Have you waited long enough? Part 2

This is the continuation from the August 4th blog. Sorry for the long delay. I have been preparing for my next board exam. It is in 2 weeks and I have been locked down studying. Here we go..

I held tight to the IV that I had worked so hard to get into the vein. The patient continued to heave while I secured the IV. I looked up at the nurse and she apologized with a smile as I looked at my once freshly pressed white coat now stained with blood. I handed the IV port to the nurse so she could begin siphoning off the blood that was needed for all the lab tests we were about to order. I took my stained lab coat off and threw it in the biohazard bin. This coat was too far gone with 40 - 50% 3rd degree stains there was no saving this coat. I washed my hands and arms in the exam room sink while the nurse continued to get the blood samples.

The patient slumped back on the exam table and moaned interrupted occasionally by surging dry heaves. I asked the husband several questions about his wife and her condition. He explained how they had been enjoying a nice evening when his wife became violently ill. He seemed oblivious to the fact that his wife looked as though she had been covered in yellow highlighter which told me that she had been yellow for a while and the onset was insidious. I asked about her drinking and he boldly denied that there was an issue with alcohol. "we only drink socially" he said. I quietly thought to myself, they must be pretty social people because her condition screams 30 years of being extremely social.

I returned to the moaning patient to examine her and continue my quest for clues. The dry heaving had subsided and I needed to get a nasogastric tube in her nose and to her stomach so that I could determine if she was actively bleeding. Many alcoholics will have a gastric bleed that can be life threatening if it is not stopped. I put on new gloves and grabbed the tube. I knew this was going to be a wrestling match to get the tube placed. The nurse helped secure the patient as I prepared the tube and numbed the patient's nose and throat with some lidocaine gel. I inserted the tube in the patient's nose and she bucked and kicked. I asked here to swallow and told her it would all be over soon if she cooperated. To everyone's surprise she swallowed without any issue and I was able to pass the tube all the way into her stomach.

I hooked the other end of the tube up to the suction and flipped the switch. I watched as a blackish red fluid began to flow from the patient's stomach up her esophagus and out through her nose. This fluid started to fill up the bucket that was attached to the tube. I had several spare buckets ready to go. I continued to push saline into her belly at the same time. This process requires that you continue to fill the patient's belly with saline and then suction the stomach until all you see is clear fluid coming from the stomach. If you do not get clear fluid and it remains red then you know you are dealing with an active bleed. Alcoholics bleed.

I leaned against the wall and watched as the fluid continued to come out. I hoped that the color would begin to fade from black red to clear. I looked at her nervous husband and could tell he loved this women and I wondered what their life had been like. How many kids did they have? What kind of work did he do? What kind of work did she do? Did they have any grand kids? How did they meet?

My thoughts were interrupted when I noticed that the patient's hand began to flap. It was like she was trying to clap with one hand. I had seen this before and knew what it was, this was asterixis.......

To be continued.... (It won't take a month this time)

Emergency Reflections

I have been finished with my recent Emergency Medicine rotation for a couple of weeks now and have not had the opportunity to write much lately. So I thought I would post about a cases I had in the emergency department. I am going to post it in first person story form. 

It was about 1:00 am when a older looking women carried by a man was violently heaving blood into a metal kitchen usually used to cook a Sunday dinner. I glanced up from the chart I was working on and I was nearly blinded by the bright yellow glow exuding from her skin. I have seen jaundice many times but this was a bright yellow and her eyes were also taxi cab yellow. The pot was filled with bright red blood. She continued to purge blood from her innards into the pot and the bright red blood popped against her bright yellow skin. It was actually a beautiful combination of colors, like a modern painting. 

This women is sick, I thought to myself as I helped move her onto the bed in the resuscitation  room. As I looked at the bright colors I quickly ran down the differential diagnosis in my brain. What is wrong with this lady?  I looked her up and down and looked at the man who had carried her here and I assumed that he must be her husband. The yellow skin and eyes was a sure sign of liver involvement. Liver pathology in America often means alcohol. I was quickly cataloging and searching in the file cabinet in my brain for everything I knew about the liver and liver disease. I was flooded with information and experiences that I have gathered over last few years. 

As I questioned the patient and began stabilizing her and talked to her husband the clues began to accumulate. The most helpful and telling clue was the stench of alcohol that filled the air. The nurse was struggling with the IV, she could not get it in and we needed access to the patient's blood. The nurse looked at me and said "doc, can you help me with this?" I wondered if this patient had hepatitis or AIDS. I had gloves on at this point and I grabbed the IV from the nurse and began feeling and looking for a vessel to exploit on the patients arm. It was small but I was confident. I began inserting the IV and all was going smoothly when the patient began surging and I knew what would happen next. I had realized I was in the vein and I did not want to loose this IV so I held on strong as the patient heaved blood all over my arm. My lab coat was speckled with bright red blood. 

I got the IV in......

To be continued.

Goals in the ED

When I walk into a patient's room in the emergency department (ED) I have 3 questions in my mind. 1) What diseases / pathology can kill this patient given their presentation? 2) What can I do for this patient while here in the ED? 3) Where is this patient going, following my treatment? 

It is important to make sure that I do not miss something that could kill the patient if missed. Fortunately I have lots of back up at this point in my training to make sure I do not miss something. In order to rule out things that may kill the patient I may need to do a thorough history and physical exam. I may also need to order certain imaging and lab studies. Eventually when I have ruled out things that could kill the patient and in the process narrowed down their diagnosis I can start a treatment plan. Finally I figure out where the patient needs to go. I could discharge the patient home, admit for observation, admit to the ICU, send the patient to the OR for surgery or several other options. Then I need to make this happen which may include getting a specialist involved or talking to the patients family. 

This is a very basic outline of some of the ED physician responsibilities. It can be easy to assume the patient is fine and just discharge the patient without worrying about some of the other things but this is a rookie mistake and will eventually get the ED doctor in trouble. 

These are just a few of the thoughts that go through my head as I meet a new patient and their family. 

Inside Emergency Medicine

I am really getting the whole idea of what it means to be an emergency medicine physician. Every specialty in medicine / surgery has their own niche in the medical world. As you finish medical school and pick the specialty you want to pursue you have to have a paradigm shift. Medical school is all about general broad level learning. You have to learn a good amount about a lot of areas of medicine. During residency you focus the learning to know a lot about your area of expertise. I am starting see what will be necessary to learn / master in order to be an excellent emergency physician. 

The unique thing about emergency medicine (EM) is that it requires a broad knowledge on a ton of subjects within medicine and surgery. You basically never know what is going to come through the door. It can be a trauma to any given area of the body, fracture, delivery of a baby, heart attack, stroke, seizure, pediatric diseases, gun shot wounds, suicide attempts, etc. You have to be prepared to see every area of medicine. You mostly focus on the acute treatment of these pathologies. You are not there to treat the chronic pathology although you are forced to treat some chronic condition for those who use the ED as primary care. It can be overwhelming because you have to know a lot about a lot.

You will end up admitting about 30 - 40% of the patients you treat into the hospital which means the remaining 60 - 70% you treat and send home and you are the patients only contact with a physician for the given problem. You are the frontline of medicine and often your diagnosis and starting the treatment will guide the rest of the care for those patients you treat. This means you have to get it right because the doctors who will go on to treat the chronic side of the pathology will rely on your diagnosis. If you get it wrong then the remaining care is often wrong as well. You have the potential to get everyone on the wrong path or steer them onto the correct path to wellness.

There is a lot of liability and lawsuits in EM. You have to juggle many complex patients at the same time. While you are delivering a preterm infant you have a patient in respiratory collapse in the next room and blunt trauma from a car accident in the trauma bay and you have to manage all of the cases, particularly if you are the only doctor working the ED that shift. Another frustrating aspect of EM is that it is always easy for others to see your mistakes in hindsight. The critics always forget that you are working under extreme time pressures and with many other patients and generally without a diagnosis. You have to simultaneously diagnose and treat all at the same time. 

EM can be fairly demanding and thankless to a certain degree. You either love it or hate it. So far I seem to love it.

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.