a little catch-up

hehe. hehe. yeah.

i figured i'd post here about once a week, maybe more often - and try to keep the fresh perspective of a fledgling doctor. something insightful for med students to use to prepare them for the road ahead, maybe something commiserating for my colleagues, and perhaps something nostalgic for others (and eventually myself) down the road a bit.

sleep and spending time with my family (mostly my new wife and the cat) EASILY became more important. sorry about that. oh, yeah - and all the other stuff involved with the job: rounding on patients; leaving notes in charts; doing H & P's for admissions or to prep patients for upcoming surgeries; dictations; chasing down labs, electrolytes, and radiology studies; attending weekly conferences; and the occasional meal.

what was i hoping to blog about? other firsts:

1. pronounced my first patient (ie, i was the one to sign the death certificate)
2. wrote various prescriptions for drugs i really know nothing about
3. participated (unsuccessfully in terms of having a real role) in a couple of codes now
4. participated as a "first assist" (read: actual major player) in several minor surgeries
5. made some solid contributions to the overall treatment plan of patients
6. made a real connection with several patients and family members
7. invoked my name as "Dr." to get some pull on the phone - several times now actually
8. remembered to thank the nurses that save my butt on many occasions
9. finally managed to change my lab coat
10. still can't stop calling myself "student"

1. Death - this still touches me when i think about it, since it was a guy that was on the service for almost a month. nicest guy and his family - i got to know them quite a bit with all the hours i spent in his room changing his dressings, etc. they were very forgiving of my lack of knowledge, and settled for my guesses about what to expect and what the next stage would be for them. [sometimes communication on the team is pretty poor at best, and us "underlings" are basically on a need-to-know basis, despite the fact that this is a "teaching hospital." not that i'm bitter.] he held his own for quite a while after the surgery, and things were actually looking good. then an unexpected turn with the outputs from his drains, and a week or more of "watchful waiting" before we really discovered just how bad off he was. the end was very quick and unexpected, although thankfully his family had the chance to gather and say goodbyes, and to gentle him on his way with relative privacy over the course of quite a long morning. i got called at 1:29pm by the nurse to inform me that there was asystole (flatline) on the heart monitor. by the time i had a chance to officially "pronounce" him dead, the family was already gone - something i was surprisingly thankful for.

it hit me later that day at home, and i cried to mourn him and in wondering about how we could have prevented things from going so wrong ... and part of me will never trust that attending surgeon for not being more proactive in the first place. with retrospect, his complication seems an easy thing to have caught earlier - especially for an experienced surgeon. as an intern, you're just left feeling helpless - not enough knowledge to really know when to get more concerned earlier, and acting as a go-between for the patients and attending surgeon, not making much of a contribution other than occupying a rung in the ladder of bureaucracy.

2. Scripts - drug interactions - DEA numbers - pain seeking - appropriate antibiotics - all these things are mere blurs in my evolution as a prescription provider. such power we're entrusted with, and not much oversight. god, i hope those pharmacists out there are doing their jobs!!!

3. Codes - thank god there is a "code team" to intervene when patients on the floor are crashing. CPR, ACLS (advanced cardiac life support) - all this training i've had really means jack. you don't get good until you get practice - so i guess i'll have to find a way onto the code team at some point. until then, all i'm good for is trying to give medical background about the case, or acting as "gopher" to retrieve charts or prior vitals, contact phone numbers, etc. i did provide a tongue depressor once when needed - i felt so helpful.

4. Surgeries - i was quite impressed with myself the first time i was left to my own devices to complete a key component of a surgery - one i had only seen 1.5 times before in fact! cutting open a vein and threading in a catheter seems like pretty small potatoes now, but it still made me feel cool. and to this day i'm still pretty nervous making an incision into virgin skin ... although i've still not had much practice at even that at this point. the last time i was even scrubbed into a surgery was in the middle of last month's rotation (ENT). now it's all but a distant memory...

5 & 6. Contributing - nothing specific jumps out, but at the end of the day i'm secure in the knowledge that - at least at some points during these past 3.5 months - my participation has contributed to the healing and/or well-being of at least a few patients. in some cases it may have been nothing more than a reassuring smile, but at some level i have helped some people. and while i would never presume to take the credit, it has been gratifying to be that intermediate who happens to be thanked for the efforts of the entire treatment team as i coordinate a patient's discharge. and some patients have even specifically thanked me for - get this - my "calm demeanor." i must have been post-call or something!!

7. "Dr. Bonzo" - in my personal life i have not yet (nor do i plan to) introduce myself as "doctor," or correct someone who calls me "mister." i have no plan (as of yet) to put the indication of the degree on my return address labels, or my checks, etc. i often do a double-take when i hear my colleagues on the phone introducing themselves as "Dr. So-and-so" - i always just use my first name. when i remember, i ask the nurses to address me by my first name as well. i'm not hung up on the title. but - sometimes ya need it. calling over to other hospitals, and to pharmacies to call in scripts - i've tried it both ways, and the results are just SO much better (shorter hold times, more receptive secretaries, etc.). i hope to keep it to a minimum. until i'm really hungry and that line at McDonald's is just too long... :-)

8. Nurses - there's too much to say, i'll save this for another blog. the short version - they really can save your butt, treat 'em well. they can also make the life of an intern hell - be nice to 'em.

9. Lab coat - only 3.5 months in, and the coat was doing rounds on its own!! yeah, i was way overdue to change it out and get it cleaned. half-done - my stuff is transferred to my brand-new whiter-than-white coat. now to get the infested one cleaned....

10. May i demote myself? - at least one or two times a week i am still introducing myself to patients or making reference to my role on the team as a "student." hard to get used to "advancement," although most of the time i just feel like a glorified student. just about at the time when i start to feel comfortable on a service and think for myself, and make decisions about patient care, i am shuffled off to another specialty, or given a rude awakening about how so-and-so attending likes to do things THIS way, and so-and-so chief resident wants to give an "ok" before you make any changes to medications or treatment plans. the process is less about learning the art of medicine and more about learning how to please the current boss, which is so different for the different attendings that it can take all month to sort it all out - at which point we're on our merry way to start the process all over again with a different service.

yup - lots of fun.

next topic - things i wished i knew / experienced before getting thrown into the deep end.

nap-time!!

Trial by fire - Day 1

Today was D-day. My first official day as a doctor. Just wrapped up a week of "orientation," basically a paperwork-fest including the all-too-fun activities of obtaining IDs, getting oriented to fifteen different libraries, getting half-useful tours of the facilities, meeting the other poor souls in my shoes, and jumping through other various hoops that have little to nothing to do with easing into my job.

What is my job? I'm an intern resident [first year, aka PGY-1 (post-graduate year 1)] in general surgery. So what do I do? Basically anything that any of the atttending doctors, senior residents, nurses, experienced medical students, and even patients tell me to. It's rough being the low-man on the totem pole, and being totally unfamiliar with the infrastructure and common workings of the facility you are newly employed at - yet being legally responsible for the "medical care" you provide. Our orientation covered some basics like how to use the computer system to enter orders, but neglected to go over basic workings, such as who ends up doing which aspects of patient care. I guess I shouldn't be surprised at the "trial by fire" nature of the beast.


So how did it go? Due at the hospital at 5:30 am to prepare to round ... I got there at 5:45 after getting only 2 hours of sleep the night before - half nerves and half procrastination, taking care of all sorts of business EXCEPT preparing for possible tasks and making up for knowledge deficits that might present during the day. Got started with the team, finally met the senior residents, and then went bleary-eyed at the pace with which the day proceeded.

About 18 patients to care for total, located on 8 different wards around the hospital - rounding on them, making decisions for orders like advancing diets or getting special labs or tests. Thankfully we worked as a team, and I wasn't left out to dry too much. After some quick rounds in the morning, we had M&M (morbidity and mortality) conference, and then I busied myself with taking out staples and sutures, pulling drains, and doing other scut-work - like running a packet of x-rays down to radiology to have them read by a specific doc (only to find out that she's out until next Tuesday!). All in all it wouldn't have been bad, except that the infernal pager I was so eager to wear was vibrating NON-STOP. I was too busy to even get a little smile off that. Apparently, I was the lucky bastard that was assigned "on call" during the day - would have been nice to have known that AHEAD of time. And about 95% of the calls I was getting were for issues that I couldn't handle on my own, with my limited knowledge of the patients on our service. So I spent a LOT of time chasing down my seniors and running interference between the nurses and other residents. And of course, running back and forth across the hospital. A LOT.

Also threw a wrench into the works that my access to the computer-based order entry was not functional. Should be fixed for tomorrow ... we'll have to see. And of course, several pages were follow-ups / complaints about the fact that I hadn't managed to get a medication order ready for a patient fast enough, or that I still had a patient's daily note in my possession instead of in the chart for the beaurocrats to play with. Little details that a more solid orientation to the inner workings of the facility would have helped.

At least they fed us periodically during that orientation week. Besides a half-bagel snagged during the M&M conference, I did not stop ALL DAY to eat or rest or veg. My only down-times were the nearly peaceful minutes between paging a senior resident and finally getting a call back to deal with the latest crisis. It was a blissfully short day as well - I was actually out of there by 5:45 pm. Only 12 hours. Not bad!

And some firsts: Wrote my first prescription as a doc (for colace - a laxative - who still says I'm full of shit?!?); went around in a long white coat; nearly peed on said coat (sometimes it is NOT easier to be a guy); applied steri-strips (glorified band-aids / step-down from staples) on my own; and threw out "disposable" tools like suture scissors with hardly a twinge of regret at the waste. Made a few good "catches" about orders that were not yet put through - hopefully I helped out the team.

Now to see if tomorrow will be less dramatic. Fortunately I won't be the on-call resident. And thankfully there is a system to prevent pages to my number from getting to me when I'm off duty - they get forwarded to the night call resident. Now if I could only forget to switch that back tomorrow.... :-) But at least my pager won't stop me from getting a decent night's sleep. Hopefully I'll be able to wake when my alarm goes off at 4:30 am. Fun, eh? G'night!!

my H & P [history and physical]

ID [identifying info]: 32 y/o WM, intern in general surgery
CC [chief complaint]: see above
HPI [history of present illness]: don't get me started
PMH, FH [past medical history, family history]: non-contributory
SH [social history]: insufficient EtOH consumption, non-smoker, eats on occasion
ROS [review of systems]: deferred

VS [vital signs]: Temp 98.6 F, Pulse 60, Resp 10, BP 110/70, oxygen sat 98% on room air, Ht: 5'4", Wt: roughly ~165 lbs, BMI [body mass index]: math is hard, about 28.3 (goal is < 25).

Remainder of physical exam deferred, as the subject was compelled to leave to answer a page. Let it be noted that mental status was impaired, physical conditioning was poor, and posture was stooped.

A/P [assessment & plan]: Highly stressed individual with increasing demands on his limited intellect and experience. Encourage extensive reading, rest, exercise, and healthy diet - none of which are compatible with expected lifestyle over next year. Expect some relief with expanded support system, if red tape ever clears. Wish him best of luck, and follow-up as needed!