Second Week in Whiteriver

 

My second week I worked in the ER. The ER is a fun experience here. I do enjoy working in the ER due to the undifferentiated nature of the patients that show up.

I worked about half of my time with ER residency trained physicians and about half my time with Family Medicine trained doctors. Both of the attendings were good teachers. Fortunately I got to work with one family medicine attending for the majority of the week and one ED doc for the majority of the week, so I got to build relationships with both of them.

The ER in Whiteriver is a busy, high acuity ER. During the day, there are 4 providers working (2 on the fast track side, and 2 seeing the higher acuity ER patients). The 20 beds are often mostly full. They see 36,000 pts a year which turns out to be 100/day. It was cool to see family doctors working down in the ED alongside ED trained doctors, and they have a good relationship. The first night, the computers went down in the middle of a busy afternoon, so everyone had to chart on paper for around 8 hours. It was cool to see everyone spring into action and work collaboratively to take care of patients in a tough situation.

There were a lot of interesting cases that came in this week. There was a septic hypotensive patient who needed a central line which I helped with. There was a patient who came in with florid hepatic encephalopathy after being off her medications for a couple weeks. I saw a couple cases of septic joints, which were interesting, and I got to perform 2 ultrasound guided knee arthrocentesis procedures, which I had never done before. One of the knees, which likely was a bacterial infection due to hematogenous spread, easily produced 60cc of milky synovial fluid, WBC count was later found to be 56. The second septic joint was an interesting case. It was a young woman in her 20s who came in with 2 days of joint pains which seemed to be moving from one joint to the next. It had started in her wrists and elbow, and had “migrated” to the ankle and knee. The pt’s right wrist, right ankle, and left knee were clearly inflamed. I took the US machine in and found a small pocket of fluid to tap in the knee. What came out was 4cc of purulent synovial fluid that looked like it could have come out of an abscess. The WBC count was 94,000. On further history, the patient did endorse having unprotected sex recently, and her partner had been having symptoms suspicious for a UTI, though she interestingly did not report any symptoms of an STI. Her workup ultimately revealed the diagnosis of disseminated gonococcal infection – a fairly rare diagnosis. She was placed on IV antibiotics and transferred to a different hospital where an on call orthopedic surgeon could perform a washout of the knee.

I worked five 12-hour shifts on Sunday through Thursday evenings/nights. After taking Friday to adjust back to daytime, I did a hike to Cibecue Falls with several of the other learners/volunteers on the reservation. A group of five of us (Claire, a family medicine resident from Tucson, Darius, a pharmacy student, Shaifer, a volunteer doing a “gap year” in between undergrad and medical school, and Danica, one of the pharmacists, and I) drove an hour and a half down an extremely mountain road, including the last 30 min on a dirt road, to reach the trailhead. It was a scorching day, and the trail followed the Cibecue creek upstream to where it tumbles about 40 ft into a beautiful cove. About a 5 mile round trip, and well worth it for one of the more beautiful swimming holes I’ve been.

Feeling recharged and ready to work at the rural outreach clinic next week!

 -Jordan