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.