So much to tell ..

.. so little time. I knew this point would come ..

Now I'm in that well-known position again where there's so much to do (in this case: write) that I don't know where to start - so normally, I just wouldn't.

I will try to circumvent that problem by deciding I'll just write whatever pops into my head first, without any aspirations of a complete or ordered report. I also don't have any pictures yet. Decided not to bring my camera to work yet.

Hmmmm. I don't think I want to even start talking about yesterday, our first shift in the ER. There were too many new impressions, so any accounts here are likely to be either hopelessly incomplete or they'd wreak havoc on your internet connections.

So we took our first Rosen's quiz today. Interestingly when we entered the conference room this morning at close to 7 am (after yet another free breakfast at the cafeteria), more than half a dozen residents were already sitting at the round table with the same copies of Rosen's chapter 115 that skriehma and I had been carrying around. So that was veritable last-minute cramming right there. The 10-point exam was rather tough - but I guess it had to be, seeing that everyone had just read that 20-page chapter. A few of the questions were not fair objectively. For example you could see that the author wanted us to have read that Rosen writes a neutrophil count of <500/mm^3 is life-threatening. So in one of the multiple-choice questions we were supposed to regard the statement "neutrophil counts of 500-1000 can (!) be life-threatening" as false, which of course is bogus. Virtually anything CAN be life-threatening. Like walking through the Bronx. Of course that's variable (12pm vs. 12am for example), but a question like that would be ripped to shreds in any board exam. There were a few more questionable answers in there, but since you had just read the chapter you could sometimes guess, like in this case, what the author of the questions was trying to squeeze out of you. After that came the department meeting, where the head of emergency medicine actually criticised some wrong decisions of his staff that they had made in the past - but you wouldn't know that from walking by since everyone in the conference room held their bellies laughing while he did it. The head of the ED presented - or retold - mistakes like a stand-up comedian would. I'm not sure everyone quite got the severity of the situation when physicians in a level one trauma center fail to x-ray the cervical spine of a cyclist who got hit by a car, though. But I suppose the residents and attendings are aware that even though their chief and themselves were laughing, he actually had a message. He had quite a bit to say though, I think the department meeting took close to an hour. Dr. G., our "receiving" attending, spontaneously gave a case report after that, when the person scheduled to do it couldn't because the beamer wasn't working. Dr. G. also proved to be a very entertaining public speaker, but you noticed he had a strong foundation in facts and numbers and much was to be learned if you listened closely. That lasted about another hour. One of the younger residents presented one of her cases after that - she did a nice job and nobody thought of the right diagnosis in the differential until shortly before CT scan, when I unfortunately said "neurocysticercosis" so softly that only the people around me could hear it, little did I know that two minutes later we would find out it actually was NCC and only Dr. G. had said it out loud after me. A shame, since skriehma and I were actually quite up to date on cysticercoses, after all we discussed it in-depth in House Club 101. Oh, we did learn that some of the ER docs watched House as well.

So then it was noon and we went over to the cafeteria to eat. The food is really pretty good over there. I'd probably pay for it if I had to ..

Well. Maybe I should lose a few words about yesterday, just in case I'll forget and will be interested later. My first "own" patient had been - what else - assaulted in the Bronx. But that was actually two weeks before. For whatever reason he had chosen not to see a doctor back then and now presented with pain from his rib contusions and (as was later apparent on the x-rays) broken nose. Michelle S. MD, chief resident with exceptional multi-tasking abilities, was who I presented my cases to usually. She is much fun to talk to, very glib, with an excellent bed-side-manner. She hardly ever does less than three things at once though - and teaching and/or explaining wasn't usually one of them, although I believe her claims that she would have liked to do that, if the rack wasn't filling up with patients by the dozens. So like in any German rotation, there wasn't really much guidance for what exactly I should do.

That's not usually a big problem in Germany, since you know many of the "elements" of daily work rather well. I mean little things like the charts you write your patient history and findings of the physical examination on. Or the syringes, tubing, containers, catheters .. you name it. Of course they use different models here. Actually nice ones with retracting needles that make it harder to stick yourself with. Problem is just that I don't recognize them for what they are at first glance since I'm not used to them. So even though I have put in many IVs before, I can't answer "yes" when they ask me to "put a line into that guy". But I've spent a few minutes with the supplies and should be able to find all the stuff I need now. The problem is though that when they ask me to do stuff (and they haven't asked for too complicated things here), I usually know how it's generally done, I just don't know how they do it. Of course I can take a history, but I had no feeling for how thorough they do it in the ER or even where I should take my patient to for that if all the beds in the department were full (and they were). If I hesitate then, I can't blame them for suspecting I'm taking on more than I can handle. But I don't feel that I am. Like when another resident gave us a tour of the ED the day before, pointed at a box and said "there's the CBG". When we asked "the what?" he shortly looked at us with an expression that seemed to say "don't they teach you ANYTHING in Germany?" and then went over to the box and opened it. We saw the very familiar shape and configuration of a machine that measures blood sugar and there would have been nothing more to say except maybe that CBG is short for capillary blood glucose. But it was hard to keep that resident from explaining how the machine works now that he thought we had never seen it before. Same thing with the IVs .. no need to explain the whole principle from how to find a vein over handling the tourniquet up to puncturing technique tips, that's fine, I basically just needed to know where the needles are.

But speaking of CBGs - if you thought German physicians abbreviate too much, think again. This is what a typical (really! I'm not kidding!) history and physical examination could look like:
HPI: 28 y/o male BIBEMS c/o SOB + (R) cp with PMH of Asthma
98.5, 70, 15, 135/75
Gen.: AAOx3, WDWN
HEENT: PERRL, EOMI, MMM s lesions, (/)PLN, (/)JVD
Chest: CTA b/l (/)crackles or wheezes
CVS: RRR s M/R/G
Abd: soft, NABS, NT/ND, (/)HSM
Ext.: WNL, equal DTR b/l

Allright, since you asked so nicely, I'll translate.
History of present illness: 28 year-old male, brought in by emergency medical service complaining of shortness of breath and right-sided chest pain with past medical history of asthma.
Temperature 98.5°F, heart rate 70/min, respiration rate 15/min, blood pressure systolic 135mmHg over diastolic 75mmHg.
General presentation: awake, alert and oriented to person, time and place, well-developed, well nourished.
Head, eye, ear, nose and throat: pupils equally round and reactive to light, extra-ocular muscles intact, moist mucous membranes without lesions, no palpable lymph nodes, no jugular vein distention.
Chest: clear to auscultation bilaterally, no crackles or wheezes.
Cardio-vascular system: regular rate and rhythm without murmurs/rubs/gallops.
Abdomen: soft, normal active bowel sounds, non-tender, non-distended, no hepatosplenomegaly.
Extremities: within normal limits, equal deep tendon reflexes bilaterally.

Well they do have a point - it takes pretty long to write it all out.

I'm not even going to start talking about the "fish" shape they use to document some basic lab values. That is also because I haven't even started memorizing it yet.

Allright, enough strain on your bandwidth for one day I guess. It's also 8:30pm by now and Phèdre will most likely wake me up at 4:15am tomorrow. So I should grab some dinner.

Oh another fun fact .. one of Phèdres relatives called .. again. Just at around 9:15pm this time. And guess what - despite the fact that we had all been in bed at the time, Phèdre was the only one already sleeping and abruptly ripped from her dreams this time. That served as pretty good payback. Good night for now!