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ER Daydreams
Change of Shift
ER Daydreams ER Daydreams Kenneth S Moore, MD
[Moore KS: ER daydreams. Ann Emerg Med July 1999;34:112113.]
Department of Emergency Medicine Pomona Valley Hospital Medical Center Pomona, CA Reprints not available from the author. Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0 47/1/98308
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In emergency medicine practice we are sometimes called upon to do things that we have never done before. I sometimes daydream about “What would I do if … ” I was confronted with an unknown situation, a critical moment requiring some kind of action. I found out one evening when I was suturing a patient’s finger, talking with her, making her comfortable while I was repairing the results of her home dishwashing accident. An emergency nurse came over to me to say that Labor & Delivery (L&D) had called to ask me to come up to do a C-section. “A what?” “A C-section,” she repeated. I stopped the suture work and headed to the Women’s Center wondering 2 things: (1) “Why are they calling me?” and (2) “How does one do a C-section?” The answer to the first question was obvious—no one else was there to do it. The answer to No. 2 was less easy. I’ve seen my own kids born by C-section but I’ve never done one myself, never even assisted on one. Must have missed that in medical school. While running up to L&D, I began to think that I have gone through this in my mind before. What to do if a lateterm pregnant lady ever came into the ED with a fatal injury and I had to deliver the baby. Large incision, midline, vertical, cosmetic result not important, just get the baby out fast. But now I was nervous, anxious, thinking quickly about how to do this surgery, a C-section, 2 patients at once, in the operating room, not my usual stomping ground—a very uncomfortable feeling. On arrival in the L&D suite I quickly learned that the Ob/Gyn was on his way. He had been called to come in within a reasonable time, but the baby took a rapid decline in condition and suddenly became bradycardic. The heart rate was 50 beats/min. The nurses and anesthesiologist decided to call “the emergency doctor” because
ANNALS OF EMERGENCY MEDICINE
34:1
JULY 1999
CHANGE OF SHIFT
something needed to be done quickly. As I was listening to this story, the nurses were gowning and gloving me. All eyes moved in my direction—including the patient, who turned her head on the operating table and looked at me with that “He’s here to save the day” look. The nurses moved me into position at the right side of the patient’s body—the surgeon’s side. Now I was really nervous. A moment later the anesthesiologist blurted out, “She’s ready.” I thought, “That’s the fastest anesthesia I’ve ever seen,” but I wondered if my perception of time had slowed down. Everything seemed to be in slow motion— except my pulse. “Who knows the most about how to do this?” I asked the nurses, hoping to find out who to lean on and get help from. “You do, doctor,” was the answer. I joked a little with the scrub nurse, “Where should I cut?” She silently pointed to the oval hole in the drape. No more time for joking, even a little, even to calm me down. The baby’s heart rate was slowing. It was time for me to do something. I took up the scalpel, took a deep breath, and cut into the skin making an incision a little shorter than the fenestration in the drape. “Where the hell is the Ob/Gyn?” I thought. I got into the subcutaneous tissue and asked the nurse for “Whatever they use to get through this layer of tissue.” She handed me a scissors. I tried to use them but couldn’t seem to cut through. Suddenly, while standing there, something changed. I realized right away when it happened. I felt a sudden confidence. There was no good reason for me to feel that way. But it was a confidence nurtured by years of ED experience. I had a feeling of never really having been here before, but of déjà vu. I’ve been here in my mind, I’ve thought about this before, I know what to do. “Give me the scalpel.” That’s the tool I wanted. And now, I was in command. I had control of the situation. I cut through the tissue with confidence. This baby has to come out now and I’m the only one here to do it. As the “emergency doctor,” you do what you have to do. I do what I have to do. Things went smoothly for a while until I cut into what I thought was the uterus. Expecting to see the baby’s head, I instead saw a Foley catheter staring up at me. “Damn, it’s the bladder.” I moved up to the uterus, cut; there’s the head. The body wouldn’t come out; the nurse pushed on the uterine fundus and out came the baby. I sent it off to the neonatal team for resuscitation— intubation, epinephrine, someone else’s responsibility. I looked down at my work. A few minutes after it had begun, I felt relief that it was over. Of course, that’s when the Ob/Gyn arrived. I assisted him with the closure. I finally left the
JULY 1999
34:1
ANNALS OF EMERGENCY MEDICINE
operating room to sit down to write a note. It felt really good to sit. I talked to the husband, told him that his wife was going to be fine, but that the baby was in trouble. He already knew about the baby. He seemed thankful and appreciative for my effort in helping. I returned to the ED completely drained of energy. Looking at the clock, I hoped my relief would show up early. I returned to the patient with the cut finger. She asked me how it went. “Fine,” I answered as I picked up where I had left off, the much more routine job of fixing her cut finger.
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ER Daydreams ER Daydreams Kenneth S Moore, MD
[Moore KS: ER daydreams. Ann Emerg Med July 1999;34:112113.]
Department of Emergency Medicine Pomona Valley Hospital Medical Center Pomona, CA Reprints not available from the author. Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0 47/1/98308
1 1 2
In emergency medicine practice we are sometimes called upon to do things that we have never done before. I sometimes daydream about “What would I do if … ” I was confronted with an unknown situation, a critical moment requiring some kind of action. I found out one evening when I was suturing a patient’s finger, talking with her, making her comfortable while I was repairing the results of her home dishwashing accident. An emergency nurse came over to me to say that Labor & Delivery (L&D) had called to ask me to come up to do a C-section. “A what?” “A C-section,” she repeated. I stopped the suture work and headed to the Women’s Center wondering 2 things: (1) “Why are they calling me?” and (2) “How does one do a C-section?” The answer to the first question was obvious—no one else was there to do it. The answer to No. 2 was less easy. I’ve seen my own kids born by C-section but I’ve never done one myself, never even assisted on one. Must have missed that in medical school. While running up to L&D, I began to think that I have gone through this in my mind before. What to do if a lateterm pregnant lady ever came into the ED with a fatal injury and I had to deliver the baby. Large incision, midline, vertical, cosmetic result not important, just get the baby out fast. But now I was nervous, anxious, thinking quickly about how to do this surgery, a C-section, 2 patients at once, in the operating room, not my usual stomping ground—a very uncomfortable feeling. On arrival in the L&D suite I quickly learned that the Ob/Gyn was on his way. He had been called to come in within a reasonable time, but the baby took a rapid decline in condition and suddenly became bradycardic. The heart rate was 50 beats/min. The nurses and anesthesiologist decided to call “the emergency doctor” because
ANNALS OF EMERGENCY MEDICINE
34:1
JULY 1999
CHANGE OF SHIFT
something needed to be done quickly. As I was listening to this story, the nurses were gowning and gloving me. All eyes moved in my direction—including the patient, who turned her head on the operating table and looked at me with that “He’s here to save the day” look. The nurses moved me into position at the right side of the patient’s body—the surgeon’s side. Now I was really nervous. A moment later the anesthesiologist blurted out, “She’s ready.” I thought, “That’s the fastest anesthesia I’ve ever seen,” but I wondered if my perception of time had slowed down. Everything seemed to be in slow motion— except my pulse. “Who knows the most about how to do this?” I asked the nurses, hoping to find out who to lean on and get help from. “You do, doctor,” was the answer. I joked a little with the scrub nurse, “Where should I cut?” She silently pointed to the oval hole in the drape. No more time for joking, even a little, even to calm me down. The baby’s heart rate was slowing. It was time for me to do something. I took up the scalpel, took a deep breath, and cut into the skin making an incision a little shorter than the fenestration in the drape. “Where the hell is the Ob/Gyn?” I thought. I got into the subcutaneous tissue and asked the nurse for “Whatever they use to get through this layer of tissue.” She handed me a scissors. I tried to use them but couldn’t seem to cut through. Suddenly, while standing there, something changed. I realized right away when it happened. I felt a sudden confidence. There was no good reason for me to feel that way. But it was a confidence nurtured by years of ED experience. I had a feeling of never really having been here before, but of déjà vu. I’ve been here in my mind, I’ve thought about this before, I know what to do. “Give me the scalpel.” That’s the tool I wanted. And now, I was in command. I had control of the situation. I cut through the tissue with confidence. This baby has to come out now and I’m the only one here to do it. As the “emergency doctor,” you do what you have to do. I do what I have to do. Things went smoothly for a while until I cut into what I thought was the uterus. Expecting to see the baby’s head, I instead saw a Foley catheter staring up at me. “Damn, it’s the bladder.” I moved up to the uterus, cut; there’s the head. The body wouldn’t come out; the nurse pushed on the uterine fundus and out came the baby. I sent it off to the neonatal team for resuscitation— intubation, epinephrine, someone else’s responsibility. I looked down at my work. A few minutes after it had begun, I felt relief that it was over. Of course, that’s when the Ob/Gyn arrived. I assisted him with the closure. I finally left the
JULY 1999
34:1
ANNALS OF EMERGENCY MEDICINE
operating room to sit down to write a note. It felt really good to sit. I talked to the husband, told him that his wife was going to be fine, but that the baby was in trouble. He already knew about the baby. He seemed thankful and appreciative for my effort in helping. I returned to the ED completely drained of energy. Looking at the clock, I hoped my relief would show up early. I returned to the patient with the cut finger. She asked me how it went. “Fine,” I answered as I picked up where I had left off, the much more routine job of fixing her cut finger.
1 1 3