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See reader questions & answers on this topic! - Help others by sharing your knowledge Archive-name: tv/er-series/medical-jargon Posting-Frequency: monthly URL: http://www.digiserve.com/er/erdex.html 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/ User Contributions:
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ER FAQ 5.00, Section 6: Medical Questions (6/8)
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ER FAQ 5.00, Section 6: Medical Questions (6/8)
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