Beer meter: 0 again!
Last night when I got to the E.D. the entire place was packed. I've come to learn that we actually have about 33 beds in the E.D. plus about 6 more in the Fast Track area. Last night, every single one was full and there were about 10 people waiting in the Waiting Area. We were officially on diversion.
Diversion means that walk-in patients can still come in and wait their turn as they are triaged. All ambulance traffic gets "diverted" to another facility. Also, since we are one of the larger hospitals in the area, we get admissions from surrounding smaller hospitals when they encounter a patient that needs a higher level of care. So, we "divert" those patients as well. Actually, they were all getting sent to E.C.M.C, so their E.D. was packed as well, but I digress.
I jumped right in and started seeing patients. I can't believe the volume of chest and abdominal pains I see. Also, SOB's. (Again, shortness of breath not a comment on the patients themselves.) So everything is becoming garden variety in this the start of my fourth week here.
Some standouts from last night:
I have no problems giving lots of narcotic medications to people with legitimate medical conditions. Cancer patients get all they want. Pancreatitis people who aren't raging alcoholics get a good amount. Drug seekers who try to scam me out of oxycodones by telling me that they're allergic to everything else and are in sooo much pain they can't do anything because of the pain get none.
If you followed the link I wrote about previously, you will understand when I say that no one can have 10/10 pain. One of my colleagues said 10/10 pain is being hit with your own amputated leg. Seriously. I think almost all of my patients tonight described 10/10 pain. If you have that much pain you should be screaming at the top of your lungs, writhing in bed, and nothing short of being knocked unconscious should relieve it.
We had things under control by about 2 in the morning. At that point we only had about 4 patients on the board and no new patients coming in. We opened to ambulance traffic again and had a few come in over the next couple of hours. We left 5 people on the board at sign-out. I don't mind, I have one night of nights left then it's back to the day shift to finish out the weekend and my rotation.
For the next 2 weeks, I have "Flat Adrian" visiting as part of a school project. So I will be showing what he's up to here. If you are not familiar with the story of "Flat Stanley" google it for an excerpt and links to the Flat Stanley Official Website.
Tuesday, November 6, 2007
Monday, November 5, 2007
Pregnant and 40
Beer Meter: 0 it was actually a tolerable night
This is a quickie:
Last night amoungst the heart failures and asthma exacerbations, I had a patient who will be turning 40 tomorrow. She's homeless, her kids have stolen her glucose meter, she has no money for her medications, and she doesn't have a regular physician. From time to time she goes to the walk-in clinic to take care of whatever ails her at the moment... oh, yeah, did I mention I diagnosed her pregnancy last night?
This got me thinking of a poem I wrote in my Literature class while in college. Our subject was to make a political comment on society. Mine was called "A Matter of Timing. I think I remember my first line as being:
For or against abortion? For or against the death penalty? What I guess you're really saying is it's just a matter of timing.
I then went on to describe a person not allowed to have an abortion who then goes and has a child they don't want. So the child is raised in a loveless poor environment where they go on to do drugs, steal, end up killing someone and then get the death penalty.
Now, I am not advocating abortion or the death penalty, but this situation made me think of that poem again and made me wonder what this child's life is going to be like. When you wonder why doctors sometimes seem cold and distant, I think it's because of situations like this. You have to block yourself off sometimes from certain aspects of your patient's lives or else you would probably end up doing more harm than good.
Now, off to the trenches again.
This is a quickie:
Last night amoungst the heart failures and asthma exacerbations, I had a patient who will be turning 40 tomorrow. She's homeless, her kids have stolen her glucose meter, she has no money for her medications, and she doesn't have a regular physician. From time to time she goes to the walk-in clinic to take care of whatever ails her at the moment... oh, yeah, did I mention I diagnosed her pregnancy last night?
This got me thinking of a poem I wrote in my Literature class while in college. Our subject was to make a political comment on society. Mine was called "A Matter of Timing. I think I remember my first line as being:
For or against abortion? For or against the death penalty? What I guess you're really saying is it's just a matter of timing.
I then went on to describe a person not allowed to have an abortion who then goes and has a child they don't want. So the child is raised in a loveless poor environment where they go on to do drugs, steal, end up killing someone and then get the death penalty.
Now, I am not advocating abortion or the death penalty, but this situation made me think of that poem again and made me wonder what this child's life is going to be like. When you wonder why doctors sometimes seem cold and distant, I think it's because of situations like this. You have to block yourself off sometimes from certain aspects of your patient's lives or else you would probably end up doing more harm than good.
Now, off to the trenches again.
Sunday, November 4, 2007
An added hour of fun... not!
Beer rating: 1
Daylight saving time is over (trust me there's no 's') and last night, the lucky 4 of us who worked the extra hour as we "fall back" in time really felt it. In a past life, I actually have been in a bar once or twice during the time change. Then it's not so painful... last call, no, oops, an extra hour to get that next drink or two in... ahh.
Some thoughts on last night, the first of 4 before I switch back to days to complete this rotation....
crack cocaine habit: $40 a day, ok, so that's about $1200 a month x the last 7 months = $8400. Wow. On Disability, you say? Once, again, your tax dollars at work. Admit with chest pain.
500 pounds is the maximum that our CT scanners can accommodate. Again, it's very difficult to get the proper treatment when you don't fit on the machinery. In this case, I will argue any statements regarding making accommodations for everyone. The lively discussion we had in our E.D. regarding how to go about treating this patient lead to some thoughts which included "vaccinating" patients with tapeworms; in case you didn't know, "diet pills" sold in the early 1900's actually contained tapeworm eggs. You ate what you wanted, the worm consumed all the calories, you lost weight. However, there's a rather nasty bit about worms not always sticking to the stomach and traveling to other parts of the body. Also, you have to one day "lose the worm." Snopes.com is my website of choice when it comes to matters of urban legend. They file this one under "undetermined" but I think there's enough evidence to support the story: http://www.snopes.com/horrors/vanities/tapeworm.asp Regardless, weighing 500 # does not make for ease of patient care.
One of my patients started "hearing voices" about a month ago. Most of the voices sounded like family members, but one voice was actually given a name: Michael Mahooly. They convinced her that her entire apartment was filled with video cameras to watch her every move. Unfortunately, the tumor in her brain that we found when we CT'd her head has nothing to do with the voices. She was transferred to psych.
Crack, alcohol and a big wad of cash do not always make for a fun Saturday night. They just might lead to your getting your head smashed and cut to bits by a broken off bottle as someone decides to lighten your wallet. It's going to take 2 teams of surgeons to repair the eyelid laceration and the mincemeat that once was your ear. Better for you to get sent to ECMC where they can handle traumas. Yep.
Ok... off to bed... tonight will come much too soon.
Daylight saving time is over (trust me there's no 's') and last night, the lucky 4 of us who worked the extra hour as we "fall back" in time really felt it. In a past life, I actually have been in a bar once or twice during the time change. Then it's not so painful... last call, no, oops, an extra hour to get that next drink or two in... ahh.
Some thoughts on last night, the first of 4 before I switch back to days to complete this rotation....
crack cocaine habit: $40 a day, ok, so that's about $1200 a month x the last 7 months = $8400. Wow. On Disability, you say? Once, again, your tax dollars at work. Admit with chest pain.
500 pounds is the maximum that our CT scanners can accommodate. Again, it's very difficult to get the proper treatment when you don't fit on the machinery. In this case, I will argue any statements regarding making accommodations for everyone. The lively discussion we had in our E.D. regarding how to go about treating this patient lead to some thoughts which included "vaccinating" patients with tapeworms; in case you didn't know, "diet pills" sold in the early 1900's actually contained tapeworm eggs. You ate what you wanted, the worm consumed all the calories, you lost weight. However, there's a rather nasty bit about worms not always sticking to the stomach and traveling to other parts of the body. Also, you have to one day "lose the worm." Snopes.com is my website of choice when it comes to matters of urban legend. They file this one under "undetermined" but I think there's enough evidence to support the story: http://www.snopes.com/horrors/vanities/tapeworm.asp Regardless, weighing 500 # does not make for ease of patient care.
One of my patients started "hearing voices" about a month ago. Most of the voices sounded like family members, but one voice was actually given a name: Michael Mahooly. They convinced her that her entire apartment was filled with video cameras to watch her every move. Unfortunately, the tumor in her brain that we found when we CT'd her head has nothing to do with the voices. She was transferred to psych.
Crack, alcohol and a big wad of cash do not always make for a fun Saturday night. They just might lead to your getting your head smashed and cut to bits by a broken off bottle as someone decides to lighten your wallet. It's going to take 2 teams of surgeons to repair the eyelid laceration and the mincemeat that once was your ear. Better for you to get sent to ECMC where they can handle traumas. Yep.
Ok... off to bed... tonight will come much too soon.
Wednesday, October 31, 2007
Happy Halloween!!
Beer meter: zero
Another short shift Wednesday. Today, most of the patients stayed away. Maybe they were busy filling their goodie bags with treats. I don't know. All I do know is I was actually able to think about my patients and their conditions today. Not too busy at all.
Instead of my usual diatribe, and the lack of anything new and interesting patient-wise (by the way, the patient with the possible pseudocyst in his pancreas did have one, woohoo on me for my ability to read "badness" on a CT scan) I will include a link to someone else's diatribe, which funny enough sounds something like my own... but it isn't.... but it could be...
http://www.craigslist.org/about/best/sfo/301345524.html
Monday, October 29, 2007
It's Just Another Manic Monday
Beer meter: 
Ok, so the floodgates opened yet again. The E.D. was FULL of patients and about 50% of them were chest pain patients. And, it seemed like all of the other E.D.'s were full and sending us their patients. There's been news that several E.D.'s in the area will be closing, and that just means more congestion for the E.D.'s that remain open.
Politics aside, my patients for today:
Chest pain - admit with pneumonia - coming in and making demands is not a good way to make friends in the E.D. I love hearing the "why I am not compliant with my medication" stories about how awful their doctors are and how they never give them their prescriptions when they need them; and then, when I call their doctors to admit them, I hear the other side of the story, how the patients don't come into clinic for follow-up appointments, or how they call saying they've "run out of all of their medications and need them refilled today." For some reason I believe their doctor's side. Don't know why, just a gut feeling.
Shortness of breath - admit with COPD exacerbation - COPD = emphysema. Somehow I don't care if you're 92 going to turn 93 tomorrow. You really shouldn't smoke... still. Maybe that's the reason you need to wear oxygen... no smoking with that on, or you'll go up in flames.
Shortness of breath - discharge with upper respiratory infection - I don't care what the bottle says, if it smells like horse liniment it probably isn't something you should take to "clear out your chest congestion."
Abdominal pain - admit with small bowel obstruction - cancer sucks when it happens to really nice people. What sucks even more is being a doctor who can look at a CT scan and go "oh crap that's a BIG tumor." When I was at in medical school, one of my attendings used to make the comment, "All he needs is a script for a cane pole and a six pack" meaning a patient had cancer with no hope. There's always hope, but looking at my patient's CT, I wondered if he'd even have time to hook the worm.
Chest pain - admit to chest pain center - seriously, stop doing the cocaine and the chest pain will stop. Or your heart will. Either or, the pain will be gone.
Abdominal pain - probably will be admitted with a pancreatic pseudocyst - if you're told you have pancreatitis and to not drink and you chose to block out the pancreatitis part and still drink, when you come back again with abdominal pain and you tell me you don't know why, I am going to find out. Electronic medical records are a great thing.
Chest pain and abdominal pain - most likely going to be discharged with nothing wrong except for the fact you haven't been able to get your methadone for the last four days so you're coming to the E.D. for your fix. Oh, and when I ask for significant medical history, telling me you're biologically a man who now dresses like a woman is important so I don't look silly/stupid in front of the nurses when I ask for a urine pregnancy test.
Day off tomorrow. I'm on a strange day on/day off/switch over to the night shift thing for the next week.
Ok, so the floodgates opened yet again. The E.D. was FULL of patients and about 50% of them were chest pain patients. And, it seemed like all of the other E.D.'s were full and sending us their patients. There's been news that several E.D.'s in the area will be closing, and that just means more congestion for the E.D.'s that remain open.
Politics aside, my patients for today:
Chest pain - admit with pneumonia - coming in and making demands is not a good way to make friends in the E.D. I love hearing the "why I am not compliant with my medication" stories about how awful their doctors are and how they never give them their prescriptions when they need them; and then, when I call their doctors to admit them, I hear the other side of the story, how the patients don't come into clinic for follow-up appointments, or how they call saying they've "run out of all of their medications and need them refilled today." For some reason I believe their doctor's side. Don't know why, just a gut feeling.
Shortness of breath - admit with COPD exacerbation - COPD = emphysema. Somehow I don't care if you're 92 going to turn 93 tomorrow. You really shouldn't smoke... still. Maybe that's the reason you need to wear oxygen... no smoking with that on, or you'll go up in flames.
Shortness of breath - discharge with upper respiratory infection - I don't care what the bottle says, if it smells like horse liniment it probably isn't something you should take to "clear out your chest congestion."
Abdominal pain - admit with small bowel obstruction - cancer sucks when it happens to really nice people. What sucks even more is being a doctor who can look at a CT scan and go "oh crap that's a BIG tumor." When I was at in medical school, one of my attendings used to make the comment, "All he needs is a script for a cane pole and a six pack" meaning a patient had cancer with no hope. There's always hope, but looking at my patient's CT, I wondered if he'd even have time to hook the worm.
Chest pain - admit to chest pain center - seriously, stop doing the cocaine and the chest pain will stop. Or your heart will. Either or, the pain will be gone.
Abdominal pain - probably will be admitted with a pancreatic pseudocyst - if you're told you have pancreatitis and to not drink and you chose to block out the pancreatitis part and still drink, when you come back again with abdominal pain and you tell me you don't know why, I am going to find out. Electronic medical records are a great thing.
Chest pain and abdominal pain - most likely going to be discharged with nothing wrong except for the fact you haven't been able to get your methadone for the last four days so you're coming to the E.D. for your fix. Oh, and when I ask for significant medical history, telling me you're biologically a man who now dresses like a woman is important so I don't look silly/stupid in front of the nurses when I ask for a urine pregnancy test.
Day off tomorrow. I'm on a strange day on/day off/switch over to the night shift thing for the next week.
Sunday, October 28, 2007
Wastin' away again...
Funny how when you have several days off, you make all kinds of plans about how you're going to spend your time. I was certain I was going to finally unpack completely, do loads of laundry, organize (and pay) all of my bills, and a number of assorted other household tasks. How much of this did I do....? Not much.
I did clear out the pile of bottles and glasses surrounding my easy chair in the living room. And, I put all the shoes that had accumulated in my living room into a pile at the foot of the stairs. I managed to empty out a few trash cans and made a trip to the dumpster. And, that's about it.
Honestly, I don't know where the time goes. Granted, sleeping in until 10, 11 or even, eek, 12 every single day hasn't helped. But I finally feel more rested. Three days of sitting around, a cat in the lap, remote in one hand and computer mouse in the other, and I feel refreshed. Ready for work again in the morning.
Too bad I can't work from home. When I was working in Boston, one of my co-workers nicknamed me "the Empress." In the ICU at BWH, there's a work area on 8C surrounded by glass and you can stand and see the entire ICU from it. The monitors were hung on a wall just above everything, so you could quickly look up and see any one patient's monitor.
One night I was working the night shift, and he had come over to chat with me. As we sat, several nurses came up to me and told me about their patient's current condition. I could literally remain seated, look over at monitors and type orders into the computer without much effort. From that, he teased me that if I set things up just right I could do all my work from home. I said, give me a computer and enough video monitors and I could rule the world. So he started calling me the Empress.
Hence, the idea of telemedicine. Of course, I'll be able to tell you more about it next month when I do the rotation. Should be interesting... Now I must sleep. Morning will come soon, and with it another set of challenging patients in the E.D.
I did clear out the pile of bottles and glasses surrounding my easy chair in the living room. And, I put all the shoes that had accumulated in my living room into a pile at the foot of the stairs. I managed to empty out a few trash cans and made a trip to the dumpster. And, that's about it.
Honestly, I don't know where the time goes. Granted, sleeping in until 10, 11 or even, eek, 12 every single day hasn't helped. But I finally feel more rested. Three days of sitting around, a cat in the lap, remote in one hand and computer mouse in the other, and I feel refreshed. Ready for work again in the morning.
Too bad I can't work from home. When I was working in Boston, one of my co-workers nicknamed me "the Empress." In the ICU at BWH, there's a work area on 8C surrounded by glass and you can stand and see the entire ICU from it. The monitors were hung on a wall just above everything, so you could quickly look up and see any one patient's monitor.
One night I was working the night shift, and he had come over to chat with me. As we sat, several nurses came up to me and told me about their patient's current condition. I could literally remain seated, look over at monitors and type orders into the computer without much effort. From that, he teased me that if I set things up just right I could do all my work from home. I said, give me a computer and enough video monitors and I could rule the world. So he started calling me the Empress.
Hence, the idea of telemedicine. Of course, I'll be able to tell you more about it next month when I do the rotation. Should be interesting... Now I must sleep. Morning will come soon, and with it another set of challenging patients in the E.D.
Wednesday, October 24, 2007
Short shift Wednesday
Beer rating for today:
Every Wednesday we have several morning meetings. First, we all meet in our individual classes (interns, second year residents, and third year residents) and discuss selected chapters in our Emergency Medicine textbook for an hour. It helps to correlate the science aspect with the clinic aspects of our jobs. Then we have Grand Rounds for about 3 hours. Grand Rounds consists of several lectures, usually themed together, with occasional guest speakers. We then might discuss a clinical case as presented by one of our colleagues (my presentation will be in May '08) or discuss some clinical scenarios.
Our shifts on Wednesdays then don't start until 1400 (2 p.m.). We work until 2100 (9 p.m.). The night shift then comes in and works 2100 - 0700. So, instead of a 12 hour shift, we work shorter shifts on Wednesdays which makes it nice because things just seem to go by a little faster.
My patients this afternoon:
- 80 something with diarrhea for a week = get admitted for dehydration and weakness
- 70 something with abdominal pain = get admitted for pain control of your underlying colon and pancreatic cancer (and, I might just add, cancer patients in my book get all the drugs they want)
- 20 something with chest pain = get admitted for observation in chest pain center
- 50 something passing out after a fall = still getting worked up when I left, but I worry when I read that the patient can't be placed in a normal shelter because he's listed as a "sexual predator" which makes living in most locations difficult
- 70 something with swollen hands = still being evaluated to make sure he's not going into heart failure, he just wanted to eat the same things he ate in the hospital so that his hands won't be swollen
- screaming 50 year old who I was asked to see because she only understood Spanish = would not listen to me when I tried to explain that I don't arrange for housing, I can only take care of her medical needs. From my conversation with the social worker, she's been thrown out of every local shelter around for being annoying and demanding.
Finally, we were signing out patients at shift change (where the on-coming residents take over our patients that are still being evaluated) when one of our own, a resident, was brought in by EMS. I think he was more embarrassed at having to be brought in than by what actually happened to him, but then he's got nothing to fear... we take good care of our own.
Every Wednesday we have several morning meetings. First, we all meet in our individual classes (interns, second year residents, and third year residents) and discuss selected chapters in our Emergency Medicine textbook for an hour. It helps to correlate the science aspect with the clinic aspects of our jobs. Then we have Grand Rounds for about 3 hours. Grand Rounds consists of several lectures, usually themed together, with occasional guest speakers. We then might discuss a clinical case as presented by one of our colleagues (my presentation will be in May '08) or discuss some clinical scenarios.
Our shifts on Wednesdays then don't start until 1400 (2 p.m.). We work until 2100 (9 p.m.). The night shift then comes in and works 2100 - 0700. So, instead of a 12 hour shift, we work shorter shifts on Wednesdays which makes it nice because things just seem to go by a little faster.
My patients this afternoon:
- 80 something with diarrhea for a week = get admitted for dehydration and weakness
- 70 something with abdominal pain = get admitted for pain control of your underlying colon and pancreatic cancer (and, I might just add, cancer patients in my book get all the drugs they want)
- 20 something with chest pain = get admitted for observation in chest pain center
- 50 something passing out after a fall = still getting worked up when I left, but I worry when I read that the patient can't be placed in a normal shelter because he's listed as a "sexual predator" which makes living in most locations difficult
- 70 something with swollen hands = still being evaluated to make sure he's not going into heart failure, he just wanted to eat the same things he ate in the hospital so that his hands won't be swollen
- screaming 50 year old who I was asked to see because she only understood Spanish = would not listen to me when I tried to explain that I don't arrange for housing, I can only take care of her medical needs. From my conversation with the social worker, she's been thrown out of every local shelter around for being annoying and demanding.
Finally, we were signing out patients at shift change (where the on-coming residents take over our patients that are still being evaluated) when one of our own, a resident, was brought in by EMS. I think he was more embarrassed at having to be brought in than by what actually happened to him, but then he's got nothing to fear... we take good care of our own.
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