Sunday, April 1, 2012

Emergency Medicine (Feb. 6 - 17)

It has been a long time since I have blogged, and I am sorry for my readers that follow and have been waiting in anticipation for the next installment of my great epic tale of my adventures abroad. Now I am writing this weeks after the fact sitting and enjoying US comforts with my friends and family. India was such a mix of experiences - there were times when I really loved it and at least an equal number of times where I really hated it. Overall, it was a great learning experience and I came away with a lot of amazing new friends. It was difficult to blog while there for several reasons: 1 - bad internet connectivity (it's difficult to get connected and when you are, the connection is not always great) 2 - social life (this was a good reason for not blogging - I was busy spending time with my new friends instead of sitting in front of my computer writing) 3 - it's difficult to write about a difficult situation when you are in the middle of it. So - this is why it has been nearly 2 months since my last post and I will do my best now to catch you up on what happened in India.

My second two weeks at St. John's I spent in the Emergency Medicine Department. The ED is a busy place that sees a whole range of complaints a day including trauma. I saw a lot of things in the ED that I had never seen before and are uncommon in the US including 2 patients with snake bites, tuberculosis of nearly every region of the body, fulminant hepatic failure resulting from a hepatitis A infection, a patient with unretractable seizures, and a pregnant woman with previously undiagnosed rheumatic heart disease. I also saw things that I have seen or will see in the US although I think the approach to the care of these patients is very different on the opposite ends of the world.

The emergency department was a great learning experience for me. Out of all of my rotations at St. John's, it is probably the place where I was able to do the most as a medical student. Since the ED was busy and oftentimes the staff and residents had their hands full with patients which meant that I was able to do more to help out. This mainly came in the form of placing patients on heart rate/blood pressure/O2 saturation monitors and periodically checking on them to make sure that they remained stable. The emergency department had fairly new monitoring equipment which is great except for the fact that a lot of the staff did not know how to or were comfortable using these monitors. For stable patients, this wasn't really a big deal. Unfortunately, this was a very scary situation for patients that were unstable including the many trauma patients that came through the ED. Kim (one of the German medical students who was in the ED with me during my first week) and I took it upon ourselves to hook these patients up to monitors and to watch them and alert the staff if the patients' vital signs took a turn for the worst. In addition to keeping track of patient vital signs, I was also allowed to help with some minor procedures - the highlight of which occurred on my birthday when I got to suture a scalp laceration.

The emergency department was also the place where I saw three of the worst things I have ever seen in my life. These three experiences are probably the main reason why I stopped blogging when I did and are also part of the reason that I have made the decision to specialize in Emergency Medicine when I finish medical school. The first of these experiences occurred on my first day in the emergency department. At least in our area of Bangalore, burn patients are brought to the ED. I'm not sure if specialty burn centers exist, but if they do, not all patients are brought to them. This patient had extensive superficial and deep second degree thermal burns on his face, upper body, and arms from a gasoline fire that occurred at his place of work. Since burn patients are brought to burn units in the US, I had never seen a burn patient before. The burns themselves looked painful and uncomfortable, but the worst part was not just looking at the patient. The worst part came when one of the ED residents took the patient back to the minor operating theatre in the ED and started to peel the blistered skin off of the patient's body before administering any pain medication. These are the first screams that have haunted my thoughts since. Kim and I asked and soon after begged the emergency resident to wait until the patient had adequate pain control before continuing but we were ignored. The resident told us that he "didn't have time" to wait for the patient to receive pain medication. Lesson #1: the most important things at the hospital in decreasing order of importance are COST, then EFFICIENCY, then the patient. Until that point, that was the worst thing I had ever seen.

In between my first and second weeks in the emergency department, I decided I needed to get out of the Annex I since it was my birthday and I refused to spend the night of my birthday in with the cockroaches. I booked myself a room at a nice hotel in Bangalore with a pool and a fitness center and a free continental breakfast buffet. The night of my birthday after having a great day in the ED after suturing up a scalp, I went out to dinner at The Chocolate Room with my German friends that were still in town for the weekend. Several of my German friends had headed to Goa for the weekend the day before so it was a small group to celebrate my birthday. We had a delicious dinner and it was a great continuation of my birthday until about 10 minutes before I had arranged for a taxi to pick me up from St. John's and take me to my hotel. I received a text message saying that due to some technical error, my taxi would not be coming to pick me up. Irate - because this is so typical India - I started to cry and complaining about all of the infuriating things about India. Thankfully, one of our Indian friends Mahesh - a psychiatrist at St. John's that I really believe may have magical Indian powers - called someone he knew and taxi was there in 30 minutes to take me to my hotel. Along the way to the hotel, Mahesh kept calling to driver to check on my progress and to make sure that I made it to the hotel okay. Once I arrived, I was given a fresh juice and my things were brought up to my room. Soon after settling in, I received a phone call from the front desk wishing me a happy birthday. They asked if I liked wine, and if so, could they bring me a bottle in honor of my birthday, complimentary from the hotel? Of course I said yes. After the taxi fiasco, it was a great way to end the night of my birthday. The weekend was exactly what I wanted it to be - I was able to work out in the fitness center, swim, eat some good food, sleep in a clean and comfortable bed and returned to check into the Annex 3 on Sunday totally recharged.

My second week in the emergency department brought the second and third worst things I have ever seen with each one being worse than the first worst thing I ever saw in my first week in the emergency department. The second worse thing I ever saw was a trauma patient - he had been hit by a truck and when I saw him in the ED, I saw the entire anatomy of the bottom 2/3 of his right leg. His knee was completely disarticulated and he had an open tibia/fibula fracture near his ankle. The muscle and bone were exposed. Miraculously, his vasculature to his foot was still intact so it looked like the patient had a chance to keep his leg despite the severity of his injuries. Like the burn patient, it wasn't the injury itself that made this the new WORST thing I have ever seen. No, it was the treatment that made this the new worst. The same resident that had managed the burn patient was in charge of this trauma patient and with no regard for patient comfort, the resident began washing out this huge open wound with saline in the emergency department before the patient had received adequate pain medication. The patient had received some, but it was clearly not enough as again the patient was screaming with the aggressive washing out that this oblivious resident was doing. At least this patient was in the main emergency ward room and so the senior consultants stopped him and made him wait for more pain medication before continuing. After washing out the wound, the resident was going to change the dressings underneath the patient's injured leg. If I had not stopped him, he would have lifted the leg (which was in three separate pieces - above the knee, the knee to the distal tib/fib fracture, and the foot/ankle) by himself holding the foot and the thigh and leaving the middle piece free. The middle piece with sharp broken bone fragments and a tenuous blood supply that was barely palpable left free to move about. I actually yelled at the resident at this point and directed him to lift holding the foot and the distal end of the middle piece while I held the proximal part of the middle piece and the thigh and counted to lift and to set the leg down. It took 4 hours from this patient's arrival in the emergency department for him to be taken up to the orthopedic ward. And I'm not sure how long after that he was able to go to surgery. The following day I switched to the afternoon shift to avoid working with this resident and to try and give myself a little break from seeing the WORST things I had ever seen.

The third worst thing I had ever seen which definitely tops the charts in WORST things actually didn't happen with my least favorite resident in the emergency department. This was another trauma patient who had been crossing the street when she was hit by a car and the car drove off. She was brought to the emergency department unconscious and bleeding from her chest. The emergency department was very busy that day and I became involved in her care when I noticed that someone had put the person that brought her into the hospital in charge of bag ventilating her. There are no ventilators in the emergency department so since she was intubated and not immediately brought to surgery or to an ICU, she had to be manually ventilated in the emergency department. I will never forget seeing the man's face who was put in charge of her breathing. He looked scared - I saw his mouth move - one, two, three - then his hand squeezed the bag - one, two, three, squeeze. I went over to him and told him that I could take over. Relieved, he handed over the bag and so began my 1.5 hours of breathing for this patient. As I breathed for her, I watched her shaky vitals signs. I watched her saturation levels drop to the 70s% and watched as I told the consultants and nothing happened. I watched her heart rate rising then falling. I watched her blood pressure start to fall. I watched the jar attached to the chest tube fill up with the blood draining out of her chest. I told the consultants and nothing happened. I went with the patient to have a CT scan of her head and her chest and stood with a falling apart lead apron covering me and no protection for my thyroid and continued to breathe for her. Finally, 1.5 hours later, the head of the department of emergency became aware of this patient and her tenuous status and brought her to the emergency ICU where she was finally attached to a mechanical ventilator. Her hemoglobin was finally measured - it was down to 2.9 from all the bleeding from her chest. The cardiothoracic surgeon was called. There is only one at St. John's and he was in surgery and he is the only person who can open up a chest and stop a bleeding pulmonary artery. Even though she and her family had the money to pay for the surgery, she couldn't have the surgery she needed to save her life. So my patient, a young woman who just moved to Bangalore for a new job, the woman I breathed for for 1.5 hours, bled out of her chest and died that afternoon. That was the worst thing I have ever seen.

Location:Bangalore, India

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