PARTY GIRL.

OLD AND BOLD.

Some days in the emergency department are boring. Nothing exciting happens, no real traumas roll in, and its just a slug of an 8 hour day dealing with aches and pains and chronic issues. We need a little spice on these days to keep us going, as there’s only so much coffee I can drink to stay awake before it starts to smell the same way on the way out as on the way in. I’m not a doctor, but that’s probably not the best.

On this otherwise boring day, I had the pleasure of taking care of an elderly 79 year old woman who lives on her own. She was brought into hospital as her home care aide came into her home, thought she had suffered a cardiac arrest, and did a short period of (unnecessary) CPR.

I post up at the bedside to give her some TLC, and she’s got her daughter in the room offering support. It becomes immediately obvious that this poor lady was just sleeping, and woke up to an overweight middle aged man pushing on her chest.

Dr. Z: Well, it seems that you don’t really need to be here then, do you?
ElderlyLady: Baby, I just want to go home for my 80th birthday next week.
Dr. Z: Is there anything that I can do for you while you’re here to make your day better?
Daughter: Ohh, she gon say something dirty now.
…
…
…

ElderlyLady: Just some nice, stiff dick.

Excellent.

On my way out of the room to tell everybody with functional ears what happened, I barely start my story before the triage nurse interrupts me:

TriageNurse: I know exactly who that is. On the way in, she pointed you out and said, “That doctor with the beard, I bet he eats some gooood pussy.”

This place never ceases to amaze me.

HPI HELL.

ENGLISH, PLEASE.

When you watch practice videos of patient interviews, or better yet make it to the show yourself, you have an idea of how things are generally supposed to go when you meet a new patient. A little introduction, some hi how are you, and then the patient gives a very neat and easy to follow history of their presenting illness (HPI), you do some appropriate tests, make a diagnosis, patient is happy, you’re a hero, bada boom bada bing. After having worked as a staff ED doc for many years now, I can make a formal statement regarding that belief.

“Old me - are you stupid are you dumb?”

Let me paint you a little picture.
79 year old female. Walking, talking, caring for herself. Doing pretty well for an old bird.

Dr. Z: Good afternoon ma’am, what brings you into the emergency department today?
Old Bird: Well, four days ago my heart was racing. And i had slime in my mouth yesterday. Not heavy slime but a thin slime, you know. And today my knees are burning. The doctor told me to use oxygen at home - how often?

Some days I just… FFS.

FECAL FRIEND ZONED.

THE HUNT FOR BROWN OCTOBER.

Bodily fluids. If you're coming into the ER, the likelihood is that we're going to be dealing with some of yours - that's just the way it goes. Everybody has those that they hate more, like less, whatever you want to call it. If you're working in the hospital, you're not that sensitive.

My order of preference? I'll take poop over vomit. That's just me - so I guess I was asking for it in the long run. Don’t get me wrong, I don’t enjoy poop. It's not as if its a One Doctor One Cup scenario, but if I'm forced to choose, I'm Team Mr. Hankey.

One night in the ED, I had the pleasure of taking care of the sweetest old lady in the world. The poor woman had been in and out of the hospital frequently over the last several weeks, but she still made sure to take care of herself. She had a fresh manicure, a new perm, and she had contoured that makeup like she was an Instagram “influencer”. Battling a recent diagnosis of cancer that left her in terrible pain, she was on a high dose of opiate painkillers. And hey - do you know what side effect they have? Constipation. And tonight, it was a constipation to end all constipations. If you’re worried about what comes next, brace yourselves - I played the role of hero. A hero in a brown cape. Captain Poo Patrol.

It's called a disimpaction. It's not the most glamorous thing that we do, but life in the emergency department is not all double rainbows and kittens. Sometimes you have to get your hands dirty... your (hopefully) double gloved hands.

A typical rectal exam consists of one finger. You just gotta ease that bad boy in there with plenty of lube and some comforting phrases that you definitely don’t believe yourself. “It won’t be that bad” said the guy who has never had a rectal exam. Most people have both emotional and physical discomfort with this procedure... Not my cute old lady.

Dr. Z: Well, I can certainly see why you haven't been able to go to the bathroom. There's a very large, hard ball of stool down here that's acting as an obstruction.
Lady: You've already started?

Game on.

As I began to form the world's worst triple scoop waffle cone, the conversation became ever more interesting.

Lady: Oh yes. Oh… yes. OH yes.
Dr. Z: Are you ok?
Lady: That's the spot. That. Is. The. Spot. Oh yes, that's it right there. Oh my god yes!
Dr. Z: Ma'am… should I stop?
Lady: Am I pooping? Oh my god I’m pooping! Oh yes, this is working. You are amazing! Please keep going!

Now, I don’t know if you’ve ever been in an emergency department before, but this ain’t no episode of House. These are not luxurious 300 square foot rooms enclosed with soundproof glass doors. The rooms are semi private at best, with curtains acting as glorified walls.

At the end of the day, I learned a couple of things. One, emerg staff really do care about their patients, and will fly into a room at Mach 3 if they think a constipated geriatric woman is being sexually assaulted. Two, it really is possible to sound like you’re having sex while taking a really good shit.

No cap, yo.

THINGS PATIENTS SAY.

EYES OPEN, MOUTH CLOSED.

Most days at work are great. Some days at work can be long, frustrating, and make you feel like you were shit on by a herd of African elephants that had just eaten Indian food. When those days come around, all you need is a single breath of fresh air to make it through the day. That, or one sassy black woman wearing a turtleneck. 

One sunny day in July, a patient came in to the Emergency Department after a motor vehicle collision, and had some neck pain. Me, being the the incredibly astute physician that I am, decided that some imaging was in order, and sent the patient for x-rays of her cervical spine. While checking for the three views of her cervical spine a few minutes later... I notice something odd. There are only two. ONLY TWO. WTF, x-ray dudes. So I call  over to xray: 

Dr. Z: Art, what's with Ms. Turtleneck only having two views of her c-spine? What happened to the odontoid view? 
Art: She wouldn't do it, buddy. She refused. Just got all upset and said it wasn't gonna happen. 

*cue Law & Order music*

Dr. Z: Hi Ms. Turtleneck. I've taken a look at your x-rays, and for the most part they look good. I only have two of the three views that I need, though, so I can't say that everything is ok with 100% certainty. Why wouldn't you do the third view? 
Ms. Turtleneck: Baby, listen here. You cute and all, and I like you. I don't know where you from, but in my neighborhood, when a strange man asks you to close your eyes and open your mouth, he best have bought me dinner first or I ain't opening shit.

Game, set, match, sassy black woman in a turtleneck.  

WE NEED A DOCTOR.

NO TIME FOR ANYTHING. 

 
Emergency departments come in many different shapes and sizes. Small, large, quiet, busy, country, urban, blah blah blah. Some departments operate on a one big room type of strategy, where all patients are placed into the same unit, regardless of complaint. Emergency departments can also be broken up into different areas to better streamline patient care, such as directing patients with minor ailments to a fast track department, moderate complaints to an urgent care unit, and the sickest to the main department ("the Main"). 

I work in the latter. Sometimes its great, such as when you're working a fast track day after a few days in the Main - you know that although you will see many more patients, the acuity will be low, nobody will die, and the worst part of your day will be saying "no" to the guy that comes in telling you that he lost his Percocet and he only had his 90 pill prescription filled yesterday.  Another nice aspect of having the department split up into different units is that we have a large number of attending physicians that are on, at any given time. Two people will man the main, and there will be one doctor in urgent and one in the fast track unit. Four doctors - and we can all help each other out if the need arises. 

Or so I thought.  

The other day, I had a little emergency of my own. I came into the Main for a morning shift. After seeing a few patients, and drinking a couple of coffees, I had... well, I had to leave the department for a few minutes. If I was Al Bundy, I would have folded up a newspaper under my arm and announced to the room that I'd be gone for awhile.  

Anyway, I'm about a minute into my leisurely escapade, when an announcement blares over the PA system:

"We need a doctor in room 8. Can we please get a doctor in room 8!"

Knowing that my partner was also working in the department, another physician was in urgent care, and a third was in fast track, I thought that one of them would get to the room first. That annoucement is never made unless a doctor isn't immediately available. Nonetheless, I began the process of getting out of the bathroom - just in case. It was a good thing that I did, because the next thing that I heard was.

"Doctor in room 8, stat!"  

Shit. 

It took me all of twenty seconds to wash my hands, and dry them on my scrubs as I trotted to the department. Sure enough, I was the first doctor in the room. A young man had been brought in by paramedics as an overdose, and the nurses had already had him lined and were hooking him up to the monitor. This was the report:

"Yeah, we got a call from somebody that said that this guy was on the ground and wasn't responding. Nobody was there when we got there, so we had to kick the door in. He was surrounded by liquor bottles but we didn't find any drug paraphernalia. We gave him some naloxone and he woke up a little, but that's all we got."

Okie dokie. I start calling out orders while I examine the patient... he's drowsy and confused but attempting to follow commands. The nurses have more naloxone at the bedside, so he is given a small dose and doesn't improve at all. He's denying any drug use, and appears very uncomfortable and quite diaphoretic. When the blood pressure cuff read 230/120 mmHg, I know that this man may be a little sicker than just a simple overdose. He is rushed to CT, where he is unfortunately found to have a brain bleed. He begins decompensating, requires intubation, multiple infusions, neurosurgery consultation, and a trip to the Intensive Care Unit. 

I get back to my seat, feeling down for his family, and feeling as though I've lost my opportunity for a bowel movement. That puppy isn't coming back until I start to drive home and I'm stuck in traffic. I can picture myself now, sweating while I pull into the driveway and running into my home, ignoring the dog and making a beeline to the bathroom.  Great. 

The other doctor that I am working with is sitting at his computer, beside mine, charting on his own patients. After a minute, he looks over at me and we have this brief conversation: 

Other doctor (OD): What happened in 8?
Dr. Z: Oh. Young alcoholic came in obtunded, ended up having a brain bleed. Pretty shitty. 
OD: Yeah, that sucks. I'm really sorry that I wasn't able to get into the room before you, but I was in the middle of an LP. 
Dr. Z: Oh, no worries. I was in the middle of a BM. Yours was probably more important. But less satisfying. 

We laughed, and then we realized we still had more than 8 hours to go in our shift, and the laughter died. Like I do, inside, every day.