La Comedie Tragique

So I have worked a couple of more shifts in the E.D. at WCHOB, and now I am on a string of swing shifts of a sort. My sleep schedule is a bit off, so I don't know whether to stay awake or sleep in. I've been doing a little bit of both.

Anyway, there was a fair bit of drama going on during my last shift. Some of it funny. Some of it sad. Hence, the title of my blog entry today. I'll share just a few of the scenes from today's episode of "Drama: Life in the E.D."

4 year old girl. Chief complaint: bloody stools. Seems this girl was sent from her pediatrician's office with several days' history of diarrhea. Over the last two, mom had noticed bright red blood in the stools. She took her to her pediatrician who immediately sent her to the E.D. I did a thorough exam as I ran through all the possible causes in my head. When I did the rectal exam, I thought, "Now this is strange."

Now, I've done lots of rectals (not something I admit readily in public). I've seen blood in its many forms before. This wasn't blood. I didn't want to say anything until I did a hemocult card. We put a small sample on the card, and then add developer. If there's blood, it turns a dark blue color. This didn't. I still didn't say anything. The parents were looking at me expectantly. I just said, "I don't think this is blood." There were two sighs of relief. I told them to hang on a second.

I grabbed another hemocult card and brought it back into the room. Mom had collected several samples. It looked red all right, just not blood red. I put some on the other card. Again, negative. I went out to tell my attending. We looked at the sample. We looked at the card. Dad wasn't convinced so I did it again with another sample. Still negative. "Do you believe 2 out of 3?" I asked him. He smiled and said, "Yes."

Now, onto the mystery of the red poops. I asked about foods. I asked about drinks. I asked about new pills or the antibiotics the patient was taking for a recent ear infection. Anything that could have a red color dye. The mom kept answering, "No, no, no..." Then her face changed, and she smiled. Vitamins. They had just changed vitamins a few days before, about the same time the patient had started having diarrhea. All the patient liked to take were the red ones. Mystery solved. Discharged to home.

9 month old patient. Chief complaint: ? seizure. Seems the little girl had been sick over the course of the day. She felt flushed and warm to the grandmother that was taking care of her. Because it was so cold, they had wrapped the child in heavy blankets. At some point she became stiff/limp, and the grandmother got scared. They ran the child to the bath and splashed cold water all over her. She recovered, and they brought her into the E.D.

I worked her up for a febrile seizure and felt that it was from an upper respiratory infection she had been developing during the day. I was talking to the Mom and Grandmom, and they started to tell me how the reason she'd been bundled so warmly had been because the landlord was not responding to calls to fix the heater. They had been using space heaters and turning on the oven to keep the apartment warm.

I found out that we can admit children to the hospital for social or welfare reasons. We were concerned about sending a baby back out into an apartment with no heat on a night when temperatures were going to reach the single digits. However, the family told me that they had somehow managed to get the heater working again in the time they were in the E.D. (about 5 hours or so), and the Grandmom told me that she would have taken the baby home with her if that hadn't been the case. We called their pediatrician and arranged for follow-up. Discharged to home.

10 year old. Chief complaint: rash ? chicken pox. Nowadays, with the chicken pox vaccination, we're seeing less of chicken pox. I had asked if all the immunizations were up to date, which the mother assured me they were. I asked about sick contacts. I asked about other kids at school being sick. No, no. I looked at the "rash." I asked if anyone else had it.

The mother turned to an older daughter, and she showed me her lesions. I asked about family pets. A rabbit. I asked about other people's pets. Some new puppies at a friend's house. The family looked at me as if I was strange. How can a pet give you chicken pox? I said I would be right back.

I went out of the room. My attending asked me, "So, is it chicken pox?" I said, "No, bed bugs." I described the characteristic "triple bite" pattern. He went to go look while I typed up the discharge information, and a sheet about treating insect bites. At least they don't have to get rid of their rabbit. Discharge to home.

The final case: I came on shift, and one of the pediatric residents came up to me and asked me how I would proceed on a case she had. It was a 13 year old girl with abdominal pain. The pregnancy test had come back positive, and the girl had vehemently denied being sexually active. I asked if she had talked about other possible circumstances which would allow the meeting of sperm and egg, and the resident said, no she hadn't asked.

I asked if she had done an ultrasound. She asked, "We can do that?" I told her that as E.D. residents we always put an ultrasound on anything we want a quick and easy answer for. I offered to do it for her. She said, "Yes." So I went into the room and introduced myself. I told them I was just looking to see if there were any obvious abnormalities.

The mother kept joking, albeit with more worry than laughter in her voice, about finding babies and how there had better not be any. The daughter kept saying, "No way" and then asking me if I was seeing anything abnormal. I told her that I didn't see anything abnormal, and that her resident still might want to do a more formal ultrasound. We got back the blood pregnancy test that confirmed there was a pregnancy. The number of the count was low, so too small for me to even see the beginnings of what is known as a gestational sac.

As the shift progressed, I asked the peds resident what had happened. Before sending the girl to ultrasound for a formal scan, she had told the girl that she was pregnant. The girl started crying and then admitted that she had a 16 year old boyfriend, and that they'd been having sex for 2 years. Something about the thought of an 11 year old girl having sex left me unsettled for some reason. I tried to think back to when I was 11; boys were still icky annoyances.

There was no badness on ultrasound (meaning no ectopic), and after OB-Gyn came down for a consult (pelvic and mom finding out the diagnosis) the patient was discharged to follow-up with her pediatrician and to get a prescription for chemical pregnancy termination. I won't discuss my thoughts on that issue, but suffice it to say that given what I see from day to day, I think it's the right decision for all involved. Sigh.

Time to get ready for another shift. Seriously, I am hoping to see something more interesting than colds and diarrhea. When is the RSV season over...?

Under Pressure

I never thought about the change that would happen in six months.

I just started my next rotation at Women and Children's Hospital. After almost two months working at ECMC, I think I was ready for the change. However, I didn't expect quite the change.

If you've been following my blog, you know that I have already done two rotations as an intern at WCHOB. And, despite the fact that I really don't like kids, I actually enjoyed them. It gave me a chance to do some preventative medicine - which I think is very important, a chance to teach - which I love to do, and, for the most part, I learned a lot about pediatric acute (and some not so acute) emergency medicine.

However, starting on Monday morning, I was the "senior" emergency medicine resident. Suddenly, it wasn't about "what does this child have?" it was about "how are you going to fix them?" Having not seen anyone under the age of 16 for the last 6 months, I really found myself rusty in my diagnostic skills, and with the added pressure of making more complex decisions about their health care, I was really at a loss my first shift.

What did not help was the fact that it was Monday. In January. At the height of RSV and flu season. And, I had an intern that had never been to WCHOB before. And, we started the morning with a trauma. A sixteen year old girl T-boned on her way to school at 45 mph. She ended up with a subdural hemorrhage. By the time we finished assessing her, we had four new patients on the board, and the fun was just starting.

I felt like an intern, trying to get used to the system again. Trying to manage the patients. Trying to just feel like I wasn't sinking. We got more residents in over the next 4 hours, but the whole system was just overloaded.

At one point we had all 26 rooms full. They opened another section of rooms (+6). And the waiting room had about 20 people waiting. The computers crashed, the nurses were surly as they were being pushed to their limits, and ambulances kept bringing people in.

We had the comic "E.R." moment when everyone was running around, a barely-breathing baby is brought into the back and starts being coded, the ambulance rolls in with another child turning blue despite ventilation, and the noise level rises to fever pitch. The baby is taken to another room so that the blue child can be rolled across the work station to the now vacant code room, and there's the rush and flurry of the respiratory therapists pushing ventilators as the radiology techs push around their giraffe-painted x-ray machines.

I left that night with 4 patients waiting to go to the Pediatric ICU (PICU), another 5 or waiting for admission, and a full board (20+) in the waiting room to be seen. You don't learn in that environment. You just try to survive and not let anyone else get hurt.

My next shift was a little better. At least I was able to think about my patients more. Review my disease processess. Come up with a plan before presenting to the attending. Not to mention, I actually knew the attendings. One of our complaints about WCHOB is that we're working with pediatric attendings who have completed a fellowship in Pediatric emergency medicine. We're guests in their house.

They've hired a whole group of new graduates, none of which I had worked with before. Not that it makes a whole lot of difference, but you get used to how an attending likes their work-up and presentation. You know who lets you fly and who keeps a close rein. I guess I could have almost called this posting "Out of my comfort zone."

Sigh. It was just the first two days. I work tonight (which is another problem, since we don't schedule our residents we get whatever schedule the pediatric chiefs come up with which doesn't always make sense or take into account shift time changes.) I know I will be able to get back into a rhythm. And, I know that by the end of the month, I will be a lot more comfortable with what I am doing in my new role.

Just in time to start my PICU month when the fun begins anew!

Until then, we'll see what interesting stories that don't involve coughs, colds, vomit, diarrhea and parents that should need a license before they're allowed to procreate we can come up with.

As for the video above. I like the way they combined two of my favorite shows "Grey's Anatomy" and "Scrubs" And, I like the song....

BCPC - Alphabet Challenge

I have another website for my creative efforts. I just posted the following for the Community Photo Challenge: Alphabet Challenge

Enjoy! See everyone else's entries at the Community Photo Challenge Website.

Slippin' and a Slidin'

Last night I started a string of nights at ECMC. Aside from my resolutions for my patients from a prior entry, I made my own resolution to not be so cynical of patients and expect the best. Kind of hard to do when you read some of the presenting complaints at the top of the patient forms, but I was going to make an effort. That lasted just about 1/2 way into my shift , and then I just gave up all hope... sigh.

Anyway, last night I drove to work in a freezing rain. It was just hovering about 33 degree F. We came into an almost empty board, at 7 p.m., and we had hopes of clearing it. Then came 11 p.m. All of that freezing rain turned to ice as the temps dropped down into the high 20's. Suddenly, there were sheets of black ice everywhere. And, then the fun began.

Four employees leaving the hospital slipped and fell in the parking lot. A police officer slipped and fell on the ice - broken leg. Another police officer crashed his car into a tree when he hit a patch of ice - concussion. A young man was carrying a porcelain toilet and it slipped out of his hands - he severed one of the major arteries to his hand and cut several tendons and an important nerve. He was going to surgery.

By 1 a.m. I counted 15 patients on the board, and 8 of them were ortho consults for fractures, dislocations, etc. And the night continued on steadily busy. One little 78 year old lady produced a similar film to the one I posted here. She'd slipped and fallen on her oxygen hosing. Her bone cut through her skin, so she was considered an open fracture necessitating immediate surgery. She was on the board to go to the O.R. when I was leaving this morning.

Well, ok. Time to head off for another shift. It's Monday, so there should be quite the crowd. Will let you know what I see tomorrow! Cheers!

A New Year and Some Resolutions (For My Patients)

I spent New Year's Eve with my hubby in Niagara Falls listening to a great concert by Roger Hodgson and then watching the fireworks over Niagara Falls. All throughout the course of the evening, my hubby kept asking what my New Year's resolutions would be. I kept trying to think of things I would change for the next year: read more research journals, study harder, try to be nicer to my patients, etc. Then I realized that the majority of my gripes are due to some of the things that patients are wont to do. So, tongue-in-cheek, I offer the New Year's Resolutions that I thought of for my patients so that I can become a better doctor in the next year...

1.) Bring a list of your medications. When your blood pressure is 210/104, and you tell me that you didn't take your medications this morning, but you're on something for blood pressure but not one type because you're allergic to it, it would really help me to know what class of medication you're allergic to or I might give you something that might kill you. And, don't say, well "it's in the computer" because we are not linked to every clinician's office in the area. If you don't know your medication list, at least know the last pharmacy where you bought your meds because we can sometimes call and get the information. Oh, and if you're supposed to be on these medications but haven't taken them in a while, that's important too. Yeah, just a little.

2.) Don't come to the E.D. if you don't plan on staying. I had two patients at risk for a major heart attack leave because they "got tired of waiting for their room." I had another patient with a severe septic infection that will become life-threatening if not treated leave because the family didn't like how long it took for them to get a CAT scan. We spend an incredible amount of time and resources making sure that patients are stable before they can be sent upstairs. That's not including the amount of time spent on the phone arranging for consults, arranging for admission, ordering tests for follow-up, etc. In the real world, aka "people with insurance not on Medicaid," the bill for the E.D. visit would not be honored by the insurance company for the patient who leaves AMA (against medical advice) or absconds (leaves without being seen), and the patient would receive the bill and be expected to pay for it. Since the majority of our patients are under Medicaid, the hospital ends up eating the bill. Not to mention the time I spent on you was time I could have spent helping someone else who might really need it.

3.) Don't hospital shop. If all of your care has been at one hospital, then you decide you don't like the way your care has been managed, don't keep changing hospitals hoping for a better experience. Some of our hospitals are connected by EMR's (Electronic Medical Records), but most of them aren't. Also, at ECMC we can check the other hospital system but not vice versa. The great thing about being in the residency program is the ability to call your colleague at another hospital to ask them to check the medical record for a patient. But, it takes time, both mine and theirs.

4.) Don't lie. We jokingly call this the "House Syndrome" in honor of the House, M.D. TV show. According to House, "everyone lies." If you don't tell us about your 12 pack a day drinking habit, we might admit you to the hospital only to have you go into the DT's 3 days later. If you don't admit to your cocaine habit, we might give you a beta blocker that will lead to a fatal arrythmia. So, just admit it. The truth will come out eventually.

and, finally,

5.) Say "thank you." My hubby was bagging on me a little bit telling me I was remembering the bad and not acknowledging the good. So Cheers! to all those patients that sincerely appreciate the help we give. Cheers! to the families that shake our hands as we walk out the door, or as their loved one is being transported up to the floor. Cheers! to the patients and family members that take the time to send a card or acknowledge us in the patient care surveys. Thank you!

I wish everyone a HAPPY and PROSPEROUS NEW YEAR. It promises to be a most exciting one!!