Cardio: It's Not Just Physical Torture Anymore

Another block down, another blog post. I think this is how it's going to go from now on. But what a block it's been. Holy crap. Cardio has been a whirlwind of drugs and pathology, but the best part of cardio is the clinical experience. We had the chance to do patient simulators, both with live standardized patients and mannequins, as well as shadow real doctors in a clinical setting. With every physical examination and patient history I gather, the reality starts sinking in. In other words,  shit is getting real, folks! I'm going to be a doctor!

One of the most eye-opening experiences so far has been shadowing an ER doc at SFGH. When I found out I had been placed in the Emergency Department for my preceptorship, I was super disappointed. I wanted something in primary care, something administrative maybe, something that was low stress and chill. My classmates were unsympathetic. As one friend put it, "Some people would kill for your spot." OK, fine. No more complaining. Still, images of amputated limbs, gunshot wounds, and traumatic head injuries flashed through my mind. While these cases may make other medical students tremble with glee, frankly, I'd much rather be filling out paperwork or constructing an immaculate excel document.  Luckily, my first day was relatively gore-free.

When I headed into the ED with my preceptor, he joked that others called him a "black cloud". Whenever he came in for a shift...bad things happened. His reputation definitely held that day, as back to back traumas soon began to flood the emergency wards. There were three cases I witnessed that stood out to me the most.

1.) A little old Asian woman was brought into the ED by her husband. He had come back from an errand to find her at home, half of her face drooping. He rushed her to the hospital, where doctors, fearing the worse, whisked her off to get a CT scan in case it was a stroke. However, the scans came back clear. In the end, it turned out to be Bell's Palsy, a relatively non-life threatening form of facial paralysis caused by inflammation of the facial nerve.

What stuck out to me in this case was the language barrier the patient faced and how it negatively impacted her care. As she was wheeled in, the ED had already called an over-the-phone translator. When asked what language they spoke, the husband repeatedly replied "Chinese". "Yes sir, Cantonese or Mandarin?" "Chinese." Going off statistics, the resident dialed for a Cantonese translator. As we listened to the dial tone and waited for a translator to come on the line, the resident asked the woman to do a few diagnostic tests, mostly directing the patient with slow/loud English and exaggerated movements.  Just as the translator comes on the line, another Cantonese translator walks through the door with the husband. We hang up on the over the phone translator. The in-person translator starts interrogating the husband for details. If you've never heard Cantonese in person before, it sounds very aggressive. "Thank you for these flowers, they're simply delightful!" sounds like "I'M GOING TO DISEMBOWEL YOUR FAMILY." The ED is already a very loud environment, but the room was soon filled with the sounds of the translator alternating between yelling at the husband and yelling at the wife. After about 5 minutes of yelling, the translator reveals that the patient and her husband actually speak Toisan, not Cantonese.

As in any cases that involve elderly Asian patients, I am reminded of my parents and grandparents. I imagined my Mom sitting in that ED, bewildered and confused, not knowing what the doctors wanted from her while they manhandled her and spoke to her in a foreign language. I thought about what would have happened if the patient was actually suffering from a stroke. What consequences could those precious wasted seconds have caused?

I want to emphasize here that the ED docs did everything right. They were patient, they did the best to ensure patient understanding and consent. They were respectful to the patient, even though they were visibly frustrated by the language barrier. But what can you do when the patient is unable to give you the information that you need to give them the best treatment possible?

2.) When the ED is overcome with traumas, it is often the patients presenting with low-urgency needs that suffer. One patient had come in after suffering a serious work injury on the job. He had waited hours to be seen and in that time did not receive any pain medications. When he was finally escorted to a room, he was again asked to wait. While he waited, he asked for a blanket because the room was cold. The nurse nodded, but never came back. After a while, he complained to another nurse that he had been waiting for hours and asked when the doctor would be by to see him. This nurse replied, "This is a free hospital. You're going to have to wait."

This is an extremely offensive statement for several reasons. SFGH is not a free hospital, but it is a public hospital. This means that doctors are obligated to provide care to any patients that need it, regardless of their ability to pay. By saying this, the nurse is making an assumption that the patient is unable to afford care. This turns out not to be the case, as the patient angrily informed us that his employers are footing the bill. Offended and in pain, this patient eventually stormed out of the ED to seek care at Kaiser instead, where he has always been treated respectfully and promptly. Before the patient left, my preceptor assured him that they would file a report about what the nurse had said. "That's not how we operate here," he told me later, "I'm very disappointed that this happened to him."

Rudeness aside, long wait times are unavoidable at the ED. As you walk into the ED, the first thing you notice are dozens of patients in beds lined up against the walls in the corridor. These are for patients who need to be observed but aren't in need of urgent care. This way, doctors can keep an eye on them as they walk around. The ED has to wait until rooms open up in the wards above (internal medicine, OBGYN, etc.) before they can transfer patients over, opening up room for other patients who are still in the waiting room. So patients get mad at the ED staff about long wait times, when in fact, the ED has no control over how long it takes for patients to be seen.

3.) At UCSF, we first years are coddled. In all our sample cases, patients survive and go on to live blissful and fulfilling lives. (I've heard that they wean us off these idealized cases starting in second year.) Of course, with my luck, I witness a death on my FIRST day in the ER.

I'm in the CT room waiting for patient #1 to get her scan when my temporary Momma Duck (the provider I was currently following around) gets a code. He looks at me, "This one should be fun. Come with me."  We race back to the ED and on the way we see four policemen running in the same direction. "Uhh, Curt, are you sure we want to head in the same direction as the cops?" He just grins at me and keeps running. (It turns out the cops are heading to the same place, but for an unrelated case.) We get to the empty trauma room. I quickly find a vacated corner tucker behind Curt and try to make myself as unobtrusive as possible. Soon, a unresponsive patient is wheeled into the room and hoisted onto the bed. He has already been intubated and the team immediately commences CPR.

Everything that you've seen on television is a lie. There is no beeping sound of the ECG. The room is eerily calm, the only sound you hear is the huffs of exertion as compressions are given. Every once in a while, my preceptor would pause CPR to see if the patient's heart would start spontaneously.

"Do we have a pulse?"
"I feel a pulse!"
"OK, the pulse is weak."
"I don't feel a pulse."
"Let's do some more compressions."

This lasted for about 40 minutes, during which time they must have given epinephrine at least six times. They tried to defibrillate the patient twice but to no avail. Finally, my preceptor surveyed the room, "Does anyone have any objections to calling this?" The room is silent. "Time of Death, 17:42"

There was no dramatic sound of the ECG flatlining. There were no grieving family members waiting outside. We held a moment of silence for this stranger who came into our lives so turbulently and left so anticlimactically.

Afterwards,  the patient's family was contacted by a social worker. My preceptor and I decided it would be inappropriate for me to shadow the resident as she delivered the news. It turns out that the patient had just gone out that day to run a few errands and never came back. While he had collapsed in the middle of the sidewalk and was rushed to the ER, as strangers did their best to restart his heart, his family was sitting at home, going on with their lives, none the wiser. In fact, they would not know about his passing until over half an hour after it had occurred. This is inconceivable to me.

I made sure to give my parents a call that night as I left the ER.




I definitely feel very blessed now that I have been given the opportunity to shadow in the ER. It's not about seeing gory cases or cool medical abnormalities -- it's about seeing what real doctors do every day to serve those who need it the most despite tremendous limitations. It's the humanizing of a practice that is known for fostering God complexes.

I know I kind of just verbal diarrhea-ed all over this blog, but my brain is still recovering from that last Cardio test. There are still several experiences I want to blog about and hopefully I'll get the chance when my family and I get back from our Death Valley/So-Cal road trip!