Category Archives: Residency
So I don’t mind if another doctor or nurse disagrees with something I order, or the way I am doing something. That said, there is a proper way that you let a person know that you disagree with them. Usually, it involves being discreet, polite and generally non confrontational about it. Let’s review an example of how NOT to do it…
The patient is a young, non sexually active female presenting with RLQ pain, who was found to have a hemorrhagic cysts on imaging. From across the far side of the ED, where the admitting resident is doing her paperwork.
Admitting Resident: (at loud volume for all to hear). Are you taking care of this patient in bed 12?
Me: Yeah, I’m just signing out the patient now, what can I do for you?
AR: I don’t see on the chart where you documented your pelvic exam (how classy of you to point that out!)
Me: That’s because I didn’t do one
AR: What do you mean you didn’t do one? Why not?
Me: (now getting annoyed, I’m happy to talk about if you think she should have one, but don’t shout it across the ED). Because the patient didn’t need one.
AR: Her urine shows 5-10 white cells which means she might have PID.
Me: Well, as I DID document on the chart, she’s never had sex, which makes that theory impossible, and she has a finding on CT which perfectly explains her urine.
AR: I really think you should do one, as she could have PID.
Me: She’s never had sex, and I’m not about to make my gianormous fingers her first experience.
Me: Fine, well, I’ll just have to do it upstairs then since your are failing to do a thorough assessment here.
(Really? We going to play the passive aggressive game? Okay fine, the ED attending is sitting two feet away, who also happens to be the chief of the department)
Me: Dr. X, the girl in room 12, the medicine team is curious as to why we didn’t do a pelvic exam. She’s never had intercourse, but the medicine team feels her 5-10 white cells on urine dip are indicative of PID, despite that she has no malodorous discharge, dysuria, bleeding or frequency. Do you want me to do an exam on her before she goes up?
Dr. X: She’s never had sex?
Me: She’s denies it up and down
Dr. X: (Turning to the medicine team). We don’t do pelvics in this ED on children who have not had intercourse. What you’re suggesting can be considered sexual assault and battery, so if you’d like to assault your patient, you can do it outside of my department.
Booya! (Fist bumps were had by ED residents all around.)
So that whole situation could have easily been avoided. The medicine resident could have been like “hey, can I ask you something about this patient’s chart?” Which would have piqued my interest, I would have walked over, we could have talked about it, discussed why or why not, I wouldn’t have had to throw her under the chairman’s bus wheels, the nurses wouldn’t have had to comment what a you know what she was when she left, and all would have been well. Just sayin’.
It’s 3am and it’s myself and one other attending struggling to keep up with an unusually busy night. From outside, I can hear a screech of brakes, which isn’t all that unusual is there is an intersection 20 feet from the doors. But about two minutes later there comes a shout and the sounds of commotion from the triage area, the main doors to the ED slam open and medics are wheeling some a guy towards Room 2, our one and only real resus room. “He’s been shot in the chest” one of the call out “He drove him self in and we grabbed him in the parking lot.” “Does he have a pulse?” “Um, if he did, he doesn’t now” “Shit, get him on the bed and start CPR”.
And so we did. We got back pulses. I got him intubated on the first attempt, despite that he vomited in the middle of it. We don’t deal with trauma at this little hospital, we stabilize and then send them up the road to big brother. And someone has to make that happen, so the attending looked at me from the end of the bed “You got this?” “Yeah, I got this”. And for really the first time, I felt like I did. I don’t know when that happened. When did I suddenly know what to do for a guy who’s been shot in the chest and has lost his pulses. It’s crazy. It’s awesome. I got this. I finally feel like I can think one step ahead. Airway is secured, satting 100%, good breath sounds, but I’m getting set up for a chest tube in case we can’t transfer, grabbing a needle to decompress his chest if his pressure or sats suddenly drop. I’m eyeballing the thoracotomy tray, making sure it’s nearby if he looses pulses again (no, I wasn’t NOT about to crack his chest on my own, but at this point, I could start it while someone got the attending), if this second IV doesn’t go in smooth, I’m putting in a cortis line. 2L are up and running, how’s that chest x ray looking? No pneumo? Okay, looks like a hemathorax, but he’s holding steady on his sats. What? He’s ready to go already? Awesome, get him out of here, the can put the chest tube in when he gets there. I’m not going to stay and play when he can go now. But better get some more sedation ready for when he wakes up on the ride though. And so it went, we got him out, alive and stable. We didn’t actually have to DO that much beyond the basics of ABC, but the point was, I was, or at least felt I was, ready for whatever needed to be done. And that felt pretty damn awesome.
First week of 6 12 hour shifts under the belt at the new hospital. Well, 5 shifts, as the tradition of getting violently ill every time I start a new hospital and exposed to the local flora of disease held true and I had to call out for one. But holy hell what a different setting that last year. Last year, was a major urban academic hospital in one of the countries biggiest cities. This year it’s a community hospital, with ER and Medicine as the only residencies present, set in a community that doesn’t exactly have health insurance. So gone are the handful of guys every night who were too drunk to get into the homeless shelter who just want a sandwich, replaced with people who haven’t seen a doctor in 10 years and now have some serious pathology going on. The learning curve has been amazing. I felt like I learned more in this past week then I did in a whole month last year. The best thing? Maybe it’s cause it’s a real hospital, maybe it’s because we’re R2’s now, but we’re treated like colleagues by the attendings and not 4th year med students, which was the case last year. And it’s a pretty great feeling. I feel like I’m a “working” doctor for the first time, finally getting an idea of how this is going to all work out in the real world.
One of the good things about being in the ICU, is that we are exempt from going to conference. But this past conference was EMS themed and I was really bummed that I didn’t get to go, especially because the residents that did go, got to do this…
Yes, it was only a controlled burn at the fire academy, but still way better than your typical day of lecture. Maybe next year…
While I still have an ICU and an OB rotation left, I’m done with my emergency medicine shifts, at least as far as my intern year is concerned. A couple of brief observations, about 1500 hours into this whole shebang:
- I still love this job
- Being an intern was not as bad as everyone made it seem like it would be
- Being deemed “good” at this is as much about how you relate to the attendings as to what you are doing for your patients.
- For as often as they talked about appendicitis in medical school, I never once saw a case of it
- Certain patients are just impossible as human beings. It’s these people that suck the joy out of the job.
- There are plenty of other kind, caring, joyful patients that balance them out.
- Patient continuity exists in the ED
- Traumas are good for two things only; taking up the last 30 minutes of shift and getting another service to take the drunk combative patient off your hands
- A bag of saline and some Tylenol can make most people feel better.
- If you do a favor for a nurse, it will be paid back in spades.
- The best two ways to earn your way into the good graces of nursing 1) Be in the room when the patient is sick 2) Get the food tray for the patient yourself.
For the past two weeks I’ve been back in the ICU. 6am-7pm or later for 12 out of the past 13 days. It’s been hard at times, but also very rewarding. Things that were challenging the last two times around are now becoming old hat. You don’t realize you are learning all this medicine, it’s not an active process as during these months you have absolutely no energy, much less time, to read when you get home at night. Somewhere along the way it just sort of happens. Without really doing anything different, you start to have a better grasps of your patients, what needs to be done for them, what others are doing for them, what’s going to work and what won’t. The flow of information feels like it starts to slow down and becomes a bit more manageable. And it’s nice when the attendings start to address you more as a colleague and less as a med student. It feels good to know they are starting to trust you just a little bit.
As I walked into the ED to start my shift yesterday I overheard the attending on the phone “We could take two level 1’s, a level 2 and about 5-6 walking wounded”. After another moment he hung up and turned to the charge nurse. “There’s been a major accident and we’re going to have incoming casualties”. Overhearing this, I could help but doing a little internal fist pump. While obviously I am not excited about people getting hurt, it’s phrases like “incoming casualties” that get your blood pumping and adrenaline flowing, and it’s one of the reasons I love this job. Things rarely turn out to be as bad as they initially sound and we ended up getting only 2 level 2’s and 3 walking wounded, plus a few just walking. The shift didn’t let up from there and I can’t think of a shift where I have been running like I was on this one. It was the first shift were I was managing several really sick people all at once. And while it was hectic, and I probably did a wretched job on my charts, and probably effectively ignored my not so sick patients, I think I did okay in the big picture. I had one guy trying to bleed death out his rectum, another trying to cut off his own oxygen supply, another getting all septic with a hemoglobin of 5. And I had a 1st year medical student trailing along all night who had me constantly fighting the urge to blurt out “Just please stop asking questions for 2 minutes so I can write one complete sentence in my chart here without being interrupted by something”. Not to mention the drunk assholes who were trying to land spit luggies on our desk while we worked. Which was fun in a way as I got to blow off a little steam breaking out a few pressure point control moves while we restrained and masked the guy. Who by the way, was later seen making out another drunk patient in one of the back hallways of the ED, while still restrained. So overall, yeah, it was a pretty awesome night and I pretty much floated home through the late night lights of the city.
I was one of the “lucky” ones to work the Thanksgiving holiday this year and it turned out to be quite a bit of fun actually. We managed to pull off a pretty successful dinner to. A few observations from the day…
- One of the nurse’s brought in a turkey fryer and a HUGE bird, and from 10am on, the ED the smelled absolutely amazing. Which was great, but also bad as the “ED regulars” were that much harder to get out the door once we denied them their narcotic scripts.
- The city shelter’s must of been doing their holiday meals around noon, as there wasn’t a single “transient” in the ED until about 2 pm. Then there was a sharp uptick which continued on for the rest of the afternoon
- Which meant, that for the morning at least, it was only legit ED patients. My first few patients were COPD exacerbation, extramural child birth, assault victim,
- There was a near three hour stretch were the waiting room was actually empty.
- Some thing’s you don’t believe until you see. I always thought those stories of “oops I gave birth” were just exaggerations. But this one today, the mom thought she had to move her bowels, so when she sat on the toilet, oops, there’s baby’s head. Both mom and baby did great, despite the baby having a close call with a swirley.
- Friday is going to be busy. It’s not that people stopped getting sick on Thursday or something, they all just put it off being seen until Friday. CHF city I suspect.
It’s been a quiet night at work in the ICU. It’s330am, and my senior has been asleep since about 9pm. A few fluid boluses here and there and the ship has pretty much been running itself. Which means I got to do a little reading at work tonight. I’m about 5 months into this whole being a doctor thing now, and I’m finally starting to get to the point where everything I read, see, do, learn is not brand spanking new, and that’s a really good feeling. I feel like things are starting to connect a little bit here and there. Last night, after intubating a patient, my senior was telling me his personal style for choosing which paralytic agent he uses. Then tonight, I ended up reading about these agents and everything he was saying last night makes perfect sense. Last week I read a paper on steroid use in the ICU for septic patients, and they kept referring to those study subjects that had been given etomidate in the ED as a special group of patients. But now after reading more about these drugs for rapid sequence intubation tonight, I can understand why (etomidate may (or may not) induce adrenal suppression, which would be important when intubating septic patients as adrenal suppression prevents steroid response which limits the bodies ability to support blood pressure, organ perfusion and mobilize defense to fight infection). So yeah, the lattice of my EM knowledge has a vine or two growing on it, slowly but surely, and I’m looking forward to filling the rest.
So, I am on “scholar” this month, which means I am not actually seeing any patients for the next three weeks (thank god, sooo needed a break). Thus, the post frequency might be down a bit for the next while. Since posting about my “hiatus” last week, I’ve gone through and taken down and posts that might even be close to violating any sort of rule, or could even remotely be able to recognized by the person I’m talking about. I realize that this idea is impossible in a way, as even if you falsify a story, it’s new form is going to describe someone out there somewhere.
In talking more with faculty, the resident’s who got in trouble were doing things like posting cell phone pictures of patients films on face book and twitter, which is asking for trouble obviously. Even though the films had no identifying information on them, I agree that this is still inappropriate to do. So, I plan to keep on keeping on, just with more of an effort to be cautions and mindful. Looking back, there was definitely a few instances where I could have done a better job. So as always, thanks for reading. If you do see something that you think might come close to crossing a line, please do let me know