How could I be mad?

When at the end of my 24 hour shift my patient’s epigastric pain changed to a STEMI? As I explained to him and his wife what was going on and how dire the situation was given his prostate cancer? As I told them the high risk of bleeding to death on our way to the city to see the cardiologist? As he kept sneaking his thumb over to touch my hand that was on his leg while I talked to him? Tough old coot was scared at the odds I gave him, worried about his wife, worried about his chest pain, worried. 

These are patients who are used to the doctor just telling them what to do. I won’t do that. I’ll present the options as I see them, and likely bias the discussion one way or the other, but I ask them to make the decision. Sometimes the decision is to let me decide, then I check if they are relieved or distressed with that decision and adjust accordingly. Not by the book med school ethics, but patient centred. Luckily my patient’s wife was able to decide for all of us. 

I’m worried too. I hate sending my patients to the city with another doc but I’m not safe to still be caring for him. Very happy I kept doing serial ECGs though and trust my gut when I think something is wrong. 

Not gone. Dead.

I love when I’m working emerg and my next patient is someone I already know. It makes it so easy to get to the bottom of what’s happening and get them feeling better.

Unless they come in VSA. Then it just sucks.

Especially when they are young and their kids aren’t ready to be an orphan in high school.

Especially when they’re your own patient.

Especially when the family thinks, because of a diagnosis you magically pulled out of your ass that you walk on water.

Especially when no matter how many of the Hs you cross off the PEA list, he just doesn’t come back. His pulse never returns. He doesn’t have another joke, or jab, or hug. He’s just purple and bloaty and looking nothing like you’re guy anymore. His brain stem hasn’t caught up to his heart and doesn’t realize he is dead so keeps telling his lungs to breath horrific, agonal breathes and you have to explain to his children that he is dead.

Not gone. Not done. Dead. Without those words his kids can’t move on.

But they need answers. Why? How? What did I do wrong?? Who can I blame? Maybe I didn’t love him enough? I just want to hide and cry. Because I have the same questions and no answers.

It’s an honour to say that I fought valiantly to save his life. But would be a greater honour to say I had actually won.

The Rural to Urban Transfer, a Primer for Urban Docs

1. If the report starts with "...is a horse and buggy Mennonite, and called an ambulance to arrive here at...", know that whatever comes after means this patient needs to be transferred out ASAP. These patients will do everything they know how to do at home, waiting until the very last minute to come to hospital. If they are willing to splash out on an ambulance, there is something very wrong. Same goes for any Mennonite that shows up the ER on a Sunday. Just seeing them there on a Sunday makes my pulse race.

2. Don't assume that we have the same resources that you do. For example, I have an RT that comes in some Wednesday mornings. There is an anesthesiologist who comes in a few days a month. I do the difficult airways. I figure out the ventilator settings. When I show up to the ICU, you have more people waiting in that room to receive us than we have in our entire hospital, usually at least 3x as many. Please ask what resources we have before repatriating a patient who requires more than we can give, or assuming we can handle the case that is being consulted on.

3. We work 24+ hour shifts. I am acutely aware of the time that I am calling you at 4 in the morning. If I say that I need to discuss a case, please be sure that I really do. I've either exhausted all my internet and paper resources and need help, never seen what is in front of me, or am having a hard time organizing my thoughts after a particularly stressful day. Rural docs are proud. If we are asking for help, assume it's legit.

4. During that 24+ hour shift, for the most part, we are it. Any and all codes are run by us. I've run several in the same day plus delivered babies, saw 30+ sore throats in the ER, and talked down psychotic patients. Not every day is like that, but give us credit for being able to handle all of that and keep going. We do this because we love our communities and are dedicated to keeping our hospitals open, we love medicine, and we are masochistic idiots.

5. Nothing makes me feel more validated than having staff ready when we show up. If I tell you it's a difficult airway and you have an anesthetist and RT waiting for us when we arrive in the city, it seriously makes me feel incredibly relieved. I know that you believe us and will treat my patient well.

6. We get attached to our patients. We see them again and again in our hospital, and in truth, I may be the family doc of the patient I am transferring. I will do everything I can to keep them in our tiny hospital. When it's time for them to go somewhere else, I will fight like a dog to advocate for their proper care. You would too.

7. Rural docs are "real docs". We are generalists who are constantly studying and upgrading. After every code, every transfer, every good and bad event, we talk to each other to learn about what went well and how we can make things go better in the future. Consult notes that belittle us and derogatory comments on the phone are entirely unnecessary. We are counting on your expertise to help us in our practice, but also on your civility.

In case I forget to thank you because I've been hand ventilating a patient for 3+ hours when I finally see you during my 27th hour on call, please assume I do. I am incredibly grateful that you have chosen to work in the city in ICUs, surgery, high risk obstetrics, etc. Without you, I couldn't have the brilliant job I do.

The patients you think about

Have a look at this article. I've been following the blog on twitter and learning quite a bit. This case in particular raised my shackles a bit.

Similar aged woman presents late at night to my ED with a week of deep, dull chest pain. No risk factors. Her ECG was beautiful. D-dimer was negative. OE viral URTI. No improvement with ibuprofen. I was reassured and sent her home to follow up with her family doc ASAP.

Even now, seems reasonable.

I recognize though that I'm someone who suffers from "Nah, it can't be." I know in this case I did all the investigations I would have done for a 45 year old except calling radiology to get a CXR.

Having cases like the one described in the ECG teaching help me to keep perspective. I think we need to share. These odd cases so we remember that not everything we learned in med school was true.

The trick, as ever, is protecting patient privacy while expanding the knowledge base we have available.
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This is NOT a 2 am consult

I'm always afraid of being wrong and making a stupid mistake in front of colleagues. I think it's fairly common, we all want to be seen as competent care givers. We never want to admit that we don't something but when our patients need us to 'fess up about our lack of knowledge, we will, and call a friend.

Working in a small ER means that rather than having in house specialists I can bounce questions off of in the middle of the night, all my specialists are elsewhere in hospitals where they are expected to be allowed to sleep from 11pm on because they'll be on call all weekend. It takes a lot of guts to call after midnight.

I'm sure you can see where this is going.

I've seen a lot, but I haven't come close to seeing everything. I try to extrapolate from what I do know to what I'm seeing in front of me. Given what I saw the other night, and what I know from other similar structures, I was going to need help. Apparently I should have known better and that I didn't need help.

I still feel like I did the right thing. I had a patient in front of me with unbearable pain. The resources in front of me where not at all helpful, though I could have looked for the procedure on youtube... I called. I got snarked at. I also got the info I needed and my patient left free of pain.

Since this blog is about making me a better a doctor, what would I do differently next time?
1. look in even more basic books than I was, something like Tintanelli's.
2. YouTube the procedure.
3. Start my consult (if I still decide to call) with "I'm not sure this is a 2am consult, but my pt is in quite a bit of pain...".
4. Take a breath and put everything in context. I frequently let my nurses guide my care. I trust them to know what to do and very often, that's a good call. But sometimes, I need to listen to my own brain and cut them out.
5. Work out how I would do what I need to do - get the patient into position, get the equipment I need in position. There's something about going through the steps first that makes a procedure easier to do and less scary as well.

Happiness is...

Having a giggle fit at one in the morning with a five year old boy who bumped his head while being silly.


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See one...

Usually in medicine, especially in the ED, you hear "see one, do one, teach one". This refers to seeing a procedure or technique done, doing it yourself then teaching someone else how.

In paediatrics however, it appears to be see one, see one, see one, see one, see one.....



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Food in the Emergency Department

In the emergency department, patients wait for hours once they are inside the doors and being seen by nurses and doctors. They need to wait for us to put their tests and imaging together, actually have it done, wait for the results and possibly start again if our differential diagnosis was incorrect the first time.

If a patient is admitted to the hospital, food is ordered for them. Otherwise they are left on their own. Sometimes dietary has extra meals if the patient it was directed to has already made it to the floor. This meal can be used but only if the nurses have the time to make it happen and if the patient advocates for themselves and asks for it.

Even if the stars align and there is food and someone to give it to you, you may be kept npo - nothing by mouth - in case you need to have surgery. The thing with emergency surgery is it can take days to get. It doesn't feel very emergent if it's you who isn't eating. By the time we do all the necessary tests in the ED, get someone from the surgical service to consult and decide if you do indeed need emergent surgery then book the surgery, it can be the better part of a day.

Anesthesia wants to keep your belly empty to make the surgery as safe as possible since it's fairly common for the anesthesia to make you nauseous and they don't want you aspirating vomit. Kind of nice of them really. Very often, towards the end of a day, surgeons and nurses of pts will call the OR and ask if they can "feed the patient".

On the other hand are the patients who are "frequent flyers" in the ED. These include those with chronic illnesses requiring multiple transfusions, sub- optimally managed epilepsy, and my personal favourite, the street folks with substance abuse problems who often pass out and get picked up to ensure they are OK.

An old favourite from clerkship was a woman with a bright orange jacket - always knew it was her. I sincerely enjoyed seeing her. Her drink of choice was listerine because it was cheap and easy to steal. For those that don't know, the listerine drunk is a stinky drunk. She was grumpy but only half-hearted at it. She'd swear at me while I was making sure she hadn't aspirated but wink at me before I left her cubicle. Her sandwich of choice from the patient fridge was chicken salad. If it wasn't there, it was only a very brave person who dared bring a turkey sandwich instead.

It is a little disturbing that so many patients do demand food be given by the department. It seems like a part of the service driven culture that health providers are expected to be a part of. If you were waiting for your car to be fixed, you don't expect a free meal. Often car repair shops have a cafeteria or a vending machine just for this. It's strange that there's an expectation for food and snacks when getting your body checked out.

I can understand the patients there on their own with no source of food otherwise, but I'm grateful for the patients with families who ask if they can eat then go to the cafeteria or Tim Horton's to get something. Hospital food is not good, emergency food even more so.

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Unmet Objectives

Yesterday was my last day in the emergency department. It was a day of mixed feelings.

I didn't feel at home in this ED. They weren't familiar with having learners in the department and tended to make me feel uncomfortable and sometimes unwelcome.

The few preceptors who were enthusiastic to teach were a lot of fun to work with and I appreciated their caring and the cake they provided to say good bye with.

Despite my personal enthusiasm to learn, I only met a few of my many learning objectives. Part of this was from the volume we saw in the ED - I can't practice inserting central lines when there is no need for it. The preceptors were not comfortable with me taking the lead in cases where I could use my ACLS. It may be that they didn't realise that I was certified to help a patient whose heart had stopped.

I did however get very good at diagnosing UTIs, sinus headaches and sciatica as well as suturing almost any body part you can think of.

While I don't want to add an extra year of learning to my residency, I do want to be proficient enough to feel comfortable being the only doc in a small ED. I may need to either add learning through simulations or electives.

I really hope that my Internal Medicine rotation that I start next will be more fruitful.

She may be onto something

I'm at a medical education retreat. Our presenter on assessment has just said "our students can't give LPs to all their patients presenting with headache - it's dangerous".

I can't help but wonder though, maybe that would encourage PTs to try Tylenol or advil before coming into the ED.


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Skateboarding accidents

Three kiddos in a row came in with skateboarding accidents.

The first was a Justin Bieber wannabe with a surprisingly limited vocabulary. He had a supracondylar fracture. I gave him heck for not wearing a helmet or pads.

The second told me he FOOSH'd. I asked what that meant. He told me his mother said to tell me that. She works with a orthopod. He got heck for not wearing pads and praise for wearing a helmet.

The third kid wasn't wearing a helmet or pads but didn't get heck from me at all. It's because he was watching his friends skateboarding and one of the boards got away, flipped in the air and hit my pt in the head.


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Barium contrast

Meant to be swallowed, not inhaled.


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Framing

Framing is something that happens quite a bit in health care settings.

It's when a patient's story is told by someone other than the patient and that story is somehow distorted.

Brian Goldman used an example of this in his talk I attended. From what I remember, the paramedics believed that the patient was on drugs, nurses thought he had borderline personality disorder. When the doc saw the patient, he believed the patient needed a head CT. This patient died of a head bleed in the CT machine. It could be that he had a personality disorder as well as the brain bleed.

When working in a rural ER, I noticed that a patient had been triaged number 5 - blue. I've never seen the lowest level of triage used before. This patient had been waiting for hours and I wanted to see why.

The nurses who had seen the patient said that it was a waste of ER space, that she just had a little cold and there was no reason to be here. I don't mind seeing kids with colds. When I asked why she and her aunt had come to the hospital, it was that they wanted to know if it was OK for the girl to see her father (dying of cancer) in the hospital or if she would make him ill.

While it's true that this wasn't an emergency, it was worth a visit for immediate help.

Last night, a patient came into the ED with "trauma". He tried to explain to the triage nurse what was happening, but she wasn't able to understand and chalked it up to "he doesn't speak English well". Same thing when he came to Fast Track, the nurse rolled her eyes and didn't understand why he was here.

I went to talk to him and asked him why he had come to hospital. He told me that he had a lot of pressure in one of his toes from trauma 1 and a half weeks ago.

In the past when he had a similar injury he had been told that he needed the pressure taken off to avoid the nail falling off. He had a whole story in his head for how it made sense. Pink finger was stage one, blue was stage 2 and a black finger was stage 3. He was stage one but didn't want to lose his nail.

His expectation for this visit was that his nail would be pierced and the pressure taken off the nail. He was afraid of losing his nail. This information made things make so much more sense and now I had something I could do.

By explaining to him how his body works and explaining how I knew that things were ok, he was happy and no longer worried. He will likely not access the health care system for something like this in the future but I armed him with red flags to show back up for.

This interaction could have easily been unsatisfactory for me and the patient if I had decided he was a drug seeker or a malingerer as he was framed to me. Instead, he left with more knowledge and I got to teach a patient about his body, something I love to do.

I'm hoping I always take the time to FIFE my patients. (Feelings Ideas Function Expectation) It's important to me and lets me sleep at night. Patients need to be heard. I need to listen to provide them the care they need.

My Astute Preceptor

The ED I'm working in has two sides - a true emergency department and a fast track for less acute cases.

I worked in fast track all day today.

When the preceptor switched over from the ED to fast track , he acted upset that I'd been hiding there all day.

"But you should have been working with me, doing all that learning that you like to do by seeing all my patients while I sit on my butt drinking coffee!"

Good to know I'm not the only one who has noticed this method of "teaching".


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Chief Complaint: abdo pain

Final diagnosis: PTSD

More than just once in a while I'd like the cute little kids who come into the ED to just have a cough.


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Reason number 652 that rural medicine is more my cup of tea

Continuity. Even if I was working in the ED in small communities I found out what happened after they went home. In this city, I have no idea how my patients do after they leave my care. I don't know if my diagnosis was correct or if I made a mistake. I want to know how things go after the patient leaves the department.


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What's the radiologist's favourite breakfast food?

The waffle.

I had three patients I was seeing in a row. One had a hurt forearm, one a sore elbow and the third (a child) had a sore ankle.

After listening to their stories I sent all three for x-rays.

When the x-rays came back, I thought, in order, fractured, not fractured and I don't know. I made my call to the preceptor I was working with who agreed on all counts. We treated the first and third patient as though they had fractures and the second as though it was a soft tissue injury (rest, ice, elevation).

Yesterday my preceptor for that shift showed me the radiologist's report. Basically he said that it could possibly be a fracture along the growth plate or a variance on normal. We should make our decision clinically.

Thanks for that illuminating report.


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My preceptor drank my pop!

I was so thirsty after class this afternoon but didn't have time to get a drink before the ER so I grabbed a pop from the vending machines. He drank half my pop before putting it back in front of me and going back to drinking his own.

If I'm not willing to tell a doc that he is putting his gross germs on my pop, how will I deal with a situation like the drunk surgeon we keep hearing about in ethical discussions.


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After

One week later, my patient with the abscess on the back of his leg was into the ED again for something else. He wanted me to show you the after picture. He's very happy with the results. Me too. The holes were made by me to allow drainage. They're healing very well.


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Geriatric Nurses

More and more Ontario EDs are employing geriatric nurses. They go by different acronyms, but their mandates are all the same - see geriatric patients at risk of coming back to the ED soon, or, even worse, being admitted. Geriatric patients who end up admitted to hospital deteriorate. There's no way around it. The hospital environment doesn't stimulate them enough to keep their minds sharp. They end up staying in bed all day and sleeping more than they should so their muscles atrophy. Even a stay of less than 4 days can have lasting negative effects. The geriatric nurses work like heck with the CCAC workers to keep elderly patients at home.

They do fantastic assessments that can take hours (time that ED docs don't have). These assessments can discover things such as medication concerns that may have led to admission, poor walking shoes, poor nutrition, mood concerns etc. With a bit of polish and increased support in the community, the patients are often able to avoid admission and the dangers that lurk within.

In one community I was working in, an 84 year old man was brought into the ED by ambulance following a fall. The geriatric nurse was ecstatic. This was a farming community where most elderly folks are strong and independent and didn't need the extra attention that a geriatric nurse can give.

She went in to check on the man and asked "how did you fall?".

He said, "Well, I was pulling my 2 seated glider back into the hangar and slipped on a bit of water on the floor".

Crestfallen, the geriatric nurse went back to trolling for patients in the ED. Not every patient in their 80s fits the geriatric profile.

What is the geriatric profile?

It changes between hospitals. In general though, it's a patient who is at risk of not coping alone in the community. This can be because they have many illnesses (comorbities), too many prescriptions (polypharmacy), a history of falling, dementia, poor social supports.

I've met patients in their 90s who I wouldn't have really considered geriatric. They live independently in the community, often helping their neighbours (much younger neighbours) with groceries and chores. They have active social lives and manage their few medications well on their own. When the idea of a retirement home comes up, they laugh and tell you that they are for old people. One woman told me she wouldn't be old until she was 96. Don't know why she picked that age, but it made me giggle.