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Preview: EM Physician - Backstage Pass

EM Physician - Backstage Pass

If the public only knew...what goes on behind the scenes in the ER.

Updated: 2018-04-25T22:22:34.521-07:00


Perfect Job, perfect specialty??


I remember how difficult it was for me to choose a specialty. Initially (as in before medical school), I wanted to be a dermatologist. I loved cosmetics and hair products, and as a college student I thought I'd go into some sort of 'beautifying' medical specialty.Once in medical school they forced upon us that primary care crap tried to encourage us to consider careers in primary care. And I did...seriously. I really, really liked the idea of family practice. The doctor that sees the entire family, and watch the kids grow up, and have continuity of care, and keep the family healthy, yadda yadda yadda.Then, I started having doubts. I met no one (even with all of this brainwashing exposure) who actually *enjoyed* family practice. It's a thankless job really. Anytime I asked a FP "do you like your job?" the response would start off "....wwweeellllll....". Not a good thing. And what followed was usually some combination of justification, hope, and regret.So, I considered internal medicine. I guess I was stuck on this continuity of care issue, and thought that would make my practice worthwhile (you know, seeing the smiling faces of the patients I help, and eating the fresh baked muffins they'd bring with them to their office appointments to show their appreciation for my time and expertise). So, as a result of all the negative comments regarding primary care in general, I thought I would preserve my option of subspecializing (just in case the naysayers were right about primary care)...and internal medicine seemed better for that purpose than FP.So, up until 4th year (FOURTH YEAR), I was all set to go into internal medicine. Then, in 4th year I did an elective anesthesia rotation. I thought about endless rounding that was internal medicine hospitalist care. I thought about the rushed office visits, and the lack of depth of knowledge (the "jack of all trades issue") and that kinda bothered me. What would I be doing all day as an internist? Rounding, taking and referring? On the other hand...anesthesia pays well over $300,000 year, and you have only one patient at a time. There is no rounding, and the job is mostly low stress. And did I mention the over $300,000 yr salary??!!I applied to BOTH internal medicine programs, AND anesthesia programs. I ranked anesthesia higher, and matched at my first choice spot. I did my prelim year in internal medicine...and off to anesthesia.Well, I realized I hated anesthesia (at least my program sucked bigtime - which is no doubt detailed on this blog somewhere in another post). So now what do I do?I didn't work this hard, for this long, and for this much debt to *hate* my job!!I thought about my rotations as an intern. My ER rotation was the best. Not necessarily the most exciting specialty ever...but I just felt 'fulfilled' on that rotation. I felt healthier since I had time to get out in the sunshine on our days off. I felt disconnected (mentally and physically) with no beeper or hospital responsibilities on my time off...and the prospect of going back to work was exciting. Everyday I started with a clean plate. No inpatient ward 'rocks' or a patient that I was responsible for, yet someone else was just 'covering' for me. I enjoyed the 'we have a life' attitude of the ER residents. And I liked the fact that I could basically 'play doctor' with the patients until they became too complicated, or I became uninterested...then I could call someone else to take care of 'em.So...I applied to EM programs (as a PGY2 anesthesia resident), AND internal medicine (in the case I didn't match in emergency medicine which was/is very competitive, I'd just finish up 2 more years in IM and be done). I guess you can say I decided on a EM career a bit late!! And even then, I *still* I wasn't completely sold...***I tell my story to demonstrate that choosing a speciality is very difficult indeed. With that said, I had a young woman send me a very thoughtful email:I was telling my husband that I was really thinking about doing ER for the flexibility and the hours, because I'm really wanting to have k[...]

Point of view, November 26, 2004


What ever happened to being responsible for yourself...owning up to your actions and mistakes, and holding yourself accountable for the circumstances of your own life? Sometimes I wonder, would people think I'm the most insensitive, uncompassionate, heartless doctor if they were privy to the ramblings of my internal monologue?At King we have lots of traveling nurses. Mostly I welcome their presence because they bring "new insight" that lots of the native King nurses lack. Yesterday RN Wendell told me that I was one of the best doctors he'd come across in his travels. Other staff frequently gives me similar compliments...and the patients express gratitude, which is what makes it all worthwhile.However, there are those people who...really are accustomed to doing whatever the hell they wanna do, with blythe disregard for consequences. And they need to be checked from time to time.For instance, there's the 55 y/o alcoholic african american male, brought in by paramedics complaining of abdominal pain. History of alcoholic liver disease, gastritis, and chronic pancreatits. He reeks of alcohol, and is mildly intoxicated. We (taxpayers) spend thousands of dollars on his workup, and after 8 hours in King's ER, we determine he has acute pancreatits. Now, as he's sobering up, he becomes belligerent and demanding (specifically) demerol 100 mg IVP. What the hell?? Well, he's certainly not gonna get that from me tonight. After a couple of critical patients are stabilized he's up and fussing about how *we* can't let him just be in pain like this.His response is "you bitch, I shouldn't have ever came to this fucking hospital."Me: "Then leave." Did I go out to the street and drag you in here? Does he think he's hurting my feelings by leaving? (We actually call our yellow AMA forms "the golden ticket).Him: quiet for a minutue "you alright doc...I'ma sit down...but how long do you think it'll be?"Or the trauma patient who comes in all shot up. Dr. Spevack saves this guys leg after an extended operation. In the ICU the following week, the guy is pissed about...whatever...and starts going off on Dr. Spevack. "This fucking hospital sucks, you suck, I can't believe I got an infection...yo mama is a forth and so on." Dr. Spevack lets him finish...and then responds: "man, I fuckin' saved your leg and that's how you talk to me?"With his baby's mama at the bedside he responds, "yeah, that's true." YEAH, asshole, that's true!!So the above stated alcoholic decides to sign out AMA. "Well, I ain't got no where to go."Me: You can't stay here.Him: Well where am I gonna go?Me: That sounds like a personal problem. You can wait in the waiting room until the morning, then go to a shelter.Him: You can't just kick me out.Me: Well, sir, this isn't a hotel. You're a grown man, I'm sure you'll figure it out.It's a shame, but no wonder, that this guy has no-one to call. But if you were in the waiting room having an MI, you'd want to trade places with this guy you can see a doctor, and he can come on out and deal with his social issues. His medical care is over, either by discharge or by his own choice, and the ER has limited space and resources. We need to get the sick people from the waiting room into the ER, and the not sick people out.Or what about the lady who calls 911, is taken to St. Frances. Is triaged to the waiting room. Decides she's dosn't want to wait...goes outside and calls 911. Is taken to King. Is triaged to the waiting room (especially after EMS tells us she just left St. Frances). Leaves, calls 911 again so "she can be seen faster." What patients don't understand is, they are *seen* as soon as they walk in the ED. If their complaints are minor, or not as severe as the rest of the people, they wait.Or the family who calls 911 to dump their mother anytime they wanna go to a movie. Or the woman who calls to "get rid of" her drunk boyfriend when he passes out drunk...again. Or the criminal who's caught committing a crime...then decides to complain of chest pain to avoid going to jail. Our EMS cannot refu[...]

The ER doctor is only as good as her hospital allows, Nov 23, 2004


Continuing on with this lower GI bleed lady.

She seemed okay after the questioning...and during rounds. But immediately after rounds she seemed to be sleeping. When the sheets were pulled back... .

..she was laying in a mound of dark red clots of blood. Looked immediately up at the monitor, low and behold she was tachycardic and hypotensive. The juniors were all over it...and stabilized her with IVF, blood transfusions, and even got a tagged RBC scan to see where the blood was coming from...exactly.

The RBC scan revealed a "sprinkler" in her descending colon. Surgery was called. They wanted an NGT lavage "the bleeding may be coming from above." But we have the RBC scan...

...initially the lady refused NGT lavage, but now she was intubated and unconscious, so it was done. No blood. Surgery was reconsulted.

"You have to get GI to see this patient first, she's too unstable for the OR."

GI was called...they can't scope until the following day (maybe). There's only one attending who scopes, and he's off today. Unbeliveable!

This went on all night. Patient seemed stable overnight, and the family was informed.

A CBC was ordered by the intern overnight...but the nurse (for whatever reason) decided not to draw one. Nor did he tell the intern. So there was no CBC overnight...and when I arrived at 7am, I ordered the (new day shift nurse) to draw one. The new H/H 3/10.

What!! How did this happen??

We order blood, which takes the better part of an hour to obtain...even noncrossmatched. We give her IVF, and talk the the (very surprised and upset) family. And we wait.

We call GI back...they are in clinic doing a procedure, and will come later in the day. What??!! Hello, we have a dying patient here... Candice the student nurse wipes the patients face because there is a bit of brownish liquid on her cheek. When she pressed on the cheek with the towel...more brown stuff came from the patient's mouth. So Candice picks up the suction and places it in the patient's mouth. Within 10 minutes there was 500cc (half a liter) of brown blood in the suction canister. 20 minutes later, there was 2 liters!! Surgery was called back.

No, we will not take her to the OR. She has an upper GI bleed, and GI needs to do endoscopy and control the UGIB. still in the clinic.

Over the course of the following 12 hours, me and Mikey transfused this lady 20 units of PRBCs, FFP, platelets. We try everything...even the blakmore tube. The daughters are at the bedside watching us work (all damn day) tirelessly. Finally, when the lady's blood was as thin as koolaid, and it was obvious we could not keep up with tht blood loss...they asked us to stop transfusions. Lined along the wall was about 14 liters of blood in suction canisters. Blood all over the bed (nonclotting), blood on the floor.. . GI comes. We've already stopped. It's too late.

Surgery blames GI, they should have come earlier. GI states that it was too much bleeding for them to control...and hat she needed to go to the OR. Surgery states that they needed better localization of the bleeding site. I guess the tagged RBC scan wasn't enough. I guess endoscopy for localization of UGIB isn't something that's done in the OR at King. I guess GI doesn't do emergency endoscopy at King. I guess surgery doesn't operate emergently at King.

All an ER doctor can do is stabilize in a case like this. We cannot operate, or scope. And the hospital's way of doing business is allowing patients to just die in the's no wonder it's called Killer King.

The worst part......her 2 daughters, one 20 y/o, one 30 y/o, watched their mom bleed out. And no-one would do a damn thing.(image)

Senseless transfer, September 20, 2006


There was this patient...67 yo Hm transferred from outside facility where he presented at 8am c/o severe abdominal pain with N/V for one hour. PTA his niece called the advice nurse who recommended she call 911. In the ED at the outside facility his work-up was essentially negative, except he continued having severe abdominal pain. Transfer was arranged to our facility because their CT scanner was broken. At the time of transfer, although all tests were negative, he was becoming increasing hypotensive/tachycardic. In fact, per family, the other facility refused to give him more pain meds b/c "his BP was too low."Upon arrival to our ER, patient was hypotensive/tachycardic and c/o continued pain. He was pale, and generally appeared unwell. He was immediately transferred to our close observation area. Initial bedside ultrasound was performed, and negative. Blood was drawn, IV hydration given, and plan of action discussed with an already very frustrated family.Although on exam his abdomen was not acute, he c/o pain out of proportion to the exam. CT scan ordered. Bedside ultrasound x2, no free fluid, aorta with no aneurysm. Surgery was consulted.The surgeons were in the OR, and said they would be available in 1 hour. IV hydration continued, pain meds administered, and eventually dopamine had to be started. NGT placed, antiemetics given, and lab results checked. No significant abnormalities.After 2 hours of resuscitation patient was still pending surgery evaluation. CT also still pending. Clinically, the patient is doing worse. Remains hypotensive on dopamine, and tachycardia worsens. Surgery recontacted, and ?still in the OR, will be down in 10 minutes - recommended the CT. CT called, patient wasn't due until 1930. Radiologist called to help expedite the CT. Before CT could be obtained, patient decompensated with waxing/waning mental status. Femoral line placed, packed RBCs transfused. Repeat bedside ultrasound done. No obvious free fluid seen, aorta not visualized, but there was a question of free fluid near the bladder (i.e. bladder vs. free fluid). Up until this time, patient with severe abdominal pain, but no guarding/rebound. Now, patient with distended, tender, belly with rebound/guarding.Surgeons arrive at the bedside as PRBCs are being transfused and ultrasound being done. They evaluate the patient, and still felt the need to do a DPL. DPL revealed frank stool. Immediately went to OR.Patient doing okay, but still intubated in the ICU.My frustrations are: 1) Why did the advice nurse not tell the patient to go to a hospital that could actually treat his problem? Had he a AAA, I doubt vascular surgery would be readily available, 911 isn't always the best option. Sometimes getting into your car and driving to a facility that you know can take care of you is a better option.note-to-self: don't listen to the advice nurse. don't sit around all day at a hospital who can't do anything, pending a transfer. Have someone drive you to another hospital.2) What took surgery so long to come see the patient. If they had a case, there should be another surgeon who can cover the ED. Otherwise, the ED is non-functional (by everyone's standard).3) how can the other hospital *not* have a working scanner. They should not be accepting paramedic runs.4) Why does transfer take so long. It's so simple to say, a simple concept...'we'll just transfer her..' but hours it takes. Dead time.5) Why does it take so long to get an emergent CT, even after attempts are made to expedite the study? A more expeditious CT would have revealed this problem sooner than clinical decompensation.6) Why did the surgeons do a DPL? Had it been negative were they *not* going to take him to the OR? It was an extra step, and a waste of time.7) Why doesn't the facility have mechanisms in place to deal with true emergencies? The CT backed up, the surgeons in the OR. I called surgery upon pt arrival to our ED. 5 hours later he's in the OR.I really do care. I did all I could do. I covered him wi[...]

Issues with Medicine


On the white coat.Everyone wears one. I wonder why. I think patients are starting to realize that it’s actually those of us *without* a white coat that are the doctors.On Customer Service.How stressful would it be if you actually gave a damn about patient satisfaction scores. Not because it’s not a worthy goal to be customer friendly; but because these scores are derived from so many factors that you, as a doctor, have absolutely no control over. Wait times, parking, whether or not you have access to old medical records. Think about it, if a patient in the ED waits 8 hours, cannot tell the difference between a doctor and a nurse manager (because everyone is wearing a white coat), gets a CNA that treats them shitty, and then goes out to their car and finds a parking ticket on the windshield….you can bet that when a survey is sent to them asking them to rate their ED doc…they’re going to use this only opportunity, to show how frustrating it was for them. And when that patient decides to go elsewhere next time, it’s the MDs who are spanked.On Complaints.All complaints don’t deserve a ‘full investigation.’ The drug seeker who’s pissed off because I wouldn’t use my medical license, and my medical education/professional decision making capacity, to give him the drugs he seeks (i.e. I decide my job isn’t to serve as his drug dealer), he complains. Subsequently the wheels start rolling…and eventually I get to ‘respond’ to this complaint. Frankly, I don’t need to know about it…and the complaint should be discarded. The patient has the right to get a second opinion. I have a right (a responsibility) to do what I believe is correct/safe. Woe is the doctor who gets bullied by Anna Nicole Smith, and when she ends up dead…all eyes on doc drug dispenser. Customer service gone too far!!I remember there was one case in particular. The patient wanted something that wasn’t medically indicated. Had I given it to her, and something bad happened, no one would have given me a pass because I was doing what she wanted. It would be like “but you’re the professional; you’re the one licensed to practice medicine; she didn’t know, but you knew better.” So, she went to administration and threw a tantrum. Some nurse administrator (in a white coat, no doubt) thought it was a good idea to walk the patient back over to the clinic, and question my decision. Needless to say, I felt very disrespected, undermined, and angry. “Why don’t you give her blah blah blah?” She asks.“Because, in my professional opinion as a physician licensed to practice in this state, it’s not indicated, and potentially harmful.”Her: “It’s not a big deal just this once to give her this or that….”“If *you* think she should have it….*you* give it to her. You go to medical school, do a residency, apply for state license, a DEA number, and get a job somewhere…then you can give her anything you want. But, I’ve made my decision.”Why did I have to go there?On Joint commissions.I wonder who appointed them, this private entity, God. Why are we closing hospitals, and compromising patient care, jumping thru impossible/impractical hoops trying to comply with various, random, and irrelevant ‘regulations’ that they pull out their asses. It’s easy to have a ‘new regulation’ on paper, but in practice, if it’s not practical to implement, it only distracts from what we’re actually able to do right. Also, what about when they’re just wrong, harmful to patients well-being. Like the 4 hour timeframe to antibiotic administration in pneumonia patients. I’ve seen more people with c.diff colitis violently ill, who received antibiotics to treat ‘possible pneumonia’, for the CXR to be clear. Passing out levaquin like candy in triage to meet some random joint commissions regulation is causing lots of undue sh*t (literally) both for the c.diff patient, and society in general as our antibiotic resistance r[...]

Letter to my patient


These 'letters' were passed to me by colleagues. I guess I work with alot of...frustrated docs. (these were not written by me)Dear Patient:You came in at 11pm last night with a chief complaint of sore throat while munching on a sandwich at triage. Next time you choose a sandwich to bring with you to the ED, try something that will go down easier. Peanut butter and Jelly – while I’m sure was very tasty, made my ENT exam, well… a bit difficult. But alas, we did get through it and I got to see your very normal throat. While I was tempted to leave the diagnosis of “no real complaint” on your chart, after envisioning my directors review of yet another unbillable chart I went ahead and replaced it with “sore throat”. Your chart will be coded with a maximum of billing incompetence by our billing company. In their defense, they follow archaic laws meant to break my balls and keep money out of my pocket. I wanted you to know one last thing. It’s ok… you don’t really have to pay that bill. There will be no consequences. If it arrives at the (fictitious?) address supplied by you, you can chuckle as to how we could possibly charge $350 for doing nothing. I wonder if giving you a depot of 2cc’s of Bicillin into your deltoid would have made us both more satisfied. In the end, you provided for yet another priceless moment in this stage we call the ER.***Advice from an ER doctor to drug seekersI am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn't require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the 'worst headache of your life' you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I'm not willing to lay my license and my families future on the line for your ass. I also don't want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your 'typical pain that is totally the same as I usually get' and we will both be much happier.The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting but you might not be lying. (See below.)The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fa[...]

Why are you here?


{walking into a patient's room}

Me: "Hi Mr. Smith, I'm Dr. Gilman and will be taking care of you today in the ER. So, I reviewed your chart, and I don't see any significant past medical history. The nurses tell me you don't feel well. Tell me, what's the matter today?"

Smith: "I'm sick"

Me: "Okay, but what's wrong"

Smith: "I don't f*ckin' know, you're the doctor."

I hate, hate, it when a patient doesn't have a chief complaint when they come to the ER.

Why are you here? Today? Right now? (i.e. why couldn't this wait until you could see your primary doctor). What changed? What are you afraid of? Specifically, what part of your body is bothering you.

My job is to determine if this...whatever it is you likely to kill you tonight, or tomorrow. If it won't kill you (or severely disable you), my job is done. I do not know why your rash won't go away. I don't have the time or resources to figure out why your toenail fungus medication isn't working. I don't usually adjust medications that your doctor has decided are best for you. And I don't write prescriptions for psych meds, viagra, or refill highly addictive meds without good (and I mean a very good) reason. I am not a substitute for your doctor. If you rely on the ER to diagnose cancer, or manage your'll die from complications related to these diseases. You could go to the ER 10 times in 2 weeks c/o abdominal pain, that eventually turns out to be an gastric ulcer or stomach cancer. Do you know when we, in the ER, will make that diagnosis? Never. Or, not until we see a big hole, or a big mass, on CT. By then, it's end-stage. And to've been coming to 'see a doctor' for weeks.

And another thing: people who 'save up' their medical issues, and then complain of everything under the sun when they go to the ER, bug us. In the ER, you get ONE problem. Choose carefully.

I wish patients could understand the limitations of the ER. I wish patients would think about why they've decided they need emergency care. And I wish they would limit their complaints to 1) emergencies, and 2) one basic problem.(image)

Letter to my peers on unionizing


(I will kindly *not* include myself in this)

Doctors are stupid, because they have allowed this to happen.

Still living in an era of the rich, private practice mentality...not accepting the fact that most physicians today are employees in one way or another. And instead of turning up their noses to unionizing, perhaps they should realize that they are now more like the average worker. They've allowed the nursing union to be the be the sole legislative voice on healthcare policy, to their detriment, and to the detriment of their patients.

As the nursing union shouts "patient advocacy," they are trying to implement healthcare policy that actually hurts the poorest, sickest, neediest members of our society (I'll elaborate as needed). The whole while, the AMA/CMA (made up of mostly people who are completely out of touch with young physicians) asks for money, but does nothing to help their cause. Time after time, taking "no position" on matters that make a huge difference with regard to modern physician's issues. Case in point - the Governor's proposed tax on doctors and hospitals. The doctor's are getting fucked, and there is no unified voice advocating on their behalf. Therefore, patients are getting fucked, and healthcare is a complete mess. And where are the doctors? Where is their voice. What solutions are *they* offering?

Doctors need to change their thinking, hold the medical societies accountable, (or refuse to join), participate in the legislative process, and drop the arrogance against unionizing. Or we can all prepare for complete chaos as healthcare continues to fall apart, without a legitimate beacon of leadership. As the doctors bury their heads in their arrogant asses, allow everyone else to take control, and then wonder why they are (directly) paying for a shitty healthcare system, run by nurses/chiropractors/optometrists/herbalists/and the 'people at the healthfood store.'

Get a clue.(image)

Hood Mentality


The consequence of hood mentality.

In the hood, lots of folks are looking for a payday. Be it by "falling down" at the grocery store, or selling things on the street that....sell. A great number of people bitch and complain about paying a $50 copay, but pull up in a pimped out Escalade with spinning wheels and a $400 cell phone. The ultimate consumers.

Well, in medicine this trend continues. And, apparently, many of the frivolous lawsuits are initiated by people just looking for a payday at someone else's expense.

At the Kingdom, there was this young guy...who was racing his motorcycle on the freeway. He fell, got crushed, and was brought in to our trauma center. The surgeons patched him up, but after a month long ICU stay (and hundreds of thousands of dollars in bills paid for by you and me), he still couldn't walk. He had a pelvic fracture that required a 'special' (complicated) orthopedic procedure to *possibly* correct his problem. There were only a couple of orthopods in the city who performed this procedure. The issue was, the 'complicated' surgery was very labor intensive, time intensive, and the end-result was based largely on patient compliance...and evenso, the results were unpredictable. The surgeon was concerned that the patient: 1) wouldn't/couldn't pay him, so he'd be working essentially for free. 2) then the patient is a dumbass, and will probably *not* be compliant with follow-up 3) and finally, when the results weren't what the patient expects (which would be 'perfection' and the ability to get back on his bike and crash again)...he'll turn around and sue the surgeon.

So, here is a patient...that no orthopod will touch. It's not worth it to the surgeon. This is a skill that he has spent years, and hundreds of thousands of dollars, perfecting...and to not only *not* be compensated for it...but then have to *pay* in the form of a lawsuit, for an expected complication/outcome...just didn't appeal to these guys. So...this patient, 3 years out from his accident, is still unable to walk...and no one will even attempt to correct his problem.

Then there was the guy that presented to the ER after some quack manipulated his spine, causing a rupture of his vertebral artery (in his neck). All the docs saw *lawsuit* on this patient's forehead...and he died because no one wanted to get involved. No one wanted to perform an intervention....and have the patient die as a result...only to have to explain to a jury (a group of folks with no medical knowledge or experience), that he did nothing wrong. So, all the subspecialists sited one contraindication or another to avoid getting involved. And, of course, the patient died.

If I ever get hurt, I hope I can convince the doctors taking care of me that...

*I will not sue you if you do your best...even if you make a mistake...even if the outcome is suboptimal*.

If you can do that...convince the doctors that their best is indeed good'll get (better) care.(image)

Emergency Department (In)efficiency - Why patients wait 6 hours...and die in the waiting room.


I've worked at more than a few places...both EDs and urgent cares. I can finally say I now fully appreciate the difference between a 'physician efficient' ED that's not.One of my gripes about working in the ED as a doctor is...the place isn't set up to maximize physician efficiency. Sure, they expect you to see 2.5 patients an hour...but when it takes 20 minutes to log into the various computer programs, trouble shoot the printing process, and then find said printout to sign and place with the chart (if you can find the chart)...there's no way the "goal" of 2.5 patients can be reached.Let's take last night......there were 4 docs there, only 2 computers available for our use. My kindergartner can tell you that 4 docs need 4 computers. As everything is computerized now, I can't even look up lab results, or discharge a patient without using the computer. So, I found myself standing...waiting...for a computer to open. While patients have been in the waiting room for 6 hours or more. Then, when 'productivity' scores are released, it seems we're just...slow. And to compensate for the utter inefficiency of the system...doctors are expected to 'just speed up'. Making an already stressful, high-liability, acute situation...even moreso. There are only so many corners you can cut. So, some of my colleagues will opt to stay hours past their shift, doing charts, and continuing to dispo patients...stuff that they should have done hours prior (which would be both better for the patients we've seen, and for the patients in the waiting room), but couldn't for fear of slowing down...and being the "slowest person in the group." So, the patients (all of them) endure less than optimal medical care.Why do we let them punk us like that? 10 hours of work should be done in 10 hours. It should not be expected/required that you do 12 hours of work in 10 hours. If the system is so inefficient that only 1.75 patients/hr can be *properly* seen...that's how many we should see. And charting/paperwork shouldn't be saved until the end of the shift. Documentation as you go is more accurate, and provides better communication to consultants and other healthcare team members. Above all, it allows you to keep everyone straight, and demonstrates real-time decision making and outcomes. Not to mention it's a total pain in the ass trying to gather all the pieces of information needed to compose a good note...after the fact.So, what have I noticed that distinguishes 'efficient' EDs from 'inefficient' ones?1. Smaller is better. The new trend is to build these 'mega emergency departments.' Where everything is spread out...very pretty...but inefficient. If you have a large ED, you need to break it down into essentially 2 completely different departments. Where one doctor is in one area...period. Not theoretically, but actually. There are EDs where the idea is to have one doc in an area, with a couple/few nurses...and that's where they stay for the entire shift. But in actuality, the doctor's patients are placed all over the various areas...depending on "which nurse is up next to receive a patient." Additionally, the beds fill up in a particular area, depending on the disposition of the patients, their acuity, etc. So, patients will then be placed...anywhere there's room. Seems logical on the surface. But, then you have a doc running around this big ass ED, trying to care for patients from one corner to the other. This is inefficient, and slows down the flow. This ultimately is not good for patients. If the ED were to be divided (physically divided) into 2 discrete entities, this would not happen. Kind of like how Starbucks will frequently put 2 (separate) stores right across the street (or around the corner) from each other. It just works better...not having a huge, inefficient, chaotic, place to conduct [...]

Is being an ER doctor as cool as it seems?


(OR - Quit Medicine? Part II)As a group, doctors are not very good advocates. Not for themselves, not for their patients, and not for their profession. Gradually (and not so subtly) everything non-medicine has played increasingly larger roles in interfering with the doctor-patient relationship. Everyone suffers (even those greedy bean-counting executives suffer when they finally succumb to their own illnesses, or as they deal with trying to navigate American healthcare for their families). And instead of demanding a seat at the table, exercising their responsibility to weigh in on all things medicine...they sit on the sidelines and complain. But this is beside the point. My point today is to talk about whether or not choosing emergency medicine (or even choosing a career in medicine) is what I thought it would be. Let’s start with what I thought it would be like. *** I knew, as a medical student, that my role was insignificant. I knew residency was hard with long hours and physical exhaustion. I understood that college and professional school would be expensive (and accrue a large debt for a girl from a non-wealthy family) and residency would mainly serve to delay my ability to pay off these debts. I recognized that I was socially underdeveloped, and had no practical knowledge about anything not in the lecture notes. I expected to wait to have a family, and accepted being continually absent from my own life to undergo this training program. However, I also expected more freedom once done. I hoped for enough money (which is subjective and constantly changing) to live comfortably. I hoped to reclaim some “lost” time (and hang out with friends, read some novels, get married, have kids). I hoped to mentally *graduate* from student status, and buy a big-girl house, and big-girl clothing. Most of all, I thought there’d be more appreciation and respect for the sacrifice doctors make in order to do what we do. I hoped for a more powerful voice as a professional. I thought doctors and patients would advocate together for the best possible health-care situation. (Vocal in a 'I am woman, hear me roar' kind of way...sorta like the nurses. I guess medicine is still too male dominated to be very vocal....) But what I quickly realized was… …being a physician is not quite what I expected. But I’m a roll-with-the-punches kinda girl (or at least I try to be), and realize that physicians are *still* quite cool. Saying you’re a doctor does offer a certain degree of legitimacy in conversation…and it is easier to get a ‘seat at the table’ if you bring a medical degree with you. I do acknowledge (and appreciate) that. Instead of complaining (further) about all the things “wrong” with being an ER doc, let me make it clear… …it really is a fabulous job. Not a day goes by when I don’t get some fantastic job solicitation (usually in not-quite-so-desirable places to live) begging me to consider a move to Podunk, Wherever, for crazy sums of money. And even locally, having board certification in a specialty that everyone uses makes finding decent job a small issue. There’s never a shortage of ‘business’ as an ER doctor. As the recession progresses (and the economy slowly recovers) our ‘business’ just increases as people lose their health insurance along with their jobs - which is unfortunate. But single payer would allow everyone to have access to (at least minimal) medical care...and (get this) we'd actually get paid for said care. (I honestly don't know why doctors, especially primary care and first-responders, would be against getting *some* compensation from *everybody* you serve).......but I digress. What I do in the ER, matters. It is meaningful work.[...]

Quit medicine? (part one)


When I was a medical student there was a girl who, after 2 years of medical school, decided…she didn’t want to be a doctor after all! I remember hearing a rumor that she decided she would rather spend her days swimming with dolphins. Then…she was gone. That got me thinking, for the first time in my life actually, what do I WANT to do? Prior to this, my standard reply of “I want to be a doctor” achieved sufficient accolades from everyone, and the satisfied look on their faces served as confirmation that I was on the “right path.” I never really gave it a second thought. But this girl…had the audacity to decide on her own that she was going to “throw away” everything she’d worked for (and all the sacrifices her family had made to allow her to opportunity to attend medical school) and make the “irresponsible” choice to swim with dolphins in lieu of becoming a doctor. I mean, who does that? At that time, I thought to myself: good for her for knowing what she wants to do, but why not finish medical school first, *then* go swim with dolphins? That way, if her perception of a dolphin-swimmer’s life was misaligned with the reality, she would have “being a doctor” as a back-up career option. So I spent no further time pondering any other choice at this time. Instead of thinking about what I *wanted* to do, I focused on completing the path I was on, because that’s what made sense to me. I reminded myself that the most difficult (academic) work was complete after taking the USMLE Step I (after 2nd year). The third and fourth years were the clinical (interesting, “field-trip”) years, where you *finally* get to legitimately “play doctor” for real! Why quit now? But *when* IS a good time to quit? Once you get on the ‘medical-training-in-America’ highway, there is no “easy” time to deviate. It makes sense to complete medical school because once you achieve your advanced degree, you can *still* go fold jeans at The Gap if you want. Nothing (but a few years) is lost by finishing the degree program. So you finish… Then, you can’t quit before internship. You can’t even get a medical license without completion of an internship! It only makes sense to obtain licensure. Why go through all of that training (and torture) in medical school to become a doctor, and then take away your ability to actually get a medical license because you’re too “lazy” to do just one more year? Unless you know something that I don’t (which is quite possible), there’s nothing you can practically do as a new doctor (with no other training) without residency completion. You can’t really make any money (and with the huge burden of student loans, *choosing* to NOT make money is a crazy option), aren’t respected as a doctor, and are ostracized completely from “real” specialists (and everybody’s a specialist these days). Who wants to sign up for that? When in just 2 more “short” years, you too can be a board eligible specialist! So…I made up my mind that I would complete the entire training program, and *then* I could reevaluate my decision from a position of “safety” – as a board certified physician specialist. As a 4th year student contemplating specialty choices, I decided *then* that (despite everything I thought I knew about myself) I had no desire to spend significant time taking care of sick people – gasp! And this realization just kind of snuck up on me as a senior medical student. Before medical school I thought I wanted to be the quintessential doctor who took care of the entire family their entire lives, family medicine. Then I realized that people are “difficult” and I do not want to be ‘responsible’ for pe[...]

Medical Memoir - In Stitches One Girl's Opinion


Medical school memories came *flooding* back as I read Anthony Youn’s memoir, In Stitches. Medical school was a time in my life where the details are sketchy because it was a blur of studying, isolation, anxiety, frustration…sprinkled with intermittent moments of fascination and joy. I can completely relate to his thoughts about pediatrics, “Little people, little dollah”, and being torn between life-style specialties and being a “real” doctor. I shared his dislike for the standardized patients and the weirdness that entire situation evokes in all of us. My favorite aspect about this book is its honesty and authenticity. As I devoured the book chapter by chapter, I felt like I UNDERSTOOD Tony. I was able to peek into a life very similar, but very different from my own. His book was truthful, the language was clear, the humor and candidness kept me interested and I really felt like I traveled this journey with Tony. As I read the pages, I thought of my OWN similar experiences….and my reaction to them. And as I flipped the page….reading his words were like reading my own mind. It was quite amazing! There were only two questions that stayed with me through-out the book: Why didn’t his family help him acquire better living conditions? And was he really a virgin until medical school? (implied, but not stated) I will say that I feel like the first part of the book would appeal more to young men, with all the talk about girls, women, and overall “manning up.” Since women do not (typically) go through this, it’s all very foreign in an annoying kind of way (as a woman). I was much more interested in…all the rest. Thankfully there’s plenty of ‘all the rest’ and the book was thoroughly enjoyable. I would LOVE to read a “part II” plastic surgery residency memoir. It really was *that* good![...]

Attendings who don't want to teach


Q: Now that I'm *officially* well into my intern year, I realize that some of our EM attendings are not interested in teaching (or otherwise interacting) with interns. As an intern, I'm offended. Is this acceptable behavior, and how should I handle it?A: You're right, the attendings should be willing to work with ALL of their OWN residents (interns included). Its one thing to shun rotating residents/intern/students, but *your own* should be taken care of. There are two different ways to look at this to help explain why SOME (i.e. not me, LOL) attendings avoid students/interns. The first way is to try and see their point of view. Imagine you’re an attending: When you go to work, you feel exposed (legally) because the residents are a liability. They don’t always know what to look for, what to tell you about, and how to treat the problem. Even if you, yourself, get up and go see/talk to the patient, you may miss something in your short interaction. And there are LOTS of patients. Actually, you feel overwhelmed at times because you’re responsible for the actions of others, although you don’t know what they’re doing/hearing/seeing. You have to ‘trust’ them…and that’s hard to do. And, you are just one person, and to have 2-4 people ‘presenting’ cases to you for 8-12 hours is just too hard. You can’t think, you don’t know who’s sick…and you can’t physically see everyone and do everything yourself. And it’s even *worse* when an intern is working. BECAUSE they *really* don’t know what to look for, ask about, check or test for. And when they present to you, the story is often unclear, and you’re left sorta confused. The differential is too broad when the intern presents, and you either have to go see the patient yourself, or ask lots of detailed questions to the intern to get a better story. If the intern didn’t ask the important questions, you either have to send them back to get a better history and physical, OR you order tons of tests/studies to compensate. Example: 10 month old baby is brought in my mom with a fever to 102.9 x 1 week. Intern presents it as a viral syndrome. Great, discharge, right? BUT they didn’t notice the dehydration and lethargy. They didn’t comment on the petechial rash. So, as an attending you can either: 1) get up and see the patient yourself as if he’s your own (this isn’t very practical if you have more than a couple of residents/interns to supervise or else the flow of the department will be very slow) 2) have the intern order more tests and studies to support the ultimate dispo (which isn’t really teaching, and isn’t really proper EM) 3) you can have a senior resident see the patient, and ‘advise’ the intern. That way, the likelihood of missing meningitis is lower if the senior resident signed off on the intern’s work. Of the 3 – it’s easier to have the senior resident involved. Also, it’s logical because it allows the senior resident to see more, do more, supervise a bit, and begin managing an entire department. And as attending, you’re there just as back-up for the senior resident. It’s easier to teach the intern if the obvious nuances of the case have been discussed with the senior (at least from July – December). And it frees the attending up to work with the senior and students as well. The attendings look forward to working with certain residents, just as much as residents like particular attendings. Typically attendings like residents who are confident, do appropriate work-ups, then come to them with their own thoughts about what’s going on, and what to do about it. Then the attending can talk to the resi[...]

Can I be cool with my nurses (and they cool with me)?


When I was a medical student, I was quite envious of the nurses.It seemed like the nurses, from the RNs to the licensed practical nurses, had the best of everything. Their lounge was big. Their area well stocked with food and drinks. They were always having celebrations...for everyone...for everything. They made late-night Starbucks runs, and had food delivered to the hospital all the time. And even though they were courteous enough to offer me a latte (sometimes), it always felt weird to 'fraternize' with *them*. They, were them...and I was *us.* "You cannot trust 'them,'" I was told. "'They' will throw you under the bus first chance they get!"So, for years, I had an awkward relationship with the nurses. If I needed them to do do I ask? "Um, excuse me Nurse, did you see my order?" Or, "Ms, I mean, Nurse Smith...can you get room 1 a bedpan?" It just seemed like...I was asking them to do I was in charge. But they are quick to let you know you're not in charge. But, you kinda are in charge. But you cannot 'remind' anyone that you are in charge...or else you belittle their contribution.What gives?Then I I advanced in my education/training...and as I spent more time as an attending...that good nurses are really there to help make your life easier. If they are not doing that...I would argue that perhaps they are not good nurses. And the thing is, I didn't realize this until I had an *awesome* nursing staff to support me!In residency, the nurses were indeed a little cult...whose primary mission seemed to be to make your life as difficult as possible. Sorta like they were jealous of a young woman doctor...and resented having to take orders from her. They were not polite. They claimed they didn't know how to do much of anything. "Um, I couldn't start the IV on room I guess you'll have to come do a central line." Or, "we cannot get blood from Ms. you'll have to do a femoral stick." Really?! Really, really! Either you're one sorry nurse...or you're just out to get me.As you progress, it becomes less acceptable for the physician to perform nurse duties...while simultaneously performing doctor duties. Time becomes more valuable, whereby if the physician isn't seeing patients quickly...someone is losing lots of money (and it's usually someone "more important" in the hierarchy than the doctor). And not tolerated. CEO losing money?! So support staff is hired so the physician can continuing 'bringing in the money.' And this extrapolates to nurses who enjoy (or at least don't mind) nursing.Fast forward to now. I have a great relationship with my nursing staff in general. Some of it is because my nurses are now there to support me (rather than antagonize me). Some of it is because it is the expectation that the nurses do nursing work. But a large part of the equation is me. I am more comfortable with myself, with my skills, and being a doctor. And because I am comfortable with me, and my role as leader...I am less...awkward. I am more willing to "fraternize with nurses because I realize that being friendly with nurses doesn't undermine me or my role. I see myself as team leader...but I give each member of my team the option to critically think and act without me micromanaging their decisions. I ask their opinion...and I don't feel like "they think I'm stupid" if I don't know something.And in exchange, they bring their kids in to see me for impromptu doctor visits. They save me a piece of baby-shower cake. They "protect" me from the patients and their families (this is a post for a different day). They sneak me a Tylenol or a Reglan out of the Pyxis w[...]

Vita-Salute San Raffaele International MD Program. A New Opportunity For Your Medical Education In Milan, Italy.


In this changing world, opportunities periodically come forward in our lives that provide us with a new path to achieve our goals. For those of you that are considering becoming a doctor I want to share with you a new opportunity that you should consider for your medical education.One of the biggest problems in becoming a physician in the United States is costs. We have watched the cost and debt load for students attending medical schools grow at rates that will make it impossible for many to achieve their dreams of becoming a doctor. This changing cost structure makes it important the perspective students consider all of their options.We would like to suggest an option for your consideration that will provide you with a cost effective and quality medical school educational opportunity. A place where you can receive a world class medical education, have access to superb faculty and develop international relations that will help you in your future. Plus it is a chance to go to medical school in Milan, Italy. Yes we said Milan, Italy.Vita-Salute San Raffaele University is part of the San Raffaele Foundation which includes Hospitals, Research Centers and the Vita-Salute San Raffaele University. San Raffaele is well known worldwide for its excellence: it is a highly specialized center for molecular medicine, diabetes and metabolic diseases, as well as biotechnology and bio-imaging. The Hospital channels many of its resources into cancer treatment, cardiovascular diseases and numerous acute and chronic-degenerative diseases and a very efficient Emergency Department that serves a vast area.The International MD Program builds on the institution’s solid presence on the international scene: San Raffaele healthcare centers can be found in many countries of the world, including Brazil, India, Uganda, Poland, Chile, Israel, Mozambique and Algeria.This degree course provides medical-scientific education at the highest level, allowing students to improve their skills and to upgrade their knowledge. It also provides clinical and laboratory research opportunities and additional education in humanities and cultural sciences: philosophy, communication skills, cognitive neurosciences and psychology, which are the building blocks of human society, regardless of social status, race, or creed.The International MD Program is designed to train a new kind of doctor: someone who possesses the necessary human, cultural and professional abilities to actively participate in health care and share ideas in today’s globalized world. Unlike other Medical Programs in Italy where clinical courses are held in Italian, the International MD Program is fully in English, including classes, lectures, practicals and all clinical activities.Students enrolled in the San Raffaele International MD Program have access to all the facilities of the Vita-Salute San Raffaele Institute and the San Raffaele Scientific Institute, including skills labs for practical training, a library with more than 20,000 books and several thousand scientific e-publications and resources, as well as to the clinical and research laboratories of the San Raffaele Scientific Institute, the largest private research institute in Italy, that further expanded with the inauguration of DIBIT, a scientific facility for basic, translational and clinical research.DIBIT is part of the largest biomedical science park in Italy, which includes the San Raffaele Hospital, Science Park Raf, created to support the foundation's development, and the Vita-Salute San Raffaele University.Applicants who wish to enroll in the International MD Program[...]

Ideal job - 6 years out


One of my attendings once told me that it takes about 5 - 7 years for a new ER doctor to master the specialty. This was music to my ears, because I knew that I was *not* confident upon residency graduation to jump into this very stressful specialty. I needed to wade in...from the shallow end of the pool...slowly.When I graduated, I did not look for jobs that required me to "roll up my sleeves" and do *real* emergency medicine. Contrary to what my colleagues seemed to believe, I realized that I was not quite ready to be a sole doctor in a small town ER, with no specialist support...trying to save lives. Emergency medicine is hard enough in a big city, at an academic institution, with every esoteric subspecialty at your beck and call. The real emergency medicine heroes are truly those docs who work out in Podunk, alone, and really have to do it all!!So, my first job was at Kaiser. First in Southern California, then Northern California. Kaiser is a very "safe" emergency medicine job. All the patients are insured, they all have primary care physicians, and everything in the ER is protocoled. Oh yeah, and the patients cannot sue you! So if you follow the protocol, you're good. They have all the standard sub-specialists available, and the patients are not that sick. They receive no trauma, and many doctors are working at the same time. So you're not alone, nor are you overly concerned about being sued.But Kaiser has many drawbacks...and for me was not my long term plan. What Kaiser offered me was...a transition from resident physician to attending physician (on the shallow end). After working at Kaiser, I felt a bit more confident. I actually carried some of their protocols with me, and those protocols allowed me to have "a plan" for patients in other institutions as soon as they presented.Next, I practiced my wading skills by taking a job with a group who allowed me to work a bit slower at first, and hone my skills. See, the thing is, if you are "slow," you do not make enough money for the group to cover your hourly pay. This means that...the other doctors in the group are subsidizing you. Thankfully I found a wonderful group of docs in CEP to take me under their wing, and allow me to work at my own pace until I developed confidence and personal protocols. (CEP is a great group, but very site specific. Some sites are not willing to "deal with" new docs.) Also, CEP has many sites California, so being with them, I was able to "try" many different sites, and find one that worked for me.It is common for ER docs to work at multiple sites - sometimes with multiple groups. After all, to have all of your eggs in one basket can be unsettling since we are all well aware of the inherent instability in group contracts and hospital adminstrators. But, working in multiple places allows the new doctor to realize characteristics that are pleasing to them, and those that are annoying.I discovered that I am not a huge fan of working in hospitals where the clientele is "upper-class." The pay is better in these hospitals, but the patients are not as appreciative, and they are 'entitled' in a way that is really annoying to me. In comparison to rural or inner-city ERs, I find that the social issues in these rich suburbs are similar (such as drug addition, alcoholism, violence) but no one dares to acknowledge these issues lest we upset someone by even suggesting that these issues even exist in well-to-do communities.Also, in these richer suburban ERs, everything is micromanaged. See, when things are 'perfect' at a facility, administrative hospital staff has to somehow 'justify their jobs' so t[...]

Difficult Airway


Last night I had this patient......He was a 45 yo male with no significant past medical history who presented to the ER in the early evening c/o "I think I have something in my throat." After further questioning his story goes like this:When I went to bed last night, I felt fine. No cold or flu-like symptoms, no trouble breathing...nothing. When I woke up this morning I felt as though there was something in my throat. Not all the time, but when I swallowed, I it was hard for the saliva to go down. I tried drinking cold water, then hot coffee, I ate a banana, but nothing seems to "push it down." I decided to come here because throughout the day it's been getting harder to swallow food, and it feels like it's actually bigger.He denied having any similar prior episode of the same. He denied h/o allergies. He insists that he didn't eat anything prior to the onset of the symptoms (such as fish, meat, chicken, seeds, etc). He had no other "allergic-type" symptoms such as wheezing, chest tightness, rash/hives, pruritis (itching). No new exposures, no travel. He was not a tobacco smoker, or involved in a fire (i.e. smoke inhalation). And he had no symptoms suggestive of infectious cause, such as fever, pain, redness, etc.On physical exam:He was a well developed, well nourished man in no apparent distress. Talking in full sentences, handling his secretions without difficulty, and able to drink water and eat soft foods with little effort.His vital signs were normal, including an oxygen saturation of 98% on room air.His face was normal, with no signs of swelling, no redness/hives. His eyes were normal without evidence of allergic reaction. His throat exam revealed a left tonsil that appear edematous. But there was no pus, redness, uvula deviation, and there was no pain. External palpation - the left neck felt "full" compared to the right side, but no mass was felt, and again, there was no tenderness to palpation. Lungs were clear. And otherwise his exam was essentially unremarkable.So...we put him on oxygen, I drew labs (basically because I had no idea if this was infectious, allergic, traumatic, etc...and with airway issues I like to have as much information as possible, just in case surgery/intubation/intervention becomes necessary). I ordered a CT of the neck.He's cruisin' along, sleeping on the gurney, when I got the CT report back:"Extensive soft tissue swelling surrounding the airway...with prevertebral soft tissue swelling...partial airway obstruction...."WTF??!!I call for ENT, no one is on call. I call the nearest THREE hospitals...and I got some combination of 'no bed', or 'no ENT'. Finally, I get a hospital 80 miles away to take this guy. The ENT surgeon there recommends steroids, IV antibiotics, and intubation prior to transfer. All of that makes sense. Especially since the patient is starting to have more difficulty breathing and swallowing. We'd held off as long as we could to allow the meds to work but...he was indeed starting to have more significant respiratory distress. We preemptively called anesthesia for an awake option since he would absolutely need intubation prior to transfer, but that was now...not an option. Now is the time to intubate...The critical care transport team will be here in 20 minutes.So, I round up the troops. Explain everything to the patient; and obtain consent. Move him to big resus room, throw in a central venous catheter (in the femoral vein of course, not going anywhere near the neck). I have my colleagues at my side (2 other ED attendings) with the difficult airway cart at the bedside. I call for anesthesia, but no anes[...]

filling my time with less frequent blogging...


I heard that blogging can be hazardous to your health.

It's interesting, because blogging can be stressful and overwhelming...especially if you're expected to produce new material more often than you actually *have* new material. After blogging about a year (more-or-less consistently), I find I have ranted and fussed about most of the things that bother me most (but don't fret, I still have a few annoyances I'd love to expose...and new annoyances things are always "coming up"). I have shared my enthusiasm for my profession. I have documented the process, the thoughts, and the transition from medical student to attending. And I've talked about memorable (pseudo-)patients. Now, I don't feel as pressured to write all the time.

Additionally, it's takes quite a bit of time on the computer to post even one (legible/comprehensible) entry. To translate your thoughts to print...and make them comprehensible by most who'll read them...takes time (depending on the thought). And, I've seen hours "disappear" as I update my blog, surf the net, return email, etc...all while the kids are on their 8th episode of SpongBob SquarePants of the evening (just kidding...kinda).

As the days get longer...and the weather warmer...and the kids get bigger (i.e. more activities, more time needed to engage them, more friends over, etc)...I think I'll have to spend less time on the computer. When they were in bed by 8pm - and me not until 11pm...I had lots of time. But now the little guys aren't in bed until 10pm (it's actually still light outside until almost 9pm in the summer here). So, I have less time to waste spend on the computer.

Just thought I'd post this for those who may wonder 'what happened?'.

Just enjoying the sunshine...(image)

What was medical school like? Years III and IV


After completing years I and II, you have a small break. At our school, this break was only a few weeks....and it wasn't really a 'break' at all.After completion of year II, it was required that we take (and pass) the USMLE Step I. This first part (of a three part series) tests your basic science skills. Basically, the things we learned in years I and II are being tested. Our school was pretty good about teaching to the test (somewhat), and boasted a high first time pass rate. But you see, that 'break' was spent cramming for this licensing exam.This exam was very difficult. You know, one of those exams that you can't even discuss afterwards because there were just so many uncertainties. You have no idea how you did. On other exams we've taken, most of us had a feeling about it:"I think I did okay...but number 10, you know, the question with the xray...I wasn't sure if they wanted this answer or that answer...etc.'" OR, "that exam was horrible...what?! you put C for number 4?? geesh, I musta missed that one too...etc" (like this). After this exam, it didn't happen. When I took the exam it was 2 days long...all day (except an hour for lunch). After lunch on day two...I just started marking everything 'B'. I was so tired of testing. After you take that exam, you begin your third year. By now it seems as if everyone knows what they wanna specialize in. And if you do, that's a good thing. The sooner you know, the better. No one told me that...and I wish they had. If you know you wanna be, say ophthalmology, you can engage in research, and start kissing ophtho ass early. You'll take the rotation as soon as possible...and as many ophtho rotations as necessary to get the letters you'll need to match. Years III and IV consist of clinical rotations. Our 3rd year rotation schedule was made for us (i.e. we didn't get to choose the order of rotations). Basic required rotations were surgery, internal medicine, psychiatry, OB/GYN, family medicine, orthopedic surgery, pediatrics, and neurology. Our 3rd year consisted of these rotations. Most were about 6 weeks. You had about 12 weeks (maybe it was 16 weeks) of vacation. You could take that as a block, in two 6 week blocks, or however you could manage it. You requested your vacation time...and the university filled in your 3rd year schedule around it. Our 4th year (frequently referred to as a 'sub-internship') we did our own schedule. There was a second round of required internal medicine...and many of us didn't necessary get all of the 3rd year (required) rotations completed in 3rd year (maybe because of vacation request, or scheduling, etc). So, you had to finish up those. Many of the rotations (the 'interesting' rotations) required the student to have completed a prior 'basic' rotation. For instance, an NICU (neonatal ICU) rotation will no doubt require the student to have completed pediatrics (and possibly OB/GYN) prior to starting. During this year, students typically take rotations like radiology, anesthesiology, emergency medicine, ophthalmology, dermatology, and maybe some bizarre elective at a far away place (but these electives are hard to get approved, and most students opt for pre-approved, 'normal', nearby electives). Also, you get to choose which hospital you'd like to do some of the required rotations. University hospital, County hospital, Community hospital, etc. There are some rotations that are notoriously easy (meeting like twice in 6 weeks) for an easy pass, and a nice break. I (am not ashamed to say it) *maximized* these opportunities. ;o) During the rotati[...]

What was medical school like? Years I and II


I remember being a pre-med. I had the full college experience, IMO. I studied to maintain an academic scholarship, had part-time work (intermittently), and pledged a sorority. I dated more than one guy, did some local traveling, and made lasting friendships.I remember being very concerned about 'med-school prep.' I wanted to take the "right" classes...and do the "right" summer programs. I had to volunteer, and participate in campus organizations so I could distinguish myself from the 'average' student. I did undergraduate research that resulted in publications. I took MCAT prep courses, and followed the recommendations of the premed office on campus regarding which classes I should take when...when to apply to med schools, and which schools I'd likely get in to.I gained early acceptance into medical school. This acceptance was arranged such that I didn't *have* to go to this school if I decided to continue on in the application process and I happen to gain acceptance into another (more desirable) school. I decided I wanted to come back home, so I applied to the local schools. Got accepted. Decided *not* to go to the 'early acceptance' school.I was ready for medical school. I'd done 2 or 3 (med school/MCAT prep) summer programs. I'd taken all the requisite courses, including anatomy, physiology, advanced chemistry, microbiology...everything. I felt pretty prepared...but utterly unprepared at the same time.I remember the first 'meet and greet.' Everyone seemed nice enough. I guess I expected everyone to look like 'revenge of the nerds' or something...but they all looked normal enough. They were social and some boasted full "prior lives" as policemen, firefighters, nurses, teachers, mothers, fathers, military...The average age of my first year class was 30. That means that half the class was *over 30* in their first year of medical school. I had no idea everyone would be so...old. There were even a few people close to 50 (after having raised families or whatever)!!There were quite a few smallish/informal meet and greets. Some indoors (dinners hosted by alumni, or AMSA, or some other group). Some outdoors, usually in the quad. Sometimes there were booths up urging us to join this group, or that group. Some upper-classmen were there, offering advice, or representing a club. We had picnics/BBQs. It was very nerve-wracking.Then, our first welcome lecture. The one where they introduce lots of faculty. The one where they give you your first taste of what medicine is *really* like. They explain the horrible state that is American healthcare...and basically express frustration with the field. They seem to hate so many things...and are so bitter. Jaw on floor, you try to take in all of this information. You try to understand the bitterness, and convince yourself that "I'm not going to be so bitter when I grow up." Then, as if they're reading your mind, they say "you just'll see. Come talk to me in 10 years."And school hasn't even started yet.There was the white coat ceremony, where a few friends/family get to listen to a lecture about how wonderful being a doctor is and how doctors love patients so much (stark contradiction to the lecture *you* and your classmates sat thru just days prior)...and you get the (short) white coat (as if it's important or something). Everyone is so proud of you.Then, the first real lecture happens. The big lecture hall. Everyone stakes out a seat. I liked to sit on the front left side, about 5 rows back. I liked to have the seat next to me empty. Everyone'[...]

A groove...and time *not* being a doctor


I finally feel like I'm getting into a groove (I'm reading Vicki Iovine's book shown here...and love it).I've been out of residency 2 years, passed my boards, and my hands no longer tremble when I have to intubate someone. My heart doesn't skip beats (as often) when I hear the MICN on the box taking a full arrest run. And, I'm more-or-less comfortable sending well babies home without worrying (too much) about whether or not they'll develop meningitis in the next week or two...I've developed a (usually) polite, yet firm, way about me and my order to get things done. Both patients and ancillary staff typically respond better to a physician who is decisive and confident. But, I know how to listen and take advice (i.e. hear the subtle, or not so subtle, inflections in the voices of family and nurses when I should consider rethinking my disposition). I know how to ask for help without feeling incompetent. I can explain myself to the second-guessers...and feel even more validated in doing so. And, interestingly, I'm not at all shy about admitting what I don't know.I'm actually enjoying myself most of the time.Of course I still have times where I'm nervous, overwhelmed, or simply just not feeling up to the task. Since it's difficult to take 'a sick day'...we doctors (and nurses) often come to work regardless of how we're feeling - and probably when we shouldn't. But I digress....The biggest thing however is my new-found *balance*. I have found the perfect number of shifts...types of shifts...and places to do said shifts. This, my friend is key. I believe that being rich means having choices, period. Money certainly allows for more choices (to a point), and is therefore a necessary part of the equation. But, choosing how you spend your time, where you spend your time, who you spend your time with, etc...for me actually defines "rich." If I'm working 25 shifts/month, I may have a $30,000+ bring home salary/month, but really, I'm not rich if I have to go to work frikin 25 days/month!!I realize that working about 10 shifts/month allows me to bring home more than enough money to cover our expenses plus savings...AND I get to spend the rest of my time (get this)...doing other things!! Additionally, I realize that I actually enjoy working at 2 different EDs, each with their own flavor. Working in two different EDs allows me to not get all caught up with the politics of a place. My residency program was the *most* political program ever (I'm sure). Every word, every action...political. Very stressful.I also realize that I actually *enjoy* working at an urgent care center/walk-in clinic. It offers a completely different perspective. It's nice to have time to sit here and update my blog (finally), and see patients intermittently while doing so. It's nice to take a lunch break (imagine that, a lunch break!!)...and its nice to visit the toilet from time to time when necessary.Also, it's nice to refer patients that you don't wanna see (for whatever reason) to the ER. Shortness of breath? need to go to the ER. Pregnant vag bleed...yep, ER for you. I see why so many clinic docs dump refer their patients to the's just so frikin easy. Not that I would ever do such a thing. All the patients I send to the ER actually belong in the ER...and I should know.Sometimes I get asked by folks when I tell 'em I only work 10-12 days a month:...what else do you do with all your time?"Seriously??!!You know what I do? I cook healthy meals because this non-organic/f[...]



There are a few things that many EM docs don't openly discuss 'else they subject themselves to criticism and judgment. Here are few of my confessions -I think leaving acute patients to 'see quickies' in an attempt to clear out the waiting room contradicts the very essence of emergency medicine...and I don't do it.In every emergency department there is (supposed to be) some sort of triage process. Where sick people are seen first, and not-so-sick people...wait. Well, our nursing staff (as wonderful as they are), will frequently ask me if I would 'come out and see some of the quickie, non-sick people, to clear out the waiting room.' If I'm sitting around surfing the net...then sure. But I'm never not busy at work. Never, ever. I rarely get to go urinate, much less grab a bite to eat. So, I don't do it. I can't justify in my mind, leaving my sick patients to go see not sick patients. And all to "clear out the waiting room?" That's really not my goal. My goal is to keep people who shouldn't die, from dying...and to get the rest to their proper destinations. When my shift is over...I leave. Waiting room full...or not. Why should my goal be to clear the waiting room? If I valued an empty waiting room...emergency medicine would be a poor choice of specialty.I think that speeding thru patients, and subsequently rewarded for it, is a bad idea.It annoys me when doctors brag about their half-ass workups in an attempt to seek reward for speeding thru patient encounters. Our patients wait, sometimes in excess of 6 hours, to see us. They deserve 10-15 minutes of face time. Even if the problem is straight forward and you only need 90 seconds. This interaction with patients (listening to them, talking with them) is why I love medicine. Minus the patient encounter...what's left?Sure, I understand being efficient is important...but seeing 3-4 patients an hour is not good for the patients you see. They won't like it...and you won't like it. Something will be missed. A something that won't be missed if the doctor just takes a minute, grabs a chair, and spends 15 minutes with a patient. Additionally, taking a minute (or 5 or 10) to look up information (for yourself or for the patient) is totally appropriate, but doesn't lend itself to "speeding thru" cases. Finally, very important thought processes would be clear if time was spent documenting this information *in real time.* Not to mention more defensible in court, and basically just better communicates (as a medical record should) with other care providers.I hate reading history and physical assessments written by people who are more concerned about capturing all the "elements" for full reimbursement, rather than actually documenting what the hell's going on with the patient.There are so many docs now who chart based solely on reimbursement, that very key information is not included in the documentation. I do understand the need to get paid...but it's just as important to communicate effectively for the well-being of our patients. And simply putting "4 elements" in the HPI...doesn't quite do the job.I hate dictating.In the ED so many of my tasks are accomplished piece-meal. I may do the HPI in the patient's room...fill in the physical once back at my desk...and document the labs/xrays as they become available. I'll later fill in consultants names, times called, and their responses. Medical decision making usually follows. Finally I have a "diagnosis" and disposition. If I dictate, I can not do it in r[...]

a trauma story


Since I got such positive feedback, I'll post one more story.I work at a couple/few different places - which is nice because my ER shifts are quite different depending on the location of the ED (obviously). One of 'em is a trauma center. The trauma center is way cool...and has top of the line everything. The trauma resuscitation bay is like 20 feet from both the CT scanner, and the OR. The anesthesia and surgery call rooms are actually *in* the trauma center. We even have a teeny-tiny police department (2-way glass and everything) in the entry-way to the trauma center.So, I was at work recently, at my trauma center ED. Things were steady. Our traumas so far consisted of a drunk dude who was riding his bike, crashed into the curb, fell off of the bike, and lost consciousness. Granted, there are quite a few things possibly wrong with 'drunk dude', but more than likely, he's just drunk. But, he fits 'trauma criteria' so he was brought to us. There was a kid who jumped off a roof, obvious deformed leg...but otherwise okay. Then we received the EMS call:"This is rescue 25 to base with a trauma run."This is base. Go ahead with your run."We have an approximately 30 yo male who jumped from a 2nd story window to escape an apartment fire. He has 2nd and 3rd degree burns over his anterior chest, neck, and his right forearm. He has an obvious deformity of his left femur, and multiple abrasions to his face. He's alert, but appears intoxicated, and is combative. We have PD on scene helping us secure him for transport. His vital signs are 150/84, heartrate 120, respiratory rate is 22, and his O2 saturation is 98%. We're attempting to establish IV access, we have him on O2, full spinal immobilization, and would like to have an order for morphine. You are our closest trauma center with an ETA, after we get him loaded, of 7 minutes. Over."We rally the troops, and congregate in Trauma bay number 4. Upon arrival, EMS notifies us that this guy was 'set on fire' by a girl. Apparently this girl is the girlfriend of a rival gang member...and 'word on the street' is that she decided to get revenge on this guy for killing someone in her boyfriends gang. Because of this, there were already members of both gangs 'interested' in our patient's condition....and our parking lot was starting to look a lot like Crenshaw Blvd on Sunday night. As firefighters approach us in Trauma 4...we see a young adult male, laying on the paramedic gurney with a c-spine collar on a long spinal backboard. His face is covered in blood and glass. His chest wall has 3rd degree burns over the entire anterior surface. His left femur is obviously fractured; as is his left tib/fib. They have no IV access. Patient is on O2 via facemask. He's yelling loudly, and wiggles on the backboard. We transfer him to our gurney. And the nice thing about trauma centers, especially where there are residents, is that there's enough people around to do everything. My mind is yelling "oh sh*t. This guy looks horrible!!" The residents are eager to *do something*. It is times like these I really appreciate the simplicity of the mnemonic ABC. As the attending (gulp)...I start giving instruction."Okay, lets get him on the monitors, pulse ox, and let's get some sterile gauze soaked in saline." That sends a few people scurrying away. Someone assess his airway and listen for breath sounds. Let's set up for intubation, and obtain central venous access...via...via..."(hmmm....can't do su[...]

obesity. viagra. heart attack. thrombolytics.


Last night in the ER.......was very busy. And "busy" in a good way. Lots of codes and respiratory distress. Not so much "weak and dizzy" and "TMD (todo me duele)". The kind of night that reminds you why you chose emergency medicine as a specialty, and not primary care.Anyhoo, there was this one guy...A 36 yo morbidly obese Samoan man with a past medical history of diabetes, hypertension, and has lots of 'bad habits', was brought in by paramedics complaining of chest pain which started 10 minutes prior to the 911 call. He was sitting on the sofa watching reruns on TV when he suddenly felt a tightening in his chest. He got up to get a cup of water, and the pain got worse. Then he felt weak and lightheaded so he sat down on the nearest chair. He then called for his wife, and she took one look at him and called 911. In the field EMS established a very tiny finger IV (because 'his veins could not be accessed secondary to excessive adipose tissue.' i.e. he was too fat). They gave him an aspirin, and after he denied using Viagra, a nitroglycerin sublingual. Immediately thereafter his blood pressure dropped from 150s systolic to low 80s. He became very diaphoretic (lots of sweating), and short of breath. Upon ED arrival the patient was alert and oriented, but very agitated sitting upright on the gurney, in moderate/severe respiratory distress. He weighed about 450 pounds, and was extremely diaphoretic, and c/o worsening SOB. EKG could not be obtained by the paramedics because the stickers wouldn't stick to the body for all the sweat. Also, the patient was so agitated and anxious that a good reading couldn't be obtained even when the EKG leads were held in place by assistants. In the ED we attempted to obtain an EKG...for over 20 minutes. We cannot make a diagnosis of acute MI requiring thrombolytics if we cannot obtain an EKG. Afterall, there are other deadly causes of chestpain, some of which absolutely cannot be treated with thrombolytics (or else you kill the patient). It's one thing for someone to die. It's another thing to kill them. So we worked to obtain that EKG...over, and over, and over, and over again. During this time we worked to establish a better IV with ultrasound guidance. We worked to improve his oxygenation (from 90% on face mask to 95% on non-rebreather). We asked basic questions (allergies, past medical history, medications, *viagra use*). His bloodpressure continued to register in the low 80s (82/64 - narrow pulse pressure, with a heartrate of 120). Are you sure you don't take Viagra (or other 'viagra-like' drugs)? we asked again. He adamantly denies.I'm so nervous at this point. Here I have a very sick patient, who I think I'm going to have to intubate. He's 450 pounds. His blood pressure sucks. And we can't get a frikin EKG. Agreed, he's likely having an MI...but what if it's an aortic dissection (which could be dissecting up to the origin of the cardiac vessels...causing the MI). On CXR it's possible that his mediastinum is widened. What if he has cardiac tamponade? (the cardiac silhouette is enlarged) I feel stuck without the EKG!!Finally we get a very crappy EKG. The QRS complexes are very wide, and there are diffuse ST segment elevations. Hmmm....hyperkalemia? Pericarditis? Massive MI? Maybe....TCA toxicity? I give bicarb and fax the EKG to the cardiologist at home after explaining to her the clinical history. She agrees that it is consistent with hyperkale[...]