ER: presentations

I have sad news. Due to some resident posting a picture of a liver on facebook, our hospital is up in arms about us no longer being allowed to take any pictures. *Sigh* this really really sucks. I have seen so many good patient photos this month. I realize that posting pictures on facebook is idiotic, but can you really call that picture of a liver a HIPPA violation?  I mean who could say, yeah that's so-and-so's liver?  You would have no idea if it was male or female or even what race. And we do multiple liver surgeries in the day so there is no way you could know what date and assume its this one person. I call this bullshit. Most patients are happy to have their pathologies looked at by a room full of doctors and discussed. Plus how else do we get photos for our textbooks?  So my blog will be full of photos from google now... which disgusts me somewhat. But now you know. Maybe other hospitals i go to will be less freakin-out about it.

So at this point you've had exposure to trauma and surgery. So the big cases aren't the impressive ones this time. Now in the ED, they are judging me to see if i'll make a good resident. And that is almost exlusively determined by how I present. In the ER, the presentations are hard. You have to display your skills but keep their attention, you have to balance giving them the basics with letting them be confident you did a through exam. So I decided todays stories would be about crazy presentations....


First, is an elderly man who comes to us in the middle of the night from a local nursing home. The patient is demented and barely knows his own name. He cannot answer any of my questions and this means the pressure is on to do a through physicial exam. The complaint on the chart and EMS squad says his PEG tube is cracked (if you don't remember what a PEG tube is, you'll have to back to my surgery months).  The poor guy gets scared everytime he is able to see the tube because he has no memory of ever having it. I look all over the stupid tube, i even pull a tiny bit out of him, but i see no crack. I grab a syringe flush from the nurse and flush water down the tube, nothing leaks no cracks to be found.  And I decide that since I'm on my audition I'll call the nursing home and find out what is going on .  The nurse who sent him over talks to me for about 5 minutes about how the tube leaks and how there is a crack at the top of the tube near the cap. Finally I realize. The nurse is describing to me the part where the plastic tubing stops and the cap starts. She finally says yes, it comes off if i pull it hard enough.

Now I tried. I really really tried to make myself as least judgemental as possible, when i told her that typically all PEG tubes have a cap installed and while there are a few models where the tube and cap are connected, most PEGs are seperate parts. This is how its supposed to be. Immediately when i hang up, the attending comes up to me and says "wow that was a bitchy tone." I still can't figure out whether this guy was joking or not.  Then i had the pleasure to try and present this patient.

"so why is this guy here"
"the nurse thought he had a crack in his PEG tube."
"oh. Well, where is the crack?"
"there isn't one. I flushed it, there was no leaking. I called the nurse. It seems she thought where the tube and the cap came together was a crack."
"so what you're saying is the nurse didn't know what she was talking about?"
"yes."
"aren't you alittle young in your career to make those calls?"
"not if they are this obvious, sir"
"aren't you a little arrogant shit."

So that went well. I am definetly going to get a residency here after that.... *sigh* can't win.


Another case was actually the same night. the complaint on the chart read "sumac poisioning"  and you konw immediately that this patient went on the internet and self diagnosed or has had it before.  It was also weird that this person had it for 5 days and it was 4am.  So i went in and tried not to be too surprised by how the patient looked.  The chart said the patient was 55, but I couldn't figure out if it was a male or female.  There were boobs but, manly other parts.  Anyway I just took the history of this chart and the patient showed me the rash, which was a contact dermatitis. I took a through history and then went out to present.

Most presentations begin with an age and sex of the person as well as the most important big symptom/complaint they have. Like :  89yo M presents with chest pain.  or 43yo F complains of abdominal pain and fever.

I take this structure of the presentation for granted. So I started saying " This is a 55yo...." and then i get stuck. I'm like is it male or female, male or female... how can i be a doctor if i don't know this....
So i lean in to the resident and say "I don't know if the patient is male or female" And the resident immediately laughs and puts his head on the desk.  "I don't know what to do with you med students" Just as that happened, the attending came up right behind me and asks the resident "you seen the patient in 17?"
"No sir, the med student was just reporting."
He looks at me "so what's your vote? male or female?"
The residents eyes get really big. "what is going on?"
"i bet transgender, pre surgery." I say.
"i'm going to see this patient," the resident heads off...
"wait don't you want to know why they're here?" i call, resident just keeps walking. completely ignores me.


So for those of you who don't know... a basic presentation goes something like this:

"56yo M complains of chest pain x4 days intermittently that he describes as squeezing pressure. Episodes last 2-3 minutes and are relieved by sublingual nitro. Tonight he took 3 nitros but the pain was not better and has lasted 4 hours. Pt states pain shooting down his arm, no sweating or shortness of breath or back pain. Denies fever or cough. Pt has 3 stents placed last year, no previous MI, but he is diabetic. EKG shows no ST elevation but some T wave inversion in v1-v3. Pt is tachy and BP 210/48. He looks like he's in trouble to me, i'm worried about a heart attack. I think we need to get an IV in him stat, the nurse already gave aspirin. I recommend chest xray, heart enzymes, chest xray, and some pain medication.  Here is the EKG. "

So for those unfamiliar, presentations should include:  what complaint is, how long its been there, description of pain, what makes it better and worse,  what patient has tried, if the pain radiates, if he has had anything like it before, what made him come in today.  Also you must include pertinent risk factors and negative findings.  This can be the trickiest part of the whole presentation and i think its the trick to impressing them. I showed I was thinking about heart problems by including high blood pressure, asking about diabetes and previous history of stents.  Including what the patient did NOT have, means you know what to look for and shows what you asked.  In this patient, the list of things that could be causing his chest pain is LONG. So to show I've ruled out some of the causes I include the negatives.  Chest pain that radiates to the back is a symptom of aortic dissection a big big problem, but he doesn't have it.  He also don't have fever or cough, which means is probably not pneumonia or a heart infection. I also listed his vitals and physical exam, what's been done, and then the biggest part that is NEW for fourth year is MY PLAN.  I told them what I wanted to do and also that I had looked at the EKG and the test results.  I don't always have a plan, which is bad. But i always try to come up with an general idea of tests I want to run to find out what my diagnosis is.  Oftentimes, I'm wrong, but the key is they know i"m thinking about what I would do.

For auditions, having that plan and including those negative findings and risk factors.  This is what I want to master by my rotation in december.