I'm working in the ER these days. I've gotten to see some interesting cases. For example, yesterday evening, I palpated my first "olive" in an 8 week old who presented with vomiting and constipation.
I also had the opportunity to sow up a pretty impressive laceration of a 2 year old's left middle finger. The kid's bone was exposed and the finger nail was hanging by a thread. It was fun!
Last night, I was on with Brian McAlvin. When it got a little bit quiet early in the evening, we decided to make up an admission to call up to Jon, who was the admitting resident as a joke. We came up with something pretty good... it was decided that I would be the one to tell Jon about the admission because it would be more believable coming from me. Here's how it went:
"Hey Jon, I have an admission to tell you about. This is a 16 year old male with cerebral palsy and mental retardation secondary to congenital rubella who presents with increased oxygen requirement and fever.
Respiratory-wise, he is trach and vent dependent and is on a baseline of 21% O2 through his humidfied trach collar, and right now, he's requiring 40% of oxygen. We got a chest xray that is concerning for aspiration pneumonia given bilateral insterstitial infiltrates. The film also shows an enlarged heart.
In terms of his cardiovascular status, he is status-post AV canal repair as a baby and is on lasix and aldactone for what mom says is depressed left ventricular function. We asked about an echocardiogram. She says there was one done some years ago, but she wasn't sure what the ejection fraction was.
He is also G-tube dependent and is status-post fundoplication and has issues with severe constipation requiring daily Miralax. We spoke with GI and they recommend a clean out, but we haven't yet placed a nasogastric tube. He takes Nutren formula 1.0 strength through his G-Tube. The patient came is looking pretty dehyrated with dry mouth and lips and cool extremities and tachycardic. We gave him 2 boluses of normal saline at 20 cc/kg and held his lasix.
Of note is that he is 3 weeks status-post testicular torsion that resulted in an orchiectomy of his left testicle. The mother thinks that after this surgery is when he really when he started to get sick with difficulty breathing and high fever.
Laboratory results have revealed a leukocytosis of 29,000 with 79% neutrophils, hemoglobin of 11.9, hematocrit of 33, and what looks like a reactive thrombocytosis of 506."
Jon interrupts periodically with "uh oh," "ok." Finally at the end, he asks me a few questions. The most important being, "Do you guys think he's ok to come to the floor or does he need to go to the step-down unit?"
"Yeah, we were talking about that and he's actually pretty stable on 40% O2, but he desats to the 70's if we go below 40% oxygen."
"Has he eaten anything by mouth?"
"Well, mom gave him some food by mouth because she thought he was hungry and didn't want to see her child go hungry, but he has a history of aspiration. He's supposed to feel only through his G-tube. The family is Spanish speaking only and I'm not sure they really understand that he can't eat by mouth."
"Have you gotten a blood gas yet?"
"No, we haven't." This was a dumb answer actually, because any moron would have gotten a blood gas on this patient if he was real. I should have made something up.
"Alright. Well, I'm going to come down and look at this kid because I'm really suspicious that this kid would be ok on the floor. He sounds like step-down material to me," says Jon.
"Ok." I wanted to tell him the best part, that the patient's name was "Ima Toole."
Jon came down and started talking to the ER attending, who totally went along with the story. We told Jon that the patient was in room one, but that he couldn't go in because they were placing a Foley catheder. Jon came up to me and asked, "Are you guys making this up?"
I said no, with a straight face, I think...
Brian eventually told Jon that we made the whole thing up. Jon claims that he knew we made up the patient, and said that the fact that the family was Spanish speaking tipped him off. "Less is more," was his advice for us. We'll keep that in mind for next time :)
Monday, February 19, 2007
Monday, February 12, 2007
The worst call on a night of call
It's 3 AM and I'm trying to fight sleep and finish my orders on a new admission. I can't seem to stay awake. My upper level is telling me what orders to write (I have no clue because this kid has a crazy genetic disorder that I would have NO idea how to manage if it was not for Genetics's input) and I'm basically trying to copy what he's saying word for word. But I just CAN'T. I have to recopy multiple meds because my eyelids are so heavy.
Later I get a call from both pharmacy and the floor nurses asking about my orders. I clarify my orders. Next I get a call from the charge nurse who wants me to come up to the floor to rewrite the orders because they're illegible. I refuse, saying that I've already clarified the orders multiple times to pharmacy and to the nurse covering the patient.
At 6 am, my upper level calls me. "Hey, whippersnapper. The nurses can't read your orders."
"I'll go rewrite them."
I go up to the floor and rewrite the orders. I glance at what I wrote before and realize how illegible they are. Not only that but it looks like I was smoking crack and writing the orders. On the admission orders, I clearly wrote and crossed off: "Follow up with primary care physician in 3-4 days," something that you usually write on discharge orders. Oops.
It's the second grade and we've just finished the first of what will be many penmanship contests. I don't expect to win, but I know that my handwriting is very neat and needless to say, very legible. It's a skill that I've inherited from my mother who has flawless handwriting.
A week later, the winner is announced. It's me! I'm excited as Mrs. Johnson tells me to receive my prize. I walk to the front of the room where Mrs. Johnson smiles at me from underneath her oversized reading glasses. She hands me a roll of glossy paper tied iwith red ribbon. I take my prize and I can feel the paper squeak underneathmy fingers. I unroll the paper and reveal to the rest of the class a poster of a puppy.
A fake puppy?! That's what I win for having the most amazing handwriting in the 2nd grade? Two months later, Micheal Leony wins a set of paints. I'm quite jealous.
Since I've started residency, I've gotten multiple compliments on how legible my writing is from both clerks and upper level residents. See what sleep deprivation does to you?!!
Later I get a call from both pharmacy and the floor nurses asking about my orders. I clarify my orders. Next I get a call from the charge nurse who wants me to come up to the floor to rewrite the orders because they're illegible. I refuse, saying that I've already clarified the orders multiple times to pharmacy and to the nurse covering the patient.
At 6 am, my upper level calls me. "Hey, whippersnapper. The nurses can't read your orders."
"I'll go rewrite them."
I go up to the floor and rewrite the orders. I glance at what I wrote before and realize how illegible they are. Not only that but it looks like I was smoking crack and writing the orders. On the admission orders, I clearly wrote and crossed off: "Follow up with primary care physician in 3-4 days," something that you usually write on discharge orders. Oops.
It's the second grade and we've just finished the first of what will be many penmanship contests. I don't expect to win, but I know that my handwriting is very neat and needless to say, very legible. It's a skill that I've inherited from my mother who has flawless handwriting.
A week later, the winner is announced. It's me! I'm excited as Mrs. Johnson tells me to receive my prize. I walk to the front of the room where Mrs. Johnson smiles at me from underneath her oversized reading glasses. She hands me a roll of glossy paper tied iwith red ribbon. I take my prize and I can feel the paper squeak underneathmy fingers. I unroll the paper and reveal to the rest of the class a poster of a puppy.
A fake puppy?! That's what I win for having the most amazing handwriting in the 2nd grade? Two months later, Micheal Leony wins a set of paints. I'm quite jealous.
Since I've started residency, I've gotten multiple compliments on how legible my writing is from both clerks and upper level residents. See what sleep deprivation does to you?!!
Wednesday, February 07, 2007
And now to formally introduce an old friend....
... namely, the DOSA! Motivated by a comment on my previous post, I would like to take this opportunity to briefly introduce the dosa to all my blog readers. This is an important moment in the history of this blog, because to know the dosa is, essentially, to know me. To know the dosa means that you know my people. To know the dosa means that you understand LIFE as speak of it. To know the dosa means that your stomach will thank you for the rest of your life.
Shall we begin? Gonzo I hope you are taking notes.
The dosa is a vital aspect of South Indian cuisine. It's made from blending rice and lentils with water, and then you leave it to ferment overnight (my mother also adds some soybeans, which helps make it more nutritious with some added protein). The next morning you have this beautiful creamy light dough, which you then pour over a hot pan in the same way you would make a pancake. The effect is a crepe-like pancake, but much lighter and thinner than an American pancake. You serve it with spicy potatoes, or spicy lentil soup, or any kind of chutney you want. I prefer my dosas with sambar (the spicy lentil soup). You can eat dosa for breakfast, but also for lunch and dinner. It's works as any kind of meal!
There are many ways to eat a dosa... but that's another discussion.
Other important points...! The best places to get one in Houston in my opinion are at Madras Pavillion near 59 and Kirby and my personal favorite... Balaji Bhavan at 59 and Hillcroft. God bless Balaji Bhavan and their $4.00 dinner dosas. I do miss that place!
The best place in Atlanta to get a dosa is at Madras Saravana Bhavan on Lawrencille Hwy. I recommend the Mysore Masala Dosa! Sooooo GOOOD!
Ok, now you a lil more about the dosa, and you can say you know a lil more about me.
Shall we begin? Gonzo I hope you are taking notes.
The dosa is a vital aspect of South Indian cuisine. It's made from blending rice and lentils with water, and then you leave it to ferment overnight (my mother also adds some soybeans, which helps make it more nutritious with some added protein). The next morning you have this beautiful creamy light dough, which you then pour over a hot pan in the same way you would make a pancake. The effect is a crepe-like pancake, but much lighter and thinner than an American pancake. You serve it with spicy potatoes, or spicy lentil soup, or any kind of chutney you want. I prefer my dosas with sambar (the spicy lentil soup). You can eat dosa for breakfast, but also for lunch and dinner. It's works as any kind of meal!
There are many ways to eat a dosa... but that's another discussion.
Other important points...! The best places to get one in Houston in my opinion are at Madras Pavillion near 59 and Kirby and my personal favorite... Balaji Bhavan at 59 and Hillcroft. God bless Balaji Bhavan and their $4.00 dinner dosas. I do miss that place!
The best place in Atlanta to get a dosa is at Madras Saravana Bhavan on Lawrencille Hwy. I recommend the Mysore Masala Dosa! Sooooo GOOOD!
Ok, now you a lil more about the dosa, and you can say you know a lil more about me.
Tuesday, February 06, 2007
A dosa for me, and a dosa for you, I like to eat dosa in a big brown shoe
I'd like to make a plug for one of the greatest ideas ever known to man OR womankind!!!
Are you sitting down?
You sure you're ready??
Here it is: UNLIMITED DOSA NIGHT at Chowpati's!!!
Get this: For just under ten dollars, you get to eat unlimited dosas of all kinds! There's dosas with cheese! Dosas with pav bhaji! Spinach Dosas! Paper Roast Dosas! Vegetable Dosa! And more!!!
I swear someone didn't pay me to write this post! It's just that I just came from having dinner there on UNLIMITED DOSA NIGHT and my myenteric plexus nerves are conducting like they never have before!
Of note, I just had dinner with Melanie and Rima. Rima and I originally made the plans. I invited Melanie to come along. Here's how the coversation went, which is kinda funny if you konw Melanie, a super nice co-intern of mine who's also a preacher's wife, who's also from Minnesota and has the super cute accent to match (it's the kind of accent that give you warm fuzzies).
"Hey Mel! Wanna come celebrate UNLIMITED DOSA NIGHT with me and Rima?"
"Oohhhh! That sounds sooooo yummy!"
"Yeah it's me and Rima... I love for you to come!"
"Ooohhhhh! But I don't want to be the third white wheel!"
I eventually convinced her to come so we could make a complete "Oreo cookie" and I think her Auerbach synapses were going a little wild by the end too.
Monday, February 05, 2007
Why I love working in a children's hospital
It's cuz you get to do stupid stuff like this:
In the middle of rounds today, I heard the screeching sounds of a toy monkey. I look to my left and see one of the Cystic Fibrosis kids playing with my co-intern. They have this slingshot toy monkey that screeches with a high pitched sound when catapulted into the air. I can't miss this golden opportunity.
I leave my team (including my attending!) for about half a minute and yell to my co-intern, "Hey Drossner! Over here!" The patient and my colleague turn to me, and my co-intern prepares to sling the monkey towards me. I crouch, ready to catch the flying monkey. Drossner prepares his shot. The monkey goes FLYING through the halls of the hospital at 10:30 in the morning and spares no set of cerumen free ears from his ridiculously high frequency yell. He flies at me too fast, and I wasn't able to catch him.
It doesn't matter.
I prepare to slingshot him back at Drossner and the patient. I pull back on the long sleeves of my white coat. I leave my stethoscope at the nurses counter. I have to do this right. I stick my fingers in the the monkey's fingers and stretch back at the monkey's legs.
I let go... SHVOOM!
He flies through the air, screaming yet one more time. Drossner catches him, and then places the monkey playfully on the patient's head full of blond hair. I step away from the open hallway and rejoin my attending and prepare to present the next patient.
Light Bulb
You know you need to sign up for cable during the college basketball season when you find yourself screaming at the computer screen every 30 seconds that the espn.com live scoreboard refreshes during the final mintues of the UConn-Syracuse game. That's a two game winning streak, baby! Maybe we'll make someone's bracket this week.
The Borrelia Blues
I'm a junior in high school. It's only the dawn of winter in East Lyme, CT although it feels as though January's chill has settled upon the concrete surface of the tennis courts at Connecticut College, where the tournament for our high school's conference is taking place. I'm wearing my tennis skirt only out of courtesy for the sake of a team uniform, with bulky wind pants swishing beneath the skirt's white pleats. I see my parter bouncing her tennis ball as she heads towards the baseline, and I take my place closer to the net. We are facing match point. We know we shouldn't be. We're inherently better than the opponents that are standing across from us with their knees bent, ready to pounce upon whatever Liz 'serves' their way. But we're here, and there's probably no way of getting out. Or is there?
A surge of confidence overwhelms me as I raise my racket to head level. Yes, we're facing match point, but haven't so many done this before and raced onto victory? The 20 degree weather that seems to stiffen my muscles more with each passing moment all of a sudden becomes something I can ignore. I turn my head over my left shoulder, seeing Liz prepare for her serve. She's got a great serve, one that I've depended on for the whole season. There haven't been many matches we lost the whole season.
"Cummon Lizzie Belle," I say, using my nickname for her, "we can do this!" She pauses and looks up at me from her position just beyond the baseline.
This isn't a moment of life or death, or anywhere even CLOSE to that. Yet, I will never forget the look on her face. It's one of defeat. Her eyes are blank, her shoulders slump. She couldn't even get the ball over the court if she wanted to with posture like that.
"Yeah, ok" she says out of courtesy, not even attempting to force a smile.
I can't remember if she double faulted that point, or if the other team won the match by the way of a winner. We might have also made an error. I just remember that we lost that next point. And I wanted to win it. But, I was helpless as the player at net.
For some reason, I'm thinking about that moment so many years ago as I write this entry. It's because of how my day went. My morning was awful. Not because it had to be, but because of my attitude. I had 10 complicated patients to see and write notes on before 7:30 conference. I hadn't seen them since Saturday when I was post-call. I was scrambling around trying to keep everything straight and before I know it, it's 7:30 and I still have 3 patients to see, whom I somehow see in the next 15 minutes.
Around 7:45, I walked toward the conference room ANGRY. How come I have to be so late to conference, when I feel it's my protected time to learn about a topic? Why can't I be more efficient? Why is our system the way it is? Why can I NEVER find charts in the morning when I really need them to be where they're supposed to me so I can do my job? Why do the nurses give me such a hard time when I take away their charts from their oh so special signout during shift change?
I angrily turn the knob on the door entering into the conference, where I'm surpised to find only a few residents sitting around talking. There is no presenter. There is no lecture.
"No need to sign in," says the chief,"there isn't a lecture today."
I do hear what she says, but decide that it doesn't matter whether there is or isn't a lecture. I sign my name on the sign in sheet. Dammit, someone is going to read this dumb sheet that indicates that I made the effort to come to this dumb non-existent lecture. With a scowl on my face, I sit down in a chair and try to take some deep yoga-like breaths to calm my sympathetic nervous system down. It's of no use... the damn catecholamines have already been released. I almost let the tears roll in front of my collegues, something that my upper level would tease me about later, "Hey whippersnapper, if you feel like your eyes are about to squirt, lemme know and I'll write some of your notes."
Now that I think about it, it was so dumb to let myself get all worked up that way. The rest of the day was great. Even though my upper level wasn't around, I felt like I managed the team well. Morning rounds was really efficient. I knew everything my attending wanted to know. We discharged 3 patients. We saw almost everyone except for one patient. I was even able to tell my attending about a disease one of our patients had since he wasn't able to read up on it during the weekend. For once, I had read about it. We didn't break for lunch until 1:30 and I was very tired and hungry, but I felt good. The rest of the day was no exception. By the time evening signout rolled around, I was quirky and cooky and back to my old self, having fun with medicine.
What does this have to do with that tennis match so many years ago? It really is ALL about attitude in how your approach your day. You can go for it - you can give just a little bit more effort, or you can resign yourself to a losing score even before the last point has been played. I wonder how that match may have ended if I had been serving that day, or if the ball somehow happened to come my way near the net. I had the right attitude, the one required to get the win. Maybe a bit too much of a sports cliche here, but I kinda liked how my day ended :) See, that's a smile!
A surge of confidence overwhelms me as I raise my racket to head level. Yes, we're facing match point, but haven't so many done this before and raced onto victory? The 20 degree weather that seems to stiffen my muscles more with each passing moment all of a sudden becomes something I can ignore. I turn my head over my left shoulder, seeing Liz prepare for her serve. She's got a great serve, one that I've depended on for the whole season. There haven't been many matches we lost the whole season.
"Cummon Lizzie Belle," I say, using my nickname for her, "we can do this!" She pauses and looks up at me from her position just beyond the baseline.
This isn't a moment of life or death, or anywhere even CLOSE to that. Yet, I will never forget the look on her face. It's one of defeat. Her eyes are blank, her shoulders slump. She couldn't even get the ball over the court if she wanted to with posture like that.
"Yeah, ok" she says out of courtesy, not even attempting to force a smile.
I can't remember if she double faulted that point, or if the other team won the match by the way of a winner. We might have also made an error. I just remember that we lost that next point. And I wanted to win it. But, I was helpless as the player at net.
For some reason, I'm thinking about that moment so many years ago as I write this entry. It's because of how my day went. My morning was awful. Not because it had to be, but because of my attitude. I had 10 complicated patients to see and write notes on before 7:30 conference. I hadn't seen them since Saturday when I was post-call. I was scrambling around trying to keep everything straight and before I know it, it's 7:30 and I still have 3 patients to see, whom I somehow see in the next 15 minutes.
Around 7:45, I walked toward the conference room ANGRY. How come I have to be so late to conference, when I feel it's my protected time to learn about a topic? Why can't I be more efficient? Why is our system the way it is? Why can I NEVER find charts in the morning when I really need them to be where they're supposed to me so I can do my job? Why do the nurses give me such a hard time when I take away their charts from their oh so special signout during shift change?
I angrily turn the knob on the door entering into the conference, where I'm surpised to find only a few residents sitting around talking. There is no presenter. There is no lecture.
"No need to sign in," says the chief,"there isn't a lecture today."
I do hear what she says, but decide that it doesn't matter whether there is or isn't a lecture. I sign my name on the sign in sheet. Dammit, someone is going to read this dumb sheet that indicates that I made the effort to come to this dumb non-existent lecture. With a scowl on my face, I sit down in a chair and try to take some deep yoga-like breaths to calm my sympathetic nervous system down. It's of no use... the damn catecholamines have already been released. I almost let the tears roll in front of my collegues, something that my upper level would tease me about later, "Hey whippersnapper, if you feel like your eyes are about to squirt, lemme know and I'll write some of your notes."
Now that I think about it, it was so dumb to let myself get all worked up that way. The rest of the day was great. Even though my upper level wasn't around, I felt like I managed the team well. Morning rounds was really efficient. I knew everything my attending wanted to know. We discharged 3 patients. We saw almost everyone except for one patient. I was even able to tell my attending about a disease one of our patients had since he wasn't able to read up on it during the weekend. For once, I had read about it. We didn't break for lunch until 1:30 and I was very tired and hungry, but I felt good. The rest of the day was no exception. By the time evening signout rolled around, I was quirky and cooky and back to my old self, having fun with medicine.
What does this have to do with that tennis match so many years ago? It really is ALL about attitude in how your approach your day. You can go for it - you can give just a little bit more effort, or you can resign yourself to a losing score even before the last point has been played. I wonder how that match may have ended if I had been serving that day, or if the ball somehow happened to come my way near the net. I had the right attitude, the one required to get the win. Maybe a bit too much of a sports cliche here, but I kinda liked how my day ended :) See, that's a smile!
Sunday, February 04, 2007
More than halfway
It's Sunday afternoon, and I'm checking my schedule online. After this week, there are only 5 more rotations before I become a second year resident. I remember checking my schedule online at the very beginning of intern year, wondering how time would pass, wondering what I would be feeling as I moved closer to the end of the first year.
And now I'm here, over halfway through, feeling mixed emotions.
I know I have gained confidence in my abilities. I can carry a heavy patient load. I can assess as to whether a child needs immediate care or not. I know I can handle working nights. I know I can use what little time off I do have to take care of myself. I know I can make time for the important things in my life such as friends, family, music and the spiritual side of me.
Even though all of this is true, there are many many moments of self-doubt and even envy. There are so many times that I wish I was smarter. I wish I had thought of things sooner that my upper level or attending brings up on rounds. I wish I had more time to read when I have time off. There are even times I doubt my choice of profession. And I envy others with things that I don't have, like those who have that special someone in their lives who will never leave them and stick with them even during these tough times. Those who have different professions that allow them to have weekends off (I CANNOT for the life of me imagine a life with weekends off!).
Sometimes I wonder how it is that at this more-than-halfway-through mark, that I'm not more competent that I am. Have I really learned anything at all in 7 months?
It does get lonely. Those are the feelings that I hate and dread the most. Those nights on call, when the hospital is more quiet than it is during the day, and you get the call by the nurse and it's a lonely walk up to the 5th floor to assess the child. It's during those times that I wish I had someone to call and talk to.
But I can't stop, and I don't want to stop. I love my job. I love medicine. I love the challenges and the patients and the families. I love the weird presentations and the intellectual quest to figure things out. I love the times when I get to steal chocolate ice cream from 5 East the night I'm on call. I also love working with my collegues who challenge me to do better every day. I love seeing my patients get better and go home. I love making the diagnosis!
I can't stop, and I don't want to stop. Residency hasn't beaten it out of me yet and hopefully never will. There's too much more that I want to learn. And I've got a bit more that I want to show off to the world of medicine.
And now I'm here, over halfway through, feeling mixed emotions.
I know I have gained confidence in my abilities. I can carry a heavy patient load. I can assess as to whether a child needs immediate care or not. I know I can handle working nights. I know I can use what little time off I do have to take care of myself. I know I can make time for the important things in my life such as friends, family, music and the spiritual side of me.
Even though all of this is true, there are many many moments of self-doubt and even envy. There are so many times that I wish I was smarter. I wish I had thought of things sooner that my upper level or attending brings up on rounds. I wish I had more time to read when I have time off. There are even times I doubt my choice of profession. And I envy others with things that I don't have, like those who have that special someone in their lives who will never leave them and stick with them even during these tough times. Those who have different professions that allow them to have weekends off (I CANNOT for the life of me imagine a life with weekends off!).
Sometimes I wonder how it is that at this more-than-halfway-through mark, that I'm not more competent that I am. Have I really learned anything at all in 7 months?
It does get lonely. Those are the feelings that I hate and dread the most. Those nights on call, when the hospital is more quiet than it is during the day, and you get the call by the nurse and it's a lonely walk up to the 5th floor to assess the child. It's during those times that I wish I had someone to call and talk to.
But I can't stop, and I don't want to stop. I love my job. I love medicine. I love the challenges and the patients and the families. I love the weird presentations and the intellectual quest to figure things out. I love the times when I get to steal chocolate ice cream from 5 East the night I'm on call. I also love working with my collegues who challenge me to do better every day. I love seeing my patients get better and go home. I love making the diagnosis!
I can't stop, and I don't want to stop. Residency hasn't beaten it out of me yet and hopefully never will. There's too much more that I want to learn. And I've got a bit more that I want to show off to the world of medicine.
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