Night and Day

I’m just about finished with a fast and furious rotation in the emergency room of a busy downtown Pittsburgh hospital, and my shifts are full of adrenaline, fun, frustration, and lots of learning. But I suppose I should back up a month and fill in the gaps. The last rotation was also a wonderful rotation, also full of learning, but very slow and relaxed. I spent a month with a group of physicians and alternative health care providers on a rotation called Integrative Medicine. Right up my alley right? Given my history of 9 years as a massage therapist, and my best friend back in Portland who is an acupuncturist, working in this clinic was like going home. I met a wonderful group of people, like minded, and supportive of alternative approaches to heath-care: chiropractor, acupuncture, massage, structural integration (also known as Rolfing: a manual therapy that works on the fascia/connective tissue), nutrition, prolotherapy (injection of solution into tendons or ligaments in an effort to encourage the body’s inflammation response to repair damaged tissue), yoga, meditation….this list goes on an on.

It was very interesting to relearn all of complementary health-care after having gone to allopathic medical school. Not much of what I came into contact with was new: I have had experience back in my hippie days in Portland with all types of alternative healing, including Aruyvedic medicine (Indian based system of healing), Chinese medicine (including herbs, and acupuncture), and even homeopathy (a system of healing I don’t really understand all that well, but entails taking a very very very diluted down “essence” of a substance that in a large form would give you the very symptoms you are trying to eliminate).  So not much was new to me during this month, although I could now take my medical education of disease pathology, and try to understand how and why these complementary medicines help the body heal. I spent most of my time watching the practitioners in action, and I even got some acupuncture and a much needed chiropractic adjustment after I threw my neck out one morning in clinic. The perfect place to be! After one adjustment and some Advil, I was back to normal in 2 days. I’m also so happy to have been introduced to so many cool people in Pittsburgh! Like minded, open minded, full of life people who are committed to helping their patients heal in natural ways.

As part of the rotation I decided to read as much literature as I could on the scientific studies that had been done on many of these types of integrative medicine. I believe that as an MD I should be aware of what research has been done, so that I can inform my patients when they ask about whether or not some other type of therapy may be helpful for their condition. Thankfully there has been an huge increase in the amout of science and research that has occurred in the last 20 years in this area. It’s necessary because traditional allopathic medicine does not always help patients, and because patients are paying out of pocket for many of these services, searching for some relief of their pain and suffering. Unfortunately many of these therapies can not be adequately studied in the traditional randomized blinded control trials that are the gold standard in Western medicine, and are necessary to prove that some intervention works better than a placebo. I did find very strong evidence that chiropractic adjustments are effective for neck and back pain, and acupuncture is effective for nausea and headache. I didn’t have time to review all the literature, but what I did read confirmed what I already knew from my own experience: that there are very small risks for most types of integrative medicine (as compared with the many interventions – drugs and surgery – that Western docs often prescribe), and that many people find benefits from these treatments.

I was happy to have made these new connections when on one of my emergency department shifts I evaluated a young woman who had injured her back after a sneeze. That’s right, a sneeze. She tweaked her back and was in extreme pain due to muscle spasms, and was unable to work due to her pain. I recommended some anti-inflammatories, gave her a prescription for a muscle relaxer, and gave her the number for the Integrative Medicine clinic so she could go see the chiropractor. I was sure that 1 or 2 adjustments would have her back to normal in a very short time. The rest of the patients I have seen in the ED however have not been so straight-forward.

Patients seem to come to the ED for 2 reasons: 1. they are really really sick, or 2) they can’t get into their primary care provider, or don’t have one. So on any given day, I may be seeing patients with heart attacks, clots in their lungs, and broken bones, or patients with sore throats, itchy eyes, and cough. I’ve really enjoyed the variety of patients, and how I have to remember everything I have learned as a physician. You have to be able to recognize a very sick patient, and be able to intervene appropriately – like the 2 patients I had to intubate for respiratory distress, and starting blood thinners on the patient with a heart attack, as I coordinated with the cardiologists to get him to the cath lab asap (where they will look at the vessels in his heart and open them up with a balloon or stent). I’ve even gotten to freshen up my surgical skills when I stitched up a woman’s face after she fell off her bicycle. Thankfully my hands weren’t too shaky, and after the initial frozen moment when I couldn’t remember how to tie the knot (as my attending or supervising physician watched), it all came back to me, and I think her scar will not be too bad.

I’ve seen lots of patients with abdominal pain, nausea and vomiting, shortness of breath, chest pain, back pain, eye pain, (see the pain theme here?), as well as patients who need psychiatric admission to the psych hospital across the street, but need medical clearance first. I had to restrain an agressive 85 year old female with severe dementia in order to get some blood and urine. All the while she’s telling me she’s wishes my grandmother would die a slow terrible death, and threatening to punch me.

Despite the chaos in the ED, I still have been able to find compassion for the suffering of others. Even though I have very little time with the patients, and even though many are challenging (demanding pain medication, or trying to dictate their care like I’m a waitress taking orders), for the most part I see their suffering and truly want to help. I’ve enjoyed the rotation so much that I was worried I’ve choosen the wrong speciality. I did a ED rotation as a medical student, but after I had already matched to my PM&R program here in Pittsburgh. Last night though, I came back to my senses. I had a very long shift, with complicated and sick patients. I was still in the ED 1.5 hrs after my shift ended, trying to tie up loose ends, and not sign out work to other incoming docs.

For some reason the last patient I had really pushed my buttons. I’ve never really had a hard time with challenging patients, and can usually calm them down with my words, with reason, and construtive conversation. But with this patient, no matter what I said, no matter what I did for him, he was not happy with me, with his trip to the ED, with the plan I had for helping him feel better. For the first time in my residency I actually did not like my patient. While I did discover what was wrong with him, and explained the treatment, he insisted that he needed to be admitted, even though he was stable enough to go home with outpatient treatment (anti-biotics). After a circular discussion that got us nowhere, I finally left his room, and told my attending that the patient was refusing to leave. So we admitted him, just like he wanted. I can only hope that his insurance company will pay for his admission, as it really wasn’t medically necessary. And if it doesn’t, then the patient will have even more reason to distrust the medical system.

After last night, and after reading the new journal of my speciality, physical medicine and rehabiliation, I have a new found clarity that I am on the right path. Yes, the ED is fast, fun, and furious, but I think it’s way too stressful, and doesn’t have enough patient continuity. I would like to develop longer term relationships with my patients, and not just be the one to stabilize them in the ED to either send them home or admit them. But I do have a profound respect for what ED docs do: although what they and physiatrists do is as different as night and day, it’s all necessary in order to take care of patients.

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