Nightlife in ED: A series of ‘night’-mares – Part 1

I arrive at the night shift, change into scrubs and proceed on to shop floor – it’s not too bad – we get handed over 3-4 patients from the evening team, and I pick up my first patient – basically a minors patient, but since there is no ENP for the night: 40something male, no prior known comorbids, was playing football (yes, in this weather, and don’t get me started on the age!) went in for a kick with his right foot, all his weight on his left leg, and he suddenly heard a ‘pop’ in his left knee, since then has had difficulty walking or even bearing weight on the limb. Very swollen and tender anterior part of the leg (just 3 hours after this ‘injury’) but the mechanism isn’t direct trauma, so do I x-ray it? do I let it go? He is unable to weight bear, so I request one – would you believe he had an avulsion fracture of the patella! I am so glad I x-rayed it! Sent him home with a cricket pad splint (controversial, but that was our only option at the time) and a fracture clinic followup the next day. (More about this patient in one of my future blog posts)  My second patient is a young female who comes in septic (with septic observations – raised heart rate and a fever in this particular case), and I start figuring out the focus for her infection, which isn’t too difficult to ascertain: an infected surgical wound from a recent C-section she had, which looks (and smells) like it isn’t healing very well. Very quick and easy – antibiotics/fluids/sepsis 6 ticked off, and referred to the obstetricians (which was the Gynae SHO at this lovely hour), before moving on to my third patient: A young male who presented 6 hours after (yes, SIX HOURS AFTER!) being in an accident. He was stopped at a red light, and a car at unknown speed crashed into the back of his van. (yes, car … into THE BACK OF HIS VAN!) and then someone decided to crash into the back of that second car so he was jarred a second time. So he waited 6 whole hours before coming to ED at 2 am to be checked out. He complained of some shoulder pain, but had full range of motion and the mechanism wasn’t significant. I advised him to have some analgesia and go home. It was pointed out to me later on that he may only have been there for A) insurance reasons or B) so he could call in sick the next morning from work – being that he had been in hospital the previous night, or C) all of the above. Likely C. Anyway, the fourth: Elderly female, diagnosed with shingles 7 days ago started on treatment (which she had not taken!) and presented to ED because the pain was unbearable. I asked her if she had taken any pain-killers (she had not) and why she hadn’t been taking the amitriptyline (because it said on the leaflet ‘do not take if you have heart failure’ – even though her GP knew she had heart failure and had prescribed it for her and this warning is for people who usually take over the counter medications on their own) Bless her, the pain was more excruciating because the shingles rash was in her lower back, and the rash went into a skin fold, and everytime the skin folds rubbed onto themselves (as they usually do) or clothing touched it, it would burn. I empathised with her, told her how sorry I was that she was in this situation, but to expect that the pain will go away with time and that she needs to use her medication regularly, the rash itself was dry and not infected or anything, there was no other treatment for it. She didn’t like it, but that was unfortunately just the way shingles was. Unfortunately. Fifth: Barndoor chest pain, cardiac-sounding, first troponin 38 – started on ACS treatment, referred to medical specialty/cardiology for repeat troponin and further management/investigations – The sixth one was not really a patient I had seen, but was being handed over to me by one of my colleagues who was going off shift, and needed to hand over this patient to me to chase their CT scan report – if normal to be sent home with advice, if abnormal to be managed accordingly – the story will be unnecessary to relate here as the report came back 2 seconds later and he very kindly dealt with it himself (I did the discharge summary). Number Seven (or 6th?) was the cutest little old man, pleasantly confused dementia patient who had had an unwitnessed fall in his nursing home, and even though he denied any pain in his hips, there was a distinct grimace when you palpated his left hip, and his mobility had declined suddenly following to fall – Pelvic x-rays were requested, yet they appeared grossly normal. I gave him some analgesia and decided to refer him to the medical team because of his significantly reduced mobility following the fall, even though we could not find any significant injury, nor any significant cause for his fall (atleast not medically correctable in ED) – the medical team very kindly accepted the referral, understanding that this late hour meant he couldn’t go back home anyway, but also that he was unsafe till he was functionally fit to go back home as well. I then took a break (much-awaited) had some lunch (?dinner? breakfast?) at 4 AM – and felt exhausted, but the list went on: Eight – 74 year old female, known to have atrial fibrillation, who was brought in with palpitations and a fast heart rate – went through the mental checklist of things that may cause your heart to go fast – ruled it as infection as her WBC was 13 something, but her CRP was over 300! Very likely the focus was chest as she had reported a dry cough for the last week, that had x2 days back become quite phlegmy. CXR/bloods, including cultures/antibiotics and fluids prescribed – referred to medics.  Patient counselled at length because she was quite upset at having to be admitted (‘Doctor, can’t you just give me something to calm my nerves, and my heart will settle – I need to be home, it’s my daughter-in-law’s birthday tomorrow and I have to bring the cake!) and moving on…ninth on my list was my most interesting case of the night – middle aged female no prior known comorbids, with no personal or family history of epilepsy, brought in by paramedics and concerned family following what was very likely a generalised toniclonic seizure that she suffered in her sleep (she woke her husband up when he felt her shaking violently). The night before she was at her daughter’s wedding reception, and reportedly never drank alcohol. All her blood tests came back negative and her ECG and urine was fine (a urine pregnancy test was also negative). She had no focal neurology or anything else significant on her examination either. I discussed it with my seniors, and they agreed that something seemed very off about the whole case – we referred her to the medical specialty for inpatient observation as well as an inpatient MRI of the head, fearing the worst. The medical team agreed with the assessment, and were happy to admit the patient (usually patient with first seizures if their investigations in ED are ok and they are back to normal/usual baseline, and they have someone who can stay with them – we send them home with a followup to be seen in the ‘first-fit clinic’ as an outpatient). I counselled the patient and her family who understandably were very worried (they were very worried to begin with, but being admitted to be worked up for something sinister like what you would require an MRI head for worried them even more) – I answered all their questions and then once the patient was moved to the ward, I took a few minutes in the back room to compose myself. You do things on autopilot for so long, start of the shift to the very end, and you just keep moving forward from one patient to the next (often more than one) and there are times when one of those cases (or maybe all of them combined?) hits you right where it matters, because you are only human. I drank some water, took a deep breath – and moved on to number ten, very likely my last patient as there was about 50 minutes left till the end of my shift and all but one of the morning team had arrived. And I regretted picking up this patient at once: middle-aged male, admitted following an alleged overdose of 50 (yes. five. zero) grams of diazepam. I say alleged because reportedly he had taken them 3 hours back – and he was literally more awake than I was. Also, when I began to ask him what brought him to ED, he … just…started! Went on and on and on about everything under the sun – His divorce. His occupation. How he worked with the police. How he was a trauma surgeon for the past 26 years, how he knew the side effects of the medications he had taken. How he was also a scuba diving instructor. How he knew a certain celebrity. How he had been kicked out of his own house because his housekeeper had taken up residence there and had forged his signature on the papers and how he had a gun permit and not a gun but how he was framed for trying to murder his housekeeper who was still alive and the police won’t arrest him coz he worked with them and taught them scuba diving….*eyes going rolling backwards into their sockets* I interrupted about 5 times politely – but he went on. And on. And on. Not how you want to end your night shift (or any shift at any time!) Dealing with him felt like dealing with 5 different patients! And the alleged diazepam wasn’t making him sleepy or any less talkative either! I literally extricated myself from the encounter and almost ran to the phone to refer him to the medical specialty – not because I believed he had indeed overdosed on the amount he mentioned – but because he clearly needed psychiatric input/help (and now thanks to him, so did I!) I ran out of that shift like a bat out of hell – and as I exited the premises, one of my nursing colleagues, fresh as a daisy for her morning shift, yelled out ‘Bye darling, see you in a few hours!’ – reminding me that I was back again tonight, for the second of four consecutive nights. *Facepalm*


If there is one thing I can not stress enough, it is that wherever you are (as in whichever country you work in, not your present location of the bathroom or the grocery store!), whatever you do (whether its emergency medicine or you’re a newly born FY1), whoever you are, always remember: DOCUMENT!

If you do something or say something or let the patient know, or if you don’t do something, or don’t say something or don’t let the patient know, DOCUMENT the conversation or the deed (or the lack thereof) and the pertinent details of the interaction – for your own good. I always try to tell my juniors (and anyone else for that matter!) that always think of your notes as someday standing up in court as a means of defending yourself; at times the ONLY means. Will you remember the 3rd patient on your 57th day of work in your 4th year of training, 3 years ago? Well, you may. But will you remember exact details? Not likely. So think of it this way, whatever you write down, or don’t write down, will always end up saving you. Or screwing you over, whichever way you want to look at it.

If you see a patient who, let’s say has epilepsy or you are working them up for a possible or probable seizure, sometime during this interaction it is your duty to tell them very clearly that they are not allowed to drive. And then also DOCUMENT that in your notes. If this patient then decides to continue driving, and ends up in an accident, it is very likely someone will pick up on the fact that he had a similar episode sometime back, and they will then look at your notes of the interaction. Now suddenly, every word you have written down (and also not written down) becomes significant. If this patient then goes on to say in court that he was not told he could not drive, and your notes do not mention you giving this advice, not only will you have aided him in escaping punishment for his poor judgement and from an unpleasant fine-slash-jail situation, but also it now becomes your fault, your poor judgement under scrutiny, your job at stake, your medical degree in question and your license in danger of being revoked. DOCUMENT!

If you use a chaperone for an intimate examination, DOCUMENT their name clearly in the notes. If you offered a chaperone and the patient declined, DOCUMENT that as well.

Always date and time your notes; always DOCUMENT your name (I prefer using my last name) instead of your signature. At the start of writing anything on a clinical document, look at the time and just put the time and date in right then and there; make it a habit to avoid problems. Any further changes or updates to the plan, document beneath it, with the new time (and the new date if applicable). When continuing to the next page, just remember, this page may at some point become lose and be put back in the wrong order, so always make some mention of the date time and who you are on the new page as well. Granted that sometimes when you are too busy to update notes continuously and in time order, you can go back and document your findings, but always do so by documenting clearly that these notes were written in retrospective. People understand; you’re a doctor. No one’s going to go ‘Right, can you intubate this patient with one hand and write up the information with your other hand? Thanks!’ and if they do, you can punch them and document why. But always document. (Ignore that last part. Do NOT punch them. Please)

You bleeped the cardiology registrar. They haven’t responded. DOCUMENT that. You bleep again 10 minutes later. Someone calls back, and tells you the cardiology registrar is busy because she is passing a critical line into a critical blood vessel in a critical patient (you see what I did there?) and you reassure them that you just wanted some non urgent advice and to ring back when free. DOCUMENT that as well. It’s not just helpful for whoever reads the notes as to why the cardiology consult took so much time, it’s also just common courtesy.

You have just broken the bad news of your 88 year old patient’s new diagnosis of metastases to the liver, unknown primary for which you give them a plan for workup. You offer your help; you offer tissues, water, a hug. You listen to their questions. You offer them to take their time digesting this information, and that you will come back when they are ready and answer any further questions and even repeat anything that they want repeated. You have the ward nurse present with you during this interaction, and the patient granddaughter and granddaughter’s boyfriend (with the patient’s permission) are also present. Your patient says she does not want to proceed with further investigation and treatment, that she has lived a long full life and is quite satisfied. You still offer your support and offer to re-address this at a later point. And any specialty that can come in offer their opinion on this situation. What do you write in the notes? EXACTLY ALL OF THIS INFORMATION. WITH THE DATE. AND THE TIME. AND YOUR NAME. And the granddaughter’s name, and her boyfriend’s if you have remembered to ask him, and the ward nurse’s.

Bottom line: Document every pertinent aspect of patient care; whether it’s your interaction with them, information from investigations, information from colleagues and staff on the ward or care staff from the patient’s nursing home, or even if it is to say that you came in to see the patient but the patient was not in her bed, or that she had gone for a CT scan. Trust me, you do not want to learn the art of documenting the hard way: when you fail to document something and it comes back and haunts you. Not just haunts you, but bites you in the ass. DOCUMENT!

Hello world!

Greetings! New blogger in da house, what?!

Three days. That’s when I had this sudden bright idea (read ‘overheard my wife and sister-in-law talking about the benefits of blogging’) of starting my very own blog. I do, after all, have some interesting stories to tell.

I am a doctor by profession, and my chosen poison or…errr…specialty is emergency medicine. Yes, all the stories you have heard are true. We not only deal with the mundane cardiac events and road traffic accidents and strokes, but we also deal with the very interesting (and not so mundane!) foreign bodies in weird places that you ‘accidentally fell on to while climbing a ladder in the middle of the night naked and that’s how it ended up in my bum’. Very classy, and we totally fall for it. Not.

I also have an almost-2 year old, and the combination of sleepless nights due to daddy duty, and that of my lesser evil but equally exhausting shift work that I do, leads to quite a collection of interesting … incidents, shall we say? Some of them I would not breathe a word to anyone, and others, well let’s face it, they do make for great dinner party conversation.

So here I am, sharing my wisdom (or lack thereof). These are my stories, memories, anecdotes, reflections and thoughts – the inner rantings of a 30-something budding (balding?) doctor, trying to be an emergency physician, while also trying to dad.