or, how i've become depressed before i reach the halfway point of my intern year

*ref: DJ Shadow "Why Hip-hop Sucks in '96"
(it's the money)

so i worked this whole weekend. so what.

today i showed up for dayfloat at the other hospital we have to work at, which requires me calling a cab to get to and from there on the weekends (because the shuttle which runs at very particular times onloy runs from mon-fri).

dayfloat during the week means you take sign-out from the interns as they finish up their work and leave for the day, and just answer pages for them until 5:30pm when night float shows up. it's actually pretty boring and easy for the majority of the day, and usually only gets a little busy towards the 5:30 mark (murphy's law).

dayfloat during the weekend is much worse. you have to write progress notes (daily progress notes are required on each and every patient - and the primary team gets one weekend day off per week, so the dayfloat writes notes on those days) as well as do any work required for the patients (whereas on a regular day, the primary intern would do all the work and tie up all the loose ends BEFORE signing out).

so i was already not looking forward to today before i woke up.

i showed up at 7:30am and was immediately warned by my first sign out (who was already waiting for me) that this one lady was breathing hard and rapidly, and her oxygen saturation wasn't as good as it should be. hmm.. okay. so i'll go see her first and foremost and make sure everything is okay.

this is a pretty sick lady. she came in over 2 weeks ago with an MI (myocardial infarction, aka heart attack) and was promptly sent to the cardiac cath lab, where they perforated her LAD (left anterior descending artery, a pretty fucking important coronary artery). she ended up in cardiac tamponade (blood filling the inelastic pericardial sac which surrounds the heart, compressing it and preventing it from contracting fully or effectively) and began throwing emboli (lil' blood clots) everywhere. she developed strokes on both hemispheres of her brain, bowel ischemia (essentially, clotting off the blood supply to the intestines and effectively killing it) and GI bleeding, and cyanosis of her feet (again, due to clotted off blood supply). however, she remained mentally stable in spite of all of this, and was able to talk and understand her situation, although at times she would become confused. normally in a patient like this we would use heparin to anticoagulate the blood and prevent it from clotting (and in turn, making it more likely to bleed), but they couldn't, given the fact that she had GI bleeding.

so i went down to see her (never seen her before - only covering) this morning and she looked bad. unresponsive, unarousable, eyes lolling back and forth (nystagmus), pupils hardly reactive to light, not moving any of her limbs, not reacting at all to pain. within 15 minutes respiratory therapy had intubated her. over the course of the next few hours i called critical care medicine, pulmonary, vascular surgery (her toes were looking worse and now her hands were turning purple), neurology, cardiology (she was having another heart attack), and hematology.

everyone said the same thing: prognosis poor, no [surgical/neurologic/cardiac/critical care] intervention indicated at this time, thank you for consult, please call us with any issues. so i basically called them all back several times today.

by the time i signed out at 5:30pm we were still waiting for hematology to call back and critical care were refusing to take her to the ICU because there was "nothing we can do" (although they expected the nurse on the floor to check vitals every 15 minutes - ridiculous!).

so that was one patient.

i covered about 30 or 40 patients today. there's two dayfloat people. technically the full patient load of coverage is divided more or less equally between the two. but there's no telling how sick one group is versus the other, so the work load can end up being very disproportionate despite the best of intentions.

but the schedule had been messed up today. unfortunately we didn't figure this out til the end of the day when the other dayfloat and i were both signing out. turns out all the interns who were sticking around all day because they were on call were assigned to the other dayfloat. that means that they're in the hospital, hence no sign-out. all the interns that were leaving early or had the day off were assigned to me, meaning i received nearly ALL of the sign-outs.

the tally at the end of the day was that i carried the boards for 8 interns and she carried 2.

..

oh, and i forgot about daylight savings and woke up and got ready for work an hour earlier than i needed to.

..

tomorrow i'm dayfloat at the nearby hospital. tuesday i begin overnight shifts in the ER, four in a row.

..

huh. and i was wondering why i was depressed.

this educational lesson brought to you by dr. j around 7:28 PM |

vacay!

today i took the in-service exam for internal medicine. the purpose of this exam, which medicine residents have to take once a year, is to gauge your knowledge base, weak spots in your clinical acumen, etc - and to see how well you improve over the course of residency, in anticipation of taking the internal medicine boards. in essence, it's step one of a very long board preparation. seeing as how i'm NOT actually going into internal medicine, i don't think i need to elaborate upon why i was not thrilled to spend 7 hours today answering 340 multiple choice questions.

today had a big upside, however - my schedule was successfully manipulated and i now have new year's eve off! hooraayyy! this means let's get started with planning NOW (not really). i'm so excited to have a holiday off, finally.

i saw the departed last night (p.s. i don't think i ever noticed that movies have myspace pages now). it's martin scorcese's adaptation of infernal affairs which is a crazy good hong kong action flick starring andy lau and tony leung (he of wong kar wai cinema fame). scorcese's version has a hell of a cast - nicholson, matt damon, leonardo dicaprio (even though i find his boston accent tough to believe - not that i know a thing about boston accents - i just know that HE doesn't have one), mark wahlberg (absolutely hilarious in his totally not funny role), martin sheen, alec baldwin (he gets funnier as he gets fatter), and even that guy from harold and kumar.

anyway, the language was politically incorrect and abrasive, the violence was graphic, the gunshots were plentiful - it was a great movie and i was thoroughly entertained. i'd seen infernal affairs several times, several years ago, so i had forgotten most of the plot details, which made it much more shocking than i expected. i give it an A PLUS PLUS.

and finally i've been catching up on that hot new tv show studio 60, and i must agree: it's great.

jesus i'm boring.

this educational lesson brought to you by dr. j around 9:31 PM |

alright, back in beloit. been gone since june.

so i haven't posted much at all in the past few weeks. what have i been up to?

the past couple weeks i was on the OPD rotation, involving a blend of clinic days, dayfloat shifts, and ER shifts. i've complained about this before in earlier posts. the ER is fucking crazy. there are three sides (north, south, west) - the sickest patients go to west, the crazies go to south, and everybody else goes to north. as a medicine intern, they stick us in north or south. i spent most of my days working in south (with the crazies) and didn't realize how much quieter the north side was until they finally assigned me to that side late in the rotation.

the ER is exciting, fast paced, and hectic/stressfully social. there's this small "island" work area that all the doctors and nurses station themselves at. all the computers and desks and charts are there, and you work side by side numerous other residents and nurses at all times. so if you get lucky and you're on a shift with a friend, it's not too bad. you go see a patient, come back, write it up and can bullshit with your neighbors for a minute, then present to an attending, put in the orders (and sometimes put in the IV lines), maybe draw some blood, bullshit some more, and then pick a new patient to go see. i prefer fast paced, busier settings (as opposed to the easy but mind numbingly boring clinic days or lonely and equally mind numbing dayfloat shifts), so the ER is quite entertaining for me. it's also located across the street from my apartment, so transportation is a non-issue (i have to take a shuttle to both dayfloat and clinic). the downside is that a 12 hour shift is pretty long. although you do get to pretty much leave when your shift is over (more or less).

it did take me a little while to warm up to the ER however. the first few days were fucking CRAZY. one side of the ER has areas for maybe 15-20 patients. ergo, the entire ER is designed to hold 60, maybe 65 patients. my first ER shift i walked into it filled with 140 patients, 60 on the side i was working on. later that day it ballooned into 165 patients. we had 3-4 patients to a "slot" (simply an assigned area for a stretcher), some in the hallway, some in the walkway, some of the less acute people were simply sitting in the "asthma chairs" (where they put wheezing folks to sit and breathe oxygen and albuterol and then hopefully walk home), and the nurses kept bringing more people in. we had to tetris beds around to get people hooked up to cardiac monitors, to pull curtains to perform rectal exams (a delicacy), and to line them up for the GYN exam room (of which we only have one). those days were painful. so when it finally calmed back down to days with a census of 80 patients or so, it seemed like a piece of cake.

i've said it before and i'll say it again: doctor dayne, how the HELL do you do this, day in and day out?

dayfloat sucks, and here's why. your job as dayfloat is to cover interns on the medical floors. the interns that have to leave early are the ones that are post call from overnights the night before, or the ones that are pre-call and have clinic in the afternoon, or the ones that are on call that day and have to leave before lunch so they can return at 9pm for an overnight shift. so on a normal weekday, you show up to round with the on call team (so you can hear about the first patients you will be covering for the day), get sign out, and then go hang out somewhere and wait to get paged. this first sign out usually occurs around 11am or so. at 12:30 there is conference, so you get pick up some food and then fight off your postprandial coma for an hour while you get lectured about something that you most likely will not retain for more than 20 minutes after the talk, probably some esoterica which will never apply to anything that you'll see for months. after lunch, the clinic people sign out to you. around 3 or 4pm, if the post-call overnighters are good, they may be finished with their work and sign out to you. and then at 5:30pm, night float arrives and you sign everyone out to them, and then go home.

the whole idea behind signout is that you're supposed to write your own notes, get all the work done, stabilize the patients as best you can, and then sign out to the float. so the float, in theory, will answer pages for little easy things like "can we give some tylenol for mrs. so and so's headache?" or "can you write a diet order for mr jones?" etc, and hopefully not "mrs smith has been bleeding out the hoo hoo all afternoon and now her blood pressure is bottoming out!". so if the interns do a good job (and they did, for the most part), then you, as day float, really don't do much.

the WORST part about dayfloat is that you have to talk to families. i have no problem speaking with families if i'm taking care of their patient. it just sucks to do it when you barely have a grasp of who the patient is. and families always come in the late afternoon, after work or something. i hate saying "i'm not sure what's next, i don't know what the plan is" and so i try to bluff my way through it after a precursory examination of the patient's chart. it's a horrible feeling and pretty much no way out of it.

the other horbs part about dayfloat is floating on weekends. that's when you have to write progress notes for the interns that get the day off. so you're examining patients and supposedly making treatment decisions and such on patients that have been there for weeks or something, and you are just learning about. and there is nobody signing out to you in the morning, you just come in and figure it out, and then answer pages on them all day long. there's no educational value in dayfloat, it is simply a distribute the work sort of thing.

clinic is just boring. end.

ANYWAY now i am on vacation. enough talk about work. i spent the past several days in philly visiting jennie. we saw "the science of sleep" which was cute like amelie and not as trippy as i had thought it would be, but i liked it a lot (a LOT) and definitely would recommend it and i want to see it again. we also saw "jackass 2" (matty was in philly too and he was a strong force in deciding to watch that movie) which was every bit as hilarious and disgusting and filled with poop as hoped. and we ate at a burger joint called five guys burgers (i think) which was also on matty's recommendation, he being the burger aficionado that he is (the walls were lined with positive press clippings). it was a painfully delicious and greasy amount of food (the small fries, for us, was a medium styrofoam cup of fries, plus about 6 inches deep of fries in the paper bag - the entire thing weighed like 7 pounds). we were also very entertained by the comment cards pinned to the walls. i expect matty to post his pictures up soon. *cough cough hint hint*

this week i plan on doing a whole lotta nothing. i got in last night after a 4 hour delay with my flight, proceeded to eat waaay too much korean food and an apple, did some laundry, and then passed out at like 9:30pm. it was awesome. i woke up and have done little else but drink a cup of coffee and putz around on my dad's imac (he's been converted). i did somehow scratch my eye in my sleep though.

this friday is korean thanksgiving. that means more eating.

this weekend i hope to coerce rob into driving down to chicago to see, um, EVERYONE, and also the may or may not show on sunday night. monday morning i fly back to philly, spend a couple more days there, and then it's back to work in the MICU by thursday morning.

oh, also, that half marathon - unofficially, i clocked myself at 1:59. not as fast as i hoped but certainly not as slow as i feared. and now the farthest i have ever run is 13.1 miles. with proper training, i hope to get it down to 1:45 or so.

i listened to the new hold steady album and so far i like it better than the other hold steady albums. i listened to the new my morning jacket double live album and so far i like it better than the other my morning jacket albums. i listened to the charlotte gainsbourg album and it reminded me of science of sleep. i was inspired by the trailer for "old joy" (starring will oldham) to dig up "i see a darkness" and listen to it again and remembered how perfect that album is for a cold grey rainy day.

how stoked are you guys for season 3 of lost? (rost)

this educational lesson brought to you by dr. j around 11:34 AM |