MICU

I survived 4 weeks in the MICU, aka medical ICU. For the non-medical people, the MICU deals with serious "medical" problems -- e.g., bad pneumonia requiring a ventilator, bad cases ond H1N1, sepsis, kidney failure, cancer, other bad infections -- while there are other ICUs for post-surgical issues (surgical ICU aka SICU). There are also similar places for heart disease (cardiac care unit or CCU), traumatic injury (trauma ICU or TICU), etc.

It was a hard month. "Sleeping" in the hospital every 3rd night, aka working through the night every 3rd night, gets old fast. I'm glad to be done with it. But I also had a really interesting time, and I learned a ton. Lots of sick people requiring a lot of care = many opportunities to practice medicine. I placed about a dozen central lines and became much more comfortable starting patients on pressors than I ever expected to be. I also realized how Not Sick many of the so-called Sick patients I see on other rotations really are. If your kidneys are still working and your lungs aren't filled with fluid, walk it off. Or something like that.

We did have a half-dozen patients with H1N1 influenza. A few were really, really sick for weeks. Most were just semi-ill for a few days and then got transferred to the floor. Seeing patients who had been on a ventilator for over a week because of H1N1 certainly made me careful about always wearing a mask!

Next month: orthopedics! And a week of vacation! And Christmas!

Internal medicine wards

Ahhh, medicine wards, aka the floor. Where things always go....so.....slowly. I learned a lot this month, some of which will be useful in the ER, some of which will not. I did spend many, many hours walking through the hospital. And many, many hours on the phone with social work. I did have a few exciting moments, such as the Code Blue announcements that I ran to and during which I (occasionally) intubated patients in trouble.

I have the utmost respect for social workers -- in part because I'm absolutely terrible at the sort of things they work on. And despite the 75 hours/week I worked in the hospital, it seemed like I spent 15 hours seeing patients, 20 hours rounding, and 39 of the remaining 40 hours working on social work and discharge paperwork.

I had a patient this month who had been in the hospital for 6 months. But by the time I saw her, she wasn't sick. She was actually my favorite patient -- every day we'd spend a few minutes talking about her medical condition (a few aches and pains), her background (Broadway performer during and just after WWII), her daily breakfast (bacon was always overcooked), and the hospital-provided socks (not as warm as she'd like).

She had been admitted for a basic problem that only needed 2-3 days of treatment, but the neuropsychiatry team determined that she wasn't safe to go home by herself due to dementia. Her doctors contacted the social workers and case managers to get in touch with family members about having her placed in a nursing home of some sort. 2 weeks passed.

Oh, except she doesn't have any family members we know of. So we tried to have a guardian appointed for her. Another month passed.

It turned out the patient has a very close friend who knows about her dementia, so we tried to set things up to have her become the legal guardian. 3 weeks go by.

Except her friend is fairly poor, and it turns out you have to pay to process the paperwork to become someone's guardian, and the friend can't afford it. So then the hospital tried to pay the fees for the friend to become the guardian, but for some legal reason you can't do that, so then the hospital contacted the state government to somehow get them to approve it, or pay for it, or something like that, but then the state said they needed a physician to certify that the patient had dementia that would not respond to medical treatment, which I did, and then the social workers said it would be another 30 days for things to get approved.

When I checked the hospital census a month later, she was still there.

The surprising thing? Her 8-month stay looks like nothing compared to the patient who had been there for 3 and a half years.

Pediatric ER

Finishing my month in the pediatric emergency department.

Highlights? Making some very cute kids feel less scared. And helping some scared parents realize that their kids will be okay. Learning to fix a nursemaid's elbow. Doing a lot of lumbar punctures. Taking medical command calls from ambulances. And learning a ton.

Frustrations? Parents who are angry they've had to wait a full hour (!) to see a doctor. ("My doctor's office is faster than this!") Especially for a child who is "feeling sad" -- nothing else. Or a kid who got in a disagreement with their parents over household chores. Or one who had a headache earlier but now feels fine. Or, parents who want a "full diagnosis" but refuse an IV for their child...or x-rays...or any tests at all. Also frustrating? Attendings who ask me at the end of my shift to "just help with a couple more things"...that then take two or more hours to finish.

Scary things? Seizing kids still freak me out. I know what to do...but still...

Week 1, so to speak

Okay, I haven't technically started emergency department shifts for real yet, but during orientation I had a couple shifts to get acquainted with my future home. I had forgotten how sick people are -- and, sadly, how much time we spend seeing patients who just want high-potency painkillers...or who want us to babysit their kids...or who insist that they need a CT scan for their stubbed toe that doesn't hurt anymore...or the drug abusers who want plastic surgery to repair the laceration they inflicted upon themselves while high. Hidden among them are the truly sick people. The trying-to-die-in-front-of-us sick people.

And in the first few shifts, I've seen patients with all sorts of problems. The normal -- pneumonia, heart failure, cholecystitis, elderly fall-from-standing patients. The semi-rare conditions like recurrent primary sclerosing cholangitis that I barely remembered from med school. The ticking time bombs like acute aortic dissections. Normal trauma cases, like the non-helmeted motorcyclist who went out for a leisurely ride and was hit at high speed by an SUV. The usual trauma cases -- "I stepped on a garden rake and it went through my foot" to "I slipped and my leg went under the lawnmower." The violent, psychotic patients who try to break everything in sight -- and then start crying -- and then threaten to kill your family. And the demented, frail older patients who are just plain confused and decide to start hitting you while you're performing an ultrasound to diagnose them.

My first month will be split between anesthesia (airway/intubation skills) and ED ultrasound. It's probably the easiest rotation of the year, so I better enjoy things I while I can!

Looking Ahead

Match Day has come and gone. And in June, I will start work at Rhode Island Island Hospital, as part of the Brown University residency program in Emergency Medicine! Between now and then, I'm also getting married, graduating from med school, and possibly buying a house or condo.

Busy much?

Hi.

Hi.

It is an interesting time. I'm done with clinical rotations, and now I fill my time by teaching first year med students, finishing my current research project, and going to the gym. I even submitted entries to a few medical student essay contests. Yes, an essay contest just for med students. Because we're known for being such excellent writers.

Anyway, things have been slow. Fortunately, for the last week, Karen and I have been on semi-vacation in Minneapolis, working on some in-person wedding planning. We visited our ceremony and reception sites, tasted some wedding cake samples, and finished most of our gift registry.

I've also been reading for fun -- Paul Starr's "Social Transformation of American Medicine" -- and keeping up my workouts. I've also been playing Wii sports for 1-2 hours a day. Tennis + boxing = very sore shoulders.

Tomorrow we fly back to Cleveland. And Monday we get emails to say whether we matched (yay!) or not. And Thursday is Match Day.

And then we can start planning next year for real!

Where does the time go?

May. Late May. Time to start blogging again.

I'm finishing my first of two consecutive months of ER rotations. I've been building up some pretty high expectations for these months. Since I've been thinking all through med school that emergency medicine is where I will end up, it's hard not to make conclusions about my future career based on these shifts. I need to recognize that there are ups and downs to it, much as there are in other fields of medicine and, for that matter, in any sort of job. But, perhaps more importantly, I need to look through these ups and downs and see whether the underlying responsibilities and daily activities of an ER doc are something that I could do for a few decades.

So far, so good.

My last few shifts have been particularly rewarding. I feel like I'm finally getting a sense of how the department works, how to most efficiently manage the patients I'm seeing, and how to handle some of the basic procedures performed in the ED. I've done a few I&Ds, a few laceration repairs, and tonight I did my first digital block. Nothing fancy, but it feels good to have at least some basic skills other than interviews and physical exams.

For non-medical folks: you'll notice that I'm using a variety of acronyms, and most of them are interchangable. People have heard of the "ER" and the classic TV show of that name. Some emergency physicians (EPs) now prefer the term ED (emergency department) since the physical space is clearly more than just a couple rooms. And EM (emergency medicine) encompasses the field as a whole.

Okay, 2:54am. Time for bed.