Monday, February 21, 2011

My Big Catch and the ER

For those of you who know me, you know that I am somebody who is very hard on myself (and, unfortunately on others sometimes as well.)  But, today, I had a moment that I am actually quite proud of.  I found it very fitting to share, especially after my last post sharing a story that reminded me of why I became a doctor, because today I had another one. 

I've been working in the emergency room recently, a great experience for an intern, as we see patients who can be very sick, but we see them from their initial presentation.  As an internist, I usually see patients in the hospital AFTER they have been seen by an emergency room physician.  There is a huge difference in the way you think of patient care in the ER vs. in a hospital admission.  As an internist I see, "Patient with a urinary tract infection with altered mental status and possible sepsis who needs IV antibiotics" with labs already drawn, imaging already done, and an assessment by a physician more experienced than I am (the ER attending) who already examined them.  My job is then to treat the patient for a few days, follow up results, make sure all of their other chronic medical problems are also continuing to be treated, and then discharge the patient to the appropriate place.  As an ER physician you see a confused patent who says, "It hurts when I pee."  At first you may think, well what is the need for an internist then?  The job of the internal medicine physician in the hospital is to make sure that first, the diagnosis was correct (which it often is not), the treatment plan is followed through (often times treatment plans are complicated and require changes and close monitoring) and to diagnose and treat any complications (of which there are maaannny).  As medicine doctors we often times criticize ER physicians for doing shotty work... for not working up a patient thoroughly enough, for not making the correct diagnosis.  After doing approximately 200 hours of ER time now, I realize that ER doctors offer a couple of amazing services to patients.  1.) Even if they are wrong about a diagnosis sometimes, they sure as hell do a good job of knowing when a patient is "sick" and when they are "not sick".  Even when a patient is admitted to me in the hospital and the ER doctors' intial gestalt is slightly off, the patient usually still belongs in the hospital.  That alone is a huge decision, and one that I have been learning a lot about with my time in the ER.  When I initially started doing ER rotations, I began my patient interviews with the mindset of an internist, with a focus on detail, on thoroughness. But it took forever.  Those are great things to do with patient encounters, but the emergency room is not the place for that.  Now that I have some experience in the ER doctor's shoes, I get what they have to do.  The ER doctor sees a patient and immediately is thinking the following:  First, "is this person dying in front of me?"  Second, "Does this patient even need to be here?"  Believe it or not half of them do not and are grossly misusing the "Emergency" part of "Emergency room". For example we get patients who present to the ER for viagra refills.  If you're a virgin and Beyonce just showed up at your door begging for you, then MAYBE you could argue emergency.  Maybe. Third, if they do need to be there, "can I treat them in the emergency room and send them home from here?" Or, "do they need to be in the hospital?  If so, do they need intensive care or not?"  They have to think that way, and think that way quickly, because when you have a line of 20 patients waiting in the ER lobby, you need to figure that stuff out fast.  You don't always have time to do a super thorough history and physical when you're the ER physician.  The core of the ER physician is always thinking:  Sick, or not sick?  It is not always the easiest decision to make in a quick situation.  I have gained a lot of respect for ER doctors after being in their shoes.  I have also learned a ton of good medicine and this experience has made me a better doctor.

However, on the flip side, my training as an internist and seeing the other side, seeing how patients fare once they are out of the ER and actually being treated for their ailments, really helped me today. 

It was just another typical day in the ER... a lot of "fast track" patients with ear aches, low back pain, coughs, viagra refills (and no, Beyonce was not in the waiting room.) , and a lot of legitimate medicine cases that we call "bread and butter":  Smokers with chronic lung disease having exacerbations, pneumonia, urinary tract infections, drunks.  I had just seen a couple of moderately sick patients and still had a lot of busy work, when my attending said to me "can you go see bed 2?  Should be real quick.  He's drunk."  We see a lot of drunks in the emergency room.  A lot of them are homeless (as was this patient) and just need a place to sober up and have a meal.  I sighed inside when given the assignment, "sure, of course I can see him."  I went to his ER bay and went to his bedside.  I began our encouter as I do with every ER patient, I introduced myself with a handshake, made sure I was pronouncing their name correctly, followed by "What brought you to the emergency room?"  His answer began with "Well, I fell off the wagon and I need help."  In my mind I already began to roll my eyes.  If I had a nickel for every time I had a drunk patient who came into the ER asking for rehab only to leave against medical advice I might not have any student loans left.  I continued into his history, it was very typical for an acute alcohol intoxication.  It would have been very easy for me to write him off and just walk away, order him some ativan, and discharge him.  But, I did my due diligence, and did what we call a "review of systems", where we ask a series of questions that cover all of the body systems to make sure there isn't anything else going on.  It turns out this patient had chest pain that morning.  Crushing, substernal chest pain, associated with shortness of breath, that didn't go away until he was in an ambulance on the way here and receiving oxygen.  Shit.  Why didn't he tell me about this as the FIRST thing that made him come here?  Sometimes patients have a different idea of what is important than we do as doctors.  It's not their fault... and that is why we do the "review of systems".  90% of the time the ROS only confirms that you already got everything you needed from the initial history, but once in a while, it totally saves your ass.

The patient's initial EKG showed no changes consistent with a heart attack, but the labs 10 minutes later showed heart muscle chemicals had leaked out into their blood, a sign of significant damage to the heart.  This was a heart attack, but fortunately looking at the EKG it was a much more benign form, which did not require emergent interventional treatment.  The initial blood test for heart damage is very fast but it is not as accurate as other tests available, so it is protocol to follow-up with the initial test with a more accurate one.  The "ultra" came back 30 minutes later and confirmed the initial positive test.  However, it was almost double the initial value.  The patient wasn't in any chest pain, and the value stll wasn't THAT high.  The ER doctor (an attending with 10 years experience as a physician, and this particular doc is one of my favorites to work with) would not have ordered a 3rd EKG so early on in this patient's ER visit.  It is almost never necessary to.  But, I saw a patient in the cardiac critical care unit earlier in my intern year, who had a severe heart attack missed by the intern on call.  That patient ended up in my care and died in front of me, most likely because their severe heart attack was missed.  My gut told me to order another EKG, right then, even though the patient had no chest pain.  Their heart muscle enzyme levels had risen from the initial, and I was worried their more benign category of heart attack was evolving into life-threatening emergent heart attack.    I ordered another EKG.  The nurse argued with me. Sounding annoyed,  "Another one?  But we just got one." She was busy, I'll give her that, but this was a very clear demonstration of the gap between my education and a nurses education. The job of a nurse is a very difficult one, and I have the utmost respect for them (I was actually a nurses aid for two years before medical school), and nurses have taught me a lot as I have gone through my intern year.  However, now was a time when I had to actually use my "MD" and remind the nurse that I was the doctor in this situation and insisted on the EKG despite her rolling eyes and the body language of a rebellious teenager. 

I tended to some lesser acuity patients while the EKG was done.  The nurse brought the printed copy to me once it was done.  I noticed some very subtle changes, but they were very alarming ones to me.  A co-intern noticed them as well when my concerned eye ran it by their second opinion.  I immediately ran it to the attending who was seeing another patient who had a possible life-threatening emergency.  He was very busy, and he peeked at the EKG, noted the very subtle changes, asked me why i had ordered yet another one so early, and told me it was my call.  +Gulp+... "my call."  This was the real deal.  The attending was busy with a very sick patient, this was a very subtle call and I had no senior resident to back me up.  Shit.  I've been a "doctor" for 7 months.  Rough day at the office. My options were to let the patient, who looked incredibly stable on the outside, smiling, telling jokes, be as is and do nothing different, or two, call the cardiologist at home and make him come into the hospital to evaluate this patient.  I thought about it a few seconds, and I had almost no hesitation:  Call the cardiologist.  Err on the side of caution in this case considering the possible risks, and despite feeling bad for calling them in from home, they signed up for that job so I shouldn't feel too bad.  They listened to me on the phone, asked a lot of questions, and agreed they should come in to evaluate the patient.  Within 10 minutes they were there, lugging a bedside echocardiogram machine, "concierge at your service." they said jokingly.  I had worked with this cardiologist in the cardiac intensive care before.  I was glad it was him.  He looked at the patient's EKG, which as non-specialist internists and emergency medicine doctors we were hesitant to make a call on.  He made no hesitation.  He immediately decided to transfer the patient to the nearest invasive cardiac care center (our hospital normally would do the invasive cardiac treatment, but it was a weekend and nobody was there at our hospital.)  This was a big effing deal.  He called the invasive cardiac team at the nearby hospital on his cell phone, the ER attending was already initiating the emergent cardiac protocol, the nurse was on the phone dialing 911 for emergent EMS transfer.  We had 15 minutes or less by protocol to get all of the paperwork done, the patient started on a heparin drip (intensive medicine to prevent further clotting in the heart vessels), and the patient transferred out by EMS to the nearest invasive cardiac center.  When it was all said and done, I realized just how much I had learned from my training.  I would have never caught this 4-5 moths prior.  I would've missed it, and this patient's heart would have been damaged greatly for it.  In the worst case they could have even died within a week or two because of it once it was caught.  My fellow interns, the senior resident (who had been seeing other patients during this), and my attending were all so glad I had checked another EKG even though they probably wouldn't have.  At that moment I was really proud of myself. 

My friends, my family, my girlfriend, they all comment about me "saving lives", and usually I laugh because I know that for the most part I just help treat people's chronic conditions and don't really "save lives", but today I actually think I may have saved someone from, at the least, a horrible prognosis by catching something early.  I caught a big one.  It was a powerful display of how good my training has been. Despite all of my whining and complaining about working so many hours, and spending many nights sleeping in the hospital on call, I knew then why all of that was necessary.  I could have saved someone's life today. For real.  I am still a little bit high from the experience as I write this, and despite the cons of my job sometimes, as far as work goes I cannot think of any better feeling than this. 


  1. Weebs!

    Outstanding posts, so many of these stories are freakishly similar to what I've experienced during this crazy year. You've done a nice job by avoiding medical jargon in the blog, and I could really see people from outside the field really enjoying this :)

    On a side note, I loved the Beyonce reference (BOOSH! ...although that would be a pretty remarkable variety of ED if a dude needed viagra in this case). On another side note, I totally read your posts this week to get super pumped about my upcoming general medicine rotation. Keep it up!

    - Dan

  2. Hello!!! I'm outside the medical field and I'm eating up these posts. You are such a good writer--so transparent.

    Also, I'm freakin' proud of you Weebs! Way to go, my friend. Nice catch. You rock!

  3. See, honey...go to bed thankful every night that your life has meaning. You help people in need. What better meaning to one's life is there? I'm so proud of you, son.