Milestone

Having finished the last shift of my intern year, I am now officially no longer an intern. Whew. That year was getting a little long.

Now comes life as an R2 -- a second-year resident. This year I'll be spending much more time in the Emergency Department, and if all goes well I will either pass pass the next step of the medical boards and get a medical license, or join the swelling ranks of California's unemployed.

Post-delivery comment

Sometimes birth can be a bit less than tidy. The other day I was doing a routine post-delivery repair when the new dad wandered down to the end of the bed and saw the aftermath. "Honey," he said, "you look like a Quentin Tarantino movie."

Whirlwind

The last few weeks have been a whirlwind, but -- unusually for this year -- in a fun way. EM conference in New Orleans, wrapped up a delightful rotation at the VA Hospital (I love working with the vets), then a much-anticipated week off, most of which I spent in Puerto Vallarta with N and her family. Currently whiling away the weekend in Palo Alto at a wedding, then I start my OB rotation on Monday; time to deliver some babies!

I can hardly believe that I'm only a month away from being finished with intern year; R2 year (i.e., second year of residency) starts on July 1. It's reported to be more difficult in some ways than the year I just finished, but at least it will be mostly spent in the emergency department, where I want to be.

Showing off

I'm in New Orleans at a conference, posting this from my brand-new iPhone -- just because I can.

Touch of the flu

First day back from vacation, and it comes as no surprise that the big topic today was swine flu. (Phrase of the day from morning conference: "death clusters.") We activated the negative pressure room, reviewed CDC guidelines, argued the merits of various antiviral strategies. Numerous worried patients presented, and several healthcare providers were armed with the heavy-duty face masks we use with tuberculosis patients. Meanwhile I'm trying to remember whether I got my flu shot this year....

Reno 911

Posting from Reno, where I'm taking my advanced trauma life support class. Most of the folks in the class are practicing emergency medicine docs and PAs, but even as a lowly intern I feel like I've been able to hold my own. Kind of a confidence-builder, actually. Hmm, perhaps during the past ten months of brutally intense training I've managed to learn something about emergency medicine.

Vacation, all I ever wanted

Haven't had a vacation since September, and -- finally! -- I've got another one coming: I have next week off. So after work today I'm going to rent a car and drive to Reno. Why Reno? Because I get to spend the weekend of my first vacation in seven months taking a required two-day trauma course. In Reno. Yes, I get to leave the hospital for my vacation and keep working! But I'm not bitter or anything.

I just love being an intern....

There's no "U" in "team"

I've been on an anesthesia rotation, where the other day I heard a surgeon say to the surgical resident, "We have to work as a team here. You need to do exactly what I tell you."

Exact fare

I take the night buses a lot to get to shifts. The other night I saw a gentleman get on and wave a $10 bill at the driver as if it were a bus pass. He then nonchalantly walked to his seat and the driver never said a word. Wonder if that will work for me...?

Sick

When I showed up for my shift this morning, my attending examined me, called in some prescriptions to a nearby pharmacy, and then sent me home. It was the first medical care I've gotten since being an intern, and it really meant a lot to me. And I'm feeling much better. Now let's see if I can get through tonight without spiking another fever.

Last rites

There are many different consulting services to call when you're on duty in the hospital, but when you call the chaplain consult pager it's not usually going to mean a good outcome for your patient.

How long have you been here?

Today one of my patients observed that I had been in to see him yesterday morning, then again in the late afternoon, then again overnight, then again early this morning, and now he was seeing me in the afternoon today. He asked "did you work the night shift?" but then realized the explanation was that I'd simply been there all along. At that point he started talking about how he wouldn't get in a cab driven by someone who'd been working for more than 10 hours, and I figured it was time to redirect the conversation.

I guess I can't complain. I did manage to get 30 minutes of sleep during my 30-hour call. But it does get a bit grueling. And now off to bed, to get some sleep before the cycle starts again tomorrow morning.

Goodbye cruel world

Tomorrow is my first Medicine call. I'm sure the next day-and-a-half will fly by....

Musicomedical nerdery

Here's an item for those of you who are fortunate enough to be nerds in the fields of both music and medicine. I recently pulled out my old violin to amuse myself with some bluegrass. I don't have anyone to play with at the moment, so I was playing along with recordings and needed to be able to tune my fiddle to a real pitch. (Sadly, my once excellent sense -- if I do say so myself -- of relative pitch has faded with years of disuse.) However, I don't have any other instruments with me at the moment; no keyboards, electronic tuners, not even a pitch pipe. Luckily, I recently did a rotation on the Neurology service and had the tools handy that are used for testing patients' vibration sense: tuning forks! Good patient care and a violin tuned to true pitch; it's a win-win.

At the opera

In my past life as a musician I've spent a lot of time in theaters -- I've done my time onstage, backstage, in the orchestra pit, and behind the scenes. However, last weekend I had a chance to see a new aspect of theatrical life. One of the faculty in our program is house doctor at the San Francisco Opera, and he took me along to house call for La Boheme. We hung out in the actor's lounge ready to deal with any sore throats, sprained wrists, or broken ankles that might arise. Fortunately it was a quiet performance, medically speaking, but it was also a nice reminder of the diverse sort of opportunities available in emergency medicine.

On-call Liveblogging: Thanksgiving edition

And here it is, Thanksgiving evening heading into night. Managed to send holiday wishes to only a few friends & family -- apologies for not being better in touch with everyone.

Kind of a crazy day today. A lot of labs and offices were closed or slow, which put some pressure on the clinical side. Not sure how tonight will go, but there'll be some cleanup to do tomorrow.

The hospital gave us meal tickets for turkey in the cafeteria, so I managed to get a Thanksgiving dinner with only the pie interrupted by a page. Rumor has it that there's some pumpkin pie in the resident room, so I'm strongly motivated to head over and, um, write a clinical note. Or something....

Who is the president?

During the course of cognitive decline patients will tend to maintain their interpersonal functioning until the very end; it's famously said of dementia that the social graces are the last to go. In fact, it's surprising how often a patient will be able to converse fluently and pleasantly, but when asked directly is entirely unable to say what the month or even the year is.

Of course, to provide appropriate treatment it's important to accurately assess the extent of cognitive deficits. A question traditionally asked by psychiatrists and neurologists as a quick bedside test of the patient's awareness of current events is "who is the president?" If you can't answer that, it's a pretty good sign that you're not well engaged, for one reason or another.

However, this question has become more and more difficult to use over the past few years. Asking it would often provoke strong but non-medical opinions. This was particularly true during rotations at Veteran Administration hospitals; vets would frequently become quite agitated at the topic. I remember that early in my training, say in 2004, this was a routine question during neuro and psych histories, whereas now I hear it used infrequently and rarely ask it myself.

However, from time to time doctors fall into the old habit. The question slips out, and there's a moment when the rounding team holds its collective breath: are we going to have to take several minutes out of a rushed rounding schedule to head off a patient's (or clinician's) political polemic? But that seems to have changed this month. Evidently the election made quite an impression on a wide range of people. Several times I've seen patients who were minimally conversant, but when the recent election is mentioned will become more alert and are able to recall names and details.

Maybe I'll start asking my patients a question that seems to be both diagnostic and therapeutic: "who is the president-elect?"

The thirteenth hour

I'm on again overnight in the ED for Peds tonight after a colorful but relatively non-disastrous Halloween last night. (One of the nurses was wearing an enormous bouffant wig with a flower in it, and it actually looked pretty good on him.) However, earlier Lady M reminded me that we go off Daylight Savings Time tonight, which means that the 12-hour shift turns into a 13-hour one. Usually the time change means an extra hour of sleep, but whaddya gonna do?

Recovering from sudden death

Recently I've been involved in the care of two patients who were in the hospital after dropping dead. Literally.

In each case there was somebody on the scene who started CPR almost immediately. They were taken to the intensive care unit, treated with a cooling protocol, and are now able to look forward to resuming their lives with intact personalities and nearly intact physical functioning. And although they received interventions that didn't even exist all that many years ago, the reason that both of them are now able to spend time with their families is that when they hit the floor someone was able to start chest compressions.

During morning rounds on one of them it was mentioned that the patient was somewhat confused and emotional. The attending physician commented "that's okay, it's expected; she's still recovering from her sudden death."

One lump or two?

These days I've been rotating on Cardiology at the county hospital. Call nights require careful planning, because the cafeteria closes at 7:00 pm and that's it for food or drink (think coffee) for the rest of the night. So the other night I managed to make it to the cafe at 6:55 and stocked up with a couple of bottles of Gatorade, an apple, and a cup of sweet, consciousness-giving cafeteria coffee. As I'm balancing all of this in my hands and heading back to the resident room there's only one obstacle in my way -- a door with a security keypad. I managed to punch in the code with my free pinkie, but the weighted door swung back into my other arm, launching half of my coffee onto the shoulder of my white coat, staining my reference books and patient notes brown, and soaking through my scrubs underneath. I quickly cleaned up as best as I could, desperately hoping that the code pager wouldn't go off while I was half undone, but I was stuck with a warm, moist spot, a huge brown stain on my coat, and a lingering coffee aroma for the remaining 17 hours of my call. By the end of 30 hours of call I'm never feeling too fresh, but I was particularly bedraggled by the end of that one. The worst part was that every time I talked to a consulting doctor, a nurse, or a patient, they stared at my shoulder, no doubt wondering what vile body fluid had splashed on me.