Day 2 of shadowing Dr. Limkakeng in the DUH Emergency Department began with “check out,” where doctors and physician assistants from the previous shift shared information about the patients that would carry over into the next shift. Dr. Limkakeng then got started with the observation unit, where he checked in on a patient suffering a Sickle Cell Disease pain crisis and admitted two patients into the hospital: a woman with a severely infected insect bite and a 90-year-old patient who was still in bad shape after a stroke.
Then Dr. Limkakeng took me to see the psychiatric ward of the Emergency Department. To run it, there is a whole psych team with doctors, a PA, nurse, and pharmacist along with security personnel. Everything is bolted to the ground to prevent suicidal patients from harming themselves, and there are plenty of cameras throughout. Some patients can spend up to days in the psych ward. Today the ED ran into a bit of a dilemma due to a bed shortage in not only DUH but in North Carolina in general. This was made even worse by the fact that the psych ward was undergoing a short-term construction project. There were many psych patients taking up ED beds, and many patients that needed to be admitted taking up ED beds with no beds for them to be admitted to in other departments. Therefore, the waiting room was building up too, and the hospital started diversion for a few hours. However, I still got to follow Dr. Limkakeng around as he saw many patients nonetheless.
The next patient was understandably very concerned by the fact that she could barely move/lift her arms. She also had a high white blood count (an indicator of infection), so an emergent MRI was ordered due to the possibility of pressure on the spine. However, Dr. Limkakeng showed me the MRI and how it didn’t seem to show any abnormalities around the spinal cord and CSF. The MRI was taken from multiple angles so results could be seen more clearly.
Another patient came from EMS during the night. He had consumed a lot of pills, but his symptoms had mostly subsided besides diplopia (double vision), so he mainly just needed a psych exam. Next was a patient with septic shock and hypotension. Dr. Limkakeng is doing research through a clinical study directly comparing more fluids and more medication as treatments for hypotension. The patient had a history of drops in blood pressure, so Dr. Limkakeng got him enrolled for if it became low enough for the study. Treatment is the main priority of course, but the randomized treatment that the patient would end up with would be fluid bolus.
While still in the resuscitation part of the ED (called “resus”) where the hypotension patient was, I was able to observe a patient with ventricle tachycardia. The hallway was cleared and all the doctors and nurses were very serious in preparation for his arrival, but when the patient came, he was not in cardiac arrest. Despite ventricle tachycardia he was not even experiencing chest pain! Everyone was quite relieved, but they still monitored him, asked questions, gave warnings, and drew blood.
After that was a woman who was discharged, but an appointment was made for a stress echo cardiogram to try to find the root cause of her worsening chest pain. Next door was a man with asymptomatic bradycardia, or low heart rate. He was also discharged and would later call his cardiologist. Later, a patient came in due to cachexia. He was sadly experiencing failure to thrive (weight loss, weakness, not eating) due to esophageal cancer, and while he wasn’t able to get a treatment in the ER, he was at least able to consume some saltines and peanut butter.
The next patient had what Dr. Limkakeng and his colleagues presumed to be some sort of food poisoning because of the acute nature of the symptoms. He was given a medicine to coat his stomach in pepsin, and Dr. Limkakeng decided to treat him symptomatically. One of the last patients had mild hypoxia, meaning there was not enough oxygen in her body tissue. In this case, it was due to Leukemia (already diagnosed before ED visit), so the liquid tumor specialists of oncology were consulted. Finally, as the shift ended, Dr. Limkakeng decided to send a lung cancer patient to resus because of their tumor, hypoxia, high white blood cell count, low sodium and high calcium. Sadly I had to leave at 3:30, but Dr. Limkakeng was going to do a pelvic exam on a patient as I left. He also never took a lunch break! Unsurprisingly, I left the ED feeling thankful, inspired, and ready for more shadowing next time.
Average wait times at DUH ED according to ProPublica
https://projects.propublica.org/emergency/hospital/340030
Example of an MRI showing the spinal cord and multiple views
https://www.ucl.ac.uk/healthcare-engineering/events/2019/jan/spinal-cord-mri-workshop