I spent this last week working in the emergency room at Los Angeles County Hospital. It’s one of the busiest emergency departments in the country, seeing an average of 465 patients per day. The average patient wait time is 7 hours. I was nervous going into it—at the start of the week, I thought it 70% likely that emergency would end up being my specialty. I really wanted to love it. I worked five 12+ hour shifts in six days, one of which was at night.
Day 1 – North Wing: emergency department (ED) for patients with mostly internal complaints (abdominal pain, cancer, chest pain, stroke symptoms, cough, etc).
The emergency department has very few doors. Each wing has a couple central stations for doctors and nurses with desks and computers, and the patient areas line the perimeter of each wing. The rooms have curtains that don’t close all the way, so as you walk around you can peek into any room and see what’s going on.
I got introduced to the grind. In emergency, the patients never stop. Every time a room empties, the next time you look into it there’s a new patient in the bed, waiting for you. I followed my resident for the first few hours as she walked room to room, sitting down every once in a while to write imaging or prescription orders. Soon she gave me my own patients to see, and I’d come out to present my thoughts and findings to the attending. When my stomach was rumbling around 1:30 pm, I asked if I could grab lunch. She said, “Definitely. Just go eyeball your next patient around the curtain really quick and see if she looks like she’s stable. If she looks ok you can go eat.” That was the moment I realized that in emergency, you have to deal with this nagging feeling that no matter how fast you move, how many breaks you take or don’t take, your patients are still lined up and waiting for you.
In the evening, I walked through the resuscitation wing to discover a horrifying scene—a ten year old boy who had just been run over and dragged by a truck, his chest splayed open on the table. The senior surgery resident was doing internal cardiac massage. Someone exclaimed that the boy’s mother was coming into the ED. “Close the curtain! Quick, someone throw a blanket on his chest while we take him up to the OR so his mom doesn’t see.” They rushed him up to the operating room, but he didn’t make it.
Day 2 – overnight shift during Halloween weekend in the resuscitation (“resus”) department. This is the ED for critically injured or ill patients.
A couple women in costume arrived wrapped in bloody towels. They had been stabbed by a stranger in the face, arm, and back while celebrating Halloween at a bar. They had copious amounts of costume blood and real blood on themselves. 20 minutes later, their assailant was also wheeled into resus, agitated and strung out and with a swollen ankle. Ultrasound showed that one of the women had blood in the space around her lung, so the second year resident put a chest tube into the space, through her back.
A teenage boy came in, also the victim of a brutal stabbing. His bowels were protruding from his abdomen. He was rushed up to surgery.
I put a few staples in some guy’s head.
I got to sew up multiple stab wounds. I have a feeling if I were at another hospital, somebody besides a third year medical student would have sutured a facial laceration, but there I was. I did my best and I was proud of the way it looked.
Why are there so many stabbings?
In the early morning, I walked out of the hospital, exhausted. I looked down at the blood on my sleeve and couldn’t match it to a patient’s face. All I remember is that sometime in the night during a chaotic trauma team activation, I looked down at my arm as I was bracing someone’s neck and realized it was all bloody.
Day 3 – more resus
A yelling man gets wheeled in, strapped to the bed, a spit mask over his face. A spit mask is like a mosquito net that goes over your face, with an opaque sock-like part that covers your eyes. It keeps you from seeing anything, and prevents your defiant spit attacks from reaching anyone. I get assigned to one of his legs, and I do my best to hold it down while he gets jabbed with some meds for his agitation. Who knew I’d be using all my CrossFit strength to hold down patients every day. I chuckle as I remember one of the core CrossFit mottos: “Training for Life.”
They take his mask off, and he’s bucking his whole body, trying to get off the bed. “Let go of my leg, you fucking bitch. I swear when I get out of here I’m going to go get my gun and come back and kill you all.” Earlier this year I think this kind of thing would have bothered me, but it’s amazing how quickly you can just stop caring about it.
A very sick patient is quickly crashing and needs to be intubated. The attending yells to the second year resident, “How confident are you that you can get this intubation? You’re only going to have about 30 seconds.” The resident takes a deep breath and says he feels pretty confident. He nails it, and everyone in the room cheers and slaps him on the back.
I realize that these are the moments that emergency residents live for. They are total adrenaline junkies. They wait for these moments when they are asked whether they are willing to bet a patient’s life on their procedural skills. I will never be a person who craves this moment. I am not a thrill-seeker. Maybe this is not for me.
A mother comes in screaming, holding her 3 year old daughter to her chest. They lay the kid on the bed, a gaping stab wound extending halfway across her chest, and another across her back. The trauma team rushed the girl up to the OR, but she died. I will never forget the look on her mother’s face, standing there in the resus hallway, sobbing and shaking, her white T-shirt completely drenched in her daughter’s blood.
Day 4 – Jail ED
The jail ED is a bizarre place. There are a few patient areas—a row of private rooms with curtains for the sicker patients, a big room filled with 12 hospital beds, a row of chairs in the hallway, and a couple isolation cells with heavy metal doors. There are guards in uniform everywhere. There is pop music playing. All the patients are handcuffed to their hospital beds, or they are sitting in the hallway, handcuffed to the bench.
One patient had attempted suicide by taking a stash of meds he had been accumulating, day by day.
Another was brought in for a medical evaluation after filing a claim that officers had used physical force against him. He gave official videotaped testimony, showing his injuries to the camera, right there from his hospital bed. The guards were standing all around him, questioning and recording him.
In the afternoon, we could hear a patient coughing and yelling up a storm in the hallway. Pepper spray had been used on him, the report said. They took him to the isolation cell, and five of us went in there to physically subdue him in order to inject him with some meds. As soon as we entered the cell, I could taste the pepper. All five of us started coughing. We held our breaths as we restrained him so the nurse could give him a quick jab. A few seconds later when we tried to open the door, we realized that it was locked. Now we were the ones coughing on pepper spray fumes and banging on the cell door and yelling. It was probably only 20 seconds before we were let out by a guard. Oh, jail.
Day 5 – West Wing: ED for people with mostly arm, leg, back, eye, breast, and vaginal complaints. No one is actively dying.
I learned how to ultrasound an eyeball. Watched my intern use a power tool to cut a ring off of a guy’s swollen finger. Watched my resident cut open a guy’s infected toe to search for a piece of the stick that he had stepped on a month ago at the beach. Watched an ultrasound on a pregnant woman with abdominal pain who was concerned about her pregnancy. Regular emergency room stuff, basically.
I can’t believe how much I saw in five days. The patients kept coming and coming and coming. The emergency doctors know how to manage any condition acutely, and also do a lot of procedures every day. I have tremendous respect for the breadth of the specialty.
I feel anxious about my own impending residency, no matter which kind I decide to sign up for. These people work so hard every minute of the day for about 13 hours in a row, with maybe a 30 minute lunch break. The second year resident was telling me that on her ‘day off’ tomorrow she has four hours of lecture, then the next day she will start back in the hospital for eight days in a row. ED residents get 4 – 7 days off per month, and alternate every two weeks between day shifts and night shifts, for the duration of the four year residency. How on earth am I going to make it through four years of residency when I am so tired after one week?
Even though I found the residents to be wonderful teachers who are easy to get along with, and the content of emergency medicine to be absolutely fascinating, I’m not a thrill-seeker at heart. These residents not only thrive under pressure, it’s what gives them true joy. They are their happiest when they are doing critical procedures, sprinting through the hospital when an airway code is called, and actively stabilizing people who are on the edge. If I was 70% sure that this would be my specialty at the beginning of this week, I am now 55%.
But for now, I have a golden weekend (a golden weekend is when you have both Saturday and Sunday off). It feels sacred. I shall treasure it by just lying here perfectly still in my bed for the rest of the day.