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...

Tags: New Year's Eve, BGH, ECMC, Minneapolis Bridge collapse, Emergency Medicine residency

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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)

Tags: organ donation, advanced directives, living wills

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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)

Tags: MSOF, multi-system organ failure

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)

Tags: wedding invitations, CCU

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)

Tags: CCU, delirium tremens, Pierce Brosnan, James Bond

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)

Tags: Christmas eve, traditions, tamales, poker

Just As Predicted

I knew it wouldn't be a "quiet" night.  There's a reason for superstitions, they come true sometimes.  I thought about this at 3:30 in the morning when we finally got our 3 new patients tucked in for the night after:  placing a central line in one because they were hypotensive requiring pressors and fluid support, intubating another because despite COPD and probable lung CA they continued to smoke ("but I'm down to 10 a day from a pack a day for the last 30 years"), almost needing to intubate a third patient who suddenly started having problems breathing, and admitting the third patient who decided to wait 2 days before coming in with a pretty significant heart attack.  Oh, yeah, another ethics dilemma:  should we be giving organs to people who don't follow up with their physicians, return to doing drugs, albeit not IV drugs ("a little marijuana now and then won't hurt"), and who don't take care of themselves in general?

Anyway, once the commotion seemed to settle down, I turned to my senior and told him it was his fault for using the "Q" word yesterday.  Suddenly, all four ICU nurses turned to him and said, "You used the "Q" word?!?!?!"  He looked around at them and said, "How come everyone knows about this except for me?"  I might have stated the obvious which is that he's a foreign medical grad who after 3 years of training in the US has not absorbed some of the nuances of our language, but I didn't.  I went off to my happy corner of the hospital to catch 2 hours' nap on a comfy recliner before having to come back to the unit to pre-round on my patients.

A nice longer nap when I got home, some pajama time with the kitties, and I am now preparing for a short round session (hopefully) in the morning followed by my 24 hours off on Monday.  Too much to do...!!
CCU Countdown:
Days left until the end of the rotation: 15
Actual number of days I will be working during that time: 13
Days left until painful attending returns:  8
Number of days until my next 24 hours off: 1
Number of short call shifts remaining:  2
Number of long call shifts remaining: 1
Number of patients: 3
Number of evil Internal Medicine residents: 3
Number of evil CCU nurses*:  3 (*names have been changed to protect the innocent, mainly me... :D)

Tags: ccu, BGH, superstitions, foreign medical graduates

Very Superstitious

I am on-call in the hospital overnight.  I think both ED and surgery residents are a very superstitious lot.  And, there are two words you never want to hear when you are on-call.  The Q (opposite of noisy) word and the S (opposite of fast)  word.  Because as soon as you say, "It's kinda ____ " it won't be.

I have actually threatened my resident with torture since he used the Q word earlier this afternoon.  So far there's only been one admission, but the night is still VERY young, and I know there's at least one more admission coming.

I used to threaten the ICU nurses with payback if they ever used either word.  Of course, it did no use since they could hurt me tons more than I could ever hurt them.  But, still, it really did seem to be more busy or chaotic when those words were uttered.

So, let's just wait and see where the evening takes us, shall we...?

CCU Countdown:Days left until the end of the rotation: 16Actual number of days I will be working during that time: 14Days left until painful attending returns:  9
Number of days until my next 24 hours off: 2
Number of short call shifts remaining:  2
Number of long call shiftsremaining: 1
Number of patients: 1 +1 pending
Number of evil Internal Medicine residents: 3
Number of evil CCU nurses*:  3

(*names have been changed to protect the innocent, mainly me... :D)

Tags: BGH, CCU, superstitions

Breaking in the Boots

A day off and one of my work colleagues and I went to the slopes.  There's a local ski resort - Holiday Valley - which wasn't too far a drive.  I had a new set of snowboard boots, and I was glad to break them in and not have anything broken on me by the end of the day.

I have to admit, I've been snowboarding for about 10 years now, and I haven't really progressed above advanced beginner.  Unfortunately, every year I feel a bit older than the rest of the boarders, and it really shows in my carefulness making my way down the hill.  It also doesn't help that I when I first started we only would go for a week about once a year, and the following year you'd pretty much have to start over.

Last year, though, I was able to make it about 5 or six times during the season, and I definitely was better able to kind of "pick up and go" when we got to the resort today.  Now if I can keep my feet from cramping I should do ok.  I know for sure, I want to go back again soon.  There weren't a lot of people, and there's something to be said for being on top of a large hill enjoying the silence.

Ah, silence.  I'll slip back to this happy place I am sure tomorrow when I am on-call overnight again.  And, I am sure my muscles will give me a constant reminder throughout the day, as if I needed any...

CCU Countdown:Days left until the end of the rotation: 17Actual number of days I will be working during that time: 15Days left until painful attending returns:  10
Number of days until my next 24 hours off: 3
Number of short call shifts remaining:  2
Number of long call shifts remaining: 2
Number of patients: 0!
Number of evil Internal Medicine residents: 3 - I am throwing the cardiology fellow in there because he makes us go look at angios and echos every day, and I had my fill of squiggly lines last month on ultrasound
Number of evil CCU nurses*:  3

(*names have been changed to protect the innocent, mainly me... :D)

Tags: snowboarding, Holiday Valley, Burton

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Wiping the Slate Clean

I have no more patients.  The "I don't do drugs, but my tox screen came back positive" patient went to the private service, and my unstable angina guy is FINALLY getting his surgery.  So, going into my 24 hour day off, I am free of patients... of course, I am on long call Friday, so I am sure to pick up an admission or two.

Today was another "Grand Rounds" Wednesday, so I showed up in the morning to round on my patients, left for my meetings, came back around 2 p.m., stayed until about 4:30 and then called it a day.  We like Wednesdays.

There's really nothing else going on... kinda boring by most standards.  I am actually sitting at the computer wearing my new snowboard boots and trying to get them sort of broken in.  The plan is to expend all my extra energy on the trails tomorrow.  Considering I haven't been on a board in about 9 months, my first day out should be pretty entertaining.  I plan to take my camera, so I will probably post pictures tomorrow.

Until then, then countdown continues:

CCU Countdown:Days left until the end of the rotation: 18Actual number of days I will be working during that time: 15Days left until painful attending returns:  11
Number of days until my next 24 hours off: 0
Number of short call shifts remaining:  2
Number of long call shifts remaining: 2
Number of patients: 0!
Number of evil Internal Medicine residents: 3 - I am throwing the cardiology fellow in there because he makes us go look at angios and echos every day, and I had my fill of squiggly lines last month on ultrasound
Number of evil CCU nurses*:  3

(*names have been changed to protect the innocent, mainly me... :D)

Tags: CCU, snowboarding

And She Was....

Couldn't think of a name for my blog today, so I decided to name it for the next song to play on my MP3 player.  Kind of fitting actually since I was called "intimidating" by one of our medicine residents today.  Ok, so I maintain a certain confidence and attitude.  Mainly I think it's because of my prior training.

If I was a character on "Grey's Anatomy," I would definitely be a Bailey.  Hard, firm, organized and a leader, but with a soft inner side that no one ever sees.  I'm a "shortest distance between two points is a straight line" kinda person, and I guess sometimes when it comes to patient care, I don't take a "wait and see" attitude.

Which is so frustrating when it comes to being on a medicine service.  No patient I ever treat in the E.D. will ever suffer because I didn't want to SUFFER through another round of "let's go look at everyone's cardiac angiography and discuss in minutiae the 10 differential diagnoses while I the fellow make all of you inferior beings look more inferior by asking you questions about angiography that I've been doing for six months while you've been on service for a week."  In that respect, I am more like Christina... I need to cut open someone or stick a really big needle into someone's blood vessel just to make the day worthwhile.  However, I don't get to do that.  Hence, my frustration.  Hence, my attitude.  Hence, the countdown continues...

CCU Countdown:Days left until the end of the rotation: 19Actual number of days I will be working during that time: 16Days left until painful attending returns:  12
Number of days until my next 24 hours off: 1
Number of short call shifts remaining:  2
Number of long call shifts remaining: 2
Number of patients: 2 - 2 in the unit
Number of evil Internal Medicine residents: 2
Number of evil CCU nurses*:  3

(*names have been changed to protect the innocent, mainly me... :D)

Tags: CCU, angiography, Grey's Anatomy

This is Your Heart, This is Your Heart on Drugs...

I think during my ED rotations, I talked about patients coming in with chest pain from doing cocaine.  Cocaine aside from making your heart race also closes down the coronary vasculature.  So, it's like asking your heart to run a marathon and then cutting off the blood supply that keeps it going.  Bad, bad, bad.

Keep doing cocaine over many years and you can imagine how much damage you can do.  Now, just to add some fun to the mix have a family history (bad genes) of heart attacks, become a diabetic, have high blood pressure... oh, yeah, and don't take any of your medication because you "don't have any available cash."  And, since you don't have any cash, wait about 6 hours for one of your "friends" from the half-way house to give you a ride to the hospital.  Why use an ambulance?  Your friend can get you there just as fast.

Of course, when I come to see you in the E.D. to admit you, you've sworn up and down you don't use drugs.  Or drink alcohol.  Or smoke more than a cigarette or two a day.  I think I might believe you more if you wore long sleeves and didn't let me see the fresh track marks on your arm.  But, that's just me.  I always want to believe my patients... but, then I think of "WWHD?" (what would House do?) and I remember the mantra "everybody lies." 

So, until your urine and blood tox comes back negative, I will have to withhold one of the drugs proven by research to be the best for people having heart attacks because since you do cocaine, the interaction between the two just might kill you.  Not that the major coronary you're givingyourself isn't going to do that for you.  Of course, given the choice between spending my money on street drugs versus pharmaceutical drugs, I might also choose the funner one.

That was my one admission for the night... the countdown continues...

CCU Countdown:Days left until the end of the rotation: 20Actual number of days I will be working during that time: 17Days left until painful attending returns:  13
Number of days until my next 24 hours off: 2
Number of short call shifts remaining:  2
Number of long call shifts remaining: 2
Number of patients: 2 - 2 in the unit, my floor patient went home
Number of evil Internal Medicine residents: 2
Number of evil CCU nurses*:  3 - Rude Ruby (who acts as though interns are small slugs she has to avoid at all costs, and she also never shares the vitals' book because she might need it 20 minutes from now after she's given report about one of her other patients in the unit), Weird Wendy (who turned off the radio because all the "thumping" was making her head pound, and who spazzes out about the littlest things), and Miss Biche (who complains all day long about everything, especially how interns have no training in doing simple things like writing orders, and who doesn't bother to learn anyone's name since it doesn't really matter to her anyway)

(*names have been changed to protect the innocent, mainly me... :D)

Tags: CCU, cocaine-induced chest pain

The Great White Way

I woke up this morning to a blanket of snow.  I had to go into the hospital to round and was running late due to a faulty alarm clock, so it didn't help that people were slipping and sliding all over the freeway.  I got to work (Lord, bless one of my colleagues who got numbers for me and the fact we don't have an evil attending over the weekend) just in time to get into the hospital garage before it really started coming down.

After about two hours in the hospital, I got to drive back in about an inch or so that had already fallen.  Yeah for my Jeep with 4 wheel drive!  I pretty much came straight home and tucked myself and my Jeep in for the day.

The kitties and I played pajama party.  We ate and slept and played all day.  Back to the evilness in the morning that is the CCU, however I've heard good things about this week's attending so we'll see.  The countdown continues.

CCU Countdown:Days left until the end of the rotation: 21Actual number of days I will be working during that time: 18Days left until painful attending returns:  14

Number of days until my next 24 hours off: 3
Number of short call shifts remaining:  3
Number of long call shifts remaining: 2

Number of patients: 2 - 1 in the unit, 1 on the floor, 2 went to private service

Number of evil Internal Medicine residents: 2 - the one who made me stay up all night and the one who accused me of not calling an attending because she happened to speak to him 5 minutes before I did.

Number of evil nurses in the ICU: 2

Tags: CCU, Buffalo, snowstorm, Jeep Liberty

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The Long Night of Nothing

So last night I worked my first long shift... that means 24 hours.  What it meant for me was being awake for a solid 30 hours since my resident told me that someone had to be in the CCU at all times "just in case something happened."  Ok.  At 4 this morning when the nurses asked what I was still doing in the unit and why hadn't I gone to bed, I told them what he'd said.  They looked at me dumbfounded and replied, "That's what pagers are for."
My thoughts exactly.  Suffice it to say, I put in the time.  Nothing really happened, and I could have slept from about Midnight after our one admission until around 4:30 in the morning when one of the patients decided to go into an irregular rhythm.  That would have been a 2 minute phone call with a follow-up in about an hour... which actually was all she needed to convert back to normal rhythm.
So, I stayed up all night and watched monitors beep, patients sleep, and played on the computer.  Now I am going to bed... to sleep... for a little while.  I want to wake up in time for the snow.  And, we're supposed to get A LOT tonight.
CCU Countdown:Days left until the end of the rotation: 22Actual number of days I will be working during that time: 19Days left until painful attending returns:  15
Number of days until my next 24 hours off: 4
Number of short call shifts remaining:  3
Number of long call shifts remaining: 2
Number of patients: 3 - 2 in the unit, 1 on the floor, 1 went to private service
Number of evil nurses in the ICU: 2 - not really evil, she justkept bitching about music playing and how it was "thundering in her ears" even though none of the rest of us could hear it after she turned it down from the already soft volume we had it on

Tags: CCU, overnight call, medicine residents

A Chorus Line

OK.  So I am sitting at the resident computer in the CCU.  It's been an all right day.  Nothing really grand.  Two of my admissions from last night went to the angiography suite:  one will need surgery and the other will just be started on medication.  My other patient will need to resolve his heart failure before he can go to the angiography suite.... if he lasts that long.  More on him in a second.
I title this "A Chorus Line" because that's how it feels sometimes on morning rounds.  This morning I had those three admissions from yesterday to present.  For every question the attending had for me there was a chorus of answers - some restating what I just said, and some giving other information.  A few times there was a disagreement with something I had just said which was either later resolved or just thrown out there.  Of course, I had 10 minutes to quickly scan the chart while the overnight residents had... um... all night.
There's also an annoying brown-noser we'll call Smithers for fun who kept interjecting an opinion or whatnot between presentations.  And, seriously, even though I was presenting directly to the attending, answering all of his questions, etc.  total House of God.  Outside of rounds, acted as if I didn't even exist even when I directed a question straight to him... oh.. and joy of joys... 2 less days with him since there's a different attending covering this weekend... in case you're keeping count along with me.
Back to my 3rd patient.  I've talked about the dangers of drinking alcohol in the past except when you drive (refer to prior posts from ECMC.)  Another danger is that you have memory loss (Alcohol affects your mammillary bodies which are important in the brain for logging and keeping memory.)  Since you can't remember what actually happened, you confabulate (make up stuff.)  There's a great "House" episode where he sends the medical students to go see a patient with a broken ankle.  Each comes back with a different story, and he gets a third story when he goes in with the both of them.  Kinda like my patient.  He can't remember some events of the last month, so he makes things up.  Or lies... whatever works.
About three weeks ago this patient had a similar episode but needed to be intubated: breathing tube put in.  After a couple of days, he pulled his own breathing tube out... ouch!  He was transferred to the floor and decided to leave AMA (Against Medical Advice) despite the fact he still needed to have further work-up done for his heart failure.  He stated he had "too many things to do" to be in the hospital.  I've explained to him (multiple times - remember, memory issues) that he could die, he's very sick, and he's lucky he didn't need a breathing tube this time.  I tried to explain it to the family today, and I seriously think there's something in the water at their apartment complex because I explained things 3 times and nothing was getting through.  So, we'll see if this patient doesn't leave again... or elope.  Means the same thing in the hospital - just gets up and walks out the door.
Ok... have to leave.  It's change of shift, and I am sure the joint will soon be jumpin'.  My count down list is changing, and in some ways I think it is even funner than a rating system.... although, I am still suicidal most of the time... especially during rounds.
CCU Countdown:Days left until the end of the rotation: 23Actual number of days I will be working during that time: 20Days left until painful attending returns:  16
Number of days until my next 24 hours off: 5
Number of short call shifts remaining:  3
Number of long call shifts remaining: 2
Number of patients: 3 - 3 in the unit, 0 on the floor
Number of evil nurses in the ICU: 1 

Tags: House, CCU, mammillary bodies, alcohol abuse

Heart and Snow

We had a taste of winter today as about 6 inches of snow fell within a couple of hours today.  And then, the snow just kept falling.  With the snow come the coronaries...  it's funny.  I went to medical school in Wisconsin, and the classic presentation taught to us regarding heart attacks started with "50 year old male comes into the E.D. complaining of chest pain while out shoveling snow."

While I was inside for my 12 hour "short call" snow fell like crazy.  The first pic is the view from the 13th floor at downtown and then looking eastward.  This was around 3:30 p.m. when most of the major part of the storm had already passed (it started around 0930) and most of the streets had been plowed.

Of course, plowed streets means people out there shoveling... men shoveling... first major storm of the season... and I got three admissions from 3 p.m. to 8 p.m.  Three heart attacks... three men most likely needing to go to the cath lab tomorrow to be ballooned, stented or worse, needing bypass surgery.  "I was out there shoveling and got this pain, so I got out the snowblower and the pain got worse... right here in the middle of my chest."

I am on my "long call" tomorrow, so we'll see what the after-affects of the storm will be...
CCU Countdown:
Days left until the end of the rotation: 24
Actual number of days I will be working during that time: 21
Number of days until my next 24 hours off: 6
Days left until current painful attending leaves:   3
Number of short call shifts remaining:  3
Number of long call shifts remaining: 3
Number of evil nurses in the ICU: 1  - should I feel bad I was actually happy when the nurse that was so rude to me in the morning came back this afternoon for her overnight shift and had been in a fender bender on her way home which ruined her day...?  I do believe in Karma, but there was a very small part of me that smiled... just a little bit... a really really little bit... like this little... :)

Tags: coronary artery disease, CABG, heart attacks, NSTEMI

Saved by Wednesday

Ok, so every Wednesday we have Grand Rounds (which I explained on my post 10/24/07.)  So I had to go in slightly earlier to pre-round on my patients and then sign them out to one of the other interns so that I could go to Grand Rounds.  After 5 1/2 hours, my colleague and I returned to see what was going on in the unit.  One of my patients had been discharged (orders written by the senior resident) and the other was leaving the CCU (transfer orders written by the senior resident.)  The new Medicine intern joining the service today asked if I would change short call with him and take it tomorrow instead meaning I could leave early today (as in 30 minutes after getting back to the unit after Grand Rounds.)  Oh, yes, I would, and did.

Let me explain:  in the late 1990's, two NY residents sued the Residency Board stating that too many long hours were leading to patient deaths, resident deaths, and were not conducive to a good learning environment.  So several new resident rules were passed:  an 80 hour work week maximum, a 30 hour limit to being at the hospital, a mandatory 24 hour period off per week, and a 10 hour limit between shifts.

Suddenly, all of the work force in the hospitals needed to be replaced since residents, per the rules, couldn't work those 48 hour long shifts anymore.  Hence, there are now more "mid level" providers such as nurse practitioners and physician's assistants to make up the work force.  And, to keep residents within those limits, a lot of residency programs instituted an overnight "float" team.  This team takes call Sunday through Thursday in-house from 8 p.m. to 8 a.m.  We take "short call" from about 2 p.m. to 8 p.m. admitting and managing our own services until we sign out to the overnight team.  On Fridays & Saturdays, we take "long call" working 24 + hours (with a maximum of 30 mind you) so that the Float Team gets their 24 hours off.

As an aside, one of the consequences is that suddenly everyone wanted to go into surgery because most people had been deterred by the long hours.  80 hours is twice the normal person's usual work week, but much better than the 120 - 140 hours which used to be de rigor in surgery.  However, the drawback is that programs are having to hire more mid-levels which take away from the residents' learning opportunities, and programs are also finding that residents are not meeting their number of required cases.  There's a movement to lengthen the usual 5 year training to 7.  The alternative is the combined programs (Vascular surgery, plastic surgery, etc.) which complete a fellowship specialty in 6 years instead of adding another 2 years to the end of  general surgery training.

Doesn't matter to me any more since I am now in Emergency Medicine.  One of those fields that never had a problem with hours or overworking its residents.  However, when we rotate on different services, we get caught up in keeping the mandatory limits on hours.

As for me, I am now taking short call tomorrow, and long call on Friday, so we'll see what admissions I end up getting then.

I tried to think of a good rating system today during my meetings.  I couldn't come up with anything.  After a day of rounds and short call, we'll see what I can do tomorrow.  For now....

CCU Countdown:
Days left until the end of the rotation: 25
Actual number of days I will be working during that time: 22
Number of days until my next 24 hours off: 7
Days left until current painful attending leaves:   4
Number of short call shifts remaining:  4
Number of long call shifts remaining: 3
 

Tags: CCU, 80 hour work week

Oh My Aching Ischial Tuberosities...!

I think I've said this before, but there was a reason I went into surgery.  Early on in your medical career you make a decision on your specialty based on a few simple questions:  do you like working in or out of the hospital?  do you like clinic?  do you like procedures?  do you like sitting around for hours on end contemplating the minutiae of a patient's clinical course?  My answers would be, of course:  in, hate it, love them, color me suicidal.

I was trying to think of what would be an appropriate rating system for the next four weeks.  Based on this morning's rounds, the beer system just isn't going to cut it.  I don't know how appropriate it would be to rate my day on how suicidal I feel and rating my day by severity of manner of suicide.  I could rate my day by how early in the day I begin to feel suicidal, but if most days are like today, they would all start about 15 minutes into rounds.

Let me explain for those not in the medical field:  I am working in the medical cardiac care unit.  It's an ICU where patients are sent for a higher level of care.  In this case, they're patients with some heart issue or other.  Most are there following a heart attack requiring an angiogram or major medications to keep them stable.  We "pre-round" on our patients - look up all of their labs, vitals signs and find out what happened overnight, so then we can "round" on our patients with the attending - present the patient to the most senior doctor who will then spend the next several minutes giving us some form of teaching based on whatever issues the patient has.

Your rotation can be very good or very bad depending on how painful the attending is during morning rounds. (Our "City of Lights" attending this week has consistently been rated one of the worst by prior EM residents.)  Considering I did two years of surgery, I am used to being hazed, belittled, pounded on, berated, and made to feel completely incompetent;  sometimes all at once and for the same patient.  But, I have to admit that since rounds lasted less than an hour for the most part, you quickly bounced back after saying "Thank you, sir, may I have another?" and went off to the O.R. for further, not-quite-so-public ritualized flogging.

You quickly learned to develop a thick skin, you learned some medicine, and you learned to be prepared for any possible question at all times.  Even so, I never felt suicidal after rounds.  Maybe it was the anticipation of going to surgery after rounds.  Like a nice reward.  Beat on me now then we'll go and cut open some people and then we'll both feel all better.

Medicine rounds are different.  You sit for hours and listen as the attending pontificates about the latest study, or his feelings on the latest study, or his study based on the other study, etc.  Then you go off and do your work.  Then there is probably another meeting so that all the residents can get together and talk about their patients and issues related to their patients, and let's pick one of those topics and talk about it for an hour.  Then you come back and finish up the work that you started but didn't have time to complete - orders to put in, orders to follow up on, studies to get the results for, doctors to call to confirm/ask about/report to regarding the studies who then give you more orders.  If you're lucky, you might get to sit down later in the afternoon and go over everyone again with the team and or attending.

So, to begin:  About 30 minutes into the presentation of the first patient on rounds this morning, my fellow ED resident getting pummeled by the attending, I seriously contemplated jamming a pen in my thigh to distract myself from the pain in my head, and in my butt.  Honestly, I am not used to sitting in one place for any length of time.  Two hours of rounds, followed by an hour of case presentations, followed by another hour of finishing rounds and then it was time to get down to work.  If I'd actually known what the plan for each patient was, I would have gotten my orders written more efficiently, but since this attending followed the "House of God" rules and only spoke civilly to his fellow (someone who's graduated from a residency program and is doing specialized training in a field - in this case cardiology) and not to us lowly interns, I didn't know the actual plans for my patient.  These were dictated to me by the third year medicine residents who are allowed to speak to the fellow.

And then, after they'd written all of my orders and told me what to follow up on, I was given another patient to follow for the next day.  One that had been presented in rounds by the overnight crew.  Of course, had I known I was going to pick up that patient I might have paid more attention, but I didn't.  Sigh. 

Anyway, I have tomorrow off.  We have a mandatory 24 hour period of rest once a week.  I will be taking call on Wednesday, so we'll see if I pick up any patients, and then I am on overnight call in the hospital on Friday.  During my day off, I will try to come up with an appropriate rating system.  Until then... we'll call it a three beer day.

Tags: CCU, BGH, angiography, House of God

On Vacation

Flat Adrian aka Flat Stanley has been shipped back to California, Mom has been settling in nicely with the cats, and I am now officially on vacation.  Very little to write about at the moment.  My next rotation will start on Monday.  I will be in the Cardiac Care Unit at BGH working with one of my fellow interns.  We'll have to see what excitement will come.

As for now, it's snowing... Buffalo is slowly turning into a Winter Wonderland... bring it on!