Failure....

Following up my triumphant post with this one is hard.  I can't stop thinking about it though. 

There are two teams that we "round" with in the morning, each with it's own set of patients.  My patients are all with team A, which we had already rounded with.  We were currently rounding with team B when the pager went off "Term 40 wk infant.  Forceps." Usually there are two attendings and when something like this happens the second attending, the one not rounding would go, but as chance would have it we were short staffed on B with only one attending for the day.  Being an easy delivery and me with no patients to present for team B, I thought nothing of it and opted to go by myself so the team would be able to keep rounding.  I should have known...

I get into the room and the nurse gives me report, basically it's as simple as that pager made it sound.  This mother has no risk factors what-so-ever, except that the baby is having trouble descending and they might have to pull it out with a device that looks similar to large stainless steel salad prongs, in which case they would need my team (high risk delivery).  I wait several minutes trading small talk and jokes with my team of nurses and respiratory therapists.  The OB doc finally decides to make the delivery a bit easier and do a cut on the vaginal opening (basically it makes it a bigger hole for the baby to come through).  I hear the 18 year old dad murmur a quiet, "Awesome..." as the doctor cuts his significant others genitals, my team exchanges questionable glances.  With that cut suddenly the baby is "crowning" (you can see it's head).  As it comes out to the neck a gush of fluid rushes out with it...it has thick meconium...suddenly this is a real high risk delivery.  I run through my head what we need and quickly order them to get the special aspirator and intubation tubes in case, God forbid, we would have to intubate him. 

Meconium is baby poop.  When the baby is older (like this one) and it is stress, sometimes it will have a bowel movement inside of the uterus.  The baby then risks aspirating this when it takes it's first breaths.  This is a very serious thing (see Tickle Me ECMO post). 

I've seen meconium deliveries before, every time the baby was born through it, it would cough a little and start crying.  My attendings had told me that if they ever come out and are not crying and the heart rate is low, you need to act fast.  What you should do is pull out your scope and temporarily intubate, put a suction tube down into the trachea and quickly remove any meconium plugging the airways.  I KNEW this...I even talked myself through it as soon as I saw the meconium.  (The moment I saw the meconium I had the head attending paged to the room, but it happened to fast for him to help). 

For whatever reason, the baby came over and I issued the orders.  We checked heart rate, deep suctioned, and put him on blow by.  Just as I was suctioning for the second time the baby sputtered and started whailing (THANK GOD!!!).  Suddenly this very blue floppy baby turned peak and became a very irritated, very pink newborn (which is a VERY good thing).  As the baby stabilized my attending came in with the other residents and everyone congratulated me on managing this baby, a job I really never should have managed on my own...honestly though every praise I received felt false...I knew they all meant it, but deep down I knew what had really happened, for whatever reason I froze up and instead of doing what I was supposed to do, I did what I was comfortable with.  I may have kept that baby alive, but it was by shear dumb luck...my hesitation and cowardice could have really hurt him.  When we were alone outside and I was running through the delivery with the attending, I couldn't help it...I had to know if I had really not done what I was supposed to.  I ran the whole scenario through to him and he confirmed what I knew from the very beginning when I saw the baby covered in that thick green goop, I shouldn't have hesitated in scoping that kid and suctioning him out. 

Thinking back to why I didn't I at first I thought of a lot of different reasons.  I was uncomfortable doing it (I had only done it twice and only one time successfully - all on stable children, not like this).  Nobody else on the team suggested it.  The baby did fine without it.  Maybe the baby didn't need it.  What I finally ended up concluding was that I failed.  I failed in being the leader I was supposed to be.  I should have been the confident leader, but when the time came I didn't make the decision I knew that was right, instead, I made the decision I was comfortable with.  I failed my attending who trusted that I could handle this (true the child was alright...but not because of me).  Most of all my courage failed me, I wasn't the bold, confident leader that I was called to be in there...I was a scared out of my mind peon that doesn't deserve to call himself a doctor.  Maybe I'm being to harsh on myself, but everytime I think of what happened today I cringe...today I failed.

Newbie Doc

Tomorrow's another day though, maybe God will give me the chance to make up for it.

Success!!!!

So after this brutal day (it's not really over as I am still sleeping at the hospital and won't leave till 1pm tomorrow), I was pretty down on myself.  I am dead tired, running on fumes, and I get offered a chance to "surf" a kid...do I pass...HELL NO!!!

Brief explanation: Your lungs are made up of tiny microscopic sacs (they look like a branch of grapes).  These sacs are like tiny air ballons that inflate with air that you breath in and deflate (not all the way normally) when you breath out (called alveoli).  If a little baby is too young, it doesn't make a substance called surfactant.  Surfactant is a natural "soap" everyones body makes. Have you ever done the experiment where you put a pin on the water and it floats on the top, then you drop a little soap into it and the pin sinks.  The soap breaks the water surface tension. That tension isn't much to us, but to a baby it's enough to keep those alveoli closed without the surfactant. Thus "surf"ing was born.  First, you sedate the child.  Then you take a small metal blade/scope and briefly intubate the kid. While intubated you inject this artificial surfactant into his lungs (you have to roll the kid on both sides so it goes into both lungs, right and left).  Then you sit back and watch the kids oxygen saturations.

SO, after a day of everything being a struggle, everything being a grind, I walk into this room and not only intubate on the first try, but also surf the kid like I've been doing it all my life (where did this come from?!?!?)  Anyways, I am very happy and it has totally made my day.  Just wanted to share my "Win" with you all.  Alright, now I'm out...and sweet sleep awaits. : )

Newbie Doc

Giving The Finger

When you go to medical school the first two years are spent in the books, going to classes and taking tests, at least that’s what my school was like. In the final two years you’re sent out into different rotations to discover your “likes/dislikes” and ultimately figure out what you want to do in medicine (or maybe it’s to do all the crap jobs the residents don’t want to do… probably both). So the beginning of my third year found me in family medicine, my first real rotation. I was nervous but in the days leading up to it my wife tried her best to assuage my fears; yet she did have one warning. According to her, there was this one “old doc” who she had the misfortune to disagree with on a clinical matter. The old doc’s reply to her clinical challenge was basically, “I’m smarter than you so why don’t you let me do the doctoring here.” If you know my wife, she’s a little stubborn and doesn’t take kindly to being brushed aside, besides she was actually right concerning this matter (we looked it up). It didn’t make her feel any better. It actually only served to fuel her anger towards this man who dismissed her so nonchalantly. On my first day she dutifully reminded me again to steer clear of him. I nervously threw on my white coat and was out the door while saying a mental prayer that all would go well.

As my luck would have it, the very first day in clinic I happened to be working under the supervision of “old doc”. Surprisingly, I didn’t find myself petrified of this guy. I had imagined a vicious, muscled up pit bull that says everything with a terrifying intensity, dogs you at every turn and has one of those evil looking mustaches, but that wasn’t him. “Old doc” didn’t really match any of my preconceptions. He actually looked very similar to Santa Clause, with a bushy white beard, pop-belly, and just far enough into his 60’s that he carried this distinguished air about him. I thought he might be a friendly guy. So without too much trepidation, I introduced myself to him and he very nicely sent me in to see my first patient.

The patient was a 56 year old man who was a farmer and as such was hard on himself and never quit working. As a result, today this man was complaining of abdominal and back pain that had been bothering him over the course of the previous week. Being a fresh off the press medical student, I did the best medical interview I could and took a history of the illness. I was extra thorough taking at least 30 minutes; I wanted to do a really good job. When I came out I thought I knew exactly how to present this case and was feeling pretty confident. I walked back into the lounge where students and attendings hang out between patients. Four other medical students and one attending along with “old doc” were waiting on me. I was nervous as I began my presentation in front of all these people but “old doc” was so unassuming and nice that he put me at ease. I did what I thought was a bang up job, highlighting the points of how the patient hurt his back previously while picking up a heavy object and continued to put stress on it without much rest. Basically I came to the conclusion that this was a musculoskeletal injury of some sort, which looking back seems ridiculously obvious. (Sort of like, “Ah, ha! I’ve deduced the exact amount of fingers on my right hand! I’m a genius!”) I started to get the feeling old doc’s eyes were boring into me. His facial features made me a bit skittish suddenly and he was putting off that “this kid is clueless” vibe. He reminded me of a shark tasting blood in the water. This Santa of a shark started to circle this wounded med student seal. His attack was well planned, his first move a simple, “and what do you plan to do about it?”

“Great”, I thought to myself, “why didn’t I think about a plan for my patient’s treatment?” Instead I panicked and impulsively blurted out, “get an MRI or uhhh….an x-ray first?” That’s when “old doc” went in for the kill. In front of everybody he slowly and methodically took me through my poorly formed logic, all the way from my shoddy history taking skills to my ridiculously expensive and useless workup. He then asked what I would do with the MRI results in deciding treatment. My answer was of course wrong and way to Grey’s Anatomy. Smoothly, without yelling or screaming at me he instead offered a very conservative, common sense approach. Somehow his friendly condescension in front of my friends sucked much, much worse. When “old doc” was done asserting his vast superiority he decided to have mercy on me with a quick, “Let’s go see this patient.” At which point I hurriedly got out from the sight of my peers….way to go on my first day.

We walked into the patient’s room where “old doc” quickly swept back through the history like a pro, elucidating all the important things I had missed. After which he recommended a simple plan for recovery and wrote out a few instructions which I don’t really remember (kind of like you don’t remember the first few moments before getting hit with a bat in the head). I do remember the next part with amazing clarity though, as he suddenly realized the patient needed a DRE. “Hey John, I see here that it looks like you’re overdue for a prostrate exam.”





DRE means Digital Rectal Exam, which is performed on males older than 50 to screen for prostrate cancer. If you’re wondering how we perform this exam, a quick hint: “digital” in DRE is not the electronic kind.




Speaking with a casualness I would have never imagined any man able to command in such a situation, the patient compliantly agreed, “Welp, I guess we better get it done then.”

To myself I’m thinking that I’ve seen DRE’s done before and even had to perform one in our student lab on a paid patient, but still….why am I so nervous? “Old doc” gloves up his right hand. I fidget nervously looking for something to do; I need to be busy right now. Am I seriously supposed to stand here? Any distraction would have been great but I’m in a small room with nothing to do except watch….should I be watching this? The patient unbuckles his belt and drops his pants. The poor guy assumes the position, turned away from us, bent over the exam table with his arms bracing him up….this is so wrong… and he is way too comfortable with this! What the heck should I do? Maybe I should step outside…this is so awkward! It would be better if I had a task. Trying to be helpful I squeezed the lube onto old doc’s fingers and as he stooped over to perform the deed I saw the roller stool behind him. It looked in his way so I quickly moved it towards the back of the small cramped room with my foot so he wouldn’t get tripped up while doing the exam…that would make this situation more awkward. But then, to my absolute horror (time began to move in slow motion) he continued on from his stooping into a slow sitting motion. I tried to say something, to stop him, but my brain had disengaged from my mouth.

When you are this “jolly” of a Santa, it’s not a quiet fall. It was of the “TIMBER!!!” quality and his landing shook the room and the wall he bounced against. I stood there for what seemed like an hour, my mouth open, gaping in shock. OH, MY GOD, I”VE KILLED HIM!!! He began thrashing his legs and arms about trying desperately to get up but in this small cramped space with his size and shape he was like a turtle that couldn’t get off his back. In shock, I stood there for a moment longer than I should have, likely beat red, before I realized that I needed to help him up. Flustered, but slowly recovering I grabbed “old doc” under his arms and hoisted him up off the ground onto his feet. This whole time the patient is still facing away from us with his pants down. Still in the position, he shyly spits out a nervous high pitched question, “Everything ok back there?”

“Old doc” quickly finished the exam, finished writing up the scripts for the patient and exited the room. Still dazed I sat down with him in the lounge where luckily all of my fellow students were off seeing patients. I waited quietly for my tongue lashing. In tortuous silence, “old doc”, with his big white beard, stared at his computer. I stared at the ground; eyes wide open like a child expecting a beating. Slowly he turned to me and as I looked up he said, “If you were my brother, I’d punch you in the face.”

If you are wondering how the rest of the rotation turned out, to my amazement I did well. I think I got a B by evaluation from that very same “old doc”. I kept this harrowing experience to myself for the longest time out of embarrassment and mortification but finally decided to let my wife in on it. She laughed until she cried. I think she felt better about her run in with “old doc”…mine was way worse. As for me, it took a long time to find this experience humorous. I suppose it wasn’t the best way to start off my clinical career but on the bright side it did put me at ease, after all, it could only get better from here.

Newbie Doc

* A special thanks to a good friend who helped me edit and tweak this - Thanks P.G. : )

You Are Not A Machine

It's been one of those days that seem like the "perfect storm" of events.  When all the right things happen for your life to totally suck for 30 hours.  As it would happen I'm running on about 5 hours sleep over the accumulative 48 hours and this just happened to be one of the busiest days I've had in a while...but just because you are tired doesn't mean you can skip out on all your responsibilities to your patient, your school, your clinic, your patients, your attendings, your friends, and most importantly your significant other.  It's really important to be able to judge how tired you are and know when to "limit" yourself...this can take the form of shelving chores that can wait, having friends help carry you through something you don't have the strenght to do by yourself, asking your wife for her understanding and pacience as you make your 80th mistake of the day, or even something as small as deciding to make a small quick blog post.  Where ever you are at in life remember you are not a machine, don't treat yourself like one, and know your limits (this isn't something I've mastered, quite the opposite in fact, but I'm trying).

Luckily for me I have a post ready for you guys.  It's not something residency related, but it's a true story that happened during medical school that I always said I would put to paper...or blog if I ever started writing.  I give you "Giving The Finger".

Newbie Doc

The Silent Lesson

Today was one of those days where I could write about a billion different things.  Should I write about how a couple of my previously mentioned patients are, overnight, doing amazing and might go home soon (my successes)? Should I write about how I was gone 1 day in the care of my patient and I come back to find this little one worse off than she's ever been (my frustrations)? I thought about these two things, among many others,...but then we got word that there was another gastroschesis baby that was going to be born at our hospital.

Apparently the mother, a 17 year old, had come in just before noon in labor without any prenatal care what so ever.  Our service was full, so we were unable to take the delivery officially, but our attendings wanted us to stay in-the-know about this one, because apparently an ultrasound done after the mothers arrival had shown that the bowel was still outside of the little one's body.

You might be wondering how this happens?

When human body is developing from a fetus it undergoes a lot of changes.  Every human being has a typical bowel arrangement that any 1st year medical student could sketch for you at a seconds notice.  It gets into this particular "positioning" during development by, basically, protruding through the abdominal wall which has not closed yet.  While protruding out of this still open cavity, the bowel twists, as it grows.  As the bowel twists into the correct position it is slowly pulled back inside the abdomen which has begun to close around it, until it lays neatly down inside this cavity in just the right way, where upon the abdominal wall will seal over it.  That's what SHOULD occur.

For whatever reason, this doesn't happen in some babies, so you get a hole in the abdomen through which the intestines are hanging out at birth (I often try to imagine being a physician 100 years ago. I can't imagine the surprise and horror that you would experience having a baby pop out on you like this).  While these babies would normally die, with the advent of modern medicine we can save them by putting their guts in a small bag fixed up a particular way that allows their bowels to slowly "settle" into the belly, at which point a surgeon closes the abdominal wall up.  This process usually takes about a weeks time and barring complications of this, they can go on to live relatively normal lives.

BUT, ultrasounds are not perfect and when this baby in question was born, the mother tragically had to face the terrible fact that her child would not survive the day.  I was not present for the delivery..and honestly I'm glad I wasn't.  However, as it is a teaching hospital, my attending decided we needed to see this and so even though the parents were in the room grieving, literally standing in the room holding the little one as it breathed what were it's last breaths, we were brought in to see this child that wouldn't be.

It made me sick to intrude on them as we did.  I felt dirty, pathetic. The mother laying there crying.  The father in tears holding this bundle that was dying or even dead. The grandparents and great-grandparents were nearby and being very stoic, but the sadness was palpable in the room.  As instructed, we came in behind the attending who needed to pronounce the baby.  It was laid gently into it's crib.  The attending's hands were unshaken as he unwrapped the cloth that was bundling this poor infant (my hands would probably have been shaking). 

Even before the cloth was unwrapped, you could tell something was wrong.  I've seen very young children, only 24-25 weeks old, this child was supposed to be older, but the head was smaller and I can't place what it was about the face but you could tell it had passed away...something had "left" it.  Even though we had been briefed on what to expect, only as our attending unwrapped the blanket did we truly understand why this child was laying there motionless.

We had thought initially that this small child had a condition which although complicated and uncommon can still be managed.  What she really "had" though was something much more rare and still much less survivable.  This little girl was born with not only her intestines outside of her body, but her liver and heart as well.  We actually watched her heart, laying on the outside of her chest, beat it's very last beats feebly and then suddenly halt (her heart's lack of strength had likely killed her long before).  My attending looked up at the clock and pronounced the time of death.  The nurse scribbled it down and walked outside the room.  I was suddenly reminded of something I had seen as a child, a small bird egg laying smashed on the rocks underneath a tree, it's small fetal body laying in the pieces of the shattered shell, an undeserved demise, in complete innocence, never aware of the sad fate they had both been delivered.

The attending didn't say anything afterwords.  We quietly walked back to the resident-room to finish our work. There was no lecture or lesson to follow, no journal article to be studied, or fact sheet to be memorized; today what this little girl had taught us in her silence was lesson enough.

Quick Note

Hey Everybody,

I just wanted to write a quick note as I try to post something once a night, this is just a quick update/note for everyone.  As you can see, I've changed a few things on here (really just trying to clean it up a bit).  I have a pretty long post that I was going to put on here tonight, but I've got it hanging in a holding pattern until I get an outside opinion on it (it's a story that's near and dear to my heart ;P and I wanted to get it right).

If you guys don't like the new changes to the blog, let me know what sucks and why, and I'll try to fix it up a bit better, just write it in the comments section and I'll get to it.

Lastly, I'm really close to putting up a calendar on this blog that will show what I'm currently doing and what I will be doing - not anything crazy, just something new.

Alright I'm out.  Thanks for reading everybody, it's what keeps me writing, so I really appreciate it! :)

Newbie Doc

UPDATE: I couldn't sleep...so the calendar is now up and running...that actually took some thinking...I had to mess with HTML code...which I'm not sure I should have been doing but it didn't destroy the blog so I'm going to count it as a win. :P Ok NOW I'm going to try and get some sleep. Goodnight.

5 Minutes Till Midnight

Today was a wierd day, wierd because although I'm not leaving the NICU for another week, it was a day of goodbyes and goofy relaxed joking (like a "last day"). My two attendings for the different teams, who we have had for most of our NICU rotation were switching to the non-resident team and new attendings were rotating on. So today they bought us breakfast and lunch from fancy places, gave us individual evaluations, and said their goodbyes until 3rd year (although we go to other NICU's, we won't come back here for 2 years). Somehow the nurses caught on to the mood and were remarking on how we did during our time here, so although not much happened for me to reflect on today, it was a day full of people reflecting on me.

It made me nervous to know that we had evaluations today...I don't like them. If you did "bad", you sit in a room 1 on 1 with the attending and discuss what you can do to remedy the situation (which hasn't happened to me...yet...but I've heard stories from friends). If you did "good", you have the equally uncomfortable task of sitting in front of someone who you respect, listening to them go on about all your accomplishments over the month (I don't know about you but I hate being singled out for anything...it's the one thing I don't like about this blog). I guess if I HAD TO choose between the two, I would decide on the latter and luckily for me, that's what it was, although I'm not entirely sure all that was said was deserved. While I hate doing evaluations, all in all, I suppose it was a nice feeling to know that barring any screw ups in the next week, my fellow interns and I have passed through the fires of the NICU unscathed, the only sadness I feel is that I was just starting to get comfortable here and really understand this place.

Of late (to my surprise) I have found myself getting done with my work WAY early, meeting all of my intern demands with ease, and comfortably answering questions from the nurses and patient's parents in that actual "doctor" personna. Here I'm becoming less of that student "playing" doctor and every day more and more of that person who comfortably fills out that big white coat that I was so scared of initially...the saddness comes from knowing that, in a weeks time, that feeling will be gone and I'll be moving on again to unfamiliar ground. Like the clock striking midnight from the stories, this stage coach is soon to be only a pumpkin once again.

Newbie Doc

...come on I'm not about to call myself a girl named Cinderella ;P

Cinderella (Two-Disc Special Edition)

A Brave Old World

When I was in medical school, from the very beginning of the first year, we were trained using fake-patients (paid actors). We would go into the room pretending that we were the actual "doctor" and we would address their make-belief concerns and problems, offering up advice, tests, and treatments. This would happen about 2 times each month. What made it scarier/funner was that we would have no idea what the patient was going to be like until we pulled the chart off the wall (moments before going into the room). The only thing predictable about it was that each patient would be based on a particular archetype of patient, for example "The Depressed Patient" who doesn't make eye contact and answers every question with a quiet, "...I don't know..." until you hit on the ONE thing that's brought them here (at which point they break down crying). One of my most embarrassing moments in medical school was doing a patient interview with the "Not-So-Secret Crush" patient.

I walked in and there sat this very attractive, late 30's woman who managed to turn every question or comment I made into a sexual innuendo (ie. in-your-endo), if you know me I was never one of the "smoothest" guys with the ladies and the result was that I turned beat red, stuttered through my interview, and did a piss-poor job of fending off her remarks and ending her advances...to add to the embarrassment there were also four other medical students (strangers to me at the time) sitting behind her, observing my performance, who were laughing so hard tears were streaming down their faces (I ended my interview by abruptly standing up, mid sentence, and leaving the room).

There's also the "Elderly Patient Who Has An STD" made for reminding you to ask about their sexual practices, even if they are advanced in years, and there is also the "I'm 12 Years Old and I Do an Illicit Drug" patient, which is the one that I wanted to bring up briefly today.

When we were in school training for these particular patients, taking a drug history was comprised of asking the youth a couple of simple questions like, "Do you drink alcohol?" or "Do you smoke anything?" or the catch all, "Do you take any recreational drugs?"...These apparently are obsolete, as my attending was relating to us today what he has discovered from discussing the subject with his teenage population.

You really have to sit down with a kid and talk about it for more than a couple of seconds, give him/her some comfort room like asking a question about what OTHER kids are doing, which allows them to indirectly tell you about what THEY may be doing. You've really gotta spend some time with them instead of firing off a simple 1 liner question, for example you might not find out from the question, "Do you drink alcohol?" that they do in fact use alcohol, since the girls don't actually "drink" the alcohol in vodka covered tampons (yes they have gotten A LOT more creative since we were in school). They've also figured out they can get a high from asphyxiation by having a friend choke them out with a leather belt, and I really don't wanna meet the kid who thought up doing Anal Beer Bongs(CHUG!CHUG!CHUG!). Yes, these are all real and apparently work to some extent, just so we are clear though, I DO NOT condone their use in the least.

It's true, we got a pretty good laugh out of our attending describing the new drug practices of the youths of today (I seriously had NO idea how out of the loop I was), but the need is actually very serious for good communication skills in doctors and those of us who are parents - otherwise you might not know that what your son calls "smurfing" is doing a drug found in a well known over the counter medication, that causes the hallucination of blue "creatures" or that your daughter is telling the truth and she isn't actually "drinking" out of your liquor cabinet.

One could say it's a brave new world out there...but really in this respect nothing has actually changed, it's just like it was with me and like it was with you - there will always be young and stupid kids doing idiotic, dangerous, and sometimes unusual stuff...sometimes reaalllly unusual.

Newbie Doc

PS Just wanted to say again that I in NO way condone the use of any of these actions mentioned in my post. I am simply using their comic nature to drive home the point that kid's don't quit doing crazy, dumb stuff just because you have grown up and aren't one of them anymore. I think these previously mentioned actions are stupid, harmful, and in some instances (like choking yourself with a belt..duh!) dangerous.

Bullet Proof Glass

One of the things I find truly amazing is how intact the "glass ceiling" is between the sexes within the arena of medicine, even in this day and age it's still very noticeable. I can't count how many times I've seen a more knowledgeable female counterpart get "grilled" in rounds for not knowing something, while the males are treated with kid gloves. I can easily think of 10 examples where a female medical student would be put down by the doctors/nurses or where males weren't expected to do as much scut-work. How about a personal example (the reason I'm bringing this up), I'm able to, at the very least, get 2-3 hours of sleep on call each night (usually 4-5) - while it may be because I communicate well with the nursing staff or maybe that I'm just lucky - most likely it's because they won't wake me up unless it's really important (my attending calls it "prince syndrome")...I found out today that for the girls (Karly, Jen, and Linda) they usually get 1-2 hours on call and are usually woken up for stupid reasons - normal laboratory test values, ect. (The attendings were relating this to me) Whether or not that is true, I do see a noticeable difference in the respect given to me, versus one of my female counterparts, by the patients and nurses. You'll hear an occasional irritated, "Yes, I AM a doctor." or "NO I'm not the nurse." from one of them in talking with a patient. Occasionally they've even ran into problems with patients vehemently disagreeing with their clinical plans...only to easily comply when the male attending says the same thing (if any, it hasn't happened to me much). On a more national scale, only recently have females reached equal numbers in medical schools and I've often heard the complaint about female attendings making less than their male peers (although this is unverified).

I honestly don't think this "rift" has an easy solution or maybe even "A" solution. This is one of those things that remains in place due to a societal thing (ie. both males AND females keep it in place...regardless whether it's a doctor, nurse, or patient).

You can't sue a patient for being sexist (maybe but realistically it would be stupid). You can't sue female staff for being "nicer" to the guys. You can't yell at someone for assuming you are a nurse. It doesn't make any of it "right" or "acceptable", but the alternative would be a medicine even more full of silly rules and regulations than it already is (ie. You can't interupt a female resident during rounds or wake her up more times than you wake up an average male intern during call). Pushing something like that through would probably be more detrimental to medicine than allowing this quiet sexism to continue, because of the implications it would have for putting other overly bureaucratic rules in place.

Nope, nobody, female or male, will be shattering that "glass ceiling" anytime soon, so if you are a female thinking about becoming a doctor, (like it or not) you better bring your $#&%-wading boots and a thick skin...me...I'll bring my pillow (joking..sorry couldn't help it).

Newbie Doc



Elliot is sick of being called "Sweetheart" by the chief of medicine.

Scrubs - The Complete First Season

What The [Confidential] Is Going On Here?!?!?

Sometimes you feel like this is how Government must work when you hear about health care reform...instead of passing a cohesive intern work hours plan...they instead opt to pass only part of it...It's like going in for a root canal and the dentist quits after only numbing you up...and then charges you for it.

Update

Just wanted to update those of you who read this blog and wonder what is going on with the patients that I have freaked out about in the past. I'm thinking of two children, one with medical necrotizing entercolitis and one with probable bronchopulmonary dysplasia.  These two aren't done yet, but as soon as they finish their respective stories, I will be sure to finish mine with you (ie. still waiting).

Newbie Doc

Why Not?

One of those things that you hear in medical school, almost as soon as you enter, is that it's a long, tough road.  Towards the end of second year when you are burnt out and sick of it, wondering why the heck you chose this profession, they will start telling you, "don't worry, when third year rolls around, you'll start to see the light at the end of the tunnel."  (seriously get ready to be sick of this phrase) and for a little while (during fourth year), things do ease up a bit, life gets better and you start to think to yourself, "Maybe that light is just around the corner."  But then interviewing hits you and in the midst of getting caught up in finding a residency, you again loose sight of that idea, that there may be an "end" to all of this constant running at full throttle.

It wasn't until this last weekend, on Saturday, that I was talking to my father that this thought reoccured to me.  I was catching up with him, when he mentioned that one of my brothers, Jason, was able to finally complete a long standing goal of his, something he has been working on for a long time...he did this a whole month ago and I'm just now finding out.  Right then, when my dad told me this, I suddenly felt a pit in my stomach.  Let me try to explain. 

If you go straight from high school to college, and straight from college to medical school, you are about 19-20 years of age when you first decide to become a doctor.  If you are committed then it only takes about a year, until you begin to see it in a "there is no going back" attitude, you've already put in too much work to quit now.  It becomes like climbing a mountain, I suppose, after all the planning, packing, and traveling just to reach the base (even though it's starting to look pretty daunting), why would you turn back now? You have to give it your best shot.  So you're into it now.  Why did you decide to climb a mountain in the first place?

For me I liked this mountain because it had good job stability, pay, nobility, and prestige (once you had climbed to the top that is).  At the time, those sounded like really strong reasons and although I knew entering into medicine's ranks wasn't a decision idilly made (that didn't stop me from doing it), I was young, immature, and nieve.  A friend once said, "You're going to be 26 anyway, why not be 26 years old and a doctor to boot."  Even though I had all these "reasons" his statement summed up my attitude better than any other, "I liked the job. So why not."

The biggest thing (I think) most self absorbed 19-20 year old kids don't think about is others, specifically their relationships with family and friends.  You think going through college as a pre-medicine major, that you are isolated from your loved ones.  You think you know what that sacrifice feels like and so you don't give it another thought as you go on to become a doctor, it's not bad at that point. But as medical school drags on, your family and friends drift further away from you.  You watch as they plan big parties that you can't go to, they buy houses, they get married, they even have children, and in the rare horrifying instances they pass away; all the while you're standing outside of their lives, isolated, static, and uninvolved.  In a way you start to see life pass you by and if medical school is a tunnel like they say, at that point, it only gets darker and darker.

I think that pit in my stomach I felt on Saturday was my denial being shattered.  Distracted at the end of school, I had forgotten about looking for the "light".  I went into residency and forgot all about that feeling of life passing you by, in the back of my mind, I think I really thought it was over.  Talking with my father on the phone, brought me crashing back to reality.  While I vastly prefer residency to medical school, in this respect they are the same, that feeling of watching loved ones live their lives without you is still present and sometimes painful...where is that dang light???  If you see that person who says this tunnel analogy crap to you, would you punch them for me?

All that depressing stuff being said, I do love my job and I'm very thankful for all the things making this choice has brought me (a great career, an amazing wife, and a new son), but this is just one of those decisions whose consequences you can't comprehend when you make it as a 19 year old.  If you're wondering whether I would still make the same decision again, knowing what I know, the answer is: Yes I would, but I think that decision would have been a smidge less impulsive.  Becoming a doctor isn't a tunnel to be passed through at the end of medical school or residency, as far as I can tell it's a journey you'll travel on for the rest of your career...possibly for the rest of your life (maybe that's what they are getting at with the whole tunnel-light-analogy), so if you're a pre-medie trying to make that decision, think long and hard before making it, it's a decision that isn't just about you, it's about you and everybody you know and love....no pressure ;P.

Newbie-Doc

Ask Your Doctor About Waiting Today

So I've just officially ended my Thursday call and I am now in the process of kicking off my "Golden Weekend" (my one weekend every 4-5 weeks where I get both days and half of Friday off). Today and possibly tomorrow I plan on carrying out one of my most beloved types of R&R, which is to sit around and accomplish absolutely nothing, which for me (and probably for everyone else too) is much harder than it seems.

In commemoration of that plan, it seems my seven patients have decided to join me in blissful nothingness, if not for the weekend, then at least for the day. As I pre-rounded on each this morning, gathering the "facts", I realized every single one of them were "kicking back" so to speak, with nothing left to do for them clinically (if things stayed their course) than to sit back and wait for them to get better with their respective therapies. However, if I'm really singing the praises of these babies for giving me absolutely nothing to do for them, as I go into my long weekend, then I've gotta talk about Miles, the patient I've had since I started the NICU, my little lesson in doing nothing (see "The Art of Medicine" and "I Hope").

Last I spoke of Miles we were working him up for a "vascular anomaly" in one of his organs that we believed might be causing all of the edema (fluid swelling) in his lungs. Well the report was that the organ was actually fine and normal, which is both a good thing and a bad thing for us. It's a good thing in that this little kid doesn't have another problem to deal with, one that would require a surgical procedure (likely imaging-guided blockage of the rouge vessel if it had existed). It's a bad thing in that his problem is looking more and more like something we can't fix with an actual "therapy" per se.

Since my last update, we have tried increasing the amount of oxygen he gets, giving him inhaled steroids, giving him another diuretic, giving him oral steroids, and even giving him nasal drops for decongestion...none of which seems to do anything for him. Day in and day out, he is still the same. Really all we may have managed to do in trying to fix him is put him at risk for other problems (ie. His therapies gave no benefit, but all therapies have risks and side effects, like the steroid that did nothing to help his breathing but will probably stunt his growth a little).

When I spoke of him in "The Art of Medicine" I mentioned how hard it was to do nothing. It's not just that we are doctors and nurses, with a specific personality type that likes to help people, it's that we are human beings like everyone else. The vast majority of human beings "do" things, when you see this little boy struggle to breath the way he does every day, a regular human being's normal response is to try everything in his/her power (within reason) to help him. My attending's response to all of my suggestions on different therapies to try on this little guy was, "Let's do nothing, he just needs to grow out of it." More and more, that attending is being proven right.

Since he has rotated off, many attendings have taken his place and all like me eventually have gotten aggrivated with Miles' disposition and tried some new therapy to help. One of the attendings that I respect the most, finally today waved the white flag, and conceded that he had gotten impatient (as I had, among others) and had tried to help this child, when all he needed to do was "do nothing".

The nurse who was taking care of Miles at the time made the statement that this little patient had just forgotten to read "The book", meaning that he didn't follow the direction manual for fixing patients that we as doctors and nurses are brought up on (You'll hear this statement all the time in medicine). I had a thought at that moment, that if we were going to go so far as to say that this little guy reads books, perhaps he just didn't wasn't reading the right ones.

"The House of God" is a classic in the medical world. It's a satirical, black comedy of medicine in the 1970's. Although a lot has changed since then (medicine treats it's interns a little better now and we use paper charting a lot less) many of the maxims in this book still hold true. What I was thinking of in particular was the "Rules" of the house, listed in the book by "The Fat Man" (a genius resident in the book). I won't list all of them because most won't make sense without reading the book, but here is the one I was thinking of.

Rule Number 13:
THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

You can see it is a very funny book from that one statement. However, if it is serious about anything at all, the one thing it tries hard to do is make fun of how inadequate our "health care" is at times and how more often than we would like, we as doctors, have little to do with actually getting the patients better, that is unless you count writing a prescription for more time as a real treatment...

"I'm going to write you a prescription for waiting. I want you to take this with a glass of water, after a meal, once a day at lunch, and then call me at the end of the week if you don't feel better." (insert paid doctor-actor cheezy smile here)

Disclaimer: The FDA is not involved in the testing, monitoring, and/or regulation of chrono-supplements and cannot therefore endorse the effectiveness of said supplements in this add.

Newbie Doc

**FYI, if you check this book out it is an adult book with adult topics, don't give it to any young impressionable minds, without reading up on it first.**

The House of God: The Classic Novel of Life and Death in an American Hospital

RSS Feeds

Hey I'm really getting into this blogger thing :P. I've added RSS feeds that you can subscribe to, if you use such things...I don't but I have some friends that do. The way I understand it, if you have a bunch of things that update regularly (like a blog) you can put them all in one place so you don't have to check multiple sites. If you want to, at the bottom of the blog it now says "Subscribe to Posts".

Newbie Doc

*Fyi you won't see the "subscribe" unless you got to the home page - to do so click on the Title of the blog and then scroll down.

Tickle-Me ECMO

When I was a medical student at my old alma, we didn't have ECMO, but I had heard the horror stories. (ECMO = extracorporeal membrane oxygenation - basically a machine that takes place of the lungs and/or heart depending on how you use it). How hard it was to manage, how complex it is, and what terrible shape the patients are in...I am here today to tell you that everything they say is true ;P...seriously though, only a couple of my attendings knew how to use it during rounds today and the rest were asking questions like first year residents...and the first year residents (ie me and my crew) were just blown away.

We had this little girl who was delivered close to term, but as un-luck would have it, she inhaled a large amount of meconium (baby poop in utero). As you can imagine, having feces coating the inside of your lungs isn't the best way to start out in life. I don't know all the particulars, but as is common with these kids she had a pneumothorax (the left lung popped)...then the other popped (uh oh - do they call that being up meconium creek without a paddle?..drum roll). They tried placing chest tubes, which would have fixed the pneumo's...but she was still being unlucky at the time. She continued to get worse and her heart started to crap out as a side effect of all the problems with her lungs. So my attending opted to just bypass those two organs completely with the magic ECMO machine.

It was pretty wild, we would round once a day on this kid, although none of us residents had her. They would pimp us to death with questions on expected lab values, "what-if" scenarios, and all kinds of other stuff (with a good 20 person croud standing around..real fun). I remember standing there the first day in total awe of that machine and simultaneously in awe of that little girl...really in awe of all human beings.

This machine probabaly weighs over a 1000lbs, I tried counting all the tubes, ports, and monitors but it was futile - there is just a crap ton of them...I think that thing had monitors for it's monitors. It has a dedicated person also just to sit there and watch it, making adjustments when needed. All these doodads, ect. and it all comes down to two tubes, one filled with bright red (oxygenated blood) and one filled with dark red (deoxygenated blood) going into and out of this tiny tot. All the while this little girl is laying there resting her little lungs and worn out heart, slowly getting better, slowly using the machine less and less, until eventually they would pull her off of this monstrocity.

First off, I was in awe of how complex this machine was, how big it was, and the skill it took to operate it. However, my second reason for being in awe was a way more impressive thought. It takes a 1000lb+ machine with innumberable wires, tubes, monitors, and human operators (probably costing around 50K per case, not to mention what the machine costs) to do what a 6 lb, little girl (usually) can do without thinking...WOW!

We've advanced so far in science and technology, it starts to seem as if the impossible is right around the corner...like we can do anything, but when you look at it like that...we still have a very long way to go.

Newbie Doc

Update: She got pulled off of it a couple hours after writing this and she is doing great. Very cool.

Update: A couple of weeks later, I walked into a patient's room to talk to a nurse who had another patient of mine, she was feeding this cute little baby, who must have been a feeder/grower (one of the uncomplicated ones)...only as I walked out of the room and gazed up at the patient's name on the door did I realize it was this same baby, who had almost died.  It's amazing that we could bring her back from the edge like that, she looks as if she was born perfectly normal...if I had known this when I wrote this post, I would have named it "The Miracle Machine" because for this little one it truly was just that.

Med-Search

I just added a new search bar to the top of the blog. It works like google search, but it's more key'd into medical subjects, should be useful in searching up any odd terminology I use, or checking my facts if you think I've spoken in error, ect. Hope you find it useful.

Newbie Doc

The Back Stabber

You have a sterile gown wrapped around you, with tight rubber gloves over your hands. Your breath keeps steaming up your glasses because of the mask you have on over your mouth. The nurse prepares this tiny little girl's back by wiping iodine all over the area that you're going to do the "procedure" on. The area is draped and sterile. You walk up to the bed, where this cute, 2 day old little girl is laying on her side in fetal position, back facing you. You move towards the bed and stand next to the procedure kit, setting up the tubes you are going to fill. You move in slow motion so your sterile field isn't ruined (it feels like you are in outer space or scuba diving; like your breathing should have a "shhhhuuuck" sound every time you exhale). With the tubes in place, you now slowly pull the cap off of a large silver needle as thick as a tooth pick and just as long. You carefully and slowly approach the bed. The nurse cradles the infants head in one hand and legs in the other. You ready the needle, bevel up. The nurse bends the infants head toward it's legs, flexing it's back toward you (it's somehow delicate and brutally forceful at the same time). The infant begins to scream shrilly in protest. Your hand reaches out onto the crying baby and feels for the hip bones. You make a mental line across them, and feel for the spine in the middle of it. Your fingers feel up and down the ridges, finding the gap between them, the soft spot, the target. Without hesitation you quickly plunge this large tooth-pick of a needle between the spinal bones. The infant squeals louder, it arches it's back, but the nurse holds it forcefully in place. You push the needle deeper (half way in...not far enough), you keep pushing (almost 3/4's of the way in...is this too far?!?!?) Your attending insists you go on. The needle advances still further, until you feel a slight resistance and then it gives way. You pull the core of the needle out and a clear, watery fluid starts dribbling out of the middle and into your tubes that you are quickly placing under it. The infant is still screaming and fighting. The mother is crying, saying something in Spanish that you don't understand. Suddenly you realize you are sweating profusely. One after another you fill the bottom of the four tubes (can this little baby have that much fluid in her?). With space-man movement, you close the last tube and replace the core of the needle, the infant screams still louder as you quickly remove the steel from it's back. Everything goes back to regular speed after that. The nurse quickly places a bandage on the baby and feeds it, the trash is cleaned up, the tubes are sent to lab, and the mother is consoled. You walk out of the room, it seemed so slow in there, but now that you are done, it's happened so fast that it's hard to process.

Today was my first successful lumbar puncture on a newborn. I've done them many times on older kids and adults, but babies are so small and fragile. The fear you feel doing something so brutal to something so tiny...it still hasn't gotten any easier. I've done it three times now on an infant and so far it still seems just as crude and brutal as the first time...but it is necessary (telling myself that is the only way I can make myself do it each time). This little girl was admitted for "rule out sepsis", which means that we think she might have a really bad infection (she is showing all the physical signs)...but we don't know where it is. When something like this happens, you have to check all the places bacteria and viruses could hide, ie. blood, urine, and regrettably spinal fluid. Someone really needs to invent a better way of getting CSF (Cerebro-Spinal Fluid) out of the body, supposedly risk-wise it's not any worse than getting blood drawn from a vein, but there is something about LPs that makes them seem so violatory, crude, and really just plain wrong. I should be happy that I actually did something right today ;P but honestly I wish it had been something else I'd gotten to do correctly. Only jerks like being back stabbers.

The Bubble Gods

One of the things that often gets glossed over in all the doctor tv shows is the ridiculous amount of tests that you have to take. 16,000 bubbles in college, 4800 bubbles in medical school or 25 straight days of testing time - that's being conservative, not mentioning the hours of practice tests for the MCAT and the 3 Boards tests we take throughout medical school. It just keeps adding up and it will never stop. I wonder how much number two graphite I will use up by the end of my career? Whatever the amount that's a lot of bubble sheets sacrificed to keep our brains on key.

Today I added another 4 hours of testing to my grand total, by taking an in-training exam, that tests us for weaknesses in our medical knowledge. We then try to strengthen those areas over the course of the year, taking more tests to gauge our progress. It's really odd and funny, all the strategies and tips that a bunch of medical school students develop over the course of all these years, it becomes kind of an art.

1) get a watch and know how much time you can spend per question
2) recognize question patterns - ie. two "like" answers usually signifies it's either one or the other and not the other two multiple choice answers. There are lots of other patterns to know.
3) "all of the above" is usually the answer
4) don't choose answers that are "absolutes" - i.e. such and such treatment ALWAYS cures cancer
5) always read the last sentence in a question first
6) if it's hard or requires calculation - make an educated guess, mark it, and come back to it.
7) In college I would get done with the test and then pester the TA's and Professors with questions about the wording of the tests until they gave me answers that would help me out...they don't allow that in medical school...or residency :S, but it worked great while it lasted.
8)...I'm going to stop, but I could definitely go on.

A really good friend of mine brought a specially made pencil for marking bubbles and an eraser-pen so he wouldn't run out.

You take so many it becomes almost like a sport with techniques and skills to be developed through repetition over the years (although calling it a sport might be glamorizing it a TAD bit ;P). That being said all of those skills mean jack when you are under-prepared as we were today. Although it was just a 4 hour test, I came out of it mentally zapped. It's amazing how much energy a test can drain out of you, especially when every question is a major mental task....but it's over now and I breath a major sigh of relief as I turn my sacrificial bubble sheet over to the bubble deities that be.

Thank You

Hey I just wanted to put out a quick THANK YOU to all my family, friends, and even strangers who have/are reading the blog. I'm really flattered that some of you have even liked it enough to actually call, email, and text to let me know that it's not crap ;P (seriously it means a lot). It's really cathartic writing this, so Thank You all for being my therapists through this and I'll try to keep it true to life and (hopefully) interesting for those of you who subject yourselves to my ramblings day in and day out. Thanks again!

Sincerely,
Newbie-Doc

The Long Sighhhhhhhh

Call night. Some nights I read a little to stay ahead of the patients I'm covering, mostly I study for about 45 to an hour. Tonight I just finished studying and it's been about seven hours of on again,off again studying (in between deliveries, a lumbar puncture, and a partridge in a pare tree)- I don't think there is anything more I can learn about NEC from a text book or research article...nothing that is going to help my patient anyway.

I came in for call yesterday, after 1 whole day of blissfully doing nothing. I went to a movie, called my family, and hung out at my wife and I's hotel room. I sat on my butt all day and it was great, no worries. When I woke up this morning I felt really "ready" for the day, a day that was probably going to be like every other call day...after all our service was full, totally full of babies that for lack of a better description were also sitting on their bums doing nothing. My six kids were probably the least eventful of the bunch, and that is saying something. So with that in mind, I was making plans for the night, what to do with my spare time...I should have known right then and there how it would go.

When I walked into the resident room, my senior, Maria was pacing the room talking to someone over her pager (Pacing is a bad sign). She looked "out" of it, with dark rings under the eyes and frizzled hair (none of this her normal smooth composure). I could tell her bad night was about to become MY bad morning.

She finally collapsed into her swivel-chair and recited the happenings of the night...it was a really long one for Maria, full of deliveries and pages, mostly about one patient...my patient. A.J., who for the first 7 days of his life, the 7 I'd known him, had been the most normal patient on the NICU...now he was trying to act up on me (and by act up I mean DIE on me).

A.J. is a little 33 week old premie, here mainly to grow and get bigger (what they call a "feeder/grower"). As previously mentioned, he has been easy-peasie. I simply increased his feeds every day and watched him eat, sleep, and poop in happiness (actually sounds pretty awesome huh?). But in the day that I was hanging out relaxing, his bowels were getting into trouble and now I come back to an infant who is pooping blood, vomiting green stuff every couple of hours, and is just generally not a happy camper.

Over the course of the next 30 hours this little fella proceeded to do to me exactly what he had done to Maria, which is to crank my switch from "Relaxed" allllll the way over to "Basket Case". Throughout the day, I skimmed 2 small books on NEC (Necrotizing Entercolitis), looked over the academic websites, poured over ways to diagnose NEC and (most importantly) looked over the ways to treat it. I did know a lot of this from previous experiences with other babies, but A.J. was MY patient, if he tried anything I didn't want to spend a moment in thought as to what needed to be done. At one point it was very touch and go, we had to load him repeatedly with fluids because he was going into shock (where the heart is beating faster than normal to keep blood pressure up, but it can't beat fast enough...that's bad :P). Thankfully, right before we would have brought in the big guns (drugs to help the heart and vessels) he started responding to the fluids. Suddenly, it seemed that as quickly as he had been deemed "really sick" by my senior last night, he had switched over to being "stable" with me (THANK GOD!!! SERIOUSLY...THANK YOU!!)

Everything magically started to get better for this little troublemaker at about 1am last night and hopefully (fingers crossed) that won't change for my little buddy. So with my "To Do's" checked off, my sign-off now signed out, and my patient sleeping soundly (as he should); a frazzled resident with dark baggy eyes, will now leave the call room once again. This resident is just as tired as the last, but happy in the thought that, at least for now, his babies are going to be alright.

Newbie-Doc

My Mask

Every doc in medicine knows about the "mask" or the "poker face". Some aren't very good at it, others are excellent. For medicine, you have to develop one, it's essential. We use it everyday, it's pounded into us to remain cool, calm, and (most importantly) non-judgemental...and if not that, then at the very least, put on your mask.

A diabetic patient pulls off his/her shoe revealing a bloody, mummified foot.

A 13 year old girl tells you she was impregnated by some 28 year old guy.

A grandmother making poor excuses for her child, while her grandson lays in the hospital bed bruised and beaten.

These are some of the memorable reasons I've had to put my mask on. I won't speak for others but I'd bet that every doc in and out of practice can easily name at least a dozen times where they've had to use it.

Today my mask slipped off. Not for the reason you would think, it wasn't some horrible abuse case, or a dieing child...the reason kind of even surprised me, in retrospect. It was a co-worker, a nurse, that knocked it off, I suppose she caught me off guard. I was going to go into this ti-raid on how exactly she did it, but the basic gist of it is that she told me false information about the patient, and then set me up in rounds, in front of everyone (patients included), to look like an idiot.

I've seen similar things happen when she's dealt with other residents. In working with her, I've ran into "instances" with Becky (I'll call her that) where I've really had to fix that mask on HARD. I should know better than to get sucked in, but this was two days in a row that she had done this to me. The first time I fumed about it all day (but kept my cool), in the second instance, instead of remaining calm and cool as I should have, I reacted emotionally. It wasn't much, but I basically interrupted her and asserted how what she was saying right then to the attending was a 180 from what she had told me 30 minutes ago. As she went on, I shook my head in anger and disagreement. Why was she doing this to me?!?!?! I still have no idea. My mask was definitely off. Becky then went on to disrespectfully question the attending's decision right in front of the patient's parents (a BIG doctor-nurse no no, we are supposed to be a team, not undermining each other). Unlike me though, Dr. Smith remained absolutely calm, he didn't yell at her as I was itching to. He calmly sighted study after study that backed his decision and beat her into submission with calm, POLITE, logic...that was very impressive.

After we were done with that patient, the attending took us, the residents, around the corner, out of view of the nurses. He told us something I thought I knew, should have known. He said, "There are some excellent nurses on this floor, Becky isn't one of them. Working here I get to know these nurses very well, this isn't the first time Becky has done this and it won't be the last. I take what she says with a grain of salt. As a doctor, you can't get sucked into that stuff. Your objective is caring for the patient and fighting with this nurse won't accomplish that. You have to know how to get the most out of nurses like Becky, you have to get her on board with your plan. That's why I took my time explaining things to both her and the family, she now understands what we are doing and where we are coming from. You can't fight with nurses like her. You can write an order or give treatment to a patient however you want and if the nurse isn't on board with the plan or has decided you are wrong, it's not going to work no matter how good the treatment is. You have to be above that."

That doc is a very wise man. He could have ripped me a new one for arguing with her in front of the patient (which I probably deserved), or ripped her a new one for arguing with him in front of the patient (which she definitely deserved :P) , but instead, he was like a father in front of two bickering children. He stopped the argument, got to the heart of the problem, and diffused the situation (even teaching me a lesson from it) all the while being calm and patient. I hope someday I can embody the calm, logic, and wisdom that he did yesterday. It was a excellent lesson, don't mind your mask, BE your mask.

Newbie Doc

Blind Man

I was post call as of 6am this morning. My responsibility then is to finish notes, orders, sign offs, and get out before 12, so at that point it becomes someone else's job to receive the babies from delivery...however that person wasn't here as chance would have it, when the pager sounded off "21 weeks gestational age, room 1B". I didn't think about the implications of what that said, I just got up and walked to the door. Just as I was about to go to it Karly stopped me and said, "Hey, you're post call, I'll take it." Which was nice of her, I objected I didn't have much to do at the moment, but she and I have a friendly competition to see who can do more while on service...because she would get this one, we would now be tied...I smiled and let her take it, letting it pass out of my mind.

Flash forward to 30 minutes later. I come in and find her sobbing. When they said "21 weeks gestation" over the pager earlier, I had simply thought, "another delivery.", what I hadn't taken into consideration is that a baby younger than 23-24 weeks is almost always non-viable (the cut off gets younger with technology getting better...this is where we are at right now). When I say non-viable, it's a cold way of saying the baby will die regardless of our intervention. She said the mother, knowing the baby wouldn't make it, didn't want to hold it or get attached...they had decided to make the baby comfortable as it passed on. The grandmother held it as it lay there in her arms, suffocating because it's lungs were not ready yet, it's brain not fully developed, pick a reason, the baby was dieing.

As rounds came Karly got back to business and probably pushed it to the back of her mind. Life went on. I have yet to experience a child's death. I've been faced with cancer patients who found out in front of me they weren't going to make it. I've seen a elderly person, with family gathered round, slip into a deep sleep. It's easy to say they've had a decent life or they chose that fate (smokers, alcoholics, ect.). I don't know how I rationalize a little person, just starting out, suffocating in his grandmothers arms. I don't know how I'd rationalize one of my patients dieing.

Kids in general if sick, get better. Even in pediatric cancer patients, most of them come around amazingly (the most common - leukemia[ALL] has a very good prognosis these days). I realized I've been insulated from death and I subconsciously have believed that this is some kind of movie and all of my patients will survive, that if I do everything right...then they will BE alright.

I was reading a pediatric diseases book last night, studying different diseases I was worried about while on call, making sure I knew what to do should XXX situation arise. I saw the percentage of N.E.C. patients that die of the disease (~25-30%). Numbers are a part of my life, I see tons of them all day long in labs, books, computers, ect. Mostly I quickly pass them over and make a decision based on them, even when I was reading over that death rate percentage as a student, it was just another thing I needed to know...but last night I stopped at it. 25-30% of patients with NEC will die, 25-30% of MY patients with NEC will die. It's like I had been a blind man and now I'm looking for the first time upon a tree.

Newbie-Doc

Flying Solo

Today's call started out easy enough...then there was a delivery...then another...and another. It happened all day long. It's insanely hard to get any work done on the patients that you have when the babies keep rolling in. Luckily I had some good friends here that took pity on me and helped me keep up till the day was over. During the afternoon (the babies were still raining down) the attending had to take some time off for a funeral. He got an attending to cover, but there were so many deliveries, we had to split up...so I was flying solo for most of the afternoon. It was crazy knowing there was no safety net for me, if there was a problem the responsibility fell on me to fix it. Luckily the worst that happened was a baby had a little meconium (baby poop) down it's throat and I had to suction it out with deep suctioning, which I'd only done once before with someone watching me...luckily I performed it and managed to look like I was in control and knew what I was doing the whole time...so lucky. I then picked up the baby after it was stable and delivered it to a smiling momma, it was really cool to see her face light up when I told her how she had a perfectly healthy baby boy. I then had to relate all we did to the OB and then I stepped out of the room to do charting (at which point I heaved a huge sigh of relief - out of sight of everybody). It was fun, I can't wait till I'm much more experienced and can do the whole solo thing no matter what the momma throws at me :)

Newbie-doc

ALERT!!!

WE GOT OUR HOUSE!!!!! NO MORE WEEKLY HOTEL SHOE BOX SIZED ROOM!!!!! HAPPY DAY!!!! :)

Newbie-Doc

I Hope

Today was like any other day for the first half. We went around and did the whole gathering labs and patient info, making our orders, and finishing with our notes. The only thing to report is that the little boy I’m taking care of keeps getting sicker. It’s not real appreciable; it’s a really slow kind of “getting sicker”. It seems like every couple of days we have to increase the oxygen or augment his diet, little choices and decisions that by themselves don’t speak to a serious problem, but more and more are worrying me, namely because we don’t have a solid reason for it. Today we got a lot more aggressive with therapy, which I’m happy about. For the last several days we’ve been making little changes and increasing therapy by small increments, which have driven me crazy, but you don’t often jump straight to conclusions with medicine, which I’m bad about. What you do is try the simple stuff and then move to the bigger guns. I often want to go straight to something I KNOW will work, the problem with using higher powered therapy straight off is that you are wasting a lot of resources if you could have done it with a lesser therapy, the higher powered therapies usually have more side effects, and the last (and more “artsy” downside) I think without gradually stepping up therapy, you have no idea what you are dealing with. If you are gradually raising the level of therapy, you are also gradually ruling out the lesser and smaller problems that could cause what you are treating. Today we ruled out all the “We’ll wait it out” or “We’ll just adjust XXX” problems and we had to switch our diagnosis to something a bit worse, BPD (Bronchopulmonary Displasia) which is the neonatal form of COPD (what smokers get). The infants don’t get it from smoking though…they get it from us, among other things.

When these babies are born so small we have to do everything in our power to keep them alive. The lungs aren’t well developed and haven’t produced the right chemicals yet, so they collapse easily. To keep them open we put a tube down their trachea and put in the chemical they need, which is kind of like soap (I’ve heard it tastes like hot dogs…but I won’t try it), we then have to give them oxygen at higher pressures than normal to keep them alive until they can survive on their own. It’s thought that this pressure is one of the causes. In keeping them alive, we have to take the risk it might hurt their lungs…it becomes a necessary evil (like breaking ribs when performing CPR…you just have to…they never show that on Grey’s). The up side in all this is that if we can get him through this rough period his lungs will continue to grow and, by age 8, the damaged part will be a very small portion of his total lung volume.

While it’s possible this is what is causing it and honestly I hope we’ve finally nailed the cause, I’m sitting here wondering, whether our changes to his therapy will work. He’s got about 2-3 more days till we’ll see measurable improvement if it does work…it’s really bugging me…occasionally throughout the day it has occurred to me several times to call my senior (upper level resident) on-call and see how that baby is doing. But I let it go, the baby isn’t going to crash overnight, and we’ve got to give time for the therapy to work…I hope we’ve got it this time, I hope tomorrow when I come back he’ll be better…I hope.

Growing Pains

Do you remember when you first went from grade school to high school/middle school? Remember how hard it was? There are all these new rules, new teachers, new friends (sometimes enemies), and new stuff to learn (much more difficult than before). You are trying really hard to make a good impression and the stress is about to snap you. I’m convinced that never really stops, it definitely didn’t stop at residency. I feel like all the kids in class are smarter than me. I feel like I don’t know what I’m doing and I’m behind in everything…I’m back in geometry in middle school or organic chemistry in college or cardiopulm in medical school. I survived and I did well, but it’s never pleasant trying something new…I don’t know if everybody else feels this way every time, but I do. Pain is part of growth and growth is a @#$!$...: )

The Edge

I was thinking about my night on call, Saturday. It was pretty uneventful overnight, but I did have one patient that stood out. It was the "scary" patient on our service. The patient we are all scared of when we take a night on call, a little boy that was born ridiculously young. I remember getting check out where the intern lets me know the what's going on with his/her babies. The attending broke in and went into a small lecture on N.E.C. (necrotizing entercolitis) a really scary complication (basically the bowels die in the infant) and how they were really watching this one for it because it's had two episodes of vomiting and it had a slightly distended stomach over the day. She described all of the signs of N.E.C. and then she went into some other technical aspects. This morning when I was thinking about last night, about how uneventful it was, I was struck by how easily I remembered everything she had told me about N.E.C., even though nothing much had really happened. I had heard about N.E.C. before and I'd even read different papers on it, yet never had things so technical stick with me so easily before. When I thought about it I realized it's the difference between being a student vs an intern. When you a student the responsibility isn't yours, you aren't "scared" for you patient the way you are when you're the one actually taking care of them, when it's all on YOU. I'm scared of heights so this is a good analogy for me, maybe not for others, but it's like if you had to learn how to dance near a cliff. You're learning the moves, you're watching others "do" it, but you are clumsy and sometimes even make stupid impulsive mistakes because you can be. That's when you're the student. But when you're the intern it's like you're the person dancing on the edge of the cliff, think how differently you would do it, as opposed to just hanging out "near" it. Think how much faster you would learn the moves, doing it so much more carefully, thinking about every small thing you do, micro-analyzing even the simplest decision (you don't feel there is any room for error)...that's how scared I was of that baby last night...I didn't fall off though (not yet anyway)...and I learned from it...even though it was a very uneventful night (Thank God), ask me about N.E.C. sometime, I bet you a month from now I'll still be able to repeat my attending's small lecture word for word.

- a small side note -
I just felt my son kicking my wife's belly...that's amazing!

Newbie Doc

Catch 22

So if you havn't been following you'll have to read "The Art of Medicine" on my blog to get the full story.

Yesterday I was too tired to talk about it, but there is a child that I've been increasingly concerned about, the one from the previous post. Yesterday, I got a laboratory value back that along with this little one's physical presentation and reaction to previous therapies basically gave me the "ok" to order a chest Xray (I knew I was going to hear it from my attending if I was wrong because he told me not to), but I really thought something else was going on in this baby, something more than the same old, same old that I'd been told to wait and see about. When the Xray came back I KNEW there had to be something there (really I was thinking pneumonia)...but when we got the Xray back it looked exactly the same as it had two weeks ago.

So as rounds came closer and closer...the dread grew more and more. I had been instructed that this was just something the baby would have to "grow out of" and that I shouldn't subject the baby to further radiation (not that it's super dangerous - just a good practice). I was worried that this action would reflect badly upon me, that it would show I had no respect for my attending and his experience...I was preparing to get grilled. However, when rounds came and the CXR was pulled up, all I was subjected to was a very friendly lecture on how as a resident he would have done the same thing and that this was all about what they called "the art of medicine" something I'd already lectured myself about on this blog! To myself, I cringed that I hadn't learned anything about patience...or patients and that I'd soon be writing again about how I jumped to conclusions ect ect. But, then the radiology report came back.

It read basically that the lungs had slightly more fluid on them than last time and the heart was abnormally larger (albiet by just a small amount). This promted us to order a cardiology echo (a fancy ultrasound of the heart)...which showed the heart wasn't exactly as it had seemed...possibly more troubling was it had picked up an incidental reading of a vascular anomoly in another organ that could possibly explain her lung's resistance to our "normal" therapy.

Well the tests are still pending, but regardless, I feel validated that the child wasn't the "same old, same old" that we had thought, it feels good to not feel crazy or inept...better than that, it would be great if this led to helping this little rascle do better...cause she isn't doing that great right now, and honestly it's freaking me out.

*A side note, I was really impressed how cool my attending was about me ordering the test, ect. (I had previously apologized for ordering it) He told me I had nothing to say sorry about and the CXR may end up helping this little baby out after all. It was very impressive and said alot about him, that ego and arrogance don't drive him to do what he does and that he's all about helping his patients and teaching new doctors...I hope one day I can be like that (although it seems like Everest right now).

Of Releasing Pressure

Just something quick because it's late (for me anyways).

Today was crazy. The in-laws are in town. It's times like these when you have obligations to your family and to your job that you feel like you are being tugged in two different directions. You feel the need to stay, learn, and do a good job, but you also want to get the hell out of there. I struck a happy medium and was running at max efficiency today. I skipped breakfast first, and then before I knew it lunch had passed me by. I had all my ducks in a row and I was set to be done by 1pm (crazy early)...then we had a delivery...then we had another delivery...then there was a procedure I needed to observe...then my senior who was supposed to relieve me was busy with another patient so I had to wait...before I knew it, it was 3:45 - I'd run myself ragged trying to get out of there, and all for nothing, I could feel the knots in my muscles from being tense all day. As I looked at my watch leaving the hospital, the hour hand had just ticked on 5pm (which normally isn't bad, but considering what I had hoped for...it was dismal). You start to see the hospital as this monster you are trying to escape and just when you think you've out ran it, it reaches up to pull you back in. Tomorrow will be my 3rd day on call...it's what they call a "black saturday" in my hospital. Because it's a black saturday, from last monday, until next saturday I will have approximately 6 hours off (which I will probably use to sleep, because I will be post call). After that sleep is over I'll go back to work. Sometimes it seems a little brutal, but I've developed a nice little trick for getting out of it (figured this one out in medical school). 1) I think of my Dad on the farm. He'll work a month straight without blinking - so what am I whining about? 2) If I'm ever feeling burnt out, I find a movie theater and go to a movie (tonight it was toy story 3). I don't know how most people do it, but for me that is my stress relief. I can go to a movie and for two blessed hours I'm not thinking about anything, I'm in the movie...and when it's over, I can take a deep sigh and find the strength to go back to it. Without little things like that I wouldn't have passed medical school and I definitely wouldn't have the stamina to attempt this residency. I'm not saying I'm a hard worker or that what I'm doing is the hardest job in the world (it definately is not easy though). All I'm saying is how important it is to have something like that, something that can decompress you, and give you the energy to go back and do it all over again tomorrow. It makes life easier and in medicine I count going to the theater among my blessings.

- oh yeah. you should see Toy Story 3 - I recommend it.

Newbie Doc