Emergency Minute – Tales From The Pit

Introduction and Guest Welcome 0:00

Alright everybody, welcome back to Emergency Minute. I know it's only our second episode of the year, but as you can see behind me, I've been working very hard at putting together some visual effects here for you, doing a visual podcast in addition to the audio podcast that we've been doing. Hard to believe this is episode number 26. Also hard to believe in 25 episodes I've never had a video podcast nor have I had a guest. And today I have both. So very honored to have a guest with us today, another emergency medicine physician.

He and I are going to talk about some tales from The Pit. Yeah, a little bit of a play on words with the show that just came out featuring Noah Wiley with The Pit, which is fantastic. If you haven't had a chance to check that out, you should. However, today, really, we're just going to talk about two ER docs, two veteran ER docs, just talking about some cases that kind of change the way we look at things and some of that. So we have with us today, Dr. Anthony Gwines, who is not only an ER physician, former minister and also private investigator, which crazy background.

So we welcome him to the show and most importantly, the owner and founder of the only scrub company in the United States that has is made in the United States and is also owned all by physicians and nurses. And we're going to get to that a little bit later. But without further ado, Dr. Anthony Gwines, welcome to the show. Yeah, thanks. Wow. Wouldn't honor to be here. I didn't realize I was your first guest. Yeah, absolutely. We're, we're thrilled to have you and um, it's long overdue. It's something I've been wanting to try, uh, but getting a little bit outside of my comfort zone and as far as getting into the visual aspect of podcasting, as well as bringing out some guests, uh, that want to be a part of emergency minute.

And I think that's only proper that the first guest should be in another emergency medicine physician. Wow. Well, I always thought I had a face for radio, but I guess we'll give this a shot. That's fantastic. So you know, Tales from the Pit. It actually reminds me of residency. We would every, I don't know, quarter or so we would have a like a resident. What did you call that? You know, like the residency meeting where all the residents are together with like a weekly kind of like weekly lecture or yeah.

So we had that but every quarter we would do this Tales from the Pit and then the seniors and Attendings would basically each present their interesting cases or usually an insertion or something weird. It was called Tales from the Pit, so that's what it reminded me of. Well, I appreciate you giving me the opportunity to use that title. I do like the title, and I do think it's a great way for us to learn some of the stories that you hear from other physicians. You're like, wow, I probably could have missed that if I wasn't thinking of that or if I didn't hear this story.

I think it's a good way for us to sort of, you know, have that dialogue and help each other because, uh, you know, medicine can be very humbling as I'm sure you are fully aware. Yeah, for sure. And, uh, so I'll, I'll kick it off in the ER, right? No. Yeah, absolutely. The ER will, will, uh, as soon as you think you've got everything figured out, a case comes in that'll, that'll change your life.

Chest Pain Case and Trusting Gestalt 3:02

No doubt. Um, and I, and I, I'll, I'll take the reins here. I wanted to start off with this, uh, this case. I'll never forget this case I had in the emergency room. This definitely has changed my approach to healthcare in general, but I had a lady that was in her 60s who came in with chest pain. Now, the interesting thing about her is that she was a bit of a frequent flyer, and we do see these in the emergency room, and they present very unique challenges, right? Because sometimes it's for a variety of reasons.

Some people do actually have pathology, sometimes people get lonely, sometimes you know people are like the attention. There's a whole lot of reasons why people come to the emergency room, but this is one of those. It's like the hot potato, right? It's like you don't want to be the one that gets stuck with the one time when there's something wrong. Exactly, exactly. And this is one of those cases that's terrifying. So I have this lady, she comes in with chest pain. And I've seen her, the good news is I've seen her a million times in my career.

So I know her very well. I know her history very well. And I worked her up for chest pain. And of course, everything was negative. The EKG was negative. The cardiac enzymes were negative. And so I kind of, you know, but her heart score, and for those of you that are not familiar, a heart score is a way for us to sort of objectively determine know who would be low risk that might be able to go home and like who's medium or high risk that would need to be hospitalized and you know her heart score was definitely positive like she should have been admitted to the hospital so i called the hospitalist who by the way is phenomenal a fantastic hospitalist i don't want this to sound like i'm being negative towards him uh and he you know he was like oh my gosh she's here all the time you know i really don't want to admit her you know, and so we're kind of going round and round.

So long story short, I get a second set of cardiac enzymes and those are still negative, but she's still having pain. And the key for me, and I think the whole crux of this case is, is the clinical gestalt, you know, and you can never, you know, for those of you that are not familiar with gestalt, it's sort of your, it's a fancy word for, you know, your gut feeling. Yeah. And yeah, exactly. And I've seen this lady before I know her and I like it's more than I got feeling. It's like it's the accumulation of years of of you know, experience and you know, those patients that have stuck with you and it's like a collection of all that sort of experience and learning that is just sort of like a general kind of gut feeling, right?

Yeah, no, exactly. And you have to learn to listen to that. I always tell my younger, you know, like my med students and interns, like you have to learn to listen to that because this lady, I know her and she's, you know, she was like, this is not normal for me. This is not my normal chest pain that you usually see me for. And so it was interesting. So I called back to the hospitalist and he's like, Again, I don't want to admit her. Call the cardiologist. I called the cardiologist. He actually came to see her in the emergency room, which kudos to that.

And he did a stat bedside echo knowing that the hospital really didn't want to admit her. Echo is completely normal. So now I have two sets of cardiac enzymes. I have an echocardiogram. uh and then i'm like well what could i be missing something you know am i missing something so i do a ct of her chest looking for like pe you know a blood clot pulmonary embolism x-ray already or yeah yeah yeah x-rays labs everything else was normal so we do the ct angiogram that's negative i'm on my third enzyme and it's still negative so i have three negative enzymes negative cta negative echo and we're coming up on there's no reason not to discharge her at this exactly, which is the whole terrifying thing.

So I, I, we're getting up on discharge or on a shift change is coming up on 7pm. And I know that the the hospital is switch at 7pm as well. And I know that the guy that's coming in, there's not a chance and you know where that he's going to deny this admission if I call him shortly after seven o'clock, this lady's got extensive disease, you know, everything else. So I signed out to my partner, I said, Listen, please admit this lady after seven o'clock. At this point, it was almost seven o'clock and I went home from my shift.

Well, lo and behold, that lady was still in the emergency room. He called and got her admitted, which was great. And while she was in the emergency room, she ended up having ST elevation ended up having an MI. She ended up having a heart attack for those that aren't familiar with that medical term. Uh, and she had a cardiac arrest, uh, in the emergency room that night around eight o'clock. Um, and she would have been home. Yeah. Yeah. And unfortunately she still, she did, she did pass away unfortunately, but I remember coming in the next day.

And that hospitalist came up to me and was like, I will never in my career doubt you or turn away at admission from you because I kept telling him like my gut feeling this is my Gestalt like this lady needs to be admitted. And it's just a terrifying story because how many patients do we see that have you know, negative cardiac enzymes times one times two times three. And then having something like this down the road is, I mean, this is, this is a pretty rare circumstance, but again, medicine can be very humbling and I'll never forget that.

And my message to the, to the students and things like that out there is listen to your, your gestalt. Yeah. Yeah. Yeah. I mean, and how, I mean, it doesn't, it never feels good when, when one of your patients, you know, doesn't make it. But I think when you, when you know that you've done everything possible, it at least gives you a little bit of consolation, you know, that what, I mean, you went, you went above and beyond and did more than any, most of us would have done. And so yeah, kudos to you.

That's yeah. Yeah, from a medical legal standpoint too, if I sent that lady home and she ended up having cardiac arrest and came into the ER as a full arrest, I might as well just call the malpractice attorney myself and just let him know, hey, I just sent this lady home. So it's crazy, very humbling. Do you have any cases that you wanted to share? Yeah, yeah, for sure. So, I have a few in mind. So, I guess I'll let you, I'll let you pick. I've got something, I've got something personal, something off duty, and something that's a little bit funny, a little bit scary.

Let's start with the funny, scary one, but I'm curious to see this off duty one. It wasn't. Yeah, okay. We do funny, scary. So, I was working, I've kind of worked all over my first couple years out of residency. I did this sort of like internal locums thing with one of the big groups where they would send me, it was called special ops. So they would kind of send me to the remote kind of places that were either struggling or they were struggling to find somebody to be there. So I was about four hours outside of the city from the closest city.

It was kind of close to where Kurt Cobain was born in Washington. And so I'm out there remote and So there's no, there's, there's very few specialists out there, but we do have this internist who he's a, he's a British doc and he's an internal medicine, you know, trained, but not specialized, but he sort of functions as a cardiologist in that area. And everybody, I mean, he is just like the best, like the best doctor. Everybody loves him. All the staff love him. The patients love him. And he's been around like forever.

He's a little bit on the older side. And just everybody loves them. And so I'm in the ED at night. And so I'm the only doc there is single coverage. And this place is like super busy, like seven to eight ambulances an hour, you know, in the evening as single coverage, you know, remote. And so just like a wild place. But so he comes in on his own. He comes in with his wife and he tells me and he's there as a patient. And so he tells me that he has a history of AFib, which I didn't know that. I think, no, no, it was a history of SVT.

So he had a history of SVT. I never knew that, but he was in SVT when he got there. And he said, he said, you know, I tried to take care of it myself. I tried to take some Diltiazem at home, which I don't know if he was on that normally, but He's like, I took 120 milligrams of dill this morning and still, you know, I've been feeling, you know, feeling like I've been in SVT all day and it's just not, you know, not getting any better. So I figure I had to come in and, you know, get some, you know, Now I'm blanking on what we give for for SVT.

SVT Episode and the Delayed Adenosine Pause 11:30

But, you know, basically like where we start some adenosine maybe. Yeah. Yeah. Yeah. So you came in to get some adenosine. And so I was like, you know, adenosine, it's nothing. You just squirt it in quick. And usually, you know, it resolves. And so we assembled the team. We had everybody together, you know, we put the pacer pads on just to just in case. I don't know about you, but I normally start with like the full dose. I just start with 12 to begin with, because I figure why why mess around with six?

Just give the photos and, you know, hopefully resolve it in one. And so, you know, we're all together. We're all kind of gather around. He's in he's in like one of our main kind of recess rooms. And the team is there. And again, this is like everybody's favorite doctor. I mean, everybody just like loves us loves this guy to death. And but it's such a, you know, it's a relatively simple, you know, procedure that we do right frequently. And so we, so we push the adenosine and I guess I hadn't fully thought through like maybe what effect the dilt might be having still or whatever.

Because normally, you know, you push adenosine, you'll see like a three second or maybe a five second pause and then, you know, it'll just restart in normal sinus and you're good to go. So, but this time we push the adenosine, we wait, you know, there's a pause. And then there's more, more paws felt like, I mean, it must've been like 30 seconds. Probably felt like an hour and nobody wanted to say anything. We were all just like looking around like you just, you just killed doctor, you know, like our favorite doctor, what'd you do?

And then, you know, then finally, you know, we saw that first beat and then started like slowly and then, you know, kind of just came back to normal sinus rhythm and we all kind of breathed a big sigh of relief and then then it was like oh my god I thought you killed doctor you know so and so and so um and then when he woke when he came back you know when he woke up we kind of told him what happened and it was kind of a big sort of joke and it all turned out fine but uh it was it was funny well I can tell you I've been there before yeah haven't been there before where you're, everybody's looking around in the room like, okay, uh, yeah, five seconds.

Uh, how long is this pause before it restarts, right? Like it's going to restart, right? It feels like a lifetime. Yeah, that's funny. Um, that, um, it reminds me, um, of a case that I had that once where, a patient came in by squad and I took the squad call. I'm not really sure why I just happened to take this call and they're like, oh yeah, you know, freaking flyer, you know, guys coming in with back pain, you know, I'm sure he wants pain meds or whatever. And I'm just like, whatever, I take the call, I hang up.

And then I'm doing my work and you know, there's other patients in the emergency room, it's pretty busy. And I watched this guy go sailing by on the gurney. And I'm like, that's the back pain guy. I'm like, something's wrong with that guy. Like you can just tell, you know, there's like a, you know, as an ER physician, you can kind of just look at someone and be like, something's wrong. Something's seriously wrong with this person. And so, uh, it's called the LLS score. Have you heard of that? No, what's that?

LLS, it's the looks like shit score. It's either a zero or a one. Fair enough. Well, this guy's definitely positive LLS score then. That's funny. I got to use that one. I think that was Scott Weinhart's. I think that was Scott Weinhart's. Okay. I like that. I like that. So yeah, so there was definitely something wrong with this guy. So I just kind of yell over to the nurses. I'm like, hey, hook him up to the monitor. Let's just see what's going on. I'm finishing something else at the time. So they hook them up to the monitor and I'm able to see like where I'm working, like my workstation.

I'm able to see like some things I'm like working on these patients and like discharging somebody or something. And I kind of look up and I'm like, somebody is a non-sustained VTAC. Like someone's keep and I'm like, that's, is that the back pain guy? And I'm like, Oh boy, I gotta go over there. So I go over and see this patient and you know, he's got this, you know, that look of doom in his face, which I'm sure, I'm sure you've seen before. Uh, patients will oftentimes when they're under, you know, some type of really bad thing happening to them, just have that look of just like doom and impending doom.

And you're like, okay, yeah, this is real. Like, let's, let's see if we can figure this out very quickly. And, um, same way. What's that? Then you start feeling the same way. Exactly. Then you have the, the impending doom. So we started, um, working this guy up and his EKG was abnormal. He was throwing all kinds of ectopic beats and little short runs of non-sustained B tech. said he really couldn't feel much with his like toes and he was having like some spotty vision. His arms were numb. Like he just kind of like had like just complete all over symptoms.

So we ended up sending him over from a basically pan scan with a CTA of the chest and abdomen. Uh, and like he, I, I don't know that I could quantify like how many P E's he had. And the best way the radiologist described it is he's like, just imagine a shower of emboli everywhere. Wow.

Back Pain That Turned Into Massive Pulmonary Emboli 16:48

And so we ended up, um, I ended up putting him on amiodarone because he was throwing all these beats everywhere. We heparanized him and we life flighted him. We're just a small community hospital. So we life flighted him to a hospital in Toledo. And, um, you know, he ended up being seen by like vascular and he had a prolonged hospital stay. But at the end of the day, they never really figured out why he had this like shower of emboli. And, uh, he, they were, they were clots or they were septic emboli?

No, just, just clots. Yeah, just clots. And so he, you know, he's till this day, he's still on blood thinners, really his only deficit. is that he had some decreased vision, uh, but really overall turned out pretty well considering like what could have happened. And for like the longest time he used to come, uh, every year around that time, like when, when I saw him and he used to bring donuts to me into the, to the department. And, uh, you know, my, my take home message on that was always like, you know, our paramedics, you know, do a great job and this is not meant to be disparaging towards them, but when someone gives you a report and they try to downplay something or anything else, man, you just never know.

And, uh, I just, I'll never forget that case. Cause it was just so bizarre seeing this guy with, you know, quote, quote, unquote, chronic back pain going into VTAC and the, you know, I'm watching them drive by it. I'm like, uh, something's not right with this guy. So it was a kind of a crazy case that, uh, that I had that I wanted to share. Um, because I think sometimes we get, yeah, exactly. Sometimes you, uh, sometimes you get taken down the wrong pathway, whether it's yourself, the patient, the nurse, the paramedic in this case kind of leading you down this pathway like, Oh, this guy just needs some pain meds and let's get them out of here.

You know, whatever. Uh, but sometimes, uh, you know, bad things happen to people, unfortunately. Yeah, wow. When I was telling you the story about the internist, it made me think of a couple other cases I hadn't planned. These are just really quick, but just interesting when you're out in the middle of nowhere like that, some things that happen. We had one guy who was, I think he was like 95, lived in a trailer park. And again, this is kind of where Kurt Cobain was born. So it's a very remote, just like depressed kind of community and lots of weird things happen, lots of drugs.

crazy things as you can imagine. And so this guy was 95 and he came in and he had been alone at night. He lived in a trailer and there was a young girl who was I think like in her 20s and she was high on meth and she for some reason got in her head that this old man had kidnapped this missing girl who had been missing in the community for like years and years and everyone talked about her a lot. and got in her head that he had kidnapped her, this 95-year-old guy who's just asleep in his trailer.

So she breaks into his trailer with a hatchet and just starts hitting him in the head with this hatchet. And so he comes in with these hatchet injuries from this young girl and it's just this old man just like asleep in his trailer. And he actually did fine. He did okay. Like we were able to ship him out to the trauma center and he did all right, but just like crazy story. And then there was one more where there was a frequent flyer kind of like how you shared this lady who, you know, it was probably in her forties and just had problems with like drugs and alcohol.

So she would come in quite frequently with like really high alcohol level and would just metabolize. But we all knew her, she was like very nice. Everybody kind of, you know, we kind of, everyone sort of felt bad for her. It wasn't like, she wasn't like a burden or anything like that. It was just, we like, we saw her all the time. But so there's this one night, it was like three in the morning when I'm there again, kind of single coverage and she gets brought in on an ambulance and she had gotten high and drunk and for some reason like fell asleep on the railroad tracks.

There's a train that kind of comes through town. and falling asleep on the railroad track with her legs like across the tracks and you know basically just amputated both legs above the knee when the train ran over her but every but other than that she's like totally fine so she's you know comes in on the ambulance with both legs amputated and like you know horrible pain not like actually not bleeding a whole lot and We, you know, we tourniqueted her, put her on a helicopter, went to the trauma center.

Again, she did fine, but we, we never saw her again. I mean, because we put her on a helicopter, you know, four hours away and I'm assuming she ended up, you know, having to go to a rehab and nursing home and never, never saw her in the ER again. Probably ended up staying there locally at one of their rehab centers or who knows? Oh my gosh. That's crazy. Yeah. Wild stuff out there. Well, you know, one of the reasons why I wanted to have you on this show is I am very impressed and I love this concept of soleil scrubs.

So I wanted to give you the opportunity to tell our, you know, the members of the show here, tell us a little bit about soleil scrubs. I am wearing some right here. Got to do the selfish plug here. I wear them at home, love them. They're super comfortable. My wife loves them. She's like, Oh, those are real nice. Those are soft. So tell us, just give us a brief story about Soleil scrubs. I think this is a fantastic concept. That was quite a segue. That's quite a segue going from a double amputation to Soleil.

That's the ER. That's the ER typical year. Yeah, so I'm an ER doctor, but my wife, Beth, is a nurse. And a couple years ago, we had always just worn kind of whatever, normal kind of scrubs. And at the end of COVID, she had been home for like 10 years with the kids, because we have four kids. And she basically took the time when I was in med school and residency.

Soleil Scrubs Story and Product Philosophy 22:48

Kind of, you know, was managing the household and so it took some time off work. But then a couple years ago decided to go that it was time for her to go back to work as a nurse. And so she tried on all the different scrubs from the different scrubs companies and. um was just feeling really frustrated and kind of disappointed of like you know she tried this one on and it was like too tight this one just like looked weird and she had just kind of gotten used to wearing comfortable clothes all the time and not having to be stuck in in scrubs you know and um And about the same time, during COVID, I had sort of gotten a little bit more interested in men's fashion and looking good and dressing nice and was just feeling like, man, why do scrubs look, why do they just look so bad?

So not stylish. And so as Beth was getting frustrated with all the scrubs, there was one night where she was like, how is it that in 10 years, scrubs haven't improved at all? changed at all. Like Figs was the last scrubs brand to really change anything. And they came out, you know, 13, 14 years ago. And really no innovation since then. And then she said, she was like, like, why can't I just wear Viori to work? you know, like Viori or Lululemon to something that's like really soft and right, right.

That's kind of what she had gotten used to wearing, you know, during COVID. And so we got to talking and we were just thinking like, well, wait, like, why can't we wear comfortable, like stylish clothes to work? Like, there's no reason why scrubs need to be made of like bed sheets and, you know, look at and so bad sheets. So true. And so, yeah, so we basically had the idea of take what's been done in kind of the world of performance apparel, like, you know, athleisure type brands like Viori and Lululemon and wanted to start a scrubs brand that kind of brought that kind of style and comfort and brought it into the world of scrubs.

And so that's how we started Soleil. But such a great story and I couldn't agree with you more. Anybody who's ever worn scrubs knows that they're, you know, they're all they're all basically trash. You know, we wear them all the time. They feel like sandpaper. And it's one of those things that you don't really think about. But now I think about it all the time because I have Soleil and I'm like, I'm wearing it. it's a game changer. And now I've got some nurses that I work with. They're like, oh, I got to have the soleil scrubs on now.

And so it's really cool to see. And I think there's definitely that niche of people that are out there like us that work really hard and want to be comfortable at work. Like who doesn't want to be comfortable at work? So I think it's a fantastic concept. And so I'm glad that uh you know my first sort of uh sponsorship uh of the show is is here today with Soleil Scrubs and I love the fact obviously made in the United States which is huge uh but even more so owned 100% by physicians and nurses which I think you know is really cool.

I think it's a really cool touch. Yeah, yeah, I mean, I think we just, you know, from talking to people and everything, you know, all the different styles and things that we have, it's all been developed, like with the people that we work with, and they're trying stuff out and giving us ideas and giving us, you know, feedback on what styles they'd like to see and what colors and what features and we just you know are trying to make something that like all of us wish that all of us wish that we had basically you know so like like for me I would always be annoyed because my pockets like my cargo pockets which is where I put my stethoscope like you know it's always like a little bit too low so your stethoscope is just rubbing on your knee the whole shift right so we just like you know we put our cargo pockets up a little bit higher pocket like sags when you put your badge clip on it.

So, we've, you know, put a stitch there so that your pocket doesn't sag and there's so many of these like little things that just like what we do is hard enough, you know. So, what can we do in terms of what we're wearing to like just kind of help us be, you know, happier and more relaxed and yeah, I mean, first time I've ever worn scrubs, we're in the middle of a shift. I'll either, you know, I'll look down and be like, man, these are like These are so soft. It's like they feel so good or or it's like someone like rubbing on my arm or something because it's so soft and uncomfortable.

And it's just like, yeah, it's like what we do is hard enough. So it's nice to be able to wear something that like makes us feel good. Yeah, I definitely get that with my shifts now, especially because I moonlighted a couple of different hospitals where people are like, what are you wearing? That looks nice. That looks good. That looks soft and comfortable. Like, yeah, Yeah, it is. So definitely. Well, and they look good. I mean, we you know, we are able to because we don't we don't you know, we're not a huge brand.

So we're able to take our time developing the styles. And, you know, they go through, you know, six, seven rounds of prototypes and having people try them like on shift and tell us what what fits good, what doesn't fit good. And so we try to take time to just like really get it get it perfect. And we want to look good and feel good. And It's worth the time. They're not the cheapest scrubs in the world. They're probably some of the most expensive, but it's worth it. Yeah, I completely agree. And to anybody out there that is interested, we're going to put a link on the show itself here.

And you can use the discount code drjparente20 and get yourself 20% off. And I feel like Solea is constantly giving away, you know, free, you know, discounts and things like that every time since I bought a few sets myself, of course, I do get a lot of emails like an opportunity like, hey, you know, if you leave us a review or you know, there's different ways that you can even knock that price down a little bit more. So I definitely encourage the listeners to give it a try. I don't think you're going to be disappointed.

I've in fact, all the nurses that have bought the scrubs already have told me that they, they love it and they're going to have a hard, I think we ruined them because now they're going to have a hard time going back to the other, to the other paper, you know, the sandpaper scrubs. So, you know, every time, every time what happens is we, we get a new, we have a new customer. They'll buy one because they've, they've heard about it from a friend or saw an ad or something. And then, you know, about, without fail, it's like about two weeks later, we'll get another order for like three or four sets because it's like once they feel it, it's like, you know, or, or it's maybe like after four weeks where they're tired of washing it, like after every shift because they want to rewear it every, you know, every shift instead of their other scrubs.

And so they kind of break down and buy more and it's, it's what we see and it's, you know, it's, it's encouraging for us to know that people love it. So. Well, good. Yeah. I definitely want to encourage the listeners to support a locally owned company that's, uh, you know, new, uh, new to the ball game and owned 100% by healthcare professionals. I think that is, you know, crucial. So I'm glad to obviously have you here on the show. I did want to talk about a couple more cases here before we wrap things up.

Um, I wanted to talk about, uh, this is sort of an ironic case more than anything. Uh, and I, I always talk to my residents, uh, and my medical students about the, uh, the fear and the, and the danger of crying wolf, right? There's we've all heard that story since we were, you know, five years old. Uh, and I had a lady that, uh, used to come to see us all the time, uh, probably about three days a week. And she was very nice, very pleasant. And she had this like migraine headache and she'd come in, like I said, three days a week.

And she had like sort of a standing order. I think her, I think she was getting like state all and Fenergan or something like some weird. narcotic thing that was used 100 years ago that we hardly ever use nowadays. Um, and you know, I don't love giving narcotics for headaches, uh, because for a whole litany of reasons. However, in this particular case, she had this set up with her primary care physician. This was like her standing order. She came in, she was pleasant. She was always nice with the staff.

She got her treatment. She went home and like it just was what it was. Uh, and you never believe what she ended up dying from. She ended up coming into our ER. unresponsive from an intracranial hemorrhage from a brain bleed and it just shows you that you know and I'm not saying she was crying wolf but she was in the ER three days a week with a severe headache and one time she came in know with a severe headache and she had an intracranial hemorrhage a brain bleed and so you know she had had she had had probably she had been there before I mean oh yeah she had been there in the last day or two and then came back yeah yeah she and she would come back and she she probably had without exaggeration 50 cat scans you know of her brain um that were all negative until the final one, which was positive, of course.

So I use this story to teach the students and the residents that, look, there's a reason why ESI levels exist for nurses. If someone comes in with chest pain or headache or any other complaint, really, you have to approach it as if this is the first time you've ever seen them.

Frequent Flyer Headache That Became a Brain Bleed 31:48

And it's hard because when you get someone that's come to the ER multiple times for the same complaint, you know, it's kind of easy to get down that road where you're like, oh, it's just, you know, this is just, you know, Bobby or whoever, and they're just here with their normal chest pain or whatever. So, this case always resonates with me because, you know, obviously even though she came in a thousand times for her headache, that was the thing that ultimately led to her her demise. So, yeah. Man, you've got no shortage of scary cases.

I know, right? These will terrify you, keep you up at night as another ER physician. But good cases to learn from. Yeah. I want to hear about this case of you off duty. I want to hear this one off duty. OK, all right. Well, so yeah, it's really interesting to me. So my like when I think back, you know, I mean, I've been I don't think I've been doing this quite as long as you because I had like a career change. But when I think back about the patients that had sort of the biggest impact on me, I mean, other than my own one of my own kids, that's the personal one.

But When I think back about the patient that had the biggest impact on me, it's ironic that it was a patient that was when I wasn't even working, I was off shift. And so what happened is this was back when I was working for that big corporate group and I was out in a remote location different than the Kurt Cobain spot. It was right around Christmas, I remember it was, It was I do. I'm in this like neighborhood poker group. And so the reason I can remember when this was is because it was our last is our last poker party before Christmas.

And so this was this was before the pandemic. Um, it was our last poker party before Christmas. And so I had finished my shift. It was like a 12 hour shift, a couple hours outside of the city. And I was on my way, on my way from my shift to this, to my poker party. And so I'm driving on the freeway. I was probably 40 minutes from, I'm in, I live in Seattle. So it's about 40 minutes out of the city. And as I'm driving on the freeway, kind of normal traffic and then it slowed down kind of a little bit, but this is in the afternoon, like a not quite rush hour, but like maybe a little bit after rush hour, I think.

But traffic started to slow down a little bit, but like kind of right in front of me, it slowed down. But there was nothing, nothing really happening. It was just kind of slowed down. And so as I'm driving, I'm in the fast lane and I look over and I see a motorcycle that's just like down on its side on the like on the shoulder of the freeway. But other than that, like everything's normal. It's just traffic slowed down a bit. I saw this motorcycle lying down and I just like I thought, you know, I should probably pull over and just like make sure that everybody's OK because you know who knows who knows what so I just pulled over on the shoulder you know by the time I pulled over I was like maybe a couple blocks down the um down the freeway and I get out and I start kind of walking back towards where the the motorcycle was and on the freeway here there was Like a really big median like maybe like 30 feet between the other side of the freeway and our sideline is all like so it's like our our freeway was up here.

The opposing was down here and so then there was this like grass median that was like a hill going down. So as I'm walking back to where the down motorcycle was, I see this guy on the median that's waving like, hey, come over here, over here, over here. And so then I'm like, oh, shit, something happened. And so I start running towards this guy. And then by the time I get there, the person who had been on the motorcycle was laying. He was down on the median, on his back, kind of laying sideways, cattywampus down the median but his head is like down like this and the guy that had been waving was down at his head and just basically like holding his head you know stable like this and um the guy is is like barely breathing And as I kind of see what's going on, the guy that's holding his head is like, hey, you know, I'm an ER nurse.

I just stopped like the same time as you and ran over here. And I look at the motorcyclist and his right arm is gone. So like about here, his left leg is gone right like at the thigh, like above the knee. And he just has like kind of like gasping, respirations, like not making a sound, not moaning, like he's just kind of like barely breathing. And this nurse is like, the nurse was there first, I was there second. He was an ER nurse that was like on the other side of the freeway. And he had seen the he had seen the motorcyclist hit the median and then kind of fly through that.

He saw him flying through the air and then landed on the on the median. And so we're basically, you know, we're like his girlfriend was calling 911. He was holding C spine. We were trying to just decide, what do we do? I didn't have a tourniquet with me. He didn't have anything with him. But then gradually, this was maybe over 10 minutes or so, people started coming over and seeing what was happening. And someone showed up that had a little jump kit with him. Not a paramedic, but just someone that was driving by.

And they handed me a tourniquet, like a cat tourniquet. So I put the tourniquet on his arm. And at the same time, someone had another tourniquet. And this is just all these, because it's rush hour, people are just showing up. And so I got a tourniquet on his arm. I got a tourniquet on his leg, weaving it. So at one point, talked about, do we try to digitally intubate him? Because someone had an intubation sort of kit, but not a laryngoscope, but just a tube. And we're like, he's breathing. We just sort of continued holding C-spine tourniquet.

I wrote the times on the tourniquets. And so then after about like 10 minutes, an ambulance pulls up and they just kind of like scoop them up really quick.

Off-Duty Motorcycle Trauma and Saving a Life 38:08

And I ask them, like, hey, where are you guys taking them? And they're taking them to Harborview, which is like our trauma center. And so it turns out that, so I knew somebody that was on shift at Harborview at the time. And so I was like, kind of texting with them to see what was going on. And it turns out that as they were, as the ambulance was pulling up to the hospital, he like, he died and he coded. um as they were pulling up and so they brought him inside you know it's one of those rare times like you know like we never almost never like crack someone's chest in the er anymore but he had like it was in the like in the trauma bay where he you know coded and so they um cracked open his chest they massaged his heart they brought him back to life um ended up having like 17 surgeries um in the hospital you know over a few weeks and months And then I got a call from the fire department, maybe, I don't know.

two or three months later. Um, and they invited me and the nurse back to the fire department to meet the guy, you know? And so it turns out that he, like, he was a young guy, like in his thirties, um, has like four kids, same as me. And ended up after that whole, you know, dying 17, 18 surgeries, he was completely like totally fine. He was missing his arm. He was missing his leg, but like completely neurologically intact, um, was completely amnestic to like anything that happened before the accident, anything that happened in the hospital, like didn't remember any of that.

I guess he had woken up at one point in the hospital and told his wife what had happened. But then when he woke up again, he could, he didn't remember any of it. Um, but completely like totally fine that the fire department actually gave us like a service award type thing and we got to meet him and take pictures with him and we've gotten together for lunch or breakfast a couple times since and so pretty and just like totally random kind of coincidence that I just happened to see the motorcycle and pull over.

But if we had, you know, if we hadn't have tourniqueted him, I mean, yeah, he would have died too. He would have died too soon and they couldn't, there was nothing they could have done. So, um, what a crazy case. My goodness, man, when we were talking about preparing for the show, I didn't know you're going to bring me that heavy hitter. I feel, I feel I'm talking about headaches and stuff over here. You got, Actually saving lives. That's awesome. That is great. So now every time. And then, so then after that, I show up at the poker party and I'm like, I was like, guys, you will not believe what like what happened to me on my way here.

They're like, yeah, whatever. Sure. Sure. Every poker party, we end up talking about that now. Wow. What a crazy. That is a crazy story and I don't know what the rate is. Do you know what the rate is for people that walk out of a hospital that undergo a emergent thoracotomy? Less than 5%. Yeah, it's probably less than 1%. I would imagine, but holy cow. What a cool story. Well, I appreciate you sharing that one. You you drop the teaser on taking care of one of your kids. Yeah, do you want to talk about that or is that is that too personal?

Oh no, I'll be good case to end on. Well, like I said, you know, like you said at the beginning, you know, I have not been, I haven't been an ER doctor forever. I had a kind of a previous life where I was a minister. And so I was like, I was essentially like, you know, I was an evangelical fundamentalist minister had been to been to seminary. We actually were missionaries overseas for a couple of years in India and Pakistan. And at this point, it was we had come back. Our oldest had been born overseas when we were in India.

And so I was I was a pastor at the at the church in Southern California. We were living like in the parsonage of the church. So it's like a little house that the church owns where where you stay in. And that's sort of like one of the fringe benefits of of working in the church because you're not making that much money. So Josiah, who's our oldest, he was about I think he was like, I'd have been like three years old, I think, at the time. This was like, it was after work. We were, we were home in the, in the parsonage and he was like, he was sick with just like a, like a cold or something like that.

Yeah, I think he was three. And so he had a fever, and so Beth, she's a nurse, she was just trying to work to get his fever down a little bit. And not that you need to get someone's fever down, but at the time, we thought, oh, he's got a fever, we should try to get it down. So she had him like in a kind of like a lukewarm bath and had given him some Tylenol and was trying to get his fever down. And again, like at this point, I had no medical background whatsoever. I never had any intention of being a doctor.

I had flunked out of biology in college like three times. Like biology for non-science majors had flunked out of that three times. So like no medical knowledge whatsoever. And so Josiah is in the, bath like just trying to get and Beth's trying to help him get his fever down and he like all of a sudden starts like shaking like basically like having convulsions and so she um remember she brings uh Josiah um sorry that's okay she um So she brings Josiah out to me and she is like, she's like wanting me to hold him so that she can call 911. And so she gives them to me and I'm holding Josiah and she's calling 911 and kind of.

telling them what's happening. I have no clue what's happening. I just know that he's convulsing. At this point, I'm holding him and he stopped breathing. And so his lips are turning blue. I think that he's dying. And I remember as she's calling 911, And I've been a pastor for quite a number of years, and we've been overseas. But I remember the thought in my head of thinking, God, if something happens to my son, fuck you. I'm done with this. I'm done being a pastor. I'm done with all this. I'm just sort of totally done with it, whatever.

And so then, obviously, it ends up, he's fine. We go to the ER. you know, it was like, it was a febrile seizure, not like super common, not a huge deal. And he was totally fine. But I was kind of like, I think I was left at the time with like, you know, I think that, I think that I probably don't believe in this, like, I don't believe in this as much as I thought I did. And so it was sort of like the beginning for me of a process of, Yeah, just kind of like rethinking my faith and what I wanted to do with my life.

And eventually, like after a couple of years, decided that, you know, rather than being in the church and doing that, that I wanted to do something that was gonna be like, you know, helping people more in like a real life way. And so that was when I decided to like go, you know, become a doctor and go to medical school. And what's interesting is so like every and so now, you know, in the ER, like we see febrile seizure patients, like, quite often, you know, like, you know, at least, I don't know, once every few months.

Yeah. But every time like every time without fail when I have a febrile seizure patient, I mean, I love it. It's very like, you know, gratifying and fulfilling, but I'll always tell the parents that story, you know, and they appreciate it. But then, you know, I also like I also end up crying every time I tell them a story because it definitely hits, you know, close to home. But um, but it's really good because it's you know, something we see a lot and it had a big impact on me and it's nice to be able to like help families that are kind of like in that same situation, you know, so.

Wow. Man, I did not see this coming on the back end of the show here. That is a, what an amazing story that is and kind of propelling you into your career as a, as an emergency medicine physician. And I, you know, kudos to you because, you know, we kind of fall guilty in the ER. I mean, we have to build some walls, right? We have to build some level of separation between ourselves and the patients. And so we don't care too much. We still care, of course, a lot, but you can't like take this type of stuff home with you.

So I feel like with febrile seizures, you're kind of like, yeah, it's just febrile seizure. Your kid will be fine. Like, you know, here's your Tylenol, you know, that kind of stuff. But Having gone through something like that with your own child and seeing the change in the color of their lips and going through that is definitely gives you a whole new perspective.

Personal Febrile Seizure Story and Career Shift 47:48

I tell my kids all the time like you know, we talk about perspective a lot and I'm like, you guys want perspective, just come, come into the hospital for one day with me and you will gain a whole new appreciation for the life that you have. And you know, you know, tomorrow's never promised. So, um, wow, what an incredible story. And obviously catapulted you down this, this pathway that you're on now. Yeah, I think, uh, you know, I think what we do, it's not, it's not easy, but I think it's gotta be one of the most, uh, you know, It's one of the most fulfilling professions I think somebody could have.

And so I think we're, even though it's hard, I think we're both pretty lucky. Yeah. And I think if nothing else, we are in a very unique position in healthcare where we impact so many people's lives on a day to day basis. And yes, mostly positive, but there's plenty of negative too. And, and you know, giving bad news and things like that never, never gets any easier. Um, but just, you know, having that ability, like you said, it's sort of a, an honor to be able to take care of patients and have the, you know, have that impact on their lives.

Um, in the emergency room. It's definitely can be very sobering, can be very humbling at times. Yeah, it's really cool. I mean, this is just like, I really appreciate being able to talk to you about this because it's not like, I don't know about you, but like it's what we do is really hard. And so I think a lot of times I tend to just feel more just kind of tired of what we do. And it's a good reminder of the impact that we have, the impact that it has on us. It's really refreshing to be able to talk to you and be able to hear your stories and share some stuff that's happened to me.

And I think it'd be good for all of us to be able to do that more often. Yeah, I think talking about these things, uh, sometimes it's hard. You don't want to talk about it at the end of your day because you don't want to necessarily relive everything when I come home and talk to my wife. Who are you going to talk about it to? Yeah, exactly. And so, you know, obviously, uh, you know, you know, bourbon at the end of the night can only, can only do so much. And I think this is a good, healthy outlet as far as, uh, being able to, to have a conversation with another ER physician.

So I'm, but I, I'm very grateful that you, you know, uh shared those stories. Those are those are powerful stories. Um so I appreciate you. This is this has been great for for first guest on the show. This is some powerful stuff man. Next uh next couple of guests are gonna have some big shoes to fill so I do appreciate your time. Where where can uh where can people go to find uh the solea scrubs uh to put an order in? Yeah, yeah, absolutely. So our website would be the easiest. So SoleilScrubs.com.

If you could, you know, reverse that SoleilScrubs.com or you can find us on Instagram. We've got tons of cool stuff on there. We're on, you know, TikTok, Facebook, YouTube at SoleilScrubs. So if you, if you Google us, we'll pop up. Well, that sounds great. Well, I can't think, you know, encourage people to use the code, you know, getting 20% off is a great, it's the best deal you're going to find. So definitely, definitely use that. So I'm sure you're going to post that code in the comments or something like that.

Yeah, so be sure guys to go check out Solea Scrubs and check them and follow them on social media. They have a lot of fun content on social media. You might even see my face here and there. Well, yeah, don't forget to follow Dr. Jay Parente too. That's always fun to always have a good time at that. I do have some upcoming shows that I'm very excited about. I have a conversation with one of my other colleagues about CPR and DNR. there's a lot of misunderstanding about that. I do have a very special guest coming up in two weeks from now, Dr.

Glockham Flecken, who many of you know from social media. So I'm super excited to sit down with him for a half an hour and talk about how broken the health care system is specifically insurance companies and a lot of that happening in Washington right now. So we're going to kind of touch a little bit on that. But I wanted to thank a funny guy. Yeah, he is. He's great. And he's actually doing stand up comedy now. So I'm curious to see what he's what show he's got going on. And we'll be happy to promote that too.

So awesome. Well, thank you Dr. Guines for joining us today. I like to always end my show with the same phrase that I learned in residency and it's just something that's always helped me feel better about the world and peace, love and happiness to everyone out there. Cheers everyone.