When I was growing up, there were two things that I wanted to be more than anything: a doctor and a writer. Before I pursued medical training, my very first dream was to be a novelist. My childhood journals and old home computer were always littered with story ideas and the beginnings of novels. Even as I prepared for a career in medicine, I also maintained my love of storytelling and writing. I majored in American History & Literature while doing my pre-med classes, I pursued a journalism degree prior to going on to medical school and I started working as a freelance writer. When I began residency in Emergency Medicine in 2015, I knew that writing would have to take a backseat as I completed my clinical training, but it's also something I've missed a great deal over these past few years.
That is why I’m so excited to share my new essay, "Exposed," which appears in the latest issue of Annals of Emergency Medicine. I’m grateful for the opportunity to join these two passions, to take an experience in medical training that was challenging and formative and share it with others in my specialty through creative writing.
This essay centers on an experience that I hope will resonate with other healthcare providers: the dreaded needlestick injury. The piece examines the constant threat of the unknown that all clinicians come to know well, a fear that also helps keep us sharp and ready for anything that comes through the door. I attempt to capture how this anxiety and uncertainty mix with the thrill of discovery and capability during medical training. The lesson for me was that such an experience reveals an inherent truth of our field: the risks and rewards of medical practice are inextricably linked.
You can read my essay, “Exposed” for free until September 7, 2018 here:
Thanks for reading!
Thanks so much to all my friends and colleagues for voting for my submission to the 2018 Essentials of EM - Academic Life in EM Visual Design Competition. Congratulations to the winners, Dr. Liz Fierro and Dr. Natasha Li from Loma Linda University Health! While my entry was not selected for the grand prize, I was happy to see that it garnered the most views of all the submissions (over 6,000 as of this post). I'm very grateful for the exposure and all the supportive feedback from my EM colleagues.
I am very excited to announce that I have been selected as a semifinalist for the 2018 Academic Life in EM - Essentials of EM Visual Design Competition!
4 semifinalists were selected from submissions in various topics in emergency medicine. My submission was inspired by my recent blog post (see below) and is an infographic on management of calcium-channel blocker overdoses. The winner of the competition is selected for an EM Education Mini-Fellowship and is awarded travel to this year’s EEM Conference in Las Vegas in May 2018 where they support multiple aspects of the conference.
I would greatly appreciate your support! Voting is open to the public until Saturday, January 27 at 8pm. Please feel free to share!
Recently, I took care of my first patient with a major calcium channel blocker (CCB) overdose. He was a middle aged man with unknown past medical history who had reportedly taken 20 tablets of diltiazem 120mg ER in a suicide attempt. Initial blood pressure in the field was 60/32, heart rate 30-40s. Knowing on an abstract level how sick these patients can get is one thing. Seeing it firsthand is something else entirely. Here are some lessons learned from a harrowing toxicological encounter.
Fortunately, this patient did well and ultimately did not need any 'end-of-the-line' therapies. This was a challenging yet valuable first brush with one of the sickest of all types of overdose patients. Like all difficult cases in the ED, teamwork and good communication were the bedrock of successfully managing the overdose.
In the emergency department, we deal with a large volume of sick patients. Not only are many acutely ill, but they are often undifferentiated. Our daily lives include encounters with sepsis, STEMI, and shock and no shortage of other surprises. As a result, we develop a certain level of comfort with these high-stress situations.
Yet there are some encounters that move beyond even the daily ebb and flow of high acuity. These are the scenarios that make us break out in a cold sweat as the CMED call comes in. The ones that can form a knot in our stomachs even days or years later. Every clinician has cases like these that are seared into their memory, cases that help us grow as doctors.
We sometimes refer to such patients as 'sick as stink' (SAS) - or even use a slightly more colorful version of the phrase. Though couched in the typical irreverence of the ED, this reference is not used in a derogatory manner. In fact, the expression is one of humility for the ways in which medicine can always continue to surprise and challenge us. It communicates a necessity for vigilance to our colleagues. It is an admission of how much a case affects us. These are the patients whose faces we can conjure effortlessly, who will become a symbol of what we learned, the unforgettable cases.
SAS will be a recurring column on this site, a collection of my most memorable cases (de-identified as always). They will be mainly educational (rather than esoteric), meant to consolidate and share what I learned from these high stress encounters. I hope you enjoy the first installment!
SAS - Episode 1
As I near the halfway point of my third year as an emergency medicine resident, I've been inspired to shake the cobwebs and dust out of the right side of my brain and start writing again. In a previous life, I was a journalist and research writer, but after four long years of medical school and about two-thirds of my residency, that person started to feel a little foreign to me. After finally completing a long-term research project and experiencing the pride of seeing it in print, I began to long for the different but just as powerful feeling of crafting writing born of creativity and imagination rather than spreadsheets and statistics. Starting with the clinical training of my third year of medical school, I've had less and less time for these activities. But I promised myself when I started out at medical school that this part of me would not disappear, that even if it went into a period of hibernation, I would bring it back to light. Now I finally feel that a cloud has started to lift. As the scaffolding of emergency medicine becomes sturdier (though certainly not yet complete), there seems to be space for this other, equally important side of myself.
The goals of this site will be severalfold and I'll attempt to outline them now to give myself a framework moving forward.
And with that, I'd like to re-inaugerate joshuacolin.com. For all of us, clinical practice is just one facet of our lives. I hope that this site will serve as a new outlet for me, to inspire creativity, learning and excellence in clinical practice in both myself and others. Thanks for visiting and enjoy!
1. "We have to remove the bullet!"
Despite the harrowing scenes this trope creates, this one drives me absolutely crazy. A character is shot, oftentimes in the abdomen, and ultimately undergoes a painful extraction of the bullet fragment (whenever suits the plot). Sweat drips from the surgeon's face as he pulls it out, usually with the help of some liquor as an antiseptic, the patient screaming or perhaps gritting their teeth stoically. And with a few hours of rest, that same character is ready to go like nothing even happened (though he or she is obligated to wince from time to time just to remind the viewer). As it turns out, you can still bleed to death from a vascular injury (in seconds) or liver laceration (in minutes to hours) or die a horrible painful death from a perforated bowel and sepsis (in hours to days). Taking the bullet out fixes none of this and has a reasonable chance of making things worse. After learning the anatomy and running real-life penetrating traumas, these scenes just demand too much suspension of disbelief.
It's true that we do say "clear" in the emergency department, though perhaps not as often as on ER or House. This inaccuracy lies more in the delivery. First of all, this doesn't happen nearly as often (which is good because it means someone is on the brink of death). And though it's often a tense moment, this phrase is about communication, not drama. More often, you're going to hear something like, "I'm clear, you're clear, everyone's clear," in a measured voice. Charging in with the paddles defeats the purpose, as 'clear' is about keeping everyone else safe from the electrical shock.
3. "We've placed him in an induced coma."
The concept of a coma is tremendously misunderstood, and television shares at least some of the blame. The term is used carelessly and imprecisely (with tragic consequences) for other types of conditions, such as persistent vegetative state and brain death, from which people do not recover. Some people, for example, those with traumatic brain injury (TBI), do recover and eventually "wake up". But sadly many with severe underlying brain injury will never wake up. And this television inaccuracy creates false hope that creates tremendous suffering for patients and families and a huge burden on the healthcare system.
Pretty much everything in the emergency department is stat (especially in comparison with the rest of the hospital) so it's really not necessary to say it out loud, much less shout it. If you tell a seasoned ED nurse that something is STAT, you are guaranteed to get an eye roll as they go back to whatever they were doing. The only folks I know who still say stat without a hint of irony are neurosurgeons, and they are in a class of their own for many reasons. After all, it literally is brain surgery.
5. "He's flatlining! Charging... clear!"
Sorry, this one is just wrong. Delivering an electronic shock via defibrillator is a method of converting someone from a non-perfusing, disorganized rhythm (ventricular tachycardia or ventricular fibrillation) and resetting their heart to a normal sinus rhythm. You cannot shock someone out of asystole or pulseless electrical activity because there is nothing to reset. All you can do is continue CPR, push epinephrine, and think about reversible causes (and cross your fingers). Put the paddles down, doctor. And speaking of which....
6. Those paddles
Maybe this one isn't so much of an inaccuracy as it is outdated. The television show ER was my first introduction into the field of emergency medicine. And, while I definitely didn't mention this in my residency interviews, at least some small percentage of my choice of speciality came directly from watching it. Gosh darn it, I just want to use those paddles one time, is that too much to ask?! But alas, as it turns out its safer and quicker to apply defibrillation through large sticky pads. Less bad ass, unfortunately, but in the end better for our patients and safer for the ED team.
7. Successful Resuscitation
8. Getting McSteamy
I'm sure it does happen from time to time, but certainly not with the frequency portrayed on television. Though emotions can run high in the hospital setting, it is still our office. Plus the stained mattresses of shared call rooms, crowded supply closets and the blood, piss and vomit of the work day aren't exactly aphrodisiacs. That's not to say that relationships don't catch their spark and blossom in the hospital, they certainly do. But the rest is better left for the bedroom, rather than the supply closet.
9. "He's seizing!"
10. Organ donation
Joshua Feblowitz, MD, MS, is currently a PGY4 resident in the BWH/MGH Harvard-Affiliated Emergency Medicine Residency (HAEMR) Program and a freelance science writer.