A Service Rotation

After three months away from medicine, starting up again at the Harborview ED has been quite a culture shock.  As I explained it to one of my patients yesterday, I feel like I've been thrown deep into the trenches and have been running ever since.  Harborview Medical Center (HMC) is a county-run hospital in Seattle and the only "trauma one" designated hospital in the Northwest.  This means that the patient population not only consists of the homeless, indigent, druggies, and drunks, but also regular people who were in the wrong spot at the wrong time and were unfortunate enough to have an accident that left them with traumatic, potentially life-threatening injuries.  All these patients enter HMC via the emergency department.



Dr. Michael Copass, a neurologist by training, is responsible for setting up the HMC ED as it stands today.  In the 1970's emergency medicine was emerging as a specialty field and he is largely responsible for establishing algorithms and protocols for taking care of "coding" patients: those needing CPR, trauma workups, and emergent medical care.  Although I have not yet met Dr. Copass, he has attained "god" status here in Seattle and across the nation.  I don't even know if he exists (although he is scheduled to give us a lecture this week); in my mind, he is a nebulous figure like the Wizard of Oz.  He not only established protocols for the medical management and stabilization of patients, he also created "the three commandments" of his ED:

1. Work hard.
2. Be polite.
3. Treat the patient graciously, even if he is not the president of the United States.

It is obvious that every staff member, nurse, doctor, student, and volunteer in the ED takes these commandments very seriously.  When patients are brought in, whether they are stable, have multiple traumatic injuries, are intubated, or drunk, they are greeted by the medical teams with the following:  "Sir/ma'am, welcome to Harborview.  We are going to do everything to take the best care of you that we can."

Dr. Copass set up the ED into three areas that patients get sent to depending on their presenting medical issue: Trauma, Medic 1, and ED Green.  There are attending physicians in each area as well as surgery residents staffing the "trauma side", internal medicine residents in "medic 1", and mid-levels (PA's and nurse practitioners) in "ED Green".  You can imagine which patients get sent to the trauma side.  Medic 1 patients are those coming in with heart attacks, COPD exacerbations, strokes, seizures, and sepsis to name just a few.  ED Green is more of an "urgent care" clinic for people with twisted ankles, urinary tract infections, and sore throats, but as one of my attendings warned me last week, "there is always one ICU patient hiding in ED Green...the tough part every day is figuring out which patient that is."

At our orientation on the first day of this rotation, the fourth year medical students were told that this was a "service" rotation.  In keeping with Dr. Copass's commandments, we were told that unlike all the other clinical rotations in medical school where we are to focus on learning disease processes and patient management, the primary goal for us should be to serve others (our education is the secondary goal).  There are 12 students rotating in the ED this month, split up so that 6 of us started on day shifts (8am to 8pm) while the remaining 6 started on nights (8pm to 8am); after two weeks, we will be switching shifts.

I just finished my first two weeks on days and will begin night shifts tomorrow.  12 hours is a long time to work, but I'm used to long hours working on the river, so I didn't think it would be too difficult of a transition for me.  I will tell you one thing: a 12-hour day in the ED of a major trauma hospital is A LOT different than the 16-hour day at RMRT in the middle of the Frank Church Wilderness: I'm exhausted every night when I get home.  I've been living on diet coke, string cheese, cliff bars, and PB&J for the last two weeks as I just don't have the time or energy to get much more creative than that.  There are no lunch or bathroom breaks through the day--you try and squeeze that in when you can or if you remember.

My first week was just okay.  I was feeling pretty neutral about the rotation in general.  I didn't feel like I was learning a whole lot because when things get busy, teaching sometimes gets put on hold.  All the residents and attendings are great about teaching me about my patients, especially when I ask questions, but I just feel like sometimes the urgency of the patient problems or the number of patients waiting to be seen necessitates action, not talk or explanation.  I've also been away from academia and medicine for the last three months and honestly wasn't that excited about getting back into it.

Now that I've been back for a couple of weeks, I feel like I've gotten settled into my roll as a medical student again and am in a better "mental space" for learning (and serving) and being excited about learning (and serving).  Since getting into that "mental space", and changing my primary focus from learning to serving, the rotation has changed drastically.  I'm having a lot of fun and feel like my work is really worth-while and rewarding.  I can't think of a better feeling than having a patient tell me "Thank you, Dr. Emily.  I want you to be my doctor when you graduate next year."  It's that interaction with the patients that reinforces that I have chosen the right career path and that medicine is my calling.

...More about that in my next post.