A Normal Day

“The trouble with normal is it always gets worse.”

-Bruce Cockburn 

I'm officially done with my first rotation, and every shift has been just as crazy and hectic as the first one.  I'm not sure if it has really gotten any easier.  Sometimes it seems like the only difference is that now I'm a little better mentally prepared for the organized chaos I encounter every time I go through the revolving door into the ED waiting room.  Several people have told me that this is not what the ED is normally like, but I already know better than to believe that.  It's like when a doctor tells a patient that this won't hurt, right before stabbing them with a syringe of lidocaine.  Of course it hurts, at least until the numbing effect of the lidocaine kicks in.

When I press people to explain what the normal ED shift is like, I can't really get a good answer except for something along the lines of, "not like this."  Presumably, normal means that there are fewer patients.  Not only that, but fewer patients with non-urgent complaints.  I can identify with wishing there were fewer patients.  There is just a feeling of desperation that I get every time I look at the growing list of patients in the triage area when I'm already stretched thin in too many directions as it is.  As for too few urgent patients, that doesn't seem like a problem to me at all.  I have already helped care for patients who were sick enough to be admitted directly to the intensive care unit (ICU), and also patients who were sick enough that they didn't make it to the ICU.  Spending every shift caring only for these high acuity patients would be more than I could cope with, at least right now.

So the main issue seems to be one of patient volume.  But what does it even mean to say that the ED volume is above normal, anyway?  It's not like the number of annual visits to the ED is a static number.  In fact, we know that the number of yearly ED visits in Massachusetts has continued to increase even though a state health care reform plan was enacted in 2006.  In other words, this increased volume isn't some kind of aberration.  It's now the new normal.

The Flying Ambulance

“...The helicopter symbolize(s) the victory of ingenuity over common sense.” 
~Montross, Lyn and Prouty, Ray, U.S. Marine Corps Helicopter Experience, p. 20.

You may recall that a few weeks ago, I was half drowned to death and the other half scared to death while going through dunker training.  (Click here to read about it.)  This week, I had my first LifeFlight shift and went on three helicopter flights.  LifeFlight is the UMass emergency medical helicopter program.  Each flight has a three-person crew consisting of a pilot, a flight nurse, and a resident.  I was a fourth person going along mainly to observe.

I will admit to being skeptical about the value of the emergency medical helicopter experience for residents in general, and even more skeptical about the wisdom of my physical presence on a helicopter.  UMass is one of the few EM residency programs in the country that requires residents to serve as flight physicians.  So I think it's fair to ask why, if being a flight physician is such a valuable experience for residents, more programs don't require it.  Not only that, why are some programs eliminating resident helicopter flying altogether?  The answer to the second question is because of the large number of emergency medical helicopter crashes that have occurred over the past several years.  (For example, click on the Program Highlights tab to see Indiana University's statement about why EM resident involvement in their air ambulance program was suspended.)

All of that being said, I came to this program knowing that flying on the helicopter was required, and it's obviously a bit late to back out now.  But as I strapped myself in for the first flight, I took the time to study how to open the emergency window exit.  Just a precaution, you know, in case I had to put my dunker training to use.

The flight itself was completely uneventful, and surprisingly enjoyable.  I had been worried about getting motion sick, but this was not an issue.  Our first transport was from an outside hospital (OSH) that had its own landing pad.  The patient was being transferred to UMass for more advanced treatment of a serious medical condition.  The resident and flight nurse helped the hospital staff prepare the patient, who was unresponsive, for transport.  We took the patient outside, loaded everything (patient plus equipment) onto the helicopter, and took off.  I went on two other flights, one for a patient who suffered trauma in a car accident, and the other a hospital-to-hospital transfer like the first flight.

Wherever we went, a crowd of onlookers gathered.  It amused me every time to see them shielding themselves from the wind created by the rotor downwash, which is a lot more powerful than I (and evidently they) had realized.  In addition, watching the upper level resident, I was able to appreciate why there could be some value in residents participating in LifeFlight.  When you're at a scene, there is no attending standing there telling you what to do; there is no team of nurses and techs to back you up; and you do not have the luxury of using much of the advanced equipment that is available in the ED.  Several of the program graduates have told me that participating in LifeFlight gave them tremendous confidence in their ability to handle emergency situations.

I still don't think that my education would suffer greatly if the residents were suddenly pulled out of the LifeFlight program.  However, I don't see the time spent working on LifeFlight as something that detracts from my education any more either.  I also have a better understanding of why the opportunity to fly is such a huge draw for many applicants to this program.

These Dreams Go On

"All the things one has forgotten scream for help in dreams."
-Elias Canetti 

A friend of mine who spent a year studying abroad once told me that the way you know when you've become fluent in another language is when you start dreaming in that language.  I only wish that this could be the criterion for fluency in the duties of internship, because I have been having all kinds of crazy emergency medicine dreams.

First, there are the "left the house without any underwear on" dreams.  Only for me, the issue is always that I have forgotten to show up for a shift.  Every day upon awakening, I have this brief period of disorientation when I'm wondering where I am supposed to be right now.  Even on my days off, my first panicky thought as soon as I wake up is, "What time is it?  Did I oversleep?"  The fact that my shifts constantly change times (overnights last week, afternoons this week, days next week) does not help things.  Neither does the fact that the summer days in Massachusetts are so long that it's just as light out at 5 AM as it is at 5 PM.  It also doesn't matter in the slightest that in real life, I have not ever forgotten about an upcoming shift, or even been late for a shift.

Next, there are the "scary monster" dreams.  Only in my case, the monster comes in the form of a grotesque patient encounter.  Sometimes it's the patients themselves that are grotesque.  In one version, I walk into the room, only to find that the patient's limbs have fallen off.  I start frantically trying to put them back on again before the attending finds out that I have let the patient fall apart.  Other times, I am the grotesque one.  I catch my reflection as I walk by the window, and I have no face.  (Don't ask how I can see myself when I don't have a face--no one ever said that dreams were rational.)  Then there are the attendings, who can easily be transformed to gremlins, goblins, and trolls of all kinds.  Some of these transformations require less imagination than others.

Finally, there are the "trapped inside and can't get out" dreams.  I'm wandering around the ED, which has turned into a gigantic warehouse filled with screaming, crying, cursing people in johnnies.  It's time for me to go home, but I can't find the exit.  Nothing I see looks familiar, and the more I walk around, the more lost I get.  (That one is actually not so far from reality, because I have gotten lost in the hospital several times in the last few weeks, including twice within the Emergency Medicine administrative suite.)

I'm not sure if the reason why my dreams are so vivid and detailed is because I'm writing them down.  But anecdotally, having dreams about residency seems to be fairly common.  I overheard another resident complaining about how she hates that even when she is away from work, it's like she didn't leave, because she still dreams about being in the hospital.  The resident she was telling this to agreed, saying that the same thing happened to him.

Hopefully, all of this dreaming means that I'm learning something.

First Day on the Job

"I am always ready to learn, although I do not always like being taught."
-Winston Churchill

I have now survived five shifts in the emergency department (ED), and I'm a little bit shell-shocked.  To say that the experience has been overwhelming so far is such a grotesque understatement that I'm reading over what I just wrote and laughing.  Or maybe it's just that I'm exhausted.  Or both.

My first shift was last Saturday evening from 4 PM to 2 AM, which actually meant 4 PM to 3 AM.  I knew I was in trouble as soon as I walked through the front door of the ED and saw the waiting room.  Every seat in the place was filled.  Not only that, but it was chaotic in there, with children running around, a dozen different cell phone conversations going on, and one person in the corner puking into a bucket.  I resisted the sudden urge to turn around and run back out the way I had just come in, took a deep breath, and swiped my badge to go inside.

The adult ED at the University campus is organized into two patient care areas called North Pod and South Pod.  Each pod has about 15 rooms, plus the capacity for another dozen patients or so out in the hallway.  The South Pod, where I was working that night, was utter pandemonium that made the waiting room look calm and sedate in comparison.  On my right was a drunk patient shouting at his nurse, and across the hall from him was a schizophrenic patient going on about some conspiracy or another to anyone who would listen.  A third patient was holding his stomach, crying and moaning.

I went into the physicians' charting area and introduced myself.  One of the other residents showed me how to log in to the computer system, and I picked up my first patient, who spoke no English.  Okaaaay.  There are on-site interpreters for several languages at UMass, but this wasn't one of them.  So I had to use the interpreter phone, which was actually pretty cool.  You just dial up, tell them what language you want, and presto, they connect you to an interpreter in that language.  It worked very well.

The rest of that first night was a blur.  I duked it out with the electronic medical record, debated whether it was ok to give Tylenol to a patient with abdominal pain, and once I decided that it was indeed ok, struggled to figure out what dose to use.  One of the seniors asked me to call the gastrointestinal (GI) medicine fellow, and when I did, I couldn't answer most of her questions since I knew almost nothing about that patient.  The fellow immediately figured out that I was a new intern, kindly told me what information she needed, and asked me to call her back once I had it.  I don't think I've ever felt more incompetent or idiotic than I did that night.

When I finally left at 3 AM, the waiting room was even more crowded, which I would not have thought was even possible.  I ran outside, where it was fairly calm and quiet, and took a deep breath.  Phew.  Just two years, 51 weeks, and six days left to go....

Ditching, Ditching!

"All the best stories are but one story in reality - the story of escape. It is the only thing which interests us all and at all times, how to escape."
-A. C. Benson

According to my circle of resident friends in other programs and other specialties, I hands-down won the dubious distinction of having the craziest "guess what they made us do during intern orientation" story.  I consider this to be a dubious distinction because winning a one-upmanship contest is not always a good thing.  In this case, I can safely say that winning this distinction means that I now know what being waterboarded feels like.  It doesn't feel very good.

UMass's EM program is one of a handful of EM programs in the entire country that require residents to fly on the emergency transport helicopter as flight physicians.  Part of our preparation for this role entails a day of dunker training.  This is a water evacuation course that teaches us what to do should the helicopter ever crash in open water.

Let me say that the water evacuation training was terrifying.  You're strapped into a helicopter fuselage, fully dressed in a flight suit and helmet.  They suspend you over a pool of cold water, drop you in, and turn it upside down, in the dark.  While you're upside down under water, completely disoriented, you have to open the emergency window exit, get yourself out of the harness, and swim out.  You get water up your nose; it's tremendously uncomfortable, and I wound up swallowing a bunch of water once I got myself right side up again.  (They flip you over because that's usually what happens when a helicopter crashes into water, and plus the pilots are trained to try to invert us on purpose so that we won't get cut to ribbons by the rotor blades if we do manage to make it out alive.).

After the first time, I came up sputtering but relieved to be alive and done with the exercise.  That was when I found out that we had to egress the fuselage a total of four times, not counting the previous four times that I had already done it in the training chair.  Of course, I balked at this, and the trainers proceeded to talk me into doing the rest of the exercises.  (Insert bad German accent here: They haff vays of making you not balk!)  The end result of this was that I got motion sick--there's a reason why I avoid amusement park rides that turn you upside down.  All in all, it was a thoroughly unpleasant experience.

I have to say on my behalf though that I didn't ever panic, and I was able to extricate myself and swim to the surface without assistance all four times.  I feel like I would be able to get myself out of a downed helicopter for real if I ever had to, and fortunately if it were for real, I'd only have to do it once, not four times in a row.