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.
Saturday, November 27, 2010
Thursday, November 25, 2010
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.
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.
Wednesday, November 24, 2010
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!
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!
Thursday, November 18, 2010
Thursday, November 11, 2010
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!
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!
Wednesday, November 3, 2010
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.
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