My First National Conference!

Back to Chi-town! A few months ago I was elected as our residency programs rep to the national group Emergency Medicine Resident's Association. Which means I get to go to the national conference being held in Chicago this week!

I can't wait. I've heard a lot about these national conferences, and I signed up for some exciting lecture presentations several weeks ago. I plan to take my camera, so I should have a lot of shots to share.

I spent my intern year of surgery in Chicago, and I loved the town. What I have mostly been talking about to my friends is the food... yum. I probably gained about 20 lbs during the year I was in Chicago.

One place I have to mention is Garrett's Popcorn on Michigan Ave with a smaller store near Macy's (formerly Marshall Fields) on State. Mhmm... they pop the corn fresh in this huge tumbler then add the butteriest caramel or cheese topping. You can buy the mixed bag or splurge and get a bucket. They also have to die for caramel nut mixes including almonds, macadamia nuts or standard peanuts. So good.

Ok, with that I have to keep packing... will write more when I can... Cheers!

No Tooth Fairy For Me...

So I spent my morning looking in eyes and my afternoon watching teeth be pulled. It was then that I realized that teeth are really gross. I'm going to start brushing like 10 times a day to avoid some of the grossness I witnessed today.

Now, you might wonder what an ED doc is doing in the dental clinic... well, I am learning to give those shots in the back of the mouth that make one side of your mouth, lip and tongue numb so the dentist can work. This way, when patients come into the E.D. complaining of a toothache, I can give them a shot to make them feel better until they can be seen by a dentist.

After giving one said shot, I stayed around to watch the dental students learn to pull and work on teeth. I guess I never realized in the adult mouth that the roots are very long. Ew... certainly not the joy of wiggling that little loose tooth in your mouth when you're 6 or 7... getting that little salty taste... and then "pop" off it comes. Put it under the pillow and the tooth fairy comes. Mine brought silver dollars which I still have somewhere... at least a couple of them.

I was lucky and never needed braces... my mom at 70 still has all her teeth, nice and straight... always bragged her father/my grandfather could pop beer caps off with his teeth... speaking of which, I am off to brush my teeth again before going to bed... brush and floss... better add in the mouthwash for good measure...

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Taking the Easy ROAD...

Ok, so I didn't get a chance to write as much while on my Trauma ICU rotation. I really meant several times to sit and write about that day's events. My feelings. My comments on the stupidity of my fellow man. Seriously. Trauma Drama 24/7.

But, I found myself coming home most days, especially after 27 hours on call, exhausted and not wanting to do much more than play with my cats, play on the computer, enter a world of escapism. My cats wondered about my strange hours; getting up at 4:30 to be out the door by 5:30 so I could start rounding at 6:00. Then coming home close to noon after having been gone since the day before and sleeping all day, waking up to eat something, pour some food in their bowls and then going back to sleep. Shampoo, rinse, repeat.

So, some of the stories from this last month on the TICU service: I probably knew more about the surgeries than most of my colleagues, and had actually performed more of the surgeries than the second year surgery residents I worked with. I got to put in central lines, I put a breathing tube in one patient, and I put in an arterial line to measure blood pressure in someone's foot.

There was an article in the local Buffalo newspaper about the inordinate amount of ATV accident victims being sent to the E.D. We had at least 3 - 4 of them, including a husband and wife who got drunk and crashed their ATV. The wife is doing better. The husband, not so much.

We had a number of shootings including a 13 year old shot by a guy rumored to be in a love triangle with her and another 16 year old girl that he'd already shot and killed. A 16 year old shot in a drive-by straight through the head. The CT showed a trail of debris from the front to the back where the bullet lay lodged. Don't know how that patient will do. We had the suicidal patient that decided to shoot themselves through the stomach. They had a large belly and shot from one side to the other. I am still trying to figure out the trajectory on that one.

We had the motorcyclists hit by cars. The drivers of cars hitting other cars, or trees, or flying off the road and flipping over. People hit by other people's cars. A patient hit by their own car which they thought was in park. A patient was hit by a city bus. And, the patient changing the oil who got crushed by their own car.

We had a number of patients that fell off of, got kicked by, or run/rolled over by their horses.

We had the fell off ladder, fell off scapholding, fell out of tree stands.

Alchohol and drugs had a lot to do with a number of injuries, including the patient who got drunk, fell down the stairs, broke their neck, and is now a quadraplegic.

We had the surgical emergencies: bleeding duodenal ulcer, perforated gastric ulcer, dissecting thoracic aneurysm, ruptured brain aneurysm, etc.

I had the end of life talk with two patients' families. I pronounced one patient and wrote the withdrawal of care orders on the second. I developed a rapport with the family of a patient assaulted with a beer bottle to the back of the head who developed a head bleed and had basically lost the right side of his brain as a consequence. As I showed them the CT scan, I learned that the patient was a very talented artist. Art and spatial relations comes from the right side of the brain. I asked the brother if the patient would want to continue on with the part of the brain gone that was their major talent. He told me the patient would want to live. But, he was torn. He considered it more of a religious decision. But, he wondered if they were making the right decision.

I ended my final shift admitting a little lady who had t-boned another car at 50mph and had a liver laceration and the patient with the bleeding duodenal ulcer. As I came home to sleep, I turned the pager on vibrate and placed it on the bottom of my bag. When I awoke some 10 hours later, about 6 trauma patients had come into the E.D. The next morning there were another 4.

I got to do something fun, despite having a cold, on my last day of the rotation:

As part of our residency, we provide medical support at Buffalo Bills' games. So, I spent the game treating the overindulgers, the fighters, the nauseated, the injured, and whomever else wandered into the north side medical clinic at the stadium. I did get to watch a couple of plays, and we all huddled around the TV as the final kick resulted in a win for the home team!

This month I am doing the relaxed, Mixed Bag rotation of Ophthalmology, Oral MaxilloFacial Surgery and Radiology. In med school, we talked about taking the "easy ROAD" R = radiology, O = ophthalmology, A = anesthesia, and D = dermatology. These were considered the high money specialties with a minimum of patient time and or short clinic hours with no weekends and minimal calls. So, I am essentially doing 2 out of the 4 with my weekends off to enjoy... oh yeah, and a week's vacation during the final week.

So, we'll see what excitement I can drum up over the next THREE weeks...

Stopped by a Chip in the Road

Well, today I had an allergic reaction to some ginger on, of all things, a potato chip. I always watch what I eat in terms of baked goods that tend to include it, and I have learned to also ask about Allspice which caused a similar reaction. But, a potato chip? Didn't even think about it when the bag was offered to me, I took one, tasted good, than about a minute later I could feel the pressure in my chest.

Luckily, I was in the TICU at that time. I grabbed my bag, sucked on the inhaler I always carry and got a Benadryl from one of the RN's. Things seemed ok for a few minutes but then my voice started changing so I went down to the E.D. where I was given a dose of IV steroids and IV Benadryl. Within a few minutes I was feeling much better, and they kept me for observation for another 1/2 hour. I came home and slept off the Benadryl.

Of course, when I awoke, I noted 5 trauma code pages that went off... wonder how many of those are going to be in the ICU when I get back tomorrow morning... I am guessing that the "gun shot wound to the chest" will most likely be there. So will I. Bright and early. Now having learned to add "Spicy Chips" to my list of "foods to check before I eat."

End of Summer Call

So, here it is the last weekend of summer, and I am on-call. Normally, there would be a medical student on as well, but they finished their rotation on Friday. So I am alone. Luckily, there are only 11 patients in the ICU. I plan to write "on the fly" during the call, so let's start off with the major players. Check back periodically, for, hopefully, updates.

11:20 - 11 patients in the ICU: 3 MVC's (motor vehicle collisions), 4 post-ops, a fall down stairs now with a broken neck, the young patient who had the car fall on them, a stabbing, and the ATV rider with the head bleed. I plan to transfer 2 out of the ICU by the afternoon. The stabbing victim has lost the bottom part of their ear and is going to have a wicked scar down their left cheek along with some loss of sensation in that part of their face. One of the MVC's is lucky that they were wearing their seat belt and the airbag went off when they had their head-on collision. Things could have been much worse. Again, pot can kill. That's about it for now. We'll see what the rest of the day, and the great weather, will bring.

1940 - The day has gone well so far. Except I had one death in the post-op group. They had a lot of illnesses, and as I have said before, seniors just don't have the reserve to overcome a major insult. I was also able to send the stabbing victim up to the general ward. I've had one admission. They fell down some stairs two days ago. The family found them at the bottom of the stairs unconscious but because of the patient's known alcohol use, the family thought they just needed to "sleep it off." Yesterday, the patient was fine. Today, not so much. They were confused and agitated. Turns out they have bleeding into their brain. There's a plan for neurosurgery to operate on them tonight. So, I am minus two, plus one. Rumors and speculation are that we might be getting another one, but I haven't heard anything yet. The evening is just beginning, and there's plenty of havoc still to be wrought. Will keep you posted...

9/1 0140 - Well, a lot can happen in 6 hours; like the2 more admissions I just got. One fell off of a ladder while working on the ceiling. High ceiling because they fell about 12 feet. Numerous broken ribs, and I had to have them intubated (breathing tube put in) because we couldn't control the pain AND have them be able to take good breaths. The second fell out of a tree stand. Not quite hunting season yet, so we're unsure what they were doing up there, but regardless, they fell about 18 feet. One broken vertebrae, and they're acting "strangely" so they come to the Trauma ICU. Oh, and to add some fun to the rest of my night, reports are that there was a riot at Attica prison, and there were a number of stabbings; all coming to ECMC. One sounds serious enough to probably be going straight to the OR. The rest we haven't heard about yet. They haven't arrived yet, but I am trying to get a jump on my morning work... speaking of which, have to be going. The patient with the brain bleed just got back from surgery, and they need a central line. Will probably fill in the rest of the night later this morning when I am finally home... home... sigh.

12:27 - Finally, home. Almost 30 hours' later from when I left. The final body count: one death, one transfer to the floor. Minus two. Four admits leads to plus two balance on number of patients. My admits last night: got drunk and fell down stairs - massive head bleed requiring surgery to drain the blood, got drunk and tried to hang some ceiling tiles then fell off scapholding - broken clavicle and multiple rib fractures so not able to breathe well and had to have breathing tube placed, got drunk and high on home grown marijuana then got depressed so climbed up 18 foot hunting stand and subsequently fell but not found for 6 hours - broken top of vertebrae actually pretty lucky no other injuries, and finally got drunk and high then drove off embankment down 20 foot ravine rolling car over several times - broken ribs leading to laceration of a part of lung and spleen causing massive internal bleeding... too bad you were still too drunk when I admitted you this morning to realize the error of your ways. As for the prison rioters, well none were admitted to the ICU, and the worst of the lot had a cut ear, cuts on the face and a long cut on the forearm. They'll all live to fight another day.

As for me, I am going to sleep now so I can get back to patching up the next round of revelers in the morning...

The Back Story

Well, I started my new rotation in the Trauma ICU at ECMC on Monday. It was actually kind of exciting to be back in the ICU, and I was on-call last night. Yes, 26 long hours of fun. Did I mention it's been a while since I've stayed up more than 24 hours straight?

One of the things I love about ECMC, as I have mentioned before, is that patients have the most interesting stories. Now, some of my colleagues will argue that BGH and Children's have their share of stories, and I agree that once in a while a good one will come up, but I still feel that the best stories come out of ECMC. And, getting to know my patients, plus the 5 new admits I had to the ICU, can be an interesting venture.

Two patients came in with blood alcohol levels that put them in the "inebriated" category having fallen. Mind you, both presented to the ED in the morning after their respective falls. They both admitted that they drank "a couple of beers a day." I guess they just didn't specify at what time of the day. Both ended up with back injuries requiring multiple scans and films. One had a broken wrist and the other had spinal shock. Both will end up doing well.

In the "payback's a b*t*h" category, don't mess with a mama's little girl. You might just end up getting a beat down with a lead pipe leading to a broken face, some major bruises and cuts, and the humiliation of having to spend the night under arrest in the ICU. Oh, and again, please stop doing cocaine, I'm having a hard time controlling your pain (because your synapses are all fried) and your blood pressure (because I have some limits on the kinds of medications I can use.)

And, again, you might want to reconsider your life's choices when you're in the ICU because you got kicked in the chest by a mad female. The bleeding led to an infection which led to a worse infection in your lungs which then led to the surgery where they had to cut into your chest to clean things out. Now, your heroin habit caused me problems like your fellow patient's cocaine habit with your pain control. Granted, you have four tubes sticking out of your chest so I feel just a little bit more sorry for you because I know those are uncomfortable. But still... rethinking those life choices might not be such a bad idea.

Of course, the worst are therandom events where someone was just having fun and it led to tragedy. Like riding an ATV and now having a spinal fracture leading to the strong possibility of never walking again. Hard when you're just 16. Or 17 doing something simple like working on your car. Now you'll be lucky to not be brain dead. Luckily both have very supportive families which will help as they'll have very long roads ahead.

One of the more interesting things is being pimped again (meaning being asked questions by the attending that tests your level of knowledge and puts you on the spot.) In the E.D., not so bad. In the ICU, back to pimping "surgery style." But still, very good to be back to the familiar. Can't wait to see what the rest of the month brings...

A Moment of Reflection

I didn't write a whole lot this month, but then not a whole lot really happened. I went on my first helicopter flight. I learned an awful lot about overdoses and toxicology. I took classes in HAZMAT, terrorism & creating a incident command post.

I think it's a bit fitting that the closing ceremonies are tonight. I was able to dedicate the majority of this last month to watching the games. Now, for some, this might be thought of as a waste of time. But, I think I can always find something inspirational. Right now, Dara Torres who is... eek!!... my age won a silver and missed gold by 0.01 seconds. Wow.

I set some new goals (a five mile Turkey Trot I plan to run with some of my colleagues), and I continued some previously set goals (I am still eating vegetarian, 6 weeks!). We'll see how I continue to do.

Tomorrow I start in the Trauma ICU at ECMC. I am sure there will be a lot of tales to be found there. So, for tonight, we'll go to bed wondering what the new dawn will bring.

A Good Day to Die... Er, Fly...

Almost 16 years ago I had the most amazing day. I was doing three weeks of training in Manhattan, and I had one day off; a Sunday. I rented a car, drove 3 hours out of the city to the end of Long Island, Mantauk where I rented a sailboat and had 2 glorious hours on the water. The whole drive out had been rainy and overcast. When I arrived to Mantauk, the cloud cover broke, and I had those two hours of sunshine and fine wind.

Afterward, I drove to a local place, Mama Jojo's, where I had a whole lobster dinner with an iced cold Corona, and the best cheesy bread rolls I think I've ever had. As I ate my dinner at an outside table overlooking the harbor, a light breeze blew, and there was a nice sunset. But then, the clouds came back, the rain started, and I made the 3 hour trek back to Manhattan. It was the best day.

The next day, back at training, my instructor asked about my day off. After I had expounded on the glories of the day, he said to my surprise, "So it was a good day to die?"

I looked at him in disbelief. How could anyone want to die after having experienced such a wonderful time. Then he explained:

There was an American Indian chief who awoke one morning, stepped out of his teepee, and proclaimed that it was "a good day to die." His fellow tribesmen looked at him confused. The chief continued, "Look all around you. The prairie grass is high and green. The skies above are the brightest blue. The buffalo are grazing nearby, and a clear stream runs close by. It is a perfect day."

"Who would want to die on a gray sullen day? Today is a good day to die."

I was thinking about this as I arrived at Mercy Flight on what was a glorious morning. The thunderstorms that had been plaguing the area had dissipated into a bright blue sky with big fluffy white clouds. A fine breeze blew from the west. What could be more perfect?

Our first flight took us north to a community event where local schoolchildren were learning about community safety. Here's a pic as we approached:



You can see the school buses and one of the local firetrucks which I got permission to climb up on and ride up on the cherry picker to its full height of 102 feet.



Here's a pic of Mercy 7 which I took from the top. This was the helicopter we were flying today:



And here she is close up. It's a much bigger helicopter than the one I rode last week.



We spent about an hour at the community event and then flew back. During our shift, we were put on alert twice but did not fly out. Finally, around 5 p.m. we were called to pick up a transfer from near the New York/Pennsylvania border. It was a 25 minute flight, so the longest I had ever been on a helicopter.

My thoughts continued as we flew over the green hills and valleys to the south of Buffalo. Cows sat in the fields. Rivers flowed through canyons. The air was clear, and everything seemed right with the world. Of course, not everyone was having my day.

Our patient was a young man enjoying his beautiful day by riding his ATV with a group of friends along the local trails through the woods and a quarry. He fell off and was knocked unconscious. On his physical exam, I guessed he had a broken nose and most likely a skull fracture. He had scrapes and bruised all over his abdomen. Relatively speaking, he was doing ok, and we flew him the 20 minutes back to ECMC where the trauma team took over. It was their 3rd trauma from this ATV event, so they were very busy.

I guess I'll find out in the next couple of days how the patient did.

From there we flew back to base, and my shift for today ended. The first pic is the sunset I saw on my way home. What a glorious day. And, although for me it was a "good day to die" that would not be allowed for the patients under my care on this most beautiful day. I can thank God for that and everything today.

"Vivir con miedo es como vivir a medidas" - a life lived in fear is a life half-lived.

Ooo... Pretty Lights!

Just a couple of thoughts on my ride-a-longs with the local ambulance service:

If you see flashing lights behind you, move to the right.

If you hear a siren, put down the cell phone, look around you, and move to the right.

If a large moving vehicle with flashing lights and a siren suddenly appears in your rear window, turn down the radio, put down the cell phone, and move to the right.

Lights and sirens coming toward you on a street means... um... move to the right.

If you are driving and come to an intersection where everyone else is stopped, don't take it to mean that they are waiting for you... it's probably because everyone else saw the big moving vehicle with the lights and sirens coming down the street.

Emergency vehicles are like deer, if you see one there might be others, so take a few seconds to make sure a second one isn't following the first.

If you call 911, a lot of people are suddenly going to show up. If they're at your house, that means that can't be at someone else's, so don't call unless you've got a legitimate reason.

One final thought: yield to emergency vehicles, they might just be heading to save someone you love.

Tomorrow, another shift with Mercy Flight. Better weather on the horizon, so we'll see what the day brings.

First Flight

Quickly, today I flew for the first time with Mercy Flight. During my 12 hour shift, we had one run: a trauma that had to be flown from a city to the north down to ECMC. I will find out from my colleagues how the patient did. I just thought I would share some photos from the event.




All in all, a very exciting day. Tomorrow back to tox and another week of being on-call for tox and EMS. Until then!

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The Spirit of the Olympics

I honestly think I must have had something to do with the olympics in a former life. Nothing will bring a tear to my eye as easily as watching the opening ceremonies and seeing the olympic cauldron be lit.

Growing up watching Nadia take the gold, I dreamed of finding my sport and competing in the olympics. At my age, my only hopes now are sailing and equestrian. Still, one of my more reachable goals is to attend an olympic opening ceremony. One day... maybe in two years in Vancouver?

As the next 17 days progress, I know I will be watching the competitions; still getting misty as the U.S. flags are raised and our national anthem plays. Do you plan on watching?

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Continuity of Care

Ok, so I really haven't written because there hasn't been a lot going on. I am in the middle of my EMS/Toxicology rotation, and I have been going daily to the Poison Control Center of WNY for lectures and to follow up on the cases we have been asked to consult on, and then my afternoons are spent in a variety of different activities. Mostly, I am enjoying driving the SMART 1 vehicle around town, and I am starting to take calls with the fire department and ambulance service.

Last week Friday, I spent the evening with the crew from Rescue 1. There were two calls, both of which were canceled en route. However, there's still something to be said for pulling out of the fire house, lights and sirens, riding the big red truck. I enjoyed the time spent with the fireman, and I wish them continued safety.

I went out with one of the attendings and a fellow resident as medical back-up for Erie County Sheriff's SWAT team. They did a raid on a house, and we were there in case of injury. It was very interesting and exciting in a "Cops" style, up close and watching the action sort of way. No injuries, thank God, and I wish on them continued safety.

I spent a good part of the weekend preparing for a lecture on ventilators that I gave yesterday at our EM grand rounds (oh, yes, grand round Wednesdays are back!) It seems to have been well-received. So kudos for me.

Today I did a ride along with one of the paramedics from the local ambulance company. It was interesting because in the middle of one of our calls, I received a page from Poison Control about a case. As I rode in the back of the bouncing ambulance, I took information about this case. I was on my third phone call by the time we reached the VA to deliver our patient.

After I called back the consulting hospital, ECMC, with our recommendations, the paramedic, Tony, asked if I wanted to go to ECMC and see if the patient had been transferred. I said yes, and we arrived just as the patient was starting to be evaluated. It was nice because I was able to follow the case. We call that "continuity of care;" when the same provider follows a patient through their medical course of treatment. Of course, one of my colleagues took the case over, and I will follow up, along with Poison Control, in the morning, but it was interesting to see one of the patients I get called about in the E.D.

Tony and I spent a good deal of the shift going from call to call, and there's a lot of forms that need to be filled out for each run,so Tony spent most of his time typing on his portable computer. The cases were pretty run of the mill, but it's always good to see what the EMS guys are dealing with "pre-hospital."

Tomorrow it's back to PCC in the morning, but Saturday is my first Mercy Flight shift. I hope the weather clears, and we get to fly! And, yes, I plan to have my camera at the ready.

As for the veggie thing. I am at the end of my last week. How hard has it been? Just a little. I spend so much time out of my home, that I usually eat out. I am realizing just how difficult it is to eat vegetarian and healthy in this town. Choices are very limited. I did find a very tasty eggplant parmesan at a restaurant called Towne near downtown Buffalo. I judge Italian pastas on the sauce, and this one was just the right blend of tomatoes and spices. Yum.

Just a few more days of the pledge, however I am considering more my choices in foods.... I just made the pledge to eat only free range egg products and limit my intake of eggs in general. I think we'd all make a difference if we just considered where our foods are coming from. And, with the gas crunch, more restaurants and local markets are supporting local growers which don't have to be shipped as far. That's something we can all benefit from. (ok, ok, off the soapbox)

I Get High With a Little Help...

Ok, so the picture above is from one of my last patients at Children's. I think I talked about the 12 year old who stuck some things up his, um, weenis. Today the picture loaded, and I am using it as an example of some strange things that people do to get high. Now, there is a certain pain/pleasure described by patients who stick things in their urethras. There's actually a name for this which I couldn't find because I am too tired right now, but the link is to an interesting article on the subject. Strange Found Bladder Objects

I am bringing this up because I am currently on my first official rotation of my second year: EMS/Toxicology. I spend my mornings in the Poison Control Center of Western New York which is based out of Children's Hospital. We go over cases that came in the day before, and follow-up on cases that are currently active. Most of the cases involve overdoses and ingestions (such as kids swallowing bleach).

Every day I have to make a small presentation about this or that drug that we've been consulted on. I have talked about acid/bases and what happens when you come into contact with them. Tonight I finished research on my project for tomorrow which is on overdoses of muscle relaxants. What those crazy kids won't take to get high.

During the rest of the day, I am on 24 hour call for the Poison Control Center and for Erie County EMS. I get called if there is a question directed to the PCC from a hospital regarding treatment of a patient in their E.D., and I could potentially be called for any incident in the county requiring a physician to be on-scene. During the school year, we get called for mostly school bus accidents where there are a large number of patients that don't necessarily have to go to the hospital, but who all need medical clearance before being released. Every once in a while we get called for something more interesting: Swat Team Shooting

i also get to do ride-a-longs with local EMS including Mercy Flight, BFD Rescue 1, Rural Metro Ambulance, and possibly some other agencies. There are a couple of other "fun" projects, but I will elaborate on those toward the end of the month.

For now, I have to go to bed and get ready for my PCC rounds this morning. Oh, and if you see this vehicle around Erie County:



That'll be me behind the wheel!!

I promise to share interesting stories as they come.... until then, stay safe!

Oh, and on the veggie front. It's been almost 3 weeks. Today I tried the Super Veggie at Subway, and it was tasty. I was sooo tempted by some fish, but I promised to make it a meat-free month, so I kept my pledge. A week to go, but to be honest, it's actually getting easier to make the veggie choices, and I am learning to be very creative when going out to eat.

Marathon Weekend

Ok, so I've been very busy over the last several days with this and that and being a vampire. Once I got used to the night schedule, I had three days in a row where I had to do daytime things, and tonight I go back to nights. Two days of a nights with a turn-around shift where I get off at 4 in the morning and go back to work at 1 p.m. But, it's my last weekend at Children's until January.

Some of the things that have happened:

We had the intern's welcome picnic at a park in Eden, very beautiful, and I was trying to share pics, but they're not uploading for some reason. Then I worked that night.

I had a very strange case of a young boy with a swollen, um, weenis. My attending was concerned he might have constipation causing a blockage of his ureters leading to infection, and we found... well, couldn't load that photo either, it showed a number of wires in his bladder. He finally admitted he had stuck them up there. He went to surgery that night.

Monday, another shift in the E.D. We actually cleaned the board, and I was lucky to get sent home somewhat early.

Tuesday I tried to clean and catch up on all the things I hadn't been awake during the day for.

Wednesday, my EM class went to U of B for some procedure training on cadavers. I got to help with the teaching, and we had a lot of fun catching up since we hadn't seen each other in a while. I kept myself awake most of the night to try to stay in vampire mode.

Yesterday I went to one of the local firehouses to run through procedures with their EMT's. One of my future jobs in EM will be medical director for the local EMS agencies, so this gave me some practice.

OK, have to be running, get dressed and off to work. We'll see what the evening brings.

On the veggie front: I resisted temptation at the picnic where they were grilling the best-smelling BBQ. Ribs that were falling off the bone. MMMM... I had the salt potatoes, salad, and mac and cheese. Ok, ok, I had a matchbook-sized piece of ribs, but I didn't enjoy it, well, yes I did. Other than that it's been soy in my coffee drinks and cheese sandwiches. Veggie burgers are the mainstay of my existence at the hospital, although they did have a veggie soup the other night. We went to a local Tex-Mex deli that was supposed to have fish tacos... I had the bean and cheese burrito. Can veggies eat fish? What do you think?

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Sharing at a Time of Pain

In my last entry, I talked about a sad case that came into the ED. A small 5 year old running in the backyard with his new bow and arrow that he received for his birthday. In a freak accident, he tripped and fell right onto the back of the arrow.

Initially it was thought that he had suffered some eye damage, but then he began to have seizures which signified a brain injury, and he was transferred to Children's Hospital. Our E.D. was mobilized from the moment we heard about the patient coming in on Mercy Flight. Neurosurgery and ophthalmology were both called in even before the child arrived. He spent less than 5 minutes in the E.D. before being rushed up to the CT scanner, from there straight to the Pediatric ICU.

The injury was devastating. There was a laceration to one of the blood vessels in the brain, and he was bleeding which was leading to the seizures. A sister hospital is the regional stroke center, and he was sent there to further assess the damage in their brain imaging suites. Unfortunately, it was too extensive.

When I came on duty last night, I ran into one of the ICU fellows that I know and casually asked about the child. His face said it all. From one of my colleagues, I heard the rest of the story. One of the ICU nurses came downstairs and was telling us that the family decided to make the child an organ donor. Throughout the evening, multiple phone calls were being made to awaiting hospitals. At one end death, on the other end hope for a life.

I keep the green donor ribbon on my sidebar as a reminder of the importance of organ donation. The lives that this little boy touched will be immeasurable, and he will remain in our memories for a very long time.

Lots of Boom, Not Much Bang

Ok, so on Wednesday morning, the SMART team was asked to provide medical backup for a Bomb Squad training session. For some reason the photos I had aren't uploading, but there really wasn't much to see other than a pic of the Erie County Sheriff's Bomb Squad van and a small explosive going off. I had to leave to go to work, but my understanding is they set off several more explosions during the afternoon. We were asked to be there in case someone was injured setting up the charges.

Wednesday afternoon I worked and saw only about 6 patients as the board was so "constipated" - nothing moving out so nothing moving in, that we couldn't get patients back to rooms. I would see one patient and then wait forever before the next one could even be brought back. I did see two corneal abrasions, one in a 15 year old who just got a new airgun for his birthday and promptly shot himself in the eye with a pellet. He was lucky and just had a scratch in his eye.

Thursday I spent the entire day in Base Station training. We have to provide "Medical Control" for the EMS units that work in the city. They have written protocols that they follow whenever they go to a run, but sometimes they face situations which are outside of their scope of practice, so they call an MD to get medical direction on how to treat these patients. The majority of our day was learning about the EMS system and the protocols. We then spent the last part of the afternoon running through actual cases and learning how to give medical direction.

Last night I started a 4 day stretch of nights. Again, I came into a "constipated" board and didn't see a patient for the first half hour that I was working. Things did not improve throughout the night. We've been seeing a lot of diarrhea and dehydration lately as it is the Enterovirus season, and a lot of kids are getting it. We make sure they don't have any fevers or other infections, hang a bag of saline and then send them off. We also continue to see a lot of traumas, mostly falls from swings, slide poles, front porches, etc.

We had one unfortunate case tonight of a 5 year old running with a bow and arrow who tripped and had the back end of the arrow go through his eye and straight back. We know he's got a head bleed, he was having seizures, and things do not look well at this time. I will find out later today or tomorrow from my colleague in the ICU how he's doing.

Ok, off to bed for now. It's vampire time for me. The vegetarian thing is going well. Lots of fruits, salads and cheese. The hardest thing is I live in Buffalo where the most common take out order is pizza and wings. Pepperoni pizza. I found a slice that had one piece of pepperoni which my colleague ate for me, and I munched on the often-forgotten celery sticks that accompany the chicken wings. I also can now sympathize with my true vegetarian colleagues who claim they can never find something to eat. Seriously, what's up with a hospital cafeteria that thinks a vegetarian entree is cauliflower with cheese? Oh, and rice milk is sooo much better than soy, or even almond.

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Summer Crushes

Today was a bad day for kids to be playing at the playground. We had two patients with broken bones as a result of playing on the "merry-go-round." You know, that big silver wheel with the bars that you spin around and around until you get your friends deliriously dizzy, and then they try to stand and fall over? When I was a YMCA camp counselor, we used to see how many we kids we could spin off. Total carnage today: a broken forearm and a broken leg.

Today was a bad day to be under the age of 18 and pregnant. We had about 4 patients come in with threatened miscarriages. Interestingly, two of them had taken the "morning after" pill after "the accident" and had still turned out to be pregnant. All of them will have to come back in a couple of days to confirm that they miscarried and to make sure they don't need any further procedures.

Today was a bad day to be the surgery resident. I think I counted about a dozen patients with abscesses that came in today. That has always been one of my favorite procedures, opening up an abscess and draining it; then packing it and having the patient come in and have the dressings changed every couple of days. I liked to watch the wound gradually heal, and the patient improve greatly. Now, I have to call a surgery consult for those patients, mostly because we are usually too busy to allow an ED resident to get away for a procedure like that. So I miss that satisfaction.

Today was a bad day to fall on your head. Patient One was sitting on a car with some other kids when the owner decided to back out of the driveway and then stop quickly. She fell on her head. Got away with a minor concussion. Patient Two took a backward header off the front porch. Depressed skull fracture that got taken IMMEDIATELY to the OR by neurosurgery to evacuate a growing hematoma (blood clot.) Patient Three has ADHD. A week or so ago, he had an accident off an ATV and also had a depressed skull fracture with a brain bleed. He was taken to the OR by neurosurgery, spent a couple of days at the hospital, and then got discharged home. Today he decided to try jumping off the porch, or something like that, and landed right on his surgical site giving himself a whole different kind of head bleed that, too, required IMMEDIATE transport to the OR.

Well, those are the major highlights of the day. I have something fun planned for the morning that I will write about tomorrow. Then I go back to the E.D. for the 1 - 11 p.m. shift.

On the veggie front: cereal with soy milk, coffee with a touch of milk, lunch was a grilled cheese sandwich with veggie chips and some fruit, dinner was a veggie brand feta cheese and spinach Hot Pocket of sorts and some of the great grapes and cherries I bought yesterday. It's funny, you would think there would be a lot of healthy things in a hospital cafeteria... not so much. I do have to admit, I was seriously tempted by the BBQ chicken wings they were serving, but I reached down below for the grilled cheese... 27 more days to go.

One Can Always Dream

This is what I came into this morning. I think it lasted for about 15 minutes.

And then, one of the early patients was this:

Look around the middle of the top third of the film, and you will see a bright long object... that, folks, is a dental drill. This 5 year old was in the dentist's chair when the drill bit "fell off," and he swallowed it. Luckily, this should pass within the next couple of days. I gave them all the warnings in case it did not pass easily.

By the time I left, this is what it looked like:

And, this was the waiting room:


As you can see, a veritable smorgasbord of ailments. Again, we were so busy and had so many providers that around 5 p.m. we had a "constipated board;" no one was moving in or moving out.

I am about midway through the rotation so I thought I would take the time to get a few rants off my chest:

onto the soapbox:

- people are not an endangered species, please stop having children. I sometimes think birth control should be federally mandated. When you come in and tell me about your 5 children at home, and how you can't afford a bottle of $2.50 Tylenol for your child's fever for which you want me to write you a prescription so that Medicare (read, us taxpayers) can pay for it, please don't also tell me about your smoking/drinking/marijuana habit, because I can't see justifying $7 a day for a pack of cigarettes, or whatever you pay for the carton, when your child is sick.

- oh, and please don't tell me you don't "smoke inside because of the kids" because we know you do. If I can smell the smoke on the baby stroller, someone's been smoking around it, or it spends a lot of time out on the front/back/basement or wherever you say it is you go to smoke.

- missing your period for 2 months after unprotected sex, and already having had 2 children should make you think that you might be pregnant; which means that if you're considering having another child you might want to stop drinking/smoking/and doing drugs. There are a lot of important developmental changes happening to your baby during this time. And, don't use the excuse that you're only 19, and it was "your birthday." Start taking some responsibility. I can only wonder what's going on with your other 2 children if you're freely admitting to me that you "like to party" and drink and smoke marijuana daily.

- I think I have said this before, but please don't bring your entourage with you into the E.D. I don't need to meet your sister, sister's baby, your neighbor, neighbor's baby, your baby's daddy, his mama, etc. Oh, and bringing your 11 year old nephew with you for a "female exam" and talking about your sexual partners isn't appropriate, and I will be asking him to step out of the room, so don't be mad when I do.

- All I cansay is that we've been seeing way too much of CPS (Child ProtectiveServices) lately. We had a horrendous case of abuse where the childwas taken away from an abusive mother, put into an abusive foster home,transferred to a second abusive home, and adopted into her currentsituation where she was being brought in for possible abuse. She's11. I can't even begin to imagine her life or what will become ofher. Sigh.

Off the soapbox...

As for my vegetarian pledge: Like I said, I can't go completely vegan. I had a little cream in my coffee drink this morning. Cereal with soy milk. Lunch was a veggie burger with cheese and mayo (not vegan as it's made out of eggs) and veggie chips. I then went to the local upscale Wegman's supermarket to make a salad. I added a number of their "vegetarian" sides to my spinach and greens. Lot of garbanzos and beans; barley and peppers. There was even a tofu curry mix that was very tasty. I bought a number of "veggie" frozen entrees, some rice and soy milks and a bunch of fresh fruit for snacks.

I am still recovering from the weekend of gluttony so I felt hungry, but I know the stomach will shrink down and adjust to the smaller portions. Here's where it becomes the mind over matter, but I know it gets easier every day. At least, that what I will remind myself.

41 Hours of Gluttony

So, I just got back from 2 days in So. Cal. visiting my mother and eating entirely too much... It's just that there are no decent, authentic, Mexican food restaurants in Buffalo, and I was dying for some home-made food, and some food from my favorite Mexican restaurant, AND my favorite steak house, etc. Afterwhich I vowed to myself that I was going to take the 30 day vegetarian challenge. However, this mostly came as a consequence of visiting my favorite Mexican food chain restaurant, Green Burrito, and having the "mini" super nachos. Carnitas, mmmmmm.

Ok, so anyway. Having thought about the amount of animal protein I consumed, not to mention all the other badness, I began to think about how I really should start taking better care of myself. I had read Oprah's 21 Day Cleanse and had been tempted to try it out. Although, I know I couldn't do the caffeine part. I live on caffeine. So, I'll make some minor adjustments.

I also don't think I could go completely vegan. I can do soy instead of milk, so that's not a problem. I don't know how I would do without cheese. I may have to try some of the soy products and see. I am planning on following the PETA recs Vegetarian Starter Kit and be a more earth conscious eater.

So, we'll see how I do over the next month. I also challenged a friend to get in shape for a 5K in November. I should be able to run it by then. At least, I hope so.

Tomorrow back to the pedis. We'll see what the morning brings!

Lawd o Mercy!

Today was a non-workday, and I spent the better part of the morning at Mercy Flight Operations. Basically, the training involved learning helicopter safety and a lot of flight physiology. Plus we had a little lunch. I missed this part last year, and so I joined this year's interns for the lectures. Which I find funny since this is relevant for me because we do our rotation with Mercy Flight in our second year.

Irregardless, we had a good time learning about their operations, and I was able to daydream a lot about getting up in the sky and flying with them. Like I said, my rotation starts at the end of the month.

So, not much to write about tonight, and I am in the middle of preparing a lecture on suturing for the new interns which I will present tomorrow.

Cheers until then!

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You Can't Chose Your Parents

I always said that I could never be a pediatrician or a veterinarian because whatever happens to children and animals usually is the fault of someone else. I felt I would always be angry at someone when treating my patients, especially the injured ones. Today was a good example of when bad parents happen to children.

Patients seen in the E.D. today:

A 5 year old with a cellulitis, skin infection ("he was at his father's and I don't know what happened to him"). I wanted to give him a dose of antibiotics and then send him home with a prescription. Mom said she was tired of waiting and needed to go "check on her bicycle" which she states she didn't lock. A nurse asked me how they had gotten to the E.D. if the mom had ridden a bike. I said some questions I don't want to know the answers to. Anyway, I asked mom to wait a few minutes, and we would have the antibiotic. Well, she disappeared with her son and didn't return. Our social worker got involved, called the contact number that was for a "neighbor" that lived 1/2 mile away who said they would try to get a hold of mother. She eventually did show up... 3 hours later. We got the child the dose of antibiotics and got them their prescription. I hope she fills it.

When I walk into a room and the mother starts the conversation by saying, "I just got her back from foster care, and she's been sick ever since" I kind of start to wonder what's going on. I don't like to judge people, but this mother was the poster girl for a "Don't Do Meth" campaign and the father looked like, per the RN, something out of "Deliverance." The mom couldn't answer my questions about fevers, vomiting, wetting diapers on her 2 year old. All she could tell me was, "she hasn't really been eating or drinking and the doctor told me to bring her here." I had a nurse ask if the girl had a genetic disease because she "had a look about her." I asked the nurse to go in and look at the parents. We ended up admitting her for hypoxia (low oxygen saturation), dehydration, and hypoglycemia (54, in kids should be around 100). I think social work might be getting another phone call.

Ok, so you're married to a doctor, and you have 4 children under the age of 5. You decide to pack the kids into the car around noon and head off to your local Target and Lowe's to pick up a thing or two. It's summertime. It's midnight as I write this and my thermometer on the way home tonight read 80 degrees with high humidity, so I am sure in the bright sunlight of midday it was much warmer. You get out of the car and leave your kids for "just 10 minutes" with the car doors closed, the windows closed, the car turned off, in the middle of a parking lot. Soon people come by and notice the children in the car, yelling and crying for help. They stand and wait to see if someone shows up while they call the police. The police arrive and wait a few minutes to see if someone shows up before they break the windows and open up the car. Total elapsed time, about 30 minutes. EMS arrives and notes the infant (9 months old) is drenched in sweat and no wet diaper. All the kids get put into the cool back of the ambulance. Dad gets called, but he can't come because he's in surgery. Mom finally shows up and get promptly shown the back of the police car. Auntie, who's also a doctor, gets called and meets the children en route to Children's. All four are seen and evaluated in our ED. CPS (Child protective services) gets called. The four are discharged to the care of their father once he got out of surgery. Will have to hear later what happened to mom.

A woman walks into a bank carrying a year old child. She walks up to another woman and asks if she would please hold the child for a moment while she takes care of something. The second woman agrees. The first woman walks out of the bank and never returns. EMS and police are called and the child is brought to WCHOB for evaluation. Social work and CPS, already there, are brought in to discuss placement of the child who is otherwise healthy. About 5 hours later the mother shows up in the E.D. looking for her child. Buffalo PD is promptly called to escort the woman to a different waiting area. Will have to ask the resident involved what ended up happening with the mom.

I had to call CPS for a case of suspected abuse. A 9 year old "smacked around" by his father causing a bloody nose. I counted and took pictures of all the bruises and lesions he said were inflicted by the father and his new stepmother. He has 3 older brothers and 2 younger step-siblings who are still living in the home. He called his mother for help from an older sibling's cell phone, and she brought him to the emergency department. Seems she is "getting help" and doesn't have custody of the children, their father does. She gets to see her children bi-monthly. She asked if there was any help CPS could give in the custody dispute. I said I didn't think so but I was sure they could connect her with the appropriate resources.

We had another child who fell out of a window and came out the other side looking like they had been thrown into a cement mixer. Head injuries, broken arm, broken ribs. She was being admitted to the PICU.

I worked on a 2 year old riding a motorized ATV who fell off the back and also had a head injury to add to an earlier one suffered when he banged his head on a wooden door. He was going to be admitted as well.

I had a 4 month old that flipped over in their car seat when the transit bus they were on stopped hard. He had bruising all over his face. A head CT did not show any injury to his head. What was interesting is that while I tried to examine the child and talk to the mother, she was more interested in berating the "baby daddy" because he, "wasn't there when his son needed him, he had no interest that his son was injured, why wasn't he a good dad and arranging transportation for them, don't blame me for what happened it was the bus driver's fault, etc."

Sigh.

On a good note, I got to show my final patient her 16 week old baby. She was concerned that she hadn't felt the baby move, and I got to print her a lovely picture of her baby, nice heartbeat, moving all their limbs, a new life ready to enter the world. Hopefully, to a good mother. Hopefully.

Hitting Hard While Heading Home

This will be a quickie as I should have written last night, and now I am in a rush to get ready for my last shift of this set. Yesterday the flood gates opened and everyone who couldn't wait one more day for their pediatrician's office to open came in. We were full in all 20 rooms and had about 20 people in the waiting room. And, trauma stops for no one.

Everyone was "on their way home" from camping, picnicking, somewhere else, etc. and ended up in the E.D.

The cases I saw:
2 year old with sudden case of vomiting - got IV fluids, drank juice, sent home

15 month old with fever - got tylenol, IV fluids, drank juice, sent home

11 year old with rash - this was a medical mystery ala House style, don't know what she ate, drank, wore, or swam in but she was broken out all over and her face was so swollen she could barely see out of her eyes - she got benadryl, steroids and some pain relief, sent home

38 year old car crash victim - since the hospital has an adult service, we don't see the over age 21 set, except in the case of trauma where they need immediate evaluation, so I was a "consultant" on her case, which basically means I told the adult medicine physician what to order, what to look out for, etc. - she was admitted along with her 8 year old daughter who was also in the vehicle for observation (they were coming home from camping and swerved to avoid a car that cut in front of them going the opposite direction, rolled their vehicle over several times, luckily, they had their seat belts on)

11 year old car crash victim - riding with mom and sister, sitting in back seat, had neck and knee pain, all of the films were negative and she was sent home

15 month old with fever - motrin, drank juice, sent home

4 year old car crash victim - sister to the 11 year old, she wasn't a trauma, so I saw her later on, she will have some bruising on her face but nothing else hurt

2 year old fell out of 2nd story window - supposedly fell off couch near window and fell down to street below, he didn't seem to have any injuries on CT scan but his fall was significant (> 20 feet) so he was kept for observation

6 year old with vomiting - IV medication, drank juice, sent home

and finally 1 year old with fever - given motrin, drank juice, sent home

If you're wondering about the juice, we need to make sure the pedis aren't going to get dehydrated until they can follow up with their primary doctors, so we make sure they can keep fluids down. Everyone gets a P.O. (per oral) challenge prior to leaving the E.D.

Ok, running off to get dressed for what will be another busy shift, I am sure, probably with less traumas since most people are home following the holiday weekend. Will post tonight as tomorrow should be a fun day learning about helicopters!

Oh, the kiddo with the wound under the arm had to go back to the OR because he became so swollen from all of the blood products he needed, they couldn't close his skin after surgery so he was left open and was closed yesterday

The other pedi with the fall down the embankment was doing ok last I heard.

On the Warm Side of the Color Spectrum

As predicted, we were busier in the E.D. today. At one point we had about 12 patients in the waiting area, and all 20 rooms full. We managed to clean out the waiting area, but then as I was leaving, it started filling up again. And that didn't include the traumas. Traumas take priority, and they go straight to the code room regardless. So you might be busy seeing patients and then have to drop everything to see the trauma.

I think at one point I might have mentioned the triage system which assigns a priority to patients based on how sick they are. In general, the color codes are:
Red - see immediately
Orange - see within 10 minutes
Yellow - see within 15 - 30 minutes
Green - see within 30 - 60 minutes
Blue - see within an hour or two

If you know anything about colors and the color spectrum, you know that blues and greens are cool colors and oranges and reds are warm colors. As an intern, you generally see blues and greens. As you get more comfortable, you venture into the yellow and might actually get to see an orange.

Now, as an unofficial second year, my colors are generally yellows, some oranges, and occasional reds. I do get the occasional green or blue depending on how busy we are, but today especially my attendings physically started handing me orange charts to evaluate, and I was directed into the trauma code room, actually paged once to the code room, where the color is always red.

Also, it makes working more interesting. I don't see as many of the garden variety patients that come into the E.D. I see the sicker kids with more extensive and chronic illnesses. Amoungst my patients tonight I saw a sickle cell patient with chest pain (orange), a cystic fibrosis patient with an exacerbation (orange), vomiting in a 5 day old (yellow), and three traumas (all reds).

The traumas were:
- a 2 year old that fell 15 feet down an embankment and ended up on a concrete landing, to CT and admitted
- a 10 year old who fell off of his bike, onto the street, where a car ran over him, he got discharged with a skin burn on his leg from where the tire scraped his skin
- a year old baby that was sitting on her sister's lap when she fell over backward off of a porch swing, a CT scan showed a head bleed, and as I was leaving they were going to the CT scanner with neurosurgery, she will for sure be admitted to the Pediatric ICU as she was intubated (had a breathing tube in) and seemed to be having seizure-like activity, I'll find out how she did tomorrow

As for the patient with the axillary artery laceration, they ended up being transfused 6 units of blood. Given that the average adult has about 5 - 6 units of blood circulating, they had to replace the patient's entire blood volume and then some. He's still in critical condition in the Peds ICU.

That's it for tonight. Back to the warmth tomorrow.

Hurray for the Red, White and Blue

So, I had to work in the E.D. this Fourth of July. Missed the local fireworks' show again. It seems as if I haven't seen a 4th of July show since I graduated from medical school. Like I said in an earlier post, the medical year starts on July 1, and it seems like I've always been on-call or working on this day.

Not that I can really call today work. In fact, I only saw 3 patients in the eight hours I was at the hospital. Why only 8 hours? Well, I got sent home early because there were so many providers (an attending, a fellow, 4 residents, and a physician's assistant) and about as many patients. Why only 3 patients? See above.

I actually thought it was going to be a crazy shift when I first arrived and was promptly directed to get dressed and head into the trauma room. We had a nine year old who fell through a glass door. He managed to cut through his axillary artery, a major blood vessel which feeds the arm located just underneath your armpit. His parents initially took him to another hospital which really only lead to a delay in treatment since they had no idea how to manage such a case.

Upon arrival to our E.D. he had bled so much and received so much fluid that his blood was like Kool-Aid when we were drawing labs. The surgery attending controlled the bleeding with his fingers, and the patient was rushed upstairs to the O.R. We later heard that he had been transferred to the Pediatric ICU with a pneumothorax (collapsed lung) thought to have occurred during the initial trauma. I'll probably find out how he did when I go back tomorrow.

That case took up about the first hour and a half of my time. When I came out of the trauma room, I didn't pick up another patient for another half an hour. I finished all the labs and work-up on the patient, and then sent them home. That's when I was able to pick up my next patient, almost 2 hours later.

So, how do you spend your time when you are sitting around waiting for patients? Why, of course, by talking about past patients and personal experiences.

One of the threads of discussion centered around the trauma case. The child had beensweeping a patio area when he stumbled and fell through the glass. We were amazed at how doing something as simple as chores could turn out to be so dangerous and then recounted many tales of events where we should have been dead but nothing happened.

mine was silver

I always think back to high school and the time I stuffed 9 members of my track team into a 4 door Mazda GLC. I was driving, two girls sat in the front bucket seat, 3 girls sat in the back seat with 2 other girls sitting across their laps, and another 2 girls jumped into the trunk. We drove from our high school to our brother school for a track meet - on the freeway, about 5 miles away. That was a tragedy waiting to happen, that surprisingly didn't.

The nurses jumped in with some of their best personal and patient stories. We ate, we laughed, we watched the clock. Finally, I was given the tap on the shoulder. Go home. As a medical student, I was told to never argue when your resident told you to leave. Just say, "Yes, thank you," grab your things and walk out the door. Which is exactly what I did.

Another day of pedi fun tomorrow as we see what damage was done by the holiday. And the fact that most pediatric offices will have been closed over the long weekend, and some things that have waited this long just can't wait a minute longer...

Treat Em & Street Em

So, the fun with the pedis today consisted of walking in a room, wondering why the patient hadn't been previously seen by their pediatrician within the last 2 weeks, wondering why they were coming into the ED at 5 in the morning with a complaint that had lasted 2 weeks, diagnosing their condition, and then signing their discharge papers as I sent them home with their script, knee brace, stretching exercises, etc.

The second bit of fun consisted of trying to decipher which personality my Dr. Jekyll/Hyde attending was going to display today. At times he switched between personalities between patients, and I had to anticipate which one I would be presenting to next. Often, I found myself going to the other attending because the thought of another round of cold indifference vs. joviality was too much to bear.

My one patient that did get admitted was a 7 day old infant with a fever. I performed my second successful lumbar puncture. Albeit, I got it on the second stick, and it wasn't a "champagne tap." That is a tap with no blood at all. Rumor has it, if you have such a tap, the attending buys you a bottle of champagne. But, it's like the Holy Grail. Everyone quests for perfection, but whether the reward is there or not remains to be seen. At least the satisfaction of doing the best for your patient is still there.

That was about it for today. Nothing exciting during my shift. I work all weekend, and I know with the holiday there are bound to be some interesting cases. Stay safe during this holiday weekend. I'd like to have a relaxing one as well... sigh, I can dare to dream...

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Starting a New Year, Figuratively

When I first found out I was moving to Buffalo, the first question I asked was, "Do they have squirrels there?" At the time, I was living in a nice suburban neighborhood near a lake just north of St. Paul, Minnesota. I'd built up sort of a squirrel army. I had 4 bird feeders set up, and the squirrels challenged my creative energies keeping them off of them.

Finally, I gave up and had a special corn feeder and corn spinner for the squirrels. During the winter, I put out a 5 pound "wildlife feeder block" and I had deer and squirrels coming to the yard to eat. My cats at the time had plenty to look at, and on my days off I could almost imagine I was living somewhere in the country. Somewhere far from the things of man to quote a line from "Joe vs. the Volcano."

I was sad leaving the financial freedom I had enjoyed as a house physician under contract. I chose when I wanted to work, and my now husband enjoyed being a kept man for those 8 months. I knew I was making the right decision, though, by taking an emergency medicine residency spot. In three short years we would once again be able to return to the lifestyle to which we'd begun to grow accustomed... and then some.

So, I moved into a much smaller townhouse with my two cats, my fiance went to live in Atlanta where he would be able to find work, and the year began. I adjusted to a new working environment, a new way of doing things, a little loss of independence since I was now an intern again, and a whole new patient base.

I went from the drama of ECMC, to the sheer wave of humanity at BGH, to the pleasant ultrasound rotation, and from there to the CCU. The new calendar year started at the small town ED where things could be just as busy as the big city ED but with fewer resources. Also, that was the month I learned how much fun a Buffalo winter could be.

February brought anesthesiology and, after almost 10 years, finally marrying the love of my life. I went from delivering babies like crazy to actually enjoying my pediatric rotation. After a great honeymoon in Riviera Maya, I came back to the drudgery of the MICU followed by ending the scholastic year in sheer hell on the geriatric service.

Now I am back on the pediatric service. Officially, this is my last month of my intern year. Unofficially, I am already considered a second year resident. In addition to my ED shifts this month, I will be attending all the required lectures and training sessions to prepare me for this next year.

Today we had our first: learning to drive the Ford Expeditions that are our SMART (specialized medical assistance response team) vehicles.

Needless to say, it was a lot of fun, and my colleagues and I enjoyed the time spent away from our clinical duties. I had a night shift on Monday which consisted mostly of patching up kids that had run out in front of cars. Most were not serious, and one I had to admit to the pediatric ICU due to a laceration of her liver. Tomorrow I start a 5 day stretch of shifts including evening call on the 4th of July. Let's hope there aren't many burn patients.

Until then, I changed the name of my blog. It's time. I found some squirrels in my own back yard. Not quite the squirrel army I had in Minnesota, but we'll get there.... in another 2 years.

Now is Not the Time to Get Sick...

There's a certain rite of passage that occurs across the nation every year at this time. Over 16,000 fourth year medical students, fresh graduates from their respective institutions, having spent 2 years learning the basic sciences (Biochemistry, Anatomy, Physiology, Microbiology, Histology, Neuroscience, Development, and Pathology), followed by 2 years spent shadowing doctors in their affiliated hospitals and clinics, are finally set free and become, dun dun duuuuunnnnnnnn: interns. Officially, July 1 is the start of the medical calendar. Most programs, like the one here at the University of Buffalo begin their new interns the week before. So be forewarned.

Traditionally, July and August are the worst times to be admitted to the hospital. There are more errors. Studies take longer. Paperwork takes longer. Everything just kind of slows down. Also, nurses tend to be surlier as the new crop of newbies get thrown into the pond that is the hospital and disrupt everything.

Please don't touch or feed the buffalo!

Our Emergency Medicine interns get broken in slowly. They are spending the next week doing orientation things: learning the various computer systems, getting introduced to the various faculty, getting lab coats and passwords. They will then have the month of July to "ease into" the emergency department. For that month they'll be in a sort of a glorified medical student role.

Our medical students on rotations see their patients, present them to the attending, and then have all of their orders co-signed. They are only allowed to follow one patient at a time. Our new interns will be able to sign their own orders and will be expected to start seeing more patients at a time. But, like when I first started, building up the number of patients you can handle takes a while.

I will do my end of the year wrap up in a subsequent blog this week. So, for now, stay safe, and stay out of the hospital if you can avoid it... :D

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Like a Surgeon... Again

SUNY Buffalo - South Campus

So, for the last two days I have been in an ATLS (Advance Trauma Life Support) class. Basically, the class teaches the principles of caring for the trauma patient. We had a series of lectures, intermixed with small group learning sessions, a cadaver lab, and then an oral exam and a written exam. It's been a wonderful respite from the geriatric service. For the last two days I have been reviewing a lot of the lessons learned during my surgical residency. As we went through case scenarios, or during particular lectures, my mind would drift back to the patients I had seen or operations I had performed. Several times I had to bring myself back to the current lecture before I lost track of where we were.

One of the funnest parts was the cadaver lab. Suddenly, for just a moment amoungst the familiar smells and sounds, I was back in medical school, excited about pulling back the plastic over the cadaver and beginning to explore and appreciate the gift that someone had given - the ultimate gift of themselves. What was interesting, and just a little eerie, was that one of the participants, an EMT who was auditing the course, actually knew the patient. He said that during his time as an EMT, he had picked up the patient and transported them to the hospital multiple times. We performed various procedures on our body donor. I remember in medical school, on the first day of anatomy lab, my group standing around the shrouded body; staring down, uncomfortable, not liking the smell, trying not to think about the fact that soon we would be meeting our first and most important patient.

Not just that. We all knew that soon one of us was going to have to pick up a scalpel and begin the dissection that would continue throughout the next 4 months of our lives. I have to admit that I was the one that picked up the scalpel and made the first incision; offering a small apology in silence to the body donor. Later, as a third year medical student on my surgery rotation, I remember being allowed to hold the scalpel and make the small incision to remove a small fatty tumor. I remember thinking that the skin was so much more pliable, so much more... alive. Then, during my last rotation of my fourth year (an emergency medicine month if you can imagine) I was allowed to place a chest tube in a patient who had a pneumothorax (collapsed lung.) The surgeon walked me through the procedure. A cut into the skin overlying the 5th rib on the side. Then a deeper cut into the muscle. I then put a Kelly clamp into the muscle layers and started spreading them. Slowly. The surgeon would come over from time to time and check my progress by sticking a finger into the wound. "Keep going. A little faster, I want to go home soon and get some dinner some time tonight," he teased. When I got just above the pleural layer overlying the lung cavity, he told me to spread and push. He was standing at the back of the room joking with the E.D. attending when I broke through the pleura, and there was a sudden, surprising, rush of air. He heard it and said, "What did you just do!!?!?!?" Then he laughed at the startled, and just a little frightened look on my face and said, "Very good. Keep going." I grabbed the chest tube, placed it into the chest cavity, and then he showed me how to sew it in place and place a dressing over it.

I was thankful for that experience as during the first month of my intern year on the cardiothoracic surgery service I placed 13 chest tubes. I've placed many more during the last 5 years. Now, here I was again. A body donor, a scalpel, talking one of the new interns through the steps, showing them some of the tricks I had picked up along the way. At one point I grabbed the scalpel myself and placed a chest tube in less than 30 seconds. Of course, on a real patient there would have been a lot of other things happening, prepping the patient, wearing sterile gowns, giving anesthesia, etc. But, still, there was a certain satisfaction in how far I had come, and how the thought of making that incision no longer frightened me. I miss surgery sometimes, but I know I have made the right choice for this point in my life. And I am happy to have to have spent the last two days, albeit slightly melancholy, reliving a very important time in my life. Tomorrow back to the Geriatric service. Seven more shifts, and it is over. Get me back to the E.D. Back to the trauma and the drama. Back to my new life.

Kiss the Rain

As I sit here thinking about the last week, I have the window open anda thunderstorm has knocked out my satellite for the last few minutes. So, I am sitting here in semi-silence while the thunder peals and thelight show flashes outside. It's great thinking weather.

Once, as part of an exercise, we were posed the following question: What would you do if you had unlimited resources and could do anythingyou wanted? It was a part of a leadership and career planning seminar,and it was supposed to direct you to what you should consider for acareer.

My answer was that I would buy a house on the coast in the PacificNorthwest with a room overlooking the ocean where I could just sit andwrite all day. If no one would want to publish them, I would do itmyself, and then keep the collection for my own personal joy. And, that's how I chose Journalism as my major. I would get paid to write. Ofcourse, that was pre-blog, and pre-deciding I wanted to be a doctor.

Still, I think at some point in my life, I will probably consider joining the ranks of other physicians-turned-writers such as Michael Crichton or Robin Cook and write a number of books, or be like Lance Gentile and be a technical adviser and writer for a TV series. Who knows.

Anyway, I am down to my last 2 weeks of Geriatrics. I like my patients. I am learning about the management of disease which I can apply to future patients. I just don't like rounding and rounding forever.

So, that's it for now. Nine more shifts, and then it's over. I am actually looking forward to going back to Children's ED. At least there I feel like I can do something for my patients. Although, I have to admit, I don't know if the parents of patients are worse than I am finding the children of patients to be. But, I will leave that discussion for another day.