ER Intern: NSICU

I was nervous about this month. ICU is one of our "harder" rotations. "NS" stands for NeuroSurgery, so this is primarily stroke patients, brain tumors, head bleeds or other such neural injury. Because it was specialized of a patient list i felt like i had a better handle on what I was doing- generally because neuro tends to be waiting to see if you recover or if you don't. It was also a place where I got lots of practice giving bad news.

In many ways ICU was like the ER but its.... easier.  You have so much more time to do everything.  When a patient is dying, I have time to think about what to do, what drugs to give and how to tell the family. If you think about it the patient is already intubated and being monitored, you already have labs and images and you already KNOW the diagnosis. Things can change and fast, don't get me wrong, but i felt like i knew a lot of the patients so well after rounding on them everyday that I understood what was going wrong. I also had days to ease the family into the idea that pulling support would be the likely end point, or getting the patient and family to understand that this paralysis was permanent.  Plus you spend hours writing a note and asking questions about their childhood and getting to know the family, so you really KNOW the context of this patient, way more than the 15 minutes or less I'm given in the ER.

We also spend so much time wasting time. I mean even though I only got 4 days off, the time I spent at work and doing work was less. Yeah you have to round and yeah it can be long but alot of times my brain doesn't have to be turned on all the time. I don't have to mange 4 people and the nurses and the attending and being yelled at and making sure I don't miss any detail that might kill someone. I get to sit and do a note for an hour. I get to think about my plan and what meds i want to give and why.

I really enjoyed this rotation.

(pt stories to come)

ER Intern: Peds ER

ah.... finally back in the ER. Its like I forget everytime I'm away how awesome the ER is.  The pediatric ER is a bit different than the adult ER. Most kids who come in are assumed well until proven otherwise-- the exact opposite mentality of the adult ER.  This is because the reality of kids is MOST of the TIME if it looks bad, its not. That said there are plenty of really sick kids out there- so don't use that as explicit medical advice. Most of why kids come into the ER are in 3 categories: 1) they shouldn't be there (cough, flu, runny nose, etc)  2) traumatic some kind of accident (broken leg, swallowed a quarter, abuse, etc) 3) congenital/genetic problems - these can be catastrophic and/or change the bodies abilities at a cellular level. This last category is every doctors nightmare (or at least mine) because all the rules are changed, what would make a normal person better can often make them worse or even kill them inadvertantly. 

That said, 90% of the patients belong to category one which means we see maybe 3 times the patients as compared to the adult ER. That means twice as many stories and way way busier. I spent many a shift so busy I could not pee for the full 12 hours.  Anyhow down to the stories and the pictures, all of which were taken with parents and patients permission.

This kid has a machine sewing needle through a finger. I took it out no worries. :) 

The tongue below is a classic exam question and often not seen so textbook-perfect. It is what is known as "strawberry tongue" and when accompanied with a rash, fever, sometimes sore throat is also apart of scarlet fever. Scarlet fever isn't as scary as it was before antibiotics- it can be treated.  It doesn't cause as many heart infections now. 

 Another story is one that caused quite a mystery in the department. A girl who came in with purple skin from her bra line to her panty line. Although I didn't think to take a picture of it until it started fading you can see the distinction if you look... It was crazy. It was so distinct and we couldn't figure it out. It was obviously venous pooling but we couldnt' figure out why. 

Last but not least. A diabetic type 1 (juvenille) and its a very distinct foot infection of the skin also known as cellulitis. This girl wanted to go back to school, she had been in the hospital and ended up having to skip a grade. Since she didn't want to have that happen again, she has been walking around on these until they started turning purple (look at her ankles)....  What can I say some kids really like school... way more than I ever did.

ER Intern:Radiology/EKG

This rotation is the most easy of all.... we often call it 'radioholiday'. Not much else to say.

ER Intern: Eye Opening Moment

So working on Ortho nights has really opened my eyes. It kinda shocks me. It shouldn't but it does. I've always heard those horror stories about the ER docs. The ones where they call consults without having seen the patient or ignore them to let the consulting docs take care of them. I always knew that maybe those things happened in the "bad ERs" or when that one really dumb ER resident who was so lazy was on.

But being on this rotation showed me that that side does exist and it happens in my home ER. And it happens often. Consults that get made before resident has even looked at the patients. I saw it.

I saw a patient who had a broken leg, but the resident had not yet seen her. She had fallen weeks ago. She was scared and dirty, unbathed. She said her husband wouldn't let her come to ER, she had been dragging her leg around for weeks. She said after awhile it didn't hurt anymore. And we asked how she broke her leg, she thinks it broke before she fell.  Her xrays show weak bones, necrotic and dying. And after hearing she had leg pain and seeing the xray, no doctors and no nurses went in the see the patient. She was waiting for HOURS before anyone saw her. And it needed way more than just an ortho consult. And the resident he was one of my upper levels, someone I had once respected-- he in no way apologized or admit he made a mistake instead he acted like it was a normal occurance. And indeed it was not all that uncommon. THis is just one of many stories like this that I have.

Situations like this make me understand how the consultants can not take us seriously.  And also made me seriously question the quality of my program.  I hate that feeling.

ER Intern: OB

Across the country, the ER OB rotation is notorious for being bad. Perhaps its because the personality of the OB and the ER is so different, or perhaps because all the waiting makes the OB residents more protective of (or impatient for) their deliveries. All I know is almost all ER residents complain about it or view it as a "vacation month".

For me, after getting off a joke month there was no way I was just going to sit around on this rotation. I made up my mind to be pushy and butt into the deliveries until I met my designated 10 deliveries required for graduation of ER residency. But when I showed up the first day and saw there were 10 students (mix of M3, M4, and auditioners) plus a family med resident and an anesthesia resident I knew the odds were stacked against me.  I did what I could to play those odds, volunteering for nights only and on top of that only nights over the weekends to clear my way.  But it was still hella difficult with even the ob residents resisting my help. I was banished to the "OB ER" (note this is not a true ER, just our nickname) where I drowned in vaginal bleeds usually resulting in dead babies and rule out labors for women who were simply sick of being pregnant. While I surprisingly found this area to be helpful since this is the type of patients I will be seeing in my own ER one day-- I also am required to get 10 deliveries and I was determined.

After lots of smiling about scut work and doing extra notes and other simple tasks to get a few residents trust, I got my first few in rapid-fire sequence. Finally! I caught 3 babies in the same night and felt triumphant!!  Then I got put on the backburner because "you already got some deliveries" and the poor M3s will never get another chance blah blah.

In the end, I only got 8 of my 10 the other two I had to simply watch someone else do.  But those last 5 i really had to sharpen my elbows and butt people aside or steal from students (which i try not to do).

As far as crazy stuff... I had no shortage of good stories despite my struggles for deliveries. And I must say the ones I did catch all seemed to be a story- there weren't really any normal married ladies having normal infants with a supportive husbands. It always seems like there is some drama. Someone cheated or they are too young or too fat or just plain crazy or the baby is not healthy or too young or there is an infection or the mom has a problem and emergent c-section is happening NOW.

For example, one young girl whose boyfriend SNORED in the chair while she was bleeding out. The postpartum hemorrhage was bad but then we looked at the dried off baby and took a picture. Look at that left leg... so white.  Turns out he had a DVT (blood clot) in his leg. Was born that way.... say what??!?!

I got to see a surprise vaginal frank breach (butt comes out first instead of head) the risk of these is very high because they get stuck so often.... so usually they go to csection. But she was just pushing and oops, there is a baby on the bed, came out butt first and nobody was helping it! Good thing everything ended up okay!

I also saw a 3 minute shoulder dystocia (the baby's shoulder was stuck). This is a huge scary complication that still happens alot today. Usually from mom's who are diabetic or babies who are too big for mom's pelvis. This can cause death of baby and death of mom. This one resulted in 3 hands inside mom and an episotomy (cutting mom's vaginal opening all the way down to rectum).  All of these things were terrifying, but incredibly informative. I remember thinking, Wow. This baby might not live through this.  And then I thought, I could be watching this baby die and the mom could be next. Birth is scary.  It terrifies me that so many people take birth control so lightly. Your body is never the same.

And overall, I don't consider my OB month a waste. Learned lots. Now scared to ever have kids myself.... Guess i better pick a guy who I'd trust to raise my kids without me.  Scary.

ER Intern: Anesthesia/Ultrasound

So yeah. I don't really know what to mention here. These rotations are a bit of a joke and everyone knows it. It sucks that this rotation is so close to the beginning for me because i'm ready to learn, I'm ready for my butt to be handed to me and to subsequently become a more bad-ass doctor.

Instead, I sit here and get about 2 intubations a day and go home at noon. Get so bored at home I clean and panic about how I'm not learning anything. hahaha. Panic mode meltdown.

Then 2 weeks later, I just walk around the ER for a few hours everyday ultrasounding random people to try to teach myself how to use the machine. In ER, the ultrasound machine can become a great tool for diagnostic purposes and can help rule out acute, life-threatening problems faster and more efficiently than any other modality. (Gallstones, ectopic pregnancies, elevated intracranial pressures in the eye, AAA, hypovolemia, blood in the belly, and other more mundane uses like abscesses and guiding IV access). However, at our program at least there is nobody to train us. {EDIT: there is officially, but that person is never around and tends to be a sports med person, so unless its a torn muscle, don't ask}.  This frustrates me, as they give me a couple of videos to learn from then let me loose. And I can only train myself to the point where I don't know what I'm looking at or how else to hold the probe to get a better image.  At one point an upper level came to help, but she knew almost as little as I did.

This month generally bodes poorly as it reflects for me that I won't likely know how to use ultrasound effectively when I graduate here. And its been generally a huge emotional downer, because nothing takes you down when you're ready to learn and be challenged like nobody giving a shit. There is nothing else to do but sit back and study for step 3 and hope next month will be better.

For those of you interviewing- look at your possible future program director. Are they the kind of person who will get things done or do they have a lot of "filler" rotations. I really should have asked these kinds of questions... but then again, I dunno if they would have told me about them or not.

ER Intern: what to study

During the day I carry a pad and ppr to keep track of what to read when I go home, a maxwells because it has cm on the back mostly, and also the Tarascon emergency medicine pocketbook. I love having all those facts at my fingertips. I do use Medscape on my phone because its free, but I find I don't have time to use uptodate or other online resources as much as everyone else seems to.  I do have a black pocket sized notebook in my bag i call my little black book... I write down all my workups and fun facts and other things I learn in it, so I can constantly reference it. 

The two big texts in emergency medicine are Rosens and Tintinelli's. While both are texts full of information, I don't really like them all that well. I just don't seem to study well from them and they don't have quick facts. I can't carry them with me and I don't find them all that practical. Plus they are sooo expensive.

I really like the podcasts:  EMbasic, EMCrit, and EMRAP.   The first two are FREE and only 20 mins per episode. The last one is more for ER only people updating old criteria and the like.  But These three have gotten me through many jams and its easy to listen to one on the way to and from work or at the gym.

I also really depend on First Aid for the Emergency Medicine Clerkship or as resident First Aid for the Emergency Medicine Boards.  These have had the basics of things I need to know are are relatively cheap.


Hope this helps.