Monday, December 31, 2007

Happy New Year 2008!!!

Saying good-bye to 2007:

Started the New Year dancing at the Withrow Ballroom just north of St. Paul, MN during the middle of a major snow storm that dumped almost a foot of new snow overnight.  I checked in my boots at the door and carried my dress shoes in my hands.

Working as a House physician at Fairview Southdale and UMMC.

Driving my Jeep on frozen White Bear Lake! 
Riding the Valentine's Day Minnesota Zephyr dinner train out of Stillwater, MN and Jerry asking me to marry him at the end of the trip.  I don't know if I was more excited about the proposal or the little blue box.

Snowboarding several times at Afton Alps.

Jerry was gone over Spring Break and I worked back to back 36 hour shifts with a 12 hour break in between.  NOT fun, but brought in a lot of "cha-ching!"

The week with Mom and Jerry in Manzanillo, Mexico with side trips to Colima, Guadalajara, Puerto Vallarta, a whole lot of seafood and snorkling Los Arcos.
Interviewing in San Diego(I didn't get the job), and showing Jerry some of my favorite beaches.

Interviewing in Mankato(I didn't get the job), and wondering what I would be doing come July 1.

The phone call from Buffalo, the phone interview, and then the offer.  A rush trip to Buffalo to look for an apartment on the day the bridge collapsed in Minneapolis.  (Several weeks earlier during rush hour traffic where I passed workmen using jack-hammers on the highway as I drove over the bridge, I wondered how safe it was and if there was a chance it could collapse.)

The three weeks I had to pack up my life, my cats and a moving van, yet again, and make the "half" cross country trip to Buffalo, NY.

Setting the date for the wedding once my job was secured.  Eeek!

Being thrown into the E.D.'s at ECMC and Buffalo General and keeping track of my adventures on this blog.

Spending three weeks with my mother and Flat Stanley who came to visit including a very memorable Blues vs. Sabres game.

Ultrasound and this CCU rotation which is, Thank God, almost over.

A new year approaches... who knows what new adventures it will bring, the biggest being a wedding and a trip to Riviera Maya, plans for a cruise, and the start of my second year of Emergency Medicine residency.

Here's to wishing you the very best the new year has to bring!  I can't wait to find out...

Saturday, December 29, 2007

Kissing Cousins

I'm going to get back on the soapbox, yet again, to talk about the importance of having advance directives, living wills, etc.  I have a patient this week who suffered a massive stroke.  So massive that they will never have a "meaningful recovery."  Essentially, my patient is brain dead.

Somehow, they managed to tell their children that they didn't want a tracheostomy (breathing tube in the neck) but not much else.  Now, I have had many discussions with families about their loved ones' health and final wishes.  I am, as some of you know, a strong proponent of "letting nature take its course."  Sometimes in medicine I think we forget that just because we can doesn't mean we should.  And, this is moreso in the critical care setting where letting go is sometimes the best medicine we can practice for our patients.

Anyway, unfortunately, this patient's family is, shall we say, mentally challenged.  Rumors abound regarding in-breeding and first cousin marriage, but regardless, my patient's children don't understand the meaning of brain death.  They still think their parent has a chance of recovery.  I spent 2 hours, and a priest and social worker spent another 2 hours trying to explain to them that their parent is dead.  They may be on a ventilator, but that doesn't mean that their parent is going to wake up.  I knew they didn't quite get it when one son kept asking if a blood transfusion or feeding the patient would help.  I don't know that I have ever been so coarse or so graphic with a patient's family, but they just didn't understand.

I plan to talk to them again on Monday and see if anything we talked about sank in.  I told them they could be at the bedside when they were ready to say good-bye to their parent, but even then, I think they thought if they didn't do anything their parent would recover.  It's a difficult situation, and very frustrating.  Again, all of this would be a moot point if my patient had a living will, advanced directive, tattoo across the chest (as I've heard rumored someone actually does) which states "Do Not Resuscitate."

So, as we go into the next year, maybe a New Year's resolution should be to talk to our families and loved ones.  Get out the box of tissues and bottle of wine, because this isn't an easy discussion.  Sit down and make a plan.  Write it down.  Come to an agreement.  And, because I am an organ donor, I always encourage parents to think about their children in these discussions.  Considering the death of your child is a horrible thought, but when you comes to terms with the possibility and make a decision regarding organ donation, you know a part of your loved one carries on.

During the week I met an 8 year old heart transplant patient who was visiting the hospital promoting blood and organ donation.  She was born with a heart defect that required multiple surgeries as an infant.  A couple of years ago, she developed a fatal complication and would have died without a transplant.  Luckily, someone else's family made the decision to donate their child's organs, and this young girl received their heart.  Now she's involved in promoting organ donations across the country.

Since I'm getting married in a few months, it's the perfect time to talk about final wishes.  My fiance knows I want to be an organ donor.  Take anything needed.  I'm not, after all, going to take it with me.  My mother and I have had the discussion.  I know her wishes should she become unable to vocalize them.  Sad, yes.  But a few moments of sadness will lead to a great relief of burden should the time come when I ever have to make a decision regarding her care.  I'll know what she would have wanted, and I will be able to carry out her wishes.

OK, off the soapbox.  The countdown continues, and we're into the final week... woohoo and boo because the painful attending is coming back... BUT, it is the final week...
CCU Countdown:
Days until the end of the rotation:  8
Actual number of days I will be working during that time: 7
Days left until the painful attending returns:  1
Number of days until my next 24 hours off:  7 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 1
Number of long call shifts remaining: 1
Number of patients: 2 1/2 - I have a multisystem organ failure that has to count as an extra 1/2 pt due to all the work needed
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Thursday, December 27, 2007

Working for the Weekend

CCU Countdown:
Days until the end of the rotation:  10
Actual number of days I will be working during that time: 9
Days left until the painful attending returns:  3
Number of days until my next 24 hours off:  9 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 1
Number of long call shifts remaining: 1
Number of patients: 2 1/2 - I have a multisystem organ failure that has to count as an extra 1/2 pt due to all the work needed
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Wednesday, December 26, 2007

Wait a Minute, Mr. Postman!

Today was a very dull day.  Which is good for a Wednesday.  We didn't have grand rounds, so I had to sit through rounds.  Luckily, rounds were over quickly, and there were no radiology rounds - meaning sitting in front of the computer and looking at angios and echos.

The most exciting thing for me today is that I mailed out my wedding invitations.  That kinda makes it just that much more real.  Real scary.  Eeek!!  That means I just have 8 more weeks to get ready.  I feel like there's so much still to do.  Luckily, my Maid of Honor Nicole seems to have a more level head and is keeping me reined in.

So, for now, the countdown continues:
CCU Countdown:
Days until the end of the rotation:  11
Actual number of days I will be working during that time: 10
Days left until the painful attending returns:  4
Number of days until my next 24 hours off:  10 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 1
Number of long call shifts remaining: 1
Number of patients: 2, I think, sometimes it's hard to keep track of the patients that go to private service.
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Tuesday, December 25, 2007

Silent Night

I spent the day at the hospital.  I took a call day so that everyone else could leave and enjoy their Christmas Day.  I called my mom mid-morning and got the report from the night before.  She enjoyed the gifts I had sent, and the extra special basket of sugar-free goodies from my fiance.

All in all it was a nice, dare I say, quiet day in the CCU.  I had one admission, and one sort of excitement toward the end of the day.  For the most part, I had about five hours of watching a CSI marathon and almost all of "Goldeneye" uninterrupted.  Mmmm, Pierce Brosnan as James Bond.  I could just watch him all day long.  For me, there is no more perfect Bond.  But, I digress.

If you've followed my prior posts, I think by now we've established some of the rules to follow when it comes to drinking.  Something I don't think has come up to this point, mostly because I see people in the ED once and not for several days in a row, is the discussion about what happens to people when they drink excessively for days and weeks and months on end and then come to the hospital where they're not allowed to drink:  a little something known as the DT's.

You're ok for the first couple of days.  Normal for the most part.  Then around day 3 you start to get a little anxious.  Maybe, a little more irritable.  Your heart rate starts going up and your blood pressure might go up as well.  Then the fun starts.  You start imagining things that aren't there.  You get confused.  You might even get physically argumentative.  If your medical team is unaware of your alcohol intake (and granted most patients lie when it comes to alcohol consumption which is why as a general rule since med school we've been taught to double anything the patient states is the amount of alcohol they admit to consuming), you might get placed on thiamine and folate and some Ativan (Lorazepam) to help you avoid the mental confusion aspect part.  When you start having seizures, that's a bad thing, and you could actually die (so admit to drinking alcohol and how much.  Please.)

If they don't, and you lied (of course you did) about the amount of alcohol you consume, you can go into full blown DT's (delirium tremens) which includes shakiness, severe mental status changes, lethargy, etc. and end up like my patient who is now on a ventilator after he became somnulent to the point he couldn't remember to breathe.  He would barely breathe when we shook him or called his name, but then he would go off into a stupor.  So, now he's got a breathing tube.  His girlfriend called later, and I had to tell her that he was on a breathing tube.  I couldn't tell her why though, there's this thing called HIPPA which is basically a patient rights document that states your medical information can't be shared with anyone not directly involved in your care.  I am sure she would tell me how much he actually drinks... if only I could ask her...

Some shots of downtown Buffalo.  I love the city, especially at night.  Merry Christmas to all!

CCU Countdown:
Days until the end of the rotation:  12
Actual number of days I will be working during that time: 11
Days left until the painful attending returns:  5
Number of days until my next 24 hours off:  11 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 1
Number of long call shifts remaining: 1
Number of patients: 4
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Monday, December 24, 2007

It's Going to be a White Christmas

All the phone calls have been made.  All the rush is over.  Now, it's just another quiet evening at home.  Somewhere across the country my mother is sitting in church for the 4:30 p.m. Christmas Eve service.  Afterward, she'll stop by the house to pick up the gifts and her famous potato salad and then head over to my aunt's house.  They'll eat tamales, sopa, potato salad, plus a number of other goodies.

Around 9, the males in the family will sit to play nickel and dime poker.  For the first time in a couple of years there won't be a female, me, joining them.  Hopefully next year.

Around 10, the children will begin to wonder how soon they can start separating gifts so that they're ready at the stroke of midnight.  Tradition holds that we start with the youngest and work our way to the oldest.  You just sit around in anticipation of getting to open your gifts.  Usually, around that time, my mother and I would leave and go home.  We'd turn the TV onto midnight mass at the Vatican while we opened our gifts.  We'd sit and talk and laugh about what we'd received that year.

Finally, around 2 or so we'd go to bed:  already planning our breakfast of leftover tamales, or ham, or whatever sounded good for the next day.

Mom promised she'd keep the tradition.  She's not going to open the gifts I sent her until she gets home later tonight.  Since it's going to be around 2 or 3 in the morning for me, and I took call at the hospital tomorrow, I won't be able to call and hear as she opens her gifts.  But, I'll talk to her tomorrow and hear how things went, the latest gossip, the usual raves about her potato salad, and it will be almost like I am there... almost.

CCU Countdown:
Days until the end of the rotation:  13
Actual number of days I will be working during that time: 12
Days left until the painful attending returns:  6
Number of days until my next 24 hours off:  12 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 2
Number of long call shifts remaining: 1
Number of patients: 3 - that's what I had when I left, we'll see who's still around tomorrow
Number of super nurses in the unit:  4
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 3 1/2 (1/2 because I like the one I took call with the other day, but he stole one of my procedures)

Wednesday, November 28, 2007

Hockey Heaven

Ok, so my fiance knows that if I ever left him for anyone it would be Paul Kariya of the St. Louis Blues.  That's hockey, folks.  Hockey came to Southern California in the early 90's in a big way with the Mighty Ducks of Anaheim, now known as the Anaheim Ducks - Stanley Cup Champions.  One of my mother's vendors at the time had season tickets, center ice.  We went multiple times over the course of 2 years.  Sure, there were the LA Kings, but now we had a hockey team in the OC... several years before it became known as the OC, but whatever.

When I left for med school, I didn't just follow the Ducks, I followed my favorite player, and I still do.  Every time his team comes to play near the town where I am, you can bet I'll have tickets.  Don't laugh, you have your favorite _____ (fill in the blank with your favorite band, actor, actress, performer, singer, baseball/basketball/football player, etc.), and I have my one little vice.  Oh yeah.  BTW, I do also have 2 hockey sweaters with his name on them.  Goal in life, to get them signed.  Sigh, one day.

Anyway, Flat Adrian will be shipped off tomorrow with a stack of photos from his visit, including tonight's little jaunt to the HSBC arena where Kariya scored a goal and had 2 assists as the Blues beat the Sabres and broke their 5 game winning streak.  What makes me sad is the Blues won't be back again until January, and they will be playing in Toronto... hmmm... wonder if I can manage tickets to that game..?? :D

I am not writing daily because ultrasound continues to be boring;  for you and for me.  In about a week I'll start working in the BGH Cardiac Care Unit, so things should pick up, Blog-wise.  Until then... some pics from tonight.  I wanna ride the zamboni!!  

flat Adrian with mom eating a pretzel

Thursday, November 22, 2007

Giving Thanks...

   What I am thankful for this year:

 - a warm apartment and warm kitties to come home to
 - a fiance who keeps me safe and loved
 - a mother who is still able to love and support me despite the long distance between us
 - a new beginning in Buffalo and the ability to be of service to others
 - a group of friends that continue to travel with me on this life's journey
 - and, the prospect of an exciting and wonderful year to come....

Monday, October 29, 2007

It's Just Another Manic Monday

Beer meter: 

Ok, so the floodgates opened yet again.  The E.D. was FULL of patients and about 50% of them were chest pain patients.  And, it seemed like all of the other E.D.'s were full and sending us their patients.  There's been news that several E.D.'s in the area will be closing, and that just means more congestion for the E.D.'s that remain open.

Politics aside, my patients for today:

Chest pain - admit with pneumonia - coming in and making demands is not a good way to make friends in the E.D.  I love hearing the "why I am not compliant with my medication" stories about how awful their doctors are and how they never give them their prescriptions when they need them;  and then, when I call their doctors to admit them, I hear the other side of the story, how the patients don't come into clinic for follow-up appointments, or how they call saying they've "run out of all of their medications and need them refilled today."  For some reason I believe their doctor's side.  Don't know why, just a gut feeling.

Shortness of breath - admit with COPD exacerbation - COPD = emphysema.  Somehow I don't care if you're 92 going to turn 93 tomorrow.  You really shouldn't smoke... still.  Maybe that's the reason you need to wear oxygen... no smoking with that on, or you'll go up in flames.

Shortness of breath - discharge with upper respiratory infection - I don't care what the bottle says, if it smells like horse liniment it probably isn't something you should take to "clear out your chest congestion."

Abdominal pain - admit with small bowel obstruction - cancer sucks when it happens to really nice people.  What sucks even more is being a doctor who can look at a CT scan and go "oh crap that's a BIG tumor."  When I was at in medical school, one of my attendings used to make the comment, "All he needs is a script for a cane pole and a six pack" meaning a patient had cancer with no hope.  There's always hope, but looking at my patient's CT, I wondered if he'd even have time to hook the worm.

Chest pain - admit to chest pain center - seriously, stop doing the cocaine and the chest pain will stop.  Or your heart will.  Either or, the pain will be gone.

Abdominal pain - probably will be admitted with a pancreatic pseudocyst - if you're told you have pancreatitis and to not drink and you chose to block out the pancreatitis part and still drink, when you come back again with abdominal pain and you tell me you don't know why, I am going to find out.  Electronic medical records are a great thing.

Chest pain and abdominal pain - most likely going to be discharged with nothing wrong except for the fact you haven't been able to get your methadone for the last four days so you're coming to the E.D. for your fix.  Oh, and when I ask for significant medical history, telling me you're biologically a man who now dresses like a woman is important so I don't look silly/stupid in front of the nurses when I ask for a urine pregnancy test.

Day off tomorrow.  I'm on a strange day on/day off/switch over to the night shift thing for the next week.

Monday, October 15, 2007

Sunrise, Sunset

Well, I lived through it.  My first official month as an EM resident.  33 more to go.  As I drove away from work this morning, I actually thought, "I'm gonna miss it (the ECMC E.D.), just a little."  It's sort of like being back in medical school.  You just start to get comfortable in a rotation, then it's time to shift again.

Last night wasn't too bad.  I had a period of about 3 hours where I had one patient on the board, and they were basically sleeping in the E.D. waiting for a bed upstairs.  I did get to do a trauma on my own.  A 25 foot fall from a tree stand while hunting will knock the wind out of you.  Not to mention breaking a couple of ribs, your arm, some important parts of your neck bones.  Yep.

One major event that made me miss my trauma days was a double stabbing.  You stab me, I stab you and we both end up in the E.D.  There's a bit of excitement in running down the corridor with your hand covering someone's gushing wound and going right into the O.R.  Last night I stood back and watched them rush by.  I had a finger to sew back together.  My patient would be leaving via the front door; not the morgue door like the trauma patient.

So this morning I sat for a second in the warmth of my car and watched the sun rise.  Pondered my choices in life.  Reflected on what might have been.  But, to be honest, I am looking forward to what will be.  Every day I pick up on something new to study, something I want to be better at doing, another skill I want to perfect. 

And sometimes, yep just sometimes, I get a patient that says "Thank you" and really appreciates that I took the time to help them.  And, that, more than anything makes me want to continue on where I am, what I am doing, this life I am living.

Sunday, September 23, 2007

Watch that first step....

I am too tired to do my usual diatribe about the events of the ED. Suffice it to say that the majority of the reports from the EMT's this evening started with the phrase: "Patient went out drinking tonight and then..."
- the patient drove into a tree and crashed headfirst through their front windshield. After all the work-up was complete, the patient was found to have only sustained a bloody nose (refer back to one of my previous posts for rule #1 for drinking and driving: drink enough and you won't get hurt)
- "several unknown assailants" (Two Dudes must be on vacation... again, refer to earlier posts) jumped on several of our patients causing a variety of injuries normally seen on boxers who are on the losing end of the prize match

- the patient got into an altercation at a wedding leading to them being stabbed in the stomach, "really, it's just a flesh wound" lead to an exploration, and when 6 inches of the probe disappeared into the belly tissue, the patient was sent for emergency surgery
- the patients went out and rode their motorcycles which they subsequently crashed requiring the services of our Mercy Flight helicopters, the orthopedic surgeons, the neurosurgeons, and admittance into the trauma ICU
and, our favorite of the evening, of which, believe it or not we had two:
- the patient got into an altercation at a local bar, went outside to avoid a further dispute, and tripped off the curb...

what I want you to realize is that this person is lying FLAT on the bed... the two spots you see on the skin just below his pant's line would be just above the front of the ankle if the foot was in the normal position. And, like I said, we had TWO of these injuries tonight.

... that first step is a doozy!

Friday, September 21, 2007

The Red Bag Sign...

So, last night was drug and alcohol night, and the majority of the patients followed the adage of the Coneheads and "consumed mass quantities."  I was told that most of the local bars run specials on Thursday night and that the local college crowd gets a little rowdy. 

I was also introduced to a new medical diagnostic clue:  the Red Bag sign.  That's when a patient is so drunk or high they're vomiting, so the EMS guys tie a red bag around their neck like a bib so the patient can vomit right into it and not mess up the nice clean ambulance.  You pretty much know the diagnosis and the management as the patient is being wheeled in the door; red bag flopping, or sloshing, just a little as the case may be.

So, while one half of our patients were partying it up and getting rowdy (crashing cars, breaking windows, falling down stairs, knocking on neighbors doors and demanding to be let in to the point of being arrested and brought in by Buffalo PD, etc.) the other half of our patients were depressed and suicidal leading to a mixed bag of drug and alcohol combinations that were each a case study on how to treat overdoses.  Some were just drug A.  Some were drug A + alcohol.  Some were drug A + B.  And several were drugs A - F swallowed down with a good slug of vodka, or beer.  Of course, if you're going to really try to make a statement, you might just be a murder suspect being chased by police through the woods and decide to stab yourself several times in the neck with a hunting knife.  That'll show 'em.

And, speaking of cutting, I did have an 18 year old with cutting scars on her feet:  one of which read, "I love you to DEATH"  Seriously.  Cut into the top of her feet.  When I first went in to examine her, I thought she'd had some sort of accident.  Then I noticed the scar lines seemed to be making some kind of pattern, which I soon understood to be words.  Then I actually got to the point I could read the words.  This on a girl who didn't want any blood work done because needles scared her.  Uh, honey, you let someone CARVE into your skin with something most likely bigger and sharper than a needle.  Hmmm...

As of the time I left, all of the overdose patients were still alive (some despite repeated attempts at offing themselves with drug cocktails), the drunks were detoxing (we usually just let them sleep it off, sometimes needing four point restraints for those that refuse to go to sleep peacefully), the crack and cocaine abusers who were developing paranoid delusions as the night went on were being sent to the psych side, and the drunken 18 year old was being picked up to be taken home by her parents with a stern warning by one of the other ED docs about the dangers of alcohol.

Red Bag Thursday night.  The other must-see event.

Oh yeah, by the way, if you once burned the back of your throat while smoking crack cocaine to the extent that you needed to have a hole cut in your neck so that you could breathe, when you come back in complaining of a sore throat after you, uh, yes, wait for it, smoked crack cocaine again, we're gonna laugh at you.  Really.  Laugh and point.  Mhmm.  

Thursday, September 20, 2007

First Shift, Late Night

Winston Churchill, the Social One, first greeter at the door.

So, I just got home, this morning, from my first "official shift" at ECMC.  I am scheduled for 4 days of nights, and if you've ever worked the night shift, you know the first day is a beast.  Your body is all out of sync.  You're tired, sleepy and grumpy even if you did manage to get a nap in the day before.  I loaded up on caffeine and sugar, courtesy of a Dunkin Donuts Vanilla Coolata which I picked up on my way in.  The buzz kept me going until around 3 in the morning when I finally hit the wall.  Then the barrage of patients kept me going until the end of shift at 7 this morning.

Just some thoughts on last night...

If you're going to start smoking... 7 is a good age to start.  Just start sneakin' em on the back porch of your grannies house with your school mates.  Keep up the habit until you're, oh say, 67.  Add "a couple of 40's" daily to that around your mid 50's and don't see a doctor despite knowing you have high blood pressure.  Come into the E.D. just about the time your blood pressure is 208/100 (btw: normal standard is about 120/60), and you're having problems standing up.  That should be just about right.

The old adage carries true even in Buffalo:  if a young male comes in beaten up, "Two Dudes" did it.  "Just mindin' my own bizness, doc, and these Two Dudes jumped outta their truck and beat on me."  There's a roving pair of hoodlums running rampant in every city in this country.  They're just Two Dudes looking to make some mischief.

If you're going to drink and drive, drink A LOT and you won't get hurt.  Drive that blood alcohol level to 0.446.  That's right, really high.  The legal drinking limit is 0.08 in most states.  For most people, 0.400 has them comatose.  Of course, you also have to remember to not wear your seatbelt and deactivate your airbags.  That way, when you ram head-on into that telephone pole and break the windshield, your body will be just loose enough to not sustain any injuries.  Well, ok, maybe a little injury like a slightly herniated disc in your neck.  No major structures around there anyway.  Nah, no problem.

When you're in the ED and you're asked if you have any medical conditions that might affect your care, say oh, if you're about to be zapped by a gazillion rads of energy from the CT scanner, please say you're pregnant.  That might affect how we manage your care.  Yeah.  That's right.  Just a little thing to remember.

When you're being sedated before a painful procedure, like setting a broken wrist, think of something pleasant and you'll remember that when you wake up.  I told my 15 year old male patient to think of somewhere fun and warm, when he woke up he told me he dreamt of candy and his bed at home.  Happy thoughts!

And, finally... didn't I mention I hate gyn exams... 'nuff said.

Monday, September 17, 2007

The Last Day of "Training"

I finished my last "training/orientation" shift this last Friday at ECMC.  It was a busy 10 hour day.  Officially, today is my start day, but somehow I managed to not be added to the schedule until Wednesday.  So, along with my two day weekend, I have an additional two days to do more personal things:  like unpack and finally stop living in the sea of boxes that has been my existence for the last 2 weeks.

I had several interesting patients on Friday.  One was an example of how a patient can be in the ED all day.  I first saw her at 08:30 and FINALLY discharged her at 18:45 (that's 6:45 p.m. in military time;  for some reason, it's also the language of doctors, along with the metric system, but don't get me started... )  Anyway, when I first saw her, I thought she should have several film studies along with her blood work.  My attending disagreed.  Several hours later, after I had asked to give the patient another liter of fluid since she was so dehydrated, the attending went to see the patient and came out to tell me they agreed with my initial assessment, and that I should order some films. The films showed some concern for bowel inflammation, so a CT scan was in order.  You have to drink contrast material to make an accurate diagnosis, and you can't have the CT scan until at least 40 minutes have passed to allow the contrast time to go through.  So you can see the additional length of time.  She was very polite about it, mostly I think because she said I was the nicest person she had ever encountered in the ED before.  Well, that's a given.. :D

The rest of my patients were a motley mix of:  a schizophrenic patient who had started walking into walls, a patient whose heart started beating in the 140's for no apparent reason, a patient who fell down the stairs and broke her foot (my first splint),  a patient with shortness of breath most likely from the "holes in my heart," and my first "trauma" a heroin addict "my last hit was 4 hours ago but I only drank one beer" who was hit by a car.  What you need to know is that drugs like heroin bind to the same pain receptors as morphine.  But, the high is SO MUCH more intense.  So much so that you actually, what I call, fry out the synapses.  So you need to give these patients HUGE amounts of narcotics to help keep their pain under control.  They get mad and belligerent at you because they're in pain, but then they're the ones who fried out their nerve endings.  So it goes...

Finally, I had my last patient that I picked up in the final hour of my shift.  I figured he wasn't going to take long, as his complaint on the board was "sore throat."  What he didn't tell me was that he was being worked up for stomach cancer.  And, his sore throat wasn't really sore throat but difficulty swallowing because food was taking a long time to go down.  Of course.  He has a big cancer blocking the entrance to his stomach, and food goes down slower as the passageway gets blocked.  All he wanted was some relief so he could enjoy eating something of substance, but even now he is barely able to swallow soup. 

This is the frustration.  That of a complete inability to help someone despite everything.  I could do nothing for this 70-something gentleman who was so calm and gentle in his demeanor.  I know he was sitting out in the waiting room for hours;  waiting his turn.  He didn't have an urgent complaint.  All my other patients definitely were more urgent than him, but I could almost see him sitting in chairs, smiling politely as other patients were called into the ED, and hours later finally getting his turn, only for me to tell him, "I'm sorry, there really isn't anything I can do." 

I didn't say that, of course.  Having been in surgery and having had an aunt who died of esophageal cancer, I knew what could be done for him.  The offer of a surgery to remove part of his stomach and esophagus and create a new path for food.  But, he is 70 and the complication rate is high.  He's already lost 30 pounds in 6 months.  He might be offered a feeding tube to bypass his stomach and give him some nutrition.  But, I more than most understand his complaint.  I enjoy food and can't imagine what it would be like to suddenly not be able to even enjoy something simple like soup.  Imagine a world with no more ribeyes!

But I digress.  His records showed pathology for a serious kind of stomach cancer.  Recent workup showed that it hadn't spread, but still.  There was nothing I could do for this gentle man.  I talked to my attending and informed him of the situation.  Theyrecommended some blood work to check the patient's level of hydration.  It was the end of my shift, and I signed him out to the oncoming resident.  But, before I left, I brought my patient a cold apple juice.  At least he could have one small pleasure as he waited for the results, and for the inevitable, "There's nothing else we can do right now."

Thursday, September 13, 2007

Trial by Fire

I did another "mini" 10 hour shift today at the main teaching hospital:  Buffalo General Hospital. 

I am going to get on my soapbox today and rant about another reason for my dislike of nursing homes.  Why?  One of my patients today was a nice, pleasantly confused almost 90 year old lady who's initial diagnosis was "ischemic fingers."  Ischemic = no blood supply, so I quickly went and saw her only to find that her purple-tinged fingertips quickly turned pink when I put my hands over hers and warmed them.  I waited to see if they would quickly return to purple, but they didn't.  I looked at her other hand.  Nothing significant.  I looked at her feet.  Perfectly fine.
She was unable to answer my question of why she had been sent, by ambulance mind you, to the hospital.  I got the number of the nursing home and called.  I was "connected" to the nursing supervisor's voice mail and left a message.  She never called back.  Finally, her granddaughter showed up saying she had received a message that her grandmother had been sent to the hospital with "blue hands" and needed "a vascular study" to determine why.  When she looked at her grandmother's hands, she said they weren't much different than usual.
My attending and I looked through my patient's paperwork.  No transfer note.  No current admission note.  Finally, one piece of paper stood out:  a patient progress note which stated that this a.m. the patient had "refused her medications and spit them out."  My attending stated that the patient was probably "dumped on us."  He said the staff most likely did not want to deal with her and sent her to the ED.  In the time it would take us to evaluate her, the nursing home staff would finish their shift, and she would most likely return when they were leaving for home.  Seriously?
I do have to admit, she was very well kempt and neater than some of the nursing home patients I have seen.  And, hergranddaughter seem to be actively involved and saw her on a regular basis.  But, just how annoying could an 89 year old be so that you'd send her out?  I almost thought my attending was being fascetious but he proceeded to give me his rant of nursing homes and this one in particular, so I am assured there must be some truth to this.
Anyway.  We drew the usual labs, took a chest ray and EKG to verify there wasn't anything unusual happening and sent her back.  Another learning experience for me.
Today I managed to see 6 patients:  the nursing home lady, a gentleman with an inflammed wrist - most likely gout, another drug reaction allergy, a gluteal (butt) abscess which I almost got to drain but which the surgery intern drained, a gentleman with a bladder infection and dehydration, and finally a very interesting case of a gentleman with kidney damage because of exposure to a high amount of gold who came in because of fevers.  He developed a number of complications because of the medications he was put on which I will have to research since I haven't heard or read about them since med school.  That's it!

Wednesday, September 12, 2007

There's a Reason I Wanted to Do Surgery

O.K. When I was deciding on my specialty in medical school, there were several criteria that I wanted to meet.  One had to do with working in or out of the hospital (I wanted in).  The next had to do with how much clinic I would have to do (little to none).  And, the final criteria had to do with gyn exams.  Hate them, hate doing them, some things in life I don't really want to see on anyone.

So when the time came to decide, surgery was a great fit.  I would be working in a hospital, I would have very little clinic, and, for the most part, very rarely would I ever have to do a gym exam.  And, so it's been for the last 4 years.  I did my last gyn exam as a 4th year medical student in May of 2003.  Until yesterday.....

My home for the next month.

On my very first shift, with my very first patient.  I saw the tag on the board, "Abdominal Pain."  No problem.  I was a surgery resident, and we are well versed in Abdominal pain.  As an Emergency Medicine resident, I walked in the room and met my patient who described a severe pain in her upper abdomen.  No problem.  "Oh yeah, Doc, by the way, the pain actually started in my lower abdomen, well pelvis actually, and now that I think about it, I had unprotected sex about the same time the pain started and could I be pregnant or have an STD?"  Major problem.

Suddenly, I felt like a medical student again.  I went to my chief resident to present the patient, and I had to admit it had been 4 years since I had done a gyn exam.  He was like, "No problem.  Grab the cart, grab some swabs, do a wet mount and I'll show you where the microscope is."   Um, "wet mount?"  I think I heard something about that during my OB/Gyn rotation in medical school, 3rd year...  So, I was walked through the procedure by my chief;  who, by the way, also had to help me with the microscope because I hadn't used one of those since 2nd year histology class.  Needless to say, it was not a very pleasant beginning.

Luckily, it was the only gyn exam of the day.  During the course of the next 9 hours I saw a total of 6 patients.  It doesn't sound like much considering some family practice doctors see 4 - 6 patients an hour.  But, you have to realize that in the Emergency Department a doctor may manage 4 - 5 patients an hour, and they all don't leave within fifteen minutes. 

For example, my first patient had to have a pregnancy test and an ultrasound (the culture swabs I obtained won't be ready for 2 days.)  So, she took about 2 hours from start to finish.  After my exam, I saw my next patient while I waited for patient #1's lab results and ultrasound results to come through.  Pt #2 was very sick and needed constant re-evaluation.  He ended up needing a chest x-ray, CT scan, multiple labs, a cardiac echo and would need admission to the ICU.  I saw him at the beginning of my second hour, it took 4 hours to get all of the labs and imaging studies done, and when I left 7 hours later, he was just being seen by the admitting service in the ICU.  While I was waiting on his work-up studies, I saw 4 more patients:  a musculoskeletal chest pain, a drug allergy reaction, a patient with fluid in one lung most likely from lung cancer, and a 20 something who woke up blind in one eye.  A nice mixed bag of patients.  Like I used to say in med school, "The ED is like a box of chocolates, you never know what you're going to get and some are just plain nuts."

So, this was my first day.  I know I will get better.  I know eventually I'll stop feeling like a medical student and start feeling like a doctor again.  I know soon I will be able to manage more than a patient or two an hour.  And, those gyn exams... I'll just have to take them one day at a time.

Friday, September 7, 2007

That funny smell

Just a random thought.... ever notice how your clothes take up the smell of the last place they were?  I've been unpacking my clothes today and hanging them in their new closet.  I am suddenly aware of a faint odor... not a bad one, just from my last house.  I also notice this when I unpack my suitcase after I've been on vacation.  Just a thought...

That and there's been too much death and despair on Meerkat Manor recently.... follow the CCdN Blog link to get recaps on the episodes...

Tuesday, September 4, 2007

The Hunt for Squirrels Begins

Well, I am in Buffalo.  For some reason, as I stood in the doorway of what had been my home for the last 14 months, this song came to mind.  I really was going to be sad to leave, but to paraphrase as I closed the door on this chapter of my life, I knew somewhere a window was opening....

Heart Hotels - Dan Fogelberg

Well there's too many windows
in this old hotel
And rooms filled with reckless pride
And the walls have grown sturdy
And the halls have worn well
But there is nobody living inside
Nobody living inside...

Gonna pull in the shutters
On this heart of mine
Roll up the carpets and pull
in the blinds
And retreat to the chambers that
I left behind
In hopes there still may be
Love left to find
Still may be love left to find.

Seek inspiration in daily affairs
Now you soul is in trouble
and requires repairs
And the voices you hear at the
top of the stairs
Are only echoes of unanswered prayers
Echoes of unanswered prayers.

Well there's too many windows
in this old hotel
And rooms filled with reckless pride
And the walls have grown sturdy
And the halls have worn well
But there is nobody living inside
Nobody living inside...

if you look closely at the horizon, you can see the outline of the Buffalo skyline

Wednesday, August 22, 2007

The Long Goodbye

“I can't change the direction of the wind, but I can adjust my sails to always reach my destination.”  - Jimmy Dean
I love to sail.  In fact, it was talking about sailing and the difference between windsurfing (board sailing) and boat sailing that started the relationship between myself and my fiance, Jerry.  And, when I stop to think about some of my favorite quotes, a lot of them have to do with sailing, the wind, yet unknown journeys, etc.  I came across this quote today while helping Jerry to write a farewell message to all of his windsurfing and kite surfing buddies on their message board.
I always hate this part.  I hate saying good-bye.  Because to me, it's a new journey, a new adventure.  It's not supposed to be an end, but a new beginning.  I blame my mother for instilling in me a sense of wanderlust, and she takes all the credit she can because she has the same spirit.  We always want to be "going somewhere." 
We plan vacations months in advance.  We talk about where we'll go, and what we'll see.  If it's to a new place, we'll research and read, plan for tours and find side trips.  We're the type of people who need vacations from their vacations because, for us, it's never going somewhere to relax, it's going somewhere for the sake of going, exploring, being able to say, "Yes, I was there."  There's a new show on the Travel Channel, "1000 Places to See Before You Die."  Kinda like that.
And, this sense of exploration carries over into my every day life.  If this blog is any indication, it shows that I can't seem to be in one place for any length of time before I am looking for that next place.  While most people freak out about moving and getting set up in a new town, I relish in the adventure of finding new places, trying new restaurants, and just the excitement of the new people I will meet along the way.
While packing, I came across my "personal box" which has cards and letters, postcards and scraps of paper with the namesof people that I have met in my many moves.  From college in San Diego, to pre-med at Cal State Fullerton, to med school in Wisconsin, my internship in Chicago, junior fellowship in Boston, surgery residency in Minnesota and in between.  So many hellos;  so many goodbyes.
Which brings us back to the goodbyes; this part I hate.  I've been saying a lot of goodbyes over the last week.  Getting phone numbers and email addresses;  wondering whom I'll actually really keep in touch with.  Granted, I think I have a better than average track record when it comes to keeping in touch with people.  Email has made bridging the distance gap so much easier.  Now, for the most part, at least once or twice a year I "catch up" on all my contacts, and I hear what's happening in their lives.
So for now I am off again.  Turning my sail once more to where the wind is taking me.... and, when I arrive, I am sure there will be some new "hellos" to greet me.
"A ship in a harbor is safe, but that is not what a ship is built for." - G. Hopper

Friday, August 17, 2007

Death Becomes Us

I've been thinking a lot about death lately.  In part, it's due to the fact that I just finished watching all five seasons of "Six Feet Under," but it's also due to the fact that I have been encountering death on an almost daily basis for the last 6 weeks.  One of my duties as a House Physician is to pronounce patients who have died while in the hospital.  Since I have been working 24 hours on and 24 hours off for a greater part of the last 2 months, I have had more than my fair share of pronouncements.
The oncology ward is on the 8th floor here at Fairview Southdale, so the majority of my calls are to this floor.  A colleague of mine has had up to five deaths in one shift.  My record is three.  These patients are usually in the end-stage of their cancer, and they are admitted as "comfort care" meaning, they receive pain medications and are kept "comfortable" in anticipation of their impending death.  Families are usually prepared.  They stay in the room as I do my exam.  It's often a very calm experience.
Contrast that to calls I get to the ICU.  There patients usually die of an acute process, most often, a massive heart attack or stroke.  Families are in shock and disbelief.  It is never a good situation.  But, families usually come to understand that the severity of the illness was so catastrophic that survival wasn't possible.
But, my rant today isn't for those patients.  It's for the patients for whom there is no hope.  Who've suffered that catastrophic illness and are kept alive because of medical technology.  My story today is of the two Russian ladies.  Both spoke no English.  Both lived alone.  Both were in their late 70's/early 80's.  And both fell down at home alone.
The first lady was found by her family about an hour later.  She was admitted to the hospital with severe back pain.  I was called to see her because her back pain was getting worse, and she was having difficulty breathing.  In med school you're taught that "sudden-onset ripping severe chest pain" means aortic dissection until proven otherwise.  And, she had the symptoms to go with the diagnosis.  As I watched her oxygenation saturations drop, I asked her, via interpreter, did she want to be intubated (breathing tube placed and put on a ventilator).  She replied, "No, I've lived a long life, and I don't want any extra-ordinary means keeping me alive."  When her EKG showed that she was having a massive heart attack, I asked her about doing chest compressions and starting medications should her heart stop.  Again, she said, "No." 
The other lady was found down immediately.  She was brought into the Emergency Department and found to have bleeding in her head.  She was admitted, and she was actually doing well until the morning I was called because she had become unresponsive.  She was showing signs of brain injury, and, because her family had said they wanted everything done, she was intubated and placed on a ventilator.  An MRI showed no new bleeding, but she never awoke again.  After an EEG showed minimal brain activity, her family had been asked if they felt she would want to continue doing everything to keep her body alive, they said, "Yes."  Because she could not tell us, and because she had no advanced directive or living will, her family made the decisions for her. 
This morning, on my way to pronounce a patient in the ICU, I heard that the family wanted to have a permanent airway (a tracheostomy) placed in her neck so that she could be on a ventilator long term.  I started having feelings of anger and indignation which were shared by the respiratory therapist who had told me of their decision.  I was still shaking my head as I came to the room of the patient who had died.  It was this second Russian lady. 
She was still on the ventilator, but her heart had stopped.  The family would not let the nurses turn off the ventilator until I pronounced that she was really dead.  I went into the room and did my exam.  When I nodded to the nurse, he quietly turned off the ventilator.  The family remained in the room, visibly upset.  I feel in some way, she finally made her own decision and let go.
My whole point in writing this, aside from the fact it's my blog and I can rant if I want to, is to illustrate the importance of having frank discussions about death and making your wishesknown. 
My mother and I have always had an open dialogue when it comes to her wishes.  Her only concern is that I might "pull the plug" too soon because I might be too interested in my inheritance.  But, she knows that if something were to happen to me, I want all organs to be donated.  Then I want to be cremated and separated into 5 mini urns to be taken by family and friends whenever they travel.  She knows I am going to turn a part of her into a diamond.  (  She's just jealous because she loves diamonds and won't be able to have one of her own.
My best friend Nicole wants to be cremated and have her ashes spread in Lucerne, Switzerland.  We once had a conversation that if she went first, I'd make sure they got there.  If I went first, she promised to have some of my ashes taken to be spread with hers.
Death isn't to be feared.  It's the one fact of life that we will all share.  So share your wants and desires before someone makes decisions for you.  Frank discussions and planning with family and loved ones will help so much when the time comes.  Make a plan, appoint a power of attorney for health care, make a living will. 
Talk about organ donation.  Be a part of the Green Ribbon team and sign the back of your driver's license, but also make sure to talk to your spouse and family members about your wishes.
My favorite poem:  Crossing the Bar, Alfred Lord Tennyson
Sunset and evening star,
And one clear call for me!
And may there be no moaning of the bar,
When I put out to sea,

But such a tide as moving seems asleep,
Too full for sound and foam,
When that which drew from out the boundless deep
Turns again home.

Twilight and evening bell,
And after that the dark!
And may there be no sadness of farewell,
When I embark;

For tho’ from out our bourne of Time and Place
The flood may bear me far,
I hope to see my Pilot face to face
When I have crossed the bar.

Saturday, August 11, 2007

The Mixed Tape

As I start to pack for the impending move, I am finding the usual odd and end things you just can't seem to get rid of, yet should, yet don't.  I have two shoeboxes full of cassette tapes that are those "mixed tapes" we all made in high school and college.  As I scanned the titles, I was instantly able to remember where I was, who I was thinking of, the club where I'd heard a particular song, or the situation involving this that or the other song.
I subscribe to Napster to fill my MP3 player, and I spent about 2 hours going through the tapes and downloading songs that I didn't have to it.  Most of the time, I knew the actual title of the song, but there were some that I had no idea what the song even was and had written just a few words from the chorus.  And, funny thing, I have no idea where to find a tape player to listen to the cassette to find out. 
My old "boom box" with the dual cassette players was given away in Chicago in the Summer Move to Boston of 2004.  A cassette Walkman is packed somewhere amidst old serial/non-USB computer cables, a 5 1/2 inch floppy disc drive, and a couple of CD Walkman's in a box labeled "Electronics."  So, I guessed one day I would find a way to listen to the tape, tossed it back in the box, and moved on.
Once I was done going through one of the boxes of cassette tapes, I found I couldn't bear to throw any of them away.  Again, I have nothing to play them on, most of the music is now on a CD or on my computer, and yet, there's something special about those cassette tapes.  How many hours did I spend picking out just the right music?  Putting it in just the right order so there would be a certain flow.  Carefully writing out the names, or in some cases typing out the names and making labels.  I can't get rid of them.
I think of the burning crushes and the unrequited love I had in college, the dance songs of Tijuana and Rosarito where my best friend Melinda and I danced for hours in a tequila haze.  I remembered the inspirational music that carried me through some of my teenage angst and rebellion.  The makeout music and the songs that came with the breakup.
I can't get rid of them.  I may still have them when I am 90, and I am listening to music waves directly into my brain through my implanted audio assist device.  They'll have been converted from cassette to digital to direct mind wave format.  So, I better keep that box.  For now.

Thursday, August 9, 2007

Sources of Inspiration

I found out today that a friend had died. I first met Allen when I was in pre-med trying to get the credits necessary to go med school. He was already in med school at East Carolina University at the Brody School of Medicine. We were AOL IM pals. All I knew about him was that he liked pipes, cigars and classical music. At the time, he knew I liked baseball caps and sent me one from ECU to add to my collection.

During that hard year of applying for medical school, and then sweating out the interviews and waiting for acceptance letters, he always encouraged me.
He had no doubt that I would be going to medical school. He sent me a caduceus charm about a week or two before I got my letter of acceptance. I didn't wear it then for fear of jinxing myself. Now, it is one of my prized possessions, and I'm wearing it now as I have daily for the last 10 years.

He graduated in 1999 as I was just getting started. I knew he had met and married a wonderful person, Pamela. I didn't know until the obituary, that he has a daughter, Amelia. I knew he had a brain tumor, but that didn't stop him from completing his Family Medicine residency and doing the work he loved: taking care of patients.

We didn't write much to each other over the last 3 years. Just an email every six months or so. Mostly prompted by yet another move on my part. But, he always answered each one kindly, and sent me a heartfelt congratulations or word of encouragement.

Pamela called me today. She'd received the email about my upcoming move and new job. She knew Allen and I kept in touch and just wanted to let me know about his passing on July 4th.

Even though we hadn't spoken in years, I will miss my friend Allen W. Chan.
Suddenly, today, the sky is just a little bit darker and the world is just a little bit colder.

Tuesday, August 7, 2007

Great new quote

"I am careful not to confuse excellence with perfection. Excellence, I can reach for; perfection is God's business." Michael J. Fox

Sounds like a new mantra to me, especially as I consider my new career choice. I am constantly going to have some small doubts about tests, diagnoses, treatment plans, etc. Striving for excellence. Sounds like a plan...

Monday, August 6, 2007

The long drive east

I just returned from my first trip to Buffalo, NY. It wasn't as bad as I thought. I found an older city with some great architecture downtown, up and coming trendy areas, and lots of water. Of course, it's not winter yet. And, I imagine it will be a lot like Minnesota... with more snow.

The trip took 15 hours going north from Eau Claire, Wisconsin and hitting Lake Michigan just to the north of Green Bay. From there, it was across the upper peninsula of Michigan, across the awesome Mackinac Bridge, and down to Flint at the bottom edge of Lake Huron where we turned east to go across Canada to Buffalo. With Lake Ontario to the north and Lake Erie to the south, I managed to see 4 of the 5 great lakes in one trip. Having been to Duluth, I can actually say I've seen all 5 great lakes. By the way, remember HOMES (Huron, Ontario, Michigan, Erie, Superior) as an easy way to remember the names of all the great lakes. Just a little trivia.

While in Buffalo, I visited Niagara Falls at night and saw the American Falls. I had been to Niagara Falls on a road trip east after graduating from med school and had seen the falls from the Canadian side. Definitely, a much better view. The American side was still impressive, and I was even more amazed at how many people were still arriving to see the falls at 10 p.m.

After 2 days of exploring most of the neighborhoods in Buffalo, and eating twice at a nice little restaurant called Pano's on Elmwood in the slowly gentrifying neighborhood to the south of SUNY Buffalo State College, I found an apartment in Amherst which is a nice suburb located on the northeastern edge of the city. I am sure the cats will enjoy having stairs and multiple levels again.

Over the next three years, I plan to keep a journal of my activities as an emergency medicine resident at the SUNY Buffalo program. I will be working out of Buffalo General Hospital (inner city), Erie County Medical Center (major trauma), and a couple of other surrounding hospitals. For the first time since med school, it will be the longest I've actually stayed in one place.

I hope you stay along with me on this next phase of my training. And, as we answer the question which has been bothering me since I found out I was moving: are there squirrels in Buffalo? Because, honestly, they keep telling me there are. I haven't seen one. Haven't even seen a dead one. I did see an article in one of the local newspapers about flying squirrels, and someone posted a pic, somewhat blurry, about a pair that lives in their backyard tree. I am still skeptical. So, we'll find out together.

I move on August 31st, so until then my postings will be random rants and raves, as well as sundry comments on the difficulties of packing up my life and moving, yet again.