#duke – CA Work Experience Program

Justin Weltz – Duke Grad Student

This morning, we met with Justin Weltz, a grad student at Duke about his research in Reinforcement Learning and Response Driven Sampling. However, something interesting is that he actually didn’t start out planning to go into computer science. He went into undergrad initially focusing on English/Political Science and decided to pursue more Statistics/Computer Science related ideas in his junior year. After making that decision, Justin applied to Duke grad school on a whim and wasn’t sure if he’d actually get in. Overall, Justin found that grad school was a good experience and much more self directed than high school or undergrad. While his first year had a lot of classes and work, his second year, when he began researching RDS with Dr. Laber, was much more research oriented and independent, without a set schedule.

Day 4 in the Emergency Department

Today I got to follow Dr. Best around for the day. Being a Sunday morning & afternoon, the ED was a bit slower than the previous shifts but I still got to experience a lot and had more time to talk to the doctors, residents, and PA student about their jobs, medical school, and more.

The day began with a meeting in the hallway including all the doctors and nurses, and then sign-out as usual. Dr. Best did rounds in the CEU (observation unit), including a patient he said came for the “Duke miracle,” which happens often, meaning someone comes from a more rural or smaller hospital thinking their inconclusive diagnosis or lack thereof is due to incompetency- but that’s just how medicine is sometimes.

One of the patients today was a familiar face who Dr. Best had seen for 15 years in the ED for alcohol and drug abuse. Today he came in for attempted overdose but was known for stealing and drinking the hand sanitizer outside each room in the ED because it is alcohol-based.

In resuscitation, there were multiple trauma patients. One was level 2, an older patient who fell while on blood thinners and broke 4 ribs. Nurses drew blood and stabilized his neck first. A level 3 patient was transferred from another hospital; he had been assaulted and had injuries to the head and face. A critically ill 92 year old was brought in by EMS for pneumonia, but her long list of medical history and problems made it more complicated. Later in the day EMS brought in someone with hypoxia likely brought on by drug use, as a PA student told me that opiods are respiratory repressors. The police actually had to come because illegal substances were found when getting the patient into his hospital gown.

Example of a chest x-ray showing pneumonia

https://www.med-ed.virginia.edu/courses/rad/cxr/pathology3chest.html

Night Shift 2/2

Today we hit the ground running once again! As soon as I got to DUH, the first patient of the day had intense pain and irritation/scratching from his contact lense, so Dr. Limkakeng examined his eye. Next was a patient who dislocated his shoulder for the third time. An xray was ordered and the patient actually popped his shoulder back in himself, making life for the PA just a bit easier. Dr. Limkakeng showed me the difference between the normal shoulder xray and the dislocated one, told me about how tendons become weakened/loosened/injured, and explained a few different methods of shoulder reduction. He secured the patient in an immobilizing sling to wear until he got a follow-up.

One of the more complicated patients of the day was a woman with congenitive heart failure who presented with low blood pressure and high potassium (hyperkalemia). With her left ventricle not functioning well, Dr. Limkakeng noticed water in the lungs (shortness of breath and heard in exam). He drew me a diagram showing me a simplified version of how IV fluid enters the blood to the heart and lungs and how too much IV fluid could actually be harmful to this patient even though it is a way of increasing blood pressure. The patient seemed to have acute kidney insufficiency and I think she was admitted to the hospital.

A cool learning moment was when Dr. Limkakeng was showing me an EKG and explaining parts of it. EKGs have a lot to do with action potentials and sodium-potassium pump, which are things I very recently learned about in Adv. Biology. Finally I kind of understood something! 🙂 I also got to see a translator in action, as one of the patients only spoke Spanish. The translator was very experienced and explained movements and a few details of the simple procedure without being directly asked. It was a bit more fluid than completely word-for-word.

Dr. Limkakeng also splinted a finger (smashed in a metal gate) and saw several other patients, but the most serious medical procedure of the day was suturing a wound. A patient had previously had plastic surgery and then fell into her dresser and split open her chest. Dr. Limkakeng and the PA student thoroughly irrigated it with water, injected a syringe full of pain medication, and used 2 deep dissolvable sutures and 10 external sutures to close up the wound.

Example of an x-ray of a dislocated shoulder

https://radiopaedia.org/articles/shoulder-dislocation

Example of an ECG

https://www.ndsu.edu/pubweb/~grier/1to12-lead-ECG-EKG.html

Day7

I am heartbroken to say that today is the last day I will be shadowing the doctors officially, for there is a fellow and resident graduation on Friday. However, today was one of my favorite days as Dr. Carlson brought in his homemade smoked wings to the office. My morning started with setting up the camera and the computer screens and shadowing Dr. Carlson. Today was somewhat of an easy day as there were not as many patients in the clinic, meaning we took long breaks during each patient. Dr. Carlson and I talked about sports and compared the college applications from more than 50 years ago to the current ones. I also congratulated him on the 38th anniversary of his first date with his wife. After meeting with about 15 patients, the entire Cornea group had lunch in the conference room eating Dr. Carlson’s wings, which were amazing. Then we went to the OR doctor’s resting room and handed out the chicken. Afterward, I was shadowing Janet again in Ocular Immunology Center. Today with Janet, I helped her set up special vision tests and watched her take out healing lens. I was sad that this was the last day for me at the clinic, and I am grateful to have this opportunity.

Day 6

Today, I spent the entire day at the Ocular Immunology Center, where there are more serve cases. The Cornea clinic would see patients that have cataracts, clouded capsules, fungus infections, and similar cases while the Ocular Immunology Center would see the more “gruesome” cases. Eyes that have previous damage or special conditions would get checked in the Ocular Immunology Center. The patient process is similar to almost the same as the Cornea’s process. First, the patient will check in at the front desk. Next, the patient will be checked up by a technician, then a fellow, and finally by Dr. Perez. After shadowing Dr. Perez for two patients, I wanted to follow a different technician around the hospital. Thus, I followed Janet for the rest of the day. Her job in the clinic was different from the other technicians as Janet would actually run around the hospital, getting prints and entering labs for results and cultures. I definitely was glad that I wore my tennis shoes because following her was not easy. I ended up in the OR to pick up cleaned instruments as the last job of the day. The experience at the Ocular Immunology Center was a completely different experience from the past week.

Day 5

I was at the Cornea Clinic today, and all day long, I was following a Cornea fellow. There was nothing out of the unusual today other than meeting with Dr. Kim later. During the day, the cornea fellow taught me how to set up the computer program which connected the camera to the screen. In some rooms, there are learning scopes attached to the lens and in some rooms a camera to the lens. So, when we are in rooms without the teaching scope, I connected the lens to the screen, allowing me to look into the eye besides the fellow. Interestingly, the older doctors such as Dr. Carlson do not know how to work the program; therefore, before the rotation starts, I would go into each room and set up the screens. I meet Dr. Terry Kim, the current head of Ophthalmology, in a conference room and learned about cataract surgery at the end of the day.

Roles in the ER

Doctors
- Attendings
- Residents
Nurses
Physician assistants
Physician assistant students
Medical school students
Interpreters (Spanish)
X-ray & other technologists
Pharmacists
Scribes
Consults
- Psychology
- Neurology
- Gastroenterology
- General medicine
- Oncology
  - Liquid tumor
  - Solid tumor
- Thoracic surgery
- Vascular surgery
- Internal medicine
- Radiology
- Hospitalists
- Neurosurgery
- Renal
- Orthopedics
- Ophthalmology
- Physical therapy and rehab
- Social workers
- Outpatient resouces
- Poison control (via phone)

Example of someone receiving an x-ray from an x-ray technician (I saw this process occur for a chest x-ray)

https://alis.alberta.ca/occinfo/occupations-in-alberta/occupation-profiles/combined-laboratory-and-x-ray-technologist/

Poison Control- a helpful resource for the ER

https://www.aapcc.org/

ED Observation: Daytime

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

Day 4

I love coming to the hospital now. I was afraid of the hospital at first because how intimidating it could be. But the team I am shadowing is so welcoming, and I can’t imagine another place to be. When patients ask me where they should go or who should they look for I can clearly answer them. If the doctors I work with forgot their masks or hats or the drops I know where to go to get them. I know which technician I should look for during specific times. The only disappointing part of this experience is that I cannot go to the OR. They placed a new policy that does not allow minors into the OR. Otherwise, I am learning the most out of this opportunity.

Legal Ramifications of Emergency Care

Dr. Limkakeng provided me with some questions to answer throughout my experience, and today, I decided to look into when an emergency department can refuse to care for a patient, when an emergency physician can transfer care to another physician, and learn about how EMTALA and HIPPA laws impact the daily functions of the emergency department.

EMTALA is the Emergency Treatment and Labor Act passed by Congress in 1986. For hospitals participating in Medicare (most hospitals in the United States do), the law outlines a patient’s right to emergency care regardless of their ability to pay for it. Without asking about insurance or payment, hospitals are required to provide stabilizing care: screening, emergency care, and appropriate transfers. It also explains that an emergency physician can transfer care when a patient has become stabilized, either on their own or because of a medical treatment. This is also where protocols like I mentioned in my previous post come into play. Of course, to avoid loopholes, EMTALA defines an emergency:

“a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”

This law has had a huge effect on the nation’s emergency care system, as direct costs for uncompensated care to physicians are in the billions of dollars. It has basically ended something commonly referred to as “patient dumping” where, for financial reasons, uninsured patients were transferred from private to public hospitals despite an unstable medical condition. It is important to note, however, that patients sometimes leave the ED against medical advice or refuse examination/treatment, in which case the medical record must contain a description of what was refused and secure the refusal in writing, including confirmation that the risks and benefits were explained.

Another important legislation is HIPPA: the Health Insurance Portability and Accountability Act of 1996. The HIPPA privacy rule establishes standards for protecting heath information, and the HIPPA security rule specifically addresses protecting health information held and transferred electronically. Obviously, technologies have vastly improved healthcare (more mobility, more efficiency, etc.), but they also cause more potential security risks. So, the electronic health records, radiology, pharmacy, laboratory systems, and more that I observed yesterday in the ED all fall under HIPPA laws. An example I observed last night: on two occasions, Dr. Limkakeng needed to take pictures of people’s feet/lower legs for electronic medical records so other doctors could view them, and he made sure to tell and show the patients how the images went straight to Haiku medical records (not saved on his phone).

Example of Epic electronic patient file

https://www.researchgate.net/figure/Example-user-interface-for-a-patient-record-in-Epics-EHR_fig2_318865889