Update: Trial by Fire

I don't know if everyone feels this way, and maybe its because I am the person who is choosing ER as a career, but I find challenge enticing. Not just enticing, but thrilling and desirable.
So when the program I interviewed at recently, told me they have all of the qualities below, I found myself undeniably attracted....

1- 110,000 inner city patients.  This does not feel like a program with a 'large patient volume' its more like a 50 bed clinic in the middle of Africa. They are SWAMPED. Patients actually wait DAYS in the waiting room. Most ERs have a patient per room and sometimes in the hall by the wall, all neat and organized. But they actually have minimum of 2 patients per room and patients in the middle of the hallway, at the nurses station, at the entry, they even converted the staff locker room into a pelvic room. There literally is NO space there isn't a patient.

2- Underfunded & Unionized nurses. This doesn't just mean that there aren't as many resources or staff. It actually means that once the hospital hires a nurse, they cannot fire them, for any reason. So they cut their costs nad their staff. The ER has on any 1 shift, a total of 5, yep as in # of fingers on your hand, nurses for this HUGE ER.  For residents, this means that they put in their own IVs, draw their own blood and urine labs, transport the patients to and from radiology, and if needed transfer them to the floor upstairs for admission.  The nurses give medications, unless its needed stat. If you want anything done fast you have to do it yourself. There are a few techs that do EKGs, but for the most part you learn to be a doctor and a nurse or as some people call it: self sufficient.

3- $$$.  This is located in an incredibly expensive city. I don't think its giving anything away to say its in New York.  And to pay for rent, parking, and food is just ridiculous!  Plus working all crazy hours is not condusive to public transport. Espeically for unsafe areas of the city, alone, in scrubs. I'm actually worried I wouldn't be able to afford rent much less all the cool things I could do in New York.


However, with all these patients and this huge workload-- there isn't much time left over for teaching.  All the residents I talked to said it was literally a 'trial by fire' residency.  Where they were put in multiple situations that they had no idea what to do next and nobody to ask questions to.  Several residents say they spend the whole peds shift with a nurse and no attending.  It was crazy!

But secretly, I love this idea.... I WANT to know if I will have what it takes to undergo a trial by fire. I WANT to be so overwhelmed and overworked that I have no other choice but to learn to be a kick ass doctor. I WANT the confidence to know I could walk into any situation, and when I don't have any idea of what is going on, I still can succeed.  This is the ESSENCE of what ER represents. And... working and training at this place would have the potential to be exactly what I want.  It would be the crazy dramatic medical drama that you see on TV.

Of course, that also means that in reality world, it could also be horrid. Often the drama in the shows we watch is not the norm. And overcoming ALL odds is rare and freakin exhausting. I am about average intelligence-- do I have what it takes to get no feedback, no real teaching, and after a hard overworked day still go home to study to save the patients I may encounter tomorrow??

I honestly don't know. And that is what makes me hesitate. To take on this challenge and fail, would be a disaster. Not only would my confidence be shot, my cynacism be maximized, but my skills as a physcian might not improve. I might actually learn to hate medicine, which is a big risk.  Too big maybe?

ER: the Ear

So. Let's start with the pictures first.  So +1 to this place, they make ALL their patients sign a waver as they register that we can take pictures of them for teaching purposes. So that means I can totally take pictures of anyone!!

So here is one of my most interesting cases.

32yo M presents with ear pain after altercation.  Pt states was drinking at bar and taking the keys from his husband of 14months. Pt states that his husband got mad at him and had been having some psych issues including bipolar and testosterone shots.  Out of no where, he leaned over and bit his ear off.  That's right savagely, with his teeth, bit his ear off. You can see down to his skull in the top there, down that large hole. The amount of ear left is actually very tiny and dripping blood.  The crazy facts I learned during this case is that human bites tend to be dirtier (aka more infections) and more savage tissue damage than animal bites. Look at there photos.

So what happened?  So we found the ear after scouring his car and finding it between the seat and the console. (yeah never knew that was in the job description did ya?)  And the plastics people came out and said the skin was dead, but they would use the cartelige to rebuild the ear and then add a skin graft.  The problem was the plastics guys were telling me that his ear would never actually look normal.  Also, he pressed charges against his husband, whose call he took while I was cleaning it out. Apparently he was complaining that police officers were going to arrest him and when he refused to drop charges, told the cops that the patient was 'beating him.'   Ridiculous.  I bet $50 tho that they didn't divorce, because he took his call.... twice.  Some people don't learn.

ER: audition #3

So I am at yet another hospital in yet another state, living in a closet sized room in some abdandoned wing of the hospital.  At least they give us free, unlimited hospital food and the cafeteria is open 24/7. :)

This ER is similarly big and a trauma 1. The ER is organized into "pods" which are about 20 rooms in a circle around the nurses and doctors station. 1 pod is fast track, 1 pod is trauma/ life threatening and 1 pod is middle stuff.  This seems to be a very popular set up for newer ERs. There are no windows and each pod is a different color, this means working night shift or day shift there is no difference and this isolates us in our own little ER world.

This particular ER uses a medical records system called EPIC, one of the big ones that everyone seems to like.  It is a bit different to learn, but as a 4 year, I put in orders including dosages and knowing which medicine specifically to be approved by the attending.  It lots more pressure than simply just presenting.  I am hoping to learn alot.

I also had my very first interview for residency. I now have 5 interviews again from DO places, and now 1 MD here, a courtesy interview for rotating here. This is a typical ER residency practice. Since many people only get 2-3 places, they assume if you are rotating there that you really like the program. Since they get to see you in action for 30 days most places will give a courtesy interview- which counts as a real interview.

In my first interview, it was different and as i expected all at the same time and in the end I liked the program, and will include it in my rank list, if i should decide to go DO.   However, I met a girl from my med school there- also interviewing. I didn't know her well but we chatted in her car for about 1 hour afterward. It was helpful because we could compare notes of where we got interviews, where we applied, discussed board scores, etc.  It was nice to know I'm not behind yet.  She went to the ACEP conference this year. They had a bunch of program director there and they announced that ER is more competitive this year, on par with surgery.  And that they are getting so many applications they are running behind.  So most programs have not offered interviews yet.  I feel relieved at this. I will wait another week or two before deciding to apply to 10 more programs if i haven't heard back....

more after my first shift....