NewlyMed

Introducing NewlyEd

2010-01-22T07:47:00.003-06:00

So the spouse of NewlyMed is a new teacher, hence NewlyEd. The last two school years he's been working as a substitute (or 'visiting teacher' as some prefer to call it!) while he completes his alternative certification and looks for a permanent position in his subject. He's got some great, funny, sad, & frustrating experiences. Here a couple amusing conversations with students.

Conversation #1.

Preface: NewlyEd wears a fossil watch, it is grey, has a plain black face and two white hands

7th grader: Ooo! That's a cool watch mister! Is it REAL?

NewlyEd: Yep, it's real metal. (no kid, I actually can't tell time and I really like wearing bracelets)

7th grader: Wow, that's like a really old watch.

NewlyEd: Well, it's about 11 years old.

7th grader: Oh, so that's like 20 years old, right?

NewlyEd: No, it's 11 years old.

7th grader: I've never had a 20 year old watch before!

7th grader #2: How do you tell time on that thing?

NewlyEd: Well the numbers on the face of a clock never move. (point's out the numbers on a wall clock). So I know the 12 is right here even if you can't see it. And the two hands move.

7th grader #2: Oh, so these never move (pointing to the hands)

NewlyEd: No... (if this were a cartoon there would be a cloud of scribbles above his head!)

Conversation #2.

Preface: Subing a 7th grade English class, the kids are doing SSR (sustained silent reading) and NewlyEd is reading a biography of George Washington.

NewlyEd: Let me tell you guys something I just learned about George Washington from my book.

student: He was a cheerleader right?

NewlyEd: No, that was George Bush. George Bush was our last president.

student: I thought George Washington was our last president.

NewlyEd: No, it was George Bush.

student: So George Washington wasn't a cheerleader?

NewlyEd: No! (again, imagine the frustration scribble cloud about his head!)

You just can't make this stuff up folks!

my night stand

2009-12-16T19:33:00.003-06:00

I have begun to notice a trend. At the start of any new rotation I'm usually ready and anxious to learn all I could possibly need to know about that speciality. It often starts with checking out a book from the library or finding a book I already own and making plans to read it during the month. Inevitably the book never or rarely gets cracked open.

I'm starting to compile a collection of books on my nightstand from my latest rotations. I've got a really short book on primary care ENT which I've left on my nightstand because surely I'll make time to read it sometime! There are some packets of practice board questions under that. The latest is an EKG book, which I have actually read about 20 pages of this month! (it must be a record! I'll not be discouraged that this particular book has tons of pictures and very large print!). The derm, acute care medicine, and gyn books have already made it back to my bookshelf or to the library.

And my nightstand only one of several places in my home where medical knowledge and study material is available! Doctor magazines are scattered about in the bathroom and on the coffee table just waiting for me. When I sit down at the computer my homepage offers me dozens of important articles, not to mention my e-mail which is filled with links to case studies.

I keep telling myself that if I don't develop some good study habits now I'm going to be a "bad doctor". But I seam to be making it along okay without the vigorous study that I have the good intentions of doing. There is always room for improvement and always things to learn or review, so I'll keep those books and articles on my nightstand and just keep trying.

Susto

2009-09-25T18:59:00.005-05:00

I saw a Spanish speaking patient the other day that was a new patient visit. I asked about her past medical history and her family history. I usually ask specifically about diabetes in the patient or their family, especially in any patient with risk factors for diabetes. This patient denied any health problems at all, but told me that they had a sister with diabetes.

"She had a susto and her sugar went high and the diabetes hit her and she's had diabetes ever since then" the patient explained to me.

(for the non-Spanish speaker- susto is a scare, or an emotional stress, perhaps what we would call an anxiety attack)

Wow... I've done some research in diabetes and Hispanics, and I had actually read about this notion that some believe that diabetes can be caused by susto. But reading about it and hearing it first hand are different indeed. So, I can now testify that there are (still) people out there that blame a metabolic / genetic disorder on susto! So watch out for anything too scary, you don't want diabetes to get you.

Anything else can be fixed!

2009-08-11T17:14:00.004-05:00

My first delivery was in the fall of my third year of medical school. The second year family practice resident I was working with had just joined our team after being out of town for the first week of my rotation. He was surprised that I had been through a whole week of the rotation and not had my first delivery yet. 'Let's get you a delivery!' he said, and proceeded to find a patient on our board that would be an appropriate first delivery. In my case that meant a G7P6 who had a teenage daughter in the room cheering her on.

I had delivered a plastic baby from a plastic model before but felt confused about the right hand position... should my right hand go on top or the left? what do I do to minimize a tear? which way do I flip the baby onto it's back after it's out? so I asked my resident. 'However you're comfortable' he says, I must have still looked concerned about doing it wrong, because he continued 'Look, whatever you do, just don't drop the baby. Anything else can be fixed'

As I caught the slippery neonate that came flying out of my experienced patient, that turned out to have been the best advice he could have given me! I remember focusing hard on 'not dropping the baby', which I didn't think would be necessary, but those things are pretty dang slippery. I kept less than a foot between me and the patient and remember at one point almost leaning against the patient to give myself leverage to support the baby and ensure that it didn't slip away. Concern for a tear was silly as her vagina was a wide cavernous opening with room for baby and then some. I have since more or less mastered the art of 'not dropping' slippery little ones!

Dedicated to anyone named Rodriguez

2009-07-16T19:44:00.005-05:00

So the other day I saw a patient named Rodriguez. As you may be aware it is a somewhat common name. Well I have many in my clinic and I had two scheduled on the same day.

I went in to see my next patient (Rodriguez) and recognized the patient as someone I had met one month earlier and started on insulin. I began by asking how things were going with the daily insulin injection. "everything is fine" was the reply

I opened my chart to the medication list and found that not only was Lantus (bedtime insulin) on the list, but Novolog was too (mealtime insulin). I felt puzzed, sure that I had started only Lantus, but now unsure that I remembered the patient in front of me. I started to update the medicine list. Then I thought 'am I confusing this patient with someone else?' so I turned back to the last clinic visit and read over my last note which made me feel even more confused, I must have the wrong patient, I though.

So, naturally I look at the name 'Rodriguez' and verify that this is my patient's name, 'yes, that's me' (At this point I had not realized or remembered that I had two Rodriguezes scheduled on the same day)

Well luckily I wasn't convinced I asked my patient a couple of details about the last visit like "didn't we start you on Lantus 10 Units last month?" The patient confirmed my memory and also confirmed that I had the wrong chart in front of me. I also asked for the Date of Birth which was incorrect. I excused myself from the room and let my nurse know that I had the wrong chart and we found the second chart labeled Rodriguez (these patients had the same first name too, by the way!) It was nice to know that I had the right patient, and identified the wrong chart before doing anything crazy like sending the patient home with prescriptions for the wrong person. Ironically the other Rodriguez never showed up!

my first viagra prescriptions (PG-13)

2009-05-24T18:05:00.007-05:00

So a group of colgueges were discusing the fact that viagra (sildenafil) is used to treat not only erectile dysfuction, but also pulmonary hypertension. In order to avoid the stigma of taking viagra, the same medicine has a different name when it is prescribed for pulmonary hypertension. Someone wondered outloud if the latter is cheaper. He said that he had a lot of diabetic patients with ED that have trouble affording ED meds. I thought to myself - wow, I've never even written a prescription for viagra... and I have plenty of middle age and older diabetic males that I see in clinic. I never ask about it, perhaps I should ask more often, or perhaps my being a female makes my patients less likely to bring up the topic themselves.

Well... within one week of that conversation I wrote my first 3 prescriptions for viagra (without changing any of my history taking habits).

On gentelman, ironically was sitting on an exam table that had 'viagra' paper roll covering the table. This is very uncommon in my clinic, in fact that was the first and last time I've seen that. Usually it's the generic white exam paper roll, and on very rare occasions a pediatric print with animals or something. Now whether or not the advertisement prompted the request or whether it was already on his agenda is anyone's guess.

Another gentelman was preparing to marry a woman he described as 20 years his junior and "frisky", he actually asked me if he could have and unlimited supply of viagra. I also had the pleasure of teaching him proper sexual terms. When I asked if his problem was getting an erection, he asked 'is that when that stuff come out?' .. no sir, that's called ejaculation. 'oh so you talking about when the dick get hard' .. yes, that's called an erection. He thanked me for teaching him the right words.

My third encounter was in Spanish, and while I know a lot of words in Spanish and pride myself on being fairly fluent, erection is not in my Spanish vocab. So the ED discussion consisted of me talking about the pene duro or the hard penis. I was hoping the patient could enlighten me on how to say erection in Spanish, but he either didn't understand what I was asking him or did not know the word himself (errecion - should have guessed!). So perhaps pene duro was better understood anyway as had been the case with the 2nd man!

I haven't seen any of these gentelmen back since ... I guess they got what they wanted ;)

feeding the babies

2009-01-26T22:14:00.007-06:00

so I keep telling myself when I'm on my newborn nursery rotation that 'when I finish my work' or 'when things slow down a little' that I'm going to sit in a rocking chair and just feed a baby - gosh dang it! It just looks so relaxing.

For the babies that are in the nursery the nurses and sometimes volunteers take that job, and I'm always stuck doing exam after exam, checking bilirubin and other labs, doing paperwork. And of course there is never a 'when I'm finished' or 'when things slow down' (or if there is I'm on call and that's when I'm sleeping!)

some of my collegues make time to feed babies because they want to. a couple even swing by the nursery when they aren't on that rotation, but they'er nearby and want to feed/hold a baby.

so perhaps I'm just not the type that feeds babies... I have yet to make time for it. Though I'm sure I'd make time for it if it were my own baby!

Seriously....

2009-01-20T19:55:00.005-06:00

So the other day I had a patient who complained of headache. Here is how part of the conversation went (and might I mention that this is an adult patient):

Dr: Do you have any problems with your vision?

Pt: What's that?

Dr: When you see is it blurry or is it normal?

Pt: Oh, I don't know.

Dr: When you look at things, can you see them ok?

Pt: Yea, I can.

So either the education gap between me and this patient was large, or I really need to work on my communication skills...! I was having a hard time thinking of any other way to ask the question or be more clear. Really more a sad story than I funny one.

My first toenail removal

2008-10-10T16:14:00.004-05:00

My first toenail removal was amazingly easy. The patient had an infection under the nail and it was almost falling off by itself. I didn't really know the steps of the procedure but my attending walked me throug it and before I knew it I was shoving a hemostat under the nail and prying it up. After that all I had to do was pull and there it was. Thank goodness for my masterfull anesthesia skills, a good digital block is key to a good nail removal.

Never a Dull Moment!

2008-09-13T10:05:00.003-05:00

So one day I was working at a walk-in clinic on a Friday afternoon and I had the following patient encounter:

Nurse: What are you here for today?
Patient: My back hurts.
Nurse: Where does your back hurt?
Patient: I dunno, up here (touching upper back) and down here (touching lower back)
Patient: Do you think the doctor will give me some pain medicine? Because if I can't get any pain medicine I don't know what I'm doing here, I should just leave.
Nurse: I really don't know what kind of medicine the doctor might give you, how long has your pain been there?
Patient: Well about 2 weeks, but this pain in my low back has been there for like 2 years!
****
Nurse (to doctor): Just to let you know the patient in room 5 is asking for pain medicines.
Doctor: Well, I'm not going to give narcotics, but I'll talk to them and check it out.
****
Doctor: Nice to meet you, what brings you to the clinic today?
Patient: I need some more treatment for my herpes.

So Many Stories, so little....

2008-09-10T09:23:00.002-05:00

There are so many random, interesting, funny, sad, whatever stories I've meant to archive in this space, but obviously it has not been happening. I could make a whole list of excuses... to little time, interest, energy, motivation, etc. But the stories are still there floating around in my memory, they won't be 'fresh' when I finally write them, but that is probably just as well. So coming someday... I will continue the "my first" series, like my first delivery, circumcision, suturing, death, chest tube, toenail removal ext. and also the "The other day I saw or did ____" series for other stories. So hopefully my memory will hold out until I can get whatever it is I need to write them down!

Paying back my sleep debt

2008-07-07T21:09:00.002-05:00

during the month of june all of the hospital employees must complete our 'net learning'. On-line power point presentations about compliance, code pinks, & stroke team activation, each with a quiz at the end. the carrot they dangle in front of us is 'no christmas bonus if you don't complete all the modules!'

residents have a special module called SAFER which stands for something about sleep.... blah ..blah... residency.

in addition to recomending the impractical if not impossible (ie-you should never drive yourself home post call!) the SAFER module teaches that a person needs 8 hrs sleep per night, and when he does not get those 8 hours he incurs a 'sleep dept' that must be paid back!

well my debtor has come for payback for all of my intern year. My second year started on July first, and for my first month I work 8-5, M-F, no call. You'd think I'd be loving life and partying and using all that extra time for fun stuff. I feel just as, if not more exhausted now than I did all year! So apparently the time has come to begin paying back my sleep debt. I really have no idea how much I owe, but I've been getting about 9-10 hrs / night, so I've started to slowly may a dent in the surely massive sleep dept of internship.

off to bed with me!

baby overdose

2008-06-12T20:24:00.004-05:00

recently I completed the required 6 weeks of pediatrics at my hospital's residency program. Our pediatrics rotation should really be call Newborn Nursery because all we see are newborns, even during our pediatric clinic hours we see the same babies we sent home just days before with a few 2 year old check ups sprinkled in and on a very rare occasion a sick visit from a 6 year old. But the morning rounds before clinic is the real exciting part: doing the exact same exam, writing the exact same note, and giving the exact same instructions to a dozen babies and moms every morning.

Even though I was blessed to have vacation during my time on pediatrics it was still too much, too many babies, too many bili's, too monotonous. That's how you learn, or so they say, by repetition. I do have my ER warnings speel down in Spanish and English!

During my rotation I told myself that I would take time out from the monotony of the paperwork and Ballard's exams and actually sit in a rocking chair and enjoy feeding one of the babies ... but it never happened, oh well. The take home lesson from the rotation is that I am so happy that I will not be a "Newborn Nursery" doctor full time, is anyone? if so how can they stand it?

an important deadline

2008-05-14T20:09:00.002-05:00

so my economic hardship deferment paperwork on my medical school student loans is due soon. Because the sum of my student loans could feed a small country for a year, and my current salary can feed only a small household for a year, I get to put off paying back my loans for another year or 2 (and allow even more interest to accrue!) Good thing I love what I'm doing!

What I've learned this year.

2008-04-08T13:38:00.005-05:00

So in response to Angie's invite, here are a few of the wonderful things I've learned this year as a Family Practice Intern:

Ditto to Angie's list, and I've learned....

- sometimes you don't know the answer, and sometime your upperlevel and attending don't know either, and sometimes the answer is irrelevant anyways.

- communication is key (with other docs, nurses, patients, families, secretaries, RTs, etc.)

- when in doubt, ask for help.

- when in doubt, don't let the med student do it.

- discuss code status in terminal patients.

- sometimes stopping to eat is more important than patient care. (you can't care for other if you don't care for yourself right?)

- the importance of staying informed about every patient I'm involved with. (ie. it's best to know if the mom had a C-Section, vaginal delivery, normal baby, sick baby or stillbirth before entering her room)

- complaining does not change things and usually does not make you feel better either.

- while carrying five different pocket manuals around in the white coat pockets is a great security blanket, it will also give you significant neck and back pain... and do I really use them that often anyways?

- to value my vacation time and days off and use that time wisely.

- it's almost impossible to read your scriptures every day as an intern, and it IS impossible to go to church every week... but it's worth trying.

- medicine is truly a profession of life-long learning. Patients, procedures, diseases, and treatments change every day!!

My First Prescription

2008-04-05T19:10:00.004-05:00

The first prescription I did not even write... it was for GoLytely. I was doing pre-op exams for patients getting colonoscopies. So everyone got a prescription for a gallon of the laxative that cleans out your entire colon so that we can stick a camera up and look for polyps! Guaranteed to have you sitting on the toilet for hours! So I stamped the prescription pad with the "GoLytely" stamp, placed a patient label on the top and just signed my name on the bottom line.

One of those days

2008-03-31T23:35:00.003-05:00

So here is what I ate today:

6AM - out the door with a pre-packaged smoothie drink in my hand.

9AM - I manage to swing by the cafeteria and pick up a breakfast burrito, (the other food I picked up went into a near-by frige on telemetry, only to be forgoten until I got home).

1PM - I stuff my face with a package of gram crackers and mini package of penutbutter that were in my white coat pocket from the day before.

7PM and 8PM - I pop some tic-tacks, not very filling.

10:30 PM - finally I'm at home, and I enjoy some real food. I love my husband!!

A Good Quote

2008-03-30T14:27:00.000-05:00

"The dedicated physician is constantly striving for a balance between personal, human values, scientific realities and the inevitabilities of God's will."
David Allman

On Medical Blogging

2008-03-29T15:45:00.003-05:00

Here is an interesting article by NPR about privacy issues. (Morning Edition March 12, 2008). Found by surfing over to White Coat Rants, one of the 'pro' medical bloggers.

And the Countdown begins

2008-03-27T20:32:00.004-05:00

The first several years of a career in medicine revolve around exams. If I added up all the money I've spent on exams alone I could probably buy a car. Add up the money spent on books to study for the exams and and I could get a bran new car! Add up the money spent on classes to study for the exams and that would buy a house or two!

Well, COMLEX 3 is behind me! Assuming I pass and assuming the great state of Texas will accept my petition and $$$, I will be getting my very own medical licence at some point in the future. But the fun doesn't stop their!! Now the countdown begins to my next exam for board certification in Family Practice, which will be at the end of residency in 2010!

Yet Another Exam...

2008-03-26T21:01:00.002-05:00

So my future is partly resting on the third step of my licencing exams, which I will be taking tomorrow morning....

Their are three levels or steps of Medical Licencing Exams. The first is at the end of 2nd year of medical school, the second some time during 4th year, and the 3rd sometime during or after internship. As they say: you study 2 months for the first, 2 weeks for the second and 2 days for the third. I know that is meant to be a reflection on the accumulative nature of the knowledge... but I've realized it's more a reflection on the time and energy available for studying as one progresses through the stages of course work - clinicals - and internship.
In other words, the fact that I have not even studied for the recommended 2 full days is because I have not found (or made) the time!

I take solace in the fact that I've got 9 months of working at the county hospital under my belt. Also, being in Family Practice means I know a little bit about everything - or at least I'm supposed to! And their will be a lot of everything on my test I'm sure. Wish me luck!

It's okay, I really don't mind...

2008-03-05T22:52:00.003-06:00

So the other day when I was on call I responded to a page from a nurse. I could tell from her voice that she was probably a couple of years older than me. She presented her patient and asked me her question. It was something easy like the patient needed pain medication, or something to help him sleep. I gave a telephone order for the medicine. She asked my name again and wrote it down. "Great, thank you Ms.Ross ... ur..um" "No problem" I responded and ended the conversation. I suppose if I were mean I could have gotten upset, but for a phone conversation (ie. not in front of a patient), it's not a big deal to me.

Now on the other hand, here is a setting where, for some reason, I DO mind! I received some mail from my alma mater soliciting contributions, and it was addressed to Ms.Ross!! Hello!?! I attended your institution to earn a degree, remember? and I graduated from YOUR medical school so now I'm Dr.Ross. Needless to say I will not be participating in the latest fundraising spectacular.

Continuity

2008-03-05T21:43:00.002-06:00

I love 'continuity of care'. I guess that should be a given because I'm a Family Pracitce doc. As they say "My Family Doctor is a specialist in ME!"

As an intern, I only have minimal continuity in my "Continuity FP Clinic" because I only have about one half day of clinic per week! I've gotten a fair amount of continuity of care during my intern year mearly from doing all my roations in the same hospital! For example...

I saw a lady in the ER and I made her an appointment to see a specialist at the OB/GYN clinic - a month later I'm doing my OB/GYN rotation and she's at the clinic seing me.

Another lady I saw on my Surgery month got a referal to OB/GYN, here appointment took three months to set up- but there I was again, back on my 2nd month of OB/GYN and seing her again!

There have been patients I've admitted while on the medicine service and then I see them as a surgical consult.

I saw a pregnant lady in the OB clinic and then took care of her baby on my Pediatrics rotation.

I even have had continuity from when I was a medical student rotating at the same hospital! I've taken care of a particular patient with bipolar disorder twice, once in my 3rd year of medical school on the psychiatry service and then again as an intern.

I've seen a psychiatry consult at a later date in the Operating Room.

There are a small handfull of 'ER continuity patients' at my hospital: mostly homeless people who come in regularly trying to get food, shelter, or pain med: which they rarely get away with because the whole ER staf know them. (However the trick is to say you have Chest Pain or want to kill yourself, they we have to let them stay for at least a little while...)

Some hospital patients (the ones who are worth seeing again!) I've invited to my clinic and they've actually come :)

and my favorite one: I saw an extra patient in clinic that was not a patient of mine (a walk-in visit). The lady had her todler who was sick. The mom looked really familiar, but I could not place her. I asked how many children she had. "well, I just had twins a couple weeks ago" and after that we both had a light bulb go off- I took care of her on the post partum floor after she delivered!

It's a small county hospital after all.

And the Family Practice Intern is an Obstetrician, Surgeon, Internist, Psychiatrist, and Pediatrician all it one!!

I'm not alone

2008-03-01T11:18:00.004-06:00

An Easy Post

2008-03-01T10:39:00.002-06:00

It's been a while since I've posted anything. I've got plenty to say... just haven't made the time to sit down and write!

So here is a forward I got today from a colleague (he stole it from another blog - the reference is noted). Pretty funny! and sad as well.

"Pulling Teeth"

Do you have any medical problems like heart disease, blood pressure problems, diabetes? No.
Anything you take medicine for on a daily basis? No.
Have you ever had any surgery? No.
Your chest x-ray shows that you have a pacemaker. Why do you have that? Because my doctor put it in.
When was that? When I was in the ICU about five years ago.
Why were you in the ICU? My heart stopped during an operation.
What operation was that? My gallbladder out.
How long were you in the ICU? About 3 weeks. It’s all in my records.
Which hospital? Oh, one of those in New York…I don’t really remember.
Do you have any family who might remember which hospital? My son. He’s dead.
Anybody else? I don’t know.
Do you smoke? No.
Did you ever smoke? Yes.
When did you quit? Yesterday.
How much did you smoke? Couple packs a day.
For how long? Oh, I don’t know. More than 50 years.
Why did you decide to quit? I don’t know. I may start again.
Would you like a nicotine patch while you are here? No. I’m not addicted or anything.

http://fatdoctor.org/2008/01/25/pulling-teeth/

my first chirstmas present from a patient!

2007-12-23T10:32:00.001-06:00

The other day at clinic, my “pain contract” patient had an appointment (groan!!). Other docs will know what the words “chronic pain patient” entails! I will describe my patient, who I believe is somewhat stereotypical of chronic pain patients everywhere! Joan has an ‘idiopathic’ condition that has caused chronic pain for years. Idiopathic meaning that so far there is no medical evidence or reason for the pain. The original diagnosis was made elsewhere and old records have not been obtained yet. Joan requires daily pain medications to function, and guess what she's “allergic” to just about every pain medication out there (meaning she’s tried them all and none of them work to control the pain). I researched the condition and all possible treatments and went over the list of therapies with Joan. Most of the things on my list had already been tried, and… big surprise, did not work! These types of patients can be extremely trying, and also take a significant amount of time.

Patients who require long term narcotics for pain control sign a “pain contract”. Basically it says that the patient agrees to
1.visit only ONE doctor (me) for their pain control needs
2.fill their narcotic prescriptions at only ONE pharmacy
3.take only the drugs prescribed and take them as prescribed
4.take a drug test at each monthly visit (to ensure that the drug prescribed and only the drug prescribed is present)

So my chronic pain patients only see me and they see me at least once a month, which I guess means that we get to know one another more. Which in this case translated to me getting on Joan's Christmas list!

At the appointment the other day, Joan actually looked pretty good, and was in a good mood. Despite this fact, she still reported that the latest medication we tried did not work, and so we are now trying the last long acting narcotic on my list, and hoping for the best! Afterwards I was in with another patient and I heard a knock on the door. It was my ‘difficult-chronic-pain-patient’ who handed me a gift card and wished me Merry Christmas!! The gift is a big deal when you consider my patient population. It was unexpected, but the gesture was much appreciated!

I’m sure there will be other Christmas cards or gifts for “the doctor” as I progress in my career. We’ll see if they can beat my free meal at Jack-in-the-Box from the patient I least expected to give me a Christmas present!

Working in the Prison Unit

2007-12-16T18:45:00.002-06:00

There is a special unit in my hospital for prisoners, complete with an officer for every inmate, a special code to get in (that most of the doctors don’t even know), and each patient cuffed to the bed at the ankles. When I arrive I try to knock on the door for one of the officers to let me in. The door is of course extra thick, so if my knock goes unheard I have to resort to waving my hands, hoping they’ll notice me through the small glass window. One of the officers then gets up, annoyed that my arrival has interrupted their focus on the crossword puzzle and types the code to let me in. I always check my name badge as the officer approaches to make sure that it’s visible, as if to say “See, I’m a doctor here, I’m not wearing the white coat to trick you into letting me in, I really do have a patient to see.” The hallway that opens into the patient rooms is lined with officers. The prisoners don’t get the prettiest or newest unit in the hospital and space is always an issue. From the patients to officers to doctors, nurses and staff it seems like everyone is cramped for space. I don’t know what the area was used for before it was the prisoners unit, but the layout is horrible, there isn’t much of a nurses station at all, each room has 3-4 beds and one small counter top with computer, sink, and patient charts, and there are passageways between the rooms that you have to turn sideways to get through.

The officers are very helpful and respectful for the most part, with the occasional one who obviously hates his job. The prisoners come in all types. Lots of them are very normal and respectable looking and you wonder what happened to them. I almost never know what they are in jail or prison for, nor do I ever want to. It’s completely irrelevant to my job. Of course I ask the same questions to prisoners that I ask non-prisoner such as IV drug use and sexual history, but no specifics on criminal activity! I’ve had a couple of patients tell me without being asked, but it wasn’t a big deal (I guess, in part, because they were not big crimes).

I had one patient where I heard all about his criminal background – mostly because a printout of the newspaper article reporting his sentence was actually in his medical chart! I don’t know how it got there or why, I should have ripped it out and thrown it away so as not to taint anyone else’s opinion of this individual. I must say it made the patient encounter different, and slightly awkward for me. This particular case was confounded by the fact that the crime was related to medicine. I guess the relation to the medical world made the story interesting and somewhat of a personal insult to us. In the end the patient was still a patient that required evaluation and treatment just like the patients on the newly remodeled 8th floor with private rooms, wood floors and flat screen TVs.

Stress

2007-12-14T11:09:00.001-06:00

Yesterday was a particularly stressfully call day for several reasons. The two that I will mention are that I only slept from 5am to 5:30am and during post call rounds I looked and felt incredibly stupid. On my post call morning I presented two of my new patients to my attending, only to be shot down by what seemed like never ending questions that I did not know the answers to. Mind you this is in front of my whole team of other residents who knew some of the answers, but of course I was the one being asked so they kept quiet or mumbled things under their breath too soft for me to understand. I had done mostly everything right (my patients were being appropriately cared for) but I did know the specific reasons why we’re doing certain things, what do we do next, what is going on specifically and why, what tests will prove this and what would we have done if things were different. When I haven’t slept the answer is “I don’t care! I just want to go home and go to bed!”

I went home feeling pretty stressed, but resolved to do some extra studying on my next day off. As much as I do want to have kids I felt so grateful at that moment when I finally laid down that I do not have any children. I feel guilty enough that my husband does not get the attention he deserves, and as I understand, children require even more attention than husbands!! I think my current situation, one husband and no kids, is best for my mental health during intern year. I don’t know how I could handle intern year if I were single; I very much need the support from my husband. And, as great as I hear having kids can be, I know some added stress comes along with that and I’ve got enough stress for the time being.

Remember Mathnet?

2007-12-11T18:47:00.000-06:00

Before I continue to publish stories about my hospital expierences, I feel the need to state that "the names are made up but the problems are real!"

Which happens to be my favorite quote from Mathnet, the detective show where they use math to solve the mystery! It was a show within the show Square One on PBS. Ah, good 'ol Kate Monday and George Frankly. The full quot is as follows: "The story you're about to see is a fib, but it's short. The names are made up but the problems are real." My stories are not always short... nor are they "a fib" per se... but you get the picture.

So... except for any stories about pregnant ladies, which by it self inplies that the patient is a female of reproductive age, I purposfully will not include or will change any and all details about my patients including but limited to: name, gender, age, ethnicity, language, and circumstances. So basically the stories are "made up" but believe me "the problems are real!"

Good thing they’re unconscious... mostly

2007-12-08T14:32:00.001-06:00

On my surgery rotation we take Trauma Call! This means we carry a Trauma Pager. When the trauma pager goes off there is a text page to read that is an encrypted message like “level I 25 M GSW Abd SBP <90 GCS 8 EMS 3 min out, trauma 5”

What that means, is that a 25 year old man was shot in the belly and even though the ambulance is still 3 minuets away, you better get down to bed 5 in the trauma bay because this guy is unstable.

Imagine for a minute that you are a trauma patient:
You are in a car accident. The paramedics show up, they put you on a rock hard plastic board on your back and strap you down tight so that you can’t move. They also put a neck brace on you. They rush you off to the hospital. You’re rolled into the trauma bay and transferred onto the bed, though still on the plastic backboard. While the paramedics tell your story to the doctor, half a dozen people rush towards you in yellow gowns and purple gloves. The two at the foot of the bed start pulling your shoes and socks off and cutting off all of your cloths, including underwear. Simultaneously two others are poking you with needles on both arms to draw blood and start IV lines to give you fluids; others are sticking plastic EKG leads on your chest, a blood pressure cuff on your arm, and a pulse/oxygen monitor on your finger. Someone pushes on your belly. At the head of the bed a doctor yells at you “Open your eyes”, “What’s your name?” “do you know where you are?” “what’s the last thing you remember?”. While this doctor is firing questions at you he also shines a bright light directly into your eyes, and then looks in your ears, nose, and mouth. Next the group tilts you to one side for some reason, and shortly thereafter someone is yelling “X-RAY!” and they tilt you to the side again. The whole time people are talking back and forth “what’s his blood pressure?” “Can you get me a Foley kit?” “Good breath sounds bilaterally” “Did you get a temperature?” “He has good pulses” “Is his chest x-ray up yet?” “Does this guy have any medical problems or allergies?”

Finally they unstrap you from the plastic board, tilt you to one side, remove the board, and push on each of the bones down your spine. “Tell us where it hurts?” they yell. Next someone yells “finger up your bottom” just before you feel it happening. They roll you back onto your back and a catheter is shoved into your bladder. Someone else is moving a sonogram probe across your belly. If the chest x-ray the doc just examined looks bad you may get a slice between two of your ribs and a tube stuck in your chest. From there it’s to the CT scanner, the ICU, or the OR depending on your condition. Hopefully not long after your arrival someone gave you some pain medications and sedatives… I would sure hate to be wide-awake for all of that!

Moral of the story: don’t talk on your cell phone while you drive!

Good Times On Call

2007-12-05T22:29:00.001-06:00

So the other night I was on call for the ICU. This means that I get called on any ICU patients with problems during the night, and I admit or transfer any new ICU patients.

So we got a call from the ER for a patient who needed to be admitted to the ICU. He had suffered a stroke and was intubated by the ER doctor. He came to the ICU on the ventilator. I was filling out my admission orders and some paperwork for stroke patients, while the nurses were getting the patient situated. I came across a section that asked if the patient needed supplemental oxygen to breath. So I turn around and ask, "is the patient requiring any oxygen or is he breathing on room air?" The nurses paused and looked very confused... "he's on the ventilator" someone said. So yea, he was not breathing, the machine was breathing for him. I've felt pretty stupid in various situations this year, but I think that may be the worst so far. I replied that I'm allowed at least one stupid comment at 2AM and we had a good laugh.

So that's not a real mistake, just a moment where I was not thinking straight and asked a ridiculous question! Fortunately I have not made any real on call mistakes. (Though if I had I would not advertise that information to the world wide web!) I definitely have moments when I'm dead tired and it takes me twice as long to do things because my brain is just working a little more slowly. I think approaching patients the same way helps avoid potential problems, for example always asking if the patient has any allergies, or always looking at the date the x-ray was taken first. When I'm on call I try to sleep when I can, even if it's just for a half hour it helps. I do not use coffee or rock star or monster or red bull or full throttle, which I believe helps in the end. I would rather yawn occasionally than be artificially awake. Eating helps too, when you’re up for 30+ hours you require more calories.

Things are better now than in "the old days". In the old days residents worked over 100 hours per week and might stay at the hospital for days (hence the term resident). Now, by law, we cannot work more than an average of 80 hrs per week during the month. When on call, we cannot work more than 32 hours straight, and we must have a minimum 12 hours off before returning to work again. It is also required that we take an average of 2 days off in each two week block. It's still a lot of work, but it's do-able. Family practice is still way better than surgery! I definitely would not want to work this hard for the rest of my life, but it's only for a few years and supposedly the hard work will pay off in the end....

Continuity OB

2007-11-20T12:33:00.001-06:00

So... as a family practice resident we have a requirement to have at least 10 continuity deliveries. This means I see the patient in the clinic for prenatal care, deliver her baby, and then see her after delivery in the clinic. The rough part is that babies come unexpectedly.
I've delivered over 40 babies, but I've only had two continuity deliveries so far... here are the stories:

Patient #1 arrives at 5am dilated to about 3cm, contracting every 5-10min. I am just finishing a 24 hr call shift, but stay in the hospital to follow this patient. I sleep in the call room and emerge every 3-4 hrs to check on her progress. Being a primagravida she progresses kinda slow, and we break her water and help things along with pitocin. So by 10pm or so she's complete and pushing! I help the nurse coach and wait anxiously to catch the baby... no such luck after two hours of pushing the baby is still at zero station. So I consult my OB colleagues and we decide a C-section is in order. At this point I've been in house for 44 hrs. As much as I did want to be there for the birth and assist with the C-section, I was not crazy enough to actually stay. I went home for a little more sleep before I had to return to the hospital for my regular duties in less than 5 hrs. The OB team did the C-section, which went fine and I took care of her the remainder of her hospital stay. I decided that with my next continuity delivery I would NOT live in the hospital to follow my patient through every step of labor, but would allow the nurses and doctors working in L&D to help and call me when it's time for the delivery part. I tried to implement this with my second continuity delivery, but it did not work quite right, as you can see below.

Patient #2, this story is even better.... She arrives around midnight, dilated to 4, contracting every 5 min. I'm 17 hrs into a 32 hr call shift. So I think, this is perfect, I'm already here, this is her second baby and so she'll surly deliver in the morning before I leave. Well, by 1pm she had not delivered yet... so I go home shower and go to bed! I had just about drifted off into a deep post call sleep when my pager went off at 2:55pm. "your patient is complete, hurry up and come if you want to deliver this baby!!" In my post-call daze I get dressed. I glance at the counter and decide that all I need is a pen, my pager and my stethoscope, I grab these three items and rush out the door! As soon as the door locks behind me I realize that my keys should have been on the list of necessary items... now not only am I lock out of my house but I cannot drive my car. Nor can I make a phone call because my cell phone is charging on the counter inside. I knock on my neighbor's door, and coincidently he's about ready to leave for work and offers to drop me off at the hospital. In route I get another page. Moments later I'm headed toward the labor and delivery floor. I rush in only to find out that it was a false alarm... the second page was to tell me never mind she's not ready. At this point my only option is to head back to the call room and try to sleep, which takes a little while but I fall asleep. The next page is the real thing and I make it just in time to catch the baby at 7pm. For being as sleep deprived as I was I did pretty good, the only think I forgot was to put on my shoe protectors and so I got blood on my sneakers.

Only 8 more to go!

my first post

2007-11-10T18:38:00.000-06:00

Well... in just 3 cliks I've created my own Blog. I created an account so that I could post comments, and then I just happened to click on the "create your own blog now!!" button. So we'll see what I do with this. I have plenty of experiences to reflect on being a Family Practice intern at the county hospital, so perhap this will be a good medium for processing those expierences.