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!

Month Three: Sports Medicine

Nearly 1/12 through my residency - 3 out of 36 months! This month I am on sports medicine - a rather laid-back rotation compared to some. My days are spent in clinic, at university athletic training rooms and sports events. I've seen some pretty cool stuff and learned how to examine most joints in the body.

Today I saw a high school kid with a football injury - got hit from the side and busted his knee. The x-ray showed a fracture through one side of the growth plate in the femur and into the joint - a Salter Harris Type III fracture. I know that doesn't mean much to most of you, but it was pretty cool to see it on the x-ray, CT and MRI. Very interesting case!

Last week I saw another pretty interesting case - a girl with an osteochondritis dissecans lesion. This is where a portion of the bone near the joint, just under the cartilage, is damaged from lack of adequate blood supply. The bone gets fragmented and the overlying cartilage can break off and travel into the joint space and cause pain. In this case, the fragment was 2.5 x 1.5 cm and had traveled from inside the knee up to the lateral thigh just above the knee. I could feel the cartilage piece under the skin! Okay, so not cool for the patient, but a great learning case.

Our sports medicine faculty serve as team physicians for several of the local high school and university teams. I am required to attend at least 4 sports events this month. My first was a Wichita State University volleyball game. The WSU team (the Shockers) are in the top ten ladies volleyball teams in the country supposedly. Of course, the night I saw them they lost - oh well. The game was great, but no inuries - except wounded pride, I suspect. Last week I attended a high school football game that was much more eventful. We had a shoulder dislocation, an ankle sprain/fracture, a hypoglycemic episode (one of the flag carriers in the marching band) and a case of cervical cord neuropraxia (CCN). CCN happens when a player gets hit with his neck extended, putting pressure on the spinal cord. Usually, there is some underlying cervical stenosis - narrowing of the spinal canal in the neck, predisposing the person to compression of the cord when the neck is over-extended. This results in temporary numbness, tingling and sometimes weakness/paralysis of the upper and/or lower extremities. Most players recover in a few minutes, and I don't think there are any cases of permanent paralysis. However, in the case of a narrow cervical spinal canal, the patient is at risk of recurrent injuries, and that is not a good thing. Anyway, the kid who got hurt at the football game had already had several similar episodes, so he needs to get an MRI before he will be allowed to play again. Unfortunately, this game ended with a score of 59 to 0 (the team we represented lost dismally - they were definitely at a disadvantage compared to the well-equipped private school team they were playing).

Last week I got to inject a patient's sacroiliac joint. The patient was having a lot of pain in his hip/back just where the sacral spine meets the pelvic girdle. It's a fairly big joint, but not always that easy to palpate depending on how much soft tissue the patient has on his/her backside. I got it on the first try though, which is good since I was using a 1-1/2 inch long needle!

I love this program! I get to do so many hands-on things. Last week I got to play around with the ultrasound machine with one of my pregnant patients. I'm still learning how to navigate around - it's so much fun seeing baby's face, hands, feet, heart...! What a great job I have!

Clinic Day

As a first-year resident, I get approximately two half-days of clinic each week where I see my own patients on an outpatient basis. The actual amount of time in clinic depends on what rotation I'm on. I just started sports medicine, so my clinic time is all day on Friday. This is the first time I've had a full day of clinic, and it was a bit challenging. Every month, the administration adds to the number of patients we are expected to see in a half day. I started with just two patients in four hours and am now expected to see four to five patients in four hours. The idea is to allow the residents to get used to the electronic medical record and to give time to check out each patient to the faculty preceptors. And believe me, I need all the time I can get!

So, Friday I had my first full day with 4-5 patients in each half dayn (ended up seeing 9 patients total). Sounds pretty easy, right? And actually, I did manage to finish on time. But I still had to finish up my notes at the end of the day, so I was at the office till about 7:30 PM. I find it hard to actually write my note while I'm with the patient. The program loans us a laptop to use in clinic, so I take it into the exam room, but I feel bad if I'm trying to listen to the patient while searching around on the computer for where I'm supposed to enter information or orders. So generally, I talk to the patient and then leave the room to enter orders for labs, imaging or medications. Those have to be done before the patient leaves, so it's important to at least finish that much. I also try to fill in my assessment and plan before the patient leaves. This is like a "to do" list. I list the problems I'm addressing that day and what I did or am going to do about them. I'm getting better at it, but it's still really slow. Sometimes my patients have to wait while I figure out how to refill their medications or how to order a specific referral. They don't seem to mind too much, but I feel bad taking up their time.

Some patients are really straightforward - pregnant or post-partum patients, for example. For these patients, there is a checklist of things to do and standard labs to order. So they get in and out pretty quickly. Pediatric visits are also fast in general. The ones that take the longest are the patients with several major chronic conditions (diabetes, high blood pressure, heart disease, COPD, etc.) on 15 to 20 different medications. Of course, I can't expect to address all their problems every time, but when a patient is new to me, I want to know how they are doing with all their conditions, especially since these problems are all interrelated and any new complaint or symptom could be linked to poor management or progression of any or all of the chronic problems. It's really hard for me to sort through all that in a short time and focus on only one or two things. I guess I have to get more efficient, and I am sure I will learn as I go. Plus, as I get to know each patient, I will have a better grasp of what their underlying issues are and what things are most important to address. Right now, most of my patients are new - to me at least. Except for the pregnant patients, there aren't many that I have seen more than once.

Yesterday I did see one of my "regular" patients. I've seen her about four times already in the two short months I've been in residency. She has chronic abdominal pain, likely caused by adhesions from several prior abdominal surgeries. She's tried a number of different medications for pain, none of them completely effective. When I first saw her she had had a seizure, and after getting her history I felt that it was likely due to the large amounts of a specific pain medication she was taking at the time. She also had elevated liver function tests, probably related to some of the medications she was taking. So we had to stop that several of her medications and essentially start over in figuring out how to manage her pain. I am not comfortable giving a patient, especially a young person like this patient, narcotics for long-term pain control. Narcotics do have their role, but they also have high abuse and dependency potential. Anyway, I was trying to find a way to keep this patient from depending on increasing levels of percocet or lortab for her pain. Chronic pain can be very debilitating, and over time can lead to depression and worsening of the pain in a vicious cycle - pain leading to depression and depression making the pain even less tolerable.

Every time I have seen this particular patient, she looks depressed, fatigued and totally demoralized by being unable to enjoy her usual life activities because of pain, even though she denies feeling depressed. Yesterday when I walked in the room I could tell she was not doing well. Her face, posture and voice all looked depressed. However, after we talked about what was going on and I made some suggestions about steps we could take to improve her pain, her face brightened and she actually left smiling! Amazing! It felt so good to develop some trust and rapport with my patient! This is the way I imagine myself as a family doctor - seeing my patients regularly and becoming familiar with their lives, their medical conditions, what things they've tried, what's worked and what hasn't worked, what stressors in their lives make their conditions worse, how their major relationships are going. Being a doctor is an awesome privilige and joy.

Last OB Call Night

Another rotation done and another month of residency under my belt. I just finished my last duty shift on my OB rotation this morning. This past week was particularly busy. I was on the "floor" on Monday and Thursday, meaning I spent the day caring for women in labor and delivering babies. On Friday, I got to see an interesting surgery. And I was on call Tuesday night, Friday night and all day and night Sunday. Total hours for the week: 90. Those 24-hour shifts are killer. At least things stayed relatively busy - not insanely busy thankfully, but steady. I have had the most wonderful upper level residents to work with, too, and I really appreciate their wisdom, advice, and willingness to answer my questions, even at 3 AM!

So after a month of OB, here are my "numbers":

• 16 vaginal deliveries (1 forceps, 3 vacuum)
• 6 c-sections (4 as the actual primary surgeon)
• 5 circumcisions

I'm definitely feeling much more confident in my skills and ability to manage various labor and post-partum problems. Last night I delivered two babies and all went smoothly. One of my patients only spoke Spanish. She was so thankful that her doctora spoke Spanish too and didn't stop thanking me all day!

Although OB was a busy and intense rotation in many ways, I am sad to see it end. I get another month of OB in the spring and will likely cover OB call nights throughout the year, as well as delivering my own clinic patients when they're due. But I will miss being there at one of the most significant and happy moments of life.

On to new things though - next month, Sports Medicine. It's a good month for this rotation since all the fall sports are well underway now. I should see some "good" injuries. Of course, I don't wish for anyone to get injured. But since young athletes do get injured in football, volleyball, hockey, etc., I'm glad I have the chance to be part of their care and learn how to diagnose and manage various types of joint and muscle injuries. During September, I'll also take call for the adult medicine service. I'm a little nervous about that - we get some very critically ill patients and have the responsibility of running codes for patients in cardiovascular or pulmonary arrest. I've never run a code before - we took a two-day course in advanced cardiac life support, so I technically know how to do it. Please pray that I will be able to stay calm and clear-headed!

Thanks for your prayers!

C-Sections, Suturing and Circumcisions, Oh My!

One of the strengths of my residency program is the training in obstetrics, including regular deliveries and c-sections. I was told that I would get the chance to be the primary surgeon on c-sections from the get-go, and now I can say that is true. Thursday I got to do two c-sections - and I mean really DO them. Up to now, I have only assisted on c-sections, scrubbing in, but standing on the left side and helping to hold retractors, cut sutures, etc. So this week when it was my turn on the "floor" I was determined to overcome my fear and dive in. I watched the step-by-step video on c-section techniques, and I asked my upper level residents to walk me through the process. I wasn't sure the OB attendings would let me take the leading role, but I've learned that showing confidence and being assertive goes a long way.

When the time came I was SO nervous. I was afraid I would completely screw things up. But I have determined not to be ruled by fear. And in learning procedures, the best and only way to learn is to do - hands-on, down and dirty, physical learning. On my first case of the day, I told the OB attending that I would really love to have the chance to do the c-section myself with her guidance. Her response was, "we'll see." But once we were scrubbed in, she pointed to the patient's right side and nodded. The right side is where the main surgeon stands (not sure why, but I suppose it assumes the surgeon is right handed and it is easier to do most of the procedure from that side). Anyway, there I was. The scrub nurse handed me the scalpel and after a moment of panic and a strong desire to flee (oh my gosh, what the heck am I doing here?!!), I made the incision and off we went. Everything went smoothly. The attending guided me through each step, the baby came out just fine, we got mom sewn up, and all lived happily ever after!

Later that day I had the chance to do another c-section. It meant staying 3 hours late on my shift. But I knew the attending was really nice, liked to teach and was very patient with residents. I figured a second c-section the same day would reinforce my learning and solidify it, as well as boost my confidence level. It was great. The second doctor did things a little differently, but he was so good about explaining each step and encouraging me. What a wonderful and amazing experience! I have now actually cut into someone's uterus and extracted a baby! Wow!

I still have a long way to go before I'm proficient in doing c-sections. Suturing is one of the toughest skills to learn. Holding the needle right, manipulating the needle driver and instruments, tying knots - all of these require manual dexterity and practice. I will eventually be able to do this in my sleep, but right now it's awkward and I am slow at it. That's why it's so good to get the chance to practice whenever possible.

Friday I also got to do another circumcision. That makes #5. After I've done 10 with supervision, I will be able to do them by myself without an attending present. That's a little scary, but no, I will not let fear get the best of me. Circumcisions are actually pretty simple, short, and fun to do. And the babies are so cute! Don't worry, I'm not being sadistic or cruel. The babies get local anesthetic and sugar water and most of them don't even cry that much. Mostly I think they cry because they're just mad at being handled.

So my job is really cool. I can't believe I get to do all this stuff! Plus, as I get more confident, I have much better interaction with my patients. A little more experience and wisdom helps me to put them at ease, answer their questions and connect with them personally. Although they have their own OB doctor, I'm the one they see most throughout their labor, so I feel like their doctor for a while, which is nice.

Well, all for now. Have a great week.