Yesterday I went for a little medical procedure. Nothing much, just a little test. And thankfully everything was alright. But every time I was on the receiving end of medical care (and thankfully, it hasn't been too many), it's always a reminder of what it feels like when you're the vulnerable patient, at the liberty of the health care professionals looking after you.
A colleague used to say, "remember what it feels like when you're sick, cause that's how you build empathy".
Very true. Even as I lie there on the stretcher, waiting for my test, looking around the room surveying the faces or other patients coming in. Some where scared. Some looked lost. Some recovering and still groggy. I waited, patiently, remembering to smile when my nurse comes to me. She look stressed. Overworked again, I bet. She came to start an IV. Would it hurt? I thought. I hate needles. I don't mind giving them, but I hate needles.
She was very good. Popped and it went in. Thank you, I smiled. How was your day? She didn't answer. She was distracted by another patient who just rolled in to the recovery room.
Then my doctor came. I've met him once already before. Super nice guy. Warm smile. Kind manner. I notices he pushes his own patients into the procedure room. Chatting with them as he goes. That's a good approach. Do a little bit of your "dirty" work. It shows that you're not just some big shot waiting for others to do everything for you. It makes you kinder, more personable. I should remember that.
The whole thing went very well. He was polite and attentive again in the end, although I don't really remember much of it.
It's funny, but I always thought consultants are often arrogant jerks who have lost all their kindness through their grueling years of training and over-extended schedules. And in my position I have every reason to think so. Most phone calls I make in the ER to consults are min-battles. They would almost universally frown when I identify myself. "Hi, this is Keith Tang from ER, sorry to bother you, but I have a patient I need to ask you to see..." Growl.
Usually, I would just ignore it and continue to pitch my case. Consultants who I work with usually know I
go as far as I should before I call them. I seldom deliver them crap
cases. One even went as far as to say that I think like an internist
(well, I started my training as one) and would put them out of their job
if I keep doing all their work for them. I know they are busy. So I try
to run with the ball as far as I should. But we all have other priorities, and mine is to
keep my department humming along without much delay. But to them, every phone call usually means more work for them, just another name to add to the bottom of the list of their never ending on-call day.
But these mini-battles add up. And soon I start to forget, they they are doctors too, and they do it because they care, and very often, they are actually very, very nice. And they care about their work, a lot.
There was one doctor who really stood out on this point. He was an ENT
consultant at one of my hospitals. Frankly, he is almost universally
disliked among my peers. When we are on shift, we frown when we see his
name listed as the on-call staff for the day. Phone calls with him are
never pleasant. One time he told me he was at a wedding and needed me to
hurry with with my call as the bride was about to walk down the aisle.
He's on call, for god's sake. Then finally, one day, I met this doctor. In person, he was every bit as condescending, blunt, and arrogant. However,
everything changed when I watched him interact with a patient. He was
kind, and gentle, and showed great care. I don't believe it was an act. I
think he genuinely cared. Yes his bedside manner was polished, but one
has to be a decent person to whip that out on the spot like that.
In the medical arena, it is easy to build up animosity towards your colleagues. When all you see is their name on a chart or on a call list, and in the context of
meaning more work and headache for you, their name never seems to shine
in that light. But more often, doctors are nice people, and they
genuinely work hard for their patients and is almost always thoughtful
for them.
It is a good reminder, however, that this is
likely how others see me as well. As much as I think I put my heart into
this, I'm sure on paper I would often come off as equally stupid, incompetent, and
annoying to those who have to pick up the chart from me. So the
lesson here is to always be kind, and to hopefully document accordingly
with thoughtfulness. And to give others the benefit of the doubts. Most
doctors put in a good effort, and sometimes we just don't see that when
we feel they left us with more work. Every time I have the benefit of actually observing my colleagues at work, I am always impressed by their knowledge, professionalism, and manners. I experienced that first hand today, from someone whom I was used to using as a a consultant and receiving consultation reports on. I'll never look at his name in that negative light again. But the same should probably go for all the other consultants I work with.
Wednesday, March 22, 2017
Thursday, March 16, 2017
Cute things.
Cute things happens in the ER. Sometimes.
Little boy. I think he was 7. Let's say 7 year old boy.
Chief complaint: Smelly discharge from nose.
Thought to myself, gotta be kidding me. This to the ER? (Of course, classic case).
Resident I was working with picked up the chart. Sure, go check it out. Let me know if you're worried about anything.
Resident came back. "The kid's just got a booger up his nose. I'm going to remove it".
Great. Done. That was easy.
Wait, that's too easy. Can't be. Let me take a look.
Resident showed me the booger. That was tiny. Can't be it.
Kid looks cute. Giggling. Shy. Brave.
Where's the nasal kit? (Resident didn't have the right tools to examine the nose).
Ah, there it is. (Taking out the kit that has the nasal speculum and bayonet forceps).
Kid freaked out, just a little. But then he braved up again. Showed me his nose.
Peek in. Something funny going on in there.
Ah. I see it. Let me go grab it.
Sticker pulled out from the left nare. Pretty big thing rolled up into his tiny nose. Cute but gross. It was a Captain America sticker, I think.
Showed it to mom (mom was hiding behind the curtain).
"Do you want to keep it?". Come on. Definite scrapbook material, I thought.
Shook her head. Guess not.
Sometimes the most silly cases still require a little digging. Reminder. No sane person (or parent) would willingly sit through hours of ER wait if it's not something they've sat on already for hours at home contemplating if they should come in (I could be wrong, I can actually think of quite a few too many who shouldn't have been here). Anyhow, if they're here, they usually get the full meal deal. Plus, this is probably as textbook as it gets when it comes to cute kiddies and nasal foreign bodies. It was a cute way for my resident (and me) to remember not to take things too lightly sometimes, even if they come in cute and giggly small packages.
Little boy. I think he was 7. Let's say 7 year old boy.
Chief complaint: Smelly discharge from nose.
Thought to myself, gotta be kidding me. This to the ER? (Of course, classic case).
Resident I was working with picked up the chart. Sure, go check it out. Let me know if you're worried about anything.
Resident came back. "The kid's just got a booger up his nose. I'm going to remove it".
Great. Done. That was easy.
Wait, that's too easy. Can't be. Let me take a look.
Resident showed me the booger. That was tiny. Can't be it.
Kid looks cute. Giggling. Shy. Brave.
Where's the nasal kit? (Resident didn't have the right tools to examine the nose).
Ah, there it is. (Taking out the kit that has the nasal speculum and bayonet forceps).
Kid freaked out, just a little. But then he braved up again. Showed me his nose.
Peek in. Something funny going on in there.
Ah. I see it. Let me go grab it.
Sticker pulled out from the left nare. Pretty big thing rolled up into his tiny nose. Cute but gross. It was a Captain America sticker, I think.
Showed it to mom (mom was hiding behind the curtain).
"Do you want to keep it?". Come on. Definite scrapbook material, I thought.
Shook her head. Guess not.
Sometimes the most silly cases still require a little digging. Reminder. No sane person (or parent) would willingly sit through hours of ER wait if it's not something they've sat on already for hours at home contemplating if they should come in (I could be wrong, I can actually think of quite a few too many who shouldn't have been here). Anyhow, if they're here, they usually get the full meal deal. Plus, this is probably as textbook as it gets when it comes to cute kiddies and nasal foreign bodies. It was a cute way for my resident (and me) to remember not to take things too lightly sometimes, even if they come in cute and giggly small packages.
Friday, March 10, 2017
Preaching tolerance
Recently, my department head forwarded me a letter sent in by a patient thanking me and my staff for their care. I looked up her case. I sort of remember her but honestly didn't feel I treated her any differently than the rest. I guess I was lucky she saw me in a good mood.
My department head said good job. My reply was much more melancholy. Thanks, I said. You win some, you lose some, I added.
For every patient who felt inclined to thank us, I'm sure there are many others who would much rather complaint about us.
In light of all the recent negative media portrayals of ER congestion and care in Fraser Health (many of which unfairly reported, I must say), frustrations and negative sediments against Emergency Rooms are at an all time high.
The down stream affect? Everyone is on edge, as if they are not on edge enough already simply by doing this job. In Abbortsford, where after an unfortunate outcome involving a pediatric patient early last month, a colleague told me the pediatric unit admission rates went sky high. That is hardly good medicine. Unnecessarily hospitalization lead to a whole host of potential adverse events and tremendous inconvenience for the families involved, not to mention a much higher financial burden on our already taxed medical system and draining of essential resources that would otherwise be serving patients who really need them. But that's what the situation is becoming. Medical practice not from sound judgement, but driven by fear or missing something.
This is a thankless job. We know this going in. We are happy to be doing it. We also know it's a field filled with landmines and it's all about mitigating and managing the risk we work with.
In fact, if there is one term that summarizes Emergency Medicine, it is essentially effective Risk Management.
Much of the Emergency Medicine scientific literature is about this. How to evaluate risk of a specific condition when a patient comes to the emergency room. How to calculate and perceive such risk. How to balance this risk with costly and sometimes invasive investigations that has its own downfalls. How to weight to risk of false positive or false negative results. What is an "acceptable" risk to miss a potentially dangerous condition? It can never be zero. Nothing in life is that definitely. In medicine, if your assessment tells you that the chance of missing something bad is down to about 1-2% or less, usually that is enough evidence to say stop.
But things are not always this easily calculated. And despite best sound judgement and evidence application, we don't work in a mathematical model, and things are just not that precise.
Clinical judgement, or gestalt, as we like to call it, counts a whole lot. Sometimes we do have to trust our gut.
But very often, I find that patients don't understand that. Patients like to (or hope to) think of medicine as black or white. Doc, do I have this? Will I get better if I do this? Are you certain this is not my heart? Is this cancer?
No, sir. I can't say anything like that. Our tests and technology cannot tell us that with absolute certainty. But I can say that having heard your story and after my examination and tests, I feel really good about you. I highly doubt this is this or that. But there's always a chance I can be wrong. Or perhaps this is too early in the illness and I'm not seeing all that I need to make a more informed decision. So, let's do this. But please, come back if things get worse.
Please, come back if things get worse.
That is perhaps the most important statement of all. And people need to realize that. Just because you are fine now, we cannot guarantee nothing bad can happen or develop. Of course, we don't want to send you home with doubts and uncertainty, and I think we can do our best to mitigate that fear. But, just in case, if things don't get better or get worse, please come back to us.
We live in a world of grey. Not back and white. Patients need to appreciate that. Emergency Medicine is MEANT to miss stuff. It is DESIGNED to miss a certain percentage of bad outcomes. That's just a fact of the limitation of the world we live in. We try our best, but you have to be your own advocate here.
I've certainly been humbled by a few cases when all my clinical judgement tells me there's nothing, but the patient asked one last question that made me change my mind, and added a test, and discovered something. These things do happen. And I'm humbled by them, and every time I told the patient thank you for advocating for themselves, and that working TOGETHER, we did something worthwhile.
But the key here is TOGETHER. Sometimes when I come across a difficult patient, I remind them. Hey, time out, let's work TOGETHER on this. We want the best for you, but you have to help me on this, so here's what I think, what do you think, let's reach a reasonable approach that we are both happy with, and go from there.
Advocating for yourself doesn't mean stomping the ground and demanding every single test to be done to "check everything", as many patients like to ask (I have no idea what that means to "check everything"). It doesn't mean demanding a CT head for every little head bump especially for your little ones. It doesn't mean antibiotics for every cold or flu. It doesn't mean admission for every elderly who is sick but can totally recover better at home. It does NOT mean projecting all your expectations and fears in an unreasonable fashion onto the medical staff until you get your way.
But it does mean you are entitled to speak up, politely, about your fears and let's work through them. And if your gut tells you something really isn't right, I usually trust that instinct, and I do promise to chase after it to the best of my ability.
We all need better tolerance and understanding at this time when our Emergency Rooms are in a perpetual state of crisis. (Having perspectives is important, however, and I do understand that wait times in a lot of departments across the country are far worse than what we have here in BC). We need patients to be aware of what we can and cannot do for them, and to look out for themselves, to advocate when it is appropriate, but most of all, to understand the importance of serial medical visits and examination. That is sound medical care, not negligence.
So please. Work with us. So that we can all do better for you. Which is why we go to work in the first place.
My department head said good job. My reply was much more melancholy. Thanks, I said. You win some, you lose some, I added.
For every patient who felt inclined to thank us, I'm sure there are many others who would much rather complaint about us.
In light of all the recent negative media portrayals of ER congestion and care in Fraser Health (many of which unfairly reported, I must say), frustrations and negative sediments against Emergency Rooms are at an all time high.
The down stream affect? Everyone is on edge, as if they are not on edge enough already simply by doing this job. In Abbortsford, where after an unfortunate outcome involving a pediatric patient early last month, a colleague told me the pediatric unit admission rates went sky high. That is hardly good medicine. Unnecessarily hospitalization lead to a whole host of potential adverse events and tremendous inconvenience for the families involved, not to mention a much higher financial burden on our already taxed medical system and draining of essential resources that would otherwise be serving patients who really need them. But that's what the situation is becoming. Medical practice not from sound judgement, but driven by fear or missing something.
This is a thankless job. We know this going in. We are happy to be doing it. We also know it's a field filled with landmines and it's all about mitigating and managing the risk we work with.
In fact, if there is one term that summarizes Emergency Medicine, it is essentially effective Risk Management.
Much of the Emergency Medicine scientific literature is about this. How to evaluate risk of a specific condition when a patient comes to the emergency room. How to calculate and perceive such risk. How to balance this risk with costly and sometimes invasive investigations that has its own downfalls. How to weight to risk of false positive or false negative results. What is an "acceptable" risk to miss a potentially dangerous condition? It can never be zero. Nothing in life is that definitely. In medicine, if your assessment tells you that the chance of missing something bad is down to about 1-2% or less, usually that is enough evidence to say stop.
But things are not always this easily calculated. And despite best sound judgement and evidence application, we don't work in a mathematical model, and things are just not that precise.
Clinical judgement, or gestalt, as we like to call it, counts a whole lot. Sometimes we do have to trust our gut.
But very often, I find that patients don't understand that. Patients like to (or hope to) think of medicine as black or white. Doc, do I have this? Will I get better if I do this? Are you certain this is not my heart? Is this cancer?
No, sir. I can't say anything like that. Our tests and technology cannot tell us that with absolute certainty. But I can say that having heard your story and after my examination and tests, I feel really good about you. I highly doubt this is this or that. But there's always a chance I can be wrong. Or perhaps this is too early in the illness and I'm not seeing all that I need to make a more informed decision. So, let's do this. But please, come back if things get worse.
Please, come back if things get worse.
That is perhaps the most important statement of all. And people need to realize that. Just because you are fine now, we cannot guarantee nothing bad can happen or develop. Of course, we don't want to send you home with doubts and uncertainty, and I think we can do our best to mitigate that fear. But, just in case, if things don't get better or get worse, please come back to us.
We live in a world of grey. Not back and white. Patients need to appreciate that. Emergency Medicine is MEANT to miss stuff. It is DESIGNED to miss a certain percentage of bad outcomes. That's just a fact of the limitation of the world we live in. We try our best, but you have to be your own advocate here.
I've certainly been humbled by a few cases when all my clinical judgement tells me there's nothing, but the patient asked one last question that made me change my mind, and added a test, and discovered something. These things do happen. And I'm humbled by them, and every time I told the patient thank you for advocating for themselves, and that working TOGETHER, we did something worthwhile.
But the key here is TOGETHER. Sometimes when I come across a difficult patient, I remind them. Hey, time out, let's work TOGETHER on this. We want the best for you, but you have to help me on this, so here's what I think, what do you think, let's reach a reasonable approach that we are both happy with, and go from there.
Advocating for yourself doesn't mean stomping the ground and demanding every single test to be done to "check everything", as many patients like to ask (I have no idea what that means to "check everything"). It doesn't mean demanding a CT head for every little head bump especially for your little ones. It doesn't mean antibiotics for every cold or flu. It doesn't mean admission for every elderly who is sick but can totally recover better at home. It does NOT mean projecting all your expectations and fears in an unreasonable fashion onto the medical staff until you get your way.
But it does mean you are entitled to speak up, politely, about your fears and let's work through them. And if your gut tells you something really isn't right, I usually trust that instinct, and I do promise to chase after it to the best of my ability.
We all need better tolerance and understanding at this time when our Emergency Rooms are in a perpetual state of crisis. (Having perspectives is important, however, and I do understand that wait times in a lot of departments across the country are far worse than what we have here in BC). We need patients to be aware of what we can and cannot do for them, and to look out for themselves, to advocate when it is appropriate, but most of all, to understand the importance of serial medical visits and examination. That is sound medical care, not negligence.
So please. Work with us. So that we can all do better for you. Which is why we go to work in the first place.
Sunday, January 29, 2017
Never walk away from a challenge...
Never walk away from a challenge...
I have that happen sometimes. In fact, quite often.
An opportunity presents itself. Somewhat anxiety provoking. I have a way out. I thought about it.
Far too often I took the easy way out. And regretted it.
When you walk away from a challenge, you keep yourself safe. But you don't gain anything from it. Other than insecurity and lack of confidence.
I've always regretted walking away from a challenge. But I'm not naturally a courageous soul. My tendency is to shy away from it. Sometimes I make silly excuses, such as saying I wasn't ready, or that I wanted to get more experience first.
Time and time again, I would realize later that I was fully equipped to handle it. I just needed a push. I just needed to seize the opportunity, and give it a shot.
When you walk away from a challenge, it only adds more doubts to the next time you are faced with the same. It doesn't make you stronger facing it. In fact, it makes you more unsure.
Without even trying, you feel defeated, you feel a loss, you feel you've let yourself down.
When you come across a challenge, don't think too much about it. Force yourself upon it. As long as it is within your skillset, something you are trained to do. Then go for it. Trust your training. Trust your judgement. Trust your abilities.
And come out on top. Or if you stumble, come out better for it. As long as you are careful, and conscientious, and calculated, and work within your minds.
It's not a given that you will be fine. But you will never know unless you try. And if it's an appropriate challenge, you are better off for having accepting it.
Never walk away from a challenge.
You'll just end up walking forever wondering about it.
I have that happen sometimes. In fact, quite often.
An opportunity presents itself. Somewhat anxiety provoking. I have a way out. I thought about it.
Far too often I took the easy way out. And regretted it.
When you walk away from a challenge, you keep yourself safe. But you don't gain anything from it. Other than insecurity and lack of confidence.
I've always regretted walking away from a challenge. But I'm not naturally a courageous soul. My tendency is to shy away from it. Sometimes I make silly excuses, such as saying I wasn't ready, or that I wanted to get more experience first.
Time and time again, I would realize later that I was fully equipped to handle it. I just needed a push. I just needed to seize the opportunity, and give it a shot.
When you walk away from a challenge, it only adds more doubts to the next time you are faced with the same. It doesn't make you stronger facing it. In fact, it makes you more unsure.
Without even trying, you feel defeated, you feel a loss, you feel you've let yourself down.
When you come across a challenge, don't think too much about it. Force yourself upon it. As long as it is within your skillset, something you are trained to do. Then go for it. Trust your training. Trust your judgement. Trust your abilities.
And come out on top. Or if you stumble, come out better for it. As long as you are careful, and conscientious, and calculated, and work within your minds.
It's not a given that you will be fine. But you will never know unless you try. And if it's an appropriate challenge, you are better off for having accepting it.
Never walk away from a challenge.
You'll just end up walking forever wondering about it.
Thursday, January 19, 2017
Chaos. Hypomania. I can't hear myself think.
3pm shift. Wednesday afternoon. Rainy day.
Arrived at the ER in a scene of surprising calmness. It's been so chaotic lately. Numbers have been record high for weeks. Seeing the tracker down to only a few people waiting was a treat to start my shift. Even had time to catch up on some paper work. Chatted with some colleagues.
Feast or famine. That's the nature of this work. Mostly feast though. Not the enjoyable type.
The bus arrived. That's the term that we use. Patients must know something. They always arrive in bunches. Not they are not all related. There is no plausible reason for this finding. But they come, in bunches, and all of a sudden you are flooded with long waits. It's still only just one of you though. Patients don't seem to get that. They all arrive at once. But you still have to see them one by one.
Red phone ring. That's the phone that rings when the paramedics notify me something big is on its way. 75-year-old male, cardiac arrest, they are working on him at the scene, ETA 8 minutes.
I looked at the tracker. I might have time to get two other patients' assessment on its way. One is an elderly with confusion from a suspected urinary tract infection. I can order a bunch of labs for and "eyeball her". The other, a man sent by by his doctor for chest pain. He looks okay. Let me talk to him. I told him I can be pulled away any minute, but let's get started right away. Focused questions and exam, targeted investigations. Ordered. He looked fine. Put him on the monitor. Promised I'll be back once labs are back.
Went back to see confused granny. Finished my assessment. 8 minute is up. Cardiac arrest guy at the door. Paramedics doing CPR at the doorway. CTAS 1 called overhead. Get gloves. Rushed over.
Trauma bay. Airway somewhat protected, will do for now. Continue CPR. Let's get pads on. Get the 5-second story. Mobilized all the forces. I have already told them my plan and what I would need when I took that initial phone call. So everybody knew their roles. Everybody on task.
Code status. I need to know how far we are going with this case. Send someone to hunt down the history. Let's focus on running the show. Control the room. Too many noises around. Quiet everyone. Only my voice for now please. Step one this. Step two that. Keep it simple. Get on with it.
Colleague did the intubation. Done. Airway secure. Pulses returned. Great. Let's get moving on more access. Lined him. Phone call to daughter. Difficult phone call, always is. She's crying on the other end. Here's what we know, I told her, Dad is alive, but he's not doing well. Do you want us to continue? What would Dad have wanted? Who is family? Yes please come in. Come in now.
Stabilized. But prognosis not good. On life support, but for the time being nothing more to be done. Moving on to further management. Internal Medicine consultant at bedside. Pass the torch. I'll stay involved, I told her, but I gotta see more patients now. It's flooded outside.
Back to the ER. Five charts already stacked, waiting to be seen. 68-year-old man, can't breathe. Nurses say can you see him now please. Fine, let's go. Red phone ring again. 65-year-old male, intentional overdose in a suicide attempt, at least five drugs involved possible more, don't know what. Guy is drowsy. Five minutes away. Fine. Let's finish of those shortness of breath guy first. Hi Sir, I'm Dr. Tang, what can I do for you today...?
Overdose man shows up. Nurses want me to go see him quick. I'm sorry, Sir, but I'll be right back. See overdose man. Luckily don't need to intubate. Quickly got the story. Surveyed the suspected pill bottles. Okay, nothing that dangerous, just need to watch him. Ordered tests. Promised to be back.
More ambulances show up. Three more stretcher patients now waiting in the triage area. I still have to finish my assessment on the man who can't breathe. Next up, a young girl threatening to kill herself. She's safe right now, but needs some talking to. Let's go, let's have a chat to see what we can do for you.
Nurses stopped me. Can I please order some pain medicine for this other lady who's in pain. Who is it? Oh I haven't seen her yet. But sounds like kidney stones. Let's do this, please order that. Tell her I'll see her as soon as I'm done here. Got it. Took the name down. Added that to the list.
Nurse handed me another chart. A guy who just had a seizure. Is this new or has he had this before? Nurses checked the chart. Ah, history of seizure, likely didn't take his medications. He's okay now. Great, let me seem him after these other patients. Keep an eye on him please?
Handed me a ECG and some lab results for overdose guy. Oh right that guy. Looks safe. Keep him on the monitor. Let me revisit when all the numbers come back.
The guy with the chest pain. All his tests are now back, normal. Let's go re-assess. Had a good discussion. Low risk case, felt safe to discharge. Discussed plan. Ok done.
Oh right, the girl who had thoughts of suicide. Let's sit down and have a talk about this. Isolate from the chaos outside. Let's take a brief moment here and explore.
Nurses wanted me to re-assess the elderly lady with confusion and now confirmed urinary tract infection. Ah right, almost forgot about her. Let's talk to her and her daughter about the plan.
By now I am very much behind, because another bus load of patients have arrived. Quickly looked at the tracker. Seems most patients are doing okay. They can wait. Let's wrap up some of these cases first. We won't have beds to see new patients otherwise anyway.
Looked at the clock, gosh when is the next doc on this side going to show up. I need help. The other part of the emerg is also swamped. Sigh. Let's just keep going here.
People often wonder what my day is like. No we are not like the ones on TV, who seems to have endless moments to chatter and gossip. My mind is constantly being pulled in all directions, many of which requires much concentration and deliberate decision making, often without the luxury of time or solid information. In the past, I have found that if I waiver on a decision, or I sit on it for too long, then I can't keep up. Decisions must be swift, but cautious. And I have learned to maximize my efficiency, by prioritizing which tasks to do first because they may take longer, and how to keep all possible doors open such that if I change direction in my approach, I do not have to restart from step one. On days like this I often feel very hypomanic, very on edge. There are reasons I don't eat and drink much when I'm on shift. Part of it is time, but the other part is that I just don't have the stomach for it when I'm stressed. It's no wonder that after my shifts, I'm usually quite physically and mentally drained. But at the end of each tough shift, when I look at my list and realized how much I have done, I feel a sense of pride that I cannot get had it not been that tough. It's a challenging field for sure, but it's also highly rewarding. And the ER is truly an arena where you can do so much, have so much tools and resources at your disposal, and make some of the biggest difference anyone can ever make to anyone else and their families.
On days when you feel all your cylinders are clicking, it's a good feeling, and it's part of why we keep doing this job.
Arrived at the ER in a scene of surprising calmness. It's been so chaotic lately. Numbers have been record high for weeks. Seeing the tracker down to only a few people waiting was a treat to start my shift. Even had time to catch up on some paper work. Chatted with some colleagues.
Feast or famine. That's the nature of this work. Mostly feast though. Not the enjoyable type.
The bus arrived. That's the term that we use. Patients must know something. They always arrive in bunches. Not they are not all related. There is no plausible reason for this finding. But they come, in bunches, and all of a sudden you are flooded with long waits. It's still only just one of you though. Patients don't seem to get that. They all arrive at once. But you still have to see them one by one.
Red phone ring. That's the phone that rings when the paramedics notify me something big is on its way. 75-year-old male, cardiac arrest, they are working on him at the scene, ETA 8 minutes.
I looked at the tracker. I might have time to get two other patients' assessment on its way. One is an elderly with confusion from a suspected urinary tract infection. I can order a bunch of labs for and "eyeball her". The other, a man sent by by his doctor for chest pain. He looks okay. Let me talk to him. I told him I can be pulled away any minute, but let's get started right away. Focused questions and exam, targeted investigations. Ordered. He looked fine. Put him on the monitor. Promised I'll be back once labs are back.
Went back to see confused granny. Finished my assessment. 8 minute is up. Cardiac arrest guy at the door. Paramedics doing CPR at the doorway. CTAS 1 called overhead. Get gloves. Rushed over.
Trauma bay. Airway somewhat protected, will do for now. Continue CPR. Let's get pads on. Get the 5-second story. Mobilized all the forces. I have already told them my plan and what I would need when I took that initial phone call. So everybody knew their roles. Everybody on task.
Code status. I need to know how far we are going with this case. Send someone to hunt down the history. Let's focus on running the show. Control the room. Too many noises around. Quiet everyone. Only my voice for now please. Step one this. Step two that. Keep it simple. Get on with it.
Colleague did the intubation. Done. Airway secure. Pulses returned. Great. Let's get moving on more access. Lined him. Phone call to daughter. Difficult phone call, always is. She's crying on the other end. Here's what we know, I told her, Dad is alive, but he's not doing well. Do you want us to continue? What would Dad have wanted? Who is family? Yes please come in. Come in now.
Stabilized. But prognosis not good. On life support, but for the time being nothing more to be done. Moving on to further management. Internal Medicine consultant at bedside. Pass the torch. I'll stay involved, I told her, but I gotta see more patients now. It's flooded outside.
Back to the ER. Five charts already stacked, waiting to be seen. 68-year-old man, can't breathe. Nurses say can you see him now please. Fine, let's go. Red phone ring again. 65-year-old male, intentional overdose in a suicide attempt, at least five drugs involved possible more, don't know what. Guy is drowsy. Five minutes away. Fine. Let's finish of those shortness of breath guy first. Hi Sir, I'm Dr. Tang, what can I do for you today...?
Overdose man shows up. Nurses want me to go see him quick. I'm sorry, Sir, but I'll be right back. See overdose man. Luckily don't need to intubate. Quickly got the story. Surveyed the suspected pill bottles. Okay, nothing that dangerous, just need to watch him. Ordered tests. Promised to be back.
More ambulances show up. Three more stretcher patients now waiting in the triage area. I still have to finish my assessment on the man who can't breathe. Next up, a young girl threatening to kill herself. She's safe right now, but needs some talking to. Let's go, let's have a chat to see what we can do for you.
Nurses stopped me. Can I please order some pain medicine for this other lady who's in pain. Who is it? Oh I haven't seen her yet. But sounds like kidney stones. Let's do this, please order that. Tell her I'll see her as soon as I'm done here. Got it. Took the name down. Added that to the list.
Nurse handed me another chart. A guy who just had a seizure. Is this new or has he had this before? Nurses checked the chart. Ah, history of seizure, likely didn't take his medications. He's okay now. Great, let me seem him after these other patients. Keep an eye on him please?
Handed me a ECG and some lab results for overdose guy. Oh right that guy. Looks safe. Keep him on the monitor. Let me revisit when all the numbers come back.
The guy with the chest pain. All his tests are now back, normal. Let's go re-assess. Had a good discussion. Low risk case, felt safe to discharge. Discussed plan. Ok done.
Oh right, the girl who had thoughts of suicide. Let's sit down and have a talk about this. Isolate from the chaos outside. Let's take a brief moment here and explore.
Nurses wanted me to re-assess the elderly lady with confusion and now confirmed urinary tract infection. Ah right, almost forgot about her. Let's talk to her and her daughter about the plan.
By now I am very much behind, because another bus load of patients have arrived. Quickly looked at the tracker. Seems most patients are doing okay. They can wait. Let's wrap up some of these cases first. We won't have beds to see new patients otherwise anyway.
Looked at the clock, gosh when is the next doc on this side going to show up. I need help. The other part of the emerg is also swamped. Sigh. Let's just keep going here.
People often wonder what my day is like. No we are not like the ones on TV, who seems to have endless moments to chatter and gossip. My mind is constantly being pulled in all directions, many of which requires much concentration and deliberate decision making, often without the luxury of time or solid information. In the past, I have found that if I waiver on a decision, or I sit on it for too long, then I can't keep up. Decisions must be swift, but cautious. And I have learned to maximize my efficiency, by prioritizing which tasks to do first because they may take longer, and how to keep all possible doors open such that if I change direction in my approach, I do not have to restart from step one. On days like this I often feel very hypomanic, very on edge. There are reasons I don't eat and drink much when I'm on shift. Part of it is time, but the other part is that I just don't have the stomach for it when I'm stressed. It's no wonder that after my shifts, I'm usually quite physically and mentally drained. But at the end of each tough shift, when I look at my list and realized how much I have done, I feel a sense of pride that I cannot get had it not been that tough. It's a challenging field for sure, but it's also highly rewarding. And the ER is truly an arena where you can do so much, have so much tools and resources at your disposal, and make some of the biggest difference anyone can ever make to anyone else and their families.
On days when you feel all your cylinders are clicking, it's a good feeling, and it's part of why we keep doing this job.
Sunday, January 8, 2017
In 2017, focus on what's important.
New year. Starting point for change. New reflections. Ditching old habits. Forming new ones.
I've spent a lot of time in the past year enriching myself. Career-wise I've made a solid effort to get to where I'm happy with moving forward, perhaps the first time in many years. Socially I've been making new friends and met very wonderful people, many of whom I still have to work harder at getting to know better. Personally I've kept myself active in once again as many sports and activities as I could muster. And for the past few months I've done a lot of reading regarding personal finances and investing, an area which I felt I was majorly weak and borderline ignorant on. All and all I kept my days filled and my calendar busting. All in an effort to grow myself, it seems.
But what's really important? What really counts? It's time to look back at within. My core values, my spirituality, my relationships. It's time to invest a little more back into myself and in the people around me. My family. My many new friends. My continued pursue to rediscover love, again.
It's time to relearn how to love. To be reborn and discover affections and romance on a new slate. As I sit here, waiting for my dearest friends to join me for an early birthday dinner to mark the occasion, I'm once again wondering, when will it happen again. Have I already found it and lost it, never to have it back again? Is it possible, that there can be different forms of it, equally impactful and perhaps even more intense but sustainable. How shall I open up to enable it to find me?
I know not to look, because it is something that is never found, only arrived. Maybe, with the new year of change, maybe I can rediscover the fire again. It's been too long. I might have forgotten how to start it. But may it come knocking with a might, and hit me when I'm not suspecting, and sweep me away.
Friday, December 30, 2016
Calling for empathy. At 3am.
4pm. Friday. Sunny afternoon in the last week of 2016.
I've finally settled into my comfortable desk, warm slippers and all, in recovering mode after my overnight shift. It's customary for me now to take a snooze a the hospital (about 45 minutes from where I live) after each night shift for fear of dozing off at the wheel on the drive home (almost happened a number of times). But that also eats into my post-night-shift free time. As I finished my work this morning at 9am (official off time was 8am but I'm used to staying an hour or two behind), I rolled into the springy squeaky hospital call room bed and snoozed unsoundly for about 4 hours. Then, feeling as if I'm utterly sick of the hospital by then, rolled out of bed to grab a light breakfast/lunch before driving home. It's usually late afternoon by the time I get to "catch up" on my life at home. Today, I felt the inspiration to restart my practice of blogging my random and impulsive thoughts (hopefully I can keep it up this time). Today the impulse was to write about empathy. Because after every night shift (or even after some quite testing day shifts), I felt I needed a kind reminder of how to be empathetic again as a doctor.
First off, it is intensely easy to lose empathy as a doctor, particularly with a role on the first line, such as myself as an Emergency Physician, as well as (my other hat), as a Family Physician. Your role as the first line of medical assessment means your time with each patient is diluted, because the key in your job is to push through high volumes of patients, efficiently, effectively, thoughtfully, and hopefully, caringly. Why is your empathy tested? It's easy to be empathetic to one or a few people. We all have kindness in us to give. But when you are seeing 20, 30, sometimes up to 40-50 patients a day (the former more in the ER, the latter sadly in the clinic), imagine listening to patients and patients' many questions and concerns, as well as often numerous complaints or expectations, while realizing you are well behind in the waiting times, and often when you are already utterly exhausted, usually more mentally but sometimes also physically. Last night, when I came on shift at 11pm, there were already about 20 people waiting to see me, many of whom have already been there over 2-3 hours waiting (the previous doctors were already working like maniacs to catch up, but holidays seasons has been often an haunting nightmare in the Emergency Rooms). Plus, usually around that time is a new flux of patient coming in to see the doctor, and I was the only doctor on staff from that point on all until 8 am the next morning. Heavy-hearted, knowing that all these patients are in for a long night along with me, scanning their sad desperate eyes hoping that I would call their name next, it is impossible not to want to rush to seem them all quickly. My friends know this. They know it's my nature not to relax until all my work is done. Seeing a waiting room like this literally eats me alive.
But it is this very notion to get through the list quickly that we, as doctors, must fight to resist. Because rushing though assessments put us at risk of mistakes and errors in judgement. And also, it eats into our empathy.
Some people are totally deserving of being in the Emergency Room. There is usually little difficulty in finding empathy for those people and their families. But many others do not seemingly seem they are in the right place for their concerns. And it is these patients, some of which have waited for hours just to get an question in for you, that you have to dig really hard to find empathy for. I try to remind myself, that if someone has waited 4 hours to see me, even if I truly believe they should not be there in the first place, they deserve at least a good few minutes of my undivided attention and care. More importantly, some of the hardest cases to deal with in the ER are patients to seemingly look well and have no right being in the ER, but yet actually presents with some pretty serious underlying condition that you better not miss and will only find if you are attentive enough. Finally, for both their benefit and mine, I think it is very important for patients to always end their encounters with their doctors on a good note. At the very least, even if I cannot immediately solve their problems (and this happens a lot in the ER), every patient should hopefully feel that they were listen to, that they had a small share of my time and attention, that their worries and their expectations and fears were voiced, and that, even if I have no direct solution, that I cared, and thought about how to help. It's like BayMax in Big Hero 6 (silly reference I know), hopefully they can all feel that they are satisfied with their care, no matter the outcome.
But it's not easily displaying all this, when you are mentally stretched to the limit with multiple things on your plates juggling numerous tasks and often overseeing a mixture of very sick patients to ones who don't seem they need any medical care at all. Those who work with me usually finds that I have a natural friendly and mild manner with patients. But those who know me have also seen me becoming blunt and short with patients when I am stressed. Especially at night, when the wait is long and the light at the end of the tunnel is far from reach, it's very easy becoming the latter. At times like these I try to remember something I learned from a preceptor who always seemed to be controlled and attentive in the most chaotic of environments. I remember asking him how he handed all the stress and distractions. He summarized his approach in one word, "mindfulness" (I actually wrote about this in a previous post I think but it's deserving of a repeated mention). In a zen-like appeal, he explained how he tries to practice mindfulness with each patient encounter, in that, during those brief moments with patients, he allows himself to ignore everything around him, and absorbs himself purely with that patient and his or her problems. It sounds easy, but its exceedingly difficult to achieve in a busy place such as the ED with many problems under your watch. But in those brief moments, I do believe he is able to almost find a little peace within him to reach further to each for each patient. It doesn't seem to take away from his decisiveness and efficiency, and I always remember him as a competent, effective, but very empathetic doctor.
It's easy to lose empathy for patients. It's easy to lose faith in people, when you see patients after patients, many of whom their names and characters get washed out among their medical complaints and symptoms. You start to forget they are people and not just names on charts, with families and loved ones and thoughts and worries and insights. You start focusing on the macro-management of the department, and lose sight of the micro-management of each person. I truly think this is one of the biggest challenge as a doctor. To both be an effective macro and micro-manager. To maintain a certain degree of care, in your voice and in your manners, even if you know truly well that you could care no more. But it's important, not entirely for you in that moment, but for the patient who has so much bottled inside them when they made the decision to come and sit through the hours of wait just to see you for their concerns.
Last night went by, thankfully, with somewhat smooth efficiency. I was mildly rattled by the end of my shift when I was pretty exhausted to have a fresh heart attack patient rolling in at 7:30am (I've not had a break since I started at 11pm, and towards the last hour of your shift is when you really hope nothing "bad" happens so you can quietly tuck into the "night" when your replacement arrives at 8). Thankfully, the nursing staff worked efficiently with me to help manage this patient effectively to get the care that he needed. I don't mind these cases honestly. They are why we have the department open 24 hours a day. I always tell patient never ever apologize for coming to the ER for chest pain. It's what we do and we do very well. Hopefully this man recovers well.
Long post. My apologizes from rambling on in my state of post-night-delirium. But hopefully I'll get in the habit of posting again soon. Mostly, if anything, just as a constant reminder to myself of how to be decent.
I've finally settled into my comfortable desk, warm slippers and all, in recovering mode after my overnight shift. It's customary for me now to take a snooze a the hospital (about 45 minutes from where I live) after each night shift for fear of dozing off at the wheel on the drive home (almost happened a number of times). But that also eats into my post-night-shift free time. As I finished my work this morning at 9am (official off time was 8am but I'm used to staying an hour or two behind), I rolled into the springy squeaky hospital call room bed and snoozed unsoundly for about 4 hours. Then, feeling as if I'm utterly sick of the hospital by then, rolled out of bed to grab a light breakfast/lunch before driving home. It's usually late afternoon by the time I get to "catch up" on my life at home. Today, I felt the inspiration to restart my practice of blogging my random and impulsive thoughts (hopefully I can keep it up this time). Today the impulse was to write about empathy. Because after every night shift (or even after some quite testing day shifts), I felt I needed a kind reminder of how to be empathetic again as a doctor.
First off, it is intensely easy to lose empathy as a doctor, particularly with a role on the first line, such as myself as an Emergency Physician, as well as (my other hat), as a Family Physician. Your role as the first line of medical assessment means your time with each patient is diluted, because the key in your job is to push through high volumes of patients, efficiently, effectively, thoughtfully, and hopefully, caringly. Why is your empathy tested? It's easy to be empathetic to one or a few people. We all have kindness in us to give. But when you are seeing 20, 30, sometimes up to 40-50 patients a day (the former more in the ER, the latter sadly in the clinic), imagine listening to patients and patients' many questions and concerns, as well as often numerous complaints or expectations, while realizing you are well behind in the waiting times, and often when you are already utterly exhausted, usually more mentally but sometimes also physically. Last night, when I came on shift at 11pm, there were already about 20 people waiting to see me, many of whom have already been there over 2-3 hours waiting (the previous doctors were already working like maniacs to catch up, but holidays seasons has been often an haunting nightmare in the Emergency Rooms). Plus, usually around that time is a new flux of patient coming in to see the doctor, and I was the only doctor on staff from that point on all until 8 am the next morning. Heavy-hearted, knowing that all these patients are in for a long night along with me, scanning their sad desperate eyes hoping that I would call their name next, it is impossible not to want to rush to seem them all quickly. My friends know this. They know it's my nature not to relax until all my work is done. Seeing a waiting room like this literally eats me alive.
But it is this very notion to get through the list quickly that we, as doctors, must fight to resist. Because rushing though assessments put us at risk of mistakes and errors in judgement. And also, it eats into our empathy.
Some people are totally deserving of being in the Emergency Room. There is usually little difficulty in finding empathy for those people and their families. But many others do not seemingly seem they are in the right place for their concerns. And it is these patients, some of which have waited for hours just to get an question in for you, that you have to dig really hard to find empathy for. I try to remind myself, that if someone has waited 4 hours to see me, even if I truly believe they should not be there in the first place, they deserve at least a good few minutes of my undivided attention and care. More importantly, some of the hardest cases to deal with in the ER are patients to seemingly look well and have no right being in the ER, but yet actually presents with some pretty serious underlying condition that you better not miss and will only find if you are attentive enough. Finally, for both their benefit and mine, I think it is very important for patients to always end their encounters with their doctors on a good note. At the very least, even if I cannot immediately solve their problems (and this happens a lot in the ER), every patient should hopefully feel that they were listen to, that they had a small share of my time and attention, that their worries and their expectations and fears were voiced, and that, even if I have no direct solution, that I cared, and thought about how to help. It's like BayMax in Big Hero 6 (silly reference I know), hopefully they can all feel that they are satisfied with their care, no matter the outcome.
But it's not easily displaying all this, when you are mentally stretched to the limit with multiple things on your plates juggling numerous tasks and often overseeing a mixture of very sick patients to ones who don't seem they need any medical care at all. Those who work with me usually finds that I have a natural friendly and mild manner with patients. But those who know me have also seen me becoming blunt and short with patients when I am stressed. Especially at night, when the wait is long and the light at the end of the tunnel is far from reach, it's very easy becoming the latter. At times like these I try to remember something I learned from a preceptor who always seemed to be controlled and attentive in the most chaotic of environments. I remember asking him how he handed all the stress and distractions. He summarized his approach in one word, "mindfulness" (I actually wrote about this in a previous post I think but it's deserving of a repeated mention). In a zen-like appeal, he explained how he tries to practice mindfulness with each patient encounter, in that, during those brief moments with patients, he allows himself to ignore everything around him, and absorbs himself purely with that patient and his or her problems. It sounds easy, but its exceedingly difficult to achieve in a busy place such as the ED with many problems under your watch. But in those brief moments, I do believe he is able to almost find a little peace within him to reach further to each for each patient. It doesn't seem to take away from his decisiveness and efficiency, and I always remember him as a competent, effective, but very empathetic doctor.
It's easy to lose empathy for patients. It's easy to lose faith in people, when you see patients after patients, many of whom their names and characters get washed out among their medical complaints and symptoms. You start to forget they are people and not just names on charts, with families and loved ones and thoughts and worries and insights. You start focusing on the macro-management of the department, and lose sight of the micro-management of each person. I truly think this is one of the biggest challenge as a doctor. To both be an effective macro and micro-manager. To maintain a certain degree of care, in your voice and in your manners, even if you know truly well that you could care no more. But it's important, not entirely for you in that moment, but for the patient who has so much bottled inside them when they made the decision to come and sit through the hours of wait just to see you for their concerns.
Last night went by, thankfully, with somewhat smooth efficiency. I was mildly rattled by the end of my shift when I was pretty exhausted to have a fresh heart attack patient rolling in at 7:30am (I've not had a break since I started at 11pm, and towards the last hour of your shift is when you really hope nothing "bad" happens so you can quietly tuck into the "night" when your replacement arrives at 8). Thankfully, the nursing staff worked efficiently with me to help manage this patient effectively to get the care that he needed. I don't mind these cases honestly. They are why we have the department open 24 hours a day. I always tell patient never ever apologize for coming to the ER for chest pain. It's what we do and we do very well. Hopefully this man recovers well.
Long post. My apologizes from rambling on in my state of post-night-delirium. But hopefully I'll get in the habit of posting again soon. Mostly, if anything, just as a constant reminder to myself of how to be decent.
Subscribe to:
Posts (Atom)
