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Cat Lady

Discussion in 'Emergency Medicine' started by Birdstrike, May 14, 2014.

  1. Birdstrike

    Birdstrike 7+ Year Member

    Dec 19, 2010
    (This is an excerpt from Chapter 11, in the upcoming book, "The Life and Times of John Birdstrike, MD: Ruminations on Hot Dogs and Emergency Medicine. By Birdstrike MD.)

    Cat Lady

    "She talks to angels, they call her out by her name." - Chris Robinson, The Black Crowes.

    The radio crackles alive, “County General...we’ve got a 20-something female……just picked her up…..bagging….we’re at your back door…”

    Boom! They slam through the double doors, and roll into room 8. Lying on the stretcher is a young thin woman. Beneath the mask over her face is a full head of golden wavy hair. I get to the head of the bed, and get ready to intubate her. I grab the bag and mask and start bagging her myself. “What have you given her, so far? Any narcan? D50?” I ask.

    “No,” the paramedic says. “We just scooped her up and had just enough time to get her here and pop an IV in. Just lost pulses a few seconds ago. PEA.”

    “Okay, give her some narcan and D50, while I get ready to intubate. Resume compressions! Etomidate, sux, scope…” roll off my tongue. I look down at the patient’s face again……blond, so young, hair and face like a movie star, except for the pale-bluish dying hue. She reminds me of Cat Woman from the old Batman comics. She’s just about dead and much too young to die. I don’t think I can handle another young patient death this week. I’m filling with dread, not from anything that has to do with the medical “case” in front of me, but because somewhere out there is an unsuspecting mother, husband or child that I’m going to have to tell that she is dead. There’s no way to candy-coat that news, and no matter how many times I do it, it still gives me chills.

    The nurse has just given narcan. She starts to move. Is she trying to breath? I look at her face, it’s pinking up. Did we restrain her before the narcan? Damnit….we didn’t!

    She VIOLENTLY sits up, blasting upwards towards my head, ripping the mask off her face, ripping out her IV and heaves forward. I’m looking straight at the back of her head and torso and she’s heaving forward violently grabbing at her own neck, making an awful guttural noise, contracting rhythmically. That noise, what’s that noise? I’m hearing my cat, she’s trying to vomit. Is this lady trying to gag up a hairball? Cat Lady.


    I look beyond her and the nurses are staring back mortified, at the patient. “Ahhhhhh! Ahhhhhhh! Ahhhhhh!” this Cat Lady is screaming. “I’m dying here! Help me!!! Oh, the pain, s—t, the pain!!!”

    I step around out from the head of the bed to the front of the patient to see what the nurses are looking at, and on the patient’s lap is a big, gooey, mucous-covered ball of something on her lap. Whatever it is, this patient was choking on it, it almost killed her and now she’s alive and well, though ready for vengeance. Why the heck is she screaming, now? This thing, whatever it is, is out of her, and she’s awoken from the dead.

    I pick up the ball of goo and examine it. I start picking it apart. Why do I have to do this, this is disgusting? I should’ve been an accountant. Hairball, I think to myself, laughing a little bit inside. Just like my cat. It seems like a ball of wadded up plastic. What the heck is this thing? There’s writing on the plastic. What is it?

    Is that an.....(read more)



    Last edited: May 14, 2014
    scummie likes this.
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  3. scummie

    scummie 7+ Year Member

    Apr 28, 2009
    P.S. The next time someone comes on here asking about burnout and careers after, you should link to the story in your sig. Just say, "Women's volleyball referee."
  4. Birdstrike

    Birdstrike 7+ Year Member

    Dec 19, 2010
    As much as I would most certainly excel at that position Scummie, one thing you'll learn is that the "Women's Beach Volleyball Ref" job doesn't come open too often. So for now, I still have to deal with patients and "humanity." Though I don't work in an ED specifically, I still work clinically full time. Different setting; same humanity.
    Last edited: May 15, 2014
  5. vengaaqui

    vengaaqui 5+ Year Member

    Sep 21, 2011
    I have a question more about management for this "patient." Why spring for narcan in PEA arrest?
  6. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO. 10+ Year Member

    Aug 21, 2007
    Land of Eternal Summer
    ... why not?

    If youre working a PEA arrest, its kitchen sink time.
  7. Birdstrike

    Birdstrike 7+ Year Member

    Dec 19, 2010
    I write these stories with more of a focus on the human side of things, and less from a scientific/teaching standpoint, but it's always great when they generate some discussion along those lines. Not having any clue where you are from med student to attending, I'll just explain it from the most basic level.

    Using this "patient" as a" hypothetical" example:

    EMS responds to a call for an "unresponsive patient." When they get there, they find a 20-something patient unresponsive with a pulse. (Note that they said they "just picked her up" and "only had enough time to get an IV in" and just lost pulses "seconds ago" while rolling in the door). They were responding to an "unresponsive" patient, initially, and picked her up just down the road, with little time to do much of anything. Your typical EMS protocol is going to have narcan and D50 in there as treatments that can make a comatose patient turn around almost immediately, with little if any downside if the person turns out not to have either opiate OD or hypoglycemia ("can't hurt, might help").

    Narcan and D50 aren't going to be the first thing done to treat PEA; that would be "Airway." In reality, when in the ED as a "team," you try to these things all simultaneously. I'm at the head of the bed bagging, getting ready to intubate, calling out RSI meds, waiting for RT to get there, a nurse is getting meds, a second nurse is walking in to help out with a second IV, etc. Remember, the patient was scooped up down the street and the call came in as "we're at your back door" with an ETA of "now" and no time to prepare. The PEA happened just seconds ago. It's classic EM with the fit hitting the shan, trying to bring order out of the chaos, with a crashing patient cause unknown, and no history at all.

    So, in the few seconds while I'm working on getting an airway going, why not have some narcan and d50 pushed to checked two of the few easily correctable causes of acute altered mental status, particularly a HUGE one in otherwise young and health people (ie, opiate overdose) ?

    So in a good ED where you have multiple members of a team, you hit the ABCs simultaneously, follow your protocols,
    without ignoring your gut feelings and instincts.

    Which in this "patient" was, "I wonder if this isn't a patient immediate post heroin/other-opiate OD, and if it only takes a few seconds without slowing down our ABCs, why not push some narcan now, rather than waiting until the bottom of the ACLS pathway where 'miscellaneous' 'other' and 'the kitchen sink' get thrown in, and you're 15 minutes into chest compressions with a now unsalvageable patient?"

    So my answer is either that (above) or this: "Sometimes you just try s---, and it works." This worked.

    Narcan + quick thinking on the feet + putting the training to work = life saved.

    (I just thought it was a cool story from the standpoint of the bizarre presentation.)
    Last edited: May 16, 2014

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