RWJMS - Cancer Institute of New Jersey

First Impressions: I could have easily driven to New Brunswick (about 90 min from Philly) the morning of my interview, but since I was post-call the day before I just decided to spend the night in New Brunswick. Home to Rutgers University (the equivalent of UT in TX), New Brunswick is essentially a college town, and the hospital sits right on the edge of the Rutgers campus. They had a few places that sold boba tea on campus so I got one after dinner. It was all right; better than Philly's boba tea, at any rate.
Interview Day: There were six applicants today, one of which was from Univ of Rochester where one of my best friends is doing her residency (small world). The program directors gave us a good overview of what the program has to offer (a lot), and then the six of us took turns interviewing with four faculty members. I think because we were a small group, we found it easy to chat between interviews, and we also shared our experiences interviewing at other hospitals. Two of the applicants just had their Montefiore interviews yesterday, and it was interesting to note that their interview day there was just as awkward and poorly planned as mine was. We each interviewed with two hematologists and two oncologists; I think I got along great with the oncologists, but the hematologists were a bit harder to connect with because I've had almost no heme experience in residency (the attendings at HUH are primarily solid tumor oncologists)

This program is a good one in that it's balanced in both heme and onc training, and it's affiliated with the Cancer Institute of New Jersey, one of only 40 NCI comprehensive canter centers in the nation. That means excellent resources for research and training. The program also has programs in Phase I trials, stem cell transplants, and even special centers for hemophiliacs and thromboses (which I'd never heard of until today), which I all found interesting. We had 1-2 fellows come to speak with us during lunch, one of whom used to be a chief resident at RWJMS so she knew all the ins and outs of the program. One thing she emphasized was the close relationship between faculty members and fellows; the fellows never have to worry about getting yelled at when they have to call an attending at 4 a.m. to go over a patient.

Overall Impression:
Pros: Good balance in both heme and onc, association with CINJ means lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, cancer center on site, plenty of research opportunities in either clinical or laboratory settings. 4 fellows a year. 90 minutes from Philly, 45 minutes to NY. Most rotations done on site except for clinic on Jersey Shore one month a year. Will rank high for sure
Cons: None that I can think of at the moment.

Albert Einstein-Montefiore Medical Center

First Impressions: The name "Montefiore," aka "Monte," is a good one on the East Coast, as it has strong residency and fellowship programs well known for preparing its graduates for anything (my ICU attending used to be at Monte and he's one of the smartest people I've ever met). One of the PGY3's in my program matched here and will start in July, and I looked forward to seeing what kind of program this was.

Since I had taken a day off after getting stranded in Charlotte overnight (see previous post), I was able to leave Philly at 1 pm. (after taking a 3 hr nap) and arrive in the Bronx by 3:30 pm. The Days Inn I stayed at was a 1/2 mile walk to the subway, which I took to the NYU area for my usually trip to get Pinkberry frozen yogurt. Walking back to the hotel at night, however, was a pretty terrifying experience; the Bronx is not exactly the safest part of NY. My biggest gripe with my hotel room was that it smelled faintly of urine. Ugh.
Pre-Interview dinner: None. I had dinner at Saint Alps, a Hong-Kong/Taiwanese cafe that serves delicious boba tea (which I can't get in Philly)
Interview Day: The drive to Montefiore Medical Center was, fortunately, not a bad one. My first impression of the hospital was that it was old, even more decrepit than JPS (which looked great by comparison). There were about 11 of us at the interview, and each of us would interview with both program directors. So the entire morning consisted of the two interviews, or else waiting for the interviews. Very poorly organized. There were 1-2 fellows who came to speak to us but that was it. We were not a talkative bunch, either; most of our downtime was spent on our smartphones checking email or sending texts. I did learn that I got another interview during this time (at my home institution), so thank goodness I got my iPhone. My interviews were not the greatest; one PD asked me about research I did in 2003, and the other asked how I'd work up a patient for leukocytosis. Not the best time to ask considering my computer was in the shop (got a Trojan) and I hadn't had time to review my application.

After a brief tour of the hospital (gloomy), we had to take a shuttle to the research campus of Albert Einstein Medical Center for lunch and a brief talk about the research opportunities here. We couldn't all fit in the shuttle so some had to take the taxi. We didn't eat until 1:30 pm, and then we went to a lecture about some of the projects that were being done here. Even THAT was cut short because we then had to take a shuttle back to Montefiore. And by the time I got to the parking garage, some idiot had parallel parked his car behind mine. Thank goodness someone was there to move the car, but I saw that there were other cars parked similarly within the garage b/c there were no more spots yet. Talk about inconsiderate! (then again, this is New York). Bronx traffic was horrible too; I was glad when I crossed the bridge into New Jersey.
Overall Impression:
Pros: Very strong program in both academics and research. Well balanced in hematology and oncology. Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, plenty of research opportunities in either clinical or laboratory settings. 8 fellows a year, subsidized fellow housing, reasonable parking prices (for those who keep their car, which I would like to do), a 20 min train ride to Manhattan.
Cons: Way too much emphasis on research, fellows rotate through 3 different hospitals, unable to gauge whether fellows are truly happy to be there. Bronx isn't the safest place to live; not completely sold on living in NY, as cost of living is ridiculously high. Program did a poor job of selling the program.

University of Florida @ Gainesville

First Impressions: I got my first invite from this program in early January, and there are lots of good things to be said about UF. Shands, its teaching hospital, is ranked 29th in the nation in cancer care, and they have a brand new cancer center that just opened in 2009. It's also somewhat associated with Moffitt Cancer Center, one of the top cancer centers in the nation located in Tampa.

Gainesville has a tiny airport with only 3-4 gates (impossible to get lost); I had to catch a connecting flight in Charlotte to get there. I rented a car for the interview, and as I drove through Gainesville, it was hard to complain about the 70 degree weather and palm trees lining the streets. The hospital was located right beside the undergraduate campus of UF; truly a college town.
Pre-Interview dinner: I met the 2 program directors (who are both very young; if I hadn't seen the PD's face on the website I would have mistaken him for a fellow, and some of the applicants did think he was a fellow) and other applicants at the hospital before we carpooled to an Asian fusion restaurant called Liquid Ginger (or "Liquid G" as one of my interviewers would refer to it). There was a lot of good food on the menu, everything from steak to pad thai. I didn't want to cost the PD too much money, however, and so avoided the ribeye and got a shrimp and scallop dish that was really good. I met another applicant from UTHSC who knew a few people I'd known from undergrad; small world. Dessert was red bean ice cream. It was a nice relaxed dinner, and I didn't feel quite so nervous about the upcoming interview.
Interview Day:
The PDs welcomed us to the program and gave a very informative powerpoint presentation about what UF had to offer. My first interview was at the VA across the street with a head-and-neck specialist who was interested in hearing about a project I was doing on head-and-neck cancer. It was slightly embarrassing when I didn't know what the side effects of cetuximab were (despite it being used in the project), but he didn't make me feel like an idiot. After that we toured the new Cancer Center and the VA, also checking out "Fellow Land" (where the fellows have cubicles and computers). Lunch was with the fellows, and then we walked almost across campus to the outpatient clinics. There was a LOT of walking to be done on this day, and I wasn't wearing the most comfortable shoes either. I ended up going across the street to the VA three times (twice for interviews), and in the afternoon it was hot and humid outside. My second interview went very well, I thought; the attending was interested in topics such as breast cancer, patient-doctor relations, and palliative care, all of which I could talk about for a LONG time. If anything can get me into this program, it was this interview.

I wish I could say that after that interview I was able to fly safely back to Philly, but things didn't happen that way. My flight from Gainesville to Charlotte was delayed 1.5 hrs because of a storm in the Carolinas and Georgia, and even then we flew for 2 hours instead of 1 b/c the pilot made a wide detour to Alabama to avoid the storm. By the time we landed in Charlotte, my flight to Philly had already departed (missed it by less than 30 minutes). Needless to say there were tons of people stranded at the airport because of missed connection flights. I went to the Special Service line and was able to get a seat on the 6:30 a.m. flight back to Philly the following day, but then I hit another problem: lodging. Just about every hotel in the vicinity was completely booked due to people missing their flights, except for a Westin with rooms starting at $319. Since it was midnight anyway, I decided to suck it up and try to get some rest in the airport. In a way I felt like I was on call minus the beeping pager. All I'd had for dinner was Cheerios at Gainesville and all the restaurants were closed; fortunately a Starbucks stayed open just for us and I got a smoothie and muffin to sustain me until morning. With the help of my travel pillow, backpack (for back support) and fleece-lined ski jacket, I managed to get somewhat comfortable in a chair and slept on and off until 4:45 a.m. I boarded the plane at 6 a.m. and was back in Philly by 8 a.m, after which I slept 3 hrs before driving to New York for my next interview.
Overall Impression:
Pros: Really liked this program. Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, new cancer center, plenty of research opportunities in either clinical or laboratory settings. 5 fellows a year, PDs friendly and approachable, personalized training with different tracks (i.e. more research electives for those interested in academia, more clinical electives for those interested in clinical practice), strong in both solid tumors and hematology, affordable living in Gainesville, guaranteed good boba drinks in Gainesville (found a Lollicup cafe not far from the hospital). Florida. Sunshine.
Cons: Gainesville is not easily accessible by plane; most major airlines fly to nearby cities Orlando and Jacksonville and people drive to Gainesville from there. Chances of getting in are very slim given UF's history for taking their own residents into their fellowships; both PDs did medical school, residency, and fellowship at UF, and the same could be said for some of their fellows. All that aside I definitely plan to rank this program high.

Penn State Hershey Medical Center

First Impressions: I was supposed to have had this interview last month, but a huge snowstorm had forced me to reschedule. Several residents told me that the fellows at Penn State work really hard but get an excellent education, so I was pretty sure the program itself was excellent. I'd heard that Hershey was in the middle of nowhere, but it was still a surprise to see how isolated it was when I drove there after work. It was dark, and there were barely any lights to be seen except from the lone farmhouse. I kept looking for a cluster of lights to show that I was in town; no such luck, as there was a single-lane road (appropriately named "Chocolate Ave") that led to the hotel. I did grab dinner at a small hole-in-the-wall sushi restaurant that was actually pretty good; got a chef's special (California roll topped with salmon and shredded lemon). I'd booked a cheap hotel room for the night, which was a bit of a let-down since the last hotel I'd slept in was the Gaylord National, but safe enough. My only complaint was that the room was cold despite the heater being on, and I'd forgotten about how I never sleep well the night before interviews. Woke up around 3 a.m., couldn't really sleep after that.
Pre-Interview dinner: None
Interview Day: No traffic getting to PSHMC, and parking was free. There were eight applicants today, one of whom was the sister of one of my classmates. Most of us were from PA. We sat in on grand rounds with the topic of the day being hormone therapy for breast cancer (a particular interest of mine so I paid very close attention), then had the program director spend about 45 min telling us about the program and the hospital itself. The PD was very charismatic and energetic; it was obvious he loved what he did and took pride in the program.

I had three interviews: one with the chief of heme/onc, one with a leader in BMT, and a rad onc attending. Unfortunately for me, the chief and I didn't seem to connect very well. He had only been at the program for a year and was formerly from UPenn (that alone probably counted against me), and his specialty was translational research. Not surprisingly a lot of his questions were directed about future research I'd like to do (rather than research I'm doing now and would have been very happy to tell him about), and he ended up doing most of the talking. I'm not even sure how much he wanted to conduct this interview; we'd already started 5 minutes late because he was working on other things up until the last minute. My second interview with the BMT attending was a little better; he actually knew the former TCOM dean from their days at PSHMC and asked if I knew where Dr. MH was now. I didn't know the answer then, but since I got home I looked him up and found that he's now the dean at UNECOM in Maine. *sigh* I guess now we'll be seeing UNECOM rise in US World News Report in the next few years.

After the first two interviews we went to breast conference and then had lunch. My last interview was supposed to be with a GI attending who just happened to be on service, so they gave my file to a rad onc attending who doesn't even deal with the heme/oncs much since his focus is XRT in GU/gyn malignancies. He, too, was a fairly new attending, so we chatted instead about his transition from Cleveland to Hershey (i.e. learning to adjust to small town life), where to buy organic food (1 hr drive from Hershey!) and more. After that we had a tour of the hospital with two third-year-fellows who were fun to talk to. One of the best things about this place is the fellows' cubicles; large windows, plenty of light and computers, just no privacy. We also learned that fellows only round on the BMT service on weekends (and units); the onc inpatients are cared for by housestaff. That's good since at HUH the weekend fellows round on EVERYONE, even the inpatients.

Overall Impression:
Pros: Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, brand new cancer center, plenty of research opportunities in either clinical or laboratory settings. 3 fellows a year. Harrisburg about 20 minutes away, Philadelphia 1 hr away by train (1.5 hr by car)
Cons: Hershey. Small rural town, lonely place to live if you're not married with children. Emphasis on research and academic careers.

Too Young to Die

Heart failure...one of the most dreaded services in this hospital. It's not so much the patient load (which was usually less than six patients per team) or the numerous medical problems the patients had, but fear of the attendings. The two heart failure attendings expect a great deal from us and we are expected to know every single cardiac detail about them. To make a single mistake on this service is to fear for your license, even for something like giving a heart transplant patient Percocet. Fortunately the two heart failure teams work together as one. My sister resident and I get along great, and the two interns called each other their "work spouses" to provide emotional and friendly support. It wasn't uncommon to see all four of us getting breakfast in the cafeteria or chatting in the lounge. But because heart failure patients are so sick, they often come to the hospital over and over, and inevitably they will die after we've gotten to know them.

A few months ago, a 19-year-old boy named N.L. was playing basketball when he gradually became weaker and suddenly collapsed in the middle of the game. His CPK was through the roof so it was believed he had rhabdo, but a high CPK did not explain his EF of 30%. A heart biopsy revealed that he had a genetic marker for some sort of X-linked muscular dystrophy, which was odd because most patients with muscular dystrophy exhibit symptoms as children, not young adults. And even though it was not the correct diagnosis, the unofficial diagnosis for his condition was called Duchenne's (DMD) by almost everyone. The first time I saw this guy 3 weeks ago, his EF had already plummeted to 15%, but both he and his mother remained hopeful that with medications they could control the progression of his heart disease. He was a college student, and he was anxious to get back to his studies.

This morning my intern called me and asked, "Do you remember N.L.?" Of course; how many 19-year-olds with so-called DMD were there on the heart failure service? I just didn't know he got readmitted last night. Then my intern said, "He just coded upstairs so I'm helping the other team out." WHAT? I quickly ran up to the tele floor and saw that N.L. had been transferred down the hall to the CCU. The CCU team was working on him, giving compressions, trying to put a central line in him. He had been on the other heart failure service the last time he was here, and the intern who had taken care of him looked extremely shook up. To say he was upset was an understatement; the poor boy was crying and wiping his eyes while trying to maintain his composure. He was on call overnight and had admitted N.L. for hypoxia (likely another sign of progression of his DMD), but no one had expected this.

The code (which I did not participate in since the CCU team was running it) lasted almost 90 minutes, but not surprisingly (ABG had pH of 7 and lactate of 10) N.L. didn't make it and died at 8:30 a.m. There was an extremely somber air on the tele floor for the next 3-4 hrs. Everyone kept talking about how young he was, only 19 years old. "At least it was quick," my attending, who was in his 70s, commented; having seen examples of prolonged suffering in the ICU/CCU setting, I had to agree. The CCU resident came by to offer support to the heart failure intern, then pulled his resident aside and asked her to let him go home. Fortunately she did; that poor guy only got 2 hrs of sleep last night and then to lose a well-acquainted patient on the last day of his heart failure month...I can only imagine how bad he needed to get away and get some rest.

Seeing this intern mourn the loss of his patient reminded me just how much the interns still have to learn about dealing with death at the hospital. I can still remember my intern from July expressing shock when I told him we wouldn't be doing anything for a DNR/DNI patient in respiratory distress except putting him on oxygen and a morphine drip. "That's it? We're just going to let him die?" he'd asked at the time. Sadly, no matter how many people we see die in the hospital, dealing with it never gets easier.

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....