Things come in threes. I hesitate to say "good" or "bad" things, but you certainly start to see patterns in the people who walk through the ER doors.
Last week I had 3 people with small bowel obstructions.
The first one I handled delicately, pressing and probing gently on their swollen belly. They got blood tests, lots of xrays and a CT scan before I felt confident about the diagnosis. The second woman got a thoughtful exam, a directed xray and a call to Gen Surg. The third? Slap on the belly and straight to OR.
My latest trend is anaphylaxis.
The first, a week ago, took place at the Urgent Care Centre (eg: not the full ER) and was a bit of a shambles. The nurses didn't realise they should give the epinephrine (epi-pen to y'all) in a muscle, not through a vein. They spent at least 20 minutes looking for a vein in a woman who's throat was closing rapidly. I quickly ordered the epi IM and then spent the next 4 hours shaking with terror at what had almost happened.
The second came in during my night shift. I was stitching up a drunk teenager (one of three!) when I heard my voice being called over the speakers. I ran to the cubicle to find the Staff calmly dispensing orders and monitoring the situation. Epi in the arm, back up drugs through the drip, monitor for 4 hours.
The third was wheeled in on an ambulance stretcher, gasping and flailing her arms. The ambos called "looks like anaphylaxis"! and I grabbed the nearest nurse. "Give her 0.5mg of epi IM stat, please!" It was done.
Then I actually assessed the patient. She did NOT have tongue swelling. She did not have a rash. Her blood pressure was stable. Her heart rate was acceptably fast. She was, not, in fact, anaphylactic.
I spent the next 8 hours watching her, waiting for the effects of the epinephrine to wear off. She was jittery and crazed all night. She settled as the sun came up. I did not.
The rule of threes may apply, but I haven't seen my third anaphylaxis yet. Because I was expecting one, I went ahead and dosed a woman with a drug that can cause cardiac arrest.
I am retreating to cold wine, a soft couch and a documentary about babies.
Wednesday, August 14, 2013
Thursday, August 1, 2013
Casting Call
I like it when people break bones.
Once they're "pain-free" (dosed with tylenol and told to suck it up) we get to pull on their broken limbs and listen for a tell-tale crunch. This means: 1) the bone has clicked back into the right location or 2) everything has just gotten much worse. The clicks and pops are very satisfying, as is looking at an xray that has gone from dinner-fork to deviation-free.
However, before you xray, you must cast. In Oz, we had one formal casting session. We wrapped our limbs in stockings, in padding and in sticky warm plaster, then pretended to have battles with our newly powerful forearms.
Today, we had another casting session. I expected much of the same, even had my camera ready for the nerdy-awesome FB photos we all secretly crave. Today, I learned I've been doing everything wrong, every time.
Folds in the stocking. Folds in the padding. Wrong.
Every fold creates a pressure-point under the plaster that slowly erodes your patient's skin. Ulceration is the beginning, infection and amputation the potential conclusion.
The plaster; I thought we just wrapped it on and sent them out the door. Not so! Every cast takes 24 hours to fully anneal, so my former patients are likely to have had their casts disintegrate, melting away and letting their bones settle into weak, painful and deformed poses.
My patients may have had their casts checked early though, as my handiwork would also have ensured a stinking, rotting layer of cotton batting between their skin and plaster. Apparently, you're not supposed to dip the batting with the plaster??
Every day brings further illustration that this year was a good idea. Not for the qualification, but for the disaster mitigation. The more I learn, the more I realize I know nothing. Call me Jon Snow.
And wish me luck; tomorrow I am the trauma team captain for 24 hours. On call, watching from our balcony, awaiting the Ornge helicopter and it's bloody cargo. That or another prison fight. Kingston Pen is a valuable source of fresh wounds & limbs. This may be the best program ever.
Once they're "pain-free" (dosed with tylenol and told to suck it up) we get to pull on their broken limbs and listen for a tell-tale crunch. This means: 1) the bone has clicked back into the right location or 2) everything has just gotten much worse. The clicks and pops are very satisfying, as is looking at an xray that has gone from dinner-fork to deviation-free.
However, before you xray, you must cast. In Oz, we had one formal casting session. We wrapped our limbs in stockings, in padding and in sticky warm plaster, then pretended to have battles with our newly powerful forearms.
Today, we had another casting session. I expected much of the same, even had my camera ready for the nerdy-awesome FB photos we all secretly crave. Today, I learned I've been doing everything wrong, every time.
Folds in the stocking. Folds in the padding. Wrong.
Every fold creates a pressure-point under the plaster that slowly erodes your patient's skin. Ulceration is the beginning, infection and amputation the potential conclusion.
The plaster; I thought we just wrapped it on and sent them out the door. Not so! Every cast takes 24 hours to fully anneal, so my former patients are likely to have had their casts disintegrate, melting away and letting their bones settle into weak, painful and deformed poses.
My patients may have had their casts checked early though, as my handiwork would also have ensured a stinking, rotting layer of cotton batting between their skin and plaster. Apparently, you're not supposed to dip the batting with the plaster??
Every day brings further illustration that this year was a good idea. Not for the qualification, but for the disaster mitigation. The more I learn, the more I realize I know nothing. Call me Jon Snow.
And wish me luck; tomorrow I am the trauma team captain for 24 hours. On call, watching from our balcony, awaiting the Ornge helicopter and it's bloody cargo. That or another prison fight. Kingston Pen is a valuable source of fresh wounds & limbs. This may be the best program ever.
Wednesday, July 24, 2013
Nope.
This is the stupidest day of my life.
Yesterday, I got up extra early to be in the cardiac cath lab for 7:45. There, I was scheduled to insert a large-bore femoral line into a man's groin. This is done in order to prepare me for emergency situations where urgent IV access is needed. I arrived, put on my new blue scrubs and introduced myself to the patient, the techs, the fellows et al. I helped set up the equipment. The head cardiologist arrived.
"Ehm, this patient is anticoagulated, so it might be a bit messy. Why don't you just watch this one?"
I smiled, nodded. It made sense. If the patient's blood is thinned (anticoagulated), there is greater risk for bruising and hematomas. I watched the fellow insert the lines, taking note of the smooth and gentle technique.
They were supposed to call me in the afternoon so I could insert the lines in a less complicated patient. They called me at 2:00pm.
"Um, the surgeon is scrubbed and they're starting the procedure. Did you still want to come watch?"
No.
Today, I was optimistic. Today, I would practice a valuable skill! Scrubs on, smile in place, I arrived bright and early.
"Today's patient is a bit complicated, perhaps you could watch the morning case and..."
I gritted my teeth, smiled.
I watched today's Fellow attempt the insertion. His technique was not unlike a jackhammer. He wiggled the needle back and forth in what could be best described as "vein-shredding fashion". I watched blood bubble out of the groin and bruises form in the patient's crotch.
The Cardiologist patted me on the shoulder. "Why don't you come back for this afternoon's case?"
I had to decline.
This afternoon, from 2-5, I was scheduled for Eye Enucleation training. That's where you remove the eyeballs from corpses so they can be used for transplant. I explained this to the cardiologist, who said, "Well, if we start early, we'll give you a call..."
No call.
I arrived, full of nervous anticipation (I am a regular anatomy-lab fainter), at 2pm. Then I checked the schedule. The class actually started at 3pm. I could have tried for another femoral line. I was annoyed, but consoled myself that at least I was missing one skill to learn another.
But. The cadavers were over-preserved. The Doc tried to pry the eyelids open and they just peeled off in her hands. We attempted to gently cut around the ligaments and little bits of stuff kept flying up like formaldehyde-scented confetti. The afternoon was a write-off.
The last 48 hours have been a useless mess. I feel like a useless, hot mess. I am going to drink a bottle of wine and get a sunburn, and celebrate my birthday in style.
Yesterday, I got up extra early to be in the cardiac cath lab for 7:45. There, I was scheduled to insert a large-bore femoral line into a man's groin. This is done in order to prepare me for emergency situations where urgent IV access is needed. I arrived, put on my new blue scrubs and introduced myself to the patient, the techs, the fellows et al. I helped set up the equipment. The head cardiologist arrived.
"Ehm, this patient is anticoagulated, so it might be a bit messy. Why don't you just watch this one?"
I smiled, nodded. It made sense. If the patient's blood is thinned (anticoagulated), there is greater risk for bruising and hematomas. I watched the fellow insert the lines, taking note of the smooth and gentle technique.
They were supposed to call me in the afternoon so I could insert the lines in a less complicated patient. They called me at 2:00pm.
"Um, the surgeon is scrubbed and they're starting the procedure. Did you still want to come watch?"
No.
Today, I was optimistic. Today, I would practice a valuable skill! Scrubs on, smile in place, I arrived bright and early.
"Today's patient is a bit complicated, perhaps you could watch the morning case and..."
I gritted my teeth, smiled.
I watched today's Fellow attempt the insertion. His technique was not unlike a jackhammer. He wiggled the needle back and forth in what could be best described as "vein-shredding fashion". I watched blood bubble out of the groin and bruises form in the patient's crotch.
The Cardiologist patted me on the shoulder. "Why don't you come back for this afternoon's case?"
I had to decline.
This afternoon, from 2-5, I was scheduled for Eye Enucleation training. That's where you remove the eyeballs from corpses so they can be used for transplant. I explained this to the cardiologist, who said, "Well, if we start early, we'll give you a call..."
No call.
I arrived, full of nervous anticipation (I am a regular anatomy-lab fainter), at 2pm. Then I checked the schedule. The class actually started at 3pm. I could have tried for another femoral line. I was annoyed, but consoled myself that at least I was missing one skill to learn another.
But. The cadavers were over-preserved. The Doc tried to pry the eyelids open and they just peeled off in her hands. We attempted to gently cut around the ligaments and little bits of stuff kept flying up like formaldehyde-scented confetti. The afternoon was a write-off.
The last 48 hours have been a useless mess. I feel like a useless, hot mess. I am going to drink a bottle of wine and get a sunburn, and celebrate my birthday in style.
Tuesday, July 23, 2013
Taking the long way...
This morning, I helped the team insert five thick wires into a man's groin. Well, his femoral artery. He was awake, and I kept patting his shoulder and saying, "It's alright Mr X, it's supposed to sting a little". Then his arterial blood sprayed me.
Then I watched a video to prepare for tomorrow's lab session. In the film, a cadaver has it's eyelids cut away in preparation for corneal harvesting. Our job, as ER docs, is to cut the ligaments that hold the eye in place, then pop out the eyeball and put it in the esky (cooler, to you Canadians).
Then, I opened up my schedule for August. ER involves shift work at all times of day. I will be working for about 10 days in a row, between chunks of time off. Most of my shifts will be at night or in the evenings. I will not see much of my partner, who moved to Kingston in order to spend time with me.
This afternoon, another groin, more wires.
I am staring over the precipice of the "What have I done?" spiral.
I could be working Monday to Thursday, nine to five, with weekends and holidays, living in Toronto surrounded by friends. Instead, I picked the worst possible option for a newly married family doctor about to take on a huge amount of debt. Blerg, blerg, blerg.
Then I watched a video to prepare for tomorrow's lab session. In the film, a cadaver has it's eyelids cut away in preparation for corneal harvesting. Our job, as ER docs, is to cut the ligaments that hold the eye in place, then pop out the eyeball and put it in the esky (cooler, to you Canadians).
Then, I opened up my schedule for August. ER involves shift work at all times of day. I will be working for about 10 days in a row, between chunks of time off. Most of my shifts will be at night or in the evenings. I will not see much of my partner, who moved to Kingston in order to spend time with me.
This afternoon, another groin, more wires.
I am staring over the precipice of the "What have I done?" spiral.
I could be working Monday to Thursday, nine to five, with weekends and holidays, living in Toronto surrounded by friends. Instead, I picked the worst possible option for a newly married family doctor about to take on a huge amount of debt. Blerg, blerg, blerg.
Sunday, July 14, 2013
flipflop
I still don't know about Kingston.
It's incredibly beautiful and offers everything I've missed about Vancouver. I ran along the waterfront this morning before attending a free Yoga in the Park. I hit up farmers markets and sat in green spaces and I can stare out across a large body of water.
Now I'm missing the ease of interaction that I had in Toronto.
It's not all bad. On Friday night, I ran into a group of ER folks on their way to the bar. They grabbed me, bought me beer & chicken and told me good things about my program.
However, Saturday night, I met another group of ER folks for dinner. One girl gave monologue about viral cultures. One guy appeared to be sleeping, but would occasionally mention how much he liked hot sauce before lapsing into silence. I found myself calculating how many minutes of Netflix I was giving up to be there.
I tried to make a joke about cocaine zombies at dinner and got a round of blank stares (when coke is cut with levimasole then they call it "zombie crack" cos it makes bits of your face fall off). The average age in my program is 25, and these bright shining kids just don't get drug humor, I guess.
At least this week I'm learning ophthalmology. I will spend my mornings ramming into people's foreheads with the slit-lamp, poking them with q-tips and trying to figure out if their red eye is serious, or just allergies. I will practice cutting out an eyeball from a cadaver so that I can harvest corneas for transplant. (I will also see World War Z, so expect nightmares).
Right now, I'll watch the sunset from my window and hope I made the right choice. 2 weeks down, 50 to go.
It's incredibly beautiful and offers everything I've missed about Vancouver. I ran along the waterfront this morning before attending a free Yoga in the Park. I hit up farmers markets and sat in green spaces and I can stare out across a large body of water.
Now I'm missing the ease of interaction that I had in Toronto.
It's not all bad. On Friday night, I ran into a group of ER folks on their way to the bar. They grabbed me, bought me beer & chicken and told me good things about my program.
However, Saturday night, I met another group of ER folks for dinner. One girl gave monologue about viral cultures. One guy appeared to be sleeping, but would occasionally mention how much he liked hot sauce before lapsing into silence. I found myself calculating how many minutes of Netflix I was giving up to be there.
I tried to make a joke about cocaine zombies at dinner and got a round of blank stares (when coke is cut with levimasole then they call it "zombie crack" cos it makes bits of your face fall off). The average age in my program is 25, and these bright shining kids just don't get drug humor, I guess.
At least this week I'm learning ophthalmology. I will spend my mornings ramming into people's foreheads with the slit-lamp, poking them with q-tips and trying to figure out if their red eye is serious, or just allergies. I will practice cutting out an eyeball from a cadaver so that I can harvest corneas for transplant. (I will also see World War Z, so expect nightmares).
Right now, I'll watch the sunset from my window and hope I made the right choice. 2 weeks down, 50 to go.
Friday, June 28, 2013
First/Last
I am in my pajamas, on my couch in Toronto. Despite this, I am counting today as the first day of my ER fellowship. I have been watching videos of rapid diagnostic ultrasound all morning, preparing for our crash course next week. I have been letting the first flickers of excitement sneak past my wall of apprehensions.
Now that Family Medicine is over, (passed, attained, whatever) I do feel some regret about moving on. There were patients that cried when I told them I was leaving. Colleagues who I will miss. A lifestyle of 9-5, Monday to Friday that I got comfortable with. ER will be more challenging, with no room for error, terrible hours and less flexibility. I know this, but I am still getting excited.
I am hoping that the ER fellowship will give me lots to write about; the people who choose to work ER tend to have strong personalities, and the patients are generally bat-shit crazy. I will also be teaching residents and medical students, which has great potential for hilarity. (First win: I will be supervising my grade 9 ex-boyfriend, the most misogynistic man on the planet. I will be his boss during August. I will carry the memory of his realization face through the rest of my life.) I will also be working weird hours, alone a lot of the time, and attempting to study huge amounts of material in a small amount of time. There is a strong possibility that my husband will leave me.
All this is just to say; I will be blogging more in the future. I look forward to it.
Finally, whenever I am leaving a city, ending a program or just making a life change, I always seem to get nostalgic for the past. If you have any desire to sit down and hash out the when, why and how of the past, now's the time to do it. I've got lots of room on the couch.
Now that Family Medicine is over, (passed, attained, whatever) I do feel some regret about moving on. There were patients that cried when I told them I was leaving. Colleagues who I will miss. A lifestyle of 9-5, Monday to Friday that I got comfortable with. ER will be more challenging, with no room for error, terrible hours and less flexibility. I know this, but I am still getting excited.
I am hoping that the ER fellowship will give me lots to write about; the people who choose to work ER tend to have strong personalities, and the patients are generally bat-shit crazy. I will also be teaching residents and medical students, which has great potential for hilarity. (First win: I will be supervising my grade 9 ex-boyfriend, the most misogynistic man on the planet. I will be his boss during August. I will carry the memory of his realization face through the rest of my life.) I will also be working weird hours, alone a lot of the time, and attempting to study huge amounts of material in a small amount of time. There is a strong possibility that my husband will leave me.
All this is just to say; I will be blogging more in the future. I look forward to it.
Finally, whenever I am leaving a city, ending a program or just making a life change, I always seem to get nostalgic for the past. If you have any desire to sit down and hash out the when, why and how of the past, now's the time to do it. I've got lots of room on the couch.
Thursday, June 6, 2013
Kokomo...
Late at night, lying in a single bed and listening to frogs chirping outside your window, you might start to relax. You can feel your sunburn radiating into the cool cotton sheets. Aching muscles remind you that you chased a pack, or flock, or rumble?... of goslings around the lake in the canoe. You stretch out, settling into a deep and untroubled sleep. Big picture happiness.
Medicine is a permanent hierarchy. Regardless of how far you've come, you will always be looking up to someone, looking down on someone else.
Friends of mine have mocked my choices; Australia, family medicine, the non-academic path. These same friends come to me now with sunken eyes and pale complexions. They need to know that their sacrifice is worth it, so they try to convince me they're having more fun than me. They talk about the work they're doing; seeing interesting cases, learning interesting medicine.
Their girlfriends ask me, "How can I get him to do what you're doing? I never see him". The answer is easy, but very hard for those who need the hierarchy to maintain their sense of self.
In family medicine, the work is not glamorous. You see the same patients. You say the same things over and over again.
- It's a virus, you don't need antibiotics.
- It's gonorrhea, you need antibiotics.
- You have got to start eating right and exercising.
- You have got to lose some weight.
Your patients will tell you you're stupid. They will counter your every suggestion with WebMD printouts. They will book an appointment to have you fill out their tax exemption forms, then shout at you when their application is denied. They will threaten to sue you whenever they're unhappy, and ignore you when you do things right. You have to be able to let go of your ego and try to see the big picture.
My big picture involves working reasonable hours for reasonable money. I need to feel that I've made a positive difference in at least one person's life every day. I need time to exercise, to cook (a political action now, according to Michael Pollan) and to wrap myself around my giant man. I need time to read for pleasure. I need time for Pender.
Family Medicine gives you big picture happiness. Emergency medicine will be icing (or gravy) on top. I used to feel defensive when I talked to my Internal Medicine colleagues. Now I look at them with sympathy and say, "When you're ready to let go, come find me".
Medicine is a permanent hierarchy. Regardless of how far you've come, you will always be looking up to someone, looking down on someone else.
Friends of mine have mocked my choices; Australia, family medicine, the non-academic path. These same friends come to me now with sunken eyes and pale complexions. They need to know that their sacrifice is worth it, so they try to convince me they're having more fun than me. They talk about the work they're doing; seeing interesting cases, learning interesting medicine.
Their girlfriends ask me, "How can I get him to do what you're doing? I never see him". The answer is easy, but very hard for those who need the hierarchy to maintain their sense of self.
In family medicine, the work is not glamorous. You see the same patients. You say the same things over and over again.
- It's a virus, you don't need antibiotics.
- It's gonorrhea, you need antibiotics.
- You have got to start eating right and exercising.
- You have got to lose some weight.
Your patients will tell you you're stupid. They will counter your every suggestion with WebMD printouts. They will book an appointment to have you fill out their tax exemption forms, then shout at you when their application is denied. They will threaten to sue you whenever they're unhappy, and ignore you when you do things right. You have to be able to let go of your ego and try to see the big picture.
My big picture involves working reasonable hours for reasonable money. I need to feel that I've made a positive difference in at least one person's life every day. I need time to exercise, to cook (a political action now, according to Michael Pollan) and to wrap myself around my giant man. I need time to read for pleasure. I need time for Pender.
Family Medicine gives you big picture happiness. Emergency medicine will be icing (or gravy) on top. I used to feel defensive when I talked to my Internal Medicine colleagues. Now I look at them with sympathy and say, "When you're ready to let go, come find me".
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