I just finished my last shift in the ER. I have to admit that I had an awesome time... despite the fact that it was an overnight shift. I had a most groovy attending (who diagnosed patients with "abominable" pain), finally figured out how to keep myself awake (afternoon nap, food bolus at 9 PM, steady stream of sugar throughout, and Coca Cola-- in fact, I'd infuse that IV if I could), and celebrated the turn of 6:30 AM with a yummy glazed donut.
Next week I'll be putting the jelly on da belly as an ultrasound tech in the ER. For now, I'm going to hydrate like a crazy mofo (my pee is officially orange) and sleep like there's no tomorrow (I know, I know, there is), and maybe when I wake up this evening I'll get to do normal people things, like eat dinner and hang out with friends.
Yay!
Thursday, February 26, 2009
Monday, February 23, 2009
ER: White Cloud
I am what they call "a frickin' white cloud." I've been an active EMT for five years, but never worked a cardiac or respiratory arrest call (I responded on one years ago in Brooklyn, but was in the second ambulance to the scene, so I watched as the other crew did CPR and used the defibrillator). In four years of medical school, I've never seen one of my patients die in the hospital, although many of my friends have gone through this experience (one, I would argue, that changes your whole outlook on medicine and is a sort of rite of passage). When I'm on the code blue team, either no code blues are called, or everyone is brought back to life. In the ICU, my attending predicted, gravely, "She's gonna die tonight," about one of my patients with fulminant colitis and a tenuous grasp on life; the patient lived to leave the hospital two weeks later. I have never performed CPR.
Today, I rode-along with the EMS Physician who responds to ALS calls from our dispatch center. As I chowed down on my chicken parm at lunch, I lamented my white cloudiness with my usual incredulity at the fact. It's something I find entirely unbelievable, that someone with as much exposure to the shit that could go wrong could possibly never accidentally land in it. Something totally inexplicable, bewildering, awesome, and awful. I wondered whether, when I have to run my first code as a real doctor, I will actually be ready for the task without past experience. The EMS Physician told me that patients should love to have me as a doctor.
Shortly thereafter, we responded to a call at a dialysis center for a patient with "hypotension." According to the doctor there, the patient had a number of issues apart from her renal failure, including aortic valve stenosis which is inoperable due to her poor performance status and dependence on dialysis. For the past several months, she had been slowly decompensating. In the lingo, she was "circling the drain." At the dialysis center, her blood pressure was barely 80 / --, and her heart rate was incredibly slow, coming down to 20-30 beats per minute; these numbers, combined with the patient's medical conditions, seemed worrisome. Yet, with an IV infusion of a few hundred mL of saline, she felt pretty comfortable, was alert and talking to us, and was asymptomatic. The medics joked that she had seen us coming and perked up because the doctor was so good looking. We got another call for a car accident two towns over, so we directed the medics to transport her to the hospital, start a line if possible, and give additional saline if the patient became symptomatic. We then left the scene.
The next time I saw the patient, she was intubated and stripped naked in the critical care room in the ER at the hospital.
The paramedics told us that they had loaded the patient into their ambulance and started driving. Out of the blue, she coded into an episode of VT's (ventricular tachycardia) and became unresponsive. They began CPR, shocked her back to a normal rhythm, rushed, and intubated. Here she was, naked on the bed, and Dr. E was mashing around in her groin trying to get a femoral line. It felt surreal... only half an hour ago, I had been making small talk with a LOL (little old lady), and now she looked like a piece of meat on the table.
I couldn't help but wonder... how large is the shadow cast by a white cloud?
Today, I rode-along with the EMS Physician who responds to ALS calls from our dispatch center. As I chowed down on my chicken parm at lunch, I lamented my white cloudiness with my usual incredulity at the fact. It's something I find entirely unbelievable, that someone with as much exposure to the shit that could go wrong could possibly never accidentally land in it. Something totally inexplicable, bewildering, awesome, and awful. I wondered whether, when I have to run my first code as a real doctor, I will actually be ready for the task without past experience. The EMS Physician told me that patients should love to have me as a doctor.
Shortly thereafter, we responded to a call at a dialysis center for a patient with "hypotension." According to the doctor there, the patient had a number of issues apart from her renal failure, including aortic valve stenosis which is inoperable due to her poor performance status and dependence on dialysis. For the past several months, she had been slowly decompensating. In the lingo, she was "circling the drain." At the dialysis center, her blood pressure was barely 80 / --, and her heart rate was incredibly slow, coming down to 20-30 beats per minute; these numbers, combined with the patient's medical conditions, seemed worrisome. Yet, with an IV infusion of a few hundred mL of saline, she felt pretty comfortable, was alert and talking to us, and was asymptomatic. The medics joked that she had seen us coming and perked up because the doctor was so good looking. We got another call for a car accident two towns over, so we directed the medics to transport her to the hospital, start a line if possible, and give additional saline if the patient became symptomatic. We then left the scene.
The next time I saw the patient, she was intubated and stripped naked in the critical care room in the ER at the hospital.
The paramedics told us that they had loaded the patient into their ambulance and started driving. Out of the blue, she coded into an episode of VT's (ventricular tachycardia) and became unresponsive. They began CPR, shocked her back to a normal rhythm, rushed, and intubated. Here she was, naked on the bed, and Dr. E was mashing around in her groin trying to get a femoral line. It felt surreal... only half an hour ago, I had been making small talk with a LOL (little old lady), and now she looked like a piece of meat on the table.
I couldn't help but wonder... how large is the shadow cast by a white cloud?
Thursday, February 19, 2009
ER: All About Poop
I've discovered something about the fast-paced and adrenaline-pumped world of emergency medicine: it's all about bowel movements (or BM's, for short). Everything that we do, everything that we talk about, and everything that we think about can ultimately be traced back to shit, by however tortuous a path.
I get up early in the morning to make it into the ER by 7 AM, when my shift begins. Dr. V, who has just started his shift as well, is taking sign-out from his overnight colleague. After this process is completed, I join him as we tour the ER to assess our patients. As we pass by each patient, we talk about disposition: "This one can go home; that one needs another hour to sober up; this one is getting admitted to internal medicine..."
Lesson #1: When it gets full, we must "flush the toilet."
Each morning, the toilet, full of last night's drunks, admissions that have yet to be moved to the hospital floors, and bullshit complainers, must be flushed to clear beds for the day's incoming patients.
Yes, folks, we have just encountered a metaphor in which the "toilet" represents the ER, and the patients are, well...
So, yeah...
You're probably thinking that that is incredibly crass and unprofessional. And kind of funny. I would agree, on all counts. But think also about the burden of patient care that falls upon the ER, the basic complaints that waste valuable resources for lack of insurance and primary care, and the systemic inefficiencies that result in a lack of hospital beds for admitted patients. The root of the problem is much deeper than meets the eye. All we see is the shit in the toilet.
I go to see a patient, whose location is listed on the board as "UTP." UTP? I think, I've never heard of such a bed in the ER. I figure out, with help from a clever nurse, that UTP stands for Under The Picture. That is, the ER is so crowded that patients are stacked up in the hallways, and mine is in a secret location with the description "under the picture." I look around for the "picture," but my intellect is severely challenged on this one. After some sleuthing, I find out that the "picture" is actually a bulletin board, and I hone in on my target: Mr. S, a homeless man who had a seizure.
Mr. S, when asked where he lives, answers "in the streets." It is no wonder, then, that Mr. S has decided to take only one of his Dilantin daily instead of the three prescribed-- to make it last longer. It is no wonder, then, that Mr. S had a seizure this morning. Mr. S is used to this sort of thing, insists that he's fine, and asks to have his workup expedited so that he can get out of here.
and overhead paging--
But at least Mr. S doesn't need a rectal exam.
Lesson #2: Everybody needs a rectal exam.
I've done it on men, I've done it on women, and I've even done it in public.
Unfortunately, a rectal exam is often the best way to get some very important information about a patient's ailment. Any patient with abdominal pain, for instance, should ideally get a rectal exam: it rules out occult gastrointestinal bleeding (a very important sign to detect, if it is present), can detect prostatic problems, and is just really fun for medical students. I smear the stool on a Hemoccult card (a special card that detects blood in the stool), and I instantly have a comedic prop:
I guess I also feel weird about rectals because I understand that once I've put a finger up my patient's rectum (or threatened to do so), the nature of the doctor-patient relationship totally changes.
Does that count as a compliment obtained under torture? Whatever. I'll take what I can get.
Mr. B laughs heartily, the first laugh he's had since beginning his sleepless sojourn in the ER.
I get up early in the morning to make it into the ER by 7 AM, when my shift begins. Dr. V, who has just started his shift as well, is taking sign-out from his overnight colleague. After this process is completed, I join him as we tour the ER to assess our patients. As we pass by each patient, we talk about disposition: "This one can go home; that one needs another hour to sober up; this one is getting admitted to internal medicine..."
Lesson #1: When it gets full, we must "flush the toilet."
Each morning, the toilet, full of last night's drunks, admissions that have yet to be moved to the hospital floors, and bullshit complainers, must be flushed to clear beds for the day's incoming patients.
Yes, folks, we have just encountered a metaphor in which the "toilet" represents the ER, and the patients are, well...
So, yeah...
You're probably thinking that that is incredibly crass and unprofessional. And kind of funny. I would agree, on all counts. But think also about the burden of patient care that falls upon the ER, the basic complaints that waste valuable resources for lack of insurance and primary care, and the systemic inefficiencies that result in a lack of hospital beds for admitted patients. The root of the problem is much deeper than meets the eye. All we see is the shit in the toilet.
I go to see a patient, whose location is listed on the board as "UTP." UTP? I think, I've never heard of such a bed in the ER. I figure out, with help from a clever nurse, that UTP stands for Under The Picture. That is, the ER is so crowded that patients are stacked up in the hallways, and mine is in a secret location with the description "under the picture." I look around for the "picture," but my intellect is severely challenged on this one. After some sleuthing, I find out that the "picture" is actually a bulletin board, and I hone in on my target: Mr. S, a homeless man who had a seizure.
Mr. S, when asked where he lives, answers "in the streets." It is no wonder, then, that Mr. S has decided to take only one of his Dilantin daily instead of the three prescribed-- to make it last longer. It is no wonder, then, that Mr. S had a seizure this morning. Mr. S is used to this sort of thing, insists that he's fine, and asks to have his workup expedited so that he can get out of here.
What's so urgent?" I ask.
"I've got stuff to do!" he answers.
"What do you do during the day?" I ask.
"During the day? I rest," he replies.
Wow.
I can't say I'm surprised at his urgency to leave, though. It's hard to rest in an ER, with all the beeping and whirring and shouting--
Stop!!! Stop!!! Number one commandment!! Can you hear me? Number one commandment!! NUMBER ONE COMMANDMENT!!"
"Yes, yes, I know, Thou shalt not kill, right? Listen, we're just trying to help you."
"NUMBER ONE COMMANDMENT!! NO!! OWWWW STOP THAT!!! What are you doing to me!?! NUMBER ONE COMMANDMENT!! NUMBER ONE!!!"
-- courtesy of Hallway Dementia Patient and Doctor Attempting to Start IV
and overhead paging--
MISTER DAWSON, PLEASE RETURN TO YOUR BED. MISTER DAWSON, RETURN TO YOUR BED."
-- courtesy of Overhead Loudspeaker and Mister Dawson, Attempting to Flee ER
But at least Mr. S doesn't need a rectal exam.
Lesson #2: Everybody needs a rectal exam.
I've done it on men, I've done it on women, and I've even done it in public.
Unfortunately, a rectal exam is often the best way to get some very important information about a patient's ailment. Any patient with abdominal pain, for instance, should ideally get a rectal exam: it rules out occult gastrointestinal bleeding (a very important sign to detect, if it is present), can detect prostatic problems, and is just really fun for medical students. I smear the stool on a Hemoccult card (a special card that detects blood in the stool), and I instantly have a comedic prop:
There are some situations in which performing a rectal exam weighs heavily on my conscience for the embarassment that it yields to the patient. One woman with severe abdominal pain got her rectal in the hallway, because there were no cubicles left (see Lesson #1, above). We did the best we could to curtain off the area with portable dividers, but I still felt the flush coming to my cheeks, a sympathetic embarassment of my own. It turned out that her abdominal pain was really opiate withdrawal, though, so a couple of painkillers later, she was sleeping like a baby and all was forgiven (or at least forgotten).
Hey, Steve, do you want some POOP?""Depends... is it cooked?"
"It's marinated in juice.*"
* juice: developer used to detect blood on hemoccult cards
I guess I also feel weird about rectals because I understand that once I've put a finger up my patient's rectum (or threatened to do so), the nature of the doctor-patient relationship totally changes.
Mr. B, I'm really sorry, but I am going to need to perform a rectal exam. I know that it will be uncomfortable, but it is a really important diagnostic step, and necessary for your treatment."
"Oh... I'm just so embarrassed!"
"Mr. B, don't worry; it's going to be okay. It's really very quick, it's a common procedure we do, and there's nothing to be embarassed about."
"No, it's not okay! You're too pretty! Why did you have to be so pretty??!"
Does that count as a compliment obtained under torture? Whatever. I'll take what I can get.
Don't worry, Mr. B; I may look pretty on the outside, but inside I'm all mean and hardened."
Mr. B laughs heartily, the first laugh he's had since beginning his sleepless sojourn in the ER.
"Hahaha!! Okay. Do what you have to do."
In the end, the biggest lesson I have learned is to approach each day with patience, and each patient with humility, gentleness, and humor. Often, laughter is still the best medicine, and it is, by extension, good to approach every challenge with good spirits and tongue in cheek.
NO... not that cheek.
Monday, February 16, 2009
ER: Hitting It
This time, I hit it on the first try. I was sure and steady and my technique was flawless. As the blood whooshed into my syringe and hit the heparin pad, I felt a sense of triumph and a new calm. I know that I am not going to hurt patients doing ABG's any more.
Saturday, February 14, 2009
ER: Love
There's no better way to show your love for someone on Valentine's day than by accompanying them to the hospital, then sitting in a hard plastic chair for 4... 5... 6... 10... hours with them while they puke, get poked with needles, go through a CT scanner... etc. Forget candy hearts. Be mine! Have a blood pressure pill!
Tuesday, February 10, 2009
ER: Losing It
I've volunteered thousands of hours in the past five years on an ambulance. It began as a "prelude to med school"-- something that many pre-meds do to boost their resumes and dip their toes into the water of patient care. Most quit after they make it into med school, the utility of the operation spent. I loved it and kept going. There's nothing quite like the family at the first aid squad: a group of community members crazy enough to spend sleepless nights each week working with sick people for free. There's also nothing quite like the thrill of rushing to an emergency with lights and sirens, the fulfillment of recognizing my competence (EMT's often joke: "Somebody call 911! Oh wait-- I am 911!"), the reward of a fellow community member's gratefulness. A lot of people ask me if I want to go into emergency medicine.
I hate the ER.
I worked my first overnight (11PM-7AM) shift on a Friday. Second years had just finished exams and were out getting drunk on the street (good for them). I showed up and stood mutely at the nurse's station, unsure of what to do with myself. I was quickly asked to dance.
"You wanna go get an ABG (arterial blood gas) on this patient?"
I jumped into action! Every medical student must meet a required number of procedures before graduation, and I had yet to collect all three of my ABG's. Inside my body, catecholamines rushed to prepare me for the exploit; endorphins signaled my excitement at getting to perform a procedure. You gotta love it! I know exactly how to do an ABG. You feel for the pulse, then you stick the needle in. It's really simple. I was totally going to show my stuff.
It wasn't until I walked into the patient's cubicle that I recoiled at myself. I didn't even know who this patient was, or what she was here for; I couldn't have known, since I just started the shift. I was about to stick her without knowing her. And what gave me the right to draw her blood, anyway? If I were her, I would have kicked me out, had I known how little experience I really had with this procedure. I felt disgusted. I was using the patient.
I tried to make things a little better. I introduced myself. I acted very confident.
I missed.
I returned to the nurse's station, troubled. The tech student looked at me with pity and said, "Don't worry, you'll get it with practice," and proceeded to discuss a few helpful tips on needle placement with me. That's the truth; these things do require practice (on real people), and I will eventually become competent at them. But I felt unable to reconcile that rational argument with the feeling that I had just toed some ethical line. I stood there, inwardly searching for some source of moral solace. I didn't find it.
Instead, I got a friendly nurse:
"Hi! I'm Steve. How are you doing? Do you want to come help me take off this woman's pants?"
The woman he was referring to was a hilariously drunk woman in her forties who had just soiled herself; Steve needed a female chaperone. Taking off her pants? That's one way to meet a patient for the first time. There was also a tube top which Steve, in his male ignorance of feminine fashion, tried to remove by pulling down past the patient's hips (guys, don't try this at home; the top comes off over the head). This resulted in a lot of wiggling of the hips and peals of laughter all around. When I say hilariously drunk, I mean we all had so much fun, it should have been illegal. She's not gonna remember any of it, though.
The next seven hours continued in the same vein. I did painful stuff to people I didn't know. I met patients with bullshit complaints that I treated in 30 minutes and dispatched; I'll never see them again. I met patients with real, serious complaints that were admitted to some lucky medicine or surgery team who will get to diagnose, treat, and build a relationship with the patient over the next few days in the hospital; I'll never see them again, either. I felt like I was losing it. I felt detached, dehumanized, and demoralized. A trauma alert came in; the woman was screaming "Fuck you, bitches!! Fuck you all!!!!" and jerking all over the damn place as the trauma team was trying to assess her injuries, so they all said "fuck it" and sedated and intubated her to end the abuse.
I'm not knocking the ER for people who want to work there; it's an incredibly important job and a vital part of a hospital-- and it's not an easy job, either. But I want to spend more than 30 minutes with my patients and have time to clarify my moral boundaries. That, in a long-winded way, is why I don't belong in emergency medicine.
I hate the ER.
I worked my first overnight (11PM-7AM) shift on a Friday. Second years had just finished exams and were out getting drunk on the street (good for them). I showed up and stood mutely at the nurse's station, unsure of what to do with myself. I was quickly asked to dance.
"You wanna go get an ABG (arterial blood gas) on this patient?"
I jumped into action! Every medical student must meet a required number of procedures before graduation, and I had yet to collect all three of my ABG's. Inside my body, catecholamines rushed to prepare me for the exploit; endorphins signaled my excitement at getting to perform a procedure. You gotta love it! I know exactly how to do an ABG. You feel for the pulse, then you stick the needle in. It's really simple. I was totally going to show my stuff.
It wasn't until I walked into the patient's cubicle that I recoiled at myself. I didn't even know who this patient was, or what she was here for; I couldn't have known, since I just started the shift. I was about to stick her without knowing her. And what gave me the right to draw her blood, anyway? If I were her, I would have kicked me out, had I known how little experience I really had with this procedure. I felt disgusted. I was using the patient.
I tried to make things a little better. I introduced myself. I acted very confident.
I missed.
I returned to the nurse's station, troubled. The tech student looked at me with pity and said, "Don't worry, you'll get it with practice," and proceeded to discuss a few helpful tips on needle placement with me. That's the truth; these things do require practice (on real people), and I will eventually become competent at them. But I felt unable to reconcile that rational argument with the feeling that I had just toed some ethical line. I stood there, inwardly searching for some source of moral solace. I didn't find it.
Instead, I got a friendly nurse:
"Hi! I'm Steve. How are you doing? Do you want to come help me take off this woman's pants?"
The woman he was referring to was a hilariously drunk woman in her forties who had just soiled herself; Steve needed a female chaperone. Taking off her pants? That's one way to meet a patient for the first time. There was also a tube top which Steve, in his male ignorance of feminine fashion, tried to remove by pulling down past the patient's hips (guys, don't try this at home; the top comes off over the head). This resulted in a lot of wiggling of the hips and peals of laughter all around. When I say hilariously drunk, I mean we all had so much fun, it should have been illegal. She's not gonna remember any of it, though.
The next seven hours continued in the same vein. I did painful stuff to people I didn't know. I met patients with bullshit complaints that I treated in 30 minutes and dispatched; I'll never see them again. I met patients with real, serious complaints that were admitted to some lucky medicine or surgery team who will get to diagnose, treat, and build a relationship with the patient over the next few days in the hospital; I'll never see them again, either. I felt like I was losing it. I felt detached, dehumanized, and demoralized. A trauma alert came in; the woman was screaming "Fuck you, bitches!! Fuck you all!!!!" and jerking all over the damn place as the trauma team was trying to assess her injuries, so they all said "fuck it" and sedated and intubated her to end the abuse.
I'm not knocking the ER for people who want to work there; it's an incredibly important job and a vital part of a hospital-- and it's not an easy job, either. But I want to spend more than 30 minutes with my patients and have time to clarify my moral boundaries. That, in a long-winded way, is why I don't belong in emergency medicine.
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