Winter

Okay - I've been very neglectful of my blogging. In fact, I've been very neglectful of just about everything that doesn't have to do with medicine, sleep and basic sustenance. But now adult medicine month #2 is over and I am on a very nice rotation - radiology. I get to sleep in till 6 AM (instead of being at work at 6 AM) and get off at 5 PM with no middle-of-the-night calls. I hope to use this month to catch up on life - beginning with this blog.



Winter in Wichita has definitely reminded me I am not in Houston any more! A few days ago, I looked at my thermometer in the morning and it was MINUS 7 degrees Fahrenheit! Apparently with windchill, it was 25 below zero. Surprisingly, the cold hasn't bothered me as much as I thought - probably because I rarely get outside. The worst part is driving to work at 5:30 in the morning. My car heater doesn't even get a chance to heat up before I get to work. So the 10 to 15 minute commute is pretty chilly. And then there's the snow. We have had two big snows. This last one left somewhere between 4 and 7 inches on the ground. At least this time the freeway was very well treated. The snow didn't even stick. The regular roads were an adventure, though. I'm glad I have an SUV, even without four-wheel drive. There were spots where the snow was deep enough I could hear the car scraping over it. As long as I didn't have to stop, things were great. This weekend we finally had temperatures above freezing - in fact it was downright balmy at 50 degrees! More snow expected this week. At least I don't have to drive before sun-up!



The adult medicine month ended with a real bang. I was on call nearly every day of the week - or at least that's what it felt like. I had my first "code" - that's where a patient goes into cardiac arrest or stops breathing. I didn't have to run the code, but I did get to do chest compressions for a while. It was good to see how things work. Next time I won't be as nervous. I also had several patients take a critical turn for the worse over the last weekend. One was in liver and kidney failure and then started having respiratory failure. I had to talk to his family about hospice and whether they thought the patient would want to be intubated and placed on a ventilator (with poor prospects of ever getting off the vent). That was a hard conversation, but by the grace of God, I think it went well and the family felt cared for. Another patient had a massive gastrointestinal bleed from both ends. I got her stabilized and eventually she got an endoscopy and they were able to find the bleeding spot and cauterize it. Finally, another patient began to have crushing chest pain and elevated cardiac enzymes - signs of cardiac ischemia (poor blood/nutrient/oxygen flow to the heart muscle) and impending heart attack. She had an abnormally and dangerously fast heart rate and her heart was already in bad shape. Following my advanced cardiac life support algorithm, we gave adenosine - a drug that slows the heart and watched her heart rate return to normal in a matter of seconds. Whew!! Another crisis averted! I thank God for a cool head and lots of help from upper level residents and attendings. He has really eased me into some of the scarier, more intense medical scenarios. And He has let me see how far I've come - how much I've learned, how much more confidence I have. I have one more month of adult medicine this year in March. I look forward to another leap forward in terms of knowledge and experience.



Another highlight of January was delivering two "continuity" patients. These are pregnant women I have been following in clinic whom I got to deliver. It's so fun to help bring a child into the world when you've known the mom and seen her through several months of pregnancy. One of my patients I started seeing at about 5 months. Her first baby was born at 24 weeks, so she had never really gone all the way through a pregnancy or a real labor and delivery. By 40 weeks she was really ready to have the baby - in fact she had been to the hospital several times for false alarms. We ended up inducing her at 41 weeks and she did great. It was such a thrill to place her little boy in her arms! I also had the privilege of circumcising her baby, and hopefully I will be his doctor. My second "continuity" was a lady who came in already nearly fully dilated. I ended up delivering her baby before the attending physician could arrive, so it was just me, the nurse and the upper level resident. But it all went great, even without an epidural! Praise God for happy moments like these!

This month I am on a radiology rotation for two weeks, then behavioral health (fancy name for psychiatry). I spend my mornings (starting at 8 AM, not 6 AM) reading xrays, CT scans, ultrasounds, etc. at the hospital and my afternoons doing OB ultrasounds at the clinic. I'm getting better at seeing and describing abnormalities on chest x-rays and figuring out what I'm looking at on CT scans. And I can pick out a lot of anatomy on the ultrasounds as well. It's a lot of fun showing a mother the baby's heart, face, hands, feet, etc. Best of all, I'm getting more sleep and less stress!

Well, all for now. I hope to get a few more blogs in this month if there is anything interesting to write about.

Long Month

Day 17 of adult medicine rotation. January is a very long month. I'm two-thirds of the way through and definitely feeling the pains of sleep deprivation, lack of personal time, brain overload...

Please excuse my lack of correspondence. Here's what my last week looked like:

Wednesday 1/12: 14 hour day on "day call" meaning I admit patients who come to the hospital. I had a friend in town who was interviewing for the residency program. She came and hung out with me in the afternoon and watched me drown under four admits at the same time. We went out for dinner after work and didn't get to bed till after 10 PM.

Thursday 1/23: 30 shift starting at 6 AM. Busy night - not much sleep at all. Delivered a baby (one of my clinic patients), which was fun.

Friday: post-call - rounded and left at 1 PM.

Saturday: rouding from 6 AM to 4 PM. Took me a long time because 6/9 patients were new to me and rather complicated.

Sunday: 30-hour call shift. Rounded starting at 6 AM. Got a call at 8:15 AM that another clinic patient had come in 8 cm dilated. Delivered baby at 8:45 AM. Returned to rounding. Did circumcision of baby delivered on Thurday. Finished rounding. Started admitting patients. Didn't stop till 4:30 AM. Slept till 5:30 AM.

Monday: post-call. Rounded from 6 AM to 1 PM. Went home to sleep. Got called on complicated patient and spent 1.5 hours on that. Slept 3 hours. Got up to work on discharge summaries. Went back to bed at 10 PM to get up at 4:30 AM.

Tuesday (today): 13 hour work day. Rounded and was on day call again. Had one patient to admit at 4:30 (supposed to get off at 5 PM). Didn't finish till 7:30 PM. Why not? I'm inefficient and sleep deprived. I got distracted talking to the patient and nurses. I had to look some stuff up on how to treat the patient's condition. And I had to call a consult. Home at 8:15. Fixed dinner. Checked my clinic schedule for tomorrow. Checked some patient labs. Now to bed....

I have no idea how many hours that is in one week, but my eyes are drooping closed as I type. So, dear friends, thanks for understanding why I can't email, write or call more often. Until next time...

New Year, New Attitude

Well, folks, I'm back on another month of adult medicine - # 2 of 3 in the intern year. Medicine is the hardest, busiest month of all. Why? because the patients are complicated - adult patients with 4 or 5 major problems going on- and because there is just so much to learn. Anyway, after my surgery rotation in December, I was close to burned out. I was just so tired of not having a life - no time for housekeeping, shopping, email, sleep. But I had a wonderful week off at home in Houston over Christmas and came back refreshed and determined to meet the challenges of medicine head-on.

My first week on the medicine service has actually been fantastic. In October, I was on medicine at a different hospital with a private hospitalist group. This month I am at our main teaching hospital working with our own family medicine faculty. There is more teaching, more supervision and just more comradery. It's still a busy and intense month, and I will undoubtedly be exhausted by the end. However, I can already see how much I've learned and how much more confident I am about caring for patients. Now that I know the system and the basic routine, and some of the generic orders to write when admitting a patient, I can focus more on learning the art and science of medicine.

I decided to approach this month with some specific goals in mind - things I wanted to work on and learn to make the third month of medicine even better. For example, I want to get more efficient at rounding on patients in the morning - writing more concise notes, focusing on the main problems and keeping the details organized. I also want to become more comfortable managing patients on ventilators. I haven't had a lot of those yet, but there are still 3 1/2 more weeks to go in the month. I am slowly becoming more familiar with what tests to order, what questions to ask, and what medications and doses to give for a variety of conditions. I'm also less intimidated about asking questions. I've gotten to know the pharmacists, the lab techs, the social workers, the nurses and some of the consultants too. They are all very helpful, and that makes it much easier to call on them when I need help.

Now that I am halfway through my intern year (902 days of residency left), what can I say?

1. No regrets - I'm still glad I did this. Residency is harder than I ever imagined, but it is well worth it and I feel sure that I CAN in fact do it.

2. I picked the right program. I love the other residents and faculty, and the learning experience is fantastic. So I feel well supported and am becoming well-trained. And Wichita is a pretty nice place to live.

3. I cannot do this alone. I need your prayers and encouragement and most of all God's grace to face the physical, mental and emotional demands of residency. I appreciate the way God has put other Christian residents and faculty in my life and provided a great church where I can be fed and nurtured spiritually. And I thank God for all of you reading this and your sweet encouragement alon the way.

4. Only God can actually heal people. As much as I would like to fix my patients' problems, take away their pain and make them well, most of their problems are well beyond the scope of medical knowledge and technology (even if I were already a medical expert). Medicine is great, and it can do a lot. But ultimately the best remedy I can provide is to connect my patients to the Great Physician. I want to learn to do this better and more consistently. What else have I got to offer?

Meditating on the birth of Jesus this year, I was reminded of the gift of new life that we have in Christ. The old has gone, the new has come (2 Corinthians 5:17). This is definitely a season of old going and new coming for me in more ways than one. I pray that you also will experience anew the grace of God this New Year.

Surgery

Well, I guess my pediatrics month went by without much blogging activity. It was a great month. I LOVED pediatrics. That doesn't mean I don't love my adult peds is just fun, even with a lot of sick kids. We had a bunch of rotavirus infections (diarrhea and vomiting) as well as asthma exacerbations and respiratory infections. I was on call Thanksgiving weekend. Thanksgiving Day was actually fairly quiet. The hospital served turkey and stuffing (not all that tastly, really), and then two of my fellow residents brought me a plate of amazing home-cooked Thanksgiving treats and hung out with me for a while in the call room. So I had a little bit of Thanksgiving. I even got 5 hours of sleep. Then I was on call on the Saturday after Thanksgiving - I don't think I sat down more than 5 minutes all day! But that's over now...

Now I'm on surgery. I didn't know if I would like it that much, but it's actually pretty fun. I get to scrub in on surgeries, cut people open and sew people up. And I get to round at 5:30 or 6 AM. Oh yeah! Seriously, though. I've seen some pretty cool surgeries. I think I could do a cholecystectomy in my sleep (take out a gallbladder, that is). I've also gotten to attempt doing colonoscopies and endoscopies. Those are not as easy. The surgeon I work for told me to go home and practice video games. Sure - in my free time. I don't know if I'll ever be any good at working the scope with its buttons and knobs. Big knob counterclockwise to look down, clockwise up - or is it the other way around? Who cares? I can never really figure out which way I want to go anyway. It's like trying to write the alphabet upside down in a mirror or something.

The long residency hours are definitely wearing on me. After the long Thanksgiving weekend, I was really ready for a break. I basically worked about 3 weeks in a row with no days off. There's no time for life - cleaning house, cooking, laundry, answering emails, blogging, catching up on other people's blogs... I thought surgery might be a little better. But Friday was the first day we had in the OR on this rotation. I got to the hospital at 5:30 AM and left at 11:30 PM. We had an emergency appendectomy at 10 PM on a gal who was 21 weeks pregnant. I was really glad I could be there and make sure all the OB details were looked after. We got the OB nurse to check for fetal heart tones before and after surgery and hooked her up to a monitor afterwards to check for contractions. She did really well and so did the baby. I got to sleep in the next day, so everyone came out okay I guess. And I had a glorious two whole days off this past weekend!

I think the hardest part about residency right now is that there is so much to learn and so few hours in the day. I know I'm learning all the time, but sometimes I want to sit down and read about my patients' diagnoses. And sometimes I want to sit down with my patients and get a really good history, find out about what makes them tick, really discuss the options and what they think would be best for them. Unfortunately, I don't have that luxury often. It seems I'm always rushing from one patient to the next, from clinic to hospital, from noon conference to surgery...I found myself getting angry the other day at just how rushed and stressed I felt. God is always kind to show me the error of my thinking, though. On Thursday night - probably the lowest point of residency so far - I went to the ladies' prayer meeting (the women residents meet weekly for prayer) at my advisor's house. Several of the residents and faculty shared stories of how God was working through them to reach out to patients spiritually and share the hope and love of Jesus Christ. I was reminded that it's not about me or my schedule or how much time I have with a patient. It's about pointing others to the one true source of life and peace and healing. Apart from Him, I can do nothing. And apart from Him, there is nothing worth doing anyway!

Two more weeks until I get to go home for Christmas! I can't wait. I actually decorated my apartment and balcony for Christmas and have been listening to Christmas music. It makes the long hours much more bearable. Meditating on the God who sent his own son into the world as a humble, helpless baby, and later sent him to the cross to suffer in my place, makes all my suffering seem petty. I pray I can share some light this month!

Merry Christmas to all!

Time to Smell the Roses

Howdy everyone! Fall is definitely here - with crisp, cool mornings, bright red and gold leaves and pumpkins! I'm finally getting the chance to enjoy it. October pretty much disappeared on the adult medicine wards. It was my hardest month yet - very challenging mentally and physically. I had the first and last weekends off but worked every day in between. My mornings started at 5:30 or 6 AM, and I usually worked till 6 or 7 PM if not on night call.

More than the long hours, though, the constant intensity of caring for really sick patients took its toll. In medical school, I did not have many opportunities to care for patients in intensive care. So it was quite overwhelming to take responsibility for patients on ventilators with blood pressures of 50/30. As with anything in life, experience is best teacher. By the end of the month, I was able to admit patients to ICU and manage their care with a bit more confidence. I could get through my morning rounds efficiently, and I didn't panic every time my pager went off. I still don't always know how to deal with every question or situation that comes up, but I feel much better equipped to handle tough cases than I did a month ago.

Now I am on pediatrics, which is a completely different world. I still have some pretty sick patients, some of them only weeks old, but in general pediatric patients are a little easier. They don't have a lot past medical history or multiple coexisting conditions. For example, my adult patients typically have heart disease, COPD, hypertension, diabetes, alcohol abuse and kidney failure, which, as you can imagine, makes their management quite complicated. Pediatric patients, on the other hand, have perhaps one underlying condition - such as history of premature birth or asthma. Some come in with no preexisting problems at all. It's still scary to take care of a kiddo with a severe asthma exacerbation or a newborn who can't breathe due to a respiratory virus. Fortunately, the pediatric attendings are really good about teaching and explaining things. I find that if I can get guidance on managing a specific case once, the next time I see something similar, I can usually figure out what to do. My team is really great this month too - I am the only intern with three upper levels, all of whom are fun to work with and very helpful. It will still be a busy month, including 60 hours of call over Thanksgiving weekend. But I think I'm going to really enjoy it.

Well, time to hit the pillows. Looking forward to a week in Houston over Christmas (Dec 24 - Jan 1). It's right around the corner!

My First 30-Hour Day

I bet you all thought there were only 24 hours in a day. Not in residency! In fact, the weeks are longer in residency too.

I just started my adult medicine rotation, and it is definitely the most challenging rotation I've had yet. The patients are very sick, and there is never enough time to truly understand what is going on with them. As a first-year resident, I am responible for six patients on any given day. Usually at least two of them are in the intensive care unit. We start rounds at 6 AM each day and try to see six patients in three hours before meeting with our attending at 9 AM. That's only half an hour for each patient, which is never enough, especially when I'm picking up new patients in the morning who are really complicated. Of course, most of the time I have no idea what I'm supposed to do with the patients - what meds to give and how much. So I have to look stuff up, which takes even more time. After meeting with our attending frmo 9 to 10 AM, we have 30 minutes to finish stuff up - writing orders, discharging patients, calling consultants. Then we have to rush over to our sister hospital to be on time for "morning report," a teaching conference for all of the adult medicine teams. Three days a week we also have a noon conference. The afternoons are spent either in clinic or at the hospital. That's the only time I really have to read up on patients, talk to them about their rest results, and figure out what the next steps are.

One or two days a week, I'm on call. Day call goes from 6 AM to 5 PM. Night call is from 5 PM to 6 AM. However, after night call, I still have to round on my patients the next day. Hence the 30-hour work day. I had my first one this week. Actually, it was more than 30 hours. I was up at 4:30 AM, got to the hospital at 5:30 AM and started getting organized to round on my patients (looking up labs and vital signs). Morning went pretty much as above, and the afternoon was spent catching up on clinic and hospital paperwork. Then I started call at 5 PM. I had a patient to admit almost immediately. Each admit takes at least an hour, sometimes more. I have to see the patient, look up their medical history and any diagnostic studies that have been done. Then I have to write the admitting orders, which means deciding what further work-up and treatment they need. This usually involves doing some research and reading if I have time to figure out what to do and how to do it. Then I go over everything with the attending. Once that's done, I dictate the history and physical exam by phone. Then it starts all over with the next patient. In the meantime, I get to answer calls on my own patients, hopefully not too many. Some calls are relatively quiet. But my first long call this week, I admitted 5 patients. Doesn't sound like that many, but three of them were admitted to intensive care, so they were pretty sick. Anyway, I didn't get any sleep that night, so I was pretty sleepy by the time morning report rolled around. But I made it! I guess I'm still young after all!

Besides being incredibly physically and mentally challenging, this rotation has its rewards. I have gotten to know several of my patients and feel like they really appreciate it when I take the time to go back by their room and talk to them later in the day. Often, they have questions that no one has answered. Or they just want reassurance that someone cares for them. There are always so many people coming into their rooms and examining them and asking the same questions - different specialists, residents, attendings, students. I'm sure they wonder who's calling the shots and if everyone is talking to each other. My job as a primary care doctor is to try to integrate what everyone's doing and communicate with the patient. I also have to think about whole picture while specialists may only focus on one organ system. And I have to think about what's going to happen when the patient goes home. Can they care for themselves? Will they follow up? Take their medications? Do they understand their illness and what causes it? Do they know how to prevent a recurrence? I wish I had more time to be able to sit and talk with my patients to make sure they understand.

Some days I feel like I'm learning by leaps and bounds. Other days I feel like I will never have a handle on how to take care of patients. But I have found that I am more confident in responding to pages - things like patient's blood pressure too high or too low, patient agitated or confused, patient spiking a fever. Now I can often spout out orders that sound pretty good.

Well, time for bed - I have to get up in 7 hours and start a 24-hour day! More on some of my interesting patients later...

Bike Trip!

My residency program sponsors an annual trip to Colorado for first and second year residents, to promote team bonding, learning and comraderie. It's called "Bike Trip" because there is always a challenging bike ride up Vail Pass (15 miles uphill) and back. Of course, those who are less athletic can opt to do the downhill portion only - definitely a good choice.

Bike Trip 2010

I had a wonderful drive with two of the second-year gals, convoying with another group of first-years. The first morning was spent in team building activities (silly games - like making a team mascot from medical supplies - see photo) and continuing medical education lectures. Then we took a "short" hike to get acclimated. Basically, we hiked straight up for an hour, huffing and puffing, and had lunch on the top of some mountain. I got talked into hiking up even farther with some of my first-year buddies. It was, literally, breathtaking. The aspens were all turning yellow and orange and the weather was perfect with clear blue skies. So the scenery was a feast for the eyes and refreshing to the soul.

Day two was the bike outing. I got talked into doing the downhill portion of Vail Pass, imagining hurtling downhill at breakneck speeds on a rough mountain trail. Actually, the path was all asphalt and the slope gentler than I expected. So the ride was thoroughly enjoyable. After the 15-mile downhill ride, which was quite invigorating, I rode around Dillon Lake, about 10 miles. This was a somewhat more challenging ride, actually - although shorter, there were a lot of uphill sections. The crystal blue lake surrounded by pockets of golden Aspens was well worth the ride. On the third day, I kayaked around the lake. That's the first time I've ever kayaked. It was great, except when the wind kicked up. Dillon is at about 9,000 feet of altitude, so I feel pretty proud of myself for being up to several hours of rigorous activity in low oxygen conditions.

In addition to all the outdoor frolics, we had lots of social activities - games, pizza, medical pictionary (harder than you'd think - try drawing benign prostatic hypertrphy!), and even dancing. On the last night, we had a line dance with a real "caller" who led us through several line and square dances. It was loads of fun - good exercise and easy for those of us with two left feet.

I came back from the trip refreshed and ready to start my adult medicine rotation, which I just started on October 1st. It's going to be a very challenging month - but more on that later.

Sorry it's been so long between posts. I miss you all!