So I worked today and realized all along that it was July 1st, but totally forgot about the significance of July 1st until just now. This is the day 2nd year med students start clinical rotations, senior med students become interns, interns become residents, residents become fellows or attendings. I’ve had plenty of angst brought on by this day in the not-to-distant past, I love that it’s just another day now. I’ve had enough of new challenges going through the medical education wringer, for now I’m content to be content.
June 22, 2009
The hospital’s electronic medical record recently underwent some major upgrades, new code written and uploaded, allowing administration to inch ever closer to their singular goal of making my head explode once and for all as the computers are clunkier, buggier, and more sluggish than ever.
Anyhoo, the cosmetic changes to the interface include a colored backdrop for patient names, the previous generic white now shaded blue for boys and pink for girls. Although I’d never picked up on this before , the new cotton candy colored screens make it strikingly obvious that the female patients substantially outnumber the males, I’d guess by about 2 to 1.
Why is this I wonder, other than my devastatingly good looks? Women outlive men by a substantial margin, shouldn’t they be healthier than men and therefore have fewer ER visits?
Then again, women’s reproductive parts are fraught with complications. Women get pregnant far more often, it’s rare not to see at least a patient or two per shift with some sort of pregnancy issue whether it be cramping, bleeding, nausea, or acute ultrasound deficiency. The number of women showing up with discharge or painful urination dwarfs their male counterparts. Ovaries are much more prone to painful problems than testicles. Tampons and IUD strings get lost. All in all I’ve learned it’s much riskier being a female. And that I should have been an accountant.
But men have gender specific diseases too, like trauma, they being far more likely to mangle themselves in various creative ways as compared to women. The root of the ER gender disparity then, I submit, is found not in the pelvis, but instead laying north within the gray and white matter between the ears.
Women are far more prone to somatization, the process of anxiety or stress manifesting itself as a physical symptom. Women seem to be wired in such a way that their negative emotions lead directly to chest pains, or abdominal pain, or shortness of breath, or headaches, or diarrhea, or weakness, or dizziness far more often than in men. The discomfort is real, but the root cause is not physiologic but instead psychosomatic.
And then, women are not only more likely to develop symptoms, but they are more likely to do something about them. Men prefer to put their heads in the sand, dealing with disease in the same way they handle the homeless guy asking for spare change at a stoplight: by looking the other way and hoping it moves on. Women are far more proactive, their threshold for seeking medical evaluation significantly lower. It’s never the husband who drags his unwilling macho wife to the ER to be checked out for this or that.
This is all about populations of course and cannot be applied to individuals — there are plenty of guys who show up with anxiety-induced chest pain scared they’re having a heart attack. But taken as a whole, and applied over thousands of patient interactions, these differences between the sexes have over time have become more and more apparent to me. And it’s a factor in what the bulk of emergency medicine is in this country: it’s not about taking care of actual emergencies, it’s about offering reassurance that there isn’t one.
June 20, 2009
Q: What is the proper amount of time to observe a drunk?
A: It depends on when your shift ends.
June 6, 2009
Nice Old Patient: “Dr. 10/10, is there any way you can please keep me overnight?”
Me: “Well, I think we have enough here that that’s reasonable.”
Nice Old Patient: “Oh what a relief! Will you be taking care of me?”
Me: “Oh no, they don’t let me out of the basement. I’ll discuss your symptoms with one of our hospital specialists, who will take care of you from here on out.”
Nice Old Patient: “Wonderful thank you very much.”
Me: (leaves room, now thinking) Hmmm, let’s see, who’s on…uh oh Dr. Wornout.
Me: Boy, he used to be great back when he first came to town and made deals with a bunch of the local doctors to admit their patients for them. He just had a handful of fully funded admissions a day, and the hospitalist was left to admit everyone else. Gosh he was so nice and pleasant then.
Me: Then for some reason the hospitalist left, and Dr. Wornout took over admitting everybody. Now he’s mean and surly for some reason, and all he ever does is complain about how many admissions he’s had and how many patients he’s managing upstairs and how he’s so overworked. He’ll try to wiggle out of this for sure.
Me: Of course he is too busy, it’s too much for one doctor to try to admit all these patients, manage them on the floor, and discharge them home. Not my fault he won’t hire extra help though.
Me: (looks at watch) 6:40pm. Hmmm. Dr. Wornout gets off at 7pm, and his partner Dr. Crosscover takes over. He doesn’t care about admissions, all he does is give admitting orders to the nurse over the phone from home. Dr. Wornout’s the one who’ll have to actually take care of him when he gets back tomorrow morning.
Me: (to clerk): “Will you page Dr. Crosscover for an admission in 25 minutes?”
A heartwarming story, I know.
June 3, 2009
A malpractice claim is not the only way to end up in court.
I happened to be on the night a toddler was brought broken to our ER essentially dead from abuse, a case that was horrific for all of us that futilely tried to stave off the inevitable. An investigation dug up even more grisly details, and eventually the perpetrator was brought to trial.
The day I was called to take the stand I put on a suit I hadn’t worn since a funeral, which seemed appropriate. I arrived at the courthouse and took a seat outside the courtroom to wait my turn to testify. I sat alone flipping through a stray Newsweek wishing my stomach would stop churning. I was really nervous although about what I’m not sure — I had already met previously with the prosecutors to go over the case and the questions they would ask. I guess it was just the gravity and the formality of the proceedings, knowing that all eyes would be on me and that all my answers would be permanently recorded, worrying some about how my answers would come across and more from the uncertainty that hung over the questions I might get in cross-examination. Maybe at some point in my career I’ll get used to providing testimony, but for now it’s all new and I found myself way out of my comfort zone.
Then they opened the door and called me in. I walked up to the stand and faced the jury and raised my right hand and said I’d tell the whole truth. I sat down, my stupid stomach on spin cycle by now, and for a split second I had trouble answering just where it was that I went to med school. But gradually I settled down and soon it was just a conversation, albeit with a lot of spectators, about what happened in the ER that night.
The defense just had a couple of easy questions, I think through my own self-centered take on the proceedings it was easy to forget that I wasn’t the one on trial. Then for me it was over and I walked out to my car relieved to be just some guy again.
The drive home gave me a chance to reflect. Some of the questions they asked bounced around in my head, and like I always do I picked apart my answers and wished I had said it this way instead of that, replaying the altered, new-and-improved dialogue again and again in my mind as if doing so would make the changes real.
But mostly I thought about that little kid, and life, and why is it that some children are born with love overflowing and others destined to savagely die. And those kind of thoughts stir up dormant emotions, because no matter how grizzled and cynical this job makes you, some things still pierce through. I wonder if time really does heal all wounds — this one just seems to scab over, rebleeding every time it’s picked at.
But I’m not much of a thinker, and by the time I got home I was ready to start forgetting. I got a beer from the fridge and turned on a mindless baseball game, appreciating the sanctuary of my home, insulated from all the monsters.
June 1, 2009
Well, I’m still lifting. I’ve also started learning to play guitar. I’m basically a sports car away from a full-on midlife crisis.
It’s definitely working. Especially after I added some juice into the mix. I figure I don’t play professional baseball so what the heck.
Last night I finally had my first chance to intubate since I started lifting. The patient was huge with a tiny mouth and no neck — a perfect test case. I flipped on Spiderwebs, put the laryngoscope blade in, and cranked up on the handle.
Unfortunately I accidently pulled his head off his neck. Oh well. At least I didn’t need the bougie.
May 27, 2009
The following is a guest post from the late great Hallway Four:
Middle-aged business man gets brought in by EMS. Patient is sopping wet and has scuba gear next to him on the stretcher. The story goes like this… The guy is at a pool party with other successful business-type people. He drinks too much. He decides to go scuba diving – in the hot tub. So, he puts on all his scuba gear and heads to the bottom of the hot tub, where he stays for TWO HOURS. After his oxygen runs out, he surfaces and starts walking around the party again. Party-goers (who apparently thought nothing of a drunk guy scuba-diving in a hot tub for hours) noted that he was “acting funny” and called EMS. On my exam, he’s fine – just really drunk. Later, when I asked him what happened, he has no recollection of the events and simply says, “I don’t know, I guess I drank a little too much.”
May 21, 2009
Everyone knows that patients are asked to rate their pain on a scale of 1-10. Lesser known is the ER doc pain scale, laid out below.
–8.5: An empty department
-Like the first time you had sex: amazing and you wonder how long it can possibly last
–6.8: A thank you note from a patient
-We appreciate being appreciated
–4.75: Birthday cake
-50/50 chance it’s cut with a tongue depressor
–2.8: Best parking space is open
-It’s life’s little things
–1.2: Running late, but hit all the lights
-I knew I’d make it all along
0.41: Respirations out of triage always 16
-20 patients in a row? Really?
0.64: Coffee machine’s broken
-Can usually scrounge some up from another department
0.82: Gown on backwards
-Hello saggers, let’s get you covered up
0.96: The drive home after a night shift
-Slapping face, windows rolled down, radio blaring
1.01: Bed not locked
-Lean up against bed to examine, awkwardly stumble forward
1.15: Spider bite
-It’s not
1.21: Otoscope light doesn’t work
-Check plug, smack in hand, decide how bad do I really want to look in these ears
1.32: Pharmacy call-backs for zofran prescriptions
-My esteemed colleagues: lots of ER patients can’t afford a $300 med
1.36: Outside hospital says they’ll fax old records, never do
-Are there medical record/DMV mixers?
1.44: Patient won’t get off cell phone
-See you in an hour
1.61: Nurses withholding blankets because of fever
-We’ve been over this
1.66: Waking up groggily, asking for more pain meds
-No
1.71: Calmly reporting 10/10 pain
-Uh huh
1.72: Calmly reporting 12/10 pain
-Bonus points for ignoring the scale
1.77: Missing vital signs out of triage
-Helpful to know if this belly painer has a fever
1.79: Patient brought back from xray, never hooked back up to the monitor
-Meh, it’s just a bunch of squiggly lines and numbers
1.81: Whiny consultants
-Should I send you a motivational poster?
1.84: Patient can’t remember meds
-Do people go to H&R Block without their W2’s?
1.88: “Wow, you don’t look old enough to be a doctor!”
- x1,000,000 and counting
1.94: Hand sanitizer bottle empty
-pump pump pump pump pump pump pump…walk over to sink
1.99: “Can I go smoke can I go smoke can I go smoke?”
-Why am I bargaining with you?
2.04: Mysterious fake swelling
-”You see how this part of my stomach is swollen?” Um, no
2.07: Antibiotic seekers
- Antibiotics don’t work against viruses
2.08: Ultrasound seekers
-Well child checks begin earlier than you think
2.09: Drug seekers
-7 allergies and something that starts with the letter D huh
2.16: Press Gainey Reports
-80 returned patient surveys out of 5,000 handed out? That sounds like solid reliable data.
2.27: Construction
-Don’t (WHAM!) worry ma’am (WHAM!) we most certainly (WHAM!) can help you with your headache (WHAM!)
2.30: Lose pen
-Anyone got a spare? Anyone?
2.32: Fully dressed patients
-Knee and hip pain? Of course
2.36: Soda fridge almost empty
-But I don’t want peach citrus fresca
2.37: Nazi nurse JACHO enforcers
-OMG! IS THAT AN OPEN SODA AT YOUR DESK?!? (I dunno, does peach citrus fresca count?)
2.40: Working on a beautiful Saturday afternoon
-Job hazard
2.43: 3fers
-Medicaider: This one’s sick, while I’m here just wanna get the other two checked out
2.44: 4fers
- +1
2.51: Forget stethoscope
-Here’s a spare, it’s glitter filled and has a care bears scrunchie
2.54: Culture followups
-Sir, it turns out you do in fact have gonorrhea
2.55: Radiology overreads
-Sorry about missing that broken bone
2.64: Hemolyzed blood samples
-Patients love getting stuck again and sitting around for an extra hour. How many hemolyzed samples are from lab ineptness? I say 80/20
2.68: Overbearing, high stress parents
-A whole day without pooping, wow
2.92: Can’t get an IV started
-Timesuck
3.38: Pelvic Exams
-If I had known how many of these I’d be stuck doing, I probably would have gone into anesthesia
3.40: Speculum light lost/doesn’t work
-Nurse get the crazy-looking bendy-armed light out and look into how long an anesthesia residency is
3.47: Specialities fighting each other to not admit
-Pregnant PE — Internal Medicine: Call OB, OB: Call Internal Medicine
3.62: Six ambulances crammed into bay as you show up for work
-Trend setter
3.64: Taking in ambulance diverts from everywhere else
-Enjoy your stay in our hallway
4.14: On call doc won’t call back
-Passive aggressive
4.53: Police bringing in patients for medical clearance
-Drunk guy, would you like to go to jail or the ER?
4.77: Post-operative complications from some other hospital
-Advice: if there are problems go back to the hospital where the person who operated on you works
4.84: Nursing change of shift
-Twice the nurses, yet zero work done
5.02: Wrong doc listed as on-call
-Hours to sort out, usually as I’m trying to leave
5.34: “Sick” nurses leave department short staffed
-It’s a big middle finger to everyone who showed up to work
5.83: Vomited on
-Can the genius bar help get the puke out of my iphone?
6.11: Unannounced shadowers
-Hi, this is the student doctor who’ll be standing 5 feet from you for the next 10 hours
6.39: Patient influx 1.5 hours before leaving
-But I’m lazy and want to get home on time
6.67: Computer’s down
-We know where the downtime forms are all to well
6.72: Computer’s slow
-Slamming the mouse against the desk doesn’t seem to speed things up, but it does feel good
7.18: VIP’s
-Get in line
7.45: No beds upstairs
-Welcome to our ER, your home for the next 48 hours
7.84: Next doc on oversleeps
-So hard to ramp back up when you thought you could start winding down
8.13: Can’t find a hospital to accept a patient in transfer
-Would it help if I, say, threw in a starbucks gift card?
8.57: Laryngoscope light goes out
-Ok I’ve got the cords…and suddenly it all goes dark
9.16: Needle stick
-Can you expound on this “free love compound” that you list as your residence?
9.37: Summons in mailbox
-So I’ve heard knock on wood
9.45: Hospital administrators who double sneakily toss your contract
-So I know
9.72: Telling family their loved one is dead
-I’m so sorry
9.83: Unsuccessful pediatric code
-Always leaves a heaviness over the entire department
9.98: Living with your mistakes
-We’d all like a few do-overs
May 19, 2009
Ways I have seen diarrhea spelled on sign in forms this week:
Diariah
Diarhea
Diaherreha
Dairra
Diearia
Maybe just go with the runs.
May 7, 2009
I forever feel uneasy about intubating. I want to excel but instead hover around adequate. I am not the guy who gets the airway that no one else could.
I’ve read airway texts and been through intubating courses and know lots of tips and tricks to bring the cords into view. It doesn’t seem to matter though, I still feel like I struggle way more often than I should. I get it done, but not with the grace befitting a skilled ER doc.
There’s one last method I haven’t tried. It’s not in any book or course, but I’m convinced it will make me better. So I’ve started lifting.
Yep, I found a ratty bench and set of weights on craigslist for $20 and have trudged out to my garage every other day for the last two weeks powering through a routine more suitable for a girl’s junior high B-team basketball squad. Oh well you have to start somewhere.
Weight-lifting note #1: I mean people it really is shocking how weak I am.
Weight-lifting note #2: Especially my left arm. I played a lot of tennis growing up so my right arm is twice as strong as my left. Which is kind of like saying Harry is twice as smart as Lloyd. Too bad when intubating you have to hold the laryngoscope with the left.
Weight-lifting note #3: Do not lift just before going into work. You may find your hands to be a wee bit shaky when sewing up a lac.
Weight-lifting note #4: I’m not that into music. All I ever listen to is podcasts but I need something a little more upbeat to get through my Curves workout. The only music I have though are some mp3’s I picked out from my sister’s old converted CD collection. It turns out the music I have is pretty mellow — the only thing I have close to upbeat is a No Doubt album. Which means I’ve had Spiderwebs in my head for like two weeks running. ”Sorry I’m not home right now, I’m walking into spiderwebs so leave a message and I’ll call you back!” Kill me.
We’ll see how it goes — the odds are I’ll quit but those dicey intubations provide motivation. Perfect technique will get you far, but sometimes you need to be able to add a little brute force.
And if I get a little cut that’s ok too.
