GSW to the head ..

.. was today's highlight, for those of you who do not live in New York, a GSW is a gun shot wound. This was one of the few times we actually heard "trauma code" instead of "trauma alert" on the intercom. The patient's heart was beating though, he just had to be intubated. Skriehma and I were just watching, by the way. It appears that the bullet may actually have missed the guy's brain and just went through the maxillary and occipital bones tangentially to the cranial cavity.

A few hours after that I went home early because I wasn't feeling so well. I just wrote an e-mail to our receiving attending that I was absent for the last five hours of the required fourteen today and appended some feedback on the rotation to try and appease him. If you're interested in what I had to tell him about the rotation so far, here it is.

Feel free to skip this part if you are short on time, they may be a bit elaborate (i. e. I've rambled on forever). These are just my views, not necessarily *edit*skriehma*edit*'s.

In the beginning - naturally - there has been a lot to adapt to. There's hardly anything that I did NOT have to be shown how to do. Mostly not because I had never done it before, but because so many details, that anyone accustomed to US hospitals would probably hardly notice, are different from what I was used to. Starting with the charts, obviously. But I presume those even differ between specialties. Then take this plethora of abbreviations. To someone who has always been taught that abbreviations are to be avoided wherever possible in documentation (a typical German chart contains maybe half a dozen abbreviations, three of which translate to "BP", "HR" and "RR"), reading something like "(...) HEENT: PERRL, EOMI, MMM s lesions, (/)LAD, (/)JVD (...)" seemed cryptic at best initially. By now I use these little acronyms amply myself - I may even miss them back in Germany.

Another thing that needed quite some getting-used-to was the fact that everyone seems to be using brand names around here. Residents, especially the ones that are not privy to the fact that I usually live and learn in Germany, look at me with big round eyes and a puzzled expression when I say things like "what the heck is Tylenol". Granted, Tylenol is a special case, since no one among the three Germans here have ever heard of "acetaminophen". After minimal research, I found that acetaminophen is synonymous to paracetamol, which is almost as widely spread in Germany as "Tylenol" seems to be here. But who would have guessed that this ominous "Motrin" and/or "Advil" is just plain old ibuprofen, "Ativan" is lorazepam and "Reglan" simply metoclopramide? And it's not that we never use any brand names .. apart from maybe Aspirin and Valium those are just completely different on the other side of the Atlantic, ibuprofen for example being sold as "Dolormin" (among many others), or "Versed", a.k.a. midazolam, is widely known as "Dormicum" in Deutschland.

I've also never used retracting needles before, never seen a hospital carry "saline locks" and your IV fluids come in bags instead of plastic bottles! When I was asked "you have started IVs before, right?" on the first day, the natural and honest answer that came to mind first, "more than I can count", would have led to the resident marching off with the words "great, start one on the patient in bed 3". When I was forced to say "I don't even know where the equipment is and which ones of those gadgets I need" I got that same look with the big round eyes again. After the first few dozen IVs here it seemed natural as well though. Thankfully, suture-, central line-, foley kits and the likes contain very similar, if not identical stuff that feels like home.

After these first little hurdles were taken, a few bigger ones remained, some of which I'm still working on. Knowing only German, French and a certain amount of English doesn't get you very far with distinct parts of the population here, obviously. Thankfully I'm apparently not the only one with that problem and the use of interpreters is rather widespread, if cumbersome and IMHO detrimental at times to the relationship with the patient and the flow of information. For example, what was apparently described as "(localized) pain below the beltline" by the patient arrived via detour in my ears as "belt-like pain" and if that had not been cleared up I probably would have stared in disbelief at the low amylase and lipase for the rest of the shift.

Naturally, patients are still amazed that I don't know any of the clinics and/or general practitioners around New York and I still ask them to spell the name for me when they say their PCP is "Dr. Quetzacoatl-something".

Another issue unsolved to date - and I don't know whether this is solvable at all - is that the amount of patients I see, procedures I do and things I learn appears to correlate significantly (p<0.05) with the residents I work with. With this regard I have to mention the residents Dr. D F and Dr. G P, who have been incredibly forthcoming in teaching me the more practical and hands-on aspects of emergency medicine. Dr. M S and of the attendings Dr. G have made great efforts elaborating theory amidst the intermittent chaos of the two EDs. That said, I am now at a point where I'm not new enough to require initiation to everything anymore, yet also not comfortable enough to handle all aspects of patient care, especially communication with other departments, consults and the likes. I'm also still not quite sure what degree of independence I am entitled to and/or is expected of me. Today, for example, the couple of hours that I did work in ED1, the residents and I knew each other by sight, they knew that I had worked here for a while, so there was no introduction that went beyond a first name. It may be partly attribuable to the fact that 1pm and 3pm shifts start right in the middle of the busy ER-afternoon, where residents are balancing three or four patients. Neither did they know what I could or could not do, neither did I know what they expected of me. Especially during the times when there were no new patients to be seen and I had no "designated" resident to follow, I didn't really know what to do with myself except copy and start reading the next two chapters of Rosen's. May have been a deficit in communication on my side, but I felt it was hard to grab and stop one of the residents to tell them my story from the beginning and ask him/her if they could .. "relieve me of my boredom", so to speak, by giving me something - anything - to do.

Allright, if you are still reading these ramblings I must congratulate you for your patience, which I will no longer tax.

Now I'll eat something and then go to sleep to try and get rid of the sore throat, headache and temperature that I of course had to contract.

Girls .. DO NOT READ

Especially not Phèdre and cute people from Cologne .. allright? Don't read. No, I mean it. Do not read this post. Yes this one. You can read the next one.

Are you still reading?

Good. Because we were greeted by a mouse, a cockroach and a fly today coming home. Now it actually feels like home.

Good night!

Howdy folks,

I'm still here too! Was a bit distracted lately, but not to worry, I think I remember most of the past couple of days.

Like for example a certain male member of our party (hint: it's not me) redecorating the apartment with what he calls "a reasonable amount of socks". I'll let each of you be the judge of that.

Next, let me show you a typical day in the life of that other member of the party, let's call her SurgiGirl, for anonymity's sake. Here's SurgiGirl on Saturday after 11 hours of sleep.12 hours.12.5 hours.

When she did crawl out of her room, her first stop was the fridge, which she raided for pretty much everything - fruit, cereal, bread .. you name it, she had it. By the way, from that point on, the following has been known around here as a Phèdre-rest.

We didn't see much of SurgiGirl again for a while.

Until there was more food.

I'm sure you can discern the pattern now.

We did manage to resuscitate her enough after that to hit the town again.We had a target, "Hogs & Heifers" in the Meat Packing District, which after some erring around the city we indeed found. And the cute resident had not promised too much - there were half-naked women dancing on the bar, which according to some sources gave rise, inspiration and a template for the movie Coyote Ugly, if that rings a bell. For some reason, SurgiGirl was hesitant to enter it, so we wandered around the blockand found a nice lounge with pretty people insideand $7 a beer. What the heck, we were there to get drunk, no matter the cost.So we did, yet at another nice place, where caipirinhas are 80% ethanol.

I need to add a disclaimer that may save my life (although I don't count on that).

All characters and situations depicted and/or described above are fictional. Any resemblance to persons living, dead or soon to be dead (me) is purely coincidental.

In other news there's another event from Sunday's late shift that comes to mind, where a 20-year-old girl either had smoked too much or the wrong kind of weed and was totally out of control. So far nothing special but what dropped everyone's jaw was her ability to punch, scratch and bite after a dose of benzodiazepines that would have put an elephant down. So this was the second almost-LP I did, with the delirious girl almost jumping off the table when I just cleaned the skin for the local anesthetic. And she had 12mg of midazolam and 5mg of diazepam inside her little 50kg-body, it still took an attending, a resident and me to pin her down so she could "only" twitch by about 10-20cm, while another resident poked into her for the spinal tap. Amazingly, he did hit her spinal canal and managed to catch about half of the CSF pouring out while the "patient" was fighting a desperate battle, where no scratching, bending fingers or biting into physicians was off-limits. She did manage to bite Chris Tucker. And he was a bodybuilder before he went to medschool.

Highlights of the day

I'm not quite sure which was my personal highlight of the day, there are two close competitors - a case of post-partum thyreoiditis and my first pericardiocentesis. The latter was in the course of a resuscitation attempt on an elderly woman that skriehma took part in as well. He cheated his way out of ped's ER boredom by just pretending to have gotten "stuck" in ED1. Yeah .. whatever :) . The little old lady (who at least in my opinion never stood a chance) apparently lost breath sounds on the left (although they weren't really regularly checked, may as well have been a misplaced tube) after I stuck a needle through her diaphragm, pleura, maybe lung and pericardium, so skriehma got to stick two needle thoracostomies into her. I think I also broke at least two of her ribs during CPR. She curiously had PEA during most of the resuscitation and was shocked when she went into V-Fib, but eventually didn't make it. I don't think anyone ever expected her to though. I don't know any of her history, but she looked asthenic, may have had a consumating illness, maybe malignancy. There is a reason these people go into arrest - and after 30 minutes without adequate circulation it is not likely to have gotten better to the point where the heart suddenly decides to start going again. Unlike young people who stumble into a cardiac arrest, these people have used up all their reserves. Compensation mechanisms, for example to tolerate acidosis or hyperkalemia were running at maximum already before the arrest, the latter being the result of just these mechanisms failing. I'm not saying we shouldn't attempt to resuscitate these people. But I guess that's the reason why everyone including me thinks the chances of meaningful recovery are very slim.

The other highlight was a woman who was actually there for acute abdominal pain. Among her copious history were only two clues - delivery of a healthy boy three months ago and she noticed some hair loss four days ago. That seemed reason enough to add a TSH to the labs and bam! 15.59! Yay!

Hooray!

Just charmed the secretary of the ED into giving me two of those pretty coats that say "Emergency Medicine" on the sleeves. The name of the actual recipient had been misspelled on them. Now I have to try to get that stitched name off ..

Oh and ped's ER today was slow but OK. I started seeing patients on my own. Again, they (fortunately) weren't extremely sick, at least not as sick as their mothers usually would have you believe. Quite a lot of gastritis actually. Hope it's not a virus.

Now I wonder whether I should bug Mr. Murray again already that I asked about tuning the piano in the Braker Building yesterday. I really hope he has it tuned soon because I have cravings for piano keys.

And another thing .. everybody keep your fingers crossed from now on until 12pm GMT+1 (6am EST) tomorrow for a smart and cute girl from Cologne going through biochemical hell. You go girl!

That's all for today folks, have a good one.

This post is going to be heavy on the pictures again. After our long, hard day from 7-12 (wink at Phèdre), we felt we needed another vacation, so we got our tourist gear (cameras) and took the subway to South Ferry, where we boarded the Staten Island Ferry.Just in case you're wondering, this is the skyline of Manhattan.And this is city hall.Now this is Wall Street, the golden letters above the big flag spell out "NEW YORK STOCK EXCHANGE". I wonder if that building is important, they did have a lot of security around. What do you think, Phèdre?Here we are on Brooklyn Bridge, which leads from .... Manhattan .... to Brooklyn. How sweet it is!

Update!

Since time is scarce (tomorrow is quiz-day again) and I don't remember everything anyway, I'll just ramble a bit.

Yesterday, ped's ER, was quite uneventful. The huge place (for a "specialized" ER in my opinion anyway) started crawling with residents around 11am, seemed very overstaffed to me in light of the low patient count. Cases were remarkably benign, a few bumps and bruises, asthma, some diarrhea and mild infections. Highlight of the day (for me anyway) was a child with surgically corrected tetralogy of Fallot. Not for the diarrhea he presented with, but because I had never seen an actual Fallot patient before.

I switched with skriehma today, went to ED1 leaving ped's to him. Interesting things today that come to my mind were .. hmm .. the cardiac arrest that was called in but never arrived. We were all assembled, ready to resuscitate, standing there for a few minutes, until people started to trickle off taking care of other stuff. The resident who was supposed to intubate stayed the longest, but eventually gave up as well. I did not find out what happened to that ambulance by the end of my shift.

Interesting as well was a scene that I at first only witnessed from a couple of meters away. An obviously agitated woman was yelling at one of the residents, asking to be let go. She wanted to go home. Said she had to be there at five to take care of her kid. Sounded logical, although yelled a bit loudly. The resident, inside the center desk area, protected by one security guard, another one was circling the patient, told her in a similarly loud voice that "if she was reasonable", she could be let go in three hours. When the patient didn't accept that, he told her that she could either wait calmly for three hours or be physically and chemically (with Lorazepam) restrained and stay for twelve hours. In a country where people can be brought into the same ER totally plastered every night and still have to be let go whenever their alcohol level permits, only a drug or definitely diagnosed psychiatric condition could elicit the resident's behavior. Since psychiatric conditions usually don't go away after three hours of observation, it had to be drugs. And it was. When the resident asked me to provide "some muscle" to pin her down for an IV (which was unnecessary, since she eventually did cooperate), he told me what her story was. She had been found unconscious with a respiratory rate of five, apparently pumped full of heroine. The thing that kept her alive and awake was naloxone. With its short half-life, a three hour observation actually seemed pretty short. And who knows if she actually has a kid. If she does, it is sad that no one down there has the means of getting mom away from opiates and her kid out of that milieu.

Time for another picture post!

Here's our search for a place to drink, get drunk and pass out in.
This is us pretending to be tired:Just in case you can't read it, the shirt says New York Princess.

... in other news ...

... we have tried and failed to find a bar that we could agree on going into. In order not to go home empty-handed after about 2.5 hours of running around the city we did buy several tourist items, including more than half a dozen t-shirts and two "bronx"-cups.

I have now via mail requested assistance by the cute chief resident who has offered to be our (or my?) nightlife guide before.

Skriehma and I are required to do 10 shifts in the ped's ER, so today I am trying to do my first. After normal rounds in ED1, I went there to find the place huge, but empty. It opens at 8am, but there was only one attending, who wasn't going to take care of me, so she told me to wait for the resident, who is supposed to come at 9, which is in five minutes. So I'll stroll over there again and see if s/he is in sight.