First EM rotation as a real doctor, mission accomplished

Wow, what can I say. So much has happened and so many crazy cases that you will find it difficult to believe. I was in a inner city poor demographic emergency department for 1 month. This ED is so busy and understaffed that it feels like the kind of training that the older physicians speak about so proudly, "When I was a resident I was just thrown in the fire and had to sink or swim ....."

Many of the patients were very sick and presenting late in the course of their illnesses. Many of my shifts were so faced pace that I never even paused to go to the bathroom for 12 hours. This hospital is an amazing place to train as a resident. You see it all and do it all. You definitely get your hands dirty. I learned a tremendous amount and became much more comfortable with several of the core procedures that every EM physician needs to perfect.

I intubated several patients, which is the process of placing a tube into a patient's trachea and then connecting them to a ventilator to breath for them. In the ED this procedure is often done emergently without a lot of time. I ran some codes (resuscitations) on patients found down. A couple we brought back and a couple we lost and I declared the time of death after all efforts were exhausted. I had to talk with the families about their loved one who did not make it.

The worst of these was a code I ran on a patient who was in town with his family for a family reunion. He was relatively young and healthy and while at a restaurant he had a myocardial infarction and came to us in the ED flat lined. We worked on him for nearly an hour. He was the father / grandpa of the family and the entire family was in town on vacation and this was completely unexpected as he was in good health. Needless to say the family was devastated. It was a tough conversation talking with the family. The crazy thing about the ED is that I still had several other acutely ill patients that needed to be seen. I finished the code and talked with the family and had to move on to my other patients.

I had a pregnant patient that was shot in the back. Gun shot wound in a pregnant woman. I had to use the ultrasound to assess her and the baby. Fortunately for both the bullet missed the vital structures of the mother and the fetus. I had multiple lacerations, stab wounds that I had to repair. I had septic nursing home patients, drug overdoses, suicide attempts, heart attacks, asthma attacks leading to complete respiratory failure, brain bleeds, traumas, kidney stones, miscarriages, rape victims, GI bleeds. The list goes on and on. I could not believe the high volume and acuity of the patients.

This rotation kept me on my toes and allowed me to get better at several procedures like lumbar punctures (spinal tap), central lines, suturing, intubations, joint aspirations, procedural sedation, resuscitations, pelvic exams and many others. I loved it and never knew what was going to come through the door. There were times when you felt stretched thin and that can be anxiety producing but it is all part of the training process. A good ED physician has to be able to manage multiple sick patients at the same time and remain calm, cool and collective.

No wonder it takes several years but I am starting to feel like a real doctor.

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.

My last day of medical school

I got to the hospital at about 6:00 am in the morning and none of the other doctors / team members were there yet. I decided to round on all of our patients that we were caring for and treating. I would enter the room of each patient and ask them how there night was and perform a focused physical exam depending on their pathology and also look for any new problems. I would then check with the overnight nurse and document any overnight complaints or problems. For example one of my patients had tried to escape and was found outside having a cigarette. Noted. I really did not mind this as this patient has terminal cancer that has metastasized throughout his entire body and his days are numbered. I had to tell the patient this was not wise and that he could not just leave and smoke. In my mind I was thinking "smoke 'em if you got 'em" at this point.

Another goal of pre-rounding on the patients is to followup on all of the consults, and procedures we had ordered from the day before to see what kind of progress had been made. Did hospice come and see patient #1? Did social work find a nursing home placement for patient #2? Did anesthesia do the epidural for patient #3? Did the infectious disease doctors see patient #4 and make their antibiotic recommendations? Did ortho come by and evaluate patient #5 who is recovering from the total hip replacement they did several days ago and have still not followed up, despite numerous calls and begging attempts. The answer to all of these follow up questions at the government hospital is unfortunately no.

This makes the day's work frustrating and stressful as I need to followup with the various specialties and needed services and kindly beg to get the work accomplished. I was all over it and started making my calls to there various doctors and one by one started to get the list taken care of and checked off. While doing all of this I have to document everything and of course deal with new situations that pop up. The nurse will come in and exclaim "Patient #2 has low blood pressure, what should we do?" I would respond accordingly and make the orders and run them by my senior to verify that he agreed and we would move forward.

The day was busy and there was not a lot of time to think about how this was my last day of medical school. Finally at around 6:00pm my senior looked at me and said "isn't this your last day?" and I replied triumphantly: "Yes" and he said "go home already!" I quickly grabbed my stuff and made a dash for the exit before I could get pulled into another crisis. I walked out the front door of the hospital and walked toward my car. I was dumbfounded and even emotional but it still had not sunk in that I was done.

I am done....

Sub Intern in a Socialized medicine hospital

Here I am finishing up my last rotation as a medical student and I chose to do this part of my training at a government hospital. This is socialized medicine. All the patients are seen free of charge and all the doctors, nurses and ancillary staff are paid by the government. The doctors do not have to carry the same type of malpractice insurance because they do not get sued and if they do the US government steps in as the one being sued so the doctor faces a different form of liability than a private doctor would face in a regular private practice.

The first thing I have notice is that no one really wants to work. Everyone spends a lot of time trying to avoid work. If the emergency doctor can refer the patient to the medical floor he/ she will and if the medical floor doctors can get the patient admitted to the ICU or surgical floor or somewhere else they will do it. There is a ton of pass the responsibility at all levels of care. Often the patients are left confused and wondering what is going on because no one takes the time to communicate the plan to the patient.

I am not saying that nothing gets done or accomplished because we are treating lots of patients but we are very inefficient and slow. Often our hands are tied because the CT scanner is backed up or ekg tech has exceeded the government allowed number of ekgs so they have to stop doing ekgs for the day. There is red tape and paper work which makes doing very simple tasks like taking the patient's temperature a 7-10 page document that multiple people have to sign off on each step of the way. This creates many opportunities for error and many bottle necks in the process.

A patient that would be in a private hospital for 23 observation gets trapped in this government hospital for 3 - 5 days and have multiple tests and unnecessary things done or necessary things not done because of all the red tape and confusion. Imagine the DMV. It is a lot like the DMV and there is almost zero customer support. No one looks at the patients as customers but rather the patients represent more work. It is really sad.

On the good side, because I am motivated and want to learn a lot I am able to get procedures and do things that I might not get to do at a private hospital. The patients are very grateful for even the smallest acts of kindest. They are not used to being talked to in a nice manner, so when I say "Hi Mrs. y, how is your morning?" She grins and appreciates the gesture.

More stories to follow. I have seen a bunch of complicated late stage cancer this past week and some other crazy illnesses.