Dashing to the codes, with a one-button white coat, down the stairs we go, hoping someone else gets there first! Ho ho ho!

I'm working in the ICU/CCU at the VA hospital through next Sunday. If you're not familiar with any of the VA hospitals, they are hospitals for military veterans. The VA's motto can best be described as: "Military veterans, thank you for serving our country, please let us serve your health care needs," and also, "It's only a matter of time before your COPD/alcoholic liver cirrhosis is diagnosed."

Why do I love the VA system so much? Most of the veterans I like well enough, but the electronic medical record is truly one giant, steaming, patriotic turd. It is a system whose organization is bizarre, the program for notes and labs is completely unconnected to the program for collecting vitals (WTF?), and trying to navigate it wastes a LOT of time.

Also... for some reason there seems to be a very low threshold for calling codes. I ran to two "codes" today- one ended up being for a man who NEARLY fainted after he got up from a blood draw at the outpatient lab downstairs (ie, was not coding), and the second code was for someone who was sitting in bed, breathing fine with a steady pulse, but was just very shaky because his calcium was low. Who the hell is calling these codes?!? "Code blue!"....you keep using that word; I do not think it means what you think it means. (Princess Bride reference!) Maybe I should start calling codes whenever I feel like it. "Code blue, I can't get the printer to work!" "Code blue, the chicken in the cafeteria is overcooked!" "Code blue, I just dropped my pager and it fell down 2 flights of stairs while running to a fake code!!!"

Today the highlight of my day was eating steamed zucchinis for lunch, heavily seasoned with Mrs. Dash. The sole purpose of my life may be to help other people feel better about their lives in comparison. Does my life suck right now? In the sage words of the magic 8 ball, "all signs point to yes."

Last CCU Call: The Last Straw

Dear night time nursing team: thank you for making my last CCU call one of my bitterest. Special thanks go out to...

... the 4am page by the CCU RN who was "just thinking about planning ahead" which nurse was going to babysit which patient in the morning, and wondering if there were any plans for transferring a patient that I was just cross-covering on out of the unit? "Not at 4am." Dude, unlike you who is paid a six figure salary to babysit and blame all your unpleasant or alarming discoveries on me ("Egad! Blood pressure of 65/42 after I gave the metoprolol outside of holding parameters! Quickly document 'MD Intern for Life notified. No new orders given.' Then page the intern and hand off the baton of liability ASAP! Whew that was a close one.") within an 8-12hr shift, I am working 30 hour shifts in 80 hour weeks, with no special protected "lunch" or "break" times. So please THINK before you page with inanities at 4am!!!


...4:30 am page from floor nurse on another patient I was cross-covering: "I noticed that this patient's sputum culture was contaminated from the other day. Do you want to get an induced sputum sample by RT?" "NOT AT 4:30 IN THE MORNING. It's a good idea for a normal time in the day though, please tell the day shift nurse so they can coordinate with the primary team."

Thus the whole night went with pages approximately every 20-30 minutes. Yay cross-covering, yay.

Goldilocks and the Three Interns

When you're "on call" in the hospital, there is a room (or a set of rooms) that are designated for the on call house staff to sleep (if by some miracle you actually get a chance to sleep). These call rooms are gross because (a) most surfaces in the hospital are gross, (b) the arrangements are shared rotating between whoever else is on call (or finds your call room first), (c) they are cleaned, theoretically, sometime during the day, when no one is around to witness this event.

Tonight, by some miracle, two other interns and I found ourselves done with most of our work and ready to retreat to our call rooms by midnight! We were almost happy, but then we remembered-

"My call room is so cold..." - Intern A

"Yeah, my call room is really cold too!" - Intern B

"My call room is freezing! AND somebody already slept in it!!!" - Intern C

Groin Check Mega Fail

Of note: this is a delayed entry.

On my second to last CCU call, as per usual, the post-call team had a lot of things they needed followed up on for their new patients, including several groin checks for patients who were going to get cath'd. As you well know, I lump all my groin checks into either 10pm or midnight rounds. One little problem; one of the patients they signed out for me to groin check, WASN'T ACTUALLY SCHEDULED TO GET A CATH. So when I did my evening rounds to do all the groin checks, I go check on this elderly lady, and guess WHAT - nothing on the right side of her groin; that's odd. NOTHING ON THE LEFT SIDE EITHER. WTF?!? Does she have some kind of magical groin? Where is she hiding her cath site??? The weirdest part, in retrospect, is that she didn't seem phased by any of this; like it was normal that I was asking to inspect her groin for "the cath site", although she must have known that she didn't have a groin-based procedure that day....wtf?!? While I confusedly look from one groin side to the other, she asks, "Here, is this what you're looking for?" and shows me the PICC line in her arm. Uh... no. But it's very nice. Once again, thanks for the shitty sign-out, post-call team!

Have you ever been in that position, where the post call team just takes a shit on you? They go, oh hey, we're post call- can we take a dump on you? Because we haven't slept in 30 hours and we don't care about ANYTHING anymore. Here's a list of a bunch of things we forgot to do, didn't have time for, many things for you to follow up on, and some problems that we gave up on trying to solve. Best of luck...

Groin Check Fail

Part of being on call in the CCU, in addition to admitting new patients and accepting transfers from outside hospitals, is cross-covering the other patients in the CCU. This involves a lot of checking fluid status at midnight, as well as the dreaded.... midnight.... groin check! (If someone gets a cardiac cath, they usually get access through vessels in the groin, and later on we have to do a groin check and make sure a huge bruise [or worse] isn't developing.)

As if it's not creepy enough that I'm coming into somone's room for the sole purpose of checking their groin, somehow they all seem to be due for groin checks around midnight. So I'm creepily coming into their room late at night, waking them up, to check their groin. Not. weird. at. all.

So I go to check this one lady's groin- and I have to get back to writing an H&P and watching a crazy hypotensive lady- and she starts yammering away about some nonsense that no one cares about. I try to slowly leave the room while she's talking and pawn the conversation off on the nurse. Then I sneak back to the nurses station to write my crappy midnight H&P on another patient and I hear this:

Nonsense McGee: "She looked REALLY tired!"
Nurse: "What?"
Nonsense McGee: "She looked REALLY tired! She just looked a MESS!"
Nurse: "Ohhh, don't say that."
Nonsense McGee: "She did!"

Yeah, and she HEARD YOU, you turd bomb! I was like all of 10 feet away!

Just see if I'll ever check YOUR groin again. I'm done with you.

Done, I say.

Please

I'm on call in the CCU tomorrow from 7am (Friday) until 7am (Saturday), and I most likely won't be able to leave the hospital before a good 30hours of work.

So? How is this call different from all other CCU calls?

Because it will be the day after Thanksgiving. Tons of people will be having CHF exacerbations and heart attacks because they ate too much food/drink at Thanksgiving or overdid it playing football in the yard or whatever else they did today that they knew they shouldn't have but went ahead and did it anyway. So this is my plea-

please, please, please, people with CHF/people who are on the verge of a heart attack- could you PLEASE just eat a reasonable amount, adhere to your low-salt diet, not tackle your friends and family members while playing football like you're a teenager, and otherwise act in a sensible manner so that we don't meet each other tomorrow when I'm on call?

In advance, I'd just like to say DAMMIT, and I TOLD YOU SO to everyone who falls into the above category.

Do you LIKE working here?

I've never had a poker face. When I'm less than enthused to be working on a certain service, I can't hide it. I'm not actively saying, "Man, this is SHIT!" but you can pretty much read it in my face.

The other day, while I was looking up some old EKGs from many years ago to compare to a newly admitted patient's EKG to see if and how the current abnormal one was different from the previously abnormal ones (fffffUCK), the attending comes and sits down next to me, scrunches up his face with a look of expectant doubt and asks, "So.... do you LIKE Cardiology?"

This is tantamount to being a work, and your boss comes up to you, looks at you doubtfully, and asks, "So... do you LIKE working here? Because it sure doesn't seem like it." AWKWARD!!! What the FUCK do you think I'm GOING to say, man? "Yeah, I hate Cardiology, it blows. I know it's your field and all, but it SUCKS! BIIIG TIME! I feel bad for you. Feel free to quote me in my evaluation."

So yeah, I'm doing really well in the CCU. I'm the best intern ever. I always feel like I know what I'm doing, and I love what I'm doing. It's rewarding. The teaching is excellent and relevant to patient care, it's never so esoteric as to be completely not useful or narrowly focused on the areas of the fellow or attending's research. The patients are pleasant, all of them. I love all of the CCU nurses. They never page me on my day off, especially not with text pages since they know they are not supposed to send those. The call shifts are a reasonable 30+hrs straight working without sleeping, and I look forward to them. I hope I get assigned to extra CCU weeks next year! Since I have no control over my schedule, I'll just keep my little intern fingers crossed!

CCU

#$%%^&!!!!

What Happens in the ER, Stays in the ER (I hope)

Despite the misleading title, nothing too exciting happened in my two weeks in the ER. Sure people were bleeding and septic and suffocating and getting emergently intubated in the ER- but for the most part the dramatic ones weren't my patients. Am I just lucky? Mmmmmm, no. Internal medicine residents aren't allowed to pick up trauma patients since we don't have advanced trauma life support training (yessss), and the senior ER residents tend to jump on the unstable patients who come in because (a) I'm an intern, and (b) I'm an internal medicine intern. There are many delightful ER residents who I really like. But in general there is some disharmony between the internal medicine and emergency medicine departments. HOW can this BE?

Why do ER residents think internal medicine residents suck?
1) We discuss patients' chronic health issues
2) We care about "follow-up" and waste time counseling patients on smoking cessation and lifestyle modification
3) We are pretty useless when it comes to traumas. If it can't be solved by buddy taping, I can't fix it.
I'm sure there are more reasons. If you're an ER resident or you've been in the ER and have some insights here, please post them below.

Internal medicine people tend to be perfectionists who try to unravel the mystery of how and why a person is ill. This is anathema to Emergency Medicine. Rather than unraveling the ball of mystery, their goal is to tape up the major loose ends as quickly as possible and bounce that ball back out of the ED. Despite these differences, I did at times enjoy the ED. Mostly when sign-out was looming just around the 12-hour shift's corner, and there was the liberation of knowing I wouldn't be responsible for following up on... anything.

Here are some "highlights", lowlights, and other "adventures" in the ER:

- BACK PAIN. An endless supply of back pain. And angry patients experiencing said back pain who can hardly wait to yell at you for however long they had to wait in the waiting room (while people who were actively bleeding/going into respiratory failure/had exploding appendixes were triaged ahead of them), and demand that you immediately fetch them whatever pain medicine they want.

- Chest pain that is heartburn. Dude; if it feels like the heartburn you've had for the past 20 years, it begins right after eating some food that triggers your heartburn, and the only associated symptom is belching- it's probably still heartburn. Fucking A, but we order 3 sets of cardiac markers, EKG, CXR, and maybe CT chest to make sure there's no aortic aneurysm or dissection, because that's the ER way. "Did you say chest pain or epigastric abdominal pain? Just to be safe, we'll order lipase and LFT's too. I'm going to take this moment to write a note documenting how I ordered every possible test so that you can't possibly sue me for not being thorough enough down the road!"

- Old person who falls. Awwww, old person! Why you have to be so adorable? You look like a koala! Little fluffs of white hair... Why do you have to fall down? Okay, admit to medicine, workup for syncope. What's that? You claim you didn't lose consciousness and you just tripped while walking with your walker? Hush hush, sweet old person, there's a team on the academic IM service that can't wait to admit you in just a few hours.

- Stroke. Not to be confused with a simple old person who falls, this is the real deal. Unfortunately most people seem to come in about 12-48 hours after their stroke actually occurs, well outside the 3-4hr tpa window. Oopsies...

- Award for biggest waste of my time:
Patient with long history of IV drug use, violence, prison time, presenting with a chief complaint of: "I have Hep C, and it's not getting treated fast enough at the county clinic. I know you can do something here to get things moving faster!" Of note- he had already had LFT's done, been referred to a hepatologist (liver specialist), etc, from county clinic. As I'm wasting my time doing his physical exam, I notice a tattoo that he confirms is in fact a swastika. Did he get it while in prison to join a gang for protection? No, he got it as a teenager because he was a skinhead. I see. Next to the tattoo is the acronym "SWP." All I could think of that it could possibly stand for was Sarah Jessica Parker, but that can't be right because there is no "J"- he explains this stands for "supreme white power." Are you kidding me? He needs to have his chronic hepatitis C workup rushed and REPEATED at the university hospital because...? He's an extra special, supreme white racist?!!

- And the award for shittiest sign-out from another resident at shift change goes to....
Residents from different services, including Internal Medicine, Family Medicine, Ob-Gyn, and Physical Medicine & Rehab all have to spend 2-4 weeks per year in the ER. None of us like being in the ER. Imagine the sounds of prisoners being tortured in a dungeon with the ambiance of poo and vomit aromas, and occasional urine and/or blood on the floor. So it's no surprise we want to bolt out ASAP when our shifts end. This can lead to super crappy sign-out. The true winner of the award I can't post because I think it's a medicolegal issue, but I'll tell the tale in real life. The runner up: one of the ER interns signed out an elderly patient who had sustained a ground-level fall, landed on his side and not been able to get up for 10 hours because he had "generalized weakness." He said the patient was moving all extremities but favoring one side, probably because he had sustained fractures when he had fallen, and would most likely be admitted to the Trauma service once his CT scan results came back. After he left, the CT head came back with NO fractures but possible ischemia in the right hemisphere (a possible stroke), so of course we ordered the MRI brain. I repeated the neurologic exam... he was only looking to the right... he wasn't just "favoring" his right side- he COULDN'T MOVE his left side. He had left hemineglect (ignoring one half of the body, which can happen with a big stroke)! He was admitted to Neuro, not Trauma, for a STROKE. If I had just blown off everything the other intern told me and done my own exam from the get-go, I wouldn't have had to wait for the CT scan to figure this out. Sigh.

- one of the low points on my last night shift: having to do a rectal exam on a transgendered patient with Hepatitis C, whose chronic nonhealing skin ulcer was dripping serous drainage onto the floor while she was eating a loaf of bread and sprinkling the floor with bread crumbs as well. Side safety note- you NEVER do a rectal exam on a patient from prison because you never know if they are concealing a tool/weapon in their rectum.

This post ends just like a shift in the ED- abruptly!!
NEXT UP: adventures in the Cardiac ICU!

ERrrrr..... it's not so bad

Current block is 2 weeks of ER shifts. First shift went uneventfully. New ED is really nice. If it weren't for all the people moaning like they're in a dungeon and the wafting aroma of people pooing around every other corner, I sure could get used to this place.

Police Ride-Along

I went on a police ride-along the other night. It. Was. Awesome. !

I got assigned to a lady police officer (as most of you know, I am also a lady!), and she was Jewish (what are the odds! I am also a police officer! I mean, Jewish!), annnnd she was hilarious. We first responded to a supermarket shoplifting case which turned out to be a FELONY because the person had prescription pills they had bought off the street (obviously with no prescription). According to the supermarket security, a lot of drug users steal tin foil so they can use it to free base (if you don't know what this means, look it up on urban dictionary just like I had to). Oh alright, I'll help. Apparently certain pills, such as oxycontin, are abused by rolling them around on heated tin foil and inhaling the fumes.

Oh no- I just said how to use a drug illegally! Aren't I worried about the info reaching the kids? I would say no, because I'm sure you could get much better and more detailed instructions just from paying attention in D.A.R.E class. Do they even have those anymore?!?

Point being: drugs are bad. Especially prescription drugs that are bought off the street. Why? (A) Drug dealers DON'T CARE about their clients. How do you know this for sure? Because they are SELLING you things to HARM YOURSELF with. Okay. (B) You can't trust a drug dealer [please refer to (A)], so how do you know for sure they are selling you what you are paying for? There are tons of pills that look and taste about the same. I've actually seen a couple of times where people come to the ER after collapsing, and are found to have mysteriously low blood sugar even though they have no history of diabetes. When they are revived, the only recent ingestion they report is "street valium." WTF does that mean? There is a diabetes medication similar in size/color to valium. The HUGE DIFFERENCE is that if you abuse the diabetes medications, it will give you prolonged hypoglycemia (drop your blood sugar dangerously low), quite the opposite of a high (pun intended). Terrible joke. But seriously kids, don't do drugs.

Back to my story. So we arrest the shoplifter and take him to jail (and when I say "we" I mean the police officer did all of this and I was following her around silently thinking the whole time "No way! No waaaaay! I'm in a jail! A jail!!"). I felt bad for the shoplifter and for everyone else there. Jail is a scary place. The one we went to was like a big concrete cave full of all kinds of people you don't want to be locked in a concrete cave with.

Other adventures that night included trolling around midtown for a drug dealer's car, driving through a residential neighborhood searching for a "suspicious" looking man, helping relocate a mentally ill woman who was evicted and directing her to resources for housing and social services, and driving along the light rail tracks in pursuit of a suspect. Who was riding the light rail, while drinking stolen alcohol.

And he got away.

Anyways, I learned that police (1) have to be incredible multi-taskers, (2) are well versed in community resources, and (3) put up with a lot of crap.

(1) Can you carry on a text message conversation with two friends, look somebody up on facebook, google a number, and do your job on your touchscreen laptop, all simultaneously, while driving? This is essentially what the police on patrol do every day. They have computer screens and keyboards in the car, which they use to send messages to headquarters or other patrol cars, use a program for running license plates, a database for looking people up, and they are continually getting a stream of new "calls" in to respond to (such as burglaries, disturbance of the peace, collisions, etc). They also have radios they need to be paying attention to at all times, and staying mindful of where their colleagues are so that if one of them started yelling for help they know where to go immediately instead of wasting time trying to figure out where that person is. Did I mention that this is all done while driving?

(2) Patrol officers need to be able to know their neighborhoods well not just for navigation, but also for using community resources effectively. The officer that I rode along with had to help an evicted woman find a motel for the night, and because she also knew where the local shelters were, she was able to pick the least expensive motel that was also within walking distance of the nearest shelters. Being able to see how community assets interface (in this case, the police officer referring a mentally ill woman to proper housing, social and medical resources in the community) was really great.

(3) Police officers put up with a lot. In a space of maybe 3 hours, 3 or 4 cars honked loudly and noticeably at the officer I was riding along with. I get alarmed when someone honks their car horn anywhere near me when I'm on the road; can you imagine getting honked at like that on a regular basis? One of the times a person appeared to make a sharp turn JUST for the sake of pulling up behind us and laying on the horn- the officer was worried that the person behind us was trying to hail her, so we actually pulled over to the side (and she also pulled out her gun just in case), to see if the person was going to pull up beside us... and they drove away. WTF man, they just drove up behind us to honk!!! This happened a few other times as well. I asked why she didn't just pull the cars over for doing this, and I suggested that I would totally have pulled them over and then said, "You were honking at me. I thought you needed my help!!!" She said that people enjoy their civil liberties and don't like being pulled over for no reason, and that "besides, you'd be surprised how often people call in to complain." Complaints about an officer can prevent him or her from getting a promotion, etc.

Speaking of things that suck, the officer mentioned that whenever the police had to go into the ER to get a patient's statement (if they were involved in a car crash or some sort of crime), the ER nurses were pretty consistently rude and unhelpful. They thought they were treated this way because they are police officers. I assured her that most ER nurses are equal opportunity assholes in their approach most everybody else who attempts to interact with them while they are doing the most important work in the world. Many ER nurses are wonderful. But many of them are also turds who are unhelpful at best and often unpleasant to boot. Can you tell I'm excited about my upcoming (mandatory) ER weeks?

I have a new respect and appreciation for what police officers do on patrol. So, the next time you see one of our friends in blue... smile and give them a wave! (Honk if you love having your license plates run!)

Feel the Community

"Community Engagement" week continues. This, my program tells me, is a week where they are empowering me to become skilled in assessing and utilizing community resources. This in turn will make me a more effective physician in my community as I am able to refer patients to said resources. Under this guise, my program sent me to a women's shelter to serve breakfast and lunch for 3.5 hours. I'm all for volunteer work- but when it's actually VOLUNTEERED and not MANDATORY. Most of the time I stood behind a table doling out cereal, nachos (popular), fruit (not so popular- one obese woman asked me what was in the fruit bowl, I said, "Fruit," she said, "What?" and leaned in closer to look into the bowl. "Delicious fruit!" I elaborated, "There are apples, oranges, even some pears!" I smiled. She gave me a look that can best be described as "Eww. You're crazy," and with a disapproving look fixed at the fruit bowl, shook her head and walked on by to get some juice. A lot of obese women walked past the fruit bowel with a dismissive wave of their hands after picking up a donut or danish. That was real encouraging for the doctor working the fruit bowl.) Anyway. Highlights included cutting my hand working in the kitchen, and a squabble breaking out in the nacho line that was eventually broken up by a nun. I spent another 3.5 hours later that evening preparing bags of food for people at the county food bank, which was actually very interesting. I learned about all the other functions that the county food bank serves in my community (they offer adult education classes including parenting skills, English language, job skills, computer literacy, and more, all FREE with free childcare offered at the same time!).

I have to go now. Why? I have to get ready for a meeting with someone who is going to talk about community asset based something or other, and then I have a police ride-along. What does that mean? I don't know. So cheers to that, I'll update you later!

Starting my week of "community engagement". Activities for this week include volunteering to serve breakfast at a food pantry, going on a police ride-along, etc., to familiarize ourselves with community resources. One such resource: Harm Reduction Services (for ex: they run a needle exchange program). Directions for this activity: "corner of ____ and _____ streets. Look for a blue van and a woman named Michelle."

What's in YOUR pee?!?

You know how some fortune tellers are into reading tea leaves? The gross bit that's left at the bottom of a tea cup after you drink it? Well. Nephrologists (kidney doctors) are big-time believers in reading the pee leaves. What the hell does that mean? It means that they don't trust the lab's report from the urinalysis. They have to see it for themselves under the microscope.

Okay...

No! It's not okay!!! Because most of the patients we've been consulted on have been in rooms pretty far from the Nephrology lair. Which means that I have to steal some of their pee, then carry it with me back to our lab set-up, several floors away. That's a lot time spent walking around the hospital with a cup o' stranger pee.

"So hey. Did you just pee in that jug? Okay great...I'm going to take some of your pee now. Yes. This is me, stealing some of your pee, from your pee jug. Now I'm walking away with it. Because the pee analyzing room is 7 floors down, and two units over. So I'll be walking around the hospital with your pee in my hand for quite some time."

I don't know how to end this. This rotation, that is. I'm just kidding!!! It's great! I love it! If you see me in the hallway this week, though, I wouldn't shake my hand. Or investigate the yellow stains on my white coat too closely... (oh come ON man, it's tea!)

....colored urine?

NO, JUST TEA.

Peepee

I'm about to go pick up a urine sample so that I can spin down said sample and look at the urine sediment under a microscope. Ewww!! I have to handle a sick person's pee?!? Of COURSE I do- I'm a DOCTOR! I probably shouldn't have said "Eww!!!" to the Nephrology fellow. OH WELL.

Enchanted Kidneys

FIRST DAY OFF HEME/ONC SERVICE. AHHHhhhhh. RELIEF!!!

The pain of heme/onc was almost a distant memory... until I was paged. By medical records. Once again. To remind me that although I am off the service, although I had finished all my transfer summaries, I still had two DISCHARGE summaries left to go.
...from last week. I have never felt so happy about a d/c summary as I felt after finishing my last summaries for heme/onc. I formally wash my hands of this service!!!

Today I started Nephrology consults. So I am a nephrologist. For the next five days. Except for Friday afternoon, I'll be in my continuity clinic then. It's kind of like how the pumpkin in Cinderella magically turns into a carriage, but only until midnight, when it suddenly and rather alarmingly turns back into a pumpkin. So what I'm trying to say here is that if you have any nephrology questions, you should ask me, but only for the next 3.5 enchanted days!

"Man. I saw my reflection today and I thought, 'Oh my God, I look like shit!' And then I realized...I felt even worse than I looked!" - another anonymous medicine intern on heme/onc

"I am not okay with my patients calling me 'baby'!" - another intern on heme-onc

Use as Directed

One of my neutropenic leukemic patients had a cold sore; we gave him antiviral pills (since cold sores are caused by a herpes virus) as well as an antiviral ointment. When I placed the order in the electronic medical record, it prompted me for directions as to where the ointment should be applied, I typed "lesion on upper lip." Ok, makes sense.

When I went in to see the patient later, he said he had received the new ointment and that it was GREAT. While he was talking, I looked at the little tube, and thought it was strange that so much of the tube looked used up... he said it felt GREAT- on his lips, on his hands, all over his face- it was SO MOISTURIZING!

Apparently his nurse had told him to go ahead and use the new "lotion" all over his arms, his face, anywhere his skin felt dry. DUDE, it's TOPICAL ACYCLOVIR! And this was not a new nurse... anyway, she called me later, laughing about it, saying she didn't realize what it was or what it was for, and that she had encouraged him to apply it liberally all over the place, since "there wasn't any directions what to use it for, I just assumed it was another lotion." Uh- I couldn't place the order without specifying exactly where the topical ointment was supposed to be applied. If you don't read the directions, then yes, you won't know what the medication is used for. Plus- isn't it a red flag how tiny the tube of ointment was? Like maybe this has a specific purpose? Plus, she's been a cancer nurse for HOW long and the name "acyclovir" is still totally foreign?

Anyway, no harm no foul. He really liked the topical acyclovir, and since it's an ointment I'm sure it was indeed moisturizing.

3.5 months into intern yr. Today is the first day I officially regret this.

F Heme/Onc...FONC !!!

Ahhh.... I'm trying hard to find the humor in the AWFUL, AWFUL experience that is Heme/Onc. I'm violating the 10hr rule all the time (supposed to have a 10hr break between shifts at the hospital...allegedly). The nurses pager-bomb us about EVERYTHING ("Just wanted to let you know the patient's temperature is in the high 98 degree to low 99 degree range! It's not actually a fever yet, but it could BECOME one- I just wanted to make sure you were aware!"), so I can't get any of my notes done until late. And I know it's random because we alternate admissions between interns, but I keep getting all the most sick, least stable patients. In the last 2 weeks, I've had 3 transfers to the ICU, 2 near transfers, and 3 deaths on service. Came in today to hear that yet another one of my patients (aplastic anemia and hemorrhaging) got transferred to the MICU overnight. In retrospect, it probably was not an appropriate transfer for Outside Hospital to admit her directly to our Heme-Onc service from their ICU. Anyway.

I usually get to the hospital around 6:15am; I'm there until 8 or 9pm. 10pm sometimes. By the time I get home, eat dinner, bathe... it's 11pm or midnight. I go to sleep, and wake up at 5am to do it all over again. This in itself would be depressing enough; add to it that the entire day we're working nonstop, trying to juggle all our patients (the service has been at or near capped most of the past 2.5wks), who are all seriously ill cancer patients. Seriously ill = time intensive care. Cancer patients = every story is a sad story. There are no happy stories. The closest thing to a happy moment with a patient today: agreed with 27yr old new mother with leukemia that she looked "very punk rock" with her newly shaved head. She had given herself a buzz cut last night since her hair was falling out in disturbing chunks due to the chemo.

Or how about another of my patients, formerly healthy construction worker, now with acute leukemia, usually so cheerful and positive but today... just starting to feel the effect of his chemo. He asks daily about his prognosis (the heme/onc fellow's predictions aren't going to change, they're all based on genetics and his bone marrow biopsy...which we review every single day)- today after he asked his usual questions, he just stared off into space and looked so sad. He looked like he was facing his own mortality for the first time as a real and imminent possibility. Like he was watching his own soul wander away from his body and leave him there, helpless. Then his wife came over and caressed his forehead and told him not to worry, they were going to fight this one day at a time, and she smiled and winked at me, and then she thanked me for "everything" and gave her husband a prompting look, and he turned to smile weakly and thank me also, and wish me a good day. I felt so worthless as I walked away. Thank me for what? The PRN antacid I ordered? I'm not doing anything for you. The fellow wrote the orders for the chemo. I'm just watching your electrolytes and making sure your red blood cells and platelets don't get too low. And as shitty as you feel now, I know you're probably going to feel worse over the next week. And this couple is SO SO SWEET. It breaks my little intern heart.

So essentially this is an oppressive, depressing rotation that consumes all my time. This leaves no time left over for...DISCHARGE SUMMARIES. I got another deficiency notice (see prior post about S/C summaries) in my inbox informing me that I'm behind in my discharge summaries, as well as death summaries (a discharge summary for a patient who dies in hospital... a celestial discharge). I ignored the damn notice because I don't have time to do my laundry on a regular basis, let alone respond to stupid notices reminding me I have work to catch up on.

And then it happened.

CONTACT.

I got PAGED by someone from the medical records department. First thing she does is laugh and make fun of the message on my pager (where I say my name and identify what service I'm on); because I "sound sooo tired! Hahaha!" [strike ONE] She informs me that I am late on two particular discharge and death summaries. I say I know, I am very busy on the inpatient Heme-Onc service, but I will get to them. She tells me that I will do them, and do them TODAY. [strike TWO] I remind her again that I am very busy with sick cancer patients, but that I am aware and will write the summaries as soon as possible, I'll try to tonight after work. She tells me that not only will I write them both TODAY, she also tells me which one I should write FIRST. [strike THREE. Patience is out.] Pause. I ask WHY. She says because they are late. I KNOW. Why does she need them done today? She says.... because they are holding up billing. "Oh I SEE. Well I'll get to them eventually!" and hang up. I stayed (extra fucking) late and did one that night. The other, I still have to do tonight. Then I'll only be 5 or 6 behind.

I hate this service. Last week, after grabbing a hurried lunch in the hospital cafeteria, I told one of the other interns that I refused to go back to work. I curled up into a ball on the floor of the lobby just outside the cafeteria, held up a fist, and said the only way I was going back to work is if she dragged me. Annnd she did, all the way across the lobby over towards the elevators. Apparently the coefficient of friction for white coats is similar to steel bearings because the ride was actually quite fun and the highlight of my day. That's right, I said getting dragged across the floor of the lobby was the highlight of my day. Do you feel better about your life yet? You should!!!

Portacath Porn

A leukemia patient said her portacath seemed swollen. Since I'm not very familiar with ports, and nothing about the concept of having a big hose hooked up to your veins in a semi-permanent fashion seems normal to me, I asked her nurse to evaluate the port (::shrug::), and then consulted Interventional Radiology, who placed the port, to have a look at it.

During rounds with the new attending today, I explained that I had not seen that many portacaths in my day, and wasn't sure what the range of normal looked like in terms of swelling or if this was an early infection.

His response: "It's like pornography. You know it when you see it. You'll know an infected port if you see one."

BEEP BEEP BEEP BEEP "doctor did you want the lab you ordered for today to be done today?" "oh no, I wanted that lab to be done next year, and furthermore I never want to find out the result." OF COURSE I wanted the lab for today, that's why I ordered it for TODAYYYY.

Shittiest Day Ever

Warning: this post is not funny.

So here is a note that I started from last night, then fell asleep while I was writing it:

"i'll flesh this out tmrw when i get a chance

basically, shittiest day ever

first, arrived to get signout that one of my most stable patients had nearly coded, and was now dnr/dni on comfort measures (i later pronounced this patient dead). side note: this was the pt that said i was the only doctor he saw for 2 days. the attdg and fellow claimed to have seen him on a daily visit, per the attdg's addendums to my progress notes.

other pt nearly coding in the GI lab

other lady who is still full code but terminal"

So the first patient- the attending said he probably had a pulmonary embolism. It was sudden and unexpected, and there was really nothing anyone could have done. It was incredibly sad, I really liked the patient's family.

Anyway, the second one... got paged by a frantic nurse, telling me that a patient who should have been coming back from the GI lab was actually about to code in the GI lab, and that they needed someone from the primary team (aka ME) there. She was so flustered she couldn't even tell me what happened, and had to pass the phone off to someone else to tell me how to get to the GI lab from the heme-onc floor. When I got to the recovery room, the patient was indeed hypoxic and agitated (vomited and then aspirated post-procedure), and soon after required intubation. Transferred patient to the MICU...

..then back to the heme-onc floor where yet another elderly, frail, sick patient recovering from sepsis, with metastatic cancer was slowly becoming hypoxic and suffering while she dies. I spent maybe an hour and a half over the course of the afternoon in gatherings with the patient and her family talking about what "comfort care" means, and that it's not "giving up" on the patient but rather recognizing that she is nearing the end of her time, and helping her ease the transition and allow her to spend her time in comfort and dignity. They kept going back and forth, and ultimately (yet again at 9pm) I just had to leave the hospital and signed it out to the night float intern (who was understandably very pissed off).

Anyway when I got in today, I found out the patient had gotten a little worse overnight, they had been on the brink of taking her back to the ICU to intubate her when she decided on DNR/DNI status and comfort care.

Sigh.

Ok, no more surprises for the day... I got 2 new patients... I'm covering one of the other intern's patients too, a "stable" one that's just "hanging out" until skilled nursing facility placement... who suddenly also became hypoxic on her way to the commode to take a dump. A deadly deuce. A code on the commode. But seriously- she did become hypoxic, didn't respond to a breathing treatment, lasix, etc., and her chest xray showed (drumroll please) a....crazy pneumonia! Maybe. Some sort of nasty consolidation. Anyway, she was still tachypneic and getting tired on 100% supplemental oxygen, so once AGAIN had to call the MICU to accept a transfer.

The new Fellow covering for today called me a "black cloud." Meaning I'm bad luck and bring bad luck to the service. OR how about... heme onc is a SHITTY service? Period!

Today was another shitty day... I actually had no time to keep track of the Intern Tear Index. Default: 25+.

HONC HONC, BEEP BEEP!

I hate Heme-Onc with the fire of a thousand suns. For the second day in a row, I got to work at 6am and didn't get to leave til 8:30pm. Today this one fat lazy nurse kept paging me q15 minutes because the patient's husband wouldn't agree with her so she kept demanding that I talk to him, or would say he was asking to speak to the doctor (which I strongly suspect was not the case based on his surprise every time I kept coming over). Finally I refused to come over and told her if she was unable to speak w the pt's husband she could put him on the phone to speak w me. This nurse wasted so much of my time and the other intern's time. One of the issues she paged me for: to tell the other intern not to hang up on her. I heartily congratulated the other intern, I wish I had the balls!!!

Anyway, had my own patients today, plus covering patients for the intern who had the day off, plus admitting new patients, so overall SHITSTORM DELUXE.

Points of shittiness about the heme-onc service:

# The fellow is a ghost
The fellow is like a junior attending; doing his post-residency training in hematology-oncology fellowship. A lot of great learning could be happening...if the fellow was actually ever around to answer questions or help with patient care issues or ANYTHING. Although he's a very pleasant fellow in person, that helps me not at all when he's gone all day and his page-to-response ratio is 2 or 3:1.

# Drive-by attending
The attending is only in house for about 2 hrs a day from what I can tell. She runs around and sees most of the patients briefly, then we quickly run through the list in the fastest rounds in the west. Efficient rounds are great, but as interns we know not a lot about a lot, and we know jack shit about chemotherapy, so maybe we could take a few min to review w the hapless interns WTF is going on and why the chemo plans are what they are?

# You're on your own
Let's review: the attending is almost never there. The fellow disappears after rounds unless he has a new patient for one of us (and selectively responds to pages) so is also effectively unreachable for most of the day. There is no resident. There are just three deer in the headlights interns managing a slew of sick patients. I have recent ICU transfer pts who get bradycardic and hypotensive annnd I don't have any supervision. AWESOME. I had a patient whose life expectancy, realistically, is maybe several months and the family called me in to talk about chemo treatment options. I DONT KNOW. I deferred the question to my attending who I assured the pt he would see the next day, and for TWO WHOLE FUCKING DAYS he told me I was the only doctor who had been in to see him. Jesus Christ!!!! I don't feel comfortable managing these sick pts who have one foot in the grave and one foot on a banana peel by myself, and it's really frustrating feeling like I have no support.

Except the support of my fellow interns. Because we're all left dangling in the wind together, a lot of treatment decisions are reached after a brief discussion involving many expletives where the intern throws out their best guess of what to do, pages the fellow, who ignores the page, and then a decision is reached based on consensus of interns ("yeah.. that's probably what I'd do.") I don't think this is always the best way to go. Three broken cars won't get you to your destination any faster than one broken car...

# Nurses with rescue fantasies
There are two kinds of nurses who work in oncology. The ones who are truly angels of mercy, and ones who are overly vigilant douchebags with delusions that they are the patient's one and only savior. I've got news for you guys: first of all, uhhhh FUCK YOU. Second of all, I'm changing my goddam pager number so that you won't be able to page me every 5 minutes, preventing me from EVER getting any of my shitty notes DONE.

BEEP BEEP BEEP
(calling nurses station)
"Hi it's Dr. X, I was paged?"
"Yes doctor, the patient has heartburn."
"ok did she respond to the PRN antacid?"
"I don't know, I haven't given it yet."
Wow, you took the time to look up my pager number and page me to let me know she's having heartburn rather than actually giving her heartburn medicine? Outstanding, soldier. OUTSTANDING.

5 min later

BEEP BEEP BEEP
(Calling back nursing station)
"Hi, it's Dr. X. Did you page?"
"Yes, doctor, you see patient's potashium today?"
"Ah, yes."
Pause "It was 3.9 doctor. You want to replete potashium?"
Ah, how about no, I don't want to replete the fucking potassium, because it's fucking NORMAL. Time to get back to my shitty progress note...now what was I thinking? Oh yes....

BEEP BEEP BEEP
(damning the nursing station to hell)
"It's Dr. X. You paged?"
"Just letting you know the new patient you admitted just arrived up to the floor."
"And?"
"Thats it."
Ok great. Don't forget to page me later if she blinks or farts or asks for an extra pillow!!!!!

It is at this point in the day that I start to think I hate my life. "Life" is really too strong of a word to describe my state right now. Can I just get one fucking progress note- BEEP BEEP BEEP BEEP

"Hi. You paged."
"Its the discharge planner. I'm a giant lazy turd of a human being and I'm a huuuuge bitch!"
She actually never says that but it's the gist of what I get out of all our interactions. "Yeah that's great dc planner. Ohhhh you want me to do MORE of your job for you? Sounds great. What else could I POSSIBLY be doing?

The ITI (see last blog) is running high today...maybe I can just finish...one...progress...note... BEEP BEEP BEEP BEEP

Well damn it all to hell. "Yeah, you paged?"
"Patient Z has been blowing her nose and blew her nose really hard and blood came out!!!"
"Is she having a nosebleed?"
"Well- no."
"So there's just blood in the mucus?"
"Yeah, but like, blood!!"
"Is it a lot of blood or a few streaks?"
"Well a few, I mean, it is bright red!"
"Yeah...so no nosebleed and a few streaks after she blew her nose hard. Ok. Well tell her try to blow her nose gently, page me if she gets a nosebleed."
"You want to order a CBC to check on the bleeding?"
Nope. You want to replace the battery in my pager for all the stupid shitty pages I've gotten from you guys all day? I got fewer pages on sicker patients working in the ICU. Fucking heme onc. I can't believe it's only day 4......of 28. :(

Intern Tear Index

The ITI today is 14. And we still have an hour left to go before sign-out...

Honk if you love Heme-Onc!

::SILENCE::

Day 1 of Heme-Onc. The best thing I can say so far is that there are only 27 days left to go.

I came up with a measurement scale today to quantify how bad the day was. It's called the ITI, or Intern Tear Index. It's measured by a sad face drawn on the white board at the beginning of the day, then the interns add tears to the face every time their day gets especially shitty. Today's ITI was 6.

Wards

Dear UC Wards:

Could I please have the last 4 weeks of my life back? No? OKAY GREAT. My experience on any given service is almost entirely determined by how I feel about my coworkers. I loved the attending and the resident we had for the first week. The med students did their work and best of all, did their own thing, and I rarely saw them. The last few weeks, our resident has been an interesting mix of micro-managing and work-averse, our attending has been very nice but also somewhat intimidating and a bit of a fan of the traumatic Socratic teaching method (ie, pimps me with questions during walk-rounds while I'm day-dreaming and not even realizing that the attending was talking to me, so I look like a big time ra-tard). Although I will admit the teaching was good. The other intern was solid and took care of his work.

The fourth year student, doing his "acting internship", was brilliant. The problem is, he is remarkably arrogant and pompous for one so young and unaccomplished and constantly infuriated me by making remarks such as a certain patient I took on call would be good for me to "practice what you learned during rounds" (after the pharmacy resident prepared a very nice presentation for us on opioid equivalents and conversions that day), or not to worry that "not much is expected of you at your level of training" in terms of teaching the med students. Or how about the time he tried to sign out to me getting outside hospital medical records for the patient he'd had for the past 5 days on his day off when I was cross-covering his patients? JACKASS.

The third year student was another little slice of heaven. No sense of personal space (we had to have a talk about what "personal space" means), wouldn't cover his mouth when he COUGHED until I asked him to repeatedly, and subsequently shared his cold with me, and I was sick for 3 WEEKS. Apparently taking overnight call isn't the best way to get over a cold. Anyway, he also decided not to listen to any of my suggestions for his notes or presentations... but he WOULD completely copy and paste my progress notes (when I confronted him about this he flatly denied... come on, he even copied my physical exam!). The BEST incidence was on our last post-call day; I offered to meet with him before rounds to go over his presentation. We sit down, his plan sounds good, but so familiar... until I look down and realized he is READING MY OWN H&P TO ME, WORD FOR WORD, and passing it off as his own!!! I interrupted him and said, "I feel like you're reading my own H&P to me." He again, FLATLY DENIED and said, "Oh no, this is MY H&P." "Okay, but the wording is exactly the same as my H&P-" "That's because we talked about the plan last night." "Right, but I wouldn't expect the wording to be exactly the same, the sentence structure, organization..." at this point he paused, then continued to read MY OWN assessment and plan to me. After listening to him read a few more sentences verbatim from my H&P, I interrupted him and said, "Ok, well you know that I'm going to agree with the rest of your plan since I wrote it, so I think we're done here." I felt kind of bad, but I was also kind of outraged that he was plagiarizing my work and then insulted me by lying about it to my face! Plagiarism is something students can fail rotations for! And it was the third time I had confronted him about it! WTF man!

But what about the patient care? ...what about it? It happened. There is so much going on with juggling your patients on most days it's like... imagine running down the length of a soccer field and there are dodgeballs coming at you from both directions. You have 3 minutes to reach the other end of the field, avoiding being hit by any of the balls. Oh, side note, the air is full of butterflies and you have to catch 20 of them on your way. With your bare hands. And protect them on your way to the other end of the field. And occasionally a great big wolly mammoth comes and just stands in your way, and asks you why we run across fields, what the butterflies are, and why you're in such a hurry. This is a wolly med student. So if every day was like this for 4 weeks... you can imagine that most days wouldn't be too memorable unless something especially good or especially bad happened. The only patients that really stick out are the young alcoholic who died from liver failure, and the diabetic man who forgot my name but asked my attending to thank me for all my hard work and care the day he was discharged (I was off that day).

Moving on.

Starting the heme-onc service Monday. For a month. The silver lining around the oncology cloud is that the other interns I'm going to be working with are EXCELLENT. I'm looking forward to commiserating with my comrades to power through the next 4 weeks. I'm also looking forward to theme days. Like Fergie Tuesdays. Whatever Fergie means to you, that is what your day should be about. Fancy Friday? Mustache Monday? I'll work on it.

The only other thing I'm looking forward to, in life, is HALLOWEEN. ONLY 6 WEEKS LEFT TO GET YOUR DECORATIONS UP!!!

Discharge Summaries: the Bane of My Existence

After a patient is "cured" enough from their hospital illness to go home (or go to a rehab facility or wherever), they are "discharged" from the hospital. Upon discharge, a report is written by one of the doctors who cared for them summarizing their prior medical history, summarizing the events leading up to being hospitalized, what happened during the hospital stay, significant physical exam and lab findings, then how things were looking the day of discharge and what the follow-up plan is going to be for each of the problems identified in the past, present, and future. It is an odious task to write this report, as you can imagine these summaries can be rather long. They are the responsibility of the hapless intern. They are the bane of my existence.

If my regular workday runs from 6am to ~6pm, and I have to wake up at 5am to start my day, and once I get home after work I still have to take care of my ADLs like eating, bathing, picking up the mail, and whatever else I do to remain a marginally functional person, it's basically already time to go to sleep again. So it's understandable how one might fall behind in their discharge summaries. I learned the other day that if you fall behind for a few days, you get a nasty message that basically says, "You fail at life. How could you NOT have the discharge summaries done? Die. Just die now." That's in my own words, of course; the original message, generated by the medical record keeping department, was much more graphic. But seriously, it did include the phrase "48 hour suspension" as a punishment for being a few days late in completing the summaries. At first I was elated- my punishment for not completing all my work would be to have 2 days OFF to catch up?! Delightful!!! But then I found out that the "suspension" means I still have to go to work, but my name just gets put on a list that goes to my program director. It would be more accurate to call it a "shaming" than a "suspension" but whatever.

You have two choices with the discharge summaries. You can type them or "dictate" them. I hate dictating. There isn't really a nice quiet place for you to do this since as a resident you don't have an office; you do this over the phone in a busy workroom full of your colleagues, or you try to sneak off to an empty conference room so that you can dictate in peace only to be interrupted halfway through your dictation and kicked out of the room by a bunch of vascular surgery residents who say they are rounding in that conference room imminently. You call up the dictation number and record yourself saying out loud all the information that needs to go in the report, following the proper report format [including instructions for "next paragraph" or "next line" so your transcription doesn't come out as one long ugly block of text], and this recording is later transcribed by someone in the basement somewhere, and a copy goes to your electronic inbox for review and signature. This is terrible for two main reasons.

ONE: apparently my voice is unintelligible to the trolls in the basement doing the transcriptions. I say this because, (a) I've never met ANYONE who works in transcriptions, thus I suspect they hire trolls, who toil away in the basement, (b) whenever I get the transcriptions back they have all kinds of strange words written down that I know can't have possibly sounded like anything I was trying to say at the time, so I end up needing to make extensive revisions.

TWO: the dumbest, most RAHtarded things come out of my face, and when I see them transcribed in the report it is mortifying. Did I really say, "The patient is taking a night-time dose of insulin at night, which is 15 units of lantus insulin, nightly... each night. At night." ?!? Or is a troll just messing with me? Sadly, I suspect I DID say that. ::Shame::

The only solution to this problem: the shitcharge.

Given the complexity of the patients we see at University Hospital, it takes over an hour to do a really great job on writing a discharge summary. I don't have that time. Or when I do take that time, I fall behind in my summary reports and then I get in trouble. So I can battle the trolls and try to dictate the summary, which always ends badly, or I can write the fastest, shortest discharge summary that contains what I hope is all the pertinent information. If I limit myself to less than 30 minutes per brief discharge summary, it becomes a highly efficient process. And by "efficient," I mean just "shitty" because it takes me like 15 minutes to write a decent email so you can imagine what kind of quality report I can put out in 20-30 minutes. Thus, we have the shitcharge summary. It's a fairly decent summary of the main issue requiring hospitalization, but every other relatively chronic issue is just going to be listed by name, followed by "stable," or "continue outpatient management". The goal is brevity, forsaking detail.

I have to go catch up on some S/C summaries...

Night Float: Assume the Position

Night Float.... 14hrs of cross-covering somewhere between 50-70 patients that you only hear a one-liner about before assuming responsibility of them for the night. We can divide these patients into two main categories: asleep, and awake.

Luckily, a lot of them will be sleeping for most of your shift. But that doesn't stop the nurses from calling you- for medication clarification (including questions they know you can't possibly answer, like why the primary team switched one medication for another sometime during the day), order clarification ("I don't see a time for the pre-meal finger stick glucose checks. What time did you want those done? You should clarify the order." It's 11 o'fucking clock! You think this can't wait for the day team, who will be here, in the day, when the patient is actually eating?!?), medication list cleanup ("So I was reviewing the medications and I noticed that the patient has 2mg IV Dilaudid as needed for pain, and also 4mg IV Dilaudid as needed for pain. Can you just delete the 2mg Dilaudid order? I think it would look neater that way." WHO CARES if they have two PRN pain orders?), to ridonculous requests ("I noticed this patient has not had a bowel movement in 3 days. The primary team wrote orders for stool softeners but not an enema. Do you want to write an order to try an enema now?" Side note: it is like 11pm and the patient is asleep.)

Ok, second category: unfortunately, a lot of these patients are going to be awake. You get paged about the fact that some of them are awake like it's a problem (as in, the nurse asks for a sleep medication to give the patient because she wants the patient to go to sleep so she can comfortably ignore them and go back to shopping for shoes on zappos). You get paged about pain medications. You get paged about breathing treatments. You get paged anytime somebody falls down, and you have to go evaluate them. ("You fell off the commode in the dark? Did you hit your head? Did you hit your head???") You have to run and evaluate anyone having chest pain, shortness of breath, bad headache/abdominal pain/random other complaint. The patients you are cross-covering are scattered in different wings between the 4th and 12th floors. And your pager is going off incessantly. There were several times that my pagers were going off simultaneously WHILE I was returning another page. That's another thing- you're carrying three pagers, like little beeping grenades, just waiting for them to go off at any minute.

Alright. Highlights from my weekend of night float:

1. Patient admitted for chronic pain exacerbation spent 15 minutes yelling at me about how the Emergency Room doctors had given him too much morphine the night before when he was being admitted to the hospital ("Y'all fucked up, BIG TIME!") and how in general we, as a hospital, as a whole, suck. Here's a thought: he probably got too much morphine because he was harassing the ER nurses for more pain meds. Anyway, after debasing the hospital, and being rude to me, he managed to offend everyone else in the room by accusing us of "tricking" him and putting him on a psychiatry ward rather than a general hospital ward, saying, "Oh I know crazy- this mind is STRONG [points to his own head]- don't even TRY to play mind games with me!!! I know this floor is full of nut jobs- including THAT one!" [gesturing obviously over to his hospital roommate. Who was sitting in bed, alert and not crazy at all, with family at bedside. All of whom heard this and glared.] I later found out from his nurse that he also accused me of being a psychiatrist, masquerading as a medicine intern. No comment. Anyway, why was I called in the first place? He wanted more morphine. OF COURSE.

2. The electronic medical record went down for "maintenance" for 4 hours on Saturday night. Hilarity ensued when we had to write STAT orders. I had completely forgotten how to write paper orders. The nurses had to guide me through step by step.
"Ok, first you write the date. The date. That's not the date. Ok, then the time. Yes... then the order. Yeah. And don't forget to specify if it's routine, urgent, or... ok, that's ok, it's still legible. Good, now sign it. Sign it. Do you know your PI#? Ok, good, you're all done. ...what do you mean 'where does it go now?' We fax it down to the pharmacy. Where did you think it went? Ok... ok, nevermind doc. Thank you, thank you...BYE."

3. The best: the fake AMA patients. Unless a patient is under a psychiatric hold or for whatever reason doesn't have mental capacity, they are free to leave the hospital at any time. But if they are leaving against medical advice, they have to sign the AMA (or "Against Medical Advice") departure form. Sometimes certain patients, ohhhh let's just say the kind who have a substance abuse history and are on chronic methadone/actively using heroin/abusing a ton of painkillers at home, will "threaten" to leave AMA. When you ask why, they will throw out a litany of complaints... that inevitably leads to their "pain not being addressed", and they will suggest that if they could get that 12mg IV Dilaudid push, they might just be able to be persuaded to stay the rest of the night.

Even though I'm complaining a lot, I got very lucky since no one coded, had chest pain, stopped breathing, or otherwise had a medical calamity on either my shifts. Thank you, hospital gods, for shining your fluorescent rays of mercy upon me.

The End of an Era

This is my last week of ambulatory block. The last few days were great- all my afternoon patients canceled or no-showed on Wednesday so I just went around saying it was Robot Wednesday and doing the robot dance with the residents, nurses, medical assistants, etc. in the medicine clinic. Thursday I had two patients in urgent care, and I can't remember much about the details of the patient encounters which is usually for the best. I do remember one of the MA's asked what the theme for Thursday would be, and I said "Lie to Me Thursday" or "Let It Be a Surprise Thursday," ie, I did not want to be told ahead of time when my patients arrived, that their blood sugars were wildly out of control, that they had 9 chief complaints, etc.

Then today in the morning the interns had "admin" time to complete paperwork or clinic notes from this block. I like to finish all my notes before I leave clinic, so I spent that time at home singing along to Katy Perry songs. Loudly. Sorry neighbors. Then in the afternoon I had two patients cancel again (can you believe the good fortune!!), and stupidly offered to help one of the residents with their urgent care clinic. Theme for today's clinic: talk in a spooky ghost voice when you have to present a patient. The best was one of the third year residents: "This is a 49 year old lady with diaRRHEEEaaa... DIArrrrhEEeeaaAAaaa..."

Goodbye, Ambulatory Block, I will miss you!

Next up: entire weekend of night float, then a month of wards.

Gyn Clinic, Continuity Clinic, and Urgent Care

County Gyn Clinic. If I liked gynecology, I would have gone into it. I didn't go into it. This is the county clinic, so you can basically expect it to be an STD-screen-for-all and PAP-fiesta. One young woman said the best place to get a copy of her prior PAP records was a state prison. Enough said. What I will say is that I genuinely like the patient population; the people I saw were surprisingly grateful and patient.

In my continuity clinic I saw one young lady who wanted her electronic medical record to be blocked from access by medical students. When I asked why, she revealed she had dated a medical student, and did not want him having access to her chart. I explained that although there is no way to block access to her record, all movements in the medical record are tracked. Keystrokes are tracked. The amount of time spent looking at any given page, report, or image is recorded. So if her electronic chart was accessed inappropriately, there would be a record of it, and the record can always be audited. There are also pretty significant repercussions, professionally and legally, for inappropriately accessing medical records. But she did bring up an interesting point; now our health information is becoming digitalized, it is more accessible than ever before...

And lastly, in clinic I had a patient try to tell me he got gonorrhea from a cat. He had already been told that he had gonorrhea... but apparently not what gonorrhea is (it's an STD). He immediately launched into a story about how all his symptoms began when his housemate got a cat, which pranced around the house, just touching everything... I asked him if he was aware that gonorrhea is a sexually transmitted disease. Long pause. OHHH.

Let's wrap it up. What am I trying to say here? If you've been wronged by a cat or a med student, the door to my clinic is always open. You might want to wash your hand after you touch that door handle though...

That was just someone who looks like me...

Today while walking to clinic, I fell down on the sidewalk. I didn't trip on anything, I just fell over for no apparent reason. I paused for a second, unhurt, and bewildered, then jumped up and brushed myself off, saying to my (laughing) fellow intern, "MAN, I'm glad nobody else saw that!" I turn to my right and there is a hospital shuttle bus full of patients. The bus was dropping off patients at the clinic where I work.

Big-time awesome.

Urgent Care Clinic

The patients scheduled for my urgent care clinic were:
1. Young man with left hand tingling/numbness
2. Middle aged lady with "mold spot" growing on her head and "bruises all over."
3. Youngish woman with "malodorous vaginal discharge" x 1 week
4. Middle aged old lady for follow-up after breaking her foot
Summary: dammit!!!

So the first thing's first in urgent care clinic: you hope for no-shows.

All of my patients showed.

Excellent. Yay patient care yay. Yay.

Anyway, so the first guy is huge- he's like 7 feet tall. He leans on his left elbow all day at work, then comes home and leans on his left elbow for another six hours while he watches TV. He has tingling in his left fourth and fifth fingers that sometimes radiates to the elbow. Any takers? Any takers?

Boom- ulnar neuropathy! Done! Easy!!!

Next lady shows up. Early. Thank goodness, I didn't want to miss out on this head "mold." So first of all, it's a small, discrete, brown "stuck on" appearing growth.... a seborrheic keratosis (benign ugly growth). She is happy to hear this. Next: she has "bruises all over." Ah, she actually has one tiny bruise on her outer arm and another little one on her knee. Show me someone who DOESN'T have any little bruises over any of their extremities. Next, she wants to talk about what her future treatment options are for her chronic sciatica. Then she wants to talk about what some good recommendations are for exercise she can do to-OKAY, THAT'S ENOUGH THANK YOU, this is URGENT CARE clinic, not BRING ALL YOUR UNSOLVED LIFE PROBLEMS Clinic.

Next lady. "Malodorous vag discharge" for a week. Great. That's the best! So after the attendings jokingly (kind of) argue between the two of them about who should have to staff this one, eventually we get the vag infection taken care of. But oh wait, as soon as I try to leave the room she mentions she has this weird neurologic past medical history and OH BY THE WAY, part of her face has been tingling for a day. Daaaaaaammit. Ok then, tell me about your face. Ok, came up with a plan for face problem. Good. Try to leave again- OH BY THE WAY, she doesn't know if she believes in taking antibiotics and wants a convincing argument. Ok, done. Try to leave the room again- OH BY THE WAY, she wants to know what her weights have been trending over the last several months because she thinks she's losing weight. !!! So I look up her weights and show her clearly that over the past two years, her weight has been the same. She insists on getting a recommendation for nutritional supplements to safely gain weight. Okay. Whatever you want. Try to leave again- OH BY THE WAY ($#%&*@!!!) she has breast lumps that come and go and she's been told they were benign and that is normal, but is it REALLY normal??? SWEET JESUS! Once again, this is not "BRING ALL YOUR UNRESOLVED LIFE PROBLEMS TO CLINIC DAY." We were just kidding when we said "Urgent Care" clinic, what we really meant was "Let's Relax and Sit Down at a Table and Just Talk About Every Problem You've Ever Had in Life Over a Cappuccino" clinic. Let me know when you're done with your life problems so we can get started on mine!

AAAAA!!!

Ok. Fourth lady (by the way, somehow I am almost an hour behind at this point thanks to 1 million + 1 problems lady). She was diagnosed with a broken foot at an Outside Hospital. Outside Hospital took an xray, gave her a brace and some vicodin, wished her good luck and told her to take her problems to University Hospital (where I work). This was more complicated than it sounds (sigh) and took some time to sort out. As I'm presenting her to the attending- GUESS WHAT- she volunteers that she has had intermittent numbness and tingling in the left hand. OH LORD. She also volunteers she has been having blurry vision. At this point the attending asks, "Okay- are there any other problems that you're going to share with us?" It took several more minutes to elicit the history that the tingling also occurs alternately in her right hand, and it is precipitated by LEANING ON HER ELBOW. BUGGAR!!! Ah- also, her fundoscopic exam is normal and her vision is 20/30 bilaterally. Oh how I wish that my vision could be that "blurry." Anyway, after several more minutes of talking to her it sounds like what she meant was that her vision had been gradually getting worse over the course of a long period of time.

Somebody must have told her about the cappuccinos....

Ambulating On

I've completed week 2 of my ambulatory block, and week 6 of my intern year.

This past week I had Urgent Care, my continuity clinic (small panel of patients that I am following for the next 3 years or until death do us part), Hepatology clinic, and Endocrinology (where they forgot an intern was coming and had no patients scheduled - yessss!).

I honestly can't remember what happened in Urgent Care clinic. This is most likely a coping mechanism whereby my memory is selectively forgetting all of urgent care clinic. Thank you, memory.

Hepatology clinic went something like this: guess what's behind doors number 1-9? If you guess Hepatitis C, you're right every time! Except maybe 1 out of 10 it's Hep B or nonalcoholic fatty liver disease, just to mix things up a bit.

In my continuity clinic I had a patient who was scheduled with a chief complaint of "itchy warts." It didn't say where the "itchy warts" were, either. I can't tell you how relieved I was to diagnose multiple skin tags on the neck of this pleasant woman with metabolic syndrome.

Then on Friday night we had an intern scavenger hunt in midtown. I made a list of 20 items for each team to find within a certain time frame. The best item on the list: "4. Tell someone that you’re looking to get a new tattoo to celebrate your recently becoming a doctor. Ask them for ideas, and get them to draw something out either on a napkin or on you." One of the girls came back with a stick figure with one shoe drawn on her bicep. The artist had told her, "This is a crackhead. Because you're going to have to get used to taking care of lots of these. See? Only one shoe. Crackhead." Other highlights from the list: "Make an intern sandwich," and "Go up to a group of strangers and bust out in your best robot moves."

Young doctors of America. Beep beep beep. BoooooOOOooop. Rrrrreeee. (Those were my best robot moves.)

Hospice

Today as part of my ambulatory block I was assigned to spend a day with a hospice nurse making house calls.

I thought that this would be incredibly uncomfortable. This is how I imagined it would go:

::knock, knock::

::front door opening::

Us: "Oh hey you! So you're still.... alive..."
Hospice patient: "Yeah."
Us: "You're not dead yet!"
Hospice patient: "Nope."
Us: "We really expected, you know after the last time... well this is a bit awkward then, isn't it? Can we... bring you some more morphine?"
Hospice patient: "Ah, no, I'm good."
Us: "Okay. Yeah. See you tomorrow then?"
Hospice patient: "Maybe."

But I was completely wrong. The visits were just like any other pleasant house calls. I also worried that we might visit to find someone had already expired by the time we got there. But nope! Luckily everyone was alive. It was kind of a good day. Relatively speaking.

Bikram Yoga (aka Hot, Nasty Yoga)

Bikram yoga: If you can't stand the heat, you probably have a better sense of self-preservation than I do.

To take full advantage of all the glorious free time on our ambulatory block, some of us interns have been getting together a few times a week. I've wanted to try bikram yoga (or "hot" yoga) for a while. So yesterday four of my co-interns and I went to a hot nasty yoga class.

Bikram yoga involves traditional poses and breathing exercise...done in a room heated to 105 degrees. Which is only 10 degrees warmer than your average summer day here, but whatever. If you've never done hot yoga before, let me take you through a virtual session:

First of all, it smells like unwashed, medieval ass. It smells like a mix of hot garbage and potent body odor with 50% humidity. It's like a face punch delivered by a multitude of unwashed socks. Alright. Then it's 105-107 degrees in a room with no air circulating and about 20 other dripping sweating people (so let's say 70% humidity. You can taste the humidity in the air, and it tastes like an unwashed mongol horde). Most of these are die-hard yoga ladies, aged late 20s through 40s, the kind who glare and loudly shush you if you laugh or fart during silent meditation time. Not that you have the kind of energy to do either of those things because it's 105 degrees.

Wait, because it gets better. Then there are the 3 old men in the back, dripping sweat, looking like they are actively having acute coronary syndromes. Jesus christ man- just because you spiked your hair and got a surfer tattoo only takes you back 60yrs in YOUR MIND, not in real life. My zenlike state of mind was frequently interrupted by the weird grunting noises they made, causing me to worry if they collapsed who was going to run the code.

The instructor is telling you to get into various poses that will "mobilize your pancreas", and encouraging you to rotate your torso even more, "take it to your edge," so that you can "massage your liver." At this point I giggled, and was shushed by a die-hard yoga lady. Throughout the class, the instructor tells all the new students not to worry if they feel nauseated, dizzy, headache, or otherwise ill, because that is the sensation of toxins leaving your body. It is coincidental that those are also the signs of dehydration and heat stroke. Anyway.

Did I achieve new yoga heights? Strengthen my core? Increase my flexibility? See my toes again? Eh, no. Good workout though. Overall, it was a very interesting experience, but not one that begs repeating.

Glorious Ambulatory Block

Day 35 of residency, and day 4 of my glorious ambulatory block. So far this week I've enjoyed half days in a variety of clinics (and more to come). It's interesting spending time in the different clinics, but it's not enough time to get "good" at any given one since we switch clinics every half-day. So I'm basically bumbling through a series of clinics, wide-eyed and bemused, carrying a vitals sheet a nurse handed off to me and trying to find the correct patient rooms. So far:

GI Clinic: you've been an intern for 4 weeks and you still don't know how to manage Crohn's disease like a GI specialist?!? Well then, you're in the right clinic. Because the GI docs don't care. For all intents and purposes it appears this clinic exists to entertain the GI attendings, and save them the trouble of writing follow-up notes. After I saw the patients and presented them, before I even shared my treatment plan, the attending is already dictating to me the plan he's had since he saw the patient's name on the schedule. Aaaaawesome. Why am I here again? Do you have carpal tunnel syndrome, Dr. Attending?

Asthma Clinic: outstanding. Overall a very pleasant experience. You get to listen to the musical stylings of the pulmonary tree while reminding asthmatics to avoid their chronic asthma triggers.
Patient: "My asthma flares up when I roll around on the grass or rub my cat on my face. I was allergic to trees, pollen, and cat dander on my allergy test 3 years ago. Do you think I still am?"
Me: "I would say so."

Endocrine Clinic: I went on a Diabetes Clinic day.
300 pound woman: "I don't know why my sugars run so high. I just have coffee and a small breakfast, salad for lunch, and boiled chicken for dinner!"
Me: "SHENANIGANS!!! So it's between meals that you're fitting in all those donuts??"
You need to be inputting a certain number of calories daily just to maintain your body weight. So if you weigh over 300 pounds, YOU AREN'T FOOLING ANYBODY with the salad routine. Unless you're slathering those salads in mayo and eating them with forks made of bacon. How about instead of injecting you with more insulin we agree that you could just stop eating so many deep fried cheese sticks and call it a day?

County Chest Clinic: surprise, this is the county Tuberculosis clinic! We can't afford N95 masks- come on, this is COUNTY! We just clearly mark the "sputum collection" room as "do not enter," and the door is closed most of the time, which is just as good as a negative pressure room. You were always wondering when you'd seroconvert on your annual TB skin test; now you know!

And lastly, my own Continuity Clinic: every other patient has fibromyalgia. Every other patient is on controlled substances. My goal is to slowly wean all the FMS patients off their narcotics and start them on yoga. The prayers for DNKAs start now.

Moments like this also end up staining my shirt with chocolate minutes before clinic. WORTH IT!!!!

Free lunch containing a massive veggie burrito and frog cookie, provided by my residency program. Ah, it's moments like this that make it all worthwhile.

The last day of the first month of intern year

While making a videophone documentary of our last day at the good ol' HMO hospital:
Me: "How has this month gone for you?"
Intern A: "There are no words..."
Me: "No words that are awesome enough?"
Intern A: "No words that are clean enough."
Me: "Alright, if you had to summarize this month in one word, what would it be? ...it can be an expletive."
(pause)
Intern A: "I don't even know..."
Intern B: "WTF."
Intern A: "Yeah, that's it. WTF."
Me: "I see. Alright. Any advice for the people who come after you?"
Intern A: "RUN."
Me: "Awww... to the codes, right? Be there first."


BEST QUOTE OF THE DAY:
Intern C: "I did a rectal exam, she like farted in my face... I was a little less concerned for obstruction after that."

On Managing Agitated Delirium: Me to the resident "do you think Mr. X is going to take the zyprexa p.o. (by mouth)?" Resident: thoughtful pause Background: Mr. X: "GET OUT OF MY ROOM YOU WITCH DOCTOR! I KNOW SATAN WHEN I SEE HIM!!!" Mr. X's (female) nurse: "Aaaa!"

Ophtho Consult

I had to call an ophtho consult today. Which was greeted in the usual fashion, with an ophtho insult. So I'm on the phone, trying desperately to convince the woman on the other end that the patient (acute unilateral orbital swelling and erythema with chemosis and ptosis in an immunocompromised host) needs to be seen today, while she tries desperately to convince me that I'm probably wrong about the severity (her indications for not needing an urgent consult included "it's Saturday" and "I'm not in house right now"). Ultimately she said for eye swelling she recommends cool compresses and that if the patient still needed to be seen tomorrow I should re-consult (aka call back tomorrow when someone else is on call).

After she rudely ended the phone call, I had two choices. I could either document in my note the conversation we had (basically find a proper medical (ie, verbose) way of saying "I told the ophthalmologist what was going on, she blew me off, then made me feel bad, and still refused to see the patient. Oh by the way, this is her name for medical-legal reasons should we all get sued some day.") OR, I could take whatever is left of my pride, wadded up in some deep pocket of my white coat, and sacrifice it up as an offering to appease the consult gods by calling back and BEGGING the ophtho to come see this patient today.

I went with option B. She actually seemed quite receptive on the second go-round, even apologized for being "brief" with me earlier. She whined that she thought I was just trying to rope her into doing "another consult for eye exam" which she had been getting all day. I assured her I was not, and again emphasized that orbital cellulitis was high on, if not sitting on top of, our differential. (Puhlease- I'm not going to consult ophtho just for a fundoscopic exam! I know how to use an ophthalmoscope just as well as the next one. Which means if I need to evaluate for papilledema I'm going to do it the true inpatient medicine way- and get a head CT.)

Four or five hours later, she finally came to see the patient. She immediately called me back and confirmed that this was likely orbital cellulitis. FUCKING A. She then also went that extra consult mile, and covered her ass by volunteering to the attending the only reason she came so late is that I hadn't relayed how serious this was over the phone. This was funny because (a) I hadn't even complained about her to my attending, because I thought that would be unprofessional, and (b) my resident was right next to me for the entirety of my TWO pleading phone calls and heard every word that I said. His assessment succinctly summarized the situation, the day overall, and frankly my life.

"Bullshit."

New attending in the ICU introduced himself to the team, saying, "I'm tough. I like to crack the whip. Every five minutes. You will be... abused. Now everyone go around the table and say where you grew up, what you want to be, and the last movie you saw!"

You know the DMX song "Get It On the Floor"? I always think of that song when we're admitting people from the ER. But when I think of it I change the lyrics to "get 'em on the floor, get get 'em on the floor!" Get it? get it? Because the "floor" is what we call the hospital wards? Eh eh? I also change the word "party" to "admit" in my version. Yeah.

Dear Apartment Maintenance Staff, I only had to submit two work order requests and one note to the front office about my broken air conditioner for you to come by. After two weeks of coming home at the end of a 14 hr day to a 90+ degree apt, it's nice to see that you finally were able to drop in. And leave a note. Saying that my a/c is already working. The note is of little comfort as I stand here sweating profusely and shaking my fist at the a/c controller which claims that the apt is going to be cooled down to 75 degrees... As it slowly climbs to 91 degrees. Flames!!!

Had to adjust the central line for a patient in the unit who is deaf. While the nurse is putting on a new dressing, pt points to my face and gestures that I need a dressing. "Me? Why?" Pt makes gestures I can't understand, then writes down 'you have scratches' and points to my face again. Ah yes. Those pathognomonic red bumps artfully decorating my face, of course. "I have acne. That's what's wrong with my face. No scratches," I clarify. Pt then proceeded to teach me how to say "acne" in sign language as she thought this would be a useful phrase that I would likely have to use again in the future. Thanks. A lotttttt. And by the way, that's DOCTOR Acne to you!!!

Breakfast Note

One of the many nuances of medicine as it's practice today: we write the most retarded notes ever. We devote a huge chunk of our day to documentation. You write a medical note to document not only what you did, but why you did it, and why you did not do something else. This is preposterously time-consuming. It's not for better patient care, it's so that the documentation is "thorough" aka so that if the doctor gets sued years later he can defend what he did at the time. Hopefully. And we have to write notes about everything: admit note, progress note, procedure note, consent for procedure note, discharge summary, transfer summary, consult note, etc, ad nauseum.

Here is an example of how this could ruin anything that might otherwise be simple and enjoyable.


BREAKFAST NOTE
7/11/2010 05:15 AM

The kitchen was entered and food was selected for breakfast. Cereal was not selected based on lack of milk. Rule out toast based on lack of bread. Or functional toaster. Breakfast bar was selected based on quickness with which it can be eaten in the limited amount of time to get ready in the morning. The bar wrapper was opened in the usual fashion. The bar was consumed in approximately 10 bites. There were no complications. The wrapper was disposed of in the usual sterile fashion. Then it was picked back up off the floor and placed in the trash.

The refrigerator was opened. The only bottle of water in the fridge was chosen. One packet of Crystal Light Strawberry flavor was added to the bottle, in the customary 80/20 fashion of counter top spillage. This was shaken, and the damp bottle was placed in the "work" bag in the usual fashion. Sigh. Sigh was made in the usual fashion.

Outcomes: breakfast concluded

Complications: none






...OH BY THE WAY, that note took me 10min to write. It took me ~5min to eat breakfast. Therein lies the rub- what I can do during the day is significantly limited by all the crap notes I have to write about what I did, what I plan to do, what I was thinking, what I plan to NOT do and why.

Ok, additionally, all the electronic medical records that I've had the opportunity to work with are all totally non-intuitive, cumbersome, pieces of shit littered with colorful side tabs. Oh come on, Intern, it can't be THAT bad! Oh can't it?!? Ok, this is what it's like. Imagine one of the top executives at Microsoft got together with Apple's best computer engineer, and they took a promising young computer whiz with them out to lunch at an unlicensed catering van. (...do you see where I'm going with this?) Ok, then they brainstorm about how to come up with the best user interface that will include all the pertinent documentation while at the same time streamline workflow to actually makes the "providers" jobs EASIER! Then, they create a program that does the EXACT OPPOSITE of ALL of those things. Then, they just get together and take a giant shit on your computer. And you sit down, and you try to work with this terrible, terrible program, and you think "this is ruining my life. I have to just click out and close this window." But you CAN'T, you know WHY? Because all the aforementioned people have REPLACED YOUR MOUSE WITH A GIANT DOODIE. All you can do is sit there, simmering in your own bitterness, wondering why you weren't invited out to the catering van, too.

The point is: it took me less time to write all my notes using the old paper system.

7th straight day admitting new patients. 2 new admits today. 1 discharge of an old patient successful, 1 failed (after literally several hours of trying to arrange for this nasty, manipulative old man to go home, his wife calls and freaks out because she "can't take any more" of his crap and won't take him back. Guess what? I've had my fill of his crap too, and I'M not the one who married him!! So thanks for eating 15 min of my time whining and stalling over the phone and thanks for killing my discharge of your medically cleared albatross.) Support is... 14.5hrs later, tears on the drive home. :(

Day 15: first tears of intern year shed.

Background info: patient is an elderly man scowling and demanding "first bring me more milk- and make it ice cold!!!" before allowing his RN to turn him in bed.

Just had a patient tell me I'm "too nice" and "wouldn't last in this business."

I'm going to get a med student tomorrow. THE STUDENT HAS BECOME THE MASTER!!!

Today

Day 7 of Internship
Today I mentioned to a nurse that I was terrible at putting in IV's, and that in med school I was signed off on being competent in placing them by a resident who felt sorry for me after watching me fail at two in a row. The nurse enthusiastically insisted on teaching me tips for successful IV placement by placing a practice IV....IN HER ARM. I whined that I hated placing IVs and besides she didn't need one, and she pointed out that I was going to have to place several arterial lines and central lines, and that being able to place a peripheral IV was an important skill that I might need.

Procedure note:
Peripheral IV Insertion

Method: First an elastic band tourniquet was placed around RN's arm distal to the olecranon fossa. A longitudinally running vein was palpated and noted to be plump and juicy. The area was prepped with chlorhexidine in the usual sterile fashion. Time-out was implied as RN said "Bevel side up!" and MD looked at the needle and said "What?". Before inserting the 22 gauge needle into the large, ample vein, the MD informed the RN, "I'm scared to poke you!", and RN confirmed, "You've got to!!!". Needle was advanced until blood was seen in the flash chamber, at which point MD was completely surprised. With cannula in place, MD advised the RN "I forgot what to do now." Tourniquet was removed, followed by retraction of needle with cannula still in place.

Outcome: Peripheral IV was inserted in RN's arm successfully with no complications.

Then immediately taken out.

With no complications.

The best part? Immediately afterward as we're laughing and the nurse is congratulating me, the social worker sitting next to us says, "Are you a nursing student or a medical student?" The RN informed her that I was a resident.
The social worker raised her eyebrows and didn't say anything.

You know what, social worker?

BOOM! There's an IV! I just gave it to you! I can do that, because I'M A RESIDENT! BOOYAH!

I'm just kidding of course.

We both know I could never place an IV by myself.

Overheard in resident room: "oh THERE'S my banana! Dammit!!!"

Already, I feel the emptiness where my soul used to be...

DAY 5 of internship

I realize that other people were right when they said maintaining a quality blog during intern year was impractical. I woke up at 5am today to get to the hospital by 6am, and stayed until after 7pm. By the time I got home, bathed, ate, briefly read up on what I needed to know yesterday...it's time to go to sleep.

This is what's happened so far: a whole lot of learnin', a whole lot of poorly written orders, a whole lot of pages about said orders, and above all, patient care.

Actually above all writing g-damn progress notes and h&p's and discharge summaries. I spend most of my day actually WRITING about my day. Odd.

Ok, so in the future I'm going to try daily mobile device posts. We'll see how that goes.