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!

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!