Rotating Through the Pediatric Emergency Room: Part I

I walk through the wooden door of the Peds Emergency Department wearing black scrubs and a non-operational badge. The door swings behind me dramatically like I’m in a movie, and I smile wide, enthusiasm on full blast. It’s day two of my emergency medicine rotation, and I’m a fourth-year medical student at a new hospital, auditioning to see if I will make it as a future emergency medicine doc.

I round the corner to the workroom and come face-to-face with four computers lined up in a narrow hall, occupied by two attending physicians and two residents. I feel like I should know something about how this all works by now, but it always takes a couple shifts. While I hover in the doorway, a nurse squeezes by. I take a step forward to get out of her way and find myself in the center of the room, surrounded by the fray. Monitors beep, people discuss, and I’m swallowed up by the hum of constant activity.

“Hi, my name is Dee, one of the fourth-year med students!” I chirp above the background noise, anticipation pitching my voice shrill and nervous.

“Hey, I’m Nic,” a six-foot-two man with a bun sitting behind the computer replies in a baritone drawl. His name is only one syllable, but he says it like he’s got all the time in the world. His ease slices through my anxiety and my shoulders settle half a centimeter lower as I step up to his computer. He doesn’t turn around and I wonder: how many times does someone step up to his computer every minute, brimming with questions, trying to grab his attention? And how does anyone ever learn to filter that constant stimulation so nothing important gets lost in the chaos of the ED?

He’s reading lab values, clearing them faster than I can register what the numbers might mean and I get the feeling that the apocalypse would not faze him, so I stick my hands in my pockets and pretend like I know what’s going on. Nic opens up a chart. “Want to go see a new patient?” he asks.

My shoulders tense; showtime. “Yes!” I chirp. He gives me a brief synopsis of what I might expect and sends me on my way.

I enter the new patient’s room and see a boy being cradled by his mom. The boy has a weird rash that’s both petechial (pinpoint dots) and purpuric (larger purple-ish patches), and the mom says this has never happened before. This is my first actual encounter with pediatric rashes and I suddenly realize I don’t know as much about pediatrics as I thought. I run through what I remember. Could it be Lyme disease? Kawasaki’s?

I head back to Nic who is perched at his computer. I don’t really know what’s going on, but medical students are supposed to present our best guess, so I launch into my defense of Kawaski vs Lyme, fully aware that my presentation is disorganized because my thoughts are disorganized. At least it’s honest. He cuts in while I’m rambling about whether the child may or may not have cervical lymphadenopathy (a swelling of the lymph nodes that can be caused by an infection).

“Is he vaccinated?” Nic asks.

I freeze. I’d forgotten to ask. It’s probably the first thing I should have asked.

Nic turns to his computer, clicks a couple times, and turns back with the kid’s vaccination records pulled up on his screen. I start to feel incredibly foolish, but he says, “alright, now, you’re ready to present to the attending.”

There’s a certain flow of information in the ED: the med student gets the first shot at figuring out what’s going on and presents the information to the resident. The resident then makes the decision of whether the presentation is solid enough to run by the attending physician, who usually manages double the number of patients and has no time to waste. Presenting to the attending is both an opportunity and a sign of trust.

I look at the screen and avoid looking at Nic. I feel thankful for his trust in me, while simultaneously feelings of imposter syndrome start to surface.

My patient presentation to the attending makes more sense the second time around.

Then I wait as our attending goes to examine the patient. Usually after the attending comes back from his or her exam, the team – attending, resident, student – discusses the plan, and the rest is a matter of execution.

But this time, it’s not clear what the child has. This case is complicated.

Uncertainty ripples through the workroom. Nic injects some needed humor into the situation, and the weight of responsibility hits me the same time as the tail end of my case of imposter syndrome. We’re in the thick of it now. There’s a sick child with real pathology who could potentially be very sick, and even if I don’t have all the answers, we’re all trying to figure this out together. I flop in front of a computer to look up pediatric rashes. The computer doesn’t let me sign in. I try to use my phone – no signal. I resort to mulling over my thoughts as another resident plops down next to me.

“Hi, my name is Dee, I’m one of the fourth-year students!” I say, sounding like one of those art museum sensors that beeps with proximity.

“I’m Drew,” he says. “what’s up?” Even though he’s managing his own patients, Drew takes the time to ask a couple clarifying questions and I give him the brief version of the situation. He listens, and my thoughts settle a little knowing there’s help all around. While we’re waiting for lab results, Drew and I have a real conversation. We talk about food options open at this time of the night and how it’s beneficial to talk to patients in their native tongue. The normalcy of the conversation reminds me that while the ED always has an edge of urgency, it’s not always the chaos that it looks like on the surface – under the thousand moving parts and life and death decisions, there’s an order and a peace once you understand how it works. I make a mental note to trail behind him and Nic at some point in the night. What better time to see how someone else practices their style of medicine.

How does the rest of Dee’s day go – and what diagnosis does the team arrive at? Find out by reading part two — to be published next week!