Day 543: Life quote

“The weak can never forgive. Forgiveness is the attribute of the strong.". -Mahatma Gandhi

Day 540: For those Waiting For Residency,Match, and Hope

Someone once said that if you treat a man as he is, he stays as he is. But if you inspire someone; if you believe in them; if you see more than they see; if you treat him how he ought to be; then he becomes what he ought to be. I hope that in the coming match and coming year I can pass to you what was given to me. We can only give what we have received in life. And what I can give you is words of hope. Words of belief and words that were once told to me. When you look back in life you will never forget the individuals that inspired you and that have made you believe that you can be so much more in life. I can only tell you friend to don't give up on your dreams. Life may seem unfair and unjust at this point in your life, but don't give up. There are people that believe in you. I believe in you. God believes in you. The final chapter of your life has not been written yet. Sometimes your heart hurts. It is unfair and makes no sense, but just remember you are not alone in your struggle. Many people in these forums and I understand what you are going through.

Throughout your walk and journey towards residency or towards the next chapter of your life. Don't forget what really matters in life. Sometimes the greatest things you need in life are right next to you. They are found in the people that surround you and love. They are found in the smile of your children. It is found in the warm embrace of the person you love the most in this world, be it whom it may be.

You are not alone. Don't give up.Keep your head up. I felt that I had to say that to someone reading this at this moment. Perhaps you needed a pause in your life and reflection. Perhaps circumstances causes you to look again at your life and question where you are or ought to be. Sometimes in life you get everything you want but not what you NEED.

Spending months and months surrounded by people sick and dying has only made me appreciate the smaller things in life. Has made me love my wife more and more each day.

Take time today to spend time with the person you love the most.Call them. Email them. Send them a message. Tell them thank you for their patience. Tell them how much you appreciate them. Life is so fast and short. Don't let the struggle to residency and match take time from spending with the people you love. Sometimes in life you will find strength to keep moving in life by the people that surround you.

Although life is filled with difficulty and heart ache, it is also filled with special people and special moments. It is these moments that give you strength when you can no longer walk or run....

If by any chance you are someone that is far away from home, stuck in a part of the united stated living by yourself and feeling alone right now, I'm here to tell you that you are not alone. There is someone that sees your tears and weary heart. I believe that person is God, and through his son jesus Can give you the strength to carry on with your life.

Don't give up. You can do it. When all is says and done at the end of the day ask yourself only one question "Did I do everything in my power? Did I try with all my heart and soul?" If you answer yes to this, then you have already succeeded in life. What you want in life and in accomplishing a task is to give it all your heart and soul, and whatever happens be as it may. If it is written for you to be a doctor or a plumber, just know that you have not failed in life. Failing is not trying. Let God and destiny take you where it may....

There is a country song called "the weary kind" (found at this end of this message) In the chorus of the song there is a part that says "pick up your crazy heart and give it one more try..." Perhaps this year I pray that you could pick up your heart, and you give the match or residency one more try. But this time around you give it all. And "let the cards fall" where it may.

Measure your success not by the materials that you possess, but by the people that surround you, and by the moments you have spend life in love...

God be with you friend... Jesus Loves you....Keep your head up.....best of Wishes..
I believe in you...jesus believes in you.... if you need a friend you can talk to him like one...he is only phone call away through honest and sincere prayer....

God Bless.

Dr.Mike (pgy2)




Don't give up my friend.... God Believes in you.......

Day 538: Good Cop. Bad Cop

I still remember when I visited a program for a residency interview and one of the invited interviewers asked the program director- "In all your years here as program director, what makes a good resident? who were your most memorable residents, and why were they special? What made them stand out amongst the rest?" He stood quiet for a few seconds and then responded by saying "I have been program director almost 20 years, and when I look back at all the residents I have ever had, the really great residents where the ones that truly cared about their patients. They always where asking why things were happening and were always trying to find a solution. Their were many times I asked residents what certain things were happening in their patients, and many of them never bothered finding answers or maybe never really cared that much."

At the time I never really could appreciate or understand these words, but I did yesterday. We had a patient that was admitted to the unit for abdominal pain and had developed a doudenal perforation, and she then became septic and had DIC (disseminated Intravascular coagulation). She had been placed on pressors for her hyotension and was getting antibiotics and frequent platelet and blood tranfusions for her condition. I also believe that she coded one time. On of these special residents had been involved on her care the entire time at her stay in the unit. She had been working vigorously with her for almost 2 weeks. The code status had not been fully adjusted and there was no agreement because the POA was a 21 year old nephew. So whether or not they should have gone as far as they did, could have been debated. The patient yesterday seem to be in her final stages of battle with sepsis. She had been on levophed and "maxed" out (according to the ICU attending, there really is no max on levophed you can go higher with the doctors approval.)The fact that they went higher on the levophed also caused more vaso-constriction on her hands and feet, and she had been developing gangrene on her hands and feet. In the morning the intensivess had passed by to see her progress, and he was told that her direct billirubin had been going up to 20 (it was believed that maybe it was caused by the tpn, so it was stopped.) They had done a hida scan and had showed that the bile duct was being obstructed. GI had seen her and did not suggest any surgery or further testing at the time except a liver ct. The intensive said that I think its time to let her go. Within the next 3o minutes he called the family to give them the bad news. The resident that had been working trying to keep her alive also tried to contact the family. The family was not yet fully responsive and wanted a few more hours to think about it. In the afternoon the family had passed by and as I walked into the unit around 4:30pm this senior resident told me "I made her comfort measure."

I turned to her and said "you did the right thing." She only smiled and started walking to visit the patient room again.

I stood around till 5pm because I needed sign out, and I was on call. She then told me "I'm going to go into room and I'm going to do the terminal extubation." The family members came out of the room, and she went into the room with 1 nurse and the respiratory tech. It took about 10 minutes when she finally came out of the room. She turn to me and said "I did it."

She then walked over to the vital signs monitor to check on the vitals signs of the patient she just terminally extubated. It was amazing to see that within 1-2 minutes her heart rate when slowly down. 80...70...60....50...20...0. Then next to go was her heart monitor. Slowly it flat lined. I stood their quietly observing her reaction. She stood their staring at the monitor quiet with her hands folded and one arm over her mouth. She seem to be thinking about the moment. She turned around and started walking back to the resident room. I met her half way and told her "you know... you did everything you could. She was lucky to have you as her doctor. You did the best anyone could. She couldn't have lived longer with nay resident, but you." She looked at me and stared down at the floor. I think she wanted to cry but she felt shy. I put my hand around her shoulders and gave her a short hug. She sign off the other patients she had in the unit, and I told her "you can go home now."

As I walked out of the resident room thinking about all that had happened and as I was about to walk out of the unit, I turned around to look back at the patient room. I could see this resident going back into the room and I could hear her tell the nurse "we can get them the funeral numbers if you need them. Let me help you."

It was passed 5 pm and she was signed off duty. But I know she was staying longer, and she did...

On my way driving home I thought about what I had just seen. I was glad that I was their to witness what I had seen. It was good to see someone who cared. Someone who had fought for someone else. She had earnestly tried everything she could and you could see. It is good too see "bad" and "good" physicians. Its good to see people who care and don;t care. You learn what you shouldn't be and what you should be.

Looking back on what I had experienced, I knew that I would always have a clear picture in my mind off what makes one doctor stand out above the rest; about what makes a human being a special one. It is healthy to have good passions, it is even better to have passions directed towards helping others. It is not really what you know, but how much you are willing to help someone. Even with limited knowledge, someone who is fighting for the life of someone, will find answers.

God Bless.

Dr.Mike

Day 530 : ZZZZZzzzzzz.....

Well I just had the busiest night in almost 2 years in the hospital, and I think we broke the record for the most unit/ccu admissions in one night. IT was about 8 unit admissions. I have started the night float, and my night began around 7pm. It usually starts around 8pm, but a friend of mines called and asked if I could go in early. I got there at 7pm and right away a friend of mines called me to do a unit admission. He was originally suppose to do it, but since it was close to 715 and they usually take around 2 hours, I did him the favor. Anyways, so I head out to go do the admission, and it was for multiple drug overdose. Apparently, this 19 year old girl had take 4 full bottles of medication wellbutrin, propronalol, and 2 other pschy meds. IT seemed like she had a long history of mental disorders. I spoke with the e.r physician and the nurse, and she was found in the room lying on her bed very lethargic. When she came into the E.R. she had a generalized tonic clonic seizure and she had been intubated. It seemed like a pretty straight forward unit admission that we get in the E.R. As I was approaching the bed of the patient the nurse hands me the paper work and he also says, oh yeah and by the way she is the daughter of one the members of the senate or governors office of the state. I was like "huh?" I got a little bit nervous. I try to play it off like it wasn't a big thing. "Ok...no problem." I proceeded to the bed side and when I arrived there, the pt was intubated, and I didn't see any of her parents. I went back to the nurse and asked if he knew where the parents were. HE went outside to get them so I could speak to them. Geesh, I don't know why I was so nervous. I was breathing a little heavy, I guess because its someone who is "famous". Most of the people and including the e.r. attending seemed paranoid too. Anyways I met with the "member of congress or senate" No noe knew if it was for sure. They seemed very pleasant and concerned about what had been going on. I told this individual that poison control had been called and she was receiving all the appropriate medications. Her vitals were stable and her oxygenation had been wnl. She was on fiO2 of about 40percent and her saturation was about 95%. She seemed comfortable. According to poison control because of the propranolol overdose, they had place a lipid infusion. It was a very rare recommendation. The director of poison control had to be called because he had not seen it in 20 years. The fact that she was also on this lipid infusion also meant that it was binding to her propofol and versed, so she was very arousable. I had to discuss with pharmacy for another agents that we could use. In the end we dscided to give her boluses of ativan and fentanyl as the last resort. After speaking with the parents, I went over to the internet, because I didn't recognize this supposed member of congress. I checked the states website and It WASN't the senator or governor who I had spoken too. (later on the following 2 days I found out that it was an official from one of the "local districts" or possible state "assembly".) Anyways, regardless of who it was, I was a bit scared I guess. Whenever you are around a person of "power", I guess you think twice about what you did, and you want to do a good job. They even labeled her a vip, and gave her the best available room. Well after I finished this admission, I went over to try to get the sign out from the ccu resident. I called his cell phone and he said that I better come sign out to him in ccu. I didn't like the sound of that, but I went anyways..lol. When I got there, everything "seemed" in order except for the patient in bed 8 whose heart rate was in the 180-190's. She was also in the middle of dialysis when it was going on. It was probably only my second time having to personally deal with it my self. (We see it a lot on the floors but the cardiologist always handles it.) It seemed like svt on the monitor we got a 12 lead ekg that showed svy at 160. We had given her multiple bolus doses of lopressor and cardizem, but she was still running 160. So we decided to give her adenosine 6mg IVx1 which didn't break it. We were looking at the moinitor to see if we can see the underlying rythym. We gave her 12mg adenosine push and at first we didnt see any change, but then in about 2o seconds we saw the underlying a.fib or a.flutter. Me and the other resident were so happy !! We then decided to call cardiology to let them know what we had done. The suggested cardizem drip. So we started it, and no heparin drip. Anyways so I got the sign out of all the ccu patients. As soon as I got back to the lounge the other senior resident on the floor told me he had a unit sign out. I told him about the one I had done. He also gave me a floor admission with the intern. As I was going down to do the unit admission, I get a call from the ccu "hey doctor, you know the lady in bed 8 she is still tachy at around 170" I then hung up the phone and went to the bedside. She was still in svt. I really didn't want to call the cardiologist, but I had no choice to wake them up, it was not too late. He recommended to use digoxin 250IVx1 and then digoxin 125mcg uvx1 after that and also place her on lopressor 2 mg IV q4h. AND, he also added "you know you can cardiovert her if her bp drops." I answered "sure...I will do it" SO I hang up the phone and told the nurse the plan. One of the head nurses asked me about the cardioversion. And I told her "he said we can cardiovert if we have to." She looked at me puzzeled "don't the cardiologist have to be at the bedside to do this?" I told her "off course, but I guess if they trust you, they might allow you to do it, lets hope that we don't have to do it." (I have seen it done in a more controlled environment in minor or, and not normally at the bed side)

Right around this time, I got another call for another unit admission. I went down to the E.r and it was for chf exacerbation for a patient on bipap. I went to see her and she seemed more or less comfortable. On the bipap she was saturating 94%. Right around the time I was examining her, the patient in the next bed started having a seizure (she was the other unit admission my friend had just done.) She was also in the middle of dialysis. I told them to give her ativan IVx1 and repeated it twice, and to call anesthesiology for possible intubation. I called my friend on the cellphone "hey, you know that pt you just admitted? she is having a seizure, you might have to come and intubate her." Sure enough he came down in a few minuted and they intubated her. Right around this time, the E.r attending tells my friend "by the way, there are 5 floor admissions." My friend looks at me and says "can you believe this guy? I think he is going home and just wants to clear all his work?"

Anyways, we grab charts and distribute the admission between us three (me, him and the intern) About 2hours into the last admission, my friend calls me and tells me "sorry mike, there is another unit admission." I try to finish up the last admission, and head over to the other unit admission. It was a female patient going to the unit for STEMI, she had st elevations on v2-v6 and she wanted to signout AMA. I get to the bedside and she tells me "I'm not staying, I'm going home. I don't have anything." I told her "you don't have anything besides a possible heart attack." AT this time her son. who is sitting next to her says "she ain't got nothing !" I look at him a bit confused and say "I'm telling her exactly how I would say to my mother. If you were my mother I wouldn't let you go home." So I convince her to stay till the morning-which it was. Just when I was finishing this admission, the intern calls me on the cell phone "hey I just wanted to let you know that I'm not letting a patient go AMA. He is not fully oriented, and I told the nurses." I said fine and hung-up the phone. A few minutes go by and I heard an alarm go off in the hospital speakers "ALERT CODE GREY, ALERT CODE GREY." I don't think twice about it, I told myself that it was probably the alcoholic patient he had just called me about. So I finish with the stemi admission, and head back to the lounge to see if I could get a break, when the intern calls me and says "hey, do you think you can take a look at this guy. he seems to be oriented but i'm not sure." just around this time the other senior resident meets me on my way to the floor. When we arrive, this patient is on 4 point lock restraints and a body net. I turn to the intern and say "this guy is in full blown DT's and needs to be upgraded to the unit and started on IV benzo's. I almost intubated the guy, but we decided to give him a chance. We started boluses of vallium and made the upgrade to the unit.

It must have been around 5am in the morning when I called the cardiologist for the STEMI admission. He sounded half asleep and said "did you check the last ekg?" I fumbled my words and said something strange, and he said "those are not new, she has thos from previous ekg's." I proceeded to apologize and also told him about ccu bed 8 "by the way she is still in the 160's. Her bp is stable, so we havent cardioverted yet." He muffled ok and went back to sleep. At around this time I got a call from the other senior who had been called to another unit admission, and he wanted my help to do it faster. So i went down with him so we can finish it up. I don't remember exactly what it was, I was half asleep, but we finished it anyways.

Overall we had about 7-8 unit admissions (including upgrades) 15 floor admissions, one code grey, one intubation, one seizure,one SVT, one hour sign out to am team and one half angry cardiologist. All in all, not too bad.

Off to sleep.....

God bless
Dr.Mike

p.s the svt was cardioverted in the am with anesthesiology and after TEE to rule out thrombus.