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.

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.

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.

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.

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.