ED shift

I'm awake after napping over four hours after an ED shift last night, which was totally awesome. Not only did I have a fantastic resident, I was on the overnight shift with my one of my best friends, making it all the more fun.

Here's what I got to do/witness:
- Watch a trauma code (fortunately, the guy had some injuries but was stable) and suture his facial lacs (first time suturing from start to finish!)
- Witness a partial complex seizure and pull an intraosseous line. An "IO" line is a means of delivering fluids when an IV cannot be placed. It screws directly into the medial side of the tibial bone.
- Drain a perirectal abscess (ouch but the guy felt so much better afterward and was so grateful)
- Evaluate pt with abdominal pain who turned out to have gallstone pancreatitis
- Evaluate pt also with abdominal pain. Dx: rectus sheath hematoma requiring angioembolization
- Evaluate pt s/p MVA who had an impressive displaced thoracic spine fracture. Admitted to neurosurgery for stabilization in the morning
- Head down to the OR to catch the beginning of an emergency leg amputation for a pt with necrotizing fascitis. The pt was covered head to toe in purpura, on a thousand pressors, auto anti-coagulating, basically a mess...incredibly sad. The team kept the OR extremely warm to prevent hypothermia, as the pt could longer autoregulate his own temperature.

All in a night's work!

Last week, I saw a guy with Gardner's syndrome and two trauma codes, where I got to place a suture (just one haha) in one man's ear for a nasty ear laceration.

Novelty is exciting and I'm finally feeling that I'm getting to learn how to do stuff with my hands. Appropriate for a surgery rotation, I suppose.

Disconnected

Hmm. I feel really disconnected from the world.  We had a snowstorm like half the country earlier this week.  While classes, schools, and most offices closed for the day, for us, it was normal day.  After all, it's always sunny and 72 degrees in the hospital. Even the roads clear super fast around the hospital so the only remnants of the storm are man-high piles of dirty snow in parking lots.

This week, I'm on ortho and so far, I've seen a total hip, knee, and laminectomy.  There's some crazy drilling and hammering action in the OR.  Cool for a few days, but I am again reminded why I will not be a surgeon.  Also, ortho has got to be the most testosterone-driven field I have yet experienced.  The ortho workroom is mixture between a boy's frat and locker room. At least it doesn't smell bad.  But I exaggerate - I'm with a great resident this week who loves teaching, and I've learned more about MSK this week than my third year combined.

It's like falling in love

From a email today from one of my college mentors, a physician and writer with heaps of wisdom and a sense of humor to match:
"Nothing is more fun [than clinical medicine] than falling in love."

Indeed, Dr. L, indeed.

Immersion

“As my life grows richer within the hospital, it becomes less so outside of it.”  ~fellow third-year classmate.

In those words, my classmate alluded to ever-elusive work-life balance and challenge of maintaining relationships with friends and loved ones while devoting full days and nights to clinical work.  It is not so much the frank amount of time spent in the hospital (although the 80+ hour weeks on inpatient months certainly contributes),  it is the emotional energy required to be in a position of constantly caring.  Indeed, there are days where I am so drained by my patient interactions that I simply haven’t any more emotional energy left to expend.  Sometimes, at the end of the day, I simply cannot give any more of myself to others.   Our relationships suffer because of it.   

Another classmate, in tears, described learning that her friend had died suddenly of cancer during her surgery clerkship.  Our school’s policy mandates no absences except for immediate family emergencies.   Forced to miss the funeral, she clearly was filled with guilt and sorrow.   All of us entered medicine understanding full well that we would have to make sacrifices.   Yet it does not make it any easier. 

Then there is the emotional disconnect.   As I grow increasingly at home in the hospital, I become more isolated from those outside of it.  I’ve noticed it with my friends and even more so with my parents.  My parents are interested; they want to understand.  In our weekly conversations they will ask, “How are you doing? What stories do you have?”   Where do I even begin?   My parents are not physicians, and luckily, have little experience with the medical system.  Even the most superficial conversations require layers upon layers of explanation (think: a resident is a doctor who has an MD but is still training.).  I don’t blame them – how could they, or for that matter, others who have not experienced the immersion that is medical school, begin to understand what it is like?  Many times, we will just end up talking past each other, and that is okay.  I am still their daughter, and it is their concern and willingness to ask and listen that matters the most.

Would I trade this for something else?  No way.  I am truly happier this year than my first two years combined.   Sure, I have good days and awful days, but I am stimulated and challenged every day by what I learn.  I am excited to talk to my patients, to understand their experiences, and learn about their diseases.   I feel the camaraderie of working within a team and a strong sense of solidarity with my fellow classmates.   I see myself growing and changing in ways that I could never have predicted.  Eight months into my third year, I have become tougher and more real, yet I remain an idealist.

Tough

Today was tough - the kind of tough that makes you want to call your mom, dad, sister right after work and tell them that you love them.

We told a lady today that she had stage 4 lung cancer and that there's no cure.  She has a teenage daughter who recently started sleeping with her parents because she wants to make sure that their hearts are still beating at night. The minute we reached the stage 4 part, she developed that deer in the headlights look.  Pure shellshock.   I watched as her husband's eyes glazed over, as he reached over to squeeze his wife's hands, as his wife struggled to maintain composure.  "4 weeks ago, I was lifting weights," she cried.   And now this.  Sometimes, medicine sucks.

Resources

I had a patient who was admitted for diarrhea - 3 weeks, every day 3-4 times/day. He came to the hospital because his daughter was worried that he looked gray and weak.  Turns out, he was really dehydrated.  So much so that his kidneys became temporally injured (acute on chronic kidney disease) and he was found to be hyperkalemic.  We took care of the hyperkalemia, but what about his diarrhea?  Ironically, his diarrhea disappeared while in hospital, just resolved entirely!  We did the whole workup - fecal cultures, leukocytes, fat, ova and parasites, stool osmolality, celiac disease workup.  It all came back negative.  This patient stayed in the hospital for 4 days.  4 days!  His hyperkalemia we corrected on the first day.  His diarrhea was resolved the minute he landed in the hospital.   In the U.S., we have such luxury.  If we'd been in another country, this guy would have been sent home after day 1, as he wasn't acute ill after his hyperkalemia was corrected.  There's nothing that would have been different had he gotten this diarrhea workup as an outpatient.

Another patient we saw was in her late 80s, who we discovered had a Cr over 7 (baseline in the 1s).  Acute kidney injury and we're starting dialysis on Monday.  Our attending mentioned that in any other country, i.e. Australia, that these individuals would not have the option of dialysis.  In Australia, apparently, individuals over age 65 are not eligible for dialysis.  Is our aggressive approach to care appropriate?  I can't help but think - this is what makes our health care so expensive!  Yet if I were these patients, I'd want the Mercedes Benz workup too!

Pooped

12 straight days in the hospital.  Or 11 if you don't count orientation on the first day.  I'm on medicine.  I love it, but I'm pooped!  Tomorrow I have a day off and then I'm on call the next day.  q4 is really brutal!