ER: summary

To start, lets go with a few of the cooler cases that I have seen.

The first is a mystery overdose. This is always why ER docs get paid the big bucks because no other doctor does this part of things (aka- if we have no information or even guesses they send in the ER doc). The patient isn't exactly unconscious but she might as well be.  All we know is she took some pills. She's seizing and doesn't really know what's going on around her. Her blood pressure is a roller coaster of too high and too low and nobody seems to be able to tantalize her enough to get her to the ICU.  It also doesn't help that her husband and her boyfriend are screaming at each other arguing over what she took and whose fault it was.  We talk to them separately and they give us two different stories of what she could have taken.  It gets frustrating. In the end, I get a list of all of the meds they had in their house and start looking up toxidromes for all of them. I figured out that bendryl was among the things she took as was wellbutrin, an anti-depressant and anti-smoking drug that increases your likelihood of seizing.  Neither of these drugs have a reversal agent so to start, i just recommended fixing all the electrolyte abnormalities that could cause a seizure-- like too low sodium or too high potassium. Eventually the seizures did finally slow and the lady admitted to taking aspirin as well. We quickly gave the antidote although it may not be as effective because of how much time went by. She finally went up to ICU and i never found out if she made it.

There was also an elderly male who came in with hypotensive crisis with multiple bouts of nausea and vomiting lasting over 2 months. We couldn't figure out why and apparently neither could anyone else. We had given him 2 liters of fluid and mulitple pressors and still he wasn't getting better.  He was in renal failure and had been getting worse because of his diabetes.  It turns out he also had a heart attack 2 years ago and was on a huge regimen of meds.  In a very cool last ditch effort, on the docs gave a 5mg bolus of glucagon which is the antidote to Beta blockers (a heart medication), which fixed him right up.  Apparently, because the kidneys were failing and were unable to clear the beta blockers out of his system so everytime he took a pill it was increasing in his system rather than clearing.  He had so many in his system that his heart simply couldn't recover and therefore it was getting worse and worse.  Talk about a very cool last ditch effort. Way to throw the kitchen sink at him.

Also here is a photo of this 8yo's rash, you should know rashes are an ER docs worst nightmare because we see them all the time but really derm is so subjective and so random that it is hard to diagnose and seems almost impossible to treat.  So most docs run the other way or force the medical student to deal with it. (ahem). So this rash literally covered him from head to toe for the past month. The reason I got to take a picture of  it was because nobody could figure out what it was. He had been to other ERs where they'd established: it wasn't hives. It wasn't scabies. and it wasn't poison ivy. no viral symptoms. All of which he had been treated for before today with no improvement. His rash was getting worse and he hadn't had any meds for a week. So we admitted him because we didn't know what else to do. This poor kid had to deal with these all over himself and nobody had any idea how to help.  The sad part about being an ER doc: Never did figure out what it was. Hope they figured it out eventually.

Now that i'm almost officially done with this audition rotation, I don't have anything clever to say.  I don't know how I did or what they think of me.  In general, I just am fearing studying for my next liscensing exam.  SO much so that I sorta just.... don't.  Which is very very bad.   Also the application program that allows us to apply for residencies opened. And I still don't have my personal statement (the essay that states why I want to be an ER doc) written. Or even a good idea conceived.  *sigh* So much to do and so much apathy....

ER: general stuffs

So the ER. Still a thumbs up on my end. But its hard to be positive. There is so much I don't know, so many questions I get wrong. I wish I was one of the students who just remembered everything somehow. That's not true because half of this wasn't covered anywhere. How the heck do they know this stuff? I don't know it.  I feel quite a long ways from being ready for intern year. I know nowhere close to what everyone else seems to know.  Anyhow, I suppose I should say its easy to be discouraged when I put lots of pressure on myself. And this is my first rotation in the ER.

Lots of people have been asking, how did you pick this program to put so early in your schedule? This ER is one that is a program in the middle of my list, something I'm not broken hearted if i don't get but something I'm excited to get a letter from. I've heard most of your rotations should be at places like this because inevitably your first several rotations you aren't that amazing-- at least I'm not. So I put places I'm really keen about last or not at all. I'm pretty happy about the way this worked out because as I'm discovering it is a slow learning curve to learn the way they want you to do your job. And even if some doc somewhere says you're really good at it, another doc at another place will say "WTF, you suck at this."  Its a little frustrating.

So in ER, the letters of rec(LOR) are not the same as they are everywhere else. Most LOR are from one doc stating how long they've known the person, and what they think they're skills are. In ER, skillz matter more than someone liking you or not. They have developed something called the 'standardized LOR' also known as SLOR.  SLORs are just a sheet with different categories of skills listed and numbers behind them.  Things like ability to handle stress, ability to think on their feet, suturing ability, where that candidate resides on your match list, etc. Its almost an evaluation. And its LOTS of pressure.

Enough about that.  So I'm not seeing super crazy stuff here. Again its not a trauma center so its just general everyday stuff.  Although, I did see this lady who was a diabetic and had high blood pressure and she was only 30.  This is her foot.  Craziest amount of edema i have ever seen.  And so you know, she was thin not obese and her foot isn't broken, its just CRAZY swollen.  I undid her bandage and stared asking over and over are you sure this doesn't hurt?  She also has and ulcer on her ankle, that has been there for 3 years. Diabetics heal slower than everyone else.  You can see her toes and how her heel sticks out more.  It was super weird. And yet neat.

I must admit there are times when people come into the ER and I wonder why we can't help out the family practice/internal med people and start them on some BP or diabetes meds. Especially when their blood pressure is over 200/110 and climbing.  It makes me a bit nervous-- i always ask if we can send them home with some meds. Maybe this is more of a family practice/internal med mentality but come on!  You can just kick them out and say good luck..... Maybe this is the difference between primary care and specialist mentality.

So since I've no special stories, I'll take this time to quickly say, in ER its all about the presentation. You have to use your presentation (which should be under 30sec) to cleverly display your knowledge. Like use your negatives to show what you are ruling out. Report only the peritent findings and be sure to only address 1 complaint. This all sounds not too hard, but in the ER is quite a skill and something I don't have yet.  Try taking a crazy patient or homeless or any weird case you got, so and so who is allergic to their roommate, was hoping to get a CT on their heart because they missed their cardiology appointment for their heart murmur, is totally out of their meds, they get beatup by their boyfriend, and are 4weeks pregnant and were hoping for an ultrasound.  SO kids what is it exactly that they are in the ER for?  Oh yeah you only get about 10 minutes while they talk to decide and then examine them because you have 8 more people to see? In someways i envy the FP/IM people. They can have their whole visit concentrating on getting all of those things done for them, but in the ER you can't. You rule out what will kill them in the next 5 min and then kick em out with a "go see your FP"

Sometimes medicine is so flawed. I feel as if no particular field has everything I want. So how do I pick the best one?  Why am I still feeling so undecided and unconfident?

ER: My first audition rotation

WOOOOOOOOOH!!! first offical ER rotation.

Since this is what I want to do this is important.  It's called an audition rotation.  Since everyone in medical school studies the same information, we have to choose what specialty or path we want to take in medicine.  And fourth year we do special rotations called 'audition rotations' where essentially we work for a month for free and they see if they like us and we see if we like them.

This first one is in a suburb hospital so its not as hardcore as it could have been, but i wanted something more low key since its my first rotation in this area. Now most people are asking how do you want to do it if you haven't been there, but the answer is easy. It all the rest of the rotations i went down to the ER to admit patients or work traumas all the time. So i've been down there alot.  And honestly, of all the types of doctors, an ER doc is the one I respect the most and would be most proud of if I could do it.  That said, i don't know if i'm particularly well-suited. But I suppose we will find out...

So I had to move states for this one month and its challenging to find my way around and find a grocery store and find places to study. I live in the hospital housing with other people and its just a two bedroom apt with bunkbeds in random places and NO INTERNET.  It's killing me slowly... :(  Luckily I found a panera but am rapidly becoming sick of panera (being i do all my studying there).

I was a little nervous but not as much as I thought I would be. I mean, it was awkward as all first days are trying to figure out where to go and what they want.  And though I feel vastly behind the other students auditioning (how do they know so much more than me?), I think my 'give-a-damn' broke and am just trying to improve over the course of my time here and learn as much as I can.  That's it.  Nothing fancy. I realize I'm not the brightest crayon in the box and tho I am envious toward them, I will be happy ultimately as long as i'm not that doctor that all the nurses say 'i would never take my family members to them.'

This is a place with a bit of smaller residency in the ER than I'm used to and its not a trauma center so they don't get the big crazy cases. I did this on purpose so i could learn the 'bread and butter' cases, the simple ones that most ERs see. We got a kid with his fingers chopped off and a few overdoses. One case I thought was an overdose but turned out to be atypical presentation of a NSTEMI (heart attack).  It was pretty interesting.

The hardest part about this rotation has been doing presentations to the docs. They don't want to hear about the case, they want to hear your differential and your plan. And I don't mean "give pain meds" or "do some imaging"  I mean they want you to know to give "4mg of zofran for nausea" and "do a upright abdominal xray because we want to look for water fluid levels to rule out small bowel obstruction."   If you order one test or have a certain differential they want to know why you are ordering that test or why you didn't order another test. They ask dosages which I know NONE.

They think i spend forever in the patients room when I actually run down one of the back halls and frantically look up things on the books in my pockets or the iphone that runs SOOO SLOW.  It never really helps me much but I try hard to organize my thoughts.  My challenge has also been including the negatives in the presentation. I can't just say rest of exam was within normal limits. I need to say no tearing back pain, no murmers and other negative finding related to specific diagnoses that I ruled out.  I had no idea 'risk factors' and criteria were so freakin important!!!  why are boards information not as helpful as i thought! Its exhausting. and i can't believe that one day i'll know all this stuff. because.... i can't possibly know it now.

And to top everything off they put me with the program director who pimps alot (asks questions in a demeanding way) about things I know nothing about.  I've been yelled at twice about not being confident enough and that i should fake it until i make it. But i don't know ANYTHING. its so frustrating. I have no idea how to change my whole personality for this one rotation.  I should have picked my rotations more carefully because i might have shot myself in the foot when it comes to getting jobs at these places.  They think i'm slow and shy and stupid.  But they also started me out on nights. So whatever.