Monday, June 23, 2008

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

Thursday, June 19, 2008

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.

Sunday, June 15, 2008

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.

Sunday, June 8, 2008

Ice Floes on the River of Life

There's an old legend that the Inuit placed their elderly or infirm on ice floes and pushed them out to sea when times were especially lean. While this might have been a rare occurrence, some of the tribes carried out a form of assisted suicide wherein an elderly person who felt they were a burden on their tribe might asked to be killed. There was a belief that a person who was murdered had a more pleasant afterlife.

I think about this a lot when I go into work every day to face the same 3 or 4 patients I have been carrying for a while. Not that I am going to assist anyone into the next life or hasten their trip, just that sometimes the limbo created by indecision I think is much worse.

We, meaning my fellow ED residents, have made the comment, on occasion, about "our tax dollars at work" when faced with patients that are prime examples of what is wrong with the health care system and the welfare system in general: ie. the meth addict who uses his disability checks to support his habit, the "blinged" out moms with their giant gold hoop earrings, cell phones and fashion handbags who want a script for tylenol so that medicare can pay for it, and the mom who came in with her infant on her lap in an ambulance to the ED for a medication refill.

I have a couple of patients who should have been transferred to nursing homes several days ago, but their families can't, or won't, make a decision about their care. They are both in their mid 90's. They have both had strokes making swallowing difficult leading to the problem of aspiration pneumonia because their throat muscles aren't working properly, and they can't even swallow their own saliva properly. One has a feeding tube placed in through their nose and the other is on IV fluid because the family keeps insisting that they will pass their "swallow exam" even though they've failed the last 3 times.

As I was leaving yesterday, both families were leaning toward placing a feeding tube called a PEG (percutaneous edoscopic gastrostomy) into their stomach. This is a minor surgical procedure, and even if done by the least invasive means possible, is still a procedure requiring some kind of sedation and proper wound healing to limit breakdown. And, these patients are in their 90's, with strokes, not swallowing their own saliva properly, at high risk for aspiration pneumonia, etc.

And this is my world, every single day. Which is why I am not writing much during this rotation. I don't like rounding for 4 hours every day. I don't like non-decisive people and being asked day after day to sit around and do nothing for my patients. And, I don't want to bring this negative energy and sound like a whiner to this blog. So, I will write less for now and maybe jump in from time to time with some interesting events from some projects I am starting. It's only 3 more weeks... sigh... I am at my ADD 2 week, losing interest point and can't imagine 3 more weeks... major sigh.