8-6 in the ED

I was on the 8-6 shift today and ended up working till about 7:15, and while every minute was worth it, it's left me with very little gas in the tank...and I'm working the same shift tomorrow, so some sleep is probably in order.  Sleepy as I am, though, I have to say that this is by far the best rotation I've been through to this point.  I love having as much responsibility as I do for taking care of patients and doing basically everything that needs to be done -- calling consults, looking at labs and images, reading previous records, and coming up with plans.  It's expanded my comfort zone tremendously -- I'm willing to make the call on some things now.  Granted, they're small things, but at the beginning of the rotation I'd have said "Hold on, let me ask the attending" rather than just saying "yeah, it's ok for him to eat" or "sure, since we're going to discharge her, you can pull the IV now."  Every day I'm learning, not only how to diagnose and manage patients, but how to improve and exercise my medical judgment -- and I'm learning to trust that judgment.

Today's kids were a varied bunch.  My first little guy came in struggling to breathe; once he got an albuterol nebulizer, he began to wheeze like crazy.  He was working hard, retracting, flaring, and his lungs sounded like junk.  He came in as a level 3 (moderate acuity) in orange pod; after a couple of hours with no improvement in his respiratory symptoms and deterioration of his general clinical picture, we sent him to the red (high acuity) team; they told me later on that he had ended up being admitted to PICU.  Poor kid...I just hope he maintained sufficient respiratory function to avoid an ET tube.  The second kid, a girl, came in with abdominal pain that she'd had for the last two weeks.  Her story was kind of scary, involving intense, rapid-onset abdominal pain for several days that suddenly became much better; it stayed that way for a day and a half before the pain began to resurface.  All the medical people reading this are now wondering if she had ruptured appendicitis -- but her exam was fine.  Mild pain and tenderness in the right lower quadrant, but nothing serious, and no decreased appetite or anything like that.  So we sent her for an x-ray.  Final diagnosis?  FOS -- Full Of Stool.  Her colon was pretty backed up from the looks of things, so we gave her  a decent-strength laxative and sent her home.  Then there was the young lady who came in with abdominal pain for a month.  I'd tell you her story except that after history, physical, and several tests, we're still no closer to figuring out what's going on.  Almost as frustrating for me as for her.  The only other interesting case of the day was an energetic little guy who looked absolutely peachy.  Mom said he'd had an asthma attack yesterday and she had taken him to the doctor this morning; they did an exam and sent him over to Children's for a chest x-ray.  I was frankly wondering what they were thinking.  The kid was afebrile and looked like a million bucks.  And then I listened to him.  His right lung was ok, but his left lung had textbook crackles at the base.  I mean, they were absolutely perfect, exactly like the sounds they record for the training videos and such.  So we got that CXR, and sure enough, even though he didn't appear to be the least bit sick, it showed an apparent pneumonia (although the radiologist read it as a right lung PNA, which didn't correlate with the clinical findings -- looking at the film, though, I could see what they were looking at).  So he came in for asthma and left with a 10 day prescription for antibiotics.  Also interesting was the fact that after he got a breathing treatment, his wheeze reappeared and his crackles became much more pronounced.  He still looked great, though, and we ended up discharging him with his meds.  (I saw two other patients as well, but there wasn't really anything interesting about either of them).

So yeah, that was the day.  I think I still owe a description of Monday; hopefully I'll get to that at some point.  In the meantime, though, I'm going to bed, so until next time, peace and God bless!