The Steep Learning Curve

"In a hierarchy, every employee tends to rise to his level of incompetence."
-Laurence J. Peter

This week, I have had three separate conversations with three of my fellow interns about how incompetent we all feel.  The common theme is that it's like we're not really learning anything, and that we're getting worse (or at least not getting better).  I don't think that's really true, though.  The difference is that when we started residency four months ago, we were so ignorant about the practice of emergency medicine that we didn't even know how ignorant we really were.  Now we're almost equally as ignorant as we were then, but we know it.

Our eyes have been opened to our deficiencies on many levels.  We've seen what the upper level residents can do, and we don't measure up.  We struggle to handle the entire pod of patients when we're working one-on-one with an attending overnight.  We're starting to learn how to do procedures like central lines and lumbar punctures, but we're painfully slow at it.  We're not confident enough to argue when we come up with a plan for our patients and the attending wants to do something else.  We're too early in training to have developed our own practice style, and so we wind up doing something different for patients with similar chief complaints, depending on what that specific attending wants to do. 

For example, some attendings are very cautious and will CT a lot of people, while others lean away from doing very much testing in low-risk patients. It's a fine line to balance: do we want to risk missing a ruptured brain aneurysm in the 24-year-old with a new-onset headache if we don't do a head CT?  Bleeding in the brain is a potentially lethal condition that can be treated if caught early.  Or would we rather do the head CT and risk causing that patient to have brain cancer in twenty years because of excessive radiation exposure?  Not to mention that the cost of CT scanning every patient with a headache is prohibitive.  Or that every bed kept full with a non-sick patient who doesn't really need to be there means that a potentially sick patient is kept sitting out in the waiting room because no bed is available.

I don't have a good solution to this problem, and I suspect that the reason there is so much variation in attending practice is because they don't have a good answer for it, either.  Once again, we arrive at the conclusion that much of what we do in medicine is not based on good evidence.  Since I have too little experience to even rely on clinical acumen, it makes the judgment call next to impossible for me.  The daily struggle with this problem is yet one more thing that I was ignorant about before I started residency, and being aware of it now makes me feel even more incompetent as a physician.

Driving Myself Crazy

"I had to stop driving my car for a while....the tires got dizzy."
-Steven Wright

Warning: this post is a rant wherein I feel sorry for myself.  So if you don't want to read a pity party rant, you should stop reading now.

I'm halfway through with the Milford community site rotation, and it has stopped being fun.  Well, not the rotation itself; I still like working in the ED.  I'm talking about the 45 minute commute I have to make before and after each shift.  The end-of-shift commute is the worst part, because the last thing I feel like doing after an exhausting day in the ED is making the 25 mile drive back to Worcester.  If it's a day shift, I get back to the Worcester area just in time to hit rush hour traffic.  If it's a night shift, I'm driving home down an unlit highway in the middle of rural Massachusetts where I can't see anything outside the range of my headlights.  Sometimes, if I'm really lucky, it starts pouring so hard that I can't even see where the exit is, or someone almost runs me off the road.  (Each of those things has happened to me once so far.)  It could be worse, I guess.  At least I haven't had to drive through a blizzard....yet.

But what really has added to my misery is that my schedule is now moving backward (getting earlier and earlier) instead of forward (getting later and later).  Usually our shifts are scheduled so that we do days, followed by evenings, followed by overnights, and then back to days.  The rationale is that it's a lot easier for your body to adjust to staying up later than it is to try to go to bed earlier and get up earlier.

Well, on this rotation, the shifts have been scheduled backward for the person who is working the weekend (me) so that the person who has the weekend off (one of the second year residents) can get out earlier on Friday before his weekend off.  But that means I go from working evenings this week (4PM-midnight), to working afternoons this weekend (noon-10PM), to working days starting on Monday (8AM-4PM).  Since our weekend shifts are ten hours instead of eights like the weekday shifts are, I'll get done around 10 or 10:30 PM tomorrow night, drive home, get about six hours of sleep, and drive back out to Milford early Monday morning.

The fact that I will be the one having Friday evening off next week right before my weekend off doesn't make me feel better about being on this schedule now.  At the same time, it's not just the schedule itself that's bothering me.  I'm annoyed with myself, too, because I know I'm making a bigger deal out of it than I should be.  I mean, some people drive this far to work all the time, day in and day out.  (I have no idea how they stand doing it.)  Plus, it's just one weekend.  My other work weekend at Milford will be followed by a string of overnights at UMass, which means that my schedule will be moving forward again, the way it's supposed to be.

Even so, I'm still upset about it.  And being this cranky about something that really isn't that big of a deal in the whole scheme of things tells me something about how sleep-deprived I probably am.  On that note, I'm going to bed so that I can make that drive again tomorrow.  Sigh....

Milford

 "It's rural America.  It's where I came from.  We always refer to ourselves as real America.  Rural America, real America, real, real America."
-Dan Quayle

I came into residency knowing that I was going to do a fellowship and go into academic EM, so I was not especially excited about being required to do two months of community EM.  The more that people kept talking about how great it would be for me to get to see "bread and butter" emergency medicine, the less excited I felt about it.  I don't like butter.  Never have.  Never will.

Well, I do like bread, and I do like working at Milford.  Nearly all of the attendings there are UMass grads, so they're familiar with our program and make great mentors.  They advised me to focus on seeing the types of patients I feel least comfortable with.  That means I have been focusing on eye complaints, peds and ortho since those are some of my weakest points. I've seen a bunch of patients with broken bones and helped with reductions. I saw a kid with scarlet fever, including the sandpaper rash and strawberry tongue. I saw a cool tox case. I've gotten to do some procedures and resuscitations.

There are other good things about working at Milford too.  One is that the shifts are mostly only eight hours instead of ten, and cleanup doesn't take as long at the end of the shift. I'm usually only running over the end of my shift by a half hour tops.  Another is that they give us a bunch of coupons for free meals, and we even have time during shifts to go down to the cafeteria and get food.  Plus, we don't have to discharge patients ourselves like we do at UMass; at Milford, the nurses do it.  But the best part is that I'm the only resident there during my shifts, and I can cherry pick which patients I want to see.  So, no pelvic exams for me this month! The only thing I don't like about this rotation so far is having to drive there and back every day. It's going to be an expensive gas month. 

One other thing about the town of Milford is that so many of the people there are native to this area of the country.  So I get plenty of people asking me where I'm from, even though MY English is accent-less.  My English is so accent-less, as a matter of fact, that I have to make an effort to control myself every time I hear someone speaking with a strong Masshole accent.  To a non-New Englander like me, that accent sounds too funny to be real.  It's funny to the point that I have been known to strike up conversations with random strangers on purpose, just so I can hear them talk.  It's not only the way they talk, either.  There is a sign on one of the printer paper trays in the Milford hospital ED that says, "Please close the draw gently." That is exactly how the locals pronounce the word "drawer."  No one to whom I have pointed out this phonetic spelling had ever noticed, and I still have no idea if it was done on purpose or not.  But it's wicked funny.

Things to Do Around Worcester

"With me, a change of trouble is as good as a vacation."
-David Lloyd George

I'm on vacation this week, and my parents came to Worcester to see me.  We've been visiting some of the local attractions, so I thought I would start a brief list of things to do in the area.

Apple Picking: I've never done this before, but it was a lot of fun.  We decided to go off the beaten path and visit Carver Hill Orchard in Stow.  It's a small orchard that doesn't have all the dog-and-pony shows that the large, popular orchards typically have.  It was a beautiful day when we were there, and we filled a bag with several pounds of apples.  The only thing I didn't like about it was that the trees were not labeled, and it was impossible to know which kinds of apples were which.  But otherwise, it was a great experience, and I highly recommend it.

Science Museum: The Ecotarium is the local Worcester science museum, and a great choice if you have kids.  But it's still fun even for adults.  There are outdoor exhibits with animals like bald eagles, owls and foxes, as well as indoor exhibits on local habitats, water, and other things.  During the summer, they have a tree canopy walk.  There is also a planetarium with movies and special events throughout the year.  It's not a huge, elaborate museum like the Museum of Science in Boston, but I liked that I could get through all of the exhibits in half a day without going through sensory overload like what happens to me in larger museums.

Other Museum: The Higgins Armory Museum has to be one of the weirdest museums I've ever seen, and at the same time, one of the coolest.  It boasts of being the only museum in the entire Western hemisphere that is completely devoted to arms and armor.  It is also still housed in its original building, which adds a kind of old-fashioned feel to the place.  The armor and weapons come from all over the world, including Asia and Africa, although most of the collection is European.  My favorite exhibit was the curiosities, which had a bunch of fake but interesting "collections," like centaur skeletons and Bigfoot footprints.  Apparently they're taking it down though, which is too bad.

Restaurant: Ok, this is actually in Framingham, but I really enjoyed Legal Sea Foods, which is a local chain.  There are several locations in Boston, too.  Well, you can't come visit this area without sampling some New England clam chowder, right?  Plus, Framingham is cool because it's the home of the Framingham Heart Study, which has followed three generations of Framingham residents longitudinally over time since 1948.  Much of what we know about risk factors for heart disease came from this study.

State Park: Purgatory Chasm in Sutton is a really cool place to visit if you like interesting landscapes.  It has a bunch of rocks of all sizes and shapes that were left behind by the glaciers that used to cover this region.  There are no restrictions against climbing on the rocks, so you can get some good exercise while you're at it.  Just be careful.

That's all I have for now.  I'll add other attractions later when I have time to do some more exploring.

Needlestick

"He who is not every day conquering some fear has not learned the secret of life."
-Ralph Waldo Emerson

One of the biggest fears that one must conquer in order to work as a physician is the fear of needlestick injuries.  Laymen focus on the risk of contracting HIV, but it's actually fairly hard to contract HIV from a needlestick unless you inject yourself with a few milliliters of blood.  No, the really scary disease you can contract from a needlestick is hepatitis C.  It's a much more contagious virus, and like HIV, there is no cure, and no vaccine.  So if you're going to be afraid of blood-borne illnesses, hep C is the one you want to watch out for.

I've been stuck twice so far.  Once was during my gynecology rotation in medical school.  I was scrubbed in for a hysterectomy and holding a retractor for the surgeons.  The gynecology fellow wasn't paying attention when she set down an instrument she was using, and she stabbed me in the finger with it.  Fortunately, it didn't break the skin, and when I called the exposure hotline, they stated that I didn't need to do anything further.  Also, since the instrument was solid and not hollow-bore like a needle, and I was double-gloved, that reduced the risk of blood exposure even further.

The second time was this past week.  I was working overnight, and I had a patient with an infected Bartholin's gland cyst.  I had drained the pus from the cyst, and I was inserting a Word catheter to help keep the incision open so that it could continue to drain.  The catheter has a balloon on it, which gets blown up with several milliliters of air using a syringe and needle in order to keep it from falling out of the wound after insertion.  Most of the needles we use in the ED are safety needles, but this was the needle that had come with the Word catheter kit, and it was a regular old-fashioned needle with no safety lock on it.  Everything was going fine until I finished blowing up the balloon and went to remove the syringe and needle from the catheter.  The needle came out with more recoil than I expected, and I stabbed myself in the thumb.

This wasn't a little poke like what happened to me in medical school.  This was a real stick with a dirty hollow-bore needle covered with pus and blood that made a visible puncture wound in my thumb.  I washed the area well with soap and water, and told my attending that I had stuck myself.  We called the exposure hotline, and I had labs drawn for hepatitis B, hepatitis C, and HIV.  Fortunately, the patient consented to be tested for the viruses as well, and the nurse drew her labs, too.

After my shift ended around 9AM, I went to the employee health office to fill out the paperwork and be counseled by a nurse.  She reassured me that it was unlikely that I had injected myself with blood, as the syringe itself contained air, and the blood and pus were only on the outside.  Also, she would contact me in a day or two to let me know the results of the tests. The next day, she called to tell me that the patient tested negative for hepatitis C and HIV, and so did I.  (I did test positive for hepatitis B antibodies, but that's a good thing, because I have had the full series of immunizations for hepatitis B.)  So it was a big relief.

Thinking about this series of events, I decided that the next time I have to use a Word catheter kit, I will inflate the balloon using a safety syringe.  We have plenty of them in the supply room, and there's no law that says I can't just dispose of the unsafe syringe that comes in the kit without using it.  I also have to accept that, no matter how careful I am, there is always a risk of being stuck.  The only way to avoid any chance of it happening, is to stop taking care of patients.

The Theme of the Shift

"The theme of the week is: the heart as a pump."
-Dr. Joseph Parambil

I don't know why this is, but it seems like every shift has a theme.  Yesterday's theme was GI bleeds.  I literally had three patients in a row with a chief complaint of melena, and I went room to room doing rectal exams and fecal occult analyses.  All three times, the stool samples on the card turned bright blue, which means a positive result for blood.  So I paged the GI fellow to tell him that I had three patients to admit for workup of GI bleeding. Unsurprisingly, he was not thrilled about getting so many patients all at one time, but I think it's probably better than paging him to come down to the ED three separate times.  At least this way, he only had to come down once.

On another shift, all of my patients were coming in with headaches.  It gave me the chance to develop my "migraine cocktail," which consists of metoclopramide, ketorolac, and diphenhydramine.  The metoclopromide helps with the patient's nausea; the ketorolac helps with the pain; and the diphenhydramine makes them drowsy so they can sleep for a while and recover from the headache.  I have to admit that I was a little skeptical when the attending suggested that I try metoclopramide with ketorolac, but it worked beautifully.  One of the nurses suggested adding the diphenhydramine, which was the perfect touch.  There are other combinations that can be used to treat migraines, but I'm pretty happy with this one.

I had a shift of all panic attacks, too.  Those patients often come to the ED thinking that they are having a myocardial infarction (MI), especially if it's their first panic attack. Typically, it's a young woman in her late teens or twenties with no medical history except maybe some anxiety.  My job is to rule out anything bad going on with the patient's heart, which entails putting him or her on a heart monitor, getting serial EKGs, and measuring two sets of troponin enzymes.  Odds are good that, unless the patient is a cocaine user, he or she is probably not having an MI.  But cocaine use is a risk factor for MI in young people, so I always specifically ask about it.  Every once in a while, someone admits to using cocaine, and that is an opportunity for patient education as well as ruling out a potential MI.

Of course, just about every shift is an abdominal pain shift.  It seems like abdominal pain is the most common complaints in the ED, and also one of the hardest to diagnose.  There are just so many organs in the abdomen, particularly for women, and any of them can cause pain.  Plus, sometimes organs in the abdomen can cause chest pain, and organs in the chest can cause abdominal pain.  For example, I've seen several patients with MIs who came in complaining of acid reflux.  That's what the MI feels like to them, and sometimes they even feel better when they take antacids.  So if someone complains of upper abdominal pain, I still have to keep MI in the differential.

It's impossible to know ahead of time what the theme of the shift will be, and that can be frustrating sometimes.  But the constant daily surprise is also part of what makes EM fun.

I Hate My Schedule

"The only reason I'm coming out here tomorrow is the schedule says I have to."
-Sparky Anderson

This was my first week back in the ED, and I'd be lying if I said that I was sorry to be done with OB.  Yeah, ok, I have to admit that the OB rotation wasn't as bad as I expected.  But it still wasn't my idea of fun, either.  I also have to admit that working two weeks of night float wasn't as bad as I expected, and I even felt pretty well adjusted to the schedule by the end of last week.  So why, then, am I so annoyed about the fact that I had to work nights in the ED this whole week?

I don't really have a logical answer to that question.  On the surface, it seems like I should be happier with my schedule.  I am working fewer hours (11-12 hours per shift instead of 13-14 hours), and fewer days (4-5 days per week instead of 5-6 days).  But somehow, I'm grumpier about it anyway.  Maybe it's because the work is much more stressful and intense.  Maybe it's because I feel like I'm expected to love it.  Or maybe it's because I know that some other people aren't working as many overnights as I am.

Ah, yes, that is the key sticking point.  When everyone is working the same overnight schedule as a team, there is a sense of camaraderie born out of shared misery.  But when you know that you're working twice as many overnights as one of your fellow interns, suddenly it makes your schedule seem relatively a lot worse, even though it's better in absolute terms.  I do feel a little bad about almost biting someone's head off for commenting that it seems like I'm always working nights.  But really, I don't need anyone else's sympathy, because I feel sorry enough for myself.

The thing is, everyone hates their schedule.  We all feel like we work too many hours.  We all wish we had fewer night shifts or morning shifts or afternoon shifts, depending on which one is burning us out the most at the moment.  (Personally, I wish I had fewer of all three types of shifts!)  We all have a block or two where we get shafted, but other blocks where we come out ahead.  And in spite of my pity party about having so many night shifts, there is a significant bright side: I have two fewer shifts overall for the month than the other intern who is working fewer overnights has.  Well, when I look at it that way, maybe my schedule isn't quite so bad after all....

Evidence-Less Medicine

"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head."
-William Osler

It's common to hear physicians say that medicine is an art and not a science.  In spite of evidence-based medicine (EBM) being all the rage these days, a whole lot of what we do is based on expert opinion, what we think should theoretically work, anecdotal experience, and unabashed personal preference.  Most laymen don't realize just how unscientific medicine really is, and sometimes that leads to a huge disconnect between patient expectations and physician expectations.

I struggled with a great example of this phenomenon while on my OB rotation.  During the first stage of labor, the mother's cervix dilates from somewhere between 0-2 cm up to 10 centimeters.  This is a process that takes several hours, and sometimes even a day or two.  As you might expect from the name, being in labor for so many hours is exhausting for the patients, both physically and emotionally.  It also gets more painful as the fetus descends lower into the mother's pelvis and the contractions get stronger.  Most of the patients understandably want to be reassured that things are progressing well and that there is an end in sight.  The way we assess labor progress is by performing cervical checks on a scheduled basis.

To perform a labor check, the examiner (generally a resident, attending, or nurse) puts on sterile gloves and inserts two fingers into the patient's vagina.  The examiner then measures the width of the cervical opening based on how far he or she can spread the two fingers apart.  This is a highly subjective and imprecise process.  We don't all have fingers that are the same size, and it's not uncommon for two experienced examiners to differ by up to a centimeter in their measurements, especially when the cervix is over halfway dilated.  Throw an inexperienced examiner like me in the mix, and the lack of precision becomes even greater.

Because of this imprecision, we sometimes ran into a situation where the second examiner told the patient that she was less dilated than the previous examiner said.  The patients would understandably get very upset by this, as it seemed to imply that not only was their labor not progressing, but it was even going backward.  After the first time I accidentally did this to a patient, I always asked the patient how far the previous examiner had said she was dilated before I did my exam, and I never said she was less dilated than that.  Sometimes I'd tell the patient that her cervix was a centimeter more dilated than what the previous examiner had said, even though I wasn't totally sure if it had actually changed.

The problem was that many patients thought our labor checks were precise measurements of cervical dilation.  But the more dilated the patient's cervix got, the harder it became to know what the actual measurement was.  As I already said, even experienced examiners can differ by a centimeter or so in the later part of Stage 1 labor, and I was sometimes off by two or three centimeters.  I didn't want to give a patient the wrong impression that her cervix was contracting instead of dilating.  To add to the confusion, sometimes the size of the cervical opening really did change during the period of time between two examinations.  And even if I had wanted to explain why examiner #2 gave a smaller measurement than examiner #1, a woman in active labor is not usually up for having a philosophical discussion about why different examiners might tell her different numbers.

I never really learned the finer points of cervical measurement late in the first stage of labor, and it ultimately doesn't matter to me if a patient's cervical dilation is eight centimeters versus nine centimeters anyway.  I realized partway through the rotation that what I really need to know as an emergency physician is how imminent the delivery is.  If I do my exam and find that the cervix is only partially dilated, that means I probably have enough time to get the patient up to the L&D floor before she delivers.  But if I feel caput and hair, that means I'd better gown and glove up pronto.  Telling partially dilated cervix apart from caput and hair is very easy and completely objective.  There is no such thing as a hairy cervix!

It's a Beautiful Noise

"An ugly baby is a very nasty object - and the prettiest is frightful."
-Queen Victoria

I'm working nights now, and it seems like what I had heard about more babies being born at night versus during the day is true.  This week alone, I have participated in almost as many deliveries as I did during the first two weeks combined.  I'm also well over the minimum fifteen deliveries that we are required to do during the rotation, which prompted me to ask the chief if that meant I could have next week off.  She rolled her eyes at me and said, "I don't think so."  Well, I thought it was funny, anyway.

As interns, we are only involved with the low risk deliveries, while the junior and senior residents take on the higher risk patients.  There was one night where we had four low risk patients in labor all at the same time, and my med student and I were running from room to room like crazy checking on them all.  Of course, they all delivered at almost the same time too, which was around 4 AM.

Maybe it was the time of night, and maybe it was just the timing, period.  But I was a little freaked out by how much deja vu I seemed to be experiencing.  Patient #1 delivers first, and the baby is in the warmer, crying.  (You'd be crying too if someone just smeared erythromycin ointment in your eyes, and then stabbed you in the thigh with a gigantic needle to give you a shot of vitamin K.)  We were congratulating the parents, and the mother says, "Is it weird that I love hearing her cry?"

Now, you have to understand that to me, a crying newborn sounds kind of like a lamb bleating, and it's not an especially pleasant sound at all.  The worst is when one of them starts crying in the nursery, and then the whole nursery-full starts wailing.  That is a grating, nails-on-chalkboard kind of sound.  But by this point, I've heard enough newborn bleating that I can kind of tune it out.  I can even tune screaming women in labor out.  So I said, "No, it's not weird at all.  Though you may not feel this way in a few weeks!"  She and the father laughed and agreed.  I filled out the paperwork, and just then, a nurse poked her head in to tell me that my patient in the room next door was also pushing and the baby's head was starting to crown.

I ran next door, gowned and gloved, and there was delivery #2 for that night.  The baby was in the warmer, crying, and the mother turns to me and says, "Is it weird that I love hearing her cry?"  What I wanted to say was, "Yes, it's weird, and what weirds me out the most about it is that the lady next door asked me the exact same question half an hour ago!"  But I didn't.  Instead, I smiled at her and said, "No, it's not weird at all.  Though you may not feel this way in a few weeks!"  She and the father laughed and agreed.  I filled out the paperwork, and just then, a nurse poked her head in to tell me that my patient in the room next door was also pushing and the baby's head was starting to crown.

I made a hasty exit to room #3, vowing to avoid discussions about the auditory aesthetics of babies crying at all costs....

Medicine Is Disgusting

"Watching a baby being born is a little like watching a wet St. Bernard coming in through the cat door."
-Jeff Foxworthy

I'm now halfway done with my OB rotation.  Our schedule in EM is a week off from the OB residents' schedule, so my entire team changed over from the week before.  The other intern who worked with me this week was the same OB intern who was working in the ED with me last month as an off-service intern, and it was nice to see her again.  It also made for the rather odd situation where she was showing me how to use the electronic medical record and charts on my first day in the ED, and I was showing her how to do the same thing on her first day in OB.

Some of the OB residents and I had an interesting discussion at one point about which field is more disgusting: EM or OB.  I argued that there is nothing more disgusting than delivering a baby: you always have some combination of blood, mucus, amniotic fluid, urine, and feces (both the mother's and the baby's) covering you from head to toe after each delivery.  Plus, the infant is born covered with vernix, and its skin is gray, both of which conspire to make it look like some kind of creature from Gremlins.  And the mother is often screaming  the whole time, which makes for a less than pleasant backdrop to this ghastly scene of childbirth.  What do we do in the ED that could possibly beat a delivery in terms of sheer disgustingness?

One of the OB residents countered with abscesses.  Abscesses?  Come on!  Incision and drainage of pus from abscesses is THE best procedure to do in the ED.  You can literally cure a patient in about ten minutes.  They come in with a lot of pain and swelling; you numb them up, cut the abscess open, and poof, all better.  Plus, an abscess only contains one body fluid (or maybe two if you count some bleeding), neither of which includes feces.  She pointed out that abscesses can smell pretty bad too, which I had to concede.  I have opened up some abscesses that smelled bad enough to make my eyes water.  But worse than feces?  You've got to be kidding.

It occurred to me later that what it comes down to is that all fields of clinical medicine are disgusting.  Really, what body fluid is there that is beautiful, pleasant smelling, and nice to have all over you?  I guess if I had to pick the least offensive body fluid, I'd go with urine.  Assuming the patient doesn't have a urinary tract infection, at least urine is relatively sterile.

Starting OB

"Anyone who hates children and animals can't be all bad."
-W.C. Fields

When I was in medical school, there were a few rotations I really liked and several that I thought were ok, but only one that still makes the hair stand up on the back of my neck whenever I think about it.  That would be obstetrics and gynecology.  Part of what I disliked about obstetrics (OB) was the medicine itself, and part was the malignancy of the environment.  So you can understand why I had some trepidation about being an off-service intern on OB.  (An off-service intern is an intern from one specialty who is doing a rotation in another specialty.)

Now that I have finished my first week of OB as a resident, I'm relieved that so far it hasn't been nearly as bad as I expected.  (Of course, my expectations were so low that it would have been hard for the rotation to be worse than I was expecting.)  The biggest thing that has made my residency OB experience better is that I like the people I'm working with.  The residents have been very helpful and understanding, especially on the first day when I had no idea what to do.  We also have two third year medical students rotating with us, and they showed me where to find supplies and helped me write notes as well.

Another major reason is that my being there has a purpose.  There is a job that the team needs me to do, and I am there to do it.  This was not the case when I was a medical student; the work went on just as well without my presence as with it, and probably more efficiently without me. It's easy to feel like you're in the way as a student, especially when the residents are busy and not really thinking about giving you a job to do.  I don't have that feeling as a resident.  Feeling useful, feeling like a part of the team, makes a big difference in terms of how important the work seems.

I still don't enjoy the medicine part of OB.  I sometimes joke that I don't like women, don't like babies, and don't like women having babies.  But I don't hate OB either, and I feel like what I'm getting out of the rotation is worthwhile, even though it isn't always fun while I'm going through it.

A Normal Day

“The trouble with normal is it always gets worse.”

-Bruce Cockburn 

I'm officially done with my first rotation, and every shift has been just as crazy and hectic as the first one.  I'm not sure if it has really gotten any easier.  Sometimes it seems like the only difference is that now I'm a little better mentally prepared for the organized chaos I encounter every time I go through the revolving door into the ED waiting room.  Several people have told me that this is not what the ED is normally like, but I already know better than to believe that.  It's like when a doctor tells a patient that this won't hurt, right before stabbing them with a syringe of lidocaine.  Of course it hurts, at least until the numbing effect of the lidocaine kicks in.

When I press people to explain what the normal ED shift is like, I can't really get a good answer except for something along the lines of, "not like this."  Presumably, normal means that there are fewer patients.  Not only that, but fewer patients with non-urgent complaints.  I can identify with wishing there were fewer patients.  There is just a feeling of desperation that I get every time I look at the growing list of patients in the triage area when I'm already stretched thin in too many directions as it is.  As for too few urgent patients, that doesn't seem like a problem to me at all.  I have already helped care for patients who were sick enough to be admitted directly to the intensive care unit (ICU), and also patients who were sick enough that they didn't make it to the ICU.  Spending every shift caring only for these high acuity patients would be more than I could cope with, at least right now.

So the main issue seems to be one of patient volume.  But what does it even mean to say that the ED volume is above normal, anyway?  It's not like the number of annual visits to the ED is a static number.  In fact, we know that the number of yearly ED visits in Massachusetts has continued to increase even though a state health care reform plan was enacted in 2006.  In other words, this increased volume isn't some kind of aberration.  It's now the new normal.

The Flying Ambulance

“...The helicopter symbolize(s) the victory of ingenuity over common sense.” 
~Montross, Lyn and Prouty, Ray, U.S. Marine Corps Helicopter Experience, p. 20.

You may recall that a few weeks ago, I was half drowned to death and the other half scared to death while going through dunker training.  (Click here to read about it.)  This week, I had my first LifeFlight shift and went on three helicopter flights.  LifeFlight is the UMass emergency medical helicopter program.  Each flight has a three-person crew consisting of a pilot, a flight nurse, and a resident.  I was a fourth person going along mainly to observe.

I will admit to being skeptical about the value of the emergency medical helicopter experience for residents in general, and even more skeptical about the wisdom of my physical presence on a helicopter.  UMass is one of the few EM residency programs in the country that requires residents to serve as flight physicians.  So I think it's fair to ask why, if being a flight physician is such a valuable experience for residents, more programs don't require it.  Not only that, why are some programs eliminating resident helicopter flying altogether?  The answer to the second question is because of the large number of emergency medical helicopter crashes that have occurred over the past several years.  (For example, click on the Program Highlights tab to see Indiana University's statement about why EM resident involvement in their air ambulance program was suspended.)

All of that being said, I came to this program knowing that flying on the helicopter was required, and it's obviously a bit late to back out now.  But as I strapped myself in for the first flight, I took the time to study how to open the emergency window exit.  Just a precaution, you know, in case I had to put my dunker training to use.

The flight itself was completely uneventful, and surprisingly enjoyable.  I had been worried about getting motion sick, but this was not an issue.  Our first transport was from an outside hospital (OSH) that had its own landing pad.  The patient was being transferred to UMass for more advanced treatment of a serious medical condition.  The resident and flight nurse helped the hospital staff prepare the patient, who was unresponsive, for transport.  We took the patient outside, loaded everything (patient plus equipment) onto the helicopter, and took off.  I went on two other flights, one for a patient who suffered trauma in a car accident, and the other a hospital-to-hospital transfer like the first flight.

Wherever we went, a crowd of onlookers gathered.  It amused me every time to see them shielding themselves from the wind created by the rotor downwash, which is a lot more powerful than I (and evidently they) had realized.  In addition, watching the upper level resident, I was able to appreciate why there could be some value in residents participating in LifeFlight.  When you're at a scene, there is no attending standing there telling you what to do; there is no team of nurses and techs to back you up; and you do not have the luxury of using much of the advanced equipment that is available in the ED.  Several of the program graduates have told me that participating in LifeFlight gave them tremendous confidence in their ability to handle emergency situations.

I still don't think that my education would suffer greatly if the residents were suddenly pulled out of the LifeFlight program.  However, I don't see the time spent working on LifeFlight as something that detracts from my education any more either.  I also have a better understanding of why the opportunity to fly is such a huge draw for many applicants to this program.

These Dreams Go On

"All the things one has forgotten scream for help in dreams."
-Elias Canetti 

A friend of mine who spent a year studying abroad once told me that the way you know when you've become fluent in another language is when you start dreaming in that language.  I only wish that this could be the criterion for fluency in the duties of internship, because I have been having all kinds of crazy emergency medicine dreams.

First, there are the "left the house without any underwear on" dreams.  Only for me, the issue is always that I have forgotten to show up for a shift.  Every day upon awakening, I have this brief period of disorientation when I'm wondering where I am supposed to be right now.  Even on my days off, my first panicky thought as soon as I wake up is, "What time is it?  Did I oversleep?"  The fact that my shifts constantly change times (overnights last week, afternoons this week, days next week) does not help things.  Neither does the fact that the summer days in Massachusetts are so long that it's just as light out at 5 AM as it is at 5 PM.  It also doesn't matter in the slightest that in real life, I have not ever forgotten about an upcoming shift, or even been late for a shift.

Next, there are the "scary monster" dreams.  Only in my case, the monster comes in the form of a grotesque patient encounter.  Sometimes it's the patients themselves that are grotesque.  In one version, I walk into the room, only to find that the patient's limbs have fallen off.  I start frantically trying to put them back on again before the attending finds out that I have let the patient fall apart.  Other times, I am the grotesque one.  I catch my reflection as I walk by the window, and I have no face.  (Don't ask how I can see myself when I don't have a face--no one ever said that dreams were rational.)  Then there are the attendings, who can easily be transformed to gremlins, goblins, and trolls of all kinds.  Some of these transformations require less imagination than others.

Finally, there are the "trapped inside and can't get out" dreams.  I'm wandering around the ED, which has turned into a gigantic warehouse filled with screaming, crying, cursing people in johnnies.  It's time for me to go home, but I can't find the exit.  Nothing I see looks familiar, and the more I walk around, the more lost I get.  (That one is actually not so far from reality, because I have gotten lost in the hospital several times in the last few weeks, including twice within the Emergency Medicine administrative suite.)

I'm not sure if the reason why my dreams are so vivid and detailed is because I'm writing them down.  But anecdotally, having dreams about residency seems to be fairly common.  I overheard another resident complaining about how she hates that even when she is away from work, it's like she didn't leave, because she still dreams about being in the hospital.  The resident she was telling this to agreed, saying that the same thing happened to him.

Hopefully, all of this dreaming means that I'm learning something.

First Day on the Job

"I am always ready to learn, although I do not always like being taught."
-Winston Churchill

I have now survived five shifts in the emergency department (ED), and I'm a little bit shell-shocked.  To say that the experience has been overwhelming so far is such a grotesque understatement that I'm reading over what I just wrote and laughing.  Or maybe it's just that I'm exhausted.  Or both.

My first shift was last Saturday evening from 4 PM to 2 AM, which actually meant 4 PM to 3 AM.  I knew I was in trouble as soon as I walked through the front door of the ED and saw the waiting room.  Every seat in the place was filled.  Not only that, but it was chaotic in there, with children running around, a dozen different cell phone conversations going on, and one person in the corner puking into a bucket.  I resisted the sudden urge to turn around and run back out the way I had just come in, took a deep breath, and swiped my badge to go inside.

The adult ED at the University campus is organized into two patient care areas called North Pod and South Pod.  Each pod has about 15 rooms, plus the capacity for another dozen patients or so out in the hallway.  The South Pod, where I was working that night, was utter pandemonium that made the waiting room look calm and sedate in comparison.  On my right was a drunk patient shouting at his nurse, and across the hall from him was a schizophrenic patient going on about some conspiracy or another to anyone who would listen.  A third patient was holding his stomach, crying and moaning.

I went into the physicians' charting area and introduced myself.  One of the other residents showed me how to log in to the computer system, and I picked up my first patient, who spoke no English.  Okaaaay.  There are on-site interpreters for several languages at UMass, but this wasn't one of them.  So I had to use the interpreter phone, which was actually pretty cool.  You just dial up, tell them what language you want, and presto, they connect you to an interpreter in that language.  It worked very well.

The rest of that first night was a blur.  I duked it out with the electronic medical record, debated whether it was ok to give Tylenol to a patient with abdominal pain, and once I decided that it was indeed ok, struggled to figure out what dose to use.  One of the seniors asked me to call the gastrointestinal (GI) medicine fellow, and when I did, I couldn't answer most of her questions since I knew almost nothing about that patient.  The fellow immediately figured out that I was a new intern, kindly told me what information she needed, and asked me to call her back once I had it.  I don't think I've ever felt more incompetent or idiotic than I did that night.

When I finally left at 3 AM, the waiting room was even more crowded, which I would not have thought was even possible.  I ran outside, where it was fairly calm and quiet, and took a deep breath.  Phew.  Just two years, 51 weeks, and six days left to go....

Ditching, Ditching!

"All the best stories are but one story in reality - the story of escape. It is the only thing which interests us all and at all times, how to escape."
-A. C. Benson

According to my circle of resident friends in other programs and other specialties, I hands-down won the dubious distinction of having the craziest "guess what they made us do during intern orientation" story.  I consider this to be a dubious distinction because winning a one-upmanship contest is not always a good thing.  In this case, I can safely say that winning this distinction means that I now know what being waterboarded feels like.  It doesn't feel very good.

UMass's EM program is one of a handful of EM programs in the entire country that require residents to fly on the emergency transport helicopter as flight physicians.  Part of our preparation for this role entails a day of dunker training.  This is a water evacuation course that teaches us what to do should the helicopter ever crash in open water.

Let me say that the water evacuation training was terrifying.  You're strapped into a helicopter fuselage, fully dressed in a flight suit and helmet.  They suspend you over a pool of cold water, drop you in, and turn it upside down, in the dark.  While you're upside down under water, completely disoriented, you have to open the emergency window exit, get yourself out of the harness, and swim out.  You get water up your nose; it's tremendously uncomfortable, and I wound up swallowing a bunch of water once I got myself right side up again.  (They flip you over because that's usually what happens when a helicopter crashes into water, and plus the pilots are trained to try to invert us on purpose so that we won't get cut to ribbons by the rotor blades if we do manage to make it out alive.).

After the first time, I came up sputtering but relieved to be alive and done with the exercise.  That was when I found out that we had to egress the fuselage a total of four times, not counting the previous four times that I had already done it in the training chair.  Of course, I balked at this, and the trainers proceeded to talk me into doing the rest of the exercises.  (Insert bad German accent here: They haff vays of making you not balk!)  The end result of this was that I got motion sick--there's a reason why I avoid amusement park rides that turn you upside down.  All in all, it was a thoroughly unpleasant experience.

I have to say on my behalf though that I didn't ever panic, and I was able to extricate myself and swim to the surface without assistance all four times.  I feel like I would be able to get myself out of a downed helicopter for real if I ever had to, and fortunately if it were for real, I'd only have to do it once, not four times in a row.

Specialty Stereotypes

“ All those things you fought against as a youth: you begin to realize they're stereotypes because they're true.”

-David Cronenberg

There are a lot of jokes among medical students and physicians about what types of people typically enter a given specialty.  Orthopedic surgeons are the clean-cut jocks.  Pediatricians are the nice people.  Psychiatrists are the quirky ones.  Internal medicine physicians are the intellectuals.  And what are emergency physicians?  We're the rebels, the people who don't quite conform to the standards of doctor-dom.

Of course, these stereotypes are just that: stereotypes, and they have limited relationship to reality.  But even limited relationships to reality are somewhat linked to reality.  This became apparent during the first half of our intern orientation this week, most of which we spent doing ACLS and PALS training.  On the first day of ACLS training, which was Tuesday, my classmates and I showed up in jeans, t-shirts, tennis shoes, and in one case, a pair of toe shoes.  What about everyone else?  The orthopedic surgery intern in my group wore a button-down shirt and khakis with loafers.  The medicine interns were dressed as if for clinic, with the men wearing shirts and ties with slacks, and the women in blouses with slacks or skirts.

I asked one of the medicine interns why he and his classmates were wearing ties.  He explained that they were told to dress professionally for clinic.  I pointed out to him that the mannequins were not going to think that he was unprofessional if he didn't wear a tie while performing CPR on them.  The next day, he and most of his classmates were not wearing ties, which was all for the best.  It isn't easy giving CPR to a mannequin when your tie keeps getting stuck between your hands and the mannequin's rubber chest.

The whole experience of giving CPR to mannequins is kind of strange anyway, especially when the mannequins are just a torso with no arms or legs.  At one of the ACLS stations, the preceptor asked my group what we wanted to do.  One of the other interns replied, "This guy has no arms, no legs, and no brain.  Are we sure that his life is worth saving???"

Introduction

“The beginning is the most important part of the work.”
-Plato 

Hi, and welcome to my blog.  I am a new resident at at the UMass emergency medicine residency program--well, or at least I will be starting on Monday.  Residency is the next stage of medical training after graduating from medical school.  As residents (also called house staff), we already have our medical degrees.  That means we are officially doctors.  However, we're not yet ready (or licensed!) to practice medicine independently.  The information that students learn in medical school provides the background for being a physician, but it doesn't provide the practical know-how.  For my residency classmates and me, the transition from medical student to practicing emergency medicine physician will occur over the next three years.  That amount of time feels both inordinately long and frighteningly inadequate at the same time.

I'm a nontraditional student who had a previous career prior to going to medical school.  Unlike some of my classmates, I was not one of those people who planned on being an emergency physician from the get-go.  In fact, I had never even considered emergency medicine (EM) as a career until I did a month-long rotation during medical school.  I found that I enjoyed doing procedures like suturing or draining abscesses; preferred being busy rather than having long stretches of time where I didn't do very much; and liked seeing patients with a variety of problems.  I also felt like I could deal with some of the negatives of this specialty, including stress, burnout, difficult patients, healthcare disparities, and changing shift hours.  Finally, I felt like I had more in common personality-wise with EM physicians than I did with physicians in other specialties.  I will leave it up to you to decide whether that is a good thing or not.

Four months ago, I ranked UMass number one in the national residency match.  I first became interested in this program because my goal is to be a medical toxicologist.  Medical toxicology is a subspecialty of EM that takes care of patients who have been poisoned or overdosed.  When I went on my residency interviews, multiple people told me that if I want an academic toxicology career, UMass was the place to go.  But I also felt that this program was strong in the other major subspecialties of EM, including pediatric EM, ultrasound, EMS, and research.  What clinched the decision for me was that I had such a great time at my interview day.  In particular, I felt like I really clicked well with the residents and faculty that I met.  To me, fit is the most important thing when selecting a program.  There aren't any "bad" EM programs in terms of the quality of training provided, but there are definitely EM programs that are bad fits for specific candidates.

What you are currently reading is going to be a weekly blog describing my experiences in residency.  The intended audience is primarily medical students and premedical students, but I'm happy to have other interested readers as well.  The primary focus is on what it's like to be an emergency medicine resident, both in general and at UMass in particular.  It's also about the universal experience of being a resident; those of you who are considering a career in medicine, or who are already pursuing one, will still get a glimpse of resident life even if you don't choose to specialize in emergency medicine.  Hope you enjoy.