Front Row

In one of the emergency departments I work in, the clerk's desk is located near the exit and, shall we say, safely the front-lines of patient care. I sometimes remark to the clerks when they missed a really good case or interesting trauma, but they seem to be happy with their location.

Late one night, I was finishing some charting near the clerk's desk when a family of three came up to say goodbye. Their son had been in a car accident, in which he had lost consciousness. After a negative head CT, a benign exam and some pain medication, he was feeling fine and good to go.

As I wished them a farewell, I remembered an abrasion on the young man's left hand.

"Wait -- I've got just the thing for that," I said, reaching for my bacitracin, gauze and tape (the interns have well-stocked cargo pants).

I put the patient's hand on the clerk's desk and squirted some bacitracin onto the gauze. "Now you're finally getting a front-row seat" I told the clerk.

As I applied the dressing, the patient wobbled a little, and I noticed he seemed a little pale. "Everything ok?"


"Hey, ah, are you alright?"

The patient was staring off beyond my shoulder, with wide, wide pupils. He replied, in a monotone: "I can't see."

He stumbled a little bit and I caught him. "Why don't we get you back to your stretcher," I offered, with a cheeriness that rang utterly false. My mind was racing -- I haven't seen a fainting spell like this, could we have missed an epidural?

At that point, the father slumped to the floor. "My son... My son is blind."

Oh my God, they're dropping like flies.

My attending rushed over to catch him. The man was cold and clammy, similarly pale.

"No, sir, he's ok!" I was insistent. "We scanned his head. He's just... doing what you're doing."

We got the father-and-son team back to the stretchers, had them lie down for a bit, and gave them something to drink. They perked up in short order -- no hematomas, just... relational syncope.

When they felt ready to try again, I walked the family to the door, passing the clerk's desk. She (quietly) warned, "Dr. Genes, I've seen enough tonight."

As we passed through the waiting room, a question occurred to me: "Hey, who's driving?"

The father shot a glance at his son, who was shaking his head slowly. The mom chuckled to herself, as the family made their way out of the hospital.

Respirar Profundo

Songs with the word "breathe" in the title that I have enjoyed, listed in order of when I first heard them:
Pink Floyd: Breathe in the Air
Prodigy: Breathe
Telepopmusik: Just Breathe
Sixpence None the Richer: Breathe Your Name (hey, cut me some slack, I'm omitting the entries from Maroon 5 and Faith Hill)
Science Dept (featuring Erire): Breathe
Sia: Breathe Me

The newest addition to the list is Anna Nalick's Breathe (2 AM), which played during the climax of Grey's Anatomy tonight. The lyrics should appeal to bloggers, or at least, MySpace users.


I found myself blathering at Medgadget the other day about the inefficiencies of chest pain admissions. It made me nostalgic for my first patient I saw as a newly-minted physician, one Saturday morning back in July.

After days of orientation, and then a half-hour shadowing a senior in the Emergency Room, learning about the translator phone, computerized order-entry, and the nurse's names, I was eager to begin.

There was one chart in the to-be-seen rack. I picked it up. The triage note declared CHEST PAIN as the chief complaint.

I put the chart back down. "Probably not a good teaching case," I thought, recalling my medical school ER rotations. "And the attending will want to make the decision to rule him out for MI, herself."

I was ready to wait for another chart when it struck me: I'm not a student anymore. And today was a good day to get re-acquainted with a symptom I'll be encountering daily, for the rest of my career.

And so, I saw my first patient. He was in his early 50's, was mildly hypertensive on no meds, quit smoking, with no other risk factors. He reported a vague pressure pain around his sternum for the past few days, on and off, unrelated to exertion or meals. Pretty normal EKG, with no older ones on file.

I poked, I prodded, I tried to get his story and exam to lean one way or another. But his diagnosis remained ambivalent.

So, with a deep breath to acknowledge this momentous occasion, I wrote my first order as a physician:
Aspirin 325 mg PO x1.

The rest of the cardiac workup followed. It seemed a little dramatic to me, ordering all this bloodwork and monitoring for what would likely be reflux or costochondritis.

I was knee-deep in other patients, an hour or so later, when the attending pulled me aside.
"That first patient you saw, the rule-out MI?"


"He's ruling in."


She smiled. "Good pickup. I guess this bodes well for your career."

As I recall, the patient got cathed and did okay. And I haven't had much hesitation to rule out MI in the many, many ambiguous chest pain cases I've seen since.


Yesterday, more snow fell in New York City than at any other time since record-keeping began. And I was working in the ER during the storm's peak hours.

Patient volume was down for a Sunday, but only a little. And, while we had some shoveling-induced chest pain toward the end of the day, the majority of patients I saw had the same routine complaints as any other day: Headache for a month, cough and sore throat for a week, and so on. Pretty remarkable, really. The only difference in my practice was my standard opener, which changed from:
What brings you in today?

What, in the name of all that is good and decent, brings you in today?

New Yorkers are clearly resilient to external influences, but perhaps not as tough when their troubles arise from within.

Acting Out

I've always considered rounding on the hospital floors to be one of the most unnatural of human interactions. The emergency medicine version -- signout -- is a far more efficient and humane process, where the new doctors coming on shift meet the patients, get a blurb about their history and workup, and learn what's pending before discharge or admission.

But, just like rounds can be a source of occasional amusement, so too can signout. The other day, a colleague was signing out a patient as follows:

"This 31 year old man was ped-struck at last night. Positive LOC according to EMS, EtOH on board, good vitals, A and O times three since arrival here. His head CT and C-Spine were negative."

"How about pain? wounds?" the receiving resident asked.

"Pain's under control, no lacs. He's got abrasions on his right ear and temple." Then she tapped her temple, for emphasis. Her expression was one of concentration -- she was recalling the man's initial presentation in the trauma room.

"His right elbow, too." As was said this, she clasped her right elbow. I looked over at my senior, who was starting to smile.

"Also a big abrasion across his abdomen," she continued, as she rubbed her belly. "And bilateral knees" -- at which point she bent down and grapsed her knees.

When the resident straightened herself up, she saw our team stiffling the giggles.

"Hey!" she offered, in good-natured protest. "It helps me remember..."

The attending started singing, Head, Shoulders, Knees and Toes, and we merrily made our way to the next patient...

Unexpected Report

Recently, there's been a lot of traffic in the Emergency Department, and a lot of traffic in social departments, as well. So many new faces and challenging interactions -- much of it is very gratifying, but some of it stings and prompts second-guessing.

All that, combined with a bone-deep fatigue, unseasonable weather, and looming deadlines has led to a kind of constant, low-level paranoia I'm not accustomed to.

Maybe this is part of developing into a vigilant attending, or being a considerate person. Maybe I should lay off the coffee and get some sleep.

Either way, Haloscan informed me, just now, that a comment was made to this post from 2004. A few weeks ago I'd brush it off as a tasteless hoax or misguided plea. But considering my mindset these days, coming at the end of a long night (not to mention the subject matter), I must say: I'm a little creeped out.

(The comment counter says 0 for older posts, but trust me, there are comments. And the commenter's handle suggests he's got a sick sense of humor, or was actually there).