Getting Busy

...with my fourth year to-do list. (I know what you were thinking! Naughty!) Here's what I have on my plate thus far:

1. Ambulatory Medicine rotation in November--location TBD
   
2. Step 2 CS on November 5
3. December: Interviews on the 3rd, 4th, 7th, 10th; Step 2 CK the 19th, interview in Colorado on the 21st, so we're spending Christmas up there with various family afterwards
4. Sub-internship in pediatrics in January--location TBD (could be county hospital, which will be asthma, or big hospital, which will be peak-RSV season with no patient caps and HELL)
5. Submitting rank list in January
   
6. Elective in February--currently Infectious Disease, but as my senioritis increases, I will probably switch to something like Diagnostic Radiology, where the hours are more like 9-noon.
   
7. March--Required senior stuff, Jurisprudence exam, MATCH DAY!!!, etc.
8. April--CHINA!
9. May--sitting on a beach drinking. Or possibly moving, if we have a house by then.

I may cancel some of those December interviews, especially if I hear from Top Choice Program. If somehow my letters don't make it in, or I don't get an interview with them anyway, then I'll keep most of those interviews. I had planned on picking from three potential local programs; I may have to choose from the two I've already heard from. This would not be the end of the world, and if I end up in a program where I'm really unhappy I can always try to transfer next year.

My hubby and I had "The Talk" the other day. I laid it out: should I rank programs outside our geographic region, and risk matching elsewhere, which would mean long-distance relationship and hubby finding new job? Or should I only rank programs in the geographic region and risk going unmatched, which means I'd have to scramble for a PGY-1 preliminary Medicine (or Surgery, shudder) year? After some consideration, he decided that it would be difficult for him to find a job elsewhere, and likely it would not be as good a job as he currently has. Neither of us wants to do long-distance again (2.5 years was enough!), so I think the verdict is that I will only rank programs in our region (and possibly Colorado).

When I expressed my slight discomfort at the idea of only ranking 2-4 programs, he laughed at me. What I see as a risk--going unmatched--he doesn't see. It's nice that he has such faith in me, but I can't turn off the anxiety that easily. Nor can I just assume that "well, of course I'll match within those programs! Who wouldn't want me?" Thank goodness psych isn't terribly competitive, so my chances are actually pretty good of matching; faced with the same decision in urology, I was sweating bullets from about January to July. It's not the reason I switched, but it's certainly a bonus.

It is nice to make the decision, and even nicer that we could make the decision together. Look out, world, in only 7 months it'll be TS, MD!

Super-Frustrated

I requested three letters of recommendation back in July and August of this year. One is from a psych attending at my school whom I've worked with twice; one from a psych attending on my away rotation; and one from a pedi attending I worked with last fall. I made sure they all had the ERAS cover letter (where I waive the right to read it, yada yada yada, and the address to my school is on it), my CV, and my personal statement.

By September 1, I still had no letters in ERAS, but I turned it in anyway. Interview offers started almost right away; I've now heard from 9 of the 10 programs I applied at, and all 9 offered me an interview. Several of my offers came in without any letters of recommendation.

By October 1, I started to panic a bit. After all, my first interview was October 19, and generally you are supposed to have all of your letters in before interviewing--I had none. My school sent out an email saying that several letter-writers had called to say that their letters had been returned, so to check with our letter-writers if letters hadn't arrived. I dutifully forwarded that letter to all three attendings.

One attending, the pediatrician, called me that very afternoon, confused. She'd prepared my letter in August, shortly after I asked her, and had confirmed with her secretary that it had been sent. Was I saying it hadn't arrived? Yes!, I said with great relief. I faxed her secretary a new ERAS cover letter, and she had someone walk it to the dean's office the next day. One down! TS 1: letters 0.

Emboldened by my success, I called the away rotation attending. I asked if she had any trouble sending my letter, as another one hadn't arrived properly. She hesitated, then said well, I hadn't gotten around to sending it yet, so sorry. Oh, uh, that's no problem, I stammered, fully feeling like an idiot. She promised to send it soon. TS 1: letters 1.

Two weeks later, still with only one letter in ERAS, I grew desperate and called the third attending; I left a message for her. She emailed me that night--I'm super busy, the letter is done, but I've misplaced the ERAS cover letter. I promptly faxed her another. That was a week ago. TS 1: letters 2.

This week, as I continue to check my email and ERAS obsessively (like, every 10 minutes when I can), I realized that I can't keep that up forever. Therefore, I decided to give them another couple of weeks, and try to contact the attendings mid-November, in order to get things moving before my December interviews.

The last program that I haven't heard from is my top choice program (pre-interview). While perusing their website and FREIDA tonight, I got startling news: their deadline for completed applications is November 1, 2007 (the date the dean's letter is released). Now, I'm in full-on panic mode, totally freaking out, chewing my fingers, etc. I just emailed the two attendings in question and laid it out for them. Look, I need my letter, do I need to come get it from you in a sealed envelope? Do you need another ERAS cover letter? WHAT IN THE NAME OF GOD DO YOU NEED I WILL DO ANYTHING BUT YOU ARE COSTING ME MY TOP CHOICE PROGRAM!!!!!!!!!!!!!!!

*is trying not to hyperventilate and seriously considering drinking wine tonight to calm down*

So, I have 6 days to get 2 letters scanned into ERAS or I'll never get an interview at this place. This effing sucks, people. For pete's sake, if someone asks you for a letter of recommendation, please do not take 3 months to get it turned in! If you can't do it, just say no!

*Author's Note: Please see the follow-up post here, where I apologize for being so whiny and continue to thank my letter writers for helping me out, despite my being a whiny, anxious little whiner.

The Mating Ritual

I sat there nervously, twirling my hair on my fingers surreptitiously. I was nervous, meeting someone new. I just knew he was going to ask me tough questions. How should I respond?

I'd dressed carefully, styling my hair, applying makeup, pulling on pantyhose and heels. Naturally, though, my hair had frizzed out, and I felt sweaty after walking in from my car. Our meal had been delicious Tex-Mex, but I could feel the beginnings of heartburn above my tight-waisted skirt. Was I shaking? Did I have a run in my hose? Were there any stray pet hairs on my outfit? Any lip gloss on my teeth?

He didn't really look nervous. He'd dressed up, too, but somehow it felt as though I were the one on the spot here, not him, even though I was here to interview him as much as he was me. I could see my photo on the table--ugh, what a terrible picture, why didn't I submit a better one? I wished he'd put it away.

We talked, asking each other careful questions, eyeing each other closely. What was he thinking? Could he tell I was so nervous? Was that the answer he was looking for? Am I asking intelligent questions?

Finally, it ended--only I knew I had 5 more people to see before I could leave. It was rather like speed-dating, residency interview style. Somehow I made it through all 6 interviews yesterday. Over all, the day went well. I believe I was able to convince all of them that I belong in psychiatry, even after we discussed the whole crazy "urology" thing. By the final interview, I felt like my brain had melted and run out my ears. Had I answered that question? What did she ask me? Could I possibly think of one more question to ask when pressed to do so? After the ending tour, I staggered to my car, found a fast food restaurant, changed clothes, ate dinner, and began the 5 hour drive home.

As of now, I have 5 interviews scheduled, one more to schedule and one I turned down. I have two programs yet to respond with an interview offer (or rejection); unfortunately, one of them is my top choice program. I still only have one letter in ERAS. I've mailed Thank You's, emailed, and called the two letter writers who are procrastinating, and I don't really know what else to do on that end. Pray, I guess.

Breaking News!

Dumbledore was gay.

Shout Out to All the First Year Med Students

Inspired by comments to this post at TruMed, I felt the need to drag out some advice to any first year med students who might need a little reassurance right about now:

Take some time out and BREATHE, now. Stat.

Hear me out: What you do in your first two years of medical school will not necessarily determine the rest of your life. Your job is to survive, and pass your exams. That's it.

But, TS, the speaker at the surgery interest group said I should make the best grades possible in order to be a surgeon! And my buddy is a super ultra gunner who told me that we'll never get into residency with any high pass grades! Help!

Seriously, breathe, and think logically.

1) If you are a med student in the US who plans to practice in the US, you are automatically ahead of the thousands of people who graduated from programs outside the US who are applying here. I'm not saying FMG's are stupid, or poorly educated, but the reality is that most US programs will accept a US grad over an FMG who is similarly qualified. Therefore, you already have an advantage.

2) If you are able to achieve passing grades in your classes, you are ahead of those people who don't. This sounds lame, but there are always people who fail classes for various reasons. Guess what? There are residency spots available for people who failed first year biochemistry, or for people who needed extra time for basic sciences.

3) The majority of med students have "average" grades. It's a simple bell curve, right? So the majority of the class falls somewhere in the middle. If there were no residency spots for people with average grades, then med school classes would be a hell of a lot smaller. In other words, most of your attendings made "average" grades, and now they're attendings. Conversely, the majority of your attendings did not make AOA, and they're still attendings.

4) Check out this article at Student Doctor Network. Residency directors care FAR more about your clinical rotation grades than about basic science grades (or USMLE scores). It's more important to show them you can think and act like a doctor than like a college student. This even applied to residency directors in ophthalmology, a highly competitive specialty.

5) Whether you know exactly what specialty you'd like to pursue, or have no idea, don't worry about it. Many people change their minds, even if they were sure at the beginning. So long as you are passing your basic science courses, you have a shot at most specialties.

6) There are ways to bolster a CV, even if your grades aren't as high as you'd like them. Want to do dermatology, but can't quite honor gross anatomy? Think about doing some research in the department. Kick ass on the Step 1. Can't handle standardized tests? Rock your clinical rotations. Do some volunteer work. It's not all about the grades, after all.

7) Lastly, whether you are a super ultra gunner type, and insist on making honors in everything, or a "P=MD" type, you should also insist on having a life. Sure, you're studying a LOT, and your apartment is filthy for a month before exams, but that doesn't mean you shouldn't take some time for yourself somewhere. Work out, or go out with your friends, or spend time with your significant other--whatever it is, take some time for yourself outside of medical school.

Remember, those two years will eventually be over, just like mine were (and I really didn't think they'd ever end), and you can get on with the rest of your life.

Thank goodness I'm not a first year anymore!

Shock Media

"U.S. Deaths From Staph Surpass AIDS" says the AP. The first line of the article reads "About 18,700 people die in this country each year from drug-resistant staph infections, according to a federal study released Tuesday — more deaths than the United States sees from AIDS annually." This number comes from a CDC study on MRSA published in today's JAMA (JAMA 2007;298:1763-1771). Using the number of yearly AIDS deaths in the US cited in the Chronicle article, 17,000, then 1,700 more people die in the US every year from MRSA.

When reading the actual study, though, I get a slightly different feel.

Basically, the authors used a CDC surveillance procedure, monitoring 9 large urban areas for cases of MRSA, then obtaining medical records for each patient. Outcomes--death or discharge--were taken from the medical record.

Here's the thing, though: they never stated explicitly that the cause of death was MRSA. It's easy to imagine that a person with an invasive MRSA bacteremia would be critically ill, but how does one determine that the MRSA killed them, or the kidney failure which had them requiring dialysis which led to them getting MRSA in the first place? Or if someone is recovering from MRSA sepsis with DIC, then throws a massive pulmonary embolism and dies from being in the ICU for weeks, is the cause of death MRSA? It's also possible that a patient had a positive MRSA culture from a cellulitis, but died of something entirely unrelated, like an MI or CHF. They never stated that the cause of death was MRSA, only that these people a) had an invasive MRSA infection and b) died. If MRSA wasn't the direct cause of death in all of these patients, then the rate of death due to MRSA would be lower than they predicted.

Also, the only record of death came from the medical record for patients who died in the hospital. It's feasible to imagine that some patients died at home or in nursing homes from MRSA or its complications who weren't included. This would mean the rate could be higher than they estimated. Lastly, we're assuming that these 9 regions represent the US as a whole, but in reality bacterial populations vary by geographical regions. One of the sites studied, Baltimore, was left out of incidence calculations because it had much higher rates than the other 8 sites.

The point of the article was really to show that the rate of invasive MRSA infections is higher than previously supposed, and that a substantial amount of these infections came from the community. The majority of infections and deaths came from the healthcare-associated disease--patients who have been hospitalized recently, or have indwelling catheters and lines, or dialysis, or live in nursing homes, etc. Healthcare-associated infections also tended to be a more dangerous strain, USA100, with more multi-drug resistance, compared to community-acquired infections. Interestingly, although they gathered the data about the strain and presented it in the results section, they give it only a few sentences in the conclusion, as if the incidence data is so much more interesting.

Much of what got quoted in the Associated Press was an editorial about the study, also in today's JAMA (2007;298:1803-1804). This is where the comparison to AIDS comes from and some of the other quotes used in various articles about this study today.

Naturally, MRSA is a huge problem. Isolates at one hospital I work at have developed alarming tolerance of vancomycin--not high enough to be considered vancomycin-resistant, but high enough that the concentration of vancomycin required for treatment is reaching dangerous levels. This hospital is considering a policy change to make linezolid the first choice antibiotic for MRSA. We're one step closer to VMRSA, a much scarier beast.

Most hospitals are not required to report MRSA rates (or any other drug-resistant bacteria) to authorities. Some hospitals have started nasal swab policies to identify MRSA carriers upon admission to isolate them sooner and prevent the spread to other patients. Hand washing policies are effective against the spread of nosocomial infections, but are sadly under-enforced.

I'm always a little amused by what the popular media will choose for their headlines, however. I guess they made their point: everyone knows about and fears AIDS, but few people know about MRSA.

Emotional Rollercoaster, or The Power of Denial

We've all heard the term "denial". It has several meanings:

A refusal to comply with or satisfy a request.

1. A refusal to grant the truth of a statement or allegation; a contradiction.
2. Law The opposing by a defendant of an allegation of the plaintiff.
3. A refusal to accept or believe something, such as a doctrine or belief.
4. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.

1. A refusal to accept or believe something, such as a doctrine or belief.
2. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.

The act of disowning or disavowing; repudiation.

Abstinence; self-denial. (Dictionary.com)

Definition 3b is the one most people think about when they hear the word "denial". It's a Freudian term which has made it into popular English. It's a pretty self-explanatory term, after all; a person is "in denial" when they refuse to acknowledge the truth of a (usually negative) situation. Denial is necessarily an unconscious defense mechanism; in order to protect the mind from a painful truth, it's pushed aside. Your mind cannot be allowed to consider the truth, whatever it may be, so instead you think "Well, that just can't be true."

It's a term that is far overused, in my opinion, just like many other Freudian terms (Oedipus complex, anyone?) It can be part of the stages of grief, but it tends to be temporary. After all, most of us eventually cave in when we're shown hard evidence of what we fear. A rational person can only deny a situation for so long before the truth becomes indisputable.
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For the past week, I've had a patient in my care who has diffusely metastatic cancer. He's got enough life-threatening issues that he has to stay in the ICU, but there's nothing super-acute. If I had to give my totally accurate, super-informed, expert opinion, I'd give him a few weeks to months to live. His kidneys have failed, but he can get dialysis for that; his gut has failed, but he can get TPN for that; his lungs are stable, and his mind is clear. The dialysis makes him hypotensive, and so do the drugs we give him to cure his arrhythmias, so he's still on pressors. Despite all this, it's not unimaginable that he could leave the ICU, go to rehab, and possibly even home for a brief time. Sadly, this will only be brief. His tumor burden is extensive, and chemo left him without kidneys. It's unlikely that oncologists will resume chemotherapy which was only for palliation after such a dreadful reaction.

One of the hardest parts of seeing my patient every day is having to deal with his wife. Last week, she accused all of us of being totally incompetent, of not communicating with each other at all, and of not doing the things medically necessary for her husband. She accused me of not giving her all the information available when I told her that my team would evaluate the chest x-ray on rounds, and that until then I didn't have an official report to give her. She tries to pin us down on specific times for procedures over which we have no control: "So, in a couple of hours? Then if it's seven now, it'll be done by nine?" Only, after a week in the ICU, she still tries to do these things, even after we've done our best to explain why it might take more or less time to obtain even a simple chest x-ray.

She has accused the oncology team of not explaining her husband's prognosis, even though they have spent hours discussing his disease. She then accused them of hiding from her that chemotherapy can cause immunosuppression and kidney failure, even though the chemo consent form clearly documents these risks. She accused us of not performing dialysis quickly enough over the weekend, even when we explained that he hadn't qualified for dialysis over the weekend. What about drug X, my friend works in a pharmacy and he suggested it? Why didn't you perform this [palliative, symptomatic-only procedure] as soon as he got here, we've been asking for it for WEEKS? Why aren't you feeding him [even though he's vomiting bile and obstructed], he hasn't eaten for so long and oh, you just don't think it's imPORtant?

In turn, she has yelled at and offended all of her nurses, every consulting team, the oncologist, every ICU attending, etc. We never know what we might say that will set her off. All of us have spent great lengths of time explaining things to her in great detail, only for her to fixate on one tiny point and perseverate for the next few days. I dread going to see them every morning, because I can't escape with generalities with her, but I never know what I might say that will make her angry and anxious, or what I might have to spend fifteen minutes retracting. She makes it hard for me to do my job, basically.

Now, I've vented all this from my point of view. To me, this is a woman who is interfering with her husband's care. She is so argumentative and demanding that sometimes, the teams cave in to her and give treatment that we were hesitant to give. She makes her husband anxious. There's a flavor of borderline personality to her; she yelled at my attending yesterday for DARING to suggest that a dialysis catheter be placed in the femoral position, but today she told me how much she preferred the same attending to all the others.

From her point of view, there are tons of doctors coming in and out of her husband's room every day. Sometimes, different doctors and their assistants and the nurses tell her different things, which is confusing to someone with or without a medical background. Her husband can't always speak up for himself, so she has to do it for him.
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There's more to it than this, though. One of the first questions she asked me during our first meeting was "what will this do to his chemo schedule? He was supposed to have chemo this week." In reality, the chemo was only to try to reduce his tumor burden for a little while--there was nothing curative about it, and it really didn't matter when he was to receive his next dose. Her concern, though, was my first clue. After that, I started to figure it out. Every one of these things she fixates on--it's like we're denying him the one crucial treatment which would cure him.

When viewed in terms of denial, her behavior makes much more sense. After all, her husband was only recently diagnosed, but was already at a late stage in his disease. Only a few months ago, there was no cancer. Her future with her husband has been stolen from her, and she is furious. She can be angry with us, because we are the incompetent doctors who aren't doing everything for her husband, and because it's easier to be angry with us than to be angry at him. To be angry at him is to acknowledge that he is dying, which she can't do. She can focus on each medication, routine chest x-ray, lab, etc, because it can be controlled, which the cancer cannot.

Eventually, this facade will crack. As his condition deteriorates, and she becomes more frantic, something will break. We called a counselor to see her (at her request) but she refused to speak with her. I doubt she's spoken to anyone willingly about his diagnosis and prognosis. Eventually, it will all come out. I don't want her to lose all her hope, but I also don't want this moment of revelation to come to her after it's too late.

I am a selfish human being, though, and I just want her to quit bugging me so much and let me take care of her husband. Just because I'm going into psychiatry and can try to understand her situation doesn't mean I don't get frustrated, too.

Where Have All the Blog Posts Gone?

So I keep checking some of my favorite blogs over and over again, because I'm bored, and I'm kinda curious as to why it's been so long since many of these blogs had new posts. Come on, people, what am I supposed to read while I'm not getting interview offers from my #1 school??? I need entertainment, dammit! I DESERVE IT!

Come on, just one little post? Just one? I only need a small one, I swear, just an update on your day or a link description, just a little fix to take the edge off and then I'll be fine...

I'm not really complaining, please don't be offended if you write one of my favorite blogs. It's a compliment to you that I'm so addicted! Really!

Edit: If you write a blog, and you update it a lot, this post doesn't mean you aren't one of my favorites. I promise. I just always seem to need a little more!

Balance

I'm a person who has a tough time with balance. I'm not referring to my klutziness (although I could, because sometimes it's amazing that I walk upright). I'm referring to a kind of balance of life that sometimes I feel like everyone else has besides me.

Medicine is certainly not the only career that promotes a skewed life. One can be a workaholic in nearly any profession or job. Both my husband and I have fathers who work 80+ hour weeks (one as an entrepreneur, one as a CPA). There's something about medicine that encourages total devotion, however, and for those who drink that Kool-Aid, there can be no life outside medicine. Since many doctors are socially retarded (extrapolating from classmates who are certainly not going to acquire better social skills between now and graduation), their lives outside the hospital/clinic are not very rewarding. They learn to base all their satisfaction on medicine, and society condones this. After all, medicine is a "meaningful" profession, so it's only right for you to spend all your time doing it.

In my life, I sometimes feel like I can't possibly do everything I want to do. I want to be a good student/doctor, a good wife, a good daughter and sister, and a good friend. I want to get my body in better physical shape, which requires going to the gym, and I want to take better care of my pets, which involves vet$ and food and the pet $tore and the dog park and boarding, etc. I want to be well-rounded, so I try to go to rock concerts, art museums, the symphony (season tickets this year!), and take vacations. I want to have a clean apartment and be a better, more frequent cook. I want to have beautiful plants in my small garden. I want to express myself on this blog in a meaningful way.

In reality, though, every one thing I try to add knocks another thing out. I get easily overwhelmed by fatigue and then lose all desire to try to cook dinner, so we eat out a LOT (especially on rotations like this one, where I'm physically and emotionally drained). This habit doesn't really help with the physical condition issue, of course, and the fatigue doesn't make it easy for me to go to the gym. I've been going to the gym more regularly for a few weeks, but then I'll have an asthma attack and miss a day or two, which is frustrating. If we go out during the weekend, somehow the apartment doesn't get cleaned, and then I spend the next week disgusted by our living conditions. I've killed almost all my plants. Also, I spend so much time at work dealing with everyone else's problems that sometimes it's hard to listen to my husband talk about his day. After all, I spent MY day HELPing people, for goodness' sake, how could anyone else's day matter?

I think part of the problem is that I try to add too much at once. If I'm not going to the gym every day, then obviously I failed. One reason I let this get me so anxious is that I realize that my life is currently going on, sometimes without me. In medicine, we put everything off for the future: we'll make money later, get married later, have children later, talk to our spouse later, and so on. Since you can't make medical school nicer, you can only make your outside life better (that's my theory). I realize that the point of making your life more well-rounded outside of medicine is NOT to get anxious about it, but hey, that's me. As someone pointed out the other day, "that's TS." If I don't have anything to worry about, who am I?

And who would I be without medicine? I have a gift of intelligence which is, for whatever reason, oddly suited to medicine. I have a repertoire of useless medical trivia that don't help me get pimp questions right, but have totally ruined my ability to win Trivia Pursuit on any other subject. I guess part of what I want is to be able to say that I have an identity other than "future doctor", and part of me worries that I don't.

As for medicine being so meaningful, I'm working on a post to address this issue. If I can work it into my schedule, that is.

The ICU Makes Me Sick

The evening after my last post was entirely uneventful. I made frozen pizza for dinner, my hubby and I watched TV, I blogged, I checked many blogs, and then went to bed. I coughed some, but then I can't really stop coughing. (For some unknown reason, my asthma has turned into "moderate persistent", with daily symptoms, for the past month and a half, despite being "mild intermittent" for years. I can't tell if it's a URI or not, and therefore I don't know if I should fill the Z-pack I was given as an "emergency" script or not.) It really wasn't a special evening.

Until I woke up at midnight and re-experienced the frozen pizza.

After a mostly sleepless night, I called in sick, notifying my nurse practitioner ("the boss"), my attending, my course coordinators, and my course director (all at 5 am--impressive!). Then, I slept till noon.

During my third year of med school, I went to work sick several times. It's something of an expectation that third year med students will not miss work. I did call in "sick" (ie, played hookie) once while on family medicine (and agonized about it for DAYS, I'm terrible at that sort of thing).

As a fourth year, I no longer have any qualms about staying home from work when I'm sick. I called in once last month because of the asthma/URI crud that hasn't gone away (it's been a month and a half!) On this occasion, I wasn't sure if I was done with the ickiness, and I figured that a) I didn't need to be around ICU patients and b) ICU patients didn't need to be around me.

When I went back to work, I felt better, but I still had the sniffles and the cough. Since these were noticeable, everyone assumed that this was why I'd stayed home. Since then, most of my ICU team has come down with some form of cough/sore throat/runny nose/sniffles, and they blame me, despite my frequent hand-washing and obsessive use of hand sanitizer. A friend called me "a walking fomite" today.

Never mind that we're surrounded by patients with every drug-resistant bacterium known to man, I get blamed for the creeping URI. Oh, well.

They All Have Cancer

...and that pretty much sums up my first few days of my required ICU rotation. I'm in a special cancer ICU, on the "solid tumors" team. As one of our PA's said yesterday, we either have "easy" patients--or not. The easy patients are mostly craniotomies for intracranial tumors--ie, brain cancer. They come to the ICU after their surgery, stay overnight, and generally get transferred to the floor the next day. Thus far, I've only managed this kind of patient, as they're not on a ventilator and have fewer serious issues (although I still write a 2 page progress note, detailing labs, meds, and physical exam for every body system + ID & oncology--they're not easy patients yet for me!)

The other kind of patient, according to my PA, come into the ICU from the floor "crazy sick", get a ton of money spent for a 1-2 day ICU stay, then DNR/DNI/withdrawal of care papers are signed and the patient disappears from the list. I believe she (the PA) was talking about what a waste that is.

The "liquid tumors" team (lymphomas, leukemias, bone marrow transplants, etc.) supposedly has a 30+% mortality rate. One of my friends is following a patient with a total bilirubin of 35; his skin is a strange neon green color. Another patient has a strange bacteria I'd never even heard of before--Stenotrophomonas maltophilia--which is apparently resistant to EVERY SINGLE ANTIBIOTIC TESTED EXCEPT BACTRIM. Still another patient has a virulent varicella pneumonia on top of her end-stage metastatic colon cancer.

I could go on and on and on. But I won't. Suffice it to say that it sucks. Yes, I am taking my antidepressant; otherwise, I don't really think I'd make it through this month.

The only thing that could make tomorrow more awesome would be if my nurse practitioner, who introduced herself as "the boss", decided to assign the medical students another learning issue. My 2 minute regurgitation of UpToDate on astrocytoma was spectacular, let me tell you.

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In happier news...

UPDATE ON THE MATCH:
Interview Count: 6
Letters of Reference in ERAS: 1, scanned in today
Letters of Reference NOT in ERAS: 2
First Interview: October 19
Anxiety Level About Lack of Letters: 10 out of 10