A Day in the Life: ER

May 5, 2016

I recently finished up my second rotation in ER. I absolutely loved it and I always look forward to my next rotation in the department. Here’s a look at a typical day while on this rotation.

5:00 – Alarm goes off. Normally Andrew goes to work before me, but not this month. I showered and dried my hair last night, so my routine takes about 15 minutes and then I pack my lunch – veggies, cheese, and guacamole it is.

5:30 – Hit the road. The hospital I’m working at is 35 miles away. Even though it means getting up earlier, I don’t mind the drive – it’s a great way to center myself for the day, and wind down when my shift is done. I find it calming. I don’t love driving on the country roads in the dark though – hello wildlife!

6:00 – Arrive at the hospital. I let my attending know I’m here. A resident will actually be my primary supervisor. He is going to be running the ER in a few months, so my attending wants to be as hands-off as possible. Luckily, I’ve worked with this particular resident before and he is pretty laid back, so I know I’ll have a lot of independence.

6:10 – Log in to the ED tracking system. I can track patients, their labs, and imaging; so I know if patients need any further testing and know right away if there are any abnormalities.

6:20 – Our first patient checks in. She tore her nail off and it will need a repair. The nurses check her in and get her cleaned up. I go in to check the patient and assess the damage. There is a lot of blood so it’s hard to see. I do a digital block on her finger to numb it up.

6:30 – I go and talk to the resident and let him know what is going on with the first patient. I tell him I’d like an x-ray to see if she has a fracture. I think the nail has been completely torn off, but there is a lot of blood so I can’t see very well. I let him know I’ll do further assessment after applying a tourniquet to the finger. He goes to take a look at the injury and I go with him to see how he would like me to approach the repair. Afterwards, the patient goes to x- ray.

6:45 – The patient is back from x-ray. I ask the nurse if she would please sterilize the area under high pressure flow for 5 minutes.

6:50 – I go back to check on the patient and start the procedure. Her finger still isn’t completely numb, so I draw up some more numbing medication and do a block closer to the tip of her finger. I let her know I’ll be back in 10 minutes and we will get started.

7:00 – Back into the room. I’m glad this has been a slow start to the morning. I’ve reviewed the repair of wounds on the nail bed and am ready to get started. I go over my plan in the room with the resident and he gives me the go ahead. The alarm goes off outside, our next patient is here. The patient says she can’t feel her finger at all. Good. I set up my sterile field and put on sterile gloves. I clean up her finger and apply a tourniquet and find she does actually still have part of the nail left. That’s great, I tell her, because her nail will grow back. The tourniquet helps a lot to stop the bleeding so I can see what I’m doing. I put in about 4 stitches before the resident comes back to check on how things are going. I think the bleeding has essentially stopped so I pull off the tourniquet. It starts bleeding again, but way less. We want to see if we can stop it by applying pressure, so I sit with the patient and we make small talk. After 10 minutes, I pull the gauze off and it’s still bleeding, so we decide to throw in a couple more stitches. I’m out of suture so I pull off my gloves and go to grab a new pack. Back in the room, I put on new gloves and throw in a few more stitches. The bleeding has essentially stopped by the time I’m done, so I go ask the nurse if she would mind applying a bandage to the patient’s finger. I go to my work station to start my note and get the patient’s discharge going.

7:45 – The nurse let’s me know the patient is ready to go. I print off the discharge instructions and go talk to the patient about proper care for the next 10 days. By this time her x-ray has come back, and it appears she may have a distal fracture. She’ll need antibiotics to prevent infection of the bone. I talk to her about the antibiotic and what she can use for pain control. She needs a work note, so  I get that ready too. With that, my first patient of the day heads home.

8:00 – I go talk to the resident, and let him know that I allowed the patient to leave and that I will finish and send my note to him. He will take the second patient. I’m thankful for that.

8:15 – I finish and send my note to the resident. A new patient has arrived, her chief complaint is leg pain that started last night, and she is now unable to walk. We also get a call from the EMS regarding a very large woman who is unable to walk. It sounds acute and serious. My attending asks me to review establishing IO access for medications (IV access can be harder to establish on bigger patients). If we need to do it, I’ll be doing the procedure. I’m glad I just renewed my ACLS certification and we went over that.  I go and review the procedure and look up our patient with the leg pain.

8:30 – The nurse has finished checking in the patient and vitals have been collected. I get report from her and head into the room to talk to my patient. She states she fell last night and was able to walk at first, but has been having to crawl around her apartment now. She is elderly, so I’m already sure regardless of what we find she can’t go home. I assess her leg and look for any deformities or areas of tenderness. It looks like it’s mostly an issue with the knee. I go ask the resident if we can give her medication for pain and order an x-ray of her leg. We throw on a hip film too, just in case. I go back to the patient and let her know what the plan is and ask her if she needs anything else right now.

8:50 – I go to start the note on the patient with the leg pain. Things start picking up around this time and I don’t want to get behind. I also review our patient who is coming in via EMS. Unfortunately, there are no records of her for the last 10 years. Sudden weakness in an elderly patient is concerning, so I’m anticipating a possible sepsis work up and assessment for a DVT.

9:15 – The patient arrives via EMS. I start talking to her right away. If she has an infection, we need to start our work up STAT. Fortunately, she doesn’t look sick and her vitals are stable so she doesn’t meet SIRS criteria. What seemed like a very acute issue turns out to be essentially chronic. We do a work up to rule out an infection or a blood clot. In talking to the patient, she tells me she feels like she needs placement at a facility for rehab to regain her strength. I let the resident know that we also need to consult social work to see if there would be an open bed anywhere.

9:35 – I go back to check on our leg pain lady’s test. To our surprise, she has a hip fracture. I ask to speak with the orthopedic doctor on call. I give him a brief history and ask him to consult on the patient. She says he’ll be right down. I finish my note on the patient and start my next one. We have two new patients.

9:45 – I start looking up each of our new patients. The first one is a middle aged man with belly pain (my favorite workup), and the second is an elderly woman with back pain for the last 6 months. The man has been here with a similar issue before, but there isn’t a lot on the lady. I check on our labs from our lady with acute weakness. So far, they look good. I talk with the social worker and she says she is going to look into availability for a bed.

9:55 – Our belly pain patient is ready to go. I get report and go talk to him. He looks really uncomfortable. He has all of his abdominal organs (gallbladder, appendix) and no history of any other surgeries. He hasn’t had a fever, but he needs a full workup. I go over the plan with the resident and we get things rolling for him. We also order a GI cocktail for him and give him some pain medication. I let him know I’m off to see our lady.

10:15 – I go see our lady with back pain. She says this has been going on for a while and she has tried a lot for pain, but nothing has been working. She has some people with her and they would like a chest x-ray. I let them know that even if she has a rib fracture, we can’t do a lot for it. Her lungs sound good, and I think she has a posterior rib. In the clinic, I’d normally do some OMT, but I don’t like to do that very much in the ER. I’m doubtful we will find anything, but we order the x-ray just to be sure. I ask for application of a lidocaine patch to see if that will help. It’s one of the few things she hasn’t tried.

10:40 – I’m glad we haven’t gotten any new patients. I get caught up with my notes and check on lab work. The radiology techs let us know that our patient with belly pain is too big for the machine. We will do an x-ray and ultrasound instead, but I’m disappointed, we can’t find our nearly as much information from that, but it’s the best we can do. The lab work looks good on him so far though, so that is reassuring. Even if we can’t get good imaging, the lab work tells us a lot.

11:00 – The x-ray for the lady with back pain comes back. There is a really suspicious consolidation at the top of one of her lungs. It looks ugly and it is a very uncommon place for pneumonia to develop. We order a CT scan and I go talk to the patient to let her know what the plan is.

11:05 – The ultrasound on our belly pain patient shows a thickened wall of his gallbladder. We consult surgery to ask them if it needs to come out. It does. The patient hasn’t eaten anything today, so he will go for surgery this afternoon. I finish his note and he is discharged to the floor to await his operation. We also find out our weakness patient has a bed available at a facility. Unfortunately, all of her tests have come back negative so there is nothing we can admit her to the hospital for. That means they will have to pay for her time at the rehab facility.

11:10 – We have another patient. She has been having arm pain. She had an abscess in her axilla not too long ago, so I’m guessing it has returned after her I&D as she couldn’t tolerate antibiotics. She is roomed quickly and I go and see her. Sure enough, she has a sizable abscess. Surgery has been following her closely. I give report to the resident and he consults surgery. They ask us to give her one dose of antibiotics and they will remove the pus pocket in the operating room tomorrow.

11:40 – I’m hungry and there is a little bit of a lull, so I scarf down my lunch and type up my note on our patient with the abscess.

11:50 – A patient arrives with suicidal ideation. She is really young, and I’m always saddened by kids who have gone through more in their childhood than most adults. The nurse goes to talk with her. In the mean time, my attending says the CT is back and it’s not good. It’s likely our lady with back pain has a large mass in the apex of her lung. He is doubtful that it is anything but cancer. We will wait for the official read from the radiologist before talking with her, just in case.

12:10 – I go in to talk with our patient with suicidal ideation. While I’m talking with her, the resident talks to her primary care provider to see if he would also come see her. She tells me she doesn’t have a plan, but she isn’t sure she wouldn’t hurt herself at home. She’ll need a 72 hour hold regardless of what she says to her primary, but it’s good for her to talk to someone she trusts. He comes in as I’m finishing talking with her, so I leave the room so they can talk alone. She’ll probably be more open with him than she will with me. In the mean time, I go report to the resident, get started on her note, and consult social work.

12:20 – The young girl’s primary comes to talk to us and says she also had an attempt last night. She had seen her therapist recently, so she has had a sharp decline in a short period of time. Social work gets started on placement for her as our facility does not keep pediatric psych patients.

12:40 – The CT scan report comes back and the radiologist agrees with our assessment, likely a malignant mass. I talk to my attending about breaking bad news to a patient. I’ve never had to have this talk with a patient alone so I’m nervous, but I had a really good rotation in Palliative Care, and I know that my fears and worries will be nothing compared to my patient’s. This isn’t about me, it’s about her, and putting myself in that mindset gives me a lot of strength. I print off the radiologist’s report and bring the x-ray with me and go talk with the patient.

1:30 – I finished talking with the patient. We went over a lot of information, but I can tell she is overwhelmed. I make sure I write a very thorough discharge summary. I know her primary care provider will go over a lot of what we talked about again, and she has a lot ahead of her. I tell her she will be in my prayers and make sure she doesn’t have any other questions. My attending writes a prescription for more lidocaine patches as she says this has provided significant relief.

1:45 – Another patient has been roomed and the resident hasn’t seen her yet. The nurse gives me the scoop. She has been having urinary symptoms and fevers. It sounds like pyelonephritis. I go talk with her and her case is textbook. I give my report to the resident and tell him I’d like a CBC and a urine on her.

2:10 – I have a bunch of notes to catch up on so I get those going. Fortunately, I start my notes whenever I have a spare minute so I don’t forget the details. Most of what’s left are the lab/imaging findings and what we decided to do. I finish them up and send them to the resident to sign off on.

2:30 – My attending let’s me know that I can leave (he has medical students work an 8 hour shift, so it’s a lot shorter than the normal 12 hours). I decide to stay until the lab results are back on my last patient so I can be a part of her entire care.

2:45 – The urine and CBC are back. It does look like pyelonephritis. I go talk to the resident and we go over antibiotic options. I go finish the discharge summary and the patient’s note and then relay the information to the patient before letting her go home.

3:10 – I say goodbye to the nurses and my attending. I check in with him regarding my next shift and make sure the resident received all of my notes before I head home for the day.

This was a fairly typical day in the rural ER I worked in. I liked the pace a lot as it was great for learning. Some days were slower than others – I saw anywhere from 6-14 patients in my shift. My next rotation in ED will be when I’m officially a doctor and I’ll be at a bigger hospital – so more traumas, strokes, heart attacks, and scary stuff. This rotation was really great and I’m ready for the next step. I plan to moonlight in the surrounding communities during my second year. Just because the hospital is small, doesn’t mean you can’t have serious stuff come in. Hope I’m ready for it by then!

Thanks for stopping by!

XOXO – Emmy Lou Lou

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