“You need to have a rectal exam” you explain to one of your patients.
He’s a 47-year-old with chronic back pain who is in the ED for an
exacerbation of his pain accompanied by many of the associated
accoutrements, such as sciatica, numbness and trouble urinating.
“Do you know the four A’s of being a great emergency physician?” a
colleague asks. He just overheard you giving your “It’s a virus” lecture
to a twenty-something with a bad URI and no PMD to call her in a
useless prescription for Fogmentin or Maxiﬂoxicin.
“Hey, save some pizza for me!” your resident exclaims as he joins the
masses indulging in a late night treat from the ED administration. Over
the past few months, the department’s “door-to-doc” times and
“length-of-stay” times have improved enough to warrant a pizza party for
“I’m 0 for 2 tonight” your resident says after yet another exasperating
interaction with one of your institution’s feisty surgery residents.
“The first consult was called too early. The last one was called too
late!” Overhearing your conversation, the charge nurse walks over and
says, “Well Goldilocks, maybe this next consult with be just right…
The labs have all come back on a 38-year-old female who you suspected
had pyelonephritis. She had presented with 24 hours of flank pain and
fever but no vomiting, abdominal pain or dysuria. Her last menstrual
period was 2 weeks ago and she denies any possibility of pregnancy.
“Seeing is believing” you mutter as you shake your head in amazement.
You can’t believe your good luck tonight. You ordered a CT scan on a
patient with pleuritic right-sided chest pain looking for a pulmonary
embolism, and instead you found her leaking thoracic aortic aneurysm.
And then, your senior resident performed a bedside abdominal ultrasound
on a 40-year-old male with chronic back pain and discovered a 5 cm
abdominal aortic aneurysm.
A 21-year-old male bicyclist is brought to the ED, fully immobilized by
EMS, after being struck by a car at moderate speed. The patient was
found on the ground a few feet from the road with an obvious deformity
to his right lower extremity (RLE).
Your last patient of the evening is a 42-year-old veterinarian who
recently returned from a trip to Mexico where he injured the dorsum of
his right hand on a cactus spine. He states that he was able to remove
the entire spine and the site subsequently became infected.
“I can’t believe I missed that airway!” she says. “I haven’t had that
happen in years!” You reiterate how difficult the airway was, and you
compliment her on changing her approach between attempts. “You know, Richard Branson once said, ‘Opportunities are like buses…there’s always another one coming’
You breathe a small sigh of relief when your senior resident begins
presenting his next case to you. The patient is a 17-year-old G1P0 who
found out she was pregnant via a home pregnancy test last month. She presents to the ED
at 6 AM because she has been vomiting all night and can’t sleep.