Farewell, Emergency Medicine

I just finished my last shift of my Emergency Care clerkship, and I have to say that I'm sad to see this rotation end. I've had a blast these past two weeks, thanks to a couple rock star residents who provided a great hands-on educational experience.

Among the procedures that stand out in my mind: performing a lumbar puncture (champagne tap), draining a perianal abscess, suturing a few lacerations, and helping to set a dislocated shoulder and hip.

For as much fun as I've had on this rotation, it's important to keep in mind that my Emergency Medicine experience as a third-year medical student is not very representative of the daily routine of an Emergency Medicine resident or attending. All of my shifts were from 12n-8p, whereas residents and attendings work plenty of overnight shifts. Most of the patients I saw over the past two weeks were cherry-picked specifically because they were interesting and had educational value, whereas Emergency Medicine in general is mostly a bunch of chest pain and belly pain with some altered mental status mixed in. I only saw a few patients over the course of an 8 hour shift, whereas attendings see on the order of two dozen patients in a shift.

Keeping all this in mind, and despite some of its drawbacks, Emergency Medicine is still on The List.

Emergency medicine teaching service

The Emergency Care clerkship at University has a dedicated teaching service. What that means, practically, is that an attending physician and two residents are there with the express purpose of teaching third-year medical students. The attendings rotate daily, but the two residents stick with the teaching service for the whole two weeks, making for some much-appreciated continuity.

The teaching service sees different patients from the rest of the department, usually picked for educational value. The pace is much slower, too, with time specifically allotted for rounds, which just consists of sitting in a conference room or outside in the courtyard, presenting a patient to the group, and discussing pertinent teaching points that the patient raised. It's ironically a very relaxed learning environment.

Pros and cons of emergency medicine

Pros:

• I like fixing acute problems and seeing immediate results.
• The idea has always appealed to me of being a doctor who can ring the call button when the flight attendants ask if there's a doctor on board.
• I like the fast-paced ADHD environment.
• I like doing procedures.
• I get to wear pajamas (scrubs) to work everyday.
• I would be doing shift work, which would allow for a life outside of medicine.

Cons:

• I don't like dealing with the drunks and drug addicts; I can easily see myself getting disheartened by humanity at its worst.
• I've already decided that I don't want to do primary care, but too many people use the Emergency Department as their primary care physician.
• As a resident and attending, I would have to work a lot of overnight shifts. I can handle disruptions to my circadian rhythm, but I don't like it.
• I value the long-term physician-patient relationship, which Emergency Medicine lacks (except for the frequent flyers).

Mock terror attack: Operation Mountain Guardian

Denver Metro and Front Range first-responders held a drill today simulating a terrorist attack. I don't really know many details, aside from what's included in this Denver Post article, but I do know that the University of Colorado Hospital participated in the drill, receiving the "wounded," which consisted of actors and actresses as well as dummies. Being in the Emergency Department, I became an accidental participant. The idea was to test the capacity of the ED to handle multiple seriously injured patients at once.

Contrary to what would happen in real life, the attending physicians were facilitating the exercise with the senior residents at the heads of the beds and the medical students assisting. I put a tourniquet on the stump of a dummy's severed arm and bagged another dummy patient; my classmate did CPR and successfully "revived" another dummy patient.

This was a fun exercise and interesting in terms of putting into perspective the role of the ED within the larger first-responder infrastructure.

Denver Paramedics ride-along

I wish that I could say that today's ride-along with Denver Paramedics was action-packed, but it wasn't. Over a 10-hour shift, we had a grand total of three calls: a Denver CARES patient in alcohol withdrawal, a minor fender-bender with no injuries, and a dialysis patient needing transport. Pure bad luck, a sleepy day in Denver.

This was a very similar pre-hospital experience as the ride-along I did during my first year as an elective, except this time it was a requirement for the Emergency Care clerkship. I think future students would have more luck scoring an exciting shift if it were scheduled for a Friday or Saturday night.

Emergency medicine

I start my Emergency Medicine clerkship at University tomorrow morning. It's only a two-week clerkship, graded pass/fail. The best part is that I've already been working at the University emergency department for the past year-and-a-half with my Foundations of Doctoring preceptor. That means I already know where everything is, how to use their computer system, and I already know most of the attendings and residents and nurses. This will be a welcome change, starting a new clerkship with absolutely no learning curve.

Also, all of my shifts except for one are from 12pm-8pm with no rounds and no pre-rounds. This is quite a change from the 5am mornings I have gotten used to over the past several months.

Halfway there

I'm officially done with Neurological Care! I'll write more about my overall impressions of neurology, and more specifically pediatric neurology, later. The more important thing to celebrate is that I am now halfway through my third year of medical school! Despite all the hard work and out-of-my-comfort-zone stress, I'm really enjoying it.

At the risk of waxing poetic, I feel that I am in the midst of a metamorphosis. It hit me while I was out to dinner with a group of classmates to celebrate the end of the block. We were sharing war stories. I stepped back from myself for a few moments, observing each of my friends in turn, how they listened to me describe my Medical Curiosity patient, and observing myself, how I had turned a History and Physical into a conversation. The structure of The Presentation has been chiseled into my subconscious as it has been for every other third-year medical student before me.

I'm still a long way off from being a doctor, but at least I'm finally starting to think like one.

Non-accidental head trauma

You know it's bad when you see police officers roaming the halls of a pediatric emergency room. It usually means that some child has been abused to the point of needing emergent medical care. Of these poor innocents, the pediatric neurology consult service usually sees those who have suffered head trauma.

My attending last week told me that the politically correct term to use in my notes is "non-accidental head trauma." That phrase didn't sit well with me because it skirts the real issue, that the head trauma wasn't just "non-accidental" but rather a result of gross physical child abuse. I was relieved this morning when my new attending told me to refer to it "abusive head trauma."

Call it as it is.

Inpatient neurology at The Children's Hospital

The Neurological Care clerkship at The Children's Hospital is split into two weeks of outpatient clinic work and two weeks of inpatient service. Most neurology inpatient services are rather low-key, but not this one. For the past week, I've been working between 13 and 16 hours per day.

A major contributor to these long hours is that my attending physician is a long-rounder. Starting rounds at 9am, we never finished before 2pm. On Friday we paused for lunch (he treated) and finished up around 3:30. The upside: this guy is a master of the neurological exam in infants and children. I learned a lot by watching his exams and started incorporating many of his tricks into my own exam.

Another reason for these long hours is simply that I'm slow. It still takes me a long time to put together a good History & Physical or a progress note. But I'm getting faster with each day.

We get a new attending for the second week of inpatient service. It will be interesting to see how this coming week compares with last week.

Jedi mind tricks

If you work at The Children's Hospital in August or September, back-to-school season, you're almost guaranteed to come across conversion disorder. This is the subconscious “conversion” of psychological stress into physical symptoms and can often be metaphorical. Conversion disorder is a diagnosis of exclusion, which basically means that you have to assume the worst and order a bunch of expensive tests to rule out all the bad stuff. While needlessly spending lots of money is never a good thing, it starts to get serious when we talk about invasive procedures, such as lumbar puncture, that carry a real risk of complication.

The phrase of the week was "Jedi mind tricks." My attending is a Jedi Master.

One kid presented with altered sensation. With his eyes closed, he tells the doctor that he doesn't feel the light touch of a cotton swab. Next, still with his eyes closed, the instructions are, "Tell me if you don't feel anything." Sure enough, he said that he didn't feel anything each time he was touched by the cotton swab. Unprompted. He's a precocious little bugger but not good enough to outsmart the Jedi Master!

Another kid presented with seizure-like episodes that were suspicious for not being true seizures, so-called pseudopesizures. When she was told that she wouldn't be able to eat dinner until her seizures stopped, her seizures suddenly stopped. Go figure.

My attending emphasized that conversion disorder is a subconscious maladaptive response to stress, a distinction that merits consideration when discussing the diagnosis. Patients will understandably get upset if the doctor implies that they are faking it. My attending has a standard script to open this conversation:

"People do funny things when they are under a lot of stress. Some people bite their fingernails, some people pull at their hair, some people pick their nose, and some people do what you're doing. I believe you that you're not making this up. That's why it's so important to figure out exactly what's going on with you. What kind of stress do you have in your life?

He also says that neurology is a glass-half-full specialty when it comes to such patients. "Give them the benefit of the doubt. Leave it to the psychiatrists to figure out whether it's conversion or factitious."

Escape from medical school: Labor Day weekend wedding

I spent Labor Day weekend celebrating a close friend’s wedding. Wait, isn’t a third-year medical student not supposed to have a life outside of medical school? The stars aligned to make this happen.

First, I arranged to have a clerkship that was known to give whole weekends off. Since clerkships are assigned based on a lottery system, I got lucky that this actually happened. Second, I arranged to do outpatient neurology during the first two weeks of the clerkship, leading up to this weekend, and inpatient during the latter two weeks. Anything inpatient tends to have longer hours, which had the potential to mess up Friday evening travel plans. Again, I was fortunate that the block director deferred to us students to decide who would do outpatient first. The way things worked out, I didn't even have to ask to get out early on Friday afternoon.

Even with all of this planning and scheming, months ahead of time, I wasn't 100% sure that I would be able to go to the wedding until I looked at the schedule during orientation on the first day.

I already missed another close friend's wedding and my Nana's 80th birthday party, which were both during my Hospitalized Adult Care clerkship. I was just slightly bitter about missing them. Such are the sacrifices we're asked to make for the privilege of training to become a doctor.