The Theme of the Shift

"The theme of the week is: the heart as a pump."
-Dr. Joseph Parambil

I don't know why this is, but it seems like every shift has a theme.  Yesterday's theme was GI bleeds.  I literally had three patients in a row with a chief complaint of melena, and I went room to room doing rectal exams and fecal occult analyses.  All three times, the stool samples on the card turned bright blue, which means a positive result for blood.  So I paged the GI fellow to tell him that I had three patients to admit for workup of GI bleeding. Unsurprisingly, he was not thrilled about getting so many patients all at one time, but I think it's probably better than paging him to come down to the ED three separate times.  At least this way, he only had to come down once.

On another shift, all of my patients were coming in with headaches.  It gave me the chance to develop my "migraine cocktail," which consists of metoclopramide, ketorolac, and diphenhydramine.  The metoclopromide helps with the patient's nausea; the ketorolac helps with the pain; and the diphenhydramine makes them drowsy so they can sleep for a while and recover from the headache.  I have to admit that I was a little skeptical when the attending suggested that I try metoclopramide with ketorolac, but it worked beautifully.  One of the nurses suggested adding the diphenhydramine, which was the perfect touch.  There are other combinations that can be used to treat migraines, but I'm pretty happy with this one.

I had a shift of all panic attacks, too.  Those patients often come to the ED thinking that they are having a myocardial infarction (MI), especially if it's their first panic attack. Typically, it's a young woman in her late teens or twenties with no medical history except maybe some anxiety.  My job is to rule out anything bad going on with the patient's heart, which entails putting him or her on a heart monitor, getting serial EKGs, and measuring two sets of troponin enzymes.  Odds are good that, unless the patient is a cocaine user, he or she is probably not having an MI.  But cocaine use is a risk factor for MI in young people, so I always specifically ask about it.  Every once in a while, someone admits to using cocaine, and that is an opportunity for patient education as well as ruling out a potential MI.

Of course, just about every shift is an abdominal pain shift.  It seems like abdominal pain is the most common complaints in the ED, and also one of the hardest to diagnose.  There are just so many organs in the abdomen, particularly for women, and any of them can cause pain.  Plus, sometimes organs in the abdomen can cause chest pain, and organs in the chest can cause abdominal pain.  For example, I've seen several patients with MIs who came in complaining of acid reflux.  That's what the MI feels like to them, and sometimes they even feel better when they take antacids.  So if someone complains of upper abdominal pain, I still have to keep MI in the differential.

It's impossible to know ahead of time what the theme of the shift will be, and that can be frustrating sometimes.  But the constant daily surprise is also part of what makes EM fun.