My Precious

Back when I worked in the Big City ED, we had a nurse named Bob. Now I'm sure Bob was a perfectly wonderful human being, but he was not a great ER nurse. Bob didn't like commotion. He didn't like multi-tasking. He was no fan of confrontation. More than anything else though, Bob hated, and I mean truly and completely despised, when someone moved his charts.

Finding a chart lying on the counter rather than stacked neatly in the rack put Bob over the edge, so much so that he once famously kidnapped all the charts, relocating them to the med room and hiding them among the lidocaine vials behind the safety of a locked door. Any attempts to access the abducted charts by another member of the team was rebuked. There, safe from greedy grubby hands grabbing his precious charts, Bob remained holed up to jealously document on his well-organized beauties. (His tenure in the ED was short.)

Sitting around the Christmas tree this weekend, I was reminded of this humorous episode by noticing the same possessive leer in the eyes of one of my younger cousins. Still a few years shy of truly appreciating the whole "giving is better than receiving" tenet of the season, the little rascal wolfishly gathered his presents from under the tree and arranged them in a neat pile at his feet. Positioned out of reach from the rest of the family, he was poised to start shredding the wrapping paper at the earliest acceptable moment.

Recognizing that look which screamed "Mine!" and smiling, I hoped at that moment my cousin would never choose a career as an ER nurse.

Around the Blogosphere

I'm sure most of you read Movin' Meat already, but if not, take a minute to stop by and leave some kind words for Shadowfax. His wife was recently diagnosed with breast cancer. Between several years of working with kids with cancer, and losing a couple family members to the disease, I can honestly say cancer sucks.

On a happier note, Nurse K is back! Brace yourself for more hilarity and snark.

Med Student Heal Thyself

For the record, I probably do not have an abdominal aortic anneursym.

I do, however, have a funny, recurring, pusatile sensation in my left lower quadrant.

Combine that with a a heightened sense of medical curiosity secondary to the elevated ignorance of a first year medical student, and you get several intriguing, bizarre, and universally fatal self-diagnoses.

It's kinda fun.

The Tables Have Turned

For the first time in several years, I experienced a visit to the ER on the opposite side of the stethoscope. Now back home for winter break, I accompanied my father to the Local Hospital this weekend after an icy sidewalk led him to experience to a sudden and unexpected burst of gravity. After countless encounters with family members in the ER, I decided to employ several of their techniques to ensure we received high quality care:

*Upon arriving at triage, I spoke over my father to answer all the RN's questions. When she asked his pain, I replied "20/10!" while waving my arms emphatically. When his temperature was measured as 97.6˚, I informed the RN that it was "high for him."

*As our time in the waiting room approached an unbearable 10 minutes, I interrupted the RN while she was triaging another patient to ask if she was trying to let my father die. I also asked to speak to a manager.

*Once brought back, I explained to everyone that I worked in an ER, pointing to my Big City Hospital ID badge that I carry with me at all times. I also mentioned that I'm a first year medical student, so I basically know everything.

*While my father waited for X-ray results, I decided to wander the halls of the department, peering into other patient rooms and trying to decipher chief complaints while reading the board.

*Since my father hadn't eaten in at least 3 hours, I demanded two box lunches - one for him, one for me.

*When the doctor explained that X-ray showed no broken bones, I hastily began packing up our belongings and accused the stupid doctor of wasting our time and money on those pointless tests before storming out.

All in all, it was a very successful trip.

Extreme EM

From the New York Times, another account of front line medicine in Afghanistan. Transporting a pregnant woman is stressful enough, but flying her in a Blackhawk helicopter over a war zone?

The Robot Will See You Now

Blood pressure 220/110? Warning! Danger Will Robinson!

So it looks like years of education, hundreds of thousands of dollars in student loans, and a small forest's worth of lecture notes will all be for naught.

That's right, doctors are out, robots are in. At least in triage, that is. Vanderbilt University is working on the TriageBot, a machine that will take patients vitals, solicit their chief complaint, even wander the waiting room to make sure patients are still breathing.

Maybe I should start focusing on learning what R2D2's bowel sounds sound like?

Law and Order: Organ Preservation Unit

We'd like to see your organs.

A patient having a heart attack calls 911, and an ambulance rushes to the scene to save a life. A second ambulance, with the words "Organ Preservation Unit" stenciled on the side, arrives a little later in case the first crew is unsuccessful. Like anything with organ transplantation, it's a concept with complicated ethical, logistical, and public relations considerations, but an interesting plan nonetheless. I still vote for a national opt-out policy instead.

I Don't Know

As a medical student, I'm getting awfully used to uttering the phrase, "I don't know." I repeat it while studying, lament it when posed questions by professors and classmates, and hide behind it when asked for legitimate medical advice by friends and family.

At this point in my training, I'm just beginning to learn how to play doctor. Flubbing my way through the lines of the interview and pantomiming a crude physical exam when I see patients, I couldn't even pass as an understudy. Yet, by virtue of my white coat and stethoscope, sick individuals lying on stretchers occasionally confuse me for an actual physician.

It's still a little exciting, and always humbling, when that happens. A mini ego boost to be sure, but canceled out when patients actually expect me to know something. Like the woman who grabbed my hand, looked me in the eye, and fearfully asked, "Do you think my cancer will come back?"

My initial reaction was a flash of terror. I wanted to stammer that I'm doing my best to learn at least 75% of the material before each exam, and feel like I'm struggling to retain even a quarter of that information the week after. My charade had been exposed - I was soliciting details without any idea of what to do with the information, and possessed no ability to respond to questions asked of me in return.

So, I told the truth.

"I don't know," I confessed, still holding her hand, "but the doctors are going to do everything they can to make sure it doesn't."

How Times Have Changed

College: Standing in line at Walgreens buying red plastic cups and ping pong balls at 10pm on a Saturday night.

Med school: Standing in that same line in sweatpants and flip flops buying a box of Cheerios.

Med School at the Movies

Sometimes, it seems, you can only memorize so many muscles that sound like Harry Potter spells (Extensor digitorum!) before taking a break from the anatomy atlas and popping in a DVD.

Unfortunately, one side effect of medical school appears to be constant reminders of things we've studied. Using The Princess Bride as a study aid? Inconceivable, you might say. But consider the following examples of high-yield medical miscellany...

Polydactyly: The six-fingered man who killed Inigo Montoya's father. He likely suffered from an autosomal dominant condition.

Acromegaly: Fezzik's great size stems from an excess of growth hormone production by the pituitary gland.

Reversible injury: As Miracle Max points out, "Mostly dead is slightly alive." Perhaps Wesley's hepatocytes simply needed time to regenerate.

Hypertrophy: R.O.U.S. = Rodents of Unusual Size.

Feel free to use this helpful study guide as you wish.

For All You EMS Types...

(To borrow a phrase from Ambulance Driver)

Esquire profiles a paramedic trainee's introduction into the unique world of emergency medicine. Hat tip to a friend for passing the article along.

Meanwhile, if anyone out there still reads this, I'm hoping to share some med school/ER stories soon.

Extreme EM

Two of my favorite things... emergency medicine and running. Great article about brining emergency care to marathon runners in New York this past weekend.

Different Perspectives

Back when I started as an ER tech, I was trained by ER nurses (kind of like being raised by wolves, but even more awesome). One nurse in particular, a seasoned veteran of several decades spent in various inner-city trauma centers, took me under her wing and first introduced me to the so-called intern's vein - a vein so easy, "even an intern can find it."

Flash forward a few years to med school, where a bunch of eager young med students attentively soak up a powerpoint presentation on how to draw blood. As the physician runs through the preferred sites for peripheral access, he finally comes to the intern's vein - a vein that "only the intern can find" (presumably after unsuccessful attempts by the nurses).

Same vein, just a slightly different emphasis that made me chuckle. Flash forward even further, and I can promise that if Second Shift the Intern is told by an ER nurse with 20 years of experience finding impossibly tiny veins on hard core heroin addicts that she can't find access, the first thing I'm going to do is grab the ultrasound.

To All My Old Friends in the Big City ER...

and in emergency departments everywhere, happy emergency nurses' week!

Remember to be nice to the nurses - they keep the doctors from accidentally killing you.

This Week's Sign of the Apocalypse

Man willingly risks death by delaying pacemaker operation in order to watch this weekend's Michigan - Michigan State game.

Back in Action

After nearly two years of sharing stories about life in the emergency room, this blog took a detour when I began medical school. No longer working as an ER tech meant that my source of material had dried up. While I'm enjoying the journey so far, blogging about hours spent studying does not make for interesting reading.

So, it is with great excitement that I will soon begin a clinical mentorship elective in our medical center's emergency department that will allow me to interact with and begin to examine real ER patients. I'm really looking forward to being back in the ER, this time with a medical student's perspective.

Speaking of life in the world of emergency medicine, this weekend the New York Times ran a profile on the Maimonides Medical Center emergency department.

Be sure to check out the article, photo essay, and video.

Nerd Humo(u)r

Science journalism, from our cousins across the pond.

After reading one or two scientific papers in my day, and then reading how they were presented in the press, this left me chuckling.

The Big Chill

Cooling the body temperature of patients in cardiac arrest is becoming an increasingly popular method of reducing the damaged caused by a lack of oxygen. In the ER, I witnessed the adoption of a "code chill" protocol that involved an ICU team with a cooling unit for arresting patients.

According to this article, surgeons at Massachusetts General are preparing to employ a similar concept to trauma victims. By pumping cold saline through a patient's blood vessels, the team can lower body temperature to 10˚C, or a frigid 50˚F.

Claims the leader of the project, "By cooling rapidly in this fashion we can convert almost certain death into a 90 percent survival rate."

Pretty cool.

(Super) Bad Moon Rising

Uh oh.

Anyone up (say, studying anatomy) later tonight should be treated to a neat celestial show. For the first time in 20 years, the autumnal equinox is occurring on the same night as a full moon, an event known as a Super Harvest Moon.

For stargazers of all stripes, I'm sure this will be a rare and exciting experience.

For emergency medical workers, I'm sure this will be a long and bizarre night indeed.

Truths About Anatomy Lab

Scalpels are sharp. Speaking from experience, using a scalpel to dissect one's own flesh should be carefully avoided.

Also, my inner 10 year old wishes our cadaver was more like this:

Check out more images at Street Anatomy.

The Examinator

One of the more exciting, and often intimidating, elements of first year is discovering how to interview and examine patients. Practicing first on actors, my classmates and I will shortly dive (closely supervised, of course) into real clinical encounters to hone these time-honored skills on the genuine article.

As I anticipate listening to my first heart murmur and palpating my first abdomen, however, debate swirls over whether the exam is properly taught, and how relevant it remains amid increasingly digitized medicine.

NPR ran a piece yesterday examining the current state of health of the physical exam, which some physicians maintain is a cornerstone of the doctor-patient relationship. For a different perspective, Shadowfax over at Movin' Meat argues that the full exam provides little benefit over a careful interview and well-chosen tests.

Will the exam stage a comeback, or will diagnostic testing continue to play an increasingly important role? I'm sure the debate will continue. In the meantime, I have a brand new reflex hammer to try out...

Med School (As Told By Cliches)

It was the best of times, it was the worst of times.

Especially with all the information we are given; it's like drinking from a fire hose.

Sure my friends are making money and starting their careers, but the grass is always greener on the other side of the fence.

And remember, nothing worth doing is ever easy.

I mean, whatever doesn't kill you makes you stronger, right?

Someday, I'm sure, we'll all look back on this and laugh.

Occupational Hazard

In light of the recent shooting at Johns Hopkins, CNN.com ran a front page story about violence in hospitals, especially the ER. Citing a study from 2009, the article highlights that more than half of ER nurses had been spit on, scratched, pushed, or verbally assaulted on job.

A nurse quoted in the piece describes how her jaw was broken in an altercation with a patient who later explained that he "was tired of waiting."

One of the draws of emergency medicine, for me at least, is the ability and mission to treat anything that comes through the doors. Given the patient population, nobody who chooses to work in the emergency department should be surprised when the occasional punch is thrown - we often see people at their very worst, and it's part of the job.

But when violence inches towards the rule rather than the exception, that's a problem. As another ER nurse observed:

"You would never go into the supermarket and say, 'the tomatoes aren't good enough' and punch the clerk and get away with it. That's exactly what happens in emergency departments all over the U.S."

"Just" A Nurse

It never ceases to amaze me how often you'll hear someone refer to an RN as "just" a nurse. GuitarGirlRN's most recent post recounts a similar sentiment, namely that really "smart" nurses should have gone to medical school. When I hear statements like these, sadly even from some of my classmates, it makes me shake my head.

During my years as an ER tech, I worked primarily with the nursing staff, and developed mad respect for the profession.

As the saying goes, be nice to nurses. They keep doctors from accidentally killing you.

Truths About Anatomy Lab

1) Anatomy lab makes you hungry. People claim it's the fumes; I happen to try to remember structures by identifying what type of food they resemble, but either way, everyone leaves lab famished.

2) Anatomy lab makes you lose your appetite. Despite having a pretty iron-clad stomach, nothing really induces nausea like swallowing a big gulp of formaldehyde and phenol while leaning your head into an empty thorax in a vain attempt to find yet another vein.

3) Anatomy lab is delicate. It only took a few attempts at scissor spreading fascia or trying to dig out a tiny vessel to confirm that I will never become a surgeon.

4) Anatomy lab is barbaric. Two words: bone saw.

5) Anatomy lab is terrible. You spend hours of your afternoon in a windowless dungeon trying to memorize an unfathomable list of terms while digging out never-ending globules of fat, only to realize that the tiny structure you're looking for is buried in fat. The fat you just ripped out.

6) Anatomy lab is incredible. In all seriousness, it truly is a privileged insight into the awe-inspiring complexity and beauty of the human body. Add the fact that a person made the choice to donate their body to further our medical education, and this rite of passage becomes all the more humbling.

*The image comes from Street Anatomy. Check it out.

**This post was written during time I should have spent studying anatomy.

The Circle of Life

One of the biggest changes I've noticed so far between college and medical school is Block-based scheduling. In undergrad, you'd have an exam or two throughout the semester, and then one massive final to worry about at the end. In med school, we're tested every three or four weeks. While we're currently only in the midst of Block 2, I've already noticed some cyclical trends, especially in terms of the weekends.

First Weekend:

We've barely covered anything this week, and we have so much time before the next exam. Hakuna Matata!

Second Weekend:

Wait... I have to learn the entire citric acid cycle again? Um, where did I put that biochem book?

Third Weekend:

Don't sneeze so loudly, this is a library! I have 800 more flashcards to memorize!

Fourth Weekend:

Post exam bliss. That wasn't so bad, right?

Just rinse and repeat for the next two years.

More Data on ER Overcrowding

Several news outlets have picked up on a new study from Health Affairs that details how emergency departments continue to replace private physicians as the source of acute care in the US. Decreasing access to primary care drives up visits to the ED, leading to longer waits, overcrowded departments, and higher cost. Read more about the study here and here.

"The Sun. It is Making Much Warmness Today!"

From the same comic genius that brought us a far more descriptive pain scale*, comes The Four Levels of Social Entrapment. I highly recommend you check it out.

Even after orientation, those first opening weeks of medical school saw the same conversation (Hi! What's your name? Where are you from? Where did you do your undergrad?) repeated ad nauseum, often with the same person. By this point, much of the initial awkwardness has subsided, though I'm embarrassed to say there are still several classmates whose name I do not know.

I wish I could claim these are people I haven't yet managed to meet. But no. While I'm great with faces, I'm terrible with names, so there is a distinct population of students who greet me with a chipper "Hi Second Shift!" each morning before class, only to receive a tentative "Hey...you..." in reply.

Since we're beyond point where it is socially acceptable to ask someone's name, I think I'm just going to have fudge it for the next four years.

*In case you need proof of hilarity:

Scale ranges from "I am completely unsure whether I am experiencing pain or itching or maybe I just have a bad taste in my mouth" to "You probably have Ebola."

I'm Not a Med Student, But I Play One On TV

"Oh, you'll see him again for the male genital exam."

So explained my Clinical Skills mentor after one of my classmates finished interviewing her standardized patient. SPs - actors paid to present with a particular history and illness meant for us to uncover - are the wading pool in which we dip our toes before interviewing (and yes, examining) real, honest-to-goodness patients in just a few short weeks.

When I worked in the ER, I had few problems establishing a good rapport and asking questions of my patients. SPs are a little different. Maybe the video camera and 12 other people watching the interview have something to do with it, but more likely is the fact that we're asking questions and obtaining information without any idea how to act on it. I know that will come in time, but for the moment it feels like we're acting just as much, if not more, than the SPs.

I suppose you could say that we're learning the importance of projecting confidence, of affecting the right demeanor with open body language and maintaining eye contact.

Put another way, the motto could be "fake it 'til you make it."

Loving My DTs

Real delirium tremens, as in the hypertensive, tachycardic, febrile hallucinogenic state of not knowing who, what, or where you are as you trash wildly against the restraints barely holding you to the stretcher while withdrawing from alcohol? Not fun (or so I imagine).

But the beer Delirium Tremens, as in the 9% ABV Belgian pale ale sipped while sitting out on the patio? Fun.

While I certainly miss working in the Big City ED, suffice it to say I am enjoying my time off before school starts next month.

Happy summer all!

Anyone Can Be A Hero

This summer, Hollywood action heros will dodge fireballs, take punches, and survive high-speed chases while saving the day.

In comparison, I look pretty lame. As an ER tech, I took vitals, drew blood, and maybe helped bandage a few wounds. As a med student, I'll start off doing even less, mainly memorizing facts and looking things up.

But one way people without any training or special skills can help is by giving blood. Every two seconds, someone requires a transfusion, and the need for blood often spikes during the summer months.

By donating just one pint of blood, you can help save up to three lives.

Be a hero. Save a life. Give blood.

Yeah, He's Faking

I'm a big soccer fan, but even I find the diving ridiculous. The similarities between international soccer stars and ER fakeurs, however, makes me laugh.

Beware the 1st of July...

As reminded by Ambulance Driver, today is the first day of residency for brand new interns in hospitals across the country. To the newbie MDs and their patients, good luck!

Finale

Looking back, it's funny to realize that my interest in emergency medicine began with a flyer for an EMT certification course. In the years since pausing at that random campus bulletin board and thinking, Hey, that could be interesting, I've learned a lot, while simultaneously realizing how very little I know. But somewhere between taking care of trauma patients and listening to drunken renditions of '80s power ballads, I realized that this is what I want to do with my life.

And in just a few short weeks, through incredible good fortune and thanks to the support of my family and friends, I'll move even closer to that goal by starting medical school. Unfortunately, the trade off means that my time in the Big City ED, and the stories that came with it, must come to an end. I'm really going to miss the wonderful people I've worked with over the years.

I'm sure med school will produce one or two amusing stories of its own, which I may try to post from time to time. To everyone who has stopped by this blog, thanks for reading. It's been fun.

A Match Made in ER

She certainly was a keeper. Vomit covered hipster plaid shirt, mouth agape with spit/drool leaking out, glasses askew, head propped up with pillows to prevent falling into the emesis basin. A definite 10/10 hottie.

Which is totally why I wrote my number down on the nasal trumpet before inserting it through her nostril to help maintain her airway. That way when she sobers up tomorrow morning and pulls it out, she can call me, and our courtship can officially begin.

Rough Start

Watching the charge nurse running down the hallway, pushing a crash cart in one hand and yelling into a phone held in the other is never a good thing. Minutes after I had punched in, I followed the commotion to a cramped exam room, where an elderly patient who presented with shortness of breath had suddenly gone into cardiac arrest.

Crammed into possibly the smallest room in the department, we had senior resident at the head of the bed intubating, a tech on one side doing compressions, a nurse pushing meds, another nurse documenting, the attending shouting orders, another tech standing by to relieve compressions, respiratory elbowing through to set up a vent, an intern attempting to start a central line, and another nurse prepping drips.

The patient, who not an hour earlier had walked into the ER, was lying on the stretcher with clear plastic tubes sticking out of her mouth, both arms, and groin. The attending suspected a PE and ordered thrombolytics, which meant by my turn for compressions, blood spilled out of the ET tube, and splattered over my arms and face shield while RT suctioned. Shocked twice with no success.

An hour later she was pronounced, and, covered in blood and drenched in sweat, I shuffled out of the room with the rest of the team, listening to the patient's daughter sob in the chaplain's arms down the hall.

Not the best way to start a shift.

Sad, But True

Over the past five years, ER visits for prescription painkiller abuse is up 111% according to new figures from the CDC, as reported by Reuters. Oxycodone alone caused over 105,000 visits, an increase of 152% over the same period.

Clearly, there is no easy solution to this problem. Substance abuse problems destroy lives - a fact lived over and over again in ERs across the country. At the same time, painkiller abuse ties up ER beds and adds to healthcare costs. I don't have the answer, but hopefully there are people much smarter than I am working on this issue.

Magic Spray

Working at a Level 1 trauma center has introduced me to many kinds of life-saving equipment. The ER staff is quite versatile with rapid infusers, thoracotomy trays, and Glidescopes, among other things.

What we don't have is Magic Spray.

Magic Spray, for those who aren't glued to the World Cup every four years, is an apparently miraculous compound liberally applied to footballers following a seemingly agonizing injury. After rolling around in the fetal position in an attempt to draw a foul, the players are escorted off the field by medics who whip out their trusty aerosol cans and suddenly return mobility to the lame.

So here's my question: if it works for the fakeurs of elite international soccer, why don't we try it in the ER?

Pain in your knee for the past 10 years that you decided you could no longer handle at 0330 in a Saturday? Well, we're not going to prescribe you narcs, but if you step back here for a second and - don't tell anybody - we have a little something something that's all the rage among European athletes.

Then a quick spritz of ethyl chloride, or lidocaine, or norMAL SALine, or whatever, and send them on their way.

GOOOAAAALLLL!

Good Idea

Pt: "I've been feeling a little off for most of the day, and finally decided to get checked out. Better safe than sorry, you know?"

Turns out it was a pretty good idea. No chest pain, but EKG showed a MI and iStat troponin came back hugely positive. Rushed up to the cath lab and ended up doing pretty well.

There are plenty of BS complaints in the ED, and plenty of people who feel sheepish coming to the emergency room for what turns out to be a negative work-up. I wish there was a simple way to predict in advance what's emergent and what isn't, but cases like these prove that it really is better to be safe than sorry.

You Know How To Breathalyze, Don't You?

Just pucker your lips and blow.

At least that's how we tried to explain the process to the extremely intoxicated teenager who arrived in the ER covered in vomit over the weekend. Poking him with the straw, I asked him to blow out like he was blowing out a candle.

Eyes still mostly closed, head perked up a little, he affixed his lips to the straw, but rather than blowing out, he started sucking.

Hard.

Said the medic, "Not that kind of blow," as he continued to go to town.

I half expected the breathalyzer's LED screen to light up a smiley face as it got more action that night than any of the rest of us.

Extreme EM

From the New York Times, another article detailing the incredible job performed by Medevac teams operating in Afghanistan.

This Just In

BLACKHAWKS WIN!

Playing the Odds

Every so often, the stars align and I'm lucky enough to work with great nurses, great doctors, and great patients. Two out of three ain't bad, and even just one out of the three can usually get me through a shift. One of the things I love most about working in the ER is the variability, which, unfortunately, means every so often I'll get none of the three. And that can make for a very long 12 hours. When that happens, you suck it up and remember that things can only get better tomorrow.

Stomach Pumping

It may be ugly, but it's effective.

Using an Ewald tube, also known as stomach pumping, isn't all that common. For ingestion patients, activated charcoal or a nasogastric tube are much more popular options, at least in the Big City ED. But after ingesting a full bottle of Tylenol less than 30 minutes prior, our patient last night won herself the tube.

Actually two tubes, if you count the intubation. One of our veteran nurses recounted how stomach pumping on conscious patients was fairly common back when she first started. I'd prefer the etomidate and sux myself.

The Ewald tube resembles a clear plastic garden hose which is inserted through the mouth and advanced into the stomach. Even with the patient sedeated, it didn't look pleasant. Saline is rushed into the tube from a large bag suspended from the ceiling, filling the stomach with water, which gravity then drains out to an empty bag.

At least the pill fragments rushing through the tube looked much better in the bag than in her liver.

Trauma On Ice

Chicago Blackhawk Duncan Keith after losing 7 teeth in one game.

Not sure how many other rabid hockey fans there are out there, but with the Stanley Cup Finals now tied up, this article about hockey doctor stories is pretty timely. Not exactly stories from the emergency room, but close, and equally (if not more) awesome.

Known Unknowns

With just over two months to go, I'm getting pretty excited about starting med school this fall. Excited, and at times, a bit terrified. The sheer amount of knowledge I'll be expected to master, and the responsibilities that come with it, can feel pretty intimidating.

With those thoughts in mind, I have to thank one of our residents (we'll call him Roy G. Biv, MD) for allaying some of my fears. To be fair, Roy's a very smart guy, a very nice guy, and a good doctor. He just cannot function in the ED, which is unfortunate given that he is completing a residency in emergency medicine. Easily overwhelmed, Roy tends to get flustered quite easily.

So I'm assuming it was the stress of juggling multiple patients, and not temporary color blindness, that prompted him to open the IV cart, remove on of the blood tubes, walk over to me, place the tube in front of my face and ask:

"Is this a blue top tube?"

Yes, there are several colors of tubes to choose from, but we're not talking about a Crayola box of 120 crayons. I could have been a smartass and argued that it appeared to be more of a ciel or even robin egg blue, but instead I simply confirmed that the tube was, in fact, blue. As opposed to red, pink, green, light green, gray, or any of the other non-blue-colored tubes we use.

I may be terrified at how much I have to learn going into med school, but at least I have my colors down.

Tough Old Bird

"My pain? Try 20 out of 10, man. I stubbed my toe real bad!"

"I twisted my knee last month and it really hurts and I can't walk, so I decided to come in at 0300 because I lost my pain med prescription."

"I was in a minor fender bender 10 years ago that left me with chronic, debilitating, whole-body pain that only responds to Dilaudid."

Needless to say, we get statements like these all the time in the ED. And, sadly, over time they can make you a little skeptical about patients overstating their actual level of pain.

So imagine our surprise last night when a very poised older lady walked up to triage with an obviously dislocated shoulder and calmly asked if a doctor might take a look at it. Apparently she fell in the morning, but managed to finish packing her bags, board an airplane, fly to the Big City, and return to her home before deciding that she might need some fixing up.

When asked how bad her pain was, she replied, "Oh, not awful. I've had worse." She initially refused pain meds for the reduction, and didn't even wince as the intern tugged, pulled, and rotated her arm back into place.

Badass, Ma'am. Badass.

Oops

Well, it took me a few years, but I finally dropped my first blood tube and sent blood glass flying all over.

The slow clap initiated by my colleagues was a nice touch.

Looks like my plans to start juggling blood culture bottles to entertain waiting patients will be put on hold indefinitely.