A new documentary was released in 2012 called "The Waiting Room" depicting life in the emergency department at Highland Hospital in Oakland. While I wasn't on the set at the time of the filming, I came afterward to experience the waiting room live for my emergency medicine rotation. I haven't seen "The Waiting Room" yet, but from its trailor, Highland is made out to depict the modern state of health care for the underserved. Meaning this group of impoverished beings must secure all their health care needs -- from dental work to cancer screening -- at the emergency department. Not the ideal place for treating chronic conditions.
As its name implies, the emergency department is meant to treat emergencies. But that's not the reality of emergency medicine -- at least from what I saw during my 4 weeks there. Sure I saw gunshot victims, knife wounds, and pneumonias, but for the most part, I saw more chronic pathologies manifested into a state of personal torture for the eventual triaged patient.
Here were a sampling of my cases:
1. 59 y/o Chinese F with PMHx of hysterectomy presenting with over a year of weight loss, abdominal distention, fullness, early satiety, bloating, and pelvic suprapubic pain. Pt recently visited China, where a CT showed a unilateral ovarian mass. Pt put off seeking medical help for 3 months after returning from China because she was scared. Outcome: Unknown. This is a chronic condition, so we referred the patient to the OB/Gyn clinic at Highland. This was likely ovarian cancer.
2. 64 y/o Arabic-speaking female with PMHx of chronic back pain presented with near-syncopal episode. She was getting up from couch, saw stars, got lightheaded, then caught herself on couch. Afterward, she felt tachycardic and SOB. I was scared this woman had a TIA, even though she didn't c/o any weakness, etc. EKG was normal. Essentially, this was a case of lightheadedness but described in other terms, which threw me. I wanted to do a CT scan because the woman was stilll c/o of headache. But my attending said to look at the sequence of events, which was important. We pretty much ruled out cardiac cause, so yeah, this came down to case of dizziness, likely from orthostatic hypotension. OH occurs in the elderly, due to a pooling of blood in the legs and a decreased cardiac output in response. There's usually an underlying etiology like hypovolemia, drugs, or other diseases because the baroreceptors should kick in to compensate for decreased CO. How to dx? Systolic BP decreases by 20 or diastolic BP drops by 10 mmHg from supine to standing position.
3. 28 y/o M with PMHx of diabetes and frequent ED visits for gastroparesis presents with unrelenting vomiting and stomach pain x several days. He's been waiting for gastric pacemaker at UCSF, but unable to be put on list. His chart listed him as drug-seeking in the past, although he didn't ask for any opioids at the time. We referred him to GI, and he's still on wait for gastric pacemaker. I saw him return twice for same complaint during my visit in ED.
4. Multiple vaginal bleeding -- pregnant and not. One of the women (black female) saw some spotting when she wiped. And she was just scared in general from pain in abdomen. Pelvic exam showed closed cervix and b-HCG was positive. She was referred to OB outpatient. The other woman was older (52) with dysmenorragia and hx of fibroids. We deferred pelvic exam and referred to outpatient OB with high suspicion for fibroid flare.
5. 32 y/o M with pleuritic like CP after lifting rock from neighbor's yard, hemoptysis, and myalgias/chills. Chest Xray positive for Pneumonia. Did case report on this patient. He was admitted for CAP, although he should have be treated as outpatient based on his PSI and Curb-65 scores.
6. Stitched up a woman's hand s/p knife fight with "baby daddy." We had to do 2 nerve blocks -- median and ulnar -- plus lidocaine injection. Learned that after nerve blocks, it's just as effective to run hand under warm water as it is to perform saline flush. Gave 9 stitches to hand, and placed in orthopedic cast.
As its name implies, the emergency department is meant to treat emergencies. But that's not the reality of emergency medicine -- at least from what I saw during my 4 weeks there. Sure I saw gunshot victims, knife wounds, and pneumonias, but for the most part, I saw more chronic pathologies manifested into a state of personal torture for the eventual triaged patient.
Here were a sampling of my cases:
1. 59 y/o Chinese F with PMHx of hysterectomy presenting with over a year of weight loss, abdominal distention, fullness, early satiety, bloating, and pelvic suprapubic pain. Pt recently visited China, where a CT showed a unilateral ovarian mass. Pt put off seeking medical help for 3 months after returning from China because she was scared. Outcome: Unknown. This is a chronic condition, so we referred the patient to the OB/Gyn clinic at Highland. This was likely ovarian cancer.
2. 64 y/o Arabic-speaking female with PMHx of chronic back pain presented with near-syncopal episode. She was getting up from couch, saw stars, got lightheaded, then caught herself on couch. Afterward, she felt tachycardic and SOB. I was scared this woman had a TIA, even though she didn't c/o any weakness, etc. EKG was normal. Essentially, this was a case of lightheadedness but described in other terms, which threw me. I wanted to do a CT scan because the woman was stilll c/o of headache. But my attending said to look at the sequence of events, which was important. We pretty much ruled out cardiac cause, so yeah, this came down to case of dizziness, likely from orthostatic hypotension. OH occurs in the elderly, due to a pooling of blood in the legs and a decreased cardiac output in response. There's usually an underlying etiology like hypovolemia, drugs, or other diseases because the baroreceptors should kick in to compensate for decreased CO. How to dx? Systolic BP decreases by 20 or diastolic BP drops by 10 mmHg from supine to standing position.
3. 28 y/o M with PMHx of diabetes and frequent ED visits for gastroparesis presents with unrelenting vomiting and stomach pain x several days. He's been waiting for gastric pacemaker at UCSF, but unable to be put on list. His chart listed him as drug-seeking in the past, although he didn't ask for any opioids at the time. We referred him to GI, and he's still on wait for gastric pacemaker. I saw him return twice for same complaint during my visit in ED.
4. Multiple vaginal bleeding -- pregnant and not. One of the women (black female) saw some spotting when she wiped. And she was just scared in general from pain in abdomen. Pelvic exam showed closed cervix and b-HCG was positive. She was referred to OB outpatient. The other woman was older (52) with dysmenorragia and hx of fibroids. We deferred pelvic exam and referred to outpatient OB with high suspicion for fibroid flare.
5. 32 y/o M with pleuritic like CP after lifting rock from neighbor's yard, hemoptysis, and myalgias/chills. Chest Xray positive for Pneumonia. Did case report on this patient. He was admitted for CAP, although he should have be treated as outpatient based on his PSI and Curb-65 scores.
6. Stitched up a woman's hand s/p knife fight with "baby daddy." We had to do 2 nerve blocks -- median and ulnar -- plus lidocaine injection. Learned that after nerve blocks, it's just as effective to run hand under warm water as it is to perform saline flush. Gave 9 stitches to hand, and placed in orthopedic cast.
