3rd Year Chronicles: Emergency Medicine

"I was trying to get a buzz," he slurred before closing his eyes and dropping off to sleep again.

I had just walked in to an evening shift in the ER and had picked up my first patient of the night. He had come in after taking about five tabs of methadone earlier that morning that he had bought off someone. After ingesting them earlier this morning, he spent the next few hours "falling out" (fainting) about four times at home. Once he had "sobered up," he decided maybe that wasn't normal and he should come and get checked out.

Probably a good idea.

We went through all of the usual questions – no, he said he didn't take anything else. No, he wasn't trying to kill himself. No, no other medical issues. He was groggy but conversational, his vitals were normal at the moment, and he wasn't having any acute issues so after we talked and I examined him I left to go find one of the ER attendings to discuss what to do about this guy going forward. Even though he had been using sedating medications, passing out several times and falling at home isn't normal. Also, his EKG (an electrical picture of what his heart was doing for a few seconds) was a little bit abnormal, so he was likely going to buy himself a bit of a workup and likely admission.

The night went on. I walked out of another patient's room a little bit later and went to a computer to check on the workup of some of my patients so far and noticed that the methadone guy had been moved to one of the resuscitation rooms. Turns out he had an episode of ventricular tachycardia (a very fast, abnormal heart rhythm) that was caught on the heart monitor in his room. It was short but that's definitely not normal, so he was moved to a room where we could watch him more closely and intervene if needed.

Turns out, that was also a good idea.

Shortly after his first brief episode of "v-tach," he went into another one – longer this time. He had a pulse but wasn't responding – the heart wasn't able to pump enough blood to the brain. We had already put the defibrillator pads on him, so after he became unresponsive we started charging the machine and delivered the shock. He almost jumped off the stretcher, but immediately he was awake and the monitor was demonstrating a normal heart rhythm again. The attending started a constant infusion of a medication called amiodarone to hopefully keep his heart rhythm normal and we started working to get this guy upstairs to the ICU for further observation and care.

Turns out, his heart had other plans. As we were working in his room, he became unresponsive. V-tach again. He had a pulse. Charge, clear, shock, jump, awake. Breathe. Time to get this guy upstairs. We began to wheel him out of his room into the hallway towards the doors to the elevator when he became unresponsive again. Again, he still had a pulse. Charge, back to the room, clear, shock, jump, awake. Breathe.

This happened five times in a space of a few minutes. This guy needed to be sedated so we could continue to care for him and shock him if needed. That means we needed to "take his airway," or intubate him – put a long breathing tube down through his mouth, past his vocal cords, and into his lungs.

As it happened, the day before we had just had a (timely, it turns out) skills session learning how to intubate, run a code, and use the defibrillator. As we were preparing to intubate him, the attending turned to me and asks, "Have you ever done this before?"

"Nope… but we did just practice yesterday."

He hands me the blade, a short curved metal instrument with a handle that you insert into the patient's mouth while standing behind their head to sweep the tongue to the side and lift up the soft tissues of the jaw to expose the vocal cords, which hide deep in the throat. "You're up."

Well ok then.

We run through the pre–intubation checklist (in medicine, as with most things, the most important part of any task is the preparation). Suction. Bag-valve mask at the ready. Oxygen on the patient. Blades. Tubes. Meds. All of the tools we need to place the airway and make sure it's in the right place when we are done. Finally, it's time. He has been paralyzed and is now depending on us to breath for him, which means we have a limited amount of time to get things in place.

The day before, we had practiced on plastic mannequins. Their airways were, well, plastic and actually really hard to work with. You have to lift up on the handle of your blade once it's inserted in the mouth to expose the cords, but you have to be careful about how you lift – if you lift the wrong way, you'll break their teeth. With the mannequins, you almost had to lift the disembodied torso off the table to visualize the cords.

Human tissue, it turns out, is a lot more pliable. I opened the patient's mouth, inserted the blade (this is the side to put it in on, right?), swept the tongue aside, and lifted the blade towards the corner of the room, surprised at how easy everything was move out of the way.

Breath in.

This is the part where everything falls into place or falls apart. Almost immediately, I could see the floppy epiglottis hanging down, obscuring my view.

"Push the blade in just a bit further."

I eased the tip of the blade in just a bit further behind the epiglottis, lifted up just a bit more… and there they were. Beautiful pearly white cords.

"I see the cords."

Breath out.

I held out my hand and someone handed the endotracheal tube to me. They tell you that, once you see the cords, you should never look away – you don't want to risk losing them. I inserted the tube into his mouth, guided it towards his glottis, and was relieved to see the tube passing easily through the cords.

"I'm through."

My job was over for now – I removed the blade, we secured the tube, and began taking care of all the other tasks that need to happen once someone is unconscious and depending on a team of strangers to help them breathe.

______________

That night was probably one of the more memorable moments of my month in emergency medicine and certainly embodies some of the reasons why I personally think the specialty is one of the best jobs in medicine, but it certainly isn't how the whole month went. Every other shift was filled with hours of seemingly more mundane encounters – sorting through which chest pain patient might actually be having a heart attack, which belly pain patient was actually having an abdominal emergency, helping patients who came in short of breath to rest a bit easier, and figuring out which kids were potentially sick or not. Not all of it was fit for prime time TV, but I thought it was one of the best months of medical school.

It was very different than all of the rest of my third year rotations. The pace, the patients, the focus – it was a huge paradigm shift from working on the floors or in clinic. In the ER, you had to move fast or drown in the sea of patients waiting just outside the double doors in the waiting room. While upstairs I might have had the opportunity to spend an eternity chart reviewing a new patient, poking through their old medical records, and even writing most of my note before I even had to go see them, when I was in the emergency department I was lucky to see their initial vitals and a triage note before I walked into the room. You had to think on your feet and form your differential diagnoses at the bedside and walk out of the room after a brief encounter with at least an initial plan of action.

One of the doctors, on my first shift, spent a few minutes giving me and another student a few pointers before sending us off to see patients. "In the ER," he said, "you don't have time to think. Don't think. Just do. You have to do your thinking outside of the ER." And for the most part, that proved to be true. If there was something I didn't know about on the floors, it wasn't unusual for me to have some time, at least in the afternoon, to sit down and read about a topic for a few minutes. That wasn't typically the case here – if I needed to look something up before presenting a patient, I had maybe a couple of minutes tops before I would start running behind. You really had to spend time off of your shift thinking through how you would react in the first few minutes of any given patient encounter, what your initial actions would be, what questions you'd ask, what physical exam portions you'd emphasize, what your top differential diagnoses would be, and how you'd go about working that patient up, if at all.

We spent about half of our shifts over the course of the month working at Loyola and the other half working at a community hospital nearby. Personally, I actually really enjoyed the community shifts more – at Loyola, a large tertiary care center, there was a "team" for everything (strokes, heart attacks, trauma, etc.) and a separate pediatrics section. So while we stayed plenty busy, it seemed like everyone had their hand in the pot. At the community center, it was you, a couple of other docs, and the waiting room. You saw all the patients, did most everything that needed doing, and functioned like you'd imagine an emergency medicine physician would.

As I've mentioned in previous posts, as I progressed through third year I realized I really enjoy practicing the breadth of medicine. As I spent time in various specialties, I was always impressed at the level of knowledge required within that particular field but always missed "everything else." I knew that I didn't want to be a "knee guy" or a "liver guy." Instead, I always have found it appealing to do a bit of everything. In the introduction chapter to Harwood–Nuss' Clinical Practice of Emergency Medicine, the author writes the following:

"Practicing emergency medicine is like carefully lining up a putt, then dropping the putter, picking up a tennis racket to return a volley or two, quickly side–stepping an onrushing tackler, and then returning to sink the putt."

Another doctor/writer said that "Emergency Medicine is the most interesting 15 minutes of every other specialty." Essentially, it's perfect for someone like myself who enjoys most aspects of medicine in general and really doesn't have an interest in spending the rest of my career focusing on a limited number of medical conditions. That said, EM provides plenty of opportunities to become a "master" at whatever particular bit of medicine you find more interesting than the rest – for example, sports medicine, toxicology, emergency cardiology, resuscitation, and so on.

I've been interested in EM since before medical school. In fact, it's what got me interested in medicine in the first place. Going through medical school, I've tried to put it on the backburner, keep an open mind, and explore other fields, but nothing else really sticks out to me like this one. When I picture being a "doctor," I've always pictured someone who could handle just about anything. There are few fields that fit that description, but I think EM is one of the best at meeting that criteria. Obviously no field does everything. Medicine is a team sport and every field has its limits, EM included.

One interesting thing about EM is that it is practiced in bit of a fish bowel – that is, everyone is watching. All the hospital staff who take over on the patient you admitted for whatever reason can see everything you've done so far in that patient's care and workup. And at least at academic centers, and especially in residents, it's sometimes en vogue to make fun of something that was done during the patient's stay in the ED. It seems to be less of an issue with actual attendings or in community settings, but it's just an interesting phenomenon I've noticed. What's often overlooked is that the same Monday-morning quarterbacking is often done from the comfort of a small, quiet room somewhere tucked away in the hospital with the benefit of 1) more time (the best diagnostician, by far) and 2) more complete information (in part because of the workup that is currently being mocked). Sure, we know the patient's not having a heart attack now, the morning after they were admitted. But that's something you only can tell using your trusty “retrospectoscope,” which unfortunately wasn't available to the ED physician at 1 am last night. Additionally, the practice of EM can be radically different than the practice of medicine on the floors – less information, higher stakes, faster paced. Sometimes that means maybe an extra test or two were ordered in the interest of time, or maybe some treatment was initiated that technically could have waited, but that's the game. Finally, what they may sometimes forget is that for every admission, veritable hordes of patients were seen, treated, and “street-ed” from the ED.

If you're interested in EM, just be aware that there are those with very vocal opinions about the field (and often other fields as well). I would just say to smile and nod and realize 1) they honestly have no idea what they're talking about. It's not their fault; they just don't know how things work in the ER. And 2) I've noticed that oftentimes the loudest critics (whether of EM or any other field) seem to be trying really hard to convince themselves that they chose the right field for themselves. If you want to learn the pros and cons of the field, talk to an actual ER doctor. So there's that. Just play along, keep a thick skin, and don't lose sight of what's important – that is, choosing the right field for you, not your burned–out resident.

Speaking of burnout, that's another concern that's commonly voiced about emergency medicine. More than likely, it's a valid concern for a lot reasons – the shift work can be brutal (especially as you get older), the actual practice can vary a lot depending on what environment you are in, the pace can be soul–crushing, etc. But if you look at some of the burnout data from the Medscape surveys, burnout is really an issue with medicine in general, not just EM. And while EM can be found near the top of lots of the charts related to the prevalence of burnout in various fields, you'll notice that the difference between EM and the next ten fields is pretty minimal (a few percentage points). What's also interesting is that while the prevalence of burnout in EM may be a little bit higher than other fields, the severity of that burnout is lower (even that that of, for example, family medicine, a number of surgical fields, and even internal medicine). The problem isn't so much with EM as it is with medicine in general – the landscape of medical practice is shifting and more and more is being expected of doctors as it relates to metrics and paperwork in addition to good old patient care, which is what we all – presumably – went into the field for in the first place. Preventing burnout is a topic unto itself and has a lot written about it by people smarter than myself, but suffice it to say that there are things we can do to minimize the risk of burning out. For example, keeping your priorities straight (e.g. decreasing shifts at the expense of some income), keeping yourself healthy, quickly doing away with your medical school debt and setting yourself on the path to achieving financial independence so you aren't chained to your job, and making room for a Plan B (e.g. a fellowship into a different niche of medicine or perhaps a different career path entirely) are all good places to start.

Ultimately, finding the specialty that's right for you can be a bit of a journey. You might have one in mind at the beginning of medical school. Or not. You might end up sticking with that specialty. Or not. You might bounce back and forth between several seemingly unrelated specialties throughout third year and maybe even into the beginning of your fourth year when you absolutely have to choose (or just go into internal medicine to defer the choice for another three years… I kid, I kid). For me, though, I'm excited to begin the residency application process for emergency medicine and looking forward to what the future holds.

The Stare of Death

I’ve been on fall break for the past week…and it’s been glorious. Loyola starts a little early, but that translates into a week-long break halfway through the first semester. Which is most excellent – and much needed. It’s been a long few months. My wife and I have spent the break basically trying to be as non-productive as possible (i.e. watching a ton of old movies that we watched as kids, eating ice cream, and occasionally doing more big-person things like shopping, home repairs, etc.). We’ve had a blast.

We also got to go to our first ultrasound, which was awesome. My wife is twelve weeks along now, and he?/she? is starting to look like a little human being. It was quite the moment when we got to see our child moving around, kicking, and generally looking cute on the ultrasound screen. Just because I can’t resist, here’s one of the pictures we were given to take home with (awww....). His/her feet kind of look like claws in this view, actually. But they’re really quite normal – we checked. I may or may not have tried to count his/her fingers.

But, alas, break is soon going to be over, and back to the grind we go. We started anatomy a few weeks ago. It’s actually been really interesting, but it’s also been really, really busy. The tried-and-true fire hose analogy that people use to describe the volume of information coming down the pipe at you in medical school – all of which you have to know, and know well – continues to be proven true, if not even more so than before.

Loyola actually recently changed up their anatomy curriculum. Their overall goal was to cut down on required time slogging through excess adipose tissue in the lab and increase the time that students had to master the material on their own. Personally, I’m a fan of that goal. Dissection is an awesome experience, and somewhat of a rite of passage for doctors-in-training, but it can nevertheless be somewhat of a drain on one’s limited amount of time. So, instead of having close to twenty bodies for the class and everyone in the lab at once with only a few instructors to go around, they’ve cut the body number down to six, posted a faculty member at each table, and split the class up into rotations, with each rotation dissecting a certain region of the body. I was assigned to the thorax and abdomen, which should be interesting. Students can, by the way, go down whenever they want, but only absolutely have to be there during their rotation. Additionally, instead of making us sit in lecture, they’ve tried to summarize the key points of lectures in short-ish videos that we’re supposed to watch before coming to class (which, during anatomy, only goes for about an hour or two max – which has been awesome). During class, the idea was that we’d go over board-style questions that made us really think through the relevant material to arrive at an answer.

There have been a few glitches in the execution of their new curriculum, however. The biggest issue has been with the videos and “lectures.” Unfortunately, trying to pare down anatomy to a few “key points” leaves a lot missing. It’s difficult to then go forth and memorize crap when we really don’t know where to stop – we could, of course, go on memorizing forever (and, being the neurotic medical students that we all are, we would). We really didn’t know where to stop. Additionally, we were supposed to watch these videos the “night before” the “questions lecture,” which really gives us no time to process and learn the information…which means that the lectures really turned into a waste of time, since we had no idea what we were supposed to be doing. Finally, some people weren’t happy about the change in lab setup – I remember one of the questions that always seemed to come up in tours of the schools on interview day was something along the lines of “What’s your student-to-body ratio?” (As an aside…this really isn’t all that important. Really.)

Thankfully, Loyola is pretty responsive to its students. We had a Dean’s forum, where we basically were given free food and were able to ask the Dean of the school any questions that we had. Anatomy was a hot topic. We all expressed some of the above concerns, and within a few days we started to see some changes. First, the “question lectures” became more “lecture-ish.” This was actually the most helpful change, in my opinion, as it’s nice to have someone walk you through certain things that don’t come as easily from a short video or staring at a textbook. Next, the professor produced a more definite list of what we should focus on. Finally, for those students who wanted more lab time, the professor started doing short, daily reviews in the lab of the previous day’s dissection, just so we can see things on an actual human body instead of simply in pictures and to save us the pain of going down on our own and trying to pick through things. So far, I think things are shaping up for the better – we’ll see how things go.

I have had a few opportunities to get out of the classroom, though. One of the things I did was volunteer at a free clinic in Chicago that Loyola students basically take over for one night a week. First year medical students essentially observe, might take a history, and pretend to listen to heart and lung sounds. Second year medical students, on the other hand, really get to run the show – they’ll interview the patient, examine them, come up with a plan of treatment, present the case to an attending, talk it through with them, and write a note. It’s really a great opportunity to get out of class and use some of the skills we are learning. So far, first years have only covered the patient interview and spent some time interviewing standardized patients, but as the year progresses we’ll learn more physical exam skills. That should be fun, and the clinic should be a great place to practice and take a break from class.

Loyola’s anesthesiology interest group also has a program called APEP, or Anesthesiology Preceptorship Enrichment Program. It’s essentially a program that pairs students up with an anesthesiologist mentor with whom they meet once a month for a few hours during the anesthesiologist’s shift and discuss some basic science concepts in the operating room. It’s a great way to translate some of our bookwork to the real world. I’ve met with my preceptor once so far, and had a great time. We talked about different sedation methods, intubation, difficult airways – and there was mention of a possible opportunity to intubate in the near future. That’d be fun. The program isn’t just for students interested in anesthesiology. I personally didn’t have a huge interest in it coming in to medical school, but I do want to explore different specialties and see what’s out there. Also, it’s a great opportunity to spend some time in the hospital and learn some practical stuff that one might not get through a lecture.

Finally, I was able to spend an afternoon shadowing an emergency physician. Since I worked for a few years in or around an emergency department before medical school, and this is the specialty I have had the most exposure to, it’s also the specialty I’m most interested in at this point (supposedly, I’m supposed to change my mind about this at least twelve-bazillion times in the first couple years. Or so I’m told. I’m sure I probably will). It was a good shift – it’s different being introduced as a medical student and getting the opportunity to participate more in the patient’s care. As a scribe, I was used to standing in the corner and writing down what was going on. Now, I actually get play some small role, and that’s a lot of fun.

About halfway through the shift, we heard the EMS radio come on. Through the static, we gathered that there was a full code about to come through the door. The usual calm before the storm ensued – people began to prepare one of the trauma rooms and gather around the stretcher, double-checking their equipment and wrestling their uncooperative gloves onto their hands. Then the double doors to the ED flew open and a stretcher came through. It was being guided by two people with another person trying their best to continue chest compressions while walking alongside the stretcher. I didn’t catch most of the story, although it didn’t sound like there was much of one – male in his mid-sixties, found down. CPR started at the scene, epinephrine given just outside the ED doors, no response.

The doctor I was shadowing didn’t have this patient, but followed the stretcher into the room to see if the other doctor on wanted a hand. My scribe instincts kicked in, and I started to look for a corner to stand in and stay out of the way. Before I found one, though, she motioned me to follow her in and threw me a pair of gloves. The poor soul who had walked in beside the stretcher doing compressions had been relieved by fourth year medical student who was rotating through the ED, but he was starting to look a bit fatigued. Before I knew it, I was standing over a very dead-looking patient, bouncing up and down on his chest, and trying to keep time to “Stayin’Alive” in my head.

This was my first time doing CPR on a real person. The first thing that struck me was how everything seemed to slow down a bit. There was plenty of time to think. The second thing that struck me was how grey the fellow looked. After that, I was surprised by how “rubbery” his chest felt – somehow, I didn’t expect the rib cage to have that much rebound. Finally, I quickly started thinking that I really should do more cardio – compressions are exhausting!

The doctors did a great job of making it a teaching experience. They showed me and the other students where to check for a pulse to make sure that the compressions are effective, and after using ultrasound to check for cardiac activity, walked us through what they were looking for and what showed up on the ultrasound. It was really interesting. They also made sure I saw the “fixed and dilated pupils” – the stare of death. That was…weird. It really was a truly empty gaze. With cadavers, their eyes are usually closed. It was different staring into the eyes of a person who, moments ago, might have been thinking about what they were going to eat for dinner that night.

The gentleman didn’t make it. Or, more correctly, he stayed dead. And life went on. We went and saw another patient, the body was prepared for viewing, and…that was it. I had seen people die before, but this was the first time I had really been involved in their care. That said, it really wasn’t sad so much as it was more of a profound moment. I wonder if that feeling will stick around.

Medical school continues to be a blast. This week off has been awesome, and I wish that it didn’t end in a couple of days, but at least the material we are learning is, I think, really interesting and fairly relevant to our future careers. So, back to the grind we go.

Can I Get You a Wheelchair?

Note: Again, another incident I wrote up for myself last year, posted here for your reading pleasure. 

December, 2011

I was on my way out of the ED today after a shift full of "malodorous" drug users, sick people, and a very persistent crying kid who had fallen on sheet metal and lacerated his chin.  Out of the corner of my eye, I noticed a heavyset man, probably in his sixties, leaning against the wall just inside the main entrance but out of sight of the triage desk.  I wasn't sure what he was up to, but I was tired and needed to get home and study for finals.  I slowed as I passed him and looked him over out of the corner of my eye--he appeared ashen and couldn't seem to catch his breath. That's not good.  I walked over to him.

"Sir, can I help you?"

No response, except for heavy breathing.  Now he is pulling himself along the wall towards the triage desk.

"Sir?  Can I get you a wheelchair?"

"My...pacemaker..." he gasped.

 Uh-oh.

I looked around quickly for a wheelchair--there was one just outside the door.  But now he was beginning to slide towards the floor.  I put my arms around him to support him and nodded towards one of the individuals in the small crowd that had gathered.

"Can you go grab that wheelchair?" I asked. He made a beeline out the door.  Then, I looked over to the triage desk, made eye contact with one of the staff, and gestured for her to come over.  By now, the bystander was running back with a wheelchair.  The triage staff member was running over with one too.

"Looks like you've got your choice of chairs, sir," I said, continuing to hold him up.

I had the bystander bring the wheelchair just behind the soon-to-be patient, bear-hugged the large man, and lowered him into the chair.  Once he was in the chair, I brought him back to the rest of the triage staff.

Working as a scribe has been an awesome clinical experience and a great opportunity to see how a doctor functions day to day in the ED.  But I realized after this episode that I really miss patient contact. Even though my previous job working as a patient transporter at a different hospital was a simple, often routine job, I had the opportunity to interact with and care for patients.  Though scribing is and will continue to be a valuable experience, one that I am extremely grateful to have, I look forward to the day when I get to "glove up" again and provide tangible care to patients.

Don't Taze Me, Bro!

Note: I actually wrote this last year, just for fun. Figured I'd post it here for kicks and giggles.

8/27/11

I had two night shifts this week.  Back to back, with school in between.  That was fun.

The first one was actually decently interesting.  Some guy almost got tazed.  He came in complaining of back pain after getting into a fight.  Apparently his girlfriend got into a tussle with some rather butch lesbians.  He, of course, came to her rescue...and got his butt handed to him. His girlfriend said something about him being thrown six feet.  Of course, after spending a few minutes around the guy, the rest of us wanted to throw him too.

"I've been waiting twenty minutes!" This came from his room. Nobody really responded at this point.  So he escalated.  He began shouting, cursing, and generally making it known that he was being treated unfairly and wanted to go somewhere else.  A nearby security guard came over to tell him to calm down.  The patient, yelling all the while, walked quickly toward the guard.  Big mistake. The guard stiff-armed him to keep him in his room and put his hand on his tazer.

"Get back in your room or you will be tazed!" shouted the now-pissed guard.  Repeatedly.  And to no avail. He called for stat backup to room 4, all the while keeping the patient in his room. The patient, of course, would have none of it.

"He pushed me!  Did you see that?" he said to no one in general. "He pushed me!"

Buddy, you're getting off easy.  The rest of us want him to taze you.

Of course, while all this is going on, EMS wheeled in a cardiac arrest victim into a nearby trauma room. This patient had been found down after an unknown period of time with a hypodermic needle nearby. The paramedics had intubated him, given ETT Narcan, and CPR was in progress,  but he was in asystole—a non-shockable rhythm. Once in the room, the doctor I was scribing for drilled a hole into the patient's left shin to insert an intraosseous line and administered epinephrine and fluids.   Didn't work.  CPR was stopped, and after the artifacts on the cardiac monitor passed, we all could see that this wasn't going anywhere fast.  CPR was restarted, epi was administered again.  No change.  Code was called at 02:42.

This type of contrast between life and death isn't uncommon in the ED. In one room, one patient had experienced his last high. In another room, the patient was going to live to be a jerk another day.