work

I come home at the end of a busy day and Mr G asks, "How was work?"...

"Busy. Nothing special..."

I saw a young woman who had been assaulted over the weekend. She met a guy at a bar, and after drinking and partying together, invited him back to her place. After a while, she asked him to leave and he got angry and beat her until she was unconscious.

I assessed her for skull fractures. She had a perforated eardrum. Her eyes were swollen shut by bruising. The rest of her injuries are too specific to mention, but they were extensive.

I documented everything carefully, and offered to give her copies of the documents for the police.

"Oh, I'm not going to report it. I know how it looks. I was drinking, I invited him home."

I said to her, "You know, inviting someone to your home doesn't mean they are allowed to beat you or hit you or physically harm you..."

But I didn't push. I didn't insist on calling the cops.

Because she's right. I couldn't say to her, "The police will help you. The police will be on your side. You will get the justice you deserve."

I know she's right. I know how it looks. She will be told that because she invited him in, she brought this upon herself. She was drunk. She was high. She didn't call the cops immediately. She waited 24 hours to come in to hospital. She is a woman who was assaulted by a man she knew.

It's infuriating, but the only thing I can do is be a good clinician. I offered her social work, I offered her pain medication. I treated her wounds and got her some clean clothes. We made arrangements for her follow up. And I repeated to her that her records would be on file, if she ever decided she wanted to report this.

As she left, she thanked me and said, "Usually the doctors aren't so nice..."

But, alas, when Mr G asks me, "How was work?" I would still say, "Busy. Nothing special." Because this is a totally normal experience in Canada in 2016.

I am so angry. All the time.

Consequences...

A 13 year old was brought to ER by his mother with flu symptoms. I assessed him, determined that there were no signs of bacterial infection and gave them my spiel about rest, fluids and over the counter analgesia. Mother seemed happy. Son seemed fine.

As I turned to leave the consult room, the mother stopped me.

"Doctor, I have another question. Just a quick one. When should my son's foreskin fully pull back?"

I paused.

Trying not to look at his mother at all, I asked him the key questions; can he pee without foreskin ballooning? Has he had any infections under the foreskin? Does it ever get stuck in the retracted position?

He stared firmly over my shoulder. Yes. No. No.

"But what we can do about it? Does he have to have a surgery?"

"Well, ma'am. As long as there are no side effects, it can be normal for the foreskin to remain tight until even as old as age 17. The recommended way to "loosen" it is to continually retract and replace it, which most young guys end up doing a lot during adolescence."

I am now looking firmly at the mother, but I can FEEL the blush running up this kid's body. She says, "What can I do to help?"

"Well, a good quality moisturiser could help with the friction..."

This poor kid. His mother and a lady doctor discussing optimal masturbation technique. I bet he ends up deeply scarred and only able to ejaculate while eating an orange out of a paper Whole Foods bag.

I was only trying to help.

Too Good Not to Share

A 28 year old woman walks into the cubicle.

Her: "My tooth has been really hurting for a few days now. I took some (branded strong painkillers) that I had at home but they didn't work and now I feel all sleepy and nauseated and weird."
Me: "Why did you have those strong painkillers at home?"
Her: "Well, they're actually for my dog..."
...
Me: "Why does your dog take these painkillers?"
Her: "Oh, he had surgery recently."

Not only did she take DOG MEDICINE, but she overdosed on it.
Not only did she overdose on painkillers, but she stole those painkillers from a WOUNDED DOG.

I didn't know what to do, so I laughed at her for a while, then sorted out a dental appointment and sent her home.

My job can be delightful sometimes.

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.