As is often the case in clerkship, it is only in the last week that you start to feel comfortable in the rotation. You know how the system works, where to find requisitions, who to talk to to get things done, which nurses to be on the good side of and the preferences of the staff you're working with. All in time, of course, to switch gears entirely and start something new. (I think I talked about this in the first post, so I won't belabour the point, but it really is the clerk's life for a year.)
In any case, I felt that I really hit my stride this shift. Presumably... I don't actually know what hitting one's stride is like. I hate running. Anyway, I was seeing a lot of patients on this shift, generating differentials that made sense, coming up with management plans and figuring out dispositions for patients, most of which was on par with the plan my preceptor came up with. It felt like I was making a substantial contribution to the team, which is always a nice feeling, no matter the line of work.
After my diatribe about alcohol in the last post, I thought I was going to go a full shift without seeing an intoxication injury... I was seeing lots of standard complaints (syncope, vomiting, toothaches etc) and it was approaching sign over time without a whiff of EtOH, when I pick up a chart that reads "Patient was drinking last night and got into a butter-knife fight with friend".
Seriously?? Who does that? It wasn't even one of these "I punched a wall, honest" types. He and his friend legitimately had a butter knife fight, for fun. I guess I appreciate the honesty.
He had a little slice that we glued shut before sending him on his way... I'm never sure how to handle these situations though. I suppose you have to read the patient. If they're laughing about it, I think it's okay to laugh as well, but they aren't always, and that can make for tense times if you crack a joke or throw in a dig. We aren't only students of medicine, but students of interpersonal interaction: sometimes that's half the battle.
Sunday, July 31, 2011
Saturday, July 30, 2011
Curveball
There's an entity in medicine that we refer to as gestalt (Although, the word is not specific to medicine, so I suppose anyone can have gestalt about any given topic...). In any case, in medicine, we use it to refer to a physician's ability to quickly eyeball a patient, hear a brief story and and then make a judgement call as to whether the patient is truly sick or not. Of course, we do the tests to confirm, but the gut feeling of gestalt will often dictate how aggressively we hunt down the pathology and how great a priority any particular patient will be during a shift. I think that it is a skill that physicians spend a lifetime honing.
Not surprising then, that barely a year into my clinical experience I occasionally get humbled by patients who I completely miscall. One such patient presented to the emerg on my last shift: Young guy, came in on his own with back and foot pain. Said that the day before, he'd been indulging in the drinks a little to liberally and consequently had fallen. Couldn't really tell us how far or when, but he'd dusted himself off and wandered home.
He was a spirited guy and spent a lot of time bantering back and forth with the staff. His physical exam was pretty normal... some bruising on the foot, but no particular tenderness. His back wasn't tender at all when we pressed on it.
My Gestalt: I figured he'd done some damage to soft tissue and could probably swallow some ibuprofen and be on his way.
In actuality, his scans showed big fractures of the spinal column and 3 fractured foot bones.
Sigh.
Luckily there was no neurological damage, so he will likely recover well from his injuries with some casts and bracing.
The thing about gestalt is that one can't learn it in a book, and not very well from the experience of others. It's a skill that one has to develop by seeing hundreds and thousands of patients: Patients who one has invested some time into, and differentiated before getting any answers. Then, when the final diagnosis returns, whether wrong or right, the case will hopefully be a part of one's clinical acumen. Luckily, thanks to my relative inexperience, every case I see is helping to shape my gestalt. I'm glad I have the opportunity to mis-call a few diagnoses now, as a trainee with a supervisor looking over my shoulder (or under my arm, as is more often the case), before having to make these calls as staff. These cases will stick with me and hopefully make a better clinician in the end.
Ps. You'll notice that most of my anecdotes involve alcohol. It is a plague on the Emergency Department. I can't imagine what the modern ED would look like if alcohol didn't make good people do stupid things... Go easy on the wine this weekend: your body and local emergency physician will thank you.
Not surprising then, that barely a year into my clinical experience I occasionally get humbled by patients who I completely miscall. One such patient presented to the emerg on my last shift: Young guy, came in on his own with back and foot pain. Said that the day before, he'd been indulging in the drinks a little to liberally and consequently had fallen. Couldn't really tell us how far or when, but he'd dusted himself off and wandered home.
He was a spirited guy and spent a lot of time bantering back and forth with the staff. His physical exam was pretty normal... some bruising on the foot, but no particular tenderness. His back wasn't tender at all when we pressed on it.
My Gestalt: I figured he'd done some damage to soft tissue and could probably swallow some ibuprofen and be on his way.
In actuality, his scans showed big fractures of the spinal column and 3 fractured foot bones.
Sigh.
Luckily there was no neurological damage, so he will likely recover well from his injuries with some casts and bracing.
The thing about gestalt is that one can't learn it in a book, and not very well from the experience of others. It's a skill that one has to develop by seeing hundreds and thousands of patients: Patients who one has invested some time into, and differentiated before getting any answers. Then, when the final diagnosis returns, whether wrong or right, the case will hopefully be a part of one's clinical acumen. Luckily, thanks to my relative inexperience, every case I see is helping to shape my gestalt. I'm glad I have the opportunity to mis-call a few diagnoses now, as a trainee with a supervisor looking over my shoulder (or under my arm, as is more often the case), before having to make these calls as staff. These cases will stick with me and hopefully make a better clinician in the end.
Ps. You'll notice that most of my anecdotes involve alcohol. It is a plague on the Emergency Department. I can't imagine what the modern ED would look like if alcohol didn't make good people do stupid things... Go easy on the wine this weekend: your body and local emergency physician will thank you.
Friday, July 29, 2011
Stigma
One of the most counter-productive and unhelpful entities in the hospitals is the stigmatization of certain diagnostic labels that are attached to the patients who walk through our doors. Of the most stigmatized diagnoses, borderline personality disorder, chronic fatigue syndrome and fibromyalgia seem to bring the most baggage. Physicians, nurses, and paramedics are all guilty: it is as if the label immediately paints a vivid picture in the health care provider's mind of the type of person beneath the label. A word worth a picture worth a thousand words.
We had a patient come to us during this shift who has been battling stigmatization for the past year, for a confusing array of neurological, muskuloskeletal and gastrointestinal complaints. She felt she was at the end of her rope and needed help. I could see from her online record that she'd been seen previously by a variety of specialists and by the mental health group, all with apparently little success.
She was bristling before I even said hello, and the interview was certainly an emotionally laden one. She felt as if she'd been let down by the health care system and that nobody believed that she was suffering. She felt that because she had no objective findings of disease, and had been diagnosed with anxiety disorder, health care providers had been attributing all her symptoms to the anxiety, without a proper work-up. I could tell that she thought I was about to do the same thing to her She'd felt so stigmatized by the label "anxiety disorder", and so defeated by her symptoms that she had even begun to think about hurting herself.
It is sad to think that health care providers were contributing to her suffering. Even if everyone she's seen in the past were completely legitimate in their diagnoses (and they may have been, an anxious mind can play strange tricks on one's body), there has been a failure somewhere along the way if the patient comes to us feeling discriminated against.
The patient is not a diagnosis in a johnny shirt. He or she is first and foremost a person who comes to us at their most vulnerable and exposed, asking for help. Bringing in any of the baggage of 'typical fibromyalgia' or 'typical anxiety' will do nothing for the patient and may even significantly worsen their well being. I'll have to work hard to fight against this stigma in my career. I think my patient felt heard and validated by the time she left the department, with some hope that plans were in place to get her the help she needed.
We had a patient come to us during this shift who has been battling stigmatization for the past year, for a confusing array of neurological, muskuloskeletal and gastrointestinal complaints. She felt she was at the end of her rope and needed help. I could see from her online record that she'd been seen previously by a variety of specialists and by the mental health group, all with apparently little success.
She was bristling before I even said hello, and the interview was certainly an emotionally laden one. She felt as if she'd been let down by the health care system and that nobody believed that she was suffering. She felt that because she had no objective findings of disease, and had been diagnosed with anxiety disorder, health care providers had been attributing all her symptoms to the anxiety, without a proper work-up. I could tell that she thought I was about to do the same thing to her She'd felt so stigmatized by the label "anxiety disorder", and so defeated by her symptoms that she had even begun to think about hurting herself.
It is sad to think that health care providers were contributing to her suffering. Even if everyone she's seen in the past were completely legitimate in their diagnoses (and they may have been, an anxious mind can play strange tricks on one's body), there has been a failure somewhere along the way if the patient comes to us feeling discriminated against.
The patient is not a diagnosis in a johnny shirt. He or she is first and foremost a person who comes to us at their most vulnerable and exposed, asking for help. Bringing in any of the baggage of 'typical fibromyalgia' or 'typical anxiety' will do nothing for the patient and may even significantly worsen their well being. I'll have to work hard to fight against this stigma in my career. I think my patient felt heard and validated by the time she left the department, with some hope that plans were in place to get her the help she needed.
Wednesday, July 27, 2011
Patience
This shift was a good experience for bread-and-butter ED visits and included numerous lacerations that needed repairing and infections that needed draining/antibiotics. Good exposure to minor, but important aspects of medicine.
In addition, this shift came with a challenging patient with physical wounds that needed patching, but emotional and mental wounds that ran far deeper. He was an older man who came to the emerg after falling and gashing his arm. I could see from the computer system that he'd been into the ED numerous times before, often leaving against medical advice. Most of his visits were similar stories to this one and were the result of chronic alcoholism. The smell of wintergreen in the room instantly told me that he'd been resorting to mouthwash in order to feed the addiction. He was still under the influence when I met with him.
We talked about what happened and whether he'd injured himself anywhere else and then he began telling me about his life and his addiction. This was a man who has been fighting these demons since early age and the havoc that it had wreaked on his life was as evident in the tone of his voice as the road-map of scars that were scattered over his body. He told me story after story of the hard life he'd been living, weeping openly and deeply about the losses in his life.
These situations are challenging. This patient clearly needed more than a suture and more than the resources of the ED are equipped to provide in one visit. This is someone who'd been in and out of detox, AA, NA, and every other substance abuse group for years. He'd had help from psychiatry, social work, occupational therapy and many other resources. In the face of all this, what help can I possibly provide him that will make a difference?
Compassion and patience is what I decided on (and a suture for the arm). I think that there is something therapeutic about letting someone talk until they've got it all out, even when they are intoxicated. I think that health care providers too often brush off the confessions of these patients and make excuses to leave the room. I don't necessarily blame them, with the weight of numerous patients piling up in the ED. One's patience is strained to the brink by the 3rd iteration of a story, told in the slow, characteristic drawl of inebriation. Yet, I think there are true therapeutic moments to be had if one can slip a few words in edgewise. Encouragement for successes in life and sobriety earned and nudges to reflect on the good times without the veil of alcohol.
I don't know if any of my time was wasted. I'd like to think that something got through to him. Maybe I'll look back on this post in a few years time and chuckle about my naivety...
In addition, this shift came with a challenging patient with physical wounds that needed patching, but emotional and mental wounds that ran far deeper. He was an older man who came to the emerg after falling and gashing his arm. I could see from the computer system that he'd been into the ED numerous times before, often leaving against medical advice. Most of his visits were similar stories to this one and were the result of chronic alcoholism. The smell of wintergreen in the room instantly told me that he'd been resorting to mouthwash in order to feed the addiction. He was still under the influence when I met with him.
We talked about what happened and whether he'd injured himself anywhere else and then he began telling me about his life and his addiction. This was a man who has been fighting these demons since early age and the havoc that it had wreaked on his life was as evident in the tone of his voice as the road-map of scars that were scattered over his body. He told me story after story of the hard life he'd been living, weeping openly and deeply about the losses in his life.
These situations are challenging. This patient clearly needed more than a suture and more than the resources of the ED are equipped to provide in one visit. This is someone who'd been in and out of detox, AA, NA, and every other substance abuse group for years. He'd had help from psychiatry, social work, occupational therapy and many other resources. In the face of all this, what help can I possibly provide him that will make a difference?
Compassion and patience is what I decided on (and a suture for the arm). I think that there is something therapeutic about letting someone talk until they've got it all out, even when they are intoxicated. I think that health care providers too often brush off the confessions of these patients and make excuses to leave the room. I don't necessarily blame them, with the weight of numerous patients piling up in the ED. One's patience is strained to the brink by the 3rd iteration of a story, told in the slow, characteristic drawl of inebriation. Yet, I think there are true therapeutic moments to be had if one can slip a few words in edgewise. Encouragement for successes in life and sobriety earned and nudges to reflect on the good times without the veil of alcohol.
I don't know if any of my time was wasted. I'd like to think that something got through to him. Maybe I'll look back on this post in a few years time and chuckle about my naivety...
Tuesday, July 26, 2011
Teaching - July 26th
One of the constants in Medical teaching is that no matter the subject, be it operative neck dissection or freezing warts, a good teacher will seize every opportunity to educate and ensure you come away richer for the experience. That was my experience today in the emerg (although I didn't cut open any necks or freeze any warts this particular shift). It is refreshing to come across a teacher who had obviously thought a lot about education and can tailor the experience to the learner. My supervisor was able to create an enriching experience out of each patient encounter I had that night. It was the right amount of responsibility, quizzing, evidenced-based medicine and hands-on experience to make a great learning environment. Additionally, I find the mark of a great teacher is one who can teach a difficult concept in simple, memorable terms, and this was also the case on this shift.
I learned about the mechanics of reducing a fracture, an easy differential for fainting, the best approach to pleural effusion and about the evidence that supports or, occasionally, doesn't support the decisions and treatment options that we provide in the ED.
However, more important than the facts I picked up is the style of supervision. I was able to observe and hopefully absorb some of that great teaching style for my own teaching. Medicine is about constant learning and constant teaching: to and from patients, residents, med students and staff physicians. Hopefully some of the lessons I've learned from this shift I will carry with me and pass on to at least some of the countless other learners I will be working with in my career.
Most impactful case: Massive pleural effusion (fluid in the space surrounding the lung) in someone we had to inform of the diagnosis of lung cancer. When we gave the diagnosis, the patient seemed as if they knew all along what we'd say... maybe they did. We can be surprisingly intuitive with our bodies if we take the time to listen to what it's telling us. The patient took a moment, took a breath and simply said "Okay, what's next?". I was impressed with the stoicism that I couldn't guarantee I'd have in her position.
I learned about the mechanics of reducing a fracture, an easy differential for fainting, the best approach to pleural effusion and about the evidence that supports or, occasionally, doesn't support the decisions and treatment options that we provide in the ED.
However, more important than the facts I picked up is the style of supervision. I was able to observe and hopefully absorb some of that great teaching style for my own teaching. Medicine is about constant learning and constant teaching: to and from patients, residents, med students and staff physicians. Hopefully some of the lessons I've learned from this shift I will carry with me and pass on to at least some of the countless other learners I will be working with in my career.
Most impactful case: Massive pleural effusion (fluid in the space surrounding the lung) in someone we had to inform of the diagnosis of lung cancer. When we gave the diagnosis, the patient seemed as if they knew all along what we'd say... maybe they did. We can be surprisingly intuitive with our bodies if we take the time to listen to what it's telling us. The patient took a moment, took a breath and simply said "Okay, what's next?". I was impressed with the stoicism that I couldn't guarantee I'd have in her position.
Monday, July 25, 2011
Trauma
Being on hand when a trauma rolls into the emerg is quite an experience. The emerg usually has a few minutes notice before anyone gets to the hospital because the ambulance or helicopter paramedics will have been in touch with the basics of the patient's condition. Most tertiary care centers have a dedicated Trauma team, who are on call 24/7 and carry pagers that will start beeping and speaking instructions insistently when a call comes in. In Halifax, that means that anyone who is deemed a serious trauma is greeted by a senior physician team leader, one or two emerg residents, the general surgery team, an orthopedics team, the neurosurgery resident, anesthesia, 3-4 nurses, paramedics, xray techs and any stray med students. All of us were crammed into the trauma bay to help if needed.
If you get queasy reading about this sorta thing, maybe better to skip the rest of this post.
The trauma team was activated twice on Sunday. The first was a young person who'd been ejected from a car that had rolled on the highway. He/she was in pretty rough shape when he/she arrived and needed most of the team there to help him out. The team goes through any trauma in the same way: start with airway, then check breathing, then assess circulation before checking neurological status and looking for less obvious injuries.
This patient needed support of his/her airway in the form of an endotracheal tube down into his lungs and ventilator to help him/her breath. Additionally, she/he was having a hard time breathing because of massive bruising and bleeding in the lung. The ribs had taken a hit and a hole was open into his lung space, which meant we needed to get another tube through the skin to suck out any air or blood that was building up. While someone was taking care of that, someone else was starting an IV to begin transfusing blood and fluids to replace some of the volume in the blood vessels. Concurrently, we were taking a look at the CT scan, which showed a pretty serious spinal cord injury. Everyone's hearts sinks seeing something like that because it will likely mean they won't walk again. Because he/she was moving their arms a little when they came in, we're hoping the patient will retain upper limb function.
At the end of the day,the patient was stabilized but will obviously have a long road of recovery ahead. Unfortunately this a is common scenario, played out over and over again in our country's emergency departments. I don't know if this patient was belted, but I can't imagine he was... makes you wonder what shape he'd of been if he had. Small decisions having huge consequences...
I'm not going to say that I enjoyed the experience, because I don't feel that word does justice to the gravity of the situation. I will say that I like providing care to patients who are very sick and need immediate help. Decisions need to be made quickly and treatment needs to be effective if we want to give our patients the best shot. This type of medicine appeals to me.
If you get queasy reading about this sorta thing, maybe better to skip the rest of this post.
The trauma team was activated twice on Sunday. The first was a young person who'd been ejected from a car that had rolled on the highway. He/she was in pretty rough shape when he/she arrived and needed most of the team there to help him out. The team goes through any trauma in the same way: start with airway, then check breathing, then assess circulation before checking neurological status and looking for less obvious injuries.
This patient needed support of his/her airway in the form of an endotracheal tube down into his lungs and ventilator to help him/her breath. Additionally, she/he was having a hard time breathing because of massive bruising and bleeding in the lung. The ribs had taken a hit and a hole was open into his lung space, which meant we needed to get another tube through the skin to suck out any air or blood that was building up. While someone was taking care of that, someone else was starting an IV to begin transfusing blood and fluids to replace some of the volume in the blood vessels. Concurrently, we were taking a look at the CT scan, which showed a pretty serious spinal cord injury. Everyone's hearts sinks seeing something like that because it will likely mean they won't walk again. Because he/she was moving their arms a little when they came in, we're hoping the patient will retain upper limb function.
At the end of the day,the patient was stabilized but will obviously have a long road of recovery ahead. Unfortunately this a is common scenario, played out over and over again in our country's emergency departments. I don't know if this patient was belted, but I can't imagine he was... makes you wonder what shape he'd of been if he had. Small decisions having huge consequences...
I'm not going to say that I enjoyed the experience, because I don't feel that word does justice to the gravity of the situation. I will say that I like providing care to patients who are very sick and need immediate help. Decisions need to be made quickly and treatment needs to be effective if we want to give our patients the best shot. This type of medicine appeals to me.
Sunday, July 24, 2011
Saturday evening shift
For some reason I expected the saturday night shift from 2100 until 0400 to be incredibly busy, mostly with young people getting injured after indulging at the bars. While the average age of the people I saw that night was probably about 23, there weren't nearly the volumes that I'd expected. Always a good thing, a little for me, but mainly for the patients.
Among the more interesting cases that came through the door were a cat bite, a dog bite and a human bite. Maybe it was a full moon? Nonetheless, it struck me as odd to have a 40 year old come into the emerg at 0200 on a Saturday night because his cat bit him... Not that it didn't need to be treated, but the juxtaposition between treating a cat bite and treating a trauma is just a little odd to reflect on at that time of the morning. All part of what keeps this job interesting, and all part of the art of medicine: clearing your mind from the previous case to focus on the person in front of you. At the end of the day, this person was distressed enough to feel the need to come into the emergency and ask for help, even if it turns out to be a minor bump. Easing that patient's distress is argueably as important as suturing up a bleed lac (that's our short form for laceration).
Among the more interesting cases that came through the door were a cat bite, a dog bite and a human bite. Maybe it was a full moon? Nonetheless, it struck me as odd to have a 40 year old come into the emerg at 0200 on a Saturday night because his cat bit him... Not that it didn't need to be treated, but the juxtaposition between treating a cat bite and treating a trauma is just a little odd to reflect on at that time of the morning. All part of what keeps this job interesting, and all part of the art of medicine: clearing your mind from the previous case to focus on the person in front of you. At the end of the day, this person was distressed enough to feel the need to come into the emergency and ask for help, even if it turns out to be a minor bump. Easing that patient's distress is argueably as important as suturing up a bleed lac (that's our short form for laceration).
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