Five Days in Texas

As part of our "Holiday Block" I got 5 days off for Christmas and chose to spend those 5 days at home with family. It was very memorable for sure. First we got SNOW on Christmas Eve that lasted well into Christmas Day (yay for White Christmas!) Then my sister and brother-in-law completely surprised us by flying to Texas to celebrate the holidays with us (the sister actually hid behind my bed and jumped out at me after I got home from visiting a neighbor. Scared the crap out of me but it was a fun surprise regardless). We went to Japan House TWICE for great all-you-can-eat Japanese food, and I also met up with high school friends for our annual Christmas get-together. The familiar faces was not restricted to family members; this morning I met up with Anita at IHOP for breakfast, and this afternoon I ran into Doug at the airport; we were flying back to Philly on the same flight. Not bad for a five-day visit =) And while I'm a bit sad to be back in Philly, it's time to get back to work. I had my five days off; now I got a black weekend ahead of me while the other half of the medicine residents get New Years off.

Snowed In

Ever since last week, news was abuzz that a huge snowstorm was scheduled to hit the Northeast this past Saturday and Sunday. When I went to the grocery store on Friday, the lines were ridiculously long as people scrambled to stock up with food in preparation for the storm. On Saturday I had the day off so I watched the snow fall from my window, marveling and how beautiful it was to watch the snowflakes dancing in the air as the world turned white.

All that marvel disappeared this morning when I went to my car and found it half-buried in nearly 2 feet of snow. I couldn't believe it; I had to be at work in 1 hr and there was no way my car was going to be properly shoveled free by that time. The only "digging" tool I had was an ice scraper and a dustpan, which helped a little but not much. One man walked by and offered to shovel the snow around my car for $25 but I didn't have that kind of money on me anyway. At 7:30 a.m. (I was due at work at 8) I called the chief resident and overnight PCU resident to let them know I'd be late. One hour later, when my car was still stuck, I called my resident and asked if she could fill in for me until I got to the hospital (she lives across the street). She immediately got angry (apparently she had a bad day at work yesterday and was really looking forward to having her day off) but said she'd go to work after she showered. I could tell she was pissed at me and knew that taking the day off was not an option.

Fortunately one of the landscapers on site walked by with a shovel and offered to dig me out. I got in my car and he was able to help push the car out of the snow blanket into the freshly paved driveway, where I thanked him and drove to work. I arrived at around 9:30 a.m. and my resident couldn't get out of there fast enough, saying that we're never to speak of this again. I had no idea what it meant but took it to mean she forgave me for calling her to work on her day off (since she was only there for about 30-60 min). The nurses, however, had noted her foul mood and said they were glad I showed up. Of the two of us, I'm definitely the nicer one.

The work day was, fortunately, fairly uneventful, though I didn't get out until 5:30 pm (which was expected since I arrived late) Of course, the day was not without its costs. I didn't have any waterproof pants so when I changed out of my wet pants into dry ones, my legs were bright red and I had to soak them in warm water to get feeling back in them. From what I can tell there was no real damage done (just an area or two of blotchiness), but even now there's a prickling sensation on my legs that doesn't feel quite right. My new Uggs are completely soaked (though I'm impressed that my feet stayed dry). And on top of it all, I feel like crap. Hopefully I won't get sick; all I need is to get through the next two days and then...back to TEXAS. Goodness knows I need to get away from Philly for a while.

The Story of B.L.

Back in late August when I was working in the MICU, my resident (who was overnight) got called for a code on a 65-year-old woman who'd been found unresponsive in her bed. The attending had last seen her awake and alert at 7:30 pm, and the code was called at 7:45 pm. No one knew how long she had been without a pulse during that time (she had PEA), and like most codes, she was resuscitated, intubated, and rushed to the ICU. Her name was B.L. She was one of the trainwrecks signed out to me on that one day in the MICU when everything went wrong, a vasculopath with ESRD who had come to the hospital days prior for left foot pain and toe gangrene due to arterial insufficiency. Hours before she coded, she had refused to have her foot amputated. Everyone--the MICU team, her vascular surgeon, her nephrologists--expected her to be dead within days.

The first time I saw B.L., she was seizing, a bad sign indicative of anoxic encephalopathy. Her EEG later confirmed that she had low brain activity. Her left big toe looked dried up and withered. I wondered if she could become septic from that toe, but the surgeons who saw her said it was dry gangrene and not a source of sepsis (she was constantly hypotensive). Finding access on her was a problem because most of her veins were too scarred or damaged to use; her only access (later put in by surgery) was a permacath for dialysis. No one could really declare her brain dead because she still had her corneal and gag reflexes, and we couldn't call her a vegetable because it takes 3 months to declare someone to be in a persistent vegetative state. Despite our low expectations for her survival, however, she hung on. Regularly scheduled dialysis and antibiotics kept her going. At one point the surgery chiefs even pulled me aside and asked why she was still alive.

B.L. had a daughter, who also served as her power of attorney. She came to visit every once in a while, and despite doctors' numerous attempts to talk to her about making B.L DNR/DNI, she insisted on keeping her mother full code. My resident tried several times to bring up code status with her, but each time she'd say that she needed to talk with family or some other excuse. Even after 1-2 weeks passed, she still wouldn't discuss the subject. I was able to arrange a family meeting between her, the ICU attending, and the neurologists so that they could explain the poor prognosis of anoxic encephalopathy, and the ICU attending asked whether she wanted to take her mother out of the hospital to a hospice center, or if she wanted a trach and PEG to keep her alive longer. The daughter immediately requested the trach and PEG (much to the dismay of the surgeons, who believed that the woman should be allowed to die peacefully since she would never have good quality of life again), leaving everyone wondering what the purpose was of keeping this poor woman alive. B.L. got her trach and PEG, but not without problems. On my last call in the MICU, she had to be reintubated because her trach was leaking. After I left the MICU, I didn't know what became of her, only that she was sent to the PCU.

Before she coded, B.L. was a fairly frequent flyer to the hospital for her PVD and ESRD. During her hospital stays, she had developed close relationships with the nurses and nephrologists, who later filled us in on her family situation. She lived with her daughter, who often neglected her and didn't give her enough food or blankets to keep warm. B.L. often ended up getting better care at the hospital because the nurses knew of her sad home life and tried to make her as comfortable as possible. Her nephrologists also told us that her daughter was taking advantage of her by living in her home (rent-free) and cashing her Social Security checks for her own use, and they suspected that her daughter wanted to keep her alive for those same purposes.

Three months later, I attended a case conference with "Futility of Treatment" as the main topic. My MICU resident had a case to present: a 65 yo woman with hx of CAD, PVD, ESRD who presented at the hospital for left foot pain. That description could have fit any lady in this hospital, but as soon as he said the pt had a PEA code and was found unresponsive for an unspecified amount of time, I knew he was talking about B.L. I then learned what happened to B.L since I left the unit: she was discharged from the PCU in mid-September and went to a long term care facility for one day before her daughter brought her back for hypotension. The pt's status was still full code, and despite numerous attempts by both the medicine and nephrology attendings to talk to the daughter about making B.L. DNR/DNI, the daughter refused to do so. She would always change the subject whenever it was brought up, and yet had the gall to ask the medicine attending to sign a form that would allow her to pick up and deposit her mother's Social Security checks. The Ethics committee was consulted three times to meet with her, but each time there was no resolution, either because she wouldn't show up to the meeting or else she'd have to "discuss" with some other family member. I couldn't believe that this had dragged on for three months, and yet I was also amazed that B.L's body had lasted this long.

Last week I started my rotation in the PCU, and one of my patients was B.L. Her left foot, which had a slow-growing gangrene when I first saw her, had been amputated (a BKA). Her eyes opened spontaneously and she sometimes moved her head from side to side, but that was the most of it. Now she could be classified as being in a persistent vegetative state. Interestingly enough, on my first day of PCU, the nephrology attending decided that she would no longer dialyze B.L, since every time she's dialyzed her BPs fall to 50s-60s/30s-40s and then we'd have to bolus her to get her BPs up again. "There is no benefit to this," she said, and stated that by stopping dialysis she was willing to be the "bad guy." After all, without dialysis, the patient would surely die within a week or two, and that would be letting death take its natural course.

Needless to say the daughter was pissed when the nephrologist and told her that they would not be dialysing B.L. anymore (the rationale being that HD dropped her pressures dangerously low and that it could no longer be safely done). My attending later called the daughter to once again bring up code status, and while the daughter agreed that chest compressions and defibrillators would be "excessive" for a dying woman, she refused to change the code status to DNR/DNI. No hospice center would take B.L. as long as she's full code, so essentially she'd be staying at the hospital until she died. And despite the daughter's claims that she'd come visit her mother at the hospital, I never once saw her (and I worked every day last week). Nephrology also recommended that we stop drawing labs on her, to minimize anything we do as much as possible. Everyone seemed to be in agreement...for a while.

Then last Sunday, everything went to hell. B.L.'s blood pressures became dangerously low once again, and her nurse asked me why there were no labs on her for the last five days. "You need labs to know what you're treating," she said, so I ordered basic labs on her. As it turned out, a week of no dialysis didn't really budge her electrolytes at all (K+ was less than 5) Then nephrology came by and asked why the heck I ordered labs on her, saying I opened a new can of worms because if she was uremic, then she'd have to be dialysed. My attending said I should start her on pressors, but pressors can only be given in the ICU. The pulm/critical care fellow knew her well (as did everyone in the ICU and PCU) and did NOT want to take her back, asking us instead to give her albumin and see if that would help her pressures. I felt bad for leaving the nurses to deal with her that night, but honestly, I was at the end of my rope, and I went home secretly hoping that I wouldn't have to deal with her the next day.

As it turned out, she did get transferred to the ICU, and my PCU resident expressed her hope that it would be a "terminal transfer" (meaning she'd die in the ICU). When the nurse called the daughter to let her know that B.L. was being transferred to the ICU, she asked (again) why her mother wasn't receiving dialysis. I couldn't believe it. Did this woman really not have a clue what was important, or was she just playing us for fools? And no, she wasn't coming to the hospital.

Early this morning, as told to me later by the social worker and one of the MICU interns, B.L. coded...three times. And because she was full code, everything was done: chest compressions, bagging, epinephrine, everything. I had half-expected the team to run a "slow code" but they went all out. She lasted about 30 minutes before she coded for a second time, and the third time they couldn't bring her back. Each time she coded, someone called the daughter to ask her how much she wanted done for her mother. The first time, she suggested (sarcastically?) that the team do "whatever was ethical." The second time, she got mad and hung up on the doctor who called her. The third time, she didn't even answer the phone; another family member had to answer for her. I'm just afraid that now there'll be hell to pay.

But even still, as news spread through the ICU, PCU, and beyond that B.L. had finally passed away after 3.5 months of living in a vegetative state, I think everyone felt relieved. From the nurses who cared for her round the clock and the doctors who coordinated her care, we were relieved that her suffering was over, and that she was truly in a better place now.

PCU: Flying solo

This month I'm working in the Progressive Care Unit, known here as the PCU. It's the step-down unit from the ICU, but is also a place where patients go when they're not quite sick enough for the ICU but need closer monitoring. I thought that a month of MICU would prepare me for PCU, but as it turned out, the two units were quite different from each other. First and foremost was the patient load: I saw 4-5 patients on average in the MICU, while in the PCU I have about 10-13. Next, the entire PCU is run by only one resident and one intern, and for what seems like the last week or so, I feel like I've had to run the floor by myself (which is NOT a good thing).

First and foremost was my resident, who was probably one of the laziest people I've ever met. Intern and resident start dates are staggered by one week so that the exiting resident can teach the intern about how the service is run and what is expected of the intern. My resident flat-out said on the first say there'd be no teaching and the goal of each day was to leave by 5:00 pm (a great rule to have). And while I was struggling to get my notes written (to give him credit, he saw 3-4 patients for me when our patient load was greater than 10), he'd be on the internet checking his email, chatting online, or otherwise being unproductive unless it's to his cause (like doing dictations). My second day of PCU, he left the floor for about 30 minutes for a meeting without telling me and left me freaking out when two separate attendings arrived for rounds. He was also lazy about documenting central line placements and important telephone conversations with patients' families (he rolled his eyes when I documented a central line removal), which caused him to butt heads with 1-2 attendings (one of them later told me my resident was flat-out stupid). To make things worse, he'd worked a black weekend before I signed on, and so I had to work a black weekend my first week as a PCU intern.

On weekends the earliest I can sign out is 2:00 pm, but I didn't leave the hospital until 6 pm on Saturday and 4:30 pm on Sunday (and that was only because I prewrote all 11-12 notes the night before). And because I was the only doctor in the unit, there was rarely any time for rest. I didn't even have time to eat, drink, or pee on Saturday aside from eating a granola bar here and some graham crackers there. Sunday was a little better b/c my patients were more stable, and today I got a new resident (fortunately it was someone I'd worked with in the MICU and I knew she was good). Unfortunately for me, she had worked the night before and left at noon, leaving me to run the PCU for the afternoon. And as expected, I didn't leave the hospital until 6:00 pm.

The PCU nurses have told me that I'm doing a good job and keeping myself together, but most days I just can't wait to go home. One of my patients became very hypotensive yesterday (among other problems), and I went home secretly hoping I wouldn't have to deal with her the next morning. Got my wish; she'd been transferred to the MICU. One of these days I'll have to tell you about this patient; it's a very sad case.

Hopefully today is my last day to work alone until this weekend, when I'm guaranteed at least ONE day off.

Coming Full Circle

Interview season has begun, and since I'm still waiting for the official approval to start doing research this month, I had time to meet with the applicants and chat with them while they waited to be called for their interviews. At first I didn't know what I could talk about with these applicants; I was, after all, just an intern and still not as familiar with Philly as some of my other classmates who lived downtown. But in the end, answering questions was no big deal and actually kind of fun. It reminded me of when I was interviewing here exactly 11 months ago, and I recalled what drew me to the program in the first place: the sense of camaraderie among the residents, the impression that people here cared, and the down-to-earth interactions with the faculty. That hasn't changed a bit. My firm leader (faculty advisor) came to pick up a student for an interview, and the first words out of his mouth were, "Hey there. Have you used the bathroom? Need a Foley?" That's just the way he talks, but I think it definitely broke the ice.

I've also found that I've been a pretty good source of info for the osteopathic applicants, and there's usually a few in each group. They had the same questions I had when I applied here, i.e. is the hospital DO friendly? How is resolution 42 approved? The upper level DOs had been a great help to me on my interview day, so I was determined to do the same here for the future applicants. I think helping out on interview days is refreshing and exactly what I needed to remind myself of why I ranked this program high, because at the end of the day, I'm happy with where I've ended up =)

Getting out on time

The rule in medicine is that you're not supposed to work more than 30 hrs straight. That if you worked overnight and are still at the hospital at 1 pm post-call, the residents will do whatever they can to help you out so that you can get out of the hospital in time. They have your back.

Lies.

There's only so much that residents can do to help their interns leave on time. They can see a patient or two for you and write notes. They can put orders in the computer or call social work for you. But they can't fill out discharge forms or transfer forms for patients that aren't their own, because they don't know the patient like the primary team does. During the weekday it's not bad, because the resident can help the intern get out on time. But during the weekend, when there's only one intern/resident per team seeing anywhere between 6-14 patients and hoping to get out by 11-12 pm (the earliest time you can sign out on weekends), the intern really doesn't get much help from the other residents. For the most part s/he's on his/her own.

I was overnight last night, and ended up not getting any sleep because one of the night float interns had an emergency and had to leave the hospital for about 4 hrs. I had to cover his half of the hospital until he returned, but thank goodness I only got about 4-5 calls in that time. It could have been much worse. I also had one patient who had both elevated cardiac enzymes and Strep/Serratia sepsis so I was keeping an eye on her for most of the night anyway. And while I saw all my patients and wrote all my notes on time, there were a lot of things keeping me from leaving at noon. I had 3 patients being discharged. One patient needed neurology follow-up, and when I paged the neurologist on call, he said the patient wasn't on his service and told me to read the last neuro note. "Maybe you should check the chart before calling me, that's just laziness," he said. Well, excuse me for being post-call. As it turned out, I'd paged the wrong neuro group anyway, and the pt's neurologist was a much nicer person. The second discharge was a patient we'd had for 3 weeks who had a very caring/overbearing wife, and when she found out we were discharging him, she insisted on making sure all his medications would be ready at the nursing home before they left the hospital. The attending originally asked me to call the nursing home with his (very long) med list, but I think he sensed I was swamped and said he'd make the call instead (thank goodness).

On weekends, we are technically not allowed to leave until we round with the attendings on each patient. The problem was that in geriatrics (my current rotation), different patients have different attendings rounding on them, so I had to touch base with about 5-6 attendings before leaving. Some were nice and responded immediately to my pages, others never returned my pages and I was sitting there wondering what to do. If we don't follow the attending's recommendations, they can call us up on it, but I didn't want to stay late and wait for the attending to arrive. Not when I was post-call. On top of that, the hospital I'm rotating through is huge; it takes aout 5-10 minutes to run from one side of the building to the other. And I did a lot of running around, i.e. I forgot to put a script in one patient's chart on one end of the hospital, then had to run back to the opposite to do a discharge form. It was miserable to say the least.

It's not to say that the residents didn't offer to help out. The two 8 pm residents called from time to time to see if I needed help, and one of them ordered morning labs for my patients for me. But they could not do the things that were taking me the longest to get through: fill out discharge forms, touch base with the attendings, making my sign-out sheet for the night floats. That was all on me, and at one point I got so overwhelmed I had to hide in the bathroom to catch my breath and keep from losing myself completely in front of the nurses, patients, and families. It didn't help that at 1:00 pm, the triage resident called me and asked if I was almost done. I felt like screaming, "NO! I am not done, and no one is helping me either!"

One resident told me to stay where I was and that she was coming over to help, but when 10 minutes passed and she still didn't show, I gave up. I was through with counting on residents to help me out, so I just did what I could and signed out to the night floats. I won't say what time I left the hospital, but having skipped lunch aside from a granola bar, I was both exhausted and hungry. Someone expressed concern about whether I could drive home (it's a 30-40 min commute), but I assured him I'd be fine. As long as I could get away from the hospital and get some freaking sleep, I knew I'd be fine. It had been a rough night and morning, and it didn't help that I'd been working every day since October 18 (2 weeks straight) and was very burned out.

Two months ago, my MICU resident told me that I should never hesitate to ask for help when I need it, but after today, I know all too well that help doesn't always come even if you ask for it. Feel free to comment on this, but for all I know, no one reads this anymore.

It's the little things that matter most

Normally I don't watch Grey's Anatomy on Thursday nights, but since this week's CSI was a rerun I switched over to ABC to watch Grey's for the first time in ages. And the episode was a very good one: a woman suffering from burns dies in the ER and the events leading to her death are seen through the eyes of all the doctors who were working with or beside her (in flashback form) in order to figure out how and why she died. And in the end, we find out that the woman died because the doctor who examined her forgot to look inside her throat. And because of that, no one saw that she had soot in her throat from the fire that later compromised her airway and set off the chain of events leading to her death. The doctor was then fired for her negligence.

That episode shook me to the core, because this is something that can easily happen in real life. As an intern, I've made my share of mistakes whenever I had to fly solo and didn't have a resident around to help out (whenever he/she was in clinic, post-call, or taking an inservice exam). I once didn't think to order blood cultures on a feverish patient while I was overnight, and the next morning the resident asked me why I didn't do so. To this day I'm convinced she thinks I'm a dumb intern. Another time I didn't order a CXR on a patient who sounded wet (even though the attending later said that was her baseline CHF), and more recently, I ordered a lidocaine patch on a patient without checking to see if she was allergic to it (she wasn't). But looking back, there are many ways in which those things could have gone wrong. The feverish patient could have been septic. The patient who sounded wet could have developed ARDS. And if I'd given my third patient morphine without checking to see if she was allergic to it, and she was, she could have died.

Which makes me wonder, how well are we protected by the hospitals that we work for? Would my program be quick to fire me if I accidently prescribed a patient allergic to sulfa some Bactrim and he went into anaphylactic shock? I'd like to think no, since the program is so dependent on its residents that if one resident leaves for any reason, things become way more chaotic (the current R3s are having this problem since one of them didn't pass Step 3, and now people are getting pulled left and right to cover her duties). But what constitutes as an unexcusable mistake that would cost a resident his/her job? The scenario from Grey's Anatomy seemed a bit unrealistic, to fire a resident after one mistake, because what would happen to that resident after that? Would she never be able to complete her residency because no one would take her into their program after she made a single deadly mistake?

If I learned anything from watching this episode, it's that you can never be too careful.

MICU: Overnight Call

The last week of MICU went pretty smoothly. I got to be pretty good at transferring patients out of the unit. Two of my patients who had been in the unit since July finally got well enough to transfer to the PCU (much to the dismay of the PCU intern, who said that every other transfer note coming to the PCU was written by me) One of my calls was hectic b/c a nurse kept pestering me about a patient's BP being 220/104 (she was asymptomatic), and when I called the fellow, his response was to ask me whether I knew the difference between hypertensive emergency and hypertensive urgency. Ohh. *sigh* Good thing I called while he was eating dinner and not in the wee hours of the morning; he must have thought I was dumb.

As "luck" would have it, my very last shift of MICU fell on a Sunday, and I was overnight until Monday morning. It was just me, the overnight PGY3, and the pulm/crit care fellow for the afternoon and a good part of the evening. One of my patients developed a bad leak in her trach (which, after what happened with the patient in my last entry, had us very worried), and after way too many tidal volume readings of 50-200 ccs, we had anesthesia come to reintubate her (but not before she got bronched and had a huge mucus plug that had been blocking her left carina sucked out; that was part of the reason why her tidal volumes sucked). No one wanted to take the chance that her trach would last until morning. My PGY3 wasn't around while all this was happening, and later the fellow asked me if this sort of absence was normal. I told the fellow that my PGY3 was easily reachable by phone if I ever needed him, but silently thought, "Yes, this is normal." We had a patient close to death after her family withdrew care, and when I asked him if he wanted to be notified of her passing, he said no. "You know what to do, right?" he said. Yes, I did (he made sure to teach me when we had our first death), so I pronounced her, filled out the packet, and called the fellow when it happened. Don't get me wrong, I liked having independence in the unit, but I thought the PGY3 could have shown a bit more interest in the patients. He never even asked about her until the next morning.

Another of my patients, SS, had continual bleeding from her permacath site (oozing). Not wanting to bother Zael, I ordered thrombin spray and gave her platelets, blood, and FFP. Nothing truly worked, not even after I applied pressure for 15-20 minutes. When my resident showed up in the morning and I told him what happened, he asked if I gave her DDAVP. -__- Nope. He asked me why I didn't call the PGY3 for help or advice. It hadn't occurred to me b/c I'd asked one of the overnight triage residents for help, and she'd never mentioned DDAVP to me. *sigh* That was negligence on my part; I guess I should be lucky she didn't bleed to death or else I'd really be in trouble. I felt bad for letting my resident down; just last Friday, when I asked him how I did on my rotation overall, his only critique was that I had to know when to ask for help so that I won't get overwhelmed on the job. And what happened? I didn't ask the PGY3 for help about my bleeding patient because I didn't want to wake him up. *sigh*

Now I'm starting ambulatory, which involves spending half-days at different departments and specialties (ENT, rheum, cardio, nephrology, to name just a few) to get an idea of what outpatient medicine is like. I'll have weekends off, hours are 7:30-5:00 pm. No complaints =)

MICU: Death on Call

When my resident was last on call, he admitted a very ill woman with a history of ovarian cancer who was dying of septic shock (I almost had to write an H&P on this woman last month, but then triage gave her to someone else. Otherwise I would have known her better). Yesterday evening the family decided to withdraw care, and after she died (surrounded by about 15-20 family members), I was called to pronounce her dead. It was very unnerving to be listening for heart/breath sounds, feeling for pulses, and checking the eyes in a completely silent room full of strangers, but when I explained my findings and said she was gone, the family took it well. After that, while the family grieved, I went to make the necessary phone calls (to admissions, her heme-onc attending, Gift of Life) before filling out the death packet. Needless to say I wasn't too amused when two of my fellow interns came into the MICU and tried to trick me into thinking that I'd be covering their patients for them tonight. Lousy timing on their part.

Shortly before midnight I got a call about a patient named Melvin whom the nurse suspected had aspirated on tube feeds, so I got a CXR that turned out to be normal. Several hours later the nurse called me again saying that he was making gurgling sounds in his (relatively new) trach (he had end stage HIV and was completely out of it mentally). Since it was close to morning at the time, I said I'd pass the news on to the R3. Everything was fine until around 7:30-7:40 a.m., I was writing notes on another patient when one of the nurses asked me to call surgery because he was really having trouble breathing. I got the pager number for the surgery intern/resident on call, but before I could do anything with it, I heard a lot of people saying that he was bradying down and someone called for the crash cart. Oh #$@%!!

Even though I'd already handed my code pager off to Dave, I was close to the room and immediately went to see what was going on. The overnight R2 was giving chest compressions and I immediately went to help him out. This was my first time doing compressions and the fellow said I wasn't pushing it deep enough. "Don't stop, keep compressing! One inch depth!" he yelled. It was a messy code. There was a lot of moving and shifting around as the patient had his trach changed (assuming it was the trach that caused his intial hypoxia), and then anesthesia came to intubate him. The table was too high and I had to stand on my toes to do compressions, and even then I knew my compressions were subpar. At one point the nephrology attending (who just happened to be nearby when the code happened) had to do compressions while I had to move to the other side o the bed. The fellow kept yelling for someone to call the code officially so that more housestaff can come and assist (the R2 and I each got tired out pretty quickly), but unfortunately no one ever called the code. Surgery did arrive because he got paged overhead, and then he and the fellow got into an argument about whether or not the patient was shockable or not. "He's in asystole!" the fellow yelled. Surgery yelled back, "He had a shockable rhythm!" Fellow: "That was with compressions!" Surgery: "No, it wasn't!" It went like that for a while, and despite the injections of epi, bicarb and more, the patient was still in asystole. Now that was definitely unshockable Finally the fellow said, "Any other ideas?" The surgeon shrugged and said, "I'm ready to call it if you are." Time of death: 8:06 a.m.

The atmosphere in the room was grim as we left, and I couldn't help wondering if there was more I should have done overnight aside from ordering a CXR on him to rule out aspiration. Later the fellow asked me if I'd done codes before. I told him that was my first code, and he said he was sorry that had to be my first one. "That was a very disorganized code," he said. "It was never called out, so it was just you, me and R2. There should have been 4-5 housestaff here. And I shouldn't be trying to keep the airway open, look at the monitor, and give orders at the same time; I should have been at the foot of the bed keeping an eye on everything going on." It made sense. Afterwards, it took about 2 hours for anyone to get ahold of the patient's family and inform them of the patient's passing (apparently they didn't visit often), but in the end, they came. Thank goodness for that.

That was more death than I wanted in one night. Thank goodness I have Labor Day off.

MICU: Time of Death

The day after my afternoon from hell, my resident reminded me that I should ask for help if I ever felt overwhelmed by work. Easier said than done; the other MICU teams don't know anything about my patients or what tests they need. I almost panicked when my newly-septic patient was found to have pus draining from his bladder (yet ANOTHER potential infectious site for his sepsis) and I was afraid of what the attending would say once he knew of all this since he grilled me yesterday for not catching the potential causes of sepsis earlier. Fortunately ID is on the case and he's on a good antibiotic regimen until his cultures return.

I was on call overnight and didn't get much rest. We got a patient with end-stage small cell lung cancer with liver mets/failure who presented with SOB and altered mental status. His wife made him DNR/DNI, so our job was to keep him comfortable until the end. I got called about him at around 2 a.m. b/c his BP had fallen to 65/47 (and later to 55/40), and his breathing was so agonized that his entire chest heaved and there was a rattling in his throat with each breath. When I listened to his lungs, it sounded like air was echoing throughout his lungs with each exhalation. I called/woke the overnight resident asking what I should do, and he suggested calling the family. So I spoke to his son, who said that his mother preferred to remember the patient as he was and not as he is in the hospital, so they would not be coming to HUH but appreciated my keeping him updated. Later I got a call from the nurse at 5:30 a.m. saying that the patient had passed away, so the resident and I went through the steps of pronouncing him dead (listening to heart and lungs, checking the eyes, feeling for pulses). Then he filled out the death packet and called the morgue while I called the patient's wife to let her know the news. She told me that in the time her husband was at home before going to the hospital, he had spent a few good hours eating his favorite foods and watching soccer games, so she drew comfort from those last few memories of him in relatively good health. She was relieved that he's found peace.

MICU: The Burden of Atlas

Today was probably my worst day in the ICU to date. My team had seven patients, three of whom were very sick (one with new-onset sepsis, one who coded last night, and one with abd pain and a giant gallbladder). My resident and sub-I were post-call so they left before 1pm, and the fellow who watches over my team had clinic in the afternoon. So for one afternoon, it was just me in the unit covering all seven patients.

It was a disaster. The patient who coded had 3-4 consults I needed to follow up on. My attending was on my back to call the surgery team about two vasculopaths on our team who had an aortic dissection and no line access. I had to contact IR to ask them to put a line in our lady who coded since she had no veins. Then one of my long-term patients was found to be septic from a possible permacath infection so I had to call nephro, pulm AND infectious disease to coordinate whether they wanted the permacath removed or not (since pt was on dialysis) Then the MICU3 resident (whom my resident had asked to help me in case I got overworked, but I barely saw her at all because HER team was busy as well) got annoyed with me for not getting back to her in time about whether my patient needed a new line to get put in ("I'm not going to be here all day.") I had no time to rest. It was one thing after another, and by the time of signout at 5:00 pm I still had work to do. Then one of the fellows got mad at me for not calling IR about removing my septic patient's permacath; it was because I was calling his attendings about him until 5:30 pm and the IR department stopped taking calls at 5:00 pm.

I didn't leave until 7:00 pm (sign-out was at 5:00 pm) because there was so much to do, and I was never so exhausted and burnt out in my life. And to think I'm on call tomorrow! But hopefully things will be better then; I can't take another day like today.

(anyone want to guess what inspired the title of this post?)

MICU: First Week

I've been in the MICU for one week, and already there are many differences from the floors here. We have fewer patients per team, but they are sicker and require lots more attention. I'm also fortunate in that there are fewer MICU patients in the summer than there are in the winter (when pneumonia runs rampant). My team currently has about 5 patients, 2 of whom have been here since July. Most of them have trachs and PEGs and just need to be weaned off the ventilator.

There are 4 MICU teams in the unit. Call here is q4 overnight; the intern from one team is paired with the resident of another team depending on whether their team is an even or odd number (i.e. I'm MICU4, so I'm on call with the MICU2 resident) so that there are doctors from two teams here at all times. Some residents cover their own teams and expect the intern to cover all the others during the night, while others will split the teams in half and say, "I'll cover 1 and 2, you cover 3 and 4." I cover all the routine calls (medications, orders, etc), but if something serious is going on with my residents' patients or if I have a question, then I call the resident.

On my first call, one of the patients on my team with small cell lung cancer/MRSA pneumonia coded (eventually brought back and put on a transcutaneous pacemaker), and there was a disagreement about which of his children could make decisions about him. One son was the power of attorney but he was overseas, and his daughter said she had papers saying that he wanted everything done (but despite being asked many times, she never brought those papers to us). It took an entire afternoon to finally reach the son with POA, and he asked if we could keep his dad alive until he got home. The pulm/CC fellow said that the patient was unlikely to survive the night, and after the son spoke with other family members (namely, a stepbrother who came to visit the patient), he told us that he wanted us to withdraw care.

The patient had his vent removed and his pacer turned off, and the nurses placed him on a drip to keep him comfortable. I poked my head into the room a few times and saw his heart rate fall to 28 while his breaths became slower. Time passed as I continued working, when suddenly I heard a loud scream. Fearing the worst, I turned and saw our patient's daughter run into his room, throwing herself over his body and begging him to wake up. Apparently the patient had just passed away and she arrived with no idea that he had been taken off life support.

One of the fellows went in the room to talk to her after giving her some time to grieve, and she went berserk on him. "Why did you pull the plug?" she screamed, stamping her foot and flinging things around the room. "You were NOT supposed to pull the plug on my daddy. He wanted everything done for him! I got papers!" And with that, she pulled out the forms that we had needed for so long, too late. "He said he wanted everything done until his heart stopped. WHO said you could pull the plug?!" I was afraid that she was going to start hitting the fellow or something like that, but he just explained that our team had directly contacted her brother who had the power of attorney, and he had made the decision along with her stepbrother to withdraw care.

"___ would never do that!" she screamed, referring to her biological brother. "And ___ isn't even his real son!" That, of course, was referring to her stepbrother. "WHY?!?" With that she broke down, continuing to alternate between screaming and holding her father, and when the paramedics came to take the body to the morgue, it took a while to get her to let go. She tried to follow the body as it was wheeled away but the security guards stopped her. "You can't keep me here, that's my daddy!" she yelled. The guards explained that she wasn't allowed to go to the morgue and she screamed they had no right keeping her here. After yelling at the guards, she turned and headed straight for the nurse's station. I was afraid she was going to find a random nurse and start screaming, but instead, she found an unguarded door leading to the lobby and promptly exited the ICU. The nurses inside the station looked started, like WTF just happened, but the security guards were alerted to go out and find her. This was sometime around 8 pm, and I was told that she was still down in the lobby at 10 pm arguing with about 5-6 security personnel. *sigh* This is why I don't want to specialize in critical care.

Yellow: Finishing Heme/Onc

I had a "black weekend" this week since I was on call Saturday and post-call today. I do get a golden weekend NEXT week so in the end it balances out. Today was my very last day on the Yellow 3 heme-onc team, and I have to say it was a good learning experience. It wasn't overwhelmingly busy for a floor month, but I feel like I got enough out of it to know what to expect on other floors. I also got along pretty well with my resident (who actually stayed late on an 8pm call day to help me organize a presentation I had to do for intern report; not many residents will do that), my med students (never worked them too hard, to my knowledge), and the fellows. I actually got my heme-onc fellow and MSIII hooked on Hi-Chew, so that was another fun thing we shared as I always kept some in my pocket (and there's plenty of Hi-Chew to be found in Philadelphia since HUH is only blocks away from Chinatown)

Most people get out around noon on Sundays, but I stayed until 3:30 pm b/c a patient I admitted yesterday had a distended bladder after not voiding in 24 hrs and no one could get a catheter in him. I, myself, have never cathed anyone and neither did the Yellow 1 resident who was supervising me (my resident had a golden weekend), so we had to call the surgery intern on call (who was also covering urology) to use a special Foley (with a tilted Coude tip). It took the surgery intern 1.5 hrs to get to the floor, but once he was there and the Foley was in, my patient drained 500 ccs of urine on the spot and felt instant relief. Thank goodness.

Tomorrow I start MICU, which will probably be another hospital culture shock since the unit is so different from the floors. But I look forward to it.

Giving "The Talk"

At some point or another throughout med school, residency, and beyond, we get pulled aside by someone above us (resident or attending, right now), for private chats which usually leave us feeling bad for a good part of the day. I got my first one-on-one back when I was a MSIII during my ob-gyn rotation, when my resident told me that I was too timid after I froze during a delivery and he had to take over. Fortunately by the time he saw me again as a MSIV during my ICU rotation, I was more sure of myself and actually asking to do procedures. More recently, I got pulled aside by an ER attending who berated me for attempting a certain procedure without supervision (even though the patient was fine in the end). In that case the fault was entirely mine, though I felt like crap for a good 2-3 days afterwards. It only made me dislike ER more, though I've since seen that same attending in the ER and we're on good terms as though nothing ever happened. I still worry about seeing him/her sometimes though.

I was the overnight intern yesterday, and after doing 3 admissions from 6 pm to 2:30 am, I was looking forward to lying down and getting at least 2-3 hours of sleep. Unfortunately it didn't happen. Just as I finished my lastest admission and was about to call it a night, the ER called me and told me that there was a patient coming to my service who had an incomplete H&P and had essentially been forgotten in the ER. "There's no admission order, no call to case management, nothing!" I remembered the triage resident telling me that the overnight sub-I was doing the admission for my team, and when I went to see the H&P, I saw that he had only filled out the history, med list, labs, and review of systems. Everything else--the physical exam, the assessment and plan--was missing. There was nothing there. This patient could have been sent to the floors hours ago, but apparently the sub-I just stuck the H&P in her chart and went to bed after the interview without telling ANYONE that he saw her.

I couldn't believe it, and worse, I was pissed that because of the sub-I's incompetence, I would now have to stay up even later to see the patient, examine her, formulate a plan, and then call the heme-onc fellow to let her know what was going on (and I really did not want to page her at 3 a.m.) Needless to say it was close to 4:30 a.m. by the time I finished my work, and I was exhausted. A part of me wanted to page the sub-I, yank his butt out of bed and demand an explanation for what happened tonight, but I decided to wait until morning. Either way, I knew that I had to talk to him, and give him one of those "chats" that I myself dread receiving.

At 6:15 a.m. (which I felt was a reasonable time to wake up), I paged the sub-I and asked him to meet me in the lounge so that we could go over his note. Fortunately the room was empty so we could talk in private. When he arrived, the first thing I asked was whether he told anyone (namely, triage) about the patient after he saw her and whether or not he did an exam. He immediately realized what he did wrong and apologized, saying that he wasn't sure whether he was allowed to write on the H&P or not. That was reasonable, so I explained to him that after seeing a patient, he's supposed to present the patient to triage so that triage can decide where to admit the patient, rather than have him/her sit in the ER for nothing. I further noted that I know he's just starting his sub-I (med students switched services last week) and that everyone makes mistakes (me included), but next time, make sure this doesn't happen again. He again apologized, both to me and the patient, and I accepted his apology. When I let him leave, however, I couldn't help but feel bad for him. Did I completely ruin his day by giving him "the talk" that he needed to hear? I hoped not.

As far as I'm concerned, the talk we had was between us only. I don't know who his resident is and even if I did, I wouldn't say anything to get him in trouble (though the triage resident, who was with me when I started ranting in the wee hours of the morning, might say something). Having been an MSIV once, I don't want this one mistake to affect his entire grade for his sub-I. Since I'm not his resident, I don't have to grade him or tell the med student coordinator what happened, and I think it's better that way. As long as he learned his lesson...just as I learned that giving one of these "chats" is just as hard as receiving one.

Yellow: First Night Float

One rule at this hospital is that night float interns work Mondays through Saturdays but get Sunday evening off. On Sundays, whoever is the overnight intern has to do double duty as overnight intern (admissions) and night float (cross cover). It's been called "Black Sunday" and was supposedly the worst night of any intern's life. Guess who had Sunday overnight call yesterday? Me.

I started getting sign-outs from the other teams (I covered a total of eight teams, the 4 Yellow and 4 Green teams) shortly after noon. For the most part things were calm until around 5 pm. Then the calls started from nurses needing orders for their patients. I let my MS3 go home at 7 pm so that she could have dinner with her husband (on top of that she had nothing to do). Shortly after that I got my first admission: a patient of Dr. RRR's with metastatic colon cancer who had exquisite abdominal pain. All I did was brush her abdomen with my stethoscope and she pushed my hands away. She wasn't really able to give me a good history because of her pain so I had to ask the ER attending what was going on.

While I was down in the ER presenting to the triage resident, I suddenly got bombarded with pages and ignored them to finish my presentation. The bottom line: this patient was not well enough to go to the floors; MICU or surgery would be a better bet. Then I got a call on my cell phone from a very impatient nurse on the 17th floor (when I didn't answer her pages, she called the operator and asked for my cell phone) practically demanding that I put in some orders for her PRONTO. Even though my note wasn't completely written (didn't elaborate on the assessment and plan), I went to the 17th floor to see what was up.

"Four things," said the nurse. "___needs a Foley renewal. ____ needs to have tube feeds held after midnight. ____is vomiting. And I need to know whether or not to give this patient (certain cardiac drug)." When I asked the nurse what indications were for giving the drug, she rolled her eyes and said she didn't know. Um, what? I looked through the sign-out list and the patient's chart and learned she was being given the drug for A-fib, and the resident had a note saying "QT < 450." Did that mean I should give the drug as long as the QT was less than 450? The QT was 380, so I told the nurse to give the drug. It wasn't until the morning, when I spoke to Alan, that I realized that the drug was known to cause QT prolongation and that it was safe to give as long as it was less than 450. Whew. Looks like I made the right choice this time around. Even still, I felt really stupid when it was all said and done.

The calls kept coming throughout the night; at best, I lay down for 10 minutes. Several of the heme-onc patients had problems, especially one from the other team who was tachypneic and agitated after getting a breathing treatment. The cafeteria was closed on Sunday nights (much to my dismay) so I ordered takeout Chinese and ate it when I had a spare minute. I also didn't eat anything after midnight until around 6:30 am when I quickly ran down to the cafeteria for breakfast. I was surprised to see medical students at 5:30 a.m.; they were on their surgery rotation and seeing patients right before their surgeries. Finally 7:00 a.m. came and I had to sign out to a new group of residents, including my own. Residents switch services one week after the interns do to give the interns a week to adjust to a new team (and pass on words of wisdom). My new resident was kind enough to let me go home at 11:30 am, but man...I hope I don't have another Black Sunday for a LONG time.

Yellow 3: Getting started

There are 16 medicine teams at HUH, four in each "color" of red, blue, green, or yellow. Red is a strictly cardio service. Blue is strictly general medicine. Green is half general med, half nephro. Yellow is half general med, half heme-onc. I was assigned to Yellow 3, one of the two heme-onc services, and I wouldn't have had it any other way.

There are three attendings that cover Yellow 3, along with one heme-onc fellow, one resident, one intern (me), one sub-I, and one MSIII. We have one attending MW, the other TTh, and the other Friday, and then they take turns covering the weekend. The MW attending just finished fellowship so he's really fun and cool, as is the Friday attending, who completed his fellowship at HUH and still wears the white coat he wore as a fellow instead of an attending's coat. The TTh attending has been on the service the longest, as she used to run Yellow 3 alone. From the first day, my resident warned me that she was everything I should strive not to be (an opinion shared by most of the medicine residents and attendings). I soon found out why. She answers personal phone calls in the middle of talking to patients ("Oh, you saw___? What was he wearing today?"), she admits patients directly to the hospital without telling triage (which confuses the heck out of them and messes up the census), and she doesn't communicate that well with her partners about treating certain patients. Not the best example of professionalism.

The rest of my team is pretty cool. The fellow's really nice and approachable, my MSIII is one of the sweetest people ever (and very helpful, too), and my sub-I puts me to shame because he's so smart and hardworking, doing all the consults and discharge forms. My current resident is a PGY-3, and he took it upon himself to tell me what was expected of me as an intern and train me to become an active member of the team. "You're running the floor," he said. "The med students and I are here to help you, but this is your service." Lots of responsibility, wow. I actually get a new resident next week (they switch a week after interns do), and this one will be a PGY-2. He was an intern just one month ago, so I imagine working with him will be different from working with the PGY-3. I just hope we won't BOTH be clueless.

Now that I'm out of the ER, I also have clinic every week. My clinic is located across the street from the hospital. So far I have 2 patients per afternoon, though I expect that number to increase with time. For now, no complaints =P

EM: Finale

Wow...these last few days in the ED were definitely memorable, as were the patients. One of them, a guy in his late 30s with a history of DVTs, had a note placed in his chart requesting confidentiality from his own family members, which didn't make much sense to me. When I spoke to him alone, he was really friendly, but when I tried to ask him more questions while his wife and son were in the room, he looked horrified and asked me to come back later. "Everything is confidential, right?" he asked. I didn't understand what he meant until visiting hours were over, and he confessed that his wife was not aware that he was HIV positive (which was written in his chart). Apparently he tested positive soon after they were married (about 5 years ago), and the most likely carrier was a woman he had a relationship with before he met his wife. At any rate, that's why he requests patient confidentiality on all his files, and why he didn't want to talk to me when his wife was in the room: he'd thought I'd ask about his CD4 count and other things. He stated he takes all his HIV meds faithfully and has a undetectable titer. His wife keeps a copy of his medications with him, and I saw that beside the usual HIV drugs it said, "Antiviral medication." I wonder if his wife questions just what kind of virus he has. Maybe she thinks he has hepatitis or something. My attending later commented that his wife can have him arrested and prosecuted for lying about his HIV status, but hopefully it won't come to that anytime soon.

For my last ever ER shift, I had to work from 11 pm to 7 am, and then run up to the 12th floor lounge at 7 am to pick up my patient list and immediately start working on the floors. Thank goodness Dr. PB was willing to let me go at 6:30 am so that I could start on time, and that I was allowed to leave the hospital at noon as though I was post-call. I saw only three patients, and they were all trainwrecks. Two of them had ESRD and their electrolyte levels were outrageous (potassium of 6.8!) The third was a cachetic man dying of terminal lung cancer who was in hospice care, but his wife brought him to the ED after he stopped eating and became less responsive. She was supposed to call hospice before bringing him to the hospital, because hospice patients are discharged from hospice once they're admitted to the hospital. I had to get on the phone with hospice to try to figure out what we could do for this patient, and that took up a huge chunk of my time. Even worse, all three patients had crappy veins, and we couldn't get blood from them without the help of ultrasound-guided line insertions, which could only be done by the third year resident (I knew nothing about using an ultrasound machine). Needless to say I felt useless in the ED and was all too happy to sign out to the ER intern and haul my butt up to the 12th floor, where I once again exchanged scrubs for business casual.

I immediately went to the heme-onc floor (15th floor) to get started on seeing patients. There were currently 5 in the service, not a bad number at all, and I was able to see them all and get notes written on them (with some help from my med students) before the attending arrived. Steve went to morning report but gave me his cell phone number in case I needed help. So far so good. There were three attendings who rotated through our service, two males and one female. The female doctor was in charge of the service; the other two are fresh out of fellowship and therefore more "cool." One of the male attendings came to round with us today and introduced himself to us as "Mickey." Mickey loves to teach, and we spent a good 20 minutes talking about breast cancer and its prognosis based on ER/PR/Her2-neu status. Pretty interesting stuff.

As promised, I got to leave at noon and slept for a good chunk of the afternoon. Hopefully I'll be able to fall asleep tonight.

Shadow for a day

On the day before residency started, new interns on wards had a "Shadow Day" in which they shadowed their future teams to get an idea of what went on and what was expected of them in their service. Since my first rotation was ER, I had "Shadow Day" off, but felt like I had missed out in not getting oriented with where things were in the hospital (i.e. the call room). I'm supposed to start heme-onc next week, and since I wasn't scheduled to work again until Saturday night, I sent my classmate Maria (who's currently the intern on my future team) an email asking if I could shadow her team for one day. She talked it over with her resident and said it was all right, so this morning I exchanged my scrubs for a sleeveless sweater and slacks to go to work.

I met Maria in the 12th floor lounge where she was getting her sign-out from the extremely stressed night-float intern. Apparently several of the heme-onc patients had trouble during the night (one became tachypneic at 44 breaths per minute, another threw up 700 ccs of coffee grounds), and no one knew the tachypneic patient's DNR status. Even worse, the night float intern didn't write a note for our patients, so the resident was extremely pissed. "I'll have to have a talk with that kid," he said.

The two residents covering heme-onc were both DOs, and next week, another DO and I will be joining the team. "There's going to be four DOs here!" Steve (my future resident) said excitedly. His enthusiasm made me look forward to joining the floors even more, and the more time I spent with the medicine teams, the more I realized I missed internal medicine. Sure, EM has a cushier schedule, but I never wanted to specialize in EM, and I'll be glad when my last two shifts are over. It's about time I returned to the internal medicine side of things. Still, I know I can't avoid the ED after this; there'll be admits to do when I'm on call, and as a third year I'll be expected to do 1-2 months of being the MAR (medicine admitting resident). Maybe it's a good thing the EM doctors will know me then.

Maria was great about showing me around the floor and pointing out where everything was. I also got to meet Mylene, the heme-onc fellow, and the two medical students, Amelia (MS3) and Karthik (MS4). Apparently the heme-onc attendings are pretty cool, with two recent grads of the fellowship program recently joining the staff, so they invite residents to call them by their first name. I think there will be a lot expected of me since from what I can tell, Maria was a pretty stellar intern. I'll have to do my best to keep up and not let my future team down. =)

EM: The difference between you and me

The medical students have started their rotations, so the ER seems twice as crowded nowadays. We've had soon-to-be second years shadowing us for 1-2 days, and we have fourth years doing their ER sub-I's. Apparently at DUCOM, ER is not a required rotation; only 4th years interested in ER can do their sub-I's here. One good thing about having the 4th years around is that they can help see patients, so I see fewer patients a day. The bad part: having to wait in a longer line to present my patients. The 4th years usually present to the 3rd year resident, who then presents those cases to the attending. Sometimes the 3rd year residents present more than one patient at a time, and that makes an even longer wait.

For all the straightforward and uncomplicated patients I see in the ER, there's always a few who insist on being a pain in everyone's butts. Sometimes it's so hard to be sympathetic for them. One homeless guy didn't want to leave the ER and purposely lay in the middle of the street after he was discharged hoping a car would hit him so he'd be rushed back inside. After someone dragged him off the street and put him under suicide watch, he was overheard bragging about how he "played the doctors." Then there was one patient who complained about everything from the bed to the nurses, and when I walked past her room she called out to me and asked me to put artificial tears in her eyes. "I got Sjogren's, ever hear of that?" she said. Yes, I have. Normally I don't mind doing small things for patients that nurses normally do (bringing them food from the nurse's station, giving them urinals and bedpans when need be) but this woman was really demanding. She said her ankle hurt and asked if I could go to the CVS across the street to pick up a special kind of Bengay cream. I told her I was on duty and couldn't go, and she said, "That's the only thing that works for my ankle, and if you can't go, put me in a wheelchair and I'll go get it myself! At the very least I need an ice pack!" The arrival of her nurse saved me from having to respond to that and I was more than happy to leave. The irony of it all is that she herself is a nurse, yet she was being mean to the nurses caring for her. *sigh* Patients come to the ER and feel entitled; don't they realize they're not the only patients and we're short staffed?

Despite working side by side with the EM attendings and residents, there is still a huge gap between me and them. I wear my white coat all the time while the EM residents wear scrubs; a handful of attendings wear their white coats. I continue to want to treat the whole patient, while the ER docs are only concerned with what they need to do to keep the patient alive/stable until they can be discharged or admitted. Even more, the EM attendings definitely favor their own. There was a patient who needed to be intubated and the attending called out that he wanted "an intern." I just happened to be in the area but he didn't even look at me; it was clear he was looking for one of the EM interns. I returned to the station and a minute later Holly (EM intern) came running down the hall saying she wanted the intubation. Later I told a prelim going into anesthesiology about it, and he laughed and asked if Holly needed any assistance (he's done lots of intubations before). I said it was probably better to stay out of the room, and later the attending proudly announced that Holly just did her first intubation with flying colors. Hopefully I'll get my chance at a real intubation in ICU.

EM: Halfway through

Happy July 4th! I was fortunate to have the day off today (though I do have to come in for work tomorrow) and went downtown to watch the Independence Day parade. Philly sure knows how to celebrate the birth of a nation; there were a lot of people in colonial attire in the parade, a few bands that I've never heard of before, and lots of talented kids showcasing their band, dance, and color guard skills. Not to mention the fireworks display: I knew better than to venture downtown b/c Sheryl Crow was performing, but I watched the program live from home and the fireworks were amazing. If I'm on call next year, maybe I can catch the fireworks from the hospital; the top floor should have a great view.

Working in the ER has been a pretty interesting experience. I'm starting to get the hang of knowing what labs and tests to order on patients before I even present my patients to the attendings. I have no idea what the attendings think of me but hopefully I'm not a total failure in their eyes. One attending said, "You did go to medical school, right?" when I forgot to do a complete neuro exam on a patient suffering from sudden bonset weakness and dizziness. "Did you forget how to do a physical exam?" *sigh* Neuro was never my strongest subject. I've seen lots of interesting cases, but will just mention a few below.

One time a middle-aged man was brought into the ER in a post-ictal state, just lying there resting, so we figured he was all right and left him alone when the woman next door to him went into V-tach and needed cardiovesion. Suddenly someone said, "Go check on the guy in ___," which was my patient. A nurse and I went in there, and we saw him lying awkwardly in bed with his head stuck between two of the sidebars along the bed. "Dammit, he's seizing!" the nurse yelled. He wasn't actively shaking, but he had persistent bruxism (he was chewing on his tongue at one point) and we had to give 4 mg of Ativan to get him to relax again. After that, when he regained some of his senses, he kept trying to climb out of bed and ended up flashing most of the ER b/c he was completely naked once the blanket was off. At one point we heard a huge THUNK! and ran into the room and saw him sitting on the floor in a puddle of his own urine. Apparently he had to pee, got out of bed to go to the toilet, leaked some urine, and slipped in it. My attending and a nurse helped him stand, and since we were near the toilet anyway, they just let him finish his business. After that, I ordered wrist restraints for him, but it still didn't stop him from kicking off his blanket and flashing the rest of the ER. *sigh*

During my first overnight shift, I had a mentally challenged patient in his 60s come in with cocaine-induced chest pain, and everytime I talked to him he got himself worked up into a frenzy, saying he'd "never had pain like this before" even though he was a regular in the ER for drug-induced chest pain. He was also very easily angered, and if anyone tried to calm him down, he started ranting about how we were talking down to him and treating him like a "dumb black man." Once he even got out of bed and got in my face because the nurse and I were discussing what to do with him while we were in the room (and not including him in the conversation), but fortunately I was able to calm him down almost every time he got mad. Even still, we pricked him 4 times and were unable to draw his blood, and he was hungry but couldn't eat until we drew his blood. Telling him he couldn't eat was the last straw. "That's not my fault!" he said about us not being able to draw his blood (his veins were shot and were wasn't a good vein left to draw blood from). "You're the ones who mess up! I came here to feel better and you only made me feel worse! (sadly, we were only torturing him by keeping him in the ER unable to eat) This is my hospital, I've been coming here all my life, and I've never been treated like this! I'm going to file a complaint, and I'm never coming back here again!" When I tried to keep him in his room (my resident had told me not to let him leave while she attended a trauma), he got even angrier and said, "What's your name? I'm gonna report you!" Well I wasn't about to tell him my name. I saw no benefit in keeping him in the hospital any longer, so I let him walk out of the ER and told my resident later. "That's okay, but next time, call security and have someone watch him," she said. I asked why other people can leave AMA and he can't. "Because he's not mentally capable of making his own decisions" was the reply. I think he'd beg to differ. *sigh* It's patients like these, the ones we can't help, that make me glad I'm not going into EM. I left the hospital that morning feeling drained and worthless, and I hope I don't have many days like that.

Welcome to the ER

My first rotation of the intern year is emergency medicine, a rotation that is required for all DOs in this state. My program director, whose wife is a DO, is more familiar with the DO regulations than I am and made sure every DO in the intern class got a month of ER. Very thoughtful and considerate of him. My first day of ER was memorable in that shortly after my shift I overheard a group of nurses talking about how Michael Jackson died. I thought it was a bad joke at first, since Farrah Fawcett had passed away just earlier that day, but as it turned out it wasn't.

Medicine interns work eight hour shifts in 3 time slots: 7am-3pm, 3pm-11pm, and 11pm-7am. At 7am and 11pm the attendings, residents, and interns round on all the patients before the attendings ending their shifts sign out to the ones who are just starting their shifts. In rounds, we present our patient in one sentence, usually stating the name, age, chief complaint, and pertinent labs and other tests. Sometimes the attendings will take time to teach a bit during rounds, but not often (especially if they're in a hurry to go home). Whenever I end my shift, I have to sign out to the EM intern who's worked the fewest hours so far. The EM interns work 10 hour shifts: 7am-5pm, 2pm-midnight, and 9pm-7am. So if I get off at 11pm, I sign out to the 9pm intern. I rarely ever leave at exactly 3pm/11pm/7am, though; I often run an hour or so over.

We don't get to choose our schedules. I can work 3 days and then get the next 2-3 days off, or else I can work 2 days and get 2 off, it varies every time. I also learned to bring all my meals with me to work since there really isn't much time to go to the cafeteria when there are patients to see (not to mention the cafeteria is expensive). The EM attendings treat the medicine interns all right, but clearly favor the EM interns more. Any procedures in the ER go to the EM interns and residents, and medicine interns never attend the traumas. While the EM team is working on a GSW victim who's bleeding out, I'm still writing notes or seeing patients. As for introducing myself as "Dr.____," I'm getting the hang of it, but sometimes I still say my first name during my introduction.

On a side note, I like wearing a long white coat =)

Orientation Week

This whole week has passed by in a blur. The first three days was general Graduate Medical Education (GME) orientation, in which we received on handbook and went over topics that applied to all residents (i.e. resident fatigue, culture awareness, etc). I did get to meet several other people within the medicine department (one of whom lives in my apartment building), but I didn't really get to know my colleagues until the last two days of orientation, which were strictly IM-focused. We met the four chief residents, who gave various presentations about how to take good notes and explained call systems and schedules to us. I had originally lamented that I had not gotten a heme-onc elective like I wanted, but I learned today that the wards I've been assigned to have a heme-onc emphasis so I'll still get to see cancer patients on the floors. That's good.

My first rotation of the year is ER, which is required for all DO interns in order to get the internship approved by the AOA (the program director's wife is a DO so he knows all about the requirements for internship approval, which I think is a good thing). Prelims also take a month of ER, so I got tired of explaining after a while that I had to take ER because I was a DO, not because I was prelim. Shifts are 7 am- 3pm, 3pm-11pm, and 11pm-7am. The June schedule is out and so far I have one 3-11 shift next Thursday and then two 7am-3pm shifts next weekend. Yes, I don't get a weekend, but that means my weekdays are mostly free. I'm just glad I'm not starting on the floors or on the graveyard shift, though I'm sure that'll come next month.

The intern class has 42 categoricals and 18 prelims. On Friday night all of us went to a bar/grill downtown called McGillin's for dinner and free beer/wine. I hung out with some of the same girls I'd been sitting in orientation with for the last few days, but I met several new people as well. When the EtOH was flowing, everyone was super friendly. One Asian guy clearly had way too much to drink (red face) and fortunately lived within walking distance of the club. A few guys who attended Drexel for med school also told me about cheap Chinatown-based buses that run to NYC or DC every day and said that if I ever wanted to visit those two cities, those buses would take me to the respective Chinatowns in each city. It takes 2-3 hrs, but is cheaper. Some of them are already making plans to visit the city every free weekend, but I know almost nothing about New York so I'm not as brave.

This morning we had a little procedures workshop to learn how to insert central lines (subclavian, IJ, and femoral). "Who in here has put in a central line?" asked one of the attendings. There were 7 of us in the room, and I was the only one who raised my hand. No surprise, since I'd done an ICU rotation and 3 of the students were prelims (rads and gas). Two others were SGU students, and I don't know how their rotations work. My biggest problem is inserting the needle in the right place, so when asked if I was proficient, I said no. I hadn't put in a line since last September, but it's really one of those things you don't forget completely. We practiced on a dummy mannequin with "soft tissue," and I think I did okay. For now.

Time To Say Goodbye

Last night I discovered on Facebook (of all places) that one of my former orchestra directors is currently on hospice at All Saints. To say I was floored would be an understatement, yet I shouldn't have been surprised. She was diagnosed with stage IV colon cancer 28 months ago (normally I'd say two years but this was the number my former private lesson teacher told me when I called her for more information), and last week her health took a turn for the worse. The person on Facebook who posted the info about her told me that she probably had days left, which, again, shouldn't have been a surprise. I'd spent a month in geriatrics; I knew that most people who enter hospice care usually pass away within a few days. But still...this was my teacher. She had always been so strong and aged well, despite being close to 70 when I graduated from high school. And she was dying.

I called All Saints and they transferred my call to her room. Her voice was weak and she spoke slowly, but she still remembered me after all these years. "Teachers don't forget," she said. "You were very special." That brought tears to my eyes, and I had to try really hard not to cry while speaking to her on the phone. I told her that I'd played my violin in college, that I went to medical school and am now living on the east coast doing my residency in internal medicine with an interest in heme/onc. I told her about meeting up with my best friend, who was one of her favorite students, two months ago in New York, and said that we were both thinking of her. She said she was flattered that I thought of her, and I said there was no way I could forget. Before medical school, and before college, orchestra was my whole life. Music was one of the few things I thought I excelled in, and part of it I owed to all my directors. Including her.

I didn't want to keep her talking for fear that she needed rest. After we said goodbye I realized there was so much I forgot to tell her, but at the very least she knows I'm thinking about her. I then called my private lesson teacher for the first time in 7 years (amazing how I still remember her phone number) to ask for more information, since she and my former director were very close to each other. Knowing that I was now a doctor, she left nothing out in telling me how my director's illness had progressed since the diagnosis. I asked if there was any pain, and fortunately she said no. "There was never any pain," she said. For that I'm extremely grateful. I just don't know how to say goodbye.

New Beginning

I've been in Philadelphia for almost a week now, and I'm finally starting to settle down in my new home. My apartment, which was frightfully bare when I first moved in (I didn't bring any of my own furniture), now looks much homier with a bed, TV plus stand, square table and chair, a floor lamp, and a sofa bed (which I bought from Ikea and built all by myself; that was an accomplishment on my part). There's a lot of furniture I'd love to buy, but can't because I'd be responsible for moving it and there's only so much I can carry at one time. My place looks like a mess because I still haven't unpacked about 50% of my stuff. No place to put it. Eventually I might build a bookcase for the rest of my junk, but for now, it's staying in the crates.

Last week I had 3 days of EMR training. The first day's EMR was for the main hospital, Hahnemann (henceforth called HUH), which uses something that looks a lot like DOS but is still workable. The other two days dealed with an EMR system used in the clinics. Everyone had to pass the first class before they could proceed to the next class. There were about 15-20 of us in the first class, but on the second day, there were only four of us (me included) who were ready to take the second class; the others had failed (in this case, "fail" = less than 90). I don't think I passed the second class (in which we had to fill out an office note, write orders, assign tasks, etc), but hopefully I won't have to retake it again.

Also to prepare for the winter ahead, I drove to an Ugg outlet store in New Jersey (about 90 min away) and bought a pair of Ugg boots. Now, I would never even think of getting Uggs at home, but the good thing about PA and NJ is that shoes and clothes are tax-free. And my boots, which have a retail value of $180, only cost me $109. Not too shabby.

Orientation starts tomorrow, and I'll also be tested in the practical portion of the BCLS/ACLS. I'm not worried about BCLS, but the online ACLS class I'm taking is really kicking my butt. Hopefully everything will turn out ok tomorrow; I'd hate to be an incompetent doctor.

Lessons outside the Hospital

Too many times in medicine, we see patients with overbearing families that question everything we do and can't seem to give us room to work. Some family members even become emotional, angry, and confrontational when they don't understand what's going on. I probably had my share of exasperation with people like these, until I found myself in their shoes for a different, yet similar scenario.

This afternoon I was at an airport in Philadelphia (where I'd been apartment hunting) with my dad to catch a flight back to DFW. My dad had accidentally left his license at home and as a result had no photo ID on him. The security people who questioned him about his identity were, to put it nicely, not very friendly. They kept asking him how he was able to get a boarding pass without a photo ID, even though he explained that he bought the ticket online and got the pass at the self check-in which did not require a photo ID (just a credit card). Despite that, they kept asking him how he got his boarding pass without a photo ID. I was standing off to the side watching quietly, and I was getting tired of the way the guards were talking to my dad. Were they being hard on him because he was Asian and spoke with an accent? Finally I couldn't take it anymore and blurted out, "We went through the self checkout line!" as if that would explain everything. Not surprisingly, they ignored my little outburst.

What was surprising was when another guard standing nearby (he was a young guy) asked me if I was okay (I must have looked really pissed off). "I'm fine," I said, "I just don't like the way he (my dad) is being questioned, that's all." He asked if there was anything he could do to help, and I said no, but told him that my dad had no photo ID on him and was being interrogated. The guard said that while it did seem like the other guards were being aggressive, they were just doing their job and trying to make sure that my dad was who he said he was. When I saw one guard on the phone, the nicer guard said that he was calling some security company to verify my dad's identity, and everything would only take a few minutes to clear up. He asked if we had a flight to catch, and I said that our flight wasn't due for several more hours, so a few minutes' wait wouldn't hurt. At this point my dad and I were allowed to proceed to the security gate, where my dad had to be patted down for weapons (they sure take things seriously in Philly). Afterwards when I grumbled to my dad about the whole process, he was way more understanding about the whole matter. "It's the government," he said simply.

I then realized that just now, I'd become one of "those" people, the family members who let their emotions get the better of them and make the jobs of the doctors (or in this case, the security guards) more difficult. I don't usually lose my temper on complete strangers, and this was a first for me. *sigh* The things we realize about ourselves when we're stressed. You'd think being a medical student/future doctor would teach me to be calm in any situation, but now I know that's not the case, especially where family is concerned. The guards may have thought they were doing their job, but I saw them as antagonizers giving my dad a hard time (even if he didn't think so). I'm very protective of the people I care about, and at that moment, I was pissed.

Enter the other guard. Somehow, he could tell I was upset, and he made the effort to find out why and explain the interrogation procedures to me so that I'd understand what was going on. And in the end, that was all I needed to hear. Just like in medicine, sometimes patients' families just need a little reassurance now and then, which is why it's important for us as future doctors to be more understanding of them and educate them whenever possible. My one regret is that I never got to thank the guard for his help. This experience has really opened my eyes, and I hope I can learn from it to be a more compassionate physician once I graduate.

Pulm: Winding Down

Today was technically the last day of my pulmonary rotation (and medical school) since Dr. JS doesn't work tomorrow and I only have to attend Grand Rounds before going back home. Dr. JS made a point of saying I was his last student ever (unless something happens to our school president or unless the Clin Med office decides to send students to Tyler anyway), which seemed kind of sad. Once again I was relieved to be graduating at a time when our school politics was not very stable. Dr. VT, the doctor in charge of the rotation, went over exam questions with us in place of Pulmonary conference this morning, and afterwards Kate told us all about what was going on down at the school as she knew it. *sigh* Again, glad to get away.

Lisa took tomorrow off and left within an hour or so after lunch, but I agreed to go out to eat with Kate, Danny, and Amber at a Mexican restaurant called Mercado's. I already ate the microwave dinner at my house so when we got to the restaurant I snacked on chips and salsa and ordered a margarita. It was a nice way to celebrate the end of medical school. I mentioned that I'd brought my violin to Tyler (and actually played on two occasions as well), so the others asked if they could hear me play. We hung out in my cabin for about 1-2 hours just listening to my violin and chatting about things music-related. I learned that Kate and Amber had great voices when they sung along to "Nearer My God to Thee;" I wish Danny could have recorded them singing. Violin in the background, voices in the foreground...it was beautiful making music together like that. I never thought I'd get the chance to do something like this again.

Pulm: Rain, Rain, Go Away

Dr. JS doesn't have clinic on Fridays, so after lecture I met him at his office so we could round on our lone TB patient. He was scheduled to have a bone marrow aspiration this morning, but we were able to talk to him before that and learned that he was finally about to cough up some sputum for a sputum sample. We don't even wear the masks when we go to his room now; Dr. JS seemed pretty confident that he was no longer contagious.

Amber, Danny, and I were free to go after Grand Rounds, but it was raining outside, HARD. After discussing it amongst ourselves, the three of us decided to make a run for the cabins. I slipped in the grass at one point but it wasn't enough to stop me from getting to my cabin. I waited about 30 minutes for the rain to slacken before driving back home.

Pulm: Damn Birds...

Argh...for some reason last night a group of birds set up roost in a tree outside our cabin and chirped at each other ALL FREAKING NIGHT. Lisa and I lay down at about 11:30 pm, but I did not actually fall asleep until sometime between 2 and 3 a.m. I spent a good chunk of that time trying to sleep and also thinking of ways to get rid of those birds (i.e. throwing stones, spraying them with a hose). Those things had better not be singing all night is all I'm saying.

I paid another visit to our TB patient this morning after the pulmonary conference, and he commented on how much he'd love to go outside since he's been cooped in his room since he's been here. It really WAS beautiful and sunny outside. While talking to him, I realized that no one had told him yet that he was due to get a bone marrow biopsy tomorrow, and when he asked about his pancytopenia, I had to play stupid. It was not my duty to tell him that someone was going to stick a needle in him and drain him of some marrow (it was the hematologist's)

There was one patient today whose case was really sad. She was a 75-year-old woman with mild dementia who was recently hospitalized for pneumonia. In the hospital, both a CXR and a chest CT revealed a huge mass in her left lung, and it practically screamed lung cancer (especially since she had a long history of smoking). She was also a Longhorn fan and had her doubts about Dr. JS b/c he graduated from A&M, so the nurse stuck a Post-It to her chart that read: "To all Aggies: Patient is a Longhorn." Dr. JS burst out laughing when he saw the note, which came at a pretty inopportune time b/c he was in the middle of telling the patient's husband how dire her prognosis was. Given her poor health and dementia, everyone agreed that chemo and surgery were not the best option for her, and that palliative care was the best option. The patient seemed to understand what was going on, and as the couple left the office they were holding hands and trying to keep from crying. =(

Pulm: Interesting patients

After morning report (7:30 a.m.!), everyone went to clinic. I had nothing to do (Dr. JS hadn't shown up yet) when Danny came over and said that Dr. V, the ID doc, had an interesting case for med students to see. So I went to the room and Dr. V asked the patient to hold out his hands. Both palms were covered with a diffuse rash that the patient said was non-painful, and Dr. V said, "He also has them on the soles of his feet." Well, if that wasn't a huge giveaway of what this patient had I don't know what it was. When I left the room, Danny asked me what I thought it was, and I said, "Secondary syphilis." "Really?" he asked; he hadn't seen secondary syphilis before, whereas I saw a case of it at JPS. When Dr. V came out of the room, we discussed potential differentials, including erythema multiforme. "What's a common cause of erythema multiforme?" he asked, and we said drug reactions. "Which drug is most common?" was the next question. Danny didn't know, but I remembered it was Bactrim, which the patient was taking b/c he had advanced HIV. But...the localized rash to the palms and soles was very characteristic of secondary syphilis. The patient, however, had a negative RPR. "Why is that?" asked Dr. V. I thought the answer was obvious; he had HIV so his immune system never had antibodies against the syphilis. At any rate it was good learning experience and teaching case.

I had some pretty interesting patients in the clinic today. One man (his wife was the patient, who had an elevated left hemidiaphragm after her phrenic nerve was injured during open heart surgery; both were in their late 80s/early 90s) was wearing an interesting yet beautiful pair of boots, and someone asked him what they were made of. "Ostrich," he said proudly. Another patient asked if he could get his sleep study done before next month because after that, "I'm gonna go kill me a bear." Dr. JS asked where he was going to go shoot a bear, and he said, "Montana." I asked if he was planning to eat the bear or skin it when he was done with it, and he said if he got a bear he was going to have it made into a rug. =( I'm glad I'm not a bear in Montana.

Lisa and I went to the gym this evening and did an aerobics class. See, we are working out! =P

Pulm: New Attending

Because Dr. JS (new preceptor) didn't start clinic until 1:00 pm, I was able to drive to Tyler this morning (after telling my dad to go to see his doctor since he's been coughing for a week). I still haven't finished filling out my paperwork for Drexel but did submit my offer letter today (among other things). I saw a few patients with Dr. JS, but it wasn't long before he fell over an hour behind schedule. I did meet one patient who had Fuchs' dystrophy (hereditary corneal dystrophy that eventually results in blindness), but she recently got an epithelial cell transplant down at TMC and has regained some of the sight in her left eye. Yet another patient had a lung removed in 1985 due to lung cancer, and he's still going strong. Amazing. During clinic, Dr. JS got a page about a new TB patient and told me to go do an H&P on him. The patient was a 45-year-old man originally from Grenada (he still has a Caribbean accent) who was diagnosed with TB in September but even on 3 anti-TB meds his hilar lymphadenopathy and infiltrate-laden lungs did not improve. He had never given a sputum samble and his notes were disorganized so Dr. JS and I had no idea how he got diagnosed with TB in the first place. By this time it was past 5:30 pm, so Dr. JS told me to go through all the notes from the other hospital and then dictate my H&P. Easier said than done. I ended up having to put the notes in order before I learned that the TB was diagnosed after a bronchoscopy revealed AFB-positive stains. And my dictating skills suck; I haven't had to dictate anything since Tanner week in family medicine which was well over a year ago. The transcriptionist is going to have a field day when she hears my stammering...

Pulm: Good Thursday

This morning I met Dr. Ozzie and Andrea down at the ICU again, and our patient is not doing too well. His vent settings haven't changed; the nurses attempted to drop his FiO2 from 40% to 30% but he didn't tolerate it. His neuro signs are still abnormal and he's minimally responsive. The only time he really showed a good response was when his childhood friend and pastor came to visit; when that happened, his eyes were open and he was looking around the room. Almost seems too good to be true, but when Andrea asked him to trace her finger with his eyes, he couldn't do it. An EEG done on his brain showed "slowing activity," indicating that while the patient is not brain dead, his chances of survival off the vent are not good. The patient's brother and sister would be visiting today, and Dr. Ozzie planned to talk to them and tell them about the prognosis. In some downtime, Dr. Ozzie sat down with Andrea and me and went over the lectures he gave earlier in the week since Andrea wasn't present for all of them. She also didn't have the PPTs like the students did, so I made her a copy of my slides as a reference.

There was a Tumor Board in the afternoon with fettucine alfredo (Lisa and I lamented not going to the gym yesterday after getting this carb-full lunch) before we returned to clinic. There was originally an ICU lecture planned for 1:30 pm, but that got moved to 3:00, and then 4:00, because Dr. T (who's in charge of the students) was seeing walk-in patients. That was fine, since Andrea and I got to see some pretty cool pulm cases like bronchiectasis and pulmonary eosinophila (VERY hazy on CXR). I also submitted my clinical question assignment to Dr. Ozzie at the end of the day (fortunately he was still at the clinic since I stayed up until nearly 1:00 a.m. looking up that assignment), and he read through it to make sure it was acceptable. Basically we had to ask ourselves a question and see how long it took to answer, so I questioned whether IPF could be better treated with immunosuppressants combined with steroids compared to steroids alone. The answer: no concrete evidence that one is better than the other.

We got Good Friday off, so after lecture the five of us returned to our cars and took off for a long weekend =)

Pulm: The IJ

This morning I met with Andrea and Dr. Ozzie in the ICU to see our lone ICU patient: a 66-year-old man who developed cardiac arrest and V-fib with a delay in CPR (but he got defibrillated, fortunately). He was intubated but not sedated, and though he reacted to pain, his neurologic signs were somewhat abnormal. Both Babinski reflexes were positive, and his eyes were sluggish and fairly non-reactive to head rotation. He also needed a central line (IJ), so Andrea got to do that while I watched. The ultrasound machine was malfunctioning for a while but Dr. Ozzie refused to do the IJ until it was fixed. This is a far cry from JPS, where central lines are done blind without the aid of an ultrasound, but this patient had a lot of fat around his neck and clavicles so in his case an ultrasound was necessary. Fortunately we got the ultrasound plugged in, but the IJ was still not without its difficulties. The patient was unconscious, but not sedated, so during the procedure he'd sometimes move his arms, legs, and head. I had to slide my hands under the sterile field in order to keep his hand down. It took a few sticks to get the vein, but Andrea got the job done. Better her than me; I've only done subclavian lines.

After work Kate and Amber invited Lisa, Danny, and me to join them for dinner at a restaurant called Bodacious BBQ. The sweet tea there was pretty good, and the five of us chatted about all topics ranging from our pets to our classmates. Then later in the evening Kate knocked on our door and asked if we wanted to play "sucker ball" with them. It's a game where you hold a racket with suction cups on one side and toss a ball back and forth with the goal of catching the ball with the suction cups. It was pretty addictive and Amber and I got pretty good with playing ambidextrously. Lisa came out to play a little later, but it was all a nice bit of fun. Danny didn't come outside at all, despite our laughter; he was probably sleeping.