And The Doubts, They Keep a' Comin

Emerg is a fickle place. One day a shift can have you feeling like you're on top of the world. You feel competent, efficient... hell, even the patients themselves are happy with the care you're providing. But just around the corner is another shift waiting to make you feel like you've been punched in the gut. Yesterday I had one of those shifts. The gut kind. 

And here is the funny thing... it wasn't even the shift itself. I saw a reasonable number of people (which is of note as I am currently working on my 'flow'... ED talk for how many patients I can see in a shift) and none of them were terribly difficult. I was over on the low-acuity side of the emerg, so there were lots of foreign bodies in eyes, MSK stuff, lacerations, cellulitis... like I said, nothing too interesting.

But because the shift was actually a little slow (I can say 'quiet' now that the shift is over, right?) the staff that I was on with decided to go over some practice oral exams with me. Now this is usually a good thing... I need all the help I can get. The first practice oral he lead me through was a trauma... I talked through it until I had an airway secured, multiple chest tubes in place, had done an EDE (ultrasound) to rule out pericardial tamponade... the staff kept asking "but what would you DO at this point" clearly looking for a specific answer. What was he looking for? An ED thoracotomy. One where I should have known to cross clamp the aorta, no less. 

Are you freaking kidding me? Not only have I never seen one done, in ATLS they actually refused to teach it to us on the poor anesthetized pigs as we should apparently never be doing them. So then he had me completely panicked because (a) it would not likely occur to me to SLICE OPEN SOMEONE'S CHEST in the middle of the ED, and (b) I couldn't tell him what 4 freaking pieces of equipment I would need to do this procedure. 

The next scenario didn't get any better. It was a difficult airway-- 350 lb guy with a goatee, fat under his chin that touched his chest (so a surgical airway would also be a nightmare), can't see cords on direct visualization, can't effectively bag and can't fit an LMA. I was still so flustered that I completely blanked on the dose of etomidate that I'd need for RSI. In the end, I was supposed to figure out that the guy aspirated his dental plate and it got hooked on his epiglottis. Sigh. Needless to say, that one didn't go well either.

And that's when the real panic set in. In discussing how I could possibly blank on the dose of etomidate needed for RSI, the staff learned that I had actually only done one RSI on my own. Yup. Three month of emerg and only one RSI. Which lead to a long discussion about what else I haven't done...

The conclusion was that I'm lacking in exposure. No kidding. I've always suspected that I have a white cloud hanging over my head... I live in a one-emerg town, and whenever I hear on the morning news that someone was stabbed/hit by a train/drove into a rock cut I regret not being at work the night before. I've done as much emerg as the next guy (well, with the exception of the two months that will unfortunately happen AFTER my exam) but I just haven't seen the really bad stuff. The staff in question went on to tell me about his last night shift, which included a case of blastomycosis pnemonia, two mixed OD's requiring RSI, and a penetrating trauma to the chest (which, incidentally, was the inspiration for the thoracotomy scenario as they actually did one... and no, the patient didn't survive). 

Really? I don't know what I can do to fix this. In the past month I've worked 3 out of 4 weekends (including a long weekend) in the hopes of seeing some good stuff. I've offered to take on double the number of night shifts in my next emerg rotation, but that still doesn't guarantee anything exciting will happen. I'm not sure if I've somehow failed over the past year or if the program has somehow failed ME. But the reality is that even after 10 out of 13 rotations completed, I don't feel at all ready to do this on my own. The thought of giving up emerg to go back to nice, safe family medicine has occurred to me with increasing frequency over the past few days.

Is it wrong to wish for a sudden influx of really, really sick people? There are just so many things I haven't done yet that I really don't want to do for the first time when I'm on my own.