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.
Monday, July 5, 2010
Tuesday, June 22, 2010
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.
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.
Tuesday, June 8, 2010
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.
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.
Tuesday, June 1, 2010
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.
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.
Tuesday, April 27, 2010
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.
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.
Monday, March 29, 2010
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.
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.
Monday, March 15, 2010
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.
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.
Sunday, March 7, 2010
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!
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!
Monday, March 1, 2010
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.
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.
Saturday, February 6, 2010
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.
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.
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