back, with an embarrassing story

So the other day I'm working in the peds ER, doing all sorts of peds-ER-related things... which mostly involve reassuring parents, and wondering why they bring non-emergencies to the Emergency Room where they have to wait 5 hours, instead of to their pediatrician where they have to wait maybe 45 minutes.  The world is full of mysteries.

But SOME Emergency Room visits are legit, such as the small child I saw next with a big deep nasty-looking cut.  Ouch.  Definitely needed stitches.  So the attending and the ER tech (both guys, which is vaguely pertinent) and I get everything ready, numb the kid up, and set about repairing skin.

ATTENDING:

[pulling back skin flap] Whew, this is a deep one.

EMILY:

[holding child's extremity still so attending can work]

Wow, it is. Yikes.

CHILD'S MOTHER:

[turns slightly pale and quietly leaves the room]

ATTENDING:

[begins to squirt sterile water under skin flap to clean it]

CHILD'S WOUND:

[begins oozing copious amounts of blood]

CHILD'S OLDER BROTHER:

[turns slightly pale and quietly leaves the room]

EMILY'S THOUGHTS:

...Is it getting hot in here?

ATTENDING:

[lines up skin and prepares to suture]

EMILY'S THOUGHTS:

...Um, okay.  Feeling kinda woozy.  This is not good.

CHILD'S FATHER:

[stoically watches from a corner of the room, arms folded]

ATTENDING:

[lifting skin flap once more and dabbing away blood]

Oooh.  I think that might be the bone we can see in there.  Or the tendon at least.

ER TECH:

[peers calmly at wound, shaking head in sympathy for child]

EMILY:

[also peers at wound, genuinely interested]

EMILY'S THOUGHTS:

Wow, that's kinda cool.  I mean, not for the kid, but... OKAY, WHY AM I FEELING DIZZY?!  BLOOD DOES NOT BOTHER ME!!

ATTENDING:

[begins suturing]

EMILY'S THOUGHTS:

What the heck, body?!  You can't go all vasovagal on me now!

CHILD'S FATHER:

[continues to stoically observe]

EMILY:

[surreptitiously leans on table in an attempt to recover without being noticed]

EMILY'S THOUGHTS:

Must.  Not.  Be.  Nauseous.

ATTENDING:

[wields needle-holder with expertise]

EMILY'S THOUGHTS:

Okay, fine.  I give up.  You win this time, autonomic nervous system.  I shake my fist at you!  ...Only not literally, because that would be weird right now.

EMILY:

[pulling off sterile gloves, sheepishly]

I um... this is kind of embarrassing, but I think I need to go sit down for a minute.

ATTENDING:

[looks at her mildly]

ER TECH:

[with mild concern]

You are looking a little pale.

EMILY:

[halfway out the door, almost running]

I'm really sorry!!

EMILY'S THOUGHTS:

Wow.  I am super-lame.  And apparently, super-girly... and not in a good way.

tv show pet peeve

Picture this scene (you know you've seen it many a time):

A terrible accident has occurred, and now a character whom you've come to know and love is lying in a hospital bed, barely clinging to life (and, I might add, looking remarkably attractive and well-groomed for someone so Critically Ill... usually without even a nasal cannula, much less an endotracheal tube, to spoil the effect).

Suddenly, the rhythmic beeping in the background gives way to an ominous hum, and you know the terrible truth. The heart monitor swings into view to show you the all-too-recognizable flatline.


Instantly, doctors and nurses rush in. What is the first thing they do? Check the Airway, Breathing, Circulation? Start chest compressions? No way, baby, because in medical drama there is nothing more glamorous than the all-powerful defibrillator. One of the (also remarkably attractive) doctors grabs those paddles, slams them on the patient's bare chest, yells "CLEAR!" and the patient jerks violently.


Lather, rinse, repeat. This goes on for a grand total of about 30 seconds (despite the fact that real codes can last more like 30 minutes at times... and do, in fact, typically involve chest compressions) before the Doctor In Charge wipes his/her brow, fights back tears, and says, forcing stoicism, "Call it."

So what is the pet peeve here? The unlikely attractiveness of... well, everyone? The fast-forwarded code blue? The lack of oxygen therapy (or any kind of medical device) on a patient who is evidently Hovering Near Death? Actually, no.

People. Asystole is NOT a freakin' SHOCKABLE RHYTHM!

four things

Thing #1- Hello, smog. Lovely to see you this fine morning as I gaze from the hospital window.


Thing #2- Why do I always manage to spill coffee on myself the mornings when I'm post-call?

Thing #3- The computers in the pediatric conference room are using a 10-year-old operating system. Awesome.


Thing #4- My school-distributed pager has them beat, though, because whenever I change the battery and the date resets, it asks me if I would like to set the year to 1999. Um, no.

five stars

So today I'm On Call. This basically means I'm in the hospital for 24-30 hours, doing admissions, helping out the residents, etc. I don't have to work the entire time, necessarily; I just have to be there. There's actually a room where I can sleep if/when I get the chance. (Incidentally, the reason residents are called "residents" is that they used to be On Call in the hospital all the time. Residents of the hospital, you see.)

And now, without further ado, this is the peds student call room, where I'll be spending the night tonight!

Look! Swanky, no?


I'll also have a desk (of sorts) and even my own sink. What more could a girl want?


I especially like how, if you look closely, you can see where past students have been practicing their surgical knot-tying skills.

(I really do like it, by the way; I'm not just saying that. It makes me feel sort of connected, in a weird way... to all med students, past and future, who have ever sat in a stark call room in ill-fitting scrubs, whiling away the wee hours of the morning practicing the intricacies of surgical knots on leftover sutures donated by some thoughtful scrub nurse... or something along the same lines. Oh, med school. How very un-glamorous you are.)

marshmallow world

View from the Pediatric Student call room in the hospital:


Some of us had to dig out our cars, but even with a Level 2 snow emergency in place, all 10 people on the ward team made it to morning sign-out on time!

(Because kids still get sick when there's a 9-inch snowfall within a 24-hour period. In case you didn't realize.)

the truth, the whole truth, and nothing but the truth

In pediatrics, usually one finds oneself taking the history from Someone Other Than The Patient. Because, y'know, the patient is a wailing 21-month-old. So for every pediatric H&P, it's important to include the line "history given by ______" and it's not uncommon to add a comment on the apparent reliability of said history-giver.

More often than not, the historian's reliability-- or lack thereof-- is pretty apparent. For example:

EMILY:
So, has she ever had any other medical problems?

PATIENT'S MOM:
Nope, nothing else.

EMILY:
Great. [writes this down] And does she take any medications?

PATIENT'S MOM:
Um, no.

EMILY:
Okay. Any surgeries?

PATIENT'S MOM:
Just the biopsy I mentioned.

EMILY:
Okay, good. [makes a note of this, then turns the page] Now I'm going to ask about family history, okay? Anyone in the family have a history of asthma?

PATIENT'S MOM:
Well, she does. [indicates the patient]

EMILY:
[taken aback] Oh... she has asthma?? Um, okay. [flips back to the Past Medical History section and adds this] Does she take any medications for that?

PATIENT'S MOM:
Well, yeah. Singulair, and Pulmicort. And albuterol.

EMILY:
[resignedly writing this down] Do you happen to know the doses?

PATIENT'S MOM:
[looking puzzled] No.

EMILY:
Okay. That's okay. Now. Anyone in the family have seizures?

PATIENT'S MOM:
[indicating the patient again] Well, she had seizures. That's why she's on the Keppra.

EMILY:
[sighing, flipping back to the Past Medical History section again and writing this down] Okay. Seizures. Keppra. Got it.

[after a few more questions]

EMILY:
Has anyone ever told you she had a heart murmur or anything like that?

PATIENT'S MOM:
Yeah, she had one when she was a baby, but not anymore.

EMILY:
Oh, okay. Did she have a congenital heart defect?

PATIENT'S MOM:
Yeah, a PDA.

EMILY:
[remembering the lack of surgical history] Oh, so they just closed that using medicine?

PATIENT'S MOM:
Oh, no, she needed surgery for that.

EMILY:
[not even surprised anymore]

can't we all just get along?

Anyone who has ever gone through medical education has some familiarity with the type of nurse depicted in this comic. (For those too lazy to click on the link, I'm talking about the Nurse Who Eats Medical Students For Breakfast.) I had a run-in with just such a nurse today, which I shall now replay for your enjoyment.

EMILY:

[writing busily in chart while copying lab values from computer-on-wheels]

NURSEZILLA:

[approaching with two nursing students in tow] Oh, THERE it is! We were looking all over for that! I need to use it.

EMILY:

[thinking she means the computer] Oh sure, no problem, let me just log out.

NURSEZILLA:

[impatiently] Yeah, the patient's going down to ultrasound, so I need the chart.

EMILY:

Oh... um... okay... [removes her progress note from the chart so she can finish writing it]

NURSEZILLA:

[grabbing the chart] Is that just your note, or is someone else's on the back of the page?

EMILY:

Oh, right, there is another note on the back.

NURSEZILLA:

[in a tolerantly amused tone, as though speaking to an idiot] See... they'll need that information. We have to make sure allllll the information goes with the patient.

EMILY:

Right, of course. [starts to put it back, then realizes Nursezilla has now opened the chart to a different place]

NURSEZILLA:

[with an air of great patience and long-suffering] Nope, not there. You have to look at what you're doing. [turns to nursing students] See, now if we do things right the first time, then mistakes won't be made.

EMILY:

[fantasizes about beating Nursezilla over the head with the chart, but instead turns back to the computer and starts copying down all the labs... again. sigh.]

more cuteness

My favorite patient this week so far has been a 2-1/2 year old who, whenever I asked him, "Can I look in your ears?" "Can I listen to your heart?" "Can I feel your belly?" would grin and say "No way, Jose!" in his squeaky little toddler voice, and then giggle. And then let me do whatever anyway.

See? This is why I love peds!

interview season

Because of Jack being in the military, and thus already knowing where he matched, I limited my interviews to programs in the same geographical area. That means I only have five, and they're all in the same two-week span... which is good, because even just five is still enough to get sick and tired of them.

The basic outline for an interview day in pediatrics, I have learned, is generally as follows:

7:45 AM- Show up. Start consuming free bagels and coffee.
8-9 AM- Observe morning report.
9-10 AM- Hear a presentation (likely PowerPoint) about the program, designed to intrigue applicants and/or answer potential questions, likely repeating information given on the website.
10-11 AM- Two 30-minute interviews, where the most popular question seems to be, "So where do you see yourself, career-wise, in 10 years?"
11AM-12PM- Go on a tour of the hospital. Ignore growling stomach.
12-1 PM- Lunch. (Most common? Sandwiches. Most interesting? Indian food. Yum.) Talk to the current residents.
1-1:30 PM- Wrap-up talk, then leave.

Now, I am not stupid enough to actually type out my opinions of said programs and post them on the internet before Match Day. But I do have a favorite, yes. And I actually have a second-favorite, too.

After the interviews, the rest of the residency-application process is pretty easy. Make a rank list in February, get your answer in March. Can't wait until it's all over and I can relax (aka, freak out about something new).

the answer

Sorry I kept forgetting to post and instead left the blog on a cliffhanger. The Navy gave Jack his first choice for residency!

Merry Christmas-eve-eve!

down to the wire

Two days from now, the military match results come out, which means that the Navy tells Jack where he'll do his residency... and thus, where we'll spend the next three years-- and to which location I'll have to limit my rank list in a few months.

I've been telling everyone for weeks that I'm no longer freaking out about this. God knows what He's doing, everything will work out, I'm sure it'll be fine, I got the worrying out of my system months ago, etc. etc. etc. All true.

But realizing that it's happening NOW? That in LESS THAN 48 HOURS the results will be final? That a large governmental bureaucracy is about to announce its decision that will affect the REST OF OUR LIVES in a rather large way?

Yeah, I'd be lying if I said I wasn't nervous.

(This also has the effect of causing me to avoid, for the past week or so, my usual hobby of intermittently checking out apartments on Craigslist in the cities where we could be sent. Because apparently my subconscious has decided that by looking, I would somehow affect the decision and jinx our entire future. Logical, no?)

exposé

First, a warning, prominently posted in the student break room of the radiology department:


We were greeted on our first day of radiology with extensive exhortations not to take food or beverages into the reading room (the room with all the computers where the radiologists work). The food rule, it was explained, was to avoid mice. Fair enough. Then we were told that beverages used to be allowed, until the day some hapless student dropped an unopened can of Coke on the floor and it exploded all over his attending. From that day forward, no drinks.

This news was heralded with some mild grumbling, of course, but we took it in stride.

Then, what did our innocent disbelieving eyes see, but this:


What is that, there, in his hand? we asked ourselves. What is that attending holding?


The answer? Coffee. (If you can't make it out in the blurry cell-phone close-up taken in a dark room, trust me. That's what it is.)

Was this for real? Surely it was just a fluke! After all, Beverages Aren't Allowed In The Reading Room.

Alas, we learned it was not just an aberration, as we became more and more jaded over the following weeks. Observe (and note that all the photos in this post were taken over the course of one day).

Illegal water bottle:


Illegal pop can:


Illegal (and very hard to see from across the room, I'll grant) coffee:


Yes, it's true. With our naive acceptance of the "no beverages" rule, we hadn't realized that the rule apparently only applied to us. Students may not take drinks into the reading room, because evidently students are not capable of holding drinks.

It's good to know we'll gain this valuable skill once we're granted our MDs, isn't it?

adventures in the reading room

I'm currently taking a radiology rotation. Now, at most schools, radiology rotations entail strolling down to the reading room, looking at x-rays and CT scans with the doctors for a couple hours, then heading home. At our school, the radiology rotations entail 40 hours a week of... watching radiologists do their jobs.


In any case, the rotation is divided into four weeks of different types of images. The first week, I was assigned to watch musculoskeletal images being read (x-rays of broken bones, knee MRIs, etc.).... this week it's neuro (brain CT scans, spine x-rays)... next week it's gastrointestinal/genitourinary stuff, and the fourth week it'll be cardiopulmonary images.

Now we have a weekly schedule telling us which radiologist will be reading which types of images on any given day, so we know whom we'll be with on any given day. The other morning I was assigned to Dr. E, with Dr. S scheduled for the afternoon.

The morning went fine... Dr. E was nice and a good teacher. Then we went to lunch conference, which was being led by my resident. Halfway through, another resident stuck his head in and told him, "Oh hey, apparently Dr. S isn't going to be in until 3:30 or 4."

Now, here is a vitally important difference between third year and fourth year. My third-year self, upon hearing this news, would have gotten dejected, sighed, and thought resignedly, "I guess I'm going to be here late." My fourth-year self immediately thought, "Oh heck no!!!" and instantly began planning how to get out of there.

As soon as the hour was over and we began filing out of the room, I turned to my resident and said incredulously, "Is Dr. S really not going to be here until 4??" ...hoping that he would realize my situation and say, "Oh, you know what? There's no point in you sticking around until then. Why don't you go home?" But instead, he just shrugged. Hmph. Well, that didn't work.

Upon re-entering the reading room, I spotted Dr. E still sitting at a computer monitor. I positioned myself strategically beside him, hoping that he was just finishing up some images from the morning and would soon leave... giving me the perfect opportunity to leave as well. But instead he smiled and said, "Oh, I'm not doing neuro this afternoon, but you're welcome to stick with me anyway," before turning back to the screen.

Oh no no no no no. This would not do. I might very well learn valuable information from Dr. E if I stayed with him through the afternoon, but I was not about to risk being kept there with Dr. E until 3:45, and then having Dr. S show up and being obliged to follow him until who-knows-when.

So I did what a third-year student would never do. I waited until an appropriate pause in his dictating, then spoke up smilingly, "Um, Dr. E? If you're not doing neuro this afternoon, and Dr. S isn't going to be here until 4, is it okay if I just go home and get some studying done?" "Oh, sure, go ahead," he replied benignly.

Fourth year? Is awesome.

oooh, burn

In yesterday's inbox:

We have begun our review of applications for possible interview invitations at [prestigious medical training program]. We have over 700 applicants and can only offer approximately 250 interviews. We have reviewed your application but are unsure at this point if we will be able to offer you an interview. We would like to finish our review of applications and see if we have enough space left to schedule applicants on our "hold" list. We hope to be able to extend you a firm offer to interview in the near future.

Ouch, I'm on the hold list! I wonder, is that like the blacklist? Or the sh--list? Evidently not at all like the wishlist. Hmph.

cool/uncool

One problem often faced in medical education is that, when seeing a particularly rare, serious, or classic presentation of a disease, the first impulse for students and residents is usually to say, “Oh, cool!” …after which, the immediate second impulse is to feel like an insensitive jerk.

I’m guilty of this myself. Of course I don’t think it’s cool that the patient who was admitted with anemia is discharged with a diagnosis of soon-to-be renal failure. But following the course, and observing the lines of reasoning, and then watching the pathologist point out the problem on the biopsy? That’s pretty exciting, from a learner’s perspective. (The resident, looking at the slide, exclaimed, “Wow, that’s so cool! --Well, I mean, it’s not cool for the patient…”)

On my Ob-Gyn rotation last year, a fellow student and I were discussing this problem. We were both killing time in the pre-op area, and I was animatedly describing the surgery I had just seen, in which the middle-aged woman who went in for a hysterectomy (she had endometriosis or something, I think) was discovered, on the operating table, to have what looked like cancer.

And all of a sudden we looked at each other and realized how much that sucked, and how weird and kind of disturbing it was that we were smiling and chattering about it like football fans reliving a particularly thrilling touchdown. So right then and there we coined a new word for such situations: learnful.

Not that I actually say “learnful” in most situations… because really, almost no one would know what I meant, they’d give me weird looks, and I’d be no better off. But still, it’s a good way to think about it. The best way to learn about disease is by seeing it, and yes, learning is cool. But we’re still talking about real people here, and real lives being ruined. And that is definitely not cool.

nerd humor

A new medical joke, as related to me by my resident today:


So a bunch of doctors go duck hunting. Before long, a huge flock of ducks flies overhead.

The family practitioner looks up and says, "Looks like a duck... sounds like a duck... let me just check with a specialist."

The internist looks up and says, "Looks like a duck... sounds like a duck... I'd better go look it up just to be sure."

The psychiatrist looks up and says, "Looks like a duck... sounds like a duck... but does it know it's a duck?"

The pediatrician looks up and says, "Looks like a duck... sounds like a duck... aww, but he probably has little baby duckies and a cute little mama duck waiting for him at home..." then puts the gun down and bursts into tears.

The surgeon looks up and immediately raises his gun and shoots. Then he turns to the pathologist and says, "Go make sure that was a duck."

deep in the heeaaaart.....

...of Texas, people. Texas.

We traveled this past week to go take Step II CS, the last part of our Big Bad Board Exam. It's just like an OSCE (which is a test where you interview/examine a pretend patient), only there are 12 pretend patients so it's an all-day thing, and it costs around $1000 to take, and it's a licensing exam so it's nationally standardized and really important. And also, in Houston.

This is how we knew we were in Texas:
Very... direct. ("That's not a threat, y'all. It's just a statement of fact.")

(Also, the test went fine.)

sunrise, sunrise, looks like morning in your eyes

Sunday morning at the hospital. An almost-empty parking lot and V-shaped flocks of geese flying overhead.

tragedy

We have a patient on the service this week, an elderly lady who recently had a massive stroke. As in, she was fine when she went to bed, and woke up the next day unable to speak or swallow properly or move her right side. It's an interesting and difficult case, because since she is unable to talk, it's hard for anyone to know just how much she still understands, beneath it all.

But I was reminded today-- and it's good to be reminded-- that she's not just an "interesting case."

Her husband was in the room when we went in to see her, sitting in a wheelchair facing his wife. The attending asked cordially, "So how is everyone doing today?" And the patient's husband looked at him and replied, "Well, I'm not doing so good." And two tears ran down his face as he looked back at his wife. And at the end, before we left, our attending put his hand on the man's shoulder and said, "We don't know just how much she understands. But she knows you're here with her." "I hope so," he replied sadly.

Their granddaughter had informed us that they've been married for 57 years. And I thought of how many Christmases and sunsets and cups of coffee and Sunday dinners they had shared together, and how young and beautiful she probably was when they got married, and all of a sudden she wasn't just an old lady who couldn't talk, and he wasn't just a hospital visitor. For a moment they were the hero and heroine of some great Shakespearean tragedy or epic tale.

I once read a quote-- I can't remember it exactly, or even who said it-- but the idea was... if we could know all the joys and sorrows of a person's life to their fullest extent, then every life would be as fascinating to us as the greatest novel.

my life as a smuggler

Bringing my contraband coffee brazenly into semi-forbidden areas of the hospital. Oh, the excitement! The danger!

(What? Extra caffeine is necessary when you get up at 4 AM.)