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Interviewer: A day in the life of an emergency room physician or in this case, a night in the life, that's next on The Scope.

Announcer: This is From the Frontlines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care and I thought it would be kind of fun to go through a typical shift, the things that you encounter in an emergency room as one of your typical days. Is there even such thing as a typical day for you?

Dr. Madsen: I think you would probably say that the typical day is atypical because it always changes.

Interviewer: But you have a list. You keep track of everything you see every single night for whatever reason.

Dr. Madsen: I do. I keep track of it mostly because I need to remember to finish the charts to make sure I get those done but I do keep track of things. I also use my list of follow up with people, give them phone calls to make sure they're doing okay if it's someone I'm concerned about.

Interviewer: Got you. So let's just go down this list and see some of the things that you encounter and if any questions come up, I'll ask them but I think this should be really interesting.

Dr. Madsen: For sure. So this is a typical night shift and I'm certainly not going to reveal any protected health information or anything specifically about these individuals but these are the kinds of things we see in an emergency department.

So I walk into ER and the first thing I see is someone who is there with a fever. They've come with a fever as the first patient I go in and see, it may have been for whatever reason but their chief complaint, as we call it, the thing that's on the chart, on the board is that they have a fever and I have to try and figure out why they have that fever.

And then there's someone with a headache. The next room I go to and typically what I'm doing, I'm coming into a shift and there may be four or five patients waiting to be seen. Maybe they've gotten some testing going. So I'm saying, "Okay, fever, next one's headache."

Next thing I know someone's coming in who has had some burns. They've had some burns they sustained from flash burns where something exploded in their face. So I'm going in to see that person next, and then moving on from there to someone who has a laceration on their face. They were injured. They have a laceration I need to repair.

Interviewer: It's a cut?

Dr. Madsen: A cut yes.

Interviewer: Okay.

Dr. Madsen: Yeah a cut on the face, and so these are all of the things that are on my mind as I walk into my shift. I'm thinking okay, what do I need to address first? I've got this facial burn. I need to make sure this person is breathing okay, that it didn't affect their airway. Thinking on the laceration, okay I could probably wait on that. I'm going to check and make sure there are no other injuries.

Interviewer: So you have to make these decisions who you're going to see first. Somebody else doesn't do that for you.

Dr. Madsen: Oh, absolutely, I do.

Interviewer: Okay, so you've got a list of the things that are there and then you got to go oh, this is going to be the first thing I want to check out.

Dr. Madsen: Exactly.

Interviewer: Okay.

Dr. Madsen: I'm looking. I've got these patients I need to see and if someone there has chest pain or I can look at their vital signs, if their vital signs are abnormal I'm getting into that room first and I'm prioritizing all the time in the ER, who do I need to go see right now of those I've been seeing, of those who are new? Where do I need to go first?

Interviewer: So obviously somebody who is having difficulty breathing is going to be seen before I'm going to be seen with my broken arm.

Dr. Madsen: That is exactly right. We're going to go in to see that person first.

Interviewer: And the ABCs, let's talk about that just briefly.

Dr. Madsen: Yes.

Interviewer: Those are the three important things that you're looking for, go ahead and explain that.

Dr. Madsen: Yeah ABCs, we're always thinking airway first, making sure their airway is intact. They can move air through it. Breathing, making sure they are breathing. And then circulation, making sure they have a heartbeat, a blood pressure. Those are the three priorities I'm always thinking through. So if I look at someone's vital signs and their blood pressure is 70/40, I'm in that room immediately and the person with the facial laceration can probably wait.

Interviewer: Okay got you. All right, keep going.

Dr. Madsen: Yeah, so that's kind of what I start out with on the night shift. The next thing I see is someone who is pregnant, someone who is coming in with some pregnancy issues, maybe in the first trimester, the first third of the pregnancy, possibly having some bleeding during pregnancy, someone I would go in to see how are things going with their pregnancy. Are there any issues there we need to address?

And then someone who is confused, and this is a common thing we see in the emergency department.

Interviewer: Really?

Dr. Madsen: Yeah, it is and it's usually older people, often times someone who maybe in a care facility, who someone in the facility says this person is not acting quite right and the challenge there is it could be any of a number of things going on. So I've got to kind of throw out a net, as we say in that situation, often times running lots of tests to try and figure out what could be causing the confusion.

Interviewer: Could confusion be life-threatening?

Dr. Madsen: It could be, yeah.

Interviewer: That could be a symptom of something life-threatening for somebody.

Dr. Madsen: Oh it could be. I've seen cases where, and you just see them again and again so you kind of get programmed to think, oh maybe it's a urinary tract infection, maybe it's their medications, but I've seen cases of people who have had bleeding in their brain. Basically they're just saying, "Well, they're confused or not, acting quite right." They may have had a fall at some point and had blood that accumulated and no one knew they fell. So you've got to really look for heart attacks. You've got to look for infections. You've got to look for signs of trauma, all those sorts of things.

Interviewer: Okay.

Dr. Madsen: And then from there I again see someone else that has a headache. Someone else came in that also had a headache.

Interviewer: All right, so how often are headache's actually a good reason to go to the ER?

Dr. Madsen: That's a great question. A lot of people have chronic headaches and they know when to go to the ER for those because they just cannot manage their migraines at home. Big headaches that we worry about are those that are worse than previous headaches you've had or sudden onset severe headaches. If you had a headache plus a fever, we think about meningitis.

So those would all be reasons to go to the ER and all of the things that I'm thinking about is I see okay, the next patient I'm going to see has a headache. From there I saw someone who is suicidal, someone who actually came in saying they had had thoughts of hurting themselves, may not have made an actual attempt, but that's certainly a reason also to go to the ER and yeah.

Interviewer: I didn't know that.

Dr. Madsen: Yeah, we see that quite commonly and partly I think because our emergency department, because we work closely with the University Neuropsychiatric Institute. So a lot of patients who are admitted there will come through us, but I would say over the course of a shift, I very commonly will see at least one, maybe several people come in who are there for either a suicide attempt or thoughts of suicide.

After that I go in to see someone who is there for what we call a "crisis evaluation." This is addressing psychiatric complaints, psychiatric issues and not necessarily suicide, maybe they've been more depressed. Some people have chronic psychiatric issues. They may have had issues where they're not taking medications and have become very manic or had a lot of issues associated with that.

And then from there I saw someone with atrial fibrillation. So this is an issue where the heart's beating very rapidly, where it's just sometimes so quickly that we have to actually give them a shock to get it back into a normal rhythm and that's something very commonly we'll do in the emergency department.

Interviewer: Like a shock like "boo" or how do you shock them?

Dr. Madsen: We shock them with electricity?

Interviewer: Really? To get their heart going to where it should be again.

Dr. Madsen: Yeah, exactly and you may have seen on movies where people pull the paddles down. They're holding the paddles on their chest and then everyone says "Clear" and then they shock. It's not quite that dramatic but it's pretty close.

Interviewer: Really? So that's what it looks like.

Dr. Madsen: Yeah, you're actually delivering electricity to the heart to take it from an abnormal rhythm and try and shock it back into an organized rhythm, and I'm not just walking in the room grabbing paddles and putting it on their chest. These are people who come in, they're talking to me, they know when it started. It may be the first time it happened or they may be familiar with this from before. Maybe they've been shocked in the past. I make sure they would meet qualification to be able to undergo this procedure safely, but then I give them medication to sedate them and give them a shock.

Interviewer: Okay.

Dr. Madsen: Yeah. From there I saw someone who is short of breath and who came in saying they just weren't breathing well. After that an allergic reaction, a severe allergic reaction. We had to give medication for it to treat it. And another fever patient, someone else with a fever and I finished up the night with another case of a rapid heart rate and atrial fibrillation.

Interviewer: That is quite a night. How long is your shift?

Dr. Madsen: The night shift's scheduled for eight hours. I usually plan I'm going to be there about ten hours, just wrapping things up and taking care of patients at the end of the shift. So that's a pretty typical day or night in the ER.

Interviewer: And from that typical day or night, I don't even know if I should ask this question, how many of those people actually made the right choice coming in?

Dr. Madsen: As I look back on these, I can't really say that any of these, I would say don't come in. These were all, as I'm looking back specifically at these, and again it's been a while ago. I'm not going to say when all this happened because I don't want to tie this into any potential health information on anyone but these all seem like fairly legitimate reasons to go to the ER.

The other issue at night is there are no urgent cares. So it's not like you can go to an urgent care or call your doctor and be seen in the middle of the night for your facial laceration and things like that.

Interviewer: Sure. Well that's very, very interesting. So I think the interesting thing for me was, my perception always was you'd see a lot of broken bones, a lot of cuts, a lot of that sort of thing, but there's quite a variety of reasons somebody might come to the ER.

Dr. Madsen: There is. You see a little of everything and that's what's fun about it. Like I said, you go from the room of someone who is pregnant to someone who is having a heart issue, to someone who is having trauma, to someone who is having a psychiatric issue, kind of the full spectrum.

Interviewer: That's really interesting insights on things that I wouldn't have expected in your list there. What are some things that weren't on the list that you do tend to see typically but maybe just not that night?

Dr. Madsen: One thing we didn't see a lot of that night was trauma. Lot of people coming in injured and the most common sort of trauma we see is motor vehicle accidents and injuries from that. We also see penetrating trauma like stab wounds or gunshot wounds. Occasionally we see that. We didn't see any of that that night either.

Another common thing we'll often see are infections, things like pneumonia or people just coming in with upper respiratory infections. I didn't see a lot of that that night either. So it's kind of funny in the ER, that's the fun thing about it that you never know what you're going to get. There are some nights where it seems like you just cannot get out of the trauma room. It's just one accident after another. Other nights, you may not even go in the room.

Interviewer: Yeah and other nights, it might just because lot of people that are confused.

Dr. Madsen: Exactly.

Interviewer: Like confused old people coming in for whatever reason.

Dr. Madsen: That's exactly right. We didn't have a lot of that that night either but there are some days where that seems like that's all you see are older people coming in confused and not sure what's going on and then you have to really kind of look for a lot of different possibilities in those scenarios.

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Dr. Miller: What happens in a level 1 trauma center? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. David Rothberg. He's an orthopedic surgeon specializing in trauma surgery. He's also a professor of orthopedic surgery.

David, tell us a little bit about what it means to work in a level 1 trauma center as an orthopedic surgeon.

Dr. Rothberg: Well, we're a member of the team that takes care of patients on their worst day generally. A lot of the patients that come to a Level 1 trauma center are patients who have been in a car accident or have fallen from an extreme height or some sort of accident along these lines. And we're a member of the team along with the general surgeons and neurosurgeons that take care of all sorts of trauma. Anything you can think of, from head trauma, spine trauma, belly trauma and extremity trauma.

Dr. Miller: So these could include industrial accidents. It could include automotive accidents. Just about any type of traumatic injury that would involve, what, multiple organs or just orthopedic injuries?

Dr. Rothberg: Really multiple organs. Orthopedics tends to take a lead role, often times in the operative care of these patients. But we're a member of a huge team and what it means to be a level 1 trauma center is that we can take care of anything.

Dr. Miller: Give me some examples of the types of injuries you particularly take care of.

Dr. Rothberg: In orthopedic trauma, we take care of just about any broken bone or soft tissue injury, but our specialty has evolved around the care of pelvic and acetabular fractures and fractures into people's joints.

Dr. Miller: Do you see these types of injuries mostly in automobile accidents?

Dr. Rothberg: They can be in automobile accidents but we see them ranging from recreational activities, like rock climbing to industrial accidents like you mentioned.

Dr. Miller: Now in a patient who's being sent to a level 1 trauma center, how far away are they coming to our center from? What is our outreach or ability to take care of these patients in terms of geography and distance?

Dr. Rothberg: Well, we're fortunate to have an incredibly large geographic catchment that involves Idaho, Montana, Nevada, parts of Northern Arizona, Wyoming and occasionally people from all around the United States who may be here.

Dr. Miller: Would the patients who are injured then be sent directly to us by helicopter or fixed wing or would they come from another hospital usually?

Dr. Rothberg: It's really variable. We have an incredible active helicopter service because of how large the geography is. But we also consult with physicians and outside hospitals who have patients that are above and beyond what they can take care of. And so we are commonly talking with them on the phone, brining patients here to help with their definitive care.

Dr. Miller: Tell me a little bit about the families of these patients. How are they directed to our hospital to follow up on their loved ones and be sure they're being taken care of?

Dr. Rothberg: That's an incredible process. So in the very beginning it's really patient-focused but as soon as that level 1 trauma activation, which can vary in time but usually is quite quick, somewhere in the ballpark of 15 to 30 minutes, we're already involving the patients. They've been in the ER talking with our social workers and then our surgeons and other providers are already talking to them as soon as possible.

Dr. Miller: Now you work with other types of specialists outside of orthopedics. Could you talk a little bit about that team approach? I mean, what happens when a patient hits the emergency department and they come in with a trauma? How do you begin to take care of them in conjunction with other specialists?

Dr. Rothberg: What happens is the general surgeons are usually kind of the quarterback of the football team. They're really in charge of what's going on in the trauma bay, along with the ER doctors and the anesthesiologists.

But when they come in, it's an incredible amount of people that are there on the spot, so orthopedics and neurosurgery and EMT and plastics. They're all there so that all injuries can be identified and taken care of in a timely manner. But we end up being involved with the vast majority of these because of the amount of extremity injuries that are involved in these traumas.

Dr. Miller: Sounds like chaos.

Dr. Rothberg: It can be but it's a pretty incredible process that we review and have almost a script that we follow each time so that nothing is missed.

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