ERs, clinics, exams, applications and nightmares

Another month of family medicine and I'm hooked. I really enjoyed my elective away. Office practice was interesting and well paced for my liking.

My month in emergency has been, as expected, a roller coaster. There were days that were boring, days I didn't have time to think, days I loved it and days I thought the time couldn't pass fast enough. I've had staff who I get along very well with and there have been staff who ask me two questions about a patient and order a test, sometimes without even seeing the patient.

Residency application time is quickly approaching. That constant nag of "did I remember to do that?" is going to make me lose sleep. So many documents and reference letters and forms and deadlines that I'm ready to explode. I feel like I gotta screw my head back on. My focus is all over the place. For example, I just realized that I completely forgot about a lecture yesterday. We get a grade based on attendance at four lectures, I missed one. Also, I just poured a tea and forgot about it. I can't get things done right now. I'm exhausted from a long, eventful month, and not in a good way. Between the GF's friend's death, my grandmother in the hospital, myself having a run-in with the ER as a patient, constantly changing shifts and nightmares for a good month I'm in need of a break.

A break. Guess what I'm doing next? ICU! By no means is this next month going to be a break. In fact, I have a heavy load in terms of rotations and work up ahead. Geriatrics at one of the busiest, craziest hospitals in the city, one that puts the most pressure on students to be assembly-line workers instead of students learning the craft. Up next, plastic surgery, where clinics that are WAY too overbooked and crazy surgeries, with anatomy that I desperately need to refresh on and a shelf-exam at the end of that month. Followed by: Internal Medicine consults! Where I'll be tested to remember the Zebras of medicine, the "Who'd have thought it would be that!" area.

And then finally, a month off. A month with no lectures, no clinics, no wards, no consults, no exams. Whatever shall I do with myself? Oh wait! I know! Interviews! I can only hope that by then I've figured out if I want Internal or Family Medicine. I'm sure it's Family. But the added stress of knowing that I really can't screw up because of the added thought of a Couples Match, where my interview isn't just MY interview, it's an interview for OUR application, TOGETHER to a residency.

But I want family medicine. A program where, usually, the programs are trying to get YOU to go to THEIR school. Instead of the usual, US trying to convince THEM to let US into THEIR school.

Have I enjoyed the hustle and bustle of the ER? Yeah. Was it what I thought it would be? No. Do I think I need to see what it's like in residency to make my decision about doing a fellowship in ER after I finish family medicine? Absolutely.

Ok, I know. I haven't blogged in ages. I could tell you all kinds of stories. I had a guy come in with the cops, another guy who avoided eye contact and would yell over my voice if I tried to interrupt him, one lady who had fibromyalgia and who cried hysterically when I examined her collarbone which had nothing wrong with it. I've had patients look at me like they would kill me, I've had others shake my hand and say "Thank you! You're going to make a great doctor" after I took the time to adequately explain things to them instead of barking orders at them like my attending did. I saw a lady with epiglottitis who became stridorous two hours after I first saw her and needed to be intubated in the OR with a tracheostomy kit ready. I saw a man with generalized fasciculating muscles, who probably is going to be told in the coming weeks that he has ALS or Lou Gherig's Disease. I had one man just recite numbers to me over and over and over and over and over and even when I told him "SHHHHH" so I could examine him he kept going and going and going and going and trying to blow out the fire on my stethoscope.

I love my job. I can't imagine doing anything else. Well I can imagine, but I can't imagine getting as much excitement out of it and feeling inspired to better myself every day, while doing something else.

I just need the nightmares to stop and my concentration, when I'm out of the hospital, to come back.

Time to remake my tea...

Priorities

I loved my internal medicine rotation. Did really well in it too. Loved my family medicine rotation, did really well in that too coincidentally. I was recommended for a career in both, nominated for prizes and everything.

The hard part is deciding what kind of life I want. I have a feeling I'd be happiest in family medicine. You want to know why I hesitate going into family? I wonder if I'd ever be good enough at it; jack of all trades, master of none. Part of me is attracted to being an internist and being "god of the hospital" as one of my residents once described rural internal medicine. A part of me would feel safer knowing more about less things. There's a bit of comfort in not having to deal with pediatrics, psychiatry and obs/gyne. But would I lose that sense of whole person care and following families for years? I think I would. I think I like dealing with preventative medicine as well as dealing with really sick people, which leads me to believe that I would be happiest in family medicine.

You know, today, I was outside for two hours. I sat in the sun with some friends from school, enjoyed life. I love my job, but I love having time to do things more. I think I'm tired of passing up opportunities and saying "oh I can't do it, cuz I'm so busy with school."

I don't think that I'll be any less of a clinician if I do family med. I think that it is what you make it and if you want to be good at your job, you can do it in either field.

We'll see where life takes me, but the idea of being a staff in 3 years and setting my own schedule makes the next little while seem all that sweeter

I'm out...

My first death

I managed to go through Peds, OB/GYN, General surgery, cardiology, family medicine and hematology/oncology without having one of my patients die.

Today that all changed.

Mr. K. was an 80 year old man who presented to the emergency room with fever and bacteremia. While in the emergency, he had a hemorrhagic stroke and went into a coma. He never came out of that coma.

That was 3 weeks ago. I met Mr. K. and his wonderful family yesterday. He was stable. We were trying to get a PEG tube put in for feeding and then we would send him off to a long term care facility. He had a Glasgow coma scale rating of 3/15 meaning that he wasn't opening his eyes, he wasn't talking and he wasn't responding to pain. This morning, his pupils were both non-reactive and he was starting to have Cheyne-Stokes breathing. He was "coning," meaning that his brain was starting to herniate through the foramen magnum. We made him comfortable with morphine, the family was called in to be with him. They started a religious chant when they were all together.

At 15:05 I was called to the room. Mr. K. was dead. I checked for breath sounds, heart sounds, breathing movement, pupillary reaction and corneal reflex. He had none.

15h10, we declared him dead.

My attending staff, who I aspire to be a fraction of the type of doctor he is, asked me about an autopsy. He then asked me if I had ever asked for an autopsy and I replied "no." He graciously showed me. He was empathetic, calm, reassuring to the family. I can only hope that one day I'll be able to talk to people the way he did in such a hard time. I guess that it will be like everything else in medicine that I've been uncomfortable with, I'll get it with time.

I'll never forget Mr. K., even though he was comatose when I met him, and I'll never forget his family.

Cardiology

Well, the holdiays are here and I'm on elective.

I'm doing cardiology which is cool and interesting, but also very advanced. I'm trying my best, I'm learning a lot. Of course I can't keep up with residents who have done this before and are trying to learn the best treatment etc.

I got to see coronary angioplasty with a stent being placed at the angiography lab. I got to cardiovert someone who was in atrial fibrillation, yeah, I got to say "we're all clear?!" and use the paddles. It worked the first time, so I have a 100% success rate hehehe.

I'm learning something about myself as well. I don't know if I'd want to specialize. It's really cool to be working with someone who knows everything there is to know about cardiology but I really don't know if I would be bored or not eventually. But a part of me is now thinking that I want to do internal medicine just so I would have added knowledge compared to doing only 2 years in family medicine. That's what I'm thinking right now, we'll see what I think when I get into family medicine.

The night shift

The night shift. There's no other students. There's only one junior resident, one senior and one staff. I did 8pm-8am last night.

I saw a lady who went into labour at 24 weeks in her pregnancy. The baby was so tiny, 700g. The parents were pretty brave considering; they were taking everything with a strong face, even though I'm sure they were terrified. I mean, their newborn baby was so premature. It came out fighting, waving its arms and kicking its feet, it even tried to take a few breaths. The pediatricians took the baby straight into the resuscitation room to intubate it and get it to the NICU (neonatal intensive care unit). It had no 'meat' on it, no baby fat. I talked to the resident in pediatrics after, the baby was doing fine but these kids usually do okay for the first day and deteriorate after day 1.

I saw another baby born at 24 weeks during my last rotation. The mum had the baby come out, basically fall out, when she went to the bathroom. The baby was so hypothermic, temp was 31 degrees (premature babies under 2100g can't keep the body temperature up on their own). The baby passed away a week later.

Last night, around 2h45, I had a consult in the emergency room for a perimenopausal lady who had such a heavy period because of a fibroid that was basically making her bleed to death. She had passed out because she had lost so much blood. The messed up thing is that she came to the hospital around 16hoo. Our service only found out about her at 2h45!! She needed a blood transfusion because of the bleeding. It's not like we were so busy we couldn't have seen her earlier, we only found out about her at two in the morning. So here was the lady, basically bleeding to death in the hospital. She was still very pleasant with me, a real angel. People amaze me at how they're in such terrible situations sometimes and yet they still have it in them to be nice and polite. It's quite charming. There's also people out there who are monsters all the time, even when they aren't sick.

I helped repair a woman's vagina after it tore, very minimally, last night. The staff literally guided my hand through the whole thing, but it was still cool to stitch someone up. For the same lady, during her delivery, I applied "fundal pressure." This basically means that I stand beside the lady, put my hands on her belly and push down while she's pushing to help pop the baby out.

There's construction outside of my apartment right now. Oh! Oh! Guess what! There's construction INSIDE my apartment too! Honestly, I don't know how people work nights. Going to bed when the sun is up and waking up when it's setting is awful. Yeah, I know it's my first day, but I really don't think I could ever get used to this. Luckily, there isn't really an area of medicine where work is only during the night.

I also had to assess a lady with stage 4 ovarian cancer who was terminal, last night. She couldn't talk anymore, it sounded like she had bad pneumonia.

It's not all fun and games, but I'm still having a great time.

Obs

This week, I work the 11pm-8am shift at the birthing center and answering consults in the ER.

My first week in Obs, I almost got amniotic fluid all over my shoes, I got sprayed with umbilical cord blood and had maternal blood splashed all over my scrubs when the placenta came out.

We had a baby born on the bed just minutes after we saw a lady and decided she was nowhere near delivering. We heard the nurse screaming over the intercom for help, but by the time we ran back to the room, the baby was lying on the table between the mum's legs, still attached, crying.

I had one lady look at me halfway through my questions with fear in her eyes and saying to me "I NEED to push and I don't know why!"

I watched one dad start crying when the baby delivered and his first words with his daughter present were "oh fuck!" Minutes later, watching her on the resuscitation table he looks at the mum and points to his chest and says "that's mine!"

I've seen fathers scramble from the baby to the mum and back not sure who to pay attention to.

I'll have more stories for sure, probably even by tomorrow.

Off to work

Gyne

5:20: I rise from bed. Grumpy, but well rested since I went to bed at 9:30 last night. I make a pot of coffee, delicious, delicious coffee. Two bowls of cereal later, I shower, dress, groom, drink 2 coffees, read and print out a summary on endometriosis and head to the hospital

6:45: Arrive at the hospital, review the teaching case that we will go over this morning

7:00 - 8:00: teaching session on endometriosis (endometrial tissue normally lines the inside cavity of the uterus, sometimes we find it where it shouldn't be. It's been found in women's ovaries, tubes, ligaments, lungs, eyes, mouths, noses. So let's say it's in the nose, they get a nose bleed whenever they get a period. Thankfully it's rare in the nose, eye and lung; it tends to stay in the pelvis)

8:00 head to the gyne wards, rounds are over, divide up the scut and head to the OR.

9:30-11:30 watch a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy. I don't get to scrub in because there's too many residents. I basically watched a woman's uterus, fallopian tubes, ovaries and her omentum (an extension of the tissue surrounding the stomach) be removed. Her ovaries are huge, they're bigger than any man's testicles but that's not good. She's menopausal, so her ovaries should be shivelled and small, and there's visible cancer eroding though the surface of both of them. After the uterus, ovaries and tubes come out, I go to the pathology lab with the surgeon to watch them measure everything and slice the ovaries open. It was pretty cool, but not very good news for the patient.

11:30 I head to the ER because I'm paged to see a woman with pelvic pain. I take her history, examine everything except her private bits (we have to be supervised) and head to class at 12:00. (don't worry, the resident ordered an ultrasound while I was in class)

1:00 No ultrasound for my patient yet. Things don't happen at the snap of a finger in our system. I collect more info from a patient's chart for a presentation on Friday for tumour boards

2:45 Head back to the ER to see the ultrasound results. Things look good. The resident and I basically decide that all we can do is examine her and get a culture to see if she has chlamydia or gonorrhea, but the patient took off. We wait a bit, going over the differential diagnosis and realize that she might have been abused, but we never got a chance to ask. We check the waiting room, she's nowhere to be seen. We document her disappearance and tell the unit coordinator to page us if she shows back up.

4:00 we get teaching from our chief resident.

5:00 head home to eat and prepare tumour board presentation

6:00 speak to the missus

7:00 buy coffee after remembering that I ran out this moring

7:30-9:00 prepare presentation. Wrap up as much as I can

9:30 Feeling sleepy... So sleepy... Feels so good

10:00 zzzzzzzzzzzzzz