One... more...shift...

The overnight shift tonight will be the last shift of my entire residency. Can hardly believe it....

Professional satisfaction

Every so often a case in the ER is the perfect balance of a pleasant patient who is genuinely interested in their own disease process, wants you to teach them more, and for whom you can provide effective treatment. Got two of those in a row the other night and left work feeling like a doctor.

Around the Bay Area: Sunrise after night shift

Isn't that a little personal?

Life in emergency medicine can be a little strange sometimes. I just checked the schedule for our department conference this week. Looks like the highlight will be the Anorectal Small Group Discussion. I guess we'd better be sure to wear clean underwear....

Like pulling teeth

This month I'm on an Oral Surgey elective rotation -- and having a blast. One of my main goals is to get experience extracting teeth. Of course, we deal with a lot of oral and dental trauma in the ER, but when it comes to teeth this usually means temporarily putting them back in after they've been knocked out. In urban ER practice we don't usually take them out, since there will be an oral surgeon or dentist available for referral. But in isolated rural and international settings there are often no dental resources available, so I'm trying to get some experience with the basics of tooth extraction and other dental and oral prcedures that I don't usually get to do in the ER.  

On top of getting to perform all sorts of interesting procedures, the oral surgery residents that I'm working with are all-around cool and pleasant folks. I can't even conceive of the training they go through: dental school and medical school plus residency. And they come out of it loving what they do. Kudos to my Oral Maxillofacial colleagues.

Getting closer

It's hard to believe, but a scant 12 years after starting premed classes in 1999 (!), I'm down to 10 months left to go in medical training. Although there's a lot left to do between now and next July, the end is finally in sight.

All of which means that pretty soon it's going to be time to start looking for a job. Starting from first principles, here's an interesting page from the CDC web site about Access to Trauma Care in the U.S. If you scroll down you'll find a map of the U.S. The purple areas are within one hour of a Level I or II trauma center. The white areas are not. Food for thought....

Alles klar, Herr Kommissar?

Last month I wrote about the new restrictions on personal expression that have been placed upon residents. There have now been some official clarifications. Ever get home from a difficult day at work and wanted to post on Facebook something like "today was a rough day at work"? Or maybe had an inspirational day and wanted to post on your blog: "today I really feel like I accomplished something?" (And maybe even share what it was that you accomplished?) We are now explicitly, officially prohibited from making any such public comments. The more cynical among us are beginning to suspect that the medical center's concerns have less to do with patient privacy than with potential litigation.

And, by the way, in this public forum I can neither confirm nor deny whether I had a good day at work today.

Taipei airport early morning

On my way to my next rotation -- Bali! It's kind of an unbelievable stroke of luck, but I'm going to be rotating at a hospital there giving emergency medicine lectures, doing bedside teaching on rounds, consulting on medivac decisions, and on call for consults 24/7.

I'm posting from the Taipei airport, where I'm transiting early in the morning. No place open for post-trans-Pacific flight rehydration but all the duty-free shops are open and there's wireless, so I guess I can't complain.

Anyway, I've never heard a bad word about Bali and I've never been before, so I'm off to see for myself. Hope to have a reliable enough internet connection that I can post about my Indonesian adventures.

Meanwhile, don't forget about the new music blog. I posted a new recording just before I left, and who knows what I'll be posting while I'm in Bali....

Synchronicity

This month I've been working upstairs in the ICU. I was on call Saturday and Sunday and at the end of the shift was signing out to the oncoming on-call resident after 30 blurry, sleep-deprived hours of adjusting ventilator settings and fine-tuning medications. When I was done my colleague said "see you Tuesday." Waitaminit, Tuesday, you say? Not Monday? There are no holiday or weekend schedules in the Emergency Room, but it turns out that today is President's Day (who knew?), and if you're not on call in the ICU you don't have to come in. Amazing! Especially since I'm in the middle of a run of 17 days on duty with no days off -- what a gift!

Then, on my way out, a couple of nurses grabbed me and insisted that I look out the window. Incredibly, it had snowed overnight and there was a dusting of white on the hills above the Marin headlands. A day off, and snow in the Bay Area: two once-in-a-residency events, and at the same time!

I celebrated by going home to sleep.

Multiple choice

While doing some practice questions for the Emergency Medicine Board Certification exams, the answer to question 366 happened to catch my eye: “C, remove the amputated part from the cooler, wrap it in saline-wrapped gauze, then refrigerate it in a plastic bag.”

I'm in a strange line of work....

Responsibility

The job's been going great lately; I look forward to my shifts these days, I've been doing a lot of teaching, and in general am enjoying medicine more than at any time since I started on this path. (12 years ago now!)

And yet, here it is, 4:00 in the morning, and I'm sitting up thinking. During my shift yesterday there was a situation that could easily have led to one of my patients dying. Quickly. It was a systems issue and nobody blames me for a failure of knowledge or skill. But it was still my responsibility. Even though there wasn't a bad outcome for the patient -- this time -- it's a reminder of how high the stakes can be in this business.

Christmas Eve in the ER

It's 10:00 am on the 25th and I just got home from a long and bloody Christmas Eve in the emergency department. The wife's still finishing a 30-hour shift in the hospital, so here I am sitting alone at home, exhausted, but not quite ready to sleep.

Last night was as busy and challenging as any other night in the ER. There were victims of heart attacks, assaults, and motor vehicle crashes. There were the suicidal, psychotic, and just kind of lost. I worked to control a spurting arterial head bleed while the patient cried about losing his girlfriend. I took care of a man who was riding his bicycle without a helmet and came in with his scalp half torn off, slumping down to reveal a broad tract of his skull.

I find myself thinking about why I wanted to get into emergency medicine in the first place. Partly it was a sense of adventure and of pushing myself to the utter limits of capability. A large part of it was a desire to take part in the extremes of the human experience. And I liked the fact that the emergency medicine, more than most other branches of medicine, is directly connected to the world outside the hospital.

Early in the morning the paramedics brought in a forty-something woman in cardiac arrest. I ran her resuscitation. We gave her all the medicines that might get her heartbeat back. We defibrillated her, and I struggled to place a breathing tube. But it was hopeless, and despite everything we know about physiology and pharmacology and the art of healing, there was nothing more we could do.

Stopping a resuscitation is termed “calling the code” and is fraught with a mixture of emotions. It's hardest when the person is young, when you know the family is waiting just outside (or, sometimes, in the room with you). I asked if anyone in the room had any other ideas for resuscitation: no answer. I asked if anyone in the room had any objections to calling the code: again, no reply. And then I announced the time of death.

I stripped off my blood- and vomit-stained gown and gloves, steeling myself for the talk with the family, checking my scrubs to make sure they were clean. One of the paramedics who had brought the patient in stepped up and complimented me on how well the code had been run. There's very little positive emotion to take away when a resuscitation fails, and I'll admit, his comment meant a lot to me. But now it was time to talk to the family. I was well aware that we were several hours into Christmas day, and that now and forever this family's grief would be tied to this day.

It turned out that her adult sons were, in their grief, verging on hysteria and violence. (This is not unusual; sometimes family members will become so violent on hearing the news of a death that they must be restrained by police officers to prevent injury to staff or others.) There were several of us present, and I briefly explained what had happened and that their mother had died. As I finished talking, one of the sons was literally crushed to his knees with emotion and began wailing. Another brother grabbed him, and without another word pulled him out the door, disappearing into the night.

When a patient dies in the ER we place them in a private patient room with as much dignity and repose as possible, and then allow family members time alone with their lost loved one. Several hours later I was collecting equipment for a procedure and happened to walk past the room where my patient was lying on a gurney. There was nobody there, and the lights were off, but somebody had turned on the overhead operating room-style light and trained it on the head of the bed. A small shaft of bright light cut through the darkness and glowed over her head. It was a moment of utter peace, of a strange chapel-like beauty. It was an image that will stay with me for a long time.

Eventually we reached the last hour of the shift. My fellow resident on duty and I congratulated each other on making it through another long night; too soon, as it turned out. Twenty-five minutes before the day team was to come on, we started to get patients from an MCI, a mass casualty incident -- a four-car crash, in this case. I ended the morning taking care of one of the passengers, a young woman. Just before I left she started being rude to her nurse about not fulfilling her requests quickly enough. When the social worker who had provided invaluable help with the family of the woman who died asked for her last name, she snapped “You couldn't pronounce it anyway.” My colleague asked her to spell it, and she spat out an unintelligible burst of letters. I was well past the end of my shift and trying to get out and go home, but still felt as protective of the staff as I did of my patients. I walked over and politely (I hope) but firmly explained that these people were trying to help her and deserved her respect. And then she slowly spelled her last name.

When I left the hospital I walked home in the gray Christmas morning light through the Mission District, past middle-aged men drinking malt liquor in doorways, past homeless people asking passing hipsters for change, past Spanish-speaking street evangelists in suits. In some ways it was a typical shift, but there was something about last night that was a little different; hopeful, somehow. Anyway, I'm too exhausted and sleep-deprived to draw any lessons now. Time to get some sleep and recuperate for tomorrow's shift.

Merry Christmas, everyone.

Let us beat pagers into plowshares

After three weeks of carrying my pager 24/7 on backup call, in just 12 more hours I take it off and start two weeks of  vacation! Man, that thing just gets heavier and heavier the longer you wear it.

Dying and not dying in the SICU

Working in the emergency department tends to give a person a thick skin when it comes to strangers' tragedies: catastrophic trauma, devastating strokes, massive heart attacks are all to be expected on any given shift. It's not that it doesn't affect you, but you have to learn how to keep going, to delay processing, because no matter how bad the situation is for the patient and the family there's always a waiting room out there full of people who still need to be seen.

However, this month I've been rotating in the SICU -- the Surgical Intensive Care Unit -- and it's been a very different experience. I really like the people I'm working with, and I've been learning a lot. But at the same time it's been a somewhat depressing experience. So many of the cases are almost unbearably tragic: the eight-year-old shot in the back and now paraplegic; the middle-aged man locked in after a stroke; the young man who shot himself through the head in front of his girlfriend and infant child and now lies in bed with his brain swelling through flaps removed from both sides of his skull; the young man whose spinal cord was severed by a bullet and is now quadriplegic, the man from Guatemala brain-dead after a stroke and sustained on a ventilator but, due to miscommunication with his distant mother, whose organs could not be donated and whose body could not be repatriated to his family.

Almost every day I spend my walk home trying to re-engage with daily life, where people walk around in the sun and almost nobody is at risk of suddenly collapsing in a coma. Often I buy myself ice cream.

Of course, I've already dealt with a fair amount of suffering and death along the way. In fact one of the most beautiful moments of my intern year revolved around a death. My patient was an elderly woman who was gravely ill. It was time to make a decision about whether to escalate medical interventions or transition her to comfort care; that is, focus on controlling pain and providing a peaceful environment. She had two adult daughters who were very involved and they asked that those of us on her medical team meet with the family to decide what to do. I still remember that meeting vividly. It was late, about 1:30 in the morning, and when I got to the family room it was overflowing with maybe 40 family members spanning four generations, from elderly to newborn. I remember sitting on a chair on a wood-paneled floor under low lights, in the middle of the room, surrounded on three sides as this family listened to my description of the medical facts, asked me questions, discussed the options, and with love and dignity decided to let the matriarch of their clan go to a comfort care suite where she died, surrounded by family, two days later.

But there's something about the surgical cases -- perhaps the suddenness of onset that characterizes them -- that seems to make them particularly demanding emotionally.

A couple of days ago I was taking care of a very ill elderly woman whose outlook was looking less and less promising by the day. Her devoted adult only son was spending hours sitting at her bedside, trying to come to terms with the fact that his mother, a vibrant active 85-year-old only weeks before, was now sedated, intubated on a ventilator, and acquiring new lines and tubes for antibiotics, pressors, and all the other interventions of modern medicine. As he told me himself, he was shocked and overwhelmed. We talked for a while, and I told him a bit about how I had recently lost my father. I wanted to do something to normalize the reactions he was experiencing, and I hope I helped ease things a bit for him. I think maybe it helped ease things a bit for me, too.

Years ago I was talking with a wise friend of mine about how curious the process of learning about sex is. It's a part of life that is central to adult life, to society, to biology, and yet we go for years early in our lives being only dimly aware of it, and spend more years trying to understand it. I remember jokingly wondering whether there was anything else out there waiting, another huge part of life that was largely unknown to us as young adults and would not be revealed until later. She answered, “of course there is: dying.”

I spend a lot of time thinking about my locked-in patient. He is utterly paralyzed, except for being able to blink and move his eyes up and down. He was estranged from his family for 20 years, but eight months ago had gotten in contact with one of his adult children. He has made it clear that he wants to live, that he wants everything done. Every morning, when I go to check on him, I make a point of standing in his field of vision. I address him by name, re-introduce myself, ask him if he remembers me. He indicates that he does with our convention for “yes,” by looking up. I touch him, squeeze his hand, ask if he can feel me squeeze his hand. One morning last week I noticed that he had had an enormous spike in his blood pressure overnight. The Neurology team said that was when they told him -- told him that he had almost no hope of recovery, that his interaction with the world would be forever limited to a few eye movements, that his only hope of survival was ventilators and feeding tubes and teams of skilled health care providers to keep his body from breaking down.

As a doctor, what is success and what is failure? We'll never “cure” him, but if he wants to survive in this state we can sustain him for a while. Every day we're privileged to be able to bring to bear therapies and interventions that would have been magical dreams come true to most healers throughout human history, but in this setting I'm not always sure whether we're doing good by deploying them. All I can do is to keep adjusting the ventilator settings, squeezing hands, talking to families, enjoying the ice cream on the walk home.

A dangerous place

When I show up for a shift in the emergency room I scan the board, looking for how many patients are in rooms, how many are in the waiting room, and what injuries and illnesses they're billed as having. My last two night shifts in a row, unfortunately, there were familiar names on the patient list: before each shift one of our own residents was registered as a patient following an injury or exposure during the previous shift.

We sometimes get complacent about it, but it was a reminder that the emergency room can be a dangerous place -- physically, emotionally, and mentally.

Family business, part 2

Tonight was our first shift working together! It was fun, and a reassuring glimpse of our hoped-for future, working together in the field.

Would you go back to work?

Recently I had a patient who was a podiatry student. She'd been in an accident but fortunately a thorough workup showed that she had escaped without any injuries. As she was about to leave she asked for a work excuse. I told her that I'd be happy to write her a note saying that she'd been seen in the emergency department, but I couldn't say that she was impaired -- after all, I'd worked her up and found nothing wrong, and if I had found anything wrong she wouldn't be leaving the ED, she'd be staying for treatment.

Then she said to me, "but I have to go back and take care of patients. You wouldn't go back to work if you were in my situation, would you?" Generally I avoid discussing my personal health experience with patients, but if they ask directly I try to answer honestly. So I said that yes, I wouldn't have a choice, I'd have go back to work and take care of patients. She didn't really believe me and pressed the question. Especially since she was a healthcare student herself, I wanted to level with her. So I told her about how I had just broken my foot two weeks ago. Not only did I not get any time off work, I worked back-to-back 12 hour shifts, hobbling around in an ortho shoe.

She paused, then said, "Sounds like you need a podiatrist." True! Then she turned to her father and said, "Podiatry is a lot nicer than Medicine." I wrote her a note for the rest of the day off.

My foot's feeling much better, by the way, although it doesn't look like I'm going to get time off work to go to my scheduled Orthopedic appointment.

Winning the Game

One in a great while, we manage to clear the board in the Emergency Department -- that is, discharge every single patient. This is known as winning the game. There are people who have worked in EDs for years and have never been there for the occasion.

Last night we won the game. Totally surreal. We celebrated by turning down the lights and having a party: funk playing over the PA system, the bar code lasers on glucometers for strobe lights, an oxygen tank with a nebulizer for a fog machine, and a Wood's lamp for a black light. It was amazing. Of course, we needed to document the occasion:

Then, about half an hour before the morning shift came on, we were back down to one patient in the department -- mine. "No pressure," said the attending. I ran back to the room, dressed the patient's wound, and we cleared the department again; we were able to sign out an empty board to the oncoming team. Of course, we had to get proof again:

I've never been in the ED for one of these, and I doubt I'll ever see it again twice in one shift. But I'll savor the memories forever....

Training day

Yesterday I helped out with the Basic Life Support training here at the hospital. It went well and turned out to be a lot of fun. The program had brought a set of adult and peds training mannikins and there was a good crowd in attendance. Everyone was very involved. When we were teaching the Heimlich maneuver, the enthusiastic nurse I was working with practically left bruises on me. Very curious to see whether the next patient to arrest in Casualty will get CPR.

Smoke and a roar

I've been sleeping during the day, working night shifts, and this afternoon I was awakened by loud jet airplane noises. It took me a moment to realize that it's Fleet Week, and the Blue Angels were practicing. We live pretty far up the hill where the hospital sits, so those F-18s were flying just a few hundred feet above our apartment, rattling it pretty good. Ordinarily I'm into loud fast things, but I realized with a sinking feeling that they're going to be flying every afternoon -- on the days I need to be sleeping! Basically, I'm gonna have jet flighters waking me up at my equivalent of 3 am for the next several days. "Smoke and a roar," according to the Chronicle. Even more sleep deprivation than usual, according to me.