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Emergentology: The Tools of Our Trade

Walker, Graham MD

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doi: 10.1097/01.EEM.0000459007.11945.6b

    If you've ever waited 45 seconds for the intubation meds to kick in and know how terrifying it is when you click open the laryngoscope blade only to find the light not working...

    If you've ever worked a Saturday night shift where you've done 10 lacerations in a six-hour period and run out of laceration trays...

    If you've ever seen a patient with ear pain and couldn't find a working otoscope...

    ... then you know how helpless we are without our tools.

    None of these scenarios, however, drove home this point more clearly than an accident I came upon about a year ago after a 12-plus-hour-I-can't-wait-to-get-home shift.

    Biking home around 11:30 at night is pretty routine for me. San Francisco has plenty of bike paths, and it's a pretty quiet ride except for a two-block stretch on a very busy street (Oak, if you know it). That night, another cyclist and I saw a car flying down the street going at least 50 miles per hour before running the red light in front of us. We commented to each other how lucky we were that he didn't hit us, talked about idiotic drivers, and waited for the light to turn green.

    Then I noticed a few people on the next block congregating in the street. I muttered an expletive to myself as I focused in on a body in the middle of the road, and instantly knew that the speeding car had struck someone. I sped toward the victim and put down my bike. I asked a few people to stop traffic and another to call 911, and I identified myself as an emergency physician (the blue scrubs were pretty revealing). The woman on the ground was minimally responsive — I calculated a GCS of 9 or 10 — and bleeding from her head and her deformed open-ankle fracture. I started to go into my trauma resuscitation mode.

    I realized, though, I had no IV, no ultrasound, no x-ray, no IV fluids, no labs, no c-collar, and no other team members.

    But I had my stethoscope in my bag and the camera light from my iPhone, so I was able to confirm bilateral breath sounds, see some minimally reactive pupils, and feel some thready pulses. I jaw-thrusted her gurgling tongue out of the way and made sure c-spine precautions were maintained (not that the patient was moving). But I realized that was the extent of my abilities outside the ED. Fire, EMS, and police arrived five minutes later, and I gave them a quick signout, picked up my bike, and pedaled home, numb.

    I hadn't thought much about the incident in quite some time until I recently heard a number of people yelling at each other on my street, which just doesn't happen. It's definitely a busy street (Market, if you know it, too), but besides the muffled tones of cars driving by, there's rarely even a barking dog. I poked my head out the window that day and saw a man on the ground and a crowd of people yelling. I ran the half-block down the street to find a conscious man face down and yelling about his lower back hurting, and I went right back into trauma mode. He certainly looked better than the former patient — talking and yelping in pain but breathing normally and interacting appropriately.

    Traffic was fully stopped waiting for an ambulance to arrive, so I sat down on the street with the man just to talk to him. I asked him what had happened, apologized that the car had hit him, and reassured him that EMS was on its way with lots of pain medicine. I told him what was going to happen once they arrived, from the EMS ride to the ED workup. I told him traumatic injuries like his are my daily job, and I think hearing that an emergency physician was there with him substantially calmed him. His breathing slowed and his voice softened after a minute of speaking calmly to him. I had him focus on a few simple tasks, like wiggling his toes and answering a few simple questions about neck pain and trouble breathing. He asked me how old I was (a good prognostic indicator when the trauma patient can make a Doogie Howser joke), and EMS whisked him away to the trauma center.

    Most of the time, we feel helpless without our tools. (EMS providers, you have a really hard job!) The physical exam can help us diagnose some things, but we can perform few interventions without some pretty basic equipment. Often, I take these supplies for granted, and it wasn't until I was in medical mode but out of my cushy hospital setting that I began to appreciate what a miraculous tool an IV or a laryngoscope was. A simple piece of plastic and a curved piece of metal with a light at the end are vital to emergency medicine.

    But I also learned that I had one more tool in my arsenal: my training and expertise. Being able to confidently and calmly control a situation and talk to an injured or ill person is a vastly powerful medical intervention that I took for granted. Obviously, we can't always be as confident or as sure about a patient or outcome, but when we can, a simple touch and the cool, collected voice of confidence can be as therapeutic as a slug of morphine or Ativan.

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