ÿþ<HEAD> <title>Eric's Archive</title> <META NAME="description" CONTENT="Eric's Journal, the irregularly updated journal of Eric Lis"> <META NAME="keywords" CONTENT="eric, lis, emperor, aerica, aerican, journal, eric's head"> </HEAD> <left><font face="Times New Roman"> <font face="Monotype Corsiva,Bernhard Modern Roman,Unicorn,BellGothic,News Gothic MT"> <center> <big><big><big><big> Eric's Archive<br> Entries 741-750<P> </big></big></big></big></font> <I> Those who forget the past<Br> Are doomed to reread it.<p></i> </center> <a href="http://www.aericanempire.com/eric/index.html">More recent</a><BR> <a href="http://www.aericanempire.com/eric/701-800/751-760.html">Entries 751-760</a><BR> <a href="#750">Entry 750</a> August 5 2010<br> <a href="#749">Entry 749</a> August 2 2010<br> <a href="#748">Entry 748</a> July 30 2010<br> <a href="#747">Entry 747</a> July 27 2010<br> <a href="#746">Entry 746</a> July 24 2010<br> <a href="#745">Entry 745</a> July 21 2010<br> <a href="#744">Entry 744</a> July 18 2010<br> <a href="#743">Entry 743</a> July 15 2010<br> <a href="#742">Entry 742</a> July 12 2010<br> <a href="#741">Entry 741</a> July 9 2010<br> <a href="http://www.aericanempire.com/eric/701-800/731-740.html">Entries 731-740</a><BR> <a href="http://www.aericanempire.com/eric/archive.html">Archive</a><BR> </blockquote> <HR> <a name="750"></a> <U><B>Day Twenty Eight</b></u><p> My twenty-eighth day working as a doctor was my last day -- well, night -- working in the emergency department. I learned a lot in this past month, including that if a kid can jump up and down he probably doesn't have appendicitis and that when someone tells you they don't smoke or drink alcohol, it really is important to find out if they *ever* did because usually they quit two or three days ago. Technically, these are both things that I knew, but another thing that really got driven home to me this month was, just because you "know" something doesn't mean you remember to apply it when the time comes. The most important thing I learned this month, though, was this:<p> I don't reeally believe that I'll ever be a brilliant doctor. I don't really understand how congestive heart failure works and despite the fact that I have measurably above-average hearing I can't detect most heart murmurs. I'm not very good at memorizing dosages of medications and I frequently forget to ask young women with abdominal pain when they had their last period. My differential diagnoses have a nasty tendency of lacking something life-threatening and I don't press hard enough on people's abdomens when I'm testing what hurts them. On the other hand, every single doctor I worked with this month rated me as "satisfactory" or "above average" and several commented that in a number of respects my knowledge base is superior to expected of a first-year resident. I'm better than doctor three years ahead of me at remembering to follow-up on lab results. Unsurprisingly, my communication skills are extremely well-developed, I work well with others, I bring a healthy sense of humour to my work and my patients report that they feel well cared for even when no one comes to see them for four hours. I acknowledge my limitations and weaknesses -- I acknowledge A LOT of limitations and weaknesses -- which is actually a strength in a young resident and something a lot of doctors don't do well enough. What I learned this month is that even though I don't believe I'll ever be a great doctor, all the doctors supervising me believe otherwise. I still think they're wrong, of course, but for purely pragmatic purposes, it's good for my future if I can make them keep thinking it.<P> As I've always said, a lie told for long enough eventually becomes the truth. In this case, it's even more applicable than usual. <P> In the end, over the course of eighteen shifts (which works out to approximately 162 hours or 189 patients), only one person asked me why she was being seen by a psychiatrist, or to be strictly accurate, why his wife was being seen by a psychiatrist. I explained, we all had a good laugh about it, and no harm came of the situation, and my name-tag brought me no further trouble over the course of the month. The winner for the month instead proved to be "Doogie Howser" comments (at no less than four times on different days, or five if you count "doctors sure are getting young these days") made by patients and their family members when they thought I was out of earshot, which I tactfully ignored.<P> One thing struck me about my time in the emergency department: the ER is a microcosm, not simply of medicine, but of the scientific method as a concept and a philosophy. The purpose of science, you see, isn't to discover new truths, but rather to attempt to systematically demonstrate numerous things which are false. Science has a miserable time finding things that are good and true, but given a few years, scientists can show things that seem to be untrue. Granted, there's the old truism that the scientific method can never prove a negative, but in practice, physicists find flaws with Newton, biologists find flaws with Linnaeus, chemists find flaws with Dalton and physicians find flaws with Galen all the time, and "truth," like my sorely out-of-date textbooks, is being constantly rewritten. In much the same way, in the emergency department, we didn't try to actually diagnose the patient's problem. The vast majority of our patients left with deliberately vague diagnoses (such as "chest pain" rather than "angina") because the tests, exams, and follow-up we performed weren't geared towards determining the precise cause, and the finalities and certainties were left for their family doctors or other specialists to worry about. The job of the emergency department is to isolate the top four or five dangerous and deadly things which a patient's symptoms *aren't* and if a treatment could be initiated for what they "probably" had during the course of that, so much the better. A patient comes in; the doctor forms a hypothesis of the top one or two things the patient probably has and the top half-dozen things the doctor really hopes it won't be; the doctor orders some tests; the test results come back and the hypotheses are systematically tested given the new data at hand; when all the bad things have been ruled out (or ruled in) within a "reasonable" certainty, the patient either gets sent home or goes to another service and gets admitted, where the emergency's hypotheses, more often than not, will be assumed false until proven otherwise. <P> This isn't necessarily the way scientific method works in real life, but it is how it's *supposed* to work, and that's what makes the emergency department a relatively special place. At least at the good hospitals.<P> And that was my first month working as a doctor. At the time of this writing, I've already started my second month of work, in radiology, which is extremely different from the emergency department for quite a number of reasons. Starting in the emergency department served the extremely important job of helping drive home to me the point that yes, I really am a doctor now, and that's the most valuable thing it taught me. The rest of this whole year will consist of nothing more impressive than proving it to myself and everyone else. Unlike this time thirty days ago, I actually believe I can do that... and I actually believe that it might be fun to prove it. <HR> <a name="749"></a> <U><B>Day Twenty Five</b></u><p> I made it most of my first month as a doctor before I saw my first genuinely sick patient. We see a lot of people who are in pain in the emergency room, but the majority of people we encounter aren't really "sick" in the medical sense of "going to die in a day or two if something isn't done now." Prior to my twenty-fifth day of work, I had seen some people who were very near death, but I hadn't had to treat them myself simply because another doctor got to them first. When I'm seeing someone with back pain, or even stomahc pain with a likely cause, I don't usually get too excited, because I have an idea of how much time I have before they have problems, and I have an idea how to approach their problem. When someone comes in who's obviously doing quite poorly right this moment, it gets a lot harder, particularly when identifying their problem is much harder.<p> During my second weekend of work, a young lady came into the hospital because of a suspected infection. This was all I knew at the time that I went to go see her: she had been sent to the hospital because the people she lived with thought she might have an infection. Usually, getting more information is easy -- ask the patient what hurts and how long it's hurt for -- but in this case, the patient suffered from a severe nerve disprder and was both completly paralyzed and unable to speak. She was unable to say what hurt -- unable even to say *if* something hurt -- and couldn't point or otherwise gesture. This being the first time I had been confronted by such a situation, I fumbled around blindly for a bit, attempting to do a physical exam and not finding much of anything. Fortunately, I was saved from total embarassment by a phone call from the patient's family, who were able to give me a bit of a story, but even so, it wasn't easy to tell what was going on. The only concrete information that I had to go on was that the patient's blood pressure was textbook normal -- which was a danger sign, because I had noticed in the patient's old chart that her blood pressure was normally sky high and not being treated -- and her heart rate was a bit fast, which suggested that her heart was trying to compensate for a falling blood pressure. She was sick, and possibly dying, and I had no clear information on what the problem might be. Fortunately, this is why the young doctors all work with experienced supervisors.<P> It turns out, the approach to this sort of patient is actually very straightforward. In some ways, it's actually easier than the approach to a patient with a clearly identifiable problem. If a patient has a clearly identifiable problem, we have to know what the proper sequence of steps is to investigate and then treat their problem; you follow different steps for a kidney stone and a gallstone, for example. When someone comes in with signs of a severe infection -- a drop in blood pressure and an increase in heartrate, for example -- the first steps are often pretty similar. We take samples of various bodily fluids to test if they're infected, and we take pictures of various organs, and then we start our most powerful antibiotics before we even get back the results. In the emergency room, there's the additional integral step, "contacting internal medicine or some other service and getting them to admit the patient so that he or she isn't our problem any more." After all, a vital element of a well-functioning emergency room is passing the problem on to somebody else.<P> The important lesson I learned that day was this: when faced with a daunting problem, it's easy to freeze up, but the biggest problems are often the ones which have the best-designed algorithms in place to manage them. A small problem, like minor low back pain, can drive a physician nuts, because it can be impossible to know what to do for it, but when someone is dying of an infection in front of you, although it's a bigger and scarier problem, there are also much more well-defined steps on how to deal with it. I let myself freeze up, in part because the patient couldn't talt to me, when in reality, the patient's ability to speak wouldn't have made any difference whatsoever in our management... at least in the short term. This is one respect in which medicine is much, much easier than real life. <HR> <a name="748"></a> <U><B>Day Twenty Two</b></u><p> As I've observed before, life has a way of following patterns. Of course, my utterly ridiculous life is by no means indicative of how anyone else's life works, but in my admittedly limited experience, while things don't necessarily come full circle, life does tend to follow a course which is at best eliptical and at worst parabolic. Life is a story, or a sequence of stories, and as any storyteller will readily agree, a good story often comes back, at least metaphorically, to how it began. If there's one important philosophical lesson that I learned from <I>Return of the Killer Tomatoes</i>, it's that the elements which get set up in the first act ought to get resolved in the third act. On my twenty second day of working as a doctor, I was supervised by the doctor who was in charge of the emergency room on that long-ago day when I went in myself to get my leg stitched up. He proved to be an excellent staff to work with, with a keen sense of humour and a rich appreciation for misanthropy. I don't think he remembered me (and there's no reason why he should, since it had been over a year and a half), and although I thought about saying something to him, I opted not to; at best, I would simply be reminding him that I was the med student who'd managed to slice open his own leg while working on an arts and crafts project. I was sure that the spirits in charge of irony and character development would see to it that some dumb kid came in with a leg wound, but my typical luck won out and it was a wholly uneventful night.<P> That same day, my second paycheck was issued. This felt somehow very important to me. First, it meant that I was, indeed, being paid to work, which I was still having trouble believing. Granted, I'd been paid once, but a single event hardly establishes a trend, let alone a reliable pattern. More importantly, this second cheque was for a full two weeks of work, as opposed to the first cheque which had been for only one or two days. This one was more indicative of my actual earnings, and gave me a much clearer idea of what sort of budgetary constraints I would be setting for the coming twelve months. When I sat down and did the math, my pay actually came out to something in the area of ten dollars an hour, which doesn't feel too bad given that I earned only a little bit more than that at my last full-time job, and *that* one required a bachelor's degree at minimum. At least working at this job, I'm guaranteed a raise at the end of one year and I get to hit people with a little rubber hammer. <HR> <a name="747"></a> <U><B>Day Nineteen</b></u><p> On my nineteenth day working as a doctor, I was still catching up on sleep from having spent my weekend a) at a wedding and b) helping my girlfriend move. Whether or not being sleepy had any particular impact on my work, I can't really say; I saw the same number of patients in a day and made about the same number of correct diagnoses (and about the same number of mistakes). The average person would be well-advised not to dwell too much on the thought that any doctor they're seeing at any given moment is quite likely to be suffering some degree of sleep debt, if not sleep deprivation. <P> The wedding I'd gone to two days earlier was still very much on my mind, for a number of reasons. First, I had yet to stop having fond memories of the delicious food that had been served -- it was a Polish wedding where all the catering was home-cooked style and was perhaps the most wonderful catering I'd ever tasted, which doesn't say much given what I expect from kosher caterers. I was also remembering walking around the reception hall. I was at the wedding as someone else's "plus 1" -- the someone else being a close friend of the bride -- and the bride's mother had met us. She proceeded to lead us around the reception hall, introducing us to various family members. Invariably, she would say, "they are both doctors, so if anyone gets sick we will be okay." Each time, this was followed by much laughter by everyone (presumably, everyone else's was just as genuine as mine, meaning, about as genuine as a 1-cent DVD sold on eBay). It was kind fo surreal; here was the mother of a bride, at the wedding, taking around two young doctors and introducing them her friends. Granted, the bride wasn't at the hall yet, and so wasn't available to be fussed over herself, and no doubt the bride's mother had a great deal of anxiety pent up which she was releasing through excessively enthusiastic socializing, but part of it, I feel safe presuming, was that she somehow felt immensely proud to have two doctors attending the wedding. Indeed, she *was* incredibly blessed to have two people of such unsurpassed niftiness in attendence, but that's wholly independent of us being physicans.<P> When I was at work on my nineteenth day as a doctor, I happened to mention this to the attending staff with whom I was working. She smiled, shook her head, and said that it happened to her all the time.<P> That day, every single patient I saw in the emergency room had a minor problem for which there really hadn't been any great need to see a doctor. The contrast between "prestige" and "usefulness" was really quite shocking. <HR> <a name="746"></a> <U><B>Day Sixteen</b></u><p> On my sixteenth day as a doctor, I got my first paycheck. I've gotten paychecks before, of course, but this one was exciting because for the first time in two and a half years, I was getting paid for my work in the hospitals. For that matter, it was the first paycheck I'd gotten in about two and a half years for anything (not counting the seventy dollars I got from <i>Weird Tales Magazine</i> some time ago), and since I've been burning through my savings and loans during that time, and the money looked extra joyous for that. Let's be clear: my first paycheck as a doctor was not for an impressive amount of money. A resident gets paid a set salary based on what year of their program they're in, and the first year salary, though enough for me to live on, is not particularly impressive compared to the stereotypical earnings of a "real" doctor. Furthermore, my first paycheck was technically issued on July 8th, when I started work on July first, and so I was paid for all of two days of work; suffice it to say, this one cheque would not cover a month's rent. In this instance, though, the size of the cheque is really wholly immaterial. What matters is that I have now officially been paid to work, which is something I've been striving towards for rather a long time. I haven't been on a reliable salary since 2005, and I've missed it. <P> Friedrich Nietzsche wrote that happiness is "(the) feeling that power is growing, that resistance is overcome." This feels like that. I wouldn't say that it's "happiness" precisely, but it's something reasonably close and nearly as pleasant. After all, a steady paycheck doesn't bring with it stuffed penguins, but it does increase one's ability to obtain stuffed penguins.<P> All that being said, my sixteenth day as a doctor was my last day working from midnight to nine in the morning, and after getting a few hours of sleep, the afternoon and evening was spent at a gathering of the Fédération médecins résidents du Québec, which amounts more or less to my union or professional organization. Residents from all over Quebec gathered in Montreal -- conveniently walking distance from my home -- where we were subjected to a long, boring powerpoint presentation which consisted largely of various insurance companies trying to persuade us to give them money. This alone wouldn't have gotten me to drag my sleep-deprived carcass out into the ongoing heatwave ravaging Montreal, but it was followed by a rather impressive amount of free food (paid for, presumably, by the aforementioned insurance companies) which included sushi, freshly grilled steak, six varieties of sausage and a great deal of free or cheap beer and wine. Tasty food was accompanied by good company, in the form of classmates (now ex-classmates, actually), some of whom I actually enjoyed talking to, and indeed, went for coffee with after dinner. Eventually, sleep deprivation forced me to bid my friends good night and return home, where I collapsed into bed and slept, if not the sleep of the just, then at least the sleep of the bastard who's put in a solid day's work.<P> The whole day basically sums up my vision of what it means to be a doctor: working extended hours at ridiculous times, then going out to schmooze with entertaining friends and be given free food and cheap schlock by morally ambiguous corporations. <HR> <a name="745"></a> <U><B>Day Thirteen</b></u><p> My thirteenth day working in the emergency room was my first over-night shift: the shift started at midnight and ended some time between 8:30 and 9:00 in the morning. I worked a similar three-day stretch during my month of emergency medicine last year, and it was... unpleasant. At the best of times, I don't sleep well, and I don't tend to adjust well to changes in my sleep schedule, so last year, my overnight shifts basically meant that I all but didn't sleep for four days. The whole point of studying medicine, though, is that you ought to learn from experience, and this year, I started keeping semi-ridiculous hours a couple of days prior to my overnight shifts. By the time I worked my first shift, I'd gottten myself sleeping in until noon, and after the first shift, I managed to sleep until about three in the afternoon. The net effect is that I actually managed to sleep during those three days and actually keep up a decent energy level while working... with the help of some judiciously-applied coffee. The real pleasant surprise was that I managed to get my sleep schedule more or less back to normal after the three shifts, and am now once again a diurnal creature. At the very least, even if I feel exhausted during the day, I'm merely at my usual levels of fatigue.<P> The other day, I commented on how the emergency department doesn't change very much from weekday to weekend. That doesn't hold true for night and day; the ER is an entirely different sort of place after midnight. During the day, the emergency room is incredibly busy. From about 7am onwards, the emergency is a crawling chaos of people running to and fro, and fro and to, and sometimes even to and to, fro to and, and even da fnoort (before you ask, no, "da fnoort" is not Dutch for "the fnords"). At any given, there are three to four emergency doctors running around, along with one or usually two to four residents, a small army of nurses, and all the consultants from other services. The evening shift isn't as bad; most of the consulting services begin to thin out after six pm, but the emergency remains fairly crowded. After the shift change at midnight, or more accurately, once the doctors get all their paperwork finished around 1am, the emergency room suddenly empties. It can be kind of creepy, actually, because there's this large space which you can get used to seeing filled to overflowing, inexplicably almost devoid of people. After midnight, there's only one doctor covering all three sections of the emergency department, and if there's a resident or a student working at all, there's never more than one. <P> In practice, the night shifts seem to go much the same way each time. The emergency doctor spends most of his or her time seeing patients in what's known at the Royal Victoria as the "acute care" side, where you find the patients who need to be hooked up to heart monitors or respirators. The medical student or resident tends to cover the "minor care" or "ambulatory care" area, which is where you find the patients who came in because of nausea, or abdominal pain, or because they stepped on a nail. The minor care side is often (though not always) less busy and often (though not always) filled with much less sick patients, and is more easily managed by a young doctor. Of the three nights that I worked, two of them were pleasantly quiet, and while there were usually patients waiting to be seen, there were never a dozen patients waiting to be seen. The one night that things did get ridiculously busy, my supervisor managed to make themselves available to take some of the pressure off, and it still didn't become a big deal. Somehow, the overall feeling that the emergency department is quieter seems to take off some of the pressure to keep seeing patients as fast as possible; the waiting room might be full, but it's dark and quiet in the little doctors' work area.<p> The big difference between the night and day shifts is that the person working overnight can't buy food as easily. The cafeteria is closed, and even if it wasn't, the meal cards that the residents use to get free food stop working at 6 or 6:30pm depending on the day. There are coffee machines and vending machines, but for actual food, an unprepared doctor is out of luck. I, of course, am never out of luck, and thrived on my usual peanut butter and jam and marshmallow sandwiches, while doctors that I worked with demonstrated for me their encyclopedic knowledge of resraurants that stay open all night and will deliver to an emergency room. This minor irritation is balanced by the fact that when the overnight shift ends and the tired resident leaves the hospital at nine in the morning, the cafeteria is once more accepting meals cards and the pastries and danish racks have been freshly filled by squishy, sugary goodies. One freshly-baked chocolate danish can make a whole terrible night worthwhile. <HR> <a name="744"></a> <U><B>Day Ten</b></u><p> My tenth day of work was a Saturday. All residents in emergency are assigned to cover two full weekends, each weekend consisting of three nine-hour shifts on Friday, Saturday, and Sunday. One interesting thing about the emergency room, at least at the hospital where I'm working is that the weekend schedule isn't terribly different from the weekday schedule. On most services in a hospital, the weekend is a time when the vast majority of the doctors on a service don't work; there might be one attending doctor and one or two residents working, which could be less than one quarter of the normal workforce. Weekends on such services tend to be a great deal of trouble, because although there's less help, there might be just as much (or more) work to be done. In contrast, the people who run the emergency department are well aware that even on weekends, people still become ill and still need to come into the emergency. In fact, it might be argued that more people ought to come into an emergency room on a weekend, since you get the people who are kind of sick but didn't want to miss work and school as well as those who only need a doctor once they've had twelve beers. For me, therefore, working over the weekend didn't feel at all different that working during the week, with the single exception I didn't have to send any patients home with a note excusing them for missing work that day.<P> The big event of the day was a patient who came in needing sutures for a large cut. I won't describe why or how he got cut, both for confidentiality and because it was a long, convoluted story of intrigue and betrayal, but suffice it to say that he needed some skin to be closed. Normally, I have an excellent track record of avoiding such things in the emergency room; I hate suturing, utterly despise it, not out of any aversion to work or blood but simply because I'm so terrible at working with my hands that my suturing is a danger to myself and others. Unfortunately, the doctor I was working with was busy elsewhere, but more importantly, is a big believer in forcing people to learn important skills even if they don't want to learn them, and stated plainly that although he would be nearby if I needed help, I was going to suture this patient even if it took me all shift. No, the doctor wasn't a complete jerk; he was actually an excellent doctor and a nice guy who I really enjoyed working with, but he felt very strongly that I should do this task, and would take no argument. Had the patient's face been cut, or had his injury been to somewhere where he needed a good cosmetic result, the doctor wouldn't have forced me, but the patient was stable, the wound was to a non-critical area of skin, and the rest of the emergency room was momentarily quiet, so I was it.<P> Suturing is fairly simple, in principle. Most people I know are quite capable of sewing, and sewing skin isn't really very different from sewing fabric. Granted, we use specialized tools to hold the needles -- you know how when you sew, you just accept that you'll poke yourself once or twice? When you sew people, you try really hard to make sure it doesn't happen -- but in the end it's still just a metal pointy-thing and a silk thread. In fact, in some ways, suturing is easier than ordinary sewing; when we open our package of needles, for example, the thread is already attached to the end, and there's no fumbling with the needle's eye. The big difference, of course, is that you rarely have to give any local anesthetic to a piece of fabric, and every knot has to be tied extremely securely because it's considered very bad form for the stitching to come undone afterwards (we use a special "surgeon's knot" and tie at least four or five throws per knot), but once that's all accounted for, it's much the same as closing any other cut or tear. Without fear of exageration, doing the job probably took me about four times longer than it would have taken the attending -- who, it must be added, had done a year of surgery residency before deciding to become an emergency room physician -- and my knots weren't very pretty, but when I left the patient his wound was closed and he was still breathing.<P> I'm reminded of the winter two years ago, when I was a third-year medical student just a few days into my first ever psychiatry rotation, and I managed to sink a knife several centimeters into my own leg while building my cane. I walked over to the Royal Victoria emegency room, the same one where I'm working this month, and the wound was somewhat clumsily closed by a first-year resident in obstetrics and gynecology. I remember thinking at the time that it was vaguely silly for him to be the one closing my wound, and indeed, looking back, I know now that he did a merely adequate and not stellar job on me. That said, obs-gyn is, at least, a semi-surgical specialty and by all rights that resident will need to be a capable surgeon for the rest of his working life, so it was reasonable for him to be the one to suture me up. It wasn't half as ridiculous as me, two years later -- a psychiatrist whose hands shake so badly so I sometimes have trouble getting the key into the lock on my door -- closing up someone else. I have renewed appreciation for the resident who fixed me up and sent me home... though honestly, my stitching wasn't much worse than his.<P> Fortunately, I've always been good at appreciating and enjoying life's little absurdities. <HR> <a name="743"></a> <U><B>Day Seven</b></u><p> With four shifts in the emergency department completed, the confusing and arcane becomes increasingly mundane and unexceptional. I'm now introducing myself as "doctor" automatically, although when I go to sign my paperwork and muscle memory kicks in, I still sometimes draw the first line of an "M" before turning it into the "R" of "resident." I'm still asked, on average once or twice per day, how old I am and how many years I've been practicing, but it's mostly being asked in the "he's so small and cute" sense as opposed to the "why am I being seen by a student" sense. <P> I have not yet had a problem with people seeing "psychiatrist" on my name tag and becoming defensive. I did not expect to make it my first week without this happening, although since I only had my the name tag for three of those shifts, it may be a bit less surprising. I do know for a fact that patients have noticed it; three or four patients have obviously seen it, as while I speak to them their gaze repeatedly tracks back down to the tag and lingers on it before returning to meet my eyes. Interestingly, all of the patients who show this sign are people who have complicated psychiatric histories, usually involving psychosis, and perhaps their experiences have led to them becoming more aware of who is coming to see them. None of them have yet challenged me, or asked me why I'm asking them primarily medical rather than psychiatric questions. <P> The thing which strikes me most now about the emergency room is the waiting time. Many people think that the long waits in an ER are due to inefficiency. While there's some truth to that, in actual fact great efforts are made to keep the ER running as smoothly as possible and the staff who work them -- myself excluded, perhaps -- are actually extremely efficient, hard workers who could hardly work any better than they already do. In actual fact, once you see how the ER works, it's hard to imagine making it run much faster. The thing about the emergency room is that we're very big on tests. Physical exams have their place, and the most important part of diagnosing a patient tends to be getting their history and talking to them, but because the goal of the emergency is to first and foremost rule out immediately life-threatening processes, a patient who comes in with almost any complaint will be subjected to at least a small battery of blood tests, EKGs, and urine samples. The basic blood work -- a complete blood count, a serum electrolytes assay, and often a test to measure the troponins (a sign of heart damage) take, on average, one to two hours to complete. Certain other blood tests take longer. It does not always get taken at the precise minute it's ordered, since the nurses tend to be rather busy people. once the bloods are taken, of course, the patient has to wait for them to come back, and suddenly an otherwise short visit is made easily three to six times longer than it might have been at a family doctor's office. Now bear in mind that just because the results come back doesn't mean the doctor can see them eventually; if bloods are taken from four patients in an hour, each set has to be received, reviewed, and then explained to the patient, which adds on some time and further backs up rooms. The time the doctor actually spends with the patient suddenly becomes a relatively small fraction of the patient's actual time in the emergency department, and a theoretically short visit becomes longer. <P> I'm quite impressed, though, with how people cope with being kept waiting. I see the occasional impatient patient, but as a general rule, even if it takes me four or six hours to get everything set up for a patient and clear them to go home, most of my patients remain quite cooperative and calm. Many of them start looking tired, but only rarely does one of them show any signs of bother in my vicinity. In part, that's because patients don't tend to want to bother the doctor with such things and instead take out their emotions on the nurses, but even that doesn't happen as often as I might have assumed it would. I suppose the nice thing about having an emergency room where each visit becomes a full-day exercise is that after a few years, people just accept that that's how things work and stop being surprised. <HR> <a name="742"></a> <U><B>Day Four</b></u><p> Today I got to work with a doctor I knew when I was working up North in Chisasibi. That was a treat, because he's a staff I was very fond of. We share the same sense of humour and the same sort of contempt for human behaviour, although I hide mine a good deal better. It was a slow night, so we spent some time sitting around, drinking cofee and discussing political philosophy and astrophysics (which, if you think about it, do have some important interconnections). A shift in the emergency room is much more fun when you're working with a pleasant supervisor, and I hope that I made his evening a little more interesting as well. The problem was, though, that when I work with an attending who has a sense of humour, I start getting tempted to start making my assessments funnier.<P> I honestly don't know if the fact that I was working with this particular doctor was a factor in my diagnosing a young lady as a werewolf.<P> A young lady comes into the emergency room. Her "presenting complaint" -- the issue which actually brought her into the ER -- is chest pain, which is one of the most common things seen at this particular emergency. Now, chest pain is a tricky thing, since it can mean anything from muscle pain to anxiety to a heart attack to a ruptured blood vessel from which a patient may die at any moment. When the patient is a young lady, there's less worry about an immediately life-threatening problem, particularly if they're awake, alert, and cooperative as this lady was. She didn't know how the pain had started exactly; all she knew was that she went out drinking the night before, and awoke this morning with no memory of the night. Her face, arms, and torso were covered in small scratches and abrasions, though none seemed to have drawn blood, and from this she concluded she had gotten into a fight while totally inebriated. Her chest pain -- and headache, as she eventually mentioned in passing -- seemed likely due to dehydration, both from alcohol and from the ridiculous heat wave Montreal has been having. Granted, that version of events was *plausible* but I immediately seized upon certain key points in her history. No memory whatsoever of the previous night? Most people who get drunk remember at least something. Scratches on her arms and face? Could have come from a fight, but it had been about twenty hour hours now and she hadn't yet developed any significant bruising. Although "secondary to EtOH" was on my differential diagnosis, my primary diagnosis was "lycanthropy." <P> Unfortunately, I must have forgotten to mention this possibility to the doctor supervising me, and somehow the patient's diagnosis in her chart and on our computer system ended up being alcohol plus heat exhaustion. Still, I'm quite convinced she was a werewolf, though admittedly since we don't have any medical treatment for that it's just as well it's not what we concluded at the time. <HR> <a name="741"></a> <U><B>Day One</b></u><p> They say that the way you start a task can set the tone for that task. Get off to a good, easy start and the whole job is likely to come along well; get off to a shaky, rough start and the whole job is likely to be trying and difficult. This is, in part, a flawed theory, simply because if you're generally better at a task you're more likely to get off to a good start when you try it. On the other hand, it's always been one of my little superstitions that you can often see how well something will go based on the first few minutes of it. I don't let this control how hard I work at a task, because while it's all well and good to have a few superstitions, it's a bad idea to act as though they're true.<P> I started my first ever day of work as a doctor by proving myself unable to log in to the emergency room's computer system. Actually, this was the second thing I did that day, happening as it did after I'd proven unable to open up the locker I was assigned, since the combination began with 45 and the combination lock's numbers only rose as high as 39. While these two events were somewhat anxiety provoking, I kept my head. I found my correct locker by trying the combination I'd been given on every locker in the row, and found the right one three tries later. I got into the computer system by finding someone with superuser access to the software and getting them to unlock it for me, whereupon we found that I hadn't been able to log in because someone else had entered my ID number wrong, putting in an extra digit by mistake. In both cases, an ironic and comedic inconvenience was found to be due to bureaucratic fumbles on the part of someone other than me and the problem was solved by my cleverness and/or my stubbornness. I went on from there to have a perfectly pleasant and relaxing day seeing patients in the emergency room and at the end of the day the attending physician and the senior resident rated my performance as "superior" and said they looked forward to working with me again.<P> And that's how I started my career as a doctor. The whole of a task isn't necessarily set by the way it starts off, but I could have done a damn sight worse.<P> The trend continues! Of the four patients I saw that day, every single one had come into the emergency department complaining of abdominal pain, a subject which is close to my heart. One of them was eventually found to have an incredibly odd presentation of a common disease which elicited puzzlement in the emergency staff and jaw-dropping confusion in the general surgeons who eventually took him off of our hands. Everywhere I went, improbable events and chaos seemed to follow in my wake... which is, of course, wholly appropriate and usually expected.<P> The big joke of the day was the tremendous difficulty I had remembering how to introduce myself. I've spent the last two years of my life introducing myself as "Eric, a medical student working with Dr. etc." This was the first day I had just cause to introduce myself as a doctor. I walked to the bedside of the first patient of the day and introduced myself as "Eric... Lis, one of the doctors working this morning." I only just barely caught myself in time, and I don't think the patient noticed the pause. I almost blew it again on the second patient of the day, though this time it almost came out as "Doctor Eric, a medical student..." By the third patient I was getting the hang of my new introductino and by the fourth I got the delivery just right. So much of how we recognize ourselves comes down to our labels that it can be hard to switch labels after they become ingrained; at a conservative estimate, I've introduced myself to a patient as a medical student about twelve hundred times in my life, and as a doctor, four. Naturally, there's going to be some work required in breaking the pattern, but by the time I'm up to my tenth patient -- or my hundredth, which will no doubt be before the end of this month -- I expect it'll be second nature, except maybe during those midnight to eight AM shifts when my body is performing physical exams and my brain is unavailable for comment. Patients already sometimes ask me if I'm over eighteen; the last thing I want is to further undermine their confidence in me by declaring that I'm still a student.<P> On an entirely unrelated note, my first day was the only day I worked without having my name tag. After it, I got my ID, which is a plastic card consisting of my picture and the words "resident" and "psychiatry" in both English and French. The downside of this card is that I can absolutely guarantee that at least once while I'm in the emergency department, some justifiably wary patient is going to ask why they're being seen by a psychiatrist. The upside is that I had the foresight to have my picture taken wearing my Miskatonic University alumnus pin; it's too small in the picture to see it unless you know what you're looking for, but it'll bring me joy in the coming years to know that my official hospital ID card includes it. You have to take the small pleasures in life, or else what else is there?<P> So... chaos, incredibly well-hidden jokes that only I will ever find funny, a relaxed work day, and still a positive evaluation at the end of the day. It's hard to ask for more than that. I might just be halfway good at this stuff after all. 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