Don't Believe What You See On TV (24/30)

     Last Tuesday was the last day of my rotation in emergency medicine. Looking back it's hard to come up with a summary of this rotation. I worked 17 shifts, saw 100+ patients, had only a few repeat diagnoses, and performed quite a few procedures. I suppose the only general statement I think I could make is to say that the ED does not lack in variety. Sure, there are particular conditions that are seen commonly, but you show up each day for your shift not knowing what you will see. Even the "common" conditions aren't always that common, or don't present in the same manner each time. Take appendicitis for example. During my surgical rotation I saw a woman with appendicitis who presented with left-sided, rather than right-sided, lower abdominal pain. It turned out that she had a long, midline appendix that extended into the left abdomen. Then on this ED rotation there was a man with right-sided diverticulitis and a boy with a right-sided abdominal abscess who both presented similar to acute appendicitis. It wasn't until my last day in the pediatric ED that I actually saw a case of appendicitis that fit the "classic" presentation, and even then the patient had not yet developed a fever, as is common. 

Being woken up by solicitors
after my last overnight shift.

     The variety of the ED was also aided by the fact that, for this rotation, I didn't stay in the same area of the ED for all shifts. My schedule was 3 days on/3 days off, and for each group of 3 days I was in a different location. I had six 12-hour shifts in the main ED (3 overnight, 3 during the day), three 9-hour shifts in the more psych side of the main ED, four 8-hour shifts in the pediatric side (I covered one shift for another student), three 10-hour shifts in the fast track, and one 8-hour shift on an ambulance. It's really no wonder that this rotation seems to have flown by. I actually enjoyed all areas of the ED, but it was nice that if a student really didn't like one area, they only had to do three shifts there. That was definitely nice in regard to the overnight shifts. I actually saw a lot of interesting things on those shifts, but man did they mess with your sleeping and eating schedules. I spent the next 1-2 days after those just recovering and trying to remember what day it was. It didn't help that there were mandatory lectures two days each week, so for two of my overnight shifts I couldn't even go home when I got off at 7 AM, but had to go to lecture and finally leave around 9 AM and 11 AM. That was painful. At least when it was quiet I had the opportunity twice to head over to the fast track side and nap in a bed for a bit. It was actually quiet enough that I got about 2 hours of sleep/nap one day.

How I got a few winks during overnights

     If you're surprised that I got any sleep while working in an ED, I should mention that E.R. and other medical dramas on TV can be a bit misleading about the day-to-day life in emergency medicine. There are quiet times when the only patients in the ED are ones waiting to be admitted. There's also just a lot of waiting. One of the attendings with whom I worked quipped that a more accurate TV show about the ED would just be a lot of people sitting around typing on their computers and waiting for lab results to come back. That's often a fairly accurate description. The waiting can be very frustrating for both providers and patients (and certainly the patient's family members), but it is a regular part of ED life. Later at night in particular it can take longer because there are fewer staff in the lab or imaging. Particular days, like Mondays (apparently everyone waits out their illness on the weekend and then comes in), will have longer wait times because there are simply more patients waiting to be seen. On that note, many patients who come to the ED, would be much better suited for an urgent care, or even their primary care. Now sometimes it's hard to tell who is truly an emergent case, but I will warn future ED patients that if they come in for a neck strain and other patients are there for potentially life-threatening illnesses, the neck strain will be waiting. Complaining will not get you seen faster if other people are in worse shape, and being disruptive might actually hurt your case because no one likes to deal with unpleasant people. So, when you're in the ED, be patient, and be observant. If there are patients being seen in hallway beds, or you hear a provider mention they haven't eaten or used the bathroom since their shift started, it's probably a busy time and you might be waiting longer. Sorry. Enjoy the free TV and snacks (if you're not NPO, that is). 

     Of course, there are moments in the ER when there's not enough time, moments when you are running because even the seconds count. These moments might not be as frequent as TV would make you believe, but they happen, and they can be terrifying. There were four times on this rotation when I thought a patient's life was in immediate danger. The first time was a young man, a healthy-looking fellow with nothing but a right-sided chest pain that he said he almost didn't come in for because it didn't seem so bad. In fact, his pain didn't seem so bad to us at first either. If you looked through the notes written about him that morning, you would see the same phrase over and over: "no acute distress." This is essentially a description saying that this man did not look sick, and gave no indication that, less than an hour after being brought to his room in the ED, he would need an emergency procedure to save his life. Physical exam however, revealed that the patient had a pneumothorax, also known as a collapsed lung. It can happen for numerous reasons, but in young, tall, thin males, like this patient, it's often a spontaneous occurrence and is not necessarily life-threatening. In fact, some studies recommend that if that the lung is not too collapsed, the patient can be managed conservatively* (i.e. they're allowed to go home and told to return if things become worse, rather than having a chest tube put in to let out the air that has escaped from their lung into their chest) because they'll likely heal on their own. In 1-2% of cases however, spontaneous pneumothoraces can become tension pneumothoraces,** meaning that the air flowing from their lungs into their chest cannot escape and begins putting pressure on the heart and other lung. This is an emergency. In the case of my patient, less than 15 minutes after getting the x-rays back that confirmed his diagnosis, and while thoracic surgery was on the way to the ER to put in a chest tube, his heart rate and blood pressure suddenly plummeted. While the nurse and doctor quickly sterilized and numbed the patient's chest, the PA and I tried to keep him talking so we could gauge his mental status and whether or not we actually had time to hit all the proper steps. I wasn't sure that we did because, as a witness later said, the patient "looked like death" and was struggling to focus and respond. Even as my worry and fear grew, the other providers remained calm, and in what seemed like eternity but was really 2-3 minutes or less, the patient's chest was cleaned, numbed, a needle was inserted between his ribs, and a rush of air came out. His vitals began to stabilize immediately, and he began to talk normally again, telling us that his pain was gone. Shortly afterward the thoracic surgery resident arrived, a chest tube was placed, and x-rays showed that the patient's lung had reinflated. He had to stay at the hospital for a couple days, but he was just fine. Unfortunately, not all my patients had happy endings.

The view on my ride along

     I worked three codes during my overnight shifts. Two were only an hour or so apart. None of them survived. It was the first time I had actually watched a patient die. I'd come close during my last day of my surgery rotation when one of my patients requested to be put on care measures only after contracting an infection, but if she did pass, she did so after I was gone. This was different. The first patient had arrived in the ED in bad shape after an overdose, but still very much alive. Once his lab work came back though, it was clear that he was not a simple case of administering naloxone and observing until better. A lactate level of 4 mmol/L (typically the highest level mentioned in most studies of lactate levels) is 55% sensitive and 91% specific for death in the next 3 days. This patient's level was 15 mmol/L. Within a few hours of arriving, he went into cardiac arrest. I ran into the room, joined the rotation for chest compression, and was shocked at how pale, blue, and still he looked. Minute after minute everyone worked, administering medications, performing compressions, and delivering shocks. Nothing helped. An ultrasound machine was brought in and we paused long enough to stare at his heart as it appeared on the monitor. Nothing moved. We tried a bit longer, but eventually the doctor told me to stop compressions, felt for a pulse, and declared the time of death. The patient's family, who had chosen to stay in the room and watch, were composed and graceful as they thanked us all for doing everything we could and then said their goodbyes. I went back to my desk and stood there, my hands shaking, as I tried to compose myself and process what had just happened. A friendly tech brought me a cup of water and told me I'd done well. When, after a few minutes, I was ready to face other people again, the doctor who'd run the code asked me if I had any questions and kindly walked me through the events of the night. I am so grateful to that tech and that doctor. I needed a bit of kindness and gentleness to get me through the shocks and experiences of that first code, and less than 5-10 minutes was enough time to get me functioning like normal again. It had to be. The ED was packed that night, so there were still more patients to see, and, though I didn't know it at the time, in less than 2 hours I would once again find myself performing CPR. That time it was an elderly woman who'd fallen and hit her head. Though her heart seemed healthy, we lost her as well because we could not fix the damage to her brain. The next night I was part of another code, and, once again, was asked to stop compressions and step back so that a time of death could be called. 
     It sounds sort of horrible to say it, but the codes became easier. Already by the second one I was used to the routine and rhythm and could perform my role without having to continually remind myself to focus on my compressions rather than being distracted by my patient's face. I also learned how to recover. You had to. One can't have a mini-breakdown after each rough case because there's always another patient counting on you. So I learned to get some water and take some deep breaths, as well as pick an easy or pleasant patient to see next, if I had a choice. Letting a 3-year-old with pneumonia play with my stethoscope was a welcome change after hearing agonal breaths, and an injured toe seemed an easy fix after watching a heart monitor show asystole. 
     I don't wish to leave this post on a low note. The truth is that the vast majority of the patients I saw did just fine, and these codes only occurred on my overnight shifts. My fast track shifts were full of sprains, lacerations, and fractures, so I had plenty of practice suturing, stapling, splinting, and performing orthopedic exams. Patients in the pediatric department could pull at your heartstrings, but the good news was that pediatric patients tend to bounce back quickly, and once their diagnosis was determined and treatment was started, the parents often needed more care and reassurance than the patients. Yes, the patients in the main ED on my day time shifts could be serious, and I still wish that I had been wrong the first time I correctly made a complicated diagnosis (a small bowel obstruction caused by an incarcerated hernia in a patient with a massive ovarian tumor), but, for the most part, my patients were treated and returned home to their normal lives. In the end, the lives of me and my patients only intersected briefly, and these encounters could be terrifying or frustrating, but for those hours I had the chance to meet an immediate problem and do something to fix it, and that is a wonderful thing. 

*Light, Richard W. Primary Spontaneous Pneumothorax. In: UpToDate, Polly E Parsons (Ed), UpToDate, Waltham, MA. (Accessed on October 22, 2015.

**Noppen M, De Keukeleire T, Pneumothorax. Respiration 2008;76:121-127