the number of bizarre and fascinating cases tends to be overblown)
and a realistic presentation of patient volume. Most lab values and imaging
studies reveal expected things when they're shown in relation to the
condition for which they were ordered, and treatment options are usually well
done.

     Before I get into where they lose marks, a caveat: I'm Canadian, and as
such, some of what I say may not translate well into the American model.
Having said that, however, I have spent some time in American emergency
departments and know their operating patterns pretty well, so I feel fairly
confident and justified in what I'm about to say. Consider this my "gripe
list," or, since it has six broad categories, ER's six deadly sins. Feel free
to disagree with me on these.

    [Gripe 1]: Speed. Early on in the fourth season, Elizabeth Corday is in
Trauma One managing a patient with a gunshot wound. Everything is progressing
the way we're used to seeing it, when suddenly, she says, "Why don't we all
just slow down? Things will go a lot smoother." The staffers look at her like
she's nuts, but the people I was watching that with cheered -- loudly. Speed
may have saved Sandra Bullock and Keanu Reeves on that Los Angeles city bus,
but it's not the rule in emergency medicine. Okay, yeah, it gets chaotic at
times and I feel like shouting across the department at somebody, but that
(practically) never happens. I'm frankly amazed that the folks in Cook County
General's ED haven't poked or otherwise caused bodily harm to themselves in
the midst of one of those insane trauma cases they seem to do over and over
and over and over again: going that fast with that much uncoordinated movement
is inviting an accident. Slowing down helps prevent bad things from happening,
both to you as a provider and to the patient. A trauma -- especially a
penetrating trauma -- is a dangerous place to be: there are sharp pointy
things going around the room and there's a lot of blood which is possibly
contaminated.. not a combination that leads to a safe working environment when
mixed with speed.
    [Gripe 2]: Get out of my emergency room, damnit! Here's a fun thing to
try: find someone who's critically injured or really sick. Go down to your
local emergency department. Get your accomplis admitted to the department,
then try to follow them back into the patient care area. See how far you get.
The point of this is that the "hysterical screaming friend/relative/
well-wisher" in the trauma bay while the patient is going downhill and
they're cranking the ribs open is really stupid. It makes for great
television, but it just doesn't happen. Patient care areas are by their
very nature restricted (come on, would you want some complete non-medical
stranger to see you in the midst of your misery?); trauma and resuscitation
suites even more so. In real life, Kenny Law would never have been around to
make the (irrational, in my opinion) judgement that his brother was being
mistreated. At most hospitals, if you don't heed a request to leave a
patient care area, you'll either be forcibly removed or arrested, or both.
Access is strictly controlled to only those people who need to be there,
because as I said before, it's a dangerous place and there's no reason
to make it more dangerous by adding someone who might flip out for
whatever reason.
    [Gripe 3]: Where is security? [Rose's note: amen, brother!] Touching
again on the stuff I just mentioned, access to the emergency department
itself is strictly controlled, and for good reason. In some places, the ED
is considered to be a refuge from the hostile outside world (inner-city
America, for example), and it's "neutral turf." That won't stop people from
trying to carry wars over into the emergency department, and it happens --
witness what happened in King's County, New York, a few years ago where a man
who felt he had been experimented on at the hospital walked in an ED and shot
(I believe) four doctors. The need for security -- as much to remove
undesirables as to restrain those who require it -- is very real in today's
ED. In every department I've been in, without exception, the first thing you
see when you walk in the door is the triage desk, and right next to it is a
security guard.
    [Gripe 4]: Those doors can't take much more pounding. It is the premise
for at least one scene in every episode: there's a siren coming off wail,
followed by a crashing of doors, and a rapid-fire string of words spewing
out of a paramedic's mouth as the patient is whisked down the hall to the
trauma room. While this may happen (in a more sedate form) at some
institutions, it's certainly not the case for all patients, and it never
happens this fast. All patients whether they come in on foot, by ambulance,
or by taxi, are seen and evaluated by the triage officer before being
allowed back to the patient care areas. Medical priority determines who
goes first, and I sometimes wonder who exactly is doing the triage at Cook
County, since more than once a character is heard complaining about the
back-up, but we somehow find time to see the patient with the incredibly
trivial problem that would never have jumped to the front of the line on
a day with a three-hour wait.
    [Gripe 5]: Prehospital blunders. While I'm on the subject of patient
arrivals, I could start a whole new section on gripes about their
prehospital care, which, I'm sorry to say (and I did look for a gentle way
to put this), sucks. Big time. Remember the opening moments of "A Bloody
Mess"? Think back -- they had people who had been involved in a motor vehicle
accident, covered in blood, and they don't find out that it's bovine until
they reach the hospital. Uh-huh. First thing's first, in the field as in the
hospital, you do a primary survey, which has a section in it where you look
for deadly bleeding. There was enough blood on those patients to make me
think they'd exsanguinated, and that certainly qualifies as life-
threatening. But did the paramedics find that? Hell no. So what'd they do,
just throw them in the ambulance like they did thirty years ago? Give me a
break. They're trained well enough to start IV lines and intubate in the
field, but they're apparently too dumb to do a proper primary survey.
     There are also some problems I have with their standards of care --
trauma patients, particularly penetrating trauma patients -- require as part
of basic trauma life support guidelines spinal immobilization, and I can
remember more than one instance of a patient coming in not only not back
boarded, but not wearing a cervical collar either. Something like 12% of
all trauma patients regardless of mechanism of injury suffer some form of
spinal injury, and roughly 30% of those patients have some long-term
deficits. Given the highly litigeous climate of the United States, I have
a really hard time swallowing that one. (But this is a mostly technical
argument and open to a lot of debate.)
     And don't even get me started on Elizabeth and the building back in
"Exodus"..
    [Gripe 6]: This place makes me sick. County's infection control practices
stink. There's no way around it. Nobody I know would even think of performing
a spinal tap without a mask, gown and gloves, never mind something as dramatic
as a thoracotomy wearing only those thin yellow gauzy things and a pair of
gloves you yanked out of a box on the shelf. Look, I know why they do it
this way, but that doesn't mean I have to like it. (For what it's worth,
there are places out there that also have pretty lax infection control
procedures, but they're generally few and far between.)  This isn't just for
the protection of the doctors and nurses out there, but also for the
protection of the patient.

     General complaints: Nobody is ever seen reading journals or going to
lectures, so I'm guessing this teaching hospital isn't very big on academics.
Although, to their credit, we have seen morbidity and mortality rounds. Twice
over four years. It's nice to know they care about the teaching process.

     Since when is the trauma team comprised almost exclusively of emergency
physicians? Heck, I've worked traumas where the team showed up, and I didn't
know any of the surgeons on it.

     Since when does a chief resident have that much time to see patients? We
laughed and pointed at Kerry when she insisted they spend more time on
administration, but that's how it works. The chief resident has to chip in
with the administrative work, which leaves {him|her} with relatively little
time to treat patients.

     We had an interesting time this past season when we tried to figure out
how Morganstern could be head of surgery and emergency medicine -- well,
because of how emergency medicine came into being (it's a fascinating story;
read the relevant sections out of the 1997 "Annals of Emergency Medicine"
[yes, that's every issue; don't worry, they're short articles] for more
information and some frank observations), people seem to think we belong to
surgery. We don't, and while I understand the logic behind putting it in
there (so there's no "Department of Emergency Medicine" but rather a
"Division" or a "Section"; a lot of it has to do with budgets and
administration overhead), it doesn't make me like it more.

     The labs and radiology department are really fast. Wish I could get them
to move here.

     "ER" staffers fail their CPR recertifications. Their compression rates
are way too slow, and their technique sucks.


*6.2  What is the general schedule for becoming a doctor?

      After completing college or university, the prospective student
goes to:

      4 years medical school:
      Years 1-2 consist of generally textbook-based learning in the
             basic medical sciences.
             Years 3-4 consist of hands-on training/learning through
             many different areas of medicine; medicine, family practice,
             emergency, etc...
      First Year of Residency, or year of Internship
             After obtaining a medical degree, the first year of
             residency consists of more rotating through the medical
             disciplines with greater responsibility.  Also the
             considered the hardest year. Some users report that today,
             many residencies have eliminated internship requirements,
             and allow residents to begin their residency immediately.
      Years 2-(up to 10) Residency:
             Residents are full-fledged doctors, depending on the
             specialty. Brain surgery is not done by 2nd year residents
             alone.
      Fellowship years:
             Optional training years in a specific specialty (usually
             a subspecialty like Doug Ross`s pediatric ER).
      Attending:
             Where the doctors watch over other residents and fellowship
             winners in teaching hospitals.  Dr. Greene is an attending
             physician.


*Check out the misc.education.medical FAQ website at
<http://www.stanford.edu/~epw/mem/faq/> for more information on
getting a medical education.


      6.21  What's the chain of command like?

            The chain of command is very confusing. Donald Anspaugh is the
      Chief of Staff, who is responsible for supervising all the medical
      personnel in the hospital (and he happens to do a lot of surgery for
      someone in this role); David Morganstern was the head of the Department
      of Surgery, which apparently has oversight for the emergency department.
      This makes some sense -- Weaver filled in as the Acting Director of
      Emergency Services after David's heart attack, and this is a title which
      would be in line with this hospital configuration. However, if he was
      the head of the Department of Surgery, there should have been
      someone else who was the Director of Emergency Services.

            If that paragraph gave you a headache, take heart -- I've got one
      too. I doubt that the writers have even figured this out; if one of you
      is reading this right now, please e-mail me <phloem@fumbling.com>, and
      clear this up, because we're very, very confused. If you think you've
      got it figured out, please e-mail me too, because my brain hurts.


 6.3  Emergency medicine: More than you ever wanted to know

      The International Federation of Emergency Medicine (IFEM) was formed a
couple years ago to act as a sort of global board to coordinate and support
the activities of emergency physicians world-wide. It currently has four
member bodies: the American College of Emergency Physicians (ACEP), the
Canadian Association of Emergency Physicians (CAEP), the British Association
of Accident and Emergency Medicine (BAAEM), and the Austroasian College of
Emergency Medicine (ACEM); the current president of IFEM is also ACEP
president Dr. Nancy Auer. Each of these organizations tries to represent
the interests of its members before governments, regional health boards,
insurance companies, and just about anyone who wants a piece of an emerge
doc. They set policies and standards of care: ACEP is very involved in
establishing clinical guidelines in such fields as patient sedation and
analgesia; CAEP has published recommendations on asthma management that
are being accepted internationally. It's not yet really clear what role
IFEM will have in all of this, as it is still in its infancy.
      In the United States, at least, there are three more agencies that
hold sway over the politics of emergency medicine -- the American Academy
of Emergency Medicine (AAEM), the Society for Academic Emergency Medicine
(SAEM), and the American Board of Emergency Medicine (ABEM). We'll go
backwards -- the ABEM is responsible for administering the "board exams" in
emergency medicine: the big, big exam that is almost a requirement for most
teaching positions in the United States and Canada these days. Qualified
doctors apply to write the exams, and about 60% of them pass on an annual
basis.
      The Society for Academic Emergency Medicine is a neat little bunch of
people who are dedicated to furthering the interests of academia and
research in the youngest of the medical specialties. They're a fun group of
folks who like to mumble things about "ANOVA variance" and "chi-square
tests," and are usually desperate for patients to enroll in their studies.
Nevertheless, they do a wonderful job lobbying for funding and promoting
the interests of academic physicians in this discipline.
      AAEM is...strange. Their basic premise seems to be that board
certification is required before you can call yourself an emergency
physician, and I don't have a problem with that. Where I start to have
concerns is when you look at their policy statements, which appear to be
diametrically opposed to ACEP's. It seems, to me at least, that AAEM's method
of setting policy is to do exactly the opposite of whatever it is ACEP is
doing, and engaging in ACEP bashing, which while I'm not going to say isn't
fair (ACEP is not perfect -- none of these groups are), I am going to say
it's counterproductive and probably not very useful in the long term.

      Most of these organizations have official journals and Web sites -- more
on the periodicals later, but here are some of the Web sites:

      * American College of Emergency Physicians
        <http://www.acep.org/>
      * Canadian Association of Emergency Physicians
        <http://www.interchange.ubc.ca/grunfeld/caep.html>
      * Society for Academic Emergency Medicine
        <http://www.saem.org/>
      * American Academy of Emergency Medicine
        <http://www.aaem.org/>
      * American Board of Emergency Medicine
        <http://www.abem.org/>
      * Austroasian College of Emergency Medicine
        <http://www.acem.org.au/>
      * British Association of Accident and Emergency Medicine
        <http://www.baaem.org.uk/>

     There are a lot of web sites out there dedicated to emergency medicine,
too.  A complete list wold exceed the scope of this document; visit
<http://www.yahoo.com/Health/Medicine/Emergency_Medicine/> and follow
the links you'll find there.


 6.4  I want to learn more! Give me something to read!

      The definitive textbook for this specialty is "Emergency Medicine:
Concepts and Clinical Practice," by Peter Rosen, currently in third
edition. Peter is about as close to a god as we get, and his textbook is
very complete and full of useful details. There is a downside to it,
though -- it's a three volume set and not very portable, and like all medical
texts, is horrendously expensive, running anywhere from $350 to $450 (all
prices in 1998 Canadian funds, except where noted).

      Smaller, somewhat cheaper, but by no means inferior is Judith
Tintinalli's "Emergency Medicine: A Comprehensive Study Guide," or as we call
it around here, "Big Red." It's big, and it is red, and it'll cost you
about $210. It's in fourth edition right now, and is an excellent book for
the student, and you can read it on the bus if you feel so inclined to stick
it in your backpack. It has hand reference charts on the inside of the covers
(which feature Large, Friendly Letters on them), good diagrams and pictures,
and a logical, sequential explanation of emergency medicine care. If you only
buy one book, buy this one.

      Even smaller and much cheaper is "Current Emergency Diagnosis and
Treatment." I used to recommend this one first to non-medical folks because
it's pretty accessible, with nifty flowcharts and it was much smaller than
either Rosen or Tintinalli. It's also about $60, but is considerably less
detailed. I also recommend it because it has a whole chapter on emergency
procedures including everything from cutdowns to thoracotomies.
Unfortunately, Charles Saunders, the editor, hasn't put out a new edition
in almost six years, which means this textbook is now out of date. The fifth
edition is due out Real Soon Now, and I suggest you consult the Jargon File
for details on what that means.

      Those are about all you, as a viewer of ER who wants to know more,
should probably have to read. If you have little background in medicine,
anatomy, and physiology, you'll need introductory texts in those fields too.
I highly recommend Appleton and Lange's Current series of clinical manuals,
despite the fact that some of them are out of date -- "Current Medical
Diagnosis and Treatment" is an excellent general medical textbook, updated
yearly, and I've gotten into the habit of buying the current edition.
(Actually, I strongly recommend to any med students and other doctors out
there reading this that you do the same, and pick one text within your
discipline and always buy the latest edition. I pick Rosen, for what it's
worth, though I buy them all sooner or later).

      If you're at all serious about emergency medicine (and even if not and
just want to look cool on the bus), there's a journal you must read:
"Annals of Emergency Medicine," the official journal of ACEP. Individual
subscriptions will run $140USD; paramedics, students, and residents pay
$47USD. It's a very useful journal, most of it well-written covering just
about every branch of emergency medicine over the course of a year. There
are also some nicely done anecdotes about emergency medicine I recommend you
read; MG Hughes' "Wings" from the February 1998 issue for an example of what
life is like on an airevac crew, for example. Annals is published twelve
times a year by Mosby's; see the ACEP Web site for more specific information
on this very cool journal, or see
<http://www1.mosby.com/Mosby/Periodicals/Medical/AEM/em.html> for the
sorta on-line version.

      BasicBooks has published "The Medicine of `ER`"; see section #8.1 for
more information.

      For a briefer look at emergency medicine (also to see the origin of some
of the show`s plot devices), Michael Crichton has re-published his book
"Five Patients".  It should be available at your local bookstore.


 6.5  What do all those medical terms mean?

      The technical reader will, hopefully, forgive me for oversimplifying
things in this section.

    + ABG: Arterial Blood Gas. A lab measurement of, among other things,
      the pH and oxygen concentration of arterial blood; the procedure is
      known as an arterial stick, and trust me, this is one thing I'll never
      tell someone is "just a little prick." It hurts.
    + ACLS: Advanced Cardiac Life Support. A protocol developed back around
      1990 that involves the use of drugs, defibrillators, and sequenced
      flowcharts to correct most cardiac dysrhythmias.
    + AED: Automatic External Defibrillator. "Idiot proof cardioversion."
      Take the pads, pull the adhesive backing off, put them on the patient's
      chest according to the diagram, turn the machine on, push the green
      button and follow the voice prompts. Very simple, very easy. Might save
      a lot of lives; we don't know yet. The data is conflicting.
    + AMA: Against Medical Advice. If I tell you stay put and you leave
      anyway, you're leaving Against Medical Advice. It's pretty
      self-explanatory.
    + Angioplasty: An invasive procedure where a catheter with a balloon
      on the end is inserted into an artery. The balloon is inflated, and the
      catheter withdrawn, kind of like a small plumber's snake. It's a
      procedure done to remove the crap that builds up inside the arteries as
      time goes on, usually after a heart attack, but sometimes for other
      things too.
    + AOB: Alcohol On Breath. Now discouraged in favour of "alcohol-LIKE
      odor on breath." Sure. Uh-huh.
    + Bag 'em: To use a bag-valve mask to ventilate a patient.
    + Bounce-back: Someone who is seen again shortly after being discharged
      from the same department. You'll hear this as a "bounce-back
      [complaint]."
    + BP: Blood Pressure. This is two numbers, like 120/80, that represents
      the pressure inside the arteries during contraction (systole) and
      relaxation (diastole) of the heart, respectively. There are a couple
      ways to take a blood pressure, one involving the use of a stethoscope
      and the other involving the use of your fingers and the artery. (Okay,
      so there's a machine, too. Yeesh.) If it's done the second way, the
      pressure is said to be "120 palp," and there's no diastolic measurement.
      It's not exact, but it'll do in some situations. (Fun fact: Did you know
      that unless the pressure is being taken by a machine, you should never
      have an odd number in a BP? Look at a BP cuff sometime and see if you
      can figure out why this is the case.)
    + "Bradying down": Bradycardia is a slow (<40) heart beat. Bradying down
      is the slowing of the heart rate. See 'tachycardia' for the opposite
      effect.
    + C-Spine: The first seven vertebrae in the spine, going from the base of
      the skull downward; the cervical spine. (C1 through C7, in other words.)
      A cross-table c-spine is a kind of x-ray taken laterally across the body
      to check for fractures of these vertebrae, a common occurance in
      traumatically injured patients.
    + CT/CAT: Computed Tomography/Computerized Axial Tomography. A scanning
      technique that involves x-rays, detectors (instead of film plates),
      and computers to make pretty pictures of the inside of the body. It
      gets a lot of use for things like head injures (because it shows
      intracranial bleeding very nicely), but also sees service in other
      parts of the body. Expensive.
    + CBC: Complete Blood Count. It's the first test most "ER" doctors order
      for the vast majority of their patients, if one is needed. It's pretty
      useful. Tells you lots of nifty stuff, like red and white cell counts,
      hematocrit, hemoglobin, and some determinations calculated from those
      values, because we're mostly too lazy to work it out ourselves, and
      besides, the computer's faster at anyway. Those determinations are the
      mean corpuscular volume (MCV), the mean corpuscular hemoglobin (MCH),
      and the mean corpuscular hemoglobin concentration (MCHC). Some people
      report that they don't get platelets and differential counts with their
      CBCs, but I always seem to get them whether I order them or not, so I
      figure them come free with my tests. :)
    + Chem 7: A blood test to measure blood urea nitrogen (BUN), serum
      chloride (Cl), CO2, creatinine, glucose, serum potassium (K), and serum
      sodium (Na). The logical follow-on to this question is, "Okay, so
      what's in a Chem 20?" Answer (in alphabetical order, as it's listed
      on this lab print-out): albumin, alkaline phosphatase, ALT, AST, BUN,
      serum calcium, serum Cl, CO2, creatinine, two billirubin determinations,
      gamma-GT, glucose, LDH, serum PO4, serum K, serum Na, cholesterol,
      protein, and uric acid. And no, I'm not going to explain what all of
      these are, because it'll take me another 60kb. You can also call these
      tests SMA 7 and SMA 20 at most places, and nobody will look at you
      oddly.
    + CPR: Cardiopulmonary Resuscitation. Go take a course in it. A six hour
      investment might help you save somebody's life someday. If it's been
      more than a year since you've done the course, your ticket has expired.
      Go take another one, and keep taking it every year.
    + Crit: Hematocrit, or the height of red blood cells over the plasma in a
      centrifuged tube, expressed as a percentage. You can probably figure out
      for yourself why this is a useful measurement. (Hint: red blood cells
      carry oxygen to the tissues of the body.)
    + Cross-clamp(ing): The aorta, the main oxygenated artery leading from
      the heart, has two parts one going up and one going down, called the
      ascending and descending aorta respectively. During a thoracotomy, the
      descending aorta can be clamped off to control massive hemorrhage below
      the diaphragm. This process conserves blood while preserving perfusion
      to the heart and brain, but obviously compromises circulation to the
      lower body. It's kind of like putting a big tourniquet on just below
      the costal margin. (See the "what's a rib spreader" question a bit
      later on.)
    + CVA: Cerebrovascular Accident; a stroke. Sometimes called a brain
      attack (I guess by analogy with 'heart attack'), it's a temporary
      blockage of the blood flow to a part of the brain. It may be immediately
      fatal or it may hardly be noticeable at all (or somewhere in between);
      if you hardly notice it, it's called a transient ischemic attack, or
      TIA.
    + CXR: Chest x-ray.
    + D5W: Not a motor oil. (No, that would be 10W30.) 5% dextrose (a sugar)
      in water. Sometimes called "D5." D10W is -- you guessed it -- 10%
      dextrose.
    + DPL: Diagnostic peritoneal lavage. Saline is infused into the
      peritoneum (abdominal cavity, in English), then expelled. The presence
      of blood in the resultant fluid is an indication for laparotomy
      (surgical exploration of the abdomen). It hurts. Sedate before doing.
    + DNR: Do Not Resuscitate. See section 6.7 below.
    + EEG: Electroencephalogram. Graphic representation of brain activity.
      See EKG for its cardiac equivalent.
    + EKG: Electrocardiogram. A lot of early work on this was done in
      Germany, so the "K" is there for what I hope are semi-obvious reasons.
      It's a graphic representation of electrical activity in the heart. A
      proper EKG produces twelve leads, and is sometimes called exactly
      that.
    + EMT: Emergency Medical Technician. A guy with cool toys and a really
      loud horn on his car and who works in one of the least fun
      professions out there. In the United States, EMTs are one step below
      paramedics in terms of training. They can use a whole bunch of stuff
      including oral airways, bag-valve masks, oxygen equipment,
      semi-automatic defibrillators, and can perform some pretty
      complicated patient assessments. Paramedics have neater toys and more
      skills.
    + Foley: A type of indwelling urinary catheter. That description is
      probably all you need.
    + Glasgow Coma Score (or scale, depending on who you talk to): A
      measurement of how conscious and alert someone is. A GCS of 15 is a
      fully alert person (although they may not be oriented); a GCS of 3 is
      someone who is completely unresponsive and unconscious. An intubated
      patient has a maximum GCS of 10. (Properly 10-T, but nobody seems to
      do this anymore.)
    + Gomer: Get Out Of My Emergency Room. A patient you really don't want
      to deal with. Usually elderly, and practically indestructible. More
      generally, those minor, irritating complaints that show up around
      03:30 when you're in the middle of a great dream.
    + Goop: Conductive gel -- that stuff that gets dumped on the paddles of
      the defibrillator before shocking the patient. I swear I am not making
      this up. Used so the person on the receiving end doesn't get the skin
      burned off their chest, which is always really pretty, hurts like hell,
      and smells really bad.
    + GSW: Gunshot wound.
    + Haloperidol: Quite possibly the most useful drug in emergency medicine.
      It's a sedative. Also known as Vitamin H.
    + ICP: Intracranial Pressure. Increased ICP is one of the results of blunt
      trauma to the head, among other things.
    + IV Push: Most intravenous line sets have a port (sometimes more than one
      port) on them that allows medications to be directly administered into
      the blood stream. This gives a more rapid systemic availability of the
      drug than if it were administered intradermally (ID; rarely done),
      intramuscularly (IM) or subcutaneously (SC).
    + Lavage: Washing out. See DPL for a specific example. Another one
      includes gastric lavage in cases of poisoning or upper GI bleeding.
    + LOC: Level Of Consciousness, or Loss Of Consciousness.
    + MI: Myocardial Infarction, sometimes called an AMI (the "A" standing
      for "acute"). Blockage of a coronary artery as a result of plaque
      formation cuts off the oxygen supply to the heart muscle, and causes
      severe pain. It's a heart attack, in other words. See also "TPA" and
      "angioplasty."
    + MRI: Or, to appease John Novak, nMRI. There, are you happy? :)
      (Nuclear) Magnetic Resonance Imaging, something I seem to always get in
      trouble for ordering. It's a type of diagnostic imaging that sucks
      money like you wouldn't believe, but produces some incredible
      pictures. Contemporary MRIs can create images that have a resolution
      that's almost as good as a dissection. Cost: If you thought a CT was
      expensive..
    + MVA: Motor Vehicle Accident. This term has fallen into official disuse
      in favor of MVI (motor vehicle incident), but I still use it, and I
      suspect most people will continue to do so as well.
    + NG tube: Nasogastric tube. Through the nose, into the stomach. It's
      about as much fun as it sounds. In the ED, it's used for gastric
      lavage and emptying.
    + NMB: Neuromuscular blockade. See "RSI" for more information.
    + NS: Normal saline, as opposed to hypotonic or hypertonic saline. 0.9%
      NaCl in distilled and sterile water.
    + O Neg: Type O-Negative blood. Called universal donor because it contains
      no amounts of the common A or B antigen. People with A, B, or O blood
      types will make antibodies to the antigen they don't have (A and/or B),
      so giving O blood won't cause a reaction. The negative relates to the
      Rhesus factor.
    + Pulse Oximetry ("pulse ox"): Arguably one of the most important
      diagnostic tools developed in the past fifteen years, and properly
      "transcutaneous pulse oximetry," it's a non-invasive and painless way
      to measure the oxygen saturation of arterial blood. It gives a pretty
      good indication of how well someone's breathing; normal values for a
      healthy individual will range between about 96 and 100. <90 is not
      good, and <85 is really bad for most people.
    + RSI: Rapid Sequence Intubation (or Induction). The preferred (well,
      it's my favourite) way of intubating a patient in the emergency
      department. It involves the use of paralytic drugs to induce apnea
      (absence of respiration) and to suppress the gag reflex. It's safe, and
      the success rate is really good -- up to 96% success on first attempt
      by most operators.
    + Sinus Rhythm: A normal heart beat and rhythm.
    + Stat: Immediately. I hate this term, and will quite cheerfully smack
      anyone who uses it around me.
    + Sux /sukhs/: Succinylcholine. It's a paralytic, and a drug used in
      rapid sequence intubation, it causes whole-body paralysis rapidly after
      administration. Some people call this Vitamin S.
    + Tachycardia: Rapid heart beat. Sinus tachycardia (normal rhythm, just
      an accelerated beat) is >120 beats/minute; ventricular tachycardia is
      a life-threatening arrhythmia that requires immediate correction (and
      is, along with ventricular fibrillation, a leading cause of death in
      arrest patients).
    + Tox screen: Analysis of blood toxins. May contain a free blood alcohol
      level without your asking for it in some places.
    + TPA: Properly tPA, it stands for Tissue Plasminogen Activator, part of
      a class of drugs known as thrombolytics. If you know anything about how
      biologists name stuff, the word should probably clue you in to what it
      does -- it dissolves clots. It's kinda like Drano for your blood
      vessels. Historically, thrombolytics have been given heart attack
      patients. Recent research, however, has suggested that tPA and other
      thrombolytics may be of value for stroke victims if it's administered
      within six hours of the actual ischemia. Most institutions now have
      guidelines on the administration of thrombolytics (there are others
      besides plasminogen) to MI and CVA patients. Some doctors like
      thrombolytic therapy because it's less expensive, traumatic and
      invasive than surgical interventions like angioplasty. There are
      concerns, however, about bleeding disorders and coagulation problems
      in some patients, so more research is needed. Time will tell how well
      tPA and thrombolytics in general work, but the evidence thus far has
      won them a lot of praise over the years.
    + Tube: Used alone, usually referring to an endotracheal tube. As a
      verb, it means to intubate someone.
    + Turf: To dump a patient to someone else, usually another service. A
      great way of making your day easier.
    + Type and Cross-Match: Blood typing prior to transfusion.

      If I think hard enough about it, I'll include a brief drug reference in
the next update.


 6.6  What's this rib spreader thing, and what's a thoracotomy?

      There's a really cool and incredibly gory picture of one in action at
<http://www.swsahs.nsw.gov.au/livtrauma/education/surgery/cardiac.asp>.
It's far more graphic than anything you're going to see on TV, with the
possible exception of stuff on another TLC program that shall remain
nameless because some people I know are very angry at it right now.
(Subliminal hint: It features operations). I probably could have opened a
chest kit, taken the thing out, put it on a drape and taken a picture, but
it's much more fun to actually see one in action, don't you think?

      For people who are easily offended and don't want to be grossed out, or
who think they may easily lose their lunches, think about what you might see
if you look at the above referenced picture, which demonstrates the operative
repair of a ventricular stab wound. It's sort of what you might have seen
from a better angle during the closing moments of the fourth season finale
when Doug and Mark were working that kid. In terms of gore-factor, think
about where the heart is in relation to the rest of the body and what you'd
have to do to get access to the heart.

      Yeah. Exactly.

      A rib spreader is pretty much what the name implies -- it's a thing you
use to...uh...spread the ribs. In the picture, it's that thing holding the
operative site open, and yes, if you think it looks like it belongs at your
local garage instead of at the hospital, you're not alone. They make a really
interesting noise that I'll never quite be able to forget when you start
cranking -- it's the sound of ribs breaking, and it's not unlike the first
time you do CPR on someone and hear their ribs break. I don't know whether or
not the fact they haven't played it on ER yet is a good thing or a bad thing.

      Anyway, there seems to be something of a running joke on ER: at least
once an episode, someone mentions a rib spreader or asks for it. This is of
specific relevance to emergency medicine, because the rib spreader is a
crucial instrument in what has long been considered our "dramatic as hell"
procedure -- the thoracotomy.

      A thoracotomy is usually performed in a traumatic arrest (cardiac arrest
with a history of trauma, generally penetrating) to gain access to the heart
and great vessels. During this time, you can repair lacerations to the heart
muscle, relieve pericardial tamponade (build-up of fluid in the sac that
surrounds the heart), and also clamp the descending aorta off to control
bleeding below the diaphragm. There's a lot of controversy over how and where
this should be performed, and once it is done, the mortality goes through the
roof. (I should point out right here that traumatic arrests have a horrible
prognosis anyway; penetrating trauma with accompanying arrest and no signs
of life in the field have a virtually zero chance of survival. There's one
case I know of where such a patient survived, but he was hit by a car
literally in front of the hospital, and a paramedic unit happened to be right
there.) There are lots of jokes about thoracotomies, including my favourite,
by Paul Pepe: "The indication for a thoracotomy [at Ben Taub General
Hospital, in Houston] is the inability to refuse it." Dr. Pepe wrote an
article a couple years back about one of his colleagues doing on in the
back of an ambulance (which is in itself interesting, since thoracotomies
require immediate definitive surgical care, but that's not the incredible
part: the patient lived), and he's got a bit of a reputation as being a fan
of the procedure. I should point out this won't happen to you unless something
is really wrong, in the incredibly unlikely event that wasn't immediately
obvious. :)


 6.7  What does "DNR" mean, and when can it be applied?

      Recently, western medicine has been faced with a bit of a dilemma -- as
our population ages, people begin dying from protracted painful illnesses,
things that didn't happen when everybody died young from communicable
diseases. Now, conditions that didn't have a chance to manifest themselves
before are beginning to occur with more prevalence, and if they're terminal,
they tend to be extremely painful.

      One of the fundamental goals of medicine is the relief from suffering,
and to that end, we spend a lot of time working on painkillers and methods
of analgesia. There are some neat ones, like the oral Fentanyl lolly-pops for
patients undergoing chemotherapy, and there are some wonderful drugs out
there to manage pain in just about every kind of case you're going to see.
But suffering is not pain, and pain is not necessarily suffering, so simply
handing out vials of morphine isn't going to relieve suffering.

      Terminal patients suffer, there's no question about that. In the hopes
of relieving their suffering, some have elected to ask their doctors to sign
Do Not Resuscitate orders. A DNR is exactly that -- it is a set of
instructions that govern the management of a patient who is suffering from a
terminal condition. You'll sometimes hear these called "no-codes" or
"no-coders." In plain English, a DNR means "Let me die," but since it is a
medical and legal document, it can't be that simple.

      And the execution of one never is. A DNR isn't a living will, and in
order to be valid (at least in British Columbia), it has to be written, dated
and signed by the issuing physician. Our ambulance crews and ED staff are
instructed to disregard a DNR if there's any question as to whether or not
it's valid. I believe this to be true of just about all DNR policies in
place today. (Put simply, in the absence of contrary instructions from a
physician, you're getting resuscitated. Sorry.) DNRs do not constitute the
withholding of basic life support functions -- like, say, food or water.

      On the alt.tv.er newsgroup, Marny Helfrich writes:

      "It was the episode (Ghosts, I think) where Maggie and Jeanie
      treat an old lady with end stage Lou Gehrig's disease and a
      signed DNR who overdosed on her tricylics (anti-depressent
      medication).  Maggie is in favor of just letting her go since
      she has a DNR and is 'veggie', but Jeannie, who is running the
      case, [well, not really. -ms] says 'Do Not Resuscitate' doesn't
      mean 'Do Not Treat'. (it means no calling a code (if the patient
      arrests), no CPR, no intubation, no shocks, no epi, no thoracotomy,
      etc.) and no extraordinary measures like intubation.  Jeannie also
      says 'We resuscitate suicides.   _All_ suicides.'

      The issue of who is and isn't DNR and what it means comes up a
      lot on the show, actually:

      -- the woman in True Lies with cardiac myopathy who refuses
         treatment and whose daughter has to watch her die.
      -- Jad Heuston in "Whose Appy Now," who wants to be DNR but
         whose mother doesn't want to let him die
      -- Mr. Johnson in "Let the Games Begin" (or "Don't Ask, Don't
         Tell") whose chart they can't find until after Mark has
         already put him on a vent.
      -- The guy in Ambush with the advanced Esophogeal cancer whose
         neighbor paniced and called 911; they didn't know he was DNR
         until the teenage wife came in."


      In reality, the DNR issue is very muddy, and is of particular concern to
emergency workers who often have to make decisions about the management of a
patient without having anything beyond the immediate history. It's only going
to get more complicated and less clear as time goes on.


 6.8  A request

      I mentioned up in the definitions section something about taking a CPR
class. This is probably the single most important thing I can think of that
anyone can do to help save lives. Sudden cardiac arrest affects nearly a
million people around the world every year, and while early defibrillation
is an important step (arguably the most important step), early CPR is
important too. It's six hours that you may never have to use, but if you
take the course and continue to take it annually to keep your ticket
valid, if you ever do have to use it, you'll know how. With the addition of
a first aid course, I think this should be required for all new parents.
Teach your kids how to call for help in an emergency, and encourage them to
learn CPR and first aid when they get old enough.

      And please -- pretty please -- be careful on the roads. Vehicular
trauma is a preventable cause of premature death which really isn't very
pretty. So use your brain, and slow down out there.


 6.9  References, thanks, and further readings

      I've spent the past three months mired in research papers (in addition
to my clinical duties), so writing something I didn't have to reference and
properly document was a nice change. There isn't much to reference here,
actually, because most of it is opinion, experience, and observations
construed as fact. All of this -- and I do mean all of it -- is coming from
my perspective. If you have another one, please let me know and I might
include it in the next update: I'm always willing to swap war stories and
listen to tales about emergency medicine as it's practiced outside of my
universe. And hey, maybe if I'm in your part of the world, we can sit down
and do this over a pint or two, which is the way it's supposed to be done. :)

      The DNR information came from Marny Helfrich and lived in the previous
version of this FAQ section. Details of when to disregard a DNR policy came
from both my local procedures manual and the policies of the British Columbia
Ambulance Service, neither of which you're too likely to run into on
bookshelves. If anyone is interested in some of the arguments surrounding
suffering, I highly recommend Eric Cassall's book "The Nature of Suffering
and the Goals of Medicine." I read this a while ago and it changed the way
I looked at medicine, probably for the better.

      I'd like to thank everyone I met and talked to at the 7th International
Conference on Emergency Medicine, but especially Sarah, who at least had the
good grace to not choke on her beer when I told her some of my stories. I
had a blast, and I'm looking forward to Boston in two years time. To my
co-workers who may find this on the net, thanks for helping to keep me
sane and for making up the best team of doctors, nurses and paramedics I've
ever had the pleasure to work with. You guys kick ass.

      Thanks also to Rose Cooper for entrusting me with this document, which,
now that I think about it, was a pretty silly move. But it's done now. Watch
for the next update to come in a year and a half. :)


      6.91  Flames, comments, additions, disclaimers

            Did I miss something? [Rose "Engineer Scott" Cooper's note: after
      all 'at? Ah canna see how, Capt'n! Ach, mah bairns, mah lovely bairns!].
      Direct your questions, recommendations, and complaints to
      <phloem@fumbling.com>, please. Letter bombs will be returned un-opened.
      I don't give out medical advice over the net, so don't ask. If you feel
      weird, go see your own doctor. Open away from you. 100% digital data;
      contents may have settled during transmission. Bits for rent, enquire
      within. Not for use with some brains, blood types, or hairstyles. File
      size is by weight, not volume [Rose's note: hmmm...]. BHT added as a
      preservative. Do not give nitrates with this product. Anything you do is
      your own fault.

            For Eric, the greatest doctor I ever knew -- irony sucks, man.
      I miss you.


-mike sugimoto, gmd/ss	<phloem@fumbling.com> <http://www.fumbling.com/>




--
Rose "MotherFAQer" Cooper,
Keeper Of The Mostly New And Somewhat Improved ER FAQ
EMAIL: erfaq@digiserve.com    ICQ: 7760005
http://digiserve.com/er/
http://manetheren.cl.msu.edu/~bambam/


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