I'm batting lots to none!!!

Can you believe it?!?!? I made it through a month of my emergency rotation without having anyone die on my shift!!! Wonder if I can make it out of medical school with no deaths...probably not.

My last shift in emerg was good. I had lots of interesting cases, got to cardiovert a patient (sedate them and shock their heart back into a normal rhythm), and got a good eval from my preceptor.

Earlier in the shift I had the choice of cases: a 70 yo lady with a complaint of "weakness" and a 52 yo lady with chest pain...I figured I'd had enough of chest pain that usually turned out to be benign, so I chose the lady with weakness. My preceptor: Look at you go! These cases are always tough to tease out (especially when the patient doesn't speak english) and are commonly due to dehydration or heart failure or a diagnosis like "failure to thrive".

I walk into the patients room and immediately see that this lady is sick. Really sick. Vital signs are stable, but she's sick. She was being treated for metastatic breast cancer and had just undergone her first round of chemo. She was incoherent, barely conscious, and yellow like a banana...the chief complaint didn't mention that. And yes, she was weak. We admitted her to her oncologist to let him sort it out, but it looks like she had liver failure.

Later in my shift I was shunted back to the fast track area. I saw 4 fevers in a row. Awesome! Surprisingly, none of them were kids. The best one was a school teacher with fever and flu-like symptoms and 9 sick kids in her class. "Why do I have a fever?" I'm not dignifying that question with an answer. Another was a guy with a fever that wouldn't go away without Tylenol. "Should I keep taking it?" Again, I'm not dignifying that question with an answer.

Like I said last post, some people are amazingly stupid.

If I didn't have my fill people who are actually sick, my next rotation will fulfill my need. Internal Medicine here I come!!! I haven't been on call since October-ish, I wonder what the call rooms will be like? I hope they have down duvets and fluffy pillows and candles. Here's to hoping!

Complaints department

I'm going to complain today...be prepared, this should be good!

I've come to the realization that a lot of people are stupid and I'm amazed that they actually get through life. My shift last night was crazy-busy. For some reason, there was a lot of people that actually required emergent care...and we were just waiting for beds on the wards so we could make room for them. So patients who were really sick or in a lot of pain had to wait. I feel for them.

Other patients, on the other hand, call the ambulance for a nosebleed that wouldn't stop after 15 minutes. Patient was "manually wetting" her nostrils i.e. picking her nose. It started bleeding. Spotted one tissue. Patient on no blood thinners. Then patient complained 3 times that she had waited for 3 hours to be seen. Nose bleed had stopped 2 hours ago.

Another patient: bit by his new puppy on the nose. Nurse: Where did it bite you? Patient: Right here on my nose...it's right there. Nurse: Where...I can't see it. Patient: Right here. Nurse: It didn't even break skin...where it is? That patient left after 2.5 hours having not been seen by a doc yet.

Another reason I'm going to hate peds...the parents. Mother brings her child into emergency (and complains about having to wait for so long...what is this, a restaurant?). Fever for one day. Goes away with Tylenol. Comes back when Tylenol wears off. Mom concerned that fever won't go away. Doc- trying to convince this mom that the fever in fact goes away with medication and it's nothing to worry about and that she should continue to give her child Tylenol regularly until kiddo is better. Anxious moms like this give my friends who have kids and are reasonable thinkers a bad rap.

Patient complains in hallway every time I walk by that she has been waiting for over an hour in the exam room. "Sorry. Someone will be with you when we can". Indoor voice: Ya, when we've taken care of the people who are actually sick. Another hour later, I finally arrive to take her history. Her chief complaint is a 'deformity' on her face and she would like a referral to a dermatologist. She never has had problems with pimples before and she's determined not to start now. Her 'deformity' is a single small pimple on her cheek, not even infected. Just a pimple. What exactly is the emergency that you had to wait over 2 hours for? Oh...you have a date next week. Go home. See your GP for a referral.

Here's my two cents worth: If you're able to pace the hallways impatiently and count the minutes go by and complain to the nurses about how long you've been waiting, you are not sick enough. Go home.

One more complaint. Obviously, most of my pet peeves that come into emergency can be dealt with in a GPs office. But there aren't enough of them!!! So many patients don't have GPs or who hate theirs so they use a walk in clinic. Or can't get in to see them fast enough. Or aren't open during the off-business hours. It's not the patients fault for having to use the emergency department to get services they need. Another reason for me to go into family medicine.

Phew. All better now.

Smokescreens

My classmates and I are undergoing a selection process to choose our electives for next year. Early, I know. We choose from a list of electives and locations and hopefully we get one of them. Process aside, it's forced us to think hard about what specialty we want to persue. And yes, family practice IS a specialty...it's only 2 years long instead of 5. Anyhoo, something interesting is happening in our class. People are using what some of us are calling 'smokescreens' to fake out others in our class.

Example #1: A classmate who has been openly hardcore into ophthomology since before Day 1 was overheard telling someone that he's super keen on plastic surgery. I suppose the purpose is to deceive others so they won't pursue the same field. (I don't get this logic)

Example #2: A classmate who is keen on anesthesia was asked if she had any of her electives together for next year. She replied that she had only just started to contact some people...as she slowly stuffed a stack of applications addressed to different programs into her bag. Clearly she already had dates and locations arranged. I call BS on that one.

I understand the need to play your cards close to your chest with faculty because often students are interested in more than one specialty and it's hard to narrow it down so you seem keen in one of them. But to be deceptive with classmates...come on! That's why our school reverted to the Pass/Fail system...so we wouldn't be competing with eachother. We are competing for residency positions but I don't see why people have to be deceptive about it...the truth will come out in the end when we begin interviewing for spots. I just don't get it...will someone enlighten me?

My smokescreen will be neurosurgery or maybe pediatrics. In time, I'm sure I will love it.

On another note, another classmate of mine has a secret admirer. She was sent flowers to the hospital where she is working with a note asking for a date. This person was a patient at some point. Thing is...she doesn't have a clue who it is! "you know how many people I see every shift??" I think she's torn over how to feel over this; flattered that someone took the time to send a beautiful bouquet, and creeped out that a patient would do that (he must have some boundary issues). PS Dating patients is a no-no and she's not gonna go there. I will keep you posted on the developments.

I forgot...

...to tell you about an interesting (for me, not the patient) case I saw a couple shifts ago in fast track. This mid-40s lady was brought in by ambulance because of urinary retention. Usually this is not the case and it turns out that the patient either is dehydrated and not making much urine, the kidneys have failed, or a blockage is making it hard to urinate but in fact they are able to. Well, this lady was not able to go as of the day before and was in considerable pain because she had the urge. So we put a catheter in and relieved her discomfort. But being the astute med student I am, the casues of urinary retension need to be investigated. As I take her history, she reveals that she had some back pain for 2 weeks in the middle of her shoulder blades, but is now gone. Last week, as she was getting onto the bus, her leg gave out and was now weak and 'drunk' to the point where she could no longer stand or walk on it. And now her urine retention. All the symptoms point to something in the spinal cord. Review of systems otherwise unremarkable.

Physical exam: pinprick sensation intact other than a strip from her nipples to above the bellybutton (T4-T8 dermatomes-parentheses are for the med geeks), motor control intact other than her left leg where she can't lift it off the bed (2/5 motor), reflexes brisk (3+) except in the left leg (2+), (upgoing toes), normal rectal tone and peri-anal sensation. All other systems normal.

Imaging: Back Xray=normal, Back CT- no acute findings (like a slipped disc for example).

As I left the hospital at the end of my shift, the doc was arranging for her to be transferred to the "mother ship" aka the "death star" aka large tertiary teaching hospital for a back MRI.

Found out the results yesterday...spinal cord tumor. Like I said, interesting for me...not for her.

More tales from the ER

I had a good day yesterday. I worked with my site coordinator in the 'treatment' or fast tract area. This is where people come for injuries and other problems that aren't too serious/acute/they-may-die-because-of-this. I like it because generally it's a quicker turnover, not much needs to be investigated (ie bloodwork, etc) and most are discharged. Also there are more procedures like suturing and casting. But it was pretty slow (the bad 'S' word of emerg). The hospital was full, so anyone that was bein admitted had to wait in emerg until they went to the ward, which meant that we couldn't see new patients unless they were dying now. The ER was essentially backed up. The treatment area was slow because no one had come in. I saw maybe 6 cases all day.

On one of the cases I had to suture this sweet elderly man who had tripped getting out of his vehicle and smashed his head on the pavement. He had had a stroke previously and was left with some deficits, but definately was not missing his humor! I might just have a date for Valentines! But while I sutured, a second year med student was there as part of one of her classes and asked to watch me. So I walked her through suturing from start to finish (examining the wound, choosing sutures, putting on sterile gloves, sterile/clean procedures, local anesthetics, etc). Just like all the surgeons I've been with, I let her cut the sutures!!!! We were also told to see a patient who had come in and had an ankle injury. As we both did the history, I pretty much knew the diagnosis from the mechanism of injury, I asked her what her differential diagnosis was (it was a ruptured achilles tendon). I got her to show me her ankle exam as a precpetor would do with me. Even though I am only one year ahead of her, I can't believe the difference!!!! Make me realize how much I've learned/seen/done in the past year! I also realized how much I like teaching and hope to be a preceptor when I am a practicing physician.

I also reduced a dislocated shoulder (ie put the should back in its socket) by myself, under supervision of course. I had done 2 already in previous shifts so I was familiar with what to do. I called for a respiratory therapist, a nurse, and 100cc of propofol (lovely clean anesthetic/amnestic that doesn't cause respiratory depression). I gave the propofol when everyone was ready, the guy went out like a light and we put his shoulder in after a few attempts. Then the patient woke up and was much more comfortable. That drug looks so fun!!!

And I saw a lady with a paper cut. No joke. I cured her...with a bandaid. I hope it was worth her 2 hour wait.

I've hit a new low

Today, was an all new low point in my med school career. No one died. No one lost any limbs. No one threw steaming feces at me or vomited all over me. No one reamed me out or made me feel retarded. I, a third year med student, had to suture a 2 y.o's forehead. Lucky me.

I met his mom and got the history from her. I knew this was going to be a doozy. He had a 4cm gash on his forehead. The kid looked at me, frowned and said "I don't like you". Nice. So I had the nurse put on some topical anesthetic (instead of needles for freezing), which he promptly wiped off. Nurse repeated. Wiped off again. Repeat. We put a see-through 'band-aid' on his head and let it marinate for a bit to take effect.

I come back and the kid is freaking! He already hates me and now I have to sew his head together. I took a deep breath and got everything ready while mom played with him. I didn't want to wrap him up in a blanket like a sausage if I didn't have to (kids tend to freak even more if they're essentially paralyzed) so we proceed to get him draped with a sterile field...which he promptly contaminated with his hand. Mom is now on top of the kid, trying to hold his hands and feet down and his head still so I could suture. Kid was a bucking bronco! Took his mom, his grandfather, and a visitor from the next bed (a retired nurse thankfully) to wrap and hold this kid down. Took me 1.5 hours to put 6 stitches in. Meanwhile the kid is pretty much having a panic attack no matter what we do or say, everyone is sweating...including me. I look like I was having a hot flash, red cheeks and all. My preceptor comes in and gives his A-OK (phew!). I asked the mom if she was OK. All she did was laugh and ask me the same. She gave me a big hug afterwards and thanked me for the great job I did. I told her that I had hit an all new low...I hated having him cry and be scared, but I knew that I had to do it. So much for the "I will not cause harm" oath

Kids scare the begeezus out of me. Peds is going to be fun...note the irony.

Emerg...aka GP clinic for those without doctors

I've worked 5 shifts in emerg so far. I'm enjoying it for the most part. I like that someone comes in and you have to figure out what's wrong with them without knowing them from previous visits. Like a detective! However, in my eyes, it's unfortunate that the emergency department is used like a family practice clinic. I personally see about 20 cases in a shift (the docs see more)...and it turns out that maybe 15% of what comes in is a true emergency...someone is dying or needs surgery or is having a worsening of a previous condition or elderly people with multiple medical problems. The rest can be managed in a GPs office:

Example #1: lady who is pregnant (but doesn't want to be) and having vaginal bleeding for 7 days with some cramping. Probably a miscarriage. What's the emergency you ask? "I just wanted to know for sure". Go home and get your GP to get you an ultrasound.
Example #2: teen girl with crampy-type pain similar to the cramps she had when she got her first period...which was 3.5 weeks ago. No other symptoms except some spotting that started today. You do the math.
Example #3: 22yo male with chest pain. Hurts when he breathes in or moves his arm. Lifted lots of weights yesterday. No other symptoms. Plus, he has an exam at school today. "Am I having a heart attack?" he asks. No. You should have studied more. Go home.
Example #4: (it's 2am) 8yo child with runny nose, fever and sore throat. Still eating, drinking, peeing, and pooping. Decreased energy. "I was worried because she wasn't herself lately and she has a fever" Yup, she sure does. She's got a virus. It's called a cold. Go home and give her tylenol.

But there's been a few memorable cases in my last couple shifts:
#1: I was asked to see a 57yo lady who came in with chest pain (doesn't really matter why she was there). The doctor and nurse were smirking when they asked me to see her. "Great", I thought. It's probably some Borderline personality or something like that (those people rub me the worng way). The doctor says to me "pay particular attention to your physical exam". So, I go take the history from the lady (no medical 'problems'), and I notice she is in no acute distress. I notice she has the ECG stickers on her right side (instead of the usual left), so I thought she had a heart attack on the back side of her heart. I listen to her heart sounds in the normal spots. The ones close to her sternum are there, but much fainter than I expected. The ones on the far left side of her chest wall weren't there. Period. Me: puzzled. I listened to her breathing and heard heart sounds on the right!!! WHAT THE F**K?!?!?!??! I examine her abdomen and find the surgical scars from a liver cyst removal...on the LEFT side (for the non-med people out there...the liver is on the RIGHT and the heart is on the LEFT). Diagnosis: Situs inversus. She has all her internal organs reversed compared to 'normal' people. I will probably never see another case of this in my career. Cool!
#2: Performed CPR for the first time Friday night in a Code Blue. 53yo lady with a bad heart (dilated cardiomyopathy) who has been on a transplant list for 6 years. Her and her 16yo daughter were having a verbal argument when she collapsed. Paramedicas were there within 4 minutes to do CPR and it took 17 minutes before getting to the hospital. We shocked her a couple times and got her back, but it doesn't look good. Code Blue's are surprisingly calm considering the magnitude of what's happening.
#3: treated the mother of a former provincial Premier. She was my patient and wasn't too clear of why she was there, so I met the Premier and got more history from him. Very nice man. His mom will be OK.