What a beautiful few weeks in Texas now that fall has arrived! We are enjoying the 80 degree weather much more than the 100 degree weather of a month ago. We had a great family vacation with my mom and dad, sisters, brother-in-law and Melissa’s sister in Puerto Rico at the end of August to celebrate my dad’s 60th birthday along with commemorating the 20th anniversary of our family coming to the U.S. We enjoyed a fun week of spending time together as a family, exploring the jungles of Puerto Rico, spending time on the beach and enjoying great Latin American food. It was also a bitter sweet time as we knew this would likely be the last big family vacation we would have before we leave for India next June and before my sister Chrisly moved up to Michigan to take a job with Kellogg.
The kids have enjoyed a month off from homeschooling. We usually give them a month off in fall when the weather is nice in Texas and keep them in school during the summer so that they can enjoy being outside during their break. The kids especially enjoyed the time in the water in Puerto Rico including snorkeling and swimming but Vivek was not quite as excited about getting salty water in his mouth!
- Christo’s US citizenship was approved. We had held off on getting my US citizenship until we knew there was a way to get some sort of dual citizenship in India and with the recent provision of overseas citizen of India (OCI) status it paved the way to get my US citizenship so that I will not have to come back to the US yearly to maintain my permanent resident status.
- A time of refreshment and a time to spend together as a family in Puerto Rico before the siblings on my side of the family move away.
- Progress in gathering together a team that will partner with the work in India. We are now at 25% of monthly support, 60% of one time support.
- That God would continue to raise a group of people that would partner with us in prayer and financially to make the work in India possible. We still need to raise about $5,600 in one time expenses and $2,600/monthly. If you would like to partner with us visit this page: Partner with the Philips or if you have received a packet from us, fill out the response card and drop it in the mail!
- Starting work part-time at a new facility: Texas Health Resources – Denton. Pray that I would get to know the staff quickly and that I would be able to care for patients well when I start working part-time in the ER there starting in October.
- Oral board exam on October 27th. Pray that the preparation would go well and that this last step in the board certification process can be finished before we leave next year.
One of the challenges and fears of working in the emergency department is caring for the patient with an unknown disease. Sometimes, the peril comes from the pathogen the patient is harboring, at other times the peril lies in the patient himself. After a total of five needle sticks since starting medical school from either moving too fast or a patient jerking back at an inopportune time, I’ve come to rely on God’s grace and protection so that one of these days I don’t get the dreaded news that I’ve been exposed to a patient with HIV or hepatitis. This month I wanted to share several stories of patients I have cared for over the years who have struck fear in my heart and how God’s protection has sustained me through it.
A 19 year old Caucasian man was brought into the ER by the paramedics because of a fall from a skateboard with a possible head injury. He was skating with his friends when he missed a jump and in the process fell and hit his head. His friends said he was not quite acting right after the fall and so they called 911 to bring him to the hospital. I met him first behind one of the curtained off rooms. He was thin, wore a white T-shirt with the emblem of a rock band, had dirty spiked up brown hair, a leather neck band with silver studs and some blood oozing from the side of his head from a scalp abrasion. He looked like a punk rocker. His neurological exam was normal except he seemed a little off. I couldn’t quite put my finger on it but I thought with his head injury and just not seeming quite with it, I needed to get a scan of his head to rule out a bleed in his brain. I ordered a CT scan of his head and then moved on to see the next patient. A few minutes later, this patient’s nurse came up to me and said, “Dr. Philip, that kid is getting a bit more agitated. Would you give him some Ativan (lorazepam, a sedative) before I take him to the scanner? I don’t think he will hold still.” ”No problem, I’ll order it.” I placed the order and went to check on another patient. About 10 minutes later I hear the page overhead, “Dr. Philip to critical care room 1, Dr. Philip to critical care room 1.”
I walked quickly to room 1 and all I could see was the stretcher half in the hall and half in the room with six police officers on top of my patient, along with three nurses all trying to restrain him. I asked, “What happened? What is going on?” ”I was taking him to get the scan of his head and he got even more agitated even after I had given him the Ativan. He was trying to climb out of bed and was talking nonsense and I tried to get him back in bed and then he started kicking and screaming which is why all the police officers came!” I helped hold down his legs along with the officers who each held down an extremity while the nurses worked on getting another IV since he had ripped out the first one. He was mad and wanted no part of this. He bucked in the bed like a bronco. He kicked at us, he spit at us, and tried to bite anyone who got near his face. We held him down while we put a mask over his face to keep him from spitting and biting us. ”Give him another 2 mg of Ativan (for those not in medicine 2 mg of Ativan would put most normal people to sleep).” No response. He was getting more agitated. ”Give him 4 mg of Ativan.” He snarled at us. ”Give him 8 mg of Ativan.” He kept trashing about. ”Give him 16 mg of Ativan.” He thrashed some more. ”Give him another 16 mg of Ativan.” Still nothing, he just kept getting worse.
Even though he was lanky, he was strong. It was almost as though he was possesed. I could see the beads of sweat dripping down the faces of the officers as we continued to hold him down because he kept ripping off any restraints we placed on him. I kept giving him 16 mg dosages of Ativan and within about 30 minutes we had given him over 100 milligrams of Ativan and there was no sign of slowing down. We ran out of the entire stock of Ativan in the Parkland ER and so we switched to Valium (diazepam). We started giving him 20 milligrams of Valium at a time and soon we had given over 150 milligrams of Valium and still no response. By this time, some of his family had arrived and we asked if he had any type of substance abuse history. ”No, he doesn’t abuse any drugs but he does drink.” Since we were now in the hundreds of milligrams of benzodiazepines, I was worried we were dealing with delirium tremens – an extremely dangerous condition precipitated by alcohol withdrawal. Delirium tremens often causes confusion, nightmares, disorientation, agitation and other signs of severe autonomic instability (like fast heart rate and hypertension). His heart rate had steadily climbed during his ER visit and was now in the 150s and his systolic blood pressure had risen to the 170s. I asked his family, “Exactly how much alcohol does he drink a day?” ”Well, besides skateboarding that is about all he does, he drinks at least 20 beers a day if not more.” Well, that explains it! He must not have drunk in several days which explained why he had gone into such horrible DTs. The nurses soon informed me that we had run out of Valium. ”Switch to Versed (midazolam). Give me 10 mg of Versed.” We kept repeating doses of Versed and soon we had given over 100 milligrams of Versed and the nurses informed me we were out of Versed. ”Do you have any other benzodiazepines in the ER?” “No, we are out of benzos in the ED.” ”Where can I get more?” ”The only way to get more is to call up the narcotics officer and have him come in from home to open up the main narcotics vault for the hospital so that you can get more.”
We had given it our best shot – it was now over two hours later with every last drop of benzodiazepine used that we had in the department. We had no other option but to intubate him and start him on a phenobarbital drip (the barbiturates work on a different site than the benzodiazepines in helping to control the symptoms of alcohol withdrawal). After the intubation and the phenobarbital drip he finally started to calm down. We had all gotten our workout for the day. I was so grateful for the police officers who stood with us for hours holding the patient down so that we wouldn’t get more hurt. The patient was admitted to the ICU for 4 days and even when he was extubated he continued on an Ativan drip at 20 mg/hr. I was so grateful to God that I had not gotten bitten or hurt worse from his violent agitation. After the patient went up to the ICU, the nurses then spent an hour adding up all the benzodiazepines that were used on this patient – the final count was 420 mg. To the best of my knowledge, this patient holds the record at the Parkland ER for the most benzodiazepines used on a single patient for DTs.
The second story is about two patients I cared for last month. It was about 10 o’clock at night when we got the call about a multiple injury car wreck from which we were going to get four patients. The first patient was a Caucasian woman in her 50s who was a frequent visitor to our ER for exacerbations of her fibromyalgia. She had run a red light and in the process T-boned a car going about 45 mph. The other car had an African American woman in her 30s with her two children in the back. The woman in her 50s hurt from her hair down to her toes. Anything I touched on her seemed to hurt. I had no option but to scan her from her head down to her pelvis to make sure there was no significant injury. The other woman in her 30s was also dramatic and hurt pretty much anywhere I touched her and so she had multiple scans ordered to rule out significant injury. The two children didn’t have any complaints and so we had them discharged quickly. The husband of the 30 year old woman soon showed up in the room and he was mad. He was furious that someone could have possibly hurt his family and he figured out quickly that the lady who went through the red light was also being treated in the ER.
He was a big man – 6’5″, at least 250 lbs and built like a linebacker. He was in no mood to be reasoned with. He pushed his way out of the room and he approached the other woman who way lying in a bed on the other side of the ER. By this time, the Caucasian woman had been joined by her husband and he was sitting next to her bed. The angry man thundered, “How dare she mess with my family!” When her husband stood up to protect her, the angry man shoved her husband to the floor across the room. Thankfully security was nearby and soon we had them separated and asked them both to leave the ER or otherwise risk getting arrested. The ED had calmed down for a while while the two women went for their scans and as we were waiting for the results we heard a commotion in the waiting room. The two men who had been kicked out had called their respective families and asked them to come to the ER. An argument ensued between the two families in the waiting room and soon an all out brawl broke out between them. About thirty people were involved in the brawl and because it was absolute chaos we called in the city police. The ER went on lockdown and no one was allowed to go in or out. A few minutes later about half a dozen cops arrived with attack dogs and they broke up the fight with several people getting shipped off to jail. To top it all – not a single injury was found on either woman in the accident! There are not many times that I’ve been scared for my safety or the safety of my staff while I’ve worked in the ED but this was one of them. I’m thankful to God for keeping me safe and for His protection over the years as we care for aggressive and violent patients. Next month, a question and answer session about returning to India…
Posted below are some pictures from the spring. The first are a set of pictures from the Dallas Zoo and Arboretum and the second set are pictures of friends and family along with pictures from the kids’ summer swimming lessons.