Austin - Something for the pain: one doctors account of life and death in the ER

I CARRY a black canvas tool bag to work. I copied the idea from David, one of the other docs in our group. My bag is filled with the essential things that help me make it through a shifta bag lunch, a snack, and a can of V-8 Juiceit can get so busy theres no time to go to the hospital cafeteria, but I can usually sneak down the hall to the break room for five minutes to wolf down a sandwich. My bag also has a Littman stethoscope. A reflex hammer with an orange rubber head shaped like a triangular tomahawk. A PalmPilot loaded with a drug database, and some other programs I dont use much. A Harriet Lane Pediatric Handbook and a Sanford Guide to Antimicrobials we have a bookshelf in the doctors dictation booth, but the books seem to wander off, and its frustrating to need a piece of essential information and not have it. Especially in an emergency.

I have a copy of the new CDC guidelines for treatment of sexually transmitted diseasestheyve recently discovered that gonorrhea is resistant to Ciprofloxacin. I also have a bottle of Hemmocult developer because I sometimes cant find it in the cabinet over the sink in the nurses station; a roll of silk tape; and a pair of trauma scissors.

I still have the Welch Allyn otoscope/ophthalmoscope kit I bought in medical school twenty-two years ago, but its zippered case fell apart during residency. I made a replacement out of walnut. It looks like a cross between a jewelry box and a miniature carpenters toolbox. I made a snug little compartment for the handle, and a special place for the ophthalmoscope head. There are five circular holders for the graduated plastic earpieces. I made a tray for the stainless steel ear curettesfine, long little spoonsthat are so handy for getting wax out of ears and beads out of noses. In the lid of the box, I keep a laminated diagram of the ear canal, the tympanic membrane, and the middle ear. I always show it to the childs mother before I start scooping with the curette, so she wont worry that Ill poke a hole in the eardrum. Under the otoscope handle, I keep a pair of delicate alligator forcepsprecisely machined of brushed stainless steel. The jaws have tiny little teeth, which are perfect for grabbing a moths wing or a cockroachs leg after the insect has crawled down into someones ear.

I keep a bunch of refills for my ballpoint pen. A portable telephone I clip to my scrub pants. A leather change purse I got in Honduras. A bottle of generic ibuprofen. Laminated copies of the NIH Stroke Scale and the Mini-Mental Status exam.

I also keep a spiral-bound copy of the research papers I had to read for the most recent annual recertification exam. I highlighted the articles that I may need in a hurry: the treatment of acute ischemic stroke, the use of dexamethasone in adults with meningitis, the treatment of pediatric head trauma, and community-acquired pneumonia in children. I also keep a checkbook in my turn-out bag in case the nurses are collecting money for someones birthday or baby shower, or if a coworker we like is leaving, and we want to buy them a cake to put in the break room on their last day.

Every day when I get to work, I put my lunch in the dorm-sized refrigerator in the docs office, and grab three teabags from my locker. I put a granola bar and a Ziploc baggie of grapes or cherry tomatoes next to one of the computer terminals in the nurses station, and then drape my stethoscope around my neck, put a few of the business cards that I give each patient into the pocket of my scrub top, the PalmPilot into my back pocket. Then I tuck the reflex hammer into the waistband of my scrub pants.

Finally, I take a blank three-by-five index card and across the top write the date, and the day of the week. I work rotating shifts, which are assigned without regard to weekends, so it can be difficult to remember if its Tuesday or Wednesday. On the card I will make a list of the patients Im taking care of. I slip the card into the pocket of my scrub top, grab a chart, and go see my first patient of the shift.