Week 4: Method in the Madness

This week was primarily spent in the ER and given the short week with 4^th of July festivities and plans, it seemed like a good way to spend my time.  I walked in and despite looking the part of a doctor, it was clear I didn’t belong. I wandered around for a few minutes looking confused before someone finally came over asking if I was lost and needed help. I had entered the Emergency Department via the walk-in street entrance and my confused state as to where I should be going and what I should be doing must have caused a little alarm and given the impression that I was in need of medical attention. Anyway, someone was able to direct me to a back room where the residents commune in one of the ER sections where I spoke to the ER attending about the Immersion program and explained some of our goals. He quickly showed me around the different stations and explained the general progression of patient care: TriageàUrgent Careàmain ER (sections A, B, C).

My first stop was triage and the ER front desk in the patient waiting room. I spent a good bit of my time with a physician’s assistant in charge of minimizing the NYP door to provider time. Upon review, NYP had a 1 hour wait time for patients that would walk into the ER before they would even see a doctor. The PA I worked with met with patients as soon as they walked in the door asking them why they had come into the ER and what they were experiencing differently that had lead them to feel the need to come in. Then he would decide the urgency of the patient’s conditions. Depending on this initial assessment and what needed to be addressed, the patient would either go into triage or urgent care.

After spending an hour or so following a few mundane cases of back pain, dizziness, and nausea concerns, I figured it was time to graduate on to the main ER. When I first walked into the section A of the ER, I was surprised to find patients sitting on beds in the hallways while doctors and nurses maneuvered through what seemed like a maze of patients and medical equipment to get from one end to the other. Despite what seemed like a chaotic situation, there was surprisingly good organization of patient care and once you got a sense of the place, it was not too difficult to keep pace with everyone. I followed a few cases one of which involved a man walking through a construction zone and having a 2000 pound cement pole drop 10 ft and hit him in the back. The concern was that he had damaged his spine but a few x-rays later and it was determined the man was quite lucky. The pole had hit him in just the right spot that it had missed his spine and he only had a very large bruise. Another case I was able to follow involved a biker accident.

The girl had come in after being taken out on her bike when a car door opened and she went flying over the handle bars landing on her left shoulder. She was in considerable pain and the consensus was that she had likely simply dislocated her shoulder but the ER doctors were hesitant to try and pop the shoulder back into it’s socket on their own instead of have someone from orthopedics come down and without confirmation from x-rays that the shoulder was in fact just dislocated.  Despite the pain medication she was given, she was still in considerable pain and kept asking when someone would be able to pop her shoulder back into place. After a few hours, the x-rays taken were not sufficient to determine whether or not the shoulder was simply dislocated or if in fact there was a fracture so they needed to take another set. While having her arm positioned in multiple angles for the x-ray, there was a loud pop and the patient felt an immediate sense of relief.

The color that had originally been drained from her face was quickly coming back and we could all sense her relief. Although the resident physician following her case was happy to see his patient transition so quickly to a more comfortable state and that his initial diagnosis of shoulder dislocation was correct, it was clear regardless of the new x-ray results they had already decided they could not put the shoulder back in place themselves and would need to wait for someone from orthopedics had her shoulder not accidentally popped back into place on it’s own during the second set of x-rays. I learned that even within a medical team of certified doctors, there are still limitations and regulations as to what one can or can not do which if not followed could then result in a serious malpractice lawsuit.