PART V: THE E.D.
Dr. Leah Palifka examines Matthew Harris of Brockton, a diabetic who had a blood sugar level 10 times the norm when he arrived in the emergency department at Signature Healthcare Brockton Hospital.(Tim Correira/The Enterprise)

ON THE FRONT LINE: Residents take a turn in the emergency department

Like all the patients Dr. Leah Palifka saw in the emergency department, she knew little else about her patient except what he and his blood tests told her. But she had to figure out quickly what was wrong — asking anything and everything that might divine not just an answer, but a cure.

By Jessica Scarpati, Enterprise staff writer

   Matthew Harris was lying on his side in the hospital bed, saying his head was spinning and his tongue felt thick and dry.
   The young man from Brockton felt miserable. He groaned. He barely lifted his head. A painful tube snaked into a vein on top of his hand; he swore it was hitting a nerve. His speech was slurred.
   Harris, 20, rested his head on his inner biceps as he tried to focus on the questions Dr. Leah Palifka drilled through.
   Any belly pain? How are your bowel movements? Were you hospitalized recently? What medications do you take right now?

E.D. SHIFTS

   On any of the three daily shifts in the emergency department at Brockton Hospital, there are:
— Four doctors
— Two physicians assistants
— 13 nurses
— One intern
— Occasionally, one medical student

   Harris had come to the emergency department at Signature Healthcare Brockton Hospital — where Palifka has been training to be a doctor for the past year — complaining of dizziness.
   Like all the patients she saw in the emergency department, Palifka knew little else about Harris except what he and his blood tests told her.
   But she had to figure out quickly what was wrong — asking anything and everything that might divine not just an answer, but a cure.
   In the emergency department, or “the E.D.” to those who work there, doctors and nurses face a nonstop onslaught of people with medical problems who can’t or won’t wait to see their family doctor.
   Chest pains earn an automatic overnight stay, even if the patient is not having a heart attack, doctors there say. The pile of charts Palifka sorts through most days start with complaints of dizziness and breathing troubles, she said.
   Clues about what was ailing Harris, the young man from Brockton, came in spurts of information — some useful, some not.
   He was under some stress lately. He was moving the following week. He had stopped taking his medication to control his bipolar disorder about a month ago. He had been smoking since he was 14. His vision was blurry. He had high cholesterol. He was a recovering addict. He had a family history of heart disease.
   Oh, and he was at the end of his insulin supply.

LIFE IN THE E.D.

    Mondays are the busiest days in the emergency department but mostly filled with patients with minor complaints who couldn’t get an appointment with their regular doctors.
   Friday and Saturday nights are more likely to bring trauma cases — victims of shootings, stabbings car crashes.

   “They might be a little expired,” he confessed. He has been diabetic since he was 9.
   She had seen the test results with his blood sugar level before she came in. It worried her.
   “It’s really high today,” Palifka told him, flipping through the test results.
   “How high is it?” he murmured.
   “About a thousand,” she replied.
   A normal blood glucose level for someone who has not eaten recently is between 70 and 130 milligrams per deciliter of blood, according to the American Diabetes Association.
   She conferred with a staff physician, who agreed with her assessment — Harris needed to go the critical care unit and fast.
   Hyperglycemia, or high blood sugar, doesn’t usually become fatal as quickly as low blood sugar, Palifka said, but his life could still be in danger.
   Had he not come to the hospital, “he could die,” Palifka said.
   Although the residents are unlikely to be the primary caregiver for someone who staggers into the E.D. riddled with gunshot wounds, they’re not just putting on Band-Aids.
   “When they do their rotation, they’re really expected to see all types of patients,” said Dr. Henry J. Grazioso, one of the E.D. physicians who helps oversee the residents who are required to spend a month there as part of their training.
   Cuts, colds and minor injuries are part of the workload, Grazioso said, but the interns are there to learn to handle anything — including life-threatening conditions — with the oversight of a staff physician.
   No one hovered over Palifka’s shoulder as she pulled folders from the bin that contains medical charts of all the patients in the ED.
   Interns maintain their own workload and there is no daily minimum. A typical eight-hour shifts means they will see four to six patients.
   They confer with staff physicians, commonly referred to as an “attending” or “attendant,” for every case — just as in other areas of their training.
   “We ask that if they identify what they consider to be a truly emergent condition, then they need to involve the attendant that’s supervising them immediately,” Grazioso said.

PLAYING CATCH-UP

   On her rotation in the emergency department, Dr. Leah Palifka had to log 140 hours there in four weeks.
   But she also had the third round of her licensing exams in Rhode Island her second week into the rotation, which meant she would spend most of those first two weeks studying.
   That left her with two weeks to fulfill most of her hours.

   “But for other purposes of patient care — as long as there is not a critical condition going on — they are essentially responsible for the full breadth of the patient’s care,” he added.
   On a recent weekday afternoon, Palifka filled out the form to order a slew of tests — blood count, electrolytes, cardiac enzymes, chest X-ray, EKG, toxicology screening — for the 46-year-old man who came in complaining of headaches and dizziness.
   She poked her head in a few rooms to look for the attending physician assigned to her that day to confirm her orders. But couldn’t find him.
   That was when Palifka noticed a flurry of doctors and nurses in a nearby room.
   “I’m just going to check to see if he’s in that room. I think they’re having trouble in there,” she said before ducking in.
   Palifka emerged minutes later, snapping a latex glove onto her hand.
   “It looks like they’re resuscitating a patient in there,” she said. “I’m going to jump in.”
   Even if the interns can’t take the lead on critical cases, such as the young woman in critical condition that afternoon, doctors in the E.D. encourage interns to expose themselves to everything.
   Cherry-picking cases — whether it’s to look for an exciting one or an easy one — is frowned upon.
   “What we ask them to do is to see patients in the order they come in,” Grazioso said. “It’s very tempting when you’re a physician in training to sift through the charts or to sort of pick among the patients that you feel the most comfortable with.”
By Jessica Scarpati, Enterprise staff writer

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   A woman finds a lump in her breast. Her doctor schedules an MRI — an expensive, inconvenient body scan that can take hours — to look for anything unusual in the tissue and sample it with a needle to see if it’s cancer.
   The magnetic resonance imaging machine is very sensitive — sometimes too sensitive, according to Dr. Justin Routhier, a medical intern at Signature Healthcare Brockton Hospital who has been researching the way breast cancer is screened.
   “MRI is relatively new. It’s the most expensive to do, but the benefit is it’s very good at picking up abnormalities,” he said, noting not all blips the machine picks up are cancer.
   “But the question is, what do we do with all these results?” Routhier added. “You don’t want to send the patient to the operating room every single time.”
   Routhier, who has spent the past month compiling his research into a manuscript for publication, said he hopes to help find a way to improve the way breast cancer is diagnosed.
   Working with one of his former colleagues at Brown University, where he studied medicine, Routhier studied a group of 64 women in their early 50s.
   About half of the women had abnormalities that could be seen on an ultrasound, he said. A 50-50 chance wasn’t good enough.
   “The point of the study was to see if you could actually predict which patients will have their lesions seen on ultrasound,” Routhier said.
   His analysis found that of those women who responded to ultrasound, their lesion was more likely to be seen if it were a “mass,” or lump, as opposed to lesions that are small speckles, clustered clumps or stringy lines.
   Routhier couldn’t prove if a “mass” was more likely to be malignant, or cancerous, but he came close.
   “We found that just by virtue of being seen on ultrasound, it’s more likely to be malignant,” he said.