An Intern In The ER

By Demetrios Tzimas, MD

New York City.  Bellevue Hospital Center.  July 17, 2009.  1:53 pm.  Intern Year. Long Call.

“Go down to the ER.  There’s a guy with chest pain for the past three days, EKG shows some non-specific changes, vitals stable.  First set of labs negative.  CXR clear.  They gave him a full-dose aspirin.  This sounds like a rule out chest pain, and since it’s Friday, he’ll go to medicine and not the chest pain unit.  I’d go down with you, but one of our patients needs a line.  If you have any problems just page me.  He sounds stable, don’t worry.”

Wait, what are non-specific changes?  What is he crazy?  I don’t want to deal with chest pain—it could be anything…pneumonia, pulmonary embolus, myocardial infarction, pneumothorax…aortic dissection.  Well, can’t be a pneumo, CXR is clear, and can’t be dissection, I’m assuming “CXR clear” means that the mediastinum is not wide.  But who read the x-rays?  Hopefully an attending signed off on them.  Whatever, if David was worried, he wouldn’t send me down there alone. Anyway, just remember MONA—morphine, oxygen, nitrogen, aspirin.  I learned chest pain a million times in med school, this will be no sweat….isn’t a beta blocker supposed to be given too? Wait no, what did the COMMIT Trial say? That’s just with an MI, this is chest pain.  I hate pneumonics.  Ok, let’s be efficient.  He’s going to need admission orders.  Labs, medications, vitals every four hours, admission order, prophylaxis.  Diet, don’t forget a diet.

Wait a minute.  What does “first set of labs negative” mean?  Did they not draw any labs on him?

I took the elevator down 17 floors to the ground floor, and walked down the long corridor from the main hospital to the Emergency Department.  I nodded respectfully at the police officer next to the CPEP (our psychiatric emergency room), and hooked a left into the Bellevue Emergency Room.

The smell of the homeless alcoholics hit me as soon as I walked inside, the same odor that I smelled every time I walked into that ER.  It was like an olfactory aura, warning me of the madness I was about to experience.

If Bellevue is a beast, then the ER truly is its belly.

Every time I worked in the ER, it seemed that no matter how fast I was trying to do things, everyone was going faster than me; everyone just runs around with tunnel vision trying to accomplish the next task at hand.

Place that IV…where’s the nurse, that patient needs a foley…where is the red speckle-topped tube…why won’t med consult call me back???

Nobody makes eye contact with you, doing so would make them available to be bothered by you.  To ask someone a question is taboo; it will not only slow them down, but it will also make them susceptible to being asked more questions by you in the future.  So everyone is just too busy–or  too busy pretending to be busy–to help you out.

An intern, especially a medicine intern, on July 17, is all alone in that jungle.

And just as the ER staff knew not to make eye contact with me, I quickly learned to avoid making eye contact with patients at all costs. They’ll most likely just ask me to get them a sandwich or something.  As I walked around the ER, I made sure not to look up at anyone.

Ok, so where’s my patient?  Oh yeah, go to those really helpful white boards.  1-2A- Diarrhea.2-7B- GI bleed.  3-dude just look for chest pain, or “CP.”   Ok, not here.  Maybe he’s on side 1.

Walking over to side 1 of the ER, it really hit me how absurd the system was down here.  I understood that patient confidentiality was an important issue, but seriously, it was about to take me 15 minutes to find this guy because all they listed on the white board was either a chief complaint or diagnosis next to a number.  Looking at the side 1 white board, I again didn’t find those magical words.

I hate this place.  Back to side 3.

I walked into the nursing station/doctor’s space/clerk’s desk/phone center/precepting room/copy and printing area: the four-sided workstation for EVERYONE in the Bellevue ER.  I had to interrupt about three different conversations as I fought my way to the white board.  I finally found those two letters “CP” on the white board of the side 3…four different times. Ugh.

Maybe the side 3 nurse knows who this person is.  Who’s the side 3 nurse?  Maybe this guy knows.

“Hey, do you know who the side three nurse is?”  Without even turning to look at me, he replied, “Sandra.” 

Thanks bro that was helpful.

“Hey, are you Sandra by any chance?” I asked the first woman I saw.  “Yeah, but I’m busy.  Find me in five minutes.”

I really hate this place.

After process of elimination, I finally figured out who my patient was.  I had to reach over the orthopedics residents looking at an x-ray at the PACS station to grab the patient’s chart.

“Excuse me…sorry…thanks.”

Ok, 68 yo M with asthma, HTN, HLD, diabetes, comes in with chest pain x 3 days.  BP 145/95, P 88, R 16, T 99.9.   So let’s look at this EKG…haven’t read one of these in so long.  I need calipers.  Ok, David said non-specific changes, whatever that means…ok, well there aren’t any ST elevations and it looks sinus, safe for now.

I finally found my patient.  He basically told me that for the past three days, he had been having sharp left-sided chest pain.  It was constant.  He wasn’t sure if it was associated with exertion and couldn’t say if anything made it better since it was always there.  He was able to walk around without a problem, and this didn’t make the pain worse.   This sharp chest pain wasn’t associated with shortness of breath, nausea, dizziness.  He denied any palpitations.  He’s had this before and has gone to the ER, but has never been admitted.

So why did you come into the hospital again? Can’t these people just stay at home?

But when I asked why he came in this morning, he said he woke up around 5am with some throat burning, and he did get short of breath then.  It had gone away, but he decided to come to the hospital anyway. He still had his left-sided sharp chest pain, which was most concerning to him.  He also informed me that, about 5 minutes before I came to talk to him, he felt the burning sensation and was short of breath.  I decided to get an EKG.

Shoot…ST depressions in the inferior and lateral leads, and he’s having some chest burning.  Let me check the troponin.

I somehow found an open computer and looked up his labs.  The first troponin drawn at 6am was negative, but the second drawn at noon was 2.3.

Didn’t anyone check his labs?  He’s having an MI! Ok, first things first. Make him chest pain free.  Nitro, sublingual.  Wait a minute, what if he’s having a right ventricular infarction, it’ll drop his pressures.  But wait, his pressures are normal now, he’d already by hypotensive at this point.  Or would he?  Just call David.

I paged David to the ER, but since I wanted to complete his management, I walked away from the phone.

Fine, give him some morphine.  Oh yeah, MONA.  He got aspirin.  He needs oxygen, I’ll put him on 2L NC.  Thank goodness I went to intern core last week.  He needs other things though: Plavix, beta blocker, statin,heparin. Ok, I can totally handle this.  He’s diabetic,I should give him his metformin.

I began to write the orders down on those archaic paper orders sheets.

Beta blocker.Ok, metoprolol.  What dose?  IV or PO?  Hold on, he has asthma.  But I can give it to him if he’s not wheezing, right?  Did I even listen to his lungs?  Wait, how’s his chest pain?  Wait, COMMIT Trial, no beta blocker yet.  Maybe cardiology needs to be called. Let me see him first.

David call me back!

The patient’s chest pain was now gone with 2mg IV morphine, although he was still slightly hypertensive and pulse was still in the 80’s.  He was satting 100% on nasal cannula and did appear comfortable.

Ok, let’s give him Plavix.  Wait, 300 or 600?

I ordered him for Plavix 300mg.If he needed 600mg, I reasoned that I could always give him more later.

Ok, high dose statin. Which one do I give him? Simvastatin 80 sounds good to me.  Or do we give Lipitor?  I’m sure they don’t have Lipitor in Bellevue, it’s a city hospital.  Should I call pharmacy?  No time dude, just give the Zocor.  Now what?  Oh yeah, heparin drip.  But has he fallen recently?  Does he have a history of GI bleeding?  Do I need a CT to make sure there’s nothing in his brain that could bleed? Shoot, I didn’t take much of a history.  Should I guaiac him?

After making sure he was still chest pain free and comfortable, I completed my history and physical exam.  He had no history of any kind of bleeding, he had childhood asthma with no history of intubations, and he hadn’t used inhalers since he was a teenager.  As his pressures were stable, I gave him the beta blocker which lowered his heart rate and blood pressure and started him on a heparin drip.

Aspirin, Plavix, Statin, Heparin, Beta.  He’s chest pain free.  Perfect.

“16 North 1 team resident on line 3015.16 North 1 team resident on line 3015.”

Proud of myself for diagnosing and treating this patient’s NSTEMI, I explained to David over the phone what had happened.

“Demetrios.  You should have given him Lipitor 80.  Why didn’t you call cardiology?  Have you ordered an echo?  What’s his LDL, AIC?  Don’t order him for metformin if he’s diabetic, just put him on a sliding scale for now.  And why didn’t you page me more than once?  You knew I was putting in a line.   I have to be able to rely on you man, we’re getting slammed today.  Don’t worry, I’ll call cardiology and put in the other orders; I have another admission for you.  He’s in the ER, side 3, coming in with chest pain…”

Dr.  Tzimas is a 2nd year resident at NYU Langone Medical Center

Image courtesy of Wikimedia Commons

 

 

 

 

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