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.

The Chameleon

Way back in high school, I had an English teacher my senior year whom I really loved. She was an excellent teacher, a truly Southern woman, yet totally liberated. After I'd received my acceptance to college, and gotten accepted into a pre-med program, I told her all about it. Her response? "You should be an English teacher." I thanked her politely, but I told her I had my heart set on being a doctor.

One of my high school band directors also played trumpet with me in our church orchestra on Sundays. I told him about my plans to go to medical school after college; he told me "I can see you going to a small liberal arts college, majoring in music, and becoming a band director." It really was too bad that I didn't see myself that way at ALL. I thanked him politely, and told him I really didn't think I wanted to be a band director. Although, there are times when that option seems more appealing than it did then...

One of my surgery chiefs got all into the idea of my being a surgeon; she offered to help me find an adviser, and help me write and publish a case review. Both of my pediatrics attendings asked me if I was going into pediatrics, and were visibly disappointed when I politely (but firmly!) told them I had no interest in pediatrics.

Last night, on call for internal medicine, was one of the worst nights ever. I made several screw-ups that got me (nicely, and rightfully) chewed out by my upper-level resident. I misunderstood an errand I'd been asked to run, and instead of heading upstairs to fetch the cards, I drove to the med school and back (an hour round-trip in 5 pm traffic). As I got progressively sleepier and more brain-dead, only 3 Cokes and intense, unholy fear of my attending kept me moving. As I prepared my notes, I kept filling in blanks I'd left: a finger-stick glucose here, a TSH there. I finished and signed my notes, transferred data around until my scut sheets had all the values I'd need (hopefully), and felt the pressure in my chest get heavier and heavier. 6 am: go time. My respiratory rate sped up. The onslaught began with chest x-rays: "what do you see?", "why do we have this CT?" (the answer was almost always, "the ER ordered it") "what other abnormalities are there?" (after we'd discussed the only abnormalities I could see). One of my fellow students, a studious but nervous guy, had a visible tremor as he fumbled his papers looking for lab values (this same student has Gilbert's syndrome, and was a distinct shade of yellow this morning from the stress). It went on, and on, and on, for 6 hours and 20 patients. Constant calm criticisms flowed: "this is unacceptable", "you guys' physical exam skills suck", "that's not the question I asked you", "I'm asking you guys to use some common sense," etc. It was brutal. I managed to escape the worst of it, and after my first patient to present, the shaking stopped, and all I could think about was the fact that I hadn't peed in 6, 8, 10, 12 hours (nor did I really need to, which was more worrisome). Finally, the last quick staff note hit the last chart, and Dr. H said "Students, come with me."

We entered his lair, I mean office, and settled in for a quick chat. "I only yell because I care", "don't be overwhelmed", "medicine is tough--a lifelong process" were only a few of the quick phrases that were tossed around. As this was our last (and only) call with him, he asked if we had any problems or questions. When no one spoke for 2 seconds, he said "Great. I want to talk to you [pointing at me] for a second--the rest of you can go." The other three filed out, relieved at having gotten off so lightly, and looking at me with pity. I collapsed in a chair and waited while he made a phone call. What had I done wrong? Did I kill a patient? Did I forget yet another lab value? My notes went on the chart at the correct time, I had all my vitals, and I'd escaped the most furious of the tongue-lashings. Then I wondered, did he want to talk about my intern or resident? My intern was convinced she was failing, although I didn't think she was the most yelled-at of the interns. My resident was definitely the better of the two on the team. WHAT THE HELL DID I DO WRONG OH GOD I SWEAR I DIDN'T MEAN IT JUST GET IT OVER WITH AND KILL ME NOW! He hung up the phone, turned his chair around to face me, and said...

"You were made to be an internist."

I don't know how I kept my mouth from dropping open. My heart had definitely stopped.

He proceeded to tell me that I asked the right questions (I didn't recall asking any), that I had a good knowledge base, that I was not only made to be an internist but also a subspecialist, because I needed to know everything, to be an expert. He discussed an article I'd given him (at his request), and how I was obviously thinking in the right way. He said he wanted me to seriously consider internal medicine as a career, that he didn't know if I already had plans but he wanted me to keep medicine in mind. He then asked if I had any plans and I politely said "I'm keeping my options open now". I thanked him and told him I'd never felt as stupid as I had during the past week and a half. He reiterated the don't get overwhelmed speech, I said "thank you, sir", and we walked out.

I didn't know whether to laugh or cry or tell him how much I'd hated the previous evening, how many times I'd picked up my purse to see the next patient and thought "I could just leave now". I didn't tell him I'd never considered internal medicine, or that I liked surgery or OB. I just said "thank you, sir".

Even now, after a refreshing post-call nap, I still think I was hallucinating.

I Talk A Lot

As I went through to edit the HTML of my blog layout and some of the posts that never quite worked right (like the Hangover post--I finally got it to work!), I noticed something. I make excessively long posts. In other words, I am exceedingly verbose (even when I'm saying that I talk too much). My apologies if the mega posts are annoying. Take some Ritalin--you'll make it through. (By "you" I'm referring to any of the 1,062 people who have visited my blog. Thanks! Fortunately, SiteMeter doesn't tell me how many of those visits are me, checking to make sure stuff worked.) I'll try to work harder at not rambling for hours through every single last detail of my boring, lame life that nobody wants to read, not even myself. I promise. I will stop talking. I swear.

More Mythbusters, then bed. I have my first call on internal medicine tomorrow, and I'm terrified. I only have 4 more days of Dr. Hardass! My goals: learn LOTS (the man is truly a walking library of evidence-based medical facts) while NOT receiving any ass chewings. We'll see.

Too Boring to Blog

Get up, go to work, quiver in face of attending, come home, watch TV (lots of CSI: Miami and Mythbusters), whine about cooking dinner, go to bed. Get up, repeat (insert a chewing-out by said attending). Get up, repeat. Get up extremely late, bake a gingerbread (I took it out of the oven a shade early, so it was too gooey in the middle), drive to the boonies, have Thanksgiving with hubby's grandmother, drive home, go to bed. Get up, watch football, go shopping to finish wedding registry, go out to dinner with father-in-law, come home, go to bed. Work Saturday, come home, watch lots of TV. Work Sunday, come home, watch even more TV. That brings us up to tonight, where I'm watching Mythbusters and reading other people's blogs.

It was a bit of a depressing week. I'm usually a "superstar" in medical things. My peds attending told me she wished all students were like me (I blushed). Fast forward a month, and I'm a gibbering idiot. Thanks to a miscalculation of my time and a misunderstanding, I failed to write any notes on my patients before rounds and failed to check DTR's on a patient with a TSH of 53, so I was told I obviously didn't want to learn and that my performance was "unacceptable". All this on the second day of the rotation. Ever since, when I have to speak to my attending, I've started shaking like a leaf--it's truly pitiful.

He's a hardass, this is true. He's also an unbelievably intelligent man, a very caring physician, and a demanding teacher. He won't be doing my eval, so I don't necessarily have to impress him; I just don't want to be a blithering idiot. It doesn't help when I have interactions like this:

Surgery intern: Hey, how's it going?
Me: Hey, I haven't seen you since trauma. I'm on medicine now.
Intern: Oh yeah? Who's your attending?
Me: [Dr. Hardass]
Intern: *Laughter*
Me: Gee, thanks.

If people didn't continue to say things like this to me, maybe my stomach wouldn't be tied in so many knots. Perhaps I'd be sleeping better, not constantly imagining my next interaction with the man.

Other than that, the only news I have to report is that one of my patients gave me a bracelet this morning. I tossed it in the trash (out of his view, of course), as it was constructed of the band from a latex glove and some sort of paper, and it wasn't entirely clean. He told me it had the power of the Bible in it. Who knew dressing a guy's decubitus ulcer could prompt such gratitude.

Scary

My new attending literally told a patient today that if he continued to do cocaine and drink alcohol, that not only would his bleeding ulcers get worse, but that he could possibly die. The attending then told him that he should find another hospital if he was going to continue these habits and quit wasting the county's money.

Last night my new team admitted patients; this morning was our first day, post call for the rest of the team. One of my interns wrote a little note on her papers and showed it to another while we were rounding (very middle school). It said "3/4 of my patients are cocaine positive".

As I read through the H&P my intern wrote, I noticed that she said the patient was "hyperthyroid" at least 4 times, yet her plan included "thyroid replacement hormone" for "hyperthyroidism". It's a good thing this patient is actually hypothyroid, or this plan could be really dangerous.

Ah, good times at ye olde county hospital. It's going to be an exciting month.