Death By Powerpoint

Last week I went through a five-day board prep course. A few of my classmates from residency and I flew out to the Midwest and camped out in a hotel. We endured 50 lecture hours over 5 days! I had forgotten how painful it can be to spend so much time in a lecture hall, and haven't slugged down that much caffeine in a long time. A couple of my classmates from medical school were there as well, although no one that I keep in touch with.

The course itself was pretty thorough. Some of the lectures were interesting, while others weren't really geared to board review. In addition to attending the lectures and following along with the provided notes and daily quizzes, lectures were continually run on one of the TV channels in the hotel rooms. There were also a couple of rooms upstairs that were filled with x-rays and images to quiz yourself on.

The first couple of days were a little overwhelming, but by the end of it, I feel like I had been given enough material. Very little of it was new, but there are a few areas like hemotologic disorders, derm stuff, and random neuro findings I need to focus in on to pick up a few points here and there. The majority of first-time test takers pass the exam, but it is pretty expensive and only offered once a year, so I would like to not repeat the experience if at all possible. Board certification in Emergency Medicine is a two-step process. The second part involves an oral exam that you only get "invited" to take once you pass the written part. After that, there's just some continuing education stuff to keep up with, and recertification isn't for another 10 years.

AG finally gets to come home for his "mid-leave" break in just a few days, and so my plan is to just relax during his leave. Afterwards, I have about a month after he leaves before the exam, so that will be the time to hunker down and really get back into studying.

An Unlikely Patriot

I have been well-intentioned about updating more regularly, but this last week has been hell. Now that I am done with residency, there is no protective 80-hour work week restriction. So far, my shifts had been scattered here and there, but due to a number of trades I did to accommodate my partners and my leaving town for a board review course, I somehow ended up doing 8 shifts in 9 days (at all different hours) logging in over 96 hours. Welcome to the real world, baby girl. There was some interesting stuff scattered in here and there and I'm now scrambling to remember it.

Just after Patriot Day, a paranoid schizophrenic showed up at the main gate on base. He wanted to borrow a bulldozer because he knew where Osama Bin Laden was, and he wanted to "corner him with a bulldozer." I'm not sure why he drove several hours to get a bulldozer from the base when there were probably several closer to his residence, or why wouldn't want something with more oomph like a tank, but I suppose he was well-intentioned. I imagine he is still inpatient somewhere, and as for Osama, he's probably on the loose again.

Jeopardy Flashback

I just finished watching "The Bucket List" with Morgan Freeman and Jack Nicholson. In the movie, Morgan Freeman's character is constantly watching Jeopardy and always knows all of the answers. It made me remember a high school math teacher of mine that only lasted a year in our meager school district. The guy had a fixation with Jeopardy and was always talking about the database that he had made over the past 10 years or so of all of the questions and answers. He seemed to think that there was a finite number of questions and was always looking for someone to coach and get to memorize all of the random facts he had collected. He was a strange guy with bizarre mannerisms and dressed like he was about 30 years older than he was-- I wonder whatever happened to him.

Teens, Take Note

If you are a teenager, please note that updating your "mood" on MySpace to "suicidal" is not a good idea. You might just end up in my world via police escort. Once you arrive, you get stripped down, and you can lie in a psych room with questionable stains on the wall for hours before the doctor can see your lame ass. And your mom will be very, very pissed.

Adventures in Babysitting

Sometimes, my patients just baffle me with their requests. Such was the case recently, when a pregnant young woman asked if she could be admitted to the hospital because, "All I have for food at home is peanut butter and Goldfish."


She was a young, newly-married Army wife, and the request made me look again at her ID which listed her age as 16. Her medical complaint was easy enough to deal with; both her and the fetus were fine. She hadn't gotten any prenatal care yet, as she said that she didn't have any insurance, which also made me do a double-take given her social situation.


I asked her where her husband was, and it turned out that he was off doing pre-deployment exercises in another state for the next several weeks. During their training, the men are unavailable by phone and the only number she had was his cell phone. I asked her if she had any money at home, and she said that she didn't. Apparently, her husband had taken their only credit card with him.


The more questions I asked, the worse it got.

I asked her who their unit chaplain was, and she didn't know. I asked her what unit her husband was in, and she didn't know. I asked her how she'd gotten to the hospital and it turned out that she had called an ambulance and that she didn't know anyone in the area to come and pick her up. And wouldn't you know it, her husband had left his vehicle behind, but she doesn't even know how to drive. The nurses were also muttering something about her not having any furniture in the apartment and sleeping on the floor, but at that point, I really didn't want to hear any more.


So Social Work got involved, and I ordered the woman/child a dinner tray. They actually contacted the runaway teen hotline because her whole story was kind of bizarre. Typically, the military does a very thorough job at providing resources for family members, particularly wives and children of active duty soldiers. This child just was completely clueless, and without any kind of foresight about providing for herself. In the end, the staff duty officer of the night had to come in and make sure she was set up with insurance, food, and resources. I'm sure that her husband got quite the talking to about the whole thing, but for all I know he's probably barely 18 himself. It was quite the contradiction to see someone with with access to nearly unlimited resources and not enough knowledge to use them. At this rate, I don't know how she's going to make it through the winter.

Gone Country

Having been raised in a very small town, I figured that I would have no problems fitting in here. After all, here there is an actual mall, a Starbucks, a hospital, and several chain restaurants. I guess I have become accostomed to all of the creature comforts that come with living in a city with a large University- theatre, museums, sports, active downtown life. Most of that I don't miss, especially as I have yet to make any social contacts here.

My mail is delivered by a man in a minivan with a flashing light on the roof. When I go to my actual post office, there is an Amish roadside vegetable stand, and several times I have seen a horse and buggy on the side roads.

Several of the gas stations here do not have pay-at-the-pump. When you go inside to pay, they try to force locally made ice cream on you. As if I didn't have enough bad eating habits without having $2 hand-packed pints shoved at me whenever I buy gas!

There is no branch of my bank here, or even an affiliated ATM. There's only one major bank here, and otherwise it's all city banks and bizarre credit unions not affiliated with anywhere else. I don't really understand this since there is such a large military contingent here, with people moving and relocating from all over the country. Most of my banking is done online anyway, so it doesn't make a huge difference, except I try to time getting cash with visits to the city to avoid ATM fees.

I guess I just need to slow down a little. Everyone here is extremely friendly, with strangers saying hello to you on the street, but the drawback to that is that it seems to take just a bit longer to get anything done. Lines are slower because cashiers inevitably have side conversations with their patrons about how so-and-so is doing or whatever, but I can't complain because it does seem like customer service is better.

Things might get a little more desolate around here in a few months based on the Army's activity. Three brigades are stationed here. Usually one brigade is deployed, one is preparing to deploy, and one has recently returned from deployment. AG's brigade is scheduled to return the beginning of next year.

According to news reports, the other two brigades are going to be sent to Afghanistan before the end of the year. Unless there's a fourth brigade being formed that I'm not aware of, that means it will be pretty empty around here for a month or two. To me, sending two brigades out at once seems kind of strange, because they won't be able to keep up with that schedule unless a big expansion is made, or they have more brigades somewhere else that they can pull from. Typically the brigades are deployed for 12 months and then home for about 15 months. Not only will it not be time for AG's brigade to go out again, but they won't have any other brigades left to deploy from here to replace them at the end of 2010.

New Beginnings

In just a couple of days, I start my new job. I pretty much took the whole month of July off, which was good because there was so much junk that needed to get done. I moved, the house got sold, I went home to AZ for a week, and I went to a family reunion in the Midwest.

The new place still needs a lot of unpacking and organizing, however I have been dawdling. It is kind of strange being up here because right now I don't know a single person in the area. I have spent a lot of time doing mundane things like resetting the router so that I can have a wireless Internet signal downstairs, and reviewing and reorganizing the file cabinet. I try to remind myself that boredom is a good thing.

AG is about to be promoted and relocated to a different part of Afghanistan. After the deployment, he'll be switching out of the infantry into a different area, and so there's a whole bunch of training to be done when he gets back. We are over seven months into the deployment now, and I am really looking forward to his mid-leave break in a couple of months.

Slaying the Trinitron

My largest television appears to be a casualty from the move. I cannot directly blame the movers because when it was unloaded from the truck, I hooked it up immediately and it worked. However, the very next day it would not turn on. I tried unplugging it. I tried resetting the fuse box. I tried a different outlet. I even tried to turn it on and off with its original remote. And nothing-- the little power light simply gave up. The movers didn't pack the TV, they just put a furniture pad over it and set other things on top of it in the truck.

I can't really be too upset about the whole thing, as this was the TV I got from the neighbor of a friend who was going to put it out on the sidewalk with his trash three years ago when he upgraded to a flatscreen. I guess it had served its purpose.

However, my new dilemma was what to do with the thing now that it wasn't working. My 13" television looked kind of goofy perched on top of it, and AG's 24" TV works just great, although I have it stashed upstairs. I tried to pick it up to haul it out to the car, but it was just too awkward, and too heavy. It was an old Sony Trinitron 32" television, and from what I've seen listed on old websites, the thing weighed 140 lbs. Even with lifting it from a squatting position, I couldn't hold it for more than a second or two, let alone walk with it in my arms.

So, I did what any stubborn woman would do: I dismantled it.

The dismantling wasn't so tough. Just six screws and the heavy front of the television was free from its awkwardly-shaped back.

Most of the back of the TV was just empty space. Several wires snaked back and forth between the two halves. I ripped off what I could, and the resistant wires I snipped with my wire cutters. I am sure somewhere a TV repairman just screamed. (And yes, I had the TV unplugged when I was doing all this. Recently, I had a patient who shocked himself pretty good working on a microwave that was still plugged in.)

Unfortunately, removing the back half only saved me about 20 lbs, but at least the concentrated weight was reduced to a size I could wrap my arms around. So, I was able to stagger the screen out to the trunk of my car and hauled the two pieces out to the dumpster. The back half I easily tossed inside, but the front half I couldn't lift up to get it into the dumpster, so I just left it in front. Today when I went to drop off another pile of trash (Moving is fun!), I noticed that someone had taken the television from it's resting place. Hopefully they're using the thing for parts or modern art sculpture, as I can't imagine they'll be able to replace the wires I snipped or figure out where they went! So I guess the saying is true-- One man's trash is another man's treasure. And now that TV set is being turned from my trash into someone else's treasure yet again!

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!

Halfway

Today marks the 6-month point in AG's deployment. For some reason, his "mid-leave" two-week break doesn't happen until October. So, I will just have to be patient, and since he was in a small group that left early to set things up for their unit, we don't know yet if he'll be coming back exactly 12 months from when he left, or if he gets stuck in Afghanistan until January. When I think about all the times that we have been able to talk over the phone, no matter how short, or via email, I am grateful. I can't imagine what it must have been like to be stuck waiting for letters to arrive.

I like this photo, and it doesn't reveal any top-secret identifying information. The mountains in the background remind me of Arizona, although it looks like they have a lot more green plants than back home.

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.

Procrastinating

I hate speaking and making Powerpoint presentations so much that I would rather type this here than work on my stupid lectures!

Island Medicine, Part 2

Of course it wasn't all work while we were in St. Lucia. Our group managed to stay at a resort for 2 nights/3 days to relax.

One night, we went to dinner at an old sugarcane plantation called Balenbouche (French for bullet-in-mouth--apparently named for a duel that took place that didn't end well for someone!). The grounds were very pretty, and there was a small, black sand beach on the property.

Old still:

Black sand beach:

Same spot, minutes later:

We stayed at the Almond Smuggler's Cove Resort, which is on the north part of the island. It was three days of eating, which made up for all of the peanut butter and frozen lamb neck at the cafeteria during the weeks before!

The Brig Unicorn (apparently was in "The Pirates of the Caribbean"):

One of many lounging spots:

There are two prominent peaks in St. Lucia. Gros Piton is the taller of the two, but the climb is slightly easier (very steep, but you don't need ropes to pull yourself up). Petit Piton is not quite as high, but is a much more difficult trail.

View of Gros Piton from the bottom:

This hermit crab was found halfway up the mountain trail!

View of Petit Piton:

Strange-looking breadfruit tree:

It was a great two weeks. Unlike my experiences in a rural hospital in Alaska, here I felt like I was able to do more for people because although we had less medications to treat people with, we had access to surgeons. It was more what I think practicing medicine was like 20-30 years ago rather than just being a pit stop hospital, where pretty much everything and anything is flown out for a higher level of care. As for the vacation aspect, I would have liked more time to explore the island and to have gotten in some scuba diving, but it just didn't work out. The island itself is pretty small- something like less than 20 x 20 miles, so I don't know that I'll be returning.

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:

Hiatufied

--Ok, so maybe that isn't a real word. What I had intended to be a month-long hiatus stretched a little longer than planned. It has been a busy few weeks, but I think I am ready to return to work and to writing, perhaps with a better attitude.

Sort of a Day Off

I had today off, but it wasn't very relaxing. My realtor met with me and did a walk-through of the house. I have a few more things to finish up and then a lot of de-cluttering to do. My plan is similar to what I do when my parents come to visit. I just throw a bunch of crap in boxes and shove it in the attic. I'll post some before/after pictures soon.


It snowed again today. Just a little bit of flurries, but it made me glad that the other day when we had "unusually warm weather" I slapped a fresh coat of paint on the deck outside to cover up all of the peeling spots. I would have liked my realtor to have been a little more optimistic today, but I guess I'll just have to see how it goes. I still think the house will show better in May when everything's green and blooming, but I would like to at least get people looking at it now.


Last night's shift was really busy. I typically average around two patients an hour, but I was at almost three per hour, and that was even with precepting an intern, which slows me up a little. I got so backlogged on dictations that I was there two hours past my shift discharging patients, slapping together splints, and stabbing at pockets of pus in the hallway and I still had to go in for an hour of catch-up work today.


The rest of the time was spent running errands... picking up empty boxes, grocery shopping, buying a shop vac to vacuum up all the cobwebs and spiders that have been breeding in the basement the past 3 years, etc.


Next week I head off on my "international medicine" rotation. Two weeks of sun, and working with limited resources. It sounds like fun... especially the nearby beach and hiking part. I can hardly wait. I'm really looking forward to lounging and reading a book in the sun.

The Steamer

In my line of work, it is important to get along with one's coworkers. Doing shift-work means that we don't stay until the patient is dispositioned. Often a patient gets seen and examined, labs and imaging studies are ordered, and then their care is transferred over to the new doctor when it is time for the original provider to go home. In regards to patient care, this can be the most dangerous time for the patient as the incoming doc typically doesn't have time to fully re-evaluate the patient.

As you can imagine, everyone has their own level of comfort in decision making. After you get to know the other doctors in the group, you can typically figure out who is going to have more patients to sign-out because they tend to order more tests than everyone else, who is going to do very minimal work-ups, and who is going to intentionally order a CT scan fifteen minutes before the end of their shift so that they don't have to make the decision about what to do about the patient during their time in the department.

Like every other job, it's frustrating to get additional work handed over to you by people who seem to be determined to get by doing the bare minimum. It also stinks to come in to a full waiting room and patients who have been in rooms for hours, not seen by anyone, and the previous staff heads home seemingly carefree on-time.

At my place, we've come to refer to bad sign-outs as steamers, because the messes left behind are reminiscent of steaming piles of... well, you get it. Sometimes it's unintentional, but sometimes someone who's billed as "stable" suddenly deteriorates after shift change and it seems to be more a factor of a shoddy exam or workup because someone was in too much of a hurry. Extreme examples of this would be the patient signed out as "possible pneumonia" ending up needing a pelvic exam because their "rib pain" turns out to actually be belly pain, or in one really bad example, a "stable" patient coding in the CT scanner.

After being in a hospital for a while, you get to know how your night's going to start depending on who the previous shift was, and steamers definitely happen at both the attending and the resident level. I think that all of us ultimately want to do right by our patients and co-workers, but when there are so many interruptions in care throughout the shift, it becomes easily to get distracted, especially by the thought of it being past time to go home. It does get old after a while, and I can't imagine what it's like to be in the same place, taking bad sign-outs from the same co-workers over and over, year after year. While the names and faces will be changing out in a few months when I leave, I am sure the situation will be the same.

Eat Your Greens

I was talking with my mother the other day and she was telling me about some new sort of lettuce-type plant that she was growing in her garden. She couldn't remember the name of it, me- something or other. Jokingly, I asked her if it was mescaline, which she thought it might be, but clearly that is not it. Although that would make it more interesting when the javelina raided her garden.

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As for working the overnight after St. Patrick's day, it wasn't too bad. I was expecting all sorts of drunks and injuries, but surprisingly, there wasn't a whole lot. We were busy all night long, and I had some very sick patients, and for some reason there were people who in the waiting room all night for little things like rashes and sore throats, but it wasn't the drunkfest I was expecting.

Silence

My attitude has been in the toilet lately. I'm not sure what did it: maybe working too much, maybe not taking the time to do anything fun/relaxing, or maybe I just need a change in pace. My vacation time is all used up, so that is not an option. Fortunately, I have an elective block coming up where I will be spending two weeks with some of my co-workers staffing a small emergency department in the Caribbean. Yes, there's work involved, but there's also a nearby beach, and plenty of sunshine.

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I deal with violence on a daily basis at work: shootings, stabbings, and plain old assaults. To be able to handle it, you have to be able to separate yourself emotionally from your patient. Too much time spent imagining the pain of a steak knife entering your gut doesn't do anyone a whole lot of good; sympathy and empathy don't mix. Desensitization is a much-needed coping skill.

Recently, all of us were shocked by the death of a co-worker. She was shot by her ex-husband in front of their children. He later shot himself during a standoff with police. Both of them were brought in to the ED, and I was extremely thankful that I wasn't there when either one happened. She was someone that I knew, although not personally. I can't imagine the pain that those who worked side by side with her over the years are dealing with it, especially those that were involved in her care.

As expected, it is taking some time for people to go back to working the way they were before. It is somehow quieter, and more orders seem to be falling through the cracks, but people are piecing themselves back together, and reforming that protective shell that keeps them going.

Sweetheart

Should I be creeped out that a teenage patient of mine called me "sweetheart" the other night? He's a manipulating emancipated teen that mainly comes in for med refills and to be fed a meal every now and then. I'm sure he has a lot of great relationships in his future.