6.11.2008

Difficult Airway



Last night I had this patient...

...He was a 45 yo male with no significant past medical history who presented to the ER in the early evening c/o "I think I have something in my throat." After further questioning his story goes like this:

When I went to bed last night, I felt fine. No cold or flu-like symptoms, no trouble breathing...nothing. When I woke up this morning I felt as though there was something in my throat. Not all the time, but when I swallowed, I felt...like it was hard for the saliva to go down. I tried drinking cold water, then hot coffee, I ate a banana, but nothing seems to "push it down." I decided to come here because throughout the day it's been getting harder to swallow food, and it feels like it's actually bigger.

He denied having any similar prior episode of the same. He denied h/o allergies. He insists that he didn't eat anything prior to the onset of the symptoms (such as fish, meat, chicken, seeds, etc). He had no other "allergic-type" symptoms such as wheezing, chest tightness, rash/hives, pruritis (itching). No new exposures, no travel. He was not a tobacco smoker, or involved in a fire (i.e. smoke inhalation). And he had no symptoms suggestive of infectious cause, such as fever, pain, redness, etc.

On physical exam:
He was a well developed, well nourished man in no apparent distress. Talking in full sentences, handling his secretions without difficulty, and able to drink water and eat soft foods with little effort.

His vital signs were normal, including an oxygen saturation of 98% on room air.
His face was normal, with no signs of swelling, no redness/hives. His eyes were normal without evidence of allergic reaction. His throat exam revealed a left tonsil that appear edematous. But there was no pus, redness, uvula deviation, and there was no pain. External palpation - the left neck felt "full" compared to the right side, but no mass was felt, and again, there was no tenderness to palpation. Lungs were clear. And otherwise his exam was essentially unremarkable.

So...we put him on oxygen, I drew labs (basically because I had no idea if this was infectious, allergic, traumatic, etc...and with airway issues I like to have as much information as possible, just in case surgery/intubation/intervention becomes necessary). I ordered a CT of the neck.

He's cruisin' along, sleeping on the gurney, when I got the CT report back:

"Extensive soft tissue swelling surrounding the airway...with prevertebral soft tissue swelling...partial airway obstruction...."

WTF??!!

I call for ENT, no one is on call. I call the nearest THREE hospitals...and I got some combination of 'no bed', or 'no ENT'. Finally, I get a hospital 80 miles away to take this guy. The ENT surgeon there recommends steroids, IV antibiotics, and intubation prior to transfer. All of that makes sense. Especially since the patient is starting to have more difficulty breathing and swallowing. We'd held off as long as we could to allow the meds to work but...he was indeed starting to have more significant respiratory distress. We preemptively called anesthesia for an awake option since he would absolutely need intubation prior to transfer, but that was now...not an option. Now is the time to intubate...


The critical care transport team will be here in 20 minutes.

So, I round up the troops. Explain everything to the patient; and obtain consent. Move him to big resus room, throw in a central venous catheter (in the femoral vein of course, not going anywhere near the neck). I have my colleagues at my side (2 other ED attendings) with the difficult airway cart at the bedside. I call for anesthesia, but no anesthesiologist is available (which I didn't understand, I mean how can you have an open/certified emergency department without OR staff...including anesthesia, immediately available? But no sense arguing/complaining now). I anticipate a difficult airway. But based on the patient's clinical status, and the fact that there is no one else readily available to secure the airway...we have to try. Or else just watch the patient decompensate in front of us...


We give the drugs, and bag him successfully. Then I try to intubate him. When I look into the airway...all I see is red translucent *pillows*. The airway is completely edematous...and I have no landmarks. I try the bougie, but I think there was too much edema to hear/feel the bumps on the tracheal cartilage...so it didn't help much. My two colleagues gave it a try after me. We didn't want to poke around in there...but we felt like we had no choice but to keep trying. We thought about waking him up, but considering his situation prior to induction...realized that that wouldn't be the best option.

So we ask the nurse manager to call anesthesia again, and if no answer she'll need to call the house supervisor...or anyone that can get an anesthesiologist in here. When I explain to her that we need anesthesia to intubate...she responds with "well they aren't here because the ER doctors usually intubate." But, after unsuccessful attempts by 3 ER attendings, I felt pretty righteous in rolling my eyes at her..and showing a bit of annoyance. Why do I have to explain to her (right NOW) why the ER doctor needs the anesthesiologist? Just fucking do it already!!

With a really shitty attitude, she agrees to keep calling.

So after 3 attempts, it seems as though the guy is intubated. Good color change on the capnometer, good breath sounds. We secure the tiny 6.5 tube. But, he starts to desaturate. Adjusting the tube and bagging him doesn't improve the situation, so we extubate him, and bag him. We are able to bag him!!

The CRNA (nurse anesthetist) shows up (no offense, but I didn't want a nurse, I wanted the physician...someone who can work independent and has final responsibility). I appreciate her presence, and ask her her opinion...but I'm still frustrated, and asking the charge nurse to continue working on getting an anesthesiologist here. And it's even more bothersome that I have to then explain to her that CRNA does not equal ANESTHESIOLOGIST. Sometimes people need to realize that shutting up and doing what's asked is 'what's best for the patient'. This was one of those times!!

We try to intubate again. LMA is at the bedside, but isn't a secure enough airway, and as long as we can bag him...we do that. And of course doing a cric (cutting the neck) is last resort, and since we could bag him...no need to get all messy. The fiberoptic scope is not something any of us ER docs felt comfortable using. There were no other fancy (easy to use) scopes/toys to help us in the difficult airway cart (actually, minus the bougie and the stuff for a cric, the cart was kinda useless, IMO).

We put a tube in, but I suspect the patient isn't intubated properly because oxygen saturation is stable at 97%. When we bag him with *no* tube, he's 100%. Why is he not at 100% with a tube?

It seems like FOREVER, but the anesthesiologist walks into the room (turns out he *was* in house as I figured). I don't think I've ever been so happy to see a consultant in my entire career!! He stands at the bedside, offering suggestions....oh, you're doing a good job...continue....don't worry about the O2 sat, etc.

NO, we're not doing a good job!! Dude isn't even intubated!!!

Initially he doesn't want to get his hands dirty, but after watching the patient desaturate to 96%, 95%, 92%...

...he'll come up, just bag faster, bigger tidal volume, more oxygen.

...90%...88%....

I hand him a pair of gloves. We extubate him (again).

He goes to the head of the bed, does some 'anesthesia stuff' and the O2 sat goes up to 1oo%. What he did was pull the endotracheal tube back into the posterior pharynx, closed the nose and mouth, and bagged that way. Then he asks for the fiberoptic scope...

While that's being set up, he takes a look with the regular laryngoscope...and couldn't see anything!! (I always feel a bit vindicated when someone else tries to do what I couldn't do, and they can't do it either).

Bagging is effective. Now the transport team is here to take the patient to the 70 mile away hospital. But we can't send him without a secure airway.

The anesthesiologist takes a look with the fiberoptic scope...
...and can't see anything!!

(now I'm thinking to myself "wow, I had no chance of getting that airway")

The anesthesiologist asks for a surgeon.

We call surgery, and he informs us that he 'cannot do trachs'.

Now what?
***

So I get on the phone, and call the only ENT surgeon anyone knows that lives in the area (that sometimes works at our hospital). He is not on call, and may not even be in town...but I call him at home anyway. It is now well after midnight.

I BEG him...PLEASE, PLEASE, come in and help us!! PLEASE we cannot send this patient anywhere...and we cannot secure the airway. Anesthesia is here, and cannot get the airway!! The surgeon can't do a trach!! We are all alone!! PLEASE Dr. ENT?!! PLEASE?!!.....

We promise him wine...we promise him gold...we promise to never call him again...
...just please come in now and help us!!

I think he heard the desperation in our voices...and maybe he likes wine, but he agreed to come in!! He asked us to call the OR team in stat. He asked us to set up the patient's ER room into an OR room. He'll be there in about 10 minutes!!

We activate the OR team, we set up everything. The OR staff is there in the ER, setting up the room before the surgeon arrives. Then *he* arrives...the ENT surgeon. To save our asses. The anesthesiologist is able to maintain ventilation by using his 'tube in pharynx' technique. We are all so very relieved...as if a boat has been sent to rescue us off a deserted island!!

The ENT surgeon does the trach in the ER. Anesthesiologist controlled the airway throughout the procedure with respiratory therapist.

Before I even complete my documentation, the patient is gone up to the ICU!!
***

I'm so grateful that this ENT surgeon, who was not on-call...may not even get paid for coming in (since the patient had no insurance, and medicaid doesn't pay sh*t)...and will likely be tired the following day at his profitable private practice clinic...agreed to come in and save this guy's life!!

This was my first time dealing with a truly difficult impossible airway (and I did anesthesia prior to emergency medicine...AND I trained at a Level I trauma center in Los Angeles!!)...

...and never had I seen a situation like this!!


**let me add: This is just a story, not an M&M. Medically people have been trying to dissect this case, but it's not (get this) an actual case.
It's a story.
The point being...the ENT surgeon who was not on call, came in anyway...and saved this patient (despite not getting paid, or otherwise benefiting personally, and maybe even professionally, in doing so). We create (and change/disguise) cases all the time to exemplify or teach a point - and this is what I've done, and will continue doing...to make the point. To create dialogue, and entertain. This case is somewhat unique in that more and more the specialists are actually *not* coming in (for anything), and lots of people die as a result of this all across America...
...this is the unusual case with one that did.

4.28.2008

filling my time with less frequent blogging...


I heard that blogging can be hazardous to your health.

It's interesting, because blogging can be stressful and overwhelming...especially if you're expected to produce new material more often than you actually *have* new material. After blogging about a year (more-or-less consistently), I find I have ranted and fussed about most of the things that bother me most (but don't fret, I still have a few annoyances I'd love to expose...and new annoyances things are always "coming up"). I have shared my enthusiasm for my profession. I have documented the process, the thoughts, and the transition from medical student to attending. And I've talked about memorable (pseudo-)patients. Now, I don't feel as pressured to write all the time.

Additionally, it's takes quite a bit of time on the computer to post even one (legible/comprehensible) entry. To translate your thoughts to print...and make them comprehensible by most who'll read them...takes time (depending on the thought). And, I've seen hours "disappear" as I update my blog, surf the net, return email, etc...all while the kids are on their 8th episode of SpongBob SquarePants of the evening (just kidding...kinda).

As the days get longer...and the weather warmer...and the kids get bigger (i.e. more activities, more time needed to engage them, more friends over, etc)...I think I'll have to spend less time on the computer. When they were in bed by 8pm - and me not until 11pm...I had lots of time. But now the little guys aren't in bed until 10pm (it's actually still light outside until almost 9pm in the summer here). So, I have less time to waste spend on the computer.

Just thought I'd post this for those who may wonder 'what happened?'.

Just enjoying the sunshine...

4.03.2008

What was medical school like? Years III and IV

After completing years I and II, you have a small break. At our school, this break was only a few weeks....and it wasn't really a 'break' at all.
After completion of year II, it was required that we take (and pass) the USMLE Step I. This first part (of a three part series) tests your basic science skills. Basically, the things we learned in years I and II are being tested. Our school was pretty good about teaching to the test (somewhat), and boasted a high first time pass rate. But you see, that 'break' was spent cramming for this licensing exam.

This exam was very difficult. You know, one of those exams that you can't even discuss afterwards because there were just so many uncertainties. You have no idea how you did. On other exams we've taken, most of us had a feeling about it:
"I think I did okay...but number 10, you know, the question with the xray...I wasn't sure if they wanted this answer or that answer...etc.'" OR, "that exam was horrible...what?! you put C for number 4?? geesh, I musta missed that one too...etc" (like this). After this exam, it didn't happen.

When I took the exam it was 2 days long...all day (except an hour for lunch). After lunch on day two...I just started marking everything 'B'. I was so tired of testing.

After you take that exam, you begin your third year. By now it seems as if everyone knows what they wanna specialize in. And if you do, that's a good thing. The sooner you know, the better. No one told me that...and I wish they had. If you know you wanna be, say ophthalmology, you can engage in research, and start kissing ophtho ass early. You'll take the rotation as soon as possible...and as many ophtho rotations as necessary to get the letters you'll need to match.

Years III and IV consist of clinical rotations.
Our 3rd year rotation schedule was made for us (i.e. we didn't get to choose the order of rotations). Basic required rotations were surgery, internal medicine, psychiatry, OB/GYN, family medicine, orthopedic surgery, pediatrics, and neurology. Our 3rd year consisted of these rotations. Most were about 6 weeks. You had about 12 weeks (maybe it was 16 weeks) of vacation. You could take that as a block, in two 6 week blocks, or however you could manage it. You requested your vacation time...and the university filled in your 3rd year schedule around it.

Our 4th year (frequently referred to as a 'sub-internship') we did our own schedule. There was a second round of required internal medicine...and many of us didn't necessary get all of the 3rd year (required) rotations completed in 3rd year (maybe because of vacation request, or scheduling, etc). So, you had to finish up those. Many of the rotations (the 'interesting' rotations) required the student to have completed a prior 'basic' rotation. For instance, an NICU (neonatal ICU) rotation will no doubt require the student to have completed pediatrics (and possibly OB/GYN) prior to starting. During this year, students typically take rotations like radiology, anesthesiology, emergency medicine, ophthalmology, dermatology, and maybe some bizarre elective at a far away place (but these electives are hard to get approved, and most students opt for pre-approved, 'normal', nearby electives). Also, you get to choose which hospital you'd like to do some of the required rotations. University hospital, County hospital, Community hospital, etc. There are some rotations that are notoriously easy (meeting like twice in 6 weeks) for an easy pass, and a nice break. I (am not ashamed to say it) *maximized* these opportunities. ;o)

During the rotations there are weekly lectures that your school 'requires' you to attend. These are usually very welcomed "breaks" from floor work/scut. Every day the students would try to get out of evening rounds by announcing: "uhhh, we have lecture this afternoon..." The residents and attendings were made *very* aware of the requirement of students to attend lecture...and were powerless to say or do anything except let us go (but beware, they'd sometimes verify that we're actually at lecture). Additionally, there were morning rounds, grand rounds, attending rounds, sometimes evening rounds. Lots of time in 'meetings'...really makes for along day when there's lots of scut to do.

The lectures were by in large *very* useful. And, in retrospect, I'm very happy I attended most of them. Learning pediatrics while doing a peds rotation...really solidifies the information. At the end of the rotation, there was an exam (on the lecture material). Some schools use the shelf exam, thankfully ours didn't. We had exams written by our professors. Everyone passed...eventually. You could take the exam multiple times, until you passed. Every (required) rotation had an exam.

Also during this time we had to take an OSCE (like a fake/simulated patient encounter). Completely bullshit (even in retrospect), where they bring in actors to play patients, and you're graded on how well you "play doctor." I hated "playing doctor." And I hear that this bullshit OSCE is now apart of the USMLE?? Requiring poor (literally, poor) med student to cough up money to take this BS? (but I digress...)

As a 3rd year, your presence on the team is largely unnecessary (despite what they tell you, and regardless of the student's arrogant belief to the contrary). You slow down the intern/residents; and all of your orders (rightfully) have to be cosigned...hence they are useless. In clinics you're really annoying to the people actually 'working.' In-house on the floor, the patients think you're 'cute' and they always 'know someone, who knows someone, who 'gonna be a doctor.'' And instead of telling you their deepest concerns and intimate medical issues...they wanna talk about *you.*

In retrospect I realize that much of that...that inability to be taken seriously by patients was my fault. I was insecure, didn't really know what to ask. My history was unfocused. AND I actually sat there with them for hours getting largely irrelevant information...which made me their "friend" and not their "doctor." (which is okay since I *wasn't* a doctor...).

The various rotations differed from each other tremendously (and I'll discuss that on a different post). But, in general, to do well in the clinical years involved working smart - and the realization that you're really gonna have to make some time sacrifices during those rotations that involve the specialties you're actually interested in applying to...because they will haze you.

Let's just take internal medicine as an example:
To do well in internal medicine you should try an be apart of the team. That means not leaving too frequently to attend "lecture" or whatever. That means arriving before everyone else does, and leaving after they do. When you have patients assigned to you, realize that *you* are not managing the patient - the attending and residents are managing the patients, and you are doing what they tell you to do. Your role is to listen and learn. But more than that, having assigned patients means you're responsible for *information gathering* for those patients. As a 3rd year (and 4th year...and intern) YOU ARE AN INFORMATION GATHERER.

Some will tell you to 'know everything' about your assigned patients. Well, that advice didn't help me much because, on a practical level, that is not possible. Better advice would have been as follows:

You come early and get the lab values (know the trends), the radiographs/results, the medication list with the antibiotic day number, fluid intake/output/weight change, any overnight events on the nursing note or per the patient. You should know what the physical exam shows (new rash? pressure sore? crappy lung sounds?) You should know the vital signs, and if any fever spike overnight (and if so, what time). You should know if any orders had to be written on your patient, why, and if what was done helped. You should know their bed number (and if they were moved, the new bed number, and why they were moved). You should know their working differential diagnosis...and do some reading about the disease(s) and how to treat them, what complications to expect. You should have written the daily progress note (to be completed after you are told by your team what the assessment and plan are). And you should anticipate (or have the handbook) of possible questions the attending will ask...and know the answers so you'll look like a star.

Your school will let you know if overnight call is required. There needs to be a place for you to sleep, and something for you to do. The nurses may (or may not) be instructed to call you first. And if they don't, well...it's kinda no point for you to be there. Especially if your orders all have to be cosigned. The intern will have to take every call, and write every order anyway...

...but at some community hospitals I rotated thru, there were very nice call rooms for everyone...and the nurses *did* take student orders...and they *did* call the student first (usually these are 4th year rotations where you're working as a sub-intern). It's easier to stay on-top of your patient information gathering duties if the nurses call you when there's an issue. And you felt important. Also, typically OB requires overnight call for obvious reasons.

Exactly what do you do all day?
Well, you go in early (whatever time makes you the first person there). You go physically look at your assigned patient (usually you'll have 2 or 3). Make sure they are alive, breathing, and are still in the location they were yesterday. If they are awake, ask them how they feel. Be sure they know you were there (this is more important as an intern and beyond, sometimes patients will complain that 'their doctor never comes by and see them' not realizing that *you* are the doctor...and see them multiple times a day. You can't have patients spreading rumors like that about you). Put a stethoscope on their chest. Pull back the covers gently and make sure there's nothing obviously wrong. Do a focused exam - meaning, check the part of the body that's causing them to stay in the hospital. Note any changes.

Then you have your paper/index card for that patient. You write their room/bed number on top next to their name and medical record number. Then you grab their chart and flip thru it...looking for the information I described above. Look at the nursing notes...and read what they wrote overnight. Look at the vital signs sheet for the last 24 hours. Look at the order sheets and see if/when anything was ordered. Read the physician progress notes, and note anything significant. Be sure to look at the medication list. Check the labs, and remember to check for any positive blood/urine/sputum cultures. Know the medication allergies. Look and see if any of the consultants wrote any (new/old) recommendations. Then, write your note with all of this information incorporated SOAP note style (leaving the AP blank until after rounds). If your note is good, only the attending will have co-sign, and it'll count as an official note (i.e. the intern won't have to write a full note, and they'll be happy).

Do this for every one of your patients. And with any time left over, you go eat, and read a bit about the diseases your patients have (and what to make of any overnight changes).

If your hospital still has plastic xray films, you should find them, and gather them. Carry them around for the attending to look at. If you have a pacs (digital) system, log on (or have someone log on for you) and look at the films. Look for any radiologist reports...and look at the images yourself. You should be able to identify any significant changes between today's xray, and the one taken yesterday. Lungs more white? Kinked chest tube? Free air?

During rounds you present your patient the way the attending likes it. Be sure to at least mention (to someone other than another student), things that *you* think are important, but couldn't say on rounds. Remember, rounds isn't always about learning or information exchange...sometimes, with some attendings, it's about providing them a platform to flex. They may not appreciate someone like you making them 're-focus' on patient care.

Many teams will have short 'okay-this-is-the-*real*-deal' rounds after the attending leaves. Where the work is divided. Then everyone goes to morning report/rounds. Morning report is a lecture where an intern presents a case, and everyone does this mental masturbation exercise about the patient.

Then it's time to work. Most hospitals where residents exist aren't very efficient. The nurses don't do shit...and the students/residents do everyone else's job. This is what takes forever. This is the problem with resident education. This is why it seems as if the surgeons aren't as well trained with restrictions in place...eventhough they're in the hospital 88 hours a week. Are the surgical interns/residents so stupid that they cannot learn what they need to learn in the 88 hours/week, 5-7 years they're there training?? (I just love what the medstudent tells Bongi in the comments section of this post). Of course not!! They aren't doing all the necessary *doctor tasks* to properly train because they spend 90% of their time doing other people's work and miscellaneous non-physician/non-educational/irrelevant bullshit. Drawing labs. Finding lab results. Pushing patients to scans/xrays. Finding xrays. Massive clerical work. Trying to plead with hospital staff to do what they're supposed to be doing for the benefit of the patient (so they can get that study done, or that consult completed...so everyone can go home). Residents/interns play social worker, trying to discharge patients with no place to go. And during it all while being constantly interrupted by pagers. Some of the bullshit is unavoidable, but much of it can be changed if the higher-ups were really interested in change and patient safety...while maintaining the high quality of the doctors being produced.

But instead, they advocate for unrestricted resident hours...

Unwritten rules include:
it does you no good to make your fellow student, the intern, or resident look bad in front of the attending. If the intern is asked a question by the attending on rounds, and s/he doesn't know the answer...don't you jump in and blurt the answer. You say nothing...unless the attending directly asks "does anyone else know?" And still you wait a minute. I would advise that 'if your superiors don't know, then you don't know', period. If you are smart and actually *do* know, it will show in different settings - such as when you concisely present your patients to the attending with a focused differential, and the subsequent pimping session proves you know your shit; or when the attending asks you a question first and directly and you *modestly* give a correct answer. You do not get cool points from anyone being a smarty-pants know it all. And if one of your teammates doesn't know something about his/her patient, you can tell them discreetly, but never one up them on their own patient in front of the attending. And, please, *never* ask questions that you know the answer to. This annoys everyone!!

It's best to not talk negative about anyone. That can only come back and bite you in the ass.

On rounds you follow the pack. You stand if chairs are limited. You carry all the crap (the stethoscopes, the otoscope, tongue blades, whatever is commonly needed but not commonly easily obtained). You don't argue. If someone says you're wrong, you're wrong. Even if you're not wrong...just forget it. If you want honors, and a match into the specialty, you'll realize being 'right' doesn't matter.

Many times inappropriate comments were said (especially on surgery), and may put you in a difficult spot. Usually some sort of sexist jack-ass with a small dick blurts out some off the wall comment about women...but sometimes it's even more hateful than that. It was not unusual for surgical attendings to throw full-on (two year-old type) tantrums. Surgical instruments thrown across the OR because anesthesia had the table too low. Or verbally abusing everyone, just to see how many times he can make the resident cry.
What seemed to work well at our school - a group of students who agree that the person is out-of-line would go to our student affairs dean and complain because it's never just one episode of ignorant behavior, and many people can usually agree that the guy (it's usually a guy) is an ass. We'd express our concerns, and demand to be moved to another team, or another service, or another facility. Usually, if there was a (big) problem, you could be moved (as it should be being that you're paying up the ass for an education). And on more than a few occasions, students were not placed on certain teams, or with certain attendings with a reputation for being assholes. But realize that as an intern...the solution is not so simple.

Offer to do a presentation for the team. Bring in an interesting journal article (if you happen to find one), and educate the team about it. Have a happy disposition. Be reliable. If your intern relies on you, you cannot miss attending rounds...because they will not know the detail about the patient that you know because they were *relying* on you to know (and be there). (Even if you're sick, you need to come in for attending rounds...then ask to go home). And don't leave until all the work is done...or at least ask if there's something you can do to help out the 'slow-poke' before you leave. Usually the answer is "no", but if you acknowledge that they are still there, and offer the help...it will be noticed.

In order to graduate from our school the USMLE Step I must be taken and passed. USMLE Step II is taken during senior year. It does not have to be passed to graduate. There are strategies as to when to take Step II. Some do it early to make their application competitive. Others do it later, as not to tarnish an already acceptable application. It depends on the competitiveness of the specialty, and the competitiveness of the student. Also a consideration, if you did awesome on Step I...you may not want to take the chance that your Step II score will be lower, and some of your shine is lost.

USMLE Step II is easier (more practical information), than Step I. It was also 2 days long. Exam topics are those of the basic rotations - peds, IM, psych, etc. Some specialties consider the USMLE score to be the single most important part of the residency application.
***
Overall, in years III and IV you have much more control of your time. Only a few rotations are brutal, and only being so because of their long hours and the amount of scut (i.e. gathering information, and pushing the patient along in the hospital diagnostic/treatment process) required. Some rotations will be more stressful because you're trying to impress the staff. Usually, by mid 3rd year everyone is pretty sure what their interests are...and it's no secret to surgery residents that you're not into what they do. And they don't torture you as much.

You have time now to see a movie. The tests are easily passed with a day or two of studying. Even the USMLE has great prep material out there such that you don't have to study much more than a 150 page book and do well (enough). If you're a good team player, and do well on the exam, you'll honor at least a few (maybe even most) rotations. If you do very well, and people really like you, you may be inducted into the honor society, AOA. AOA on your CV looks very good to program directors of competitive residency programs. Also, you have time to engage in some research (not alot of time, but *some* time). And some students will take a year or two off after 2nd year to do research (or have babies, or travel, or get an MBA, etc). This will also look good on your CV (well, maybe not the 'have babies' part, but that can be disguised as 'research' if done correctly).

Many medical students decide to have children during 4th year. Some do away rotation in Costa Rica. Some take no vacation...and save it all to the end (this is what I did). This was fantastic since my last rotation ended in early February, and I had 'vacation/freetime' until I graduated in mid May!!

That was my last 'summer vacation.'
-
p.s. so, now that you understand what medical school is (sorta) like...you'll appreciate the (hilarious) humor in these videos on my sidebar:
This one. This one. and this one. (you just have to see them all. After the first one plays there's an opportunity to watch the others...)
I'm LMAO just thinking about them!!

3.31.2008

What was medical school like? Years I and II

I remember being a pre-med. I had the full college experience, IMO. I studied to maintain an academic scholarship, had part-time work (intermittently), and pledged a sorority. I dated more than one guy, did some local traveling, and made lasting friendships.

I remember being very concerned about 'med-school prep.' I wanted to take the "right" classes...and do the "right" summer programs. I had to volunteer, and participate in campus organizations so I could distinguish myself from the 'average' student. I did undergraduate research that resulted in publications. I took MCAT prep courses, and followed the recommendations of the premed office on campus regarding which classes I should take when...when to apply to med schools, and which schools I'd likely get in to.

I gained early acceptance into medical school. This acceptance was arranged such that I didn't *have* to go to this school if I decided to continue on in the application process and I happen to gain acceptance into another (more desirable) school. I decided I wanted to come back home, so I applied to the local schools. Got accepted. Decided *not* to go to the 'early acceptance' school.

I was ready for medical school. I'd done 2 or 3 (med school/MCAT prep) summer programs. I'd taken all the requisite courses, including anatomy, physiology, advanced chemistry, microbiology...everything. I felt pretty prepared...but utterly unprepared at the same time.

I remember the first 'meet and greet.' Everyone seemed nice enough. I guess I expected everyone to look like 'revenge of the nerds' or something...but they all looked normal enough. They were social and some boasted full "prior lives" as policemen, firefighters, nurses, teachers, mothers, fathers, military...

The average age of my first year class was 30. That means that half the class was *over 30* in their first year of medical school. I had no idea everyone would be so...old. There were even a few people close to 50 (after having raised families or whatever)!!

There were quite a few smallish/informal meet and greets. Some indoors (dinners hosted by alumni, or AMSA, or some other group). Some outdoors, usually in the quad. Sometimes there were booths up urging us to join this group, or that group. Some upper-classmen were there, offering advice, or representing a club. We had picnics/BBQs. It was very nerve-wracking.

Then, our first welcome lecture. The one where they introduce lots of faculty. The one where they give you your first taste of what medicine is *really* like. They explain the horrible state that is American healthcare...and basically express frustration with the field. They seem to hate so many things...and are so bitter. Jaw on floor, you try to take in all of this information. You try to understand the bitterness, and convince yourself that "I'm not going to be so bitter when I grow up." Then, as if they're reading your mind, they say "you just wait...you'll see. Come talk to me in 10 years."

And school hasn't even started yet.

There was the white coat ceremony, where a few friends/family get to listen to a lecture about how wonderful being a doctor is and how doctors love patients so much (stark contradiction to the lecture *you* and your classmates sat thru just days prior)...and you get the (short) white coat (as if it's important or something). Everyone is so proud of you.

Then, the first real lecture happens. The big lecture hall. Everyone stakes out a seat. I liked to sit on the front left side, about 5 rows back. I liked to have the seat next to me empty. Everyone's very excited. The lecture is introductory and entitled "is healthcare a right?" Clueless to the political implications (as many medical students are completely apolitical), you start formulating your thoughts based on this lecture...and others that follow.

At our school we had these 'classrooms' where everyone had a desk (with lots of locked storage). In each of these rooms (there were about 10 of 'em) there were about 16 student desks - arranged alphabetically by last name. The person that happened to be sitting next to you, was your partner for the year. In these rooms there were slides, microscopes, bone sets, television with videos...learning aids, stuff like that. Immediately everyone brought artifacts from home to decorate their spaces. Magnets, plants, pictures, books, lamps, snacks, etc.

I remember the first day of (real) class. After the intro courses, and the welcome to our school speeches...the first real day. We were each given a stack of papers about 1 and a half feet tall. "Learn all of this by December." In addition to the stack, we had pre-filled notebooks for lab (gross anatomy and histology). Learn this too...and be sure to be able to identify these slides (box of micro slides handed to each of us), and you have to show up once a week for ICM (intro to clinical medicine).

I don't remember all of the classes off hand, but I do remember anatomy (lecture/lab), physiology (which is *quite* separate and much more difficult than anatomy, unlike in college). Microbiology (lecture and lab). Biochemistry (like hard core biochemistry); pharmacology, neuroanatomy, preventative medicine (epidemiology) embryology, and family medicine/ICM. The exams were during 'exam week' with 3 exams a day M W F. The multiple choice wasn't 'regular' multiple choice. They asked us to 'choose all possible correct answers'. If you chose too many, you missed the question. Missed one...also missed the entire question. There were k-type questions. I'd never taken a *multiple-choice* exam that was so difficult.

And they try to trick you. You have to read the questions very carefully, and consider the *exact* wording of the question. For instance, they'd show a picture of a large white blood cell...surrounded by a bunch of small red blood cells. White blood cells are big, have nuclei; red blood cells are smaller, and do not. (see above picture for example). Well, the question will be: "what are the characteristics of the predominant cell type in this slide." You ask yourself, predominate as in this big ass WBC? Or predominate as in the sheer number of RBCs shown. They were talking about the RBCs...and basically wanted to know if you knew that they had no nuclei. But, many students assumed they were referencing the WBC (that was huge, front and center)...and they missed the question.

Year one was also the year of gross anatomy. We had a few people who had issues with gross. The smell, the dead bodies, the thought of dead bodies...the dissecting. They would faint, couldn't stand blood and gore. We had pregnant students who had to wear respirators. But these issues are all worked out (through desensitization exercises). The only time it was difficult (for me) was when we got to the hands (and some of the women actually had pink fingernail polish on)...and the face. Usually, everyone kept the face and hands covered until the moment we *had* to actually dissect them).

There were all sorts of bodies, all sorts of ages. Mostly old white men...but lots of old white women too. Not so many of anything else...so when someone actually had a black body, it was very cool to compare/contrast the structures and such. Likewise, a young person, with well-defined muscles, offered something that the old people didn't. The bodies (on the inside) of course were more alike than different...but there are differences.

We had lab coats in plastic bags in lockers located in the gross lab. We were divided into groups of 5 per cadaver. We started with the back. Two people are supposed to dissect, one on each side of the body, and two others give 'instructions' on the proper technique/strategy by reading aloud the directions provided in the notebook. The notebook had key terms, and a list of structures that we're supposed to find and learn. And learning, not just their identity, but their blood supply (and the origin of said blood supply, it's branches, where it ends, what type of muscle lines the walls of the vessel), the nerve supply (and any thing else that the nerve innervates, muscles, organs...and where the nuclei of the nerve is housed...and which nervous system is responsible for the actions of the nerve).

If you cannot find a structure (either because your body didn't have one...but more likely because you destroyed it dissecting)...you had to come back to the lab after others dissected their bodies, and find someone who did it right. The person dissecting is supposed to switch day to day. Lab was 2x week. Lasted from about 1-6pm. There were TAs and tutors there for part of that time.

Lots of things to recognize, and the exam consisted of secondary/tertiary questions. Never are there questions like "what is this structure?" Too simple. Rather, a cadaver arm will be completely dismembered from the body, laying on a stool, covered with a towel...except for a 2x2 inch window. Three different color pins will be stuck into 3 structures. A card next to the arm will read: Where are the cell bodies located of the nerve that innervates the structure indicated by the red pin?

Even if you know the structure indicated...and even if you know the nerve that innervates it...damn if you know where the cell bodies of that nerve are located.

And 'knowing' what the structure is in the first place is a minor miracle in itself - being that you can't tell which way is up/down/right/left (since the arm, at least you think it's an arm, is detached from the body). And, to make matters worse, the tiny 2 inch opening makes it difficult to orient yourself with even local cues.

There are like 30 or so stations, with a portion of the class scheduled to take the exam at various times during the day. The questions are shuffled, but are the same. Each station has one student. Each station has 3-5 questions. You are timed. At the end you are (sometimes) allowed to go back to previous stations for 5 minutes or so.

Micro was alot like gross, except you get seasick looking at slides. And part of the exam was administered via a slide show.

All lectures were optional except ICM. Some students would show up for the first day of the semester...and disappear with their stack of notes, slides, and notebooks until exam time. We had a note taking process where the notetaking responsibility was shared among all students. So one student would attend a particular lecture, tape it, take notes, and go home and type them up nice and pretty. Then distribute them to the rest of the class.

There were tapes and videos of the lectures. And old lecture notes and exams from years past. So, there was plenty to study. I went to class everyday, but didn't attend every lecture. Some professors were great...and others wasted your time. Some topics were very confusing to try and do on your own...and others were quite clear after reading the notes. So, you pick and choose which lectures you wanted to attend. Our medical school spoon-fed us...which I think is a good thing being that I'm now over a quarter million dollars in debt because of it. It's the least they could do!! I deserve to have 'eaten well' for that much money!!

Medical school is like....they took everything you've learned in all of your undergraduate science courses and composite it into 2 days of lectures...as your introduction. On day 3, no matter what you've done in undergrad, no matter which courses you've taken, or how great your professor was at teaching it...on day 3, it's like you had *no* prior knowledge of the material. On day 3, everyone is on the same level playing field...science majors, biochem PhDs, art majors, and those who took every premed course they could. No matter.

I remember sitting in front of the computer, taking a practice biochem exam (WITH MY NOTES OPEN), and still utterly confused, flunking the practice exam one week before the real thing...and I graduated from undergrad with a degree in CHEMISTRY and a minor in biology!

At my medical school it was imperative that you pass all exams. There was a curve so that almost everyone passed...except in a few subjects. If you failed an exam, you had to retake that exam and pass it. If you failed the retake, or didn't take the retake, or it was the last testing period of the year (hence no time for a retake)...you had to retake the entire year's course in the summer. If you failed the summer course, you had to repeat the entire year of medical school. There were always a few students who had to repeat their first or second years.

The students helped each other. There was no pyramid nor was the curve based on the highest scores. The curve only served to lower the pass percentage in the instance that more than 10% of the people scored below 70%. Pass was 70%. Honors was 90%. Our grades were pass/fail/honors.

Do not need to be smart, per se, since it's mostly memorization. You just had to know what to study, and how to study. And you had to know how to take the test. Anticipate the questions...learn to read carefully...do the practice exams...and study in groups (at times). You had to use your time efficiently, especially if you had other things going on competing for your time. I didn't know anyone in my class that worked...but there were a few parents. I realized that I had to read the material 3 times in order for it to stick...and that was straight forward stuff. The complicated stuff...physiology, epidemiology, and biochem...I actually had to *figure out* before I could attempt to memorize.

Second year material is more complicated than first year. Second year was organ system based, and 'illness/pathology'. Whereas first year was micro/histology, second year was pathology. Whereas first year you're learning about the heart and cardiovascular system, in year 2 you're learning about congestive heart failure and strokes. It was easier than first year because you are now an 'experienced' medical student, able to pick and choose what's important to study...and how to take the exams so you pass. Also, a few things are repetition, and you have a base to hang new knowledge on...
***

Overall, most people who flunk out of med school, do so during 1st and 2nd year. And of those, almost all flunk out because of some competing personal issues. Family, marriage, financial, illness, mental, emotional, etc. Not because the work is too hard. Because, actually...it's not. It's memorization. It's being able to choose the 3 most important points in a given lecture...and commit those 3 points to memory...then reproduce those points in one way or another on an exam. It's knowing what to study. Focused study. If you don't focus, you won't do well. You cannot know everything...and if you try, you will have a more difficult time.

It takes some time to become okay with going from being the top in your class (from kindergarten, onward) to being "average" among your med school class. It's hard to incorporate 'family time' and 'friend time' into your life. You feel guilty for spending your Thanksgiving "goofing off" with family rather studying in preparation for mid-terms. And movies are out...2 hours of "lost time" is just...unacceptable. You take your backpack *everywhere*, just in case you get 'stranded' you won't fall behind in your study. And don't even think about getting sick...

No one in our class had outside employment. There were a few parents, usually fathers with stay at home wives and the rich grandparents supporting the young family. Many students even stayed at home where their parents prepared healthy meals daily and washed their clothes. No wonder they did well!!

You cannot spend the time worrying about money...so you must take out loans to support yourself (if you don't have rich parents). You have to have a car and a computer. You have to spend money taking exams and joining organizations.

Living close to school is a plus (that way you avoid wasting valuable study time on the road). If you must spend lots of time in your car...get some audio lectures to listen to.

There were a few women who managed to have babies in med-school and do very well. They often did not attend lecture, spent all day studying in the library instead. Stayed late (until 6 or so) in study groups/labs. Were very focused and didn't take breaks or goof off during 'study-time'...and did well. On the other hand, those of us without kids/families spent 12-14 hour days in the library, 6 days a week (easily). We snuck food into the group study rooms. We did alot of chit-chatting, and often went from study site (i.e. library)...to another study site (i.e. cafe')...and yet again to another study site (i.e. someone's apartment). Our lives were studying in different locations...sometimes inefficiently moving from place to place, talking about off-topic things.

The first 2 years are fun...but requires lots of attention (to say the least). There's no real patient contact (that ICM bullshit doesn't even begin to count as 'patient contact'). Your life is your backpack. Your notes are guarded with watchful eyes and taken everywhere (there's no way you can lose those notes after spending 2 months color-coding everything, and highlighting the pertinent points). And the fun you have is...in the gross anatomy lab, eating pizza and drinking beer while comparing the structures in various cadavers!!

2.20.2008

A groove...and time *not* being a doctor

I finally feel like I'm getting into a groove (I'm reading Vicki Iovine's book shown here...and love it).

I've been out of residency 2 years, passed my boards, and my hands no longer tremble when I have to intubate someone. My heart doesn't skip beats (as often) when I hear the MICN on the box taking a full arrest run. And, I'm more-or-less comfortable sending well babies home without worrying (too much) about whether or not they'll develop meningitis in the next week or two...

I've developed a (usually) polite, yet firm, way about me and my practice...in order to get things done. Both patients and ancillary staff typically respond better to a physician who is decisive and confident. But, I know how to listen and take advice (i.e. hear the subtle, or not so subtle, inflections in the voices of family and nurses when I should consider rethinking my disposition). I know how to ask for help without feeling incompetent. I can explain myself to the second-guessers...and feel even more validated in doing so. And, interestingly, I'm not at all shy about admitting what I don't know.

I'm actually enjoying myself most of the time.

Of course I still have times where I'm nervous, overwhelmed, or simply just not feeling up to the task. Since it's difficult to take 'a sick day'...we doctors (and nurses) often come to work regardless of how we're feeling - and probably when we shouldn't. But I digress....

The biggest thing however is my new-found *balance*. I have found the perfect number of shifts...types of shifts...and places to do said shifts. This, my friend is key. I believe that being rich means having choices, period. Money certainly allows for more choices (to a point), and is therefore a necessary part of the equation. But, choosing how you spend your time, where you spend your time, who you spend your time with, etc...for me actually defines "rich." If I'm working 25 shifts/month, I may have a $30,000+ bring home salary/month, but really, I'm not rich if I have to go to work frikin 25 days/month!!

I realize that working about 10 shifts/month allows me to bring home more than enough money to cover our expenses plus savings...AND I get to spend the rest of my time (get this)...doing other things!! Additionally, I realize that I actually enjoy working at 2 different EDs, each with their own flavor. Working in two different EDs allows me to not get all caught up with the politics of a place. My residency program was the *most* political program ever (I'm sure). Every word, every action...political. Very stressful.

I also realize that I actually *enjoy* working at an urgent care center/walk-in clinic. It offers a completely different perspective. It's nice to have time to sit here and update my blog (finally), and see patients intermittently while doing so. It's nice to take a lunch break (imagine that, a lunch break!!)...and its nice to visit the toilet from time to time when necessary.

Also, it's nice to refer patients that you don't wanna see (for whatever reason) to the ER. Shortness of breath? Hmmm...you need to go to the ER. Pregnant vag bleed...yep, ER for you. I see why so many clinic docs dump refer their patients to the ER...it's just so frikin easy. Not that I would ever do such a thing. All the patients I send to the ER actually belong in the ER...and I should know.

Sometimes I get asked by folks when I tell 'em I only work 10-12 days a month:...what else do you do with all your time?"

Seriously??!!

You know what I do? I cook healthy meals because this non-organic/fast food shit is killing us. I read for pleasure (for the first time since college). I keep my babies out of daycare from time to time so I can take them to the park, then to the ice-cream shop...and maybe even to the mall. I manage the business that is a household (which is a full-time job). I make sure the bills are paid on time; I negotiate online payments, allocate funds for various usages, manage half of our accounts, and basically (since it is my strength) manage the finances. I am the historian of our family - blogging, documenting, video-taping, photographing, and scrapbooking our lives...so we won't forget, and so the children will have a sense of what their childhood was like.

If not me, who will go thru my kids drawers and determine what fits and what doesn't, what I adore and will save for them vs. give to a shelter? If not me, who will decide where I want things to go in my home...how to decorate...and how to organize? If not me, who will take inventory of what we have, and what we need as a family? There are some things a house-keeper can help you with...other things, I'd rather do myself. If I don't change my own kids diapers, how will I be able to tell the pediatrician that their poop is consistent with prior poops? If I don't bathe them, how will I know that my little guy likes to play submarine with his Thomas the Tank Engine train set? Or even more importantly, how long would it take me to notice an injury or a rash if someone else (or various someone elses) are doing the parental tasks? If I don't read to my kindergartener, how will I know she's progressing as she should in school...and in life? If I don't find time to really talk to her, how will I know who her friends are, and what they're like? I wonder if my colleague knows how much fun she's missing when she leaves the house before having had the opportunity to dress up her cute little girl in almost-as-cute clothing...and spend time fixing her hair just so? Isn't this why we dream of having daughters? Why would you want to delegate all the fun stuff? And...if I don't have sex with my husband, and listen to his hopes and dreams, how can we stay connected in this partnership that is raising our family...and enhancing our lives? I waited almost 30 years to be 'mommy/wife'...and I want to be intimately involved!!

You know what I do? I walk my (often neglected, despite all my "free time") dogs, and train them to obey me. I do yoga so my back won't be sore after my shifts. I get massages and facials...and my eyebrows threaded. I do my hair, my nails, and read fashion magazines. I have like 4 blogs in progress...and enjoy being 'in the world' in this way. I'm (still planning to) write a great book (but there isn't quite enough time).

I've discovered that I actually love photography...and it is not my style to do things half-assed so I actually devote a bit of time to this hobby. I am in a Sorority, and like many sororities, our membership doesn't end upon college graduation...and there are time commitments involved as we serve as mentors, organizers, advocates, and community activists in my Sorority as a graduate. I plan awesome trips for our family (that we have time to take because I don't work all the time). And not huge extravagant/over-compensatory (i.e. I work all the time so when we go 'on vacation' it has to be big so our friends will be impressed, and my working all the time seems justified) 3 week European-type trips...but rather Disneyland Resort trips...Legoland trips...Vegas trips...Tahoe trips. Frequent trips. Easy trips.

You know what I do? I can attend school field trips with my daughter. I can keep the laundry done (most of the time). I can be mentally and physically available and present for my husband. I can unwind and tend to my needs so I can be patient and understanding with my kindergartener and toddler without yelling all the time over spilled milk, literally. And without sitting them in front of TiVo'ed Little Einsteins cartoon for days on end (hours? maybe. days? no).

I can have 2 hour conversations on the phone with my parents...and/or my girlfriends. And I have the time/energy to spend a weekend or two a month (or at least every other month) socializing with good friends as a family (their kids, our kids, red wine, good food, background jazz playing, with the BBQ grill going, or tandori chicken and naan waiting for us in the family room...OR maybe an exciting night out at the bowling alley - the one with bumper guards to keep the bowling ball in the middle of the lane). And I have flexibility, and enough 'extra' time off that I can actually pick up shifts quite easily from other partners who need/want days off...but the schedule is already printed.

Above all...I just have time to think. You know, be bored...like a child in the summer, back in the day ('cause these days, kids are overextended and never have the pure luxury of just being bored). To just think. Think about investments, think about purchasing property, think about our next trip...and just let the creative energy flow. Think about ways to be more fully involved and engaged in this life I've been blessed with. Think about life. Think about my purpose...expanding my spirituality.

And, of course...time to *not* think...and just be.

Just be.

There are so many things to do when not cooped up at work...running around crazy, neglecting your own needs. There are so many places I'd rather be, despite the fact I love being a doctor. Actually, I love being a doctor *because* I have plenty of time to *not* be a doctor.

I've said it before...and Dr. Leap repeated it here:
It's so important to realize that we are so much more than doctors. We are mothers, wives, daughters, spiritual beings, individuals, pet-owners, aunties, girlfriends, sisters, mentors, community activists, here to serve a Divine purpose. We have other loves and interests. And life marches forward.

Balance is so important...
...hopefully new doctors will realize that - and find their groove.

1.28.2008

Confessions.*


There are a few things that many EM docs don't openly discuss 'else they subject themselves to criticism and judgment. Here are few of my confessions -


I think leaving acute patients to 'see quickies' in an attempt to clear out the waiting room contradicts the very essence of emergency medicine...and I don't do it.
In every emergency department there is (supposed to be) some sort of triage process. Where sick people are seen first, and not-so-sick people...wait. Well, our nursing staff (as wonderful as they are), will frequently ask me if I would 'come out and see some of the quickie, non-sick people, to clear out the waiting room.' If I'm sitting around surfing the net...then sure. But I'm never not busy at work. Never, ever. I rarely get to go urinate, much less grab a bite to eat. So, I don't do it. I can't justify in my mind, leaving my sick patients to go see not sick patients. And all to "clear out the waiting room?" That's really not my goal. My goal is to keep people who shouldn't die, from dying...and to get the rest to their proper destinations. When my shift is over...I leave. Waiting room full...or not. Why should my goal be to clear the waiting room? If I valued an empty waiting room...emergency medicine would be a poor choice of specialty.


I think that speeding thru patients, and subsequently rewarded for it, is a bad idea.
It annoys me when doctors brag about their half-ass workups in an attempt to seek reward for speeding thru patient encounters. Our patients wait, sometimes in excess of 6 hours, to see us. They deserve 10-15 minutes of face time. Even if the problem is straight forward and you only need 90 seconds. This interaction with patients (listening to them, talking with them) is why I love medicine. Minus the patient encounter...what's left?

Sure, I understand being efficient is important...but seeing 3-4 patients an hour is not good for the patients you see. They won't like it...and you won't like it. Something will be missed. A something that won't be missed if the doctor just takes a minute, grabs a chair, and spends 15 minutes with a patient. Additionally, taking a minute (or 5 or 10) to look up information (for yourself or for the patient) is totally appropriate, but doesn't lend itself to "speeding thru" cases. Finally, very important thought processes would be clear if time was spent documenting this information *in real time.* Not to mention more defensible in court, and basically just better communicates (as a medical record should) with other care providers.


I hate reading history and physical assessments written by people who are more concerned about capturing all the "elements" for full reimbursement, rather than actually documenting what the hell's going on with the patient.
There are so many docs now who chart based solely on reimbursement, that very key information is not included in the documentation. I do understand the need to get paid...but it's just as important to communicate effectively for the well-being of our patients. And simply putting "4 elements" in the HPI...doesn't quite do the job.


I hate dictating.
In the ED so many of my tasks are accomplished piece-meal. I may do the HPI in the patient's room...fill in the physical once back at my desk...and document the labs/xrays as they become available. I'll later fill in consultants names, times called, and their responses. Medical decision making usually follows. Finally I have a "diagnosis" and disposition. If I dictate, I can not do it in real-time. Otherwise I'd constantly be calling the dictation line back adding "addendums". Not to mention the time it would take to dictate "Dr. Cardiologist paged at 12 pm; no answer." (click) Then call back: "Dr. Cardiologist paged again overhead at 12:20." Or what about when patient has a change in condition? I can type over 75 wpm. I can write on the paper chart standing at the bedside. I can get distracted, and return to the charting very easily. But dictating...every chart...is unreasonable. Dictating looks pretty, and after the final disposition has been obtained, perhaps going back and dictating on selected patients would be helpful. But, I think it's a bad idea to do essentially no charting (scribbling notes to yourself on the paper chart with the intent to go back and dictate, *isn't* charting) until after your shift (sometimes *days* after your shift). I think that's a set-up for disaster.


I like to leave on time after my shift.
What's wrong with saying that? If I'm scheduled to be off at 4pm...I wanna leave by 4:45 (really right at 4, but I do understand expecting to stay up to an hour later to wrap things up). For some reason, some people think you're being lazy if you get out on time. On the contrary. It takes crazy planning to get out on time...and still see new patients up until the last 30 minutes or so of your shift...AND not sign-out a whole bunch of shit. It's an art, really.

I do not like being made to feel guilty because I actually have a life outside of the hospital. Not to mention that staying late isn't compensated time. I don't like to stay late (or come back on my day off) to chart on previous patients...not to mention that this isn't best medicine, IMO. And I expect oncoming colleague to take a reasonable sign-out without bitching and moaning. Of course staying is sometimes unavoidable. Of course some sign-outs are inappropriate. But I'm not talking about an occasional late day...or defending docs who chronically dump on their colleagues. I'm talking about a general attitude that everyone is expected to stay 2 hours late (cuz if they don't it means they were "slacking" during their shift and not seeing patients near the end...or didn't see as many patients as they "could have" because they completed their charting within the shift.) Neither is necessarily true...and on the contrary, docs who are efficient enough to finish their work on time...should actually be rewarded (rewarded with going home on-time without comments from the peanut gallery).


I get really annoyed when folks show up to the ED talking a whole lotta crap.
If you haven't been in the ED all day, you are not allowed to stroll thru and pass judgment. Nor are you allowed to show up for your shift and pass judgment. If you have not been here, you don't know what's been going on. And looking at the chart rack, seeing 15 patients waiting to be seen, is no indication of how fast/slow, diligent/efficient, the staff has been working.

I wish that everyone could understand that everyone has a bad sign-out from time to time.
Sometimes, the patients are all actually sick. Sometimes the xray machine is broken. Sometimes the medicine consultant is stuck in the ICU with a coding patient...all day. Sometimes, you're just friking tired...and want to go home.


I don't think that physicians should be "time card punchers."
We are not time-card punchers. We spend hours of "extra" time in the hospital in a given month. Leaving 10 minutes early one day...is earned. A right almost. Especially if the sign-out is clean. Afterall, staying for the sake of staying (it's not like a new patient encounter is going to be initiated 10 minutes before you're off) is demeaning. I understand why high-school students stay on their Burger King shift until the clock strikes twelve. But I am no high-school student...and I am not at Burger King. Holding highly trained professionals (who give away tons of time for "free"), accountable for every minute (or ten, or fifteen...) is indeed a slap in the face...and shouldn't be done.


I kinda like that the patients see me as a nurse (or other non-doctor person) at times.
When patients start bitching and complaining....it's so easy for me to say, "lemme get your nurse." If they knew I was the doctor, I don't think that response would work quite as well. Also, looking like a clerk nurse cafeteria worker non-physician allows me to roam the ED in peace. Most of the time, this is kinda nice.


I hate it when patients lie to me.
I mean, it really annoys me. I can no longer trust them...and I no longer believe anything they say. I get urine tox screens on them. I don't spend as much time with them. I am less likely to give them what they're asking for. And I don't take the time to do the extra things (get blankets, cups of water, or even listen to their tale of woe about their inability to pay for a cab). I treat them, and disposition them.


I like male nurses.
Male nurses are fun. They rarely challenge me...and there is no animosity between us. Male nurses seem to become nurses because they wanted to be nurses. Sometimes, female nurses have this thing...where I get the impression they actually wanted to be physicians...and they are jealous of me? Or think they're smarter than me because they are older...perhaps they feel they have something to prove (like "I coulda been a doctor too, you know".) Maybe it's just too much estrogen. Either way, I love male nurses.


I like female physicians.
The guys tend to be immature, socially inept, sexist, arrogant, pompous little dick-heads. Racing their fast cars, and staying late to avoid going home to their wives and families. Rushing thru patients for bragging rights: "I saw 26 patients on my 8 hour shift yesterday dude..." They balance their personal/professional lives very poorly, and rarely have anything to talk about that matters (outside of medicine). It's no wonder they die off early. Whereas women tend to do a better job listening, and taking the TIME to figure out what's going on with the patients. They are not as concerned with playing the testosterone games the men boys play, and seem to be more patient focused, more balanced, and better adjusted individuals.


I don't like it when female ED staff cross boundaries with male physicians.
I'm not just talking sex here. I'm not even talking about dating (I'm okay with that). What I don't like is the gifts, the shoulder rubs, the playing with the hair, the flirty remarks the fawning...and the all around degradation of character they demonstrate when they pimp themselves out to these dick-head male doctors. It bothers me more when the men are married. Sometimes I'll comment. Is there no shame...?? These "hos" misrepresent women, they undermine family, and make it even more difficult for women to be taken seriously in the workplace. I say, be friendly at work...and a tiny bit of flirting may be fun. But leave the touching, and the gift-giving at the ED door.


I really envy the way the nurses organize potlucks, make Starbucks runs, and overall, make their work environment more 'friendly' by virtue of having involvement of more women.
If physicians had more female members in the ED, I'd bet our lounge would have plants, and family photos, cutesy posters, and the like. I bet we'd even have clean linen and tampons in the bathroom. And best of all...we'd have a strong union.


I hate colorful scrubs
You know the ones the nurses wear...with all the pictures all over them (dancing puppies, and little happy faced sunshines)? I don't exactly know why. Maybe because I can't wear them without looking like a complete fool...??


I like seeing children more, now that I have my own.
I used to *hate* seeing kids. All they do is cry...and they provide no useful information. Just like being a vet. I didn't know what "fussy" meant...and I couldn't understand why parents brought their very well children to the very germy ED for a cold. I couldn't understand why it had to be at 3am? I couldn't understand why they even thought anything was wrong with the kid. Now...I understand better.

I have more 'feelings' for patients that I relate to.
I can easily tolerate people doing stupid, self-destructive things. This is what keeps us in business. However, when I can identify with the person on a personal level, I feel personally disappointed when they make bad decisions.


But, if I can relate to a patient, and they are ill...I feel sad. If a patient is a mother, for instance, I can talk to them for hours about their hopes and fears for their children. I'll fight back tears as I listen to her history. Then, once home, I'll take extra moments to smell the breath of my own children, and feel their soft baby cheek. And I remind myself that I am truly blessed.


I think emergency medicine is the coolest specialty ever.
I actually believe that those who talk negatively about EM...are simply jealous!!

Updated 4/2011
*Stating the obvious: there are many great female nurses that I just adore...many male doctors that are wonderful friends of mine; there are patients who lie that I still trust, and people who look like me (or that I can relate to), that I feel no emotion for. No one should dump on their colleagues by showing up habitually late for a shift, nor should one give shitty sign-outs consistently. I do go out to triage every now and then to dispo 'simple' patients...depending. I understand moving quickly, documenting to get paid, and needing to stay late to finish documentation (or whatever). I realize that in the ED, every patient will not get 10-15 minutes of face-time with the physician. Dictation is wonderful, and should be available...and a bit of innocent flirting at work is okay at times. I encourage people to find love, and have no problem with finding love at work. And I realize that not all men who work late are cheating on their wives (or otherwise avoiding them). I do get annoyed when I have to almost 'prove' I'm the doctor to people, when the white *male* is often 'mistaken' for being a doctor no matter what his role may be in the hospital. There are no absolutes...and I get this. You get this. I wrote this 'Confessions' entry with blanket statements to keep it interesting (and direct). Please don't argue the fine points (i.e. not all colorful scrubs are embarrassing). I know this. And remember, these are my *general* opinions. General. Opinions.

1.07.2008

a trauma story

Since I got such positive feedback, I'll post one more story.

I work at a couple/few different places - which is nice because my ER shifts are quite different depending on the location of the ED (obviously). One of 'em is a trauma center. The trauma center is way cool...and has top of the line everything. The trauma resuscitation bay is like 20 feet from both the CT scanner, and the OR. The anesthesia and surgery call rooms are actually *in* the trauma center. We even have a teeny-tiny police department (2-way glass and everything) in the entry-way to the trauma center.

So, I was at work recently, at my trauma center ED. Things were steady. Our traumas so far consisted of a drunk dude who was riding his bike, crashed into the curb, fell off of the bike, and lost consciousness. Granted, there are quite a few things possibly wrong with 'drunk dude', but more than likely, he's just drunk. But, he fits 'trauma criteria' so he was brought to us. There was a kid who jumped off a roof, obvious deformed leg...but otherwise okay.

Then we received the EMS call:
"This is rescue 25 to base with a trauma run."

This is base. Go ahead with your run.

"We have an approximately 30 yo male who jumped from a 2nd story window to escape an apartment fire. He has 2nd and 3rd degree burns over his anterior chest, neck, and his right forearm. He has an obvious deformity of his left femur, and multiple abrasions to his face. He's alert, but appears intoxicated, and is combative. We have PD on scene helping us secure him for transport. His vital signs are 150/84, heartrate 120, respiratory rate is 22, and his O2 saturation is 98%. We're attempting to establish IV access, we have him on O2, full spinal immobilization, and would like to have an order for morphine. You are our closest trauma center with an ETA, after we get him loaded, of 7 minutes. Over."

We rally the troops, and congregate in Trauma bay number 4. Upon arrival, EMS notifies us that this guy was 'set on fire' by a girl. Apparently this girl is the girlfriend of a rival gang member...and 'word on the street' is that she decided to get revenge on this guy for killing someone in her boyfriends gang. Because of this, there were already members of both gangs 'interested' in our patient's condition....and our parking lot was starting to look a lot like Crenshaw Blvd on Sunday night.

As firefighters approach us in Trauma 4...we see a young adult male, laying on the paramedic gurney with a c-spine collar on a long spinal backboard. His face is covered in blood and glass. His chest wall has 3rd degree burns over the entire anterior surface. His left femur is obviously fractured; as is his left tib/fib. They have no IV access. Patient is on O2 via facemask. He's yelling loudly, and wiggles on the backboard. We transfer him to our gurney. And the nice thing about trauma centers, especially where there are residents, is that there's enough people around to do everything.

My mind is yelling "oh sh*t. This guy looks horrible!!" The residents are eager to *do something*. It is times like these I really appreciate the simplicity of the mnemonic ABC.

As the attending (gulp)...I start giving instruction.

"Okay, lets get him on the monitors, pulse ox, and let's get some sterile gauze soaked in saline." That sends a few people scurrying away. Someone assess his airway and listen for breath sounds. Let's set up for intubation, and obtain central venous access...via...via..."

(hmmm....can't do subclavian because of the burn...or IJ for that matter. He has an obvious left lower extremity long bone fracture...so maybe that's not the best place to stick him).

"via right femoral vein. Someone call the burn center and let them know this guy is here."

The crowd around the bed is now half it's original size...with everyone doing their various tasks and all. Now, we have some room to work.

A - airway first. "let's intubate this guy" I tell the junior resident. There's some resistance from the nurse, "but he doesn't need to be intubated." I try to quickly explain to her (while the resident proceeds with the intubation) that this guy has major trauma, major burns, and was in an enclosed space, likely intoxicated, with fire...and smoke...and CO...and CN. His airway is closing...and every moment we contemplate will just make the edema in the airway even more difficult to overcome. The resident struggles, "I can't see anything." Keeping the cervical spine secure makes the procedure more difficult. The monitor goes from a high-pitched 'blip-blip-blip' to a decrescendo 'bloop-bloop-blooouuuppp' as his oxygen levels drop. Okay, that's enough. Let's bag him up.

I'm too 'insecure' to let him try again. We bag mask the patient, restore the oxygen saturation to an acceptable level (and the nice high pitched blipping)...and I try. Wow. All I see is pink mucosa - there are no landmarks!! I do the BURP maneuver and a small opening reveals the cords. I use a bougie and successfully intubate this guy with a 6.5 ETT (tiny little tube)!! We listen to breath sounds, and the left is decreased. We pull the tube back a bit. Still decreased. Then I ask the resident, "did he have equal bilateral breath sounds before intubation?"

He isn't sure. Maybe the left was less audible. We order a chest xray.

As we secure the ETT the patient, who intially improved his oxygen saturation, started to desaturate, and his blood pressure was about 115/70 with a heart rate of 130. Let's bolus him warm saline thru the Level 1. And let's get some o-positive blood here (we like to use 0-positive for the fellas).

Moving on to B - breathing: I instruct the resident to dart his chest. Things got a bit better after that. Then, he placed a chest tube. 500mls of red blood squirted out of the left chest...but his breathing improved. Let's autotransfuse that blood right back in.

And now to C - his blood pressure was stable at the moment. His arms/hands had good circulation. Palpation of the left elbow elicits a painful response. His right forearm has a medium sized 2nd degree burn on the radial surface - it is not circumferential, and his distal pulses are good. His right leg is fine, and our femoral line is working wonderfully. His left leg is mangled. There is decreased pulse to the foot, which is cool and cyanotic.

At this point we order initial labs and studies. Xray...basically everything. Order CT of...basically everything. Call ortho for the leg. Trauma panel of labs. And dress his burns with the sterile saline soaks. We keep him sedated. And order a tetanus and antibiotics while we're thinking of it. Then we go back and do a secondary survey.

We look into his eyes. In the left eye there's a piece of glass obviously penetrating the globe. The right eye is reactive and appears normal. Typanic membranes reveal no hemotympanum. There was no evidence of midface injury. However there are multiple deepish lacerations to the forehead and scalp. The PA is eager to repair these.

The neck has 1-2nd degree burn over the anterior surface, but it's not circumferential, and is not deep enough to expose any underlying structures. The chest tube is in place, and the breath sounds are present bilaterally, but greater on the right. There is a 3rd degree burn over the majority of the anterior chest wall.

Abdominal exam is difficult to execute....so we'll just scan him.

Pelvis is stable. Left hip is questionable. And his back and rectal/genitalia are unremarkable.

We continue IV hydration per Parkland Formula, and call ophthalmology for the eye injury.

Xrays reveal a femur fracture, tib/fib fracture. There's a distal humeral shaft fracture on the left. CXR shows what we interpret as a likely pulmonary contusion on the left. Chest CT angio, cervical spine, and abdominal CTs were unremarkable (except the pulmonary contusion and some rib fractures). CT pelvis revealed a small, but significant pelvic fracture, with acetabular involvement. Labs revealed an alcohol level of 420 (legal limit is 80). Utox positive for cocaine, marijuana, and meth. And head CT revealed a left parietal skull fracture (with no underlying brain involvement apparent), and glass fragments in the left eye with globe rupture.

Ortho took over the management of the broken bones, and decreased distal blood flow to the left leg. The leg was splinted, and vascular surgery was consulted. Because the patient had extensive chest trauma, I believe trauma consulted CT surgery. And, of course you can't ignore the burns. We are not a burn center...but we have the capacity to care for burn patients (yeah, go figure).

At our institution, it's the trauma service that stays with the patient thru his scans, and see to it that the appropriate consults are obtained after initial stabilization is achieved. So, at this point...we're actually done. My residents stay and play with the trauma service...but I have other residents to supervise (only one junior and one senior responds to the trauma calls, the other 4 continue their work in the ED).
***

Later I found out that the guy, unfortunately didn't have insurance...and the ortho procedure he required involved a series of operations, close follow-up, and specialized equipment. And because orthopods don't work (much) for free...especially when the patient is a high risk patient (high risk meaning not likely to be compliant, and more likely to sue, as determined by his lifestyle...and according to them, it's the poor, uninsured, disenfranchised, non-contributor to society that's likely to try and take something that doesn't belong to them...and is therefore more likely to sue). So, no orthopod in the City would do his surgery...and he will require the use of a cane/walker for the rest of his life (or, I guess, until someone thinks it's worth it to fix him).
And he lost the sight in that left eye.

As for us...
...well, it was interesting leaving our shift that night. Navigating the parking lot in the middle of gang warfare is quite stressful - especially when, no matter the outcome...someone's going to be pissed off.