seriously, how do people who write blogs find the time and energy to do it everyday? maybe if one is getting paid, but for real, do these people have jobs? i know there are plenty of jobs that require less work time than mine, but egad, some folks post extensively 4-5 times a week or more! i've been working 12-13 hours a day, 6 days a week since mid-october and i tell you, i don't have the energy to write much. yeah, boo hoo for me.
i'm rotating again on the trauma service, and the patients are just as dysfunctional as they ever have been. in case you never read my prior entries from my time on trauma as an intern (if those actually exist in print or in my mind is something of which i am unsure)the majority of trauma patients fall into 2 catagories: first, the sunstance abusing sociopath who gets beat-up, shot, punched, stabbed, kicked, etc. population number 2 are the demented old folks who fall of ladders, crash their cars, fall down stairs, fall out of wheelchairs, or fall after they have been hit by cars because they were walking in the middle of a dark street at 9pm. people from catagory number 2 are intoxicated about 1/3 of the time, and it's not just alcohol these geezers are imbibing. about 3 weeks ago a delivery van ran over a nice 76 year-old female who, in her own words, ran across the street against a red light because she wanted to be sure to meet her crack dealer before the weekend and it was getting past the time he generally hung out in front of the liquor store. she later admitted to being high on crack when said poor decision was made.
there has also been a steady stream of old men falling off roofs and out of trees. i guess fall (the season) encourages ladder climbing. to be fair, it's not always men who fall; take for example, the following story about an unfortunate 65 year-old female: it seems that she ascended a ladder to clean the gutters and remove other debris from her roof. a portion of the roof is flat so she was actually off the ladder for 10-15 minutes. during this time, her demeted (i use "dementia" here in the actual medical sense)husband thought that she had finished her task and neglected to put the ladder back in the garage, so he did it. now returns the female to find an absent ladder and no means of egress from said lofty locale. fearing a chilly night outdoors, she leans over to see if the ladder has fallen or if anyone is around to retrieve said ladder. i guess she leaned too far because she is now the proud owner of a fractured pelvis and a shattered elbow. ouch.
*****
i will close with an explanation of why i pray for pediatric trauma between the hours of 6-7pm. i don't actaully pray for kids to get hurt, what i wish for is that when traumas come in that time period, i hope they are of the pediatric variety. this is why: i have a pager, it makes noise whenever a trauma arrives. there are different codes for adult and pediatric trauma, and there are also 2 levels of trauma activation depending on the severity (or presumption thereof) of the injury. from 7am until 7pm i have to see every single adult trauma patient who arrives at the hospital. this is not so bad--somedays are slow and i can fit in a nap here and there, and when it's bust it can be fun as trauma patients often need procedure performed upon their injured frames; tubes, lines, stitches, etc. as you might imagine, it can take a good amount of time to deal with a trauma, and they often come in in rapid succession. at 630pm, the night shift comes in and we sign-out the patients on the service--basically, we tell them about all the patients and make them aware of any active issues or things that need to be completed or follow-up overnight. then it's time to go home.
idiots and assholes all over our fair city must know this because there is often a rapid influx of trauma between 6-7pm. the problem here, is that the disrupts the sign-out process, which must happen, so both the day and night teams respond to the trauma and sign-out doesn't happen until after the patient is stabilized. depending on the severity, this can mean extra hours in teh hospital. i do like my doctor-type work, but after 13 hours in the hospital (even if there has been a siesta) i am ready to hit the road.
the caveat is that we don't respond to pediatric trauma. thus, anytime after about6pm when the trauma pager goes off, there are at least 6 people here hoping that it's a kid who has been injured and not an adult. although i can't speak for the others, i always pray for minor injuries.
Monday, November 9, 2009
Saturday, October 24, 2009
we few, we happy few!
as you know, i have completed my sicu block. huuzzah! as with nearly everything else, in hindsight, it wasn't such a bad experience. it really wasn't too torturous when i was doing it. the call days were quite tough--there were times when i was managing 12 critically ill patients by myself. sound scary? it was. usually there was a sicu fellow in-house to help, but i had several call nights when it was just me. there is an attending there at all times as well, but this person covers the trauma service as well as so he/she spent a good deal of time in the operating room. this didn't make them inaccessible, since one could go down to the OR and talk to them, but that is tough to do when 3 or 4 bad things are happening on the 6th floor and the OR is on the 3rd floor; i can run fast, but not that fast.
it was certainly a stressful time--partly because of the threat of death as a result of my management, something that was totally new to me. i've been in the ICU before, and i've taken care of some pretty sick people in the ED before. but in those situations there was always someone more senior than i within a 50 meter radius. as i said, there were nights in the sicu when it was just me, 10 patients, 5 nurses, and an attending that was nowhere to be seen. not every decision was life-or-death, and not every patient was trying to die, but it's still a lot of pressure. what's more, not only did i have to worry about the ramifications of each choice i made for the patients, but i know that these choice would be scrutinized by the attending the next morning.
the latter happened every post-call day, occasionally with horrifying results. a little background first: the day in the sciu starts as sit-down rounds in a conference room. there are 2 sicu teams consisting of 2 attendings, 3 residents, and 2 sicu fellows. then there are a few PAs and APRNs who always work there, plus the pharmacist, the med students, the PA students, the pharmacy students. close to 20 people some days. each resident who was on-call the previous night presents a brief summary of the new patients as well as anything that happened with the old patients. there are probably 30-40 interventions completed by each resident per night, and each one of these represents a unique opportunity to have you judgment questioned (as best) or get reamed (at worst). at least, i thought that was the worst that could happen.
i was post-call one morning with an attending known for his volatility and his insistence that males always be cleanly shaven, including post-call days (yeah, right). i'd worked with him before and aside from some goof-natured sparring over the infrequent meetings between my face and a razor, we got along well. all of this was about to change. i will not re-create the entire story, but the general idea is that i made 2 decisions that he really didn't like. they weren't dangerous decisions, just actions that he himself would not have made (one of them involved giving 2 units of blood to a post-transplant patient after having been asked to do so by the transplant attending himself. dr a (for angry) had only wanted 1 unit. without getting into a debate about the risks, etc. of blood transfusions, i figured that the transplant surgeon owned that patient, so i should do what he said).
upon hearing about the 2 units of blood, dr a launched into a 5 minute tirade about my inability to follow direction, my incompetence, etc. i tried to interject at one point that it was not my own decision, but rather that of dr transplant, as which point he said "this is just unbelievable. i can't take it anymore." at which point he walked out of the room, leaving everyone quite stunned. it was the most public yet of my many humiliations.
in his defense, he later apologized. well, he didn't apologize per se--i think his ego does not allow him to acknowledge that he ever actually does anything wrong--but he did say that his anger towards me was not personally motivated. he didn't think i was a bad person, or stupid, etc., that my lack of knowledge given my level of training did not allow me to make such decisions in an appropriate manner. he then proceeded to tell me why he thought the 2 units were such a bad idea.
on the whole, while a bit startling, the experience was not all that bad. partly, i'm sure, because of my sleepless post-call stupor. the real reason is that after all the yelling (which was considerable) there was a good bit of teaching. he made an effort to make me see the patients condition differently and to consider multiple factors and options that i had theretofore not considered. that is to say, he spent some time teaching me, which i need and love. i can take cursing and irascibility as long as there is some effort, somewhere, to show me the error of my ways so that i don't make the same mistake again. failure to do so, in my opinion, is both mean and irresponsible since residency is a time to learn (which says nothing about the fact that it's just juvenile to yell at someone for doing something without telling them why what they did is wrong, how they can fix it, or what they should have done).
the latter is the style of dr rc ("r" for red face--she has one, and "c" for the giant cold-sore she had on her lower lip at which i spent a good amount of time intentionally staring. petty, i know, but i was powerless and abused and i needed some way to revolt).
in hindsight, she is probably the least-favorite attending that i have ever worked with. she spent most of rounds alternating between trying to establish blame for incorrect decisions and making me feel stupid. she never made an effort to teach. i would ask questions in an attempt to learn, and her responses were generally mean "you just got lucky," "did you even think about this patient before you did this?"and even occasionally insulting.
on my last day in the sicu i was on call and there were 2 very sick patients. one was a 30 year old who had been shot in the head and was dying and the other was a woman who had just had a liver transplant and was rejecting the liver. i sat up all night outside these 2 rooms talking constantly with the liver transplant team and the neurosurgery team. during rounds, while discussing one of these patients, she said "sam, just because it's your last day doesn't mean that you can forget about or neglect your patients." this was near the end of rounds so the condescension had been flowing for some time. in addition i had been awake for nearly 28 hours, had not eaten in 16 hours, and there is only so much ignominy i can handle quietly.
this comment put me over the edge; i was raging inside. calmly, however, i said " dr rc, i sat up all night with these patients doing the absolute best that i could. i was constantly on the phone with the transplant team, with neurosurgery, and even the overnight sicu attending. i can accept that i may not have done everything correctly or how you would have done it, but for you to imply that i ignored these patients because it was my last day here is insulting, and i will not accept that."
i think i was shaking when i finished speaking. there was a long and, you guessed it, awkward pause; no one spoke. fortunately, the transplant team arrived after about 20 seconds and broke the silence. the remainder of rounds was largely uneventful, although i'd guess a bit uncomfortable for everyone. after that, i went home and until now, i haven't thought about that day too much.
it was certainly a stressful time--partly because of the threat of death as a result of my management, something that was totally new to me. i've been in the ICU before, and i've taken care of some pretty sick people in the ED before. but in those situations there was always someone more senior than i within a 50 meter radius. as i said, there were nights in the sicu when it was just me, 10 patients, 5 nurses, and an attending that was nowhere to be seen. not every decision was life-or-death, and not every patient was trying to die, but it's still a lot of pressure. what's more, not only did i have to worry about the ramifications of each choice i made for the patients, but i know that these choice would be scrutinized by the attending the next morning.
the latter happened every post-call day, occasionally with horrifying results. a little background first: the day in the sciu starts as sit-down rounds in a conference room. there are 2 sicu teams consisting of 2 attendings, 3 residents, and 2 sicu fellows. then there are a few PAs and APRNs who always work there, plus the pharmacist, the med students, the PA students, the pharmacy students. close to 20 people some days. each resident who was on-call the previous night presents a brief summary of the new patients as well as anything that happened with the old patients. there are probably 30-40 interventions completed by each resident per night, and each one of these represents a unique opportunity to have you judgment questioned (as best) or get reamed (at worst). at least, i thought that was the worst that could happen.
i was post-call one morning with an attending known for his volatility and his insistence that males always be cleanly shaven, including post-call days (yeah, right). i'd worked with him before and aside from some goof-natured sparring over the infrequent meetings between my face and a razor, we got along well. all of this was about to change. i will not re-create the entire story, but the general idea is that i made 2 decisions that he really didn't like. they weren't dangerous decisions, just actions that he himself would not have made (one of them involved giving 2 units of blood to a post-transplant patient after having been asked to do so by the transplant attending himself. dr a (for angry) had only wanted 1 unit. without getting into a debate about the risks, etc. of blood transfusions, i figured that the transplant surgeon owned that patient, so i should do what he said).
upon hearing about the 2 units of blood, dr a launched into a 5 minute tirade about my inability to follow direction, my incompetence, etc. i tried to interject at one point that it was not my own decision, but rather that of dr transplant, as which point he said "this is just unbelievable. i can't take it anymore." at which point he walked out of the room, leaving everyone quite stunned. it was the most public yet of my many humiliations.
in his defense, he later apologized. well, he didn't apologize per se--i think his ego does not allow him to acknowledge that he ever actually does anything wrong--but he did say that his anger towards me was not personally motivated. he didn't think i was a bad person, or stupid, etc., that my lack of knowledge given my level of training did not allow me to make such decisions in an appropriate manner. he then proceeded to tell me why he thought the 2 units were such a bad idea.
on the whole, while a bit startling, the experience was not all that bad. partly, i'm sure, because of my sleepless post-call stupor. the real reason is that after all the yelling (which was considerable) there was a good bit of teaching. he made an effort to make me see the patients condition differently and to consider multiple factors and options that i had theretofore not considered. that is to say, he spent some time teaching me, which i need and love. i can take cursing and irascibility as long as there is some effort, somewhere, to show me the error of my ways so that i don't make the same mistake again. failure to do so, in my opinion, is both mean and irresponsible since residency is a time to learn (which says nothing about the fact that it's just juvenile to yell at someone for doing something without telling them why what they did is wrong, how they can fix it, or what they should have done).
the latter is the style of dr rc ("r" for red face--she has one, and "c" for the giant cold-sore she had on her lower lip at which i spent a good amount of time intentionally staring. petty, i know, but i was powerless and abused and i needed some way to revolt).
in hindsight, she is probably the least-favorite attending that i have ever worked with. she spent most of rounds alternating between trying to establish blame for incorrect decisions and making me feel stupid. she never made an effort to teach. i would ask questions in an attempt to learn, and her responses were generally mean "you just got lucky," "did you even think about this patient before you did this?"and even occasionally insulting.
on my last day in the sicu i was on call and there were 2 very sick patients. one was a 30 year old who had been shot in the head and was dying and the other was a woman who had just had a liver transplant and was rejecting the liver. i sat up all night outside these 2 rooms talking constantly with the liver transplant team and the neurosurgery team. during rounds, while discussing one of these patients, she said "sam, just because it's your last day doesn't mean that you can forget about or neglect your patients." this was near the end of rounds so the condescension had been flowing for some time. in addition i had been awake for nearly 28 hours, had not eaten in 16 hours, and there is only so much ignominy i can handle quietly.
this comment put me over the edge; i was raging inside. calmly, however, i said " dr rc, i sat up all night with these patients doing the absolute best that i could. i was constantly on the phone with the transplant team, with neurosurgery, and even the overnight sicu attending. i can accept that i may not have done everything correctly or how you would have done it, but for you to imply that i ignored these patients because it was my last day here is insulting, and i will not accept that."
i think i was shaking when i finished speaking. there was a long and, you guessed it, awkward pause; no one spoke. fortunately, the transplant team arrived after about 20 seconds and broke the silence. the remainder of rounds was largely uneventful, although i'd guess a bit uncomfortable for everyone. after that, i went home and until now, i haven't thought about that day too much.
Saturday, October 17, 2009
my fifteen minutes
i have successfully completed my tenure in the surgical intensive care unit. overall, it was a positive experience. despite the stress, icu months are always great in that one learns a lot--far more than in other rotations. before i conclude my narrative of said month, i'd like to share a few humorous moments from my current rotation--trauma surgery.
you may remember that i did a month on this same service during my intern year. it is a busy service, but it's not too bad being back there since i am no longer responsible for the intern-level nonsense. my duties this year include seeing and running the traumas that come to the ED. i also spend some time doing general surgery consults on inpatients. the point of EM residents being on this service, so we are told, is to get more experience evaluating and managing trauma patients, although based on my experience so far (2 days) i think the surgery department needs an extra body to help with the high patient load. said another way, they want me to do some of what i did last year. the problem with this is that the intern year trauma rotation was taken out of our curriculum after last year (ie, my class was the last class to be subjected to it) because it was felt to be lacking in educational value for EM residents. the solution was to have us rotate there during our 2nd year and get some actual trauma experience. so far, that hasn't really panned-out, although as i mentioned, i have only been there for 2 days so that may change. as it was last year, there is still too much work for the interns to do and not enough time in which to do it. i've have been helping out, which i am actually enjoying quite a but--much to my surprise. i like having the opportunity to teach and help out; i enjoy the feeling of contributing to the education of other residents and easing the onus of the trauma drudgery that i know so well.
enough of waxing sentimental. the point of the prior introduction was to relate something funny.
so, here goes: last thursday, october 15th, i had the honor of inserting my right index finger into the anus of a pulitzer prize winning author. i no longer remember his/her name, or the name of the work for which said prize was awarded; in fact, i didn't learn about it until after the handshake had taken place. but i suspect that there are not a lot of other people out there who have done the same (as an aside, i will mention that the finger in the anus is part of the head-to-toe exam that all all trauma patients receive).
humorous anecdote #2 comes in the form of a cautionary tale, as follows: it is not a good idea, while lighting the propane furnace in one's trailer-home, to be simultaneously be engaged in the enjoyment of a cigarette. unintentional explosions and fires may result.
"it was chilly inside so i decided it was time to start-up the furnace. i went outside and opened the gas line, then i came back in to light the pilot since the electric starter is busted. i got down on my knees in front of it and the next thing i remember was waking-up in the bedroom [15ft away, according to the husband] with the paramedics and firemen all over"
her husband, who was at home at the time but in another part of the trailer, informed us that just prior to attempting to light the furnace, she had come to him and asked for a newport from the fresh pack he had just opened.
obviously i cannot say exactly how and why the explosion occurred, and i have certainly perpetrated my share of boobery. however, the words "propane furnace" and "smoking" in close proximity to one another sets of numerous alarm-bells, at least in my mind. apparently this is not the case for all.
two hours after she arrived, i went home. i ran 5 miles, took a shower, and i could not rid myself of the smell of burned flesh and singed hair. i had nightmares last night as well.
you may remember that i did a month on this same service during my intern year. it is a busy service, but it's not too bad being back there since i am no longer responsible for the intern-level nonsense. my duties this year include seeing and running the traumas that come to the ED. i also spend some time doing general surgery consults on inpatients. the point of EM residents being on this service, so we are told, is to get more experience evaluating and managing trauma patients, although based on my experience so far (2 days) i think the surgery department needs an extra body to help with the high patient load. said another way, they want me to do some of what i did last year. the problem with this is that the intern year trauma rotation was taken out of our curriculum after last year (ie, my class was the last class to be subjected to it) because it was felt to be lacking in educational value for EM residents. the solution was to have us rotate there during our 2nd year and get some actual trauma experience. so far, that hasn't really panned-out, although as i mentioned, i have only been there for 2 days so that may change. as it was last year, there is still too much work for the interns to do and not enough time in which to do it. i've have been helping out, which i am actually enjoying quite a but--much to my surprise. i like having the opportunity to teach and help out; i enjoy the feeling of contributing to the education of other residents and easing the onus of the trauma drudgery that i know so well.
enough of waxing sentimental. the point of the prior introduction was to relate something funny.
so, here goes: last thursday, october 15th, i had the honor of inserting my right index finger into the anus of a pulitzer prize winning author. i no longer remember his/her name, or the name of the work for which said prize was awarded; in fact, i didn't learn about it until after the handshake had taken place. but i suspect that there are not a lot of other people out there who have done the same (as an aside, i will mention that the finger in the anus is part of the head-to-toe exam that all all trauma patients receive).
humorous anecdote #2 comes in the form of a cautionary tale, as follows: it is not a good idea, while lighting the propane furnace in one's trailer-home, to be simultaneously be engaged in the enjoyment of a cigarette. unintentional explosions and fires may result.
"it was chilly inside so i decided it was time to start-up the furnace. i went outside and opened the gas line, then i came back in to light the pilot since the electric starter is busted. i got down on my knees in front of it and the next thing i remember was waking-up in the bedroom [15ft away, according to the husband] with the paramedics and firemen all over"
her husband, who was at home at the time but in another part of the trailer, informed us that just prior to attempting to light the furnace, she had come to him and asked for a newport from the fresh pack he had just opened.
obviously i cannot say exactly how and why the explosion occurred, and i have certainly perpetrated my share of boobery. however, the words "propane furnace" and "smoking" in close proximity to one another sets of numerous alarm-bells, at least in my mind. apparently this is not the case for all.
two hours after she arrived, i went home. i ran 5 miles, took a shower, and i could not rid myself of the smell of burned flesh and singed hair. i had nightmares last night as well.
Thursday, October 8, 2009
CTD*
continuing with the thread from the previous posts, i herein provide an update on the condition of the unfortunate ms k.
i was on call last night, and she survived. when i left this morning at 11am, her blood pressure was 53/31 and additional medications were being started to augment it. not a positive indicator.
*circling the drain.
i was on call last night, and she survived. when i left this morning at 11am, her blood pressure was 53/31 and additional medications were being started to augment it. not a positive indicator.
*circling the drain.
Wednesday, October 7, 2009
follow-up
continuing on the story from my last post, the meeting between the judge, the conservator, and the doctors occured today. not surprisingly, the outcome was not in the best interest of the patient, in my opinion. he decided that the "best" thing to do was to let the patient's daughter make the decision about changing the goal of care to comfort measures.
this is the same daughter who was been estranged from her mother for more than 10 years. in addition, the mother repeatedly stated, after admission, that she wanted her daugheter to be given no information about her condition, and have no role in any decisions. she lives in california and now we must start the process of trying to contact her, inform her of the situation, etc--this will take days, at best.
meanwhile, the patient is deteriorating: her liver failure is accelerating and now she has begun to bleed--from here nose, mouth, eyes, and IV sites. i doubt she will survive much longer, but i truly cannot see why she should be made to suffer. i cannot understand how a rational and pragmatic person, such as this judge should be, can make a decision like this, which is essentially consigning this woman to die a slow, prolnged death.
this is the same daughter who was been estranged from her mother for more than 10 years. in addition, the mother repeatedly stated, after admission, that she wanted her daugheter to be given no information about her condition, and have no role in any decisions. she lives in california and now we must start the process of trying to contact her, inform her of the situation, etc--this will take days, at best.
meanwhile, the patient is deteriorating: her liver failure is accelerating and now she has begun to bleed--from here nose, mouth, eyes, and IV sites. i doubt she will survive much longer, but i truly cannot see why she should be made to suffer. i cannot understand how a rational and pragmatic person, such as this judge should be, can make a decision like this, which is essentially consigning this woman to die a slow, prolnged death.
Tuesday, October 6, 2009
let's have bizarre celebrations
i currently spend my days toiling away in the SICU (i may return to earlier events later). one of my patients is a 78 year-old woman who has been in the hospital since may. she initially came in as a trauma--according to the ED chart she tried to kick a box of kleenex out of her way and lost her balance and fell. she broke several ribs. being on the older side, and with a few other medical problems, she subsequently developed pneumonia, then sepsis, and things have not gone well for her since then.
skip forward to september. she is still on a ventilator and there is difficulty weaning her. she also has a huge hiatal hernia (meaning her stomach is in her left chest cavity) which is felt to be a possible contributor to this problem, as the left lung is much compressed by her ample stomach. during the surgery to remove the stomach from the chest there was a colon injury, and she wound up with a colectomy and end-colostomy. this is major surgery for anyone, recovery can be slow and is not guaranteed, particularly if one has spent the preceding 3 months septic in an ICU.
where she stands now: she has had repeated episodes of sepsis, is on some serious antibiotics, and her wound is not healing well. in fact, about 7 days ago it fell apart--literally. the skin incision broke open, and a day after that a brown-green liquid--enteric contents, ie, shit--began leaking out her abdomen and mouth. her blood pressure remains low, despite 2 medications that artificially raise it. she makes almost no urine, and her liver is failing. we are doing everything we can for her, yet her condition deteriorates daily. she will never recover from this.
why, you ask, does this continue? where is her family? someone to make her comfort care only and end her suffering? she has none. she is estranged from her only daughter--something about a suicide of a boyfriend the daughter blames the mother for instigating. instead, the patient has a court appointed conservator who gets paid for every day that she spends in the hospital. it takes him three days to call back every time we try to get consent for another procedure. he wants us to do everything we can; shocking.
as i was falling asleep last night, i was thinking of her. no one should have to suffer like that. i was trying to think of ways that i could surreptitiously hasten her demise and not get caught, thereby ending her suffering.
of course i would never actually do this. i unequivically state that i have no intention whatsoever of attempting to harm this patient.
the most execrable part of this whole situation is not that i had this passing thought, but that a system has been set up that allows her conservator to financially benefit from his malfeasance (read, inaction) while her condition progresses to such a lurid extreme.
skip forward to september. she is still on a ventilator and there is difficulty weaning her. she also has a huge hiatal hernia (meaning her stomach is in her left chest cavity) which is felt to be a possible contributor to this problem, as the left lung is much compressed by her ample stomach. during the surgery to remove the stomach from the chest there was a colon injury, and she wound up with a colectomy and end-colostomy. this is major surgery for anyone, recovery can be slow and is not guaranteed, particularly if one has spent the preceding 3 months septic in an ICU.
where she stands now: she has had repeated episodes of sepsis, is on some serious antibiotics, and her wound is not healing well. in fact, about 7 days ago it fell apart--literally. the skin incision broke open, and a day after that a brown-green liquid--enteric contents, ie, shit--began leaking out her abdomen and mouth. her blood pressure remains low, despite 2 medications that artificially raise it. she makes almost no urine, and her liver is failing. we are doing everything we can for her, yet her condition deteriorates daily. she will never recover from this.
why, you ask, does this continue? where is her family? someone to make her comfort care only and end her suffering? she has none. she is estranged from her only daughter--something about a suicide of a boyfriend the daughter blames the mother for instigating. instead, the patient has a court appointed conservator who gets paid for every day that she spends in the hospital. it takes him three days to call back every time we try to get consent for another procedure. he wants us to do everything we can; shocking.
as i was falling asleep last night, i was thinking of her. no one should have to suffer like that. i was trying to think of ways that i could surreptitiously hasten her demise and not get caught, thereby ending her suffering.
of course i would never actually do this. i unequivically state that i have no intention whatsoever of attempting to harm this patient.
the most execrable part of this whole situation is not that i had this passing thought, but that a system has been set up that allows her conservator to financially benefit from his malfeasance (read, inaction) while her condition progresses to such a lurid extreme.
how embarassing
several days ago i included a factoid at the end of a post about the success rate of cpr on television shows. the numbers i quoted, were, in fact, incorrect. the correct data is as follows: the success rate for immediate return of circulation was 79%, and survival to discharge was 67%.
the prior post has been addended to reflect the knowledge of said error.
i sincerely regret the error.
yours &c.,
SC
the prior post has been addended to reflect the knowledge of said error.
i sincerely regret the error.
yours &c.,
SC
Saturday, October 3, 2009
side effects may include...
this is one of my favorite bits from the colbert report. the funniest stuff starts around the 2:15 mark.
watch me!
watch me!
why do i have to be mr pink?
my, my, how time slips away. i was just looking back at my last post, which detailed the close of my intern year, and now here i am nearly 25% through my 2nd year. yikes. i'd like not to skip any of the wonderful experiences i've had, but it seems as though i just can't keep up. so now i will quickly summarize the end of my first year and the first few months of this year.
end of the year as an intern, orthopedics and back-up:
basically, during this month we are supposed to go to work from about noon until 8pm with the ED ortho consult resident. i think the goal is to learn basic management principles of orthopedic injuries and how to apply splints and casts. i say "think" because i'm only guessing what they want us to learn because i never actually went. not once. it was the end of a tough year and i needed some time to decompress. you only work with other residents so no one really knows if you are there or not--the ortho resident is usually very busy and my guess is that they don't really care if you are there or not. there was a little scare for me after the fact--apparently, part of this month was supposed to include a few afternoons in an outpatient ortho clinic. i actually didn't know this, so of course i didn't go (nor did 11 of 13 residents in my class, since they didn't know about it either). essentially, my program director asked me if i went and i told the truth, stating that i had not attended because i didn't know about it. i got scolded a little, was told to pay closer attention to the rotation requirements, and sent on my way. phew.
i also got called-in to work 3 shifts in the ED for back-up, meaning someone else called-in sick so they needed someone. that someone was me. not too bad to have to work 3 out of 28 days; plus, the residency now "owes" me 3 shifts, meaning that i get to work 3 fewer shifts this year in return for the 3 i worked this month.
what did i do with all my free time? i did a lot of pleasure reading, i got back in shape, lost 15 lbs, drank a lot of wine, and did lots of bike riding (i even won a race and brought home $200 dollars). all much more rewarding than splinting some broken bones (i should mention that i have done a good deal of splinting in my time as a resident, and am fairly adept at it, so i don't think i really missed any great opportunity).
exit intern year.
HOORAY!
2nd year, block 1: pediatric intensive care (PICU)
not such a bad month. it was pretty slow when i was there, so i generally had only 2-3 patients at a time. kids don't generally get that sick, so often (not always) kids get admitted to the PICU for higher-level nursing needs rather than because they are really sick (eg, frequent vital sign monitoring). this month also required being on-call every 4th night, which as an ED physician, i naturally eschew. i think that i slept at least 5 hours on each call night except 1, so on the whole, not so bad.
i learned a fair amount--largely due to the amount of reading i did during the slow call nights--including the fact that it is somewhat more sad when a child dies than when an adult dies. i also saw a good number of children with rare genetic disorders and bizarre deformations. there was a lot of stuff i had read about in medical school but never actually seen first-hand: rocker-bottom feet, dandy-walker syndrome, poly-dactyly, and cri-du-chat (yes, they really make a cat-like sound). this was both interesting and depressing.
the disappointing portion of this month was that there are no interns in the PICU, so i was left to do all the degrading intern-level work: pre-rounding, writing notes, making pointless phone calls, etc. wasn't this kind of thing supposed to have been completed last year? fortunately, given the low patient volume, there was not enough of this work to make it truly ignominous.
2nd year, block 2-4: ems, pediatric ED, surgical intensive care.
i'm in the SICU right now, and am on-call tomorrow, and every third night thereafter. egad. thus, there is not much time for ranting these days. but my goal is to churn out at least 1-2 malevolent soliloquies each week going forward. i'm cautiously optimistic about this goal, but we shall see.
to close, an interesting fact: a study published in the new england journal of medicine in the late 1990s found that on TV shows, the success rate for the immediate success of CPR was 67% and survival to discharge was 93%.**
**the above quoted numbers are incorrect; for the corrected data, please see the posting dated 3, october, 2009.
end of the year as an intern, orthopedics and back-up:
basically, during this month we are supposed to go to work from about noon until 8pm with the ED ortho consult resident. i think the goal is to learn basic management principles of orthopedic injuries and how to apply splints and casts. i say "think" because i'm only guessing what they want us to learn because i never actually went. not once. it was the end of a tough year and i needed some time to decompress. you only work with other residents so no one really knows if you are there or not--the ortho resident is usually very busy and my guess is that they don't really care if you are there or not. there was a little scare for me after the fact--apparently, part of this month was supposed to include a few afternoons in an outpatient ortho clinic. i actually didn't know this, so of course i didn't go (nor did 11 of 13 residents in my class, since they didn't know about it either). essentially, my program director asked me if i went and i told the truth, stating that i had not attended because i didn't know about it. i got scolded a little, was told to pay closer attention to the rotation requirements, and sent on my way. phew.
i also got called-in to work 3 shifts in the ED for back-up, meaning someone else called-in sick so they needed someone. that someone was me. not too bad to have to work 3 out of 28 days; plus, the residency now "owes" me 3 shifts, meaning that i get to work 3 fewer shifts this year in return for the 3 i worked this month.
what did i do with all my free time? i did a lot of pleasure reading, i got back in shape, lost 15 lbs, drank a lot of wine, and did lots of bike riding (i even won a race and brought home $200 dollars). all much more rewarding than splinting some broken bones (i should mention that i have done a good deal of splinting in my time as a resident, and am fairly adept at it, so i don't think i really missed any great opportunity).
exit intern year.
HOORAY!2nd year, block 1: pediatric intensive care (PICU)
not such a bad month. it was pretty slow when i was there, so i generally had only 2-3 patients at a time. kids don't generally get that sick, so often (not always) kids get admitted to the PICU for higher-level nursing needs rather than because they are really sick (eg, frequent vital sign monitoring). this month also required being on-call every 4th night, which as an ED physician, i naturally eschew. i think that i slept at least 5 hours on each call night except 1, so on the whole, not so bad.
i learned a fair amount--largely due to the amount of reading i did during the slow call nights--including the fact that it is somewhat more sad when a child dies than when an adult dies. i also saw a good number of children with rare genetic disorders and bizarre deformations. there was a lot of stuff i had read about in medical school but never actually seen first-hand: rocker-bottom feet, dandy-walker syndrome, poly-dactyly, and cri-du-chat (yes, they really make a cat-like sound). this was both interesting and depressing.
the disappointing portion of this month was that there are no interns in the PICU, so i was left to do all the degrading intern-level work: pre-rounding, writing notes, making pointless phone calls, etc. wasn't this kind of thing supposed to have been completed last year? fortunately, given the low patient volume, there was not enough of this work to make it truly ignominous.
2nd year, block 2-4: ems, pediatric ED, surgical intensive care.
i'm in the SICU right now, and am on-call tomorrow, and every third night thereafter. egad. thus, there is not much time for ranting these days. but my goal is to churn out at least 1-2 malevolent soliloquies each week going forward. i'm cautiously optimistic about this goal, but we shall see.
to close, an interesting fact: a study published in the new england journal of medicine in the late 1990s found that on TV shows, the success rate for the immediate success of CPR was 67% and survival to discharge was 93%.**
**the above quoted numbers are incorrect; for the corrected data, please see the posting dated 3, october, 2009.
Wednesday, August 12, 2009
nihilists with good imaginations
with trauma behind me i headed back to the ED for my last month there as an intern. hooray. not much changed--it was still busy, dirty, loud, crowded, and understaffed. on a positive note, i was more confident and competent which improved the whole experience.
i think that the biggest difference that i noticed between my last month in the ED and my first month was my comfort level with the amount of work that existed and realizing that there was only so many things i could do at one time. the result of this is that some tasks get completed immediately, and others get postponed. what gets done when depends on multiple factors, but essentially it comes down to how many personal tasks i have to complete at any given time. thus the birth of the absurdly long ED visit. if i have 15 things to do, the non-critical tasks get put at the back of the line; this might include discharging patients, or informing them of "normal" or "negative" test results. this is important information to deliver, but doesn't command the same immediate attention that the 55 year-old man vomiting blood does. repeat this situation 10 times an hour over 12 hours and you can begin to see why the ED can seem like the 5th circle of hell.
anyway, the aforementioned difference i noticed was, stated simply, knowing that the work would never be completed, that there would always be a steady flow of patients and tasks over the course of a shift. as a result, there will likely never be a "good time" take a break and eat lunch, go to the bathroom, etc. previously, i had been overwhelmed with the feeling of being behind and a need to get everything done, right away; not having it done, and having more work piling up was demoralizing and filled me with a sense of dread. i now know that this is the way it will always be; rather than fighting it, i work withing the system. i triage my task lists, and put off non-essential activities (of note, eating and going to the little-boys room are not, "non-essential") and i don't obsess about what i'm not doing; this is the way it has to be. i would say that this increased my happiness by at least 50%.
****
some of the interesting patients from the month:
-a 22 year old with a blood alcohol level of 660 (the legal limit 80), the highest i've ever seen
-a woman with chronic pain and traumatic brain injury resulting from a sno-cone machine falling on her head; she threatened to kill me when i suggested she try a medication other than morphine
-an "ex-marine" threatened to kill me when i told him i would not give him a prescription for percocet. he wasn't really a marine; it turned out that he stole the jacket from someone at the homeless shelter. he stopped being my problem after he pissed-himself and then slipped and fell in the pool of urine that had accumulated under his bed--he was escorted out by security after accusing me, rather loudly, of putting the urine their myself.
-i tried to do a spinal tap on a 350 pound mentally retarded man with HIV. his guardian consented and then inexplicably left the room halfway through the procedure despite my protestations. the man began to scream and gyrate and he then attempted to roll-over onto his back. knowing that this was an important test i did my best to continue--at one point, i had my shoulder pressed into his back in an effort to keep him on his side. however, i soon decided that having the 3 inch needle (that was in his back) pierce a vital organ or my hand were not good options, so i stopped.
i think that the biggest difference that i noticed between my last month in the ED and my first month was my comfort level with the amount of work that existed and realizing that there was only so many things i could do at one time. the result of this is that some tasks get completed immediately, and others get postponed. what gets done when depends on multiple factors, but essentially it comes down to how many personal tasks i have to complete at any given time. thus the birth of the absurdly long ED visit. if i have 15 things to do, the non-critical tasks get put at the back of the line; this might include discharging patients, or informing them of "normal" or "negative" test results. this is important information to deliver, but doesn't command the same immediate attention that the 55 year-old man vomiting blood does. repeat this situation 10 times an hour over 12 hours and you can begin to see why the ED can seem like the 5th circle of hell.
anyway, the aforementioned difference i noticed was, stated simply, knowing that the work would never be completed, that there would always be a steady flow of patients and tasks over the course of a shift. as a result, there will likely never be a "good time" take a break and eat lunch, go to the bathroom, etc. previously, i had been overwhelmed with the feeling of being behind and a need to get everything done, right away; not having it done, and having more work piling up was demoralizing and filled me with a sense of dread. i now know that this is the way it will always be; rather than fighting it, i work withing the system. i triage my task lists, and put off non-essential activities (of note, eating and going to the little-boys room are not, "non-essential") and i don't obsess about what i'm not doing; this is the way it has to be. i would say that this increased my happiness by at least 50%.
****
some of the interesting patients from the month:
-a 22 year old with a blood alcohol level of 660 (the legal limit 80), the highest i've ever seen
-a woman with chronic pain and traumatic brain injury resulting from a sno-cone machine falling on her head; she threatened to kill me when i suggested she try a medication other than morphine
-an "ex-marine" threatened to kill me when i told him i would not give him a prescription for percocet. he wasn't really a marine; it turned out that he stole the jacket from someone at the homeless shelter. he stopped being my problem after he pissed-himself and then slipped and fell in the pool of urine that had accumulated under his bed--he was escorted out by security after accusing me, rather loudly, of putting the urine their myself.
-i tried to do a spinal tap on a 350 pound mentally retarded man with HIV. his guardian consented and then inexplicably left the room halfway through the procedure despite my protestations. the man began to scream and gyrate and he then attempted to roll-over onto his back. knowing that this was an important test i did my best to continue--at one point, i had my shoulder pressed into his back in an effort to keep him on his side. however, i soon decided that having the 3 inch needle (that was in his back) pierce a vital organ or my hand were not good options, so i stopped.
Sunday, August 9, 2009
pity this busy monster, manunkind
as i was saying, my month on trauma wasn't too bad--certainly far less painful than described by the ED interns who preceded me. i certainly wouldn't want to have been there for more than a month, but i can handle pretty much anything for a month. this brief return to the world of surgery (recall that i began my medical career as a surgical resident) confirmed a few things for me: first, being a surgeon is a fascinating job; you get to do all sorts of crazy stuff to people. there is no other job like it in the world. second, however engaging the job is, you really have to enjoy it, because it becomes their life. i worked 13+ hours a day (more on that later), with only 4 days off a month. i felt like i was always at work. contrast this with the 18 12hr shifts i work in the ED--that gives me 10 days off per month (that increases to 12 as a pgy-2)!
furthermore, as surgical residents become more senior, hours worked do not decrease--in fact, they may increase. granted they are in the OR more, meaning less humiliating grunt work, but regardless, there is little time in the surgeon's life for anything other than surgery. if one wants that great--i actually believe that type of single-mindedness makes for strong surgeons--but pity fool who thinks one can be a surgeon and have an active life outside the hospital; i should know, i tried.
enough proselytizing...i survived, and i actually enjoyed my month, but i am happy about my current situation as an EM resident.
back to those 13 hour days: as i said, it was very busy from 6am until 10-1030am with rounds, calling consults, ordering tests, etc. from 11am-1pm i would work on discharging people--dictations, prescriptions, etc--and then lunch time. the period from 2pm-5pm was generally very slow for the trauma service: generally, not a lot of traumas arrive in the ED during these hours (unless it's a weekend), imaging studies ordered earlier in the day are yet to be completed, and the discharges are frequently "waiting for a ride home."
what to do with these 3 hours? being an industrious lad, i decided to use it to build my fund of knowledge--that is to say, i set out to read, to learn more medicine during this time. where to read? well, sitting at the nurses station on the surgery floor was out of the questions, since one quickly learns that if nurses can physically see you, they will ask you to do something. since i prefer quiet, i opted to read in the call room (the place that one desperately tries to reach for a few hours of sleep when on-call). so, seminal ED articles in hand, i trudged off to the call room for some quality learning...
it wasn't long before the early mornings got the better of me and i drifted off to sleep. i was rudely awakened by my pager--another inane request from a nurse, no doubt, nothing i couldn't address quickly and still easily return to slumber.
i felt guilty about this for 2 days, until i realized that it was not the horrible transgression it initially appeared to be. as long as all my work was done, did it matter what i was doing? as far as patient care is concerned, i was still reachable by pager; whether i was sleeping or talking to a patient on another floor, or in radiology with an unstable new admit was irrelevant, as long as i promptly returned pages, and handled them appropriately. problem solved!
i think that i averaged 1.5-2hrs of sleep per afternoon, occasionally getting up to 3 ( i should also note the fact that my presence not being necessary for stretches up to 3 hours was a testament to the lowly nature of the work i was being asked to do)! what a difference that made.
i would emerge well rested at 5pm, and immediately set to work getting ready for evening sign-out, which took place at 630pm. my tasks for this 90 minute stretch included following-up any labs and/or imaging studies from the morning, updating the patient list, making sure labs were ordered for the next morning, and my favorite activity, making sure that the patients i had discharged had physically left the hospital.
i know this sounds ridiculous, but you would be surprised by how many people actively try not to leave once they have been discharged. regardless of the amount and ferocity of abuse they hurl upon you every day when you tell them they cannot go home that day, as soon as they are told that they can leave, there are suddenly 101 things keeping them in their room. no ride, no house keys, no cab/bus fare, no money in general, new symptoms (usually pain), fear of gang retribution, no clothes, "i'm just not ready yet", "you don't care about me", "you just need this room for someone else", etc. did i mention the fact that most of these people are degenerate alcoholics?
so i would rush around for those 90 minutes, tie-up loose ends, and arrive at evening sign-out refreshed and ready to go home.
a few weeks after the rotation ended and i was back in the ED, my program director approached me during a shift and informed me that i was well-liked by the trauma service and that a trauma attending even went as far as to tell her that i was the best ED intern they had had in a long time. i mention this not to inflate my ego, but rather to point out that stellar performance is not incompatible with afternoon napping.
furthermore, as surgical residents become more senior, hours worked do not decrease--in fact, they may increase. granted they are in the OR more, meaning less humiliating grunt work, but regardless, there is little time in the surgeon's life for anything other than surgery. if one wants that great--i actually believe that type of single-mindedness makes for strong surgeons--but pity fool who thinks one can be a surgeon and have an active life outside the hospital; i should know, i tried.
enough proselytizing...i survived, and i actually enjoyed my month, but i am happy about my current situation as an EM resident.
back to those 13 hour days: as i said, it was very busy from 6am until 10-1030am with rounds, calling consults, ordering tests, etc. from 11am-1pm i would work on discharging people--dictations, prescriptions, etc--and then lunch time. the period from 2pm-5pm was generally very slow for the trauma service: generally, not a lot of traumas arrive in the ED during these hours (unless it's a weekend), imaging studies ordered earlier in the day are yet to be completed, and the discharges are frequently "waiting for a ride home."
what to do with these 3 hours? being an industrious lad, i decided to use it to build my fund of knowledge--that is to say, i set out to read, to learn more medicine during this time. where to read? well, sitting at the nurses station on the surgery floor was out of the questions, since one quickly learns that if nurses can physically see you, they will ask you to do something. since i prefer quiet, i opted to read in the call room (the place that one desperately tries to reach for a few hours of sleep when on-call). so, seminal ED articles in hand, i trudged off to the call room for some quality learning...
it wasn't long before the early mornings got the better of me and i drifted off to sleep. i was rudely awakened by my pager--another inane request from a nurse, no doubt, nothing i couldn't address quickly and still easily return to slumber.
i felt guilty about this for 2 days, until i realized that it was not the horrible transgression it initially appeared to be. as long as all my work was done, did it matter what i was doing? as far as patient care is concerned, i was still reachable by pager; whether i was sleeping or talking to a patient on another floor, or in radiology with an unstable new admit was irrelevant, as long as i promptly returned pages, and handled them appropriately. problem solved!
i think that i averaged 1.5-2hrs of sleep per afternoon, occasionally getting up to 3 ( i should also note the fact that my presence not being necessary for stretches up to 3 hours was a testament to the lowly nature of the work i was being asked to do)! what a difference that made.
i would emerge well rested at 5pm, and immediately set to work getting ready for evening sign-out, which took place at 630pm. my tasks for this 90 minute stretch included following-up any labs and/or imaging studies from the morning, updating the patient list, making sure labs were ordered for the next morning, and my favorite activity, making sure that the patients i had discharged had physically left the hospital.
i know this sounds ridiculous, but you would be surprised by how many people actively try not to leave once they have been discharged. regardless of the amount and ferocity of abuse they hurl upon you every day when you tell them they cannot go home that day, as soon as they are told that they can leave, there are suddenly 101 things keeping them in their room. no ride, no house keys, no cab/bus fare, no money in general, new symptoms (usually pain), fear of gang retribution, no clothes, "i'm just not ready yet", "you don't care about me", "you just need this room for someone else", etc. did i mention the fact that most of these people are degenerate alcoholics?
so i would rush around for those 90 minutes, tie-up loose ends, and arrive at evening sign-out refreshed and ready to go home.
a few weeks after the rotation ended and i was back in the ED, my program director approached me during a shift and informed me that i was well-liked by the trauma service and that a trauma attending even went as far as to tell her that i was the best ED intern they had had in a long time. i mention this not to inflate my ego, but rather to point out that stellar performance is not incompatible with afternoon napping.
Friday, August 7, 2009
flight of the phoenix.
wow. 3+ months since i was last here. time flies, i guess. what happened was that first i got busy--a month of trauma surgery--and then i got lazy. in actuality, the trauma month wasn't that bad. it did involve getting to work very early (6am...ok, not that early) in order to "see" all the trauma patients; then there was a flurry of work with rounds, etc., until about 1030-11am, and then things would generally calm down.
the trauma service can be very busy--it seems that degenerate, sociopathic, alcoholics often do things like fall down stairs, drive their cars into bridge abutments, etc.--so there may be 20-30 patients on the service. rounds are at 715am, and in theory the intern is supposed to have seen all the patients by that time. some quick math would reveal that, at 5 minutes a patient (a conservative estimate since in those 5 minutes you have to, track down flow-sheets, write down vitals, talk to and examine a person, listen to their whining...; not to mention the walking all over the hospital to see people on different floors), this would take 100 minutes. that would require getting to work at 530am, not horrible. did i mention that they also wanted your notes written prior to rounds? adding another 5 minutes per person and i'm arriving at 4am. when the service swells to 30, as it often does in warmer months (apparently warm weather and sunshine is a catalyst for idiotic behavior), one would have to arrive at 3am!
but then there is the 80 hour work week limit, and it's not hard to see that if one arrives at 4am and goes home at 7pm, it's hard to adhere to this. the solution is that the official policy is that one is not to arrive prior to 6am. but it's still expected that all the aforementioned work is complete. if that sounds dubious, you are right, it is. this issue is handled basically in 3 different ways: 1--some people actually arrive at 4am in order to get all the work done and then lie about it. 2--others will arrive at 6am, do as much as they can, although they never are really close to getting it all done, and then freely admit it; attendings cannot be openly angry since that is the official policy.
3--still others (including me) will arrive at 6, collect the necessary data, and see only certain patients (this depends on multiple factors, such as how sick they are, what happened overnight, etc.), and talk to the nurses quickly about any acute events. thus armed, these people can then pre-round on the entire service in the 75 minutes allowed and when it comes time to round with the entire team, it appears that you have pre-rounded on everyone. this leaves the attendings happy, and the intern looks like a hero (ok, maybe not a hero, but at least not like an incompetent slob).
i never outright lied about having physically seen a patient that morning or said i did something that i hadn't; i did dissemble, but there is a difference. the other thing i never did was say that i had arrived earlier than 6am (which i hadn't); and i never complained about hours, the patient load, etc. no one likes that. if you complain you get labeled as such, and it will stick with you for the rest of your resident-years; obviously as an ED resident i will be calling the surgery residents quite often and therefore i want a good working relationship. what you want most of all is to keep everyone happy (including oneself), and make it look like things are not as miserable as they really are. how did i accomplished this? i came to work at 6am and busted my ass for 75 minutes. i did only what was absolutely necessary during that time so that on rounds i was ready with the essentials, and because of this, it appeared that i had done everything. i eventually did all the requisite tasks, but some things do not need to be done at 6am. the attendings were happy, they respected me since i never complained, and the work environment was far more pleasant.
the ED intern who followed me did not heed this advice. he complained about the hours, the amount of work he was expected to do in limited time; he never used my strategy of doing enough in order to give the appearance that you had done it all. the month did not go well for him. i was working in the ED the next month and saw he getting screamed at by a chief resident and an attending on 3 separate occasions. there were meetings with our program director, the trauma surgery chief, in addition to daily battles and complaints about this or that. no everyone from surgery dislikes him, and i suspect there is some discontent in our department as well.
there is a time and a place to complain; this was not it. one always must pick which battles to fight; sometimes, especially as an intern, you have to suck it up and do the things that suck and not complain about it. i freely admit that as an ED resident my hours aren't that bad, particularly compared to those of a surgeon, and especially surgeons who trained prior to the 80 hour limit. complaining in that circumstance is asking for trouble. he got it.
the trauma service can be very busy--it seems that degenerate, sociopathic, alcoholics often do things like fall down stairs, drive their cars into bridge abutments, etc.--so there may be 20-30 patients on the service. rounds are at 715am, and in theory the intern is supposed to have seen all the patients by that time. some quick math would reveal that, at 5 minutes a patient (a conservative estimate since in those 5 minutes you have to, track down flow-sheets, write down vitals, talk to and examine a person, listen to their whining...; not to mention the walking all over the hospital to see people on different floors), this would take 100 minutes. that would require getting to work at 530am, not horrible. did i mention that they also wanted your notes written prior to rounds? adding another 5 minutes per person and i'm arriving at 4am. when the service swells to 30, as it often does in warmer months (apparently warm weather and sunshine is a catalyst for idiotic behavior), one would have to arrive at 3am!
but then there is the 80 hour work week limit, and it's not hard to see that if one arrives at 4am and goes home at 7pm, it's hard to adhere to this. the solution is that the official policy is that one is not to arrive prior to 6am. but it's still expected that all the aforementioned work is complete. if that sounds dubious, you are right, it is. this issue is handled basically in 3 different ways: 1--some people actually arrive at 4am in order to get all the work done and then lie about it. 2--others will arrive at 6am, do as much as they can, although they never are really close to getting it all done, and then freely admit it; attendings cannot be openly angry since that is the official policy.
3--still others (including me) will arrive at 6, collect the necessary data, and see only certain patients (this depends on multiple factors, such as how sick they are, what happened overnight, etc.), and talk to the nurses quickly about any acute events. thus armed, these people can then pre-round on the entire service in the 75 minutes allowed and when it comes time to round with the entire team, it appears that you have pre-rounded on everyone. this leaves the attendings happy, and the intern looks like a hero (ok, maybe not a hero, but at least not like an incompetent slob).
i never outright lied about having physically seen a patient that morning or said i did something that i hadn't; i did dissemble, but there is a difference. the other thing i never did was say that i had arrived earlier than 6am (which i hadn't); and i never complained about hours, the patient load, etc. no one likes that. if you complain you get labeled as such, and it will stick with you for the rest of your resident-years; obviously as an ED resident i will be calling the surgery residents quite often and therefore i want a good working relationship. what you want most of all is to keep everyone happy (including oneself), and make it look like things are not as miserable as they really are. how did i accomplished this? i came to work at 6am and busted my ass for 75 minutes. i did only what was absolutely necessary during that time so that on rounds i was ready with the essentials, and because of this, it appeared that i had done everything. i eventually did all the requisite tasks, but some things do not need to be done at 6am. the attendings were happy, they respected me since i never complained, and the work environment was far more pleasant.
the ED intern who followed me did not heed this advice. he complained about the hours, the amount of work he was expected to do in limited time; he never used my strategy of doing enough in order to give the appearance that you had done it all. the month did not go well for him. i was working in the ED the next month and saw he getting screamed at by a chief resident and an attending on 3 separate occasions. there were meetings with our program director, the trauma surgery chief, in addition to daily battles and complaints about this or that. no everyone from surgery dislikes him, and i suspect there is some discontent in our department as well.
there is a time and a place to complain; this was not it. one always must pick which battles to fight; sometimes, especially as an intern, you have to suck it up and do the things that suck and not complain about it. i freely admit that as an ED resident my hours aren't that bad, particularly compared to those of a surgeon, and especially surgeons who trained prior to the 80 hour limit. complaining in that circumstance is asking for trouble. he got it.
Friday, March 13, 2009
i tie my nose with a spandex hose before i get a drink
wow...nearly 2 weeks have elapsed since my last rant. how much has changed! well, ok, not really much has changed, but it's nice to pretend sometimes.
allow me to summarize what has transpired since march 1: i finished my stint in the ccu and with that my 2nd call month in a row--hooray! as i recall, my last days there were mostly uneventful. i became ill rather suddenly on saturday--congestion, runny nose, copious sneezing--which in the end worked out well for me since because i looked so infirmed everyone insisted that i go home early. i spent the rest of the day on the couch feeling rather horrendous. much to my surprise, by sunday morning i was feeling nearly normal; perhaps my shortest cold ever?
i was on-call on my last day, which can be terrible, since it means that you might have to work overnight and then get up the following morning and go to whatever service you switch to. i was lucky in that i went to an ED month and was not working the next day so it turned into an afternoon off. call was rather uneventful from a medical standpoint. i did, however, get a piece of bad news from a friend. it seems that he overheard some nurses discussing an intern who was particularly cantankerous when returning phone calls at night. you, dear reader, can probably guess the identity of said grouch. yes, it was in fact one s. crtiwick. that designation is probably deserved; so it goes. once i heard this bit of info, i tried to be more patient, although that didn't last too long. i will not turn this post into another rant about nursing staff, so that is all i have to say on that subject.
i moved back to the ED after that, a move about which i was quite excited. none of the 4 shifts that worked before going on vacation--where i am now--were particularly exciting, much to my chagrin, despite working overnight on friday, and saturday. here are some of the highlights (or lowlights): a heated argument with an attending that started as a discussion about evidence-based medicine and degenerated substantially, particularly after it became clear that said attending did not know the definition (literally) of the word "semantic." i was sprayed with purulent urine while helping an attending change a suprapubic foley catheter. i was then verbally abused by this same patient and his wife who returned 3 days later when the replacement catheter fell out, blaming me, even though i hadn't actually played any role in the prior changing--i basically watched--and was asked several times if i was a "real doctor." i insisted that i was, even going so far as to show my ID badge with the illustrious "MD" after my name (although i made sure to keep my thumb over part of my name in hopes that she might not be able to later identify me by name--not that anything improper was done, but more because i don't want these two idiots bad-mouthing me for something that was a minor issue, and nobody's fault in the first place.
to end on a positive note, i did see 2 cardiac patients, and being fresh out of the ccu, i was all over them like stink on a monkey. that was satisfying.
***************
"I want you to look me in my eyes; I haven’t slept a peaceful night in more than seventeen years. I am incapable of human connection. I am constantly in danger of drifting into total mental oblivion. These eyes, they looked upon the earth and saw an inconsequential particle in an incomprehensible, infinite universe. You think the Jets have a shot this season? I walked on the fucking moon. Thanks for the drink”
- Neil Armstrong
allow me to summarize what has transpired since march 1: i finished my stint in the ccu and with that my 2nd call month in a row--hooray! as i recall, my last days there were mostly uneventful. i became ill rather suddenly on saturday--congestion, runny nose, copious sneezing--which in the end worked out well for me since because i looked so infirmed everyone insisted that i go home early. i spent the rest of the day on the couch feeling rather horrendous. much to my surprise, by sunday morning i was feeling nearly normal; perhaps my shortest cold ever?
i was on-call on my last day, which can be terrible, since it means that you might have to work overnight and then get up the following morning and go to whatever service you switch to. i was lucky in that i went to an ED month and was not working the next day so it turned into an afternoon off. call was rather uneventful from a medical standpoint. i did, however, get a piece of bad news from a friend. it seems that he overheard some nurses discussing an intern who was particularly cantankerous when returning phone calls at night. you, dear reader, can probably guess the identity of said grouch. yes, it was in fact one s. crtiwick. that designation is probably deserved; so it goes. once i heard this bit of info, i tried to be more patient, although that didn't last too long. i will not turn this post into another rant about nursing staff, so that is all i have to say on that subject.
i moved back to the ED after that, a move about which i was quite excited. none of the 4 shifts that worked before going on vacation--where i am now--were particularly exciting, much to my chagrin, despite working overnight on friday, and saturday. here are some of the highlights (or lowlights): a heated argument with an attending that started as a discussion about evidence-based medicine and degenerated substantially, particularly after it became clear that said attending did not know the definition (literally) of the word "semantic." i was sprayed with purulent urine while helping an attending change a suprapubic foley catheter. i was then verbally abused by this same patient and his wife who returned 3 days later when the replacement catheter fell out, blaming me, even though i hadn't actually played any role in the prior changing--i basically watched--and was asked several times if i was a "real doctor." i insisted that i was, even going so far as to show my ID badge with the illustrious "MD" after my name (although i made sure to keep my thumb over part of my name in hopes that she might not be able to later identify me by name--not that anything improper was done, but more because i don't want these two idiots bad-mouthing me for something that was a minor issue, and nobody's fault in the first place.
to end on a positive note, i did see 2 cardiac patients, and being fresh out of the ccu, i was all over them like stink on a monkey. that was satisfying.
***************
"I want you to look me in my eyes; I haven’t slept a peaceful night in more than seventeen years. I am incapable of human connection. I am constantly in danger of drifting into total mental oblivion. These eyes, they looked upon the earth and saw an inconsequential particle in an incomprehensible, infinite universe. You think the Jets have a shot this season? I walked on the fucking moon. Thanks for the drink”
- Neil Armstrong
Sunday, March 1, 2009
the end is near!
yes, that's right, the end is near. the end of my 2 contiguous months of call--a 54 day stretch of being on call every 4th night. i am happy for many reasons, not the least of which is because in another week i will be on vacation. i have to work approximately another 24hrs in the ccu, and then it's back to ED town! hooray.
the last week has been pretty tough; i've been sick, first with a virus and now what i believe to be a bacterial infection that is rapidly progressing to a sinus infection. try staying awake for 30 hours straight and making decisions that could change someone's life while you have the sensation of having an icepick driven into your forehead; not so nice. it's also difficult to get better when you get so little sleep. my call days have also been tougher for the past week as well--sicker, more complicated patients. what this means is that it takes more time to figure out what is going on, and it also means i have to spend more time with that patient because their situation is more tenuous. yes, these cases are often more interesting, more fun, and i certainly learn a great deal, but it is also very physically and mentally demanding. getting 2 such patients in a day is one thing, but try 4, and that's something else all together. furthermore, when i am on call, i not only admit new patients, but i also take care of the old ones; and once the other team goes home, i deal with all of their patients.
so at 1045pm last thursday, i have 6 old patients, 4 new ones--2 of which i have yet to see--and i'm covering 15 patients from the rest of the ccu team; that is a lot of sick people. i'm sitting in the ccu, trying not to let snot drip onto a patient chart, calculating that if nothing major happens that i can be in bed by 1am, when the code pager goes off. a "code" is short for "code blue," which means that someone has been found unresponsive, ie, they are dying or dead, although about 20% of the time it's something totally bogus and a code was called simply because it's a great way to get lots of people to come and help very quickly. the on call ccu team is the primary code team--this means that they run the show. specifically, the ccu senior resident "runs" the code--he/she is on charge and tells everyone else what to do. as one might imagine, a code code can be quite teh clusterfuck. there are usually more people in the room than necessary which can create spatial problems, in addition to organizational and procedural ones. this is why the ccu senior is in charge; it is vital to have one person in command during this type of incident. the ccu intern (me) does physical tasks for the patient such as cpr, and procedures (eg, putting in lines, etc).
this was the second code of the day. we arrived and heard a few quick words about the patient--one of the most salient details was that he was hiv positive. i feel a bit guilty saying that, but a code is extremely chaotic, with many pointy objects and plenty of opportunity for needle-sticks. i've seen this happen three times this year during codes. the dangerous part is not necessarily what you are doing, but what the person next to you might be doing. trust me, it can be frightening.
this patient already had a central line (large IV) in his neck--this is important to know because one of the first tasks that needs to be accomplished it establishing IV access in order to get blood and give medications. IV access in place, i went to work with chest compressions. cpr looks and sounds easy, but it is quite tiring. the other thing that many people don't realize is that it's fairly common for a patient to suffer rib fractures during cpr, since studies have shown that the depth and rate of chest compressions are what lead to the best outcomes, meaning that there are many over-zealous chest-compressors out there.
this gentleman was quite small and thin and i am rather tall and large. i don't remember what his main illness was, but he was cachectic [cachexia ca·chex·i·a (kÉ™-kÄ›k'sÄ“-É™) n.Weight loss, wasting of muscle, loss of appetite, and general debility that can occur during a chronic disease.], and i could feel ribs crunching with every compression of his tiny chest. he was initially pulseless, but after about 20 minutes we brought him back; he also received a surgical airway--his mouth was clenched shut so he couldn't be intubated so instead, a hole was cut in his neck through which a breathing tube was inserted. off to the micu he went. i learned the next morning that he died about 4 hours after we brought him in.
participating in a code is actually rather fun; it is stressful but exhilarating. i enjoy the rapid pace at which one if forced to think and act. the downside is that once the code ends you have a bit of a rush going, but often you are forced to deal with more prosaic issues, and this can be a difficult transition. for example, the code lasted about 40 minutes, from the time the code was called until we got him to the micu. during this time i was paged by 3 different nurses a total of 7 times. i heard the senior resident's pager beeping as well, so i was pretty sure they were paging him as well once i hadn't answered. i had a twinge of fear that something bad had occurred; it hadn't. all 3 issues were non-urgent. i won't turn this into another tirade about the innumerable asinine pages i get on a daily basis and the subsequent rage i spew forth, but imagine, if you will, the juxtaposition of the following situations, in rapid succession: sticking a needle through someone's chest wall and into their heart to make sure there is no fluid collection in the sac surrounding the heart that is preventing the heart from properly contracting. this task completed i leave the room to answer the pages and here is what i get from those bastions of intelligence, the telemetry floor nurses: 1) doctor, i saw that you ordered 10pm labs for patient X, did you still want me to send them? 2) doctor, mr z refused to take his colace (a stool softener). 3) doctor, mrs s would not let us weigh her this morning; i'm not making this up, this nurse called felt the need to pass on this information nearly 14 hours after the fact. i thought i might be missing something so i asked her how this could be important at 11pm and i was told that she just wanted to keep me informed. i thanked her and went about my business. the point of relating that information is to illustrate how difficult it is to go from the former situation--the code--the the latter, and not lash out at someone, especially when someone wants to know why it took me so long to call them back.
following this, i went back to my work, finished up with my remaining two new patients, and headed off to bed about 215am, not far off my estimated time of horizontality, adding in the extra time for the code. i was nodding-off to sleep around 230am, after responding to yet another page relating to a patient's bowel activity, when i felt a familiar vibrating in my pants--the code pager. it's a bit funny, the alert made by the code pager is so feeble that everyone leaves it in the "vibrate" setting since that is more likely to get one's attention. shouldn't this be the loudest pager on earth?
so i jump up and run off down the hall sockless, with my wallet and iphone in the call room (this was all i could think about during the code, since the rooms do not lock). this lady was not so fortunate--we worked on her for about an hour, but she died. she had no iv access and when the code occured and she happened to be a vasculopath (the end result being someone in whom it is extremely difficult to gain iv access) so it took about 45 minutes to establish it, despite 3 people working simultaneously at 3 different locations. we tried to get an inter-osseous line ("io," which means into the bone), but she was so portly that the io needle was too short, that is, she had too much leg fat for the needle to get where it needed to be. someone finally arrived with a special device for situations such as this--basically a drill that had a long enough needle to get through her fat hock and bone into the marrow cavity. by that time it was too late; we continued for a bit longer, giving the medications that we previously were not able to give due to lack of an iv, but it was hopeless, so the code was called: time of death, 337am.
i got up at 610am that morning to start my daily work, but i probably only slept for 15-20 minutes, and i bet you can guess why that was. it was an interesting night, to say the least, and there was even a moment when my anger morphed into something sublime, given all that i had seen in the previous 12 hours. but alas, it was fleeting, erased and replaced by questions about turds.
the last week has been pretty tough; i've been sick, first with a virus and now what i believe to be a bacterial infection that is rapidly progressing to a sinus infection. try staying awake for 30 hours straight and making decisions that could change someone's life while you have the sensation of having an icepick driven into your forehead; not so nice. it's also difficult to get better when you get so little sleep. my call days have also been tougher for the past week as well--sicker, more complicated patients. what this means is that it takes more time to figure out what is going on, and it also means i have to spend more time with that patient because their situation is more tenuous. yes, these cases are often more interesting, more fun, and i certainly learn a great deal, but it is also very physically and mentally demanding. getting 2 such patients in a day is one thing, but try 4, and that's something else all together. furthermore, when i am on call, i not only admit new patients, but i also take care of the old ones; and once the other team goes home, i deal with all of their patients.
so at 1045pm last thursday, i have 6 old patients, 4 new ones--2 of which i have yet to see--and i'm covering 15 patients from the rest of the ccu team; that is a lot of sick people. i'm sitting in the ccu, trying not to let snot drip onto a patient chart, calculating that if nothing major happens that i can be in bed by 1am, when the code pager goes off. a "code" is short for "code blue," which means that someone has been found unresponsive, ie, they are dying or dead, although about 20% of the time it's something totally bogus and a code was called simply because it's a great way to get lots of people to come and help very quickly. the on call ccu team is the primary code team--this means that they run the show. specifically, the ccu senior resident "runs" the code--he/she is on charge and tells everyone else what to do. as one might imagine, a code code can be quite teh clusterfuck. there are usually more people in the room than necessary which can create spatial problems, in addition to organizational and procedural ones. this is why the ccu senior is in charge; it is vital to have one person in command during this type of incident. the ccu intern (me) does physical tasks for the patient such as cpr, and procedures (eg, putting in lines, etc).
this was the second code of the day. we arrived and heard a few quick words about the patient--one of the most salient details was that he was hiv positive. i feel a bit guilty saying that, but a code is extremely chaotic, with many pointy objects and plenty of opportunity for needle-sticks. i've seen this happen three times this year during codes. the dangerous part is not necessarily what you are doing, but what the person next to you might be doing. trust me, it can be frightening.
this patient already had a central line (large IV) in his neck--this is important to know because one of the first tasks that needs to be accomplished it establishing IV access in order to get blood and give medications. IV access in place, i went to work with chest compressions. cpr looks and sounds easy, but it is quite tiring. the other thing that many people don't realize is that it's fairly common for a patient to suffer rib fractures during cpr, since studies have shown that the depth and rate of chest compressions are what lead to the best outcomes, meaning that there are many over-zealous chest-compressors out there.
this gentleman was quite small and thin and i am rather tall and large. i don't remember what his main illness was, but he was cachectic [cachexia ca·chex·i·a (kÉ™-kÄ›k'sÄ“-É™) n.Weight loss, wasting of muscle, loss of appetite, and general debility that can occur during a chronic disease.], and i could feel ribs crunching with every compression of his tiny chest. he was initially pulseless, but after about 20 minutes we brought him back; he also received a surgical airway--his mouth was clenched shut so he couldn't be intubated so instead, a hole was cut in his neck through which a breathing tube was inserted. off to the micu he went. i learned the next morning that he died about 4 hours after we brought him in.
participating in a code is actually rather fun; it is stressful but exhilarating. i enjoy the rapid pace at which one if forced to think and act. the downside is that once the code ends you have a bit of a rush going, but often you are forced to deal with more prosaic issues, and this can be a difficult transition. for example, the code lasted about 40 minutes, from the time the code was called until we got him to the micu. during this time i was paged by 3 different nurses a total of 7 times. i heard the senior resident's pager beeping as well, so i was pretty sure they were paging him as well once i hadn't answered. i had a twinge of fear that something bad had occurred; it hadn't. all 3 issues were non-urgent. i won't turn this into another tirade about the innumerable asinine pages i get on a daily basis and the subsequent rage i spew forth, but imagine, if you will, the juxtaposition of the following situations, in rapid succession: sticking a needle through someone's chest wall and into their heart to make sure there is no fluid collection in the sac surrounding the heart that is preventing the heart from properly contracting. this task completed i leave the room to answer the pages and here is what i get from those bastions of intelligence, the telemetry floor nurses: 1) doctor, i saw that you ordered 10pm labs for patient X, did you still want me to send them? 2) doctor, mr z refused to take his colace (a stool softener). 3) doctor, mrs s would not let us weigh her this morning; i'm not making this up, this nurse called felt the need to pass on this information nearly 14 hours after the fact. i thought i might be missing something so i asked her how this could be important at 11pm and i was told that she just wanted to keep me informed. i thanked her and went about my business. the point of relating that information is to illustrate how difficult it is to go from the former situation--the code--the the latter, and not lash out at someone, especially when someone wants to know why it took me so long to call them back.
following this, i went back to my work, finished up with my remaining two new patients, and headed off to bed about 215am, not far off my estimated time of horizontality, adding in the extra time for the code. i was nodding-off to sleep around 230am, after responding to yet another page relating to a patient's bowel activity, when i felt a familiar vibrating in my pants--the code pager. it's a bit funny, the alert made by the code pager is so feeble that everyone leaves it in the "vibrate" setting since that is more likely to get one's attention. shouldn't this be the loudest pager on earth?
so i jump up and run off down the hall sockless, with my wallet and iphone in the call room (this was all i could think about during the code, since the rooms do not lock). this lady was not so fortunate--we worked on her for about an hour, but she died. she had no iv access and when the code occured and she happened to be a vasculopath (the end result being someone in whom it is extremely difficult to gain iv access) so it took about 45 minutes to establish it, despite 3 people working simultaneously at 3 different locations. we tried to get an inter-osseous line ("io," which means into the bone), but she was so portly that the io needle was too short, that is, she had too much leg fat for the needle to get where it needed to be. someone finally arrived with a special device for situations such as this--basically a drill that had a long enough needle to get through her fat hock and bone into the marrow cavity. by that time it was too late; we continued for a bit longer, giving the medications that we previously were not able to give due to lack of an iv, but it was hopeless, so the code was called: time of death, 337am.
i got up at 610am that morning to start my daily work, but i probably only slept for 15-20 minutes, and i bet you can guess why that was. it was an interesting night, to say the least, and there was even a moment when my anger morphed into something sublime, given all that i had seen in the previous 12 hours. but alas, it was fleeting, erased and replaced by questions about turds.
Monday, February 23, 2009
nihlists with good imaginations?
well, it's been some time since my last rant. 7 days to be exact. which is the same number of days i have left in the ccu. actually, it's 5 days: i have 1 more off day, plus one day "off" during which i will be taking an exam rather than going to work. so that makes it 5 days; 2 of those are post-call days where i go home by noon, and since i am usually so tired/delirious i almost enjoy the morning, that really becomes more like 3 days. but there are 2 call days, which can be horrible and never-ending, which brings me back to 5 days. i can handle 5 days. especially since it is now t-minus 14 days until i have 2 weeks of vacation!
i was on call last night. it sucked. not only was i sick, but 2 patients came after midnight, meaning i got basically no sleep. i thought that was bad, but then on rounds this morning the attending was not thrilled with the manner in which 2 patients were managed and insinuated that i was not such a competent doctor after all. not so much fun.
that didn't bother me too much, since it is quite easy to come in ex post facto and deride overnight decision making, but i did spend the few free moments i had this morning re-thinking some of the choices i made. the end result was that i spaced-out and lost my train of thought many times when discussing other patients, leading to paroxysms of gibberish coming from my mouth, which only further this attending's low opinion of my abilities.
so i did what anyone is my position would do: i took out my frustration on someone beneath me; in this case, it was a nurse and then a patient. the nurse was someone who paged me 3 times in a row to ask me about orders for a patient that wasn't even a ccu patient, so i knew absolutely zero about her. i was very pleasant the first 2 times, but at number 3...
the patient i yelled at was a 50 year old woman who was supposed to be discharged today and then return this thursday for an outpatient surgical procedure. she told me that she would need to stay until then because she would have no ride back to the hospital on thursday. i told her that she didn't need to be an inpatient for 4 more days, that bad things can happen in the hospital, etc., but she was unbending. i asked why she thought she couldn't get a ride and she said her husband worked early in the morning. what about friends? no one would do it, she informed me. i was livid. i asked if she really had no friends who would drive her to the hospital for a life-saving procedure? nope. how about a cab? she told me she lived too far away and that it would cost too much and that it would be easier for her to stay. this is when i told her that she needed to take some responsibility for her health and well-being and just because something was "easier" for her doesn't make it the right choice. i told her that there were people who were actually sick who needed her bed and the hospital was not a hotel.
i was so angry that i left while she was talking, telling her i would be back to discuss it later. these type of people make me hate-filled that i can't even type more about it. what is so irritating is that everything i said is true: a person shouldn't stay in the hospital if it is not necessary--some very bad things can happen. second, there are people who are acutely ill who do need her bed. third, the wasted health care dollars spent dealing with patients like her is astronomical and wasteful, particularly in this resource-poor environment. aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaahhhh!
i will update you on her discharge status tomorrow.
i was on call last night. it sucked. not only was i sick, but 2 patients came after midnight, meaning i got basically no sleep. i thought that was bad, but then on rounds this morning the attending was not thrilled with the manner in which 2 patients were managed and insinuated that i was not such a competent doctor after all. not so much fun.
that didn't bother me too much, since it is quite easy to come in ex post facto and deride overnight decision making, but i did spend the few free moments i had this morning re-thinking some of the choices i made. the end result was that i spaced-out and lost my train of thought many times when discussing other patients, leading to paroxysms of gibberish coming from my mouth, which only further this attending's low opinion of my abilities.
so i did what anyone is my position would do: i took out my frustration on someone beneath me; in this case, it was a nurse and then a patient. the nurse was someone who paged me 3 times in a row to ask me about orders for a patient that wasn't even a ccu patient, so i knew absolutely zero about her. i was very pleasant the first 2 times, but at number 3...
the patient i yelled at was a 50 year old woman who was supposed to be discharged today and then return this thursday for an outpatient surgical procedure. she told me that she would need to stay until then because she would have no ride back to the hospital on thursday. i told her that she didn't need to be an inpatient for 4 more days, that bad things can happen in the hospital, etc., but she was unbending. i asked why she thought she couldn't get a ride and she said her husband worked early in the morning. what about friends? no one would do it, she informed me. i was livid. i asked if she really had no friends who would drive her to the hospital for a life-saving procedure? nope. how about a cab? she told me she lived too far away and that it would cost too much and that it would be easier for her to stay. this is when i told her that she needed to take some responsibility for her health and well-being and just because something was "easier" for her doesn't make it the right choice. i told her that there were people who were actually sick who needed her bed and the hospital was not a hotel.
i was so angry that i left while she was talking, telling her i would be back to discuss it later. these type of people make me hate-filled that i can't even type more about it. what is so irritating is that everything i said is true: a person shouldn't stay in the hospital if it is not necessary--some very bad things can happen. second, there are people who are acutely ill who do need her bed. third, the wasted health care dollars spent dealing with patients like her is astronomical and wasteful, particularly in this resource-poor environment. aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaahhhh!
i will update you on her discharge status tomorrow.
Monday, February 16, 2009
no. 31
14 days to go.
i'm not sure why i'm counting, since i am actually enjoying my month in the ccu. but it seems like the thing to do, possibly because when this month is over i have 1 week in a community hospital ED, and then 2 weeks of vacation. hooray!
one of the biggest indicators that i am content is that i don't feel as much compulsion to write. i think that when i am angry or unhappy i need the catharsis of putting my gripes into words. but right now, i don't really have any on-going discontent, so i don't have much to say.
although i am getting sick, which is fairly horrible. there are few things worse that being on call and being sick. i have 2 days to get better.
on that sentiment, time for some sleep.
i'm not sure why i'm counting, since i am actually enjoying my month in the ccu. but it seems like the thing to do, possibly because when this month is over i have 1 week in a community hospital ED, and then 2 weeks of vacation. hooray!
one of the biggest indicators that i am content is that i don't feel as much compulsion to write. i think that when i am angry or unhappy i need the catharsis of putting my gripes into words. but right now, i don't really have any on-going discontent, so i don't have much to say.
although i am getting sick, which is fairly horrible. there are few things worse that being on call and being sick. i have 2 days to get better.
on that sentiment, time for some sleep.
Wednesday, February 11, 2009
scientific progress goes "boink!"
this is a tough time of year for many people in the hospital. for interns, their first year is about 2/3 complete, which means rejoice! only a few more months of being the bottom of the doctor chain; but this comes with a price.
while intern year is stressful and awful in many ways, it is also great, and one of the reasons that makes it so is the obscenely steep learning curve--in just 8 months one's knowledge of clinical medicine probably increases by a factor of 100, at least. now that it is mid-february, most interns know what they are doing 80-85% of the time, and they can handle nearly all the mundane, routine issues that come up in daily patient care. perhaps more importantly, their confidence has increased exponentially as well. this means that they are no longer afraid to interpret information and make decisions based on this, and then tell people what to do.
this is a great feeling because after years of feeling lost in the endless sea of information they are finally able to make some sense of it all, to focus on and synthesize the salient data, ignore the chaff, and move forward. hooray!
the pejorative side of this issue is that interns still have to do all the mindless gruntwork at 8 months that they did on day 1, which is essentially data collection, presentation, and paper work that needs to be completed by an MD (when in fact it could be completed by a moderately-well trained primate). this is frustrating since they realize that they now have actual skills as a physician--they can think critically and independently--but are still doing what amounts to secretarial work.
this evolution is in contrast to the careers of nurses and, in reference to my prior post, often leads to friction. nurses are extremely valuable, and there are great nurses, especially in the ICUs, and they absolutely improve patient care, which leads to better outcomes for patients. but nurses are not doctors; they are not trained as such, and they generally lack the clinicopathologic knowledge that doctors have been building since the first day of medical school. the veteran nurses know quite a bit, but it is generally due too pattern recognition rather than a true understanding of pathophysiology.
this can lead to problems in complex, multi-factorial disease states, such as heart failure. in a somewhat simplified scenario, if the heart can only pump forward 2/3 of the fluid that it receives, the remaining 1/2 will back-up behind it, in places like the lungs, legs, etc. if some of the fluid is removed from the body, then there is less net fluid which the heart must pump, and this can relieve the backup (i am talking about removing the liquid component of blood, which is essentially a bunch of cells and proteins floating around in water).
seems pretty simple, right? well, it can be and often is, in say, 7 out of 10 cases. however, it can be significantly more complicated if in addition to the heart failure, there are other, co-morbid conditions, such as poorly functioning kidneys from diabetes, hiv, liver dysfunction from hiv medications and a history of alcohol abuse, peripheral vascular disease, and mild cognitive dysfunction from early multi-infarct dementia. not so simple now, as there are multiple reasons for this patient to have fluid derangements, and treatment is further complicated by the fact that target organs may not be responsive to medications.
as i said, in a basic case, the treatment may be medication x, but in the above patient, medication x may actually be harmful. and this is where doctors (and specifically interns) and nurses are at odds. the latter, in general, lack the complex knowledge and understanding needed to make the aforementioned decision about medication x. interns however, are beginning to realize that they, in fact, do posses the ability to grasp the nature of the situation, or at least the realize that it is not a simple case and the usual treatments may not work. furthermore, they now have the confidence to speak their mind and make decisions on their own;they are progressing, and this is difficult for nurses to except.
why? look at it this way: in july i was the the new guy; i didn't really know what i was doing (i know, i'm switching to the first person here). i lacked a great deal of knowledge and confidence. in some respects, the nurses know a lot more than i did, particularly when it came to completing many of the simple tasks that i was expected to do, even though they weren't things that really "required" an md to complete, that is just how they are done. jump forward to february and now i posses much of the same prosaic information about daily hospital operation that i formerly lacked but the nurses did not and the playing field is somewhat equalized. in addition, i have my 4 years of medical school, which have increased my fund of knowledge, plus 8 months of residency which has furthered both my knowledge and confidence.
can you see where this is going? every year it's the same process: interns come in green and timid and a year later they are seasoned and confident. three or four years later they may be attendings at the same hospital; now they are in charge. contrast that with the career of a nurse whose duties and leadership roles never really change (this is not totally true, as there are levels of nursing seniority, but nurses will essentially always be subordinates of physicians). at this time of year the transition is taking place for interns--i am taking a step forward, but the nurses are standing still. this is often difficult for them to except, particularly the ones who have been there for years as they have seen hundreds of us ascend from lowly interns to successful attendings, all while they have continued to do the exact same thing.
it is not always a problem--there are certainly arrogant interns just as there are needlessly cantankerous nurses--but it can certainly can be, as evidenced by my previous rant. 6 months ago i might have relented and just put in the orders myself, but at this point i call bullshit when i see it. i have the confidence to ask people to do things, but also, when necessary, to tell them to do it. therein lies the transition, and the true difference between doctors are nurses: at the end of the day, i can tell them what to do, and they cannot do the same. i am not a bellicose or capricious person, and i do not seek to wield power just for sake of doing so, but when it comes to medical decision making, that is what doctors do, and sometimes you must speak loudly in order to be heard.
i refuse to let myself be needlessly pushed around, although i realize that this sense is likely somewhat over-developed merely as a reaction to having been the lackey for the last 8 months. i am usually open to criticism and suggestions, but if someone is going to antagonize me by questioning my medical knowledge and judgment, they damn well better be able to back it up with a cogent, rational, and knowledge-based explanation which, sadly, nurses are generally not able to provide.
while intern year is stressful and awful in many ways, it is also great, and one of the reasons that makes it so is the obscenely steep learning curve--in just 8 months one's knowledge of clinical medicine probably increases by a factor of 100, at least. now that it is mid-february, most interns know what they are doing 80-85% of the time, and they can handle nearly all the mundane, routine issues that come up in daily patient care. perhaps more importantly, their confidence has increased exponentially as well. this means that they are no longer afraid to interpret information and make decisions based on this, and then tell people what to do.
this is a great feeling because after years of feeling lost in the endless sea of information they are finally able to make some sense of it all, to focus on and synthesize the salient data, ignore the chaff, and move forward. hooray!
the pejorative side of this issue is that interns still have to do all the mindless gruntwork at 8 months that they did on day 1, which is essentially data collection, presentation, and paper work that needs to be completed by an MD (when in fact it could be completed by a moderately-well trained primate). this is frustrating since they realize that they now have actual skills as a physician--they can think critically and independently--but are still doing what amounts to secretarial work.
this evolution is in contrast to the careers of nurses and, in reference to my prior post, often leads to friction. nurses are extremely valuable, and there are great nurses, especially in the ICUs, and they absolutely improve patient care, which leads to better outcomes for patients. but nurses are not doctors; they are not trained as such, and they generally lack the clinicopathologic knowledge that doctors have been building since the first day of medical school. the veteran nurses know quite a bit, but it is generally due too pattern recognition rather than a true understanding of pathophysiology.
this can lead to problems in complex, multi-factorial disease states, such as heart failure. in a somewhat simplified scenario, if the heart can only pump forward 2/3 of the fluid that it receives, the remaining 1/2 will back-up behind it, in places like the lungs, legs, etc. if some of the fluid is removed from the body, then there is less net fluid which the heart must pump, and this can relieve the backup (i am talking about removing the liquid component of blood, which is essentially a bunch of cells and proteins floating around in water).
seems pretty simple, right? well, it can be and often is, in say, 7 out of 10 cases. however, it can be significantly more complicated if in addition to the heart failure, there are other, co-morbid conditions, such as poorly functioning kidneys from diabetes, hiv, liver dysfunction from hiv medications and a history of alcohol abuse, peripheral vascular disease, and mild cognitive dysfunction from early multi-infarct dementia. not so simple now, as there are multiple reasons for this patient to have fluid derangements, and treatment is further complicated by the fact that target organs may not be responsive to medications.
as i said, in a basic case, the treatment may be medication x, but in the above patient, medication x may actually be harmful. and this is where doctors (and specifically interns) and nurses are at odds. the latter, in general, lack the complex knowledge and understanding needed to make the aforementioned decision about medication x. interns however, are beginning to realize that they, in fact, do posses the ability to grasp the nature of the situation, or at least the realize that it is not a simple case and the usual treatments may not work. furthermore, they now have the confidence to speak their mind and make decisions on their own;they are progressing, and this is difficult for nurses to except.
why? look at it this way: in july i was the the new guy; i didn't really know what i was doing (i know, i'm switching to the first person here). i lacked a great deal of knowledge and confidence. in some respects, the nurses know a lot more than i did, particularly when it came to completing many of the simple tasks that i was expected to do, even though they weren't things that really "required" an md to complete, that is just how they are done. jump forward to february and now i posses much of the same prosaic information about daily hospital operation that i formerly lacked but the nurses did not and the playing field is somewhat equalized. in addition, i have my 4 years of medical school, which have increased my fund of knowledge, plus 8 months of residency which has furthered both my knowledge and confidence.
can you see where this is going? every year it's the same process: interns come in green and timid and a year later they are seasoned and confident. three or four years later they may be attendings at the same hospital; now they are in charge. contrast that with the career of a nurse whose duties and leadership roles never really change (this is not totally true, as there are levels of nursing seniority, but nurses will essentially always be subordinates of physicians). at this time of year the transition is taking place for interns--i am taking a step forward, but the nurses are standing still. this is often difficult for them to except, particularly the ones who have been there for years as they have seen hundreds of us ascend from lowly interns to successful attendings, all while they have continued to do the exact same thing.
it is not always a problem--there are certainly arrogant interns just as there are needlessly cantankerous nurses--but it can certainly can be, as evidenced by my previous rant. 6 months ago i might have relented and just put in the orders myself, but at this point i call bullshit when i see it. i have the confidence to ask people to do things, but also, when necessary, to tell them to do it. therein lies the transition, and the true difference between doctors are nurses: at the end of the day, i can tell them what to do, and they cannot do the same. i am not a bellicose or capricious person, and i do not seek to wield power just for sake of doing so, but when it comes to medical decision making, that is what doctors do, and sometimes you must speak loudly in order to be heard.
i refuse to let myself be needlessly pushed around, although i realize that this sense is likely somewhat over-developed merely as a reaction to having been the lackey for the last 8 months. i am usually open to criticism and suggestions, but if someone is going to antagonize me by questioning my medical knowledge and judgment, they damn well better be able to back it up with a cogent, rational, and knowledge-based explanation which, sadly, nurses are generally not able to provide.
the straw that broke the sleepy resident's back
i have now completed 2 of 7 calls, and have 19 days left of ccu. hooray! in all honesty, i don't mind the ccu, i actually like, as i mentioned before. but i still dislike being on call, and my experience last night reminded my why--it was without a doubt the worst night i have had as a resident at my new program. in fact, i had flashbacks to my many unhappy calls as a surgical intern; ugh.
why was it so awful? it wasn't the new patients, since there were only 2, and they were straight-forward heart attacks; not much going on there. what really got me was the never-ending stream of completely inane questions and information i got from the nurses. literally, i was paged every 15 min from 1am until 6am. this is not an exaggeration either. and there was not a single incident that required me to see a sick patient; it was all garbage that did not require attention in the middle of the night. my favorite was a nurse who informed me that a unit of red blood cells that i had ordered for a patient at 245pm had not been given. it was now 345am; did i still want that transfusion? this sounds like a joke, but it is the truth, this is how medicine works.
i was barely able to contain my anger at this point--i asked the nurse, after a useless attempt on my part to figure out why this had happened, if she really thought that she needed to call me at 3am to ask me this question. she told me she didn't understand the question. so i rephrased, and inquired under what circumstances she imagined i might tell her that the blood was not necessary (presumably she knew that patient and why there was blood ordered--she was bleeding. not a massive hemorrhage, but loosing blood). she sputtered out some gibberish, obviously not sure what was happening. at this point i felt a little guilty for being terse with her, so i relented a bit and asked her what she needed from me--another order for the blood? clarification as to why we had ordered it? maybe she thought i was patronizing her because at this point she snapped at me informed me she knew the patient was bleeding (slowly) and in fact had just been with the patient who had informed her that she (the patient) was still bleeding, not 5 minutes prior to our conversation.
she did not relay this information in a friendly manner. at that point, i lost control. here is a summary of what came out of my mouth next, although admittedly my memory may have been clouded by my intense rage: so you are telling me that there was an order for a blood transfusion for a patient who was bleeding that was entered 12 hours ago but that was never given. and now you are calling me at 3am to ask me if you still should give it, when not 5 minutes ago you with with the patient who informed you that she was still actively bleeding? this is not the type of order that can be "overlooked" and is certainly not something that needs to verified after it has been forgotten. this was all conveyed at a very high volume.
once my rage was unleashed, it was hard to contain. i did the best i could for the next 2 hours, and had moderate success. once the other teams had arrived for the day, around 6am, i thought i would be unburdened, since most of the calls had been on their patients. oh how wrong i was. i got called around 630am and was told that a patient did not have any orders written for morning labs; the blood had been drawn, but there were no labels for the tubes so they couldn't be sent to the lab. she asked if i would enter the orders. normally i would be happy to, i informed her, but i was dealing with an active issue with one of my own patients and furthermore, the primary team was there son they could decide what they wanted. she asked me if i knew who the intern was. i told her it was either intern x, or y (i gave the last names). she asked if i know their pager numbers, which i did not. she then, in a rather snide manner, asked me how she was supposed to track down the proper person. i replied that i was sure that this wasn't her first day and that i was confident there were ways she could obtain the required information--for example, the blue sheets of paper taped-up at every nurses station that list the names and pagers of all the residents currently working in the ccu.
she then told me "nevermind...it's not that important. we just won't send any labs." my anger went to 11. i said (actually, i screamed; i was so angry that i was shaking) there is a solution, which is to call the physician who is taking care of that patient and find out what needs to be done. the solution is not to call the first person who's pager you have and then imply that you won't follow through if that person won't track down the responsible doctor; that is both irresponsible and negligent. you need to do your job, which is to discuss this issue with primary resident. i waited for about 5 seconds, during which time there was only silence, and then i hung up.
i felt another twinge of guilt and was about to enter the orders myself, when my pager went off again--fortunately this time it was about one of my patients, so off to work i went.
i'm sure this will all come back to haunt me, but this was one of the rare times when i completely lost my temper. i will try to do better next time.
why was it so awful? it wasn't the new patients, since there were only 2, and they were straight-forward heart attacks; not much going on there. what really got me was the never-ending stream of completely inane questions and information i got from the nurses. literally, i was paged every 15 min from 1am until 6am. this is not an exaggeration either. and there was not a single incident that required me to see a sick patient; it was all garbage that did not require attention in the middle of the night. my favorite was a nurse who informed me that a unit of red blood cells that i had ordered for a patient at 245pm had not been given. it was now 345am; did i still want that transfusion? this sounds like a joke, but it is the truth, this is how medicine works.
i was barely able to contain my anger at this point--i asked the nurse, after a useless attempt on my part to figure out why this had happened, if she really thought that she needed to call me at 3am to ask me this question. she told me she didn't understand the question. so i rephrased, and inquired under what circumstances she imagined i might tell her that the blood was not necessary (presumably she knew that patient and why there was blood ordered--she was bleeding. not a massive hemorrhage, but loosing blood). she sputtered out some gibberish, obviously not sure what was happening. at this point i felt a little guilty for being terse with her, so i relented a bit and asked her what she needed from me--another order for the blood? clarification as to why we had ordered it? maybe she thought i was patronizing her because at this point she snapped at me informed me she knew the patient was bleeding (slowly) and in fact had just been with the patient who had informed her that she (the patient) was still bleeding, not 5 minutes prior to our conversation.
she did not relay this information in a friendly manner. at that point, i lost control. here is a summary of what came out of my mouth next, although admittedly my memory may have been clouded by my intense rage: so you are telling me that there was an order for a blood transfusion for a patient who was bleeding that was entered 12 hours ago but that was never given. and now you are calling me at 3am to ask me if you still should give it, when not 5 minutes ago you with with the patient who informed you that she was still actively bleeding? this is not the type of order that can be "overlooked" and is certainly not something that needs to verified after it has been forgotten. this was all conveyed at a very high volume.
once my rage was unleashed, it was hard to contain. i did the best i could for the next 2 hours, and had moderate success. once the other teams had arrived for the day, around 6am, i thought i would be unburdened, since most of the calls had been on their patients. oh how wrong i was. i got called around 630am and was told that a patient did not have any orders written for morning labs; the blood had been drawn, but there were no labels for the tubes so they couldn't be sent to the lab. she asked if i would enter the orders. normally i would be happy to, i informed her, but i was dealing with an active issue with one of my own patients and furthermore, the primary team was there son they could decide what they wanted. she asked me if i knew who the intern was. i told her it was either intern x, or y (i gave the last names). she asked if i know their pager numbers, which i did not. she then, in a rather snide manner, asked me how she was supposed to track down the proper person. i replied that i was sure that this wasn't her first day and that i was confident there were ways she could obtain the required information--for example, the blue sheets of paper taped-up at every nurses station that list the names and pagers of all the residents currently working in the ccu.
she then told me "nevermind...it's not that important. we just won't send any labs." my anger went to 11. i said (actually, i screamed; i was so angry that i was shaking) there is a solution, which is to call the physician who is taking care of that patient and find out what needs to be done. the solution is not to call the first person who's pager you have and then imply that you won't follow through if that person won't track down the responsible doctor; that is both irresponsible and negligent. you need to do your job, which is to discuss this issue with primary resident. i waited for about 5 seconds, during which time there was only silence, and then i hung up.
i felt another twinge of guilt and was about to enter the orders myself, when my pager went off again--fortunately this time it was about one of my patients, so off to work i went.
i'm sure this will all come back to haunt me, but this was one of the rare times when i completely lost my temper. i will try to do better next time.
Saturday, February 7, 2009
post call addendum:
22 days to go.
it's now post call day number 1 for me. i have to admit that last night wasn't too bad. only 2 new patients, although one of them did come at 3am, right in at the height of the time i could have been sleeping. i was not so excited when my pager went off and i called back to find that there was a new patient. ugh, i thought, there goes any chance for sleep. thus, when i was laying down at 408am, hopeful that i'd get a few hours of sleep, i was both surprised and gladdened.
how did this happen? how can a patient get admitted in just over an hour? well, i'm going to tell you. in the ccu, things run somewhat different from other intensive care units, as i discovered. many patients who come to the ccu have had heart attacks, and many of these people go to the cath lab prior to coming to the unit (that is the place where angioplasty is done and stents are placed).
this particular gentleman also had an intra-aortic balloon pump placed:
this all sounds very complicated, and in some ways it is, but the end result is that most of these patients arrive with their definitive treatment already carried out; furthermore, there are numerous studies which have looked at the best way to treat these patients for optimal survival. therefore, there is not much thinking and decision making that needs to be done when they arrive--in essence, they come pre=packaged. this isn't to say that there is no value in this experience for me, because there is, as i need to learn what is done to these patients and why, but it is easier to deal with these patients when they arrive because you are not spending time trying to figure out what is wrong, rather, you are treating them.
this is how it differs from other areas in medicine, and particularly the medical icu, where patients are essentially train wrecks who arrive with many problems, nearly dead, requiring copious time and energy to figure out what is actually going on--which is what takes the most time--before they can be treated.
in addition, since there were only 2 new patients, i actually had time to read about their conditions and our treatments so that on morning rounds i actually felt like i could speak intelligently about what was going on.
so as much as i can't believe i am saying this, i actually enjoyed myself!
day 6 beings in just 10.5 short hours; time for sleep.
it's now post call day number 1 for me. i have to admit that last night wasn't too bad. only 2 new patients, although one of them did come at 3am, right in at the height of the time i could have been sleeping. i was not so excited when my pager went off and i called back to find that there was a new patient. ugh, i thought, there goes any chance for sleep. thus, when i was laying down at 408am, hopeful that i'd get a few hours of sleep, i was both surprised and gladdened.
how did this happen? how can a patient get admitted in just over an hour? well, i'm going to tell you. in the ccu, things run somewhat different from other intensive care units, as i discovered. many patients who come to the ccu have had heart attacks, and many of these people go to the cath lab prior to coming to the unit (that is the place where angioplasty is done and stents are placed).
this particular gentleman also had an intra-aortic balloon pump placed:
this all sounds very complicated, and in some ways it is, but the end result is that most of these patients arrive with their definitive treatment already carried out; furthermore, there are numerous studies which have looked at the best way to treat these patients for optimal survival. therefore, there is not much thinking and decision making that needs to be done when they arrive--in essence, they come pre=packaged. this isn't to say that there is no value in this experience for me, because there is, as i need to learn what is done to these patients and why, but it is easier to deal with these patients when they arrive because you are not spending time trying to figure out what is wrong, rather, you are treating them.
this is how it differs from other areas in medicine, and particularly the medical icu, where patients are essentially train wrecks who arrive with many problems, nearly dead, requiring copious time and energy to figure out what is actually going on--which is what takes the most time--before they can be treated.
in addition, since there were only 2 new patients, i actually had time to read about their conditions and our treatments so that on morning rounds i actually felt like i could speak intelligently about what was going on.
so as much as i can't believe i am saying this, i actually enjoyed myself!
day 6 beings in just 10.5 short hours; time for sleep.
Thursday, February 5, 2009
hell of the south.
no, i'm not talking about my brother's wife or toxic her family. what i am referring to is my new place of work for the next 28 days: the cardiac intensive care unit, or ccu, which is located in the south pavilion of my hospital. actually, it's only the next 25 days since i started last tuesday, and then minus the 4 days i'll have off it's only 21 more days, which really isn't that much.
being in the ccu is both good and bad. it's good because it means that i survived my internal medicine month, and good because i am halfway through the 2 months in a row of call, and good because at the end of this month i have 2 weeks of vacation. and it's bad because...well, i am on call again every 4th night. other than that, i guess it's not so bad, although there is the potential.
i am trying to be positive, which i know is contrary to the theory i espoused earlier, but i'm getting a little tired of being cranky all the time. so i am going to give the whole positivity thing a shot. on that note, i will describe some of my positive experience from internal medicine. the first thing, and what made it tolerable, was that the people were fun. everyone was pretty mellow and easy-going. some might see this as a euphemism for "lazy" but this is not true! there are some of people out there who word hard when it is necessary, are quite intelligent, do their jobs well, but don't take themselves too seriously. i was fortunate to work with some of these folks the past month--one of them is destined to be a Chief Resident next year, so she is obviously no chump (you get selected by the faculty for this position from a class of about 50 or so).
we worked hard, did well by our patients, and got the hell out of the hospital when the work was done. there was a tacit agreement that we all liked medicine, wanted to learn, but that we also wanted to enjoy our personal lives, so we should all work together to make sure everything was completed in a timely and proper manner; but there was no needless standing around or staying at the hospital until an arbitrarily determined "appropriate" time (deemed by many to be at least 4pm, sometimes as late as 5pm). sometimes it is necessary to stay late, as people are sick and need care, but there is no reason for 5 people to stand around with their thumbs in their ears when all their work is done and nothing is happening. there is almost nothing that will throw me into a rage as fast as time wasted in the hospital when i could have been anywhere else. fortunately, this was not a problem for these like-minded individuals, and i was grateful.
anyway, this is heading into a negative direction, and that is not in fitting with my new MO, so i must desist, as we all know where this attitude leads.
being in the ccu is both good and bad. it's good because it means that i survived my internal medicine month, and good because i am halfway through the 2 months in a row of call, and good because at the end of this month i have 2 weeks of vacation. and it's bad because...well, i am on call again every 4th night. other than that, i guess it's not so bad, although there is the potential.
i am trying to be positive, which i know is contrary to the theory i espoused earlier, but i'm getting a little tired of being cranky all the time. so i am going to give the whole positivity thing a shot. on that note, i will describe some of my positive experience from internal medicine. the first thing, and what made it tolerable, was that the people were fun. everyone was pretty mellow and easy-going. some might see this as a euphemism for "lazy" but this is not true! there are some of people out there who word hard when it is necessary, are quite intelligent, do their jobs well, but don't take themselves too seriously. i was fortunate to work with some of these folks the past month--one of them is destined to be a Chief Resident next year, so she is obviously no chump (you get selected by the faculty for this position from a class of about 50 or so).
we worked hard, did well by our patients, and got the hell out of the hospital when the work was done. there was a tacit agreement that we all liked medicine, wanted to learn, but that we also wanted to enjoy our personal lives, so we should all work together to make sure everything was completed in a timely and proper manner; but there was no needless standing around or staying at the hospital until an arbitrarily determined "appropriate" time (deemed by many to be at least 4pm, sometimes as late as 5pm). sometimes it is necessary to stay late, as people are sick and need care, but there is no reason for 5 people to stand around with their thumbs in their ears when all their work is done and nothing is happening. there is almost nothing that will throw me into a rage as fast as time wasted in the hospital when i could have been anywhere else. fortunately, this was not a problem for these like-minded individuals, and i was grateful.
anyway, this is heading into a negative direction, and that is not in fitting with my new MO, so i must desist, as we all know where this attitude leads.
Saturday, January 31, 2009
bits, bobs, this, that, and the other.
chf: congestive heart failure. your heart is a pump. when it doesn't work so well, fluid backs up in the pipes behind the heart and you get fluid in your lungs or swelling in your legs, amongst other things.
there was an interesting/silly article in the nytimes a few days ago about facebook and the odd position one can get into when deleting friends. it made me wonder if i should defriend the 2 residents from my program who friended me basically so they could ask for favors. one guy wanted me to change vacation time with him, and the other wanted to swap my ccu and medicine floor month. neither worked out, or i should say, i didn't want to do either, but now i am left with these 2 "friends" who aren't really friends. i can't help but feel that they befriended me in a effort to make it harder for me to deny my request. they easily could have emailed me--my email address is firstname.lastnmae@_____.edu. they obviously have my name since they found me on facebook. it's easy to say no in a faceless email, but perhaps not so easy to deny a "friend." fortunately, i am impervious to such chicanery, and these folks are no longer my "friends."
a while ago i mentioned that i would reveal my method for faster pre-rounding, so here it is: i don't actually see all my patients. this isn't a big secret, since i am pretty sure many other interns do this, although i don't think many of them will admit it as openly as i do. rounding is when the medical team walks around and sees and discusses each patient and then informs him/her of the plan for the day. pre-rounding takes place before this and consists of the intern gather vital signs, lab results, and other information from overnight, and then physically seeing and examining the patient so that when it comes time for real rounds one has all the pertinent information.
this might seem like a lot of work, and it can be, depending on how sick the patient is and how much data there is; pre-rounding on icu patients is both necessary and time consuming as there is far more going on with them as they are actaully sick and have the potential to die quickly if ignored. the same is not true on many inpatient medicine patients. they might be ill, but generally they are not circling the drain like icu patients. you would be surprised at how frequently people get admitted who really have no need to be inpatients. even more surprising is the fact that many people, even if they had a legitimate reason for admission, often resist discharge once they are better. furthermore, there are often people who remain as inpatients to receive treatments that they cannot easily get as an outpatient--such as iv anitibiotics--or who are simply awaiting a bed at a rehab facility, nursing home, etc.
those last 4 groups of people are not generally actively ill, so i don't really feel that i need to see them at 6am. i do eventually go back and talk to them examine them, etc., but i don't do this in the early morning, before rounds (unless something happened overnight). right now i have 8 patients and 6 fall into one of those aforementioned categories. so when i get to work i just right down their vital signs and lab results which takes about 1-2 minutes per patient. i see and examine the other 2 which, takes up to 10 minutes. all together this take less than 30 min, but if i gave everyone the 10 minute treatment, it would take me an hour or more to pre-round. this would quickly lead to sleep deprivation, more medical errors, increased crankiness on my part, and generally bad outcomes for everyone.
it's a good thing i'm so pragmatic and forward thinking.
there was an interesting/silly article in the nytimes a few days ago about facebook and the odd position one can get into when deleting friends. it made me wonder if i should defriend the 2 residents from my program who friended me basically so they could ask for favors. one guy wanted me to change vacation time with him, and the other wanted to swap my ccu and medicine floor month. neither worked out, or i should say, i didn't want to do either, but now i am left with these 2 "friends" who aren't really friends. i can't help but feel that they befriended me in a effort to make it harder for me to deny my request. they easily could have emailed me--my email address is firstname.lastnmae@_____.edu. they obviously have my name since they found me on facebook. it's easy to say no in a faceless email, but perhaps not so easy to deny a "friend." fortunately, i am impervious to such chicanery, and these folks are no longer my "friends."
a while ago i mentioned that i would reveal my method for faster pre-rounding, so here it is: i don't actually see all my patients. this isn't a big secret, since i am pretty sure many other interns do this, although i don't think many of them will admit it as openly as i do. rounding is when the medical team walks around and sees and discusses each patient and then informs him/her of the plan for the day. pre-rounding takes place before this and consists of the intern gather vital signs, lab results, and other information from overnight, and then physically seeing and examining the patient so that when it comes time for real rounds one has all the pertinent information.
this might seem like a lot of work, and it can be, depending on how sick the patient is and how much data there is; pre-rounding on icu patients is both necessary and time consuming as there is far more going on with them as they are actaully sick and have the potential to die quickly if ignored. the same is not true on many inpatient medicine patients. they might be ill, but generally they are not circling the drain like icu patients. you would be surprised at how frequently people get admitted who really have no need to be inpatients. even more surprising is the fact that many people, even if they had a legitimate reason for admission, often resist discharge once they are better. furthermore, there are often people who remain as inpatients to receive treatments that they cannot easily get as an outpatient--such as iv anitibiotics--or who are simply awaiting a bed at a rehab facility, nursing home, etc.
those last 4 groups of people are not generally actively ill, so i don't really feel that i need to see them at 6am. i do eventually go back and talk to them examine them, etc., but i don't do this in the early morning, before rounds (unless something happened overnight). right now i have 8 patients and 6 fall into one of those aforementioned categories. so when i get to work i just right down their vital signs and lab results which takes about 1-2 minutes per patient. i see and examine the other 2 which, takes up to 10 minutes. all together this take less than 30 min, but if i gave everyone the 10 minute treatment, it would take me an hour or more to pre-round. this would quickly lead to sleep deprivation, more medical errors, increased crankiness on my part, and generally bad outcomes for everyone.
it's a good thing i'm so pragmatic and forward thinking.
Thursday, January 29, 2009
no. 21: cheating death...with parsimony.
as i sit before my computer in my 6th post-call haze, i am gladdened but the fact that i only have 1 more night of being on call for medicine. hooray! but then i go to the cardiac icu, which means more call. oh well. at least i am almost to the halfway point.
anyway, the past 2 call nights have been seen me admitting patients with similar problems. last week it was infected AV fistulas and other dialysis-related woes. last night it was people with chf and falls. that is not germane to the story i am about to relate, but rather is psychological defense mechanism on my part that i am using to help me feel better for the confusion i experienced on rounds this morning. i will admit that i got some details confused on a few patients, but in my defense, there were 3 gentlemen in their 70s who all had chf and leg swelling and who all came in between midnight and 2am.
moving on from tangent #2 to my humorous yarn: mr h was, as i previously noted, a man in his 70s with chf and leg swelling. we finished taking his history and then moved to the discussion of code status, that is, does the patient want cpr, electric shocks, etc., in the event that the "worst" happens? (i use the quote there for 2 reasons: first, i never say that because it seems, well, an inelegant and cowardly way to frame it, and second, because sometimes dying is a better option for these folks. i mention the latter as it related to discussions had with families who refuse to let their father/mother/etc. die even though that is what nature had intended for them long ago and who, in my mind, is being tortured by a combination of the ability of invasive medicine to keep them "alive" and their family's inability to make the humane choice.)
as i was saying: we got to the code status conversation with mr h he promptly informed us that yes, he wanted to be kept alive...at least until april. i couldn't refrain from asking him what was different in april. he informed me that it is cheaper to get buried in the spring and summer given the difficulty of being laid to rest in frozen ground. apparently cheapness is a force that cannot be constrained by mortal bounds. this was the first conversation all night that peaked my interest, so i probed deeper. he later revealed that he had "run some cemeteries," whatever that means, so he had the inside scoop on the scene. i then proceeded to inquire why, if he had friends on the inside, couldn't he get a deal? he informed me that he had secured a plot for his final mortal remains at a substantial discount, but that there was no flexibility on the "landscaping costs," which he assured me, were "significant."
i am, after all a doctor--someone who fixes problems, so i chimed-in with my sagacious wit and wisdom. the suggestion i offered first was cremation. he said that was an impossibility as he had already secured the aforementioned deal on a plot. he also was afraid that it would "hurt." i posited that a rapid burn at high temperatures might be more comfortable than a slow decomposition in a box whilst underground might actually offer less discomfort, but he was unbending. i paused to consider this quandary and arrived at the following answer: shovels. why not have his family dig his own grave? at this point i should mention that our previous conversation had involved a lengthy diatribe on his part on the ingenuity and stoicism of his family, so that wasn't as inappropriate as it sounds. he hesitated. i suggested that this was actually a grand plan since it would provide the family with a final memory of him. what better way to celebrate the life of the departed than discussing it while digging his grave in the frozen, january ground?
mr h, however, thought there would be many more efficacious manners in which to remember him and so alas, he remains full code.
SC
anyway, the past 2 call nights have been seen me admitting patients with similar problems. last week it was infected AV fistulas and other dialysis-related woes. last night it was people with chf and falls. that is not germane to the story i am about to relate, but rather is psychological defense mechanism on my part that i am using to help me feel better for the confusion i experienced on rounds this morning. i will admit that i got some details confused on a few patients, but in my defense, there were 3 gentlemen in their 70s who all had chf and leg swelling and who all came in between midnight and 2am.
moving on from tangent #2 to my humorous yarn: mr h was, as i previously noted, a man in his 70s with chf and leg swelling. we finished taking his history and then moved to the discussion of code status, that is, does the patient want cpr, electric shocks, etc., in the event that the "worst" happens? (i use the quote there for 2 reasons: first, i never say that because it seems, well, an inelegant and cowardly way to frame it, and second, because sometimes dying is a better option for these folks. i mention the latter as it related to discussions had with families who refuse to let their father/mother/etc. die even though that is what nature had intended for them long ago and who, in my mind, is being tortured by a combination of the ability of invasive medicine to keep them "alive" and their family's inability to make the humane choice.)
as i was saying: we got to the code status conversation with mr h he promptly informed us that yes, he wanted to be kept alive...at least until april. i couldn't refrain from asking him what was different in april. he informed me that it is cheaper to get buried in the spring and summer given the difficulty of being laid to rest in frozen ground. apparently cheapness is a force that cannot be constrained by mortal bounds. this was the first conversation all night that peaked my interest, so i probed deeper. he later revealed that he had "run some cemeteries," whatever that means, so he had the inside scoop on the scene. i then proceeded to inquire why, if he had friends on the inside, couldn't he get a deal? he informed me that he had secured a plot for his final mortal remains at a substantial discount, but that there was no flexibility on the "landscaping costs," which he assured me, were "significant."
i am, after all a doctor--someone who fixes problems, so i chimed-in with my sagacious wit and wisdom. the suggestion i offered first was cremation. he said that was an impossibility as he had already secured the aforementioned deal on a plot. he also was afraid that it would "hurt." i posited that a rapid burn at high temperatures might be more comfortable than a slow decomposition in a box whilst underground might actually offer less discomfort, but he was unbending. i paused to consider this quandary and arrived at the following answer: shovels. why not have his family dig his own grave? at this point i should mention that our previous conversation had involved a lengthy diatribe on his part on the ingenuity and stoicism of his family, so that wasn't as inappropriate as it sounds. he hesitated. i suggested that this was actually a grand plan since it would provide the family with a final memory of him. what better way to celebrate the life of the departed than discussing it while digging his grave in the frozen, january ground?
mr h, however, thought there would be many more efficacious manners in which to remember him and so alas, he remains full code.
SC
Monday, January 26, 2009
you say pessimism, i say realism; no. 20.
i expect the worst when i go to work. i plan that everyday is going to be long and painful. that patients will be sick and difficult and whiny. i set my sights low for what time i will depart. what i'm saying is, i fully expect that each day of work will be like the 7th circle of hell. well, maybe not the 7th...maybe the 4th or 5th.
anyhow, there is a method to my, err...madness. no, i mean sensibility. my general reasoning is as follows: if you enter into something with the expectation that it will be a horrible disaster, and it turns out to only be half a disaster, then you leave feeling good. the converse is that if you expect warm, happy, pleasant things, and in the end someone coughs bloody phlegm onto your new tie, well, you would be disappointed, to say the least. some more examples: if i think that i am going to go home at 330pm, and i leave at 530, i wind up angry for the rest of the evening because i left 2 hours late. however, if i plan on a 5pm departure and i actually get out at 430pm i am overjoyed because i left "early." i excel at convincing myself of things like this. similarly, on call days, i fully expect to admit 6 new patients (the maximum we can admit on any given call day). it's not hard to see why--if i plan on an easy day with 3 new folks and i wind up with 5, i fly into a rage, but if i expect 6 and end the night with 4, i feel blessed.
it is truly amazing to me how quickly i have been able to convince myself that my life isn't so bad by merely keeping my expectations low. i also frequently adopt the "it could always be worse" position.
does this sound a bit morose? well, it shouldn't. consider the alternative: i expect great things every day--that patients will be compliant and truthful, that i will not get a surfeit of inane pages from nurses at 3am, just as i have fallen asleep (eg, on my last call night i got called at 445am by a nurse who just wanted to know if it was acceptable for the patient who had requested a stool softener at 11pm who was now sleeping to get in the morning and or if she should wake him up and give it. you be the judge. strange that i got called about this but not the man with pyelonephritis (infection of the kidney) who had a blood pressure of 74-48--i discovered this when checking vitals on my patients the next morning), that i will go home at a reasonable hour (yes, i know i have brought that up many times, but i work 80 hours most weeks, so forgive me if i want a little extra free time), or that each day will not be worse than or equal to the day that preceded it. if i behaved that way i would quickly become the facinorous man i was last year as a surgical intern. that would not be beneficial to anyone.
so i will continue on this way, willfully ignorant of the way things are, but smiling each morning when i get to work. well, perhaps not smiling, but perhaps not scowling, which is more than i can say for some other residents i know.
anyhow, there is a method to my, err...madness. no, i mean sensibility. my general reasoning is as follows: if you enter into something with the expectation that it will be a horrible disaster, and it turns out to only be half a disaster, then you leave feeling good. the converse is that if you expect warm, happy, pleasant things, and in the end someone coughs bloody phlegm onto your new tie, well, you would be disappointed, to say the least. some more examples: if i think that i am going to go home at 330pm, and i leave at 530, i wind up angry for the rest of the evening because i left 2 hours late. however, if i plan on a 5pm departure and i actually get out at 430pm i am overjoyed because i left "early." i excel at convincing myself of things like this. similarly, on call days, i fully expect to admit 6 new patients (the maximum we can admit on any given call day). it's not hard to see why--if i plan on an easy day with 3 new folks and i wind up with 5, i fly into a rage, but if i expect 6 and end the night with 4, i feel blessed.
it is truly amazing to me how quickly i have been able to convince myself that my life isn't so bad by merely keeping my expectations low. i also frequently adopt the "it could always be worse" position.
does this sound a bit morose? well, it shouldn't. consider the alternative: i expect great things every day--that patients will be compliant and truthful, that i will not get a surfeit of inane pages from nurses at 3am, just as i have fallen asleep (eg, on my last call night i got called at 445am by a nurse who just wanted to know if it was acceptable for the patient who had requested a stool softener at 11pm who was now sleeping to get in the morning and or if she should wake him up and give it. you be the judge. strange that i got called about this but not the man with pyelonephritis (infection of the kidney) who had a blood pressure of 74-48--i discovered this when checking vitals on my patients the next morning), that i will go home at a reasonable hour (yes, i know i have brought that up many times, but i work 80 hours most weeks, so forgive me if i want a little extra free time), or that each day will not be worse than or equal to the day that preceded it. if i behaved that way i would quickly become the facinorous man i was last year as a surgical intern. that would not be beneficial to anyone.
so i will continue on this way, willfully ignorant of the way things are, but smiling each morning when i get to work. well, perhaps not smiling, but perhaps not scowling, which is more than i can say for some other residents i know.
Thursday, January 22, 2009
no. 19: please, let me die.
to those who know me and/or care about me, this is my living will:if i am ever involved in a horrible accident and the prognosis is poor, please, if you love me, pull the plug. i do not want to spend days, months, years, etc., rotting in an ICU. if my condition, as judged by my doctors, is is not likely to lead to a meaningful recovery, put me out of my misery. no feeding tube, no trachs. nothing. let me die in opioid-induced bliss. in addition, i don't want you, my family and friends, to be the people coming to visit the sorry lump of flesh that was me, saying and doing silly things that will make us all the subject of ridicule.
let me go. it's been a good ride for me, for the most part, and i don't want to check-out covered in bed sores, emaciated and stinky, taking up valuable hospital resources and the time of residents who are forced to care for me even though they know my case is futile. spare us all, please!
i want to be cremated. not, under any circumstances, do i want to be buried. no prosaic funeral with a lame-ass photo of me on the coffin. you can celebrate my passing, by make it something that i would have enjoyed. high quality gin, some single malt scotch, maybe some wine. there should be plenty of food too, including sweet things. and for god's sake, don't invite people who didn't know me very well who just want to jump on the sympathy bandwagon. i don't have many friends, but i don't want them hobnobbing with a bunch of jerks who want to pretend like they cared about me when i was alive now that i am dead.
there should be plenty of crying, not really for my sake, but for the lack of joy there may be given my absence. i also expect that you who know me best will make plenty of jokes about my death that make others feel extremely awkward. please do this not only in the immediate days and weeks after my demise, but for years to follow. that's how i would have wanted it.
in closing, please understand that i say this all with sound mind. this is what i truly want. do it for me, cause i would do it for you. and if you don't be forewarned: i will haunt you from beyond the grave!
yours in eternity,
SC
let me go. it's been a good ride for me, for the most part, and i don't want to check-out covered in bed sores, emaciated and stinky, taking up valuable hospital resources and the time of residents who are forced to care for me even though they know my case is futile. spare us all, please!
i want to be cremated. not, under any circumstances, do i want to be buried. no prosaic funeral with a lame-ass photo of me on the coffin. you can celebrate my passing, by make it something that i would have enjoyed. high quality gin, some single malt scotch, maybe some wine. there should be plenty of food too, including sweet things. and for god's sake, don't invite people who didn't know me very well who just want to jump on the sympathy bandwagon. i don't have many friends, but i don't want them hobnobbing with a bunch of jerks who want to pretend like they cared about me when i was alive now that i am dead.
there should be plenty of crying, not really for my sake, but for the lack of joy there may be given my absence. i also expect that you who know me best will make plenty of jokes about my death that make others feel extremely awkward. please do this not only in the immediate days and weeks after my demise, but for years to follow. that's how i would have wanted it.
in closing, please understand that i say this all with sound mind. this is what i truly want. do it for me, cause i would do it for you. and if you don't be forewarned: i will haunt you from beyond the grave!
yours in eternity,
SC
Wednesday, January 21, 2009
the list
i carry a pager at work so that anyone can get a hold of me at anytime of the day or night. the following is a list of the pages i received in the 30 hour period from 6am on jan 20 to noon on jan 21. for simplicity, i will note what i was asked to do.
730: order tylenol
735: paged on a patient who was not mine
804: is mr x leaving today?
810: when can mr x leave?
811: is all the paperwork for mr x done? (of note, all these questions were addressed by me at 804)
840: mr x's family wants to talk to you
900: please change diet order
930: you have a new patient in the ED
945: new patient arrives on floor (i had to leave the patient's room to answer this one)
1130: call the hospital operator
1215: you have 2 new ED patients
1259: you have a new patient in the ED
1320: your 2 new patients are on the floor
1400: please put in orders on your 2 new patients so they can eat
1410: please put in orders on your 2 new patients so they can eat
1420: please put in orders on your 2 new patients so they can eat
1445: please put in orders on your 2 new patients so they can eat (i didn't do this earlier because the patient who arrived at 1259 was very sick and had to be transferred to the icu--more important that putting in diet orders)
1523: mr y is agitated
1529: ms d has a blood pressure of 165/69
1630: other medicine team wants to sign-out
1710: 2nd med team wants to sign out.
1810: dinner has arrived. yay!
1900: family of mr z is on the phone and wants to talk to you (i don't know this patient at all)
1950: mrs u is agitated
2020: please renew orders for restraints
2050: patient has a blood pressure of 190/100
2200: your new patient just pooped blood.
2245: ms g wants something to help her sleep
2250: ms g has a bp of 85/44
2300: ms g has a bp of 106/82
2301: can i still give ms g that sleeping pill?
0030: mr s has a heart rate of 200 (this one was serious)
0032: mr s has a bp of 51/19 (this one came while i was going to see this patient)
0100: can mrs h have something for constipation? (while mr s is actively trying to die)
0120: can mr v have something for sleep? (same nurse from above, knowing i was occupied).
0150: mr p is spitting at his roomate and screaming
0205: mr p has a blood sugar of 61
0330: please renew restraint order
0335: are you covering mr b?
0530: are you covering pt x? no!
0630: intern #1 wants sign-out
0645: intern #2 wants sign-out
0700: do you want some coffee?
0750: is mr t your patient?
0755: is mr t your patient?
0915: is mr b going home?
1000: is mrs l going for her CT scan today?
1010: family of mr b wants to see you.
1050: mrs s just had blood in her stool.
1110: mr s just tried to escape.
1140: mr c has a bed in the psych hospital
1205: mr s just tried to escape again. then he tried to punch a nurse--"i'm no longer in the hospital."
730: order tylenol
735: paged on a patient who was not mine
804: is mr x leaving today?
810: when can mr x leave?
811: is all the paperwork for mr x done? (of note, all these questions were addressed by me at 804)
840: mr x's family wants to talk to you
900: please change diet order
930: you have a new patient in the ED
945: new patient arrives on floor (i had to leave the patient's room to answer this one)
1130: call the hospital operator
1215: you have 2 new ED patients
1259: you have a new patient in the ED
1320: your 2 new patients are on the floor
1400: please put in orders on your 2 new patients so they can eat
1410: please put in orders on your 2 new patients so they can eat
1420: please put in orders on your 2 new patients so they can eat
1445: please put in orders on your 2 new patients so they can eat (i didn't do this earlier because the patient who arrived at 1259 was very sick and had to be transferred to the icu--more important that putting in diet orders)
1523: mr y is agitated
1529: ms d has a blood pressure of 165/69
1630: other medicine team wants to sign-out
1710: 2nd med team wants to sign out.
1810: dinner has arrived. yay!
1900: family of mr z is on the phone and wants to talk to you (i don't know this patient at all)
1950: mrs u is agitated
2020: please renew orders for restraints
2050: patient has a blood pressure of 190/100
2200: your new patient just pooped blood.
2245: ms g wants something to help her sleep
2250: ms g has a bp of 85/44
2300: ms g has a bp of 106/82
2301: can i still give ms g that sleeping pill?
0030: mr s has a heart rate of 200 (this one was serious)
0032: mr s has a bp of 51/19 (this one came while i was going to see this patient)
0100: can mrs h have something for constipation? (while mr s is actively trying to die)
0120: can mr v have something for sleep? (same nurse from above, knowing i was occupied).
0150: mr p is spitting at his roomate and screaming
0205: mr p has a blood sugar of 61
0330: please renew restraint order
0335: are you covering mr b?
0530: are you covering pt x? no!
0630: intern #1 wants sign-out
0645: intern #2 wants sign-out
0700: do you want some coffee?
0750: is mr t your patient?
0755: is mr t your patient?
0915: is mr b going home?
1000: is mrs l going for her CT scan today?
1010: family of mr b wants to see you.
1050: mrs s just had blood in her stool.
1110: mr s just tried to escape.
1140: mr c has a bed in the psych hospital
1205: mr s just tried to escape again. then he tried to punch a nurse--"i'm no longer in the hospital."
Monday, January 19, 2009
sorry to bother you, but...
i had my 3rd of 7 days on-call last friday. all things considered, it wasn't too bad. things did get a bit gnarly for a few hours when it was brought to my attention that a patient was in danger of dying at any second due to a previously undiagnosed aortic dissection. once that was dealt with, it was basically smooth sailing.
i tried explaining to a non-medical type what being on-call means, and why it can suck. it basically means that you are the person in the hospital who takes new admissions to your service. for me, it currently general medicine. in my opinion, the admitting new patients is not what really sucks, but rather it's the coverage of other patients that drags me down. what i mean is this--i am on call every 4th night, which means i stay in the hospital for 30 straight every 4th night. on the other days i go home around 4 or 5pm. what happens to my patients between 4pm and 7am the next morning? the on-call person takes care of any acute issues that arise. when i am on call i cover the other patients. since it is every 4th night, there are 4 total interns, which means that on any call night there is 1 person covering for 3 other people. the on-call person is really there to deal with acute issues, but this, as you will see, is generally not what happens at all. what tends to occur is that the on-call sap gets called to straighten out items overlooked by the primary team during the day (ie, things they forgot) as well as answer the inane nighttime requests of patients, including, but not limited to: requests for more pain meds, requests for sleeping meds, requests for enemas (no, i am not joking), requests for explanations of why they are here, etc. the second set of requests comes from nurses, asking for orders for tylenol, restraints, and all kinds of other things that don't require immediate attention by a doctor--or anyone for that matter--at 3am.
the latter are difficult to deal with in that initially, when interns are new and inexperienced, they take everything very seriously. this is ok, but at some point one has to triage these late night calls as there are up to 40 patients being covered by 1 intern (although it's usually closer to 20). once they have some experience they learn that not everything they are told by a nurse is a) true, and b) needs immediate attention. then it almost becomes a "boy who cried wolf" thing with the nurses requests--there are so many garbage requests (say 85%, while certainly less than 5% are true emergencies) that one becomes inured to them and eventually is less likely to respond quickly, because it's so difficult to tell when something is urgent. i know this sounds callous and unreasonable, but it's physically impossible to run full-speed to every "emergency" called by nurses when it turns out that the situation is not as it has been described. a few examples--i got called that a person was "unresponsive." i tear-ass down 4 flights of stairs into the patient's room only to discover that he was not in fact unresponsive; he was, in actuality, verbally abusive. my second example is a call that a patient was "coughing up blood." once again, i run like a mad-man to the room only to discover the source of the hemoptysis (medical word for coughing up blood) was from a nose bleed, which the patient informs me she gets all the time. these were not emergencies. next time the same nurse calls me i am less likely to trust her judgment. obviously, there are certain things that one has to take seriously everytime, but at some point, one cannot physically be in multiple places at once and i will be less likely to believe this rubette (the female version of "rube").
i am, once again, on call tomorrow night. i will log all the pages i get and share them in an effort to bring you closer to the experiencing the agonizing pain in which i spend every 4th night.
i tried explaining to a non-medical type what being on-call means, and why it can suck. it basically means that you are the person in the hospital who takes new admissions to your service. for me, it currently general medicine. in my opinion, the admitting new patients is not what really sucks, but rather it's the coverage of other patients that drags me down. what i mean is this--i am on call every 4th night, which means i stay in the hospital for 30 straight every 4th night. on the other days i go home around 4 or 5pm. what happens to my patients between 4pm and 7am the next morning? the on-call person takes care of any acute issues that arise. when i am on call i cover the other patients. since it is every 4th night, there are 4 total interns, which means that on any call night there is 1 person covering for 3 other people. the on-call person is really there to deal with acute issues, but this, as you will see, is generally not what happens at all. what tends to occur is that the on-call sap gets called to straighten out items overlooked by the primary team during the day (ie, things they forgot) as well as answer the inane nighttime requests of patients, including, but not limited to: requests for more pain meds, requests for sleeping meds, requests for enemas (no, i am not joking), requests for explanations of why they are here, etc. the second set of requests comes from nurses, asking for orders for tylenol, restraints, and all kinds of other things that don't require immediate attention by a doctor--or anyone for that matter--at 3am.
the latter are difficult to deal with in that initially, when interns are new and inexperienced, they take everything very seriously. this is ok, but at some point one has to triage these late night calls as there are up to 40 patients being covered by 1 intern (although it's usually closer to 20). once they have some experience they learn that not everything they are told by a nurse is a) true, and b) needs immediate attention. then it almost becomes a "boy who cried wolf" thing with the nurses requests--there are so many garbage requests (say 85%, while certainly less than 5% are true emergencies) that one becomes inured to them and eventually is less likely to respond quickly, because it's so difficult to tell when something is urgent. i know this sounds callous and unreasonable, but it's physically impossible to run full-speed to every "emergency" called by nurses when it turns out that the situation is not as it has been described. a few examples--i got called that a person was "unresponsive." i tear-ass down 4 flights of stairs into the patient's room only to discover that he was not in fact unresponsive; he was, in actuality, verbally abusive. my second example is a call that a patient was "coughing up blood." once again, i run like a mad-man to the room only to discover the source of the hemoptysis (medical word for coughing up blood) was from a nose bleed, which the patient informs me she gets all the time. these were not emergencies. next time the same nurse calls me i am less likely to trust her judgment. obviously, there are certain things that one has to take seriously everytime, but at some point, one cannot physically be in multiple places at once and i will be less likely to believe this rubette (the female version of "rube").
i am, once again, on call tomorrow night. i will log all the pages i get and share them in an effort to bring you closer to the experiencing the agonizing pain in which i spend every 4th night.
Thursday, January 15, 2009
Wednesday, January 14, 2009
does this beard make me look fat?
i have not used a blade to shave my face since a friend of mind got married over labor day weekend. i do not like shaving. he is a good friend and i was part of the wedding, so i figured it was the right thing to do. i am not rocking a rip van winkle style, however; i do shave every now and then, just not with a blade. i use some electric clippers, which work just fine, but they are really for hair cutting, not beard cutting, so in order to be effective i have to get 4-5 days of stubble going before they will work. so that's what i do: i trim every 4-5 days. now that it's winter i am sporting a tasty beard--i ride my bike to work so the beard is like a natural balaclava. therefore, all the trimming i do is on my neck, but again, only every few days.
why do i bring this up? well, i'm going to explain. we get anonymously evaluated by our superiors and i occasionally read these in a effort to better myself. one such comment i read noted that my lack of daily shaving was slightly unprofessional. first of all, i wonder why this fellow couldn't just say something to me directly? actually, i think i know the answer, as i am fairly certain of the identity of the commenter as he used some phrasiology in his evaluation that he often used in person. the first possibility is that he was intimidated by the overpowering vibe of masculinity that i exude; opntion "b" is that he is a redneck, white-bread, chicken-shit motherfucker who doesn't understand or appreciate the value of diversity. it's probably some of both, but i don't think my personal opinions are the issue here.
what makes me so angry is not the comment itself--i've been called much worse--but the fact that this remark is filled with ignorant sanctimony. given the chance to reply, i would ask: "is your bad grammar unprofessional?" it is not proper to end a sentence with a preposition! "where have your blood sugars been at?" NO, NO, NO! nor is it correct to ask a patient if she feels "nauseous." this word is the equivalent of "poisonous." what this troglodyte wants to ask is "are you experiencing any nausea?" substituting "nauseous" in the preceding sentence would imply that the patient could somehow make those around her feel nauseated. i admit that the strength of this argument is somewhat obviated by the fact that many of these patients are dim bulbs themselves and don't know the difference, but my point is that my reviewer likely believe that there is some objective, higher standard to which we, as doctors, should adhere, even if patients are not aware of it.
further interlocution would find me asking if it professional of him to be wearing a dingy oxford-blue shirt with visible armpit stains, a poorly tied tie, and a white coat with a mustard stain on the lapel? not to mention the khakis he frequently wore that seem to never see the inside of a washing machine. further unprofessional transgressions included lapsing into some kind of homeboy/ghetto dialect when speaking to black or hispanic people, constantly saying "fustrating," and walking into a meeting with a family while eating a donut. despite all this, my less-than-frequent shaving raised his ire. in my opinion, this man has somewhat spurious--or at least incomplete--notions of the meaning of "unprofessional." i would prefer a ruggedly handsome, stubble-ridden doctor, to one with poor grammar and a dirty shirt.
some decidedly un-professional facial hair:
i do not look like any of these folks.
why do i bring this up? well, i'm going to explain. we get anonymously evaluated by our superiors and i occasionally read these in a effort to better myself. one such comment i read noted that my lack of daily shaving was slightly unprofessional. first of all, i wonder why this fellow couldn't just say something to me directly? actually, i think i know the answer, as i am fairly certain of the identity of the commenter as he used some phrasiology in his evaluation that he often used in person. the first possibility is that he was intimidated by the overpowering vibe of masculinity that i exude; opntion "b" is that he is a redneck, white-bread, chicken-shit motherfucker who doesn't understand or appreciate the value of diversity. it's probably some of both, but i don't think my personal opinions are the issue here.
what makes me so angry is not the comment itself--i've been called much worse--but the fact that this remark is filled with ignorant sanctimony. given the chance to reply, i would ask: "is your bad grammar unprofessional?" it is not proper to end a sentence with a preposition! "where have your blood sugars been at?" NO, NO, NO! nor is it correct to ask a patient if she feels "nauseous." this word is the equivalent of "poisonous." what this troglodyte wants to ask is "are you experiencing any nausea?" substituting "nauseous" in the preceding sentence would imply that the patient could somehow make those around her feel nauseated. i admit that the strength of this argument is somewhat obviated by the fact that many of these patients are dim bulbs themselves and don't know the difference, but my point is that my reviewer likely believe that there is some objective, higher standard to which we, as doctors, should adhere, even if patients are not aware of it.
further interlocution would find me asking if it professional of him to be wearing a dingy oxford-blue shirt with visible armpit stains, a poorly tied tie, and a white coat with a mustard stain on the lapel? not to mention the khakis he frequently wore that seem to never see the inside of a washing machine. further unprofessional transgressions included lapsing into some kind of homeboy/ghetto dialect when speaking to black or hispanic people, constantly saying "fustrating," and walking into a meeting with a family while eating a donut. despite all this, my less-than-frequent shaving raised his ire. in my opinion, this man has somewhat spurious--or at least incomplete--notions of the meaning of "unprofessional." i would prefer a ruggedly handsome, stubble-ridden doctor, to one with poor grammar and a dirty shirt.
some decidedly un-professional facial hair:
i do not look like any of these folks.
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