Lately I've been feeling like a real ER doctor. I've had a few good days in a row.
A couple of days ago at the D I had a nice CVA. The guy came in 1 hour after the onset of symptoms. I bullied the CT tech into doing a STAT CT Head and pushed this guy hard. The highlight of it all came when we hijacked a critical care team en route to the ICU and forced them to take our biy instead. The guy had a huge bleed and was way, way, way not a TPA candidate. I called the local community hospital and expedited the shit out of him. This guy came in, was worked up and was on his way out in 1:45--that's some good fucking Emergency Medicine. It felt good and I let the nurses know that I was ready to put my wallet where my orders were (forgive the incredibly awkward phrasing) and buy the department some pizza or Starbuucks, whichever they preferred.
And today I was CPR boy. We had a lady come in in full arrest. She got coded up and somehow we pulled her back and saved her for a agonizing family agony-fest that resulted ij her husband kissing her good-bye and telling me to stop the pressors and let her die. In the meantime I got called to the floor and ran a code up there. Holy shit. Floor nursing is the biggest scam in medicine. These people are idiots and thanks to the beauty of the nurses union they make the same miney that actual real honest to God competent nurses make. Running a code with these idiots was unbelievable. I would have been better off with a troop of high achieving cub scouts. I kept on telling myself "Stay calm, be polite. Stay calm, be polite. Stay calm, be polite...." Somehow, even with Strike Force Idiot on my side we pulled the guy back.

The med students were impressed. I was reminded of the time when I was awed by this stuff. When reaching into death and pulling people back made me wax philosophical and (honestly) stand in awe at the momentousness of it all. Now the wonder of it all is gone--I run the codes and sometimes they live and sometimes they die. I fill out the billing form and go on.

I got an email from my Bro. He nailed the F'ing LSAT! 99%! How's that for some strong fucking work! Good to have a lawyer on team 561.

Strong work, Bro. Strong work.
U-561

Great case at St.D's!
The PA brought back this EKG on a guy who had come in with abdominal pain, probably mid to late sixties. Because it was abdominal pain he was a lower priority EKG and it had taken an hour to get it. Son of a gun, but he had tall broad ST segments in the inferior leads and reciprocal changed in V1 and V2. Acute inferior MI! I put in for Cath lab and as I'm waiting to hear from them this woman calls out "Help--there's something wrong with my husband!"
I run over. New patient. Laying in the gurney, eyes open, teth bared, clenched hands held up towards his neck and a stricken look on his purpling face. Monitor? Coarse V-fib! Holy shit--he must have just dropped out! I yell "Code in C!" and I go for the pre-cordial thump. I haul back and punch the guy as hard as I can. In the text books they have images of a very dignified fellow in a white coat thumping his palm on the patient's chest, but I can't believe that technique gets any sort of discharge so I go with a clenched fist hammered into the sternum. Except I missed and punched this poor guy right in his gut. Shit, I reloaded and fired again and this time nailed him right on target--2 centimeters bove the Xiphoid process, mid sternum.
The team arrives, the wife flees the room, and I yell "Paddles first! Paddles first!" I start doing CPR. Our top gun nurse is on and we are a smooth team. The pads go on the chest and we defibrilate. Nothing. More CPR while the machine charges and we fire again. Got him--QRS's on the monitor and in seconds he's awake and fighting us. Minutes later he's relxed and I'm chatting with the family. Then off to cath lab.

Good, good, God damn Emergency Medicine!
U-561

Today I was better. I felt good and on top of the patients. I still hit the ER Call doc pretty hard but a) they were legit, b) I went out of my way to spare him whenever possible and c) he takes call 4 out of every 7 days--he's going to get a lot of pain in his life. I don't know if he has an alimony or a girlfriend or an ego to pay tribute to, but something is flogging this guy.
Regardless, I had some interesting cases: a knee cellulitis, a pair of interesting overdoses (one recreational, one suicidal) a surprise 8mm renal stone, a respiratory failure. Not too hard. I got put a half hour early and got home to the Biscuit on time.
Prior to me leaving, however, we had a plane crash. Yes--an airplane crash. Really. Local airport, 11 o'clock at night, a little private plane crashed and we got a pair of burns. One was a horrible burn--young girl who is in desperate straits. I was off and the night guy was handling it. Even so, I was around and had to force myself not to interfere with his management. I would have done it differently. It's odd and, also, nice to find myself thinking not, "Thank God he's on....", but "I could be doing this better..." It's good to be confident.
U-561

Last night I definitely did not have my A-game. I was mediocre. Lot's of patients with unclear dispos and a sense of flailing about. Fortunately, nobody was too sick and nothing untoward happened.
We had an odd case a few days ago--a kid got a barbeque fork through the elbow. I yanked it out (after suitable pre-amblle and preparation) and billed for foreign body removal.
I also gave a little talk about EM to a group of high school kids. One of those summer camps that caters to the dreams of aspiring professionals and their deep-pocketed parents. I may have overdone it a liittle, but the kids loved it. This year it was pro-bono work, but I think I made a sufficiently strong impression that next year I can make a case for being paid for my services next year.
I've got an animal work coming up--miserable 7 shifts in the next eight days.
U-561

Mercifully I've had a long stretch off. I'm sure I have a pneumonia--I haven't been that sick in a long time. Still recovering--I can make it through the day without collapsing, but walking uphill leaves me gasping for breath. Apparently I'm getting old.
Today the U.S. got whallopped in the World Cup. Really poor play. Dismaying.
U-561

Bizzarely I am writing from work. It's 0330 and the place is dead. I've seen five or six patients, but none in the last two hours. A unique experience. Quite pleasant.
The staff fell into a conversation about child abuse and molestation--one of our nurses works with the victims. I checked Megan's law for abusers near my house and the list is long enough to be disturbing. Though I guess having even one name on the list is disturbing enough.
Hopefully we won't get a early morning rush.
U-561

Had a good shift.
Coming off the shift before I home and got to bed at 9 am and laid in bed worrying I wouldn't be able to sleep. I knew I needed to be up by 4 to make it to St.D's for my night shift so I decided on the following: if I was still laying in bed awake at 10am I'd take fifty of benadryl and a couple of ounces of Maker's Mark and just put myself down for the count. Fortunately the last thing I remember seeing on the clock was 9:49...and then I was out. Unfortunately, the next thing I saw was 1:13. Some Jehova's Witnesses the Biscuit had befriended (Woe unto them!) came knocking on the door. I was awake and when I laid back in bed I realized that it was gone--that precious window of opportunity has passed and I would not sleep again. Twelve hour night shift, Saturday, St.D ghetto, and I was going to has three and half hours of sleep. I braced myself for the pain to come.

It began horribly--Willie G. was on the day shift signing out to me. This lazy sack of crap is one of the old guard at St.D's who bankrupted the ED, demoralized the entire department, drove the hourly to $100 an hour and basically drove the F'ing car off the cliff. I hate coming on after him because there is always a load of patients waiting to be seen that he somehow just hasn't been able to get to. Lazy shit! He makes me fucking sick! How he can have the balls to speak to me after he pulls one of his little fairy princess disappearing acts I can not fathom. The only answer is that he has no honor. He's one of those vile little people who have no pride and no integrity and who worm their way through life with shit eating smiles and greasy little hands and a thousand excuses for every occasion. When I come on to relieve Bearie the patients are seen, the dispos are in and the rack is clear: Bearie owns his ED and he takes care of his shit. Which is why I admire Bearie and why I wouldn't cross the road to piss on Willie G if he were on fire.

So, I saw seven patients in my first hour and was only one patient behind by 7pm. The resident who was on (Yes, the G had a 3RD YEAR ER RESIDENT WORKING WITH HIM--2 ER DOCS IN THE THE 14 BED ED!!--AND HE STILL LEFT SIX OF THE 12 FILLED BEDS FOR ME TO SEE!!!) didn't do shit for that hour. It's not her fault--I got to know her when the G finally left and she's strong, hard working, competent. She worked hard for me. With Willie she got sucked down into his sick little world of hateful inadequacy and probably wasted an hour of patiwent care time learning about how to differentiate Hemophilia A from Hemohilia B using only a sheet of newspaper, a tallow candle stub, and a common pocket knife. He's a cancer.

Then, bizarrely, a good friend from residency called because he knew I was on and he was bringing in his relative with a psychotic break. She got the cadillac treatment and I'm pretty happy with the care I gave and got for her. Psych issues are so delicate and so delicate.

And right at 5am (11 hours deep in the shift) we got a full arrest. Guy got up to go to the bathroom and just dropped dead in front of his wife. Medics brought him in and I'll be damned if we didn't get a pulse, a perfusing pressure, and a pulse ox of 100%. Pulled his pH back to 7.16.....and I think we were headed towards even better. His BP was just hanging on when I left at 7--he was in the 80's on max'd Dopa and a little Levophed--but I felt I had managed him pretty well.

Bed soon. One night shift to go and the Biscuit gets home tonight.
U-561.