A Week of Nights

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

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

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

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

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

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

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

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

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

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

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

Sophomore Stories

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!

Passing Gentle Into That Good Night

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.

Under Pressure

I never thought about the change that would happen in six months.

I just started my next rotation at Women and Children's Hospital. After almost two months working at ECMC, I think I was ready for the change. However, I didn't expect quite the change.

If you've been following my blog, you know that I have already done two rotations as an intern at WCHOB. And, despite the fact that I really don't like kids, I actually enjoyed them. It gave me a chance to do some preventative medicine - which I think is very important, a chance to teach - which I love to do, and, for the most part, I learned a lot about pediatric acute (and some not so acute) emergency medicine.

However, starting on Monday morning, I was the "senior" emergency medicine resident. Suddenly, it wasn't about "what does this child have?" it was about "how are you going to fix them?" Having not seen anyone under the age of 16 for the last 6 months, I really found myself rusty in my diagnostic skills, and with the added pressure of making more complex decisions about their health care, I was really at a loss my first shift.

What did not help was the fact that it was Monday. In January. At the height of RSV and flu season. And, I had an intern that had never been to WCHOB before. And, we started the morning with a trauma. A sixteen year old girl T-boned on her way to school at 45 mph. She ended up with a subdural hemorrhage. By the time we finished assessing her, we had four new patients on the board, and the fun was just starting.

I felt like an intern, trying to get used to the system again. Trying to manage the patients. Trying to just feel like I wasn't sinking. We got more residents in over the next 4 hours, but the whole system was just overloaded.

At one point we had all 26 rooms full. They opened another section of rooms (+6). And the waiting room had about 20 people waiting. The computers crashed, the nurses were surly as they were being pushed to their limits, and ambulances kept bringing people in.

We had the comic "E.R." moment when everyone was running around, a barely-breathing baby is brought into the back and starts being coded, the ambulance rolls in with another child turning blue despite ventilation, and the noise level rises to fever pitch. The baby is taken to another room so that the blue child can be rolled across the work station to the now vacant code room, and there's the rush and flurry of the respiratory therapists pushing ventilators as the radiology techs push around their giraffe-painted x-ray machines.

I left that night with 4 patients waiting to go to the Pediatric ICU (PICU), another 5 or waiting for admission, and a full board (20+) in the waiting room to be seen. You don't learn in that environment. You just try to survive and not let anyone else get hurt.

My next shift was a little better. At least I was able to think about my patients more. Review my disease processess. Come up with a plan before presenting to the attending. Not to mention, I actually knew the attendings. One of our complaints about WCHOB is that we're working with pediatric attendings who have completed a fellowship in Pediatric emergency medicine. We're guests in their house.

They've hired a whole group of new graduates, none of which I had worked with before. Not that it makes a whole lot of difference, but you get used to how an attending likes their work-up and presentation. You know who lets you fly and who keeps a close rein. I guess I could have almost called this posting "Out of my comfort zone."

Sigh. It was just the first two days. I work tonight (which is another problem, since we don't schedule our residents we get whatever schedule the pediatric chiefs come up with which doesn't always make sense or take into account shift time changes.) I know I will be able to get back into a rhythm. And, I know that by the end of the month, I will be a lot more comfortable with what I am doing in my new role.

Just in time to start my PICU month when the fun begins anew!

Until then, we'll see what interesting stories that don't involve coughs, colds, vomit, diarrhea and parents that should need a license before they're allowed to procreate we can come up with.

As for the video above. I like the way they combined two of my favorite shows "Grey's Anatomy" and "Scrubs" And, I like the song....