If I try to describe every patient, I’m never going to get back to sleep, so we’ll just stick to the two most memorable:

I saw one of the patients on the PA’s side of the ER, ie less urgent/critical. She had a migraine, but had been sent on by an urgent care clinic because the usual medications didn’t seem to be helping. I thought she still sounded like just a bad migraine. The PA thought her blood pressure (~180/115) was problematic, and decided to give her a beta blocker – in spite of a heart rate of 60. Dr. Dimant caught sight of the chart before this plan had been carried out, and chewed me out for agreeing with that medication choice. (Which wasn’t really fair, because the PA did it, but I didn’t say anything.) She went and talked to the patient, who made the mistake of admitting that her pain was slightly different in character and location than her usual migraines – thus buying herself a head CT and an LP. I think subconciously I didn’t want to be creating procedures, so I was trying to avoid coming to that conclusion on her; which was bad from an ER point of view, where you do everything and rule out everything; but I did turn out to be correct in the long run, as she did not have a subarachnoid hemorrhage.

Her CT was negative, so it was time for the lumbar puncture. Dr. Dimant had me tell her the steps, which I did know, and she let me prep and drape the patient, and insert the needle. After I of course didn’t get anywhere, she took over, advancing it farther. There was something difficult about the patient, because it took even Dr. Dimant three needlesticks to get in; so it wasn’t my fault that I missed it. I felt guilty about not being aggressive enough in the first place, and also for having subjected the patient to this lengthy LP which in the end was completely normal. Fortunately her headache resolved around this time.

Around 3am, a guy fell off his roof while putting up Christmas lights (we automatically assumed that he had to be drunk to be doing such a thing at that time of night), another drunk guy was pushed out of a window several stories up, and a nursing home sent a lady in her 80s with chest pain, and a history of MIs and CABG. Since the second fall counted as a trauma, Dr. Dimant went to concentrate on him, and sent me to the chest pain lady (the PA having left by now). I took a nice detailed history from her (which later proved to be useless since she was almost totally demented, oriented only to person, and totally willing to change her story for a new listener), and then noticed that her heart rate had fallen to 50 from 95 at admission, and her monitor looked really funky. And then she said, “Oh, my heart! It’s hurting in my back now!” So of course I totally panicked. I was sure she was going to code on me, while Dr. Dimant was occupied elsewhere. I asked the nurse to recheck her blood pressure, which had increased by about 50 points since admission. About a minute later I figured I was probably hurting her more by standing in the room and looking worried, causing her to ask anxiously what was wrong, so I went to watch her monitor from the hallway and try to figure out how I would know if she was in trouble, and what I would do about it. I got as far as thinking that giving her nitroglycerin would be a good idea – but I couldn’t order any.

She survived quite nicely till Dr. Dimant finished verifying that the drunk guy, with the usual alcoholic luck, had not broken anything in his several-story fall. I told her my lady’s story, and explained the numerous gaps in my presentation by admitting that I was scared for her. Of course in a few minutes her heart rate picked back up, and her monitor straightened out. Dr. Dimant did put her on a nitro drip, but her first cardiac enzymes were negative. She got admitted uneventfully.

So, bother it, I panicked badly, and unnecessarily. I hope, I hope, I hope, that when I know what should be done, and have the authority to do it, I won’t be quite as flustered. Also, I need to go read the ACLS book, and ask Dr. Dimant to explain when it’s appropriate to be worried, and when not, about cardiac patients. Thinking about it now, I bet the trick is that high blood pressures aren’t half as bad as low, in this situation. And the EKG was ok, so that should have made me calm down some.

Advertisements