Apr 25, 2011

Tales from the ER

I ended my one and only rotation in the emergency department today. I learned two valuable things:
1. It is correct when doctors tell you that the emergency room is 90% boredom, 8% interesting, and 2% terror.
2. I cope well with true emergencies, making fast and accurate decisions...but I don't like them.

Here are some stories from the ER:

  • A woman comes in for hand pain. Further elucidation reveals that she "slept on it wrong."
  • Countless drug seekers, with some nonspecific abdominal pain complaint, who have had so many CT scans that you expect their belly to light up from the inside. They will moan and writhe so much that you finally cave and write the script just to get them to shut the hell up and get out of there.
  • A kid with a rash x 3 weeks, which has been evaluated by numerous primary care providers. What makes you think that at 10 pm with a busy ER, I will be able to accurately diagnose and treat your rash any better than the other doctors you have seen?
  • Colds and viruses. Please, go see your primary care doctor.
  • Anxiety. Anxiety. Anxiety. You would not believe how often this diagnosis came up and how many insidious ways it can present. And how even thought you are 99% sure it is anxiety, they need a full, expensive, cardiac workup for you to be able to discharge them since they came in complaining of chest pain and/or shortness of breath. These typically present between 10 pm and 7 am.
  • A parent wondering if permanent marker was toxic if absorbed through the skin (kid had done some "face-painting"). Definitely a firstborn child. Subsequent kids would walk around for months with marker on their faces.

  • A woman came in with numbness and tingling down her right thigh. She was dressed very nicely, and told me that she had just come from a wedding. The (male) attending wanted an MRI. I asked if she was wearing anything new. Turns out she had worn Spanx for the first time under her nice dress, and it had compressed her lateral femoral cutaneous nerve. She took off the Spanx, and the numbness and tingling went away.
  • A poor ninety year-old woman came in after tripping and falling on her carpet. The carpet ripped away her paper-thin skin, leaving her patella and a good part of her lower leg tissue exposed. I spent an hour and a half putting in fifty stitches, and had a wonderful conversation with her while doing so, learning all about her long life. She loves to needlepoint, and asked how I did the stitches, and if sewing people was similar to sewing upholstery.
  • A man came in under arrest after attempting burglary. He had fallen on glass while robbing someone's home and was brought in by the police to get his knee sewn up prior to going to jail. As per usual, I asked him what happened to his knee. He told me he fell on a rock while playing basketball. I commented that the rock must have been pretty sharp, given the perfectly clean laceration he had (a confidence afforded by the fact that he was handcuffed to the bed).
  • A kid who had eaten a scorpion. Is it toxic if the venom is ingested?
  • An old Hispanic man, yellow as a canary, coming in with abdominal pain and a big stone in his bile duct.
  • A four year-old girl with a cut deep into her foot from a rotary blade. I made a game of wrapping her up in a sheet like a burrito, which she liked, and then cringed as I began to inject lidocaine and start suturing while she screamed and tried to flail the arms and legs that I had wrapped up so tightly.
  • People on/withdrawing from drugs. Always interesting to watch.
  • A heroin user with a kidney stone who begged for pain medication. Nothing worked. He was furious when I told him that since he had developed so much tolerance to narcotics, they weren't effective for him anymore.
  • A heroin user who unscrewed his IV and left AMA ("against medical advice"), then used the line to inject mass amounts of heroin and ended up right back in his old exam room, now unconscious and apprehended by the police.
  • A heroin user who had multiple abscesses from skin popping, each filled with several CCs of pus. They needed to be drained (fun to do). She had a lot of anxiety over the needle with the numbing medicine. I tried to refrain from pointing out that she put needles in her skin several times a day anyways, so what was the big deal?
  • A woman complaining of vaginal bleeding during pregnancy. Normally this would fall under the "boredom" heading, but what made this unique was that this individual was transgender, and I was greeted by a penis and testes when I lifted up the gown for the pelvic exam. He/she was so desperate to identify as female that she had sought medical attention for a "female" problem. Definitely a psychosomatic diagnosis.
  • Multiple trauma victims of a multi-vehicle crash, all coming in at once.
  • A child bleeding to death internally after sustaining blunt abdominal trauma from a trampoline fall.
  • A man with an eyeball hanging out of his socket after an injury.
  • A drunk driver laying in the trauma bay next to the man he killed, separated only by a curtain.
  • A ten year-old who successfully hung himself.
I'm glad I'm going into Ob/Gyn. There is some inherent terror in that specialty as well, and the emergencies affect two people, not one...but thankfully, they are few and far between. In the meantime, I can enjoy an overall healthy population and followup with the same patients for a long time. I missed that in the ER...I wonder about some of these patients and don't like that I will never find out how their story ends. It was a good rotation for me to do. And good that it's over.

Apr 2, 2011

Dr. Jekyll and Ms. Hyde

I am not a mean person. I think I am generally good-natured, thoughtful, reasonably patient, and kind. I am not unreasonable unless my blood sugar dips too low. I try not to sweat the small stuff, try to take good care of myself and others.

But everyone has a breaking point.

Mine seems to come after about being awake over thirty hours. If I have worked all night and sometimes the day before, I leave my house Dr. Jekyll and return as Ms. Hyde.

Dr. Anne Jekyll knows she is just tired. She can look at dishes in the sink and know that they can be done later, after a long nap. Email can wait. She knows she doesn't need to run with the dog right now, even though it is cool and light outside- a rarity in the Phoenix sun. She can recognize that even though she was up working all night, it is okay for others to be sleeping, doing nothing productive except restoring themselves.

Ms. Anne Hyde is unglued about dirty dishes in the sink. She thinks, "if I have been awake and working for the last umpteenth-and-a-half hours, at LEAST have the kitchen clean before I get home." She feels like she needs to immediately start her daily duties and rest later. She scowls at those that have been sleeping all night, expecting others to at least achieve partial productivity in the many hours that she has been gone. She has no patience for hearing that someone hasn't slept well, and even less patience for hearing that someone has.

Dr. Jekyll and Ms. Hyde are both predictably, undoubtably me. These characters of duality persist across level of training, rotation assignment, and seasons. And I have medicine to thank for introducing me to Ms. Hyde...I don't know if I ever would have experienced such impatience, discompassion, and crabbiness if left on a normal schedule. I don't think I would have believed that I could feel this way, that these emotions and thoughts could come from the person I thought myself to be.

I think many doctors struggle with this, and it partially fuels the burnout of medicine. Like Mr. Hyde in Robert Louis Stevenson's original novella, our meaner selves can grow from a part-time appearance to an ever-present alter ego. Dr. Jekyll saw the transformation too late, and lost himself to Mr. Hyde. Doctors enter medicine for all the right reasons, and, sensing their bitter change too late, leave for all the wrong ones.

They say recognition is the first step to recovery. Well, I don't know if I can ever completely recover. But I can recognize Ms. Anne Hyde, acknowledge her for who she is and the place of exhaustion that she comes from, and choose to go to sleep. I can wake up as Dr. Anne Jekyll, kindness and patience restored, ready to see another patient.