Closing down this chapter...

I've decided that blogging about life in medicine isn't something I want to continue doing.  Not because it's not a huge part of my life with interesting and vexing elements to it, but because it is more stressful to think about those things a second time for the sake of sharing.  While some may find it therapeutic to share anecdotes from daily life that were anxiety inducing, scary, stressful, difficult, or harrowing learning experiences, much of medicine for me is now either "the usual," or stuff that just gets me frustrated.

I have participated in National Novel Writing Month during 2012, 2014, and 2015 - this year I finally beat the challenge and wrote 50,000 words in 30 days, despite my many obligations.  The setting was a Martian terraforming colony in a dystopic near-future, in case anyone was wondering.  I bring this up because in 2014, I thought I would try "writing what I know," which meant a comedic satire on life as a doctor, ending up someplace that you didn't think you would end up a la Northern Exposure, gaining insight into a world not many people have.  I found that trying to describe my life and the lives of my fellow residents in prose simply made me feel depressed.  It was much like reliving those experiences and was hardly cathartic or helpful.  It just enhanced my jaded attitude, which is already premature considering my length of practice.  I find it better not to think about it and just do my job the best that I can.

In that regard, I have succeeded.  I am pretty darn good at what I do for my level of experience and training compared to my peers, and will only improve from here.  I will still devote myself to providing the most evidence-based, clinically and personally appropriate care for my patients.  Whenever there is an unanswered question, I will leave no stone unturned and never stop working for them.  My passion for medicine and knowledge has not ceased, but I no longer have any desire to write about it at length for the sake of psychosocial commentary or sharing it with others.  One time is more than enough.

I am now halfway through my third year of residency.  I am poised to easily pass my boards come April, according to our yearly assessment test.  I still have a few residency hoops to jump through, but then I will be leaving and moving on to bigger and better things.  I find I prefer in my spare time after long days in the hospital or at the clinic, provided I don't have extra stuff to read up on at home, to ruminate on fantastical things and fictional worlds, or enhance other skills such as languages, musical instruments, art, knowledge of the natural world, etc.  I have enough medicine in my life, so blogging about it feels superfluous.  Time to tie up this final loose end here.  If there are any who follow this who are curious about the non-medical side of my life, though medical stuff does pop up from time to time there as well, you can switch over to my other rarely updated blog Embracing Obsession.  With that, adieu.

A couple weeks from being a senior resident!

It has been a long time since I posted, things have been busy.  I guess the big updates include... being advanced to second year, getting through nearly all of first year with essentially flying colors and strong recommendations within my program, passing COMLEX Step 3 with a better score than Steps 1 and 2, and making a few new friendships.  Made it also through my first year of marriage, and couldn't be happier.  I guess I don't know what else to say - I've heard from some people that some of my patients have been recommending me, or at least saying good things about me to other people in the community, which is about as unbiased an opinion as you can get.  

What's on the horizon...I get to be a senior resident, and I'm on the internal medicine service first, so I'm trying to mentally prepare for the task of being the first to manage the completely green interns.  The two I am with I feel optimistic about, but we will see what skills, expectations, and experiences they come in with and go from there.  I've got a bunch of handouts and things to talk about planned, without overloading them I'm hoping, so should be interesting.  I am looking forward to my vacation in September, which will be a more official 1 year wedding anniversary celebration, since there aren't any good times in the next couple weeks to celebrate...  

Anyhow, I am still alive, I'm feeling more confident in my skills and knowledge, and looking forward to as well as feeling anxious about the coming year.  Soon I'll have my DEA number assigned and have more autonomy, too!  Speaking of which...I need to start the paperwork for that...

Night Float...

Well, this is my second week on Night Float - 5:30pm to 7:30am.  The roughest thing isn't so much medicine itself, but rather only having 2 hours of time where you are awake at home.  I get home around 8am, sleep until 3pm if I want to get 7 hours, shower, put some kind of food together for "lunch," prepare a sandwich and grab some fruit for the night shift, and...well, there's not really much time for anything else.  Do some chores, maybe watch one episode of something.  

The nights themselves, for me anyhow, have been pretty relaxed.  It is rather nice to not have a senior staring over your shoulder, checking to make sure you've done your work the way you are supposed to, etc.  The extra responsibility isn't too much to shoulder, as I've been pretty self-sufficient for a while.  Since it's pretty much living at the hospital for 14 hours, it's a mix of work and play.  I've been going through American Board of Family Medicine modules (well, admittedly just one because it requires a lot of focus, but hey, that one I did is complete!), reading guidelines (management of supratherapeutic INR, hospital-acquired and community acquired pneumonia, definitions of leukocytosis, to name a few), and updating the patient list and of course admitting patients as I get pages, which hasn't been particularly frequent.  I also have practice board questions to go through.  

As for the play, well, I have my computer and my external hard drive, so possibilities abound.  Lately the other night resident (who is on a different service) and I have started watching Breaking Bad.  I think we can justify it because it gives us an inside perspective on all the meth abusers we see here, plus on giving patients bad news about cancer or medical conditions, and just seeing more and more of the drug abuser and patient perspective.  Plus it's good drama.  I can't quite justify playing Doom 3 the same way...

Only three more night shifts and then I get to go on vacation!  It is sorely needed.  Sometimes I feel less motivated, I need more time to do my own thing.  I am studying but it's hard to do that when you're trapped in one place.  Cabin fever a bit, I guess.  Lots of fun planned, mostly with friends and family.  Simply being in Davis will be a relief, where there are many other young educated people, enthusiastic about education and life, and where you feel comfortable walking around town to get dinner at 8:30pm and don't feel like you need to speed walk to your car.  Plus boba and fresh sushi!

Half way through Intern Year

Well, I'm still here, still doing the doctor thing.  It's been exhausting of course, but still trying to find time to do fun stuff.  I'm about ready to make my New Year's resolution list, usually I choose 10 things, but that will go on the other blog.  Recently I've done more Obstetrics, Medicine, and Pediatrics.  A recent development in the last couple weeks - I had heard whispers that some of the second and third year residents were concerned about one of the first years' readiness for night float, where we are the only one on the service without a second or third year helping us.  As it turns out, they all met and discussed the readiness of the interns, and they decided to swap me into this intern's slot and rearrange things so that that intern would be going last, to allow more time to be ready.  It actually works out well for me because now I get to have my two weeks on Medicine at night right before my two week vacation, instead of right after.  Also is nice to know that the residents think I'm doing well. 

Coming up for me is a week on psych, so I should be able to get a little bit of a break before I start on night float.  There have been difficult patients, challenging patients, all that, but it's hard to know when something is interesting enough to report.  Seen a lot of drama in the hospitals, luckily I'm staying out of all that.  Anyhow, I'll try to think of something good to write about... just working and working and working for now!

Night on Call

Well, here I am, another night in the hospital. I decided to plan ahead and took about an hour nap, maybe slightly longer, before coming to work at 7pm, and took a 100mg caffeine tablet. Just took my second 100mg tablet now, at 12:45am. I was anticipating it being a nonstop night, however everything is all organized now, did a vaginal delivery, my notes, etc. and now... just waiting for admits or for all hell to break loose. This is just a weekend call though, 7pm to 11am the next day (at most). OB and Pediatrics. This past week and this coming week I am on surgery. It's been a nice change of pace, and getting home at a more reasonable hour as well. My attending looks and sounds exactly like Hugh Laurie on House. It's rather uncanny. One of his patients even pulled me aside and asked, "Does Dr. so-and-so look like Dr. House to you?" I don't know if it's surgeons in general, but he also has a lot of interesting stories. My previous surgery rotations were also filled with story telling. I wonder if it's because sewing, cutting, spreading, etc. isn't super cerebral and you can just chat while doing it. I had my in-training exam last week - I kinda just rushed through it... I know I probably should have taken it more seriously but...meh. Just wasn't in the mood, and at this point I feel like either I know it or I don't. Well, next weekend I get both days off, yay! I'll be driving over to my parents for my dad and sister's birthday - should be fun! Anyhow... guess I'll go back to studying random stuff... what to study, what to study...

Starting on Obstetrics

Well, after having four nightmares in a row about starting Obstetrics and hearing horror stories about staying horribly late and being super busy and stressed all day charting, I wasn't expecting this OB rotation to be as enjoyable as it is.  It's fairly relaxed, the Attendings are nice, and the first day I got to deliver two babies in a row, delivery times were 11:44am and 12:07pm, and they were in rooms across the hall from each other!  Felt pretty exciting.  I also have all the notes I need to write prepared in templates, so I can get things written a lot faster.  Today I delivered another baby and the family wanted me to take a picture with them - it's definitely a different environment than Medicine or ICU.  

Vacation was great, though I was sick for the first few days - back to the grind.  The weather is getting cool and routine is returning after a lack of much of a schedule for two weeks.  A few things I still have to get around to are my loans, which will be due December 7th, and I need to schedule my Step 3 exam.  For now though, things are quite peachy.  After this, is Pediatrics.

Medicine and ICU

Phew, it's been exhausting!  I had a month on internal medicine service where basically every day for 12-15 hours I'd be at the hospital managing a panel of patients and admitting new ones from the emergency department.  It was rough, and there was plenty of weekend hours put in as well.  I had an easier time of it compared to some of my colleagues because, again, I'm pretty comfortable with electronic medical records and working with computers in general.  I didn't have any real time to do readings, however, so now that I'm on ICU which is more about learning than having any intense responsibility for patients, I'm finally able to catch up on all the stuff I wanted to review.

For example, while on medicine service I saw at least 3 cases of "acute pancreatitis," with two legit cases and one (maybe more) case of not-so-legit pancreatitis.  I finally had time to go to the American Gastroenterological Association website and find their guidelines for acute pancreatitis and read up on the latest "word" from the experts.  We definitely weren't managing the patients ideally, we were managing them fine but not particularly ideally.  That's one of the challenges in medicine is that it's a constantly evolving field and you have to stay super up to date on the latest treatment protocols and what the studies are saying.  We even have a website that is essentially a wikipedia for physicians, called "UpToDate" - the name says it all, it's where doctors go to stay up to date on information.  However, UpToDate isn't always the best organized website and I don't particularly like how it's structured, plus the articles aren't necessarily peer reviewed by experts in the field based on only the best, most solid, studies.  That's where specialty society guidelines come into the picture.

In ICU, we actually had a pretty 'exciting' semi-TV moment of emergency patient care - an older woman currently on a ventilator suddenly started having blood come up her nasogastric tube, so essentially she suddenly developed bleeding and her vital signs showed she was in distress.  The rooms in ICU should be bigger than they are, and this one felt particularly cramped.  The crash-cart was between the end of the bed and the opposite wall, and I was on the inside half of the room and my attending (a very intelligent younger doctor who looks more like a college student than a seasoned ICU doctor) literally ran over the bed to get to my side so we could insert a chest tube - he didn't have a gown on (just a white coat with the sleeves rolled up to his elbows) and ended up getting sprayed with some of the fluid when the tube was in - he had eye guards in place at least (aka glasses).  Then we immediately pulled from the other cart a fiber optic cable to see where the bleeding was coming from and it was essentially seeping from every surface in her lungs - diffuse alveolar hemorrhage as they call it.  No source to suture, cauterize, or slap a bandage on - just have to keep giving her suction, oxygen, and start steroids.  She had developed a chronic lung condition over the past year and it was not going well.

Heroics aside, ICU can be a very difficult place.  We had a young girl come in and die within hours, and it shook the ICU physicians and staff for the next several days, and it made news in the community.  It's not part of the plan for young, otherwise healthy people to suddenly die of overwhelming bacterial sepsis, but it happens and there's very little you can do to stop it.  Also, one of my patients who I had been managing a week prior on the normal hospital floors for a pneumonia and fluid in her lungs, a very sweet older woman with mild Alzheimer's dementia, ended up choking on her morning breakfast and ended up in the ICU on a ventilator, likely with brain damage from lack of oxygen.  She had been on a dysphagia diet, but hadn't been officially evaluated for her swallow by a speech therapist - her eating challenge wasn't obviously apparent, it was more that she would eat too fast and choke slightly on her food rather than any physical deficit.  I hadn't seen her since, and she was probably going to be discharged from the hospital that day or the next to a rehab facility and then an assisted living home.  I don't know if it would have made a difference to have that swallow evaluation or not, part of me thinks it would have gotten her out of the hospital, home, and then maybe a little longer in this world, but on the other hand, it may have only been a matter of time before something like that happened.  If she'd been switched to a liquid only diet, would it have changed anything, or would she have developed an aspiration pneumonia later and ended up in ICU in a month anyway?  She died that night - no code was called, so it's likely the neurologic findings were dismal and the family agreed to withdraw life support.

On the more positive side of things, I've been appreciating more how much patients like seeing their doctor in the hospital, even if it's a resident physician.  It's still hard for me to see myself as a REAL doctor, but we are making decisions for the patients and know them better than the attendings.  We check on them two or more times a day, not including all the calls to the nurses, reading up on previous visit notes, calling their physicians and specialists, and checking and ordering labs and radiographs, which patients don't get to see.  After I moved to ICU service, I went back and checked on one of my other patients from medicine a few times, as she was an especially complicated case, and helped the new team manage her discharge a bit.  She was really appreciative that I was still coming and managing her - she had had a somewhat 'flat' affect and wasn't all that talkative or cheerful so I wasn't sure initially if she even liked seeing me, but she made it clear later that she was glad I was still involved in her care.  Another patient I had discharged a couple weeks ago, a young person who had gotten frustrated several times while in the hospital about being kept there for treatment and had landed himself there by some fault of his own, came back today to get some paperwork filled out and actually said of the doctors who were coming to see him he liked me the most and was glad to see me.  I was his regular doctor, and when people are in pain and are grumpy it's hard to tell if they're mad at you or if they think you should be doing something that you're not doing.  I'm glad to know that even the patients that I think are not satisfied with their care do actually appreciate the work we do.

In another example of networking and working as a team, I talked to a nurse who had semi-challenged me on a medication decision.  Long story short, I thanked her for voicing her concerns, because after the fact I went and re-examined the data behind the study that a senior resident had very emphatically told me was going to be the new standard of care, and decided that the risks do not outweigh the benefits.  Initially she may have thought I was blowing her off because I told her my justifications for wanting to prescribe the medicine which, don't worry folks, never ended up getting taken by the patient because he felt like refusing meds and even if he had gotten that one dose before I discontinued it, it's the kind of medication that takes time to build up to a therapeutic level.  I didn't HAVE to talk to her about it, as it wasn't really an issue, but I elected to for a number of reasons.

First, it's important for nurses to feel respected and not marginalized in a very hierarchical system where doctors are traditionally seen as their opponents, not partners.  We rely on them for patient care and we want them on our side and voicing concerns, when legitimate.

Second, nurses talk - if she thought I had blown off her concerns, she probably would have gone complaining to all the other nurses that I'm a bad doctor and endangering a patient, or that I'm one of "those doctors who think they are better than nurses," and I have to work here for the next three years.

Third, if nurses think their patients are in danger and that physicians aren't listening to their concerns, they will start doing things on their own - which in rare cases does help patients, and in many other cases doesn't, like times when nurses think a doctor has prescribed too high an insulin dose, pretend or abstain from giving it to the patient, and in the morning the patient has blood glucose > 300.

Fourth, good karma.

Well, at the end of this week, I'm free for two weeks to do whatever - my first vacation of intern year.  When I get back I get to jump into OB/GYN... Not looking forward to it very much.  On the plus side, I got my call schedule for next month and I won't have to do a weekend shift for the first two weekends, which is great since on the first weekend there is a Cardiovascular Symposium I'd really like to attend!  I've got a bunch of nice stuff planned for my vacation, and can't wait to get started, but I'm also really liking the pace and learning opportunities in ICU.  Having an attending who likes discussing the latest care guidelines and is passionate about evidence-based medicine is always very invigorating - it's the most academic we get, as clinicians.  Time to go read more stuff!