All Done!

The past two weeks have been a blur. I graduated from my residency program. My parents were here for a week-long visit. An aunt, uncle, and cousin came out for the occasion, along with my older brother and his wife. My classmates and I were roasted in appropriate fashion by the second- and first-year residents. It was a good sendoff. My last two shifts in the department were crazy-busy with very sick patients. My last shift was with my closest friend here, and after staying three hours late to finish up all of our charts, we went out to Denny's to celebrate. As I was getting home from my "4pm - midnight" shift, the sun was coming up.

Some of my classmates I was more than ready to be done working with, and some I was sad to see go. The past three years have flown by so fast that it is sometimes hard to believe how much learning and activity was crammed into them. Despite moonlighting for the past year, I am still nervous about starting my new job, learning and new system, and trying to do my best for my patients without harming them in the process. When I matched here, I wasn't certain what to expect, however I couldn't have been happier with my program. I think that the teaching has been excellent, and I couldn't have asked for better people to work with every day.

I have received my first schedule for my new job, and I am almost flabbergasted by how few hours I will be working compared to what I have been juggling lately. My written board exam is coming up in just a few months, but after that is out of the way, it looks like I might be able to have some semblance of a normal life in the very near future. After four frantic med-school years followed by three years of residency, I am not sure that I'm going to know what to do with myself!

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In regards to the house, it is pretty much sold. I met with my lawyer on Thusday and signed my end of the paperwork with the actual closing scheduled to happen sometime next week.

On Tuesday, the movers packed up the house, and loaded up the truck. Wednesday was unloading day, and the number of boxes crammed into the new place was almost overwhelming. I have been steadily unwrapping and sorting through stuff for the past three days, and only now is starting to look like an actual liveable space rather than a storage room around here.

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Happy 4th of July!

Seven

Seven shifts, that is all that remains of my residency. Part of me is eager for it to be over, and the other part is panicked about not having that safety net of an attending to run things by. There will be a new safety net--specialists to talk to on the phone, skilled nurses and physician assistants who know the in's and out's of my new hospital.

Some things I am happy to leave behind, like dictating a full note after every single patient. Others, like going out for breakfast after an overnight shift, or potlucks with the nurses I'm going to miss. As for my residency classmates, the group of us will probably never be together in the same room again. We are spreading out accross the country, and although right now everyone's promising to return for the wedding next Spring, some of these people whom I have spent so much time with, I will never see or hear from again.

Shifts are longer at my new hospital, but in return there are more days off. And despite being a "community hospital", the volume is practically the same as my current Level 1 Trauma Center. There are less specialists and no residents, which translates into me doing more procedures myself than I do here. I fully anticipate to be stressed this first year out, but it's what I want... I think. Some of my classmates are staying here where they are comfortable, and others have negotiated better contracts for less hours and less patients than I will be seeing. I tend to learn more by doing than reading about it, so I think I would rather struggle now in my career and gain experience and confidence rather than slowing down and maybe having to learn to increase my productivity later in my career.

Island Medicine, Part 1

Our residency program has been sending senior residents down to St. Lucia for several years now. We volunteer in an Emergency Department at a small hospital there and in exchange, they provide us with food and housing. It's a different experience than back home. Resources are limited, and patients must pay for service and medicines up front. Patients pay a fee before they are even seen in the Emergency Department, and then they get billed for any medications dispensed, or supplies used, like gauze and suturing materials. If x-rays are ordered, they have to pay for them before they will be taken and blood tests are paid for before they are drawn.

This was our drug supply cabinet. It was organized by shelf. The third shelf was mostly empty, and was our only cache of antibiotics to work with.

Unfortunately, most of our antibiotic supply was this:

If you look closely, you'll notice that it's expired.

The Emergency Department itself was fairly small, and is one of the only air-conditioned areas in the hospital. There were four curtained off rooms. The big pink chair is the asthma chair, and standing next to it is a large oxygen tank.

The system seems to work well. Most of the patients are in and out fairly quickly. I put on splints, reduced a dislocated shoulder, and did a fair amount of suturing. What we could fix, we fixed, and unfortunately the mortality rate seems to be fairly high. The hospital has a fair amount of specialists- (pediatrics, obstetrics, orthopedics, general surgery) but there's not a whole lot that they can do for things like strokes or heart attacks. I saw one child with chicken pox-- which I haven't actually seen at all during my residency because of the vaccine. Another of my patients had lost a leg due to leprosy.

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There is only one certified paramedic on the island, and unfortunately he was not on any of the ambulances that brought me patients. The ambulances seem to function more like the old hearse system. They are minivans with equipment inside, but for some reason, other than arriving with oxygen, nothing seems to get done for the patients. IVs are not started, medicines are not administered, and sometimes you may not even get a set of vital signs.

My patient with the dislocated shoulder was transfered from a clinic and had gotten nothing for pain. He apparently bit his first ambulance attendant, so they dropped him back off at the clinic and took their attendant to a different hospital for a tetanus injection before returning back to pick him up and bring him in.

Two of my patients were brought in pulseless and apneic (not breathing) and neither one of them had CPR being performed as they arrived. When I asked one of the ambulance dudes why they weren't doing anything, he said that the patient had already had a minute of CPR by a bystander when they arrived, and it didn't help, so he didn't think the patient needed CPR or ventilation apparently! So our codes were pretty futile, but we attempted anyway. There was only one ventilator in the hospital, and it was occupied by some guy with a head injury, so intubation would have meant riding in the ambulance with the patient to a hospital over an hour away and bagging the whole time.

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During our two weeks, the Carifta Games were going on. The Carifta Games are kind of like a Caribbean Olympics for athletes ages 14-20. Several of the athletes eventually go on to compete in the Olympics. The group of residents prior to ours had helped develop a mass-casualty plan for the event with the hospital, and we were there to staff the medical stations. The actual spectator turnout seemed to be a lot less than what was originally anticipated, and the weather was mild. Something like 200 patients were seen over 3 days, but most of it was minor cuts, twisted ankles, nausea, or "Can you just check my blood pressure?" type complaints. I spent most of my day there watching the races and long jump competition.

These stands were in the sun, so they were largely empty. The one behind me probably held a couple thousand people.

If I remember the uniforms right, these two young ladies were from Barbados.

The Jamaican athletes were clobbering all of the other teams, just like in Beijing.

Our favorite thing to do after work in the evening (unfortunately it was dark by 6:30!) was to sit around drinking and playing cards. The hospital sold cases of Piton (local beer) at a discount. If I worked the evening shift, the day was spent hopping on buses and getting myself down to the nearest beach, where the wind was apparently perfect for kite surfing and windsurfing. It was also a great spot to pull up a towel in the shade and relax before work.

My favorite reading spot:

Drats

Last week we wrapped up the first arm of our rat study. The study was time consuming, in that I had to drive into work 2-3 times per day to check on them and do testing. It was also interesting in that we learned to develop our protocol along the way. For example, one of the symptoms that we were looking for was renal failure, so we were monitoring urine output. At first, we were going to base this on cage weights, but that seemed too variable. Then we decided to line the cages with an absorbant pad that we could easily glance at for urine output. The rats responded in kind by chewing up the pad to make nesting material. Finally, we had to resort to wire cages with pads below to collect specimens. This, of course, required more paperwork.

This was the control arm of the study, so we were giving the rats a known chemical compound, and then treating them with placebo (saline). The next arm of the study would be administering the same weight-based dose of chemical to a new group of rats, only this time administering a likely antidote with the expectation that there would be less behavioral changes and less cellular damage.

Our dose of toxin was based on an "established" LD50 from other people's research (Being a child of the 80's I'm going to call this O.P.R.). LD50 is short for lethal-dose 50, and means that 50% of subjects receiving that dose should die. This is somewhat variable given that nothing in medicine is exact. From OPR, death or at least renal failure was expected to develop in 3-5 days. Our control arm was 10 days long.

Unfortunately, we ran into a huge problem: NONE of the rats died. There was some weakness noticed with behavior testing and at least one of the rats was doing some odd drunken head-bobbing, but that was about all that we noticed.

Being the suspicious women that we are, we had ordered extra rats in case some of them failed the baseline neuro testing, so we had a few extra rats to work with. On day 6, we gave those extra rats double the LD50 and....

NONE of them died, either!

So now there's a huge problem with our study in that if our chemical compound is not actually toxic at the dose we gave, we can't really proceed with the antidote arm. We have contacted the people behind OPR, and not really gotten anything other than, "hmm, that should have worked." Currently, our tissue samples are with the pathologist, so hopefully there will be some sort of changes at the cellular level, otherwise we have to either ditch the remainder of the study or do another study to first determine the proper LD50.

In trying to figure out what went wrong we've thought of:

1. Maybe our chemical isn't what the label says it is (and it didn't have an expiration date), so we have sent samples to an outside lab for analysis.

2. Maybe by administering saline we prolonged the renal failure and study wasn't long enough to reach our endpoints of renal failure/death.

3. Maybe our math was wrong, but it's been quadruple-checked.

4. OPR was wrong, and we need to do a separate LD50 study.

So there has been a lot of learning with this project. Either way, I have something to present for my required academic project, but I really wanted this to work. There have been a few accidental contaminations in consumer products with this compound, and it would have been cool to be part of the research behind developing a protocol for treating an ingestion. There are still blood tests pending as well, so for now, I am crossing my fingers and trying to be patient.

duh!

So, my conclusion from today's test was that I definitely need to read more. Parts of it were good, and I think I probably misinterpreted stuff, but I still think my score will be up from last year. Maybe this was the inspirational kick in the pants that I needed to get back on track.

I cleared 8" of fresh snow off the driveway before I went in to the test this morning.

Mock Me

Sometime tomorrow, emergency medicine residents all across the country will be sitting down with #2 pencils. It's that time of year again, mock EM boards. Bleh. Luckily, our program doesn't put too much weight on your scores, but I would like to at least improve on my performance from last year (which should be pretty doable, as I set the bar REALLY low).


Most of my time this year has been in the ED, so I think I am probably at least learning things more relevant to my profession. The last two days I have been taking practice tests, which range from "duh" answers to what-the-Hell-is-that syndrome-type questions. I generally find it's not good to hear of a condition for the first time ever during testing. Judging from the way the count of tests taken on the website has been going up rapidly over the past 3-4 days, at least I know I am in the company of fellow test-crammers.


Last year it took several months before we got results back as there was a program that was caught cheating. Some programs like to use their residents' scores as bragging rights for future applicants. At my program, we just take our applicants out to drink. This year, I think I will probably have to face the music a lot sooner.