Fortunately, I only have one more shift left, and the nice thing about working in the ED is that it’s shift work. That makes up for the 10 bajillion other issues that make it difficult. The weirdest thing about seeing patients in the ED is that you’re only seeing a tiny sliver of the patient and family dynamic, usually at their worst moment. Because, you know, they’re in the ED, and you only go to the ED (supposedly) when you’ve got an emergency. And how many people do you know who are at their calmest, most communicative, friendliest, smartest selves when they’re in the middle of an emergency, or occasionally, an “emergency”?

Also making it hard to work is my ever enlarging girth in the setting of physically demanding spaces, which the ED is all about - it’s an ergonomic challenge, to say the least. Doing lumbar punctures and IV’s and catheterized urine samples kind of sucks if you’re not comfortable.  The other day, I started a cath urine on a (very strong, extremely wiggly) kid and started having a contraction right in the middle of it. Fun! Also, if I don’t drink at least 3 liters of water a day, I start having contractions, and (a) it’s hard to drink 3L of water in the ED, and (b) it’s hard to pee that much when you’re in the ED. I’m tempted to just roll around with my own IV bag and IV pole, although again, how am I going to do lumbar punctures or suture a laceration with an IV in my own arm?

Oh, and I forgot to mention, I’ve “graduated” from residency. We had a graduation ceremony and an end-of-year party to close out the year, and I was tempted to get all nostalgic about my last three years or at the very least, excited about moving on, but really, I’m just too tired to care. Honestly, what would make life easier these days:

[1] normal sized ankles that are not made of memory foam.
[2] someone to make me a real solid dinner every day, instead of stealing ginger ale and crackers in the ED and eating pre-packaged pineapple chunks and chugging milk from the container when I get home.
[3] a real pineapple-fruity alcohol based drink instead of pineapple chunks.

I might have even put on that wish list that I just want this pregnancy to be done and over with, but that’s not true. Gully needs to stew for a little longer because I have to get through new-fellow orientation and some clinic time in July which I have a feeling I’ll enjoy, but honestly, if she wants to be a late pretermer, I don’t mind one bit - their outcomes are apparently ok, despite all the recent hub-bub about neurodevelopmental outcomes in late pretermers.  The nerd-bomber in me has already lovingly cleared a space in my file cabinet for my NICU fellowship and labeled a new file folder “late preterm - dev outcomes,” and I’ve packed a few articles into it; not that I’ve actually read the articles. Does this count as “nesting”?

As for the actual physical nest, I think it’s almost done, mostly thanks to Joe, who assembled the crib, purchased a twin bed (for nights when cluster feeding shouldn’t prevent the other parent from getting a solid 4-6 hours of sleep or when my mom or dad will be “taking call” with Gully when I’m on call at the hospital and Joe’s in California), hauled furniture around, hung curtains and pictures, washed all of the clothes we’ve amassed, and tucked little diaper inserts into her tiny little Gdiapers. He even bought diaper wipes and butt cream. I think he’s more ready than I am - as evidenced by the fact that he will bend down and tell my girth, “hurry up, I want to meet you!”

Last week, I meant to call Joe for a “check-in” conversation (only because we hadn’t talked to each other in 72 hours), but we both ended up getting very worked up about health care costs for some reason.

I don’t remember how it came up, but for example: do you know how much it costs, in your state, for you to get an x-ray if you break your ankle? You probably don’t. Because it isn’t listed anywhere that is particularly easy to access. And I don’t care if you’re a liberal or a conservative - aren’t you even curious about how much it costs?

Now that I’m 3 years into residency, I am amazed that I know how to suture a laceration but I have no idea how much that service, plus the sterile drapes and lidocaine and suture material, costs. This has come up maybe only twice in my training.

Once, a family from France was visiting Boston, and they needed to have their daughter’s foot laceration repaired in the ED. They asked me how the hospital would be able to bill them for the service once they left Boston, and if they could just write a check right then and there for the service.

Another time, I was a third year medical student at SFGH, on a trauma surgery rotation, and a woman visiting from China rolled in strapped to a gurney, after having been badly injured in a car accident.  Through the medical interpreter, she wanted to find out how much a chest x-ray would cost before they x-rayed her; she explained that she had used up all her savings to come visit her daughter in the U.S., and wouldn’t have any money to pay for this accident.  The senior trauma resident rolled her eyes and said to the interpreter, “Explain to her that in America, we save lives first and worry about the cost later.”  I think that despite the patient’s furious protestations, she was wheeled into an OR anyway to stop her massive internal bleeding.

The lesson learned here - maybe people outside of the U.S. are more cost-conscientious about health care than we are?

I am very much in favor of universal health coverage, and I do understand the argument that if you’re in a real pickle - if you are so unlucky as to be a victim of a massive car crash, or your son develops leukemia - you really don’t want to have to worry about the cost of your medical bill.  You don’t want to even be unfortunately jobless and have to see your primary care doctor for a nasty cough and fever - because what if you have pneumonia, and have to pay for a chest x-ray and antibiotics? (And not knowing how much this costs beforehand can be really scary if you have no income but a potentially huge bill looming).  So why can’t we make costs just a little more transparent?

I start in the ED this week, and I just know something about cost containment and the ridiculousness of the ED will make me have a conniption.  (Although there are plenty of other things about the ED that I know will make me have a conniption, but that’s another story…)

And now for a completely separate topic…In more amusing news, Joe and I went to our “birthing class” over the weekend (cost: $185.00! Insurance reimbursement? Questionable!) and Joe learned that amniotic fluid is fetus pee.  “What’s in it that makes it okay for the baby to breathe it in and swallow it?” he asked me later that night.  I really wish he had asked the RN teaching the class instead, but then he pointed out there was another couple in the class with an annoying engineering husband who was asking annoying technical questions, and Joe pointed out “it’s people like him who give nerds a bad rep.”

ME: “It’s got hormones and nutrients and proteins in it that are important for growth and for their lungs to mature. I think.”

JOE: “Okay, but, still, it’s got waste products in it.”

ME: “Yeah, but it’s sterile, not like our urine, because the whole womb is sterile.”

JOE: “Okay, so if I, like, microwave my pee and drink it and aspirate it, will I be okay?”

ME: “Uh.  By all means, give it a shot.  I dare you.”

Not that I’m complaining (well, actually, I am complaining) but I would really like a tiny break between residency and fellowship instead of an overlap.  It is not a huge overlap - just 5 days - and fortunately, it’s just a few days of adolescent medicine clinic that I’ll be missing to attend orientation for fellowship.  But it’s enough of an overlap to create a likely adjustment disorder in my mind.

The scheduling powers-that-be have been sage enough to put me on “back up call” and “clinic” on my first month of fellowship in July in case I deliver early, which means that with some advanced warning, I can get called in to take call or cross-cover someone who may be sick or otherwise ill-disposed. However, I’m not sure how that will work if I’m unfamiliar with the NICU that I’ll be covering in.  Because I hate the fact that I will be brand squeaky new at my job and will not even know where to find scrubs nevertheless intubate a premature 28 weeker (haven’t done this since my second year of residency) or place a chest tube in a baby (haven’t done this ever), or….lots of ridiculous skills that I wish I were more confident with.  I know that’s part of the point of fellowship training - to get better at this stuff - but I also know that the first year of fellowship is going to be harder than intern year.

At this stage of residency, however, I am also extremely mentally exhausted, and I want a small break.  A long weekend in Vermont, or something equivalent would have been nice.  The one weekend that that I had off where this was possible is now being eaten up by a semi-baby shower that my in-laws are hosting; neither Joe or I wanted this, and we should have been more adamant in refusing, but now we are stuck.

I think this pregnancy is also making me tired.  My feet have swollen width-and-length wise to the extent that I needed to buy new shoes that are a whole size and a half larger because the only shoes that fit now are my Crocs.  Also, the joints in my hands hurt like arthritis because they are so swollen.  I wish my physical limitations didn’t make me so cranky!  Fortunately, I only have 8 more weeks of this.

They say that doctors make the worst patients, which isn’t always true, but can be true.  In the case of a pediatric resident doing a genetics elective at the beginning of her pregnancy, this is true.  I’ve only done three days worth of genetics & metabolism clinic, but it’s enough to drive me nuts.  I thought it would be good to do a genetics elective since I’m going into neonatology (and quite a few of the patients we will see in the NICU will have genetic anomalies), but I couldn’t have timed it any worse.

To begin with: it appears that the majority of the anomalies we see and counsel cannot be tested for in pregnancy.  Those three diseases we test for on the early risk assessment - Down syndrome, Trisomy 13 and 18 - are only the tiny tippy top of the iceberg!  About 2% of all healthy pregnancies that are carried successfully will have some sort of genetic syndrome that cannot be anticipated.  And this 2% risk is just the baseline risk.

Still, though, I managed to calm myself down somewhat.  Even if you could test for other genetic syndromes prenatally, the question is…so what?  Having a baby IS taking a risk, and you have to just make a blind leap of faith, genetics and all.  And not everything is entirely genetic - you could have a bad delivery and your kid could wind up anoxic with seizures and a brain injury, and you couldn’t have predicted that.  You can’t predict that your kid will have autism, even though the chances are 1 in 160.  You can’t predict that he or she will be Republican (although apparently, early childhood personality traits can predict political orientation).  You take the good and you take the bad, just like the theme song to that 80’s sitcom “The Facts of Life.”

Joe said that maybe we should have our genetic risk factors sequenced commercially, but I looked at the website and realized that the disease risks they test for and carrier status that they are able to accurately assess aren’t things that matter much to me anyway.  For example: even if Joe might or might not have Jewish ancestry, I’m pretty sure I don’t have any, and I’m even more confident Gully is at low risk for any of the diseases on the Ashkenazi panel, like Canavan disease.  And big deal if he/she ends up having maple syrup urine disease.  It can be medically managed.

Plus, there are things to worry about where the genetics haven’t even yet been elucidated, like the nerd n’ weakling gene that Gully will obviously inherit.

Having taken a blow from ye-olde-merry-virus season, I am laid up, febrile and coughing and achy and bored.  My eyes can’t focus long enough to do anything significant, so I decided to organize the ever-growing stack of journals, random articles, and old sign-outs on my desk.  I came across this great article about how hospitalists spend their time.

Hospitalist fun facts from this article: 18% of their time is spent on direct patient care, meaning speaking directly to patients and their families and examining them, whereas 69% of their time is spent on indirect patient care, meaning charting, orders, speaking to other involved medical team members about the patient’s care, yadda yadda.

I think it would be interesting to see how it breaks down for residents.  As an intern, I have really intensely colored memories of working with patients and their families, all topped on a hum-drum backdrop of indirect patient care, i.e. scut…so maybe it was half n’ half?  As a senior resident, I think I spend even less time with patients and more time on paperwork, working with other staff / physicians to advance patient care, more paperwork…a lot of clicking and typing and staring at a computer screen and having arguments with the computer order entry system, the computer medicine reconciliation list, and other computerized computery things that make me go nuts.

Also, I’m a terrible Pubmed searcher, so while there are multiple articles popping up on resident work hours rules and its effects on how residents spend their time, I can’t seem to find anything specific to year of training and it’s correlation to amount of time involved in direct patient care. 

This begs the second question, does more face time with patients make you a better doctor?  I can certainly say that qualitatively, the brief interactions I have with patients and families feels somehow better, even if the minutes are fewer.

This is tiring me. Thinking too much about one subject while my arms and tummy and knees and hair follicles hurt is really really exhausting.

Residents are good at complaining about their lives, and I’m really good at complaining.  However, that does not make me a good resident.

Last night, I was on call at one of our “outside hospitals,” meaning a community hospital.  “Outside hospitals” have a less-than-perfect reputation among housestaff, but don’t get me wrong, there are fabulous “outside hospitals,” as I am living proof that you can be born at Outside Hospital and live to tell the story.

Every resident has “a system,” by which they keep track of the patients and action items that they need to follow through on while they are on call, and 99.9% of the time, this system is kept on “the signout.”  Sign-out is when one resident passes on information to the next resident on call about what they will need to know about patients and patient care when the former resident goes off-duty and the latter resident starts call.  It usually consists of a verbal report of patients and agenda items that need to be taken care of, and a piece of paper on which all of this is outlined that is usually typed in miniscule font with various check-boxes scattered throughout.  Residents have their own systems on the paper sign-out: some like to order their events chronologically, writing down everything that needs to happen at every-hour-by-the-hour on their list of stuff to do.  Some like to just put check-boxes next to each item that needs to be addressed.  Some just like to use multi-colored pens to organize their thinking about what’s important (RED for important stuff to do now, BLUE for “just watch and follow,” GREEN for lab data, BLACK for everything else.)  Some incorporate all three techniques.  I am a check-box kind of resident, as are 95% of residents, and on busy services at busy hospitals, I will use the multi-colored pen system as well.  And always, on what I anticipate to be busy nights or potentially terrible nights, I will make myself an agenda item and put a check-box next to it: [ ] Am I having a good time? And it is usually written in blue.

Last night, I went wild, and decided to change my personal agenda item to: [ ] Be an awesome doctor!

That was my first mistake on call last night.  Because being an awesome doctor doesn’t necessarily mean being an awesome resident.  If you imagine a Venn diagram, the two spheres overlap to varying degrees, depending on what stage of training you are in and what your responsibilities are.  And at Outside Hospital, where any interesting, chaotic issue can present itself, the two spheres might not even be overlapping, as was the case last night.

Last night, I spent the majority of my time trying to help this poor patient and these poor nurses who were dealing with her, as she was having pseudoseizures.  After a little while, we were able to get the patient off the floor and into a room and eventually get a set of vital signs but this whole process took about an hour because (1) I couldn’t get into the unit because the unit does not have a working doorbell, and it is locked, and no one knew I was banging on the door outside trying to get in, (2) there were no gurneys or wheelchairs available to get the patient to a more ideal spot other than the floor, so we had to use an office desk chair with wheels to slide her into a room, and (3) the only reason we needed a room is because the room had equipment like oxygen, a thermometer, a blood pressure cuff, and there was no way to get any of this stuff to the middle of the hallway where she was pseudo-seizing, and (4) I guess I was called to this problem because the girl was kind of big, and the two nurses weren’t enough to help her off the floor and they didn’t realize that she was also congenitally deaf, so it was hard to communicate.

Regardless, it felt inordinately bizarre because it wasn’t a situation in which you needed a doctor.  You just needed someone, anyone, anyone at all with common sense, to take charge.  Really, people just needed to be told what to do, because it was confusing, but it wasn’t life threatening, and no one was really sick.  From a medical perspective, she was okay - I just wanted a basic set of vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygenation) to make sure she was okay, and even this was hard because (5) there were no working adult-sized blood pressure cuffs on the floor.  And she was a big girl with big arms.  It was clear this was a patient in a lot of distress, and these were nurses who were at their wit’s end, and this was a psychiatry unit with not a whole lot of technological functionality, but no one was acutely ill, so I felt somewhat at a loss.  Be a good doctor?  How?  Be a good resident?  Okay.  That involves: finding an accurately sized blood pressure cuff to take a good set of vitals on this child; communicate with her by writing things out on a piece of paper and letting her write back; flipping through her chart to find out what her underlying medical and psychiatric issues were; helping the nurses get her to a safe place in the room.

The whole night was like this.  I was dealing with complaining parents, overwhelmed interns, sad patients, confused staff members.  And I realize, there are really very few moments in your life when you need to be a good doctor, in the traditional sense of, oh, saving lives - you just need to be a good resident.  And that only means: make the medical system work in your own small way.

Waking up next to Joe this morning at 6:00 am, I mentioned that I got to see Amy and Chris’ dogs and how funny and strange they are, and any mention of animals throws us into a variation on a conversation we (oddly) often have:

ME: I miss the cats - right now they would see we are awake and Manzie would walk up onto me and sit on me.  Walk walk walk.

JOE: I would rather be a dog than a cat, because cats are always worried and dogs just have to do one thing and they’re happy.

ME: …

JOE: (rolling over in bed with eyes still closed, smiling) All you have to do is love your owner and if you had a great owner, then it’s nice, and that’s it, that’s all you have to do, love them. And then you’re happy.

ME: Yeah, cuz that’s his job.

JOE: (still sleepily smiling) No, it’s not a job, it’s his soul.

ME: (pause) I want a job that’s my soul.  Like a dog.

Here’s the thing: I would like to be all worked up about California and prop 8, and I would like to be ardent about Sonia Sotomayor’s nomination, but I’m too tired to get my panties bunched up about these things.  I get home and I read cheesy chick lit or recommended stuff from Oprah’s book club.

And yes, it has made me dumber, but I am too tired to care anymore.  I didn’t realize how tired I was until this morning, during rounds. In the mornings, we walk-round in the PICU with COWS, which are “Computers on Wheels” - essentially, laptops on wheeled stands that we can roll in front of ourselves so that we can type notes and enter orders as we go from room to room talking about patients.  This morning, I was leaning on my COW with my head down, and while my co-residents were busily looking up the diverticulum of Kommerell, and updating discharge summaries and entering orders, I was sneakily reading xkcd comics on my computer.  Life is just too much to bear these days.

I think part of my tired-ness is due to my shoes.  Rounds hurts my feet, despite the fact that I wear the clog-wear that is standard for most residents.  I think I need to wear sneakers.  Too tired to care anymore.

One of the board review questions that came up today included this lovely picture:

Yes, tick removal.  The thing that kills me is that you would never be able to find tweezers this fine in the doctor’s office or the emergency room where parents take their children for tick removal, so to all parents out there: look, you got over the heeby-jeebies of changing poopy diapers, so you can get over the heeby-jeebies of using your Tweezerman to remove a tick.

These days, I am on night float, which means I have hooker hours: I wake up when the sun goes down, work all night long, and go to bed after breakfast.  It doesn’t feel normal; I can feel the vitamin D leaching from my bones from lack of sunlight, and since I don’t sleep well during daylight hours, I just don’t sleep.  I am starting to feel like a vampire, but not of the Twilight-genre, no, more of the 90’s Buffy-Vampire-Slayer-Angel kind. 

The admissions I’m getting also feel vaguely made-for-TV, and the whole scene in the hospital at night has that surreal-this-is-not-your-real-life kind of quality.  Maybe because everyone is awake when they shouldn’t be and therefore, human interactions are all that more bizarrely technicolor. 

And speaking of TV, ABC is apparently making a documentary TV series at our hospital, much like that series, Hopkins, and they are looking for residents to follow in the next month!  Too bad I am going to be at an outside hospital next month (Outside Hospital: Just When You Thought Your Health Was in Jeopardy), so I will be missing all the action.  Although, never having seen the series, I don’t know if this is a good or a bad thing. I can’t possibly imagine how interesting it would be to follow a typical call night, although they will probably edit together all the Medflights, crashing patients, and gory OR scenes, so it looks more exciting than it really is.  The lovely possibilities of an edited version of reality.     

This past week, there have been a bunch of interesting articles in the Health section of the NYTimes regarding doctors’ sleep, courtesy, and meanness.

On Sleep

The Institute of Medicine just released a new report affirming the 80-hour work rule and additionally recommending some strategies to introduce sleep into the residents’ hospital schedule.  This sounds nice, but I also know it introduces problems into the already chaotic resident scheduling system.  For some people it might be nice if it were built into their schedule to take a nap, as sleep makes them more functional, but I know for me, if I am working 24 hours straight, catching a 1 hour nap on call only confuses me — I wake up completely confused (huh? wuh? where am I? did Xavier die? did so-and-so nurse page me or did I dream it?), in a panic that I missed a page, unable to put together two thoughts about the patients I am covering.  And if I were required to take a longer nap — good luck trying to wake me up.  Being tired, on the other hand, makes everyone prone to making mistakes, which is never good, but I’m not sure a mandatory nap-on-call makes everyone a better doctor.

On courtesy

Dr. Michael Kahn recommends that physicians follow some simple etiquette rules, like knocking on the door and asking if it’s OK to come in to the patient room (duh?!) and introducing yourself, pointing out your name on your name tag and explaining your role on the patient’s medical team (if they don’t know already).  Really basic stuff that makes patient care better, and I’m not surprised we often times forget to do this.  It’s much easier to remember all this stuff in clinic (I point to my nametag a lot there), but in the hospital, where you’re rushing, rushing, rushing to get a quick physical exam, or to quickly check a patient’s vital signs on her monitor, I admit, I probably forget to do this.  And even when I do introduce myself carefully and with consideration, I am not surprised at how easily patients forget who I was even 2 hours before, because they have to meet so many nurses and physicians and other members of their care team.  “Weren’t you the nurse who promised my son Valium two hours ago?” a father angrily asked me as I walked into a patient room for the first time to meet them.  I couldn’t even introduce myself in any courteous manner — the father was just too upset.  And when you walk into a room where the patient is not breathing, you don’t really have time to ask them or their parents how they feel about being in the hospital; your number one job is to get that patient to breathe again.

On Abusiveness

This article horrified me.  Where does some jerkwad resident come off telling a nurse she has no skill in recognizing signs and symptoms?  Unbelievable.  Pediatrics is fortunately not stocked with swelling egos and soul-crushing mockery, but I remember these were things that I was sensitive to in medical school and made sure to steer away from.  As a sub-intern I once had a senior resident who treated everyone like they were the enemy, and at the end of the month, I was feeling very indifferent to both the insults that he hurled at me and to the concerns of my patients - on my last day, a patient incidentally mentioned to me how her left leg would occasionally feel crampy and tingly when she went running, which I shrugged off in my review of systems as I presented her in the morning; after I left the service, I later heard about her suffering from a DVT (a blood clot in her leg) after her abdominal surgery, and that she had May-Thurner syndrome — something I might have been able to address had my senior resident not yelled at me, “yo, med student - pertinent positives only.  Pertinent positives.” You lose perspective of what is pertinent when you are worn down to a defensive shell of emptiness.  I do not ever want to be in a lackey position that prevents me from thinking about a patient as carefully as I can.

I’m more tired than I have ever been in a long time, and it’s all because of the damned PICU.  My first day, I got there ridiculously early to learn about my patients; the second day, I ended up staying until 9 pm; the third day, I stayed until 7:30 pm; I was on a nightmare call over the weekend, and I started a ridiculously busy Monday feeling exhausted already. (But I’m surprisingly not violating any work hour rules!)

My feet hurt and my head hurts all the time. Also, I got a haircut that makes it impossible to put my hair into a ponytail, and it bugs me all day long.

Whine whine whine whine, I know, pauvre bebe.  Even at home when I could be sleeping, I can’t because I can’t relax.  My body is too hopped up on the adrenaline of being in an ICU, and my mind is racing because I’m constantly thinking about patients.

The thing that kills me, though, is that I know I’m not managing that many sick kids, and I feel lame because I don’t know that much  — my internal medicine friends are managing 20 cardiac ICU patients ALONE on call nights, AND doing procedures (which is rare in pediatrics) so I feel like a really lame resident.  The weakest link.  Bah.

I’m making myself a rib eye steak tonight to cheer myself up.

After going to a meconium delivery, eating a leisurely breakfast while chatting with the attending, and checking on the intern in the ED, I went to drop my backpack in the call room and found this book on the night stand. I read the first four chapters, and then realized, “wow. I’m reading about another resident’s stories about being on call while I’m on call.” It’s like watching yourself on TV watching TV. Except not really. Because this resident’s stories are craaaaazy, and I’m snacking on almond butter and reading a novel.

Getting peed on is one of the hazards of pediatric practice - when the diaper is off for more than 20 seconds, what do you expect when you’re examining a freshly circumcised dongle or palpating for a reducible inguinal hernia?

It’s not like I hadn’t been peed on by a tiny tot before but I have never until last night been peed on and had the pee land in my mouth. (Pause for collective horror, then for a piece of you to die inside, then go brush your teeth, floss and gargle in defense.)  The neonate had a money shot straight into my open mouth as I turned to talk to the nurse. The irony of it all is that I was wearing a face mask all night long because I have a small cold brewing, and momentarily pushed the mask aside and forgot to put it back on when I examined this kid. Serves me right.

The nurses at a good laugh at me because clearly, I am so awesome. All I can say is that wee tastes exactly how you’d imagine wee to taste. (Pause for more collective gagging and dying inside).

All the reading I’m not doing.