emandme

[emandme]

AEGIS 2020

As promised, here are the slides from the Rapid Response Workshop at AEGIS 2020. 

https://drive.google.com/drive/folders/1WskuUUiOqPiU1ZCtPY9Wk_MdEopJNP7g?usp=sharing

[emandme]

Let them die

Did you channel your inner Ken Watanabe from the Godzilla movie saying “Let them fight”, while you read this title? No? K. 

That is the only relative humor you will find in this post because it goes pretty down hill from here. What was that? Already downhill you say? I’ll see you when I see you.

This blog post is about the futility of CPR. Most people who are reading this know by now that I am a proponent of CPR and resuscitation science. I’ve spent almost the entirety of my teaching career advancing Life support skills, and implementing this knowledge on patients on an everyday basis. Over these three years in emergency medicine, I’ve seen seen things that I cannot unsee and this has, on occasion, made me hyper vigilant in resuscitation scenarios. Multiple studies have shown that such behavior is akin to PTSD in soldiers returning from war and that brings us to the point of this article - the flip side of CPR. 

The idea for this blog post came to me on a sunny sunday afternoon shift.  A hypothetical 65 year old was brought into the emergency by bystanders in an unresponsive state. Collapsed on the sidewalk some 20 minutes ago. With no one accompanying him. Bystanders thought it would be wise to just shift him to the hospital in an auto rather than wait for 108, rightfully so. One look at the patient and we knew he was dead. Long gone. No brainstem reflxes, cold and cyanosed - this was a classic brought dead scenario. The first person I broke the news to was the bother in law who had arrived before anyone else. He took the news in, processed it while I sat next to him and looked up to me and said “My sister will not take this well”. I break bad news on a daily basis. I follow set guidelines while I’m breaking the news and I’ve even given a talk about how to do it, empathetically. But I was not ready for what was about to unfold over the next 90 minutes. The dead patients wife was brought in to the room we have for privacy and she was already crying and wailing as to what had happened to her husband. She still doesn’t know he’s dead. She did not give me a chance to speak and as I was trying to calm her and  start explaining her what is happening,  her brother barks out - He’s no more. In a flash, her hands were on my collar and she was at my face yelling -  You cannot do this to me. It took her sometime to let go of me, but she still didn’t accept the news. I was stuck in the first stage of the  5 stages of grief with her, in that room, for the next 90 minutes. 

There’s no denying that this was the worst moment of her entire life. It was my duty to stand by her and make sure she comes to terms with this hard fact, stay until she accepts it. India still doesn’t have social workers or grief counselors to handle the emotional needs of our patients and that job is being taken care of by untrained and under prepared Emergency Physicians and Intensivists who basically just wing it, in whatever they know best. I did not mind any part of her out burst or emotional response. I do not blame her for it , nor do I wish it was some one else in my place. This was the most dramatic response I’ve encountered in all my experience of dealing with bad news and emotional family members. But that is not what led to this post. When we later sat down as a team to debrief this particular event, a suggestion came up that may be we should have attempted CPR on this dead man for the sake of the family, for their satisfaction, and that ladies and gentlemen, brings us to where you are now. Too long of a back story? No. You, as doctors, are bound to face this choice and how you chose will reflect how righteous you are. 

Do you perform CPR on a patient who you know is dead? Do you perform CPR on someone who has been unresponsive and pulseless for more than 5 minutes? Who is already cold and without brainstem reflexes?

To answer this question, you need to understand what the ‘successful’ revival of a patient actually means, or to put it in medical terms - what does ROSC (Return of spontaneous circulation) entail and is getting a pulse back always a good thing?

CPR and advanced resuscitation is not some magic trick that brings patients back from the dead. So lets first understand what Cardiopulmonary resuscitation does to the body. A cardiac arrest is a sudden event, an instantaneous collapse, like falling over the edge of a cliff, and these are the patients in whom CPR can make a difference. When a patient has a cardiac arrest, his or her heart has essentially stopped pumping blood and the most vital organ of them all, the brain, stops receiving blood. The Brain is extremely sensitive to this lack of circulating oxygenated blood and all it takes is one minute of absence of blood supply for the onset of permanent Hypoxic Ischemic  Encephelopathy, or in lay man terms, brain death.  When we resuscitate a patient, what we’re essentially trying to do is making sure that the brain receives blood supply, by pumping the stopped heart from outside, by chest compressions, while we’re simultaneously trying to figure out  which one of the ten reversible causes has caused this sudden cardiac arrest and injecting drugs like Epinephrine which are hypothesized to “restart” the hearts contraction. Go on, read this paragraph again if you need to. Resuscitation is making sure the brain receives oxygenated blood while you’re figuring out how to restart the heart so it can beat on its own, or - ROSC! Makes sense? 

But what if the patient’s brain is already a goner - what we in Emergency medicine call “Down time”. Remember, all it takes is a minute of lack of blood to cause permanent brain death. So lets say a patient with about 15 minutes of down time is brought to the emergency room. You checked for response, no response, you checked for pulse and breathing - nope  and you went all out on him - started CPR, intubated him, went at him like there was no tomorrow. Gave him shot after shot of Epinephrine and then out of nowhere, you start feeling a pulse. Great! You got a pulse. Thats ROSC!  Do you think your resuscitation is a successful one? The answer is no. Not by any means. Success is measured by how disabled this patient is going to be. 15 minutes of down time and brain is already scrambled eggs. What you basically did was bring back someone who is going to be in a vegetative state for the rest of his or her mortal life. Why did the heart restart though? that’s what chest compressions and epinephrine can do.They force the autonomous cardiac myocytes to start contracting again. But what’s the point without any brain to function? That- Brain function or neurological response -  is the sole measure of success of resuscitation and that brings us to the flip side of resuscitation - Letting them Die.

That was about Down time. This piece is incomplete if I don’t talk about the very sick and the very old. A very damning article published in the Irish times started off like this -  “Stop the barbaric practice of using CPR on the very old”. This article tries to reason the difference between sudden cardiac arrest and natural death.  The processes in ordinary dying are quite different from cardiac arrest. Like I explained earlier  A cardiac arrest is an instantaneous collapse, like falling over the edge of a cliff. In ordinary dying, usually now after a long life, from “not cardiac arrest”, there is prior deterioration over months, days, hours, minutes and seconds until finally the heart stops.  Imagine for a moment the fragile body of a woman in her 90s, who has a multiplicity of chronic diseases, including dementia, after it has been subject to vigorous and unsuccessful CPR. Rib bones will have been crunched, soft tissue bruised and teeth broken.

Do you remember your oath? To do no harm. The onus is on you to ensure that the treatment is not worse than the medical condition you are trying to treat. No one knows better than doctors that death is a very real entity. It hounds every one of our patients and it is time we start recognizing when it is time. 

Doctors are not cowboys. Do not swing your fancy Endotracheal tubes and bougies and resuscitation knowledge on unsuspecting families. Yes, they will beg and plead and bargain with you to try, but it is your imperative to stand your ground, to let them die. 

[emandme]

For AEGIS!

I’m a little drunk on nostalgia tonight and I’m a little emotional. This is uncharacteristic of me, considering I’ve spent the better part of the last two years boxed up. Personal tribulations aside, it is that time of the year again that has been my constant. Constant only in its presence but never in what it entails, as I discover with great pleasure, year after year. 

This year marks the fourth edition of AEGIS, the Annual Edition of Gandhi’s Intermedical Symposium. This year also marks the fourth time I’ve been associated with AEGIS in whatever capacity I can. At the close of AEGIS every year, right from the first edition, I find asking myself and my people - What about next year? Do we need to worry about it? Who are we trusting to carry the mantle forward? and every following year, I’ve always discovered that my concerns are needlessly misplaced.

 I found myself asking the same questions this year too, but I think its safe to say that AEGIS has finally taken its rightful place in the rich legacy of Gandhi medical college. Third times the charm? or was it fourth? or is it just me growing older by the year and finding more charm and energy amongst my juniors than I could ever fathom myself. AEGIS has a simple tradition - the volunteers for AEGIS in that year from the junior batch take over as organizers the following year. Its straight forward, its logical and has worked every year. For me personally, by the time I graduated and left Gandhi, the last batch I actually interacted was the batch of 2k13. I’ve seen them volunteer and be a part of every AEGIS since the first and do an amazing job themselves with the 3rd edition of AEGIS, and I thought that was it for me. Who’s gonna remember li’l ol’ me, let alone ask me to be a part of it. As life would have it, I found myself amongst the organizers of this years AEGIS brainstorming ideas for how to shape this event, organizers who were volunteers last year, whom I didn’t get to know too well last year. This year, I found myself amongst volunteers who will go on to be organizers next year and this is how I know the legacy of AEGIS is set in stone.

Volunteers do not necessarily have the time, they just have the heart.

I am a volunteer at AEGIS. I’ve been one for four years in a row, I see myself being one for times to come.

Why AEGIS? Why do it at all? Why conceive this elaborate painstaking conference that needs a thousand things to go right and be wary of a thousand other things that could go horribly wrong?.

I recently heard about a former professor of mine, whom I respect a lot,  express displeasure with AEGIS. He was of the opinion that AEGIS was challenging the existing system of medical education, teaching undergraduates things they don’t necessarily need to know. He is right, but not entirely. Our very purpose at AEGIS is to challenge the system. It exists to teach undergraduates what the system feels is unnecessary, what the system feels is redundant.  AEGIS exists because the system fails. AEGIS exists because the system feels interns can start treating patients from the very first day with no orientation whatsoever. The system feels interns can learn basic life support after internship, after enough people have died from the system’s negligence towards competency building and through AEGIS, we say - we’ll see about that. AEGIS exists to impart skills that you are otherwise unfairly expected to learn on your own - through the system. Enough with this system. Enough with us having to learn the hard way. Enough with ignorance.Enough with didactic lectures. Enough with the system that feels it is doing us a favor. Enough. We resist.  AEGIS is the Resistance. AEGIS is the light. 

We have never settled for less at AEGIS. We’re pushing the anvil every year. We’re challenging ourselves every year with new ideas and new workshops to teach you things that are essential but aren’t part of the undergrad curriculum that hasn’t been reviewed in over half a century. Every edition of AEGIS has set the bar higher for the next, and every year we’ve far outdone ourselves and I trust every successive edition of AEGIS to break molds and strive for an identity of its own.

I was a mediocre student back in my college days. I’m sure most of my batch mates thought I wouldn’t amount to anything. I would find myself focusing on a lot of things extracurricular, much to the amusement and ridicule of people in the system. I organized a conference by my own when I was in final year, I was involved with the Indian Medical students association and I was all for student activism and this sense of restlessness is  exactly how I got involved in the first AEGIS. The first AEGIS helped me discover what I was actually passionate about and what i’m good at. I taught students for the first time in my entire life at the first AEGIS, at my own medical college, surrounded by MY people. Can there be a more evident sign of things to come? This romance practically writes itself. 

I met a class mate and an old friend at AEGIS today. We realized it has been exactly ten years since we set foot in Gandhi medical college. We reminisced over how back in 2008, around this time, we used to run for dear life after the orientation classes at the SPM lecture hall, hoping no senior abducts us to the hostel. It has been a decade of Gandhi, and I’m still around.Clearly, I need to get a life already! I feel old, as if my juniors don’t remind me that enough already. 

I met and finally came to terms with someone who has shaped me into the person I am today. I found out today that there are people who actually read this blog. I found today that almost everyone universally agrees I need to speak slower - thaaanks guys!. 

AEGIS has been a path of self discovery. I’ve met my mentor through AEGIS, I’ve made an identity through AEGIS. I’ve met my best friends through AEGIS. I met some of the people I can call my own through AEGIS, and through AEGIS, I’ve discovered a place I can call home, for home is where your people are at. 

[emandme]

Its not personal

The last two weeks have been incredibly stressful. I haven’t felt this pressured since, lets see, 2018. No one told me this job was ever going to be easy, but at least leave me the right to crib about it. I don’t usually though. You might ask “Well, isn’t that what this blog is all about?” No. This blog is an outlet in my journey towards  self realization, so don’t be a douche about it. This post is a tale of personal trial and tribulation and how this has had a profound impact on how I treat my patients. Needless to point out, like every other blog post, this is fairly long, so brace yourself. 

I had just come back from an evening shift and was catching up on season 2 of The West Wing, nothing different from the usual post shift nights. It was around 1 am when my neighbor knocked on my door. His father who lived 3 hours away from the city was taken to a nearby hospital with complaints of severe retrosternal chest pain. The doctors there diagnosed it as a cardiac event and did not have the facilities to handle the patient. My visibly worried and flustered neighbor, who is other wise one of the most calmest people I know,  had come to me for counsel. I spoke to the doctors over the phone and their diagnosis was clear - ST depressions in the ECG and typical nature of the pain - this was likely an NSTEMI or Unstable Angina. I asked for a cardiac enzyme panel and an immediate transfer to my hospital in Hyderabad. The cardiac enzymes came negative in the time they were arranging for the ambulance, So most likely an unstable angina. I asked my neighbor to relax and bring him to Hyderabad immediately. This should be pretty straight forward to handle. We both left to my hospital in anticipation of his arrival. I spoke to the managers on duty before hand so we could get  the financial conversations out of the way early. This was around 3 AM in the morning and  I was in the ER following up lab and radiology reports of the patients I admitted the previous night as I awaited their arrival and my neighbor waited at the hospital entrance.  The ER door slammed open with a trolley being wheeled in in a rush and a patient lying in a pool of vomit, semi conscious, and then right behind the trolley, I saw my neighbor running in breathless, looking for me. Shit. This patient was my neighbor’s father. Something had gone very very wrong. 

We moved him to Priority 1, me and two other ER docs took charge. The patient was now coming around and writhing in chest pain radiating to his back. He was incredibly restless, bouncing up and down the trolley to a point where we had to physically restrain him just to get the ECG. Pain score easily at 9/10. Non medically speaking - imagine being awake watching a bear maul your guts. The cardiologist was right by side, ecg now showed a qRBBB pattern - this is bad, very bad. I was holding the patients hand trying to calm him down as pain meds were being pushed in in rapid succession, and then it happened. I was talking to him, calming him down, and in that moment, he stopped talking, his eyes rolled up, he protruded his tongue, clenched his jaw, squeezed my hand in a death choke,  started seizing and crashed. My colleagues crash intubated him and as I looked away in despair, my eyes met with my neighbors. 

I was at a loss of words to explain the turn of events over the last five minutes. Most likely vasovagal, but this was unanticipated. I felt responsible and I felt helpless. A 70 year old in cardiogenic shock on mechanical ventilator and likely aspiration - I knew the odds. I knew I was staring down a barrel of potential complications most likely ending in death, but little did I know there was far worse in store. For now though, I tried to explain to my neighbor that we’re doing whatever we possibly can, that we’re taking him to the cath lab and I’m going to be there by his fathers side through all this. One look at his father lying motionless on the bed with an Endotracheal tube down this throat, he held my hand and broke down crying. 

We rushed him to the cathlab, angio showed double vessel disease with stenosis but it didn’t explain the pain. This was not an infarct and the flow to myocardium was still intact. It had to be something else. We took the cue of the severe tearing type of pain radiating to the back  he complained of on presentation and took him to CT aortogram to rule out a dissection, also because there was some disagreement over how his distal pulses were. It was negative for dissection but I noted a mildly bulky pancreas and asked for a serum amylase and lipase to cover that base. It was 6 am by now and there was nothing more to be done than wait and hope the vasopressors held on to dear life. I walked out of the Cardiac ICU, mustered all my courage and told the family that this is looking bad. We’re doing our best, but with no concrete diagnosis, I had little to offer. The neighbor drove me and his family back home. His sister and his completely unaware mother sat in the back seat worried and . The silence on the way back home was defeaning.

I hadn’t felt a depressive episode like this, not in the last 8 years. I tried to sleep it off, but that was futile. I was responsible. It was my decision to treat him at my hospital and he was my responsibility. Despite doing everything we possibly could, I was going to lose him. The very thought that I would have to face my neighbor everyday, and be seen in his eyes as the guy who couldn’t save his father, broke me. I came home at around 6 30 am and got a call from my HOD at 8 am that there’s an acute shortage in the ER and they needed me to come in to work and help out. If this were my older self, I would have been there in a jiffy, but on this morning, I could not get myself out of bed. I felt despair, I felt pain and I felt hopeless. I did not want to disappoint my HOD and I also wanted to know how my patient was doing, so I pushed myself and got to work to one of the most messed up shifts I’ve done in a while. May be it was just my depression, but it was a one hell of a busy republic day morning. Why oh  why do people save their illnesses just for the holidays?! My patient was still on the ventilator, high inotropic support, an unreasonable no. of ectopics on the ecg and pretty bad lungs, but negative amylase and lipase. I still had no hope to offer and everything seemed so futile. I don’t even recall how the next few days passed. I barely ate, barely slept and I still put up a face at work, try and be the most pleasant doctor you could find in the ER. 

On the third day, he started improving rapidly. No more vasopressor support, no more ectopics, resolving TLC. On day 4, he was extubated and I finally breathed a sigh of relief. I finally slept peacefully. I finally smiled at home and spoke up to my worried sick mother. I haven’t seen her this helpless before. She knew I only had the best intentions, she liked to believe that I did nothing wrong at all, that I was their best hope. Can’t blame her. Mothers are like that. Unconditional love, unshakable confidence in you and blind faith. She could not do or say anything that would make me feel better. She knew how much I cared about this, how much I’ve put myself into this, but for now, she was helpless. That all changed like I said. The patient was off the ventilator and on his way to a full recovery.

He came home today. After two full weeks in the Cardiac ICU, he came home today. I paid him a visit and he himself pulled up a chair to offer me a seat. Today is a good day. I smiled with all my heart and a sense of satisfaction I haven’t felt in ages. I cannot take credit for all the hardwork put in by some of the finest cardiologists, intensivists, emergency physicians and nurses to bring him back. I am proud that I can look up to these people at times of despair and I am lucky. As for his loving wife and caring son, I can only feel happy and thankful. I did give him a thorough dressing down for popping NSAIDs like tic tacs and trusting his local pharmacist more than his doctor, but that’s just most Indians. 

The purpose of this post is not to talk about a very odd presentation or a difficult case management lesson. The purpose of this post is to talk about physician wellness. The toll that the responsibility of someones life in your hands takes on your mental state of being is indiscernible to someone who has never faced it before. I spent the last two hours on this particular sentence trying to come up with a way to explain it and I’ve failed. Writers block? No. It is a sense of duty and privilege we can never fathom fully.

This is a tale of a very personal emergency. I went the extra mile with this patient. This made me ask myself if I’m not doing to this every patient. Is it humanly possible to feel this deeply about all of my sick patients and live a normal life without going absolutely mad?. It’s like having 40 to 60 of your family members fall incredibly sick in a span of 6 hours and all come to you for treatment. That’s my ER’s average foot fall in a day. I will most definitely die an early death , not that i’m not going to now. It is tough, what we do. It breaks us and yet, we keep going. It takes a different kind of crazy to go back to all this, everyday, every patient. It is my hope through this blog that my people realize that these heroes don’t wear capes or don’t have billboards. They’re fighting a system rigged against humanity in general and doing their part as best they can. Cut them some slack, because they’re walking a thin line - to feel, yet not to feel. 

[emandme]

I wake up, I gear up,

I head in fearless, steady and thirsty,

I glance around curious and apprehensive,

I look away, I tell myself I’m ready,

I scrub in, I grab my pen, my steth,my torch,  and I hit the floor,

There’s no time for pleasantries, no time to let it sink in,

I take them as they come, the healthy and  the sick,

The unreasonable, the angry, the sad, the dying, the dead.

I stop to take a breath, I start again before I can finish,

there’s another patient being wheeled in in a rush.

I clear my head of the patient I just tried saving but failed,

I press pause on the other dying patients, if only.

I start afresh? Sigh, if only the man demanding better of me knew.

My legs, my hands and my head point in different directions,

I remain put,

I try to gather,

I try to hold the fort,

He died, you did everything you could, yet he died.

Look up and look around,

Look down the hallway, on either side,

There’s more of them and they are waiting,

But not for long.

I chose this life, I fought for this life,

A Life in the fast lane.

There is a door where I work,

A door to the outside,

A door through which people walk in looking for answers,

Looking for freedom from pain, looking for hope, looking for a right to live.

I stand at this door everyday,

I hear death knocking,

I see death creeping in,

And I say to death everyday,

Not today,

Not on my watch.

[emandme]

Occam’s Razor

"Entities should not be multiplied unnecessarily."

You've probably heard it before: The simplest explanation is usually the right one. Working at a Tertiary health care center exposes you to a unique subset of patients - the “referred to a higher center for further management” kind. These are patients still left undiagnosed, or those who have developed multiple complications from the standard treatment or those who have just not responded to the standard treatment. All these point to one indication - there’s more than one thing wrong with his physiology. More often than not, this requires interventions from multiple specializations and the person guiding all of this, the person sitting firmly in the drivers seat - is the Emergency physician. 

Most referral letters and discharge summaries will enlist a series of diagnoses to make your job easier(?). It is easy to get lost in the intricacies of these various seemingly unrelated diagnosis in the same patient, to assume that these are actually different problems in the same single biological unit, but they’re probably not, because Occam’s Razor. 

Que back to House MD , Season 1, Episode 3 titled “Occam’s razor” when Dr. Foreman disagrees that the same patient could have two unrelated life threatening conditions at the same time. In a unrelated note, the same episode has a poetic monologue from Dr. Cameron on the subject ‘sex kills’. Yes, very very poetic, and probably a future pick up line for all you lonely nerds out there. 

Fast forward to the present - 55 year old Diabetic, Hypertensive with a history of psychiatric illness presents to the ED after he allegedly consumed 250 ml of bathroom acid 6 hours ago. Patient alert, coherent, oriented. ABCs in order. Two episodes of vomitings (non blood stained) and now complaining of epigastric discomfort. Systemic examination doesn’t reveal any significant finding, except for ST elevations in the Inferior leads of the ECG. FUCK.

What are the odds of a corrosive acid ingestion patient also having an Acute inferior wall Myocardial infarction, all at the same time? The odds are there, but still worth reconsidering. Enter Occam’s Razor - the simplest explanation is usually the right one. One thing that is common to Corrosive acid Ingestion and ecg changes is electrolyte imbalance, but ST elevations in Hyerkalemia? YES.

There is a rare occurence called “psuedoinfarction” - hyperkalemia masquerading as ischemia, all but confirmed by a bedside screening echo which showed no regional wall motion abnormality and an arterial blood gas which showed a severe metabolic acidosis with, you guessed it, Hyperkalemia. This carries a lot of significance here because because an MI would restrict fluid therapy to this patient, even though Inferior wall MI is preload dependent.  No fluid in metabolic acidosis = No survival = bad doctor. 

Occam’s Razor - now comes with a single blade, keeps things simple.

[emandme]

Monday Afternoons - Edition 2

I blame the four month sabbatical on my Intensive care rotation. I thought i’ll do a post on how that went, but knowing that I can never see myself there, ever, I am chucking that idea entirely. After wandering aimlessly for four months, shipped from from one speciality ICU to the other, I am home.

Okay fine, its not really that bad as I make it to be. I did do a lot of things -  I perfected my procedural skills, I continued to suck at paperwork, I packed on more pounds, lost those pounds, caught up on a year of lost sleep, traveled the country, fucked up potential relationships (yes, plural, very very plural), met great mentors, discovered the pleasure of watching someone who most thought had no chance, walk out of the hospital, finally understood the idea of evidence based medicine, perfected the art of critical appraisal, missed my ER and whined and whined about it, lost my cool and made someone cry, guilty to this day, crash intubation with less than 5 seconds of interruption like a boss,  mock code blue like a boss, mass embarrassment in rounds like a boss, learned to love central lines,  learned to hate arterial lines - fucking hate em man!, perfected staring into emptiness, apparently saved myself from a dark few months in the ER - to name a few. I was nervous to be back in the ER. Four months is a long time and enough to derail the pace you’ve adapted for a life in emergency medicine, a life in the fast lane.

Manic mondays -boy does this have a whole new meaning in emergency medicine. If you still haven’t  read the first edition of Monday afternoons, you should most definitely do that here. So four months of a sabbatical and a monday afternoon to kick start the emergency state of mind, I was not ready da!

Take the early morning metro to work (sooo proud of the metro), carefully time the trip to the nearest minute for future use, walk in to a near empty ER and look at the clock - five minutes early,  and look condescendingly at the juniors from the previous shift, who have garnered quite the reputation for collectively lacking an understanding of the concept of punctuality. Piece of work, I tell you. Take hand over of two patients - one dislocation of shoulder and one ureteric colic. Call shotgun on the triage doctor role. This hierarchal system was something they introduced while I was gone and was super excited to try it out. The triage doctor sees every single patient that comes into the ER, makes a quick assessment, assigns priority, assigns provisional diagnosis and performs any immediate interventions if required and hands over patient to respective priority area. So there I was at the top of the ladder, on my first monday afternoon after four months -  What the fuck was I thinking! Its still 8 in the morning, barely any patient flow, so I went to Priority 3 to check on the shoulder dislocation. The X ray wasn’t conclusive but Dugas positive and you could quite literally palpate the empty joint space and humeral head separately. No one wanted to try and reduce it, so the ortho resident could come do it and I was like, Hell NO! Shoulder dislocation, to the surprise of many , is a vastly disagreed subject. There’s so many iterations of reduction techniques that’s its not to a stretch to say that each  emergency physicians has his or her own signature maneuver and needless to say, I have mine :). So I pulled a chair close to the bed, sat facing the patient and did my thing. 3 minutes in and pop goes the humerus right back where it belonged. I wish I could describe the astonishment and the sudden surge of relief on the patients face, I wish I could describe the beaming smile I had on for an hour after, I wish I could tell you the things the patients said to thank me, I wish I could describe the mindblown reactions on the faces of my juniors, I wish I could describe the fuming ortho guy, but all I can say is - You should have been there! I’m three for three on this maneuver. No pain, no sedative, no relaxant, no operation theater, no crazy pulling and pushing, just pure medical bliss! Thank you! I send him his way with a shoulder immobilizer and go back to triage duty. 25 year old male rushed in with typical renal colic - debate in my head trying something experimental on him too but decided against it. Figured i’d be stretching my luck a bit much, so went for the usual colic pain cocktail and shipped him to P3. This followed by a hit and run - 40 year old struck down by a rash two wheeler. Head injury, LOC, ENT bleed, amnesia, all warranting an early CT brain. Get the ABCs in order, and send her down to radiology, figured i’d work this one up myself. Normal CT - happy patient, happy family - Straight up observe and discharge. Anterior wall MI - Loading doses, shift to P1. Old lady with a TIA - they just want to see their family physician so bad, despite scoring a very high ABCD2 score - fine, suit yourself, P3 it is. Two fevers - straight to p3 you go. Elderly couple with an entire assessment sheet worth of complaints, HOD comes for rounds - debate what speciality to admit them under, brag about the shoulder dislocation from early in the morning, and turn to the right to an RTA being wheeled in. Elderly couple run over by a truck - flail chest, multiple broken ribs, crush injury of arm. Bad - real bad, panic ensues- real panic. Entire team arrives, start ATLS - ABCs in order emergent ICD, followed by inubation and blood transfusion - all this condensed into one sentence sounds so straight forward, but this took an entire hour of the entire ER on its toes, the coordinated effort of three different specialities and some how managing to keep the ER on track , notwithstanding all the other emergencies that still kept pouring in. 45 Year old, had a by pass last month, severe dehydration following diarrhea, came in with complaints of no shit. No shit dude, you took redotil, theres obviously going to be no shit. EF 44% - hmm, fluids are going to be tricky here. Spend another hour working up an atypical chest pain - confirm an MSK etiology and discharge home, acknowledge a grateful nod from the missus ad move on to a 48 YEAR old inferior wall MI out of window period, another 40 year old  RTA - superficial laceration who will not stop crying, 17 year old walks into the ER and faints as I make eye contact with her, query status dramaticus (but that wasn’t the case), and the clock strikes 2!

Until next monday, here’s  me telling myself with this post - This is what I live for!

[emandme]

Monday afternoons - Edition 1

Monday afternoons are the worst. One of the many things you start understanding  after starting out on your emergency medicine residency is human tendency. Specific to this post- the human tendency to wait out your illness over the weekend and visit the hospital on a Monday, god damn Mondays. I was on the Monday afternoon shift this week (that’s the 2 pm to 8 pm shift). Presenting an average Monday afternoon at my ER -

Reach five minutes early, walk into an already full ER, curse my luck, change into scrubs, close my eyes, take a deep breath and hit the floor. Take  handover of an evolved anterior wall MI, pending a screening echo, fist pump in my head thinking this is going to be an interesting echo to do, take handover of an adolescent male with a one month history of vague abdominal pain, take handover of a dyspnoeic patient with vague chest discomfort and uncontrolled diabetes, forget that echo, ask the patient a history, refuses to cooperate, says her son is getting the files, take a look at it and you’ll understand. Great. Two hours to find what’s wrong with her and this is what I get, wait for the files. I’ll just have to treat the stats. Hang around the PACS console (basically, a computer which is a digital repository of every single investigation, scan ever done and updated real time with easy access to every patient’s records at the touch of a button) following up reports of patients I admitted the previous day. Transport crew rushes in a breathless and anxious patient. Son says something about a brain problem and hands over a 2-inch thick file. Wait dude, let me at least get my ABC’s in order. Yep, check, WNL (Within normal limits). Intraventricular bleed extending into all ventricles, likely hypertensive. Maintain MAP, counsel the attenders. They beg me not to reveal it to the patient, beg to tell him its food poisoning. Hmm, this is a quandary. Become a  mathematician at a moments notice when they ask you for odds of survival and how serious he is. Look them dead in the eye and tell them, I’m serious, he’s pretty serious. Look right to glance at the door and regretting my decision already - patient wheeled in with nurse accompanying him yelling “seizures, seizures”. People shouting orders, someone grabbing patients hand to put an IV, someone yelling for lorazepam, and me yelling, stop, he’s hyperventilating, its anxiety neurosis and that is carpopedal spasm. Lorazepam withheld, high concentration O2 mask with zero flow, shift him to priority 4. Neurologist arrives for the IC bleed, asks a repeat CT. Attenders say government health scheme, just when I was thinking “whew, that was wrapping up nicely”. Medical registrar arrives for the anxiety neurosis, says she’s done with her shift, request to take this one last patient. PA system overhead yells “CODE BLUE, FIRST FLOOR, OP 3″, ignore medical registrar, Break into a sprint,  running and yelling “MOVE, MOVE, MOVE”! First on the scene, still keeping the streak alive, seizures on a couch, no left lateral coz he’d fall off, so screw it, right lateral, HOD  reaches, Code blue bag in hand, try IV, ignore four other consultants standing around giving opinions, ignore anesthesia resident tell emergency physicians how to do emergency medicine, shift patient to ER, Walk into the ER head held high. First on the scene, again, BOOYAH. Wait, is anyone even counting?! Get schooled by the registrar for letting others tell us how to do our job, boy he’s pissed. Agree with him, code blues are so chaotic and so full of nonessential staff. When will we ever subdue the goddamn curiosity? Walk back to check on anxiety attack patient, medicine registrar not convinced, glance at the door, regret doing it coz guess what?  watch another sick patient being wheeled in. Ignore medical registrar, again, walk up to patient covered head to toe in mud and dirt, run over by a tractor apparently. ABC WNL. Shortening and external rotation of right lower limb. Look around for a cubicle,damn it , the ER is full. Keep patient to side, Start IV, Start multiple pain meds, get a ward boy, spend the next 45 minutes washing him head to toe. Clinically diagnose a subtrochanteric fracture, debate a Thomas splint vs. a malleable splint, go with malleable temporarily, shift him to radiology. Go back to pain abdomen, shift him to outpatient. Cardiologist in the other cubicle calls “Raj, idhar ao”, oh no , what did i do? Nothing, he just wanted to show me a beautiful echo of a mural thrombus, which I was supposed to do in the first place! HOD walks up behind and chimes in “Hey, I wanna see too!“ Take a quick video of the echo to post on the sonology whatsapp group. Admit the IC bleed to the Neuro ICU, Shift a reverted SVT all the way to second floor, cardiology ICU. Deal with crap from the attenders for delay, don’t let them board the lift,  because that’s how I roll!. Come back to the ER, Sit down to finish out triage sheets, glance at the door, unconscious patient wheeled in. Low GCS, massive ischaemic  stroke,  counsel attenders need for intubation, inform neurology, intubate, thank the nurses, shift patient for MRI. Receive a patient walking in with chest pain, make her sit on my chair because every single ER Bed is full. Get admin to send in an extra bed, accommodate her and glance at the door, watch transport crew wheel in another unconscious patient, most definitely aspirated, Intubate again, handover to pulmo and neuro, hear about previous history from pulmo and kick myself for missing out the alcohol withdrawal treatment and yet the alcohol binge. Hand over subtrochanteric fracture to my good friend in ortho. Sit down to write inubation notes, look up to see a father walking in holding his son’s hand who just punched a wall. Look up at the clock and guess the time?- 8 15 pm.

Cut me some slack with the grammar, alright? This is a ramble, what else do you expect! This was just my story, there were 4 more colleagues on the same shift equally busy or even busier. Too bad they don’t blog.

See ya next Monday!

[emandme]

Relevant History?

I figured out only recently that writing can be therapeutic. Before I put it to this particular use though, I wandered aimlessly between the lines. I wrote to impress, I wrote to woo, I wrote to make money, I wrote to inspire, I wrote for attention, I wrote for up votes and I wrote to be heard. I am writing now to connect with something that every single decision, good or bad, impulsive or well thought of, certainty or chance, has led to - a life in the fast lane, a life in Emergency Medicine. I like to think of myself as a rationalist, it helps get by the steaming pile of shit life seems to be sometimes, but considering the circumstances and events leading up to where I am now, I can’t help but blame fate and say - well played life, I see what you did there. All that for a later day, gotta stick to message at least in the first blog post.

Emergency medicine has been a dream come true, or you keep telling yourself that until you believe it to be true? I like it to think it’s more former than the latter. I was oblivious to the very existence of emergency medicine as a unique specialty for most of my medical school years. Shout out to Dr. Vivek Gopinath for coming down to Hyderabad when he did and putting this idea in my head. The idea of taking the road less traveled and living a life on the front line, the idea of Emergency Medicine. I owe you, good sir. The idea fed off my impulsive persona, less like a parasite and more like a commensal. After a month of unshackled work in the “Casualty” of Gandhi Hospital, two mass casualty incidents and a whole lot of dying people, I said to myself - perfect, just what I want in life. I know, I know, the term “casualty ” in a self-proclaimed emergency medicine blog is making all you emergency physicians cringe. Calm your horses, don’t run away just yet because that’s what the place really is, and is going to be for a few more years. I call it as I see it.

 It doesn’t take a genius to figure out the informal tone of this blog. This isn’t a personal blog trying to masquerade as a professional one or a place for the ramblings of an overworked, stressed emergency resident. Every day in emergency medicine is one of a hundred different experiences. I don’t think it’s an exaggeration to state that no other specialist in the field of medicine deals with so many people in a single day than an emergency physician does, and that reminds me why I’m even in medicine - for the people part of medicine. I certainly got my wish, I’m dealing with more people than I ever dreamt I’m capable of. Maybe I should have been more careful with my wish - a wish for “normal people”. What I instead got is a mix of angry, scared, frustrated, impatient human beings some of whom are waiting to die on me. Don’t you die just yet, not on my watch. The grateful smiles and the whole hearted thank yous keep me going, but it’s easy to get lost in the pace of residency to even remember them. These moments slip out the back of your head faster than the feeling of the pulse slipping away between your fingers in a collapsing patient. 

This blog is my way of reminding myself that what I do matters so much. This is my attempt to inspire not just myself, but anyone who treads down this path. All I need to do different this time is to keep at something I’ve started. You, yes you, my “best friend” who’s reading this and going “ha, we’ll see about that”, stop sniggering. I’ll prove you wrong this time. 

Every day on the floor is one like never before. There are days of heroics, there are days of firsts, there are days of pride, there are days of camaraderie and solidarity, but there are also days of self-doubt, there are days of mourning and regrets. What there isn’t, is a single day where you don’t want to look back and learn from it. This is so I learn not just to be a better doctor, but to be a better human being. I thank you for visiting. There’s more to come, I promise. 

Before I wrap this one up, a message to my fellow emergency residents around the country in doubt and turmoil over what’s been happening around you. Don’t let anyone tell you that you cannot be a good, qualified Emergency Physician. Rise up and come out all guns blazing. The only person standing between you and everything you’ve ever dreamt of, everything you’ve stood for, should be you yourself.