Welcome to the ER

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

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

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

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

Orientation Week

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

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

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

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

Time To Say Goodbye

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

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

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

New Beginning

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

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

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

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

Lessons outside the Hospital

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

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

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

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

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

Pulm: Winding Down

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

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

Pulm: Rain, Rain, Go Away

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

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

Pulm: Damn Birds...

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

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

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

Pulm: Interesting patients

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

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

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

Pulm: New Attending

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