A couple days off

It's been nice to have an orientation month to ease into things. I spent the weekend home moving my stuff out of my mom's house, met a few of my med school friends for dinner in Boston, came back my apartment with beer supplies in hand and brewed up a nice Belgian Witbier with a clone of Abita's Turbodog on the way sometime this week. I also managed to fit in an 11.5 mile run yesterday and one of my classmates took me into the Adirondaks for some backcountry crack climbing and assorted shenanigans.

I think I work on thursday and friday followed by a weekend of backpacking in the high peaks, followed by vacation the first week of August, my birthday plans of packing a UHaul full of my girlfriend's stuff and driving FOREVER from Arlington, VA upstate...but I guess her moving in is my present.

Quick story: Reason #1 why upstate NY is awesome- the people are so damned nice. I lost my wallet at a lake-side beach this evening after hopping in to cool down. By the time I got home, I had a text from one of my co-residents notifying me that I had lost it and a call from a guy who had it in his posession and was willing to meet tomorrow to hand it off. I am so lucky that I didn't get my life stolen, my meager finances ransacked, etc.

Novel Homeopathic Therapy

3:40AM- Rash

click-click...sweet this will take 5 minutes to dispo...WTF

Nurse was convinced it was scabies...it wasn't.

Turns out one of the frequent flyers was in not for his usual drunken altercation with facial trauma but for his poison ivy...for the 4th visit in 48 hours. For the fourth time, he was discharged with instructions to GO TO THE PHARMACY AND GET SOME HYDROCORTISONE and BENADRYL.

Dr. Bostonian: Have you gone to the pharmacy yet?...hydrocortisone costs like $3

Frequent Flyer: I don't have ANY money...do you have any here, any samples?

Dr. B: No, we're the EMERGENCY DEPARTMENT...Have you tried anything else?

FF: Yeah I rub alcohol on it, which doesn't help

Dr. B: Rubbing alcohol?

FF: No...beer...I figure it has alcohol in it and that might help

Dr. B: Hold off on 2 beers and buy some hydrocortisone...this will go away with time

FF: No samples???

Dr. B: NO...pharmacy won't even send that here! This is an emergency department...poison ivy is not technically an emergency, you follow up at the free clinic tomorrow and maybe they can help you out with samples. I have to go deal with a sick patient, I'll get you your discharge papers...

In his defense it did look very itchy...

47 f-ing RBCs and other fun...

So I got to do my first LP in the department the other day...heavily supervised by one of the more intimidating docs. He was actually quite the patient individual while teaching one on one. He did a great job of teaching in a friendly manner and not making the patient flip the fuck out because I'm doing it for the first time...

The LP goes smoothly, and I'm in the spinal canal on my first stick get the opening pressure and everything looks great...I'm thinking CHAMPAGNE TAP!!!! No...47 f-ing RBCs

______

Anyway, life is good and I have a few days off before my next shift, so I decided to swing home for the weekend to grab the remainder of my stuff...just to grab my stuff and hang out with my brothers. I also got a chance to swing by my local homebrew store to snag supplies for a delicious belgian witbeir and a clone of Abita Turbodog.

I've had a pair of Vibram five fingers (the toe shoes) for a few months and I decided to try them out for a short run. I had no problems and felt great after the run but I've spent the past two days hobbling around from the most hardcore soleus pain I've ever had. Hopefully it'll be more tolerable for my next run tomorrow before I head back to NY.

Sorry...it's July

"It's OK, it's July" is something you hear a lot as an intern. But you quickly learn that it means different things coming from different people:

Other EM residents run around to pick up the slack that us slower members of the herd create...they see the sick patients, the low-acuity urgent care cases and manage to keep things from grinding to a halt. When they look bedraggled, and I've chased them down to ask them how to get in touch with ultrasound for the 4th time that shift they give a look of "it's ok, it's July" before their answer.

Nurses/techs/CIMs mean that you've done something wrong to screw with their universe. Putting a chart in the wrong slot, forgetting one of the 700 boxes you have to check to discharge a patient, not filling out the discharge med rec correctly, ordering something that doesn't exist...basically not knowing how to move efficiently about the department. Usually this is said with a sigh, but sometimes it will have a note of contempt in it.

Fellow interns use it as an expression of commiseration and bonding: e.g. I only saw 4 patients last night, or I got out 2 hours after my shift or I created a new sepsis treatment protocol called delayed early goal directed therapy... the proper answer is "it's ok, it's July".

Admitting/consulting residents will fully understand the fact that you are fresh meat and the weakest member of the ED herd. They will separate you from the pack, jump on you when you show any signs of weakness in your story and disembowel you over the phone...and you have to take it because...it's July.

EM Attendings, those blessed souls, find themselves running around doing 3x the normal work to be hyper-vigilant over the us new docs who could seriously injure/kill patients and aren't credentialed to do any of our own procedures. I chase them down 100 times a night to run my patients by them with some half-baked plans and dispos and they just look at me with that slightly more tired look and say "it's ok, it's July".

August is just around the corner and looks about 100 times better for all levels of the health care profession.

Fireworks

I strolled into the first day of work on July 3rd with expectations that I would be a little overwhelmed by everything that was happening. After all, everything would be unfamiliar to me: the docs, the systems, the nurses, the techs, my job as Dr. Bostonian...everything except for the medicine. I dropped my bag off, met the other intern on with me in the lounge and we headed down to get things rolling. Introduced myself to the attending who I had met only briefly before, said hi to the day team of interns and found my resident for the evening.

Within about thirty seconds- Posterior wall MI with cardiac arrest rolls in and the day team hopped onto it. And another 30 seconds later VFib arrest rolls in across the hall...guess I'll hang out and see what needs to get done. We worked on the guy for about half an hour without success. Great...first patient of residency didn't make it...way to start out your career Dr. Bostonian.

Anyway, I saw about 5 other patients (read: slow as molasses). Diagnoses included Anxiety (caused by father's VFib arrest), temporal arteritis (ok...they were sent in by an ophthalmologist with that as #1 in their ddx), painless hematuria (found a simple cyst in the kidney...will follow up), EtOH intoxication (metabolized to freedom) and first trimester bleeding (now with BV!). I made the mistake of stacking up all of my dictations until the end of my shift so my 9 hour shift turned into a 12...especially because I didn't know how to work the damned dictation service and had to re-dictate one patient 4 times.

Second day was July 4, and the temps topped out in the mid 90's with a large festival planned downtown...with explosives everywhere...and alcohol...it could have been a LONG shift, but everyone was still out partying when I walked in mid afternoon. I'll just say that my first case was Peds, involved evidence collection and a lot of paperwork which filled in the otherwise slow afternoon. Then after a few hours devoted to that patient, I was able to re-enter the rising tide of the ED and start pulling my weight. I saw 5 over the final 5 hours of my shift, admitted 3 and signed out nothing. I managed to dictate one of the patients as I went, but the rest were stacked up towards the end of my shift but I still managed to get home about an hour earlier than my first shift.

One interesting patient I had was discharged 2 days prior and had been having nausea/vomiting/abdominal pain without any distention and had popped his trach out with all of the vomiting. He looked sick as stink, and I knew he wasn't going home. While his oral contrast was winding its way through his bowel on his way to a CT for a final diagnostic piece, I called the admitting resident to get things rolling...and found that's a good way to get your head bitten off. Mental note, unless you have the work-up completely done with a billable ICD-9 code and a plan of treatment, don't call the admitting resident...sorry, it's July.

Rollin

After suffering through HOURSSSSSSSSSS of GME orientation and VA orientation over the past two days, jumping through the flaming rings of paperwork/med school/repetitive PPD tests I have some schwag that says Dr. Bostonian, MD and a matching prescription pad.

EM orientation tomorrow where I get my monogrammed scrubs and free lunch, a few days off and then evenings for July 3 and 4...I'm on the med/cards side of the ED, so I won't have too many fireworks injuries but I'm willing to bet I'll get my fair share of CHF exacerbations from cookouts...too bad I have to work the first major holiday...hopefully it's not a recurring theme!

Interwebs on and a new format

I was without interwebs for around a week and it hurt my soul...but now, FINALLY I have some lovely broadband all to myself (and a new TV with some HD/DVR capabilities to allow my brain to turn to mush after my crappy shifts and so I can catch all of those shows/sporting events that I'll probably be working through).

I'm all moved into the new Upstate digs! I'm in a very nice/affordable apartment on the edge of a not-so-nice neighborhood, across from one of my city's gorgeous parks and about a mile from the hospital. Let's just say that I'm about 300 yards from Martin Luther King Jr Blvd, but I've only heard gunshots once or twice and it's actually quite pleasant during the day. So it's just me in this big quiet apartment until the fiancé gets moved up in August.

I've had a few opportunities to hang out with the new residency classmates over the past week as we collectively suffered through our ACLS and ATLS certs. In just a short time, I can already tell that they're seriously cool kids who share a scarily similar sense of humor. I think we'll get into some trouble and to enjoy some good climbing/skiing/backpacking/paddling/biking/whatever-the-hell-else-we-want-to-do on our days off....I'm psyched.

**********

You've probably noticed the lovely new format. I saw it in the new design tab and liked it...so there it is you have to look at it. I'll continue to tweak the format so it's as pretty as I can make it and I'll probably play around with the pages settings to clearly delineate my med school posts from my residency posts, I'll toss some of my fun photos up and try to get some EM-related posts going once I start actually thinking about learning again. I've recently stumbled onto a whole wealth of online EM resources (thanks to a post from Graham Walker over on the ACEP Central Line blog) and I think having all of that posted will be a good resource for me and anyone else that might be interested (not too many EM folks read this though). It will be my fun little education project for myself. I might re-post or link to it here in an attempt to keep myself semi-anonymous so I can still gripe provide constructive criticism about whatever I want my continuing medical education, as vulgarly...er...openly...um...often as I want without the recourse of my faculty/hospital administrators/prosecutors raining down on me and potentially ruining my happy-go-lucky, laid back image and future career prospects/aspirations.

The donor

You do it hundreds of times in medical school, so much so that it becomes reflexive. Knock, open door, walk into a patient's room, introduce yourself with a smile and a handshake and then promptly tell the patient to get nekkid and toss a gown at them before invading every inch of their privacy. Then you close by saying something reassuring, and telling them they can get dressed.

I had the fortune of being on the receiving end of such a wonderful encounter today for my pre-employment physical and battery of exams. I think the highlight of the day had to have been the paperwork for the urine test...but I'll come back to that.

*****

The low-light of the day was having to shave for my respirator fit testing. I usually keep a bit of scruff, preferring to shave every other to every 3rd day to keep my sensitive skin happy. It's usually not a problem when I don't have to look professional (it's not like anyone's around to watch me build my Ikea furniture with a beer in my hand, muttering under my breath at 1AM...I hope). The secretary shook her head and told me I'd probably have to shave for my fit test. The LPN that drew my blood wished me luck with the hospital supply closet razor and offered me my tetanus booster in the next breath. So following my physical I was lead to the dreaded bathroom with a little hospital can of "shaving cream" (worst shaving cream ever) and a flimsy-handled, single-bladed hospital razor. Now I'm somewhat particular in my shaving habits because it keeps my face from feeling like it's on fire for the rest of the day...but those OCD tendencies went out the window today. I begrudgingly scraped the scruff off with the blunt instrument, lost about half a unit of RBCs through a thousand tiny cuts on my face. Then came the fit testing where an N95 was strapped onto my face for 15 minutes and I was made to do all sorts of stupid maneuvers to try to break the seal between my face and the mask...so needless to say, my face feels like burning right now.

*****

Then the urine drug test...my personal highlight. I hadn't had much to drink the morning prior, nevermind my normal cup of high-test coffee that allows me to tolerate tedious bullshit without wanting to strangle everyone in sight. Couple caffeine withdrawl with some Ikea-induced sleep deprivation, the medieval shaving experience and being made to wait for something that should have taken all of 35 minutes, and I was getting sort of punchy toward the end of the 2-hour extravaganza.

They stuck me in the waiting room while the folks before me finished up their tests...f-ing awesome, I love waiting rooms. With everything that had transpired that morning, I wasn't really "feeling the urge", so to speak. The nurses had attempted to orally hydrate me at every opportunity by handing me two little dixie cups of water every time one of them passed, however my GFR was clamped down pretty tightly. "Bostonian?" the nurse called...and I trotted over to get the stupidity over with. I had to then sit there and watch her fill out 4 different forms which had quadruple carbon copies (yellow, white, pink and orange!) which took exceedingly long. Finally, I was escorted to the rest room, read my list of rights (don't wash your hands!!!) and there I was, alone, staring down at the empty plastic cups. I had a stupid running dialogue:"60cc's of urine to freedom...sweet sweet freedom...try not to quote Braveheart out loud...don't laugh...valsalvaaaaaaaaa and there it is...don't pee on your hands. Wait, I can't wash my hands???"

Now for anyone that's been through this ordeal, the hospital makes you sign like 4 different forms for the urine drug screen, and everything must be done according to a stringent procedure to eliminate common sources of fraud. Usually there's a legally binding document that at refers to producer of the urine sample in a consistent terminology. Not so at my institution: one form that had 3 different terms for me, including "donor". Generally I reserve the word donor for pleasant things that confer a benefit upon the recipient...eg money, blood products, semen and the like. But there was my cup freshly voided pee...and I had to sign on the line that said "Donor Signature". Who knew!

Brain...activate...

I've realized that my brain has been completely shut off for the past 6-8 weeks. Nothing new coming in (except for experiences and beer) and nothing creative (or even remotely intelligent) coming out. So in an effort to not kill every patient that I see over the first week of internship, I have tried about a dozen times to crack open my copy of the ACLS book to get the brain rolling with some fundamentals...and then I fail miserably. I've loaded the cd to try and get something useful to fire a neuron or two...and I get through a few of the preview questions and then find something on TV like my beloved baseball team, the NBA Finals, a soccer match or really anything with moving pictures that isn't studying.

It's going to be a long intern year...

-One friend is on call Q3 in the CCU for all of July

-Another friend is in a military OB/GYN program and has to be in at "Oh dark thirty" (aka the butt crack of dawn)

-I'm working a half schedule in the ED and have class two days a week for July...not too shabby

Where I've been, where I'm going...

My 5-year college reunion was a great time (except for the 2 day hangover and some time-traveling) and it did give me a chance to catch up with a bunch of quality folks that I hadn't seen in far too long. With the newly minted MD after my name, mt friend's girlfriend altered my nametag to read Dr. Bostonian. I spent a lot of time explaining to the non-med folks why I've disappeared for the last 5 years, what I am up to and why I didn't have much control over where I'll be for the next 3. Of course the medical people gravitated toward each other to, took turns calling eachother Doctor, figured out where everyone is heading for residency. Then we drank, ate some crappy mass-produced food that wasn't worth the price of admission, drank and danced until about midnight (exact timeline is hazy) when they kicked us out because we're not in college anymore.

One of my best friends was there, despite being in the middle of studying for his Step 1 at the end of the June. I met him at his apartment to drop off some books and to pre-game the reunion. I walked in on him in his studying nest, going over a block of q-bank questions. He had that all too familiar look of despair, sleep deprivation and fraying sanity that all med students have during boards time. How I don't miss those days...at all. At least he was showered and his girlfriend had made him change his clothes unlike some other med students I know .

***********

Those two glimpses back on where I've been made me think all the more about where I'm heading. I start up this week with some health clearance awesomeness (yay for being stabbed with needles and having strangers touch my genitals and watch me pee!). Then I have a weekend off to get settled and help my former roomate move into his new digs (for a nominal fee of beer/dinner). And then shit gets real with some ACLS training and ATLS and formal orientation activities where I get my ID, long white coats and monogrammed scrubs.

Luckily my program is big on residents having a life outside of the hospital, and EM residents are limited to 65 hours nationally now so life will be awesome! My program also dedicates the first month an orientation month with lots of didactics/labs, reduced clinical hours and several gatherings/outings.

For now I'm just trying to get the ever-expanding list of home-improvement stuff done at my parents' house (STILL PAINTING!!! just a little bit of trim and a second coat on one bedroom left). I'm definitely looking forward to completing my move and building all of my fancy new Ikea furniture (that store is the DEVIL!), adopting a pup and getting my frigging life on its way already. I'm especially looking forward to playing with my little graduation presents to myself (plasma tv and a 4 season tent).

Until then, I'll be huffing paint fumes (too bad we buy the low volatility latex stuff) and talking to myself while lying on the floor to paint the baseboards...not a pretty picture.

I feel panicky...I feel old

I have two more glorious weeks off before my orientation starts up and I've been hanging out at my parents house in MA. They're relocating to the west coast because of my dad's employment situation (now employed, but on the west coast). So by hanging out I mean I've been cleaning out all of the relics of my childhood and being forced into unpaid labor to get the house ready for the market (painting, cleaning, repairing, etc). I'm a frigging Doctor! I shouldn't be painting the woodwork...I should be out living or hiking or paying someone to do this for me!!! ButI guess I do owe it to them for draining their finances, crushing their social lives and causing 33.3% of their graying hair for the past 26 years.

Anyway...all of this manual labor led to alot of thinking.

I was going through the ample piles of my stuff in my bedroom and stumbled across my Middle School and High School yearbooks...and I felt suddenly as if I was ancient. I don't even recognize the chubby little, pre-pubertal runt I was back in 8th grade or the know-it-all, post-pubertal asshole I was in 12th grade.

Then I remembered that my 5 year college reunion is this weekend where I get to suit-up and talk with my classmates to hear about their families/jobs/houses/cars/positive net-worths (oh wait, I haven't seen a paycheck since 2006 and can't even afford the cash bar).

Then I remembered that I'm going to be in charge of people's medical care. People are going to page me in the middle of the night and ask "Doctor, what should we do?". My loans will be coming due and I have to start saving for retirement and the college funds of my unborn children.

And then I looked into the mirror and noticed the grey hairs starting to multiply and spread into my beard, the crows feet starting to form at the corners of my eyes, the careworn creases in my brow, the incredibly awesome sunglass tan I have from Utah (Ok, so I photoshopped those crows feet out of my ERAS application photo...I am not immune from vanity).

And I felt dizzy and hyperventilated a bit as the realization washed over me that...I am officially old. Or maybe it was the paint fumes.

*****

As I regained my composure I realized, I'm still 26 going on 27. I've spent the last 10 or so years of my life in the singular pursuit of this stupid degree...but I'm not even middle aged yet. I've put off a lot of living in the process of getting here and a lot of my former life goals have been tossed to the wayside along the way.

One of my college friends was lamenting that he hadn't been on a vacation with his wife in over 2 years...I haven't gone away on vacation with my girlfriend since July 2005 (sorry sweetie)! This trip to Utah was the closest thing to a vacation I'd done since March of 2007. I keep telling her...just 3-4 years and life gets soooo much better when we have a real income that can cover our collective loan payments, and I can move my schedule around enough to accommodate a real vacation.

I guess that one of my goals for this residency thing is to to make sure that I do remember to squeeze in some time to live in the midst of the chaos of a flip-floppy schedule, my academic aspirations (and the work that goes along with them) and the parents living 3ooo miles away in the Pacific North West. And it doesn't help that I'm still missing being places like this:

Anyway, I should get back to my chores...that woodwork wont paint itself.

Brief update and transitions

So where has this former blogging addict with an increasingly jaded streak disappear to for the past few months?

2 words: 4th year. I finally hit the sweet spot between matching and graduation where nothing mattered but enjoying the last few weeks of having absolutely no responsibilities.

How to celebrate? An epic 3 week trip to Utah for credit learning about wilderness medicine with awful views like this (Wasatch range):

And this (Desolation Canyon)...

and this (Needles District of Canyonlands)...

Yeah...awful, I know...and it was for credit.

I met some of the best folks that I've ever interacted with. There's something special about living together outside of the hum-drum hospital-based world, outside of the rigid rules of medical hierarchy and on the edge of everyone's comfort level. Seeing attendings play in the mountains/desert, listening to them speak passionately about both their medicine and their wilderness pursuits in the same breath reminded me that doctors are allowed to be people too. I guess that I had sterilized my images of my attendings and didn't think of what they dowhen they hang up the white coat. It was so easy to do while I spent the past 2 years on the wards being dehumanized, deprived of sleep and weekends, constantly discussing medicine and being humbled by lack of knowledge on a daily basis. Regardless, it was the best month of med school by far and it has given me a good deal of hope heading into my residency.

*****

So I turn to my transitions: I should probably mention that I'm officially a doctor now (whatever genius is trusting me with that title should probably have their head examined!). My ACLS stuff showed up the other day and that reaaaaly hit home (you mean I have to run codes not just watch the code team bumble through the ACLS protocol???). On a cooler note, I'm also in the process of moving into my new city upstate and the fiancé will be moving in as well later this summer after she finishes up some work stuff. Our apartment overlooks a big park and is huge and bright and pet-friendly and perfect. Oh yeah, and I'm registered for the Marine Corps Marathon on Oct 31st, so we'll see how marathon training as an intern goes.

For the first time in a loooong time I can confidently say...life is good and I am at peace.

*****

As for the fate of this blog...who knows. I'm still a Bostonian in NY, and I'm sure that residency will bring its fair share of angst/frustration/ridiculousness/fun for me to litter the interwebs with as well as some fun adventures through the 'daks, 'gunks, Greens and Whites as I meet my very outdoorsy co-residents/attendings. Or it will turn into a cat blog.

For now, I'll be enjoying the last few weeks of freedom by helping my mom get her house on the market, getting back on the roads when my feet are healed and into the woods whenever I can.

Status post match

Ok...it's been a month since the last post. Bad blogger...I know. And it's not for lack of things to write about, but for lack of any sort of desire to write them and a nasty case of acute "oh crap I'm going to be a doctor soon"itis.What you've missed while I was away:

The Match

Woke up to a 70-degree blue-bird day, cooked a nice pancake breakfast for my friends and mixed up some adult beverages to cut the tension (mimosas, "Irish" coffee, Bushmills, etc). Then we suffered through 2 hours of meetings...with boxes of envelopes sitting just a few yards away and our fate sealed inside.

So then we headed outside to wait for the clock to strike noon. Anxiety was 11/10 on the pain scale, so we had some STAT car-bombs before the speeches started. Lots of praise and this is the day you've been waiting for, and dropping of some very big name programs which culminated with the line "well it's 12 o'clock somewhere". Line up alphabetically, try not to vomit, get your envelope, try not to vomit. Breathe in, close your eyes and realize that you've been waiting for this one moment for the past 8 years, try not to vomit.

Open your envelope...feeling the anticipation build, the hours of reading and studying and not sleeping and being made to do stupid things by obnoxious people.

breathe...open eyes and feel the weight of the past four years

ZOMFGWTFBBQ!!!!...I'm going to learn how to be an Emergency Physcian at my #5 (Undisclosed location in upstate NY). A little bit let down because I'm still not home in Boston, but definitely someplace I liked alot! Told my friends and we all hugged/high-fived. Called the fiancé and she cried. Called mom and she cried. Called dad and he said good job. Then got down to partying.

Then there was the matter of about a dozen unattended bottles of champagne, an equally unattended keg of local microbrew and 30 of my favorite med school peeps needing some lunch. barbequing. Then we headed down to NYC for our post-match party via school bus and I have never been more afraid for the future of Medicine in America...a little bit scary. None the less, we survived

Marathon Training/Running

The weeks leading into the National Sun-Trust marathon were also the weeks leading up to match...and there was much drinking and eating and merrymaking (and less running). My taper was more like a huge party so going into the race expo I wasn't feeling quite up to the full 26.2...so I chickened out and just ran the half with my friend who hurt his knee early into the training. I clocked in around 2 hours and felt pretty great despite missing three planned water stops and a gel stop. Lesson learned: always carry some food for when the aid station runs out.

I'll keep you posted on marathon effort number 2 scheduled for the Marine Corps Marathon...cause why not try to cram in a whole bunch of running with the start of residency???

Family Stuff

My dad, due to the recent turn in the economy couldn't find a job on the east coast so now he's Bostonian in Oregon with his new job. Mom isn't taking it well, but she's managing to suffer through the empty house. It's brought up all kinds of issues and made the match in upstate NY that much more difficult because mom wanted the fiancé and I to move in with her if I matched into any of the MA programs I applied to. Such is life and we're reassessing what to do with her over the next few months. And my brother got a motorcycle...while I was rotating through ortho clinic with all of the old bikers who can't go through a metal detector because they did something stupid.

Wilderness Medicine Preparations

I'll be spending 3 weeks out in Utah on a wilderness medicine elective and getting that all pieced together has been kind of exciting! 1 week in the Wasatch, 1 week of whitewater and 1 week in the desert around Moab. Gonna be awesome and if I'll be posting as many pictures as I can! It's also brought out the inner gear slut and has given me complete leeway to buy whatever I think I might need.

Feelings about the end of med school

It's tough. I've met some of my favorite people over the past 4 years and our relationships have been galvanized by suffering through long overnight calls, stupidly ridiculous amounts of reading/studying together, hours of boredom waiting for things to happen in the hospital, lack of being able to get away to see family/friends all the time and the stupidly juvenile things we do to entertain ourselves. At the same time, I'm ready to move my life ahead and stop reliving college with binge drinking, lack of income and unfocused academic requirements. It'll be nice to be able to finally focus on the areas of medicine that I'm interested in and stop having to constantly move around from hospital to hospital, subject to disparate subject and to just get into a routine of seeing patients, reading and living my life again. Plus I'm ready to finally get a chance to live with the sainted fiancé even if that means another bar exam that she has to take. Plus I'm really getting sick of living off of ramen, mac and cheese and very few veggies!

Anyway, that's probably enough of my blathering. But before I go I'll leave you with one of the funniest quotes of the past month:

Young 20's patient in Ortho clinic has some serious hardware in his arm for a humerus fracture that he suffered after he let his ex-girlfriend drive his "souped-up Infiniti" into a wall at 60 mph.

Attending: You probably won't ever be able to fully extend that arm like you were before. Keep up with the PT and we'll see you in a month. (Exits)

Patient: Thanks doc. (Under his breath but getting louder) F*** her. Stupid f*** *****. She had to drive my f***ing car into a f***ing wall and break my f***ing arm. (and on and on and on). I'm going to get an Escalade and a bat and go over to her house and break her f***ing arm and her car and see how she likes it.

Me: Hey man, don't do anything stupid or illegal, she's not worth ending up in jail for.

Pt: Yes she is, f*** that f***ing s***. She's f***ed with like 8 other guys the same way...I warn everyone I know. her name is ________

Me: I'll do my best to avoid her...or at least not let her drive my Corolla into a wall.

Pt: So I'm going to Miami for a week to (do unsavory things to women, and drink and drive fancy cars)...do I have to worry about this scar? What's your medical advice?

Me: 1. wear a condom, 2. sunscreen for the scar, 3. don't let crazy chicks drive your car

BLACK MONDAY...

For those of you that don't know...today is affectionately known in the academic medical world as Black Monday...the monday before the actual match. You get an email in your inbox at 11:57 AM titled "DID I MATCH?". Double click. Valsalva... Sphincter clench.........F*&^ING LOAD ALREADY!!!!!

Congratulations! You have matched.

Check the Match Site at https://services.nrmp.org/r3/ on Thursday, March 18, 2010, at 1:00 PM eastern time to find out where you matched.

Exhale...Try not to be creeped out by my 6'4, bearded friend who is both crying and hugging me in joy. Go back to radiology class...

I'm pretty convinced that the NRMP consists of a bunch of sadomasochists performing a massive social experiment on one of the most anxiety prone segments of the population. I mean really...I've spent the past 4 years studying until I died, reading Robbins until my eyes hurt, taking board exams, doing the scuttiest of scut, being demeaned by every level of the health profession (Janitor to CEO), running all over the northeastern US dressed up in a suit answering stupid questions about my personal life and agonizing over where I want to spend the next 4 years of my life, just to get to this point...the match.

At noon on Thursday, all of us lemmings will simultaneously open our envelopes and finally know where the hell we're going in June...every range of human emotion will be played out. Exciting? Yes. Nerve wracking? Yes...I'll be starting a course of protonix tomorrow morning to ward off the ulcer. And partying...lots of partying...because beer is cheaper than anxiolytics.

Match day is coming...if you know a fourth year med student, please give him/her a hug, share a refreshing adult carbohydrate beverage and reassure them that everything will be all right.

Welcome to the Jungle...

So I sucked it up for the past month on the Medicine floors paying the hospital about $200/day to play intern... and I have never been sooooo frustrated with how things run in the medical world. Diagnostics/studies/consults are ignored or delayed because of where the patient's request was put in line behind the other 600 beds in the hospital. Nurses are paging with annoying dietary/social work complaints that my 8 years of higher education have not prepared me to deal with. Patients are left to rot over the weekend because their nursing homes "don't accept transfers on the weekends"...even though they had no reason to be there in the first place and there is no good reason they couldn't be tossed from stretcher to bed by the medics.

Just to rub in the awesomeness...Snowpocalypse hits, not once but twice in 1 month causing every service in the hospital to be sent home by noon...except for the medical call team...which happened to be my team both times. Not only did most of the medical housestaff shirk their responsibilities (leaving us to pick up the slack), but they drove home in the middle of a blizzard for the express purpose of shirking their responsibilities. For Christ's sake, the nurses and techs were sleeping in empty beds, lounges, offices, etc to make sure that their responsibilities were taken care of despite the snow (which made them understandably happy to be at work for 36+ hours straight), but the housestaff skedaddled as soon as they were told it was a half day. Such a ridiculous disparity...

Then there's the spectrum of attitudes from the nursing staff which varied from loving (hugs, smiles and cookies) to legitimate questions of patient care ("How do I mix this tube feed at half strength? Tap or sterile water?") to downright adversarial (from a covering nurse, "I've never seen this done in 30 years of nursing, you are incompetent" because I'd rather give an IV antiemetic regimen that worked wonderfully this morning before the patient pulled her IV access instead of IM because A) she is unable to tolerate PO, B)is going to bitch and complain about any IM medications because she has the pain tolerance of a 2 year old and C) has annoying, micromanaging parents who will have you page me every 10 minutes until she stops being a giant baby about her arm hurting...more on this to come in a later post).

Looking back, I've been spoiled with my time in the ED.

The team just works better in that environment. Attitudes are generally directed at patient care over making it through the tedium of the day. The problems with the patients are more often acutely medical rather than dietary/social work. My hours aren't spent documenting the full diagnostic workup and recovery of every patient for weeks on end. People go home when I say they go home. The consultants come (usually) when I need their help. People get a CT within 2 hours of me deciding they need a CT. Labs come back within 45 minutes. There are no rounds to dissect every morsel of the patient's life and how they may contributed to their metabolic syndrome. There are no pagers. There are no pages over ham sandwiches at 9:30 at night. The nurses don't blow me off when I'm managing their patients and address their doubts about my competence with helpful guidance instead of thinly veiled disgust.

I'm just not cut out for the floors...I'll take a double shift in the pit any day.

Against Medical Advice

Time for a little thought experiment here folks:

Imagine that you weigh about 500 pounds. You get one of those big boy beds with the inflatable mattress that prevents new decubitus ulcers on your ass (like the one you have at home). You haven't moved said ass from your bed since last fall. You've got a couple new-ish metal joints because your massive girth destroyed the perfectly good ones you were born with and you can't even move your own legs because of their enormity.

Yeah, you remember the glory days when you qualified for the 1980 Olympic games in Greco-roman wrestling (but didn't go because of Regan) . You were an Engineer and that white coat wearing kid is talking down to you when he explains hypertension. You don't want to eat the low-fat, low-sodium diet ordered for you and send your tray back to the kitchen. It tastes like cardboard...

However, you are too ignorant of your own health to remember that time you were in florid pulmonary edema and dyspnic back in May. You got an ultrasound of your heart showing some diastolic heart failure...but they treated you with maalox and you got better. You're on an ACE, a Beta blocker, a duretic, lipitor and aspirin...the standard care for heart failure...but no one ever told you that you had heart failure.

Now imagine that you're hungry because you've been in a few hours of tests, and all you really want is a nice big ham and cheese sandwich...an no one will get it for you. You're ordered for a cardiac diet. Now imagine that you call the nurse and demand that your diet be changed to allow you a ham and cheese sandwich...shouldn't be a problem, the doctor will fix that right away. MMMM salty ham and fatty cheese...you're really hungry. Good thing you got rid of that crappy dinner tray 10 minutes ago...too many veggies.

Now imagine that some jackass in a short white coat comes in and tells you that you have a history of CHF (Surprise) and HTN and that a low salt, low fat diet would be best for you and that he's not going to change your diet...no you can't have your sandwich. You've never had CHF, no doctor ever told you that!!! That has to be wrong, get that out of your charts.

When he's paged a second time (you really are hungry this time), he proceeds to remind you of this CHF thing that no one ever told you about and explains how a salty diet will make you retain fluid and cause you to go into heart failure and get you into the same situation you were in last time. You're livid and want to talk to an administrator to have the CHF thing removed from your record...it's 8PM on friday and you want a damned sandwich...no that fruit plate and 2 bowls of cereal won't do.

The next time he's paged that fucker pulls the echo report from may and points to the words "Dyspnea" and "Edema" under diagnoses. He explains how even though your systolic function was ok for the time being, your dilated right heart will cause you to drown in your own juices if you have a regular diet...so no ham sandwichs for you! Well, you might as well leave this place cause they're not going to feed you (that dinner tray looked too healthy) you tell the nurse that you want to sign out AMA. Someone will drop you off at home and get you into bed...you can get those Q8Hr antibiotics at home anyway...i mean you just hook them up to the PICC.

That fucker in the white coat is back with the AMA form all filled out for me to sign. You'll have to find your own way home? In the snow storm? The medicaid crane to move you back to your bed at home at 9:15PM?? No one is setting up care for you at home if you leave now and there's the chance you may die of sepsis??? That's it...you're calling your lawyer. You're going to sue everyone over a ham sandwich? They can't threaten me with death and heart failure. How? You'll find a way...you were an olympic athlete!

Oh, the nice nurse is going to get you a nice low-sodium grilled chicken sandwich from the overpriced hospital cafe...that'll work! How can that white coated guy be concerned for your well being??? He won't even give you what you want for dinner! Thank you ma'am...

Reason number 1,000,000 I will not be going into internal medicine...stupid shit like diet orders and ignorant patients.

Can we strangle patients?

Have you ever had one of those days where your stupid patients have stupid problems that the poor nurses have to page you for? Here's two dandies from today:

Patient 1- 30's female with a personal and family history of DVT, now at 15 weeks gestation with a DVT in her thigh. Should be simple enough, hypercoaguability work-up, heparinize and discharge on lovenox. Yeah, right...

• "Where was your lovenox made"- New Jersey...perhaps the one place on earth scarier than China.
• "Are there any preservatives in lovenox"- not in the single dose form that you'll be getting...but that room-temperature, unpasteurized, farm-fresh, organic kefir you're chugging might contain some brucella or mycobacteria bovis...I hear those are bad for babies.
• "I've read there are all sorts of side effects of that nasty drug lovenox"- Most of them are bleeding related...it beats a PE that could kill you and your baby! We could always try rat poison.
• "Can I eat an avocado? I read all about the food interactions of heparin and avocado was on there"- you read about warfarin, avocados and many foods interact with warfarin. Lovenox works by a completely different mechanism. Bon Apetite and I question your sources.
• "I've read that people who inject their skin with insulin loose fat at the injection site. Will that happen with lovenox?" No lovenox is not a good way to lose that pesky baby fat.
• "Why is the hematologist so interested in all of those tests...what if I don't want to know?"- Wait...you just asked me what preservatives are in lovenox and you don't want to know if you have a clotting disoder? Either be OCD or non-chalant about it...don't flip-flop.
• "What are the potential side effects of ultrasound on my baby? I've read studies about them damaging the ears and eyes and I know it hasn't been studied because there isn't a big enough group of un-ultrasounded women out there." Um...no. Actually due to your advanced maternal age, you may want to consider an ultrasound to screen for potential birth defects since women of your age are at an increased risk. The benefits would probably outweigh the risks. I bet you take your immunization advice from a porn star too!
• "What percentage of EMLA cream is absorbed by the skin into the body?" Um...adults don't generally use EMLA cream...no idea.
• "My homeopathic doctor...blah blah blah"...not that I'm skeptical or anything, but crystals and accupuncture aren't going to fix your DVT or genetically based hypercoaguability.
• "With my first baby, my membranes ruptured on Sunday and I delivered on Thursday...my midwife got a little worried on Wednesday"...Um ever hear of chorioamnionitis or GBSS? Oh, you never saw an OB or had an ultrasound?...no wonder your dates were a month off.
• How'd that lovenox shot go? ::dramatically:: "Oh it was so horrible!"

Patient 2: 25 yo guy admitted for a CF tune-up, ended up having an exlap for an intussiception, on a PCA for pain control. POD#3, just got the NG tube out and starting to eat. Still has PCA (Patient Controlled Analgesia) pump with dilaudid.

• He pounds down his liquid breakfast tray in under 10 minutes, and has belly pain shortly there after. Covering SubI (who witnessed the first episode of belly pain leading to surgery 4 days ago) was paged. Explains that the bowel "goes to sleep" after surgery and while taking opiates. Downing his tray so fast was probably a bad idea...take it easy on the food for now.
• SubI paged for worsening abdominal pain. Now rolling on the floor, howling in pain, patient is still able to text and talk about his wife and make a few jokes. Benign exam...I'll reassess in an hour
• SubI paged for worsening abdominal pain. "This feels like right before the surgery"...patient not texting any longer but still a benign exam. SubI orders STAT labs and imaging and pages surgery, discusses with medicine attending who agrees to examine the patient and is not very impressed either but agrees that labs should be sent anyway. SubI calls his resident to cosign STAT orders. Writes progress note re: plan.
• SubI reassesses patient after ordering labs. Patient eating dinner tray, talking on phone to wife, pain well controlled with PCA pump. "Yeah, I just decided to start using my PCA pump again. I feel ok now man! Hey do you play Dungeons and Dragons?" SubI explains the finer points of the PCA machine (Push the green button until the pain is tolerable...if you're unconscious, you're gonna get a rude awakening). And no, but I do play fantasy baseball and football...no you're not getting a draft invite.
• "I get lonely in here...thanks for talking to me man" SubI checks his not-ringing pager, excuses himself to answer his phantom page, calls resident to cancel STAT orders because the patient is a fucking idiot, writes a progress note that the patient is a fucking idiot, bangs head on desk and questions so many of his poor decisions in life...like going to medical school.

It was a long day...and I only covered 12 patients...I felt bad for the interns who had to cover dozens of them and the resident getting killed in the ED with admissions...more fun tomorrow

Stupidest dispo of the week

96 yo M- medically cleared for transfer to Inpatient Psych Unit for suicidal ideation

Listen...if I ever make it to 96 (and I plan on killing myself with a lifetime of bacon, red meat, beer, scotch and family cardiac history long before that) and I feel like dying, just put me on Comfort measures and send me to hospice so I can have some compassionate care instead of medical wards or the fucking locked psych ward!!! The poor guy will get knocked over by one of the aides or another patient, break a hip and throw a lethal DVT...please rethink that one kids.

Words of wisdom

I love old folks because they drop these hilarious little pearls off the cuff without thinking twice.

Yesterday from an 81 yo guy:

"You know you've become old when moving your bowels is better than sex ever was."

Man, I hope I never get old.

my whereabouts

I know that I've been a bad blogger...but 4th year has been sort of more than I thought it would be.

What have I been up to since October when I used the blog as a procrastination tool for step 2?

1. Training for my first marathon in March, sort of half-assing it through partly due to weather, partly due to interviews/traveling and partly due to laziness
2. Residency interviews- invited to 16, went to 14 and ranked 13 with some really phenomenal programs in the mix. We'll see where that goes on March 18th at noon. There's a significant chance that I could remain a Bostonian in NY for a few years to come...saving me that awkward blog transition.
3. I was either at home doing nothing worth writing about, on the road, skiing or sitting in the library on my tox rotation...nothing really to write about
4. SubI- I'm on my medicine subI right now and it is everything I hate in the medical world with a fucking beeper attached to my hip. And it never stops buzzing for the stupidest shit...case in point happened today:

• "Are you covering X?"
• no, I was last night though
• "Do you know who is?"
• nope, there's like 100 patients on the medicine service, 12 interns and 6 subI's. If you look at the bottom of any progress note, the pager number for the intern is there
• "I didn't want to have to walk alllll the way over to the chart rack"
• glad I could help

Anywho, subI is crushing my soul and providing plenty of fodder, rage and learned helplessness for me to polute the interwebs with. You'll note the new privacy settings...I was getting sick of spam comments. Anyway...gotta get up in a few hours, might as well sleep.

~BinNY