ER: concluding with bubbles

Well, in the end I know this program is somewhere I want to do my residency. I feel like i know these people and this place so well that I could function here.  But when I left this rotation, I had to take a 30 question quiz that I did not do well on.

However, I did see this amazing case. Something great to remember them by.  It was a rare slow day in the ER and I was desperate to see something anything, because being idle means I have to think about that stupid quiz and what that'll mean for my chances getting in here. So finally EMS calls and reports they are bringing in a patient from an unknown trauma with unknown injuries. This report is... at the very least vague and unusual. So I decide, I'm going to take this case with the resident.

44yo M comes in on a stretcher,  he is awake and has blood on his head. EMS still doesn't know his story or what happened, they picked up from an apartment building. They couldn't find blood or heavy objects or any clues.  So we go all out, like back in my days of trauma service, priority #1: find out what happened.  We get whole body xrays, CT of the brain, STAT blood work, and begin cutting off clothes and asking questions.  The patient answers questions, but he seems not to remember what happened or who called EMS, and he also seems a bit off.  Either he's had a significant head injury or he is mentally delayed. Everyone is rushing around listening to patients heart and lungs, looking at lab work and xrays, when I do something that nobody has really done yet.  I touch the patient.  Just on his shoulder, skin to glove. I meant it to get his attention to ask more questions, but something is off.... his skin feels strange. I put my other hand on his chest, then quickly run my hands down his arms, abdomen, and legs.  Its everywhere. What is this?  I call the resident, feeling stupid because I can't explain what i feel.  It feels like bubbles, like that plastic bubble wrap you put in packages, only the bubbles move when i push on them.  The resident looks at me like I grew a second head, but since he's been working with me for a year now, he does something I don't expect.  He believes me.

He gets into the room and starts feeling the patient, yep he feels it too. Soon he calls the nurse and everyone outside looking at grey swirls of brain tissue on CT to get in here. The patient is being gently mauled by hands feeling all over his skin. and sure enough the CT shows it: MASSIVE airpockets all throughout his body.  They aren't just under his skin like we thought, they are between his muscles, around his heart, around his fat cells, and even in some organs.

This case was just so crazy, that i did steal this very illegal CT photo for you.  Its the actual guy.  Now subcutaneous air pockets can happen in patients who perforate a lung or intestine. But usually its located only in one area. The amount of pressure it takes to put air in our tissues is vast. Air outside of the GI tract or lungs is called "free air" and always a warning that the person will be on the operating table within hours. It is often the first and only indicator of something life threatening. But even the surgeons stared at this guy in awe. There were no holes in any organs they could find, but the air was everywhere. They couldn't take him to surgery because we didn't know where it was all coming from. The first theory was that it might be from a rare condition called Boerhaave's syndrome, which is a rupture or complete tearing of the esophagus.  This is life threatening and is rather rare.  The problem is we couldn't find the tear in the esophagus with the CT.  So, basically nobody knew what to do with him.

While the trauma surgeons were calling every specialist in the hopsital looking for possible other answers, we as ER were trying to come up with a way to fix his symptoms. He had no head injury and no fractures. Besides there air and abnormal but confusing lab results we had nothing to go off of. Usually for air in the body we cut a hole to let it out, but  making tiny incisions in the skin whereever there was a bubble was just assinine, he wouldn't have skin left!  So in the end we admitted him, put in chest tubes to relieve air around his heart and lungs, left a tiny air in the middle of his belly and admitted him. The surgeons told us they would be doing special studies that day to see the esophagus and make sure that wasn't the cause.  And they took him upstairs.  I never did find out what it was.... as is the true spirit of ER. :)  What a send off.... i got to conclude my month with bubbles.

Update: Residency Application

so for kicks since its a huge part of medical school, i am posting about my application process.  I'd liekt to say after 53 programs I got 2 interviews thus far that are set up. 1 is still pending.  All of them are DO so far. MD programs seem to take longer... or so I hope.

Anyway, for those not in medicine you might want to disregard the following.

ERAS is the program/internet site thru which all residency applications happen. This site usually opens in July. I honestly didn't start filling mine out until August because I was focusing on boards.  That said here are a few pearls for other students:

1- fill out the 'application' tab AS SOON AS POSSIBLE.  This is a tab that you can submit to be verified before you actually send out any applications to residency places.  It takes a few days to be verified so get it done early. Once you submit this section tho, you cannot go back and edit. SO make sure you take some time. It took me about a day to fill this part out, while watching TV.

2- After submitting my application tab, I then started to work on the 'documents' tab.  This tab includes personal statements, letters of rec and releasing your scores. If you took USMLE, you do have to release them to MD programs. Not DO.  This tab always takes longer than you want. So go ahead and release your scores, you won't have to pay for them until you apply to your first program. Also you have to go in an enter your letter writers info and you're required to finalize them as well. This is so you can enter as many letters as you WANTED by the people you WANTED. Then when they actually send the letter to the school, you can finalize the letter.  Hope you've been asking for those letters in third year.

3- Your personal statement(PS) is what really takes forever. You never really get it quite the way you want. So give yourself probably a week to get it right (or more). Remember if all you are waiting on is  your letters or PS go ahead and submit your application to be verified. So there are 3 unwritten questions you must answer in your PS: why this specialty, why pick you, what do you want to do in the future of the specialty.  Lots of ppl fudge that least question and instead answer what they want in a residency program. Its up to you. Be sure you have at least 2 other people edit it before you submit. 1 of your editors MUST be in medicine.  You are allowed to upload multiple PS. And you can edit them UNTIL you start submitting applications.

3.5-  ** many programs give you the option to upload your picture, and many highly suggest you do it. However you DO NOT have the option to use your school photo. Please go out and get a professional photo done. easy places are like JCPenny. These pictures must be emailed in digital form to your school in lots of advance. So be sure this gets done. I got pictures taken for my VSAS application third year and used the same photo.

4- IF you get frustrated with your PS you can always move on to the 'programs' tab for a few days. This is where you must search, select, and assign documents, PS, letters, photos, scores to each program.  and yes you must do this with every program. Eventually you also apply and pay money under this tab.  It is here that i recommend you research your programs.  You can search by specialty, state and DO vs MD. They also include the residency specific website.  Remember that you can select programs before you submit so you might as well get your selected programs pool started.

To apply to programs be sure you have a few criteria. For me it was a trauma level I or II, since I'm ER I wanted 60,000 patient visits per year in the ED minimum, also I wanted programs that had a DO in their program (i found this out by going to each of their websites individually and looking).  In the end I applied to 53 programs. This was approx $600.  I applied to 11 DO the rest MD.

5- When you apply remember that you will be paying in 'sections' and that your bare minimum # of programs should probably be 10. after that you can decide how many more based on how competitive your specialty is and how competitive of an applicant you are.  The general rule is 10 interviews mean you will match somewhere.   Sept 15 was the big day this year when MD programs started accepting applications.  That was a saturday, I submitted this day and 19 of my programs downloaded applications on saturday. So get them in early. I'd say the first week if you can.

6- Once you start submitting to programs, you are still able to upload NEW letters and assign them to programs so there is no excuse to wait for letters or scores. Its better to get your application in and call them once the new letter or score is available for download. Many programs will wait for all your letters or your scores... and many will offer interviews without waiting. Don't miss out. Also you can always add programs and if you want, ADD PS. For every specialty you apply you'll need a diff PS.

7- Dean's letters come out Oct 1st. No school anywhere is allowed to put them up before Oct 1st. Many programs ask for the letter early, but no program gets them. So don't let them make you feel guilty. Also students are allowed to see their Dean's letter, so keep an eye out for your letter in your email.  Don't wait until Oct to submit if you have a chance.

8- last but not least, on the very top right there is the ADTS link, it is here where you can see what documents if any each program has downloaded. This is way you can track to see who has downloaded what. if some program hasn't downloaded, or you haven't heard from them in 2 months- then you can call and make sure they had no problems with your applications.

9- You must pay and register for the match (either DO or MD or both) BEFORE DEC 1st. DON'T MISS THIS DEADLINE or you CAN'T match. If you're not sure, enter both and drop out of one or the other.

ER: presentations

I have sad news. Due to some resident posting a picture of a liver on facebook, our hospital is up in arms about us no longer being allowed to take any pictures. *Sigh* this really really sucks. I have seen so many good patient photos this month. I realize that posting pictures on facebook is idiotic, but can you really call that picture of a liver a HIPPA violation?  I mean who could say, yeah that's so-and-so's liver?  You would have no idea if it was male or female or even what race. And we do multiple liver surgeries in the day so there is no way you could know what date and assume its this one person. I call this bullshit. Most patients are happy to have their pathologies looked at by a room full of doctors and discussed. Plus how else do we get photos for our textbooks?  So my blog will be full of photos from google now... which disgusts me somewhat. But now you know. Maybe other hospitals i go to will be less freakin-out about it.

So at this point you've had exposure to trauma and surgery. So the big cases aren't the impressive ones this time. Now in the ED, they are judging me to see if i'll make a good resident. And that is almost exlusively determined by how I present. In the ER, the presentations are hard. You have to display your skills but keep their attention, you have to balance giving them the basics with letting them be confident you did a through exam. So I decided todays stories would be about crazy presentations....


First, is an elderly man who comes to us in the middle of the night from a local nursing home. The patient is demented and barely knows his own name. He cannot answer any of my questions and this means the pressure is on to do a through physicial exam. The complaint on the chart and EMS squad says his PEG tube is cracked (if you don't remember what a PEG tube is, you'll have to back to my surgery months).  The poor guy gets scared everytime he is able to see the tube because he has no memory of ever having it. I look all over the stupid tube, i even pull a tiny bit out of him, but i see no crack. I grab a syringe flush from the nurse and flush water down the tube, nothing leaks no cracks to be found.  And I decide that since I'm on my audition I'll call the nursing home and find out what is going on .  The nurse who sent him over talks to me for about 5 minutes about how the tube leaks and how there is a crack at the top of the tube near the cap. Finally I realize. The nurse is describing to me the part where the plastic tubing stops and the cap starts. She finally says yes, it comes off if i pull it hard enough.

Now I tried. I really really tried to make myself as least judgemental as possible, when i told her that typically all PEG tubes have a cap installed and while there are a few models where the tube and cap are connected, most PEGs are seperate parts. This is how its supposed to be. Immediately when i hang up, the attending comes up to me and says "wow that was a bitchy tone." I still can't figure out whether this guy was joking or not.  Then i had the pleasure to try and present this patient.

"so why is this guy here"
"the nurse thought he had a crack in his PEG tube."
"oh. Well, where is the crack?"
"there isn't one. I flushed it, there was no leaking. I called the nurse. It seems she thought where the tube and the cap came together was a crack."
"so what you're saying is the nurse didn't know what she was talking about?"
"yes."
"aren't you alittle young in your career to make those calls?"
"not if they are this obvious, sir"
"aren't you a little arrogant shit."

So that went well. I am definetly going to get a residency here after that.... *sigh* can't win.


Another case was actually the same night. the complaint on the chart read "sumac poisioning"  and you konw immediately that this patient went on the internet and self diagnosed or has had it before.  It was also weird that this person had it for 5 days and it was 4am.  So i went in and tried not to be too surprised by how the patient looked.  The chart said the patient was 55, but I couldn't figure out if it was a male or female.  There were boobs but, manly other parts.  Anyway I just took the history of this chart and the patient showed me the rash, which was a contact dermatitis. I took a through history and then went out to present.

Most presentations begin with an age and sex of the person as well as the most important big symptom/complaint they have. Like :  89yo M presents with chest pain.  or 43yo F complains of abdominal pain and fever.

I take this structure of the presentation for granted. So I started saying " This is a 55yo...." and then i get stuck. I'm like is it male or female, male or female... how can i be a doctor if i don't know this....
So i lean in to the resident and say "I don't know if the patient is male or female" And the resident immediately laughs and puts his head on the desk.  "I don't know what to do with you med students" Just as that happened, the attending came up right behind me and asks the resident "you seen the patient in 17?"
"No sir, the med student was just reporting."
He looks at me "so what's your vote? male or female?"
The residents eyes get really big. "what is going on?"
"i bet transgender, pre surgery." I say.
"i'm going to see this patient," the resident heads off...
"wait don't you want to know why they're here?" i call, resident just keeps walking. completely ignores me.


So for those of you who don't know... a basic presentation goes something like this:

"56yo M complains of chest pain x4 days intermittently that he describes as squeezing pressure. Episodes last 2-3 minutes and are relieved by sublingual nitro. Tonight he took 3 nitros but the pain was not better and has lasted 4 hours. Pt states pain shooting down his arm, no sweating or shortness of breath or back pain. Denies fever or cough. Pt has 3 stents placed last year, no previous MI, but he is diabetic. EKG shows no ST elevation but some T wave inversion in v1-v3. Pt is tachy and BP 210/48. He looks like he's in trouble to me, i'm worried about a heart attack. I think we need to get an IV in him stat, the nurse already gave aspirin. I recommend chest xray, heart enzymes, chest xray, and some pain medication.  Here is the EKG. "

So for those unfamiliar, presentations should include:  what complaint is, how long its been there, description of pain, what makes it better and worse,  what patient has tried, if the pain radiates, if he has had anything like it before, what made him come in today.  Also you must include pertinent risk factors and negative findings.  This can be the trickiest part of the whole presentation and i think its the trick to impressing them. I showed I was thinking about heart problems by including high blood pressure, asking about diabetes and previous history of stents.  Including what the patient did NOT have, means you know what to look for and shows what you asked.  In this patient, the list of things that could be causing his chest pain is LONG. So to show I've ruled out some of the causes I include the negatives.  Chest pain that radiates to the back is a symptom of aortic dissection a big big problem, but he doesn't have it.  He also don't have fever or cough, which means is probably not pneumonia or a heart infection. I also listed his vitals and physical exam, what's been done, and then the biggest part that is NEW for fourth year is MY PLAN.  I told them what I wanted to do and also that I had looked at the EKG and the test results.  I don't always have a plan, which is bad. But i always try to come up with an general idea of tests I want to run to find out what my diagnosis is.  Oftentimes, I'm wrong, but the key is they know i"m thinking about what I would do.

For auditions, having that plan and including those negative findings and risk factors.  This is what I want to master by my rotation in december.

ER: med wars

So med wars is a BIG DEAL.  It happens all across the country and is divided by region. Medical professionals (including residents, med students, nursing students, nurses, etc) are all encouraged to participate. But it usually ends up being residents and usually ER residents, maybe because they have the time or maybe because they tend to be outdoor people. Who knows.

They pretty much go to a national park, camp and then do a sort of adventure race competition during the day.  Each team has 3 people. The one i saw they began at the starting line in canoes. Their task was to make it to the first "station" within the hour.  They had to paddle some 5miles, where we were waiting. There they were given a scenario where an event happens and someone is "hypothetically" injured. They must make medical decisions in front of judges (like me!) and  we grade them.  This year's theme was an ALIEN INVASION! The first station they were told that purple clouds spouting lightning descended upon them and one of their team members ended up with a severed leg.  They had to put on a tourniquet and carry the patient out of danger before they could get their next clue and map.  While they did not sever anyone's limbs, they did have to apply a tourniquet and carry their member up a hill.   Each map had only enough information to get them to the next station, where more plotline was discovered and more wilderness medicine challenges had to be completed. Along the way there were "mini games" which included trees with signs on them asking medical questions, like when to give which medication, lightning safety, or which animal is associated with which disease.  Many of the stations were heavy physical work, including saving a baby from aliens by swimming through a lake to rescue a baby (baby doll) then swimming back without getting the baby wet. Of course then they had to do baby CPR.  In the end you had to fight the aliens and save the world. Can't tell you how, it would ruin the surprise...

The total race ended up being 20 miles including canoeing, swimming, hiking, and going through a swamp. I was a judge for many of the different stations. There were a total of 5 stations and 25 mini games. Time was a factor but they also had to get as many of the questions in the mini games right as possible, this would subtract time for you. Players start at 7am and most don't finish until 5. We had several that got lost and had to send out search parties.  This whole situation is celebrated at the end with  hundreds of pizza, snacks, drinks, soup, chile, ice cream, cookies, brownies, hot dogs, etc. Basically the biggest bonfire you've ever seen and then we sit around and camp another night talking about how crazy that plot line was or how hard it was to wade through the mud, etc.

Residents that win the med wars, get bragging rights and often get to be the makers of next year's race. Personally, i was heart broken I didn't get to be on a team. It looked so fun! But at least I got to go. This year we had 35 teams of 3. So there were lots. And it was SOOOO FUN.

Next year, i'm making a team. You all should too!! Go look it up by your region and enter your team early. Besides 3 days off it only costs $12-14 per team to register. All that money goes towards food.

ER: audition #2

So I'm back in the ER. I'd like to say that the smell of blood and urine and the anxiety hanging in the air excites me yet again. But this time, I am just numb. I feel like my confidence has been shredded into tiny pieces--- what with all the residency application stress of writing my personal statement, getting my lower than average step 2 scores back and the reality of the application submission opens saturday I am just exhausted and way too over stressed. Not to mention this is now audition season and next several months will be having to prove to everyone around me that I am a smart candidate that they should want.  

I go to work and instead of looking around at patients and stories of those in the ER, I stare at the first year interns instead. Wondering what they did to get in that spot and desperately hoping I have what it takes.  The whole of it exhausts me. I am tired of feeling inadequate and trying to prove to them that I am worth something. Not to mention, the prospect of dozens of exhausting interviews to try and make my mark--or worse no interviews at all...

The good news is that a few residents here have said they have my back. These residents get to vote when our applications come through. So now I have to decide if i want my audition rotation to count as my interview or if i want to come back for a formal one.  The option to save money is always nice, but I don't want to be out of their minds or not get a chance for the faculty to remember me.  So I don't know what to do with that.

I was also invited to Med Wars, so I'll have some pretty good stories then.

Since I have only done 1 shift in the ED, i'm going to take this opportunity to say, I'm applying on saturday for residency in the ER.  I have already sent 11 applications to DO places and i will send 30 more to MD places.  After that it is all a waiting game hoping that I get interviews and don't screw things up.  I'd like to chronicle here some of the struggles I've gone through and some of the answers I've realized, but since there is a small chance that while I am applying someone else could steal my answers, I won't risk that right yet. HAHA nothing like feelings of inadequacy to bring out my competitiveness......

Radiology: medical humor

So radiology was a bright idea of mine. I signed up for it knowing that I would be studying for my USMLE step 2. I wanted a quick and easy rotation and I wanted to be good at radiographs for my ER auditions.   This was a great idea in theory, but I can't say I couldn't have learned what I got out of my rotation in a single day.

The structure was to watch the test being done in the morning, and then watch radiologists 'read' them in the afternoon. Needless to say, this rarely ever happened.  Watching a single MRI, CT, ultrasound, is enough for me to know what i need to know. While watching the actual test wasn't all that great, I was happy to sit with the radiologists and read the panels.  I can see how some people would be attracted to this lifestyle. While many people don't give credit to these guys sitting in the dark looking at shades of grey, there is a real art to it.  And the amount of people contact is vastly underrated.  Physicians of all specialties are constantly calling and asking for clarification or questions.  Not to mention the nervous patients in the hallway, who often want to meet the radiologist.

I did have a single day in interventional radiology and I must say, this specialty might be the best kept secret in medicine. You interact with patients all day long, doing diagnostic procedures. Things like difficult lumbar punctures, artery embolization removal, and any other procedures you can think of. And when you are done, you call and tell other doctors the answer then move on to the next patient.  So if you like procedures, patients, and knowing answers who wouldn't like it?  For me, it lacks the urgency of the ER, but it was pretty close to awesome.  Since I was not able to grab any pictures, I decided to post on here a few super funny ones the Radiologists showed me.

During that day, I saw a 14 year old male with a large thrombus in his ARM.  Now for those of you not in medicine, a thrombus is a blood clot in your vein. If the blood can't leave the area, the area will swell. Thrombi can happen anywhere in your body but its is mostly in your legs.  Certain conditions can cause your blood to be sticky or clot easily, some of them include: pregnancy, cancer, or taking oral contraceptive pills.  But a clot in a kid happens very very rarely and for a clot to be in the arm is even more rare.  So it was probably a once in a lifetime patient.  The interventional radiologist did end up clearing out the clot, but we never did find out why the kid had one.

The only other neat story I have from this rotation I wish I had grabbed the CT.  It was a 'stat' read on several CT images for a patient in the ER that had been hit by a car. We were discussing the pneumothorax in the lungs (a hole that was popped in the lungs) when suddenly the radiologist leaps up and yells shit and calls the ER frantically. He asks for the resident and shouts this patient has an aortic dissection, call the trauma surgeons! Luckily, the resident had already called the trauma surgerons and the patient was whisked off to surgery. I never did find out if she made it. But it was intense. :D

*the majority of these images came from this website.  It was a pinup calendar that a radiology company (Eizo) produced to help with marketing. I thought it was hysterical. Several radiologists had it hanging up in their secret radiology 'batcave" :)