At only one point did the night become stereotypically exciting: the ER doctor was called up to the ICU for a difficult intubation, which the resident there couldn’t get. So she and I ran through the halls to the ICU, where after a little bit of hard work, she placed the tube basically by feel, since the airway was so occluded with blood. She was then immediately called back to the ER to talk to a squad which had been attempting resuscitation for a long time without success, and needed permission to stop; which she gave them.

That was the only time we actually had to run anywhere, and the only interesting procedure that happened all night. A lady did come in with apparently pneumonia leading to bronchoconstriction, but she remained stable enough to keep breathing on her own. There was another very elderly gentleman, who looked to be in rather good repair considering his birthdate, who was the first truly jaundiced patient I have ever seen. I walked into the room and I knew what the differential diagnosis was. If Chinamen were yellow, he would have been that yellow. (Do you suppose that racial description is related to the high rate of hepatocellular carcinoma in Asia, which probably leads to more jaundiced people in the general population there than in the West?) Although he had already had three kinds of cancer, we were able to demonstrate that he didn’t have pancreatic cancer (the classic cause of painless jaundice in the elderly; although he didn’t have the palpable epigastric mass that Courvoisier described), but something more easily repairable. So we had the excitement of thinking of classically presenting pancreatic cancer, and the pleasure of ruling it out. Nice for everyone.

The ER attending was very nice. Dr. Dimant is young, just out of residency, and correspondingly friendly to students. She declared herself pleased to find that I want to do surgery, since she thinks such students fit into the ER better than my most recent predecessor, who wants to do psychiatry. She promised me all the intubations, lines, and chest tubes that are needed – except of course for difficult ones on which the resident calls for help! Hopefully, the next few nights and days will generate more excitement than the last one.

There was also a PA working there for the first part of the night. He was friendly enough, but a student who wants to do procedures will almost always clash with a PA in procedure-driven field, because we both want to do the same things, and we’re both limited to the same field. Plus, this PA mentioned to me that he had worked for a number of years as a surgical PA; so I knew that he would be very particular about stitching. A couple of hours into the evening a young man arrived, having injured his hand at work, with a laceration to the thumb. It wasn’t long or deep, just enough to need stitching. After verifying (for workman’s comp, not because medically indicated) that there were no broken bones, it was time to sew. I asked if I could do it, and he asked, “Do you know how to sew?” Which is a reasonable question, but one I had trouble answering, because that’s the one thing I am (or should I say was?) fairly confident at, but I could tell if I said I knew all about it, I’d get in trouble. Then he wanted me to describe the steps I’d take; which was reasonable. “I would first prep the area with betadine – ” “We use hibiclens here.” “Ok, I would prep the area with hibiclens, and then I would inject lidocaine.” “With or without epi?” “Without, because it’s a digit, and you don’t want to cut off circulation.” “All right, but you should inject the lidocaine first, and then prep.” (Which is what the surgery residents would strongly disapprove of me for doing; but ok.)

So after that exchange, he injected, prepped, and draped, and put in the middle of the three stitches, then handed me the needle. Of course, with the patient and family watching me, and the PA watching and commenting, I couldn’t even hold the needle in the needle-driver, but kept getting it twisted; and couldn’t place the stitches correctly; and couldn’t tie tightly. Very frustrating, and I’m sure not a good experience for the patient – although thank God he was well anesthetized. When we got out of the room, the PA said, “Now, don’t be offended, but . . .” and proceeded to give me some good instructions about suturing. Which I had heard before, but obviously hadn’t been carrying out correctly. So, I failed to keep from telegraphing my pride and frustration; which was inexcusable, because I wasn’t able to do the job correctly. Tsk. Will do better next time.

After he left around 1am, it was just Dr. Dimant and me. She had told me to take only three patients at a time, and not to write on the orders sheet “till I know you better.” By 2am, I was picking up every second new patient’s chart, and she was having me figure out what tests to order. Our favorite patient was a pleasant elderly black lady, who presented at 3 am, with her husband, nicely dressed, complaining of – I kid you not – a superficial scratch to the back of one hand which she had incurred the previous day due to the high winds blowing a tree branch against her hand, and did she need a tetanus shot? With superhuman control, I managed not to laugh in the room, but inspected the hand, checked for other injuries, and verified that her last tetanus shot had been ages ago. I circled the tetanus order box, and went to report to Dr. Dimant, who was beginning to be a little stressed by several true cardiac patients arriving simultaneously. “This 71 yr old female presents with a very superficial scratch to the dorsum of her right hand, which occurred yesterday afternoon due to a tree branch blowing in the wind. I doubt that it broke completely through the epidermis. She has no other injuries. She is neurovascularly intact. She is requesting a tetanus booster. I took the liberty of marking that box. I know you don’t get tetanus from trees, but perhaps it would be simpler not to argue about that with her.” Dr. Dimant raised her eyebrows at me, and presently went back to see the patient. When we got out of the room she started laughing. “I thought you were exaggerating when you presented that. You took the liberty, indeed!” (The patient stated that she had a birthday party to attend the next day, which was why she choose to wake up at 3am and come to the ER for a shot.)

I wasn’t happy with myself because out of the several cardiac patients I saw, they all turned out to have really worrying EKGs or cardiac enzymes, and I couldn’t tell who to take seriously and who not. This was the first time I saw real MI patients. Before, on internal medicine, the cardiologists got all the ‘real’ people, and the residents only got the GERD and cocaine folks. So I felt skeptical about the guys who came in after two days of chest pain, without many typical symptoms, and had a little reproducible tenderness. Their medical history made me agree that we should do a good workup; which kept coming back positive. I need to rethink my criteria for taking chest pain seriously.

Also, I believed the nurse when I shouldn’t have. I went to see one patient, a nice guy who told a straightforward story of having been in a bar fight the week before, and hurt his hand on someone’s teeth, with the swelling now not decreasing on the antibiotics he had been given, and increased wrist pain. It sounded like a change of antibiotics, and a repeat xray for scaphoid fracture would be indicated. When I got out of the room, the nurse told me, “Oh, he’s a drug-seeker. He comes here all the time with crazy stories. Today he took a break and just said he’s in pain.” And I believed her, and presented it to Dr. Dimant as, this guy looks pretty real, but I’m not sure about the infection in his hand, and the nurse says he’s a known drug-seeker. Well, when she examined him, she thought his pain was very realistic and consistent, and decided to take him seriously and do a thorough workup. So I let the nurse change my first impression by telling stories. Bother it, Alice, shouldn’t do that. Even drug-seekers can break their wrists.

Anyhow, Dr. Dimant and I liked each other, and I’m getting the hang of the ER. The nurses are nice, even if they are too cynical. Maybe something bigger will happen tonight. (I tried to donate blood again, and managed to increase my BP by 25 points (definitely cheating), and then my hematocrit was one point too low. I guess I should take the hint. Even if I wanted to try again, it will probably be another two years before my schedule allows the attempt.)

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