So last night I worked my first long shift... that means 24 hours. What it meant for me was being awake for a solid 30 hours since my resident told me that someone had to be in the CCU at all times "just in case something happened." Ok. At 4 this morning when the nurses asked what I was still doing in the unit and why hadn't I gone to bed, I told them what he'd said. They looked at me dumbfounded and replied, "That's what pagers are for."
My thoughts exactly. Suffice it to say, I put in the time. Nothing really happened, and I could have slept from about Midnight after our one admission until around 4:30 in the morning when one of the patients decided to go into an irregular rhythm. That would have been a 2 minute phone call with a follow-up in about an hour... which actually was all she needed to convert back to normal rhythm.
So, I stayed up all night and watched monitors beep, patients sleep, and played on the computer. Now I am going to bed... to sleep... for a little while. I want to wake up in time for the snow. And, we're supposed to get A LOT tonight.
CCU Countdown:Days left until the end of the rotation: 22Actual number of days I will be working during that time: 19Days left until painful attending returns: 15
Number of days until my next 24 hours off: 4
Number of short call shifts remaining: 3
Number of long call shifts remaining: 2
Number of patients: 3 - 2 in the unit, 1 on the floor, 1 went to private service
Number of evil nurses in the ICU: 2 - not really evil, she justkept bitching about music playing and how it was "thundering in her ears" even though none of the rest of us could hear it after she turned it down from the already soft volume we had it on
Saturday, December 15, 2007
Friday, December 14, 2007
A Chorus Line
OK. So I am sitting at the resident computer in the CCU. It's been an all right day. Nothing really grand. Two of my admissions from last night went to the angiography suite: one will need surgery and the other will just be started on medication. My other patient will need to resolve his heart failure before he can go to the angiography suite.... if he lasts that long. More on him in a second.
I title this "A Chorus Line" because that's how it feels sometimes on morning rounds. This morning I had those three admissions from yesterday to present. For every question the attending had for me there was a chorus of answers - some restating what I just said, and some giving other information. A few times there was a disagreement with something I had just said which was either later resolved or just thrown out there. Of course, I had 10 minutes to quickly scan the chart while the overnight residents had... um... all night.
There's also an annoying brown-noser we'll call Smithers for fun who kept interjecting an opinion or whatnot between presentations. And, seriously, even though I was presenting directly to the attending, answering all of his questions, etc. total House of God. Outside of rounds, acted as if I didn't even exist even when I directed a question straight to him... oh.. and joy of joys... 2 less days with him since there's a different attending covering this weekend... in case you're keeping count along with me.
Back to my 3rd patient. I've talked about the dangers of drinking alcohol in the past except when you drive (refer to prior posts from ECMC.) Another danger is that you have memory loss (Alcohol affects your mammillary bodies which are important in the brain for logging and keeping memory.) Since you can't remember what actually happened, you confabulate (make up stuff.) There's a great "House" episode where he sends the medical students to go see a patient with a broken ankle. Each comes back with a different story, and he gets a third story when he goes in with the both of them. Kinda like my patient. He can't remember some events of the last month, so he makes things up. Or lies... whatever works.
About three weeks ago this patient had a similar episode but needed to be intubated: breathing tube put in. After a couple of days, he pulled his own breathing tube out... ouch! He was transferred to the floor and decided to leave AMA (Against Medical Advice) despite the fact he still needed to have further work-up done for his heart failure. He stated he had "too many things to do" to be in the hospital. I've explained to him (multiple times - remember, memory issues) that he could die, he's very sick, and he's lucky he didn't need a breathing tube this time. I tried to explain it to the family today, and I seriously think there's something in the water at their apartment complex because I explained things 3 times and nothing was getting through. So, we'll see if this patient doesn't leave again... or elope. Means the same thing in the hospital - just gets up and walks out the door.
Ok... have to leave. It's change of shift, and I am sure the joint will soon be jumpin'. My count down list is changing, and in some ways I think it is even funner than a rating system.... although, I am still suicidal most of the time... especially during rounds.
CCU Countdown:Days left until the end of the rotation: 23Actual number of days I will be working during that time: 20Days left until painful attending returns: 16
Number of days until my next 24 hours off: 5
Number of short call shifts remaining: 3
Number of long call shifts remaining: 2
Number of patients: 3 - 3 in the unit, 0 on the floor
Number of evil nurses in the ICU: 1
I title this "A Chorus Line" because that's how it feels sometimes on morning rounds. This morning I had those three admissions from yesterday to present. For every question the attending had for me there was a chorus of answers - some restating what I just said, and some giving other information. A few times there was a disagreement with something I had just said which was either later resolved or just thrown out there. Of course, I had 10 minutes to quickly scan the chart while the overnight residents had... um... all night.
There's also an annoying brown-noser we'll call Smithers for fun who kept interjecting an opinion or whatnot between presentations. And, seriously, even though I was presenting directly to the attending, answering all of his questions, etc. total House of God. Outside of rounds, acted as if I didn't even exist even when I directed a question straight to him... oh.. and joy of joys... 2 less days with him since there's a different attending covering this weekend... in case you're keeping count along with me.
Back to my 3rd patient. I've talked about the dangers of drinking alcohol in the past except when you drive (refer to prior posts from ECMC.) Another danger is that you have memory loss (Alcohol affects your mammillary bodies which are important in the brain for logging and keeping memory.) Since you can't remember what actually happened, you confabulate (make up stuff.) There's a great "House" episode where he sends the medical students to go see a patient with a broken ankle. Each comes back with a different story, and he gets a third story when he goes in with the both of them. Kinda like my patient. He can't remember some events of the last month, so he makes things up. Or lies... whatever works.
About three weeks ago this patient had a similar episode but needed to be intubated: breathing tube put in. After a couple of days, he pulled his own breathing tube out... ouch! He was transferred to the floor and decided to leave AMA (Against Medical Advice) despite the fact he still needed to have further work-up done for his heart failure. He stated he had "too many things to do" to be in the hospital. I've explained to him (multiple times - remember, memory issues) that he could die, he's very sick, and he's lucky he didn't need a breathing tube this time. I tried to explain it to the family today, and I seriously think there's something in the water at their apartment complex because I explained things 3 times and nothing was getting through. So, we'll see if this patient doesn't leave again... or elope. Means the same thing in the hospital - just gets up and walks out the door.
Ok... have to leave. It's change of shift, and I am sure the joint will soon be jumpin'. My count down list is changing, and in some ways I think it is even funner than a rating system.... although, I am still suicidal most of the time... especially during rounds.
CCU Countdown:Days left until the end of the rotation: 23Actual number of days I will be working during that time: 20Days left until painful attending returns: 16
Number of days until my next 24 hours off: 5
Number of short call shifts remaining: 3
Number of long call shifts remaining: 2
Number of patients: 3 - 3 in the unit, 0 on the floor
Number of evil nurses in the ICU: 1
Thursday, December 13, 2007
Heart and Snow
We had a taste of winter today as about 6 inches of snow fell within a couple of hours today. And then, the snow just kept falling. With the snow come the coronaries... it's funny. I went to medical school in Wisconsin, and the classic presentation taught to us regarding heart attacks started with "50 year old male comes into the E.D. complaining of chest pain while out shoveling snow."
While I was inside for my 12 hour "short call" snow fell like crazy. The first pic is the view from the 13th floor at downtown and then looking eastward. This was around 3:30 p.m. when most of the major part of the storm had already passed (it started around 0930) and most of the streets had been plowed.
Of course, plowed streets means people out there shoveling... men shoveling... first major storm of the season... and I got three admissions from 3 p.m. to 8 p.m. Three heart attacks... three men most likely needing to go to the cath lab tomorrow to be ballooned, stented or worse, needing bypass surgery. "I was out there shoveling and got this pain, so I got out the snowblower and the pain got worse... right here in the middle of my chest."
I am on my "long call" tomorrow, so we'll see what the after-affects of the storm will be...
CCU Countdown:
Days left until the end of the rotation: 24
Actual number of days I will be working during that time: 21
Number of days until my next 24 hours off: 6
Days left until current painful attending leaves: 3
Number of short call shifts remaining: 3
Number of long call shifts remaining: 3
Number of evil nurses in the ICU: 1 - should I feel bad I was actually happy when the nurse that was so rude to me in the morning came back this afternoon for her overnight shift and had been in a fender bender on her way home which ruined her day...? I do believe in Karma, but there was a very small part of me that smiled... just a little bit... a really really little bit... like this little... :)
While I was inside for my 12 hour "short call" snow fell like crazy. The first pic is the view from the 13th floor at downtown and then looking eastward. This was around 3:30 p.m. when most of the major part of the storm had already passed (it started around 0930) and most of the streets had been plowed.
Of course, plowed streets means people out there shoveling... men shoveling... first major storm of the season... and I got three admissions from 3 p.m. to 8 p.m. Three heart attacks... three men most likely needing to go to the cath lab tomorrow to be ballooned, stented or worse, needing bypass surgery. "I was out there shoveling and got this pain, so I got out the snowblower and the pain got worse... right here in the middle of my chest."
I am on my "long call" tomorrow, so we'll see what the after-affects of the storm will be...
CCU Countdown:
Days left until the end of the rotation: 24
Actual number of days I will be working during that time: 21
Number of days until my next 24 hours off: 6
Days left until current painful attending leaves: 3
Number of short call shifts remaining: 3
Number of long call shifts remaining: 3
Number of evil nurses in the ICU: 1 - should I feel bad I was actually happy when the nurse that was so rude to me in the morning came back this afternoon for her overnight shift and had been in a fender bender on her way home which ruined her day...? I do believe in Karma, but there was a very small part of me that smiled... just a little bit... a really really little bit... like this little... :)
Wednesday, December 12, 2007
Saved by Wednesday
Ok, so every Wednesday we have Grand Rounds (which I explained on my post 10/24/07.) So I had to go in slightly earlier to pre-round on my patients and then sign them out to one of the other interns so that I could go to Grand Rounds. After 5 1/2 hours, my colleague and I returned to see what was going on in the unit. One of my patients had been discharged (orders written by the senior resident) and the other was leaving the CCU (transfer orders written by the senior resident.) The new Medicine intern joining the service today asked if I would change short call with him and take it tomorrow instead meaning I could leave early today (as in 30 minutes after getting back to the unit after Grand Rounds.) Oh, yes, I would, and did.
Let me explain: in the late 1990's, two NY residents sued the Residency Board stating that too many long hours were leading to patient deaths, resident deaths, and were not conducive to a good learning environment. So several new resident rules were passed: an 80 hour work week maximum, a 30 hour limit to being at the hospital, a mandatory 24 hour period off per week, and a 10 hour limit between shifts.
Suddenly, all of the work force in the hospitals needed to be replaced since residents, per the rules, couldn't work those 48 hour long shifts anymore. Hence, there are now more "mid level" providers such as nurse practitioners and physician's assistants to make up the work force. And, to keep residents within those limits, a lot of residency programs instituted an overnight "float" team. This team takes call Sunday through Thursday in-house from 8 p.m. to 8 a.m. We take "short call" from about 2 p.m. to 8 p.m. admitting and managing our own services until we sign out to the overnight team. On Fridays & Saturdays, we take "long call" working 24 + hours (with a maximum of 30 mind you) so that the Float Team gets their 24 hours off.
As an aside, one of the consequences is that suddenly everyone wanted to go into surgery because most people had been deterred by the long hours. 80 hours is twice the normal person's usual work week, but much better than the 120 - 140 hours which used to be de rigor in surgery. However, the drawback is that programs are having to hire more mid-levels which take away from the residents' learning opportunities, and programs are also finding that residents are not meeting their number of required cases. There's a movement to lengthen the usual 5 year training to 7. The alternative is the combined programs (Vascular surgery, plastic surgery, etc.) which complete a fellowship specialty in 6 years instead of adding another 2 years to the end of general surgery training.
Doesn't matter to me any more since I am now in Emergency Medicine. One of those fields that never had a problem with hours or overworking its residents. However, when we rotate on different services, we get caught up in keeping the mandatory limits on hours.
As for me, I am now taking short call tomorrow, and long call on Friday, so we'll see what admissions I end up getting then.
I tried to think of a good rating system today during my meetings. I couldn't come up with anything. After a day of rounds and short call, we'll see what I can do tomorrow. For now....
CCU Countdown:
Days left until the end of the rotation: 25
Actual number of days I will be working during that time: 22
Number of days until my next 24 hours off: 7
Days left until current painful attending leaves: 4
Number of short call shifts remaining: 4
Number of long call shifts remaining: 3
Let me explain: in the late 1990's, two NY residents sued the Residency Board stating that too many long hours were leading to patient deaths, resident deaths, and were not conducive to a good learning environment. So several new resident rules were passed: an 80 hour work week maximum, a 30 hour limit to being at the hospital, a mandatory 24 hour period off per week, and a 10 hour limit between shifts.
Suddenly, all of the work force in the hospitals needed to be replaced since residents, per the rules, couldn't work those 48 hour long shifts anymore. Hence, there are now more "mid level" providers such as nurse practitioners and physician's assistants to make up the work force. And, to keep residents within those limits, a lot of residency programs instituted an overnight "float" team. This team takes call Sunday through Thursday in-house from 8 p.m. to 8 a.m. We take "short call" from about 2 p.m. to 8 p.m. admitting and managing our own services until we sign out to the overnight team. On Fridays & Saturdays, we take "long call" working 24 + hours (with a maximum of 30 mind you) so that the Float Team gets their 24 hours off.
As an aside, one of the consequences is that suddenly everyone wanted to go into surgery because most people had been deterred by the long hours. 80 hours is twice the normal person's usual work week, but much better than the 120 - 140 hours which used to be de rigor in surgery. However, the drawback is that programs are having to hire more mid-levels which take away from the residents' learning opportunities, and programs are also finding that residents are not meeting their number of required cases. There's a movement to lengthen the usual 5 year training to 7. The alternative is the combined programs (Vascular surgery, plastic surgery, etc.) which complete a fellowship specialty in 6 years instead of adding another 2 years to the end of general surgery training.
Doesn't matter to me any more since I am now in Emergency Medicine. One of those fields that never had a problem with hours or overworking its residents. However, when we rotate on different services, we get caught up in keeping the mandatory limits on hours.
As for me, I am now taking short call tomorrow, and long call on Friday, so we'll see what admissions I end up getting then.
I tried to think of a good rating system today during my meetings. I couldn't come up with anything. After a day of rounds and short call, we'll see what I can do tomorrow. For now....
CCU Countdown:
Days left until the end of the rotation: 25
Actual number of days I will be working during that time: 22
Number of days until my next 24 hours off: 7
Days left until current painful attending leaves: 4
Number of short call shifts remaining: 4
Number of long call shifts remaining: 3
Monday, December 10, 2007
Oh My Aching Ischial Tuberosities...!
I think I've said this before, but there was a reason I went into surgery. Early on in your medical career you make a decision on your specialty based on a few simple questions: do you like working in or out of the hospital? do you like clinic? do you like procedures? do you like sitting around for hours on end contemplating the minutiae of a patient's clinical course? My answers would be, of course: in, hate it, love them, color me suicidal.
I was trying to think of what would be an appropriate rating system for the next four weeks. Based on this morning's rounds, the beer system just isn't going to cut it. I don't know how appropriate it would be to rate my day on how suicidal I feel and rating my day by severity of manner of suicide. I could rate my day by how early in the day I begin to feel suicidal, but if most days are like today, they would all start about 15 minutes into rounds.
Let me explain for those not in the medical field: I am working in the medical cardiac care unit. It's an ICU where patients are sent for a higher level of care. In this case, they're patients with some heart issue or other. Most are there following a heart attack requiring an angiogram or major medications to keep them stable. We "pre-round" on our patients - look up all of their labs, vitals signs and find out what happened overnight, so then we can "round" on our patients with the attending - present the patient to the most senior doctor who will then spend the next several minutes giving us some form of teaching based on whatever issues the patient has.
Your rotation can be very good or very bad depending on how painful the attending is during morning rounds. (Our "City of Lights" attending this week has consistently been rated one of the worst by prior EM residents.) Considering I did two years of surgery, I am used to being hazed, belittled, pounded on, berated, and made to feel completely incompetent; sometimes all at once and for the same patient. But, I have to admit that since rounds lasted less than an hour for the most part, you quickly bounced back after saying "Thank you, sir, may I have another?" and went off to the O.R. for further, not-quite-so-public ritualized flogging.
You quickly learned to develop a thick skin, you learned some medicine, and you learned to be prepared for any possible question at all times. Even so, I never felt suicidal after rounds. Maybe it was the anticipation of going to surgery after rounds. Like a nice reward. Beat on me now then we'll go and cut open some people and then we'll both feel all better.
Medicine rounds are different. You sit for hours and listen as the attending pontificates about the latest study, or his feelings on the latest study, or his study based on the other study, etc. Then you go off and do your work. Then there is probably another meeting so that all the residents can get together and talk about their patients and issues related to their patients, and let's pick one of those topics and talk about it for an hour. Then you come back and finish up the work that you started but didn't have time to complete - orders to put in, orders to follow up on, studies to get the results for, doctors to call to confirm/ask about/report to regarding the studies who then give you more orders. If you're lucky, you might get to sit down later in the afternoon and go over everyone again with the team and or attending.
So, to begin: About 30 minutes into the presentation of the first patient on rounds this morning, my fellow ED resident getting pummeled by the attending, I seriously contemplated jamming a pen in my thigh to distract myself from the pain in my head, and in my butt. Honestly, I am not used to sitting in one place for any length of time. Two hours of rounds, followed by an hour of case presentations, followed by another hour of finishing rounds and then it was time to get down to work. If I'd actually known what the plan for each patient was, I would have gotten my orders written more efficiently, but since this attending followed the "House of God" rules and only spoke civilly to his fellow (someone who's graduated from a residency program and is doing specialized training in a field - in this case cardiology) and not to us lowly interns, I didn't know the actual plans for my patient. These were dictated to me by the third year medicine residents who are allowed to speak to the fellow.
And then, after they'd written all of my orders and told me what to follow up on, I was given another patient to follow for the next day. One that had been presented in rounds by the overnight crew. Of course, had I known I was going to pick up that patient I might have paid more attention, but I didn't. Sigh.
Anyway, I have tomorrow off. We have a mandatory 24 hour period of rest once a week. I will be taking call on Wednesday, so we'll see if I pick up any patients, and then I am on overnight call in the hospital on Friday. During my day off, I will try to come up with an appropriate rating system. Until then... we'll call it a three beer day.
I was trying to think of what would be an appropriate rating system for the next four weeks. Based on this morning's rounds, the beer system just isn't going to cut it. I don't know how appropriate it would be to rate my day on how suicidal I feel and rating my day by severity of manner of suicide. I could rate my day by how early in the day I begin to feel suicidal, but if most days are like today, they would all start about 15 minutes into rounds.
Let me explain for those not in the medical field: I am working in the medical cardiac care unit. It's an ICU where patients are sent for a higher level of care. In this case, they're patients with some heart issue or other. Most are there following a heart attack requiring an angiogram or major medications to keep them stable. We "pre-round" on our patients - look up all of their labs, vitals signs and find out what happened overnight, so then we can "round" on our patients with the attending - present the patient to the most senior doctor who will then spend the next several minutes giving us some form of teaching based on whatever issues the patient has.
Your rotation can be very good or very bad depending on how painful the attending is during morning rounds. (Our "City of Lights" attending this week has consistently been rated one of the worst by prior EM residents.) Considering I did two years of surgery, I am used to being hazed, belittled, pounded on, berated, and made to feel completely incompetent; sometimes all at once and for the same patient. But, I have to admit that since rounds lasted less than an hour for the most part, you quickly bounced back after saying "Thank you, sir, may I have another?" and went off to the O.R. for further, not-quite-so-public ritualized flogging.
You quickly learned to develop a thick skin, you learned some medicine, and you learned to be prepared for any possible question at all times. Even so, I never felt suicidal after rounds. Maybe it was the anticipation of going to surgery after rounds. Like a nice reward. Beat on me now then we'll go and cut open some people and then we'll both feel all better.
Medicine rounds are different. You sit for hours and listen as the attending pontificates about the latest study, or his feelings on the latest study, or his study based on the other study, etc. Then you go off and do your work. Then there is probably another meeting so that all the residents can get together and talk about their patients and issues related to their patients, and let's pick one of those topics and talk about it for an hour. Then you come back and finish up the work that you started but didn't have time to complete - orders to put in, orders to follow up on, studies to get the results for, doctors to call to confirm/ask about/report to regarding the studies who then give you more orders. If you're lucky, you might get to sit down later in the afternoon and go over everyone again with the team and or attending.
So, to begin: About 30 minutes into the presentation of the first patient on rounds this morning, my fellow ED resident getting pummeled by the attending, I seriously contemplated jamming a pen in my thigh to distract myself from the pain in my head, and in my butt. Honestly, I am not used to sitting in one place for any length of time. Two hours of rounds, followed by an hour of case presentations, followed by another hour of finishing rounds and then it was time to get down to work. If I'd actually known what the plan for each patient was, I would have gotten my orders written more efficiently, but since this attending followed the "House of God" rules and only spoke civilly to his fellow (someone who's graduated from a residency program and is doing specialized training in a field - in this case cardiology) and not to us lowly interns, I didn't know the actual plans for my patient. These were dictated to me by the third year medicine residents who are allowed to speak to the fellow.
And then, after they'd written all of my orders and told me what to follow up on, I was given another patient to follow for the next day. One that had been presented in rounds by the overnight crew. Of course, had I known I was going to pick up that patient I might have paid more attention, but I didn't. Sigh.
Anyway, I have tomorrow off. We have a mandatory 24 hour period of rest once a week. I will be taking call on Wednesday, so we'll see if I pick up any patients, and then I am on overnight call in the hospital on Friday. During my day off, I will try to come up with an appropriate rating system. Until then... we'll call it a three beer day.
Monday, December 3, 2007
On Vacation
Flat Adrian aka Flat Stanley has been shipped back to California, Mom has been settling in nicely with the cats, and I am now officially on vacation. Very little to write about at the moment. My next rotation will start on Monday. I will be in the Cardiac Care Unit at BGH working with one of my fellow interns. We'll have to see what excitement will come.
As for now, it's snowing... Buffalo is slowly turning into a Winter Wonderland... bring it on!
As for now, it's snowing... Buffalo is slowly turning into a Winter Wonderland... bring it on!
Wednesday, November 28, 2007
Hockey Heaven
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!!
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