A busy day in the emergency room

I had a great time in the emergency rooms around Vancouver when I went through my third year rotations. I guess I liked the variety of cases that come through the door, and doing what I think is one of the most fun parts of medicine: diagnosing and stabilizing all sorts of patients until the right experts can take over.

But my 4 weeks of emergency in Vancouver was nothing compared to what I did in a rural rotation during my fourth year. In a small town emergency manned by just one doctor, I suddenly became a useful member on the team. The nurses look to me to take on patients so that I can help with the workflow, seek me out to do procedures “because the student should learn this”, and the doctor place me up front and center for my first cardiac arrest code…

During the day, I sutured a few lacerated fingers (I love suturing no matter how many times I do it… I think it has to do with liking to do small arts and crafts that are fun but not overwhelming), examined a few patients with various ailments, pushed the shock button and zapped a patient out of her multifocal atrial tachycardia, all in a day’s work.

But in the evening, things got more interesting. While I was talking to the ER doc about anaphylaxis, a family member suddenly called out: “we need some help!” I jumped up and rushed to the bedside; I interviewed the frail lady just several minutes ago and thought she just had a partial bowel obstruction, and ordered the standard set of workup.

She looked very different now. Her eyes rolled back, and her muscles started to spasm. Her false teeth came loose and was about to fall into the back of the throat when I threw on a pair of gloves and grabbed it.

“Open her airway,” the ER doc said. “Start bagging her. Call a code!” He turned and called out to the nurses.

I grabbed the bag-valve-mask and the thing fell apart. I clumsily put it back together and starting bagging (providing artificial respiration by pressing air into the lungs with the bag) the patient. I was so focused on my task that when I finally looked up, the family member has been gone, a team is already around the patient, and an ECG was showing ventricular tachycardia (and she is pulseless)- one of the most deadly heart rhythms that means certain death if not corrected in minutes.

“All clear!”

The patient jerked while the shock was delivered. I resumed bagging the patient right away, but almost immediately she started showing signs of life, moving her limbs and spitting out her oral airway. I pulled out the airway and the doctor told me to keep bagging her. After a minute or two, she started breathing on her own and I just held the mask delivering 15L/minute of oxygen over her face, and took in the scene.

A nurse was having difficulty with placing the oxygen pulsimeter, another nurse is placing a large-bore IV, and someone else is fitting a bag of fluids into a pressure cuff. The ER doc was giving orders for interventions and investigations. The patient continued to stabilize, and things finally settled. She was saved from death, for now, but we haven’t figured out what she was dying from.

As a part of tests to find out, we ordered an arterial blood gas. This requires puncturing the artery with a needle to draw arterial blood, to find out about the gases and pH values of blood that the body sees. I had practiced on a classmate more than a year ago, so I was poking my head over a nurse’s shoulder to get a look.

She suddenly asked, “where’s the student?”

“I’m right here behind you.” I said.

“You should be doing this.” She said, matter-of-factly.

“I was thinking ‘I wish I could be doing this'”, I said, which was the truth.

So we switched spots. I struggled at first, but another nurse holding the patient’s hand was steady and patient, and the ER doc gave me some directions, and I got a steady stream of arterial blood from the radial artery. First ABG, success.

The ABG later showed that the patient had plenty of oxygen in her blood, and no other abnormalities. “You bagged her well,” the ER doc said. First time bagging a coding patient, success.

Later on that evening, just as everyone felt they’ve put in a good day, a call came in notifying us that there’s a cardiac arrest patient being rushed in by ambulance.

A team of nurses that make up the trauma team got ready in the trauma bay, and I volunteered to do chest compressions. But the ER doc had something else in mind.

“You will intubate the patient.” He said.

“Alright!” I said, excited.

“Have you intubated before?”

“Only in very controlled settings (in the operating room).” I said

“Well, there will be nothing controlled about this,” he said.

We checked the intubation equipment, and someone pulled up the glidescope. The guidescope is basically a camera that shows the patient’s airway on a screen, which often helps visualizing the trachea into which the tube has to be inserted.

After a few minutes of calm when the whole team waited, the ambulance arrived. A nurse closest to the door took a look, and said quietly: “god, he is 400lb.”

The ambulance crew flew in with the morbidly obese patient, and somehow managed to drag him over to our stretcher. The continued to pound away on his chest until our nurses took over. The team got to work, placing IV’s, defibrillator pads, and I pulled over the glidescope.

“Go?” I asked.

“Go.” The ER doc said. “And 1mg of epinephrine!” He said to the medication nurse.

I opened the man’s mouth. His neck is massive, and his tongue seemed as big as my palm. I couldn’t even fit the glidescope into his mouth, and I think it is at least 2 inches too short for him.

“Let’s use the traditional way,” the ER doc said after he couldn’t get a view either.

I pulled up the laryngoscope, and naturally used my right hand to put his head (which must weigh 8kg) into the sniffing position. I saw the epiglottis, and it was impossible to see the vocal cords.

Thankfully I learned how to use a flick motion with the tube in this suboptimal situation, and I got it in one go.

Unfortunately, despite our best efforts, the patient was too far gone. The ambulance crew has been doing CPR for about 30 minutes before arriving to the emergency, and he was in asystole on arrival. The most likely cause of death is a massive MI, and there is little CPR can do in this situation.

The ER doc called it, and commended on everyone’s efforts. He was especially impressed with my intubation.

“Truly a great job. Things were chaotic, the nurses were doing chest compressions, the man is so obese that even anesthetists would have to try hard.” He said. “You won’t have to do a harder intubation in your life.”

Although the outcome of my first case of cardiac arrest was not successful, I left the emergency room at 2am knowing that I have done as well as what anyone in my situation could have, and that was a good feeling for a medical newbie like me.

And I realized: the more I do in the emergency, the more I like it.

 

Only in Taiwan

have I seen the following senario so widely accepted to be the norm:

My grandma, who is a happy and pretty healthy 82 year-old, recently had a cough. She has been afebrile, and maintained good hydration and appetite. She has no constitutional symptoms like malaise and weight loss either. Her cough is productive of some yellow phlegm, and it’s been going on for about a week, so she was prescribed some antibiotics and some antitussives, and was asked to follow up in the clinic in 3 days.

Bread and butter primary care, right?

Except she went to a pediatrician‘s office.

And the thing is, I would not have thought twice about this situation a few years ago, because that is really normal in Taiwan where I grew up. There are virtually no family docs (and no patient knows what family docs do even if they see one) on the streets where medical clinics tend to cluster and where patients go see doctors. There is no concept of longitudinal care either; if the doctor in this clinic isn’t helping, patients will go to the next one down the street. (And if all else fails, or if the patients decide the problem is serious enough, they will present to the best tertiary hospital they can get to.)

So that’s what my grandma did after seeing two different pediatricians and still had the cough. She went to an ENT surgeon’s clinic.

Yes. Ear, nose, and throat surgeons who went through years and years of extra surgical training to operate on some of the most vital (airway) and aesthetically important (face) areas of the body are common go-to doctors for mild URTI in Taiwan.

Imagine the hilarity if that happened in Canada. If a 82 year old woman is referred to a pediatrician for a case of mild URTI or bronchitis? Or, heaven forbid, an ENT surgeon? The primary doctor who made the referral would not even be taken seriously enough to be yelled at. The pediatrician’s or ENT’s secretary (or medical office assistant) would probably politely talk to the primary doc’s secretary and ask him or her to check the correct addressee.

Now, this is not a criticism of the patients or the doctors in Taiwan. Both parties are doing what everyone is doing, in a way how everything has been done. In other words, this is the current medical culture of Taiwan, and no one can be faulted for doing things in the most culturally accepted way.

But just because something has always been like that in the past doesn’t mean it should alway be the same in the future. Think about the downside of having streets of medical clinics run by specialists, advertised to be the former attending doctors or even heads of departments of prestigious tertiary hospitals and academic centers, to whom hundreds of ill patients and their worried families present any condition under the sun. The patients have only their understanding of the specialty title to base their self-referral on. “ENT? Sounds like a good doctor for coughing which is kinda in the throat.” “Stomachache? Probably like the ones I had when I was a kid. Let’s see the nice pediatrician who saw little Johnny last week.”

Well, for starters, the specialists would either go mad and burn out (“WHY AM I SEEING 30 CASES OF VIRAL DIARRHEA A DAY AS A COLORECTAL SURGEON!?”) or become content with being a GP. There goes years of intense, valuable specialty training. Also, the patients are probably getting suboptimal care because of their inappropriate self-referral. They can decide that an internist is the best for their child who is vomiting, but the internist may very well not know the complete list of differential diagnoses of pediatric vomiting by heart.

I can probably go on with the problems with the current medical model in Taiwan, but I think you get the idea. The bottom line is, this model probably poses a serious drain on the health care dollar, creates unnecessary confusion and suboptimal care for the patients, and leads to much headaches and burnouts for the doctors.

The big question is, how do we change it?

That, my friend, is a good question. If you can answer it well, you should consider becoming Taiwan’s health minister.

As for me, I just ordered some delish Chinese take out and will be too distracted after the break 🙂

Yum yum yum yum.