Buffalo Squirrels Won't You Come Out Tonight?

New Blog Site

2010-09-13T00:02:00.000-04:00

I have changed over to my new blog site.... California Dreamin' Squirrel
Come visit me there!

Epilogue

2010-09-10T23:13:00.000-04:00

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

2010-09-02T00:37:00.001-04:00

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...

2010-08-21T20:26:00.000-04:00

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

2010-08-13T22:38:00.000-04:00

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

2010-07-28T15:38:00.000-04:00

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...

2010-07-25T21:36:00.001-04:00

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

2010-07-22T23:51:00.000-04:00

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

2010-07-21T22:46:00.000-04:00

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

2010-07-06T09:18:00.000-04:00

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

2010-07-01T23:41:00.000-04:00

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?

2010-06-27T23:14:00.000-04:00

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

2010-06-20T15:58:00.000-04:00

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

2010-06-17T16:35:00.000-04:00

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...

2010-06-02T23:52:00.001-04:00

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

2010-05-19T12:18:00.000-04:00

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

2010-05-15T22:35:00.001-04:00

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!!

2010-04-17T16:15:00.006-04:00

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

2010-03-20T22:14:00.000-04:00

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...

2010-03-17T17:39:00.001-04:00

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!

2010-03-04T14:26:00.000-05:00

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

2010-02-15T23:27:00.000-05:00

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...

2010-02-01T00:51:00.000-05:00

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...

2010-01-19T21:39:00.000-05:00

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

2010-01-12T15:15:00.000-05:00

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

In the Raw for 2010

2010-01-01T17:38:00.000-05:00

Ok, so for the last month and a half I have been doing the "Raw Food Diet." No, I don't eat raw meat. It's a vegetarian-based, nee vegan, way of eating that believes in the principle that cooking food destroys valuable enzymes necessary for the digestion of the food, and also decreases the valuable vitamins and nutritional value of the food. So, I've been eating a lot of cold food lately.
I am happy to admit, about 12 pounds off later, that I am feeling better and definitely seeing the results of a healthier way of living. Not that it's been easy. It took a lot, a LOT, of discipline to not nibble on any of the yummy Christmas goodies that were brought to the hospital and laid out for everyone to enjoy. I sort of miss my daily Diet Coke. And, I haven't had a Starbuck's Caramel Macchiato since before Halloween.
I have to plan my meals, and the biggest problem I had in the beginning was keeping my sugar levels up. I would get shaky right around 10 or 11 in the morning, and I realized that I could no longer go without eating something substantial in the morning. Now I pretty much nibble all day long.
I also spend a little more at the grocery store. But I enjoy seeing the different colors of the foods I am buying... from the deep greens of the romaine lettuce and zucchinis to the reds of the radishes and radicchio, the yellows and oranges of the peppers, oranges and bananas. I got a box of avocados from my uncle in California for Christmas and am teaching my Southern DH (who had never seen an avocado before he met me) how to peel and prepare them.
I drink a ton of water, and I am learning how to be more creative when it comes to preparing food.
Now, I have to admit, I have a fondness for the lamb hummus from a place called Falafel Bar, and I have been known to eat a piece of chicken here and there. But, my treat is one meal a week, and to be honest, I don't miss it if I don't have it.
So, my resolutions for the new year:
- to continue my raw food healthy habits
- to study and read more journal articles
- to finally get better on my snowboard
- to pet a cheetah
- to finish at least 2 of the UFO's (that's unfinished projects) in my quilting stash
- and to make it to church more often and thank God for the wonderful gifts of family, friends, and health He has bestowed on me this year.

My best wishes for your new year... what are your resolutions?

Voices Carry

2009-12-23T21:24:00.000-05:00

Along with those patients we see during our shifts, there’s a group of patients we never see…. the ones on the other end of the Medical Direction line. At the hospitals we rotate through, there are the “Bat Phones” - the phones on which pre-hospital care providers call us for, well, medical direction. It’s actually red at one of the hospitals. Cool.

Interns, not allowed to touch the Bat Phones. Junior residents, encouraged to field calls. Us seniors, we’re on it most of the time. I’ve given orders for medications, orders to keep a patient home, orders to have a patient sign off AMA. And, I’ve given the order to pronounce a patient in the field.

I don’t think about those too much. Usually it’s an elderly patient, found down after EMS was called to a home for a welfare check. “Lividity?” Yes. “Cold with no signs of life?” Yes. Ok to pronounce.
I did have one funny situation where I was told the patient was “obviously dead” however they still were showing a sinus rythmn at 60. Pacemaker. I told the EMT’s to get a big magnet, and/or to make sure that anyone that was going to be handling the body knew about the pacemaker. Wouldn’t want anyone to get an unpleasant jolt.

During my overnight shift, though, I had the hardest medical direction yet – pronouncing victims of a house fire. I got the first call about 3 in the morning. I could hear the sadness in the usually jovial EMT’s voice, “thirty-something year old found in a burning house; soot around their face and mouth. No signs of life. Asystole on three leads.” I didn’t know what to say. How long had they been in the house? “Unknown. Found by first responders to the scene. Fire had just shown up.” I put them on hold.

Now, I’ve asked my attending about some complicated scenarios that I’ve been faced with. Early on it had to mostly do with medications during in-the-field resuscitations. But, last night, I felt I needed his advice. I told him the scenario. He too paused for a moment and asked the same question I had asked, “how long?” We both knew too long. I gave the order to pronounce.

Saddened by this, I went back to the bustle of the E.D. Then about 20 minutes later the Bat Phone rang again. It was the same EMT sounding even more morose. “I have two more, doc. Twelve and about 15 years old. Pulled out by Fire just a few minutes ago. Soot on the face and asystole on three leads.” In my head I calculated 4 – 6 mintes for brain damage to start and they had been in the house already longer than the first victim. Kids have a smaller reserve. I gave the order to pronounce.

My attending walked over to where I had been on the phone, documenting what I was hearing. He read over my shoulder. He walked away quietly. I hung up the phone and placed the run sheet in its place; suddenly feeling as though I had pronounced that family in the E.D. instead of from a distance. I had lost three patients in 30 minutes.

I gathered myself and went to pick up another chart. As I walked to the patient’s room I glanced at the Bat Phone, wondering when it would ring again, and what my next patient would be.

Isn't Sunday a Day of Rest...?

2009-12-06T21:59:00.000-05:00

So I knew things were going to be bad when I woke up late for work this morning. I was able to grab a pair of clean scrubs and run out the door. All I could think about was getting sign out from the night team and heading downstairs to get a cup of coffee. Little did I know... I rushed to get to work quickly. Made it in the door just at 0700, change of shift. Before I even had a chance to take off my coat, the senior from the night shift told me that there were three victims from a house fire coming in; one was a child and unresponsive and the other was an adult in respiratory distress.

I quickly took off my outer coat, grabbed my lab coat and stethoscope, figured out who my junior resident was going to be and got ready. We got the adult patient first. They were not responding coherently, so the decision was made to put a breathing tube in. I left my junior resident to handle that while I took off to the next room as the child was being brought in.

She was brought in barely conscious but breathing. She had soot around her nose, and we knew she probably had inhalation injuries. We quickly made the decision to intubate her, and I put a breathing tube in. We got her stabilized and started arranging transport to Children's Hospital. We had no names for either of the patients, so we would just have to wait to name our little Jane Doe.

About this time, a third victim from the fire was brought in. We asked if they had a little girl. They immediately started crying but could not give us a name. Carbon monoxide poisoning from a fire can make you goofy and delirious which they were. They became argumentative and refusing treatment, but it quickly became apparent that they were not breathing well and would quickly be needing to be intubated.

After a quick sign-out from the night team that had patiently waited while we stabilized the fire victims, I talked to the patient who was starting to complain of a sore throat. I told them what I was about to do and got some feeling that they understood. We sedated the patient and placed the breathing tube... three patients intubated and it wasn't even 0930.

Somewhere around here time started to speed up. I know from time to time I asked if it was Sunday and was anyone going downstairs for coffee. Seriously, it was a cold snowy day. A Sunday. Why were we so busy?

Things that also happened during my shift, sometimes at the same time or right after each other:

- alcoholic who vomited a liter and half of blood and needed a blood transfusion and admission to the ICU

- a patient who heard voiced telling them to stab themselves in the chest, so they did, and then ate kitty litter in an attempt to kill themselves, they also needed a breathing tube

- a possible stroke that turned out to be worsening heart and kidney failure

- a teenager shot while driving with a friend "minding their own business" who initially went to Children's and then needed to be transfered to us

- a teenager who decided to drink and drive and had a head-on collision with another vehicle; they and their passenger forgot to wear their seatbelts and both had head injuries

- an older driver who should have known better and drove while under the influence. They had a head-on collision too, with a tree. Again, no seatbelt. Again, major face trauma

- a very sick elderly patient that was transferred from another hospital and brought in by the helicopter. I'll have to see if they're still alive when I go in tomorrow

- another patient "minding their own business" who was stopping at a convenience store and was shot; they came in just at the end of my shift which just about rounded out my day. I will find out in the morning what the extent of their injuries were.

Wow. What a Sunday. And, tomorrow is Monday; traditionally the busiest day of the week. I better get to sleep early and double set my alarms... I think being late starts the day off on the wrong foot... yeah, we'll blame it on that!

When Art Imitates Life, Exactly

2009-11-25T20:39:00.000-05:00

One of my colleagues posted this on Facebook, and I am sad to say I am sure someone stood outside the Emergency Department room while I interviewed a patient.... seriously....

Today a mother presented with her teenage son and said she wanted him tested for the Swine Flu and a prescription for Tamiflu. When informed that we don't routinely test for the flu and that Tamiflu was only for those at high risk showing symptoms (which her son was not), she told my attending she wanted to speak to his supervisor. When he informed her he was the senior medical staff, she told him that she was in the medical profession (a secretary at a nursing home) and no one was going to fool her like they did everyone else, and that she wanted a second opinion. He told her she could check her son back in and be seen again. But, she had a 50/50 chance of seeing him again.

She then stated she wanted to talk to a supervisor, and she demanded a second opinion. She saw the nursing supervisor who advised her to go to her child's pediatrician which just happened to be at the pediatric clinic across the street. When my attending called over to warn them that she was coming over, he was told that she had already been there and that they had told her the same thing. Last we heard, she was on her way to get a third opinion...

Bang Your Head

2009-11-22T20:07:00.001-05:00

Ok, so it's been a while.... Funny how some shifts just seem to have a theme. Last night I found out all the different ways that someone could suffer a head injury. It made for an eventful but tedious shift, and also kept the CT scanner burning away. I think we all had radiation exposure since 80 percent of the patients that came in from 11 p.m. onward needed a head and face CT.

There was:

- drunk, fell down and smashed head on concrete

- drunk, tripped and fell down hitting face forward on concrete

- drunk, minding own business, and got whacked on head with metal pipe

- drunk, minding own business, and got slammed on head with baseball bat

- drunk, jumped into middle of fight and got hit on head and face with beer bottles

- doing cocaine and got hit by several people's fists across the face

- got drunk, drove without a seatbelt, crashed into several cars, jumped out and ran for about a mile from police that were chasing them, then needed an ambulance for a minor injury and ended up unresponsive with a breathing tube in the E.D.

and then there was the:

- out with family and suddenly collapsed. This patient had a massive brain bleed and ended up dying in the emergency room before the end of my shift. They most likely had a brain aneurysm that ruptured and that was it.

The rest of the patients I had ended up being everything from a cracked skull to facial bruising, and I put the medical student to good use stapling and suturing all the various lacerations. This, of course, kept me free to move onto ordering the next CT.

What Did I Just Say?

2009-10-29T22:53:00.000-04:00

I have a friend who works as a transcriptionist. She blogs and occasionally talks about her work. However, she talks about the business side of her work: how much she makes per line, how she can’t understand what the doctor is saying, how she has to undergo QI, etc. One thing she’s never mentioned is if she ever takes the time to think about what she’s transcribing.

I’m currently on rotation with a group that dictates their H&P’s along with their assessments and plans. After a day or two of dictation (which by the way I hate to do because I can’t stand the sound of my own voice) I started to wonder if transcriptionists laugh at some of the content in dictations or if they’re like mailmen who deliver postcards without reading the back. I know I sometimes chuckle when I get the transcribed note back to sign for the chart… especially when I read things like:

“Patient states they have been constipated for a whole month.”

“87 year old patient states she fell off a chair while painting her ceiling. She states her bridge club was coming over and didn’t want them to see a brown water spot that was on it.”

“Patient states that she has vomited several times. The last emesis looked like blood, or it could have been the cranberry juice she had been drinking just prior.”

“Patient denies any alcohol, tobacco or drug use, except for the occasional marijuana use whenever her son is in town.”

“Patient states he thought his abscess was due to an ingrown hair, so he shaved off his all the hair in his axilla thinking it would go away.”

“Patient presents asking for Tamiflu because “there’s a lot of sick people hanging around the grocery store.”"

Did I really dictate that…? Yep, patients say the funniest things…

p.s. ;) Betty this is for you...

A Cowboy Needs a Horse

2009-10-15T17:50:00.000-04:00

I never thought much about our “regulars” until I came back from vacation to find that one of them had died. We’ll call him “the Cowboy.”

I met him when I was an intern. He was the anginal patient with known severe coronary disease who had suffered from alcohol abuse for many years. He would come in from time to time; usually drunk, complaining of chest pain. We would run some cursory labs and an EKG, let him sober up, and then send him on his way.

As the months passed, he would start to come in more and more frequently; trademark hat and boots in place as the ambulance gurney brought him in. He had developed cardiomyopathy somewhere along the way and had an AICD placed. He started coming in complaining of it firing frequently and chest pain. He would be admitted and usually signed out AMA after a day or two.

Over the last 6 months, he was an almost weekly visitor to the downtown hospital, but then we started seeing him at the county hospital where we also have shifts. The Cowboy started becoming one of those “repeater” patients that become annoying. You’d see his name on the triage board, sigh, and then go in and ask, “Seriously, Cowboy, what is it today?”

About 3 months ago, though, he really started declining. His prior history of medical non-compliance and signing out AMA was making it difficult to get him admitted even when his heart failure was severely affecting his health. Somehow, we would convince the attending that he really did need to be admitted, and true to form, the Cowboy would get diuresed, refills on his nitro, and then sign-out AMA or abscond yet again.

Recently, though, on one of my admissions, I convinced him that he needed to stay for evaluation by the cardiac surgeons who had wanted to take him to surgery during the previous admission. He agreed only to be told that his disease was so severe that only a specialized center like the Cleveland Clinic might consider his case. He told me this about a week later when I saw him, yet again.

As soon as he saw me he said, “Wait a minute. Before you say anything I did stay, and this is what they told me…” As I was ordering his now routine chest x-ray, EKG, POC troponins and BNP, I looked at the Discharge Summary from his most prior admission. The angio said it all. He had severe disease of his left main, LAD and circumflex. His right was open about 80%. Basically, the Cowboy was surviving on one coronary artery.

He lived alone and didn’t have much family support. He was practically homeless. There was not going to be a life-saving trip to Cleveland. We all knew he didn’t have long. During my first shift back I was told that he had presented in fulminant pulmonary edema. One of my colleagues intubated him, but there was nothing else that could be done, and he died.

I tried to think back to the last time I saw him. Did I even pick up the chart, or did I leave it to one of the interns? Did I make conversation with him? Was I polite to him the last time I treated him or was he just one of the “regulars” who is quickly “treated and streeted” to make room for the “real” patients? I really can’t remember now, but I know that he’s a patient I won’t soon forget.

So, ride on, Cowboy. Keep riding; riding, along.

Play to the End

2009-10-13T23:29:00.000-04:00

I was thinking a lot today about a post I wrote some time last year in which I talked about a "good day to die." The patient that prompted me to remember this was my last patient of the day. Having just come back from 11 glorious days off, it was very hard to try to get back into the rhythm of things.

Just at the last hour, we suddenly got a Mercy flight. The report was a patient who had suffered a stroke. As the helicopter landed, we began to learn more about our new patient. They were in their 90's and had traveled with friends to a casino about 4 hours away from home.

While at the casino, they had felt suddenly ill and began to exhibit signs of a stroke (* I'll give a quick easy way to remember these at the end.) EMS was called and the patient was transferred to us. Unfortunately, they had suffered a severe bleed into their brain and their prognosis is grim at best.

Later, as I thought about this patient, I felt they'd had their "good day to die." Or, at least, what I would consider a good day: a trip with friends, gambling, probably a good buffet lunch, dressed to the nines... in their 90's. Keep partying on, brother, keep partying on...!

*Signs of a stroke:

Think

F - face - is one side drooping?

A - arms - are you not able to hold one of them up?

S - speech - is the speech garbled or slurred?

T - time is brain, get to a hospital as soon as possible

!!!

Weary Road Traveler

2009-10-11T23:00:00.001-04:00

Ok, so we missed our flight due to delays in San Francisco, and we had to spend the last 7 hours at the airport. Suffice it to say, it's been a looonnng 7 hours. And, we still have another 2 hours to go. Eeek!

I've been sitting here for the last several hours watching the droves of humanity walk to and fro, and I've come up with a few thoughts based on my own travel experiences.

- Wear something comfortable and practical. Low rise jeans that have to be constantly hitched up and short shorts that show everyone whether or not you've waxed recently do not make for comfortable clothing. Me, I prefer the loose velour-type pants. More stylish than sweats and more comfortable than jeans. Scrubs will work in a pinch, but people keep asking if you're on your way to surgery somewhere.

- Along that line, wear comfortable shoes. Those three-inch wooden wedge heels look awesome with that studded denim mini, but when you fall over running to your gate, it's not going to be a pretty site. Me, I like the slip-on tennis shoe. Comfy and you can sprint like a track star when you need to.

- I see a lot of people wearing the "I bought it at the airport" pashmina. Now, while some may say they're not really still in style, I think there's nothing better than having something warm to wrap around your shoulders on a cold flight. And, that's a good thing considering the scarcity, or high cost, of in-flight blankets lately.

- Next, the travel bag. Now while I am not a fan of the cat-covered "I bought it at the airport" tapestry bag on wheels, I can understand the attraction. It's light. It rolls. It doubles as a floor mat for your feet. No, really. Anything small on wheels is all you should be taking on a plane. Except for a tote... you can never have enough tote bags.

- Or, for that matter, over the shoulder bags. I have several in different colors, and I always travel with one. Except for this trip I went with a tote. Two actually. Three if you count my handbag, but it's a Coach and I wanted to look stylish for my interviews. But, I digress. The shoulder bag provides plenty of pockets for your ID, pens, travel documents, cell phone, etc. And, it can be unisexually stylish. Well, except for this one, it's got horses on it.

Finally, the ultimate travel need:

- the neck pillow. The softer the better. And, since I tend to like to sleep all through my flight, mine gets plenty of use. Along with my face mask and slippers which I got in a travel pack with the pillow. Did I mention I bought them at the airport Brookstone?

Interesting Road Sites

2009-10-10T00:38:00.000-04:00

You never know what you are going to find when you drive willy-nilly along the road. We were in no hurry as we made our way down the Oregon coastline, so we took the time to stop at various beaches, pull-outs and memorial plaques along the way. Here's a few of our finds today:

I love sand dollars. I collect them whenever I can. We walked this whole stretch of beach and I did not find one intact sand dollar. So I am bringing home a whole mess of partials for my collection. Some interesting facts about sand dollars can be found here.

We stopped to take a picture of the marvelous ocean view and overshot the turn-off by several yards, but luckily there was a smaller turn-off which we were able to pull into. As I was stepping around looking for the perfect spot, we came across this plaque on the ground. I Googled the name and came across a few facts. Here are two links telling the story of this local hang glider.

The obit and the Cascade Paragliding Club.

This is a monument in Depoe Bay memorializing two fishermen, Roy Bower and Jack Chambers, who went out to rescue another boat that was in distress and lost their lives. The town honors all of the lost in their annual "Fleet of Flowers" which is held on Memorial Day every year. Something about the quote (who is quoted I cannot say) really got to me, so I end with it here.

"It is not true. Life is not slain by death. The vast, immortal sea shall have her own, shall garner to her this expiring breath, shall reap where she has sown."

Recurrent Thought

2009-10-09T00:00:00.000-04:00

My DH and I made our way through Mount Rainier National Forest today as we worked our way across the Cascades back toward the Pacific.

As we drove, for some reason the words of Thoreau passed through my thoughts several times; especially as we walked through the Grove of the Patriarchs.

Here are the words and some of my pics:

"I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived."

On the Road...

2009-10-07T00:28:00.000-04:00

Just a few quick thoughts as my DH and I make our way around the Pacific Northwest...

I love Victorians

Purple never comes out in pics

I love the beach... any beach

I like helicopters... my husband, not so much

I really love bears, and Black Bear Diners

Sometimes you just have to do what your DH is into

My favorite time of the day is still early morning

Even crippled horses by the roadside have a certain beauty

Take the scenic road, you never know where it might lead

You can find simple beauty in unusual places

I thank God at the end of the day for allowing me to do all the things that I have been able to do in my life... And for allowing me to enjoy the splendor of nature.

Strangers on a Plane

2009-10-03T23:59:00.002-04:00

Did you ever get the talkity talk seat mate while traveling? I have been post 24 hour call or have just come off several night shifts in a row the most recent times I have traveled, so I have basically fallen asleep from just before take off to just before landing. I have become conditioned to waking up the minute my ears start sensing pressure changes in the cabin. Seriously, my ears start to pop, I wake up, the captain gets on the loud speaker and announces we're on final approach. Sleeping is the only way to travel. Wake up and you're in a whole new place.

However, I have been traveling with my husband lately, and we've been meeting a series of gabby travelers during our journeys. We had the "Name Dropper" who talked loudly and passionately all the way from Chicago to Los Angeles about her friend's wedding, who was going to be at her friend's wedding, the Who's Who who would be at the wedding and how they were all connected to this other Who's Who, etc. This is one of those times I am glad cell phones are not allowed to be used during flights.

We met "The Local" who spent the entire trip talking about local restaurants and hotels and recommending places we visit. She was not discouraged at all by fact that we would only be in town for a day and continued to regale us with stories of places she had been 15 years before which she felt would probably still be open and as wonderful as she remembered them to be. All this while pouring liquor from the two small bottles she brought on the 50 minute flight into her soda.

I am sure there will be more as we make our way across the Pacific Northwest... at least it's better than getting that baby who cries the whole trip... or is it?

Hitting the Road...

2009-09-29T18:06:00.000-04:00

I feel like I have been neglecting this blog a bit. Ok, I admit I have. But, things have been so crazy, and I just finished a three day battle with a cold. Maybe the flu... eek! I did have the fevers and everything. But, anyway.

I am headed out on the interview trail to the Pacific Northwest. I am carrying my computer with me, so I promise to post lots of pretty pictures and tales of my adventures along the way. I have 5 interviews scheduled, so hopefully I will find the perfect spot in which to begin my career. 'Cause, let's face it, it's about time I actually started working for a living, right?

See you on the other side! Au revoir! Bon Voyage!

And, the Countdown Continues....

2009-09-19T21:12:00.000-04:00

Along the side of my blog site you may have noticed the countdown graphic... slowly working its way down... down... down... Today it slipped below 365!

Next month I go for several interviews.

Let the final year begin!

Safety Dance

2009-09-13T18:35:00.000-04:00

I am training to be an Emergency Medicine physician, but sometimes I wonder how I would do in an actual emergency. I mean, I can run a trauma or cardiac arrest code without much problem on my own turf. But, how would I hand a situation at 36,000 feet?

Obviously, most of us won’t be faced with a situation like Wallace who relieved a tension pneumothorax with a wire hanger, a catheter and a bottle of brandy. However, I would like to think I could handle something reasonably simple. A bump on the head from a piece of falling luggage?

The British Medical Journal in 2000 ran an article listing the top 10 medical emergencies as: chest pain, collapse, asthma, head injury, psychiatric problems, abdominal problems, diabetes, allergic reactions, and OB-Gyn emergencies. Since 1986, most airlines carry an AED, and most also carry oxygen and some basic medical supplies. A study in 2008 by USA Today stated that three overseas airlines and only one US airline seem to do more than carry the minimum medical equipment.

Of course, I didn’t think about what could potential be in this particular aircraft’s safety kit as I sat watching the other passengers start to board the airplane: the morbidly obese person who was wiping sweat off their face as they hurried aboard, the obviously pregnant woman who was pacing around the waiting area, the barrel-chested passenger who looked as if they couldn’t wait to land to be able to pull out their cigarette pack and take their next drag, the laughing out loud been-at-the-airport-bar-during-their-layover pair, and the other 50 or so ticking time bombs of potentially unknown medical problems.

Armed with my medical knowledge and last year’s ACEP presentation “101 Uses for a Safety Pin and Duct Tape” I boarded, thinking in my head, “Surely you can’t be serious?” “I am serious, and don’t call me Shirley.”

Why I Love Firetrucks

2009-09-05T16:51:00.003-04:00

They're big.
They're red.
They're shiny.
They make lots of noise.
And the firemen inside are always nice.

I probably wrote a poem similar to this when I was in first grade, and our class visited the fire house located right next door to our grade school. I thought it was cool that the firemen got to live in a big house and had a pole to slide down. Plus, they helped people, and I thought that was the best thing of all; helping people. Because that's what it's all about!

Today myself and a group of residents spent the day with the gentlemen of BNIA (Buffalo Niagara International Airport) Fire and Rescue. Along with learning about their day to day operations, it was nice to become familiar with some of the people we work with. As part of our EMS and SMART responsibilities, we respond to airport alerts. These get sent out whenever a plane is having a problem, mechanical usually. Code 1 is for less than 5 passengers. Code 2 is for more than 5 passengers, Code 3 is plane down. We had one Code 3 last year which everyone has heard about. No more of those please.

Here are some pics from the day, enjoy! And wave at your local firemen when they go by!

Vampire Nights

2009-09-04T22:06:00.005-04:00

I haven't been blogging as I worked a series of 5 days followed by an overnight shift, late morning with Grand Rounds, night off and then another overnight shift. I'm just a wee bit tired. My mind has barely mastered the concept of "upright" much less "typing a coherent thought."

One of the thoughts that came to me last night as I was walking the empty hallways of the hospital is how eerie a familiar place can suddenly seem. We occasionally have to leave the E.D. which is located in the basement of the hospital and go up to the second floor to inject a patient who is getting a CT scan with IV contrast. We do this because there is a small possibility that the IV line will infiltrate, or spill its contents into the surrounding skin, during the injection phase of the scan. This is bad. You can get a very nasty skin necrosis with this.

During the day, there are plenty of radiologists around to do the injection, but in the middle of the night, there's only a radiology tech running the scanner, so we get called up. As I walked the empty hallway heading toward the back of the radiology department, I started wondering about all those scenes in horror movies. You know, the one where the unsuspecting person is casually walking along when the scary music starts playing. There might be a sudden soft squeak. Or the sound of a breath. The person stops and looks around. Then walks a little more quickly. The music begins to rise. The person starts to walk faster. That kind of a thing.

I guess I was thinking of scary stuff because we'd had a patient come in with their own little stuff of horror movies. Seems the patient had been sleeping when they felt something near their ear. In their sleep they reached out and felt something warm and furry. They suddenly woke and grabbed it with two hands and ran to the bathroom.

They called out to their father sleeping in the next room. When he turned the light on, the patient realized they were holding a live bat in their hands! The father shot the bat with a BB gun, and they came into the E.D. with the bat in a baggie. The patient needed to start on rabies vaccinations because the bat had actually scratched their ear.

The bat was placed on ice in a container for the Health Department to come and pick up. One of the clerks called it her "pet" since it spent the majority of the morning sitting on her desk, and she had to keep renewing the ice supply. We had quite a laugh at sign out, and everyone had to go look at the bat.

I tell you, we can't make this stuff up...

p.s. a shout-out to one of our attendings, Dr. Jehle (yay-lah) who made the local media following a multi-car pile-up. I was at the General that night so my buddies at the County and Children's suffered through the multiple traumas.

Main story
His story

My Brilliant Feat

2009-08-28T23:17:00.004-04:00

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

2009-08-23T16:58:00.006-04:00

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

2009-08-17T21:46:00.005-04:00

(**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

2009-08-15T22:01:00.003-04:00

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

2009-08-10T20:30:00.003-04:00

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

2009-08-06T11:30:00.005-04:00

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]

2009-08-02T20:54:00.004-04:00

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.

Sophomore Stories

2009-07-26T22:43:00.005-04:00

I thought I would take my time tonight and post some comments on my second year of residency. Last year I wrote a post on my original blog "Do They Have Squirrels in Buffalo?" wrapping up my first year. So here we go through the second year:

Essentially, I started off my second year in July as an "unofficial, but acting in the capacity of" second year. Since I was hired late in the medical year, I still owed another month of internship. But, in essence I was acting as a second year. I spent the majority of the month getting ready for all the activities of second year, such as taking ATLS (advance trauma life support), a base station course (where we learn to give medical direction to EMS providers, learning about Mercy Flight, and learning to drive real fast in our SMART (specialized medical assistance team) vehicles, while at the same time dealing with summertime pediatric dramas. Oh, and I became a vegetarian "For the Animals!" in a 30 day pledge.

The next month I was on my EMS (Emergency Medical Services) rotation. I spent my time with firefighters, doing several runs with the EMT supervisors, and I got to fly in a helicopter for the first time with Mercy Flight. The other part of this rotation is being the resident for the local Poison Control Center. Whenever there's a drug overdose, we get called. We then call our attending who guides us through the correct treatment for all the drug overdoses we're going to face as E.D. physicians. It's learning through experience.

The next month had me reliving life as a surgical resident. During your second year of surgery, you spend a great deal of time in the ICU. Emergency medicine residents spend a month in the trauma ICU at ECMC. It was fun going back to the pimping, and the early morning rounds. I really enjoy the ICU and had for a time considered a fellowship (an extra time after residency for more advanced training) in critical care. But, I think by the end of the month, I really did look forward to getting back to the E.D. and did not regret my change in careers at all.

The next month was spent learning about ophthalmology, dentistry and radiology. Mornings were spent with the dentists learning to provide anesthesia to the mouth, and afternoons were spent looking in people's eyes. Not a very exciting month, but a nice 9 - 5 kind of month with weekends off and no call. I did get to work a Buffalo Bills' game providing medical support to the fans in one of the clinics at the stadium, so not an overall bad month.

Of course, October is when we made the move from J-land to, for the most part, Blogger. I had been chosen as the representative to the national residency organization (EMRA), and I was able to attend my first national conference back in my old stomping grounds of Chicago. I then spent the next month working at one of the suburban hospitals in the area. I learned a lot, and I got a new pair of shoes!

My next rotation took me back to the drama that is ECMC. I know I have mentioned several times that most of us really enjoy our rotations there. The system is a lot easier to deal with, and the patients are a lot less medically critical. So, let's see, what happened...? Thanksgiving came and went. I continued to be a vegetarian. I worked 5 days straight and had some interesting tales to tell. I went home to California for an early holiday.

I then did the "Swing Month" which is not as exciting as it sounds. Basically, we split our time between ECMC and Buffalo General. I spent 15 of my shifts at ECMC and 2 shifts at Buffalo General. Sounds about evenly split. Oh, yeah, and snow came to Buffalo and started the winter off with a bang. Christmas came and went, and I made you all take the Resolutions for New Year's Oath.

I then started my official second year rotation at the Children's Hospital and tried the best that I could not to catch the RSV and other bugs children were flocking to the E.D. with at the time. I failed miserably and took it into my next rotation in the Pediatric ICU where I spent a great deal of time writing notes, and not so much time doing anything else.

Of course, I must take a moment to remember the 50 who died when Flight 3407 crashed on final approach to Buffalo Niagara International Airport. I was on scene as a member of SMART providing support for the workers who had the dangerous task of removing the wreckage as others worked to collect their remains.

My husband and I celebrated our first wedding anniversary at a great little B&B in Pennsylvania near Gettysburg. We then spent the next couple of days exploring the battlefields (mostly on the Confederate side since my hubby is a Son of the South), followed by a trip to Lancaster where my interest in quilting began to develop. Who knew it would blossom into a new hobby?

I finished my rotation at Buffalo General and spent my vacation that month in Florida visiting the Everglades and the Florida Keys. A very nice way to take a break from things medical which was good because my next two months were going to be purely hellishish.

The Ortho Service: two months of pure immersion into orthopedic surgery. You spend two weeks on the Hand Service working in the clinic and going to the O.R. Then you spend five days on the service, take a 24 hour call, and then another 5 days on the service. After that marathon 2 weeks you flip over to nights and become a vampire for a month. I learned to set a lot of broken bones, and I learned to sew a lot of messed up hands and feet. I learned how to complete an amputation. I did get to go to the second national conference in New Orleans which broke up the month very nicely. And, I was already used to staying up during the night which played into the festivities nicely.

My final month was spent as an elective in the Medical Examiner's office, and I have shared a lot of the tales and stories which were encountered during my month there. It was a light relaxing month, and I even had time to do some additional ride along time with Buffalo's Finest on Rescue 1, and to provide back-up in the SMART car.

Wow, what a year. This year, I will spend 90% of my time in the emergency departments of Buffalo General, ECMC, and Women and Children's hospitals. I do have spend one more month, a "make up month" which is a carry over from my second year at the suburban hospital again. I'll be looking for a real job this first part of the year. By the time 2010 begins, I will be looking forward to my graduation, my new job, and a new and exciting chapter in my life... Hope we all make it there together, and thanks for being here for the journey!

The Defenseless Ones

2009-07-24T22:17:00.007-04:00

Something I thought about today that isn't usually discussed is the problem of Elder Abuse. Now, while most people think about physical violence when they hear abuse, you don't often think of other ways in which the elderly are taken advantage of. I had a case today that kept me late and which turned into a very disturbing story.

Again, while I cannot discuss the particulars of the case because this will now be a criminal investigation, I can say that a moment of kindness offered by a stranger turned into a break-in and physical abuse on the elder person. To add insult to injury, the attacker portrayed a health care worker "acting concerned" about the elder when they somehow managed to call 911 and police arrived.

The elder was then transported as having Altered Mental Status and ended up in the ED. Meanwhile, the stranger and their accomplices ransacked and stole from this elder person. Luckily, a concerned neighbor was able to get a license plate, and the suspects are being tracked. But this poor person had to suffer some humiliation with no one believing them, not to mention the losses suffered in their home, and probably some loss of faith in humanity. I was in shock as I was told the story. If I get an update I will post it.

Unfortunately, we often see some form or other of elder abuse. Usually neglect, sometimes by families that mean well, but are just not prepared to handle the demands of a frail aging person with multiple medical problems. Or by the hands of those in the nursing homes to which they are entrusted. I haven't written about some of the more horrific stories I've heard and seen. I've had a patient I've called Adult Protective Services for due to concern their fracture was inflicted by a staff member.

As for the rest of the day...

I spent the morning cleaning up from a multivehicle accident that resulted in the death of a Buffalo police officer.

I then had a patient come in with a steak knife sticking out of their belly. The driver and passenger of a motorcycle crash who both needed trauma work-ups. An overdose who needed to be intubated upon arrival. And assorted other crazy patients that each took up their own space of time.

Tomorrow it's back to the fun at the County. What a way to spend the weekend!

p.s. you can link to the National Council on Elder Abuse by clicking on the purple ribbon.

Passing Time

2009-07-21T21:04:00.008-04:00

I had a few minutes so I thought I would jot down a few brief thoughts from the last two overnight shifts I worked. One at the County and one at the General....

The Canadian Healthcare system sucks. Just because you have healthcare doesn't guarantee that you have access to everything. I could have an illegal migrant farm worker walk into the E.D. with a severed thumb, and he would have a hand surgeon evaluating his thumb and most likely reattaching it within a few hours. A Canadian citizen cut his thumb and was transferred to a receiving hospital who then spent the next 6 hours looking for an orthopedist who might consider operating on his hand. They then spent the next 2 hours calling U.S. hospitals to find a hand surgeon willing to take the case. He then spent another 2 hours trying to get transportation arranged across the border. We had accepted him to the County, but by then it was too late. He will have to do his work sans his thumb.

Psych patients drive me crazy. While I can go along with some delusions, it's the scarily quiet ones that freak me out. Questions that go unanswered. Or a question that is answered, "well the last time I felt like this I went totally crazy and ...." Ok, stepping away from the patient before they, "...." on me.

Why do people insist on driving while under the influence of anything? It just isn't safe to take 2 sleeping pills, chase them down with alcohol, and then decide you're hungry and NEED to get something to eat right now. Ride your bike, no. Walk, no wait. Just stay home and sleep.

Patients with pica are weird. We got this patient who likes to swallow things like pens and markers. Not sure if it meets the technical diagnosis of pica but close enough. The GI fellow told me they have scoped this patient multiple times and pulled out a variety of objects. He told me that they have several patients known for all the items they've swallowed. Also, we had to get psych involved because this patient can't be trusted in their room. Last time they were admitted they unscrewed the screws on their bed and swallowed those while waiting for their upper GI scope. So, they got a 1 to 1 sitter.

Um, weenises come in all shapes and sizes. Just saying. We put in a lot of foleys for traumas. Not judging, just noticing.

How come patients who come into the E.D. complaining of pain never take anything at home for it? And, why do they all seem to know that "that stuff that started with a d... dil-something, that they put in my IV, that works really well." One of my colleagues argued that we should have a Lortab dispenser in the waiting room because it would cut down on the number of patients we would actually have to see.

Why is it I can go to work for 12 hours having to shake my hand all day because my carpal tunnel is acting up and I'm having ulnar neuropathies (my ring and pinkie finger are falling asleep), but you need a work note and a prescription for Lortab (see could have used a dispenser here) because the toe you stubbed 3 weeks ago is "really bothering you" and you just can't handle your six hour shift sitting down and answering phones?

I really wish we had a Room Nine. When I was in medical school, the E.D. at Froedert had a back room where the drunks, inmates and psych patients were held. It was Room Nine. There was a seperate area with a few shower benches and a drain in the middle. "It puts the lotion on the skin or else it gets the hose again." Actually, no, but they did have a power hose for unruly patients. And, if someone had an accident, or on-purpose soilage, clean-up was a snap. About the time I graduated, the room had been converted as part of an observation area for 23 hours' admissions, but during that first year doing tag-a-longs in the E.D., it was the site for some very interesting patient encounters. We could use a Room Nine in our E.D.'s at times.

Did I mention I like polite patients? The ones that say, "no problem, I know you're very busy" and "thank you, I appreciate every thing you did for me tonight." On some nights, they're the bright spot of my night.... except for a messy trauma of course. Again, it's not that I want you to get hurt... I just want to be there when you do.

I have several days off to recharge. Teaching a procedures class in the morning and then hopefully some sailing. A dinner party on Thursday night. Then it's work the weekend. Till then, stay safe out there!

Traumarama Thursday Night

2009-07-17T17:05:00.005-04:00

So I started my first night of three at the County last night, and from the onset to the end of my 12 hour shift, it was one trauma after another. Actually, one trauma with another because they seemed to come in pairs. Now, I love traumas, don't get me wrong, it's just that sometimes having to work with different departments, ie. surgery, can be very frustrating. Especially when you come from different systems where departments actually get along and run real trauma codes, ie. U of Minn.

This is so not U of Minn.

Anyway, here is how my night went...
1900 get sign out from the day team. I pick up nine patients that are left over. Three are already admitted, and the rest are waiting for consults, lab results, etc. Sign out takes about 15 - 20 minutes, and about the time we are done and everyone is leaving, I get word from the charge nurse that Mercy Flight is en route with an MVC (motor vehicle collision). I sigh because I am working with a rotator (an internal medicine resident) and a medical student.

This means that my night is going to be twice as busy since, as a rule, the off-service rotators don't have the same, um, sense of urgency that we, Emergency medicine residents, do. And, there's a great quote passed along the medical tradition that says something to the effect of, "give me a medical student that will only double my work and I will jump for joy." I also had a physician's assistant and one of the new interns, so there was going to be enough fun for everyone.

So about 1930, Mercy Flight brings in SUV versus semi. The semi won. However, you have to admire the semi driver who saw the SUV about to hit him, watched the impact, then jumped out of their cab to help the person get out of their car. Luckily, no major injuries, and the driver of the SUV stayed overnight for observation.

About the time that I finished this evaluation, EMT's arrive with Gear Wheel Flew into Face. The eye is involved, so GWFiF goes into a room and I get ophthalmology and ENT involved because there is going to be some serious damage, and a lot of fine sewing involved.

I work on one or two of my sign-out patients, deal with a surly (I would use harsher language, but I don't have the parental control warning on this blog) surgical chief who will be the bane of my existence for the rest of the night, give someone procedural sedation for a dislocated shoulder, and start to write up the trauma patient when I get word from the charge nurse that an ambulance is en route with a partial amputation and low blood pressure.

I get to the trauma room, and we get Motorcycle versus car. The patient's lower leg is hanging on by a few tissues, and we make plans for the patient to go to the O.R.; of course, after a couple of units of blood and stabililization. I am just putting up the orders from this patient when a patient I had heard about earlier, Bike versus Tree, rolls in the door. They were transferred from another hospital when the patient started dropping their blood pressure and complaining of chest pain. We get them into another trauma room (we have four) and start their work up.

By now it's about midnight. Somehow I have managed to dispo (disposition meaning getting someone admitted or discharged) my signout patients and I pick up a non-trauma MVC. I get them pain meds, order spine films, and go talk to an alcoholic who just got out of rehab two weeks ago and started drinking the day they got out. I explain that there is no room in our rehab program and tell them to go back to their initial contact. I always write on the disharge instructions, "only use alcohol in moderation." While I can write "stop smoking" I am not allowed to tell someone to stop using drugs or stop drinking. Fancy that. Drug abusers get, "only use medications or narcotics as prescribed by a physician."

I stop in the middle of things to help out the intern with an assault victim that is bleeding profusely from their head. After finally getting his pain under control long enough for him to allow us to start to work on his head, I walk the intern through stopping bleeders with a figure 8 stitch and then get them started on a double layer closure. I leave them to finish the suturing and close the skin with staples. Now, where was that chart I put down...?

My BVT goes for further evaluation by the cardiologists for a possible heart injury (after I had to intubate them for dropping oxygenation saturations) which clears the back room just in time for Struck by Car While Getting Beer at the Corner Market. The patient was clipped by the mirror of the car, fell to the ground, and didn't break the 40 they were carrying. We start the work-up, but the patient will most likely be sleeping it off in a room until they are sober enough to be released.

It's about 0330 and one of the ER techs runs downstairs and gets me a coffee. I take a sip or two and then go to the trauma room for T Boned While Leaving Sleepover. The trauma team is activated yet again, and I am handing in orders for this patient when Lost Control of Motorcycle rolls in. We meet this person and see two obvious leg fractures. They will end up having about 3 other fractures which are found during the course of the work-up.

I sit to write my notes. It's getting close to 0600, and I pick up some more patients as the medical student and the rotator seem to be satisfied with managing their one patient for the final hour (did that sound catty?). I get "went to concert and got kicked in the head." I give them something for their headache and order a CT scan. (Excuse me while I clean my name badge. There seems to be some blood on it. I wonder from whom?) Then I get "my gout is acting up" which I give pain meds to, write a script and their discharge paperwork. At 15 minutes to 0700, I go and see "Chest Pain since Yesterday," and I put in their orders to get them started for the next resident.

I sign out 4 of my patients from the overnight, and I discharge T Boned because they had been cleared by surgery. I head to my car and drink the last of my now-cold coffee and head off to sleep. Another shift begins tonight. I can't wait!

A Midsummer Nights' Sailing

2009-07-15T22:06:00.005-04:00

I don't know that I've blogged about this yet, but I have been sailing with one of my attendings for the last several weeks. He has a racing boat named the "RagAzzi" and he races her during the summers here in Buffalo. He asked for crew for his boat, and since I had sailed during and after college I volunteered. I thought I would share some photos I've taken during our races.

Here's a video that shoes the boats getting ready for the start.

There's an imaginary line between the Committee Boat and an inflatable marker that is set some distance away.

You have to maneuver your boat to the starting line, don't hit any other boats, and don't cross the line until the signal sounds. If you cross before the signal, you suffer a penalty and have to make a 360 degree turn before you're allowed to restart. Now, you can imagine it's all about timing. Boats don't start and stop on a dime.

Once you're underway, then it's all about strategy. When do you turn (tack upwind, jibe downwind), which line do you follow, etc. You're racing toward several markers that make up the course. Usually you have an upwind leg and a downwind leg.

If you watched sailboat races, everyone gets excited when the big spinnakers go up. Those are the full fluffy sails you see on the front of the boats. That's when you're going downwind.

The most exciting times for us as crew are the starts and the turns. The rest of the time we are hanging out on the side of the boat to provide counterweight to the pull of the sails. Except for me, I work the mainsail. So I sit in the boat and make small adjustments as wind conditions change.

We haven't won a race, yet, but it has been fun spending those hours on the water, concentrating on nothing but feeling the wind in your hair, the sun in your face, and the pleasure that comes from controlling the wind.

The Pleasure Boat (selected stanzas)

by Richard Henry Dana

Come, hoist the sail, the fast let go!
They're seated all aboard.
Wave chases wave in easy flow:
The bay is fair and broad.

The ripples lightly tap the boat.
Loose!-Give her to the wind!
She flies ahead:-They're all afloat:
The strand is far behind.

No danger reach so fair a crew!
Thou goddess of the foam,
I'll pay thee ever worship due,
If thou wilt bring them home.

O, might I like those breezes be,
And touch that arching brow,
I'd toil for ever on the sea
Where ye are floating now.

The boat goes tilting on the waves;
The waves go tilting by;
There dips the duck;-her back she laves;
O'er head the sea-gulls fly.

The sun-light falling on her sheet,
It glitters like the drift,
Sparkling, in scorn of summer's heat,
High up some mountain rift.

The winds are fresh-she's driving fast.
Upon the bending tide,
The crinkling sail, and crinkling mast,
Go with her side by side.

The parting sun sends out a glow
Across the placid bay,
Touching with glory all the show.- -
A breeze!-Up helm!-Away!

Veronicology

2009-07-14T22:07:00.008-04:00

I know you don't want to hear more gory stories about life in the emergency department. So, as an interlude in preparation for my weekend stint on the overnight shift at the county hospital and, hopefully lots of gore, I am going to follow Winevere's blog posting and share a little Veronicology:

These are the directions: Let others know a little more about yourself. Re-post this as your name followed by "ology."

What is your salad dressing of choice? Blue Cheese

What is your favorite sit-down restaurant? Depends on the city I am in, all time though would be Ruth Chris' Steak House

What food could you eat every day for two weeks and not get sick of? Mexican

What are your pizza toppings of choice? Pepperoni & Mushrooms

What do you like to put on your toast? Butter and blackberry jam

Chocolate or Vanilla? Vanilla

How many televisions are in your house? 3

What color cell phone do you have? iPhone with the white back

Do you have a laptop? Yes

Are you right-handed or left-handed? Right

Have you ever had anything removed from your body? Um, no...

What is the last heavy item you lifted? a backboard from a patient

Have you ever been knocked unconscious? No

If it were possible, would you want to know the day you were going to die? No, I like surprises

If you could change your name, what would you change it to? Growing up, I always wanted to be Cassandra Taylor

Would you drink an entire bottle of hot sauce for $1000? How big's the bottle?

How many pairs of flip flops do you own? 4

Last time you had a run-in with the cops? By choice, a week ago to talk about a homocide, not by choice, as a freshman in college

Last person you talked to on the phone? my hubby

Last person you hugged? my mom

Favorite Holiday? Christmas!

Favorite day of the week? any day I am not working

Month? September, I love the fall

Missing someone? yes

Mood? Tired, it's been a brutal and emotional two days

What are you listening to? XM radio on my iPhone

Watching? nothing, see prior question

Worrying about? how messy my apartment is, and how dirty is the kitty litter

First place you went this morning? Dunkin Donuts before work

What's the last movie you saw? Step Up Two

Sleeping Alone Tonight? You're never alone with three cats on the bed

Do you always answer your phone? Depends on the caller I.D.

If you could change your eye color what would it be? Green, like my grandmother's

What flavor do you add to your drink at Sonic? I've only been to a Sonic once in OKC, and I don't remember having the option

Do you own a digital camera? Yes

Have you ever had a pet fish? Yes, until moving here, I'd maintained an aquarium of some size or other since the age of 7

What's on your wish list for your birthday? Balloons and teddy bears, I love teddy bears.

Can you do push ups? Can, yes, do, no.

Can you do a chin up? Depends, am I on the exercise machine that gives you a little boost?

Does the future make you more nervous or excited? excited

Do you have any saved texts? Yes, mostly from my hubby

Ever been in a car wreck? three, none my fault

Do you have an accent? Yes, a combination of California Valley girl with a hint of dem dere upper Midwest folk

What is the last song to make you tear up? The Book of Love by Peter Gabriel

Plans tonight? Sleep eventually

Have you ever felt like you hit rock bottom? Yes, but somehow managed to climb out of that hole, and now here I am!

Name 3 things you bought yesterday - Starbuck's coffee, lunch, dinner

Have you ever been given roses? Yes

Current hate right now? feeling uninspired

Met someone who changed your life? yes, had a lot of good influences in college

How did you bring in the New Year? With my hubby at an outdoor concert watching fireworks over Niagara Falls on the Canadian side

Name 3 people who might complete this? Nicole, De, and someone from work

Would you go back in time if you were given the chance? Yes, I have three "do overs" I would love another chance at

Have you ever dated someone longer than a year? Yes. Amazingly, only my husband. Prior to that, three months was the record. I have short attention span.

Do you have any tattoos/piercings? Both my ears are double pierced

Does anyone love you? I can think of at least 5... do my cats count too?

What songs do you sing in the shower? 80's Madonna or "Big and Chunky" from Madagascar 2 or "Low" by Flo Rida

Ever had someone sing to you? Hmmm... Do you like to cuddle? Of course

Have you held hands with anyone today? I don't think examining a patient counts

Who was the last person you took a picture of? probably one of my work colleagues since HIPAA prevents us from taking pictures that in some shape or form lead to the identification of a patient which violates their right to privacy

What kind of music did you listen to in elementary school? Whatever was top 20, but a lot of 50's and 60's stuff too

Do you believe in staying close with your ex's? refer to prior question about long term dating, no long term connections

Are most of the friends in your life new or old? both, I love meeting new people, and I treasure all the friends I have made and keep them close

Do you like pulpy orange juice? Like my beer, I like an orange juice I can chew

What is something your friends make fun of you for? Which friends and from which social occasion?

Have you ever ridden an elephant? No

Do you like to play Scrabble? sometimes online

What are you saving your money up for right now? Vacation and moving expenses for next year

When is the last time you ate peanut butter and jelly? together? not in a long time

What were you doing 12 AM last night? zzzzzzzzzzzzzzzz

What was the first thing you thought of when you woke up? Just make it through the day and you'll have sailing to look forward to tomorrow

So, now, how about you???

The Answer is 42

2009-07-12T00:14:00.005-04:00

In his book, "Life, the Universe and Everything," Douglas Adams writes that the answer to the aforementioned was found to be 42. Of course, the book never answers what the question is. In fact, according to the story, the question and the answer cannot exist in the same time frame in the universe. Whatever the case, today I turn 42.

Do I know the answer to life, the universe and everything? No. Do I know the answer to most things? No. Am I even close to understanding even on the most basic level about most things? No. And, I am o.k. with that.

When I graduated from college, I was very bummed. It was a bummer, Dude. (Still so very So. Cal.) I didn't want to stop learning. I wanted to continue taking classes and finding out about everything. College is a protected time. I didn't have to work. I had a whole world of knowledge sitting in front of me in the shape of the college catalog. I could learn about anything.

One word of advice I received is one that I continue to pass along to those undergrads I meet: take at least one class a semester that has nothing to do with anything. I was given that advice when I thought I was going to be a civil engineering student and change the world. Or at least my town's sewer lines, or so it seemed. I made sure that every semester, one of my classes had nothing to do with math or science.

I learned archery, fencing, horseback riding. I studied celestial navigation and "Voice and Diction for the Theatre." I took Ancient Greek as my language requirement, Chinese philosophy, and Greek Theatre. When I changed to Journalism, I minored in English, and was two classes away from a double major. Lit and film, Lit and the theatre, Lit and poetry, I took them all. I also studied Egyptian literature and learned to sail.

Even at that time, I wished I could be a professional student. Funny how life turns out, because in some ways I am. I will always need to keep up with advances in medical care. I will always need to attend seminars on how to perform certain skills or keep current on the latest drugs. I will always want to learn more so that I may serve my patients better.

So here I am. At the age that is the answer to Life, the Universe and Everything. I know that there will be a lot of questions answered during this year. Where am I finally going to settle down. What is my house going to look like. Will my husband divorce me if I say I want another cat.

And there are a lot of unknowns... that's the fun part. It's fun knowing the answer and seeking the question because there are so many possibilities. You're not limited by a question; answers have no limits, because they could refer to just about anything. I think this will be the year of no limits because I already know that the answer to Life, the Universe and Everything is 42.

A is for Airway

2009-07-08T22:22:00.006-04:00

I had to go home for two days to attend to my mother, but this is the blog entry I would have written after my last shift on Sunday night had I had a choice other than using her slow-as-molasses dial-up or typing out my entire post on my iPhone.

From the beginnings of medical school, you are taught the rules of patient assessment; you are taught the "ABC's" - Airway, Breathing, Circulation. You don't move onto B until you have established A. You don't move onto C until B is established. If at any time you lose A or B, you go back to the beginning. Emergency Medicine docs are all about the A. My first patient on Sunday night was all about the A.

While it's difficult in this setting to talk about the specifics of a case, let me just lay out the scenario for you. You get a patient who is having an allergic reaction and everything is swelling. When they start to cough and drool and can barely get their words out, you know you're heading for intubation (putting a breathing tube in.) When you get a heavier set person with a short thick neck, you know you should be prepared for anything. I asked for a scalpel to be nearby before I even thought about getting the standard intubation set up. And, I was later glad I did.

Now, I have performed tracheostomies on patients under controlled settings (i.e. in the operating room or in the ICU), but I never had to perform one in the Emergency Department on a patient that was rapidly becoming critically ill. We spend some time in the cadaver lab learning how to perform this emergency procedure, but somehow with all the beeping and buzzing of alarms, with the addition of other people coming in and out of the room, with the knowledge that the patient's family is standing right outside the curtain crying because their loved one is unexpectedly in a dire situation, it's not that easy. I know my landmarks, I know the technique, and now I know I can handle an attending standing behind me going, "So what are you going to do now?" after every failed intubation technique that lead up to this.

The somewhat surreal aspect of all this is that once I established the airway and we got B under control, I was about to breathe my own sigh of relief when suddenly C became a problem. Another round of medications, another round of procedures, another bout of handling the inevitable continued questioning, "So what do you want to try now?"

Nothing, I want to try nothing. I want to go outside and have a beer in celebration of getting a breathing tube in my patient. I want to be seeing the seven patients I got at sign-out who are currently languishing in their rooms. I don't want to be here now having to think about the C!!!!

That's when God, in His infinite wisdom, provides me with some comic relief. We get a heartbeat back, yeah! I step outside the curtain to talk to the two adult children of the patient and explain the events of the evening when suddenly a psych patient that had just rolled in starts yelling, "Get the &*^%$! off of me! Stop touching me! What do you think you're ^&%$ing doing?!?" Sitting on the stretcher just behind him is a woman who is wearing an oxygen mask because she was feeling short of breath. She starts to breathe faster. Her daughter, who is standing at her bedside starts yelling, "Momma can't breathe! Momma can't breath!"

Three security guards rush in and grab the psych patient. I tell the EMT's to take the short of breath patient to a room. Mayhem ensues as the SOB (short of breath) patient is being wheeled past the psych patient and everyone starts freaking out a little more and there's yelling between the two beds. The volume in the E.D. rises to a fevered pitch, and then... silence.

The SOB patient is in a room where she starts to calm down and breath slower, and the psych patient has been given drugs and he has started to fall asleep. I have talked to the family of my critical patient, and I start to do paperwork - history and physical, intubation note, cricothyrotomy note, tracheotomy note, code note. Almost three hours have passed since I started my shift, and I have been in with one patient the entire time. I watch them being wheeled upstairs to the O.R. for a more definative airway placement followed by placement in the awaiting ICU.

I grab my now-warm bottle of diet soda and take a long swallow before grabbing some charts and getting started with the rest of my shift....

Last Night at the County

2009-07-04T13:17:00.002-04:00

Some of the cases from last night's revelry:

OD's - My two of the half dozen or so OD's we got last night were of unknown substances. One we think was methadone the other is a complete mystery.

GSW's - we got one last night but one shot was all it took to take the life of an 18 year old

Stabbings - mostly superficial wounds on the patients, but my patient's assailant decided stabbing wasn't enough. He was going to run over him with the car too. I think he's going to be lucky and wind up with some relatively minor injuries

Motorcycle crash - again, please don't take drugs and then think you can control a motorcycle. You'll end up with lots of broken bones in the trauma icu and the police placing you under arrest.

All this plus the chest pains, the abdominal pains, the shortness of breaths, and the eight or so patients signed out to me last night.

Have a great and safe Fourth! Stay out of the ED!! I don't want to meet you under those circumstances...

The Year Begins Anew

2009-07-03T15:51:00.005-04:00

Another year is gone. The medical year that is... Last year I wrote about how you shouldn't get sick around this time. This is when the interns start in all of the medical specialties. Having worked two shifts into this new year, I have already begun to experience the in-experience of some of the new residents. I mean, come on surgical 'tern, don't you know that "incarcerated hernia" means an automatic trip to the OR? Can you list for me the 5 pre-op tests that you need for me to order for you prior to admission? Drop and give me 20!

Ooops, sorry, I forgot for a moment I'm not the Senior surgery resident, I am the Senior emergency medicine resident, so 'Tern, go wake up your senior and tell him Dr. Smith's post-op patient needs to go back to the OR to fix the bottom edge of his mesh so that his guts don't keep poppin' out of his belly. Oh, and I know the 5 tests that need to be ordered, so I will do them. Meanwhile, call pre-op and tell them you're coming upstairs with a patient so that I can get them out of my E.D. while I make space for the next 1 of 50 people showing up this shift to let me know they heard about someone with the flu and think they might have it too because they sneezed, twice!

You see, being a Senior Resident (I kinda like it like that all in capitals) means that I am in charge of the Emergency Department. This is my turf. This is why I kept getting yelled at by my attendings during my first two shifts that, "You have this situation going on... what are you going to do about it?" Um, I don't know... can I go back to being a junior so I can take all the good cases and leave the rectals and pelvics to the interns and rotators? No? Oh, well.

Let me, therefore, tell you about my first two senior shifts. Grab a cup of coffee and a muffin because I am going to be writing in a stream of consciousness and this might take a while. If you think I am making this up or I copied this from an episode of "E.R." "Chicago Hope" "Grey's Anatomy" or "Scrubs" you are mistaken. They copied it from us first:

- We start off the morning with sign-out. The night crew signs out to the oncoming team. We work 12 hour shifts. Any patients that haven't been seen are still on the board as well as patients that are still in the middle of their work-up (still waiting for labs, xrays, CT's, admission bed, etc.) As the senior, I take all the leftover patients that still need work. I got 6 the first morning, and 8 the second morning. So I spend the first hour or so of my morning not seeing new patients for the most part, but trying to clean up what is left over from the night before.

- Then the "chest pain needing to go to the cath lab" because they're having a STEMI, or the "I'm still drunk from last night so I decided to punch my hand through a window" come rolling in. So now I am dealing with these two patients.

- I finally make it back to Room 19 (we call it the Death Room because it is the furthest room in the back of the E.D. and if you crawled into the Nurse Server cabinet you'd probably find a passage to Narnia) to sew up the "I have brain cancer and fell headfirst into my chest of drawers" that has been sitting since last night because he needed a CT scan. While I am preparing my sutures, the "still drunk from last night" starts to tell everyone in the department what they can suck if they come near her. Yes, her. Suddenly, I am being overhead paged to the main arena, and when I don't respond within 2 seconds my attending comes down the hall calling out my name. I am reminded for the 5th time that this is my department, and what am I going to do about a potentially escalating situation? I walk over to the nurses' station and order a B-52 for my patient (Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg). The nurse reminds me that we are not at ECMC so she will give the Haldol and Ativan. Ok. Three security guards hold the patient still while the nurse sneaks into the room and administers the two shots. As I walk back to my patient in the Death Room, I hear the patient screaming something about being violated twice in the E.D. A minute or two later, silence. I finished my sewing.

- Ten minutes later I go into the room to finally thoroughly examine my "drunk since last night." She's got some minor cuts on her right hand, but her left hand looks funny to me. I order bilateral hand films and go off to see some new patients.

- We start at 7 a.m. and now it's about 11. I am arguing on the phone with the newly advanced MICU senior (yesterday a second year, today a third, kinda like me but they're a medicine resident while I am an EMERGENCY medicine resident). I tell them about a patient who can't breathe because they have too much fluid on their lungs, around their lungs and that they need dialysis. They're too unstable for the floor, and I am about to put them on bi-pap because their breathing is so bad. They argue why don't we send them to dialysis and then they'll be good enough for the floor and not the unit. I say I can't send an unstable patient to the dialysis room. We continue to argue. My attending tells me for the 9th time that day that I am in charge and to get that patient in the MICU. I tell the MICU resident that this patient needs to go to the MICU because there is not portable bipap machine AND bipap machines aren't allowed in the dialysis suite. Let them be dialyzed in the unit and then they can send the patient to the floor if they are stable enough. The resident says they are going to talk to their fellow. I hang up and put in for an ICU bed.

- I then go off to see chest pain #4 or 5 of the morning. This 30 year old probably just wants a day off work, this other 30 year old might have something. We've seen MI's in patients as young as 17. I get their labs, EKG's and chest x-rays ordered. I head off to see my next patient.

- About an hour later, everything is humming along. I don't think about my "I need the ICU and Bi-pap" patient because they got sent upstairs to the unit and about 5 minutes later needed to be intubated. Hmm.. guess they were sick after all.

- It's about 2 in the afternoon. The E.D. is getting full. We have 22 beds, plus hallways beds A - K. They are almost all full. I am in the midst of paperwork trying to get patients out the door to make room for a waiting room that has about 15 people in it. That doesn't include the new Fast Track area which is handling its own crowd. I hate paperwork. The patient chart has two pages to fill out. They also have a medical reconciliation form. Then there's the discharge form. If they get discharged, it's 4 forms to make sure I have filled out. If they're admitted, then 3. Anyone I admit to the chest pain center for overnight observation and stress test in the morning has another 2 pages of admission orders. I am trying to discharge, admit, and write progress notes on about 4 patients. I think about the "still drunk from last night" and wander over to look at her x-rays.

- They haven't been shot yet because despite enough drugs to render me unconsious for 48 hours, she threatened to beat the %&*!! out of the radiology tech. So I wander to the E.D. x-ray room to provide some support. Of course, the patient behaves for me, and we get all the films done. I go see another patient while I wait for the films to load.

- I spend several minutes explaining to family that their father has lung cancer. They got a biopsy four days earlier and didn't know the results. He was feeling short of breath this morning and seemed to be walking into walls. As I looked up the pathology on the computer, I already knew what I would find on the head CT I ordered. Sure enough, an hour later I was back in the room explaining that the densities we had seen on the CT were most likely spread from the lung cancer. I called to get him admitted, and I explained to the family about the parade of specialists that would be coming to see him: oncology, neurology, neurosurgery, etc. At the VA in Wisconsin we had a similar patient. When I asked the attending what I should order, he told me "a cane pole and a six pack." When this patient's son came out and asked if he could get some coffee for this patient and maybe something to eat, I told him the patient could have whatever he wanted. Pain meds? Sure. Anything you want.

- For those that don't know, I did 3 years as a surgical resident. I can tell when things aren't as they are supposed to be. A black stump of a colostomy doesn't mean that things are going well. Especially when it is a new colostomy. I call the attending and describe the site. He tells me to call the surgical resident (a second year) but that he's sure I am mistaken. No colostomy site of his is anything but perfect. I order pre-op labs and place a call to resident. When she shows up 30 minutes later, she walks into the room and tells the patient, "your colostomy site is dead and you need to go to surgery today." V stands for vindication.

- I place a cast on the broken hand of my "still drunk from last night," which she doesn't even wake up for. I use skin glue to fix her one laceration because she probably wouldn't follow up to have her sutures removed, and she'd probably end up ripping the sutures out with her teeth. I then make her wake up and get up out of bed. I walk her around the E.D. and give her a sandwhich. There, clinically sober, and I start working on her discharge paperwork. Which is a good thing considering all the beds are now full and there's a full waiting room.

- It's after 5 p.m. and I am standing with Discharge Planning trying to decide what to do with a chronic pain patient who doesn't have enough insurance days to be readmitted, and who burned her bridges with the rehab facility she was living in. She wants more drugs because her pain isn't being controlled adequately. Funny how this all started the second she signed herself out of the rehab facility where her pain was controlled over the course of 4 months. I tell her I can't prescribe Methadone or Fentanyl patches. What can I do to make her pain better so she can make it to her primary doctor's appointment the next morning? A 10/500 Lortab and a Dilaudid shot? Ok. Off you go.

- It's 7 p.m. The night crew arrives. I have 5 patients to sign out. Two I have discharge paperwork completed. They just need one or two labs to come back. Two I just started, so they need a little more work. One is waiting for admission. My colleague, God Love Her, is a bit of a Black Cloud. So, while I am finishing up some paperwork, a code rolls in the door. The E.D. is packed already. It's change of shift for the nurses too. I run in to help my colleague out.

- I call my husband in Atlanta while I am driving home at 9:30 p.m. I stop for some Chinese food from my favorite place, and listen to him gabbing away on my Bluetooth while I eat my first meal in about 8 hours. I go home to crying cats, empty food bowls, and a pile of mail. We crash in a pile of fur and purring on the bed. I set the alarm. Six a.m. and my next 12 hour shift in charge will be coming way too soon.

I am working the weekend at the County. Mind you, Fourth of July weekend, as a Senior resident, in the Emergency Department, on nights. Fun, fun, fun. I did a wrap up of my intern year last year, and I will do a wrap up of this year at some point over the weekend. Have a happy and safe Fourth of July!

Another Month Did and Done

2009-06-28T21:14:00.005-04:00

Well, it's Sunday. Officially, the last day of the module, and the last day of the medical year. Tomorrow morning I start as a senior resident in the Emergency Department. Fifteen more months and I will be done. I am going to put a counter on the sideline to count down the days.

After the excitement and interesting tales from this last rotation and the two months of Orthopedics before this, my husband was telling me that I was going back to the usual "boring stuff." I reminded him that I would be doing this "boring stuff" for the rest of my career; unless, of course, he lets me return to surgery and be a resident for another three years. By the groans and threats of moving to live in an RV on a beach in Florida I take it he is about ready for this to be over too.

My last case at the ME's office on Friday was a sad tale of a massive thunderstorm and downpour, a car out of control and hitting the curb at about 75 mph, jumping the curb and over a about a 3 foot wall and slamming into a church. The driver had major trauma to his head and lower legs. His passenger died.

Again, while I can't discuss the specific findings, I can say that this was the most trauma I had ever seen on one person. That the driver survived at all is incredible. I was in amazement throughout the entire post-mortem exam. I couldn't even begin to think of what I would do had this patient come into the emergency department. Where to even start. But, this is one of the reasons I did this rotation. To make you think about the traumas. To make you understand more fully the traumas. And, to realize that there are some things that can't be fixed.

What I'll be missing tomorrow: a second child has died of the H1N1 flu virus. We had been following her condition very closely throughout the last week. And, a victim of a train accident has died. I heard the radio call out when he was first injured and was amazed that he survived to make it to ECMC. I heard about his progress in the ICU. They will probably be posted tomorrow. With tongue in cheek, this just goes to show that even at the ME's office, life goes on.

Passing Gentle Into That Good Night

2009-06-23T23:49:00.004-04:00

Yesterday (Monday), we had the autopsy of the first case of H1N1 Flu to die in our area. It was very sad because the young man was so young and previously healthy. I wasn't present at the post-mortem because of the high level of precautions being taken. However, I did hear about the case during morning report, and one of my colleagues is on their PICU (Pediatric ICU) rotation, and I heard some information from them.

Today we had three cases. Three people who died in their sleep and were found after a friend, relative, or neighbor grew concerned enough about them that they sent someone to check on their welfare. In one way, I think most people would like to just pass from this life in their sleep. A simple blink from existence. However, I found myself somewhat saddened by their stories, because to me they died alone. Although someone checked on them, thought enough about them to be concerned, no one was actually with them when they passed.

I think I've only been at the bedside of one or two patients when they've died. Both of which I later had to deal with guilty feelings for turning off the ventilator. Medically, I knew that they were brain dead. I knew that the best thing I could do for them was to let them go. Emotionally, though, I still felt as though I was the one ultimately responsible for their death. I talked to their families and got them to understand that their loved one wasn't going to recover. I signed the orders for morphine and to stop medications to keep their hearts going and their blood pressure up. I turned off the breathing machine. I pronounced them when they flatlined.

I thought a lot about Dylan Thomas' poem today. As a physician, and especially one who works the "front line" in the E.D. , I can't help but daily think I "rage, rage against the dying of the light." And, when we lose the fight, I am glad that someone was there to witness and to pray.

Do Not Go Gentle Into That Good Night
by Dylan Thomas

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on the sad height,
Curse, bless me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

Not Newsworthy

2009-06-19T20:59:00.003-04:00

I have been working at the ME's office for the last three weeks. Wow. While I can't talk about the specifics of what I see every day down in the autopsy suites, at least I can post the local news stories about the cases that are coming down to the morgue.

I attempt to find stories that don't list the names, but some stories are so widespread that names have already gotten out. Most of those are the locally high profile killings and deaths. While I might list that we did a suicide on a particular day, although I know the person's name, I don't list the obituary because I think that would be disrespectful to the person, and especially to the surviving family.

Some deaths, though, no one reads about. The prisoners who die while serving their sentences. The single overdoses that are found by friends or family members. I add the suicides in here, because they sometimes don't even get an obituary. Children are in here because SIDs, suicides and sudden deaths, for the most part, don't get reported. And the tiny victims of drug-influenced mothers who never live to take their first breaths, mostly because they are too premature or died before they were born, they generate no print as well.

We had a full room today. Three tables all going at once. No news stories on any of them. They were simply: The Overdose, The Accidental Overdose, and The Found in Woods.

Stories that did make the news from earlier this week:

Hot Dog Death
Shooting on Porch

Until next week!

Young Lives Cut Short

2009-06-16T20:45:00.006-04:00

It's been sort of a bad week at the ME's office. Even moreso for some of the local EMT's.

Seems there's been a rash of teen deaths over the last two weeks, and there's nothing as disheartening for these first responders than arriving at a scene, doing everything they can, and then having someone young die on their watch.

When I run into some of the EMT's I get asked about how some cases ended up. Those that know I am in the ME's office ask for outcomes, causes of death. I tell them what I legally can. Sometimes the news gets a press release and then preliminary causes of death are released. Sometimes I can offer a little comfort that the person was going to die despite rescucitative efforts. Still, the EMT's take these young deaths personally. For the most part, young people aren't supposed to die.

Teen dies unexpectedly at home
Teen dies from shooting
Teen found, suspected homocide
Teen dies while playing soccer

Other cases these last couple of days:
Teen dies after choking
3 separate men complain of chest pain and collapse
Motorcyclist killed

Grand rounds tomorrow... until Thursday!

Happy Birthday to My Hubby Bear!

2009-06-14T01:18:00.004-04:00

Happy Birthday to my Hubby Bear!

I love you,

Veronica

To see his birthday gift follow this link...

A Night with Buffalo's Finest

2009-06-13T15:20:00.008-04:00

So, last night after a morning with the ME's office, I spent the evening doing a ride-along with Rescue One. Some of you may remember that I did a ride-along with them about a year ago in August. We had a little more excitement this year than we did last year.

Link: Buffalo Warehouse Fire

Here's one of my pics. You can see the rest of my pics of the fire by following this link: Buffalo Fire

This morning I am still recovering from having spent the night at the firehouse. I did go on several runs with the crew of Engine 95 until well past midnight, so I was very sleepy.

Not much to do today, it will be clean, clean, clean the rest of the weekend. Oh, and look for a special posting tomorrow on my other blog...

The Brain Box

2009-06-09T13:01:00.005-04:00

Ok, so I am still rotating through the Medical Examiner's Office. The cases from the last couple of days have included several suicides and several mass traumas. We talked about how the patients that don't make it to the Emergency Department end up at the ME's office.

This is why I am doing this rotation. Nowhere else am I going to be able to be elbow deep in someone's chest looking for the traumatic aortic rupture, or holding someone's brain following the path of a bullet with my finger. (By the way, the pic is a Jello mold not a real brain.)

I wanted to quickly respond to some questions I received from Betty:
- The ME's office gets cases that warrant a forensic medical examinination as deemed by the County Coroner (there's a difference between coroner and medical examiner), and cases that fall under certain protocols - an unwitnessed death in a person who has not been under a doctor's care for a certain period of time, any death involving an inmate, an unexplained or unnatural death (murder, suicide, accident), deaths involving children or infants, and several other specific circumstances.

- We have a protocol sheet we follow in the E.D. and in the hospital when there's a death. We have to call the M.E.'s office, and they "sign-off" or take the case. If there is an autopsy that's not the same thing... a family can ask for an autopsy and that is performed by the hospital pathologist.

- I usually don't participate in autopsies, but I occasionally get to cut something or dissect an organ, and I get to touch most things after the official examination is done, which is a good thing because I am not a "spectator"

Tomorrow is an off day, so I will be back at the ME's on Thursday. Here's the case list from the last few days, including 3 suicides -
Homocide
MVC Fatality

Humpty Dumpty, et al...

2009-06-04T16:07:00.004-04:00

Today I have been mentally thanking God for allowing me to have so many interesting and unusual experiences throughout my life. I have been allowed the privilege of participating in some events that most people never will.

This morning while in the ME's office, I was able to participate in the post-mortems of several patients. Due to confidentiality issues, I can't say what I did, but let me just express again how thankful I am to be a physician and how awed I continue to be at times with the complexity of the human body. I am also saddened by those who don't appreciate the miracles that we all are.

Having said that, yesterday was Grand Rounds Wednesday, so no ME's office. These are the some of the cases from this morning... it was a full board and all three tables were going at once:

Prisoner with Lung Cancer
Motorcycle accident
Fire Starter

I try to find articles that don't list the person's name, however since I am using public media sources I can't help what gets put in print.

Until tomorrow!

I See Dead People

2009-06-02T18:51:00.005-04:00

Ok, so this week I started my new rotation: Forensic Pathology. I get to spend every morning with the Erie County Medical Examiner. Now, you might ask what would make this a good rotation for an E.D. Doc. Well, let me tell you...

1. You get a great review of anatomy. No where else do you get the chance to see organs up close and personal. You get back to your first year of medical school when you were learning how things were connected and where everything went. And, you get to touch things again... I love lungs... they're crunchy like Rice Krispies!

2. You can see what happens to the insides of those patients that never make it to the Emergency Department. I remember doing the rotation in medical school and seeing the dissected aorta that instantly killed a victim of a car crash. You could imagine the shearing force that it would take to rip the aorta in half. You see the routes that bullets and knives take as they make their deadly way through the human body. You learn to recognize entry and exit wounds and how to follow their paths.

3. You can see the natural progression of disease. You see the lungs of a young person, and then those of an older person who has spent their life smoking. You see the clean coronaries of a 20 year old, and the beginnings of atherosclerosis in a 40 year old.

4. You gain a different perspective on your living patients. A lot of the M.E. patients come with crime scene photos. You see how they live, how they died, and you can better understand where your patients are coming from.

5. You see life differently. No matter who you are, everyone dies. I think it make you appreciate your life and that of those around you just that much more.

Since I can't talk specifically about the findings on the cases we are doing, I can at least let you know the cases we worked on:

Yesterday's and today's cases that I saw the "posts" (post-mortems) on:
Lake Floater
Car Crash
Drug Overdoses

Grand Rounds tomorrow and then back to the action on Thursday!

Dem Bones, Dem Bones...

2009-05-26T05:30:00.003-04:00

So, I continue on the night ortho service. It was quite a week back following my wonderful time in New Orleans. I can't even begin to list all of the injuries I have seen so far, but suffice it to say that I have told my husband he's not allowed to pick up any powertools, chainsaws, table saws or use a lawnmower. He's not allowed to ride on a bike, in a car, or on a motorcycle. He's definitely not allowed on a horse. And, he can't go up or down any stairs, any ladders, and under no circumstances is he allowed up on the roof. Seriously, the world doesn't seem very dangerous until you're up all night tending to people's injuries.

Of course, I haven't even begun to list injuries caused by other people... gunshots and stabbings, assaults with hammers, baseball bats, and other metal objects.

I have had a lot of fun, for some odd reason, with amputations. I took off someone's finger this evening and then sewed their hand back together after an encounter they had with a table saw. I had another gentleman on Friday who caught his hand between a chain and the tailgate of a dump truck. It took me almost 2 hours to make his finger look like a finger again. Maybe it's the surgeon in me that keeps popping up. I get a lot of satisfaction in seeing something put back together and knowing that they are going to have a good result.

I have one more week left on this service then I start my elective. For anyone actually reading this, I am going to leave it as a surprise. Let's just say I will probably be doing some cutting... off to go do morning rounds... maybe if I figure out how to post from my iphone I will send tidbits during the next several shifts. It's hard to post because most nights I am too busy, and I spend 7 out of my 10 hours off between shifts sleeping. We'll see if the experiment works. Until then!

A Little Quickie

2009-05-18T18:41:00.006-04:00

Hello, all... just got back from the Big Easy, the Crescent City, Nawlins' to some. It was a fun business mixed with some pleasure trip. I did get to tour and see a lot of the city.

I thought I would post a link to a small fraction of the almost 300 pics I took. Most were of work colleagues, but those I am saving for future blackmail ;) I am back on the Orthopedics' Night Service for another two weeks, so I will blog later about that.

Here are the links, enjoy!
Around Town
Food

I did want to share a photo of the fire that hit Bourbon Street on our last night there. A Four Alarm fire that hit a night club. You can see one of NOFD's finest climbing the ladder up to the upper floor:

A Shot in the Dark

2009-05-12T04:28:00.005-04:00

So, I just spent the last two hours sewing together a hand which had gone through a glass window. It wasn't the first time this drunken patient had done this. It was their third.

As I did so, I listened to the exchange between my patient and their spouse. They got married when they were 18 and she was pregnant. They had a son. They separated a year later when she says she stopped loving him romantically. He now lives with his girlfriend and their daughter. She lives with her boyfriend of 9 years.

They see each other daily because of their shared child. She says she loves him, and that they are still "family." She says they won't get divorced because he won't divorce her, and it would cost her too much money to divorce him. So, they live this way and everyone is in agreement and happy. If only he would stop drinking and punching things harder than his hand.

Wow. As for me, I am on my last shift before heading out to a national conference. I put up the gun picture because during the prior two shifts I had not one, but two patients shot in the arm that had broken bones. Both patients were "walking down the street minding my own business" when shots rang out. Both had what looked to be entrance and exit wounds with no severe damage. Both had broken bones that needed setting. Both could have been brothers. Both handled things in very different ways.

The first patient I can only describe as "a real jerk." The kind of patient that cusses out everyone, moves around screaming for pain medication while you are trying to do an exam, and who finally settles down when security gets called and stands outside the door. He told the police that showed up where they could "(*^&!" themselves. He tried to sass the nurse who showed him and told him in no uncertain terms who the boss was now. We cleaned out his wounds and splinted his arm. He was admitted and taken to the OR that morning. He's now got a metal rod where his radius bone used to be.

The second patient was very polite; asked questions about taking care of his wounds. Asked about his medications and how he should take his antibiotics. He was concerned about how his mother was going to take the news and if he should worry her or not. He needed cleaning and a cast. His bone will heal without surgery. He said "thank you" as I was giving him his follow-up instructions.

So now I am counting down the last 2 hours before the end of my shift. A couple of more hours, and I will be on a plane. Hopefully, that hand is the last torn flesh I will see until next week. Pics, etc. when I get back!

Happy Mother's Day

2009-05-10T16:53:00.002-04:00

Here's the link to the entry I posted on my other blog...
Happy Mother's Day!

Happy Mother's Day Quilt
Mom's dog Peppy

A review of this week's ortho madness tomorrow....

Bambi Meets The Motorcyle

2009-05-05T21:46:00.005-04:00

I don't know why I started thinking of the famous short film, "Bambi Meets Godzilla" while on-call last night. I was just finishing up a couple of other consults in the Emergency Department when I was told by one of my colleagues that Mercy Flight was bringing in "deer vs motorcycle."

It's usually not a good thing for either party involved. And the same held true for this unfortunate patient. He had a broken arm and a nearly amputated leg. The arm is fixable; the leg, not so much. He had to go straight to the OR last night for a completion amputation.

We get a lot of motorcycle vs. deer accidents. When I was in Minnesota I had a week on trauma call where it seemed we were seeing one to two a day. I was convinced there was a rampant herd of deer jumping out on unsuspecting motorcyclists at every turn. You know, kinda getting even for the hunting season.

Last night, though, as I held what was left of this gentleman's leg hoping against all practical hope that there was anything left to salvage of his lower leg, for some reason the short film came to mind. Maybe because of the humor behind the utter senselessness of how Bambi meets Godzilla. Maybe I needed that to help myself continue to help my patient as he went through a series of raw emotions after being told that he would be losing his leg. I don't know...

He was doing fine this morning. He went for his arm surgery today to try to put it back together again. I will find out tomorrow morning how he's doing. I guess I can say they do great things with prostheses these days. He'll actually do better functionally in the long run. I don't know if he'll ever ride a motorcycle again, but at least he's alive to ride again.

Here's the film... there was a subsequent, "Bambi's Revenge." Doesn't quite have the impact of the original, but still kinda funny.... I'm back in the hospital tonight. We'll see what tonight brings!

Sew Far, Sew Good

2009-05-02T12:16:00.006-04:00

Ok, so I finished my last "day" shift on the Ortho service, and I spent the last part of my day sewing up 2 patients...

One was an inmate who decided to end his life by taking a whole mix of pills he had stored up, and then, for good measure, cutting his wrists with a razor blade. Well, not so much his wrists but the majority of his forearms.

I put in about 50 stitches including a repair of his muscle fascia and some deeper layers of tissue but not a repair of his palmarus muscle tendon which was what the original consult was for. About 16% of the population don't even have a palmarus muscle. Do you have one? To check, hold your arm out and clench your fist. Now bring your fist toward you like you are flexing your muscles... if you see a long band pop up around the middle of your arm like in the picture below, you have one. If not, no big deal, you've been living without one and don't miss it. Just like this patient won't miss not having his attached any more.

The second patient was involved in a fight with another person wielding a knife. He had several cuts to his right hand including a deep cut at the webspace of his thumb for which we were consulted. Luckily, there were no nerve or muscle defects, and I was able to sew the laceration closed, plus put in a few stitches on his finger lacerations.

And, so ends the first month of my Orthopedics rotation. On Monday, I transform into a month-long vampire mode as I am on the Ortho Nights service. Fourteen hours of fun in the middle of the beginning of trauma season! Should be interesting!

As for this weekend, I will spend it still sewing... but of a more calming and artistic nature.... Quilting...

All in a Day's Work

2009-04-28T21:02:00.004-04:00

Just a quick note. We seemed to have a theme on the ortho consults we received from the E.D. today. All of them seemed to start with the history of...."Patient was at work doing ______ when they ______, and now they're in the E.D. with a broken ______."

We had a pressman working with a machine that came down on his finger, and now he's missing a piece of it and broke the little bone at the end. He's scheduled for surgery.

We had a construction worker on the roof of a building who was hit by a piece of sheet metal and knocked off of it. He has two broken wrists and a broken foot. He'll most likely be going for surgery.

We had a pipe worker who was loading a pipe into a grinder which then exploded sending a piece of metal flying that cut his hand and broke several bones in it almost cutting off a finger. He's going for surgery.

In addition to the laborers we had a number of other consults most of which were bread and butter broken bones. Tomorrow is Grand Rounds Wednesday and then two more days on the day shift before I become a vampire for a month. But, at least I get 2 days off this weekend to make the transition...!