Thought experiment

If your 85-year-old grandfather came to the emergency room at 9:00 pm, unable to swallow and not having been able to eat or drink anything for the past two days, would you want him to be admitted to the hospital?

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.

Ghanaian connection

Many traditional Ghanaian names are based on gender and the day of the week that you were born. For example, Kofi Annan's first name indicates that he was a boy born on a Friday. The other night in the ER I took care of a little girl whose day name is the same as the wife's, and whose brother's was the same as mine. Mom was delighted to find out that we had gotten engaged in Ghana while Dr. N was working there.

Bikinis, fruity drinks, carnage

I've been seeing some very interesting cases lately, including some great teaching cases for the junior doctors. (Unfortunately, I can't share any of the enlightening, poignant, or instructive details here, for fear of the privacy consequences.)

However, I will share my top five tips for safe travel in a tropical surfing paradise (physician-recommended, mother-approved).

• Don't get drunk while on a balcony, roof, or while otherwise not at street level.
• Don't try to ride a motorbike in local traffic unless you really, really know what you're doing. (Or while you're drunk.) 
• Don't try to surf, body surf, or boogie board in circumstances that you're not absolutely sure you can handle. (Or while you're drunk.) 
• Carry a flashlight if you're going to be walking places without streetlights. (Especially if you're drunk.) 
• Don't get drunk while on a balcony, roof, or while otherwise not at street level.

As you can imagine, in the past two weeks I have collected multiple clinical cases to illustrate each of these priceless jewels of advice. However, enough people will never follow these tips that an ER doc will always have job security.

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.

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.

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....

Quote of the night

On Orthopedics call the other night, went to see a seven-year-old girl with a busted arm. She was crying when I walked into the room, and as I knelt down next to her she turned to me with tears and sniffles and said, "I need to pee. I'm not kidding!"

You're welcome

Weekend overnights at the county hospital ER can be a parade of drunken brutality -- accidents, assaults, all-around bad judgment and poor life choices. These are the patients whose stories so often begin "I was just minding my own business...." They're generally soused to the gills. We spend hours stabilizing their fractures, scanning their head bleeds, sewing up their lacerations, and in return we get cussed out, vomited upon, spat at, and even assaulted. All part of the job, although sometimes it gets a little stale.

And then, usually once a night, there will be the patient who has equally bad injuries but who was, in fact, just caught in the crossfire -- a sober citizen who was assaulted out of the blue, or who had the unfortunate but non-alcohol-related auto accident. These are the patients who, as we're sending them home with a cast or admitting them to the Orthopedics service at 4:00 in the morning, will say "thank you." And that usually makes all the rest of it worth it.

Neurological exam

We see large numbers of intoxicated people in the emergency room who come in after unknown events. The problem is, most of them are just drunk or high, but some of them have had injuries including head trauma. So we need to watch them and see if they sober up or if they have other problems that we need to take care of.

The other night a young lady came in, apparently drunk, and spent a few hours face-down on a gurney. As she started to clear and move around, it was time for a repeat neurological exam. I looked down the hall, and saw that she had put on her 4-inch stilettos and was starting to walk around. I figured that anyone who can walk around in those shoes must be neurologically intact, and started printing out her discharge papers.

District 9

I've been cycling between day and night shifts, which leaves some odd chunks of time off in the middle of the day. So a few days ago, unable to decide whether I should be sleeping in the middle of the afternoon, I went to see District 9. Then on my very next shift, a young man came in having his first psychotic episode. The subject of his psychosis? Among other things, he believed that he was trapped in -- District 9! By the end of my shift, I was beginning to suspect that I was, too.

Spider bite

It's quite common for people to come to the Emergency Department reporting a spider bite, but most of the time it turns out that they weren't actually bitten by one of our eight-legged friends. (This phenomenon is very interesting to me, and I have a theory about it that I should share in a future post.)

However, tonight our team in the ED had a rare moment of being able to sit down together for a few minutes, and as the newly-minted big bad R2 it was my duty to use the time well to do some teaching for the intern and medical student. So we talked about black widows and brown recluses and the diagnosis and treatment of actual spider bites. And the weird part wasn't the medical information (although some of it is kind of weird), but that I was sitting there, knowing a little bit about the subject and able to share it. Maybe these long hours in the hospital are driving something through my thick, sleep-deprived skull after all.

Phrase of the workday

"Aerosolized vomitus."

That is all.

Mass casualty incident

Long time, no post. A week of vacation followed my last post, and now I've started R2 year -- the second year of residency.

I worked an overnight shift last night on the Pediatrics team. When I arrived in the Emergency Department things were pretty chaotic; there had been what we call a mass casualty incident: two light rail trains had collided. As you can imagine the department was pretty backed up, but fortunately no one who presented to our hospital was too badly hurt. One of the trains involved was headed to a Chinese-American neighborhood, so when I got there the halls were full of elderly Chinese people in cervical collars.

Pain in the ass

As I was discharging a 96-year-old patient recently, he told me, "Doc, you're a good guy. Some people may tell you you're a pain in the ass, but I think you're a good guy."

Yes, establishing those bonds of trust and respect is what medicine's all about.

Seized by love

The other day I had two patients, a young man and a young woman, both about 20 years old. They had each had the first seizure of their lives earlier that day, within an hour of each other. Both were visiting from out of town, had friends with them, and required a slightly more complicated workup than is usual for a first seizure. They were lying in adjacent gurneys in the hall. When I spoke with the attending physician about them, her recommendation was: "we should introduce them; they'll probably hook up!"

Sew what?

For the past couple of weeks I've been working in the university hospital's ED. Although the cases are often medically complex and interesting -- liver and lung transplants, patients with multiple diseases, etc. -- we don't always see the same sort of banged-up trauma that we see on every shift at the county hospital.

But the other night at the end of a shift, a guy came in who had bashed his forehead. No multiple co-morbidities, no metabolic diseases I'd never heard of before, just a moderately complicated laceration that had to be repaired carefully given the cosmetic issues of facial injuries. And I have to confess -- I love sewing up lacerations. It was strangely peaceful to just settle into a room for a little while with my last patient of the night and stitch up his wound.

Such are the simple pleasures of my life these days....

Scary

I'm on the overnight pediatric shift in the ED tonight for Halloween. Wonder what we'll see....

Chief complaint

Went in today to see a patient triaged with belly pain. When I asked what was wrong he said "my yin and yang are out of balance."

That'll do it.