I think it's a pretty safe bet to say that I'm not the same person that I was four weeks ago. And that's mostly a good thing. I no longer think that everyone coming into the ER is going to die in twenty minutes, unless I save them by making a miraculous diagnosis of some super rare disease. Although I'm still hoping for one of those.
I'm also starting to finally find the right balance between jaded and naive when it comes to prescribing narcotic medications. The 72 year old woman that comes in with shingles probably isn't looking to score some percoset. But on the other hand, the twenty year old that comes in describing textbook symptoms of gall stones (but doesn't seem to be in any particular pain) can probably go home safely without a prescription. Especially without the prescription for hydrocodone + acetominophin that she asked for by name.
And I can almost make it through an entire toenail extraction without losing my breakfast. Almost.
There are a few patients that stick out in my mind, and I'm probably not going to forget them any time soon. The almost-delivery is definitely one of those. The young mother and father-to-be had an odd disconnect from the entire situation, as if they were just there for a sports physical. But then again, I can't imagine what it must be like to go through that as a late teen. I might not have acted any differently.
We had a patient a few days ago that came in to the ER for a "hand injury", but the situation quickly progressed away from any orthopedic concerns. When it was apparent that her one month old injury came from punching someone, the nurse practitioner asked the patient who a sweet young girl like her would be punching. She cryptically responded that she was defending her mother. When the NP finished addressing the hand pain, the patient meekly asked if she could have a pregnancy test. We both froze. Our immediate concern was whether or not the patient was defending her mother from the same person that potentially made her pregnant. She wasn't. However, this still clearly needed to turn into a heart to heart between the patient and the NP, so I spontaneously heard my name over the intercom. The NP filled me in afterwards, and the sex wasn't as consensual as the NP would have liked ("Well, I didn't say no..."), so she spoke with the girl about how she can better assert herself next time. And, thankfully, the girl didn't turn out to be pregnant.
Another patient last week came in with a pain in his abdomen. He was about twenty five.
Me: "Ribs?"
Him: "No, lower."
"Stomach"
"No, lower."
"Intestines?"
"No, lower."
"Bladder?"
"No, lower."
"Legs?"
"No, higher."
Damn. Time to get out the rubber gloves.
After a quick inspection, I couldn't find anything wrong downtown. Of course, I only have a comparison sample of one, but I still think that I have a pretty good idea about what things should look like down there. After a bit of conversation, he opened up to me about a recent, less-than-safe sexual encounter. So I initially thought Syphilis or Gonorrhea. ("Which one do you have, leaking or burning?") But those lab tests came back normal, so I was back at square one. After some more conversation, the patient explained that the sex occurred sometime between breaking up with his girlfriend, and the two-week binge that he put himself though in response. And by binge, he meant that he had consumed nothing but beer for two weeks straight. He shouldn't be alive. The extreme dehydration and shock on his kidneys resulted in him developing a urinary tract infection. These are extremely rare in men (which was why I thought that he was on the train to STDville), but they're not unheard of. We kept the patient in the hospital for a few hours to rehydrate him, during which his
But I don't want you to get the wrong impression. These cases are memorable because they're the exceptions. As a whole, the Hopi are a reasonably healthy group of people. Certainly no worse that the average non-Native American. Granted, they still seem susceptible to the alcoholism seen with other tribes, although they do a pretty good job avoiding the bottle altogether. Plus, their traditional diet and long history of being runners have survived the ages remarkably well, despite the relentless outside pressure. This could be due, in part, to the lack of fast food restaurants on the reservation. I'm guessing that economics has a little bit to do with it, but I'll bet that there's also a tribal decree keeping them out. After all, McDonald's hasn't ever been shy about putting branches in other low-income communities.
The rest of this week should be as equally incredible as the four that preceded it. I spent this afternoon with an IHS doctor doing her weekly round of acupuncture treatments. It was very interesting on a lot of levels. First, I was impressed with IHS's willingness to think outside the box to make its clients healthier. Also, the practice of acupuncture, itself, was pretty fascinating. I was curious about it before today, and now that I've seen it in action, I'm sold. I have a pretty strong hunch that I'll be spending a fourth-year rotation in China.
On deck is an outreach trip with the traveling public health nurse, a health-focused call-in radio program (I may actually talk this time), and an overnight shift in the ER. I can hardly wait!
-M
