friends and family

to take a break from writing about work life, i'm recounting some moments where i've felt like a normal person over the past few months, which generally involves connecting with friends and family on my precious days off. although im on vacation now with chris in bangkok (yay!), i normally get one day off every 7-8 days while im on the wards or in the icu. im often tempted to sleep the whole day, but then would waste an entire day off and miss spending time with chris, so lately i've been more proactive about seeing people and doing things. this has been helped by the fact that a lot of friends and family have visited over the past few months, including:

rollie and meena from michigan! our first real houseguests, they cooked us amazing vegetarian meals like dutch babies (pancakes, not people) and enchiladas. in turn, we took them to the inner harbor where both me and meena got food poisoning from phillip's seafood. crab mac and cheese sounded like a great idea to begin with, but didn't turn out so well in the end...

meeting up with judy, a fellow swattie classmate in dc, who invited us to a "crafty bastards", a local diy craft fair which also showcased a breakdancing competition. one of our fave booths at this fair was mean cards ,a collection of hilarious cards for all different occasions. judy regaled us with stories from her days of intensive russian language learning at USAID, while i ate ice cream and drank coffee and whined about intern life.

sleepover with sae-rom, a fellow AMSA GHAC'er who's spending a year at Hopkins School of Public Health and is never in town, ever.

catching up with liz and andrea in dc, who came out for the annual GLMA conference. we mostly just hung out in dupont circle near the fountain, but it was great to catch up with some michigan peeps. i've also run into former classmates at bayview, including having a late night coffee with carl miller while he was on nights in the radiology reading room, and catching a short conversation with christina weng, who kindly came to do an ophthamology consult while i was in the CCU.

going to the sauna in columbia as rachel, a co-intern's guest. chatting and drinking ice cold water out of bell jars that rachel provided.

eating a post-call early dinner with mary (friend from high school) and her boyfriend tom, before they ran off to virginia for a peace corps friend wedding.

hanging out with matt alemu, a ford school classmate, who kindly drove out to visit us to play wii with chris :) .

having my family over and taking them out to eat chinese food, thai food, italian food...yoda remembering them and being super excited! (they came to pick him up to dogsit him while chris and i are on vacation in bangkok).

snapshots of intern life

i was really good about writing for awhile, but then fell off the wagon when i started my first month on the wards (general medicine inpatient service) and then went straight from there to the cardiac icu. i've taken care of a lot of patients during that time, and had some real ups and downs, but i've also realized that i'm becoming a lot more competent and don't totally panic whenever i get a page in the middle of the night, which is a real improvement.

i've also gotten more used to my schedule, and realized it was a sad day (or perhaps a happy one?) when I got out of work after being there for 12 hrs and was rejoicing because I was going home early. mind you, the only reason i realized this was because i called chris and he was like, "um, i thought early was like 4 pm or something, not 6:30." grrr chris and his normal job! at the beginning of intern year, i did harbor some resentment against chris for working a third of the hours and getting paid disproportionately more money, but i am pretty over it and am thankful that he's able to entertain himself on my call days by doing various home improvement projects, like painting and installing recessed lighting. i also really appreciate that he drives me to work on call days and picks me up post-call so i don't have to drive after being up for over 30 hrs!

speaking of being up for over 30 hrs, i feel like call is when i really get to bond with a lot of people, including not only my fellow interns and residents, but also nursing and other ancillary staff, and finally, with patients. while on the wards, we take call every 4th night, which means that as an intern, we'll admit five patients to our service over the day and serve as the primary physician for that patient until they're either discharged from the hospital or transferred to another service.

because so many of our patients either don't have insurance or are really underinsured, their health care can often be really fragmented. as an inpatient, case managers, social workers, and medical staff attempt to bring about a smooth transition to outpatient care, but things don't always work out. this can be because a patient doesn't show up for follow-up, but that can be for so many reasons, like they didn't have a ride, or didn't have the money for co-pay or whatever. i've also been impressed by a serious lack of primary care among our patients, and tried to use the connections i make with patients to establish primary care relationships with them when possible.

one patient that i really hope to see in clinic soon had a pretty terrible infection that started in a joint and spread to the blood. patient X also had a bunch of other complications from the original infection, which required long-term intravenous antibiotics. a lot of times people can get a PICC line placed and go home and get their IV antibiotics, but if you have a history of drug abuse, that's usually a no-go. this is interesting to me, because if you don't have a urine toxicology screen that's positive, the only way you would have this kind of information is if the patient discloses to you or you have some old records documenting this (or you can just be suspicious, given their own history if there's complications related to drug use). in any case, if you are an IV drug user, you don't get home IV antibiotics because there's a fear (likely well-founded) that you'll inject illicit drugs into your central line (which goes straight to your heart). this also means that in order to get IV antibiotics, you have to go stay in a nursing facility instead of going home for up to months at a time, depending on the length of course of your particular antibiotics.

this particular patient totally denied past IV drug use, but later admitted to it when a complication happened that's more often than not seen in drug users, although it probably wasn't related in this person's case. because she had so many complications, she ended up being re-admitted to the hospital a few times during my month ont he wards and i got to spend some time with her, sharing her frustrations at failed treatments, or setbacks in the road to recovery. when we finally got to discharge her home, she asked if it was ok to give me a hug and thanked me for not just taking care of her, but also really caring about her, which was totally great.

ive had lots of little moments like this throughout residency so far. sitting with an italian immigrant patient an talking about where our families are from and who makes up our family now and listening to him talk about how he used to go dancing in the city. taking a break from writing history and physicals with a co-intern to watch music videos together on youtube 20 hrs in to a 30+ hr shift. holding a patient's hand when he requested to be taken off oxygen so that he could die peacefully and with dignity, without noise, without machines. saying goodbye to another patient who had been through so much in his fifty years of life, and feeling sorry that i'd never gotten to buy him the fried chicken that he'd asked for, feeling even sorrier that he couldn't eat in the last two weeks of his life. a unit secretary feeling sorry for me as i fell asleep at a computer and bringing me a fresh cup of coffee that she'd fixed at 4 am. feeling proud of myself when i got an arterial line on my first stick, feeling bad about myself when i couldn't thread a central line, and a little less bad when the resident couldn't do it either. seeing people suffer and recover, and really respecting the strength of a lot of people in times of great distress.

i think that's what i've most appreciated about my intern year so far -connecting with people.

death and the icu

so, i haven't written in awhile, and im coming up on my last of eight calls this month in the ICU (intensive care unit). there are two icu's we rotate in as interns, the cardiac icu (CCU) and medical icu (MICU); this month i've done two weeks in each unit.

as my first inpatient month, the cardiac icu was a bit of a shocker. the first week, i worked 95 hrs and was a bit overwhelmed by the experience even if i wasn't super busy admitting patients. like learning a foreign language, it took a bit to get used to the EMR (electronic medical record) and ordering system they have at bayview, and figure out who to talk to to get things done. i have a better grasp of how the whole hospital works after a month, but im sure i still have a lot to learn.

i actually have really been enjoying critical care. one of my friends laughed when i told him this, and said "yah, the patients don't talk!" that's part of it, maybe, but i really like patients most of the time, and often, patients' families, some of who can talk A LOT.

part of being in the hospital so much as an intern makes me feel disconnected from what's going on in the outside world. even though i try to read some news websites while im at work, i am pretty much clueless about what's going on, including at first, all the talk about "death panels" in the media. i mean, it's pretty sad when i learn about death panels from someecards.com or rely on youtube clips like bernie frank's diss of this woman who compared obama health care reform to nazi germany to see how misinformed so many people are about what is actually going on. that's not necessarily the point of this blog though, so i'll stop here, and share some patient stories with you.

from the cardiac icu:

an elderly man was admitted to the cardiac ICU with a heart attack. our attending was excited because it might be a manifestation of stress cardiomyopathy, which can happen when people experience some kind of huge stress, whether it be a crazy surprise party or a death of a loved one. it ended up not being that, but i talked to him a lot anyway one morning when i went to check on him before rounds. his wife had passed away at home hospice a few weeks prior to his heart attack, and he was still in grief. he talked about how they had been married for almost sixty years, how she had made him happy, and how he hoped he had done the same for her. he also shared how proud he was of his daughter, who had taken both him and his wife in when he couldn't take care of his wife's needs as much anymore, and how they had all been there together when she passed away. then, he joked that nobody really wanted to listen to the ramblings of an old man anyway, and i replied that i did, if he wanted to talk. he decided that he wanted to rest, but thanked me for listening. he was later discharged from the hospital in pretty good condition, and i was really impressed with his daughter who was managing to keep it all together while her parents were nearing the end of their lives. i hope she gets to hear from him how proud he is, because she was a real patient advocate for her father, refusing tests that wouldn't change management and that would also make him uncomfortable. they had decided together that he did not want to be resuscitated or intubated (have a tube put down his throat and be connected to a ventilator) and i really think this is such an important discussion to have while you still have your wits about you and you can communicate what you'd like to happen with someone close to you.

on the flip side, from the medical icu:

a middle-aged man was admitted to the medical icu after being found down at a nursing home. it was difficult to piece together what exactly happened, but our best guess is that he had an episode of low blood sugar, causing him to go into seizures and eventually asystole (flat-lining). he was successfully resuscitated but never responsive. he ended up having continuous seizures for days before high doses of multiple anti-seizure medications could control them; his mri showed multiple infarcts (aka dead matter). he had no family, so a friend was located who eventually agreed to act as his medical decision-maker (aka surrogate). it's definitely a tough situation to be in, and we have not withdrawn care yet, even though the prognosis is really poor and he's being kept alive by machines.

and finally, i did experience my first death during a code, or resuscitation, in the unit. i didn't know a lot about the patient, but he was supposedly very functional, living and taking care of his wife with dementia, and his death was really sudden and a big shock to his family. he came in in a really bad way, and we all thought he was going to die, but then suddenly the curtain to the room was being pulled and the crash cart was being pulled in and the code was going, an X-ray was done and it came up with the lungs in complete white-out, blood was pouring out of the endotracheal tube, and it was over.

i've had patients die before, but for some reason, this time felt different, even if i wasn't his primary caretaker, and just participated a little bit in his care before he passed. we talked about dealing with death at one noon conference earlier this year and what stuck in my mind from that time was how often you just erase the patient's name from the board where you keep the census and then fill out the death certificate and forms and then that's it. that's kinda what happened in this situation; i followed my resident who told the family that their loved one had passed, there was crying, and then a short visitation with the body after he had been cleaned up by the nurses. then his name was erased from the board, and we went on doing our other work, rounding on patients, putting in orders, admitting new patients to the unit. later on in the night, we were discussing the case with another resident who came to visit, and i almost couldn't even remember his name when we were trying to find the X-rays to show him. i felt terrible about it for a second, but then i reminded myself that i only knew him for less than an hour, and what i did know about him wasn't anything at all about his life, but just his death. this was sad to me, but that's what sometimes happens in the unit, and i hope he is resting in peace.

my secret life as a psychiatrist

so, im on this rotation named 'med-psych'. i actually thought about doing med-psych combined residency and was thinking this month might be like that, but the name med-psych is somewhat of a misnomer. the month is more a combo of physical diagnosis rounds, lectures, simulated patients, reflecting on experiences, clinic, and some psych here and there.

psych was actually one of my most fave rotations in med school, so im happy to be doing some psych this month and learning about how the psych department interfaces with medicine as a consult service and what services are available both on the inpatient and outpatient side of things.

i was basically just oriented on my first day on psych consults, saw a patient with the attending, and then listened to social workers in the ER talk to the attending about cases. the next time i was back on consults, the attending was swamped, and asked if i wanted to see a patient on my own. of course, i said yes! it was my chance to be a true med-psych person for one day.

the consult was to evaluate a woman who had some chronic chest pain for anxiety. i fumbled through my disorganized papers and kicked myself for not having on hand the lecture notes on anxiety disorders that this same attending had given me a few days before. i was paying attention during the lecture, i swear, but it still helps to ground myself before i go to see the patient. in any case, i read some stuff quickly online, looked over the patient record, and then went off to see the patient.

when i entered the room, the nurse was giving some medication, so i just said "Hi" and waited for him to finish. the first thing the patient said to me was, "Hi! You're really beautiful." internally, i was like uh-oh, this could be trouble. after saying thanks for the compliment and asking how she was doing, i introduced myself as an intern with the psychiatry team. the patient totally flipped and yelled at me to get out, saying she did not want to see a psychiatrist, did not need to see a psychiatrist, and didn't want anything to do with psychiatry. i tried to clarify that i was not an actual psychiatrist (but was working with the psych consult team) and just wanted to ask her a few questions. the nurse had my back (yay!) and was like, 'why don't you just listen to what she has to say before you tell her to leave?' unfortunately, this was to no avail, and she kept yelling at me, saying she was going to sue the hospital, asking who had sent me, etc. i switched tactics and asked her if she'd had a bad experience with psych before, but she wouldn't respond. eventually, i ended up leaving, and the nurse was like, "well, you can't help people who don't want to be helped."

i was dejected as i headed back to one of the doctor work rooms to page the psych attending. i felt like i had failed without even trying, and wasn't helping out because i wasn't able to complete the consult. when i talked to the attending on the phone, she apologized for putting me in that situation and said that i'd done what i could do. patients who are competent have a right to refuse psych consults (or any other procedure) but i still felt like there was unfinished work to be done on her - i hope the primary team was able to sort things out.

after my unsuccessful attempt to see a patient alone, i accompanied the attending to see a pleasant man who was totally manic after he had been taken off his psych meds during a medical hospitalization. he was seriously talking a mile a minute, not making a ton of sense, and constantly on the move. the psych attending miraculously was able to get him to sign a voluntary commitment form for him to be transferred over to the psych ward after spending about 10 minutes with him, redirecting him at times, and just trying to listen to what he had to say (which was a lot). i hope he gets back on meds that help him get back to his baseline and he can go back to living in his pseudo-assisted living facility for people with chronic mental illness.

despite not having gone into psych , im happy i had a chance to do some psych consults this month and attend some psych lectures, which i've really enjoyed, except for an off-topic comment by one of the lecturers about how he didn't believe that accepting pens or other paraphernalia from pharmaceutical companies was a conflict of interest. "As if we were so easily swayed," he muttered. it was the end of the lecture and i didn't want to drag it into lunchtime, but under my breath i was like, "We totally are! And there's tons of EVIDENCE to prove that marketing makes a DIFFERENCE in physician prescribing patterns." and then i remembered from amsa days that the APA has a really terrible record of accepting all kinds of $$ from pharma and that ive rarely seen a pharm-free psychiatrist. oh well - have to choose your battles, right?

in conclusion, even though my med-psych month is ending, im sure ill have *tons* of psych issues to deal with in my own clinic (ive already had two patients with bipolar disorder) and also on the wards. more to come! :)

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'.