The alarm went off at 5:20. It was dark out. I didn’t have time to eat breakfast or get coffee. I crawled onto my bike and had to rush to work to make it for a 6:30 shift.

Along the way I thought about the traffic ticket I had gotten a few months ago and how dismissive the judge had been to me. I thought about the doctor I had worked with yesterday who kept forgetting my name and dictated faster than I can type (this is the only doctor it happens with). I thought more about doctors I didn’t particularly enjoy working with, including the one who made a joke about a child with an intracranial injury which probably was a result of abuse. How could someone become so jaded that they make a joke about that?

I was pissed. But I made it to work on time.

I finished my short two hour shift with no problems. I have another 8 hour shift that starts at 10AM.

And while I was angry earlier, things are looking up. Why?

-The doctor who forgot my name yesterday made a joking apology this morning.  

-I just listened in on a fascinating conversation between and intensivist and cardiologist about a child with fungal endocarditis. It was during rounds which meant about 10 other people were there. It was a respectful conversation, but the tension was palpable as there was clear disagreement on the best course of treatment for this child.

-I’m working with a great physician at 10AM.

-I have a cup of coffee next to me.

-I have the next two days off.

-I have an incredible job. I get to listen to teaching conversations between attendings and residents. I get to see patients with all sorts of crazy illnesses and injuries. I’m learning tons of medical terminology that should make a transition to medical school much easier. It’s awesome.

- If everything goes according to plan I will have started medical school this time next year. That above almost everything else puts a smile on my face.  I’m enjoying the journey.

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.

No sleep + driving = bad idea

He fell asleep while driving the next day and ran into a pole. Oops.

Who knew elections could be so dangerous?

Photo Credit

But no matter what I say, it’s difficult to truly capture what working in the ER is like. It’s a completely different world. It’s a world I’ve never been exposed to. I’m only just beginning to understand how things work, and why things are the way they are.

A post over at ER Stories has helped me understand much of what I’ve been seeing. The author describes life from the perspective of an ER doctor, and it is an amazing description. It’s long but worth reading. Here’s a quote:

“Simply put, if you have not spent any significant time either working or volunteering in an ER, you really don’t know what it is like. People are at their WORST in the ER. Sometimes it is because they are sick or a loved one is sick. Sometimes it is just their true colours coming out. If many of you extremely touchy-feely types actually had to work a shift in the ER you would probably want to kill someone. Why? Because you don’t realise it but much of the population is either nasty, manipulative, violent, malingering, antisocial, and or disrespectful. Of course the majority of people we treat are not, but I guarantee if you have to deal with even 4-5 out of the 20-30 you might see on a given shift, you will re-think things. Imagine getting threatened by people who you are trying to help. Getting spit on. Getting told what do by people who don’t know anything about the practise of medicine except what they read on blogs or in newspapers. Witnessing the gross indifference people have for sick loved ones. Witnessing child abuse regularly. Dealing with intoxicated persons who want to kill you. Listening to people bullshit you about their medical conditions so they can either get out of work, get disability, or get narcotics (often for resale). Imagine getting zero respect from people for the years of training you have.”

Read the rest of the post here. It is worth your time. It not only provides insight into life in the ER, but also to the practice of medicine in general.

Anyway, I was in the room as my physician administered the sedative. As the patient was drifting into his semi-conscious state, he said something that got a nice chuckle from everyone in the room.

“I feel like I’m back in the 60’s!”

I need to start a quote-book or something.