Saturday, April 28, 2007

Patient Art

This was given to me by a patient the other night. It looks like it should be a tattoo.

Thursday, April 26, 2007

Closing Time

I went out for a quick drink with a couple of people after work last night.

I don't know that it's necessarily a good thing to show up to a bar in scrubs, but whatever. My bartender friend was there and he was just as clever and eccentric as ever.

Being tired + a shot of very fine whiskey = a numb nose for several hours.

Monday, April 23, 2007

Spit It Out

Chris asked the other day what grosses me out, so here goes:

I can't stand spit.

I can't watch people cough up phlegm, and spit it out with a gleaming string of drool hanging from their lips.

Even worse are the drunk, or near passed-out ones that end up with globs of mucus slipping and running down their cheek like raw eggs.

It makes me nauseous and start gagging. Luckily, I've never actually puked from seeing someone hawk up a loogie. And I don't know what's worse, watching them spit it out or swallow it back down.

You can reach for the suction tubing and try to get rid of all of that stuff, but the gurgling sound of the spit getting sucked up grosses me out also.

And I don't like sticking my hands in people's mouths, either. There's nothing worse than peering intently at someone's rotten away molars and having them breathe in your face. I don't know how dentists do it. If I worked in a dental office, I would require patients to gargle with mouthwash before I saw them.


Feet are not my favorite either. Especially, when you peel off someone's sweaty socks and large flakes of skin go flying into the air. You try and time your breathing, but it's impossible. Somewhere in your nasal passages, some foot flakes get stuck, and the memory of the smell will be stuck in your head all night.

The other day I saw this guy with nasty trenchfoot... as in George Washington's soldiers marching barefoot through snow, trenchfoot. The bottoms of his feet were slimy and yellow, with thick, soggy skin. The tops were swollen, red, and ulcerated. Luckily, there were no maggots. That I actually haven't seen... yet.

Old, twisted, thick with fungus toenails creep me out, too.


So there you have it: dental hygienists and pedicurists are people who in my mind cannot be paid enough.

Thursday, April 19, 2007

Monday, April 16, 2007

2nd Chance

The tulips I planted last fall aren't anywhere near blooming, but these ones are keeping me happy in the mean time.

Last night I got another chance at intubating. A woman came in who was unresponsive, jerking her arms and legs all over the place. She was fighting against everyone and randomly coughing and spitting. Her husband was there, but he said that she was very secretive about her medications and he had no idea what she had taken, just that she was acting bizarre all day and kept falling throughout the day. We tried calming her down with some benzodiazepines, but that did nothing, and didn't help her tremors. She seemed to be having a lot of trouble breathing and controlling her secretions, so intubating was an easy decision.

I once again had a full audience as prior to intubating her, it took five people to hold her down. This time I got it! It took two tries because she had a tight airway and the first tube I tried was too large. Things also got a little hairy as she started dropping her heart rate and oxygen saturation after the medication was given, but that all corrected with intubation.

Since we weren't sure if she had overdosed, was going through some sort of withdrawl, or had a brain injury, she got a pretty extensive workup. When everything came back essentially normal, I called the neurology resident who proceeded to yell at me for intubating her and literally hung up on me. Then he snuck in and saw her without talking to anyone. He basically copied my notes off the chart and wrote that he didn't think it was a seizure and that she needed to be seen by a psychiatrist when she got extubated. I am really getting tired of that service. We wanted her to get an EEG, but those unfortunately have to be ordered by the neurology team. I realize that her being sedated kind of messes up his ability to examine her, but I couldn't very well wait until she aspirated on her saliva and stopped breathing. I also didn't have time to wait for him to come down and see her before securing her airway.


My other "big case" of the night was a 25 year-old with two seizures earlier that day. He had been seen at another hospital, and sent home. I was waiting for the report from that other hospital to decide what all we needed to do for him. My attending said that as he had another seizure since being evaluated there, we needed to do the whole workup. That turned out to be a very wise decision. I was sitting at the computer reviewing all of my patient's results when I pulled up his CT scan. It hadn't been read by the radiologist yet, but clearly there was a huge problem. I saw what looked to me like a tumor, and he had some sort of blockage (obstructive hydrocephalus) that was causing the CSF to accumulate on one side of his head and compress the brain tissue. It wasn't good, and just seeing it made me nauseous.

I pulled my attending away from what he was doing and told him he had to see this scan. I think he thought I was crazy at first. Then I went over the images with the radiologist, talked to neurosurgery, and ophthalmology. Then I had to talk with the patient and his entire family about the findings. I tried to explain it as best I could, but in the end, I ended up showing his mother his head CT. I don't know how to explain the other hospital's decision to send him home, but when I left he was going to get an MRI and he may need surgery right away.

Last night I had a hard time getting to sleep. Two traumas came in at 5 minutes before sign-out and I stayed late doing some dictations, but I was still wide awake at 3 am when I got home. It was snowing hard on my drive home. I just kept thinking about that patient. If it had been up to me, I would have just repeated his labs and not his head scan. This scan was so abnormal that staff from across the room noticed it and kept asking who it was. We never did get the report from that other hospital. Everything else was faxed over, but they said there wouldn't be a typed report until during the week. That's the sort of thing that terrifies me. Forgetting to check one lab or study could be crucial.

Sunday, April 15, 2007

Just Another Day in the Department

Last night was a Traumafest. So far, traumas haven't really meant all that much to me because the second-year residents run them. So while they are busy assessing patients and getting to do cool procedures, I'm off in the back of the department talking with Mrs. Smith about just exactly where her belly pain is and getting her to describe her vomitus. Last night my favorite attending was on. This guy just has such a great attitude. Even when he's stressed out, he's still really good-natured and great at supervising.

A trauma came in that the second-year had taken a radio call about. I was free, so I went and helped assess the patient. His breath sounds were good, but when you pressed on the lower left part of his chest there was a crunching sensation and it was quite painful for him. Sure enough, the chest x-rays showed a lot free air was trapped under the skin and several of his ribs were broken. His lungs were both inflated so we ordered a CT scan to get a better view. The CT scan showed a pneumothorax (dropped lung) and the surgery team started talking about putting in a chest tube.

The third-year resident looked at me and said, "You're doing this tube." I was happy about this, but also somewhat concerned about screwing over the second-year resident as it was technically her patient. To get certified in procedures we have to do so many under supervision and get signed off on them. There have been instances in which interns have been given procedures when a second-year still needed them and has less time to get them done because they are closer to graduating. To me, it wasn't worth gaining an angry co-worker for the next year. I gingerly approached the second-year and made sure that she had all of her chest tubes. Luckily she did, so the chest tube was mine!

Now the heart starts beating faster and the anxiety starts kicking in.

For an emergency medicine resident, putting a chest tube in is about the closest that we get to performing surgery. Technically, post-mortem cesarean sections (yikes) and thoracotomies (cutting open the chest to directly get to the aorta to clamp it) are more difficult, but those procedures are so few and far between that I most likely won't do them on real patients during my training.

My attending asked me to get everything set up. I hadn't done a chest tube since September. And, while the patient was stable enough that I had time to get him to sign consent forms, order the medications, and talk to his family first, I didn't have enough time to read over the procedure first. So, I wasn't as prepared as I could have been.

To make things more high stakes, there was a fourth-year medical student, a psychiatry intern, and an internal medicine resident that wanted to watch. The third-year and attending were supervising me, the second-year was going to perform the sedation (which made her happy as she still ended up with a procedure), and the patient's nurse was present, as were a couple of techs.

There were certainly a lot of eyeballs focused on me now, while I tried to run through the procedure in my head. I gowned up with a mask, booties, sterile gloves, and the sweating started. I had to be helped prepping the chest with betadine as I had forgotten to do this before getting sterile. Luckily, the patient was sleeping soundly, so I was free to take my time.

My attending and senior coached me through the procedure. After numbing him up, I cut into the chest with my scalpel and felt for the next higher rib. My hemostat found its way to the parietal pleura (rubbery-like layer of tissue that encases the lungs). By this time, everyone was pressed up against the bed, and air was bubbling up through the blood because of all of the pockets of air that were trapped in the layers of skin. I traced the path of the hemostat with my finger and made sure I was right where I wanted to be.

With a quick plunge, I shoved the hemostat up over the top of the rib and into the thorax.

Air gushed out at me. I widened the hole with my finger and my attending checked my position. This chest tube was different than the other ones I had done because the lungs were mainly still inflated. You could feel their rubbery fullness. I guided the chest tube into place and then closed my incision. An x-ray confirmed it to be in the right place.

I couldn't have asked for a better scenario. The patient was stable, and my supervisors were patient. I was rusty enough on the procedure that my confidence was somewhat shaky. Now I feel much more prepared. If an unstable patient comes in tonight needing a chest tube, I am sure that I can get one in much more quickly.


Then there was the asthmatic that came in very combative and in respiratory failure. My attending took a radio call saying that they were 2 minutes out, and told me to get the room ready. This time I redeemed myself by having the suction, laryngoscope, and endotracheal tube prepped and ready, with backup tubes and blades if needed. The rapid-sequence intubation (use of a sedating agent and a paralytic) went smoothly with the exception that I couldn't see the vocal cords, so my attending had to help out and reposition. The patient got switched over to the ventilator and sent up to the ICU for management.


By this time of night, the second-year resident had left. Another car accident came in, and that meant I was running the trauma. It was a young guy, and he was a lot more stable. I was able to take my time and systematically look him over from head to toe. X-rays and labs didn't turn up anything, and I ended up turning him over at sign-out with a nearly-completed negative workup.


Another cool thing I got to do was trephinate a toenail. This lady had dropped something heavy on her foot and there was blood trapped under the nail. So, we grabbed an electrocautery tool and basically shoved a red, hot poker into her toenail... after numbing her up with a nerve block first. It wasn't very satisfying though, as the injury was old, so there wasn't a whole lot of blood released.


All in all, I don't think I could have asked for a better shift. I was carrying a crazy amount of patients because the senior basically acts as a supervisor and doesn't see his own. Also, the off-service interns typically don't handle more than a couple of patients at a time. For my other patients, it took a little bit longer for me to get them taken care of, but by the end of the night things were pretty well cleaned up. Now I just have about 90 minutes of dictations to do, and an hour of review reading to keep up with myself.

Friday, April 13, 2007


I just ran 7.15 miles! Woohoo! I think I'll go collapse now.

Wednesday, April 11, 2007


At the end of my shift last night I signed over three patients to the incoming residents. Oddly enough, they all had a complaint of seizure. It's weird how sometimes there is order among the randomness of my job.

This morning at 5:45 I awoke in a cold sweat. My heart was racing. I suddenly remembered there being a fourth patient that I completely forgot to tell anyone about. And worse yet, I had sent her for a head CT and given her a whopping dose of fentanyl (a narcotic) by IV. I could picture her face and remembered a bit of our conversation, but not much. Today was going to be a crappy day, particularly if it was several hours before anyone found out about her overnight. What if she had stopped breathing or had a head bleed that no one discovered for hours? I drifted back to sleep, dreading going in to conference this morning.

Now that several hours have passed and I am awake, I know for certain there was no fourth patient. It was just a dream. The face I'd pictured was one of our nurses. But this morning it seemed so real. I have been a little frazzled lately. I think this is just a manifestation of my worries about forgetting something in all of the rush. It was creepy though, waking up like that.

Oh well, back to work...

Monday, April 09, 2007


I may not have touched on this before, but I am a person who thrives on deadlines. Papers in college got written in massive marathon sittings the night before. Often things were printing as class was starting. Sometimes I didn't have time to spell-check them first. And yet, papers I cranked out generally tended to get scored higher than the ones I edited, and re-edited to the point that the original passion behind my arguments was diluted out.

I have signed up for a 10K next month. I HAD been working out pretty regularly, however I have done nothing for over a week now. Today I tried to do some speed intervals on the treadmill, but I died on the second segment. I think that a good part of that is due to getting up on 5 hours of sleep, and consuming nothing from 6:30 am until after my failed 6 pm run. I just didn't have anything left.

Part of my problem is the last three shifts I have worked have been starting earlier each day, so I have been building a sleep deficit. I start later tomorrow though, so hopefully I can put a stop to it tonight.

Here's to hoping I can step it up a notch.

Saturday, April 07, 2007

...and Another Thing

On my flight out, my tube of toothpaste got confiscated! I know there's the whole 4 oz limit on liquids, but the tube was nearly empty, so I figured they would count the amount of substance present. Apparently, they are more concerned with the size of the container? I don't know how having an 8 oz tube with 1 oz of toothpaste is more of a threat than 4 oz in a smaller tube, but whatever. I didn't even know that toothpaste was officially a liquid, but apparently it is quite the dangerous substance! I also got chastized because my clear plastic bag was not the quart size, but the half-gallon size. I only had about 4 items in there, so they didn't give me too hard of a time about it.


Also, on another street in Manhattan, there were several firetrucks stopped in front of a high rise. As I passed a woman on the street, she asked me for money for food. I was in a hurry, and she was dressed better than I was, so I said "No." Along the way, she said hello to several bystanders as if she knew them personally, and I noticed that she wasn't asking just anyone for money. When I stopped at the next corner to wait for the light, she caught up to me and asked me again for money. I said, "You just asked me for money a minute ago!"

"Well hey, that's good luck!" she replied.

I've never heard of it being good to be hit up by the same panhandler in a few minutes' time, but I sure must look like a sucker. Not only did she select me out as being an easy target once, but twice!

Friday, April 06, 2007


I went out of town for a few days earlier in the week and met up with some friends from back home who were visiting family in New Jersey. It took a plane, a subway, and a metro train to get there. Their sons are now ages 2 and 4 and have grown so much since I lived with them last year. It was a noisy two-day visit and I was quickly reminded of all of the noise that goes along with living with toddlers. We did not do anything special, just visited for a couple of days.

J and I went to college together, both on pre-med tracks. Somewhere along the way she got married, went into nursing, and started raising a family of her own. I think that there's always a bit of awkwardness between us now. When she looks at me, she wonders what it would be like to still be single and going through residency training. She sees me struggle and I think that she's happy with her decision for the most part.

When I look at her, I think of the people I pushed away to get to this point, always afraid of getting attached to someone. Most of the time I think that I am happy with my decision, but every now and then she makes me question it. Overall, I guess I feel like all of this education and training has kind of put my life on hold. I'm at the point where I can finally start having more say in what I do, and where I'm going as far as this whole career thing goes. I think that the present and the future look good, but much of the time I am not sure whether or I would choose the same path if I had to do it all over again. I suppose that doesn't really matter, and I should just quit looking back.


On the way home, I hit Manhattan at rush hour. As I walked up the stairway to the street at Penn Station, commuters were streaming down the stairs in the opposite direction. There was a nonstop flow of people, like ants swarming out of a nest once it has been stepped on. They were lined up, tightly shoulder to shoulder, like the Greeks with their war formations, but instead of working together for the greater good, it was every man for himself.

On 34th street, crowds were gathered on either side of the street. There was the sharp sounds of a police officer's whistle and lots of honking. From within the crowd I heard someone say there had been an accident and a person had been hit by a taxi. I strained to get a better look. I couldn't see anything. I didn't know if I could be of any help, but I knew if I just kept walking away I would feel guilty about it for the rest of the night.

It must have taken me a few minutes to work my way across the street and through the crowd. Finally, I got close enough to see what appeared to be a teenager laying on her back, with her arms folded across her chest. She was talking to woman crouched by her side and seemed fairly calm. There didn't look like there was any bleeding or gross deformity. By this time, the sirens had become louder. An ambulance turned the corner. My plan had been just to ask if they needed any help, but she looked pretty stable, and other than keeping her still until she could be checked out further, there was nothing to do. Then, I left.


I took a long subway ride to the airport after first stopping at a pricey soap/cosmetic store that one of my friends has raved about. If you have a smelly subway ride in your near future, I highly recommend traveling with a bagful of bath products. There's nothing quite like a mixed bag of "bath bombs" to wipe out that gross sweaty smell of the train car.


Since I had given myself generous amounts of time to not only get back to the city, but get to the airport, I arrived at JFK 3 hours before my flight. This, of course, ensured that my flight was delayed yet another hour. On the plus side, I had plenty of time to get all of my journal articles read for conference the next day! This was my first trip flying on Jet Blue. While it's true that there is more leg room, and free personal cable TV for each seat, I would have gladly traded these amenities had I been able to avoid the turbulence and near-death experience I had just prior to landing!


I think it is quite possible that I need a vacation from my vacation!