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.

Saturday, August 30, 2008

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. 


Anonymous Anonymous said...

This is a dilemma but I hope you don't give up ER because of this. I want to do emergency medicine, btw, (I'm still in my undergrad right now though) and I get a lot of info that I wouldn't normally get from you guys who blog about your experiences. I'll admit that, in reading what some of you go through, I wonder if I'd rather do internal med! But I LOVE ER. Love it. It's why I'm pre-med.

I worked in an ER for 5 years and, since I am in the inner city, this was never really a problem for our residents. But, like I said, I hope you don't give up ER becuase of this if you really like it. I hope something will work for you.

As for wishing for an influx of patients being bad...well, I don't know about that but I've done it too. When my small rehab. hospital was cutting shifts for two months and I was having trouble paying rent I found myself wishing for an increase in patients, which would mean an increase in nasty car crashes, etc. I felt guilty, but it happens. I don't cause the accidents after all.

12:15 AM

Blogger Rach said...

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.

No, I don't think it's wrong - it's the nature of the beast.
I feel the same way as an EMT - I'll sit at the table with colleagues, and when the bell rings, I'll let someone else go on the rig because I'm in the mist of a deep conversation... Only to find out that they responded to something (who knows what) that I really SHOULD have been at, just to see it - it was just that, well, weird.

Is there a way of moonlighting at another ER, or otherwise having access to a slightly more busy ER or trauma centre?

3:01 PM

Blogger Couz said...

Good though, rach, but not only are we the only ER game in town, we're the busiest one within a 4 hour drive.

Hopefully my luck will get better (and by that I mean worse) for my last couple of months.

3:35 PM

Blogger Jared At The Doctor Job said...

about 8 more days! Good luck!

4:38 PM

Anonymous Anonymous said...

exam is coming up. How are you feeling now? Think you'll be able to pull it off?

11:05 AM

Blogger Resident Anesthesiologist Guy (RAG) said...

Tough spot. I think that part in parcel of residency is trying to get enough exposure before being done - wherein the documentation of actual procedures and treatments comes in to play for many residencies. A program at my hospital is having some trouble because of low numbers in one major area, so you're definitely not alone. I'll wish a lot of sickies towards you and hope that you'll get over this recent run of self doubt.

11:33 PM

Blogger Liana said...

How small is your program? In my residency, the preceptors were kind enough that if you told them "I still need to see this and this and this" and were willing to come in, they'd call you. Any chance that could happen?

12:21 AM

Blogger ATW said...

Hey Couz, I haven't seen your blog for a long time. And holly ****!!! you are almost done!!!! Congrats!

Your posts are fabulous as usual, but I think you are having a case of cold feet. Firstly, you had a bad pimping session. Didn't we all in medicine know how it makes us feel? Scared, incompetent, and like WE failed... nope, not so... who cracks chests open in EDs? And more importantly, who survives after that? Will it make you better EP? Nope. How many did your pimper do before he finished his residency? Unless he did his residency in Detroit (which I hear is CRAZY) probably none.

You will get exposure, you will learn what you need. I am sure you remember form the 1st year of medical school - medicine is a life-long learning experience and not 4+2+1 years of schooling. This is why we all subscribe to up-to-date and this is why we jump on every opportunity to learn a new procedure. It is not possible to know it all, I don't care if you are attending in the busiest ED in the country. And I know you loooove emerg. You told me long time ago that this is the best career in medicine, and I listened. I am pretty sure you don't want to settle for the comfort of Family Medicine. So warm up your feet and go get them! Good luck on the exam! You will be fine.

9:15 PM

Blogger Couz said...

ATW... I'm getting the distinct impression that we know each other... do we?

E-mail me.

3:23 PM

Blogger ATW said...

only in cyber space, but I guess it kinda counts :) But who knows one day we may meet in some ED in some hospital, eh?

10:53 PM

Blogger ATW said...

... and I had your email once, but I don't think i do anymore... also... are you writing your exam this week in the most important city in this country (do not confuse it with the centre of the universe)? If yes, we should go out for dinner... or martinis... or whatever.... My treat...

10:58 PM

Blogger Couz said...

Ha! The exam is only written in one site in Canada. And yes, it's the COTU. But unfortunately, I am unable to squeeze in martinis. I'm headed home right after the orals on Saturday... my Bean has been virtually mom-less for so long I'm eager to get reacquainted with my kid!

10:43 AM

Blogger ATW said...

That is too bad, but in any case, happy studying and message me whenever you are in town in the future!

6:35 PM

Blogger Serena said...

I have to say that even though i'm in nice safe family medicine, i worry about that too...whenever my white gets a little too big...

5:41 PM

Blogger Dr.Rutledge said...

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6:25 AM

Anonymous Anonymous said...

do you think neurosurgery has good job prospects?

plz answer!

12:25 PM

Anonymous Anonymous said...

Hope the exam went well!

5:26 PM

Anonymous Anonymous said...

dr. couz,

what would be the best way to ask a physician if a premed can shadow them?


11:52 AM

Anonymous Anonymous said...

Thank you for saying you won't hack someone open or punch a whole in their neck or what ever dark aged thing a thoractomy
(sp) is...For a moment I was terrified to go to the emergency room for any reason.

9:33 PM

Blogger Castillonis said...

1. You need to practice your RSI on a dummy periodically to maintain your skill level and ability to react calmly under pressure. This will really help you.

2. At the level 1 trauma centers that I have been at, the academic trauma center has the general surgery residents do the thoracotomies in the trauma bay. For most patients they do this as training exercise, except for the cases that happen in the OR. I need to check the literature, but I have been told that the only likely positive outcomes will occur for decompensation due to a penetrating trauma that may sutured and happens in front of you.

3. I don't know how your trauma system works in Canada, but it sounds like you would rcv the patient unless they could be life flighted to another center. Here I think you need to be able to save 10 minutes to justify it.

4. The community EDs here are so different from the academic ED and the non trauma center do not rcv these patients. The physician staffing levels are much lower at the community EDs.

5. I did clinicals for my paramedic which I did not complete. I am trying to get into PA physician assistant program. Due to the economic situation, I may need to go to nursing school for now as I have a family and I am changing careers. I did not want to get stuck working as a paramedic, although it would have been good experience and a path to PA school.

6. I volunteered at the academic ED here doing clinical research for two years, so I was able to see things like retrograde intubation that some of the residents saw for the first time just before completing there 3 year residency. I changed my mind about EM after doing clinicals at some of the community EDs. I would still consider an Academic ED.

4:28 AM

Anonymous Anonymous said...

This comment has been removed by a blog administrator.

3:53 AM

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8:46 PM


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