This was the greatest day ever, even surpassing the time I was mistaken by an OB for an intelligent person and asked to assist with a C-section.
We received a large snowstorm last night, thus most of the doctor’s patients cancelled today. So I didn’t argue when he sent me home early. After doing some Christmas shopping in an undisclosed location I went around to the ER, and found a female doctor, whom I had followed once a couple years ago, back when I didn’t know what the different waves on an EKG were. After about half an hour of intelligent conversation, wherein I demonstrated that I knew what atrial fibrillation ought to look like on an EKG, and what the usual dose of IV lasix is, she asked me whether I would rather take histories, or do the physical exam. I said both, or whatever she would let me. So she handed me a chart, and told me to go see about it!
I wasn’t even supposed to be there; and she let me alone with a patient, which even the internal medicine residents wouldn’t do. So I went and talked to the lady, who had “angina” since the night before, when she lay down to worry about her family. And she had had a negative stress test a few weeks ago. So I asked all the questions I could think of (having in mind to satisfy the kind of detail the medicine team looked for), and after about 20 minutes went to tell the doctor, who had been with another patient, that I suspected this lady was having a panic attack, and could use some Xanax. The doctor agreed that this was a “frequent flier,” and that ativan works better for her. I said we should probably check cardiac enzymes just to be sure, and then send her off. (Except that when she heard this the lady started developing very contradictory symptoms, that was the plan we followed.)
A while later she handed me another chart. I spent about five minutes with the man, who was rocking back and forth and just about crying, and concluded that a kidney stone was the only thing that could happen that fast with those symptoms. The doctor asked what we should do, and I very hesitantly suggested that he looked bad enough to be given some morphine. I thought that was the strongest opiate. Apparently dilaudid is stronger. And I knew that the next step for diagnosis was an ultrasound or CT scan. She did take a quick look at that guy, while the nurse was starting the IV.
After a little bit there were two more patients, and she kindly allowed me the old lady who was sick to her stomach, instead of the drunk who was sick to his stomach. So I went and talked to her, and deduced that she had either food poisoning or viral flu, and needed IV fluids. And the doctor agreed with me, and let me write orders, without looking at the patient much because they’d just gotten this poor sweet little girl who had managed to fracture her femur most amazingly. Everyone in the ER was gasping when they looked at her Xray: the proximal end of the femur was snapped off and the long end displaced superiorly, and angulated almost 90 degrees (I think that’s how you describe fractures). There was nothing anyone could do for her there, except morphine and a splint, because the growth plate was probably involved; so she had to be transferred to a children’s hospital.
So in just two hours I almost independently assessed three patients, and almost figured out what to do with them. That’s more independence than I’ve had at any point this year. I love the ER; I love this doctor. Those were easy cases, and I took a fair amount of hinting before I guessed what to do, but I did get it mostly right, and I got the diagnoses right – and she let me. But it’s not just that doctor; people in the ER usually have something pretty obviously wrong. Even if it’s too complicated to figure out the root cause, you can always see what needs to be done to help them right away. There were two people in there with kidney stones, just about screaming, and in fifteen or twenty minutes they were completely calm. I also love how in the ER you don’t need a whole complicated, detailed history and physical, just the main points about what happened recently, and a general idea of whether they’re seriously sick with something else chronic, and what meds they’re taking. My rushed history-taking fits better here. I was going to say scatter-brained, but you can’t be; the nurses were calling out information and questions about five different patients, and she was just picking up their short phrases and dealing with them in the context that she had firmly established in her memory of the different patients.
I’m hooked. I’m going to be back in there every shift this doctor is on, just about. I don’t know whether her colleagues would be as free and easy, so I won’t chance it, I’ll just stick with her. This is great. I can diagnose panic attacks, kidney stones, and viral flu and dehydration, and I know what to do about it. Wonder what else I can learn by the end of December?