The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Friday, April 07, 2006

Some Actual Tales from the Emergency Room

So after bitching about my first shift in the community emergency room, I should be fair and rave about my subsequent three shifts. I spent two full 10 hour shifts in the emergency room since my preceptor had headed down to Windsor for the OMA hockey tournament. Ontario was a bad place to be sick last week... all the docs were in Windsor. Then I spent an additional afternoon in the ER which I'll be continuing to do on a weekly basis until the end of my family medicine rotation.

Small town emergency room? Not so much. This place was crazier than any academic centre I had ever worked in. With the possible exception of the Royal Alex in Edmonton, which is located smack in the middle of the seediest part of town and where the safest rule of thumb is to assume your patient is an alcoholic/addict until proven otherwise. Had I followed this rule of thumb I would have prevented one of my patients from going into DT's (alcohol withdrawl seizures) just seconds after I had nicely reduced his dislocated shoulder, promptly dislocating it again. But I'm getting a little tangential...

So here's a quick sampling of the good, the bad, and the completely bizarre that I was privy to over the course of 2 and a half shifts in my sleepy, small-town emergency room.

  • 5 CVA's in 5 hours. Holy crap. I am now well-versed in the criteria for clotbusters.
  • One child with the worst case of chicken pox I'd ever seen. She was admitted with varicella pneumonia, a complication of chicken pox. Poor kid. Someone should have taken her picture to show all of the parents who think having chicken pox is a natural part of childhood.
  • An elderly guy who came in two days post-MVC with some impressive hematomas. The bags under his eyes were filled with blood, and looked like two purple testicles hanging off his face. Even more impressive was the hematoma on his head, which although it wasn't bruised, probably measured a good 15cm in length and protruded about 3cm from his head. A few days later he came in again-- the hematomas under his eyes had receeded, leaving nothing but bruising, but the scalp hematoma was unchanged. So I got to drain it. So... cool...
  • Two cases of cellulitis secondary to IV drug use. I got to cut them open, debride them and pack them. Further confirmation that most doctors are the same kids who used to pick at scabs incessantly.
  • A guy who came in with a 1L pop bottle stuck in his ass. The outline was plainly visible on x-ray. That wasn't even the best part... a hooker put it there, and he was desperate that his wife not find out about it. Consult surgery!!!
  • A case of what was most likely THC-induced gastroenteritis. (I've been seeing a lot of young men with abdominal pain lasting 2-4 weeks, intermittent vomiting, some weight loss but no change in bowel habits (no bloody diarrhea, in particular). The one thing that they all had in common was that they smoked pot regularly. Normal bloodwork, normal abdo ultrasound... resolves if they lay off the pot. Diagnosis of exclusion, sure, but it seems to fit the bill.)
  • A 35-year-old tall, thin guy with severe chest pain that radiated through to his back. If you work in any health-related field, you're probably thinking what we did. And it was. Marfan's syndrome! Chest pain! Dissecting aortic aneurysm! Holy crap! Confirmed by CT within minutes of his arrival, but was left hanging around in resus for nearly 4 hours as CritiCall desperately tried to find a centre with an available cardiothoracic surgeon and an ICU bed that could take this guy. Three 'no room at the inn' responses later, he was on his way to the nearest American centre. And our tax dollars paid for it. Sometimes, our health care system just sucks. But the whole thing was cool to see anyway.
  • More 'rule out MI' than I care to think about. Ironically, though, the only person who was actually having an acute MI was the woman who sat quietly in the waiting room whose chief complaint was 'funny feeling'.
  • Four nosebleeds, one in a guy with an INR of 7.2. He apparently thought that after he was stabilized on coumadin, he didn't need to monitor his INR anymore. I became very efficient at the use of Merocel (basically, nose tampons).
  • A woman who was 2 weeks postpartum with calf pain. Sure enough, big honking DVT. Ouch.
  • A 'found unresponsive' who never actually became responsive. After some creative detective work and the shotgun approach to the tox screen, it was ruled a TCA overdose.
  • No really cool procedures, but I got three ABG's on my first try. Hey, those count too!

Sigh. I've REALLY missed emerg. I can't believe that for a minute there I was actually doubting my resolve to do that third year of training. Family medicine is good and all, but nothing makes time go by faster than the emergency room.

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12 Comments:

Anonymous grass said...

cool - but for your non-medically versed readers, i'd love to know what some of the acronyms mean! i even tried googling but all that came up for CVA was college of visual arts... :-)

12:28 AM

 
Blogger Tamara said...

grass: Try the acronym finder (www.acronymfinder.com) - I figured them all out except TCA and ABG where I couldn't decide between two or three medical-sounding terms.

I think CVA is "Cerebrovascular Accident (stroke)".

9:02 AM

 
Blogger Nikki said...

THREE ABG's on the first try?! If I ever need one done on me, I'm tracking you down! Well done!

9:13 AM

 
Blogger Couz said...

My bad. I forget that non-medical people read this stuff too. :-)

CVA = Cerebrovascular Accident aka Stroke (like Tamara said)

TCA = Tricyclic Antidepressants (old school antidepressants that aren't used nearly as much anymore partly due to their danger in overdose)

ABG = Arterial Blood Gas (measures the amount of gases and acid in the arterial blood-- usually blood is taken from a vein)

If I think of any more I missed I'll clarify.

11:03 AM

 
Blogger Couz said...

I found some more:

MVC = Multi-vehicle collision

INR = International Normalized Ratio (measure of the clottiness of blood)

DVT = Deep Vein Thrombosis

THC = Active ingredient in marijuana

All good?

11:05 AM

 
Blogger Tamara said...

Thanks Couz! :)

8:33 AM

 
Blogger mrbunsrocks said...

Wow. Awesome post.

And the whole bottle story...priceless. hahahahaha.

2:52 PM

 
Blogger Fat Doctor said...

I've worked in both small hospitals and huge university medical centers. I think some academics think community hospitals just take care of really bad sore throats, but that certainly wasn't my experience. Sounds like you are getting some good time in the trenches.

9:30 PM

 
Blogger docsubramax said...

ER postings are indeed some of the best of postings, as you have yourself discovered. i have been in ER for 13 years. no two days have been the same. and i've got tons of stories to tell.

i'll let you in on one:

I was at the emergency room of a private hospital at about 12 midnight, when I received an adult male, about 25 years old, who had apparently been involved in an accident, a short while earlier. He had been riding a large motorcycle, which knocked head-on into a car.
He looked very well in spite of the nature of the accident, and walked in by himself into the empty emergency room, but he certainly was very anxious.
I asked him what his complaint was, and he said pointing to his center, “they are missing!” I asked, “what is missing?” and he said, “my b****!”.
My first thought was that he had a tear in his scrotum and his testes had come out. So I asked him if there was such a tear, and he said ‘no’ – they were just missing!
“Both of them?” “Yes, both of them!”
“Was there any pain anywhere?” “No”.
“Are you sure they did not fall off anywhere; did you search the area?” “No. I and my friend searched the whole area.”
A thorough examination confirmed that they were indeed missing, with not a clue as to the whereabouts! There was no inguinal area swelling of tenderness. The surgeon who came to review the case was equally baffled. He concluded that the only logical explanation was that they had somehow gone into the abdomen.
At the surgery the testes were found in the abdominal cavity.
The patient had hit his privates onto the motorcycle’s petrol tank, and “just as in the game of billiards, one accurate hit netted two balls!”(That’s exactly how the surgeon described it)

10:24 AM

 
Blogger dog food sugar said...

Wow! What a crazy list! Sounds like you had quite a shift.

And subramax's story - gees!

12:21 AM

 
Blogger Medstudentgod said...

I'm glad to see you enjoy EM so much. I have been considering it as a career choice and often wonder if it will get dull or tedious. Sounds like it is a fast paced, quick fix career - just what I want. I'd prefer to not get too involved with the lives of my patients.

9:25 AM

 
Anonymous Anonymous said...

I just posted about your previous financial discussion--here I am again. Just wanted to weigh in on the whole "3rd year in emerg" option.

If you're planning or needing to work in a big centre, you may need it or they won't hire you. But from my experience, your confidence and capability in EM will actually be worse after the official year of training than if you just graduated and worked in community ERs for the year. You will get used to working in a building filled with specialty residents, a CT scanner etc and will have a really hard time working anywhere smaller, ever--and your skills will not be as good as if you had worked in smaller centres for the year. Not to mention, your debt will continue to accumulate where it could have been paid off already!

I did a "self-designed" third year where I chose small communities with excellent backup to work in (office, hospital and ER, I chose my hours). I did all the "LS" courses (ACLS, ATLS, NRP, AIME, mostly during residency--they're cheaper!). I also took some good time off, when and for how long I wanted it.

When I look at my friends who did the ER year, they know more academic stuff but are generally way less confident in dealing with actual emergencies on their own.

Don't be afraid to just get out there and do it!

8:16 AM

 

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