Monthly Archives: May 2011
The other day, after hearing about the tragedy at Joplin, I wondered what it would have been like to be an ER doc at the hospital that was hit. This is the answer.
Joplin Missouri, A Doctor’s Story
“My name is Dr. Kevin Kikta, and I was one of two emergency room doctors who were on duty at St. John’s Regional Medical Center in Joplin, MO on Sunday, May 22, 2011.
You never know that it will be the most important day of your life until the day is over. The day started like any other day for me: waking up, eating, going to the gym, showering, and going to my 4:00 pm ER shift. As I drove to the hospital I mentally prepared for my shift as I always do, but nothing could ever have prepared me for what was going to happen on this shift. Things were normal for the first hour and half. At approximately 5:30 pm we received a warning that a tornado had been spotted. Although I work in Joplin and went to medical school in Oklahoma, I live in New Jersey, and I have never seen or been in a tornado. I learned that a “code gray” was being called. We were to start bringing patients to safer spots within the ED and hospital.
At 5:42 pm a security guard yelled to everyone, “Take cover! We are about to get hit by a tornado!” I ran with a pregnant RN, Shilo Cook, while others scattered to various places, to the only place that I was familiar with in the hospital without windows, a small doctor’s office in the ED. Together, Shilo and I tremored and huddled under a desk. We heard a loud horrifying sound like a large locomotive ripping through the hospital. The whole hospital shook and vibrated as we heard glass shattering, light bulbs popping, walls collapsing, people screaming, the ceiling caving in above us, and water pipes breaking, showering water down on everything. We suffered this in complete darkness, unaware of anyone else’s status, worried, scared. We could feel a tight pressure in our heads as the tornado annihilated the hospital and the surrounding area. The whole process took about 45 seconds, but seemed like eternity. The hospital had just taken a direct hit from a category EF5 tornado.
Then it was over. Just 45 seconds. 45 long seconds. We looked at each other, terrified, and thanked God that we were alive. We didn’t know, but hoped that it was safe enough to go back out to the ED, find the rest of the staff and patients, and assess our losses.
“Like a bomb went off. ” That’s the only way that I can describe what we saw next. Patients were coming into the ED in droves. It was absolute, utter chaos. They were limping, bleeding, crying, terrified, with debris and glass sticking out of them, just thankful to be alive. The floor was covered with about 3 inches of water, there was no power, not even backup generators, rendering it completely dark and eerie in the ED. The frightening aroma of methane gas leaking from the broken gas lines permeated the air; we knew, but did not dare mention aloud, what that meant. I redoubled my pace.
We had to use flashlights to direct ourselves to the crying and wounded. Where did all the flashlights come from? I’ll never know, but immediately, and thankfully, my years of training in emergency procedures kicked in. There was no power, but our mental generators were up and running, and on high test adrenaline. We had no cell phone service in the first hour, so we were not even able to call for help and backup in the ED.
I remember a patient in his early 20’s gasping for breath, telling me that he was going to die. After a quick exam, I removed the large shard of glass from his back, made the clinical diagnosis of a pneumothorax (collapsed lung) and gathered supplies from wherever I could locate them to insert a thoracostomy tube in him. He was a trooper; I’ll never forget his courage. He allowed me to do this without any local anesthetic since none could be found. With his life threatening injuries I knew he was running out of time, and it had to be done. Quickly. Imagine my relief when I heard a big rush of air, and breath sounds again; fortunately, I was able to get him transported out. I immediately moved on to the next patient, an asthmatic in status asthmaticus. We didn’t even have the option of trying a nebulizer treatment or steroids, but I was able to get him intubated using a flashlight that I held in my mouth. A small child of approximately 3-4 years of age was crying; he had a large avulsion of skin to his neck and spine. The gaping wound revealed his cervical spine and upper thoracic spine bones. I could actually count his vertebrae with my fingers. This was a child, his whole life ahead of him, suffering life threatening wounds in front of me, his eyes pleading me to help him.. We could not find any pediatric C collars in the darkness, and water from the shattered main pipes was once again showering down upon all of us. Fortunately, we were able to get him immobilized with towels, and start an IV with fluids and pain meds before shipping him out. We felt paralyzed and helpless ourselves. I didn’t even know a lot of the RN’s I was working with. They were from departments scattered all over the hospital. It didn’t matter. We worked as a team, determined to save lives. There were no specialists available — my orthopedist was trapped in the OR. We were it, and we knew we had to get patients out of the hospital as quickly as possible. As we were shuffling them out, the fire department showed up and helped us to evacuate. Together we worked furiously, motivated by the knowledge and fear that the methane leaks could cause the hospital could blow up at any minute.
Things were no better outside of the ED. I saw a man crushed under a large SUV, still alive, begging for help; another one was dead, impaled by a street sign through his chest. Wounded people were walking, staggering, all over, dazed and shocked. All around us was chaos, reminding me of scenes in a war movie, or newsreels from bombings in Bagdad. Except this was right in front of me and it had happened in just 45 seconds. My own car was blown away. Gone. Seemingly evaporated. We searched within a half mile radius later that night, but never found the car, only the littered, crumpled remains of former cars. And a John Deere tractor that had blown in from miles away.
Tragedy has a way of revealing human goodness. As I worked, surrounded by devastation and suffering, I realized I was not alone. The people of the community of Joplin were absolutely incredible. Within minutes of the horrific event, local residents showed up in pickups and sport utility vehicles, all offering to help transport the wounded to other facilities, including Freeman, the trauma center literally across the street. Ironically, it had sustained only minimal damage and was functioning (although I’m sure overwhelmed). I carried on, grateful for the help of the community.
Within hours I estimated that over 100 EMS units showed up from various towns, counties and four different states. Considering the circumstances, their response time was miraculous. Roads were blocked with downed utility lines, smashed up cars in piles, and they still made it through.
We continued to carry patients out of the hospital on anything that we could find: sheets, stretchers, broken doors, mattresses, wheelchairs—anything that could be used as a transport mechanism.
As I finished up what I could do at St John’s, I walked with two RN’s, Shilo Cook and Julie Vandorn, to a makeshift MASH center that was being set up miles away at Memorial Hall. We walked where flourishing neighborhoods once stood, astonished to see only the disastrous remains of flattened homes, body parts, and dead people everywhere. I saw a small dog just wimpering in circles over his master who was dead, unaware that his master would not ever play with him again. At one point we tended to a young woman who just stood crying over her dead mother who was crushed by her own home. The young woman covered her mother up with a blanket and then asked all of us, “What should I do?” We had no answer for her, but silence and tears.
By this time news crews and photographers were starting to swarm around, and we were able to get a ride to Memorial Hall from another RN. The chaos was slightly more controlled at Memorial Hall. I was relieved to see many of my colleagues, doctors from every specialty, helping out. It was amazing to be able to see life again. It was also amazing to see how fast workers mobilized to set up this MASH unit under the circumstances. Supplies, food, drink, generators, exam tables, all were there—except pharmaceutical pain meds. I sutured multiple lacerations, and splinted many fractures, including some open with bone exposed, and then intubated another patient with severe COPD, slightly better controlled conditions this time, but still less than optimal.
But we really needed pain meds. I managed to go back to the St John’s with another physician, pharmacist, and a sheriff’s officer. Luckily, security let us in to a highly guarded pharmacy to bring back a garbage bucket sized supply of pain meds.
At about midnight I walked around the parking lot of St. John’s with local law enforcement officers looking for anyone who might be alive or trapped in crushed cars. They spray-painted “X”s on the fortunate vehicles that had been searched without finding anyone inside. The unfortunate vehicles wore “X’s” and sprayed-on numerals, indicating the number of dead inside, crushed in their cars, cars which now resembled flattened recycled aluminum cans the tornado had crumpled in her iron hands, an EF5 tornado, one of the worst in history, whipping through this quiet town with demonic strength. I continued back to Memorial hall into the early morning hours until my ER colleagues told me it was time for me to go home. I was completely exhausted. I had seen enough of my first tornado.
How can one describe these indescribable scenes of destruction? The next day I saw news coverage of this horrible, deadly tornado. It was excellent coverage, and Mike Bettes from the Weather Channel did a great job, but there is nothing that pictures and video can depict compared to seeing it in person. That video will play forever in my mind.
I would like to express my sincerest gratitude to everyone involved in helping during this nightmarish disaster.. My fellow doctors, RN’s, techs, and all of the staff from St. John’s. I have worked at St John’s for approximately 2 years, and I have always been proud to say that I was a physician at St John’s in Joplin, MO. The smart, selfless and immediate response of the professionals and the community during this catastrophe proves to me that St John’s and the surrounding community are special. I am beyond proud.
To the members of this community, the health care workers from states away, and especially Freeman Medical Center, I commend everyone on unselfishly coming together and giving 110% the way that you all did, even in your own time of need. St John’s Regional Medical Center is gone, but her spirit and goodness lives on in each of you.
EMS, you should be proud of yourselves. You were all excellent, and did a great job despite incredible difficulties and against all odds
For all of the injured who I treated, although I do not remember your names (nor would I expect you to remember mine) I will never forget your faces. I’m glad that I was able to make a difference and help in the best way that I knew how, and hopefully give some of you a chance at rebuilding your lives again. For those whom I was not able to get to or treat, I apologize.”
Borrowed from ER Stories
Another hot tune for the summer months. This one is perfect for poolside drinks and sunglasses. The bass is lush and deep, so if you don’t have quality speakers, your missing about half of this track.
There is quite the discussion going on out there on the blogosphere, often heated at times, about “professional” conduct of doctors on the internet. The original post is from 33 charts, but has spilled over onto other blogs such as Scepticemia and Movin’ Meat. All the hullabaloo is based on this series of tweets.
I’ve already outlined how I feel about the discussion of patients on the internet (here) and the standards that I am going to try and hold myself to, so I will just summarize it by saying this: “If you wouldn’t say it in crowded hospital elevator, don’t say it on the internet”. More so than anything, I’m glad to see people are talking about it, and in an impassioned sort of way. For me personally, the discussion made think about what I have been writing about since I posted my own thoughts on the matter back in January. Have I done what I set out to do? Granted I haven’t had many patient experiences since then to serve as potential sources of blog fodder. But, what about my pelvic exam posts? Did they cross any sort of line. I wasn’t talking about specific patients, rather about how I felt during the whole experience, the thoughts going through my head. When I re-read them last night, I made a few small changes to make them sound a little less crass perhaps. And I’m not necessarily looking for an answer to these questions either, rather, what’s more important is to keep these questions in mind when writing. To at least be cognizant of the issue. If we can all do that, that would be a pretty good start.
Interesting article in Scientific American Mind this month.
T. gondii, the cause of toxoplasmosis and the bane of pregnant women and the men who have to change the cat litter, is a pretty amazingly designed bug. It’s a pathogen that sexually reproduces only in the intestines of cats, but can maintain itself indefinitely in pretty much any warm blooded animal. As you likely recall from those exciting ID months in med school, infected cats shed millions of the toxo oocysts in their local litter boxes. From there, they are taken up by all kinds of animal, including humans, and they infect muscle and brain tissue, hiding out and escaping the host’s immune system. But in order to reproduce, they must get back into cats belly’s. But how? How can a simple bug dictate its own course of inter intestinal travel?
Recent research has the answer and its pretty mind blowing (no pun intended).
Toxoplasmosis has been most thoroughly studied in rats and mice. Both species have deep seated, innate fear of cats for obvious reasons. Spray a bit of cat urine into a corner, and the rodent will avoid this location. In contrast, an infected animal loses it innate fear of cats. By some measures, it even appears to be mildly attracted to the smell of felines. This is an unfortunate turn of events for the rodent, because it is now more likely to be successfully hunted by a cat. On the other hand, this is a great deal for T. gondii. When the cat devours the sick critter and its contaminated brain, T. gondii moves into its final host., where it reproduces, completing its life cycle.
And this subtle change in behavior is all that is different with Mr. Rat. For all other intents and purposes, the rat still acts like a rat, unlike in rabies where the rat starts acting like, well a nutjob. But what’s awesome about this, is that since T. gondii can only reproduce in felines, it wants the rat to be attracted to not just any old pee, but specifically cat pee, and only cat pee. Amazing that a little bug can cause this sublte and specific change in behavior in order to promote its own reproduction.
Now what’s also interesting is that schizophrenic patients are two to three times more likely to carry antibodies to T. gondii than controls. Could this bug also cause some of this abhorrent behavior in these patients? Coincidence? Perhaps, as I don’t think the voices are telling them to seek out feline urine samples, but they could be contributing to behavior on some level. The exact link between T. gondii and psychiatric disorders is still unclear.
Looking back, my last Zen post was not really a zen post. Originally, I had intended these posts to have something in them, not necessarily from medicine, that makes you say “That was pretty sweet” after you view it. Clearly a dog talking about a sandwhich is not pretty sweet, but it IS kinda funny. At least I thought so. I will try to keep simply funny posts to a minimum unless I found it literally laugh out loud funny, as those are far and few between on the internet. And everyone can use a laugh. But I enjoy sharing the Zen posts, so hopefully you won’t mind them too much. With that said, the below video is “pretty sweet”. Especially the last minute. I might even upgrade the last minute to “incredible”. It’s better than the speeder chase in Return of the Jedi, and that’s saying a lot.
The Hawk and the the Falcon
Windows were blown out, gurneys tossed up to five blocks away, and 183 patients and about 200 staffers were evacuated. X-rays from St. John’s reportedly were found in driveways in Dade County, Missouri, about 70 miles away.
The building in southwest Joplin stood empty Monday morning, looking as if it had been bombed. Mangled cars had been tossed about the parking lot and strewn in front of the emergency room entrance. The hospital’s medical helicopter lay some distance away from its landing pad, heavily damaged.
While 116 died in the Tornado, there was no information on whether anyone was injured or killed when the tornado struck the hospital.
Full story on CNN
I can only imagine what this would be like working in the ED there. What do you do, knowing that a tornado is bearing down on you, but you have others to worry about? Tough stuff.
This past weekend one of my med school friends got married. It was a great party and we all danced our butts off all night. Naturally, being the end of the year, and with people on the verge of scattering to the four corners of the country, one tends to get a little sentimental. There was definitely more than one occasional of sentimentality this past weekend, but it was well deserved and earned. The people at this wedding the past weekend, were all my closest friends the past 4 years. And hands down they are some of the best people I have had the pleasure of knowing. They are all good and kind people, but all so different in their own ways. Which is probably a tribute to our med school in a way. Our school definitely picks who they accept based on if they are good human beings rather than how they did on their MCATs. We certainly have some brilliant people in our 260 person class, but even the gunners in our class still have a soft spot. It might be a teeny weeny soft spot, located between their bulging muscles, but it’s still there.
So its been a pleasure to know you all and I’m sad that we’re all parting ways, at least for now. But you’ve all made this experience that is med school not too bad, dare I say enjoyable? So I raise my glass to you and wish you the best and hope that our paths will cross again. Slainte!
In thinking about what I wrote, I would still say that about 90% of the pelvic exams I have done to this point were not pleasant experiences. But maybe that’s because most of them were done in the ED. I had FAR more exams there than I did on GYN. Maybe one on GYN. Maybe 5 in a month of family medicine. But easily 1 a day in the ED. And maybe I dislike them because when you are having this exam done in the ED, its usually not a healthy check up. But its part of the job, so you do it, all while trying to make the whole thing as easy as you can for both yourself and the patient.
And looking back, the one place in medical school that I was actually worried about doing pelvic exams was on Labor & Delivery. I couldn’t imagine any women wanting a male med student all up in her business during childbirth. But I was completely surprised that not a single mom to be had a problem with it, regardless of what number birth this was for them or their age. And I fully believe it was because I had a chance to be in the room for a while first, to get to know them a bit and show that I cared about what was going on. The complete opposite of what it was like in planned parenthood, where I just kinda snuck in there unannounced and poked around a bit. Whereas on OB, the women were often joking telling me to get in there and don’t be shy. My favorite patient on OB was this young women probably 20 years old. She was VERY shy at first, wanting me up at the head of the bed when the intern would examine her. It ended up being a false labor, but they came back for the real deal a few nights later. She and her husband were glad to see a friendly face and because I had established rapport with them before, she was all about having me involved this time. She actually requested that I come out of a C-section to help deliver her baby boy and she ended up being the first mom that I delivered solo (granted the attending was 2 inches away, but I did the whole thing). It was one of my favorite experiences from med school and one of the few times where it was actually felt right to be “all up in her business” haha.
I guess the point of this is as well, if you are a female patient, please don’t worry more than you have to about having a male doctor do a pelvic exam. I think I speak for most of us when I say we don’t want to be there any more than you want us there. We’re doing everything we can to not look, to get it over with as soon as possible. We don’t want it to hurt you or to make you feel weird in any way, because that makes US feel weird and uncomfortable. I know those stirrups are uncomfortable. I actually got my own butt up there one day just to see what its like. It wasn’t pleasant and I was fully clothed. I can only imagine what its like for you. When we formally learned how to do them third year, I remember being told “If you can come away from this being able to do it and keep a neutral face, it will have been a complete success” (and not look like the guy below during the exam)
Added airway managment to the clinical skills page. Has a few links to the strong work done by the guys over at LIFTL. Again, thes extra pages are just a collection of useful stuff that I want to be able to quickly find again from other resources on the web. Any suggestions on how to improve these pages is welcome.