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Sunday, August 9, 2009

The Emergency Room... Oh the Anarchy!

If I had one word to sum up the ER and what comes through there in a day, it would be Chaos. But it's amazing. Challenging in a way I could never have imagined. It took me 2 days to realize that what you can learn in one day of an ER clerkship really amounts to more than you will learn in 2 weeks of patient care and follow up on the ward floors. There is no comparison. You can see, examine, process, and discharge 10, 15 patients a day with ranges of problems so varied it'll make your head spin!
On any typical day you can see:

-The prissy church choir girl (girl being a serious misnomer here, seeing as how she was 74, but hey...) who "burnt" her hand trying to put out a blanket, placed a bit too close to a candle, caught on fire near the church store room. She had two of her fingers covered with melted nylon which stuck after cooling down. She came to the ER not because she had a burn, but because she had no idea how to remove this thing of DEATH that had entrapped her silly fingers!!!

And then minutes later...
-The poor 24 year-old construction worker (A.) who had a 6-kg rock fall over his head from the top of a 9-storey building while he was out for a walk on his break. He sustained multiple fractures of the skull, and was brought to the ER with his mashed brains pouring out the top of his head. Scientifically speaking, and to put things in perspective for my med readers, the brain CT report was significant for multiple skull fractures reaching the base of the skull, severe depression of a part of the calvarium deep into the brain causing midline shift, trans-tentorial herniation, and severely increased intracranial pressure with all of its sequelae.
We stabilized his vitals after 3h of fighting and 4 L of I.V. fluids.
The poor guy died in the ER exactly 48 hours later.

This is a small idea of the spectrum of sights and colors we see on a day at the ER. But what struck me the most is surprisingly not the patients. It was not the drama, the excitement, the rush of dealing with life and death. It was the patients' families. Why? It became apparent to me how everyone saw nothing but themselves, nothing but their own, and just dismissed everything and everyone else in complete and utter disregard.
As poor A. was expiring in Trauma 1., we were also handling a patient (in S2) with mild head trauma. He had been hit by a car at low speed and hit his head against the windshield. He was awake and oriented, and his studies all came back negative, so basically he was fine. All he had left was a small laceration on his forearm that we had to suture before we could send him home. Naturally when the alarms went off on A.'s monitor screaming that he was going into severe tachycardia and O2 desaturation, we all left S2 to go check on A. and see if there was anything that could be done. Obviously there wasn't.
Now imagine this. Coming out of Trauma 1, heavy with heartache and shaken to your core by your first ever encounter with death and a patient who slowly died in your hands, you and your resident take a tough walk out to the ER waiting room and make sure the parents know that their worst nightmares have come true; "we are truly sorry to have to tell you that your son passed away 2 minutes ago. There was nothing more we could have done."
Now imagine walking back into the ER, in that state of mind, to find an obnoxious old lady, S2's grandmother, in a panic, screaming at you and yelling all sorts of nonsense asking you how it was possible for "doctors" to leave his wound uncleaned, knowing that she was coming to see him. She hates the sight of blood apparently.
How could we? how could we have such disregard for her great presence and not have wrapped him up before we tried to help a truly dying person? I don't have an answer to that.
This was even more destabilizing to me when I thought back at A.'s parents' reaction when we told them what had happened. Actually it was not in any way worse than the old lady's panic. No. Even less dramatic in my opinion.

So is worrying about a loved one an all-or-none sentiment? Can anyone worry, but at the same time have as little as an ounce of consideration? Can anyone worry, but realize that there are priorities and that there are always people who are worse off??
The answer is, YES, worrying is an all-or-none sentiment. From the stupid prissy choir girl who came for a hand-cleaning session, to the exceedingly unfortunate A., rest his soul, brought in by the Red Cross with only a few breaths of life left in him, and to the mind-twistingly annoying and naggy fat boy who twisted his ankle and had no signs of injury remotely indicating even as much as an X-Ray, you will be surprised to see that the parents all act in the same craze, the same insanity, and the same "treat-my child-first" attitude. You will be surprised to know that sometimes it is even reversed, that families of patients in dire emergencies will seem more composed and cohesive than families of patients with petty scratches not even worthy of a band aid. And for now, this is what makes the ER stand out.


poshlemon said...

This is quite an interesting read.

You know, I always thought if I'd get into med school, I'd love to serve in the ER for as many years as possible for the same reasons you listed. And then specialization comes later. I don't know if this is the norm actually.

You get patient A, B, C, and then Posh lol Posh coming to the ER after having waited for 4 hours (in London) to check on a little bump she thinks is cancer only for it to turn out to be some fatty bump or something lol So my question is, have you encountered so far any hypochondriacs? And how irrational are their fears? I always wondered if I were one of a kind (though I'd love to think so).

I wonder how it must've felt to encounter death, maybe for the first time. I don't know if it gets easier with time or you become numbed. I have heard so many different individual opinions from doctors but I guess each experience is a unique experience. You'll only find out with time.

I just have one thing to say though... I understand that there may be death round the corner and it has priority over a simple fracture. But it is not a patient's responsibility or place to feel compassion or excuse a doctor for being late on his duties. I think each patient deserves their attention and in due time. I hate how sometimes we have to wait for hours and hours to be seen by a doctor. At the end of the day, each patient cares about his/her wellness and it is not the patient's place to have that concern for other strangers in the same ward/hospital. This is why there are doctors and patients. Maybe this could be solved by including more doctors or nurses, etc.

Le colleague said...

Hey posh. Good to hear from you again! thanks for your lengthy comment and here's one right back at you!

We see everything in the ER. From the hypochondriacs who come in with stupid scratches thinking they might get an amputation, to the even dumber workers coming in with their limbs barely attached thinking they'll be fine with a couple of stitches, to the horny women in their 40s practically begging to be felt up by someone like yours truly, we see everything!!
watching someone die made me feel life-alteringly hepless, gutted, disgusted in a way you can only imagine. And yet at the same time it was such a rush that I felt guilty to be even the slightest bit excited... It's just out of this world. But like you said, only time will tell how that will change...

About the priority thing...
Everyone, including you, nurses, doctors, patients, and their families, needs to understand that no matter which hospital you go to, chances are their ER is understaffed. This is a worldwide problem. Did you know that the average waiting time in any U.S. hospital is 3 hours? 3 hours!! and that's before anyone even comes near you! We do so much better here at AUH!
That guy I talked about was taken care of... Everything life-threatening was assessed and controlled. and as we started to tend to his minor laceration (less than 1 cm) we were interrupted by the code blue alarm. That meant that everyone on the surgery team (1 resident, 1 intern, and 2 med students) had to drop everything and get to the Trauma room to help a dying patient. Simple as that!
And people NEED to understand. This is not a restaurant, I'm sorry but if you hear the things they say to us you will be dumbfounded, it's not even funny! lol
IT's true that we need more doctors, more nurses etc... i agree with you 100%. but until we, and every other hospital out there, can get that, any ER where 'service' is quick and tidy will remain strictly a utopic concept. That said, it is a sad reality that there will and SHOULD be priorities, forget about anything else... maybe not in the normal healthcare setting, but DEFINITELY in an understaffed ER, and remember, there are not any ERs out there that are capable of providing that service like we want them to.

poshlemon said...

Honey, I go to UCLH. The A&E there is crazy. Minimum wait time is 2 hours - that's if you're lucky. Once I had to wait 5 hours to be seen and I was seriously ill - like seriously ill.

I've been to AUH and I know the waiting time is less. But, I don't get the understaffed concept. There are so many doctors out there, so many med students, etc.

Le colleague said...

... ...
I don't know what to tell you :)
Except that so many doctors and students are assigned to so many teams including family medicine, pediatrics, and surgery etc... And naturally patients on triage are sent to one of these teams, which consists (at AUH) of 1 resident, 1 intern, and 2 med students and that' it...That's what outsiders don't see.

Again I agree, there should be more doctors, but it's unrealistic to expect an ER NEVER to be overloaded. No matter how many doctors it has... It's crap, but it's what we've got. Shoestring budgets dictate :)


LaColleague said...

I guess I'm just gonna put in my two cents and say that people need to understand that the ER has such a high turnover that the physicians there inevitably want to attend to their patients as fast as they can, if only were it for them knowing that no matter how busy it is, it can get busier! And they will have to clean up a bigger mess...

So the ER problem I believe is basically in the triage, and it's not a problem but more so a solution. An effective triage will assure fairness even though patients will still complain. And it's fine. Because as much as I understand that when someone hits their toenail they might have nowhere else to go but the ER, people need to understand that it is not your round-the-block-speedy-drive-through-McDonalds-consultation. You will have to spend a couple of hours there, and you will have to cancel on that party in Skybar. Especially if the triage deems that your case is not so urgent, heck you might wanna rethink going to the ER for that toenail and call your doctor instead. Which will be welcomed by those other patients who really need the urgent medical care and by the community as whole, everyone is almost happy.
Hooray for social medicine!

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