Emergency Medicine – CA Work Experience Program

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

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

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

Day 1 in the Duke University Hospital Emergency Department

(Most of) My Overnight Experience:

Dr. Limkakeng’s yellow pager rang, and after a brief conversation, he was off! I quickly followed, and we walked past a wall full of medical supplies into a nearby room. An elderly patient had come into the emergency room with cellulitis- a large infection in his jaw. He suffered a seizure for the first time, so Dr. Limkakeng decided to perform a lumbar puncture, or spinal tap, so that the patient’s spinal fluid could be tested for a variety of things such as meningitis. Before performing the procedure, Dr. Limkakeng and a resident explained the pros and cons of a lumbar puncture to the patient’s family members. Agreeing with Dr. Limkakeng’s suggestion, the patient’s wife signed a consent form and the resident got to work. She meticulously sterilized the patient’s back and inserted multiple needles, drawing CSF (cerebrospinal fluid) and containing it in test tubes for the lab. Afterwards, she kindly took the time to explain to me that the CSF would be tested for many things including white blood cell count, which could decipher whether the patient had meningitis.

Like the consent form signed by the first patient’s wife, protocol is very important in the emergency department. Dr. Limkakeng showed me various written guidelines outlining how patient care should be carried out based on certain criteria. For instance, he mentioned that deciding whether a patient should temporarily stay in the observation unit is based on protocol. Treatment of the second patient followed GI protocol, as the patient experienced bleeding. Dr. Limkakeng took into consideration the patient’s history of diverticulitis and diverticulosis, performed an exam, and ordered a CT scan.

The third patient’s treatment involved CT scans as well. She came in with a severe headache, so Dr. Limkakeng and the PA, Melissa discussed the possibility of subarachnoid hemorrhage and a lumbar puncture. Dr. Limkakeng said he was taught that CT scans are not sufficient to indicate SAH, but that there are studies being done on the topic. I found it amazing how even people who are so incredibly knowledgeable in their fields are still in the learning process. The patient’s symptoms quickly completely subsided, so she was discharged later in the night/morning.

That patient didn’t end up needing a consultant, but the next patient required a vascular surgery consultant for her feet. Due to her history of kidney disease and renal failure, combined with hypertension and diabetes, the tissue at the ends of her feet was blackened and fell under the threatened limb protocol. Dr. Limkakeng explained that the immune system attacks dead tissue, so it would likely have to be surgically removed. He also showed me the patient’s x-ray, pointing out the extreme calcification of the blood vessels in her feet. Blood vessels should not be dense like bones, so they should not be visible in x-rays, but hers were so hardened that we could see them quite clearly in the x-ray image.

Another patient across the hall had a similar issue. I asked Dr. Limkakeng if this was common, and he said it is actually rare, so it was simply a coincidence that there were two similar cases in the ED at the same time. Another patient had lower leg issues, though his were less severe. He suffered rashes, fungal infection, bacterial infection, and swelling. A nurse gave him a water pill to begin the healing process, and Dr. Limkakeng gave him further advice.

By 2:37 am, everyone in the Pod B computer area was surprised that there was no one left in the waiting room after a holiday weekend. However, there were still plenty of patients ready to be seen in different rooms. Next was a patient experiencing severe chest pain, and a CT scan was once again very important. The patient was given a contrast liquid to drink so that it would appear white in the CT scan image. Dr. Limkakeng showed me how there was black, showing air, where it should not have been, so thoracic surgery was consulted.

Three of the last patients of the shift showed how much substance use and social stressors impact patients. Dr. Limkakeng talked to me about how substance use greatly affects health directly and indirectly through decision-making. I also observed him navigating patients’ anxiety and stressful events going on in their lives, as it greatly affected their perception of how they felt physically. Overall, my first day observing Dr. Limkakeng in the DUH ED was incredible. The way he treated every single patient with the same utmost respect and kindness was amazing, and I was fascinated by his explanations of EKG’s, CT scans, diseases, how the ED functions, how he decided on his profession, and so much more. Thank you to the doctors, PAs, nurses, and others of the DUH ED for being so welcoming. I cannot wait to learn and experience more on Friday.

Apologies- no photography allowed inside the Emergency Department, and all dates are incorrect on purpose.

Example of a Brain CT Scan

https://en.wikipedia.org/wiki/File:Brain_CT_scan.jpg

Lumbar Puncture

https://curesearch.org/Lumbar-Puncture

Example of Calcification of Arteries

https://www.researchgate.net/figure/Vascular-calcification-of-the-hand-arteries-examined-by-roentgenography-at-a-voltage-of_fig1_266745119

My Last Shift of Observing in the ED

Today was quite bittersweet because it was my final day of shadowing in the DUH ED. I’ve had a really amazing time learning on-site and have never been so inspired. Big thanks to Dr. Natesan, Dr. Best, and especially Dr. Limkakeng for this opportunity!

I had the pleasure of following Dr. Natesan around today, and after the morning meeting and sign-out, she began with a patient in the CEU. Unfortunately the patient’s symptoms were brought on because she hadn’t been taking her medicine, as she couldn’t pay for it- yet another example of a social determinant of health (in this case finances). After the initial trip to the CEU was a patient who was a bit uncooperative, but Dr. Natesan handled it gracefully.

A great thing about this shift was that I got to shadow a medical student and resident as well. For instance, I went in with Alyssa (a fourth-year med student) first to get patient history and information that she relayed to the residents and attending. One of these patients was a woman in a lot of pain from osteoporosis, arthritis, and a torn tendon. She also received an xray to check for a hip fracture and an ultrasound of her aorta. Another patient who went through the sessions of questioning had intense pain in the lower left side. She already had an appendectomy years ago and ovarian torsion and ectopic pregnancy were ruled out, so this patient had everybody pretty stumped.

The next patient was unique because he spoke Mandarin Chinese and no English, so Dr. Natesan used a translator over the phone to communicate with him. He had blurry vision and headaches due to hypertension, so he likely needed his medications adjusted, but it was tough for him to call his primary care provider due to the language barrier. I was able to be helpful for a little while by using my Chinese in small talk and to go back and ask him if he had his doctor’s card or phone number.

One of the procedures I observed in resus was thoracentesis by Dr. Natesan and Dr. Al-Jarani. The patient had lung cancer and needed pleural fluid removed because it wasn’t letting her lung expand, making her short of breath. Before the procedure, Dr. Natesan showed me this video so I knew what was going on. Dr. Al-Jarani meticulously drained a whole liter of fluid, going over the rib to watch out for the neurovascular bundle under the rib.

The other patient in resus was brought in after she had a seizure. The patient’s medical history included HIV, and this was the first seizure she’d ever had. Right after having a CT scan to check for a brain bleed, while still in the CT scan room, she had another seizure. Many doctors and nurses were working together to insert an endotrachial tube and urinary catheter.

Afterwards, Dr. Natesan saw four more patients including someone with gastrointestinal pain. Another patient who presented with low heart rate had liver failure, and while he was in the ER, he received news that he could get a liver transplant that night! He and his wife were very happy to hear the news, which was so great to see.

Then, to end the shift, Dr. Natesan finished up with some notes and charts so I headed out a little bit early. I had a fantastic last day of shadowing and am so grateful for everyone who made this inspiring experience possible.

Endotracheal Intubation

https://medical-dictionary.thefreedictionary.com/endotracheal+intubation

Example of a translator phone at a hospital

https://ditchingsuburbia.com/blog/grr28-st-jude