ER: Last Day

My last ER shift was a 4 a.m. shift, so I thought things would be relatively slow like the previous 4 a.m. shifts I'd worked. Hardly. When I arrived at the ER, I was surprised to see both the 9 pm and the 11 pm attendings still there. This was the first time I'd seen any 9 pm doctor still in the ER at 4 a.m. (they usually leave before I arrive), so when Dr. L asked what was going on, they replied that they got swamped around 3 a.m. The 9 pm doctor passed along two patients to us so he could go home and get some rest, while the 11 pm doctor stuck around b/c he had a meeting to attend at 7:30 a.m. anyway. At first he asked us to watch over one of his patients, a young black guy who pulled over to the edge of an overpass to "take a piss" after a wild night of drinking and fell over the overpass to the ground many feet below b/c he was drunk out of his mind. He landed on his back and head, yet was well enough to walk up the hill back to his car where his sister had called an ambulance for him. At present, he was sometimes sleeping, sometimes awake and cussing at people, including his mother (who was in the room with him worried to death). *sigh* This is one of those stories of stupid people that'll be passed down from doctor to doctor, student to student.

One of the first patients we saw had "altercation, shoved cocaine into officer's mouth" as the chief complaint, and we wondered what the heck that meant. It turned out that the patient was a police officer who was trying to break up a fight when one of the perps shoved a ball of crack cocaine into the officer's mouth as a defense mechanism. First time I ever heard of anyone using crack as self defense. Aside from some tachycardia and numbness around his mouth, the officer said he felt fine and wouldn't have come unless he "had to"; his partner had forced him to come to the hospital b/c he was worried that the crack may have been laced with rat poison (warfarin). Dr. L said she'd run tests, but we all knew that even if the crack DID contain warfarin, it wasn't going to show up in the officer's blood after a few hours. Still, it made for an interesting story, and even the nurses had fun with it. "What are we going to do about the crack-in-the-mouth cop?" one nurse asked at one point? LOL.

Then we got a fresh trauma case: a 68-year-old guy suffered a stroke while driving and hit a wall at around 40 mph. I went with Dr. L and Henry (the scribe) to see him, and what we saw was 4-5 nurses trying to hold down a man visibly struggling against them (altered mental status, anyone?). He looked to me like he was moving all four limbs fine, and I wondered if he really did have a stroke. As Henry and I watched one nurse struggle to put a Foley in him while the others tried to keep him from squirming away, I said, "I feel like we should help." Henry agreed and gave me his laptop so he could help the nurses hold the guy down. (One guy there makes a difference). In the meantime, I'd seen a patient for abdominal pain but because traumas kept rolling in Dr. L couldn't get a chance to see him. I poked my head into his room and apologized, but he said he'd heard the trauma announcements and understood why we were running late.

Around 7:20 a.m., one of the nurses ran over to let us know that "T2" (the stroke patient) was crashing, but that one of the other doctors was running to code so there was no hurry. We still got to the patient withint 3 minutes just in time to watch the patient get a shock. A sonogram machine was wheeled into the room so that the other doctor could look at his heart and see if it was beating well. At first the patient seemed to be responding well to the epi; his heart rate shot up to the 130s and then gradually slowed down. I kept my eye on his heart monitor and watched him go from sinus tach to V-fib in seconds. Uh oh. Once again he was shocked, and after about 10 minutes I saw one of the chaplains bring the patient's wife into the room to see him. When she saw her husband lying on the stretcher with the techs pumping on his chest, she looked shocked. Calling him by name, she told her husband that she was here and begged him to open his eyes. The other doctor (surgeon) was looking really beat down at this point; I think he knew this wasn't going to end well. Dr. L quietly said that she always dreaded telling patients' families that their loved one wasn't going to make it, because that moment will forever be etched in their minds as "before s/he died" and "after s/he died." Finally, around 7:58 pm, time of death was called. The nurses and techs left the room in tears, and the wife stayed by her husband's side.

No one could be absolutely sure what had happened to our patient. Dr. L thought it was likely he had suffered "the one," the first and final heart attack that hits a lot of men, but when his blood work came back about an hour after he died, we found to our chagrin that cardiac enzymes hadn't been ordered. At any rate, he didn't have any electrolyte abnormalities to speak of, so it looks like his cause of death will be found on autopsy. It's strange; I saw more deaths in the ER during my surgery month at JPS than in my one month at Harris. Does that mean Harris has a better survival rate b/c of their care, or do more patients arrive at JPS too far gone to be saved?

One last memorable case happened later in the shift: a 24-year-old girl and her husband came to the ER after she developed an abscess on her butt and he "sterilized" a knife with a lighter's flame and opened the abscess to let the pus drain. She admitted to feeling better after the abscess was opened, but said she still needed antibiotics. I can't imagine how much that must have hurt, opening that abscess without anesthesia, and Dr. L later quipped, "You did my job for me." The girl had just been too embarrassed to have someone else (other than her husband) looking at her butt b/c "it was so gross." Yeah, but still...

At the end of the shift, Dr. L said I did well and wished me all the best. And now...on to allergy/immunology at Baylor in Houston!

ER: Fifteenth Day

I was supposed to work yesterday morning, but all the icy roads on the highway from Tuesday night (not to mention the slow traffic) kept me at home instead. That means I'll be short one day, but I don't think Dr. W will mind (I know for a fact that some of the others worked less than 17 shifts as well) ER was empty this morning. We had one trauma patient who was thrown through his windshield and had numerous cuts on his face and one huge cut on his hand. Later Dr. L had me sew up the hand while she sewed everything else. It was hard approximating some of the tears on that laceration b/c the edges were fairly jagged but I tried my best. Dr. L commented that I wasn't as slow as other students, and I didn't know whether to take that as a compliment or not. When there was time for a break, Mathilde (the scribe) said she didn't carry cash on her, so I offered to buy her something. She said no, but I went ahead and got her a huge peanut butter cookie =)

One of the patients I saw today was a pretty sad case. She was the same age as my sister and had suffered from hidradenitis suppurativa for the last ten years, to the point where she had reconstructive surgery done on her perineal area and got a colostomy bag put in. Her chief complaint was lower abdominal pain, and she said that she felt like dying but had two kids and another on the way to keep her going. When I mentioned "hidradenitis" to Dr. L, she noted that the patient had been hospitalized many times in the last few years for similar pain and wondered aloud if this was the same "girl" she saw about ten years ago who required extensive surgery for her illness. As it turned out, it was; the patient remembered Dr. L, and Dr. L said that she'd thought about her (the patient) on and off throughout the years. Apparently Dr. L saw her not long after she first started working at Harris, and her case was so serious that it stayed in her mind all these years. But it really was a sad case. The patient was obese and her folds were rubbed raw and pink, and you could tell from the smell in the room that she had a yeast infection. She admitted gaining a lot of weight b/c she liked to cook, and Dr. L told her that if she lost a little weight, her skin problems might improve. We tested her beta-HCG levels and found her levels to be appropriate for a pregnancy, but she was so large that sono couldn't detect her uterus OR a fetus. *sigh* Poor girl. I hope for her sake she recovers from her pain so that she can enjoy her pregnancy and have that baby she wants so much.

ER: Fourteenth Day

Because of the sleetstorm/icy roads from Tuesday night, I didn't go to work yesterday, but I did go this morning to a nearly empty ER. We had one trauma patient who was thrown through his windshield and had numerous cuts on his face and one huge cut on his hand. Later Dr. L had me sew up the hand while she sewed everything else. It was hard approximating some of the tears on that laceration b/c the edges were fairly jagged but I tried my best. Dr. L commented that I wasn't as slow as other students, and I didn't know whether to take that as a compliment or not. When there was time for a break, Mathilde (the scribe) said she didn't carry cash on her, so I offered to buy her something. She said no, but I went ahead and got her a huge peanut butter cookie =)

One of the patients I saw today was a pretty sad case. She was the same age as my sister and had suffered from hidradenitis suppurativa for the last ten years, to the point where she had reconstructive surgery done on her perineal area and got a colostomy bag put in. Her chief complaint was lower abdominal pain, and she said that she felt like dying but had two kids and another on the way to keep her going. When I mentioned "hidradenitis" to Dr. L, she noted that the patient had been hospitalized many times in the last few years for similar pain and wondered aloud if this was the same "girl" she saw about ten years ago who required extensive surgery for her illness. As it turned out, it was; the patient remembered Dr. L, and Dr. L said that she'd thought about her (the patient) on and off throughout the years. Apparently Dr. L saw her not long after she first started working at Harris, and her case was so serious that it stayed in her mind all these years. But it really was a sad case. The patient was obese and her folds were rubbed raw and pink, and you could tell from the smell in the room that she had a yeast infection. She admitted gaining a lot of weight b/c she liked to cook, and Dr. L told her that if she lost a little weight, her skin problems might improve. We tested her beta-HCG levels and found her levels to be appropriate for a pregnancy, but she was so large that sono couldn't detect her uterus OR a fetus. *sigh* Poor girl. I hope for her sake she recovers from her pain so that she can enjoy her pregnancy and have that baby she wants so much.

ER: Thirteenth Day

Today I worked a 3:30 pm shift with Dr. D, one of the younger attendings (mid-30s), who willingly let me do as much as I was comfortable with. Several of my patients were interesting. One was a 16-year-old kid who looked really sick, and he said that there was a "funny smell" in his urine. Naturally I asked about his sexual history thinking he had an STD, but he said he always used protection. Turns out he had a pyelonephritis. Another woman came in with a complaint of "I think I swallowed glass," which sounded alarming until I got the whole story: she was in an MVC in which the window broke and she'd coughed up glass fragments. Fortunately she had no cuts in her mouth. When I saw the name of one of my last patients, a girl about my age, I thought, "Uh oh" b/c it was the same name of a girl I knew in the 2nd grade. She'd gained a lot of weight, naturally, and her face was rounder than I remembered, but it was her. Nevertheless, I introduced myself and asked her what brought her to the ER. She had abdominal pain, which of course required a lengthy workup. But I don't think she recognized me, thank goodness.

Around 10:00 pm, Dr. D was asked to put in a central line on a woman who'd coded en route to the hospital. She was a dialysis patient and there were scars on her neck from catheter insertions or previous IJ lines. The biggest fear was that we'd hit scar tissue. Dr. D let me glove up to assist, but one problem after another soon happened. The sonogram wouldn't work after Dr. D slipped on the sterile covering for the probe and he had to find the vein blind (which is how they do it at JPS but not at Harris). Then while advancing the wire, blood suddenly started pouring from the incision site in pulses, so he had to apply a lot of pressure to the neck to stop the bleeding. What was weird was that this was venous, not arterial blood, that was coming out. Deciding to give up on the IJ, we tried a subclavian next, but again, the veins were not good. I felt a small thrill just by placing my fingers against the vein and it felt like an artery. AV shunt maybe? The last option: an art line in the femoral artery. This, again, was no easy task. First Dr. D hit the vein, and then when he got the artery, I accidentally dropped the tip of the guide wire and they had to get a new kit. Then, on another attempt, Dr. D accidentally pulled the wire out before he could thread the catheter over it. It took another try or so before we finally got it in, and by then it was 11:30 pm. Prior to that, the scribes had done rock-paper-scissors to see who could go home earlier, and before the art line Dr. D had discharged the rest of his patients. Either way, I didn't get home until midnight. This had to be my longest shift yet.

Cheesecake Factory Pictures

Who's that adorable baby?

Proud dad

The birthday girl who "just turned 21" =P

ER: Twelfth Day

Another 4 a.m. shift today. Seriously, all this switching back and forth has thrown my sleep cycle out of whack. It was a relatively slow morning, as they usually are. There are an awful lot of fast track patients presenting with cough, fever, and body aches; Dr. L, who says she usually goes overboard with prescribing antibiotics, did pretty well today in writing scripts for mostly cough syrup and telling the patients that their illness is viral. We had one patient, a middle-aged man, come in with a long history of cough and he asked us if it was possible he had lung cancer. He'd been retiling his floors in a 50-year-old house and thinks they might have asbestos in them. "Here, look," he said, fishing pieces of a tile out of his jacket and showing it to us. Needless to say I started wondering myself whether or not there was asbestos in that tile, but Dr. L assured him that asbestos doesn't cause cancer unless the patient is exposed to it over long periods of time. After he left, Justin the scribe joked that now he feels like coughing. Dr. L agreed, saying it was the same after seeing scabies patients; suddenly you feel itchy.

ER: Eleventh Day

Because I switched shifts with Garrett, I went to work at 9:00 a.m. with Dr. B, with whom I've never worked before. He hasn't been around for the last several days b/c he attended Thursday's inauguration to help out at the first-aid tents, and everyone knew it. Almost every nurse and doctor we passed by asked him his thoughts about the inauguration since he got a front-row seat, and he told us about the different patients who came to his tent before and immediately after the inauguration. Chest pains, head injuries (from falling in the crowd), but mainly hypothermia from the cold. "Some people just don't know how to dress," he said. Too true.

We had several interesting patients today. Two of them had genetic illnesses: one had hereditary angioedema (his bowels can swell and cause nausea and vomiting), and the other had some kind of THR deficiency that makes her prone to PEs and clots (but her main complaint was for nausea and vomiting). One case was defined in triage as, "Hit in eye by bra strap," which puzzled Dr. B and the (male) scribe so I went to talk to the patient. It turns out she was adjusting a strap on a convertible bra when she accidentally yanked the strap too hard forward and it snapped backward and hit her eye like a rubber band. As a result her eyes became extremely sensitive to light, to the point where it hurt just to look at the dials of her cell phone. Dr. B called it "traumatic iritis," and when we later asked if he saw it often, he nodded his head. He also has a habit of ordering pregnancy tests on every female within childbearing years, which turned out to be a good thing b/c one patient who denied the possibility of being pregnant twice was actually 9 weeks pregnant (as confirmed by sono later on). This same patient also had personality issues and was a "bitch" to everyone until her discharge.

The last patient of the day was a sweet woman in her 60s who had a finger lac. I felt bad for her b/c she cried after getting the marcaine injection (which I hope never to get), and afterwards I asked Dr. B if I'd be sewing up her lac. "Sure, I don't want to do it," he replied (he was pretty eager to get out of the ER and had some charts to finish), so I gladly went to the room to sew the lac. Craig, the scribe, came in halfway through the procedure and we chatted with our patient to keep her mind off her finger. Fingers have way too many vessels; she bled more with each additional suture I put in. When I finished, I asked Craig to get Dr. B, and our patient said, "Oh, he's been poking his head in here to check on you." Probably a good thing; Dr. T pretty much let me sew away unsupervised. Dr. B came in and said I did a good job; there was one small tear remaining but he said it would heal fine on its own without sutures. And so concluded my day =)

ER: Tenth Day

Another 4 a.m. shift this morning with Dr. L and Julia, one of the scribes whose dad is a cardiologist at the hospital. We actually had to consult him twice today and Dr. L told him over the phone, "I'm working with your lovely daughter right now" which made Julia smile. This was a relatively slow graveyard shift; the 11 pm attending went home around 5 a.m. because there was nothing to do. We did get a couple of chest pains and one elderly man with diarrhea; his room reeked of Code Brown. I was happy to see some of the patients on my own, but we ended up becoming so busy in the morning that we didn't take a break until 9:30 a.m. Then Dr. L introduced us to her husband, who came to visit her at the hospital. She then said her arm was sore from playing the Wii against her daughter last night, which I could definitely relate to. Our last patients of the day were a "three-fer" consisting of a mom and two kids, and all three of them had scabies. The mom and the younger daughter, who slept in the same bed, had the worst of it. That doesn't sound fun.

Garrett called after work asking if he could switch his 9 a.m. shift for my 4 a.m. shift tomorrow. I'd told him no at first (it means one less day to work with my grading attending), but in the end I agreed. I'm always happy to help, but I've already had to rearrange my schedule several times to help him out, and I hope this is the last time. He owes me a slice of cheesecake. XD

ER: Division Meeting

Every month, the ER physicians, charge nurses, and other staff members get together for about 4 hours to discuss everything that's going on within the department and how things can be improved. Other doctors I've worked with have hinted that the meeting can range from benign to turning into a huge blown-out argument, and for some reason, medical students are required to attend these things. So Kate, Adam, Garrett, Jeremy, and I went to the meeting not knowing what to expect.

The first two hours were a huge snoozefest. There were discussions with the nursing staff about new hires within the nursing and physician community (i.e. Harris hiring new neurosurgeons while trying to keep nurses from leaving), and more importantly, how to improve patient care. Several doctors (I think Dr. Trot was among them) wanted to do away with the hallway beds until all the medicine and fast track rooms were filled, since a patient has no privacy or confidentiality in a hall bed where people are passing through all the time. "Can't do a rectal exam on someone in the hall," said one. Then there was the issue of computer availability. Some wanted certain computers to be used only by physicians and not nurses or med students (understandable), and then there was the issue of overcrowding at the fast track station b/c doctors, med students, and scribes tend to congregate there and then create a mess. Sometime around 11 a.m. someone quipped that we were missing the inauguration, but no one even said a word about turning on the flat-screen TVs in the room to watch it. There was no point to the students even being there; we were only there b/c it was required by Dr. W and Dr. McC, who weren't even there the whole time b/c Dr. W was working! Adam got to leave early with Dr. K (who purposely schedules to work on the day of division meetings so he can leave earlier), but the rest of us passed the time by playing with our PDAs. At one point Garrett and I scribbed out our tentative rank lists to show them to each other, and since I had my 12 programs clustered into "tiers," he decided to rank some of my programs for me based on location alone. When I saw what he labeled as #12, I couldn't agree more.

One of the more amusing topics brought up was how the radiology system keeps a lot of the number of times an image is viewed. "If the x-ray of the patient with a fork shoved into his urethra is viewed 200,000 times, that's a HIPPA violation right there," said one. This, of course, made all the students' eyes pop open. A fork in the urethra?! Jeremy commented quietly that the other day he saw someone with an eggplant in his rectum (what on earth...). Towards the end of the meeting, however, the doctors each presented case studies. One of the doctors, who wasn't present, was on the verge of getting sued b/c he removed a foreign object from the foot of a diabetic who couldn't afford the antibiotics prescribed to him, and he ended up losing his leg. In hindsight, maybe he could have been given IV antibiotics, but it's a hard call. The doctors ended up closing the discussion b/c the doctor in question wasn't there to explain what had happened. The meeting closed on a more fun note, though, with Dr. W telling us other things that he has found in people's rectums like onions. "That was hard to remove, one slice at a time!" he said. *sigh* Why do people do stupid things in the name of pleasure?

ER: Ninth Day

My shift today started at noon with Dr. J (whom I worked with last week), but he was stuck in traffic and therefore did not show up until 20 minutes after the hour. And even after that happened, we saw all the trauma patients together. There were a few interesting trauma cases today. One woman in a wheelchair got run over by a car while her caretaker, who had been pushing the wheelchair across the street when it happened, lamented that she should have been the one to get hit. There was a large flap of skin hanging off her leg, exposing fascia, and I immediately wondered if Dr. J would let me sew that up. The woman, obviously in pain, asked for a pillow, so I went and got one for her. I was so busy trying to stuff the pillow into a pillowcase that I didn't see where I was walking, and suddenly I stopped to see huge gobs of brown vomit covering a section of the ER floor. "Whoa, what'd I almost step in?" I wondered aloud, then turned and saw a couple of scribes watching me with semi-amused looks on their faces. *sigh* Nice of them not to warn me. I then saw a girl lying on a stretcher that had been turned vertically so that her back was facing the wall rather than the floor. It didn't hit me until later that it was this girl that had vomited and that she'd been turned sideways to prevent aspiration.

One of our next patients was a 15-year-old girl who'd been driving an ATV vehicle that flipped, and somehow she escaped with only a bruised thigh. "Can I go see ___ now?" she asked when we were done, and her dad explained that a friend of hers who'd been riding with her had also been brought to the ER. We then went to see the friend, who turned out to be the same girl who'd thrown up all over the floor. She had a huge cut in her head that I didn't get to see, and later CTs showed a contrecoup injury with minor bleeding. Throughout the afternoon I saw her friend (the driver) crying and talking on the phone; no doubt she felt guilty and responsible for what happened to her friend (who got admitted to the ICU for her head bleed).

I expected the girl's head lac and the other woman's leg lac to be sewed up pretty quickly, and though we saw both patients between and 12 and 1, their wounds weren't sutured until close to 5:30 pm. For some reason Dr. J decided to pass on the care of those patients to Adam and Dr. K, who actually signed before us at 10:30 but ended up staying later to do the sutures. When the two of them were discussing our patients earlier, Dr. K had said, "I have a medical student who's going to be a general surgeon, he'd love to do those." What was I, chopped liver? Granted, I know Adam could do a better job of sewing than I ever could, but if he took all the good cases, then what am I going to do as an intern and I have to sew up a really complicated laceration? They'll ask, "What did you learn in your ER rotation?" Ryan's wife Margie was shadowing Dr. K again, and she told me that Adam had already drained 3 abscesses before getting to work on our teenager's head lac. How many abscesses have I drained in this ER? None. *sigh* Either I need to stop working so closely with Adam (shift-wise) or I need to work with docs who'll let me do stuff. Not to say Dr. J didn't let me see patients by myself but it's not the same.

As far as the hierarchy goes, I don't know if medical students are really on the same level as scribes, especially the ones who've worked for at least one year. One of the scribes on the team today really knew her stuff, constantly following up on my notes and getting annoyed when I tried to fix a flashing printer and ended up losing her documents. It's also interesting getting referred to as "the med student," which is usually what I hear from other physicians. Speaking of interesting cases, we had a woman present with what looked an awful lot like a UTI, but Dr. J decided to do a non-contrast CT that was able to diagnose diverticulitis. Dr. R, one of the docs we're not supposed to work with, had an elderly lady with appendicitis symptoms but did not believe it would be. "Want to bet on that?" said Dr. J, and Dr. R agreed. Apparently the winner has to buy the others' bullets at a shooting range. -__- Men.