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Discussion in 'Emergency Medicine' started by docB, Oct 12, 2004.
Now that we have full neurosurgical and interventional neurorad support the brain bleeds are non-stop... and usually have a couple young bleeds my age on service. Seeing person after person sent to long term care with a trach and no meaningful interaction is getting old.
Not too long ago had a young guy my age, came in for acute abdomen, probably perforated appy per CT..... nope, cancer all over.
When the guy who works in environmental services in your ER that you always talk sports with brings his wife in with a cough and you diagnosis her with metastatic cancer.
In the same 7 day stretch....
60 year old no problems...feeling a bit weak and lost a few pounds of late.....10cm mass at head of pancreas with over 40 total mets in the liver and colon. He came in on thursday and died on wednesday before we could even get him to home hopsice
45 y/o...yes 45 with no family history and thus too young for routine screening....comes in with some bright red rectal bleeding. Scope shows massive tumor in the splenic flexion with multiple liver mets.
52 year old with known 4 month history of pancreatic ca with mets to the liver and colon and tumor invasion into the celiac plexus. Celiac block fails. Dies writhing in pain after 48 hours on 30, yes 30mg/hour continues dilaudid drip and 300mcg in fentanyl patches.
49 year old female comes in with hemoptysis. >15cm Small cell lung ca with 3+ brain mets with surrounding hemmorage, and bilateral pulmonary emboli. IR drops her lung during the biopsy and she gets a chest tube. No previous health issues cept obviously a smoker. Goes full head of steam to chemo and whole brain irrad. Goes home. Readmitted her about 3 days ago and I didn't even recognize her. She is a ghost with a heartbeat.
That week I drank quite a bit of Gin. Life is just too short.
I diagnosed 3 new cancers in the last 48 hours. All < 50yo. It just makes you feel tired.
Agreed, the neuro ICU is truly a depressing place to be...
More than half of my patient panel is made up of people <50 with "old people cancer." Mostly colon and breast but a bunch of GBMs, a few lungs and way too many metastatic melanomas.
Agree that it's painfully exhausting...and it's the business I chose (unlike you all).
Let's go get a beer
10 month old big TV falls on head, skull fractures and brain bleeds everywhere :'(
I'm posting the following not to be more of a downer but, well, because this thread is titled 'medicine sucks.' This post actually comes from a dental website that I read (I left dental school for medical school) and was made by I believe an endodontist. The post was made in response to someone who is trying to decide between medicine and dentistry and asked for opinions on this forum.
Personally I think medicine rocks, but I want your opinion:
"Medicine sucks. My best friend since childhood was my roomie when I was in dent school and he in med school. I still have contact with some of those guys. My friend went into plastics, and is doing pretty well. Many of the others in primary care (family, internal, peds) are unhappy. A few are so disillusioned it borders on pathology. One buddy of mine, an ENT, got completely out of clinical medicine, and he was double boarded in ENT & general surgery. Working on a Jewel in AmWay now, and working on some foreign ventures with hearing aids in Asian markets.
My one friend who's still damn happy is an ophthalmologist netting close to $2M a year doing, you guessed it: Lasik. The urologist across the street from our home works his freakin' ass off but makes a great living. A derm I know and go to, loves it and takes no PPO's! They're in the minority.
My other buddy, a neurosurgeon, had a molar RCT/BU/Cr. He was being flippant at a social gathering, saying that he paid me $1800 up front for that treatment, yet he takes longer than he spent in my office taking out a brain tumour for $1300 from Medicaid or Medicare, $1550 from an insurer, and he's lucky to see that money in six months.
We now graduate fewer dentists per year than we did when Eisenhower was president, yet dentists are quitting and retiring at a higher rate. Think what's happened to the population since then. Med school admissions are obscenely high, heavily govt subsidized and the INS gives foreign-trained MD's immediate priority status for expedited admission to the US, then they just have to pass a standardized exam for licensure by credential in the US. The influx of foreign dentists, on the other hand, is close to zero, since states refuse to permit them licensure by credential or exam. They all have to do at least the last two years of dent school at a US dental school, pass parts I and II of the Nat Boards, and only THEN they are permitted to take a licensure exam.
More than half of dental graduates are women, but female dentists don't work as long a career as female physicians do, nor as long as male dentists.
The prestige of physicianhood is still high, but they're not as esteemed as they used to be.
Needless to say, after all the bragging rights have been spent; after all the cocky presumptuous sideways glances at mere mortals have lost their ability to instill a smug sense of self-satisfaction; and after the brutal reality sinks in that the money ain't that great and is getting worse while working for a patient population that neither pays for their own care nor feels an iota of shame for calling the ambulance chaser at the first hint of a complication...after all that, medicine just ain't what it used to be. Today it is a job, a vocational commodity, traded and jockeyed around like pork bellies or unskilled labor pools. And it is so sad you could cry, that the profession that used to only attract the best and the brightest, now attracts the misinformed and the liberal-fed altruists, yearning to "make a difference" or the terminally insecure obsessed with being what their equally-misinformed elders felt was the quintessence of success...al while ultimately being overworked, overscrutinized, over second-guessed and vilified.
Go for it if you want or you must, but don't say no one ever told you about the down side."
Edit: The reference is here, post #16:
Question: Did you read anything on this thread before you posted?
As for me, today on the ambulance I got to see the aftermath of grandma fatally side swipe a door frame, and rip out her dialysis fistula, take two steps, and fall in a pool of blood everywhere. All in front of her 8 year old grandson, who called 911 and witnessed the entire scene.
had a patient sequence the other day that was sadly representative of EM..
busy friday night halfway into a 12 hr shift when I see a 55 y/o M p/w CP, substernal, blah blah, states he had negative cath 6 mo ago at outside hospital. cardiac w/u started, records faxed, etc. pt requesting pain meds, etc. get records from outside hospital stating pt has never been there, later find out he is known drug seeker at other ERs/pain clinics but just hadn't been to ours yet.. told he would not be receiving more narcotic pain meds but still recommend stress test.. pt storms out AMA.
Go directly from that enjoyable interaction to see a 23 y/o F 20 wks OB p/w unresponsiveness. found to have nonsurvivable ICH likely 2/2 aneuryms rupture. tons of family, crying, very emotional. genuine tragedy.
After talking with family, neurosurgery, and medicine admit for above patient, I move to to see a 66 y/o F p/w SOB/CP states she has lung cancer and gives me name of her oncologist. Work up begins, r/o MI/PE/PNA/compression etc... call oncologist and he has no idea who the patient is and chews me out for calling him.. CT chest shows pulm nodule but no evidence of CA. review narcotic database and shows multiple opioid rx from different providers in different cities in past month.
I'm usually pretty good about smelling the BS but when you say you have lung cancer and p/w CP/SOB and I'm slammed busy, ya I might miss your malingering and end up giving you some dilaudid. but seriously, WTF? Where do these people come from and why do we let them act this way? Being civil and trying to reclaim whats left of your "physician patient relationship" to a grown adult who is lying to you about having a terminal illness in order to score some dope (all at the expense of taxpayers) when you've just seen a pregnant young persons life destroyed has got to be one of the most difficult scenarios in medicine.
In EM, this can be our game. Just as we often can't tell sick from not sick without a little testing or tincture of time, we also can't always tell who's malingering. You should never feel bad about either choosing to give or not give analgesia, as long as you have a decent reason at the time. Everything always seems clear in retrospect. Focus on the sick patients and the ones you can help. Look right past the BS and let it roll off your back. If we can consistently do this, EM is a lotta fun.
Coding children sucks. Coding the children of your colleagues really suck. Coding the children of your colleagues after an utterly preventable trauma (aren't they all)...devastating.
Still reeling and my soul aches. Not an EM colleague, but still "family," especially at my small-ish hospital.
Don't really know how the others are doing, as they're spread out among several hospitals, but my kiddo got flown out with one of the worst TBIs I've seen since residency. Had a pulse, but didn't look good.
As much as I hate this thread, it has a purpose.
I'm sorry. I feel your pain. Brutal. Mostly, thanks for being there. Best wishes go to that child and his/her family. It reminds me of something I posted a while back, first here on SDN, then here:
My input may or may not be welcome here, but I'll offer it up anyhow in the hopes that it can help ease the pain of at least someone here. I just recently hit 15 years in EMS, 12.5 of which have been with an extremely busy department in a lower class urban area. I've also worked in rural environments, and my most recent side gig is as medic on a helicopter.
I've not seen it all, but I've seen a lot. I've cried in my bunk, I've frozen up, I've been angry, and I've also been overjoyed. I'm certain I could be diagnosed with PTSD if I thought that diagnosis actually changed anything, but as it is I'm just floating through.
I know that many of you ED docs have extremely limited interactions with us medics, and probably see us as arrogant jerks who really don't own our patients, but in actuality many of us really do take personal ownership, even during our relatively short interactions with them.
So the upside to this post is, at least for me, that over the years the emotional response gets less and less. I don't dwell on the bad runs as much as I do the good runs. I am able to dig myself out of the tragedies much quicker than I used to, and for the most part, I can function as a normal human being. I think it's important to be able to tell yourself that YOU'RE not the one who has the horrible (insert terminal/unfair injury/illness), that life can be unfair, and if you're religious, that it's not up to you to figure out why God is doing this/letting this happen. All too often, as healthcare providers, we actually make an effort to insert ourselves emotionally into these situations, "wow I can see myself as a part of this family, and how would I feel?", which is clearly not healthy.
I'm not going to pretend I still don't get negatively affected by bad stuff on occasion, and I'm also not implying that you should be a cold, inanimate, emotionless being, I'm just sharing the coping mechanisms I've developed. Hopefully some of you can find more peace with these methods.
Lastly, CISD works wonders. I have avoided these things for years, but finally utilized one after a somewhat recent bad incident, and I was amazed at how helpful it was to vent all of my thoughts to a peer who had shared similar experiences, MUCH better than a 3rd party counsellor who'd never done what we do. I'm not sure if there's peer CISD for physicians, but there should be.
I can't handle sick kids. I thank god daily that my EM/CC path ended up panning out IM/CC. If I'm in the Ed admitting whatever old homer septic shock pt and I here a code pals or see a sick tyke or abused tyke or kid trauma roll by I literally start sobbing openly. I called my wife one night as an intern. Had done like 5 admits myself already in the first 3 hours getting slammed, exhausted and they call the code pals. Drowned kid rolls in in his pajamas. All I could think of was my son and I started balling and called her sobbing. I came home the next morning and hugged my son for what must have been 10 minutes. Will never forget that night.
God steered me away from my intentions into med/CC because he knew. I can't handle hurt kids.
Like everyone else, I hate sick kids. But I don't have kids yet. And I hate it, but I can keep going with my day. I mean, it sucks. It upsets me. But I've never cried, been super shaken, etc by sick/abused kids. My question is this:
Do you think it will be easier for me to get used to seeing sick kids since I don't have any of my own yet? Will the way I view sick kids drastically change once my wife and I have kids? Or, once I get in a habit of treating/used to treating them, will I still be OK after having kids?
I don't have kids, so I can't speak to that, but you definitely get used to seeing them and like everything else, it generally rolls off. Truly sick kids are actually fairly rare. Truly awful cases (like the one I wrote about the other day) are exceptionally rare.
There are 3 cases I've had in my career that really shook me to the core and I remember them all vividly. Two were children. One was the other day... and it was primarily because it was a physician friend's child... who met us in the ambulance bay, crying "it's my son, it's my son," and watched the entire rescus, helplessly. I will let the others speak to how they cope having their own children - or you can start a new thread, as it will probably get lost here. This thread, I think, encompasses the worst cases we have collectively ever seen.
We see different sides of the same coin. I think many of us have some element of PTSD over the stuff we've seen, though it may be subclinical for many. And you're right, it helps to vent or express it in some way. That's part of the reason I write the long posts I do about some of the stuff I've been through (though they are fictionalized extensively to maintain privacy). Some of the things we see can rattle around in the head for years if you don't expunge it in some way. Good post.
It did for me. It also made me much better able to take care of kids, though it hits much closer to home when the outcome is bad.
I think people that sign up to work in an ED (or EMS, cops, and soldiers even more so) rarely give themselves enough credit for what they do. Anything, I mean anything can roll in that door and it's on you: Someone incredibly famous passing through town, your own kid or spouse or your own worst enemy. You just never know. Panic! "Call 911!" isn't an option when you are 911.
I have tremendous respect for those that put themselves in that position such as docs, nurses, cops, EMS, soldiers (the most), bomb squads (and whichever other unsung heroes I forgot). These are my real heroes. Not the many false heroes often idolized in today's world.
Had a horrible abuse case the other day. Another pediatric abuse within 2 months. These are rare in our ED, but I've gotten probably the only 3 which have rolled through within the past few months. At least this child didn't go straight home to the parents until they finish the investigation. I heard one of the cases had a person confess to doing it. Don't know the outcome of the 3rd. This one is going to court, I'm sure. It sucks. Oddly, 2/3 cases were brought in for fever. Found spiral fractures. The third was brought in for complaint close to accurate...2 yo went through her second rape kit in her short lifetime. These cases are horrible. I remember exactly which rooms these patients were in and what everything looked like on exam / on x-ray. I could go without seeing another case. However, I have to think I am doing something good for all of these kids to make it all worth it. I'm helping them hopefully stand a chance at avoiding further abuse and having a better life.
For me it's the things people say that stay with me. I can still hear clear as day a dying little boy say "Daddy." That wakes me up at night or pops up in my mind sometimes. I wish I could shake that one.
This is true. Having had young kids I can now advise parents better about how to manage stuff like fevers, vomiting, diaper rash and so on.
One day I hope to be able to no longer hear/see the mother screaming at me for not saving her infant's life.
I have one of those. It's there but it's not as gut wrenching. It was a mother of an adult who died prehospital and she was demanding to know "Why is my child dead?" I wasn't there when it happened but as is often the case I'm left to try to explain it.
I remember a few who said "I feel like I'm going to die." and then did. There's a reason we take that seriously.
I remember one lady screaming "Wake up! You've got to just wake up!" over and over at her dead husband after I called it.
I don't know why but for me it's the voices, the words. For others it's the images, the environment (a certain room in the ED), the smells or even just a feeling. Everyone has their own thing.
It isn't all bad. As many who frequent this board know I can be pretty jaded sometimes. The fact that those things are in there, stressful and terrifying as they are, reminds me I'm still human. They haven't gotten it all.
For all of these <50 cancers, could they have been detected earlier? Were there obvious symptoms being experienced that were ignored? Or was it just feeling bad, check into ER, and then realize how bad it has metastisied? Reading about all these cases makes me worried, I wish there was some sort of routine 'cancer check' everyone could get.
Some can, some cant.
I had a lady recently come for belly pain. She knew she had cancer and was told that something was in her liver, but no one took the time to explain to her what exactly that meant. Her belly was extremely tense, thought she had involuntary guarding - turns out her liver just took up 100% of the space in the anterior portion of her abdomen down to her pubic bone. She had an appt in 2 weeks with an oncologist "for staging" - and then she asked me if she was going to get better. That was rough.
I started to cry reading this. All the s*** you guys get aside, and some from me, i praise you guys for taking care of these kids. Someone has to. And I know I don't have the strength top. Carry on men.
Late 20's nice guy one young kid newly married newly on the prestigious city fire department (you see where this is going...), known melanoma however was given a more or less clean bill of health. His own guys bring him in on the medic for lethargy and fatigue...huge brain mass and subsequent bleed...straight to hospice. Ruined my at that point great day, and gave me a headache. I had to call the wife and let her know I loved her once the thoughts started creeping in.
And I had just thought of this thread a few days ago.
Taking care of fellow providers' family is the worst. In the last year I've intubated one of our PA's 3 month old due to rsv (got better) and the husband of our of our young nurses after a large SAH (did not improve). I'm glad this thread exists, lets us know we're all in the same boat.
Just went to ED for a consultation and seeing one of my best collagues' father who is diagnosed with small cell lung cancer with lymp node metastases(whom brother has passed away two weeks ago because of lung ca also). After first dose chemo and a few days he had started to feel bad. There were no white cell in peripheral blood smear. Procalcitonin level was 341 (1/5 diluted). Everything went bad. We lost him after 8 hours. We could only cry while he was dying in res room.
Young patient. Not too much older than me. Sudden onset of stroke symptoms. BIBA code 3 to my stroke center. Decompensated rapidly enroute. Massive, truly massive, ICB. Very sad.
Let the consultant games begin.
I call neurosurg who is pissed off at being called in general. Explain the situation.
NSG: This is bull****! I can't do anything with that. Make them DNR.
Me: Dude! This isn't some gorked SNF patient. They were walkie talkie an hour ago. No family would go for that and they shouldn't.
NSG: [expletives deleted] Fine!
NSG comes in. Tells me I dragged him away from an activity with his kids and sees the patient. Pupils blown, no respiratory effort, nothing on exam. He calls brain death, writes a note and leaves.
Family shows up a few minutes later. I have to explain that NSG has already seen them and there's nothing to do but wait for the inevitable. Family is pretty sharp. Some healthcare background. Picks right up on the seriousness of the situation. The leader suggests keeping the patient full code for the time being, running one or two rounds primarily for the other family members and then calling it when the time comes. I though that was just about the best, most reasonable suggestion from a family I've heard.
I'm totally comfortable giving bad news. But this was tough. There really is something to being told there's no surgical fix by the surgeon. I suppose the good thing is that dealing with situations like this makes me more cognizant about keeping myself in check when I'm pissed off (even though that definitely doesn't work all the time).
that would be reviewed at our medical staff meeting. The surgeon should be talking to that family explaining the nature of the injury, the care he can or can't offer, and their options. That dude is a douchebag. It isn't our fault you hate your job. I don't like being pulled away from my wife and kids either....that's why I chose a career that utilizes shift work without any additional call. He didn't. totally unprofessional.
and yes, very sad case. We had a similar 30-32 y/o the other day come in with abdominal pain. Sudden onset. Collapsed. CT showed ruptured triple A (he did look marfans like). ED doc called me to reserve post Op bed, on way to OR now. went to OR, bled out in about 30 minutes, exhausted our entire blood bank. OR called shortly after to release the bed. Im sure that was a horrible conversation to the 30 y/o wife and 2 small children.
34 male years old
Tried to stole a bike and his fingers were cut off by citizens as punishment. Is not the wound that sucks, is the grisly minds we have in our society.
A few months back, I had to do a perimortem c-section. Young woman at 36wk with massive upper GI bleed brought in by her husband. Thankfully anesthesia was there to take over coding the baby while I continued working mom. Anesthesia called baby, but I managed to get mom back. Mother coded about 20 minutes later. I let the husband stay in the room. He asked us to stop after 30 minutes or so. There weren't any dry eyes in the ED the rest of the night.
Recently, 50F c/o SOB x5 days and a "spot on my breast" for 1 month. She had about a 12cm eroding mass on her breast. Turned out to be stage IV breast CA with mets to lung and bone. Also had diffuse PEs causing the SOB. She just stared blankly at me when I gave her and husband the results.
Medicine sucks. Keep up the good work.
Wow, there are so many things wrong with those two sentences that it's amazing. And you probably can't even recognize it.
Not as bad as some, but this case really got to me. 70 year old female whose only PMH was HTN brought in by husband for "not acting right for the past week." Neuro exam mostly intact, but patient seemed to have a mild expressive aphasia. Sat down and told the family that I thought she had had a stroke several days ago and there was nothing I could do. Went ahead and got a head CT to look for bleed, and found a tumor. Called neurosurgery who took one look and said "That's a metastasis. Where's the primary?" Had to go back in and tell the family that I was very sorry, but it wasn't a stroke it was a tumor and it wasn't "just" brain cancer... I was doing okay up until the husband looked at me and said "She's in God's hands now."
Do elaborate please.
Sure. It's great that you, by your own words, not mine, picked your profession based on the fact that you didn't want to be on call. Which is pretty sad. What's worse is that you then proceed to have zero empathy for people who do have to be pulled away from their families and just say, essentially, "who cares, it doesn't affect my life." A lot of us didn't get to choose "shift work" and the reason there's a lot of disdain for people who do shift work is because of the mentality you described.
Did that clarify things for you?
If I'm not mistaken, it is a choice?
Tough cases. I can't tell if those cases make we want to get out more or stay in more. I have mentioned before that I find some comfort in the fact that I can still feel anything.
I have noticed an even shorter fuse with the seekers and the sociopaths after a case like that. It's had to humor a fibromyalgiac after a pedi code.
I'm used to telling people about cancer - don't like it (who does?). I'm used to delivering bad news - comes with the job. I'm used to people dying - I work in the last house on the block. I've even had my share of horrible codes in the young adult population.
With all that said . . . the case you shared with us here. Man. I can't even. And there's not much else to say.
Sure, but that was sort of my point. You literally have to put that ahead of everything else and then turn around and say "anyone who didn't do that, too bad, nobody cares about you!!" That's actually a pretty despicable attitude, if you stop and think about it.
I agree. Of course it's a "choice" to go into any given specialty. But if everyone went into a non-call specialty they're be a whole lot of people who couldn't deal with patient from beginning to end especially on the big procedure side of the equation. There's just not enough surgeons and surgical sub-specialists to make a shift work model work in almost any location where you need them at least SOME of the time - sure in areas that will support enough trauma for 4 trauma surgeons you can have those guys working in shifts. But even on the general surgery side of things, even in busy locations, the need for emergency surgery for anything that is NOT trauma just isn't there enough to support any shift type of model.
That plus, a lot of people go into ER specifically because they DON'T want a long-term relationship with a patient. That's great for them, but a lot of the rest of us do, so we don't accept just hitting the end of our shift and handing off a patient (or receiving that patient, either). Regardless, if all you're doing is working a shift, even an overnight one, one would assume that they would have some empathy to people who are on call. But instead, it''s usually like "hey, I'm up at 2 AM, too, so what's the big deal?" The big deal, Einstein, is that you started working a few hours ago and you stop working in a few hours and most likely you get the next day or even next few days off. It's amazing how thick-headed some people are.