Lessons learned

Ok, so for everything I did right today, I made at least two mistakes.  I've definitely got a lot to learn.  One of the things I learned today is that attendings are attendings for a reason, and when you disagree with them, prepare to be proved wrong.  Twice today I was surprised by the conclusions and management plans of attending physicians, and both times it turned out that their "gut feeling" had caused them to interpret the evidence correctly (even though my explanations seemed more obvious).  [Also I should point out that I wasn't stupid enough to SAY anything in either case...good thing, too.]  First case was a little kid who had been in a couple of days ago after lacerating his eyelid with a colored pencil.  He had a superficial lac and was sent home with some erythromycin ointment (that's an antibiotic for the non-medical folks keeping score at home).  Today he came back because his eyelid was swollen shut.  And I mean SHUT.  It took four of us to hold the kid down that the resident could peel back his eyelid and the attending could get a quick look at his eye.  Still, though, his eye was moving ok and didn't look super-bad, and when we weren't poking at him the kid was in a pretty good mood, so I figured the attending would give him a dose of IV antibiotics (probably clindamycin as the kid had a history of drug reactions to penicillins), observe him for a while, and probably send him home on PO ( = oral) antibiotics.  Thus, I was fairly surprised when she said "You know, I wasn't able to get a great look at the eye, and I don't feel comfortable sending him home.  I think we should get a CT of his orbit to make sure there's nothing going on there."  I mean, it's a textbook superficial cellulitis, right?  ...not so much.  An hour later, I ran into the resident in the work station.  "You're not gonna believe this," she says.  She pulls up the CT, and there in the kid's orbit is a decent-sized lesion.  Apparently some of the lead from the colored pencil had embedded itself in the orbit.  Last I heard, he was scheduled to go to the OR with ophthalmology.  Bit of a turnaround from wondering if we could send him home, and my first lesson on the ability of the attendings to integrate experience, "gut" instinct, and data to arrive at the proper course of action.

The second case involved a teenage girl with abdominal pain.  A resident and I saw her together, and when we came out, we were pretty confident that it wasn't appendicitis.  After all, her pain had been getting a little better rather than worse, she was eating and drinking fine, and her obturator and psoas signs were negative.  So we were talking about ultrasounds and other testing for ovarian pathology and the like.  I presented our findings to the attending who listened attentively and then went to do a quick check of her own on the kid.  She was back five minutes later.  "I think this kid has appendicitis."  Again, I was skeptical.  Again, I was wrong.  As the day progressed, the girl's pain went from midline to right lower quadrant and it didn't improve.  She began to display rebound tenderness and her white count was elevated.  By the end of the day, it looked like pretty classic appendicitis.  Attendings 2, SL 0.  Once again, an integration of multiple sources of insight allowed the attending to reach the correct conclusion even before all of the data was in evidence.

Still, though, despite my stumbling and bumbling, I had the time of my life today.  I started picking up and following patients on my own (a 1 year old with possible dehydration + asthma-like symptoms and a 5 year old with a supracondylar fracture [translation: broken elbow]), and realized that I actually have the tools to be able to do this successfully.  It's a gratifying feeling to realize that even though I still have so much to learn, I'm already in a position where I can be successful in patient care (albeit with a little guidance).  I can't tell you how excited I am to go back tomorrow!  This is going to be a great month, and I'll be looking forward to every single shift.

Anyway, that's all for now...back tomorrow with more tales from the ED.  Till then, peace and God bless!