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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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Sun, Sep. 16th 2012(no subject)
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If that doesn't work, you can stop by to visit the old fashioned way. :)
Wayne State University Class 2009
Finally, an update! I've long since neglected both this blog as well as fortuna_juvat.

By combining them, I hope to jump-start both.

Hope you enjoy, thanks for reading.

Wayne State University Class 2009
Thu, Dec. 15th 2011 - It's kind of scary, actually.
Pages of my life that in retrospect, were taken directly from episodes of the TV show Scrubs. (Episode name in parentheses)

Cast of characters: genders occasionally switched. Yes, I'm JD. It's my journal, I get to be the main character.

My best buddy is a surgical resident. We frequently greet each other with over-the-top displays of mock-affection.

My co-Medicine chief (and wonderful friend) is a leggy blonde (though I will note that we have NOT slept together) (my office)

One of the ER nurses decided to take pity on me as a clueless intern and is now a really good friend. (who just recently had a baby)

Memorial has its own version of "The Todd" Yes, he's a surgeon. And he makes ridiculous sexist comments around any female employee. And then wants to give you a high-five.

Our ICU Doc loves giving people nicknames. And talks faster than anyone I've ever met.

I secretly suspect that one of the janitors has a grudge against me, after an incident with a floor waxer my intern year.

Memorable incidents:

On my very first day on the wards, I was on overnight call, and scared out of my mind. (My first day) The scene starting at 1:45 is still the most accurate depiction of what it's like to be on call ever.

I took call overnight on my first Christmas, and very much lost any "Christmas Spirit" when I had when I had to tell a mother her young son was dead. (my own personal jesus)

One of my first students was a cocky jerk who didn't want to do their work and I got to set him straight. (my student)

After becoming fairly adept at intubations, I hit a streak where I just couldn't get it right as an upper level, much to my frustration and worry about my abilities as a doctor. A crashing patient and me being the only person around to intubate got me out of my head & back in the game. (my porcelain god)

All the male residents have a crush on one of the pharmaceutical reps who brings us lunch. (my first step)

I use the word "Bajingo" More often than I say vagina, probably. (my dirty secret)

We frequently hang out up on the roof. (Sadly, there is no toilet up there)

I had a patient who I trusted and vouched for burn me on scripts for narcotic pain medications. (my moment of un-truth)

The best urologist in town is female. (My urologist)

I helped smuggle in a beloved pet to a patient on a hospital ward, consequences be damned. (my no good reason)

We admitted a beloved colleague to the ICU after a tragic car accident, trying our best to separate personal feelings from providing the care they needed. (my long goodbye)

Surgeons do have favorite scrub caps and are legitimately superstitious about them. (my butterfly)

As chiefs, we simultaneously protect the interns from critical attendings while having them compete in amusing ways to get out of call/go home early. Though instead of physical fighting, it was wearing a hideous christmas sweater for a week straight or holding their breath until they drop their O2 sat on a pulse oximeter. (My Ocardial Infarction)
Wayne State University Class 2009
Thu, Dec. 8th 2011 - Tell me about yourself.
Mandatory Mea Culpa over once again letting this journal go empty for… months.

Chief is in full swing, and has been for months. It's been a ridiculous journey, and I still have yet to receive my ceremonial feathered headdress.

What it really has given me is an extraordinary insight into the interview process. Three years ago, I was on the interview trail looking for a residency program to call home. Now I'm bringing nervous students in black suits to my office, telling people to have a seat.

So, let's talk about what you should (and shouldn't!) do on your interview.

First, the suit. Yes, you have to wear it. I personally compliment everyone who goes with gray, navy or any other color. Also, please make sure it's pressed and fits you well. We do notice this stuff and it does matter.

Women, for the love of GOD, wear shoes you can walk in. I had to stop a hospital tour half way through one day because a female applicant had made a poor choice in her very tall heels that weren't broken in. She looked ridiculous and it reflected poorly on her as an applicant. Is it trite or superficial to judge her on that? Possibly, but we are having to make a snap judgement on your character based on approximately 4 hours of interaction and your file.

Which brings me to your file. To date, there are only a few things that have given me pause in a person's application. A DUI, a dispute with the med school administration (which the applicant then spoke about in a fairly unprofessional manner) and someone who had purposefully chosen to delay Step 2 until after they had interviewed.

The personal statement is sweet, and I could probably make a drinking game out of them. A shot for a dying patient, someone you "really reached" because they were noncompliant and you explained their meds to them, or "this doctor made an impression on me when I was younger, so now I want to be one!"

The letters of recommendation are usually glowing - but I really caution you against going for a "name" in your institution who doesn't know you. We can spot a bland letter of rec in a second and it doesn't do you any favors. The genuine ones can really help, because we're looking for anyone who actually gets to work with you for more than a day.

On the interview day:

DON'T BE LATE. If some catastrophe causes you to be late, call IMMEDIATELY. Nothing looks worse than someone who is late and doesn't appear to care about it.

DON'T SWEAR. (You'd think I wouldn't have to say this….)

Relax. Please just relax. If you're funny, crack jokes. If you're chatty, make conversation. If you high five people when you agree with something, go for it. We want to see who you really are, and I get frustrated by the people who I suspect are warm, fun interesting people who are petrified into statues of their former selves.

Because at the end of the day, all we want to do is figure out two things: are you going to do the work, and am I going to want to work along side you?

The applicants I ranked the highest spent a not insignificant portion of the interview talking about our mutual interests (trashy reality television as a guilty pleasure and food policy in the US, respectively). Their file had already demonstrated that they were a smart, hard working and capable med student but those conversations convinced me that I wanted that person to come to my hospital and join the ranks of my residency.

We can beat the stupid out of people as long as you work hard, and the scores and grades are really just what get you in the door. Once you're there, please just have fun and enjoy the free dinner.

And I promise not to make you sculpt an Eiffel tower out of toothpicks while reciting the mechanism of action of various antibiotics.
Wayne State University Class 2009
Less than 72 hours ago, I cared for a critically ill patient. The details below are altered to avoid identifying information.

I admitted them to the intensive care unit, did invasive procedures on them, called consultants to assist in their care, and resuscitated them through a cardiac arrest.

I know their lactate was 104 on an initial ABG, their creatinine was 2.2, and they had been on the new alternative to Vancomycin for their resistant infection. I know that they were a code blue response in room 422 at 6:40 PM, received two rounds of epi and were shocked out of pulseless ventricular tachycardia after being intubated by the on-call surgical resident.

I know they were on Dr. _____'s service since Aug 12th.

I recall pronouncing them dead at 0105 with family at the bedside.

I did not know their name.

How is it that I could have been so intimately involved in their care, up to and including giving my condolences to their son and daughter who came to witness their last minutes alive on this earth and not remember something as personal as their given name?

When asked to follow up with a death summary by my attending, I stopped short. I could rattle off their history, start to finish with a full assessment of the likely causes of their arrest and subsequent decompensation as well as the entirety of our diagnostic and supportive efforts, but I found it impossible to recall what name to dictate the summary under.

My efforts to determine my patient's identity were further complicated; my intern, the daytime medicine resident who initially went to the code, the unit coordinator and the head nurse in the unit - not a single person could remember their name. We all remembered the room number, incidentally.

Ultimately, I resorted to pulling up all the echocardiograms done by the cardiologist we consulted for the day of their evaluation. I recognized the findings (LV hypertrophy with preserved EF and no apparent RV dysfunction or elevated RVSP indicating hemodynamically significant pulmonary embolus) and subsequently found the patient's name.

It is a sad commentary when an ejection fraction means more than a name.
Wayne State University Class 2009
Interns and medical students are notorious for jumping on the "zebra" diagnoses when they see routine patients. Differential diagnoses for uncontrolled blood pressure always include pheochromocytomas or renal artery stenosis, and Tb is inevitably brought up as a possibility on any given pneumonia patient.

So when my intern, on his second day on the wards walks out and says "That patient has acromegaly" my knee-jerk response as their older, wiser upper level was "No they don't."

Except.... they did have rather large hands. And feet. And they looked... well, acromegaly-ish. So I asked to see a driver's license.

The picture from five years ago revealed the subtle change over time - not enough that anyone who saw the patient on a regular basis would notice but I could definitely see the textbook "coarsening" of the facial features.

And so, I sent him off to figure out what tests he wanted to order, and put in for the TSH, cortisol, prolactin and IGF-1 off the list he brought back for me this afternoon, with the promise of a free cup of coffee - (the real kind, from the coffee shop in the patient waiting area) if the diagnosis was real.


While the patient's (totally unrelated) diagnosis has responded well to routine treatment, with a planned discharge monday morning, the CT head we ordered for confirmation just came back "enlarged pituitary, question mass."

Guess I owe the kid some coffee. :)

It's a small price to pay to watch a fledgling physician experience the thrill of a great diagnosis for the first time; seeing it reminds me of why I want to go back into academic medicine eventually. There's a certain satisfaction that comes with practicing effective, thoughtful and compassionate medicine just by yourself - but being part of the training to make someone else into a great physician is a reward beyond measure.
Wayne State University Class 2009
Wed, Jul. 6th 2011 - (well, besides sunscreen)
If I could give one piece of advice to new interns, rising second years and anyone else who gets a promotion every july.... stress management would be it.

Note that I didn't say stress relief. Outside of those precious weeks of vacation where you run off to see family, tropical beaches or just a 168 hour nap, people in our field rarely find relief from the stress that permeates our daily lives.

I joke that I'm naming my new ulcer "Chief", given all the little details that have made my job just that much more interesting lately, but the truth is that I'm just learning to manage the stress load a little better.

Because despite what popular media shows resident life to be like, excessive drinking and sleeping with the nursing staff are not good options.

And so, a primer. What I've learned so far from my own experience and watching those around me either crash and burn or thrive under the unique combination of sleep deprivation, self doubt and a diet of starchy carbohydrates that is residency.

Things that help, but don't mitigate the need for a stress management:

Cohabitation with a warm body:
-Significant others

The luxury of coming home to a place that is Not Empty can not be understated. Even if your cohabitant has a tendency to groom their nether region with their tongue, it's nice to have companionship at the end of a long day.

People who are contractually/morally/spiritually obligated to listen to you whine
-Significant others**
-People of whatever manner religious cloth you prefer

Once you move past the comforts above, it is useful to have someone to talk to outside of work. Residents are skilled in the art of bitching to each other; we share the same language, we know that Dr. R gets grumpy if they don't get a second cup of coffee. But to have a sounding board completely removed from the job is important - these people know who you are outside the hospital, and provide a new perspective on the Issues At Hand.

**Caveat: Don't abuse these people; despite their love for you, they WILL get sick of hearing about your job, especially if it's all suck, all the time. Share the victories, vent about the losses and then go do Something Else.

But, you ask - what can I do by myself to manage my stress? Well, you're going to have to figure it out for yourself. My go-to activities tend toward the simple and domestic - cooking, gardening, figuring out if I can actually spin the mountains of hair my dogs shed into useable yarn with my spinning wheel.

Others go to the gym or voluntarily go out running in Savannah heat. Those are the lucky ones who actually feed off the endorphin rush and can avoid the intern 15 so closely associated with aforementioned carb heavy diet.

Point is, there has to be something. Something constructive, just for you and not related to patient care in the slightest. Failing that, you need a guilty pleasure - something that is guaranteed to soothe and comfort after a day where the guano has completed coated the fan.

It may not work for everyone, but Riesling, Thai takeout spicy enough to make your face numb and Breakfast at Tiffany's has yet to fail me.
Wayne State University Class 2009

24 hours in 60 pictures, again, with very careful crops to avoid massive HIPAA violations.

For reference, here's the previous years:
intern year

4th year med school

3rd year med school

2nd year med school

1st year med school

Read more...Collapse )
Wayne State University Class 2009
Tue, Jan. 25th 2011(no subject)
7 things that cross my mind frequently:

1. Any one of my 6 password/user name combinations I use on a semi-regular basis. Which are required to be changed on a semi-regular basis. (And this is WITHOUT an Electronic Medical Record in the clinic)

2. Where the crap I left my pen. True story: while on an especially demanding ward month, I would have a daily census printed off, with a to-do list, and whatever notes I took during the day. As the month wore on, I would simple fold the previous day in half and put the new sheet in front. (Proved useful, as I'd note family phone numbers and lab values as I went) I misplaced the whole stack on about day 17 and nearly had a meltdown.

3. What I'm going to do with my life. I frequently vacillate between hospitalist (which is a very tempting position right now as I wouldn't even need to move or take a new ID picture) outpatient clinic with or without inpatient duties (only tempting on days that my lovely, compliant and non-crazy clinic patients come to their appointments) and then, just to throw a monkey wrench in the whole damn thing, I think about how much I enjoy teaching and how lovely an academic position in a residency program would be.

4. What I'm going to make for dinner. I try to be a semi decent wife to Dear Husband, and will at very least ensure that we're both fed each night. (Vacuuming is right out.) Happily, I've had some lighter months and thus was able to work on culinary skills. Even though his very favourite dish of all time is my thrown-together-in-20-minutes Peanut Chicken and Rice.

5. "Oh, yay, lunch at noon conference!" If the residents experience the good fortune that is a drug-rep catered lunch at noon conference. Yes, you may recall my previous diatribes against the pharmaceutical industry. And while their fiscal expenditures courting physicians is part of the problem, I feel pretty comfortable in the reforms that happened. And dammit, there's chicken terriyaki over there, and I can't face another limp-lettuce salad from the cafeteria.

6. I should go to the gym (see numbers 4 and 5). There is such a thing as the intern 15. Frequently, these pounds stick most to those who drink beer during their time off. (ahem, the surgeons and radiologists) Thanks to the efforts of Jess, my fellow intern and gym enthusiast, I routinely spend some time in memorial's gym. Unlike her, I do not enjoy it, or the heinous lunges she makes me do. But, I still fit into clothes I wore in med school, so Victory.

7. "Ok, who has 434?" I swear, finding charts on 5 surgery, 4 medicine or the cardio floor on three is like pulling teeth between 7 and 11 AM. If there are more than two consultants on a patient's case, I seriously consider putting a lo-jack on it.
Wayne State University Class 2009
Wed, Jan. 19th 2011 - A cop out? Perhaps.
Care of "The survey everyone else is doing" (abbreviated)

Day Two: Nine things about yourself.
Day Four: Seven things that cross your mind a lot.
Day Six: Five people who mean a lot (in no order whatsoever)
Day Ten: One confession.

1. I am compiling a list of things that my previous Yankee Self would be horrified by (wearing dresses+pearls on a regular basis, driving my husband's Big Effing Truck, my use of the words "Buuull sh-yi-it" or "y'all")

2. My coat has gotten progressively lighter every year I've been on wards. I'll have to do another video post soon.

3. Despite having two electronic gadgets that will conveniently store and then remind me to do tasks, if something is *really* important, I write it on my hand. Which led Dr. G to ask one day on rounds "I have to know. What does VER 15 MORT mean?" (Answer: go to the verizon store to sign up for the hospital discount, give Amy 15 dollars and pay the mortgage)

4. As a half-way done second year, I'm already at the stage where I'm giving away procedures to interns and med students. Love my no-fellows hospital.

5. Every once in a great while I wonder what my life would have been like going into ER. (Usually when a trauma protocol rolls in) Then I walk through exams (aka STD alley, home of the pelvic cart) and I feel good about internal medicine again.

6. I frequently worry that my patients think less of my abilities because I a)look young and 2)avoid medical jargon like the plague. Hence the wearing of dresses and pearls.

7. Despite #6, I can pull of righteous fury when the time calls for it. Most frequently, it happens if a patient is being.... unkind to the nursing staff.

8. No matter what I do, no matter how many times I memorize tumor markers and clotting cascades, hematology/oncology material just slides right out of my head when it comes to test time. Can't do it. (Good news: I doubled my percentile in heme/onc this year. Bad news: it's still less than 20th percentile.)

9. When I was young, I would come with my Mom to the hospital where she worked as a post-op recovery nurse. She'd take me to the hospital cafeteria and I couldn't understand how she could complain about sick she was of the food there when there were some many different things to eat. Totally, totally understand that now.
Wayne State University Class 2009
Fri, Jan. 14th 2011 - As always, promises to do better.
So I'll try and kick-start this thing. Seems I left off as my intern year was winding down, finally making the decision not to go into pulmonary critical care.

Seems right to pick back up with the first day of my second year.

I couldn't have asked for a better Critical Care team. The third years were Joe (a linebacker for the Florida Gators in a previous life and thus is scared of absolutely nothing now) and Jess (our hard-working and utterly brilliant co-chief) and a freshly minted intern who was pretty damn smart and also willing to work. Oh, and one of my very favourite attendings, the one who calls me "Red".

The thing I always sell to interviewees to the program is that you're never alone. (Because I remember being a 4th year med student and thinking "Oh, god, I need to get to the code... just not quick enough to be first.")

Which is true, as an intern, you're never alone. But as of July 1, I was a (supposedly) big, badass upper level. Which meant I did nights in the ICU solo.

Not many stories end well when they start with "It was a dark and stormy night", but I'm happy to say that my first night went well enough. The sepsis, the massive MI's, and the post-code resuscitations rolled through my door and I rolled with them, trying my best to look calm and in-charge while my stomach did somersaults and I second-guessed every decision.

But after awhile my signature on the post-procedure note would be a little less shaky, my stream of verbal orders would be a bit less hesitant and I'd even get a "good call on that patient in MICU8" the next day. Baby steps, each of them.

I can actually pinpoint the moment when I finally feel like I came into my own as an upper level. Residents help run our Medical Emergency Team, (called the "MET team" even though it reminds me of "ATM machine" every time I say it.) which is designed to step in when a patient is crumping, instead of coding.

Room 384 is on our ortho floor, not a place you'd expect to find someone with the unfortunate combo of liver disease and COPD. But when there's only a few rooms left in the hospital, you make do. I get a call from our respiratory therapist, saying "his breathing looks pretty crappy, come take a look."

When Darren wants me physically in the room, I know to get my ass in motion. He once brought me a patient's ABG on top of the intubation kit, and my only response was "So I guess this is your way of telling me the gas doesn't look good?"

But back in 384, it was almost zen. I snap on a pair of gloves, see my patient sitting bolt upright, gulping air and wide eyed. Laying on stethescope yielded the nastiest crackles I've heard to date. A few reassuring words to patient "We're going to put a tube in your mouth to help you breathe. But first, I'm going to give you medicines so you go to sleep. When you wake up, you're going to feel better."

A few healthy doses of fentanyl and versed later, and I pull up my beloved Mac 3 to see a gorgeous pair of vocal chords. One pass, and even though I silently chant "turn yellow" to the end-tidal CO2 monitor, I know I'm there.

Just another day at work as the team tidies up and gets ready to move the poor guy upstairs but the floor nurse's remark pulls me up short. "I'm impressed, you did that like a pro."

"Well, I guess third time is the charm." I reply, trying not to ruin the moment by tripping over the travel vent's O2 tubing.

Which in turn, stops Darren mid-ETT taping. "Whaddya mean, third time?"

"That was my third solo intubation." I admit, blushing now.

"No shit!" I shrug and we all get on with our day, but inside I'm grinning like a fool, for once feeling like the badass I had pretended to be up until that point.

Once again, I cannot understate the importance of "Fake it until you make it".
Wayne State University Class 2009
Thu, Sep. 2nd 2010 - ICU, ICU I see me... in the ICU?
"So are you going to subspecialize?"

At each stage of your medical career, you're asked what your next step is going to be. For all of med school, you're asked to pin down a specialty - and as soon as you make it to said career path, people want to know if you're going to subspecialize, especially in a field as broad as internal medicine.

My answer remained the same for most of intern year "That's an excellent question, ask me again tomorrow."

It's no secret that I love the ICU. I like sedated patients, septic shock, acid-base status, central lines and vasopressors. I love our intensive care nurses, and am in awe of the intensivists we have on staff. To me, there is a certain zen in knowing that you have the sickest patients in the hospital, but it's ok - you have A Plan, and incredible staff to help you carry it out, and what will be - will be.

You save the ones you can, and learn from the ones you can't.

A decade ago, I was convinced I was going to be an ER doc. I wanted the adrenaline rush, the variety - the be a cowgirl and jump into the thick of a trauma and save the day.

And then I learned that the experience described above describes MAYBE 5% of a typical shift in the emergency room. Also that the other 95% was like pulling teeth for me. I hate abdominal pain, have little to no interest in syncope triage and dealing with headaches gives me one.

So I was left with the rest. Peds? No. Surgery? Oh HELL no. Ob-gyn? Maybe... but do I have to do all the gyn stuff too? Yes? No. But then I found medicine and thought "This could work, this is fun."

And then I hit ICU in november of my 4th year - and not just any intensive care unit. This was Henry Ford, birthplace of the Rivers Protocol - my attending was a legend in the field, and my upper level was a 5th year ER/IM resident whose favourite phrase was "C'mon Kat, I have another procedure for you."

So I trekked across the south for interviews, saying "I like medicine, but I really love critical care. Can I see your ICU?" Ultimately I found Memorial's - an enormous, sunlit loop that comprised our 40 bed Neuro/Cardiovascular/Medical/Trauma intensive care unit. It felt like home.

I worried that my expectations were unrealistic, though - after all, medical students were shielded from the worst duty hours, and were rarely given the truly sick patients to manage. But I hit the ICU as an intern with a pair of 6.5 sterile gloves in my pocket and the phrase "I'm here to learn" on my lips. I loved it. I loved the variety of the patients, the in-depth understanding of physiology and the procedures.

But then I found myself at the end of intern year, and the put-up-or-shut-up moment. To get into a critical care fellowship, I was going to have to shine up my CV with some really impressive pulmonary research, start gunning for chief resident and start looking at uprooting from Savannah in two years. Oh, and commit to an additional 3 years of resident pay and lifestyle.

I definitely was not without guidance - I talked to the ICU docs, the female attendings, our critical care-bound chief resident, my Mom. All the factors were brought up, rehashed, reconsidered again and again. I'm young, I've got time. But I want kids, and not when I'm 30. It's only 3 more years, but the closest program is in Augusta. But you're good at it! But do I want it enough? It's harder to go back later! But I have loans NOW.

And so I decided. No. No, I don't want it enough - enough to uproot Nick and myself (again), try and sell the house and match again. Not enough to commit to the lifestyle and missed time with my family.

I realized I'm going to happy "just" being an internal medicine doc. I'm still going to see seriously sick patients, do my own procedures and know that I can call in calvary when they need more acute management than what I can provide.

Besides. I really, really hate sputum.
Wayne State University Class 2009
Wed, Aug. 25th 2010 - Thanksgiving in 31401
A fridge previously stocked with premade sandwiches, salad dressing, old takeout containers cleared out and instead filled to capicty with covered casserole dishes. Tables dragged together and carefully set with orange paper napkins and plasticware. Spouses snuck into the resident lounge and the Macy's day parade on in the TV in the background.

This was the scene of my very first (but definitely not my last) holiday in the hospital on call.

So many of my generation are stranded away from family for Thanksgiving - justifying the expense for a plane ticket home when Christmas is right around the corner is tough. One's early 20's are the time between flying the nest but before you generate a family of your own, and so "Orphan's Thanksgiving" is a popular tradition in our set. Fledgling adults gather around Ikea dinner tables with someone's first turkey in the oven, researched via Google:"How to Cook a Turkey" or a "Ok, now what?" phonecall home to Mom. Discussions inevitably turn to a competition of who had the craziest family shenanigans at the holidays.

All we wanted was familiarity - we didn't have the luxury of making our own plans, of joining our peers in relaxed camaraderie. We had a 2 hour window after morning weekend rounds and before the ER admits picked up steam. So we prepared pies, stuffing and all manner of vegetable drowned in butter or brown sugar - the holiest of comfort foods. Every available countertop was covered with the foods our all-female team spent our pre-call day preparing. Residents drifted in and out, some surgery, peds and even a stray radiologist but we somehow managed a Thanksgiving miracle - everyone sat down together and ate. We stuffed ourselves, made snarky comments about being grateful for the absense of the "census assassin" - an ER attending notorious for soft admits by the cartload.

But in residency, you create the family you need. My family that day was a mother of 3 who made amazing crock-pot turkey as her husband and children went to her in-laws, a pair of residents managing their simultaneous engagement and intern year, a surgical 3rd year between cases and my dear husband, smuggled in for a bit of time together.

And it was ok. Nobody could ever replace my Mom and Aunts cracking jokes after they killed the 1st bottle of wine, my cousin's latest camera and the 50 shots later uploaded to facebook or my Grandmother's gleeful torment of whatever cousin she's decided needs to give her another great-grand.

A family at its core is a family because they care for and support you - so even though I shared zero genetic material with the people around they table, we had ranted when times were tough, celebrated when we had it good and comforted each other when the shit really hit the fan.

So, here you go - my Memorial family, circa Thanksgiving 2009.
Wayne State University Class 2009
Mon, May. 17th 2010 - Something more light-hearted.
Looking back, I see that a significant portion of my entries have dealt with suffering, death and other generally "downer" subjects.

So I'll tell you about Mr. B.

First off, Mr. B cracked me up. He had significant psychological pathology, along with some developmental delay, but his demeanor was as happy and pleasant - not something I routinely count on during my day.

There's a wise quote that counsels Doctors not to take offense at anything a sick man says to us. It's good advice - it reminds us that we frequently see typically kind people in a position where they're in pain, scared and often alone. They say and do things they never would under normal circumstances.

Of course, I'm reminded frequently that the people we deal with are thoroughly unpleasant, strung out on any number of illegal substances and enjoy abusing the hospital perks of a warm, clean bed, free television and food brought to you three times a day.

So I will absolutely take happy-go-lucky any day, even if the first day I met him I nearly documented "Pt's ileus and constipation has resolved, as he has now passed sufficient stool to fingerpaint with." (I ended up with him just passing "stool.")

So yes, Mr. B was covered in his own poo the first time I met him, and still remains one of my favourite patients.

He remembered who came to see him, and would light up when the whole team tromped into his room. He would sing songs, typically at the urging of my upper level resident who found his musical stylings endlessly hilarious.

Did I mention the songs were topical?

He would sing about the cartoons on his television, his "Good poo poo!", and purple popsicles. (The day we restarted his diet to clears).

His "Going Home" song the day of discharge was pretty impressive. I think he borrowed a bit from "Sweet Chariot", actually.

So few of my stories end with a nice, pleasant person going home cured of their illness, but that's exactly how this story ends. Well, with that and a big musical number. :)
Wayne State University Class 2009
Tue, May. 11th 2010 - LAZINESS
Sheer laziness, care of a Demanding Ward Month. Note the capitals. Demanding in the way that I am HUSTLING in order to not break the 80 hour rule, in a program that is pretty darn good about not giving us more than 320 hours' worth of work to do in a month.

So yes, busy times.

Quick updates:
New house! Out in the burbs. Longer commute, but I have a backyard. And flower beds. And a functional kitchen. All of these are extremely important to maintaining my sanity.

Still married! To a saintly, patient husband doing his own share of studying these days - taking the final EMT certification here soon! It is awesome watching him take to complex acid/base questions and trauma scenarios like a pro. I like to think I helped in some small way as my blathering about medical stuff for the last three years primed him to learn the material. :)

Almost Not An Intern! Less than 40 days until the end of this year, and my turn to be an upper level. The thought than in 2 months, instead of BEING an intern, I will HAVE interns is.... a little crazy, but also very cool.

So all that said and done, here's my laziness. I have 6 excellent entries written, if not typed (2 all-day lectures) so while those percolate.

Questions about matching, residency, or the occasionally spirit-sucking year that is internship? Ask me about the best, the worst, the weirdest, anything you want!

I'm bad about responding to comments as I inevitably forget to turn on email monitoring and thus find questions months later, but I'll do my best to post questions to anything you want to ask.
Wayne State University Class 2009
Yes, I mean it. There is just ONE MOST IMPORTANT THING to know as an intern. I could wax philosophic about not putting off D/C summaries (really, when there's 10, it's just going to cause you MORE dyspepsia), the perils of the hospital cafeteria (The Intern 15 is real, usually due to carbohydrates and increased stress) and the importance of the Red Book that should be in every medicine intern's coat... but if I could teach you just one thing "Errrmmmmmm" would be it.

"Errrmmmmm" is the name I've given to that odd little feeling that sits in the middle of your chest, makes you purse you lips and give pause. The medicine version of Jiminy Cricket, it is the thing that will guide you out of bad situations time and time again.

Things that have made me go "Errrmmmmm"
-A patient who we were seeing on GI for likely sepsis from a bad gallbladder and the nurse who was standing outside looking flummoxed and saying "Her breathing is a little slow now, I paged the attending, but he's not answering"
(End result: Septic shock in the unit from bad gallbladder and some dead gut to go with it.)

-Seeing ritalin ordered on a patient with hemorrhagic stroke in the previous month. (BP found to be 167/92)

-A patient in the clinic whose daughter - the nurse, calls in saying "she just won't stay awake today. I'm really worried!" (Sent to the ER, found to have a hemoglobin of 7.)

"Errrmmmm" should always be met with sending it up the ladder. Although you are Super Intern, and you can do it - you're still just an intern. Know when to run something by your upper level, know when to find out who is on call for the ICU. Some people call it "loading the boat" so that when the ship goes down, they're not alone - a grim way to look at it, but when the crap does contact the fan, I find vast amounts of comfort in not being alone.
Wayne State University Class 2009
"So as to not occlude your 6th cardiac stent, please take your medications and avoid cocaine."

"In order to heal your bleeding gastric ulcer, please avoid alcohol and stop taking Goody's powder three times a day."

"Patient's husband and daughter are not allowed in the room. If they come here, please notify Security and Adult Protective Services."

The good news today is pretty much limited to the fact that I have somewhat recovered from the evil GI bug I had on Sunday. Thank God for Zofran, Ginger Ale and Saltines.
Wayne State University Class 2009
Thu, Mar. 4th 2010 - Me and 1013.
In the library of forms that one uses in the great state of Georgia, form number 1013 starts off with the words "Emergency Admission and initial civil commitment"

Funny how a number takes on a life of its own when you refer to it often enough. The classic combo of 5 mg Haldol plus 2 mg Ativan is now a "B-52", so named because it "takes out" any target you use it on. 20/20 vision. GCS 15.

A Ten-Thirteen is how you commit someone to the hospital against their will. Not uncommon in my line of work where we get overdoses, drunks in fulminant delirium tremens, and the occasional psych complaint in addition to heart failure and pneumonia. So issuing a 1013 form in the ER is routine.

Doing it from the clinic is significantly less common. So of course, I'm the only intern who has had to do it. Twice, now.

The first time, it was a very dear patient who was struggling with depression as I struggled to get them on the right combo of meds. They came in, worse than usual and I asked the Gryphon House approved question "Do you ever think about hurting yourself?" as I chanted to myself "Please say no, please say no..."

But they did. And they had a plan. And they had the means carry out their plan at home.

I trudged out to the work room, knowing what's coming next. An involuntary ride to the ER with our helpful neighborhood EMTs as they kept telling me "But you know me! You know how much I love my children, I'd NEVER do it!" As your doctor, I am obligated to see to your safety in the setting of self-harm, even if you don't want me to.

Our veteran attending kept telling me that I did the right thing as the ambulance pulled out of the parking lot, even as he knew I wasn't hearing a word.

I nearly cried when they showed up at the follow up visit. "I know you were just looking out for me Dr. Zechar, I'm not mad."

I saw them again today. Doing so much better. God Bless Elavil.

But Fair warning: if you ever offer to see a fellow resident's work-in patient in clinic because they're swamped and it's 4:00? It WILL be a nightmare.

Which brings me to 1013 number two.

A routine check on how a patient was doing on their new SSRI depression med was met with a torrent of psychiatric issues - self harm, attacking family members, auditory hallucinations, visual hallucinations, mood instability, even dissociative symptoms.

I had to tease the nurse who gave me the "shouldn't take you but a minute" patient when we were calling for EMS. "See if I do YOU any more favors!" :)

Happily, they went without any issue - but the 1013 was tucked in the back of the admission note, just in case. With the same attending physician's signature as the first ordeal.

Perhaps it's my psych background that helps me find more issues, or the crazy is simply drawn to me... either way, Dr. B has threatened to run away the next time I try to staff a patient with him.
Wayne State University Class 2009
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