Settling In

My first month of residency is almost over - three more ER shifts and I will be done! It has been a long month, but I think I have actually made some progress in figuring out how to be a doctor. The variety of cases and conditions I've seen is incredible. Even if two patients have the same condition, the presentation can be completely different, and thus the treatment will also be different.

For example a few nights ago I saw a middle-aged woman with acute chest pain radiating to her neck and jaw with nausea and sweating relieved by a nitroglycerin tablet under her tongue - the typical description of a heart attack. However, she had had a full cardiac work-up recently revealing no atherosclerosis or blockage of her coronary arteries. She likely has a condition called Prinzmetal angina, where there is spasming of the arteries leading to ischemia (decreased blood flow and oxygen) to the heart. A cardiac catheterization or bypass surgery won't fix her problem since it is not an issue of stopped up plumbing. Last night, a 50-year-old man came in with the same presentation. Although he had no past medical history suggesting heart disease, he did have a strong family history. After following his cardiac enzymes for a couple of hours, he did turn out to be having a heart attack. So he gets to go for a catheterization to look for and hopefully correct blocked arteries. So how do you know if someone's chest pain is caused by a heart attack? Fortunately, there is a standard set of labs and tests that get done on any patient with suspected myocardial infarction. So that takes some of the guesswork out of it.

In the past week, I have been able to do a lot of small procedures - particularly, draining abscesses and suturing lacerations. I've sewn up faces, fingers, arms, scalps, even an eyelid. I must admit that last one made me really nervous. It wasn't right over the eyeball, but pretty close. But I managed to do a pretty good job - hope it heals well without a bad scar! Generally suturing is not too bad - I'm always a little nervous about getting the wound to come together properly, but at least you can numb people up well enough that they don't feel anything. Abscesses are different. No matter how much lidocaine you use, the patient always feels some pain. They are just so tender and tense under the pressure of the abscess, and the lidocaine just doesn't penetrate into the underlying tissue well enough to make the entire operation painless. I'm still not entirely comfortable cutting people open with a scalpel. But that's not the worst part. You have to go into the abscess and break up the pockets so all the fluid can drain out. That is almost always very uncomfortable for the patient. It always makes me feel so bad to hurt them, even though I know in the long run it is for their good and will facilitate healing of the infection. Anyway, with all the practice I've had this past week, I'm beginning to at least feel more confident about my skills and more at home with a needle and scalpel in my hand.

More than anything, I love interacting with my patients. It is so gratifying to feel like I am able to help patients when they are most scared and vulnerable - reassuring them when appropriate and explaining what tests we're doing and what the results mean, educating them about how to take care of themselves when they go home, answering their questions...I think there are many patients who come to the ER just to have someone listen to their problems and "take care" of them. We have a lot of "frequent flyers" who come for every little ache and pain. Maybe some of them come because they want refills of their pain medications (narcotics). But I think some are just lonely and depressed, and perhaps their problems are more psychosocial with the pain being either a secondary issue that exacerbates or is exacerbated by their emotional issues, or a direct result of psychological problems (somatization). I admire how some of the ER docs handle these cases with compassion and patience, without doing unnecessary tests or giving out unwarranted narcotic pain medicine.

Bottom line: I have a lot to learn about doctoring - the medical part and the interpersonal part. I'm sure you will get tired of hearing that, but I think it will be a major theme for me in the next year or two. Keep praying for me and stay in touch.