Friday night

It was really by the amount of people still pouring in at 2am that I realized it must be a weekend night.

I'm sitting on the sofa with the notebook in my lap in the abandoned apartment I just returned into. When I came home, light was burning in the living room, a half-full glass of milk, the bottle of milk, a bottle of juice, a half-full glass of water and a tomato were on the kitchen table. It seems like people left in a hurry. The milk was still cold, so it couldn't have been long ago either. If they ever return, I may find out what caused their flight. Oh and if you're wondering why I didn't come home with skriehma - that's because I stayed behind to play piano again.

But back to yesterday's, our last Friday-night-shift (sniff). Started out by having one patient signed out to me by the late shift's medstudent, a 41 y/o HIV+ F with coughing x1wk. She already had a bed upstairs assigned so there wasn't much for me to do.

My first own patient was a 56 y/o F c/o a sudden-onset, burning abd. pain to the RUQ (right upper quadrant) x3d, which has not been getting better since, only worse with movement or palpation. She had visited the ER four times this year before for the same symptoms and was scheduled for a CT in a couple of days. She also vomited once that day (which was still Friday). Currently she had no n/v/d, no fever, no chest pain, no urinary changes, just a headache x1d. After we ruled out most emergent causes of her pain with the clinical exam, labs and a chest x-ray and when her pain responded to medication, we discharged her recommending follow-up with the clinic for possible gall stones. Actually this is what I find to be one of the best parts of working in the ER - all you have to do is find out whether the patient has something serious, if so, treat him/her, if not, give him/her supportive meds if applicable and send him/her to see a doctor or clinic later. You may object that this actually implies chickening out of seeing every patient's diagnosis and treatment through to the end, because after excluding all that can kill the patient quickly you leave the delicate work of diagnosing and treating the correct underlying ailment up to others. But yes, I find it very pleasant to only have to make sure the patient presenting with, say, RLQ abdominal pain does not have an ectopic pregnancy, appendicitis, abscess, ovarian or AAA bleed, kidney stone or UTI (urinary tract infection) and whatever else can be serious enough before discharging them to have the clinic find out what the hell is wrong with them. Even though you are not diagnostically following the patient all the way through, you get to use your diagnostic skills on the subset of diseases made likely by the patient's presentation. This makes the hope of being able to identify and treat all "acute and relevant" diseases more realistic. Of course it would be nice to finally be able to tell the difference between all those annoyingly complex rheumatic diseases and become an attending in internal medicine - but I find it even more appealing to practice telling cardiac tamponade and tension pneumothorax apart (which an internist could, of course, do as well), yet at the same time being able to distinguish a hot appendix (surgical) from an ectopic (gyn), an abscess (internal) and a slipped disk (ortho/neurosurg) without having to call for a consult on every patient. Anyway, the 56 y/o was discharged, feeling well with Dilaudid (hydromorphone).

In between a few drunks whose chief complaints ranged from "what am I doing here" to "let me goooo, I'm sooobaaah", one of them finding the soft restraints we put on him kinky, there was a 68 y/o M nursing home resident who decided today to rip out his PICC (peripherally inserted central catheter) and to start yelling at people and a 39 (!) year old stroke alert whose entire left side went limp today after, as we later saw on the CT, suffering an impressive intracerebral bleed secondary to his inadequately controlled hypertension. After the resident's first intubation attempt I heard the familiar bubbly sound of blowing up the stomach, after relocating the tube strong breath sounds only on the right side but after pulling back a bit we were finally golden.

Then a 22 y/o M was brought in as a trauma code with a stab wound to the left chest and decreased breath sounds over that lung. You guessed it - time for a chest tube, the first one I'd see on a conscious patient. I usually got myself a spot on the trauma team (i. e. immunity from being chased away from the patient) by putting the IVs into patients. So I had a front-row seat watching the trauma resident cutting and sticking her finger into the guy's chest, judging from the screams a very painful experience - actually not so surprising though, considering they gave the lidocaine about 30 seconds to work before ripping through his chest. But hey, he probably did want to breathe and get his sats above 85% again rather quickly.

Shortly before our shift started, the ER staff had tried and failed to resuscitate a pediatric trauma code, 12 y/o F hit by a car while crossing the street. The reason I tell you this is because my next patient was the 51 y/o mother of this child who had a PMH of hypertension, which now, to no one's surprise, was exacerbated to 193/126 and a pounding headache. The resident actually asked me what I wanted to do and considering the circumstances, I pleaded for a Ativan (lorazepam) instead of Lopressor (metoprolol), which seemed a more causal treatment. I am by the way writing up and signing for medications myself now, usually, as in this case, running the proposed treatment and dosage by the resident or attending first though, since my trust in the convenience and ease of relying on my malpractice insurance is limited. The attending agreed with 2mg of Ativan and shortly after the nurse gave the medication I found the patient standing amidst what appeared to be family, friends and teachers of the dead girl who surrounded and questioned a police officer about the perpetrator of the hit-and-run. The poor officer's answer that she couldn't reveal anything about an ongoing investigation did not seem to pacify the group (she also claimed that she actually wasn't involved in the subsequent investigation, only the initial response and therefore actually didn't know anything). After I went back to ED1 while they were still arguing I never saw that patient again. She walked out with 2mg of Ativan in her, let's hope she didn't get behind the wheel of any car herself afterwards.

After another trauma code with a stab wound to the back this time (after bullet night this was stab night apparently) I saw my last "own" patient for the night, a 41 y/o M with chest pain and SOB (shortness of breath) that made him "think he was dying" - again - since he had a history of this for years now. Still did the obligatory EKG and cardiac enzymes on him, his EKG admittedly looked funky but was nonspecific for MI and I never saw the results of the cardiac enzymes, because they were looking for someone to suture a large laceration in ED2 and since I had nothing better to do at the time I took the job.

The guy had some AOB and recently put his fist through a window, making for himself the invaluable experience that glass, indeed, is harder than skin. He ripped open his forearm, wrist and hand over about 11cm, the laceration went down to the fascia but apparently missed any major vessels or nerves. Thus, I spent the last hour of my shift numbing up, irrigating, putting 18 stitches into and documenting the care of this wound in ED2, which turned out to be a wise decision since I was spared from the onslaught of apparently more than half a dozen patients who came in between 6 and 7am, but I also missed a code in ED1. That was the mother of a guy who rushed into the ER, stating his mother was in the car and had trouble breathing, "something was wrong with her". Sitting on a stool suturing in ED2 I could only hear what this guy said and later on deducted the mother at some point had a shockable rhythm since residents were yelling "clear!" in short intervals. Unfortunately, this code went like any other we have witnessed in the ER and the next thing I heard was the son crying and mourning. Skriehma told me later though that they were overstaffed with two attendings and three residents working on the code anyway and that there hadn't been room for us medstudents to do anything useful. Then after sign-out rounds came the much-awaited breakfast and piano for me.

By the way, after dodging everything in the past six weeks, I managed to get blood on my pants twice today, in two separate instances.

And my roommates are still not back now, at noon, the milk would have been standing outside for 90 minutes. Should I be worried?