Another day a the Saint D's. It starts at 6am and it's about an hour away so....well, to make a long story short I was underslept and Dead Man Walking. At work I was bit by a ten year old. She was funny and urbane so I was fooled into thinking she was more mature than she was. I needed to wrestle an impacted tooth down out of her gum line and was going to bruticaine it out, but witty and urbane or no a scared ten year old is a scared ten year old. She chomped down hard on my finger, right on the tip. It was all my fault and as I reviewed the ultimate scenario I had created (five people packed into a small room holding down a screaming little girl) I felt like an idiot. An absolute idiot who deserved, at the very least, to have his finger mauled. I also was responsible for the worst fracture reduction ever done in the history of medicine. We eased the kid out with Ketamine and yanked and pullled on his arm. Totally incompetent. In two days he is going to take his XRays to the Orthopod clinic and that orthopod is going to have every one of his biases about crappy ER physicians spectacularly confirmed. Despite a pretty goof shift it made me feel so lousy. The truth of my situation is that even though I'm out of residency I still have a lot to learn. That was one of the appeals of Emergency Medicine, the broad domain of knowledge, but its humbling and, in times when I screw up and hurt a patient, really demoralizing. Also, I had one of those cases that I think would seem horrible from a civilian standpoint. A little Philipina woman (I think a mail order bride) came in feeling weak and sleepy. She had been vomiting and not taking her psychiatric meds. I worked her up, hydrated her, and it was time for her to leave. She flat out refused. She feigned weakness and refused to walk. She slid from her wheelchair like a limp noodle. She just wanted to be kept and cared for. The denoument involved me and the tech lifting her bodily by the armpits and dragging her to the door. Her husband had pulled the car up. We pulled her, bare feet dragging on the floor, to the door and outside. Outside, after a few seconds of her feet dragging on the asphalt her weakness dissipated and she was able to walk to the car and get in wihtout assistance. It had a certain brutal heartless air about it. How did I know this woman was feigning illness? Could I have been wrong? There's an answer, but it's a long one. In brief: that event is the whole of my job writ small; making a medical decision and acting on it. I do so in the full knowledge that at times I will be wrong. But to delay action until certainty is achieved is to be paralytic. And that's not good in an ER doc. U-561