The biggest exam of my life…

I spent my 29th birthday in a smokey coffee shop studying for my first medical school exam. Now, about 6 months shy of turning 38, I am less than 24 hours out of the LAST and BIGGEST exam I’ll ever have to take for medicine!

I just finished my Oral Board exam, the last exam required to obtain board certification in my specialty (Emergency Medicine). It’s a pretty wierd exam, held in a hotel in Chicago, all teh applicants spread out over 6 sessions in the spring and 6 in the fall. I was lucky enough to get a spring slot.

The exam consists of 15 – 30 minute simulated cases with no props, just a pencil and paper that they provide for you. The examiner sits across from you and plays the part of the patient, police, family, paramedics, consultants, etc, etc. You get no feedback, simply an “and that concludes this case,” at the end.

Although on several cases, just as I had wrapped up my case, he immediately said, “that’s the end of this case,” so I knew that I had done it all correctly. A few cases there were long, awkward silences, and an occasional, “The nurses would like to know if you’d like to do anything else for Mr. Red?” And I would sit there speechless. If I hadn’t thoguht if it the first go round, it sure wasn’t going to pop into my mind while sitting in silence under pressure!

Anyway, it’s done, and now I can have my life back. Heck, I could even quit now if I wanted, but that would make it hard to pay loans back.

Best line from an x-ray tech…

So this afternoon, the x-ray techs were changing shifts, and discussing the cases they saw. I always find it interesting to overhear the signouts of the ancillary staff and technicians because they each find patients interesting or fascinating in their own way. We the ER is busy, EVERYBODY is busy. When sick patients arrive, there is something of interest for everyone from the paramedic who arrives sweating and pumped full of adrenaline, to the technician who gets the initial EKG showing an acute MI that even they can interpret with ease, to the secretaries who handled the lab work of the septic patient, to the technicians who are the first to see a “white-out” of a young lady with crack lung or heroin induced pulumonary edema.

So this afternoon, one x-ray tech says to the other, with a bit of dry sarcasm:
“This morning we shot x-rays of a girl who decided to have crack and wine for breakfast.”

And the award for the best line overheard from an x-ray tech goes to Curly, who wondered, “Hmm. What kind of wine do you serve with crack?”

I need a new post

Boy, reading this past week of posts is really depressing. I need to get out and do more biking…and then post about it. I think an epic mountain bike ride is in store for the near future!

Read my first EPIC RIDE story!

A stream-of-consciousness reply…

This started as a comment on Shadowfax’s blog, where he went into significant detail about the study I (incorrectly) referenced yesterday. It just turned into some raving-sleep deprived mumbles that I felt guilty about leaving on his comment box, so I figured I’d just post it here…make of it what you will.

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I’m sure you’re right regarding the comments you left on my blog. I didn’t read the original study, just the press release (shame on me!), but the whole general idea of uninsured=ed visits really gets to me sometimes.

Today I had a young gentleman who wanted some bloodwork to check for “everything” just to make sure his drinking wasn’t a problem. I tried to nail him down about what specifically he was concerned about. (needle sharing, HIV, hepatitis, etc). He didn’t really know. But he wanted “everything” done. He had no insurance, no PCP, and no concept of the cost of the visit, bloodwork, nor it’s inappropriatness at specific point in time and place.

In fairness, I may have been the only doctor he’ll ever see, and the abnormal LFTs we discovered may be enough for him to follow thorugh with the AA/rehab/detox info I gave him. But if that’s the case, it’s a shame that healthcare is so inaccessable to a young man like this!

I wouldn’t mind it so much if my day was not already full of “for real” sick patients who are waiting in the hallways for my time and attention. Even if I would have kicked this joker out, which I was tempted to do, he would have still consumed 10 minutes of my time trying to sort out what he wants, plus 5 minutes of paperwork to document the encounter. Would he have been adequately screened for an ’emergency medical condition’ per EMTALA? In the same amount of time, I could assess and begin treatment on an acute MI and gotten him on the way to the cath lab. Which one is a better use of ER resources and nursing/staff/physician time?

The joker needed basic preventative health screening and counsiling, which I, in the emergency department, do not do. Even if I do, it costs 3 times as much as it would for a PCP do to the same visit with the increased costs due to “stat” labs, xrays and ED basic visit charges.

THe emergency department is not a free clinic, but sadly gets misused that way all the time, and is in many ways mandated to be that way by the federal government in spite of no compensation for doing so aside from what would otherwise be reimbursed from the patient/medicaid/medicare/etc… This reduces the time and attention we have remaining for the truly ill patients or patients who are percieved ill by themselves, their parents or their children, even if they do not have an “emergency medical condition”. This increases potential for patient risks and reduces patient safety as we try to do twice as much work in the same allotted time/space/resources.

I’ll stop here. Feel free to post any comments below. Nothing will be considered a flame, as this is just random rambling about what I see from my side of the stethescope, and you really can’t debate the stuff that goes on inside someone else’s head. What is there, is there.

Oral Boards

So emergency medicine is one of the few medical specialties that still requires oral exams prior to board certification. The board states that the written exam, which I took (and passed) last fall, is just a screening tool to see who can take the oral exams. Regardless of it’s justification, I have to do it if I want to get board certified.

So I took this review course by an un-named state board group, and during the Q&A, I raised my hand and asked, “Will we be expected to know the new Advanced Cardiac Life Support Protocols?” (Just published in December of 2005, and teaching materials are not even available yet…some ACLS courses have not begun to use the new guidelines yet). The course director emphatically stated, “YES, of course!”.

So later that morning, I am doing a case scenario with the same gentleman. Naturally, my patient crashes, goes in to pulseless vfib. I start CPR, then deliver a single shock at 360. No response, so I continue CPR, give epi, shock again and she comes back to life. During the critique, he tells me, “We still use 3 stacked shocks of defibrillation at escalating doses.” I figure he’s right, since I had just asked him, only an hour before, about the ACLS guidelines. I figured I must have read the information wrong.

So TONIGHT, I’m reading section 7.2 of Circulation’s 2005 ACLS guidelines on pulseless algorithms. Guess how many shocks you give on teh first attempt? ONE. At 360 Joules. I was right. When he takes his ACLS recertification (if he ever does), I guess he’ll feel pretty silly. Or maybe it will never even cross his mind.

Anyway, wish me luck this weekend!