An exciting week of being a nurse AND a PA! (warning- gory picture:)

So far my month in the ED has been pretty dang awesome. I've learned so much about medicine but probably more about people that come into the ER. I really really really do my best not to judge people but in the ED, you almost have to. It's crazy how great people can act to try to get pain meds from you, I've been fooled so many times already. They use the typical

"doc, I know you can help me, not many people have been able to. THere has to be something going on with me, this pain is unbearable (all while in tears) and I wouldn't be here if i wasn't at my wits end."

So naive newbie over here buys into it and really starts thinking of all the terrible things that could have bee n missed on a CT or the multitude of other studies the pt has had, all of which are completely normal. I distress myself thinking of all the things on a differential and present it to my attending really concerned. He takes one look in the room, without even really entering the room, and goes, "ok, got it, she's going home." His explanation was that she has "the look." Apparently, and i think I am starting to catch on, whether its good or bad, the look is just something you can just pick up after years working in an ED. There really isn't a way to describe it, its has no real specific features, but you know it when you see it. Is it just a biased/prejudiced opinion against the way some people look that come into the ED? Maybe, to some extent. But when "the look" proves to have a specificity of about 98% for diagnosing somebody as a "frequent flyer, drug addict that makes up stories for pain meds", I'd say there's some validity to that, not just biased and jaded opinion.

Here are some more highlights from this past week:

-On the way to work, not even in the ED yet, was driving and witnessed a teen vs. car accident right in front of me! It was pretty scary seeing the kid fly in the air and land on the street not even 20 ft from my car. For a split second I thought "holy crap, this kid is dead, I really hope there's a doctor in the area..."
And then i had the "oh crap, this is all me...the doctor in the area...ahhhhh that's me!!!" So before I could finish that thought and even begin to freak out about how I wasn't really sure what I was doing, my car was parked in the middle of the street and i was running over, in full scrubs as i was on my way to the ED, to see what was left of this poor kid who, by the way, was hit straight on by an extremely old driver going no less than 40mph!  The kid, Antonio, was 16yrs about, was laying on his back just moaning in pain, left arm road rashed to hell, totally mangled, lacs all over his face. It was crazy because for the first time ever, I was telling people what to do, what not to do, and to calm down. It was funny, if you're a med student you'll appreciate this, I almost spouted off the "sir sir are you ok? you call 911, you  go get a crash cart!" line from BLS/ACLS lol. But anyway, he was lucid enough to know what happened and to thankfully tell me his mom's phone number.  It was almost 8 minutes before the paramedics came and all i really did was hold his head still and straight and have someone else hold his legs. After a few minutes he lost consciousness and most likely went into shock, just in time for the paramedics! (whew!) So I was able to talk to the medics and give them pretty much the story and most of what they needed. As I'm standing there with Antonio's blood on me, about to turn around and head back to the car to head to work, one of the medics walk over, shakes my hand and says..."thank you, he's lucky such a great nurse was around to help."   Awesome lol.

- Going with the same "all females in scrubs are everything BUT doctors" theme, I was called "PA" by an asshole doc for my ENTIRE shift yesterday. It's me third week in the ED, he's seen me a million times with other docs. And he calls me, not even by my name, just "PA." He says things like "hey Dr. B, i got this great case for PA if she's interested." Most of me wanted to just correct him and tell him to at least learn my f'ing name. I don't mind as much if you think I'm a PA or a nurse, but at least have the respect to learn somebody's name for God's sake!

- Saw a lady with  blood glucose of 1617, this is not readable on a finger stick. She came in in DKA (diabetic ketoacidosis) with a pH of 6.7. The pH that is compatible with life is no less than 7.0. We intubated her, pumped her with fluids and insulin as fast as we could, and just sort of watched her deteriorate. Her husband was out of town an last spoke to her at 0730 and found her at 6:00pm...which means she was probably in DKA most of the day. Her husband didn't seem too concerned in the ED, she'd been in DKA before, just not this bad. He said her insulin pump hadn't been working right lately. His only comment was "so is she saying overnight?" It was really sad to stand next to the doc who flat out told him, "well actually, her chances of living until tomorrow are slim."

- Got to reduce this sweet complete wrist disarticulation:

 The story was this mexican lady who, naturally, was skateboarding at 2am while drunk fell and landed on her wrist. Her hand was literally dangling by the skin and that bone popping out is her ulna. The pre-reduction x-ray showed that both radius and ulna weren't even close to her carpal bones, pretty gnarly. Needles to say, the reduction was cool. I yanked on the hand while helping the doc push the bones back into the right spot. I was super lucky that night, thank you lady for being drunk and contributing to my learning!











- Witnessed a carotid massage ACTUALLY convert somebody back to normal sinus rhythm...that actually worked! I thought it was just in books. It converted right back to a-fib in 5 minutes and we had to cardiovert her, it worked for a bit! Crazy!

- For the first time I appreciated the honesty of a drug addict. Lady came in for being "zonked out" in a grocery store, nobody knew what was wrong with her, she walked there, sat down, and was out of it. After medics and nurses asking her if she had pain anywhere, the whole sleu of "protocol" questions, I was annoyed at her babbling and fighting with everyone and spitting on me, I just asked "what's wrong with you???" She politely responded in her slurred speech "nothing,  just took a handful of methadone and xanax." My response, "ok great, bye!"


That's it for now. I'm in the Peds ED next week so I'm excited to be with the little ones that just make me happy.  Something about a Madagascar decorated portable x-ray that just makes me smile :-)

"Suck It Up America"- This is what's wrong with healthcare-worth the read!

So this is not my writing, but I COMPLETELY agree with it!


Sunday Forum: Suck it up, America

We have become a nation of whining hypochondriacs, and the only way to fix a broken health-care system is for all of us to get a grip, says DR. THOMAS A. DOYLE
Sunday, October 11, 2009
Pittsburgh Post-Gazette

Emergency departments are distilleries that boil complex blends of trauma, stress and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation’s medical system.

It’s obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not health-care reform. It’s only health-care insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.
Health care costs too much in our country because we deliver too much health care. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We’re turning into a nation of anxious wimps.

I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care and actually saving lives. Illness and injury will always require the best efforts our medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn’t need treatment.
In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant.
Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu or headache, I often feel I am like one of those cute little animal signs in amusement parks that say “you must be taller than me to ride this ride” only mine should read “you must be sicker than me to come to our emergency department.” You’d be surprised how many patients wouldn’t qualify.

At a time when we have an unprecedented obsession with health (Dr. Oz, “The Doctors,” Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics) we have substandard national wellness. This is largely because the media focuses on the exotic and the sensational and ignores the mundane.

Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.

Somehow we have developed an expectation that our health should always be perfect, and if it isn’t, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.
Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.

The human body is exquisitely talented at healing. If bodies didn’t heal by themselves, we’d be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we’re really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It’s as if you could put your car in the service garage, make sure you give it plenty of gas, oil and brake fluid and that transmission should fix itself in no time.

The bottom line is that most conditions are self-limited. This doesn’t mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or back ache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn’t your doctor being lazy in the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, “Our best medicines are Tincture of Time and Elixir of Neglect.” Taking drugs for things that go away on their own is rarely helpful and often harmful.

We’ve become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.
There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn’t always right. Sometimes a doctor needs to show tough love and deny patients the quick fix.

A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it’s time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what’s really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

Modern medicine is a blessing which improves all our lives. But until we start educating the general populace about what really affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our health-care dollar on treatments which just don’t make any difference.

Anita Dufalla/Post-Gazette
Dr. Thomas A. Doyle is a specialist in emergency medicine who practices in Sewickley (tomdoy@aol.com). This is an excerpt from a book he is writing called “Suck It Up, America: The Tough Choices Needed for Real Health-Care Reform.”

Read more: http://www.post-gazette.com/pg/09284/1004304-109.stm#ixzz0TgtnEINR

Tri and some other funny ED quotes...

So first a disclaimer about my excessively large blog picture- I swear I'm not that narcissistic to put up a huge pic of myself, I'm just trying to figure out how to make a collage of pics and use that as my blog picture and i can't figure it out, while not making it so freaking huge...work in progress :)

Reflections about my Triathlon-
Overall it went really well. Having my family there to support me was the best part though. All my races in the past have been with a couple of friends in the crowd, and while I love them, it was something else to have a lot of family there. They've never seen me race in anything and other than my dad, I'm not sure they even understood how big of a part of my life this is! So, I was really excited to see them there supporting me and it really reminded me that we really are nothing without family.

The swim in the ocean, although it was short, was a new experience for me. After being punched in the chest while warming up by a guy who was swimming in the wrong direction 30 mins before start time, I realized this swim would be the toughest part! I will say that i certainly didn't feel as cramped and like I was trying to swim over people as I do in a lake. The waves and chop were what made me nervous. I was lucky that I breathe on my Right side because I could sight all along the shore, that was nice. At one point I got really scared when I looked up to see the buoys and i saw nothing but open water...ahh! The first thing I could think of was omg i've been swimming deeper and deeper this whole time and i'm going to swim so far out right into a shark's mouth! But then I looked again and saw them not too far away in front, i just happened to be in a down slope of a wave lol. Other obstacles were the hundreds of jellyfish everywhere just waiting to sting me (they failed), drinking the saltwater, and actually being able to see the bottom of the ocean floor. Seeing the floor was different than swimming in a deep black lake because it added both a sense of comfort and fear to my thoughts. I could see that there were no huge creatures swimming under me as opposed to a lake where I'm blissfully ignorant to the creatures in the water...but then again, I was scared that I would actually SEE the shark that is about to bite my leg off! Maybe I should be thinking more about the swim time/technique than my imminent death by shark/jellyfish attack eh? But maybe it made the time pass faster because before I knew it I was at the last buoy and out of the water in 19 mins :) I was predicting about 15 mins, but I'll take it for my first open water swim!

The Bike and run were smooth, but slow sailing. I used my dad's bike, which was great! It was incredibly windy and going up some of the intercostal ramps was gorgeously brutal most of the time! I tried not to wear myself out and enjoy the weather and scenery while not being too much of a turtle on the bike. My time was about average mainly because I hadn't been riding much in the months leading up to it, oh well, I had a fun ride. Running is always my easiest leg of the race, luckily it's at the end. I use it as a time to think about the first 2 parts of the race and either yell at myself for sucking at swim and bike and force myself to make it up at the end, or just cruising along taking everything in. In this case I was just cruising along people watching mostly lol. It was a short distance and it was HOT! I ended up passing several people I saw fly by me on their bikes, this always makes me feel good :)
I saw my family towards the end and they were there waiting for me as I finished and I'll never forget my little cousin's comment "where have you been?!" lol...love it!

Some experiences in the ED this week and reasons I LOVE it:

- Had a lady tell me that she talked to God and he wanted me to know that he was always with me and my family no matter what happened. Made me worried at first because when old people (she was 90 and surprisingly not demented) start talking to God it usually means they're going to die. Later made me sort of emotional because I believed her. Crazy things happen in the ED, I just thanked her for the message and told her I'd never forget it.

- Saw a lady actively tweaking on meth. I never knew what "tweaking" meant but now I'll never forget it. She was very coherent and alert (which was surprising) but she looked like she was crawling out of her skin. Her head was jerking all over the place, her feet were doing these weird movements, and her hands went back and forth from fists to all these weird movements. It was crazy but mostly incredibly sad to see. I flat out asked her why she did meth and she replied that she just got out of jail and had been on meth for 6 days straight, she was sad because she couldn't see her 12 yr old son. She was actually brought in by a city bus driver, yes the driver pulled his bus up to the ER drive through/drop off, and brought her in because he was worried. (I guess there still are some good people in this world...or he just wanted her off his bus lol) Despite my usual cynicism with the angry drug addicts, I actually felt sad for this lady as she cried through her cracked out state talking about her son. She wasn't my patient, I just went in to see what "tweaking" actually meant and we ended up talking for about 15 mins about her son and how he's going to be her reason for living and to stop killing herself. It was a great conversation I never thought I'd have with somebody who was "tweaking" on meth for 6 days.

- Was a split second from getting into it with an ER TECH who told me I wasn't "allowed" to be part of a code because I was just a student and I was in "the way".  A TECH, for those that don't know, are people that get trained for a few months to work in the ED assisting nurses/docs with little procedures, IV's, and basically filling any gaps.  Let me just say that I'm a VERY calm person in the ED and I don't fight with people, or have an attitude and i CERTAINLY do not overstep my boundaries because after all, I AM learning, and I AM a student, and until I can master many more skills/knowledge, I don't think I, or anybody, should feel entitled or like we have some power over those on our team, regardless of our roleS or future role. That being said, I sooo wanted to kindly remind that tech that I've gone to more school than her probably 5 times over and that not only was I ALLOWED to watch, but I was actually going to be the one at the head of the table on this code (thanks to my awesome attending) and in a few short months, I would be the one telling her to get out of the way thankyouverymuch!!!!! BUT of course, I didn't say anything to her, I didn't need to really. I just took my coat off, walked to the head of the pt with my attending and proceeded to intubate the patient and call out orders to the nurses who are actually ALLOWED to put them in.  After all was said and done in my head I was thinking "Take that ER tech, now who's not allowed!? In your face!!"  lol...I'm a mature person, I swear.  It's these little victories that make my days awesome!  Oh and that intubation took a turn for the worse when he started vomiting black as I'm trying to see the cords...real nice. I ended up trying for about 6 minutes and was SOOOOOOO mad at myself (still am) when I couldn't get it. I felt better when the attending struggled before getting it though. Oh well, maybe next time! :)

- Chief complaint: "I'm high on crack. I usually take 100mg of morphine twice a day and I'd like my dose now and a cheeseburger."

- As I walk into the room to meet her for the first time ever, patient starts yelling at me "are you fu@*ing kidding me??? You aren't even old enough to know anything about kidney stones!".....I just told her i'd take that as a compliment and just turned around and walked out lol.

- Son of my above mentioned patient that coded and I tried to intubate, "I saw him lying on the floor for a couple hours but he's usually passed out drunk by noon so I didnt think anything of it. But when I brought him another beer and he wasn't breathing I figured I should call 911."  


These are just a few reasons I love the ED and my life!

Song for the night...

Post on the tri is coming soon! Crazy day, love this song!  I always ask myself this about things in my life...

It must be an accelerated program...

Crazy of the night...

CC: hand pain

I walk up to a 22 yr old girl in a hall bed and find her drawing organic chemistry equations on her sheets and giggling to herself...

Me: Hi S, what seems to be going on with your hand?

S: I'm working on my doctorate in chemistry, I have 1 year left, and this asshole in my lab spilled calcium oxalate on my hand today and it was burning and I just want to make sure crystals don't precipitate in my tendons.

Me: (trying to remember something about organic chemistry and decide if this girl is crazy or not) Oh ok, well i see that your hand isn't really burned at all, so that's good. Where is the pain exactly?

S: You aren't a chemist so you don't know the molecular composition behind anything but trust me, i've worked out the equations and i know my tendons are being saturated with crystals and I need calcium gluconate to bind them and stop the reaction.

Me: Nope, I'm not a chemist, but the strength in your hand is normal and judging from the little pain you have right now along with your normal x-ray and lack of burns, there doesn't seem to be any reason to think you have any damage to your hand or any need for Calcium gluconate.

S: Let me speak to toxicology and educate them on the chemistry behind this, you don't understand, I'm not leaving until I get calcium gluconate.

Me: Well, let me talk to my attending and we'll be back to talk to you. One last thing, where are you doing your doctorate?

S: Maricopa Community College

Me: .......nice.

First ED shift!

So today was my first ED shift and it was awesome. To start off with, one of my attendings went to UF and is the VP of the Scottsdale Gator club and said he could get me cheap tickets to Gator games!!!! That just made my whole rotation from the beginning. But on top of that I got to do so much more than I thought. To sum it up, I did this today:

- had a patient tell me he tried to shoot himeslf but his gun jammed

- pelvic exam on a lady with a prolapsed bladder...that was weird.

- participated in a code/defibrillation (that was pretty scary and awesome at the same time!!)

- watched a crazy 22 yr old patient punch a nurse in the back of the head
- watched same crazy 22yr old patient get restrained against her will by the cops and in the process set off a schizophrenic in the hallway
- listened to crazy 22yr old and schizophrenic argue through the hallway about how who was going to kill who...for 2 hours.

- intubated a 21 yr old kid with severe asthma (also really scary)

- sutured a lady's head lac completely alone (the docs really trust me for some reason haha)

So I'm still really surprised I got to do all of this on my first day. I never thought they would let me do that much, esp on my first day, it was great. I think a part of it was that it was just a busy day and I got lucky enough to get cool cases today, but we shall see I guess.  I'm working night shift for the next 2 days and I'm not so sure the middle of the night is that exciting.  I'm purposely staying up late right now so I can sleep in late tomorrow haha...i can just see myself dozing off before I even have to be at work tomorrow! More stories to come I'm sure :-)

Getting ready for 4th year!

So It's April! Where did March go??? This year is going by so fast already, it's scary. Before I know it it's going to be December! I was in Kirksville a few days ago for OMSIII testing, and wow...I don't miss it AT ALL!!! I miss my friends but honestly, you couldn't pay me enough to move back there. It served its purpose, and i don't mean to sound like I hated it, because I didn't. I appreciate the quiet beauty and convenience of the small town, but 2 years is enough. Also, there are a lot of bad memories that I would rather leave in Kirksville and not revisit. So I'm happy to say that the next time I go there it will be my most exciting trip to kirksville as well as my last...graduation!!! :)

In other news I have officially started my 4th year of medical school! I start my first ER rotation tomorrow and I'm really excited. THe docs I'm with seem pretty cool and I hope to learn as much as I can before I do my military rotations.  I can only imagine the stories I'm going to get this month, I'll keep you posted! Also, I'm going home to FL this weekend to see family and do a short triathlon :)  I'm not in the best shape for a triathlon, but it's a short race. I'm really excited for my family to be there supporting me, that has never happened before. I've never done a race in FL or close enough where family can watch, so I'm pumped about that. My dad already asked if he can follow me in a car...he clearly doesn't know how triathlon's work lol. ALso, Abbey is coming back with me!! I've missed her so much. She keeps me sane and I need her to take me for walks again.

So these next few months are going to be super busy for me. I have boards, which I NEED to blow out of the water, work my butt off on my audition rotations, and apply for residencies (i just got so nervous just typing that right now) lol.  I know the rest of this year is going to be SO stressful, I can already feel it coming. I also know myself and how I can let stress overcome me and drive me crazy. So, one day at a time, that's my goal, for everything.  I know I'm still going to worry/stress, but I can at least make a conscious effort to take it easy, enjoy right now, travel, experience new things and people while I have the chance. So much of my time is spent planning for the life I want in the future. That is a good thing, so long as I don't ignore the time I have in the present.

Song for the night:  "wheel" John Mayer...one of my favorite songs.