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!!!"