In the Emergency Department, we treat a wide variety of patients, so you must learn how to harmonize with everyone from CEOs and celebrities to blue-collar workers, alcoholics, drug dealers, criminals, feisty old folks, exhausted parents, defiant teenagers, babies, and everything in between.
As a first year resident in Emergency Medicine — I have had many colleagues ask me one simple question, “What about burnout?” To be honest, I never quite understood why so many non-Emergency Medicine colleagues seem to think burnout is more likely to occur in Emergency Medicine than in other specialties. Perhaps because Emergency Medicine is so appealing, that it must be too good to be true!?
But let’s be honest, working as an ER doc is probably more stressful than you imagine — but a career in Emergency Medicine is also vastly more rewarding than you likely realize. You will have some people wrap their arms around you and not want to let go, but you’ll also have other patients who will want to rip your spleen out and eat it. At the end of the day — saving lives is arguably the most important and rewarding job in the world. As an Emergency Physician, no other specialty will give you so many opportunities to help so many people in so many ways.
Ketamine is primarily used for the induction and maintenance of general anesthesia, usually in combination with a sedative. Other uses include sedation in intensive care, analgesia (particularly in emergency medicine), and treatment of bronchospasm.
Let’s get down to the specifics..
Ketamine is a noncompetitive N-methyl D-aspartate (NMDA) receptor antagonist that blocks the release of excitatory neurotransmitter glutamate and provides anesthesia, amnesia, and analgesia by virtue of decreasing central sensitization and the “wind-up” phenomenon.
“Two gun shot wounds,” the emergency medical technician says, breathing fast, the summer night pouring down his face. “One in the right flank, one in the right thigh.”
“I don’t want to die, doc,” pleads the victim, whom I will call Mr. Smith. His vital signs are stable.
“This is the trauma team,” I say. “We’re going to take good care of you, but we need to ask lots of questions.” I press my stethoscope to his chest. “Can you take some deep breaths?” I listen for the airy hollow of a punctured lung but am calmed by the hum of normal respiration, even as his alcoholic breath warms my cheek — or so I believe. He denies drinking, but this is one of those overnight shifts when everyone — motor vehicle crashes, chest pains, depressions, confused grandmas, even rashes — has thrown back one or two.
Once inside, we palpate Mr. Smith’s neck, chest, back, abdomen, and muscular extremities. “Does it hurt here, and here, and here?”
He doesn’t answer us. Now he acts annoyed and bothered. “Call my cousin,” he says.
“Sure,” I say, “after we make certain you don’t have an injury that needs immediate attention.”
“And you are?” he says.
I’d already introduced myself, but I know what he means: Who am I in the hierarchy? “I’m the doctor in charge,” I tell him.
“Good,” he says. “Go call my cousin.”
“First things first,” I say.
“Hey, douchebag,” he says, his voice hardening. “Call my cousin.”
I pretend the comment was what he might, on reflection, consider a regrettable slip of the tongue. But his head arches off the stretcher and his eyes meet mine. “Now, douchebag.”
I feel the heat of the trauma team’s averted gazes. I say nothing, but inside, I grasp at explanations. He’s been popped with two bullets. Maybe he’s scared, anxious, emotionally shocked. Or he’s a thug, a power-fiend, and now he’s vulnerable. He distrusts authority. Perhaps he is drunk, his tongue greased.
He refuses intravenous fluids, blood draws, x-rays. “Let us take care of you,” I say, proffering shared control, thinking he’ll soften up and participate. “You don’t want to die, do you?”
“I’m not afraid of dying,” he says, despite his plea on arrival. “Listen up, douchebag. Are you calling my cousin or what?”
I swallow hard. The ache in my stomach will ease somewhat when I find time to eat my tuna sandwich. But the frustration feels bottomless — untouchable and undeniable. “What gives you the right to talk to us this way?” I finally say.
He stares me down. I tear the blood pressure cuff from his right bicep.
“I’m not fighting you. Many patients are waiting to be seen. You’re free to go if you want.”
He stares at me. “I’m calling my lawyer!”
“Good luck. We’ll dress those wounds before you leave.”