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.

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 =)