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....