A Week of Nights

So for the last two weeks, I have been looking forward to a leadership conference that I will be attending in Washington D.C. this week.  To make up for the fact that I would be gone for about 6 days during a non-vacation month, I had to squeeze in my required shifts into the rest of the time.  So, I just ended a string of 6 nights in a row.

Now, a 72 hour week is nothing compared to the sometimes 120 hour weeks I'd put in as a surgery resident. However, the last time I did something like that was over 3 years ago, so I was a little rusty.  Suffice it to say, there were a lot of patients seen during that time....

 - the "newlyweds" who came in concerned that an infection on one had spread to the other... it hadn't, but I was more concerned about the fact one of them had Hepatitis C.  Now, that's something that you don't want to be sharing...

 - why are the nicest patients always the sickest?  I had the status-post bone marrow transplant for leukemia who came in with a pulmonary embolism.  He and his wife were the nicest people.  She kept track of every doctor's appointment, lab result, medication schedule, and he showed an inward strength I can't begin to imagine.

 - on the opposite spectrum, I saw my share of 10 out of 10 abdominal/chest/back/etc. pains who are "allergic to everything except that di, dil, daldid, something d stuff.  Of course their pain is always something non-specific with random symptoms, and they have to have the full work-up and treatment... I did say "seriously?" once or twice as several I knew had multiple ED visits came in crying and writhing on the bed.  They just stopped for a second and said, "Well, maybe it's a 7 or 8.."

 - moving someone from the ambulance gurney to the hospital bed and seeing brains is never a good sign

 - I actually admitted a 10 year old for "severe constipation"... come on, parents, more leafy greens and water and less processed chicken nuggets and colas... make your kids run around instead of sitting in front of the Playstation... I can't tell you how many "rule out appendicitis" kids I see that turn out to be constipation

 - some things come in pairs:  I had a Martin and a Marvin both come in with the same wrist fracture on opposite arms, one from roller skating and one from skate boarding on the same night... wierd

 - we are not fast food, you can't come in, pick what you want off a menu and then leave if you don't want to finish your meal... also, if you're crying and writhing in the hallway and you've been waiting about an hour, I am still going to bypass you for the little old lady who's turning blue who just came in the door... keep screaming, I'm going to be just a little busy saving a life across the hallway

 - some people are crazy, literally.  I always wondered about mental illness.  I had to do an evaluation on a paranoid schizophrenic...  it was something like the scene in "Patch Adams" where Robin Williams fights the squirrels with his roommate... yeah, something like that...

Ok, I think I touched on the highlights.  I'll be blogging from the conference this week, so stay tuned!

A Cowboy Needs a Horse

I never thought much about our “regulars” until I came back from vacation to find that one of them had died.  We’ll call him “the Cowboy.”

I met him when I was an intern.  He was the anginal patient with known severe coronary disease who had suffered from alcohol abuse for many years.  He would come in from time to time;  usually drunk, complaining of chest pain.  We would run some cursory labs and an EKG, let him sober up,  and then send him on his way.

As the months passed, he would start to come in more and more frequently;  trademark hat and boots in place as the ambulance gurney brought him in.  He had developed cardiomyopathy somewhere along the way and had an AICD placed.  He started coming in complaining of it firing frequently and chest pain.  He would be admitted and usually signed out AMA after a day or two.

Over the last 6 months, he was an almost weekly visitor to the downtown hospital, but then we started seeing him at the county hospital where we also have shifts.  The Cowboy started becoming one of those “repeater” patients that become annoying.  You’d see his name on the triage board, sigh, and then go in and ask, “Seriously, Cowboy, what is it today?”

About 3 months ago, though, he really started declining.  His prior history of medical non-compliance and signing out AMA was making it difficult to get him admitted even when his heart failure was severely affecting his health.  Somehow, we would convince the attending that he really did need to be admitted, and true to form, the Cowboy would get diuresed, refills on his nitro, and then sign-out AMA or abscond yet again.

Recently, though, on one of my admissions, I convinced him that he needed to stay for evaluation by the cardiac surgeons who had wanted to take him to surgery during the previous admission.  He agreed only to be told that his disease was so severe that only a specialized center like the Cleveland Clinic might consider his case.  He told me this about a week later when I saw him, yet again.

As soon as he saw me he said, “Wait a minute.  Before you say anything I did stay, and this is what they told me…”  As I was ordering his now routine chest x-ray, EKG, POC troponins and BNP, I looked at the Discharge Summary from his most prior admission.  The angio said it all.  He had severe disease of his left main, LAD and circumflex.  His right was open about 80%.  Basically, the Cowboy was surviving on one coronary artery.

He lived alone and didn’t have much family support.  He was practically homeless.  There was not going to be a life-saving trip to Cleveland.  We all knew he didn’t have long.  During my first shift back I was told that he had presented in fulminant pulmonary edema.  One of my colleagues intubated him, but there was nothing else that could be done, and he died.

I tried to think back to the last time I saw him.  Did I even pick up the chart, or did I leave it to one of the interns?  Did I make conversation with him?  Was I polite to him the last time I treated him or was he just one of the “regulars” who is quickly “treated and streeted” to make room for the “real” patients?  I really can’t remember now, but I know that he’s a patient I won’t soon forget.

So, ride on, Cowboy.  Keep riding;  riding, along.

Vampire Nights

I haven't been blogging as I worked a series of 5 days followed by an overnight shift, late morning with Grand Rounds, night off and then another overnight shift. I'm just a wee bit tired. My mind has barely mastered the concept of "upright" much less "typing a coherent thought."

One of the thoughts that came to me last night as I was walking the empty hallways of the hospital is how eerie a familiar place can suddenly seem. We occasionally have to leave the E.D. which is located in the basement of the hospital and go up to the second floor to inject a patient who is getting a CT scan with IV contrast. We do this because there is a small possibility that the IV line will infiltrate, or spill its contents into the surrounding skin, during the injection phase of the scan. This is bad. You can get a very nasty skin necrosis with this.

During the day, there are plenty of radiologists around to do the injection, but in the middle of the night, there's only a radiology tech running the scanner, so we get called up. As I walked the empty hallway heading toward the back of the radiology department, I started wondering about all those scenes in horror movies. You know, the one where the unsuspecting person is casually walking along when the scary music starts playing. There might be a sudden soft squeak. Or the sound of a breath. The person stops and looks around. Then walks a little more quickly. The music begins to rise. The person starts to walk faster. That kind of a thing.

I guess I was thinking of scary stuff because we'd had a patient come in with their own little stuff of horror movies. Seems the patient had been sleeping when they felt something near their ear. In their sleep they reached out and felt something warm and furry. They suddenly woke and grabbed it with two hands and ran to the bathroom.

They called out to their father sleeping in the next room. When he turned the light on, the patient realized they were holding a live bat in their hands! The father shot the bat with a BB gun, and they came into the E.D. with the bat in a baggie. The patient needed to start on rabies vaccinations because the bat had actually scratched their ear.

The bat was placed on ice in a container for the Health Department to come and pick up. One of the clerks called it her "pet" since it spent the majority of the morning sitting on her desk, and she had to keep renewing the ice supply. We had quite a laugh at sign out, and everyone had to go look at the bat.

I tell you, we can't make this stuff up...

p.s. a shout-out to one of our attendings, Dr. Jehle (yay-lah) who made the local media following a multi-car pile-up. I was at the General that night so my buddies at the County and Children's suffered through the multiple traumas.

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Hot in the City

We've had a lot of shootings over the last several days. I have been working the night shift, so it's always very difficult to post because I am often too tired in the morning when I get home, and then I am usually in a rush out the door when I head off for the next shift. I do manage to sneak in a quick post from time to time.

Anyway, onto the shootings. I worked the overnight shift at the county hospital on Tuesday night, and we had three unrelated shootings, plus a couple of stabbings, plus the token rollover... and a whole lot of drunks. I was in the middle of dealing with several different patients that I received on sign-out (some things are never what they seem) when a patient comes running in the door saying "I got shot in the face, don't let me die."

I took a look and saw the wound on his face. A larger caliber round and his face would have been an empty hole. A couple of inches further back, and I wouldn't been seeing this patient as they would have been either an organ donor or in the morgue. He was the lucky one that night. The bullet scratched just under his eye and ended up stopping and breaking his nose. Oh yeah, the bullet fragments are still there. He's going to need to have those removed at some point. That night, though, just some fancy stitching by the facial trauma resident and a referral to specialty clinic to fix his nose.

While I was finishing getting him settled I was told by the charge nurse that another shooting victim was coming in. This time, multiple wounds in the extremities and torso. We got the trauma team notified and I waited in the room as they were brought in. He lost his pulse as he was brought in the door. There was no saving him. I had to tell his family members. I worried about retaliatory shootings.

I kept working the shift. In the early morning hours we got another victim. This one had multiple bullet holes and a fracture in an arm and a leg. Not to mention the bullets that went into their abdomen. They went to the O.R. They survived.

Thursday night I went back to work at the General, and there was a large security presence in the area in front of the E.D. Now, at the county when there's a shooting, we get a strong police presence, so it's no big deal to see the ambulance ramp shut down to traffic. Just not used to seeing it at the General. But, that evening there had been a shooting that resulted in a death of a member of the community. Their family along with many neighbors were all there and had just gotten news of the death when I pulled up trying to get in for my shift.

I made my way through the crying, screaming people holding onto one another and demanding to be let into the E.D. to be with their loved one. Security let me through as several people tried to push their way through. They were held back.

Today I worked a day shift. I had a GSW (gun shot wound) to the legs in the morning, and a GSW to the abdomen in the evening. Kinda like book ends. Both were in the process of an attempted robbery. Both were taken to surgery. Both will most likely survive.

Some say people are going a little crazy from the heat. The heat wave is supposed to continue through the weekend. I wonder what tomorrow's going to bring...

Chronic Pains

My primary diagnosis for many of my patients last night was "Acute on Chronic _____." I don't know what it was about last night, but a lot of people just couldn't face waiting until Monday a.m. to see their PMD's. Of course, a percentage of my patients don't have PMD's (that's Primary Medical Doctor) and come to the E.D. to get their primary care; as well as a couple of shots of Dilaudid or Lortab.

The local media discussed one such patient who is a daily visitor to the E.D.; mostly at ECMC, but we see him on occasion at BGH. Last night, I got several more of the "regulars" who decided to come in. I also got the "I've been admitted multiple times and left because I didn't feel like staying around any more" group; patients who regularly need to be admitted because they have legitimate medical problems (like one patient who is daily killing heart cells because he refuses to stay in the hospital long enough for surgery to be done) but who have worn out their welcomes with the medical staff.

I did get a couple of emergencies: a gentleman who started having a GI bleed and also a heart attack, a new onset diabetic who was initially thought to be having a stroke because he had been having strange symptoms for over a week, another known diabetic who suddenly started having problems when they couldn't keep any food down, and a another lady who was rapidly filling up with fluid to the point she couldn't breathe any more.

But it's those chronic pain people that drive us crazy. Now, I have said many times that I have never had a broken bone, and I have never been shot, but I can imagine that it would hurt... badly. But when you're told to not eat fatty foods because you have gallstones and it's going to hurt if you do, and then you go out and have the cholesterol special at your favorite fast food joint, I can't quite draw enough sympathy. Oh yeah, and the first words out of the patient's mouth were, "I have Chronic Pain Syndrome so the usual dose of pain meds doesn't work for me."

Sigh. I am all about being a patient advocate. I threatened my "killing my heart cells" patient with "if I see you back in the E.D. without a new hole having been cut in your chest, I will do it myself." Seriously, I just spent 10 minutes on the phone presenting a case arguing how they had already been cleared for surgery, this time they "promised" that they would stay and not leave AMA (against medical advice), and they really should be given one more chance.

Maybe I am too hopeful. Maybe I believe in people too much. Or, maybe I am playing a similar game, the one played in "The House of God" known as a Turf... or as we call it, the Dispo. Luckily, our Dispos don't bounce, oh wait... yes they do.

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!

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!

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....

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!

I've Been a Bad, Bad Blogger....

All right. So it's been a while.

Let's recap:
I finished my time in the pediatric ICU. While controversial, I still maintain the idea that sometimes just because we can do something to prolong life doesn't mean we should. Also, I did get to see one child placed on ECMO (extracorporeal membrane oxidation); sort of a mini-heart/lung bypass machine but not within the sterile confines of the O.R. Big and scary.

I completed my month-long rotation at the main hospital BGH. This time, not so bad. If you remember back to last year, I was rating my days in the number of beers I needed to get over the shift. This time, I don't know... maybe it was the responsibility. Maybe it was knowing more than I did last year. I actually sort of enjoyed it. And, I learned a lot. Maybe I'm just growing up academically.

After three weeks at the "General", I took my vacation, and tonight just returned from the Miami area of Florida were I spent the last week. A couple of things that I learned: the Everglades are awesome, alligators are an important part of the ecosystem of the Everglades, I continue to not like foreigners who travel because they're just rude, and I think I would be suicidal on a cruise if I had to be on the boat for longer than a day. Oh, yeah, and Key Lime Pie... tasty!

So, tomorrow I start my two months on the Orthopedics' service. It starts with two weeks of Hand Surgery. I'll have a better idea in the morning of what that entails. Hopefully, something new and interesting to blog about. It will take some time to catch up with everyone else's blogs, so forgive me if I haven't posted recently.

Bookends

Ok, so I had to work a shift at Buffalo General yesterday. It's one of the least favorite places for us to work because the system issues drive us crazy. To admit a patient takes a minimum of two phone calls. Most of the time it's three or four. And, the patients are generally sicker, have more medical problems, and can change on a dime.

I call this entry "Bookends" because during my last two shifts, yesterday at "the General" and the prior one at ECMC, it seems my shift started and ended with similar cases....

I walked into the E.D. at the start of my ECMC shift on Saturday and was immediately directed by my attending to follow the incoming ambulance crew into Trauma One. We walked in to find a 70 year old gentleman with known dementia who had decided around 4 in the morning that he wanted a coffee from a local drive thru called Tim Horton's. The only problem with that is: 1 - it was 4 in the morning, 2 - he didn't take a coat, 3 - we had just had the season's highest snowfall in the days before, and 4 - had he wanted his usual frappacino he would have walked just a block down the road, but he turned in the opposite direction to the Tim Horton's located about 10 miles away.

He was found only about a block and half away from his home, but he had been out in the snow for several hours. He came in with frostbite to his hands and feet. His body temperature... 87.5 degrees F! Now, normal is 98.6 degrees. You begin to have heart arrythmias at around 91 or 92. The fact that he was actually talking to us, albeit just repeating over and over that he was cold, was a miracle.

We quickly stripped him down and placed him on top of and under warming blankets. We placed a catheter in his bladder to put in warm saline internally. I placed a central line so that warm saline could be infused as well. He was admitted to the burn center so that they could treat his hands and feet. I will check on his progress when I go back in tomorrow.

From there, the rest of the day flew by in a flurry of the usual standard fare of patients. About 45 minutes before the end of the shift, I was trying to wrap up my patients for the day when one of the EMT's asked me to triage a patient they were bringing in. It was a 40 something known opioid addict who was found in a snow drift.

I quickly directed them to Trauma Four where we learned that the patient had started throwing up after being given Narcan which is a reversal drug for opioid overdoses. When they were clearing his throat with suction, they noticed what looked like a gumball in the back of his throat. They couldn't remove it, so I quickly intubated him for a potential threatened airway. We didn't see a gumball, but there was a lot of irritated tissue and a foreign mass seen on CT. I'll find out what happened to him as well tomorrow.

Cookie break:
So, I ended up working late. I had the next day off and then went to work at Buff General yesterday. One of the first patients we saw in the morning was a 65 year old gentleman who had gone outside to shovel the overnight snow. His wife saw him collapse and immediately called 911. Within two minutes BFD arrived and started CPR which continued until he got to the hospital.

My senior and I went into the room, and I immediately took over and continued CPR. We worked on him for about 30 minutes while family started arriving. Unfortunately, we weren't able to get him back although we thought we had several times. My senior went to talk to the family, and I went back to work on the rest of my patients.

At the end of the day, after admitting a 43 year old who didn't want to comprehend that he'd had a heart attack and would have to, OMG, stop smoking and drinking and take medication for, um, the rest of his life because he'd had, oh yeah, A HEART ATTACK, I was signing out my patients to the on-coming senior when one of the patients that I'd had started having heart arrythmias.

I walked over with my attending and watched on the monitor as my patient's heart rhythm changed from something regular to something completely scary. His wife was just telling me that his AICD (automatic defibrillator) had just gone off. My patient was commenting that he'd been napping and had just had a rude awakening when all of a sudden he went into a deadly rhythm known as ventricular fibrillation. His heart started beating with no coordination at all.

We immediately gave him several external shocks as his AICD started firing off as well. Then he went into asystole, no heart activity at all. We started CPR and worked on him for about 10 minutes pushing a number of different drugs. He was intubated and we were able to get his heart rate stabilized and beating regularly. His pacemaker kicked in at that point and kept him going as well. I stayed late and placed a central line in him and watched as they took him up to the MICU.

I can see how far I've come, but I know there's still a long way for me to go. It's back to the County for me for the next two days. We'll see what kind of gifts Santa, via the EMT's, brings me for Christmas.