June 21, 2007 | Leave a Comment

Free at Last, Free at Last

After six years of screwing around, I finally have a job. As many of you know I had to repeat my intern year because of a little something I like to call The Biggest Fucking Mistake of My Life. I won’t mention where I did my first intern year because its very name would serve as chum to attract the fearsome creatures guarding its reputation, not to mention awakening Those Who Guard The Sacred Flame of the specialty from whose clutches I barely escaped.
So I’m done with off-service rotations and as of July first will be a fully functioning second year Emergency Medicine Resident (but a PGY-3, you understand). The best thing about this is that I will be working predictable shifts for the rest of my residency with no call and the ability to sleep every day. I actually finished my off-service rotations a few months ago and have been working in this manner ever since. It’s pretty cool but I want to caution those of you thinking of matching into Emergency Medicine because you don’t want to work hard to think again. While it may be true that at most programs you will get what seems to be a ridiculous amount of free time (we work 14 shifts per 28-day block), at the end of a stretch of four shifts you are going to be wiped out, in a good way mind you, but wiped out none-the-less.

The pace at a typical Emergency Department that can support a residency program is relentless. I don’t deny that other residents work hard. I’ve done enough off-service rotations to know that they do. On the other hand the long days of, say, an internal medicine resident are broken up a little with conferences, the occasional slow clinic day, and frequent lulls in the action where one may take a breather which is not the case in the Emergency Department.

In Emergency Medicine when we are at work we are working, usually flat out, for the whole shift. As most residency programs are in what amount to charity hospitals there is never a shortage of patients and they will keep coming and coming, at all hours, and for a terrific variety of chief complaints. If you are ready for this and don’t mind multi-tasking then you will enjoy it. If not, this is not the specialty for you.

I Try to Be Empathetic But Come On Now….

I actually have a great deal of sympathy for addicts. It’s hard not to as they are some of the most miserable human beings you will ever meet. It can’t be much of a life bouncing around the various Emergency Departments in town looking for your next fix, getting more feral as the delay between presentation and your lucky strike, a new resident who has never seen you before, stretches to minutes and then hours.

Where addicts get the money for their habits in between emergency department visits is sometimes a question you do not want to ask. While it is true that some have money from disability and some have family or friends from whom they steal, many do unspeakable things for their drugs, things that would curdle your blood to think about.
There are two distinct philosophies regarding drug seekers. One school of thought believes that it is easier to give them a little morphine or vicodin with the goal of getting them the hell out quickly before they become a space occupying lesion. The other school believes that giving narcotics to the addicted enables drug-seeking behavior and encourages the waste of resources, sometimes leading to delays in treatment for people who are really sick. I probably lean towards the former school of thought because my first instinct is to give everyone the benefit of the doubt. Laughable as it may seem, even drug seekers may occasionally have a real medical problem so I try to be open minded.

But for God’s sake, “Rectal Bleeding” is not the thing to fake if you want drugs. Not only does it involve a complicated and expensive workup but it is going to require me to stick my finger up your ass, not something I generally like doing. And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry. It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit. Indeed, the fact that you couldn’t prounounce the name of the only pain medication to which you weren’t allergic, something starting with a “D,” made me a little suspicious. And then when I discovered that you had a complete workup for rectal bleeding three days before with no findings whatsoever it was disappointing…and embarrassing for me because I was really gung ho to save yer’ friggin’ life until I got the old chart.
I also want to point out that if you are an addict and present with constipation after going on an oxycontin binge, reaching back and pulling feces out of your ass is not going to make me want to help you. You accused me of not caring but there is no way I am going to get close to you until you put your hand, the one covered in fresh manure with half-inch long nails under which is packed several year’s worth of other unspeakable things, down on the bed and stop trying to grab me. If you tried that on the “skreet” you’d get your ass kicked or arrested. Why is it all right in the Emergency Department? I understand that you’re jonesing but it is too much to expect of nurses and doctors to put up with this. If I made the rules I’d taser you and throw you back out on the street.
Wille Sutton robbed banks because that’s where the money is so I guess it makes sense for you to come to the Emergency Department because that’s where the drugs are. But being your dealer is not really our job and athough this would shock you, neither is taking care of you in the hospital or solving your personal problems.
And don’t kiss my ass either. I am not the best doctor in the world and your telling me I am just reminds me how crappy it is to be a resident at the bottom of a steep learning curve. Thanks for ripping that scab off and rubbing salt in the wound. If you just kept your mouth shut and complained of back pain like every other drug-seeker I would have probably given you something…except for that thing with your ass of course.

Silver Bullet

I am no luddite. While I am not on the cutting edge of technology I generally embrace it willingly when it is mature enough to simplify my work. Lately however I’ve had a change of heart about PDAs. Oh, I was enthralled four years ago when I was first introduced to them. Here at last, it seemed, was the one device that would put the bewildering immensity of medical knowledge at my fingertips and eliminate the need to carry the myriad pocket reference books that never really seemed to contain what I actually needed to know.

That’s all most us want. A simple reference book to carry around. A silver bullet, if you will, the one thing that will do the trick. The PDA is not it. Maybe it’s because the thing is so expensive. I already dropped one and fractured the screen. I got a new one from my program but it’s only a matter of time before it is damaged or stolen leaving me $300 in the hole if I want to replace it. Perhaps I have grown to dislike the complexity of the device, especially downloading software which never seems to work for me and my seven-year-old Toshiba laptop. It probably takes less authentication and verification to launch a nuclear missle then it does to download Epocrates. And the silly thing keeps begging me to update it, to synchronize it, and to hold its hand and comfort it.

Supposedly using the PDA to keep track of your patients is all the rage now but unless you are at a hospital that is totally committed to integrating medical records wirelessly and uses bullet-proof software, it is probably more trouble than it’s worth. An index card with the patient’s sticker at the top is actually a lot quicker, especially if you learn to only recored pertinent information. I also find that I can remember the important things about my patients and I don’t need to write much at all.
So I have ditched the PDA and most of my pocket reference books. In their place I carry a Tarascon Pocket Pharmacopia for a drug reference and the most excellent Tarascon Adult Emergency Medicine Pocketbook. The Emergency Medicine Pocketbook in particular, while as compact as all of Tarascon’s Pocketbooks, is packed with nothing but useful information. It at least tells you how to start the workup for the great majority of presenting complaints. Anything else you probably have time to look up later.

Just something to think about, especially those of you starting intern year in a couple of weeks. The Internal Medicine/Critical Care pocket book is a pretty good reference for most of your rotations.

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