So, what typical issues does the typical community ED doc deal with on the typical day in a typically overcrowded emergency department (ED)? Here is a partial day’s roster I saw recently. Details have been changed to protect confidentiality.
Old man found slumped in his chair after breakfast with his eyes rolled back in his head. Hypotensive when EMS arrives, he perks up without interventions and denies that anything unusual happened. Remembers not a thing. This is the sixth episode in five months.
Esophageal cancer patient with a G-tube (gastrostomy tube) is sent in by his home nurse because his tube is clogged. We instilled some cola (Coke vs. Pepsi – I will never tell) and unclog the tube. But, before he leaves his heart rate jumps to 170 and EKG shows superventricular tachycardia. Takes adenosine, diltiazem, and metoprolol to get him under control. As he is about to go upstairs he remembers: “Oh yeah, Doc. I ran out of some medicine called metoprolol a few days ago. That isn’t important is it?”
Teenager with belly pain. Has not had a bowel movement today. Eats lots of cheese and is about twice his ideal body weight. He was constipated. Would most of you think that missing a bowel movement was an emergency?
Old lady fell on her hip yesterday at the grocery store and cannot walk today. Hip xray was negative.
Young man with a lump over his right shoulder for about 8 years. Today he decides it is an emergency. When I explain that it is most likely a lipoma, he tells me that is what another doctor told him last year. He was given a surgical referral but did not because he thought it was not serious.
Middle age lady’s face swelling for a day. Usually this is an ACE inhibitor reaction, but she isn’t on one. Maybe it is her daughter’s new laundry soap? Benadryl and prednisone seemed to help. No stridor or wheeze, so she was sent home.
Lady who had a negative stress test the day before comes in with the same chest pain she has every week. She got the same workup she gets every week. It was negative again. Only morphine can make the pain go away. Surprise surprise.
Mechanic pummels his dominant mid-hand with a three pound hammer. Nasty bruise and swelling but negative xrays.
Histrionic, morbidly obese 26 year old woman demands narcotics for her “fractured spinal cord”! “Call my doctor if you don’t believe me!” Stomps out in a huff after some intramuscular Toradol and Norflex. She has not yet learned to put Toradol, Ultram, ibuprofen, and Tylenol on her list of allergies.
Forty-five year old man with recurrent bouts of epididymitis for the last several years comes with testicle pain persisting after three-weeks of Levaquin. So, we ultasounded his scrotum and only found some bilateral hydroceles. I changed his antibiotic and sent him to the urologist.
Thirty year-old with frequent migraines comes with her same headache. Same aura, no thunderclap, no fever or neck pain. Neurologically non-focal exam. Responded well to the cocktail I like to use: Reglan, Toradol, Imitrex, O2 and a Norco for good measure. Discharged without a CT scan or a LP (spinal tap). Imagine that!
Seventeen year old mom dropped her 7 week baby out of the car seat in the grocery store. The store called an ambulance and she comes in to get the baby checked out. In the waiting room, she drops the baby out of the car seat again. Landed on his face, no loss-of-consciousness, swelling of the upper lip. Cried immediately. I know. You think it simply must be neglect, abuse, or intoxication. After a thorough exam and interview I am convinced that this well intentioned and basically competent mom just had some very bad luck combined with some bad judgement. I sent them home after a period of observation.
Eighty something little old man comes in complaining of constipation for 5 days. Abdominal xrays show dilated colon and air fluid levels indicative of a large bowel obstruction. In a old person, new colonic obstruction without another obvious cause is usually badness (i.e. cancer).
So, often a patient’s mild sounding complaint turns out to be an emergency. Far more often, what the patient feels is an emergency is at most an urgent problem, and usually is something they should have taken to their primary doctor. But, we also get the most critically injured and medically ill patients. We have to know trauma care and resuscitation inside and out, but we also have to be skilled at reassuring the young parents who bring in their new baby with his first cold. We may have clear ideas about what constitutes a genuine emergency, but they only know that their baby is sick.
As a EM Doctor working in London, this is a pretty representative day. Nice to see lots of similar presentations, especially the non-emergency stuff. Have been thinking about doing a blog myself, but the days seem too short. Keep up the good writing.
More, more! These are fascinating for a medical junkie (wait, that sounds wrong) like me.