EMS

EMS is over... thankfully. It had its moments - but that is just it. These were moments. Most of the time it was boring and felt like a real waste of time. I think this is best left to the realm of electives.

We have a lot of differences in how we do things. For instance, they are dunkin donuts fanatics, you know the give me a little coffee with my sugar. I suggested starbucks but this did not go over as an idea.

The entire time was filled with testosterone and lots of story telling. Considering how little work we actually had, I wonder whether I came in too late and missed the golden age or if these are stories collected over 10 years.

In the place I worked in New Jersey, there was an aura of intimidation. These were tough guys practicing the delicate art of medicine, always afraid they were going to get in trouble with the upper level guys. There was one guy who constantly started each justification of his actions with "I only have a few weeks left so..."

There was a shit rolls down hill attitude. The Advanced Life Support guys always let Basic Life Support arrive early to access the situation and hopefully to cancel the ALS call.

The administrators were annoying at best. I looked around the room during the inservice on the autopulse and determined these were not going to be my future coworkers.

One night shift with the ALS, I had a Jay and Silent Bob experience. 4 ALS guys and myself stood outside a gas station that serviced dunkin donuts coffee, eating potato chips, talking shit. 2 of them showed me nudie pics on their cell phones and wished me a happy thanksgiving. We were soon joined by an undercover cop who told us a story.

Some guy said to him, "I pay your salary!" so the response was the uc cop thinking that person could lick his nuts. What he did however was ingenious. He threw change at the "yuppie" and said "here's your refund!" Talk about man shit.

frustrated aggression

A homeless polysubstance abuser finds his way to our ED and places the responsibility on us to get him into detox for cocaine, heroine, smoking and alcohol. Unfortunately all we can offer him are directions to the bus station and a token for a free ride to another hospital which offers these services.

On the way out, he explodes and it looks like he is ready to fight. My senior resident and 2 police officers come by to back me up. It takes a long time but we finally get him out the door and on his way to the bus station.

That was the closest I have gotten as a resident to having a patient ready to hit me.

Tolerance

The attending tells me to administer ativan and haldol to a belligerent alcoholic. I go over there, do just that and wait. Around a minute or two later he is chilled and sleeping. Soon after the nurse comes running and says my patient is bleeding. I go over to him and see he has ripped out his IV and is storming out the door. I follow and start yelling "security! security!" to no avail. He escapes into the night.

We expected to see him again later BIBEMS but he never came back.

Vasovagal LP

I was perfoming an LP on a hispanic lady with her daughter in the room and there was a senior level resident as backup. She has a curvy spine and is obese and I miss it at first so I try to redirect to no avail. Instead I decide to switch positions and ask her to sit up.

At this point the senior level resident takes over. At the time he was about to reinsert the needle, she does a vasovagal and her daughter starts screaming. The lady is cold, passed out, with a BP around 84/56. We lie her down, start monitoring and fluids, and place the head of the bed down in trendelenberg.

A little later the attending got it exactly at the 7A bell before rounding with the new crew. He kept her in lateral decubitus.

Vasovagal IV removal

I am taking the IV out of a small hispanic female upon discharge. Just as I do this, she looks from the removed IV to me then makes the dizzy move. The nurse and I run over around 5 seconds later, by which time the patient is still holding her purse and coat in her left hand and hasn't fallen. Then we grab her and she lets go of her strength and we bring her to the nurse's chair. I let her sit there and about 10 minutes later she is ready to go.

Urine

I was transporting a patient to the CT scanner and when I arrived the tech took the bed and then began to yell at me, saying how disgusted he was by the urinal hanging on the bed at the head of the bed.

I looked at the patient's bed and saw that HIS urinal was hanging on the siderail.

marathon sprint

We had a guy from the cardiac room code in asytole then PEA and we knew digoxin was one of his meds. At one point during the resuscitation, I am nominated to run to pharmacy and get digibind. I sprint across the hospital then up 4 flights of stairs.

I enter pharmacy with the look in my eyes of someone who has done multiple cycles of CPR and run across the hospital and who was in a hurry. I try to mobilize multiple techs to find the digibind, since no one knew where it was located and I promised to return later to fill out paperwork.

I ran back faster than I have in years and we gave the patient, who was still being coded 5 vials. Finally the code ended and he did not survive.

Patient insight

We were in the trauma room complaining about a nurse working in the cardiac room who won't do anything. At one point, one of the older patients chimed in and said "she hasn't changed for 10 years"

drink

So there is an elderly gentleman who was in an automobile vs pedestrian. He has tenderness around his 9th rib on his flank so we order an abdominal CT with contrast.

Slight problem. He doesn't want to drink the po contrast after trying it out and the nurse in the room refuses to encourage him. So every few minutes I had to go by, encourage him to drink, watch the unhelpful nurse smirk, and listen to him yell at me about how he won't drink anymore.

Therapeutic wait times

One patient who had waited to be seen for around 3-4 hours starts marching around the nursing station and says "I need to get out of here - I'm going insane - I'm not even sick!"

So why did she come in the first place?

Bad signout

I think I had my worst signout last night. It was an elderly lady who had a fall and fractured her shoulder. Ortho saw and slung her and she was about to go out the door when her daughter complained she couldn't stand and she would need to be admitted. I asked if she normally had this issue since she had a cane at the bedside.

This caused the daughter to blow up and yell that the cane was because of her glaucoma.

Then the lady does a puffy cheek, vague look and I call the nurse over to help get her into bed. I go to discuss this with the attending who was in the room and didn't come over to help.

Then I return to evaluate and the daughter calls me "dense" and says she doesn't want me on the case. I was about to just walk away from them when the attending comes by and says I am a great doctor and this is an emergency room and I will be her doctor.

So I was stuck. The lady was actually ok. Her daughter was only somewhat helpful on the reeval and after I asked 3 times, only showed me 3 of the meds this lady was on, hiding 1 of them which added to her being a little bradycardic.

So we fed the lady and she still wouldn't move and I admitted her for weakness.

therapeutic pelvic

An 18 year old 1 month post partum comes in with vag D/C x1 month which "smells like dead people." She has midline abdominal mild tenderness and is afebrile.

I bring her to the GYN room and as I am about to insert the speculum, I ask her about what looks like a pad and she says there is no pad.

I take it out and see that it is black and oozing. Someone had left a 4x4 in her vagina at the delivery. The rest of her exam was normal.

Once the 4x4 was gone and she was put on antibiotics and GYN saw her, we sent her home with Augmentin and close follow up.

1st joint

I get a signout from fast track who had smoked weed for the first time today with the chief complaint of "dry mouth."

The problem was that he wouldn't move. He was passed out and wouldn't open his eyes spontaneously or cooperate with motor strength testing.

So his family is there, shouting "something is wrong with him! Figure out what's wrong! Why isn't he moving!"

I told them it would take time and they were livid. They didn't know anything about his drug experimentation.

Around 330A, after his family had gone home, he finally wakes up, we take a stroll through the ED and he says that that was some strong stuff and I give him the lecture about not doing that again then D/C him home.

Springing from the bed

I was in the middle of seeing a patient and my attending grabs me and says that I should go drain the paronychia on a prisoners thumb right away. This is directly after there is shouting and he has jumped onto the floor handcuffed to the bed yelling at a corrections officer.

So I went in there and did the I&D of a thumb paronychia without incident except him yelling at the officer from time to time.

Then I found out the real reason he was here is because he had seized but was therapeutic on his meds. He was hyponatremic but was refusing IV access and had ripped out his first catheter.

It took some doing to explain to him what sodium is and that his was low and this is dangerous. He never really grasped it. So my job for a while ended up being to try to transfer him to Bellevue for further investigation. They finally accepted him after I had gotten an IV and started IV NS bolus on him.

food

We never have food in the ED. Once in a while, the nurses will dig up some for the hypoglycemic diabetic but in general no one eats.

So an inmate was asking me for food and I brought him a slice of bread in a wrapper, which was all we had. He said no thanks and threw it in the garbage in front of me.

laugh or cry

So a psych patient was making a weird noise. One of the drunks walked by her room and asked whether she was laughing or crying. This caused the entire police force around the room to bust out laughing.

She ended up being my patient and I am not sure what the sound was but she didn't repeat it once I gave her some attention and figured out her issue.

Good to Mama

I was in the B side, surgery cramped room and none of the nurses were mobilizing to make anything happen for the patients. So I began to think about how bad our system can be. Then a song came to my head and I began to sing.

"The system works. The system works. The system called reciprocity.... You be good to mama and she'll be good to you."

The nurses heard me singing and laughed. For some reason, they actually started mobilized and we slowly cleaned out the chart rack.

Interpretation

We use a lot of interpretors at my hospital. Pretty much you try to elicit the services of a family member or a nurse or anyone really. If not you can always go to the translator phones.

This works most of the time. I was signed out an old man whose radiology was pending. His family had been in the ED earlier but had left and hadn't been back for a while. At some point he became really rowdy and kept trying to catch an Asian attending's attention and speak to her, but she couldn't speak hsi language and he kept being frustrated with her. Then he decided to get his clothes on and get off his bed and drag his IVNS on the ground.

So I somehow convinced him with somatic gestures to lay down on the bed and drove him over to the trauma room and plugged in the translator phones. Cantonese Chinese did not work so we were transferred to a Mandarin interpretor. This person could not understand him and got out of him that his language was some village dialect from around Shanghai, called Ningol. Then we are transferred again to a supervisor who tries multiple languages who then puts on another Mandarin interpreter. She tries very hard but in the end couldn't understand him and convinced herself that maybe he understood a little of what she was saying. So that was our attempt to communicate.

Meanwhile still no sign of the family. I am thinking social admit. I call their house and no answer and leave a message. Time goes on and around 2A we still dont have an answer from the family. We call again and finally get someone who we convince to come in.

He comes in very mad. Apparently the security guards were confused and thought he was just trying to sneak into the ED and didn't understand that he was the family member of someone in the ED. So it was really our (the ED's fault) that we couldn't dispo the village man all night.

If I had been him and NO ONE spoke my language and I had no clue what was happening or where my family was, I would have also been riled up.

Enzymes

"That lady? She would spill cardiac enzymes if you tapped her on the arm."

Foley in ED

A patient looked like he was in urinary retention and an order for a foley cath was written.

The nurse responded "We don't do foleys on young males."

The resident responded "what do you mean! Of course you do. I can't believe you'd tell me that. That is unacceptable!"

GI bleed

"Can she consent for a central line?"
"no she has no brains"

AMA??

"He wants to sign out AMA. Go talk to him."

"You want me to try to convince him to stay or go?"

XRT

Resident speaking to family member: "they might need radiation therapy"
"What is that?"
"You know, it's radiation."
"oh..."

Ultrasound guided peripheral IV on splitting psych pt

"Ow! You're in my nerve!"
"That's not your nerve."
"Don't talk to me that way! Get the hell out of my room! Go away! I'm mad!"

20 minutes later:

"I'm sorry I was so upset."
"That's fine. Can another doctor get the IV"
"Of course."

Happy ending with a RUE IV after a failed, infiltrated attempt on the LUE with ultrasound.

Cycle of Medicine

The CCU transferred a patient to my regular medicine floor who is now DNR/DNI. As I began to flip through the chart I stumbled upon the ED note. It was written in my handwriting. It was clear. I had admitted her from the ED for a tune up to medicine with a stage IV decub and some bilateral crackles and LE edema on my exam. Medicine whisked her away so fast I never finished the workup in the ED. Little did I know she would have such a complicated stage IV CHF course in the CCU.

I saw her and she was the same sweet lady with a failing heart physiologically but not figuratively.

Max Discharge Meds

Today I filled out the discharge paperwork for a patient, sending him home with 15 home meds. My question is, shouldn't we just let him live at the hospital. I believe that is a record.

The worst part was that I had to fill out the scripts, then retranscribe the info into the discharge summary then rewrite the info again into his home health care request.

On the way out the door with his sister, he complained to me that he was on too many meds.

Hell no! We won't go!

Top 10 reasons patients are still in the ward in the AM after you left thinking they would be discharged

1. Some dumb paperwork error
2. The nurses changed shifts and the new nurse didn't know the patient was pending discharge
3. Doctor forgot to put in the order to discharge
4. Healthy patient without relevant medical history for it, experiences sudden onset chest pain and shortness of breath
5. Patient's ride didn't show up
6. Some obscure lab abnormality was noted which can't be explained away
7. The home health aid reinstatement didn't happen
8. Patient with no psych history suddenly experiences a psychotic breakdown
9. Vascular access stopped working
10. Patient is undocumented or uninsured and shouldn't have been sent home and this was caught by the social worker
11. They don't want to go because they either don't have A/C or a heater at home.

1st day of medicine digested

Food is an experience which is starkly appreciated with all 5 senses, the crackling sound of pan frying, the smell of a tea, the taste of strawberries, the feel on your tongue of melted chocolate, the sight of a chef's creation.

But then at some point it comes out the other end as stinky shit.

Such is the difference between working in the ED vs the medicine ward. One service brings them in and the other must deal with sending them out.

Return to SICU

I went to the SICU to request a PICC line. 4 of the nurses recognized me and sat me down in the break room for a quick break of coffee and cookies. They were very sweet and asked a lot about how I was doing. It was so nice to see those tough nurses who gave me hell for a month but obviously liked me.

Night of Trauma

Last night was my most busy night of traumas as a resident (although I have seen much busier nights as a medical student in new orleans with 15+ activations in a night).

Everyone was smashed and had BALs that bought them a bed overnight. There was a lot of variety. One guy had a gash ripped out of his abdomen and torso, exposing his muscles, which was done by the claw end of a hammer. Another guy got drunk and fell onto the subway tracks, ending up with a periorbital flap with extension deep to his skull. 2 brothers came in whose faces were sliced open by a knife wielded by a crazy uncle. Another guy was hit in the head with an unknown object and had a big forehead hematoma.

There were also plenty of drunk injuries who weren't activated. One guy drank himself silly, fell and landed on his head then had a lot of neck pain. He already had neck surgery so I wonder whether he really did fracture his C-spine or have ligamentous injury. The official read wasn't up by the time I left.

The toughest guy to babysit was one of the inebriated guys who got mad at the surgeons suturing him and tried to hit them and when we tied down his arms, tried to pee on them. He got a lot of Ativan, around 8mg and plenty of Haldol to go with it. I tried waking him up when the alcohol should have cleared his system but the Benzos needed some time so he ended up being a sign out.

In between traumas I was seeing the other patients including what should have been fast track. One guy had a small cyst on his lower extremity that had been there for 5 years and it popped tonight and was a little bloody without any pus. He had no other complaints but felt this was an emergency. He was tough to take seriously.

The morning really sucked because the oncoming team did not see how busy our team was during the night. Instead they saw a full chart rack of surgical patients to be seen. The way our system is set up, the surgical patients and traumas are seen by the same team. Being inundated with trauma really slows things down. I think it would be better to have a resident assigned to the trauma room, who takes care of all the traumas and the other 2 residents could work their way through the slew of surgical patients.

Line of the night: "Why did you come in?" "I'm don't know. I'm not a fucking doctor!"

Out of house radiology - Good or Bad

We don't have in house radiologists overnight and the films and CTs are sent to Minnesota.

I felt bad for one of my patients who was a construction worker who fell down one floor and whose spine and left leg I pan scanned. There were problems all night with the radiologists receiving the C-spine CT and T-spine CT. So this guy had to sit in a C-collar around 10 hours while I constantly went back and forth to radiology asking what was the problem.

Finally one of the techs in our department got my guilt trip. I explained to him how the inability of our department to get the CTs to the out-of-house radiology was making the entire system suffer, including the patient who was in an uncomfortable C-collar, the nurses who were responsible for him, me, the other patients whose bed he was taking up, etc, etc. When my tirade was over, I shook the tech's hand to let him know I wasn't his enemy just a concerned person. Somehow this did it. Within 20 minutes, I called back the radiologist, who had received the films and who read them right away.

Back on it

After about a week of being back in the ED, I feel like I am finally back on the horse. I am coming up with better A/P and starting the workup before actually presenting the patient to the attending. We don't always agree but a huge part of the learning process is making my own decisions and defending them when someone believes something else should be done.

Feces or Playdoh

I was told today by my attending that it is a right of passage to remove a fecal impaction manually. I brought the unfortunate elderly lady to an iso room, gowned up completely, and began my work with a generous portion of surgilube.

This lady's impaction filled most of a bedpan. pulling it out was tricky because it was sticky to the walls of the rectum and it kept sliding away. Once I removed my finger I would have a little glob of sticky playdoh like substance that I flicked into the growing pile in the bedpan. Then back to the task.

pelvic history

I saw a mexican lady with abdominal cramping for a few days and a +B-HCG. During the rule out ectopic and rule in IUP, I performed a pelvic exam. She said that this was her first one which I found very odd considering she already had a 7 year old boy, who was birthed during a C-section.

One of my coworkers chalked it up as a cultural thing that many mexican women deny they had ever had a pelvic. Why is this?

High tech already dx

A patient presented with R lower extremity pain on ambulation and erythema over the majority of his anterior lower leg. At first I was considering DVT vs thrombophlebitis, but then my exam didn't fit that. He had pain to plantar flexion and relief with dorsiflexion. In addition the R leg was a little colder than the L leg. Upon further questioning the family had already done a workup in Equator and gave me a USB stick.

I went to a computer and viewed the arteriogram they had given me. Next I sought out a radiology expert who was very happy that I could explain to him how to get the MPEG on the USB stick working on his computer.

The patient had filling defects the inferior patellar to a little superior to the malleoli with peroneal preservation.

I handed over the USB stick to the surgeons and told them that they would find their film right next to the family's school essay on history.

How fair is life

2 codes in one day, both very different patients and very different outcomes.

The first patient was had tons of problems mainly secondary to his lifestyle and no family. The second patient had one problem - a car fell on his head while he was under it using a car jack.

The first patient survived his code and now is protected with pacing pads.

The second patient did not survive his code and the family grieves.

Forest

"you can't send her to the floor. That is like the forest and she can't fend for herself yet. Send her to step down."

What is wrong with the floor? Why can't they take care of really sick patients?

My first uncontrolled intubation

Our new admit came in with respiratory distress taxing out her accessory respiratory muscles. I took one look at her and decided that she had impending respiratory failure so I grabbed the intubation box and called my nurses together and asked for the attending to be in the room.

She was full of more mucous than I had ever seen in my life. I could not suction enough out. I just kept taking turns between ventilating and suctioning. The venting also did not go well because I couldn't get a good seal because she didn't have teeth and every ventilation was accompanied by a gurgling of air escape.

I tried versed and my attending did not want to use a paralytic. Everytime I tried to open her mouth I was greeted with locked jaws and lots of mucous.

Everytime she began to desat a little I bagged her back up, air leak and all.

I finally tried propofol and she took a lot before I was finally able to open her mouth. What greeted me was lots of mucous to suction.

Her head had torticollis and she was in a C-collar so I used in line traction. Even with the less than optimal angles I found her epiglottis relatively easily with a mac 3, lifted and found tons of mucous in front of the vocal cords. I called for suction and cleared a path.

Then the cords - finally. The tube passed easily.

Her breath sounds weren't equal bilaterally and she was satting around 80% so I pulled out the ET tube a little and then her sats went up to 100% and the breath sounds became equal.

It was a tough first non-OR/anesthesia intubation I had done and it was tough.

The search for flow

"You hit something... but was it the subclavian"

Obviously not because I could not thread the guidewire.

"It's not so easy. If it was easy we wouldn't need doctors."

True. I really need more practice.

"Everybody calls me and says they want a line right now. They think it is so easy."

I believe you. It is not so easy. I can't find this vein.

Fellow's 1st Rounds

"Did she have a BM?"

Something so simple that we should know, especially since it is a SURGERY intensive care unit. Yet we did not know the answer. Why? We don't have our eyes on the ball. We are pulled in a million directions chasing insignificants and forgetting the important things.

Where are we going?

It is a prevailing theme on rounds that many times we have the inability to mobilize our SICU patients and get them transferred to other places. We never get moving. Much of this is related to the fact that we are not the primary team and must consult them with management decisions and their usual course is to try to keep the patient in the SICU as long as possible. Because of this and the lack of patient mobilization, it is difficult to really know what the patient prognoses are. So I was on the phone with infectious disease trying to push the fellow to make a consult and she kept asking questions trying to find a way not to consult. Finally she asked me what the prognosis on a certain patient was. I immediately got my attending on the phone, because we just don't deal in prognoses during our rounding and discussions of the patients.

First big fight with a nurse

I had my first big fight with a member of nursing staff today over something ridiculous. I wonder if the 27+ hour calls are already catching up to me. I looked at my white coat, which had been moved from a chart rack to a chair, and some of the contents from the top pocket had spilled out onto the nasty SICU floor. I replaced the contents and placed it back on the chart rack. A nurse came up and told me I couldn't do that. So I showed her how it would be out of the way of people trying to access the charts. She took it off the rack and handed it to me. So I placed it on the other chart rack. Then she said I should put it on the chair or on me. I explained that on me it was too cumbersome while I was writing orders in the computer and that on the chair it would always get run over by the wheels and leave black streaks on my nice white coat and how professional did that look? So she asked what was wrong with me and I asked what was wrong with her.

Conversations

I was just realizing how different the SICU conversations are from the ED conversations. I miss the patients in the ED cussing at me, yelling, and spitting. Now I engage in monologues in which I ask them really loudly to show me 2 fingers.

The End and Beginning

Orientation month is over. All the residents I was probably seeing too much of are finally off to their separate ways. I wonder how they are liking things. Is residency, actually internship everything it was cracked up to be.

This program sucks!

Sitting around in the beeping SICU waiting for the next problem. That is what I do. I solve problems. Most problems though I am not smart enough to solve so I call the fellow or a consultant.

The bane of my existence is the computer. You would think everything would be easier with computers. It could be except that the system they bought for this public hospital is very counterintuitive and miserable to use. Sometimes I get caught in loops of trying unsuccessfully to input an order while everyone is waiting, or I can't find a lab result, or how much of a certain medication someone is getting. It is rotten and it is because I am inept at using this piece of shit medical informatics program.

My first real shift

Actually my first call, my first shift after the orientation month and my first off service. 730A on Monday until 1230P on Tuesday with a 3 hour nap during the night.

SICU is crazy busy. We rounded until around 12P on my on call day and that was with 2 other efficient residents. Then I spent until dinner time doing procedures and ordering things for the nurses. I did my first central line, a right femoral. I also did a few arterial lines. The procedures were good and I had a fellow teaching me who knew his shit well.

Speaking of the fellow, he was the only thing between me and falling off the edge many times that night as new orders needed to be inputted and management decisions on extremely complicated patients needed to be made.

The computer is your worst enemy. Multiple I needed to input a STAT order but could not figure out how to do it and the nurses had no clue and the fellow was gone.

It was a long call and the worst parts were by far the times I was alone and nurses started giving me information or asking for new orders. Probably the worst was the new admit at 1A that I basically had to do myself because the fellow wouldn't wake up, and who was complicated by the fact that he wasn't in our computers and he needed a propofol drip.

It's all about survival and I am still kickin. One more day towards the goal of never having to do off service again

Systems

So I have heard the greats talk about systems for so long but I didn't really get the full ramification until being a resident. The issue is that along with gathering data and making educated management decisions, I am responsible to make sure these decisions get carried out. If I want a patient to go for an abdominal CT, I can put in the orders and hope he magically gets there, but the reality is, if too much time goes by and the CT doesn't get done, I must bring him myself to radiology or find some other means.

The problem with systems is that they are dependent on people. You don't just make a decision and automatically it happens. There are many bottle necks in the system for many reasons. Every health care worker is in essence a potential bottle neck for the patients who have waited for what seems like forever for service.

As I understand things, the way to be a good resident is to know how to work the system. By now I should already be a great information gatherer. I make decisions in conjunction with attendings. The real trick to master at this point is how to mobilize the system.

First paycheck

They warned us that the first paycheck would be less than usual. Still. It was sad to see the faces drop, mirroring shock and dissappointment as my fellow interns received our first paycheck. I think it was really outrageous to the people in my group who had not yet had a job in which federal taxes were taken out. These people were quite surprised that Uncle Sam actually demands around 30% of your paycheck. I think I was most upset that my wife still has more take home than me, which makes her the provider in our house yet again. Need to sit down with someone who knows their shit and find out why.

1st ED shift

Today was my first shift and I was thrown into the fire. 12 hours at the Mt Sinai ED with the complex computer system, constant private physician consult, and infrastructure in which I am not yet experienced. I worked on the South side with Meika.

I introduced myself as Dr. Curtis for the first time this morning. It felt natural, much more so than the medical student introduction of "I'm Henry, your medical student" or "I'm student doctor Curtis", etc, which automatically discredited your knowledge even before you told the patient you had no clue and would have to discuss things with another doc. This was different. The first impression lent itself to a better alliance with the patient.

At about 1015A I started getting really hungry even though I had eaten cereal and drank my Illy coffee. I kept being consumed by the thought of food until lunch finally arrived, a shrimp burrito. Even after it arrived though, I was behind the 8 ball and had 2 patient H&Ps to enter into the computer so I had to keep working for a while before I could take a 10 minute break. I ate alone in the physician room. Food has rarely tasted so good. I was carniferous.

Things got a little crazy for me at this point and at one point I realized I was seeing 4 patients at once, with one of them being an altered mental status, possibly septic, satting at 87%, but DNI resuscitation. Besides the logistics of the resus room being on the other side of the ED, taking a resus patient was complicated further by the fact that his family was there and one member was a surgeon at the hospital, who was overseeing all the treatment.

There were rewarding moments and good connections with the patients and nurses. For instance one elderly woman with a Klebsiella colonized GU tract stated that I was the best looking doctor in the hospital. When I attached a vent up to a patient I had transported to the MICU, one respiratory therapist said I almost did it right and removed a piece of tubing then reattached the ventilator circuit. I was defended by the other respiratory therapist with whom I had transported the patient and she said I did a perfect job. My first ABG was successful, just not by me. The nurse with me finally tried and succeeded after I tried for 3 minutes and couldn't hit the radial artery on my volume depleted elderly patient. She showed me her trick of holding the slippery artery in place with her free finger and we were cool the rest of the shift. It is all about making a connection with people and building a working alliance, whether it is the patients or your coworkers.

Although I must say in general the ancillary services were incredible, I requested an abdominal CT on one patient and was caught up in tons of other work, thinking that it would be done. At 630PM, the nurse informed me that he still hadn't gone even though I had personally spoken with the radiology intern who said it would happen. I had enough and wheeled my kidney stone patient to CT myself and dropped him off. This meant a signout, as my shift was over at 7PM, which isn't the best form.

Signout went well. I was able to quickly encapsulate the story of my signout and to throw in buzz phrases to let the other team know that he was perfectly stable like "he's had kidney stones for 5 years" and "he had no nausea and vomiting and is well hydrated" and "we are only waiting on the official radiology read of the CT." This let them know that they wouldn't have to treat him as a new undifferentiated patient to figure out.

This was a great shift and reminded me just how exciting and rewarding ED work can be.

Thunderous voice

So I went to my first official residency conference this morning. Our program director was making a point of how suspect residents have been drug tested in the past. Just as he made his point, a roaring thunder resounded. His response, "and I mean it!"

1st official orientation day

The week of the real EM orientation month started well and breakfast and lunch were included. We began the morning with 2 activities ordained by our residency director. First he asked us to compare thumb sizes and line up in order of size. Then he compared height to thumb size.

The next activity was a little more engaging. We had to meet everyone and ask them for a similarity and difference.

There were such examples of differences such as one liking Queens better than Manhattan, one having a wife who is pregnant, one who plays golf, one who is NOT a coffee snob, one who grew up in NJ, one who likes mainstream music, one who prefers the bus to IKEA, one who previously had stitches to the left hand, one who visited China and Japan, one who thought speed dating was cool, one who preferred Adidas, one bad at inlining, one who owned a house, and one who preferred spas to relax.

Examples of similiarities included enjoying yoga, being married, liking concerts, liking NYSC, preferring lounges to bars, liking all foods, going to starbucks in the AM, playing tennis, living in a small apartment, being married to a non-medical person, thinking the Eiffel tower is overrated, enjoying travel and Harlem, speaking German, and needing breakfast in the morning.

Our RD is a very cool guy and I liked his activities. It will be interesting to watch how he shapes our future experiences.

White Coat Ceremony

Today I took part in a new breed of white coat ceremony. I had previously ordered my 4 allotted white coats which were too big. I seriously got lost for half a day in the one I tried on. So I went down to the laundry department and waited in line for service. It was totally chaotic. Everyone was trying on new sizes and I modelled between size 44 and 42 for my EM residents who were with me. They all agreed on 44 which is still a little big for me. Today it was much more about the practical aspect of sizing instead of the ideal. Will much of residency follow this trend?

First day of Resident Training

Today and tomorrow taking an Advanced Cardiac Life Support course. It was a fitting seguay for Emergency Medicine residents.

I arrived early thinking that I would go to the bookstore and purchase the book. I found out first from the building security guard then from verifying the information with three medical students on the street that Sinai no longer has a bookstore and hasn't had one for about a year. They order their books online.

So I accepted that I wouldn't have the book and strolled over to the Starbucks and ordered my usual, very plain, grande regular. After a little bit, I was approached by someone at a nearby table who asked if I was EM. I said yes and she said she remembered me from an interview. So I had met one of my fellow EM interns and conversation flowed well.

We headed over to the lecture hall, heard some dynamic speakers then ate lunch and afterwards broke up into small groups. Our residency got our own small group and the main course instructor. It was a great chance to get to meet the people in my class. I think I spent as much time trying to remember everyone's name as I did concentrating on what was being taught in the small groups.

My big errors of the day were theoretically breaking the manikin's teeth, whom I was attempting to intubate and proposing an epinephrine drip after converting a dysrhythmia with Amiodarone.

I like my fellow interns and believe it will be a good four years. We all seem to come from different backgrounds so it will be cool to see how we mix.

Last rotation

Today was the last day of the last full rotation of medical school. All that is left is one week of Special Topics and graduation. This is amazing. Four LONG years of my life are finally coming to a close and making way for the next adventure to begin.

The feeling is great. It is like having a huge weight lifted off my shoulders. I also have 2 months of vacation built in before residency separated only by my graduation ceremony.

Catch the suttleties

A medical goal to strive for as a provider is to consider things others wouldn't.

A fellow told me that "it is very easy to catch the slam dunks. We get paid the big bucks to recognize the suttleties."

MATCH INTO EM

Congratulations, you have matched!

Monday before Match Day. This is the moment when you know that you have succeeded. This is the moment when you know that you will enter into the career path which you chose and which you believe will fulfill you. This is the point I mark where the real journey begins.