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The daily life of a medical resident..
a.k.a "It's 2 AM and I'm looking at urine outputs."
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Tue, Jan. 26th 2010 - Mr. and Mrs. 353
As part of the inevitable increase in a hospital census that comes in December and January along with the worsening health care crisis we've had to change to semi-private rooms.

The patients hate it. They have to share televisions, there's about 4 inches around the beds, with only a curtain bewteen. God help us if there's a code. I admit, I was spoiled by our hospital being private rooms only for the first six months of my career.

That said, we had two patients who didn't mind at all.

Mrs. 353 was in with pyelonephritis, a virulent case that was thankfully responding to our thwacking it repeatedly with big hairy antibiotics.

Mr. 353 was my patient. Colon cancer. Grim news. The words "Poor prognosis" were uttered by the surg-onc service, the heme-onc service and the GI service.

He held Mrs. 353's hand while I told him what we had found so far, and what the options were.

I can't imagine what it's like to receive news like that, or to know that your spouse is pretty significantly ill at the same time. The wife presented just after he did, thinking it was just an average UTI until the 104 fever popped up. Until then, she was more worried about her husband's horrible abdominal pain and weight loss. We couldn't put them in the same room until her sepsis resolved, but both had been asking about their spouse every day - they were admitted to different medicine teams, so there may have been some minor HIPAA violations among the residents while we tried to put their minds at ease.

But finally, she was wheeled into 353 with admonitions from the telemetry monitoring staff that if they saw any suspicious arrythmias*, they'd be separated.

It wasn't a perfect solution, especially as Mr. 353 was kept NPO prior to surgery as his wife wolfed down a tray of meatloaf and apologized to him as she polished off her dessert, but I was glad they could be together in the hospital.

Even though they had an undue amount of grief to bear, sharing it does lighten the load.

*A waveform that looks scarily like ventricular tachycardia can be emulated by tapping on the telemetry reads at a regular interval, or in this instancce by two telemetry leads tapping against each other at regular intervals. :)

Personally, if they were up to it, I wouldn't have objected too strongly.
Wayne State University Class 2009
Wed, Jan. 6th 2010 - The blog, attempt 2.
At a hospital that shall remain nameless, on a service that I may or may not work on, the following occurred.

I would present the events without comment as they are remarkable all on their own, but the lesson I learned -
the lesson we all learned is what will likely be the most important of my intern year.

--

There was no question that the patient was going to die the minute he came in. Even though he was a regular guy who held a job, had insurance & a family, something had been brewing under the surface.

His chief complaint? "I turned yellow."

Sunshine, Dandelions, highlighters - we couldn't decide on what hue he actually was. Ultimately a lifetime of drinking had caught up with him, and culminated in hepatorenal syndrome.

Our attending put on what we took to calling the "full court press" - every medication and therapy shown to improve the dismal prognosis of HRS was started, increased and then maximized as we lost ground more and more quickly. His renal function fell off completely, and he began to bleed, that slow ooze that comes at the end of liver failure.

His wife, having only been married to him a year despite a childhood friendship would not leave his bedside. He ultimately left the final decision about code status up to her, hepatic encephalopathy setting in that morning -faster than any of us could have predicted.

The predictable ascites swelled up, the respiratory distress started - but before the end, a brief moment of clarity.

"I want to see Lizzie. Please, before I go - I want to see her."

Lizzie was his best friend, his faitful dog, and she was the only one not at his bedside.

Those who loved him, and the nurses who had been helping us fight the fight made a decision, one you have to make quickly or else you'll think too much about it. There was a flight of stairs just steps down the hall from his room, stairs that spit you out just around the corner from the hospital ER entrance. Rarely used and not monitored, they're usually where employees sneak out for a quick cigarette but tonight, there was a different contraband coming in.

Lizzie was carried up the stairs, through the medical care unit and swept into his room before anyone but those involved knew she was there. "Oh" one might think. "She's one of those small dog, that women carry in purses!".

Not this time. Lizzie is a 40lb lab mix, full of energy and mischief. The friend who carried her was, I was assured "quite strong".

Immediately, she saw her master and started wiggling happily. But when she was lifted into the bed with him, she realized what was happening in the way only dogs can and quietly curled herself beside him as IV tubing was lifted out of the way.

He passed not long after, and I comfort myself by thinking that he knew that everyone was there to say goodbye, and there was no sense in fighting any longer.

I can't forget this. No matter the number of cocaine-induced heart attacks or non-compliant diabetic amputees I treat, I can't forget that the reason I do this is every day. To rage against the dying of the light for as long as we can, but to know when it is time to lay down arms and let them go gently.
Wayne State University Class 2009
Thu, Oct. 8th 2009 - The blog.
The decision.
The answer was always the same, the question inevitable. "If I were to specialize, it would be for Pulmonary/Critical Care."

The rash.
"Classic Presentation! Very interesting." It's remarkable to see the change in an attending's attitude when a board-worthy illness pops up in real life. Especially when the patient is one of the residents.
See also: Scrofula.

The hobby.
On the first day of med school, I was told that you needed one thing that was just yours, completely unrelated to medicine that you could fall back when times got tough. As an intern, I finally found it.

The test.
Internal Medicine Inservice exams are coming up. Everyone has their own way of preparing for it, and even the attendings are in full-on board prep mode, regaling us with memories of when they took their own board certifications.

The cycle.
Just a little less than a year ago, I was sitting in the same seat, savoring the same crab stuffed, bacon wrapped shrimp. Feels strange to be the one scrutinizing potential applicants, instead of the reverse.
Wayne State University Class 2009
Now that I'm on night float and doing H&P's every single night, I've come to recognize and love the one page H&P.

Obviously, the one pager is a special kind of patient. They're not the 76 year old with heart disease, diabetes and chronic renal failure, who inevitably have an assessment and plan that's 10 points long. These are the younger, softer admits who have one specific problem (chest pain rule out, cellulitis, acute pancreatitis, overdose, etc.) that really only need one page to fully explain what's going on and convey a thorough assessment and plan.

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And here it is. The key is to take advantage of the minimal history - the people who are generally healthy, aren't on 10 medications and only have one or two medical issues.

Believe it or not, 3 lines is sufficient to document 2 points in 10 systems, especially if you're thoughtful about what are pertinent positives and negatives in the HPI.

The other part is to be succinct in your HPI. I used to write 1 page histories of present illness with "The patient was watching television and sitting on the couch when they experienced sudden onset of the pain" which in reality is a lot of useless information. "Pain is substernal, sudden onset at rest." gets your point across, and the attending immediately knows what they need to know.

In my view, an HPI should be like a resume - get all of the information out before the person reading it loses interest.

And of course, the exam. If a patient is straightforward, they're going to have findings in one to two systems, tops. The rest of it is assuring people that yes, their belly is soft and no, they don't have left sided weakness. So what I do is take half a line to write my "Lungs are CTAB w/out wheezes/crackles, no dullness to percussion" and take more room to fully document the erythema and tenderness of their left foot. I'll arrange the order of my H&P to either lead or end with the most important system.

**Just avoid the trap I fell into - I would write "S1, S2 heard, reg rate/ryth, no mumurs, rubs or gallops." which is actually 5 or 6 points, but they're all based on auscultation. So I have to remember now to include a visual or tactile finding - comment on thrills, the PMI or JVD. (Or for lungs, dullness to percussion or symmetric expansion/accessory muscle use)

Of course, as a student early on, I would encourage you to continue writing your lengthy notes and H&Ps - at this stage of the game people are looking for you to be thorough, because you're learning what's pertinent and what's not.

It's an interesting transition, that point where you realize that you can anticipate what the people above you are going to want to know, and it's not found in any kind of book. You only learn from presenting patients over and over and getting feedback.

It's been said over and over, but residency is there for a reason. You could have every drug and every disease process memorized the day you graduate med school, but you're not a doctor until you work with people who have cared for patients with years, and are held accountable for every treatment decision you make.

When I studied in school, I would get a sense before the test "I know X material, and can spit it back out for the test." Now, I don't even have a sense that I'm learning, but when I am asked a question, the information is there - because I've done it before, seen it before, thought about it before.

Of course, I wonder how much more would stick in my head if I actually got to sleep normal hours, but it's residency and you can't have it all. :)
Wayne State University Class 2009
Thu, Sep. 3rd 2009 - Caution: Wet Floor.
So, some background.

At the hospital I trained at in med school, codes were bad news. There was no Medical Emergency Team, no Rapid Response, no surgical residents, or respiratory techs that would magically appear to save the day. At night, I had the pleasure of being one of the first to a code as a student. That was fun.

So now, when I hear Code Blue, I book it. Even though now I'm at a more functional hospital, and really there's a fairly skilled MET to help with the code until we get there, I book it.

Enter the floor-washers. The floor washers is this huge crew of people with mini-zambonis and floor buffers who are CONSTANTLY cleaning the floors.

We're sitting in the very back of the ER in our little admissions cubbyhole, and the code goes off at 4 AM. We barrel out of our area to find the floor washers at work. "You need to go around" they say, and I'm looking at the hallway I need to get to - three steps and I can get to the stairs to run to the code. "I'm sorry, I need to go Now, and I need to get there." And I wade into what I thought was just a regular wet floor.

Evidently the floor cleaners use some pretty potent stuff. That turn floors into oil on a skating rink slippery mess.

Down I go. And I mean down - arms flailing, on my rear, soaked in floor goo. My upper level is behind me, clutching the rail with just one foot in the stuff.

After trying to get up twice more, one of the guys has to drag me out on my knees. Now that I'm absolutely covered in the stuff, we finally get to the code, only to find that another resident has things well in hand. So we trudge back to the ER to finish admitting, only now my shoes are coated in soap - foaming out the sides with each step.

The story gets funnier with retellings and the knowledge that the code went just fine, the patient got a pulse back, etc. My senior cracks up every time she tells it.

And of course, I walk into morning sign out with an illustration of the whole event with a "Kat, beware of wet floors!" warning.

I love my residency. And right now, I love motrin.
Wayne State University Class 2009
Wed, Aug. 26th 2009 - The curious case of Mr. Gibley.
*Note: names and details changed.

Enter Mr. Gibney. A middle aged man with a rather unique diagnosis - neutropenia. His white blood cells were generally low, but he had absolutely no neutrophils, leaving him open to infection. Of course, the narcotics that showed up in his urine weren't helping the picture.

My fellow intern Wes rounded on the patient with the team every day, but since we put the patient under infection precautions, he never actually went in the room, as we needed to minimize exposures.

Two weeks later, enter Mr. Gibley. It's come around that I'm on night float, while Wes is covering a ward team and on call overnight. "Oh", I say. Mr. Gibley's back with neutropenia again. Oh, and he's positive for narcotics again.

Wes ultimately takes the patient, but we're confused - we can't find records from the previous hospitalization anywhere. Meanwhile, our senior resident who saw the patient in May, is talking about this right arm infection that I never saw during the last visit.

Weird.

We check for extra Medical Record Numbers, I look back in my old records to see if I had missed something. Ultimately Wes figures it out, with the help of his upper level who say him in July. There's two Mr. Gibleys.

Now, let's state this for the record. Two patients with the same last name, roughly the same age and ethnicity who are both neutropenic and have problems with narcotic abuse. Not that durg use is all that unique in our population, but Gibley is a reasonably uncommon name, and severe neutropenia is not an every-day diagnosis.

FInally, I just go in the room and sure enough, the Mr. Gibley in 307 is not the patient I took care of. None of us realized it because of the neutropenic precautions - only the resident treating the patient at the time actually laid eyes on them. So my night was definitely more surreal thanks to Misters Mitchell and Michael Gibley, and their dueling neutrophil counts.
Wayne State University Class 2009
Wed, Aug. 26th 2009 - How'd that happen?
Well, there went another month. I blinked once and it all flew past.

Finished up Green team, a grueling haul to the finish with a huge census full of terminally ill, kind people. I gave the "Your loved one is dying, it's time to make them DNR/get hospice on board" talk about 8 times.

In 2 weeks.

Compassion fatigue is real. I would collapse on the couch at the end of the day, too drained to have a conversation besides "I'll make dinner in a bit." and tune into mindless television. I'd actively tell my sainted husband "I know that really sucks, but I'm just done." when the job search took a depressing turn. (Happily, that aspect is looking up. We looked at our finances and with some juggling and him bringing in part-time monies, we can get him through EMT school. Husband is excited, and I'm already buying him test books.)

Ultimately, my team got me through. A fellow intern who never fails to make fun of me (in return I mimic his thick-as-honey southern accent) and an upper level who is equally as adept at paracentesis as he is at Friday night Karaoke, and the kindest attending an fledgling intern could hope for.

And now, nights. Kids, if I could give you one piece of advice for those who are about to float 7P to 7A, blackout curtains would be it. Blackout curtains are crucial in being able to come home at 8 AM, fall into bed and sleep past noon. Ultimately, I've settled into an 8AM-2PM sleep along with a 1 to 2 hour nap in the afternoon before I head back at 7.

Husband has been very tolerant of my zombie status during the day, and doesn't mind an increase in lean cuisine microwave meals. (5 for 10 dollars on sale!)

I really like the work of night float though - I've gotten to know 1 radiology, 2 surgery and 1 pediatric resident very well as we all hang around the resident lounge at 2:30 AM and watch reruns of shows that normal people watch during primetime. I'm getting better and better at history and physicals every day, which is a skill that I'm glad to brush up on.

The best part is simple though. Once I dictate the three admissions I did tonight, I am absolutely sure there are no pending dictations. ESPECIALLY no discharge summaries. (The un-fun-ness of discharge summaries could get a post all of its own.)

But since it's late, I'll sum up with the following.
-Aim toward the gooshy spot for paracentesis. That's the potential space where fluid is pooling, instead of the tense belly above it.
-Neutropenia/Anemia are huge and interesting topics. If not for my inability to deal with kind people and their unfairly high rate of terrible cancers, heme/onc would be a good field. Possible cyclic neutropenia, aplastic anemia and pernicious anemia, all in one month. Bone marrow biopsies, ahoy!
-Neurologists are scary smart. I would cry if I ever had their job, but still - wow.
Wayne State University Class 2009
Wed, Jul. 29th 2009 - A sum of parts
Back in medical school, we had the wonder that was streaming video of almost every single lecture. Professors who you could pause and rewind (for either bathroom breaks or incomprehensible concepts) were a fantastic resource, and something that I would often take advantage of. I could stay in my comfortable warm bedroom and avoid the nightmare that is Detroit traffic during a full-on Michigan winter.

But even though the whole strategy was beneficial to my grades, I found myself craving contact with my fellow medical students - a set of people who proved themselves to be excellent students and now wonderful young doctors. I needed to talk with the people who understood my frustration with memorizing cancer drugs and would laugh at our respiratory professors latest in-class antics.

And again, during residency I find myself relying on the bits of downtime in our resident lounge, providing running commentary on who has the longest census or what horrible pun our infectious disease attending inflicted on us at the last morning report. Intern year is such a strange and singular event to go through, it becomes a uniting event for all residents, as if you replaced hardcore learning instead of drinking while pledging a fraternity. (Though to be fair, some EtOH helps the Harrison's go down.)

A medical team, starting at the attending right on down to our brand new third year medical student (more on that later), is more than meets the eye. Yes, the interns do a bunch of legwork after the students take histories, and run back to their senior for questions and the team will finally go to the attending for final decisions on patient management.... but at each step there's a "How are you doing?" or "Do you need any help?" The team will always provide better care than a similar number of practitioners working solo - medical bugs are rarely shallow, but extra eyes always help.

I am so thrilled to be in the Memorial program, because we truly are "non-malignant", the watchword of so many scutwork reviews. I've heard of the things that happen when pressure to excel and gain access to high powered fellowships trumps that camaraderie between residents - and cringe to think about what it would be like to work in such an environment.

Our residents routinely pull together and help each other out - at current count, there's a pregnancy, a recent birth, and a wedding - every single one taken care of because we as a group are committed to helping each other. We do this not only because we could easily be the one needing a hand next time, but also because we like each other. My fellow residents are kind, funny and good at their jobs - people who I am proud to call my colleagues.

Don't ever underestimate the need to connect and spend time with your fellow residents and students - family and friends are your bedrock, of course, but there is a comfort that only the ones who walk beside you on that long and sometimes grueling road to becoming a physician can provide.

One of my favourite quotes is from Spider Robinson, as Callahan's law: "Shared Joy is increased, Shared Sorrow is lessened."

This is how 34 physicians can come from all over the map, with different destinations and ultimately become a residency, it's why we are more than a sum of our parts.
Wayne State University Class 2009
The patient sat quietly in the chaos of the ER, not paying any attention to the people who constantly bustled by their slot as "Treatment hall 3" .

He answered my questions honestly, even admitting that yes, he'd smoked marijuana lately because the cancer had taken his appetite as well as his strength. I told him I understood, but please could consider trying pot brownies and avoid the smoke exposure? My typical staunch opposition to pot and the people who abuse it tends to disappear when I see a white blood cell count that runs at 26K on a really good day.

He was actually relieved to find out he had a rib fracture, something to explain the horrible chest pain that wasn't a metastatic lesion or a heart attack.

My heart went out to him though, hearing about the endless rounds of doctors and tests that comes with any cancer diagnosis.... but my brain kept fixating on his not eating, especially seeing how thin he was. Not cachetic, but certainly heading in that direction without something being done.

I knew about Megace, and its obscene price tag (something on the order of 590 dollars for 2 doses)... but I also knew about their bare-bones insurance.

Knowing when to run for help, I asked one of my favourite attendings about what I could do to help them get this horrifically expensive drug on an admission that wasn't for weakness, fatigue or wasting.

And then came the magic words. "Why don't you just try cyproheptadine? That stuff is cheap as dirt!"

Turns out there's an "old timey" antihistamine that in addition to treating hay fever pretty well, makes patients ravenous as a side effect. 4 milligrams about an hour before meals does the trick.

The next time I walked into my patient's room, I saw a half-devoured lunch tray instead of the untouched food I'd seen every time before. The gratitude in his eyes was something I hope every doctor can experience some day.

"No more pot!" he crowed. "Thank God, I can eat. Thank you... thank you so much, you have no idea what this means to me."

This is a win today. This is a light I'll hold close when all other lights have gone out - when we can't get someone back, when the grandmother comes in with signs of elder abuse, when my patients scream at me for trying to help.
Wayne State University Class 2009
So the fantabulous Anna was doing research on how Wayne could better train fourth year students to teach. Because not only is she going into family practice in an underserved area, she wants to teach the next generation coming up.

Anyways, the Irby method is great and with it being July, I thought everyone could benefit in a low-stress, quick, high yield teaching method.

It's 5 questions, that you ask your student after they've gone to interview the patient and want to staff it with you. For best results, let them sit down, don't do it in front of anyone else and give them at least a minute to answer each question, with gentle prompting if they need it.

Question 1: What do you think is going on?
-Make the student commit to at least a loose diagnosis. This is not the point to pin them down on systolic or diastolic dysfunction. It's also ok for them to have two competing diagnoses, as long as they support it. Once they commit to a diagnosis, go through the rest of the questions - even if they're really wrong. They'll figure it out, and you can start over, but it provides a solid teaching moment for them - you can have a wrong diagnosis and have to go back to step one. (Like the patient we were SURE was having a CHF exacerbation and came back with an EF of 59%)

Question 2: Why do you think that?
This question gives you insight into how they got to the diagnosis, and gives you an opportunity to correct a wrong line of thinking. Unacceptable answers include "Because that's what the ER doctor said". Ask them to pull from physical exam, history and lab values separately.

Question 3: How would you like to work them up?
This is where they tell you what tests they want to order. Labs, Radiology, and all that jazz. For any outliers, ask why they want to order it, and work with them from there. The phrase "Anything else" is especially useful

Question 4: What do you think your labs are going to tell you?
Don't get too technical about specific values, it can be as simple as "elevated creatinine" or "an infiltrate on chest x-ray." But it will help them reflect on #3 and reinforce the point that we don't order things unless we think it's going to tell us something useful.

Question 5: What do you want to do about it?
As a student, the part I was always weakest on was treatment plans. It's a good time for them to learn common orders, common meds and dosage. Ask them specifically if the patient needs to be in observation, on the floor, in the unit. That way, they get an idea of what comes with admitting a patient.

Once they're all done, give them one specific teaching point. For pneumonia, talk about a CURB-65 score or Community vs. Hospital acquired antibiotics. For heart failure, talk about why they need to be on an ACE. Don't try to overwhelm them about the whole epidemiology/pathology/diagnosis/treatment - just end it with one salient, practical point.

I really, really like this method for two reasons. One, it's because I don't need to rattle off a big prepared talk about a specific disease - it draws on the strengths that any resident should have already. Two, it's quick. and Three - it makes the student be proactive when thinking about a patient, because so much of rounds as a student is listening to residents and attendings debate diagnosis and treatment plans without being able to suggest something to try or think about.
Wayne State University Class 2009
Tue, Jul. 14th 2009 - 247 reasons for not posting.
That would the number of hours I've worked since June 22. As an intern, I'm not surprised I'm hitting the 80 hour mark every single week, but wow. Tired.

I had something like 5 Twitter updates in a row that all started with "I am so bloody tired" or some variation thereof.

I have so many things to talk about and precious little time to do so properly.

I got through my first call, even though I was scared stiff - first day on the wards, first intern to be on overnight. Since then, I have learned how to admit a patient in 30 minutes or less, how to properly cross cover 25 patients from bed, and that dictations - when not done ASAP somehow breed and create a crop of baby dictations.

I learned how to teach, a bit. I hope I did well by our med student, which ultimately means teach them what's going to be useful for them at that point without being a pushover or a slave driver. Hopefully he learned ABG's - because the only thing I learned from that conversation is that 8 AM on a post-call weekend morning is NOT the time to teach.

The exhaustion, the constant feeling you're on a treadmill that can't slow down, the worry and stress have been worth it. It doesn't seem like I would be able to learn this quick, but in the last month the white coat and the "I'm Dr. Zechar, I'm going to be your doctor" feel less strange.

It helps that it's stuff I love. Pancreatitis, Diabetic Ketoacidosis, Heart Failure, COPD... I know it doesn't seem as sexy as the major trauma the surgeons see or the baby my fledgling ob-gyn colleagues have caught, but we keep people alive and that's what counts.

...Except for the times we don't. I had two deaths on the service, and one person still critically ill in the unit. With each death, I've questioned what could have been done to have a different outcome, and it keeps coming back to stuff I couldn't have stopped - you can't undo 100+ pack year smoking history or 150 tylenols in a night.

What I can do is get right back on the horse and take the next hepatitis patient who walks through the door.

The goal right here is to stay afloat, but I know in the back of my mind that this is the time to push myself harder than ever before. Because each patient that dies with AST/ALT over 15K or a CO2 over 100 means that the liver patient or COPD-er I treat out on my own after residency has a better chance to survive.
Wayne State University Class 2009
Sun, Jun. 28th 2009 - I meant to post, I really did.
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This is what 80 hours looks like. And I'm running with a relatively light load! To learn this week: time management.

Thoughts from my first call:
have been a doctor for real for 6 hours and nobody has died yet, including me. Probably b/c my team is awesome.
12:16 PM
They really are. The attending is efficient, open to resident suggestions for treatments, and teaches. My upper has yet to get even mildly upset at us interns for the stupid things we do, and helps keep us on task. My fellow intern is a superstar, and fun to hang out with. The student is completely on top of his patients, and really puts in the effort.

Hour 12 and people are still alive. For the record: testing the code blue system on the interns first day is MEAN.
5:40 PM
TWICE.

Cross coverage is like doing a word-search, except you get interrupted to do a Sudoku puzzle, while simultaneously trying to do a crossword.
10:41 PM
The individual tasks aren't difficult or complicated (Potassium is 3.3? Give 20 mEq PO) but do require some amount of attention to detail, so when you are constantly interrupted, things get hairy.

Law in the hospital: the Very Second your head hits the pillow on overnight call, the pager goes off. I mean, immediately. Like murphy.
12:57 AM

Walked in at 6:45 AM on Monday, walked out at 12:45 PM today. Up 4 patients, down some sleep and very happy to have my 1st call over.
4:22 PM Jun 23rd
Current post-call strategy: fall face first on couch and don't move for ~2 hours, then get up and be a person again.

So far, call has been ok. I am slowly learning the art of cross-cover. So far, there seem to be a few rules to go by.
1. No controlled substances without going to see the patient.
1.5. If you get more than one call on a patient (that doesn't deal with poo), go see them.
2. The phrase, "Do (X), check (Y) and call me with the results, please" is magical. Because I can't guarantee I'm going to check on Y in 45 minutes on my own.
3. Take good notes at sign-out, and keep them next to the phone. The hospital is wireless enabled and computer based, but at 3 AM I want paper. Paper is simple and gives immediate information.
4. Sleeping for even half an hour is better than not sleeping at all.
5. The 10 minutes you in the AM spend brushing hair & teeth, putting on deodorant, etc will keep you going until 1PM.
6. DRIVE SAFELY.

And finally: The coffee maker in the resident lounge has a vendetta against me. It broke (at my hand) on my first day, and now mixed up a nice cup of warm steamed milk when I pushed the cappucino button.

Warm milk at 6 AM after call is the opposite of helpful.

Upcoming topics:
Our very awesome med student and the things I try to teach him.
My first patient death. Yes, in the first week. It's not the typical story, though.
Wayne State University Class 2009
Sun, Jun. 21st 2009 - Also, naps PRN.


Hope all the Dads out there have a great father's day.


HIPPA disclaimer: all golf and cookie levels were fabricated. Any resemblance of the patient in the video to my own father is completely on purpose - but it's ok, he's my Dad. :)
Wayne State University Class 2009
Tue, Jun. 16th 2009 - Residency, Day -7
And so it starts, as it always does.

Orientation. Find the room, nibble on the continental breakfast, size up your fellow classmates-now-coworkers, introduce yourself with your name/school/interesting quirk, and then sit and try to absorb half the information they throw at you.

I definitely absorbed one piece of information: my schedule.

My first month? Wards.

My first overnight call? My first day.

Yes, like on Scrubs.

I'm actually feeling pretty good about it. I met the other resident and my senior, and both appear to be friendly, upbeat and very level-headed. So I might as well jump in with both feet - besides, if you get through the scariest part of being a resident on your first day, then things can only get better from there.

The only other surprise today is that my program has been forced to start a hybrid night float schedule - another service decided that they simply weren't taking call anymore and instead of making us Q4 overnight, we're Q8 overnight with a call until 7 PM in between. I still dislike the night float model, but I firmly believe that Memorial is going to Make This Work. Their handoff system is beautiful, and it sounds like everyone is supporting it, right down to the ER holding all admissions from 6:15-7 (both AM and PM) so the teams have protected time to sign out.
Wayne State University Class 2009
Mon, Jun. 15th 2009 - This I believe
Concept taken from the Edward R. Murrow and continuing NPR series, "This I believe" - a series in which everyday people talk about one thing that they believe in.


I believe in daring. Not daring as in double-doody-dog dare, where one is forced into action by another but in taking actions that make people who don't quite understand take notice and say "How dare you!"

Daring to be and do outside of the norm is a genetic for me. Our family motto "Audentes Fortuna Juvat" assures all descendants of the Clan McKinnon that fortune will assist them when in need if they simply dare to take action. This action began with a rural Scot defending himself against a wild boar by shoving an already feasted upon bone vertically into the swine's mouth, and continued through my maternal lineage. My grandmother, who has never failed to speak her mind in her 80 years upon this Earth even when society told her it did not befit her gender. My mother, who dared to go back to school after practicing as a nurse for nearly 30 years so she could climb the hospital ladder, and now gives marching orders doctors who used to throw charts at her.

Having been steeped in audacity, I now dare to speak up about our broken healthcare system. I dare to maintain a visible and critical presence in the medical blogosphere and refuse to pretend I don't see patients suffering because they don't have the money or power to advocate for their interests that pharmaceutical and insurance companies use so freely.

I dare to practice primary care medicine, even though I know the hours are longer, the paychecks are smaller and the battle will always be uphill.

So I say to everyone who is struggling against something bigger, stronger or more entrenched to be daring; be slightly reckless, make the kind of noise people don't want to hear, and don't give in to complacency. You may find that fortune smiles upon you as well.
Wayne State University Class 2009
Sat, Jun. 6th 2009 - In sum.
I made it through. I am a Doctor.

It still doesn't feel "real", and I'm sure it won't until I have my first terror-filled day on the wards, but knowing that our current address in Savannah is helping to make things more concrete.

I could say so many things about the journey, about the ups (honoring my first (and only!) exam, the first time an attending told me I'd make a good doctor, going to my Savannah interview and *knowing* I wanted to work for them) or the downs (failing an exam, my first patient dying, going to my 5th interview in a week and falling asleep) but I can say that every second was worth it.

It's worth the money, time, and tears to spend the rest of my life doing a job that I've dreamed of for about 20 years now. The bad times taught me the things I need to know about being a doctor - the importance of being patient, thorough and kind. The good times got me through the bad times.

Of course, I'm not done. Not by a long shot. I look around and see so many examples to live up to - my training truly begins now.

I started this whole blog with "I'm just a bit nervous", and I've come back around to that. Excited, of course - but still dealing with the knowledge that it's my signature on the line now.

I hope to once again return to prolific blogging. This journal has been such a joy - not only to record my thoughts along the way, but also the people I have met through it. The end of 4th year was a bit of time off - taking care of some important real-life issues - getting married to my wonderful and supportive husband, honeymooning, graduating and then immediately packing up & moving 945 miles.

(And yes, the above was crazy. Also fantastic.)

I'll leave you with a photo from the wedding, care of our awesome photobooth. The lovely people in the background are my parents, who have also shown themselves to be wonderful and supportive on occasion. :)

Photobucket
Wayne State University Class 2009
Wed, May. 13th 2009 - For the record
Getting married/moving 944 miles away (Mom, stop crying)/Graduating from med school/Starting residency?

Plays merry hell with any kind of regular blogging schedule.

As a mea culpa once again, here's the talk I did at Penguicon - How to Kill a Character 2.0, No bullets or pointy bits.


Topics I would have loved to cover and forgot:
Infections (flesh-eating bacteria and the plague)
Compartment syndrome (I don't think I covered it last year, and it's always good for an EWW.)
Seizures (not all seizures thrash around on the ground, and status epilepticus is v. scary)

As you can see, I pick topics on a basis of how common they are, how interesting they are...but mostly if I can get my audience to say "Oh my."

Once again, it was standing room only. :) Penguicon next year is April 30th through May 2nd, in Troy Michigan - you should come!
Wayne State University Class 2009
If I had tried to manage a cardiology consult/ICU month this last month instead of Radiology.

Life lesson: If there is ever a month to take a rotation that focuses on "self motivated learning", make it April of your 4th year. Weddings, bridal showers, trip to Georgia to find an apartment, trying to sign a lease from Michigan, residency paperwork, finding furniture and a dishwasher for the new apartment, my own wedding...this whole month has been a series of "Let me get through X, then I'll work on Y!"

Y right now being the finishing touches on a presentation for Penguicon 2009 "How to kill a character 2.0: No bullets or pointy bits." Y'all should come.

There's also something reasonably exciting that just went down today, but let me get through Frostbite and Full-body radiation first. :)

Instead, a fun exercise: describe your chosen field of medicine in 6 words or less.

Mine (internal medicine): "Take insulin or lose your foot" or "Yes, 220 over 140 is high."
legeix How's this: "I'm going to cut you open." or "Just turn your head and cough." or "This wont hurt me a bit." I like this game! (Oh, surgeons...)

spartanmd "Recieved in formalin is a tan . . ." or " The decident appears to be a . . ." (Pathology has a definite form to their notes...)

Hazelrah@twitter Mine is: What did the diarrhea look like? (my sister-in-law-to-be, the Vet student.... we are REALLY good at playing the gross out game during family dinners)

turnberryknkn "Today, your child's blast count: zero." Jeff cheats with colons. But he's got peds heme-onc fellowship results waiting to come out, so we'll cut him some slack. :)

exxorcyst "Say peace out to your gallbladder." (Again, with the surgeons. If they weren't such great guys, I'd worry.)

"Thoughts of hurting yourself or others?" and "So tell me about your mother...." a pair of Wayne alum psychiatrists, my first med school mentor and the other newly minted.

Allergic to all meds except Dilaudid??? or He wants a sandwich? D/C home... (One of my favourite new ER docs. She also believes in the Sandwich Sign)

"Yes you must brush AND floss" My cousin, the Dentist. Ask her why you need actual tooth left to have a crown put on.

"You put WHAT in WHICH orifice?" My brother-in-law-to-be, in nursing school and just assigned to his clinicals. Godspeed man, Godspeed.

Rat A differs from Rat B. Karen's that kind of Dr. that sounds more like "Fudd" than "Mudd".

"So...is it like physical therapy?" The battle cry of PM&R. Lucky guy gets to practice out in Colorado, too.

fuzzyfoxtess I'm the jack of all trades. She's not kidding, folks. Looking to do underserved/rural family med, even.

"Seriously, you all have Aspberger's Syndrome." Or does computer programming not count as a medical profession? (The source works for an unnamed large computing conglomerate that has an operating system named after a paned glass housing feature. I have no doubt that some of their colleagues have "difficulty engaging socially with their peers")
Wayne State University Class 2009
Thu, Apr. 16th 2009 - Day In The Life 2009
The last one of medical school! We'll see if I can manage one as an intern. :)



If it's in my ER case logbook, it's gonna happen. For this month, that pink cardstock spent more time nestled up against my backside than my favourite warm fuzzy blanket.

And so it goes...Collapse )
Wayne State University Class 2009
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