It’s been a rough month.

Lately, I feel like I have been sliding into a bit of a funk for no good reason. Let me preface by saying what follows is (probably) unjustified bitching from someone who is well aware he has good health, a loving family, a host of supportive friends, a caring girlfriend, a job that I (usually) enjoy and all in all, no real reason to be feeling like shit lately

That said, I am beginning to feel like the hospitalists have all been ganging up on me and turned me into the hospitals whipping boy. It doesnt matter how many difficult diagnoses I catch, or studies I order creating my differential, I never really get any feedback for positive things. But the moment I forget to order something or am not aware of every lab that is back instantly, the hospitalist saunters around with a “I am concerned about your performance, it seems you lack motivation, or clinical judgement, or whatever the complaint du jour is of my abilities.” 

It didnt help that during my most recent wards month I was saddled with a difficult intern who would copy paste notes, not follow up on labs, and in general was just slow moving and disorganized. So in attempting to work with said intern, and eventually just doing the interns work so I could get out in a timely fashion, certain things that may not have slipped my attention otherwise did. Now nobody died or got sicker as a result of these decisions, but I cant be everywhere and do everything at once, and being blamed for things that are essentially beyond my control is not fun for anyone. 

I never seem to hear these complaints during subspecialty months, but the second I am saddled with a hospitalist, I apparently turn into the worst resident ever.

Now I like to think I am well aware of my faults and limitations, have good insight and in general try to constantly improve myself and take all feedback and or criticism into consideration. But I have finally reach a point of learned helplessness, where it seems that no matter what I do, I end up with a average to mediocre evaluation which results in the equivalent of being called into the principals office to discuss concerns with the program director.

And because our program tends to be very hospitalists vs residents, it always comes down to my word against theirs, so extenuating circumstances such as personality conflicts or any sort of positive improvements or efforts dont come into play, just a lecture that i should be performing at a higher level, i managed to get into fellowship and where is all that potential i apparently was showing back when the housestaff didnt hate me.

At this point I am so tired of playing the game. I just want to sign my contract for fellowship and get the heck out of this program, this environment, and this state. It’s time for a change of pace, and to bring back the happy carefree person I feel like I used to be.

And for icing on the cake, while I am finally back on GI, my attending is the program director who rejected me (although thank goodness I matched to a program that will train me better anyway) and the fellow is our former chief resident, who we all disliked for being two-faced. However, at least I like what I am learning and anything I go through now will only help prepare me better for fellowship next year

I just wish I could catch a break.

After a fairly intense ward service, I have been back on consult for a relaxing few weeks.

Final thoughts on my first month of wards?

*Holy jeebus, I learned a lot in the space of one year-did I really used to know this little?

*It is way easier to do the work yourself than to have to constantly check up on others people’s orders; conversely, if you can trust those below you, life is pretty easy

*I cant believe I am the deciding factor in somebody’s grades now.

I mean, the med student still has to take the shelf exam, but at least 30% of grades come from evaluations and 100% of evaluations come from me, as I am the only spending any significant time with the med student. Now I understand why sometimes I just got straight B’s or satisfactories down the line…I may not have been outstanding or terrible, but you dont want to lie, nor do you want to destroy someone’s chances to apply for their field in the future. Apparently I developed a reputation as being a tough resident for constantly “pimping” my student with medical questions. Or at least asking him things to the point where he felt the need to complain to other students I was being hard on him, and they mentioned it to their residents just in normal conversation and those residents mentioned it to me. I figured I was just trying to prepare him for his exam, and never pimped in front of an attending, only gave reading recommendations rather than presentations and tried to teach everyday, but oh well, if thats being hard, then I feel bad for the next student I get.

I got feedback of my own of course as well from my interns in a one on one session who if they were lying to my face, at least told me pleasant lies that I was helpful, low key, and good. And I got a very nice compliment from my attending on the service, who told me I was operating at the level of a 3rd year resident (I am a 2nd year) and he trusted whatever my plan for the patients was and would basically sign off on whatever I did. Given that my last wards service before this was as an intern, and one who failed the rotation due to a particulalry strict attending, this was great validation of all the things I had been second guessing myself on since that time. If one attending can give me straight 3′s (out of 9) and a mere few months later another attending with whom I have more responsibilites gives me straight 9′s, either i made a miraculous improvement, or I was not as bad that month as I had been led to believe.

The last few weeks have otherwise been pretty eventful, although not in ways I can really come up with an engaging way to tell. Most exciting, I finally got my license in the mail.

That’s right, I am now officially a LICENSED PHYSICIAN AND SURGEON. No more calling myself “almost Dr J” even in my head anymore. I shall not be performing any surgeries, but it is nice to know I am licensed to do so.

I have been back on consult service this month, nephrology in particular where most of my patients are on dialysis and I have not been able to think of cool ways to present them on here. Maybe in time.

I also have two grand rounds to present which are basically big hour long presentations to an associated specialty. This week is to the GI department (who I want to join) on applications of probiotics in GI. Next week is to the renal department (my current service) on papillary necrosis. Doing these presentations is a good learning experience and actually not as bad as I was worried it would be although coming up with an academic lecture for an hour is a significant amount of work.

Oh yes, and for those of you following along with my relationship history (or until recent lack thereof) I have broken my gypsy curse and have now been dating the same girl for over a month. She is a PA student who I know from college, and of course there is more to the story, but I will leave that for another time. Suffice to say it is nice to be dating someone who understands my schedule as I am sure my fellow healthcare folks out there can attest to.

So that is the update for the last month. More patient stories to come beginning next week, as I finish up renal and move on to my research elective (aka 2 weeks call of duty time)

-Dr J

Am I keeping to my once a week posting, or have I already broken my resolution?

In either case, it has been a busy busy week. I have been fortunate enough to perform two lumbar punctures on patients and it wasnt anywhere near as scary as I thought it would be. I find that happens a lot in residency…I spent all medical school getting all psyched up about one thing or another that I thought would happen when I became a real doctor, and then it actually happens and it turns out not to be anything I can’t handle.

But I digress. My very first lumbar puncture ever was on a elderly (surprise surprise) gentleman who was pretty much comatose by the time he came in. The ED doc had stopped by the workstation to talk with the attending and asked if there were any residents around who wanted to do a procedure. As part of residency, we have to do X number of procedures like paracentesis (draining belly fluid), lumbar punctures (spinal taps) and ABG (drawing blood from arteries) to ensure that we are capable to provide any kind of care at any time as part of the diagnostic workup. So off I went to do the procedure with the ED doc providing a watchful eye and a guiding voice as I did my very first solo spinal tap.

The gentleman was rolled on his side and placed with knees to chin, balled up in the fetal position as tight as the nurse could make him. This helps curve the spine and presents the maximum surface area available for me to slip a needle in between. This is good because the last thing you want to do is miss the spinal fluid and accidently stab the spinal cord. Then after feeling for the anatomical landmarks, the spot was marked and confirmed by the ED doc and I numbed the area and in I went. I’m told by friends who have had it done that it is a fairly painful procedure but this gentleman didnt even flinch, which told me just how sick he was. Fortune smiled upon me however and I got it on my very first try…a gentle popping sensation and sound as I passed through the vertebral colum, and when I withdrew the trocar (guideline inside the hollow needle) a clear fluid came dripping out. I collected in into 4 small vials and then sent them off for studies to find out if he had an infection in his spine.

Now quite often interns will cause a “traumatic tap”. This means that they dont find the right space on the first try and the first vial will have a high degree of red blood cells, and thus be pretty much useless to the lab. High degree is 60rbc or higher. COnversely, there is also a “champagne tap” wherein no rbc’s are seen, and the csf (cerebro-spinal fluid) collected is clear like champagne. It is also called that because if you actually achieve fewer than 10rbc’s, or a totally clear tap, the attending who supervised you is supposed to buy you a bottle of champagne. So my very first one had 22rbcs in the field…too high for free alcohol, but a pretty respectable number for a first try by a rookie.

….

About three days later, I have an 80 year old woman with severe dementia who initially came in with a pneumonia, but has altered mental status a little more severe than could be explained by her dementia alone. So infectious disease specialist is consulted and recommends a lumbar puncture to rule out meningitis (inflammation of the spinal cord). No ED doc around this time to help, and my resident has clinic. She offers to find a third year to supervise me, but reassures me that, “you have already done one, you will be fine” The third year who is there to supervise has only done one in his three years of residency.

Let’s pause there for a moment, shall we. The person supervising me during this procedure will have less experience than me by the end of the procedure. Ah, residency.

Carrying on. Unlike my first patient who was knocked out 6 ways from sunday, my current lady is demented, angry, fidgety, and has a mouth like a sailor. It takes 2 nurses to hold her in position and this time I am doing the whole procedure from memory, with minimal input from the supervising resident. (which I am okay with, i just didnt want to be alone to do this) I found the landmarks on my own, I cleaned and draped the patient and even had to use my “doctor voice” to quiet the lady down because all her moving only prolonged the pain and procedure for the both of us.

Unfortunately, the first attempt, I missed the landmark completely, placing the needle about 1inch too high…whether because of the difficult behavior of the patient or my own inexperience is anyones guess.

Rallying to the fight however, I knew my mistake, and just like in showbizness, you never let them smell the fear. I simply told the patient that I had to do the procedure again and she would have to stay still this time. I then re-anesthetized the same area 1 inch lower, and set back to work…and a short time later was rewarded with spinal fluid. I had guessed my mistake correctly and adjusted myself accordingly with no one other than myself (and the resident) the wiser. And for all that the rbc’s in tube 1 was only 61, with the patient not suffering a post-lumbar puncture headached that commonly occurs after traumatic taps.

So while my second attempt did not warrant a bottle of champagne, I still celebrated with a glass of beer for a job well done. One of the procedures that had frightened me so much in medical school, the thought of putting a needle into someones spine, had succesfully been done by me twice in one week on an easy and a difficult patient and both times I had achieved success.

Looks like I’m starting to get the hang of this whole doctorin’ thing after all

SO this is my first post of the new year, and my first attempt to keep up with the resolutions i made, most importantly the return to at least weekly posting. It may take a while for me to get back into the habit of writing things that you guys want to read, so bear with me and fire away with any criticism, constructive or otherwise…no such thing as bad publicity, right?

I am post call today. I was lucky enough to only work a half day on New Years, but then drew the short straw of being on call on january 2nd. Why is this such a bad thing?

marriedtothesea.com

Because just like the above comic demonstrates, people tend to put off their health problems during the holidays because they want to spend time with their loved ones. Which if you have a cold or some indigestion, or even a mild copd exacerbation is not a problem. But people with heart failure, broken bones, and chest pain, as well as asthma exacerbations also tend to ignore their problems. Compliance with everything slips during the holidays

marriedtothesea.com

Now with one or two people coming in sick, it would be one thing. But everyone and their mother decided that this was the day they would get all their issues taken care of. On an average overnight call, I admit 3-5 pts, 6 on a busy night. Last night I admitted 10. Me personally, to say nothing of how many the rest of my team, plus the two moonlighters, plus the covering intern all admitted.

Got some very interesting patients overnight, and I have finally managed to get my speech about code status down to the point where people seem to understand that DO NOT RESUCITATE does not mean DO NOT TREAT. Other than that, I am still working on my hepatitis c research projects, with my next deadline by the 22nd to finish the chart review, and studying for the last phase of my licensing exam.

Oh yes, and I have finally achieved one of the classic doctor hallmarks in that I am (at least for the moment) dating a nurse. It really does happen, and it basically means two people who can never coordinate their schedules to get together outside the hospital, but when they do, they have a fascinating conversation about…you guessed it…work stuff. And 80′s pop culture, because that’s how I roll.

So until next post guys, hope you all had a great new years!

I think there is an unspoken expectation that people at the time of their death will have last words. Some final message they have been waiting to impart, whether it be words of reconciliation for long estranged relatives, or a simple goodbye to those they love. In this archetypal deathbed image, family members are gathered around the bed of the dying, who is clear, lucid, and distills a lifetime of experience into a few words of wisdom before sighing once, and passing on.

The sad reality is that most people never get a chance to say anything before they die, because they have long since lost the power of speech.

I recently sent a man home to die. A man who, a mere month ago, I had treated for a relatively straightforward pneumonia. Unfortunately, old age is insidious, and at a certain point, it can become quite hard for individuals to recover even from straightforward diseases. On his readmission, this elderly gentleman stated his pneumonia had resolved, but he still had fatigue. So we admitted him, and began working him up to locate other possible sources of the infection his labs indicated he still had.

And I spent the next 2 weeks watching him slowly but gradually decline from an interactive, lively, hard of hearing old gentleman breathing on his own to a nonverbal, nonambulating, shell of his former self, lying in bed on oxygen, while the family met with the palliative care team. A thorough inspection had revealed no infectious source, his cardiovascular status had gone from poor to practically nonexsitent, and finally I had the dubious responsibility of telling his family, “I’m sorry, there’s nothing more we can do. Perhaps it’s time you think about taking him home.”

The family, while saddended by the news (understatement though THAT be) understood, and we discussed the options available before they decided they were in agreement with comfort measures only, a do not resucitate order, and bringing the patient home to die in a familiar setting.

I signed the discharge orders, knowing I would never see this patient again. I tried harder than I could say to recall when the last conversation I had with him was, reaching to find anything at all that could be construed as last words and not just my one sided questioning of daily symptoms to which he could only respond with nods. I came up with nothing.

So I sent the family home with last words of my own: Whatever your beliefs are, I sincerely hope that your loved one finds peace and happiness in accordance with them. Then I stepped over to the computer, clicked the order to discharge, and watched as they disappeared forever.

The numbers on the clock read 3:30. 30 minutes until I am protected from admissions, 90 minutes until I get to go home. I spend my time idly performing chart review for my research project, digging through months of notes to grab minor details for the statisticians. Suddenly the pager goes off.

“Oh no oh no oh monkeyfeathers!”

“Hi Dr J, we have a patient for you to admit, and this is a good one for the subintern, so have him do the H&P.”

I inwardly cringe. The sub-intern on my team is a nice guy, but like all students cant help but slow me down when I was hoping to knock this out and be out by 5. Nonetheless, I agree, the sub-I and I briefly review the pts chart and down we go to visit him.

The pt is a 55 yr old gentleman with a past history of high blood pressure, high cholesterol, and recurrent urinary tract infections here with another urinary tract infection and some shortness of breath. I let the student take the lead in questioning while I scribe notes. After 10 minutes (my patience threshold when I am trying to go home) I subtly begin to help direct the students questions to the pertinent information.

The biggest concern with our gentleman is his low blood pressure. Someone who reports a history of high blood pressure coming in to the ED with 74/61 is worrisome. More so when that blood pressure barely corrects after 4 liters of fluid. To clarify, I want you to imagine you have just drunk 2 of those giant soda bottles.

Despite the fact that this man is sitting up and talking to me, that he appears relatively healthy, he is in septic shock. Lab tests revealed more disturbing values. A creatinine (kidney function measurement) of 5.4, where a normal level is 1.0 So on top of his sepsis, he had acute renal failure. Oh yeah and troponins were elevated as well (heart injury lab) meaning he had some demand ischemia (almost, but not quite heart attack) also likely due to his sepsis.

So it was off to the ICU with him. I called up the admitting fellow and informed him of our plan.

“Yeah that sounds fine, but drop a central line in him so we can give pressors and antibiotics”

No problem, except I had never done one of those before. Looked at my watch. 5:30pm. Duty Hours and my internal devil are telling me to sign it out and call it a night. But how in good conscience am I just supposed to walk away? Do I tell the family, sorry, residents have an 80 hour cap, some other doc will come in and jab a needle into a major vessel.

So I sighed once for my lost evening, and went to track down an attending to supervise me while I placed a central line. A central line is a large bore catheter placed in either the neck, chest, or groin. Most interns/residents tend to opt for the femoral option as it is 1)slightly easier to place a line and 2) does not carry the risk of puncturing the carotid artery or causing a pneumothorax among the more traditional complications of the procedure

I, however, am not most residents.

I explained all the risks of the procedure to the patient, and then the benefits and why I thought he needed this and should consent. I clearly managed to convey the appropriate authoritative and experienced image because rather than saying “YOU ARE GOING TO JAB A HUGE NEEDLE INTO MY JUGULAR VEIN? ARE YOU EFFING CRAZY?” instead he went with the more traditional-”whatever you think best doctor.”

Perhaps he may not have had the same level of confidence if he knew this was going to be my first one ever. But hey, that’s the price of going to a teaching hospital, right? The secret to success is sincerity-once you can fake that, you’ve got it made.

Gowned and gloved in sterile attire, I palpated the gap between the two heads of the sternocleidomastoid, finding that magic triangle, in which the ultrasound tech located the compressible vein. Then, after cleaning the site, and injecting lidocaine to numb away the sensation of having a rookie poke around in your jugular area, in I went!

I wish I could tell you I was insanely talented and got it on my first try. However it took about 3-4 times of advancing and retracting the needle, and finally moving more lateral away from my initial puncture wound before I finally saw the inrush of venous blood. I maintained my serious doctor face the whole time while my internal monologue was screaming “YOU HAVE A NEEDLE THE LENGTH OF YOUR HAND IN THIS MANS NECK, QUIT MUCKING ABOUT!” and successfully inserted the catheter with only a modicum of blood spilling onto my gloves, and no complaints of pain from the patient.

I had successfully inserted my first central catheter, with no complications, and in a more challenging location. I ordered a chest xray to check the placement, and sent him off to the ICU. The time was 8pm, 3 hours after I was supposed to be off, but totally worth the experience. Next time, I will be much less hesitant and once again, I will go for the throat!

Dr J

Residency is hard work. There’s a lot to keep track of, whether it is patient care issues, studying for licensing exams, or just wondering about my overall performance and what the other residents/interns think of me. Am I the intern that has the horrible notes? or the one who everyone is glad to have on their team? I know the medication i need to prescribe, but what is the proper dosage and why does everyone but me know it? WHY DOES THE PAGER KEEP GOING OFF?

So with the minute little stresses throughout the day, it’s important to find ways to keep myself grounded in reality. Or at least my reality. So what helps me get through those stressful days?

–Taking the stairs from the 6th to 7th floor and pausing to look at the hollywood sign through the glass wall

–shouting “wheee” and throwing my hands up as i enter the steep highway ramp on my way home from work

–wandering the halls of the hospital humming whitesnake when nobody’s looking (and journey when they are)

–checking off boxes on my to do list for patients

what helps keep YOU sane?

So My first week on wards is finally complete, and I have to say, I like it. Sure, I work 12-13 hour days, but at even when i dont particularly like my patients, i still find them interesting. And for all my complaining about night float, it did a surprisingly good job of preparing me in developing my assessments and plans.

And as usual, after checking over past entries, its amazing how much i have learned in a short time. We have a medical student on our team who is a 3rd year and just learning how to do histories and come up with assessments himself. Admittedly, when we got a late admission, i was a bit frustrated with how long he was taking, and I stepped in to finish the case, because, hey, I wanted to go home. I can now only imagine how irritating my pace must have been to my residents now that I am in that position. Nonetheless, I try to sit down and teach the med student when i can and provide the same sort of positive reinforcement that i was given, because hey ultimately that was a large part of what made medicine so attractive to me in the end.

No new fascinating patient stories this week, but stay tuned, because much like myself, you never know whats coming up!

I have been neglecting those of you who still come here, I know. I also know that this meta-regretting is a typical way for me to start posts lately. So by way of brief apology, let me just say I do miss those of you who i have virtual conversations with, and I will make more of an effort to at least comment, if not post more on my own.

That said, I finally began service on the wards today! Yes, my 2 months of night float are over, and now I am back to a more classical residency block…admitting patients, rounding on them, and treating them until they get better, get transferred, or get dead. Ideally less of the latter.

Now I am a fairly proactive person, so when the resident was handing out patient assignments I volunteered for the liver patient. Liver patients tend to be complicated, as since the liver metabolizes most drugs and produced the majority of clotting factors and proteins, pts with defunct livers have a ridiculous amount of things they cannot be prescribed or have to be monitored closely to prevent multitudinous complications.

One of these complications is known as Ascites. It is basically a fluid buildup in the abdomen due to loss of proteins by the liver. But while i could get technical all day, lets consult Dr Google for a picture, shall we?

The main way to treat an ascites that has gotten this bad is to drain it. That’s right, just stick a needle in and deflate the belly by draining all the liquid into vacumn sealed liter bottles. Did I mention the yellowish ascitic fluid can occasionally be reminiscent of beer

That’s right, my first day on wards and i was setting up my own microbrewery!

So cheers to my first completed procedure of the year! Anyone want a stella?