What a difference a shift can make! My second shift in the ED was literally and figuratively a night and day difference from the first. The 0400 - 1200 shift has the advantage of beginning after the daily innundation of patients have been seen and bandaged carefully to go home or up to the floor of the hospital for other sleepy clerks to assess. The torrent of patients from the previous evening has slowed to a trickle and the mood on the floor is much more relaxed. The waxing and waning of patients seems not unlike the tide, ebbing and flowing through the sliding glass doors of the ED, and I have a sneaking suspicion that the moon has something to do with these tides as well.
While I saw fewer patients on this shift, I was able to spend more time with them and develop what I feel was a stronger therapeutic interaction. My first patient was shivering uncontrollably when I entered the room, which, in MD lingo is called 'rigors'. He was an older gentleman who had recently had a recurrence of his lymphoma, a cancer of the bones and blood. He had just finished a round of chemotherapy and presented to the ED with a fever. We take these patients very seriously, because both the cancer and the chemotherapy treatment decrease the number of white blood cells (defense cells) in his body. Without white blood cells, we are sitting ducks for infections that would normally be handled easily by our immune system. Unfortunately for this patient, he had caught a bug that was just starting to make him very sick. I'll spare you the details, but we started him on antibiotics quickly and got some fluids into him while the medicine resident came to see him. There aren't too many times when I've given someone a 50% chnace of needing to go to the ICU within hours, but this was one of them. Happily he remained stable by the end of the shift thanks to the attentive and quick care of the medicine team (who, incidentally, required 8 Litres of fluid to stabilize his blood pressure).
Another case I'll talk about is a lady who was admitted for a small bowel obstruction. Again, I won't focus on the medical details, but there were a few key aspects to her care that I learned from this morning. She was scared. Scared and in a lot of pain. She'd been admitted for the same reasons in the past and had had what sounds like a torturous stay that had clearly scarred her mentally and physically. This was one of the cases where I bet the patient stayed home in agony until the last possible minute to avoid having to face the spectre of her previous admission again.
It is with these patients that an MD needs to spend a little extra time and with whom a hand on the shoulder and the words "we're going to take care of you" can be almost as therapeutic as definitive management of the medical problem. The relief in her eyes when she felt that message from the physician and I was unmistakeble and memorable. I'm glad to have been involved, even in that small way.
Work in the ED is certianly not only about treating patients, but a big part of the experience is working with nurses, paramedics and other physicians. These interactions are not always smooth. Towards the end of my shift, a treatment decision that was made for one of our patients was clearly being questioned by the nurse taking care of the patient. Based on the patient's need for intravenous access to deliver drugs and fluid, and on the lack of suitable veins in the arms or legs, the decision was made to insert an intra-osseous catheter. This is an exceedingly rare occurence in the ED, but has some advantages over trying for the large veins in the neck or groin (decreased pain, risk of infection, lung puncture or hitting an important artery). The disadvantage is that the catheter can only stay in for 24 hours before needing to be changed. In addition, I think because the nurses don't often see these type of catheter being used, there is some unfamiliarity with its use and care. The patient's nurse was clearly unhappy about the IO catheter and she may well have very good reasons to feel that this was a poor choice. I imagine that this is a common scenario that I will be facing in medicine, so I think I need to develop a better approach for the next time. I think that with any new or unfamiliar treatment, it might be best to gather the team together for a few minutes to discuss the decision and to encourage people to air any concerns before the patient receives the intervention. Hopefully if the team has the chance to discuss the plan, difficulties like this one can be avoided.
The ED is great. I hope I don't see any of you there.
