Sophomore Stories

I thought I would take my time tonight and post some comments on my second year of residency. Last year I wrote a post on my original blog "Do They Have Squirrels in Buffalo?" wrapping up my first year. So here we go through the second year:

Essentially, I started off my second year in July as an "unofficial, but acting in the capacity of" second year. Since I was hired late in the medical year, I still owed another month of internship. But, in essence I was acting as a second year. I spent the majority of the month getting ready for all the activities of second year, such as taking ATLS (advance trauma life support), a base station course (where we learn to give medical direction to EMS providers, learning about Mercy Flight, and learning to drive real fast in our SMART (specialized medical assistance team) vehicles, while at the same time dealing with summertime pediatric dramas. Oh, and I became a vegetarian "For the Animals!" in a 30 day pledge.

The next month I was on my EMS (Emergency Medical Services) rotation. I spent my time with firefighters, doing several runs with the EMT supervisors, and I got to fly in a helicopter for the first time with Mercy Flight. The other part of this rotation is being the resident for the local Poison Control Center. Whenever there's a drug overdose, we get called. We then call our attending who guides us through the correct treatment for all the drug overdoses we're going to face as E.D. physicians. It's learning through experience.

The next month had me reliving life as a surgical resident. During your second year of surgery, you spend a great deal of time in the ICU. Emergency medicine residents spend a month in the trauma ICU at ECMC. It was fun going back to the pimping, and the early morning rounds. I really enjoy the ICU and had for a time considered a fellowship (an extra time after residency for more advanced training) in critical care. But, I think by the end of the month, I really did look forward to getting back to the E.D. and did not regret my change in careers at all.

The next month was spent learning about ophthalmology, dentistry and radiology. Mornings were spent with the dentists learning to provide anesthesia to the mouth, and afternoons were spent looking in people's eyes. Not a very exciting month, but a nice 9 - 5 kind of month with weekends off and no call. I did get to work a Buffalo Bills' game providing medical support to the fans in one of the clinics at the stadium, so not an overall bad month.

Of course, October is when we made the move from J-land to, for the most part, Blogger. I had been chosen as the representative to the national residency organization (EMRA), and I was able to attend my first national conference back in my old stomping grounds of Chicago. I then spent the next month working at one of the suburban hospitals in the area. I learned a lot, and I got a new pair of shoes!

My next rotation took me back to the drama that is ECMC. I know I have mentioned several times that most of us really enjoy our rotations there. The system is a lot easier to deal with, and the patients are a lot less medically critical. So, let's see, what happened...? Thanksgiving came and went. I continued to be a vegetarian. I worked 5 days straight and had some interesting tales to tell. I went home to California for an early holiday.

I then did the "Swing Month" which is not as exciting as it sounds. Basically, we split our time between ECMC and Buffalo General. I spent 15 of my shifts at ECMC and 2 shifts at Buffalo General. Sounds about evenly split. Oh, yeah, and snow came to Buffalo and started the winter off with a bang. Christmas came and went, and I made you all take the Resolutions for New Year's Oath.

I then started my official second year rotation at the Children's Hospital and tried the best that I could not to catch the RSV and other bugs children were flocking to the E.D. with at the time. I failed miserably and took it into my next rotation in the Pediatric ICU where I spent a great deal of time writing notes, and not so much time doing anything else.

Of course, I must take a moment to remember the 50 who died when Flight 3407 crashed on final approach to Buffalo Niagara International Airport. I was on scene as a member of SMART providing support for the workers who had the dangerous task of removing the wreckage as others worked to collect their remains.

My husband and I celebrated our first wedding anniversary at a great little B&B in Pennsylvania near Gettysburg. We then spent the next couple of days exploring the battlefields (mostly on the Confederate side since my hubby is a Son of the South), followed by a trip to Lancaster where my interest in quilting began to develop. Who knew it would blossom into a new hobby?

I finished my rotation at Buffalo General and spent my vacation that month in Florida visiting the Everglades and the Florida Keys. A very nice way to take a break from things medical which was good because my next two months were going to be purely hellishish.

The Ortho Service: two months of pure immersion into orthopedic surgery. You spend two weeks on the Hand Service working in the clinic and going to the O.R. Then you spend five days on the service, take a 24 hour call, and then another 5 days on the service. After that marathon 2 weeks you flip over to nights and become a vampire for a month. I learned to set a lot of broken bones, and I learned to sew a lot of messed up hands and feet. I learned how to complete an amputation. I did get to go to the second national conference in New Orleans which broke up the month very nicely. And, I was already used to staying up during the night which played into the festivities nicely.

My final month was spent as an elective in the Medical Examiner's office, and I have shared a lot of the tales and stories which were encountered during my month there. It was a light relaxing month, and I even had time to do some additional ride along time with Buffalo's Finest on Rescue 1, and to provide back-up in the SMART car.

Wow, what a year. This year, I will spend 90% of my time in the emergency departments of Buffalo General, ECMC, and Women and Children's hospitals. I do have spend one more month, a "make up month" which is a carry over from my second year at the suburban hospital again. I'll be looking for a real job this first part of the year. By the time 2010 begins, I will be looking forward to my graduation, my new job, and a new and exciting chapter in my life... Hope we all make it there together, and thanks for being here for the journey!

The Defenseless Ones

Something I thought about today that isn't usually discussed is the problem of Elder Abuse. Now, while most people think about physical violence when they hear abuse, you don't often think of other ways in which the elderly are taken advantage of. I had a case today that kept me late and which turned into a very disturbing story.

Again, while I cannot discuss the particulars of the case because this will now be a criminal investigation, I can say that a moment of kindness offered by a stranger turned into a break-in and physical abuse on the elder person. To add insult to injury, the attacker portrayed a health care worker "acting concerned" about the elder when they somehow managed to call 911 and police arrived.

The elder was then transported as having Altered Mental Status and ended up in the ED. Meanwhile, the stranger and their accomplices ransacked and stole from this elder person. Luckily, a concerned neighbor was able to get a license plate, and the suspects are being tracked. But this poor person had to suffer some humiliation with no one believing them, not to mention the losses suffered in their home, and probably some loss of faith in humanity. I was in shock as I was told the story. If I get an update I will post it.

Unfortunately, we often see some form or other of elder abuse. Usually neglect, sometimes by families that mean well, but are just not prepared to handle the demands of a frail aging person with multiple medical problems. Or by the hands of those in the nursing homes to which they are entrusted. I haven't written about some of the more horrific stories I've heard and seen. I've had a patient I've called Adult Protective Services for due to concern their fracture was inflicted by a staff member.

As for the rest of the day...

I spent the morning cleaning up from a multivehicle accident that resulted in the death of a Buffalo police officer.

I then had a patient come in with a steak knife sticking out of their belly. The driver and passenger of a motorcycle crash who both needed trauma work-ups. An overdose who needed to be intubated upon arrival. And assorted other crazy patients that each took up their own space of time.

Tomorrow it's back to the fun at the County. What a way to spend the weekend!

p.s. you can link to the National Council on Elder Abuse by clicking on the purple ribbon.

Passing Time

I had a few minutes so I thought I would jot down a few brief thoughts from the last two overnight shifts I worked. One at the County and one at the General....

The Canadian Healthcare system sucks. Just because you have healthcare doesn't guarantee that you have access to everything. I could have an illegal migrant farm worker walk into the E.D. with a severed thumb, and he would have a hand surgeon evaluating his thumb and most likely reattaching it within a few hours. A Canadian citizen cut his thumb and was transferred to a receiving hospital who then spent the next 6 hours looking for an orthopedist who might consider operating on his hand. They then spent the next 2 hours calling U.S. hospitals to find a hand surgeon willing to take the case. He then spent another 2 hours trying to get transportation arranged across the border. We had accepted him to the County, but by then it was too late. He will have to do his work sans his thumb.

Psych patients drive me crazy. While I can go along with some delusions, it's the scarily quiet ones that freak me out. Questions that go unanswered. Or a question that is answered, "well the last time I felt like this I went totally crazy and ...." Ok, stepping away from the patient before they, "...." on me.

Why do people insist on driving while under the influence of anything? It just isn't safe to take 2 sleeping pills, chase them down with alcohol, and then decide you're hungry and NEED to get something to eat right now. Ride your bike, no. Walk, no wait. Just stay home and sleep.

Patients with pica are weird. We got this patient who likes to swallow things like pens and markers. Not sure if it meets the technical diagnosis of pica but close enough. The GI fellow told me they have scoped this patient multiple times and pulled out a variety of objects. He told me that they have several patients known for all the items they've swallowed. Also, we had to get psych involved because this patient can't be trusted in their room. Last time they were admitted they unscrewed the screws on their bed and swallowed those while waiting for their upper GI scope. So, they got a 1 to 1 sitter.

Um, weenises come in all shapes and sizes. Just saying. We put in a lot of foleys for traumas. Not judging, just noticing.

How come patients who come into the E.D. complaining of pain never take anything at home for it? And, why do they all seem to know that "that stuff that started with a d... dil-something, that they put in my IV, that works really well." One of my colleagues argued that we should have a Lortab dispenser in the waiting room because it would cut down on the number of patients we would actually have to see.

Why is it I can go to work for 12 hours having to shake my hand all day because my carpal tunnel is acting up and I'm having ulnar neuropathies (my ring and pinkie finger are falling asleep), but you need a work note and a prescription for Lortab (see could have used a dispenser here) because the toe you stubbed 3 weeks ago is "really bothering you" and you just can't handle your six hour shift sitting down and answering phones?

I really wish we had a Room Nine. When I was in medical school, the E.D. at Froedert had a back room where the drunks, inmates and psych patients were held. It was Room Nine. There was a seperate area with a few shower benches and a drain in the middle. "It puts the lotion on the skin or else it gets the hose again." Actually, no, but they did have a power hose for unruly patients. And, if someone had an accident, or on-purpose soilage, clean-up was a snap. About the time I graduated, the room had been converted as part of an observation area for 23 hours' admissions, but during that first year doing tag-a-longs in the E.D., it was the site for some very interesting patient encounters. We could use a Room Nine in our E.D.'s at times.

Did I mention I like polite patients? The ones that say, "no problem, I know you're very busy" and "thank you, I appreciate every thing you did for me tonight." On some nights, they're the bright spot of my night.... except for a messy trauma of course. Again, it's not that I want you to get hurt... I just want to be there when you do.

I have several days off to recharge. Teaching a procedures class in the morning and then hopefully some sailing. A dinner party on Thursday night. Then it's work the weekend. Till then, stay safe out there!

Traumarama Thursday Night

So I started my first night of three at the County last night, and from the onset to the end of my 12 hour shift, it was one trauma after another. Actually, one trauma with another because they seemed to come in pairs. Now, I love traumas, don't get me wrong, it's just that sometimes having to work with different departments, ie. surgery, can be very frustrating. Especially when you come from different systems where departments actually get along and run real trauma codes, ie. U of Minn.

This is so not U of Minn.

Anyway, here is how my night went...
1900 get sign out from the day team. I pick up nine patients that are left over. Three are already admitted, and the rest are waiting for consults, lab results, etc. Sign out takes about 15 - 20 minutes, and about the time we are done and everyone is leaving, I get word from the charge nurse that Mercy Flight is en route with an MVC (motor vehicle collision). I sigh because I am working with a rotator (an internal medicine resident) and a medical student.

This means that my night is going to be twice as busy since, as a rule, the off-service rotators don't have the same, um, sense of urgency that we, Emergency medicine residents, do. And, there's a great quote passed along the medical tradition that says something to the effect of, "give me a medical student that will only double my work and I will jump for joy." I also had a physician's assistant and one of the new interns, so there was going to be enough fun for everyone.

So about 1930, Mercy Flight brings in SUV versus semi. The semi won. However, you have to admire the semi driver who saw the SUV about to hit him, watched the impact, then jumped out of their cab to help the person get out of their car. Luckily, no major injuries, and the driver of the SUV stayed overnight for observation.

About the time that I finished this evaluation, EMT's arrive with Gear Wheel Flew into Face. The eye is involved, so GWFiF goes into a room and I get ophthalmology and ENT involved because there is going to be some serious damage, and a lot of fine sewing involved.

I work on one or two of my sign-out patients, deal with a surly (I would use harsher language, but I don't have the parental control warning on this blog) surgical chief who will be the bane of my existence for the rest of the night, give someone procedural sedation for a dislocated shoulder, and start to write up the trauma patient when I get word from the charge nurse that an ambulance is en route with a partial amputation and low blood pressure.

I get to the trauma room, and we get Motorcycle versus car. The patient's lower leg is hanging on by a few tissues, and we make plans for the patient to go to the O.R.; of course, after a couple of units of blood and stabililization. I am just putting up the orders from this patient when a patient I had heard about earlier, Bike versus Tree, rolls in the door. They were transferred from another hospital when the patient started dropping their blood pressure and complaining of chest pain. We get them into another trauma room (we have four) and start their work up.

By now it's about midnight. Somehow I have managed to dispo (disposition meaning getting someone admitted or discharged) my signout patients and I pick up a non-trauma MVC. I get them pain meds, order spine films, and go talk to an alcoholic who just got out of rehab two weeks ago and started drinking the day they got out. I explain that there is no room in our rehab program and tell them to go back to their initial contact. I always write on the disharge instructions, "only use alcohol in moderation." While I can write "stop smoking" I am not allowed to tell someone to stop using drugs or stop drinking. Fancy that. Drug abusers get, "only use medications or narcotics as prescribed by a physician."

I stop in the middle of things to help out the intern with an assault victim that is bleeding profusely from their head. After finally getting his pain under control long enough for him to allow us to start to work on his head, I walk the intern through stopping bleeders with a figure 8 stitch and then get them started on a double layer closure. I leave them to finish the suturing and close the skin with staples. Now, where was that chart I put down...?

My BVT goes for further evaluation by the cardiologists for a possible heart injury (after I had to intubate them for dropping oxygenation saturations) which clears the back room just in time for Struck by Car While Getting Beer at the Corner Market. The patient was clipped by the mirror of the car, fell to the ground, and didn't break the 40 they were carrying. We start the work-up, but the patient will most likely be sleeping it off in a room until they are sober enough to be released.

It's about 0330 and one of the ER techs runs downstairs and gets me a coffee. I take a sip or two and then go to the trauma room for T Boned While Leaving Sleepover. The trauma team is activated yet again, and I am handing in orders for this patient when Lost Control of Motorcycle rolls in. We meet this person and see two obvious leg fractures. They will end up having about 3 other fractures which are found during the course of the work-up.

I sit to write my notes. It's getting close to 0600, and I pick up some more patients as the medical student and the rotator seem to be satisfied with managing their one patient for the final hour (did that sound catty?). I get "went to concert and got kicked in the head." I give them something for their headache and order a CT scan. (Excuse me while I clean my name badge. There seems to be some blood on it. I wonder from whom?) Then I get "my gout is acting up" which I give pain meds to, write a script and their discharge paperwork. At 15 minutes to 0700, I go and see "Chest Pain since Yesterday," and I put in their orders to get them started for the next resident.

I sign out 4 of my patients from the overnight, and I discharge T Boned because they had been cleared by surgery. I head to my car and drink the last of my now-cold coffee and head off to sleep. Another shift begins tonight. I can't wait!

A Midsummer Nights' Sailing

I don't know that I've blogged about this yet, but I have been sailing with one of my attendings for the last several weeks. He has a racing boat named the "RagAzzi" and he races her during the summers here in Buffalo. He asked for crew for his boat, and since I had sailed during and after college I volunteered. I thought I would share some photos I've taken during our races.

Here's a video that shoes the boats getting ready for the start.


There's an imaginary line between the Committee Boat and an inflatable marker that is set some distance away.

You have to maneuver your boat to the starting line, don't hit any other boats, and don't cross the line until the signal sounds. If you cross before the signal, you suffer a penalty and have to make a 360 degree turn before you're allowed to restart. Now, you can imagine it's all about timing. Boats don't start and stop on a dime.

Once you're underway, then it's all about strategy. When do you turn (tack upwind, jibe downwind), which line do you follow, etc. You're racing toward several markers that make up the course. Usually you have an upwind leg and a downwind leg.

If you watched sailboat races, everyone gets excited when the big spinnakers go up. Those are the full fluffy sails you see on the front of the boats. That's when you're going downwind.

The most exciting times for us as crew are the starts and the turns. The rest of the time we are hanging out on the side of the boat to provide counterweight to the pull of the sails. Except for me, I work the mainsail. So I sit in the boat and make small adjustments as wind conditions change.

We haven't won a race, yet, but it has been fun spending those hours on the water, concentrating on nothing but feeling the wind in your hair, the sun in your face, and the pleasure that comes from controlling the wind.

The Pleasure Boat (selected stanzas)

by Richard Henry Dana

Come, hoist the sail, the fast let go!
They're seated all aboard.
Wave chases wave in easy flow:
The bay is fair and broad.

The ripples lightly tap the boat.
Loose!-Give her to the wind!
She flies ahead:-They're all afloat:
The strand is far behind.

No danger reach so fair a crew!
Thou goddess of the foam,
I'll pay thee ever worship due,
If thou wilt bring them home.

O, might I like those breezes be,
And touch that arching brow,
I'd toil for ever on the sea
Where ye are floating now.

The boat goes tilting on the waves;
The waves go tilting by;
There dips the duck;-her back she laves;
O'er head the sea-gulls fly.

The sun-light falling on her sheet,
It glitters like the drift,
Sparkling, in scorn of summer's heat,
High up some mountain rift.

The winds are fresh-she's driving fast.
Upon the bending tide,
The crinkling sail, and crinkling mast,
Go with her side by side.

The parting sun sends out a glow
Across the placid bay,
Touching with glory all the show.- -
A breeze!-Up helm!-Away!

Veronicology

I know you don't want to hear more gory stories about life in the emergency department. So, as an interlude in preparation for my weekend stint on the overnight shift at the county hospital and, hopefully lots of gore, I am going to follow Winevere's blog posting and share a little Veronicology:

These are the directions: Let others know a little more about yourself. Re-post this as your name followed by "ology."

What is your salad dressing of choice? Blue Cheese

What is your favorite sit-down restaurant? Depends on the city I am in, all time though would be Ruth Chris' Steak House

What food could you eat every day for two weeks and not get sick of? Mexican

What are your pizza toppings of choice? Pepperoni & Mushrooms

What do you like to put on your toast? Butter and blackberry jam

Chocolate or Vanilla? Vanilla

How many televisions are in your house? 3

What color cell phone do you have? iPhone with the white back

Do you have a laptop? Yes

Are you right-handed or left-handed? Right

Have you ever had anything removed from your body? Um, no...

What is the last heavy item you lifted? a backboard from a patient

Have you ever been knocked unconscious? No

If it were possible, would you want to know the day you were going to die? No, I like surprises

If you could change your name, what would you change it to? Growing up, I always wanted to be Cassandra Taylor

Would you drink an entire bottle of hot sauce for $1000? How big's the bottle?

How many pairs of flip flops do you own? 4

Last time you had a run-in with the cops? By choice, a week ago to talk about a homocide, not by choice, as a freshman in college

Last person you talked to on the phone? my hubby

Last person you hugged? my mom

Favorite Holiday? Christmas!

Favorite day of the week? any day I am not working

Month? September, I love the fall

Missing someone? yes

Mood? Tired, it's been a brutal and emotional two days

What are you listening to? XM radio on my iPhone

Watching? nothing, see prior question

Worrying about? how messy my apartment is, and how dirty is the kitty litter

First place you went this morning? Dunkin Donuts before work

What's the last movie you saw? Step Up Two

Sleeping Alone Tonight? You're never alone with three cats on the bed

Do you always answer your phone? Depends on the caller I.D.

If you could change your eye color what would it be? Green, like my grandmother's

What flavor do you add to your drink at Sonic? I've only been to a Sonic once in OKC, and I don't remember having the option

Do you own a digital camera? Yes

Have you ever had a pet fish? Yes, until moving here, I'd maintained an aquarium of some size or other since the age of 7

What's on your wish list for your birthday? Balloons and teddy bears, I love teddy bears.

Can you do push ups? Can, yes, do, no.

Can you do a chin up? Depends, am I on the exercise machine that gives you a little boost?

Does the future make you more nervous or excited? excited

Do you have any saved texts? Yes, mostly from my hubby

Ever been in a car wreck? three, none my fault

Do you have an accent? Yes, a combination of California Valley girl with a hint of dem dere upper Midwest folk

What is the last song to make you tear up? The Book of Love by Peter Gabriel

Plans tonight? Sleep eventually

Have you ever felt like you hit rock bottom? Yes, but somehow managed to climb out of that hole, and now here I am!

Name 3 things you bought yesterday - Starbuck's coffee, lunch, dinner

Have you ever been given roses? Yes

Current hate right now? feeling uninspired

Met someone who changed your life? yes, had a lot of good influences in college

How did you bring in the New Year? With my hubby at an outdoor concert watching fireworks over Niagara Falls on the Canadian side

Name 3 people who might complete this? Nicole, De, and someone from work

Would you go back in time if you were given the chance? Yes, I have three "do overs" I would love another chance at

Have you ever dated someone longer than a year? Yes. Amazingly, only my husband. Prior to that, three months was the record. I have short attention span.

Do you have any tattoos/piercings? Both my ears are double pierced

Does anyone love you? I can think of at least 5... do my cats count too?

What songs do you sing in the shower? 80's Madonna or "Big and Chunky" from Madagascar 2 or "Low" by Flo Rida

Ever had someone sing to you? Hmmm... Do you like to cuddle? Of course

Have you held hands with anyone today? I don't think examining a patient counts

Who was the last person you took a picture of? probably one of my work colleagues since HIPAA prevents us from taking pictures that in some shape or form lead to the identification of a patient which violates their right to privacy

What kind of music did you listen to in elementary school? Whatever was top 20, but a lot of 50's and 60's stuff too

Do you believe in staying close with your ex's? refer to prior question about long term dating, no long term connections

Are most of the friends in your life new or old? both, I love meeting new people, and I treasure all the friends I have made and keep them close

Do you like pulpy orange juice? Like my beer, I like an orange juice I can chew

What is something your friends make fun of you for? Which friends and from which social occasion?

Have you ever ridden an elephant? No

Do you like to play Scrabble? sometimes online

What are you saving your money up for right now? Vacation and moving expenses for next year

When is the last time you ate peanut butter and jelly? together? not in a long time

What were you doing 12 AM last night? zzzzzzzzzzzzzzzz

What was the first thing you thought of when you woke up? Just make it through the day and you'll have sailing to look forward to tomorrow

So, now, how about you???

The Answer is 42

In his book, "Life, the Universe and Everything," Douglas Adams writes that the answer to the aforementioned was found to be 42. Of course, the book never answers what the question is. In fact, according to the story, the question and the answer cannot exist in the same time frame in the universe. Whatever the case, today I turn 42.

Do I know the answer to life, the universe and everything? No. Do I know the answer to most things? No. Am I even close to understanding even on the most basic level about most things? No. And, I am o.k. with that.

When I graduated from college, I was very bummed. It was a bummer, Dude. (Still so very So. Cal.) I didn't want to stop learning. I wanted to continue taking classes and finding out about everything. College is a protected time. I didn't have to work. I had a whole world of knowledge sitting in front of me in the shape of the college catalog. I could learn about anything.

One word of advice I received is one that I continue to pass along to those undergrads I meet: take at least one class a semester that has nothing to do with anything. I was given that advice when I thought I was going to be a civil engineering student and change the world. Or at least my town's sewer lines, or so it seemed. I made sure that every semester, one of my classes had nothing to do with math or science.

I learned archery, fencing, horseback riding. I studied celestial navigation and "Voice and Diction for the Theatre." I took Ancient Greek as my language requirement, Chinese philosophy, and Greek Theatre. When I changed to Journalism, I minored in English, and was two classes away from a double major. Lit and film, Lit and the theatre, Lit and poetry, I took them all. I also studied Egyptian literature and learned to sail.

Even at that time, I wished I could be a professional student. Funny how life turns out, because in some ways I am. I will always need to keep up with advances in medical care. I will always need to attend seminars on how to perform certain skills or keep current on the latest drugs. I will always want to learn more so that I may serve my patients better.

So here I am. At the age that is the answer to Life, the Universe and Everything. I know that there will be a lot of questions answered during this year. Where am I finally going to settle down. What is my house going to look like. Will my husband divorce me if I say I want another cat.

And there are a lot of unknowns... that's the fun part. It's fun knowing the answer and seeking the question because there are so many possibilities. You're not limited by a question; answers have no limits, because they could refer to just about anything. I think this will be the year of no limits because I already know that the answer to Life, the Universe and Everything is 42.

A is for Airway

I had to go home for two days to attend to my mother, but this is the blog entry I would have written after my last shift on Sunday night had I had a choice other than using her slow-as-molasses dial-up or typing out my entire post on my iPhone.

From the beginnings of medical school, you are taught the rules of patient assessment; you are taught the "ABC's" - Airway, Breathing, Circulation. You don't move onto B until you have established A. You don't move onto C until B is established. If at any time you lose A or B, you go back to the beginning. Emergency Medicine docs are all about the A. My first patient on Sunday night was all about the A.

While it's difficult in this setting to talk about the specifics of a case, let me just lay out the scenario for you. You get a patient who is having an allergic reaction and everything is swelling. When they start to cough and drool and can barely get their words out, you know you're heading for intubation (putting a breathing tube in.) When you get a heavier set person with a short thick neck, you know you should be prepared for anything. I asked for a scalpel to be nearby before I even thought about getting the standard intubation set up. And, I was later glad I did.

Now, I have performed tracheostomies on patients under controlled settings (i.e. in the operating room or in the ICU), but I never had to perform one in the Emergency Department on a patient that was rapidly becoming critically ill. We spend some time in the cadaver lab learning how to perform this emergency procedure, but somehow with all the beeping and buzzing of alarms, with the addition of other people coming in and out of the room, with the knowledge that the patient's family is standing right outside the curtain crying because their loved one is unexpectedly in a dire situation, it's not that easy. I know my landmarks, I know the technique, and now I know I can handle an attending standing behind me going, "So what are you going to do now?" after every failed intubation technique that lead up to this.

The somewhat surreal aspect of all this is that once I established the airway and we got B under control, I was about to breathe my own sigh of relief when suddenly C became a problem. Another round of medications, another round of procedures, another bout of handling the inevitable continued questioning, "So what do you want to try now?"

Nothing, I want to try nothing. I want to go outside and have a beer in celebration of getting a breathing tube in my patient. I want to be seeing the seven patients I got at sign-out who are currently languishing in their rooms. I don't want to be here now having to think about the C!!!!

That's when God, in His infinite wisdom, provides me with some comic relief. We get a heartbeat back, yeah! I step outside the curtain to talk to the two adult children of the patient and explain the events of the evening when suddenly a psych patient that had just rolled in starts yelling, "Get the &*^%$! off of me! Stop touching me! What do you think you're ^&%$ing doing?!?" Sitting on the stretcher just behind him is a woman who is wearing an oxygen mask because she was feeling short of breath. She starts to breathe faster. Her daughter, who is standing at her bedside starts yelling, "Momma can't breathe! Momma can't breath!"

Three security guards rush in and grab the psych patient. I tell the EMT's to take the short of breath patient to a room. Mayhem ensues as the SOB (short of breath) patient is being wheeled past the psych patient and everyone starts freaking out a little more and there's yelling between the two beds. The volume in the E.D. rises to a fevered pitch, and then... silence.

The SOB patient is in a room where she starts to calm down and breath slower, and the psych patient has been given drugs and he has started to fall asleep. I have talked to the family of my critical patient, and I start to do paperwork - history and physical, intubation note, cricothyrotomy note, tracheotomy note, code note. Almost three hours have passed since I started my shift, and I have been in with one patient the entire time. I watch them being wheeled upstairs to the O.R. for a more definative airway placement followed by placement in the awaiting ICU.

I grab my now-warm bottle of diet soda and take a long swallow before grabbing some charts and getting started with the rest of my shift....

Last Night at the County

Some of the cases from last night's revelry:

OD's - My two of the half dozen or so OD's we got last night were of unknown substances. One we think was methadone the other is a complete mystery.

GSW's - we got one last night but one shot was all it took to take the life of an 18 year old

Stabbings - mostly superficial wounds on the patients, but my patient's assailant decided stabbing wasn't enough. He was going to run over him with the car too. I think he's going to be lucky and wind up with some relatively minor injuries

Motorcycle crash - again, please don't take drugs and then think you can control a motorcycle. You'll end up with lots of broken bones in the trauma icu and the police placing you under arrest.

All this plus the chest pains, the abdominal pains, the shortness of breaths, and the eight or so patients signed out to me last night.

Have a great and safe Fourth! Stay out of the ED!! I don't want to meet you under those circumstances...

The Year Begins Anew

Another year is gone. The medical year that is... Last year I wrote about how you shouldn't get sick around this time. This is when the interns start in all of the medical specialties. Having worked two shifts into this new year, I have already begun to experience the in-experience of some of the new residents. I mean, come on surgical 'tern, don't you know that "incarcerated hernia" means an automatic trip to the OR? Can you list for me the 5 pre-op tests that you need for me to order for you prior to admission? Drop and give me 20!

Ooops, sorry, I forgot for a moment I'm not the Senior surgery resident, I am the Senior emergency medicine resident, so 'Tern, go wake up your senior and tell him Dr. Smith's post-op patient needs to go back to the OR to fix the bottom edge of his mesh so that his guts don't keep poppin' out of his belly. Oh, and I know the 5 tests that need to be ordered, so I will do them. Meanwhile, call pre-op and tell them you're coming upstairs with a patient so that I can get them out of my E.D. while I make space for the next 1 of 50 people showing up this shift to let me know they heard about someone with the flu and think they might have it too because they sneezed, twice!

You see, being a Senior Resident (I kinda like it like that all in capitals) means that I am in charge of the Emergency Department. This is my turf. This is why I kept getting yelled at by my attendings during my first two shifts that, "You have this situation going on... what are you going to do about it?" Um, I don't know... can I go back to being a junior so I can take all the good cases and leave the rectals and pelvics to the interns and rotators? No? Oh, well.

Let me, therefore, tell you about my first two senior shifts. Grab a cup of coffee and a muffin because I am going to be writing in a stream of consciousness and this might take a while. If you think I am making this up or I copied this from an episode of "E.R." "Chicago Hope" "Grey's Anatomy" or "Scrubs" you are mistaken. They copied it from us first:

- We start off the morning with sign-out. The night crew signs out to the oncoming team. We work 12 hour shifts. Any patients that haven't been seen are still on the board as well as patients that are still in the middle of their work-up (still waiting for labs, xrays, CT's, admission bed, etc.) As the senior, I take all the leftover patients that still need work. I got 6 the first morning, and 8 the second morning. So I spend the first hour or so of my morning not seeing new patients for the most part, but trying to clean up what is left over from the night before.

- Then the "chest pain needing to go to the cath lab" because they're having a STEMI, or the "I'm still drunk from last night so I decided to punch my hand through a window" come rolling in. So now I am dealing with these two patients.

- I finally make it back to Room 19 (we call it the Death Room because it is the furthest room in the back of the E.D. and if you crawled into the Nurse Server cabinet you'd probably find a passage to Narnia) to sew up the "I have brain cancer and fell headfirst into my chest of drawers" that has been sitting since last night because he needed a CT scan. While I am preparing my sutures, the "still drunk from last night" starts to tell everyone in the department what they can suck if they come near her. Yes, her. Suddenly, I am being overhead paged to the main arena, and when I don't respond within 2 seconds my attending comes down the hall calling out my name. I am reminded for the 5th time that this is my department, and what am I going to do about a potentially escalating situation? I walk over to the nurses' station and order a B-52 for my patient (Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg). The nurse reminds me that we are not at ECMC so she will give the Haldol and Ativan. Ok. Three security guards hold the patient still while the nurse sneaks into the room and administers the two shots. As I walk back to my patient in the Death Room, I hear the patient screaming something about being violated twice in the E.D. A minute or two later, silence. I finished my sewing.

- Ten minutes later I go into the room to finally thoroughly examine my "drunk since last night." She's got some minor cuts on her right hand, but her left hand looks funny to me. I order bilateral hand films and go off to see some new patients.

- We start at 7 a.m. and now it's about 11. I am arguing on the phone with the newly advanced MICU senior (yesterday a second year, today a third, kinda like me but they're a medicine resident while I am an EMERGENCY medicine resident). I tell them about a patient who can't breathe because they have too much fluid on their lungs, around their lungs and that they need dialysis. They're too unstable for the floor, and I am about to put them on bi-pap because their breathing is so bad. They argue why don't we send them to dialysis and then they'll be good enough for the floor and not the unit. I say I can't send an unstable patient to the dialysis room. We continue to argue. My attending tells me for the 9th time that day that I am in charge and to get that patient in the MICU. I tell the MICU resident that this patient needs to go to the MICU because there is not portable bipap machine AND bipap machines aren't allowed in the dialysis suite. Let them be dialyzed in the unit and then they can send the patient to the floor if they are stable enough. The resident says they are going to talk to their fellow. I hang up and put in for an ICU bed.

- I then go off to see chest pain #4 or 5 of the morning. This 30 year old probably just wants a day off work, this other 30 year old might have something. We've seen MI's in patients as young as 17. I get their labs, EKG's and chest x-rays ordered. I head off to see my next patient.

- About an hour later, everything is humming along. I don't think about my "I need the ICU and Bi-pap" patient because they got sent upstairs to the unit and about 5 minutes later needed to be intubated. Hmm.. guess they were sick after all.

- It's about 2 in the afternoon. The E.D. is getting full. We have 22 beds, plus hallways beds A - K. They are almost all full. I am in the midst of paperwork trying to get patients out the door to make room for a waiting room that has about 15 people in it. That doesn't include the new Fast Track area which is handling its own crowd. I hate paperwork. The patient chart has two pages to fill out. They also have a medical reconciliation form. Then there's the discharge form. If they get discharged, it's 4 forms to make sure I have filled out. If they're admitted, then 3. Anyone I admit to the chest pain center for overnight observation and stress test in the morning has another 2 pages of admission orders. I am trying to discharge, admit, and write progress notes on about 4 patients. I think about the "still drunk from last night" and wander over to look at her x-rays.

- They haven't been shot yet because despite enough drugs to render me unconsious for 48 hours, she threatened to beat the %&*!! out of the radiology tech. So I wander to the E.D. x-ray room to provide some support. Of course, the patient behaves for me, and we get all the films done. I go see another patient while I wait for the films to load.

- I spend several minutes explaining to family that their father has lung cancer. They got a biopsy four days earlier and didn't know the results. He was feeling short of breath this morning and seemed to be walking into walls. As I looked up the pathology on the computer, I already knew what I would find on the head CT I ordered. Sure enough, an hour later I was back in the room explaining that the densities we had seen on the CT were most likely spread from the lung cancer. I called to get him admitted, and I explained to the family about the parade of specialists that would be coming to see him: oncology, neurology, neurosurgery, etc. At the VA in Wisconsin we had a similar patient. When I asked the attending what I should order, he told me "a cane pole and a six pack." When this patient's son came out and asked if he could get some coffee for this patient and maybe something to eat, I told him the patient could have whatever he wanted. Pain meds? Sure. Anything you want.

- For those that don't know, I did 3 years as a surgical resident. I can tell when things aren't as they are supposed to be. A black stump of a colostomy doesn't mean that things are going well. Especially when it is a new colostomy. I call the attending and describe the site. He tells me to call the surgical resident (a second year) but that he's sure I am mistaken. No colostomy site of his is anything but perfect. I order pre-op labs and place a call to resident. When she shows up 30 minutes later, she walks into the room and tells the patient, "your colostomy site is dead and you need to go to surgery today." V stands for vindication.

- I place a cast on the broken hand of my "still drunk from last night," which she doesn't even wake up for. I use skin glue to fix her one laceration because she probably wouldn't follow up to have her sutures removed, and she'd probably end up ripping the sutures out with her teeth. I then make her wake up and get up out of bed. I walk her around the E.D. and give her a sandwhich. There, clinically sober, and I start working on her discharge paperwork. Which is a good thing considering all the beds are now full and there's a full waiting room.

- It's after 5 p.m. and I am standing with Discharge Planning trying to decide what to do with a chronic pain patient who doesn't have enough insurance days to be readmitted, and who burned her bridges with the rehab facility she was living in. She wants more drugs because her pain isn't being controlled adequately. Funny how this all started the second she signed herself out of the rehab facility where her pain was controlled over the course of 4 months. I tell her I can't prescribe Methadone or Fentanyl patches. What can I do to make her pain better so she can make it to her primary doctor's appointment the next morning? A 10/500 Lortab and a Dilaudid shot? Ok. Off you go.

- It's 7 p.m. The night crew arrives. I have 5 patients to sign out. Two I have discharge paperwork completed. They just need one or two labs to come back. Two I just started, so they need a little more work. One is waiting for admission. My colleague, God Love Her, is a bit of a Black Cloud. So, while I am finishing up some paperwork, a code rolls in the door. The E.D. is packed already. It's change of shift for the nurses too. I run in to help my colleague out.

- I call my husband in Atlanta while I am driving home at 9:30 p.m. I stop for some Chinese food from my favorite place, and listen to him gabbing away on my Bluetooth while I eat my first meal in about 8 hours. I go home to crying cats, empty food bowls, and a pile of mail. We crash in a pile of fur and purring on the bed. I set the alarm. Six a.m. and my next 12 hour shift in charge will be coming way too soon.

I am working the weekend at the County. Mind you, Fourth of July weekend, as a Senior resident, in the Emergency Department, on nights. Fun, fun, fun. I did a wrap up of my intern year last year, and I will do a wrap up of this year at some point over the weekend. Have a happy and safe Fourth of July!