2 easy pieces...

I'm chatting to a lovely man as I pull the bandage from the back of his head. He is charming the nurses, calling me "bellissima" and thanking us all for his care. The bandage is heavy and thick with blood. When I peel it away, I notice a pulse, a spurt of red from his lower scalp. I slam the gauze back in place and ask the nurse to apply pressure, then run to get the stapler.

12 staples, 5 sutures, 3 deep silk ties and a second doctor later, the bleeding has been contained down to a slow ooze. I'd asked the nurses to grab a second doc after I put the fifth suture in and the wound continued to spurt blood AROUND the closed tissue. I estimate that this poor man lost about a litre of blood between his fall (a simple trip) and getting his scalp closed.

As I wrote my notes, the sweat dried on my body and I thought, "Phew. First night back, pretty exciting..."

And then the PA called me to come see another patient.

PA's (physicians assistants) are a new thing in Canada. They have a 2 year diploma from a college and are employed to do the minor scut work in ER - placing simple sutures, casting, examining sore throats and ear infections, diagnosing UTI's. Some PA's are highly experienced, having worked in military medicine or been medical professionals outside of Canada.

Some are...not. This particular PA is about 19, has exactly 2 years of post-secondary education, and believes that she knows more than anyone in the department.

She grabbed me and said, "I think this patient is sick". I thought, "Uh oh". I walked into the room to see a person curled in the fetal position, shaking and pale. Temperature? 39 degrees. Heart rate? 110. Her voice was noticably muffled, as though her mouth was full of cotton wool. Or, say, a hot potato. Alarm bells began ringing all over my brain, and then the PA said, "I couldn't get a good look at the back of her throat, but I really tried!"

Kids, what is the most concerning diagnosis in this case?
If you said epiglottitis, you'd be right!
And kids, what is the NUMBER ONE rule of epiglottitis? A rule so fundamental that every medical student can recite it in their sleep? A rule so important that it is a pass/fail question on medical exams?
DO NOT EXAMINE THE THROAT OF A PATIENT WITH SUSPECTED EPIGLOTTITIS.

You are supposed to get the ENT team, the anaesthetists and a surgical OR ready before you even ask the patient to open their mouth wide. This is because an epiglottis can swell so quickly and completely obstruct the airway that even asking a patient to say, "Ahh" can be fatal.

Anyway, the PA got huffy when (after calling in ENT, pediatrics, anaesthetics and the OR team and seeing the patient safely shipped off) I suggested that next time she should not examine a patient's throat.  "Well, I didn't think it was epiglottitis, so I needed to look!" she said.

First day back. I am ready for another vacation.

grades???

I miss residency.

Alas, I am not joking. I don't miss the mandatory shift hours, the scut work or having to run every decision by someone subjectively senior to you.

What I miss is the feedback.

After every shift, I want someone to go through my list of patients and say, "You know, you could have done this better, but overall, you did a good job tonight"...

I realised this at the end of my second solo night shift. (Yep, just me, in charge of the whole ER, through a long and hectic night).

As I was leaving, a nurse grabbed me.
"Doctor, you've written a prescription for the kid in room 3?"
"Yes!" I cheerily replied.
"Yeah, you've written it on the chart for room 6..."

I groaned, tore up the script and made a joke about how I wouldn't be safe to drive home, as my brain was all goopy. The nurse smiled politely, but then, as I was leaving said, "You're doing a good job".
I stopped, frozen in place. "Sorry?"
"You're doing a good job! Have a good sleep."

The words were like pure chocolate, a rush of warmth and sugar and support and validation and...
And that's when I realised. I miss residency. I need external validation, which grownups don't get. So yes, maybe I'll go back to school. That critical care fellowship looks appealing. Just another 5 years of school???

Unleash the Sharpei!

Sometimes, a man's foreskin gets stuck in the retracted position. The tight band of the inflexible foreskin acts as a barrier to return blood flow, causing the head of the penis to swell, become engorged, turn red, turn black and eventually (if left long enough) fall off.

This happens most commonly in little boys - kids who play with their foreskin and forget to replace it. It can sometimes happen in men with botched circumcisions, who have lots of scar tissue on their remaining foreskin. And sometimes, little old men with dementia wake up for a pee during the night and forget to put the turtle back in its shell before going back to bed. This was my patient.

The great news is that my patient, a gentleman of some advanced years, did not have any pain with his paraphimosis. Yes, his penis was red, swollen and tender to touch, but he was pleasantly unaffected by the pain. His adult daughter was beside herself, wanting to support her father during his ER visit, but also really really really not wanting to see her Dad's schlong. We did a dance, trading places every time I went in and out of the room.

The treatments for paraphimosis are varied and mostly case studies. It doesn't happen often enough for a large body of evidence to exist. Sometimes people drain the blood with needles. Sometimes people use force to drag the foreskin over the mushroom cap. And sometimes you simply slice through that foreskin with a scalpel, releasing the tension and sending a wave of stagnant blood back into the body.

I did not do this. I dipped a stretchy bandage into a 50% sugar solution. I wrapped the wet bandage around the swollen red tissue firmly, but not tightly. I walked away (do-si-do with the daughter) and came back in 5 minutes. Then, I gently but firmly eased the foreskin over the now-shrunken penis. The osmotic pressure from the dextrose solution pulls the fluid from the foreskin. The compression helps. It all moisturizes the tissue and boom! The pig is back in his blanket.

I was lucky. I don't know if I could slice a confused old man's penis with a blade. But medicine with a spoonful of sugar? Happy to provide.

Suddenly, everything is terrible...

I've started my new job. ER in a busy city hospital. The patients are less wealthy, less healthy and need more done for them.

The staff (my colleagues) are stereotypical ER docs - big egos, borderline offensive jokes, lots of back-slapping and ribbing on the scene.

Sample: "This is John. He's the less virile Smith brother - he only has 3 kids!"
John: "Says the guy who can't get it up at all!"
etc etc...

These guys are all about the numbers. Their sense of professional satisfaction is tied to how much meat they can move and they are not interested in being slowed down by a new doc who hasn't figured out the computer system or how to cherry-pick the rapid cases.

On my first shift, I got left with 5 (FIVE!) sick, elderly, demented patients who had been transferred from nursing homes. All of these patients needed admitting for various reasons. By the time I presented the third admission to the medicine doc, she was irate. She took my arm and marched me down to a more senior ER guy.

"Your colleagues have screwed over this girl",  she said. He looked vaguely annoyed and made excuses about the new pickup system.
"No!", she said. "She is getting screwed over because she doesn't know enough and your colleagues took advantage of her!"

While I do appreciate the support, this is not a good way to get introduced to your team. This guy took me aside later and suggested that I bring in some home baking "to help get people on your side".

In addition to this humiliation, I also got blindsided by a PA. A physician's assistant. These are people who have a 2 year undergrad degree and are supposed to see low acuity patients. This PA had taken on a complex patient and (hindsight being 20/20) totally ignored her diagnosis, while focusing on her chest pain. She was in ER for 12 hours with no pain relief and turned out to have a broken hip.

My 8 hour shift lasted 11 hours. The admitting medicine doc (correctly) thinks I'm an idiot. My new ER team think I'm a pushover. I am not meeting my targets for patients to be seen. I am not providing very good care. And I have committed to 5 years at this hospital.

Maybe I'll run away and live in the country. When I work at Smalltown Hospital, I have great patient interactions, I have great relationships with the admitting docs, the nurses and I get along and (most importantly) my numbers are GREAT!

One week down, 259 to go.

cordial

During my ICU rotation, we had a very sick patient. The traditional cocktail of medications and machines were doing nothing and we, as residents, were stumped. We appealed to the Big Boss - what were we missing? What secret twist or turn would bring this patient back?

He shrugged. "I guess we could try methylene blue?"

And so we hooked a bag of blue dye to the patient's vein. It looked like a melted popsicle was running through the IV. Over some days, the patient did get better.

My boss couldn't explain why or how it had worked, just that he sometimes tried it, "When I'm out of ideas".

This case keeps coming to mind as I run through cases and old exam questions. Yes, on paper, the patient has A, we give B and the outcome is C. It's formulaic and relies on pattern recognition and memorisation.

In the ER where I work, I have yet to see a formulaic patient. The 7 year old girl with seizures? Could have been heat stroke, could have been meningitis. The 70 year old with a stroke? Also had renal failure and a cardiac event. The guy who shot himself with a nail gun? Well, actually, he was pretty easy to manage (pliers and a strong counterforce).

It reassures me, as I shuffle piles of paper and sort through antibiotic classes. Even my senior bosses sometimes have no idea. My patients haven't read the textbook. My nurses "smell" the diagnosis before I've walked in the room. The cops tell me someone is "hot and crazy" and know what to do.

Now I just have to convince a panel of examiners that all this is true.
When in doubt, give methylene blue.

newbie

What did you see during your first week of work?

I saw a kid who had been out in the sun all day. Her core temperature was 40 degrees celsius and her brain was cooked like an egg. We cooled her down until the helicopter could come to transfer her to the children's hospital.

I saw a glass dildo sitting high in someone's tummy; I wanted to ask them, "If you're going to spend all that money to put things in your butt, shouldn't you make sure they're butt friendly?" I want to make pamphlets for the waiting room: All about that bass? Try a flared base!

I saw a toe that had been disconnected from it's owner (mostly) and reunited these lost friends.

I saw a nail through a thumb that somehow missed the bone. The owner was learning to be a roofer. It was his first hour on the job. I suggested alternative career options as we yanked it out.

I saw fractures and cuts and coughs and colds and sore tummies and hernias and one thousand vaginas and one swollen ball.

All in all, a good week, I think.

Heavy Metal

The median level of ferritin in women is 45. This means that roughly half of women (surveyed in an American study) are low in iron. The study also found that women who were iron-deficient perform worse on basic cognitive tests.

Extrapolating from this, half of women are not meeting their cognitive potential due to low iron levels.

This information was delivered to me by my emergency medicine podcast, as I drove home from my first staff shift. My immediate thought was, "Well obviously! The patriarchy keeps us malnourished to prevent us from reaching our potential!"

Hear me out...

Society pushes women to be thin and sweet and docile. This involves being gentle - not red meat eating carnivores, but salad grazing ladies. This means eating less; smaller portions proportional to our dietary needs. This means eating restrictive diets that prevent women from getting their required levels of iron, folate and thiamine; all required to maintain healthy hemoglobin levels.

I'm not saying the patriarchy is consciously forcing women to have a low-iron diet in the hopes of keeping them docile and dumb. I'm just saying it's a nice coincidence that the same societal mandates that keep us hungry and weak also work to keep us cognitively slow and cardiovascularly deplete.

I got a nice rage burn as I drove. I pulled a chicken bone out of someone's tonsil yesterday, no sedation required, so I'm pretty sure I'm at the top of my game. And my iron levels are spectacular. Fight the patriarchy! Eat a steak! Or take your ferrous gluconate regularly.