A Budding Emergencist
Monday, July 31, 2006
  "if you build it, they will come

Note: this began as a comment reply, but I dug the idea of "build it and they will come," so here's my thoughts:

Hey platypus,

Thanks for visiting! I love your blog. From the trenches, eh?

No, no, it is true--build it and they will come. I think it's some kind of corrolary to Parkinson's rule where work grows to fill the time alloted to it.

Bear with me for a minute here, it's like this: Long ago, I stopped beig a perfectionist. I was working for a painter, cleaning up and painting repo'ed HUD homes for the state to sell. Now, it's understandable that having your house repo'ed is not an incentive to keep it sparkling clean. But this house was a ****hole; there was a dead bird in one of the cabinets, and the grease was 2 inches thick on the kitchen floor. I started scrubbing the kitchen floor. 2 hours later, I had reduced about 1/4 of the grime coving the floor to a fine mist that was insidiously making me insane. My boss comes over, and says, "What the hell? This should take 1/2 hour, not 10! Stop being such a perfectionist, you'll never get anything done."

I realized then that "good enough" was a worthwhile goal to strive for, and now I'm realizing that it's very important in medicine. In a small and busy ER, the idea is, get them stabilized, and get them wherever the hell they're going, NOW! But in a slightly larger ER, it's "well, we're not that socked in, so I can get that CT that would make the diagnosis a slam dunk." Yes? Makes sense, yes? Is good?
  Second Shift
Things were pretty interesting last night--I worked the night shift. I didn't realize how busy things were until my orders started backing up, and my attending started getting on my ass about stuff that wasn't getting done.

I got a sign out of a woman in her 20's with a beta-hcg of about 20,000, last menstrual period April 13, and three days of vaginal bleeding in july with dark red blood. Her exam revealed a closed os, and transvaginal sono showed no intrauterine pregnancy. Belly sono showed no free fuid, but her blood pressure was low, 80's over 40's, so we sent her to ob/gyn--ECTOPIC! So, poof, first patient gone.

Next patient was a 82 year old woman with cellulitis. She also had atrial fibrillation, cofirmed on exam by the tachycardic irregularly irregular rhythm. But she wasn't on coumadin, a blood thinner. Later I found out it was because she had had some bleeding on coumadin. She was a pleasantly demented woman--I guess I'm still pretty naive, so it didn't really click (she lives at home with an attendant) until I saw that she had like 20 previous ED visits within the last 5 years or so. So yay for computers--the level of dementia was obvious just from the number of ED visits. She also had some pretty intense seborrheic dermatitis (dandruff to you and me), but I mean, giant hyperkeratosis all over her face and legs, too. Both legs showed very thickened skin, and the right was red and tender from her mid-foot all the way to her knee. I demarcated the cellulitis, and given the history and extent of her cellulitis (despite her surprisingly un-ill demeanor), she got a gram of ancef and was admitted. Oh and we controlled her rate with some cardiazem, so there.

Next was a 93 year old man, also pleasantly demented, sent from the nursing home for change in mental status and fevers to 102. Treated at the nursing home for a urinary tract infection with bactrim, but the fevers worsened. Upon exam, he was yellow, with yellow eyes. Not that subtle, if you look, but not that obvious if you just glance. And he had a huge cholecystectomy scar, but no mention of it on the transfer note--nothing on him in the computer--so we've got an incomplete picture here. So I tacked on some liver function tests to the chemistry, complete blood count, and blood cultures that were sent. The urinanalysis came back--surprise! no indication of a UTI, but positive for blood and bilirubin. The LFT's came back, and, whoa! Albumin low, liver enzymes 4-5x normal, bili was 5x normal too, direct bili 4x normal. So now he doesn't have a UTI, he's got "painless jaundice". Although, to be honest, the guy had a pretty high pain threshold. I went to do an arterial blood gas, which hurts like hell. He didn't even blink. He wasn't acidotic, actually a little alkalotic. Creatinine comes back 2.0. Admit! Next day, I dind out that he had ascending cholangitis, a deadly disease. And I caught it! Woohoo!
Tuesday, July 18, 2006
  Some background...
Fortunately, since I'm being very careful to moderate all of my posts and my entire website for any indication of where I am working, being entirely HIPAA compliant about any patient details, and especially not the name or location of the hospital where I work, I can pretty much say whatever I want.

So, forthcoming vague details; I work in a fairly large urban center in the United States. Not on of your major teaching hospitals, call it a minor teaching hospital. But boy, we're trying. We're building like crazy--new designations galore--stroke center, cancer center, children's hospital, heart center, and we're building a giant new addition that will complete in about Feb 2007 and fill up in about a week.

The funny thing is, the ER is tiny. It's fairy new, too--finished about ten years ago. The paramedic in charge of prehospital services quit when he saw the plans for the current ER. "You mean the ambulances gotta back up in the middle of a busy street to get into the ambulance bay, which has room for two ambulances! I'm outta here!" So the new ER is full in about a week. Now we've got patients stacked 4 deep around a single nursing station where about 35 people all have to do their work. It's a nightmare. No way I'm gonna apply to be a resident here, unless...

The new building also has plans for a new peds ER. The current peds ER, a side department off of the postage stamp, will reopen as the acute side of the current postage stamp. (Note: the ER of this facility will heretofore be known as "the postage stamp".) I'm hoping they'll move the adjacent cardiac cath lab, as well. The new medicare reimbursement schedule will improve Evaluation and Management (E&M) reimbursement by 30% for maderately complex office and hospital visits (to the detriment of "hospital procedures," like colonoscopy, ambulatory surgery), so I hope the hospital will take note and act now. (Medicare reimbursement is revamped every 10 years.) However, the change will be phased in over four years.

More background, and personal background, later.
Friday, July 14, 2006
  The Emergencist awaketh
I'm a new doctor, just graduated--join me as I work my way up academic medicine's ivory tower on my road to becoming an ER God.

This is only the beginning! For now, check out:
Fingers And Tubes In Every Orifice--the blog that reads like an action movie
Emergiblog, about an ER Nurse
Dr. ibear
Movin' Meat
Tales from the Emergency Room and Beyond..., from our northern neighbor

All will soon be joining us on my sidebar.


The Emergencist
Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

July 2006 / August 2006 / September 2006 / October 2006 / November 2006 / December 2006 / January 2007 / June 2007 / July 2007 / December 2008 / August 2009 / November 2009 / December 2009 /

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