Today I arrived at 0715. At 0810 the first patient rolled in: hit in face by someone, either her son's cousin or her ex-boyfriend or both. I don't ask certain questions. In any case, she didn't require much time to see, as it was a quick exam followed by pictures of her facial bones, the application of ice, and a see-you-later. She'd already talked to the police. She was followed by a girl, about 18 weeks pregnant, with abdominal pain. Pelvic room please.
Apart from the smell (I am overly sensitive to personal odors; I am good at ignoring them because at any given time about half the population, including those near and dear, smells strange to me) her exam was unremarkable. A sharp contrast from the pelvic-exam before her, two days ago, when I was greeted by a wash of thin, greyish, unhealthy-looking vaginal discharge as soon as I opened the speculum. Trichomonas positive, O Best Beloved, and then I had to explain to this girl, who had already borne one child, that yes you can get trichomonas from a simple in-and-out, particularly if that in-and-out were unprotected.
"Trich." She was in shock.
Pelvic exams are an unfortunate reality of the ER, and I do them on all deserving comers, rich or poor. There is something about the technical aspects of hunting for the cervix with a metal spatula, of trying to get the becursed thing out without pinching the collapsing vaginal walls, of burying two fingers to the near knuckles in blind search of the elusive cervix and whisper-faint sensation of ovaries - there is something about all that work that ensures that this is anything but an erotic experience. Not to mention, O Best Beloved, that if any part of a well-kempt woman is going to stink, it is the nether regions.
Did I mention that pelvic exams are a necessary evil?
Got some more story from my patient. She'd been seen at another hospital, three weeks ago, and diagnosed with a urinary tract infection. Uncomfortable in ordinary women, must-treat in a pregnant lady. Preferably before she develops pyelonephritis and endangers baby and mother in one. It is not advisable to do as this young woman did, and opt for a pack of cigarettes instead of a prescription for penicillin. Urine leukocytes: packed. Automatic admission.
Little boy attacked by a windowsill. Standard child-getting-stitches talk. "This is going to hurt." He screamed while I injected marcaine without epi into his chin. He was amazed when it worked. Five stitches, including one corner I was particularly proud of. It should come out neat in the wash. Just a little scar, for the girls.
Little boy throwing sticks when one attacked him. 3-cm lac across the base of the thumb made for tricky anaesthesia, and he screamed even louder. I redid one stitch and added an extra to make it come out neat; the last thing I want to do is limit the child's thumb range of motion. It's always little boys, it seems. Girls do things like step on glass and open restaurant doors across their toes while wearing flip-flops, so I have to pull their toenails off with forceps. And the next day, another stick attack. This time, an older boy, who fell on a stick and got it lodged in his leg. "Why is everyone laughing at me?" Because, O Best Beloved, we laugh at the morbid. Two inches of splinter I did not remove; my staff did it instead.
And the mundane, bread and butter of the ER. Chest pain and abdominal pain and my-prescription-for-narcotics-ran-out-an
A lot of patients who come to the ED because they have no primary doctor. Every ER doctor I work with has a speech about the sad state of primary care and health care in this country, and how family doctors won't make time to see patients any more because they have to meet quota for their HMOs and don't have time for work-ins. Every ER doctor I work with rolls his or her eyes when another patient with NFD (no family doctor) listed under "MD" comes into the ER with symptoms that would normally warrant a quick call to the family physician. Nobody knows how to fix it.
And then there are emergencies. Heart attacks. CODE STROKE scrawled in large letters across the orders section of a chart, a patient whose papers are printing out after she's already down to CT scan. The little girl who fainted for the third time in her five-year lifespan, right onto the glass coffee table. Unresponsive and 80% oxygenation (she died), possible radial artery puncture (false alarm), drug overdose, rape. The short code discussions - "If this doesn't work, the next step is a tube down your throat to help you breathe. Do you want us to do that, if it comes to that?" Assault with a brick. Assault with a fist. Miscarriage. Child swallowed a penny (Mom got it out, baby is fine). Child is lethargic and not responding well (there are rules based on age and appearance, who stays and goes). Although it is rarely used for its named purpose, the emergency room is there, O Best Beloved, for emergencies.
There was one bed occupied in the ER when I arrived at 0715. When I left at 1615, there was one bed empty in the hospital. $major_trauma_center was on diversion, we had chest pain patients in any available room, monitored or not, and there were six charts to be seen and ten more in the waiting room.
Broken ribs and digital blocks and who are you going to call when you wake up in the middle of the night and your stomach hurts so badly you cannot breathe?