A Budding Emergencist
"A Nation of Anxious Wimps"
In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant. Hilarious.
Is Airborn good for a cold?
Lord don't move the mountain..
...Just give me strength to climb it.
Please don't move my stumbling block,
Just lead me, lord, around it.
Don't move this mountain.
--Soulfire, Stand in the Fire
Relaxing after a burly shift in the ER. Working with the right attending/boss on a busy shift is very satisfying. There is a harmony achieved where each will see/work up the different patient, and then switch, to emphasize/modify/push through/confirm/or question each other's workup, blending, persevering, consolidating, reassesing, learning, laughing, frustrating, disbelieving, disapproving, criticizing, resuscitating, reanimating, engaging, enlisting, hand-waving, hand-wringing, consulting, sharing, politicking, magic-making, cajoling, enforcing, patronizing, brow-beating, and testosteroning our way through a shift. The only way out is through! No catastrophe too big! No work environment too austere! No PMD too unreachable! The show must go on!
pic via http://roughwriter.yc.edu/2008/05/because-its-there-2/
To Sleep, You Must Cold
NYT Article--to sleep, you must cold
I remember during my internship year, the crucible, I was rotating in the ER. I was very excited to rotate there, as I had recently discovered the thrill of the emergency room in one of my last 4th year rotations as a medical student. My dreams of becoming a psychiatrist sloughed off me like I was molting.
I was on a string of nights, in the middle of a hot summer. Despite having lived in my apt for nigh on 2 years, I had yet to invest in an air conditioner. Hey, I was a tough guy, living au naturel, windows and fan only, thank you very much. I could take it. I finished my third of four nights, increasingly sleep deprived, because, well, it's hard to sleep, drenched in sweat, during the daytime.
I bought an air conditioner. I bought a strong model--hey, maybe I could cool the whole house! After it was installed and began producing a cool, cool breeze, I went to sleep. I set my alarm clock, and slept very, very well.
I woke up, and it was mostly dark. Not the winding down twilight that preceeded my upcoming night shift, but the silent crepiscule that heraled the end of my shift. Slightly uneasy, I was. The analog clock above my bed read 6:15. Perfect, I thought. Just enough time to get ready for work in my preferred leisurely fashion.
Beep! goes the cell phone. Gee, I missed the alarm, that's weird. Oh hey, I've got some messages. Let's check.
"Hey Dex, it's the chief resident. Just wondering when you're gonna make it to your shift."
"Dex. What's going on? It's two hours past your scheduled start time, and no show, no call. What gives?"
I check the time on the computer. 6:20, indeed. Okay. I check the date. One day later.
That sinking feeling turns into a vortex, sucking my stability away. I am suddenly aware of my heartbeat, which has been pounding away for a while now. Idly I realize that I am unusually refreshed and alert. Too alert. I just slept for 16 hours.
I frantically call the chief; forcing calm into my voice I definitely do not feel. I tell the chief I just got his messages. I tell the truth about my heat induced sleep deprivation and the marvelous benefit of air conditioning on the quality of my sleep. I apologize profusely.
I show up for my next shift. Early, of course, and eager. Very eager. Everything seems to blow over.
Months later, at residency match time, I am so confident and sure of my assured spot as a resident in the next year's class that I only interview at one other place, just to get some perspective on what other ERs look like. It seemed okay, but a bit of a hike from my current digs, which are perfectly serviceable now that my sleep is blissful. Confidently I check my status on the match website. Rejected.
I am shocked, hurt, and victimized that my first choice for residency, the hospital where I sweat blood to get through, the epitome of The House of God, where I know Everybody, has rejected me. I barely made it onto their list. I was not going to be an ER resident there.
There was a bright spot, however. My second, and only other choice, ranked me high enough to match. I had a residency spot. And Lo! though with His Left hand he Taketh Away, with His Right hand he Giveth. In my hurt I question my would be friends and mentors about why I wasn't ranked higher at my own institution. Well, They Replied, you failed to show up or call for a shift, and it was felt that endorsing such an unreliable precedent would be unwise.
So yes, I am intimately familiar what a benefit to sleep a cool room can be. Painfully aware. And now you know too.
Emergency Medicine is fantastic--I am posting here today because scheduling allowed me a three and a half day weekend this block! Much better than my colleagues in Medicine, Surgery, or OB-GYN--it would never happen on those rotations.
Let's do a case. A 42-day old infant girl presents at 8pm, upgraded from the pediatric urgent care center located at your ER (don't you wish you had one!), with bleeding from the rectum. The parents were concerned because of a 5 day history of worsening blood mixed with mucous (currant jelly) and a normal appearing green stool. Stooling frequency unchanged--4-5x per day. No apparent pain with passing stool or abdominal pain, no vomiting, no fever. Weight gain was appropiate, and baby did not seem overly fatigued, although mother thought she was a little pale. No recent antibiotic use or NSAID use reported for baby or mother. They had come to the our ER after it started and baby was started on a soy based formula and sent home. 1 day previously, baby was started on Neutramigen (last resort before hyperalimentation), but the bleeding had worsened--more obvious blood in the stools for the last day. Prior to starting the soy based formula, baby had been breast feeding. Mother had had cracked nipple previously about two weeks ago with a little bleeding, but it had resolved after 2 days. Baby had been born 2 days post dates by C-section for failure to progress. Normal primigravida prenatal course, no NICU time, no peri-natal infections reported. Parents report an iguana and two dogs in the house, are non-smokers, have no medical problems, and the baby has no siblings.
On exam, baby was well appearing, in no distress, and appeared well hydrated, with no pallor or jaundice. Mild baby acne over L lateral face and forehead seen. VSS, afeb. No bruises noted on skin. Oro-nasopharyngeal exam revealed pink mucosa without bleeding, hyperemia, or thrush. Normal cardiovascular and lung exam. Normal bowel sounds. No tenderness, distension, or masses on abdominal exam, no organomegaly. No caput medusa. No cracks, fissures, or hemmorhoids appreciated. During the (normal) digital rectal exam,I got an episode of forceful pooping for my trouble, getting baby shit on my pants, eliciting knowing smiles from the parents, and endearing me to them forever. Strongly guiac positive semisolid green stool mixed with red mucous.
CBC revealed a HB/Hct of 12/36, WBC of 14, plt of 640. Complete metabolic panel within normal limits except for slightly elevated AST/ALT, but normal bilirubin and alkaline phosphatase.
So what's the differential?
--Whenever you see currant jelly stools in a child less than 2, my spastic reflex is "intussusception," which is a good reflex, as this is a dangerous and often-missed diagnosis, it can lead to
"the process progresses to transmural gangrene and perforation of the leading edge of the intussusceptum." . Other features of this diagnosis missing from this picture: altered mental status, intermittent abdominal pain, vomiting, intestinal obstruction, preceeding upper respiratory infection, wrong age--"intussusception occurs in infants aged 5-10 months," and palpable abdominal mass.
--Meckel's diverticulum--which often presents with painless rectal bleeding, and can be a lead point for intussusception. However, in this case: no signs of abdominal pain, the bleeding was relatively mild (Meckel's typically produces profuse rectal bleeding--because of ectopic gastric mucosa ulcerating), wrong time frame (remember 'rule of two's'--2% of population, 2% manifest clinical sx, 2 feet proximal to the terminal ileus, and 45% of symptomatic patients are less than two years old) and again, no sign of obstruction, and the patient did not appear acutely ill (which would prompt perhaps a search for a meckel's--typically via Meckel's scan, a nuclear test.).
--Necrotizing enterocolitis: Less common in normal birth weight babies, no peritoneal signs, and simply not ill.
-- swallowed maternal blood--excluded by history in this case--cracked nipple most common--not an issue here.
--Anal fissures, cracks, and fistulas--rectal exam is mandatory in case of rectal bleeding, fortunately negative in this case.
--Milk protein allergy--quiet, can last for days after last milk ingestion, can lead to GI bleeding. This ended up being our probable diagnosis.
The patient was discharged after a discussion with the PMD and referral for close GI followup.
*Picture from www.restaurantwidow.com
Is there Life Before Death?
Yeah...the new place. Can't say where it is, 'course, y'unnerstan', but...it rocks. I think one of the most critical things is that people are happy here. I mean, the people who have been here for a while. And they keep people here. Not like my last place, where people would only stay a couple of years (as attendings, I mean.) But this place--when I asked how many from the graduating class they hired, they said, "None!". And I thought, well, that's not good--the new attendings want to get away, right? No, actually...as it turns out, there were just no positions open; that lots of the graduating class would stay if they could, but there was no positions because nobody leaves because they are happy here.
I'll have to admit, I really didn't want to move...so I didn't. Now I have an hour commute, but I'm never bored, and I never wait. I figure I'll listen to my Gold Standard
stuff left over from studying step 3. The pharmacology at least will still not be old. And since it is such a chore for me to study when I'm home (I'd rather watch Battlestar
or The Daily Show
or clean or read novels like Lois McMaster Bujold
, or (hopefully) get back into Aikido
or back into Guitar
or talk to my GF.)
As always, more later...
Labels: Hobbies, Interning, The Job