"What we have here is a failure to communicate."

Over the past few months I have learned how imperative good communication is in medicine. I realize it's important in every area of life but we can't do our job successfully unless we are able to communicate well with our patients and with each other. Here is a prime example of a failure to communicate correctly between me, the PA I'm working with, the white board, the triage nurse, and the poor unsuspecting patient.

I randomly picked a chart up today out of the rack and it said "s/p colon resection c/o bloody muscousy discharge". On the board in the ER we have a floor plan of the entire ER and you write your patients name and chief complaint in the room that they are in. This guy's room was right next to another guy's room who was having rectal bleeding. I go into the gentleman's room and do an H&P as usual. Now somewhere between reading the chart, the board, and entering the patients room my mind decided that this patient was having rectal discharge. His entire H&P was based on the fact that I think he is bleeding from his butt. I must have asked the man 10 different questions regarding his bowel movements. We are talking extremely detailed questions like color, consistency, frequency, if he's been farting, etc. The guy just kept on answering them. He never once asked why I was asking him all of this stuff. I moved on to the physical exam. I pulled the blanket off of him and he had light reddish/pink wet stains on the front of his gown sort of over his crotch area. At this point I'm thinking 'Daaang this dude has blood coming the whole way up the front of him!' I lifted up his gown and he had a huge incision running from a few centimeters below his rib cage to just above his pubic bone. There is a serosanguinous discharge oozing very slowly from the bottom of the incision but nothing too crazy. My dense brain STILL didn't realize he was here for "incisional bloody muscousy discharge". I left the room and went and presented the case to the PA. She too was very confused by the case I presented. We both went back into the room and she started going over the same things I just did except after three questions she realized that he was here for his incision not his rectum!! As soon as we left the room I apologized and turned at least three different shades of red. Thankfully the PA I was working with is understanding of the fact that I am a stupid inexperienced student and just laughed at me.

I spent the rest of the day kicking myself and replaying that case over and over in my head trying to figure out how I could have gotten so far off base. I'm going to blame it on the fact that it was early this morning so I was not completely awake yet and the fact that it was busier in the ER than I'd ever seen it before. I'm just thankful we caught the error before I seriously violated him! Can you imagine the surprise on that man's face?! Needless to say I will be double checking everyone's chief complaints before walking through that exam room door.

Just call me the Grim Reaper

Today I saw a patient in the ER who was 64 years old. He was complaining of right chest pain, right abdominal pain, and right thoracic pain. He was also complaining of shortness of breath. His physical exam revealed absent breath sounds in the lower right lobe and a distended abdomen. He was in the ER on Sunday for the same problem and they told him he had pneumonia. The physical exam I did didn't really point to pneumonia so I expressed this concern to the PA I'm working with. She too thought there was something off. We ordered a CT of the chest, abdomen, and pelvis. The results revealed a 7 cm mass in his right upper lobe, a large pleuarl effusion, and a 4 cm mass in his sigmoid colon. :/ People don't have a tumor in their lung and in their colon and NOT have cancer. It's most likely metastasized at that point. The PA I'm working with took this information and turned it into a learning experience for me. She said that she and I would have to break the news to him since we were the ones that found it. Off we went to his room...

He took the news much better than I thought he would. We recommended that he be admitted and start the testing right away. I think he was in a state of shock and was denying that it was actually going to be cancer. One of the things he stated was that he shoudln't even be in the hospital because he was a scientologist and they don't believe in this sort of thing. They believe the body will heal itself. At this point in the conversation the attending walked into the room and told the guy not to be a "dumb shit" and let us at least figure out the severity of the situation. The patient tried to talk us out of it but eventually he seemed to grasp the seriousness of the situation and agreed to stay. I felt terrible when I left that room. This is the part of medicine that nobody talks about. I always figured the docs were the ones that had to deliver these kind of devastating blows. Unfortunately that probably won't be the last time I have to do this sort of thing. I don't think I'll ever forgot this guy.

ER Edicate

This week I started my emergency medicine rotation. I was releived to be done with psychiatry and to start doing "normal" medicine again. I thoroughly enjoyed my first day. It's fast paced and every patient has a different problem. The people I am working with are great too. They give me a lot of freedom and make every case a challenge for me. I was glad to be moving on to ER from psychiatry so I could get back to practicing medicine on "normal" people. Now I am not so obtuse that I think that the ER is full of "norma" people but I figured most would be relatively down to earth. I went wrong with this thought when I forgot the simple fact that I am in Scranton. "Normal" here is not exactly what an outsider would expect. A normal person would come into the ER, get their problem fixed then leave, never to be seen or heard from again. This is not so in Scranton. In Scranton there is no social code of ethics.

One of the cases I saw on my first day was a 29 year old male with foot pain. Being a student I did a thorough history and physical on him. We worked him up for a possible stress fracture, treated him, then sent him on his way. That was the last time I thought of the guy...until I checked my facebook tonight. I had a message from some random person that I didn't know. When I read the message it was from the guy I saw in the ER! The message itself was harmless. He was flirtatiously thanking me and complementing me on a job well done. The part that was freaky was the fact that he mentally stored my name in his head and then the next day facebook stalked me!! As if that wasn't weird enough he then attempted to contact me by writing a meaningful email. I'm going to give the guy the benefit of the doubt and say that he was just being friendly and wanted to express his gratitude. But it still freaked me out a bit. They really should rethink requiring us to have our full names on our badges. People here really have no boundries and will take any opportunity to meet you or hit on you. I have learned to expect this kind of behavior in the local bars but in the ER?? C'mon men of Scranton, pull yourselves together!

16 hours and counting

This may be a little premature but Im going to go ahead and say it, I survived psych! I only have 16 more hours left there and I'm home free, never to set foot on a pscyh unit again. I made it without being attacked, spit on, choked, or chased down the hall so I would say it was a success. The worst thing that happened was having a book thrown at me. Physically Im coming through the other side in tact but mentally is a whole other story. Being locked up with people who either tried to kill themselves and failed, have no wits about them, or are drug addicts takes a toll on you. The windows even have special screens on them to prevent people from throwing things (like themselves) through them. I dont like not being able to take my patient's word for it. When I ask someone how they are doing I expect an honest answer. In this place you are second guessing everything the patient tells you. Today was probably the most uncomfortable moment I've had here though.

I was standing at the nurses station doing documentation when out of nowhere this crazed looking man is suddenly standing with his face roughly a foot from mine. I looked up at him and said hi trying to act normal. When I looked into this man's eyes I got the most chilling feeling I've ever felt. He looked like the main character from a psycho thriller movie. You know the ones where the whole movie revolves around catching the pscyhopath who escaped from the hospital for the criminally insane. Well this guy was that psychopath. He had long stringy greasy hair, his eyes were bulging out from his face and surrounded by dark circles. He had a creepy grin that showed both his upper and lower teeth. He stared straight through me and started talking. Im not sure you could call this talking though. He was making jiberish words with this crazy sounding voice. Then he would randomly laugh this high pitched creeper of a laugh. He also decided that this time was as good as any to pee his pants. Im sure this only lasted for a minute but it felt like an eternity. I've never been so chilled from the look of a human as I was with this guy. The tech's came over when they saw what was going on and tried to convince him to walk away but he wouldnt budge. They had to physically remove him from where I was standing and put him in the isolation room. I will not be forgetting his face anytime soon. Unfortunately I will have to see this guy two or three more times before I'm done. Maybe with some luck he'll be sleeping everytime we need to see him.

I never thought I'd say it but I really miss my overweight hypertensive bacon loving cardiac patients.