5.13.2007

overview, the process

Doing emergency medicine is very...scary. You never know what's going to come thru the doors...and you'll likely see lots of stuff you know absolutely nothing about.

Emergency medicine is also very frustrating. Much of what you see is the end result of people being dumb-asses. Drinking too much, racing cars on the freeway, fighting over city blocks that belong to the taxpayers. You see people who have no primary care, and use the ER for said care. And you have those vagueomas - those people who come in with no real emergency, that complain of everything (multiple vague complaints)....most of which you can do absolutely nothing about.

If I had one wish for patients with regards to coming into the ED, it would be to know exactly why you're there (more on that another day).

***
As a medical student you feel pretty good about yourself. Eventhough you get your ass handed to you regularly by attendings and senior residents...at the end of the day you probably actually know more than most people give you credit for. (Actually, you get no credit at all, for knowing anything...so it's not hard to know more than 'nothing'). Not very stressful.

As an intern, you know enough to know...that you know nothing. But, everyone seems to expect you to know everything. Nurses are calling you...asking you stuff. Patient's and their families are calling...asking you stuff. The attendings are calling...asking you stuff. Very stressful.

As a junior resident, you're super stressed (at least in my program). You realize that, in fact, no one actually expects the intern to know anything. And the student is just in the way. But you....you should know. At King, it was the junior resident who took care of the sickest patients. The full arrests, the traumas, the pediatric codes, the premature labors and deliveries in the ED. You took the calls on the box (the paramedic runs) and directed the paramedics to various facilities as appropriate based on the type of patient they had, their problem, and the capacity of the surrounding hospitals. As a junior at the Kingdom, you were plenty busy.

Personally, I would arrive for my shift a full hour before. I would get my critical care space ready with intubation tubes, IV lines, scalpels, suctions...everything. I would take unofficial sign out, and start my progress notes, because once my shift actually started, it wasn't easy to stay on top of things. And overnight shifts were especially stressful because in the morning we had rounds with the Chairman. And after a long night of critical patients, I had to stay an additional 2 hours for pimp rounds.

During these rounds, it was expected that the residents present the case in detail, know everything about the patient, be able to recite lab values, go thru the differential diagnoses, the treatment plan, the outcomes of the various treatments, the ultimate dispostion. Then be prepared to get pimped on the subject matter. How many times did we simplify a complicated patient to "pneumonia"....just so we could anticipate and prepare for the pimp session that is rounds. Also, we had to stand in a semi-circle, and look directly at the Chairman (and *only* at the Chairman). If you're presenting to someone else in the Chairman's absence...and he shows up...you must immediately refocus or feel his wrath.

So...I remember this one time. I had a patient in congestive heart failure. We worked on him all night, and by morning he was better.

side note:
Sometimes is so much easier on rounds when the patient is in a coma because there is no "feedback" from them.

For example: "Good morning Dr. Chairman, this patient is a 65 year old gentleman - "
The patient interrupts with an attitude: "I'm not 65...I'm 63!!"
Who gives a shit? Doesn't really matter dude.
So you can imagine what it's like when you totally forget the past medical history...or get the medications wrong, in the presence of a patient who's alert and paying attention.

okay, back to dude:
He presented in near arrest, but after treatment he was alert and interactive. So, on rounds I knew his history, meds, and could recite the ED course. But, I got caught giving eye-contact with someone other than the Chair. He interrupted my presentation "I AM THE CHAIRMAN OF THIS DEPARTMENT, YOU LOOK AT ME!! YOU PRESENT ONLY TO ME!! IF YOU WANT TO GRADUATE FROM THIS PROGRAM WILL YOU *NOT* DISRESPECT ME"

Wow!! It took *everything* in me to keep from running to the bathroom with my arms waving over my head and crying out loud like an infant. Suddenly, I couldn't remember anything about the patient. His name, his chief complaint...nada. So...I do what every good resident does when they don't know something....I made it up on the spot. As I fubbed my way thru the rest of the case, the patient looked at me smiling, nodding in agreement (eventhough, as I mentioned, nothing I was saying was accurate). Then, after I completed my 'story' the pimp questions came. And, this poor patient actually tried to help me by interrupting rounds to answer questions and defending me. This...brought tears to my eyes. After we'd moved on...I hung to the back of the semicircle. As I make eye-contact with the patient, I hear him say..."don't let him get you down, he's an ass-hole." Smiling inside...I was able to move on.

***
Anyway...I'm done being a medical student (where you learn about medicine). I survived internship (where you learn to be a doctor). I made it thru that very stressful junior year (where you learn how to be an ER doc). Then as a senior resident...I realized that I actually did know some stuff. Supervising interns and medical students. Supporting the juniors. Running the floor (i.e. taking care of all the patients, either directly myself, or indirectly by supervising junior residents/interns). Delegating tasks.

As a senior resident, people start to really take you seriously, especially if you're a chief resident to boot. You can successfully argue, now...and even challenge the attendings (if done correctly). You talk more sh*t to the interns from other services when their "professional opinion" is...stupid. It's like, "I'm done talking to you...either get down here and see this patient, or get your resident to call me." You feel very confident...a bit arrogant even.

Then...you become an attending. Suddenly, it's all you. You're not a senior resident with an attending to take responsiblity for all your fuck-ups. It's all you. That's scary...on a whole nother level. Then, the supervision of residents....sucks. You realize that they don't listen, don't follow thru, and they (get this) lie on rounds!! Imagine that? How irresponsible. You can't trust them. And they always talk back!!

Sometimes I miss being a senior resident!!

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