MOMMMMMYY!

So just when you think you're getting a month off of hospital call, the residency surprises you with something called "Mommy Call." It sounds innocent enough. Not only in the name of the call, but its home call---how bad can that be?

bad.

First let me say that when you're on Mommy Call you are also the resident for jeopardy call (see previous post). Secondly, parents will call about anything and everything. At all hours of the night. Demanding things.

My first (really second, cuz the first one I was Jeopardized. again see previous post) Mommy Call consisted of Moms calling about a child jumping on a couch and fell on her face and wondered when she should check to see if her face is "mushy." Another call was from a mom about her child having a rash and wondering what it was. Over the phone.

But my last call of the night (at 5am) was a mom who wanted to discuss illnesses in her 5 children. 5 CHILDREN! So I said start with the oldest and go from there. All in all, the whole call took about 40 minutes to get through it. Just enough time for me to get ready for work. Because even though we take Mommy Call overnight we still gotta work a whole day the next day.

Oh the joys of residency. Even with all this craziness, I love my job and would not change it for anything.

JEOPARDY!

Not the fun American Game TV show that we all have come to love. No, this is an intern nightmare. Its the phone call you wish would never come. Its the request to come in and work someone's call. When you had made dinner plans. Or in my case, a Saturday in which I was to go hiking, then to a movie, and then out for drinks. All down the drain with a simple phone call.
The first idea is the intern you are covering for is really sick. Or has had a disastrous emergency. The second idea is you will be "paid back" by the person who jeopardizes you for one of your calls. So you can schedule a time when you should be on call, in my case a Saturday call, and poof! It goes away without any guilty thoughts. I dreamt about this payback all 30 hours of jeopardy call.

First illness

Ugh. I am home sick today. One of the little tykes decided I needed the viral gastroenteritis. Well I didn't. I haven't called in yet and I am upset that today was the day. I was hoping to make it at least a year. But the idea of puking on a little kid was disturbing, so I am home today. Dang it.

Ahhhhhhhhhh

My new recent pet peeve in the hospital is examining a patients throat. Especially adults. I have my little light turned on. I ask the patient to open their mouth. Then I ask them to stick out their tongue. And then usually their big fat tongue is blocking their pharynx so I have to ask them to say "ahhhhh", which will raise their uvula and pushes down their tongue bringing their pharynx (back of the throat) into clear view. Do you know how many times I have to ask before the patient actually does it? It usually takes three.

This sort of perplexes me because they followed all the other directions prior to that on the first command. They will even roll onto their side with ease for the rectal exam without a hesitation. But there is something about saying "ahhh" that people just do not want to do. So I ask them to say it multiple times. I'm even doing it when I ask it. And generally without a response. Until I explain why I am asking them to say it. Then I finally get an "ah" but not an "ahhhhhh."

With kids they don't understand the "say ahhhh" command. Which is why I have to gag them with the tongue blade. And then they cough onto my open mouth and I get mycoplasma pneumonia. But they are kids, and are cute, so I quickly forgive them.

But I am fed up with resistant adults. So adults beware. I know we all have flashbacks to our pediatricians using a device to see our throat. I'm pulling out the tongue blade. Thats right. Without me asking you to say "ahhhhh" first.

Reassurance

Today marks my final day of OB---a two week stint of up at 415 in the morning, pounding on women's bellies that had just delivered a baby and asking if it still hurt, about 200 pelvic exams, 15 babies delivered by yours truly and three sad cases of babies that did not make it.

It was a whirl wind.

I remember my third year rotation where I heavily considered the field of OB/GYN. Delivering babies was fun and those residents work their tail off. But after these two weeks I realize that I am in the right field, which is one of the most reassuring things I have felt since I started residency.

I may still have the opportunity deliver more babies in the Emergency Department. Which to me is the most exciting idea---you just never know what will walk through those sliding glass doors on the first floor of the hospital. And thanks to the amazing ladies of the OB program I feel more prepared.

going to hell

My last call was particularly difficult. I know I've semi discussed ethics in previous posts but I honestly didn't think it would be such a huge part of my life as a resident. I am quickly learning that this isn't the case.

Around 130am I got a page about a pt on the floor who was not doing well. He was a 90 year old man who has recently been in and out of the hospital for pneumonia. He was actually getting better when that evening he aspirated an entire bottle of ensure. He then started breathing really fast (tachypnea) and required more and more oxygen (hypoxic)and started running a fever. So we transferred him up to the ICU and started to get ready to intubate.

But then we all paused.

He was a full code. He wanted CPR, intubation, cardiac life saving drugs.

And yet we paused. He was 90 years old. The likelihood he will be able to come of the ventilator is small. We tried to explain that to him and he responded with "I dont want to talk about that right now. I dont know what to do." Thats when everything changed.

To go up the chain of command in terms of power of attorney (POA) it usually starts with the patients spouse (but only if they are straight---dont even get me started with that), then their kids, then their parents/family, and then maybe friends? It all gets muddled.

So we called his son because that was the only number we had in the books. He comes into the hospital and we have a 2 hour conversation about to intubate or not to intubate. Meanwhile Mr. H's respiratory rate is slowly declining. After this discussion we realize its his wife who has the medical POA. So then we call her, who says to do everything.

So we set up the intubation again. And I start tearing up. If this man was 20 years or even 50 years old I wouldn't think twice. But with all his other diseases there is a very high chance he will not survive this. I am about to intubate someone who probably will never come of the vent. I am supposed to be doing this to save people. I am exhausted because it is now 4 am. So I start tearing up but try to hide it by pretending I am excited to "do a procedure".

When my pulmonary fellow comes in that morning I start with "I may be going to hell because of this one....."

this is what i've come to....

This when I feel like the singleness is just pouring out of me.....

I recently got a message from one of my pediatric attendings--one who I am fairly close with socially--asking me if I was interested in going on a blind date with a friend of a friend.

That was all it said. So of course my next question is "who is this guy? any more details??"

The response made it all a bit more embarrassing. Apparently another peds attending that I worked with last month "loved" me and wants to set me up with his nephew so he asked around the attendings to find out if I was single.

My attendings are working harder on my social life than I am.

ouch.

The thin line

I am currently on my first medicine ICU or MICU month of residency. And not only that, but it is at the VA where all the patients are already knocking on deaths door, and just waiting for the final say so to move on. Yeah, its pretty intense.

We had our first almost code situation today. And I say almost not because it was a close call---he did pass away---but it was almost called a "code."

He was a 60 something year old man who had perfed his bowel and required extensive surgery to remove the damaged small intestine and then got an infection in his blood which then gave him a really bad infection in his lungs and he started to down spiral around 3pm today. He was actually on the surgery team, we were just the medical help out. His blood pressure dropped and then his oxygen saturation dropped to the 60s (we want most patients above 90) and the highest we ever got it back was the mid 70s even after turning up his ventilator all the way. When his pressures dropped again, we were about to flip on the code button--which announces to all the pagers that someone is in a "code blue" situation and everyone comes running. Thats when someone decided to call his wife and verify his "code status."

We were told we were not to do chest compressions. So we turned off the code blue announcements and continued with increasing his pressures and such. Then there was a discussion what exactly his status was: increase pressures? start drips? chest compressions? withdraw all care? withdraw only some care? give shocks? only do CPR? It has gotten so specific of all the different choices a person has that it got me thinking about the thin line of what each person wants and how it can make such a difference---I needed to know how this whole DNR stuff actually started.

In a basic search on the internet it appears that the history of a person being able to decide what forms of resus they wanted started in 1976 with the case of Karen Ann Quinlan v New Jersey in which a 21 year old woman was found comatose after taking tranquilizers and ETOH. Her family wanted to withdraw life support but the medical team just flat out refused and the case was brought to supreme court where they ruled in favor of the family ruling "Karen's "right of privacy" included a right to refuse medical treatment and that her father, under the circumstances, could assume this right in her stead."

It wasn't until 1991 when the Patient-self Determination Act that mandated hospitals honor a patients desire in their healthcare. And now today's occurrence is so common place across the US.

In the middle of us giving a stronger pressure medication we were told to stop doing what we were doing. What does that mean? Stop the medication? Turn off the vent? The surgeon was running back and forth from where the family remained asking each specific question. Finally an understandable conclusion was given: Stop the pressure medication all together. Then 5 minutes later: turn of the ventilator.

He passed within minutes, hopefully at peace with the decision his wife made for him.

being a (good) teenager....

I recently saw a 16 year old boy who was super awesome. He was a talker. I mean I asked him how school was going, and I think I got a 10 minute response. Straight. Without pauses. Loved it! It sorta reminded me of myself when I realized someone was listening. Now I dont even need people to listen...

Anyway, after kicking mom out to do the genital exam and HEADDSSS exam (Home--are they safe?, ETOH use, Activities besides watching the tube, Drugs,Depression, Suicide, Sex, Smoking) he said, "yeah they asked me if I wanted a female or a male doctor. And I was like, come on! I am 16 year old boy. My hormones are screaming 'Female! Female! Female!' But I'm more mature than that, so I told them either one is fine. Because it is."

Then he immediately followed it with "are we gonna talk about sex now??" I said, "Well that is one of the topics I'd like to cover." When asked if he was having sex his response was "I dont really think of it as having sex. Its called making love for a reason. And I am not in love. So not really making it either."

CLASSIC.

Hmpf

I was extremely excited to be on vacation. And then it suddenly hit me that no one else was going to be on vacation at the same time as me. The amazingness of medical school was we could all go on a trip together. All these new interns I have desperately tried to connect to are still slaving away in the hospital, while I get to roam free. But who wants to roam all by their lonesome? I have recruited my hound on a trip, which he'll have a blast, but he's not much of a conversationalist. But the truth of the matter is my next vacation is in 8 months so I best enjoy this one!!

Listening skills

A conversation between a nurse and a patient in the Emergency Department....

Patient: "Excuse me nurse? Are my testicles black?"

Nurse lifts up the patient's gown and takes a peek, "No they look normal."

Patient: "What are you doing? I asked if my test results were back!"


Gotta love the communication that goes on in the ED....

LOST

This is one of my favorite televisions shows. This is also my constant emotion these days. I haven't felt so, well, LOST since the beginning of medical school where I was convinced that everyone was constantly studying and I was incisively behind. I eventually just did stuff on my own pace and my own way and things went fine.

But doing things my own didn't really affect anyone else. My actions did not influence patient care. Now I can't really hold off on reading that chapter on hyperbilirubinemia because that kiddo is in the ED NOW.

I know I don't need to and can't possibly know all the answers now (why would I be doing residency if i did??), but I feel like I've got nothing in terms of knowledge. I am just roaming the island trying to figure out how to get back to what I know.

Did you goose it???*

The first trauma red came in around 1030 am yesterday. Being an intern and not having done trauma or ATLS (adv. trauma life support) it means I cannot sign up for the trauma patient. But it being 1030 in the morning, and nothing else to do, I asked my third year resident if I could tag along.

The pt was running from the police, up a hill, and fell, severely dislocating his right knee. After a few xrays and a quick physical exam, the residents and attendings quickly realized that the leg was pulseless below the knee and that compartment syndrome was setting in...and fast.

It felt almost like a Greys Anatomy episode (except no one was sleeping together)-- the decision was made to intubate in the ED and I quickly jumped in and asked my third year if I could do it. He paused for about fifteen seconds. When he finally said yes, I did a double take--wait did I really want to try this?

I got my stuff all set up. And we discussed which drugs we were gonna use. My attending pushed the drugs and said, "Ok, you ready?" I had a quick "OH MY GOD YOU ARE NOT READY!!" But I picked up the laryngoscope and started opening the mouth. The patient was in C-spine so I couldn't open the mouth too widely for fear of hurting his possibly fractured neck. I used a CMAC (we have an awesome airway man attending who tries out all the new airway stuff before it even goes to other hospitals)--it is a video laryngoscope but allows the intubator to also use it as direct, meaning you look into the patients mouth while intubating, and not at the video screen. Which is what I did---I didn't even realize it was video until my attending said "Go in a bit deeper."

I wasn't used to seeing the mouth with saliva. I was used to the plastic dummys so when I saw all the bubbles, I quickly yelled "I need suction!" but then I got a glimpse of the vocal cords (hahahaha! see previous blog) I yelled "Need the tube!" and I quickly jammed that thing down there. Then I reminded myself DO NOT LET GO OF THE TUBE. We use a color indicator to help us make sure we are in the correct spot (if the color looks like urine, then "ur in!") The stress and excitement quickly came rushing at me and I had some uncontrollable shaking. I left the trauma bay to try and pick up where I left off with my other 3 patients.

I was on a high the entire shift.


*Apparently this means did you stick the tube down the esophagus into the stomach. I of course screamed a yes! when asked this the first time. I quickly realized this is not a good thing. and luckily I did not do this.

watching it convert

I know I have said this before, but I loved my trip to Nepal. It was absolutely amazing and I would never say it wasn't worth it.

It may have not been worth it.

Today I spent several hours at my hospital being reminded of washing my hands after every patient (even after just entering the room), who the lawyers are to call when I get in a bind, and the number for the pharmacists for when I have no idea what the dosage is.

Then we got our ppd skin test. I had an inclining (ok I thought it was definitely going to happen) that I might sero-convert. This occurs when you are in contact with a patient of TB. You can either sero-convert and not get the disease, or you get the disease and sero-convert. It depends on the length of contact with the patient, the health status of the person who is exposed, the type of TB the patient had.

I had contact in Nepal almost everyday.

So this evening, while I baked cup cakes for my birthday tomorrow, I watched as the ppd test slowly enlarged over time. (dang it!!)

The next steps entail: a chest xray to prove I do not actually have active TB currently and then 9months of Isoniazid (INH) therapy. This drug does not come without heavy side effects. It can cause serious liver damage; especially if you drink while taking it.

What does that mean for me? I will be sober for a solid 9 months and I wont even get a baby out of it.

Thank you Nepal.
(I'd go back in a heartbeat!!!!!!!!!!!!!)

birthday

A year ago I spent my birthday in one of my favorite vacation spots in the US: Lake Tahoe. I was surrounded by a group of fabulous ladies and it was possibly the best birthday of my life. I ran an amazing 10 mile trail race (although I got lost and added an extra mile to it) two days before my birthday. I went kayaking. We laid out on the lake shore. AMAZING is all I can really say.

This year, I turn 27 and I have to say the birthday will be completely opposite of last. My birthday marks the first day of residency (well, for most programs) and thus I will spend 12 hours of it in the hospital (doing more orientation) and I will attempt to round up ANYONE who would be willing to grab a beer. And although it won't be a bad night--I love birthdays and I dont believe they could ever truly be "bad"--it will be different. Instead of being surrounded by people I know, for the majority I will be surrounded by people I am desperately trying to get to know.

I am to have a birthday party filled with those I met about a week ago.

So I guess this goes back to a previous post---I LOVE YOU AND MISS YOU GUYS!!!!!!!!

Pop Up Thoughts

Over the past two weeks and for the next couple of weeks, I have been and will be certified in several life saving courses. They include Basic Life Support (BLS) twice, Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP), Advanced Pediatric Life Support (APLS--this is basically the same as PALS), and Advanced Trauma Life Support (ATLS).

By the second course it all starts to sound very similar. ABC--Airway, breathing and circulation, then do other stuff. That other stuff varies based on age and what the monitor says.

One of the "exciting" things in all of these courses is the idea of getting to do some procedures that I've wanted to get my hands on for awhile now. Putting in advanced lines, and intubating a patient. I know this will sound a bit off color, but I've decided that the human vocal chords really look like a very small vagina. I know I know, its bizarre. But here's a picture



And once this idea got into my mind I couldn't stop thinking about it each time I intubated. And now I think this might just be what I think of each time I intubate in the future. And maybe its not a bad thing because codes are a bit hectic, so to have a moment of lightness could be actually helpful.....

So if you see a flash of a grin while I intubate it may because this pop up thought has appeared. Or it may be because I still cannot believe I am intubating someone; that I have actually graduated from medical school and in residency.

cambio

As things change rapidly around me, and we are warped closer to the start of residency, there is a large melancholy feeling about everyone "moving on."

Most of my closest friends have left the state to pursue amazing residencies elsewhere. And while I am so excited and proud of them, I am also sad when I realize many of them I may not see again. When will I have time to travel in residency? When will they? And of course I will make new friends, as will they. But I started this medical journey with them, and it would be nice to continue it and complete it together.

So while my own excitedness for my residency start date grows, so does emptiness of missing my friends, my classmates, my colleagues. I love you guys!!

MD!

Well it is official---I am now an MD!! Patients beware--especially starting July 1st--I would suggest you visit a non-teaching hospital, at least for the month of July. But then please come all you want, I gotta learn somehow! :)

Graduation weekend was a lot of fun, but it seemed a bit anti-climatic at the same time. I've been trying to remind myself that I am actually done with medical school. Although I believe we learn throughout life, I am no longer an actual "student" anymore. I have spent 20 years of my life as a student. Weird.

The house drama continues---I think we might actually close next week!---but I am (trying to be) kinda glad---being an MD and house owner all in the same week is a bit overwhelming!

So do I change the name of the blog and just keep on telling my tale? Or do I just put this to rest (already!)?? hmmmm....

Sadness

Its been a pretty awful week. I am sure some will be upset with this blog, but I have to write it. I guess this makes me selfish in some way, but that is how it goes at times.

We, as a class, were informed that one of our classmates a week from graduation committed suicide. Although we hadn't spoken in a little over 2 years, I knew her well.

Our first year of medical school we became study partners. Unlike me, she was a true genius. Her photographic memory helped with her with graduating high school and college in 6 years total. It made studying really difficult since I was super slow compared to her. But we still made it as fun as possible.

As I got to know her, she began to tell me how hard life really was for her. She was extremely depressed---everyday. She once described it as being unable to hear the birds sing, or kids laugh. She was amazing and could hide it with her wonderful smile when she needed to. But I was deeply worried. Eventually I went to our school counselors about my fears, and was reassured that she was receiving treatment--both therapy and medications. Unfortunately it was these medications she used for her first attempt.

It was the day after spring break. I was pretty sick and took some NyQuil to go to sleep. She called me around 945 pm. NyQuil had done its job--I didn't even hear the phone ring. She didnt come to school the next day. I called her about three times in between classes throughout the day. I got a phone call from the police department at 5pm that evening. She was picked up for a DUI and needed a ride home. I was shocked--she didn't even drink. I went down there and she was a mess--I was told she took her prescription meds and she should not be operating a vehicle. I got her in the car and she confessed she took all the meds at once. I immediately took her to the ED, called her psychiatrist at home, and our closest friends. They met me at the hospital. While she was evaluated, we lied to her and got her parents phone number to tell them what had happened. I am pretty sure that she figured that one out, but she never let on if she was upset. She was admitted to the psych ward for a few days. During that time she blamed me for not answering the phone that night. She wouldn't have taken the pills, if I had just answered. The blame even came from her parents. It was so difficult to have a friend try to end her life, but to get the blame for it was unbearable. I started seeing a psychiatrist at that time.

She called me again at night after she was released. I freaked out. She called just to say hello. No big deal. But I stopped sleeping. I found myself checking my phone throughout the night. I would wander my apartment late at night. I was in a constant worry about how to keep her alive. I was not doing well.

At the time I did what I needed to. I was trying to save myself. I eventually had to sit her down and tell her that if she ever called me late at night again, I would just send a police officer to her apartment because I was so worried she would hurt herself. She laughed at me. But I was very serious. When the blame continued after that conversation, I left the friendship.

Over the next couple of years I worried about how she was doing. But the space between us was too great---I had created a canyon to protect myself and left her (with psychiatry help) alone.

Now that she is dead the guilt has hit again. I know that this is not in any way my fault. But what I feel is completely different--I feel that blaming me makes perfect sense. My feelings and my knowledge are in disagreement. I am devastated by the circumstances. It is entirely possible that if we had remained friends she still would have died--that is not what I feel guilty about. I feel guilty about leaving a friend when I knew that she was not okay. That she was not, by any means, stable. And when I left I was/felt relieved. How sick am I? Would I do it this way again? How angry did I make her then? Before she died?

How do I say I am sorry?

Considerations

I like to travel. Roadtrip, long flight, bus--no problem. I like getting all my things situated into the car, plane, bus and then listening to music, reading, sleeping. Just enjoying the ride.

I do not like airports. Its a holding situation for me. I can't really get situated yet because I'm not going anywhere, and as soon as I try to get comfortable, they're gonna call my seat number to board and I'll have to gather everything up. So I sit in this semi-anxious situation, just waiting for them to call me so I can really get comfortable and get a move on to where ever I am going.

I have the same feelings towards buying a house. The inspection process is just like me sitting in the airport. I am so ready to get moved in, get situated, put my towels in the linen closet. But that readiness/anxious feeling may mean that I am over looking serious issues that are going on with the road ahead.

I found out today that the house may need a new roof. The pipes are pretty old as well. The two things I really didn't want to deal with when buying a house. We're talking a huge cost at some point. Or maybe not.

So do I just jump in with the first classers even though I know I will be pushed into economy and possibly out of the plane just because I wanna get on the road so badly? Or should I really stand by, and see if another house will come my way.....