29 ER Expectations
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Dynamic Chiropractic – August 26, 2008, Vol. 26, Issue 18

ER Expectations

By John Cerf, DC

In classic World War II movies, John Wayne crawled through the mud with a gritty smile as machine-gun fire spit up dirt around him and mortar shells whistled menacingly overhead. Over the years, millions watched those scenes and dreamed jealously of the glory of adventure and hoped of one day serving in that capacity.

In recent years, movies became more realistic. Films like "Platoon," "Full Metal Jacket" and "Apocalypse Now" showed parts of war previously ignored by playwrights. We became aware of the concomitant aggravations, e.g., never-ending rain, bugs, snakes, sleepless nights and soldiers urinating on themselves from fear. These new films educated us that honorable service requires more than dodging bullets, injury and death. There are significant discomforts to consider as well.

While it's easy to belittle discomfort, the toll of discomfort must be considered. Investigators attempted to discover why apartment-fire victims would let go and fall to their deaths just as firefighters were about to reach them. The investigators had test subjects hang from a chin-up bar until they couldn't hold on any longer. The investigators then examined the muscles for evidence of fatigue but found none. They concluded that people let go because of severe discomfort. With only seconds remaining before rescue, they dropped to their deaths because of discomfort. While the discomfort associated with hospital work is not life-threatening, it can be a significant motivator.

In our local newspaper, a classified ad read, "Wanted for hospital staff. Job requires cleaning blood, urine, feces and vomit. Training and uniform included. Salary $9 per hour." Are you ready to sign up? While this advertisement is not part of a search for hospital chiropractors, it is a description of what is in the hospital. Obviously, not every moment in the ER contains something distasteful, but it's best to understand the reality before accepting the challenge.

If, while entering the ER, you notice a nurse's aid is wearing a disposable lab coat and mask, stop breathing immediately. The reason for the mask is not apparent unless you lean in close. Take a deep breath and you will notice the smell of Vicks VapoRub. A trick of the trade is to coat the inside of the mask with the smelly menthol gel to cover the putrid smell of the patient. The smell may be from a homeless drunk who needs to be cleaned up, or worse, from a nursing-home patient who was transferred to the ER upon discovery of an infected maggot infestation.

In the office setting, we can choose to avoid certain patients. You may have asked an occasional patient not to return due to intoxication, unacceptable behavior, inappropriate remarks to your staff, or extreme disregard for personal hygiene. We do not have the same luxury in the ER.

While the chiropractor is not directly involved in most of the extremely nauseating situations, there are times when close proximity is inevitable. A nurse or doctor might suddenly need assistance reaching for supplies or holding a patient for a procedure. A good example of a difficult olfactory insult is when the patient's body has to be opened for a procedure such as placing a chest tube into an empyema. Tumors can drain pussy, smelly fluid. A gangrenous toe with a few maggots can be very difficult to stomach. Of course, if there were many maggots, the toe wound would be clean and it would not smell nearly as bad. It always is good to stand clear when the shoes and socks of a homeless alcoholic are removed.

It's interesting to hear some complain of the smell of burnt flesh. This is an excellent example of the psychological component of aversion to severe injuries. The smell is no different if the burn is to a human or to a steak cooked at home. The physiology of burning is the same for both, and the resulting smell is the same. The difference is in the individual's interpretation. The brain's interpretation of other types of visual, olfactory and auditory stimuli applies similarly.

While it's possible to refuse an ER consultation, odor or other personal disgust is not an acceptable reason. A patient involved in a motor vehicle collision, also might have an accident of a more embarrassing nature. Even if you're not called to consult with such a patient, you can expect to be subjected to the olfactory assault by virtue of having to work within the confines of the department. Unconscious drunks and others with hygiene issues frequently are bedded in the hallway while patients with more serious emergencies are assigned to rooms.

Empathy can be a wonderful quality. One description of the difference between sympathy and empathy involves the analogy of caring for a sick friend. If your friend vomits and you pat them on the back, that is sympathy. If they vomit and it causes you to vomit, you are experiencing empathy. If you tend to experience this type of empathy, the ER could be a dangerous place. The sounds of retching and splashing into plastic emesis basins are common.

Bedpans don't always reach the patient before the diarrhea reaches the bed. Even if the bedpan does get there in time, it still requires transportation back through the hall to the dirty utility room.

While the disgusting aspects of the ER are not constant, they are relatively common. In addition to personal difficulties with noxious stimuli, the practitioner also must consider the dignity of the patient. A chiropractor considering hospital practice needs to be prepared. As with most discomforts of life, we learn to adapt. Being forewarned always is better - especially when considering a change in practice style that involves leaving your pristine office for an environment where you are expected to handle whatever is thrown at you - even if what is thrown at you is something your mother told you never to handle.

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