Good to Be Home

After five days in the desert, two at home, and four in Charleston; two flights on Southwest Airlines (one with peanuts, one with Oreo ChocoStix), two flights on American Eagle ($2 for nuts, $5 for a pillow/blanket), one flight on US Airways Express and one on Mesa Air/America West Regional/US Airways (which included George Foreman!); two rented cars (Chevy Impala and Ford Focus); and tons of restaurant food, most of it fantastic, I am finally home. I'm such a boring person, I really prefer to be at home, where I can sleep when I want, eat on my own schedule, and use my own bathroom. I really like using my own bathroom, especially since my stomach was upset the entire time I was in South Carolina and I was forced into some unsavory restroom facilities. For some unknown reason, my whole abdomen swelled up until I looked about six months pregnant. Fortunately, it has since deflated and I feel much better (thanks for asking).

And now, I'm ensconced on my couch, watching some crazy sci-fi show that my husband loves (and it is actually kinda cute). We took our dog to a big park today, then brought home some Boston Market. I doubt we'll even watch the ball drop.

And I'm happy as a little clam to be back in my little world.

Update

Travel, travel, travel. I just spent 5 days in West Texas with my dad's family and my grandmother (eating lots of Rosa's and Taco Villa, the world's greatest fast-food Tex-Mex). Back home Christmas Eve, spent Christmas with my wonderful hubby, then today I'm flying to Dallas and tomorrow to Charleston, SC for a short vacation with my aunt and my seester, a recent college grad with honors.

I really have nothing exciting to say, so Merry Christmas, Happy New Year, or Happy Whichever Holiday you celebrate!

PS- Best quote of the day: "I'm 100% genuine fortified!" (from the Dog the Bounty Hunter commercial on A&E). Pure brilliance.

Ambrosia

I don't remember when I started eating this soup, but I was very young. It's always been one of my favorites, even though most other people in my house thought I was nuts. It has a warm, rich broth and is FULL of salt, which to me is one of the best parts.

Today, I was post-call and sniffly. I've had a scratchy throat and post-nasal drip since Friday. I didn't feel awful, necessarily, but I didn't feel good, either, and I felt just bad enough to whine a little. Well, hopefully only a little. My intern let me come home at 7 this morning since we'd already presented my patient to the attending and, um, since I whined a little. (Actually, it was non-verbal whining. You know, the well-timed sniffle or cough, the oh-so-pathetic offer to stay and help out in that annoying scratchy voice.) I came home and slept for 5 hours in my own bed--much better than the sofa I slept on last night (although I was glad to get that sleep, sofa or not). When I woke up, I knew what I wanted to eat for lunch. Only one thing would coat my scratchy throat and go down easily, and I would accept no substitutes.

While my soup was heating, I was thinking to myself "you know, this stuff has absolutely ZERO nutritive value. It's basically salt with beans." So I decided to read the label on the can. I realized that in at least one aspect, I was definitely wrong: the label declared that one serving of this soup contains 8 grams of fiber, or 32% of the daily value. By comparison, one serving of oatmeal contains 4 grams of fiber. I was shocked. Then, looking further, I realized that there were 2.5 servings of soup in this can; therefore, there are 20 grams of fiber, or upwards of 75% of the daily recommended fiber allowance.

I concluded that I will spend a large part of my day tomorrow in the fourth floor student library bathroom at the hospital. It was sooooooooo worth it, though.


Speaking of fiber, if you're ever interested, go check out your local medical book store. There, you can find pocket laminated cards with various types of information: EKG's, Spanish, ACLS, and fiber. Yes, this company sells pocket cards with information about daily fiber intake and amounts of fiber in various foods. Just in case you ever wanted to know...

Interns

Interns come in many shapes and sizes, as well as all levels of skill. Some interns are FMG's, foreign medical graduates; some were even attending physicians in other countries before coming to America. Some FMG's really suck; some American-trained interns really suck. Interns are like a box of chocolates: you never know what you're going to get.

My half of the team currently has two interns: one from Chicago and one from Europe. I'll call them C and E respectively. I am drawing no conclusions about their abilities based on their places of origin; I am simply trying to identify them in an anonymous fashion.

Intern C is efficient but rather bitter. It's funny bitterness, and not directed toward students, so I don't mind so much. He's pretty good with patients, likes to teach, and doesn't mind when I ask a million questions of him or of the patients. It's easy to get into "complain" mode when I'm around him for a length of time, which is my only real complaint (and it's not a strong one).

Intern E is almost entirely the opposite. He's a nice enough guy, new to this country. Since he's a recent immigrant, I expect things to be difficult for him in some ways: just learning America is tough, let alone American medicine or Texas (an entirely different proposition). However, he seems to think that students are his personal assistants, like we exist to do his work. If we don't do his work, or don't take patients with him, his work doesn't get done. He also makes decisions about patient care, after the attending has made his plan, without consulting the upper-level resident or the attending. Case in point: attending (an oncologist) makes a plan to consult pulmonology on a cancer patient with possible respiratory stridor. After attending leaves, E decides the patient doesn't really have stridor and therefore doesn't need a pulmonary consult. He didn't discuss this with anyone, so today when the attending came, this patient with a potentially life-threatening condition (if she really has respiratory obstruction due to her tumor) did not receive the consult he'd discussed with the team.

My attending, a very soft-spoken, nice man, has a side that I had suspected when I first met him. He is the nicest guy possible unless you obstruct patient care, and then he gets very angry. Politely angry, but angry nonetheless. While I continue to feel that some of the tests we order are not terribly necessary, he makes the decisions, not me--I'm not the boss (although I'm definitely bossy). He's willing to go to bat for the consults and tests he orders, he's made himself available at all hours to his residents and interns, and he's willing to come to the hospital at any time. One reason he orders so many tests, also, is he has worked at many private hospitals and is highly offended that the county hospital would treat patients any differently--I understand that, too. I respect the man, and I've seen residents politely debate (for lack of a better word) ordering certain tests or consults with him--he listens closely, and if they have a good reason for their opinion he gives it consideration. There is NO REASON to go behind his back and just not do something because you suddenly disagree with the plan.

I feel kind of bad that I've quit taking patients with E, because stuff doesn't get done on his patients. He doesn't listen while the attending is giving the plan, and expects the student to know everything that's supposed to get done. Never mind the fact that the plan is written in the attending's very thorough notes (it's part of why we round for so damn long every day)--he can't seem to be bothered to listen or go back to the chart to copy down the plan. The other student on my half of the team agreed, saying she didn't want to babysit him all the time.

He also gave me a little "lecture" the other day on patient care: "It's not your job to get the social stuff done, it's your job to get the medical stuff done." This on a patient who remained in the hospital overnight simply because he couldn't be bothered to write "d/c home" on her chart--I had to get the other intern to write it for me the next day at noon when she was still there. He had gone to see the patient after I paged him to tell him the wheelchair would be delivered to her home, and that she would be able to borrow one until then, so she could go home right away--since he'd gone to see the patient to tell her she'd stay overnight, I know he was still at the hospital, and I know he wasn't just being lazy, so what the bloody hell was he doing??

I think I want to try to talk to him first, or perhaps Intern C, but I'm unsure of what to say. I've thought about talking to the upper level resident, or the attending, but I don't want to do that just yet. I also know that I'm a know-it-all, and it must be annoying to have some smart-ass student always thinking she knows better than you, an actual MD. I don't want to offend him further. I'm really concerned that I'm going to say something that will get me in trouble, though, if I continue to be this frustrated. How in God's name do you not check the vitals on a patient with bacteremia and suspected endocarditis??? I feel like I could help his patients if I took some of them, but at the same time I don't want to cover for his ass.

I'm much too grouchy lately to be a doctor. Sometimes I think the only people I'm nice to are my patients and occasionally my long-suffering husband, who has heard me bitch WAY TOO MUCH about this situation. I'd better go kiss him to try to make it up to him.

Favorite Time-Wasting Spots

Since I have nothing better to talk about, I'm going to briefly talk about my favorite blogs & places to waste time on the internet.

• The Underwear Drawer: My first blog, my first med student blog. Michelle is now an anesthesia resident with a toddler and an ophtho resident husband. I periodically go back and reread her student-era stuff because it reminds me that other people feel the same way I do during med school. That, and I am a huge stalker.
• Ah Yes, Medical School: One of the funniest and most bitter of the med school blogs. Posting under "the Fake Doctor", this California student has written some stuff that caused me to need to wipe off my monitor because I spit all over it while laughing my ass off.
  
• The Fat Doctor: "Famine-resistant doctor, pastor's wife, stroke survivor, singer in the church choir, mom of one toddler and two dogs, cynic and active daydreamer." Funny, poignant--an excellent account of life as a family practice doc.
• UroStream: A female urologist describes life as... a female urologist. Hilarity ensues.
• Medstudentitis: Inflammation of the med student, or the blog of a Canadian student in her second year.
• Fingers and Tubes in Every Orifice: An ER doc details life on the front lines of medicine: the drunks, the frequent fliers, the lawsuits, the lives saved and lost.
• The Berry Patch: A med student in Israel talks about her cat, buying kosher cat food, and the differences between living in America and living in Israel.

One reason I read so many student blogs is for solidarity--even across different countries, many of the experiences are the same. The frustrations, the huge piles of books, the pain of shoving information in your brain ("drinking from a fire hose"). I read "grown-up" blogs because it's nice to hear from those who survived, who walked through the fire and came out the other side. I read some others, but I'm too lazy to type about any more blogs.

Shorts

• Driving to work at 0630 sucks because it is dark and early, but traffic is nil. Driving to work after 0700 is nice because it's actually light out, but traffic is remarkably thicker.
• Homemade fudge is super tasty.
  
• Being on call sucks.
  
• When on call, it is entirely possible to sleep comfortably on a chair, in my white coat, with full pockets, under a thin hospital blanket, wearing a hat, in a room with multiple people walking in and out and a television on mute.
• Brushing your teeth at 0445 after a night in the hospital and 3 Cokes is only temporarily refreshing.
• Two packages of stale Saltines from the hospital "Nourishment" closet are wonderfully sustaining while on 5 hours of rounds.
• Hearing from an old friend first thing in the morning over AIM is the best part of waking up.
• I love my tiny Christmas tree.
• 40 degree weather here feels colder than 12 degree weather in the Rocky Mountains. I am also a huge wuss.

I am totally NOT creative while post-call, even after 4 hours' sleep in the hospital and a good nap this afternoon. Hopefully tomorrow will be a bit more inspiring.

Crabby

Sorry to be such a grouch. Today wasn't nearly as bad. I think the real thing about my attending is that he is inconsistent: he treats some patients fearfully (let's order everything under the sun) and some with confidence (I know what they have and I can treat it, and they're well enough to go home). I love it when patients go home, and I have less work to do. (Kidding!) But it is a good thing when patients go home. The county hospital is definitely aromatic, and with 4 patients per room, separated only by curtains, very noisy as well. I wouldn't wish a prolonged stay in the county hospital on my enemies, let alone my patients.

Currently watching: the AKC Dog Show, Part II. My hubby has a real soft spot for these shows. I will totally confess to loving to watch beautiful, happy dogs prance around for the audience. Speaking of dogs, our dog is located on the papasan chair, buried under a pile of thick blankets with only the tip of his nose poking out. I really ought to take more pictures of stuff like this, so then people will have no doubt that I'm a crazy dog lady.

New Attending

My new attending for the month started off well. Tall, soft-spoken, I'll call him Dr. C for "Castilian"--I think he may be Spanish. He didn't place a lot of demands on the students at our meeting--he even said we could choose to write H&P's. We're finally allowed to do long and short call--every other call, I get to go home in the afternoon. He made an arrangement with the residents to come to the hospital at 5 pm on call days, to round on the earliest-arriving newly admitted patients. It all sounded well and good. He's new to our school and this hospital, but has worked in our hospital district before.

Today, we were post-call. I woke up at 0430 so I could get to work by 0530 to round at 0630. At 0445, the other student paged me to say that the attending had changed his mind--we wouldn't round until 0730, and the other half of the team would go first. I got a wee bit more sleep, finished my H&P (I only had one new patient), and got to the hospital by 0700. Between vitals, seeing patients, and writing my note, I was ready to go by about 0800.

The rot set in by 0930 when we still hadn't begun to round--Dr. C was still with the other half of the team. We finally began around 1000. For some reason, Dr. C insisted on seeing the patients he'd already seen the evening before, as if he'd never seen them before. What, then, was the point of him spending so much time there the evening before? He also started ordering multiple tests on patients that were maybe not so necessary (like a D-dimer on a patient with chronic chest pain, most likely related to GERD). One of my patients had a cough and a fever, with sputum production and some hemoptysis. His CXR showed an upper lobe process. My diagnosis? Pneumonia. My attending, for some reason, started worrying about fungus balls, and ordered a stat CT of the chest. What did the CT show? "Ground-glass opacity in the upper lobe"--the radiology resident told me "if he clinically has pneumonia, then he has pneumonia, honey". This CT gave us absolutely nothing that would help us. The patient wasn't severely ill, he's responded well to antibiotics overnight, he's not requiring oxygen--did we really need to start chasing zebras? I was finally dismissed by one of the interns at 1400 (well past the 30 hour rule for the rest of the team--at least I'd gotten some sleep).

I'll make the "I'm lazy" argument--I don't like chasing tons of labs. I'll make the "primum non nocere" argument--every test has risks to the patient; nothing is totally benign. I'll make the statistics argument--every test could be falsely positive or negative. My old attending, Dr. H, railed at us about "pre-test probability"--clinically, how likely is it that the test will be +/-, and then order those tests which will change your therapy. Now, I know why he harped on us about this.

Another thing. If a residency group is going to enforce the 80 hour week/30 hour shift rules, the attending should take care not to round for so long that 30 hours comes and goes while the team is still rounding. If you get there at 0600 on call, then you *should* be leaving by noon the next day. We should not be rounding until 1400. This is how residency programs get in trouble (when this stuff happens all the time--let's hope this was a one-time thing).

Damn, now I miss Dr. H. Sure, I was terrified of him, but he used rounds to direct patient therapy and to teach. Rounds today had no purpose; we did a lot of sitting while the attending wrote lengthy notes on each patient, then asked every patient if they had any breast masses and when their last breast exam was (even the men). I realize his specialty is heme/onc, but still. Another Dr. H-ism holding true: "Pick your specialty and you'll pick your disease."

Between the agonizing long rounds (until 1400 on a post-call day) and my new, disorganized, slow intern, it's going to be a pitiful 2 weeks.