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.