Study, Study Study

So I have been studying for 14+ hours and have at least another 20 or so to go to get ready for my exam tomorrow at 10:00 am. The test will cover a 700+ page book we were given about Emergency Medicine. The book covers everything in great detail. 

The challenge here is how to go through the 700 pages and determine what will most likely be tested and then figure out how to memorize those details. Like everything else in medical school it is like trying to drink through a fire hose. I was so busy and tired during my rotation that it was very hard to come home and read from the book and study. There is no way to guarantee that the things I was learning during my rotation are the same things that will be tested.

However, be cause I have been doing this for 3 years now, I no longer panic and worry about it. I basically just keep studying and hope that some of it sticks and that it is the same stuff that will be tested. We had a review yesterday which was helpful. 

Back to studying. 

The ER rotation is over

My last shift was yesterday. I feel bummed it is over. I loved the ER. Even before I started medical school I always thought ER would be one of the specialties that I would be interested in, and this rotation pushed me closer to choosing ER rather than away from it. I want to keep an open mind for the other rotations. Right now my considerations are:

ER, Radiology, Surgery, Psychiatry, Dermatology, GI, Pathology. We will have to see how this changes. Whichever specialty I choose I will need to set up rotations in that field for my 4th year. 

4th year is an interesting year. You have a few required rotations and then the remaining rotations are electives. You make up your mind during your 3rd year what you want to do and then you set up electives for your 4th year in that field at locations that you want to apply to, so that you can make relationships with the faculty and increase your chances of matching. 

I got your back!

Yesterday I was in the peds ER again. We had had a couple of interesting cases. One was a 28 day old female infant that started having a fever at home at 11:00 am. The mom reported that they took the temp with home ear unit and it was 102 degrees. She waited until 12:00 and took the temp again and it still read 102 degrees. So she called her pediatrician and the office was closed for lunch. She waited to call back and decided she would just head into the office to be there at 1:00 when the office opened. However her doctor called her at 12:45 as she was driving in and he said if the temp really was 102 just go straight to the ER. 

So she and her husband arrive at the ER at about 1:00 with the feverish child. We immediately take the temp and it is 99.5 degrees. So the baby gets the full work up. Blood culture, straight catheter for urine culture and lumbar tap (spinal tap). With a child this young there is no messing around. The infant was poked and prodded and not too happy. It was the parent's first child and they were very angry and the discomfort of the baby and acted as thought we were trying to torture the infant. It was uncomfortable to say the least. 

We had the parents wait outside while the spinal tap was done. Unfortunately the spinal fluid had blood in it which made it unreliable for the lab so it could not be used. The spinal tap is done to rule out meningitis and the CSF is collected and measured for protein, glucose and WBC's also the pressure is measured as well. These tests can help rule out viral and bacterial meningitis. If blood from the procedure taints the CSF then the test will not be useful. The other labs came back and indicated a possible UTI. 

The source of infection appeared to be the UTI. So we started the infant on antibiotics and had the baby admitted into the peds unit where she will be seen by the pediatric hospitalists. We spoke with the pediatrician who normally cares for the infant and he wanted to admit her so we obliged, Most likely the infant will be monitored and continue treatment with antibiotics and then released after 24 hours to complete the antibiotics at home. 

Then I had about 10+ cases of complete crap. Be stings, 5 year olds with fevers, bent finger, bruised leg, sore tongue etc. Mostly hyper anxious parents. The issue here is that even though we know it is mild or does not need emergency attention once they enter our ER we become liable and must do a complete work up. The parents see this work up as validation for there concern and think "it is a good thing we came in, look at all the concerned people running around!" The reality is we want to say, "you must be joking! you brought your kid in because his forearm itched after he rolled around in some wool sweaters in the attic" What can you do? 

Smile, that is what I do, and I think about job security. 

Kids, Kids, everywhere

Today I worked in the pediatric ER. It was a good shift despite the fact that I do not like the pediatric patient as much as I do some of the other patients. I like patients that are old enough to understand that we are trying to help them and not kill them. Suturing little kids is always hard because it is like a moving target and they get mad. I enjoyed the shift and it was busy and hectic.

Common things seen in the pediatric ER = appendicitis, febrile seizures, intussusception (intestines fold in on itself), lacerations, overdoses, pneumonia, fevers, pharyngitis, stange rashes, burns, allergic reactions, traumas.

A sample of some of today's patients:

We had a 2 year old who had acute hepatitis from a tylenol overdose. Evidently the mother had been treating his fever with tylenol for the past couple of days. We administered an antidote; N-acetylcysteine. The child was put into the pediatric ICU and hopefully will not have long term liver damage.  I am not sure why this product is still on the market. The ped. ER doctor says that she this is a common case for her to see and that many times the patients are within the regular dosing amounts.

I was working with a pediatric emergency physician who did a residency in emergency medicine and a residency in pediatrics. She has been working in pediatric ER's for 15+ years. It was amazing how much she knows.

We had 2 cases of appendicitis that I saw and diagnosed and sent off for surgery. Then we also had a handful of scared parent syndrome, which is usually a child with a completely benign issue that the parent is worried about and rushes them into the ER. Today we saw a bee sting case (not allergic), 5 year old with a 100.1 fever, vomiting 8 year old, and a couple of other not so serious illnesses. 

The most exciting case was a 6 month old infant in respiratory arrest. This infant had cerebral anoxia at birth which led to developmental delays and seizures. The child is a very sick baby and has been in and out of the hospital since birth and this morning stopped breathing. We quickly intubated the baby and were able to keep the baby alive. The case was touch and go. I realized how hard it is to put IV's in infants. Generally everything is harder on infants. It was rewarding to see the baby's  vitals return to normal.

The joys of inebriation

Early Saturday morning, while I was debriding an abscess on the rear end of a female patient I heard a bunch of commotion out in the hall way and figured we must be getting in another drunk who has somehow injured himself in his state of genius. 

I quickly made the incision into the abscess and the nasty smell of anaerobic infection filled the air. The patients boyfriend asked what that awful smell was and I jokingly said, I thought it was you. His girlfriend laughed and I then explained why the infection smelled. Anaerobes are bacteria that thrive on lack of oxygen and can be found in abscesses and usually have a rotten smell associated with them. Once the incision was completed I inserted my surgical forceps and bored out the abscess. A cottage cheese like substance bubbled out of the incision. I nursed the wound to make sure to get all of the rotting tissue out. I then packed the wound with iodinized strips of packing material. I started her on some antibiotics and told her to follow up with her primary care doc or to come back to the ER to have the packing removed. She was so grateful and felt so much better once the pressure was released from the abscess. 

I quickly ran out to see what the commotion had been about only to find a police officer and several nurses / techs and 1 doctor trying to hold the patient down and get him to quit fighting everyone. I had a 67 year old male with SOB (shortness of breath) that I had to see and could not get in on the action. Once I finished the SOB patient I asked the attending doc what was up with the drunk. He explained that the guy had passed out and cut his head open. He was brought in via ambulance and wanted to be immediately released. The problem was that because his blood alcohol was 250+ we could not release him out of liability. So if we released him and he went out and fell down and injured himself he could then sue and we would be found liable for this wonderful individual's poor decision making ability. 

Now we had a dilemma. He did not want to be there and we did not want him there as he was rude loud and generally a pain in the ass. The doctor explained that 10 different people had tried to calm him down and get him to accept treatment for his laceration and everyone had failed. I sheepishly offered my assistance trying not to offend the doctor who had just failed at his attempt. The doctor said "good luck, this guy is impossible!" So I grabbed some cookies and made my way to the patient's room. I entered the room and tried to sum up the situation. I noticed the patient had a burberry suit on and name tag from a local bank branch. I quickly asked the police officer to uncuff the patient from the bed and I asked everyone to leave the room. The cop said "Doc, this guy has attacked everyone and is a complete asshole. Are you sure you want me to unlock him?" I smiled and nervously told him to uncuff the guy and then wait outside of the room.

The officer uncuffed him and then left the room. I offered the patient a cookie which he reached for immediately. I commented on what a bummer it was that his amazing suit now had blood all over it, I then said "life's a bitch, isn't it" to which he laughed and sat up. I sat next to him on the bed and begun to talk about some of my frustrations with life. He kindly offered some advice and thanked me for the cookies. I continued to break all the codes of professionalism and enjoyed a cookie myself. This was the first time I had sat down the entire shift. We continued our conversation about life and I maneuvered the conversation into a discussion about his problems. 

He was fired from work that day and was out drinking his sorrows away and the next thing he knew he was in an ambulance. He had no money and was in debt already and was nervous about how he would pay for all this medical care. He asked to be released and because he was considered a danger to himself and others, not to mention his 3.0 cm bleeding gash on his head, his request was denied. He then admittedly became belligerent and was soon manhandled into submission which led to more A-hole speak and then more manhandling and the cycle continued as both party's egos were bruised and insulted. 

I listened as he explained the calamities of his life. I then asked him if he would let me put staples in and fix the wound on his head. I explained the risk of infection if he chose to leave the wound unrepaired. I also explained that if he may be able to negotiate a deal with the hospital once he gets his bill. I continued to explain that many times due to all the "no pays", the hospital and other medical fees can sometimes be negotiated. He appreciated this but still only wanted to go home and put hydrogen peroxide on the wound. I told him he would have a blond spot on his head which would require other blond spots to be bleached in to make it look like he was going for the spotted cat look. You can't really wear a Burberry suit with dignity with 1 blond spot on your head. We had a good laugh and he finally gave in when I explained that the practice would help me out. 

I quickly put 7 staples in the wound after I irrigated and cleaned the wound. No one would assist because they were all still fuming over their wounded egos. The entire process took me 18 minutes. I came out of the room and told the doctor to document that I had put in 7 staples. He asked me "how in the hell did you get him to allow you to do that" I replied by saying "I promised to show him photos of your momma and that the patient jumped at the opportunity" The doctor chided back with you mean the picture of my mom and your mother making sweet, sweet..."

Many hours later after the patient had sobered up and we discharged him, on his way out the door he yelled "Everyone in here but Doctor J, can go F&*%%^ yourselves! Dr. J you my man!" I replied with "thank you" and then told the doctor that the customers always right and the he should get on the patient's request immediately and that bathroom 4 was vacant. He laughed and we both went to see our different patients. 1 overdose and 1 suicide attempt. 

You down with PID, yeah you know me!

I get in at 10:30 pm Friday night and a nurse grabs me and says:

"you have a 16 y/o african american female in room 18 complaining of abdominal pain. Her mother is here with her".

What could it be? One thing is for sure, she has to be in some pretty good pain to get her mom to drive her here on a Friday night. Abdominal pain in a female could mean a lot of things. We call this a differential diagnosis, which basically means listing out everything it could possibly be. A few possibilities = gastroenteritis gastric ulcer, duodenal ulcer, GERD, Barrett's Esophagus, Mallory-Weis syndrome, Boerhaave Syndrome, Gall bladder disease, kidney stones, appendicitis, diverticulitis, diverticulosis, ovarian cysts, endometriosis, ovarian torsion, pelvic inflammatory disease (PID), ectopic pregnancy. This by no means is a complete list but a few of the things that went through my mind as I contemplated this patient. 

Each of these disease states will have different clues to help guide you but you can never be too sure. There is always the atypical presentation.  For example if you suspect an ulcer one way to narrow down the location of the ulcer is to find out when it hurts, duodenal ulcers = the pain is relieved by eating but in gastric ulcers the pain is made worse by eating. Usually through asking some questions and doing a physical exam we can narrow the diagnosis down to a few things and the hopefully through imaging studies and labs finally nail down the diagnosis. 

I went in to see the young girl and started to ask a few questions when I realized I would not get too far with her mom in the room. So I told her mom to head for the hills, beat it, scram, etc. Once mom was gone the patient started to cry and said I think that I am pregnant. On physical exam I found that she did have bilateral pain in the lower abdomen / groin area. I knew that she would be needing a pelvic. I asked a few more questions and had the nurse get her urine and some blood to run some labs. My attending and I went back in with a female nurse chaperone and I did the pelvic. I will spare you the nastiness that ensued. It turns out our patient had PID. She was not pregnant. 

I spent a lot of time answering the girl's questions and trying to scare her to think twice about unprotected sex. Her pregnancy test was negative. We treated her PID and sent her home. 

As she was leaving a nurse told me that I had a patient who had overdosed in room 20. 

Welcome to the ER on a Friday night. My shift had just begun....

ER the uninsured primary care clinic?

I would say that about 60% of the patients we see at this ER are not even close to emergency. Of those 60% about 80% are uninsured and have now where else to go to see a doctor. It is an interesting dynamic and it is about 3 - 4 generations deep. For example when grandma was sick she went to the ER, so when mom was sick she went to the ER and now all of Mom's kids and Grandma's grandkids all go to the ER for a sore throat. 

How did this start? I am not sure but in today's generation, these patients have an illness and try to make an appointment to see a doctor and the doctor asks what insurance do you have, and the patients responds with public aid or no insurance. They are consequently told that "the doctor does not see public aid or take uninsured patients". They may try this a few times with different doctors and finally they just come to the ER because they know they will get seen at the ER. It's the law. 

Once in the ER if they do not have a primary care doctor they get assigned to the on call internist or pediatrician. I get to call the on call doctor and tell him/her we have an uninsured patient here for you that you now have to see. As you can imagine the on call doctor is never very happy about this. So, Why would he sign up for call in the first place? A lot of hospitals require a certain amount of call to be on staff, some hospitals pay a nominal rate to take call and others rely on the other insured patients who get referred to them through the same process. 

If the on call doctor does have to come in and see the uninsured patient you can be sure that he is not getting paid. In fact, it costs him money to come in and see the patient and makes him liable because he can and occasionally will get sued by these same patients. 

These are just things I have observed about our medical system as I have worked here in the ER. I am not trying to make any statements or judgements, but just simply saying; here is what I have seen. 

Now I must leave to get to the hospital for my overnight shift. It is friday and I am sure the drinking/drugs have begun so it should be a good night and a busy night. All these partying people keep the ER busy. I shall go down and report!

Beer bottles, blood and tears!

So last night I worked the 11:00 pm to 7:00 am. It was crazy, I tell you! The night started off slow, I had a 32 year old girl with a bruised leg (small bruise) who thought she was having a DVT. She was scared and had no real reason to be in the ER. We did all the appropriate tests for DVT's, Pulmonary embolisms, hypercoaguability syndromes, platelet issues and electrolyte imbalances. When all was normal we reassured her that she would be fine and that she should return home to her husband and 3 young children and explain to them that in the ER she had just spent all the Christmas and vacation money for the next 3 years. 

Then all hell broke loose. 2 opposing gang member got into a fight over a lady friend and attacked each other with beer bottles. They were brought in by the police and continued to try and fight in the ER. I was assigned to put both of them back together again. The first guy was kicking screaming and swearing at me and everyone else. I had 2 detectives, 2 police officers and a couple of nurses all crammed in a room while I tried to calm him down and suture him up. He looked at me right as I was starting and said "you look nervous" and "I have AIDS!" Those were such comforting words as I prepared to inject his many lacerations with lidocaine 2%.  Finally I had to ask everyone to leave so that I could finish the suturing without all the fanfare. The patient was given some Ativan which helped calm him a little and I sewed him up. 38+ sutures in all. He had a huge forehead flap that I had to repair. You could see the skull looming below the laceration. He also had several lacerations on his arms. Once I finished him up I had the other guy he had been fight with.

This patient had more lacerations but was much easier to work on. He was calm for the most part. So I put 40+ sutures in him which included fixing both his upper and lower lip. He told me he wanted JayZ lips. I also had to put his ear back together and the attending Doc helped me with the ear surgery. I calmed the patient by talking to him about old school rap artists like KRS1, Slick Rick and NWA. He thought it was funny that I even knew who these artists (term used loosely) were and that a cracker like myself could actually be cool. 

Then I was ready for a break and as luck would have it, some 30 year old white male was drunk and happened to get attacked in his own kitchen by 4 knife wielding assailants. Evidently he had done nothing to get involved in this altercation and was simply a victim of circumstances. It does not matter to me, I just get to fix him up. So I sutured him and looked at his nose which turned out to be fractured. Circumstances can be a bitch! I fixed him up and finally had a chance to breathe. 

It was 6:00 am as I put the last suture in, I finished my paper work and left for home realizing that I never ate or drank or urinated the entire shift. I was busy having too much fun. I get go back tonight for another graveyard shift.

Lesson = do not be a victim of circumstances.

How does patient flow work?

Last night I look on the computer to see what patients are being triaged and roomed. We can see a list of patients that are checked in the waiting room and why they came to the ER. The note next to these patients is usually what the patient said to describe their problem, "sore throat", "knife wound", etc. If it is a major issue they are assigned a higher acuity and moved quickly into the exam room. 

Once the patient is triaged by a nurse or tech and put into an exam room, the nurses description is next to the patients name on the computer. This is usually a more accurate or descriptive explanation. The patients are assigned to one of the attending physicians and usually are up for grabs for the medical students to go and see once the patient has been prepped

At this point the patient is in the exam room and a tech will enter the room and start drawing blood, putting in an IV and some basic protocol tests will be started depending on the type of patient. For example if the patient has chest pain and EKG may be started before the doctor even gets to see the patient. 

Once the tech is done I can go and see the patient and start the work up. I will get a history and perform a physical exam. Then I will report my findings and recommendations (assessment and plan) for treatment to the attending physician. If the physician agrees we move forward with my plan or maybe a slightly modified plan per the doctors suggestions. Depending on the acuity of the patient the doctor may poke his/her head in the room and say hi or he/she may come in and repeat a history and physical or certain aspect of it to make sure we did not miss anything. 

The assessment and plan include tests, drugs, hospital / surgical plans.

Sutures and Staples

I have become very comfortable with suturing and stapling lacerations. I have done 15 + laceration repairs with sutures and another 10 + repairs with staples. If the laceration in on the head, in the hair I will use staples and if the wound is elsewhere like the hands, arms, legs, etc I will use sutures. I use thinner sutures in the face 6.0 nylon and on the hand I use 4.0 nylon. I now handle these repairs from beginning to the end. I give the anesthetic / nerve block and I will order an Xray if I think that bone may be involved or if I think there may be a foreign body in the wound. Then I repair the laceration and send the patient home. We also give a tetanus booster if needed.  I like suturing. 

Panic Attack

Today I worked from 1:00 pm to 12:00 am. I saw 5 different  patients with panic attacks / anxiety. Of course they do not show up complaining of "panic attacks", instead they say that the can't breath, they think they are having a heart attack, they feel like they are dying and they feel tingly / numb in their extremities. So I come into the room and have to try to sort things out. Is this a heart attack? Are they having an anaphylactic reaction to something? Usually we get an EKG to look at the heart and rule out an arrythmia we will look at cardiac enzymes to rule out MI. We also look at electrolytes and other blood work to help diagnose what is going on. Usually we can get to the diagnosis without all the tests but we have to do the tests "just in case". We give them ativan to calm them down and then talk to them about anxiety and treatment options. Usually just talking to them and helping them realize that they are not dying. Most of these patients have a history of anxiety and depression and are usually on medication for the anxiety / depression. While they are having the panic attack they really do feel like they are dying.

What does a medical student do in the ER?

We can do all kinds of things in the ER under the loose supervision of one of the attendings. I have done 10+ cases of sutures, many staple sutures of head lacerations, rectal exams, pelvic exams, nasogastric tube placement, IV lines, blood draws, assist with intubations, CPR, cyst debridement, assist with traumas, assist with central line placements, and many others.etc. Many of these things we do unassisted and on our own. 

Most of these procedures depend on the confidence that the doctors have in your ability and your assertiveness. I love doing these procedures and get excited every time I get to do one. I imagine after doing many of these they would become less and less exciting. 

Welcome to the ER

The hardest part about my first rotation is trying to figure out the expectations of each of the different attendings. Some want you to be aggressive and take patients and then do a H&P (history and physical). Others find this behavior way too forward and feel that because it is our first rotation we should only observe and follow a doctor around all day only observing. Still some want kind of the combination of the 2 extremes. These differing doctors are the same doctors who will evaluate us and provide us with the feedback that ultimately determines our grade. 

Figuring each attending out and what they expect can be the challenging part. I have completed 11 shifts and I think that I have figured out most of the doctors but there are several I have not worked with yet. I am really hoping for an A in this rotation given that I may decide to go into emergency medicine. The A would help strengthen my application.

At the end of this rotation we have an exam about emergency medicine topics, like pancreatitis, kidney stones, etc. I have heard the test is a little nit picky and it is the only exam we take all year that is not a national exam. In years past the department has offered a review for the exam but this year they are not doing the review.

3rd year rotations Intro to ER

Sorry for the lack of activity. I am back. I started my rotations on July 7th. I am 1/2 way through my first rotation, which is Emergency Medicine. I love it. There are lots of procedures and lots of medicine. Plus there are tons of different pathology. I think that ER is near the top of my list for possible choices. 

I like the fast crazy pace and the ever changing plots of the ER. The time seems to wisk by at a rapid pace. I will look down at my watch and realize that 4 - 5 hours has gone by in what seems like 30 minutes. I work 9 hour shifts = 7:00am - 4:00pm, 12:00pm - 9:00pm, 2:00pm - 11:00pm and 11:00pm - 7:00am.