To the patients (and families) who yell at the ED staff

I don't really understand what is with patients who feel the need to yell at the ED nurses and Docs. I'm really just a fly on the wall, so I miss most of the flak, but watching it go down is probably one of the most annoying parts of my day...hence it inspired the following compiled synopsis of interactions with that lovely family that came in today:

Yes, ma'am, we know that your c-spine collar is very uncomfortable and that it doesn't allow you to watch your stories or look around the room for your call button, which we conveniently located directly next to your head. Fortunately for us, your voice was shrill enough carry over all the noise of the over-crowded ED all the way to the nursing station at the other end of the hall. Screaming "Help me, I'm dyin', I'm dyin', I can't breathe" at the top of your lungs, really communicated the urgency of your situation. Unfortunately, I don't think waiting room was able to hear you though the sold oak fire doors.

What's that? Yes, we need to keep that collar on because we haven't been able to look at your spine with the CT machine yet. No, it's not choking you, that's your panic attack that's making it hard to breathe. Apparently not being able to breath doesn't stop you from screaming at the top of your lungs...I think you're breathing fine, please just breathe deeply. Yes, we know that your neck hurts, that's why we need to keep the collar on and look at your spine with the CT machine. Yes, I know that you've been here for 45 minutes, but we have several other people that need to have their heads and necks imaged with the CT machine too, we're waiting until they're finished. Because they were here hours before you and they waited their turn.

Oh that's nice, you're son's here to visit you...what's that? You want your mother to get her CT scan and to go home as soon as possible. Funny, that's what we want too. However, there are sicker patients, like the lady with the sudden onset of the worst headache of her life and the man who came in 2 hours before your mother with his head split open from the fall that he took when he fainted at work. There's no need to raise your voice, sir. We're getting her through as fast as we can, sir, but there are patients with life-threatening injuries that we must deal with immediately because they could DIE. Your mother is sitting up now watching Days of Our Lives and laughing with your brother and aunt...oh that's your grandmother, I'm sorry. Regardless, we just need to be sure that there was no damage to her head, neck or spine before we let her go. So you don't sue us, that's why.

We're doing the best we can, sir, we've got patients in every bed in the department. Listen, yelling at me and the nurses isn't going to get your mother out of here any faster. In fact, it's taking time away from the nurses and ultimately delaying your mothers care and discharge. She should be going to CT in the next hour or so. No we need to get a radiologist to read the scan, that will take some time, but your mother should be out of here in 2-3 hours. We're also waiting on the labs we sent up earlier, and then we need to figure out where your mom needs to go after her scan comes back.

Sir, the nurses can hear you cursing about them, the work station isn't soundproof and you're standing 3 feet away in the middle of the hall way. Yes we know you said it, you're the only one with a Rastafarian accent in earshot of us. You're also the only one shooting menacing glares at the nursing station...besides that psych patient, but he can't help it. Do you really kiss your mother with that mouth???

...2 hours later...

Yes we're glad your mother is fine too. Have a nice day.


ED quote of the night

Middle aged woman, presenting with swollen right foot.

Attending: So, that looks like a bite of some sort.
Patient's Mom: Does it look more like a snake bite or a spider bite to you? I can't tell the difference.
Patient: I think it's a snake bite.
Attending: I'm can't quite tell, but it's more likely to be a spider bite around here.
Pt: I definitely think it's a snake bite. I've been bitten by snakes a bunch of times before. You know, normal snakes like pythons. I barely felt those.
Attending: (deadpan with a hint of sarcasm) Can I ask why you've been bitten by snakes more than once???


First Overnight shift...

7:30 am and I just finished up my first overnight shift in the ED, and surprisingly it didn't suck as much as I thought it would. We (I shouldn't say we because I am basically useless and the docs and nurses do everything) had a couple of shoulder injuries, possible anterior compartment syndrome, a couple CHF, a couple diarrheas and a punctured globe with a bb gun.

Overall, the variety and rapid turnover of cases is what's drawing me to EM. I also like the idea of being able to quickly diagnose whatever comes through the door, getting it to the point where it is under control and then moving the case to whatever service it needs to be admitted to. So far, the residents and attendings that I've worked (read: followed around like a lost puppy) have been more than willing to teach me practical tidbits from how to actually read EKG in a practical setting to some of the pathophysiology that is sorely lacking from the first year of medical school.

Anyway I'm exhausted...


An ethical dilemma...

This post is probably going to sound like one of those hypothetical cases thrown around in an ethics conference, but it's not and I watched it unfold yesterday at work.

An alcoholic gets out of a 10-day rehab stint and celebrates with a few drinks...to the point where her friends drag her kicking and screaming into the ED to prevent her from taking her car out for a little drive on a Tuesday afternoon. She was pretty calm by the time she got to the door, and her friends just wanted to get her back on the wagon again. Unfortunately, the friends were operating behind the patient's back to get her sister involved. Her sister came in and wanted the attending to release the patient into her custody so that she could take her back to the rehab facility that she had left the day before. After a couple hours the patient was completely coherent, did not have a history of violence/suicide attempts, and had no suicidal/violent intents. The sister, on the other hand, claimed that the patient was absolutely a danger to others and going to harm herself and should be admitted immediately to the psych ward or to a rehab facility.

What do you do?

Now, my gut reaction to this whole situation was something along the lines of "Go ahead an release her to her sister and let them fight about it in the car. It will free up the bed for someone in the stacked waiting room, and maybe she'll get some more help at the shelter for her drinking problem instead of trying to drive drunk." I'm sure that a number of you had a similar reaction. Yeah, but it's not the right ethical answer.

Beyond the knee jerk reaction of getting an alcoholic out of the general population, that thought process removes a competent patient's autonomy, which gives the patient grounds to sue your sorry ass. Placing her in her sister's custody to be unwillingly taken to rehab is essentially aiding in her kidnapping.

The proper response is to call Psych to have her evaluated for competence and suicidal/violent thoughts. Then you should document that she is not an apparent threat to herself or others, document that her sister is concerned for her well being and wants to send her back to rehab against her will, and document the psych consult confirming that the patient is not a threat to anyone but her liver. Discharge her with a taxi voucher to get home, take a deep breath and move on to the next patient.

Adult ED conversation of the day

60-something yo patient, post-menopausal vaginal bleeding

Resident: Are you sexually active?
Pt: Nope, told you I was boring
Res: When was the last time you were?
Pt: Before you were born, honey

...later during vaginal exam...
Res: Any discomfort?
Pt: None at all, this is the most action I've gotten in 30 years!!


Peds ED conversation of the day

15 yo high-as-a-kite Female, bloodshot eyes, face stuck in a grin and previously diagnosed, poorly managed adjustment disorder.

Resident: "So why are you here?"
Patient: "My face is stuck in this smile..."
Res: "Do you use drugs?"
Pt: "Just a little pot"
Res: "When was the last time you used it?"
Pt: "A few hours ago..."

Later, after patient has slept it off for a couple hours and is now impatiently glaring at the nurses station, like she's about to tackle the next person with a stethoscope that walks by.
Attending: "So what do you want to do with the patient?"
Res: "Send her home and tell her not to smoke pot."
Att: "Yup..."

New Beginning...sort of

I start working in the Pedi ED this afternoon. Ironically, as I was writing this, the trauma Chopper was buzzing about 30 feet over my apartment. Hopefully there'll be some interesting stuff towards the end of my shift for me to write about. But then again, I assume that anything is more interesting than sitting around studying for neuro.

1 year down, 3 years to go until my first paycheck, my first non-lab job...there's just a great sense of relief and exhaustion at this point. This last summer of my freedom couldn't have come at a better time!!!!


A word on curriculum

Dearest Medical School Scheduler,

You obviously do not have a life outside of scheduling my medical school exams, or access to an up-to-date calendar for that matter. I would just like to inform you that I have begun to take offense to the lousy job you have done. Your first mistake came by scheduling an exam THE MONDAY AFTER THE SUPERBOWL. You apparently are oblivious that it is a national day of recovery following the consumption of massive amounts of food and delicious, delicious beer...but instead of enjoying that most sacred sporting event that only comes once a year, I was relegated to half-assedly study while trying to catch some of the game. I can forgive you for that slip, because my beloved Pats had been knocked out much earlier in the playoffs by the unholy Colts in a most disappointing fashion (Peyton, you're going down this year buddy...Randy Moss...receiver problem solved).

But then, oh wise keeper of the master calendar, you scheduled another exam the Monday following Daylight Savings Time. I can also let that slide this time, because the unexpected three week move in the "springing ahead of the clocks" only deprived me of an hour of precious sleep. You could not have forseen the unexpected act of congress to save energy by giving us more waking hours in the sun. I only checked my alarm clock, and my roomate's alarm clocks 5 times before I could finally close my eyes and sleep that horrible pre-exam sleep.

Really though, you could have cut us a break this week and maybe spread things out a little bit. But, NO, you scheduled 5 exams within 9 days. Did you think that I wouldn't notice the beautiful mid-June weather outside of my apartment? Did you think that I would really be focused in the 11 lectures you scheduled two days before the exams? Didn't you realize that I wouldn't actually care by the end of the third consecutive day of testing? To be completely honest, I'm more or less out of the running for any distinction in these classes and I need a 36 on the finals to pass...I'm burnt out after a year of your abuse, exhausted from the studying and living on Subway, Red Bull and Dunkin Donuts for my sustenance.

If I ever find out who you are, I'm going to head on over to payroll and have them "rearrange" your work schedule. I know you had your heart set on checking out the opening night of this year's Shakespeare in the Park production, but sorry you're stuck in your cubicle all weekend. Thank you for your continual (lack of) consideration for my sleep patterns, success in medical school and mental health.

Bostonian in NY
Class of 2010


Medical School year 1 in review

As I sat here, procrastinating studying for my psych and neuro finals, I was thinking about the past year:

With great power comes great responsibility...

I started on this journey not so very long ago, on a hot August day. I packed my Corolla with everything that I owned, and put my TV and bike into my parent's car and headed on down the 'pike, leaving behind my beloved Bay State. I was feeling good, new doors opening, new people to meet, a new chapter in my life. I had no idea what I was getting myself into, and between the free beer and everyone on their most friendly behavior life seemed good. They repeatedly told us "with great power comes great responsibility" and other such comic book-esque speeches. Then they put the short white coat on me, and they instilled that same sense of power and responsibility which they spoke of.

I compare the short white coat to the venom suit in Spiderman 3, it felt really good to have that token costume showing who I was going to become. Unfortunately, much like the venom suit, it is parasitic in nature. As the year wore on, I became more and more isolated from everyone that I care about for the pursuit of medical school. My life has become a constant battle between having enough time to do what I need to do to survive school and and having time for the things that matter most in life-my family and friends. Unlike Spiderman though, I'm not saving people and I'm not defeating evil, I'm frigging studying Neuro...

Medical School Year 1 in review

So over-all the year has had the constant theme of change. I've moved to a new place, met a bunch of wonderful friends, and completely changed my lifestyle. I've also
figured out what I'm getting myself into, and I'm surprisingly OK with it.

I'd have to say that the overall sense of uselessness at this point is the most frustrating part of medical school. I'm a smart person, I'm paying a lot of money to be here, but I'm just sitting here like a sponge, absorbing science that is starting to overflow from my pores. I was also disappointed in the level of social maturity of my classmates; you'd figure that most of the whackos would be screened out in the application process but we've got some of the most socially stunted human beings roaming our campus waging passive aggressive battles amongst eachother, and complaining when things don't go their way. There's also a level of accountability that I've seen missing from these kids and it makes me worry for the future of medicine. Finally, the insight I've gained into the economics of medicine are horrifying, and I wonder how I'm ever going to pay back these loans.

With the bad, comes good too: I have a definite sense of accomplishment when I look back on all of the material that I've covered. I now know a decent bit about the normal, healthy human body and how it functions, and I have to say that some of the processes are absolutely fascinating. I've made a bunch of good friends here at school, and there is a definite sense of comaradarie that has formed between us from the collective suffering, and the sigh of relief that we breath after every exam. Most of all I feel like I have some foward momentum in my professional life, whereas my year off in research felt like Ground Hog Day (The Bill Murray movie). I'm on a career path, and all I have to do is my best and that part of my life will turn out just fine.

On the docket for the summer is a 6 week pediatric EM fellowship in our hospital affiliate, which I am pretty stoked about. In my free time, I'm probably going to watch the Red Sox, drink some of the quality local microbrew, hang out with my family down the cape, teach myself how to fly fish, catch up on movies, read a few books that have been gathering dust on my shelf and generally catch up on sleep. I know there's only 9 weeks of summer and that seems like alot to accomplish, but I've got to squeeze in the good life before I'm locked away in the hospital for the rest of my life.

Hopefully, I'll have some interesting cases to post on here, as I'm sure that I get a lot of hits for people searching for whiny med student angst. Peace


First really depressing case/zebra

With the recent happenings in the Medical Blogosphere, I'm hesitant to post this. I've tried to keep things as anonymous and HIPPA-compliant as possible, to keep my ass out of hot water.

I was at my preceptor's office the other day, and she pulls me aside as soon as I walk in the door and tells me that she has an extremely interesting case for me. 6 m.o. boy with Osteogenesis Imperfecta II or III (preceptor wasn't sure).

Immediately, my brain flashes back to our biochem lecture on collagen formation that casually mentioned failure to thrive and fragile bones and all the clinical afterthoughts they throw into the pre-clinical years to remind you that you're actually in medical school. So, I thought I had a pretty good idea of what to expect: tiny baby that has fragile bones, history of multiple fractures, malformed limbs...check. Cool and composed, yet empathic and interested clinical face...check. Name tag clearly identifying me as medical student...check.

I have never seen such a pitiful little creature as this. His limbs were pathetically undersized for his trunk and so malformed that that he couldn't even extend his hands. Both feet were completely plantar-flexed at the end of his bowed little legs. His fingers were maybe 3 mm wide and looked as if even the meager pressure he could apply while sucking on them would pull them right off of his hand. His head was far too big for the thin little neck that it sat on. He barely looked human...except for his eyes. The huge brown globes kept darting around the room, from face to face, fixing on anything that moved. His bony little chest and slightly distended belly, heaved with exertion around 100 times/min as he gasped for air. Failure to thrive does not describe this poor creature...barely over 6 and a half pounds of humanity, trapped in a fragile and helpless little body. His struggle for breath was over-coming his ability to take in food, leaving his growth chart absolutely horizontal. And aside from all of that were severe legal, financial, and social complications in the family that would absolutely rend your heart if I wouldn't identify the patient with them. (I won't post them here since they were in the newspaper). My preceptor ended up sending the family over to the local ED. We spent the rest of the afternoon in a daze over the patient, depressed about how sad the situation is, about how hopeless and futile this child's struggle would be.

The whole encounter brought together a lot of feelings for me, about how lucky I was to have loving and responsible parents. About how we're born into whatever situation God hands us. About how medicine is powerless in the face of some diseases and ultimately death. Finally, about how our individual choices that a parent makes can absolutely tear a family apart and destroy the lives of his/her children.

I'll end by saying that even though most people have the ability to reproduce, doesn't mean that they should, especially if they can't handle the responsibility or pay for it.