Ahem

So yeah, apparently I'm not exactly a great communicator. About 10 minutes after my last post, "needy co-worker" called me up complaining that she's fat when she's about 3 sizes smaller than me. How rude do I have to be? I guess at least I'm learning how to be more confrontational.

Right now I'm ticking away minutes in the call room. I really just want to go to bed, but I'm stuck waiting on some lab results so that I can send someone home. Labs and pagers, these are the enemies of an intern.

Think Happy Thoughts

I'm ok, but I almost completely lost it with a co-worker tonight who won't stay out of my business. I have told her over and over that I keep my personal life personal, but she just keeps prying and trying to guilt me about not opening up to her. I told her off, but I think I was pretty diplomatic about it. I really just want her to leave me alone. Someone with common sense would, but then I'm not exactly dealing with that here.

The plan is to just relax when I have time off and avoid all contact... perhaps with everyone. Kind of like mini-hibernating. Maybe I'll take a day trip somewhere this weekend and get out of town. No phones, no internet, no pagers. It sounds lovely already.

Eat, Drink, and Be Merry

I think I accomplished all three of the above over this weekend, and even risked four hours of shopping on Friday. I even managed to find a cocktail dress for the upcoming department party! It actually wasn't all that bad, but I still have quite a bit of shopping to do. With having relocated this year, unfortunately most of my gifts will require shipping. Argh. The goal is to be done with it by next week.

My body took advantage of having three days off in a row by completely shutting down yesterday and going into full-on exhaustion mode. I guess I had it coming.

Today I'm back for another 24-hour day at the hospital, which will end with my semi-annual evaluation with my program director tomorrow morning. Yuck. I like the guy well enough, and I actually have some entertaining tales to tell him from "medicine" last month-- let's just hope I'm not completely delirius. Wish me luck!

Seriously?

24-hour call, again.

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My head hurts.

I just got paged by a local pharmacist wanting to know how much Robitussin with codeine to give to my pregnant patient. I wrote "1 bottle". You would think this would translate to whatever standard cough syrup-sized bottle is on the shelf. You would think wrong.

This guy tells me, "We carry this stuff in bulk, I can give her as much as you want."

I'm thinking: that's great dude, give my pregnant patient everything you've got, give her so much cough syrup with a narcotic in it that she can't carry it out the door. Let's see what happens. Perhaps she can score some sweet cash on the street for that stuff. Instead, I say: "How much did I say she could have?"

"You wrote for 1 teaspoon every 4 hours." (1 teaspoon = 5 mL)

"Good, let's give her enough to last her just a few days."

"Um, so how much should I give her? We carry it in bulk. I've got TONS of this stuff."

"Just give her a small supply, she's going to see her real doctor soon."

"Ok, how about 500 mL?"

Seriously? Seriously? Did you really just say that to me? This is a controlled substance, and my DEA number is technically not even real. "Um, let's go with SIXTY."

"Ok, we can do 60. Just so you know, I have this stuff in bulk."

"Great, thanks. You might want to save some of that stuff for someone else." Click.

And yes, I am being a little stingy with the supply on this one. My attending approved the dose, but I still don't like giving it, and the patient said she really didn't want to take it anyway.

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My head hurts.

Just prior to that I got a call from the nurses' station. Apparently, one of them is vacationing in Chicago with her mom, and wanted to know if her mom's antibiotic eye drops could be causing the rash on her face.

1. It's 10 pm. I have been here since 6:30 am.

2. I'm an intern.

3. I'm an intern on the "Obstetrics Service".

4. I don't even know this nurse.

So what do I do? I get out of bed(!), walk down there, punch the drug into my PDA and say, "Nope, don't think so. She probably doesn't need to go to the ER unless she can't breathe or her mouth/throat starts swelling up. Glad her eye looks better. Happy Thanksgiving."

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My head hurts.

I currently have an "induction of labor" cooking. Only instead of putting in a cervical-ripening agent that lasts for 12-hours, my attending went with the one that lasts for 4. This means that I have to check the patient and place another tab at 11 pm, 3 am, and 7 am. Perhaps he hates me? I don't know, I think perhaps he just didn't think about it as he also ordered her a sleeping pill. How is she supposed to sleep for 8 hours if I'm supposed to check her cervix several times overnight? Then, in the morning, after she's had a crappy night's sleep we'll start the pitocin drip, which will make her uterus start contracting and she'll really feel awful. Great technique, eh?

Just a few more minutes, and hopefully we can get her next dose going and I can grab a few hours of sleep.

A Bit of Bell Ringing

One of the nurses this morning said something about how she couldn't believe it was November 21st. Having had my coffee prior to rounding this morning, I quickly shot back, "I can't believe it's 2006!" And yeah, I was being a smartass, but I can't believe how fast this year has gone by. Many days I feel like I just got here. And yet there are signs that I've adapted: most days I am no longer consulting a map, and I have actually given someone else directions to get around town.

Given the time of year, some of you may be looking for a charity to make a contribution to. Or perhaps this is a daily challenge, as you sit around a room filled to the ceiling with Benjamins, thinking "I wish I could get rid of some of this cash."

Anyway, I just want to put in a quick plug for Heifer International. They help battle against hunger and create self-reliance for many impoverished families by providing them with livestock and training. You can contribute as much or as little as you want, and there's something rewarding about ordering something physical like a basket of chicks or tree seedlings to send to a family. I had never heard of this charity until Silk mentioned them in her blog one day, and I'm glad that she did.

I'm off to the grocery store. We're having a potluck on Thursday and I'm going to attempt to make my mother's mashed potatoes of buttery goodness. It will probably end up with me ruining her reputation as an excellent cook as my reproduction will be a mockery of the real thing. I guess I need one of those hand mixer thingy's as well.

Alarming

Since I didn't leave the hospital until after 8 am on Sunday, I wasn't required to be there for 6:30 rounds this morning. Hip-hip-hooray! At least that's what I was thinking when I went to bed last night. And yet, at 5:00 am this morning, I was awakened by alarms. At first I thought I had forgot to set mine back the night before. Then, I realized the noise was coming from outside.

I was thinking that is must have really dumped on us overnight as there were some flurries last night when I went to bed. However, when I peeked out the window, the streets were snow-free. The noise was that of several plowers, however they were scooping up the piles of leaves that have been pushed into the streets. Why there is a need to do this when those leaves have been there for at least 3 weeks, I'll never know.

It was still chilly outside. As I pulled out of my driveway, I noticed that there was a dusting of powdery snow on each roof, although none remained on the ground. The houses were decorated, like they were dusted with sugar... or perhaps cocaine--whichever simile you prefer, you decide. Anyway, it was powdery!

Long Road Ahead

My shift on call wasn't too bad. We had a c-section at 2:30 am. This one wasn't technically a "crash section" as the baby looked good. The woman had gone into active labor, and was scheduled for a section on Monday as she was 2 weeks past her due date, and the baby was estimated to be too large to deliver. At 5 am a "first-timer" came into triage, and to our surprise, she was over halfway dilated and ended up delivering at 7 am. This woman was a champ-- she labored mostly at home and had less than a half-hour of active pushing. All with only one dose of narcotics, and no epidural. I must admit I'm somewhat scared of the idea of giving birth.

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I was looking back at some of my older entries, and I came across this one. It occurred to me that I haven't done any goal setting in a while. Today I was back at the gym. I jogged for almost 37 minutes straight, and was able to do 3.5 miles without any breaks. Not bad, eh?

So here's my new set of 90-day goals:

1. Owe less than I do today. Lately, my credit card debt has been increasing, rather than decreasing.

2. Be at the gym at least 3 times/week. I think it is a little less depressing to set a schedule for myself rather than a goal weight.

3. Make some local friends who don't work at the hospital.

Uh, long-term goals I'm still not so good at coming up with. I do want to travel more, and figure out my career of course, but I have a hard time thinking that far ahead.

Lost and Found

Imagine it: there you are, asleep in your own room. It's completely dark, the temperature is perfect, and there is no place else that you feel more safe. A soothing lub-dub creates a gentle background noise that lets you block everything else out and go back to sleep. Your heart rate begins to slow, as you drift off...

Suddenly, the room shifts, and the pressure in the room itself begins to increase. A white light pierces the room from just behind you. It blinds you with a harsh intensity that you've never seen before. The very wall of your room is splitting open. You want to scream, but you can't. Not yet. There is a sudden burst of air against your skin, and giant rubber tentacles clamp over your head and drag you out of your room... surely, to certain death.

And suddenly, there it is. You can scream, and you do. With all of your might. The noise is overwhelming. You suddenly realize that you are completely soaked. And naked. And it's freezing. The tentacles are moving all about, and before you know it, you've been grasped by your shoulders and feet--not unlike a pig on a spit-- and passed over to a warm, dry bed. The tentacles use warm, white cloths to dry you off, but the noise is still there. It is deafening. You scream and scream and scream, but you're lost. You don't know where your room is. It is gone.

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That's how my morning started on Friday, only my hands were one of the sets of rubber tentacles.

6:30 am- It started when we walked by the OB triage room. Normally, heart tones on external fetal monitors tick away at a staccato pace. This one was about half what it should have been-- it was just above the pace of a second hand. The patient had been scheduled for a cesarean section at 7:30. The slow heart rate was a sign that the baby might not be getting enough oxygen-supplying blood via the placenta. We repositioned the patient and gave her oxygen, but there was no improvement in the baby's heart rate.

6:45 am- I'm scrubbing in at the OR

6:50 am- The first incision was being made.

6:54 am- The baby is out, and "just fine".

Although I've scrubbed more c-sections than I can recall, this was only my second "crash" c-section. My responsibilities are minimal as a resident in the OR, so I can just stand there, hand things back and forth, suction up blood/fluid, cut sutures, and help with the closing. I really like scrubbing in because you get to see a lot, without being the one under pressure.

This surgery was interesting to me because unlike all of the other ones, they did a vertical incision on the skin, but did the regular, low-transverse incision on the uterus. It's always fascinating to me to see the variance in practices of different doctors. This particular obstetrician believes he can get the baby out faster using a vertical incision.

Even more interesting, was that during the case, the scrub tech asked the doctor where a particular pair of forceps was. He had dropped one pair on the floor in all of the rush, and was using a second pair. However, the third forceps was nowhere to be found. Nowhere. Much cursing ensued. It is part of the tech's job to count the equipment before, during, and after each case. As there was no time beforehand, the pre-packaged kit was opened and used without counting. A similar problem had happened last week when the same forceps was missing from the kit.

He couldn't be sure that the forceps had not been included in the kit. All we knew was that we didn't have it. It could have never been included, or it could be lodged somewhere in the bedding, the patient's abdomen, or her newly sewn-up uterus. Bad times. Much more cursing ensued. Threats to file a formal complaint against the packaging service were voiced.

Then, I said very quietly, "I guess we need an x-ray."

"X-ray!" he bellowed. "I want x-ray in here now!"

While we waited for the x-ray to show up on the computer in the OR, he performed the tubal ligation, and we started closing. The x-ray confirmed our suspicion. There were no forceps in the patient; they simply had not been in the kit.

The rest of the day was uneventful. Today I'm back for a 24-hour shift. I'm kind of lounging right now. My work is done. I'm just waiting for the next mess to begin. None of the other residents wanted to scrub the case yesterday. It was the best part of my day. I guess I am an adrenaline junkie. Today, mama and baby are still looking great.

Toxic

On Monday, I participated in three delivieries. I was surprised the doctors let me do as much as they did on my first day since they didn't know me at all. Call overnight was painful. We had started inductions on a couple of ladies, and one didn't tolerate the medication at all. Part of night call responsibilities for this rotation involve returning messages to women calling the answering service with complaints. Surprisingly enough, I was actually able to answer a couple of the callers questions and prevent them from having to come in. I almost felt like a real doctor for a minute or two!

Today I attended an all-day toxicology conference. I had been looking forward to it for over a week as it meant an entire day outside of the hospital. Most of the speakers were well-prepared and had great powerpoint slides, but I just couldn't focus on anything. Normally, I'm interested in toxicology, as it's kind of a mystery to figure out what sort of medication the patient has taken to cause their symptoms. I just felt confused the entire time. I'm not sure that I gained a single thing out of the whole day, other than more calories than I should have consumed.

I had planned on going to the gym tonight (I went for a short run yesterday) and doing some homework, but that got dashed to pieces when my friend called in tears saying she was having a breakdown. Instead, I drove to her house where we watched "Lake Placid" and ordered Chinese food. I really didn't want to go over at all, but she's so unstable emotionally that I just felt like I had to. It's hard to be supportive of someone who internalizes everything and thinks everyone's out to get her. In reality, I'm pretty sure she is not much of a concern to everyone else. I also went over there partly because I felt kind of guilty for asking her if she's been taking her medication.

And then there was the 30 minutes I spent listening and supporting my other co-worker whose pregnant fiance is obviously having gallbladder issues.

Maybe it shouldn't come as any surprise that I often just want to sit on the couch in front of the TV and not answer the phone.

Just Call Me "Grace"

My mother told me once that her and my father picked my middle name because my first and last names were so long that they thought that the middle name should be short. My middle name, Ann, means "grace". This has always been somewhat laughable to me as I am anything but graceful.

Over the past 4 months I have been acclimating to life with hardwood floors. When I looked for a house, I specifically sought out one with hardwood floors. I have allergies, and didn't want to deal with musty carpets. For the most part, they make me happy. I can often be seen taking a few quick steps and sliding for a foot or two in my socks ala Tom Cruise in "Risky Business" only without the tighty-whiteys.

Anyway, on Sunday without even thinking about it, I went running up the stairs in my socks and tripped, striking my left thigh on the edge of a stair. People, I look like I've been hit with a baseball bat, and not just once, but a couple of times. I now have a dark bruise that wraps around the outer left half of my thigh, and it's larger than the area of both of my hands.

One of the things they teach us is that there are three areas of the body that one can bleed out into: the abdomen, the pelvis, and the thighs. One can lose a lot of blood into the chest too, but usually you will have symptoms of difficulty breathing from compressing the heart before all that much of volume has been lost. So there you have it-- a lesson in common sense and a reminder of the workup of a trauma patient all in one moment of clumsiness.

Regrouping

I survived my last call night on medicine! It was miraculous... no pages after 10:30 pm! I slept a whole night without being disturbed. I actually kept waking myself up every few hours to check my pager and make sure it still worked.

Tomorrow I'm on call for another 24 hours to start off my first day of my OB/Gyn rotation. I like delivering babies, though. It's not always convenient, and the hours are even longer, but it's fun. Besides-- 99% of the time, the baby and placenta just come out on their own, with your main function being to ensure that the kid doesn't fall to the floor and split its head open. And it's generally a happy environment, with nurses who really know their stuff and run the show... especially when the attending can't be bothered to make it to the delivery on time.

How to Save a Life

Ok, so the correct title for this entry should probably be something along the lines of "How to Keep a Senior Citizen from Having His Ribs Unneccessarily Broken", but whatever.

Today I was all done with my work, so I was just sitting around when all of a sudden a "Rapid Response" went off over the hospital intercom. A "Rapid Response" requires every available resident, respiratory tech, and critical care nurse to rush over like a mad person to try and help out.

Anyhow, one of the other interns and I took off down the stairs and over to endoscopy, where some dude had stopped breathing after they had given him some sedation medications. I was helping a respiratory tech give him some breaths via a bag-valve-mask when someone goes, "He doesn't have a pulse, start CPR!" Unfortunately, that person was feeling around unresponsive dude's feet when she said that. (Small arteries are not a good place to check for a pulse when in a critical situation.) I reached down and felt a good femoral pulse, and before they could do anything yelled, "NO CPR!" We hooked him up to a monitor which showed that heart was still working just fine-- he just had stopped breathing on his own after being given a benzodiazepine.

By that time, anesthesia arrived with a reversal agent which woke him up. I'm not really sure why the guy was sedated without being hooked up to a cardiac monitor, which would have let everyone know right away that he was still having a good strong pulse and in a regular rhythm. I'm also not sure why whatever surgical specialist stood back while an intern stepped in and assessed his patient, but then there's quite a few things about this hospital that I don't understand. I think the other intern was hovering somewhere in the corner during all of this, but then he's going into ophthomology, so maybe I shouldn't be too critical.

Tomorrow's my last day on inpatient medicine. Unfortunately, it's another 24-hour shift on call. I'm just hoping for more than 20 minutes of rest.

Cuckoo's Nest

With her heart racing, and her feet hammering down the stairs as fast as she could go, she ducked out of the stairwell. She had to get there quickly-- not that it would make any difference, but she was expected to be there. Heads would be counted, and if hers wasn't one of them, there would be consequences.

She flung open the stairwell door so hard that it bounced off the wall. Ahead of her, a metal pair of double doors was just about to shut. She slipped through, careful to avoid their menacing pathway.

She had never been in this hallway before, but she was sure that it was a shortcut. It would save her time; it had to. Where else could it lead but to her destination?

The doors closed with a confirmatory thud.

Ahead of her was a long, narrow hallway. There were no doors. People were scattered randomly along the hallway. All of them were talking, and yet not to each other. Some were in jeans, and some were in wrinkled hospital gowns, with only pasty, spindly legs supporting them.

She spun back around suddenly. The doors were locked.

There was no way out.

She looked frantically along the wall for the button.

Her eyes met his.

He hadn't shaved in about three days and there was a rolled up piece of paper dangling from his lips-- a crude imitation of a cigarette.

"Right here," he leered. "The way out."

He pointed to a intercom button. She jabbed it with her finger.

"Yes?" a cold voice inquired.

"Uh, I think I took a wrong turn," she sputtered. "I really shouldn't be in here," she said while looking up at a sky of insulated tile, her eyes searching for the video camera.

"Honey, neither should I. None of us should!" cackled a voice to her left.

She strode out of the unit and didn't look back, her face flushed. From then on, she would stick to more familiar passages.

Rollin'

As part of the next phase of my "Let's Not Die This Winter" project, I put snow tires on my car today. A couple of my friends were surprised when I mentioned that I was doing this myself, but it's really not that hard. I went to www.tirerack.com and bought a winter package to include tires and wheels. The tires show up at your door in about 4 days. Installing them took little over an hour. Best of all, it didn't include sitting around a greasy lobby trying to be engrossed by a 2002 copy of People magazine while someone else did it. If you are going to change your own tires though, perhaps the most important thing besides knowing where to put the jack is using a cross-shaped tire iron. It makes the job much easier.


Afterwards, I took the car out for a much-needed wash and vacuum. I cleared enough space to be able to park in the garage, too. The next step is an automatic door-opener, but that is not a project I'm going to attempt.

Short Circuit

Sometimes it is the little things that surprise you. Of course I knew that the leaves would fall as it got colder. What I didn't know is that they would fall in order. The leaves on the maple out front are like mini-paratroupers... all crammed in together, each one waiting for its turn to jump. It was surprising to me how orderly they seemed to fall, starting from the very top of the tree and working their way down the branches.


I am sure there is some sort of scientific explanation for it-- such as the nutrient-providing xylem and phloem not being able to reach the distal tips as efficiently. Perhaps if I had paid more attention in botany I would know, but then that kind of destroys the romance of it, doesn't it? Not exactly the sort of thing Walt Whitman would write about, I suppose.


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I worked a 24-hour shift yesterday. We had 9 admissions overnight. That's a whole lot of paperwork. One of the worst things about being an intern is that you aren't independent. Most of the time I end up being micro-managed by a senior resident, whose own responsibilities take precedence over mine. Sometimes they aren't the greatest at time management.

The hardest thing about being on call is that in addition to managing your own stuff you take calls on patients that you've never met. Half the time is spent trying to catch up, while being constantly interrupted by other junk. And then, because a lot more mistakes are made overnight, it's always necessary to check and re-check orders against plans to make sure that the morning team has everything set up. I slept 20 minutes total, and had about a 15-minute lunch and scarfed down a bagel at midnight for dinner while checking labs. Because we were so far behind all night, I didn't get to start my morning notes until we had signed out to the new team. I ended up staying 27 hours, at which point I got sent home.

Last night my PDA died again. This time my pharmaceutical program keeled over due to some inborn error, which just slowed me down more. Medicine is all about being able to access information quickly. And then, after I woke up this afternoon, I realized that I had left my cell phone at work! The electronics, they are out to get me!

Between all the quality of life issues we deal with, sometimes I think it would be better to go back to having only a handful of medications. So many people are on so many medications that it's all too easy to dose things incorrectly or have interactions. There was a pharmacist (not the cute one) that paged me about a dozen times last night. He kept cancelling my orders and switching medications without even speaking to me. In one case he stopped something because he thought that the patient was allergic, but she just develops some nausea and she'd already been given the medication by the ER without any problems. In another case, he switched someone to a cheaper antibiotic, but he wasn't aware of the culture results and didn't know that the bug was resistant to the cheaper med. Micromanagement, I hate it.

And then there was the nurse that paged me at 2 am to ask for the correct spelling of my name. My name is misspelled in charts all over the place, it's not really a big deal. Apparently, she thought I would get ticked off if I saw it misspelled in the chart. Fortunately, I wasn't sleeping, but I think that perhaps that one takes the cake for the most inappropriate page ever.

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Theme song for last night:

You need to know your friends,
You need to know that
I'll be waving my hand,
Watching you drown
Watching you scream--
Quiet or loud.

And maybe you should sleep,
And maybe you just need...
A friend.
As clumsy as you've been,
There's no one laughing.
You will be safe in here...

"Clumsy" -Our Lady Peace

Craptastic... literally

My friend, Ru, once wrote about driving down the road and spotting some roadkill lying there with a fresh coat of white, striping paint running right over its flattened carcass. Her observation was how no one bothered to take responsibility to move the dead beast because "It's not my job."

That was kind of how my day was today. So far November is kicking my butt. I think I had a 15-minute break total during my 10-hour day. The story is too boring and difficult to condense, but it basically ends with me having to do a rectal exam on a patient that should have been done 5 days ago. In the process, I got chewed out by a discharge planner who said I had to "get it done in the next 10 minutes or the patient won't have a bed to go to tomorrow" when said discharge planner did not return my pages for > 2 hours earlier in the day.

From my point of view, today's chain of events are the end result of a big steaming pile of incompetence involving the admitting attending, senior resident and intern; the intern that dumped this patient on me; my senior resident; my attending; and the discharge planner. I have no idea if this lady will get out of the hospital tomorrow or not, but I think the above persons should have to split to $500 cost of another day in a hospital bed between them. I was fuming by the end of this task, as I couldn't simply develop the test card on my own as there is another steaming pile of beaurocracy that prevents one from being able to get anything done without formally having a nurse enter orders in a computer.

If I was a smarter woman, I would have just told the planner that the task was impossible to get done that quickly and not spent another second worrying about it. But I am not a smart woman, and I don't even heed my own advice about not letting people get on your nerves.

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And then I stepped out into the night... It was only 5:15 pm, but the sky was completely black. Snowflakes twirled in the yellow light of a streetlight. The flakes stuck like velcro to my black wool peacoat, and for an instant it was oddly tranquil, the calmness flickering down on me like the little chips of plastic in a snowglobe.

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I went for a run at the gym after all of that. And now, instead of being exhausted and angry, I am simply exhausted.