Archive for category Residency
I think we’ve all experienced what I like to call “case envy.” Or even sometimes, “shift envy.” You come on and your colleague immediately starts telling you about the interesting case, or the polytrauma, or the fantastic save/diagnosis/procedure that they just completed.
“Hey, bud, I just performed an open thoracotomy, cross-clamped the aorta and threw in a central line just after performing a cric while I was watching this guy’s aorta rupture during my ultrasound of his belly during which we lost pulses. Sorry about the rest of the mess here in the ED, but those three pelvics and a disempaction might yield something interesting… Enjoy your shift!”
I sometimes hear the story and wonder what I might have done. Would I have handled things the same way? Is that the diagnostic approach I would have followed? Would I even have considered things the same way? Why don’t I ever get the cool cases…?
In residency, we had one colleague who was the perpetual “Black Cloud.” Now, they got to see a lot of cool stuff. However, you didn’t want to follow them because you knew it was going to be chaos in the ED when you arrived. And, if you came before them, you knew the last part of your shift was going to start going to pot about an hour before the end of it.
So maybe it’s not so bad being a bit of a white cloud… but still… I think we all like to have a little something that gets the juices flowing, the mind working, a bit of “yeah for me” moment… After all, that’s why we got into Emergency Medicine… at least for me… how about you?
Congrats to everyone matching in an hour. Emergency Medicine was apparently especially competitive this year; I personally interviewed an insanely outstanding group of applicants. Not sure if I would have gotten into my own residency program any more!
I am a self-confessed EMRAP addict. If I end up being half as much of a Captain Cortex with one-tenth the witty repartee as Billy Mallon, I’ll consider myself a success. Being from Kansas, I wouldn’t mind having an Australian accent, but I think that just may confuse people.
But am I the only one who just feels perpetually sick to my stomach when they’re listening to a Bouncebacks case? A teenager dead from PID, an older patient dead from cerebral edema who had peripheral vertigo and a positive Dix-Hallpike test? I send these things home all the time. Maybe it’s just a recall bias, but it’s often the same day that I listen to the talk I will have just had a very similarly-presenting patient the day before.
Is “Bouncebacks” supposed to significantly change my practice? I don’t think so–but don’t think it’s supposed to. I’m a “First, Do No Harm” kind of guy, and feel like if I practice to find the completely outlying one-in-a-million case, I’m going to be hurting many more people along the way. But at the same time, the cases stick in my head for the next month and definitely make me think harder about the case and broaden my differential, which is never, ever a bad thing. Maybe I order an image. Or a lab test. Or repeat the physical exam. Or arrange closer follow-up.
We shouldn’t practice based on our own personal lists of “burns”–patients that went bad–but these cases should make us practice a little differently. And that’s what Bouncebacks is great for. Maybe the nausea it induces is really just that same feeling I get when a colleague says “Hey, remember that guy you had,” and my stomach sinks. Hopefully, I learn something with each one of those encounters: I read up on the topic more, I decide to get the EKG a little faster, I check that aspirin level, or I push on the belly one more time after the CT is negative.
My dearth of blogging as of late has good reason! Both are websites that are being launched this month–one today and one at ACEP! Today’s was our residency website, now with bells and whistles. As one of the chiefs for our program this year, I wanted to try to use the web to make things more accessible for our residents and attendings. Medicine itself may still in the 1980s, but we don’t have to be. I really like the sinaiem.org site, and wanted to do something similarly practical.
A few bits to highlight:
- Yes, yet another blog. We’re going to try to use this to communicate and re-iterate highlights and pearls from conference as well as social announcements as well.
- A password-protected page for residents, complete with “Chief on Call” information.
- A Google Docs-embedded block schedule (this is surprisingly easy to do)
- The coolest is the Resident Docs link. I’ve setup our Gmail account as a repository of Google Documents, and made a folder viewable by the residents. We can then save any interesting/good/talked about articles as PDFs to the account, and residents can then download them at their leisure. I find this much better than emailing an article out or sending a Pubmed link.
Any other cool or cutting edge things other programs are doing out there?
Not really words that as an E.D. doc we used to have to think about. Of course, these words are taking on a whole new meaning for us when we try to readmit that CHF’er who decided they really needed
a smoke to go home to “take care of business,” and we then get push-back from the admitting service or Utilization Review nurse.
It’s not our fault the patient decided that they didn’t like the food. Or that they felt they would get more frequent narcotic administration by absconding from the hospital ward and coming down to the E.D. I get that patients become bored on the floor and feel like no one is paying attention to them when rounds are just once a day. I understand that patients sometimes feel like “the doctor wasn’t doing anything anyways just sending me off for a bunch of tests.” I’m sorry if they left last time; however, their lung cancer, GI bleed, cardiac disease, end-stage renal disease is a reality, and they really do need to be in the hospital.
Somehow, though, I don’t quite get the patient who was stabbed in the shoulder, had a tension pneumothorax we needle decompressed and who we then admitted with a chest tube, who didn’t want to “wait around the hospital” and so absconded with their chest tube in place and carrying their Pleuravac. To their credit, they did show up back in the E.D. two days later saying that’s when he was originally told he was going to have his chest tube removed and was back to have it taken out.
I also had another patient who developed chest pain and walked to their closest fire department where they proceeded to collapse on the steps. The firemen performed CPR and defibrillated the patient getting back a pulse when EMS arrived. The STEMI was evident on the pre-arrival EKG, and we got the patient to the cath lab within 30 minutes. He, of course, absconded just after his angioplasty because, “he’d been on his way to do something, and couldn’t be sitting around the hospital doing nothing.” He shows up from time to time with anginal pains. Probably because a proper discharge would have included medications which he didn’t get that would have helped with those pesky clogged arteries.
Don’t even get me started on why he hasn’t filled his scripts yet….
One of the things that I am going to miss most about being in residency will be conversations like this with my fellow off-service residents:
Mel EM3 in ED: 59M MVC w ICH need consult
Me on Neurosurgery: k b down soon
(20 minutes later…)
Me on Neurosurgery: Plan crani w ventric admit TICU
Mel EM3 in ED: k
Me on Neurosurgery to BB EM2 in TICU: crani ventric 2u s/p MVC
BB EM2 in TICU: k drugs?
Me on Neurosurgery: dil loaded ED by Mel
BB EM2 in TICU: plts?
Me on Neurosurgery: ask Mel in ED
BB EM2 in TICU: k
(Ten minutes later…)
Mel EM3 in ED to both: plts in, bed in
Me and BB to Mel: tnx
Mel EM3 in ED to both: NP
(One hour later…)
Me on Neurosurgery to BB: crani ventric done C U soon
BB EM2 in TICU: k
Me on Neurosurgery to Mel: big clot, TICU bound
Mel EM3 in ED: nice
Me on Neurosurgery: yep
Mel EM3 in ED: 1 more, SDH 78F s/p fall
Me on Neurosurgery: :p
Mel EM3 in ED:
I think the first and most lasting memory we all have of medical school is cadaver lab. That is where we met our first patient and started to learn about disease processes. It’s where a lot of us experienced death up close for the first time and began our lifelong pursuit of staving it off for as long as possible. We shared the experience with our classmates – bonding us together as future physicians. So many friendships (and a few romances) were made over that cadaver.
I remember the nervousness as we decided who would make the first cut. We started our dissection on the upper extremities, and that first incision to expose the flexor muscles of the arm seemed so impossible. Who were we to cut into another person? Shaking scalpel aside, we made our way through.
Today I was faculty at my final cadaver lab of my residency teaching the junior residents advanced procedures such as venous cutdowns and thoracotomies. There was no hesitation in their hands as we identified landmarks and dissected out veins. Everyone reached for the scalpel in anticipation of making the thoractomy incision. Eager hands reached in to find and cross-clamp the aorta. No nervousness here. Everyone was eager to cut and learn.
As I count down the final several weeks of my residency and look to my future as an Emergency Medicine attending, I find myself thinking back more and more on my training. Days like today take me back to where I started; scared, unsure, wondering if I would be able to pick up that scalpel. Now I can see where those first tentative days have led me to. And, I thank all of those patients who gave of themselves along the way so that I could continue the promise I made to that first patient so many years ago… ”Rage, rage against the dying of the light…”
We’ve all had that hysterical patient. The one that comes in during a busy shift. Grabbing at their head, their chest, their abdomen. Yelling out that they are in pain.
You know the one. They makes the nurses’ eyes roll. They add to an already chaotic scene. Other patients stop to watch as the gurney rolls by.
You debate how long you’re going to wait to go into the room when the triage nurse hands you the chart and tells you the patient is so agitated that they can’t give her a history. The EMS crew tells you the call came out as a chest pain, a headache, an abdominal pain.
This is the patient where you go in the room and try to patiently get a history. You count under your breath as the patient continues to cry and “carry on.” Finally, frustrated you tell the patient you can’t give them anything until they talk to you and tell you what’s going on. Even then you might not get some useful information other than their presenting complaint.
You walk out of the room. The nurse asks, “So what are we going to do with this one?” You shake your head in exasperation. ”I don’t know. Let’s start with…”
You jot a quick note. Go to tend to the other demands of the department. A while later the EKG or chest x-ray or flat plate or lab result comes back, and you think, “Oh crap!” You rush back to the room. Suddenly that crying, wailing patient is the STEMI, the widened mediastinum, the free air in the abdomen.
You look at your watch. How much time has passed? What needs to be done? You start to mobilize your team. You get the nurse to run extra labs. You order the CAT scan. You call your consultants.
You go back in that room with a different view on the patient and start to explain what is going on, try to reassure them, ask them what you can do for them. You get consents, place lines, make phone calls to families.
The patient is rushed off to the Cath lab, the OR, the ICU. Then you wait. You’re seeing your other patients in the E.D. but your mind is on that patient. What did you miss? What could you have done sooner?
You get some information. The patient had a 100% lesion in the LAD, a ruptured AAA, necrotic bowel. They’re going to Tele, the ICU, or they died on the table in surgery.
You stop and think. Was I professional? Did I make them comfortable? Was I even nice?
Then the next patient comes in the door yelling and screaming that the only thing that’s going to help their pain is “something that starts with a D.. dill… doll…” You take the chart, go in the room, and start again.
Working a few Peds shifts lately I’ve run into the same question: when should your urine pregnancy test (or quantitative serum hCG) be negative after a regular pregnancy, a termination, or a miscarriage (meaning, could she really already be pregnant again)? I hear different answers depending on the obstetrical consultant I ask, so I decided to do a little literature search myself. It’s really only been looked at in very small studies; I’ve got the specific numbers if you want them, but based on the studies I found, it looks something like this:
After a Full-Term Pregnancy:
- Should be 3 weeks or less. In some women, ovulation may occur as early as 3 weeks after delivery.
After a Termination with Misoprostol/Mifepristone:
- In one study, following up at 6-18 days, if the hCG level was 80% lower than the initial hCG level, there was a positive predictive value for successful expulsion of 0.995. There was no information on when the level dropped to 0 or <5.
After a D&C Termination:
- Depends on the initial hCG, but mean time was 35 days, but could be up to 60 days.
After Miscarriage in Women Who Then Had a D&E for Continued Bleeding:
- Median ~20 days, range 9-22 days.
After Ectopic with Laparotomy:
- Ectopics had the lowest hCG to begin with, reached 0 by 1-31 days, median 8.5 days.
- Routine terminations of pregnancy—should we screen forgestational trophoblastic neoplasia? The Lancet, 2004.
- Human chorionic gonadotropin in maternal plasma after induced abortion, spontaneous abortion, and removed ectopic pregnancy. Obstetrics and Gynecology, 1984.
- Verifying the effectiveness of medical abortion; ultrasound versus hCG testing. European Journal of Obstetrics and Gynecology, 2003.