Wednesday, February 6, 2013
Friday, January 25, 2013
Underserved: Free Clinic & Homeless shelter
So this is a required rotation and honestly, I signed up for the site I did was because I wanted to be close to home. I also wanted to blow it off because I was so burnt out of working in places where I have to try to prove to someone every second of every moment that I belong there.... I just wanted to something chill. So I picked somethin close to home. And my school strong armed me into this place 45 minutes away from my parents. Its a free clinic right next to the homeless shelter, where I slept during the week--- partially.
And it was so much better than I ever could have asked! This rotation is stressful because well, any rotation during January is because that is when all medical students have our Rank List is due. (more on that in a different post). Anyway, suffice it to say I have to sum up all the choices I have for residency.
But this place functions only on volunteers. Which means that we only had docs, what 4 days I was there. The rest of the time we had other students and the one nurse practitioner who ran the place and signed our scripts if needed. So it was ALL me. Nobody checked behind me. I was the doctor.
It was intimidating but it also was the single best learning experience I've ever had. It forced me to go remember what I learned and remember mistakes on the job. And the clinic was special. We didn't deal with insurance. So it means that I now know almost every medication on the $4 list by heart and where to get what medication for cheaper. I also now know the dosages for most of the antibiotics as well. For example did you know, Albuterol inhalers without insurance costs $45.
Beyond no insurance, we also don't have nurses. So we did our own procedures. Preg tests, Urine Analysis, Blood Sugar, Vaccinations, and all the paper work that goes with it all. Its actually super helpful to know.
My favorite part was working with so many students. Nurse practitioners and PAs and med students. And we could all sorta be each other's brain trust and bounce ideas off each other and it was the kind of environment I wanted to work in!
This whole thing ended up being pretty cool, because my patients would call in and ask me questions or specially request me. I had refills and it made me feel very official.
So i decided that if i don't get into ER this year.... I will be applying for family med. And maybe I won't be so unhappy with that....
And it was so much better than I ever could have asked! This rotation is stressful because well, any rotation during January is because that is when all medical students have our Rank List is due. (more on that in a different post). Anyway, suffice it to say I have to sum up all the choices I have for residency.
But this place functions only on volunteers. Which means that we only had docs, what 4 days I was there. The rest of the time we had other students and the one nurse practitioner who ran the place and signed our scripts if needed. So it was ALL me. Nobody checked behind me. I was the doctor.
It was intimidating but it also was the single best learning experience I've ever had. It forced me to go remember what I learned and remember mistakes on the job. And the clinic was special. We didn't deal with insurance. So it means that I now know almost every medication on the $4 list by heart and where to get what medication for cheaper. I also now know the dosages for most of the antibiotics as well. For example did you know, Albuterol inhalers without insurance costs $45.
Beyond no insurance, we also don't have nurses. So we did our own procedures. Preg tests, Urine Analysis, Blood Sugar, Vaccinations, and all the paper work that goes with it all. Its actually super helpful to know.
My favorite part was working with so many students. Nurse practitioners and PAs and med students. And we could all sorta be each other's brain trust and bounce ideas off each other and it was the kind of environment I wanted to work in!
This whole thing ended up being pretty cool, because my patients would call in and ask me questions or specially request me. I had refills and it made me feel very official.
So i decided that if i don't get into ER this year.... I will be applying for family med. And maybe I won't be so unhappy with that....
Thursday, December 13, 2012
ER: last stand
Another hospital and my very last ER rotation. This one is a big deal. A much bigger hospital system with many different hospitals. And allegedly my biggest chance to shine since I've had lots of previous experience before, but something was up with this place. The people were fun, other students who were rotating, but the residents and the attending docs I dunno they were just blah. They didn't really want to be there, nobody was super pumped to be there. And the whole time I just couldn't put my finger on it. But I knew I didn't really want to go there, even tho they looked awesome on paper. This hospital system saw crazy amounts of pathology tho.
One of my best cases was 29 year old was dropped off at the ER all burned over his thighs, legs, arms and belly. He stated he "woke up and was on fire." So we are in the ambulance with him in the back. He has already been intubated, as we must do with all burns over 40% of your body to prevent lung collapse (this is a long explaination just trust me on that) so he is unconscious. When we get to the big hospital, they route us to the wash out bay. Apparently, since the fire is of unknown origin and obviously suspicious they are going with meth lab explosion. Since that kind of a burn would involve various caustic chemicals that could burn hospital staff it means we must go through decontamination protocol and wash him off with a certain amount of water before they will bring him in the building. Unfortunately, this guy has been crashing in the ambulance, with irregular heart beats and the heart monitor is not something that works well when sprayed with water.
Despite our attempts to fix it, they took off his monitor for 3 minutes to wash him down. Luckily, nothing unseemly happened and the doc got in to see him right away. It was quickly determined these burns were not from a meth lab explosion but rather from electricity. The muscle in man's leg was rock hard under those horrible burns. It was something I've never seen in real life until today, but something med school always warns us about: Compartment Syndrome. The muscles and skin in his body were so inflamed from having electric bolts running through them, that they were expanding and filling his thighs to the point where they choked off his arteries and nerves. He can lose body parts and eventually have his heart give out because of this. The doctor took out a big knife and cut a long, deep cut down to the muscle from pelvis to knee on both sides, his pink muscles squeezed out of the cuts like toothpaste. Then he did his arms, lucky this guy wasn't awake. Apparently, he had been stealing copper wire from a live set of wires on a power line. And of course got burned. He ended up having several of his fingers amputated because the flesh and muscle were so burned they would never be functional again. This is a picture of his hand. I didn't get the best shot, which was his palm because the docs didn't want me to take pictures because of his critical condition.
Beyond that case, I did get to participate in a Code Grey or a Mass Casualty. We had a huge 10+ car pile up including a bus full of kids. So we called in all our docs and had people being checked over in hallways, closets, and 3 people per room. We had crazy parents running all over the place and causing a rukus, which didn't help anything and in the meantime we had several seriously injured adult patients from the same crash. It was amazingly chaotic, just the way I like it!
We also had a inner hospital tradgedy. A 28yo internal med resident who went down to the ER on her shift and checked in as a patient because she had such a huge headache. And 6 hours later, she was dead. Meningitis. It was intense. Everyone around the hospital that day was crying and calling in to see if they could get antibiotic prophylaxis. Then her parents came and everything in the hospital stopped because everyone wanted to talk to them, docs, nurses, even some patients for whom she had made a difference. It was just so close to home, I think it really made a lot of people think hard about their choices.
The final crazy story I have from this rotation was a 15yo boy who came in after playing paintball. He had taken off his helmet to wipe the fog from the visor, when a paintball nailed him in the eye. When I saw it was swollen to the point where it couldn't open even when i tried to pry it open. THe poor kid was in shock I think, because he didn't really know what was happening. We got a CT scan to see what was going on and we noticed that the normal bulge of the eye wasn't there. And sure enough, the eyeball had ruptured, we call it a globe rupture. There is very little likelihood that he will ever be able to see out if it again. They took him to surgery to see if they could save it. This case was especially memorable for me, because I had to tell the parents what happened and that their son would most likely not have 2 eyes. Last I heard, the surgeons were discussing glass eyes with the parents.
One of my best cases was 29 year old was dropped off at the ER all burned over his thighs, legs, arms and belly. He stated he "woke up and was on fire." So we are in the ambulance with him in the back. He has already been intubated, as we must do with all burns over 40% of your body to prevent lung collapse (this is a long explaination just trust me on that) so he is unconscious. When we get to the big hospital, they route us to the wash out bay. Apparently, since the fire is of unknown origin and obviously suspicious they are going with meth lab explosion. Since that kind of a burn would involve various caustic chemicals that could burn hospital staff it means we must go through decontamination protocol and wash him off with a certain amount of water before they will bring him in the building. Unfortunately, this guy has been crashing in the ambulance, with irregular heart beats and the heart monitor is not something that works well when sprayed with water.
Despite our attempts to fix it, they took off his monitor for 3 minutes to wash him down. Luckily, nothing unseemly happened and the doc got in to see him right away. It was quickly determined these burns were not from a meth lab explosion but rather from electricity. The muscle in man's leg was rock hard under those horrible burns. It was something I've never seen in real life until today, but something med school always warns us about: Compartment Syndrome. The muscles and skin in his body were so inflamed from having electric bolts running through them, that they were expanding and filling his thighs to the point where they choked off his arteries and nerves. He can lose body parts and eventually have his heart give out because of this. The doctor took out a big knife and cut a long, deep cut down to the muscle from pelvis to knee on both sides, his pink muscles squeezed out of the cuts like toothpaste. Then he did his arms, lucky this guy wasn't awake. Apparently, he had been stealing copper wire from a live set of wires on a power line. And of course got burned. He ended up having several of his fingers amputated because the flesh and muscle were so burned they would never be functional again. This is a picture of his hand. I didn't get the best shot, which was his palm because the docs didn't want me to take pictures because of his critical condition.
Beyond that case, I did get to participate in a Code Grey or a Mass Casualty. We had a huge 10+ car pile up including a bus full of kids. So we called in all our docs and had people being checked over in hallways, closets, and 3 people per room. We had crazy parents running all over the place and causing a rukus, which didn't help anything and in the meantime we had several seriously injured adult patients from the same crash. It was amazingly chaotic, just the way I like it!
We also had a inner hospital tradgedy. A 28yo internal med resident who went down to the ER on her shift and checked in as a patient because she had such a huge headache. And 6 hours later, she was dead. Meningitis. It was intense. Everyone around the hospital that day was crying and calling in to see if they could get antibiotic prophylaxis. Then her parents came and everything in the hospital stopped because everyone wanted to talk to them, docs, nurses, even some patients for whom she had made a difference. It was just so close to home, I think it really made a lot of people think hard about their choices.
Monday, November 12, 2012
Allergy: frustrating
So allergy rotation is 2 weeker. And to be honest, its hard to focus on it. The doctor doesn't even see his own patients- he has his nurse practioner do it. Which is totally fine, she is very competant and has been working with him for 15+ years. She knows what to do and what he would do. But it makes it so boring for me. I don't even see patients by myself I just shadow silently. It bores me to tears I actually bring my LAPTOP to work and in between patients have begun reading kindle books. If you are a preceptor who is somehow reading this, let the students at least THINK they are helping or doing something. It is so hard to have gone over a year doing things, at least training to form opinions or learn things, to go back to being silent in the corner. I'm no longer satisfied with just being there, I want to engage.
Anyhow, sorry no pictures unless you want endless rashes.... which i don't care enough to even take pictures. I suppose it also doesn't help that i have serious romantic troubles and also maybe if i learn something rather than staring at walls, i will post more.
Anyhow, sorry no pictures unless you want endless rashes.... which i don't care enough to even take pictures. I suppose it also doesn't help that i have serious romantic troubles and also maybe if i learn something rather than staring at walls, i will post more.
Saturday, October 20, 2012
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?
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?
Friday, October 12, 2012
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.
Thursday, October 11, 2012
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....
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....
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