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.
Wednesday, August 12, 2009
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.
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