#457

Two ED shifts in the past 24 hours, and I'm feeling a bit sheepish about my last post. Studies suggest that only about 16% of patients who visit an emergency room are actually admitted. Last night I was running at 75%, and the rest of the ED appeared to be falling suit. I had one patient with diabetic ketoacidosis, a very complex and potentially life-threatening complication of type 1 diabetes (although it can be seen in type 2 patients), and I was proud of myself for recognizing the condition quickly. One of the biggest skills you pick up in third year is the ability to distinguish "sick" from "not sick." In our notes, we typically describe patients as "pleasant" (if you like them), "well-appearing," "in no acute distress" (if you're not sure if you like them), "uncomfortable," "ill-appearing," "toxic-appearing," and "in acute distress." Understanding the rubric takes time, because as a medical student you are more likely to describe someone as "ill-appearing," where your resident or attending might describe them as "uncomfortable." In other words, medical students (and myself in particular) have a tendency to "over call." My other patients had interesting soft tissue infections, something I have not seen much of, so they were a great learning opportunity. The attending I worked with gave me a lot of responsibility to manage the work-up, but I wished he had pushed me more on how I would actually treat this patient - what antibiotic, was admission necessary? (it was), what route of antibiotic delivery (oral, IV, intramuscular injection), etc, etc...Nevertheless, he proclaimed me a "rock star" as he sent me home, so I was feeling pretty stupid about my last post.

I had 7 hours off between shifts, and then I was back for the daytime. The ED got slammed about mid-morning, and we still hadn't caught our breath by 3 PM sign-out. I didn't actually do much today because I had several required activities that took me away from the ED, and I was surprised by my resident's resentment of this (he mentioned several times that I had not been around all morning, even though I was required by the course director to be somewhere else) as well as my anger and frustration towards him. I've fast learned on this rotation, and in reflecting on my obstetrical/gynecology experience, that rotations or departments in which you continously work shifts with different teams tend to utilize people with a passive aggressive streak. There's little reason to be on your best behavior when you know you won't be seeing your colleague for a few days, if ever again. This is in contrast to the "floor teams" where you work as a group for two to four weeks at a time. In this scenario, it behooves you to play nice because you're going to need something from each other every day, continuously, for several weeks. As the saying goes, you get more with flies with honey than you do lemon.

I attended my medical education journal club today (to my resident's frustration) where the topic of the day was the utility of the fourth year of medical school. It was an interesting discussion about how education is usually temporally-structured, when the reality is that it is based on competency. Why do you graduate in 4 years from high school, college, medical school, if you need five years to learn skills, or six, or seven? I came home and past out for 5 hours - 4 emergency room shifts in 4 days is brutal, and while the hours are fewer, the fatigue reminds me of my surgical experience. I have a delicious 4 days of before my next shift in the trauma bay. (Conveniently a Saturday overnight - guns, knives, drunk driving, brawls, and general human stupidity.) So I tired of my wedding and design blogs and decided to try something new: professional development. I read this week's New England Journal of Medicine and Pediatrics in Review. One of the best questions I asked during residency interviews was: what journals should a pediatric resident read? By far and away the most common responses were the clinicopathologic conferences in the New England Journal and Pediatrics in Review. It was in Pediatrics in Review that I found this gem about the treatment of ear infections, circa 1918.

"In uncomplicated cases the patient should be kept quiet in the house, while in severe cases he should be put to bed and given a light diet. ... The author formerly used the artificial leech with satisfactory results in many cases, especially those of a mild type, and still feels that in certain instances it can be used to advantage. The artificial leech is much to be preferred to the natural one, for the following reasons: 1. The scarificator and cupping-glass are always at hand, while natural leeches are frequently very difficult to obtain, especially at night. 2. Leeches are very repulsive and disagreeable to most patients, and especially to children. 3. After the artificial leech has been removed, the bleeding ceases at once, while with the natural leech it is often difficult to control the hemorrhage. ... In the case of children, hot water instilled into the ear often affords great relief."

From Bacon G, Saunders TL. A Manual of Otology. 7th ed. New York, NY: Lea and Febiger; 1918

Leeches are distasteful indeed!