Manch Medic’s post reminds me to ask: Any tips from EMers on transitioning to a week of night shifts? I’m incredibly excited to dive back into clinics with another ER month next week, beginning with a week of 10pm-6am shifts. Sleeping suggestions, napping suggestions, caffeine suggestions? Thanks in advance.
Clutch quote from an OB resident 3 weeks ago that’s still been bothering me, in reference to a patient with metastatic cancer who was in pain and needed a CT scan but was refusing contrast:
“I am so sick of these patients. Just suck it up already and deal with it. God.”
If you’re ever working with me, and I ever say anything as remotely cruel and disgusting as that about a patient, especially one with metastatic cancer all over the place, please, please, sock me in the gut, or slap me, or something. There’s ranting, and there’s bitching, and then there’s just plain inability to have any sort of compassion or caring for your patients.
I feel guilty that I didn’t speak up and put the resident in her place. Granted it was 3 residents versus one med student, but I wish I would take the right path rather than the easy one a little more often. Sigh.
I’m getting really sick and tired of the media’s portrayl of Cho as a mentally-ill individual and all the following of “leads” from his psychiatric hold and the fact that two girls complained about him to police.
People with mental illness– and that’s 1 in 4 of Americans –are NOT dangerous. Even schizophrenics, those with the classic disorder that comes up when someone says “crazy person”–are NOT dangerous. They are suffering, sick patients. Did you know that the prevalence of schizophrenia in the population is about 1%? That’s 2.2 million Americans. If schizophrenics are so dangerous, we should be expecting to have about 2.2 million more school or workplace shootings sometime soon. (t’s absolutely important that if people need treatment, they get it, and there’s follow-up to make sure they’re getting it.)
Are there exceptions to the rule? Of course . Was Cho a very sick individual? Absolutely. But if we take aggressive, radical steps against every student or person who gets evaluated or placed on a psychiatric hold, we’re going to be hurting a huge number of people based out of fear and ignorance–and wasting a lot of time, money, and energy in the process. Terrible things happen in the world, and I’m sorry World, but there’s not always someone to blame.
Mental illness often reveals itself in the late teens and early 20s, and it’s often genetic. It takes a terrible toll on patients–they go from functioning in the primes of their lives to becoming isolated, lost, and removed from the world that they know. Imagine for one minute that you’re schizophrenic. Voices from inside your own brain tell you things–they’re so real that your brain’s auditory centers actually light up as if they’re hearing things. They tell you terrible, horrible things, 24 hours a day. That you’re a terrible person, that the police are coming for you, that you’ve done something terribly wrong. Want to know why schizophrenics so often are wearing headphones or earplugs, or are singing to themselves? They’re trying to find some way to drown out the voices that speak to them all day long.
These people don’t need our judgment and punishment, they need our compassion and help.
While reviewing infections of the neck and complications of strep throat, I read about
PANDAS
, which stands for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
I hereby decree that all new Pediatric Syndromes must have similarly-cutesy acronyms. Like BUBBLEGUM or DUCKY or KITE or BINKY or BUNNY. Alternative spellings, like ELEFUNT, are acceptable.
(Not trying to offend anyone here, the name of the disease is cutesy, obviously the disease itself nor the patients it affects are being joked at.)
Have you ever read a comment someone posted on your blog, and then they double-dipped and turned it into a post on their blog, so you decide to triple-dip and post their comment from their blog from your blog back onto your blog?
I didn’t think so.
I’ve been meaning to follow-up on last week’s GOMER post , and Nick is just the inspiration .
I was intending to be snarky with my “Get Out of My ER” title, as I am far from the jaded, paternalistic assholery that would say such a thing. I got lots of great responses, everything from the short and sweet to the longer explanation to the scolding for ignoring a possible influenza to the “don’t do that you’ll just make trouble for yourself.”
I think Nick’s wins , or is at least the closest to what I try to do. I believe as ER professionals we’re not only supposed to evaluate, treat and determine dispo, but we’re also supposed to educate–all physicians are. We know the most about the human body out of the entire society, and it’s our job to not only provide education about the body, but also about normal and healthy.
This mostly happens seeing pediatric patients, and often it seems that the pediatric ER visits are frustrating for all parties involved: docs, nurses, staff, parents, and the kids themselves. Kids are, in general, healthy and resilient. And most pediatric ER visits that I’ve seen are in general, healthy.
These kids are fine. They have a cold, or a GI bug. They are eating well, peeing and pooping fine, they’re active and well-hydrated. Their vitals are all stable. Sometimes they have a fever.
These are kids that will, in general, do fine at home, or at the very most, need a sick child appointment at the pediatrician. It’s not an emergency. It’s not life-threatening.
Have things changed? Has it always been like this? If not, where’s this coming from?
The medicalization of childhood , where everyone is freaked out their kid has some killer nasty terrible disease?
Or how about the breakup of the extended family unit? When you don’t have grandparents around or aunts or uncles or friends with older children who can re-assure a parent, maybe they’ll take them to the ER more often?
Or lack of access to pediatricians? And maybe lack of health insurance? More and more patients tell me that the advice nurse in the pediatrician’s office told the parent with the kid with a cold and a 101 fever to go to the ER, since the pediatrician was booked solid for the day.
The “I want it now” culture? An inability to just let a child be sick for a week or 10 days? An inability to be patient?
Cultural norms? I read somewhere that seeing a doctor in Latin and South America generally means spending hours in a waiting room, so it’s perfectly normal to just go to the closest, most accessible doctor instead of calling one’s pediatrician to schedule an appointment.
Lack of education about what are normal things for a sick kid to do, and what are abnormal ones? Maybe it’s just that the population has grown, and we haven’t kept up to provide the resources to educate them all?
Sometimes I wonder if it wouldn’t be more efficient to have the triage nurse take a kid’s vitals, and watch the kid in the waiting room, and if he or she looks fine, suggest heading to the local clinic–the wait is probably shorter, anyway.
(All of this is spoken from a non-parent of course.)
A call to all the ER docs out there: how do you tactfully, non-insultingly tell patients who come in with minor complaints, “You’re fine, go home, this is not an emergency, you should not come to an ER for a problem like this?” (For example, kid with a cold and low grade temp who is otherwise playful, active, eating and drinking well, with good sats, etc.)
They always tell you the first thing you should always do when looking at an imaging study is verify the patient’s name and date of study.
Today I got nice and burned by it, but luckily the attending caught it. Nothing deathly serious, just a stupid, stupid mistake, which I will not do again.
As I’ve always said, I’d much rather make stupid mistakes as a med student than as a doctor.
While a somewhat amusing look at med student clerkships like Medicine , Pediatrics , and Ob-Gyn , I’d be doing a disservice if I didn’t say that I felt like Panda took the wrong approach to clinics.
Maybe it’s just different med school cultures, but he mostly starts out each one essentially saying the med student doesn’t matter, and isn’t really important to the team. If you don’t feel like you’re a valued member of the team, prove to your attendings that you are . Ask questions, take an active role, challenge yourself, ask for more responsibility, and most of the time, you will be rewarded. I was treated like an intern during my Medicine, Peds, Psych, and ER months. I had my own patients, and my attendings and residents pretty much let me manage my patients myself (with their oversight, of course). I wrote the H&Ps, daily notes, and discharge summaries. On my inpatient Peds month when I was on call, it was just me and the attending in-house! We managed the entire floor and PICU together ourselves. Did I do anything the attending couldn’t have done him or herself? Of course not. But I wrote orders, responded to questions from nurses, and got called throughout the night for admissions and procedures (again, with attending oversight). The medical student knows the patient better than anyone else on the team , and often I was able to provide medical history or dispo information that no one else on the team knew. Are you saving peoples’ lives? Often, no, but you’re learning how to, and if you don’t feel like you’re contributing to the team, you’re missing the experience.
Note: if month after month you’re having plenty of “slacking potential,” complain. Maybe it’s just me or my teams, but more often than not I was busy almost all the time–if not with patient care activities, note-writing, order-writing, etc, then with didactics or classes. Call me goodie two-shoes, that’s fine, but I’ve always preferred to work my butt off during clerkships and really try to learn a lot now than when I’ve got the MD after my name and people expect me to know stuff.
So an overall thank you to my programs and attendings and teams–I’d hate to be the exception! Make yourself matter, you’re paying for it dearly!
I may possibly be the last person to discover them, but UpToDate has a bunch of really good ECG tutorials broken up into a ton of different sections. Just search for “ECG Tutorial” and you’ll find them.
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It’s funny what people can live their lives with thinking it’s just normal–that everyone operates on the same assumptions. If it’s always how it’s been for you, how can you know any better?
Three patients reminded me of this fact.
The first is a teenage Russian mother. Her 4-month old adorable little baby had a terrible case of eczema. She was seen in the ER a week ago, given some medications, and told to get a pediatrician at a local clinic. A week later, she shows up in the ER again. For the eczema. There are mutterings and under-the-breath annoyed words spoken–what the hell is she doing back here with her baby’s eczema? This is not an emergency. We ask her why she didn’t go to the clinic, as instructed, and she says, “I went there and they said I was going to have to wait 3 hours.” We say, “Well, yeah, you’re going to have to wait, it’s a clinic. But if you make an appointment, you’ll be able to get in faster.” She kind of nods, and we kind of stand there for an extra beat, hoping she gets it. We re-iterate to her that we cannot manage the kid–she needs to see a dermatologist, and get a referral from her pediatrician. Once we explained how referrals work, I think she figured it out.
My instincts were to think, “What, is she stupid, does she not understand how doctors work? Does she not realize this isn’t an emergency? Is she just lazy and abusing the system?” But the more I thought about it, I think she just honestly didn’t know how the medical system works. She didn’t know how to get care, or how to get a pediatrician, or get help for her baby, so she went to the one place she knows there will be doctors: the ER.
The next is a 30-something administrative clerk at a law firm, with an exquisitely tender ingrown toenail. Ouch. She tells me she gets these rarely, and I ask, “How rare is rarely?” and she shrugs, “Oh, about once a year or so.” (She usually gets a pedicure, but was too busy with the holidays to get one this year.) She has special clippers to prevent it from happening. She is bewildered when I tell her that I think that’s pretty frequent–that most people don’t get them so regularly. “They don’t?” I tell her there are ways to remove the nail matrix causing the ingrown toenail, and suggest she ask her doctor about it.
Again: she’s had ingrown toenails since she was a kid, and just thought it was your normal, everyday thing. Maybe her family had them too, so the notion was enforced. (This also supports my theory that “All families are weird,” because you’ll hear someone describing what traditions they do for Christmas, or birthdays, or whatever, and you think it’s totally bizarre because it’s not how your family does things.)
The last is a 24 year-old student with a chronic cough. He’s got a pretty good family history of atopy and a brother with asthma. He describes the coughing fits as generally after exercising, like running on a cold day–but sometimes even after weird things like drinking a Slurpee too quickly. They last for a good hour or so–but as far as he can remember, he’s had them his whole life.
Now you may be thinking that these patients are just uneducated about their disease, or don’t have a whole lot of medical knowledge or background. But this last one is nothing of the sort. Turns out he’s a medical student. Turns out his father is a doctor. His mother is a former nurse.
Turns out that it’s me, and my cough-variant asthma.
I had no idea — no freaking clue –that other people didn’t cough and cough and cough like me–I just thought that was normal human behavior, a normal reaction to exercise, or cold air, or… Slurpees. It wasn’t until I was reading about asthma that it finally hit me, Mr. Medical Student.
Don’t make assumptions about what you know, what you think you know, or what you think your patients know. Educate, educate, educate, and if something doesn’t seem “normal” or “right,” there’s probably a good reason (or maybe you’re the weird one, and there’s no good reason at all).
Ahh, medical ambiguity.