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.
