The Bird in Flight - Daily Life

Good Times in PA

nospam@example.com (Randall) — Sun, 13 May 2007 23:37:52 -0600

Want to see what the life of EM residents are while their IM/Peds counterparts slave away 80+ hours a week? Building swing sets and stuff... Anyways, until Dan gets off his lazy butt and makes a post, I'll post some pics of the girls that he's sending me. As you can see, they love their new swing set.

More pictures below the fold...

Continue reading "Good Times in PA"

So cold...

nospam@example.com (Randall) — Sat, 24 Feb 2007 00:06:21 -0700

Wow, it's been a while since I've posted anything... I have two new cameras - a canon sd800 that I got as a replacement when my trusty old s230 became not-so-trusty (thank goodness for warrantees) and a panasonic dmc-fz20 hand-me-down from my dad when he decided to go D-SLR. And the picture I post? From the cell phone, actually. *shrug*

So I finally feel competent as an intern. Seven admissions in an evening? No problem! I can do that without breaking a sweat, I might even be done with my paperwork by one AM... the little things, though, like knowing the all the lab values and culture results? umm... I might have to go back to medical school, as I swear I've lost all my med student skills. sigh.

Oh yeah, the picture. That's the view I get of the train station every morning, waiting for the train. 4:30AM, 30-40 degrees, the winds blowing by... it's pretty miserable. I can't even imagine having to deal with snow.

Top of the World

nospam@example.com (Randall) — Wed, 11 Oct 2006 01:42:38 -0600

I'm on the top of the world... looking down on creation...

Wow, done with my first medicine ward month! To say it was brutal would be kind. At times it felt like I was starting internship over, and well, yeah, I felt like an idiot every day. There's no doubt in my mind that some people hurt more because of me, and some folks suffered unnecessary injuries. I've never needed a good night's sleep more in my life.

Anyways, one of the few things that got me through were actually my call buddies - two of my fellow interns (whom I consider good friends now ^_^) were on call with me, and we always got into some sort of mischief. From the campfire (see two posts down) to breaking into the doctor's cafeteria at 2 am to get raisin bran to whatever else have you, the few minutes of play in the hours of work made for a much better experience. I'm gonna miss our little group.

The last night on call, we decided we wanted to see the city. Previously we had gotten on the roof (19th floor) but the walls were high and the stairwell to the 20th floor landing was locked behind a big door with a high voltage symbol. I had seen a landing on the 12th floor, so we tried to get there, but no luck, the walls were high around that terrace as well. On the other side of the hospital, we saw an open door to the 13th floor terrace, and although it was surrounded by high walls too, it was kind of cool just by it's odd design, and you could kind of see the city from the stairwell... not good enough.

Finally, we went back to the high voltage signed door on the 19th floor. I noticed the lock was the auto-locking kind, not an actual deadbolt... 15 seconds and 2 credit cards later, I had the lock open. (Hopefully no one from my residency office is reading this...) The promised land! Thus, the photo above, from a dizzying 20 stories up, with naught but a flimsy railing. At 2am, I just had to snap some more photos. And so, a photo of my partner in crime:

I had wanted to get a photo of all three of us, but someone didn't want to wake up to go exploring... Finally, the view I had lusted after:

A little hazy, but then again, LA always seems to be covered in that smog.

Around the campfire...

nospam@example.com (Randall) — Tue, 19 Sep 2006 19:18:55 -0600

Let's face it, Q4 sucks. There are few experiences as grueling as staying up for 30 straight hours, seeing patients through the night as your pager drags you from one hospital floor to the next; and at the end of it all, you get it do it again after 2 days.

I lucked out this month, though; two of my new friends (and fellow medpeds interns) happen to be on call with me! We're not on the same team and we otherwise wouldn't see each other at all, but we make it a point to page each other before dinner and before the midnight meal. The midnight meal in particular is a perfect time to find a little solace from the insanity of the hospital, a time when most patients are sleeping and we're each somewhere between admissions 3 and 4. So that's how, last night, we found ourselves on the roof of our hospital eating cereal and cheezit's.

It felt like an imaginary campfire of sorts, a small corridor surrounded by high walls and barbed wire and the open sky above. Luckily no one actually paged us while we were up there, although we didn't get to stay too long. The creaking and the groaning of a 75-year-old building can get to you, and that thump-thump-thump-buzz did sound like a zombie dragging a chainsaw across the ground, just about to turn the corner... Thus the photo above of my compatriots turning to see what just made that crashing sound.

Also, I've now definitively decided that, while the razr is a very nice phone, its camera sucks something terrible.

This is why we have residency, isn't it?

nospam@example.com (Randall) — Sun, 20 Aug 2006 16:45:00 -0600

Sorry no posts in a while, I haven't really touched my camera since residency started... but here's photo of my medpeds intern class of 2010. They're awesome, I love them to death. Anyways, my post is totally unrelated to this picture. ^_^

10 yo HM. Nephrotic syndrome. They say you never forget your first patient. Yet I cant remember his name for the life of me. I do remember Dr. Opas telling me that 1. He never forgot his first patient and 2. That my job as a doctor was to turn down the air conditioning when the room got cold. I remember the kid was cute, and that he had all the side-effects of cyclosporine like gingival hyperplasia and hirsutism, as Dr. Opas pointed out to me after I matter-of-factly told him that my patient had a normal physical exam. Oops. Screw-up number one

So Ive managed to survive my first two months of internship. The first month was pretty easy; after all, theres really nothing like a nice month of outpatient pediatrics to ease my way into residency. The second month wasnt nearly as easy. I got to experience my first night on call admitting 5 patients (which is not nearly the crazy censuses of some teaching hospitals, btw) and things frankly started to get confusing. Falling asleep over my paperwork, my pen would continue to move as I would nod off, and first my carefully constructed sentence would start to go to nonsensical words, and finally just pen strokes as my pen would fall out of my hand.

More mistakes happened than I really thought would, as well. Some were minor, such as when a friend of mine sent a patient off to the CT scanner on the wrong date a big affair only because, well, we dont have a CT scanner in the women and childrens hospital, and getting a CT involves a quick ambulance ride to the general hospital. Oops. The annoyed look on the faces of the paramedics, patient and her mom were priceless as they came back to the floor from CT, where they were undoubtedly told in a very kind manner that they had arrived on the wrong day.

As for myself, well, Ive made plenty of mistakes too. Judgment really clouds up under stress. Most involve things like the wrong dosing on a medication (which luckily are checked both by nursing and by the pharmacy prior to administration) or the wrong test (I ordered an xray+contrast study instead of a nuclear medicine study). Just the other day, I confused two patients who had the exact same name and described the wrong patient entirely to our endocrinologist. I ended up having to page him five minutes later and explain how I just told him everything I knew about the wrong patient.

One patient in particular was a much closer call, however. I ordered a load of dilantin on this child, after having reviewed his order log to make sure that he had not already received one. Medication loads are high doses that we use to bring rapidly someones blood levels of a medication to therapeutic levels. They really should only be done once. My mistake was that I had forgotten that the patient had already been loaded in the ER, which uses a different order sheet.

So there I was, sitting at this desk and falling asleep when I remembered that this patient had indeed received a load. I debated whether or not it mattered, prudence got the better of me and I told my senior. I think he already got a dilantin load in the ER She snapped out of her half-asleep state and after verifying it on the ER ordering sheet, ran out of the room to see if she could cancel the order. Thankfully the patient had not yet received his medication, and she was able to cancel the order in time, and I did not poison my patient. Its truly amazing the dumb things I can do.

Where in Norfolk? #2

nospam@example.com (Kevin) — Sat, 12 Aug 2006 22:45:21 -0600

Hopefully not too easy..... but if it turns out to be too difficult, click on the image for 3 more clues. If you don't know by the last clue then you are no longer my friend.

Where in Norfolk?

nospam@example.com (Kevin) — Tue, 25 Jul 2006 17:38:59 -0600

For those "homesick" for Norfolk here's a little quiz. Where in Norfolk was this picture taken? Post your answers in the comments.

General Hospital

nospam@example.com (Randall) — Thu, 1 Jun 2006 12:08:52 -0600

There it is, the hospital I will be spending the next four years in. It's definitely in a scary neighborhood, mere blocks from skid row, but it's also a grand old hospital. 21 floors, built some 75 years ago, with a dedication in the lobby stating that it was built so that the residents of Los Angeles will always have healthcare regardless of ability to pay (edit: oops, not just free healthcare, drat!). Now I'm the polar opposite of a socialist and I do view healthcare as a commodity, but the idealist in me is darn proud that I'll train here. As long as I survive the process, anyways, I think I'll be very happy in the end. Btw, I'm gonna have to learn Spanish. Easiest part? General hospital in Spanish is "Hospital general." Awesome!

Oh, and I dunno why I named the last post "part 1" since it's clearly part 1 of 1... well, I have a few more photos from oklahoma, arizona, etc, but none of them really came out all that well, unfortunately.

The iPod Exposed

nospam@example.com (Randall) — Sat, 29 Apr 2006 15:12:12 -0600

So I wasn't originally going to post this, but what the hey. My 3rd gen iPod's battery had been wearing down after two years of use, and so I put in a new battery. It was a little scary of course, but really in the end it was pretty easy. My old battery probably could've lasted another 1-2 years, but this one actually is higher capacity than my old one, so I thought what the hey. I've been actually very happy with the performance, and for less than $20 on ebay... Gotta love it. Click here or on the above image to see it full size.

Crazy films

nospam@example.com (Randall) — Tue, 21 Mar 2006 12:43:41 -0700

So Amit suggested I post this nifty xray that was shown to me last night in the ER. Even if you don't have too much medical knowledge, you can probably take a stab at interpreting it. Take your time...

The key is that L in the corner, it means the patient's left side.

Yup, situs inversus. All her organs are backwards. Her heart is on the right, her liver is on the left, her stomach is on her right, and so forth. Pretty rare. She knew about it, and told everyone except the poor resident, who was trying to listen to her heart on the left and couldn't hear much of anything...

So I had started to type up a cool story from the trauma bay last night, when I realized I have an exam on Friday and my time would be better served studying...

Match Day on TV

nospam@example.com (Amit) — Sat, 18 Mar 2006 15:37:00 -0700

Queens NY here I come!

Until someone figures out how to save this video, here's a link to the local news story on our match day...

www.wavy.com (click on the EVMS story on the right)

Life Experience

nospam@example.com (Randall) — Fri, 10 Mar 2006 16:56:23 -0700

58 year old Caucasian male, found in a parking lot at the side of his car... complained of difficulty breathing, some epigastic pain. has become unresponsive en route and tachycardic to the one forties... blood pressure is ninety over palpable... ETA to MTA is 5 minutes.

Understood, awaiting your arrival. Ten-four.

Status update... the patient is deteriorating, no longer has a pulse and we cannot get a BP reading... we are starting CPR. ETA 2 minutes.

The patient comes in on a stretcher, with one emergency medical technician (EMT) doing rescue breathing with a bag mask and another doing chest compressions - desperate measures to keep that vital oxygen flowing to his brain when his heart and lungs have all but given up. They rush the patient into bay 11, and our staff start to take over. We hear that he was on the way to the bank, and that he has metastatic colon cancer. The patient's head and shoulders are already visibly blue. My resident has all his intubation equipment ready, and he gives the order to stop CPR. He attempts to slip the tube into the patient's trachea. No good, restart CPR. I grab a bigger tongue blade and a better handle, and again he tries. The tube slips in gently, and we start feeding him air through the tube. We give ever more fluids. We give epinephrine. Atropine had already been given in the ambulance, so that's no option. We give more epinephrine. Still no good.

We are now 20-25 minutes from when he first crashed in the ambulance, and a quick ultrasound exam shows no cardiac activity whatsoever. The heart simply refuses to beat, despite the electrical rhythm displayed on the monitor. My attending decides that the effort is futile, and over.

Time of death, 10:31 am.

And that was it. The first time I've ever seen a man die in front of me. Sure, I've had patients of mine die (only twice though), but it was always something I heard about the next morning, or later after I've left rotation. It was a strange experience. I wasn't broken up nor did I want to break down or something. Why should I? I did not know this man, and although he was on the young side, his odds were certainly stacked against him. I had suspected he would die before he even arrived, I figured he had a 10% chance of seeing tomorrow. Still, there he was, blue and cold and still as can be, with a plastic tube coming out of his mouth. Still, life went on in the ER, people going back to work and joking around as they always did, seemingly unfazed. Who knows how many they've seen die. Heck, I'm sure some friends of mine are surprised it took me this long to see someone die.

I was fazed. My next patient clearly was not dying, and I started getting annoyed by his babbling on about his problems. When I realized this, I had to tell myself that he was no less needing or deserving of our help, just because he was not critically ill. I was there for him. That wasn't all though. I was just a little more jumpy the rest of the day. Every other patient looked sick to me, and I more often than not grabbed my resident to have him evaluate the patient first, just in case. Funny, I guess I do fear death, after all. Also funny, that feeling that my problems are trivial compared to that of the man I met in the ER today, the man who woke up today planning to wake up tomorrow and the day after. It's not true, of course; if anything, he's the one that has no problems now. Certainly up until now his life has been tougher than mine; a battle with metastatic cancer is no easy thing on one's life or psyche. And it's a terrible thing to die so tragically and unexpectedly. Still, I suspect it's a gut instinct to feel the way I felt, I guess part of what makes us human.

I dunno. I guess we do all have to go sometime. I just wish this guy could've not died today.

Emergencies

nospam@example.com (Randall) — Thu, 2 Mar 2006 18:10:51 -0700

No photo today, sorry folks. So I haven't posted in a while, I think the last time I did I was still in California. I've just finished up my month on Radiology, and I suppose now I can read a chest x-ray better than before. Certainly better, but still not quite up to par. I just don't know why those darn things are so difficult.

So I'm on Emergency Medicine now, and of course they started me off with a solid 8 days in a row, 3 evening shifts followed by 5 graveyard shifts. Ugh. I don't know if I like this hectic, fast paced type of medicine, with patients flowing in just a tad faster than I can see them. I like a little downtime in my day, a chance to breathe... In the ER, though, there are always more people in the waiting room, and it's expected for my resident to be juggling 5-6 patients at once. Which means, thankfully, I'm only juggling 2-3. Crazy stuff.

So last night, 'round eight, the ambulance pulls up and in comes the cutest 7-year-old girl sitting on a stretcher. Strapped to her (via seatbelt) is a massive metal bedframe, made of colorful pipes welded to each other. In a tiny hole on the side of one of the pipes (who know's what it's for) is stuck her middle finger. She was very amused as a mass of doctors and nurses surrounded her, and my attending chats with her with a smile as he pours a generous amount of lubricant around her finger. Doesn't work, she's still quite stuck.

Now the picture isn't quite right already - I can see there's small smears of blood on her pajamas. She's gotten cuts around her finger already where it's inserted in the hole, which apparently was quite sharp and she's already tried to free herself. Her finger is presumably pretty swollen on the inside. So it's off to the pipe shop. Pipe shop? I didn't even know our hospital had a pipe shop. I wonder what they do there during the day? Tonight, however, they were going to cut that bedframe to pieces.

Of course, once I get over there (along with a very dedicated nurse and ER tech), the pipe folks (plumbers?) have their own lubricant to try - some sort of silicone grease (quite different from our stuff) - but it doesn't work either. So we do our best to comfort the child while they tear the bed apart before our eyes. The first few cuts are easy, using circumfrential cutters to debulk the massive thing. The small pipes welded on come apart easily, but her finger is stuck in a huge pipe (2.5" diameter maybe?) , which requires a powersaw to go through. We do our best to brace her hand and the pipe in a vice. As we get closer, the nurse and I put our fingers in the way of her fingers, so if the saw missed, we'd get maimed first. His idea, not mine. Are all ER nurses so brave? I was pretty scared.

Slowly her charming demeanor melted away with the increasing pain. Each further cut got worse and worse, as the pipe started to bend and pinch her finger. We finally cut enough of the pipe to fully expose her finger, a horribly swollen mess covered in blood and grease. Any further cutting simply bent the pipe too much, she would cry out in pain. We attempted to use teflon tape to squeeze the edematous fluid out of the proximal part of the trapped finger, hoping to squeeze it through bit by bit, similarly to how we remove swollen rings from fingers using dental floss. It didn't work. (btw, unless you're trained in it, I would not recommend trying to remove your own stuck rings this way - go to the ER!)

"Do you have any ideas, doctor?" they ask me for the 5th time in 2 hours. Me? I'm no surgeon! "I think she needs to be sedated. This is causing too much stress and we can't get good access here." Or something like that. The nurse recommends I go talk to my attending. He demands of me, "Why sedation? Is she no longer cooperative? Has her condition deteriorated to the point where she simply can't take it anymore?" No, and no. Or no and maybe. I'm not sure. I suggest we might be able to get to her finger with a hacksaw - I'm simply not comfortable with using any more powertools at this point. He agrees - one more try with the hacksaw, and if it doesn't work, the patient comes back to the ER for reevaluation.

I tell the nurse the plan, and he agrees. We clamp what's left of the pipe wall, and go to work. We simply can't hold the pipe still enough (it's really only half a pipe now - meaning it's only half the circle and so has no structural integrity). The girl cries in pain from every single movement of the saw, and we were barely able to make a centimeter of progress before we decide it's just unsafe. Back to the ER. By this time the pipe guy had already called in several his maintenance friends, and they all are sad to see her go. More so, I think they were truly disappointed they weren't able to save the day and free her finger, and I'm sure they were all wondering what more they could do.

We get back to the ER, and my attending comes over and looks at the poor finger, still stuck inside the remnant of bedframe. He begins to try the dental floss trick, but the nurse convinces him we've already tried that. Okay. Time to call the hand surgeon. The nurse starts an IV on her, something they could easily do in the operating room, but I think he too wanted to do something for her, despite everything he's already done. I finish up all my paperwork on her - what else can I do? I'd like to follow her to the OR at the next door children's hospital, and through to the next day and round on her, but seeing as I'm on ER, I can't quite do that.

My resident calls me over to sew someone's laceration closed. It's been a long time since I've done stitches, but somehow they come out looking pretty nice. I guess I learned something these past few years. And then on to the next patient...

Champagne Tap

nospam@example.com (Randall) — Fri, 18 Nov 2005 19:17:08 -0700

Sorry, no picture today. I haven't really had the inspiration to take any photos lately, hence my lack of posts... Anyways, life is speeding along as always. I finished up my month at CHOC, and I'm still pretty happy with the idea of becoming a pediatric cardiologist. I'm working at UCI now, doing a sub-internship in pediatric ward medicine. UCI's pediatric program is mostly based at Miller's Children Hospital, and interns really only spend one or two months at UCI Medical Center (where I am). As such, it's a very low-key rotation, and I don't follow a lot of patients. Things were very frustrating at first: it took some 30 phone calls to get access to the computer system, they refused to give me a pager so I had to buy my own, and lots of small things like the way they do their discharge summaries infuriated me. But I settled in and now I'm enjoying myself quite a bit. Phew!

Which brings me to the title of this post. To cap off the first week and my first night on call, I got woken up by a page in the early morning because one of my kids had broken yet another fever. The kid needed a lumbar puncture (aka spinal tap), and I had to do it. I got a little scared, imagining the horror of sticking a needle into the spine of a 4-month-old baby and somehow wrecking the spinal cord or something, paralyzing him for life. Which of course couldn't happen if I even barely knew what I was doing, since really the most serious complication would be an infection or maybe an allergic reaction to lidocaine. I wouldn't be poking around where the spinal cord lies, just where the fluid collects.

So I went over the procedure with my senior resident, and we got the baby ready. With the parents just outside the treatment room all teary-eyed and the baby crying inconsolably, I put on my sterile gloves and got to work. Finding the right spot was tricky at first, but I figured it out. I broke sterility. Oops. I changed gloves, and finally put in the needle. I pushed forward in a gentle motion, staying straight as I could, and I felt the pop I was told to expect. I pulled back the stylus, and badabang! CLEAR AS WATER! No blood at all, just pure, pure sweet cerebrospinal fluid (brain urine). A champagne tap! On my first try!

Now I know I was lucky (there are so many variables), but hey, that was still awesome. Bwa! And no, I didn't paralyze the baby. I checked in on him about 30 minutes later, and he was just as happy as he could be. (He was being fed.)

Birthday number three

nospam@example.com (Randall) — Sun, 6 Nov 2005 01:05:54 -0700

Had dinner with a bunch of family tonight, it was my cousin's third birthday. This was about the best photo I could take, I was shooting somewhat blind and had slow exposure. To explain how blind this shot was, I thought there was a birthday cake in front of her. Turns out they had moved it.

For some reason, I still can't get my flash to fire independently of my meter, something my old camera could do... grr. I think I'm just doing it wrong. As you can see, she's a cutie, although her movements seem to have given her a black eye in this photo. Weird.

Click here for a larger version.