LUCY...............I"M......HOME!

At long last, my Emergency Medicine sub-internship has started. Last night was my first shift and despite what Tom Wolfe said, it was EXACTLY like going home again!

Home- assuming your home was a chaotic, loud, disorganized, subterranean outpost of the hospital where the teeming masses of the sick and injured (and not-so-sick-or-injured) are congregated on stretchers that appear to be engaging in some constant breeding program and occupying just about every square inch of real estate. If your home is filled with the cacophony of ringing phones, beeping monitors, wailing patients, colorful language and smells like a cross between a Calcutta sewer and a North Philadelphia manhole cover, then yeah- it is just like home.

I can't believe how much I have missed this!

My shift started at 3pm. There were several students there some 3rd years and some 4th years. We met with the attending who was working that evening and since he is also the administrator in charge of the medical students, he gave us a brief orientation. It was your basic "Welcome to the ED" kind of orientation, but he did tell us that they expected a bit more from the 4th year students doing the sub-internship. They expect us to be completely be involved in all aspects of our patient's care. They made a big emphasis on procedures as well. The 4th year students are supposed to get the first shot at any procedure that their patient may need, central lines, intubation, sutures, etc. More important than this in my opinion, is that we really are expected to function at the intern level. We see patients independently, come up with a differential, formulate a plan and then present directly to the attendings. We then go back and "do" all of the things in our plan: if the patient needs an IV we insert one, if they need blood-work, we do it, ditto Foley catheters, NG tubes et cetera, et cetera. This is probably done just as much out of necessity as it is for educational value. There is a high volume of patients and there is only a finite number of nurses. So I suppose it works out for everyone.

After our brief orientation I was handed a chart and told to see my first patient. A patient that the test writers at Step 2 CS would love! ( I promise I will post about my CS experience very soon) She had symptoms that easily covered about 5 diagnoses. A great medical student case.

My next patient was a woman who elderely woman who only complained about "not feeling well". She was not the most easy pateint to get info out of and kept saying very ambiguous things like "I am just not feeling up to par". After a long list of questions from me including her opinion on East coast versus West coast Rap, I was only able to get her to admit to slight shortness of breath. OK on to the exam. Lungs: rales at the bases..hmmm. Heart: systoloic murmur, irregular and kinda quick...the plot thickens. Of course she was in a A-fib with rapid ventriclular response with a rate of about 160. Interestingly enough, after some rate control with cardizem her CHF got worse and she teetered on the intubate/no intubate fence for a while before she finally started to improve.

Not to be outdone, my very next patient was an 80ish year old man sent from a nursing home for evaluation of an isolated extremity injury, seemingly a pretty mundane case except when his EKG printed out:



The patient was asymptomatic (as much as an 80 year old demented man can be asymptomatic).


Not a bad way to start a shift. I got to do a bunch and saw some pretty high acuity for my first night there.

I entered med school with the idea that I wanted to do Emergency Medicine. I did try to keep an open mind and stay receptive to the possibility of another specialty, but nothing is as satisfying to me as EM. For me, I suppose the choice was made long ago. But if I was on the fence about what to do, last night would have sealed the deal- not because I saw some interesting patients or the 'excitement' of treating a high acuity case. For me the thing that stood out was how comfortable I felt to be back in an ED doing what I think I am meant to do. It was like putting on a very comfortable broken-in pair of jeans.

To the uninitiated, the ED must appear simply chaotic where there is no chance of anyone receiving anything even approaching decent medical care. With stretchers packed in one practically right on top of the next and only a thin curtain to distinguish where one patient's "room" ends and the next one begins it must look more like some makeshift M*A*S*H unit from days gone by, than a modern American hospital. Despite all of this, if you watch closely enough you start to see some order in the chaos, and somehow, however unlikely, people are cared for and the staff seems to have a handle on what is going on. Make no mistake, the ED is not without its share of problems and given the current state of health care in this country is likely to be one of the targets for any real reform.

Emergency medicine is not perfect, far from it, I know; but somehow (perhaps because I am so very far from perfect) I feel like we are perfect for each other.

I am actually looking forward to my shift tonight. Sick, I know.