The pains of Monday, the gray of growing

In the emergency room, Monday is the worst. There’s no way around it. People hold off coming in during the weekend; they hope their symptoms will get better, figure they can hold off just a little longer. And this sentiment begets the Monday afternoon flood of patients – inevitable, painful, never ending. There are some days when things are simply off – today was one of those. My rhythm was broken – in part by an extra person in my critical care area, in part by the patient volume. And so I limped along, feeling as though I was missing something on every patient. There are days like this, I have come to realize. There are days when I find my rhythm easily, get in the groove of things, and then there are days when this breaks down and frustration builds. Unhappy patients who have been waiting hours to be seen does not help the situation. It breeds a highly tense environment, where I feel that I need to first calm people down, then need to care for them properly, and – lastly – to calm myself down. Easier said than done.

The light at the end of the tunnel is here, though. Tomorrow will be my last shift in the emergency department as a third year resident. Hard to believe, really. Only seven more months to go in the coming year, and I will be an attending physician. My blog post on On winter solstice, or becoming real is ever present in my mind and my heart. This is really it. I am savoring every moment left I have with an attending shepherding me, offering his or her insight. And at the same time, I feel as though I am ready – more than ever – to fly. For my patients, I have a strong, growing desire to execute my own plans rather than those of my supervisor. I am ready to be their doctor.

Hues of Gray, Marsha Heiken

I used to believe that residency was a mountain I needed to climb, and that as soon as I reached the summit, things would become clear. But residency is just a small part of a much larger journey – an uphill climb – continuing to learn, continuing to improve my skills, continuing to question myself. Becoming a doctor is a lifelong process. It requires constant questioning, self-reflection, and yes – even self doubt. To become a good physician is to continue working and learning, day in, day out, year after year.

Because no patient is ever black and white. Each one is gray, with subtleties to their stories that can trick you, trap you, mislead you. The skill and art lies in finessing your skills in interpreting each and every shade of gray, in considering each subtlety, each shadow of doubt that crosses your mind. It lies in continuing, no matter how many years of experience you have, to harbor that fine element of uncertainty, of imperceptible fear, that keeps you on your toes, that keeps you wondering. We doctors will never have all the answers. Thoroughness, experience, compassion, and most of all humility are the best we can offer our patients.

Where Trauma Meets Tragedy

“Full Trauma Now.” The words blare across the emergency department. There is a rush towards the trauma bay – stretchers, x-ray technicians, nurses, medical students, residents, attending physicians. We dress in our protective gear – plastic blue gowns, gray gloves, face masks, blue marshmallow hats. And we wait. “Have you heard the story?” One nurse whispers to another.

“It sounds bad…car vs. tree, I think, or maybe bike vs. tree, I’m not exactly sure…” She tilts her head up, as if trying to grasp the story from thin air.

One of the technicians pipes up, “GCS 4 in the field. Not intubated.”

A nearby resident raises an eyebrow, “Really? They haven’t intubated yet?” He gets his equipment ready – suction, tube, blade. Everything is in order.

And we wait.

Minutes go by.

A nervous, hushed wave of conversation ripples across the room. The hum of stretcher wheels fast approaches, or perhaps we are only imagining it. The air is thick with anticipation.

This is the trauma bay. The small, rectangular room where life meets death. But I have rarely seen a death here. Because we have become so skilled at keeping people alive, we are often able to stabilize patients for just enough time to whisk them away to the operating room or the intensive care unit. Even so, this is the room where a sudden life change is first realized, observed, and recorded. This is where it all begins. A bay – it is not a fitting term, really. Bright red airway bags, big computer screens, beeping monitors, life-saving carts, stretchers, fluorescent lighting. And there is no peace here. It is not a bay – more of an ocean, with unseen waves, trade winds, thunder, lightning strikes.

I have watched many patients meet their fate here. And yesterday, for one, the tears welled up. I know exactly how to hold them back – have become an expert, in fact, at letting them come just far enough to the brim of my lashes, so that if I smile it almost looks as though they are a twinkle and not a tear. Have I begun to feel again, after these years of blocking everything out? Perhaps. I was pleased to discover them – quite unexpected, I might add. Incredible that after all this time the tear ducts still function in the old, familiar way. A miracle, really.

As I watch this woman’s tragedy unfold in front of my eyes, I realize that she will not make it. I look at her, I look at the CT scan, and I know – with certainty. I no longer have the naïve hope of a medical student. I no longer need to look to my attending for confirmation. I almost wish I did. I glimpse the family at her bedside. Children, grandchildren, sister. I watch them weep. Their eyes are wide – too much hope, I think. I want to brace them for what lies ahead. But I know that would be impossible. A shock is not absorbed, or even felt, at first. It just is. It glares you in the face.

This is my last day as a second year resident. How the time has gone by. How much has changed. Children, grandchildren, sister. I watch them weep. And for a moment, I let myself remember what it feels like to be one of them. I, in my white coat, with too much knowledge for my own good. I, the doctor. No more or less powerful than they are, when it comes down to it. I put myself in their shoes. Slip them on my feet, feel the worn leather, tap them on the white floors, now splattered with blood. I watch them weep. And I feel something – not as much for her, but for them. For all the trials they will face in the coming hours, for all the tears they will shed, for their loss.

They loved her so much, didn’t they?

Coming to a close…

As the first half of residency nears an end, I recall this year – with all of its trials and tribulations. There were days when I walked through the ominous double doors of the hospital’s front entrance and wondered if I would ever emerge from them again – and if I did, how changed I might be. There were days when I was so frustrated to look down at my pale blue uniform and realize that the blueness had penetrated me, coursed through my veins, made me sad. There were days when I was angry to be in the hospital and not home. And there were days I was grateful to be here, honored to care for my patients with compassion and concern. This place has grown on me, and it has challenged my perspectives on healing, illness, and hope.

As I glance out the windows at a stone garden where a little girl in a hospital gown throws a ball to her father, I wonder if residency is a process that will encourage me to close the doors of the hospital, inch by inch, never to return again, or if it is a process that will allow me to re-open the doors, ever so slowly, as I recover from the hours that I have spent here healing patients.

The sun shines bright, and rain pours down outside. Clouds linger in the distance. The rain is gray but sparkles. The greatest paradox. A beaming smile curled with doubt at the edges. Eyes wide and bright through tears. Hope high in the midst of devastation. Expect the worse, hope for the best. Residency is not unlike a downpour in sunshine – and I, drenched but warm, through it all, have reached the peak of this mountain and am now ready to trek down the other side. Unchartered territory, slippery at times, but less daunting – and less exhausting – than the ascent. This I can do.

We are entering into a transition time in the hospital. As July approaches, the new interns – with fear and enthusiasm that now amaze me, although I was one of them only 24 months ago – are entering the realm of the hospital for the first time as doctors. A momentous occasion. But as I gaze at them, I realize that an insurmountable barrier has formed between us. How can I tell them what to expect? How can I explain to them how they will change in these coming years, how they will be challenged, and how hard they will be pushed – emotionally, physically, and intellectually? No words or experiences will do this journey justice. It is very much an individual journey – shaped by our unique encounters with patients, physicians, and one another.

Earlier this year, I used to approach my drive to the hospital with dread. But now I approach my drive to the hospital with a sense of wonder. I understand, sadly, that I will not be able to save everyone who rolls through the doors. But I am confident that I will be able to make a difference in the lives of my patients. I am confident that I will work to help people heal – and even to alter the course of their lives.

The sun shines on a downpour. Tears, regrets, the past trickle down into the drains. The grayness of the world is lessened by these rays, which boldly penetrate a place where they are unexpected, but where their warmth – and persistence – are always welcome.

Trauma

It is the title of this month’s rotation. In practice, it is more than that. It is lives changing in an instant. It is the careless slip of the wheel beneath a distracted driver’s hands, the slightest swerve of a motorcycle to avoid a bump in the road. It is lives that will never be the same again. In the hustle and bustle of daily life, it is easy to forget how quickly the world spins into catastrophe.

A young girl, without a seatbelt, drives into a tree and is now unable to move her legs. An older gentleman, riding a motorcycle without a helmet, no longer remembers what year it is. A high school athlete, driving drunk in the middle of the night, now lies in the hospital incapacitated – three of his limbs splinted, immobile. A pedestrian, in a moment of impulse, runs across the street and is hit head-on by an oncoming car. He does not survive.

Trauma. It strikes at all hours of the day and night. It happens in the blink of an eye, and the world shifts permanently.

Do not drive drunk. Wear your helmet. Do not get distracted by the moth in your car. Do not text while driving. Do not eat while driving. Do not let your anger get the best of you – pull over, cool off, then continue on. Do not let anyone interfere with your concentration. Do not get in the car with an unsafe driver. Do not take your seatbelt off 30 seconds before the car is parked.

Always, always wear your seatbelt. Never, never let your eyes leave the road. Do not take this 5 minute trip home for granted. Do not assume that you will be saved. Be safe. Take care of this fragile, precious vessel – the human body. It is not as durable as you might imagine, or wish.

Perhaps we do not educate children enough about the importance of these messages. Perhaps it would not make a difference.

We will never have the chance to exchange our bodies for another one . The spinal cord does not fix itself. The brain does not heal so easily. Our eyes – they are our once chance at vision on this earth. Do not forget these things. Remember them, act on them, before it is too late. There is no second chance.

The Downsides of the Emergency Room

An article published in Smart Money on January 24, 10 Things the Emergency Room Won’t Tell You, discussed some of the downsides to emergency room care. I will tackle these claims one by one.

1. Patience will get you nowhere.

The emergency room is a busy place, and it is generally true that being clear about your symptoms is important. However, patients are generally triaged by experienced nurses and physicians who are particularly attuned to the dangers mentioned in the article – shoulder pain, for example, should not simply be disregarded because it is not chest pain. The initial workup, including an ekg to analyze the rhythm of the heart, will be performed immediately for patients who are in high-risk groups based on age, gender, and other predictive factors. This ekg will be interpreted by an experienced physician. The moral of the story? Be clear about your symptoms and alert the triage staff if there are any changes in your symptoms.

Patience will get you somewhere – it will get you, even if it takes time,  to the emergency room. Although waiting can be frustrating, if your condition was serious enough to bring you to the ER in the first place, then it is probably serious enough to warrant waiting for a complete examination by a physician. Although some conditions will not cause death or serious consequences in the first few hours, many of these conditions can progress to cause serious problems in the next 24 to 48 hours. Thus, the wait may very well be worth it. It is your health, after all, and it is better to err on the side of caution.

2. There’s a cheaper option down the street.

Urgent care centers, if they are open and are conveniently located, are certainly an alternative worth considering. They are especially good for straightforward medical problems, such as lacerations or sprains. It is true that the ER does not offer extensive information on cheaper options, other locations, or alternatives to ER care – we are there to take every sick patient who walks through our doors and to treat them as best we can. That is our primary focus. And we certainly do not want any patient to feel that we are turning them away just because their condition can be treated elsewhere. Furthermore, many ERs now have urgent care centers as part of the facility, where patients can be seen and treated by physician assistants.

3. Bring a book.

Excellent idea. I could not agree more. Waiting – to be seen, to be treated, to receive test results, or to be admitted to the hospital – are all part of the normal course of things in the hospital. Bring a book, a magazine, music, or anything else that will keep you occupied during this time.

4. Come back in the morning.

Be careful on this one. We have many patients who decide to wait until morning to come to the emergency room – and by this time they may have already been trying to “ride out” a heart attack, aortic aneurysm, or other life-threatening condition for several hours. Although the wait may be shorter in the morning hours, if there is a possibility that you have a life-threatening medical condition, you will be seen quickly at almost any hour of the day – this is the main purpose of the ER. And ultimately, experienced nurses and physicians are better equipped than you to decide how serious your condition might be – patients often underestimate the gravity of their symptoms.

5. We might make you sicker.

This is not any more true of the ER than it is of the hospital. In fact, the case used as an example in the article was of a patient who was admitted to the hospital and underwent surgery – her complications are likely not associated with her ER visit. However, it is true that hospitals are places where infections can spread. As a result, hospitals have been proactive about placing Purell dispensers outside almost every patient room in the hospital. They have also been proactive about instituting hand-washing measures with rewards and punitive measures for physicians, nurses, or other hospital staff based on overall performance. In the ER, we are especially attuned to the potential spread of infections. During the 2010 H1N1 outbreak, many ERs were so cautious that they required patients, visitors, and physicians to wear masks if there were signs or symptoms of flu (fever, chills, cough, and the list goes on).

6. To us, you’re like a lab rat…

I don’t think ER physicians would bother to do such extensive medical workup on a lab rat. And most of these tests are not invasive. The “workup” for chest pain involves blood tests, an ekg, a chest x-ray, and possibly the scheduling of an outpatient stress test if everything checks out – not an unreasonable test, I would argue, for any middle-aged person who has chest pain. Many people have chest pain, but chest pain that is serious enough to bring you to our doorstep – the ER – is taken just as seriously by us as by you. As for unnecessary testing, refer to Defensive Medicine Supersedes Quality Medicine. This is one of the problems at the heart of medicine in this country, and it is a problem that we must fight to overcome.

7. …but don’t expect us to figure out what’s wrong.

This is generally true. In the emergency room, we determine if your condition is life-threatening or if it needs urgent intervention. We decide if you need to stay in the hospital or not. We elicit certain important characteristics about what is wrong, but we cannot necessarily give you a diagnosis in the brief time period that we care for you. In the end, however – and this goes back to the title of my blog – much remains a mystery in the world of medicine and human health. Many conditions will take months or years to diagnose, and other conditions will never be given a formal diagnosis. Many conditions necessitate extensive testing or knowledge of symptoms over long periods of time – information which, for purposes of time and money, the ER is simply not equipped to obtain. But even after all the testing has been done in the outpatient setting, physicians cannot always come up with a diagnosis. This is one of the great frustrations of medicine.

8. Good luck seeing a specialist.

This is completely dependent on where you go. Furthermore, many conditions necessitate being seen by a specialist in the next few days (especially orthopedic injuries, hand injuries, and urologic issues, which are all mentioned in the article), and in these cases you will be referred to the appropriate specialist in a specific time range. Ultimately, these referrals may delay but should not compromise the quality of  your care.

9. Your doctor can get you priority access.

If you have time, alerting your physician that you are going to the ER is a good thing. However, there has been a trend since the 1960s that private physician like to rely on ER physicians more and more, and many private physicians no longer come to the ER themselves. If they are willing to, they serve as an invaluable resource – after all, they know you far better than the emergency physician who will be treating you.

10. You can choose your doctor.

There are two different points made here – one is that you can choose to see your own specialist in the ER. This is generally true if he or she is affiliated with the hospital in some way – otherwise, as in the previous point, it is difficult to get a specialist to see you in the ER if he or she does not have an established relationship with you. In fact, ER physicians often view these people as a valuable resource – even if they do not come in to see you, we make a point of calling them to obtain important medical information.

The second point is about ER certification. The article cites statistics by the Institute of Medicine that 40% of ER physicians are not board certified in emergency medicine. It is almost ironic – and a good thing – that being board-certified in EM is now the gold standard. As recently as the 1990s, it was commonplace that physicians trained in medicine and surgery ran the ER without any emergency medicine training. With the rise of ER residency programs, which began in the 1980s, we are finally catching up with the nation’s demands for board-certified ER physicians. EM residency programs continue to expand, and the requirements for full-time ER positions are becoming increasingly stringent. This is a positive trend, and I hope it continues well into the 21st century.

Emergency medicine is an invaluable part of medical care in this country, and it is important that we fill our emergency rooms with physicians who have the diagnostic skills and the proper training to recognize sick patients, to stabilize sick patients, to save lives, and to devise for all patients who walk through our doors the appropriate disposition plans that will optimize their care. Thus, in spite of some of the flaws of the ER and of the hospital in general, it comes down to risks and benefits. Do not let some of the downsides of the ER turn you away – the consequences of avoiding the health system, however unpleasant it may be, can be devastating.