Newbie Dad

Just a really quick update on the baby (My wife won't let me tell people his name...I really like the name :S).  It's crazy how attached we are getting to this little guy, he really kicks my wife a lot now, mostly at night.  I get right up to her belly and talk to him...sometimes it seems to calm him down almost.  Last night though, I told him I was going to wrestle him when he got out of his momma's belly if he didn't leave her alone...suddenly he paused in his "thumping" on her (as if he was contemplating the consequences)...and then he kicked her abdominal wall so hard you could almost see the foot imprint pressing out on my wife's belly...what a little rascal...I wonder often what he's going to be like when he grows up.  My wife and I are already so attached to him and we haven't even really seen him yet...this whole thing is giving me a whole new perspective on my parents, my patients, and life in general. 

Newbie Dad

Scrambled Insides = Scrambled Intern

2nd day on the job and already much easier...there could be a lot of different factors at play causing this, I think the biggest one is that I discharged 2 of my patients and so now I am only carrying 2 total...I'm told this isn't a good thing.  Each intern has a personal cap of 9 patients (the biggest I've ever had)...so while I'm on easy street it's really similar to a red neck who just one the lotto...easy come, easy go...I'm open for 7 admits, which if I get all at once will be hell on earth...and it's happened before, so I've been told by my wise seniors.  I'm crossing my fingers I will build up my list slow though..it's all I really can do.

One thing that never gets easier on the blog or in medicine is making and admitting to mistakes.  This one wasn't a mistake in my medical judgment though...really what it was is that I was rushed and I was cutting corners, which is ridiculously immature. My complex patient (who I'm calling Jamie) has a lot of problems and a really deep history (by deep I mean her daily progress notes make a small novel).  I was rushed yesterday while learning all the new things you have to learn on your first day and so I did a down and dirty run through of "who she was" and made myself well acquainted with her "acute" history, but only very lightly skimmed her back story.  Yesterday, I'd made a note to know her in and out before rounds today, but as we were yet again pressed for time today I again managed her acute issues and brushed through her history very, very briefly...passing by a word called in her history "Heterotaxy"...I was skimming.  I thought about it and I had never heard of it before. "Must be some neurological finding.", I thought to myself.  I kept on skimming and never thought to look it up...that was my mistake.  Well I can tell you exactly what the word "Heterotaxy" means now.  That one word is the explanation for all of her complex pathophysiology, directly or indirectly, from her heart malformation to her kidney insufficiency.  If they had said "Situs Ambiguus" it might have caught my eye more, because I know of a similar condition, "Situs Inversus".

Most people, unless you are extremely unlucky, are born with their organs in particular positions.  For instance, the heart faces ventricles left in most, the spleen is on the left of the abdomen, and the liver on the right.  What if you took that image and "inverted" it (like a mirror)...that is "Situs Inversus".  Having your organs in "mirror" position can cause problems (arteries can get "kinked", surgeons can operate on the left when they need to be on the right, etc.).  "Situs Ambiguus" is somewhere in between, it covers a lot of different defects in the organs, as well as, a lot of different organ orientations.  This seemingly simple word, "Heterotaxy" defines my patients clinical picture...and in a effort to be efficient I glazed right over it...so you can see how much of an ass that made me while presenting in front of my group.  I start presenting and the attending had to break in and correct the history, because I didn't know the patient well enough...pathetic, considering I only have two patients.  Luckily, I redeemed myself because I was managing her health care very well (in the acute setting)...still a major stigma not knowing her full history like that.  I can learn two things from this, if you see a word you don't know...LOOK IT UP!!!!!!! and secondly, know WHY you are treating your patient, don't get so lost in the minutia that you can't or won't see the big picture.  As for my student...

I don't know much about teaching and I'm not really sure if I should be teaching a medical student when I myself am still learning, but I sat her down after rounds and talked to her about my presentation.  I carefully pointed out each of my mistakes and how I could have corrected them...I also pointed out the very obvious lapse in clinical thoroughness, why I made that mistake...I thought the "why she shouldn't do what I did" was pretty obvious ;P (seriously though it sucked).  I then talked about her patient and her presentation, I tried to be much less critical of her than I was of me and instead highlighted the things she did good (I've heard that it's a better way to teach than to point out all of the students mistakes...I'm trying to figure this teaching thing out as I go).  I did point out one mistake of her's though, but instead of telling her specifically what she did wrong and how she could correct it, I instead compared it to a mistake I made on a patient not too long ago...showing why it was a mistake and why it needed to be done differently, by my story and not by hers.  I don't know if this was the right way to "teach" it, but I really hated it when residents taught me by just pointing out mistakes and then would say "fix this" when I was a medical school student...I don't know I'm honestly really at a loss for all this...it's hard feeling a responsibility and obligation to do something for someone and simultaneously know that you are the one of the least qualified people to be filling those shoes (but you have to anyway).

Ha, I think that last statement actually sums up residency quite nicely, because I often feel the exact same way towards my patients.  In that respect, maybe my goal for my student should be the same as the one I hold for my patients I care for...to do the best I can possibly do  and leave them both, at least, a little better off than when I found them.

Newbie Doc

The Student Becomes The Teacher

Another first day of rotation...another day of feeling totally out of place and really stupid.  My pride is becoming more flexible though with each subsequent rotation ;P.  Today I was given 4 kids, 3 of the four were pretty simple cases (thus far - don't want to jinx it).  The fourth name sounded really familiar...and then I realized I had first heard her name in the NICU...not as a patient but just spoken in passing by the attendings to each other in the kind of camaraderie from dealing with her...ie.  "Wow that patient was a mess, still nothing like Jamie Thompson" (not real name).  It's a testament to her complexity that she was spoken enough in passing that I would remember her name...and I would have to say after 1 day with her that she earned every bit of her notoriety.  She's not half way to a year old and she already has a problem list that would rival a geriatrics patient in a nursing home (that doesn't even cover her medications)....somehow though we survived the day together though and I'm a bit wiser for it. 

I think the real adjustment was dealing with a medical student for the first time.  A student assigned to ME! As if I should be leading anyone...still I was determined to be a good teacher and leader.  I expected her to know as much as I did and for her to be teaching me...I must have low medical esteeme...it's amazing how little you think of yourself clinically (constantly feeling like you don't know enough day in and day out) it was nice for a change for someone newbie-er than me to highlight how much I do know...not that it increased my ego and pride (I know how little I am on the clinical knowledge food chain)...but it gave me a fair bit of relief to know that I'm not that resident who has the same medical knowledge as a 3rd year.  No offense meant to 3rd years, but if I have the same knowledge I did as a third year...then I should be a third year and not a resident...I am very happy to know that (at least with this med student ;P) this is not the case.  I even had a little time to teach her some good physical exam "tricks" and assign her some reading that I think will benefit her exam scores and her patients (differential diagnosis of different kinds of breath sounds...whooohoo...exciting huh?)...as an aside only in medicine can you teach a girl "good physical exam tricks" and have totally good intentions...alright I'm hitting the sack...I am obviously sleep deprived.  Goodnight!

Newbie Doc

Black Holes

Last night I worked the ED for a 10 hour cross cover shift from 12pm to 10pm.  It wasn't crazy busy but I was never without 2 or 3 patients.  The way the ED works is that there is an electronic board on the wall where all the docs and nurses hang out.  As patients come in their names go on this board, along with a complaint (ie. difficulty breathing, abdominal pain, etc.).  If you aren't busy with any patients or you can take an extra you simply go on the computer and type your name in as the doctor taking care of the patient.  It sounds pretty simple, but whenever I'm in the ED, I live in a state of constant anxiety.

"What if this patient is too complex for me?", "What if I screw up?", "What if I have no idea what is wrong with this patient?", "What if...". 

These are the type of questions that come to mind as I look at the patient complaint and place my name beside theirs.  It may be an easy thing to type my name...but its painful powering through that anxiety every single time.  What makes the ED different from something like Wards or really any other part of medicine is that people are coming to you with an emergent problem that no one has likely seen before.  In Wards the patient comes in already having been stabilized in the ED or you get the patient in clinic and they are following up from a previous visit to the ED...in most other places in medicine you get patients that have already seen other doctors, other docs that have already braved that "fear of the unknown" and have put a face (diagnosis) to that problem for you.  When you are in the ED and next to a patient's name you see "Hemophilia Disorder with Trauma and Bleeding", that could be anything...most likely it's nothing super severe or there would be tons of people rushing to that room...but you aren't thinking rationally when you see those words...you just don't know...and you fear what you don't know.  That's how my entire night went anxiety alternating with relief.  I'd see a name on the board, followed by a chief complaint.  I'd go in the room and see the "scary" patient and realize it wasn't that bad.  After awhile you start to realize it's not these patients or these situations you fear...it's the fear of what you can't see...it's your imagination scaring you not the patient.

Movie directors know this trick.  The best directors in horror know that the secret to developing terrifying fear isn't putting something scary ON the screen...it's putting the audience in the mood for a scare and then leaving them with that infinitely expansive question, "What if?!?!?" and not answering it for as long as possible...that's how you build suspense...that's how you build anxiety...that's how you create true fear.  That question is a powerful one, it's our imagination unbridled and uncontrolled, it can crush you into paralyzed inaction, it can drive you insane, and it can even kill you (or your patient) if you stay in it and with it long enough. For me it's a constant struggle to take another patient with a "scary" chief complaint, I wish I could say I'm never scared...but I'm scared almost every time I sign my name onto that board...but because I know where that fear really comes from, I can deal with it enough to get over it and help people.  This isn't something that is exclusive to being in medicine...this kind of fear can be found all over.  It's a lot like a black hole. 

A black hole is so heavy that it's gravity wraps all forms of light around itself.  The only way you can really detect one is indirectly.  Looking at one distorts objects behind it, as if the stars bend to get out of it's way, and free floating nebula explode...seemingly for no reason.  Sometimes the only way you can tell that type of fear is acting on you is by recognizing that you are trying to avoid something...or that you are "exploding" for no discernible reason and you have to ask yourself "why?"  Because if you don't, that fear will suck you in and eat you alive., but if you can recognize that it really is there you at least have a chance at compensating for it and you might even learn something about yourself if you're lucky.  That's a struggle we all deal with in fighting these little black holes that pop up in our lives, it can be found everywhere from walking into a garage without lighting, to putting your trust into a new relationship...you can even find it walking into see the patient in room 5 that's vomiting blood.

Newbie Doc

Update

Just wanted to give a quick shout out to all my visitors and say thanks again for checking my blog out.  This shows state by state where the blogs visitors are at...I bet you can tell where all my family members and friends are at.  Anyways when I first started this up about a 2 months ago, there was only Kansas and Arizona...now look at it go (I even have 2 visits from France and Austria...crazy).  Seems like the amount of visits and new visitors I get is increasing faster as time goes on...I know I say it a lot but thank you all for reading, it's kinda scary and humbling that I have this many people reading what I write each day, I hope I can keep it interesting for you all.  Thank you.

Newbie Doc

Click on the picture if you want to zoom in on it.

Jumping Rails

I'm taking a long deep breath...I'm nervous.  It's how I am every time I get ready for that "BAD" rotation.  Wards (Inpatient General Pediatrics) which is my next rotation, starts on Monday and is notorious for "breaking" interns and students.  You can send the most laid back, unphasable intern into Wards at my hospital and you will end up with a puddle of exhausted goo by the end of the rotation, where once you had an energetic, optimistic doc.

In life you run into these things that have a lot of "hype", that are ridiculously difficult (so they say).  As an intern here at my hospital this is just something  I'm going to have to do, an obstacle, a challenge.  Earlier in life, things like these are an option, they are "rails".  I think it was in college sociology where I first found a name for this, it's called "railing".  Maybe a really smart, privileged person doesn't run into any of these "rails", but regular people run into them all the time.  Have you ever tried to do something in life that someone tried to stop you from doing, because it was too hard?

In third grade they had these reading groups; one, two, and three.  Group one had the fastest readers, three had the slowest readers, and two was somewhere in between.  I was in group two.  I asked the teacher how the groups were chosen and her answer really made me feel like crap...I think everyone can relate to being told they aren't good enough (whatever that means).  That night I talked to my parents about it and the next day I asked my teacher to be moved into group one, she was annoyed and told me she was worried I wouldn't be able to keep up, but she agreed to let me try.  At first I read a lot of words wrong, trying to go so fast and I even remember at one point they all laughed at me because I couldn't pronounce the word "snarky"  correctly.  I ran out crying that day and even considered going back to group two, but I'd put myself "out there", I couldn't just quit, and I wasn't about to give them the satisfaction.  I told myself that eventually I would get through this and before I knew it I had finished the year and could read as fast as any...honestly to this day I would say my skill in reading is one of my greatest assets.

Years later, I was in high school and the teacher of my pre-algebra class informed us that, at the end of the year, if any of us had made good enough grades in her class that they would be eligible to take, not one, but two math classes the next year, Algebra and Geometry....some of you reading this are talented at math...but I'm not, I have to think long and hard to perform even average mathematics.  I barely got a B in pre-algebra, but it was enough to go for it...so I did.  This time it wasn't my teachers telling me not to do it, it was my classmates.  My peers told me I was going to "melt down" and I wouldn't be able to "cut it".  I remember being really scared, with everyone I knew telling me I would fail...but if I backed down then I would automatically do so and simultaneously prove that they were all right.  So after all other eligible students had backed down, it left only me, a student that was barely eligible for this and probably too stupid to know that he couldn't do it...being to stupid to know any better I went for it.  I'd love to tell you all that I sailed through it, but that's just not true, it was a pain in the @$$ and I had to grind it out every inch of the way.  To my amazement though, I survived...I didn't kill myself as some of my class mates had inferred I would and even more amazing still was that I got two B's in those classes (Not the best of the best, but I had worked hard and I was really proud of those two letters).

Now I'm in college, half-way through the first semester.  I'm making C's and D's in my classes...maybe even an F in there somewhere.  Being a stupid kid, totally naive I tell my adviser that I'm thinking about going to medical school and becoming a doctor, he doesn't laugh in my face, but if he had I think that would have been better.  The way he dismissively said, "You don't have the grades." had an undertone of, "You wouldn't cut it...You'd melt down...You're not good enough".  That was all I needed to get me started, I went to a friend that was making straight A's and asked how he was doing it.  From then on, I copied his every habit and after that I didn't make less than an A minus...even in my Math courses.  Saying it like that sounds simple...maybe making an A in one class is simple, but maintaining that level of performance for me over the next 4 years in a world of college distraction was anything but simple. There were friends that I had to quit hanging out with because they could not or would not understand what I was trying to do and kept trying to drag me away from it.  I missed out on some important memories too, I really regret not getting to see my baby brother right after he was born, but I had a test and I took it THAT seriously (I know it sounds pretty lame now, but I was crazy focused on my goal).  In the end I finished college with a GPA as close to a 4.0 as you could get, not perfect since I had screwed up my first semester, but with a very acceptable MCAT score (the entrance exam for medical school) I was a solid candidate that ended up getting in without too much of a fight (that's another story for another blog post).

The long and skinny of this whole thing is, everyone experiences these "rails" throughout every stage of life.  Some people go with the flow and follow them where they lead, others jump them every chance they get...neither way is necessarily wrong; you can jump the wrong rail and get pancaked by a train and, conversely, you can follow a rail straight into a deep dark tunnel without end...those choices are left up to you and you alone, but for me I've gained so much by jumping those rails. This guy, Robert Frost, gets quoted every five seconds in medical school and residency and although by now hearing another doctor quote it is cliche, I think you'd be hard pressed to say what he says any better, which is probably why it gets cited so frequently.

Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth.

Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same.

And both that morning equally lay
In leaves no step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way,
I doubted if I should ever come back.

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I--
I took the one less traveled by,
And that has made all the difference.

Newbie Doc

I looked for a picture of a "Yellow Wood" road, but it looked to "easy".  The path I'm talking about scares you...but you do it anyway.

Scary Movies

One thing I found interesting as I became a doctor was the "distance" I put between my patients and I.  You find yourself in increasingly uncomfortable situations beginning with things like talking about sexual habits with a person you met only 5 minutes ago finally escalating to delivering news to a relative stranger that melanoma has spread throughout their entire body...actually that wasn't the worst, that person took it rather well, which was really surprising.  The saddest experience I can think of was in relation to a 4 year old boy, not much different from my youngest brother (who was also 4 at the time).  I was just starting my new rotation and this was one of those days where you just hang with the attending and they show you the ropes to where you will be working for the next month.  My boss had just gotten the results back on this little guy...he had come in because of increasing fatigue and a high white blood cell count, everybody in medicine knows what you are getting at when you say something like "fatigue, bruising, and a high white blood cell count"...you may not be able to figure out the exact diagnosis from those three words but in a 4 year old boy it's likely something bad and it's most likely leukemia...which was what the lab results confirmed in this case.

I still remember my attending handing me the results on a piece of paper.  I had read results like that many times...in books and in tests...I realized what it meant, but my gut reaction wasn't to pity the child (who I hadn't met yet) it was to look for leukemia (ALL) in the multiple choice bubble sheet on my test (although I knew the answer to the question, I didn't know jack about what that answer actually meant).  I walked in with her and we discussed that we had some results back and we'd like to speak alone with the parents.  As we walked in, the father was sitting in a chair next to his boy's bed.  I immediately made a connection with his son, they were playing video games and as the parents became more engaged with the attending, I distracted this little boy by taking his dad's place at the second video game controller.  We talked about what games were our favorites.  He was a cute kid, with long, blond hair, he looked like a kid that might already be surfing our kicking a soccer ball around with his friends.  He looked like the kind of kid that should have been full of life with a nice sun burn from his last visit to the swimming pool, but I remember how pale he was, how his eyes were sunken in slightly and he had dark rings under his eyes.  When it was time to speak to the parents, the father stated that he should speak with us alone, the mother had recently lost a brother to cancer and he preferred to spare her if there was any bad news.

Moments later, we are in a private room and we tell this very strong, very positive dad that his 4 year old son has leukemia...It was like watching someone take a baseball bat to glass...he just shattered.  He was screaming and crying.  He buried his head in his hands and wouldn't stop shouting, "Oh God NOOO!!!"  I remember how oddly disconnected I was from the whole situation, like I was watching it on TV.  Now when I think of this it makes me tear up a little, but when it was all actually happening I was thinking about the survival probability his son had, thinking that he actually had a really good chance (ALL is pretty curable now days)...I don't know what other doctors do in situations like that, but for me I've realized, as my experience has grown with these horrible moments, that I automatically disconnect myself...honestly I'd say I do that for most of what I do, it allows me to continue acting to help my patient instead of getting bogged down in the emotion of the moment...at least that's what I tell myself...maybe I'm just scared to actually become emotionally connected to my patient at that level...I can't help disconnecting like that, it's just what I've observed that I do. 

It's like when you are watching a scary movie and the screaming girl runs passed the kitchen knives (should have grabbed them for defense) and runs upstairs (should have ran outside and yelled for help)...what they do doesn't make sense to those of us who have watched a billion scary movies, to us they just made the same mistake every scared person makes when being chased by a murderer in a scary movie.  Well I'd venture to guess its the same for doctors, we watch these type of horrible moments all the time and we watch them as if we are watching the TV, not because we are cold, but because we have to cope with it somehow...I couldn't deal with it if I broke down like that dad did every time I saw something that sad - there's just too much of it.  But then you get a doctor who has a sick child or someone in their family gets really sick and suddenly those same docs aren't "watching the scary movie" any more, they are in it...and you'll see them "run up stairs" just like you would...or I would for that matter.

My wife was sent home 27 week pregnant with premature contractions, she's probably going to be fine, she's going back to work tomorrow, but no amount of rationalization is going to calm the jolt we got from this.  My wife and I are both doctors and all it took was a few tiny muscle contractions to put us right into our own little "scary movie". 

My thinking is that if a murderer were chasing me, I would rather have someone calm and collected sitting disconnectedly outside of the situation telling me what to do, rather than having someone running from the murderer with me making the same panic-ed, emotional decisions...but even that is a rationalization.  All I can say is this, when my wife and I have the baby, I won't be delivering.  I want someone calm and collected running the whole show, someone who has done this kinda thing a thousand times (1 million preferably jk). 

Newbie Doc

Two Sides of a Coin

Do you know the origin of the doctor's white coat?  It's a lab coat, more specifically a scientist's lab coat.  That's what we started out as, laboratory scientists.  However, as science progressed the two careers separated and today the connection is not as obvious as it once was...yet we are all still scientists, even if the only lab you visit as a doctor is your own private clinic.

When you think about how we treat patients, it actually is very similar to how a scientist runs experiments.  A doctor knows the basic science concerning a problem (the physiology of the patient complaint), he or she posits a hypothesis as to what is causing that problem (differential diagnosis), the doctor then performs a physical exam, obtains patient vitals, and lab tests (laboratory studies) that are all used to back up the hypothesis, with enough data to back up that hypothesis it then becomes a theory (diagnosis), and finally the doctor uses that theory to treat the patient's problem.  So even though many today would not immediately associate the word "scientist" with the word "doctor", that is exactly what we are at our most fundamental.

We go through this logic process everyday, a process developed hundreds of years ago, and everyday we see it work these tiny miracles. I remember seeing salt fall out of solution for the first time, you have this pristine decanter of water and then suddenly it's as if this tiny world inside of the water is magically created as minuscule crystals fall to the bottom of the glass, seemingly out of nowhere...it was beautiful and it was awe inspiring.  Hearing me talk about it maybe you can see how we get caught up in it at times.  Sounds harmless doesn't it...even fun? 

I remember my first class in evolution.  I remember how logical it all was, how through the scientific process I came to believe in something that I had been taught as "wrong" by the teachings of my church, my high school, and even my own parents...that kind of thing isn't harmless...any process that has the ability to change beliefs so profoundly is dangerous...it has killed people.  Reconciling my science with my religion was one of the single greatest challenges I have ever faced.  If you decide to follow the path of a scientist and you do so while carrying a fair amount of personal beliefs, as I did, prepare to have those beliefs challenged...you may even run the risk of having those beliefs damaged irreparably.

I've been dwelling on this for most of my life and only within the last couple of years have I found any peace with it.  It's a complex issue.  I don't condone one side or the other, for my part I'm of both sides.  I'm a Christian and a Scientist.  I don't believe one side negates the other as many do.

There is a common parable that those who support creationism often bring up when trying to convince the other side of their folly.  You are walking alone on a beach.  You come across a finely made Swiss watch buried in the sand.  Do you assume that it appeared out of thin air or do you assume that something of such craftsmanship had a maker?

Personally, I find the analogy of life to a great marble pantheon buried in the sand more to my liking.  Could something this complex and amazing be created by the wear of water and wind...yes it could.  If time is infinite then even as unlikely as it is that something like that could occur by chance, it is actually possible.  Could it be possible that someone or something has such vast and amazing powers that it could singularly create something so majestic and beautiful directly out of nothing, I'd agree with that as well.  Could it be that God made the wind and the water that wore the rock into the pantheon, that he is so vastly powerful that he can indirectly build such a beautiful thing with no real imprint of his artistry save the beauty that he bestows upon it...that's more where I stand. Any of these hypothesis' are as likely as the other, the question isn't what your preacher believes or what the doctor writing this blog believes, it's what do you believe?  YOU answer that question for you and you alone and it's your faith in that answer that gets you by, whatever that answer may be. Good luck : )

Newbie Doc

PS I won't speak on this subject anymore, it's heavy and boring to some, but I had to talk about it a little.  It's a big part of medicine/science for me.  Thanks for bearing with me.

If you would like a scientist's view on evolution I would point you towards this excellent book, "The Beak of the Finch".  Most people grow up understanding their religion's teachings on creationism, but few truly understand evolution before picking on it...it's a much more complex and logical idea than you would believe from pictures of monkeys turning into humans and I don't believe that it negates God or religion.

The Beak of the Finch: A Story of Evolution in Our Time

Sidelined

Vacation is here! Thing about vacations at least for me is that they are never quite as exciting as they sound on the other side of the fence. It's a nice change of pace though to be able to get up in the morning and do the things in your day to day life that you have neglected for so long. It's weird that suddenly you have time to cut the lawn on a weekday or do any of those other chores that take an act of God to schedule when you are working. Most of all it's really nice to do something that has an instantly noticeable effect. I think that's what I disliked so much about my GI elective last month, throughout the entire rotation I had this sneaking suspicion that were I not there no one would be the wiser.

When you first start out as a medical school student, well actually even before that (maybe as a college hospital volunteer, you are relegated to doing the "scut" work...all the inglorious things no one wants to do. Medical decisions are left up to the doctors and you are expected to carry out those actions for them...in some cases you aren't even trusted enough to do that, instead you watch on the sidelines. After 4+ years of being on the side line, you start to itch to be the quarterback making the plays...and then you get to do it and although you fumble your way through it most times...it feels amazing. Even still, you only make the plays that the coach (your attending) wants you to make, you make suggestions and recommendations, but he/she has the final say on where the ball goes.

In medical school this "getting put in he game" thing only happens for the briefest of momentous occasions, but in residency the expectation is that the plays are ran by you every single time and for the most part this is how it happens, but occasionally you get switched to a team, rotation, where you are out of your league or the attending is really just a big ball hog...and suddenly you're back on the bench as water boy...it doesn't matter why you are back to being on the sidelines, the one thing that does matter is that it SUCKS! But you make the best of it and you try to learn by watching the game being played by someone else...it's just that its a poor substitute for the real thing.

That was what GI was like. I came to work each day, gathered the "facts" about the patient and handed them off to my attending, who would then run them for a touchdown. No patient was "my" patient and even the charitable question of, "What would you do with this patient?" was nowhere in sight. In this rotation I got all of the rectal exams...none of the glory ;P

I guess writing this I feel like a immature punk complaining about what I didn't get, when I should be thankful for all that I learned...and I did learn quite a bit. I learned about caloric intake, nutritional requirements in relation to different diseases and food intolerance's. I better understand the paradoxically simple, yet complex, treatment of constipation in the pediatric population and thanks to my presentation I have a much better handle on managing GI bleeding in the pediatrics patient...but no matter how much I learned on the sideline during this last rotation...there is still that kid inside me that was whimpering day in and day out, "Put me in coach!".

In that respect I'm REALLY ready for my upcoming rotation, Wards, cause I may have just started vacation, but as far as medical decision making goes I've been on vacation all month.

Newbie Doc

My "Gal" Bladder Pain

In one of my earlier posts I had talked about the different "types" of patients that you get. I talked about how I got the "flirtatious" patient. Well it was about 2 weeks ago that I got the "angry" patient.

I don't remember the cause but for one reason or another I didn't sleep well the night previous. So that day I came into clinic already wiped out. When I enter I immediately hear this high-pitched screaming and yelling coming from my patient's room...I look over at my nurse who is sitting there reading a magazine like she doesn't hear the ear full reverberating down the hall. With a bit of apprehension I read through the patient's history which, of course, is a monstrous one. The patient initially presented looking like gallbladder disease.

The gallbladder is a pretty simple organ. It's a storage organ that holds bile (used to break down fats that you eat). Sometimes it spasms, sometimes it gets plugged with a stone, sometimes the bile turns to sludge and plugs it up...regardless it always presents with right sided abdominal pain that radiates to the right arm. You can have vomiting and nausea with it.

This patient was having exactly these symptoms, so her pediatrician got an ultrasound and it turned out that the gallbladder was perfectly fine...but she had a fatty liver and her liver enzymes were high (her liver is irritated and inflamed). When I see that and check her history, she's got a BMI (body mass index) in the 40's (she's grossly obese)...and her last name is of Hispanic origin (Native American and Hispanic genetics give you a higher chance of getting fatty liver with obesity). So I'm ready to see this young woman and deliver the results...what was I thinking!!! I wasn't the slightest worried that the yelling/anger would enter our conversation...usually when the doctor walks into the room the patients get all polite...even if you have heard them screaming at their children moments before.

I sit down and introduce myself to the mother and daughter (my patient)...I get blank stares. I inform them that I've looked over her chart, but I like to have an idea about why they are here and what their concerns are.

"We want to know what the mass is on her gallbladder!", she blurts out with impatience. I'm getting this vibe that she just does not like me. At this point I'm reeling...(WHAT MASS!?!?!?! There was no mass!) My questioning in relation to this only pisses her off more, because she thinks I haven't seen the ultrasound and I'm an incompetent intern (which maybe I am, but not as incompetent as she is). I explain that I have seen the ultrasound, I relate what I saw when I looked at it and that I didn't see anything resembling a mass on the gall bladder. I calmly tell her I'm going to go outside and review the findings and double check though...I do and it's exactly what I had read previously...I even look through every single image again...and still find nothing. I step back in and question her further. What I find out is that, the patient's mother is a nurse, who apparently without any education in ultrasonography, is CERTAIN she saw something "funky" on the gallbladder..."cause I'm a nurse and I see stuff like this all the time."

That's like me saying to an engineer that, because I commute over a bridge everyday, I know beyond a shadow of a doubt that he constructed the bridge wrong and used metals with inadequate tensile strength (actually to be like her I would have had to say "dat bridge is built all crazy wrong man!".)

As it turns out the mother had some past experience with her gallbladder and she was really fearful that some "punk" doctor was going to mis-diagnose her daughter. I offer to take her out and go over the U.S. with her if she really feels there is something, but she redirects and asks "THEN WHAT IS WRONG WITH MY GIRL!!!" I calmly explain that I hadn't had a chance to tell her about the lab results in full, which I do (this whole visit is going wrong...you should never open with results...but I'm getting sucked in). I explain the fatty liver, which she then wants to know the "why?" about. I explain that her daughter is grossly obese (compared to mom she's a tooth pick though, so the mom thinks I'm full of it) and that paired with their genetics they both are set up for problems like this. I could have sugar coated the whole obese thing, but come on, if she hasn't heard it then she needs to hear it...when I told them all these things I was as calm, objective, and rational as you could be, what I was telling them had no venom in it at all (You are doing patients a disservice if they are obese and you tell them they are healthy)...apparently she hadn't heard that she was grossly obese (seriously?!?!?)...they were also super pissed that I had gotten all "racist" on them.

"We're ENGLISH!!! Just like you, pure AMERICAN!!!" I don't disagree with her I simply remind her that just as I have German ancestors she has Hispanic ones in some form or another(her name alone gives it away)...Seriously at this point the visit is a disaster, we are arguing the color of paint on the wall. I finally come to the realization this is going NO where, if she were my patient, and not my attending's, I would have explained that she is hampering her daughter's quality of care and politely ask them to leave and not return, until they can converse calmly with me...sadly I couldn't kick that mom out on her ass. So instead I tell her that I can see this isn't getting anywhere and I apologize that I've angered her so much...(I definitely was not sorry, but that's what you are taught to do/say...I had my mask fixed on tight right then). I then went out and explained the whole situation to my attending.

My attending walks in and suddenly this enraged bull of a woman is all smiles and politeness. The rest of the visit goes exactly how I had envisioned it going when I first turned the door knob to that damned room. Dr. H agrees on a plan of care with the patient and mother, then leaves the room with happy goodbyes and a "see you soon." As I say a quick and simple "good bye" (a "have a nice day" at that point would have been blatantly disingenuous) and step out of the room, my last sight of the pair is them sharing this quick mischievous smile...like devils...fat ones (I'm being unprofessional...sorry) :P.

My advice to anyone, as a patient, is to always be polite to those taking care of you (ie. don't bite the hand that feeds you). Not that we will spit in your IV fluids or dose you with a sedative (...well at least not the IV fluids thing), seriously though, we would NEVER retaliate, but what you get for all of your fury is that you push the staff away from you. Nurses and doctors, regardless of how saintly they are, will find reasons to "skip" over your room during rounds and opt not to check up as often as they normally would with the "nice" patient...it sounds bad, but it's a well known fact that in medicine the "angry" and "mean" patients get poorer care (Not for sure but I think it's actually proven by scientific study now).

Dr. H actually took this into account. She's a feisty doc and I have no doubt that she would kick a patient out of her office in an instant if they pulled that with her, but as she explained later, since they were polite and understanding with her, kicking them out for abusing me or even having a conversation about it would only hurt the patient's care (they would likely blow up and storm out), so she allowed it. I was totally drained by the end of it, but I was fine with her course of action...it sounds lame but it really is true, at least in medicine, almost always the only thing you achieve with a stunt like that is that you hurt yourself.

Newbie Doc

The Presentation

My presentation is over with!!! Whew...it was 30 minutes of pain and anguish...all on my side though luckily..I really hate standing up in front of people and talking, which (who would have guessed it) is a regular part of the whole doctor thing. You have to give educational presentations ALL the time and while you can make it as superficial or in-depth as you want, you don't want to seem like you didn't try...err on the side of beating your audience into submission with information (that's my motto...if I had a motto)...I also try to make it easy to "digest" although when your presentation throws around words like "hematochezia", "hereditary hemorrhagic telangectasia", and "hemolytic uremic syndrome"...the talk is always going to be a bit "dry", for me adding lots of pictures and graphical flags (like highlighting the areas of interest in a table filled with big words) helps ease the plate of crap you are serving down the audience's gullet. Anyways I'm glad it's over...honestly I'm glad this whole GI elective is over. If I get the chance to do it again, I would, but not because I like it. I generally dislike everything "GI", it's a lot of talking about pooping and dieting, still though I would do it again because it's one of those areas I think most docs are a little weak in (who really likes managing the crazy patients with GI problems...and most patients with GI problems ARE crazy - chicken or the egg first? I don't know). Whatever, I'm done with it...at least for a little while, and vacation awaits!!! I'm out.

Newbie Doc

Like A Bee

So I'm talking with my attending yesterday and she says hey, "I forgot about that presentation I was wanting you to do over rectal bleeding to the residents, I know you've only got a couple of days to prep...you think you could do it Friday in the afternoon?" What she's really asking me to do is discuss an extensively broad/complex topic (GI bleeding), with power point slides, an example case over juvenile polyposis syndrome finishing with an discussion/lecture of JPS with just two days of preparation time...oh yeah, you've got to do all this in 30 minutes and in front of about 20 strangers...no prob right? I could have said it's not enough time...but that would be a sign of weakness and I wouldn't give her the satisfaction ;P

Anyways, that's why I didn't post last night and why I'm barely posting today. I'll be sure and let you guys know how it goes but I gotta get back to it...In GI the crap never ends :/

Newbie Doc

Update

First - I'd just like to thank everybody again for keeping up on my blog. Several of you have sent me messages, emails, and comments of encouragement and it's those messages that keep me writing this blog so, THANK YOU ALL SO MUCH!!! It really means a lot to me :)

Second - I have had my blog hooked up to a site where I can see who is visiting from where, etc. I haven't been on it in a while with the house move and everything...honestly I had been avoiding looking at it because I didn't want to see that nobody was reading it anymore as I had taken a bit of a hiatus. Anyways I checked today and more people than ever are reading it! There were especially a lot of newcomers from California, Montana, Kentucky, Indiana, and Texas...Crazy. Thank you all for checking this blog out and just one more Thank you to all my fans/readers in Kansas, Oklahoma, and Arizona that keep coming back.


Lastly just a quick note that I made a schedule change earlier this week and pushed my vacation back so I could have more time on GI. I'm a glutton for punishment, but I really feel like this is a weak area of knowledge for me and I can use all the teaching I can get. So here I am still working when I could be sleeping in tomorrow :/

Alright I'm out. Thank you all for checking out this blog, have a great night!

Newbie Doc

Perfect Day

GI has been quite a paradox in how I typically envision rotations.  When I started on the NICU, I had heard that it had long hours and was extremely challenging, when I got ready to transfer to GI I heard quite the opposite.  I was told that it had easy hours and the work you did wasn't very difficult at all...and to some extent that has all been very true. However, for whatever reason I have had a really difficult time adjusting to this rotation and in this particular month I have made an abnormal amount of mistakes.  So today as I planned in the back of my head what I was going to blog about, I had decided to commemorate this post to my first "Perfect" day on GI.  Every now and then you have one of these days where you don't make a single clinical mistake (at least in relation to what your superiors deem "correct").  Part of me really was happy for this day, I needed a "win", it's been a really long month, but as I sat dwelling on what a "Perfect" day meant for me I gained a different slightly less optimistic outlook on it, or rather a less pessimistic view of the rest of the month.  If you go through one of these days where everything goes perfectly, what it really means is everything was too simple for you, you weren't challenged, and you didn't learn anything...while that sounds like a downer the flip side of it is that I have been learning a hell of a lot of stuff over this last month - from taking a good GI history to doing a consistently thorough rectal exam (not sure I ever wanted to do that well) - it's been rough and for that I'll be a better doctor. 

In writing this little blurb I got to thinking how chaos (mistakes) can lead to order (perfection) and I was going to get into science versus religion and my struggle in reconciling the two (apparently) warring sides.  However, while that is a really interesting subject, it is going to take me much more time than I have tonight to get it to paper/post.  Instead let me leave you with a promise to revisit that subject and a video (some of you may have seen this).  It's a video recreation of all that goes on inside a single cell at a molecular level.  It's the very picture of complexity and perfection.  Everything you see in this video is coded into DNA, transcribed codon for codon, into these tiny molecular miracles that work 99.99999% of the time.  To me this video really demonstrates perfection and complexity in a way you rarely see.  Regardless of your beliefs on what or who makes miracles like these happen, I think anyone would be hard pressed to refute the miraculous nature of things like these occurring in nature, all the time, every single day, without fail.  It's truly impressive...and this video if anything is likely a vast oversimplification of these processes.

Long Disgusting Day

If there is one day that I could call disgusting it would be today.  Today I had to perform rectal exams galore.  Seemed like everybody had constipation, or dark stools, or was a new patient (new patients in GI get rectals...it's like a "welcome" to GI...I think a handshake would be better).  Later in the day we had two endoscopies where you ram a huge black tube with a camera on it down someones throat.  After that we had to replace a tube in a little girls stomach.  When you can't feed by mouth we poke a whole in your upper abdomen, right below your left rib border and insert a tube into your stomach that we feed you through...I've never seen one of these replaced so I was standing at the foot of the operating table watching Dr. H pull and tug on that thing...I should have seen this coming...suddenly it gives and gastric contents/mucus flies right out and sprays me in the face...good thing I had glasses on.  No one noticed, they just kept talking and laughing...I was so shocked I didn't even gag...I laughed along with their jokes and made witty banter until I could get away from them to scrub my face with as much soap as I could get my hands on...GROOOSSSSS!!!

I then had cross cover at the ED tonight (I actually just got done) I'm exhausted but I need to get back into the habit of writing on this thing.  Tonight I stitched up a wound all by myself for the first time...I was hoping for something a bit easier...instead I got this huge laceration on this kids knee...he had a fight with a swing-set...and lost.  Not wanting to be whiner I don't complain that I've never done this before...I just sneak off into a room and watch a couple you-tube video's on stitching for refreshers (I'm glad my patients didn't see me).  I then walk out and act like I've done it a hundred times (except for the fact that it took me a good 45min to 1 hour to stitch that wound up...you know what they say about practice...I hope they are right).  The ED was like that tonight - it was a lot of patient types I'm "uncomfortable" with  (laceration, seizure, new mass lesion, ect)  I could have probably dodged out on them and found some easy fever or vomiting patient, but I had the energy and something was pushing me step out of my comfort zone and better myself...my only regret is that in getting my "practice" I inconvenience other people...but that's another talk for another day.  I'm exhausted and I have to get up in 6 hours.  I good you bidevening ;P.

Riding The Wave

I have this tattoo on my left hand. If anyone in my family was going to get one, it would be me…I’m sort of an odd ball. But I didn’t get this tattoo because I’m “artsy” or I wanted to set myself apart …I had it placed there to remind me of a thought that kept me afloat once. It was impulsively done, but at the same time, I don’t regret it. Often people ask me what it’s meaning is, it’s personal and hard to explain, but it’s an important part of medical school, the tattoo is about hitting rock bottom.

The reason this is so common is that the type of person that usually gets into medical school is already the uptight, type A personality; then you isolate them from family and friends, make their life studying, and you place such a high financial burden on them that failure seems to disappear from the option list, as anyone who’s been through it can tell you, medical school (really medicine in general) is a very dangerous place. Some will take a year off, some quit school, some quit life (a good friend ended her’s with pills), and the lucky majority pass through the dark times with stories similar to mine, stories you don’t usually wear on your sleeve…or your hand.

The tattoo which I’m writing about is a simple, sinusoidal wave, very similar to the letter “S” on it’s side, similar enough that I hear this a lot, “Why do you have an “S” on your hand?” My quick and dirty explanation, if I don’t feel like explaining the story is, “It’s like a Ying-Yang, but 20$ cheaper.” If I feel like explaining the whole story then I start with the end of my first year of medical school.

It was one of those times when things couldn’t get any better. My girlfriend and I had just arrived to class for “debriefing”, where we receive our scores for our last test, and the chancellor tells us bye and to have a nice summer. This girl I write of, I had been seeing/dating for the last two months. I was in love with her, so much so, that the previous week, in my impulsivity, I had told her just that (I’m an idiot huh?). When I told her that I loved her she didn’t say anything, she just smiled and kissed me, I was amazed that she hadn’t run for the hills, after all, she had just gotten out of a really long and serious relationship. So there I sat, feeling like the luckiest guy in the world. I had just passed my first year of medical school, I was a soon-to-be-doctor, in love, and with the summer break I knew life could only get better.

Fast-forward ten minutes later when the grades were handed out for the last class of the year, Sexuality and Reproduction. I stared in disbelief as I held a test graded “C” in my hand (in medical school anything below a C is failing). If I had gotten 5 points lower, I would be retaking this course! I was in shock, I had tried so hard during the year, all I had gotten were B’s and A’s…this was impossible! (I had been spending too much time with my new girlfriend) Stunned I sat quietly through the rest of the chancellor’s words and sullenly walked back with her to my apartment, where I was in for yet another “surprise”.

As it turns out, my girlfriend really had been freaked out by my confession of loving her. She had simply held her tongue until the final test was over and done, she didn’t want it to damage my performance (ha!). So there we sat in my bedroom, my heart pounding panic through my veins, as she slowly told me how she needed time alone to think things over and that she wasn’t ready just then for another serious commitment. It all happened so fast, she was saying it and then she was walking out the door, stepping into her car, and finally she was gone…there was nothing I could say…I sat there in silence watching her go, inwardly I was a knot of anxiety and shock. That hurt, but not so much as the final crushing blow.

It wasn’t but an hour later that my father called me with horrible news. I might have barely passed the previous class, but I got an “A” in Neoplasia and I knew exactly how much of a death sentence Inflammatory Breast Cancer was to my Aunt, who I was learning had recently been diagnosed. I was wide eyed, in horror, tears streaming down my face as my father cried on the other end of the line…I had never heard my father cry…I don’t ever want to again. She died not long after. Her death was crushing to my family, both close and extended.

As it turns out, the other two “downers” had just been softening me up. I may have been sitting in my room blankly staring at a wall, but in my mind I was shattered, sobbing, and broken. I spent the greater part of the day like that. I walked the streets of the city by myself looking for a distraction that wouldn’t come. My friends weren’t any help, how could anyone be. It was nearing noon when I started walking and when I finally laid down upon the concrete of a random city parking lot and gazed up into the air, a full moon was visible among a cloudless, starry sky. I didn’t know how I would get over this, how I could move on. I was considering how such a seemingly amazing day could turn so horribly bad in such a small instant of time, it was like it had flipped on me…that’s when it hit me.

Life is just like a wave, it’s up one minute and down the next. Getting into the mindset that things will always be good and grand, will set you up to come crashing down. Conversely, trapping yourself in a dungeon of darkness, certain in the belief that there is no hope of escape, will lead you to just that…or worse. As I dwelled on that thought over the course of an hour, I also realized that happiness and sadness were dictated by me and not my situation, they were states of mind, and if I chose so, I could be happy once again, just as quickly as I had become depressed.

I walked to my house, got in my car, and went to the end of the year celebration with my friends. I pretended nothing was wrong and in my pretending I rode the wave back up once again. I graduated medical school and I’m now a working doctor. My girlfriend one year later became my wife and though my Aunt is gone she lives on through her children and grandchildren, through our memories, and the love we shared for her.

That following morning I visited a tattoo parlor, intent on never forgetting the lesson I had learned that day. There are so many emotions and thoughts embodied by this small, seemingly simple symbol, I really don’t think I can put it all to paper (or blog), but in it’s simplest form, it’s a reminder to hold steadfast while waiting for life’s swells and a warning to always be wary of it’s troughs. Life is as unpredictable as it is uncontrollable. You’ll be flying high one minute and dashed upon life’s jagged rocks the next. Life is a wave, ride it.

Newbie Doc

If I asked you where the “low point” of the wave was, could you tell me…or does it depend on your point of view?

Non-Emergent Emergencies

Wow, I'm finally back. I was beginning to feel really bad about not posting this entire time ...especially since I said I would start again come last Wednesday. My life is like that though, seems like I will set a self-imposed "due-date" and then it will be about a week later that I finally accomplish the said task. Without further ad due lets get back to the blogging.

My First ED Night

During easy months at my hospital (like GI elective) you have to do cross-cover shifts, which means that about 4-5 times a month, after you get done with your 7-5 job you then go work a 5-10p or 8p-2a shift at the Emergency Department. The emergency department is a scary place in medicine. There are a lot of crazy things that happen there.

I remember this one time as a 20 year old in college doing my time as a hospital volunteer in the ED. It's a bit "fuzzy" all the exact medical problems this guy had suffered, but the short and simple is that he fell off a construction scaffold and hit his head. They did a CT of his brain that showed a decent bleed, but for whatever reason he wasn't unconscious. The man started hallucinating and became aggressive, before he could be taken to surgery he took his 8 year old son hostage with a pair of scissors and tried to escape the hospital. They had us block the doors and a cop snuck up and grabbed him from behind...I really don't know how the story ended after that, as a volunteer you are about as medically uninvolved as you can get (all you do is things like take patients water, etc.)

Anyways, going into the ED for the first time as a doctor, just had this surreal feel. In retrospect, I may not have been entirely with it. I hadn't been sleeping well and on nights when I got home at any decent time I would get no break because I was moving into a new house, so that could be the reason for why I felt such a lack of excitement...if I could describe my how I felt the word would be "resigned"...at that point I was so burnt out I was going to just accept whatever came and deal with it at that time...I had no energy to waist on worrying at that point. As luck would have it my patients were fairly simple. I remember my first, it was a little 7 year old girl who had been bitten in the face by an unfriendly rat terrier..I think part of me expected her face to be hanging off in shreds...any second George Clooney would burst in yelling orders and the over head speakers would start playing that catchy TV music...but really she only had what looked like a small puncture wound on her cheek that had become swollen and red. It wasn't any rocket science what I did, I bet most people could treat her using common sense - I just ordered a saline wash of the wound and put a little medical "duct tape" on it (steri-strip) and wrote her a scrip for some antibiotics (George would be proud :P). The thing about the ED is it's much like the girl with the dog bite, not very TV worthy, sure you have the occasional crazy person or tumor, but in my experience it's not very often that the Emergency Department is very "Emergent". Most of the patients are not going to die in 5 seconds if you don't intervene, often it's busy enough that you'll sit in the room a good hour before you are seen and you'll be in there for about a 4-5 hour stint before they will admit or discharge you.

Update

We're in the process of moving into our new house. Currently we don't have internet and i'm forced to use my mobile phone to
make updates. Just wanted to let you know that i'm still writing blog posts... but for now they're just word documents on my home computer. 1 way or another, I will start posting them on wednesday. Even if i have to do it through this phone :) thank you all for reading my blog.

Newbie doc

Yin & Yang

Well I don't want to call it early, but I think this month is going to be much easier than the NICU ever was, probably just as interesting, but I don't have to get up at 5 every day.  I don't have to work 30 hours straight every 4 days and I'm not expected to save infants from the jaws of death (not that it happens much but one time it did was enough for me), which has got to be the most stressful thing about that job.

This job is a lot of sitting in clinic so far.  The patients just mossy on in, I get to take my time reading their histories, and then I go in and examine them.  I then step out and speak with the attending on what I found, what I think it might be, how I think we should test/treat for it.  After that I punch out a note on the patient and then see another one.  I REALLY like outpatient work, the pace is so chill.  I think the hardest thing to do is "switch" your mind from inpatient thinking to outpatient thinking.  On the wards and in the ICU's everybody is REALLY sick, otherwise they wouldn't be there.  You get used to being really "aggressive" with your medicine.  If you see a fever and a couple other signs and you jump all over it in seconds with CBC's (blood cell counting), Bcx's/Ucx's (Blood & Urine Cultures), CXR's (Chest Xray's), LP's (lumbar punctures), Abx (Antibiotics)...the list goes on and on.  On inpatient you are trying to find out the problem and fix it...or at least keep it from killing them.  Outpatient is the "Yin" to inpatient's "Yang".  On Outpatient most of the patients are fairly healthy (or nothing is wrong with them at all) so your approach to medicine is WAY more conservative.  You are still looking to fix their problem, but instead you gear down your methods.  For instance you would never here this statement on inpatient, "Here I want you to take this medicine, see if it solves your problem, and I'll see you back for follow up in a four weeks" (on inpatient if you told a patient that they would go home and die).  So my problem in short comes normally when I come off an intense inpatient month (like the NICU) into something much more laid back.  I can't stop it, there is always this phase that takes me about a week where a patient will say something like, "I've got blood in my stool."  My differential will immediately jump to the five worst things, I'll have about 20 different lab tests in mind to do and when my attending asks me what I think, I inevitably miss the obvious common and benign problems, like diverticuli (little pockets that some people have in their gut that can become irritated and bleed) vs colon cancer...and I'll think to myself, "DUH!!!".  It's not a huge thing (I'd rather be watching for the big things and miss the little ones any day) but it's one of those adjustments I'm making right now.  I'd go into more detail about my day, but I am dead tired - we just got done moving into our new house...we are "moved" in, but not "settled" (ie Everything is sitting in boxes all over the house)...but very soon we're going to be out of this tiny shoebox of a hotel room we've been stuffed into for over a month.  I'm crashing.

Newbie Doc

Somebody Call A Plummer???

Today was one of those days that if you look at all the things you have to do...you would flip out and end up a bum on the beaches of CA (not that I've been thinking of it or anything ;P) The first half of the day consisted of showing our replacement residents how to run the NICU...given that we only have 5 hours to do this task, it was a hard one in itself.  These poor guys seemed pretty flabbergasted at everything they had to do and learn, we must have had a similar look on our faces at the end of our first day, dazed and confused (but not the kind from having too much fun - very much the opposite).  In 5 hours these new residents had a crash course in 3 different computer systems for tracking health data, learned how to present a NICU patient to an attending in rounds, got slammed with multiple math equations for calculating IV nutrition/medication dosages/feedings, and stacked nicely on top of all that was the diseases and histories of our little kids that we were handing off to them.  Now that I'm on the outside looking in, I can see why it was such a brutal first day for me.  Since we were pressed for time today, we "experienced" residents (sarcastically speaking) did most of the work, presentations, and notes.  The few things that they did do they did really well, I think probably better than I did on my first day...but I'm not surprised, I'm not one of those people that picks things up really well right off the bat, I need lots of repetition. 

After that we were off to our new places.  My new one, as mentioned before, is GI.  It's nice in a way, all we deal with everyday is that long tube that runs from your lips to your ...pooper.  At first you think that it seems simple and that studying will be pretty straight forward, but the GI system has a lot of pathology involved with it.  If you think about it although it is one "system" of your body, it's composed by many different things.   The small intestine is as different from the large intestine as your teeth are different from your anus...each part being different, there is a lot of different tissues and really with each different type of tissue there is multiple things that can go wrong with them (that's not to mention the effects that each different tissue has on the others...which adds a whole new layer of "what-the-heck" to the equation. 

My first day on GI was really simple, I met up with my attending who was in the middle of sticking a long black tube, that looks disturbingly like a rubber roto-ruter, up a 3 year old child's butt; she pauses in the middle of this looks over at me, smiles friendly-like, and says, "Hey, come watch this." (Only in medicine).  If they've ever shown colonoscopies on TV, I'm pretty sure they left out the sound effects (Oh My God).  This kid was playing base trombone in his own personal band...among other instruments to still be invented.  Having worked in some way or fashion within a hospital for 6 or so years, I've developed that "poker face" when things like this happen...but it still made me chuckle a bit (on the inside) to have 7 people standing around this kid, with all these "noises" being made and everyone of them as emotionally "monotone" as the next - I'm pretty sure they were wearing their "masks" too (or maybe I'm just immature...maybe that's why I'm a pediatrician).  Anyways that doesn't keep me from feeling sorry for the kid, he's got some kind of immune system problem that is basically causing an allergic response on the wall of his colon - the tissue looked a lot like you nose and eyes get when you get a cold, red, irritated, and injected with little red vessels.  It's weird when they take "biopsies", it's a nice way of saying they put in a small wire with a metal set of "jaws" on the end that takes bites out of your colonic wall - it looks as traumatic as it sounds - but I'm sure it's exaggerated quite a bit since the video is blown up on a big screen TV.

Anyways I'm going to check on him tomorrow and see how he's doing.  After that I have GI clinic, which I'm still kind of in the dark on...and then I'm off to our new house again.  My father-in-law drove up early today and as of 7pm tonight we have unloaded about 2/3rds of all the crap my wife and I have accumulated over the last 3 years...fun.  Hopefully tomorrow we will be finished totally and we can get the hell out of this small cramped hotel room...it felt really awesome standing in the wide open spaces of my house, can't wait!!!

Newbie Doc

Just a quick note, I don't know how we would survive without family.  When I first started out in medicine, I was in college.  It seemed that even the most difficult things, I could handle by myself (most times, if not with a little struggle).  But as you move on up the ranks and into medical school, you get more and more stretched, until you barely have time to keep up with old friends.  It seemed that, as independent as I would like to be (I don't like to be a burden to others if I can help it), more and more I've had to lean on friends and family to help me out, now to the point where I don't know what I would do if I hadn't been blessed with such great people in my life.  I'm not saying you can't do medicine if you don't have a good support system...I'm just saying I don't see how ;)


Thank You all for being there for us - We don't know what we would do without you : )

Check The Poo!!!!

A little song in commemoration of my move into one of the "crappier" jobs in medicine...

Scrubs - The Complete First Season

Looking Back

Wow, I thought the end of a rotation would be relaxing, but really I'm feeling pretty stressed and cramped for time, there is just so much stuff to do before the next one...I've got a lot to do in a day or so (a day I will be post-call in).  Maybe this end of the rotation stuff would be easier if I had my weekend like the other two interns, but that's the way things go sometimes.  My wife and I also have the additional stressor of trying to move into a house at the same time, it's like doing 80 things at once...I feel like a plate juggler...I can't imagine what my wife feels like.

SO I thought I would do a quick recap on the babies I have here and end there stories, while I have a break...hope you are not looking for too much closure.

There's the little kid that has medical necrotizing entercolitis.  He has been NPO (nothing by mouth) for the better part of 2 weeks now.  We keep getting him better, trial feeding him, and going back to square one, with him having bloody stools and abdominal distention/pain.  It's all very frustrating, I can't even imagine what the parents are going through.  I go by and update them every morning and night before I leave.  At first it was nice to answer all of their questions and put their minds at ease, but now as we go into week 2 of the same stuff, I feel useless...we are doing everything for this kid at the moment...currently though everything we are doing isn't really good enough...not for him and not for the parents anyway.  When he stabilizes we'll get an imaging study and figure out if he really IS having this NEC or it is something else...it doesn't exactly present like NEC so I wish I could find out the results of that study before I leave...which leads me to my biggest frustration....I'm leaving...  I won't find out what happens to him, he could miraculously get better the day I leave...or he could get way worse, only the new residents will know.  The best I can do is ask one of the interns later on how he did, but I doubt they will remember.  I was really hoping he would pull through this one, he might still, but I'll be left in the dark on this one.

The other child I talked about more than once was a little babe an oxygen requirement that kept increasing.  I honestly had no idea why, we tried heart echo's, liver echo's, diuretics, ect ect ect...but nothing worked.  We finally opted to feed her lots of protein, calories, and iron.  Giving her iron would bulster her hemoglobin in the red blood cells making it easier for her to breath.  Giving the extra protein was for increasing her albumin stores (a protein responsible for keeping your body water in your vessels...instead of your lungs).  We put her on this little "treatment" and within two weeks she was peeing off a lot of her excess fluid and requiring much less oxygen.  She even ended up feeding without the use of a naso-gastric tube (tube down the nose to the stomach) which I still can't believe.  It's been really cool to see her slowly change into a baby that can go home and, for the most part, survive without any real medical treatments. Yes, she will go home on a small amount of oxygen but with the way she is improving it is likely she won't be needing it in a couple of weeks.  It's really crazy that all those fancy tests and treatments we did for her and really all we needed to do was prescribe a little time and a lot of food.  She's the bright spot of my NICU experience.

Besides that I have several other kids that are in the middle.  None of them came here really sick at all, we are either just watching them to make sure they are not infected...or we are watching them to make sure they can eat and grow without our assistance.  They will all likely go home without event.

If I had to name one moment that really stood out for me in my experience on the NICU, it would have to be that first night of call.  When I was in it, I was really excited and scared...but looking back now at how un-experienced I was that first night...I really should have been much more of both.  I find myself getting a little sad about leaving it behind, I've made some good friends here and I've gotten really comfortable with it...at the same time, I find it harder and harder to get up on the days I'm on call, I sometimes fumble up my thinking during those long nights for no reason (which isn't normally like me), and I come home and just feel like doing nothing (although that is sadly not an option most days)...I can say "I'm fine" all I want, but I can tell I need a break.  I wish I could say that at the end of this rotation I'm A OK, but with life stacked on top of this decently demanding job, I can say I'm going to be glad for a change. The NICU's a nice place...but I wouldn't want to live there. : )

Newbie Doc

Thanks for sticking with me on this NICU ride.  NEXT STOP: Poop City!!! Wooohooo!!! (GI elective).