Colorado Trip 2011

Every year, my residency program takes a trip to Colorado with the first and second-year residents. I posted photos about the trip last year. This year I was on the organizing committee, so it was a different experience. But it was lots of fun. Despite the fact that we call the trip "Bike Trip", I did not actually take a bike ride. I did get a massage (very nice) and take a hike to a lake and waterfall. The weather was fabulous and the aspens were just beginning to change color.

Here are some photos.

Toenail Removal

Yep, you read that right. That's what I've been doing this past 2 weeks - removing toenails. Sounds pretty gruesome, I know, and actually it is pretty gruesome to watch. Doing it is not too bad though. And it has to be done. Ever had an ingrown nail? They hurt; they get infected; they make life miserable. It's really pretty easy to fix. And I have now learned how to do it!

Podiatry is a pretty important thing for a family doc to know. Foot problems are so common! All diabetic patients reach a point when they need regular foot exams to trim nails and callouses and check for neuropathy. Athletes and regular people who work out have heel pain, pain in the ball of the foot, capsulitis. The foot is an amazing appendage - it bears all of our weight, allows us to walk, run, jump and gives stability and balance. So you can imagine how much of a beating the foot takes and how prone to injury it is! I've learned to recognize and treat plantar fasciitis, bunions, joint capsulitis, warts, ulcers, corns and callouses, fungal infections, arthritis, and lots of other conditions. I can inject steroids and anesthetics in the right spot to provide relief, take off all or part of a toenail without pain, and suggest exercises and inserts to relieve pressure on different parts of the foot. It has been a very practical two weeks.

September also included a trip to Colorado for our annual first and second year resident team building activity. Once again, the scenery and weather were spectacular. The aspens were just beginning to turn colors to yellow and orange. The air was fresh and cool. I enjoyed walking around Dillon Lake (reservoir actually) and up to Continental Falls. As one of the trip organizers, I had a bit more responsibility for all of the logistics. But even with that, I had time to enjoy the time away.

Well, all for now. My eyes are starting to close of their own accord. Miss you all!

Family Meeting

This past week I had the opportunity to conduct a family meeting regarding a patient whose prognosis was extremely poor. The patient was a 71 year old woman with advanced breast cancer who was in hospice at home doing fairly well. She comes from a large and very close family. One night she woke up, felt dizzy, vomited and passed out. When EMS arrived, she was in asystole - her heart had stopped beating. No one knows for how long. They shocked her, did chest compressions, put a tube down her throat and started mechanical ventilation. Generally speaking, the recovery rate from "coding" someone (doing all those things I just mentioned) is pretty poor. Technically the patient was dead, and the EMS team brought her back. Unfortunately, her brain suffered extensive damage during the time her heart wasn't beating. By the time she arrived at the hospital, it was evident that she was severely compromised. At first the family wanted to do everything possible for her in the hopes that she would recover.

The purpose of the family meeting was to help the family understand the patient's condition and make decisions about how aggressively to treat her. It was a pretty emotional meeting. There were about 10 family members present, mostly the patient's children. Most of them understood that the patient was not going to get better. They knew she did not want to be kept alive on a ventilator and they did not want her to suffer unnecessarily. After many tears, honest answers and prayers (on my part), the family decided they would take the patient off the ventilator. We stopped all of the medications and IV fluids and wrote orders to keep the patient comfortable (medications for pain and anxiety). The family all gathered at the patient's bedside and later, when they were ready, they had the patient extubated (pulled out the tube that was helping her breathe). She passed shortly after that. It was one of the hardest things I've ever done, but also beautiful in a way - helping a patient die with dignity surrounded by their loved ones and helping the family through a very difficult time.

New House

Here are some pics of my new house. I moved at the end of June and have gradually been settling in with my new roommate Alexis. I don't have any pictures of her yet but I'll try to update soon.

It's a townhouse/duplex - pretty cute and comfy. Trying to fit two people's stuff in is a challenge, but we're managing to downsize bit by bit and get organized.

Started a new year and had a great first month as a second year resident on adult medicine. I'm on pediatrics now, so totally the other end of the spectrum. Life is still ridiculously busy, but I guess that's just the way it's going to be for another two years.

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.