Notes from an Upper Level Resident!

Well, I survived my intern year - the first year of residency! It's July, and a fresh new crop of interns has arrived. That means I am officially promoted to PGY-2 or second year resident. I don't really feel any different, but I can definitely see how far I've come in the last year. My first rotation this year is adult medicine - the hardest and most challenging rotation we have. I started off on a week of "night float."

(Digression - due to changes in the duty hour requirements, first-year residents are only allowed to work 14 hours in a row, instead of 30 like we did last year. So we had to change our call system. Now, rather than take 6 30-call shifts spread across the month, we do a week of night float. We are on call for 5 days in a row, taking new admissions overnight. In the morning we get to go home instead of staying 6 more hours to round on patients. It's actually pretty nice once you get used to doing the night shift.)

I was on night float with one of the new interns. My role as supervisor was to supervise (duh), or rather provide support for the intern as she worked up all the admissions. Of course, I was very helpful and even did a few admissions when we got backed up. But she was really smart (smarter than I was when I started), so she didn't need that much help. I still stayed up all night and saw all of the patients with her, but it was a much different role than last year. I found myself giving advice on how to write orders, what to tell attendings, what to consider in terms of diagnosis and treatment. Wow - I must have learned a lot last year! In fact, I can tell I'm much more efficient and confident with my own patients this year. What a journey! I still have so much more to learn, but it's fun to see how far I've come.

In between first and second years, I managed to move to a new apartment/townhouse. I have a new roommate - a Baylor med school alum who graduated from my residency program last year and spent a year doing an international fellowship in Zimbabwe. I also took my last set of board exams - Step 3 - a two-day test that will allow me to get my license (if I pass). Once I get my license, I can "moonlight" at immediate care centers and rural hospitals for more experience. I also want to volunteer at a free clinic in my free time.

Maybe second year will mean more time for keeping up my blog. I hope so! Meanwhile, I'm enjoying staying inside the hospital during this 110-degree heat.
Stay in touch!

Home Visit

One of the requirements of the family medicine residency is that we make home visits to two of our patients. I just finished the second visit last week and it was a really wonderful experience. My patient is 81 years old. She has 7 children scattered across the USA. Her youngest son lives with her and takes care of her - including cooking, laundry, cleaning, and help with bathing. For 81, she is pretty spry - both physically and mentally. She walks every day, goes to church every Sunday, and can tell you all about her 7 children, 20-something grandchildren and 12 great-grandchildren. Her medical problems include diabetes, high blood pressure, high cholesterol, and a history of strokes. I first met her in the emergency room in July when she had severe back and abdominal pain that turned out to be shingles. She was looking for a new doctor, and I offered to see her in clinic. I haven't seen her too many times, but the last time I saw her, I thought it would be a good idea to check out her home situation. I had some questions about the management of her medications - it seemed like she wasn't taking some of them as prescribed. Unfortunately, some elderly individuals are not well cared for by their family members. They may be exploited for their social security checks or other assets, or their family members may use prescription drugs for themselves. My patient's son seemed to be very caring, but I wanted to see for myself. I learned a lot about my patient and her family during my visit. The house was adequately adapted for an elderly patient - including wheelchair ramp up to the door, bars on the walls and shower for support, a shower chair, and a low-lying bed to prevent falls. These amenities alone demonstrate the family's willingness to invest in their mother's health. Then again, as I got to know my patient better, I began to realize that she is not about to let anyone push her around or neglect her. She's a tough lady with a strong personality and sense of family loyalty. Even so, there appears to be some discord in the family. Her son feels that the rest of his siblings are not doing their share to help out, despite the fact that one of them lives across the street. He may be too proud to ask for help, but he feels that they should offer. Caregiver burn-out is quite common, even when the patient is relatively healthy. But my patient's son seems to handle the responsibility well. He has some of his own activities that get him out of the house a couple of times a week, and that is probably very important for his mental health. My patient's uncle is a pastor, and she has attended his church for most of her adult life. She is well-loved in her church family, and for her 80th birthday, they celebrated with eight days of honoring her in various ways with treats, cards, prayers, encouraging words, acts of service, games and favorite memories. Her son showed me the photos and commemorative plaque they made for her. In fact her house is adorned with family photos - demonstrating how important her family is to her and how proud she is of them. At the end of my home visit, I asked if I could pray for my patient. We gathered around her - the son, a granddaughter who had come in during our visit, myself and my faculty advisor/preceptor. It was an honor and privilege to pray for this saint - for her physical and spiritual well-being, for her family and loved ones, and for the Great Physician to pour out his blessings on her and through her. I know I was blessed by this short visit, and I believe my patient was blessed as well. I think her son felt encouraged and validated in his efforts. He was able to voice some concerns that we had not addressed in the office. Our clinic social worker attended the visit and was able to provide some advice on resources for home care, equipment, prescription plans and insurance issues, which was a tremendous help. The home visit is so much more intimate, personal, and meaningful than any office visit! I wish it were possible to always see my patients at home, at least once in a while. Although we are only required to do two home visits as residents, I hope I will be able to fit in many more!

Spring is here!

Finally, I am coming out of hibernation! Spring is definitely in the air, intern year is almost over, and I have a renewed sense of joy and purpose. March was my last month of adult medicine. I was totally dreading it - hard work, long hours, working with a private group of hospitalists rather than my own family medicine faculty. I really prayed for a good attitude and an open mind, and God definitely answered that prayer. I had a good month overall. Lots of really tough, sick patients - that I was actually able to manage with some confidence (not completely, but MUCH better than when I started residency!). My attendings were all pretty good to work with. I learned a LOT. Just comparing how much more comfortable I feel now with most of the common conditions we see in the hospital, and even with the critical patients in intensive care, I can truly say I've come a looooonnngg way since July, and it feels good! Even so, I had a heart-felt celebration when the month was over. It is awesome to be done with adult medicine for the year. Of course, there will be at least four more months over the next two years, but somehow that doesn't bother me right now. I feel as if my load is suddenly lighter. One of the things I love most about family medicine is the variety. In the midst of my crazy adult medicine month, I got to do a c-section on one of my clinic patients, circumcise her baby and then see both mom and baby in the clinic a few weeks later. What a cool job I have! Now I am on cardiology, which promises to be a pretty relaxing month. I'm doing mainly outpatient medicine - that is, clinic. So no late night pages, no discharge summaries to dictate. I do have to be at the clinic by 6 AM for lectures, but that doesn't seem so bad when my day ends at 5 PM instead of 8 or 9 PM. I hope to learn how to conduct treadmill stress tests and echocardiograms (ultrasounds of the heart). And of course, I want to get really good at managing congestive heart failure, angina, acute heart atttacks, high blood pressure, and arrhythmias since we see a lot of that in practice. I still have to do 5 call nights this month - including two weekend calls. But three of them are on pediatrics and one is obstetrics, so at least it's different. For the last 4 months, all I've done is adult medicine. And my calls last month were brutal - non-stop patients to be admitted from 5 PM to 6 AM (that's after a full day's work and before another half-day of rounding, etc.). I guess it could be worse, and calls are when I learn the most about managing medical problems. But I'm glad for a break from that routine for a while! Some highlights of the past few months include: a visit from my parents, a visit from my good friend and former roommate, Melissa, warm weather - starting to run and bike again, and Bible study with some of my fellow residents. We're going through a book called Connecting with God. It has increased my longing to commune with God more deeply and consistently and has made me appreciate how much God desires to communicate with us, his children. From the beginning, God spoke the creation into existence; then he spoke with Adam and Eve, Abraham, Moses. He gave us his Word to communicate who he is and what he wants from us and for us. And he sent his Son to show us in person the way to the Father. And now he gives us his Spirit to guide us and teach us. I just need to learn to listen and tune my ears and adjust my perception to hear what he wants to say.

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!