So Sleepy

Ru moved out yesterday morning... onwards towards colder lands and her pursuit of writing. The house seemed strangely quiet when I got home from work this afternoon. It was good having her here, and when I think of her stay, I'll remember being reintroduced to Nutella and graham crackers, Mexican hot chocolate (it has cinnamon in it!), and her showing me how fold origami cranes while I complained about my daily frustrations.

Today it has been a great struggle to stay awake. I went to a hospital recruiting dinner last night with some of the other residents, and getting home after midnight made today's early rounds particularly painful. Tomorrow is another day of being on-call, so I'm definitely laying low tonight.

... Pants On Fire

One of my favorite things about working the Emergency Department is that you never know what you are going to encounter.

The other day, I pulled back the curtain in Room 5 to find a couple of paramedics sliding over an elderly gentleman onto the stretcher. A quick survey of the room revealed that there were several police officers there as well. The guy kind of smelled funny, so I thought maybe he had been picked up off the street.

As it turned out, the guy had gotten into an argument with his girlfriend. Apparently, he tried to shoot her with a shotgun (and missed). When the police officers got on scene after being called for shots being fired, they noticed that the house smelled like there had been a fire. Upon further questioning, it turned out that the guy had caught the cuff of his pants on fire while he was burning some leaves in the yard a couple of weeks back. He had trouble putting out the flames, and suffered some pretty severe burns to the back of his legs. Not liking to waste time with the doctors, the guy decided to treat his burns himself... by applying a home remedy of boiling water and Vaseline! The entire back side of one of his legs was one big, black scab, and his foot was now swollen.

To the officer's dismay, there was no way this guy was getting medically cleared to go to jail, especially as he turned out to be septic, and it looked like he had an arrhythmia as well. Apparently, he hadn't seen a doctor in over 20 years. When I asked him what his daily medications were, he answered "90 proof alcohol"! I had expected this guy to be from some rural area, given the shotgun use, and lack of healthcare. However, oddly enough, his address was right in the city!

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As for my ICU rotation, I now have survived two nights on call. During each one, I only slept about an hour of the twenty-seven hour shift. The first call night was an admission-palooza with just constant work to be done. Last night, there were a few breaks here and there, but I didn't manage to catch much sleep as I always seem to have trouble sleeping in foreign surroundings. I suppose this will get easier throughout the month as fatigue kicks in.

Less Whining

So far, not much to talk about in the ICU. I will actually have THREE days off during this rotation. Unfortunately, I have to work almost two weeks straight to get to the first one. Today was a short day as there was some confusion about the schedule and I was allowed to leave after rounds.

Since I had the rest of the day off, Ru and I went to a late lunch at the very popular local "honky-tonk" BBQ restaurant. The place is always packed-- its clientele an odd mix of bikers and businessmen. We dined on fried green tomatoes, and I ordered the "Big Ass Pork Plate." Ru, being much more ladylike, instead of saying the title said, "I'll have what she's having." So there we were with our plates of "road food" surrounded by beer swillers, and she sips her hot tea like nothing has changed (including the tattoo-to-tooth ratio).

Happy early birthday Ru, and don't ever change!

Slow, Deep Breaths

Tomorrow I start my four-week rotation through the ICU. I am somewhat anxious about it, as I am going to be the senior resident on the service (ha!) with some poor medicine intern to help/hinder me. Every 3rd day will be a 27-hour work day, after which I will go home, try to enjoy part of the day, work a normal 8-hour day the day after that, and then show up for another 27 hours. Repeat this about nine times. No actual calendar days where I am not physically in the hospital at least for some part of the day.

The ICU is not my favorite place. It is where we keep all of the actively dying people. Many times, their loved ones are completely unaware of just how sick they are. Sure, there are people that recover, sometimes miraculously, but often it seems to be a slow, steady decline. A decline over days and weeks, in which one gets to know a patient's family. I remember the rotation from medical school as being a month of terminal weans from ventilators.

It is also a good rotation for learning. There are a lot of bedside procedures to be done, and I am definitely going to be challenged to make quick decisions and know my own limits. There will be an attending physician on call at night, but they aren't even in the hospital.

I was talking with one of our chief residents about his experiences the other day and he said, "Well, you are either really going to learn a lot, or there's going to be a lot of people dying and you won't have a clue why." Great, I can't wait to get started.

Snow!

It is after 2 am and I just got home. My shift ended at midnight, but I ended up staying late to do some last minute stuff, and to sew up somebody's face. I am tired, and I left over an hour's worth of dictations behind. Stuff that can wait for tomorrow.

Today was the first real snow of the year. Very fine flakes this afternoon, and just before I went in to work, the thick, "lake effect" flakes that I love. When I got home, there was about 3 inches coating the fence and my roof. At this point, it's so clean and somehow magically insulates all of the background noise (although admittedly there's not much at 2 am). The slippery crunch under my sneakers is somewhat therapeutic. I am sure I will be sick of snow soon enough, but right now it's a welcome change.

Mothering

The other day I got a stern lecture from the charge nurse. The family members of my gunshot wound patient had arrived, so I went back to the family room to talk to them. I introduced myself, got everyone's relation to the patient, and sat down with them. About halfway through, the charge nurse showed up at the door and she did not look happy. I told the family members several times that the patient was doing just fine, that he had been shot through the ankle. It looked like the blood supply was ok, but he was going to need surgery and rehab to get back on his feet. I thought I did a good job, and other than not being able to answer any questions about who shot the guy, the family seemed pretty satisfied.

Later, the charge nurse told me not to EVER go into the family room by myself because I had basically surrounded myself with upset family members in a room with only one exit. Oops. I guess that I didn't really even think about it because the guy's wounds were so minor. We have had family members flip out and attack our staff, but usually it tends to be in situations where the patient is a lot more critically injured. Anyway, I guess it was nice that somebody was looking out for me.

Know a Good Priest?

The other night, I had a patient that needed an exorcism. She was rolling around on the bed, throwing up/spitting and inappropriately touching herself. You can imagine that this made her somewhat difficult to talk to. I thought briefly about calling a priest, but at our hospital, we have different clergy people that rotate through... so I just pictured some poor Presbyterian minister showing up and wringing her hands. However, I did think that needing an exorcist would be perhaps the only way I could ever justify transfering a patient to the nice, community Catholic hospital in town, a place I like to refer to as St. Elsewhere. With a crucifix in every room and nuns running up and down the stairwells in their habits and sneakers, there would be no escape there for her!

A quick scan through the computer showed she had just been discharged two weeks ago for an admission for intractable abdominal pain. The lady had a 3-year history of abdominal pain, and had been through the gauntlet as far as colonoscopies, catscans, etc. Clearly, this was a problem I was not going to fix that night.

She was thrashing around so much, that the IV team couldn't get a line in her. After she had been there three hours, the lab called and told us that there was only enough blood for them to run the lactic acid level... that I could forget about all the other tests I had ordered. So finally, I went in there and consented her for a central line insertion because if nothing else, I can't even admit someone for intractable pain if they don't have IV access.

She was sleeping soundly when I went in the room. After explaining the procedure to her, she started slamming her arms and legs into the bed, like your average two-year old throwing a tantrum in the candy aisle at the grocery store. I just stood there until she wore herself out. I had a long discussion with her about how I would not continue to give her muscular injections of morphine because if something bad happened I needed an IV line. She agreed to the line, and also agreed to let the nurses try one more time. This time, she miraculously held still so that we finally got her labs. Everything was negative.

A contrast-enhanced catscan was ordered. Then she started playing new games, "accidently" spilling her oral contrast solution all over the floor and whining about having to drink it. I went in there again and had another discussion with her about why she would come to the hospital for help and then refuse any kind of assessment from blood draws, to x-rays, to CT scans. She was still there drinking contrast at the end of my 8-hour shift. The new attending coming on decided to take over this patient personally. She has a reputation for not putting up with any behavioral crap, and was talking to me about putting restraining orders on patients that spit at her. I'm interested to find out how the situation turned out.

Randomness

One of my Flickr photos of the Tomb of the Unknown Soldier was picked to be part of an online map of Philadelphia:

www.schmap.com/philadelphia/home/#p=44873&i=44873_6.jpg

Lighter Stuff

Sometimes you have to find the humor in small things. A chapter in our textbook that was part of this week's required reading titled "Male Genital Problems" was written by someone named Robert Schneider.

The Switcheroo

Many Emergency Medicine doctors would probably agree that one of the main times where mistakes happen with patient care is at sign-out. At the end of a shift, care of any remaining patients left in the department is transferred over to the incoming physician. The goal is to get as many of one's patients dispositioned (discharged home or admitted with orders by the admitting service) prior to sign-out. As one may imagine, with "emergencies" continuously filtering in throughout the shift, it is sometimes difficult to know exactly what is going on with Mrs. Smith or her catscan. Patients are re-assessed by the incoming physician, but is generally a much more brief process than the initial history and physical exam, and often patients that are signed out as "stable" may not be checked up on until other, larger fires are put out first.

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The other morning, I took over a patient with a rectal bleed. However, this was not your typical rectal bleed. This patient had intentionally shoved a paring knife up her rectum. This story of course set off all sorts of bells and whistles in my head regarding psychiatric issues. The overnight team left, saying that she had some blood products ordered and the surgery team was taking over. Fortunately, it was slow enough, and her story was bizarre enough that I went in to see her right way. The woman was pretty quiet, and seemed rather hesitant to talk about it. At first she just said that she cut herself so that she could get admitted to the hospital. However, after a few minutes of talking, it turns out that she thought that she had "telepathic" powers with her dead boyfriend, and that by killing herself she thought that she would be able to see him. At that point, I had the patient put on a psych watch as she had been left unattended before that. She ended up staying all morning in our department though as her blood was too-thinned with coumadin and had to be reversed with transfusion before surgery would take her for exploration under anesthesia and repair the damage. She ended up doing fine, but she definitely required more time and attention than what was discussed at sign-out.

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On the overnight last night it was pretty much a one-woman show. There was a medicine intern there, but she can only handle about two patients at once. This meant that I took all of the patients at sign-out, plus saw my own new patients, and supervised patients picked up by the med student. The shift started off with a very minor gunshot wound in the trauma bay, and several transfer patients from other hospitals that had multiple injuries. Much of my night was unfortunately spent on the phone with consultants. It took hours just to wade through the sign-out patients that I had assumed care of at midnight. Our nursing staff is pretty awesome, and I get along with them. I think that what saved me was having the patient's nurses let me know when studies had been completed or the patient was essentially wanting to go home, because there were just too many people to check up on.

I think that we did a pretty good job, and by sign-out at 8 am, there was no evidence that we'd had a messy night. However, the shift was such a blur that I can't help but worry about things that may have been missed here and there. There were definitely people who could have been sent home sooner if it weren't for the volume of patients.

I watch the attendings in our department, and their styles range from very conservative with workups to relying almost entirely on clinical assessment. At the end of the day, this is a specialty where one definitely has to be able to rely on their colleagues. Sometimes there simply isn't enough time or resources to check and re-check someone else's work. It is becoming obvious to me that you have to like the people in your workplace, but I don't know how to assess whether a place will be a good fit when it comes time for interviews.

Daylight Savings Time

While I appreciate that the extra hour gained over the weekend meant that I only slept in until 9 am on Sunday, I hate the fact that it is now pitch black by 5:30 pm. I definitely DID NOT SIGN UP FOR THIS. It's hard to combat seasonal affective disorder when it's dark out before you go into work and after you get out. Bleh. I suppose that the crazy swings of ED shifts (8 am to 4 pm today, MN to 8 am Tues night) help combat this, but the whole Daylight Savings thing drives me crazy.

It's Not Them, It's Me

On Thursday I noticed that pretty much all of my patients were lovely, nice people. And then I started to think about it. Were they really all pleasant, or was it more that I was well-rested and not stressed out? I think that I am definitely guilty of letting stress influence my interactions with other people. Yes, there were constant interruptions all day long. I even had a secretary personally snip at me for not hearing her page me overhead. The difference was that I didn't let it get to me. Normally, I think I just let people dump their frustrations on me, and I end up internalizing it, and probably passing it on to others. I don't know how long it will be before cynicism returns, but hopefully I can keep it away for a while.

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Yesterday, I spent almost 11 hours with Army Guy. Last night we went to a comedy show, after just spending a day hanging out. We have been dating for a couple of months now, and it's going pretty well. Sure there are times when our schedules don't align (or he gets shipped to Georgia for two weeks for weird training stuff), but I still like him. He's smart, funny, polite and can even tolerate my teasing. I think that it helps that he has a career completely different than mine, so that I don't have to talk about work stuff, but he's always interested to hear about my work escapades. I have some rough scheduling ahead, and he has to run off to Ranger School in a few months, but for now, I am just enjoying having someone to go out and do things with.

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Today I worked at the basketball game downtown. We cover the first-aid station at the local University's football and basketball games. I was allowed to watch the game and have free range of the stadium, as long as I wore a headset and carried a walkie-talkie. It was an exhibition game, so the full crowd wasn't out today, and I didn't get ONE SINGLE CALL. The home team won (although they made us nervous for a bit), and the whole thing was over in two hours.

A funny thing happened during one of the breaks. The male cheerleaders each grabbed a large flag and together spelled out the home team's name. However, for some reason, the last guy wasn't a cheerleader, just some random band guy. Well, the cheerleaders took off at a sprint around the perimeter of the court, forming a parade of the team's name. Poor random band guy couldn't keep up with their pace. It was obvious he wasn't used to running with a large flag. The last letter was sadly a good court length behind the rest of the flags. Worse yet, as he turned the corner, random band guy slipped and fell. The mascot, who was keeping up with him, despite being in a full-costume grabbed his flag and finished off with the others. Guess you shouldn't expect to keep up with trained flag carriers.

It was a good day, and I think my game coverage (three hours total) replaced a full eight-hour shift! We don't get paid extra for covering, but you just can't beat a work day of eating nachos and watching basketball!