***Note, some of this material may not be suitable for those sensitive to squeemish topics. Those sections will be starred for your own warning***
Last night was my first day of ACE (Ambulatory Care Experience, basically a glorified shadowing patient-seeing experience before your clinical years) and this block I am doing my ACE in the Emergency Department. I was apprehensive at first, not because of what I might see, but because having volunteered there as an undergrad I was not given much to do in terms of volunteer service. In fact, they acted like they didn't know what to do with me.
I called the ER to get the passcode for entry shortly before 4 p.m., and then, donning my white coat, proceeded down the hallway leading towards the west elevators and turned the corner towards the ER door. I let myself in, walked confidently up to the first person manning a desk station, and asked for the attending. There were two that night, and I was recommended to go to Dr. D. Introducing myself to Dr. D, I was then told he needed to catch up some stuff and to introduce myself to Dr. C. Dr. C was very busy, and it was a good 10 minutes before she finally stopped and slowed down to catch my name. And then she embarrassed me thoroughly by yelling for the entire ER to not show me anything except "interesting" stuff, and that I wasn't here to see anything boring.
After I had been sitting around a while, I finally managed to see my first patient. It had only taken about a 30 or 40 minute wait for someone to offer to take me in tow on their duties. So I ended up with an M4 named A, and saw my first case of the night.
S was a 20 yo student at the University who had had a terrible headache for the course of the day that was localized behind her left eye, accompanied by photophobia (an aversion to lights) and an episode of syncope upon standing in class (fainting, likely due to low blood fluid levels). I got to perform a funduscopic (eye) exam, just to be sure she didn't have any increase intracranial pressure from some more serious pathology. She was later discharged with some migraine medicine I believe.
Dr. D later motioned for me to follow him, and I was led to a room where M4 L was working on a kid's ear. His barbell had been ripped out of his earlobe sideways while he was playing with some dog, and he was going to get his earlobe sutured back on. Dr. D said he would let me suture except it was the ear and not as easy as somewhere more accessible. After Dr. D left however, L asked me if I wanted to learn to suture and she taught me how to do the tie off and how to insert the sutures. Most people get their first practice on pig's feet, but mine was on some guy's ragged ear.
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"Want to see a guy with priapism?" Dr. D asked as he started to walk towards an exam area. I didn't see anything better to do but to follow, not seeing any patients at the moment. Priapism, for the unawares, is a painful non-excited erection that can lead to serious consequences (read: loss of the male organ) if not treated. I didn't stay in there long, as there was not much to do but see the man's priapism and leave. It turned out that the man had sickle cell anemia, a red blood cell disease that causes the red blood cells to "sickle" or elongate into long hard slivers, almost like tiny shards of glass. When they pass through the tiny capillary vessels, they can get stuck and cause a lot of pain. In this guy, they happened to get stuck and block the venous outflow of his penis.
Case 3 was a Hispanic woman who had awoken that morning at 4 a.m. with the "worst headache of [her] life". Mind you, this is always a red flag, as it could signify a subarachnoid hemorrhage (a bleed into the brain that can cause serious damage due to the increased pressure), but she had no neurologic deficits upon physical exam. She had an aversion to noise and mindly to light. Since it was already past 5 pm and she wasn't dead, the subarachnoid bleed seemed less likely, but she was sent for a CT anyways. The M4 I was accompanying, SS, almost didn't do a fundoscopic exam, but finally remembered to do so and I mentioned I would have suggested it had he not.
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Priapism wasn't finished with me yet, and I was motioned to join Dr. D and the physicians assistant back to the priaprism room. They had paged a Urologist who was going to take charge of the case. The means of treating the man entailed draining the organ via a butterfly needle inserted into the side and having the sickled blood pumped out via a syringe. I watched about 70 - 100 mL of blood pumped out (roughly three syringes) until I got tired of balancing on the edge of a vaso-vagal response and left the room.
Case 5 was an intoxicated man named J who said he "fell down". However, a single glance at his face would say that if he did indeed fall down, the curb had beat the living bejeezus out of him for violating it's personal space. He had several lacerations, one on his chin which very evidently was from hitting a curb or something rough, but several other cleaner cuts that looked like they were inflicted by a sharp knife or other tool. He was given a shot of Ativan and SS, a female physician's assistant, and myself proceeded to scrub J's face and start suturing. With the door closed, this was the calmest area of the ER to be in at that point. SS and lady calmly sutured in quiet, all of us lightly conversing until it had reached 8 p.m., and I announced that I had other stuff I needed to get done that night and took off.
Life in the ER will be continued next week.
