tomorrow will be interesting

I start my life as a attending tomorrow.

I feel pretty much as anxious as I did  that sleepless night before I started my residency. It is a different type of anxiety. It’s different for sure, but it is so obnoxiously there.

I am not as nervous about the doctor part as I was the night before I was an intern. To be clear, I am very nervous about being a doctor (as I am sure, in my chosen specialty, I will always be), but the night before I was an intern, I didn’t even know what it meant to be a doctor.  At least now I’ve been a doctor for more than a minute.

Graduating from residency is emotional, something I will write about at another point.  But one thing is for sure, you make good friends.  One of my closest started his attending gig on July 1.

I asked him how it went, and he told me that for the first 6 hours of his shift he completely forgot how to be a doctor.

I can see that happening to me.

It’s a new place, new people, and for the first time ever, you are on your own. There were many times in residency when we were probably actually on our own, but it didn’t feel that way. At the point where we had been given enough responsibility and trust to be somewhat on our own, we had been there for 2, 3, or even 4 years and, for better or worse, we knew our team. If our attending wasn’t available, we still had seasoned nurses, pharmacists, and even techs who had good clinical judgment, who knew our strengths and weakness in a crisis, who could do good cpr….

So he told me, a 70 F came in after a mechanical fall… no head strike, no LOC, otherwise healthy, currently feeling great.  If she made it past the trauma bay and into the general department, that generally means the mechanism was insignificant and her primary survey was intact. In other words– her airway was patent, breathing/lungs/O2 sats were fine, circulation was functional, her vitals signs were beautiful, GCS pristine. SO, easy peasy, right? Complete a secondary survey.  If she’s over 65, depending on mechanism and other factors more than likely she’ll be getting a head and neck CT, you know this off the bat.  You keep this in mind as you prepare for the secondary survey where you’ll figure out the rest. And as always, you’ll be thorough. Xray an elbow? Arm? Great. Belly tender? CT a/p.

This is our bread and butter.  We trained at the busiest level 1 trauma center in our region.  And on this bread and butter case, my friend could not think. He literally could not decide what xrays to get. If we were back at our home shop, this would have been second nature. This would have been the patient the senior picked up because it would be uncomplicated, allowing him/her to supervise the junior residents as they picked up the more complicated, time-consuming, teachable cases.

But this wasn’t his home.  He didn’t know anyone that worked there.  No one knew him, no one yet trusted him.  This was an entirely new experience.Screen Shot 2015-07-12 at 10.57.10 PM

And with that, I get it.  He is one of our best, and I know without a doubt this woman got the best care possible, but I know better than most– when you are nervous and anxious, and on top of that, OUT OF YOUR ELEMENT, as I have mentioned a million times in the past, your brain just_ stops_ working.

Sigh.

I won’t sleep well tonight.

And tomorrow will be interesting.

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really?

“Until I get there,” the urology resident instructed me, “you must apply direct manual compression to mechanically disperse the penile and preputial edema.  This will hopefully minimize the swelling and allow for manual retraction by the time I get there.”

So in other words, as my attending so eloquently directed me “grab that thing and hold on tight.”

There are a lot of awkward moments in the emergency department.  Many of them have to do with interactions with nurses (I am really sorry my patient threw up on your leg AGAIN yes he can have some Zofran), paramedics (last time I saw you, I am pretty sure you were making out with one of my co-residents in the middle of a bar), and even correction officers (um, please, just un-handcuff him for the lung exam. Fine, you can keep his feet chained to the bed).

My most awkward moment of late, however, had to do with one particular patient with one particular penis problem.

Paraphimosis is when, in an uncircumcised or partially circumcised male, the foreskin gets retracted behind the glans penis, starts to swell, and gets stuck in that position.  The reason this is an emergency is that this swelling then cuts off blood flow to the head of the penis.  The head will start to turn dark and eventually may become necrotic.  It’s usually iatrogenic in nature, meaning, we cause it.  In this case the patient has a foley catheter in his urethra (secondary to a recent surgery).  He resides at one of the homeless shelters that also provides some medical care, and the nursing staff inadvertently forgot to replace the patient’s foreskin after the most recent foley catheter change. This is actually a great case for me, it’s one of the few urologic emergencies and a case up until now I had only read about.

As great of a case as it may be, the treatment is nothing short of mortifying. Very reluctantly I pulled a chair into the room, and for the next fifteen minutes I sat by my 65 year old patient’s side and “mechanical dispersed the penile and preputial edema,” AKA, I very firmly held his penis in my hand.  For fifteen freakin’ minutes.

Really? I am really doing this right now? Please, just for a moment, put yourself in my shoes.  What are you going to talk about to make this less awkward… football? The weather?

I am a doctor, and this is what I do at work.  Really.

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by the way, it’s sunday

I think was feeling a bit nostalgic tonight. I got out of work early and for the first time in what feels like 9 months, it was still light out for my walk home.  I also may have hallucinated the smell of spring in the air.  Not entirely sure what day it was or what to do with a whole extra one hour of free time, I decided to read through some of my old posts and I– as I have said to myself many times before– realized I need to write more.  I have so many stories from this year.  Some are disturbing, some are sad, most of them are just dumbly entertaining.

As I try to get my act together, allow me to refer you to a post I wrote almost exactly two years ago about what was, in retrospect, maybe one of my favorite days of medical school.

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the wheels on the bus go…

I need a new method of transportation.

Sitting in front of me, alert, oriented, and chatting away on her cell phone was a patient I treated the Friday before.  I saw her last week when I was working triage on the Labor and Delivery floor.  She was high as shit and annoying the piss out of me.  She was complaining of leg pain but wouldn’t answer any of my questions.  It was an imposition that I needed to know about her leg pain, that I needed to know her medical history, and that I not only did I need to know her daily dose of methadone I needed to know what other drugs she took today. I lightly touched her leg and she started wailing uncontrollably and making a scene.  While everyone else on the floor was freaked out about this, I actually felt like I was at home, in my element back in the ED. She is status post c-section, post-op day 8, and is boarding at the hospital because her baby is withdrawing from methadone.  At this point I am tired, annoyed, and have about a million other things that needed to be done 20 minutes ago.  The trouble with this though, as an emergency medicine physician, is that as much as people piss you off, and as much as you think they are full of shit, people can still be sick.  This woman was recently hospitalized, had recent surgery, is an IV drug user, smokes cigarettes (all risk factors for a deep vein thrombosis), and is now having unilateral lower extremity pain and tenderness (which may or may not be real). Those of you who read this blog who are in the medical field (none of the three of you), will understand this: I recommended a lower extremity doppler to my attending.  He, who had the benefit of knowing this patient well (perhaps there’s something to be said for continuity, or maybe just experience), nodded politely at my “emergency medicine” work-up, and discharged her with some Tylenol.  A week later on that bus she was still annoying me but I was relieved to see she was not tachypneic, DVT and pulmonary embolus free.

On that same bus ride, sitting directly next to me was another lovely gentleman I ran into two weekends earlier.  Two weeks prior he was asking for money on the subway.  “I just need $6.75 for the commuter rail. I already have a dollar.  I can’t get into the shelter tonight and have nowhere to stay and really need money for the commuter rail.”  There was no response from the passengers and next thing I know he’s making a scene, screaming, swearing, punching the walls, and scaring the crap out of those from whom he was just begging for money. Before my experiences working as an intern at the hospital where I work I think I probably would have been frightened, or maybe felt bad for not giving him money. I think it’s also important to note, however, that I know this guy.  During my first month as a doctor I saw him come into our trauma bay two times over the course of one twelve hour shift.  The first time he left angry and AMA (against medical advice) as soon as he was able, the second time he was admitted for a heroin withdrawal. During his outburst on the subway I was neither frightened nor felt compassion for his plight. Mostly because he turned into a jerk and started scaring people. Needless to say, yesterday the same dude, in the same red sweatshirt, hopped onto my bus.  “I just need $6.75 for the commuter rail. I already have a dollar.  I can’t get into the shelter tonight and have nowhere to stay and really need money for the commuter rail.” And as luck will have it, there was a seat open right next to me.  I was about to get a bit nervous, I didn’t want to be between him and the window when no one offered him money.  Luckily, there was a nice gentleman with one of those classic heroin toothless smiles (who also looked vaguely familiar) in the front of the bus who gave him five bucks.  My buddy in the red sweatshirt got off at the next stop.

And then, no joke, toward the front of the bus on the right there was another familiar face.  It was an overweight 28 yo male who I have treated on numerous overnight shifts.  He lives in a shelter and has a multitude of mental problems and likely a very low IQ.  He abuses the system, but has no idea what that even means.  He likes coming to the ED.  We give him sandwiches and we’re nice to him.  Last time I saw him it was at 3am because he had a cut on his foot.  It wasn’t infected, though with his lifestyle and medical history, it easily could have been.  It was just a little cut.  I cleaned it and gave him a band-aid and wrote him a doctor’s note so the shelter would let him back in at such a late hour. Twenty minutes after he left I called the shelter to make sure he arrived, it was a slow night.  I walked by him on my way off the bus and we made eye contact, there was no recognition on his part.  And I’ll probably see him again next week.

Oh how I love taking the bus.

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kickin’ it

Just about four months in, and I still get a kick out of being called Doctor.

Thus far I’ve spent 2 months in the ED, a month in the MICU, and am now finishing up my month on OB.  All four months have been utterly exhausting. But I can’t believe how much I’ve changed in such a short amount of time.  You really only realize it when you compare yourself to the med-students.  Once every few days, for survival purposes, it’s necessary to listen to them present on rounds and realize that you are not the total asshole that everyone else makes you feel like. You’ve actually come a long way. God I love med students, especially the third years.

Intern year sucks and there is no way around it.  Sometimes I wonder how anyone makes it through, and then I realize that everyone makes it through.  It’s a year of being perpetually tired, shit-on, abused, uncomfortable, and anxious.  That being said, I’m at an amazing program, working with awesome people, and I see  fascinating/hilarious/upsetting stuff on a daily basis.  As much as it sucks, and as much as I complain, I really do love what I do. I love what I’m learning, I love my crazy-ass patient population, I appreciate the strange group of people that are drawn to emergency medicine in one form or another, and I most of the time love the raw emotion that I get to be a part of every single day.

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all grownz up

On June 19, 2008, Dr. French Fry was born.

Well, not really, but I was one year into medical school and decided that medical school was an incredible, wonderful, soul-crushing and terrifying experience and that I needed an outlet.  That day, on that first post, I wrote about three promises I made to myself: 1)stay normal, 2) do not become a crazy bitch, and 3) do not turn into a goblin.

Three years have passed, Dr. French Fry is all grownz up.

Tomorrow I start my residency. Tomorrow I  become an intern.  FuckShitFuckCrap.

On the eve of this horrifying day I am going to amend these promises:

1) Stay normal.  Sometimes I think of medical school as a dark brown smelly slop of quick sand.  If you are not watching where you walk you will take one big giant step into a pile of shit that will straight up swallow you.  You will either never emerge, or if you do you will return to the world entirely unrecognizable.  Since complete avoidance is impossible, I spent four years of my life trying to make sure I didn’t blindly fall in. I tried to keep my ties to the real world and when I got about waist deep I was usually able to tug on them to bring me back.  The verdict is still out on whether or not this was a wise decision, but I managed to get the residency I wanted while continuing to lead a somewhat “normal” life.  I fear this will be harder to do in residency, but I’m gonna give it a shot.

2) Do not become a crazy bitch.  Well, I am going to do us all a favor and combine this with #3, do not turn into a goblin.  I will not turn into a goblin if I am able to sleep.  Likewise, I will not become a crazy bitch if I am able to sleep.  I am going to, against all odds, get some goddamn sleep this year*.

3) Write.  I am going to need an outlet. I am going to have some good stories.  I am going to make an effort to document my experience.

* I should probably apologize in advance for turning into a giant crazy goblin bitch.

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medical personnel

Thank fucking god, I thought to myself, it doesn’t sound cardiac, pulmonary, or neurologic.  I think this guy is going to be okay. The nurse next to me asked what I thought.  I looked at her and tried to sound confident but the increase in pitch at the end of my sentence likely gave away my doubt, “a panic attack?” She concurred and suggested aspirin just in case.  Good thinking, I thought, I am so glad you are here.  Aspirin is the first step in cardiac care and has proven benefit.  So I said outloud to the patient and those listening, “Though we don’t think this is cardiac in origin we are going to give you some aspirin.  It’s only precautionary and won’t hurt you.”  So the flight attendant got the aspirin and the nurse gave it to him.

Deep breath.

It all started with the innocent little ding of the seatbelt noise on the airplane.  “Any medical personnel on board, please ring the call bell, your help is needed at the back of the plane.”  Before I had time to decide whether or not I was actually the medical personnel of whom they spoke, my friend in the seat next to me had already rang our call bell, forcefully, four or five times.  Well, I am sure there’s a doctor on the plane, I’ll just go back and see if I can help.

I trail a woman who says she is a nurse to the back of the plane.  When we reach the galley at the back I notice three things: 1) there is a sweaty man lying on the floor; 2) the only two people who have responded to the request for help are me and this nurse; and 3) I am sweating and after that long walk to the back of the plane my face is certainly bright red.

The flight attendant looked at me, are you a physician?  No, I am a fourth year medical student (yes, I emphasized those words), can you tell me what’s going on?

I crouch down on the ground next to the man, ask him his name, and introduce myself as a fourth year medical student.  “Bruce,” he responded.  Okay good, I thought, airway intact.  I did a quick survey, breathing is fast but unlabored, radial pulse is 110 and strong.  Determining what appears to be immediate stability I continue with questions.

And so this, organized as a medical HPI (history of present illness) as I might present to an attending, is what we were able to gather:

50 year old man with a past medical history of asthma and high blood pressure is presenting with shortness of breath. The shortness of breath started about five minutes prior to presentation while sitting in his seat on an airplane, shortly after the initial symptom he felt as if there was mucous stuck in his throat.  This made him aware of his breathing, which subsequently made him extremely anxious with associated feelings of imminent death.  He was diaphoretic, lightheaded, and noted a tingling in his fingers.  He denies chest pain, back pain, nausea, vomiting, loss of consciousness, or numbness anywhere in his body.  He has no history of diabetes, his last meal was breakfast, he had only water on the flight, and took his daily hypertensive medication this morning as scheduled.  His asthma is well controlled, he uses his rescue inhaler one every 3-4 months.  He had one panic attack, one year prior, that felt similar but not identical.

The nurse mentions that she has a prescription for clonazepam, an anti-anxiety medication.  She asks me if she should get it.  Umm, why are you asking me?  I’m a med student.  And why is everyone is looking at me?  Oh. Okay I get it. I am making this decision. I racked my brain for any contraindications.  If this is cardiac clonazepam won’t hurt.  If this is neurologic clonazepam won’t hurt.  If it is a panic attack it will help, shit, even if it’s not a panic attack it will help.  There are no contraindications with asthma, and in this situation with such a low dose I’m really not worried about respiratory depression.  Is there anything else I should worry about?  Fuck Shit Fuck. “Okay, go get it,” I respond. She returns and shows me the bottle.  I nod.

Twenty or thirty minutes have gone by and I crouch back down by the man lying on the floor.  “How’re you feeling, Bruce? Any changes?” “No, feeling a bit better,” he responds. But he looks terrified and his legs are trembling. I tell him that it doesn’t appear that anything acutely dangerous is going on and that I think he is going to be okay.  Most likely this is a panic attack, but with the resources we have there is no way to know for sure and that I want him to go to the doctor when he gets home.  “I am so embarrassed.” Don’t be, I tell him.  I had a panic attack before and I felt like I was going to die, it’s a real and seriously scary feeling. I explain to him that if anything changes, if he starts having chest pain, if he starts having more difficulty breathing, if he feels numb anywhere, I want him to tell me or the flight attendant immediately.

We all stand around for another while, watching Bruce, checking his vitals, trying to think of things to talk to each other about. His pulse is down, his BP is down, he is looking much better. The nurse heads back to her seat. Slowly I start feeling like my old self again. I am left with Bruce and the flight attendant who asks me for help with the paperwork.  I help her fill out the presenting symptoms and vital signs and I see there is a spot to write down the name of the medical personnel.  I remind her, “You know, I’m just a medical student. I am not sure that counts as medical personnel?”

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