In the Emergency Department, home sweet home

For my second rotation of residency I am in the ED (Emergency Department) in an inner-city hospital. Some may think; "You are doing a residency in emergency medicine, so why are you not always in the emergency department?" In the first year of residency I will do about 40% of my training in the ED and about 60% on off service rotations like OB, ICU, Anesthesia, Ortho, etc. During my second year I will do about 60% of my train in various ED's and 40% off service. In my third year I will be in various ED's 100% of the time.

The off service rotations are great for getting training in specialties that you have to know as an ED physician. YOu have to handle OB, Ortho, pediatric, etc patients in the emergency room. It is nice to be in the ED as I feel at home there and everything I am learning has a direct impact on my skill set as a physician. There are several different emergency departments that my residency works in and this was one of the things that attracted me to this program. Many residency programs keep their residents in 1 ED the entire residency. Unfortunately those residents only see 1 ED and 1 type of patients during their whole training time. An inner-city ED is a much different environment than a suburban ED or a small town ED or a trauma 1 ED. My residency program has us do rotations in all of these types of emergency departments.

Some residents do not like all the traveling between the different locations. You spend 1 month at 1 hospital and another month at a different hospital. I feel the different environments and different patient types makes you a much stronger, well rounded ED physician. My first ED rotation is in a very busy inner-city emergency room. It is a little crazy and you see amazing pathology and illnesses. I had a patient the other night that was bitten by his own pit bull and his leg was pretty torn up. As I explored the wound I noticed a foreign body within the bite wound. I sent the patient for an X-ray and sure enough there was something in the wound. I continued to explore the wound until I actual found the foreign body and upon extraction of it I realized it was one of the dog's teeth. Crazy. Of course the patient did not want the dog to be put down. Fortunately animal control gets to deal with the animal issues. I cleaned the wound and started the patient on antibiotics. Fortunately the dog did not have rabies so the patient did not have to get treatment for rabies.

In the ED you never know what is going to come threw the door and that is what I love!

Wow the CCU is done

I lived through my first month of internship. It really is out of control. I had heard all the legendary tales of those who went before me. Never ending hours, sleep deprivation, extreme exhaustion and living in the hospital 24 / 7. I have to say the tales were fairly accurate. I got worked. I used to look at residents and wonder how they did it. However as a resident you have no option but you also have the extra layer of responsibility which makes you busier which makes your time go faster. As a medical student you were often at the mercy of what your residents told you to do. You had to wait around at times for an assignment.

As a resident you have to make sure things get done and patients are seen. This keeps you busy which makes the time go by much faster. There used to be no hour limits on residents and many of the older doctors love to point out "back in the day we worked 2000 hours / week and had to walk barefoot in the snow uphill both ways" I remind them that back in the day the patients were much more likely to die while they were waiting for modalities like CT, MRI and medications to be invented. :) Now we have the 80 hour work week which tends to be complicated. You are supposed to only work 80 hours / week however education hours like conferences and paperwork do not count. It is 80 hours of patient care hours and it is averaged over 4 weeks. You can work 100 hours 2 weeks in a row and then you could work 60 hours for the next 2 weeks and you would still be ok. The educational and the paperwork hours can really ad up and push you towards 100 hours / week anyways.

In reality it can end up not much different than the "old days". Also very few residents are willing to turn their program in if they are required to work longer than the 80 hours / week. No matter how you look at it, you work insane hours during residency and especially during intern year.

I really enjoyed the CCU. I learned a great deal about cardiac patients and the management of sick heart patients. I became very comfortable treating patients with very high blood pressure, very low blood pressure, myocardial infarction, congestive heart failure, pulmonary hypertension and all manners of cardiac pathology. It was a very high yield experience and I feel a lot more comfortable around these sick patients. I still have lots to learn but it is a good feeling to know that I have made it through my first month of residency and one of the more difficult and demanding rotations.

It is great. I love what I am doing.

Over Night, Who is in charge?

I have started on the CCU which is an ICU for cardiac patients. It is a demanding rotation with long hours. It is a great learning opportunity and the patients are fairly sick. I am on call every 4 days. My nights on call it is just me and my senior resident taking care of all the CCU patients. We also admit any new patients coming in from the emergency department or other hospitals.

Overnight all kinds of things seem to happen to prevent sleep from occurring. I will get several pages from nurses with everything from; "can I give patient xyz a tylenol?" to "patient xyz is not breathing!" Generally I try to handle everything on my own allowing my senior resident to sleep. If I get something that I am not sure about or that requires additional hands then I will get my senior to help, teach, or explain. It can be very intimidating when you get a call to respond on a sick patient in a crisis. My first night on call I had 2 patients that were crashing and I had to manage their symptoms. As I responded to one patient who was having difficulty breathing. He was a 75 year old man with a recent MI where he had to be shocked and intubated and now was recovering. As I entered the room I saw that he was sweating, and sitting up in his bed trying to get the oxygen in and was struggling to do so.

It was 3:00 am and I was just hoping that he would not de-compensate to complete respiratory failure and or die. I sprung into action and position the patient in a manner that helped him to breath. I increased the oxygen level and administered some medication to calm him down because he was panicking and making it worse. I had the nurse get respiratory therapist to bring some breathing treatments. It was touch and go and I got the crash cart ready just incase I had to intubate the patient. The respiratory therapist showed up with breathing treatments and we started the nebulizer and the patient started to calm down and his airway opened up. He started to look better and I started to feel better and my heart rate slowed to a normal rhythm. The patient returned to his baseline and stabilized.

As I left the room with a sigh of relief and I was surprised at how in the heat of the moment the therapies and treatments just came to the forefront of my mind as I responded to the situation. It was reassuring to know that some of this stuff has stuck in my brain and is actually accessible when necessary. I feel like these experiences and situations each add to my training and hopefully help me become a better doctor. It is still very surreal to me that I am making the calls and the treatment plans on many of these patients. As a medical student you had some input but there was always filters and ultimately everything you did was reviewed and modified by a doctor before it went into action. It is a crazy feeling and makes me extra cautious/ even paranoid about making a mistake or not doing the right thing. As a resident physician you always have access to help from an attending physician or a senior resident to help if you are stuck or do not know what to do but often you are expected to be able to handle a lot of the cases without help.

I have been thrown into the ocean and it is sink or swim. It is a good thing I like swimming.

Is there a doctor in the house?

I know it has been a long time since I last posted but I am back. I finished medical school and am now officially a doctor. It is strange to have MD behind my name. I guess it has been so many years and such a circuitous route to this point that the whole thing is kind of surreal. It has not sunk in completely but it quickly is becoming a reality as I have started residency in Emergency medicine and I just finished my first night of call where I worked 32 hours straight and I was anything but excited to be called doctor or have any initials behind my name.

We need to get caught up. I applied for residency in emergency medicine which is a 3 - 4 year training program depending on where you do the residency. I applied to over 40 programs, as emergency medicine has become more competitive. In order to get enough interviews to get an acceptance I had to cover all the bases and apply to enough programs. I ended up with 15 interviews and attended 12 total. I then ranked the 12 programs from 1 (my top choice) to my 12th (last choice) and waited for the programs to rank their applicants. Finally once everyone's lists were submitted the computer matches the programs with the applicants and you hope to get as close to the top choice as possible.

I was lucky enough to match at my top choice which is an inner-city trauma level 1 center. I officially started on July 1. My first rotation is on the CCU, Cardiac Care Unit. It is an ICU for heart patients. It is an intense rotation and a difficult one to start on. You get thrown into the fire day one. I am on call every 4th night. Last week my first day was Thursday and I worked from 6am to 7pm and then on Friday I worked from 6am to 7pm and then Saturday I was on call, so I started at 6am on Saturday and worked straight until Sunday at 2pm. It was some intense long hours and much of the night I was the only doctor on the floor with lots of sick patients.

It has been a hectic, exciting and good start to residency. I have lots of great stories and cases already. I will have many more to come. So you can check back to see how things go. This week I will work about 80 hours all on the CCU.