End of ER

This morning was the ER exam, which meant I spent all of yesterday (with the exception of the time spent going into the medical center to get my flu shot) studying for said exam. Studying for exams usually means sitting around going over a couple hundred practice questions. Here's an example:

A 27-year-old woman with known idiopathic intracranial hypertension (IIH) presents to the ED complaining of a bifrontotemporal headache several times a day for 6 weeks after running out of her medications. She complains of occasional pulsatile tinnitus but no visual disturbances. Fundoscopic exam reveals no papilledema and normal venous pulsations. Which of the following factors determines the need for urgent treatment in patients with idiopathic intracranial hypertension?
a) The presence of papilledema on fundoscopic exam
b) A history of pulsatile tinnitus
c) Presence of an empty sella on CT scan
d) Complaint of visual loss or visual disturbances
e) A history of concomitant minocycline use

The answer is D. A short and sweet explanation is that in emergency medicine, the most top priorities are preservation of life, limb, and eyesight, so anything that threatens those must be thoroughly investigated and treated.

Anyway, so that was my yesterday, and then today I went in to the school, took my 100 question exam (which I'll get the score from in about a week), and then came back here. No plans for the afternoon, which is always nice.

Last shift in the ER

As you can guess by the title, today was my last shift in the ER. The theme for the day seemed to be "patients I have seen before". A headache patient from last week came in after passing out today. An abdominal pain patient came in with chest pain. A 15-month-old with a broken elbow came in with burns on his hands. It was like the series finale of Seinfeld, bringing back everyone who had come before.

The most interesting patient was not a repeater, however, but someone with a nail gun (I'm sure you can see where this is going...) He was working on some overhead beams while building a new house, and here is the result:

When we wiggled on it, it was stuck pretty good, so we had to do some more x-rays to prove that it wasn't going through the bone (it wasn't). If it was, we would have to ship him down to OSU for emergent hand surgery with a board-certified hand surgeon. Fortunately, since it didn't go through the bone, we just numbed up his thumb and pulled. Post-nailectomy (I made that up) x-rays proved that everything was okay. He also got a tetanus shot and some antibiotics.

So, that is the end of my ER rotation in a nutshell. Tomorrow is a fun day of studying, and then the exam is Friday at 9. Fun times.

Why adults need vaccines

Just as a warning... I'm getting on soapbox here. As a future preventive medicine physician, there are few things that I deem more important than vaccines, and few things more frustrating than seeing patients with vaccine-preventable illnesses. Despite what Hollywood mothers like Jenny McCarthy would have you believe, there is no link to vaccines and deafness or autism.

Anyway, we had two 22-year-olds come in yesterday during my shift with pertussis (whooping cough). It was a classic story for both of them, with a barking cough that comes in paroxysms (intense, uncontrollable, painful coughing for a few minutes, followed by a few hours of feeling perfectly fine, followed by more uncontrollable coughing for a few minutes). So we took throat cultures and wrote them prescriptions for azithromycin (Zithromax, or Z-pack), and then I had a little chat with them about their vaccinations, which, of course, neither of them knew. Before a couple of years ago, kids got the DTaP vaccine, which is diphtheria, tetanus, and acellular pertussis, and then adults got a booster of Td (tetanus and diphtheria) every ten years after that. However, the CDC started to notice that whooping cough was coming back, especially in adults who had gotten the full DTaP series as kids, so they changed the recommendation for adults to get Tdap (yes, the capitalization is important, but I won't bore you with the explanation) as one of their tetanus boosters.

Fortunately (?) for me, I needed a tetanus booster as part of my pre-travel vaccines, so I got my Tdap less than a month ago, which meant I "won" the debate about who got to see these two patients. When I presented my history and physical to one of the attendings, he rolled his eyes and went off on his soapbox about vaccines. Apparently, his sister-in-law is one of the Jenny McCarthy-type mothers who think vaccines will kill their children, so his nieces and nephews aren't vaccinated. Last year, the whole family had whooping cough.

So, in conclusion, GET YOUR VACCINES! If it has been more than ten years since your last tetanus booster, go see your doctor and get a Tdap, because enough people have gotten lax about that that whooping cough is coming back, and there's no need for that, since we have a vaccine that works.

Okay, stepping off my soapbox now. In happier news, they finally posted my grades from my two preventive medicine rotations, and I got honors in both :) They also upgraded my overall ratings, so I'm now a "very good" medical student, not just a "good" one. So I'm average to above average again.

Columbus Half Marathon!

This morning I got up early, had breakfast, and braved the marathon traffic to go run 13.1 miles with 12,000 of my closest friends (okay, that's not exactly true... some of them were running 26.2 miles). Here's the course map:

Adrienne is on an away rotation in Cleveland this month and had to work today, so I was on my own for the race. That's okay, because running ridiculously long distances seems to make everyone good friends. I talked to a girl running her first half before the race, chatted with some random people while running, and ran with a couple of Marines for a mile or so before they stopped for a bathroom break (they were running the whole marathon, so it's really not that impressive that I was keeping pace with them).

Overall, it was a really good race, although really cold at the beginning (my fingers were so cold, I couldn't bend them for the first two miles). I ended up breaking the two-hour mark (yay!) with a time of 1:56:17. Not my fastest ever, but it was only the second time I came in before two hours, so I'm happy. It was about an 8:47/mile pace.

Here's my medal.

And, of course, since I live right on the full marathon course, I had to be creative in driving back. Here was my route to and from the parking garage (C is my apartment):

I got to drive along High St. to get to the parking garage, but it was closed when I was headed home, so I had to get creative to drive back. I was just impressed with myself that I found an alternative route without the help of my GPS. I guess after living in Columbus for more than three years, I finally know my way around (somewhat).

Long day and new shoes

Yesterday I decided to PT with the ROTC cadets before working from noon to ten, so by the time I got home at eleven, I was wiped out and went straight to bed.

The shift itself wasn't too bad, but just like other shifts, we seemed to get the same type of patients all day--yesterday, it was lacerations. I got to do quite a lot of sewing--a head, a little finger, and an arm. One of the attendings did another arm (different patient, thankfully), and a family medicine resident did a pretty complicated laceration repair on a leg. Although I'm not all that great at suturing (it's one of those things that just takes practice, and I don't have much desire to practice it), they are nice patients to have. They have one thing wrong with them, you can diagnose and fix it there, and they go home happy. It's nothing like the abdominal pain patients, who get a huge workup which usually doesn't lead to a diagnosis, and go home feeling only a little better than they did when they came in.

Today was the expo for the Columbus Marathon (and half-marathon) tomorrow, so I went in to pick up my packet (I'm doing the half, not the whole thing), and ended up buying a new pair of running shoes. My usual shoes cost $100, and they had them for $76, so I couldn't pass that up. While I was there, I ran into a second year who recognized me from a Military Medicine Interest Group meeting, so we talked shop for a bit. It was a nice little reminder of how far I've come, and how glad I am that it's almost over.

Slow attendings and swallowed coins

The attending I worked with for the first part of my shift was very, very slow, which, of course, caused the patients to pile up. I think the average length of stay for patients this morning was over four hours. I had two patients who had been in the ER for over three hours before being seen by a physician, and that was the physician who took over at 3:00, when the first attending got off. One of them was a 17-year-old girl with abdominal pain, which the mother was positive was appendicitis (it wasn't when she was in on Monday, and still wasn't today), and the other was a 92-year-old man with congestive heart failure and a chronic cough. Both are okay and hanging out at home (I assume).

The excitement came later in the shift, when we got a 20-month-old patient with a complaint of "swallowed a penny". It wasn't the first "foreign body" complaint that I had seen (we had a few when I was doing a couple of shifts a week in the ED at Children's Hospital on my pediatrics rotation). This was the first I was handling "on my own", so I was the one ordering the initial x-rays to see where the penny was.


First of all, it looks more like a quarter than a penny to me, but that's beside the point. The point is, it's in his esophagus. Two clues: 1) in the frontal view, if you can see the face of the coin, it's in the esophagus. I don't know how they've come up with that conclusion, but it's likely based on many, many x-rays and some sort of anatomical studies of the musculature of the esophagus and trachea. 2) Also in the frontal view, you can see the airway (gray shadow that branches off, like an inverted Y), and it's not distorted by the coin. 3) In the lateral view, you can see the airway in the neck in front of the coin.

General rule is, if the kid is asymptomatic and the foreign body is in the GI tract, not the respiratory tract, you can let it pass. However, this kid was gagging and drooling, which means it has to come out. If he had been in Columbus, we would have just paged the ENTs to take it out. However, in Bellefontaine, there aren't any ENTs willing to do a foreign body removal on a 20-month-old, so this kid bought himself an hour-long trip to Columbus for a three-minute procedure at Nationwide Children's Hospital. My attending (not the slow one) wasn't happy about this. As he was saying, if he were in Alaska and there were no children's hospitals, the ER doctor would be the one taking care of it. However, since there are pediatric ENTs within a reasonable distance, it would be "irresponsible" for the ER physician to do it. Defensive medicine at its best.

Endless shifts and more class

Yesterday's shift was pretty much more of the same, with one interesting twist: instead of ending the shift with football injuries, that's how we started it. The night before, he was tackled and took a helmet to the chest, and had been having pain since, so he came in for an x-ray. Everything was fine, no broken bones or collapsed lungs, so we cleared him to continue playing.

That was our first case of the shift, and just like on Sunday, once they started, they didn't stop. I felt like I was several patients behind the entire day, but such is life. The attending I was working with wanted me to get some practice with procedures, so she had me starting my own IVs and such, which usually the nurses do. I also got to staple an 11-year-old kid's head, which was all sorts of fun. We gave him a little something to take the edge off first, so he was actually pretty still the entire time.

Today was a class day (ugh), which started with two hours of discussing ER cases. After that we had an hour of simulation, going over management of acute emergency patients with the clinical skills lab's computerized dummy. The first one ended up coding (respiratory arrest), because the student running the case kept asking the patient questions instead of noticing that the patient's (dummy's, whatever) vital signs were crashing. Fortunately, he had the rest of us backing him up, so we were able to do CPR and treat him and bring him back to life. I got in an argument with my fellow students, and the ER resident running the cases, when I said that we can give the patient O+ blood instead of O-, because studies have shown that while giving a woman with O- blood of childbearing age O+ blood can cause problems in any subsequent pregnancy, men obviously don't have the same problem. Well, the resident said he had never heard of that. When we went over the case afterwards, the attending said that I was right, and in times where you might have to conserve your supply of O-, men should receive O+ blood to save the O- blood for women. So, I was right, and they were wrong, and I was very proud of myself for that.

Anyway, after that I had to take my car to the VW dealership for its 5000 mile maintenance. I still can't believe I've put that many miles on it.

No winning the game this time

Silly me... I thought a Sunday day shift (8am-6pm) would be slow. HA! There was only patient waiting to be seen when the attending and I started at 8, but then the board quickly filled up, and never went down. I spent the entire day feeling like I was running several patients behind, because most of the day, I was running several patients behind.

For some reason, we seemed to be giving a special deal for dental pain and knee injuries. No joke. For about an hour somewhere in the middle of the day, I only saw patients with dental pain and knee injuries (and for some reason, they seemed to alternate). When I'm talking dental pain, I'm talking about really gross teeth--cavities, infections that spread to the jaw and ear, the whole bit. So they got antibiotics, phenergan (anti emetic--keeps them from vomiting the antibiotics), and the vicodin that they probably came in for.

Knee injuries aren't fun--for the patient or the emergency room physician/med student. For the patient, they hurt, and it makes it really difficult to get around when you can't put weight on your leg. For the people trying to figure out what's going on, it's pretty difficult when your primary imaging modality is an x-ray, and your primary injuries involve things that can't be seen on x-rays. Here's an x-ray of a knee with an ACL rupture:

Yeah, it's not much different from an x-ray of someone with no injury. So we did our x-rays, saw nothing, and told them to follow up with their primary care physicians to schedule an MRI.

The shift ended with the obligatory football injury (obviously, nobody told these middle schoolers that it's Sunday). Eleven-year-old boy, tried to tackle his opponent and missed, slamming his open hand into the ground and getting a buckle fracture of his radius. They're a bit subtle on x-ray. Here's an example:

His was actually a bit more obvious than that, but it did me a minute or two of staring at the x-ray to decide that it wasn't right. He was pretty excited about getting his first broken bone.

Tomorrow is a day off (yay!), which will consist of sleeping (yay!) and listening to Podcast lectures (boo!) and doing online quizzes (boo!). Ah, the busy-work... gotta love it.

On a happier note, I have my flight and hotel for Hawaii :) I'll be flying on Sunday, Nov. 2, leaving Columbus at 8 am, and staying at the Tripler Lodge (military housing right next to the hospital) until Thanksgiving (Nov. 27), when I fly back at 4 pm, getting me back to Columbus sometime the morning of the 28th.

This is educational?

As per the rotation requirements, I had to do at least one overnight shift, which I did last night/this morning. In a small rural hospital without trauma services, this was pretty pointless.

When I arrived at 11 last night, there were a few patients waiting to be discharged or transferred, and a few still waiting to be seen. So I went and saw the ones to see and gave my presentations to the attending, who was still working on transferring a patient to Columbus. The transfer took awhile, and so it was a little after 2 before everyone got out. And then...nothing. No new patients, nothing to do (unfortunately, I didn't realize how close I was to the end of the book I brought for just a situation). Finally, at around 4, the nurses took pity on me and put me in room to take a nap. They came and got me around 7 when the next patient came in.

So, I spent ten hours in the emergency department and saw a total of three patients, because I was required to do an overnight shift. If I had done those ten hours during the day, I would have seen between eight and fifteen patients, which to me seems like a much more educational experience.

Different attendings, different work

Yesterday (last night? I'm confused about time these days) I worked with an attending I hadn't worked with before. The other attendings I've worked with to date have been more of the "treat 'em and street 'em" type, which means get the patient stabilized, rule out anything life threatening or can easily fixed, and have them follow up with their regular doctor, who knows them and knows their history, in a couple of days. That's typically how emergency rooms work.

The attending last night, however, seemed more interested in finding out exactly what was going on. We had a 25-year-old woman complaining of abdominal pain, and although she didn't have an extensive history of visiting this ER, she had obviously had similar complaints many times in the past--she had already had both her appendix and gall bladder removed. Automatically at that point, you can rule out just about anything that has to be taken care of immediately--it's not appendicitis, since she doesn't have an appendix; bowel perforation is so rare in a person that age that we could probably write it up as a case report if that's what it was; and without a gall-bladder, she's unlikely to have a gallstone causing pancreatitis. Since she came in just as the previous set of doctors were coming off, they had me give her toradol (non-narcotic pain med) for the pain, get a urine sample to check for urinary tract infection, give her some IV fluids, and check a blood count and electrolytes.

No urinary tract infection, blood count showed that there was either a mild infection or mild inflammation, and electrolytes were normal. Oh, and the toradol didn't help the pain at all. By this time, the new attending had come in. He ordered IV dilaudid (narcotic pain med), a more complete blood chemistry panel, and an abdomen and pelvic CT. The more complete chemistry panel didn't show anything wrong with her liver or pancreas, the CT was normal, and the dilaudid helped "some". By this point, she had been in for over three hours, and still complaining of the pain, so the attending offered to admit her to the hospital for a more thorough workup, which she declined. When she was discharged, after getting more dilaudid, she walked out just fine, after a work-up that probably cost around $5000, which since she doesn't have insurance, probably won't get paid.

I don't think it's the role of the ER to find out the source of every ache and pain, but apparently, there are some who do. As a medical student, there's not much I can do about it except go along with whatever the attending wants to do. After all, it's their name on the chart, not mine.

Yesterday's shift

Yesterday I worked from 8am-6pm. It wasn't a bad shift; at one point we "won the game", meaning that we cleared the board and there were no patients. It happened at the perfect time, too--right at 11:00, when the drug reps were scheduled to bring in lunch (shh... don't tell Ohio State that I ate the evil drug rep's food--it's against the rules).

Nothing too exciting all day. We had a few of the typical abdominal pain patients, with nothing to diagnose. They always felt better after some IV fluids and a dose of Reglan (anti-nausea medications). At one point, every patient we had was not only related, they all lived together--a 14-year-old getting stitches removed (which should be done at the primary care physician, not the emergency department), her fifteen-year-old brother in for vomiting, and their eighteen-year-old cousin with abdominal pain.

Late afternoon/early evening on the weekdays during football season usually means the middle and high school football injuries start coming in. During my first shift last week, we had two broken arms. Today, only one football injury, a twelve-year-old who wouldn't straighten his elbow and sporting a bruise that went from his wrist to his shoulder, swollen and everything. I assumed something would be broken, and when I looked at his x-ray, I thought for sure it was broken. It looked something like this:

Although the piece on the right wasn't quite so distant from the rest of the bone. So I proudly showed it to the attending stating that it was broken, and he said, "Actually, that's the growth plate. Get a comparison film on the other elbow to see what his normal growth plate looks like." When we got the comparison films, it looked identical to the first--down to the label on everything of "left". So I thought they screwed up and x-rayed the bad elbow twice. I went in to talk to the patient, and he assured me that they x-rayed his good elbow the second time, so I called radiology, and they said they'll fix the films to have the right labels. Anyway, cutting to the chase, his elbow was not broken, he just had enough of a gap in his growth plate (as twelve-year-old boys do) that it looked like a fracture to my untrained eye.

A Saturday at Mary Rutan ED

Today I worked in the Emergency Department from 10am-8pm, a nice Saturday in the ED. Most of the cases could have waited to see their primary care physicians on Monday or Tuesday (sore foot, headache, etc), but we did have a few legitimate ED patients (although, not emergencies): a split finger that had to be sutured (I did the suturing), a fifteen-month-old with a broken elbow from last night, and a nine-year-old with a Jones fracture (break of the metatarsal of the pinkie toe). Oh, and I diagnosed the Jones fracture (with the right name and everything), so I was feeling rather proud of myself. The girl, though, is probably less excited--six weeks in a full fracture boot and crutches.

Here's an x-ray of a Jones fracture (not my patient, but you get the idea)

And, of course, there were the ones that shouldn't have gone in to see a doctor at all. We had a 21-month-old girl brought in by her mother because she got stung by a bee on her ear. No, she didn't have a bee allergy. She had never been stung before. But her ear started to swell, so her mother brought her in to make sure she's going to be okay (she is). We also had a 22-year-old girl come in with cramps. Yeah. That was fun.

Of course, there were a couple of patients that just go to show why fourth year medical students must be supervised. There was a man in his seventies with metastatic cancer, complaining of cough and chest pain. So, he got a chest x-ray, which the doctor was able to tell right away what was wrong. I could tell that there was something not right, but I had no idea what it was. The doctor tried giving me hints, but I was oblivious. It turns out that the area that looked a bit off was a Westermark sign, which is indicative of a pulmonary embolism. Here's an example of a Westermark sign:

If only my x-rays came with labels like this one... But sadly, they do not, which tells me that I have to brush up on my radiography, which does not make me happy.

Next shift... Tuesday, 8am-6pm.

Hours and hours of class

Today was a full day of didactics. I came in an hour or so early to meet with a dean to go over my MSPE (I don't really know what that stands for... medical student performance evaluation? Your guess is as good mine), which is basically a dean's letter for my residency application. Full of glowing comments about my performance and talk about how wonderful I am... and concluding with how I'm a below average medical student. Needless to say, I was not in a happy mood by the time I got to class.

The morning was dedicated to shock and ultrasound. We spent an hour and a half getting a lecture about how you can use ultrasound in shock patients, and then two and a half hours playing with the ultrasound machines. A few of my classmates had their kidneys, bladders, and hearts examined multiple times before lunch. The afternoon was one really long lecture about toxicology--three hours of going over various toxidromes and how to treat aspirin, tylenol, atropine, organophosphate, narcotic, and a few other forms of poisoning. Good times.

First shift and EMS ride-along

Tuesday afternoon/evening (2pm-12am) was my first shift in the Mary Rutan ER. Mary Rutan is in Bellefontaine, OH, which is an hour away from Columbus, so with the commute, it make for a pretty long shift--and they might be getting longer, as Dr. Mackey suggested I work ten twelve hour shifts instead of twelve ten hour shifts, to cut down on my total commuting time. I'm still waiting for that to be approved by the clerkship coordinator.

The first shift went pretty well, although it was my first time using the computer system and their electronic medical record system, so I was a bit awkward and slow on my charting. I still did manage to see several patients pretty much by myself, and got to help Dr. Mackey (and by "help", I mean be an extraneous person while he taught me how to do it) put a splint on a five-year-old with a broken arm and suture a thirteen-year-old with a cut lip. And I ended up doing two pelvic exams by myself, which I was less than thrilled with. Overall, it was a good shift, and I think I'm going to enjoy, or at least survive, the month.

After that long shift and the long drive home, arriving around 1 am, I pretty much crashed and got a few hours of sleep before my ride-along with Columbus Fire Department Medic 2, which is the busiest medic in the state. I think we had more than ten calls in the eight hours I was with them, most of which were nonsense calls (only three had to be taken to the emergency room, and two of those weren't all that necessary). It was a lot of fun, especially having a day where nothing I did was graded or evaluated, but it was also really good to see what happens with the patients before they come through the ER doors. The paramedics seemed to enjoy having us along as well, and talked about how they usually have good relationships with the doctors, because most have gone out with the squad at some point and know what goes on. Nurses, on the other hand, usually don't, and so they don't have that same understanding.

Tomorrow is a full day of class (which I'm less than thrilled with), and then I scheduled myself Friday off (which, unfortunately, will be spent studying and doing some of the online requirements for the rotation). My next shift is Saturday at 10 am.