Me: Hey, did I wake you up?
Chief: Yes. Is anyone dead?
Me: No.
Chief: Keep up the good work.
8/4/10
Chicken biscuits and burn patients.
So, I'm a southern girl and ever since moving to this little University town I've been trying to find somewhere I could find an economical chicken biscuit. I didn't think it would be hard. Seeing as there are college students everywhere and we are in the south. So, it hasn't happened in the 2 months or so I've lived here. Until this morning. I stopped by the cafeteria on my way out this morning because I really wanted an orange juice. But I decided to stay for some breakfast. It was amazing. I also hadn't eaten for 12 hours. So that might be part of it.
I don't why I'm fixating on this biscuit. I think it's cause tonight got a little crazy, 6 burn admits. I'm just going to list them all out for you and you decide if I'm making any of this up.
#1 - A man driving around on a John Deere tractor said it just exploded from underneath him (his blood alcohol was 438)
#2 - A spanish-only speaking lady burned her face when she tried to pour hot grease into a plastic container and it exploded.
#3 - A woman came in with Stevens-Johnson Syndrome. An allergic reaction that causes your skin to literally peel off.
#4 - A young boy was trying to build a smoke bomb out of stump remover (potassium nitrate) and sugar got his arm singed and took some shrapnel to the eye.
#5 - A little girl accidentally had boiling water spilled on her when her aunt tripped carrying the pan.
#6 - A man working at taco bell came in with a deep fryer basket stuck to his back after a fellow employee hit him with it.
I'm going to head for a shower and bed now. And hope that I manage to block out enough of this crap to get a decent night's (day's) sleep. Yesterday my circadian hadn't caught up with me yet so I wasn't very well rested when I woke up.
I don't why I'm fixating on this biscuit. I think it's cause tonight got a little crazy, 6 burn admits. I'm just going to list them all out for you and you decide if I'm making any of this up.
#1 - A man driving around on a John Deere tractor said it just exploded from underneath him (his blood alcohol was 438)
#2 - A spanish-only speaking lady burned her face when she tried to pour hot grease into a plastic container and it exploded.
#3 - A woman came in with Stevens-Johnson Syndrome. An allergic reaction that causes your skin to literally peel off.
#4 - A young boy was trying to build a smoke bomb out of stump remover (potassium nitrate) and sugar got his arm singed and took some shrapnel to the eye.
#5 - A little girl accidentally had boiling water spilled on her when her aunt tripped carrying the pan.
#6 - A man working at taco bell came in with a deep fryer basket stuck to his back after a fellow employee hit him with it.
I'm going to head for a shower and bed now. And hope that I manage to block out enough of this crap to get a decent night's (day's) sleep. Yesterday my circadian hadn't caught up with me yet so I wasn't very well rested when I woke up.
8/3/10
Night floating.
So, the next two weeks I'll be working nights. Which means I'll be working roughly from 5 pm every night to 7 am every morning. I'll be on for the burn unit. But I'll also be making sure the patients for Neurosurgery, Vascular and Plastics don't die over night. The average for burns is about 40 patients and the other three add up to about 30-40 depending on the time of week (the lists tend to be cyclic. Emptying out at the beginning and end of the week and filling up over the weekend and mid-week).
A lot of people hate being on night float. And I get the down sides. Especially you have something resembling a life. Being nocturnal is not how people were meant to live. But if you only have to do it for a couple of weeks it's really not so bad. For starters, no 24 hour calls, a guaranteed weekend off, no rounding, a very focused amount of work. Your basic goal is just make sure no one dies. So you aren't worrying about calling consults or dealing with social work. It's straight reflex patient care.
All that being said you are all by yourself. Sure there is a senior resident you can call. But he or she is at home, asleep in bed. And it's always a judgement call. There are basically two bad outcomes and only one good one. Option one you didn't need to call. The resident can yell at you then and make fun of you for the rest of your time with them. Or you can not call when you should have. This is by first the worst thing you can do. Even if you did exactly what they would have done you shouldn't have done it without clearing it with an upper level. And you don't have to worry about a little good-natured you have to worry about loosing your residents trust in your judgement. Which is something that will spread like wild fire through all the senior residents and will make your intern year suck. Of course you can be right on the money about calling. But no one care when you do the right thing. They didn't hire you to screw up.
So, two notable things happened last night. The first was a 12 year old boy who came to us from out in the sticks some where with a second degree burn to one palm and another second degree to a shin. (Random note about burns, when a patient comes in. They have to go through an extremely painful washdown of the burned area as well as a peeling off of all the burned skin because dead tissue is just a breeding ground for bacteria) The hand was basically just one big blister which had to be popped, drained and then peeled off. The charge nurse, a a 6 foot tall bear of a man was in charge of this part of the procedure. While I held the young boys hand and tried to make him believe that the giant man leaning over the bed wasn't going to hurt him. I asked the boy to look at him. I asked him about his pets, a cocker spaniel named cocker. I asked him about his girlfriend. A girl named Cheyenne whom he "guessed was pretty." All of this was in an attempt to keep his mind off the painful procedure that was literally happening an arm's length away from him. But with one painful last tug on the blistered skin the boy snapped his head out of hands and took his first look at the newly exposed hand. "THAT'S MY MEAT, I CAN SEE IT!" he balled before just dissolving in tears. The words were hilarious but watching that boy cry was heart breaking.
Not too long after that a patient on the burn floor I had admitted over the weekend was found by his nurse out of bed, with his IV pulled out, blood all over the floor tugging on the foley catheter coming out his penis screaming about having tickets to the Braves game and having to get out of there. This patient was admitted for second degree burns to all extremities. He was also a heavy, heavy drinker and his Urine tox screen had come back positive for cocaine and marijuana. The trifecta. We knew he was going to be a pain control nightmare. His body being used to a high would need much higher doses of pain medication to relieve his significant pain, but those high doses were going to make respiratory shut down a real possibility. But our main concern was the inevitable alcohol withdrawal. We put him on some meds to try and wean him off the alcohol but it wasn't going to prevent them. And as soon as I ran into the patients room I knew that was what was happening. I immediately asked the nurse to give him some extra ativan and hoped that was the end of it for the night. But two hours later he was at it again. Thrashing against the restraints I'd ordered just in case he decided to pull out another line. I really didn't want to have to fix his penis. We gave him some more ativan but oxygen saturation started to drop and then when he woke up a bit he went crazy again, he spike a fever of 105, his heart rate was going in the 140s and 150s, he was breathing twice as fast as he needed to and wouldn't keep the face mask on so his oxygen was again dropping. At this point it was 4 am and my chief would be in in a couple hours. The charge nurse was telling me he needed to be intubated so he could ride out his withdrawal heavily sedated the respiratory therapist was telling me that if we could just calm him down enough we could manage this with a nasal tube and an albuterol treatment. I was telling myself that I had not idea what to do. I was leaning towards the intubation (for all the wrong reasons, basically it was just the easiest for me). But I knew I was going to have to wake up my chief.
When I made that call he immediately started barraging me with questions. I only knew the answers to about half. And the ones I did know I couldn't get across quite right. I swear that man thought I was a moron. He decided not to intubate, then called his chief who told him to intubate. So there I was calling anesthesia, placing orders I'd never placed before and panicking that I should have made the call earlier, I should have thought about this when I admitted him and a thousand other insecurities. Three hours later I left and now I'm sitting here typing about him and wondering how he'll be when I come back at 5 pm. How long is going to be intubated? Is he going to get pneumonia? Is he going to hate me when he comes off the vent?
I need to get some sleep now. But I know my vent patient and that little boy are going to be my last thoughts as a I fall asleep. And I'm a little worried where my subconscious my head when I'm not reining it in
A lot of people hate being on night float. And I get the down sides. Especially you have something resembling a life. Being nocturnal is not how people were meant to live. But if you only have to do it for a couple of weeks it's really not so bad. For starters, no 24 hour calls, a guaranteed weekend off, no rounding, a very focused amount of work. Your basic goal is just make sure no one dies. So you aren't worrying about calling consults or dealing with social work. It's straight reflex patient care.
All that being said you are all by yourself. Sure there is a senior resident you can call. But he or she is at home, asleep in bed. And it's always a judgement call. There are basically two bad outcomes and only one good one. Option one you didn't need to call. The resident can yell at you then and make fun of you for the rest of your time with them. Or you can not call when you should have. This is by first the worst thing you can do. Even if you did exactly what they would have done you shouldn't have done it without clearing it with an upper level. And you don't have to worry about a little good-natured you have to worry about loosing your residents trust in your judgement. Which is something that will spread like wild fire through all the senior residents and will make your intern year suck. Of course you can be right on the money about calling. But no one care when you do the right thing. They didn't hire you to screw up.
So, two notable things happened last night. The first was a 12 year old boy who came to us from out in the sticks some where with a second degree burn to one palm and another second degree to a shin. (Random note about burns, when a patient comes in. They have to go through an extremely painful washdown of the burned area as well as a peeling off of all the burned skin because dead tissue is just a breeding ground for bacteria) The hand was basically just one big blister which had to be popped, drained and then peeled off. The charge nurse, a a 6 foot tall bear of a man was in charge of this part of the procedure. While I held the young boys hand and tried to make him believe that the giant man leaning over the bed wasn't going to hurt him. I asked the boy to look at him. I asked him about his pets, a cocker spaniel named cocker. I asked him about his girlfriend. A girl named Cheyenne whom he "guessed was pretty." All of this was in an attempt to keep his mind off the painful procedure that was literally happening an arm's length away from him. But with one painful last tug on the blistered skin the boy snapped his head out of hands and took his first look at the newly exposed hand. "THAT'S MY MEAT, I CAN SEE IT!" he balled before just dissolving in tears. The words were hilarious but watching that boy cry was heart breaking.
Not too long after that a patient on the burn floor I had admitted over the weekend was found by his nurse out of bed, with his IV pulled out, blood all over the floor tugging on the foley catheter coming out his penis screaming about having tickets to the Braves game and having to get out of there. This patient was admitted for second degree burns to all extremities. He was also a heavy, heavy drinker and his Urine tox screen had come back positive for cocaine and marijuana. The trifecta. We knew he was going to be a pain control nightmare. His body being used to a high would need much higher doses of pain medication to relieve his significant pain, but those high doses were going to make respiratory shut down a real possibility. But our main concern was the inevitable alcohol withdrawal. We put him on some meds to try and wean him off the alcohol but it wasn't going to prevent them. And as soon as I ran into the patients room I knew that was what was happening. I immediately asked the nurse to give him some extra ativan and hoped that was the end of it for the night. But two hours later he was at it again. Thrashing against the restraints I'd ordered just in case he decided to pull out another line. I really didn't want to have to fix his penis. We gave him some more ativan but oxygen saturation started to drop and then when he woke up a bit he went crazy again, he spike a fever of 105, his heart rate was going in the 140s and 150s, he was breathing twice as fast as he needed to and wouldn't keep the face mask on so his oxygen was again dropping. At this point it was 4 am and my chief would be in in a couple hours. The charge nurse was telling me he needed to be intubated so he could ride out his withdrawal heavily sedated the respiratory therapist was telling me that if we could just calm him down enough we could manage this with a nasal tube and an albuterol treatment. I was telling myself that I had not idea what to do. I was leaning towards the intubation (for all the wrong reasons, basically it was just the easiest for me). But I knew I was going to have to wake up my chief.
When I made that call he immediately started barraging me with questions. I only knew the answers to about half. And the ones I did know I couldn't get across quite right. I swear that man thought I was a moron. He decided not to intubate, then called his chief who told him to intubate. So there I was calling anesthesia, placing orders I'd never placed before and panicking that I should have made the call earlier, I should have thought about this when I admitted him and a thousand other insecurities. Three hours later I left and now I'm sitting here typing about him and wondering how he'll be when I come back at 5 pm. How long is going to be intubated? Is he going to get pneumonia? Is he going to hate me when he comes off the vent?
I need to get some sleep now. But I know my vent patient and that little boy are going to be my last thoughts as a I fall asleep. And I'm a little worried where my subconscious my head when I'm not reining it in
8/1/10
Post-Call = Split pea soup
*AS I'M WRITING THIS I'VE BEEN UP FOR 32 HOURS*
For those of you not in the know. After we interns have been been in the hospital for a full 24 hours we are referred to as being "post-call." Per the current regulations we can stay for an additional 6 hours while we are post-call. It's really not the first 24 hours that's hard. It's that transition into being post-call. Something about hitting the 25th hour of being awake make all your systems shut down. Your depth perception is off. Your thermoregulators shut down. Your filter disintegrates.
Of course by this time you probably haven't eaten in the last 8 to 12 hours so you are definitely dealing with some hypoglycemic issues. And if you did drink anything it's been super caffeinated so you are dehydrated. Not to mention that you've had anywhere from 5-20 bouts of high intensity cardiovascular activity. Whether it was a critical lab, a trauma, a code, a scary attending. Something kept you running all day and all night.
They've done studies on what sleep deprivation does to a person's reflexes, recall ability and even judgment. I am sure there are interns out there who gripe about it so often they have these stats memorized. I for one am not griping. I approve of this system. Don't get me wrong I don't think the days when surgeons spent 80 hours straight in the hospital made any kind of sense. But this 24 + 6 system is a good one.
By the time you hit your post-call mark the entire team has reassembled. You are no longer responsible for patient care decisions, you are no longer allowed to operate. You are there solely to maintain the patients' continuity of care. You can tell each and every member of the time exactly what happened for each patient after they all went home last night because not only were you there but you managed each situation. And in managing the situation is where true learning starts. Yes there are dozens of safety-nets in place, from the nurses experience to the computer binging every time you order contraindicated medications. Not to mention the mid-level, senior and chief residents who are all available for you to call (if you are brave enough). But the autonomy of being the only person on the floor, and sometimes the only one physically in the hospital gives you the balls you need to take charge of a situation. And, yes mistakes will be made, but that's why the overly redundant back-ups to make sure they caught before ANY damage is done the patient.
But, I digress - as one is wont to do after 32 hours of sleep deprivation. One is also wont to wax philosophical and use high-falauting phrases one would never normally use for fear of sounding like a pretentious jack ass.
Anyways, back to my point. Which is that when you are post call it often feels like the rest of the world is coming at you through a dense fog of split-pea soup. Everything is insipid and murky and bogged down. When people talk to you the words sort of float past you and you can't quite grasp what's being said until the third repetition. Simple tasks like a dialing a 5 digit extension become monumentally difficult. Was that 5-6561 or 6-5651? Remembering that PCs use Ctrl+C to copy and not Command+C like your mac at home leaves you hunting for that damned command key for a full 30 seconds before you realize idiocy of your mistake.
All-in-all I've never really been a fan of split-pea. It had something to do with it's ickiness and goopiness and greenness. But that doesn't mean I won't shovel down a full mouthfuls if there is absolutely nothing else (hospital cafeterias have the worst soup selections so this has been the case before).
So that is the simile I wanted to put forward. Post call like split pea soup. Check.
Falling asleep with computer on lap. Must shower and sleep. I haven't showered in 32 hours either. It's kinda gross.
For those of you not in the know. After we interns have been been in the hospital for a full 24 hours we are referred to as being "post-call." Per the current regulations we can stay for an additional 6 hours while we are post-call. It's really not the first 24 hours that's hard. It's that transition into being post-call. Something about hitting the 25th hour of being awake make all your systems shut down. Your depth perception is off. Your thermoregulators shut down. Your filter disintegrates.
Of course by this time you probably haven't eaten in the last 8 to 12 hours so you are definitely dealing with some hypoglycemic issues. And if you did drink anything it's been super caffeinated so you are dehydrated. Not to mention that you've had anywhere from 5-20 bouts of high intensity cardiovascular activity. Whether it was a critical lab, a trauma, a code, a scary attending. Something kept you running all day and all night.
They've done studies on what sleep deprivation does to a person's reflexes, recall ability and even judgment. I am sure there are interns out there who gripe about it so often they have these stats memorized. I for one am not griping. I approve of this system. Don't get me wrong I don't think the days when surgeons spent 80 hours straight in the hospital made any kind of sense. But this 24 + 6 system is a good one.
By the time you hit your post-call mark the entire team has reassembled. You are no longer responsible for patient care decisions, you are no longer allowed to operate. You are there solely to maintain the patients' continuity of care. You can tell each and every member of the time exactly what happened for each patient after they all went home last night because not only were you there but you managed each situation. And in managing the situation is where true learning starts. Yes there are dozens of safety-nets in place, from the nurses experience to the computer binging every time you order contraindicated medications. Not to mention the mid-level, senior and chief residents who are all available for you to call (if you are brave enough). But the autonomy of being the only person on the floor, and sometimes the only one physically in the hospital gives you the balls you need to take charge of a situation. And, yes mistakes will be made, but that's why the overly redundant back-ups to make sure they caught before ANY damage is done the patient.
But, I digress - as one is wont to do after 32 hours of sleep deprivation. One is also wont to wax philosophical and use high-falauting phrases one would never normally use for fear of sounding like a pretentious jack ass.
Anyways, back to my point. Which is that when you are post call it often feels like the rest of the world is coming at you through a dense fog of split-pea soup. Everything is insipid and murky and bogged down. When people talk to you the words sort of float past you and you can't quite grasp what's being said until the third repetition. Simple tasks like a dialing a 5 digit extension become monumentally difficult. Was that 5-6561 or 6-5651? Remembering that PCs use Ctrl+C to copy and not Command+C like your mac at home leaves you hunting for that damned command key for a full 30 seconds before you realize idiocy of your mistake.
All-in-all I've never really been a fan of split-pea. It had something to do with it's ickiness and goopiness and greenness. But that doesn't mean I won't shovel down a full mouthfuls if there is absolutely nothing else (hospital cafeterias have the worst soup selections so this has been the case before).
So that is the simile I wanted to put forward. Post call like split pea soup. Check.
Falling asleep with computer on lap. Must shower and sleep. I haven't showered in 32 hours either. It's kinda gross.
7/30/10
My First Day Redux
So, it's the end of the first day. I think the most surprising thing was the fact that I spent very little time with patients today. Don't get me wrong, they were on my mind almost all day. But, I spent very little time with them. As a medical student you are the one who spends 30 minutes talking to each patient, but spend absolutely no time worrying about their management. Today I fretted over the dose of pain meds, whether to discharge a patient or not, the state of their wounds, their mental capacity but I spent very little actually talking to them.
I always thought the residents I'd worked with in the past were callous for not spending time with their patients. I guess I'd never realized how much time they spent dwelling on their patients even when they weren't there. Right now as I sit here typing this I keep thinking back to the Polish man who woke up from surgery with a strange dry patch on his face, the woman whose endocrinology follow up I'd scheduled and all the other patients from today. Their faces and our brief conversations keep swimming on the periphery of my psyche.
But, I have to shut that all out. Because my alarm is going to go off at 4 am, I need to be in the hospital at 5 am and I go on call at 6 am . . . I'll get off again sometime after 6pm on Sunday. That's a 36 hours in the hospital. 24 of them responsible for all the burn, plastics, vascular and neurosurgery patients in the hospital and an additional 12 in charge of just the burn patients. It's my first call as a grown up a doctor. I really need my subconscious to settle down so I can get a few hours sleep.
I always thought the residents I'd worked with in the past were callous for not spending time with their patients. I guess I'd never realized how much time they spent dwelling on their patients even when they weren't there. Right now as I sit here typing this I keep thinking back to the Polish man who woke up from surgery with a strange dry patch on his face, the woman whose endocrinology follow up I'd scheduled and all the other patients from today. Their faces and our brief conversations keep swimming on the periphery of my psyche.
But, I have to shut that all out. Because my alarm is going to go off at 4 am, I need to be in the hospital at 5 am and I go on call at 6 am . . . I'll get off again sometime after 6pm on Sunday. That's a 36 hours in the hospital. 24 of them responsible for all the burn, plastics, vascular and neurosurgery patients in the hospital and an additional 12 in charge of just the burn patients. It's my first call as a grown up a doctor. I really need my subconscious to settle down so I can get a few hours sleep.
7/29/10
My First Day
Some of you may know that the pilot episode of Scrubs was titled "My First Day." Some of you, with lives, probably don't know that. But I'm sure that most of you know what Scrubs is and that for doctors, it's the most realistic medical show on TV. Well, I recently got into a surgical residency and was supposed to start work on at the end of June. But because of a number of unfortunate delays getting my license I'm only just starting. Hopefully tomorrow.
So, I'll be about a month behind my co-interns. I'll be the only intern still getting lost, forgetting to sign out my pager and making people wonder why I was hired in the first place. I've been looking forward to starting my residency for years. I've studied, I've worked hard, I've spent sleepless nights in hospital trauma bays all leading up to this one moment. And suddenly, a terror is gripping me. I'm feeling it right now in the pit of my stomach. It's been growing slightly larger ever since I got the call saying my license had been issued. I've spent the past few weeks in a state of panic convinced that this moment would never come and now that it's here I'm wishing I'd done more to prepare myself.
I know it's totally irrational, and that every new intern feels the same way I do. But I also know that tomorrow marks the actual beginning of my career as a doctor and that today is the last day I can use the "I'm just a student" excuse. From now on I am the one that is responsible for ordering the 3 am labs, for writing admit orders and for making sure the prescriptions are renewed on time. I know all the things I am supposed to do. I even have an inkling of an idea as to how to go about doing them. And I also know that no one is expecting perfection on my first day. Except me, of course.
"Four years of pre-med, 4 years of med school and tons of unpaid loans had made me realize one thing . . . I don't know jack" - Dr. John "J.D." Dorian
So, I'll be about a month behind my co-interns. I'll be the only intern still getting lost, forgetting to sign out my pager and making people wonder why I was hired in the first place. I've been looking forward to starting my residency for years. I've studied, I've worked hard, I've spent sleepless nights in hospital trauma bays all leading up to this one moment. And suddenly, a terror is gripping me. I'm feeling it right now in the pit of my stomach. It's been growing slightly larger ever since I got the call saying my license had been issued. I've spent the past few weeks in a state of panic convinced that this moment would never come and now that it's here I'm wishing I'd done more to prepare myself.
I know it's totally irrational, and that every new intern feels the same way I do. But I also know that tomorrow marks the actual beginning of my career as a doctor and that today is the last day I can use the "I'm just a student" excuse. From now on I am the one that is responsible for ordering the 3 am labs, for writing admit orders and for making sure the prescriptions are renewed on time. I know all the things I am supposed to do. I even have an inkling of an idea as to how to go about doing them. And I also know that no one is expecting perfection on my first day. Except me, of course.
"Four years of pre-med, 4 years of med school and tons of unpaid loans had made me realize one thing . . . I don't know jack" - Dr. John "J.D." Dorian
4/3/10
"I'm not a serial killer, I swear"
You would think that being a surgery resident is as easy showing up at the hospital on July 1st and grabbing the nearest scalpel. Well, you would be wrong. Setting aside all the usual adminstrative nonsense of starting a new job there is still the hassle of the car, the computer, the phone, the apartment all of which have to be sorted out well before your first paycheck. A few days ago I tackled the furniture for my new apartment. Today I took a two and a half hour road trip from my hometown to the University town where I'll be doing my residency and looked at about 6 different apartment complexes.
Now, as a resident I need some place that takes less than 10 minutes to commute, including parking. Not to mention, it should be quiet, have a rent drop box and things that deliver and a number of other little variables that become necessities when you work the hours I'll be working. So, I had to explain to each property manager why I was asking seemingly irrelevant questions. Well, it seems I forgot to mention this to one lady. So, when she said that dividing my renter's insurance out over 12 months made it a nominal fee and I said that I don't need to do math because "I cut people open" I caused her a brief moment terror. In fact, she took a step back, the color drained from her face and she stared at me open-mouthed while I floundered for a rational explanation. The best I could come up with was "don't worry, I'm not a serial killer" and "I don't cut people up for fun, I swear." After a few more minutes of this I eventually got her to understand the whole surgeon thing.
I think living there for the next couple of years should prove entertaining.
Now, as a resident I need some place that takes less than 10 minutes to commute, including parking. Not to mention, it should be quiet, have a rent drop box and things that deliver and a number of other little variables that become necessities when you work the hours I'll be working. So, I had to explain to each property manager why I was asking seemingly irrelevant questions. Well, it seems I forgot to mention this to one lady. So, when she said that dividing my renter's insurance out over 12 months made it a nominal fee and I said that I don't need to do math because "I cut people open" I caused her a brief moment terror. In fact, she took a step back, the color drained from her face and she stared at me open-mouthed while I floundered for a rational explanation. The best I could come up with was "don't worry, I'm not a serial killer" and "I don't cut people up for fun, I swear." After a few more minutes of this I eventually got her to understand the whole surgeon thing.
I think living there for the next couple of years should prove entertaining.
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