Ebb and Flow of the ED

Everything about working in an Emergency Department is unpredictable.  From what the patient volumes will be to what case/illness will present to what the drama will be that day.  While we can't control what will walk in the door or when the proverbial "bus" will unload, we like to think we have some clue of how things will be.

There are some trends in the patient volumes (and somewhat illnesses) that present.  Take, Monday's for example.  They are inevitably crazy.  No matter what the staff numbers are, we get behind and usually really far behind.  When I walked in close to midnight last Monday there were wait times nearing 2 hours.  Usually, on any other night at that time wait time is 30 minutes max.  There are a few theories about why they are so busy.  Some being: people don't want to spend weekends in the ER so they wait until Monday to be seen; people waited over the weekend with their illness hoping to see their doc Monday morning, but they're too jam-packed to fit anyone in; someone is looking to get out of going to work or school.  And one that I think, but haven't really discussed with anyone - incubation periods.  Kids share germs at school on Thurs/Friday and the illness starts to rear it's ugly head 2-3 days later.  Again, all theories, who knows how much merit any of them hold.

Wednesdays are historically the "slowest" day.  If anyone knows why I'd love to be educated.  That's just the way its always seemed.

Now time.  What is the busiest time?  Seems to be right around 4-6pm.  Everyone comes home from work/school and its time to get those injuries that occurred at school taken care of.  Or they injure themselves while playing after school.  Also when people realize its too late to get into the doctor's office to be seen that day.  Slowest time?  I'd say 3-6am.  Its a beautiful thing when you've started off at midnight with 80 patients in the ED and by 4 there's only 10 (with only 1-2 coming in per hour).

Trends as far as illness presentation?  Flu and RSV/bronchiolitis season is usually November-February/early March.  However, not always the case!  This year we seemed to start early and end late.  Spring/Summer is definitely orthopedic injury season.  Once the first hint of beautiful spring sun peeks out, we are flood with broken arms, legs, fingers and even noses.  Asthma has a predilection for weather changes - i.e. end of winter/start of spring and other season changes, Texas springs full of thunderstorms, wind and pollen, and fall when all the molds are prevalent.  And seasons dictate patient volumes as well.  Winter is most definitely the busiest time with RSV, flu, pneumonia, etc on top of all the other "normal" ER things like lacerations, abdominal pain, abscesses DKA, GI bugs...you get the idea

So the moral of the story?  If you want to be seen quickly in an ER - show up between 3-4 am on a Wednesday or Thursday morning in the mid Summer months, preferably not on a night with a full moon (that is if your emergency can wait that long).  ;o)

Sleepless Nights

I haven't been posting much lately and I'm not completely sure why.  I think its a combination of things like being exhausted, not feeling like writing and feeling uninspired.  I've been working a lot in the last couple weeks and its taking its toll.  Also, I don't want to write just for the sake of posting something, I want it to matter.  Anyhow, here goes...

Like I said, I've been working a lot lately.  I'm not sure how it happened, but my scheduled managed to get pretty jam-packed over the last couple weeks.  Sure, I still have my days off, but they seem fewer and further between than previous.  With all this working of back-to-back-to-back 12 hour shifts, you'd think I'd fall into bed at night and pass out once my head hit the pillow.  Unfortunately for me that hasn't been the case.  I've never had a problem falling asleep until now. 

Despite my eyes being heavy and my inability to stop yawning on my drive home, I would lie in bed wide awake with the shift's events running through my brain.  I found myself thinking about this patient or that wondering if I messed something up or worrying about a frustrated parent.  I know this isn't totally uncommon for people working in medicine, in fact I used to feel like the odd one out because I hadn't experience it.  This was the first time it had ever happened to me and it was happening every night after work.  Did I do a good job suturing?  Did I miss something on that patient's presentation?  Will that patient bounce back?  Do my attendings think I'm totally incompetent?

It may sound crazy, but those were actual thoughts.  I found myself second-guessing almost everything I had done each day.  Worrying myself to the point where I couldn't sleep.  A couple nights I ended up on the couch with the TV on to drown out my thoughts because that's the only way I could actually get some sleep.

It took me speaking with a colleague in a different department before I realized why this was happening.  Starting tomorrow I will be acting a sole provider.  By that I mean I will no longer have to check out every patient to an attending physician.  I will still have the option to do so (and required to do so on some) but I will have the ability to see, diagnose, treat and discharge my own patients without that second opinion.  I think the knowledge/anticipation of this change was sitting in the back of my mind and that's why I've been second-guessing myself so much lately. 

Once realizing the root cause (and checking on my patient's charts a week later realizing none had come back due to my ineptitude), I was able to work things through.  I'm still new at all this.  I'm not going to be an expert and I'm not expected to be one.  However, I am intelligent, learn quickly and can apply what I learn.  I will do my absolute best and if I can't figure it out, I have a great resource in my colleagues and attendings.  Also, there's a difference between a healthy and unhealthy amount of doubt/second-guessing.

I'm happy to report that after my last several shifts I was able to fall asleep.  Sure, I still think about my patients and sometimes doubt things, but those thoughts are no longer keeping me up at night.  I have a feeling my first several shifts "solo" will bring back the sleepless nights, but I have some new coping tools.  And if all else fails, my couch is a pretty comfy spot to sleep...