Day 15 ER: Last Day

So here it is, my last 12 hour shift in the ER. This month, I officially spent over 180 hours in this place.

It was kind of a bittersweet feeling. At first I thought this place would drive me crazy with how unorganized everything is. But this rotation granted me a lot of freedom to practice a ton of patient care. I got to pretty much do everything for a patient, from the initial exam, to ordering diagnostic tests, getting medications, and performing procedures. And from what I've heard from other students, you don't get this kind of freedom in other rotations. One student told me that in surgery you are lucky if the attending lets you hold a retractor, let alone suture the patient.

Anyway, today was pretty much your standard day in the ER. Lots of super ghetto people who were raised to believe that the ER is the place to go when your joints hurt (even though there is a FREE clinic for that stuff literally next door), then complain and become verbally abusive when we don't see them for hours because we have patients with acute issues.

There were nursing home vegetables sent in because their mental status has changed.... usually meaning that they could respond to verbal commands before, but now just lay there. So we did a basic physical, ran a bunch of labs, then told ICU/Internal Medicine it was their problem. Usually a good kind of patient to practice listening to heart sounds on, because they usually have some kind of cardiac issue, and they don't care if you take forever to listen to their chest.

Towards the end of the day another med student, who's last day it was today as well, pulled me aside and said in a whisper: "I've secured a laceration case in the Fast Track area, its all ours, lets quietly go over before another student/resident sees and takes it"

So like ninjas we exit the ER and go down to the fast track area. She had already grabbed everything we would need and laid it out on a bedside table. For our last case in the ER, she had found: a nursing home patient who had a laceration on his scrotum.

What.

How does that even happen.
He had a deep, Y shaped cut along the whole front surface of his ballsack.

The patient couldn't or wouldn't tell us, and the nurse we called at the nursing home wasn't forthcoming either.

Anyways we got to work. The patient kept saying "Get off my balls!!!". At one point he grabbed my elbow and tried to bring it to his face.

 "Don't bite me sir!!" I said

"Don't have real teeth anyways" he grumbled as he let go.

One of the nurses came over to see what was causing the big commotion. He said, while laughing, "honestly I'm taking his side, I'd try to bite you too!".

Anyway, it was a memorable last case for the ER rotation. Suturing some old guys scrotum.

See y'all in September for Family Practice, probably won't have anything exciting to say there :(

ER day 11: Procedure day

I went to go see my first patient of the day, all I knew was that the nursing home was sending him in for "unresponsiveness", and that's all he'd been triaged as. I go over to the bed, and shit. The guy was blue.

I left the bed ran over to the attending at the nurses station and said like a cool doc: "I think we need to intubate nursing home guy, he's REALLY cyanotic". So then I was helping the attending intubate the guy, then place an NG tube on him. Pretty exciting start to the day.

Maybe 20 minutes later, another patient arrived that needed a central line put in. Whenever that needs to be done in the ER, they usually call for the surgical resident to come and do it. Being the overexcited little bugger I am, I asked the surgical resident if I could watch, and promptly dumped my ER duties to check it out.

The central line was cool. It was kinda like an ABG, in that you are taking a big needle, and basically trying to hit a hard to get blood vessel. They had to thread some big thing up it tho, and there was something involving a scalpel (I did end up getting called away halfway thru), but in the end, they actually sutured the thing into the patients skin.

For awhile, there wasn't much going on, so I sat at a computer pretending to be busy.

I figured something cool would come along soon, and I kinda didn't feel like seeing the boring cases like pediatric fevers, or old people with arthritis pain today.

Then I got the call.

"Are there any medical students here?" The charge nurse asked. Oh oh me!!!!

"Dr. S over in the fast track area wants to see you".

Fast track is a small area off to the side of the ER where they take the less critical patients. I walked over there, and Dr S was standing there next to Dr. B. Dr B is a double specialized plastic surgeon and Ear Nose Throat (ENT) guy that we sometimes call in to consult on cases. Dr B loves to teach, so anytime he is in the ER, he likes to have students and residents around.

Dr B asked "Hey Alanna! You're the ER student today right? Did you happen to see any surgical residents over there?"

(ok I did, but fuck them) "No sir I didn't". (I know I'm bad)

"Well they are missing out. I guarantee you won't see something like this again" he told me.

And then he brought me over to the patient. This guy had a bike accident, and he managed to tear his ear half off. He showed me how some of the cartilage had become necrotic and black already. We basically had to cut out the dead cartilage and tissue, then reconstruct the ear using tissue from behind the ear and skin pulled down from the skull. He taught me a bunch of plastic surgery stuff while doing all this. Then came the awesome moment. "Ok kiddo, want to show me your suture abilities?"

"Yes sir!!!" So he let me do a bunch of the sutures in the less complicated parts. It was really awesome because he was critiquing me as I did so, and I think I got a lot better at it with his help. In the ER, they usually don't care so much cosmetically, they just want the two ends of skin to come together. But he showed me how to do some plastic surgery grade sutures, and how to make sure it will look good when you are done.

So that was my procedure filled day. I'm off to take a nap, have night shift again tonight!!! See you later :P

ER Day 7: Office Politics

You know those awkard "political" moments in the workplace? I had my first experience with that today. I was spending some time in the Pediatric ER today (basically the back corner of the ER where they stuck a couple cribs). I saw a bunch of people bringing their kids in with fevers to get some free motrin, a couple ear infections, then the holy grail of the day: a rash!!!

Rashes are kind of fun to diagnose in kids. Based on the distribution of the rash, associated symptoms, and timing of onset, you can create a cool differential and narrow down the list of suspected causes. For some reason rashes are one of the things that really stuck in my head. Anyways this kid had a very classic rash presentation: he was young- only 10 months old, the rash was on his hands, feet, and in his mouth. The kid had no fever, up to date on his immunizations, and no other symptoms except the rash. My thoughts immediatly ran to coxsackie virus. Some other students at the hospital were saying they've seen a lot of cases of it recently, and the presentation was exactly like coxsackie aka "hand food and mouth disease". I told the mother my clinical suspicion, but that I had to run it by the attending.

I went up to the attending in charge for the day, and gave an oral presentation of the case and my clinical suspicion and treatment plan. My attending disagreed.

He believed it to be related to the childs history of eczema (which was a valid point, it could have been, but it really didn't look like it.... who am I to say, I'm still a newbie). The attending then goes on to explain that if it is an eczema related flare up, he had to chose between treating with steroids or antibiotics. If he gives steroids and there is a bacterial infection there, the rash will get worse. But if there is no bacterial component and gives the antibiotics, the rash will also get worse. The attending decides to call in a pediatric resident for a consult.


When the pediatrician comes down, I follow like a diligent student to learn how a pediatrician evaluates the patient (and also to play with the patient's adorable twin sister). The pediatrician does a quick exam and looks at the rash and says: "This just looks like coxsackie". The mother turns to me and says "thats what you said!".

I decided to let the pediatrician give my attending the news, and didn't mention the case again.

Things I saw today:
-A grade 4 bed sore (you could see her muscle and almost down to her bone!!)
-Pancreatic cancer patient with a likely DVT (cancer patients, especially pancreatic, tend to clot easily and are prone to them)
-Fluid overloaded renal failure/congestive heart failure patient that we intubated

Things I did today:
-Replaced a suprapubic catheter solo (the attending just handed me a kit and said "you've seen one done? go do one")

http://splicd.com/CcKmAuhpOBE/213/224 (pretty much how I felt when I was doing it)

-Did an arterial blood gas by myself
-Helped intubate our fluid overloaded patient

ER Day 5: Sutures and Good News!

This was originally going to be a post about today (which was a mixed bag of craziness), but I just got some awesome news so I'll be brief.

Today started out with the weekly Residents Confrence. Basically the first hour is a Morbidity and Mortality meeting for the ER where we discuss a case where a patient died, and how to do better next time. The case discussed today was for a patient that had come through the ER a few weeks ago (before I got there) with NECROTIZING FASCIITIS. Which was kinda cool because I got to learn more about it, just wish I actually could have been there... I wanted to see the case!!!!

After The Morbidity and Mortality meeting, there were a few lectures by medical students on cool cases they've seen. They basically present the case and how it was managed, then lecture on the disease for about 20 minutes. I have to go next week, I still haven't decided which patient to present on. Plus I kinda suck at presentations so I'm really starting to procrastinate this...

After all that, one of the attendings showed up with a present for us all. He had grabbed a bunch of expired suture kits and a ton of chicken legs from the grocery store. He sat all us medical students and residents down and helped us practice suturing for about an hour. I stationed myself next to a resident doing a rotating interm year at the hospital before going on to a surgical residency next year. He was able to really help me learn "surgical grade" sutures. (ER residents and students are usually content if the edges of the skin meet and if the ties aren't going to come apart anytime soon. I wanted to learn the RIGHT way to do it.) I got to practice my suturing skills later on an actual patient (under supervision of said future surgical student), so I'm feeling a lot more confident about them :).

And on to the good news.

When I got home from the hospital today, I saw that I had an email stating that my USMLE scores had been released and could be downloaded from their website.

I was really scared to download it, but thanks to some encouragement from a certain ginger, I opened it and saw....

I passed my USMLE :)

I got the score I needed to pretty much do whatever haha. I found a table that somewhat represents what the scores means for residency applications. The bottom line indicates the lowest scored applicants a particular program will look at, and the top line indicates the score that almost always merits an invite to interview for a program.

And since I have off tomorrow, I'm off to do some celebrating. Toodles :)

Day 4 ER: My first Spanish Word

We shall not speak of the horrors that happened on my third day in ER (my overnight shift) suffice to say, I'm not looking forward to my next overnight shift, and I can cross ER off of my differential list of possible residencies.

Today for some reason, everyone decided to cut themselves. I had many many patients that needed suturing. Within the first hour, I had a kid who cut his head running into a door, another kid who cut his eyebrow with a fishing lure somehow, and a man who stepped on a broken piece of glass. I guess one good thing about getting this rotation out of the way first is that by the time I get to surgery (which is now top of the list of specialties I'd like to do) I'll be kick ass at stitches.

I know I've mentioned this earlier, but I'm starting to think that rotations are the best kind of diet. Seriously, in 12 hours, you really only have time for a quick snack now and then.

 I am glad I started carrying around granola bars in my pocket. What with all the bloody cuts today, the last think you want to be is lightheaded. The sight of a lot of blood + no food for a long time= fainting medical student. So thankfully I wasn't a cautionary tale to young medical fledgelings and was able to keep from feeling faint all day :).


So ready for a story that made me happy but sad at the same time?

My last patient of the day, was as per theme of the day, a laceration case. He was a young man from El Salvador who was brought in to the ER accompanied by some Police. The poor man, as it turned out, had been beaten and hit with a broken glass bottle by a gang. He was cut and scraped all over. His shoulder was badly hurt, and he had several deep gashes on his hand and forearm where he tried to shield himself from the glass. The gang took the money he had just recieved for a weeks work ($500). He spoke very little english, and at first he was just so upset and shocked he could do little more than sit on his stretcher and cry.

The resident and I brought him into the room and started to give him some morphine for his shoulder and start numbing his arm with lidocane for the stitches. The resident knew a little spanish, mostly the word "dolor" (pain). While the resident was injecting him, I tried to keep him distracted by talking to him. I asked about where he was from, and what he did. He said he worked for a construction company and proudly showed me some pictures on his phone of some tile work he did. I also learned that it was his birthday.

What a day this poor man had!! While we were working on his stitches, I got him laughing by saying that we would give him an extra shot of morphine as a birthday present. He asked what it would do, and I said "much better than cervesas" to which he laughed. Somehow, after such a wretched thing to happen, he was able to laugh and have such a good humor while having people sew him up. We did give him another shot of morphine when we were finished as promised (although the poor guy really did need it).

Anyways, just in that little space of time, I felt that I had seen the worst (gang violence against an innocent) and best (laughter and good humor in horrible circumstances) of humanity.

Thats my two cents for the day. I have tomorrow off, and another night shift on monday..... wish me luck.....

Things I saw today:
-Cuts
-Cuts
-More cuts
-Pseudotumor cerebri (!!!)
-a possible hyperparathyroidism
-Diverticulitis

Things I did today:
-Assisted in suturing
-Followed nurses around to learn the basics of drawing blood for labs, getting arterial blood gases, and refreshing my knowledge on doing EKGs.

ER Day 2- Poop

Yesterday was my first full 12 hour shift, and it got much better. Instead of having all the new residents and medical students there at once, it was just me and a 4th year student, and one of the new residents with 2 attendings. The 4th year student was so nice to me. She let me follow her around all day while she showed me the ropes. She made me do and assist her with some procedures, and gave me some basic tips for surviving rotations.

That said, as the title of the post suggests, the theme of the shift seemed to be poop. I dont think I could ever be squemish with any kind of bodily function after yesterday. The first patient I saw, the 4th year made me do a rectal exam and get a quiac sample (basically smear poop on a card). That same patient for the next few hours had me look at her poops because she kept thinking she saw blood.

Another thing that I had to adjust to yesterday was the fact that everyone refers to the med students as doctors. I'm really not used to being called that, and I really don't feel like I've earned it yet. The patients call us doctor out of ignorance (white coat seems to = doctor), the nurses call us doctor with a humourous/aww look at them try tone, and some of the residents refered to me and the other 4th year as "baby doctors".

I did get the hang of what is expected of medical students and how ER shifts generally work. Basically we keep an eye on the computer's grid of patients as they get admitted. If we see a patient on there that has yet to be seen by a doc, we go up to an attending and ask if we can go see the patient. If they say yes, you go and get a basic history of why they are in the ER and do a physical exam on them. Go back to the attending and give them a brief report on what you found. The attending asks you for what you think the diagnosis is and what labs/tests you want to order to confirm. They either agree with your plan or go tell you to learn more cuz you are an idiot and come back when you know what to do. When they like your plan, you order the relevant tests (ER we get PA privliges so basically we can order stuff and meds, just need an attending to cosign). You wait for the labs to come back, interpret the results and again present to the attending. Then they ask you for a treatment plan. If they like your plan, you place an order for the meds and you are basically done. You go back and can check on the patient later but thats as much as they really expect the students to take care of.

                         (pretty sure thats what some of my patients thought yesterday haha)

Also I'm learning slowly how to survive the shifts. You really are on your feet for most of the shift, so I caved today and bought these super expensive but medical grade orthotics that I saw all the residents wearing:

We really also don't get much of a chance to eat. I packed myself a lunch but I didnt really get to eat it all because we only are allowed one 30 min break for the whole 12 hour shift. I think I'm gonna go to trader joes later and buy a shit ton of granola bars to hide in my white coat.

There's more to report but this post is long enough as it is. I'm off to enjoy the rest of my day off, because tomorrow is..... MY FIRST OVERNIGHT SHIFT. omgbbqwtf.

Things I saw today:
-Gastroenteritis
-Lots of dehydrated little old ladies
-A hypotensive chronic renal failure patient who became unresponsive during dialysis
-Lots of alcohol overdoses covered in sand from beach parties (one enterprising 14 year old, poured out her urine sample and replaced it with water... like we wouldn't notice.....)
-Many many psych patients (the ER gives psych admits quick exams to make sure there is nothing medically wrong with them)

Procedures learned to do today:
-Rectal Exam
-Replacement of a suprapubic catheter

ER Day 1: Lets Play Doctor

Welp. First day was pretty nuts. Not sure if it was in the good way. At least I kinda looked the part:

The subway ride to the hospital wasn't terrible, once you get out of Manhattan the subway goes above ground and you get some pretty views of the water during the trip. Once we got to the hospital and up to the administration floor for orientation, it was crazy. Me and the other girl were told to go to the Medical Library to watch a video on how to work the computer system, but it turns out they were supposed to send us to the ER confrence room for an ER specific orientation. We showed up to the ER after getting our badges to meet our very pissed off attending because we missed his orientation. We were abruptly given our schedules (4 12 hour shifts per week with at least 4 overnight shifts this month) and were sent out on the floor.

Now this is an infamous day in the medical world. The first monday in July is the first day for medical students and new residents. So it was pretty crazy. The ER at my hospital is tiny. Only 12 or so exam areas. There were 4 new residents, 2 4th year med students, and 2 3rd year medical students (myself included). For the first few hours we basically stood around like:

Eventually the new residents figured out the swing of things and us newbie medical students started following them around like lost little puppies. The 4th year med students had a ton of great advice for me and the other 3rd year uber noob, so hopefully things will go better tomorrow.

On a brighter note, I stopped by school after I got out of work and my loan check came in. This is exactly how I felt carrying a check for a huge sum of money through Harlem back to the UWS:

(Marshall running down the street shouting "Im carrying a lot of money"- How I Met Your Mother)

Cool things I saw today:
-Sickle cell anemia patient in a sickle crisis (aka super jaundice)
-Stab wound (which was pretty much immediatly sent to OR)