Round and Round

Much to my dismay I'm out of the ER now. I only get two months in the ED my first year and it's halfway over. I'm on medicine right now, and I hate medicine. Everyone picks their specialty for different reasons but most of us in the ED say the same thing about medicine: we can't stand rounding.
Rounding is the art of doing and saying absolutely nothing for hours on end while standing up and pretending to be interested. Each patients every past and present medical complaint must be examined and discussed ad nauseum. They could be here for pneumonia or DKA but we still have to talk about that time when they were twelve and they got an ear infection. Why? What the hell does that have to do with why their here now. And do I really have to miss breakfast because Mr. Smith's INR is not exactly two and a half. Is 2.4 really that unacceptable. Ever little lab abnormality must be worked up to the fullest. Maybe he has hypercalcemia because he had too many TUMS for dinner. Maybe it's a lab error. But I really don't think we need to talk about it for ten minutes and start a work up for multiple myeloma. Even completly normal people are allowed to have abnormal labs from time to time. If someone invented a machine that could give out a minute by minute Chem-7 the internist would strangle themselves with their stethoscopes. This of course would make rounding infinitly more interesting.
It's not like we only round once a day either. No the entire process has to be repeated in the afternoon. The same patients, with their same problems, get the exact same discussion not just once but twice. That's a real good use of my time. "What? We only spent a half an hour this morning discussing whether Mr Johnson should be on the renal diet for his kidneys or the cardiac diet for his heart. Let's do it again please, pretty please, with sugar on top. Let's not go home at a reasonable hour and spend time with our actually families or better yet get some sleep. This is critical life and death stuff".
Thank God it's only for a month.

Something new

Now I haven't been an ER doc for too long, but you get used to the usual stuff pretty damn quickly. Under thirty with chest pain-either panic attack or cocaine. Big lady with abdominal pain- gallstones. So it was kinda nice the other day to get a suprise. I was hanging out in the trauma bay with the typical MVA when the security gaurd comes running in. "we've got a situation out in the ambulance bay" So I run to grab gloves and run out the doors to see what's up, and by the way, unlike what you see on TV we never go outside. Only in "ER" do the doctors meet the ambulances, it drives me nuts. In runs a nurse with a bloody bundle, and sure enoug it's a newborn baby.
We all run around trying to grab the warmer from whatever dusty corner it's been relegated to and shove the baby inside. With a new baby you have one mission in life. Warm, dry, stimulate. That's it, that is the magic of life. God needs no other help then that. After a heart stopping second the trauma bay is alive with the sound of a brand new human being. It was one of those moments that brings every one, the nurses and the attendings, over for a seconds as we all looked at her. It was kinda neat, we don't get to see pure happiness too much. People die all the time in the trauma suite. I still remember what it was like the first time I called out the time of death of a patient. But it was really cool to see a new baby, a new life. And sure enough she went upstairs to the NICU to get checked out, and the ED once again belonged to the tragedy unstead of the ecstacy. But it was still one of the moments that I'll always remember.

Constipation in the ED

I hate when the board isn't moving. No one is going upstairs, no one is comming back from triage and everybody starts getting bitchy. The board is the center of activity in the ED. As the patients come back from the waiting room they get a spot on the board, but not necessarily a bed in the ED. It lists their age, complaint, which MD is seeing them and there final dispositon. People essentially either go home or head upstairs. But the board isn't moving today because we have NO beds upstairs. Nada. No ICU beds, no PCU beds, no ward beds. At least half of the board is filled with patients who have been admitted to the hospital but have no place to go. So they sit in the ED, taking up space. And the board doesn't move.
So now we start the delicate dance of walking the waiting room, trying to figure out which patients can afford to wait another twelve hours to get on the board and who really needs to go back now. Every year at least a couple people die in the waiting room because we couldn't see them in time. Usually in our department it takes 12-15 hours to from registration to getting back and on the board. The total time it takes to figure out what's wrong with you is usually another 4-8 hours ( blame radiology and lab for this). Then it can take another day or so to get a bed upstairs. It's a scary thought that in our country people can literally be 24 hours plus to see a doctor.
Just because we have no beds and the waiting room is beyond capacity doesn't mean the ambulance runs stop. We are officially closed to trauma today but the paramedics can use their "clinical judgement" to decide if they need to come to us. So from time to time we are running traumas in the middle of the ER. Almost all of our traumas are sick enough that they need to be admitted, but we have no beds, so they stay downstairs with us-backing up the ED. Right now there's a line of ambulance gurneys with patients that have no bed in the ED. In the ED there is a board full of patients that need to go upstairs. And upstairs there is a hospital full of patients who are too sick to go home. And I only have nine hours left on my shift.