nihilists with good imaginations

with trauma behind me i headed back to the ED for my last month there as an intern. hooray. not much changed--it was still busy, dirty, loud, crowded, and understaffed. on a positive note, i was more confident and competent which improved the whole experience.

i think that the biggest difference that i noticed between my last month in the ED and my first month was my comfort level with the amount of work that existed and realizing that there was only so many things i could do at one time. the result of this is that some tasks get completed immediately, and others get postponed. what gets done when depends on multiple factors, but essentially it comes down to how many personal tasks i have to complete at any given time. thus the birth of the absurdly long ED visit. if i have 15 things to do, the non-critical tasks get put at the back of the line; this might include discharging patients, or informing them of "normal" or "negative" test results. this is important information to deliver, but doesn't command the same immediate attention that the 55 year-old man vomiting blood does. repeat this situation 10 times an hour over 12 hours and you can begin to see why the ED can seem like the 5th circle of hell.

anyway, the aforementioned difference i noticed was, stated simply, knowing that the work would never be completed, that there would always be a steady flow of patients and tasks over the course of a shift. as a result, there will likely never be a "good time" take a break and eat lunch, go to the bathroom, etc. previously, i had been overwhelmed with the feeling of being behind and a need to get everything done, right away; not having it done, and having more work piling up was demoralizing and filled me with a sense of dread. i now know that this is the way it will always be; rather than fighting it, i work withing the system. i triage my task lists, and put off non-essential activities (of note, eating and going to the little-boys room are not, "non-essential") and i don't obsess about what i'm not doing; this is the way it has to be. i would say that this increased my happiness by at least 50%.

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some of the interesting patients from the month:
-a 22 year old with a blood alcohol level of 660 (the legal limit 80), the highest i've ever seen
-a woman with chronic pain and traumatic brain injury resulting from a sno-cone machine falling on her head; she threatened to kill me when i suggested she try a medication other than morphine
-an "ex-marine" threatened to kill me when i told him i would not give him a prescription for percocet. he wasn't really a marine; it turned out that he stole the jacket from someone at the homeless shelter. he stopped being my problem after he pissed-himself and then slipped and fell in the pool of urine that had accumulated under his bed--he was escorted out by security after accusing me, rather loudly, of putting the urine their myself.
-i tried to do a spinal tap on a 350 pound mentally retarded man with HIV. his guardian consented and then inexplicably left the room halfway through the procedure despite my protestations. the man began to scream and gyrate and he then attempted to roll-over onto his back. knowing that this was an important test i did my best to continue--at one point, i had my shoulder pressed into his back in an effort to keep him on his side. however, i soon decided that having the 3 inch needle (that was in his back) pierce a vital organ or my hand were not good options, so i stopped.