A med student rekindled

Truth be told, I have not been a fan of medical school to date. I haven't enjoyed the hours of lecture on scientific minutiae, the exams focused on the obscure corners of said scientific minutiae covered in lecture, the people who spent endless hours memorizing the aforementioned corners of scientific minutiae without having anything else in life to talk about, and generally the solitary nature of the pre-clinical years of medical school. When it comes down to it, I have been downright frustrated about not learning any actual MEDICINE in MEDICAL SCHOOL!!!

But I digress. The past few weeks in the ED have somewhat rekindled my willingness to slog through another 12 months of studying before being thrown to the wolves on the wards third year. I think it was actually being immersed in the thick of the ED chaos that did it for me...seeing sick patients, seeing what the doctors do and how the department runs, seeing medicine in one of it's few remaining purer forms medicine where someone is sick (kind of, most of the time) and we supply the healing (or call in a consult from someone who knows what to do).

Honestly, I have never felt as at home in a hospital as in an emergency department. There are no pissing matches between the EM physicians, there are no patients that have been hopelessly "circling the drain" for months on end in one of the beds sucking the resources from other patients, just people who feel that they need emergency care for anything from poison ivy to shortness of breath in a guy with spontaneous pneumothorax diagnosed 30+ years ago to the lady that collapsed with a sudden "worst headache of her life to the guy with a complex medical history of liver failure, diabetes, CHF, COPD, and a case of "the Clap" flaring up since he bought that hooker in Vegas. It is the ultimate renaissance profession, where you get to know a little about a lot of illnesses, do procedures and coordinate with every service in the hospital to get people the help they need...and I think I'm in love with it.


Furthermore, outside of the confines of the stuffy auditorium, it is nice to see my limited knowledge coming into practice...well the random tidbits that I was pimped on by every service the saw me looking over their shoulder anyway. It was nice to expand the pile of notes into the practical realm FINALLY!!! It almost makes that $60k tuition worth it...:)

Holding another man's junk

I put in my first male Foley Catheter today.

Hopefully it will be one of the few times in my life that I'll be instructed to "firmly grasp" another man's junk in my left hand, and whilst applying proper tension to the member hear the softly spoken words "retract the foreskin...around the frenulum...very good, you're doing great..." coming from another man standing next to me.

Ramming a large diameter rubber hose into the bladder of another man through the business end his firmly grasped one-eyed trouser snake was actually a lot less scaring than I would have thought. No referred pain, no serious psychological trauma...just another tool added to the medical toolkit.

SMA

Spinal Muscular Atrophy is a genetic deletion of the gene Survival Motor Neuron 1 that causes degradation of motor neurons that is present in 1 of 6000 live births. There are 4 forms of the disease 1 being the earliest onset and most severe, 4 being adult onset and the most mild. Symptoms generally present as muscle weakness, decreased muscle tone, respiratory problems, failure to thrive, etc. Also known as Floppy Baby Syndrome.

There was a baby in the ED yesterday with type 1 SMA and that description does not do the disease justice...it is just sad to see a helpless little human struggling to breathe, struggling to exist.

Child abusers suck

I've never understood how child abusers live with themselves. About once a month or so, you'll see some teenage parent who microwaves their child, or something like that on CNN or the evening news. I've seen at least 3 CPS workups being done in the last month. The most heart rending case that I've seen came in yesterday, where a 6 month old girl was submerged scalding water leaving her with burns over 40% of her body, including her head, arms and the front of her torso...

There's a special place in hell for someone that would do that to a child.

ED summer in review

I've been pretty lazy about blogging lately, mostly due to the pile of good books on my desk, some traveling, and needing to catch up on my summer research project. Not to mention that the the monotony of being a newly minted second year medical student "working" in the ED doesn't exactly make for exciting blogging. As my six weeks in the ED come to a close, I'd like to share a few of the many things that I have learned while either holding up the wall for 6-8 hours of a shift, running around doing scut for the understaffed, overworked nurses or just sitting around thinking about trying to fall asleep after a night shift.

1. I learned nothing in first year of medical school
Seriously. $60,000, hundreds of class hours, hundreds of study hours...and I'm still completely useless. You could drop dead in front of me, and I'd be standing there with my thumbs up my ass. I wouldn't know where to begin beyond what I already know from my long-expired EMT-B certification (ABC's, bleeding=bad, stablized c-spine=good, call paramedics).

Feeling useless is the most frustrating situation that I can be in. Being paid to stand in the corner and observe for the summer is about the equivalent of Chinese Water torture. I can't wait until third year when I can be made to perform useless tasks for nothing more than the benefit of my education...at least I'd be doing SOMETHING. One of my least favorite attendings said that my experiences this summer would be "valuable" in the future because I would be "used to being around very sick people." I contend that (since he dumped me off with the NP in fast track instead of teaching me anything) the past six weeks were pretty close to worthless because I barely know any patholgy/pathophys. I've learned about as much about medicine this summer as a 4 year old learns about zoology from a day at the zoo.

2. Your attending/resident can make or break your learning experience I've had the chance to work with pretty much every attending in the department, as well as a few of the residents and interns rotating through. I loosely define "working with them" as following them around for my shift. The individual responses of the physicians vary between mild annoyance to completely ignoring the fact that I am there. There were 7 of about 15 EM physicians that were willing to acknowledge my presence, and about 3 of those that actually took time to explain ANYTHING that they were doing (the physician who organized the program has yet to acknowledge me). I mean honestly, how long does it take to explain what the lab results indicate as you're typing up your note...30 seconds? 45 seconds? How about explaining what pertinent information you gleaned from the history as we're walking back to the nurses station? I understand you're busy, but treat me like the somewhat intelligent human that I am, not like part of the wall.

To be fair, there are a few of the attendings who are very good about explaining what they are doing, and the tidbits of knowledge they dropped have been extremely helpful in understanding what's happening with patients, why we're using certain treatments over others, etc.

3. Nurses are amazing resources
The nurses in the ED have been wonderfully patient with me. I mean sure, I'm a complete annoyance who barely knows how to stand out of the way, but they figured out that med students (surprise, surprise) learn pretty quickly and come in handy as an extra body for procedures that generally suck. But then there's those times when the floodgates have been opened and there's patients in every stretcher in every room (most afternoons) when I actually get to help out and move the meat along. Yeah, I may be doing scut, but atleast it's something.

4. Night Shifts aren't all that bad
Sure it's dark when you show up at the door of the ED and light when you leave. Sure you know that every normal human being is comfortably nestled in their bed at home asleep, while you're pounding that next cup of coffee. Sure the crazies, the drunks, and the drug seekers are the only people that roll into the waiting room at 2AM...and that lady with poison ivy who's getting really itchy again. But there's a certain cohesiveness of the night staff that I haven't experienced during the day. It seems to come out of the feeling that "this really sucks for all of us, there's no one else who's awake right now so we have no backup...just whoever is in the department and the residents up stairs." That feeling is pretty much all that gets you through the night, especially around 4-5am when you've been awake for about 30 hours and that little forced nap before your shift just didn't cut it. You know it's morning when those urgent Urology and Plastics consults that got called in at 3AM start showing up. There's really no words to describe the feeling that I have when those Ambulance bay slide doors open at 7:30 AM, the sun hits my retinas full force sending pain shooting all the way back into my visual cortex and seeing all of the hundreds of people streaming into work. It feels like "HA, we made it through another night without all of you...good luck with the mess we left behind."

5. Wear you freaking helmet
If I see one more helmetless moron falling off his motorcycle, flipping his ATV while holding his 5 year-old helmetless daughter or riding his bicycle without a helmet that rolls up in the ED with a GCS of 8, I think I'm going to flip. For the love all that is good and holy, wear your frigging helmet. It may not look cool at the time, but it certainly looks better than that depressed skull fracture you're sporting or that fancy respirator that's breathing for you since the blood and edema currently compressing your brain stem is making you unable to sustain your own life.

And while you're at it, it would be great if you could also not drive into that tree with your minivan full of children after 10 beers, drive your motorcycle like a maniac only to be clipped by that car your just cut off at 70 MPH, and please don't hit pedestrians any more...their bodies aren't really made to stand up to your 25 MPH attempt to nudge them along in the crosswalk. Don't even get me started on power tool safety.

ED Quote of the night: Why dating is a bad idea...

I got stuck running some scut for the nurses the other night (drawing blood, taking vitals) on a particularly busy night. One of the murses (who I thought was gay) pulls me to the side and asks if I can talk to patients yet...

Me: Yes
RN: Good, I want you to go talk to this lovely young lady and then report back to me on why dating is bad. She's really cute...if it wasn't for the shame I would bring my family I would [naughty things]
Me: Ok...

So I go ahead and do my history taking thing...

Fairly gorgeous 21 y.o., 9/10 backpain for 3 days. Ran out of opiate of choice and needs more but isn't medically insured since her employment was terminated due to inability to perform her job due to backpain. Also treated for anxiety d/o with three different meds.

I report back to the murse:
Me: Dating is a bad idea because most beautiful women are insane.
RN: (Pointing to the meds on triage sheet) Very good, you're learning quickly. You take care of me, and I take care of you... (wink)

NY Rant

Being from Boston, I am fairly accustomed to impatient people, an arcane public transportation system and the far-too-early closure of said transit system. I had a little adventure that took the cake in pain-in-the-ass transit in the Big Apple. Here's the time table:

11:31 PM- Flight lands at JFK
11:41- Pick up mandatorally checked baggage (so that I could bring shaving cream, deodorant and toothpaste on to my friends wedding in San Francisco)
11:45- Arrive at the "Air Train" station (dedicated train that loops around JFK and goes to 2 separate subway stations. Sign says that the train is going to both stations subway...which is not possible
11:53- First train arrives, without the sign changing
11:55- Leave the first train at the next stop, attendant announces that the train is indeed going to the wrong station
12:07- Next train arrives. Sign says it's going to my station, attendant says it's going to the other station. Impatient people flood off of train, train looses power at the station for two minutes and then leaves.
12:19- Next train arrives, sign and attendant agree that this is the train that I (and 200 angry New Yorkers) want to be on. Cram into car, listen to some guy's story (that contained more 4 lettered F-words than I've ever heard in a minute long rant).
12:31- Arrive at desired station, buy MTA card for exorbitant fee ($5 for a 2 mile ride)
12:32- Discover that the inbound side of the station is under construction so both trains are running on the outbound side of the station every 20 minutes or so.
12:40- First train arrives...no indication of which way it's going...I guess it's the wrong way.
12:53- Next train arrives going the other way...no indication of which way it's going... I guess it's the right way. Fortunately they don't make the announcement UNTIL THE DOORS ARE CLOSED.
1:38- Arrive at 53rd and Lexington...15 minutes to get onto the 6 train and down to Grand central
1:43- No train...10 minutes to go, no train
1:45- No train...7 minutes to get on the next train, get to my train at Grand central...not gonna happen. Attendant says the next train is about 10 minutes away...
1:46- Run up to the corner of Lexington, grab a cab and offer a huge tip if he can get me to Grand Central in 5 minutes...
1:50- Arrive at Grand Central, drop $10 for the cabbie's valiant land speed record attempt.
1:52- Run to platform 23, hop on the train, take a deep breath
2:43- Get off train, get picked up by my friend.
3:00- HOME...bed after 10+ hours of traveling.

It's times like 1:46 in the morning in the middle of the NYC subway system feeling completely stranded that I miss Boston. 2 years, 10 months, and 17 days until I leave the Empire State.

Quote of the Day: Absconding...

After a wonderful hour in the Adult ED, I was politely asked by the attending to hang out in fast track with the NP. Actually the conversation went something to the effect of:

Attending: "Who are you?"
Me: "My name is Bostonian, I'm a second year Med Student."
Attending: "What are you doing here?"
Me: "Observing you today."
Attending: "So following me around all day?"
Me: "Yep..."
Attending: "Yeah... That's not going to work for me. Go talk to the fast track Nurse..."

Usually, I feel pretty useless because the physicians basically ignore the fact that we summer students exist. Fortunately, the nurses are my saving grace and they actually allow me to do some of their scut, which is nice for the time being. I'd rather do stupid go-for errands than hold up the wall for 8 hours.

Anyway, second patient that I talk to has a pretty out-there triage sheet claiming that he's being abused by another person. The NP picks up that the guy is pretty out there, so he pulls me aside and has me make sure to ask the guy if his abuser is here now because he's a presumed psychotic patient.

Me: "So, why'd you come in today sir?"
Patient: putting his fingers really close to my face "There's writing in there, in the nail beds, do you see it?"
Me: "It must be pretty small because I can't. I heard someone hurt your elbow, how did that happen?"
Patient: "This guy comes in and puts me out with narcotic sedation and does things to me. See the smiley face he put on my elbow?"

You probably get how the rest of that interview went...delusions and he appeared to be lost in his own world (hallucinating? not that he would admit to it)

Long story short, at the mention of seeing a psychiatrist the grossly psychotic patient took off to the parking lot with a nurse and security in hot pursuit. When he reached his car, he took off at a high rate of speed across the front lawn of the hospital, swerving at the nurse and security guard

...never a dull moment

Depressing week in the ED

There were a disproportionately high number of horrible cases that I've seen in the past week...to the point where even the attendings were getting a bit down.

• It started with the 18 yo girl who fell while riding her bike without a helmet and had multiple depressed skull fractures. When I left that night she was in rough shape, but I never actually found out what happened to her.
  
• Two days ago a 47 year old woman came in who had collapsed at home after the worst headache of her life. She died while she was in the OR having her dual ruptured aneurysms clipped. She left behind her 4 year old daughter and a teenage son
  
• Then there was a 41 year old woman that had an MI that died (I wasn't there for that one).
  
• And last night, there was a healthy 36 year old man that collapsed while playing hockey. He was stabilized and sent up to the cath lab, which showed a 100% occlusion of his LEV. 2 stents were placed and the guy appeared stable after a few hours in the CCU. Then about 3AM we heard the code called overhead, and found out shortly afterward that he didn't make it. He left behind a 4 month pregnant wife, and both of his parents.
  

Now, I'm not one of those med students that was planning on spending half of his career in aclinic in Sudan ridding the continent of AIDS, but I'm finding that I still have a sliver of the starry-eyed optimist that I once was. It's mostly because I'm not all that far removed from my own pre-med misconception of medicine as a land of sunshine and puppy dogs. I go into the ED most shifts expecting the majority of the patients that come through the doors to leave happily or healthily, or at least to be somewhat cordial to us since we are refilling their narcotic stash and pumping them full of opiates. However, I've gotten a cold dose of reality over the past few shifts: not everyone gets better, people die, people lie and some really crazy shit happens in the ED (including a guy apparently threatening to go home and return with his pistol because he was "mistreated" before he walked out the door).

The sad part of it all is, that medical admission committees expect us to be deluded in our interviews and applications. They want us to paint our own grandiose pictures of serving the under served and curing sick patients who are always compliant. Meanwhile, the majority of us have no idea what we were getting into, and walk into the hospital to have our sunny dispositions squelched by hostile or non-compliant or really sick patients that not very much can be done for.

ED quote of the night

17 yo male walks into Boondocks Regional Hospital ED after flipping his ATV at high speed and hitting several fixed objects including a mailbox and a few trees. Transferred to our ED in good spirits, but in a little bit of pain. Head/C-spine and Spinal CT's reveal multiple vertebral body fractures along the entire spine and a crush fracture to L5...

Trauma Attenting: "I'm going to have to do a rectal exam, you're going to feel some pressure around your rectum."
ED Attending: "He's going to put his finger in your butt to check for bleeding."
...finger inserted...
Patient: "AHHH, doctor you've touched me like no one else ever has."
Trauma: "I certainly hope so."
Patient: "I have to take a dump."

A crying shame...

18 yo female in bicycle vs asphault and trees. Not wearing helmet, resulting multiple depressed skull fractures. GCS of 8 at the community hospital ED, given a quick CT workup and intubated, flown into our ED for further care.

She had probably just graduated high school, may have even been headed off to college. She had the best years of her life ahead of her. And now, because she didn't want to wear a helmet, she'll be lucky if she ever has the capacity to breathe on her own, let alone live a normal life...

ED quote of the day:

80 something year old woman, mistakenly sent from nursing home to Trauma Center ED for psych evaluation when she should have been sent to Psych ED. Completely lucid, displaying no signs of dementia...

Patient: Overly detailed story about how some other guy was getting in her personal space... "I don't like it when other people push me around, so I told him "You pick up that towel or I'll punch you in the face". So he stomped on the towel to spite me, and so I punched him in the face.