Category Archives: Emergency Medicine

It ain’t all bad

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Okay, fine, maybe peds is not 100% bad. When you examine a kid, and he crawls across the bed and into your lap and starts trying to auscultate himself with your stethoscope, huge grin on his face,  maybe that part is okay.

 

Due Dilligence

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Being at the children’s hospital for the past few weeks, especially coming off a month of vacation, has been absolute torture. Just…give…me…one…sick…patient! PLEASE! I know that sounds horrible to ask for, but when there are 5 residents covering 13 rooms, and it’s yet another kid with fever, but running around the room like a tornado, it feels like pulling teeth one agonizing patient at a time. The challenge here, and the thing that scares me a little, is that 95% of these kids are totally, absolutely, no doubt about it fine.  But some of these other little buggers, there may be some little thing, some little harbinger of impending doom, that if you don’t pick it up, these kids might not do so well. And that’s really no different than adult medicine when you think about it, but still, they are kids, and no one wants to do harm to a 1 year old. So the challenge has been to stay sharp, to do due diligence on each kiddo, get them all undressed, look em’ over from head to toe. Ask all the questions, to each patient, each time, even though, the majority of these kids can be discharged from the doorway.

So last night, I was seeing a 4 year old, mom brought her in for cough and congestion and some dry skin on the face. Clear as day, the kids got a simple URI, but I got the kid undressed anyways, just to make sure she wasn’t retracting or anything like that. And when I did, I noticed two 4cm marks on her forearm.

“Sweetie, what happened to your arm?”

“My mom hit me with a belt!” (all smilely when she said it too). And of course mom is sitting right there. Mom openly admitted to it, giving the reason that she has six kids, lost her cool one day, it only happened once, she feels horrible, and has enrolled in parenting class.  Fine. Still gotta fill out my paperwork and call child services.

I’m not trying to say, oh look how great my H&P is, rather, just how easy this would be to miss. I’ve been really trying to do my H&P’s the same for most everyone, adults and kids, regardless of what the complaint is, same set of basic questions, same basic physical exam maneuvers, and then focus and expand based on the complaint, just to make it habit, so when it’s 4 am and I’m dragging my feet, habit will kick in and make me check these things that I might not bother to otherwise, as was the case with this kid.


(plus, the set of questions I ask, hits 10 systems on the ROS, two per system, so that way I’m not actually committing medical billing fraud when I document my level 5 chart! Bonus!)

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I think that one of the best things we do in the ICU is when we allow people to die with some degree of peace and respect. We recently had a Cambodian patient, on life support, with no hope of recovery. Discussions were started with family about withdrawal of care. And while they were in support of the idea, their concern was that he somehow had to die at home, and not on a Tuesday.  I understand the dying at home part, but I was never clear on what it would be bad for him to be allowed to pass on a Tuesday. It had something to do with his Buddhist religion, but I was never informed of the specific reason. I would have asked all the monks that where there in their orange robes, but none of them spoke English. So when Wednesday morning rolled around, the monks and family gathered in the room, the ambulance crew showed up. We loaded him onto the stretcher and literally pulled the breathing tube out as he rolled out the ICU doors. Medics were instructed to NOT check a pulse, NOT check for breathing, not to do anything other than get him home as quickly as possible. And, under no circumstances, where they to come back to the hospital. It was the best thing we did in terms of patient care all month.

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One of the things in medicine that most amazes me, is when a woman chooses to have prophylactic mastectomies. I can only imagine how difficult a decision that must be to make for a woman, or anyone facing a similar choice. I say this as I had a 25 year old patient who had undergone elective bilateral mastectomies a few months ago, and was presenting with breast pain. Now, most of the young people I see in our ED’s, especially the women, for whatever reason, seem to be a good 5-6 years behind on the mental maturity curve. I’m sure the guys are just as far behind, and that’s probably why they don’t bother coming to the ED, haha. But, this woman was different. Maybe she was just innately mature, or perhaps it was having to make such a  heavy decision at such a young age that made her grown up fast. Regardless, she was incredibly impressive in her outlook towards her situation, and her life in general, and was true pleasure to be able to treat.

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I was in seeing an older couple, probably late 60’s, the wife having come in for chest pain. They were recent immigrants from Turkey, if I had to guess, within the past few years. The husband had a basic grasp of English, but hers was still a work in progress.  Culturally, they were still obviously working on acclimating, the husband wearing a bright red, entirely too tight tank top, and leather biker’s cap, on a freezing cold winter day.  They were both very pleasant people, trying their best to understand what was happening, but anxious nonetheless, despite multiple reassurances, both very concerned that I was admitting her to the observation unit for a chest pain rule out. Looking back, their anxiety makes sense, I can imagine that in other countries being admitted into the hospital must be a pretty big deal, and probably only happens if you are pretty sick.  Not necessarily so in this country, but a topic best discussed elsewhere. After multiple trips into the room to answer all the husbands various questions and to reassure the wife that she in fact was not dying, I noticed that they both were wearing matching necklaces. The necklace was a gold chain attached to a black leather triangle, maybe 3cm at it’s widest point, and it actually appeared to be a pouch of some sort. On my final trip into the room, I couldn’t help but ask about the necklace and what it was. The husband turned to me slowly, and put his finger to his lips is a “shhh” gesture. He leaned in close to me, and whispered in heavily accented english “ Wife and I are exiled Turkish royalty, necklace contains key to safe deposit box. BIG stacks of money”, making a wide gesture with his hands.  He must have seen the incredulous look on my face, because he waited a few seconds before him and his wife both broke out laughing. Realizing it was joke, made extra funny given the language barrier, I couldn’t help but cracking up too. He then explained it was a prayer necklace, not in fact a pouch holding a key to untold riches.

Catching Up

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I’ve notice among my fellow residency bloggers, that there tends to be significant posting drop off sometime during the second year, and I’ve really tried to not let that happen, but indeed it has.  Maybe it’s that not every single thing is all shiny and new anymore, maybe it’s that I like to think about things other than work when not at work, maybe it’s this or that, who knows.

Regardless, time has been chugging along. Hard to believe that I’m more than half way done with residency at this point.  This year up to this point, has been pretty great, I have to admit.  I feel that I can walk into most any room and have a pretty good idea of what to do. I don’t claim to know it all, by any stretch, in fact, I have a pretty good idea of how high the mountain of knowledge is, still looming above me. But, I feel like it this point, I know how to find the information that I don’t know, if that makes sense.  And this has been something I’ve been actively working on, trying to find answers to new problems, problems I may have never have had to consider before, without just asking my attending.   I do this intentionally, knowing that when this is all said and done, I’ll probably end up taking a single coverage job is some small ED somewhere, somewhere that might not have a lot of backup readily available.

I’ve seen the way I approach patients change as well, over the past 1.5 years, and over this 2nd year especially. I no longer get frustrated by drug seekers, sickle cellers, gastroparesis and what not.  I’ve realized that getting mad, playing bad cop with them, doesn’t actually do anything to fix their problems or relieve their burden on you. Given the wide variety of places they have us work as resident, I’ve seen how many different institutions and doctors have dealt with these types of patients, and are using these as models to develop a strategy that I feel good about personally, while striking a balance between treating the patient and feeding an addiction. “Nasty” patients, still do get under my skin, they still make me mad and frustrated,  but I think that’s a good thing quiet frankly. I’d be more worried if these type of people didn’t upset me from time to time.

And yes, I still loathe nosebleeders. I don’t think that’s ever going to change.

Medical Errors

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I’ve been working in the ICU for the seven days. And 8 days ago, I was actually looking forward to it, which should give you an idea of how bad things were getting downstairs. Like the ED, the ICU has been slammed. The flu has just simply been gumming up the whole hospital, from top to bottom. And unfortunately, it’s led to me witnessing my first medical error. The scary thing is it was not just one, but four, that I can think of, in this past week alone. Going from zero, to four in one week, is kinda worrisome and sobering. One of these errors was directly my fault as well, thankfully to no adverse outcome.  I did beat myself up a bit over it,  but I’m also pleased with myself in that when I learned of the error, I did the right thing, I alerted the team, my attending, completed an incident report, and even called the patients family to tell them of the error, despite there being no real way they would ever find out about it. That was the hardest part, talking to the family.

At least one of the other errors, unfortunately, may have had much more dire consequences. Nobody was particularly to blame, it was a problem with the systems being overwhelmed rather than negligence, but regardless, it’s still hard to not feel somewhat responsible. When the family asks “What happened, how did we get here?” What are you supposed to say? Thankfully, when they did ask me that, in the middle of the night, I had no idea, at that time, of what had happened, so I wasn’t forced to have to decide to tell the whole truth or just part of it. (not that I would keep it from them, but in such a grave error, I’m sure they would rather have heard about it from an attending, not a resident).

Anyways, I think the flu bug is starting to move on and away, thankfully. I know I am still new to medicine, but this was bad. You don’t need years of experience to know that it’s not supposed to be this way, to read the weary expressions on everyone’s face, to hear the anger in the voices of patients being forced to wait hour after hour, to have that aching tiredness from working hard all day and not really sure if you made actually dent in the problem.  It was hard, but as they say, what doesn’t kill us makes us stronger. I hope so.

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I thought this article summarized up beautifully both all ups and downs of the job. What makes it so great, but also so tough at times. Reading it though, makes me proud to say I do this for a living and drives home some of things that get me up in the morning ready to face another shift.

How to be a Real Emergency Physician: An Open Letter to the Recently Graduated and the Seasoned Veteran

James Roberts, M.D.

You’ve found the bathroom, unknotted your stomach, minimized your palpitations, made your first huge mistake, saw a case you never even heard of before, missed your first intubation in years (in front of the medical students), and ordered a BMW pending spouse approval. And you so loved that 10-year-old Honda Civic.

Now it’s time to consider the magnitude of your plight: a real patient’s life or a child’s future are now squarely in your hands in a real ED. Awesome and frightening. It scared the hell out of me when I started, and it still does.

Allow me to pontificate my personal perspective. I don’t want to sound like your father or be too maudlin, corny, or holier than thou, but bear with me; I’ve been around for a while.

Any philosophy is much easier said than done, and this one is the quintessential example. A lot of what I say here is what I like to strive for personally, but I have often fallen short. I screw up about three times a week; I’m just better at hiding it than you. That also will come with experience.

Even after 42 years in the ED, I still struggle with the ideal and philosophical versus the real world. The real world is rife with serious limitations of resources and time, disappointing to incompetent colleagues, ignorant policy makers, and the unavoidable stresses of treating the sick, injured, frustrated, and downtrodden as well as the noncompliant, drugged, drunk, demanding, and overtly hostile. Keep in mind, however, that the 19-year-old with PVCs and the 43-year-old with obvious musculoskeletal chest pain truly think they are going to die. The prisoner TASERed and beaten with a cop’s nightstick or the 26-year-old single mother of five (with two screaming infants in tow) with lower abdominal pain probably does not want to be in the ED at 3 a.m. any more than you do. And maybe those two dudes actually did jump that drunk guy for no good reason.

Few will ever believe the bizarre and macabre milieu that you know as everyday life in the ED. Most of society could not begin to appreciate or fathom what you have chosen to do, most opt to ignore or disbelieve the unpleasantness and think it’s simply a really cool job. Your significant other and your parents will never understand your day at the office. (When will you get a real office like all those other doctors?) They will never understand that “It’s your turn to watch the kids,” or “Can you walk the dog in the snow because I did it four times already” is really not what you want to hear after a 12-hour shift. My wife forgets that I told her not to get that yappy dog in the first place. They muse, how hard can it really be chatting up loquacious nurses, schmoozing with those all too flirtatious medical students, and ogling those much-too-attractive drug reps? Why are drug reps all so hot, anyway, my wife always asked. The answer to that is … duh! The vomit on your shoes and the dried pus on your scrubs should send a message, but go figure.

Talking to the spray paint cans under the Kmart blue light special will often win you a free trip to the ED. The ED will always be at the end of the social, medical, and unsolvable problem funnel. It comes with the territory. You are expected to handle problems that no one else could ever solve; many would not even try. Welcome to reality; sometimes it sucks. Love-hate does not even begin to describe the ED.

Nothing should annoy or faze you, not even an impossible bipolar crack addict, the child molester with AIDS, hellacious maggot-filled bedsores, a paralyzed teenager, or a sudden infant death. You will be expected to be cool, calm, and collected, a compassionate and caring individual, a sympathetic listener to even the most annoying tales, a quintessential politician, and a role model doctor at the same time. You often perform above your comfort level and way above your level of training. News flash: No training totally equips you for this job.

Many of your patients will have no other advocate or support system. If not for you, they are toast. You are the team leader, and you should always portray a positive attitude and professional demeanor and set the tone for the entire staff. Any negative attitudes toward the hospital, paramedics, administrators, housestaff, or especially the patients are quickly transmitted to and adopted by everyone.

You are often treating the disadvantaged, poor, helpless, hopeless, and hapless in a warzone-like atmosphere. If you want a quiet ED with all the bells and whistles and a respectful, polite, sweet-smelling, cash-paying clientele in Versace, you picked the wrong hospital and probably the wrong profession. Should have been a plastic surgeon in Las Vegas.

The system is imperfect, so very, very imperfect. It always has been and always will be. The ED can be God-awful. You will never ever have enough time, resources, personnel, equipment, or backup to make this job an easy one. Deal with that reality. If you want a thank you or even a lunch break, go sell shoes at Nordstrom’s. What size? Which credit card? Now that’s a cake job. On a good day, you have a cold pizza job.

Always put the patient’s well-being and the family’s expectations first and foremost. Everyone thinks you know a lot more than you actually do, so take advantage of that secret, step up, and be the Godsend they expect and think you are.

Above all, always, always, always be nice. Remember, patients and family rarely remember exactly what you said, but they always remember exactly how you made them feel. There is only one time to make that first impression, a great opportunity to brand you as a hero and angel of mercy or a complete jerk. Be nice to the cleaning lady, security guard, cafeteria worker, and x-ray tech. Learn their names; they know yours.

Talk effusively to your patients, talk to them again, and always, always, always talk to the family. Sit down whenever possible; it says you are truly giving them the personal time and attention you would also want. That 300-pound demented nursing home patient with bedsores and a feeding tube is somebody’s mother, and maybe she was the best third grade teacher your city ever had. Last month we unknowingly treated Joe Frazier’s father, the governor’s cousin, and one of Gladys Knight’s Pips.

Many colleagues and patients need a lesson in manners and compassion. Do not argue with patients over nonissues such as a few Percocet, an x-ray, a blood test, or even admission to the hospital if it’s a close call.

Resist the ubiquitous temptation always to be right.

Don’t publicly criticize another physician or another hospital. You will develop a firm grasp of hindsight, but you are in the fishbowl every day and often talked about by name at surgery’s M&M conference. You may not know them, but the housestaff know you, and they develop a lasting impression after their first encounter. Let that overpaid prima donna surgeon look like an ass to all who witness his barrage against you, a hardworking clinician who has to make the difficult real-time decisions. Take the higher road; emergency physicians respond to a higher calling anyway.

The nurses’ station is a recording booth — with megaphones. Your vociferous opinions about anything quickly become common knowledge with a very long half-life.

Hubris should be eschewed at all times; you’re simply not that good, that smart, or that accomplished to be inflexible or pious with a colleague or a patient. Arrogance gets you into trouble more quickly than incompetence. As Clint Eastwood said, “A man’s got to know his limitations.”

Residents, nurse practitioners, and medical students can be fragile and insecure. You can give them confidence in their ability and career choice or totally shatter their self-esteem with a single thoughtless encounter in the middle of the ED. Housestaff may seem totally in control on the outside, but they are often scared stiff on the inside. It’s a fine art to learn how to critique without criticizing, to instruct without insulting, and to evaluate without emasculating. Teach them how to be a better doctor than you are. Students are expected to surpass their teachers in many talents, and maybe you were not such a good teacher after all if they do not.

There is no shame in calling a consultant for a medical problem or situation that is going poorly or if you are in over your head. Even a pediatrician probably possesses some talents that you do not. If the husband of a woman with her 100th migraine demands a CT scan and neurology consult, tell him they are already ordered, then whisper instructions to the clerk. Then let the family hear loud and clear, “Where the heck is that neurologist I paged?” It’s not your money, she won’t live long enough to statistically get cancer from the test, and just maybe she does have a bleed this time. Again, arrogance is worse than incompetence. If your patient wasn’t happy with your first plan or diagnosis, maybe it is flawed, so reconsider. Calling a consultant is a good way to share the liability.

The family can accept that a loved one will die, but when the time finally comes, it is a harsh reality, even if the patient is in hospice for comfort measures only. The children will always remember their father’s last ED encounter. Make that time as painless as possible for all concerned. Someday you will face that reality yourself, as a patient and a relative. You can’t change much at the end of one’s life, but you can listen, care, and usually do something to console the patient and family. A bed in hospice is waiting for many of us.

Be especially nice to old people; you will be one in a heartbeat. Trust me, I have already had those heartbeats. That old guy from the nursing home can’t remember what caused that 12-inch scar on his abdomen, but he just might remember the jungles of Vietnam.

Be nice to the homeless; these patients don’t need your attitude or comments about their lifestyles superimposed on their illnesses. Get them a meal tray, and don’t discharge them at 3 a.m. That sickle cell patient, alcoholic, or heroin addict would probably like to be drug-free if there were a better life for them. Usually there is not.

Having a baby at age 14 can be a normal lifestyle when your mother had you at 13. The next time you make a snide comment about the pregnant teenager with herpes or the kid who took an overdose after being dumped by his girlfriend, remember that your son or daughter may not be immune to a similar fate.

Most physicians, even family members, shy away from the mentally ill, and it’s very, very difficult to be that patient’s relative or doctor. Usually they can’t find a good friend, let alone a good physician. That’s why they are always in the ED. They actually like you, and sometimes you even seem to care and listen. Nobody wants to be psychotic; just be thankful that your serotonin and dopamine levels are under the bell curve most of the time. If you won’t help this segment of society, who will? Few will even try.

If AIDS, mental illness, teenage pregnancy, or drug or alcohol addiction have not courted you or a member of your family, you are truly blessed.

When things are the darkest, remember what Mel Herbert told you: “What you do really does matter.”

Medicine is a proud and noble profession, but it is actually just another service industry. Get used to hearing, “When are you going to wait on me?”

Everyone feels entitled to the best health care; some feel more entitled than others. No one will ever know how hard you work, and most patients don’t really care. They think you make half a million to start, confusing you with that orthopedic surgeon who graduated the same year you did. I find a patient’s rudeness, belligerence, and most importantly, ubiquitous entitled attitude the most difficult to ignore. Get over it or it will drive you nuts.

Being a doctor can be viewed as a privilege or an entitlement; choose the former. You are well compensated for your time, no one gets paid what they are worth, and although we are not NFL players, we do OK in the grand scheme of things, and are usually spared the repeated concussions.

Please don’t whine or complain. Nobody likes a high-maintenance employee, especially a highly paid professional who should be innovative and self-sufficient.

If you can find a better job, don’t tell me about it, or bargain with it; just take it. But remember that greener grass always requires more fertilizer and more weeding.

I remember some very fun times in the on-call room as an intern, but it’s best to keep your love life (and lover) out of the ED.

The schedule is sacred. Don’t miss a shift for two inches of snow. Learn how to show up on time. No one likes a replacement who is always 10 minutes late. (You know who you are.) That dead battery or behind-a-school-bus excuse only works a few times. We pay you enough to buy a new car, and find a different route to work. Here’s a novel idea: be that doctor who always shows up 10 minutes early. And getting out on time is not one of life’s sacred privileges.

Emergency medicine is a lifestyle, but there is more to life than medicine. You can never make up a missed championship soccer game, anniversary, birthday, or chance to take your son fishing. Remember that you might need a shift off one day, so be ready to help a colleague with a similar request.

In my opinion, we currently have the medical world by the tail. Set schedule, no beepers, no calls for orders, no insurance forms to fill out, and no bills to collect. Heck, we get paid even when the hospital does not collect a cent. You don’t have to fill the nursing schedule or even find a replacement for your vacation time. You clearly work hard for your paycheck, but any general practitioner or pediatrician would take your job and salary in a nanosecond. Next time you think you are underpaid and overworked, consider the GP who works 70 hours a week, calls with lab results at 7:30 in the evening, and makes less than you do. And never discuss your salary with a hospitalist!

Let’s hope Camelot lasts until retirement, but the way things are headed, I doubt it. You will be lucky if you are not making less and working harder five years from now. I suspect these days are the good old days of tomorrow.

If you plan to give expert medical testimony, start a side business, speak for a drug company, watch out for common pitfalls we all make. I have never turned down a chance to earn an honest buck, but it’s a very seductive world out there, and your reputation can sink like a stone.

Malpractice litigation is a slimy business that makes little sense. If you can rid the profession of just one bad doctor or get compensation for someone injured by blatant indifference or incompetence, go for it with gusto. We all need to support a patient wronged by neglect or injured by negligence, but many horrible cases are often bad luck and bad diseases, not bad doctors. It’s easy to second-guess a colleague with a retrospective analysis or the autopsy in hand. But you can build a home in Hawaii on what you make by using your Ivy League education, bloated CV, meaningless titles, and EM board status.

Don’t sell your soul to the plaintiff with absurd opinions and outright lies, doled out so eloquently to a clueless doctor-hating jury with a bizarre, inscrutable, or blatantly concocted definition of standard of care that you yourself would never follow. If you testify for money, and there is so, so much of it to be readily made, all of your colleagues will recognize you for what you have become. Shame on you!

Finally, be careful with alcohol and your ready access to Vicodin and Percocet. Addiction can ruin a lot of lives in a very short time, and it’s so easy to succumb.

Many of those idealistic halcyon thoughts of being a doctor, coupled with the blissful insouciance you had as a medical student, will sadly never, ever materialize. Hopefully this will help you endure a bad shift, embrace your profession, and avoid many of the same mistakes I have made over the past 42 years. Perhaps not. Maybe selling shoes at Nordstroms is not such a bad idea after all.

 

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And despite how busy it was this past month, it didn’t change one bit how I feel about this job. Judging by a few comments advising me to change fields, perhaps that hasn’t been coming across in my posting, but really, this past month has been pretty awesome. Sure there were some obnoxious patients, ones that want to make you pull your hair out (and yes, even fantasize about doing them bodily harm), but there were also plenty of kind, thoughtful patients and family members, ones that inspire you to work hard, put a smile on your face and drive you to do your best for them, both as patients and people. There was actually many times where I felt bordeline high at work, the dopamine and serotonin being released in my brain from some of these experiences was at very high levels indeed. And it wasn’t just from doing sexy adrenaline like procedure stuff either, it was from doing basic things, making a patient with the flu feel better with some fluids and tylenol, explaining to a family what was going on, helping them understand their loved one’s illness, being thanked for doing nothing more than listening.

The hospital I am working at now, is about an hour commute from where our program is centered, but I used to live out by this hospital for 4 years during medical school, so I know many of the surrounding communities, and the people that live in them.  I was caring for this patient and family who actually resided a street over from where I lived. I had never met them before, but there was that natural comradeship of people sharing a geographical location. The cue for inpatient beds was hours long, so they had spent my entire shift in the ED, waiting for one, so I would check in on them every hour or so, just to make sure everyone was alright and what not. At one point we had talked about the neighborhood, and I had mentioned how I loved the hoagies from the place that was at the end of the block. Towards the end of my 12 hours shift, the nurse came over and handed me a hoagie, from my favorite place, saying it was from the family in bed 12. Totally awesome. Made my day.

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It’s been almost a month since my last post, and that’s more a reflection of the busy holiday season, both at work and in personal life, than not having anything to write about. I in fact have a whole list of things to write about, that I jotted down over the past 4 weeks, but now as a little time has passed, the feelings I had at the time, are now faded a bit and the motivation to try to summon them up has somewhat flagged, so we’ll see what ends up getting posted.

So yes, it’s been a very busy holiday season. And it’s not just me saying that. The attendings were all complaining about it, much more so than the resident’s as honestly we don’t know better at this point in our careers. They were constantly remarking how they could never remember it being so busy, so backed up, the weekends and holidays just as bumping as the Monday afternoons. At one point, we were on divert for 4 straight days. Divert means that ambulances, unless it is something super serious and time sensitive, are supposed to take their patients to another hospital. It’s a great idea in theory, except when the entire region is on divert, then it doesn’t really mean anything. And brace yourself for the moment you come off it. Picture a scene in a zombie movie, those bloody corpses piling up against and banging on the glass doors, trying to get in. That’s what the impending flood of ambulances feels like the moment you come off divert.

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