Day 359 Last Day as an Intern !!!

Well it finally came. My last day as an intern!! I just can’t believe it has already been a year. Its truly amazing. I had a really stressful week. I was in the hospital 7 days straight. My on call schedule was something like this:

June 14th Sunday on-call 7am-8pm
June 17th Wednesday on-call 7am-8pm
June 19th Friday Graduation 7am -11pm
June 20th Saturday on-call 730am-8am (24hours)
June 22th Monday On-call 7-8pm
June 23rd Tuesday Presentation

I was basically in the hospital 9/10 days !!! Geesh I was exhausted. Thank goodness I’m on vacation now!!! It Was an activity filled week. We had the senior’s graduation ceremony that we were planning on Friday. I had several things I needed to do for the ceremony. Me and another 2nd year planned award plaques and I had to purchase 2 separate Award plaques that I had to custom order online for about $160 dollars. I had searched about 50 different sites, but I was able to get to only one I thought was good. We had made a collection for the cash with the other residents and the rest of the cash, I had to put in. The 2nd year gave me extra cash to cover a few of the cost. I had also spent the last 4 weeks editing a special video presentation for the graduating class. It was so exhausting to do, but I was able to do it. We included the video as part of a graduation gift bag. I almost got in big trouble on Friday the day of the ceremony. It was around 3pm when one of the program secretaries called me to her office. She sat me down and said “I need to talk to you.” She said it so serious. I got so nervous. I must have done something really bad I thought. She went on “You know a lot of people don’t know a lot of what has happen. And you don’t know a lot of what has happen. I saw the presentation that you did. And I hate to ask you, but you have to take one picture out.” She then went on to tell me how that person had had a turbulent relationship with her and the other staff members and the program director now, and she would appreciate it if I would take out the picture from the presentation.” I was relieved to hear her say that, I thought that I had done something awful or injured a patient. She was so serious, her tone was so different. She told me that it’s the program directors night, and I shouldn’t spoil it for her bringing back pass memories of relationships. Well I said no problem ran to my computer which I had in the car and edited the picture that was on my computer. I had to do it fast, because the graduation party was about to start. I went back and edited the picture, and went back to her and told her that I had taken it out. I also told her to tell the program director indirectly, that I had taken the photo out, but that the video show had to be played with my computer since it’s the final edit. Well it seemed like the problem was avoided and I left the hospital around 5:00pm to go set up the presentation. The program director was going to meet me there.
Well It seemed that everything was going to plan until I plugged in my computer to the sound system they had their and realized that I didn’t have the power cord of the lab top. My face turned white and cold. My wife was there and she looked at me and asked what was wrong. I told her “I forgot the power cord of my computer. I need the power cord! I can’t play the video show from any other computer. I gave my word to the program director and I didn’t want to make her feel bad…” I was in a state of panic. My wife said “take it easy. I’ll go back and get the cord for you. Don’t worry.” At this time the program director walked in and she asked if everything was ok, I turned to her and said. I “I think so, except for the fact that I forgot the cord for my computer, but don’t worry my wife went to get it.” Her face changed and she seemed a bit worried. Luckily for me, I had backed up the power point presentation on my flash drive and tried to load it to another computer that was there. I spend the next 10 minutes trying to edit the show as best as I could. And by God’s grace I was able to fix it. I went over to the program director and told her everything is fine. She seemed relieved. (the power point was the presentation I had been working on for about 4 weeks. It was a tribute with pictures we took over the year of all the events in the program.)
Well needless to say the night went out without a flaw. My wife came back with my cord, but I didn’t need it, but the program director was glad to see he had made the effort. The night went rather well. They gave out awards and resident awards – award for hardest working residents, nursing staff favorite resident etc.. I didn’t win any awards but probably came close. The program director publically thanked me and my friend for all our hard work this year.

The high point of the night was when I got to present the program director and associate program director the $160 plaques we got them. It was memorable because they didn’t know we were going to do that. The 3rd years had gotten their awards, and me and the 2nd year resident stood up and presented the awards to them. They were really surprised! You should have seen the look on their faces. After the award ceremony the residents danced and we took pictures, and really had a good time.

I was really glad for my wife, she was able to meet the program directors and staff-Which was really good for her, because she wants to start residency soon. When it comes time to applying and she will at least be “guaranteed” an interview.
After this award ceremony I spent the next weekend on call and studying for my mortality and morbidity conference I was holding with SUPERMAN ! Can you believe it? And it had to do with the code we both ran on the patient who they found the ETT in the esophagus. I think none of the seniors wanted to do it, so they put it on me to do it. I spent the entire weekend studying for it. It was pretty fun. I learned a lot of good stuff. I tried to do my presentation design almost similar to how the ACP doctors I saw in ACP. When they talk about certain points, they always refer to journal articles. So the majority of what I said on my presentation was from articles and journals. It was a lot of fun.
I almost forgot. The New interns are here !! and they look nervous !! just like we did 1 year ago. They look like they are going to crap their pants. Lol. Hard to believe 1 year ago we were in their exact shoes. They have been in the hospital about a week doing orientation. They seem to be a stronger group academically. 2 or 3 of them are surgeons (eye & colon). A few of them have phd’s and have had publications-Pretty impressive. However impressive it is, it really doesn’t prepare you for what they are about to go through.
I still remember having the first meeting with the chief and him telling us “on day one we start right away. It’s like the military. You are thrown into the fire.” I didn’t realize what that meant until the first day I was on call and got paged by the telemetry nurses 60 times.
Overall, it was a good and exciting year. I’m Glad some of you have followed my journey reading this blog. I hope and pray that one day you can begin your residency journey. I also hope that you find true meaning in your lives. What we do doesn’t define us. What we do is an extension of what we have inside. I hope that you find happiness in purpose in your career- Whether that involves having residency or not. I believe happiness comes from doing what you are meant in life. You have a purpose. And I hope you can discover that. I Hope and pray God grants you the strength and will to carry on in your long journey to finish with your career.

God Bless you and your family. Keep on working hard. Don’t Give up ! You can do it! Anything worth in this world comes through hard work and determination. Find strength amongst people that lift your life up. And when you can’t find peace in your life. When you feel the clouds of darkness surrounding you, when you feel alone and unsure of your life, look to God. He will life you up. Jesus can bring peace to your life. He can give you strength and the patience you need to carry on. Goodluck

God Bless
Dr.Mike

Day 346 My battle with Superman

It happened when we were on-call a few nights ago. It was the first time I have worked with him in about 7 months, since I first had my Unit rotation with him (you can read about it here: http://thankyougodforresidency.blogspot.com/2008/06/day-5-good-bad-and-ugly.html). It's kind of strange but he is probably one of the only residents that I actually have NOT talked much with him the last few months. I have spend a lot of times with the other residents and have built a good relationships, but he has to be the one that I'm least closest to. He is a nice guy. A bit serious on most occasions. I get the sense he wants to maintain a slight distance amongst himself and the interns. A sense that he is the teacher and we are the students. Its the same odd feeling you feel when your hanging out with a teacher or attending. You don't really feel like letting your "hair down". You conversation is reserved and you are not as open. I personally like joking around and having laugh with most of the residents, and some attendings, but with some people you just feel like you have to be reserved. Anyways, so thats how I act sometimes when I'm around superman. He is the "teacher" and I'm a "student"..lol. But its still a good relationship. I have no ill will towards him. He is very knowledgeable and helpful. He is always ready to review something with the interns.

So I was on-call with him. He was covering the floor and He called me for an admission. I went to the ER to do the admission, and in the middle of the admission a code blue was called in the ct scan room. I have to say that I really was looking forward to doing the code with him. I wanted to see how his approach to running a code was. At the sound of the code blue alarm we ran to the ct scan room. It was a female patient that was getting a ct scan, they were working her up for PE. There was a controlled mayhem that followed. Nursing screaming, radiologist tech screaming and anesthesiologist trying to in-tubate while everyone was screaming around him. The code had started in the ct scan room to the dismay of the CT tech who was like "can you guys take this outside?" It must have been less than 2 minutes, when the anesthesiologist said "Ok we got it, lets take an xray and move her out." Superman agreed and told everyone to take it outside. The respiratory tech started bagging the patient and we slowly worked ourselves out of the ct scan room and headed towards another empty room about 1 minute away. When we arrive at the second room the code was still continuing , and it was my turn to do the chest compressions (its usually about the only thing the interns are allowed to do) I started the chest compression. When I place my hands over the sternum and started compressing, it felt as though her ribs or sternum were a bit cracked. I remember feeling a chest similar to that a few months ago when I was running one of my first codes. The chest wall was very frail. I tried not to compress too hard while I did the compression. Superman saw how I was doing the compressions and yelled loudly "Hey do those compressions harder." I started to do it it a little deeper and faster. About 15 seconds of trying and superman was like "look that's not how you do it" and he came over and tried to show me how to do the compressions. Its not that I didn't mind him showing me how he did compressions, but it was the way he did it. And yelled in front of all the other nurses and techs. (by the way this was not my first,second,third or fifth or tenth time doing chest compressions....) He then told one of the critical care techs to take over the chest compressions. Less than 1 minute into doing the chest compressions superman yells "good chest compressions. Very good." He kind of said it really while I was next to him. It was really irritating. It felt as if he was trying to rub it in my face. Maybe he wasn't doing it on purpose, but it made me really upset. This was probably not the time to try to "teach me" how to do chest compressions.

Anyways I didn't say anything and the code kept on running. About 6 minutes into the code. He asked for a pulse. I tried to feel for it but didn't feel one. Superman came over and "felt" one in the carotids. He said we had a pulse and proceeded to cal of the code. "Her rhythm was sinus tach. (no afib or flutter). The code was over for now and I went to look for a phone, because an attending was waiting to get in contact with me. I went back to the E.R. to call the attending. And the female that we had coded was brought back to the E.r. While I was in the E.R about 8 minutes. Another code blue was called again. (Codes in the E.R are run by the E.R doctors and not the residents. I went to find the room in the E.R that the code was being run, because I figured it was superman running the code. I found the bed number and sure enough superman was their running the code. All in all it must have been at least 40 minutes all together that this female was being coded. While he was running the code and one of the techs was doing compressions, superman again said while he was next to me "keep those compressions going. " He then turn to me again and said "you see that's how you do it." I turned to him and said "no, that's not how you do it. He is doing the compression way to hard (this guy must have weighed about 260 lbs and the female was about 140lbs.) He is doing the compressions too hard and she probably has cracked ribs and is going to lose all the negative intrathoracic pressure your trying to preserve." I didn't say it too loudly. But he kind of stayed quiet when I responded the way I did. Anyway, another 20 minutes passed and he decided to call of the code. Even after trying to rule out tamponade (which he had the Head of E.R do a bed side sonogram). Cold was called, and the team was dispersed. I have to be honest with you. I was extremely pissed. I thought it was really inappropriate for superman to start giving me lectures on cpr in front of the entire code team.

I waited for some time to pass by and when I saw him sitting down at a desk I told him. "You know, that's not how you do chest compressions. You are gonna crack ribs and cause lose of pressure. DO you remember ICU bed 13? The guy with hydronephrosis? We coded him 1 hour and a half. (me and another resident doing the chest compressions), and we brought him back. You don't need to do he-man compressions on someone. Thats not the standard." (later when I got home I even read more on the AHA guidelines about chest compression which need to be 1 1/2 -2 inches. I also remembered one of the lectures of critical care telling us in a lecture to make sure you try and not break the ribs and you lose pressure and air. When I first heard this few months ago, because I felt that I had broken some ribs on a patient I had done cpr on. If you read on the net and some specialist they will say that breaking ribs is better than not doing any at all. But ideally you want to make sure you try no to break the ribs.) Anyways superman said "i know. I know." and didn't say anything again. I didn't want to keep on, because it wasn't the place for it, but I was just so upset at the way he was acting or by his approach.

Anyways fast forward a week later, and I saw superman approach me at the resident lounge. He said "guess what?" I said "what?" he said "its your turn to do an M+M (morbidity +mortality) conference." I said "on whom." He said "remember that lady we coded? come here sit down, and check out this xray?" I sat down and he opened the xray from the computer system. I looked at the xray and coudnt really see anything. He pointed to the trachea, and said "you see the Et tube that was placed, looked at it? You see, its in the ESOPHAGUS!!!" I was like "wow.. your telling me the anesthiologist put the tube in wrong place? and nobody caught that? Wasn't the xray read by someone in the E.R? " He was like "yup, one of the experienced staff E.r Docs read it during the code, and it was wrong!!" I was a bit in shock. Looking back her stomach was a bit distended. But because of the chaos, no one bother to check the breath sounds from the Et tube placement.

Looking back, it really was a chaotic night. Seemed that everything went wrong, and sometimes goes wrong. Looking back I'm sure there was a lot of things that could have been done, that was not. Overall one of the toughest nights I've seen in a while. Me and superman are still friends though his approach might not be ideal, but he tries to do the best he can for his patients.

Gd Bless

Dr.Mike

Day 342 Almost Euthanasized a patient Today !!!

It happened in the afternoon. The case manager on the floor called me and she told me under the phone if I could increase the morphine on a PCA drip that a patient who was in comfort measure (basically end of life care) I didn't really think about what she was asking me to do until it was too late. I wrote down the name of the room and went to visit the patient. An elderly gentleman about 80yrs old. Non-verbal and lying comfortably in one of the rooms on the general medical floor. I was surprised to see how relaxed and calm he was. I thought it was strange that she wanted me to increase the morphine. Anyways, I went over to the computer, and increased the morphine by 1mg on the pca pump. As I walked away to go to another floor. The nurse assigned to the patient came up to me and said "Can I talk to you." She seemed a bit upset. She then said "listen, I understand what you are doing. But I just wanted to tell you that I can't. And I'll tell you why." At this point she began to quietly cry. "I have a problem with this situation because I was the person who gave my husband the last does of morphine while he was dying. And I just can't do it anymore. I just can't.." She said the last words with difficulties as the tears ran down here face. Not even half way into the conversation I realized what I almost did. "I almost euthanasized this guy!!" I told myself in my mind. I told the nurse "I agree with you. And we will not go up on the pca dose." I'm gonna d/c the order and just put him back on his previous. Don't even touch it, leave it alone" I told her. She thanked me and walked away. As soon I walked the corner near the elevator, I looked behind me to make sure no one was behind me, and I "ran" to the nearest computer I could find to take off the order!

After all this, I took a step back to take a breath and went to the lounge. I couldn't believe what I almost did. I could have gotten in huge trouble. I can't believe I didn't realized why the case management was pushing for more morphine. The hospital has been flooded with full beds, and they are trying to discharge as much patients as they can. It seem like this guy was just in their way. I'm Glad an angel was looking at for me that day. I'm glad the nurse was smart enough to challenge the order. Glad I didn't break the Law !! Yet alone get kicked out of residency !!

Sometimes as an intern you make mistakes but some are harder to correct. The hardest of which is death!!!! I still remember running to my seniors in the unit when the patients were literally crashing before me!! I was scared out of my mind. Thank God for good team work.

God Bless

Dr.Mike

Day 339 End of the Year Update

Its been a while since I last updated the blog. I wanted to let you guys know what has been happening. I have about 2-3 weeks left in the year before we become 2nd years. Its amazing how fast time flies. I remember just yesterday spending my first night on call and spending my first weeks in the unit. I'm really glad you guys have been following the blog. I hope it has helped all of you who read it. If I have not answered all your emails please give me time. I will respond to all of them. I hope that you have walked away after reading my journey to first year with some insights into residency and the match. I have tried to post information that you can use to help you better in this years match that is coming up. Whenever there is information that helps those to get into programs I try to post it here.

I'm finishing my last 2 weeks in the general medical Medicine floor. I just finished the night float system (on-call 8pm-8am 2 weeks in a row.) I was surprised how smoothly it went. The nurses didn't seem to bother much. Most if not all of the calls where handled smoothly. I had good seniors with me. I did most of the admissions with little or no supervision. I also got to spend my night float one week with superman !!! (check out day 5 of the blog : http://thankyougodforresidency.blogspot.com/2008/06/day-5-good-bad-and-ugly.html)
Some of you might remember him from previous post. I really had a good night float with him. We had a good time reviewing some protocols and debating everything and anything. I spent an entire night arguing whether to use xopenex or albuterol on a asthma exacerbation admission that I did. He had stated that albuterol was preferred over xopenex. I didn't completely believe him, but was kind of irritated by the way he asked me about it. he kind of scolded me for placing her on xopenex. I was so annoyed I spent an hour on the internet comparing journals and articles on both of them and found conflicting information. I found articles stating that xopenex was sometimes preferred for cost because it might diminish the number of hospital stays. I showed him the articles to his surprise and we had a loud discussion about it. lol. I came of a little upset while we argued because I was annoyed that he was trying to lecture me on admitting an asthma exacerbation which we have done 100 times. Anyways overall it was a good night float. A lot of other stuff happened throughout the night float and I'll post it later.

The resident graduation is in 10 days and I'm preparing some slide show presentation which is taking me a long time to do. I have been sorting out from a group of pictures. I was also up late last night ordering some special award plaques that we wanted to give to the program director and associate program director for all their help this year. It came out about 160$ but we will try to collect money from the residents to see if they can chip in.

I also have vacation coming up. There is a group of residents that are going to the Bahamas, but me and my wife might go to Dominican Republic. I sure miss Dominican republic. We spent 6-7 years their when we were back in school. IT is a great country to relax and have fun. It was difficult when we were there, but we really miss it a lot. We lived near 27 de Febrero and went to an English/Spanish speaking school called Unibe. I'm sure a lot of you know the school. (you can pretty much find all the unibe students on facebook these days). We want to go to D.R. but the price is so expensive. I think a ticket is like 1000$ per person. We want to go to bavaro resorts that we are very familiar with.

Other happenings with my life : we have had several tragedies hit some of the residents and people that I know. One of the residents husband was found to have cancer (stage 3-4) and another residents dad passed away from cancer 3 days ago. They took some time off to deal with these difficult situations. Our prayers go out to them and their families. Its been very difficult for them. A lot of times in life you complain of problems and difficulties, only to see someone else have a bigger and more serious one. It was very devastating for us to hear the news. Specially when she also has 2 small kids with them. You hate to see people you love and care about it pain. I pray that they will be able to bear all these trying times.

I'm on call today till 8pm. I'm a little exhausted. I hope I can give a betetr update. I have blog inserts that I have finished I just have to upload them I will upload it this week.

Make sure you guys check out this blog has a lot of helpful material:
http://www.usmletomd.com/tips4match/


Take care guys. I need to take a short nap. I'm beat......

God bless

Dr.Mike

Day 334 Helicopters,Cops and Xanax

9:46 pm Man I'm tired. I'm on call the second Saturday in a row. I wanted to write about what has been going on in the hospital but I can't right now. I feel a bit drained. There is this resident that has been asking me for help to do his power point, and I guess he has never used it before, and I have been helping him even with the little time I have free this week. I hope I get some time of next week when I go to ACP in Philadelphia. (which the program is paying for !!! weee!!!) But anyways. Man I'm tired. By the way my friend called me from the parking lot before he left. He is a second year resident. He wanted me to come out and watch the helicopter on the roof. I was like "huh? helicopter?" He said "yeah you can see it hanging from the roof come and take a pic!!" I was like "this is not a joke right?" he said " no, no man... its for real. If you are coming I'm turning around." So I took my camera and I went outside the hospital lobby. And sure enough there was a helicopter on the roof. Boy my friend was excited. Not sure if he had ever seen anything like that. But he was a "kid in a candy store" happy. It got really cool when the helicopter starting moving the tail and started to speed up. And as it was taking off my friend said "you know what this means right?" I was like "what?" He said "that's means someones got a unit admission!! " He started laughing. It was a cool site to see.

Other than that the floor has been ok. I saw a patient of mines that has been pretty "un-popular" here with the staff. I remember seeing her about 2-3 weeks ago in the general medical floor. She had come in for sinusitis/ recurrent and was staying in the GMF floor, and she was giving the nurses a really hard time. I wasn't sure what they met till I went to talk to her. I think she spoke to me almost an hour. I was trying to "escape" but I tried to be understand and listen to her as long as I could. She seemed very anxious, and I have learned that sometimes anxious people just need to be heard. She when on to tell me how she thinks there is a conspiracy against her. The last 2-3 hospitals she has been to have been really bad. I think she said she was going to call her congressman. She said that she was also kicked out of R__ W___ hospital too, but that the fault was mostly the nurses. But when I saw her she was upset because they were being "racist" towards her. The African American nurses were treating her bad she said. And also her neighbor in the bed next to her had her family over last night which was about 20 of them (according to her) and she really felt a bit uncomfortable, even though she has no problem with black people. She has a lot of black friends. She says that while she was lying in her bed, there was a little girl just staring at her, and it made her really uncomfortable. She said it got so bad she even called the cops!! I was like "what, you called the cops?" She said "yup, I sure did. You can't treat people like this. What kind of country do we live in? These people are just racist." That has to be one of the first I have heard of patients calling cops from the hospital at the bed side. It didn't take too long talking to her to make me realize that she has some anxiety issues. I tried to listen as much as I can. I told her I would get the patient advocate to come and see her. The following day I saw the attending who she was under. He told me "Hey, Dr. Mike did you make MS.___ non teaching?" I smiled and laughed and told him "her? no....lol. I wouldn't do that to you. By the way, you know she called the cops yesterday right?" His eyes widened and he seemed shocked, he said "what ? are you serious?" I said "no..I just wanted to tell you. She called the cops and they came here, so if I were you I would be careful." I left the room, but I got the sense he was a bit worried. He is one for the attendings that try to avoid any legal issues or situations like this. Who can blame him? The next morning on sunday, I actually saw him come in to personally discharge her. I think thats the first sunday I've ever seen him in the hospital. I laughed when I saw him. I think he looked at me and smiled back.

Well fast forward to today , and here she was again. Guess what ? she was a patient of Dr. DEvil !!! (http://thankyougodforresidency.blogspot.com/2008/08/across-your-time-in-wards-and-floors.html) out of all people!!! I saw her this morning and she was in a state of mild panic. She seemed very upset and was angry.I said "what happen?" She said "last night was horrible. I had the doctor come in and he basically screamed at me and told me that my asthma is triggered by my anxiety, and I told him that was not possible." She then asked me to give her a second because she was upset now, and she was having a hard time breathing. I tried to "explain" to her that maybe the stress of the situation might be causing your body to react differently and it might cause you to breath differently. She said she doubts that it was from the anxiety, but that while she spoke to me she felt a little better. I told her I would give her some more respiratory treatment, incentive spirometry and mucomyst. She said ok and she agreed to try to relax. I told her if she had any problems that she could call me. Surprisingly she hasn't called the entire day.

10:12 gonna try to get some rest. Have to wake up at 4am to do some notes. and tomorrow that resident is coming to my house to finish up the power point at 7pm!!! amazing huh...... geesh must be nice to sleep and have a day off........

God BLess
Dr.MIke