Addicted to Emergency

I did it again.

In the words of a wise Nigerian Pharmacist, "Medicine is your calling".
I received a text from a fellow med student this morning saying that the ED was short of its boss and that it would be a great opportunity to go help out. And so, I decided to go down there and check it out. As soon as I sunk my teeth into my first patient, I knew that I wasn't going to leave for a while. In this case it was 10pm and I was supposed to go back to Melbourne - 3 hours drive away.

There's something about the emergency department that brings a sense of togetherness to those who work there, especially when you know everyone on a first name basis. To me, the atmosphere of ED reminded me of some of my fondest childhood memories, being  in "after-school care" or hanging around the front gates of school waiting for mum or dad to pick me up after work. There's something about the ED which wants to make me linger and not care about what is happening in the rest of the world. Perhaps, it's the lights and lack of windows which everyone talks about, where no-one has any idea of what time of day it is until they walk out the door. Perhaps, it's this sense that the staff have tried really hard to make the department their home to help them cope with the stress of their work when seeing patients. I'm not sure. Whatever it is, ED always feels like home to me.

The hardest thing for me this year to sort out, was that things continue to happen with you or without you. That no one person could fully appreciate everything that occurs in the hospital. I've thought about this purely from an exam vs. reality perspective. This is especially after spending a good top half of the year entrenched in getting as much clinical exposure as possible. The result was a poor paper-based exam outcome. Sure I was really good at talking to patients, but I really lacked the knowledge for academic success. This half of the year I felt better at integrating these two worlds, as I catch up in the book study department. Just let it all go, Chris.

The thing about ED is that there is often so much distraction that it is hard to let go of what it has to offer. The only thing that holds me back is tiredness. I wanted to know about the patients I saw. I wanted to know whether I called the same shots that my senior colleagues did. I want to know that the patient in the resus bay is stable and made it through the night. It's hard, because sometimes I might even lose sleep over the worrying.

On Friday, I was so busy trying to help out that I totally did not realize that my phone died. I was so caught up that I decided to change my plans to go to Melbourne without telling anyone. And as a result upset the apple-cart, causing everyone to worry. Not a good look. There are just so many things going on in my life, that I lack the ability to organize it all. Sometimes I wish that I had no strings attached and could do anything that I wanted whenever I wanted.

Obviously my other life commitments (parents, sister, girlfriend, friends) were more important and it was a simple temptation to sacrifice these, when you're caught up in the action of emergency - after all I am tending to other people's emergencies, right? Breaking promises over this excuse, is probably going to cost my the trust of others for a while. Maybe I have a problem with commitment, but why does it always happen when I'm doing something altruistic? I don't know. People weren't happy at me, but I'm okay about it. I guess I'll keep trying to make them understand.

After reviewing the development of 10 month old-child of Mrs. W, I was about to send her out of the office. My supervisor had given me the okay, and the child was fine. As I was about to lift my bottom off the chair, she fortuitously asked for the results of a recent pap smear test performed by the GP intern 4 weeks ago.

I pulled the results from her file. They were abnormal. As a student, I was a little confused as to where my responsibilities lie. How do I explain the results to her? Was this out of my scope? Should I be notifying the GP supervisor again? Fortunately I had been spending a lot of my time in the OBGYN wards at the local hospital and knew a little about the cervical cancer. Yet, I had not even performed a pap smear on a live woman before, nor had I attended any colposcopy sessions.

The results yielded an HSIL result, which stood for High grade Intraepithelial lesion (HSIL), which was what I divulged to her.

“What does it mean? Does this mean it is cancer?” was her initial response.

 The report went on to characterise the risk of CIN2/3 and the immediate need for colposcopic investigation. I reiterated what the pap smear was about, what it was looking at.

“This does not necessarily mean it is cancer. The pap smear picked up some abnormal cells in your cervix which may turn into cancer. We need to do a colposcopy to find out what exactly is going on.”

“What’s a colposcopy? Does it hurt? Do I need to be anaesthetised”

“Colposcopy is microscope that looks at your cervix. The doctor will apply some vinegar in there which will highlight any abnormal cells. This part shouldn’t cause any pain, just some discomfort.”

At that point, for some reason she felt less anxious about the whole situation. “As long as it is not cancer”, she said.

“I think it is important for you to follow this up with your regular GP to arrange for the colposcopy as soon as possible.”

 Her mother who was also in the room reassured her, saying that she had had the colposcopy done before.

As a student, I found it difficult to break this news and recall the risk of cancer in HSIL which required immediate colposcopy. I was unsure whether these changes were related to her recent pregnancy. I was in a situation that I didn’t want to be in, but decided to take that dive to help someone. I could have easily said that the results had not returned and to make an appointment with the GP to discuss them later.

In the end, I decided to cover myself with a disclaimer and reminded the patient that I was only a mere medical student, to not take my word as gospel but to confirm these findings at her next appointment.

I’m not sure how I handled this situation, given that in hindsight there is a high risk for CIN2/3 and a 1-2% risk of invasive cervical cancer on biopsy. I wasn’t sure whether I should have written out a referral for her. I did not know how immediate “immediate” was. Should I have contacted the GP about this? I think that maybe I should. What should one do when faced in a situation where a student has to divulge an abnormal test result for the first time – especially one that is of high impact?

In hindsight, perhaps I should’ve explained more about her risk of cancer. I failed to discuss the possible need for a cervical biopsy. I could have discussed with her the management plan. Did I really handle this situation satisfactorily? I felt like I left the patient with the impression that she had nothing to worry about, despite stressing that she should see a qualified doctor and not me, but at the same time I felt like I did all that I could.  She left the rooms, saying “as long as it’s not cancer, I’m glad to have met you”.  Perhaps it would have been wise to at least google HSIL and clarifying the facts before counselling her. Or even, to print out a colposcopy handout from the Royal Women’s web site to give to her. These were all things I had not thought about. After all, the consult was not even for her, it was for her son.

That night I asked myself the question, what if the Pap smear test revealed AIS (adenocarcinoma in situ)? Would I have handled the situation a little differently? I’m not sure. I still feel that fear of regret, in the case in which the colposcopy results come back with invasive cancer or if she forgets to make that crucial appointment. Until then, I won’t be able to find out. 

Urgent referral to ED

It is definitely true to say that GPs undergo several stages in their development. Those in their first 10 years of life tend not to be attached to any specific practice and are focused on developing their own careers and experience. In the second decade of GP life, many are attached to the practice, usually as a principal partner, and the focus shifts onto the business and they start to become more willing to teach, and often have pet interests but some become jaded by clinical practice due to their experience. The next decade refers to pre-retirement where older GPs reignite the spark of clinical work and become very keen on teaching and continual education of their successors. 

Today, I would have to say that I nearly experienced the attitudes of all these stereotypes at the medical clinic. To begin with, I began the morning co-consulting with a young-middle age GP, career and business focused. A very efficient executor of clinical decisions. Well-respected by his patients, but also tongue-in-cheek humour. I spent from 9-12 working under him, booked in to see 3 patients. Of whom only 2 showed up. Both who came for reviews and checked out normal. What a waste of time I thought. I spent the long intermissions between patients reading case studies and learning that way. Whilst the patients were here, I practiced on them as if clinical skills mannequins on the various aspects of physical examination. Yet, despite their obliging nature, all they wanted was a pat on the back plus/minus a script.

The afternoon, however, proved more interesting as I caught the attention of a pre-retirement GP examining a patient for ?fb in eye in the slit lamp examination room. Curious, due to my interests in eyes, I poked my nose in. Found out who I was dealing with, and was invited to perform the SLE. Recommended Fluorescin to exclude penetrating injuries - and discussed future actions. What a marked contrast! We ended up bringing him into the treatment room everting his eyelid and looked for grit together with dorky jewellery magnifying specs. Being the duty doctor, he later asked me to see his next patient. 

Happy to do so, after such a boring clinical day. Little did I suspect that I would have to be dealing with an acutely unwell gentlemen requiring hospital attendance. As I saw him walk in holding his belly, a prominent hernia protruding from his shirt, and in tears from the pain, I felt a sense of unease in the atmosphere. I quickly took a simple AMPLE history (NKA; Novomix, crestor, amoxil, Candersartan, Effexor; Diabetes on insulin, phx of rectal cancer, CKD; last ate in the 2/24 ago, last opened bowels in the AM, 3/7 h/o worsening abdo pain with assoc n/v today), performed a brief abdominal exam which revealed signs of peritonitis - guarding, percussion tenderness, distended abdomen. Good to note that no rebound tenderness was detected and his herniae was reducible. There were also previous midline laparotomy scar noted from previous bowel surgery - which surprisingly were not mentioned in his notes. I did all this without my stethoscope or any equipment, as this was fortuitous and unplanned!! 

I was thinking about bowel obstruction -with his history of hernia and surgery being the major culprits. I dashed quickly to tell the GP that he needed to be reviewed in hospital for AXR and NGT insertion with IV access. I told the patient straight away, despite him requesting some water. On the way back, I declined him any water thinking that if it is surgical that it would be better to be NBM. The GP came to confirm my assessment and we made the necessary paperwork for emergency hospital review with ?admission. The adrenaline pumping through me at the time, thinking that this could have been life-threatening if my skill wasn't good enough to exclude strangulated herniae and possibly ischaemic bowel. The GP was more calm and took control of the phone call to ED, while I nervously huddled over and typed the referral letter and faxed it off. What a great learning experience I thought to be shoved into the deep end of private practice. To make the call to send someone to hospital. This was what it was this IMMERSe program was all about.

After doing the necessary paperwork, I followed this patient to the emergency department at the local hospital. When I arrived, the attending was already assessing him. I managed to squeeze a brief handover after this, despite her already knowing the story. Clarified the actions of blood tests: fbe, uec, lft, crp, amylase/lipase, coags, trops; and axr - erect/supine + cxr. Whilst the nurse cannulated and collected bloods. 

Whilst waiting for these results, there was an interesting fall in the bed opposite which I decided to check out. 

This gentleman had sustained some lacerations to his right brow and cheek which required sutures. Seeing a tired intern on the case, I decided to help out. After putting in two sutures with an arched back at 45 degrees. Both of us learnt the invaluable lesson of adjusting the bed to an appropriate height before establishing a sterile field. Relieving each other from the struggles of awkward positioning, together we put in 6 stitches into the brow. However, in the meantime, I did miss the NGT insertion on the previous patient with the distended belly. XR later revealed multiple dilated loops of small bowel and multiple fluid levels. Diagnosis success - confirmed SBO. Winning. What an awesome day!!!