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.

Nope.

This is the stupidest day of my life.

Yesterday, I got up extra early to be in the cardiac cath lab for 7:45. There, I was scheduled to insert a large-bore femoral line into a man's groin. This is done in order to prepare me for emergency situations where urgent IV access is needed. I arrived, put on my new blue scrubs and introduced myself to the patient, the techs, the fellows et al. I helped set up the equipment. The head cardiologist arrived.

"Ehm, this patient is anticoagulated, so it might be a bit messy. Why don't you just watch this one?"

I smiled, nodded. It made sense. If the patient's blood is thinned (anticoagulated), there is greater risk for bruising and hematomas. I watched the fellow insert the lines, taking note of the smooth and gentle technique.

They were supposed to call me in the afternoon so I could insert the lines in a less complicated patient. They called me at 2:00pm.

"Um, the surgeon is scrubbed and they're starting the procedure. Did you still want to come watch?"

No.

Today, I was optimistic. Today, I would practice a valuable skill! Scrubs on, smile in place, I arrived bright and early.

"Today's patient is a bit complicated, perhaps you could watch the morning case and..."

I gritted my teeth, smiled.

I watched today's Fellow attempt the insertion. His technique was not unlike a jackhammer. He wiggled the needle back and forth in what could be best described as "vein-shredding fashion". I watched blood bubble out of the groin and bruises form in the patient's crotch.

The Cardiologist patted me on the shoulder. "Why don't you come back for this afternoon's case?"

I had to decline.

This afternoon, from 2-5, I was scheduled for Eye Enucleation training. That's where you remove the eyeballs from corpses so they can be used for transplant. I explained this to the cardiologist, who said, "Well, if we start early, we'll give you a call..."

No call.

I arrived, full of nervous anticipation (I am a regular anatomy-lab fainter), at 2pm. Then I checked the schedule. The class actually started at 3pm. I could have tried for another femoral line. I was annoyed, but consoled myself that at least I was missing one skill to learn another.

But. The cadavers were over-preserved. The Doc tried to pry the eyelids open and they just peeled off in her hands. We attempted to gently cut around the ligaments and little bits of stuff kept flying up like formaldehyde-scented confetti. The afternoon was a write-off.

The last 48 hours have been a useless mess. I feel like a useless, hot mess. I am going to drink a bottle of wine and get a sunburn, and celebrate my birthday in style.

Taking the long way...

This morning, I helped the team insert five thick wires into a man's groin. Well, his femoral artery. He was awake, and I kept patting his shoulder and saying, "It's alright Mr X, it's supposed to sting a little". Then his arterial blood sprayed me.

Then I watched a video to prepare for tomorrow's lab session. In the film, a cadaver has it's eyelids cut away in preparation for corneal harvesting. Our job, as ER docs, is to cut the ligaments that hold the eye in place, then pop out the eyeball and put it in the esky (cooler, to you Canadians).

Then, I opened up my schedule for August. ER involves shift work at all times of day. I will be working for about 10 days in a row, between chunks of time off. Most of my shifts will be at night or in the evenings. I will not see much of my partner, who moved to Kingston in order to spend time with me.

This afternoon, another groin, more wires.

I am staring over the precipice of the "What have I done?" spiral.

I could be working Monday to Thursday, nine to five, with weekends and holidays, living in Toronto surrounded by friends. Instead, I picked the worst possible option for a newly married family doctor about to take on a huge amount of debt. Blerg, blerg, blerg.