Tonight I'm spinnin' a little Son Volt and sippin' 15 year old Macallan...and needing a break. I got some time off last week to prepare for my Board exam which was last Thursday. Prior to that I had about the worst two weeks that I've had in my new employment. Gone are the County days, and while I saw more than my fair share of critically ill, the community ED is a melting pot of critically ill trauma, pediatric and geriatric patients that you don't get in the compartmentalized world of tertiary care medicine...and I have a black cloud. I walk through the door and the shit follows.

For the better part of the two weeks, I was working the early shift which means I'm on my own. Start at 6, the EMS radio usually goes off around 7 with the first nursing home run of the day (hey, it's bed check) and we're off and running. Most of it comes down to pattern recognition or plug the holes as they arise, a sort of paint by numbers approach. Occasionally, you get the, "I know this patient looks bad, and I know this real subtle ECG finding is bad, but I can't articulate why because I have two other critically ill people to take care of" to the cardiologist who grudgingly takes the patient to the cath lab only to find a horrendous blockage in the left main coronary artery and the man needs a bypass, not a stent. I've earned some street cred for later.

Occasionally, a real sick child comes in. And sphincter tone increases. Kids don't get sick and when they do, you need to act fast. Seconds and minutes matter. They will compensate for awhile, but once the start to slip, the decline is precipitous. This baby was working real hard to breathe and didn't even move while the nurses were getting in the IV. I had intubated her and with IV fluids running and antibiotics within ten minutes of hitting the door. She was maintaining her blood pressure and being mechanically ventilated. Stability...or so I thought. As the lab results came back, it seemed to be more than RSV bronchiolitis, perhaps an inborn error in metabolism, diabetes...I don't know. Nothing fit. She was transferred out after I spent another two hours trying to work it out in consultation with a neonatologist and the peds ICU at the accepting hospital. Two days later, she was brain dead. No autopsy. I would like to know if I could have done anything differently, but now it's a lost opportunity. Ten fingers, Ten toes and twenty-one holes?

The break did nothing to change my luck. The black cloud has followed for the past four days culminating in Monday, the busiest day of the week. I seem to attract the nursing home patients with the Do Not Resuscitate order that is mysteriously absent from the nursing home chart only to be found after I've intubated the patient, put in the central line and admitted to the ICU. Unbelievable. Today I was 1 for 2 (thankfully, the hospice nurse poked her head in at the right time to save me from batting 1.000).

I was at a funeral for a friend of mine and got together with some high school buddies that I hadn't seen for awhile and my old cross county/track coach who was like a second father through my high school years, and he asked me if I take the work home with me. Well, I certainly don't take it, I would rather leave it behind, but sometimes it follows me. Cheers.