nANIMOv

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.

I had to work with some new residents today so workflow was a bit different, but the good part was I got more facetime with the attendings, the bad part was I got more facetime with the attendings. It’s just more nerve wracking than presenting to the residents, and I definitely embarrassed myself multiple times today by suggesting stupid or outlandish things to add to the differential while forgetting to include some of the most obvious ones. At the same time I think I did a decent job of proposing appropriate plans and following up on work up for patient to expedite their dispo. Also definitely getting a better handle on the notes. Also I did an ultrasound by myself to confirm a pregnancy and got told that my Spanish is really good by a patient.

Got to be back in a primary care clinic this morning which was kinda nice. It was nice to talk about health maintenance and more quality of life issues rather than people racking up bills $2342 because they had a bit of diarrhea. I was back in the ED in the afternoon/ evening, and what’s nice is it’s still a brand new experience every day. Today we had an older gentleman who just arrive in the country not too long ago but has been having nausea and vomiting ever since. Interestingly his daughter was a doctor and after the work up, seems like they got more than they bargained for in terms of diagnosis.

Anyway so far still digging the variety. No procedures today, but hopefully tomorrow, and maybe something that is not pasta for lunch.

It turns out I’m a black cloud. Today there was a bomb threat at a government facility (not that there was a increase in patients because of this) and a train derailment. Only 2 patients from the derailment showed up to our ED, but the department was definitely a-buzz with excitement/ activity in anticipation for a potential influx of patients. It was good we only got 2 though because we had plenty enough to deal with (and according to my resident yesterday was pretty quiet). I got to do a thoracentesis and we also pulled a fishhook out of a kids cheek. The thora was kinda exciting and satisfying, but I also had to manually pull out the fluid with a syringe (no vacuum bottle) which was kinda tedious, but the guy was very thankful which is always a good feeling.

Still getting used to ED note writing, I feel like I never got a formal run down, and it almost feels like it doesn’t really matter what I right ’cause the resident is going to write is own note anyway, but it’s good practice. Also have the time when I’m talking to attendings its hard to tell if they are testing me or if they actually want to know what I think about a case. It’s likely both, but it just has different vibes than what I’m used to.

Maybe it’s a misnomer to title all these as FM ED. Technically, this is all just FM inpatient, but it’s being split into 2 weeks of ED and 2 weeks of like wards. But to make it more confusing during these first 2 weeks I’m also spending time in the Urgent Care clinic and the normal primary care/ continuity clinic. Today I was in Urgent Care which was my first exposure to working UC as a student. It was kinda a nice blend of ED and primary care in that it’s single-problem, but there is some opportunity to do more patient education and create follow-up (just not with the UC). Note writing is also relatively simple and focused.

One of my attending today gave me some pretty high praise and I was feeling good cause I was kinda nailing my patient encounters from getting the history, to doing a focused physical, and creating assessments and plans (albeit for relatively straightforward cases), including a case of likely EBV/ mono. There was a rising 2nd year resident who was also working his first shift in the UC and I felt like I was at least keeping up with him.

Later in the afternoon we had “core conference” but today it was more of a promotion ceremony for the incoming residents, rising 2nd years, and graduating 3rd year residents. There was lot of good wisdom being thrown around. One of the things that kinda stuck with me mostly cause I thought it was kinda sweet and sounded fun was one of the residents talking about how their experience in this residency felt like “running a hospital with your friends,” and I just thought that was a nice sentiment.