Medical jargon drives me crazy sometimes. It makes sense to use with other health professionals who will know what you’re talking about. It facilitates communication in certain situations. With patients though, it seems to just get you in trouble, or make you look like a fool.

A focal neurologic deficit as I understand it is a deficit that is affecting a specific part or side of the body. Right sided weakness, a facial droop on the left side, or right arm numbness would be examples of a focal neuro deficit. Focal designates that the symptom is in a specific area.

Most people don’t know that, heck, it took me many months to figure it out working as a scribe.

So, naturally, it was surprising and frustrating when a physician I was working with asked a drunk guy coming in complaining of weakness-

“Do you have something focal going on? Anything focal?”

Wow. I think the blank stare would have been the response of 99.5% of the population in a similar situation.

Note to self: never ask someone if they have something focal happening to them, unless my patient is a neurologist.

A while back I was working with a physician and we had just seen a psychiatric patient. Someone had pointed out to me how it was dumb to have the psych rooms so close the pediatric side of the Emergency Department. I decided to bring this up with the physician, in hopes to stimulate some conversation. There’s nothing like complaining about something to find some common ground, right?

So I mentioned it. His response was not what I was hoping for. He kind of half agreed with me, seemed uncomfortable, then justified why the rooms are there. It was awkward. So I didn’t bring it up again.

Later I realized I was working with the director of the Emergency Department. Oops.

He probably has big role in designing the layout of the department. In criticizing the placement of the rooms, I was also criticizing him.

Sometimes I think I’m an idiot.

I saw a very sick child recently at one of the children’s Emergency Rooms I work in. At only 9 months of age the child has had a brain tumor removed as well as multiple surgeries involving a VP shunt.

The kid was there for increased vomiting and fussiness. As the physician talked with the parents I noticed something different in the way they acted compared to most parents in the ER.

I mentioned this to one of the nurses. We talked about how parents who have had a lot of hospital experience have a different demeanor. They answer questions more quickly and succinctly- they have heard them all before. They ask fewer questions- they already know the answers.

The nurse also mentioned something that I hadn’t identified when I was in the room but I recognize now. The parents also had a sense of detachment relating to their child. Why? I have no idea. Were they already creating distance from their child who probably had a poor prognosis? Were they just tired from this exhausting ordeal?

Impossible to know. But I do know the whole thing was very sad and I feel for those parents. They’ve been through hell.

Everybody loves talking about themselves. I’m guilty just as much as any other person. But you’d think parents with a sick kid in the ER would have the presence of mind to realize that their kid is the sick one who should deserve the attention, not them.

I worked in Pediatrics tonight and I swear half the parents tonight wanted to talk about their own medical conditions, or how they were recently sick, or that one time they had pneumonia and half their lungs were filled with “stuff”. I rarely speak in my role, so I’m always a little anxious to say something, but tonight I just wanted to scream, “Shut UP. Why are you so self centered?!”

Well, just needed to rant for a sec. People are weird.

A few days ago we received evaluations from doctors we have worked with. Most of the ER Scribes on our team are new this year and have worked for about 6-7 months, and this was the first time we received any feedback since training.

Here is what one of the doctors wrote on my eval:

“One of my favorite scribes! Reminds me of myself 12-15 years ago.”

What a nice thing to read. It helps that it was from a doctor that I like and respect.

Anyway, it was great to get some feedback. I feel lucky to have this job.

Vitum Medicinus says it’s because it will help you get into medical school. Check out this stellar article outlining all the reasons it’s a good idea to read as many medical blogs as possible.

Among some of the best reasons provided: you’ll write a better essay, you’ll know for sure if medical school is right for you and you’ll get a chance to have a conversation with medical professionals. The best part about the post is that it is stuffed with links to blog stories providing examples backing his reasons.

I hope Vitum is right, because I read a lot of medical blogs. They are terribly entertaining. Vitum Medicinus is one of my favorites, although the author is in medical school and he doesn’t write often enough (which is completely understandable).

So what are you waiting for? Find some great medical blogs, fire up that RSS reader, subscribe and have at it! Here are a couple ER blogs to get started:

Crass-Pollination: An ER Blog

ER Stories
Have fun!

80 something year-old woman, traveling down an escalator. Unwitnessed fall. Presents to the ED with contusion and small laceration to the back of the head. Patient mostly complaining of left knee pain. She is triaged to one of the less acute rooms.

The doctor I’m working with goes to see her, hears a bit of the story from the patient’s sister. She states the patient is more confused than usual. The patient can hold a fairly normal conversation, but does appear a bit confused. The patient can name the president of the US, but cannot remember what she ate for breakfast. She is quickly transferred to one of the trauma rooms and then sent to CT.

At CT she vomits, her heart rate slows for a moment and then starts racing. Her blood pressure climbs.

We see her as she returns from CT, and she is clearly deteriorating. She can hardly speak now. Head CT shows a significant subdural hematoma. Her heart rate is about 180, in Atrial fibrillation. O2 sats start dropping. Given Cardiozem to slow the heart rate. She’s intubated. She stabilized and then went off to neurosurgery (her sister wanted everything done to save her). I’ll find out soon what happened. The repeat head CT looked much worse, my knowledge is incredibly limited, but from what I picked up from the tone of the conversations between doctors, it didn’t seem great.

I had a great conversation with the doctor I was working with at the end of the shift about this case. He explained some of what was going on. As the patient’s hemorrhage grew, it put more and more pressure on the brain. The more the brain is squeezed, the harder it is for blood to get to the rest of the brain. So the body compensates and raises blood pressure in order to force more blood into the rest of the brain (our bodies are so cool). Her heart rate complicated matters.

As my doctor explained, a rapid heart rate can be bad for the brain as well as the heart. At a rate of 180, the patient’s heart rate needed to be slowed. (Why the rapid HR? Doc said it may have been pain.) The problem is that the medicine given to slow the heart can also drop blood pressure, which in this case could be catastrophic. If the patient’s blood pressure drops, she may end up with a stroke due to the brain not getting enough blood. That would complicate matters a bit more.

All this meant the medication given to slow the patient’s heart rate had to be administered carefully. Too much, too quickly could have lowered her blood pressure too much. The nurse giving the medication did not know this, and had to be stopped from pushing the Cardiazem too fast. The doctor was watching carefully.

Apparently intubating can also drop blood pressure, but at that point it had to be done.

Fascinating case for me and the doctor I was working with. I’m grateful for the time the physician spent explaining it to me. Tragic for the patient and family. If she survives, she may have significant neurological deficits.

UPDATE:

She did survive surgery. I don’t know anything about any deficits. Here’s to hoping she has a full recovery.

"Ten out of ten? Really? Is this really the worst pain you could possibly imagine?"

"Wow, this person has been in the ER 15 times in the last three months. You know what that means."

"Where are the normal people?"

These are just a sampling of the kinds of thoughts I’ve been having lately during my job as an ER scribe. These cynical thoughts are bothersome.

What’s even more bothersome is the lack of compassion I’m starting to develop. Seeing people in pain used to surprise me. I would feel a certain amount of empathy for someone in obvious pain. But it’s so common, and it’s so hard to differentiate between who is actually in pain, who is exaggerating their pain, and who is not in pain at all. I don’t know what to feel.

When I first started working, the psych patients were the cases that bothered me the most. My own family history has made me aware of the difficulty and complexity involved in mental illness. But I’ve noticed a disturbing lack of care

Why is this happening? I’ve only worked in the ER for four and a half months. Why do I suddenly feel so cynical and jaded?

Part of it is obvious. I’m just mirroring the voiced thoughts of those I work with.

However, I do wonder if it is a product of my specific role in the ER. I see every patient the doctor sees, but I do very little in the actual treatment of those patients.  Some doctors don’t even introduce me as I enter the room. Indirectly I’m helping these patients by allowing the doctor to spend more time with them face to face, keeping the doctor informed of incoming lab tests and imaging studies, and making sure they get informative discharge instructions. But x-ray techs have more interaction with patient’s than I do.

Maybe this lack of connection with patients helps contribute to my lack of compassion. I don’t want to make that an excuse though. The change in my thinking has been startling as I look back on how I thought in the past. I want to do something about it.

I’m curious to hear from others who work in health care. How do you deal with this issue? Can you give me any advice?

I guess I’m trying to integrate a realistic world view with a compassionate one. I’m faithful that they can co-exist, I’m just trying to learn how.

An overheard conversation:

“Can I tell you about this patient?”

“Sure, what’s the chief complaint?”

“Well, they’re coming in because they were struck on the side of the face by a clock that fell from a bookcase above them.” A short pause. “Yes, that’s correct, this patient got clocked.”

Good times.