Tonight was a great night to be an ER doctor. It was a perfect storm; Monday, after a long holiday weekend, evening shift--all the stars were aligned for a brutal, brutal shift in the ED. Me and Pableo have noticed the pick up in the traffic since early November: the virus season is taking its toll on the very old and very young and we are caring for a lot of sick babies and sick old folks who require a high level of vigilance. Today was going to be especially bad. The waiting room looked like a zoo. Just a madhouse. What a lunatic way to provide emergency medical care to a population, but so be it. Back in Trauma I was doing a fairly decent job keeping on top of my patients and charts, when suddenly things turned ugly. Ugly, ugly, ugly. Medics brought in an old guy with rectal bleeding. Severely demented. I went to check a quick rectal and (DANGER-MATURE CONTENT WARNING!) found a diaper filled with thick gelatinous red blood. Uh-oh, this is not a little cosmetic internal hemmorhoids bleeding, this is something muy muy malo. The guy is on Coumadin-a fairly large dose-and his last INR was checked.....last year. Oh, shit. Low blood pressure, but not tachy. But he's on "heart medicines" which may include a beta blocker so...procede with caution. I decide on the full court press--the "presumption of acuity" I call it. Order two units of red blood cells, a unit of fresh frozen plasma, all the labs, place a central line, start bolusing fluids (but he has a history of renal insufficiency and CHF so, double underscore, procede with caution). Call his primary and wait for the hemoglobin. Then the medics bring in a woman found down at home. Unresponsive, eyes deviated to the left. Snorting and gurgling through her clenched teeth. She is freezing! We can't get a pulse ox. Mercifully she has a narrow complex rhythm that is producing a pulse. I order the STAT CT Head, tell them to prep for intubation, order labs....and then the nurses tell me her rectal temperature. Guess what this woman's body temperature is? Guess. It's....84 degrees Farenheit. That's--what?--29 degrees Celsius! Holy shit! Doing a residency in California didn't really prepare me for managing a whole lot of hypothermia (I've seen a grand total of one mildly chilled patient in my career), but my Board preparation did cover this material. And this woman is sick, sick, sick, sick, sick. Whoah--I must be delicate with the intubation, as it has been shown to possibly precipitate VFib in hypothermia. Pre-load with lidocaine and relax her with Etomidate and Sux. A tube in and....still in sinus brady. Good. Then I worry about whether this woman who has been laying on the ground presumably all night long has rhabdo and an elevated K+. Geez--I cover for hyperkalemia and get her bundled for a STAT CT Head. And then the hemoglobin comes back on my bleeder--3.3! Whoah! I have a acute heady sense of tense heightened awareness. Suddenly we are in it deep. And then my hypothermic lady arrests. VFib that swiftly drops into Asystole. Total unambiguous Asystole. No pulses. Okay--I yell some orders for the bleeder and send the med student to chase down some STAT O negative and jump on our frozen lady. ACLS protocol is going nowhere. She's just too damn cold. We kick our warming measures up a notch and I commit myself to a long, long flog on her. She will not be dead until she is warm and dead. And then they show me the EKG on the little Asian lady with chest pain who is in the gurney next to the bleeder. Acute MI. Huge 4-5 mm ST segment elevations in all the inferior leads. A quick check on the history--yes, yes, she is having some chest pain--and I pull the trigger on the Cath lab. Call Cards, call in the nurses and techs and start the lady on a little Aspirin, a little Beta Blocker (very little, she was bordeline on her BP) and a soupcon of Heparin. My frozen lady, thirty minutes into our code and well into the bag of pharmeceutical tricks, develops a rythm. Irregular, narrow complex, rate of 18. But by God she has a thudding pulse (occasionally) in her carotids. We nurse it up to a rate of 48. The nurses had been obliquely suggesting we call the code, but I had persisted in the face of reason and statistics and here she was, cold but perfusing! She was hypothermic and relatively young and we knew she had a myocardium capable of conducting and contracting so I had pushed it deep into Code Blue no man's land. Whew! I called the intensivist in and she promptly told me that there was no hope for meaningful life and the certainty of catastrophic brain injury--well, be that as it mayy, I'm damn happy to have gotten her back. Her son arrives....about my age. Poor guy. My bleeder is doing okay. Turns out his Coumadin levels were about four times what they should have been. Still, we have the blood and the plasma running and his pressure looks decent. And the myocardial infarction is off to the Cath lab--nice work team! Got off work two hours late and because of the severely ill patients that took up all of my time my statistics or the shift will look bad--we get paid more for seeing a lot of healthy patients then for managing one sick patient in the same amount of time. I've let the partners down in terms of billing and raising money for the group. Still, satisfying day, and hopefully the money and billing side of things will work out in the next few days. Before I sign off I need to say the nurses were fantastic! So, so strong! When it's a madhouse like that the nurses bear a heaviest burden and the teams yesterday were incredible. Took the overload with total grace and professionalism. I really enjoyed working with them. Can't wait to go back. U-561

T called and told me about a miserable case he had. Ruptured AAA that came in. The ER doc did everything right and because of the failure of California Emergency Medical system the guy was left to die, slowly, over the course of several hours, in front of his family's eyes. Total system failure. But because the deaths and human misery are considered a) par for the course or b) physician incompetence or c) both--the system will not be fixed. I deal with it every single shift. Sick, worried, pained people wait five or six hours to be seen. Ridiculous. The Biscuit is proving herself to be wonderful. I scheduled myself to work during the second half of our honeymoon. Once she overcame her stupefaction and astonishment she dealt with it with remarkable grace and forbearance. I picked a magnificent woman.

Had two days off in a row. Well, almost, because I worked the overnight on Monday and that took a bite out of Tuesday. Still, off for Thanksgiving so that will make 2.5 days off in a row. Pretty nice. The Biscuit and I have nothing going on tonight. We had down time and hardly knew what to do with ourselves. Invited some friends over and are cooking dinner for them. Still, it was odd to find ourselves with time on our hands. Tommorow I plan on going out on the bike. Burn some calories before our marathon Thanksgiving: lunch with the Biscuit's family and then dinner with mine. It'll be a 8,500 calorie day. It's a little intimidating. Of note: a great girl, a great job, and alive after a scary crash--Thanksgiving 2005 finds me with a full plate of gratitude. U-561

Last night I was called up to the floor for a "Come up here before we have to call a code." Well, there you go--what does that mean? I went up to find out. An old guy laying in bed with a heart rate of 177, diaphoresis, chest pain. Getting a little info from the nurses the possible history of WPW arose. Hmm...The guys QRS interval was 120ms, right at the edge of normal. I decided this was most likely ortho-dromic conduction and....you know what, this is too much inside baseball. suffice it to say that the gy needed Adenosine promptly and I gave it to him and the situation settled down nicely. Two things stand out for me: One, I like being the guy that is called when bad things are happpening and something needs to be done. Two, there was another doc there, waiting for me to come up and deal with the situation, and I am SO glad not to be that guy. Of course, isn't that what just happened last night when I called anesthesia for a tube I couldn't get? Interesting....Another win for humility in medicine. Competence and humility--those are what you want in a doctor.

Busy couple of days for me. Met with my financial guy yesterday. Went in after 2 hours sleep and felt like the hick in the city; me sleep numbed and dressed in rumpled jeans and everyone else at the office dressed to Fortune 50 pressed slack, button down standards. When I say "my financial guy" I mean this guy who for eight years I occasionally had to call late in the month to ask him to spot my account a few hundred dollars until my next paycheck cleared. Now I guess he's the guy who's going to turn my $20k monthly paycheck into a lush lifestyle, early retirement and life of luxuriant leisure. He seems like a decent sort. Not smarmy. Basically competent. Able to communicate financially with an ignoramus. Our first meeting went fairly well. I find he's a little more agressive with my money than I am; since he and I will have different emotions in the event of my complete bancrupty I think this is understandable. Still, I'm paying him for his expertise--I have to respect that being a little less conservative might be the right way to go. I'm just so emotionally attatched to the money I bleed for and so adverse to a retired life of poverty and fatigue that I find it hard to be objective. My basic plan: Save a lot early on. If I put 40-50k away for the next five years it will create a nice lump of money for compound interest rates and the magic of Wall Street to work on for the next 20 years. Also, it will acustom the Biscuit and me to a life style below our means. When kids show up we'll have some room to adjust to the new financial demands they pose. And today, speaking of money, I dropped $25,000 on a new car. Wow! I was barely able to keep my hear rate under control as I signed the check. There's always that twinge of buyer's remorse, but I'm basically happy--think it's a good car and think I got a good deal on it, $22,700 for a 2006 Subaru WRX TR. $1200 under sticker. Other considerations were a Mustang GT and briefly the Mazda Eclipse or the Pontiac G6. But they were more expensive and uglier. And maybe it's not a great idea for me to have a car with too much power. I'd love to have a 300HP motor on a 3,000lb body, but I'd also like to live to see my 35th birthday and those two things may be mutually exclusive. It's a god damned good looking car. And it has some nice zip when the turbo kicks in. U-561

It's embarassing to be an ER doc. A patient will wait over eight hours to see me. Madness! Here is why: When I come on a 4pm there are twelve beds at my disposal. But four are locked up with patients who are admitted and waiting for a bed in the hospital. Now, there are beds available...there just aren't nurses to cover them. And because of the strict nursing ratios won by the nursing union, there is no felxibility even for the short term. and because the nursing managers are drawn from the ranks of nurses and have primary loyalty to the nurses all sorts of nonsense goes on up there--a bed can be kept empty for eight hours at a stretch by a nurse who knows how to play the game right. Shameful. Whatever--the result is shitty patient carfe in the ED. And the CT scanner has one guy in it to service 30 ER beds as well as the whole hospital. We're staffed for the average patient load--we're grossly inadequate for the above avrage lload which, by definition (almost) occurs half the time. In the meantime I have two drig seekers, one Hewroin addict and two illegal Mexican immigrants in the other beds. I'm running a 3 bed ED for everyone else. What can I do to compensate for making a patient wait eight hours in pain? Nothing. And yet my performance will be measured on how satisfied those poor patients are. Satisfied?! They should be in rebellion! No system like this should ever have been allowed to come to pass. And yet it has. The poor patient patients get shit on by nurses unions, the hospitals, the politicians, etc. and they just accept the abuse. Madness! Absolute madness. U-561

At work we had a labor crisis--one of the PA's quit. Just quit. No 2 weeks notice, nothing. She had just started with us and she felt "overwhelmed" and "anxious before every shift". No shit? Really? Welcome to the game, idiot. This isn't a Derm clinic where you get $150 an hour to decide which pimple to pop first. It's the real fucking deal and if you don't feel overwhelmed you're not working hard enough and if you don't feel anxious before every shift you're deluding yourself about what the day holds in store for you. So because she quit we were down a PA in ED2. But that's no problem. 12 beds and moderate acuity--it meant more work for me, but it also meant that I could see a shitload of patients and inflate my patients-per-hour stats. Fine. Then one of my first patients of the shift was our other PA--out with a bad malady. Uh-oh.....that's a problem; nobody up front to do the rapid exam and dispo. Definite system failure time! The department director came in (on a Sunday evening) to work the PA shift. Strong. That's leadership! Alas, because he came in he was on hand to witness another miserable U-561 reduction. Embarassingly bad. My ortho training was just not adequate (largely my fault....but not entirely...) and I'm bad at ortho. I'm bad at ortho. What a miserable thing to have to acknowledge. Must improve. Where could I go to just reduce fractures for a week?--just reduce forty fractures a day for five days? That's what residency is for....and I blew it. Have been dismayed recently. The long work hours, the few days off, the studying, the crash, the possible lawsuit, the seasonal affective disorder, etc....I just have been dissatisfied with what I'm making of my days and weeks. But feel better now. In large part because of the Biscuit. She's wonderful. U-561

At work we had a complete shutdown. In our 13 bed ED we had 9 of those beds filled with patients waiting to be admitted. Madness! And, yet, all too common a phenomenon. The economics of medicine and the politics of nursing have created a perfect storm of bed shortages. Patients just bunk out in the ED waiting for a hospital bed to open up and that creates enormous back up in the ED waiting room. Absolute madness--no civilized society would do this. Even double-bunking patients only got us as many as five or six working beds. And we had a PA training in ED1. So instead of me, alone, trying to keep a hold on 16 beds, it was me and a PA managing 6 beds. A slow day at the office. So be it--the variety makes for a nice change of pace. But if this keeps up...yet another California ED will have to close. California medicine is in crisis, California Emergency Medicine is in failure. U-561

You know you work in a good job when it eases the demoralization out of you and replaces it with a sense of mild satisfaction and accomplishment. I have a good job. Yes, I mayy be sued for uncountable damages by some guy who crashed his motorcylce into my car, and I may enter my new life and my new marriage with the loadstone of an unpayable settlement around my neck, but I had a pretty good shift. We had a surfeit of medical practioners--in order of decreasing competence: me, a PA, a Fam Med resident, a medical student who wants to be a psychiatrist. It made for a pleasantly relaxed day. My first patient was a little lady with premature rupture of the membranes at 17-19 weeks. I went to do the pelvic exam and saw a small foot protruding from her vagina. My heart sank. I delivered the stillborn fetus. This is one of the things that I have yet to harden myself against; it was really a disturbing experience. I delivered this little baby and had it clasped in my hand, tiny and lifeless. Poor, poor lady. We wrapped the baby in a small towel and she cradled it to her and cried. Rest of the day was uneventful. We had a full arrest that came in, V Tach, but the medics shocked him out of it and when I saw him he was stable and feeling pretty good. The paramedics absolutely saved this guys life. I got my dictations done (Oh Joy!--that albatross around my neck is finally cast off!) and got out opf work only 30 mins late. Sweet! Also--one of the ladies at work just had pupppies. (You know what I mean). Half Lab-half German shepard. Perfect! 2 days old--so in 2 months i plan on having a little mutt puppy running around. Great--I like both those breed and the time is right! I'm pretty excited! U-561

Find myself demoralized today. I was filling out the paperwork for the insurance on the car today and one of the letters was a warning that I might well be sued and that the cost would probably be more than the insurance company would be willing to cover. Great--some guy crashed into me and now can sue me for whatever he wants. I see these people every day--they come into the ER days after an accident and they have some mysterious unidentifiable ailment that they want me to "document". The cops warned me about this--when they saw I was in my scrubs they told me I'd probably be hearing from his lawyer. What a fucked up society. The reasons to leave California get better each day. Also, with me working an ER schedule and the Biscuit working weekdays and going to school at night and going to the Corps one weekend a month we don't see much of each other. Dismaying. We end up spending about one day a week together. U-561

Written Boards done with. The sensation is something akin to being kicked in the crotch and getting out of a bad relationship. If I pass all I have to worry about is orals, and I think that will be a little easier for me. UCLA lost this weekend. Lost ugly. Exposed themselves as what they are. They're a 7-4 team that's been masquerading as a 7-0 team. Still--a good step in the building process. We'll see what the end of the year shows us. U-561

This lunatic stretch of work is over. I've worked 14 of the last 16 days. Madness. Bad for me and bad for the patients. I almost killed myself on the freeway. God knows what harm I've done to my patients in the last two weeks. I'll never, ever do this again. Not the fact that it was suicidal before Boards. Nor the fact that it was physically painful. But it wasn't good for my attitude towards work. It added points to my burn-out-o-meter that can't be entirely removed. It was hard on the Biscuit. It was a dumb, dumb thing to do. You live and you learn--no more of this nonsense. Got an email from St.D's The Miracle Worker has done it--we're all getting a fat bonus. $50 an hour. Yes, an extra $50 for every hour we worked. The base is $120 so that comes out to be more than a 40% bonus. Wow--that inspires loyalty, my friend. He may give us a lot of nights and weekends, but as long as he's putting a extra $7k per month in the pockets of his docs they're going to worship at his feet. I'm a part timer, but the $4000 I just landed has made quite an impression on me. The full time guys must be euphoric. Boards in a few days. My motivation to study is zero. Christ!--I just made $4000 by checking my email--who cares if I'm a competent doc! U-561