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.

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

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 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.

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.

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.

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...

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.

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...

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.