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03 July 2009

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!


a corgi said...

I liked what a B-52 is; wow what a first week you've had just stuffed in a day or two; wow!!! should be an interesting weekend for sure!


Julie said...

The 4th of July weekend if the one we all dread. To me it means blown up hands and burnt little fingers. I am glad I am not the only one who has to convince a doctor that the patient can't stay on this floor when she needs ICU. Hang in there.

Claudia's thoughts said...

I am glad I have off for 11 days, I am exhausted by reading about your day....

Lisa said...

Wow.....I don't know what else to say except I just don't know how you can handle that day after day. I find this so very interesting to read.