I think it’s called Deluded?

They say you always remember your first drug seeker.  I think they’re right. 

I was working a shift in the middle of the afternoon when the triage nurse rolled this young guy through the ER.  He was shaking, crying, and moaning in pain and even from where I was sitting it was obvious there was some blood pouring out of his leg.  Now the ER I was in that day wasn’t a Level One Trauma Center, but we have the occasional gun shot wound that’s dropped off at our door step by someone’s concerned friends.  I figured he either caught a bullet through his leg or had an open traumatic fracture.  Usually neither would be the case for an intern to grab, but all the seniors were busy so I decided to overstep my bounds a little.  Plus, the guy was still audibly moaning and I figured he could use some immediate pain control.

I walk into the room with one of our medical students and the guy immediately begins asking for pain medicine.  Now that’s not so unusual and as I gave him a quick once over I figured we’d start with some morphine.  I took a look at his injured leg.  There was a large knot a few centimeters beneath the knee that was heavily abraised but most of the bleeding had stopped.  He was complaining of a lot of back pain so I asked what exactly happened.  (Be sure to add in the gasping and tiny yelps of pain for the full effect).

“I was in the shower and I spilled some shampoo.  I slipped and literally flew up in the air and landed right on my back.  My leg scraped the faucet and that’s how it got cut.  I’ve had a bad back for the last couple of years and now I have sciatica.  I’m actually supposed to get some sort of surgery next month to fix everything.  I’m in a lot of pain, Doc, please give me something.  I was in the hospital a few months ago and I think they gave me something that began with a ‘D’?  Maybe it was duh… duh… deluded?  Is that right?  I just remember they gave me 4mg of it before it got better.”

And that’s when the red flags went up.  I had actually just finished a mandatory online course about respecting patient’s need for pain control and how physicians have preconceived notions about drug seekers, specifically that we judge people who ask for a particular drug and a particular dose.   I didn’t want to unfairly judge this guy.  He was shaking and crying so much that my student said it made her nauseous just being in the same room as him because he seemed like he was in so much pain.  But something about the story itself sounded fishy not to mention him pretending he didn’t know the proper pronunciation of Dilaudid (duh-laud-ed).  I went over and grabbed an attending and asked him to come take a look to make sure I wasn’t missing something.  He told the same story and we walked out telling him that we’d get him some pain medication immediately.

The attending asked me what I thought and I said “Well… the pain seems pretty legit, but the story doesn’t seem right and I don’t like that he’s asking for 4 of Dilaudid off the top.”  He agreed and said there’s no way he would have gotten the abrasion on the leg from a faucet while falling and that it looked more like a motorcycle road rash.  Plus, he had some scratches and redness over the back that didn’t fit with falling in the shower.  We agreed to give 4mg of morphine and see how it went.  

In the meantime, I went to see if I could find any other ER records.  Lo and behold our friend had visited the ER twice in the last 5 months.  Both times he had similar stories to today and similar physical finding and both times he left after eventually getting 4mg of Dilaudid.  The first time he left AMA (against medical advice) because he had “a cooking class he had to get to and had sunk too much money and time into it to miss it”.  Now I don’t care how expensive the damn class was.  If you’re in so much pain that it only goes away with 4mg of Dilaudid you don’t just up and leave the ER if you’re really injured.  Plus, this residents who saw the patient in his previous two visits described the same abrasions over the lower back and over a knot below his right knee.  That’s just strange.  

By that time about a half hour had gone past and I went to see how the morphine worked.  The patient was still writing and crying in pain.  He again asked for the ‘deluded’.  I told him I’d talk to the attending and let him know what we were going to do. I went to talk to the nurse who told me that the patient almost wouldn’t let her push the morphine.  He asked what the medicine was and how many milligrams she was giving.  I was more or less convinced at this point, but I felt bad for the guy since he had went to so much trouble to get his narcotics.  I talked to the attending and said I wanted to give 2mg of dilaudid and see if that helped at all.  I also figured I’d order X-rays of the lower back and the right leg to make sure he had injured himself too vigorously.  

About a half hour later I hear a big ruckus being made over by X-ray.  The patient was refusing any X-rays because he was still in so much pain.  He accused me of not taking his sciatica seriously.  I assured him we were which is why we had given him 4mg of morphine and 2mg of dilaudid which is more pain medicine than I had given any other patient that month.  I asked if I could call his doctor who was managing his sciatica and planning on doing the surgery and get some better direction on how to best handle his pain.  He told me he had a chiropractor but no doctor.  

And that’s when I was done.  

Chiropractors do not do surgery.  I decided he had gotten enough pain medication from us until I was able to get to the bottom of his injuries.  I told him we needed to get x-rays to determine the extent of his injuries.  He told me he was going to ’sign out’ if he didn’t get more Dilaudid.  I said I wouldn’t be able to give him more pain medication because I was worried that that much narcotic would depress his respiratory status and stop his breathing (a very real and very serious side effect of narcotic overdose).  He said he wanted to leave.  I asked where he was going to go and what he’d do for his injuries.  He said he’d just go to another ER where his condition would be more respected.  I again assured him we respected his pain and his condition and that I wanted to get an x-ray because someone in so much pain might have fractured something during a ‘fall’.  He said he wanted to ’sign out’ and I asked him what he meant.  ”I want to sign out AMA”.  Well, not everyone can let that roll off the tongue; you have to be a pretty savvy ER customer to know about AMA.  I agreed to get the forms together and told him the nurse would be by to clean up his wounds.  Magically, the crying, moaning and shaking all stopped and we didn’t hear another peep out of him for the rest of his short stay.

After everything was signed and cleaned up he asked for some apple juice.  He drank it, grabbed his cane, and then hobbled out of the ER with no drama or obvious pain in his movement.  My attending congratulated me for handling my first drug seeker and not succumbing to his demands.  We were both hopeful that he wouldn’t be coming back to our ER anytime soon since he never got his full 4mg of Dilaudid.  

I expressed my concern for the patient’s narcotic addiction to the attending, “Is it ever worth while attempting to acknowledge their obvious lie and ask if they’re interested in a treatment program?”  He said that the patient was most likely beyond anyone’s help if he was going to the great lengths of self inflicted injury to make his story more believable.  Plus if he really wanted help, he wouldn’t be bouncing in and out of ER’s looking for Dilaudid, he’d be looking for a treatment program.  I realized while a bit jaded, my attending was probably right.  But it didn’t leave me feeling any better about the whole thing.  Even though I ended up being right, I felt bad I had judged this guy as a drug seeker from the beginning.  On the other hand, I was pretty satisfied with my good instincts and I felt a small moral victory was achieved by not allowing the patient to get all the Dilaudid he was looking for.  

It still sucks though.

Radio silence

Sorry for the relative quiet.  It’s been a bit busy and hectic around here lately.  Things are calming down a bit the end of this week and I’ve got a few stories piled up.  Look for a few updates over the next couple of days to make up for lost time.

You’re Always So Calm

I promised weekly updates and so here I am.   I’ve got another story or two in the pipe and maybe a random thoughts blog in the future.   Don’t hold your breath on those since I’m about to work a string of nights starting in a few hours.

I’d say about once a week a nurse comes up to me, either as soon as I walk in or at some point during my shift, shoves a clipboard in my hand and says “Please go see this patient next.  I’m really worried.”  Usually it’s because they have extremely high blood pressure (220/120) or they’re bleeding from somewhere you shouldn’t be.   Honestly, it’s rarely ever serious or immediately life threatening.  As much fun as we poke at the triage notes, the nurses in triage do a good job of alerting the ER docs to the severely ill patients.   Most of the time I’ll take the chart and get to it in the next 10 or 15 minutes which is all they really want.

The other day though I walked in for my night shift at 6pm and one of the nurses handed me a chart saying “She’s having trouble breathing and her pressure is through the roof.  She’s a young girl with no past history.  Could you go see her right now?”  If the nurse is giving me the chart, I’m rarely worried.  The really sick patients end up in the resuscitation/trauma room and this girl wasn’t in one of those rooms.   She was in a normal room.  I grabbed her paper chart from the nurse, took a look at the triage note and went to talk to the patient.

She was a professional in her early 30s.   No past history to speak of.   She noticed about a month ago that she was having trouble walking up a flight or two of stairs without losing her breath.  Now this was no overweight, out of shape woman.  She was about 5′4 and 105 pounds sopping wet.  She went on to tell me that over the past week she’d had a lot of trouble sleeping because whenever she layed down she couldn’t breathe.   “I only slept about an hour last night and that’s when I figured I should come in.”  Now I was a little worried.   First because she had a believable story (not always the case in the ER).   Secondly, I laid the head of the bed down and sure enough she wasn’t breathing well.  Young, healthy people who suddenly have deteriorating health worry me because it usually means something unavoidably bad has happened.

We keep talking.  She doesn’t see a doctor yearly, not even a gynecologist.  She had never seen her blood pressure this high and it was making her a bit anxious.  We chatted a bit more.  She didn’t smoke or do any drugs.  She drank on rare occasion.  The only thing currently bothering her was her shortness of breath.  No headache, no nausea/vomiting, no visual problems, no neurological symptoms.  A bit odd.   Her physical exam was essentially normal except for her fast heart rate.  I was expecting that maybe she had new onset asthma, but she had none of the tell tale wheezing sound when I listened to her lungs.  I told her I wasn’t sure what was going on but we were going to run a bunch of tests and get some X-rays and we’d certainly get to the bottom of it.  I also said “Don’t worry about anything.  You really don’t have any of the concerning signs that this high blood pressure has been around for a while and is doing damage to any of your organs.  Right now it’s just high and your heart is beating fast and we need to figure out why so we can fix it.”

It turned out the nurse was worried about a PE, which wasn’t a bad though.  Pulmonary embolism, or PE, is a blood clot that lodges in one of the large pulmonary arteries that carries de-oxygenated blood from the right side of the heart to the lungs so that it can be re-oxygenated and returned to the body.  PEs are one of those things like a heart attack that can kill you cold in your tracks.  The clots often come from the deep veins of the legs.  The clot breaks off and travels through the venous system to the heart.  It doesn’t get stopped anywhere because veins get larger the closer you get to the heart.  Once in the heart the clot gets pumped around until it gets stuck in the pulmonary arterial tree.   It can kill you could because if the clot is large enough it can entirely block blood flow to the lungs.  Which means no oxygenated blood to the body, which means no oxygen for the heart or the brain… you can take it from there.  Fortunately for her, PE doesn’t present with a month or even a week of worsening shortness of breath.  It presents with a couple of hours of shortness of breath at most.  But something still didn’t feel quite right.

We sent off the typical labs and as I was documenting my history and physical in her chart we got a call from our lab: hemoglobin of less than 5.  Which is good news and bad news.  The good news is that it entirely explains her symptoms.  A low hemoglobin means your blood can’t carry enough oxygen so the heart starts beating faster to keep up with the demand.  It has to pump the blood around faster to make up for the lack of red blood cells or again your heart and brain are out of luck.  It doesn’t entirely explain the high blood pressure which is part of the bad news.  The other part is that a hemoglobin of 5 is bad.  It means something is destroying her red blood cells.  She’s either bleeding from somewhere internally or her body’s immune system has gone haywire and started munching on the red blood cells as a snack.   It also means she gets to have a blood transfusion.   Time to have a talk…

I let her know that her hemoglobin is very low:  “It’s okay though, it explains your high heart rate, and we can give you a blood transfusion to help the hemoglobin level go back up.  We still need to figure out why your blood pressure is high though.  And we need to figure out where all your blood is disappearing to.”

She was worried that something truly terrible was about to happen.  She was still very anxious.

“I understand you’re worried.  I’d be worried too if we switched places.  But right now?  I’m not worried about you.  You’re awake and alert and talking.  We figured out half the problem, once the rest of the labs come back we’ll figure out everything else.  Trust me: I’ll tell you when to worry.  When you see me frantic and upset: that’s when you worry.  But you’ll never see me like that.  I only get that way when my patients pass out.  And if you’re passed out, you won’t see me all frazzled and frantic.  It’s a win/win for you.”

She laughed and thanked me for explaining everything.  I told her I’d come back once we knew more.

As the labs came back it was clear she wasn’t bleeding from her GI track or her kidneys/urinary tract.  That made it pretty unlikely she was bleeding internally from anything else as she had no history of trauma and had no pain on abdominal exam.  I went to look at the chest x-ray.   More bad news.   Her heart was huge and you could see more of the pulmonary (lung) blood vessels that you normally should.  Her heart was in failure.  It had been beating so fast for so long that it couldn’t keep up.  The heart re-modeled itself and recruited new muscle tissue.  We call that high output heart failure.  But it’s okay, only one failing organ.  We can handle that and once we correct the hemoglobin everything will start going back to normal.

The chemistry panel came back not too much later: kidney failure.  She told me, almost in passing, about this kidney biopsy she had when she was around 6 or 7.  They diagnosed Berger’s disease which didn’t make sense to me or my attending.  Berger’s disease is today defined as a kidney disease of older men who have a long history of smoking.   So we wrote it off and figured since she hadn’t had any follow-up in the last 25 years it must not have been very serious.   But now her kidney’s were failing.   Which surely was the cause of the high blood pressure.  Most people don’t realize this, but the kidneys control the blood pressure in the body.  They dictate the amount of sodium, chloride, potassium and several other elements that either get excreted into the urine or are kept around in the body.  If more of something is kept in the body, more water is kept around to balance everything out.  More water means more fluid which means more pressure within the blood vessels.

But she now had two failing organs.   And a very low hemoglobin.   Back to the bedside I went.  I explained that I was going to call the ICU residents because she had two failing organs: her heart and her kidneys.  I explained the results of her tests that led us to those diagnoses.

“The upside is that you’re still breathing fine and your heart rate is starting to come down.  You’ll be the healthiest person in the ICU and you’ll get the best care the hospital has to offer.”

She looked at me like I was somewhat crazed and said “You’re always so calm!  You’re not even the least bit worried about me with a bad heart and bad kidneys?”

“Not really.  The heart will be fixed once we get your hemoglobin back up to normal.  The kidneys are a problem but we have to figure out what caused the kidney to fail.  It might be something that’s reversible with medication, it might be something that requires dialysis.  You may even need a transplant.  But it’s nothing that’s going to kill you today or tomorrow, which makes you healthier than just about every patient in our ICU.  You’re conscious, you have a good blood pressure (high is always better than low) and a good heart rate and your oxygen saturation is normal on room air.  Based on your vitals you look better than some of our 7 year old asthmatics in the pediatric ER right now.”

I told her the ICU senior resident would be in to talk to her and I’d let her know what our decision was after that.  The ICU resident saw her quickly and decided she wasn’t appropriate for intensive care: even with two failing organs and requiring 3 or 4 units of blood and dialysis in the next couple of days she wasn’t sick enough for the ICU.  I went back to tell her the good news.

“The ICU decided you weren’t sick enough to hang out with the really sick patients.  We’ll have you go to the general medicine floor with one of our excellent medicine teams and the kidney doctors will be consulted to figure out what’s going on with your kidneys.”

She thanked me profusely for taking the time to explain everything that was going on and for not treating her like an idiot.  Which is our first lesson for the day: never treat people like they’re idiots.  Unless you’ve been directly proven otherwise, start in the middle and shift your explanations up or down based on what the patient seems to understand.   Use diagrams: most people are visual learners.   You’re doing yourself and them a huge service.  First, a well educated patient is more likely to take their health and disease seriously, which is good for them.  Secondly, it’s good for you, because well educated patients take better care of themselves and are more compliant with treatment and medication which is good for you.   My job is easier when people do what I ask them to do.   And I think these lessons apply well beyond medicine.  Anyone who has a job dealing with customers can take this approach to improve their customer’s understanding of the product or service that you offer.

The second lesson I learned is that even when you don’t exactly know what’s going on, a calm caring bedside manner trumps all.  I honestly was never worried about her.  I’m not well seasoned, but I’ve seen enough to know very sick when I see it and she wasn’t it.  I let my body language convey that.  I was always relaxed around her and her family and I was never in a rush to do anything.  I meant what I said: if I was worried she wouldn’t know it anyway, because she’d be unconscious by that point.   I guess I was surprised because I don’t always feel so calm and confident internally, especially mentally.   I know this is only my first month on the job.  I know that there’s more that I don’t know than I do know.  Sometimes I get easliy frustrated when I realize that my senior colleagues and attendings expect me to have a skill set in my first month that they likely didn’t.   But I try my best to never show my patients that.  They’re already in pain or another discomfort… why give them any additional reasons to be concerned.

I went up to the floors to visit her the other day.  She was sitting comfortably in her bed.   The nephrology service (kidney specialists) had diagnosed her with “likely IgA nephropathy”.  Apparently 20 years ago IgA nephropathy was known as Berger’s disease along with the kidney disease that old men who smoke get.  Some where along the way, someone realized it was really two different diseases and they split IgA nephropathy off from Berger’s disease.  I wish I could explain IgA nephropathy well to the blogosphere, but I can’t.  But here goes anyway:  essentially your immune stystem deposits proteins into your kidney that make the kidney unhappy, so it stops working.  Unfortunately for her, there’s no medication she can take to reverse the effects.  She’s starting dialysis today and they’re looking for a live kidney donor.  When I saw her a couple of days ago she already knew all of this.  She thanked me several times for my care in the ER and told me she was so happy to have me visit her on the floor.

“You’re the best doctor in this whole hospital.  You explained things to me better than some of these specialists.  You took more time than they did and you always did a wonderful job of keeping me calm and in perspective.  Are you sure you can’t take care of me up here?”

I thanked her and told her that the specialists are probably much busier than a lowly little intern in the ER and they were the true experts that would really end up helping her in the long run, especially now that she needed dialysis and a kidney transplant.   I reassured her that come Monday the hospital would be filled with medical students, residents, fellows, and attendings who hadn’t been around on the weekend and would be dying to talk to her.   She made me give her a hug before I left and I promised to check in on her if she was around the hospital later in the week.

As I was walking back down the hall to the elevators her boyfriend came out of the room and caught up with me.  “I just wanted to let you know, that we’re all really grateful for what you did.  We were actually talking about you right before you came into the room.  She really does think you’re the best doctor she’s ever had.  And I just wanted to say thank you for saving her life.  I know you kept saying she was never in any real danger, but I think that’s because you made sure she wasn’t.  I’d tell you you’re going to be an excellent doctor someday, but you already are.”

Sometimes it’s not the obvious lives you save that are the most grateful or stick with you.  And I guess that’s as good a reason as any for why I’ll never stop loving this job.

Sometimes it’s not how you say it

But what you say…  

(Thanks to dillinja for the post idea)

We had a subarachnoid hemorrhage the other day.

It was actually a woman in her early 30s, no prior medical problems, and she was the wife of a cop so everyone was on high alert because he and his partner were right outside the room. I was in another patient’s room when they came in with her so I wasn’t there from the jump. When I walked out there was all this action in the resuscitation room so I wandered over to see what was going on. It became quickly obvious that it was a code situation and right as I got near the bed she started vomiting. Never good.

So I try to make my way from the foot of the bed to the head so I could help suction the airway so that one of the senior residents could intubate her and protect her airway. But there must have been 20 people in the room and about half that around the bed. There was an attending, two residents, a med student, at least 3 or 4 nurses, an equal number of techs, the EMTs who brought her in, respiratory therapy, and a handful of Pharm Ds. And it’s not that big of a room. So I was being shoved out of the way by some of the nurses. I made eye contact with our attending who motioned me to make my way to the head of the bed. It just wasn’t possible. Moses had an easier time parting the red sea. 

I walked back outside the room and one of the nurses in the main area asked me why I had left. I said “I really should have never gone in. There are too many people in there already. There’s nothing for me to do.” Then something awfully strange happened. Another nurse came over and bear hugged me and told me to “shut your damn mouth”. I was somewhat confused but I went back to taking care of my other patients. The nurse who bear hugged me came over a few minutes later and said 

“What you said earlier was pretty inappropriate.” 

Uhhhhhh what? 

“Never open your mouth when you walk out of the resuscitation room, you never know who’s standing around. The patient’s husband, a cop, was right next to you when you said that.” 

Ohhhhhkayyyyy, but I didn’t say anything wrong. 

“You said there was nothing you could do and you shouldn’t have gone in there.” 

No, I said there was too many people in there and I couldn’t get near the bed.

“Well that’s not what I heard. Just try to be more careful and thoughtful in the future.”

Now that’s never bad advice. And again, I don’t think that’s what I said or how it came off. It’s certainly not what I meant. But at this point the seed was planted and I started to beat myself up. I almost broke down while I was writing a note on another patient. I felt terrible. I thought I knew what I said, but I can’t be sure. And I’d hate to think that I caused the poor man anymore grief than he was currently going through. 

She got a head CT not too long after and they found a subarachnoid bleed. For the uninitiated that means she had burst an artery that sits directly on top of the brain. They’re very bad and much worse than epidural or subdural bleeds which are arterial or venous bleeds that are a couple connective tissue layers in the dura mater that surrounds the brain. 

She died early the next morning up in the ICU. I’m not sure they know what caused the subarachnoid bleed. For the husband and her family that information rarely helps anyway. I think the most comfort it gives is that they did everything they could and there was no way it could have been prevented. I just hope that my possibly careless words did cause them any more pain than they were already going through. Yet another lesson that you have to be 100% on when you’re taking care of other people’s lives.

My first overnight shift in the ER

It managed to produce several other firsts of it’s own.

We were pretty slammed and didn’t have a whole lot of room in the ER. A lot of people who needed complicated work ups or were waiting for a bed upstairs. I was really just hanging out at the beginning of my shift waiting for things to happen. And that’s usually one of two times when badness happens in the ER. When you’re sitting around not doing a damn thing or when you’re so damn busy that you can’t imagine being able to handle anything else. 

So of course that’s when we get a call from an EMS crew that they have a guy found slumped in his car on the side of the road. Cardiac arrest. So we get the resuscitation room ready and everyone decides I should put in the central line. Now when you get a call from an ambulance you can never be sure that it’ll be exactly what was reported over the EMS radio. Sometimes you’re told the patient is in arrest, but they get to the ER and they’re alert with a semisteady pulse. Other times you get exactly what you expect. This was one of the latter times.

Patient comes in with full arrest. I go to place the central line in the patient’s L thigh after cutting off his clothes. The central line will allow us to dump a lot of fluid in very quickly (in case he’s bleeding internally) and deliver heart stimulating drugs directly to his heart even faster than we could with an IV line in his arm. Unfortunately he has no pulse, so it’s a bit of a crap shoot. You find the anatomical landmarks and aim for the big vein deep in the thigh. I wasn’t doing it briskfully enough so one of the attendings grabbed my syringe and showed me what needed to be done. After you find the vein with the needle, you thread a wire through the syringe and into the vein. Then you make a small nick in the skin with a scalpel, twist in a dilator over the wire to open up the pathway from the skin to the vein, pull that out, and then put in the catheter over the wire, remove the wire, and then suture the catheter into place. 

It sounds a bit easier typing it out than it is in real life. Especially when real life involves people performing full on CPR right next to you. The patient is shaking with each chest compression. You’re a bit shaky because you haven’t done this before. And the person in front of you is dying. You start to think if you’re really cut out for all this. All these people around you have been doing this rather expertly for at least 2 years more than you. They can do it in half the time, maybe less. But they walk you through it, alternating encouraging words with barking orders. 

Once I had the central line in, I went to the side of the bed to assist with chest compressions. It’s one of my favorite things to do: it’s been shown time and again to save lives, I know what I’m doing, and I’m pretty good at it. At least that’s what I’ve been told. We continued our life-saving efforts for about 20 minutes in total before my attending called the time of death. He was down at least 30 minutes before he got to our ER with EMS. There truly wasn’t much more we could do. He never had any electrical activity in his heart and his pupils were fixed and dilated, a sign of brain death. 

We waited for the family to gather and then told them what had happened. That’s always the hardest part of any unexpected death. As you begin to talk to the family, they almost always know where you’re going. You can see it in their eyes and you feel terrible. We’re taught to be direct and stick to the story: what we know about how the patient came to our ER, what we did, and what the outcome was. The last part is always the same. And we’re taught to always end with “And despite our best efforts, they died”. You never say “they passed” or “there was nothing else we could do” or any other euphimism. It’s best to be direct. 

Last night there were about 14 various family members. I’d been involved in talking to family members before after a patient’s death. This wasn’t the worst time or the best time. Actually, I don’t think there’s a best time. And maybe every time is the worst time. It doesn’t seem like it ever gets easier.

A few hours later, we had to intubate an intoxicated gentleman. I’ve intubated a handful of people in the OR with anesthesia before surgery, but never someone having difficulty breathing. There’s a lot that goes into it… I don’t know that the details are very exciting. I made a couple solid attempts but I couldn’t get the tube to pass properly into the trachea, so after a couple tries, my senior resident took over and was able to get it in properly. Both he and the attending admitted it was a bit more difficult than they first suspected. We went over my technique and what I could do differently next time. They complimented my effort and the fact that I never seemed rushed or frustrated. But in the end I failed. Which sucks. I’m glad someone got the tube in to help the guy breathe, because he wasn’t doing so hot, but I wish I had been able to do it.

Everything that went down last night I had done before in one capacity or another. I’ve put in central lines in the thigh in the middle of traumas but it’s been at least 10 months. And when you haven’t done it much before it’s easy for your skills to get rusty. I’ve talked to family’s before after a patient’s death, but as I said earlier, I don’t think it ever gets easier. 

I guess at the end, there’s going to more firsts and more ‘failures’ during first attempts… although I hope not too many. But there’s also going to be a lot of second, thirds, fourths, etc. It’s a learning process with a damn steep learning curve. Hopefully, I’m climbing well.

Tales from Week One of Doctoring

The first two days were a nice ease-in to what I’ve got in store for the next year, 5 years, and really the rest of my working life. We had double resident coverage so I really never had more than 3 or 4 patients. But when the holiday weekend rolled around? Yeah, I got bodied. At one point I was seeing 8 or 9 patients at once. And a good half of them were pretty damn sick. 

I think the thing I was least prepared for was that now that I’m a resident, some attendings feel little need to get overly involved except with the sickest patients. They have total faith that I either a) know what I’m doing or b) will figure it out on my own. I’m so damn slow because I sweat over whether my Vicodn scripts should be for 5, 7.5, or 10mg of the narcotic portion. Should I only write for 12 or is 24 okay if they have a legitimate pain diagnosis? 

I’ve also learned that I’m the type of doctor who is willing to send people home if they’ve been in our ER for 8 or 9 hours and their pain is gone or their original problem has been more or less fixed even if it was somewhat serious on arrival to our ER. We have some doctors who just want to admit everyone to cover their ass. I think it’s a waste of the patient’s money and possibly taxpayer’s money. I also don’t think every headache needs a spinal tap or that everyone with new numbness deserves a neurology consult. If the head CT was normal and all their bloodwork was normal and the patient now wants to go home? Their numbness wasn’t that severe to begin with, especially when you’re now begging me to go home. 

The winner of the week though was this drunk guy who was threatening to kill everyone in the ER if he didn’t get his methadone (he’s been on for 14 years). He started to try and flip over his bed and then threw a chair at one of our transportation guys. So he bought himself 4 point restraints and some haldol. I went in to talk to him 10 minutes later and he was very sweet and apologetic and asked if we could at least reposition him so his back didn’t ache as much. I told him we couldn’t because it took 4 cops, 2 techs, and 2 nurses to put the restraints on and everyone was worried what would happen if we loosened the restraints. He ended up getting admitted for his blood alcohol level of .37 and his questionable history of shakes/seizures.

It was an exciting week that reassured me that I have much learning to do. I already knew that but it’s different having daily and hourly reminders.

In some ways it wasn’t very different than being a med student.  I don’t know all that much more. It’s not like they handed me an MD and then the dean layed hands on my head and I was suddenly bestowed with all medical knowledge. Although talking with some of the med students rotating through our ER, I do know a little bit more than they do.

 
It’s just that now that I have a long coat and a temporary physician’s license and can sign my own prescriptions and orders without needing a co-signature from a resident or attending, there’s this added sense that I SHOULD know more. You discuss your patient with an attending and they’re like “so what do you want to do?” Sometimes you hit it on the mark, but most times I forget something that should be more obvious to me, or I add something that shouldn’t have mentioned. Or I’ll take a look at the order list and notice that the attending added some medications or tests, which is a bit more embarassing than had they just told me to my face that I had forgotten something and I should order this or that.

I told a friend over the weekend that every day I re-learn that I know very little about this job. I think that should be the mantra of every intern. As long as you know what you don’t know and you’re willing to ask questions and look dumb in front of someone, at some point you’ll be able to do things on your own.

Welcome to the Jungle

We got fun and games.  ….   Well we don’t really have fun or games here.  It’s not that type of blog.  As the header up there says, I’ll be mostly posting stories from my residency.  But my hope is that the stories will be insightful, informative and occasionally amusing.  

I tried the blog thing once a long while ago.  But that was before I was an intern with all of these exciting stories.  I’m hoping to update this at least once a week, more often if I’ve got good stories or personal insights/reflections to share.

Quick shouts to the OKP family in general for convincing me that these stories were worth telling and that I should be the one to tell them.  Special thanks to Payne for the blog name and to Rob for the inspiration of said name.  Enjoy.