Author: nanimov

Today was long-call. I was actually out sick yesterday, feeling a lot better today. I had not patients who I was previously following on the list, and the list was short as it was (only 4 patients), so I just waited for new admissions given were were on call.

I first got a alcohol withdrawal patient who was agitated and pulling out his IV with his teeth, then a code stroke who was clinically completely normal by the time of exam, and then a cellulitis vs DVT complicated by psychiatric issues. Overall they were pretty straight forward, but good learning and review cases.

It ended up being an extra long day though because right as our shift was ending we had to consecutive trauma calls that we had to go down to (that’s how it works at this hospital). For the second one I was at head of bed. My job was basically to make sure patient was protecting his airway and to stabilize his neck. I also had to perform the physical exam on his head and get some history from him. The whole process is pretty chaotic cause their are like 5 other people all doing their own things on him. With these relatively minor traumas I kinda feel bad because the patient is fully alert and aware that they are kinda just being tossed around (safely) and man-handled and getting their clothes cut off with scissors.

Then after the trauma there was a code rapid response on one of our patients, so we had to run up and make sure that was all ok. Turned out to be nothing too serious, but in a high risk patient so important to rule-out. Then finally almost an hour after we were supposed to sign-out to the night team, we were able to sign-out. It was a long day, but exciting, especially near the end, and definitely got some good experience in.

Overall, it was a pretty smooth day and a new attending. Today we talked a bit about surrogate decision making. This was in regard to our Creutzfeldt-Jakob patient. The new attending told us about the “empty chair” technique; inviting a potential surrogate decision maker to imagine the person as they once were sitting in a chair at the table and then to further imagine what they would want if they could see themselves as they are in the present. This was a kinda moving exercise for me just imagining myself in the shoes of the family of this patient. The idea of putting aside our own selfish wishes and desires to deeply empathize with the memory of a loved one is heart-breaking.

As far as the rest of the day, some of my patients who I thought were definitely going home over the weekend were still on the list today. It’s interesting how quickly things can change in medicine in a short amount of time. Or in some cases it’s a slight difference in assessment by different doctors.

Regardless, I picked up my old patient and picked up 2 new ones and they were all pretty much on the path home, or at least I thought so. In a couple cases, my senior thought they should stay overnight and so I went along with that plan, but when I presented to the attending that they stay overnight, he suggested that they could probably go home. I felt a bit vindicated in that, but also I still have a long way to go in terms of clinical judgement because there have been plenty of times where I have been wrong.

We have some pretty complex patient on our list. It’s interesting though that we actually don’t have that many cirrhotics, alcohol, or heart failure patients unlike at County. We have a lupus flare patient, a likely Creutzfeldt-Jakob patient, new multiple sclerosis diagnosis, and just some other curious cases. It’s been fun to think about these cases and it’s been good learning. It’s kinda hard to believe it’s only day 2.

I was a bit concerned transitioning back to the inpatient side. I thought I would not have my chops or that I would get a bit under-stimulated after the constant fluctuation I had gotten used to in the ED. While I wouldn’t say I necessarily shined today in terms of performance, I definitely have come a long way from when I was on Internal Medicine almost a year ago, and I enjoyed working/ thinking though long problem lists and wide differentials. I do think that I maybe prefer walking rounds compared to table rounds. We have a few interesting patients and I feel like I’m missing out when I don’t get to at least briefly see or examine the other patients. But I get it, it takes a bit more time and you can’t simultaneously work as much while table rounding. As I continue to become more competent and further develop my clinical reasoning this all just becomes more fun (the main barrier is still just the anxiety of presenting/ failing/ saying something dumb to an attending who doesn’t explore why you think what you think).

Today was my last day in the ED. I got to learn to use a slit lamp to look at people’s eyes and I had a return patient for some good “continuity of care.” I also had a bad leg infection from a guy who had his wound surgically debrided a few weeks ago and then left AMA without completing his course of antibiotics and just happened to come back because he got picked up by the police for a stolen bike. Then there was a lady that was screaming at everyone while getting medically cleared for jailed because she was destroying the flower arrangements at the grocery store. So overall it was a very ED day.

I’m going to miss being here because of the variety of stuff I got to see and the different stuff I got to do. It was definitely a good learning experience for me as a student. A lot of medical school condensed into a short amount of time. Hope this isn’t my last time doing a lot of this stuff.

I was in clinic this morning. Putting primary care clinic right next to emergency medicine, I can see why people like EM. There more variety, not so much routine health maintenance, less chart review, less time writing notes, etc. That said I think my experience is slightly skewed because every time I’m going into these clinics I’m talking to these patients for the first time and don’t have a prior relationship with them. That doesn’t matter so much in EM. I do enjoy talking to patients, my concern is that I do too much conversation/ go overboard with details in both. I also feel like as a medical student I’ve felt more judged in some of my interactions with family medicine preceptors than by ED ones, in general. Of course there have been exception, and not that it’s necessarily a bad thing, just an observation. Today I had a patient with a genital rash and another who I had to do a digital rectal exam on. Tomorrow is my last day in the ED, sure going to miss it.

This morning was pretty exciting. It was a relatively slow morning in the ED, perhaps surprising day after 4th of July which is notorious for hand-related firework injuries, but then again any of those probably would have come in overnight. But because it was slow I was able to work on a firework-unrelated hand injury; I got to sew up the fingers of a young lad who works as junior arborist and accidentally grabbed a live hedger blade. It was a pretty gnarly injury. Lacerations along all 4 fingers, some of them going down to the tendon, but the tendons were all intact. He still had good strength and function, so no need for a plastic surgeon apparently. He was wearing a thick leather glove when it happened and I can only imagine what would have happened if he wasn’t. The lacerations were not very neat so it took of thought as to how best to re-approximate the wound edges and took us all of 4 hours to finish the the whole thing, but in the end I think it looked pretty good. Ended up putting a total of 26 stitches. He was a good sport with the whole think. Putting in sutures is definitely an activity I’ve come to enjoy and one I hope I’ll have space to do in my future practice.

The rest of the day was pretty unremarkable, but good overall. Wasn’t bored and got to see some bread and butter cases.

After a week in the ED, definitely feeling a bit more comfortable with the flow. I feel like I’m being treated like an intern by the attendings and staff, probably in part because the new interns just started late last week so some people do actually think I’m a first year resident. There was a new senior resident today, a fresh 2nd year, so similar to last week he was kinda hands-off so I got to work more directly with the attendings. The good part of that is I feel more independent and like a true sub-I, the bad part is if I say something dumb the attending will know I’m dumb without it being filtered through a resident. Though so far it’s been going ok. Today was pretty standard in terms of the cases I saw, nothing too interesting from a medical standpoint. I had to interrogate someone’s implantable cardioverter-defibrillator (ICD; I had to figure out how to do this first). I also had a patient with suicidal thoughts which I haven’t had since my psych rotation and as well as an individual with body lice which I hadn’t seen since I was working with Doctors Without Walls. The days go by fast and there is a certain satisfaction about doing acute interventions to make someone better in the ED. At the same time, there’s a lot of cases where we aren’t actually solving people’s issues, just getting them stable enough to find someone who can help them. Pluses and minuses, but overall I’m having a good time.