My Brilliant Feat

So, today was not a good day to be elderly and male in my E.D. Besides having someone die (came in as a cardiac arrest), I had two other gentlemen come in who most likely have some form of metastatic cancer, both of whom are married, one of whom takes care of his wife who has Alzheimer's. He is 75.

I've been blogging for over two years now, and I recently had the opportunity to apply to blog to the American College of Emergency Physicians Blog site The Central Line. I am happy to report, I was accepted, and I will start posting some thoughts there as well.

This site however will continue to be my main blog despite my new-found fame and increase in readership from 4 to 6. (I love you Ladies, Betty, Julia, Lisa and Claudia!!) I will post the link from today's post on The Central Line (my second, so don't think you missed anything.)

Happy reading! My Brilliant Feat

Blood on My Scrubs

I can't say I've honestly thought about what happens to my scrubs throughout the course of my medical career. Until last night. I don't know why I had this surreal moment in the middle of a trauma code. I was handing a chest tube to one of the surgery residents to place in this patient's chest, and I looked down to step back as a puddle of blood had formed on the floor.

I noticed the blood spattered on my scrubs, and my first thought was, "Darn, I don't have a clean pair and it's the middle of the shift." Then, I started thinking about all the bloody, vomited on, amniotic-fluid covered scrubs I have worn during my medical training.

In medical school, most of the scrubs worn in the anatomy labs were new, bought excitedly in anticipation of starting your medical training. By the end of the year, we had a mass burning of these soiled clothes that had spent countless hours, literally elbow-deep at times, working to understand and learn the intricacies of the human body. I threw my shoes out too.

In your third year when you start your clinical rotation, you grabbed scrubs whenever you could. The residents had access to the scrubs machines and some hospitals had a general pile. We didn't have access to the machines so you stocked up when you could. Sometimes your scrubs got soiled midshift, and you had to have some kind of backup. I kept an extra pair in my "on-call bag." So, by the end of your medical school training you had this mixed bag of scrubs sporting the "not to leave the premises" or "property of" imprinting from the various hospitals.

These became a badge of honor in a way when I started my internship. You'd go to work in your home scrubs some nights on call. Everyone would look at your scrubs and say, "Oh, you worked there?" or "Oh, do you know so and so at that hospital?" We had access to the scrub machines there when we had to go to the OR, but you were only allotted 3 sets at a time. Sometimes you just didn't have time to run to the machine (or most likely the machine was empty), so it was more convenient to always have a pile of scrubs in your locker. We learned ingenious ways of getting more scrubs (including timing your visit to the locker room when the filler of the scrub machine was loading the machine... "Geesh, I don't have my card right now and I've got to get to the OR, can you help me out?") so that you had quite the surplus too by the end of the year.

Of course, the bloody, messed up ones went into the dirty bin. So all the scrubs you kept were nice and clean. At this point in my life, I have a pile of scrubs from all the places I've been. Most of them are blue in some shade or other. Some are what I call OR green. I have a cool teal green pair from a hospital in Rhode Island where we went on a transplant run while I was in Boston. We had to wear their scrubs to go to the OR for the harvest, and we didn't change out on our way home since time is of the essence in transplants.

But, when I became an Emergency Medicine resident, we didn't get scrubs. So we all had to go back to grabbing them when we could while on other off-service rotations.

Last year, our residency bought us these cool black "Ninja" scrubs. I don't like to think about what collection of body fluids accumulates on my shoes and the bottom of my scrubs by the end of the night. And, like last night, you can't help but get something on you.

Because we got a limited amount, they go right in the dirty bin when I get home. They get washed with the super-extra strength detergent after an Oxy-Clean soak. You just don't know what's hiding on them....

Lowered Expectations

(**Warning: venting today... warning! warning! warning! High pressure release! warning! warning! warning!)

And, I had such high expectations for today because we started off with three patients on the board...

I have goals for the year. Every day I strive to improve my efficiency. Every day I set a goal that I will succeed in learning one new thing about a disease process. Every day I will treat my patients with the honor and dignity due to a member of the human race. Today I failed miserably on the last.

I went to a private Catholic parochial school. Somewhere around 5th or 6th grade we were visiting neighboring churches (Lutheran, Methodist, Jewish, etc.) to learn about the similarities and differences in our faiths. At the Jewish temple, the rabbi asked us what the worst word in the world was. My naive brain could only come up with one or two words that are tame compared to some of the words used on network TV these days.

Then the rabbi told us that "weird" was the worst word in the world. He said we should never call anyone "weird." Just because someone does something in their culture or faith that you don't doesn't make them any less deserving of respect. This started my understanding of the idea of tolerance. I never forgot that.

My husband feels that the word "stupid" is the worst thing you can call a person. It implies, to him, that you are the lowest, most ignorant being on the planet. Worse than "retarded" because "retards don't know any better." When you're stupid you have brains, you just can't use them. You are, in a way, "low class" and uneducated.

Unfortunately, my first round of patients this morning were seriously stupid. And, then they just got weird. So much so to the point that I got very frustrated this morning with what I was doing during my shift. And, to add to the mess, there was a situation with a sick patient that was signed out to me from the night before that just pushed me over the edge.

I was lamenting, in part, to an unsympathetic ear who told me that I needed to lower my expectations. Once I did that, they said, I would be able to survive my shifts in Emergency Medicine. Seriously? Really? Seriously? I'm about a year from starting my career and you're telling me this?

I went off in need of a break. I considered my options: try to match in surgery, take a year off and do a fellowship, move to Mexico and be a beach-side doc-in-the-box catering to tourists, get a new career, maybe something in retail or truck driving.

I pictured myself at a town hall meeting standing up and saying, "You know, instead of spending my hard-earned tax dollars on taking over medicine with a potentially corrupt and inexperienced socialistic government Health Czar, why don't you take those billions of dollars and educate people on the importance of preventative medicine, on seeing your doctor on a regular basis, on taking medication as directed, on not cutting off your cast every two weeks because you think it smells and you want a new one, on not treating the emergency department like a drive-through that will provide services on your time schedule? How about that? Why don't you tax them for taking up valuable time in the E.D. and wasting, oh yeah, again, my small resident's salary tax dollars? Instead of Hope and Change how about Personal Responsibility and a sense of agape (ἀγάπη)?" Huh? I can't hear you....!

At what point should I expect nothing of my fellow human beings? My colleagues in medicine? I was very surly. I was thinking I would like nothing more than to pack it all up and go home. Start again in the morning.

Anyway, my foul mood might have continued had my attending not come around the corner at this point and, seeing me, started singing, "Don't go changing... to try and please me..." in the most honest and sincere voice I think I've ever heard out of him. I had to smile and then laugh. I was still snickering to myself as I continued to work my way through the flood of patients that came in this afternoon.

Somehow, it didn't seem so bad after that....

Early in our relationship my husband and I discussed an email that was circulating around the web at that time. It had to do with a man who went home every night and touched the tree that stood just outside his door. One day a neighbor asked about his ritual. He said that the tree was their "Problem Tree." Before walking in the door, any problems from the day were "hung on the tree." The neighbor asked what happened when he left in the morning. The man answered that somehow the problems never seemed to be there.

We made a promise to leave any problems "hanging outside" and not bring them in. Tomorrow I will wake up and head into my shift. There will be a clean slate and anything from today will not be carried forward. Sure lessons will be learned, but I will again try to achieve my goals, especially the one that can be restated simply as, "Love thy neighbor." Lord, love it, but it's hard sometimes...

Hot in the City

We've had a lot of shootings over the last several days. I have been working the night shift, so it's always very difficult to post because I am often too tired in the morning when I get home, and then I am usually in a rush out the door when I head off for the next shift. I do manage to sneak in a quick post from time to time.

Anyway, onto the shootings. I worked the overnight shift at the county hospital on Tuesday night, and we had three unrelated shootings, plus a couple of stabbings, plus the token rollover... and a whole lot of drunks. I was in the middle of dealing with several different patients that I received on sign-out (some things are never what they seem) when a patient comes running in the door saying "I got shot in the face, don't let me die."

I took a look and saw the wound on his face. A larger caliber round and his face would have been an empty hole. A couple of inches further back, and I wouldn't been seeing this patient as they would have been either an organ donor or in the morgue. He was the lucky one that night. The bullet scratched just under his eye and ended up stopping and breaking his nose. Oh yeah, the bullet fragments are still there. He's going to need to have those removed at some point. That night, though, just some fancy stitching by the facial trauma resident and a referral to specialty clinic to fix his nose.

While I was finishing getting him settled I was told by the charge nurse that another shooting victim was coming in. This time, multiple wounds in the extremities and torso. We got the trauma team notified and I waited in the room as they were brought in. He lost his pulse as he was brought in the door. There was no saving him. I had to tell his family members. I worried about retaliatory shootings.

I kept working the shift. In the early morning hours we got another victim. This one had multiple bullet holes and a fracture in an arm and a leg. Not to mention the bullets that went into their abdomen. They went to the O.R. They survived.

Thursday night I went back to work at the General, and there was a large security presence in the area in front of the E.D. Now, at the county when there's a shooting, we get a strong police presence, so it's no big deal to see the ambulance ramp shut down to traffic. Just not used to seeing it at the General. But, that evening there had been a shooting that resulted in a death of a member of the community. Their family along with many neighbors were all there and had just gotten news of the death when I pulled up trying to get in for my shift.

I made my way through the crying, screaming people holding onto one another and demanding to be let into the E.D. to be with their loved one. Security let me through as several people tried to push their way through. They were held back.

Today I worked a day shift. I had a GSW (gun shot wound) to the legs in the morning, and a GSW to the abdomen in the evening. Kinda like book ends. Both were in the process of an attempted robbery. Both were taken to surgery. Both will most likely survive.

Some say people are going a little crazy from the heat. The heat wave is supposed to continue through the weekend. I wonder what tomorrow's going to bring...

Chronic Pains

My primary diagnosis for many of my patients last night was "Acute on Chronic _____." I don't know what it was about last night, but a lot of people just couldn't face waiting until Monday a.m. to see their PMD's. Of course, a percentage of my patients don't have PMD's (that's Primary Medical Doctor) and come to the E.D. to get their primary care; as well as a couple of shots of Dilaudid or Lortab.

The local media discussed one such patient who is a daily visitor to the E.D.; mostly at ECMC, but we see him on occasion at BGH. Last night, I got several more of the "regulars" who decided to come in. I also got the "I've been admitted multiple times and left because I didn't feel like staying around any more" group; patients who regularly need to be admitted because they have legitimate medical problems (like one patient who is daily killing heart cells because he refuses to stay in the hospital long enough for surgery to be done) but who have worn out their welcomes with the medical staff.

I did get a couple of emergencies: a gentleman who started having a GI bleed and also a heart attack, a new onset diabetic who was initially thought to be having a stroke because he had been having strange symptoms for over a week, another known diabetic who suddenly started having problems when they couldn't keep any food down, and a another lady who was rapidly filling up with fluid to the point she couldn't breathe any more.

But it's those chronic pain people that drive us crazy. Now, I have said many times that I have never had a broken bone, and I have never been shot, but I can imagine that it would hurt... badly. But when you're told to not eat fatty foods because you have gallstones and it's going to hurt if you do, and then you go out and have the cholesterol special at your favorite fast food joint, I can't quite draw enough sympathy. Oh yeah, and the first words out of the patient's mouth were, "I have Chronic Pain Syndrome so the usual dose of pain meds doesn't work for me."

Sigh. I am all about being a patient advocate. I threatened my "killing my heart cells" patient with "if I see you back in the E.D. without a new hole having been cut in your chest, I will do it myself." Seriously, I just spent 10 minutes on the phone presenting a case arguing how they had already been cleared for surgery, this time they "promised" that they would stay and not leave AMA (against medical advice), and they really should be given one more chance.

Maybe I am too hopeful. Maybe I believe in people too much. Or, maybe I am playing a similar game, the one played in "The House of God" known as a Turf... or as we call it, the Dispo. Luckily, our Dispos don't bounce, oh wait... yes they do.

Number Two

So, I started writing down my little musings two years ago when I found out I was leaving the very cosmopolitan Twin Cities and moving to Buffalo. Before interviewing for my current residency spot I only knew a few things about Buffalo: the song "Shuffle Off to Buffalo" from the movie "42nd Street," Buffalo wings, the song "Buffalo Stance" by Neneh Cherry, "The Dominator" Dominik Hasek who played for the Buffalo Sabres, and, of course, the song title of my blog, "Buffalo Girls Won't You Come Out Tonight" which I first heard in the movie "It's a Wonderful Life."

I can now say that I know a few more things mostly involving the Assassination of President McKinley at the Pan-American Expo held in Buffalo in 1901. Mostly because our program is facinated with the fact that the on-call M.D. was an OB-Gyn and that the President was operated on at the exposition fair grounds instead of being brought to Buffalo General.

Anyway...

Thanks for following along with me during this time. From my original post on the original blog, "Do They Have Squirrels in Buffalo?" which was posted, originally, on AOL's Community Site. A year later I was starting my second year of residency. Somewhere we made the transition to Blogger, and I changed the name to Buffalo Squirrels. Since then, I've started two other sites: My Paper Cuts and This Squirrel's a-Quiltin' to show off my more creative side and new-found hobby.

Wow... thanks for reading along. Thanks for being with me (D from the start who told me, yes, there were squirrels in Buffalo) on this incredible journey. I wonder what my new title will be in another year... another two years... and where we'll all be? Are you just excited at the prospect? I know I am.

30 Days of [BLANK], actually now 29 Days of [BLANK]

Although I've been working a lot, I haven't had the energy to write in my blog. Most of the stories I think I have told before, or so it seems, and the most exciting thing rumbling the E.D. is the constant undercurrent of discussion relating to the socialization of medical care. Now, I am not going to get on my soap box and declare my position about this... if you've read my blog long enough I think I've talked about what needs to be fixed.

Instead, I am going to discuss my 30 Day Plan. I was reading "Pioneer Woman" which is a fabulous blog site. She posted a link which lead to a link, where I followed another link to a blog called "Room 704" in which the discussion was about how a habit can be formed by doing something repetitively for 30 days. The author challenged their readers to do something for 30 days.

So, since I know I will never make it to the gym every day for 30 days, given my schedule, I made the following plan: drink more water, drink less diet soda and eat a salad or greens every day. I was also thinking of renewing my Pledge to Be Veg for 30 days, but I knew I would already be cheating today since we had a Surf and Turf BBQ, the key words being Surf and Turf. Oh well, I can start tomorrow and carry over into the next month.

Now, I challenge you! What new habit are you going to form over the next 30 days?? Thirty days of: yoga? taking an hour to read a real book instead of watching tv? prayer or meditation? speaking to one person a day who you don't know? showing affection to your spouse or loved one in a way you don't normally do?

p.s. speaking of which, I can give an example of this from my own life. I came from a family that really didn't express emotions. Hugs, kisses, not really common. I always say I learned to hug in college because we just didn't do that in my family. Around the time I was about to start medical school, I read somewhere that you should always say, "I love you" to people you care about because you never know if it's the last time you're going to say it.

I can honestly say I wasn't brave enough at first. Express emotion to my mother? Are you kidding? Then one day I was leaving for a trip of some sort, and I was talking to her on the phone telling her I would call when I arrived. Just before I hung up, I said, "I love you, Mom, talk to you soon." Silence. I could tell she was stunned. After a short time when I sure she was going to mutter something quick and hang up, she said quietly, "Love you, too."

I started saying it after every conversation on the phone and just before leaving home after a visit. The hugs came much later, but now she's quick to say it if I haven't just before we hang up. It took a little longer with my uncle who was always the father in my life. I still am glad I was able to say it to him the last time we spoke which was a few weeks before he died. At least I said it, and he knew.

That's one habit, I am not going to break.