almost 2 months without bloggin', that's some absence


kind of at a loss where to start. i think i'm going to do the numbers thing again.



1. i signed on an apartment in the east village! it's in a nice little area just off of tompkins square park, it's near plenty of wonderful restaurants and bars (some of my most favorite ones that i've found in the city so far), and it's a little bit farther away from the subway than i'd like to be, but honestly i couldn't be too picky after all that huntin'. living in the bronx, 1 hour away from downtown, working 6 days a week, makes for difficult apartment hunting. after spending 2 full weekends looking for and finding awesome apartments that i would then lose out to other applicants because they either saw it before i did (i could never get into the city much earlier than 5pm) or they didn't need a guarantor (since i definitely do not make 40x the annual rent for most places), i decided to bite the bullet with this one. it's undersized and overpriced and it's going to be probably the smallest bathroom i've ever had, but i will be in the city and i will be happy.

2. one of my apartment hunting stories is kind of funny. it involves car accidents and lost and found cell phones. supposedly my broker's office was contacted by the new york times for "funny apartment hunting stories" and they want to interview me for mine. if they think it's funny enough, i'll be in the new york times. i'm totally going to put this on my CV if i get it, since i don't have any research publications to list.

3. i start at NYU in 6 weeks! only 5 more clinics to go! i move in 3 weeks!

4. i need to hire movers.

5. living in the bronx, in hospital housing has been very cheap and frugal and i've saved a lot of money. then i spent it all on first + last month's rent + broker's fee + (movers). my tax return came and i was excited and then paid off the credit cards and then bye bye tax return.

6. my computer's hard drive died. i was very sad because i thought i lost all my digital photos and my music (as in the stuff i composed, not the stuff i put on the ipod). turns out long ago i had moved my iphoto library to an external drive, so most of my photos were saved (hooray!). turns out i didn't move my music stuff over though. booooo.

7. so now i have an old computer with a brand new hard drive.

8. my rotation right now is at the county hospital. it fucking blows. my attending, who isn't even a "real" attending, but a teaching attending (who is basically just supposed to give us lectures and stuff but we don't follow his management), who retired and came back as a volunteer attending JUST to do teaching rounds, is a COMPLETE FUCKING ASSHOLE. he's condescending, demeaning, belittling, arrogant, narrowminded, sexist, loves to beat dead horses, loves to ask esoteric questions and then sigh and groan loudly when we say "i don't know," yells at us for management decisions that were not ours (i.e., for a patient that was admitted overnight by the nightfloat resident), and today decided to make an example of the meek 3rd year medical student that follows me (i.e., is on call with me) and berated her to the point where she was crying. fuck him, that fucking asshole. medicine should not be taught by means of fear and shame.

9. and while i'm all pissed off, good fucking riddance, jerry falwell

10. congratulations to zamelia! thankfully i have secured their wedding weekend off and will be flying back to the midwest (on the same flight as tamz and bard, interestingly enough) for the first time since last october. very excited for what will undoubtedly be in the lead for wedding of the century!

11. see you there, chasbot!

12. have you guys heard the new battles album? straight heat

13. packing up my things in the studio makes it feel like a dust bomb went off.

14. there is a 10 year high school reunion in early august, back in wisco. haven't decided if i'm going to go yet, assuming i have that weekend off. not sure if i'll be able to justify the flight home, though i know my folks would love it. besides, i gotta save up the bucks for c-wiggle's wedding in september.

15. it is so damn humid.

this educational lesson brought to you by dr. j around 5:47 PM |

jeepers creepers, it's been a million years since i wrote anything worthwhile. so what have i been up to?

since my own memory is probably not functioning up to snuff, let's go in reverse chronological order.

my family was in town this weekend. we did a lot of stuff that mostly revolved around eating.

they came in on saturday afternoon, and we immediately hoofed it to k-town and dined at kum gang san, which made us smell like kalbi for the rest of the day (a sweet delicious aroma). then i took the crew to pinkberry for dessert, which blew everyone's minds because janice had read so much about it and it was low-cal and low-sugar so it was ok for my mom and we watched some dude suck down the large pinkberry bucket of froyo all by himself in record time. then an employee made my dad put away his camera because there were no photos allowed.

neeext we went to times square, where we watched an afternoon matinee of THE HOST (the korean campy monster movie) which was pretty fun and exciting even though my dad fell asleep, but my mom loved it and actually understood most of it, since it was in korean. the theater, by the way, had a million stories and we went up a million escalators to get to our screen. fyi.

then we went to chinatown for dinner, and slurped down soup dumplings at joe's shanghai (where i'd never been, but heard much about, and o lordy, thems some good xiaolongbao). i also ordered the braised pork shoulder, which was about 25% fat and gristle. but that remaining 75% was delicious, brother.

afterwards we had very loose plans to go out, but considering the idiot quotient in the city (being St. Patrick's day and all), and our caloric quotient (since we had only paused the eating for 2 hours to watch a movie), we are all pretty pooped, and called it for the evening.

on day 2, we had breakfast at the little cafe metro that was right next door to my family's hotel. then my parents took us all to st. patrick's cathedral for sunday services, since they realized that they would be the only way they'd get us all together to do such a thing. i'm not sure when the last time i went was (since i was on call on christmas last year), and jennie was pretty sure it had been years since she's been. but hey, it's st. patrick's cathedral on st. patrick's day. and i'm technically still a catholic, so why not? it was surreal though.

next we dined on noodles at hyo dong gak, a chinese/korean noodle house near k-town (more korean food!), and then purchased discounted tickets (i mean, TKTS) to Mamma Mia! on broadway. then to kill time i brought the field trip to soho where we did a spot of shopping (everyone oohed and aahed at uniqlo. also, everyone used the restroom at uniqlo) and then returned back to times square for the show.

i've only seen one broadway show before and it was the lion king and it expanded my mind. it was freaking unbelievably amazing and i'd go see it every week if tickets didn't cost $120. so i expected a similarly mind-bending experience with Mamma Mia!. i knew nothing about it except that it was all ABBA songs and probably about a wedding since all the ads have a woman in a bridal gown.

OMG it was such a chick flick musical (jennie's words). a story of 3 women who grew up strong and single in the 70s and now one of them has a daughter who's getting married, but oh no, we don't know who the father is, because 20 years ago the mom had summer trysts with THREE DIFFERENT SEXY MAN BEASTS (one american, one brit, one aussie). also the whole thing takes place on a sexy greek island.

it was done well but it was no lion king. highly recommended if you're 40 and female and reuniting with the sorority sisters for cosmos and a NIGHT IN THE CITY! WOOOOO

so that was the weekend.

prior to that i took the USMLE step 3 exam. it was misery. i don't want to talk about it. ok i'll talk a little about it. it's 2 days long. the 1st day i came out feeling confident because i finished like 2 hours early. the 2nd day was painful. there was some error with the computer system so the 8am test didn't actually start until about 10:15am, and they warned us that they might have to reschedule us (and my family was flying in the next day). then as i was taking the test it seemed so much harder than the day before and i think i might have failed. it was horrible. won't get the scores for weeks.

prior to that i was on night float for 2 weeks. now THAT's misery. it's a long shift, 5:30p-8am, factor in the commute and it's about 15.5 hours everyday. if you do the math, that leaves you 8.5 hours to sleep, assuming you fall asleep the second you walk into your apartment. factor in more time to maybe eat a little something, check some emails, make some phone calls, take a shower, and you're left with NOT MUCH TIME TO SLEEP. and the one day i decided to do laundry was a bad idea - that cut into my sleep margin by almost 2 hours.

night float was a difficult rotation. as everyone leaves to go home, they sign out their patients to me, the idea being that if any shit went down, i'd be there to take care of it. so it's common courtesy for people to wrap up as much work as reasonably possible during the day, and leave me with NTD (nothing to do), which is what is "supposed" to happen.

of course, if you have a sick or crashing patient, then inevitably there will be lots to do but that's a given, and the daytime MDs should try to set things up to go as smoothly as possible overnight (i.e., "if the BP does this, then give this med. if that doesn't work then add this med. and if that doesn't work then call this consultant, they are already aware of the patient"). that's the least stressful way to do it. the worst is when there's a really sick patient and i'm told "oh he's fine, nothing to do" and THEN he craps out after they leave. then i have to run and get the chart, read about the patient, try to make a decision on how to act, if i'm stumped i can call my senior (who is busy admitting patients in the ER overnight), and decide if i need to call a consultant or not. and then i hope that whatever intervention i decide on works.

some nights went better than others. and some of my colleagues give much better signouts than others. nightfloat is a way to really see what all your co-workers are like. when you work with them during the day, it's hard to tell, because you all work side by side, but independently of each other. so if my buddy is doing a crap job, i might not be able to notice, because it doesn't affect MY work directly. but if he's doing a crap job, i'll DEFINITELY find out overnight, because all the loose ends that he leaves hanging at the end of the day will be my mess to clean up overnight. there are some classic violations like IV lines that are just barely hanging out that the interns will try to duck out of, telling me that there's nothing to do, then high-tailing out of the hospital, and then not even 5 minutes later i'll get called that i need to place an IV. and i don't MIND placing lines and such, but it just sucks when your night starts off with several of those calls, all because people don't want to do their own work.

then there are the calls from family. it sucks when the family insists to speak to a doctor because the daytime MDs haven't told them anything. and then at 645pm, when all that's there is me, the guy that's covering 80 patients overnight, and they want ME to tell them what exactly is wrong with grandpa and what tests do we have planned for tomorrow and how come nobody has called his cardiologist and are we sending him to a nursing home? and so i read the chart and try to decipher handwriting and figure out what exactly the primary team thinks is the diagnosis and where they're going with it, and then regurgitate that info to the family. lots of times i had to deal with family members who are angry at what happened during the day (i.e., when i'm NOT THERE and have NOTHING TO DO WITH WHAT'S GOING ON), and so they take it out on me. one family yelled at me repeatedly over the course of a night because they weren't allowed to stay past visiting hours and wanted to speak to a supervisor (who's not there at 1am) and they said a nurse said such and such to them and she's a bad nurse (she's not) and one of the doctors earlier promised them this and that and none of it happened (i didn't make those promises!) and because of all this, they want to remove their ventilated vegetable mother from our hospital and take her home at 1am - a horrible idea. so i have to go there and calm them and remind them that i'm not the enemy and that pulling their mother is a terrible idea and they should just let her stay the night and re-address the issues in the morning. and after a couple of hours of berating me, they agreed.


blech. anyway i'm on vacation now. not going anywhere too fancy, heading to philadelphia this weekend (it's jennie's birthday). looking for an apartment to live in (east village). gotta get my tax return filed, pronto. and then: 3 months left in internship. halle-freaking-lujah.

this educational lesson brought to you by dr. j around 2:03 PM |

i'm on night float right now.

5:30pm - 8am, on the daily.

also i'm studying.

this educational lesson brought to you by dr. j around 9:15 AM |

last wednesday i was on overnight call. that means instead of coming in at 6am and picking up admission #1, and accepting a total of 4 admissions over the course of a day and leaving around 10pm, i come in at 7am, do NOT pick up an admission, see my old patients, leave by noon (that never happens) and then return at 9pm to pick up 5 admissions throughout the night - and then the next day is a full day. (yes, overnight call sucks).

so i forgot that i was overnight and just assumed i was on regular long call, so i started off my day by showing up at 6am for no reason. awesome. the morning was uneventful and i left and returned by 9pm. i had 2 admissions already waiting for me, and those got worked up at a fairly sluggish pace (as an intern, you are only as fast as your resident, and the night admitting resident that night was SO s-l-o-w). by 2am we had only finished 2 admissions. i received admission #3 shortly thereafter, and this was quickly followed by #4 and #5, around 3:30am. so the idea is to get all the admissions done by 7am so you can again see all your old patients and be ready to round with the team by 8am. having 3 admissions left to do around 3:30am is a bit of a crunch, so i was a bit anxious and really pushing my resident to pick up the pace a bit.

4:00am i get a call that one of my old patients is not doing well, i'm needed on the floor.

***

this is a guy who's my age, only medical problem being wildly uncontrolled type 1 diabetes, who came in with a pretty bad pneumonia. his pneumonia got worse despite IV antibiotics and he continued to spike fevers through it all. for a while we thought he might have had TB but all of his tests came back negative for it. he then developed a large loculated pleural effusion (basically, pockets filled with fluid in the space surrounding the lung, which essentially pushes on the lung and collapses it). we expected it to be full of pus (an empyema) and thus be the source of his infection - except that when we drained one of the pockets, there was no bacteria in the fluid and no pus. we then decided that a drain would need to be put in to take out this fluid, since it MUST be the source of his infection, even though all the cultures and gram stains were negative. so we put in a pigtail catheter and he drains a few 100cc's (which is not really all that much) overnight.

the next day the pulmonary fellow comes by and infuses tPA (tissue plasminogen activator, used during heart attacks to break up clots) through the pigtail, the idea being that the tPA will break up the loculations and allow more fluid to drain without having to place a second pigtail. so we do that and it works, he drains about 500cc's overnight. the following day, pulmonary decides to repeat the procedure, which he does and this time it only drains about 25cc's overnight.

so we either have run out of fluid to drain, or something else is wrong. clinically the patient seems to be feeling better, he says his breathing is easier, his cough is better, his chest hurts a bit less. but he still continues to spike fevers, really high fevers up to 104 degrees F. he's still on 3 different IV antibiotics that should cover just about any bug that could be causing this.

we call and ask the cardiothoracic surgeons to come and evaluate him as we think he may require surgery to decorticate (strip the loculations) the lung and help it reexpand. they say they will come by, and they left a note, but for the "plan" section of their note (the most important part) they leave it blank. which is of no help whatsoever.

the next day we call CT surgery again and ask them again to come see the patient and remind them that we need a plan from them otherwise their consultation is useless. later they come by and write "discuss with attending" in the plan section. that's it. nothing else. the patient continues to be clinically stable, the pain in his side hurts a little more, but otherwise breathing is okay. his oxygen saturation continues to be about 97-98% on room air, which is fine.

that night was when i got paged to come to the floor.

***

so i arrive and the overnight team is already at the bedside, a 100% non-rebreather oxygen mask is over my patient's face, and he looks delirious and woozy and doesn't recognize me when i first show up. i find out that the nurse came in to do a routine vital signs check overnight and found that his oxygen saturation was 74%. she called the overnight team to assist, they placed him on 100% oxygen and rechecked, and his saturation went up to about 85% (still not good). critical care medicine was called, CT surgery was again called, and pulmonary was called. critical care recommended a BiPAP machine, which is basically the last step before you intubate someone. it forces oxygen into the lungs and is this hugely uncomfortable mask that you have to strap on to your face. we tried that for a few minutes, got him up to 95%, but then he dropped back to the 80s because you have to be awake and cooperative for BiPAP to work, and he wasn't either one. the respiratory therapists were forced to ambu-bag him to keep his saturations up as they prepared for intubation.

to intubate someone you need to sedate them, or at the very least relax them. you're placing a tube into their throat and down the trachea, past the vocal cords. as you may imagine it is a very unpleasant experience to be awake for. but this guy just would not calm down. we push nearly 50mg of sedative (4mg at a time) trying to get him to calm down. after the third attempt, he was finally intubated, and coughing up pink frothy foam, which is a sign of pulmonary edema - fluid and blood in the lungs. chest X-rays showed signs of fluid all over both lung fields - he was in ARDS, acute respiratory distress syndrome. yes, this is bad.

after the initial incident and intubation, all the services write event notes for the chart - medicine, pulmonary, critical care, nursing. CT surgery does not write a note. the resident was present during the event but did not contribute anything. she had left to go look at chest X-rays and never came back.

i proceeded to spend the next 15 hours more or less at his bedside, managing his sedation and ventilation, suctioning him as he needed it, pushing more sedative as he needed it, speaking to family on the phone, talking to all the consult services, speaking to my attending, etc. by 7:30pm that evening he finally was transported to the PCU (pulmonary care unit).

***

it was only then that i was able to finish my next 2 admissions (#4 and #5, which i had to put on hold because of all of the aforementioned events). i left that evening around 9pm. 24 hours straight, no sleep, no food, no water. i pissed orange that night.

since that horrible day was technically my "post-call" day, i was due for an admission the next day. that meant coming home at 9pm, showering, passing out, and waking up to be at work at 6am the next day to get my short-call admission.

***

but my karma has come back around. yesterday i was on long call again, this time not overnight. eligible for 4 admissions between 7am and 7pm. i received zero. i don't know if that's ever happened before, to be on long call and receive no admissions. but it was great. i watched a lot of football (though i missed the end of the bears game) and ate a lot of food.

***

my patient is still in the PCU, still intubated, still on sedation. he looks a little bit better. i can tell he recognizes me again. he makes a bit of a smile when he sees me. but otherwise they still haven't fully drained the loculations and they still don't have a source for the fevers. he continues to spike through the antibiotics. more than likely he will eventually need surgery and this will probably become a chronic problem for the rest of his life. CT surgery now sees him and writes notes daily.

this educational lesson brought to you by dr. j around 10:21 AM |

my flickr account expires in 4 days.

so far this year i watched tv and ate chinese food.

resolutions for 2007 to come later.

this educational lesson brought to you by dr. j around 9:37 PM |

work is painful.

today we had an ethics meeting concerning the care of one of my patients.

she is young, by our standards (under 50 years old), HIV+, infected with a horrible brain disease called toxoplasmosis (the same toxo that can be found in kitty litter, which is why doctors recommend that pregnant women don't scoop it - although most patients with normal immune systems don't get THIS sick - and the danger is more for the baby than the lady) for years. a disease like toxo doesn't go away. you have to take a massive dose of medicine every single day just to get it under control, and then you have to continue to take a slightly smaller dose of medication every day just to keep it from coming back. this woman's partner had passed away from AIDS related illnesses at least a year prior. until then she had been doing well, coming to the infectious disease clinic once a month to get checkups and modify her treatment and pick up cases of ensure. after her partner's death she called it quits.

toxoplasmosis basically eats at your brain. well, it really causes encephalopathy, but in the end it destroys your brain. this used to be a high-functioning woman who owned her own real estate business and raised three children. right now she is bedridden with a nasogastric tube pumping her nutrtion and medication into her stomach because she's simply not awake enough to take her medication by mouth (and toxo treatment requires that you take some medications by mouth - they're simply not available in IV form).

unfortunately, before she reached this state, she had not established a health care proxy - someone to make her health care decisions for her, in the event that she would be unable to. so we had to have this meeting with family members to decide what to do, and to gather their input as to what they believed she would want done. a nasogastric tube isn't a permanent solution (she pulled it out once) and the other options were a PEG (percutaneous gastrostomy tube - a tube directly from the stomach to the skin) or to stop treatment and let her die. even after a PEG tube, there is no guarantee that she'll get better, but without one, she would have no chance.




it's impossible not to become completely cynical and bitter and angry as an intern. some of the more astute readers may have picked up on my less than complete enjoyment of the internship experience from my previous posts. you begin to hate everything. patients become less human, another name on the list, another checklist of things you need to get done in the same amount of time, another "rock" that will never leave the hospital because of any myriad of reasons (they refuse treatment, they refuse nursing home placement, they can't be placed because they've punched nurses/patients in the past, they threw a box of sharps at a doctor, they tear out their IVs/NG tubes/foley catheters every night, they continue to spike fevers despite antibiotics, they use angel dust while in the hospital (i've had two patients have their urine tox screen turn positive for PCP while in the hospital), they're nauseated, their back hurts, their chest hurts, they're anemic, they're vomiting, they had diarrhea, they're depressed, they hate their family, their family hates them).

we look up past information on every patient that gets admitted. this is all past hospital information - former diagnoses, medications they were on, imaging studies that were done, surgeries they had, who their primary care provider is, are they at a nursing home?, etc. we find out very little about their lives outside of the hospital, other than do you drink? smoke? drugs? work? sexually active?

then you have a patient like the one above, who's nonfunctional and nearly nonverbal and you can't get a story from until 2 weeks later when you're at a breaking point so you call the family in and then you finally fill in the blanks and realize that this patient had a life and a family and a business and an apartment and a husband and a daughter who just got married two weeks before admission (and she even attended the wedding). and suddenly the burden you carry feels even greater and even more depressing.



then i come home and i eat dinner and watch reruns and think about how hard and awful and terrible my life is and i become selfish and cynical and bitter again and almost spite the woman for creating more work for me to do and making me stay an extra hour and a half later because of this meeting.



this of course, only breeds more self-loathing.



then i flip open a magazine that came in the mail and read about reasons to love new york, which includes a small blurb on firefighters that died fighting a fire in the bronx earlier in the year. and it includes a passage on a fireman that i helped care for while in the ICU. and i can remember that bizarre night, the first overnight call and first day in the ICU, with firefighters and family swarming the bed. the commissioner of the FDNY was there that night. bloomberg was there too. they turned one of our conference rooms into an impromptu pre-funeral reception, as grim as that sounds. that was one of the longest nights of my life.



then once a month i write something that seems profound but is really just thinly veiled complaints and whining, brush my teeth, go to bed, wake up, shower, iron a shirt, and go back to work and do it all over again, and every morning, before it even turns 9am, i already feel defeated.


merry christmas. don't get sick.

this educational lesson brought to you by dr. j around 9:20 PM |

hello, faithful readers, intern year is breaking yours truly.

once again we find ourselves overdue for an update.

for the first time i will be missing thanksgiving with my family. if i was celebrating it with friends or some other group it wouldn't be so bad, but i will be celebrating it with ICU nurses and patients who are determined to reach the grave one step earlier than we will let them. this is a depressing prospect.

i thought i would try to make myself feel better by making a turkey sandwich for dinner tomorrow night, but i forgot to buy turkey. so it will be peanut butter, but i will pretend that it is sweet delicious roast turkey with stuffing and cranberry sauce and mashed potatoes and green bean casserole. then i will pretend to curl up on the couch and watch football til i pass out in a tryptophan coma when really i will be drawing bloods and informing family members that their beloved aunts and uncles and mothers and fathers and grandparents are imminent and this is really serious and they should be prepared for an outcome that may not be the best case scenario, no matter how much they pray, and that auntie may not ever wake up even though she twitched a toe after 2 weeks of complete unresponsiveness, no matter how well christopher reeve was doing after his accident, and just because we are going to ask the surgeons to slice open their neck and put in a tracheostomy doesn't mean they're going to be awake and talking again, and that large mass that is growing in the upper lobe of their left lung isn't going to go away and it keeps getting bigger and bigger and one day it will keep them from breathing properly and that day could be very soon but in the meantime we really need to open a bed in the ICU so we may be sending them out tomorrow.

it's hard not to assume such a horrible, cynical view of the inevitably dying patient while you're working in the ICU. i spent 90 minutes this morning compressing the right femoral vein of a 55 year old diabetic cocaine user, because the doctors previously treating her had suspected she had a bloodclot in her lung and gave her blood thinners and then decided to try to put in a femoral central line and missed and she bled and bled and bled and bled and her hematocrit slowly went from above 30 to about 15 in the span of 3 hours (she didn't have a blood clot). around the same time this happened, a 47 year old guy who came in with a stroke started having a seizure while he was on dialysis and afterwards became very agitated and aggressive and nearly pulled out his dialysis catheter (which is a huge, huge IV that would very likely spell disaster if forcibly removed). and one of our patients died today, an IV drug user with a crapped out cirrhotic liver who had never even had anything approaching a viable mental status throughout his entire stay in the ICU, who had no family we could contact and only had a common-law wife who did not own a telephone and only appeared twice and we were sending her telegrams (seriously) with daily updates of his deteriorating condition as each of his organ systems went from barely functional to completely failed, one-by-one, and to whom we sent another telegram this afternoon informing her that he had passed.

honestly i don't know what my point is, i'm just saying that today was hectic and crazy and scary and i feel completely worn out and exhausted and tired but more so mentally than physically. my head hurts.

anyway, i've eaten my tuna sandwich dinner and i'm tired and dirty and would like a nice shower and pass out in bed while reading one of the three books or two magazines i'm slowly plodding my way through.

and so and on and on and on and on, and so it goes.

this educational lesson brought to you by dr. j around 7:58 PM |

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 |