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.

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.

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...

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.

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.

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.

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....

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.

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.