Is this really it?

And 30 hour call is the only thing that's keeping me from sleeping in my own bed. I'm truly glad to be leaving Harrisburg. I did a lot of traveling, and I think the time passed quickly, but I'm not sure how much I learned here that I will be able to use in the future. I have learned that I am really terrible at being the middle-man, so when people want to complain about either side, I'm generally agreeing with them, instead of being Switzerland, which I need to work on.

I also learned that the friendships you make when the times are the worst really mean the most. I'm really going to miss these people. They are so funny to be around, and some of that could just be because I have no horrible history with them, we trucked thru this together etc, or its because there are actually really nice people out there, and I finally found some.

This marathon of two weeks straight has been pretty rough. 80hr / week should probably be illegal, as I'm not sure half the time of what I'm doing since I'm not sure I'm awake enough to function most days. As a direct result of that, I'm way behind in my working out, and I really really can't wait to get back and do that again. I feel like such a disgusting blob.

I really think that at the end of the day I will be happy. But at times, I can't see myself getting through the next 3 years without so much trial/tribulation that I wonder if its worth it. So I've been thinking of other jobs I set out to do or had that I could have done instead...

1. Ambassador - I'm probably not the right political affiliation for this anyway, but speaking Spanish still gives me more of a high than putting central lines in people

2. Broadcast Journalism- Probably with my huuuuge self esteem issues, this isn't the way to go anyway

3. Rink Supervisor. Now, honestly, if this didnt pay minimum wage, I'd have looked into moving on up. I can say this was the best job I've had. But only cuz I made the best friends while working there :)

4. Sears deposit counter. Safe job, I was decent at it... But it bored me to death!

5. Babysitter. Um... probably not a good plan since I didn't become comfy w/ kids til recently! lol

6. Travel Agent - I'd never make any money cuz I'd just take the deals myself!


honestly I'm probably on the right path. I truly believe that there is some sort of plan for us, but we're just not let in on that. I hope that I can do something cool in the future like, working for a cruise line or living somewhere because i wanted to and not because I had to. For once, I really would like to pick the place I live because it appealed to me, not because I had to go there...

anyway, not a productive blog... lol

pgy-2

So, I can safely say I did NOT keep this blog up last year.

Intern year, when I reflect, was a year of trying to balance life and work, and often failing miserably. I didn't mind the work honestly, as I wasn't pushed to better myself in the hospital very often. As usual, my favorite docs to work for were the ones that made me feel like such an idiot that I actually did go home and read. But, as with most times in my life, I didn't find these people often enough to make me happy all the time. But who is happy all the time?

Actually, most of the time I was truly happy. But who knew that the biggest stressors of a resident's life wouldn't be her patients but her co-workers. I think I spent most of my time worrying about why people hated me or treated me like crap, and very few hours at home worrying about how to make my patients well faster. I think that shows how not ready for medicine I was this year. Sometimes I envy these people who had lives before they went back to medical school... They had time to go live out some stupid kid stuff that I'm still dealing w/ since I'm only 27. Or maybe I'll never grow up, which I'm okay with too.

At any rate, I started second year on July 1st. And, I started my second year on an out rotation. I am on my toxicology rotation, which is 80 hrs/week. Its worse than my intern year, actually, at least by hours. but I'm learning I think, and that has to be worth something, right??

well anyway, i'll try to post better stuff soon...

6-11ish

So another few weeks have passed. I finished up my second week of peds ophthalmology unscathed. There were students and residents who were actually doing that for their career so I just sat back and took in what I could. lol I'd probably saturated what I was going to get out of it anyway by that point.

So I started my first in house rotation this month (september). Medicine. The bane of my very existance. I should start with, I got out of doing regular medicine as a student because I hated it so very much. There are too many things to think about and there are too many things wrong with all of these people. Its so sad to see 40 year olds coming in on more medications than most 80 year olds. Most geriatric patients are on at least 4 medications. I can't remember to take a multivitamin every day. I don't know how they do it. The simple answer is a lot of them don't. So they end up back in the hospital all whacked out again, and as an internal medicine person, its our job to patch them up and get them back out there.

I'll admit it. I cried every night the first week. I hated it. I don't have any other residents on my service, I had to ask the medical student to show me where the patients/lists/etc even were, and I just felt like I couldn't remember where to be. They have a million lectures throughout the day. I dont' know how they expect us to do anything when we have to go sit thru another freaking lecture every 2 hours or so. But, as with anything, if you keep at it, you'll come up with a way to make it work for you.

I never get there before 6 am. I refuse. I promised myself when I decided not to go into ortho that I would never electively go in for a rotation before 6 am unless it was required, and I luckily have the nicest attendings, and theyd on't mind that I don't get all the patients seen by 8 am, just that i get some of them done.

The medical student is helpful too because he can usually knock out a couple of the more difficult patients (difficult cuz the want to talk for hours) and that saves me time.

i've had some pretty complex patients come into the hospital since I started last week.

My first super complex patient was a 70ish year old man who came in generally not feeling well. He was extremely short of breath, and was unable to stand up without passing out. As I looked at him, I noticed he was extremely pale and working pretty hard to breathe. He had open heart surgery about a month prior and had a complication of an upper GI bleed, which he had to receive blood for already. I examined him and he had a positive guiaic (blood in the stool) but no occult blood seen, and he had a new murmur. this murmur was pretty pronounced as well. At this point, I was very nervous. I hadn't had this acuity on the floor before and he wasn't on a floor that could handle it if he crashed. I told the nurse to start some fluids and work on transferring him to the Unit. I called the physician in charge, and he almost poopooed it, saying to order a bunch of tests and wait for him to get there. The only relief was that when he arrived he said "okay we're going to the unit!" I was right! haha Being able to distinguish sick and not sick is a big skill. He ended up having lost about 20% of his blood into his abdomen, and received blood and an emergency endoscopy that night. about 7 days later, he's a completely different man. Very healthy sitting up in bed, getting ready to be discharged. I can't help thinking how badly that could have gone if I just waited for the doc to come later.

i have also survived a 24 hour call. I feel like I'm an invisible sort of idiot now. i had a very helpful senior on with me, which was great because I would have been so far in over my head otherwise.

We experienced just about anything on call. We had a code blue (when someone stops breathing and their heart stops beating), we had a rapid response (what they call before the code blue if someone's circling the drain) I had to see patients in the psych ward, i had 6 admissions, I had to be in the room as we told someone their dad was going to die very very soon, and I had to do a death pronoucement.

The only story I really want to share about this is what can happen when communication is less than optimal.

So I get a page and I call it back (protocol people!) and I say "this is dr barlow i was paged" the nurse proceeds "Yes, Dr barlow, we have a Mrs. X here, she was transferred from the ICU to our floor and she was doing okay for a while but she's stopped breathing." At this point I freaked out. My heart stopped. I repeated to her "She stopped breathing?" "yes" "did you call a code?" at this point my senior looks at me and whispers, I think she means she died! the nurse laughs and says "oh, this was expected, she's DNR... we just need you to come do the pronouncement" Couldn't you have opened with that line?! Anyway, poor communication!

so now i'm halfway through the month (roughly) its the hump week, as there are about 5 weeks total in this rotation. My mom comes this weekend. That won't stress me out at all! (ha!)

but, I'm getting better, and i've only been rude/mean to other residents once, and I have stopped crying about work. Here it goes to keeping up that trend!

6-7

Per usual, I have been unreliable in my weekly postings. Sorry... There is a lot more to residency than meets the eye, and a lot more stuff that I'm not willing to blog about publicly, which makes for some skewed views sometimes, and I want these postings to only reflect my feelings about work, not about my personal life as well, so... i have to wait for neutral times. This is one of those times.


So, i finished up my first month in the ER without any major hangups. I went into my second month of residency, which is considered a pediatrics outpatient month. Its also somewhat of an ER month because I have yet to take any call, and I've only worked one weekend. I'd say the highlights (or low lights?) of my first two weeks, which were spent in our Urgent Care (fast track) area include:

suturing up a 10cm laceration on a 3 year old's face. I almost threw up I was so nervous to do this. And she screamed the entire time. And I learned that if you look hard enough, every suture kit has actual needle drivers instead of hemostats. too bad I didn't find that out until muuuch later into the procedure.

I learned how to remove fishhooks from fingers. Since we live on the coast of Lake Erie, people apparently are always getting hooks in their fingers. I had never seen this before. Learn something new every day

I also learned not to trust technology. I got a letter saying I totally screwed up a script for a little girl, dosing it for someone 3 times her weight. I honestly do not remember writing it like that, but the computer must have calculated it as such and I didn't double check the script, so I was in trouble. I felt horrible for my entire shift, not to mention my attending had to watch me like a hawk to see that I didn't screw anything else up. Talk about feeling horrible.

so yeah, thats' gonna be what i'll write about for that experience.

On to the second two weeks of the month (well the first week anyway, i start the second week tomorrow). Now i'm on pediatric ophthalmology. This is something i had been dreading. Everyone had said how horrible this rotation was going to be, the hours are long, you just stand there, blah blah. Honestly, its not that bad. I have actually learned things, and gotten to see anatomy of the eye in a way I never did as a student in the lab. I got to scrub in on some eye muscle cases, which is kinda neat to see, once u stop gagging and almost passing out because ur cutting up the eye. lol its a very delicate surgery... unlike the months of ortho I did.

I get to look in the backs of peoples eyes as they are dilated if they are wellbehaved. and I decided early on, that if i got nothing else out of this rotation, I was gonna work on my interactions with children, because they used to make me so nervous. by the end of the week, I was told to consider pediatric ER because I was so good with kids.... GO ME! haha

I'm definitely not an expert in looking at eyes, but I feel wayyyy more comfortable this week than i did starting residency.

So, next week i have another round of peds optho and surgery... we'll see how it goes :)

6-1, week 3

Well, this was my third week of simulated patients, working in the ED and just getting through life knowing as positively little as possible.

my mom called today to say i should be complaining about having days off... Honestly, I need that time to clear my head and think about what has happened in the past few days... Sometimes, being in the ED can overwhelm you until you learn to dissociate from it.

I've woken up by 5 am every day this week, and Monday and Tuesday & Thursday I had to be in the ER by 6 am. by 6:20am we'd pronounced someone dead. Nothing starts off your day quite like that. I am reminded of House of God's rules... They can always hurt you more, and the patient is the one with the disease. Also I recently read Match Day, and the rules were "patients will die, and doctors can't stop it" None of this really helps when it lingers over you all day though.

It was sort of a depressing week if I had to look back at it. Several codes a day... "where' sthe best place to collapse if ur going to code?" "On television" they always get them back there... in reality, thats not the case when its real life. People usually don't make it.

My simulated patient this week was a gunshot victim. I didn't roll him fast enough to see his back where he was shot again,a nd I didn't put the neck collar on fast enough so he was paralyzed anyway. I guess thats why I'm training... so I don't make these mistakes on real patients some day.

I did get a central line this week, I'd never seen a femoral line done, let alone do one, and I got one on the second code we did. Didn't matter though, she didn't make it, but I got it in really fast, and I was really confident after that. I needed that after having so much issue with intubating this week. I was really good at it when I did my anesthesia rotation, but now that its in the ER and there are patients needing me to do it, an dthe patients are much larger than in surgery, I guess i'm struggling more than I anticipated. I'll survive, its just frustrating.

we were given the videos of our performances in the simlabs... I'm afraid to watch mine to be honest. I know I'm doing not well enough, and I wish theyd give us the upperlevels to compare. I would have liked to see how they did comparably. I could get some tips that way lol

Residency isn't always glamour and happiness... sometimes its seeing lives being shattered apart and you are standing there covered in the patients blood but for all your efforts you couldn't change a thing... and accepting that it isn't really failing, you got through everything the way it was supposed to be done, in really good time, its just reality... fate... destiny... whatever you want to call it... and it can be a bummer!

Revealing the inner doctor

I should probably start with the fact that I just completed 21 years of schooling to get to this point. K-12, 4 years of undergrad and 4 more of medical school. Approximately every four years, I have "started over" at the bottom of the totem pole and worked my way to the top five times already, only to realize life is a lot like playing Mario. You get to the last year of this level, and the princess is in another castle. Its something I have become accustomed to. I no longer fear the starting over, which is important given that I am yet again at the bottom of the totem pole. I consider Residency chapter 6.

6-1

Life in Erie, PA as a PGY1 EM resident.

I previously wrote about how I got to this point, so I won't rehash it, but I would be lying if I said I was completely confident in my decision prior to my first day in the hospital where I am working. I had two months off before I started residency. In that time, I contemplated my future, my decision to move to PA, my utter alone-ness in a new city and state. I wondered if I had settled, having found the first place that treated me like I belonged and committing myself to it.

However, vacations go faster than when you work, and before I knew it, orientation was upon me. My first event was the graduation of the past year's fourth years from my program. If there is anything more inspiring for the intern, I am not sure what it would be. I was able to see the light at the end of the tunnel before I even entered it. I knew these people, having worked with them, and I knew they were very competent. There they were, walking up, receiving their goodbye plaques and such and they left the world of academia for the real world of a full doctor's salary, no one looking over their shoulders constantly and a daily reminder of what they'd gone through to acheive this status. I met some fellow interns that night. We bonded instantly. I relaxed a little too. I had made friends, and they all seemed very nice.

Orientation was long. 2 weeks of hospital policies, manuals and ID badge creations. They talked to us about benefits, disability insurance and 403b plans. I started to feel scared again, no longer was I a student, oblivious to all of this nonsense. This was the real world too, and I just entered it.

But, nothing compares to the first real day of work.

My first day, July 2nd (the first was a didactics day so I don't count that as my "first day"), we had to show up in the ED at 6 am. The plan was 6-1 we'd see patients in the ER, then from 1p-6p we'd go out to the simulation lab and practice key procedures such as chest tubes, intubations, etc, that as EM residents we would be looked to do w/ confidence. I certainly didn't have the confidence yet.

I vividly remember picking up my first chart: Chest Pain. "oh no" I thought in my mind. I quickly looked to see where the patient had been triaged, 206. Not a critical care room. "phew" I thought. The program director showed up, and since I had worked there as a student, he said he felt confident that I could see the patient on my own first. Okay, here goes nothing, I thought. I took a blank piece of paper for notes, along with the patient's chart into the room. On my way I reviewed my pockets "stethoscope, ink pen, penlight, check check check" I was ready. I entered the room after knocking. "Mrs Davis*(name changed), I'm .... Doctor Barlow, and I'm here to take care of you today." It was the first time I'd introduced myself to a patient as a doctor. I almost said I was a medical student! After introducing myself as such for four years, it rolled off my tongue too easily. I had to actually think about each thing I was doing, including my introduction! After my introduction, I awaited the patient to begin laughing, or to say that she didn't believe me. I didn't believe myself to be honest. It was the defining moment of "I have begun my new life."

I had dreamt about that day for years, since I decided to go into medicine. But after it actually happened, I was just surprised how it felt and how easily patients trusted their doctors. I ended up working her up for everything, but my gut told me this was not cardiac (heart) in origin. I was right. My attending had said he agreed with me but we had to cover the bases. I am new, he suggested, so i needed to get used to doing the workup too. Plus, she had a cardiac history, so we couldn't rule it out.

The rest of the day went smoothly until we went to simlab. My first day in simlab we were going over intubations (putting a tube in the trachea to aid in breathing) and crichs (when you cant intubate u can put a tube through the front of the neck to access an airway). I look at these days like this "here's what you're supposed to do, and if you screw it up, or can't manage it, here's how u fix it." I've tubed approximately 30 people, because I did a 2 week anesthesia rotation as a medical student. I felt very confident I could handle this. However, I struggled a great deal. The manniquin we were using was a very difficult intubation. My fellow interns struggled as well. Finally, I got it. It was a serious blow to my already fragile intern ego. I had to work extra hard after that to build some confidence, but I haven't missed an intubation on the manniquin since. I'll let u know how my first one post-manniquin experience goes when it happens.

The next day of work was a Friday. We dubbed Friday's "Vagina Fridays" because it seems that there are a lot of cramping/bleeding/etc complaints that come in on Fridays. My first patient started off Vagina Friday with a bang. Her chief complaint (reason she was there) was that she started her period. I took the chart, looked at the program director and laughed while I said "I quit..." He said I was already cynical, but he appreciated my honesty. I went to see the patient. Now, whoever said there was no continuity of care in the emergency department just didn't hang out long enough. I saw this patient while I was a medical student. I recognized her as I walked in the room. I also recognized her complaint then. We had treated her before for an STD, and she was back again. I tried to explain to her the importance of safe-sex practices and taking the medications we were going to prescribe her. I really hope not to become her OB/GYN, as I didn't go into that field, but if she comes back again, and she probably will, I'll continue to educate and treat her.

On Wednesdays this month, we're having test-out days. Every Wednesday morning, I arrive at the simulation classroom at 845 am prepared to treat the manniquin for whatever his ailment is. the manniquin is very expensive, it has a pulse, heart beat, lungs that inflate, (as well as a belly if u intubate incorrectly), and can even talk to you by means of the person "behind the screen" doing the talking. (similar to the Great and Powerful Oz in Wizard of Oz). However, unlike Dorothy I can't have my trusty dog go and remove the curtain to make it appear more normal!

My first encoutner the patient came in having chest pain. He was having a heart attack. A million things ran thru my mind, "ekg, cardiac enzymes, oxygen, morphine, aspirin, nitro" but only a few of them came out of my mouth. The patients heartbeat changed on the monitor to pulseless v-fib (the heart quivers but not enough to pump blood adequately to the body). I saw the change, recognized something needed to happen, but completely forgot to deliver a shock to the patient's chest wall. I couldn't figure out why the blood pressure wouldn't rise. I intubated, put in a central line (my hands shook so hard that apparently they could see it on the video later), hung more fluids, administered drug after drug, and then tried consulting cardiology. After 10 minutes, I realized "OMG DUH" and I ordered to shock the patient. Because it was my first time, and the patient was simulated, and probably because they felt bad for me, they allowed me to revive the patient. "in the real world, if you had gone that long w/o shocking him, he'd be dead" my program director later mentioned to me. I killed my first sim man in less than 10 minutes.

The next week, I was determined to do better. I studied ACLS, I read things online, I reviewed procedures. I wanted to make sure I could handle what they threw at me. I arrived feeling much more prepared knowing what to expect to the following Wednesday's "mock code".

This week it was a patient w/ COPD, who was having difficulty breathing and was turning blue. This time, the case required we know how to do RSI (rapid sequence intubation) which required a series of steps since the patient was awake. Intubation can cause the patient a lot of stress and to vomit if done while the patient is alert. I quickly looked up dosages of a commonly used induction agent as well as a paralytic. I knew what the case wanted. I quickly asked the patients permission to intubate him to help him breathe. He agreed. I gave the drugs and intubated the patient. Then I realized the patient's cause of not being able to breathe. Pneumothorax (one of his lungs had collapsed, probably secondary to a bleb (large air bubble in the lung) popping. The treatment is first sticking a needle in the top of the chest to allow the negative pressure to escape, followed by a chest tube. I nailed those. Then the patient had low blood pressure and the IV wasn't adequate, therefore he needed a central line (an IV into a major vein belowt he clavicle). I got that on the first try as well. This went much better than my last test. The program director said he was very impressed, and said not to get too comfy since next week would undoubtedly be harder. I felt good though, my patient lived.

My residency is unique. The ER residents don't have to take call their first two months because they're on ER services. I won't know what the horrors of residency are until September when I start on medicine. Call is every four days with multiple weekends. Nightfloat keeps us from staying all night during the week, but weekend call is long and overnight. I will become accustomed to that lifestyle, with a retreat back to the ER every 4 months. I'm hoping that the floors are as nice as the ER is... but for now, I just had a week off to collect my thoughts, and appreciate my new life, which I cant imagine ever having questioned in the past. I'm very happy with what I've chosen as my profession, and I love living here. I'm making friends too, which I think makes a difference. It helps to have people to run around with.

But mostly I can't wait to get back into the ER tomorrow morning, even if it is another 6 a- 6p day... I belong there and I can't wait to grab another chart, introduce myself as Doctor Barlow, and get to work solving the mystery of why they came in this time.