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.

reflections on thanksgivings past

I will never forget my Thanksgiving on trauma as a 3rd year. I was on call for thanksgiving day. I was really mad too cuz I wanted to be with my family. Lucky for me though, my family came to LA and we had thanksgiving the day after. Anyways the day of thanksgiving there were a lot of car accidents. There was the elderly asian couple that crashed into a young latino guy. Forunatly everyone was ok. Just a long night in the ER. Another couple was riding home on their motorcycle. The guy ended up very badly injured, with the c collar and his girlfriend a little scratched looking on him. Her parents arrived very concerned. But by far the worst of the accidents. A 50 year old African-American man who was changing the tire on his van on the side of the freeway. He was changing the rear tire on the side with the railings when another car side swiped his van leaving his legs trapped between the railing and his van resulting in mangling of both of his legs. When he arrived to the ER he was conscous and completely unaware of the state of his legs. Everyone assumed their places around the beg checking airway, breathing circulation. THey FAST scanned his abdomen. Stripped off his clothes. And tried to get his name. All this as blood oozed of the table and his legs lay in a dissarray - sideways straight curved twisted, mangled like strips of ground beef and bone. "Can you feel your legs, sir?" He said that he could. Well quite obviously there is no way he could feel it. They quickly morphined him up and knocked him out. Vascular and ortho were called to determine if there was any intact circulation. In these situations they use the MES score (Mangled Extremity Score), who knew? I just kept thinking why do these people keep calling his legs a mess? Thats so mean. Unfortunatly for this man there was no intact circulation and both of his legs had to be amputated above the knee. I didn't see him the day after but I can't imagine how he felt when he woke up and realized he no longer had legs. So this Thanksgiving I am thankful for my legs and good health. You never know when they'll be taken away from you.

Goethe

A wise attending quoted Goethe today, he said, "we can only see what we know how to see." or something along those lines. Essentially what I learned is that don't take every opinion. Question always. Don't accept. We had a patient for which we were considering CABG vs Stent placement for a very bad heart. The CT surgeons, interventional radiologist, and whichever cardiologist was the attending of the moment agreed that CABG was not an option. My attending said - well how do you know they were right? are u sure? this could dramatically change the number of years this man has to live. Certainly as a medstudent my opinion doesn't ever matter much, and i personally really had no idea, but I never stopped to question the opinion of these experts. Maybe the experts were right - but what if they weren't. The worst part is that we as a team never stopped to consider that maybe they were wrong. I guess its true what they say in medicine - you can never trust anyone but yourself. this is why you double check labs, findings, make sure you wrote your orders correctly, review and review to make sure you dont' miss something and if someone tells you something you go back and check it again for your self. And it goes the same for any expert opinion you ask for. always do your own research. always push for more answers, i mean it could be your only family members life on the line.

fear

i was thinking today after hearing this woman, who is an intern in family med after completing three years of a general surgery residency - that fear at this point has stopped me from being great. She said, "if you hide in the call room, no one is going to come looking for you, you have to get out there." And i realized that I have been hiding in a metaphorical call room. Cowering away from questions, procedures, opportunity. why? because I am afraid of not knowing the answer, fumbling, looking dumb in front of my peers. Because its really not a fun feeling - looking dumb in front of your colleagues, your residents, your attending. Maybe one of our practice cases or standarized patient experiences should be practicing not knowing, fumbling around, looking dumb in front of everyone. i have escaped most humiliation but maybe its not a good thing.

angry surgeons

Most people either love or hate surgery. These people are so busy that they don'' have time to have lives outside of the hospital. My first day of peds surgery I was told to show up at this vague computer and find the "list " of patients. The team consisted of myself, R3 and the surgeon, who we only saw on the day of surgery. Once I found the list i was to update it with vitals, labs, and new info for each patient. I couldn't find the computer. I tried calling the previous med student to find out but she was not answering. I asked the nursed and they had no idea what I was talking about. I found a computer with a paper list next to it from earlier in the week with the names of patients. So I went ahead and used that one. A half and hour passed and my resident still wasn't there. So i just kept reading my review book. I didn't' want to page him as I know a lot of times the residents show up late. Finally he came in red faced and angry. "What have you been doing this whole time? I've been calling you." "Reading, I updated the old list. I couldn't find the computer." "SO you've just been sitting here? Why didn't' you ask, see all these nurses here, you have to ask? Keep looking around? I already filled out the list for today. " That was our first encounter. Then i had to follow him around and help him with each patients note. I felt like crying. I felt like melting away. I tried not to make peep so as not to make him more mad. I felt so incompetent. Felt so small. I looked for every way that I could help to make up for the time i had wasted him. All day i was on my toes. Replaying the moment in my mind. I even stayed extra late that day to do an H and P on a patient to help him out. He didn't yell at me again but he certainly wasn't very nice. The next day he semi apologized for yelling at me, and in good med student form i said, "oh i guess i deserved it. I should have been more proactive." Even though in my mind I thought you bastard! It was my first day how was i supposed to know, huh? and I'm a med student not ur intern, interns do all the stuff you are asking gme to do. But that's how it is, you put ur best face forward and just suck it up, especially on surgery.

here's looking at you kid

I'm not sure if every young doctor experiences this sort of thing, but I certainly do, mainly because I'm petite and have young face i guess. I recently interviewed a patient who is 71 years old, lives in a motor home, alone, and eats once a day at the salvation army. He suffered a stroke about three years ago and since then has weakness on his left side as well as short term memory loss. He said he was luck that he was even at the appointment since he usually can't remember. This man was clearly frustrated at the world, at his situation, at life. He was pissed at his brothers for not supporting him even though he had for them. And I think he even had pissed himself, in reality. Maybe there is no shower in his mobile home. maybe he couldn't remember to change his clothes? regardless he was a grumpy old man to say the least. I tried to do a SIGECAPS assesment for depression. I got to suicadility and he said, "Listen carefully before you start writing any of this down. I want to die. I'm dying means I will be in heaven and not here then I want to die. I still take my pills, excercise, watch my weight and do as I am told, but I want to die." I comisserated with his sentiment and told him I didn't blame him for being pissed off and grumpy, not in those words of course. I asked him what we could do for him, physical therapy? counseling? start an antidepressant? All of which he turned down, and said, "Thanks for trying, sweetie." and Pinched my cheek the way my uncle would. He pinched my fatty little cheeks. He went into my space. I wasn't mad but I did feel belittled. For a second I thought i was sitting with my grandpa and not as a doctor sitting with her patient. I know he didn't mean anything by it but it was a strange feeling. As physicians we frequently push our hands into the space of others but remain untouched ourselves, with an imaginary shield that protects our space. When my shield was broken I felt strange.