threshold

Maybe I am getting lazier.
Maybe I am getting weaker.
Maybe I am getting softer.

But:
I am not getting out of bed at 5:30 am to stand around a bed with a bunch of other residents, saying "Um, yeah, I think the wound looks better, but we'll come back at noon with the boss and check..."

Admittedly, I have never been great with early morning. Surgical rotations have always seemed hellish to me, but I could see the point of seeing surgical patients at 6 in the morning. If you have a huge belly wound, and were in pain all night, and we're going to be operating all day, we should see you before we go to theatre.

Plastic surgery, however, is not about big belly wounds.

Rounds on Tuesday were excruciating. We saw 6 patients. It took over an hour (avg # of gen surg patients seen in ward round = 17, in about 30 mins). Because there are only residents in the morning, seeing these patients is useless. We make no decisions, write no orders. We literally wake up these groggy patients to look at their wounds, then say, "We'll be back at noon with the consultant!"

I don't know if it's cos I only have 5 months left.
Maybe I'm drunk with the power of being a senior resident.
All I know is that I haven't been to rounds since Tuesday.
I may not go again this week.
And if they try to make me?
They can't. There is literally nothing they can do to make me.

Ok. I am drunk with power. Never had this realization before. May never go to work again.

PS: Last week I started work at 6am every day - it was ER shifts, so it was a pleasure to get up and go do useful, valuable work. Plastics can burn in hell.

babies for everyone!

I've been threatened with my first lawsuit!!

"J" is a young transgender woman who presented to the emergency department with abdominal pain. She said to me, "My mother wanted a boy, so she fed me hormones as a child. That is why I have an Adam's apple, some facial hair, and sound like a boy."

Ok.
"So, what hormones are you taking, J?"
"NO HORMONES! I'M REALLY A GIRL!"

Ok.
 "Well, tell me about this abdominal pain..."
"Fine. So, I'm pregnant and I want an ultrasound to check on the baby. See, I have this pregnancy test here."
(J is showing me a positive "Clearblue" home pregnancy test. The result has been drawn in with magic marker.)

Ok.
"When was your last period?"
Silence.
"I mean, how pregnant do you think you are?"
"Oh! I'm 17 weeks pregnant!"
I look at her slim build, flat stomach and overall male physique.

Ok.
 "Well, J, I'll just get you to pee in a cup for us here, we'll confirm that you're pregnant, and if that's positive, I'll grab the ultrasound machine!"

At this point J becomes visible angry. She yells.

She tells me I'm a bitch. That I should trust her home pregnancy test and that she refuses to do one in hospital. She tells me that she has a lawyer in Vancouver who will take away my license. She tells me she has a doctor in Toronto who has done a previous ultrasound that shows she's having twins. There is a lot of anger, threats and verbal abuse.

I re-iterate, "You give us a urine sample, if it's positive, I'll do your ultrasound!"

More abuse.

J eventually needs to be escorted from the premises by 4 security guards. She is a big girl. (Such broad shoulders!) As she leaves, she pauses at the physicians desk.

"I hope you don't like your job!! Cos you'll never be a doctor again when I'm done with you!"

I think about this on my way home. Lets say, worst case scenario, that my license was taken away, and that I could never practice medicine again. I have almost NO idea of what I would do for a living.

Seriously. I can't go back to Starbucks. I don't have any real computer or tech skills. I don't have the patience for customer service (when I deal with the public now, I'M always right. Ish.).

I am good at asking people personal questions within minutes of meeting them. And touching them intimately right after that.

I guess I could be a journalist?
Or a prostitute?
I'll keep thinking.

scrub-chafe

Moments I will cherish from the Peterborough ER (in 2013) -

1. Man with epistaxis (massive nosebleed) requires packing to stop the flow. "Which side did it start on?" "The left." I then proceed to meticulously and painfully pack his right nostril. After some time he clears his throat and asked, "Are you going to do the other one now?" Oops. And yes.

2. Older man brought in by paramedics. Found in bathroom with no pulse, no vital signs. They had done CPR for an hour before he arrived with us. He was, in short, very unofficially dead. I, being team leader, have to run the code. I intubate him and then immediately declare him officially dead. My staff asks me "why tube?" Answer: Um...cos he was there??

3. Stab wound to L chest causing pneumothorax. Inserting chest tube, hearing that beautiful rush of air and hearing the patient say, "Oh...that's better".

Moments I will not cherish from Peterborough the town (in 2013) -

1. Discovering that when they say, "Let your car warm up before you drive it", they mean it. Did you know your brake pedal can freeze in place?

2. Trying to find one of 30 recommended breakfast joints in P'bo's famous "cafe district". They all close between Christmas and New Years. The only open cafe stopped serving breakfast "Oh...just....now." (watching the clock tick over to 11am). They deigned to serve me their leftover oatmeal. Plain. No milk. No sugar. Tepid.

3. Coming home starving from said breakfast debacle and desperately looking for food in the apartment. Other residents have lefts bits and pieces behind. Finding a tin of "fish-bites" - herring fillets in hot sauce. Eating said herring fillets. Spilling the hot sauce on my pants and the floor. Coming home to an apartment that smells entirely of herring.

Roses and thorns, really.

I'm working NYE until 1am. Am planning to scout out a party hat and some snacks for the shift.

Would really like to come home and chug champagne, but fear that that will somehow lead to further herring-related incidents.

Worse. Could eat the pop-tarts. They expired Jan 2013, but how bad could they be?

Maturity

What makes a "bad" call shift?

When I was a first year resident, I would lie awake in my narrow bunk, praying that nobody would page me. Any night that I didn't make a decision was a good one.

Last night, I got called twice between midnight and 7am. This is unprecedented, especially for ICU call. The calls I got involved simple medication changes (labetolol, I love you) and clarification of nursing orders. I never got out of bed. At one point I thought, "This is weird. Maybe I should get up and check if everything's ok". But then I reassured myself that my phone and pager were both on and working, and pulled the covers tighter.

As it turns out, I was right to be suspicious. The junior resident HAD received a call, a consultation from ER. He had seen the patient, made some decisions about treatment and done admission orders. All of this would be fine, but he had done it without making a diagnosis. He approached the patient with a shotgun of drugs, all for different causes of respiratory failure, and gave them all.

I went over his decision making with him this morning.

Me: So. You had very sick patient, the ER gave you a terrible handover and didn't tell you why they had intubated him, you were unsure of the diagnosis and you didn't call me. Why?
R1: I wanted to manage the patient on my own.
Me: But you were worried about them and didn't know what to do. In that case, you are supposed to call for help. If not me, then the staff.
R1: But I want to manage patients on my own.
Me: (murder eyes burning through his skull) But. You. Are. Not. Qualified. For. That. You are a junior resident who is supposed to be operating as part of a team, in a teaching hospital that spells out clear rules for when to seek help.
R1: I wanted to manage him on my own. And...I thought you might want to sleep???

Now that I am a senior resident, I want to be making decisions. I want the R1's to call me and tell me what they're thinking. I am comfortable making choices at 3am that affect patient outcomes. I am happier to be sleep deprived and thinking all night than sleeping in the call room.

I guess this is growing up?

As a side note, I also did a kick-ass thoracentesis and took a litre of fluid off an old dude's chest, allowing him to breathe without oxygen for the first time in weeks. It wasn't a totally terrible night.

Humbug.

Once again, my profession is stepping up to try and ruin Christmas. Manitoba Christmas, to be more precise.

I'm sitting in a toasty living room while snow falls softly outside. My hot chocolate is Irish, my niece & nephew are napping and I don't have to shovel the walk again for at least 6 hours. Bliss, yes?

Weeeeell...

This morning we went to the Polar Bear zoo. As we walked around the "Churchill South" enclosure I was reminded of a story my boss told me.

A family med resident had gone up north with her new husband to celebrate their graduation from medicine. They canoed for 4 days, then were attacked by a bear. The girl was mauled until her husband fought the bear off with a pen-knife. He then carried his wife back through the wilderness for 3 days, trying to get help. She died on the way.

I told my in-laws this tale as we watched Hudson the Bear tearing apart a tire.

When I watch Mr G play with the kids, my first thought is, "That's how you break an arm", "That's how head injuries happen", "That kid is gonna aspirate that pen-cap"... He's big, they're small, he doesn't know the meaning of the word "aspirate".

I was hoping to let go and not think of work while we were in Manitoba, but it is not to be. Instead, I'm leaning in; when the kids nap, I'll read about mechanical ventilation. While my in-laws curl, I'll look up head-injury guidelines. As my father-in-law pounds litres of coke, I'll think about managing SVT in older adults.

Not very festive, but very G.

The Why & the How

I am on vacation this week, which means sleeping in, drinking expensive lattes and walking the dog as far as her paws can carry her. It also means a chance to catch up on my reading.

I started with "Pre-oxygenation in patients destined for Endotracheal Intubation".

It turns out that there are many things we do in the ER, that I do without thinking, that have a scientific basis I didn't know.

Why do we try and get a patient's oxygen saturation up to 100%?
Because when they drop below 90%, they lose the partial pressure of oxygen required to maintain saturation, de-saturate rapidly, develop cardiac arrythmias and die.

Why do we continue to oxygenate a patient after we have paralyzed them, effectively stopping their breathing?
Because oxygen behaves like a liquid, pooling in the back of the throat and diffusing into the lungs, even without the driving force of breath to guide it.

I know. These seem like things a kid could tell you.

Why do we breathe? Cos if you don't breathe, you die.

Still, it's nice to know that the things I do have science behind them. And I forgot how lovely academic reading can be. Coffee in hand, Pickle at my feet, knowledge washing over me in gentle waves. Almost distracts me from my imminent trip to Winnipeg. In November. Almost.

shift.

I got home from work at 2:45 am this morning. My boss of the night was very disorganized and likes to touch every patient before letting them leave the hospital. "I like to lay eyes on them, so I know you're telling me the truth..." As a result, instead of finishing at 1, I left at 2:30.

At home, the dog had eaten some chocolate chips, so I got to hear the tale of how Mr G had attempted to make her vomit (hydrogen peroxide in yoghurt, fingers in dog-mouth) and was now wracked by guilt and fear. Settling them both back to sleep (in the guest room; chocolate makes dogs poop) and I was asleep by 3:30.

I woke at 11:30 today. Washed myself, ate some food, and now it's time to go back to work. Days like this are a write-off (unless you consider burning through Netflix an achievement) and then I go, buy more coffee and go back to work. I have worn my sweat suit for the last 3 days straight. No point in changing, I've got scrubs to put on in an hour.

I know this is my dream job and technically, I'm getting all the perks of random hours. I can go to yoga in the middle of the day! No lineups at the bank! Brunch on a Wednesday morning!

I just wish it didn't take me 12 years of post-secondary education to finally start living like a teenager.