Those stupid ER Docs

I am in my second year of Emergency Medicine Residency. It is an interesting specialty because we tend to be universally hated by every other specialty because they view us an "unintelligent" since we are not as skilled at their specialty as they are. Hence the following statement, albeit in jest, by my ICU attending,

Attending: This lady suffered an anoxic brain injury and will probably end up in a vegetative state, she must be applying for ER residency.

Of course, I reply with a hearty laugh and let it roll off my shoulders. The truth is I wanted to say, "do you even know what we deal with in a day?" "Do you really, truly think we call you for every old guy with a cough?" "Do you realize that yours is probably the only specialty that you are more versed in than a fully, residency trained ER doc?"

Now, I would never say these things because they are not helpful. We, as ER physicians are put in a place where we are viewed as stupid because any time we call another specialist, we are asking for help. Yes, maybe this is the third abdominal pain I am calling the surgeon about in a single night. But I am not a surgeon and I need help with this particular case. The surgeon is not aware of the 10 other abdominal pains I already sent home that night.

So from an ER doc in training, I apologize that I am not as good at all other specialties as my own, and I am sorry that whenever I call I am giving you work to do. But I have to say that I do not view an ophthalmologist as stupid because he probably couldn't diagnose brugada syndrome on an EKG, I don't view an orthopedic surgeon as stupid because she would have a hard time performing RSI. I don't think the hospitalist is unintelligent for not being able to emergently perform a lateral canthotomy. We, as emergency docs, have to be able to do all these things and sometimes, we have to ask for help. So, can't we all just get along? (Insert "Why can't we be friends?" here).

So I'm a Resident Now

I have just completed one month of residency and this is the main thing so far that I have found that is different from being a medical student...

As a medical student I usually felt somewhat justified when I didn't know something. I mean, after all, I'm only a student! I'm still learning! Now, I just feel like an idiot almost 24 hours per day. I mean, I second guess almost every little thing I do. I'm not even comfortable giving someone tylenol. I nearly poop myself any time a nurse wants me to make a decision about a patient. But that's okay. All part of growing up. Besides, at least the hospital has to do my scrub laundry.

Now, completely off topic is my patient-resident conversation of the day, or I guess of the year judging by how well I have been keeping up...

Patient high on Benzos while I'm irrigating a giant laceration on her arm: (jumping off the table)What the @$#%!
Me: Oh, sorry, did that hurt?
Patient: No! Don't you realize that my dress isn't squirt proof?!?
Me: Uh, what?
Patient: Shut up! I'm trying to sleep!
Me: Yes mam.

That's right people. Another life saved.

Matched!

That's all I have to say! Goodbye Medical School!

What is pimping again?

Well, it has been about 3 months now since any attending has asked me a serious question about medicine. Does that mean I have forgotten everything? Yeah. Mostly it does. My thoughts as of late mostly center around when my next meal is and what I have to do in order to escape medical school.

Today:

Attending: Okay you two. Name the most common areas for an aneurysm in the brain?
Me: (looking at ceiling, thinking about lunch)
Other student: blah blah blah (gets it right)
Attending: Good! Now what are the most common brain tumors in adults?
Me: (still thinking about lunch, also wondering why he has never tried nacho cheese in a burrito. I know! Sounds awesome right???)
Other student: blah blah blah (gets it right again)
Attending: Great! (looks at me) She is so much better than you.

Shortly after this my phone was confiscated by this attending because I was checking my email.  I has gots to get out! Luckily this eval wont be on the MSPE...

Also, Nacho Cheese, as it turns out, is not that good on a burrito.

Okay fine, I will update you all

Here we go.

What to say about 4th year?

Magical? Yes.

Enchanting? Yes.

Expensive? Holy freaking crap yes.

I must say that I had no idea that I could spend the massive amounts of money that I have been spending on interviewing this year. Looking at my credit card statement is much like looking at Mt. Everest and contemplating a climb. Both give you this sense of utter hopelessness. Ah well. That's what loans are for right? After all, we all know this is fake money.

Interesting interview dialogue of the month:

Medical Student: Hello Dr. Attending, it is a pleasure to be interviewing at your institution
Interviewer (in slow, dramatic voice): Why. The. F*CK. would you want to come to this place?
Medical Student: I, uh, thought that, uh...
Interviewer: Ah that's okay. Did I mention that my greatest hobby is carving meat?

I have a good feeling about this place.

Is it okay if I rant?

Last week I was assigned to follow a Physician Assistant for a day since the MD was out of the office. I have nothing against PAs. But this one was really starting to rub me the wrong way (figuratively speaking). 

PA: Medical Student, go assess these patients.

Medical Student: Okay.

Medical Student: Patient number one has a cough that comes in paroxysms with post-tussive emesis. He has had the cough for 6 weeks. I think we should cover for pertussis.

PA: Um, no. It's just viral.

Medical Student: (what the @#%$@!!)

Medical Student: Patient number two is a well child check. Everything was fine but there is a 2/6 systolic murmur at the apex. I think it should probably be checked out.

PA: (listens at the 2nd and 4th ICS) Nope. No murmur.

Patient's Mom: I think he's right, we have been told he has a murmur and that he should have a "heart ultrasound."

PA: (listens at the apex) I found a murmur here.

Medical Student: (glares at back of PAs head)

Medical Student: Patient number three has perfect circular patch of hair loss with a boggy mass on his scalp. It's classic for a fungal infection. I think we should treat him with an oral anti-fungal.

PA: Nope. This is a lipoma or maybe a sebaceous cyst.

Medical Student: I really don't think...

PA: We need to cut it out.

Medical Student: Should we try an anti-fungal first?

PA: Nope. We need to cut it out. (makes an incision on patient's head) Weird, there is nothing in here. Oh well, stitch this up.

What a day.

How the Dementia Patient Out-smarted Me

Every once in a while you have to let go of your pride and admit that someone has gotten the better of you. Whether it be sports, politics or even the world of medicine, the time is sure to come. It just sucks when the person who gets the better of you has dementia. 

One of my patients in clinic today appeared rather confused so I decided to perform a mental status exam on her...

Medical Student: Okay, can you spell world backwards?

Patient: No.

Medical Student: You don't want to try?

Patient: Why would I do that?

Medical Student: Okay. um, I'd like you to take this pen and draw a picture of a clock face showing ten past eleven.

Patient: Fine. (starts drawing) There. (shows me picture of a circle with 11:10 written inside of it)

Medical Student: What's that?

Patient: It's a digital clock. 

Medical Student: You win. I don't care if you think the president is Woodrow Wilson. 

Learn from the best

As I go through medical school I like to see what I want to incorporate into the way I practice medicine by watching those who have gone before me. For instance, humor:

Attending: Well, you haven't been taking your medication, you aren't changing your diet, you aren't exercising and you aren't losing weight. Your kidney function is failing. It looks like you are going to have to start dialysis if you can't get with the picture.
Patient: What? Oh no! I don't want to do that. My children would just die!
Attending: No, you would be the one who dies. (chuckles)
Patient: ("I don't find that funny" stare)
Attending: (continues to chuckle)

I'm learning so much!

Moving On

Family Medicine. The "who the hell knows what is coming in next" specialty (second to emergency I suppose). My first day on family went a little something like this:

Medical Student: Hello 75-year-old lady! Lets talk about what kind of exercises you have been doing since we saw you last.
Patient: Huh? Are you kidding? The only exercise I want to do is at night in the bedroom.
Medical Student: I wish you didn't look like my grandma

Hour later...

Medical Student: Hello super stressed out angry guy! What brings you into the office today?
Patient: My wife is bipolar, has scleroderma and addicted to oxycontin.
Medical Student: (practicing his empathy) I'm so sorry to hear that. That must be really stressful for you.
Patient: Look at these pictures I took of her on my phone of her passed out on the floor.
Medical Student: I wish you hadn't shown me that.

Oh what joys will come next!?!

Make sure you lock the door

So I found out the hard way that the bathroom door on the peds unit doesn't lock that well. Actually, I would say the poor old filipino nurse who walked in on me found out the hard way. Oh well, nothing she doesn't deal with every day right?

Pneumonia

Sorry for the gigantic lack of updates. The reasons are two-fold. Firstly, everyone is so nice to me on peds that I feel like there is nothing interesting to report. I mean, it seems writing everyday that everyone loves me and gives me respect would bore most people. It's only funny when I'm getting abused. I miss surgery. Second, this happened:

Medical Student: Hello small child and family with pneumonia! I see you were just seen yesterday in the emergency department and given amoxicillin. 

Small Child: (all cutesy) mmmhmmm! (big smile) (little cough)

Medical Student: Aww, how cute, here is a sticker of mickey mouse!

Small Child: Yay! Thanks! (cutesy smile)

Medical Student: What a polite little girl! Now open wide for me!

Small Child: Okay! (coughs in my face)

Medical Student: (!#$^%@) 

Small Child: (cutesy smile) sorry...

Mom: Oh, I'm sorry...

Medical Student: (you can take sorry and shove it...) That's okay! Here is another mickey sticker!

Small Child: Yay!!

So, yes, I have been sick all week and weekend. I did not know it was humanly possible to shed this much mucus onto the earth. I wish I could extract all my goblet cells. Also, I don't care if that was gross. Suffer with me!

I cannot escape it

It's understandable when you are in the academic medicine environment to expect a certain level of pimping. I've done my fair share of griping on this blog about the questions I've received as a medical student, but in all honesty things haven't been too bad. When you exit the academic world and escape into real life, however, you tend to let your guard down. Especially when you or your family member is now a patient.

My wife needed to have a minor surgical procedure performed and was undergoing general anesthesia for the operation. I, the loyal husband that I am, was waiting by wife's side in pre-op and inevitably the surgeon came by to do the final pre-op check and asked me what I did for a living.

Surgeon: (lighting up like he just found his next hit) "Ah, so you're a medical student! What are you interested in?"
Me: "Well, I'm still trying to decide. I like peds a lot."
Surgeon: "Well, try to stop liking that. There is no money in it."
Me: "Okay..."
Surgeon: "So I'm currently injecting your wife with Versed, you know, midazolam. Then we will give her some propofol for induction."
Me: (feeling he is about to go deeper with this) "Alright..."
Surgeon: "You remember your pharmacology?"
Me: (No freaking way is this guy about to pimp me as he is about to induce my own wife) Yes...
Surgeon: "Well, what is the mechanism of action of Midazolam?"
Me:(Are you freaking kidding me?!?) That's evading me...
Surgeon: "Well, it acts on the GABA receptor."
Me: "Ah, yes, of course."
Wife: (looking off into the distance) "Is this what being high is like..."
Me: "Yes, sweetheart."

So, in the future, whenever I'm asked what I do, I am going to say that I'm an accountant. Because you never know where a pimp addict may be lurking. And the surgery went fine, in case anyone was wondering.

I don't know

Peds. Gotta love those kids.

Medical Student: Hello little 5 year old girl! How did you get this bump on your leg?
Child: (excitedly) I was asleep and then my friend woke me up and then... and then... and then... (big breaths, getting more excited) I was just jumping on her spongebob pillow and then she pushed me off and then I fell on a sharp thing and then I pulled it out all by myself!
Medical Student: (jotting down everything) Wow! How did you do that?
Child: Do what?
Medical Student: Pull out the sharp thing!
Child: Huh?
Medical Student: You fell down on a sharp thing right?
Child: Yeah!
Medical Student: After you fell off the spongebob pillow...
Child: What? No!!!!
Medical Student: Okay... Then what happened?
Child: I don't remember!! I was sleeping silly!

I love it when you write out a whole H&P and then get to write a big "X" through it.

*There was nothing wrong with this kid (no concussion, brain damage etc.) she was just being her five year old self.

The Dark

Radiology. I just finished it. Let me give you a little taste of my glorious schedule:

9:00am - Arrive at hospital

10:00am - Attending arrives at hospital

11:30am - Attending takes lunch, so I go too

2:00pm - Go back to hospital

3:00pm - Go home

Granted, going into the reading rooms is like entering Gollum's cave (Yes, I did just make a Lord of The Rings Analogy), but that schedule freaking rocks. 

On a more serious note, I did meet one radiologist that looked like Gollum. Sounded a little like him too, but wow, could that guy read a chest x-ray.

Yeah, well, I made another one

This is a slightly embellished, real life conversation.

Am I missing something?

I've been pondering this one for a while. Can anyone show me exactly what I'm missing?

Attending: Medical Student, this patient has bilateral pitting ankle edema, shortness of breath and borderline hepatomegaly. What do you think could be going on here?
Medical Student: Well, it sounds like it could be right heart failure.
Attending: I don't think so. It's most likely Cor Pulmonale.
Medical Student: (confused) oh.

This is the second time I've had this conversation. Lesson: Always use latin when available.

Kids

I never thought myself one to enjoy the kids on my rotations, but they are starting to grow on me. They actually have quite a few qualities that I am jealous of. Mainly, they know how to say "no," they demand what they want, and they will do nothing for you until you give it to them.

Me: "Hello little 4 year old child, can I listen to your heart?"
Kid: "No!"
Me: "I really need to listen to your heart."
Kid: "I want to draw my name"
Me: "You know how to draw your name?"
Kid: "Yes! I'm the best at it! I want to draw it!"
Me: "Okay, okay, can I listen to your heart after?"
Kid: "mmmmmmmmm. okay."

So I give the kid a marker and await his masterpiece. He proceeds to draw a circle and a triangle.

Me: "Okay! Good job!"
Kid: (beaming) "I'm the best"

So to recap. I am 25 years old. Kid is 4. I have no control of the room. Kid has total control. I don't get to decide what my name is (usually I'm called, "move" or "I need to be standing there" or "watch out"). Kid gets to call himself circle triangle.  Ah, the lessons we can learn from children.

Wash Your Hands!

Sometimes it's the patients that give you a hard time. I don't know if I just had a look about me or what...

Medical Student: Hi There, I understand you've been having some stomach pain and I came by to do a quick exam.

Patient: Okay.

Medical Student: Great. Let me just wash my hands and we'll get started.

Patient: Yeah, you better.

Medical Student: (nervous laughter) why's that?

(Why did I ask him that? I don't know.)

Patient: Cause I can tell by lookin' at you that you just sit around touchin' yourself all day. I don't want all your junk germs on me.

That's it. I'm shaving my mustache.

I'm so confused

Look. I can handle the pimping, the long hours, the belittling comments, the general craziness of it all... but can we please at least agree on what the heck I am supposed to be doing on this service?

Intern: Go pre-round now on these 8 patients.
Medical Student: (feigning interest) Okay!

Later...

Intern: Why did you do the physical exam? Only we do the physical exam. Just get numbers.
Medical student: (Hiding confusion) Okay!

Next day...

3rd year Resident: Go pre-round on these 8 patients.
Medical Student: (Feeling confident in his role) Okay!

Later...

3rd year Resident: Why didn't you do a physical exam on any of these patients? Did they teach you the proper way to write a soap note here? Don't forget that again.
Medical Student: (confidence shattered) Okay!

Next day...

Senior Resident: Go pre-round on these 8 patients.
Medical Student: (Hell No!) Okay!

Later...

Senior Resident: Please don't write your physical exam in the chart. It's not as reliable as ours. Just get the labs.
Medical Student: (Through clenched teeth) Okay!

Someone. Help me.

Superpowers

Today I realized that one of my Attendings has a superpower. Let me explain. Perhaps you have been in the situation where you need to get somewhere but someone is in your way. Usually in such a situation you would say something like, "excuse me" or "I'm sorry, could I get by you real quick?" Not so with this Attending. He has the ability to move you using only his eyes (or maybe it's mind control, I'm not sure.) Basically this guy walks up to you and stares at you until your body just moves out of his way. It works every time too. Not once have I had the balls to just stare back at him and not move.

Caveat: This does not work on nurses. I have tried.