Do They Have Squirrels in Buffalo?

My First National Conference!

2008-10-26T06:50:00.000-07:00

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...

2008-09-23T20:28:00.000-07:00

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...

Taking the Easy ROAD...

2008-09-22T20:41:00.000-07:00

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

2008-09-03T20:44:00.000-07:00

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

2008-08-31T08:30:00.000-07:00

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

2008-08-27T20:53:00.000-07:00

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

2008-08-24T19:03:00.000-07:00

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...

2008-08-16T21:35:00.000-07:00

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!

2008-08-15T21:02:00.000-07:00

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

2008-08-10T19:48:00.000-07:00

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!

The Spirit of the Olympics

2008-08-08T21:17:00.000-07:00

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?

Continuity of Care

2008-08-07T21:03:00.000-07:00

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...

2008-07-30T21:37:00.000-07:00

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

2008-07-25T14:12:00.000-07:00

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?

Sharing at a Time of Pain

2008-07-20T10:18:00.000-07:00

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

2008-07-19T02:01:00.000-07:00

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.

Summer Crushes

2008-07-15T21:01:00.000-07:00

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

2008-07-14T21:31:00.000-07:00

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

2008-07-13T20:18:00.000-07:00

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!

2008-07-08T20:44:00.000-07:00

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!

You Can't Chose Your Parents

2008-07-07T21:59:00.000-07:00

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

2008-07-07T09:12:00.000-07:00

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

2008-07-05T21:25:00.000-07:00

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

2008-07-04T20:59:00.000-07:00

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

2008-07-03T21:08:00.000-07:00

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...

Starting a New Year, Figuratively

2008-07-02T20:08:00.000-07:00

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...

2008-06-23T19:36:00.000-07:00

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

Like a Surgeon... Again

2008-06-19T19:34:00.000-07:00

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

2008-06-15T20:28:00.000-07:00

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.

Ice Floes on the River of Life

2008-06-08T20:18:00.000-07:00

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.

Dying a Little Inside Every Day

2008-05-31T13:52:00.000-07:00

Ok, so Geriatric medicine has me feeling suicidal. My mother told me that as long as I didn't have a plan, I was o.k. Thanks, mom.

I don't mind the work - going in and seeing patients every day, following up on their care, seeing their progress. Not too bad. It's the rounds. Rounds are where every patient is presented to the attending and a care plan is developed for each one.

On surgery, you start around 0630 with the senior resident and see all your patients by the time of the first OR case... usually around 0830 or 0900. You "pre-round" earlier and get all the information (vitals, labs, xray results, etc.) about your patients so that you can present them during rounds. At each patient's room, the resident or medical student following the patient presents the information to the senior resident. One person holds the patient's chart and writes orders as the care plan is developed. Depending on the amount of time and/or number of patients, some teaching is done about a particular topic or disease process. Later in the day, in between cases, you round with the attendings and give them an update on their patients.

In Geriatrics, rounds are scheduled to start at 0930. Our attending this week has been showing up around 1000. Then you sit in a room and talk about all the patients. In surgery, we used to call this the "card flip" in honor of a scene in the "House of God" where instead of physically going from room to room you quickly talk about all the patients. However, in Geri nothing happens quickly. We usually spend a good hour or two talking about the patients. Disease topics and social issues are brought up. Teaching is the primary focus.

THEN, you go see the patients on "walk rounds". You stand around while the attending performs their physical exam on your patient. I sometimes feel like an animal trainer at a dog show hoping that my patient will perform for my attending as well as they did for me earlier in the day. However, by now it's around 1300, and all you can think about is how that bagel and coffee you had at 0800 are long gone, and wondering when are you going to eat lunch. Of course, it's around this time the attending decides to start a diatribe on diabetes and wound care, and all the while my mind is drifting andgoing through the indications for an above the knee amputation vs a below the knee amputation. Several minutes later and thinking about the time I launched the bone saw across the OR, I look up to see that the team has already moved onto the next room; stomach grumbling and looking at the list to see how many more patients have to be seen, I follow them.

So, this happens every single day. After rounds, we grab patient charts, make sure we have orders for the next day, follow up on any consults that might have seen the patient during the morning/afternoon, and then get ready to sign out. Of course, that's if there isn't an afternoon lecture, or some other discussion group that you have to go to... uugghh..

Luckily, I had today off... which is good because I went out for dinner and drinks with colleagues from the MICU last night, and I woke up this morning with a bit of a headache and dry mouth. I also didn't sleep very well due to a new addition to the family.... yes, I went and did it.... I got a new cat. Her name is Lacey. She's about six months' old and was abandoned and picked up as a stray. She's really skinny, and needs a bath once the spaying wound heals, but she's lovely.

Right now there's a little bit of a war zone going on in the house, with everyone except for Lacey on edge. I kept her in my bedroom and the other cats are upset with not being able to sleep with me. There's a lot of hissing from Winston and skulking from Sophie. I've heard these things take time, so hopefully, soon, I'll be able to open doors and have the family all together....

Tomorrow, back for "weekend rounds" that are supposed to be short and efficient... we'll see.

My Big Fluffy White Cloud

2008-05-25T21:16:00.000-07:00

So, I don't know if I've ever talked about the "Cloud Theory" in this blog. Essentially residents come in two flavors: white clouds and black clouds. White clouds keep the badness away. Calls are lighter. Not too many admissions. Black clouds bring chaos. Everything goes wrong. Admissions are numerous.

I've always considered myself a white cloud. My calls are generally on the easier side. Other than the "Night of 13 Traumas" and the "Week of Deaths" my call nights have been mostly, well, boring. Last night, nay, this whole month, has been an example of that. I had one admission yesterday at around 10 in the morning... and that was it. After 10:30 p.m., the most important medical decision I had to make was ordering some nasal saline for a patient complaining of a dry nose from their oxygen. Twelve hours later I was on my way home. End of rotation.

So, what did I learn this month on the MICU service?
1. Take care of your body.
75% of our admission were complications due to patients not taking their meds or not taking care of themselves. The complications were further complicated by the fact that these patients smoked or drank in excess. When you need to have a breathing tube put in, because you're in acidosis (producing too much acid) because you decided to not take your insulin for several days, it's going to take a while to get you off the breathing tube because your 2 pack a day smoking habit has lead to COPD and emphysema, and your chronic pint a day habit is leading into withdrawals and DT's. So you stay in the MICU while we correct your acid imbalance, try to prevent you from getting a ventilator associated pneumonia, and keep you turning from side to side to prevent bed sores. Three weeks later, we might be able to get you well enough to make it to the ICLU (intermediate care level unit) with a tracheostomy, on hemodialysis, and several new holes in your skin.

2. Learn when to give up the fight.
I was lucky this month to have attendings who know when care has become futile. I have heard of attendings who "flog" their patients until the end. The ones I had this month acknowledged that there was a time to fight, and a time to pull back and let nature take over. Luckily, they also had the personal skills to be able to help families with the making these very hard decisions.

3. Even different disciplines can work together when you've got the right group.
I am an emergency medicine intern. We had a family medicine & neurosurgery intern as well. All of us mixed in with the three medicine interns. One of our senior residents is a medicine-pediatrics resident. And, we worked as a team. No one complained. Everyone did the work. We gave each other breaks, and helped each other out. No one took advantage of the situation. Toward the end, the three of us "non-medicine" interns began to focus on our up-coming rotations outside of the MICU, but we still got the work done.

Of course, in every group there has to be someone who doesn't quite fit in. That was, unfortunately, one of the medicine interns. Early in the year, you figure out who "gets it" and who's having some problems. By this point in the year, you hope that everyone has pretty much caught on to how things work. You worry about those that haven't. This person is in the "hasn't quite gotten it yet" group. Which is scary.

It's the end of the year. In a month, this intern is going to become a resident and be in charge of interns and running the unit. The senior residents tried to limit their patient care, and the rest of us tried to keep them from managing our patients as much as possible.

And, again, unfortunately, a lot of the lighter times in the unit came at their expense (these are funny to those in the medical profession, let me know if you need an explanation):
- asked if it was possible to put a drain into a brain abscess to help with the infection. Um, the answer to that would be no.
- when asked to check a heme-occult on a patient with a falling hemoglobin, they came out of the room and said no blood noted on exam. When asked what the card showed, they answered first, "what card?" and then answered that since the stool was brown, there couldn't be any blood in it.
- was asked to go to the floor to evaluate a patient for possible admission to the MICU. They came back an hour later, and when the resident asked about the patient's condition that required admission to the ICU, the intern stated that they had spent the last hour explaining to the family about Do Not Resuscitate and Do Not Intubate orders because it hadn't properly been explained to them. When asked about the patient, they stated they hadn't examined the patient.

These are just a few examples. Again, scary. I am just wondering when they are going to be scheduled in the emergency department as second year medicine residents do a rotation through the E.D. We already heard about an OB-gyn intern that was asked to leave in the middle of a shift because of incompetence. I am just wondering if I will be working the E.D. when this intern comes through. Like I said, scary.

OK, have to be going to bed. Tomorrow I start the geriatric medicine service. My last rotation of my own personal intern year. We'll see what the new morning brings, and if white clouds will continue to color my sky.

Where's the Story?

2008-05-20T03:35:00.000-07:00

It's been a week since I've last written, and, seriously, not a whole lot has happened. I honestly thought the MICU would have a bit more... um... drama? Live and Death battling over patients while we do our best to heal our patients. For the most part, it's been trying to find placement in a full hospital and boarding well patients while occasionally needing to make room for a sicker patient.

We've had one very awesome save. A woman who came in with fulminant sepsis. Coded just as she arrived on the MICU. Got CPR, intubation, multiple drugs, and was able to leave to the floor 5 days later completely intact. No brain, heart, kidney or other damage.

We've had some patients that we've been able to make comfort care and ease their transition into the next life. Patients that the best medicine we could provide was to allow nature to take its course.

We've seen alcoholics in withdrawal, psych patients testing the limits of the nursing staff, many many non-compliant diabetics in diabetic ketoacidosis, and many septic patients that eventually get better or die. I think we're about 50/50. The "Surviving Sepsis" campaign is barely reaching Buffalo. I was implementing it 3 years ago in Minneapolis on the surgical ICU. As the system improves, I am sure the survival rate will too.

As for now, I am counting down the last week of this service and looking forward to the future. A month of geriatrics, followed by a pediatric ED month, and then the official start of my second year. I will be working on a protocol to make post-cardiac arrest patients hypothermic (low temperature) in order to protect brain cells. I will be working on my EMS requirements. And, hopefully, I will take my first helicopter ride.

Now it's off to the unit to see what has come in overnight, and how my patients have done. We can only wait to see what the rest of the day will bring.

Making Sacrifices...

2008-05-13T20:38:00.000-07:00

I think if I was to stop and think about the power that I have sometimes, I wouldn't be able to handle it. I haven't been writing lately as the patients haven't been that interesting; the stories maybe not so dramatic. Life for me in the MICU is simple: patients come in, patients go out, new patients come in.

Based on what I've heard, it seems that we're not as busy as some of my colleagues have been. At most, I've carried about 3 patients. Most of them have been DKA (diabetic ketoacidosis), septic infection, or a mixture of problems. I've discharged patients straight from the unit to home, and we've had one patient with a series of misadventures who died within 8 hours of being transferred from another hospital. Tomorrow I'll see if I can find out how the Guillain Barre patient is doing.

On an earlier post, I wrote about talking to families about making the decision to withdraw care and "let nature take its course." It's a powerful position to be in. In essence, we make a clinical decision that a patient's outlook is grim or continued treatment is futile - we feel that it would be in the best interest of the patient to stop medical treatment. Primum non nocere - first do no harm.

In medical school, the first time I thought about my actions leading directly to a death was in the "Dog Lab" during physiology. My medical school still had a live dog lab where we studied the cardiovascular system en vivo by giving various cardiac medications to sedated and intubated dogs. I was the one giving the medications. After a time, you stopped thinking about the dog and focused on the beating heart lying in front of you; watching the various effects the drugs had.

One of the last things we did was give a medication that would cause ventricular fibrillation "a bag of worms." We all reached into the chest and felt the irregular heart beat. We then shocked the heart and watched it slowly return to a normal rhythm. The final medication I gave was potassium chloride. This would stop the heart... for good.

I didn't think about it as I reached for the syringe and started giving the medication. We all just peered into the chestto watch the heart give several strong contractions and then suddenly stop. We were all thinking about the physiology: cardiac monocytes being flooded with potassium leading to a contraction with no release. Then I took a step back to cap my needle and realized I had just killed a dog. (We say "sacrificed" in research.)

On days like today I feel the same as I did on that day. I talk to the family who look to me to do "what I need to do for my patient." I talk to them and guide them to the decision to withdraw care. And then I write the orders: morphine bolus, morphine drip "titrate to agonal breathing," d/c (discontinue) all medications (including the ones currently keeping the heart going), d/c lab draws, d/c ventilator support. These are the "comfort measures" orders, but as I write them, I feel like I am back in medical school, pushing the syringe.

Tomorrow is Grand Rounds Wednesday, and I will be helping the medical students learn how to intubate in the evening. We'll see what the morning brings.

The Farmer and the Cowman

2008-05-08T20:48:00.000-07:00

I titled my entry today based on the great song in the musical "Oklahoma!" It has to do with the conflict that existed on the open range between farmers building fences to keep their cattle in and the cowmen who pushed their cattle across the open spaces. Both are raising cattle, just in their own way. So too surgeons and medicine doctors, or internists, treat patients, but in their own way.

Which brings me to one of my favorite episodes of "Scrubs" where the main character and his best friend (a medicine intern and a surgical intern) play out the dichotomy between medicine and surgery ala "West Side Story."

Anyway, the reason I bring this up is because part of what is driving me crazy in the MICU is the way the medical interns approach patients. I know in part my prior training is affecting my perception, but seriously, I am suicidal most day on rounds. I just want to know: what is wrong, what are we going to be doing about it, and how soon will they be able to transfer out of the ICU? I don't think about their clinic visits, what their medications were six months ago and 3 hospitalizations earlier, or if they eat beets on Thursdays.

Facts, that's all I want to know. Now, medical people will say the most important part of the exam is the history. In fact, I had a professor in medical school that said that 80% of the time you could make the diagnosis based on history alone. I guess I have to work on my patience... and, dealing with some of the medicine residents, I am going to need a lot of it.

My patients:

an alcoholic, diabetic admitted for leg ulcers who we admitted to the MICU for management of their alcohol withdrawal. They were intubated because we had to sedate them before they went into DT's.

a patient with knee pain who has been taking a LOT of Alleve over the last 2 weeks. So much that they gave themselves an ulcer. In fact, several since I saw the endoscopy while the GI doc did it. Ortho will be coming to see the offending knee tomorrow.

a patient who smoked for a long time, now has emphysema and came in with shortness of breath. They were having a CT scan to look for a pneumonia or possible mass when I was leaving. I wonder if they'll be off of the bipap mask tomorrow.

That's about it. I really don't have a lot going on. It seems like I pick up patients and send them out. I actually picked up a patient that was admitted overnight and discharged them to home this morning. Maybe things will pick up next weekend when I am on-call. Until then, I will be enjoying the attending we have now who also was a surgical resident before changing to anesthesia.... at least I have someone, along with the neurosurgery intern that I can roll my eyes with during rounds... the long, slow painful part of my day.

The Honeymoon Book

2008-05-06T17:26:00.000-07:00

The Honeymoon Book : Seriously, nothing much happening in the MICU. It's actually been... shhhh.. very quiet! I have had a patient or two, and I actually went two days with no patients of my own. Just at sign-out tonight (around 1600) things started getting a little crazy, and the intern on-call tonight is a bit of a black cloud... we'll see what he brings in over night and what I'll pick up in the afternoon after my Grand Rounds Wednesday... until then, enjoy the entry I placed in my photo blog...!

In Case of Emergency...

2008-05-03T19:06:00.000-07:00

I had fun today. While most people wouldn't consider it fun, I thought it was great. As part of my EMS (emergency medical services) focus, I got to participate in a disaster drill.

The scenario was a mass casualty incident (think Katrina) where the local hospitals are either destroyed or overwhelmed, and patients need to be shipped out. We, Buffalo/Erie County, were on the receiving end of a group of patients that had been evacuated.

A C-130 from the NY National Guard flew in the patients. It was amazing being on the tarmac on the opposite side of where I usually am in the terminal.

the c-130 landing, people in the terminal had posted signs that there was a drill going on so they wouldn't panic at all the uniforms and flashing lights

The patients had been previously triaged (arranged in order of severity). Our people then performed a second triage as patients were brought off the plane:

"patients" being unloaded off the airplane

We then brought them to our staging area where we evaluated them and re-triaged them for transport to local hospitals:

Most of the patients didn't change from their original diagnoses, but some patient became worse or got better, and we needed to re-evaluate them. We then got them all on ambulances and "discharged them" from our triage center.

After this, we had a chance to check out the plane and some of the other equipment. The airport firefighters were very nice and let me climb up on their fire truck:

And, then they let us explore the plane a bit:

the plane is able to carry about 244 patients stacked 5 high on gurneys

a view from the cockpit

All in all a very interesting day. I have no patients of my own in the ICU, and I covered someone else's patients on Friday. Tomorrow I am on "short call" meaning all day until 2100 but not overnight, so we'll see if I pick up any admissions then...

For now, a little souvenir, and the truck I will be driving in August when I do my EMS rotation. If you want to see all the photos of the drill, they are on my Facebook page on the following link: http://www.facebook.com/album.php?aid=36038&l=9b58b&id=715126579

Enjoy!

Small Victories

2008-05-01T18:52:00.000-07:00

My Guillain Barre patient took a breath today. Just a small one. Well, maybe half of one, but it's a big thing! Even she was surprised. So excited she tried another breath and was able to do it. It all started this morning when I noted that she was able to flex her fingers, ever so slightly.

We decided to do a "nif" (negative inspiratory flow) test. It tests how much pressure a patient can create when inhaling. You and I, normal lungs, we can generate a high pressure, greater than 40 or 50. My patient inhaled to an 8 or 9. But this is HUGE considering that she has been on a ventilator for over a week, not able to move anything below her neck during this time.

She finished her last session of plasmapheresis and was being transferred back to Children's Hospital as I was leaving this afternoon. Of note, her primary caretakers since her admission have been my fellow Emergency Medicine residents. One of my colleagues evaluated her in the Emergency Department. He then sent her to the Pediatric Intensive Care Unit (PICU) where a 2nd year EM resident intubated her and took care of her. When she was transferred to BGH, another of my colleagues admitted her to the ICU and then transferred her care to me when I started. We're hoping the 2nd year EM resident on service in the PICU tomorrow will be able to take care of her... kinda like keeping it in the family.

Other than that, the most I can comment on is other patients in the unit. My fluffy white cloud is following me around, and as I left this afternoon my second patient was being transferred out. I picked up no patients during the day, and tomorrow I will round on one of the other intern's patients as she will be taking the day off. We'll see if I get any patients after rounds tomorrow from the overnight service.

So, these are some of the other patients in the unit:

- a schizophrenic patient intubated with pneumonia. They are literally "crazy" and won't be easy to extubate. We'll have to see how they do.

- a patient with severe aortic stenosis (heart valve that is blocked) who is not eligible for surgery and who needs to remain on the ventilator to keep their lungs from filling with fluid. The attending is trying to talk to the family about placing a tracheostomy versus extubating the patient and "letting nature take its course."

- a patient that pulled their own endotrachial tube out and actually seems to be doing ok despite the fact that they were near death about 3 days ago. Still touch and go, but holding their own right now.

- a patient with lung cancer who has multiple complications and abscesses. They are end-stage, so for the most part we're doing palliative care. They were too sick to be in the cancer institute so we are trying to get them stable enough to be transferred back.

- a patient who developed severe sepsis, almost died and needed to be intubated within a few minutes of arriving in the ICU, who is unable to clot their blood and who had the misfortune of having a venous line placed into a non-compressible artery. They were headed for a procedure to try to safely remove the line when I was leaving.

- a patient who ate something bad (not sure if at a restaurant or some old hamburger meat) and was infected with e.coli 0157:h7 which causes a severe bloody diarrhea. Unfortunately, this patient developed sepsis and is now in multi-organ system failure. I will have to see if they are still alive when I go back in the morning.

finally, the GI bleeder with a "spurting" artery at the base of a massive stomach ulcer. I placed an NG (nasogastric - nose to stomach) into him when he came back from the endoscopy suite, and he was being wheeled to interventional radiology/surgery when I was leaving.

Funny, I keep saying, "as I was leaving" but that's how my day went. Everything happened in the afternoon, as I was leaving. That's what's been interesting about this rotation, not knowing what I am going to find when I step in the door in the morning...

Speaking a Different Language

2008-04-29T19:16:00.000-07:00

Far Side Cartoon - Gary Larson

I really don't know what to write about. It seems pretty basic at the moment: I show up for pre-rounds about 0630, get all of my patients' information, start writing my notes, formal rounds are at 0800, they end around 1020, we have Medicine Morning Report at 1030, that lasts about an hour, we then come back to the unit to finish up notes and assignments for the day, you sign out your patients around 1600 unless you're on "short call" such as I was tonight in which case you take admissions until 2030, and then come back the next morning and start all over again.

My patients are interesting:

An 18 year old with Guillain Barre Syndrome that has completely taken over her nervous system and left her completely paralyzed. She's on a ventilator and getting treatments to try to "clean" her blood of the antibodies that are affecting her nerves (plasmapheresis.) Best case scenario is that she will start to recover in about a week (she's already been here a week) and come off the vent. Worst case is that she will need to have a tracheostomy placed and will take over a month to recover from the initial insult. We'll see. Right now she's battling a pneumonia. However, she's young and healthy and should do all right.

I have a 39 year old with bad insulin dependent diabetes who came in with Diabetic Ketoacidosis. Oh yeah, she's been in and out of the hospital for over 10 years with the same thing. So much so that most of the staff know her and her history; which includes experimenting with multiple drugs, not taking her medication, and generally not caring for her own health.

My last patient has lupus. She also doesn't like to take care of herself. Her diet consists of pizza and potato chips, sodas and snacks. She's got a heart condition where too much fluid makes her short of breath (not helped by her years of smoking) and too little fluid causes heart issues since she needs a higher volume to maintain her blood pressure. However, the fact that she's also "non-compliant" means she's a frequent flier as well. Also, I hate to say, but she's something of a slug: doesn't like toget out of bed and wants everything done for her.

We just started yesterday and not much happened so I didn't write. I had short call today, but I was protected by my "white cloud" and only got the 39 year old as an admission this morning and nothing else. I have Grand Round Wednesday tomorrow after I pre-round on my patients. Then I will "clean up" for a couple of hours afterward.

We'll have to see how things develop over the next couple of days. For now... the fun is just beginning.

Gift From the Sea

2008-04-27T18:13:00.000-07:00

The sea does not reward those who are too anxious, too greedy, or tooimpatient. To dig for treasures shows not only impatience and greed,but lack of faith. Patience, patience, patience, is what the seateaches. Patience and faith. One should lie empty, open, choiceless asa beach -- waiting for a gift from the sea.
- Anne Morrow Lindbergh

I am back from vacation (aka my honeymoon) and about to start my new rotation in the MICU (Medical Intensive Care Unit) tomorrow. I know that things will get a bit technical and, maybe, controversial as I go through the next month... but, before then, let's reflect on a great week:

I was on the Riviera Maya at a great resort (the Grand Mayan) which is located between Puerto Morelos and Playa del Carmen. From there we drove up to Cancun, down to Xel-Ha and Tulum, and then took the ferry to Cozumel for a day of awesome snorkeling (pics still being developed) and amazement at the sheer beauty of nature. Enjoy the mini slideshow. If you'd like to see a larger collection of the over 125 pics I took, you can go to my facebook.com page: facebook.com/album

Enjoy!!

Finding It Hard to Breathe

2008-04-18T02:21:00.000-07:00

Well, it's over... I just got home from my final shift of this rotation at WCHOB. It was a night of asthmatics for the most part. Neb treatment, steroids, another neb, pulse ox's still low, another neb, kid's heartrates and jitteriness levels rising. Etc.

Plus, to be honest, I had a bit of "clock-watching" going on, and I didn't really want to be there. All I kept thinking about was, "8 more hours and then I am on vacation." "Six more hours..." "Four more hours..." "Will this night ever end...?"

And, it did...! Woohoo...!!!!

I finished the last of my packing. Now I need to run downstairs and make sure everything is in order for the cats. One of my work colleagues will be cat-sitting. Or as she calls it, "Dog and Cat" sitting since she feels Winston is almost like a little dog instead of a cat considering the way he likes to jump up on people when they come over to the house.

I am posting my seal graphics as a slide show for your viewing pleasure.

If you've been following the seal photos and counts (last count: 124.899) over the last couple of weeks, the HSUS has stopped reporting from the ice. The EU will most likely be making an announcement to ban seal products some time in the next couple of months. Pressure from all sides and low prices have decreased the number of seals killed from the allowed 275,000. Let's hope that number will not be reached, and that next year the number will be zero.

When I get back I will have the photos of my trip to share... hope you come back on the 28th when I start my new rotation in the MICU. I've heard the patients are really sick, and there's a lot of work to be done, and a lot of learning to be had! Plus a lot of interesting stories waiting to be told...!

The Shhh (slow) Long Day

2008-04-15T19:33:00.000-07:00

I came into work this morning at 0800 to find one patient on the board. One of my EM colleagues was working the 0700 - 1900 shift, and he was the only resident there. He told me the board had been completely empty when he took over. It stayed at one for about an hour an a half. Well, the pediatric side of the board did.

At WCHOB it's Women AND Children's, so we get adult females too. However, during the time that we rotate through the E.D. here we are not expected to see anyone over the age of 21. So, there's always an adult medicine attending who comes down and sees those patients. And, for the first couple of hours of my shift, they kept her pretty busy. In fact, I didn't pick up my first patient until almost 1000.

I saw a total of five, yes, five patients during my 10 hour shift today. Partially because a lot of patients didn't come in, and also because we added the PA during the morning, a fellow at 1100, another resident at 1300, and another resident at 1600. So, we had tons of people fighting over a handful of patients. I had three that kept me occupied all of my shift, so I didn't really mind that I wasn't seeing the other runny noses and fevers that were coming in.

I had a 5 year old with pyelonephritis (kidney infection) who came in with 2 days of fever, vomiting and back pain. The PA (physician's assistant) in the office thought she had appendicitis and had wanted us to do a CT scan. We "dipped" her urine after a complete history and diagnosed the pyelo. I spent the day breaking her fever, fluid hydrating her, keeping her comfortable with pain medications, gave her a dose of IV antibiotics, and then made sure she could drink juice and not throw up before she went home. She went from a whining, crying inconsolable little girl, to a perky, demanding spoiled little girl, albeit a bit sleepy from the tylenol with codeine, but still.

My next patient had dacryostenosis. I carried the little 11 day old up to my attending and told him this was how I was going to present patients from now on. Kind of like Show & Tell. Everyone oohed and ahhed over the baby, and I just wanted to know what was wrong with him. The attending took one look and gave me the diagnosis. Now I know. It's actually very common and very treatable, and I had the mother in and out of the ED in less than 20 minutes.

(**Oh, and no fair reading the prior comments... add your own before looking at everyone else's.... :D )

Next was the 4 year old that was told by one of his friends, maybe dared is a better word, to jump off the top bunk. He did and hurt his ankle. His mother said that he couldn't initially walk on it, but he seemed to be doing better today. We took films and initially thought he had a break but decided to wait for the "official radiology read." This ended up taking almost an hour. We tried paging the radiologist, which took another 45 minutes. Finally, I went up to radiology only to find that the attending was "getting a quick bite." Twenty minutes later, I finally was able to sit down with him and review the film. No break. Ace wrap and a week off of gym for this little guy. And, a warning not to jump off of any more bunk beds.

I don't mind being a patient advocate. Especially when there's a young child involved who sincerely just needs a simple procedure (like a tonsillectomy) to solve all of his problems. I spent four hours on the phone trying to arrange an appointment with ENT (Ear, Nose and Throat, or Otolaryngology) or try to find an ENT willing to operate on a patient with no insurance. This little guy's parent fell into the, we don't make enough money or have the kind of jobs where we can have private insurance, but make too much money to qualify for state or government aid. Finally, the Social Worker and Finance Planner were able to work something out with Catholic Charities, who would pay for the entire surgery except for the anesthesiology bill. The mother could prorate and get a payment plan for that part. However, it was near to impossible to find an ENT willing to do the surgery mostly because there are tons of roadblocks to even get in touch with one. But, luckily, the insurance thing is going to be worked out as of May 1, and I got him an appointment for May 15th. When I called the mother and told her, she said, "Is that the best you can do...?"

Deep breaths, in with the blue, out with the green. Say to yourself a hundred times, "I will not become a sullied, evil, people-hater who is cynical and burned out before I graduate from this program." And, remind yourself, again, why you're not a surgical resident... why is that again...? At times like this I wonder....

Finally, I had the longest patient in the E.D. A little 1 month old with a hydrocele. I thought it was one. My attending thought it was one. The patient's primary thought it was a hernia and wanted a surgery consult. When surgery showed up 3 hours after I called the consult because she had 8 other consults, and after I had already ordered an ultrasound which confirmed it was a hydrocele, I already knew that the patient wouldn't be going to surgery and would be sent back to their primary's with a diagnosis of hydrocele, I remembered why I wasn't a surgery resident any more... Because once I discharged this patient at 1800 I got to go home. Clocked out (well, not really). Hasta la vista, baby!

Grand Rounds' Wednesday tomorrow and then the weird 1600 - 0200 shift.

95,900 seals killed to date. Free the Farley Mowat!

Occupational Hazards - Or Testing My Immune System

2008-04-14T20:55:00.000-07:00

Daffodils are Yellow for Hope!

Ok, So I worked Saturday and Sunday, but I didn't post anything on those days because on Saturday I came home to later find I had the stomach flu. I thought I was tired enough to get a good night's sleep, but of course, that didn't last long as everything I'd eaten over 24 hours was violently expelled from my body - several times over, so I got very little sleep. Sunday, I was recovering from working with little sleep and frequent bathroom "breaks," but the patients never stopped coming, and I actually ended up working an hour past my shift just trying to dispo (admit or discharge) my patients. So I came home to crawl into bed... for as long as that would last...

Luckily I had today to recover. I think everyone should go on a 48 hour fast. It will be so much easier to keep my diet this week as the mere sign of food makes me nauseous, and even the small amount I ate at dinner tonight feels like Thanksgiving dinner. So, it's small sips of clear soda and maybe some soup for me.

I direct your attention to the title, because no matter how often I and my fellow residents wash our hands, hold our breaths, or try not to touch anything in any of the rooms, we all get sick on the pediatric rotation. Kids are amazingly savvy about sticking their fingers in various parts of their bodies and then touching every conceivable surface of a room. Then, to further mark their territory, they seem to aerosolize all of their germs as well. Sigh. We just keep saying at least our immune systems will get tougher...

Anyway, let's see what we've missed over the last 2 days:

- tonsillitis
- mental status changes in an HIV patient who'd acquired it from his mother, he's also now developed lymphoma and gets chemotherapy, the most he would let us do was a CT scan (no lesions), he gets chemo again on Thursday, and they plan to admit him and get all their tests then, he's 18 so there's no holding him against his will, even though he's probably very sick, we had to let him go
- reactive airway disease, aka 1st episode of wheezing but not asthma
- hematuria (blood in urine) in a 15 y.o. who had perfectly clean urine when he got tothe E.D., strange
- "toe strain" which I didn't even get an X-ray for, it would make no difference if it was broken or not, I still would "buddy tape" the toe with its closest mate and tell them to take the tape off in a week
- enlarged lymph node in the neck
- asthma exacerbation
- 5th MCP (metacarpalphalangeal) Salter-Harris II fracture; in regular terms, he broke the hand bone of his pinky finger across the growth plate when he fell down while rollerblading, I advised wrist guards next time he goes out
- vomiting, when we don't know why, and the baby is able to drink and keep down fluids before we let them go, we just call it what it is, adenovirus season is coming up, and this may signal the start of it
- costochondritis, kids usually don't get heart attacks, so chest pain in a pre-teen is usually just an irritation of the chest wall ribs and cartilage, his story was good for it especially when I pushed on a certain part of his chest and he said, "Ouch! it was just like that!"
- gluteal abscess which I am bummed I didn't get to drain, we called for a surgery consult (which used to be me and this is the nice juicy type of abscess I enjoyed), however, it was the end of my shift on Saturday, and I was really tired, so maybe I wasn't so upset after all....

Sunday started off as kind of an "Urgent Care" kind of morning with quickie cases and resolutions, which was a good thing because my stomach bug was getting into full swing:
- strep throat, we (the residents) do our own rapid streps in the E.D., and I had done many, all negative, this was my first positive and I was actually excited to see the double bar on the test strip, a diagnosis is always pleasing
- anal fissure, seriously, kids (and adults) need to have more fiber in their diets, less constipation and prevention of diverticulosis when you're older
- laceration on the eyebrow of a 17 month old, I patched it with steri strips and glue, she actually did very well, no more climbing chairs for her
- abdominal pain: I've told my colleagues I want there to be a separate institution that takes all 9 - 19 year old girls who come in complaining about abdominal pain because it could be anything, and we have several "repeat offenders" who come in constantly with undiagnosable pain, it can be everything from appendicitis to pregnancy (I've heard of pregnant 10 year olds) to endometriosis to constipation, etc. And, I can't say to my patients "suck it up" like I'd like to, that would be poor bedside manner, and I want all good evaluations on my rotations...
- asthma, admitted for hypoxia, he just couldn't keep his oxygen saturations up
- pharyngitis
- vomiting, when you're sitting there all "blinged out" with a $250 dollar baby carrier, cell phone, double "ginourmous" pairs of gold earrings and bracelets to match, with the designer purse and you tell me you stopped giving your baby the "good" formula because it was too expensive, I am not going to be very sympathetic, spend less on clothes and more money on the baby, and don't explain to me how you're waiting for WIC to kick in because then I'll just be thinking about how my tax dollars are paying for you to text page your friends with updates... yeah
- reactive airway disease with hypoxia, my last patient of the night, poor little guy just wasn't getting better despite multiple treatments, we had to admit him, I just hoped he wouldn't need to be intubated because he was having such a hard time breathing, and, again, I wondered about the possibility of a need for a passing score on a nationally mandatory exam prior to allowing someone to have a child... don't even ask, I was already grumpy and not feeling well

I had today off and I did very little. I am on vacation next week and I had a pile of laundry and cleaning chores planned. Those will have to wait until later... it's off to bed with a little more club soda to keep the intestinal bugs at bay. Day shift tomorrow. We'll see what the morning brings.

On another note, I saw a great quote that's had me thinking, maybe you can all comment on what it means to you:

Senegalese Proverb: Every morning when the gazelle wakes up and sees the rising sun he has to think to himself, I must run faster than the fastest lion or die. Every morning when the lion wakes up and sees the rising sun he has to think to himself, I must run faster than the fastest gazelle or die. So, whether predator or prey, when the sun rises we must all run as fast as we can.

And, finally:

44,350 seals killed so far. The EU commissioner is very close to making a decision about banning the import of seal products. Let's hope it passes!

Some Really Sick Kids...

2008-04-11T22:01:00.000-07:00

So, my shifts are 10 hours' long. Usually I come in at the beginning of the shift and pick up a chart and get to work. Within the first hour I have 3 or 4 patients I am working on, and over the next several hours, I discharge one, admit one, pick up another one, etc. I had 3 patients that I picked up within that first hour that I worked on over the next 5 hours.

The first was a little seven month old that needed to be evaluated for seizures. He had been having tremors or shaking spells for his entire life. He was born a few days late. His mother "failed to progress" after being induced and had to go for a C-section. When they finally performed the C-section, it was noted that there was a knot in his cord. How long the not had been there is not known, but there was some underlying concern for poor oxygenation during the end of the pregnancy.

His orders: CT scan of the head, basic labs, neurology consult. Seven hours later, I discharged him home with a normal CT scan, normal labs, and he will follow-up with neurology in the morning after he gets the results of an EEG (brain wave analysis) which was performed prior to his being discharged from the ED. Dx: seizures. Even though it's not official, we still have to call them that based on the description.

My next little 4 year old was having problems breathing. I got labs, put him on oxygen and we got a chest x-ray. His chest x-ray showed that his lungs were hyper-inflated (over-inflated) meaning that his airways weren't open enough to allow air out. He got a breathing treatment, but he still could not maintain an oxygen saturation above 92%. You need a 95 or 96% to be allowed to go home. And, he just looked sick. He got admitted.

Next came the 5 year old, also with low oxygen saturations. She had just not been feeling well for 3 - 4 days and went to see her doctor on Thursday after having a fever of 103 on Wednesday night. She had an oxygen saturation of 95%, and a chest x-ray was obtained. It showed a right middle lobe pneumonia. She was given antibiotics and sent home. As soon as she took the first antibiotic, she started throwing up and continued to do so all night and into this morning. They called their pediatrician who said to go to the E.D.

My expectation, and my attendings, was to get a repeat chest x-ray, give her some fluids and a dose of antibiotics. As soon as we saw the chest x-ray, we knew things were much worse. She had a fulminant pneumonia which covered about 2/3 of her lung, but worse, she had an effusion (fluid collection) as well. So, she was pretty much functioning on only 1 lung. We then had to go back and draw labs, blood cultures, and I got her admitted. We ended up doing a CT scan which showed a LOT of fluid around her lungs; so much that part of the lung was being compressed and damaged. I consulted the surgery service, and they will most likely need to go in and drain an empyema (infected fluid collection around the lung.) Very cool to do, but will not be much fun for this little one.

I also saw:
*wrist and elbow fracture - splinted and sent home
*sickle cell patient with pain in a shoulder after an immunization - antibiotics for possible infection, pain meds and sent home
*teen with abdominal pain that had been going on for 6 weeks and had undergone multiple CT scan, ultrasounds, and even exploratory laparoscopy with no diagnosis. When I left they were considering appendicitis, and she was going to be admitted after she underwent ANOTHER CT scan.

And, I think that's about it. Not a lot of patients by any means, but sometimes it's the quality and not the quantity that makes for good learning experiences. And, I have to admit, I am learning A LOT on this rotation. Off to sleep and back again tomorrow. We'll see what a rainy Saturday afternoon has in store.

You Give Me Fever...

2008-04-10T22:55:00.000-07:00

Four out of the nine patients I saw this shift came in with a complaint of fever. We usually say that anything over about 101.5 is significant and should be seen. As I commented in a prior entry, it seemed as though all fevers coming in were 103. Tonight, at least I got some variety. Anywhere from 100.4 to 105.2 (yes, that last one is correct, it was recorded in the hospital ED).

So, our main job when a child presents with fever is to find out where the fever is coming from. Usually we have a visible source (runny nose, cough, vomiting & diarrhea, infection in the ears, etc.) But, sometimes a child just has a fever, and it becomes our job to rule out all of the bad things that it could possibly be: bacteremia (infection in the blood), meningitis, etc. All of these involve large scary needles. And, in my case, learning to do procedures.

I did my first successful lumbar puncture (LP or spinal tap) on my 15 month old with a fever. It was nearly a "Champagne Tap" but a few red blood cells sneaked in there, darn it! I got the spinal fluid on my second pass, and I honestly think the blood came from my first pass which was unsuccessful. However, I got the tap, and that's what counts most. Also the fact the child did not have any signs of infection in their spinal fluid. We can't forget that.

Also, today I got my first official thank you from one of my patients:
Dear Nurses and Doctors, I liked all the nice things you did for me. Ainsley
(In case you can't tell, that's a picture of me at the bottom.)

Today I saw:

constipation - seriously, these kids need to eat more veggies

ulcerative colitis in a 17 year old - I really feel bad for this kid. It's a horrible disease and the consequences of it are going to affect his entire life.

abdominal pain - seriously, if it's anywhere from 7 to 10 out of ten pain, I want to see you writhing on the bed and crying, not sitting back, asking to eat a sandwich and telling me "it hurts so bad."

fracture of a metacarpal bone in the hand - broke it on Easter Sunday, didn't think to get it seen until it was probably re-broken today. I splinted it and he'll see ortho in about a week.

jaundice - my second case, a 3 day old, very yellow, immediately placed under lights

and my 4 fevers.... the last was still being seen when I left, so I will find out tomorrow what happened. The other three were discharged and will follow up with their pediatricians.

And, that's it for tonight's patients. Or, last night's patients since it's almost 2 in the morning. I have my next shift tonight, and we'll see what the evening brings.

Overheard in passing:
- dog bite to the face, plastics came in to see
- broken tibia/fibula - ortho came in to see, and set in the ED
- domestic dispute and father got so angry he lifted the couch on which a 4 day old was lying, and the infant fell to the floor. He was being seen and will probably end up with a CT scan.

Here's my seal pic for today. 2900 seals out of the allotted 275,000 have been killed so far. The seal hunt was suspended un-officially for the last week, and it is set to resume tomorrow. Thick ice and fog may be keeping the sealers away for another day. The price per skin has fallen, and there's reports that even more sealers may chose not to participate as the cost of fuel has risen. However, the hunt has now changed to the area of the Gulf of St. Lawrence and "the Front" where the majority of the killing is usually done, so numbers of seals killed are expected to rise exponentially in the next several days. With continued pressure on the EU to ban seal skins & products, hopefully an end is in sight.

Making a Fashion Statement

2008-04-09T19:00:00.000-07:00

Since it's Grand Rounds Wednesday and not a clinical day for me, I thought I would take a few minutes to highlight the photographer for the majority of the seal pictures I have been using to make the graphics on my blog the last several days.

Nigel Barker is better known as a judge on "America's Next Top Model" reality show, but he has been a fashion photographer for many years after having been a model himself. This year, the Humane Society of America named him as a spokesman for the Protect Seals 2008 Campaign. The pictures I have used come from his website Nigel Barker and the ones that he shot which are used on the HSUS.org website.

He traveled to Newfoundland to visit the harp seal nursery and took amazing photos, then returned a couple of weeks later to catch the "molting" fluffy white pups. Unfortunately, his last entry chronicles the return trip several days later when he captured images of the hunt.

As an animal lover, and junior photographer, I hope there will come a day when trips by boat to Newfoundland and the Gulf of St. Lawrence carry eco-tourists instead of hunters, because I certainly will be one of those that signs up to see what must be an awe-inspiring sight.

Tomorrow, it's back the ED for my next block of shifts. The schedule will be more physiologically tolerable, a pseudo "swing shift" from the early afternoon to late evening. We'll see what the day/night brings.

It's Hard Being a Kid

2008-04-08T19:31:00.000-07:00

Stickers are like gold in the pediatric E.D. I don't remember ever being that excited about them when I was growing up. Around 5th or 6th grade, I got into the girly "Hello Kitty" thing with the cute pencils and erasers (mind you this was the first "Hello Kitty" era in the late 1970's.) But, I really don't remember having a thing for stickers. Kids today, though, love them and actively seek out their favorites.

Unfortunately, we can't heal everyone with stickers, but sometimes it's the best gesture you can make after what these kids go through.

#1 - Foreign body in nose: "I wanted an adventure." 4 year old that decided to stick a rock up his nose. A few problems with this:
a) he lost the rock in the nose and couldn't get it out
b) he didn't like the idea of my sticking a tube in his nose to get it out
c) the "rock" turned out to have been made by a rabbit
- Sponge Bob stickers for him and some antibiotic ointment for his nose

#2 - Hand injury: 13 year old that got beaten up in front of her house by the neighborhood female bully. Supposedly. she lives in a very bad neighborhood, and there's a family that moved in that has caused a lot of problems. This is just the latest. The police report showed that after the girls started fighting, a social worker tried to pull them apart and she was struck and injured, and then more family members jumped in and there was a bigger altercation. Not to mention the reason why there was a social worker at the house: the mother is, to quote one of the ED RNs "Dumb as dirt." There are 4 other children in the house, one of which has cancer, and the mother can't be counted on to assist in his treatment (ie: remember to give him his medications and get him to doctor's appointments for chemo.)
- Princess stickers will help this poor girl feel maybe a little like a kid; she's having to grow up very fast.

#3 - chest wall contusion: 16 year old playing basketball got hit with a knee in the chest as he was bending to pick up a basketball during a game. No stickers for him; he's a little too old for them, althoughI might have given him the Spiderman one just cause.

#4 - possible sexual abuse: this was the hardest case of my night. I had to talk to and exam a 2 year old whose family was suspecting sexual abuse. Seems the little girl spends 2 weeks at her father's and 2 weeks at her mother's. Her mother has a boyfriend, and the father's family was concerned that this was the person abusing her. I had to take statements, do an exam, and call in a report to Child Protective Services. I don't know if I can follow-up with a case worker or not, so I will just have to follow her medical records to see if she pops up again.
- No number of Princess or Dora stickers could make up for the fact that I had to do a vaginal exam on a child already suspicious of anyone trying to have anything to do with that area. I can only be comforted by the fact that she's safe... at least for 2 weeks while at her father's.

#5 - #10: The usual montage of diarrhea, constipation, vomiting and diarrhea, etc. I do have to make one comment: if you're going to tell me that your child hasn't been able to eat or drink anything for two day because they throw everything up, do not hand your child a soda bottle and allow them to drink half the contents in front of me while you are telling me this. I might not believe you. And, when I ask if the child seems to be doing better, don't tell me, "No, she spits up everything she drinks down, " while the child is happily swinging her legs in the chair, sucking down her bottle of pop, and play burping along with me. Seriously, I'll wonder why you came, and you'll be left wondering why I am not doing a million dollar work-up on your child.

This was our ED whiteboard at 2030: we didn't clear it until almost 2 in the morning - and this is with 20 rooms, 2 surgical rooms, a trauma room, and an ortho room - all full.

Ok. Enough of being a vampire. Tomorrow is Grand Rounds Wednesday, and I am presenting the chapter on Pediatric Cellulitis to my reading group, so I better go read it. Back to the E.D. fun on Thursday.

Save the Seals!:

The Little Pink Book

2008-04-07T13:34:00.000-07:00

I bought a bunch of these small notebooks when I started this residency. Actually, a total of 6, two in each color. This is the first one, and I have its mate sitting in my white coat out in the car. As a part of our residency program we have to do a "follow up" on a certain number of patients that we see in the emergency department. We want to see "how well we did" in managing their care.

So, I carry my notebook, and every patient I see goes into it. I log down what their presenting complaint was (why they came into the E.D.), what I did (labs, x-rays, etc.), and what their dispo was (dispo = disposition: admitted or discharged.) It's also where I keep track of any procedures I performed: suturing, chest tubes, central lines, intubations, all of my 16 deliveries, etc. We have to have a certain number of procedures to be deemed "certified" and able to perform on our own without supervision.

Usually, I have my little book next to me when I am blogging the past shift's events, but... I left it out in the car, in my white coat, and I am feeling very lazy. So, I thought I would give some general comments about my shift last night:

- again, we were very busy. I think around 3 in the morning, we finally had no patients waiting in triage. Then around 0305 the next patient arrived.

- I am starting to feel like all pediatric thermometers are set at 103.something. I had 2 patients yesterday, and have seen several others, who all had home reported temps > 103 and who had temps of 99, 100, 101 by the time they arrived in triage. Ok, so maybe the Tylenol or Motrin finally kicked in, maybe the fever was at its peak and broke, maybe the trip to the ED in the crisp cool Buffalo air brought the fever down, but still. The kids shouldn't be nice and dry, playful and alert, etc. if they've had that high a fever. Of these two patients, one ended up with a respiratory viral syndrome, and the other I will have to find out about today as I had to sign them out when I left last night.

- I have come to realize that I am no good at math. Everything in pediatrics is mg/kg or ml/kg. Aside fromthe fact we're working in the metric system, and I have to consciously convert Centigrade to Fahrenheit, I just seem to have a mental block when it comes to simple multiplication. Not to mention that I also don't know, off the top of my head, the maximum doses of all of the medications we give (luckily I have my attending and a slew of nurses to remind me). So, it's been quite the challenge when I am called to give a medication order. Which I do, obviously, quite often. Sigh...

- If you're jumped while leaving a bar at 3 in the morning and knocked unconscious, you probably should come into the ED. When your face swells up and looks like Quasimodo's, probably a good time to get that checked out. You shouldn't pop a couple of your buddy's 'pain pills" and then go out to a BBQ with your blurry vision and massive headache. Just not a good idea. Luckily, when his parents finally found out, via an uncle who went to the same BBQ, they made their son come in to be evaluated. Luckily, the CT scan only showed a small fracture in one of the nasal bones, but things could have been much worse. My excitement, of course, was in dealing with something other than vomiting, fever, diarrhea, and, "oh, what's this rash?"

- when you come to the E.D., it is not necessary to bring your "posse" or "entourage" with you. The rooms are small, I am trying to get information, and I don't really need a running commentary or additional information from your supporting cast. There's a rule that only 2 people should accompany any one patient, but somehow others always seem to slip past the front desk, and usually our staff is too busy to notice the comings and goings and exchanges. I don't mind playing to an audience, just not while I am trying to take a history.

- little boys seem to get constipated an awful lot more than girls

- and, finally, there's something about sitting back during those brief moments of "down time" and listening to the "war stories" the nurses exchange with each other. Last night, the comments focused on pregnancy and all of the events that had been witnessed: some funny, some sad, some a testament to my sometimes thoughts that we should adopt a national "contraceptive" vaccine that doesn't allow you to procreate until you've reached a certain age, achieved a passing score on the "baby test" (kinda like your driver'stest, but you're only allowed to fail it once), and passed several rigorous written exams; after which you present with a folder of references and recommendations by others who are nationally certified to procreate. If only...

Ok, off to my last night of being a vampire for a while. We'll see what the evening brings...

S is for So Many Patients to See

2008-04-06T13:03:00.000-07:00

When I left the ED at 5 a.m. this morning (an hour late), there were still about 5 patients waiting to be seen.... and a full board. This was the result of the backlog that occurred from earlier in the day. And, the fact we went from 2 attendings down to 1. And, the fact we had numerous ortho injuries requiring procedural sedation, which I will explain later.

At start of shift at 6 p.m. yesterday, I had two patients which my colleague signed out to me as he finished his shift. As I picked up new patients, I felt like I was wallowing my way through a pool of mud and having a hard time reaching the other side. Just when I thought I was finally getting caught up, something else would come up to stop the process.

Things should move faster... but I am going to save my rants on the other residents for a day when I don't have clinical duties and can editorialize more fully. As for now, into the melee:

Dx: Torn frenulum - 20 month old who came in with bleeding from the mouth. If you pull up your top lip, there's a small piece of tissue that forms a connection from the back of the lip to the gumline. You might even be able to run your tongue right up the middle of your top teeth and over the gums and feel it. This is your frenulum, and I learned yesterday that it is common in children to sometimes pull or separate and then bleed. As soon as I opened this young one's mouth, I saw where the bleeding was coming from. And, yes Mom, these bleed a lot. Your head, not surprisingly has a lot of blood vessels, and they bleed a lot. Tx = treatment, place pressure until it stops bleeding.

Dx: Dehydration - 9 year old who had his tonsils removed and became nauseated so he couldn't eat or drink anything then started vomiting. It becomes a viscious cycle: nausea then not drinking, vomiting, not drinking, more vomiting, then you find you can't or don't want to drink and you get dehydrated. Tx: IV fluids and admission to the hospital.

Dx: Ankle sprain - 10 year old who fell off of his skateboard and landed on his ankle the wrong way. Tx: wrap the ankle with ace wrap, crutches for a few days, and no gym.

Dx: Shortness of breath - 10 year old who suddenly "couldn't breath" while watching television with her family. These are difficult cases because "there has to be something wrong." You go into the room, the patient has no clinical signs of being ill, the vitals are all normal, and, as the child begins to describe what happened, you start thinking in your head "panic attack" or "attention seeking" you know you are setting yourself up for catastrophe if you don't start really focusing more on the story. Luckily, that's where the attendings jump in as you're telling them the history and say, "yeah, probably from hyperventilating during her panic attack." However, you get the chest x-ray or blood sample just to, honestly, appease the parents, and maybe assure yourself, that there really isn't anything wrong. Tx: none, come back if it happens again.

Dx: FB (foreign body) removal. Actually, I think this was my feel-good, pat my own back, moment of the evening. A 4 year old shoved tissue paper in both ears. When the mom found out, she took her to the Family Medicine doctor who was unable to extract the tissue. They prescribed some ear drops for pain and gave them a referral to the ENT specialist. They came into the ED last night because the pain was becoming unbearable. One piece was very deep, and I was able to extract it. The second was easier. They were my trophies. No one else appreciated it, but I did my own little victory dance and praised my steady hands. Woohoo to me. I know you may think this wasn't much, but seriously, I needed a little fun in the sea of pediatric misery that was last night. Tx: counsel patient to not put anything bigger than their elbow into their ear.

Dx: Salter II, distal radius fracture. 10 year old out rollerskating at a friend's party who fell and broke his forearm at the wrist. He needed procedural sedation (used to be called conscious sedation - basically giving medications to place a patient in a "twilight" state so that they can have painful procedures performed with minimal discomfort. One of the drugs given actually has an amnesiac property, so the procedure part is usually never remembered) which my attending supervised. He got his cast and will be followed in the ortho clinic.

Dx: Pityriasis rosea - 18 year old with a "rash for a month." Her friendtold her it was scabies, which is a parasitic, highly-contagious disease, but I assured her it was a self-limiting rash that would get better on its own. Tx: Benadryl for the itching.

Dx: LWOBS - left without being seen. Some people just can't wait any longer... they'll be back I am sure.

Dx: Newly diagnosed diabetes mellitus - this was probably one of the more interesting cases last night. An 8 year old who suddenly started drinking large amount of water and was urinating "more than was possible for a little boy his size." He'd been doing so for about a week, but yesterday had suddenly become more tired and shaky. Given the story, we immediately suspected diabetes. A fingerstick glucose was >500, which is the meter's highest setting. The lab recorded his glucose level at 743. Given the top normal for a non-diabetic is about 120 for a fasting level, this was just a little high. Yeah. He was immediately (even before we got any labs or levels) started on the diabetic ketoacidosis protocol and given fluids. He was admitted to the endocrinology service who will get his blood sugars under control, give the family a lot of teaching and education, and start to learn how to live with the disease.

Dx: minor head injury. 10 month old who flipped himself out of his playpen and onto his head. No injury, just a little bump on the forehead. Tx: monitor for signs of further injury.

Dx: dehydration - 17 month old with vomiting and diarrhea for a week, and not able to eat or drink. Now, I have to editorialize just a little on this one. His parents both looked like they were in their very early 20's. Not together since this was "dad's week" with the young one. When I asked why they had waited so long to get medical care since this had been going on, and the baby hadn't been keeping anything down at all, the mother looked at the baby's father and said, "Because he just told me about this." They weren't able to tell me how many diapers the baby had wet, did he have tears when he cried, and when I asked if they had given any sort of Pedialyte, the dad answered, "Well, I gave him some sips of ginger ale." The dad's only concern was, "Can you give him something for the cough that will knock him out?" House would say, "Um, no, I'm going to give him some IV fluids so that his kidneys keep working, his heart is under less strain, and so his eyes stop having this reddened sunken in look." I, of course, tried to politely explain that ginger ale is not a good idea and Pedialyte is a better choice. Tx: IV fluids and parent education.

Dx: chronic otitis media, I think - I actually had to sign this one out to the senior resident when I left this morning. A 4 year old with cerebral palsy, chronic seizures, who went to another hospital with a fever of 103 and was found to have "some kind of infectious process" due to a high white cell count, who subsequently got transferred to us because "we're the experts." This poor mother had been up since the day before and would soon have to drive back home with her daughter since, when I left, we weren't planning to admit her. I'll have to see what happened.

Whew. That was my 10, no 11 hour shift last night/this morning. What I want you to realize, and I know I've said this before, is that I don't see the patients one at a time. I see one, present it, start the workup, then go see patient two, present it, start the workup, check if labs/films are back on patient one, go see patient three, call a consult on patient two, check labs on one, start admitting two, see patient four, etc.

Given that we were so busy last night, the time between seeing and presenting a patient was sometimes as long as 45 minutes. Meanwhile, I am not allowed to see another patient until I have presented my most current. This explains some of the wait encountered. I could have probably seen 3 patients while I was waiting for my attending to come out of the procedural sedation room, but we're just not allowed at this point in our training, which, really isn't a bad thing. I know I still have a lot to learn.

Patients overheard but not treated by me:
- a patient with Henoch-Schönlein Purpura which is a trio of rash, kidney involvement and arthritis that is caused by an autoimmune response.
- as predicted 2 or 3 victims of the Hockey USA tournament being held in Buffalo this weekend. I saw the films on one of the boys with a broken leg... ouch!
- a girl who'd been bitten by a dog. Plastic surgery was consulted to help repair the damage
- a child who might need an amputation of one or more of their fingers, I never heard the story, but our 2nd year on the hand service came in to take the consult (that will be me a year from now when I do my ortho hand rotation).

That's it... off to enjoy two more hours' of freedom before my shift tonight. At least it's Sunday night... right?

Friday Night with the Kids...

2008-04-05T14:34:00.000-07:00

Ok, so let's jump right into this:

The E.D. was busy and "standing room only" when I got there. We had so many providers (attendings, residents, and PA's) that I actually didn't pick up a chart for 1/2 hour. I got my bag settled under the counter (we don't get lockers, so it's first come, first served space), filled my lab coat pockets (scripts, pens, penlight, stethoscope, pregnancy wheel, etc), and pulled out the newest EM journal I brought to read "in case things were, hmm, not the S word or the Q word, umm.. "calmer" later in the evening.

Finally, I picked up my first chart: "toothache." Great. I looked at the clock. Six thirty p.m. on a Friday night is not a good time to be coming into the ED for a tooth complaint. I went off to see the extent of the damage and wondered what I might be able to offer.

It was a 7 year old who's mom had tried to get her into a dentist's office, but wouldn't be able to for another couple of weeks. She a had a cavity in one of her back molars that went all the way into the pulp of the tooth. Very painful. I went off to find my attending and to see what was able to be offered. Luckily, WCHOB has a dental service, and so I was able to consult the dental resident who came down and prescribed antibiotics, pain relief, and got her an earlier appointment. One down, nine more hours to go.

Since I am running late, I will briefly highlight what I saw last night:

13 month old who fell and bumped his head. Dad works in the neuroradiology department and sees what can happen with even minor head trauma. I examined the child, gave the parents assurances, and sent them on their way - Dx (means diagnosis) = minor head injury.

10 year old with left arm pain after falling while playing soccer. Dx = left distal radial buckle fracture. She broke her forearm bone close to the wrist. Splint for her, and she will follow up with ortho for a cast. No gym for 10 weeks.

13 year old with "nipple swelling" and left arm pain after getting into a fight at school. The nipple swelling was normal due to hormones. Dx = gynecomastia. The x-rays didn't show a fracture. Dx = left wristsprain. Ace wrap and ibuprofen.

18 month old with "nipple swelling." Actually, this little one did have an abnormal breast mass. By this time, it was almost 10 p.m. We didn't have an ultrasound tech in-house, and this wasn't an emergency. She will definitely need to have follow-up and probably a biopsy of the mass. We sent her out with instructions for follow-up with her pediatrician. If I get any follow-up I will let you know. Dx = breast mass.

3 year old with a severe asthma attack. This was my longest patient in the E.D. in terms of disposition. He ended up receiving 3 rounds of nebulizer treatments and his oxygen saturations never got any better than the low 90's. He ended up having to be admitted. Dx: hypoxia, asthma exacerbation.

2 year old who mother reports wasn't "drinking enough." We gave him some pain control since he'd recently had a tooth pulled, and then gave him something to drink, he did, so he went home. I honestly don't know the diagnosis since my attending was "cleaning house" when he came on shift and discharged the patient on his own.

18 year old with cramping and vaginal bleeding. She was just about 7 weeks pregnant. After no seeing anything on the ultrasounds and finding a lot of clots on my vaginal exam, we drew some blood levels and sent her home with instructions to return on Monday for a second set of lab draws. If the numbers go up, the pregnancy is still viable, if they go down, she most likely miscarried. Dx: threatened miscarriage.

And, finally, 20 year old with concern about STD exposure. Sex with Boy A who had a history of an STD. Then sex with Boy B about a month later. A couple of days ago Boy B said she'd given him an STD. I took cultures and treated her for STD's. I also advised her on the importance of wearing condoms and birth control.

And, that was it for patients. I am running off for another night of fun with the chillin's. Also, Hockey USA is in town for several tournaments. I wonder how much ortho trauma we might be seeing tonight...

**on a side note: I want to thank "D" (Donna) for including my blog while doing a stint as Guest Editor on the Magic Smoke blogsite.
Thank you, D!

A Quickie - No. 1

2008-04-03T20:28:00.000-07:00

As stated previously, this is my "turn-around" day where I try to reset my clock to vampire mode for an upcoming 4 nights of shifts long weekend. I took a long nap this afternoon, flanked by cats, and am now trying to keep myself awake by doing odd and end things in my office.

Nothing much else, so I won't bore you with any further musings today...

***************
In case you have been following the seal counts, I was wondering what had happened to the HSUS.org website since they hadn't done any updates, and I found out today that the seal hunt is being suspended for 7 days while memorials are held for drowned crew members of an overturned boat.

The larger hunt is looming just over the horizon, and I know the totals will start sky-rocketing then. Again, "Don't Buy While Seals Die." There's a nice letter to give to your grocery store manager if their store is still on the list buying Canadian Seafood on the HSUS website.

Dead Man's Party

2008-02-15T19:56:00.000-08:00

I couldn't think of a title for today's entry, so I decided on the next song to play... and, surprise surprise it was "Dead Man's Party," which believe it or not is actually kind of appropriate.

When I was applying to medical school, I had to take a test called the M-CAT (Medical College Admissions Test.) On the night after I took the test, I invited people over for a "Dead Man's Party." Everyone was invited to dress in black. They were to "BYODF or V" bring your own dead flesh or vegetable for the cook-out. I threw the party because after taking that test, I had done essentially everything I could do to be accepted to medical school, so I could die in peace.

Kind of how I feel now.

I think I have done everything I can to make sure everything goes well for the wedding. I shipped the last boxes today, I've arranged for kitty care, I have sent out information to all the participants. At this point it's just sit back and wait for the week to pass.

Of course, I still need to pack, but like I was telling one of my bridesmaids, I could essentially walk onto the plane with the clothes on my back and everything I need is in California.

So, I am enjoying my evening. Spending time with the children. Watching the hours tick by on the clock. Wondering if I am forgetting anything. Wondering if everything will go okay. Wondering if I forgot anything. Wondering.

Tags: MCAT, wedding, Bodega Bay, Dead Man's Party

Hockey Heaven

2007-11-28T21:20:00.000-08:00

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

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

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

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

flat Adrian with mom eating a pretzel

Tags: hockey, Paul Kariya, Flat Stanley, St. Louis Blues

It's Just Another Manic Monday

2007-10-29T18:52:00.000-07:00

Beer meter:

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

Politics aside, my patients for today:

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

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

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

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

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

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

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

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

Tags: transexual, cocaine-induced angina, pancreatitis

Watch that first step....

2007-09-23T07:18:00.000-07:00

I am too tired to do my usual diatribe about the events of the ED. Suffice it to say that the majority of the reports from the EMT's this evening started with the phrase: "Patient went out drinking tonight and then..."
- the patient drove into a tree and crashed headfirst through their front windshield. After all the work-up was complete, the patient was found to have only sustained a bloody nose (refer back to one of my previous posts for rule #1 for drinking and driving: drink enough and you won't get hurt)
- "several unknown assailants" (Two Dudes must be on vacation... again, refer to earlier posts) jumped on several of our patients causing a variety of injuries normally seen on boxers who are on the losing end of the prize match
- the patient got into an altercation at a wedding leading to them being stabbed in the stomach, "really, it's just a flesh wound" lead to an exploration, and when 6 inches of the probe disappeared into the belly tissue, the patient was sent for emergency surgery
- the patients went out and rode their motorcycles which they subsequently crashed requiring the services of our Mercy Flight helicopters, the orthopedic surgeons, the neurosurgeons, and admittance into the trauma ICUand, our favorite of the evening, of which, believe it or not we had two:
- the patient got into an altercation at a local bar, went outside to avoid a further dispute, and tripped off the curb...

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

... that first step is a doozy!

Tags: alcohol intoxication, dislocated foot, assault, trauma

There's a Reason I Wanted to Do Surgery

2007-09-12T12:26:00.000-07:00

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

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

My home for the next month.

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

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

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

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

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

Tags: emergency department, ECMC, gyn exams, first day

The Hunt for Squirrels Begins

2007-09-04T16:22:00.000-07:00

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

Heart Hotels - Dan Fogelberg

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



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



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

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

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

Tags: Buffalo, Fogelberg, Hearts Hotel, moving

Sources of Inspiration

2007-08-09T15:01:00.000-07:00

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

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

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

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

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

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

http://www.cartertrent.com/obitdetail.html?id=740

Great new quote

2007-08-07T18:57:00.000-07:00

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

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

The long drive east

2007-08-06T05:08:00.000-07:00

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

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

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

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

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

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

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