I know it's comming and there's nothing I can do about. There are two empty beds in the MICU and this can only mean one thing. I will not sleep tonight. There are comming. The Code Blue down the hall, the ER patient with urosepsis. All conspiring to seperate me from the necessity of sleep.
Only in medicine is it considered a badge of honor to go thirty something hours without sleep. Every other profession from piliots to the military accept that the human body has needs. That we are not mearly cogs in some great machine. Every one except medicine. And this is one of our greatest mistakes. There is nothing noble in what we do. Our patients are certainly not the better for it. Studies bear that out. Patients would be better treated by a drunk resident than one that has been up overnight. I've certainly made mistakes, and at any one time there is a least one patient here because of a medical mishap.
This notion of not sleeping is just a giant pissing contest that pre-dates modern medicine.
And yet it just won't go away. After high profile deaths efforts are always made to limit hours, to bring some semblence of normalcy to a residents life. And each time it is met with resistence from our attendings, our peers, sometimes ourselves.
So here I am tonight, sleepy as all hell, but not sleeping. Because I know as soon as my head hits the pillow I will get my new admit. So I wait for them to come.
Maybe then I can get some sleep.
Monday, August 14, 2006
Sunday, August 06, 2006
The First
Everyone dreads there first night on call and I 'm certainly not cool enough to pretend that I wasn't scared. For those not in the know, call means that you start work in the morning, stay overnight in the hospital and round again in the morning. It's about a thirty hour shift. The scary thing about being on call is that most of the people who know what the hell there doing leave around six, and then it's all you. The attendings make a big deal about the fact that you can call them at home so technically were not really alone. But if you believe that then I'll order you a psych consult.
Lay people also fool themselves into thinking " Hey, your doctors. What's the problem" Seriously though, we graduate as med students on a Friday and start work on a Monday. There's no great infusion of knowledge over that weekend, so one day we can't order an asprin without a co-signer and the next day were left overnight with critical patients. I highly advise you never to enter a teaching hospital in June or July. The monkeys are running the asylum. But I digress.
So I'm on call in the ICU and I have known my patients for about four hours. Just long enough for me to figure out there names and ventilator settings but not long enough to get used to the incessant beeping of alarms that is the background music in any ICU. My resident, whose job it is to orient me and make sure I don't accidentely kill any one, has clinic and will be gone for the afternoon. Ummm, I'm not really sure this a good idea. And sure enough out comes the nurse from Bed 8 " Mr Alberto has a pulse of 180, blood pressure is 70 over 40 and he's sating (O2 saturation) at 73%. What do you want to do?" What do I want to do: RUN. I don't know what the fuck to do, are you kidding me. I've never felt that inadequate in my life. I walk in the room and sure enough, things are as bad as the nurse says they are. "Page the resident" I order with some semblence of authority in my voice. Vague recollections of orientation are comming back to me, but I can only remember the drugs we give when the heart stops or slows. Not exactly the case I'm facing now. And then I remember that I can give a beta-blocker, a wonderous drug that slows the heart rate and is generally not all that dangerous. So I push my drug waiting for it to fix things and nothing is happening. My patient still has the heart rate of a coked-up hummingbird. My resident calls back and as calmly as I can fake I explain that things have promptly gone to hell upstairs. "Well did you give Metoprolol" he says. "Of course I did" I answer, like how dare he think I don't know what I'm doing. "And it didn't work" Umm, no. "I think you should come up here" Now he's pissed. That whole discussion of how we can call for help when we need it-total bullshit.
My resident heads back to the ICU, walks in and says "This isn't good". Yeah, I'm pretty sure I had already made that determination. Can we move on to the 'How to fix it' portion of the conversation. Out comes a whole arsonal of drugs that I clearly have no idea how to use. We push dig, we give dilt, nothing works. Then the Cardiology team comes wandering in and announces to the world that we need to break this rhythm. I'm going to file that under the "Duh" category. We tell them what we've tried and that nothing has worked and they offer a simulataneously exciting and terrifying option:Cardioversion. Cardioversion is shocking the heart and hoping that when it restarts it decides to beat like its supposed to. It freaks us out because in rare instances you can shock it and it doesn't restart. As the new intern I get to be the one who cardioverts. "Charging 100. Charged. Clear" Blam 100 joules hits the guy and he jumps of the bed. We all stare at the moniter and see the most wonderous sight. Normal sinus rhythm at a rate of 83 beats per minute.
This is that part in the movie where we all walk away and congratulate ourselves for a job well done, but I'm an call. There is no walking away. I'm going to be taking care of this man all night long, by myself, and he could probably do this again and again and again. And next time my resident will be gone and Cardiology won't be in house. I started my call night scared. And that's where I stayed all night long. White knuckling it until the cavelry arrived the next morning. In spite of how hard I can try I will never be able to properly articulate what momments like these do to the soul. Its easy to say well everything worked out, and it did. But looking back I can laugh and joke, but that night was so terrifying. Our only goal is to keep the patients alive until the morning, and you can't fail at that. You can't fail as a doctor. This year is going to be so painful, because I will fail, and people will die. And I will never forget that feeling of just wanting to run and knowing that I couldn't. I cried the entire way home from the hospital.
I'm on call again in three days.
Lay people also fool themselves into thinking " Hey, your doctors. What's the problem" Seriously though, we graduate as med students on a Friday and start work on a Monday. There's no great infusion of knowledge over that weekend, so one day we can't order an asprin without a co-signer and the next day were left overnight with critical patients. I highly advise you never to enter a teaching hospital in June or July. The monkeys are running the asylum. But I digress.
So I'm on call in the ICU and I have known my patients for about four hours. Just long enough for me to figure out there names and ventilator settings but not long enough to get used to the incessant beeping of alarms that is the background music in any ICU. My resident, whose job it is to orient me and make sure I don't accidentely kill any one, has clinic and will be gone for the afternoon. Ummm, I'm not really sure this a good idea. And sure enough out comes the nurse from Bed 8 " Mr Alberto has a pulse of 180, blood pressure is 70 over 40 and he's sating (O2 saturation) at 73%. What do you want to do?" What do I want to do: RUN. I don't know what the fuck to do, are you kidding me. I've never felt that inadequate in my life. I walk in the room and sure enough, things are as bad as the nurse says they are. "Page the resident" I order with some semblence of authority in my voice. Vague recollections of orientation are comming back to me, but I can only remember the drugs we give when the heart stops or slows. Not exactly the case I'm facing now. And then I remember that I can give a beta-blocker, a wonderous drug that slows the heart rate and is generally not all that dangerous. So I push my drug waiting for it to fix things and nothing is happening. My patient still has the heart rate of a coked-up hummingbird. My resident calls back and as calmly as I can fake I explain that things have promptly gone to hell upstairs. "Well did you give Metoprolol" he says. "Of course I did" I answer, like how dare he think I don't know what I'm doing. "And it didn't work" Umm, no. "I think you should come up here" Now he's pissed. That whole discussion of how we can call for help when we need it-total bullshit.
My resident heads back to the ICU, walks in and says "This isn't good". Yeah, I'm pretty sure I had already made that determination. Can we move on to the 'How to fix it' portion of the conversation. Out comes a whole arsonal of drugs that I clearly have no idea how to use. We push dig, we give dilt, nothing works. Then the Cardiology team comes wandering in and announces to the world that we need to break this rhythm. I'm going to file that under the "Duh" category. We tell them what we've tried and that nothing has worked and they offer a simulataneously exciting and terrifying option:Cardioversion. Cardioversion is shocking the heart and hoping that when it restarts it decides to beat like its supposed to. It freaks us out because in rare instances you can shock it and it doesn't restart. As the new intern I get to be the one who cardioverts. "Charging 100. Charged. Clear" Blam 100 joules hits the guy and he jumps of the bed. We all stare at the moniter and see the most wonderous sight. Normal sinus rhythm at a rate of 83 beats per minute.
This is that part in the movie where we all walk away and congratulate ourselves for a job well done, but I'm an call. There is no walking away. I'm going to be taking care of this man all night long, by myself, and he could probably do this again and again and again. And next time my resident will be gone and Cardiology won't be in house. I started my call night scared. And that's where I stayed all night long. White knuckling it until the cavelry arrived the next morning. In spite of how hard I can try I will never be able to properly articulate what momments like these do to the soul. Its easy to say well everything worked out, and it did. But looking back I can laugh and joke, but that night was so terrifying. Our only goal is to keep the patients alive until the morning, and you can't fail at that. You can't fail as a doctor. This year is going to be so painful, because I will fail, and people will die. And I will never forget that feeling of just wanting to run and knowing that I couldn't. I cried the entire way home from the hospital.
I'm on call again in three days.
Monday, July 31, 2006
Round and Round
Much to my dismay I'm out of the ER now. I only get two months in the ED my first year and it's halfway over. I'm on medicine right now, and I hate medicine. Everyone picks their specialty for different reasons but most of us in the ED say the same thing about medicine: we can't stand rounding.
Rounding is the art of doing and saying absolutely nothing for hours on end while standing up and pretending to be interested. Each patients every past and present medical complaint must be examined and discussed ad nauseum. They could be here for pneumonia or DKA but we still have to talk about that time when they were twelve and they got an ear infection. Why? What the hell does that have to do with why their here now. And do I really have to miss breakfast because Mr. Smith's INR is not exactly two and a half. Is 2.4 really that unacceptable. Ever little lab abnormality must be worked up to the fullest. Maybe he has hypercalcemia because he had too many TUMS for dinner. Maybe it's a lab error. But I really don't think we need to talk about it for ten minutes and start a work up for multiple myeloma. Even completly normal people are allowed to have abnormal labs from time to time. If someone invented a machine that could give out a minute by minute Chem-7 the internist would strangle themselves with their stethoscopes. This of course would make rounding infinitly more interesting.
It's not like we only round once a day either. No the entire process has to be repeated in the afternoon. The same patients, with their same problems, get the exact same discussion not just once but twice. That's a real good use of my time. "What? We only spent a half an hour this morning discussing whether Mr Johnson should be on the renal diet for his kidneys or the cardiac diet for his heart. Let's do it again please, pretty please, with sugar on top. Let's not go home at a reasonable hour and spend time with our actually families or better yet get some sleep. This is critical life and death stuff".
Thank God it's only for a month.
Rounding is the art of doing and saying absolutely nothing for hours on end while standing up and pretending to be interested. Each patients every past and present medical complaint must be examined and discussed ad nauseum. They could be here for pneumonia or DKA but we still have to talk about that time when they were twelve and they got an ear infection. Why? What the hell does that have to do with why their here now. And do I really have to miss breakfast because Mr. Smith's INR is not exactly two and a half. Is 2.4 really that unacceptable. Ever little lab abnormality must be worked up to the fullest. Maybe he has hypercalcemia because he had too many TUMS for dinner. Maybe it's a lab error. But I really don't think we need to talk about it for ten minutes and start a work up for multiple myeloma. Even completly normal people are allowed to have abnormal labs from time to time. If someone invented a machine that could give out a minute by minute Chem-7 the internist would strangle themselves with their stethoscopes. This of course would make rounding infinitly more interesting.
It's not like we only round once a day either. No the entire process has to be repeated in the afternoon. The same patients, with their same problems, get the exact same discussion not just once but twice. That's a real good use of my time. "What? We only spent a half an hour this morning discussing whether Mr Johnson should be on the renal diet for his kidneys or the cardiac diet for his heart. Let's do it again please, pretty please, with sugar on top. Let's not go home at a reasonable hour and spend time with our actually families or better yet get some sleep. This is critical life and death stuff".
Thank God it's only for a month.
Saturday, July 22, 2006
Something new
Now I haven't been an ER doc for too long, but you get used to the usual stuff pretty damn quickly. Under thirty with chest pain-either panic attack or cocaine. Big lady with abdominal pain- gallstones. So it was kinda nice the other day to get a suprise. I was hanging out in the trauma bay with the typical MVA when the security gaurd comes running in. "we've got a situation out in the ambulance bay" So I run to grab gloves and run out the doors to see what's up, and by the way, unlike what you see on TV we never go outside. Only in "ER" do the doctors meet the ambulances, it drives me nuts. In runs a nurse with a bloody bundle, and sure enoug it's a newborn baby.
We all run around trying to grab the warmer from whatever dusty corner it's been relegated to and shove the baby inside. With a new baby you have one mission in life. Warm, dry, stimulate. That's it, that is the magic of life. God needs no other help then that. After a heart stopping second the trauma bay is alive with the sound of a brand new human being. It was one of those moments that brings every one, the nurses and the attendings, over for a seconds as we all looked at her. It was kinda neat, we don't get to see pure happiness too much. People die all the time in the trauma suite. I still remember what it was like the first time I called out the time of death of a patient. But it was really cool to see a new baby, a new life. And sure enough she went upstairs to the NICU to get checked out, and the ED once again belonged to the tragedy unstead of the ecstacy. But it was still one of the moments that I'll always remember.
We all run around trying to grab the warmer from whatever dusty corner it's been relegated to and shove the baby inside. With a new baby you have one mission in life. Warm, dry, stimulate. That's it, that is the magic of life. God needs no other help then that. After a heart stopping second the trauma bay is alive with the sound of a brand new human being. It was one of those moments that brings every one, the nurses and the attendings, over for a seconds as we all looked at her. It was kinda neat, we don't get to see pure happiness too much. People die all the time in the trauma suite. I still remember what it was like the first time I called out the time of death of a patient. But it was really cool to see a new baby, a new life. And sure enough she went upstairs to the NICU to get checked out, and the ED once again belonged to the tragedy unstead of the ecstacy. But it was still one of the moments that I'll always remember.
Friday, July 14, 2006
Constipation in the ED
I hate when the board isn't moving. No one is going upstairs, no one is comming back from triage and everybody starts getting bitchy. The board is the center of activity in the ED. As the patients come back from the waiting room they get a spot on the board, but not necessarily a bed in the ED. It lists their age, complaint, which MD is seeing them and there final dispositon. People essentially either go home or head upstairs. But the board isn't moving today because we have NO beds upstairs. Nada. No ICU beds, no PCU beds, no ward beds. At least half of the board is filled with patients who have been admitted to the hospital but have no place to go. So they sit in the ED, taking up space. And the board doesn't move.
So now we start the delicate dance of walking the waiting room, trying to figure out which patients can afford to wait another twelve hours to get on the board and who really needs to go back now. Every year at least a couple people die in the waiting room because we couldn't see them in time. Usually in our department it takes 12-15 hours to from registration to getting back and on the board. The total time it takes to figure out what's wrong with you is usually another 4-8 hours ( blame radiology and lab for this). Then it can take another day or so to get a bed upstairs. It's a scary thought that in our country people can literally be 24 hours plus to see a doctor.
Just because we have no beds and the waiting room is beyond capacity doesn't mean the ambulance runs stop. We are officially closed to trauma today but the paramedics can use their "clinical judgement" to decide if they need to come to us. So from time to time we are running traumas in the middle of the ER. Almost all of our traumas are sick enough that they need to be admitted, but we have no beds, so they stay downstairs with us-backing up the ED. Right now there's a line of ambulance gurneys with patients that have no bed in the ED. In the ED there is a board full of patients that need to go upstairs. And upstairs there is a hospital full of patients who are too sick to go home. And I only have nine hours left on my shift.
So now we start the delicate dance of walking the waiting room, trying to figure out which patients can afford to wait another twelve hours to get on the board and who really needs to go back now. Every year at least a couple people die in the waiting room because we couldn't see them in time. Usually in our department it takes 12-15 hours to from registration to getting back and on the board. The total time it takes to figure out what's wrong with you is usually another 4-8 hours ( blame radiology and lab for this). Then it can take another day or so to get a bed upstairs. It's a scary thought that in our country people can literally be 24 hours plus to see a doctor.
Just because we have no beds and the waiting room is beyond capacity doesn't mean the ambulance runs stop. We are officially closed to trauma today but the paramedics can use their "clinical judgement" to decide if they need to come to us. So from time to time we are running traumas in the middle of the ER. Almost all of our traumas are sick enough that they need to be admitted, but we have no beds, so they stay downstairs with us-backing up the ED. Right now there's a line of ambulance gurneys with patients that have no bed in the ED. In the ED there is a board full of patients that need to go upstairs. And upstairs there is a hospital full of patients who are too sick to go home. And I only have nine hours left on my shift.
Friday, April 14, 2006
Show me the money
I'm broke. You wouldn't think you'd hear that from a doctor to be, but we are the poorest humans on the face of the planet. I already owe close to 250,000 and currently have -1000 in the bank right now. So I'm searching for yet another loan. I'm not a total jackass with money, inspite of my debt load. I never owed any money before medical school, didn't even own a credit card. But financial aid in medical school is a complete joke. It doesn't matter how old you are, whether or not your married or even if you have kids, your still considered dependant on mommy and daddy for fin aid purposes. Are you kidding me. I moved out of my parents house almost ten years ago and I have to ask them for their tax information and assets. I feel like I'm trying to see what's in their will and there not even dead yet. So that's how I ended up in so much debt. But with all that money I must be living it up right? People buy houses for less so why am I still broke. Well most of that money went for tuition and the rest for rent and food. Were not exactly supposed to work in medical school. Can you imagine my job interview."Yea, I'm just staying in medical school untill I get promoted at In and Out Burger"
It doesn't help that we get all our money in a lump sum and are expected to portion it out just right. When you got ten thousand in the bank what's a couple hundred on groceries. But when your down to your last fifty bucks your just trying to figure out how much Top Ramon you can eat without hurling. So where else did all the money go? Oh yea, that's right, I had a kid this year. No, there not expensive at all. You would think fin aid would let me take out some more money but noooo, adding another human being to your family is not grounds for needing more cash. "Student loans are for students not students families"-thanks alot to my financial aid counselor. Way to be helpful.
But wait I have a job in June. I'll be a doctor that's when they money starts flowing. My salary for my first year is $37,000. That will support me, my husband and my kid-right? That's it boy and girls that's what I spent 10 years in college for. Oh and did I mention that I won't get my first paycheck until August 30. Fuck, won't somebody give me another loan.
It doesn't help that we get all our money in a lump sum and are expected to portion it out just right. When you got ten thousand in the bank what's a couple hundred on groceries. But when your down to your last fifty bucks your just trying to figure out how much Top Ramon you can eat without hurling. So where else did all the money go? Oh yea, that's right, I had a kid this year. No, there not expensive at all. You would think fin aid would let me take out some more money but noooo, adding another human being to your family is not grounds for needing more cash. "Student loans are for students not students families"-thanks alot to my financial aid counselor. Way to be helpful.
But wait I have a job in June. I'll be a doctor that's when they money starts flowing. My salary for my first year is $37,000. That will support me, my husband and my kid-right? That's it boy and girls that's what I spent 10 years in college for. Oh and did I mention that I won't get my first paycheck until August 30. Fuck, won't somebody give me another loan.
Friday, April 07, 2006
Is there a Doctor in the house?
So congratulations to me. I'm going to be a doctor, and I'm so excited about it I could just die. Or at least kill my younger self who decided this would be a good idea. Like at least 50% of my classmates I don't want to be a doctor anymore. But were all fucked because we owe so much money that there's no backing out now. It's less painful to pay back the mob then pay back medical school debt. At least the mob is willing to kill you and put you out of your misery. I graduate from medical school in two months and I'm already burned out. Oh yea, this is going to be a great year for me.
I'm starting internship soon. Also known as the worst year of my life. I get to have all the compassion and empathy squeezed out of me while enduring 30 hour shifts every three days, not sleeping for months on end and never seeing my family. Internship is supposed to mold you into this great all knowing doctor, or completly break your spirit - whatever comes first. So I thought I would let the civilians into the mind of what doctors are really thinking this first year. This won't hurt a bit.
I'm starting internship soon. Also known as the worst year of my life. I get to have all the compassion and empathy squeezed out of me while enduring 30 hour shifts every three days, not sleeping for months on end and never seeing my family. Internship is supposed to mold you into this great all knowing doctor, or completly break your spirit - whatever comes first. So I thought I would let the civilians into the mind of what doctors are really thinking this first year. This won't hurt a bit.
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