It was shaping up to be quite a boring shift. Only a couple hours to go, and nothing very interesting. There must have been a notice in the paper that the super keen medical student (myself) was going to be working a shift in Emerg, because there really could not have been any other explanation for the massive numbers of people showing up in droves with a chief complaint of "I have a runny nose."
Then suddenly the night got very interesting. Here's the play-by-play.
6:30 pm :::
A call came in from ambulance dispatch, and the unit clerk quickly summoned the doctor and charge nurse to keep them informed: "There's been a massive car accident down in the valley. A minivan and a car carrying six people in total crashed into each other head-on, somehow got entangled to the point where they were attached, and then both went over the side of the bridge, careened down an embankment, ran into a few trees and then burst into flames. We're setting up for massive burns, tree trunk impalements, major trauma and who knows what else. The medevac helicopter will likely take out the most serious victims to the larger hospital in the next city over, so we'll likely get a few of the less severe tramas...but by the sounds of it, even those will be pretty serious. By the time they get them extracted and bring them in, they should be here in about 50 minutes."
6:40 pm :::
There is a buzz around the department. The night shift MD shows up to start what he had hoped would be another routine shift, and is instead informed about the upcoming chaos, with several curious other ER staff crowding around to hear the briefing. More reports have come in - the area is too heavily forested, meaning the helicopter can't land. All the traumas will be brought in by ambulance to our hospital!!
7:00 pm :::
The night resident has been paged to show up earlier, the afternoon shift MD (whose shift was just ending) made the decision to stay a bit later, and people are busy in the trauma bay setting up IV bags. The care aides and clerks are suddenly finding solutions to the longstanding province-wide 'no beds in the rest of the hospital' crisis, magically clearing up four beds in emerg in anticipation for the incoming carnage. I'm helping out a lot, too, I'm told, by going to see a patient who had a bookshelf fall on her head. And another runny nose.
7:10 pm :::
Another report comes in. The meat wagon won't be in with what's left of the survivors for yet another hour; it seems as though the army or search & rescue might have to be called in to access the area. There's even a suggestion that there might even be gunshot wounds if the drivers got into a road rage argument after the dust settled. In the meantime, my patient with the bookshelf falling on her head turned out to only end up having a textbook fall on her head, the rest of the shelf narrowly missing her body. Her friends were quite concerned, and brought her in. Oh, and she also wants me to assess her runny nose.
7:20 pm :::
The latest from the disaster zone is relayed to the physician: there is an indication that things may not be as serious as they were initially thought. Three of the people walked out of the accident unscathed, but the other three still seem to be pretty serious. No word on the accuracy of the gunshot rumour. For my patients, I continue to prescribe kleenex, one of the few things that I as a medical student can actually dole out, like it's nobody's business.
7:40 pm :::
Word arrives - the ambulances are on their way! One is coming Code 3 - lights and sirens - with the major trauma victim. The other two will follow, as they're coming routine, without lights and sirens, as their patients aren't too serious. The afternoon shift doctor figures that she may as well go home, since things aren't as bad as they first seemed.
8:00 pm :::
Things have somewhat died down, until the first ambulance is heard in the distance bringing in what must be the major trauma victim. A crowd of ER staff instantaneously gathers at the ambulance bay entrance to greet the incoming disaster. Notably absent from the crowd are the seasoned veterans among the emerg staff, and the doctors, who are going about their own jobs.
8:05 pm :::
The ambulance has screeched to a halt, and the paramedics are throwing open the rear doors to reveal their mangled cargo. The crowd that gathered utters nearly an audible, collective groan of disappointment as the patient is wheeled out of the ambulance, sitting up on the stretcher, laughing and joking with the paramedic, without so much as a single indication of major burns, tree trunk impalements, or missing limbs or appendages. In fact, the patient has a makeshift splint on one of his legs, and other than that, appears to be completely well. The patient is deemed non-urgent, and the doctor sends me in to see him. He explains that the accident was pretty much a fender-bender that ended up with his car ramming the guardrail. And despite having what might have been a broken leg, he says that it doesn't hurt that much, and that actually the major thing bothering him right now is his runny nose.
Friday, October 17, 2008
The call any med student in Emerg is waiting for: "There's been a massive accident."
Sunday, October 12, 2008
She was one of those 'natural' people, and the odd x-ray terrified her.
She was one of those 'natural' people, who always wanted to do things naturally, and even the odd x-ray terrified her. Too much radiation. She once wore a cast on her arm for 6 weeks after falling off a horse, for what could have been just a sprain, just to avoid the two x-rays it would have taken to rule out a fracture.
So, obviously, getting a mammogram was out of the question.
Her doctor tried over and over again to explain to her that a mammogram gives you a very minimal amount of radiation, the same amount as living in a city for 7 months (0.7 milliseverts) - the average U.S. citizen is exposed to 3 mSv per year of 'background' radiation.
The mammogram would have picked up her breast lump long before she felt it, long before it was diagnosed as cancer, and long before she would have to get her breast surgically removed.
A few years later, she started losing weight suddenly, then one day coughed up a startling amount of blood. She had never smoked, so lung cancer never even crossed her mind. Fortunately the radiation dose of 1 chest x-ray (0.1 mSv) no longer scared her, given her past experience, so she got the x-ray her doctor recommended to check it out. Unfortunately, however, breast cancer can spread to the lungs, which is what her doctor found on the x-ray. She died a few weeks after I met her in hospital, surrounded by her family, and countless beautiful flowers and cards showing how much she would be missed.
The week before she died, she said to her doctor over and over, over the sound of her oxygen and between short, gasping breaths, "I should have listened to you. I should have gotten that mammogram."
I had a conversation with another patient last month who is younger than my dad, an incredibly friendly and cheerful man, who is dying because he was too afraid to have a doctor stick a finger up his bum. Had he done that, his prostate cancer would have been discovered a long time ago, long before the it had the chance to spread to his spine, ribs, and legs, forcing him to live his last few months unable to get out of bed and suffering from excruciating pain every time he tried to take a breath. While you are celebrating Christmas with your family this year, his family will be celebrating their first Christmas without him.
It takes a lot to wrap my head around the fact that I am meeting and treating patients who will be dead very soon.
It's harder to accept the fact that a good number of these patients, who drink litres of alcohol a day, smoke like a chimney, don't get off their couches, and especially those who don't bother getting screened for cancer, could have had much longer lives.
Yeah, the screening tests we have aren't perfect, and some of them are uncomfortable and seem a bit undignified. But they do save lives, and so if you are in that age group, there is no excuse to not get them done.
This is not the place to get medical advice, so talk to your doctor about getting a prostate exam, a pap smear, or a mammogram. Sooner rather than later, please.
Monday, October 06, 2008
If this post ends abruptly...
Note - I'm writing this in the hospital as I'm on call, so if it ends abruptly it means I got paged and have to run and was up all night and didn't get the chance to finish it.
While most of my call shifts have been pretty interesting, tonight seems to be very slow. So far, I've just been sitting around in the library, doing noth
Saturday, September 27, 2008
The curse of the medical student on obstetrics
Number of babies delivered on Monday and Tuesday morning while I was scheduled to be in the obstetrician's office: 9
Number of babies delivered on Monday and Tuesday afternoons while I was on the ward waiting for deliveries: 0
Number of babies delivered on Wednesday when I had been scheduled for a day of looking at rashes with a dermatologist: 6
Number of babies delivered on Thursday when I had been scheduled for academic sessions: 5
Number of babies delivered on Thursday night and all of Friday when I chose to give up sleep and instead sit on the ward in order to assist with some deliveries: 0
Plan to increase the number of deliveries for my second week of Obstetrics: Release prostaglandin into the city water supply, show up at the hospital, and wait. (For those who don't know, prostaglandin is used to induce labour)
I did get to see two c-sections, including an emergency one at 3:00 am for a prolapsed umbilical cord - very intense - but so far, no natural deliveries here.
Friday, September 19, 2008
When patients try to fool doctors - four interesting types of fakers
Most people have heard of Munchausen's syndrome, a fascinating condition in which patients try to fake a condition in order to draw attention or sympathy.
There are a few syndromes that doctors need to keep in mind, some of which are quite fascinating, in which the patient tries to fool the doctor for various reasons. Here are some of those conditions, how the patients fool the docs, and how the docs avoid being fooled.
1. Drug-seekers
What are they –
In a sentence, the bane of any ER physician's existence. They're either addicted to pain meds, or obtain and fill prescriptions then sell them on the street to addicted people for a huge profit.
How they fool doctors -
Drug seekers can be very slick. I have seen a patient had another doctor vouch for them, one who wore their full police uniform, an adorable 80-year-old church organist, and even nurses and doctors ... all of whom were found to be getting prescriptions for pain medications and selling them illegally.
How doctors recognize them -
Besides being highly suspicious of any patient who asks for narcotics, some regions have databases that doctors can use to determine if a patient has filled a suspicious number of pain prescriptions. However, some drug seekers raise a lot of suspicion on their own. They'll claim to be allergic to every non-addictive type of pain medication, which is statistically unlikely. Others are just bad actors. They’ll shriek and cry at the lightest touch when a doctor pokes their back to find out which part hurts… then later, the doctor will give them a friendly pat on the back, and find that the supposedly painful spot no longer seems to hurt.
2. Malingerers and Insurance Hopefuls
What are they -
A "malingerer" is defined as a person who fakes an illness with the intention of avoiding duty or work. I'll lump these in with patients who fraudulently fake or exaggerate illnesses to try and get insurance payouts.
How they fool doctors -
Malingerers will seem to have a lot of pain, and some actually are suffering from very real pain. They use this, however, to prey on a doctor’s empathetic side. They can also be quite convincing actors when they demonstrate just how incapacitated they are.
How doctors recognize them –
By knowing the physical exams and anatomy very well, doctors can get suspicious if the results of a few different tests of the same joint or muscle aren’t consistent. Some malingerers, though, can be fooled quite easily. Even I have had my suspicions raised with a patient who struggled to raise her arm a few inches when I asked her to demonstrate her range of motion. When I then asked her to show me how high she could raise it before her accident, she effortlessly shot her arm up high above her head!
3. Psychogenic nonepileptic seizures
What are they –
This is a term for people who appear to be having seizures, but it turns out that they are actually not suffering from epilepsy – for various reasons, they’re faking the seizures.
How they fool doctors –
Anybody in a doctor’s office or emergency room who is having what appears to be having a violent seizure, will obviously get the benefit of the doubt. In fact, in some cases, it is many years of investigating and giving high doses of seizure medications before a doctor realizes that the patient has been having nonepileptic seizures the whole time.
How doctors recognize them –
Research has shown that nonepileptic seizures occur more commonly in a doctor’s office or waiting room, or when there is a witness around. Some medical textbooks suggest giving such patients a sugar pill or an injection of water while telling them that this medicine has been known to cause seizures, and seeing if the patient starts shaking. While this can seem deceitful, the lie isn’t usually necessary: some patients still have these fake seizures even if they are told that they are being given something that can induce both real and fake seizures. Other things doctors look for are things such as where the patients bite their tongues, which is often in a different location for real and fake seizures, and the length and frequency of the seizures.
4. False comas
What are they –
Hopefully I don’t need to explain what a fake coma is. I will mention though, that people fake comas for a variety of reasons. Some people with psychological conditions feel safe in a hospital, and fake a coma so they are surrounded by doctors and nurses. Others have been found to fake being knocked unconscious on a ski hill, because they can’t afford a bus ticket home and would instead prefer taxpayers pay for a helicopter to fly them to the nearest city.
How they fool doctors –
By laying very, very still.
How doctors recognize them –
While there are some non-invasive tests that can be done to determine if a coma is indeed real, sometimes doctors aren’t even trying to “catch” a fake coma when they do their neurological exam and find that some results don’t add up. Also, patients who appear to be in a coma but resist the doctor opening their eyes, or flinching when the doctor’s stethoscope swings close to their face, obviously raise suspicion. Obviously to determine legitimacy it’s important the doctor knows what is normal, because strangely enough, patients with legitimate comas have been seen to do odd things such as cross and uncross their legs.
That’s not to say, however, that these “fakers” don’t need help. While the financial gains for drug-sellers or insurance scammers are usually based on greed alone, people who are addicted to drugs, or feign comas and seizures, can have very real and complex psychogenic conditions (to give you an idea of how complex these conditions can be, some patients may not even be aware they are faking). While they can make a doctor’s work more challenging, at the end of the day all of these people do need real treatment – not with narcotics or anti-seizure medications, but with psychological counselling to determine the underlying reasons that are compelling them to fake these conditions.
