Sunday, January 11, 2015

5 Terrifying Secrets of Hospital Emergency Rooms

The ER is a place seemingly designed for Hollywood-level drama. It's a big room full of people suffering the after-effects of tragic accidents or the sudden onset of vicious illnesses.

You've got mourning families, bullet wounds, people shouting STAT and waving electric paddles.

But what about the men and women who call the ER, well, not home, but at least "the office"?

We wanted to know what television leaves out, so we sat down with an ER doctor for a candid look behind the blue, plastic, blood-spattered curtain. She told us ...

#5. Doctors Train on Your Body

Once, I was showing a new family-medicine doctor how to do his very first spinal tap -- a procedure in which a long, thin needle is jammed in between two vertebrae in the lower back.

I started by having him watch a video of someone else doing it. On YouTube.

So, he watches the YouTube video outside the room, and I remind him that if he felt resistance as he was pushing the needle in, that was probably bone, and he'd need to withdraw and try again.

So, he starts on the patient (who is awake, but out of it) and pushes in hard. He keeps pushing, and finally says, "I don't think I got it in the right place."
So I go to pull the needle out of the patient's spine, and I can't. The needle's stuck in there.

When we finally got it twisted out of the patient's spinal column, we saw the damn needle was bent at a 45-degree angle because he'd slammed it into the bone so hard.

The patient never knew (drugs erase all mistakes and bleach every sin).

"Why was he practicing on a live human being?" you might reasonably ask.

The answer is that there is no perfect analog for a live patient, and somebody had to be his first.

That's why we have teaching hospitals: you can't learn everything with dummies and simulations.

We're all OK with this in theory, but in practice it means at some point you'll be at the hospital and someone will be training on you.

It might be a nurse doing an IV, a physical therapist getting you out of bed, or it might be your doctor.

In the good old days, medical students got more of this hands-on training before they graduated, but due to changes in medical education, brand-new doctors often have to learn on the job.

As a senior resident, I've walked interns through everything from a pelvic exam to a lumbar puncture to a central line placement (that last one might not sound too bad, until you realize a "central line" is a large IV usually inserted directly into your jugular).

Unless the patient asks, I never volunteer the fact that someone hasn't done a procedure before -- it just adds a level of stress for the patient and the doctor that neither party needs.

Instead we play it cool, trying to project an aura of confidence like the intern didn't just look this up on YouTube a few minutes before entering the room.

And I guess here I should address the obvious question ...

#4. I Also Google Your Illness

People expect doctors to know everything.

We go to school for years more than most people, we seem to make a ton of money, and a lot of us have nerdy-looking glasses.

So it would make sense that we are bottomless wells of knowledge, and shows like House and Grey's Anatomy don't do anything to dispel that notion.

In the real world, if a patient shows up to the ER with a somewhat rare disease, instead of immediately knowing the nuances of the pathophysiology, epidemiology, and treatment, I'm struggling to remember the basic details of a disease that I learned about back in medical school.

There are just so many things that can go wrong with the human body, and no doctor has the capacity to remember every single one of them.

There's a reason we keep all those giant, impressive books in our offices.

And Google, well, it's just a book that works instantly, and occasionally directs you to porn when you're trying to study up on genital warts.

And even if whatever rare sickness you've contracted is something I've studied before, it might have been years -- if ever -- since I've had to actually treat it.

Goodpasture syndrome ... is that the kidneys? The lungs? The ... hooves? Is it treated with steroids or do steroids make it want to kill you more?

In pseudopseudohypoparathyroidism, is your calcium too high or too low?

These are not things that I see every day, or even every month, so I need to refresh myself on them when a patient turns up with one of them.

I'll get your history, do a physical, and then hurry out to Google your disease before I talk to you again.

#3. We Have to Find Time to Relax While Other People Are Dying

Patients (and their families) don't like to see doctors relaxing at the hospital.

I understand that -- if your husband is having a heart attack, you don't want to see me laughing with my colleagues about the crazy ending of The Walking Dead the other night ("I cheered when Daryl smashed that zombie's head in the car door!").

Or if I just put a breathing tube down your mother's throat because she had a massive stroke, you really don't want to see me sitting at my computer a minute later, eating gummy bears and texting my boyfriend about what's for dinner.
On an intellectual level, you know doctors lead normal lives outside of the ER.

But on an emotional level your loved one is sick and I'm blithely popping candy in the next room like some sort of sociopath.

But this is my everyday life, my job.

How many of you go a 12-hour shift at work without any sort of break?

Doctors need downtime too.

For most people, a trip to the ER is a scary, very rare occurrence.
For me, it's 60 to 70 hours a week, every week.

Once we've diagnosed a heart attack and started treatment, there's not a lot more for me to do if the patient is relatively stable.

If you see me chatting, it's because I'm waiting for a blood test to come back, for the cardiac specialist to call me back, or for the pharmacy to deliver medications.

It's not because I don't care or because your loved one's suffering isn't important to me.

It's because I wouldn't be able to survive in this job if I couldn't compartmentalize.

On a bad day, I've had to go from an hour-long code on a young girl who died in the trauma bay after being hit by a drunk driver, immediately into the room of someone looking for a prescription for pain medication.

I have to show compassion to that person, with the echoes of that little girl's dead eyes in the back of my mind.

#2. We Notice Some Weird (Cynical) Trends

Mondays are the worst.
About 5 percent of what I see in the Emergency Room are actual emergencies, 10 percent are urgent cases, and the rest of the people who come into an ER could probably have waited for a normal duty doctor.

And a huge number of those non-emergency, non-urgent cases flood us on Monday.

Why? Well, if someone pulls their back on a Friday, they're not going to waste weekend time in the hospital.

They're going to come in Monday -- to get their minor injury seen to and a doctor's excuse for their work absence.

There are a lot of things like that we start to notice over time.
Another one: the patients most likely to pass out while getting stitches are young guys with tattoos -- women and old people do so much better.

I make the young guys lie down before we even start. They're going to pass out anyway, and anticipating that makes less work for me.

And then there are the drug-seeking people;
They're not usually hard to spot.
They'll claim, "I'm allergic to everything but one drug ... it starts with a D?" That's the narcotic painkiller Dilaudid, and they damn well know the real name.

But every drug-seeker seems to follow the same script: they'll come in claiming some legitimate, recurring problem, and then act as if the name of the only pain drug that works for them (which just happens to be a narcotic, every time) is some half-remembered riddle.

If this all sounds like I'm being judgmental, well ...
#1. Yes, I'm Judging You

I said above that only a small percentage of what I see are actually urgent cases.

Well, everything about the whole ER experience -- from the long wait to the annoyed look on a nurse's face -- makes more sense if you keep that in mind.

As for me, it takes only a few minutes to know if I like you or not.
It's not going to affect your standard of care, because I'm a professional. But it might affect if I remember to tell your nurse you asked for a blanket, or if I go out of my way to offer you a written work excuse. Petty? Maybe.

But this is what you're going to get until they finally staff hospitals with robots: ER doctors are human beings and compassion fatigue is an actual thing.

Once you see enough gunshot wounds and car wreck victims, it gets difficult to care about someone who declares their chronic back pain to be an emergency.

If you think it's callous to be annoyed by someone who is truly in pain, you have to keep the context in mind.

Everyone who walks in thinks their situation is an emergency -- it's right there on the sign -- but only some of those people are right.

And there is no correlation between how much people complain/make demands and how urgently they need help.

The person screaming for pain pills for their pulled muscle is going to have to wait behind the guy who is quietly hemorrhaging.

And the person who has to wait is not going to like it.

Things that will earn my wrath: boasting that you have a "high pain tolerance" (if you've had that thought, it's almost certainly not true), not having any idea what medications you take, not having tried anything for your pain at home (you are young and healthy, it's OK to take a Tylenol for your toothache before coming into the ER), being above the age of 10 and bringing a stuffed animal in with you, the list goes on.

Doctors are human, and we definitely do not have an endless amount of patience.

And nothing in medical school taught me how to be forgiving of someone who, for instance, claims they couldn't afford the antibiotics that were prescribed for their child, but show up with cigarettes in hand.

If you're worried about pissing off your ER doc, remember: it's not hard to avoid.

Just be honest about your symptoms, and don't be offended if we aren't always as sympathetic as you'd like.

You have no idea what we saw 10 minutes before walking into your exam room.