Winter time . . .

Wow its been awhile . . . I'll sum up my time since I've posted:

November was colorectal. 30 solid days of suck. I loved colorectal as a student, the surgeries were great and the diseases were too. But my month as an intern on colorectal was painful. Very stressed attending, very stressed residents, and sick, obnoxious patients were the standard. Which added together makes for a tough time as the intern. Every mistake that was made came down on my head. Which I'm used to, but the more patients I have, the more mistakes are made. And my census averaged 20 for the first 3 weeks of the month. Twenty notes to write, 20 patients to see and pander to. Great times.

Okay, rant over. December is now. I'm on the laparascopic service, which is better in so many ways. First of all, the surgeries are less involved, so patients usually go home earlier. Second, everyone's happier, so I get yelled at less. And I have time to work out again, which is great. Last month I turned to mush, and I'm still pretty much trying to dig my way out of my non-fitness hole.

It snowed here yesterday. By snow I mean the lightest dusting of frozen stuff, most of which has already melted today. It was nice though. Made it feel like home. And speaking of home, I'm headed there in 2 short weeks. I'm excited, but sad that Dennis cant come with. He has to work. He and Maddie will be here for Christmas. Last weekend we got a tree and decorated. I'll try to take pics when I have more energy.

getting a new hospital perspective

Well, its a new month and I have a new job in the hospital: I work overnights, covering a multitude of services for the day teams. I have 3 or 4 services on any given night. I also am the intern who responds to all traumas in the ED. Which is good for me, because I haven't had much exposure to trauma and I tend to get a little ADHD when I get into the trauma bay.

Here are the things I love about night float:
1. I get to wear scrubs every day. Actually, all I wear this month is scrubs and pajamas. How's that for fashionable?
2. The hospital is a cool place at night. Things move at a slower pace, and you really get to know staff.
3. Seeing lots of daylight. Its great to wake up when its light out, and get to be outside for a good part of the day.

Here are the things I hate about night float:
1. The inability to do most anything for patients. One of my more senior residents summed it up nicely, when he compared night float intern to a person trying to patch holes in a dam. You're holding your finger over one hole, another finger over another, and just when you think you've got it, a new leak springs. Basically my only job is to make sure patients stay alive through the night. Its also nice if they stay comfortable/stable :)
2. I rarely get to see the BF. We now work opposite schedules, and so our time together is rare. It stinks.
3. I go to sleep when its light out. That's been a little distracting; less so as I start to get exhausted, but still tough. I often wake up at noon freaking out that I'm late for something.

I have so many more thoughts to post, but I really should go do some work (its a slow night but I still have plenty to do). I need to post some pics of scenery plus horse stuff that I've seen lately, so be on the lookout for that!

"If I haven't spent $10,000 by noon, I start to feel a little antsy"

Only in health care. The above is a quote from one of our trauma surgeons. And its so true. I've never actually tried to add up the cost of all the stuff I order in a day, but its considerable. Probably cheaper now than when I was in the ICU, but still. Labs for all, scans, tests, medications, consults . . . the list is never-ending. Medicine is crazy; every piece of equipment has an extraordinary amount of labor/engineering/technology behind it, plus the fees of the person giving it. It adds up quickly. Take the OR, for example. They charge for OR time by the minute, and although I'm not sure how much the exact amount is, I can assure you its not pennies :) If I think about it too hard I start to feel guilty about how long it takes me to do stuff like suture.

In other news . . . Wow, its been awhile since I've blogged. Its been quite a busy month, despite my being on one of the 'easy' surgery services. My first two weekends were on call, so I logged over 90 hours each week. Last week was lighter, but I was out of energy after working 22 straight days, so it was hard to get my butt to the gym after work. Now, I had last weekend off, and I'm refreshed! What a difference a couple of days of sleeping in makes! Sleeping in for me is now until about 8am (sounds hilarious, but its a weird feeling to wake up when its light out, freak out for a second that you're late for work, then realize its your day off and snuggle back under the covers).

And I've gotten to operate a fair bit. Mostly small breast surgeries, but I've done a couple mastectomies and helped with some implants on the plastic surgery service. Tomorrow I do some melanoma resections. Pretty sweet huh? I'm getting more comfortable in the OR, asking for instruments and knowing what the next step is. And I love the attendings I've been working with, they're so patient and give me great tips for how to improve. Its been overall a very positive experience. A little too much clinic time, but otherwise a good month.

Today was fabulous. Our last OR case cancelled (sad but okay for today), so I got to go home at 4pm! Its funny how a 10-hour day seems short now. Makes me realize how warped my view of life and work is. I probably wouldn't know what to do with myself if I only worked 40 hours a week. Anyhow, this afternoon I had time to work out, walk the dog, pay bills, blog, and I'm on my way to have ice cream with my surgery team. Its great to have time to do more than drive home, see the BF and fall asleep.

Several of you have asked about my BF. He's doing well, loving it here as much as I do (in other words, "It's not terrible"), but meeting people and enjoying his job for now, at least so he says. He's still working on school, but has plenty of time to watch me sleep when we hang out together. I'm not exactly sure how I keep him interested/entertained, since I do sleep so much of the time we're together, but I try not to dwell on that. I think we'll be okay here in VA, and although we might never fall in love with this area, we'll be happier and happier as time goes on.

Finally, the reason I'm here . . .

I'm on my first general surgery month. Finally. A real team, with a chief, midlevel, and intern (me). My service includes breast and endocrine surgery. That means we take out breast cancers and thyroid nodules and cancers, for the most part. Usually relatively simple procedures, and the patient goes home the same day or stays overnight and goes home the next morning, if all goes well.

And when I say "we" take out nodules and cancers, of course I mean the grand "we." As a team, we look at the case list for the day, and my chief picks the cases she'd like to do. Then, the midlevel picks his cases. If there are any cases left, they go to me. Its sort of like being picked last in dodgeball, but in reverse. At any rate, the other day I got to go to the OR!!! Victory :)

Let me try to explain why I love the OR. First of all, its where surgery generally happens. That's a given. But also its where surgeons feel at HOME. Its where we're in our element, as it were. The OR is full of mini-rituals and very, very anal retentive practices, which is why surgeons are generally type A people. I'll run though the prepping of a patient for surgery for you, step-wise.

1. I go and see the patient in the preop area. All I have to do is say hello, and maybe update his documented History and Physical. The patient also needs to be consented for the procedure, if that hasn't happened before.

2. The patient gets wheeled into the OR suite. We do a TIME OUT, which means we all agree that we're doing the right procedure on the right patient on the right side. The patient then gets moved from their bed to the operating table, a very skinny very hard board that goes up and down and lots of other nifty directions. They pretty much get strapped in, covered VERY BRIEFLY with warm blankets, and anesthesia does their magic to put the patient to sleep. Usually they put an endotracheal tube in to help the patient breathe during the case. They also tape the patients eye's shut to prevent any corneal damage. Squeezy boots are put on their legs to prevent clots from forming during the case.

3. As soon as the patient is asleep, the fun begins. We immediately strip off all those warm blankets, put a catheter in if its a long case, and shave any really hairy body part we're working on. I then use a sterile prep to clean the patient's skin where we'll operate. Usually its betadine, so I'm (carefully) slopping this wet brown stuff all over them. Starting at the middle of the site, and moving outward in a circular motion until my sponge gets dry. Then get a new sponge, reload, and repeat. I do at least 4 runs with scrub, and 2 runs with dye. This shows us where we've prepped once the scrub dries.

4. Then I go to the scrub sink to scrub myself. This is a 5+ minute process of cleaning under my nails, then scrubbing every side of my fingers and hands (5 strokes each side of each finger, 30 on each palm, 20 on the back of the hand, 30 on each side of the arm to the elbow. um, scary that I count this? probably). Then I walk into the OR, careful not to touch anything, and the scrub tech helps me into my gown and gloves. Hopefully I've already put on safety goggles, but usually I forget and get yelled at by the circulating nurse. Once I'm done getting gowned/gloved, I start draping the patient. This is the part where my heart rate goes up, because I don't want to mess the draping up and have to start all over, and get called incompetent. Its very important that the patient stay sterile, so nothing can touch the prepped part except our sterile towels, drapes and instruments.

5. The patient gets fully draped with towels and drapes to cover every single part except the part we operate on. This is key, and its the reason why the OR's not really as grisly as people imagine. Its quite easy to focus on the part in question, and forget you're operating on a full person, in some ways. Keeps the queasiness to a minimum. This is not the case for an operation on the head, where the patient is pretty much in plain view. Anyhow, the draped area is sterile now, and not to be touched by anyone except those who have scrubbed as I described above. Usually this will include the attending surgeon, the assisting intern, a medical student, and the scrub tech. In the room, there is also an anesthesiologist and a circulating nurse, who gets us anything that's not already sitting on the instrument stand.

6. The scrub tech then wheels her stand over, full of fun operative equipment that I'm just starting to learn the names of. Tools sometimes have many names, and include blades, clamps and graspers of all types, and retractors, among other things. A key feature to any case is the Bovie, an electrocautery device that can both cut and coagulate bleeding areas. Also key is the suction. Any med student who has had that job can probably laugh along with me as I fondly remember my first case in the OR: "suck, dammit, suck. I can't see anything. That's better, now try to keep it dry, and suck whenever I'm not in there, okay?"

7. Then the magic happens. The magic first involves staring at the site for what seems like forever, trying to figure out where to make the perfect incision. If I get to decide, my mark usually gets altered once or twice before actually proceeding. The area of choice gets marked with a (sterile) pen, and I ask for the scalpel. "Fifteen blade" is actually what I say. Then I get to make the cut. Either I do okay, and get praise, or I do a bad job, and halfway through the attending screams at me to stop.

And I won't continue boring you with my favorite things, but that's basically how the OR works. And it works that way every time, and there's quite a sense of ritual and exactness about it that makes me happy. Probably because of my borderline OCD.

Here's hoping I get to get back in the OR frequently this month!

a brief guide to medical lingo

I had a recent conversation with a family member that makes me laugh. I told him I was on call, and he replied "oh so you could have gotten called into work." This makes me laugh because, althgough its called CALL, it really means WORK. But most people don't know that.

So right now I'm on q2 call. This means that every 2nd day, or every other day, I'm on call. Call means that I'm the intern carrying the pager, and all patient issues come my way. It in no way means that I'm at home eating bon bons waiting for a question to come from the hospital. Often call means that I'm running around from room to room in the ICU, attending to patients and fixing potentially scary situations before they happen. I also see patients that are done with surgery before they get upstairs to the ICU, because other interns don't always make sure that patient is optimized when they get to me. Case in point: I get a patient from the OR Friday night about 11:30 pm with a blood pressure of 40/20's. Normal is 120/80, and in the ICU I'm happy with 90/60s. At any rate, my call shifts are fairly busy and I generally work the entire time.

That brings me to another vocabulary issue I get over-quizzed about: who's who in the hospital.

ATTENDING: that's the boss. He's the physician who admits patients, operates on them, or oversees their care. In the ICU the attending spends 0-10 minutes in the patient's room PER DAY, depending on how sick they are. They spend more time in consultation with us making sure that the plan on their patients is carried out.

CHIEF: this is the highest ranking resident on a patient's care team. In surgery, this makes them a 4th or 5th year resident. They operate a lot, and generally tell me what they want done and scream when I don't get it done exactly as they'd like. They communicate most directly with attendings.

RESIDENT: anyone with an MD who's not yet board certified. This means that they can't take care of patients without an attending above them, but they generally oversee the patient care for the attending. Therefore, they spend a bit more time with the patient. The most junior resident on the team has the most boring, innane patient work to do. Residents are also called HOUSE OFFICERS.

INTERN: The lucky souls who are always the most junior resident on the team. Intern year is the first year of residency. Interns generally take calls about patients, write notes, enter orders, call consults, admit and discharge patients, paperwork-wise, and basically do all the boring stuff regarding patient care you can think of.

There are a variety of nurses also, but I'm less familiar about them. There are also pharmacists, respiratory therapists, physical therapists and occupational therapists that see patients in the hospital. Not to mention speech pathologists, wound care specialists, dieticians, social workers, and chaplains. And many, many other people that I'm forgetting right now. And everyone wonders why health care is expensive. You basically have a small army of experts working their magic on you to try to get you better.

What else is part of my daily lingo that normal people would ask about?

ROUNDS: This is the act of seeing your patients one after another and writing a note on them. It usually happens in the morning. The goal of this visit is to check and see how their night went, and formulate a plan for the coming day. It involves talking to the nurse, talking with and examining the patient, and gathering labs and vital signs. First, the unlucky med students pre-pre-round on patients. Then the interns get there and pre-round before the team comes in. Then the full team of residents rounds and comes up with a semi-finalized plan of the day. THEN, whenever they have time, the attending comes and rounds on the patients. This can happen with all residents present or not, depending on how much is going on. In the surgery world, all of this happens before 7:30 am because that's when the OR starts. So you can imagine how early those poor med students get there in the morning. Interns too :(. Especially when you have 15+ patients to see and your med students are unreliable.

CODES: These are called on patients that are unresponsive or who's condition is rapidly declining. Sometimes they are quickly resolved, and sometimes they involve intubating (putting a tube in the throat) and shocking heart rhythms. Either way, as an intern, they scare the crap out of you. I've never been the first one to a room when a patient is coding, and I hope I won't pee my pants the first time it happens.

I'm out of energy to type. As an update, I'm still enjoying my time in the SICU (surgical ICU) and I'm learning an incredible amount. As one of my co-residents put it, you either learn what you need to know or you hurt people. So far I've put in central lines, chest tubes and arterial lines. I've done upper endoscopies and bronchoscopies (scopes looking at the stomach and lunge, respectively). I've done bedside wound explorations and wound vaccuum changes. But I'll be happy when this insane schedule is over and I get to move onto a different rotation with 'healthier' patients.

in the bubble

I'm back to work. And my newest post is SICU intern, the oh-so-glamorous position which includes getting shat upon by attendings AND chief residents. And ICU nurses who feel as though they know more than a lowly intern could ever know about anything. Exciting. The good part is, I share this duty with one ER second year resident and an anesthesia 3rd year resident (CA-2 for those who know the lingo). The ER resident is nice but blah, but gets her stuff done without a fuss and is very helpful. The anesthesia resident is the bomb. In fact, the majority of anesthesia residents I've met are similarly awesome. I think its because, with the exception of surgery off-service rotations, their life is pretty sweet. Not that I want to be an anesthesiologist. That's probably because I enjoy being sullen more than they do. But they've got a good thing going, that's for sure.

At any rate, the title of this entry is a tip of the hat to the SICU, where I am 99.9% of my day. In general, I have no idea what's happening in the rest of the hospital, nor is it my job to care. When codes get paged overhead, we get excited for about 0.5 seconds, until we find out that the patient will go to a different ICU. If they're coming to us, then we care, and maybe even run to join in on the fun that is a floor code. Otherwise, we're blissfully content in our 16-bed paradise, doing crazy stuff to sick people all in the name of saving lives. Today the only craziness I indulged in was putting in NGtubes and Dobhoff tubes (they go in the nose and either to the stomach or intestine. Their ultimate destination depends upon the skill of the operator. Today, mine went where they ought to have gone. Whew.) I also got to change a central venous line over a wire, a task that always makes me cringe because I wonder if I'm maintaining sterile technique. I picture the little bacteria marching in through my new contaminated central line and killing the patient. Then I try to block that image out of my brain. The only other fun came when I was busy rounding, and a patient needed to be intubated. I didn't get to do it, but got to help with a bronchoscopy of him later. So all in all, a quiet day in the SICU. Perfect for starting off.

No day here is complete without learning that a patient is even closer to death than previously expected. The SICU is filled with . . . how do I say it . . . generalized badness. Many people make it out alive and well, but some . . . not so much. And the way they go out is grizzly, to say the least. Remind me to tell you the story of Moomba someday. Being just back from vacation, I got the scoop on who did great and who tanked while I was gone. Some were expected, and others were a surprise. Today's new badness was the very large lady who went for a pelvic washout of an abscess that turned out to be fungating uterine cancer. Always a fun thing to tell the family. I'm fairly certain that the SICU is the focal point for extreme badness in medicine. I'm going to have to remind myself of that every day, or I'll start to think that everyone is really really sick with no chance of getting better.

I'm on vacation

and I hate it. Not really, but I want my vacation to start already! I've been off since Aug 1st, and can't leave for WI until Dennis is off work. And I'm doing my best not to spend money on ANYTHING, so I've been pretty bored. I've never been one of those people who does well with nothing to do. I'd rather be at work, quite frankly. At least there are patients to laugh with/at there. I feel like a slacker, sleeping in and watching too much HGTV while all my fellow 'terns work their butts off.

Of course, I'm excited to head back to WI. I miss everybody, and I'm just not comfortable in VA yet. I like my job, and I love my house, and that's about it. People suck at driving here, I know practically nobody, and the people I do know are too busy to hang out with me! I'm sure I'll get more and more comfortable, and everyone I know will get more used to going out despite little or no sleep the night before, but for now its hard.

Today Dennis and I went to the county fair. It was the biggest disappointment! Everything was set up in crappy tents, and I'm used to the tons of animals, activities and other stuff that the Kenosha fair has. This one had maybe 1/4 of that, and far fewer animals. I expected fewer cows, but there were maybe 5 horses and a couple of donkeys. I even brought my camera, to take pics, but was too bummed to do that. Dennis pointed out that it was the last day, and many of them probably went home, but still! It pretty much ruined my day (see how much I have to look forward to here?). So I went home and made some brownies and now I feel better :). Its sad how little there is to do here. Especially when on a budget. Sigh.

At least I've been busying myself with reading for school, so I can continue to answer somewhat intelligently when pimped at morning report. Yep, that's right, I said pimping. Those of you not in medicine: pimping is asking questions of someone under you that you already know the answer to. Its usually done to med students. Except here, where the interns get pimped every morning at about 6:30 am. Nothing like dozing off in your chair at conference, waking up just in time to hear "Dr. Burpees, why don't you tell us the Henche classes of diverticulitis?" Whoo hoo. I'm already looking forward to not being an intern, and I have about 11 months to go.