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Epilogue

My last shift has been worked.  My diploma is in hand.  All the good-byes have been said.  I don't know if I was sadder walking out the door of the E.D. for the final;  seeing the rays of the new day poking over the horizon, or packing my patient book into a box for the move cross-country.

For those of you who have followed my blog, you know that I have kept track of all the patients I have seen in the Emergency Department over the last three years.  There's a lot of stories held within those pages.  Stories of new life, and stories of death.  Stories full of hope, and stories of hope diminished.  My procedures are logged within the pages.  My disappointments are logged within the pages.  There's more than a few repeats;  some a sorry testament to the current healthcare system.  Sometimes, a sorry testament to the current government system that spends our tax dollars on those that know how to bend the rules.  But I digress.

The page has closed on this chapter in my life.  I don't know what the future will hold.  I know what hopes and plans I have for my future.  I know the type of physician I hope I will be.  There's still a few more challenges to overcome:  ie. board certification - a written and oral exam.  And, I will be a freshman attending working on my own for the first time.  It's going to be an interesting year.

I hope that you will continue to follow me on this journey.  Follow me to my new home:  California Dreamin' Squirrel where I will continue to write about my life, my hopes, my dreams.  Tomorrow the journey begins.... So, Let's Roll...

I'm Sailing Away

Tonight would have been my last night crewing on a colleague's boat, however last week we had extreme wind conditions and I re-injured my shoulder during two very taxing spinnaker exchanges.  Not to mention I almost fell into the water during an emergency maneuver to avoid hitting another boat, so I am sure that stressed my shoulder a bit as well while trying to hang on to the safety line.

I've enjoyed these weekly summer respites.  My husband finds sailing "too slow" for his taste, but there's nothing more soothing and relaxing to me than spending time on the open water.  Of course, I learned to sail on smaller boats like Lasers and Hobie Cats, so speed has always been an enjoyable part of the experience for me, which is probably why I like crewing on a racing boat.  But, some of the most pleasurable times have been the ride home, sipping beers while slowly making our way back to the harbor.  We rehash the race, talk about upcoming events, there's even been a few discourses on the merits of the local professional teams.

While I am excited about moving to California, I am saddened at all the things I am leaving behind, one of which will be this summer experience.  However, one of my favorites quotes is about sailing, and so I will end with this as I look ahead to my move and new life's experiences...


"A ship in harbor is safe -- but that is not what ships are built for." - John A. Shedd

At the Beginning with You...

So, Guido and Donna reminded us on Facebook that the original anniversary of J-land was today.  Funny to think that about 3 years ago on August 6th I started my first blog "Do They Have Squirrels in Buffalo?"

I remember clicking on the AOL Journals button a little more out of curiosity than actually thinking that I would be keeping up a blog for this long.  I'd heard of blogs at that time, I just didn't think I'd have anything that interesting to say which would keep people reading.  I started it more as a way of keeping my family and friends up to date on what I was doing.  "Need to catch up, read my blog."

I never expected I would make the friends I've made online.  Donna was one of the first people to comment on my very first blog posting.  She actually lives in Buffalo and assured me that, yes, there are squirrels in Buffalo.

Along with her, I've shared in so many stories of celebration, heartache, new life, and sudden deaths.  Through Guido we've shared prayers and thoughts, visited those who are ill, and have become a close community whose members are only known mostly through these postings.

I think about my own journey as chronicled through this blog... I'm going to save my end of the year wrap-up for just before I leave for California and close this chapter of my life to start a new one... and a newly named blog.  Until then, relish in the friendships, relish in the sharing of this human condition, and relish in the forum that started it all... Happy Anniversary fellow J-landers... I'm glad to have met you along the road.

Workings of the Mind

As I wrote before, for the last 3 weeks I have been on an elective in Neurosurgery.  It's been a heady (hee hee) experience being back in the OR.  Learning SO much about neuroanatomy.  Since the beginning of the month, we have been on-call for spine, so I've also been getting quite the education about spinal lesions and learning how to read MRI's.

We've been rather busy due to "trauma season," and at times have affectionately nicknamed the Trauma ICU as "Turban City" since 90% of the patients are ours and have their heads wrapped following surgery or ventriculostomies.

During the last several weeks I've come to realize a few things:

 - drunk anything is bad.  It makes you drive carelessly and hit 70 year old grandmas who then bleed into their brains.  It makes you jump on the hood of a car that then drives away, and you fall and fracture your skull and then bleed into your brain.  It makes you jump off a porch causing you to break several bones in your spine which leave you with weakened legs and needing a urine bag because your bladder no longer works properly.

 - you can be hurt by the ones you love.  The guy whose name you tattooed on your shoulder can shoot you in the head and dump you by the side of the road.  The family of your boyfriend can object to your relationship and cause broken bones in your face and head.  Your drunk husband can roll over the car causing you to have massive brain injury and leaving you as helpless as your two young toddlers.

 - walking down the street is dangerous.  You can get shot at, run over, mugged, or just trip and fall.  All of which can land you on our service.  So is riding your bicycle, driving in a car, or flying in a plane.

 - I like opening and closing surgical cases more than the actual procedure.  I know, weird.  But there's something very satisfying about gaining the exposure, identifying the lesion, then trying to cosmetically close the wound.  While drilling and plating is interesting, once I've seen the anatomy I'm satisfied.  I know, weird.

 One more week then it's back to the E.D. for my final 11 shifts.  We're on a countdown of 30 more days until I move from coast to coast... I've got to start thinking of new names for my blog...

The Brain Drain

So, I am on the Neurosurgery service this month, and one of my responsibilities is learning how to place ventriculostomies.  They look like this...

As I mentioned in my prior post, they serve to help monitor the pressure inside of the skull, and can be used as a means of releasing pressure if it starts to get too high.


You basically find your landmarks, put some anesthesia into the skin, drill a hole, hit the right spot, slide the tube in, connect it to the monitor, and then sew everything in place.  Before you get too freaked out, remember that the patients we are putting these into are the victims of head trauma.  So far I have helped put in four. 


Last night I put in one under CT guidance.  That's where we get a CAT scan, put the tube in part way, get a CAT scan, adjust, and repeat until we have it in the right position.  At one point I was leaning against the machine, standing on one foot, drilling the hole while my attending leaned against my shoulder to make sure I was heading in the right direction.


Again, while I can't talk about specifics, these are a few of the patients we are currently monitoring:


 - gun shot wound to head
 - hit while riding bicycle
 - roll-over car accident, not wearing their seatbelt
 - intoxicated and fell off moving vehicle
 - assaulted and hit on head
 - not wearing helmet and flipped over front of bicycle


It's just been a week, but it's turning out to be a great learning experience so far!

Under the Pale Moon Light...

So, this month, I am on-call with one of our neurosurgeons.  Since I am going to a place with no neurosurgery back-up, I thought I would take the initiative and find out what I would need to know to be able to manage any patient that came into the E.D. that would need to be stabilized before transporting them several hours away to a University facility.  Plus I get to spend some time in the O.R.and learn other procedures so that is a bonus as well.

Last night I was awoken from my sleep and drove to the hospital in the middle of the night under a full moon for this....

Let me explain... this is a CAT scan of someone's skull.  The shiny thing at the bottom of the screen is what is left of the bullet that struck this person's head.  In the upper left, you can see the hole the bullet made, and the small white pieces that are scattered just to the right of the hole are pieces of bone that entered the brain when the bullet came through.  We spent the first part of the surgery clearing out the clot that had formed.  We spent the next part of the surgery clearing out many of those pieces of bone.  We spent the final part of the surgery getting "the heck out of Dodge" as the patient was bleeding profusely and needed to be stabilized in the Trauma ICU.

When we arrived in the TICU, we put in an ICP monitor at the bedside.  This will measure the pressure inside of the skull (IntraCranial Pressure - ICP).  High pressure is bad because there's a certain pressure above which the brain doesn't get any blood flow.

I'll post photos as I can during the next month... hopefully there will be some happy endings as well to talk about.

Back to the Future

From my Central Line posting:

I think the first and most lasting memory we all have of medical school is cadaver lab.  That is where we met our first patient and started to learn about disease processes.  It’s where a lot of us experienced death up close for the first time and began our lifelong pursuit of staving it off for as long as possible.  We shared the experience with our classmates – bonding us together as future physicians.  So many friendships (and a few romances) were made over that cadaver.

I remember the nervousness as we decided who would make the first cut.  We started our dissection on the upper extremities, and that first incision to expose the flexor muscles of the arm seemed so impossible.  Who were we to cut into another person?  Shaking scalpel aside, we made our way through.

Today I was faculty at my final cadaver lab of my residency teaching the junior residents advanced procedures such as venous cutdowns and thoracotomies.  There was no hesitation in their hands as we identified landmarks and dissected out veins.  Everyone reached for the scalpel in anticipation of making the thoractomy incision.  Eager hands reached in to find and cross-clamp the aorta.  No nervousness here.  Everyone was eager to cut and learn.

As I count down the final several weeks of my residency and look to my future as an Emergency Medicine attending, I find myself thinking back more and more on my training.  Days like today take me back to where I started;  scared, unsure, wondering if I would be able to pick up that scalpel.  Now I can see where those first tentative days have led me to.  And, I thank all of those patients who gave of themselves along the way so that I could continue the promise I made to that first patient so many years ago…  ”Rage, rage against the dying of the light…”

We Got Your Back--board

There's two ways to come into the E.D. at the County:  one is passing by the waiting room, and the other is coming up the back stairs and passing the hallway where the backboards are stacked.  Either way, I can get an idea of what's waiting for me inside the E.D.

Most of the time when we take someone off the backboard, they've been placed on it as a precaution following a fall or a traffic collision.  Sometimes there's blood on the boards.  Sometimes worse.

They all get brought here... to the back hallway.  Here they wait for Environmental Services to give them a good wipe down.  There's actually a separate stack for clean versus dirty.  The clean ones get picked up eventually by their respective EMS agencies so there is a constant ebb and flow to the stack.

Still, in general, it's a good indicator of how a day is going, or how the day has been.  Lots of boards means lots of traumas, and they slow the whole E.D. down, hold up resources, overwhelm the staff.

I make a conscious decision on most days - front entry and pass the waiting room to see what's coming;  back hallway and backboards to see what's been... it helps to prepare me for the shift ahead.

Theme Night

Talk to anyone working in the Emergency Department, and inevitably it seems that some days there's a theme running through the department.  Last night was "I Broke My Face" night.

36 year old who fell headfirst off of a balcony down to a sandy bottom below.  They thought they had a small scratch on their eyebrow.  They came to the emergency department because their eye swelled up and looked like a beet was growing out of their eye socket.  CT scan showed they broke their face.  They were  admitted for having pneumocephalus - "air in the skull."

20 year old who fell headfirst over the handlebars while biking with a friend.  Seems their front tire struck their friend's back tire.  No helmet.  Landed right on their face.  CT scan showed they broke their face.  The eye socket is made up of 4 walls.  They broke three of the four.  They got to go home with antibiotics and a follow-up with the facial trauma service.

25 year old that got mugged.  They were punched in the face and came in with a swollen cheek.  CT scan showed a broken cheek bone, otherwise known as the zygomatic arch.  Because it was broken in multiple places and pushed in, they most likely will need surgery.  I left that one at the end of my shift, so I will find out what happened to them when I go back.

40 year old that was drunk and crashed their car.  Since they weren't wearing their seat belt, the windshield stopped them from flying out of their car.  However, they broke the windshield with their face.  They broke their face in about 10 different places.  The facial trauma service was going to look at that one when I left.

I worked all Fourth of July weekend and kept expecting it to be a "Drunk and Disorderly" theme weekend, but surprisingly it wasn't.  However, the Trauma season is in full swing, so the hits will, literally, keep on coming.

Playing Doctor

 For those of you that followed me from the time I was writing on "Do They Have Squirrels in Buffalo?" you might remember that I left Minnesota to move to Buffalo and start an Emergency Medicine residency.  My first post about working in the Emergency Department included my saying, "I know eventually I'll stop feeling like a medical student and start feeling like a doctor again."  That was on September 12th, 2007.


Since I have to give my residency program a full 36 months, I will be in Buffalo until September.  All of my colleagues are gone and most will be working their "real job" starting this month.  So, I am working as the senior-most resident in the E.D. along with the new 3rd years.


It's been kind of interesting, and I've taken a bit of ribbing, especially from the attendings.  Today, my nickname was "pre-ttending."  I sometimes feel like I am.  While my third year started along with my colleagues, and I actually have done my 12 months of being senior resident, I think you really need to be on your own to make that final leap from resident to attending.


What I do notice is that I seem to go on auto-pilot a lot of the time.  I remember a case where a patient coded and the attending asked what I wanted to do next.  I froze.  Now, I run codes without thinking.  I guess that's where the training has come in.  Come in with chest pain, get chest x-ray, EKG, cardiac enzymes, MONA, etc.  Come in with abdominal pain, IV fluids and anti-emetics then plus/minus on the CAT scan.


While I still falter a little on the esoteric nuances of EKG's and multiple sclerosis, I think I am doing pretty good for the most part.  Another three months and I will be close to perfect... at least I hope so... for my patient's sake.

Are You Ready for the Summer?

Every year at this time I write about how now is the worst time to go to the Hospital... in 2008 and my old blog I talked about how a month ago the new doctors were medical students and now they are interns responsible for patient care.  Last year I wrote in an almost stream of consciousness about my first two shifts as a Senior Resident.  Now, I am 77% done with my senior year, and I am starting a new medical year as a resident and will finish it as an attending.

I've been kind of depressed thinking about all of my colleagues that have scattered to different parts of the country ready to begin their new lives as junior attendings.  It almost feels like I am stuck here watching everyone else move on ahead of me.  However, this time it's different.  In just a few short months I will be there too.  This month, I have 16 shifts in the E.D., then I have a month of glorious hell as Dr. Bennett's resident in neurosurgery, and then 11 short shifts the final month until I finish my residency.

It's hard to believe that three short years ago I was looking at a notice of an opening in Buffalo, NY.  I had to look at a map to even know where Buffalo was located.  When I got the call asking about my interest in coming here for residency, I had to consider the fact I was joining an established group of interns who had been working together for the prior 3 months.

I knew what it was like being an intern having gone through my surgical internship in Chicago.  You're like a bunch of scared puppies thrown out into the world together.  You huddle together for warmth.  You encourage each other along the way.  You live under the thumb of the attendings and the senior residents yet they are the very people you seek approval and reassurance from constantly.  You grow together, you play together, you learn together.

Tomorrow,  I start my new year on-call with Mercy Flight.  I will miss the first day jitters as a new set of junior residents suddenly take on the responsibility of being senior residents for the first time.  The interns are becoming junior residents.  And, a whole brand new group of medical students will become interns.  And, this is happening everywhere across the country.

So be careful out there... a new generation of doctors will be getting their feet wet over the next 2 months.  They don't know yet if they will sink or swim...



I love the movie "Meatballs." It always means summer to me... not to mention I was in love with Chris Makepeace as a teen... enjoy!

Night Flight

After several negotiations, we (emergency medicine residents) have been allowed to fly again with Mercy Flight.  Without going into detail, it had to do with who was covering our insurance while we were providing medical direction up in the air.  I went on my second flight this last Friday, and for the first time we flew at night.

We went on two runs... both for falls from about 15 - 20 feet.  One was from a zip line from a two story barn down to a tree.  The other was from the top of a bleacher stand at the local speedway.  Both involved kids... one nineteen, one four.  The nineteen year old didn't seem to have any apparent injuries, and the four year old had an obviously broken leg.  Both were very stoic in flight.  Both I am sure will do well.

I am excited to be back up in the air.  You never know what that next call is going to be....

Bittersweet Symphony

Congratulations to the Emergency Medicine

Class of 2010

On Tuesday my colleagues and I celebrated the completion of our three years of residency training.  It was bittersweet on so many levels.  I started "off cycle" so I will be staying to finish my last three months while the rest of my colleagues leave to begin their new careers.  I will miss them. 

For the last 3 years, twelve of us have gone through the same experiences.  Been taught by the same instructors.  Dealt with a lot of the same patients.  We can tell you which colleagues in different specialties we love and hate.  We can tell you which hospitals have the best off-service specialties, the best nurses, even the best food.

Three years passed by quickly, and I am sure the next three months will pass even sooner.  If you've notice my countdown calendar, I am 74% done as of today, and there are 93 days left.

I say "good luck" to my colleagues... I'll be joining you amoungst the ranks of "new attending" very soon.  But, until then, I'll continue to write on this blog while I finish out the last leg of my journey.  The end is in sight!

My Own Purrsonal Doctor...

Winston is my male cat.  Over the years I think he has somehow gleaned some medical knowledge from me.  I was thinking about it this morning as he used the AVPU system to assess my level of consciousness.  I know it's a "get up and fill the food bowl" thing for him.  But, still... eerie.

First he noted that I was not Alert.  So, he then assessed whether I would respond to Voice. When his meowings did not lead to the desired response ( I was actually awake at the first meow but refused to play his game) he then came up and butted his head gently across my elbow which was laying close to the edge of the bed.  Still not response to soft touch so he implemented Painful stimuli by biting my elbow.  

This, of course led to my sitting up and yelling at him to get out of the room.  Always the unflustered professional and mission accomplished, he raised his tail and walked out of the door.   I shudder to think of what he might do if I was really Unresponsive....

A Room at the Inn

So I've spent the last several days in Washington D.C. at a Leadership and Advocacy Conference.  Instead of spending my non-existent resident salary money on the fancy conference hotel, I stayed at the Kalorama Guest House in Woodley Park.  Now, granted I had to share a bathroom on my floor, and I was on the top-most floor with no elevator, it was very much worth the value.


As I was packing my bag this morning, I started to think about all of the hotel and inn rooms I have stayed in my life.  Now, overnights don't really count.  But, when you've stayed in a room for several days, it becomes like home.  You know which pillow is the firmest, how to set the air vents, even the creaks and moans become familiar.  I often find myself a little melancholic just before I leave;  as I look around one more time making sure I didn't forget anything.


Rooms have a life of their own.  They all have tales of life and death.  They are where new life begins and where life sometimes ends.  They see happy families, tired business travelers, passersby, and evicted spouses.  By our hospital, I am sure the hotel sees expectant families, worried spouses, excited and anxious interviewees, and hopeful patients.  There are a thousand tales a hotel room could tell.


Of course, one of my friends told me that the hotel where our conference was held is haunted.  So there's another set of stories that could be told.  Be sure, though, considering the guest house where I stayed was built in the late 1800's, I left an extra light on... just in case.

A Week of Nights

So for the last two weeks, I have been looking forward to a leadership conference that I will be attending in Washington D.C. this week.  To make up for the fact that I would be gone for about 6 days during a non-vacation month, I had to squeeze in my required shifts into the rest of the time.  So, I just ended a string of 6 nights in a row.

Now, a 72 hour week is nothing compared to the sometimes 120 hour weeks I'd put in as a surgery resident. However, the last time I did something like that was over 3 years ago, so I was a little rusty.  Suffice it to say, there were a lot of patients seen during that time....

 - the "newlyweds" who came in concerned that an infection on one had spread to the other... it hadn't, but I was more concerned about the fact one of them had Hepatitis C.  Now, that's something that you don't want to be sharing...

 - why are the nicest patients always the sickest?  I had the status-post bone marrow transplant for leukemia who came in with a pulmonary embolism.  He and his wife were the nicest people.  She kept track of every doctor's appointment, lab result, medication schedule, and he showed an inward strength I can't begin to imagine.

 - on the opposite spectrum, I saw my share of 10 out of 10 abdominal/chest/back/etc. pains who are "allergic to everything except that di, dil, daldid, something d stuff.  Of course their pain is always something non-specific with random symptoms, and they have to have the full work-up and treatment... I did say "seriously?" once or twice as several I knew had multiple ED visits came in crying and writhing on the bed.  They just stopped for a second and said, "Well, maybe it's a 7 or 8.."

 - moving someone from the ambulance gurney to the hospital bed and seeing brains is never a good sign

 - I actually admitted a 10 year old for "severe constipation"... come on, parents, more leafy greens and water and less processed chicken nuggets and colas... make your kids run around instead of sitting in front of the Playstation... I can't tell you how many "rule out appendicitis" kids I see that turn out to be constipation

 - some things come in pairs:  I had a Martin and a Marvin both come in with the same wrist fracture on opposite arms, one from roller skating and one from skate boarding on the same night... wierd

 - we are not fast food, you can't come in, pick what you want off a menu and then leave if you don't want to finish your meal... also, if you're crying and writhing in the hallway and you've been waiting about an hour, I am still going to bypass you for the little old lady who's turning blue who just came in the door... keep screaming, I'm going to be just a little busy saving a life across the hallway

 - some people are crazy, literally.  I always wondered about mental illness.  I had to do an evaluation on a paranoid schizophrenic...  it was something like the scene in "Patch Adams" where Robin Williams fights the squirrels with his roommate... yeah, something like that...

Ok, I think I touched on the highlights.  I'll be blogging from the conference this week, so stay tuned!

Happy Birthday to My Mom!!

Other than telling me that "you can't go to a coed high school," 

I can't remember another time when my mother said, "you can't."  

She always told me "try it" and "whatever you put your mind to, 

you can do."  I think the closest she ever got was "no, you 

cannot fly in that open cockpit biplane...remember what 

happened last time."

She instilled in me the confidence to live in Mexico by myself 

for a year, to travel all over the world, to go to medical school, 

to be my own person and never let anyone tell me I couldn't, 

wouldn't or shouldn't.  The last she felt confident in doing 

because, as I've written before, my mother instilled in me

a sense of personal responsibility for my actions.

I love you, Mom. Thank you for shaping me into the woman 

I've become.

Happy Birthday!

Livin' La Vida Veggie

Ok, so it's been about four months, and I am still living the Raw Food lifestyle.  Well, let's say about 80% of the time.  I do occasionally have an egg, and I can't give up cheese.  Although, I have found a source for raw milk cheese.   A lot of my friends and colleagues are amazed and say, "you're still doing that thing?"  Well, yes. 

Why you might ask:

 - About 2 weeks ago I grabbed the wrong black pants to take with me while I was in Boston.  Most women will understand when I say we have our clothes separated into "what I can wear" and "what I used to wear but may get back into so I can't get rid of it."  These pants were definitely the latter.  I pulled them out of the suitcase planning to wear pants to dinner with friends.  When I saw them I thought, "no way."  Then I pulled them on and buttoned them right up.  Oh, yeah.

 - I sleep better.  I have always been a morning person.  I have always had the ability to sleep about five hours and then be able to wake up and get on with my day.  What I have noticed, though, is that my sleep is deeper.  I wake up rested and seem to function better during the day.

 - I think I'm getting younger.  For some reason I haven't had to color the grays away (there don't seem to be as many) and my skin feels smoother (I think drinking all the water has something to do with that).  My joints don't seem to ache as much as before.  I feel like I can just keep going on the treadmill, and I seem to recover faster during a work-out.

 - Things move better.... I'll just leave it at that.

What I have learned so far:

 - there's no such thing as Fast Food:  it takes a lot of preparation.  My fastest meal is a bowl of muesli with almond milk and sliced bananas.  A fruit smoothie means cutting fresh fruit and blending everything together.  Even a salad takes at least 10 minutes just slicing the mix of herbs and vegetables.  Fifteen if I have to make a vinaigrette.

 - I shop more frequently.  I used to go to the grocery store about once a month and then slowly work my way through the cans and boxes and pre-packaged meals.  Now my meal planning consists of which vegetables I want to combine in my salads, what fruits are available, what fruits do I need to augment my dehydrated supplies, etc.

 - really, you can eat that?  One of the 20% of items I actually cook is quinoa (kween-wah).  Slightly toasted, cooked and then tossed with olive oil, pine nuts, and garlic it's very yummy.  It's also a good source of protein.  Even my DH asks for it from time to time, and he's not "choosey."  We also stand and stare at the exotic foods' section of the grocery store and try to find something new to try.  We've made some good finds.  Like golden beets.  Chopped raw on a salad.  Mmhmm.

Also, if you've noticed I've made it to the 50% done with this year.  Woohoo!  We are so looking forward to moving to the land of plenty... Farmer's Markets, a vegetarian's paradise, and some of the best wines anywhere.

Ship of Fools...

Tomorrow is Match Day.  It's the day that 16,000 US medical school graduates will find out where they will be completing their medical training in residency programs across the country.  Tomorrow is also Doomsday for the health care industry... or so some say.

Let's think about what's underlying all the hype;  everyone should have health care coverage.  I agree, everyone should be able to afford health care insurance.  If you're under the socialist model, if you work you have health insurance.  You go to a state-sponsored clinic, show your worker's card, and get your basic medical care.  As for those 16,000 graduates, they would all be working at those clinics in return for having had free medical tuition.  They complete their mandatory one to two years of service then go off to specialize in their desired fields.  They don't have to worry about an average $150,000 in medical school debt.

But, our 16,000 new graduates do.  They have to face a health care system that is paying less and less for state-sponsored medical plans.  So much so, that many physicians won't see those patients.  I've been told we get paid $19 for a Medicare patient.  That's for an E.D. visit.  My insurance co-pay (so I found out one day due to an allergic reaction) is $50.  A family medicine physician gets about $9 for a Medicare patient.  Our insurance co-pay for an office visit is $20.

Now, before everyone gets all huffy about those "poor rich doctors who just want to make a bunch of money" let's take into account the price of practicing medicine.  I have no qualms saying my medical school debt is over $200,000, and I don't have undergraduate loans like many of my colleagues do.  If I went into primary care I would have to join a group, that rents an office, pays utilities, rents their medical equipment, buys office and medical supplies for their office, has to pay a billing specialist, a medical assistance, several nurses, and not to mention their own salaries.  Most practices are also adding physician-extenders like nurse practioners and physician's assistants to handle the work-load.  The more patients you see, the more money you make.  And, several of the larger  hospital-based groups have set R-something-U (Reimbursement something Units) that they have to meet.

So, you have to see more patients to bring money into your group to cover your expenses.  You're under pressure to "perform" or risk losing your job.  And, the government is paying less for the patients that are under their programs.  I am sure those 16,000 graduates-to-be would like to live their American Dream having worked toward it for the last 8 years and who are now getting ready to dedicate another 3+ years toward.  Maybe that's why recent articles in the Associated Press, Journal of the American Medical Association, and USA Today show that only 2 - 9% of graduates are going to go into primary care.

Given a generous 10%, that's 1600 graduates to be mostly spread around the lower 48 states.  So, on average each state will get about 33 new primary care doctors.  Of course, the more popular states like California and New York will get a bigger share of those, and less popular states will get the leftovers.  Ever wonder why there are so many foreign-born doctors in some areas...?  They fill the spots left open where there is still need.

Ever wonder why you can't get in to see your doctor?  Wonder why it takes several hours for a 10 minute appointment?  Well, that's part of the reason.  So, I get the overflow in the E.D.  A large percentage of the time when I ask a patient why they didn't go their own doctor it was because of a 2, 3, sometimes 4 week wait for an appointment.  Or, as one patient told me, they did go but after waiting 5 hours they left.

Now, let's pass a bill that's going to make insurance mandatory for everyone.  Let's flood the system with new patients who suddenly have the means to see a doctor.  There's a shortage of primary care physicians because reimbursement is so low.  And, I sincerely doubt that any federal program is going to pay much more than is currently being paid.  So, my business is going to go up.  However, in some parts of Los Angeles there's no E.D. to go to because they're closed due to budget constraints.  Small clinics are going to have to close down.  Everyone will have health care but there will be no where to go.

Also, from the grumblings I've heard, a lot of doctors are looking for alternative careers.  Just amoungst my med school colleagues I've heard of people practicing non-clinical medicine.  Many are saying they are thinking of working less hours to fall just under the $250,000 earnings line... remember that campaign promise that will probably actually be kept?  A friend of mine said, "Who wants to pay their patients to come see them?"  We pay the taxes that fund Medi-whatever State Care that is given to illegals, those on disability (don't even get me started on some of the bogus diagnoses that get a free ride), and many others who don't put a dime back into the system and then come in expecting everything.  As you can imagine that $19 doesn't even cover the cost of a chest x-ray.

So, at the risk of being long-winded, give doctors and teachers and police and firemen what they're worth.  If government is going to get into the business of medicine, make us all federal employees who will be eligible for our lifetime pensions when we turn 54.  You can't sue the federal government so we would no longer have to worry about tort reform.  Pay for our medical education and in return we will care for your huddled masses who came to this country to earn their American Dream.  They didn't expect anything to be handed to them... they expected to make money the Old Fashioned Way - they earned it.

Our 16,000 graduates-to-be have earned it... let's hope we give them a future that's worth it.

Ship of Fools - Grateful Dead

"Though I could not caution all, I still might warn a few:  

Don't lend your hand to raise no flag atop no ship of fools.  

Ship of fools on a cruel sea.  Ship of fools sail away from me."

I Object!

So, I just spent the last week in Boston.  From July of '04 to June of '05 I was there as a Junior Fellow in Cardiac Surgery.  Basically, I was the Cardiac Surgery ICU scutmonkey.  Well, one of them actually as there were four of us hired that year.  My days and nights were spent taking care of the many, many different types of cardiac surgery patients in the ICU.  I learned a lot during that year.  Many of the events of that year helped mold me into the type of physician that I would want to become.  I think back to that time as an amazing experience.  However, during the last several months I have had to look back at that experience and wonder if I even realized then how a simple series of actions could lead me to spend four days in a courthouse; three of which were on the witness stand. 

Now, I like to think of myself as a pretty honest, thoughtful, considerate physician who lives by the philosophy of "Primum non nocere" - "First do no harm."  I think this governs my actions even more than the Hippocratic Oath.  And, in general, I don't like (not that anyone does) being asked in a public forum to defend my actions, my honesty, my very integrity.  But I had to.

I'm not going to delve into the whole experience which at times left me feeling every emotion from pure anger, to self-doubt, to honest reflection, to sheer relief.  I was lucky to have one of my colleagues from that time there to support and share in the experience.  If anything, we were a sounding board to each other about our thoughts on the day, the lawyers, the plaintiffs.  We also shared memories of the time.  And, revisted a few of our old haunting grounds.

She's continued on in surgery and will graduate this year and start her practice of medicine.  I changed to emergency medicine and will start my own practice later this year.  We're amazed at what we remember from that time and what we've done since then.  In a lot of ways both of us have been changed by this experience.  I feel for the better... however, just don't get me started in an argument about healthcare reform... except for my awesome legal team I'll be quoting Shakespeare, "The first thing we do, let's kill all the lawyers."

My Central Line Post

My Life in Six Words

I was catching up on some of the blogs that I follow, and I came across a blog that I had kinda given up on because the author Russ hadn't written (or drawn actually) in a while.  Today, I found that he's actually posting again, and this is based on one of his posts...

When I googled "life in six words" to find my image for this posting, I found that somebody actually collected several authors' memoirs into a book.  So I challenge you now... Write your autobiography in six words... leave a link, we'd love to read it!

As for mine...

Have traveled the world.
Still learning.

At the End of the Day...

I haven't written about a day in the E.D. for a while, so I thought I would blog tonight about my shift today.  Just another day in my world.  For some, this was no ordinary day...

So, I started my shift at 0700, taking over from one of my colleagues and picking up about 10 patients right off the bat.  While I sent off my rotating resident and medical student to pick up a couple of the new patients that were waiting to be seen, I went to look at the lacerations on a stabbing patient that I had picked up on sign out.  My colleague hadn't been able to sew the wounds because they had been waiting for a few more films to come back, but by sign-out the patient was ready to have their wounds fixed.

I looked at the 4 inch cut to the face and the inch long wounds to the arm and back, and I knew that I would be sewing for a while.  When you're the senior, you're not just in charge of your patients, but you're also responsible for the flow of the department (what's coming in and what's going out and where).  So, I knew that I couldn't just leisurely tie myself up in one patient's room.  I had to think about what could potentially happen.

I stepped out to gather my supplies and went and saw a new patient coming in complaining of back pain.  She'd had recent back surgery and was having post-operative pain.  I wrote for some medications after some discussion with my attending and continued gathering my suture supplies.  About that time an elderly patient that had fallen down the stairs came in.

There was some concern because the patient was on blood thinners, and she had hit her head.  I did her exam, did a FAST exam and wrote order for the multitude of CAT scans I would be getting on her.  I then went to go start stitching my patient's face.  It took me about 30 minutes to get his face sewn up.  In the middle of my stitching, nurses would come in from time to time to ask about orders for patients.  At one point near the end, the nurse taking care of my elderly fall lady came to tell me that the patient wasn't as alert as she had previously been.  I told her to rush her to CAT scan.

I finished the patient's face and went out to see what had happened while I was gone.  The patient tracking board was filling up with patients, and I quickly went and saw another senior who had passed out in church, and one of our sickle cell frequent fliers.  I put in orders then went back and quickly spent about 5 minutes sewing up the laceration on my patient's arm.  Two lacerations down and one to go.  As I was putting in the last stitch, the nurse for my fall patient came in to tell me that the patient had bleeding in the brain.

I went out and told the charge nurse that we needed to move the patient to a trauma room.  I paged out the trauma team, and I put out a call to the neurosurgeon.  I wrote some order discharging a couple of the patients that I had been signed out that morning and answered returned phone calls.  I got the medical student started on sewing the last wound on my stabbing patient.  He got the first stitch in about the time I heard my name paged to the trauma room.

I went and found that the fall patient had an even worse neurological exam and would need to be intubated.  I went to find my attending as I grabbed the airway box and went to the room.  My attending told me to wait because he didn't feel there had been much of a change, and he wanted the neurosurgeon to get a good exam.  I went back to my medical student and got him through another stitch.  I got called back out of the room to talk to the family of the fall patient.  I explained about the head bleed and how I might have to put a breathing tube in.  They understood, and I went back to the stabbing victim.

One more stitch and I was called back to the fall patient.  She'd just vomited everywhere.  I told my attending I was intubating.  I got the breathing tube in and went to tell the family I had just done so.  They were very upset asking how the patient was going to do.  I couldn't answer them, but elderly patients who fall down the stairs and bleed into their brains don't often do well.  Another stitch with the medical student plus one or two I quickly threw in to move things along, and we were done.  By this time it was close to 1 p.m.  Where had the morning gone?

My fall patient went to the ICU, and I discharged (finally) the stabbing victim.  I picked up a nursing home patient brought in for altered mental status and another patient with swelling in their lower extremities.  After discussing the cases with the attending, I placed my orders and sent the resident to lunch.  I quickly saw a prisoner with a hand injury from a fight in the jail and placed orders for films.

My swollen patient ended up needing a cat scan, and for some reason it took 2 hours to get a head CT on my altered mental status patient during which time I sent the prisoner back to his cell and sent the medical student off to lunch.  I grabbed a quick salad myself (still doing the raw food thing) while I saw a pseudoseizure (nee big faker) and a patient bleeding from just about every orifice.  Oh, and a short of breath pregnant patient who did a whole lot of cocaine.

By this time it was after 5:30 p.m.  I got a neurology consult on the big faker, um, seizure patient, and I started ordering blood products for the bleeder.  My cocaine patient settled down, and I picked up a patient that had lost their battle with a table saw.  Almost missing - one pinky.  I called orthopedics.

Around this time I was cleaning house.  I got my big faker patient admitted, my swollen patient admitted, and my bleeding patient admitted.  We got word about this time that my fall patient had suffered a major bleed and now had a ton of blood in her head.  This was not going to end well.

Seven p.m. and my colleague returned.  We signed out our patients to her, and I spent about another hour doing paperwork and getting my altered mental status patient admitted and got my cocaine patient information about her reproductive choices.  While morally I oppose abortion, a cocaine and alcohol addicted patient whose three children are in the custody of her parents probably should have the option.  I don't condone it, but at time I think of it as a necessary evil.

Anyway, I signed out the cocaine patient because her heart rate was still irregular and my almost missing pinky patient because ortho was busy with a dislocated knee that had rolled in the door just at change of shift.  Tiredly, I packed my belongings and made my way home.  Vacation started the minute I left the hospital.  After another "usual" day in the E.D., I really need it.

For those reading on Facebook, my original blog site is buffalosquirrels.blogspot.com and I also blog for the American College of Emergency Physician's (ACEP's) website thecentralline.org

It's the Journey and the Destination...

So, today it's official... I signed my contract, and in a couple of weeks we're going to take a second trip to Humboldt County to begin looking at housing.  Earlier this week, I got an email from a friend coordinating our 25th high school reunion.  How far I've come.


My plan when I graduated from high school:  graduate with a degree in civil engineering, meet my future husband, start a career, have three kids (2 boys and a girl), and build the cities of the future.


Five years later when I graduated from college with a degree in Photojournalism my plan was:  get a job as a reporter, try to get a job as a foreign journalist, meet someone and think about marriage later when I've gotten the wanderlust out of my system.


About five years later when I turned 30, I thought I could probably safely die and feel as though I had led a rich life.  I had been traveling across country to train in Washington D.C. for a demographic researcher position in Mexico City.  I lived in Mexico City for a year and met an amazing group of people.  I had traveled to Europe and Australia, and I had seen parts of the country that I never thought I would.  And, despite some dire odds against me, I actually got accepted to medical school.  Marriage and family was a distant memory... I had things to do.


I don't know that I had much of a plan going to medical school other than to actually graduate. I originally went in with the intention of doing emergency medicine, however when I did my fourth year elective I hated it.  How could anyone possibly want to work with people who did not take care of themselves?  Why did all the cool traumas go to surgery?  Was it too late to change my mind?


I found out it wasn't which is how I ended up doing three years of surgery.  Over that time, though, I found I missed the patient contact.  I missed teaching my patients.  After taking a year off, I went back to emergency medicine.  I got married.  I have three children of the furry kind;  a boy and two girls.  And, now, I have just taken the next step.  We're actually going to be "settling down."  Wow.


It definitely wasn't the destination, but the journey that has brought me to this point.  I can stop and think about several points in my life where a decision I made definitely changed the course of my life.  They're the "what ifs" that everyone has faced from time to time.  I'll ponder them in another post.... might even base a story on them.  But for now, I will relish in the fact that I'm just about to reach my next destination... I don't think it's the final one.  Ask me again in five years...

Real World Lessons

Thank you for all the comments on the Raw Food way of life that I started at the end of last year.  I thought I would take some time to answer some questions:


1.  To the left is the book that got me started.  It's really a gourmet raw food cookbook, but the authors took the time to research the science behind the Raw Food lifestyle.  In that it was great.  Practically, I can't find most of the ingredients that are listed (although the book has a great resource index at the back), but I am sure that once we move back to the land of fruits and nuts that is Northern California I know we will have a coop nearby and a ton of fresh locally grown produce from the farmer's markets.


2.  No, I don't eat raw meat.  We're not eating any animals at this time.  We are doing about 85% raw at this time because I can't quite give up cheese (Wisconsin raw Monterey Jack, yum) and my hubby needs his cream for his coffee (definitely not raw on both accounts) not to mention we will occasionally eat eggs (soon to be our own;  home-grown from our own chickens).


3.  The best website I have found is this one by Esme Stevens which has a lot of practical advice for newbies.  I also consult the Raw Food Community site and also the Raw Way site.  There are tons of other sites out there for recipe ideas.  Also, I have been collecting some site for finding deals on many of the staples:  nuts, dehydrators, etc.


4.  What do I miss?  At this point over 2 months into it, seriously not much.  I always said I couldn't be a vegetarian because I couldn't give up ribeyes.  Now they don't taste the same (not to mention the assault on my GI system).  Bread - almost like I can taste the processing.  Pasta - it just doesn't have a fresh taste.  There's something about the crisp clean crunchy taste of fresh foods.  After this time, some days I am starving for a big salad, other days I just want a shake.  We've learned to be very creative with different ingredients.  Oh, but I do miss warm things... you're not allowed to cook anything.  But I have popped my Manna bread into the dehydrator from time to time.


5.  How can you go out?  You get creative.  I've eaten a lot of salads with oil and vinegar.  I have eaten grilled vegetables.  And, I allow myself one meal a week that is not completely raw.  I talked on my last blog post about some of the foods I enjoy.  I recently went on a trip to Phoenix for a medical conference and took my bag of dried fruit and nuts for snacks.  I was able to pick appropriate foods, and one night I indulged in some awesome soft corn carne asada tacos .


6.  "I don't know how you do it" - I don't know either, but it took a lot of discipline.  The first week was the hardest.  It does take a certain amount of prep time to get everything together.  You go to the grocery store more often, and spend a little more money, because everything is fresh.  But, after the first week of drinking water instead of Diet Coke, skipping the grill and heading to the salad bar at work, bypassing all my favorite fast food and take out places, I started to feel better.  I noticed I was sleeping better, felt more rested when I woke up, and didn't have a mid-afternoon post-lunch sleepy feeling.  Not to mention the weight loss benefits I talked about before.  Now, I am adding some exercise to my routine keeping the idea of running a five K and wearing a swimsuit by summertime as a goal to achieve.


Not that I expect to convert everyone to the Raw Food lifestyle, in fact the authors of the Raw Food Raw World book have a goal of 80% raw for most people, but I do hope this has helped to encourage you to make some lifestyle changes that will keep you out of my E.D. :) Not to mention help keep you around as my friends for just a little longer.  An easy way to get into a healthier way of eating is to do the "Pledge to be Veg" which I did last year, and which really got me thinking about what I was eating.  Good luck!


p.s. for those on Facebook, these notes are imported from my blogsite:  buffalosquirrels.blogspot.com