Date Night

So Army Guy blew me away again with surprises. The night started with greeting me with red roses at the door. Then we went out to a very nice restaurant downtown, and later we went to a local production of "Arabian Nights". The play was awesome, with several of the actors really hamming up their parts and quite a bit of acrobatics. We ended up being right in the front row with the stage literally ending 6 inches in front of our feet. It was great!

I countered with homemade sugar cookies, a card, and some warm mittens that fold back into gloves to keep his trigger fingers warm, but I think he clearly outdid me once again.

Valentine's Day

For Valentine's Day, I gave Army Guy laryngitis... just kidding. He's out "in the field", whatever that means. You would think the Army would let their people sleep indoors when it's below zero outside, but I guess they are literal believers in "what doesn't kill you, makes you stronger."

We have plans for a big date later this weekend. I have mixed feelings about Valentine's Day: while it's fun to do something extra special for your significant other, it's also annoying when you're single.

Partying Like a Rockstar

Last night I went to a rock concert with some friends. The weather was not so good, and I still had a hacking cough. Worse yet, I had been scheduled at the very last minute to present at trauma conference today. Trauma conference involves presenting not only in front of your peers and attendings, but the trauma surgeons, all the surgery residents, and burn unit and ICU staff. I HATE speaking in front of people... even small groups, but just shy of 100 people is definitely large enough to make me all sweaty and tachycardic.

So did I stay home like a sensible person and blow off the concert? No way. One of my teenage favorites was opening for the main group, and there was no way I was going to miss seeing that!

The case was easy enough: teenager shot in the chest, filmed, and given a therapeutic chest tube. Yesterday was spent scrambling to load x-rays and CT scan images into a Powerpoint presentation. I was fortunately able to also track down a rare video shot in the trauma bay of the procedure being performed on the patient.

The concert went much later than I had expected. It was also at this weird venue where you have to provide your own alcohol. Fortunately, one of my friends is a good planner. She brought a couple of bottles of wine as well as champagne that she had earned a few months back. (There is a longstanding tradition in medicine of rewarding residents who successfully perform a lumbar puncture without any RBC's on the lab results with a bottle of champagne.)

I finally got home at 2 am, slept for about 4 hours and got up early to run over my presentation. For once there wasn't any problem transfering my files onto the hospital's computer system. It went pretty smoothly, I was able to answer every question, despite not really having been all that involved in the case. My role was to essentially look at the kid, check his airway, breathing, and circulation. Maybe I should precede every presentation with a night of drinking and sleep deprivation-- it seemed to help my nerves anyway. More likely, I should just chalk it up to a fluke, and be more responsible next time.

The Dress

Last week I drove a couple of hours away from here to catch up with Ru. Her boyfriend proposed over the holiday and we were now on a mission, a mission to find her dress. She already had some ideas about what style she wanted, so that made things easier.

I enjoyed the drive out to meet her. It had been a while since I had driven anywhere far enough away to actually enjoy the drive. It was kind of foggy out, with a mist that was just slightly too warm for snowflakes. Bare trees lined the road, and snow still covered the ground. Between the poor visibility and the somberness of winter, it was almost like I was driving in a monochromatic world. The trees are in that completely state of dead right now, with no promises of spring. It's almost like looking at their roots, and if you could just flip them upside down, maybe you could find some leaves and life somewhere.

Dunkin' Donuts and Starbucks were in a neck-and-neck competition, alternating their wares at progressive rest stops along the toll road. The further east I drove, the more country music stations there were. The snow accumulation also started to grow, and I began to pass evergreens with branches so laden with snow that they stooped like old widows.

The dress shop turned out to be a perfect midway point, with Ru and I arriving within minutes of each other. We found her size, and begun the process of heaving plastic bundles containing precious volumes of lace, beads, and satin on a rack. (My shoulders are quite thankful that she wasn't interested in the full-skirted dresses.)

She stepped out of the dressing room with the first one and it was amazing. Gone was the girl with the rainbow t-shirt and sneakers I had walked in with. The first dress fit amazingly, so well that it blew the next several out of the water... but it wasn't quite right.

We went back for more, gleaning the rack of everything in her size that wasn't immediately offensive to the eye. A few more dresses, and then there it was. When she stepped out of the dressing room, she suddenly looked like a bride, instead of a pretty girl in a pretty dress. I was pretty sure that we were on to something because she kept that one on longer and endured more of the banal chatting from the saleswoman. Reluctantly, she took the dress off and tried a few more, but clearly we had a winner.

I couldn't believe that we had found her dress in one outing, and Ru was hesitant to make any rash decisions. So, we went out for an early dinner, scarfing obscenely potent garlic bread, spinach salad, gnocchi, and chocolate cake. Ru was back to her quirky self, asking the waiter to bottle up the quart of milk they brought her with the cake. We went back to the shop, made arrangements to pay for the dress, and because I had to work early the next morning, we parted ways. Mission accomplished.

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In other news, Army Guy came back early from Ranger School this past week. He was disappointed to return not having completed the training, but it boiled down to a whole lot of unfairness on the part of the instructors. While I'm disppointed for him, I am glad to have him back early, and have promptly responded to his returning by getting a nasty runny nose and cough, and being great fun to hang around with. Sigh.

A Feather in Your Cap

On overnight shifts, nursing homes are the bane of my existence. If you have been reading for a while, you probably have noticed that I actually tend to favor geriatric patients, particularly those with dementia. The problem with nursing home patients on an overnight is that we are on a strict time limit. In this city, while there are plenty of ambulance services to get patients to the hospital, once a bed-bound or even wheelchair dependent person gets here, if we are ready to send them home, there are no transport services available between the hours of 10 pm and 8 am.

This is appalling.

What it boils down to, is that if I can't get my geriatric patients dispositioned by about 9:30 pm, then they are stuck in the Emergency Department until the next morning as "Overnight Guests". Imagine being 80 years hold with dementia and being stuck on a plastic lined mattress for over 12 hours, with all sorts of screaming, bright lights, and not to mention bad smells surrounding you. A sleepless night certainly isn't going to help any, as a lot of dementia patients tend to decompensate at night. Sure, there's a call bell at their bedside, but for someone who can't remember their address or thinks that Harry Truman is the president, how do you expect them to remember to call for help? It's difficult on our staff too, to have to go in and reassure these patients every 15 minutes when they cry out for help.

So, when I see a nursing home patient in the rack on a night shift, there's always a ticking sound going off in my head to get the labs done, and get the x-rays back in time to arrange for a ride. On overnight shifts, the deadline has already passed, so any patients that come in are guaranteed to be stuck until morning. We have tried all sorts of creative options ranging from calling local family members for transportation to taxi cabs, if the patient is able to be transported sitting up and can fit in the backseat of a regular vehicle.

Unfortunately, some of the staff members at these facilities seem to be aware of our transportation problems and take advantage. If grandpa or grandma is being particularly cantankerous, one phone call gets them transported to the ED for "changes in mental status" and gets them off the hands of the night staff, sometimes even for a day or two. While some of these assisted living places are great about sending paperwork, too many times I walk into a room and meet a senior who not only can't tell me if anything hurts, they can't tell me anything about why they are in the department. This leads to what we call the Granny Grope-o-Gram, a workup including lots of tests that are probably unnecessary, but rule out major bad things... head bleeds, hip fractures, pneumonia, etc.

The other night, I walked into Room 4 to find a nursing home patient who was sent in for "purple, pulseless feet." She was very with it mentally, but when I asked her why she was there, she said, "Frankly, my dear, I haven't the foggiest idea." I examined her feet: they were not swollen, and were warm and pink. She had great pulses. Nothing hurt. After calling three different numbers and paging the provided "staff nurse" someone finally returned my page 3 hours later, to verify that my patient had just been sent for a foot evaluation. By this time, it was 4 am. So, I tucked my friend in, ordered her a breakfast tray, and sent her home in the morning.

The other night, I was amused to see a complaint of a rattlesnake bite listed on the board. There are no rattlesnakes here, and it is winter, so there should not be anyone getting bitten by anything other than a pet snake. As it turned out, the patient was from a nursing home. He was a creative guy, and had an old Stetson hat that he had decorated with several feathers and the head of a rattlesnake. This thing was at least 10 years old, but apparently during the day, he had scraped his finger on one of the fangs of the snake. No way he had been envenomated, but the facility had sent him in for evaluation after-hours. So he was an overnight guest too.

I guess these sort of transport issues are why some departments have opened observation units for people who don't have any active issues going on, but either they can't be set home (too intoxicated, no available psych beds, etc.) either. It's easy to see how having 3 or 4 patients stuck in rooms indefinitely causes waiting room overload, and eventual department closure to ambulances as we have no space for more patients. It's a frustrating thing. Hopefully, someone will eventually start up a transport service in the near future, but until then I don't know how to fix it.

Hot Boxing

I'm tired. I skipped going to the gym tonight. I'm two shifts into a six-day stretch. It takes me a half a pot of coffee to get going in the morning. Let me know if you have seen my motivation running around anywhere, because I can't seem to find it.


Outside, freezing rain pelts against the glass. I decide that a quiet night in is just what I need. I heat up a frozen pizza, sip a glass of red wine, start up the fireplace, and then a movie.

Just what I want.


Suddenly, the movie gets interrupted by loud beeping.

?

It is the downstairs smoke alarm.

I didn't burn the pizza, so I shut it off, and resume my movie.

Minutes later, the upstairs smoke alarm starts going off.

?

I wander upstairs and jump and swat at the thing to knock it down (Apparently, I could use a few chairs or stepladder upstairs.)


As I head back downstairs, I realize I'm walking into a hazy, smoke-filled room...

That's right...

You guessed it...

I forgot to open up the damper on the fireplace.

Pure genius.


I guess at least it doesn't smell like paint in my house anymore!

Sticky Fingers

I have been filling out paperwork and taking computer training to for an upcoming rotation at the local VA Hospital. I was really surprised when I walked into the place the other day as everything was so new and shiny! The VA hospital back home was Maalox green and would make you wonder what the veterans did to deserve such a building.


Anyway... I had to get fingerprinted as part of this process, as apparently there had been a problem in the past with an employee stealing computers. However, instead of inking me, they scanned in my fingertips. For whatever reason, the thing wouldn't accept the prints of my left middle, ring, and pinky fingers no matter how many times I rolled them across the screen. So I guess I can be sneaky, as long as I only pick things up with those three fingers.


As a taxpayer, I think a more economical option would be to just go back to ink and paper, but what do I know? I can't see how sending everyone an "Economic Stimulus" check makes a whole lot of sense, either.

Ketchup and Caulk Fighting

So, tonight I go back to work after having had the past week off. I didn't do anything exciting with my vacation, just stayed put. I had all sorts of productive plans for the week, including organizing all of my digital photos, doing my taxes, cleaning the entire house, doing tons of educational reading like a good little resident, and updating this thing regularly.

Um, none of that happened. The house is somehow actually messier than it was before I went on vacation. I still can't do my taxes as I am missing a few things, so that one's not technically my fault. I did run over 20 miles this week, and my body is now reminding me why it's better to build up miles gradually rather than triple one's mileage out of the middle of nowhere.

I did get quite a bit of painting done. One of the living room walls is now a very bold blue, as is part of the eat-in area of the kitchen. The dining room is in disarray though. I was able to strip the wallpaper, plaster and sand parts of the walls, but now it is even uglier with painter's tape and 3/4 of one layer of primer. The primer boasted of its ability to cover up just about anything, but the half burgandy portion of the walls is still glaring through. I also filled in the gaps between the baseboard and the walls with paintable caulking and found it much easier process with the use of a caulking gun, having learned from last year's debacle. I'll post some before and after pictures once I get things picked up a little around here.

Other activities this week included the recruiting dinner, a social at my program director's house, another intramural soccer game, interview dinner for applicants to our program, and on Saturday a bunch of spent the whole day on a wine tour. I did also get a chance to talk to Army Guy, and he sounded tired, but was in good spirits.

Pimp My Ride

I went to a recruiting dinner last night. It was at a hospital over an hour away, so they sent a limosine out to my house to pick my friend and I up. It was just the two of us that went, so it was kind of awkward. We just hung out and chatted with three of the physicians from their Emergency department over a bottle of wine and some steaks. They seem like a fun group. There's just so much uncertainty about that first job after residency.


It's exciting, and yet I really don't want to spend too much effort thinking about it right now. I'll probably look into the place a little bit more. It sounds like they would be happy to have us moonlight there every now and then, so that would probably be the best way to really check it out.


It was fun having a limo idling in my driveway for about 10 minutes. I hope it got the neighbors talking.

A Little Bit of Sole

The other day I really stuck my foot in my mouth, although it was kind of necessary to counter future embarassment.

I had picked up a new chart, and went to go find my new patient. When I went to claim my patient on the whiteboard (unfortunately we are soon switching to a computerized tracking program), I noticed that the patient was actually in a different room than the one listed on the chart. Patients often get relocated if the room isn't quite clean yet, so I went to the room listed on the whiteboard. Instead of finding a middle-aged male, I walked in on a topless female. I apologized and ducked out.

My second attempt was in the room originally listed on the chart. Nope, that was an octogenarian male, and clearly the wrong room as well. At this point, I threw up my hands and consulted the charge nurse. He had no idea where this patient was, so he called up the triage nurse, who also walks the patients back to their rooms.

"Didn't you see my stickey?" he asked.

"Um, no."

So, the triage nurse flips around through chart and finds a small 2x2" yellow Post-It note. It reads: Patient wants to be called [insert female sounding version of a male name here].

"Um, ok, so what does that mean?" I ask.

The triage nurse just rolls his eyes at me and mouths the words "he looks like a girl."

This isn't helping matters. The patient's chief complaint is hematuria, or blood in the urine, so it makes a big differnce whether or not they have male or female anatomy. I have already observed what are obviously augmented breasts, so there's no getting around asking what other sort of surgeries the patient has had.

Finally, I develop a game plan. I go into the room, and act like I think registration has made an error and marked the patient as a male instead of a female. He says no, and after a lengthy discussion, he explains that other than breast augmentation, he hasn't had any sex change surgeries. Although I think I may have alarmed him at first, I think he probably found me to be concerned and attentive in the end.

I was explaining my technique to the charge nurse later and he said, "I can't believe you did that." When I asked him how he would have handled it, he said he would have asked the patient when their last menstrual period was. Maybe I'm wrong, but that seems a lot less diplomatic way to bring up the issue.

While nobody likes to be asked what sex they are, sometimes you just can't tell. I think it's better to be direct rather than to end up with a male in the stirrups or asking all sorts of unnecessary questions. And in medicine, gender totally matters. Workups revolve around it, so there's no excuse for ending up in court saying, "Well, I didn't get a pregnancy test because I thought she was a dude."

Winter Doldrums

I can't wait for tonight's shift to be over and done with. During this four-week block, there are too many residents in the department. This means that as soon as patients get brought back into a room, they get seen immediately. It also means that I haven't been having to stay late to finish dictations. Last night we all walked down to a local pub and nursed a couple of beers. It sounds like a little slice of heaven, right?

The problem is that I am bored. I don't know what to do with myself when I have less than four patients at a time. I just end up pacing from computer to computer, checking and re-checking lab results. I had a stabbing that promised to be somewhat involved last night, but he was completely stable. The acuity was good: I had an acute stroke, and another one with hypovolemic shock, but when those are your only patients it still gets boring.

Starting tomorrow, I have a week off. This time I am not going anywhere, just planning on sleeping, reading, maybe taking a skiing lesson or two, and doing some projects around the house.

Professional Courtesy

In medical school, we are taught not to bash our colleagues. We all make mistakes, and particularly when you are going to be stuck encountering the same people over and over, it is not a good idea to burn bridges. If someone has mistreated or misdiagnosed a condition, you fix it, and do what's best for the patient without pointing fingers. I think that this is generally a good policy, but sometimes it is hard to not question the other person's judgement or values.

To prevent myself from rambling for several paragraphs, I'll keep it short:

• A small child was accidently overdosed on an antibiotic.
• It was a non-toxic ingestion, and we advised the prescribing physician of this.
• Despite being the one who had potentially harmed the child, the physician was "too busy" to see her in the office and sent her into the ED anyway.
• The only reaction to the medicine the baby had was 2 episodes of vomiting and 1 episode of diarrhea.
• I asked why she was put on the antibiotic just the day before.
• Parents said their doctor "heard fluid in the lung".
• The doctor diagnosed "pneumonia" in a non-febrile infant without a chest x-ray.
• What I saw was a smiling, playful infant with absolutely clear lungs and no signs of dehydration.
• The child was sent home, and her parents were told that she was fine and we did not see any need for the antibiotic (or the oral steroid) prescribed by their doctor, but to discuss stopping the medications with her.

What I would have liked to have done would be to recommend that they find a competent physician, or at least one who cares enough to personally check up on his/her patients when they potentially cause harm. But I didn't. Their doctor will get a copy of the transcribed report about her patient's evaluation, but my guess would be that it will probably just get filed, unread in the patient's office chart.

Willy-nilly handing out of unnecessary antibiotics is a big problem in medicine, but what bothers me more about this case is the apathy of this physician. If you make a mistake, you should do everything in your power to fix it, or at least stay an extra 15 minutes late in your office to see the patient. It is aggravating to be the after-hours dumping grounds for non-emergencies, but this doctor didn't even make a quick call later to see how the patient looked.

I know that primary care providers are under a ton of pressure to see many patients every single day. At the same time though, this family practitioner is the sole provider for this entire family. She delivered this baby, does all of her pediatric care, and she does annual physicals on both parents. From a purely business perspective, isn't it in this doctor's best interests to keep a strong rapport by not just dumping them on the ED? I don't get it.

Footwork

I just got home from playing on our department intramural soccer team. They have been trying to get me to play for several weeks now (not that I'm any good, more that they were desperate for more players), but the games kept conflicting with my work/sleep schedules.

People weren't really into soccer where I grew up. Honestly, I think the last time before tonight that I played was during 8th grade gym class. And the few memories that I did have of it were of getting kicked in the shins really hard. Well, for this intramural league, players have to wear shin guards, which at least is better than the lack of equipment requirements for our pickup softball league last summer. I played most of the game tonight, and it was a good workout. I think it's a little easier to challenge yourself to doing very short sprints when you are chasing someone down rather than just picking up the pace on a treadmill.

After the game (We lost 2-8), we all went out to a sports bar for drinks and food. I really am happy with the program that I am in here. Our team tonight was made up of nurses, residents, and techs. While there was some gossiping going on, everyone here is just so good-natured and fun to be around. For me, I think that's what has really made moving so far away from friends and family easier. I don't know how people can do it in more cut-throat residencies.

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In other news, I turned in my state licensing paperwork yesterday. It will take a few months for everything to get processed, but that means that I should be on my way to moonlighting in smaller hospitals this summer. It makes me kind of antsy just thinking about being out on my own, but there are some options where you can work in a fast track, or double-coverage with another physician, so I may ease myself out with those.

Army Guy started ranger school yesterday, so phone calls will now be few and far between. I am sure that he will do great, and the time will fly by quickly. Talking was kind of awkward leading up to him starting the program, but like I said before, I'm not the greatest at goodbyes.

Treadmill Woes

I generally try to not incorporate the word "hate" too much into everyday conversation, simply because I think that overuse diminishes meaning. For example, people tend to snap their heads around when they hear me drop an f-bomb at work rather than some of the residents who tend to incorporate f-this and f-that into every third sentence. But, I'm getting off topic here...

I hate my gym. Hate it, hate it, hate it. I belong to one of those big organizations with clubs all over the country. When I moved here, I signed up for another 3-year contract as I couldn't beat their renewal price anywhere, and there was a club only 3 miles from my house. Last year, I was using it regularly, when the roof collapsed after a very nasty storm (fortunately it was overnight when no one was in it). Immediately afterward, they put up a sign announcing that they would be re-opening soon. Months went by, and as the weather got better, I started running outside, rather than working out at their other location conveniently located in the city's largest shopping mall.

Now the weather is bad, so I am stuck hitting the treadmill again. I pretty much dropped running almost entirely since my vacation, particularly with my crazy ICU schedule and then the holiday season. Things were fine when I went on Thursday for a quick run. However, when I got there today, there was absolutely no parking. It took me a good 20 minutes to find a spot that left me having to walk through the entire mall, with bargain shoppers everywhere.

Today was probably an exceptionally bad time, but I don't want to deal with all of this on a regular basis. I said something about it to one of the employees there, and she said that she thought they were letting us go to one of the smaller, private clubs in my neighborhood. The "re-opening soon" sign at the old club has been taken down, and apparently they now don't plan on renovating it. Unfortunately, I'm paid through 2009, and I can't cancel the membership since there's technically a location within 30 minutes of my house. Hopefully, this independent club thing will work out, otherwise I suppose I will just be stuck with dealing with mall parking and gaggles of shoppers.

A New Year

I don't really have any deep thoughts about the past year, or any spectacular ideas for 2008. Right now, I'm just scratching my head and wondering exactly where the heck 2007 went. I suppose that in a few years, when I think about 2007 there will be a few rough days that stand out in my head. That's partly what I like about having this blog... the ability to look back and remember what I was doing and feeling at the time. I guess the highlights were hiking the Grand Canyon, scuba diving, renewing an old friendship and starting a new relationship.

2007 Reading List (Somehow, I seem to be reading less every year.)

Old Testament: Jeremiah - Malachi

It took well over three years, but I finally finished reading the Bible (I started with the New Testament) sometime during the spring.

Walk On: The Spiritual Journey of U2 - Steve Stockman

I don't really remember much about this one.

The Lucifer Effect: Understanding How Good People Turn Evil - Phillip Zimbardo

I picked this one up after seeing an interview on television with the author. This guy ran the famous Stanford Prison Experiment in 1971. In it, he compares the breakdown of social conscience between the college students placed in guard roles in his experiment with that of American soldiers towards detainees in Abu Ghraib.

Traveling Mercies, Some Thoughts on Faith - Anne Lamott

"Bird By Bird" by this author is one of my favorites. A large part of the focus of this book is her experiences of raising her son by herself.

The Memory Keeper's Daughter - Kim Edwards

This novel was given to me by a co-worker after she finished it. It held my attention, and I plowed through it pretty fast.

Crocodile on the River Banks - Elizabeth Peters

I haven't read anything by this author before, and this quick historical piece of fiction was written in the 1970s and features a stubborn, independent, and educated English woman who gets herself into all sorts of trouble-- I can't imagine why my mother would have passed it on to me!

Death Comes for the Archbishop - Willa Cather

Ru gave me this one just before I moved here, and I read in on my way back to Arizona for the holiday. It kind of made me homesick for the desert heat.

2006 list

2005 list

Hard Day's Night

I just finished a string of overnight shifts. Fortunately, last night was slow and I was able to catch up on all of my dictations. For two blissful hours in the middle of the shift, I actually didn't have a single patient. I saw a nursemaid's elbow early in the shift. Nursemaid's elbow is subluxation of the radial head. It occurs in small tots when they get picked up by the arms or sometimes from sudden pulling forces. It is one of my most favorite things to fix because it is so dramatic. Usually, the toddler comes in with one arm hanging limply by their side, and they refuse to lift it. All it takes is some slight pressure in the right spot and a quick twist, and you get a satisfying click. When you check up on the kid a few minutes later, they suddenly have full function of that arm again. I guess I just like quick and easy solutions.

I was glad to have a catch-up shift after the frenzied pace of the previous nights. In our hospital, there's typically an attending on the pediatric side until about 2 am, and after that it goes down to one attending covering both the adult and the pediatric sides until 8 am. As as 2nd year resident, I now work overnights by myself on the peds side, or with one intern and usually no senior resident on the adult side. The decreased coverage at night is usually adequate, but we can get overwhelmed in a hurry. Discharges can get slowed down as each patient has to be seen by the attending before they can go, and they are often busy with more critical patients on the adult side.

For some reason there is this phenomenon on overnights where parents will awaken their children from a dead sleep and drag them in for the silliest of things (runny nose, rash, etc.) thinking that there will be no wait to get Tiny Tim evaluated at 3 am. This stuff is all pretty benign, but it clogs up the works, and when we actually are busy in the middle of night, people get pissy pretty fast at having to wait.

Things that stalled me up on seeing the rashes in a timely fashion on some of the overnights included: a teenager shot in the neck (the bullet went right through the spinal cord and he's now paraplegic), four teens involved in a rollover (none of them wore their seatbelts), and 5 stab wounds that presented on the adult side all at once. The stabbings didn't involve me directly, but they resulted in a riot in the lobby. It was bad. At one point, parents were asking me if they were safe, and I had to tell them to just stay in their rooms with the doors closed. Apparently, there was a metal detector malfunction.

Last year, we had a metal detector that didn't actually work. Then they put up a "No Guns" sign. Finally, we got a working metal detector. When the thing goes off, the entrance door to the waiting room automatically locks. Apparently, the lock malfunctioned, so there was suddenly a horde of people in the waiting room, and people fighting in the street. We have our own security guards, and PD was there quickly, but we basically had to go on internal disaster and completely shut down until the lobby could be cleared out. All of my sore throat and fever kiddos had to be police escorted with their parents to the parking lot.

It didn't help matters either that I'm still getting over my stupid respiratory virus. I was feeling much better, but then started to lose my voice. It was so bad that by the end of one of my shifts, the parents were having trouble understanding me. My voice kept cracking like a 13 year-old boy's. I can only imagine all of the blanks that will be showing up on my dictations.

Wild Hogs

Christmas was nice and quiet.I spent most of the time just sitting around visiting with my parents, brothers and sister-in-law. The rest of the time was spent napping as my parting gift from the children in the ED was a nasty respiratory virus. I don't know why anytime I have any time off or my schedule slows down my body insists on getting sick.

One thing that I guess is a little bit different about the part of the country where my parents live is that javelina rove the streets at night, looking for food anywhere they can find it. My mother was bitterly complaining as on Christmas Day they decided to completely obliterate the pointsettia that she had out by the front door. They really are a small-sized pig, and more of a menace than anything else, knocking over trash cans. Kind of like what raccoons are in northern areas, minus the rabies.

Tamales are also a Southwestern part of our Christmas traditions. Ever since we moved to that small town, one of the ladies that my mother used to work with brings us tamales every year. Tamales are such a pain to make that many women in that area will get together and make a day of it, and then freeze them to serve throughout the year. Her tamales are different than what you can get in a restaurant as they are made with more of a white cornmeal, and she always sticks an olive in each one for extra flavor.

So that was about it: continuous feeding and talking for a few days. My flight back the other night got in just in time for me to run home, turn the heat in the house back up, and head off to work. I was a little more tired than usual after sitting around the Philadelphia airport for about 6 hours due to my jet being stuck somewhere in Canada, but it wasn't bad.

Home for the Holiday

Tomorrow I fly back home for a few days. The visit will be very short, but it will be good to be home for Christmas. I haven't seen my younger brother since he left for Kenya over 2.5 years ago. It will be nice to have a few days of warmer weather, too. I am a little nervous about the flight back here, as I work the overnight shift. I gave myself a four-hour gap between my arrival time and the start of my shift, but with the way the weather is around here, you can never be sure that a flight won't get altogether cancelled. At least I know the flight out of Arizona won't be a problem, it's always the small connector flights that are the problem.


I also just saw Army Guy for what will be the last time for several months. He went home to see his family. However, immediately after the break, he heads down to Georgia for Army Ranger training. Army Ranger school, if one passes each phase on the first try, takes about three months. Three months of being out in the field, being pushed to the limit physically, without access to a phone or the internet. Bleh. He does get a few hours here and there in between phases, but it isn't like we know when those will be, or what my work schedule will be like. I am happy for him as he has been wanting to do this since he joined the Army last year. And, I really can't complain at all about it, as originally he was scheduled to deploy to Afghanistan for 15 months next fall, and that has been cancelled indefinitely. It's just a long time to go without communicating with someone. I suppose it will be a good period of time to throw myself back into my workouts, reading up on educational stuff, and maybe even getting some projects done around the house. I do wish that I was better at saying goodbye. I kind of just tend to avoid it until the very last minute. And then it is probably not very romantic to send someone off with warnings to keep their feet dry and change their socks often so that they don't lose any toes. Sigh. Wordsmith, I am not.


Merry Christmas!

Fever & Diarrhea Land

Want to know how to not be taken seriously by the doctor in the emergency department?

Bring your kid in for fever, vomiting, and diarrhea and then give him an 12" chocolate Santa to tide him over while I'm examining him.

I couldn't thank these people enough. Normally we give our viral illness kiddos anti-emetics and then hesitatingly give them some juice or a popsicle an hour later and see what happens. As long as they are not clinically dehydrated and can tolerate oral intake, they can go home and safely outlast their stomach/respiratory bug. But if Junior is in there chomping away with chocolate running down his face at a faster rate than the mucus running out his nose, I have just deemed him immediately dischargeable. This kid seriously got a quick glance-over from me and a head-nod from the attending. It took longer to get him registered than it did to interview and examine him.

Jesus Loves Bad Spellers

All I am saying is that if you are going to tattoo something on your person in big 1" letters as a statement to others for the REST OF YOUR LIFE, you might want to consult a dictionary or encyclopedia first to make sure that you have spelled everything right.

"Jeasus Saves" just doesn't have the full effect.

Free at Last

I survived my ICU month. Yesterday I stumbled out of the hospital after my last call night EVER. I know that it was a good rotation education-wise, the hours were just so tiring. Last week I spent 85 hours in the hospital, with much of them being without an attending being in house.

My last call night was rough. Most of the day we spent trying to fix this guy that needed surgery. His pH was 6.9 and his potassium was over 7. All day long we poured blood and various medications into this guy, and even dialyzed him, hoping to get him stable enough for surgery. In the end, the surgeon signed off, saying it was just too risky.

Meanwhile, one of my usually more stable patients responded to being ignored all day by going into SVT. I pushed adenosine (medication that temporarily stops the heart) and when that didn't work but slowed him down long enough for us to see that he was in a-flutter, we started him on several other medications. While all of this stuff was going on, we put central lines into two other patients, performed a lumbar puncture, and admitted another patient who was having a heart attack.

So it was a busy four weeks. While there wasn't much time for reading, I did learn a lot on the job. I also suppose my confidence level went up a bit. I am halfway through my residency program now, with the remaining time being pretty much all in the emergency department. There are just a few more rotations left, but none will have the intensity of high-acuity patients or the time demands of the intensive care unit.

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In the last 24 hours it has snowed over 12 inches here, and rather than the usual melt away mess, it really has built up. This morning I wasted by lounging away, but it took me 1.5 hours to clear the driveway and we're supposed to get more tonight.

Jingle Bells

This is all gossip and hearsay, so of course I am determined to repeat it:

Apparently, after a patient passed away in the unit the other day there was quite an uproar. As they were being taken to the morgue by the transporter, a maintenance worker stated that he saw one of the arms of the patient move.

He said something about it to the transporter, who just kind of shrugged him off and continued with their delivery. The worker was really bothered by seeing this though, so he then reported it to the charge nurse. In the meantime, the body was delivered to the morgue and placed in storage (I don't know if there's a technical term for a morgue refrigerator).

The charge nurse immediately got on the phone with the morgue, who confirmed that they had the patient and was told that they hadn't observed any movement, but couldn't say for sure that the patient had expired.

And this is how one of our poor junior nurses got ordered to go into the morgue and confirm on the cardiac monitor that the patient was in fact, dead.

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First of all, I don't know who pronounced this particular patient, but it was someone who had been on a ventilator for days and was in multi-organ system failure. The odds of them having the strength to move anything other than it just being an act of gravity are extremely small. Usually, although the monitor screen is turned off in the patient's actual room so as not to distress family members, staff members are watching and recording heart rate, respirations, blood pressures, and oxygenation on a main screen behind the desk. While I can't speak for my colleagues, when a patient expires in the unit, they are examined for any signs of life. Despite all the technology, there's no substitue for listening for a heartbeat, feeling for a pulse, and feeling for any air movement from even the slightest of breaths.

Then, there is also often a lag time from pronouncing the patient to transporting them to the morgue to give the family plenty of time to come in to the hospital or time alone with the patient.

Finally, this particular hospital has a bizarre thing that they put over the stretcher (almost like a covered cake plate) so that people passing by in the hallway/elevator don't know that they are next to a dead body. I don't know how anyone could have seen any arm movement, unless it was before the patient was even moved over to the stretcher.

However, this story brings me to two conclusions: 1) The transporter should have stopped and checked the patient. If, by any slight chance the patient wasn't dead, it certainly didn't help to put them in a refrigerator. 2) The maintenance worker should be commended for not only having the courage to say something to the transporter, but also for bringing it to the charge nurse's attention.

So, I don't think we put anyone on ice prematurely. However, in the small off chance that this could happen, maybe morgue drawers should have bells in them, not unlike quaint Victorian coffins.

For an interesting read on urban legends and being buried alive, check out this snopes.com article.

Lost in Translation

I finally got all of my holiday shopping and even mailed all of the packages. It actually wasn 't too difficult this year as my immediate family makes use of Amazon's wish list feature.

I was in Macy's today, trying to use up a $15 off on $50 worth of purchases coupon, and had picked up just enough stuff to meet the spending requirement (60% off flannel sheets and a sturdier spatula to replace the one I melted last week). The clerk at the counter was very confused by the card.

Clerk: This says it's good on your NEXT Macy's purchase.

Me: Right, I got it in the mail last week. This IS my NEXT Macy's purchase.

Clerk: Oh. Hmm... will you be charging this to your Macy's card?

Me: No, Mastercard.

Clerk: You have to use your Macy's card.

Me: I don't HAVE a Macy's card. Why would you send me a coupon to be used with a card I don't have?

Clerk: Oh. Wouldn't you rather spend $100 and get $25 off? (referring to an attached coupon)

Me: Why would I want to spend more to save less?

Clerk: You would save more... $25 instead of $15.

Me: Right, but that's a smaller PERCENTAGE.

Clerk: What?

Me: Nevermind. How about I pay cash?

She finally credited the coupon, but it was a bit more painful process than I had expected. I guess I was just surprised it was difficult to use an actual coupon when just earlier at a sporting goods store, I said something about there being a sign that the item I was buying was marked $10 off and they just subtracted the amount without even verifying it.

Very Superstitious

This morning there were painters doing touch-up work in the room where we had a particularly messy code last night. Coincidence? I think not.

People in our Emergency Department are constantly discussing the White/Black Cloud Theory. The idea is that things either stay relatively calm (white cloud) or rapidly go to Hell (black cloud) depending on whether or not a particular person is on. I am typically a white cloud, with shifts being hectic, but not typically all-out disasters when I'm at work. I seem to have lost my white cloud this month. Three patients died last night. Two were rather expected, as they were on comfort care status (no interventions), but the third was a freaking mess, despite having a cardiologist, nephrologist, intensivist, and general surgeon available in the unit.

I keep checking my pockets to make sure I don't have some sort of scythe hiding in my coat, but am coming up empty-handed. At first I thought it was just me, but this morning at shift change, the charge nurse was telling me that I am getting a reputation for being on during general badness. On the plus side, one of the floor nurses sought me out last night to tell me that a patient I had been called about several hours before had expired, and complimented me on being calm and collected (which was totally not the case internally) on the code I ran the other night.

Two more call nights and I am done.

Post-Mortem

He flipped the thick slab over on the white cutting board. In a different place, at a different time, you might think that we were in the kitchen, not in the sub-basement of a hospital. As he maneuvered the slice of liver, it kind of jiggled-- purple and shiny. With a probe, he poked at one of the bile ducts, digging around until he felt the scrape of the metal against something solid. With a quick twist of his wrist he dragged out the stone, black and yellow-speckled. Behind that stone, several more pebbles were lodged.

It seemed so small, but there it was, cause of death: biliary sepsis, secondary to obstruction.

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This is what I was dreading in my last post. The other day, we went to the autopsy of one of my patients, the one that suddenly crashed overnight. Despite having spent hundreds of hours in cadaver lab, I dreaded this. I didn't want to be there when they opened the chest of a patient that I had talked to and examined, a patient whose family I had several conversations with. Luckily, we weren't there for the whole thing, just for the gross inspection after they had already removed the organs.

Maybe I was being over-dramatic, and when I talked to a friend, he didn't really think this was any more gory than the things I witness in the trauma bay. I suppose that from that aspect he is right. Technically this isn't any worse, but it was something that bothered me emotionally. I can deal with blood and guts. I still remember the rush during the first month of med school of reaching into an abdominal cavity, sliding my hand down the posterior ribs, and blindly finding the spleen when everyone else at the table was still too squeamish to really look for it. However, mentally I have difficulty seeing someone opened up and explored, someone that I had planned on being able to fix.

The autopsy itself was performed to find an answer. We had suspected biliary sepsis all along, but couldn't find an obstruction. The patient had a cholecystectomy several years ago that was complicated by a biliary leak. We were suspicious of there being a stone stuck somewhere in the remaining bile ducts, despite not being able to see anything on ultrasound. The patient was septic, and we couldn't find the source of his infection. His hepatic panel was elevated, like there was something stuck somewhere. When a more invasive study (ERCP) was performed to look again for the stones, the patient expired on the table.

Technically, we did everything right for this guy. He was placed on an appropriate antibiotic in the ED, confirmed later by sensitivities on his blood cultures that came back after he had died. He was fluid resuscitated, intubated, and ventilated aggressively. It was simply a case of not being able to catch up with a late presentation. The stones sat there hidden, slowly leaking bugs into his bloodstream, while the symptoms of his illness were masked from his wife by his dementia. By the time anyone realized he was sick and he came to the hospital, it was too late.

It is what can be so frustrating about medicine: when everyone works so hard to fix someone, and in the end, it's the battle of pulling a brake on speeding train already mid-air, going over a cliff.

It's Over

It is official: the vacation glow has worn off.

I have had a horrible stress headache today... the kind where you feel like your brain is going to herniate into your spinal cord and run down your neck in a sloppy, not quite finished over-easy egg-like concoction. There is something coming up tomorrow that I really don't want to do, and am hoping it doesn't come to fruition.

Urban Hiking

Last night I felt like I was living in the stairwell. All the silly climbing back and forth reminded me of M.C. Escher's drawing, "Relativity". By the time I get to the ICU in the morning, I have climbed 7 flights of stairs. I decided to keep track of just how many flights I would do in the course of a shift on-call. My final number was 54, but that includes both going up as well as going down stairs. I did take the elevators once during the shift, but that was only because my intern was with me at the time. A few weeks ago, she had a bad experience of getting locked in some obscure stairwell, without her cell phone, and had to pound repeatedly on a door until someone happened to walk by. I personally found this hilarious, but took pity on her and got in the elevator. (It is hard to empathize with someone who averages 8-10 hours of sleep on call nights compared to my 1-2 because she only gets paged by me for admissions, and doesn't get woken up every 30 minutes by "updates" or lab results from well-meaning nurses.)

Last night was my 5th call night of the rotation out of a total of 9 scheduled, so as far as I am concerned, it's all downhill now. Things got a little hairy this morning when a patient that we had expected to do well overnight decompensated and now doesn't look like he's going to make it. When I left, the ICU attending thanked me for my hard work, but part of me thinks he was just being nice. As far as keeping up on people's studies and labs, I tend to stay pretty well on top of things, but these people are so sick that I don't think I always understand the whole picture of what is going on.

When I got home this morning, there was over 6 inches of snow on the ground. I couldn't get my car into the driveway, so after a quick nap, I cranked up the snowblower and got to work. The thing works so much better on a level driveway, unlike last year when it was pulling up chunks of asphalt with the snow. Hopefully it doesn't snow so much tonight that I can't get the car back out onto the street, but there's no way I'm getting up early to make sure I have a clear path.

Things I Didn't Think I Would Need to Say

Sometimes discussions with a patient's family members don't go as planned. When there's a large group involved, no matter what gets said, someone will be unhappy. Here's a few lines I said the other night that I wish I hadn't had to:

"The face mask is helping him breathe, but I don't know if it is actually prolonging anything."

"No, I can't take the face mask off. He is awake, and is choosing to keep it on."

"I understand that you are his healthcare proxy, but as long as he is capable of making his own decisions, we go by what HE wants."

"No, I can't intentionally drug him into unconsciousness and then take the face mask off."

"I understand that you were told he had less than 24 hours left, and that it has now been several days. I really can't accurately tell you how much time he has left."

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As life would have it, a few days after this, my parents tell me that they have just listed me as their healthcare proxy in the new revision of their will. I told them they have never been specific with me as to what their wishes are. To this my Dad said, "Just do whatever you think is reasonable." Argh.

Ditto

I couldn't agree more.

Last night, I benefited from the Emergency Department being closed. The ICU was short on nurses, so while we actually had empty beds, there was no one available to take care of any more patients. Meanwhile, all of the regular floor beds were full, so the Emergency Department was closed all night to ambulances. (Despite being overcrowded with horrible wait times, ED's are required to stay open to walk-in patients, but transfers and ambulance patients get rerouted to any open departments in the area. The exception to this is that if a patient demands to go a specific facility the ambulance crew has to follow their wishes, and if all of the local departments are closed, then we take alternate taking ambulance traffic.)

For me, this meant only 2 admissions overnight (we had to steal a float nurse from another floor), as compared to the sleepless night of 7 admissions last week.

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!