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.