Category Archives: Emergency Medicine
“Our Lady of Perpetual Sepsis Nursing home, this is the nursing supervisor how can I help you”
“Hi, this is Dr. ERJedi, I have a man here from your nursing home with what appears to be a 2mm paper cut on his finger. I’m just wondering if I’m missing something or if there was another reason you sent him over”
“We though we should send him over because he’s on a blood thinner and we were worried he was going to keep bleeding”
“What blood thinner is he on?”
People talk about burn out all the time in this field. I know I’m only two years into this, but I’m pretty sure it’s not the job that burns people out, its the asshole patients. Those people that are just unkind, cruel, self centered. I fully admit, that I have positively loathed some of my patients.
“Hey there, I’m Dr. X, how can I help you?” ”Fuck you, fix my arm” Ohhhhh kayyyy then.
But these people aren’t anything new. They exist in every ED. They suck your good will out and just pour it down the drain. But fine, whatever, I’ll deal. But everyone once in a while…. you get that one guy….
There is this guy that comes into our hospitals about every two months. Always an overdose of his calcium channel blocker, usually a half assed suicide attempt, always goes to the ICU, gets tuned up, set up for out patient support, psychiatric follow up, never goes, comes back two months later, rinse and repeat. The thing is though, he is the most racist, sexist human being I have ever met, or even heard of for that matter. Once he comes to, wakes up, he runs his mouth constantly, spewing forth the most vile things you’ve ever heard. When I was in the unit with him one time, he had this kind, sweet nurse, one of the good ones, whom he quickly sent out of the room by calling her a “cunt nigger”.
Everybody hates this man, loathes him, wishes one of these times he would just get it right and come in as a code blue. How horrible is that, to think that, and then having to perform life saving medicine on him. That’s what burns the docs and nurses out, that’s what eats at the fiber of your soul. It takes 50 happy, kind, thankful patients to replace one of the scars left by these horrible people.
I wish more than anything, we didn’t have to put up with it. I’ll treat you, quite happily, but only when you act like a human being. Fine, I’ll come back in 20 minutes and you can try telling me about your arm again. But nope, not allowed to do that, cause door to dispo times matter more. We have to take it, to the let the patient smear all their vile feces all over our faces, while we stand there and take it. THAT’s where the burnout comes from, not from the long hours, not from the over crowding, lack of resources, or what ever other factor experts say makes us burn out.
It IS a problem though, even in residency. A poster that was presented at ACEP showed that 50% of EM residents experience mild burnout, 25% of them have SEVERE burnout (Ironically, 50% of participants failed to respond to the follow up survey)
And deep breath. I’m not saying I am in any way burned out. Far from it. I am a little angry about it, but beyond that….well, just keep doctoring on, and doing my best to not stab these patients in the eye with a angio cath, at least for the time being. There are days when that is a distinct possibility. And I think I’m better than most at keeping my cool. One of my other residents almost came to blows, patient telling the resident “GIRL I WILL FUCK YOU UP IF YOU DON”T GIVE ME A SCRIPT FOR PAIN MEDS” and her in response… getting right in the patients face and going all calm and quiet Clint Eastwood like…. “Go ahead, hit me, I dare you”….. Yup, let’s just keep packin’ powder into that keg.
I’m not sure what I’m going to do about, other then just vent about it anonymously for the time being. And a good vent always helps. Ahhhh, much better.
On toxicology at the moment. Earlier this week, we had a 2 year old up at the children’s hospital. Parent’s brought him in because the kid was ravenously hungry. Ate a whole 20 piece chicken McNuggets and was still hungry for more. As part of the workup, the kid had a drug screen done, and sure enough, the kid tested positive for cannabis. Oh, and when the parents called their house, dad’s brother was pissed because someone had gotten into his Marijuana stash and made a mess of it. Kid, don’t know you know your supposed to bake it into brownies and not eat it plain? What are they teaching in pre school these days.
I’m always getting these advertisements for jobs, even though I’m a year away from serious starting to look. I got a post card today extolling the virtures of one particular opening. They claim that you work one 24 hour shift and then have 3 days off… Really? A 24 hour shift? I couldn’t imagine. Maybe life as an attending is different, but when I work an ER shift, I’m pretty much husltin’ the whole time. At the end of a 12 hour run, I’m pretty much spent. I couldn’t fathom doing a 24 hour shift. Much less the overnight part… AFTER already working 18 hours! (I can handle them okay now, but that’s with a three hour nap before my shift starts…) Now the ER was some where in the state of Maine, so maybe it’s a podunk little ED where the attending actually goes to bed over night since no one comes in. If that was the case… that actually sounds kinda sweet.
Anyone know anything about these 24 hour shifts?
This is why I love this job. Monday positively sucked, but Tuesday positively rocked.
- Intubated my first baby, 9 month old came in not breathing. Major box checked off my list of “Thing’s that I am still nervous about doing for the first time”
- Kiddo with a severe anaphylactic reaction after sneaking on of his grandma’s cashews. Didn’t have to tube him, but he had one serious swollen face. Did alright though after treatment
- Girl who held the staple gun backward and put the staple into the palm of her hand
- A case of pertussis
- A case of croup
- A (few) case(s) of asthma, just to round out the pulmonary trifecta
- Nursemaid elbow
- Abscess on a 3 year old’s cheek that with just a little pressure erupted in a glorious volcano of pus (Sounds gross, but a good abscess is to an ER doc what a fine cheese is to a Frenchman)
- And also secretly satisfying…. I was one of three residents working, myself, another ER resident, and a peds resident. The attending and the ER resident were tied up on a sick kid for about 40 minutes. When the attending comes back, ask’s the peds resident if she had any new patients to present since being all tied up “Nope! I’m all good!” Turns to me “Do you have any?” “Yeah I have 4 new ones” (and I hear the peds resident under her breath “Four? How the hell did you see four new ones?”
So yeah, Tuesday was pretty baller. But it’s Wednesday now and I had to call out sick, which is bound to happen when ever you rotate at the children’s hospital. Can’t complain too much though after such a satisfying shift.
Top 10 Things you don’t want to see pulling into your ED drop off area…
#8 School Bus packed with kids.
Apparently some generator or something had broken down at the school and the carbon monoxide detectors started chiming. The report on the scene was that they all read low levels, and that all the kids were fine initially when asked if anything was bothering them. But then the teacher started asking specifics, does your head hurt? Does your throat hurt? Does your tummy hurt? And of course every kid now says yes to every question, so they all get packed into the school bus and off to the ED they go! We of course had to go into mass casualty mode, which was actually kinda fun and a good way to break up an otherwise dull shift. I was out on the bus as it pulled in sorting kids into “sick” vs. “not sick”. Only one for the 30 was even remotely concerning for “sick”. And all the ones that ended up being tested, had their CO levels turn out just fine. Dealing with the pandemonium of a bunch of 4th graders on a spontaneous field trip and their concerned parents was much harder to actually sort through than any of the symptoms the kids had.
I’m currently working at a community hospital (more on that later). The nurses, paramedics, and EMTs are all friends with each other, so the if the EMS crews are bringing in something even slightly concerning, they try to give us a heads up so we can be ready, and we appreciate it when they do. So when they called at 3am, stating that they were bringing a 91 year old guy in with back pain, you had to wonder what it was they are worried about. Well, the ONE thing you would worry about in an old guy, with sudden onset back pain at 3am, bad enough to call an ambulance, is an aortic dissection or anneuryism.
The attending I was working with, just graduated our program, and it was just the two of us on at that hour. We were having a good time in between patient, catching up on a few laughs and stories. But when the medics called in he was like “soon as this guy rolls in, put the ultrasound on his belly”. About 10 minutes later the guy rolls in, wide wake, totally with it, in appearing in a perfect state of health, except that he’s complaining about his back killing him. “I got up to use the bathroom, and when I sat back down, my back just started killing me, worst pain I’ve ever felt, non stop for 30 minutes”. So we sat him in the bed, got him to lay back, and I put the probe on this belly. Before even looking at the screen, you could make an easy prediction of what you were going to see. I could feel the probe throbbing in my hands, boom, boom, boom, at oh, about 72 BPM. And when I turned to the screen, I saw….
That line is measuring the diameter of the aorta. A normal person’s is about 1.5cm at the spot I was measuring. So bam, this guy is now officially having a AAA (abdominal aortic aneurysm). They are fairly safe with a low risk of rupture under 5.0 cm, but above that, they are the proverbial ticking time bomb, especially when they start hurting. But okay, this guy is just fine right this second, still perfectly stable, but lets call surgery sooner rather than later. I step out, show my attending the image… and see him turn a slighter shade of paler (he’s pretty white to start with), which is understanding given it’s only his third time being a single coverage attending. So we get surgery on the horn, and the nurse pops guys “GUYS! HE’S LOST PULSES”….. SHIT. Did this guy just rupture his AAA in our ED? Yeah… he did. But, because our nurses are so bangin awesome, they started putting that second line in the moment I showed them the ultrasound, so, for the time being we were one step ahead, as we had the classic “two large bore IV’s” already in place. Fluids wide open, CPR under way, epi in, blood on the way, intubated with good breath sounds, surgery at the bedside,”IF you get pulses back, the OR is getting ready”. And we did,we got him back after only two rounds of EPI, got 3 units of blood into him, 3 L of fluid, and he kept holding steady, good blood pressures and heart rates, and he got wheeled up to the OR. When I left 3 hours later, he was still there, but more importantly he was still alive. If this had happened 15 minutes earlier, he probably wouldn’t have been.
The weirdest part for me, was that during this whole code part…. it was deathly silent in the room. I’ve never heard a code so quiet. Everyone was just doing their job, and doing it quietly perhaps. The machines and monitors were’t beeping, you could have heard a pin drop it was so quiet. I don’t know if that’s significant for anything, but it just struck me as bizarre at the moment, like, are we forgetting something here? Is there some crucial piece of equipment that’s missing that normally makes all this unnecessary and useless background noise or something? It was just weird.
I’d like to take a brief moment to propose a new standard of health care. If you are a patient in a nursing home, and you code between the hours of 5 and 6 am, I would like to make it an official rule that you have to be seen by the nursing home doctor before being transported to the ED. Because really, if you are found down at 530 am, lets be honest, you’ve been down since the 10pm bed check. And those medics that have responded to your call, are doing the exact same thing we’re going to be doing here in the ED before we call the code. Let’s let the home doctor have the privilege of making the final call and saving the time, expense and effort of transporting a person in rigor mortis to the ED.
Okay, I realize I may sound a little bitter here, but at the end of a 12 hour overnight, when you’re feeling a bit like Scarface coming off a week of blow (Ie, your 3 cans of Redbull are wearing off) the LAST thing you want to hear is the haste going off with a code blue in route from the local nursing home. Just sayin’
A few thoughts from the last week of work
- I both love and hate the new work schedule. 12 six hours shifts are exhausting. Feels like all you do is work and sleep. But then we get four days off at the end of it…. which is pretty baller.
- Did a conscious sedation on a patient so we could relocate he mangled thumb. She had a pretty profound reaction to the propofol, taking a good 15 minutes to come back to acting like her normal self. At one point during her altered period she looks me dead in the eyes “Sir… you suck….balls!” Hilarious.
- I was expecting it to be quite in the ED over the labor day weekend. Instead it’s like all the nutter’s came out to play at once. We had 5 1:1′s going at once. It’s a 24 bed ED!
- I had one patient who was particular grumpy. I asked him why. Apparently it was raining pretty hard, so when the ambulance pulled up, they just laid on the horn until he opened the door. And when he did, the driver got on the PA and hollered “Get in the back of the truck!” So he did, and he was pissed about the lack of door service. No idea if it’s true or not.
And of course, the learning curve was steep as always. A couple of pearls and rules of the road from this past week
- “Two-fers are never sick, unless it’s poisoning, usually of the carbon monoxide variety” (A two-fer is a two for one patient room, usually two related kids in one patient room)
- Give a miligram of ativan to anyone with a complaint of seizure and alcohol is in anyway involved, even if not seizing. Cuts down on repeat seizures, admissions, mortality & length of stay.
- PE’s and EKGs – S1Q3T3 is actually pretty rare. The most common EKG finding in PE is non specific T wave changes. Then, inversion of T waves in the anterior leads.
And finally, what’s an ED shift without a little humor. There is one attending who drinks a two liter of soda every shift. When he was off seeing another patient, the other attending dermabonded the cap shut (skin glue with the strength of rubber cement). After a few moments of struggling the first attending simply shouted “GOD DAMMIT” and stormed off, only to reappear 15 seconds later with an 11 blade scalpel in hand and quickly decapitated his bottle of soda.