Friday, September 23rd, 2005.15 months into residency and a lot has happened and quickly. The Emergency room is a blast. One minute you are strapping a drugged out troglodyte to a bed and throwing Haldol darts, the next treating a long time friends father for a heart attack. You learn quickly, you have to. Nurses, Bosses and Patients all respond better to honey than a dose of god-doc vinagrette. Some patients are sick and others just want to be told they aren't. Some are both. Skepticism is good, but if you get cynical you should take a step back or change jobs.This month I am in the ICU. Once a place I thought I wanted to work, but I think I would end up depressed. As you walk through the halls certain smells and an ocean of beeping monitors not so gently remind you of the fragile ice we walk on, and how quickly everything can be taken away.Some patients land there for just getting old, and some because they didn't take care of themselves. For example, my current patient with various body parts moved to his mouth frankenstein-style to replace the tongue they had to cut out for his cancer after smoking and drinking for years. Currently we are placing leeches on his tongue every 2 hours to help increase the blood flow, sounds crazy, but I saw it work.The ones that really bother me are the 18-30 year olds with spontaneous brain bombs. You are happily eating your rice-a-roni one minute and the universe deals you the shit card on the river and you were all in. Game over. Sure, we fix some. Sometimes it is state of the art miracles, and others it is tribal voo-doo with a tincture of unicorn teardrops and cross your fingers watch and waiting.I look forward to getting back in the ER, and I get my chance tomorrow. A lot of residents moonlight in their days off, a great way to pay some extra bills and to force yourself to learn by taking the leap off the cliff. At some point you have to start making decisions about patients independently, and that is scary as hell. I will let you know how it goes tomorrow.
Drug Rep quote: "...… those side effects of anal leakage and oily stools happen in only a small group of people."Well, I had my first moonlighting experience last weekend. Pretty uneventful, except for the kid who supposedly ate some castor beans, which I now know contain the most lethal natural occurring toxin known to man, (ricin.)News flash to all parents: Don't keep castor beans around your house.Last night in the ICU. This weekend I go back to the ER. I will have better stories then. The only interesting I came out of this month with was about the man who was in a car accident, became paralyzed from the neck down and his fiance never came to see him. After several months in the ICU, he got closer with a friend and they got married this weekend, right here in the ICU. I signed their card, partly because I wish them the best, but mostly because I didn't want to feel bad having a slice of their wedding cake. After all, I was on call.
"Soo, then you would say your bowel movement was more of a softy softerson?"-Dr. Make em smile, CR staffAnother month in the ER, this one a new one. It started out with a bang on one of my first shifts, here's how it went down:Ambulance arrives with a patient rolling him in on a gurney, but instead of lying on his back like most patients, he is on all fours grimacing in pain, his shirt partially cut off and a knife sticking out of his back. Blood was trickling down his side, and as I knew this was my patient a second of panick and a bit of excitement flashed over me. I looked to my staff, and ER doc of 30 years and said without hesitation, (and I am sure a gaping maw), holy shit, I've never seen that before. He promptly responded, "Me neither, looks fun, lets go take a look".Turns out it was stuck in his sacrum and we could just give it a yank out.
Sunday, December 18th, 2005"I'm not going to eat that shit, it would kill a horse." - 95 year old Tillie after I tried to force feed her Levaquin hidden in applesauce.Actually, after the first spoonful she picked out all the pill fragments and ate the applesauce. So we switched to IV antibiotics. She made multiple demented statements hourly, but did mention she thought I was cute..., If only I wasn't married.So, to back up a little bit, I moonlit in a small northern Wisconsin town of 765 people this weekend. For 48 hours I was it. I saw the patients that came in the ER, admitted them to the hospital if need be, took care of any problems throughout the night of all the (8) inpatients and answered questions from the local nursing home when they needed help. This place was really a la Northern Exposure, and I was Dr. Joel Fleischman. It was beatuiful.Every night and morning a jolly red dressed man would come intto the ER, (his long white beard was real), and get dressing changes for his abdominal wound. The nurses know almost all the patients who come in, and would predict the course of the patients work up before I even entered the room, and were almost always right.Everyone says "hi", "how are you?" and "where are you from". The last question the most important because if they don't know you directly they will know your brother or father or so on. Quaint, pleasant, friendly. Also slow enough to work a straight 48 hour shift, because you will always get at least a little chance to sleep. But don't let this description fool you.I grew up in a similar community. Overall, the mind set is, "no reason to go to the doctor until I might be dying." My first patient was an asthmatic who developed BOOP and after not being able to wean her off of BiPap, (a special breathing machine), we had to send her via ambulance to an ICU at a bigger hospital. 2 patients later, an old woman, with every major organ system manifesting some sort of disease presents with a dangerously low blood pressure, (SBP in the 60's). We ended up have to start pressors on her and fly her to a bigger hospital ICU at yet another hospital to manage her heart, kidney and lung failure. A couple more of sick old people that had to stay in the hospital and one pretty impressive concussion from a local skiing accident. The bottom line is, yeah, you get sleep, but when people come in, you better have your eyes open because there is a good chance they are really sick in these small farming communities with the tough-as-nails mantra. I think the fun part about it is you usually have a little more time to be cerebral about it, although with less resources making it a challenge in its own special way.Despite the 5 hour drive, I loved it and will continue to work there. I think experiences I have gotten from these places are unmeasurable in my growth as a physcian both as becoming wiser/more knowledgable physician and as a person who can adapt to unique situations and resources in different medical scenarios.
I am back in the ER full time, and having fun at it. So far this month I have been pushing myself to see more patients per hour, which inevitably leads to me silently curling up in a fetal position inside my head about half way through my shift and slowly siphoning minutes off of the end of my life as a sacrifice to perform these feats.It seems we have had a rash of drug overdoses recently. I love to treat overdoses. They are easy to take care of. First off, ABC, airway, breathing, circulation. Then it gets even easier. They are almost always young women, and there are usually two possible pathways. The first one, where they really did it right, they are sick and I get to intubate them, (e.g., so sick they can't be trusted to breathe on their own safely and I get to stick a tube down their throat and put them on a breathing machine until they are better), and quickly get them the hell out of me ER. The second one, either weeny OD, (aka watch 'em for a few hours and admit them to psych), or the gray zone. The gray zone is the most fun, because you are not really sure if they will be a-ok, or took just the right amount to look ok now, but walk towards the bright light in 3 hours from now inevitably leading to a law suit because you didn't save them. (I will leave out my thoughts on Darwin, survival of the fittest and the possibility that my profession fights against the grain of nature that was designed to ensure the strengthening of each living species.)Anyway, the middle ground OD's you have to do a little detective work, figure out what they took and deliver an antidote. It is the closest I get to practicing magic in medicine, and for a D&D cultivated nerd, this is divine.The best part is I actually help them, at least for the short term. They almost all get better in 24 hours, get shipped to the psych floor and reveal the reasons they did it, depression, "cry for help" and all that Oprah-esque crap. I don't know what the final outcome is for most, unless I end up seeing them in the ER again, which means it is probably not good. I have noticed that looking at their legs is helpful, the hairier their legs, the more serious their depression and more likely I will see them back in the ER for their next OD in 2 months. I wonder if that study has ever made JAMA? 'Density and Length of Leg Hair in Females Directly Linked to Severity of Depression', sponsered by Eli Lilly.Until next time.
Outside ER doc transferring patient: "Right after I gave him the IV contrast he got severely proptotic"Me: "So you're saying his eye is coming out of his head?"Other Doc: "yes"Me: "oookkaaayyyy, well send him here and we'll be glad to see him", (giving me ample time to call an opthomologist, get out textbooks and try to figure out what the hell could be going on.)These are the kind of calls we get sometimes. Sometimes they are exactly what they say when they show up and you say to yourself, "damn there a lot of medical problems out there that they never told me about in medical school, (or I wasn't listening) and I don't ever want to have.I am working primarily back at the university hospital now, or as I like to think of it, the Big White Castle. It isn't really big, or white, but rather it's attitude. Being away and working in a couple of the smaller towns I have mentioned has really shown me a few things, besides how to increase anal sphincter tone at the drop of a hat.Being in the Big White Castle people are often removed from the patient and their family, and it many cases seem less accountable. When I am working at a small hospital in a smaller town, and Mrs. Johnson comes into the ER for a rather piddly thing that is probably no big deal but the family is very concerned, (and there still is always the possibility that a brief observation overnight in the hospital would reveal pathology), I call the family doc, tell him we are going to watch her overnight and we do just that. I am happy, Mrs. Johnson is happy, (and potentially safer), and Mr. Johnson and family is happy. Here at the Big White Castle that same lady goes home, which is part because of there is only so much room for some very sick patients, and part because sometimes people don't want to make extra work for themselves and the system is so inefficient they are already bogged down and overloaded. The difference is that if I and admitting small-town family doc send Mrs. Johnson home in little-town Iowa, the next day Family doc may see Mr. Johnson and/or family at the cafe or gas station and they may be left wondering why he didn't do what they think he should have done and he may be left questioning if he did the right thing. He has to face the family often directly, maybe in his practice, the grocery store and other settings. It really can be a la Northern Exposure. This creates tremendous accountability. There is a separation of this relationship at the Big White Castle that doesn't created the same accountability.We can argue the merits of this. Maybe this works out just right, the big hospital only takes care of the really sick folks and the little places the rest. One of my mentors told me to do what is right one night. Do what I think is right, what I would feel good about when I go home at night. My care feels more right at the smaller places with the small town hospitality and accountability. In the meantime, we can continue to be advocates for our patients at the Big White Castle when it needs to be done. The system chugs on.
She came in on a guerney, trapped inside this 375 lb. body that hadn't moved in two weeks, lying in her own soil. For TWO weeks. I could see in her eyes, the fear, frustration, helplessness. No longer able to talk, she squeezed my hand. She had a severe blood infection, a heart attack, a hole in her intestines leaking air inside her abdomen causing intense pain. Her kidneys were failing, and the rest of her body was soon to follow.Within the hour things got worse. I put a tube into her lungs to breath for her. Soon after her heart went into a dangerous rhythm with no pulse."Everybody Clear!"ShockAnd repeat.And more medicines.Nothing is working.I can't help but wonder if her fear was dying, or to keep living going what she had gone through the last two weeks.Death doesn't always bother me. Sometimes, you see into someone's life just enough to make it so real that I can't help but let it bother me. I think that's ok, as long as the toll isn't too heavy for too long.
trav we all dont know how u do ur job but we all are very proud of u. when people as me what my brothers do i am proud to say that one is full time army and the other is the best er doctor at the u of i. we dont say it but just to let u know we all think it. good job trav!!!! ur youngest bro....
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