Jacob Lentz attended the David Geffen School of Medicine at UCLA. He is in his first year at UCLA Emergency Medicine Residency Class of 2019. Prior to medical school, Jake worked as a comedy writer for the Jimmy Kimmel Live Show for 8 and a half years. Here at Pondering EM, Jake blogs about his journey through EM residency.

Thoughts After My First Month

As of today I am a month into my first official rounds of working in the emergency department, all so far at the public hospital attached to my program. Next week I switch to the large academic center, where the patients are more complex and generally sicker, and as an added bonus the whole system is totally different.

If I am being honest, I would have to admit that I left medical school feeling fairly confident in my own medical knowledge. That has all been washed away this month, as I have repeatedly found how little I know and the vastness of what I have to learn in order to be a competent emergency physician.

A few lessons so far:

1. In a teenaged boy who feels short of breath and feels like he had a vague chest pain, who has a normal exam and a normal ECG, do a testicular exam and then consider a chest X-ray. Twice in the past month this complaint, thanks to an attending (a consultant) hearing about the case and suggesting those two examinations, was discovered to be mets from a testicular neoplasm.

2. Check the labs. While as a med student we would analyze each lab value for its relation to the other values, considering everything an abnormality might mean, I’ve discovered that as a resident, unless it’s a wildly high K or an insane uric acid in a cancer patient, I tend to avoid too much worry about slightly off lab values. To the point: I had a chemotherapy patient with an infected tooth. I noticed – and didn’t pay mind to – a slightly but noticeably low sodium. It took me two hours to realize he might have necrotizing fasciitis, the first sign of which is often a low sodium. He was fine and did not, in fact, have nec fasc, but my mental anguish could have been obviated by thinking about the labs for a moment.

3. Check the skin. That same patient had a back covered in ecthymas. I might have worried more about a fungal infection if I had taken the time to look at his skin.

4. Count the respirations. The respiratory rate almost always gets charted at 18. If you actually count the respirations per minute in a patient, you may notice that he or she is blowing off acidity to compensate for a festering septic shock. Which I did, and what seemed like a viral gastritis patient ended up the intensive care unit.

5. Consider the other doctor. No surgeon, psychiatrist, or pediatrician is glad to have their sleep interrupted by a bleep from the emergency department. I have learned to let them sleep as long as I can, and then to apologize for waking them up, and then extend florid praise in both my note and in the work room when they show up.

6. Wear eye protection. I’m writing this after an eye spray of blood from a gentleman’s seemingly unremarkable finger laceration. Stuff sprays, so think ahead.

7. Cut a glove. You can tamponade bleeding digits by cutting the finger off a sterile glove, snipping the tip, and then rolling it down over the digit like a rubber band. This does require assessing the proper glove size, however. Respect to the doctor who taught me that trick and then was not overly annoyed when I forgot it.

8. Take the history. My admitted habit in the emergency room is to rush. While necessary, I am hoping to develop the ability to realize the moments when I need to listen longer. A diabetic fellow with back pain came into the emergency department recently, and the chart read ‘back pain that began while working.’ Since it was slow, I sat down and chatted with him. It was flank pain, really. And he had blood in his urine briefly. He also had pleuritic chest pain that was worse with inspiration. The eventual CT revealed a hepatic abscess that had violated the diaphragm and was encroaching on his kidney. It was mostly because things were slow that I took the time to listen to what he had to say.

9. A good way to get hyperkalemia is visiting the doctor. I do not have an anecdote, but I did learn today that the number one cause of hyperkalemia, in the States at least, is not renal failure but well-meaning doctors. ACE inhibitors, NSAIDs, Cox-2 inhibitors, and BACTRIM – trimethoprim-sulfamethoxazole! – can cause the most dangerous of electrolyte emergencies. Why is it the most dangerous? Because the number one presenting symptom of hyperkalemia is death. Bonus: Hyperkalemia (say, in the renal patient who comes in) can give a pseudo-MI ECG pattern.

10. Ignore lead AVR unless you see depressions in II, III, and AVF. A super smart consultant told me that twice in the past week, and it’s starting to stick. That is more or less the grand total of my ECG knowledge at this point.

11. Fear the GI bleeder. This message was rammed home to me by a great attending. Fear them.

Though there’s a lot more, I will stop now. The brain can only take so much. But everything is harder than it seems – chest drains, intubations, ultrasound-guided vein cannulations. It’s all just very hard and I have a great amount to learn. The last time I felt so utterly incompetent and stupid was the first year of medical school. It is unpleasant and also, on some level, encouraging to know that I chose a field that has so very much to teach me.

Until next time.