1.28.2008

Confessions.*


There are a few things that many EM docs don't openly discuss 'else they subject themselves to criticism and judgment. Here are few of my confessions -


I think leaving acute patients to 'see quickies' in an attempt to clear out the waiting room contradicts the very essence of emergency medicine...and I don't do it.
In every emergency department there is (supposed to be) some sort of triage process. Where sick people are seen first, and not-so-sick people...wait. Well, our nursing staff (as wonderful as they are), will frequently ask me if I would 'come out and see some of the quickie, non-sick people, to clear out the waiting room.' If I'm sitting around surfing the net...then sure. But I'm never not busy at work. Never, ever. I rarely get to go urinate, much less grab a bite to eat. So, I don't do it. I can't justify in my mind, leaving my sick patients to go see not sick patients. And all to "clear out the waiting room?" That's really not my goal. My goal is to keep people who shouldn't die, from dying...and to get the rest to their proper destinations. When my shift is over...I leave. Waiting room full...or not. Why should my goal be to clear the waiting room? If I valued an empty waiting room...emergency medicine would be a poor choice of specialty.


I think that speeding thru patients, and subsequently rewarded for it, is a bad idea.
It annoys me when doctors brag about their half-ass workups in an attempt to seek reward for speeding thru patient encounters. Our patients wait, sometimes in excess of 6 hours, to see us. They deserve 10-15 minutes of face time. Even if the problem is straight forward and you only need 90 seconds. This interaction with patients (listening to them, talking with them) is why I love medicine. Minus the patient encounter...what's left?

Sure, I understand being efficient is important...but seeing 3-4 patients an hour is not good for the patients you see. They won't like it...and you won't like it. Something will be missed. A something that won't be missed if the doctor just takes a minute, grabs a chair, and spends 15 minutes with a patient. Additionally, taking a minute (or 5 or 10) to look up information (for yourself or for the patient) is totally appropriate, but doesn't lend itself to "speeding thru" cases. Finally, very important thought processes would be clear if time was spent documenting this information *in real time.* Not to mention more defensible in court, and basically just better communicates (as a medical record should) with other care providers.


I hate reading history and physical assessments written by people who are more concerned about capturing all the "elements" for full reimbursement, rather than actually documenting what the hell's going on with the patient.
There are so many docs now who chart based solely on reimbursement, that very key information is not included in the documentation. I do understand the need to get paid...but it's just as important to communicate effectively for the well-being of our patients. And simply putting "4 elements" in the HPI...doesn't quite do the job.


I hate dictating.
In the ED so many of my tasks are accomplished piece-meal. I may do the HPI in the patient's room...fill in the physical once back at my desk...and document the labs/xrays as they become available. I'll later fill in consultants names, times called, and their responses. Medical decision making usually follows. Finally I have a "diagnosis" and disposition. If I dictate, I can not do it in real-time. Otherwise I'd constantly be calling the dictation line back adding "addendums". Not to mention the time it would take to dictate "Dr. Cardiologist paged at 12 pm; no answer." (click) Then call back: "Dr. Cardiologist paged again overhead at 12:20." Or what about when patient has a change in condition? I can type over 75 wpm. I can write on the paper chart standing at the bedside. I can get distracted, and return to the charting very easily. But dictating...every chart...is unreasonable. Dictating looks pretty, and after the final disposition has been obtained, perhaps going back and dictating on selected patients would be helpful. But, I think it's a bad idea to do essentially no charting (scribbling notes to yourself on the paper chart with the intent to go back and dictate, *isn't* charting) until after your shift (sometimes *days* after your shift). I think that's a set-up for disaster.


I like to leave on time after my shift.
What's wrong with saying that? If I'm scheduled to be off at 4pm...I wanna leave by 4:45 (really right at 4, but I do understand expecting to stay up to an hour later to wrap things up). For some reason, some people think you're being lazy if you get out on time. On the contrary. It takes crazy planning to get out on time...and still see new patients up until the last 30 minutes or so of your shift...AND not sign-out a whole bunch of shit. It's an art, really.

I do not like being made to feel guilty because I actually have a life outside of the hospital. Not to mention that staying late isn't compensated time. I don't like to stay late (or come back on my day off) to chart on previous patients...not to mention that this isn't best medicine, IMO. And I expect oncoming colleague to take a reasonable sign-out without bitching and moaning. Of course staying is sometimes unavoidable. Of course some sign-outs are inappropriate. But I'm not talking about an occasional late day...or defending docs who chronically dump on their colleagues. I'm talking about a general attitude that everyone is expected to stay 2 hours late (cuz if they don't it means they were "slacking" during their shift and not seeing patients near the end...or didn't see as many patients as they "could have" because they completed their charting within the shift.) Neither is necessarily true...and on the contrary, docs who are efficient enough to finish their work on time...should actually be rewarded (rewarded with going home on-time without comments from the peanut gallery).


I get really annoyed when folks show up to the ED talking a whole lotta crap.
If you haven't been in the ED all day, you are not allowed to stroll thru and pass judgment. Nor are you allowed to show up for your shift and pass judgment. If you have not been here, you don't know what's been going on. And looking at the chart rack, seeing 15 patients waiting to be seen, is no indication of how fast/slow, diligent/efficient, the staff has been working.

I wish that everyone could understand that everyone has a bad sign-out from time to time.
Sometimes, the patients are all actually sick. Sometimes the xray machine is broken. Sometimes the medicine consultant is stuck in the ICU with a coding patient...all day. Sometimes, you're just friking tired...and want to go home.


I don't think that physicians should be "time card punchers."
We are not time-card punchers. We spend hours of "extra" time in the hospital in a given month. Leaving 10 minutes early one day...is earned. A right almost. Especially if the sign-out is clean. Afterall, staying for the sake of staying (it's not like a new patient encounter is going to be initiated 10 minutes before you're off) is demeaning. I understand why high-school students stay on their Burger King shift until the clock strikes twelve. But I am no high-school student...and I am not at Burger King. Holding highly trained professionals (who give away tons of time for "free"), accountable for every minute (or ten, or fifteen...) is indeed a slap in the face...and shouldn't be done.


I kinda like that the patients see me as a nurse (or other non-doctor person) at times.
When patients start bitching and complaining....it's so easy for me to say, "lemme get your nurse." If they knew I was the doctor, I don't think that response would work quite as well. Also, looking like a clerk nurse cafeteria worker non-physician allows me to roam the ED in peace. Most of the time, this is kinda nice.


I hate it when patients lie to me.
I mean, it really annoys me. I can no longer trust them...and I no longer believe anything they say. I get urine tox screens on them. I don't spend as much time with them. I am less likely to give them what they're asking for. And I don't take the time to do the extra things (get blankets, cups of water, or even listen to their tale of woe about their inability to pay for a cab). I treat them, and disposition them.


I like male nurses.
Male nurses are fun. They rarely challenge me...and there is no animosity between us. Male nurses seem to become nurses because they wanted to be nurses. Sometimes, female nurses have this thing...where I get the impression they actually wanted to be physicians...and they are jealous of me? Or think they're smarter than me because they are older...perhaps they feel they have something to prove (like "I coulda been a doctor too, you know".) Maybe it's just too much estrogen. Either way, I love male nurses.


I like female physicians.
The guys tend to be immature, socially inept, sexist, arrogant, pompous little dick-heads. Racing their fast cars, and staying late to avoid going home to their wives and families. Rushing thru patients for bragging rights: "I saw 26 patients on my 8 hour shift yesterday dude..." They balance their personal/professional lives very poorly, and rarely have anything to talk about that matters (outside of medicine). It's no wonder they die off early. Whereas women tend to do a better job listening, and taking the TIME to figure out what's going on with the patients. They are not as concerned with playing the testosterone games the men boys play, and seem to be more patient focused, more balanced, and better adjusted individuals.


I don't like it when female ED staff cross boundaries with male physicians.
I'm not just talking sex here. I'm not even talking about dating (I'm okay with that). What I don't like is the gifts, the shoulder rubs, the playing with the hair, the flirty remarks the fawning...and the all around degradation of character they demonstrate when they pimp themselves out to these dick-head male doctors. It bothers me more when the men are married. Sometimes I'll comment. Is there no shame...?? These "hos" misrepresent women, they undermine family, and make it even more difficult for women to be taken seriously in the workplace. I say, be friendly at work...and a tiny bit of flirting may be fun. But leave the touching, and the gift-giving at the ED door.


I really envy the way the nurses organize potlucks, make Starbucks runs, and overall, make their work environment more 'friendly' by virtue of having involvement of more women.
If physicians had more female members in the ED, I'd bet our lounge would have plants, and family photos, cutesy posters, and the like. I bet we'd even have clean linen and tampons in the bathroom. And best of all...we'd have a strong union.


I hate colorful scrubs
You know the ones the nurses wear...with all the pictures all over them (dancing puppies, and little happy faced sunshines)? I don't exactly know why. Maybe because I can't wear them without looking like a complete fool...??


I like seeing children more, now that I have my own.
I used to *hate* seeing kids. All they do is cry...and they provide no useful information. Just like being a vet. I didn't know what "fussy" meant...and I couldn't understand why parents brought their very well children to the very germy ED for a cold. I couldn't understand why it had to be at 3am? I couldn't understand why they even thought anything was wrong with the kid. Now...I understand better.

I have more 'feelings' for patients that I relate to.
I can easily tolerate people doing stupid, self-destructive things. This is what keeps us in business. However, when I can identify with the person on a personal level, I feel personally disappointed when they make bad decisions.


But, if I can relate to a patient, and they are ill...I feel sad. If a patient is a mother, for instance, I can talk to them for hours about their hopes and fears for their children. I'll fight back tears as I listen to her history. Then, once home, I'll take extra moments to smell the breath of my own children, and feel their soft baby cheek. And I remind myself that I am truly blessed.


I think emergency medicine is the coolest specialty ever.
I actually believe that those who talk negatively about EM...are simply jealous!!

Updated 4/2011
*Stating the obvious: there are many great female nurses that I just adore...many male doctors that are wonderful friends of mine; there are patients who lie that I still trust, and people who look like me (or that I can relate to), that I feel no emotion for. No one should dump on their colleagues by showing up habitually late for a shift, nor should one give shitty sign-outs consistently. I do go out to triage every now and then to dispo 'simple' patients...depending. I understand moving quickly, documenting to get paid, and needing to stay late to finish documentation (or whatever). I realize that in the ED, every patient will not get 10-15 minutes of face-time with the physician. Dictation is wonderful, and should be available...and a bit of innocent flirting at work is okay at times. I encourage people to find love, and have no problem with finding love at work. And I realize that not all men who work late are cheating on their wives (or otherwise avoiding them). I do get annoyed when I have to almost 'prove' I'm the doctor to people, when the white *male* is often 'mistaken' for being a doctor no matter what his role may be in the hospital. There are no absolutes...and I get this. You get this. I wrote this 'Confessions' entry with blanket statements to keep it interesting (and direct). Please don't argue the fine points (i.e. not all colorful scrubs are embarrassing). I know this. And remember, these are my *general* opinions. General. Opinions.

1.07.2008

a trauma story

Since I got such positive feedback, I'll post one more story.

I work at a couple/few different places - which is nice because my ER shifts are quite different depending on the location of the ED (obviously). One of 'em is a trauma center. The trauma center is way cool...and has top of the line everything. The trauma resuscitation bay is like 20 feet from both the CT scanner, and the OR. The anesthesia and surgery call rooms are actually *in* the trauma center. We even have a teeny-tiny police department (2-way glass and everything) in the entry-way to the trauma center.

So, I was at work recently, at my trauma center ED. Things were steady. Our traumas so far consisted of a drunk dude who was riding his bike, crashed into the curb, fell off of the bike, and lost consciousness. Granted, there are quite a few things possibly wrong with 'drunk dude', but more than likely, he's just drunk. But, he fits 'trauma criteria' so he was brought to us. There was a kid who jumped off a roof, obvious deformed leg...but otherwise okay.

Then we received the EMS call:
"This is rescue 25 to base with a trauma run."

This is base. Go ahead with your run.

"We have an approximately 30 yo male who jumped from a 2nd story window to escape an apartment fire. He has 2nd and 3rd degree burns over his anterior chest, neck, and his right forearm. He has an obvious deformity of his left femur, and multiple abrasions to his face. He's alert, but appears intoxicated, and is combative. We have PD on scene helping us secure him for transport. His vital signs are 150/84, heartrate 120, respiratory rate is 22, and his O2 saturation is 98%. We're attempting to establish IV access, we have him on O2, full spinal immobilization, and would like to have an order for morphine. You are our closest trauma center with an ETA, after we get him loaded, of 7 minutes. Over."

We rally the troops, and congregate in Trauma bay number 4. Upon arrival, EMS notifies us that this guy was 'set on fire' by a girl. Apparently this girl is the girlfriend of a rival gang member...and 'word on the street' is that she decided to get revenge on this guy for killing someone in her boyfriends gang. Because of this, there were already members of both gangs 'interested' in our patient's condition....and our parking lot was starting to look a lot like Crenshaw Blvd on Sunday night.

As firefighters approach us in Trauma 4...we see a young adult male, laying on the paramedic gurney with a c-spine collar on a long spinal backboard. His face is covered in blood and glass. His chest wall has 3rd degree burns over the entire anterior surface. His left femur is obviously fractured; as is his left tib/fib. They have no IV access. Patient is on O2 via facemask. He's yelling loudly, and wiggles on the backboard. We transfer him to our gurney. And the nice thing about trauma centers, especially where there are residents, is that there's enough people around to do everything.

My mind is yelling "oh sh*t. This guy looks horrible!!" The residents are eager to *do something*. It is times like these I really appreciate the simplicity of the mnemonic ABC.

As the attending (gulp)...I start giving instruction.

"Okay, lets get him on the monitors, pulse ox, and let's get some sterile gauze soaked in saline." That sends a few people scurrying away. Someone assess his airway and listen for breath sounds. Let's set up for intubation, and obtain central venous access...via...via..."

(hmmm....can't do subclavian because of the burn...or IJ for that matter. He has an obvious left lower extremity long bone fracture...so maybe that's not the best place to stick him).

"via right femoral vein. Someone call the burn center and let them know this guy is here."

The crowd around the bed is now half it's original size...with everyone doing their various tasks and all. Now, we have some room to work.

A - airway first. "let's intubate this guy" I tell the junior resident. There's some resistance from the nurse, "but he doesn't need to be intubated." I try to quickly explain to her (while the resident proceeds with the intubation) that this guy has major trauma, major burns, and was in an enclosed space, likely intoxicated, with fire...and smoke...and CO...and CN. His airway is closing...and every moment we contemplate will just make the edema in the airway even more difficult to overcome. The resident struggles, "I can't see anything." Keeping the cervical spine secure makes the procedure more difficult. The monitor goes from a high-pitched 'blip-blip-blip' to a decrescendo 'bloop-bloop-blooouuuppp' as his oxygen levels drop. Okay, that's enough. Let's bag him up.

I'm too 'insecure' to let him try again. We bag mask the patient, restore the oxygen saturation to an acceptable level (and the nice high pitched blipping)...and I try. Wow. All I see is pink mucosa - there are no landmarks!! I do the BURP maneuver and a small opening reveals the cords. I use a bougie and successfully intubate this guy with a 6.5 ETT (tiny little tube)!! We listen to breath sounds, and the left is decreased. We pull the tube back a bit. Still decreased. Then I ask the resident, "did he have equal bilateral breath sounds before intubation?"

He isn't sure. Maybe the left was less audible. We order a chest xray.

As we secure the ETT the patient, who intially improved his oxygen saturation, started to desaturate, and his blood pressure was about 115/70 with a heart rate of 130. Let's bolus him warm saline thru the Level 1. And let's get some o-positive blood here (we like to use 0-positive for the fellas).

Moving on to B - breathing: I instruct the resident to dart his chest. Things got a bit better after that. Then, he placed a chest tube. 500mls of red blood squirted out of the left chest...but his breathing improved. Let's autotransfuse that blood right back in.

And now to C - his blood pressure was stable at the moment. His arms/hands had good circulation. Palpation of the left elbow elicits a painful response. His right forearm has a medium sized 2nd degree burn on the radial surface - it is not circumferential, and his distal pulses are good. His right leg is fine, and our femoral line is working wonderfully. His left leg is mangled. There is decreased pulse to the foot, which is cool and cyanotic.

At this point we order initial labs and studies. Xray...basically everything. Order CT of...basically everything. Call ortho for the leg. Trauma panel of labs. And dress his burns with the sterile saline soaks. We keep him sedated. And order a tetanus and antibiotics while we're thinking of it. Then we go back and do a secondary survey.

We look into his eyes. In the left eye there's a piece of glass obviously penetrating the globe. The right eye is reactive and appears normal. Typanic membranes reveal no hemotympanum. There was no evidence of midface injury. However there are multiple deepish lacerations to the forehead and scalp. The PA is eager to repair these.

The neck has 1-2nd degree burn over the anterior surface, but it's not circumferential, and is not deep enough to expose any underlying structures. The chest tube is in place, and the breath sounds are present bilaterally, but greater on the right. There is a 3rd degree burn over the majority of the anterior chest wall.

Abdominal exam is difficult to execute....so we'll just scan him.

Pelvis is stable. Left hip is questionable. And his back and rectal/genitalia are unremarkable.

We continue IV hydration per Parkland Formula, and call ophthalmology for the eye injury.

Xrays reveal a femur fracture, tib/fib fracture. There's a distal humeral shaft fracture on the left. CXR shows what we interpret as a likely pulmonary contusion on the left. Chest CT angio, cervical spine, and abdominal CTs were unremarkable (except the pulmonary contusion and some rib fractures). CT pelvis revealed a small, but significant pelvic fracture, with acetabular involvement. Labs revealed an alcohol level of 420 (legal limit is 80). Utox positive for cocaine, marijuana, and meth. And head CT revealed a left parietal skull fracture (with no underlying brain involvement apparent), and glass fragments in the left eye with globe rupture.

Ortho took over the management of the broken bones, and decreased distal blood flow to the left leg. The leg was splinted, and vascular surgery was consulted. Because the patient had extensive chest trauma, I believe trauma consulted CT surgery. And, of course you can't ignore the burns. We are not a burn center...but we have the capacity to care for burn patients (yeah, go figure).

At our institution, it's the trauma service that stays with the patient thru his scans, and see to it that the appropriate consults are obtained after initial stabilization is achieved. So, at this point...we're actually done. My residents stay and play with the trauma service...but I have other residents to supervise (only one junior and one senior responds to the trauma calls, the other 4 continue their work in the ED).
***

Later I found out that the guy, unfortunately didn't have insurance...and the ortho procedure he required involved a series of operations, close follow-up, and specialized equipment. And because orthopods don't work (much) for free...especially when the patient is a high risk patient (high risk meaning not likely to be compliant, and more likely to sue, as determined by his lifestyle...and according to them, it's the poor, uninsured, disenfranchised, non-contributor to society that's likely to try and take something that doesn't belong to them...and is therefore more likely to sue). So, no orthopod in the City would do his surgery...and he will require the use of a cane/walker for the rest of his life (or, I guess, until someone thinks it's worth it to fix him).
And he lost the sight in that left eye.

As for us...
...well, it was interesting leaving our shift that night. Navigating the parking lot in the middle of gang warfare is quite stressful - especially when, no matter the outcome...someone's going to be pissed off.