strong work: night float, part 2

so, i don't anticipate describing every patient i ever see in residency on the blog, but i did want to talk briefly about my second night as night float, when i served as the admitting intern.

i admitted one patient overnight on my first night float night, which was a good way to start - it was also slow, so i definitely would've done more if there were more patients admitted to medicine. at the outset, it seemed to be a pretty straightfoward case - young woman, nausea, vomiting, abdominal pain for a couple days, CT scan showed signs concerning for pancreatitis. the basic treatment for pancreatitis is really straightforward - nothing by mouth, lots of IV fluids, pain control. great way to start out, learn basic ordering in the computer system.

i went to talk to the patient and her boyfriend and learned about what had been going on - it seemed like the pain had been going on a lot longer, and i got some other information, but the working diagnosis was still pancreatitis. she seemed really anxious, didn't have insurance, and didn't really want to stay. i tried to 'talk her down', let her know what the plan was, and told her i would check in as the night went on. looking at her bloodwork over time; however, i noticed that her blood count was dropping. this could be due to a dilutional effect, where the IV fluids you get 'dilutes' your blood count so it appears that there are less red blood cells than there really are. her blood count kept dropping over time though, so i told the resident i was concerned that there might be more going on even though the patient "looked" great. he agreed that the blood count was low, and it was still low even after we repeated the blood draw, so we decided to get another CT scan, just in case she was bleeding.

as predicted, when i called the radiology resident to ask if she could read the CT, she questioned why we would order another CT eight hours after the patient had just gotten one. i told her that the blood count had dropped considerably and we were concerned about bleeding. she said she didn't see anything, and then i was like, ok, well, better safe than sorry.

as i was getting ready to catch a few winks of sleep, the radiology resident called me back and said on further review, there was hemorrhage in the cul-de-sac, but she couldn't identify the source of the bleeding. i called the general surgery team to evaluate her right away and they said they would see her. after a couple hours, i called them back to see if they had any recommendations and they determined that the likely source of the bleed was a ruptured ovarian cyst. i felt happy because this was on my differential (a list of possible diagnoses you think of at the outset), and then called gynecology to come take a look at the patient before handing her off to the day team who would assume her primary care.

there was more to the story than just this, like keeping the patient informed about developments, trying to enforce rules about family (or boyfriends) staying in the room overnight but letting the patient know that i was still on her side, and making sure everyone was on the same page. when i left in the morning, i was proud that i'd been part of "catching" something that could have been easily overlooked, and also happy that the resident i'd worked with had given me one of the best compliments that a doctor-in-training can get - "strong work!"

patients and patience

so, as many of you know, i 'officially' started residency at johns hopkins bayview on july 1, 2009, which is the official start date for residencies throughout the us. in reality, most of us start before, and we had three days of orientation before starting our first rotation on june 25th.

i started on one of the "easy" months of intern year named "Med-Psych". med-psych is basically a smorgasbord of physical diagnosis rounds, where we go see patients with interesting findings and work on honing physical exam skills, attend different clinics (derm, psych consults, and our clinic where we follow patients over 3 years) and lectures, work on physician-patient communication skills, and do touchy-feely activities talking about our experiences, which i generally like. we also do one weekend of night float.

so, as a doctor, i have my 'own' patients, patients that i serve as the primary care provider for. i saw my first patient in my first clinic on my first day of residency. after a whirlwind orientation by our trusty senior resident attending, i grabbed the chart and walked in. the patient was new to the practice, so there were no old records to look at - just starting off afresh.

even though my first patient was there for a physical, he also was establishing care for the first time in awhile and i spent most of the time just talking to him. he was older, around my parents' age, and he reminded me of a trucker, in a lonely type of way. he had some pretty wicked tattoos, and i asked about them - many of them were related to martial arts, and we ended up spending some time talking about that, and buddhism, and meditation. after we had gone through all the required questions and physical exam and i finally (half) figured out how to complete all the paperwork for a new patient, he said,

"thank you so much for listening to me! i can tell you really care - that's why you went and got that MD after your name. i'm really glad you're my doctor."

i was kinda speechless, and was just like, "thank you. im glad youre my patient" or something lame like that. but it felt great, because i was so nervous, and he was my first 'real' patient, and i was happy i was generally on the right track.

my second patient of the day was a woman who had a genetic condition that had caused both physical and mental delays since birth. she was wheelchair-bound and had to have all her needs taken care of by her mother. talking to the mother, i was totally amazed at her strength and ability to find ways to make sure her daughter was involved in family activities. i really didn't have a clue about lots of her medical problems, but tried to get social work involved because it sounded like she was having lots of problems coordinating care and payment of a lot of the things she needed to take care of her daughter properly. i haven't had a lot of experience with disabled people or patients, and hope to learn more in the future.

after my first clinic i was feeling better about myself. my medical assistant that helps me out, patience, and the supervising resident, liz, also totally saved my butt helping me figure out what - and where - everything was in clinic, and that i had filled in everything properly. next stop: night float.

there are two things you can do on night float: cross-cover (take care of urgent issues that come up at night for patients whose primary md's have left for the night) and admit patients to the hospital after the admitting team has capped (met their limit) or after a certain time (midnight?) so the admitting team can take care of the patients they've already got.

the first night at the hospital i was on cross-cover. the day float really took time to transition and orient me, which i was super grateful for, and then she handed me the 'float' pager. one of the first tasks that i was asked if i wanted to help out on was to try an arterial blood draw from a patient who was a hard stick because she had blown most of her veins injecting drugs. she was totally NOT happy to see us, and totally sensed that i clearly wasn't 100% confident about doing the art stick. she ended up yelling at me before i even got a chance to try and said she wouldn't allow me to do it, that there was no way i could possibly be a doctor. she also stated that didn't understand why she was being experimented on, and demanded that the senior resident supervising me try. the senior defended me (i was so grateful, especially since we had just met like 10 minutes before!), explained to the patient why we had to do the blood draw, and calmly convinced her that the procedure was necessary. unfortunately, the senior couldnt get it either, and the patient kept being belligerent.

after we left the room, i felt relieved and thanked the resident for sticking up for me. she was really supportive and said she was sorry to had to deal with that my first night, but i know i totally will have to deal with patients not agreeing with everything or totally trusting me. at the end of the encounter, the resident mentioned that she believed that the patient also needed to take responsibility for the situation we were in - if she hadn't blown all her veins, we wouldn't be having to put in lines or trying to stick her all the time to get blood. i hadn't thought about it this way before, and im still trying to wrap my head around how i feel about it. so that was my first inpatient experience at the hospital. the rest of the night went pretty well, and by the end of it, i was feeling pretty ok about calling a nurse back, ok'g orders, and being called 'doctor'.

tanyaporn wansom, md, mpp in thailand!

not much to say about graduation. the end of the year was hectic for me, trying to finish up papers and projects for my last semester of policy school, making sure things were in order. i loved the policy school's speaker, bryan stevenson from equal justice initiative, and did not love the med school's speaker, sanjay gupta. i felt more a part of my policy school class (having spent the last three semesters with them) but still an outsider in a lot of ways. for med school graduation, a lot of my family came into town, which was great, but it was also weird thinking about finally having those letters after my name and being officially done with school. anyway, i didn't thinka bout it too much, and tied up loose ends in michigan pretty quickly after graduating to head off to thailand for a month to work/play with some of my favorite people!

i was kinda disappointed since i spent a ton of time applying for awards/grants and had received rejection letter after rejection letter until the end of april, when i found out that i had been awarded the jw saxe fund prize for public service to go to thailand and work with karyn at thai aids treatment action group (ttag). this was fab news during the midst of finals, and chris found a super cheap ticket for me to fly to bangkok on northwest even on really late notice. as the most supportive husband in the world, he also volunteered to pack and move our entire house to maryland. he is amazing, for sure!

so, thailand was totally amazing even though i was really stressed out about going. i was only there for a month, but still got to do a ton of stuff and be involved in projects im really excited about. quick snapshot of work-related activities:

• Participated and helped out at a weeklong hepatitis c training for community advocates, iv drug users, and people living with HIV/AIDS in cha'am outside bangkok. two awesome trainers, tracy and lei, from treatment action group (TAG) in NYC led the training with karyn, and i jumped in and helped out with medical advice and other activities. this was the first time i was really called 'doctor' by everyone all the time, which took awhile to get used to, but was also kinda exciting! my most fave compliment was at the end of the training, when a woman (below)told me "i thought you were an iv drug user when we first started the training because you looked so tired and out of it (i had literally *just* gotten off the plane when we started), but then i realized you were a real doctor and your explanations really helped!"

• Translated at a training for a study sponsored by UBC in Vancouver based out of Mit Sampan Harm Reduction Center in Bangkok. The study is basically a really long interview conducted by peers (former/current users) for users re: all kinds of risk behaviors, police interaction, health status, etc. My co-translators included an ex-physician who now owns a small bookshop catering to college kids and a transgendered woman, who convinced me to accompany her to a photography exhibit/benefit for SWING (Sex Workers In Group). as a previous volunteer at EMPOWER, i hadn't seen surang (the head of SWING) and tee for YEARS but they immediately remembered me at the greeting table and we had lots of hugs and catching up - i hadn't even been married the last time we'd seen each other, but good to know that i can return, and that people still remember me!

• Wrote a brief report at the CDC on my project re: the use of Binax testing to detect S. pneumoniae from alarm positive, subculture negative blood cultures. Don't know if this is going to go anywhere, but hopefully something comes out of it.

• Got hired by Karyn to write a policy brief for TTAG/MSF Access to Meds Campaign re: hepatitis C treatment access in Thailand; will also touch on issues in China and India.

• Dave (Amalee's husband) hooked me up with some people at his work, the Mahidol-Oxford Tropical Medicine Research Unit (funded by the Wellcome Trust). They do some really interesting work re: malaria and meliodosis, and I'm trying to set up an elective in October/November with them in Ubon Ratchatani now!

So, the month was totally productive, but also totally fun! Highlights included:

• A day trip to Petchaburi with Nan & company (what Chris refers to as "lez trip" - this was lez trip #3). A new girl came with us this time and brought two of her male cousins, one of which was Thai-American, like me! We spent the day eating massive amounts of food in a raised hut next to a river and floating down the river in lifejackets. It was relaxing and awesome.
• Spa date at Divana with Tracy (Hep C expert!) and Karyn and Ott
• Lounging around near the pool and on the balcony during the Hep C retreat with the gals
• Dinners with a great couple, Paul and David, who have done MSF work in Thailand for ages. I was totally embarassed, however, when I drank a little too much wine at their place and ended up lying down on the floor of their bathroom while trying to not pass out.
• Eating at new places in Ari and hanging out with Dave and Amalee
• All-you-can-eat buffet madness with old Thai friends and new ones (from IFMSA!)
• JJ Weekend Market and Katak and catching up with Nan

great trip overall, and i was really happy chris supported me in going. we'll be back in october for vacation!

matching and moving

despite my best intentions, i again have fallen off the face of blogspot status post (medicalese for after) match day. the past three months have seen a ton of things fall into place, and i feel like my professional life - and my life with chris - is really moving forward. quick flashback to match day:

1) match day.
prior to match day, you submit your rank list and then wait for three weeks to find out the result of your match. i actually ended up making a lot of semi-last-minute changes after talking out things with chris and others, but ultimately ranked programs in the order i thought would best meet my needs (and also that of chris and yoda!)

the week of the match, you first get an email on the Monday telling you whether or not you matched. the night before this email went out, i told chris i was going into preventive med or something if i didn't match because i didn't think i could deal with the scramble.

while I was at the Ford School, a friend I met on the interview trail instant messaged me: "I matched! Check your email!" I quickly found the email with the subject line, 'Did you match?' and then you open it - I got, 'Congratulations, you matched!' . this was good, but i still had no idea where i matched - i had to wait for a few more days to find out!

on thursday, chris stayed home from work so we could match together. i didn't end up attending the school's 'celebration' because i knew very few people in the class i ended up graduating with (i entered with the class of 2007 and did three years with them) and just opened my match results on the computer. the subject of this email was 'Where did I match?'
and this is what i got when i opened the email:

March 19, 2009

AAMC ID: 11458085
School Code: 145
School Name: University of Michigan Med Sch
Applicant Name: Tanyaporn Wansom

Congratulations, you have matched!

Program Code: 1237140C0
Program Name: Internal Medicine
Institution Name: Johns Hopkins/Bayview-MD

i was kinda freaked out because i just read the top part, and was like, what, i matched at Michigan? but then kept reading and was really happy to see that i matched at Johns Hopkins Bayview Medical Center. i had done a 2nd look there over the winter holidays since we were down there visiting Chris's extended family and really liked the flexibility of the program, the residents, and also the ID faculty and substance abuse/HIV clinic faculty that i met with while at the hospital for the day. Chris was also thrilled because he wanted to be near his family and we knew there would be tons of jobs in the area, esp. with the government.

right after i matched, chris disappeared downstairs because he had been eyeing this job posting on monster.com for months. i helped him throw a cover letter together even though i was like, weh, i want to celebrate (but good for him to get a job too!). he was interviewed on the phone and then got called in for a hardcore all-day interview less than two weeks later. After the interview, he was offered the job right away. so that was cool - he is now officially assistant VP/network services manager at sandy spring bank, which is a local community bank with 50+ branches in maryland/dc/va. we both feel super incredibly blessed that he was able to get a job in this economy, especially one that would help him move into the management track and let him be based close to home.

my parents were super pumped to hear i was going to hopkins bayview although my mom was sad that i was (officially) leaving michigan. i finished celebrating with friends from the med school and Ford school at Dominick's.

matching is much more anti-climactic than you think it might be, but i think it's just waiting and waiting. it was exciting to get text messages from my friends matching around the country though and a relief to know where we were going to finally end up!

2) post-match day: househunting!

one of the chief residents who i'd gone to med school with referred us to his realtor, wendy slaughter (he chose her out of a phone book because her last name sounded like someone who would fight for you, and he was right!) after talking on the phone with her, she helped chris and i find a lender (and get pre-approved for a mortgage), narrow down our price range, and identify things that we wanted in a house (# of bedrooms, garage, stuff like that). once that part was done, she sent us all the listings that matched our criteria, and we chose around 25 that we liked from the ads/virtual tour online.

two weeks after matching, we headed down to maryland for the weekend, where wendy had organized a 2 day tour of all the houses that we liked. in between coffee stops, getting a little lost in her pilot, and snarky commentary all around, we narrowed down our field to two or three places. one of the places we loved was a foreclosure, and when the price dropped on it a week or so after we looked at it, wendy helped us put in a bid right away, hounded the listing agent until he got back to us, and advised us on what to do once multiple offers got to the table. luckily, our offer was accepted, chris was able to do the home inspection while he was in maryland for his job interview, and we got everything squared away for closing.

only chris attended closing so i could take acls and go to thailand (subject of another post later). most people thought it was weird that i wasn't present (it is our first house and everything), but you know, that's just the way we roll sometime. in the end, it was really fortunate that i DIDNT attend closing because i had to emergently wire $$ to chris - he learned the hard way that banks clearly DON'T accept personal checks for closing costs/down payment, and need a cashier's check. just an fyi for all you house-buying ppls out there. :)

ok, this is a good update for match and house right now. more and more updates to come!

it's been a long time

it's been a really long time since i last blogged. looking at the time stamp of my last entry from thailand, it's been about nine months. im kinda shocked by how easy it is to let go of something you do so regularly because it's not a priority and you don't make time to do it. writing is one of those things for me, but i don't want it to be. it's just one of those things that's perpetually on my to-do list, and today i was like, i am writing a blog.

the task is sometimes overwhelming because the longer i wait to write, the more i don't know where to start. so much has happened since last june, in my personal life, and in the larger world as a whole. some quick snapshots:

• the 2008 american presidential election (yay obama!)
  
• finishing my 4th year of medical school with an emergency medicine at Henry Ford Hospital in the city of Detroit,
• attending the International Federation of Medical Students' Associations General Assembly in Jamaica
• meeting up with Liz and Suhani for a weekend in Denver (and having breakfast with Alex and her fiancee Matt)
• going back to the Ford School for my final year and making some new friends :)
• welcoming home the newest member of our family, a miniature schnauzer I named Yoda, from a local rescue
• surviving the madness of interview season, emotional roller coaster waiting to be offered (or not be offered) interviews, scheduling travel to and from the airport, thirty flights in a little over thirty days, crashing on friends' couches, loving/hating places i didn't expect to, keeping an open mind, testing my small talk skills, the finality of the rank list, waiting waiting waiting...
• chris joining me for weekends in new orleans, seattle/portland, and christmas holidays in baltimore/dc, exploring new places, falling in love with new orleans, the prospect one exhibition, the lower 9th ward, the devastation of katrina, rebuilding and ghosts and roots and houses, and understanding a little more about catherine and her love and her life there!
  
• spending three weeks in South Africa, first time to the continent, two weeks helping to teach a STATA workshop at university of capetown, living in a dorm again, connecting with new people, mountains, oceans, animals, confronting poverty and racism and hope, one week traveling with Chris in Kwazulu-Natal, more on this later...
• trying to keep up with working out at fitness together (the personal trainer/fitness studio), losing close to thirty pounds in a year! and feeling good about myself!
• spending a lot of time at caribou coffee and having an elderly man tell me my smile was a gift :)
• the requisite AMSA stuff, being chair of the Global Health Committee again, and being excited about the future of AMSA and helping people go abroad and find their paths and dreams!
  
• realizing i'm going to leave michigan after six years and being happy and sad about it all at once! yesterday we spent time with a lot of different friends here - breakfast at northside grill with michelle and brian debbink, lunch with rollie and meena, cora's first birthday party at emily and ali's (and chatting with paula anne and kevin), joey's birthday with all the fitness together trainers, and coffee with nick (chris's coworker) and his gf joanne. i was like wow, we have a great community, and we're leaving! but it's totally time too!

so this is my first blog and im excited to be back!