OB/Gyn

After TICU, my month on the OB/Gyn rotation was pretty relaxing. And that's saying a lot, considering that I truly hated my OB/Gyn clerkship as a medical student, and that I consider Gyn to be the area of medicine which I least understand.

I'm sure I got a bit of favorable treatment since Karen is an OB/Gyn resident. But I also tried to work hard and combat the unfortunate stereotype that rotating ER residents are always watching the clock.

Most of the attendings were great. During my first week on the delivery floor, I caught 10 newborns and got some excellent teaching from the private attendings. There were also a few occasions when things moved along faster than expected and there was an urgent call for "any doctor" to a delivery room. I arrived moments later, threw a pair of gloves on, and caught the kid before any of the attendings showed up. It made me feel like I was actually doing something useful.

Overall, good schedule, good conceptual learning, good procedural learning.

Trauma ICU

Trauma ICU, aka TICU.

Ugh. Just thinking back to this month makes me cringe. My time there was just so painful. With the exception of my immediate team of residents, it felt like everyone there was miserable. All the time. I don't mind working hard. But I mind it when attendings mistake ridicule for teaching. Hence me not going into general surgery.

I did a bunch of subclavian lines,which was a good procedure to get comfortable with. I had the opportunity to do two chest tubes...until the visiting MICU resident stole one and the attending insisted the surgery resident do the other one. Grrrr. That was one thing I really wanted to work on while I was there. Since my other residents never screwed up their lines, there weren't any iatrogenic pneumothoraces giving us cause for chest tubes. I suppose that's for the best.

Most of the nurses were smart and reliable. Some were friendly and offered tips on dealing with different attendings. Some were loud, mean, and untrustworthy for reasons passing understanding. At least I made enough friends so that they would usually let me sleep an hour each night.

Anyway, there were no major screwups while I was covering the unit. No preventable deaths. And while I emerged as a more confident doctor, I'm not really sure what I learned. How to be a more efficient lackey, perhaps?

Pediatrics

Pediatrics floor month.

Since pediatrics was my very first rotation as a third year medical student, and it has now been (thinking...) nearly three years since that time, I'm due for some review. Yes, I already worked a month in the pediatric ER, but it's hard to really get a sense of "sick vs. not sick" if you don't see what sick kids really look like. And since H1N1 already hit (the peak was 3 weeks ago, maybe?), and we're at the near-peak of bronchiolitis season, I have to put on the additional "contact precautions" attire for nearly every patient I see during the day. I've done a few LPs during this month, mostly since I've done more of them recently than most of the other interns. Otherwise, lots of parental counseling regarding home antibiotic regimens, warning signs of more serious illness, etc. One parent was particularly hyper-vigilant. Her daughter had thankfully survived a bout of septic shock precipitated by a community acquired pneumonia, and she was terrified about bringing her home again. We explained the mechanism of septic shock over and over, and said that after 3 weeks in the hospital, she was back to her regular healthy self. I had to review the child's full set of labs, including some of the esoteric results we get from the lab that none of us really use (e.g., mean platelet volume), and explain to the mother that not every single value has to be perfectly normal before discharge (or that, in the average healthy person, not every value will be perfectly normal all the time).

Anyway, the pediatrics residents were generally nice and fun to work with. Overall, a good month.

ER

I'm working in the adult ER this month. Finally! I'm excited to finally work in my part of the hospital -- although this is my only month here until May-June. I better enjoy it while I can -- TICU is coming up next month.

Orthopedics

Orthopedics.

A relative easy month...mostly since we're not allowed to do much. It's understandable in a way, since the 2nd year ortho residents only get a few months of orthopedics their first year. I assisted with a bunch of fracture reductions and casting, "revised" a few finger amputations before closing them, and otherwise looked at a lot of films. Learned a lot conceptually, learned only a little in terms of procedures.

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.

Happy 2008

Hello!

It's 2008. Things I have celebrated (?) so far in 2008 include:

- the start of my surgery rotation! Seriously. Waking up at 4:30am is one of my favorite pasttimes.
- the arrival of springtime in Cleveland (65 degrees in January?) followed by the return of actual winter
- my new hatred for Bank of America. I really, really loathe them. If every BofA were to spontaneously erupt in a shower of giant fireballs, I would feel much better. Maybe I can just hope that their purchase of Countrywide (one of the leading sub-prime lenders in the country, I think?) will somehow lead to their own little Enron-style corporate implosion. I doubt it, but one can hope. Grrrrrrr. Fireballs.

One more thing

I hate my upstairs neighbors. While there are many things I like about this place, the neighbors are not one of them. The loud rap music blasting out their windows at 12:04am on a Monday night is just one reason I hate them.

Back in the routine

Another day, another attempt at a blog post.

I'm tired. And I shouldn't be. I'm on an outpatient block right now, which means I'm working an easy 8-to-5 schedule, more or less. I should be resting up for the inpatient surgery and medicine rotations I have coming up. From what I hear, those are supposed to kill me.

Except that I'm not resting. Part of it comes from the fact that I'm trying to finish up my two research projects. One was supposed to be done ages ago and is still somehow taking up my time. The other one, well, I suppose I knew I'd be working on it at this point. The other challenging thing is the fact that Karen has a particularly brutal schedule that requires her to get up at 4am every morning for work. (That's what I'll be doing in January and February.)

But that means that I also wake up at 4am. I don't stay up long, but it's usually long enough for me to fully wake up and spend a little bit of time getting back to sleep. I just don't feel as rested afterwards. I don't blame her; we all know that we'll have that schedule at some point. In January and February, she probably won't be too thrilled to hear my alarm going off at 4am as I get up and head into the hospital for surgery pre-rounds.

Time to stop whining and get to work. This abstract isn't going to write itself.

A short hello

Hi there.

It is December. I keep starting to write on here, then I get distracted, save the draft, and forget about it. This post will be short so I can write it, save it, and post it.

It has been a busy few months. I finished my research block at the end of October and have been back on rotations since then. And I'm starting to think pretty seriously about the residency-related application fun that will be coming up in just a few short months.

Between now and 2008, however, I just have outpatient clinics to attend. They're usually not that hard. However, the surgery clinics are always overbooked, which means angry patients, which means frustrated residents, which means no real interest in teaching. Wonderful.

Happy holidays to everyone!

(cough, cough)

Hello.

It's August. I started writing this post in July. Early July, in fact. The real post I wrote was in April, and I think I made some comment about trying to post more frequently since I would have less free time than ever.

At least I was half right -- on the "less free time than ever" part.

The last four months were pretty intense. A month each of Pediatrics, OB/Gyn, Neurology, and Psychiatry. I thought Peds was fun and worth considering, and Neuro was interesting but probably not my future path. Psych was fascinating, but not in a wow-I-would-like-that-career sort of way. And my month of OB/Gyn, despite my best efforts to like it, made me feel primarily like I were being flogged. I was lucky to deliver a half dozen babies during this time, but it wasn't enough to make up for the rest of the experience.

Anyway.

I'm now on a break from rotations. We have 4 months to do research during third year, and I was lucky that I got my research block during the summer months. I don't have to start my next set of clerkships until November.

Let's see what has happened since I last posted...not that much, really. Except for...

• going to two weddings on opposite corners of the country (San Diego and Maine)
• taking out yet another outrageously large student loan
• moving into a new place with Karen
• starting a garden
• getting screwed by my ex-landlord (re: security deposit) and making plans to take her to small claims court
• training for a marathon
• buying a kitten!

I think that's about it for now. I'll try to get some photos of the kitten online at some point.

Time flies!

What a busy month! I took the boards, vacationed in San Diego, and tried to mentally prepare myself for life in the hospital. And after just a week and a half as a 3rd year medical student, I can say with confidence that I had no idea what I was getting myself into. That isn't to say I'm unhappy -- in truth, I've loved my first real exposure to working in the hospital. But it's just such an enormous change from anything I've done before.

"It's like an 18-month job interview," said one of the speakers at our orientation last week. And she was right. Try getting to know your coworkers, while knowing they're responsible for evaluating you, and do it in a completely new environment, with completely new software, with a completely new schedule that is often revealed to you just days beforehand. Also, remember that your responsibilities are not clearly outlined, they change according to who is supervising you each day, and you should always try to anticipate what will be expected of you.

So far, though, I'm having a blast. Now I just need to get to sleep earlier. I have a relatively easy schedule this month -- getting up around 5:45 am, in the hospital by 6:45, done most days by 6:00pm. My friends on Neurosurgery, though, are waking up at 3:45 am to be in the hospital by 5:00 am. Or earlier.

Anyway, sleep time. Now that I have less free time than ever, I'll try to start posting again. :-)

Mood: optimistic
Song: The Killers, "Read My Mind"

Coming Up For Air

I'm back. For as long as it takes me to write this post. I'm in midst of my preparation time for the USMLE -- the United States Medical Licensing Exam -- and I frankly don't know how I'm going to keep studying. I finished class more than two weeks ago, and in that time I have been studying. All the time. I did take one quick trip to California for a full 48 hours, but other than that weekend I have been studying.

How much studying? I'm aiming for 12-14 hours/day. I usually get in about 9 to 10, maybe 11 if I'm really on top of things. The schedule is pretty simple:

8 am: Wake up
9am - 12pm: Study block 1
12pm - 3pm: Study block 2
3pm-4pm: Magical afternoon free time for errands, recovering my sanity, talking to myself, etc.
4pm-7pm: Study block 3
7pm-9pm: Eat, go to the gym, eat, sit around in a stupor.
9pm-12am: Study block 4
12am: Bed.

Now, let's be honest. Am I really following this schedule? No. But am I trying? Yes. Sort of. Keep in mind that it's 2am now and I'm just finishing for tonight. Eh, so it goes.

And this is what I aim to do between now and March 7th. On March 8th, I will do my best to relax. On March 9th, I take the exam. And the next morning, I'm on a flight to San Diego.

For now, though, it's time to sleep. Tomorrow's Study Block 1 is rapidly approaching, and neuroanatomy is on the schedule. Good times.

Mood: determination, mixed with a little cabin fever
Song: Boston, "More than a Feeling" and David Gray, "The One I Love"

Merry Christmas!

Hi all --

Here is the obligatory Christmas post. Merry Christmas! I'm thrilled to be home, rested, well fed, rested, with family, and rested.

Time for another snack!