Several months ago, I stepped into the role of attending. No more safety-net superior to catch my resident mistakes. I became the sole decision maker. Yet venturing out on my own did not worry me, because as a senior resident nearing the end of residency, my confidence was at an all-time high. One might say I was a little cocky. However, patients are the ultimate teachers, and that cockiness would soon disappear.
It was during one of my first moonlighting shifts after graduating residency when the experience of being a single-coverage provider truly set in. The patient was a middle-aged man who presented to the emergency department for arm pain. As I looked at his chart on my computer screen, I noticed he was tachycardic and febrile, with a relatively low blood pressure. As I went to assess him, he actually looked better than his vitals indicated. He told me that he had a history of a chronic nonunion fracture in his left arm and, over the last three days, had worsening swelling and pain in that same arm. On exam, he had fairly prominent swelling, erythema, and tenderness over his arm. In my mind, I knew he was septic, likely from an overlying cellulitis, but I kept things like osteomyelitis and necrotizing fasciitis in my differential. I initiated sepsis orders, started him on IV fluids and antibiotics, and ordered a CT scan of his arm. I left that room thinking it would be a straightforward case, and that I had a clear plan in sight. I was woefully wrong.
Twenty minutes later, I got called by the nurse to assess the patient because she thought he might have ventricular tachycardia (V-tach) on the monitor. I raced to the patient’s room to assess the situation. He looked at me, bewildered as to why I looked so frantic. I looked at the monitor, , and it was definitely V-tach. I asked him how he was feeling, and he said he felt fine. I took his blood pressure and it was stable. I turned to the nurse and told her to place cardioversion pads on the patient, transfer him to a resuscitation room, and start a procainamide drip.