Good Night or Should I Say Good Morning?

I just came off of my night float rotation.  What is night float you ask?  Well I worked approximately 2 weeks as the night shift - coming in at 5pm and leaving around 6:30 am.  Admitting patients overnight and taking care of all the other patients on the floor - when they needed more pain meds, blood pressures dropped, hearts went into funky rhythms, or heart's not receiving enough oxygen.  Well at least my attending took care of a lot of patients and I stood faithfully by her side trying to learn.

Things I learned:  That it's better to stay up all night than try to get a nap.  That the ring of that phone we carry in which we get all the calls about our patients and admits is the worst, most dreaded noise in the world - especially while asleep and that my body has a physiologic response to that ring -my heart beats faster, my blood pressure goes up, and I hope I'm smart enough to answer the question that comes from the other end of the line.  That my stomach doesn't handle blood, guts, and puss quite as well when it has been up all night and is tired.  That my body was confused for 2 weeks as to when it was appropriate to eat and when it was appropriate to sleep.  That next time I'm on night float Penny is going to live at my friend Sarah's house, so she won't wake me up, by shoving her cold wet nose in my eye, 1 hour after I've fallen asleep when I get home.  That dusk and dawn can look very much the same.

I'm in the Tucson airport now, on my way home for my 1 week vacation.  I have an exciting day to tell you about, but am waiting to upload all of my pics before I share.

Decisions, decisions, decisions

I make probably hundreds of decisions a day.  We all do, some bigger and some smaller than others.  The last 2 weeks I have spent my days in the hospital and for the next 2 weeks will spend my nights in the hospital - learning to be a doctor.

My attending doctors slowly giving us more autonomy to make our own decisions, to figure out how to practice medicine and feel that we are managing our patient's care.  It started out small last week, with how to make my patient's poop.  "What's your favorite treatment for constipation?"  Options include - Milk of Magnesia, Colace, senna, Magnesium Citrate, lactulose, and a variety of suppositories.  So I picked one, no poop, next day try a different one.  There you go that's what I'm learning :)  Hey, all decisions matter the faster I can get my patients to poop, the happier they'll be?!
My little decisions and slowly advancing to other parts of patient care.  Learning from watching the decisions my attendings make in their choice of bedside manner - when to play tough and try to scare the patient and when to sit down and really talk out the situation.  As doctors, I am still learning much like a 2 year old, through mimicking.  I watch and then I do - picking and choosing which pieces of my attendings I want to mimic.  Taking those little pieces to make me into a doctor.

I am able to see the consequences of many of my patient's decisions.  Deciding to be an IV drug user and blowing out all of your veins may buy you a central line in order to be able to draw blood or give you fluids.  You also will likely get stuck umpteen times in an attempt to get a peripheral line before heading for the big guns.
Shooting up into your external jugular vein may cause a life threatening abscess in your neck that may actually scare you enough to come clean.  Or perhaps you'll be admitted to the hospital with what I learned is called "cotton fever."  Apparently when shooting up heroin or crushing up pills, then dissolving it in a liquid in order to shoot up - during this process at some point they filter it through cotton, but oftentimes it is a cigarette filter - well sometimes microfibers from the filter get into the bloodstream when shooting up and the body has an inflammatory response which causes high fevers.  Apparently if you go to the needle exchange program in town you can also get clean cotton which will prevent the likelihood of cotton fever.

And working in a hospital makes it inevitable that end of life decisions will be made.  When is the proper time to send your mentally handicapped brother to hospice rather than try to prolong his life with feeding tubes?  Rather to let him enjoy eating whatever he likes, but knowing ultimately he will likely die from aspiration pneumonia.  Apparently, I have learned that pneumonia is not such a bad way to go, because the brain becomes hypoxic and there is not much pain.  They know this from patients who were nearly there and came back from the edge.
What decision would you make if you were able to choose your death.  I watched from the sidelines, as she was not my patient, a late 90 year old lady make the decision on whether or not she wanted to go to surgery for an incarcerated hernia.  Take a chance to die on the operating table from a MI or other complication versus dying from your bowel dying inside of you, a likely very painful death.  Hospice is a wonderful service and provides great care to those in their last moments for both themselves and their families.  I cannot imagine making that last decision - being rolled into the OR knowing there is a good chance that I would not come out of those doors, that this was it.  Or if I do make it out who knows how long or horrific the recovery would be.  It was a decision I could see going either way - both sides equally difficult to choose between.

Decisions, decisions, decisions - all day everyday we face 100s of them.  Many are decided without even realizing we've made a choice.  I guess just keep practicing, find out what works or makes poop and hopefully when those big time decisions roll around we'll be prepared.

A little medical humor

I'm not sure if you will all find this funny, but I find it pretty hysterical.  It's a play on the stereotypes on the different specialties :)  There are more on youtube, but these are my favorites

1/4 of the way done

It's crazy, I'm already 1/4 of the way done with my intern year.  3 months have already passed out of 12.  Wow - time really does fly.  And I know with residency it's only going to get faster.
I spent the last month on my surgery rotation.  I actually took call from home, which meant I carried a pager with me at night and had to answer calls from the nurses about our patient's on the floor or occasionally go into the Emergency Department to see patient's who may need surgery.  It pushed me and made me think, because even though back up from a more senior resident or attending was only a call away - I was still the first line and didn't want to bother them with stupid stuff.

Shh...now don't tell patient's in the hospital this, but just picture.... me asleep in bed (got to go to bed early when you have to rise before the sun), sound asleep.  Then at 10:45 pm my pager goes off.  I wake up and dial back the digits that show up on my pager.  "Hello, this is Dr. Chun with surgery, I was paged."   The nurse comes on the line - informing me that my patient's pain was not being controlled and if I could give her a telephone order for something stronger.  I suspected this might be an issue earlier in the day, but had never heard anything.  My senior resident told me if necessary I could order a PCA (patient controlled analgesia) - so the patient can give themselves pain medications, obviously there are parameters and it locks out after a certain amount.  So there I am sitting in bed, opening up my newly purchased ICU book ready to read off what it tells me on how to order a PCA.  I have no idea how to order a PCA.

I don't think that's what patient's picture when going into the hospital - there's my doctor sitting in bed, glasses falling off their face as they try to read what the book says to do.  It's crazy and yet - that's one way in which we as physicians learn.  Ultimately I did not end up ordering a PCA but rather increased the strength of the medicine the patient was already receiving.  There is still so very much to learn.

3 months in and I can say that my clinic population is building.  It's fun to see the same patients back for follow up - to learn what their test results show and to be able to see them get better with treatment.  This continuity was something you don't often get in medical school.  There are those patient's you don't want to come back and then their are those patient's who you really want to take under your wing.  I guess it's like teacher's playing favorites.  At least no one has to know about mine.  ;)

I wish I had more exciting things to share, but not too much has been happening - work, work, work.  Well, I guess the other weekend I did go to a UA game.  Ok, that was fun.  College football and I don't seem to mix though.  For whatever reason, I never seem to watch the game.  I'm too busy having too much fun.  I only went to part of one Trinity game and that was while rushing a sorority and well...here are some pics from last week's game and as you can see that's not much game watching going on.

Outside the stadium!

My co-residents Vidhi and Sarah!  You can see the field behind us!

The field!  woo woo

And....just because the game is over doesn't mean the tailgating has to stop! :)

For Fun!

My dad sent me this link today and it just makes me laugh.  I've been taking Penny to behavioral training class....let's just say she can't do what this dog can do.  Heck, this dog dances better than me!  :)

Hiking Through Residency - Mount Lemmon Loop Trail

Today was the first of many hikes that I will take while in Tucson.  Sarah (my co-resident) and I headed up to Mount Lemmon for a hike.  It was a nice way to get out of the heat.

This may have been a little bit of an ambitious first hike, but we survived :)

Trail stats:

Distance:  8.6 miles

Trailhead elevation:  9100 feet

Elevation loss/gain:  2100 feet

The loop of course started out with the easier part, heading down hill.  It was cool atop Mt. Lemmon today.  I was happy to be wearing pants and a long sleeve shirt.  At the beginning of the hike, the mountain is covered with pine trees and wildflowers.  

It rained on us some in the beginning of the hike - HUGE raindrops!  Well...actually not raindrops.  Turned out it was HAIL.  That's right, I got hailed on in Tucson in the middle of August.

Storm Clouds

Proof - HAIL!

After hiking down 2100 feet the vegetation changed and became more desert like in nature.  The sun came out and the sweating began.  eww....  At this point, about 6 miles in I was still feeling pretty good.

Then the ascent began.  Let's just say it was much quicker than the descent had been.  My right calf was burning and I was sucking wind and could feel the elevation.  We had approximately 2 miles of switch backs to the top where we had originally started.  It started to rain, but it felt good - cooled me off some.  The view from this side of the loop trail was GORGEOUS!!!  It was amazing and completely worth it.  

Of course the picture doesn't do the view justice!

A horrible picture of us on our hike - nice.

By the time we reached the top I was exhausted.  Poor Sarah who drove home, watched my head bob like a bobble head in the seat next to her, trying to stay awake.  It's 8pm now - my legs still feel like spaghetti.  I think I'll be in bed and passed out by 8:30pm.  It ended up being a great hike, but probably a little much for my first hike in a while. 

Bugs on the trail:

swarms of ladybugs sitting on these plants for some reason?!

close up of a bunch!

Purple/blue beetle!!!

immature

It's funny, how I waited 4 years to finally have some responsibility.  To finally be able to write a note that didn't have to be rewritten by someone else, to finally be able to write for fluids or antibiotics and the patient actually get the fluids or medicine.  4 years!  It seemed so long, like the time would never come.

Well...the time has finally arrived.  During this last month working in the Emergency Department, I have given patients more morphine and dilaudid, than I ever imagined.  Ok, maybe not ever imagined, but A LOT.  It comes with the territory, the sickest, the ones in the most pain, the ones without insurance or primary care -they are the ones that end up in the Emergency Department.

The rotation was great - I got to get my hands dirty a do a few procedures.  I learned to think like an ER doc and got to know Sief's colleagues better.  It started to feel like a home away from home.  I was comfortable in the department and still am - which is good, because I'll be admitting a lot of patients from there soon enough.

The most humbling moment of my career happened behind those Emergency Department doors.  A moment that made me for the first time in a long time feel extremely young and unprepared.  I had a young patient, less than 50, who walked into the emergency department, but will not walk out.  I am not going to give details, but I left that night thinking, "I'm not mature enough or old enough to handle this." The weight of responsibility that is my profession finally hit.  Daily, people lay their lives in my hands, let me in on their deepest secrets, expose their most personal body parts, all because I wear a white coat and have M.D. after my name.  That's a big deal.  A responsibility I never took lightly, but also one I am unsure I will ever be able to fully grasp.

I need bigger, broader shoulders to carry certain memories with me.  I now know, some patient's will never leave my side.  They will not always be on my mind, but they will be living in my memories, right at the surface.  Time to time I will recall those patients, will reflect on the situation and remember.  Learn from those difficult patients, learn from the surprises, and learn from those who were saved and those that could not be.
As physicians we do not have al the answers.  We cannot save everyone.  There are higher powers and diseases too strong for modern medicine.

My job is to never be mature enough to handle certain obstacles that will appear in my career.  My job is to learn and grow, to embrace the opportunity to learn and to reflect.  I have sacrificed for my patients and some of my patients have and will make sacrifices for my continuing education.  I am privileged to have the honor of working in the field that I do.  Now it is my duty and joy to do the best that I can.