I guy came in last night at 3 in the morning. He had been shot in the leg three times and stabbed in the arm. Per policy, the hospital police came to interrogate him about the incident. Of course he wasn't talking. He didn't know who shot him, couldn't give a description, or any details what so ever. I entered the room and asked him how far away the person was who shot him, "he was standing about where you were," he replied.
I thought to myself, somebody walks up to you and shoots you from point blank range and you can't give any details of the person. Of course the guy doesn't want to be considered a "narc." He just wants to be fixed up so he can return to his gang-banging lifestyle.
He didn't have any life threatening injuries. I tanked him up and discharged him. I'll see him again one day, only then the bullet hole will be in a different location. He might live then too, then again he might not. I guess it is better to die in your twenties than to live long, prosper, yet be called a narc.
Monday, May 10, 2010
Friday, April 30, 2010
Redundancy
So I have only a few more days left on the cardiology rotation. Thankfully I'll be back on the ED soon. I have enjoyed being a part of the cardiology team and having the opportunity to provide a more definitive care. In the ED, heart attacks, although obviously very serious, are pretty routine. A STEMI goes straight to the cath lab, an NSTEMI is stabilized medically and then admitted to the cardiology service, and of course CHF exacerbations are initially cared for in the ED and then transferred to the floor should it be necessary. I've enjoyed being a part of the receiving team this month and seeing the patient through until the end.
While interesting, cardiology did seem a bit redundant towards the end. If you have a blocked artery or two, you get a stent(s). If you have multi-vessel disease, you go to surgery. If you're having a CHF exacerbation, you get diuresed until your kidneys can't take it anymore. That is obviously and over-simplified viewpoint of it, but it did make me realize I still made the right decision to go in to emergency medicine.
I chose to become an ED physician because there was nothing in medicine that I enjoyed so much that I would want to do it everyday for my career. I always thought being a sub-specialist in medicine or surgery, focusing on basically one organ system of the body would become boring after a while. I've only bend doing cardiology for 25 days now, but I'm already tired of treating heart attacks.
So, while I lack the opportunity to provide definitive care more times than not, there is nothing redundant about a day in the ED. When I get back to the ER next Friday, I may see one person having an MI, seven people having an MI, or not see one for three weeks, and that is fine with me.
While interesting, cardiology did seem a bit redundant towards the end. If you have a blocked artery or two, you get a stent(s). If you have multi-vessel disease, you go to surgery. If you're having a CHF exacerbation, you get diuresed until your kidneys can't take it anymore. That is obviously and over-simplified viewpoint of it, but it did make me realize I still made the right decision to go in to emergency medicine.
I chose to become an ED physician because there was nothing in medicine that I enjoyed so much that I would want to do it everyday for my career. I always thought being a sub-specialist in medicine or surgery, focusing on basically one organ system of the body would become boring after a while. I've only bend doing cardiology for 25 days now, but I'm already tired of treating heart attacks.
So, while I lack the opportunity to provide definitive care more times than not, there is nothing redundant about a day in the ED. When I get back to the ER next Friday, I may see one person having an MI, seven people having an MI, or not see one for three weeks, and that is fine with me.
Thursday, April 22, 2010
Code Blue
So at this point in the year a code blue doesn't get the adrenaline rushing like it used to. Don't get me wrong, it still pumps pretty strong, but its a different feeling with the adrenaline rushing and not knowing what to do versus having the adrenaline rush and the competence to know how to proceed.
I'm still on my cardiology off-service month, and the other day during rounds the code blue alert sounded. The entire team knew immediately it was one of our patients as we had been expecting it at any time. Me, the other intern, and the senior resident all rushed to the room. Along with a handful of nurses, two respiratory therapist and a pharmacist, I was the only ED doc in the room. I walked to the head of the bed and started bagging as the patient was found to be in P.E.A. I requested fentanyl and versed and immediately began preparing to intubate. All we had for access was two peripheral IVs and I heard the senior resident (who was running the code) request a triple lumen kit. I looked at him and politely suggested we put in a triple lumen. He agreed. While waiting on the medications I requested I observed the other medicine intern preparing for the central line placement. I've seen people put together jig-saw puzzles quicker. After I secured the airway, I went over and took over the line placement. First attempt, got it.
Don't get me wrong, my medicine colleagues are very competent when it comes to practicing medicine. I'm definitely not trying to suggest otherwise, but when it comes to procedures, especially in the emergent setting, that is when we ED docs shine. The patient survived the code, and we all felt pretty good about ourselves.
Whenever I'm on an off-service rotation, the other docs are never at a loss of words when it comes to expressing their opinion about the ED. But what it boils down to is, in the acute setting, no one is better in saving lives, and the above situation is just further proof. I didn't run the code, I just did all the work.
I'm still on my cardiology off-service month, and the other day during rounds the code blue alert sounded. The entire team knew immediately it was one of our patients as we had been expecting it at any time. Me, the other intern, and the senior resident all rushed to the room. Along with a handful of nurses, two respiratory therapist and a pharmacist, I was the only ED doc in the room. I walked to the head of the bed and started bagging as the patient was found to be in P.E.A. I requested fentanyl and versed and immediately began preparing to intubate. All we had for access was two peripheral IVs and I heard the senior resident (who was running the code) request a triple lumen kit. I looked at him and politely suggested we put in a triple lumen. He agreed. While waiting on the medications I requested I observed the other medicine intern preparing for the central line placement. I've seen people put together jig-saw puzzles quicker. After I secured the airway, I went over and took over the line placement. First attempt, got it.
Don't get me wrong, my medicine colleagues are very competent when it comes to practicing medicine. I'm definitely not trying to suggest otherwise, but when it comes to procedures, especially in the emergent setting, that is when we ED docs shine. The patient survived the code, and we all felt pretty good about ourselves.
Whenever I'm on an off-service rotation, the other docs are never at a loss of words when it comes to expressing their opinion about the ED. But what it boils down to is, in the acute setting, no one is better in saving lives, and the above situation is just further proof. I didn't run the code, I just did all the work.
Thursday, April 8, 2010
Off service
So I'm on an off-service rotation right now: Cardiology. I already have some good stories to tell, but now I have to deal with q4 call and the sorts so my postings will slow for the next few weeks. They'll pick back up soon. Hang in there.
Wednesday, March 31, 2010
Can't Help Everyone
A few weeks ago I blogged about now being able to save everyone. I wrote about it after I had signed up for a "simple" back pain that ended up dissecting his aorta from the arch down to his iliacs. Yesterday I came to the realization that not only can you not save everyone, but not everyone can be helped either.
Yesterday I signed up for a patient with a chief complaint stating, "General complaint." These complaints are always interesting, the "Lets make a deal" of the emergency room, because you never know what you're going to get when you open the door. Usually it's a young male with penile discharge that was too embarrassed to tell the female triage nurse about his recent escapades.
I walked in the room yesterday and saw I young male unable to sit still. Every one of his extremities jerking, almost violently, in a random pattern. I look at him with his arms and legs flailing all around as he and his wife told me his story. He was diagnosed with an unknown movement disorder two years prior. He was initially started on one medication regiment that significantly improved his dystonic jerks, but later was recommended to try another regiment to see if it would it further improve his symptoms. Not only did it not improve, but when he return to the initial medication regiment that had provided relief, it no longer helped.
I asked him why he came in to the ED yesterday as this had been ongoing for two years and he had a nuerologist.
"I'm tired of it all, " he replied. "I just wanted to see if you all could help."
Looking at this poor fellow reminded me of the news story/youtube video of the chearleader that developed a dystonic reaction supposedly after receiving the flu vaccine. http://www.youtube.com/watch?v=cEN5KGwNGeo
This guy had seen numerous primary physicians, numerous neruologist and even medical doctors at the state level. I'd like to think that I'm not a stupid person, but I fill pretty confident that I'm not going to think of anything that hasn't already been pondered.
The only truly beneficial option, although not practical for obvious reasons, was to RSI the guy so at least he could get some sleep for a while. Alternatively, I told him to start taking benadryl 50mg every 6 hours and started him on some Cogentin telling him to see his neurologist again this week.
I felt really bad for the guy, but in the end I'm an emergency medicine doctor, and he needs help I can't provide. Hopefully he find some who can help.
Yesterday I signed up for a patient with a chief complaint stating, "General complaint." These complaints are always interesting, the "Lets make a deal" of the emergency room, because you never know what you're going to get when you open the door. Usually it's a young male with penile discharge that was too embarrassed to tell the female triage nurse about his recent escapades.
I walked in the room yesterday and saw I young male unable to sit still. Every one of his extremities jerking, almost violently, in a random pattern. I look at him with his arms and legs flailing all around as he and his wife told me his story. He was diagnosed with an unknown movement disorder two years prior. He was initially started on one medication regiment that significantly improved his dystonic jerks, but later was recommended to try another regiment to see if it would it further improve his symptoms. Not only did it not improve, but when he return to the initial medication regiment that had provided relief, it no longer helped.
I asked him why he came in to the ED yesterday as this had been ongoing for two years and he had a nuerologist.
"I'm tired of it all, " he replied. "I just wanted to see if you all could help."
Looking at this poor fellow reminded me of the news story/youtube video of the chearleader that developed a dystonic reaction supposedly after receiving the flu vaccine. http://www.youtube.com/watch?v=cEN5KGwNGeo
This guy had seen numerous primary physicians, numerous neruologist and even medical doctors at the state level. I'd like to think that I'm not a stupid person, but I fill pretty confident that I'm not going to think of anything that hasn't already been pondered.
The only truly beneficial option, although not practical for obvious reasons, was to RSI the guy so at least he could get some sleep for a while. Alternatively, I told him to start taking benadryl 50mg every 6 hours and started him on some Cogentin telling him to see his neurologist again this week.
I felt really bad for the guy, but in the end I'm an emergency medicine doctor, and he needs help I can't provide. Hopefully he find some who can help.
Saturday, March 27, 2010
Healthcare
Well, it happened. For better or for worse our leaders passed a landmark healthcare bill last week. I'm not going to sit here and rant about whether or not I think this is a good or bad thing for our country, but I will provide my two cents about what I believe the impact on emergency medicine will be.
I believe the impact will be two fold: initially positive, yet progressively negative as time progresses. Currently, federal law (i.e., EMTALA) requires the emergency department to provide care to everyone, regardless of insurance. So it only begs to reason that if this bill is going to provide insurance coverage to 35 million additional Americans, less patients will present as self pay ( aka: good luck getting reimbursed). Using elementary math, more patients in the ED with insurance equates to more payouts.
One could argue that there are numerous negatives to this plan. I'm going to argue that this bill does nothing to address the shortage of primary care physicians which I believe is one of the largest problems with our current healthcare system. As an ED doc, why do I care you ask? As the shortage of primary care docs in this country grows, so does the amount of primary care I have to put up with in the emergency department.
The common cold.
Lost medications.
Poor glycemic control.
Depression.
Those are just a handful of daily complaints I have in the emergency department. None of which are emergencies. I predict that as more and more people receive insurance, intuitively there will be an increase in people seeking care. Instead of waiting three, four or even five weeks to see a primary care physician, they'll just jump in the car and come to the ED. "Why not, I have insurance now," they'll say.
Technically according to my first paragraph this wouldn't necessarily be a bad thing; however it would inevitably worsen ED overcrowding. About once every couple of years I here about a patient dying in the lobby of an emergency department as he or she was waiting to be seen. Incidences like that, albeit rare, do represent consequences to ED overcrowding, and the prevalance of these negative consequences under this new system I believe are destined to rise.
Then again, I'm just an intern, and this is a very simplistic view of a very complicated matter. Time will tell how it all plays out.
I believe the impact will be two fold: initially positive, yet progressively negative as time progresses. Currently, federal law (i.e., EMTALA) requires the emergency department to provide care to everyone, regardless of insurance. So it only begs to reason that if this bill is going to provide insurance coverage to 35 million additional Americans, less patients will present as self pay ( aka: good luck getting reimbursed). Using elementary math, more patients in the ED with insurance equates to more payouts.
One could argue that there are numerous negatives to this plan. I'm going to argue that this bill does nothing to address the shortage of primary care physicians which I believe is one of the largest problems with our current healthcare system. As an ED doc, why do I care you ask? As the shortage of primary care docs in this country grows, so does the amount of primary care I have to put up with in the emergency department.
The common cold.
Lost medications.
Poor glycemic control.
Depression.
Those are just a handful of daily complaints I have in the emergency department. None of which are emergencies. I predict that as more and more people receive insurance, intuitively there will be an increase in people seeking care. Instead of waiting three, four or even five weeks to see a primary care physician, they'll just jump in the car and come to the ED. "Why not, I have insurance now," they'll say.
Technically according to my first paragraph this wouldn't necessarily be a bad thing; however it would inevitably worsen ED overcrowding. About once every couple of years I here about a patient dying in the lobby of an emergency department as he or she was waiting to be seen. Incidences like that, albeit rare, do represent consequences to ED overcrowding, and the prevalance of these negative consequences under this new system I believe are destined to rise.
Then again, I'm just an intern, and this is a very simplistic view of a very complicated matter. Time will tell how it all plays out.
Tuesday, March 23, 2010
Ultrasound
I'm fortunate in my residency program to have a handful of attendings that are extremely proficient in using the ultraound for various procedures in the ED. The ultrasound has recently gained a lot of popularity in the department for its practicality. Most seasoned physicians have at least taken a CME course or two to learn how to do a pretty accurate F.A.S.T. exam in trauma bays, but now there are entire fellowship programs devoted to its use.
We had this huge woman present today in DKA. She had ketones in her blood and urine and her blood glucose was around 800. Initially, none of the nurses were able to get a line on her so I strolled in the room with the ultrasound machine. I took one look and popped in an IV. The peripheral line was a temporizing measure as I got everything I would need for a central line. Using the ultrasound I took one look at her neck, found her IJ, and with one stick, got the line. If you look at the new data floating around that shows the decrease in complication rates with ultrasounds guided central lines, some would say it is malpractice to attempt CVLs without it.
The lesson of the day: the ultrasound machine is your friend. It takes practice, especially in using it for peripheral IVs, but it is absolutely worth it. I've used the machine for the following: scanning for aneurysms, gall stones, comparing kidneys for hydronephrosis, looking for pericardial effusions, and evaluating for ectopic pregnancy.
It is a great tool for the ED doc to have in his arsenal.
We had this huge woman present today in DKA. She had ketones in her blood and urine and her blood glucose was around 800. Initially, none of the nurses were able to get a line on her so I strolled in the room with the ultrasound machine. I took one look and popped in an IV. The peripheral line was a temporizing measure as I got everything I would need for a central line. Using the ultrasound I took one look at her neck, found her IJ, and with one stick, got the line. If you look at the new data floating around that shows the decrease in complication rates with ultrasounds guided central lines, some would say it is malpractice to attempt CVLs without it.
The lesson of the day: the ultrasound machine is your friend. It takes practice, especially in using it for peripheral IVs, but it is absolutely worth it. I've used the machine for the following: scanning for aneurysms, gall stones, comparing kidneys for hydronephrosis, looking for pericardial effusions, and evaluating for ectopic pregnancy.
It is a great tool for the ED doc to have in his arsenal.
Sunday, March 21, 2010
The night train
I haven't posted as mush recently. I've been working a lot of nights and its tough to keep something like this up. Briefly, one of our regulars came in last night. Only this time she was coding. Found down by EMS, she arrived intubated and actively receiving chest compressions.
She was young (in her 40s). Always came in with pancreatitis because she couldn't stay away from the alcohol. She was actually one of our more pleasant regulars. I felt sorry for her in some way. She wasn't addicted to narcotics, just alcohol. She only came to the ED because her habit caused her pancreas to flare up.
She died last night. It was her thirteenth visit this year. How unlucky.
I'll be back on days soon. Better blogs will return...
She was young (in her 40s). Always came in with pancreatitis because she couldn't stay away from the alcohol. She was actually one of our more pleasant regulars. I felt sorry for her in some way. She wasn't addicted to narcotics, just alcohol. She only came to the ED because her habit caused her pancreas to flare up.
She died last night. It was her thirteenth visit this year. How unlucky.
I'll be back on days soon. Better blogs will return...
Friday, March 12, 2010
Crying Wolf
A guy came in to the ED last week. He also came in three days ago and again last night. I've only been doing this for about 10 months now, but I'm already starting to recognize some of our regular customers. He uses different chief complaints every time only to mask the real reason for his routine visits: he is homeless and has nothing better to do. Last night's chief complaint was back pain. He says it started four days ago which, oddly enough, was before his last visit three days prior in which back pain was not mentioned.
There was nothing special about the circumstances of his pain: no falls, no recent trauma, and his vitals were stable. I rely on vitals often when someone is complaining of pain. If they are in the room saying this is the worst pain of there life with a heart rate of 68, I'm always a little suspicious about their "pain". As was the case with this guy tonight: severe pain with normal vitals. I gave him a shot of dilaudid IM and was going to reevaluate. Twenty minutes later he was asleep.
I went back in to reevaluate about an hour later and told him I was going to be sending him home soon. He said I had done nothing for his pain. I didn't buy it, but feeling generous I gave him a script for some percocets and told him to follow up with the free clinic in the coming days. He reluctantly agreed.
I got a page from one of my friends who was working the day shift today. The patient came back in with bilateral pulmonary embolisms.
Shit.
Sure I feel bad for sending this guy out with blood clots in his lungs. Could I have done more of a work-up on him? Sure. Should I have? I don't think so. Some people will argue a D-dimer maybe, but I've seen too many false negative even in low risk patients for me to put any credibility in that test (my apologies to Wells and his criteria). Also, you can't Ct scan everyone. Especially those who have spend years abusing the system.
So the guy ended up being put on anti-coagulants and he'll be fine. At least until he comes back tomorrow...
There was nothing special about the circumstances of his pain: no falls, no recent trauma, and his vitals were stable. I rely on vitals often when someone is complaining of pain. If they are in the room saying this is the worst pain of there life with a heart rate of 68, I'm always a little suspicious about their "pain". As was the case with this guy tonight: severe pain with normal vitals. I gave him a shot of dilaudid IM and was going to reevaluate. Twenty minutes later he was asleep.
I went back in to reevaluate about an hour later and told him I was going to be sending him home soon. He said I had done nothing for his pain. I didn't buy it, but feeling generous I gave him a script for some percocets and told him to follow up with the free clinic in the coming days. He reluctantly agreed.
I got a page from one of my friends who was working the day shift today. The patient came back in with bilateral pulmonary embolisms.
Shit.
Sure I feel bad for sending this guy out with blood clots in his lungs. Could I have done more of a work-up on him? Sure. Should I have? I don't think so. Some people will argue a D-dimer maybe, but I've seen too many false negative even in low risk patients for me to put any credibility in that test (my apologies to Wells and his criteria). Also, you can't Ct scan everyone. Especially those who have spend years abusing the system.
So the guy ended up being put on anti-coagulants and he'll be fine. At least until he comes back tomorrow...
Monday, March 8, 2010
Can't save everyone
Last night I signed up for a back pain. I had about five other active patients at the time so I figured a back pain wouldn't hinder me too much. I walked in to the room just as EMS was leaving. I heard them mention to the nurses that they had given him 75 mics of fentanyl, 4 mg of morhpine and 4 mg of zofran. I could tell this guy was really uncomfortable. He was diaphoretic and his blood pressure was 225/115. I ordered 1 mg of dilaudid and 10 mg of hydralazine (his pulse was 65). We waited a few minutes, cycled the pressure and saw no change. This guy was in his 30s so I looked at his wife and asked if he did any drugs. She looked at her husband and then looked at me with remorse. She didn't say anything, but her eyes had YES written all over them.
The patient then began to say he felt the pain tearing up his back. I looked at the monitor and saw a once normal heart rate now beating at 150 bmp. The patient grabbed his chest, and then he took his last breath.
I couldn't believe it. This guy's presentation was so classic it was surreal. I blogged a few weeks ago about how useless pneumonics and "classic presentations" were in real-world medicine, and then this guy classically dissects his aorta right in front of me. Of course we started ACLS on the guy, but it was useless. While chest compressions were being performed, one of the other residents grabbed the ultrasound machine and placed the probe on his abdomen. We all saw the dissection clearly.
I went to talk to his wife as she had been escorted out of the room while all this was going on. She looked at my face, and with tears in her eyes I knew that she knew there was no good news coming. I was blunt but compassionate when I explained the circumstances of her husband's death. I concluded with saying "despite out bests efforts, your husband died today." I find there is no substitute for the "D" word. If you say "he passed away" or "he didn't make it" a patient will, for one reason or another, maintain the faintest bit of hope that there is chance for their loved one. Death is death, clear, and unmistakable.
The patient then began to say he felt the pain tearing up his back. I looked at the monitor and saw a once normal heart rate now beating at 150 bmp. The patient grabbed his chest, and then he took his last breath.
I couldn't believe it. This guy's presentation was so classic it was surreal. I blogged a few weeks ago about how useless pneumonics and "classic presentations" were in real-world medicine, and then this guy classically dissects his aorta right in front of me. Of course we started ACLS on the guy, but it was useless. While chest compressions were being performed, one of the other residents grabbed the ultrasound machine and placed the probe on his abdomen. We all saw the dissection clearly.
I went to talk to his wife as she had been escorted out of the room while all this was going on. She looked at my face, and with tears in her eyes I knew that she knew there was no good news coming. I was blunt but compassionate when I explained the circumstances of her husband's death. I concluded with saying "despite out bests efforts, your husband died today." I find there is no substitute for the "D" word. If you say "he passed away" or "he didn't make it" a patient will, for one reason or another, maintain the faintest bit of hope that there is chance for their loved one. Death is death, clear, and unmistakable.
Sunday, March 7, 2010
The Panic Button
Last night around 3 in the morning everything seemed to be winding down when suddenly we heard shouts erupting from the lobby. I looked around the corner to peer through the doors that lead in to the waiting area. There is a small square of glass on each of these locked doors that allow us to see through. Not only are they locked, but everyone in the ED lobby has to walk through metal detectors before they can enter. (Believe me, I don't practice in "gangsta-land", we just play it safe). I looked through the glass just in time to see a cop come out of nowhere and slam one of the guys causing trouble straight to the ground, and then the place really went crazy.
"PRESS THE BUTTON!!, " I heard one of the nurses say. That's a great idea I thought to myself. It was comforting to know that we had a panic button around for everyone's protection. Then I was a little disheartened when I realized I had no idea where the panic button was.
"PRESS THE BUTTON!!," I shouted to someone else in the hopes that person knew where the button was. Within minutes a storm of hospital and city police had filled the lobby. I was actually impressed at how quickly they responded. I'm usually picking fun at them as they crawl around campus on those stupid segways.
In the end no one was seriously injured. The bad thing was everyone involved in the brawl checked in to be evaluated. I know at some point they will all be claiming police brutality. It was funny to see one cop manhandle one dude to the ground. He slammed his face on the floor and held it there with his hand.
"Bite my hand and I will jack you up!," I heard him say. Pretty funny stuff.
Anyway, lesson of the day: know where the panic button is.
"PRESS THE BUTTON!!, " I heard one of the nurses say. That's a great idea I thought to myself. It was comforting to know that we had a panic button around for everyone's protection. Then I was a little disheartened when I realized I had no idea where the panic button was.
"PRESS THE BUTTON!!," I shouted to someone else in the hopes that person knew where the button was. Within minutes a storm of hospital and city police had filled the lobby. I was actually impressed at how quickly they responded. I'm usually picking fun at them as they crawl around campus on those stupid segways.
In the end no one was seriously injured. The bad thing was everyone involved in the brawl checked in to be evaluated. I know at some point they will all be claiming police brutality. It was funny to see one cop manhandle one dude to the ground. He slammed his face on the floor and held it there with his hand.
"Bite my hand and I will jack you up!," I heard him say. Pretty funny stuff.
Anyway, lesson of the day: know where the panic button is.
Friday, March 5, 2010
Baby, it is cold outside.
The other day a young guy came in by EMS. They said they found him down outside a bar and beat up. So that, in and of itself, is normally not that big of a deal; however, that night it had been snowing. This guy was as white as a ghost, and had a rectal temp of 30 degrees Celsius (moderately severe hypothermia).
The EMS had appropriately removed his clothes so when he came in to the trauma bay we placed him under the bair hugger. We got an IV, started some warmed IV fluids, gave him some warmed humidified 02, and I tried to get a central line. The guy was shivering so much I turned his leg in to swiss cheese before I got flashback. Nevertheless, I got the line and we really started pumping so fluids in him.
So the moral of the story today: if you're going to go out drinking, don't follow the binge by getting your butt kicked. And if your going to get your butt kicked, don't let it happen in a back alley in sub-freezing temperatures.
So I've been working nights lately, and I have a quite a few ahead of me. I'll get back to updating the blog more regularly soon.
The EMS had appropriately removed his clothes so when he came in to the trauma bay we placed him under the bair hugger. We got an IV, started some warmed IV fluids, gave him some warmed humidified 02, and I tried to get a central line. The guy was shivering so much I turned his leg in to swiss cheese before I got flashback. Nevertheless, I got the line and we really started pumping so fluids in him.
So the moral of the story today: if you're going to go out drinking, don't follow the binge by getting your butt kicked. And if your going to get your butt kicked, don't let it happen in a back alley in sub-freezing temperatures.
So I've been working nights lately, and I have a quite a few ahead of me. I'll get back to updating the blog more regularly soon.
Thursday, February 25, 2010
Just when I start to feel comfortable..
For the last couple of months I've really gotten in to the groove of things. Gone are the days when I would interview a patient and then immediately discuss it with the attending to make sure I was on the right track with my treatment plan. Now, it is not uncommon for me to see two or three patients, start the orders on them, and then sit down with the attending to discuss what I've done. I feel much more like a actual doctor now.
However, every now and then I still get humbled. Case in point, yesterday I was walking by a room the EMS guys had just dropped a patient in. I noticed he was screaming in pain and grabbing his abdomen.
"I got this," I said. He was then placed on a monitor and his vitals where: Pulse: 158, BP 65/40, Resp 34.
"Shit, I don't got this." I thought. The patient subsequently leaned over the bed and vomited at least 250ccs of bright red blood. His wife looked at me and said he's been doing that all day. The guy continued to scream aloud in pain. I was relieved to see that his screams had gotten the attention of my attending. He took one look at his vitals and the blood on the floor and then called for emergency release blood. The guy leaned over again and vomited another 250 ccs of blood.
I remember standing at the bedside frozen while multiple nurses were trying to place two IVs to start rapid fluid resuscitation. The attending came back in and asked me if I minded transferring this guy to the trauma bay (a very polite way of telling me that is what was going to happen.) I ended up putting in a central line along with intubating him as it was deemed he could not control his airway. Long story short, Gi was called in and he ended up getting a scope right there in the bay. The guy turned out just fine.
That's the problem with being an intern. The common things come in so frequently we get complacent and or cocky only to swiftly brought back down to earth when something new comes along. This guy was a great case, and now one less emergency medicine topic that will freeze me in the future.
However, every now and then I still get humbled. Case in point, yesterday I was walking by a room the EMS guys had just dropped a patient in. I noticed he was screaming in pain and grabbing his abdomen.
"I got this," I said. He was then placed on a monitor and his vitals where: Pulse: 158, BP 65/40, Resp 34.
"Shit, I don't got this." I thought. The patient subsequently leaned over the bed and vomited at least 250ccs of bright red blood. His wife looked at me and said he's been doing that all day. The guy continued to scream aloud in pain. I was relieved to see that his screams had gotten the attention of my attending. He took one look at his vitals and the blood on the floor and then called for emergency release blood. The guy leaned over again and vomited another 250 ccs of blood.
I remember standing at the bedside frozen while multiple nurses were trying to place two IVs to start rapid fluid resuscitation. The attending came back in and asked me if I minded transferring this guy to the trauma bay (a very polite way of telling me that is what was going to happen.) I ended up putting in a central line along with intubating him as it was deemed he could not control his airway. Long story short, Gi was called in and he ended up getting a scope right there in the bay. The guy turned out just fine.
That's the problem with being an intern. The common things come in so frequently we get complacent and or cocky only to swiftly brought back down to earth when something new comes along. This guy was a great case, and now one less emergency medicine topic that will freeze me in the future.
Wednesday, February 24, 2010
Feeling worse than your patients.
For the past few days I've been fighting a minor cold: a little cough, congestion, and general malaise. Nothing major, but it is enough to make me feel like crap. I take some tylenol cold and a couple of vitamin C and muscle through my shifts. The best part was today I was working on the non-acute side and would walk in to the patient's room and say, "HI, I"m Dr. __, What is your emergency today."
It actually gave me a little joy to stand in the ensuing moment of silence as the patient looked at me and realized I was sicker than they were.
I'll feel better soon and write more, in the meantime, enjoy the video...
http://www.youtube.com/watch?v=_qkZ8vfxZYI
It actually gave me a little joy to stand in the ensuing moment of silence as the patient looked at me and realized I was sicker than they were.
I'll feel better soon and write more, in the meantime, enjoy the video...
http://www.youtube.com/watch?v=_qkZ8vfxZYI
Monday, February 22, 2010
Classic presentations
If medical school teaches you one thing about disease processes, residency will teach you another. Take for example intussusception (the telescoping of a proximal segment of bowel in to a distal segment). Medical school teaches numerous mneumonics and classic presentations such as abdominal pain, vomiting, and currant jelly stools (whatever that means) however, in residency you learn that only a small, very small percentage of intussusceptions present that "classic" triad.
A real life example: two weeks ago I had a patient sent from an outside urgent care clinic with periumbilical abdominal pain that later shifted to her right lower quadrant. She was nauseated, had been vomiting and had a positive Rovsing's and Psoas sign. The clinic that sent her knew she had appendicitis. I knew she had appendicitis. The CT scan, however, said she didn't.
So where does that leave us. Typical presentations commonly present atypically, and uncommon presentations typically can be common.
Yesterday I had a 24 year old present in tears, almost screaming in pain form her headache of acute onset. She could barely answer the questions I was asking, and if medical school taught my anything, its that in that situation there is really only one question that needs to be asked: "Is this the worst headache of your life?"
"YES!", she screamed emphatically. Off to the doughnut she went. Not much time had passed before I got a call from the radiologist. Anytime that happens you know its bad, and in this case I knew what happened. She popped an aneurysm. She was sent to the operating room and actually ended up doing well. There were a few post-op complications, but she was eventually discharged back home at her baseline.
In this case, all the mneumonics and classic presentations actually correlated to the disease process. So I guess they are good for something, just not all time (or maybe even a fraction of the time).
A real life example: two weeks ago I had a patient sent from an outside urgent care clinic with periumbilical abdominal pain that later shifted to her right lower quadrant. She was nauseated, had been vomiting and had a positive Rovsing's and Psoas sign. The clinic that sent her knew she had appendicitis. I knew she had appendicitis. The CT scan, however, said she didn't.
So where does that leave us. Typical presentations commonly present atypically, and uncommon presentations typically can be common.
Yesterday I had a 24 year old present in tears, almost screaming in pain form her headache of acute onset. She could barely answer the questions I was asking, and if medical school taught my anything, its that in that situation there is really only one question that needs to be asked: "Is this the worst headache of your life?"
"YES!", she screamed emphatically. Off to the doughnut she went. Not much time had passed before I got a call from the radiologist. Anytime that happens you know its bad, and in this case I knew what happened. She popped an aneurysm. She was sent to the operating room and actually ended up doing well. There were a few post-op complications, but she was eventually discharged back home at her baseline.
In this case, all the mneumonics and classic presentations actually correlated to the disease process. So I guess they are good for something, just not all time (or maybe even a fraction of the time).
Sunday, February 21, 2010
$$$$
A very spry 83 year old lady was brought in by her two daughters the other night after falling while undressing. She did not lose consciousness; however, she did have to call for assistance to get back to her feet, but that is due to her chronic knee pain. This person was not only alert and oriented times three but very adamant about not needing to be brought to the emergency department. For her age she was relatively healthy. Her only red flag was she was on coumadin for her atrial fibrillation. The only evidence of a fall was a minor abrasion on her occiput. It was hemostatic and clean appearing.
"Do not stick me! You do not need my blood for anything. I'm ready to go home!" She said aloud. A cantankerous old woman she was, but to her credit her physical exam was completely unremarkable. She didn't even have the first signs of dementia. Her family stated she was just seen a few days ago and her INR levels were appropriate.
I thought to myself I could abide by this ladies wishes and send her home, or I could do a full work up. Draw blood, check INR, and then send her to the CT scanner. I went and told my attending the story of this 83 y/o lady who fell, has a small bump as is on coumadin, that I plan to send home. His got real big as if I was the one needing a CT scan.
"Send her to the scanner. Falls with trauma on patients on coumadin get scans."
*sigh*
I wasn't disappointed at him. After all, it is ultimately his ass in court if this family sues. So I never make it a point to second guess the attending even I feel good doing the opposite. So long story short, her INR was still normal and her CT scan showed no signs of trauma, and she was discharged. Her bill from the ED and the radiology department will be at least a couple of thousand bucks. Now I'm just an intern, and I barely have time to read the emergency medicine textbooks that have been assigned. I'm sure there is a study out there that justifies this work up, but I don't know what it is. I do wonder, though, if this lady had shown up in an ED in England if she would have received the same work up, or would they have said, "Your 83 years old and you fell? Go home."
I'm not trying to say which country is right or wrong. Here, even though she didn't want it, her family got piece of mind she was not going to die from a massive head bleed, but it was at the cost of approximately $2500. In other countries she may have been sent home, at the cost of $0. Which system is better? I don't really care to be honest. Just interesting to think about the differences.
"Do not stick me! You do not need my blood for anything. I'm ready to go home!" She said aloud. A cantankerous old woman she was, but to her credit her physical exam was completely unremarkable. She didn't even have the first signs of dementia. Her family stated she was just seen a few days ago and her INR levels were appropriate.
I thought to myself I could abide by this ladies wishes and send her home, or I could do a full work up. Draw blood, check INR, and then send her to the CT scanner. I went and told my attending the story of this 83 y/o lady who fell, has a small bump as is on coumadin, that I plan to send home. His got real big as if I was the one needing a CT scan.
"Send her to the scanner. Falls with trauma on patients on coumadin get scans."
*sigh*
I wasn't disappointed at him. After all, it is ultimately his ass in court if this family sues. So I never make it a point to second guess the attending even I feel good doing the opposite. So long story short, her INR was still normal and her CT scan showed no signs of trauma, and she was discharged. Her bill from the ED and the radiology department will be at least a couple of thousand bucks. Now I'm just an intern, and I barely have time to read the emergency medicine textbooks that have been assigned. I'm sure there is a study out there that justifies this work up, but I don't know what it is. I do wonder, though, if this lady had shown up in an ED in England if she would have received the same work up, or would they have said, "Your 83 years old and you fell? Go home."
I'm not trying to say which country is right or wrong. Here, even though she didn't want it, her family got piece of mind she was not going to die from a massive head bleed, but it was at the cost of approximately $2500. In other countries she may have been sent home, at the cost of $0. Which system is better? I don't really care to be honest. Just interesting to think about the differences.
Tuesday, February 16, 2010
The physical exam: it isn't lost on all.
I did a rotation at a pediatric emergency room once as a medical student where I would routinely see pediatric surgeons operate on kids with just the story alone. What I mean is the guy didn't demand a large set of labs or even a ultrasound or CT scan to take a kid to the operating room. Obviously he didn't just take any kid to the OR; he needed to have a certain constellation of symptoms: nausea/vomiting, abdominal pain (specifically at McBurney's point), a postive Rovsing's and/or obturator sign, positive rebound to name a few. I left that month amazed thinking how quickly a kid could end up in the OR after presenting with abdominal pain.
Fast forward a year to my institution where we do not have a pediatric surgeon. Today a kid presented to our institution's pediatric outpatient clinic complaining of abdominal pain with nausea and vomiting. It was recognized there that he most likely had appendicitis and was subsequently transferred to the ED. I picked up the kid after talking with the pediatric resident. He knew the kid had appendicitis and after talking with him I did as well.
I was going to have to transfer this kid to another institution about 90 miles away where a peds surgeon could perform the appendectomy, but I would have to get a confirmatory ultrasound before he could be sent. Transferring the kid to another institution and telling them to prep their OR only to find he did not have appendicitis would be poor form. Fortunately the ultrasound confirmed our suspicions, and fortunately, for the patient, it had not ruptured. We started fluids, antibiotics, pain medications and got on the horn. Much to our disappointment the neighboring hospital said they were at capacity and would not be able to accept the patient.
Seriously?
Anyway, after another hour on the phone we got this kid in route to another hospital via helicopter. I left the hospital remembering my experience as a medical student at the peds ED where kids could be in the OR in less than an hour. My patient today probably spent an hour in the waiting room at the clinic alone. Add that to the time in transit to our ED, the time waiting for an ultrasound and radiologist to read it, and then the hassle of being transferred. From initial presentation to OR will probably easily exceed 7 hours.
Now nobody did anything wrong here. Just everyone doing the best with what they have. I just hope that kid didn't perforate his appendix as he rode to the accepting facility.
Fast forward a year to my institution where we do not have a pediatric surgeon. Today a kid presented to our institution's pediatric outpatient clinic complaining of abdominal pain with nausea and vomiting. It was recognized there that he most likely had appendicitis and was subsequently transferred to the ED. I picked up the kid after talking with the pediatric resident. He knew the kid had appendicitis and after talking with him I did as well.
I was going to have to transfer this kid to another institution about 90 miles away where a peds surgeon could perform the appendectomy, but I would have to get a confirmatory ultrasound before he could be sent. Transferring the kid to another institution and telling them to prep their OR only to find he did not have appendicitis would be poor form. Fortunately the ultrasound confirmed our suspicions, and fortunately, for the patient, it had not ruptured. We started fluids, antibiotics, pain medications and got on the horn. Much to our disappointment the neighboring hospital said they were at capacity and would not be able to accept the patient.
Seriously?
Anyway, after another hour on the phone we got this kid in route to another hospital via helicopter. I left the hospital remembering my experience as a medical student at the peds ED where kids could be in the OR in less than an hour. My patient today probably spent an hour in the waiting room at the clinic alone. Add that to the time in transit to our ED, the time waiting for an ultrasound and radiologist to read it, and then the hassle of being transferred. From initial presentation to OR will probably easily exceed 7 hours.
Now nobody did anything wrong here. Just everyone doing the best with what they have. I just hope that kid didn't perforate his appendix as he rode to the accepting facility.
Monday, February 15, 2010
DNR
Last night was another regular busy night for us. I was carrying seven patients, six of which I did not have a good disposition on when a code blue was brought in by EMS. Now when this happens the nursing staff's gut reaction is not actively search out for the intern; however, the senior resident was involved in a sterile procedure and the attending was busy with a patient the medical student had jacked up. So I guess this was going to be my moment to shine. I had been involved in numerous codes previously while on off-service rotations, but I've never run one before. I went back to the trauma bay, gloved up, put on eye protection and waited patiently until the EMS brought the patient in. She arrived. A 91 year old lady from the nursing home with skin as pale as the snow that was on the ground outside. I could see the disappointment in everyone's faces. They all knew she was dead and were thinking this was going to be a giant waist of time. I checked the placement of the E.T. tube and resumed compressions. She was in P.E.A. on the monitor so we gave another round of epinephrine and bicarb. I let someone else take over the chest compressions and started to put in a central line. After a few rounds of compressions and medicine the respiratory therapist shouts out, "I feel a pulse!"
Everyone stops. I look down at the patient to see that her skin is nice and pink. No one could believe we got this 91 year old lady back. We actually felt kind of bad because we knew whatever piss poor quality of life this person had at the nursing home was going to be much worse after this anoxic event. The patient went in to ventricular tachycardia a few times and would require a few more rounds of amiodorone; however she eventually stabilized.
Her son arrived about five minutes later only to say that she was a DNR (do not resuscitate). I couldn't believe it. The only real wish that lady had left in life was to die, and we didn't even let her do it, but after learning of her status we told the son we would stop all heroic measures in continuing to save his mom's life. A few moments later she went in to v-tach again, and about half an hour later she passed. This time she got her wish.
Everyone stops. I look down at the patient to see that her skin is nice and pink. No one could believe we got this 91 year old lady back. We actually felt kind of bad because we knew whatever piss poor quality of life this person had at the nursing home was going to be much worse after this anoxic event. The patient went in to ventricular tachycardia a few times and would require a few more rounds of amiodorone; however she eventually stabilized.
Her son arrived about five minutes later only to say that she was a DNR (do not resuscitate). I couldn't believe it. The only real wish that lady had left in life was to die, and we didn't even let her do it, but after learning of her status we told the son we would stop all heroic measures in continuing to save his mom's life. A few moments later she went in to v-tach again, and about half an hour later she passed. This time she got her wish.
Friday, February 12, 2010
Entertainment
So I've mentioned in previous posts how nice it is to have job security. Another example last night being I walked in to the ED and noticed 5 ambulances just waiting in the trauma bay. I knew I was going to be working on the non-so-acute side last night so most of that I wasn't going to have deal with but a good feeling again none the less.
Another good thing about emergency medicine is the entertainment factor. I signed up for a patient whose chief complaint was an asthma attack. I thought this should be pretty routine. Chest xray and repeated duoneb treatments (usually) until they improve clnically, and then they can go home. When I walked in to the room I noticed a guy lying on the bed that did not appear to be in too much stress at the time. Then I looked in the corner and saw a large refrigerator-like dude sitting down in street clothes with a badge hanging from his neck.
"Are you a friend that happens to be the police, or are you the police?"
"I'm the police," he responded in a deep voice.
I couldn't help but chuckle a little bit.
"So what happened?" I asked the guy sitting on the bed.
"Man, I was running the police and my asthma started acted up, and then they caught me!"
In my mind I kept wanting to ask, "so why didn't you call time out?"
Anyway, I've gotten to the point where I don't even ask why he was running from the police. I think it is funny enough the O.G. (original gangsta) had an asthma exacerbation while trying to escape. I treated him, and then I sent home. In this case, to jail. Good times in the ED. More to come...
Another good thing about emergency medicine is the entertainment factor. I signed up for a patient whose chief complaint was an asthma attack. I thought this should be pretty routine. Chest xray and repeated duoneb treatments (usually) until they improve clnically, and then they can go home. When I walked in to the room I noticed a guy lying on the bed that did not appear to be in too much stress at the time. Then I looked in the corner and saw a large refrigerator-like dude sitting down in street clothes with a badge hanging from his neck.
"Are you a friend that happens to be the police, or are you the police?"
"I'm the police," he responded in a deep voice.
I couldn't help but chuckle a little bit.
"So what happened?" I asked the guy sitting on the bed.
"Man, I was running the police and my asthma started acted up, and then they caught me!"
In my mind I kept wanting to ask, "so why didn't you call time out?"
Anyway, I've gotten to the point where I don't even ask why he was running from the police. I think it is funny enough the O.G. (original gangsta) had an asthma exacerbation while trying to escape. I treated him, and then I sent home. In this case, to jail. Good times in the ED. More to come...
Thursday, February 11, 2010
Check out.
Towards the end of my shift last night an older man came in to the ED complaining of pretty significant abdominal pain. The differential in the elderly with abdominal pain, especially if they are hypotensive and have blood in the their stools, can be pretty scary. Fortunately for him, his pressure was stable and he was guaiac negative. The patient stated he had vague diffuse abdominal pain for the last few days that acutely worsened a few hours prior to arrival. He could have had anything from a busted appendix to a kidney stone to a torsed testicle.
I obtained some general belly labs, a urinalysis and got a CT scan. The end of my shift rolled around and my patient was still trying to drink the contrast for his CT. My replacement walked in and asked me if I was ready to check out my patients. Lucky for him the abdominal pain patient was the only person I didn't have a solid disposition on so there was going to be much work for him to do. I was tempted to stick around and wait for the results of the CT scan because I was curious to see what the problem on this guy was going to be, but after working 12 hours in the middle of night leaving the hospital is a sweet feeling as well. So I checked the patient out to the oncoming intern and left.
I felt a little disappointed not being the one to diagnose that guy with whatever it was that was going on. The sun was starting to rise when I was walking to the parking lot and I could see the morning round of medicine and surgery residents making their way inside. I could tell the ones that were coming on to a call shift because they were the ones that looked their dog had just died. Again, emergency medicine isn't perfect, but looking at the gloom on those guys faces, I'll take shift work any day of the week.
I obtained some general belly labs, a urinalysis and got a CT scan. The end of my shift rolled around and my patient was still trying to drink the contrast for his CT. My replacement walked in and asked me if I was ready to check out my patients. Lucky for him the abdominal pain patient was the only person I didn't have a solid disposition on so there was going to be much work for him to do. I was tempted to stick around and wait for the results of the CT scan because I was curious to see what the problem on this guy was going to be, but after working 12 hours in the middle of night leaving the hospital is a sweet feeling as well. So I checked the patient out to the oncoming intern and left.
I felt a little disappointed not being the one to diagnose that guy with whatever it was that was going on. The sun was starting to rise when I was walking to the parking lot and I could see the morning round of medicine and surgery residents making their way inside. I could tell the ones that were coming on to a call shift because they were the ones that looked their dog had just died. Again, emergency medicine isn't perfect, but looking at the gloom on those guys faces, I'll take shift work any day of the week.
Sunday, February 7, 2010
Nurses
So I've been on vacation for the last week and a half. It has been excellent, but I don't have any specific stories to write about pertaining to the ED so I'll write a little quip about nurses...
One of the top factors that determines whether or not I'm going to have a good shift is, usually, not the quality of the patients that come through the door but the quality of the nurses that happen to be working. Nurses can make or break a shift. There are a couple of nurses that I absolutely loath working with, and I cringe when I see them come in to work. I don't know what happened in their life to make them perpetually bitchy and lazy, but they always seem to take it out on everyone around them. The real problem is they actually have worked in the ED for quite some time and have a lot of experience on me, and with that experience, if I order a lab that requires a extra work and they don't think it is absolutely necessary they will confirm its necessity with the attending before doing it. For example, if I order a lactic acid on someone (it has to be placed on ice before sending it to the lab) they bitch, if I order an in/out cath urinalysis, they bitch, or God for bid I order orthostatics. I bet a nurse is still complaining now for the orthstatics order I placed two weeks ago.
Most of our nurses are great and I absolutely love working with them. A good relationship between any doctor and the nurse goes a long way in providing excellent care. Having said that, I can't help but love when I get to order multiple enemas on a patient that is being care for by a nurse that I don't get along with. :)
More ED stories to come soon as I start back nights on Tuesday...
One of the top factors that determines whether or not I'm going to have a good shift is, usually, not the quality of the patients that come through the door but the quality of the nurses that happen to be working. Nurses can make or break a shift. There are a couple of nurses that I absolutely loath working with, and I cringe when I see them come in to work. I don't know what happened in their life to make them perpetually bitchy and lazy, but they always seem to take it out on everyone around them. The real problem is they actually have worked in the ED for quite some time and have a lot of experience on me, and with that experience, if I order a lab that requires a extra work and they don't think it is absolutely necessary they will confirm its necessity with the attending before doing it. For example, if I order a lactic acid on someone (it has to be placed on ice before sending it to the lab) they bitch, if I order an in/out cath urinalysis, they bitch, or God for bid I order orthostatics. I bet a nurse is still complaining now for the orthstatics order I placed two weeks ago.
Most of our nurses are great and I absolutely love working with them. A good relationship between any doctor and the nurse goes a long way in providing excellent care. Having said that, I can't help but love when I get to order multiple enemas on a patient that is being care for by a nurse that I don't get along with. :)
More ED stories to come soon as I start back nights on Tuesday...
Monday, February 1, 2010
Shift Work
I was once told that an emergency medicine resident can always be picked out in the cafeteria. "They're the ones with the smiles on their faces," a surgery resident once mentioned to me referencing the fact that we work 8 to 12 hours shifts and never have to take call. Generally speaking, with the exception of off-service moths, he has a point. We really don't have too much to complain about.
I realize this may sound slightly hypocritical in light of my previous post complaining about how little time we have. While it may seem cushy to the other residents, they haven't taken into account the toll shift work can take on someone. Take me and a typical other non-ED resident at any given time. It is not uncommon for us to both work six straight days followed by a day off. One difference is the other resident will have had a call shift (or two) during those two days and I didn't; however, after the day off the other resident will return to work for five or six more straight days while I will be switched to nights.
I knew going in to emergency medicine I would have to work my fair share of nights and, unfortunately, holidays, but the difficulty of that schedule is something I didn't anticipate. It is extremely difficult work a string of nights and then switch to days in less than 24 hours. For the first two days (sometimes three) before my sleep schedule has normalized, I walking around totally sleep deprived practicing medicine like a zombie. During my first year of medical school I read a book called "Something for the Pain". It is written by an ED doc working in North Carolina and one of the underlying themes is the difficulty of this line of work and the strain rotating shifts can have on your life and the lives of those around you. While I read the book I kept thinking I'd be able to handle the stress a little bit better and would not be bothered by the stresses that author was having. Now seven months in to my residency I completely understand everything he was writing about.
By the end of the book the author had managed to discover a way that helped him coupe with this lifestyle. I hope I will find my way sooner rather than later.
I realize this may sound slightly hypocritical in light of my previous post complaining about how little time we have. While it may seem cushy to the other residents, they haven't taken into account the toll shift work can take on someone. Take me and a typical other non-ED resident at any given time. It is not uncommon for us to both work six straight days followed by a day off. One difference is the other resident will have had a call shift (or two) during those two days and I didn't; however, after the day off the other resident will return to work for five or six more straight days while I will be switched to nights.
I knew going in to emergency medicine I would have to work my fair share of nights and, unfortunately, holidays, but the difficulty of that schedule is something I didn't anticipate. It is extremely difficult work a string of nights and then switch to days in less than 24 hours. For the first two days (sometimes three) before my sleep schedule has normalized, I walking around totally sleep deprived practicing medicine like a zombie. During my first year of medical school I read a book called "Something for the Pain". It is written by an ED doc working in North Carolina and one of the underlying themes is the difficulty of this line of work and the strain rotating shifts can have on your life and the lives of those around you. While I read the book I kept thinking I'd be able to handle the stress a little bit better and would not be bothered by the stresses that author was having. Now seven months in to my residency I completely understand everything he was writing about.
By the end of the book the author had managed to discover a way that helped him coupe with this lifestyle. I hope I will find my way sooner rather than later.
Tuesday, January 26, 2010
Duty Hours
When I was a medical student an attending once stopped the entire medical team during rounds in the middle of the hallway, singled me out by asking what my Step 1 score was, and then (appearing only semi-impressed) stated the following: "You know, you guys will never be as smart as I am."
Long awkward pause..
"And it is because of the new duty hours."
What!?! Did he actually say that I, and I imagine the rest of the team, was thinking. He went on an entire monologue about how we could only hope to be half the physician he is because his workload during residency was much more demanding. "We didn't have post-call days off and the ability to leave once we had worked eighty hours. We had to see everyone, not being able to leave until all patient care was completed," he continued to ramble. As arrogant as he was at the time, I can't say I entirely disagree with him. A lot of the younger generation will argue that the oldies didn't have half the patient population that we deal with on a daily basis, and there is some truth to that. However; regardless of whether it is family medicine, surgery, or everything in between (ok, maybe not so much dermatology), residency is hard, and it is hard because not only are you juggling your time at the hospital, but also your family life, your social life, and even your personal life. Everyone needs there alone time at some point.
There are times when I go over my 80 hours, but it is rare. I worked 86 hours a few weeks ago and it was a drag. Here is some math if you work 12 hour shifts:
12 hour work schedule + 30 minutes round trip to and from work + 6.5 hours of sleep + 30 minutes of reading a day = 4.5 hours in the day of "free time".
We're not done yet, however. That 4.5 hours of "free time" is not all yours. Some of it belongs to your family and friends, and trust me, if you don't make time for them you'll go crazy (and so will they). At the very least residency makes you figure out who your really good friends are because they other ones you make time to see. I have good friends that I haven't seen since the start of residency, but they understand.
At the beginning of my residency, my director told me to think about all of my hobbies and which one I like the most because that is the only one I would have time for, and now I believe her. Maybe that is why older doctors are so cranky: they lost of their hobbies.
Long awkward pause..
"And it is because of the new duty hours."
What!?! Did he actually say that I, and I imagine the rest of the team, was thinking. He went on an entire monologue about how we could only hope to be half the physician he is because his workload during residency was much more demanding. "We didn't have post-call days off and the ability to leave once we had worked eighty hours. We had to see everyone, not being able to leave until all patient care was completed," he continued to ramble. As arrogant as he was at the time, I can't say I entirely disagree with him. A lot of the younger generation will argue that the oldies didn't have half the patient population that we deal with on a daily basis, and there is some truth to that. However; regardless of whether it is family medicine, surgery, or everything in between (ok, maybe not so much dermatology), residency is hard, and it is hard because not only are you juggling your time at the hospital, but also your family life, your social life, and even your personal life. Everyone needs there alone time at some point.
There are times when I go over my 80 hours, but it is rare. I worked 86 hours a few weeks ago and it was a drag. Here is some math if you work 12 hour shifts:
12 hour work schedule + 30 minutes round trip to and from work + 6.5 hours of sleep + 30 minutes of reading a day = 4.5 hours in the day of "free time".
We're not done yet, however. That 4.5 hours of "free time" is not all yours. Some of it belongs to your family and friends, and trust me, if you don't make time for them you'll go crazy (and so will they). At the very least residency makes you figure out who your really good friends are because they other ones you make time to see. I have good friends that I haven't seen since the start of residency, but they understand.
At the beginning of my residency, my director told me to think about all of my hobbies and which one I like the most because that is the only one I would have time for, and now I believe her. Maybe that is why older doctors are so cranky: they lost of their hobbies.
Friday, January 22, 2010
The Airway
As an emergency physician it is all about the ABCs: Airway, Breathing, and Circulation, and it is always comforting for me to know that no matter the condition any patient presents, as long as the "ABCs" are intact, that person is, at least in the short term, stable. Every medical specialty has their area of expertise. A cardiologist obviously focuses on the heart, a pulmonologist the lungs, and one could argue that an ED doc's should be the ABC's.
I remember running to codes in the hospital as a medical student, and by the time I got there, 100 white coats would already be crammed in to the room shouting out orders. One order I never heard was, "Quick! We need a medical student in here stat!" A specific incident I will never forget is being on my psych rotation and hearing a code called out in the room adjacent to where I was standing. In a matter of seconds every psychiatrist was in the room and the psych intern had gone to the head of the bed. I though to myself this was going to be a train wreck, and before the on-call medicine team arrived the patient's front two teeth had been knocked out by the laryngoscope. Nothing against psychiatrist, but I wouldn't want them running my code. Lets just say intubating is not their area of expertise. I had intubated mannequin after mannequin in the simulation lab at the start of my M-4 year, and as I stood there watching the intern attempt to pass the tube I could name about twelve errors he had made.
Fast forward one year.
In the middle of a morning while I was on a medicine off-service, I had just made it to my call room when the code pager rang. I ran to the room and instead of seeing see it overflowing with white coats I was the only one. Thinking this was my time to shine I ran to the head of the bed and starting bagging the patient and asked the nurse to bring the airway cart close by. I had a good seal on the bag and the patient's oxygen saturation was rising. I looked up and saw that suddenly the room had filled with nurses, respiratory therapist and other in house docs. It was time to intubate, and for the first time I actually took a good look at the patient to see what I was about to tube. She was morbitly obese, had no neck or chin, and looked nothing like the simulation lab mannequins I had tubed previously. I grabbed the laryngoscope and opened her mouth only to see a colossal tongue and a pair of dentures floating around. I inserted the mac blade and she vomited everywhere. It was terrible; a total train wreck. A senior resident stepped in and he was able to get the airway on his third attempt by using a bougie, but it didn't matter as the patient didn't survive. I left the room seeing the medical students in the back with same looks on their faces that I had when I watched the psych intern. In retrospect I can see a few errors I made, but the problem was she had a terrible airway and I lacked experience.
Simulation labs are one thing, observing others run codes is another, but being the one actually calling the shots is a lifetime of experience crammed in to 20 minutes.
I remember running to codes in the hospital as a medical student, and by the time I got there, 100 white coats would already be crammed in to the room shouting out orders. One order I never heard was, "Quick! We need a medical student in here stat!" A specific incident I will never forget is being on my psych rotation and hearing a code called out in the room adjacent to where I was standing. In a matter of seconds every psychiatrist was in the room and the psych intern had gone to the head of the bed. I though to myself this was going to be a train wreck, and before the on-call medicine team arrived the patient's front two teeth had been knocked out by the laryngoscope. Nothing against psychiatrist, but I wouldn't want them running my code. Lets just say intubating is not their area of expertise. I had intubated mannequin after mannequin in the simulation lab at the start of my M-4 year, and as I stood there watching the intern attempt to pass the tube I could name about twelve errors he had made.
Fast forward one year.
In the middle of a morning while I was on a medicine off-service, I had just made it to my call room when the code pager rang. I ran to the room and instead of seeing see it overflowing with white coats I was the only one. Thinking this was my time to shine I ran to the head of the bed and starting bagging the patient and asked the nurse to bring the airway cart close by. I had a good seal on the bag and the patient's oxygen saturation was rising. I looked up and saw that suddenly the room had filled with nurses, respiratory therapist and other in house docs. It was time to intubate, and for the first time I actually took a good look at the patient to see what I was about to tube. She was morbitly obese, had no neck or chin, and looked nothing like the simulation lab mannequins I had tubed previously. I grabbed the laryngoscope and opened her mouth only to see a colossal tongue and a pair of dentures floating around. I inserted the mac blade and she vomited everywhere. It was terrible; a total train wreck. A senior resident stepped in and he was able to get the airway on his third attempt by using a bougie, but it didn't matter as the patient didn't survive. I left the room seeing the medical students in the back with same looks on their faces that I had when I watched the psych intern. In retrospect I can see a few errors I made, but the problem was she had a terrible airway and I lacked experience.
Simulation labs are one thing, observing others run codes is another, but being the one actually calling the shots is a lifetime of experience crammed in to 20 minutes.
Tuesday, January 19, 2010
People do stupid things...
When you're young and thinking about a career path it is always important to consider job security. I remember growing up and one of my friend's dad lost his job, and I remember how devastating it was to the family. His father was involved in an industry that, with new technologies, became obsolete. Having said that, I experienced my first object in the rectum the other night. Not MY rectum, of course, but the patient's. Oddly enough it was followed only a few hours later with a foreign body in a patient's vagina. Now part of being a doctor is job security, and knowing that every second of every day someone out there is doing something absolutely retarded makes me feel safe about my spot in the general workforce. Whether it is riding motorcycle without a helmet, welding shards of metal without eye protection, or the always comical, "I fell on something and now it is in my rectum", the emergency physician will always be needed.
A rather short post today, I've been working nights. They'll get better...
A rather short post today, I've been working nights. They'll get better...
Sunday, January 17, 2010
Dr. Gupta is no hero!
I was really disappointed in CNN the other day. Truth be told, I haven't been pleased with the way they portray the news in quite some time; however, yesterday was a new low. The headline on their website read, "UN doctors and nurses leave hospital in Haiti leaving our Dr. Sanjay Gupta to treat everyone."
Wow.
Now the truth. The UN doctors and nurses were told to leave because mobs of angry people, most with machetes, were becoming rowdy around the hospital, and for the safety of everyone they were ordered to leave. Dr. Gupta, on the other hand, was surrounded (off camera of course) by tons of the private security forces hired by CNN to shoot the faces of anyone that could be a threat to Gupta. Did the UN MDs and RNs have the same luxury of private security (or even UN security at the time)? No.
Personal safety always comes first and patient care a very close second. One hundred dead doctors are about as useful as one Sanjay Gupta alive. Don't misunderstand me, I have nothing against the man, just the was CNN tried to portray on him.
The tragedy in Haiti is exactly that, a tragedy, but the media exploitation of it has made the situation that much worse. Shame on you CNN.
I don't know how many out there are reading this. I'm thankful for all who do and I hope you gain some insight in to emergency medicine from it. I promise to not make this my soapbox and to return writing about EM stuff in my next post. CNN, and most of the media, just really pissed me off this week.
Wow.
Now the truth. The UN doctors and nurses were told to leave because mobs of angry people, most with machetes, were becoming rowdy around the hospital, and for the safety of everyone they were ordered to leave. Dr. Gupta, on the other hand, was surrounded (off camera of course) by tons of the private security forces hired by CNN to shoot the faces of anyone that could be a threat to Gupta. Did the UN MDs and RNs have the same luxury of private security (or even UN security at the time)? No.
Personal safety always comes first and patient care a very close second. One hundred dead doctors are about as useful as one Sanjay Gupta alive. Don't misunderstand me, I have nothing against the man, just the was CNN tried to portray on him.
The tragedy in Haiti is exactly that, a tragedy, but the media exploitation of it has made the situation that much worse. Shame on you CNN.
I don't know how many out there are reading this. I'm thankful for all who do and I hope you gain some insight in to emergency medicine from it. I promise to not make this my soapbox and to return writing about EM stuff in my next post. CNN, and most of the media, just really pissed me off this week.
Tuesday, January 12, 2010
DEATH!
Death, it happens. It happens everyday in emergency rooms all over the world. The tragedy is not the death itself, even if it was unexpected. The tragedy is having to inform someone their father, their spouse, or, the absolute worst, their child has just passed away. The loudest scream I ever heard was about four weeks into my internship. I was walking down the hall when I heard a deafening shrill fill the ED, and I knew instantly someone had just been given the news.
I thought to myself that whenever my times comes to give the news I would do it with such compassion and support that no one would feel the need to scream. I mean, I did take a two week course in medical school called death and dying. I felt adequately trained on the proper technique and the words to use. The problem was when the time came, I wasn't ready. It was 2:45 in the morning and I was on call on the trauma service. We had been pummeled all night, and even at that time in the morning things were still going strong. I was walking alongside a patient being wheeled to the CT scanner when I heard the trauma page ring out again overhead.
"Shit!"
I left the patient to return to the trauma bay. "Three car MVC, two trauma reds are five minutes out," I heard. At this point in the night I was numb to the whole thing. I was already staring at the clock counting down the hours until I could leave, go home, and fall asleep next to my wife. The two traumas arrived, and after just one look I knew they would be headed to the ICU. The problem was in the entire ICU we had only one bed remaining. 2 critical ill patients + 1 ICU bed = not a good situation.
Fortunately (depending on how you look at it), we received a call from the ICU saying one the patients that arrived earlier in the night had just expired. The attending looked at me and said, "Go tell that family of the patient in room 312 the situation. Do it quick so they can get the room ready for one of these guys.".
"The situation," I mumbled under my tongue. The situation was I have to go tell a family I don't know that their family member, a person I never met because he belonged to the other intern that was off handling other business, has just died. I got up to the room just in time to see the house staff putting the infamous white sheet over the body.
"Where's the family?" I asked the nurse.
"I'll send for them."
I looked in the patient's chart to see what caused his injuries. It turns out he was assaulted during a robbery at his residence and suffered massive head injuries. I didn't feel like reading any more, too depressing. The family approached, already shaken up from the events of the night. I looked at them, complete strangers, introduced myself and said, "in spite of the entire medical staff's efforts tonight, Mr. Johnson did not survive the injuries he sus... "
Screams.
I wasn't even able to finish the sentence. Other family members starting asking questions to which I did not know the answers, but as the only physician around I felt obligated to provide them with the most nebulous responses possible. It was terrible and at the end of the shift I think I felt just as bad as that family.
Now I'm not sure there is a good way to inform a family member about the death of a loved one. I haven't had to the give "the news" to anyone else since that time. I'm beginning to think there is no right way to inform someone about a death, and that it might just be easier to get used to the screams.
I thought to myself that whenever my times comes to give the news I would do it with such compassion and support that no one would feel the need to scream. I mean, I did take a two week course in medical school called death and dying. I felt adequately trained on the proper technique and the words to use. The problem was when the time came, I wasn't ready. It was 2:45 in the morning and I was on call on the trauma service. We had been pummeled all night, and even at that time in the morning things were still going strong. I was walking alongside a patient being wheeled to the CT scanner when I heard the trauma page ring out again overhead.
"Shit!"
I left the patient to return to the trauma bay. "Three car MVC, two trauma reds are five minutes out," I heard. At this point in the night I was numb to the whole thing. I was already staring at the clock counting down the hours until I could leave, go home, and fall asleep next to my wife. The two traumas arrived, and after just one look I knew they would be headed to the ICU. The problem was in the entire ICU we had only one bed remaining. 2 critical ill patients + 1 ICU bed = not a good situation.
Fortunately (depending on how you look at it), we received a call from the ICU saying one the patients that arrived earlier in the night had just expired. The attending looked at me and said, "Go tell that family of the patient in room 312 the situation. Do it quick so they can get the room ready for one of these guys.".
"The situation," I mumbled under my tongue. The situation was I have to go tell a family I don't know that their family member, a person I never met because he belonged to the other intern that was off handling other business, has just died. I got up to the room just in time to see the house staff putting the infamous white sheet over the body.
"Where's the family?" I asked the nurse.
"I'll send for them."
I looked in the patient's chart to see what caused his injuries. It turns out he was assaulted during a robbery at his residence and suffered massive head injuries. I didn't feel like reading any more, too depressing. The family approached, already shaken up from the events of the night. I looked at them, complete strangers, introduced myself and said, "in spite of the entire medical staff's efforts tonight, Mr. Johnson did not survive the injuries he sus... "
Screams.
I wasn't even able to finish the sentence. Other family members starting asking questions to which I did not know the answers, but as the only physician around I felt obligated to provide them with the most nebulous responses possible. It was terrible and at the end of the shift I think I felt just as bad as that family.
Now I'm not sure there is a good way to inform a family member about the death of a loved one. I haven't had to the give "the news" to anyone else since that time. I'm beginning to think there is no right way to inform someone about a death, and that it might just be easier to get used to the screams.
Sunday, January 10, 2010
Something for the pain
There are some things that an emergency physician can expect when he goes to work, like the mailman getting chased by the neighborhood dog or a teacher dealing with the problem child. We ED docs know that drug-seakers never cease to disappoint. Their constant lumbar or cervical back pain from falling at work, car accidents that are never their fault, or the rare (but comical) post-coital muscle strain is a daily occurance that we can bank on. Rain or shine, morning or evening, a seeker always finds his or her way through the ED doors (although having an ambulace pick you up i'm sure makes the hike through the cold a bit easier).
The "cry worf" scenario wouldn't be a problem if seven lawyer's offices were not located within 2 blocks of my hospital. I've just started my seventh month in emergency medicine (only three of which have actually been in the ER due to office service rotations) and I already know, almost personally, a handful of patients I can expect to see regularly. The other day I had had enough and practically begged the attending to let me not treat this guy's knee pain because we all knew he was there for his dilaudid and percocet scripts that he could take home and sell. That day I working with one of the more conservative attendings and he told me a story about a patient he once had, a seeker, that came in regularly complaining of the same thing. One day he was in my situation, fed up with the same complaint and he decided to discharge the patient without treating her. She walked out and died.
The lawyers loved it. All they had to do was go to court and say, " you mean to tell us that the now deceased patient came in to your ED complaining of pain and you did nothing to take the pain away, doctor?" That's an instant settlement.
Its easy for me to not want to treat these folks because technically the responsiblity lies with the attending. I may be as conservative three years from now when I'm the one facing the lawyer. So for now I will continue to give these folks something for the pain eventhough they are a major problem in our healthcare system. Everytime he comes in complaining of knee pain I have to be sure it is not going to kill him, and that's not cheap, and, of course, he ain't paying.
The title of this post was borrowed from a book that looks at one MDs life as an ED Doc, very interesting. I highly recommend.
Wednesday, January 6, 2010
The Chaos
I struggled today. As an intern that's not uncommon for me (or anyone I imagine), but today was different. There was nothing special about the day, a random wednesday on the outside but absolute chaos on the inside. Every patient room was full (some with whole families being seen), the waiting area was standing room only and there were even patients being seen in the hallways.
I remember getting oriented and listening to my program director tell the intern class that we really aren't expected to see more than one patient an hour. That's all well and good until a day like today comes along and your looking around seeing everyone from the ANAs to the attendings trying to maintain some sense of sanity in the department. I don't know if it is the competitive spirit in me or if I feel the same urge to maintain a steady flow in the department the upper levels have, but inevitably I realize I am carrying way to many patients for not only my educational benefit but, more importantly, the well-being of the patient. In this I case I've noticed I start treating the patient's chief complaint rather than being a competent emergency physician. For example, I will enter a new patient's room already overloaded with patients and say, "Hi there, I'm one of the ED residents. What's the problem today?"
"My stomach hurts, doc!"
Abdominal complaints are classic in the ED, and I especially like them because I feel a good ED physician that takes a solid history and performs a thorough physical exam will, more times than not, be able to to discern the cause of the pain: whether it is a hot appendix, a lower lobe pneumonia, a biliary process or any of the other seemingly million causes of abdominal pain The problem with days like today is that when the person is further explaining what has been going on, I'm half paying attention and half thinking about the other labs and x-rays that I have to review, and by the time I leave the room I realize the only thing I truly remember is that my new patient has belly pains. Now I could go back in and repeat the questions, but then the patient will think I'm an idiot and lose all confidence (if he had any) in me in the first place. The other option is to go back to my computer an order all the labs possible that would like determine the cause of this guys abdominal pain: CBC, basic, hepatic, lipase, amylase, urinalysis, acute abdominal series, CT, EKG, cardiac enzymes, lactic acid, the list goes on...
The good thing about this technique is if all the labs come back negative I can feel pretty good telling the patient there is nothing emergent going on and he can be sent home to follow up with his regular doctor. After all, I am an emergency physician right?
There are so many things wrong with that scenario it is difficult to know where the critiquing should begin. FIrst and foremost this is terrible patient care, and secondly I gain nothing of educational value from practicing medicine that way. I don't mean to sound self-seeking, but that is the purpose of resident, right? I guess I'll maintain hope that improved efficiency comes with time....
Tuesday, January 5, 2010
You don't have to go to Africa....
It seems like the cool thing to do in medical school is a rotation in an a foreign country. Hell, even I went to South America for a month with aspirations of seeing rare pathology and getting to perform procedures that a medical student would not routinely perform stateside due to that ever-present (and annoying) chain of command. I was fortunate to see a lot of things that I never imagined were possible. The irony is the weirdest things I saw south of the border are nothing compared to what I experience daily in the E.D. here. I've seen maggot infested wounds, basketball sized goiters, and obese women "poop" out a baby because they were unaware they were pregnant. The majority of these patients present saying they didn't come sooner because they were sure their problems would resolve on their own.
I guess my point is third world medicine, unfortunately, is right here in out backyard. I'd say we are the only country in the world that has both third world pathology and diseases of prosperity (obesity, diabetes, heart disease).
Is all of this a result of our current healthcare system, inadequate public health measures, or just plain medical apathy? I don't know. I just continue to show up at the start of my shift and do the best I can.
Nothing beats emergency medicine.
Sunday, January 3, 2010
The Beginning
Six months down, 3o more to go. Emergency medicine is a three year residency, and now that I have those six months under belt I am beginning to feel a little more confident about myself. A far cry from day one...
July 1st, 0900: I still remember how perfect a day it was. The blue skies, the cool breeze, even the diesel fumes blasted in my face as the hospital transit bus drove by didn't seem to bother me that much. I looked across the street to see the empty helipads. They must be out bringing us business I thought.
I had spent three months working in various emergency rooms during medical school. So I knew what to expect when I walked in the door. I was used to the EMS busting through the doors with people vomiting, the nurses running from room to room collecting blood and giving medicines all while being yelled at by ungrateful patients, and the doctors trying their damnedest to not forget to review that x-ray, check that lab result, reevaluate the patient, etc...
So I wasn't shocked when that is exactly what I saw on day one. I walked back to the physician's room, hung my coat and signed in at a computer. Not two seconds had passed when the attending approached me.
"Good morning" I said.
"Have you eaten?"
"No. I'm not a big breakfast eater," I replied. Which is the truth by the way.
"Well, go grab some. There was an explosion at a plant in ---town two hours ago. The choppers are bringing in six crispies. They'll be here in about 20 minutes."
So that I wasn't expecting. Medical school taught me the genetic defect that causes sickle cell disease, the seriousness of a cough in someone who has AIDS, how to manage a patient with Chrone's disease, but it didn't even begin to teach me how to handle a situation like this.
That's where residency comes in, and that is what this blog will be all about. The lessons of residency. For anonymity the names and locations will be changed, but everything, like the multiple burn victims as my first patients, will be true.
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