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paging dr jess





Updated: 2015-09-16T13:52:45.731-04:00

 



On the wards .. finally!

2008-10-03T12:28:56.200-04:00

It's finally here! I'm finally a wards resident!

We had a junior resident retreat a few weeks ago so that people could share the highs and lows of being promoted to resident. As I've had 6 weeks of elective and 2 weeks of vacation during the first 3 months of this year, my colleagues joked that they were trying to keep me away from the new interns! July sounds like it was pretty crazy in the hospital, so it's nice to have some interns who have been in the system for a few months when it's my first time being the team leader.

At the retreat, I confessed that I had been dreaming of my first day as wards resident and had been crafting my first day speech for months. My fellow residents chuckled at me, but based on my experiences from last year, I feel the resident sets the tone from the very beginning. My speech wasn't as articulate as I had imagined it would be, but I hit my main points:

1. I believe in the duty hours limits. Interns have to leave the hospital after 30 hours if not sooner!
2. We should function as a team. There's no "That's not my patient."
3. Training is about learning -- about diagnosis, disease management, and communication skills. Paperwork is something we have to learn how to do efficiently so we have time for the rest of our learning.

I was unleashed onto the wards a little over a week ago and met with the members of my team recently to see how things have been going. I've been trying so hard to be the kind of resident I would want--pitching in with orders and paperwork, making sure everyone gets food, and ensuring my team members go home and sleep. However, I wasn't sure if I was being the kind of resident they want.

Overall, it seems like things are going well. My attending said she couldn't tell it was my first time doing this, which plastered a big smile on my face. My interns appreciate our efficient rounding, and they feel well supported. However, they're both kind of worried about how much I've been eating and sleeping. And there it is. I'm totally exhausted. When I'm stressed out, my appetite goes down the tubes, so I haven't been eating right. Today is the first time I've spent more than 15 minutes with my husband in 3 days, and that's only because it's my day off. I've been so worried about my patients, students, and interns that I haven't been taking care of myself at all. Instead of helping everyone else in doing their jobs, I have to figure out a better way for me to do *my* job so that I can stay sane.

Despite my total exhaustion, I absolutely love my job.



I want to see a doctor, too!

2008-08-20T13:27:10.310-04:00

(image)
I have a confession to make. I haven't seen my primary care doctor in almost two years. I'm relatively young and healthy, but I'm a believer in the annual visit. Those visits are not just for Pap smears, colonoscopies, and mammograms. It's just plain healthy to spend 30 minutes talking about your health with a doctor at least once a year. My primary care clinic is in a community health center, and I see a large percentage of young African American men. I usually don't run any tests, but we spend the majority of the time talking about safe sex, wearing seat belts, guns in the home, and developing good eating habits. (You won't believe how often young single guys eat fried chicken! Learn how to make a sandwich, guys!)

Anyway, so I haven't seen my doctor in a while. I actually made two appointments to see him last year. Making an appointment is half the battle since I have to remember to call during office hours and then find a day when both he and I are free. Sadly, I forgot to go to both appointments! I know I'm a bad patient. That's what happens when I schedule them on my one day off a week and then get so excited about sleeping in that I forget.

Instead, I try to monitor my health myself. I know what I'm supposed to be doing, but sometimes people, including doctors, need an authoritative voice to push them in the right direction. For the past two years without my doctor pushing me to take care of myself, I've turned to Oprah. I'm an avid Oprah watcher, and I really enjoy her medical shows. I'm sure I'm not the only American getting my health information from her gurus Drs. Mehmet Oz and Christiane Northrup. I even took Dr. Oz's Real Age Quiz. Despite my lack of exercise, I'm surprisingly one year younger than my real age, but I took the tips the website had to offer to heart. I went to a yoga class on my day off, and I've started flossing again as it was one of those habits that went by the wayside during intern year. I'm still working on the fruits and vegetables. Getting in five servings a day is hard work!

I'm a big fan of Dr. Oz although part of me feels strange about getting my medical information from a cardiac surgeon on television. So, I called my doctor's office today. His first appointment ins October 15th, but my first weekday off after that isn't until November. See you in three months, doc!



Google to the rescue!

2008-08-14T22:45:25.166-04:00

Okay, I'll admit it: I use google to find medical information. I know I'm not the only one. Use of Google, Wikipedia, Emedicine, and other web sites is very common in the hospital among med students, residents, and attendings. I've seen you all using it! Usually I use google to confirm information I'm pretty sure I already know, but once in a while, I'm really not sure what's going on and give it a try.

Recently in the emergency room, I was pretty sure my patient had a viral gastroenteritis, but she had a black tongue. I had actually woken up with a black tongue last week, and it went away within a day. I didn't think any of it, but understandably, my patient really wanted to know why her tongue was black. So, I turned to google, and I found a wiki that linked to this:

The active ingredient in Pepto-Bismol contains bismuth. When a small amount of bismuth combines with trace amounts of sulfur in your saliva and gastrointestinal tract, a black-colored substance (bismuth sulfide) is formed. This discoloration is temporary and harmless. It can last several days after you stop taking Pepto-Bismol. Individual bowel habits, your age (the intestinal tract slows down with age), and the amount of the product taken all help to determine how long Pepto-Bismol is in your system.


I went back to the room and asked if she had any Pepto-Bismol recently, and she had! And I had some Pepto last week the night before my tongue turned black. Thanks, Google!



Nightfloat as therapist

2008-08-13T16:20:40.818-04:00

As nightfloat, I was usually the last person interns saw at the end of their days and then the first person they saw in the morning. Being a social gal, I would usually ask, "How was your day?" More than once an intern started tearing up. Sometimes they would be angry, sad, frustrated ... the list goes on. Last year, I remember bottling up my emotions all day as I interviewed and assessed patients, tackled mounds of paperwork, and crammed some learning in, but when interns sat down to hand off their patients to me, sometimes it would all come out. That was fine with me as I didn't have anywhere to run to; I was working all night.



An end to the USMLE trilogy

2008-08-08T12:54:44.608-04:00

I'm continuing on what seems to be an annual tradition of studying for some ridiculously expensive required standardized exam so that I can be a doctor. This year's test: USMLE Step 3.

Yes, I'm hunkering down in preparation for the last step in the USMLE trilogy. Don't worry, there's still the Internal Medicine boards! Plenty more testing to go in my lifetime! I like doing practice questions because reading prep books can be pretty dry. Step 3 covers a wide range of subjects, including surgery, obstetrics, and pediatrics. It feels like a long time since those third year clerkships, but after some studying, I know that you need some sterile saline, gauze, and ice to pack a severed finger for transport and that lesbians are at lower risk for cervical cancer than heterosexual women. My tip for Step 3 is that the answer is never "Quickly examine the patient in the parking lot." Got to love those ethical conundrums!



PPD negative and cavity-free!

2008-07-26T00:33:18.272-04:00

The nice thing about being on nightfloat is that I have daytime hours free. I should be sleeping, but when else am I going to be able to run my errands?

I'm pretty sure intern year had a negative impact on my health. (Those hospital cafeteria chicken wings are pretty hard to resist.) However, it's nice to know that my teeth are still intact and that those N95 masks really do keep the tuberculosis away.

If only I could have gotten an appointment with my primary care physician! There's an 8-week wait for an appointment. Somehow I called my dentist, and I got an appointment within a week. I also called my mechanic and was able to bring my car in the next day. I have high hopes for change in our healthcare system not just because I'm a frustrated doctor; I'm also a frustrated patient.



Hello, PGY-2!

2008-07-06T20:00:26.759-04:00

Now that I'm a PGY-2, I'm really looking forward to leading a team of interns and doing more teaching, but July 1st was a bit anticlimactic for me as I'm starting out on elective. In some ways, it seems wise to stay away from the inpatient wards this month. I've gone to visit some friends on the wards, and it seems like controlled chaos. My fellow PGY-2's are a little frustrated that their interns are not as efficient as we were, but we remember well how difficult the first few weeks were for us. Looking back, I was thankful to survive each day somewhat intact.

Although I'm not leading a team, new responsibilities abound everywhere I look now that I'm a resident.
  • In the urgent care clinic, I'm now expected to see six patients a session instead of the four I saw just two months ago in the same clinic. I haven't become magically more efficient, but I'm quickly learning lest the nursing staff kill me for keeping them late!

  • Next, I will be admitting patients overnight as the junior resident nightfloat. While there is a senior resident around if I have questions (in addition to fellows and attendings by phone), I'm largely expected to admit these patients on my own. I know it is something I am capable of, but I feel a bit like I'm swinging on a trapeze without a safety net.

  • After a few weeks of nightfloat, I'll be in the emergency room, again without any interns to "boss" around. Instead, I will be running the "medical traumas" that come into the ER, such as overdoses and strokes. Yes, a patient will be rolling into a trauma room, and I will be yelling out orders!


This year will be an adventure, for sure. I'll keep you updated!



A Minute to Mourn

2008-07-01T23:58:06.305-04:00

There's so much to write about, especially since I haven't written in over 3 months and today I officially am a PGY-2. However, I just wanted to take a minute to express something I'm feeling now -- the time missed with friends and family over the last year.

I remember when I was applying to residency programs and thinking about how each would affect my friends and family. My advisor said, "The people in your life will have to understand that for the next three years your needs, your training, your life will have to take priority." I know what she was trying to get at. For the last year, I have become less available, less flexible, less able to take care of the people in my life due to my training.

As I pour over my schedule for this coming year trying to find ways to be with my loved ones for weddings, birthdays, and holidays, I mourn all the ones I missed in the last year. I mourn the ones I will miss this year and next. I mourn all the unexpected twists and turns in the road they are experiencing without me.



Here comes the new blood!

2008-03-21T02:12:22.820-04:00

People said February would be the worst, and it was. Even my CCU attending told me he remembers February of his intern year being a lowpoint in his life. Now that it's March, my spirits are magically improved. Is it because I was in the CCU in February pulling those fun 30-hour shifts? Is it because I am on my first vacation in eight months? Is it because spring is finally in sight? Or is it because yesterday was Match Day?

It seems that my Match Day was a lifetime ago, but alas, it was only last year! What a strange day! People were laughing and crying, but regardless of elation or misery, everyone wanted to drink as much alcohol as they could until their bodies said, "No more!" That's because they have spent the last nine months, the four years, or their entire lives waiting to find out what that envelope said.

What it means for me as an intern this year is that my replacements are on their way! They will shortly be signing contracts for the wild ride of intern year, and I will be moving on. Yes, the end of intern year is in sight! I know this means that I will be a resident in a few short months. It's a scary thought that I will try not to dwell on while soaking in the Caribbean sun.



ER vs everyone else: Where's the love?

2008-03-16T20:53:51.678-04:00

I have to say that there is no love between the emergency room and the rest of the hospital. The main reason is because when the ER decides to admit patients, they are creating work for the residents on the wards and in the ICU. While sitting upstairs, it's easy to criticize the emergency room staff. We criticize them for admitting patients who look too well, and we criticize them for not doing more for the very sick. What I had not realized until working down in the ER was how difficult it can be to make judgment calls about a patient when they come in. Sure, the next morning when you know how the patient did, it's easy to say what should have been done. However, in the ER, sometimes there are so many patients in the waiting room, that you can't wait to see which way the patient is going to go. You make a clinical decision--you admit the patient to the hospital or you send them home with some good instructions on what should bring them back. And then you pray that you erred on the correct side.



Adventures in the emergency room

2008-03-09T18:16:30.392-04:00

After working 30+ hour shifts in the CCU, I thought a 12-hour shift in the emergency room would be nothing. I was wrong.

First of all, I started with night shifts. There seems to be no easy way to switch your body over to being awake all night. I tried afternoon naps, but that didn't work. After three nights of work in the ER, I was finally able to sleep nine hours during the day. Too bad after four night shifts I now have to flip to doing day shifts!

The ER is an interesting place. I'm used to being upstairs where someone else has already decided that someone's problems are serious enough to be in the hospital. My biggest problem in the ER is adjusting my "bullshit meter". Who is in the ER for secondary gain? It's not the coziest place in the world, but it does offer a warm place to sleep and as many 4 oz containers of juice as you want. I've had people come in saying "I had a seizure" or "vomited up lots of bright red blood" or "I want to kill myself!" Individually any of these would be a serious complaint, and I quickly started to realize that they know if they say one or sometimes all of these things we can't kick them out the door for at least a few hours. Yes, the people who say these things are usually drunk and sleepy. However, they are also symptoms that are more likely in people who are drunk, and the fact that they're sleepy would normally be more concerning. Did they overdose? Try to kill themselves? Hit their head and lose consciousness? Probably not, but I worry and often rely on the judgment of those who have more experience.

The other thing I find interesting is that people come to the ER in the middle of the night for the most mundane things--sore throats, tooth pain, a cough that's been going on for a week. They know the wait is shorter if you come at 3 am. I know that this is a symptom of our broken healthcare system. I myself haven't seen my primary care doctor in two years because it's too darn hard to get an appointment. Sometimes the wait for a sick visit is a week. However, there are people who keep coming to the ER for the same complaint, and I ask them why they don't go see their primary care doctor in between visits. Usually, they say "I didn't think about going when I felt okay." It's probably silly of me to try to change the system one person at a time, but I sit down and tell them about the role of the primary care doctor. Despite the frustrations of the system, that person is the main coordinator of their health. If they continue to have complaints serious to them but not serious enough to be admitted to the hospital, they're not going to get fixed until something very bad happens. I might be imagining a light bulb going off in their head, but hopefully my pleas to go see their regular doctor are heard.

One more week until my first vacation in eight months! Can't wait!



Isn't it supposed to be a bad flu season?

2008-02-27T22:33:39.869-05:00

People say February is when the interns hit rock bottom. Honestly, I'm so tired and burned out that I started wishing for the flu. Even if I had to stay home with rigors all day, I would get to see my husband and sleep more. I need a break! Despite my co-intern getting some terrible viral illness and my team treating two patients with influenza pneumonia, somehow I've escaped without a single sick day used this month. Oh well, a girl can dream.



an intern's worst nightmare ...

2008-02-14T21:18:20.597-05:00

is falling asleep during rounds! I didn't even know it was my worst nightmare until it actually happened. To be fair, I was post-call without a wink of sleep and into the third hour of rounds. My attending called me out on it in front of everyone but was laughing. Whew!



A lifetime of learning, no kidding

2008-01-27T14:32:49.307-05:00

I'm in the last week of my month-long outpatient rotation, and I had a long list of tasks to accomplish before entering the CCU next week. In addition to seeing friends and cleaning my apartment, I also wanted to slog through the tall pile of journals that has accumulated since last time I was on an outpatient month. Flipping through the January 17th issue of the New England Journal of Medicine, I was reminded how medicine is ever-changing. There is constant revision of therapies in addition to the social and political aspects of the medical field, and I need to keep up! Here are a few excerpts for those interested in what I've been reading.

I've had the opportunity to work with foreign medical graduates in the past, but this article really describes the sacrifices they make and the hoops they jump through in order to practice medicine in the Western world.
[Foreign medical graduates] must not only relearn the theory, which many of them first studied decades ago, but also master the social and behavioral nuances of being a doctor in the West. Some must do so while supporting themselves by driving taxis or picking fruit; others rely on meager personal savings or small government handouts. They are driven by the dream of becoming doctors again, but the reality can be a nightmare.

I need reminders like this so that I remember how lucky I am to do my crazy job everyday. I've heard about publication bias, but this article really lays the numbers out there.
Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published ... Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive.

I haven't had an ethics course since I was a first-year medical student, but there are still many unanswered questions. When I read this case about cell lines derived from a patient's splenectomy specimen, I couldn't believe that the law wasn't more clear.
Under ancient Roman law, when agricultural crops were in the ground, they were owned by the landowner, but picked fruits and vegetables were owned by the farmer who worked the land. Trees taken from the land, however, belonged to the landowner. Is a removed spleen more like an ear of corn or an oak tree? ... Since the cells in human tissue are living and reproduce, perhaps they are more analogous to farm animals than to fruits or vegetables. The progeny of animals are the property of the mother's other. Is the cell line equivalent to [the patient's] "progeny"? Similar, an owner wrongfully deprived of livestock is owed the value of the eggs from converted chickens and milk from converted cows. Are [the patient's] immortal cells like chickens, and the protein products derived from them like eggs? The need to resort to cases that involve the ownership of corn, trees, cows, and eggs demonstrates the need to create modern rules that deal directly with the ownership and use of human tissue.

I remember in my medical school application essay I stated I wanted to enter medicine due the ever-change challenges the field encountered requiring a lifetime dedicated to learning. Boy, I don't think I knew what I was getting myself into!



Health Care in an Election Year

2008-01-24T21:38:44.740-05:00

Our health care system is broken. I see examples of it everyday. People who can't afford their medications in the emergency room, hospital wards, or ICU due to poor control of their chronic medical problems. I am going into primary care praying that there will be meaningful change in the system that will allow me to take better care for my patients, but how does that translate into who to vote for? Well, I've been pouring over this site comparing the candidates' plans today. There are flaws in each of these plans as I really do believe in a single payer system, but they are all a step in the right direction. The devil will be in the details of how these plans are implemented. I'm still struggling with which candidate understands the deficiencies of the current system the best. I want my candidate to know which of the many parts of their plans to push for and which will have to be sacrificed as the plans are made into law.

I'm excited that I will be able to make it to the voting booth for my state's primary on Super Tuesday. I'll be post-call from the CCU and will go directly from the hospital to my polling station. I just don't know yet who to vote for.



Planning the future

2008-01-21T09:53:41.102-05:00

As an intern, I take days one at a time. Once in a while, I'll actually look a few days ahead and plan to do something fun on my day off. However, I rarely look much further in the future. One of my medical students was bemoaning that the school was asking them to put in schedule requests for their rotations next year. It does seem difficult when you've only finished half a year to figure out what you want to do the next year, especially when these years are supposed to shape your future career. I told my medical student to suck it up because it doesn't end. I just submitted my schedule requests for the 2008-2009 year.

Filling out that form was mind boggling. When do I want to take vacation next year? I had to email all my engaged friends and ask if they were planning weddings before July 2009. When do I want to be in the ICU? Which ICU? What about electives? What do I want to be doing on July 1st? That's when I'm a brand new resident with brand new interns. I'll be a resident in less than six months!

Luckily, I'm on emergency coverage now with more than average free time. (Thank goodness my co-interns haven't been inflicted with that raging diarrhea that's going around.) So, I was actually able to step back and look at myself. I found that a lot of me is the same. I still want to spend vacations with my husband when he's on break from school. I'm still interested in outpatient medicine despite the copious amount of time I have spent in the hospital this year. And I'm still terrified that I will make a mistake and kill someone. Those were my guiding principles in filling out my requests.

What's changed about me? Less than I thought. While I'm on the wards or in the ICU, time is limited, so I don't get to indulge myself in my hobbies. Yes, spending time cooking or watching TV seems like an indulgence. (Luckily the writers' strike is making it easy for me to stay away from my television.) However, now that I have more free time, I have found happily that I am much the same person that I remember I was. And I'm relieved. Yes, I've changed as a clinician, but I'm still me.



Is the silence deafening?

2008-01-21T09:33:03.009-05:00

So, it's been a long time since I've posted. I've started a bunch of entries, but in the end, I justified my long pause between posts by saying that the silence was saying a lot.

The greatest skill of an intern is the ability to prioritize. There's always lots to do each day. After rounding each morning, I think, "Should I write my notes? Go to morning report? Call my consults? Put in orders? Teach my medical students?" The ranking of priorities extends beyond the walls of the hospital, too. A few weeks ago, my car ran out of gas. That's never happened to me before, but time is limited. On my list of priorities, filling my car with gas was probably lower than it should have been. However, getting home to spend time with my husband is pretty high, and the gas would have been helpful in getting that task accomplished. I'm still learning how to prioritize, but on the list of priorities, this blog is somewhere below filling my car with gas.



The Intern 15?

2007-10-16T19:14:14.163-04:00

At our recent intern retreat, our program directors took the liberty of flashing a picture of each intern in a slide show. Most of the pics were taken from those submitted with our residency applications, and we just had to laugh! We all look so different. Shiny, happy, and new in our best suits. Now I'm wearing T-shirts over drawstring pants covered up by my greyish white coat.

After the slide show, two people commented to me that it looks like I've lost weight since my picture, and after weighing myself (finding a scale in a hospital can be surprisingly difficult), I found that it's true! While my friends have been moaning about the "intern 15" as equivalent to the "freshman 15" gain in pounds, I've been losing weight. I guess it depends how you deal with stress, and for me, I usually can't relax and eat until all my work is done. That means I've missed a meal here or there, and I rely a lot on snacks in my pockets, mostly granola bars.

However, I just started on a new wards team, and there's food everywhere! Munchkins! Candy bars! Pumpkin-shaped cookies with frosting! Maybe the "Intern 15" will be in my future!



Starting at the VA / Winning the game!

2007-10-05T22:38:07.521-04:00

I'm about three weeks into my rotation at the VA, and at first, it felt like I was starting internship all over again.

Being in a different hospital means many things are different. As an intern, it's my job to get stuff done--tests, labs, consults, etc. If they don't get done, I see it as me failing at my job. Patients staying extra days in the hospital means higher risk for hospital-acquired infections and complications, so all around it's frustrating for me and somewhat dangerous for my patient when there are delays in diagnosis and therapy.

The VA computer system is regarded as one of the best if not the best in the country. However, if you don't know how to fully utilize it, it can be a complete disaster! Although I did a rotation at this hospital as a medical student, I wasn't familiar with all the steps it takes to get things done. It was taking me 30 minutes to figure out how to order regular finger sticks to test blood sugar levels on a diabetic! There's also cultural things about each hospital--which antibiotics they tend to use, availability of certain imaging, consults, and pharmacy rules. If you don't know these things, you'll definitely be less efficient.

However, I'm on another great team, and we all helped each other out as best we could. My first week was plagued with late nights cursing the separate menus on the computer system, and I would come home every night wondering why I could not get myself out of the hospital earlier. I have slowly picked up tips in my weeks there, and today, I won the game!

"Winning the game" in the medical training sense means discharging all your patients the day before a routine day (a day when you are not admitting patients to the hospital). It's a big deal because it means that you don't have to go into the hospital on your routine day--an extra day off! I didn't even realize I had won the game until my last patient left the hospital and my list said "no patients found". There were lots of high fives all around, but it felt that the stars aligned for this to happen. I don't know about other programs, but I see it as pretty unlikely that I'll repeat this feat again.



Performing my IADLs

2007-09-15T14:46:27.030-04:00

When I started internship, I knew that posting would be intermittent, but the longer it had been since I posted, the more pressure I felt to write something especially insightful. The days turned into weeks, and here we are at a whole month since my last post! I've read about this happening to other physicians-in-training with blogs, and I decided just to post about whatever comes into my head. Here we go!

The last month was fantastic! I was on an outpatient rotation, which entailed seminars and clinical experiences aimed at residents interested in primary care. While I should probably write about my excellent clinical and didactic experiences, the best part of the last month was having time for what physicians call "Instrumental Activities of Daily Living" or "IADLs". During a geriatrics conference, IADLs were jokingly referred to as "Things interns don't have time to do." It's funny but sadly true. IADLs include the following:
  • Using a telephone. During my last wards month, I had many voice mails from my mother, and at one point, she called my husband to make sure nothing had happened to me. Well, internship happened to me, but during the last month, my whole family came to town to visit. Plus, I was able to chat with some old friends I hadn't spoken to in a few months.

  • Grocery shopping and cooking meals. After burning myself on the oven my first month, I've not been as keen to cook. I do have a few recipes that I can throw together in a few minutes, such as fried rice or spaghetti, but after two years of marriage, my husband is now learning how to cook basically out of necessity. Plus, my stomach wasn't adjusting well to our greasy take-out diet. Over the last few weeks, I was able to indulge in one of my favorite hobbies--trying new recipes. Yesterday, I made my own pizza dough, and I put some in the freezer for the upcoming wards month along with some frozen vegetables.

  • Housekeeping. During this month, my husband and I actually bought some furniture and finished unpacking our boxes from our move over three months ago. Yay!

  • Laundry. If my husband didn't wash my clothes for me, I probably would be wearing scrubs daily because the hospital launders them. I hate wearing scrubs mostly because they don't fit and drag on the ground behind me, making me look like a kid playing doctor, but if my husband goes on strike, I'd wear them.

  • Paying bills. Credit cards would never get paid without the automatic payment feature.

IADLs contrast with another scale used by physicians describing Activities of Daily Living (ADLs). They are things that interns (hopefully) still do regardless how busy they are, including bathing, brushing teeth, feeding themselves, dressing, and using the toilet. However, I've been known to be driving home at 9 pm realizing I hadn't been to the bathroom since the morning, and there are days when I would have starved had it not been for the granola bars in my pockets.

I really do want to write about some of my other experiences during this month, including giving a talk in front of my fellow interns and residents and learning about outpatient pain management. However, I'm basking in my last two consecutive days off until January.



My pager: Putting things in perspective

2007-09-15T14:47:32.339-04:00

I meant to write this post last week, but I kept putting it off. Anyway, I had that really crazy week, and as my husband pointed out, it wasn't a bad week, just a very busy one. I went to the beach on my day off, and while soaking in the sun, I was able to reflect on my week.

With a little distance, I could see that I was getting overwhelmed. What I really needed to do was take a few deep breaths and tick things off my to do list one at a time. It's easy to feel overwhelmed when my pager is going off every 30 seconds interrupting my routine. Coming from the ICU, I was used to returning pages right away, but I've learned that I don't always need to sprint to the nearest phone when my pager goes off on the wards. Sometimes I should take a few minutes and finish eating or the conversation I'm having with a consultant. About 99% of the pages I receive are not urgent at all. Most of the time it's the phone number of a nurse who wants to tell me that someone didn't eat any breakfast or would prefer ibuprofen over tylenol. With anything urgent, they text message me what I need to know immediately. After figuring that out, I've managed to avoid heartburn from gobbling up my lunch in the elevator and actually sit through a few conferences.

I'm on my last week of this wards block. Tonight will be my last overnight call for a few months because I'll be on a few specialty services (cardiology, oncology) that have different call schemes. While I like admitting all my own patients, I won't miss overnight call and how it screws up my sleeping schedule for days. I can't wait for next week because I start a whole month of primary care!



What a week!

2007-09-15T14:47:49.901-04:00

If I've been painting a rosy picture of internship, maybe it's because I've been lucky enough to have a few good weeks or maybe a bad day here or there mixed with mostly good days. This week was terrible. Everyday was a nightmare. When I tried to explain my bad days to my husband, he pointed out that nothing really bad (e.g. patient dying, giving someone the wrong drug) happened; I just had long, busy days. The wards are a crazy balancing act, and I'm working on my juggling skills. Our schedules aren't so bad if everything goes according to plan, but some things can really screw up your day:1. When admitting, all your new patients can come to the floor at the same time. The way we're assigned patients is designed to avoid this. However, patients come from the ER, directly from clinic, transferred from other hospitals, and transferred from the ICU. Although I hear about the patients at neatly spaced intervals, through the mysteries of patient transport, sometimes they all come at once. So, I have to run around and make sure they're all stable and then try and do a quick assessment to put some basic orders in the computer (patients will complain if they don't get dinner, and nurses will complain if there are no orders in the system!). Once they're stable with dinner on the way, I have to figure out what's wrong with my new patients and how I'm going to fix them (or at least what to order to help narrow down the differential).2. Patients can become unstable. Nothing can destabilize my day like a call that says, "Your patient is having shortness of breath and is desating to the 80s." Yikes! People not being able to deliver oxygen to their organs is really bad, and it requires dropping whatever you were doing (e.g. rounding with the team, writing prescriptions so another patient could catch his 2 pm ambulance to rehab, eating lunch and enjoying a teaching conference, or preparing your signout to leave for the day) and running in that direction. Having been in the MICU, I have some experience with unstable patients, but I also have more patients to take care of. Once the patient's oxygen saturation has gone back up with a face mask, blood has been sent to the lab, the STAT portable chest xray team are on their way, when is it okay for me to resume my other activities? For me, not for a while. The best I can do is park myself at a portable computer outside the patient's room and try to move my other patients along, but it's hard to think about anything else except my patient possibly needing to be moved to the ICU.3. The absence of a member of your team. I'm fortunate to be on another great team, but when one team member is gone, things can get crazy. Sometimes they're at clinic or have the day off, and in addition to my work, I'm responsible for their patients, too. Double the patients to take care of! Whenever that's going to happen, we try to make sure everyone is "tucked" (e.g. discharge summaries and prescriptions ready for possible discharges, labs ordered, consults called, etc.) but sometimes you can't predict what will happen when you're covering someone else's patients. Also, having a covering attending or resident can throw everything up in the air as he or she can have a different interpretation of events and labs and want to completely change the plan. Of course, they'll say to me, "It's your patient, and your team has a plan. However, I'm not sure why you haven't considered this possibility." Well, when you put it like that, [...]



Goodbye, MICU! Hello, wards!

2007-09-15T14:48:11.568-04:00

Oh man, my last overnight call in the MICU was pretty rough. No sleep. All my other nights I slept at least 45 minutes to an hour, but the next morning I took the advice of my attending and just kept moving because if I stopped I would realize how tired I was. It's really my own fault for not getting any sleep. If things aren't too busy, I usually update future discharge summaries and note templates until 1 or 2 am. If all is quiet then, I aim to sleep between 2 and 5 am, but if a patient starts becoming unstable around then, sleep is hard to come by.

After a week on the wards, I surprisingly find myself missing the MICU. There's a wonderful sense of teamwork among your fellow interns and residents as well as with the nursing and support staff. They were all my new best friends because we depended on each other so much, and now if I pass by one of them in the hallway, we chat as if it's been years since we've seen one another.

However, there are things I don't miss about the MICU:
1. Overnight call every fourth night. It wasn't so bad at the beginning, but the sleep deprivation towards the end was making me a grouch.

2. Carrying the code pager and being on the code team. Although I had the code pager, codes were always announced on the overhead paging system first. I still get a catecholamine rush whenever there's an overhead announcement even though nine times out of ten it's something like "there will be a nondenominational mass held in the chapel at 11 am." Going to codes was fine because my role was well-defined (chest compressions, get an ABG, fetch anything that someone yelled out), but the constant state of readiness was exhausting.

3. Calling family members to let them know their loved one has taken a turn for the worse. I don't mind talking to families. I usually enjoy it, but breaking bad news isn't something that I want to do. It comes with the MICU territory because all the patients are so sick.

It's a bit of a shock to be on the wards again. My patients aren't intubated. They can talk to me, walk to the bathroom themselves, reposition for me to examine them, and often complain about the quality of the food. After being in MICU, these patients barely look sick to me, so I'm working on recalibrating my eyes. I can't say that the schedule is loads better than the MICU because some days I went home relatively early from the unit, but I can't emphasize how nice it is to sleep in my own bed more often.



Being "Doctor" Jess

2007-09-15T14:48:29.300-04:00

One of my first nights, a patient's family member came up to me and asked if I was one of the doctors, and after a confused paused, I realized that the correct answer was "Yes!"

I haven't yet introduced myself as "Dr. ____" to anyone yet. It's still too strange to me. I usually just state my full name and then say "I'm one of the doctors in the ICU." I've only signed my name with "MD" a few times and only when it seemed necessary to say explicitly that I'm a doctor, such as death paperwork. For my charting, I just stick with "PGY-1".

As hesitant as I am to shout from the rooftops that I'm a doctor. I'm realizing how much I love being one. My worst experiences in medicine have been when I just followed orders instead of questioning the plan set by my residents and attending. In the ICU, I'm on a great team that values my opinion. When I say I'm concerned about my patients, they listen, and we discuss the best course of action. It's hard to believe that I only have two calls left in the ICU, and then I'll likely be on the wards, which will present a new set of challenges.

Outside the hospital, I've been making an effort to see my husband and friends. There have been definitely sacrifices, such as missing a friend's out-of-town wedding and not seeing my husband everyday. However, this week after my usual post call nap, I went to see the new Harry Potter movie and have a delicious meal in Chinatown. Despite the constant exhaustion, I never regret going out. It makes me feel like a normal person for a little while. Even working up to 80 hours a week (and it's pretty close to that), I haven't had to sacrifice all the joys in my life. My Tivo keeps all my favorite reality TV shows, such as So You Think You Can Dance, for me, and I've been rereading my Harry Potter books in my spare time.

It's taken me three times as long to figure out what to say in this post. What am I really trying to say? I'm surviving, and it's not so bad. It's actually pretty darn good.



As the sleep deprivation sets in

2007-09-15T14:48:52.006-04:00

I woke up this morning and thought, "I can't believe I'm on call again tomorrow. Wasn't I just on call the other night?" Yes, I was just on call Saturday night and again tomorrow night. That's the beauty of a q4 call (every fourth night). On my noncall days, I used to stay in the MICU an extra hour to do paperwork--update notes, discharge summaries, or the signout, but now when the resident suggests I go home, I say thanks, grab my bag, and run out the door.

I now recall during intern orientation an excellent talk about sleep deprivation. The presenter said that trying to judge how impaired you are when sleep deprived is as accurate as doing so when you're drunk. During one of my first post call days, I woke up from my nap and tried to cook some dinner for me and my husband. I thought I was fine after my nap, but I ended up burning my arm on the oven door! How bad was my reaction time? I have a very nice, painful, second-degree burn to remind myself that I'm a poor judge of how impaired I am post call. We eat out now on post-call days!

I'm going to sleep earlier and earlier every night trying to remedy the sleep debt, but the truth is I'm just plain tired most of the time. I have 3 more calls in the MICU but I honestly don't think being on the wards next is going to be any easier on my sleep schedule or social life. All I'm thinking about now is seeing the new Harry Potter movie on my post call day. Just one more 30-hour shift until the movie and a day off!