Monday, March 12, 2007


We are no other than a moving row
Of magic Shadow-shapes that come and go
Round with the Sun-illumin'd Lantern held
In Midnight by the Master of the Show.

The ER, on the last few busy days, has been much like any other rotation, but sped up. I imagine the kind of physician who is attracted to this specialty is the kind with a shorter attention span than most. No matter who it is, they certainly all have a healthy sense of defensive medicine. So for instance yesterday, a man and his son came in together. The dad was worried that they both had pneumonia, despite having no symptoms except those of a typical cold. The son, through this interview, was active enough to begin (like any good five year old) the destruction of the triage room. Obviously, he was oxygenating just fine. But my attending insisted on getting chest x-rays for both dad and son. His explanation was that, in the last conference he went to, there was a presentation on malpractice, and the speaker made the point that patients come to the doctor for the show, and if you can do something to make it look like you're doing something, even if they don't need it, they are less likely to sue you. Maybe that's smart, but I wouldn't have x-rayed them. Radiation isn't benign either.

The next patient was a little 2 year old who fell off something at his day care, landing on his arm, and was now complaining of elbow pain. We checked it out, felt a click when manipulating it, got some x-rays, and settled on a diagnosis of nursemaid's elbow. So we applied the textbook treatment for it, heard a click, and gave the kid five minutes to recover.

He didn't improve, and still held his arm like it hurt. We tried twice more to reduce the injury, with no more luck. We paged orthopedics. They tried four times. Finally, we decided to get full arm and shoulder x-rays, and discovered a Salter-Harris type IV fracture of the humeral head. Lesson learned? That back in second year clinical labs, when they told us to x-ray the joint above and below an orthopedic injury, they weren't kidding. Also, just because a two year old tells you his arm hurts while pointing to his elbow doesn't mean his elbow is what he means. The kid got a sling, a bunch of stickers, and congratulations from the ortho team for playing hard.

I also saw one patient who made me question my choice of specialty. A first time mother was concerned about a rash her one month old daughter had. The kid was fine, just a little baby acne, but kids are cute, and healthy ones more so. The mom was the second mother to look crestfallen when I told her I was not going into peds. But I steel my resolve with the memories of Sarah, the first peds patient I had on my inpatient rotation. For whatever reason, dealing with adults facing death is much easier on me.

And I'll close with a word of advice. If you come into the ER complaining of fever to 100.5 degrees, for which you have not taken Tylenol, and have no other complaints, you are not allowed to complain when you wait 4 hours to be seen. There are actual sick people in here.

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