Time of Death

When I was on call two days ago, my cards fellow called me to say there was an eval in the ED and could I please go downstairs to assess the patient. The only information I had was that he was just discharged 1 hr ago after a 2-day stay s/p BiVICD upgrade, and not long after he left the hospital, he suddenly became unresponsive and his wife immediately drove him back. He arrived pulseless and in V-tach; a shock of 200J pushed him into PEA and it was only with epi that he regained his pulse. The ED residents were putting a central line in him by the time I got down, with the attending planning to initiate the "Arctic Sun" protocol, also known as hypothermic therapy. Studies have shown that if a patient's body temperature is cooled to 33 degrees Celsius for 24 hrs after a cardiac arrest, then rewarmed after 6 hrs, s/he is less likely to have long-lasting neurologic damage. I had seen this method used at the JPS ICU, and this was the first time I'd seen it done here. Once the patient got up to the CCU, they placed cooling pads on him and proceeded to lower his temperature. Then he went into another sustained run of V-tach and I, as the most senior resident in the unit, had to decide whether or not to shock the patient. This was the closest I've ever come to running a code and I was terrified (even though I didn't show it), and I told them to administer the shock. It fixed his rhythm but only temporarily; it took 150 mg of amio to get him back to his baseline A-fib. Even still, I called my fellow and asked him to come to the hospital to help me out. We ended up putting A-lines in my two patients (I got my first successful A-line that night), but they were such hard sticks that we went through 10 A-line kits before we got the lines in successfully (not joking).

The next morning (yesterday) the patient's cardiologist came in to see what had happened. He told us that the patient had a history of cardiac amyloidosis that caused him to have diastolic dysfunction and increasing episodes of V-tach (they'd attempted an AV junction ablation during his last admission but it was unsuccessful). We also learned that his ICD had shocked him twice while he was in the car, but it wasn't enough to correct his V-tach. The patient's wife stayed with him and requested that we call his PCP, who was a prominent figure in the medicine program. He later came to see the patient and spoke to the family at length about the patient's overall prognosis. It also came to light that the patient wanted to be DNR/DNI, and the family agreed that once the patient was brought out of hypothermia, if he didn't regain consciousness, then they would withdraw care.

This morning the patient continued to be unresponsive and comatose even after the Arctic Sun was turned off. The patient's PCP, gastroenterologist, and EP physician all stopped by in the morning to speak to the family and offer their condolences. When all the family members had gathered, they requested that we withdraw care as they didn't want to "draw things out." The end came pretty quickly after he was extubated and the pressors turned off. We left the room but kept an eye on the tele monitor, watching his blood pressure dip lower and lower while his heart raced in V-tach in an attempt to keep his BP up. Less than five minutes later, I was in the room pronouncing the patient dead while his family members held each other and cried.

It had been a good year since I'd had to declare anyone dead, but fortunately I remembered the steps and was able to fill out the death packet and make the necessary phone calls. *sigh* And here I'd hoped to go through this rotation without ever having to fill out a death packet. In this case, however, I'm glad that the patient had made his wishes known and that his family had honored his wishes. Too many times have I dealt with families who could only think about what THEY wanted and not what's in the patient's best interests. I have yet another patient who's comatose after a PEA code, and even though it's been two weeks his wife has YET to find his living will. She says she'll bring it tomorrow; we'll see.

Code 99

I've been on CCU for two weeks so far, and I can easily say it's the most stressful rotation I've had so far. Even more so now that I'm the resident and am expected to know how to read EKGs, assess patients for heart failure vs ACS, and (ideally) run a code. I had only been in one code so far as a resident (this patient ended up coming to the CCU after going into PEA), and at that time there were so many people in the room I didn't play an active role in the code. Even still, I dreaded the day when I would be the first responder in the room and would have to run a code.

My most recent call (which took place on a Saturday) was fairly uneventful until around 3 pm, when the dreaded code pager went off. My intern and I went to see what was going on and I went to grab the patient's information. When I saw the name on the sheet, my heart froze. The patient was a 35 year old woman I had seen just 3 weeks ago while I was on the heme-onc consult service. She had been admitted for abdominal pain and found to have a pelvic DVT, and I had been working her up for a hypercoagulable condition. There had been a MICU eval called on her at that time b/c she'd been persistently SOB and tachycardic, but when a CT angio ruled out a PE, the MICU team decided she could remain on the floor. I remembered she was a very sweet person, apologizing for not having shaved her legs in days and often speaking of her son and daughter (both in elementary school), always hoping she could get better and go home soon to be with them. The last time I saw her, I was under the impression that once her INR was therapeutic she could go home. I had no idea that she was still here, and when I realized that she was the patient coding in the room, my first thought was, "Did she have a PE?"

By the time I got into the room, there was a cardiology fellow standing at the foot of the bed giving orders while the MICU resident and the heart failure resident were already assessing the patient and getting in line for chest compressions if need be. BP 80s/30s and HR 56; it wasn't long before she went into PEA and I took turns with the other residents doing compressions while the nurses pushed epi, vasopressin, amiodarone, and fluids. Compared to the last code I was in, everything in this code was done in a very orderly fashion. The heart failure resident got an ABG with help of chest compressions; needless to say it came back extremely acidotic (pH 6.8, CO2 80s). At one point I roped my intern in to help with compressions while I called the patient's primary team resident to fill him in on what was happening. He later told me that his attending was in the process of getting the patient transferred to the PCU or MICU because of her persistent tachycardia, and that the patient's family had just been at the hospital to visit her a mere hour before this happened. Several residents tried to call the patient's family, but all the phone numbers (much to our dismay) were invalid.

At one point the cardiology fellow asked if anyone objected to his calling the time of death. Someone suggested he check the pulses one more time, and the patient was found to have a carotid pulse on Dopplers. Then I felt a pulse in her foot. We'd finally succeeded in getting a pulse, and the patient was now in V-tach. One of the nurses warned, however, that this could be the drugs working, and once they wore off, she'd go back into PEA. The defibrillator declared that the patient was not shockable, despite the rhythm looking as though she was in V-tach/sinus tachy, and so we resumed chest compressions. Then we had to pace her heart because her HR fell. Things were not looking good. The entire code lasted over an hour; I think the reason we worked so hard was b/c she was so young. My intern and I ended up leaving before the code ended in case anything happened in the CCU.

Later I ran into the resident who'd cared for this patient and he told me that he'd found prescription bottles for Indocet and Ambien in the patient's purse. The team had not been giving her narcotics, and apparently she had her family bring her some from home. So cause of death COULD have been due to overdose or drug interactions, but I doubt we'll know unless there's an autopsy. *sigh* Her poor family.

Falling Apart

In medicine, people generally expect doctors to be cool and calm, able to withstand stress under pressure. Sadly, I don't fit that mold. I crack pretty easily under a lot of pressure, and I know it. When I first started residency, I set a rule to myself to never lose control of my emotions at work, no matter how bad things got. I already broken that rule twice during my intern year. The first was during a MICU shift when I had to juggle 7 patients while my resident was post call. The second was during a floor month when I had to juggle 14 patients (including 2 discharges) while post-call on a Saturday with no resident to help me get out before 1 pm. The first time, a MICU nurse was there to reassure me that it was still early in the year and I was doing a good job; the second time, a resident heard me out while I ranted. The insight I got from this is that I'm more likely to lose my temper when all hell breaks loose while running a service alone.

My last Friday on the heme-onc service was no exception. First we had a new admission that had been wrongly assigned to my team and I must have wasted an hour of my time calling the general medicine services to see if they would take this patient (fortunately one attending said yes) and then arranging his transfer instead of caring for my own patients. Then, after my intern went home (she was post-call) we had 5 discharges and 6 admissions in a single day (fortunately I didn't have to do the admissions but I had a black weekend ahead of me so I had to learn all about them). Then a patient who was supposed to be discharged had a clotted J-tube that neither I nor surgery could fix, so our only option was to call IR. The problem: it was 4:40 pm when I called and IR closes at 5:00 pm. And it's a Friday. Needless to say the IR attending (who's an ass to begin with) totally ripped me a new one, asking me why I waited so long to call and if I was just "sitting on this all day." Hardly! The last thing I wanted to do was to call IR to fix a J-tube; that's why I tried every other possible option! At any rate, the stress of caring for 14 patients, worrying about my patient in the ICU, trying to do well on this rotation and now getting yelled at for something beyond my control was too much, so I just broke down and cried.

Fortunately I was in the med room (complete with a computer so I could update my patient list and signout from there) when this happened, so the attendings didn't witness my breakdown. My 4th year student, the other heme-onc resident, a couple of nurses, and later my fellow tried to comfort me, saying that today was a bad day, I was doing a good job, there was only so much I could do, etc., but the waterworks just wouldn't stop. There were times where I thought I'd finally composed myself, but then something else would set me off and I'd be back to square one. One of the nurses even brought in a box of Kleenex so I'd have something to blow my nose on. In the midst of all this, IR called and said they'd take my patient if he came down to the department ASAP, so my med student ran outside, got a wheelchair, and personally took my patient down to IR. I felt horrible that he had to witness his resident falling apart the way he did, but I think he understood how stressed I was. When he came back to the med room, he offered to come in to work tomorrow morning to help me get my work done faster. That was a kind gesture. Finally I regained enough composure to leave the med room and finish up my work. If my attending noticed that my eyes were red, he was kind enough not to say anything about it.

The following Saturday my 4th year came in as promised, and the attending covering the service that day commended him for coming in on his day off to help out. "You've got a fine young student here," one of the patients told the attending, to which she (and I) agreed. I was able to finish most of my work on time with his help and let him go before 1 pm, telling him that today's shift would count as a call (4th years have to take call with residents). The rest of the black weekend went smoother than I thought, and I was so relieved to be done.

But then again I'm a sucker for punishment and went straight from the heme-onc service to a month of heme-onc consults, which is run by the same attendings whose service I just left. In a way it was good because now the attendings can see how I work without the pressure of trying to run a full service, and the consult service is way more relaxing. I still saw my old team from time to time and got the new resident oriented into how the team runs. I was also relieved to learn that my patient who got sent to the ICU was doing better; she was off pressors and recently extubataed, though now she has an EF of 10-15%. Whether this was due to the chemo or infection I can't be sure, but I'm grateful that she's turned the tables...for now.

Deadly Mistakes

This morning I got to work to find out that one of my patients, a young woman in her 30s who was neutropenic after getting chemotherapy, had been sent to the unit. She had spiked a fever overnight and become hypotensive, which given her neutropenic state wasn't too surprising. She'd first shown signs of infection four days ago, and we'd put her on vanco, Zosyn, and flagyl to treat her empirically. Or at least, I thought we did. Her blood had grown zosyn-sensitive Klebsiella, and I remember thinking, "Oh good, at least she has coverage for it." Then when I spoke to the night float, he said, "You know, she only got a one-time dose of vanco and flagyl four days ago, and hasn't had any since. The only antibiotic she'd been getting was Zosyn."

To say that I was stunned would be an understatement. I can't even describe what I felt when I heard him say that: it was a combination of shock, horror, worry, and fear. Definitely fear. We put our patients' medication lists on a Word document and copy them onto the progress notes everyday, and even though I put my med student and intern in charge of updating those lists, sometimes things aren't done. When our attending had told us to add broad spectrum Abx to this patient's med list, we added it onto the Word document without checking the EMR to see if it was actually being ordered. And all this time, we believed the patient was getting broad spectrum antibiotics when she wasn't. And now she's in the MICU on 2 pressors, intubated and septic, unlikely to survive the remainder of the week unless she really recovers.

It's hard to say who was at fault. The person who put in the abx orders as a one-time stat dose instead of a standing dose had only been at this hospital for 2 months and probably didn't know better. The medical student who's supposed to update the medication list each day never saw that the antibiotics had fallen out of the computer. And I, the resident, have been so busy doing admissions, trying to oversee a capped service, and keeping things in order that I never double-checked the computer to make sure she was getting her abx. Even the patient did not help matters by refusing blood cultures over the weekend (they drew stat cultures in the MICU and it grew out gram negatives within 8 hrs) I felt sick all morning and couldn't help but feel guilty over everything that happened. More so because I am strongly considering applying for a heme-onc fellowship and plan to ask my attendings for rec letters. Would they even look at my application after what happened? Fortunately the attending never once blamed any particular person for this, but I knew very well that that if something like this had happened to a patient on the heart failure service, the heart failure attendings would have done everything in their power to get me kicked out of the residency program. After all, this was a matter of life and death.

I went to see the patient later in the unit; by then she was intubated and had a central line and art line. All she wanted these past few days was to get better and go home to be with her kids. And now she might not survive. *sigh* Hoping she gets through this.

Friday the 13th

"You guys do know today's Friday the 13th, right?" These words were said by my attending during rounds today, but I didn't even know that it was Friday the 13th until he brought it up. And even if it was Friday the 13th, I've never been superstitious and I didn't expect this day to be worse than any other day. I was wrong.

I started the morning with 15 patients on my service (the other heme-onc team had 16 so our teams were both beyond capped), and starting at noon I had to run the whole service alone. My intern had clinic, and my sub-I was attending his brother's wedding on the West Coast. I knew my afternoon would be hellish since I had to be a "resi-tern," but between 11 am and 2 pm everything went to hell. One of my patients who had been admitted with anasarca and was responding well to Lasix and albumin suddenly had grossly bloody stools and a drop in Hgb from 8.4 to 7.2. We transfused her 2 units, but when she had a second equally bloody BM, we knew that was trouble. The poor woman had been doing so well and was crying when she learned we had to put in an NG tube. At the same time, I had a patient whom transport was supposed to pick up at 1:00 pm exactly, and I had to scramble to do his discharge paperwork while the GI fellow was at my heels telling me to throw in an NG tube and start Nexium and octreotide on my GI bleeder. Fortunately my fellow could see I was swamped and put in the NG tube (which yielded bright red blood), and she helped transfer that patient to the unit while I ran around like a madwoman filling out scripts, admitting two direct admissions, answering calls from nurses, etc. There were a few times where I felt like crying, but fortunately that didn't happen. Then a patient on the other team had an unwitnessed fall, the same reason for which she was admitted, and we had to send her down for a head CT. *sigh* Is it Friday 13th, or just a bad day? Who knows. At any rate I didn't leave work until 9 pm (I was on call until 8 pm).

What a day....

Two Days Later...

After my hellish non-call day, I wasn't sure what to expect on the day that I was actually on call, but this call was probably the best one yet. My poor intern stayed at the hospital until 5-6 pm yesterday discharging patients and trying to hold the team together; it was his first weekend shift and he'd never written all 14 notes at once before. I was told that he seemed stressed and a bit overwhelmed (not unlike how I was on Friday), so sometime this week I'll have to find time to sit him down and go over things with him. Fortunately for me I only had 11 patients to see this morning, and between seeing patients and rounding with both the fellow and the attending, I managed to get all my work done by 1 pm. Not too shabby.

I emailed the triage resident and we were able to clear the air about what happened on Friday (she got 6 admissions at once and thought we were almost done with the admission so she wanted me to oversee it without realizing that my intern hadn't even started on it). I wonder if she told today's triage resident (who was my resident back in February) to cut me some slack today, because I didn't get called for a single admission all day. At most I was asked to oversee another intern's admission, and when I found out she wasn't able to do it b/c she was sending a patient to the unit, I took it out of her hands and did the H&P myself to help her out. We went over it together afterwards since the patient was going to her team, but overall I had enough time today to dictate about 6-7 patients. And I got to leave on time. If only all calls were like this =)

Overwhelmed....

As glad as I am not to be an intern anymore, being a resident has its own share of trouble. I'm now working on a heme-onc floor service, a rotation which I'd requested because I'm interested in heme-onc and the attendings on this service are also the program directors for the fellowship program here. If I did well on this rotation, then the attendings would take notice of me and possibly write me a letter of recommendation when time came for me to apply for fellowships. I had just completed a heme-onc floor month at the other hospital, so I thought the transition from one hospital service to another wouldn't be difficult.

Wrong.

This service is notorious for always being capped and being extremely busy, but I had no idea how busy it would be until now. There are new patients being admitted to our service almost every day for chemotherapy, neutropenic fever, etc., so I have to do admissions on days even when I'm not on call. There was one day where we got 3 new admissions before noon, and I already had 13 patients on my service. But the 14-patient cap doesn't really exist for this service. The chemo patients are pretty easy; they come in for chemo for 1-2 days and then leave (it just means more dictations for me to do later on; by the end of this rotation I'll be a pro at dictating). But that also means our census is always fluctuating, and it's hard for me to know everything that's going on with all 14+ patients. Which is bad, because as the resident I'm supposed to know what's going on at all times. Instead it's my sub-I who knows the patients best since she's been on service for 4 weeks and knows more about them than my own intern (who's similarly overwhelmed since this is his first floor month). And now she'll be leaving too, and I'll have a brand new sub-I and MS3 next Monday to train.

Today was especially bad because my intern had clinic this afternoon at the "Bing," the private hospital located 13 miles away (a 1 hr commute during the day), so I was intern-less for the afternoon. At this time I was carrying a grand total of 17 patients; 2 new ones got admitted for chemo in the morning. There would also be 4 patients leaving after completing their chemo, so my med students and I were doing discharge paperwork like crazy. On top of that, one of my patients needed a MICU eval b/c he fell out of bed and was found to have a head bleed (MICU ended up rejecting him b/c of his DNR/DNI status), another one got a last minute ERCP for abdominal pain, etc. There was so much to follow up on I was running around like crazy. My intern, despite having clinic this afternoon, was also on call until 8 pm tonight, so I did 1 admission and 1 accept note for him this afternoon. I felt bad about leaving my med students alone when I had to run to the ER for the admission, but fortunately they did fine. The other heme-onc resident helped out by supervising my MS3 in her first successful ABG, and I rewarded my med students by sending them home at 5 pm (which is "early" for this service; this entire I week I never left work earlier than 5:45 pm)

Then there were 3 direct admissions to my team starting at 5:30 pm, and all of them for nausea/vomiting/sick symptoms. The triage resident told me to do one of them, but by then my intern had returned so I gave the admission to him. Ideally, I was allowed to leave as soon as my intern returned to complete his call, but I stuck around the hospital to help him with floor stuff while he worked on his admission. The problem: he started doing floor stuff instead, and I tried to get him to focus on the admission in order to get him out at 8 pm. By this time it was 7 pm and after the day from hell I was anxious to leave. The triage resident had told me that she would supervise his admission, but around 7:10 pm another resident (who's known to be extremely two-faced) came by and told me, "By the way, triage wants you to supervise your intern's admission."

I was stunned. Never mind that I wasn't even on call today, why were the residents making me stay until 8 pm to supervise my intern's admission? Was it because the patient was going to my team? I wasn't even supposed to BE at the hospital right now! I'd only stayed so that my team would have continuity of care until my intern returned, and now this?! Were they doing this just for the sake of convenience? I did not believe that the triage resident had wanted this; she had apologized for making me stay late until my intern returned. Rather, I think the other resident said this so that he wouldn't have to supervise my intern himself. A part of me wanted to call the triage resident and ask if she really wanted me to stay late to supervise the admission, but then what would that have done to my intern? He was sitting right beside me when I was told to supervise him; if I bailed on him now, then he'd probably think all I cared about was going home rather than help him out. So I didn't argue and agreed to supervise the admission. Even when another resident stopped by and asked if I needed help, I said I'd take care of it since, after all, the patient was going to my team and I needed to know what was going on. I think at the end of the day my intern could tell I was stressed to the max (I was "sighing" a lot more than usual), but he still couldn't sense my urgency to get out on time. We didn't wrap things up until 8:30 pm, at which point I couldn't leave the hospital fast enough. I didn't let myself break until I got home.

I never expected to be on call with my intern like this, and I have my own call in 2 days. That is Q2 call. I should consider myself lucky that residents don't have to do overnight calls except in the units, but I am still extremely stressed, angry and frustrated. I feel like I'm not a good resident since I don't know my patients as well as I should (even consulting residents knew to ask my sub-I for information instead of me), my medicine knowledge is lacking, and I've yet to do well by the attendings. At this rate I don't think I'm in any position to apply for a fellowship this year. If I even want to do a fellowship anymore. I also want to email my chiefs about this, but I don't want to come off as being lazy or weak. *sigh* I don't know what to do anymore.

Just hoping things get better next week.

Being a Resident

I've been a PGY-2 for about 5 days now, and I must say it's been quite a transition from being an intern. Sure, I have fewer notes to write, but there's a greater sense of responsibility that comes with being a resident. My intern is very helpful and hardworking (which is good; I don't know if I can deal well with lazy interns), but I still have to look over his shoulder to make sure things get done right. Yesterday he was on call overnight (and covering night float), so I expected him to be a zombie. When I ran into one of the Drexel attendings, however, she confided that she didn't know what to think of this year's batch of interns. One intern ordered methadone for a patient's pain (when she was already on dilaudid and not a recovering addict). Another called the attending at 3 am asking what dose of kayexalate to give a patient for a K of 6.2. My own intern, to my dismay, told her over the phone that he was "too busy" to take care of something she wanted done as soon as possible. And while I believe that he was busy since he was getting signout from other teams at the time, that's just the wrong thing to say to an attending. I still remember my fellow MSIII's response at Methodist when the attending asked her why she didn't go to the pathology lab to look at a patient's biopsy results as instructed: "I guess I didn't feel motivated to do it." *facepalm* When I told another classmate about my intern's faux pas response, he asked me, "Were we that bad when we were interns?" I'd like to think no, but who knows. -__-

The current batch of interns here at the "Bing" (the private hospital where we rotate through 1-3 months of the year) really do seem overwhelmed. I feel pretty fortunate that I'm now a resident on a service that I did just 3 months ago as an intern; the attendings still remember me and I know how things run. That's not to say I haven't made mistakes; my intern mistakenly told me that a patient's bone marrow biopsy wasn't back and instead of checking the results myself, I took his word for it. Later I found myself in trouble when the attending clearly pointed out that the biopsy results had been noted in the chart. "How long have you been on service?" she'd asked. That was a real FML moment, but makes me more determined to be careful when chartchecking. Clearly it's too soon to believe everything that comes out of the intern's mouth for now; I just hope it gets better by the time med students start. Then I'll have my hands full.

The End of Intern Year

Today was the very last day of my intern year, and honestly, it couldn't have come fast enough. After 2 weeks of night float followed by 4 weeks of CCU, I was drained and in desperate need of a break. My license expires tomorrow and won't start again until July 1st, so until then I have a glorious 1-week break which I plan to spend at home with family and friends.

The newest batch of interns arrived this morning to shadow us for a couple of hours to see what their jobs tomorrow would be like. They showed up in their brand new white coats and notepads in hand ready to jot down new information. We were pretty amused to find that of the four new CCU interns, three were named David; we joked that they'd have to be called by their last names to tell them apart. One of the Davids would be taking my spot tomorrow, so I told him a little about each patient and what was going on. The fellows, too, welcomed the interns, and one of them immediately sat down and started teaching them about Swan Ganz catheters, right heart caths, and other things essential to the CCU. It was surprising because he'd never taught my fellow interns and me any of this (we had to figure it out on our own), but I guess with these guys being new to medicine and the CCU they had to learn quickly what was important. Our attendings, too, were interested in meeting the new interns "fresh out of medical school;" when the heart failure attending came by and didn't see the interns anywhere (b/c they were in another patient's room), he wondered where they'd gone.

Unfortunately for the new interns, one of our patients coded right in front of them today. This was a woman in her 60s who had been admitted back in April for an infected pacemaker; the infection had spread to her spine, forming an epidural abscess. During her stay in the CCU, she went into multi-organ failure (intubated, needed dialysis, platelets fell to 19 and only responded to HLA-matched platelets, became jaundiced from a failing liver, etc), and we all knew that her prognosis was very poor. Yet through it all, she never complained; she always smiled when she saw us and (once she was extubated) said she felt all right. When we saw her this morning, she was her usual alert and smiling self, albeit more short of breath than usual. Finally it became obvious that she would need to be reintubated, and I felt sad b/c she'd being doing better.

Then she went into PEA, and half the residents ran into the room to assist in the code. One of the Davids donned gloves, ready to help with compressions, but the fellow told them to stay out of the room. So while half of us stayed in the nurse's station to round with the attendings (and sneaking peeks at the tele monitor all the while), the other half stayed in the room with the patient. Fortunately I knew my patients well enough to present them while my resident (who was post-call, too) was helping with the code. Twice this lady recovered with the help of bicarb and amiodarone and epi, but in the end it wasn't enough. Time of death was shortly before noon.

One of the residents later commented that the interns had looked terrified while all this was going on, and I don't blame them. These were all prelims going into radiology, anesthesiology, or PM&R; they probably haven't done a medicine rotation in many months. I, too, was jittery when presenting to the heart failure attending (who's pretty high up there on the cardiology totem pole), and at one point he said, "Calm down, you've got these guys to replace you, and soon you're going to be the boss of them. Scary thought, isn't it?"

Yes, it definitely was. Although the prospect of being a resident (and being expected to teach interns and med students) was frightening, it's also exciting. What's not to love about limited overnight calls (residents only do 30 hr shifts in the units) and having fewer notes to write per day? On the other hand, now I'm expected to do chart dictations and actually know stuff. It's easier to get away with being stupid as an intern, but as a resident I'll have no excuse. One of the cards fellows already knows I have zero cardiology knowledge, and he's going to be the CCU fellow again in 5 months when I return to CCU as a resident. My only hope is that by then, I'll have gained enough knowledge to be more confident as a resident.

Doctors Are Not Gods

Last month I finally got a chance to read The House of God, which came highly recommended by several attendings at this hospital. For those of you who don't know, The House of God describes a brand new doctor's (mis)adventures during his intern year at a prestigious Harvard-affiliated hospital (aka the House of God) during the 1970s, when overnight was q3 and the intern didn't leave until 5-6 pm the following day (essentially a 36 hr shift). The main character starts his intern year fresh-faced and eager to save lives and help people, but halfway through the book he and his fellow interns were losing their tempers at patients, kicking at elevator doors for being too slow, or secretly euthanizing dying patients with KCl. All this sounds ridiculous to the newly graduated medical student, but interns and residents can definitely relate to the long work hours and the crap we put up with at home and at work.

I'd be lying if I said that I was the same person I was one year ago before intern year started. This year has changed me, and not necessarily for the better. I've become more disillusioned, more angry, and more cynical. When the same patient comes to the hospital week after week for abdominal pain after drinking a pint or two of vodka, then leaving the hospital AMA when he doesn't get narcotics for his pain, it's hard to be sympathetic. And unfortunately, that patient represents a huge chunk of the general patient population here. Sometimes I feel like medicine is draining away my humanity and turning me into a robot. Quite a difference from the medical student who liked taking the time to get to know her patients and strongly believed that doctors should be better listeners and better advocates for their patients. I still believe that, but sometimes I find myself forgetting how to become a better doctor.

One of the patients I had to cover for in the CCU last night was a 42-year-old man with A-fib, chronic kidney disease (on HD) and end-stage cardiomyopathy (EF 5%). Despite having a pulse ox of 100%, he felt like he couldn't breathe properly and was afraid to fall asleep for fear he'd wake up struggling for breath. I assured him that his room was right outside the nurse's station, that he was on tele and we could easily monitor his pulse ox and heart rate, and that his call button was within reach, but he would not be dissuaded. "When I woke up just now, I was panicking! I don't know where the call button is when I panic! I'm scared, Doc! You need to fix this tonight!" The problem: this guy couldn't be fixed. His heart was a quivering mass of muscle on echo, barely alive and pumping right. He couldn't undergo dialysis to get fluid removed because he was too hypotensive. He was also obese with OSA and for some reason has not been on a CPAP ever since his admission. When I told him we couldn't safely dialyse him, he asked if I've been hearing a single word he's said. "I can't breathe! I'm scared!"

His nurse had pretty much given up listening to him rant, so a great deal of my night (which I would have preferred to be in bed) was spent at his bedside, listening to him rant about how he's done everything right ever since he's been in the hospital in order to get well (not true; he's refused beta blockers and cardioversion on several occasions for his symptomatic A-fib), but despite multiple tests and X-rays and even a defibrillator implantation, he's been getting worse. "You aren't doing anything!" he said. "You're a doctor, aren't you? What do they teach you in medical school? There's got to be SOME technology out there that can fix this! You say that my blood pressure's low and you can't give me lasix, I get that, but if I went to the emergency room, they wouldn't just let me lie here and do nothing! Can they send an emergency room doctor here?" I didn't have the heart to tell him that if he did show up in the ER with SOB and an EF of 5%, they'd immediately turf him to CCU. After listening to him rant for a good 20-30 min or so, I called my resident and asked what we should do. We ended up calling the cards fellow, who said we could put him on pressors to get his pressure up and give him some Bumex for his ease of mind. Guess what? He didn't put out a single drop of urine because his kidney function was so bad. He'd officially failed medical management.

Needless to say I didn't get much rest during last night (on top of which I had to share a call room with the heart failure intern and he was snoring loud enough to shake the walls), and in the morning, I told the attending what had happened during the night. She, too, wasn't sure why he was feeling short of breath when his sats were fine, but was concerned that his BP was too low for him to tolerate HD. "If we can't dialyze him, then he'll have to go home on hospice care. End of the road," she said. Later she went into the patient's room and told him the cold hard truth: that if his BP doesn't improve enough to tolerate dialysis, then he's going to die. She then called the patient's wife to the hospital to explain the same thing. I wasn't present at that meeting, but I later saw his wife enter his room with two toddlers (he has seven kids) to see him. Almost immediately, he started venting his frustrations (and reasonably so) about how nothing is helping him, and his wife yelled back, "Are you giving up? If you're gonna give up, you let me know!" The doors couldn't close fast enough to give them privacy.

It's times like this where I wonder why I chose this profession, if only to have patients yell at me and pretty much accuse me of being a crappy doctor, and I wonder if quitting medicine would really be such a bad thing. But that's when I remember that I am only human, that it's all right to be upset and frustrated at times. As a med school professor once told me, doctors aren't gods. We make mistakes, and we can't always fix everything wrong with a person, as much as we'd like to try.

A Hole in the Heart

I started my CCU rotation last week, and even though the cap for each team is 4 and I only have 3 patients right now, I'm feeling more than slightly overwhelmed. The patients who come up here range anywhere from relatively healthy (rule-out cocaine-induced MI or measuring Swan-Ganz numbers on a heart transplant candidate) to actively circling the drain. I haven't done a unit month since September, and it shows. On top of that cardiology is not my forte, so compared to some of my fellow CCU interns who do like cards, I'm the dumb one of the bunch.

Last week an 81-year-old woman was transferred here from another hospital because she had developed a VSD within five days of having a massive MI. From the start we knew she would be a hard case. She was intubated but had an air leak, had a white count of 25, had elevated creatinine, and had 300 ccs of coffee grounds suctioned from her stomach. The biggest issue, however, was the hole in her heart, the VSD. On echo it was located near the apex of the heart. CT surgery evaluated her and said her mortality risk was too high for open heart surgery. Interventional cardiology said they could probably do it, but the risk of failure was high b/c the patient had a flailing tricuspid valve that could potentially interfere with repair efforts. On top of all that, she had a balloon pump to help her heart and was on 2-3 pressors.

The biggest challenge was her family. Her husband, daughter, and son-in-law were all physicians; in fact, her daughter was once a chief resident here and her son-in-law gave the residents a quick talk on acids and bases when we discussed the patient's acidosis with him. They knew, I'm sure, that the patient's condition was poor, but they still insisted that everything be done, as they saw the VSD repair as her only hope for survival. The interventional cards team took her down to the cath lab around noon, and someone suggested that she needed all the prayers she could get to make it through the procedure.

She returned to the floor 5-6 hrs later, and the fellow looked worn out. He said that the procedure itself went well, that she no longer had a VSD, but afterwards she lost electrical activity in her heart and had to have a pacemaker put in. She left the floor on only 2 pressors, and came back with 5. Despite being maxed out on the pressors, her pressure continued to decline. As the intern (and scutmokey), I was told to take elevator 16 flights down to collect PRBCs and FFP for the patient (who was actively bleeding) or else throw in bicarb drip orders into the computer. Her ABG came back with a pH of 6.8 and a bicarb less than 10. 2 residents and I stayed an extra 2 hrs to help my resident (who was overnight) keep this woman stable, but things were not looking very good. When my resident finally sent me home, I passed the conference room and saw the patient's daughter sitting alone in the conference room. Surely she knew her mother was in bad shape, worse off now than she'd been before the VSD repair, and I was just grateful that she was not in the CCU with us watching us work. That would have been way too much pressure on us.

What upsets me the most is that even after 11 months of internship, I still don't know what to do when patients crash like this. I was just standing around waiting for orders while the residents were already gowned up at the bedside or on the phone making the necessary phone calls. I was almost no better than a medical student. I was useless. And my defense mechanism for all this? Daydreaming about being back in Austin, taking a dip at Barton Springs Pool, sipping milk tea from Momokos while walking down the Drag....*sigh* I wish I were back in TX.

AMH 3: Looking back

Yesterday I finished my last floor month of intern year (not counting CCU in June, which is strictly a unit month), and boy was I glad to be done. The service was pretty full the entire month; the lowest my census ever got was 7 (cap was 14). Even worse, this was the only service where I went home worrying about my patients' well-being, because they were that sick. When I took a day off to attend a convention, I sent the intern covering for me a long email telling him everything he needed to follow up on and later called him to make sure everything was fine. For the most part the service was evenly split between general medicine patients (university) and heme-onc patients, but both sides had several rocks that, for various reasons, wore me down both mentally and emotionally.

On the medicine side, we had a man admitted for nausea and abd pain with bilirubin levels that rose from 12 to 18; we were just watching him turn more yellow each day. Liver biopsy just showed EtOH disease, and surgery said his GB was fine and didn't need to be removed (patent bile duct). When I left the service they still didn't know what to do for him. Then we had a 20-year-old girl with a horribly displaced hip due to Legg-Calve-Perthes dz that ortho won't operate on b/c she's too young for a hip replacement, so she's here for pain management and inpatient rehab almost indefinitely b/c her insurance won't cover acute rehab. They both wanted answers as to what would happen to them next, answers I did not have.

The heme-onc side was no better. One patient who's been on the service longer than me was a 35-year-old woman with metastatic breast cancer. She has jaundice, massive ascites, and major LE edema due to her liver mets, not to mention horrible back pain, but she's fighting the cancer the best she can for the sake of her husband and two kids. Her support system is excellent, as she always has either her mother, husband, or sister at her side, but when I see her CA27-29 rising week by week I know the chemo is not working. Then there was an older woman with CLL and extensive lymphadenopathy who'd been spiking fevers of 101-102 almost every day for the past week or so, and every night we drew cultures on her only for them to be negative. My last day at work, she was frustrated with the daily lab draws and was refusing further cultures. She accused us of causing her nothing but more pain ever since she was hospitalized, and I always dreaded going to see her because she would always accuse me of not doing anything to help her (whether it was making her LE edema go away, help her cure her constipation, etc). Every time I left her room I felt like I just took a beating.

To make things worse, the last week of this rotation I became sick with what started as nasal congestion but later progressed to full-blown sinusitis. I constantly felt feverish (even though my thermometer kept claiming my temp was 97.7 at the max) and kept wads of tissue in my coat because I couldn't breathe. Nyquil and Dayquil did nothing to help, though Sudafed helped a lot. My resident could tell I was miserable and once told me to lie down in the call room while he took my phone (we carry SpectraLink phones at this hospital so we can be reached easily). That gave me about 30 minutes of uninterrupted sleep, which I desperately needed. I ended up writing myself a script of Amoxil (signed by a fellow intern), which I believe is working, but what I really needed and could not get was sleep. While I was sick, I kept waking up in the middle of the night to either blow my nose or because I was too hot. The night before I had overnight call, I woke up with belly pain and ended up throwing up (mild food poisoning). Fortunately that was a one time thing.

I ended my last week on a black weekend, with overnight call/night float this past Sunday. And that was when everything went to hell. My CLL patient developed yet another fever but had such a bad case of rigors, shaking, and tachypnea that I was afraid I'd have to send her to the unit (especially after her CXR came back reading "mild failure"). Fortunately the rigors subsided and she fell asleep, but damn that scared me. Then my other patients all wanted to "talk" to me, and I wondered why they couldn't ask to talk to me during the day rather than at night. Sometime around midnight, I developed a headache and felt myself getting warm again (see what no rest will do to you despite being on antibiotics?), and I was afraid the hell would never end. Fortunately I only got about 4-5 phone calls after 1 a.m. and got a few hours of sleep. The overnight resident took pity on me and didn't call me for any admissions (to which I'll always be grateful to him for), but did snag me and the intern at 1:30 a.m. to teach us about how to manage hyperkalemia. In that case, the teaching was warranted (I had a pt with a K of 6.1) and helpful. And once my shift ended, I went home and spent most of the day in bed, relieved to be done.

Now I have 2 weeks of heme-onc elective ahead of me, and I think this will give me a chance to see if I really like heme-onc or not. If my last month was any indication, I don't know if I can deal with the emotional burden that comes with being an oncologist. But the interest is still there at least.

The VIP Patient

Vacation's over, and I've started another month of floors at "the Bing," the suburban community hospital where we rotate 2-3 times a year. The last time I did a floor month there was back in October, so it took a while for me to remember my password and the way things worked in this hospital. Right away, I got a list of 12 patients, among which was the father-in-law of one of the PGY3's in the medicine program. We were told that he was a "VIP" patient, and to treat him well. To be sure, he was more intelligent than most of the patients I've seen, almost to a fault.

One thing for certain: he didn't make things easy for us. He was a noncompliant diabetic who had already lost a toe to amputation, and when I saw him both legs were bandaged up due to ulcers. "They told me to keep it wrapped up and that once it starts to smell, it's really serious," he said, then added that he never smelled anything bad from his foot ulcers. The wound care nurse who later saw him begged to differ; she called to tell me his ulcers were oozing and the stench was foul. We were hoping to discharge him later today but he needed home care and case management wasn't called in time to set it up, so my resident had to break the news to him that he had to stay in the hospital an extra night.

Needless to say the patient was pissed. When I first saw him in the morning, he was respectful and in good spirits ("Have you met my daughter-in-law?"), but when he heard he had to stay an extra night at the hospital, he demanded to leave and even wanted to drive home (never mind that he was admitted secondary to a fall --> fx and his driving would be dangerous to both himself and others on the road) My resident even called his classmate (the patient's daughter-in-law) to see if she could talk him into staying at the hospital, but that only made him angrier. "That wasn't fair," he told my resident, and I can't say I blame the guy. It was only when the nurse said the patient's insurance may not cover his admission if he leaves AMA that the patient said he'd think about staying. I have no idea at this time whether he's still at the hospital or gone, but hopefully he'll stay until at least someone picks him up to take him home.

Home Again

That's right...I'm back in TX and couldn't be happier. My last week of night float was miserable because I got a pretty bad cold (the congestion and sinus headaches sucked) and was living off Dayquil to get through my shifts in one piece. Now that I'm home, I can sleep as late as I want to take the time I need to rest and recover, something I definitely need. My parents are glad to have me home, and I learned just how spoiled Pearl has become in my absence. For the past few months my parents have been buying more expensive multigrain wheat bread from Whole Foods instead of the usual Oroweat Health Nut bread we've purchased faithfully all of Pearl's life (which she loved to eat). And since Pearl's still a bread lover, they've been feeding her Whole Foods bread, and now she won't accept anything else. I tried to feed her some Oroweat bread that I'd brought home with me, and she wouldn't even look at it. *sigh* My rabbit has always been a food snob, but this is taking it to a whole new level.

I drove past TCOM today to check out the changes that have happened since we graduated. The new building across the street is well underway and looks impressive; I'll have to take a picture sometime. Our Class of 2009 poster is also up on the "Wall of Fame," and as I looked through it, I couldn't believe the mistakes I saw on there. Jerry was on there twice under two last names. Liza's face was over Carisa's name. One of the Liu's had her name spelled "Lui." Pretty bad, considering this poster is going to be up for all future generations of TCOMers to see (not that they'd know the difference anyway but still). Wonder if there's anyone I can contact about this.

Night Float Week 1 Recap

At this hospital, night float is done in 2 week blocks. 5 pm - 7 am on weekdays, 6 pm to 8 pm on weekends. Six days on, one day off. And of course, when working 14 hrs a day, my routine was to wake up at 3-3:30 pm (depending on whether I make dinner to bring to the hospital), leave the apartment by 4:30 pm to make it to work on time, work my shift, get home around 7:30 am, then shower and surf the internet for about 30 minutes before going to bed before 8:30 am.

There are two night floats: one covering the heme-onc/nephro/university medicine patients, and one covering the cardiac/GI/private medicine patients. I currently have the first, which is universally dreaded by all interns because it covers more patients and the patients tend to be sicker. On average, my night float partner does get fewer pages during the night than I do, but when cardiac patients do get sick, they go downhill FAST. There have been times where I've been able to sit in the lounge and take pages as they come while she was gone trying to keep patients from bleeding out. That's not to say I've never had emergencies; last night one of the patients I was covering had a rapid response called for suspected aspiration PNA and had to be intubated and sent to the MICU. The room was full but I got to attempt an ABG (didn't work; the guy's pulse was weak and even though I hit the artery, the blood didn't flow in) and later called and met with his family. Fortunately things died down after midnight somewhat.

I have to say, though, despite my pager beeping constantly during the night, night float hasn't been totally bad. There were only a few times where I got truly overwhelmed, but I've learned to prioritize nurses' calls pretty well. And after midnight, the pages are more sporadic; I've gone 1.5 hrs at a stretch without a single page. Luckily for me, every night there is an overnight intern who covers their own team (there are 8 teams and I cover 7 at a time), and sometimes the team being covered affects my own night. There was one team in particular with a lazy resident-intern duo who always gave me the worst signouts (claims of "nothing to do" and ending up with me running around during the night b/c their patients had problems that weren't addressed during the day), so when that intern was overnight I took great pleasure in sitting back while he got paged every hour and never really got a chance to sleep (easiest night ever for me). After that, signouts from his team were much better.

There's a pretty good camaraderie among the interns and residents working overnight; we sometimes order dinner at 8-9 pm if there's enough orders for a delivery. If there are lots of admissions, the overnight residents are rarely seen during the night, but on slow nights, the residents and interns gather in the lounge and chat, which is usually a pretty fun experience. Sometimes any medicine interns/residents working the 11pm-7am shift will sneak out of the ER and come upstairs to eat and chat for 10-20 minutes (a luxury I didn't have during my ER rotation since it was my first rotation and I, being new, didn't dare to leave the ER).

I was actually surprised by how fast this week passed by, and now I finally get a day and a half off to myself. I'm going home for vacation as soon as my last shift ends, so soon I'll be back in TX =) Can't wait!

Goodbye, Wards. Hello, Night Float.

My last month of wards was probably the most laid-back service ever. My census never went above 8; for a while we only had 2 patients at a time. This was great for my resident and me, but bad for the two med students and PA student who were working with us. We were also hit by 2 snowstorms in the span of one week, which was ridiculous and unusual for this state. Fortunately the "snow days" were treated like weekends and only one member of each team had to work. And since I was post-call just before the snowstorm hit, I got 2 days off from work because of the way the schedule worked out. Great for me, and also good that my resident lived across the street from the hospital and didn't have to fight snow to get to work like others did. Some people ended up just spending the night at the hospital rather than try to drive home. Even though the snow was a huge pain, I have to admit that the following day, when the sun is out and all the neighbors are out shoveling their cars free from the snow, there's a strange sort of peace in the air.

My last day of medicine wards, I was on call until 8 pm and had to attend to a rapid response at 7 pm. A patient I was covering suddenly became dyspneic and had audible stridor. The nurses kept asking me what to do, and I just about froze. It's somewhat pathetic that I'm almost 3/4 through my intern year (and did a month of MICU, too) and didn't know what to do in that situation. So I did what was most logical: call the MICU resident and one of the triage residents to come assess the patient and see if she needed to be transferred to the unit. Fortunately she eventually stabilized, but definitely gave us all a scare. When I voiced my concerns that I would not be ready for night float (which I start this evening), the residents said, "That's how you learn." They also assured me I did the right thing by calling them for help when I was in over my head, but I can't help but worried that this will happen again on night float. I'll be covering the general medicine, heme-onc and renal patients, and everyone knows the heme-onc and renal patients are SICK. *sigh* I'm doomed.

Medicine and Snowstorms

This month I'm back on wards, but fortunately I was assigned to a relatively laid-back service that started the week with 8 patients and ended on 2 (I am not kidding). For the first few days there was a psych intern working with me so we split the work, and when she pulled from our team to do a neurology rotation instead, the work was still more than manageable. I even had time to go to morning report (which is almost unheard of for interns on wards). I had a great resident (future nephro fellow) and two med students, a sub-I and a MS3, and together we worked extremely well. When we only had 2 patients, however, I think I became too relaxed, and actually became less efficient with my work. My resident picked up on this when he called me from his clinic and asked why a patient's BNP still wasn't back yet (our attending had wanted it since 10:00 a.m.) I told him that I'd asked the nurse to draw it, and he said, "It's your job to make sure it gets done. And it's not like we have 14 patients, we only have 2." Then he told me not to leave the hospital until the BNP results came back (we were trying to figure out whether one of our patients had SOB b/c of heart failure or COPD) *sigh* Although I was annoyed to have to stay later (I was trying to get home before the snowstorm started, and fortunately made it just as the snow started falling), I could understand his reasoning. I had grown soft. I think I was more on top of things in the PCU when we were almost always capped. At the very least, my sense of responsibility was greater. I'll get a new resident next week, and hopefully we'll be able to work well together. Just as interns chat amongst themselves about which residents are good and bad, residents compare interns, too, and I'd like to think my past residents thought favorably of me (unlike 1-2 interns whom the residents think are lazy and sloppy)

One big adjustment is having 2 med students around (a luxury I haven't had since August). We get along pretty well and can find things to teach each other; my sub-I had to teach me how to put a Foley in a woman since she's going into obgyn and had done it many times previously. Instead of textbook knowledge, I've been teaching them real-life lessons, i.e. how to call consults, mistakes not to make on call, and more. My MS3 takes calls with me so I have her see the patient first before going in after her. We were working on orders together in the ED when a schizophrenic patient suddenly began screaming obscenities and threatening to kill the nurses and security guards trying to hold him down. ("Frank Sinatra is not dead! **** you mother ****ers, I'm gonna **** you all," you get the idea) At one point I accidentally clicked "Uric acid" instead of "Urinalysis" because I got so distracted by his screaming, and while my MS3, another intern, and I couldn't keep a straight face during his tirade, the ER attending nearby kept a poker face as he yelled, "Someone give him from Versed" and then, when the patient was still screaming 5 minutes later, "Did it go in yet?" Eventually the patient got knocked out completely before his transfer to the CCU (they're gonna have a field day with him), but this only reinforced my reasons for not wanting to specialize in emergency medicine (no offense)

There was a huge snowstorm that started last night and went on until around 2 pm today. I had been poorly prepared for the last snowstorm (no shovel, no waterproof clothes), but this time I was ready. I'd purchased a shovel weeks in advance and I also had a pair of ski pants and gloves that I'd bought for a ski trip to Blue Mountain. Shoveling was much easier this time around, and even better when one of my neighbors offered to help me shovel one side of my car. After that one of the ground caretakers offered to plow my parking spot with his truck (and snowplow), so everything was cleaned up within 1 hr. All in all, things were much better this time around.

COMLEX Level 3 Thoughts

For the COMLEX, I prepared using USMLEWorld, Master the Boards by Kaplan, and the Simmons manual for OMM. I answered every single Qbank question in USMLEWorld and read Master the Boards twice; sadly, I neglected the Simmons manual until the last 1-2 days before the test. That turned out to be a mistake; somehow, in my OMM review, I completely neglected the section on counterstrain and trigger points. There were a good number of questions on the COMLEX asking about how I'd use counterstrain in treatment, and I wanted to kick myself. I remembered "fold it, hold it" but not whether I was supposed to fold around it or away from it. *sigh* It was helpful knowing the innervations for sure; that stuff is always high yield. Overall, however, the COMLEX was, once again, poorly written. The questions were either very easy (i.e. asking how to treat hyperlipidemia when there was only one cholesterol drug in the answers), reasonable, or outright ridiculous like asking which law allows doctors to ____. Where, in what textbook, would I get that info from?! So while I don't think I failed, there's still a part of me that's uneasy about how things might turn out. We'll see what happens; I should get my residents in the next 2 months.

Afterwards I joined several friends for drinks downtown. Unfortunately I do not have the greatest EtOH tolerance and was bright red after 1 and a half beers (one of which was only 4% EtOH). Still, it was nice to be done, and to celebrate my turning 27 (belated) and being done with the COMLEX, I'm going skiing this weekend and attending a Philadelphia Orchestra concert next week. The orchestra concert promises to be awesome; they'll be performing two pieces I'd played in the University Orchestra at UT and I love hearing pieces I've played before.

The downside is that after a wonderful month of ambulatory medicine (which gave me tons of time to study for the COMLEX), I'll be returning to the wards full-time on Monday. Fortunately the medicine team I've been assigned to has been rumored to be laid back, so I don't expect too much trouble. I'm extremely grateful that I've not had been assigned any months of heart failure (which everyone dreads b/c the attendings are pretty malignant; one likes to threaten people's medical licenses if they don't do as they're told). I'm better off away from all that =P

The COMLEX countdown

I am exhausted. Beat. On top of reading Master the Boards by Kaplan I have spent the last two weeks doing 100+ USMLE questions a day, and I'm proud to say that yesterday I finished my last set. All 1377 questions have been answered at least once, and yet I still feel woefully unprepared for the exam next week. For starters, I've barely touched the Simmons manual. On top of that, all the stress and staring at the computer screen that I've been doing is starting to take its toll. I've been getting daily headaches that resolve with Tylenol. I rarely get a good night's sleep, always waking up at least once in the wee hours of the morning before going back to sleep until the alarm goes off. My eyes are constantly tired to the point where my vision starts to blur, which somewhat makes considering my current prescription is 2.5 years old. I went to see an optometrist last week and was told that my vision has worsened.*sigh* Well that sucks. At any rate I won't be able to function if I keep going in my current state, so I'm off to bed early tonight.

Disrespect

The hospital I work at has a "re-entry program" for physicians who have been out of practice for anywhere from 10-30 years. They rotate through different departments, attend morning reports and noon conferences, and have to take an exam at the end of six months in order to get recertified. This month there are two such physicians who attend ambulatory care and doctoring sessions with me and about 10 other interns. One was a surgeon who's now going into general medicine, and another was an internist who left medicine to raise her kids (who are now starting medical school this coming fall). The internist (whom I'll call Dr. H) is friendly enough but naive to a fault. Once when we were asked about feedback regarding what we learned in the day's lesson, she said that her husband (also an internist) told her there were 3 A's in medicine: availability, attitude, aptitude. Sure, that's all good, except that was not what our attending asked. As a result of this (and other times where she brought up things she learned back in the 1970s but no longer apply today), several of the interns in my small group dislike her immensely.

In our ambulatory care sessions, we each have to choose a topic to teach the other people. This afternoon Dr. H presented a powerpoint on tracheoesophageal fistula and how to treat it in the adult patient, since her daughter was born with TEF and now suffers from GERD, scoliosis, and other complications. She had told us last week that her talk would last 40 minutes, but in reality it was close to an hour long. It was a very interesting talk, and for someone who didn't know how to make a powerpoint presentation a few weeks ago I thought she did very well. Even still, TEF is a predominately pediatric issue, and indeed, a good 80% of her talk focused on the diagnosis and treatment of TEF in childhood. I sat near the attending so I paid close attention, but when I looked toward the back of the room where the other interns were, one guy was clearly snoozing while the others were either playing games, texting each other, or reading stories from fmylife.com (not joking here). I don't mean to be hypocritical since I've been known to occasionally play games on my PDA during some talks, but this was a much smaller group and I was sure our attending wasn't oblivious to what was going on.

After the presentation, our attending asked for feedback. One guy said that while he could understand that this topic was very personal to Dr. H, it was too much information to digest all at once. When we were asked if anyone wanted Dr. H to highlight the points of her presentation, there were a lot of shaking heads (everyone just wanted to get the heck out of there). Dr. H then told us that when we start families, we need to decide which spouse is going to stay home with the children. Originally, she said, her husband was supposed to be the caretaker, but when her first child (the one with TEF) was born, she couldn't feed from a bottle so Dr. H, being the only parent able to breastfeed, ended up staying home for the next 22 years. Several of us exchanged looks; what did this have to do with anything? One of my classmates must have snickered a bit, because Dr. H then turned to her and said, "When you have children someday, this is a choice that you will have to make."

To this, my classmate snapped, "My boyfriend and I have talked about it, and this isn't the forum I want to discuss it in." Anyone could tell from listening to her voice that she was pissed off, and fortunately Dr. H didn't say anymore about it. Later several people berated my classmate for being so rude to Dr. H. "Well, she shouldn't be asking such personal questions!" my classmate replied, and that led the others on another discussion on how "stupid" Dr. H was. I kept my mouth shut, but inside I was pretty appalled by their behavior. Dr. H is about the same age as my parents, and even though she's been out of practice for decades, she's still an "elder" (Asians understand this terminology) and deserved basic respect, which few of my classmates showed her today. Sure, her presentation was unnecessarily long, but since the topic was a disease her daughter has, I know she worked very hard on her presentation.

Another of my classmates who was equally stunned by the others' disrespect said it best: "I treated Dr. H the same way I'd want to be treated. If I was up there doing a presentation, I'd want the others to pay attention, too." Honestly, I don't know if my classmates didn't care because she was older or because they just didn't like her, but I have to do a presentation next week and if they made out like they didn't care, I'd be pissed. I'm pretty close to the interns in my small group as well, so hopefully things will go well next week.

In-Service Exam Blues

The results of our inservice exams from last fall are in. Not surprisingly, I didn't do very well, and it wasn't much of a consolation to hear that I was not the worst of the intern class. I'll be taking Step 3 at the end of the month and I don't feel ready at all. Granted, Step 3 won't ask me totally detailed questions like the inservice exam did, but I still worry. *sigh* Oh well. Nothing to do about it now but study.