Show, don't tell...

Last night, a kid came into ER. He had sand in his eye. His eye was irritated, red and leaking thick tears. He was not a happy chappy.

Part of our standard eye exam is to put drops into the eyes to make them numb. They also dye the eye yellow, so we can see any scratches in the surface of the eye. They (allegedly) sting a bit, but most people tolerate them fine.

This kid had already had his parents squirting water in his eye and the teachers at school trying to flush him out, so he was understandably nervous about the drops.

I decided to try and make him feel comfortable.

"Look!" I said. "I can put the drops in my eye to show you it doesn't hurt!"

I stood up, tilted my head back and opened my eyes wide. A single drop of yellow dye hit the surface of my cornea with a splash.

"FUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUU*K", I thought.
"Oh holy sh*t this burns with an unholy fire!", I thought.
"Owowowowowow", I thought.

I stood totally still. Rigid, even. I couldn't move a muscle or the kid would know how bad it hurt.
"See?" I said. My face with a rictus smile. "Not so bad!"

The kid looked at me with total suspicion, but submitted to his drops. He bounced up after they were placed. "That was fine!"

As for me, I had yellow snotty-looking dye leaking from my eye for the rest of the night. Every patient I saw leaned away from me during exams and one little girl burst into tears when I walked into the room.

Good with kids? You bet.

Coasting

The Pitch:

Welcome to the Community! In this Emergency Department, you will see a wide variety of cases under the supervision of an experienced physician. You will have the opportunity to practice resource management, while providing excellent care for the people of your town. Friendly nursing staff and a safe, engaging place to build your skills!

Yay.

The Reality:

Welcome to the Community. In this ER, you will see little old ladies who have sprained their ankles (plus one who broke her foot and walked around on it until it turned black!), old farmers who have cow-bite-related infections and lots of lovely babies with coughs, colds and rashes. So far, so good.

The usual lacerations, back pain and UTI's will cycle through the department. The nursing staff will alternate between feeding you and making fun of you (this is ok). Your (one) staff doctor will let you see patients and manage them as you see best, while keeping an eye on sicker people to make sure you're doing the right thing.

Then, the ambulance phone will ring.
A VSA arrest is coming in. Vital Signs Absent. The ambos gave 3 shocks and some epinephrine, and this guy now has a heartbeat. Your boss, knowing you need this practice, will ask you to run the code. You will think over your training and stand at the door, gloves on, pits sweating. When you see the lights coming towards the driveway, you feel sick.

They roll in with the guy on the stretcher. His heart is beating, his pulse is strong, but his pupils are not reacting to light and he is totally limp. He doesn't fight when you put drips in, when you shift him onto the stretcher, when you pull his teeth out and stick a tube down his throat. You can't remember what order the drugs are supposed to go in; should you give the amiodarone now? Does he need the full dose, or can he have less cos he has a heartbeat? Do you need to paralyze him before putting the tube in? Or is his total non-resistance an indication that he's braindead and you're just temporizing? The one staff doc is watching you through this whole process and nodding, so you keep going, but then it's 5pm and shift change and she has to go home and pick up her kid so you're suddenly alone in the trauma bay, trying to remember what the next step is and...

Anyways. Community ER. It's like that whole "Air Traffic Controllers" joke; mind-numbing boredom 90% of the time, pant-wetting terror 10% of the time. This is my future.

I am trying to remember why I picked this job.
Anyone? ... Anyone?

ER is the Worst.

Young women are the worst.
They come into the ER shrieking about their pain being "the worst of my life", they cry when you examine them and they snap at you when you tell them the test results will take an hour to come back. "But we have dinner reservations for seven!"

Middle-aged women are the worst.
They talk down to you for being a young woman, bitch about how their kids are waiting at home for them, then tell you they've had this pain for at least a year and "can you hurry up and fix it so I can go for a smoke?"

Young men are the worst.
They're drunk. They cup your ass when you're stitching up their faces. They throw up when you put freezing into their cuts, and yell at you for hurting them, when they've been in a bar fight that resulted in 7 new ER customers. They hit on you as they leave the ER, despite behaving like jackasses all night.

Old men are the worst.
They tell you they have no pain, that they feel just fine and would like to go home. They don't acknowledge that their chest is filling up with blood and that they're having trouble breathing. They decline pain meds for a chest-tube insertion, then cry silent tears as you jam a finger through their rib-cage.

Old women are the worst.
They pat your hand and call you dear. They say how lovely it is to see a young doctor these days. When you tell them their cancer has metastasized and there is nothing more we can do, they smile and tell you it's ok. They thank you for your help, when you did nothing.

Babies are the best.
They are fat and smiley.

Off to Napanee ER for a month of hard-core community medicine. No CT scanner? No problem!

flow...

As a third year ER resident, you have three objectives:

The first is obvious; you need to increase your medical knowledge to the point where you can manage most crisis situations without having to rely on books/looking things up/phoning a friend.

The second is important as well; you need to learn to interact with multiple health care providers, the general public, hospital staff, police, ambos and miscellaneous drunk people, all while maintaining a professional demeanour.

The third is the hardest; you have to learn "flow". Alas, this is not a yoga term describing the transfer of healing energy. It is getting as many patients through the department as quickly as possible.

A few weeks back, we had a lecture from an ER doc who works in a town between TO and K-town. He told us that new ER grads are "ruining emergency departments" across Ontario. "35 patients per shift" he said. "That should be your target, your minimum."

If you don't see that many, you leave a snarled and tangled mess for the doc coming on after you.

I have kept this in mind over the past weeks. I have increased my multi-tasking.

"Ok, I'll leave the ultrasound machine to warm up in room 5 so I can see if she's having a miscarriage and while that happens I'll give this kid some freezing so I can reset his cast and in the meantime check this guy's ECG to make sure he's not infarcting and order bloodwork from the nurses..."

In theory, it's great.

In practice, sometimes the kid needs you to be calm and reassuring while you jam a needle into his hand, so you have to sit and play and build rapport.

Then, the young woman is indeed halfway through a miscarriage and you have to go in and yank the dead tissue out of her cervix so she doesn't bleed out, and then, by the time you go see the chest pain dude, he's left the department cos he really wanted a smoke and couldn't be bothered waiting for his test results, which are positive. So you chase him around outside trying to convince him he's having a heart attack, all the while keeping an eye out for the drug addict you had escorted from the ER for threatening to kill you and boom! Suddenly your shift is over.

This was last night. I saw 25 patients.

I think I am learning to cover the bases. I may not be a medical expert yet, but my interactions and flow are coming along...Right?

My vicious brain.

Yesterday was exciting. At 9am, I sat down in our teaching simulation centre. Every Thursday during the Summer, we are given a topic to research, then locked in a room with a bleeding mannequin and told to "fix it".

Yesterday's topic was Procedural Sedation; that is, giving people drugs in ER to make them drowsy so you can hurt them with minimal distress. I had not done the reading. I stayed up late watching a documentary on Netflix called "Babies", instead.

"Sam, you be the team leader." said my friend/senior Jen.
"This is a 200kg woman who has popped her prosthetic hip out of alignment. It's the third time this happened and she is in a lot of pain. The orthopaedics team is here to do the relocation, what drugs would you like to give?"

I could feel the stress flush creeping up my neck. I couldn't remember any drug names, doses, side effects, nothing... The mannequin started moaning and crying. My team looked at me expectantly. My peers, watching on the other side of the 2-way mirror, tunneled through the glass with their eyes. My armpits steamed up.

I gave propofol and ketamine. Not enough initially, too much eventually. The woman, once her hip was back in place, stopped breathing on her own due to my drugs. We had to help her breathe until they wore off. And my peers, while supportive, judged me with their eyes.

After this intense humiliation, I walked across the street and began my 8 hour ER shift. During this shift, 2 traumas rolled in. A young guy having some sort of seizure and a man who had been pinned under his tractor for many hours. I successfully intubated the young guy, giving the right drugs at the right dose. I scanned the tractor guy's belly using our portable ultrasound and identified some internal bleeding, teeing him up for surgical exploration. I also poked 3 year old with broken clavicles, old men with tummy pain and young women with bleeding in early pregnancy.

It was a good day. I happened to also be on call for the Trauma Team last night, so my pager was by my bedside, waiting to go off all night. When I turned it off at 8am this morning, I fell into a deep sleep.

A woman named Laura (I don't know any Lauras!) with dark hair and an acerbic attitude, was walking with me through the snow. She had talked to all my ex-boyfriends, and took me through all the stupid and humiliating things I've done in previous relationships. "You shouldn't have bothered with the surprise birthday, I'm just saying..." She told me that my enjoyment of my work was a sign that there was something wrong with me. "Sadistic, though?". Mentioned that most people thought I was a loser and breaking up with me was the best thing they ever did. I woke up shaking.

I don't know if my brain was just waiting to remind me of my Sim Lab failures, or if 20 hours of work/stimulation/emotion is too much. I do know I am never going to sleep again.

Fear-Based Medicine

Things come in threes. I hesitate to say "good" or "bad" things, but you certainly start to see patterns in the people who walk through the ER doors.

Last week I had 3 people with small bowel obstructions.

The first one I handled delicately, pressing and probing gently on their swollen belly. They got blood tests, lots of xrays and a CT scan before I felt confident about the diagnosis. The second woman got a thoughtful exam, a directed xray and a call to Gen Surg. The third? Slap on the belly and straight to OR.

My latest trend is anaphylaxis.

The first, a week ago, took place at the Urgent Care Centre (eg: not the full ER) and was a bit of a shambles. The nurses didn't realise they should give the epinephrine (epi-pen to y'all) in a muscle, not through a vein. They spent at least 20 minutes looking for a vein in a woman who's throat was closing rapidly. I quickly ordered the epi IM and then spent the next 4 hours shaking with terror at what had almost happened.

The second came in during my night shift. I was stitching up a drunk teenager (one of three!) when I heard my voice being called over the speakers. I ran to the cubicle to find the Staff calmly dispensing orders and monitoring the situation. Epi in the arm, back up drugs through the drip, monitor for 4 hours.

The third was wheeled in on an ambulance stretcher, gasping and flailing her arms. The ambos called "looks like anaphylaxis"! and I grabbed the nearest nurse. "Give her 0.5mg of epi IM stat, please!" It was done.

Then I actually assessed the patient. She did NOT have tongue swelling. She did not have a rash. Her blood pressure was stable. Her heart rate was acceptably fast. She was, not, in fact, anaphylactic.

I spent the next 8 hours watching her, waiting for the effects of the epinephrine to wear off. She was jittery and crazed all night. She settled as the sun came up. I did not.

The rule of threes may apply, but I haven't seen my third anaphylaxis yet. Because I was expecting one, I went ahead and dosed a woman with a drug that can cause cardiac arrest.

I am retreating to cold wine, a soft couch and a documentary about babies.

Casting Call

I like it when people break bones.

Once they're "pain-free" (dosed with tylenol and told to suck it up) we get to pull on their broken limbs and listen for a tell-tale crunch. This means: 1) the bone has clicked back into the right location or 2) everything has just gotten much worse. The clicks and pops are very satisfying, as is looking at an xray that has gone from dinner-fork to deviation-free.

However, before you xray, you must cast. In Oz, we had one formal casting session. We wrapped our limbs in stockings, in padding and in sticky warm plaster, then pretended to have battles with our newly powerful forearms.

Today, we had another casting session. I expected much of the same, even had my camera ready for the nerdy-awesome FB photos we all secretly crave. Today, I learned I've been doing everything wrong, every time.

Folds in the stocking. Folds in the padding. Wrong.

Every fold creates a pressure-point under the plaster that slowly erodes your patient's skin. Ulceration is the beginning, infection and amputation the potential conclusion.

The plaster; I thought we just wrapped it on and sent them out the door. Not so! Every cast takes 24 hours to fully anneal, so my former patients are likely to have had their casts disintegrate, melting away and letting their bones settle into weak, painful and deformed poses.

My patients may have had their casts checked early though, as my handiwork would also have ensured a stinking, rotting layer of cotton batting between their skin and plaster. Apparently, you're not supposed to dip the batting with the plaster??

Every day brings further illustration that this year was a good idea. Not for the qualification, but for the disaster mitigation. The more I learn, the more I realize I know nothing. Call me Jon Snow.

And wish me luck; tomorrow I am the trauma team captain for 24 hours. On call, watching from our balcony, awaiting the Ornge helicopter and it's bloody cargo. That or another prison fight. Kingston Pen is a valuable source of fresh wounds & limbs. This may be the best program ever.