Express Wedding Planning November 9, 2009

I spent the first half of my wonderful vacation relaxing and catching up on sleep. The last few days were full of wedding consultations. My fiance, mom and I managed to meet with 3 florists, 3 bakeries, 4 DJ/Entertainment companies, our photographer, the reception coordinator, the wedding planner, the pastor and a bridal show in just 2-1/2 days!

As you can imagine I didn’t get much sleep doing all of that. However, it was very productive. We have decided on a cake design, flavors, and the baker that will make my vision come true. Even better, they can create the innovative groom’s cake that my fiance wants! Cake tasting was by far my fiance and mom’s favorite part of the consultations. The DJ meetings were variable. They ranged from the inexperienced-in-weddings DJ to the wedding expert-MC-lighting extraordinaire DJ. We definitely met the DJ that would be out in the crowd leading the line dances, along with the one that would be playing the completely wrong genre of music. Finally, we met the DJ that literally had my mom and I in tears with his improv of introducing the father-daughter dance. He is definitely the one! My fiance notes that my mom and I took away all negotiation leverage by revealing the tears…

The most difficult part of it all is definitely the flowers. Each florist we met with had different versions of making my vision come true. They each had a different vibe, neither of which was superior to the other, just different. One thing they did share in common was the cost! Both of them presented me with quotes almost twice my stated floral budget. I’m going to have to put on my negotiation hat at this point and see if we can make it happen!

All in all it was an amazing time. I loved getting to be a bride-to-be for a few days and put all of my organization skills toward an event that I will remember for a lifetime.

Rapid Response to Room 13 November 3, 2009

I get a page with 7 numbers and nothing else, no name, no patient name, nothing. I call back thinking that it’s a nurse asking can my patient have a one time dose of zofran or dilaudid for breakthrough nausea, or pain, you know, the typical stuff. Instead it’s a frantic nurse, “We called an RRT on room 13.” My response, “Okay, I’ll come as quick as possible. Breifly, what happened?” “I’m not sure Dr. Obsession, but she is not very responsive. She desat’ed and she is only breathing around 8 times a minute” We go back and forth with a little convo as I’m running there with my upper level resident. My final response, “Okay, is there a physician at the bedside?” “No, we are waiting for you!”

Wow… yes, a rapid response was called and they were waiting for me. A rapid response is pretty much 1 step below a code blue. It’s not something that can wait an hour for attention, but it’s not like the patient has stopped breathing or had some cardiac event in a code blue. At my medical school we had a rapid response team. So whenever a rapid response was called, the RR team would go to the bedside, often before the primary team arrived. I was under the impression that we had one too, but I guess not.

Back to the story. We get to the bedside and there are about 5 nurses and nursing assistants at the bedside and a pharmacist. The patient is on oxygen and that is it. What amazed me was that it really took about 15 minutes of questioning to get the full story. The patient had an extensive cardiac history and had been having some intermittent episodes of various arrhythmias throughout the hospitalization. Our first thought was cardiac. After a brief physical, and realizing that she was lethargic, but arousable, we proceeded with further tests. It was a relief to see that her oxygen level was being maintained on 2L oxygen, and right now a full code didn’t seem imminent. We did a host of tests: EKG, ABG, CBC, BMP, cardiac enzymes and coags.

At this point, something in my gut is telling me that it’s a medication she got. Initally the nurse caring for her told me the only medication she got was a tiny dose of narcotics. Considering she had been taking this dose for several days, I wasn’t completely sure that would do it. I ask my upper level whether they thought naloxone was appropriate and I was immediately told no. Naloxone is a medication that basically blocks the actions of narcotics and can be used in overdose situations. Once we got all these tests cooking, I asked the pharmacist to go through the medication record, only to find that another nurse had given the patient a nice sized dose of a sedating anti-nausea medication just 10 minutes after that narcotic. The combination of these medications made her sedated and decreased her respiratory drive. At that point I spoke up again to my upper level indicating that I thought naloxone was necessary. The nurse grabbed the medication and pushed naloxone. It was amazing… just 45 seconds later the patient was completely alert. She told us that she could hear us the whole time, but couldn’t open her eyelids! I learned that naloxone also works for phenergan overdosing as well!

That was a pretty intense moment. It was crazy to be the ones called to the bedside for an acute event. I learned the importance of considering all things in the differential, not just what initially seems obvious. It was important to work as a team. The nurses, respiratory therapy, pharmacist and the doctors worked well together. It was also a learning moment for the nurses because they had 2 nurses giving this patient meds – one in training the other full time. I am so happy that it was just a matter of giving one medication to solve the problem!

Scheduled Day Off October 25, 2009

In keeping with the discussion of Duty Hours, we are supposed to get 4 “Scheduled Days Off” in a 28 day period. I have been on call the last 3 weeks in a row, so I was spending most of my days off sleeping post call. Not this weekend!

I had the most fun that I have had in the longest time this past weekend. I had the coveted “Golden Weekend,” meaning I had the whole weekend off. On Friday I went out with a few fellow interns to eat and drink at this cute restaurant downtown. Saturday, I spent the day getting my hair done, cleaning up and catching up on much needed sleep. That night I met up with my college friend and one of the second year residents at my program. We went to this party that was so much fun! We basically danced and talked all night about so many things having nothing to do with being at work. It was nice this weekend to just get out and be a normal 20-something year old again. I can’t wait until next weekend since that starts my official VACATION!!

Program Director Review October 19, 2009

I can’t believe that I’m already well into my 4th month of internship! Damn time really flies… and working like crazy definitely helps the time to go by more quickly. In order to make sure that we are on track, we have meetings with the Program Director twice a year. My meeting was last week. I was pretty nervous!

Thus far there is not much to evaluate me on. I’ve done a few rotations and the faculty evaluations were reviewed for those. It’s amazing the things that people notice. As an intern, it’s not really about your medical knowledge, but about your ability to remain organized and to get all of the tasks of the team accomplished. If you can manage to do that it seems to go a long way! Even better if you show a reasonable knowledge base on top of good organizational skills then they love you. Of course the icing on the cake were the student evaluations. I remember that the only way I could retaliate at some of the meaner residents was through my evaluation of them… I felt I had done a good job with the students, but wasn’t sure what the students would say. I was pleasantly surprised! They all seemed to appreciate me taking time out of my day to teach them something. One eval stated Med Obsession was “my favorite intern of all of the residents and interns.” That made me feel really good.

I’m going to try to remember this session with the program director when I’m feeling down. So far it appears that all of my hard work is not going unnoticed. It’s not why I went into the field, but let’s be honest, I’m still in training and positive feedback definitely helps my morale! Who knows, maybe I’m developing a knack for teaching? Maybe academics is in my future… we shall see.

80 Hour Average October 11, 2009

Well this week I learned about the 80 hours, averaged over 4 weeks rule. My program is actually very compliant with duty hours, and both my chief resident and the program director are good about making sure I get out of the hospital at a reasonable hour.

Last week, however, was a different story. We ended up having the most patients that we’ve had during this rotation. We got up to 23 patients this week. It’s not so bad in the AM since we all split seeing the patients. It’s bad during the day when every patient needs labs, electrolyte repletion, specialty consults, CT scans, urine output monitoring, NGT placement… etc, etc, etc! Then I do afternoon rounds to gather all the vitals and round again in the afternoon.

With all of these patients the days just got longer and longer. There was one night when I was there from 5:15am until 8pm. Then, by taking call Saturday after a week like this put me at 97 hours this week!! I’m pretty exhausted and will be on call again on Friday… I’ll try to post when I can.

Death #3 October 6, 2009

Well there has always been that saying that death comes in threes. After the patient died that I posted about below, another patient took a turn for the worst. Since she was end-stage cancer, once this turn occurred the patient decided she would rather die at home. She passed away within days of discharge. Death #3 was the other patient that I talked about in my “Predicting Death” post. It’s weird. As I was driving into work my mind drifted to thinking about her. I was overtaken by thoughts of her condition and hospital course. I actually cried about her condition and felt that this woman was dealt an unlucky set of cards. When I arrived to the hospital, I found out she died overnight.

I’m really hoping that this third death will be the last while I’m on service. We have been so busy that I have barely had time to even let it sink in except as I drive into work or drift off to sleep. This service has been so demanding of my time and definitely of my emotions. I haven’t ruled it out as a fellowship option entirely, but it’s been tough. It’s only Tuesday and we have 18 patients with 7 operations tomorrow (6 of which will be admitted). That’s going to take us to over 20 patients. I’m the only one on the floor since the upper level residents split the OR vs clinic. Pray that I survive the rest of this week! I hope we can discharge some of these patient’s home. I think with the recent deaths, everyone is making sure to give these patients a clean bill of health before discharge. I completely understand.

Time of Death September 30, 2009

Well one of the patient’s that we predicted would die, died. I was called to the bedside because the patient stopped breathing and her heart stopped beating. She had been pronounced dead by the PA on our service. I saw the patient’s family member crying like no other. It definitely brought tears to my eyes, but I didn’t allow myself to cry. I just kept saying, “I’m sorry.”

Next, the descendant care came by and I had to sign the death certificate. I had to list the diagnoses leading to death, how long they were present, the time of death, and then sign. I had to fill out another form about whether or not she needed an autopsy. Forever my name will be listed on her death certificate. It was very surreal… still is.

Literally, I had seen her 2 hours before and now she is gone. It broke my heart to see the family as well. To be perfectly honest, I avoided her room the rest of the day. I didn’t feel it was right for me to start crying with them because I don’t really know the patient. I mean, I cared for her in her final week of life, but I have no true relationship with her. I didn’t want them to think that I was in anyway really able to feel the same grief they were feeling. So I held it in…

Predicting Death September 29, 2009

These last few days, rounds have been dominating by discussing the imminent death of two of the patients that we have on service. One patient is relatively young and the other is relatively old. The families of both of these patients both understand that death is looming in the future. Despite the knowledge of their diagnosis and their current status, the process of waiting for death (or survival) is painful for everyone involved.

As the doctors, we are challenged about whether or not we are doing “everything” on a daily basis. Sometimes “everything” means that we try every surgery, every medication, every consultation, full code… EVERYTHING imaginable in order to help the patient survive. This doesn’t always lead to a resultant improvement in status because there can be too many recommendations, too many surgeries, too many medications, all of which can effect the overall picture. Then sometimes “everything” means full disclosure with the family regarding the prognosis of the patient. It may be most necessary to make sure the patient is comfortable in their final moments of life, rather than having to much intervention from the doctors.

As you can imagine, we have one patient getting everything done to survive, while the other is getting everything done to die in peace. Palliative care leaves notes for both like “Patient with a positive death rattle” or “100% mortality with or without intervention.” I think that both “everything” methods are reasonable for both parties, but equally unsatisfying. In the end we are in the business of trying to predict when death will occur.

It weighs heavy on me to visit these patients several times throughout the day. I have long discussions with crying family members wondering what is going to happen next. It’s as if we are all in limbo wondering when things will change leading to life or death. We know it will likely be death, but definitely don’t know exactly when. I don’t think I’m cut out for this prediction of death…

Intern Outings September 27, 2009

This was a great weekend. I had the entire weekend off to catch up on sleep. Even better, quite a few of the other interns were off too. On Friday night I had a chance to catch up with the other interns that were on Ob Days, while I was on the night team. We had a great time just reflecting on all of our experiences over the past weeks. During the day on Saturday I had a chance to catch up with one of the other interns for lunch. She is definitely the other intern that I feel the closest to. It’s great to have another person in the program that you can just vent to about the tough times.

I would imagine the main reason that people quit (beyond it just being completely the wrong field) is that they feel isolated and alone. While having my fiance to talk to is great, I don’t like to always weigh him down with my work issues. It’s nice to have someone going through the same rotations to talk to. By talking with my fellow interns, I realize that they are having tough times too. It makes me take things alot less personally because I realize that all of us have had “one of those days”. Thus far, I think we all have been able to find someone to confide in.

I’m definitely happy to be an Ob/Gyn resident, but I will say it sucks to have 2 tough rotations back to back. Night float was tough just because of the hours – consistently 77-80 hours per week. Onc is tough because of the severity of the patient’s illnesses. These patients are SICK and I really feel responsible for their lives. The fellows definitely put alot of pressure on me as the intern to keep the service organized and to keep the patients alive while they are in the OR. It’s hard to have that level of responsibility on my shoulders on a daily basis. I’m happy that during this first week the census was manageable and all of my patient’s stayed alive. I hope these next few weeks are full of learning opportunities, and more outings with my fellow interns!

Welcome to Onc September 22, 2009

This has been a whirlwind last 2 days. I’m on Gyn Onc right now and it’s pretty intense! On night float I was responsible for postpartum patients, triage, and deliveries… I thought that was alot. Now this is taking it to another level! Instead of bringing new life into the world, I spend my days with women on the brink of death.

Each day I have to see my own patients, however, on top of that I’m responsible for covering the floor for ALL the patients while the team is in the OR and in clinic. I have to have separate rounds with our PA and then round with the social worker and appt nurse. I literally have gotten damn near 50 pages in just 2 days! I have not even had a chance to read since I’m running around all day and then fall right asleep when I’m home. I will definitely be stepping that up in the next few days so that I can make sure that I completely understand why we are doing what for each patient.

So far I have not had anyone die, and I hope it stays that way for a while. I still remember the first patient of mine that died as a third year – a Gyn Onc patient. I really have already grown to care for the patients considering I visit each of them at least 3-4 times a day. I will definitely learn so much from these patients. Doing all those medicine sub-I’s fourth year definitely paid off. I’ve had to tap into that knowledge quite a bit.