Starting a New Year, Figuratively

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

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

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

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

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

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

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

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

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

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

Like a Surgeon... Again

SUNY Buffalo - South Campus

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

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

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

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

My Big Fluffy White Cloud

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.

The long drive east

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

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

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

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

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

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

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