Week 3 - Amanda

This week was a whirlwind of activity. Due to my "I want to get the best bang for my buck" mentality, I signed up for as many shifts in other departments as I could between my time spent on research and shadowing Dr. Prince. My first shift was in the Emergency Department, starting at 7:30 am. When I arrived, I was quite surprised to see patients sitting on beds in the hallway. Apparently all of the ICUs were already full for the day (each resident is only allowed a certain number of patients, so they reach capacity quite quickly), so it was imperative that only patients who absolutely needed the care be admitted. The morning report, which appeared to be a learning opportunity for the residents, was a review of several case studies consisting of an EKG and syncopy (i.e. fainting). One of the most common patient complaints in the ER is that they fainted recently for no reason and now they feel fine, but their family members or friends encouraged them to go to the hospital. One of the routine tests is an EKG to check heart rhythm, so most ER doctors have to decide whether or not to admit the patient based on the EKG and a banal description like, "I was walking to the laundry room, and I suddenly felt hot and fainted. I got up right away though and now I feel great." The doctors have to pick up on small clues like irregular spacing or small bumps on the EKG printout. 

By the end of the morning report I felt semi-confident in my ability to examine an EKG and notice irregularities. One patient came in after having a few fainting episodes, and her EKG had very low signal. The resident automatically assumed the test leads were connected poorly, but the physician halted him and quizzed him on potential pathologies that could lead to low signal amplitude. He got stuck after a few guesses, but I came up with pericarditis, inflammation of the lining around the heart that would effectively muffle any of the electrical signals that the EKG picks up on. The resident looked pretty nervous since he was new, so I didn't dare say it out loud. However, the physician then named that as a very probable possibility. It was reassuring to know that my approach to solving engineering problems (i.e., why does this signal have such a low amplitude) works in medicine too! 

The rest of my time in the ER oscillated from incredibly busy to very slow. The doctors spent a lot of time updating patient records and ordering various tests and procedures. However, halfway through the day an older lady came in on the ambulance with a serious case of pneumonia, so I got to see a series of procedures ranging from the CT to diagnose the pneumonia, to intubation to bring her blood oxygen level up. I was very surprised at the risk involved with the insertion of a tube for the ventilator (in this case bilevel positive airway pressure). When the doctors decide a patient needs intubation to raise blood oxygenation, the patient already has a significantly low level. However, they need to remove the oxygen mask to insert the tube, which will further drop the oxygenation level. That means time is of the essence, and the procedure needs to be completed quickly and smoothly before the patient "crashes". This patient had oddly disproportionate mouth and throat anatomy, so a physician and two residents both initially failed to get a tube in. They were on the verge of giving up and performing an emergency tracheotomy when the head resident just managed to get a tube in. I didn't realize how dangerous the situation was for the patient until after the doctors succeeded and I noticed they began shaking from the adrenaline. I admire their ability to stay calm and focused under pressure and decided quite quickly that it takes a certain type of person to become an ER doctor.

My favorite thing during the week was my visit to the Pediatric ICU. There was such a variety of cases ranging from Duchenne Muscular Dystrophy to pneumonia. I only attended rounds for one morning, so I'm planning to go back so I can get a sense of how the doctors handle the wide range of cases and determine treatment options.