ER Tales

My mind is still reeling from the more typical ER experience of yesterday. I started at noon and the steady flow of patients rolling in turned to more of a deluge around 5 or 6 pm. It was a constant onslaught until I managed to limp out a little after midnight, feeling sorry for my fellow ER doc who has the harrowing task of flying solo in the ER from midnight until 8 am. Why the limp, you ask? Well, it was more of a hunched shuffle than a true limp, secondary to attempting to run yesterday against gale-force winds and freezing my buns off followed by a 1.4 mile walk to the hospital against the same winds followed by 12 hours of running in circles in the ER. Now that's just bad math. The equation I would prefer would go something like this: long night sleep in own bed + thorough soak at Korean day spa + mind-altering massage + chilled bottle of Gewurztraminer waiting for me in fridge in Seattle = happy.

The ER is tough. Big surprise. I'm trying to remember all the patients I saw but there were so many they are all melding together. I admitted 2 patients: a 1 year old with an abscess and extensive cellulitis on her trunk with high fevers, dehydration; and a 70 year old woman with a venous stasis ulcer and cellulitis. Skin infections are king out here. Not like king salmon (which is also big), but a huge issue. The infections seem to spread faster and have more complications than the lower 48 variety. In addition to my admissions, I did a few other I and Ds (incision and drainage, which basically involves cutting open a pocket of pus to drain it). I will spare you the details but let's just say there was pus. And a lot of it.

We also had some medevac action. It's interesting to be on the receiving end of the medevac now. A 30 something year old woman was flown in from the village after an ATV accident (very popular out here). She succeeded in flaying open her entire R lower limb in a spiral wound that went from the lateral side of her thigh and continued around her knee to end near her ankle. Layers of muscle were splayed open and somehow the wound managed to spare major vasculature. She was taken to the OR by the head doc who found the wound was also a degloving type injury where the skin had been torn off the underlying layers. By the time they took stock of the extensive damage they were already elbows deep in the repair. She may have been better served in Anchorage but that's not clear. The repair took 4 hours.

The medevac also gifted to us a 7 year old with a nasty humerus fracture. My fellow ER doc said to me as she was about to put a complex splint on the arm (as instructed by the orthopod in Anchorage), "I'm about do something I've never done before." I though to myself, at least I'm not the only one!

The strangest and most unsettling aspect of my ER experience is that patients come in, I see them, I treat them for things, I diagnose them with things, and then they leave. And no one is checking up on me. My word goes. What, do they think I'm some sort of qualified doctor? It is very odd. The good news is that the other docs here seem to have the utmost confidence in me once they witness me in action a bit (Eggimann said he thought I rose to the wards challenge - high praise!). But just about everyone here thinks I'm a resident or medical student on first glance. I called a high risk OB consult about a patient in the ER yesterday and the doc, who I had been introduced to the day before said, "Oh. Dr. Cabou. You're the one that looks like you're 12, right?" Exactly.

Another challenge of ER care here in the YK delta is the difficulty in getting good follow up. If a patient needs to see a doctor in follow up, which happens frequently, they get discharged to the town hostel where they stay overnight and come back to clinic in the morning. But after that, unless they are much worse, they are headed back to their village. It is no big surprise that most of the patients I saw with chronic medical issues either ran out of their meds awhile ago, never really started taking their meds, or take their meds sporadically with a general lack of understanding on proper med administration.

One very cute 79 year old woman came in with a complaint of blood in her stools. She actually brought in her pill bottles which pleased me greatly. Until I realized that she had been reusing the bottles for years so the labels did not match the pills inside (which were not labeled themselves). It was a mess. After much chart digging, I discovered she has a diagnosis of ulcerative colitis and hasn't been taking the proper medications.

Not to say this is a unique problem out here. This is an issue, especially in a geriatric population, in the lower 48 and I assume the world over. Adding the element of plane travel to see a doctor puts the issue in even more of a spotlight here.

But the time is drawing nigh to gear up for another round of ER madness. I'm sure an exciting day awaits. If I can manage to walk through the wind currents to get there. At least it's still sunny. I hear snow is around the corner.