My Play Ground, The Emergency Department

I finished up my first week in the emergency medicine. I have seen so many wild cases. I have had 3 gun shot wounds, 2 stabbing, car accidents, trauma, liver failure, drug overdoses, diabetic keto acidosis, drownings and a bunch of seemingly more boring cases. In the ED you get your hands dirty and you get to do lots of procedures. I never know what I am going to see prior to each shift which makes it exciting and never boring. I will try to document some interesting cases over the next few weeks.

My attending shouted across the room and said "will you go see the patient in room 11 and I will take care of room 8". I yelled back "no problem" and quickly made my way to a computer to see if I could see what was waiting for me in room 11. I scanned the computer screen and saw the words spider bite on the screen. "Easy enough" I thought to myself. The patient had been here for 3.5 hours so if it had been too bad or poisonous I am sure we would have already treated the patient. I opened the curtain and saw a large African American male with a baseball cap on backwards and arms covered in gang tattoos. I introduced myself and asked "what brings you here today?" He glanced up and replied "doc I think I got bit by a spider or something and it hurts!"

I looked at his arm where the alleged spider bite was supposed to be and sure enough he had a large bulging bump on his forearm. I began to examine the bump and ask the patient about when, where and how this happened. It did not look like a spider bite to me. It looked more like an abscess and I noticed a "head" in the middle of the bump. I began to ask him all about his medical history and his life to see if I could piece together an explanation. He explained that he never saw or felt a spider bite him. He just assumed by looking at it that it must be a spider bite. He explained that he worked as a barber and as I looked closer at the bump it looked a lot more like folliculitis (infected ingrown hair). It certainly was infected which meant it needed to be opened up an drained and packed. 

I left the room t present the case to my attending physician and get the supplies to fix the abscess. The attending physician poke his head in and looked briefly at the abscess and told me that he agreed with my findings and to "just take care of it". I returned with all the tools and medication to fix it. I injected the lidocaine to numb the area and then made a small incision to avoid any important structures in the arm. The pus began to flow like a river out of the abscess.

As the pus flowed I realized that there were a few small hairs in the middle of the abscess and I cut them out. It looked like the source of the problem. I showed the patient and explained to him the pathology behind  his abscess. 

I nursed as much fluid out as I could and then used forceps to break apart the abscess and proceeded to clean it out completely. The patient could not watch the action and continued to look away. Finally I packed the wound and bandaged it up. He felt a lot better because I had relieved most of the pressure when I cut it open and drained it. 

The patient thanked me and I sent him out. I am not so sure that this was an emergency but we took care of it anyways. 

Emergency Medicine (EM)

Life is good in the Emergency Department (ED). They do not like it when you call it ER or emergency room (whatever). I am in the middle of a month long rotation at an inner city emergency department. I am using this rotation to hopefully "wow" them so they consider my application when I apply. It is like a month long interview. This makes the experience a little more intense because you are on edge and trying to impress everyone. I really do like EM. It feels like I was born to do this. 

I just completed the first week of the rotation. I have had so much exposure and hands on experience. The attending physicians tend to give you more respect and trust you slightly more as a 4th year medical student. During my 1st shift I was talking to the head doctor of the ED and he basically told me that I have free reign and can do as much as I would like and the only way I would get in any trouble is if I get in over my head and do not ask for help. My first couple of shifts they watched me closely to make sure that they could trust me and also evaluate my abilities / knowledge. This of course was not openly discussed but by my third shift I felt that I had gained their trust and the "set me free" to work like a resident which is still under supervision but I was able to do and see a lot more.

I like the excitement and the constantly changing environment of the ED. You never know what is going to come through the door. It could be a gun shot wound (GSW), a laceration, MI, stroke, motor vehicle accident (MVA) or a headache. You see it all. It is fast paced and always changing. You either love it or hate it. I guess I fall into the "love it" category". It is never boring. Another great thing about the ED is that you get to do lots of procedures, put in central lines, laceration repairs, intubate, cardioversion, set broken bones, chest tubes, nasogastric tubes, ultrasound guided procedures, etc. So far this week I have done several wound repairs with sutures and staples, paracentesis (draining fluid out of the belly), chest tube for a collapsed lung, several nasogastric tubes, chest compressions, set fractured bones, fix a dislocated shoulder and it has only bee 1 week. 

4th year! I am in my last year.

I have officially finished my 3rd year of medical school and I am no longer a junior medical student but now I am a senior medical student. As a 4th year student you receive less of a beating from superiors but you are also expected to know more and be able to do things. 

What is the difference between 3rd year and 4th year? During 3rd year you are required to complete all of the required core rotations. These include rotations in pediatrics, internal medicine, surgery, etc. Generally you are there to learn the basics and you are not required to have a ton of responsibilities. You do get grilled a lot on the basics. During 3rd year ideally you should figure out what you want to specialize in and what residency you want to pursue.

4th year is all about doing electives in the area of medicine that you want to pursue. You can use these rotations as an extended interview to showcase your abilities at programs that you want to apply to for residency. Also during 4th year you apply to residency. You have to submit all of your applications to residency programs. If a program likes you application you are then offered an interview which are done October - February. Then in March you find out where and if you matched at a residency program. During 4th year you also have a little more free time and the attending physicians are easier on you because they know that next year you are going to get slammed during your intern year. 

This week I started my first 4th year rotation. I am doing a month long rotation in emergency medicine at a teaching hospital. I have only had a couple of shifts so far but I love it so far. 

I shrunk the fetus.

So I was on the MFM service the other day and the attending physician who is very well respected and a talented clinician was supervising my work. I had worked a couple of shifts with him and I was slowly proving to him that I was not completely inept. However I still had a long way to go. This doctor is well known among the students and the residents for having a very "in your face" style of medicine. You had to have thick skin and realize that this is just how he taught. He likes to ask you progressively more difficult questions and when you miss one he goes overboard; "doctor you have disappointed me!", "Unacceptable, how do you not even know the very basics?", "you are a danger to the medical community", "did you read anything?" "what is wrong with you?",  "You do not know anything!" Following his hoopla he begins to teach you like no other can. He has vast amounts of experience and really knows medicine from every angle. More importantly he takes the time to teach you and he really does care about your learning and knowledge.

He gives you a lot of autonomy to perform the ultrasounds and make all the measurements of the fetus. Of course, he checks your work and determines if you are doing the ultrasound correctly. Many students become nervous on their own and while taking measurements / pictures with the ultrasound they can back into the numbers by figuring out how old the fetus is and what the fetus's measurements should be. Students can "cheat" this way and everything will be correct if the fetus has progressed normally. If you have a fetus and according to your ultrasound the fetus is measuring small for it's age you can adjust or re-measure and try to get normal measurements. If you report that the fetus is small according to your ultrasound measurements and when he checks the measurements he finds the fetus to be normal size you are going to get an earful about not knowing / understanding how to do ultrasounds. Many students will "fudge" their numbers. 

I had a 22 week pregnant mother who presented to have her baby measured and evaluated via the ultrasound. She had had a normal pregnancy up until this point. I made several different measurements and they kept coming up small. I looked in the chart and saw that the fetus had normal measurements 10 weeks ago. I continued to work the ultrsound and finally had confidence in my measurements and recorded my findings. I stepped out of the exam room and found the attending physician and explained that the fetus was small. The doctor immediately squawked "you have no idea of what you are doing! I am sure the fetus is normal, go remeasure it!" I replied; "actually I think that this fetus has asymmetric intrauterine growth retardation (IUGR)and I am confident with my measurements." In a huff he ran to my exam room and began to ultrasound the patient and her fetus. As he was doing this he continued to explain that I do not know what is going on and I need more practice / experience. I noticed as he was measuring he kept getting similar measurements to what I had found. He would quickly remeasure and check again. Finally after realizing my measurements were accurate he blurted out: "Doctor you have shrunk the fetus! What did you do?" This baby has asymmetric IUGR. 

On his way out of the room he said "good job doctor! at least I know you do not cheat with your measurements, which is more than I can say for a lot of the residents! Nice catch!" "Now get back to work!"

Maternal Fetal Medicine

This week I have been on the Maternal Fetal Medicine (MFM) service. MFM is a specialty fellowship that some OB/GYN doctors do to get specialized training in the management of high risk / complicated pregnancies. These pregnancies include many different scenarios. For example they manage complicated multiples, drug addicted pregnancies, pre-eclampsia, pre-term labor pregnancies, maternal disease / illness pregnancies, etc. If a pregnant women is being cared for by her regular OB/GYN and he/she determines that there are or will be complications in the pregnancy then they will refer the mother to a MFM specialists. Some regular OB/GYN's may continue to manage high-risk pregnancies but usually when it becomes too complicated they will refer out. MFM doctors spend all of their time managing difficult pregnancies with complications. 

I liked this service because most of the cases were interesting. The mothers I saw and helped with their treatment would have lost their pregnancies 20 years ago. However because of advances is knowledge and technology we are now able to help a lot of these patients have successful births. I would see women in the MFM clinic all day that were either regular MFM patients that we were monitoring or they were new patients referred to MFM to be evaluated. I would  ultrasound the mother's fetus and measure the amount of amniotic fluid, check the cervix and then make management discussions based on the findings. I would present my findings to the MFM attending physician and he would check my work to make sure I had the correct measurements and interpretations.

I saw pregnant drug abusers, diabetics, cancer patients, pre-eclampsia, seizure disorders, triplets, quadruplets, heart failure, kidney disease, and many other diseases. All of these patients had one extra complication; they were pregnant. With the proper management many of these mothers will go on to have a fairly normal birth. However there were also many who would end up with fetal demise or severe complications that would affect the mother and the fetus. MFM believes that you treat the mother first and then the infant. This is a complicated and controversial. Some of these cases were sad and involved difficult scenarios where entire families were involved and concerned. 

I did some many ultrasound evaluations this past week that I feel pretty confident in using an ultrasound to evaluate pregnant patients. I can determine the age of the fetus, the sex of the fetus and many irregularities with ultrasound. I am glad I had this opportunity and the attending physician gave me a lot of autonomy to learn by doing. 

Labor and Delivery Nights

Last week I was on L & D nights which started at about 5:00 pm and went until 9:00 am the next morning. I had some long nights but I really liked the work. I hated being away from home and when I was home I had to sleep while everyone was up. That part was not fun and I think it gave me a taste of what some of my residency will be like. Basically, with a long schedule like that you pretty much just work at the hospital and sleep with no time to do anything else. 

Like I said, I did enjoy the work. I was in charge of evaluating any new patient sent to L & D by their private doctor or by the Emergency Department. Many of the patients were in real labor and showed up to deliver. There was also a large group of patients who were in false labor and finally we had many who were in preterm labor with complications. I would examine each of these patients, I would take a detailed OB history asking about their number of pregnancies last menstrual period, Expected due date, related problems, past medical / OB history, etc. Then I would do a cervical exam to determine the status of the cervix, I would see if the cervix was dilated. I would also take samples of fluid to test for certain infection like gonorrhea and chlamydia. I also would test the fluid to determine if it was amniotic fluid. You put the fluid on a slide and let it dry and then look at it under the microscope and if you saw "ferning" you could figure that there membrane had ruptured (water broke). A second test for ruptured membranes that I also did was nitrazine paper test. If the nitrazine paper turned blue when exposed to the fluid, it also indicated membrane rupture. The nitrazine test reacts to the pH of the vaginal fluid. Amniotic fluid has a more alkaline pH compared to the normal vaginal fluid. 

If the patient had premature rupture of membranes then we had to manage them according to how far the pregnancy had progressed.  Following these tests / exams I would do an ultrasound to determine how the fetus was doing and look for any complications. I also would hook the patient up to a fetal monitor and check the fetal heart tones and monitor contractions. By the end of the week I could go through these exams fairly quickly and determine if the patient needed to be admitted or discharged. This was a good rotation for me because these skills will be required in my residency and practice after residency. 

I also saw lots of complications of pregnancy; drug abuse, premature delivery, fetal demise, preeclampsia, eclampsia, and the list could continue. I had my fare share of normal deliveries and was able to help in some c-sections. We made every attempt to deliver the babies vaginally but in some cases a c-section was ultimately required. I really enjoyed delivering the babies. I had some very sad cases where the baby was born dead due to various problems and these cases where always difficult. The family was always devastated and there was not much that could comfort them. Fortunately I did not have too many of these cases. The drug abusers were also difficult cases because it was hard to see these innocent babies born with addiction and into that kind of environment. It was hard to have hope for those children given their environment and inept parents. 

It was a great week. I am tired. 

Learning the details

L & D (Labor and Delivery) has been long, long hours but I have liked the work. I miss the time at home with the family. It stinks to not be at home much but at least I enjoy the work. 

I have been on nights this week. The overnight shift is a whole new world and is different than working the days. You do not have all the back up staff and specialists available but you do have the basics like anesthesia and other needed staff. The cool part about nights is that I get to be more involved and play a more active role. I have come a long way on doing ultrasounds to check out the fetus. I can now do them completely on my own and actually make all the proper measurements and interpret the findings as well. I run my work by the chief resident to make sure everything is good and done properly. I also have become adept at doing pelvic exams to determine cervical status. It is really great to have the opportunity to learn all these things. I am fairly comfortable with most births at this point and how to do / manage the birth. I also can do the proper repairs if the mother tears. 

Regardless of the specialty I go into, I think that this information and skill set will be handy to know. You can use these skills in the ER and in various situations as a doctor if needed. I enjoy the whole process. The families are usually happy and there is a good feeling in the air at the births. Occasionally it can be devastating if there are problems with the fetus but fortunately a lot of the births are healthy. It is a great feeling and pretty cool to be involved and part of the lives of these parents / families. They will take pictures with you and remember you as part of their process for a while at least. 

My last shift is Saturday night / Sunday morning. There is something miraculous about birth no matter how many times I am involved in the process I find it amazing every time.