EM Physician - Backstage Pass

Perfect Job, perfect specialty??

2015-09-08T17:19:00.000-07:00

I remember how difficult it was for me to choose a specialty. Initially (as in before medical school), I wanted to be a dermatologist. I loved cosmetics and hair products, and as a college student I thought I'd go into some sort of 'beautifying' medical specialty.

Once in medical school they ~~forced upon us that primary care crap~~ tried to encourage us to consider careers in primary care. And I did...seriously. I really, really liked the idea of family practice. The doctor that sees the entire family, and watch the kids grow up, and have continuity of care, and keep the family healthy, yadda yadda yadda.

Then, I started having doubts. I met no one (even with all of this ~~brainwashing~~ exposure) who actually *enjoyed* family practice. It's a thankless job really. Anytime I asked a FP "do you like your job?" the response would start off "....wwweeellllll....". Not a good thing. And what followed was usually some combination of justification, hope, and regret.

So, I considered internal medicine. I guess I was stuck on this continuity of care issue, and thought that would make my practice worthwhile (you know, seeing the smiling faces of the patients I help, and eating the fresh baked muffins they'd bring with them to their office appointments to show their appreciation for my time and expertise). So, as a result of all the negative comments regarding primary care in general, I thought I would preserve my option of subspecializing (just in case the naysayers were right about primary care)...and internal medicine seemed better for that purpose than FP.

So, up until 4th year (FOURTH YEAR), I was all set to go into internal medicine. Then, in 4th year I did an elective anesthesia rotation. I thought about endless rounding that was internal medicine hospitalist care. I thought about the rushed office visits, and the lack of depth of knowledge (the "jack of all trades issue") and that kinda bothered me. What would I be doing all day as an internist? Rounding, taking call....clinic and referring? On the other hand...anesthesia pays well over $300,000 year, and you have only one patient at a time. There is no rounding, and the job is mostly low stress. And did I mention the over $300,000 yr salary??!!

I applied to BOTH internal medicine programs, AND anesthesia programs. I ranked anesthesia higher, and matched at my first choice spot. I did my prelim year in internal medicine...and off to anesthesia.

Well, I realized I hated anesthesia (at least my program sucked bigtime - which is no doubt detailed on this blog somewhere in another post). So now what do I do?

I didn't work this hard, for this long, and for this much debt to *hate* my job!!

I thought about my rotations as an intern. My ER rotation was the best. Not necessarily the most exciting specialty ever...but I just felt 'fulfilled' on that rotation. I felt healthier since I had time to get out in the sunshine on our days off. I felt disconnected (mentally and physically) with no beeper or hospital responsibilities on my time off...and the prospect of going back to work was exciting. Everyday I started with a clean plate. No inpatient ward 'rocks' or a patient that I was responsible for, yet someone else was just 'covering' for me. I enjoyed the 'we have a life' attitude of the ER residents. And I liked the fact that I could basically 'play doctor' with the patients until they became too complicated, or I became uninterested...then I could call someone else to take care of 'em.

So...I applied to EM programs (as a PGY2 anesthesia resident), AND internal medicine (in the case I didn't match in emergency medicine which was/is very competitive, I'd just finish up 2 more years in IM and be done). I guess you can say I decided on a EM career a bit late!! And even then, I *still* I wasn't completely sold...
***

I tell my story to demonstrate that choosing a speciality is very difficult indeed. With that said, I had a young woman send me a very thoughtful email:

I was telling my husband that I was really thinking about doing ER for the flexibility and the hours, because I'm really wanting to have kids...
...he responded by saying: I should do 'whatever I'm passionate about, no matter what the hours look like' because 'we didn't go through all of this to do something we're not passionate about'.

My Take -
Overall I think this is a very naive point of view. No, you don't wanna do something you hate. That wouldn't be fair...."after all of this time" you don't wanna go to a job everyday you *hate* (like me with anesthesia). But passion about a job.....??? I don't think that's a requirement at all, and if that's the *sole* determining factor in your specialty choice...you will be disappointed.

There is no way you'll *love*, say OB/Gyn if you cannot have your *dream life* because of it. Period. And, since being a 'part-time' OB is difficult....don't do it. It's kinda like buying a big house. Med students are basically telling themselves "you've worked hard...you deserve a mansion." So, you go buy a mansion....you're passionate about the house, and love the house....but after working 2-5 years around the clock, and never really having the opportunity to appreciate the home (or any other aspect of your life), you realize that you're just a slave to this house. Working to pay the mortgage....

...and you realize that you would be happier in a smaller house so you can work less and enjoy your life (and the small house) more. So, instead of finding joy swimming in your personal Olympic sized pool at your mansion (which you never had time to do anyway b/c you were working all the time)....you instead find joy swimming in the pool at the sports club you're a member of....and you actually have time to go and enjoy it.

Do you just absolutely LOVE your little house....??? Not necessarily. But, do you love your life...and the time this smaller home allows you to have free? Absolutely.

~~Do what you love.~~ Love what you do!!

***

I don't like the lack of continuity with patients. I don't like not building relationships with families. I don't like the way it is in general...

My take -
I was very idealistic...."I wanna help people and build a relationship with them....". But, honestly, medicine isn't like that for most of us. Ask around...I think you'll find (I'm sure you'll find) that the *concept* of continuity of care is attractive, but the *practice* of continuity of care...sucks. You'll realize that, in your family medicine practice, you'll never see your "well patients" (the nice ones that do what you tell 'em to do...because they aren't sick frequently). And with all of your patients (in order to make a living) you can only spend 10-15 minutes with them (I get more time than that with my patients in the ER...and I actually probably get to know them better than their crazy-busy primary care doctor during their sometimes 6+ hr stay with me).

As a primary care doc you work long hours for little appreciation (and even less pay). And you realize that you'd rather have continuity of care with your own children, than with patients who don't listen to you, may actually sue you when they decide they have a bad outcome for not listening to you....and want it all for FREE!!

I say, continuity of care ideology is nice...but not the reality, and I wouldn't choose a specialty thinking that the continuity will be good thing.
***

I've never considered myself to be the type to gravitate toward "jack of all trades".

My Take-
Emergency medicine is the best of all worlds. No matter what area of medicine you go into, you will not be the most specialized person in the field. And doing the same thing everyday sounds very boring, doesn't it? If you're not a 'jack of all trades' you'll be seeing the same stuff your entire career.
***

"I don't think I'm an ER doctor type."

My Take-
Most of emergency is medicine is non-emergent stuff (so it's not like you'll be running around like on the TV show ER - of course depending on the hospital). In a given month (10-12 shifts) I may see 5 true emergencies. The rest is ruling out very unlikely things just to protect yourself (CYA), and urgent care/primary care things. I see these same people *way* more than I'd like - so there's the 'continuity of care' b/c they don't have access to primary doctors' offices.

Anyway, what is an 'ER type'? I think it's the type of person who values their time off...and realize that getting paid is important, and that life outside the hospital is more important to your health (sanity, and job satisfaction) than life inside the hospital. It's a person that realizes that having a dream life consists of balance, and that a job/career does not replace meaningful relationships (that require time and nurturing) with friends/family. That it is not necessary to become a martyr or forgo everything else to be a good doctor.

Now, what these ER types *do* with their time off...varies greatly (sometimes depending on gender).

Other pluses: you feel like a *real* doctor...not a technician or a pawn in a larger political game (at least not most of the time). And, you can always go work in a GP or walk-in clinic and see patients on an ongoing basis as a EM trained doctor.
***

Overall, it's important to remember (cuz lots of docs don't, and they are unhappy):
You don't have to LOVE (every aspect of) your job for it to be the PERFECT job.

*pictures from Life is Good Collection...it's an awesome collection. Check it out.

Point of view, November 26, 2004

2015-09-08T17:17:00.000-07:00

What ever happened to being responsible for yourself...owning up to your actions and mistakes, and holding yourself accountable for the circumstances of your own life? Sometimes I wonder, would people think I'm the most insensitive, uncompassionate, heartless doctor if they were privy to the ramblings of my internal monologue?

At King we have lots of traveling nurses. Mostly I welcome their presence because they bring "new insight" that lots of the native King nurses lack. Yesterday RN Wendell told me that I was one of the best doctors he'd come across in his travels. Other staff frequently gives me similar compliments...and the patients express gratitude, which is what makes it all worthwhile.

However, there are those people who...really are accustomed to doing whatever the hell they wanna do, with blythe disregard for consequences. And they need to be checked from time to time.

For instance, there's the 55 y/o alcoholic african american male, brought in by paramedics complaining of abdominal pain. History of alcoholic liver disease, gastritis, and chronic pancreatits. He reeks of alcohol, and is mildly intoxicated. We (taxpayers) spend thousands of dollars on his workup, and after 8 hours in King's ER, we determine he has acute pancreatits. Now, as he's sobering up, he becomes belligerent and demanding (specifically) demerol 100 mg IVP. What the hell?? Well, he's certainly not gonna get that from me tonight. After a couple of critical patients are stabilized he's up and fussing about how *we* can't let him just be in pain like this.

His response is "you bitch, I shouldn't have ever came to this fucking hospital."

Me: "Then leave." Did I go out to the street and drag you in here? Does he think he's hurting my feelings by leaving? (We actually call our yellow AMA forms "the golden ticket).

Him: quiet for a minutue "you alright doc...I'ma sit down...but how long do you think it'll be?"

Or the trauma patient who comes in all shot up. Dr. Spevack saves this guys leg after an extended operation. In the ICU the following week, the guy is pissed about...whatever...and starts going off on Dr. Spevack. "This fucking hospital sucks, you suck, I can't believe I got an infection...yo mama is a ho...so forth and so on." Dr. Spevack lets him finish...and then responds: "man, I fuckin' saved your leg and that's how you talk to me?"

With his baby's mama at the bedside he responds, "yeah, that's true." YEAH, asshole, that's true!!

So the above stated alcoholic decides to sign out AMA. "Well, I ain't got no where to go."

Me: You can't stay here.

Him: Well where am I gonna go?

Me: That sounds like a personal problem. You can wait in the waiting room until the morning, then go to a shelter.

Him: You can't just kick me out.

Me: Well, sir, this isn't a hotel. You're a grown man, I'm sure you'll figure it out.

It's a shame, but no wonder, that this guy has no-one to call. But if you were in the waiting room having an MI, you'd want to trade places with this guy too...so you can see a doctor, and he can come on out and deal with his social issues. His medical care is over, either by discharge or by his own choice, and the ER has limited space and resources. We need to get the sick people from the waiting room into the ER, and the not sick people out.

Or what about the lady who calls 911, is taken to St. Frances. Is triaged to the waiting room. Decides she's dosn't want to wait...goes outside and calls 911. Is taken to King. Is triaged to the waiting room (especially after EMS tells us she just left St. Frances). Leaves, calls 911 again so "she can be seen faster." What patients don't understand is, they are *seen* as soon as they walk in the ED. If their complaints are minor, or not as severe as the rest of the people, they wait.

Or the family who calls 911 to dump their mother anytime they wanna go to a movie. Or the woman who calls to "get rid of" her drunk boyfriend when he passes out drunk...again. Or the criminal who's caught committing a crime...then decides to complain of chest pain to avoid going to jail. Our EMS cannot refuse anyone a ride to the hospital...eventhough a few years ago they could. They used to assess a person, provide appropriate treatment, and if indicated, transport them to the hospital...consulting with the online physician if necessary. Too bad our society is so litigious and reactionary, because now they have to offer everyone a ride to the hospital, no matter the complaint or issue.

People come to the ER with their $400 i830 Nextel phones, in their Escalades with the Sprewell spinning rims, decked out in Fubu with Prada handbags...but can't pay 4 bucks for Tylenol to ease the discomfort of their 4 year old child...or pay $50 for healthcare or an ER visit? Who's holding these people accountable?

Or the government funding housing. It seems to me that if I (i.e taxpayer) give you a place to stay...I state the terms up front...you agree...then break those terms, you shouldn't get mad when I kick you out. No gang activity (graffiti, shooting/violence, felons hanging around with each other, etc) is a fair "rule." And even if it's not, you agreed to it. You're living in a place that I own, and you don't keep it clean, you don't follow the rules, and then have the nerve to get mad when I bring in police to "clean up" the place. It ain't yo shit...let's not get it twisted.

I'm not a left wing liberal, or a cross-hugging/burning conservative. I just believe what I believe, and whatever people decide to call it, so be it. Yes, there should be access to healthcare for everyone...but measures should be in place to hold people accountable. Granted lots of social problems that we face in the ED is simply a reflection of society at large..but they need to be dealt with.

Ultimately, people need to be held responsible for *something.*

The ER doctor is only as good as her hospital allows, Nov 23, 2004

2015-09-08T17:16:00.001-07:00

Continuing on with this lower GI bleed lady.

She seemed okay after the questioning...and during rounds. But immediately after rounds she seemed to be sleeping. When the sheets were pulled back... .

..she was laying in a mound of dark red clots of blood. Looked immediately up at the monitor, low and behold she was tachycardic and hypotensive. The juniors were all over it...and stabilized her with IVF, blood transfusions, and even got a tagged RBC scan to see where the blood was coming from...exactly.

The RBC scan revealed a "sprinkler" in her descending colon. Surgery was called. They wanted an NGT lavage "the bleeding may be coming from above." But we have the RBC scan...

...initially the lady refused NGT lavage, but now she was intubated and unconscious, so it was done. No blood. Surgery was reconsulted.

"You have to get GI to see this patient first, she's too unstable for the OR."

GI was called...they can't scope until the following day (maybe). There's only one attending who scopes, and he's off today. Unbeliveable!

This went on all night. Patient seemed stable overnight, and the family was informed.

A CBC was ordered by the intern overnight...but the nurse (for whatever reason) decided not to draw one. Nor did he tell the intern. So there was no CBC overnight...and when I arrived at 7am, I ordered the (new day shift nurse) to draw one. The new H/H 3/10.

What!! How did this happen??

We order blood, which takes the better part of an hour to obtain...even noncrossmatched. We give her IVF, and talk the the (very surprised and upset) family. And we wait.

We call GI back...they are in clinic doing a procedure, and will come later in the day. What??!! Hello, we have a dying patient here... Candice the student nurse wipes the patients face because there is a bit of brownish liquid on her cheek. When she pressed on the cheek with the towel...more brown stuff came from the patient's mouth. So Candice picks up the suction and places it in the patient's mouth. Within 10 minutes there was 500cc (half a liter) of brown blood in the suction canister. 20 minutes later, there was 2 liters!! Surgery was called back.

No, we will not take her to the OR. She has an upper GI bleed, and GI needs to do endoscopy and control the UGIB.

GI...is still in the clinic.

Over the course of the following 12 hours, me and Mikey transfused this lady 20 units of PRBCs, FFP, platelets. We try everything...even the blakmore tube. The daughters are at the bedside watching us work (all damn day) tirelessly. Finally, when the lady's blood was as thin as koolaid, and it was obvious we could not keep up with tht blood loss...they asked us to stop transfusions. Lined along the wall was about 14 liters of blood in suction canisters. Blood all over the bed (nonclotting), blood on the floor.. . GI comes. We've already stopped. It's too late.

Surgery blames GI, they should have come earlier. GI states that it was too much bleeding for them to control...and hat she needed to go to the OR. Surgery states that they needed better localization of the bleeding site. I guess the tagged RBC scan wasn't enough. I guess endoscopy for localization of UGIB isn't something that's done in the OR at King. I guess GI doesn't do emergency endoscopy at King. I guess surgery doesn't operate emergently at King.

All an ER doctor can do is stabilize in a case like this. We cannot operate, or scope. And the hospital's way of doing business is allowing patients to just die in the ER...it's no wonder it's called Killer King.

The worst part......her 2 daughters, one 20 y/o, one 30 y/o, watched their mom bleed out. And no-one would do a damn thing.

Senseless transfer, September 20, 2006

2015-09-08T17:16:00.000-07:00

There was this patient...

67 yo Hm transferred from outside facility where he presented at 8am c/o severe abdominal pain with N/V for one hour. PTA his niece called the advice nurse who recommended she call 911. In the ED at the outside facility his work-up was essentially negative, except he continued having severe abdominal pain. Transfer was arranged to our facility because their CT scanner was broken. At the time of transfer, although all tests were negative, he was becoming increasing hypotensive/tachycardic. In fact, per family, the other facility refused to give him more pain meds b/c "his BP was too low."

Upon arrival to our ER, patient was hypotensive/tachycardic and c/o continued pain. He was pale, and generally appeared unwell. He was immediately transferred to our close observation area. Initial bedside ultrasound was performed, and negative. Blood was drawn, IV hydration given, and plan of action discussed with an already very frustrated family.

Although on exam his abdomen was not acute, he c/o pain out of proportion to the exam. CT scan ordered. Bedside ultrasound x2, no free fluid, aorta with no aneurysm. Surgery was consulted.

The surgeons were in the OR, and said they would be available in 1 hour. IV hydration continued, pain meds administered, and eventually dopamine had to be started. NGT placed, antiemetics given, and lab results checked. No significant abnormalities.

After 2 hours of resuscitation patient was still pending surgery evaluation. CT also still pending. Clinically, the patient is doing worse. Remains hypotensive on dopamine, and tachycardia worsens. Surgery recontacted, and ?still in the OR, will be down in 10 minutes - recommended the CT. CT called, patient wasn't due until 1930. Radiologist called to help expedite the CT. Before CT could be obtained, patient decompensated with waxing/waning mental status. Femoral line placed, packed RBCs transfused. Repeat bedside ultrasound done. No obvious free fluid seen, aorta not visualized, but there was a question of free fluid near the bladder (i.e. bladder vs. free fluid). Up until this time, patient with severe abdominal pain, but no guarding/rebound. Now, patient with distended, tender, belly with rebound/guarding.

Surgeons arrive at the bedside as PRBCs are being transfused and ultrasound being done. They evaluate the patient, and still felt the need to do a DPL. DPL revealed frank stool. Immediately went to OR.

Patient doing okay, but still intubated in the ICU.

My frustrations are: 1) Why did the advice nurse not tell the patient to go to a hospital that could actually treat his problem? Had he a AAA, I doubt vascular surgery would be readily available, 911 isn't always the best option. Sometimes getting into your car and driving to a facility that you know can take care of you is a better option.

note-to-self: don't listen to the advice nurse. don't sit around all day at a hospital who can't do anything, pending a transfer. Have someone drive you to another hospital.

2) What took surgery so long to come see the patient. If they had a case, there should be another surgeon who can cover the ED. Otherwise, the ED is non-functional (by everyone's standard).

3) how can the other hospital *not* have a working scanner. They should not be accepting paramedic runs.

4) Why does transfer take so long. It's so simple to say, a simple concept...'we'll just transfer her..' but hours it takes. Dead time.

5) Why does it take so long to get an emergent CT, even after attempts are made to expedite the study? A more expeditious CT would have revealed this problem sooner than clinical decompensation.

6) Why did the surgeons do a DPL? Had it been negative were they *not* going to take him to the OR? It was an extra step, and a waste of time.

7) Why doesn't the facility have mechanisms in place to deal with true emergencies? The CT backed up, the surgeons in the OR. I called surgery upon pt arrival to our ED. 5 hours later he's in the OR.

I really do care. I did all I could do. I covered him with antibiotics. I called surgery 2 or 3 times. I called them very early. Immediately after my evaluation, ultrasound, and speaking with family. They knew he was sick...hypotensive/tachycardic with belly pain. They knew and asked about AAA. Did they think the patient would just go away? Why didn't the surgeon send his resident down...to evaluate if he didn't 'believe' us. It's not okay to just not believe, and not come see...

I know I did all I could. I could not cut his belly open. I could not physically carry the surgeon to the bedside.

I did all I could have done.

Issues with Medicine

2015-09-08T17:14:00.000-07:00

On the white coat.
Everyone wears one. I wonder why. I think patients are starting to realize that it’s actually those of us *without* a white coat that are the doctors.

On Customer Service.
How stressful would it be if you actually gave a damn about patient satisfaction scores. Not because it’s not a worthy goal to be customer friendly; but because these scores are derived from so many factors that you, as a doctor, have absolutely no control over. Wait times, parking, whether or not you have access to old medical records. Think about it, if a patient in the ED waits 8 hours, cannot tell the difference between a doctor and a nurse manager (because everyone is wearing a white coat), gets a CNA that treats them shitty, and then goes out to their car and finds a parking ticket on the windshield….you can bet that when a survey is sent to them asking them to rate their ED doc…they’re going to use this only opportunity, to show how frustrating it was for them. And when that patient decides to go elsewhere next time, it’s the MDs who are spanked.

On Complaints.
All complaints don’t deserve a ‘full investigation.’ The drug seeker who’s pissed off because I wouldn’t use my medical license, and my medical education/professional decision making capacity, to give him the drugs he seeks (i.e. I decide my job isn’t to serve as his drug dealer), he complains. Subsequently the wheels start rolling…and eventually I get to ‘respond’ to this complaint. Frankly, I don’t need to know about it…and the complaint should be discarded. The patient has the right to get a second opinion. I have a right (a responsibility) to do what I believe is correct/safe. Woe is the doctor who gets bullied by Anna Nicole Smith, and when she ends up dead…all eyes on doc drug dispenser. Customer service gone too far!!

I remember there was one case in particular. The patient wanted something that wasn’t medically indicated. Had I given it to her, and something bad happened, no one would have given me a pass because I was doing what she wanted. It would be like “but you’re the professional; you’re the one licensed to practice medicine; she didn’t know, but you knew better.” So, she went to administration and threw a tantrum. Some nurse administrator (in a white coat, no doubt) thought it was a good idea to walk the patient back over to the clinic, and question my decision. Needless to say, I felt very disrespected, undermined, and angry. “Why don’t you give her blah blah blah?” She asks.

“Because, in my professional opinion as a physician licensed to practice in this state, it’s not indicated, and potentially harmful.”

Her: “It’s not a big deal just this once to give her this or that….”

“If *you* think she should have it….*you* give it to her. You go to medical school, do a residency, apply for state license, a DEA number, and get a job somewhere…then you can give her anything you want. But, I’ve made my decision.”

Why did I have to go there?

On Joint commissions.
I wonder who appointed them, this private entity, God. Why are we closing hospitals, and compromising patient care, jumping thru impossible/impractical hoops trying to comply with various, random, and irrelevant ‘regulations’ that they pull out their asses. It’s easy to have a ‘new regulation’ on paper, but in practice, if it’s not practical to implement, it only distracts from what we’re actually able to do right. Also, what about when they’re just wrong, harmful to patients well-being. Like the 4 hour timeframe to antibiotic administration in pneumonia patients. I’ve seen more people with c.diff colitis violently ill, who received antibiotics to treat ‘possible pneumonia’, for the CXR to be clear. Passing out levaquin like candy in triage to meet some random joint commissions regulation is causing lots of undue sh*t (literally) both for the c.diff patient, and society in general as our antibiotic resistance rates rise. I think doctors need to take more responsibility, and *regulate joint commissions*. Afterall, who regulates them?

On universal health care.
When this happens…because it will…these groups that import doctors and nurses…who cut costs with cheaper mid-level practitioners in environments that should have physicians…who have unhappy doctors…had better watch out. CEOs need to understand: patients have health insurance to see me. Everyone else is supporting cast. Everyone else is there to allow me to do what I do.

On diversity.
You can’t advertise that you have a ‘diverse’ staff as a medical group/institution, if you’re counting foreign doctors/nurses, and minority/immigrant housekeeping and cafeteria workers as “medical staff.” When an Asian American, Mexican American, or African American patient seeks a diverse insurance company (i.e. anyone on staff that looks like them), they’re actually hoping for American doctors with various ethnic roots. The racial makeup of support staff…is very much less significant. And it is misleading to tout diversity in a medical group when the diversity you speak of doesn’t include the physicians…the very reason one seeks the services of a medical group/insurance plan.

On a Doctors Bill of Rights.
Doctors need a bill of rights. The right to do what they deem appropriate for the patients under their care. To prescribe the best medications, perform the necessary procedures. To refer to specialists as needed, and feel free to do the best they can without fear of friveouls malpractice suits. Doctors need legislative protection from insurance companies, CEOs, and other non-physicians hindering their ability to provide the very best care for their individual patients. Compensation needs to be fair. Medicare/cal, and insurance companies should not be allowed to short-change doctors for their own profit. Likewise, doctors should not be punished for providing medical care in the way of additional taxes. Tax the insurance companies who are making a profit (and those who are not). What sense does it make to tax the doctors? Why not the nurses as well?

I think we need to unionize….

Letter to my patient

2015-09-08T17:13:00.001-07:00

These 'letters' were passed to me by colleagues. I guess I work with alot of...frustrated docs. (these were not written by me)

Dear Patient:
You came in at 11pm last night with a chief complaint of sore throat while munching on a sandwich at triage. Next time you choose a sandwich to bring with you to the ED, try something that will go down easier. Peanut butter and Jelly – while I’m sure was very tasty, made my ENT exam, well… a bit difficult. But alas, we did get through it and I got to see your very normal throat. While I was tempted to leave the diagnosis of “no real complaint” on your chart, after envisioning my directors review of yet another unbillable chart I went ahead and replaced it with “sore throat”. Your chart will be coded with a maximum of billing incompetence by our billing company. In their defense, they follow archaic laws meant to break my balls and keep money out of my pocket. I wanted you to know one last thing. It’s ok… you don’t really have to pay that bill. There will be no consequences. If it arrives at the (fictitious?) address supplied by you, you can chuckle as to how we could possibly charge $350 for doing nothing. I wonder if giving you a depot of 2cc’s of Bicillin into your deltoid would have made us both more satisfied. In the end, you provided for yet another priceless moment in this stage we call the ER.

***

Advice from an ER doctor to drug seekers

I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.

The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn't require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the 'worst headache of your life' you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I'm not willing to lay my license and my families future on the line for your ass. I also don't want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your 'typical pain that is totally the same as I usually get' and we will both be much happier.

The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting but you might not be lying. (See below.)

The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fake name so we can't get your old records I will assume you are a worse douchetard than you really are. More importantly though it will really really piss me the fuck off. Pissing off the guy who writes the rx you want does not work to your advantage.

The fifth rule is don't assume I am an idiot. I went to medical school. That is certainly no guarantee that I am a rocket scientist I know (hell, I went to school with a few people who were a couple of french fries short of a happy meal.) However, I also got an ER residency spot which means I was in the top quarter or so of my class. This means it is a fair guess I am a reasonably smart guy. So if I read your triage note and 1) you list allergies to every non-narcotic pain medicine ever made, 2) you have a history of migraines, fibromyalgia, and lumbar disk disease, and 3) your doctor is on vacation, only has clinic on alternate Tuesdays, or is dead, I am smart enough to read that as: you are scamming for some vicodin. That in and of itself won't necessarily mean you don't get any pain medicine. Hell, the fucktards who list an allergy to tylenol but who can take vicodin (which contains tylenol) are at least good for a few laughs at the nurses station. However, if you give that history, everyone in the ER from me to the guy who mops the floor, will know you are a lying douchetard who is scamming for vicodin. (See rule # 4 about lying.)

The sixth and final rule is - wait your fucking turn. If the nurse triages you to the waiting room but brings patients who arrived after you back to be treated first, that is because this is an EMERGENCY room and they are sicker than you are. You getting a fix of vicodin is not more important than the 6 year old with a severe asthma attack. Telling the nurse at triage that now your migraine is giving you chest pain since you have been sitting a half hour in the waiting area to try to force her into taking you back sooner is a recipe for making all of us hate you. Even if you end up coming back immediately, I will make it my mission that night to torment you. You will not get the pain medicine you want under any circumstances. And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don't really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says 'I am a drug seeker' and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don't want that. I don't want that. So lets keep this simple, easy, and we'll all be much happier.

Sincerely,
Your friendly neighborhood ER doctor

***

Why are you here?

2015-09-08T17:13:00.000-07:00

{walking into a patient's room}

Me: "Hi Mr. Smith, I'm Dr. Gilman and will be taking care of you today in the ER. So, I reviewed your chart, and I don't see any significant past medical history. The nurses tell me you don't feel well. Tell me, what's the matter today?"

Smith: "I'm sick"

Me: "Okay, but what's wrong"

Smith: "I don't f*ckin' know, you're the doctor."

I hate, hate, it when a patient doesn't have a chief complaint when they come to the ER.

Why are you here? Today? Right now? (i.e. why couldn't this wait until you could see your primary doctor). What changed? What are you afraid of? Specifically, what part of your body is bothering you.

My job is to determine if this...whatever it is you have...is likely to kill you tonight, or tomorrow. If it won't kill you (or severely disable you), my job is done. I do not know why your rash won't go away. I don't have the time or resources to figure out why your toenail fungus medication isn't working. I don't usually adjust medications that your doctor has decided are best for you. And I don't write prescriptions for psych meds, viagra, or refill highly addictive meds without good (and I mean a very good) reason. I am not a substitute for your doctor. If you rely on the ER to diagnose cancer, or manage your hypertension...you'll die from complications related to these diseases. You could go to the ER 10 times in 2 weeks c/o abdominal pain, that eventually turns out to be an gastric ulcer or stomach cancer. Do you know when we, in the ER, will make that diagnosis? Never. Or, not until we see a big hole, or a big mass, on CT. By then, it's end-stage. And to think...you've been coming to 'see a doctor' for weeks.

And another thing: people who 'save up' their medical issues, and then complain of everything under the sun when they go to the ER, bug us. In the ER, you get ONE problem. Choose carefully.

I wish patients could understand the limitations of the ER. I wish patients would think about why they've decided they need emergency care. And I wish they would limit their complaints to 1) emergencies, and 2) one basic problem.

Letter to my peers on unionizing

2015-09-08T17:12:00.003-07:00

(I will kindly *not* include myself in this)

Doctors are stupid, because they have allowed this to happen.

Still living in an era of the rich, private practice mentality...not accepting the fact that most physicians today are employees in one way or another. And instead of turning up their noses to unionizing, perhaps they should realize that they are now more like the average worker. They've allowed the nursing union to be the be the sole legislative voice on healthcare policy, to their detriment, and to the detriment of their patients.

As the nursing union shouts "patient advocacy," they are trying to implement healthcare policy that actually hurts the poorest, sickest, neediest members of our society (I'll elaborate as needed). The whole while, the AMA/CMA (made up of mostly people who are completely out of touch with young physicians) asks for money, but does nothing to help their cause. Time after time, taking "no position" on matters that make a huge difference with regard to modern physician's issues. Case in point - the Governor's proposed tax on doctors and hospitals. The doctor's are getting fucked, and there is no unified voice advocating on their behalf. Therefore, patients are getting fucked, and healthcare is a complete mess. And where are the doctors? Where is their voice. What solutions are *they* offering?

Doctors need to change their thinking, hold the medical societies accountable, (or refuse to join), participate in the legislative process, and drop the arrogance against unionizing. Or we can all prepare for complete chaos as healthcare continues to fall apart, without a legitimate beacon of leadership. As the doctors bury their heads in their arrogant asses, allow everyone else to take control, and then wonder why they are (directly) paying for a shitty healthcare system, run by nurses/chiropractors/optometrists/herbalists/and the 'people at the healthfood store.'

Get a clue.

Hood Mentality

2015-09-08T17:12:00.002-07:00

The consequence of hood mentality.

In the hood, lots of folks are looking for a payday. Be it by "falling down" at the grocery store, or selling things on the street that....sell. A great number of people bitch and complain about paying a $50 copay, but pull up in a pimped out Escalade with spinning wheels and a $400 cell phone. The ultimate consumers.

Well, in medicine this trend continues. And, apparently, many of the frivolous lawsuits are initiated by people just looking for a payday at someone else's expense.

At the Kingdom, there was this young guy...who was racing his motorcycle on the freeway. He fell, got crushed, and was brought in to our trauma center. The surgeons patched him up, but after a month long ICU stay (and hundreds of thousands of dollars in bills paid for by you and me), he still couldn't walk. He had a pelvic fracture that required a 'special' (complicated) orthopedic procedure to *possibly* correct his problem. There were only a couple of orthopods in the city who performed this procedure. The issue was, the 'complicated' surgery was very labor intensive, time intensive, and the end-result was based largely on patient compliance...and evenso, the results were unpredictable. The surgeon was concerned that the patient: 1) wouldn't/couldn't pay him, so he'd be working essentially for free. 2) then the patient is a dumbass, and will probably *not* be compliant with follow-up 3) and finally, when the results weren't what the patient expects (which would be 'perfection' and the ability to get back on his bike and crash again)...he'll turn around and sue the surgeon.

So, here is a patient...that no orthopod will touch. It's not worth it to the surgeon. This is a skill that he has spent years, and hundreds of thousands of dollars, perfecting...and to not only *not* be compensated for it...but then have to *pay* in the form of a lawsuit, for an expected complication/outcome...just didn't appeal to these guys. So...this patient, 3 years out from his accident, is still unable to walk...and no one will even attempt to correct his problem.

***
Then there was the guy that presented to the ER after some quack manipulated his spine, causing a rupture of his vertebral artery (in his neck). All the docs saw *lawsuit* on this patient's forehead...and he died because no one wanted to get involved. No one wanted to perform an intervention....and have the patient die as a result...only to have to explain to a jury (a group of folks with no medical knowledge or experience), that he did nothing wrong. So, all the subspecialists sited one contraindication or another to avoid getting involved. And, of course, the patient died.
***

If I ever get hurt, I hope I can convince the doctors taking care of me that...

*I will not sue you if you do your best...even if you make a mistake...even if the outcome is suboptimal*.

If you can do that...convince the doctors that their best is indeed good enough...you'll get (better) care.

Emergency Department (In)efficiency - Why patients wait 6 hours...and die in the waiting room.

2015-09-08T17:10:00.000-07:00

I've worked at more than a few places...both EDs and urgent cares. I can finally say I now fully appreciate the difference between a 'physician efficient' ED and...one that's not.

One of my gripes about working in the ED as a doctor is...the place isn't set up to maximize physician efficiency. Sure, they expect you to see 2.5 patients an hour...but when it takes 20 minutes to log into the various computer programs, trouble shoot the printing process, and then find said printout to sign and place with the chart (if you can find the chart)...there's no way the "goal" of 2.5 patients can be reached.

Let's take last night...
...there were 4 docs there, only 2 computers available for our use. My kindergartner can tell you that 4 docs need 4 computers. As everything is computerized now, I can't even look up lab results, or discharge a patient without using the computer. So, I found myself standing...waiting...for a computer to open. While patients have been in the waiting room for 6 hours or more. Then, when 'productivity' scores are released, it seems we're just...slow. And to compensate for the utter inefficiency of the system...doctors are expected to 'just speed up'. Making an already stressful, high-liability, acute situation...even moreso. There are only so many corners you can cut. So, some of my colleagues will opt to stay hours past their shift, doing charts, and continuing to dispo patients...stuff that they should have done hours prior (which would be both better for the patients we've seen, and for the patients in the waiting room), but couldn't for fear of slowing down...and being the "slowest person in the group." So, the patients (all of them) endure less than optimal medical care.

Why do we let them punk us like that? 10 hours of work should be done in 10 hours. It should not be expected/required that you do 12 hours of work in 10 hours. If the system is so inefficient that only 1.75 patients/hr can be *properly* seen...that's how many we should see. And charting/paperwork shouldn't be saved until the end of the shift. Documentation as you go is more accurate, and provides better communication to consultants and other healthcare team members. Above all, it allows you to keep everyone straight, and demonstrates real-time decision making and outcomes. Not to mention it's a total pain in the ass trying to gather all the pieces of information needed to compose a good note...after the fact.

So, what have I noticed that distinguishes 'efficient' EDs from 'inefficient' ones?

1. Smaller is better. The new trend is to build these 'mega emergency departments.' Where everything is spread out...very pretty...but inefficient. If you have a large ED, you need to break it down into essentially 2 completely different departments. Where one doctor is in one area...period. Not theoretically, but actually. There are EDs where the idea is to have one doc in an area, with a couple/few nurses...and that's where they stay for the entire shift. But in actuality, the doctor's patients are placed all over the place...in various areas...depending on "which nurse is up next to receive a patient." Additionally, the beds fill up in a particular area, depending on the disposition of the patients, their acuity, etc. So, patients will then be placed...anywhere there's room. Seems logical on the surface. But, then you have a doc running around this big ass ED, trying to care for patients from one corner to the other. This is inefficient, and slows down the flow. This ultimately is not good for patients. If the ED were to be divided (physically divided) into 2 discrete entities, this would not happen. Kind of like how Starbucks will frequently put 2 (separate) stores right across the street (or around the corner) from each other. It just works better...not having a huge, inefficient, chaotic, place to conduct business - but rather 2 (or more) completely separate places of business.

2. Each physician needs his/her own work station. As demonstrated above, it is a bad idea to require the usage of computers with not enough work stations. Waiting in line for a computer...isn't conducive to ED flow. And, not just random computers should be available...but rather each doc their very own. That way, you can set up the computer...log in...and not have to worry about getting up for a second...and losing your spot. Additionally, I could argue that this is better for patient privacy.

3. The computer should stay logged on. I'll approximate that I spend 30 minutes a shift logging on to various programs...each of which shut down after a couple of minutes of "idle time". Another joint commissions bright idea, I'm sure. HIPAA, CMS...someone who doesn't understand the practical impact this has on ED flow and subsequent patient care. The computer should be in a place that patients don't have ready access to. Once I log on, I should stay logged on. Perhaps there should be a way to tell the computer how long I'm working, and to log me out at the end of my shift. But logging on every 2 minutes...is not the most efficient option.

4. Speaking of logging on...can I have 1 login name and 1 password? Currently I have like 4 different login names/passwords. So...I end up writing them all down in my pharmacopoeia. I also see people put little stickies on the side of the computer. It has to be 'safer' and 'more protective of patient data' for me to have 1 login/password in my head versus all my info in a book...or on a stickie pasted on the side of the computer!!

5. And, can we quit changing the passwords every 3-6 months. This is another reason you find passwords on scraps of paper, stickies on the computer, or written in frequently lost pocketbooks.

6. Decrease the scut. Can we hire a clerk, high-school student...anyone, that can load the printer with paper, keep the necessary documents stocked, and print out aftercare instructions and acquire the patient's signature? I do so much scut...it's no wonder patients wait for 6 hours. It takes hours of my day printing pieces of paper, signing them, and placing them with the chart (after finding the chart). When my lab results are available, put them with the chart and notify me. When my radiographs are done, do the same. If an extended period of time has passed, and the data remains incomplete, call the lab, call the xray tech...find out what's going on, and fix it.

7. Have ED techs set up procedures, irrigate wounds, gather equipment, etc. And when rooming a patient, place them in the appropriate space. ENT, eye, Gyn, etc.

8. Have the nurses take less breaks. Man, they are *always* on break. I must say, I'm very jealous. We get no breaks. I can't even urinate or take a sip of water during many of my shifts. They get like a 45 minute 'lunch' and 2, 15 minute breaks. I can only dream!!

9. I need necessary work items in my work area. Can we have needed documents, trash cans, printers...you know, the things we need to work, near our work stations - and not solely across the way in the nurses station? It is a poor use of my time to make multiple trips *per patient* to the island for supplies when those very items could be placed in a spot more convenient for me.

10. The location of my patients matter. Ultimately, the flow of the ED, how many patients are seen, and how quickly they are dispositioned depends on me. And if things are not set up for me...the ED doesn't work well. Ancillary staff and nursing are important...but so am I. That needs to be taken into consideration. It's easy to understand why the nurses need their patients together, so why would it be any different for the physicians?

11. Don't bring patients back from the waiting room until they are ready to be seen. Bringing a patient from the main lobby into a smaller waiting room is a stupid idea...and only serves to frustrate the patient. Just when they think they're going to be seen, it's more waiting. Kinda like being in line at Disneyland, going thru the maze...thinking you're finally at the front of the line...turning the corner only to see a brand new maze. This frustration on the part of the patient only serves to slow us down...and lowers ~~customer~~ patient satisfaction scores (for those in admin who seem to get a hard-on over such things). It doesn't help when patients are constantly coming out of their rooms (or this "inner waiting area") to bitch and complain about the wait. It just slows us down even more. The lobby is a perfectly fine place for them to wait.

12. One thing that worked well at one place I worked: have the clerk call the medicine consultant. We, physicians, requested a medicine consult by asking the clerk to obtain one. She wrote the patient's name, chief complaint, and a 1-2 line "reason", that we provided, on the book. When they returned the call, she gave the consultant that info, and they came down. If they had questions, or we had a more acute patient, of course we'd be more aggressive and communicate more directly. But for the routine 'chest pain r/o MI' on a patient that you know didn't have an MI, but you can't send home because 'what if he did?'...this process works well. And most of our admissions are more or less well-appearing, low risk, CYA, bullshit...so, why fake the funk? Why waste time calling medicine and hanging around until they return the call for these patients? It's not like they won't come see the patient. The process is streamlined, and it works very well.

13. Writing holding orders for admission works well.

14. Paperwork. There's absolutely too much paperwork. Documentation, is done for billing, and less so for patient health information communication...which is unfortunate. Much of what we write is irrelevant, but required for payment. Therefore some medically pertinent items are excluded...because there just isn't enough time to do everything. Decrease the number of sheets of paper, and the amount of random bullshit we need to include for payment, and things will move faster.

And finally an ED Wish
I wish I could go out to the waiting room and tell people "Look, tonight is busy...and if you're not very sick, the wait is in excess of 5 hours. We'll see you, but don't ask us 'how much longer?'" It seems appropriate to tell people the honest answer to that frequently asked question ("How much longer, I've been here for 3 hours already?")...but we don't. We say "ummm, weeelllll, it depends on how sick people are....I don't know exactly....yadda, yadda, yadda", when in fact we absolutely know that it won't be in the next 5 hours!! We did this a few times in residency...and the ED waiting room cleared out. Non-urgent people left, and the emergent people got better care. I also heard about UC Davis doing this rapid screening (meeting EMTALA) then sending people out *from triage* if they were non-emergent. The only thing is...the paperwork is a rate-limiting factor, even in a 'rapid' triage system. If that could be stream-lined....the ED would work so much better.

Getting feedback from those of us *actually working in the ED* is the best way to make things better!!

Is being an ER doctor as cool as it seems?

2012-03-09T13:52:00.004-08:00

(OR - Quit Medicine? Part II)

As a group, doctors are not very good advocates.

Not for themselves, not for their patients, and not for their profession.

Gradually (and not so subtly) everything non-medicine has played increasingly larger roles in interfering with the doctor-patient relationship. Everyone suffers (even those greedy bean-counting executives suffer when they finally succumb to their own illnesses, or as they deal with trying to navigate American healthcare for their families). And instead of demanding a seat at the table, exercising their responsibility to weigh in on all things medicine...they sit on the sidelines and complain.

But this is beside the point.

My point today is to talk about whether or not choosing emergency medicine (or even choosing a career in medicine) is what I thought it would be.

Let’s start with what I thought it would be like.

***

I knew, as a medical student, that my role was insignificant. I knew residency was hard with long hours and physical exhaustion. I understood that college and professional school would be expensive (and accrue a large debt for a girl from a non-wealthy family) and residency would mainly serve to delay my ability to pay off these debts.

I recognized that I was socially underdeveloped, and had no practical knowledge about anything not in the lecture notes. I expected to wait to have a family, and accepted being continually absent from my own life to undergo this training program.

However, I also expected more freedom once done. I hoped for enough money (which is subjective and constantly changing) to live comfortably. I hoped to reclaim some “lost” time (and hang out with friends, read some novels, get married, have kids). I hoped to mentally *graduate* from student status, and buy a big-girl house, and big-girl clothing.

Most of all, I thought there’d be more appreciation and respect for the sacrifice doctors make in order to do what we do. I hoped for a more powerful voice as a professional. I thought doctors and patients would advocate together for the best possible health-care situation. (Vocal in a 'I am woman, hear me roar' kind of way...sorta like the nurses. I guess medicine is still too male dominated to be very vocal....)

But what I quickly realized was…

…being a physician is not quite what I expected.

But I’m a roll-with-the-punches kinda girl (or at least I try to be), and realize that physicians are *still* quite cool. Saying you’re a doctor does offer a certain degree of legitimacy in conversation…and it is easier to get a ‘seat at the table’ if you bring a medical degree with you. I do acknowledge (and appreciate) that.

Instead of complaining (further) about all the things “wrong” with being an ER doc, let me make it clear…

…it really is a fabulous job.

Not a day goes by when I don’t get some fantastic job solicitation (usually in not-quite-so-desirable places to live) begging me to consider a move to Podunk, Wherever, for crazy sums of money. And even locally, having board certification in a specialty that everyone uses makes finding decent job a small issue. There’s never a shortage of ‘business’ as an ER doctor. As the recession progresses (and the economy slowly recovers) our ‘business’ just increases as people lose their health insurance along with their jobs - which is unfortunate. But single payer would allow everyone to have access to (at least minimal) medical care...and (get this) we'd actually get paid for said care. (I honestly don't know why doctors, especially primary care and first-responders, would be against getting *some* compensation from *everybody* you serve)....

...but I digress.

What I do in the ER, matters. It is meaningful work. And the pay is not bad either.

I often get asked: would you recommend this career for your children (or some variation thereof).

The answer is (still) absolutely yes!! But with caveats.

I think it’s important to go early, go hard, and get done. Doing it this way, you could be done with all your training by age 29. Still plenty of time to “catch up” on everything else in life. After all, what better way to spend your twenties than setting yourself up professionally (and possibly financially) for the rest of your life. All before you have children, get married, or acquire additional responsibilities (such as elderly parents) or in society.

I think it’s important to focus on the practical aspects of choosing any career, medicine included. It is not “a calling” or some sort of “special” state of being. It is a career. A way to make a living and contribute to society professionally. Just like a photographer (with better pay)….or a plumber (with equal pay).

Realize that having a fantastic career (any career) will not adequately replace loving relationships, family, and personal development. Temporary sacrifice is expected of many low-rung staff in any career…but constant/permanent sacrifice is not worth it.

If you put off having a family, miss your grandmother’s funeral, miss your cousin’s wedding…and then, at 35 realize that you cannot conceive…medicine would NOT have been worth it.

Everyone has their own ‘balancing act’ to achieve. Some of us put more emphasis on family…while others lean more towards career. That balancing act is highly personal. I will say, it’s very easy to weigh career more heavily (even when you don’t intend to) because of external pressures and the societal value placed on wage-earning and 'work' – especially for the “liberated woman.”

If you’re not careful, you’ll become imbalanced, convincing yourself that you’re where you want to be…even when it’s not. And…discontent sets in.

But, if you are able to put “everything in its proper place” in the ranking of your life priorities, medicine can be an excellent career. And EM...allows a doctor to do this. To work a lot...or work a little.

There are days, nonetheless, when you think to yourself...

....what *else* might I be good at? Is there anything else I might want to do?

Quit medicine? (part one)

2012-01-04T13:37:00.000-08:00

When I was a medical student there was a girl who, after 2 years of medical school, decided…she didn’t want to be a doctor after all! I remember hearing a rumor that she decided she would rather spend her days swimming with dolphins. Then…she was gone.

That got me thinking, for the first time in my life actually, what do I WANT to do? Prior to this, my standard reply of “I want to be a doctor” achieved sufficient accolades from everyone, and the satisfied look on their faces served as confirmation that I was on the “right path.” I never really gave it a second thought. But this girl…had the audacity to decide on her own that she was going to “throw away” everything she’d worked for (and all the sacrifices her family had made to allow her to opportunity to attend medical school) and make the “irresponsible” choice to swim with dolphins in lieu of becoming a doctor. I mean, who does that?

At that time, I thought to myself: good for her for knowing what she wants to do, but why not finish medical school first, *then* go swim with dolphins? That way, if her perception of a dolphin-swimmer’s life was misaligned with the reality, she would have “being a doctor” as a back-up career option.

So I spent no further time pondering any other choice at this time. Instead of thinking about what I *wanted* to do, I focused on completing the path I was on, because that’s what made sense to me. I reminded myself that the most difficult (academic) work was complete after taking the USMLE Step I (after 2^nd year). The third and fourth years were the clinical (interesting, “field-trip”) years, where you *finally* get to legitimately “play doctor” for real! Why quit now?

But *when* IS a good time to quit? Once you get on the ‘medical-training-in-America’ highway, there is no “easy” time to deviate. It makes sense to complete medical school because once you achieve your advanced degree, you can *still* go fold jeans at The Gap if you want. Nothing (but a few years) is lost by finishing the degree program. So you finish…

Then, you can’t quit before internship. You can’t even get a medical license without completion of an internship! It only makes sense to obtain licensure. Why go through all of that training (and torture) in medical school to become a doctor, and then take away your ability to actually get a medical license because you’re too “lazy” to do just one more year?

Unless you know something that I don’t (which is quite possible), there’s nothing you can practically do as a new doctor (with no other training) without residency completion. You can’t really make any money (and with the huge burden of student loans, *choosing* to NOT make money is a crazy option), aren’t respected as a doctor, and are ostracized completely from “real” specialists (and everybody’s a specialist these days). Who wants to sign up for that? When in just 2 more “short” years, you too can be a board eligible specialist! So…I made up my mind that I would complete the entire training program, and *then* I could reevaluate my decision from a position of “safety” – as a board certified physician specialist.

As a 4^th year student contemplating specialty choices, I decided *then* that (despite everything I thought I knew about myself) I had no desire to spend significant time taking care of sick people – gasp! And this realization just kind of snuck up on me as a senior medical student.

Before medical school I thought I wanted to be the quintessential doctor who took care of the entire family their entire lives, family medicine. Then I realized that people are “difficult” and I do not want to be ‘responsible’ for people, sick people…and certainly not their entire lives! Whose crazy idea was that in my head all those years, thinking I could pull that off?

So I eliminated the kids and pregnant women which is essentially internal medicine. That felt better. But still, too big. Too much. Too long. But, nothing else was particularly appealing, and this late in the game many options are essentially removed from the table. So IM it was. But then, I signed up to do an anesthesiology rotation because I’d heard it was super easy…and after 3.75 years of medical school, I was so ready for easy!

True to its reputation, the rotation was a cake walk! Show up at 6am (which was the most difficult part) and intubate a patient or two, then go “read” (i.e. do whatever) until the next morning. There was the opportunity to see trauma anesthesia, which allowed the student to do a-lines, venous lines, and more! Very cool stuff! Still not completely sold on my IM choice, I switched to anesthesia, just like that. I was desperate to “find” my “place.” I was a gypsy, and even as 2nd semester 4^th year (senior) student, I was uncommitted!

So I clung to anesthesiology. Sure, I was cognitively aware that I would not be able to intubate and leave. I realized that the days began very early, and were long. Call was busy, and the training stressful. But, I *also* didn’t have to take care of a bunch of people…forever. One patient at a time. Done with surgery/procedure, done with patient. Sounds perfect.

Let me say, it is about this time I began to awaken from the unconsciousness of whirlwind academic overachievement and hierarchal indentured servitude, and realize that “maybe this whole doctor bit is overrated by those *stuck* IN it.” As a coping mechanism, I think many doctors just don’t *think* about their lives, and are unable to consider alternative life paths because they subsist on the delusion that this way is the only way to “be somebody.” And it doesn’t help that doctors typically see themselves as professional corporations and not the workers that they are, so their work conditions are super shitty, but no one cares. Especially not the doctors.

But I digress.

As an internal medicine intern (required prior to starting my anesthesia training) I actually had a great time. Becoming an intern is, in many ways, the prize for years of hard work and being invisible. Years of proclaiming “I’m going to be a doctor on day” to finally *being* a doctor is a huge step forward. Because, honestly, how many of us know someone who’s “going to be a doctor one day?” Not a big deal.

Just *finally* being the DOCTOR was enough positive momentum to sustain me through the internship year. And the amount of practical knowledge I acquired was worth the “abuse” and “sleep deprivation” at that time in my life. I felt legitimate (although incompetent). Also helpful was the knowledge that I was moving on to ‘bigger and better things’ with anesthesia. I was NOT going to be “doing this” (rounds, carrying a pager, writing long H&Ps, the whole deal) much longer. I was going to do short notes, cool procedures, and sit on my ass all day as an anesthesiologist listening to uplifting music, reading trash magazines, and getting paid well. Couldn’t wait!

So you can imagine my disillusionment when I actually began the anesthesiology residency. It was early mornings and long days. It was being on-call and lack up sleep. It was lonely. And in some respects, demeaning, boring, yet stressful all at the same time. And, the worst part was (for me) – there was no one to talk to, and minimal patient interaction. Who knew that taking care of sleep people would be lonely and impersonal?

Clearly, I hadn’t thought out my specialty choice well.

What now? I don’t want long term relationships taking care of sick patients. I don’t particularly like small children (even more so before I had my own). Being all up in vaginas all day was the *last* thing I found appealing. What else is there? Maybe I would go back and finish IM, and then subspecialize? But that would tack on like 5+ years to my training, and after this whole fiasco, I had no time for such nonsense. After all, I’d been trying to find an exit off this medical highway since 2^nd year medical school, but stayed on for very logical and practical reasons. But at some point, I just had to draw the line.

It is important to keep in mind that doctors have done themselves a huge disservice by subscribing to the current status quo of medical training. Unlike nurses, or PAs, we cannot just “switch” specialties and “do a new thing” when we get bored with the current thing, or otherwise we can no longer do certain procedures or function in certain capacities. Nor can you move to another part of the country on a whim and expect be granted a medical license from another state (never mind the fact that you already HAVE a medical license after passing a *national* exam, which is asinine and a post for a different day). For multiple reasons it is not practical for a mid-career physician to “go back” and do another residency to obtain different credentials to do a new thing. Overall, medical education does not easily extrapolate into meaningful work outside of medicine. So, once you choose a specialty, you’re essentially stuck! A decision you make about your career at age 25 had better serve you well when you’re 50.

Oh, the pressure!

After all of this, I decided to pursue emergency medicine, primarily because it allows doctors to be doctors when they want to be doctors – and cool doctors at that. But, when you didn’t WANT to be a doctor, you could do something else. Anything else! And still be cool. With a solid “back-up” plan that is EM. And the cherry on top of that sundae was: I didn’t have to take care of sick patients for forever. I can step in when they really NEED help, I can TALK to them, I won’t be lonely, I get to do cool stuff….and then…I get to go home! To my life. All the while, making 100% more than a pediatrician, and 50% more than FM with less stress, less work, less ‘distraction’ from my REAL (non-doctor) life. (And judge if you must, but money *does* matter, especially when the cost of medical education is in the hundreds of thousands of dollars!)

Fabulous.

Right? It’s all good now as an ER doctor….isn’t it?

Medical Memoir - In Stitches One Girl's Opinion

2011-11-09T17:33:00.000-08:00

Medical school memories came *flooding* back as I read Anthony Youn’s memoir, In Stitches.

Medical school was a time in my life where the details are sketchy because it was a blur of studying, isolation, anxiety, frustration…sprinkled with intermittent moments of fascination and joy. I can completely relate to his thoughts about pediatrics, “Little people, little dollah”, and being torn between life-style specialties and being a “real” doctor. I shared his dislike for the standardized patients and the weirdness that entire situation evokes in all of us.

My favorite aspect about this book is its honesty and authenticity. As I devoured the book chapter by chapter, I felt like I UNDERSTOOD Tony. I was able to peek into a life very similar, but very different from my own. His book was truthful, the language was clear, the humor and candidness kept me interested and I really felt like I traveled this journey with Tony. As I read the pages, I thought of my OWN similar experiences….and my reaction to them. And as I flipped the page….reading his words were like reading my own mind. It was quite amazing!

There were only two questions that stayed with me through-out the book: Why didn’t his family help him acquire better living conditions? And was he really a virgin until medical school? (implied, but not stated)

I will say that I feel like the first part of the book would appeal more to young men, with all the talk about girls, women, and overall “manning up.” Since women do not (typically) go through this, it’s all very foreign in an annoying kind of way (as a woman). I was much more interested in…all the rest. Thankfully there’s plenty of ‘all the rest’ and the book was thoroughly enjoyable.

I would LOVE to read a “part II” plastic surgery residency memoir. It really was *that* good!

Attendings who don't want to teach

2011-09-06T09:44:00.000-07:00

Q: Now that I'm *officially* well into my intern year, I realize that some of our EM attendings are not interested in teaching (or otherwise interacting) with interns. As an intern, I'm offended. Is this acceptable behavior, and how should I handle it?

A: You're right, the attendings should be willing to work with ALL of their OWN residents (interns included). Its one thing to shun rotating residents/intern/students, but *your own* should be taken care of.

There are two different ways to look at this to help explain why SOME (i.e. not me, LOL) attendings avoid students/interns. The first way is to try and see their point of view.

Imagine you’re an attending:

When you go to work, you feel exposed (legally) because the residents are a liability. They don’t always know what to look for, what to tell you about, and how to treat the problem. Even if you, yourself, get up and go see/talk to the patient, you may miss something in your short interaction. And there are LOTS of patients. Actually, you feel overwhelmed at times because you’re responsible for the actions of others, although you don’t know what they’re doing/hearing/seeing. You have to ‘trust’ them…and that’s hard to do. And, you are just one person, and to have 2-4 people ‘presenting’ cases to you for 8-12 hours is just too hard. You can’t think, you don’t know who’s sick…and you can’t physically see everyone and do everything yourself.

And it’s even *worse* when an intern is working. BECAUSE they *really* don’t know what to look for, ask about, check or test for. And when they present to you, the story is often unclear, and you’re left sorta confused. The differential is too broad when the intern presents, and you either have to go see the patient yourself, or ask lots of detailed questions to the intern to get a better story. If the intern didn’t ask the important questions, you either have to send them back to get a better history and physical, OR you order tons of tests/studies to compensate.

Example:

10 month old baby is brought in my mom with a fever to 102.9 x 1 week. Intern presents it as a viral syndrome. Great, discharge, right? BUT they didn’t notice the dehydration and lethargy. They didn’t comment on the petechial rash. So, as an attending you can either:

1) get up and see the patient yourself as if he’s your own (this isn’t very practical if you have more than a couple of residents/interns to supervise or else the flow of the department will be very slow)

2) have the intern order more tests and studies to support the ultimate dispo (which isn’t really teaching, and isn’t really proper EM)

3) you can have a senior resident see the patient, and ‘advise’ the intern. That way, the likelihood of missing meningitis is lower if the senior resident signed off on the intern’s work.

Of the 3 – it’s easier to have the senior resident involved. Also, it’s logical because it allows the senior resident to see more, do more, supervise a bit, and begin managing an entire department. And as attending, you’re there just as back-up for the senior resident. It’s easier to teach the intern if the obvious nuances of the case have been discussed with the senior (at least from July – December). And it frees the attending up to work with the senior and students as well.

The attendings look forward to working with certain residents, just as much as residents like particular attendings. Typically attendings like residents who are confident, do appropriate work-ups, then come to them with their own thoughts about what’s going on, and what to do about it. Then the attending can talk to the resident as an educational ‘coach’ and (almost) colleague about the case. This is fun for attending.

Being stressed out about missing something because an unreliable resident (whether it’s because they’re ‘new’ or just ‘suck’) is telling you half-truths and cannot think for themselves…is miserable.

***

The second way to try and understand what’s going on is to realize that this has nothing to do with you, and everything to do with their own issues:

Imagine you’re an attending…and you’re a bit bitter about your job (for whatever reason). Really, you don’t want to work shifts, you’d rather get credit for shifts worked, while NOT doing any shifts. BUT, you’re not quite *important* enough for the department to allow you to engage in other scholarly activities…and since they NEED attendings to work shifts, you get more than your “fair share” (for your rank and experience), in your opinion. But you can’t quit, because you need your benefits and paycheck too bad. So you make due.

There are two types of doctors (those who actually are comfortable with themselves, their knowledge, and love to share and can readily admit when they are unsure of something....and there are those who pretend to know *everything* and don't want to answer questions because they feel threatened by the resident who's actively reading, and who, on any given day, may be better-read on a particular topic than the attending).

So let's say I'm the second type of attending -

I don't want to 'expose' myself as interns don't know much about 'the way things work' and instead of just 'going with it' they'll ask:

"why? why? why do we use this drug instead of that drug? why can't we just do the procedure this way like Rivers said? Tintinali's new edition said that we shouldn't use this study, that the new ultrasound technique is better..."

Whereas a senior would be more apt to 'just go with it' as per current local ED culture. And if the senior asks questions, it's more appropriate for the attending to follow-up their question with a 'reading assignment' to be presented the next shift. So the residents ‘learn’ to not ask questions.

So, in short: either this is their way of hiding the fact that they don’t know something….OR they’re acting out because they don’t want to be in the position they’re in….

Either way nothing to do with you.

My advice is: YOU SAY NOTHING! Go with the flow...and do not let the Eye of Sauron fall upon you. Stay below the radar right now. Learn, learn, learn. Shine on the inservice in February.

Next year...maybe say something if you're still so inclined (maybe). It's not worth the risk right now. If you're black-listed, you will have a horrible residency experience. Lots of former residents can attest to this fact.

Can I be cool with my nurses (and they cool with me)?

2011-04-19T17:45:00.001-07:00

When I was a medical student, I was quite envious of the nurses.

It seemed like the nurses, from the RNs to the licensed practical nurses, had the best of everything. Their lounge was big. Their area well stocked with food and drinks. They were always having celebrations...for everyone...for everything. They made late-night Starbucks runs, and had food delivered to the hospital all the time. And even though they were courteous enough to offer me a latte (sometimes), it always felt weird to 'fraternize' with *them*. They, were them...and I was *us.* "You cannot trust 'them,'" I was told. "'They' will throw you under the bus first chance they get!"

So, for years, I had an awkward relationship with the nurses. If I needed them to do something...how do I ask? "Um, excuse me Nurse, did you see my order?" Or, "Ms, I mean, Nurse Smith...can you get room 1 a bedpan?" It just seemed like...I was asking them to do things...like I was in charge. But they are quick to let you know you're not in charge. But, you kinda are in charge. But you cannot 'remind' anyone that you are in charge...or else you belittle their contribution.

What gives?

Then I realized...as I advanced in my education/training...and as I spent more time as an attending...that good nurses are really there to help make your life easier. If they are not doing that...I would argue that perhaps they are not good nurses. And the thing is, I didn't realize this until I had an *awesome* nursing staff to support me!

In residency, the nurses were indeed a little cult...whose primary mission seemed to be to make your life as difficult as possible. Sorta like they were jealous of a young woman doctor...and resented having to take orders from her. They were not polite. They claimed they didn't know how to do much of anything. "Um, I couldn't start the IV on room 3...so I guess you'll have to come do a central line." Or, "we cannot get blood from Ms. Jones...so you'll have to do a femoral stick." Really?! Really, really! Either you're one sorry nurse...or you're just out to get me.

As you progress, it becomes less acceptable for the physician to perform nurse duties...while simultaneously performing doctor duties. Time becomes more valuable, whereby if the physician isn't seeing patients quickly...someone is losing lots of money (and it's usually someone "more important" in the hierarchy than the doctor). And that...is not tolerated. CEO losing money?! So support staff is hired so the physician can continuing 'bringing in the money.' And this extrapolates to nurses who enjoy (or at least don't mind) nursing.

Fast forward to now. I have a great relationship with my nursing staff in general. Some of it is because my nurses are now there to support me (rather than antagonize me). Some of it is because it is the expectation that the nurses do nursing work. But a large part of the equation is me. I am more comfortable with myself, with my skills, and being a doctor. And because I am comfortable with me, and my role as leader...I am less...awkward. I am more willing to "fraternize with nurses because I realize that being friendly with nurses doesn't undermine me or my role. I see myself as team leader...but I give each member of my team the option to critically think and act without me micromanaging their decisions. I ask their opinion...and I don't feel like "they think I'm stupid" if I don't know something.

And in exchange, they bring their kids in to see me for impromptu doctor visits. They save me a piece of baby-shower cake. They "protect" me from the patients and their families (this is a post for a different day). They sneak me a Tylenol or a Reglan out of the Pyxis when I'm not feeling well. They catch my oversights...and they have my back.

Short story:

Last week I had to reduce a patellar dislocation. SUPER easy to do...but I'd never done one before. So, I gathered my nurse and my tech, and confessed. "Hey guys, we have to reduce this...and I've never done one. So I'm going to read up a bit, then we'll do it, okay?" Amazingly, they were even more excited to learn *with* me. We checked out emedicine. We watched a short video. Gave each other encouragement. And went in the room like we knew what we were doing. Like we did this sort of thing everyday. "Don't worry Mr. Johnson, this will be quick and over in less than 10 seconds" (hopefully). We exchanged glances...smiled a little bit. And did exactly what the doctor did in the video. For about 6 seconds, it didn't seem like it was going to work. But then we heard it. The "clunk" of the patella going back into place! We all exchanged glaces again...with big grins on our faces.

We walk out of the room, and into the back, giving each other hi-fives! WE did it!

How fun is that?! This is what makes emergency medicine a team sport.

Ideal job - 6 years out

2011-04-04T09:13:00.000-07:00

One of my attendings once told me that it takes about 5 - 7 years for a new ER doctor to master the specialty. This was music to my ears, because I knew that I was *not* confident upon residency graduation to jump into this very stressful specialty. I needed to wade in...from the shallow end of the pool...slowly.

When I graduated, I did not look for jobs that required me to "roll up my sleeves" and do *real* emergency medicine. Contrary to what my colleagues seemed to believe, I realized that I was not quite ready to be a sole doctor in a small town ER, with no specialist support...trying to save lives. Emergency medicine is hard enough in a big city, at an academic institution, with every esoteric subspecialty at your beck and call. The real emergency medicine heroes are truly those docs who work out in Podunk, alone, and really have to do it all!!

So, my first job was at Kaiser. First in Southern California, then Northern California. Kaiser is a very "safe" emergency medicine job. All the patients are insured, they all have primary care physicians, and everything in the ER is protocoled. Oh yeah, and the patients cannot sue you! So if you follow the protocol, you're good. They have all the standard sub-specialists available, and the patients are not that sick. They receive no trauma, and many doctors are working at the same time. So you're not alone, nor are you overly concerned about being sued.

But Kaiser has many drawbacks...and for me was not my long term plan. What Kaiser offered me was...a transition from resident physician to attending physician (on the shallow end). After working at Kaiser, I felt a bit more confident. I actually carried some of their protocols with me, and those protocols allowed me to have "a plan" for patients in other institutions as soon as they presented.

Next, I practiced my wading skills by taking a job with a group who allowed me to work a bit slower at first, and hone my skills. See, the thing is, if you are "slow," you do not make enough money for the group to cover your hourly pay. This means that...the other doctors in the group are subsidizing you. Thankfully I found a wonderful group of docs in CEP to take me under their wing, and allow me to work at my own pace until I developed confidence and personal protocols. (CEP is a great group, but very site specific. Some sites are not willing to "deal with" new docs.) Also, CEP has many sites California, so being with them, I was able to "try" many different sites, and find one that worked for me.

It is common for ER docs to work at multiple sites - sometimes with multiple groups. After all, to have all of your eggs in one basket can be unsettling since we are all well aware of the inherent instability in group contracts and hospital adminstrators. But, working in multiple places allows the new doctor to realize characteristics that are pleasing to them, and those that are annoying.

I discovered that I am not a huge fan of working in hospitals where the clientele is "upper-class." The pay is better in these hospitals, but the patients are not as appreciative, and they are 'entitled' in a way that is really annoying to me. In comparison to rural or inner-city ERs, I find that the social issues in these rich suburbs are similar (such as drug addition, alcoholism, violence) but no one dares to acknowledge these issues lest we upset someone by even suggesting that these issues even exist in well-to-do communities.

Also, in these richer suburban ERs, everything is micromanaged. See, when things are 'perfect' at a facility, administrative hospital staff has to somehow 'justify their jobs' so they *create* problems to "fix." Sometimes these "problems" include...improving upon 99th percentile positive patient satisfaction scores ("let's have the doctors escort the patients to their cars to get that last percentile!") Or, "lets do away with triaging altogether, and promise patients we'll see them within 10 minutes of their ED arrival." Both are bad ideas...

In the inner-city, or out in Podunk, no one has the time or energy to micromanage. There are so many REAL issues for an already overwhelmed admin staff...that every idea is designed to help everyone be more efficient and decrease bad outcomes, period. It is understood that 100% patient satisfaction is not possible, or compatible with running an ER. It is understood that we are all doing the best we can, with what we have, and there is no need to "sell" a well functioning ER to a community. It will sell its self. When "customer service" interferes with the ability of the ER staff to perform their duties...ultimately everyone suffers. Unhappy staff that have better options, leave. Patients who are really sick are not recognized (as everyone caters to our "customers") and good medicine is not practiced as we try to appease every flight of idea a "customer" may have regarding their own care - even if they are wrong!

But I digress.

There are many variables that contribute to an ER docs job satisfaction. Money is a part of the equation. But more than money, is the work environment in total.

Can I get a patient admitted, or is each admission request World War III?
Will a surgeon or a cardiologist come in to see a sick patient on Sunday afternoon...or will that patient code and die overnight because they refused to see them?
Will the laboratory run blood samples timely, or are they constantly "lost" or otherwise "insufficient"?
Are the patients appreciative, or are they demanding you be their drug supplier?
Is ER group more focused on pleasing hospital administration and patients, then getting "buy-in" from the physician members and practicing sound medicine?
Are the ER group members more interested in making as much money as possible apiece than actually staffing the ER safely?
Is the culture of the group to "cover" and switch shifts with each other to accommodate changes in life events, or is finding coverage impossible?
Do you get to leave on time...or is it necessary to constantly stay late because of inefficiencies in hospital staff...or colleagues who are unwilling to take a sign-out?
How many nights, weekends, holidays do I have to work...and how are they divided?
Is the schedule maker respectful of physicians, or are they just pawns who are "in charge of the pencils?"
Are my schedule requests acknowledged?
How far in advance does the schedule come out?
How many patients am I expected to see per hour?
Are there mid-levels available?
Is the hospital so close to my house that I bump into patients in the grocery store - and does that bother me?
What are the nurses like? Do they play well with others...or is everyday a battle?
Does the hospital allow you to eat in the cafeteria for free? - this is actually a bigger deal than you might think!
Parking, and call-room access (to take a nap after a long overnight shift before attempted to drive home in rush hour traffic) also demonstrates to physicians their value, and shows appreciation by the hospital admin for the services you're providing at 2am!
Are you going to be alone in the hospital at times (running ICU codes, delivering babies and such) in addition to managing your ED - and how do you feel about that?
How long are the shifts? 12 hours? 7 hours?
How are patient complaints handled? Are you guilty until you prove your innocence? Is every frivolous dissatisfied patient's letter taken seriously? Sometimes, a complaint does not need to be passed on. Sometimes, a patient will write a letter, and a polite response can be given, because their gripe is clearly not with inappropriate medical treatment.

And these are just a few of the questions that came to my mind in the moment! And each of these issues contributes to physician happiness with a group, and at a site. Getting with "your type of people" is a process of trial and error. And after a few different experiences, I realize that my personality fits best in groups who are a bit more authentic in their practice and in their lives. And this...this attribute tends to be more often present in 'non-rich' communities. I feel more like a real doctor, making a real difference in communities that represent where I came from.

So now, I'm happy working in Podunk, with my lovely nurses...and appreciative patients. I am now on the deep end, swimming without undue fear as an ER doctor 6 years out of residency. As I developed my confidence, I was able to trust my staff more, and rely on them without feeling judged or inadequate (which is huge). I am the only doc in the entire hospital at times (much of the time)...and am responsible for any acute issues that arise. My consultants are fantastic (and NICE), they don't bitch and complain about working...and transfers are not very complicated or time-consuming. I get to eat in the cafeteria for free...and it is not too close to my home where the bank teller recognizes me as the doctor who treated her daughter 2 weeks ago (that was uncomfortable)!

Most docs do not expect perfection in a job...but there are certainly some that are closer to our personal ideal than others.

Finally, (I think) I've found my ideal ER doctor job :)

filling my time with less frequent blogging...

2008-04-28T10:44:00.000-07:00

I heard that blogging can be hazardous to your health.

It's interesting, because blogging can be stressful and overwhelming...especially if you're expected to produce new material more often than you actually *have* new material. After blogging about a year (more-or-less consistently), I find I have ranted and fussed about most of the things that bother me most (but don't fret, I still have a few annoyances I'd love to expose...and new ~~annoyances~~ things are always "coming up"). I have shared my enthusiasm for my profession. I have documented the process, the thoughts, and the transition from medical student to attending. And I've talked about memorable (pseudo-)patients. Now, I don't feel as pressured to write all the time.

Additionally, it's takes quite a bit of time on the computer to post even one (legible/comprehensible) entry. To translate your thoughts to print...and make them comprehensible by most who'll read them...takes time (depending on the thought). And, I've seen hours "disappear" as I update my blog, surf the net, return email, etc...all while the kids are on their 8th episode of SpongBob SquarePants of the evening (just kidding...kinda).

As the days get longer...and the weather warmer...and the kids get bigger (i.e. more activities, more time needed to engage them, more friends over, etc)...I think I'll have to spend less time on the computer. When they were in bed by 8pm - and me not until 11pm...I had lots of time. But now the little guys aren't in bed until 10pm (it's actually still light outside until almost 9pm in the summer here). So, I have less time to ~~waste~~ spend on the computer.

Just thought I'd post this for those who may wonder 'what happened?'.

Just enjoying the sunshine...

What was medical school like? Years III and IV

2008-04-03T09:36:00.000-07:00

After completing years I and II, you have a small break. At our school, this break was only a few weeks....and it wasn't really a 'break' at all.

After completion of year II, it was required that we take (and pass) the USMLE Step I. This first part (of a three part series) tests your basic science skills. Basically, the things we learned in years I and II are being tested. Our school was pretty good about teaching to the test (somewhat), and boasted a high first time pass rate. But you see, that 'break' was spent cramming for this licensing exam.

This exam was very difficult. You know, one of those exams that you can't even discuss afterwards because there were just so many uncertainties. You have no idea how you did. On other exams we've taken, most of us had a feeling about it:

"I think I did okay...but number 10, you know, the question with the xray...I wasn't sure if they wanted this answer or that answer...etc.'" OR, "that exam was horrible...what?! you put C for number 4?? geesh, I musta missed that one too...etc" (like this). After this exam, it didn't happen.

When I took the exam it was 2 days long...all day (except an hour for lunch). After lunch on day two...I just started marking everything 'B'. I was so tired of testing.

After you take that exam, you begin your third year. By now it seems as if everyone knows what they wanna specialize in. And if you do, that's a good thing. The sooner you know, the better. No one told me that...and I wish they had. If you know you wanna be, say ophthalmology, you can engage in research, and start kissing ophtho ass early. You'll take the rotation as soon as possible...and as many ophtho rotations as necessary to get the letters you'll need to match.

Years III and IV consist of clinical rotations.

Our 3rd year rotation schedule was made for us (i.e. we didn't get to choose the order of rotations). Basic required rotations were surgery, internal medicine, psychiatry, OB/GYN, family medicine, orthopedic surgery, pediatrics, and neurology. Our 3rd year consisted of these rotations. Most were about 6 weeks. You had about 12 weeks (maybe it was 16 weeks) of vacation. You could take that as a block, in two 6 week blocks, or however you could manage it. You requested your vacation time...and the university filled in your 3rd year schedule around it.

Our 4th year (frequently referred to as a 'sub-internship') we did our own schedule. There was a second round of required internal medicine...and many of us didn't necessary get all of the 3rd year (required) rotations completed in 3rd year (maybe because of vacation request, or scheduling, etc). So, you had to finish up those. Many of the rotations (the 'interesting' rotations) required the student to have completed a prior 'basic' rotation. For instance, an NICU (neonatal ICU) rotation will no doubt require the student to have completed pediatrics (and possibly OB/GYN) prior to starting. During this year, students typically take rotations like radiology, anesthesiology, emergency medicine, ophthalmology, dermatology, and maybe some bizarre elective at a far away place (but these electives are hard to get approved, and most students opt for pre-approved, 'normal', nearby electives). Also, you get to choose which hospital you'd like to do some of the required rotations. University hospital, County hospital, Community hospital, etc. There are some rotations that are notoriously easy (meeting like twice in 6 weeks) for an easy pass, and a nice break. I (am not ashamed to say it) *maximized* these opportunities. ;o)

During the rotations there are weekly lectures that your school 'requires' you to attend. These are usually very welcomed "breaks" from floor work/scut. Every day the students would try to get out of evening rounds by announcing: "uhhh, we have lecture this afternoon..." The residents and attendings were made *very* aware of the requirement of students to attend lecture...and were powerless to say or do anything except let us go (but beware, they'd sometimes verify that we're actually at lecture). Additionally, there were morning rounds, grand rounds, attending rounds, sometimes evening rounds. Lots of time in 'meetings'...really makes for along day when there's lots of scut to do.

The lectures were by in large *very* useful. And, in retrospect, I'm very happy I attended most of them. Learning pediatrics while doing a peds rotation...really solidifies the information. At the end of the rotation, there was an exam (on the lecture material). Some schools use the shelf exam, thankfully ours didn't. We had exams written by our professors. Everyone passed...eventually. You could take the exam multiple times, until you passed. Every (required) rotation had an exam.

Also during this time we had to take an OSCE (like a fake/simulated patient encounter). Completely bullshit (even in retrospect), where they bring in actors to play patients, and you're graded on how well you "play doctor." I hated "playing doctor." And I hear that this bullshit OSCE is now apart of the USMLE?? Requiring poor (literally, poor) med student to cough up money to take this BS? (but I digress...)

As a 3rd year, your presence on the team is largely unnecessary (despite what they tell you, and regardless of the student's arrogant belief to the contrary). You slow down the intern/residents; and all of your orders (rightfully) have to be cosigned...hence they are useless. In clinics you're really annoying to the people actually 'working.' In-house on the floor, the patients think you're 'cute' and they always 'know someone, who knows someone, who 'gonna be a doctor.'' And instead of telling you their deepest concerns and intimate medical issues...they wanna talk about *you.*

In retrospect I realize that much of that...that inability to be taken seriously by patients was my fault. I was insecure, didn't really know what to ask. My history was unfocused. AND I actually sat there with them for hours getting largely irrelevant information...which made me their "friend" and not their "doctor." (which is okay since I *wasn't* a doctor...).

The various rotations differed from each other tremendously (and I'll discuss that on a different post). But, in general, to do well in the clinical years involved working smart - and the realization that you're really gonna have to make some time sacrifices during those rotations that involve the specialties you're actually interested in applying to...because they will haze you.

Let's just take internal medicine as an example:

To do well in internal medicine you should try an be apart of the team. That means not leaving too frequently to attend "lecture" or whatever. That means arriving before everyone else does, and leaving after they do. When you have patients assigned to you, realize that *you* are not managing the patient - the attending and residents are managing the patients, and you are doing what they tell you to do. Your role is to listen and learn. But more than that, having assigned patients means you're responsible for *information gathering* for those patients. As a 3rd year (and 4th year...and intern) YOU ARE AN INFORMATION GATHERER.

Some will tell you to 'know everything' about your assigned patients. Well, that advice didn't help me much because, on a practical level, that is not possible. Better advice would have been as follows:

You come early and get the lab values (know the trends), the radiographs/results, the medication list with the antibiotic day number, fluid intake/output/weight change, any overnight events on the nursing note or per the patient. You should know what the physical exam shows (new rash? pressure sore? crappy lung sounds?) You should know the vital signs, and if any fever spike overnight (and if so, what time). You should know if any orders had to be written on your patient, why, and if what was done helped. You should know their bed number (and if they were moved, the new bed number, and why they were moved). You should know their working differential diagnosis...and do some reading about the disease(s) and how to treat them, what complications to expect. You should have written the daily progress note (to be completed after you are told by your team what the assessment and plan are). And you should anticipate (or have the handbook) of possible questions the attending will ask...and know the answers so you'll look like a star.

Your school will let you know if overnight call is required. There needs to be a place for you to sleep, and something for you to do. The nurses may (or may not) be instructed to call you first. And if they don't, well...it's kinda no point for you to be there. Especially if your orders all have to be cosigned. The intern will have to take every call, and write every order anyway...

...but at some community hospitals I rotated thru, there were very nice call rooms for everyone...and the nurses *did* take student orders...and they *did* call the student first (usually these are 4th year rotations where you're working as a sub-intern). It's easier to stay on-top of your patient information gathering duties if the nurses call you when there's an issue. And you felt important. Also, typically OB requires overnight call for obvious reasons.

Exactly what do you do all day?

Well, you go in early (whatever time makes you the first person there). You go physically look at your assigned patient (usually you'll have 2 or 3). Make sure they are alive, breathing, and are still in the location they were yesterday. If they are awake, ask them how they feel. Be sure they know you were there (this is more important as an intern and beyond, sometimes patients will complain that 'their doctor never comes by and see them' not realizing that *you* are the doctor...and see them multiple times a day. You can't have patients spreading rumors like that about you). Put a stethoscope on their chest. Pull back the covers gently and make sure there's nothing obviously wrong. Do a focused exam - meaning, check the part of the body that's causing them to stay in the hospital. Note any changes.

Then you have your paper/index card for that patient. You write their room/bed number on top next to their name and medical record number. Then you grab their chart and flip thru it...looking for the information I described above. Look at the nursing notes...and read what they wrote overnight. Look at the vital signs sheet for the last 24 hours. Look at the order sheets and see if/when anything was ordered. Read the physician progress notes, and note anything significant. Be sure to look at the medication list. Check the labs, and remember to check for any positive blood/urine/sputum cultures. Know the medication allergies. Look and see if any of the consultants wrote any (new/old) recommendations. Then, write your note with all of this information incorporated SOAP note style (leaving the AP blank until after rounds). If your note is good, only the attending will have co-sign, and it'll count as an official note (i.e. the intern won't have to write a full note, and they'll be happy).

Do this for every one of your patients. And with any time left over, you go eat, and read a bit about the diseases your patients have (and what to make of any overnight changes).

If your hospital still has plastic xray films, you should find them, and gather them. Carry them around for the attending to look at. If you have a pacs (digital) system, log on (or have someone log on for you) and look at the films. Look for any radiologist reports...and look at the images yourself. You should be able to identify any significant changes between today's xray, and the one taken yesterday. Lungs more white? Kinked chest tube? Free air?

During rounds you present your patient the way the attending likes it. Be sure to at least mention (to someone other than another student), things that *you* think are important, but couldn't say on rounds. Remember, rounds isn't always about learning or information exchange...sometimes, with some attendings, it's about providing them a platform to flex. They may not appreciate someone like you making them 're-focus' on patient care.

Many teams will have short 'okay-this-is-the-*real*-deal' rounds after the attending leaves. Where the work is divided. Then everyone goes to morning report/rounds. Morning report is a lecture where an intern presents a case, and everyone does this mental masturbation exercise about the patient.

Then it's time to work. Most hospitals where residents exist aren't very efficient. The nurses don't do shit...and the students/residents do everyone else's job. This is what takes forever. This is the problem with resident education. This is why it seems as if the surgeons aren't as well trained with restrictions in place...eventhough they're in the hospital 88 hours a week. Are the surgical interns/residents so stupid that they cannot learn what they need to learn in the 88 hours/week, 5-7 years they're there training?? (I just love what the medstudent tells Bongi in the comments section of this post). Of course not!! They aren't doing all the necessary *doctor tasks* to properly train because they spend 90% of their time doing other people's work and miscellaneous non-physician/non-educational/irrelevant bullshit. Drawing labs. Finding lab results. Pushing patients to scans/xrays. Finding xrays. Massive clerical work. Trying to plead with hospital staff to do what they're supposed to be doing for the benefit of the patient (so they can get that study done, or that consult completed...so everyone can go home). Residents/interns play social worker, trying to discharge patients with no place to go. And during it all while being constantly interrupted by pagers. Some of the bullshit is unavoidable, but much of it can be changed if the higher-ups were really interested in change and patient safety...while maintaining the high quality of the doctors being produced.

But instead, they advocate for unrestricted resident hours...

Unwritten rules include:

it does you no good to make your fellow student, the intern, or resident look bad in front of the attending. If the intern is asked a question by the attending on rounds, and s/he doesn't know the answer...don't you jump in and blurt the answer. You say nothing...unless the attending directly asks "does anyone else know?" And still you wait a minute. I would advise that 'if your superiors don't know, then you don't know', period. If you are smart and actually *do* know, it will show in different settings - such as when you concisely present your patients to the attending with a focused differential, and the subsequent pimping session proves you know your shit; or when the attending asks you a question first and directly and you *modestly* give a correct answer. You do not get cool points from anyone being a smarty-pants know it all. And if one of your teammates doesn't know something about his/her patient, you can tell them discreetly, but never one up them on their own patient in front of the attending. And, please, *never* ask questions that you know the answer to. This annoys everyone!!

It's best to not talk negative about anyone. That can only come back and bite you in the ass.

On rounds you follow the pack. You stand if chairs are limited. You carry all the crap (the stethoscopes, the otoscope, tongue blades, whatever is commonly needed but not commonly easily obtained). You don't argue. If someone says you're wrong, you're wrong. Even if you're not wrong...just forget it. If you want honors, and a match into the specialty, you'll realize being 'right' doesn't matter.

Many times inappropriate comments were said (especially on surgery), and may put you in a difficult spot. Usually some sort of sexist jack-ass with a small dick blurts out some off the wall comment about women...but sometimes it's even more hateful than that. It was not unusual for surgical attendings to throw full-on (two year-old type) tantrums. Surgical instruments thrown across the OR because anesthesia had the table too low. Or verbally abusing everyone, just to see how many times he can make the resident cry.

What seemed to work well at our school - a group of students who agree that the person is out-of-line would go to our student affairs dean and complain because it's never just one episode of ignorant behavior, and many people can usually agree that the guy (it's usually a guy) is an ass. We'd express our concerns, and demand to be moved to another team, or another service, or another facility. Usually, if there was a (big) problem, you could be moved (as it should be being that you're paying up the ass for an education). And on more than a few occasions, students were not placed on certain teams, or with certain attendings with a reputation for being assholes. But realize that as an intern...the solution is not so simple.

Offer to do a presentation for the team. Bring in an interesting journal article (if you happen to find one), and educate the team about it. Have a happy disposition. Be reliable. If your intern relies on you, you cannot miss attending rounds...because they will not know the detail about the patient that you know because they were *relying* on you to know (and be there). (Even if you're sick, you need to come in for attending rounds...then ask to go home). And don't leave until all the work is done...or at least ask if there's something you can do to help out the 'slow-poke' before you leave. Usually the answer is "no", but if you acknowledge that they are still there, and offer the help...it will be noticed.

In order to graduate from our school the USMLE Step I must be taken and passed. USMLE Step II is taken during senior year. It does not have to be passed to graduate. There are strategies as to when to take Step II. Some do it early to make their application competitive. Others do it later, as not to tarnish an already acceptable application. It depends on the competitiveness of the specialty, and the competitiveness of the student. Also a consideration, if you did awesome on Step I...you may not want to take the chance that your Step II score will be lower, and some of your shine is lost.

USMLE Step II is easier (more practical information), than Step I. It was also 2 days long. Exam topics are those of the basic rotations - peds, IM, psych, etc. Some specialties consider the USMLE score to be the single most important part of the residency application.

***

Overall, in years III and IV you have much more control of your time. Only a few rotations are brutal, and only being so because of their long hours and the amount of scut (i.e. gathering information, and pushing the patient along in the hospital diagnostic/treatment process) required. Some rotations will be more stressful because you're trying to impress the staff. Usually, by mid 3rd year everyone is pretty sure what their interests are...and it's no secret to surgery residents that you're not into what they do. And they don't torture you as much.

You have time now to see a movie. The tests are easily passed with a day or two of studying. Even the USMLE has great prep material out there such that you don't have to study much more than a 150 page book and do well (enough). If you're a good team player, and do well on the exam, you'll honor at least a few (maybe even most) rotations. If you do very well, and people really like you, you may be inducted into the honor society, AOA. AOA on your CV looks very good to program directors of competitive residency programs. Also, you have time to engage in some research (not alot of time, but *some* time). And some students will take a year or two off after 2nd year to do research (or have babies, or travel, or get an MBA, etc). This will also look good on your CV (well, maybe not the 'have babies' part, but that can be disguised as 'research' if done correctly).

Many medical students decide to have children during 4th year. Some do away rotation in Costa Rica. Some take no vacation...and save it all to the end (this is what I did). This was fantastic since my last rotation ended in early February, and I had 'vacation/freetime' until I graduated in mid May!!

That was my last 'summer vacation.'

p.s. so, now that you understand what medical school is (sorta) like...you'll appreciate the (hilarious) humor in these videos on my sidebar:

This one. This one. and this one. (you just have to see them all. After the first one plays there's an opportunity to watch the others...)

I'm LMAO just thinking about them!!

What was medical school like? Years I and II

2008-03-31T16:23:00.000-07:00

I remember being a pre-med. I had the full college experience, IMO. I studied to maintain an academic scholarship, had part-time work (intermittently), and pledged a sorority. I dated more than one guy, did some local traveling, and made lasting friendships.

I remember being very concerned about 'med-school prep.' I wanted to take the "right" classes...and do the "right" summer programs. I had to volunteer, and participate in campus organizations so I could distinguish myself from the 'average' student. I did undergraduate research that resulted in publications. I took MCAT prep courses, and followed the recommendations of the premed office on campus regarding which classes I should take when...when to apply to med schools, and which schools I'd likely get in to.

I gained early acceptance into medical school. This acceptance was arranged such that I didn't *have* to go to this school if I decided to continue on in the application process and I happen to gain acceptance into another (more desirable) school. I decided I wanted to come back home, so I applied to the local schools. Got accepted. Decided *not* to go to the 'early acceptance' school.

I was ready for medical school. I'd done 2 or 3 (med school/MCAT prep) summer programs. I'd taken all the requisite courses, including anatomy, physiology, advanced chemistry, microbiology...everything. I felt pretty prepared...but utterly unprepared at the same time.

I remember the first 'meet and greet.' Everyone seemed nice enough. I guess I expected everyone to look like 'revenge of the nerds' or something...but they all looked normal enough. They were social and some boasted full "prior lives" as policemen, firefighters, nurses, teachers, mothers, fathers, military...

The average age of my first year class was 30. That means that half the class was *over 30* in their first year of medical school. I had no idea everyone would be so...old. There were even a few people close to 50 (after having raised families or whatever)!!

There were quite a few smallish/informal meet and greets. Some indoors (dinners hosted by alumni, or AMSA, or some other group). Some outdoors, usually in the quad. Sometimes there were booths up urging us to join this group, or that group. Some upper-classmen were there, offering advice, or representing a club. We had picnics/BBQs. It was very nerve-wracking.

Then, our first welcome lecture. The one where they introduce lots of faculty. The one where they give you your first taste of what medicine is *really* like. They explain the horrible state that is American healthcare...and basically express frustration with the field. They seem to hate so many things...and are so bitter. Jaw on floor, you try to take in all of this information. You try to understand the bitterness, and convince yourself that "I'm not going to be so bitter when I grow up." Then, as if they're reading your mind, they say "you just wait...you'll see. Come talk to me in 10 years."

And school hasn't even started yet.

There was the white coat ceremony, where a few friends/family get to listen to a lecture about how wonderful being a doctor is and how doctors love patients so much (stark contradiction to the lecture *you* and your classmates sat thru just days prior)...and you get the (short) white coat (as if it's important or something). Everyone is so proud of you.

Then, the first real lecture happens. The big lecture hall. Everyone stakes out a seat. I liked to sit on the front left side, about 5 rows back. I liked to have the seat next to me empty. Everyone's very excited. The lecture is introductory and entitled "is healthcare a right?" Clueless to the political implications (as many medical students are completely apolitical), you start formulating your thoughts based on this lecture...and others that follow.

At our school we had these 'classrooms' where everyone had a desk (with lots of locked storage). In each of these rooms (there were about 10 of 'em) there were about 16 student desks - arranged alphabetically by last name. The person that happened to be sitting next to you, was your partner for the year. In these rooms there were slides, microscopes, bone sets, television with videos...learning aids, stuff like that. Immediately everyone brought artifacts from home to decorate their spaces. Magnets, plants, pictures, books, lamps, snacks, etc.

I remember the first day of (real) class. After the intro courses, and the welcome to our school speeches...the first real day. We were each given a stack of papers about 1 and a half feet tall. "Learn all of this by December." In addition to the stack, we had pre-filled notebooks for lab (gross anatomy and histology). Learn this too...and be sure to be able to identify these slides (box of micro slides handed to each of us), and you have to show up once a week for ICM (intro to clinical medicine).

I don't remember all of the classes off hand, but I do remember anatomy (lecture/lab), physiology (which is *quite* separate and much more difficult than anatomy, unlike in college). Microbiology (lecture and lab). Biochemistry (like hard core biochemistry); pharmacology, neuroanatomy, preventative medicine (epidemiology) embryology, and family medicine/ICM. The exams were during 'exam week' with 3 exams a day M W F. The multiple choice wasn't 'regular' multiple choice. They asked us to 'choose all possible correct answers'. If you chose too many, you missed the question. Missed one...also missed the entire question. There were k-type questions. I'd never taken a *multiple-choice* exam that was so difficult.

And they try to trick you. You have to read the questions very carefully, and consider the *exact* wording of the question. For instance, they'd show a picture of a large white blood cell...surrounded by a bunch of small red blood cells. White blood cells are big, have nuclei; red blood cells are smaller, and do not. (see above picture for example). Well, the question will be: "what are the characteristics of the predominant cell type in this slide." You ask yourself, predominate as in this big ass WBC? Or predominate as in the sheer number of RBCs shown. They were talking about the RBCs...and basically wanted to know if you knew that they had no nuclei. But, many students assumed they were referencing the WBC (that was huge, front and center)...and they missed the question.

Year one was also the year of gross anatomy. We had a few people who had issues with gross. The smell, the dead bodies, the thought of dead bodies...the dissecting. They would faint, couldn't stand blood and gore. We had pregnant students who had to wear respirators. But these issues are all worked out (through desensitization exercises). The only time it was difficult (for me) was when we got to the hands (and some of the women actually had pink fingernail polish on)...and the face. Usually, everyone kept the face and hands covered until the moment we *had* to actually dissect them).

There were all sorts of bodies, all sorts of ages. Mostly old white men...but lots of old white women too. Not so many of anything else...so when someone actually had a black body, it was very cool to compare/contrast the structures and such. Likewise, a young person, with well-defined muscles, offered something that the old people didn't. The bodies (on the inside) of course were more alike than different...but there are differences.

We had lab coats in plastic bags in lockers located in the gross lab. We were divided into groups of 5 per cadaver. We started with the back. Two people are supposed to dissect, one on each side of the body, and two others give 'instructions' on the proper technique/strategy by reading aloud the directions provided in the notebook. The notebook had key terms, and a list of structures that we're supposed to find and learn. And learning, not just their identity, but their blood supply (and the origin of said blood supply, it's branches, where it ends, what type of muscle lines the walls of the vessel), the nerve supply (and any thing else that the nerve innervates, muscles, organs...and where the nuclei of the nerve is housed...and which nervous system is responsible for the actions of the nerve).

If you cannot find a structure (either because your body didn't have one...but more likely because you destroyed it dissecting)...you had to come back to the lab after others dissected their bodies, and find someone who did it right. The person dissecting is supposed to switch day to day. Lab was 2x week. Lasted from about 1-6pm. There were TAs and tutors there for part of that time.

Lots of things to recognize, and the exam consisted of secondary/tertiary questions. Never are there questions like "what is this structure?" Too simple. Rather, a cadaver arm will be completely dismembered from the body, laying on a stool, covered with a towel...except for a 2x2 inch window. Three different color pins will be stuck into 3 structures. A card next to the arm will read: Where are the cell bodies located of the nerve that innervates the structure indicated by the red pin?

Even if you know the structure indicated...and even if you know the nerve that innervates it...damn if you know where the cell bodies of that nerve are located.

And 'knowing' what the structure is in the first place is a minor miracle in itself - being that you can't tell which way is up/down/right/left (since the arm, at least you think it's an arm, is detached from the body). And, to make matters worse, the tiny 2 inch opening makes it difficult to orient yourself with even local cues.

There are like 30 or so stations, with a portion of the class scheduled to take the exam at various times during the day. The questions are shuffled, but are the same. Each station has one student. Each station has 3-5 questions. You are timed. At the end you are (sometimes) allowed to go back to previous stations for 5 minutes or so.

Micro was alot like gross, except you get seasick looking at slides. And part of the exam was administered via a slide show.

All lectures were optional except ICM. Some students would show up for the first day of the semester...and disappear with their stack of notes, slides, and notebooks until exam time. We had a note taking process where the notetaking responsibility was shared among all students. So one student would attend a particular lecture, tape it, take notes, and go home and type them up nice and pretty. Then distribute them to the rest of the class.

There were tapes and videos of the lectures. And old lecture notes and exams from years past. So, there was plenty to study. I went to class everyday, but didn't attend every lecture. Some professors were great...and others wasted your time. Some topics were very confusing to try and do on your own...and others were quite clear after reading the notes. So, you pick and choose which lectures you wanted to attend. Our medical school spoon-fed us...which I think is a good thing being that I'm now over a quarter million dollars in debt because of it. It's the least they could do!! I deserve to have 'eaten well' for that much money!!

Medical school is like....they took everything you've learned in all of your undergraduate science courses and composite it into 2 days of lectures...as your introduction. On day 3, no matter what you've done in undergrad, no matter which courses you've taken, or how great your professor was at teaching it...on day 3, it's like you had *no* prior knowledge of the material. On day 3, everyone is on the same level playing field...science majors, biochem PhDs, art majors, and those who took every premed course they could. No matter.

I remember sitting in front of the computer, taking a practice biochem exam (WITH MY NOTES OPEN), and still utterly confused, flunking the practice exam one week before the real thing...and I graduated from undergrad with a degree in CHEMISTRY and a minor in biology!

At my medical school it was imperative that you pass all exams. There was a curve so that almost everyone passed...except in a few subjects. If you failed an exam, you had to retake that exam and pass it. If you failed the retake, or didn't take the retake, or it was the last testing period of the year (hence no time for a retake)...you had to retake the entire year's course in the summer. If you failed the summer course, you had to repeat the entire year of medical school. There were always a few students who had to repeat their first or second years.

The students helped each other. There was no pyramid nor was the curve based on the highest scores. The curve only served to lower the pass percentage in the instance that more than 10% of the people scored below 70%. Pass was 70%. Honors was 90%. Our grades were pass/fail/honors.

Do not need to be smart, per se, since it's mostly memorization. You just had to know what to study, and how to study. And you had to know how to take the test. Anticipate the questions...learn to read carefully...do the practice exams...and study in groups (at times). You had to use your time efficiently, especially if you had other things going on competing for your time. I didn't know anyone in my class that worked...but there were a few parents. I realized that I had to read the material 3 times in order for it to stick...and that was straight forward stuff. The complicated stuff...physiology, epidemiology, and biochem...I actually had to *figure out* before I could attempt to memorize.

Second year material is more complicated than first year. Second year was organ system based, and 'illness/pathology'. Whereas first year was micro/histology, second year was pathology. Whereas first year you're learning about the heart and cardiovascular system, in year 2 you're learning about congestive heart failure and strokes. It was easier than first year because you are now an 'experienced' medical student, able to pick and choose what's important to study...and how to take the exams so you pass. Also, a few things are repetition, and you have a base to hang new knowledge on...
***

Overall, most people who flunk out of med school, do so during 1st and 2nd year. And of those, almost all flunk out because of some competing personal issues. Family, marriage, financial, illness, mental, emotional, etc. Not because the work is too hard. Because, actually...it's not. It's memorization. It's being able to choose the 3 most important points in a given lecture...and commit those 3 points to memory...then reproduce those points in one way or another on an exam. It's knowing what to study. Focused study. If you don't focus, you won't do well. You cannot know everything...and if you try, you will have a more difficult time.

It takes some time to become okay with going from being the top in your class (from kindergarten, onward) to being "average" among your med school class. It's hard to incorporate 'family time' and 'friend time' into your life. You feel guilty for spending your Thanksgiving "goofing off" with family rather studying in preparation for mid-terms. And movies are out...2 hours of "lost time" is just...unacceptable. You take your backpack *everywhere*, just in case you get 'stranded' you won't fall behind in your study. And don't even think about getting sick...

No one in our class had outside employment. There were a few parents, usually fathers with stay at home wives and the rich grandparents supporting the young family. Many students even stayed at home where their parents prepared healthy meals daily and washed their clothes. No wonder they did well!!

You cannot spend the time worrying about money...so you must take out loans to support yourself (if you don't have rich parents). You have to have a car and a computer. You have to spend money taking exams and joining organizations.

Living close to school is a plus (that way you avoid wasting valuable study time on the road). If you must spend lots of time in your car...get some audio lectures to listen to.

There were a few women who managed to have babies in med-school and do very well. They often did not attend lecture, spent all day studying in the library instead. Stayed late (until 6 or so) in study groups/labs. Were very focused and didn't take breaks or goof off during 'study-time'...and did well. On the other hand, those of us without kids/families spent 12-14 hour days in the library, 6 days a week (easily). We snuck food into the group study rooms. We did alot of chit-chatting, and often went from study site (i.e. library)...to another study site (i.e. cafe')...and yet again to another study site (i.e. someone's apartment). Our lives were studying in different locations...sometimes inefficiently moving from place to place, talking about off-topic things.

The first 2 years are fun...but requires lots of attention (to say the least). There's no real patient contact (that ICM bullshit doesn't even begin to count as 'patient contact'). Your life is your backpack. Your notes are guarded with watchful eyes and taken everywhere (there's no way you can lose those notes after spending 2 months color-coding everything, and highlighting the pertinent points). And the fun you have is...in the gross anatomy lab, eating pizza and drinking beer while comparing the structures in various cadavers!!

A groove...and time not being a doctor

2008-02-20T09:23:00.000-08:00

I finally feel like I'm getting into a groove (I'm reading Vicki Iovine's book shown here...and love it).

I've been out of residency 2 years, passed my boards, and my hands no longer tremble when I have to intubate someone. My heart doesn't skip beats (as often) when I hear the MICN on the box taking a full arrest run. And, I'm more-or-less comfortable sending well babies home without worrying (too much) about whether or not they'll develop meningitis in the next week or two...

I've developed a (usually) polite, yet firm, way about me and my practice...in order to get things done. Both patients and ancillary staff typically respond better to a physician who is decisive and confident. But, I know how to listen and take advice (i.e. hear the subtle, or not so subtle, inflections in the voices of family and nurses when I should consider rethinking my disposition). I know how to ask for help without feeling incompetent. I can explain myself to the second-guessers...and feel even more validated in doing so. And, interestingly, I'm not at all shy about admitting what I don't know.

I'm actually enjoying myself most of the time.

Of course I still have times where I'm nervous, overwhelmed, or simply just not feeling up to the task. Since it's difficult to take 'a sick day'...we doctors (and nurses) often come to work regardless of how we're feeling - and probably when we shouldn't. But I digress....

The biggest thing however is my new-found *balance*. I have found the perfect number of shifts...types of shifts...and places to do said shifts. This, my friend is key. I believe that being rich means having choices, period. Money certainly allows for more choices (to a point), and is therefore a necessary part of the equation. But, choosing how you spend your time, where you spend your time, who you spend your time with, etc...for me actually defines "rich." If I'm working 25 shifts/month, I may have a $30,000+ bring home salary/month, but really, I'm not rich if I have to go to work frikin 25 days/month!!

I realize that working about 10 shifts/month allows me to bring home more than enough money to cover our expenses plus savings...AND I get to spend the rest of my time (get this)...doing other things!! Additionally, I realize that I actually enjoy working at 2 different EDs, each with their own flavor. Working in two different EDs allows me to not get all caught up with the politics of a place. My residency program was the *most* political program ever (I'm sure). Every word, every action...political. Very stressful.

I also realize that I actually *enjoy* working at an urgent care center/walk-in clinic. It offers a completely different perspective. It's nice to have time to sit here and update my blog (finally), and see patients intermittently while doing so. It's nice to take a lunch break (imagine that, a lunch break!!)...and its nice to visit the toilet from time to time when necessary.

Also, it's nice to refer patients that you don't wanna see (for whatever reason) to the ER. Shortness of breath? Hmmm...you need to go to the ER. Pregnant vag bleed...yep, ER for you. I see why so many clinic docs ~~dump~~ refer their patients to the ER...it's just so frikin easy. Not that I would ever do such a thing. All the patients I send to the ER actually belong in the ER...and I should know.

Sometimes I get asked by folks when I tell 'em I only work 10-12 days a month:...what else do you do with all your time?"

Seriously??!!

You know what I do? I cook healthy meals because this non-organic/fast food shit is killing us. I read for pleasure (for the first time since college). I keep my babies out of daycare from time to time so I can take them to the park, then to the ice-cream shop...and maybe even to the mall. I manage the business that is a household (which is a full-time job). I make sure the bills are paid on time; I negotiate online payments, allocate funds for various usages, manage half of our accounts, and basically (since it is my strength) manage the finances. I am the historian of our family - blogging, documenting, video-taping, photographing, and scrapbooking our lives...so we won't forget, and so the children will have a sense of what their childhood was like.

If not me, who will go thru my kids drawers and determine what fits and what doesn't, what I adore and will save for them vs. give to a shelter? If not me, who will decide where I want things to go in my home...how to decorate...and how to organize? If not me, who will take inventory of what we have, and what we need as a family? There are some things a house-keeper can help you with...other things, I'd rather do myself. If I don't change my own kids diapers, how will I be able to tell the pediatrician that their poop is consistent with prior poops? If I don't bathe them, how will I know that my little guy likes to play submarine with his Thomas the Tank Engine train set? Or even more importantly, how long would it take me to notice an injury or a rash if someone else (or various someone elses) are doing the parental tasks? If I don't read to my kindergartener, how will I know she's progressing as she should in school...and in life? If I don't find time to really talk to her, how will I know who her friends are, and what they're like? I wonder if my colleague knows how much fun she's missing when she leaves the house before having had the opportunity to dress up her cute little girl in almost-as-cute clothing...and spend time fixing her hair just so? Isn't this why we dream of having daughters? Why would you want to delegate all the fun stuff? And...if I don't have sex with my husband, and listen to his hopes and dreams, how can we stay connected in this partnership that is raising our family...and enhancing our lives? I waited almost 30 years to be 'mommy/wife'...and I want to be intimately involved!!

You know what I do? I walk my (often neglected, despite all my "free time") dogs, and train them to obey me. I do yoga so my back won't be sore after my shifts. I get massages and facials...and my eyebrows threaded. I do my hair, my nails, and read fashion magazines. I have like 4 blogs in progress...and enjoy being 'in the world' in this way. I'm (still planning to) write a great book (but there isn't quite enough time).

I've discovered that I actually love photography...and it is not my style to do things half-assed so I actually devote a bit of time to this hobby. I am in a Sorority, and like many sororities, our membership doesn't end upon college graduation...and there are time commitments involved as we serve as mentors, organizers, advocates, and community activists in my Sorority as a graduate. I plan awesome trips for our family (that we have time to take because I don't work all the time). And not huge extravagant/over-compensatory (i.e. I work all the time so when we go 'on vacation' it has to be big so our friends will be impressed, and my working all the time seems justified) 3 week European-type trips...but rather Disneyland Resort trips...Legoland trips...Vegas trips...Tahoe trips. Frequent trips. Easy trips.

You know what I do? I can attend school field trips with my daughter. I can keep the laundry done (most of the time). I can be mentally and physically available and present for my husband. I can unwind and tend to my needs so I can be patient and understanding with my kindergartener and toddler without yelling all the time over spilled milk, literally. And without sitting them in front of TiVo'ed Little Einsteins cartoon for days on end (hours? maybe. days? no).

I can have 2 hour conversations on the phone with my parents...and/or my girlfriends. And I have the time/energy to spend a weekend or two a month (or at least every other month) socializing with good friends as a family (their kids, our kids, red wine, good food, background jazz playing, with the BBQ grill going, or tandori chicken and naan waiting for us in the family room...OR maybe an exciting night out at the bowling alley - the one with bumper guards to keep the bowling ball in the middle of the lane). And I have flexibility, and enough 'extra' time off that I can actually pick up shifts quite easily from other partners who need/want days off...but the schedule is already printed.

Above all...I just have time to think. You know, be bored...like a child in the summer, back in the day ('cause these days, kids are overextended and never have the pure luxury of just being bored). To just think. Think about investments, think about purchasing property, think about our next trip...and just let the creative energy flow. Think about ways to be more fully involved and engaged in this life I've been blessed with. Think about life. Think about my purpose...expanding my spirituality.

And, of course...time to *not* think...and just be.

Just be.

There are so many things to do when not cooped up at work...running around crazy, neglecting your own needs. There are so many places I'd rather be, despite the fact I love being a doctor. Actually, I love being a doctor *because* I have plenty of time to *not* be a doctor.

I've said it before...and Dr. Leap repeated it here:
It's so important to realize that we are so much more than doctors. We are mothers, wives, daughters, spiritual beings, individuals, pet-owners, aunties, girlfriends, sisters, mentors, community activists, here to serve a Divine purpose. We have other loves and interests. And life marches forward.

Balance is so important...
...hopefully new doctors will realize that - and find their groove.

Confessions.*

2008-01-28T12:54:00.000-08:00

There are a few things that many EM docs don't openly discuss 'else they subject themselves to criticism and judgment. Here are few of my confessions -

I think leaving acute patients to 'see quickies' in an attempt to clear out the waiting room contradicts the very essence of emergency medicine...and I don't do it.
In every emergency department there is (supposed to be) some sort of triage process. Where sick people are seen first, and not-so-sick people...wait. Well, our nursing staff (as wonderful as they are), will frequently ask me if I would 'come out and see some of the quickie, non-sick people, to clear out the waiting room.' If I'm sitting around surfing the net...then sure. But I'm never not busy at work. Never, ever. I rarely get to go urinate, much less grab a bite to eat. So, I don't do it. I can't justify in my mind, leaving my sick patients to go see not sick patients. And all to "clear out the waiting room?" That's really not my goal. My goal is to keep people who shouldn't die, from dying...and to get the rest to their proper destinations. When my shift is over...I leave. Waiting room full...or not. Why should my goal be to clear the waiting room? If I valued an empty waiting room...emergency medicine would be a poor choice of specialty.

I think that speeding thru patients, and subsequently rewarded for it, is a bad idea.
It annoys me when doctors brag about their half-ass workups in an attempt to seek reward for speeding thru patient encounters. Our patients wait, sometimes in excess of 6 hours, to see us. They deserve 10-15 minutes of face time. Even if the problem is straight forward and you only need 90 seconds. This interaction with patients (listening to them, talking with them) is why I love medicine. Minus the patient encounter...what's left?

Sure, I understand being efficient is important...but seeing 3-4 patients an hour is not good for the patients you see. They won't like it...and you won't like it. Something will be missed. A something that won't be missed if the doctor just takes a minute, grabs a chair, and spends 15 minutes with a patient. Additionally, taking a minute (or 5 or 10) to look up information (for yourself or for the patient) is totally appropriate, but doesn't lend itself to "speeding thru" cases. Finally, very important thought processes would be clear if time was spent documenting this information *in real time.* Not to mention more defensible in court, and basically just better communicates (as a medical record should) with other care providers.

I hate reading history and physical assessments written by people who are more concerned about capturing all the "elements" for full reimbursement, rather than actually documenting what the hell's going on with the patient.
There are so many docs now who chart based solely on reimbursement, that very key information is not included in the documentation. I do understand the need to get paid...but it's just as important to communicate effectively for the well-being of our patients. And simply putting "4 elements" in the HPI...doesn't quite do the job.

I hate dictating.
In the ED so many of my tasks are accomplished piece-meal. I may do the HPI in the patient's room...fill in the physical once back at my desk...and document the labs/xrays as they become available. I'll later fill in consultants names, times called, and their responses. Medical decision making usually follows. Finally I have a "diagnosis" and disposition. If I dictate, I can not do it in real-time. Otherwise I'd constantly be calling the dictation line back adding "addendums". Not to mention the time it would take to dictate "Dr. Cardiologist paged at 12 pm; no answer." (click) Then call back: "Dr. Cardiologist paged again overhead at 12:20." Or what about when patient has a change in condition? I can type over 75 wpm. I can write on the paper chart standing at the bedside. I can get distracted, and return to the charting very easily. But dictating...every chart...is unreasonable. Dictating looks pretty, and after the final disposition has been obtained, perhaps going back and dictating on selected patients would be helpful. But, I think it's a bad idea to do essentially no charting (scribbling notes to yourself on the paper chart with the intent to go back and dictate, *isn't* charting) until after your shift (sometimes *days* after your shift). I think that's a set-up for disaster.

I like to leave on time after my shift.
What's wrong with saying that? If I'm scheduled to be off at 4pm...I wanna leave by 4:45 (really right at 4, but I do understand expecting to stay up to an hour later to wrap things up). For some reason, some people think you're being lazy if you get out on time. On the contrary. It takes crazy planning to get out on time...and still see new patients up until the last 30 minutes or so of your shift...AND not sign-out a whole bunch of shit. It's an art, really.

I do not like being made to feel guilty because I actually have a life outside of the hospital. Not to mention that staying late isn't compensated time. I don't like to stay late (or come back on my day off) to chart on previous patients...not to mention that this isn't best medicine, IMO. And I expect oncoming colleague to take a reasonable sign-out without bitching and moaning. Of course staying is sometimes unavoidable. Of course some sign-outs are inappropriate. But I'm not talking about an occasional late day...or defending docs who chronically dump on their colleagues. I'm talking about a general attitude that everyone is expected to stay 2 hours late (cuz if they don't it means they were "slacking" during their shift and not seeing patients near the end...or didn't see as many patients as they "could have" because they completed their charting within the shift.) Neither is necessarily true...and on the contrary, docs who are efficient enough to finish their work on time...should actually be rewarded (rewarded with going home on-time without comments from the peanut gallery).

I get really annoyed when folks show up to the ED talking a whole lotta crap.
If you haven't been in the ED all day, you are not allowed to stroll thru and pass judgment. Nor are you allowed to show up for your shift and pass judgment. If you have not been here, you don't know what's been going on. And looking at the chart rack, seeing 15 patients waiting to be seen, is no indication of how fast/slow, diligent/efficient, the staff has been working.

I wish that everyone could understand that everyone has a bad sign-out from time to time.
Sometimes, the patients are all actually sick. Sometimes the xray machine is broken. Sometimes the medicine consultant is stuck in the ICU with a coding patient...all day. Sometimes, you're just friking tired...and want to go home.

I don't think that physicians should be "time card punchers."
We are not time-card punchers. We spend hours of "extra" time in the hospital in a given month. Leaving 10 minutes early one day...is earned. A right almost. Especially if the sign-out is clean. Afterall, staying for the sake of staying (it's not like a new patient encounter is going to be initiated 10 minutes before you're off) is demeaning. I understand why high-school students stay on their Burger King shift until the clock strikes twelve. But I am no high-school student...and I am not at Burger King. Holding highly trained professionals (who give away tons of time for "free"), accountable for every minute (or ten, or fifteen...) is indeed a slap in the face...and shouldn't be done.

I kinda like that the patients see me as a nurse (or other non-doctor person) at times.
When patients start bitching and complaining....it's so easy for me to say, "lemme get your nurse." If they knew I was the doctor, I don't think that response would work quite as well. Also, looking like a ~~clerk nurse cafeteria worker~~ non-physician allows me to roam the ED in peace. Most of the time, this is kinda nice.

I hate it when patients lie to me.
I mean, it really annoys me. I can no longer trust them...and I no longer believe anything they say. I get urine tox screens on them. I don't spend as much time with them. I am less likely to give them what they're asking for. And I don't take the time to do the extra things (get blankets, cups of water, or even listen to their tale of woe about their inability to pay for a cab). I treat them, and disposition them.

I like male nurses.
Male nurses are fun. They rarely challenge me...and there is no animosity between us. Male nurses seem to become nurses because they wanted to be nurses. Sometimes, female nurses have this thing...where I get the impression they actually wanted to be physicians...and they are jealous of me? Or think they're smarter than me because they are older...perhaps they feel they have something to prove (like "I coulda been a doctor too, you know".) Maybe it's just too much estrogen. Either way, I love male nurses.

I like female physicians.
The guys tend to be immature, socially inept, sexist, arrogant, pompous little dick-heads. Racing their fast cars, and staying late to avoid going home to their wives and families. Rushing thru patients for bragging rights: "I saw 26 patients on my 8 hour shift yesterday dude..." They balance their personal/professional lives very poorly, and rarely have anything to talk about that matters (outside of medicine). It's no wonder they die off early. Whereas women tend to do a better job listening, and taking the TIME to figure out what's going on with the patients. They are not as concerned with playing the testosterone games the ~~men~~ boys play, and seem to be more patient focused, more balanced, and better adjusted individuals.

I don't like it when female ED staff cross boundaries with male physicians.
I'm not just talking sex here. I'm not even talking about dating (I'm okay with that). What I don't like is the gifts, the shoulder rubs, the playing with the hair, the flirty remarks the fawning...and the all around degradation of character they demonstrate when they pimp themselves out to these dick-head male doctors. It bothers me more when the men are married. Sometimes I'll comment. Is there no shame...?? These "hos" misrepresent women, they undermine family, and make it even more difficult for women to be taken seriously in the workplace. I say, be friendly at work...and a tiny bit of flirting may be fun. But leave the touching, and the gift-giving at the ED door.

I really envy the way the nurses organize potlucks, make Starbucks runs, and overall, make their work environment more 'friendly' by virtue of having involvement of more women.
If physicians had more female members in the ED, I'd bet our lounge would have plants, and family photos, cutesy posters, and the like. I bet we'd even have clean linen and tampons in the bathroom. And best of all...we'd have a strong union.

I hate colorful scrubs
You know the ones the nurses wear...with all the pictures all over them (dancing puppies, and little happy faced sunshines)? I don't exactly know why. Maybe because I can't wear them without looking like a complete fool...??

I like seeing children more, now that I have my own.
I used to *hate* seeing kids. All they do is cry...and they provide no useful information. Just like being a vet. I didn't know what "fussy" meant...and I couldn't understand why parents brought their very well children to the very germy ED for a cold. I couldn't understand why it had to be at 3am? I couldn't understand why they even thought anything was wrong with the kid. Now...I understand better.

I have more 'feelings' for patients that I relate to.
I can easily tolerate people doing stupid, self-destructive things. This is what keeps us in business. However, when I can identify with the person on a personal level, I feel personally disappointed when they make bad decisions.

But, if I can relate to a patient, and they are ill...I feel sad. If a patient is a mother, for instance, I can talk to them for hours about their hopes and fears for their children. I'll fight back tears as I listen to her history. Then, once home, I'll take extra moments to smell the breath of my own children, and feel their soft baby cheek. And I remind myself that I am truly blessed.

I think emergency medicine is the coolest specialty ever.
I actually believe that those who talk negatively about EM...are simply jealous!!

Updated 4/2011
*Stating the obvious: there are many great female nurses that I just adore...many male doctors that are wonderful friends of mine; there are patients who lie that I still trust, and people who look like me (or that I can relate to), that I feel no emotion for. No one should dump on their colleagues by showing up habitually late for a shift, nor should one give shitty sign-outs consistently. I do go out to triage every now and then to dispo 'simple' patients...depending. I understand moving quickly, documenting to get paid, and needing to stay late to finish documentation (or whatever). I realize that in the ED, every patient will not get 10-15 minutes of face-time with the physician. Dictation is wonderful, and should be available...and a bit of innocent flirting at work is okay at times. I encourage people to find love, and have no problem with finding love at work. And I realize that not all men who work late are cheating on their wives (or otherwise avoiding them). I do get annoyed when I have to almost 'prove' I'm the doctor to people, when the white *male* is often 'mistaken' for being a doctor no matter what his role may be in the hospital. There are no absolutes...and I get this. You get this. I wrote this 'Confessions' entry with blanket statements to keep it interesting (and direct). Please don't argue the fine points (i.e. not all colorful scrubs are embarrassing). I know this. And remember, these are my *general* opinions. General. Opinions.

a trauma story

2008-01-07T12:49:00.000-08:00

Since I got such positive feedback, I'll post one more story.

I work at a couple/few different places - which is nice because my ER shifts are quite different depending on the location of the ED (obviously). One of 'em is a trauma center. The trauma center is way cool...and has top of the line everything. The trauma resuscitation bay is like 20 feet from both the CT scanner, and the OR. The anesthesia and surgery call rooms are actually *in* the trauma center. We even have a teeny-tiny police department (2-way glass and everything) in the entry-way to the trauma center.

So, I was at work recently, at my trauma center ED. Things were steady. Our traumas so far consisted of a drunk dude who was riding his bike, crashed into the curb, fell off of the bike, and lost consciousness. Granted, there are quite a few things possibly wrong with 'drunk dude', but more than likely, he's just drunk. But, he fits 'trauma criteria' so he was brought to us. There was a kid who jumped off a roof, obvious deformed leg...but otherwise okay.

Then we received the EMS call:

"This is rescue 25 to base with a trauma run."

This is base. Go ahead with your run.

"We have an approximately 30 yo male who jumped from a 2nd story window to escape an apartment fire. He has 2nd and 3rd degree burns over his anterior chest, neck, and his right forearm. He has an obvious deformity of his left femur, and multiple abrasions to his face. He's alert, but appears intoxicated, and is combative. We have PD on scene helping us secure him for transport. His vital signs are 150/84, heartrate 120, respiratory rate is 22, and his O2 saturation is 98%. We're attempting to establish IV access, we have him on O2, full spinal immobilization, and would like to have an order for morphine. You are our closest trauma center with an ETA, after we get him loaded, of 7 minutes. Over."

We rally the troops, and congregate in Trauma bay number 4. Upon arrival, EMS notifies us that this guy was 'set on fire' by a girl. Apparently this girl is the girlfriend of a rival gang member...and 'word on the street' is that she decided to get revenge on this guy for killing someone in her boyfriends gang. Because of this, there were already members of both gangs 'interested' in our patient's condition....and our parking lot was starting to look a lot like Crenshaw Blvd on Sunday night.

As firefighters approach us in Trauma 4...we see a young adult male, laying on the paramedic gurney with a c-spine collar on a long spinal backboard. His face is covered in blood and glass. His chest wall has 3rd degree burns over the entire anterior surface. His left femur is obviously fractured; as is his left tib/fib. They have no IV access. Patient is on O2 via facemask. He's yelling loudly, and wiggles on the backboard. We transfer him to our gurney. And the nice thing about trauma centers, especially where there are residents, is that there's enough people around to do everything.

My mind is yelling "oh sh*t. This guy looks horrible!!" The residents are eager to *do something*. It is times like these I really appreciate the simplicity of the mnemonic ABC.

As the attending (gulp)...I start giving instruction.

"Okay, lets get him on the monitors, pulse ox, and let's get some sterile gauze soaked in saline." That sends a few people scurrying away. Someone assess his airway and listen for breath sounds. Let's set up for intubation, and obtain central venous access...via...via..."

(hmmm....can't do subclavian because of the burn...or IJ for that matter. He has an obvious left lower extremity long bone fracture...so maybe that's not the best place to stick him).

"via right femoral vein. Someone call the burn center and let them know this guy is here."

The crowd around the bed is now half it's original size...with everyone doing their various tasks and all. Now, we have some room to work.

A - airway first. "let's intubate this guy" I tell the junior resident. There's some resistance from the nurse, "but he doesn't need to be intubated." I try to quickly explain to her (while the resident proceeds with the intubation) that this guy has major trauma, major burns, and was in an enclosed space, likely intoxicated, with fire...and smoke...and CO...and CN. His airway is closing...and every moment we contemplate will just make the edema in the airway even more difficult to overcome. The resident struggles, "I can't see anything." Keeping the cervical spine secure makes the procedure more difficult. The monitor goes from a high-pitched 'blip-blip-blip' to a decrescendo 'bloop-bloop-blooouuuppp' as his oxygen levels drop. Okay, that's enough. Let's bag him up.

I'm too 'insecure' to let him try again. We bag mask the patient, restore the oxygen saturation to an acceptable level (and the nice high pitched blipping)...and I try. Wow. All I see is pink mucosa - there are no landmarks!! I do the BURP maneuver and a small opening reveals the cords. I use a bougie and successfully intubate this guy with a 6.5 ETT (tiny little tube)!! We listen to breath sounds, and the left is decreased. We pull the tube back a bit. Still decreased. Then I ask the resident, "did he have equal bilateral breath sounds before intubation?"

He isn't sure. Maybe the left was less audible. We order a chest xray.

As we secure the ETT the patient, who intially improved his oxygen saturation, started to desaturate, and his blood pressure was about 115/70 with a heart rate of 130. Let's bolus him warm saline thru the Level 1. And let's get some o-positive blood here (we like to use 0-positive for the fellas).

Moving on to B - breathing: I instruct the resident to dart his chest. Things got a bit better after that. Then, he placed a chest tube. 500mls of red blood squirted out of the left chest...but his breathing improved. Let's autotransfuse that blood right back in.

And now to C - his blood pressure was stable at the moment. His arms/hands had good circulation. Palpation of the left elbow elicits a painful response. His right forearm has a medium sized 2nd degree burn on the radial surface - it is not circumferential, and his distal pulses are good. His right leg is fine, and our femoral line is working wonderfully. His left leg is mangled. There is decreased pulse to the foot, which is cool and cyanotic.

At this point we order initial labs and studies. Xray...basically everything. Order CT of...basically everything. Call ortho for the leg. Trauma panel of labs. And dress his burns with the sterile saline soaks. We keep him sedated. And order a tetanus and antibiotics while we're thinking of it. Then we go back and do a secondary survey.

We look into his eyes. In the left eye there's a piece of glass obviously penetrating the globe. The right eye is reactive and appears normal. Typanic membranes reveal no hemotympanum. There was no evidence of midface injury. However there are multiple deepish lacerations to the forehead and scalp. The PA is eager to repair these.

The neck has 1-2nd degree burn over the anterior surface, but it's not circumferential, and is not deep enough to expose any underlying structures. The chest tube is in place, and the breath sounds are present bilaterally, but greater on the right. There is a 3rd degree burn over the majority of the anterior chest wall.

Abdominal exam is difficult to execute....so we'll just scan him.

Pelvis is stable. Left hip is questionable. And his back and rectal/genitalia are unremarkable.

We continue IV hydration per Parkland Formula, and call ophthalmology for the eye injury.

Xrays reveal a femur fracture, tib/fib fracture. There's a distal humeral shaft fracture on the left. CXR shows what we interpret as a likely pulmonary contusion on the left. Chest CT angio, cervical spine, and abdominal CTs were unremarkable (except the pulmonary contusion and some rib fractures). CT pelvis revealed a small, but significant pelvic fracture, with acetabular involvement. Labs revealed an alcohol level of 420 (legal limit is 80). Utox positive for cocaine, marijuana, and meth. And head CT revealed a left parietal skull fracture (with no underlying brain involvement apparent), and glass fragments in the left eye with globe rupture.

Ortho took over the management of the broken bones, and decreased distal blood flow to the left leg. The leg was splinted, and vascular surgery was consulted. Because the patient had extensive chest trauma, I believe trauma consulted CT surgery. And, of course you can't ignore the burns. We are not a burn center...but we have the capacity to care for burn patients (yeah, go figure).

At our institution, it's the trauma service that stays with the patient thru his scans, and see to it that the appropriate consults are obtained after initial stabilization is achieved. So, at this point...we're actually done. My residents stay and play with the trauma service...but I have other residents to supervise (only one junior and one senior responds to the trauma calls, the other 4 continue their work in the ED).

***

Later I found out that the guy, unfortunately didn't have insurance...and the ortho procedure he required involved a series of operations, close follow-up, and specialized equipment. And because orthopods don't work (much) for free...especially when the patient is a high risk patient (high risk meaning not likely to be compliant, and more likely to sue, as determined by his lifestyle...and according to them, it's the poor, uninsured, disenfranchised, non-contributor to society that's likely to try and take something that doesn't belong to them...and is therefore more likely to sue). So, no orthopod in the City would do his surgery...and he will require the use of a cane/walker for the rest of his life (or, I guess, until someone thinks it's worth it to fix him).

And he lost the sight in that left eye.

As for us...

...well, it was interesting leaving our shift that night. Navigating the parking lot in the middle of gang warfare is quite stressful - especially when, no matter the outcome...someone's going to be pissed off.

obesity. viagra. heart attack. thrombolytics.

2007-12-31T12:21:00.000-08:00

Last night in the ER...

....was very busy. And "busy" in a good way. Lots of codes and respiratory distress. Not so much "weak and dizzy" and "TMD (todo me duele)". The kind of night that reminds you why you chose emergency medicine as a specialty, and not primary care.

Anyhoo, there was this one guy...

A 36 yo morbidly obese Samoan man with a past medical history of diabetes, hypertension, and has lots of 'bad habits', was brought in by paramedics complaining of chest pain which started 10 minutes prior to the 911 call. He was sitting on the sofa watching reruns on TV when he suddenly felt a tightening in his chest. He got up to get a cup of water, and the pain got worse. Then he felt weak and lightheaded so he sat down on the nearest chair. He then called for his wife, and she took one look at him and called 911.

In the field EMS established a very tiny finger IV (because 'his veins could not be accessed secondary to excessive adipose tissue.' i.e. he was too fat). They gave him an aspirin, and after he denied using Viagra, a nitroglycerin sublingual. Immediately thereafter his blood pressure dropped from 150s systolic to low 80s. He became very diaphoretic (lots of sweating), and short of breath.

Upon ED arrival the patient was alert and oriented, but very agitated sitting upright on the gurney, in moderate/severe respiratory distress. He weighed about 450 pounds, and was extremely diaphoretic, and c/o worsening SOB. EKG could not be obtained by the paramedics because the stickers wouldn't stick to the body for all the sweat. Also, the patient was so agitated and anxious that a good reading couldn't be obtained even when the EKG leads were held in place by assistants.

In the ED we attempted to obtain an EKG...for over 20 minutes. We cannot make a diagnosis of acute MI requiring thrombolytics if we cannot obtain an EKG. Afterall, there are other deadly causes of chestpain, some of which absolutely cannot be treated with thrombolytics (or else you kill the patient). It's one thing for someone to die. It's another thing to kill them. So we worked to obtain that EKG...over, and over, and over, and over again.

During this time we worked to establish a better IV with ultrasound guidance. We worked to improve his oxygenation (from 90% on face mask to 95% on non-rebreather). We asked basic questions (allergies, past medical history, medications, *viagra use*). His bloodpressure continued to register in the low 80s (82/64 - narrow pulse pressure, with a heartrate of 120). Are you sure you don't take Viagra (or other 'viagra-like' drugs)? we asked again. He adamantly denies.

I'm so nervous at this point. Here I have a very sick patient, who I think I'm going to have to intubate. He's 450 pounds. His blood pressure sucks. And we can't get a frikin EKG. Agreed, he's likely having an MI...but what if it's an aortic dissection (which could be dissecting up to the origin of the cardiac vessels...causing the MI). On CXR it's possible that his mediastinum is widened. What if he has cardiac tamponade? (the cardiac silhouette is enlarged) I feel stuck without the EKG!!

Finally we get a very crappy EKG. The QRS complexes are very wide, and there are diffuse ST segment elevations. Hmmm....hyperkalemia? Pericarditis? Massive MI? Maybe....TCA toxicity? I give bicarb and fax the EKG to the cardiologist at home after explaining to her the clinical history. She agrees that it is consistent with hyperkalemia. We call the lab..."hey, we so *need* the results of the chemistry ASAP!! please!!" And push more bicarb. He seems to get a bit better. The QRS complexes narrow a bit. He admits to a questionable history of renal disease.

35 minutes have passed. Out of the window of thrombolytics. Now I'm going to have to justify to administrators (and those who wear suits) why I didn't push the thrombolytics in less than 30 minutes. For those that don't know, thrombolytics are very powerful clot busting drugs that have lots of potential deadly side effects. Afterall, they make the blood so "thin" and remove the ability of the blood to clot...and destroy existing clots...that brain bleeds and GI bleeds are not uncommon. And, again, if this guy had an aortic dissection or cardiac tamponade...or pericardities even...I'd kill him with this drug. My biggest source of stress was trying to mentally justify *not* giving this drug in 30 minutes or less (so my chart won't go to 'peer review', or whatever)...which is crazy being that I'm the doctor taking care of him, and arbitrary 'rules' shouldn't apply to individual patients. I should just focus on practicing best medicine, and not doing things simply to make it easier to 'explain' and 'justify' (to non-involved non-physicians analyzing *my* patient thru their retrospectoscopes) my actions after-the-fact. So I hesitate for a second, but proceed doing what I feel is good medicine...and continue trying to obtain EKG #2.

As we 'encourage' the patient to 'just "hold still for one minute," he starts blaming himself for being "so fat", not following his doctors advice...and how he deserves to die. He feels this is the end...

...all doctors know, it's never good when a patient says "I'm going to die." Especially when they're circling the drain.

Suddenly the monitor flickers, the heartrate speeds up, and the patient mumbles, "I don't feel well." Then he becomes altered. The monitors reveal v-tach...so I shock him. He wakes up with the shock. The monitor reveals sinus tach, and he's yells "what tha hell?!"" I breathe a sigh of relief. "Sir, I'm sorry, I had to shock you...your heart started having trouble."

Then it happens again. This time I warn him...."it looks like your heart is doing that thing again...I'm going to have to shock you again, I'm sorry."

"Bring it on Doc!!" he yells.

EKG #2 is obtained (finally)....and seems clear now that he's having an MI. So we get the 'thrombolytic box' out....and fax the 2nd EKG to the cardiologist. She agrees that thrombolytics may help (especially since everything we've been doing so far hasn't helped much....and the patient seems to be getting worse - with the whole v-tach/shock thing). I do a bedside ultrasound and there is no cardiac tamponade, and the heart motion....well, the heart is moving.

I suggest trying to get him to the cath lab instead of thrombolytics since this guy is in cardiogenic shock....and only a cath *may* save him. I was informed by the cardiologist that the cath table can only accommodate up to 350 pounds, so our patient couldn't go for cath. Thrombolytics are the only option for treatment of MI at this point. I ask her to come in to see the patient. She agrees. While she makes her way to the hospital, we obtain consent...and push the thrombolytics....

...30 seconds after the lytics are pushed into the IV, the patient becomes altered, agitated, and his breathing seems (more) labored. I think to myself, I'm just going to intubate him. All of his agitation isn't good for our treatment, but it's also not good for his heart. Additionally, he's nearly 500 pounds so a controlled intubation is preferable. I anticipate a very difficult airway because of his size, the severity of his medical problem, and the fact that he's in cardiogenic shock with frothy sputum coming up his airway.

I intubate him (despite the fat, and thru the pink froth). RT (respiratory therapy) secures the tube. And just then, he's in v-tach again. Before we charge the paddles he deteriorates into asystole. WTF? We'd already given the thrombolytics so I was hoping that this was the 'reperfusion rhythm.' But. It. Wasn't.

We started ACLS...and coded this guy. We got him back....kinda.

The cardiologist comes in and we agree the guy was in bad shape when he arrived. And the fact that he couldn't go to cath lab because of his weight....and the fact that (we later found out) he wasn't honest about his viagra use...and his multiple medical problems, bad habits, etc. made a bleak situation, worse.

In typical fashion, we coded this guy every 45 minutes or so...until he got a CCU bed (maybe 90 minutes later).

He made it to the CCU....and eventually started bleeding from every orifice (including his eyes and ears). It's like he was crying blood. That's what thrombolytics will do. Like most full arrests, he didn't live to hospital discharge.

Most doctors have memorable patients they think about for a long time after their encounter with them. This guy was one of mine.

The Hospital Credentialing Process Dog and Pony Show!!

2007-12-17T08:18:00.000-08:00

So, I've been filling out multiple hospital applications lately. It's not uncommon for physicians to have hospital "privileges" at multiple hospitals, you know? And it's *crazy* what's involved in this process. Addressing this issue would be the perfect 'lifestyle, morale boosting, lovey dovey project' that our professional organizations could tackle, that will validate the membership fee (and PAC contributions) to those of us who are too busy to really get involved in the mundane, ever-changing politics of healthcare. Isn't that their purpose?

Okay, here's how it goes -

First you get this huge packet, maybe 70-100 pages of...who knows what. A piece of paper for everything...completely unnecessary and purely a hospital CYA. Read, sign, read, sign. They ask for accompanying documents, such as a CV, copies of your medical license, DEA, ACLS, PALS, board certification, diplomas, health clearance, etc.

There's a credentialing fee...which is a crock of shit. Aren't these people paid by the hospital to do this job? Why am I being charged a fee? Are other people charged a fee to apply for a job? The nurses....the techs? Everyone wants to be 'treated equal', yes? Where am I supposed to get this fee money? I have no money, hence the application for a *job*!! The fees range from $200 to over $500. Then, you want *me* to gather all the information....and pay the fee to boot?!! If I pay the fee....seems only right that you gather the information. Isn't that what I'm paying for?

The application - requires the standard info like name, address, etc. Then they ask for work history, educational history, and references. It's all on the CV. But they write "do not write see CV". Why not?!! Why ask for the damn thing? My CV has my work history, my references, contact info....all the basic stuff.

Then they ask you *again* (as if to catch you in a lie...as if you're that stupid), your work history....just to be sure there are no gaps. What they really want to know is if you've ever been committed to a psych hospital, or drug rehab...or otherwise MIA due to being "weak" or "crazy." It would be much easier to just write "I have never had a problem with drugs/alcohol, nor am I crazy" than to do this song and dance, that in the end proves nothing.

There's a sedation packet with a quiz...because this makes you "safe" to administer sedatives (can you feel the sarcasm?)

There's a core privileges packet, where you request which privileges you'd like. What the hell? I would like to do everything I'm trained to do, please. ACGME doesn't accredit residency programs, and ABEM doesn't allow one to graduate from a residency program, without showing competence with basic EM tasks. So, by being a graduate of an approved EM training program, I shouldn't have to pseudo-justify my competence in basic shit....like sedation, and ultrasound. Nor should I have to request privileges one by one. Even if I've never done a cric....I need permission to do one if needed. And if you tell me "no", how can I do my job? So...this packet could be eliminated if I'm an ER doc asking for ER privileges only.

Then there's a background check. Makes me wonder what is the Medical Board for, and why do I pay them almost $700 every other year if they can't vouch for me, and their 'blessing' isn't enough to practice medicine in my state's hospitals. It's insulting, and unnecessary.

References - are a joke. I give you 3 doctors....of the 100+ I know. So, what does that prove? Not that I'm a good doctor. Even the worst docs can find/pay 3 people to fill out a form. Then they call these 'references' (over and over and over again) and ask stuff like "would you say she's competent at LPs?" As if they'd know. They are not standing over me...ever...watching my LPs. ER docs don't stand over each other, and honestly have no idea what our colleague is doing 99% of the time.

Then there's the residency verification. Again, board certified should be sufficient to demonstrate my competence in my area of specialty. So why go thru contacting my residency program...and how long do they do that? I mean, my program director is an old guy already...

Then contacting every employer? I don't understand this either. Obviously, by the questions that are asked of them, there is that concern (again) of drug/alcohol use, and mental health issues. It's not like they're interested in "was she a good person....did she work hard?" Nope, the hospital doesn't care about that (the Group might, but they don't contact all prior employers). It's a CYA thing, again...no real value. Again, if I'm okay with the medical board, and my professional organization....board certified and a clean record (which is public and could easily be obtained by the medical office staff , which may begin to justify that $500 fee)...I should be okay to work (from the hospital's point of view).

I thought was ahead of the curve by saving all of my 'important documents' (LoR, malpractice certificates, employment letters, board scores, etc). Not. Get this...the information has to be "primary source information." This means, *they* have to contact someone other than you to get this information. (yep, crazy, I know). But, if they are unable to contact these people (people such as secretaries of departments to "confirm" you actually worked there, and weren't in rehab), they blame you: "I couldn't contact Doctor's Office up the street so we can't verify your credentials." Okay. I know I worked there. You're the one who wants "first hand proof." What the f*ck do you want me to do? You offer up the letter of recommendation from the medical director of that clinic. "Oh it's not addressed to us specifically....and we need to talk to him directly." Seems to me my letter is far more reliable than whomever you happen to get on the other end of the phone. Besides, I think he's probably dead by now....

Then there's the medical malpractice questionnaire. "Please list all of your malpractice carriers for the last 10 years." WTF? I could understand asking about any pending lawsuits...but even that doesn't concern the new job...until the outcome is known. We need a HIPAA for malpractice insurance companies (to protect us from the sharing of sensitive information which would be used to exclude us from being insurable. Afterall, isn't that the original intent of HIPAA? But we've allowed it to go as far as preventing us to obtain vital medical information from the PMD of our comatose patient...who cannot, and I repeat (to the person in charge of the pencils) *cannot* for the love of God, sign a authorization to release medical records right now!!) But I digress.

We have been successful in eliminating the ACLS/PALS/ATLS requirement for board certified ER docs. I mean, what the hell? I'm board certified as an emergency specialist, and you want a little red/white card saying I can complete an online open-book quiz...is that supposed to prove something?

Then they ask for your passport, social security card, drivers license, shoe size...and a strand of hair for DNA testing!!

The process takes a few hours of actual work time to complete...and that's if you have everything readily available at home. It's ridiculous!!

I'm all for interventions that contribute to actual improvement of safety or security. But many of these hoops are akin to the prohibition of lotion and chapstick on airplanes. It's just a hurdle that penalizes "good" people, and does nothing to increase safety or security. It serves to increase the cost of healthcare, and aggravates those of us who are on the front line.

I say, ACEP or AAEM should help us lowly grunt docs streamline this process. Maybe help us implement policies that will allow ABEM to be enough certification of our training and ability by virtue of being board certified. Our medmal should be private. The Medical Board issuance of a license should be sufficient to practice medicine in any hospital in the state. If I have a drug/alcohol problem that's significant to prevent secrecy, the Medical Board should know about it, and my licensure should be adjusted accordingly (understandably the Medical Board needs to be held accountable, which currently they are not). A CV should be sufficient to explain our professional lives (afterall, it's not like I'm writing something 'different' on the application. It's not more 'sacred' or 'accurate' because I write it twice...just more believable). And a 'central databank' would be excellent. One that could be referenced, and taken to be accurate by 'all the bullshit people who interfere with healthcare' (i.e. joint commissions, CMS, etc).

Here!! Here!!

2007-12-14T17:19:00.000-08:00

The New ER Fad

The fad of the day in the ER is some form of Provider is triage, Rapid Medical Screening or whatever name admin can come up with. In their endless search to increase business we are now catering to the very business that is bankrupting us, the med-i-caid or indigent self-pay people that rarely pay their bill. Hospitals are dedicating rooms to prompt care to increase the speed at which we see the dental pain, back pain, cold symptoms crowd while the sicker people, who are having oh, say an emergency are still waiting in the lobby for a bed to open up.

Agreed!! and, I hear you too ER Murse:

The fundmental problem with Provider is Triage where the "Provider" is a midlevel is that the care is biased towards the low acuity patient. The midlevel does not categorize patients correctly in many cases. They get in over their heads when the main ED gets busy and tend to see patients they should not be seeing to help out rather than have the patient wait. Both Provider is Triage and Zero Wait ED's or Triage Bypass plans tend to get rid of an effective Triage systems and once beds are full +1 then there is frequently not an effective way to safetly priortize patients because Triage has been eliminated and the staff are assigned elsewhere. Then the system of prioritizing falls back to first come first serve with higher acuity patients in low acuity areas and low acuity patients in high acuity areas. Yes its a fad and a dangerous one.

Couldn't have said it better myself...