September 8, 2007

• Crazy times in the ED

  Worked the medical side of the ED today. To clarify, our ED is divided into two sides, medical and trauma. The medical side is supposed to be for problems that are primarily medical in nature, such as chest pains, infections, psych evals and the like, while the trauma side is supposed to be more for broken bones, car accidents, and things caused by trauma. This is rarely the way it works out, but it is a beautiful idea in theory. In reality, trauma side is where medical students do more procedures, and medical side is where they learn more workups, which will hopefully help me not fail out of med school* when i take the ED exam in 2 weeks

  *Yes, I know i am being melodramatic, when i threaten med school
  failure every time i have an exam coming up. I dont care...these exams
  are scary, and i am trying to convey my level of unease and seeming
  unpreparedness to an audience whom i can only assume does not consist
  of primarily med students.

  First patient of the day was a psych eval. This was a little intimidating because the triage chart mentioned the patient in question had a history of schizophrenia. Now we have all seen numerous movies, or books, or have an idea in our head of what a schizophrenic patient should be like, and lets face it, it is a kinda amusing mental picture, with a paranoid nutjob who here voices and reacts in a comical way.

  Allow me to disabuse you of that notion. I go in to see the patient and introduce myself, and the convo goes somewhat like this

  Dr. J: so sir, why did you come today
  Pt: i dont know, leave me alone
  Dr.J: well someone must have brought you or told you something...why did they think you needed to come
  Pt: you cant help me. no one can help me
  Dr.J: that may be true sir, but i would like to try. could you tell me whats bothering you?

  At this point the pt switches from a otherwise bored apathetic monotone to an agitated angry tone. I use my keen powers of observation to realize that he is not in actuality secured in any way to the bed, and i am alone in a room with a known schizophrenic with the door closed. mmmkay

  Pt: FINE. you want to know whats wrong with me?! I'll tell you...the freakin polic brought me in, the doctor says i am a threat to the community which is all just govt bullshit. I mean, what the fuck. I never said i wanted to kill his mother, it was his girlfriend, and i didnt want to kill her, i just wanted to HARM her.
  Dr.J: (oh crap oh crap oh crap) And why did you want to do that sir?

  In a normal tone of voice
  Pt: Now i dont have any superpowers or anything, but I can read minds.
  Dr. J: when did this start?
  Pt: when did what start?
  Dr.J: the ability to read minds
  Pt: I CANT READ MINDS, THATS NOT WHAT I TOLD YOU!
  Dr.J: i am sorry sir, i misunderstood I am just a medical student
  Pt: no you're not, i know what you're thinking
  Dr: J: (dangerous nutjob) alright sir anyway,  So why did you want to harm his g/f?
  Pt: She put a hex on me, and now the evil spirits tell me things and i can read people's minds
  Dr. J: are you hearing them tell you anything now?
  Pt: I DONT HEAR VOICES, WHAT THE FUCK MAN
  Dr J: (omg, i am going to die) Okay, well do you see anything?
  Pt: yeah an image of my friend, but he's not my friend, i cant trust him anymore, i can see his thoughts and is conspiring against me

  At this point the patient breaks down in tears and begins sobbing loudly
  Pt: I'm sorry. I dont mean to yell at you. its just that my life is falling apart and I am missing so many opportunites and I cant control it. I feel like I am going insane, and nobody understands me, and I dont have any friends and I just dont know what to do
  Dr.J: I'm sorry you feel that way sir, do you mind if i briefly examine you
  Pt: (still sobbing) yes go ahead

  So my heart goes out to this guy, because here he is just clearly feeling terrible. At the same time, i am more than happy to have him crying, because if he is sad, i can examine his heart lungs and rule out any medical problems and not worry as much about my own safety.The goal is to make the exam as quick as possible because his mood changes every couple of minutes and i dont want him agitated and yelling when i am close enough for him to grab. One of the first things they teach you in academic lecture medicine is never get in between a psych patient and the exit. Well, eff that, i want the faster route of egress if things go south.

  So i conclude my interview and go back report to my resident and we go see him together, after which she apologizes to me for sending me in there alone. I shant lie, it was intimidating, Yes there were several things he said that were amusing, but to even crack a smile could have changed his mood in an instant, which was already unstable. And the worst part is, there is absolutely nothing that we could do for this guy, but call a psych consult, with an end result of which he will probably be kept drugged up enough to not be a danger to whatever home has to take care of him, or until his meds run out and he is back on the street.

  Thankfully, the remainder of my day was uneventful compared to that. Saw a woman with chest pains, most likely due to her cocain use the previous day. Of course, she neglected to mention that to me, only noting she used heroin every day. If nothing else, ED has reinforced the fact that you can never trust a drug or sexual history from anyone. PATIENTS LIE! ALWAYS! I mean, if you are going to tell me you snort heroin, why leave out the fact that you snort coke too? especially when i specifically ask about it? is it too make me look foolish in front of the attending???? if so, it works, good job! *grumble grumble*

  This was followed by a gentleman who was downright pleasant in comparison. He needed to have an abscess drained in his arm. Listened calmy to us as we explained the procedure, all in all a perfect gentleman, and then the second we started, this guy suddenly developed the mouth of a sailor, dropping f-bombs left and right at me and the resident about how we were hurting him, we were incompetent, doctors live for torturing others (which is actually true ) and a string of various obsecenities and arm movements that turned what should have been a 2 minute procedure into a 10 minute one. All because this guy was basically a big baby.

  A few of the pleasant side effects of this are that I am beginning to develop the authority voice. By which i mean I can tell people much larger and older than me to calm down and let me do my work, using a calm, collected, by firm tone with a touch of exasperation, and a lot of these people will actually do it. The patients do not just brush me off, but respond to the autoritative directions. It is a great feeling. Also, after having a schizophrenic yell at you,  just being cursed at by a rational human being isnt even enough to break the metaphorical skin and even annoy me. It is just amusing, cute even.

  The rest of the shift was downright easy by comparison, just a chest pain workup and another female evaluation, meaning a lookie-loo into someobodys vagina for infections, problems etc. I even got to operate the ultrasound machine and brought up some amazing angles and visualizations of a 5 week old fetus, not an easy thing to visualize, earning kudos from my resident. It also didnt hurt that those three patients were all spanish speaking

  btw, totally fluent in spanish now. Above and beyond conversational level, i can speak almost as rapidly as some of the natives, i can joke with them, and most importantly i can get full histories from them. In some ways, the spanish speaking patients are almost easier to deal with than the english speaking ones, because most of them are more than happy to tell you in minute detail what is going on (its a cultural thing-hispanics just have a lot more trust for docs in general) and the fact that i can speak and understand them puts them at much more ease than having someone talk at them through a translator.

  I say at, b/c a lot of medical professionals still do that, talking at the translator about the patient saying ask them this or ask them that, instead of just looking at the patient and asking them directly, with the translatory doing their job. Frankly, it's insulting to be ignored when you are right there. I never liked it as a kid, I certainly wouldnt like it as an adult, and I do my best to avoid it as a physician to be.

  So another routine day in the ED. Halfway done, and in the next post or two i will elaborate on where Emergency medicine falls on the future career o meter

  • 2:13 am
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