intern year: the beginning

Lets see, after two weeks of orientation, being bombarded with parking passes, computer training's and information that doesn't even make sense to you yet, starting to see pts was a great relief.  Every night was a social extravaganza meeting everyone, getting to know everyone etc.

Starting on Psych was a great intro.  As a third year I started on psych and its just a nice easy transition back into the swing of things.  My first call wasn't even that bad.  I had an excellent third year holding my hand and pretty much pulling half the weight.  The first week and a half was just handp discharge h and p and discharge, virtually all the same day.  In my first few days I met a schizoaffective guy with cellulitis of the hand, Anti social personality disorder traumatic brain injury pt, bipolar manic impulse control guy, druggie who fell asleep naked on the toilet, depressed drug addict, really depressed druggie, borderline chronic painer, psychotic ptsd and it goes on.
  My second day of work my TBI and Manic pt got in a huge physical fight.  There was only one male staff who held down the TBIer and the manic just kept on provoking him, as the TBIer just lunged all over the place.  Finally the TBIer grabbed a cleaning spray bottle and threw it across the length of the hallway, narrowly missing all the interns who cowering behind the gate separating pts from staff.  TBIer and manic each grabbed a mop handle and were trying to beat each other down with it. Meanwhile the nurses are yelling for meds, and continuously paging security, and I am quivering in the corner of the hallway not knowing what to do.  I blinked and my med student ran to the manic's back side and in an aggressive football move swiped the mop handle from the manic pt.  My chief yelled at me to order Haldol 5mg IM, Ativan 5mg IM, Benadryl IM STAT.  It was crazy.  Really.
  Both pts were discharged without a blink of an eye. SO Lesson learned, make sure if you have violent and agitated pts make sure to have strong prns on board before hand.  Must protect you staff and the other patients.
  Everyday I was finishing around noon with all of my work.  And just as I was getting cocky I have been leveled down.  Which is good.  My borderline pt is quite a handful and I am learning to limit set and grow a thicker skin.  She is equivalent to two pts so with an admission of a pt with acute psychosis and disorganization it took forever to get all the work done.  Its good.  I am forced to think and make quick decisions.  Next comes Family Med Wards.

more dermy derm

Lets see today at peds clinic say 1)little cutie with eczema  2) and 3) two teen guys with honestly, not that bad of acne  4) girl with seb derm aka dandruff and keratosis pilaris, which are these hereditary little bumps on your skin, i guess plugged up hair follicles, totally benign.  Hopefully won't forget that.  And that was it. Tomorrow more VA outpt.  lots of toe fungus and athletes foot.  Just two more days and I'm done.

being told what to do

If anything medical school has prepared me to follow set guidelines, think in  a certain line of thought, check labs and facts, double check labs and facts, ask questions, and most importantly do as I am told.  I see patients all day long take their histories, examine their bodies, document the information and present it to a senior either a resident or attending.  Most commonly said senior will say mmhmm ok lets do xyz, give them this, and see them back in x months.  Occasionally they may ask well what do you think they have? and even then I may guess correctly but still they will proceed to say give them this and do that etc.  In theory I am supposed to internalize and process this information about treatment for said condition - but usually happens is that i write it down, document it in the chart, explain it to the patient. and poof its gone outta my head.  So i n SUm what I learned from a day of seeing patients is how to  follow directions.  I fear for myself as I enter intern year as I am expected to not only do the bidding of all senior residents and attendings but make decisions on my own about treatment for my patients.  Granted there will still be some presentations and modification and for the sake of my patients and myself I hope that it is not more of the same sort of "do what I tell you" learning.

perspective

Being on dermatology i've been dealing with lot of little rashes, itchiness of an  unknown cause, anxiety provoking moles, spots, dots, and the like.  And for some of the more chronic things like eczema and psoriasis, I feel like patients are never satisfied.  Some have only the mildest form and yet they always ask - can i get rid of this? do i have to use these meds forever?  is there anything else you can do?  and By this point they've got big gun steroids and creams being thrown at them.  And they're skin is truly not that bad.  Now I realize if it was my skin I may feel like them, I realize that.  But also I wish some of these patients could see the more moderate or severe cases and see that theirs isn't that bad.  Right?  There are people with worse problems if that makes anyone feel any better.
  On a brighter note it is exciting that as a family med practitioner  I can easily treat the things the derm docs do.
  Today I watched Mohs surgery.  Its quite a detailed procedure for a very small area of of the face.  All to protect from a benign cancer - basal cell and a more malignant but not usually a cause of death squamous cell carcinoma, from causing a cosmetic scar to the face.  I appreciated the time and care the docs put into making sure the patients eye lid wasn't puckered after the suturing but wow it took so long.  I guess in the end the pt will have a very minimal scar on her cheek, but she certainly had to be very patient to attain it.

senioritis?

Maybe cuz we are nearing the end of "medical school" the formal education = these last three weeks are just dragging. i have no desire to see patients, write notes, ask questions, scut around for residents etc. I am weary as I know I will begin seeing pts yet again in June - am I ready?

*image from http://blog.timesunion.com/breakfastclub/senioritis-already-but-its-only-december/1244/

some guate musings

Sometime in between:
I worked with a general physician who practices both psych and essentially family med (minus ob and gyn) . He had a unique perspective on his patients and esp psychosomatic presentations. A young man came in brought in by his mom and aunt after he received the news that his brother was killed. The kid was catatonic. Dr. Llamas checked him out, then took two plastic chairs to a small corner of the hospital, his "office," and as he says, "le di un sacudo" (i gave him agood shake) essentially a mini therapy session. the kid came out a whole new person. it was amazing.

later a woman who was their for gallstones and I suppose you could say intractable pain was just laying in the ER, moaning and groaning - obv. pain. Dr. Llamas went to her and of course she asked for something for her pain, yet again. And he said,(in spanish)"I could give you all the pain medicine in the world, and i have already given you a lot. But you know this will only work if you have a positive attitude and believe it will work." after that we didn't hear a peep from her and she went home. who knows.

more guatemala emails

Feb 7 2010:
MOst recently on Saturday we went to the Volcan pacaya. we all went with another family friend and his famly, short of julio roberto who had to go to work. we went in the back of the pick up and the weather changed so much in that short distance. it got more fresh. i took some video leaving town and on the volcano. we rode up on horses and walked the rest of the way with our young uide, of 15, elder. we maneuvered over hardened molten lava until we reached the top. where others were roasting marshmallows from the fresh lava. it was crazy being so close to it, as if any second we may be in the way of upcoming lava. we put a quarter in the hot lava and took it home as a recuerdo. it rained on the way bck but fortunatly we were not too wet. ana was cold! and it was not even cold at all i assure you. she´s just so used to warm wather. we take it with a grain of salt when they say it is going to be ´cold. haha. today we grilled some lomito marinatd in garlic and salt, ate some corn, and made some salsa with roasted tomatos, cilantro and onion. i made some salsa with the chiles chaltepos )piquines) and cilantro. i had shannon finish it off by putting lemon ' but she put way to much, and then the famly blammed me for putting too much lemon! who knew that girl needed so much supervision. i was mad that she didn´t speak up and say sorry my fault. brat. today we are just resting and tomorrow we start pediatrics

Feb 16 2010:
hey guys, chugging along over here. thigns are better. i am working er and they are atually letting me see patients by myself, super scary esp since i do´nt konw the names of meds here and stuff. today my patient this little old woman with light eyes siaid eres extranjera i said yes and she said ah por su accneto y por que estas muy amable it being nice is strange this world is twised. but its very hot and sweaty in the place., the docs are really nie. i helped to manually ventialte a woman today as well. she was very sick. what lelse oh i can now use a glucometer, do blood gases from the radial artery its good. timne is flying. and there is not enough time for everything. yesterday we made pizza for the fmaily. a bag of cheese was 14 dollars crazy

Feb 20 2010:
family came over and one of the wifes, here name is lady, took us out for a spin on her moto. she showed us all her favorite discotecs. she is this tiny little woman too. and then we took a series of pics on her scooter. everyone said how coool that papi had a vespa. it was a hard last day in the ER. three real emergencies. one of which died in front of everyone, she had an incarcerated hernia of her intestine that caused her to vomit blood and feces. it was petrifiying and absoluely gross they offered me the chnce to practice intubating on her afterwards, now that she was deceased, but i declined. and then our two favoirte little babies in the peds intensive care also died. i took a pic with the >Er team on my last day. they said my despedida was all the action in the ER today. ha.

guatemala emails

Feb 2 2010:
so far i have tried two new food. unos chuchitos which is tiny but masa filled tamale with a lump of pork very delicious and atol not atole which is like atole but made with rice and tastes like rice milk and its warm interesting. it so hot and humid i don´t know why they like to eat such warm foods. we never eat vegetables here etiehr. iam going to get fat. and tortillas, not skiinyy ones, but fat ones that the native women make in their puestos. that go with every meal even pasta. and ofcourse tons of black beans. the family is impressed by my ability to eat chile. they hvae chile piqines that i have been devouring with each meal. thaknfully sinec the food is not very spicy


Feb 3 2010:
i got to deliver a baby today, and we watched three c sections. two were due to emergencies, one of th ebabies was being born with one foot out, another the cord was coming out before the baby which is a major emergency. today we ate chicken homado? it tasted like ham. i am very unimpressed by the food. i miss leafy greens. also we ate some papaya and sandia,

derm

don't even need my stethoscope. lots of punch biopsies and excisions. very quick and dirty. just gotta learn the common stuff and ur good.

patients you want to strangle

i worked my first full 12 hour shift, I must say better than being on call but still a very long time. My first patient was a woman who spoke zero English and for whom I had to struggle to get anything out of a translator. Atleast she smiled and was cooperative. My second patient - was a homeless man who apparently came in for chronic back pain. When i went in he was sleeping (even though he had just arrived.) I tapped his arm and attemped to rouse hiim. He briefly fluttered his eyes at me and then quickly closed them again. It was like pulling teeth, begging, pleading please Mr you need to answer my questions, we cant help you unless we know whats going on, you need to wake up, you need to answer this, if you answer my questions i'll leave you alone and you can sleep, i know you are sleepy but i need to get t his information from you in order to help make you feel better. He would whisper his answers, and i would repeat myself to speak louder. Then he would grouchily shout his answer, annoyed that I had asked so many times. I felt my tone getting angrier and angrier. Finally I just skipped to the physical exam. Possibly still frustrated from trying to take his history I about gagged when i had to lean over him and listen to his heart, as i could smell his scent, his odor, his energy. There is nothing i hate more than hot breath breathing down on me. I hated this poor patient, who was feverish, likely intoxicated, and as it turns out positive for cocaine and benzos. My resident finally took over and maybe because he is a man was able to get the patient to cooperate - atleast more than he was with me. this patient made me feel like not helping him and we are not supposed to feel that way about any patient.

on being a guide

I stepped into the Peds ER, was asked to bandage an ankle. And before I knew the two quiet latinas sitting at their sons bedside were asking me all the questions in the world. does he need follow-up, what is this medicine the doctor prescribed, can he get a note for school to use the elevator, is he going to be ok and some. Move to the next bed to find a mom with a chronically ill son who is monolingual spanish and is dealing with complicated seizure medications, who calls me over to ask what fluticasone is. they prescribed it to her son and she uses it, but she didn't know what it was for. Flash to walking to lunch out on the quad, atleast two people ask me for directions, everyday, anytime. My classmate turns to me and says, wow people always ask you for stuff? how do they know you can help? Guess its these pretty brown eyes, tanned skin, unkept curly hair and approachable face.

procedures

It was a better night, I got to write up one of the new admits - vaginal bleeding. Not too complicated. I don't know where all the time went becuase reall did nothing else but sit and wait for her labs and US to come back. During that time my resident told me I could get a chance to do a Lumbar puncture on a woman with a suspected subarachnoid hemorrahage. He asked if I'd like to watch or just do it. Attempting to break free of the timid shroud that overcomes me, I said yes i'd like to try.
two hours later I was gowned up, wearing sterile gloves and a huge mask shield. My resident positioned the patient, betadined it all. I layed out the sterile field and then he gave me the needle to anesthesize the area. I injected all of the lidocaine. Then I got the lp syringe and slowly guided it through checking for csf after about 3cm. I repeated this over and over, removing the needle then reentering. At times my resident was engaged inanother conversation not even looking at what I was doing. I thought I hit bone and my resident checked it, and indeed it was not bone, I had got it. He handed me the manometer and we measured the pressure. At this point i started to feel nauseous and light headed. I struggled to hold the manometer straight as I felt I was going to keel over. Got throught it and he handed me the vile to collect the csf fluid, drop by drop. At this point I could no longer take it, I told him I felt sick and he said go ahead and step back get some fresh air. Which I did. I felt my body gettign extremely hot and then cold sweat. I stepped out, pulled off the gown and went to splash water on my face in the bathroom. I wasn't scared, I wasn't grossed out, I wasn't nervous - I don't know what came over me at that moment. I stepped back into the room and even the patients daughter asked me if I was ok. I did it. The resident said good job. hopefully the next time will be easier

night shift#2

either I'm lazy or I keep getting residents who think I'm lazy, or residents who are lazy and don't want to deal with having a medstudent. in either case I finally got my own patient to talk to - but my resident decided it better he write everything down - as if i can't write or i might write the wrong thing. ugh. While talking to my patient the nurse informed me of all the other traumas going on - my resident didn't even tell me. one motor vehicle accident vs pedestrian, one bar fight, and one 15 ft fall after removing xmas lights. I felt so awkward as everyone seems to have a purpose and you are just there. and in everyone else's defense its not like they have time to tell you what your role is. later i asked my resident and he just said, he's some scissors you can cut their clothes off. ok. oh and bring warm blankets. so thats what i did. cut shirts off if the patient had a c-spine collar. That and paced around the 12 room circle, looking around, peeking into rooms behind curtains. Checking on my patient, making sure she was comfortable, makign sure someone was doing something for her. All she wanted to do was eat her food. But we had to wait for labs, Cxr etc and determine what might be causing her problem before we let her eat in case we were going to do "something." what i have no idea. finally after 4 hours in being in the ER we let her eat. And finally after being in the ER for 4 hours my resident went in to listen to her lungs. and even then she never got his full attention. neither did I. i hope to get more procedures next time. atleast a foley for petes sake. its almost a disadvantage being a fourth year becuase everyone thinks you just want to skip out and go home. and no! i just want to learn something, have some responsibility, before I become an intern and have no idea at all.

Night shift #1

Well truly not as bad as I had thought. I only worked 4 hrs. And it was busy - but slow for me. I just stood around and ended up talking to the three patients my resident was caring for. There was one nurse assigned to those three - who was just almost frantic all the time, and had his preceptor nurse looking over him, correcting him, grilling him. My resident is a tall skinny latino guy with glasses. He was so busy and yet i have no idea what was so time consuming. i swear to you he was pacing around, making phone calls, writing stuff down on the papers, ordering the nurses around, breathing coffee breath down on me, and he kept on tell the patient, "sorry sir, i'm going to get to you soon." Craziest part is, there is a waiting list of 100 or more waiting to be seen. Some have been waiting for 12 hours for their turn to come in to one of the rooms and be seen. Depending on acuity they will be seen sooner or later. The guy that got in was an older man in his sixties with a rare condition acquired after a sting from a yellow-fish in the Alaskan waters where he worked as a fisherman. The venom caused him to get Endocarditis - this is extremely rare, and the last documentation of such an occurrence from this fish was in 1958. As a result this poor man has received three consecutive aortic valve replacements. The first was from a cow and somehow fell out, causing him to go into immedicate congestive heart failure. The second was porcine and somehow became ineffective over time and was replaced with a mosaic porcine valve. today this man was presenting with acute stabbing, squeezing pain at the precordium, radiating to his jaw and left shoulder and occurred during exertion, with diaphoresis, nausea. The pain was 8/10 and lasted for an hour until the paramedics arrived and gave him some aspirin. In the ED he was given nitro, serial EKGs, and troponins. The EKGs were negative for ST elevations (meaning no ST Elevation MI) but the Tn returned as .14. Nitro drip was started and teh cards team consulted - calling it Non ST elevation MI. The poor guy was homeless on his way to see his daughter here in LA. We took his boots off to look at his feet and feel his pulses - and boy did those feet stink! the room just reeked. pobrecito.
The other patient we had was not too interesting, latino guy with 9 days of watery diarrhea and three days of RLQ pain, here to rule out appendicitis. What was the most interesting was his phone conversation to his mom that I overheard. He called his mom and said, "Ama pues aqui estoy. todavia no me atiendan. Pero me toco un doctor chicano y una chicanita." Pretty awesome. Doesn't happen very often. He told me he thought the white doctors treated him worse, he said he felt like they didn't care, they would send him home with pain killers y ya. they never tried to figure out what was really wrong with him.
ANyways, most of my night was spent chopping it up with these two guys. About life, diarrhea, and fishing in Alaska.