A day in the life: RiverBend emergency department physician Bianca Jacobs

Editor’s note: This day-in-the-life portrait is based on an interview with the doctor as she referred to her notes from the day, with careful attention to patient privacy. The reporter was not in the emergency department and did not witness the events described.

A 68-year-old man with chest pains.

Dr. Bianca Grecu Jacobs strides down a long hallway to the room he’s been taken to, one of 44 private single-patient rooms, along with two twin-bed trauma bays that make up the emergency department at PeaceHealth Sacred Heart Medical Center at RiverBend.

Her nine-hour shift began at 6 a.m., when she examined a woman who was 10 weeks pregnant and bleeding.

With precision born of training and practice — Jacobs, 41, has been an emergency medicine doctor for 11 years — she asked a series of questions, performed external and pelvic exams, and put in orders for an ultrasound and blood work.

She is focused and efficient — the work demands it — but not detached. She chose a career in medicine because, she says, “I want to help people.” Then she smiles and shakes her head. “Yes, I know that’s obvious, a cliché. But it’s true.”

What tethers her to emergency medicine, an unrelenting and exhausting job, is that she gets to problem-solve in the moment. She must be an expert, not in curing but in diagnosing, in distinguishing quickly between the superficial and the serious, the chronic and the critical.

In these brief encounters with dozens of patients during a single shift, she has to know what questions to ask and how to parse the answers. She has to listen to the heart and the lungs but also the stories.

She has to know what tests to order, how to read the results, what decisions to make, when to call in consults, and when a patient needs to be admitted to the hospital, stat. And she has to do it quickly without getting it wrong. This is the revved-up engine that powers her days.

She will tend to the pregnant woman for perhaps 20 minutes, circling back to her room when test results come in. But now she is with the man who experienced chest pains. He is not in distress at the moment, which is good, but she learns he has a history of high blood pressure and diabetes. She orders an EKG and blood work. She’ll wait for the test results, but the risk factors worry her. He needs a stress test and an angiogram. She starts the process of admitting him to the hospital.

Recently, Jacobs and her ER colleagues at RiverBend — 32 doctors and nine physician assistants — won a major victory when PeaceHealth agreed to renew their contract, preserving local control over patient care. Behind that administrative story is the day-to-day work of doctors in the emergency department. What do they do? What does a shift look like? Who comes to the ER and why?

Jacobs moves quickly to the third patient of the morning. Behind the pretty emergency department waiting room with its stone fireplace, earth-toned tile floors and soft lighting — the RiverBend aesthetic — the department is no-nonsense, utilitarian, organized as a grid with five 60-foot-long hallways lined with standardized equipment-packed rooms.

There are defibrillators, pacemakers, mechanical ventilators, and carts stocked with endotracheal tubes, laryngoscopes, video scopes, and suction devices. Rapid infusers, crash carts, wound care supplies, personal protective gear. And more. The goal is for each room to be set up identically to eliminate wasted motion.

Because there are no intersecting cross hallways, getting from a room along one hallway to a room in another — often at more of a jog than a walk — can be a significant journey. Jacobs doesn’t bother to look at her smartwatch. She knows she clocks thousands of steps during a shift.

Now she makes her way to a room on a parallel hallway where she finds a 60-year-old woman who is experiencing dizziness. She is losing her balance. She is falling. As Jacobs takes her medical history, asking increasingly specific questions, she sees this will be a complicated case. The woman has metastatic breast cancer that has traveled to her brain. Jacobs needs to find out more, and quickly.

She conducts a neuro exam. This is a compact, highly targeted check that will help her evaluate the seriousness of the situation and make a decision about what to do next. She goes through it with her patient: What’s your name? What day is it? Where are we? Follow my finger. Look at the light, smile for me, raise your eyebrows, squeeze, push, hold … 

She orders a blood test and an MRI. She’ll have to wait for those results. Waiting for test results is a big part of her job. 

In the meantime, she has another patient, an octogenarian brought in from a nursing home who, according to staff from the nursing home, is “not her normal self.” The woman smells of urine and has elevated blood pressure. Did she fall? Did she have a heart attack? Is she suffering from pneumonia?

Jacobs orders a series of tests to find out. She calls the nursing home. She speaks to the woman’s family. When the lab results come in an hour or so later, the diagnosis is neither dire nor life-threatening. The woman has a urinary tract infection. She is discharged to a family member with a prescription for antibiotics.

Her next patient is a 50-year-old man with sudden abdominal pain so severe that he is vomiting. She gets an IV started to deliver pain medication. She takes his medical history. She orders blood and urine tests and a CAT scan to check for internal injuries, organ damage, tumors. Again, she must wait for the results, but the medication is helping relieve his pain. She leaves him to go on to her next patient. She’ll be back when the lab results come in.

These are not the thrilling cases that make for gripping ER television drama: explosions, building fires, raging epidemics. In actual emergency departments, the vast majority of visits are for chest pain, stomach aches, minor cuts, infections and chronic illness flare-ups. Broken bones, pregnancy complications and, especially this time of year in the Willamette Valley, asthma attacks are a part of Jacobs’ world. Drug overdose cases and people in the midst of psychotic episodes also come to the ER, which has a separate hallway just for psych patients, who may be loud or disruptive, or sometimes violent. 

Jacobs’ patients are babies and octogenarians, teens, college students, and, not surprising given lack of healthcare and dire living conditions, a significant number of people who make their home on the street.

There is a crazy rhythm to her days and nights — she sometimes works shifts that begin at 10 p.m. and end at 7 a.m. — that defy dramatization. It is not about delivering babies or extracting metal spikes from the torsos of bridge workers. It is about ping-ponging between the critical and the commonplace, the urgent and the ordinary, making decisions that must be fast and right.

“I compartmentalize,” is what she says about her ability to handle all this. She laughs. “I am very good at that.” She also debriefs with colleagues, exercises and goes home to an entirely different kind of energy: her 6- and 8-year-old children.

She says she’s tired. But her eyes are clear, and there’s no slump to her shoulders. Her pale blue scrubs are, miraculously, spotless.

“I am drawn to this job,” she says. “I knew I wanted to do this long ago.”

As an undergraduate at the University of Pennsylvania, she worked as a tech in an emergency department, wheeling patients into rooms, taking them to get scans. After earning her M.D. at Jefferson Medical College in Philadelphia, she did her residency in Sacramento, where one of her colleagues was from Portland and regaled her with the beauties of the Pacific Northwest. Case closed.

She rushes to her next patient, a 70-year-old woman who may have suffered a stroke. “Stroke alert” protocol means fast action: an IV to deliver clear fluids, an immediate CAT scan, a call to one of the hospital’s neurologists. Jacobs gets the woman admitted to the hospital. She has done what she can.

Now she has a minute, literally, to grab a cup of coffee. She drinks it as she logs on to one of the computers at the work station, scanning charts, entering data, checking updates on the tests she’s ordered.

It’s early afternoon. She tends to a 92-year-old man, brought in by an ambulance, who fell. She orders labs and a CAT scan, staples the cut on his scalp. Moves on. She’ll circle back when the results come it. Her next patient is a 30-year-old intravenous drug user with an abscess at a needle site. She gets an IV antibiotic on board, orders blood work, and listens to his concerns about what will happen to his two dogs in his absence. He has to leave, he tells her. He pulls out the IV.

An ambulance brings in a car-crash victim who is considered a “modified trauma,” meaning the man is at moderate risk for severe injury. This is one important step below the bloody television episodes that focus on life-threatening crashes that require heroic efforts. The man is conscious. His heart rate is elevated, and he has belly pain. Tests will show if there are other injuries.

In another room Jacobs finds a teen who attempted suicide by overdosing on ibuprofen. In massive doses, this common over-the-counter medication can cause serious harm, from violent vomiting to kidney failure to coma. The teen didn’t take enough to cause great damage, but Jacobs is still on alert. She talks to poison control, gets an IV line going with fluids, and brings in a crisis worker to talk to the patient. The suicide attempt was the result of bullying at school.

The final patient of the shift is a toddler, a 3-year-old who fell from a couch and hit his head. Talking to the parents, who are understandably distressed, Jacobs finds out that the child didn’t lose consciousness — which is good — but he took a long nap, and he vomited three times, which is concerning. Jacobs conducts a detailed exam and orders a CAT scan.

All the lab results are in now: The pregnant woman she saw nine hours ago? The labs came back with the good news that the baby was fine, and the pregnancy was stable. The man with severe abdominal pain? It’s a kidney stone small enough, according to the consulting urologist, that it has a good chance of passing naturally. That Beltline crash victim? No internal damage, just scrapes and cuts. And the 3-year-old? He’s an active toddler who took a bad spill.

It’s 3 o’clock, the end of this shift. She’ll be back for another one tomorrow, and the day after that. She tries to schedule no more than four consecutive shifts a week, but sometimes there are five. And occasionally more. 

It’s close to 4 p.m. before she leaves the hospital. She wraps up paperwork, updates charts, debriefs incoming colleagues about her patients. Finally, she makes her way to the locker room, exchanges her work phone for her personal phone, checks messages, exchanges her work shoes — Hoka sneakers — for home shoes and rushes to pick up her two kids at school aftercare.

This is a piano lesson day. (Some days it’s a soccer day.) That means she has a half-hour for a quick jog or a little walk. Exercise resets her clock. She needs that. She heads home with the kids. There’s dinner to be cooked.