At the End of the Day...

I haven't written about a day in the E.D. for a while, so I thought I would blog tonight about my shift today.  Just another day in my world.  For some, this was no ordinary day...

So, I started my shift at 0700, taking over from one of my colleagues and picking up about 10 patients right off the bat.  While I sent off my rotating resident and medical student to pick up a couple of the new patients that were waiting to be seen, I went to look at the lacerations on a stabbing patient that I had picked up on sign out.  My colleague hadn't been able to sew the wounds because they had been waiting for a few more films to come back, but by sign-out the patient was ready to have their wounds fixed.

I looked at the 4 inch cut to the face and the inch long wounds to the arm and back, and I knew that I would be sewing for a while.  When you're the senior, you're not just in charge of your patients, but you're also responsible for the flow of the department (what's coming in and what's going out and where).  So, I knew that I couldn't just leisurely tie myself up in one patient's room.  I had to think about what could potentially happen.

I stepped out to gather my supplies and went and saw a new patient coming in complaining of back pain.  She'd had recent back surgery and was having post-operative pain.  I wrote for some medications after some discussion with my attending and continued gathering my suture supplies.  About that time an elderly patient that had fallen down the stairs came in.

There was some concern because the patient was on blood thinners, and she had hit her head.  I did her exam, did a FAST exam and wrote order for the multitude of CAT scans I would be getting on her.  I then went to go start stitching my patient's face.  It took me about 30 minutes to get his face sewn up.  In the middle of my stitching, nurses would come in from time to time to ask about orders for patients.  At one point near the end, the nurse taking care of my elderly fall lady came to tell me that the patient wasn't as alert as she had previously been.  I told her to rush her to CAT scan.

I finished the patient's face and went out to see what had happened while I was gone.  The patient tracking board was filling up with patients, and I quickly went and saw another senior who had passed out in church, and one of our sickle cell frequent fliers.  I put in orders then went back and quickly spent about 5 minutes sewing up the laceration on my patient's arm.  Two lacerations down and one to go.  As I was putting in the last stitch, the nurse for my fall patient came in to tell me that the patient had bleeding in the brain.

I went out and told the charge nurse that we needed to move the patient to a trauma room.  I paged out the trauma team, and I put out a call to the neurosurgeon.  I wrote some order discharging a couple of the patients that I had been signed out that morning and answered returned phone calls.  I got the medical student started on sewing the last wound on my stabbing patient.  He got the first stitch in about the time I heard my name paged to the trauma room.

I went and found that the fall patient had an even worse neurological exam and would need to be intubated.  I went to find my attending as I grabbed the airway box and went to the room.  My attending told me to wait because he didn't feel there had been much of a change, and he wanted the neurosurgeon to get a good exam.  I went back to my medical student and got him through another stitch.  I got called back out of the room to talk to the family of the fall patient.  I explained about the head bleed and how I might have to put a breathing tube in.  They understood, and I went back to the stabbing victim.

One more stitch and I was called back to the fall patient.  She'd just vomited everywhere.  I told my attending I was intubating.  I got the breathing tube in and went to tell the family I had just done so.  They were very upset asking how the patient was going to do.  I couldn't answer them, but elderly patients who fall down the stairs and bleed into their brains don't often do well.  Another stitch with the medical student plus one or two I quickly threw in to move things along, and we were done.  By this time it was close to 1 p.m.  Where had the morning gone?

My fall patient went to the ICU, and I discharged (finally) the stabbing victim.  I picked up a nursing home patient brought in for altered mental status and another patient with swelling in their lower extremities.  After discussing the cases with the attending, I placed my orders and sent the resident to lunch.  I quickly saw a prisoner with a hand injury from a fight in the jail and placed orders for films.

My swollen patient ended up needing a cat scan, and for some reason it took 2 hours to get a head CT on my altered mental status patient during which time I sent the prisoner back to his cell and sent the medical student off to lunch.  I grabbed a quick salad myself (still doing the raw food thing) while I saw a pseudoseizure (nee big faker) and a patient bleeding from just about every orifice.  Oh, and a short of breath pregnant patient who did a whole lot of cocaine.

By this time it was after 5:30 p.m.  I got a neurology consult on the big faker, um, seizure patient, and I started ordering blood products for the bleeder.  My cocaine patient settled down, and I picked up a patient that had lost their battle with a table saw.  Almost missing - one pinky.  I called orthopedics.

Around this time I was cleaning house.  I got my big faker patient admitted, my swollen patient admitted, and my bleeding patient admitted.  We got word about this time that my fall patient had suffered a major bleed and now had a ton of blood in her head.  This was not going to end well.

Seven p.m. and my colleague returned.  We signed out our patients to her, and I spent about another hour doing paperwork and getting my altered mental status patient admitted and got my cocaine patient information about her reproductive choices.  While morally I oppose abortion, a cocaine and alcohol addicted patient whose three children are in the custody of her parents probably should have the option.  I don't condone it, but at time I think of it as a necessary evil.

Anyway, I signed out the cocaine patient because her heart rate was still irregular and my almost missing pinky patient because ortho was busy with a dislocated knee that had rolled in the door just at change of shift.  Tiredly, I packed my belongings and made my way home.  Vacation started the minute I left the hospital.  After another "usual" day in the E.D., I really need it.

For those reading on Facebook, my original blog site is buffalosquirrels.blogspot.com and I also blog for the American College of Emergency Physician's (ACEP's) website thecentralline.org