The Shhh (slow) Long Day

I came into work this morning at 0800 to find one patient on the board. One of my EM colleagues was working the 0700 - 1900 shift, and he was the only resident there. He told me the board had been completely empty when he took over. It stayed at one for about an hour an a half. Well, the pediatric side of the board did.

At WCHOB it's Women AND Children's, so we get adult females too. However, during the time that we rotate through the E.D. here we are not expected to see anyone over the age of 21. So, there's always an adult medicine attending who comes down and sees those patients. And, for the first couple of hours of my shift, they kept her pretty busy. In fact, I didn't pick up my first patient until almost 1000.

I saw a total of five, yes, five patients during my 10 hour shift today. Partially because a lot of patients didn't come in, and also because we added the PA during the morning, a fellow at 1100, another resident at 1300, and another resident at 1600. So, we had tons of people fighting over a handful of patients. I had three that kept me occupied all of my shift, so I didn't really mind that I wasn't seeing the other runny noses and fevers that were coming in.

I had a 5 year old with pyelonephritis (kidney infection) who came in with 2 days of fever, vomiting and back pain. The PA (physician's assistant) in the office thought she had appendicitis and had wanted us to do a CT scan. We "dipped" her urine after a complete history and diagnosed the pyelo. I spent the day breaking her fever, fluid hydrating her, keeping her comfortable with pain medications, gave her a dose of IV antibiotics, and then made sure she could drink juice and not throw up before she went home. She went from a whining, crying inconsolable little girl, to a perky, demanding spoiled little girl, albeit a bit sleepy from the tylenol with codeine, but still.

My next patient had dacryostenosis. I carried the little 11 day old up to my attending and told him this was how I was going to present patients from now on. Kind of like Show & Tell. Everyone oohed and ahhed over the baby, and I just wanted to know what was wrong with him. The attending took one look and gave me the diagnosis. Now I know. It's actually very common and very treatable, and I had the mother in and out of the ED in less than 20 minutes.



(**Oh, and no fair reading the prior comments... add your own before looking at everyone else's.... :D )

Next was the 4 year old that was told by one of his friends, maybe dared is a better word, to jump off the top bunk. He did and hurt his ankle. His mother said that he couldn't initially walk on it, but he seemed to be doing better today. We took films and initially thought he had a break but decided to wait for the "official radiology read." This ended up taking almost an hour. We tried paging the radiologist, which took another 45 minutes. Finally, I went up to radiology only to find that the attending was "getting a quick bite." Twenty minutes later, I finally was able to sit down with him and review the film. No break. Ace wrap and a week off of gym for this little guy. And, a warning not to jump off of any more bunk beds.

I don't mind being a patient advocate. Especially when there's a young child involved who sincerely just needs a simple procedure (like a tonsillectomy) to solve all of his problems. I spent four hours on the phone trying to arrange an appointment with ENT (Ear, Nose and Throat, or Otolaryngology) or try to find an ENT willing to operate on a patient with no insurance. This little guy's parent fell into the, we don't make enough money or have the kind of jobs where we can have private insurance, but make too much money to qualify for state or government aid. Finally, the Social Worker and Finance Planner were able to work something out with Catholic Charities, who would pay for the entire surgery except for the anesthesiology bill. The mother could prorate and get a payment plan for that part. However, it was near to impossible to find an ENT willing to do the surgery mostly because there are tons of roadblocks to even get in touch with one. But, luckily, the insurance thing is going to be worked out as of May 1, and I got him an appointment for May 15th. When I called the mother and told her, she said, "Is that the best you can do...?"

Deep breaths, in with the blue, out with the green. Say to yourself a hundred times, "I will not become a sullied, evil, people-hater who is cynical and burned out before I graduate from this program." And, remind yourself, again, why you're not a surgical resident... why is that again...? At times like this I wonder....

Finally, I had the longest patient in the E.D. A little 1 month old with a hydrocele. I thought it was one. My attending thought it was one. The patient's primary thought it was a hernia and wanted a surgery consult. When surgery showed up 3 hours after I called the consult because she had 8 other consults, and after I had already ordered an ultrasound which confirmed it was a hydrocele, I already knew that the patient wouldn't be going to surgery and would be sent back to their primary's with a diagnosis of hydrocele, I remembered why I wasn't a surgery resident any more... Because once I discharged this patient at 1800 I got to go home. Clocked out (well, not really). Hasta la vista, baby!

Grand Rounds' Wednesday tomorrow and then the weird 1600 - 0200 shift.



95,900 seals killed to date. Free the Farley Mowat!