Posts
Happy New Year everyone! As with every year, 2009 was filled with ups and downs. Being a glass-half-full kind of girl, I like to look back on the ups. The historic presidential election that not only got Bush out of the White House, but got our first African American president in. The beginnings of much-needed health care reform. Jake Gyllenhaal becoming available again. (Haha, kidding on that last one. Sort of.)
In my own life, this was a year filled with events I have been waiting for my entire life: graduating from medical school, becoming a doctor, starting at a great residency program in a field that I am incredibly passionate about. I cherish being at a place in my life where I am comfortable in my own skin, where I am blessed enough to have health, a loving family, and wonderful friends on both coasts.
So what next for the upcoming year? I hesitate to make any big plans – I’m where I always wanted to be and would like to simply enjoy where I am at for awhile. Rather than focus on the future (which will inevitably come) I want to focus on the present. Live in the moment. Laugh a lot. And love.
Saturday, January 2, 2010
Friday, December 11, 2009
Fighting the Cynic Inside
I have always envisioned myself as becoming a doctor who would empathize with her patients. Regardless of they were, where they came from, or what they presented with, I always wanted to approach my patients with patience and compassion. Now, three weeks into my Night Float rotation, I am finding this vision much more challenging than I anticipated.
One of the wonderful aspects of my residency program is that our hospital runs its own Emergency Department for women of all ages, pregnant or non-pregnant, with any sort of acute OB or GYN issue. It is a high paced environment in which patients are rolling in with anything from labor, miscarriages, cancer complications, surgical complications, sepsis (aka widespread infection)… the list goes on and on. It makes for fantastic resident training.
On nights, when I am not in the delivery room or the OR, I am often found tending to these high acuity patients. After all, one would think that a person would have to be really sick to come into the ED at 1:00am, right? Ha. This is where the issue of my dwindling patience comes in. Let me introduce you to the 24yo non-pregnant female who came to see us last night. Her chief complaint? Vaginal SPOTTING between periods. In the setting of a history of irregular menses. I’m serious, this was a regular problem for her and she decided that one day of spotting was an emergency. She had gone through HALF of ONE pantyliner. Clearly not hemorrhaging. There are also the dozens of women each week who come into the Emergency Room after getting a positive home pregnancy test. I mean, really? You need to come in to the ED at 2:30am for a positive HPT?!? Oh, and the woman who “lost a tampon” in her vagina?
The icing on the cake was a patient I had the other night. She was a 20yo female who was pregnant with her THIRD child in the last THREE years. She had had ONE prenatal care visit during this pregnancy and not for lack of insurance or health care provider. She didn’t know her last period and as a result, we had no idea how far along she really was. Her chief complaint? She had come to the ED because she decided that she wanted a C-section that night. SHE decided. I was shocked.
I’ve seen many a bitter physician throughout my training - the sort that blame their patients for everything. I don’t ever want to become that person. Fighting cynicism, however, is an ongoing battle. Especially when you feel like there are so many patients who take advantage of our services.
Now I am educated enough to understand that our shabby health care system, with its limited access to primary care, is largely to blame. Our G-rated version of sex education has also left women so unfamiliar with their bodies that they run to a physician for the most minor issues. I also understand that WE were the ones who failed S.M. when we let her have two babies at our hospital and never set her up with reliable birth control. But remembering this is a struggle. I am resolved to doing it, to be the kind of doctor that I would want to go to. But it takes a conscious decision I make each and every day.
One of the wonderful aspects of my residency program is that our hospital runs its own Emergency Department for women of all ages, pregnant or non-pregnant, with any sort of acute OB or GYN issue. It is a high paced environment in which patients are rolling in with anything from labor, miscarriages, cancer complications, surgical complications, sepsis (aka widespread infection)… the list goes on and on. It makes for fantastic resident training.
On nights, when I am not in the delivery room or the OR, I am often found tending to these high acuity patients. After all, one would think that a person would have to be really sick to come into the ED at 1:00am, right? Ha. This is where the issue of my dwindling patience comes in. Let me introduce you to the 24yo non-pregnant female who came to see us last night. Her chief complaint? Vaginal SPOTTING between periods. In the setting of a history of irregular menses. I’m serious, this was a regular problem for her and she decided that one day of spotting was an emergency. She had gone through HALF of ONE pantyliner. Clearly not hemorrhaging. There are also the dozens of women each week who come into the Emergency Room after getting a positive home pregnancy test. I mean, really? You need to come in to the ED at 2:30am for a positive HPT?!? Oh, and the woman who “lost a tampon” in her vagina?
The icing on the cake was a patient I had the other night. She was a 20yo female who was pregnant with her THIRD child in the last THREE years. She had had ONE prenatal care visit during this pregnancy and not for lack of insurance or health care provider. She didn’t know her last period and as a result, we had no idea how far along she really was. Her chief complaint? She had come to the ED because she decided that she wanted a C-section that night. SHE decided. I was shocked.
I’ve seen many a bitter physician throughout my training - the sort that blame their patients for everything. I don’t ever want to become that person. Fighting cynicism, however, is an ongoing battle. Especially when you feel like there are so many patients who take advantage of our services.
Now I am educated enough to understand that our shabby health care system, with its limited access to primary care, is largely to blame. Our G-rated version of sex education has also left women so unfamiliar with their bodies that they run to a physician for the most minor issues. I also understand that WE were the ones who failed S.M. when we let her have two babies at our hospital and never set her up with reliable birth control. But remembering this is a struggle. I am resolved to doing it, to be the kind of doctor that I would want to go to. But it takes a conscious decision I make each and every day.
Tuesday, December 8, 2009
She Growns Up
I don’t know how it happened. But it finally has. I am starting to feel like a bona fide doctor.
As you can read in my previous posts, the first couple of months of intern year were racked with insecurity. For instance:
The first week of my intern year, my 2nd year resident and I got called to a postpartum hemorrhage on the floor. One of our recently-delivered patients was found to have active vaginal bleeding a couple hours after the birth of her child. We rushed to the bedside. There was blood all over the bed, her hospital gown, and her legs. She was crying. Before I knew it, my 2nd year bolted into action. She was calling for vital signs, IV access, Pitocin, Misoprostol. She shouted out an order for Morphine to make the patient comfortable. She gowned up into sterile gear and started a vaginal exam at the bedside. Before I knew it, she was using her hand to clear out the uterus. Out came handfuls and handfuls of clot. In less than 5 minutes, the uterus had been evacuated and the bleeding had stopped. I will always remember that moment in my intern year. It was one of awe – awe regarding my resident’s ability to keep her cool and bring order to a frantic clinical scenario. It was also one of terror – terror regarding the idea that in 1 year, I would be expected to handle that situation with the same level of calm and skill. It seemed a daunting task.
Fast forward to my first shift on OB nights. It was 2am. The high pitched squeal of my pager shot me out of my near slumber. “Postpartum hemorrhage, pt J.K. in room 5015.” I jumped from my seat and headed towards the elevator. On the ride up, I recalled the steps in the management of post-partum hemorrhage in my head. Before I knew it, I was running it. I was calling for vitals, calling for IV access, for Pitocin, Misoprostol. I was clearing out her uterus. I was calling for a stat hemoglobin. Before I knew it, the patient was stable and her bleeding had stopped.
It didn’t hit me until later, when I was recalling the experience in my head, that I had missed something. That feeling that had haunted me for months – the panic, the insecurity, the tachycardia – was not there. In its place was an excitement, a sense of pride, and a rush that shouted “yes! I did it!” Yes, folks, I am growing my doctor wings.
As you can read in my previous posts, the first couple of months of intern year were racked with insecurity. For instance:
The first week of my intern year, my 2nd year resident and I got called to a postpartum hemorrhage on the floor. One of our recently-delivered patients was found to have active vaginal bleeding a couple hours after the birth of her child. We rushed to the bedside. There was blood all over the bed, her hospital gown, and her legs. She was crying. Before I knew it, my 2nd year bolted into action. She was calling for vital signs, IV access, Pitocin, Misoprostol. She shouted out an order for Morphine to make the patient comfortable. She gowned up into sterile gear and started a vaginal exam at the bedside. Before I knew it, she was using her hand to clear out the uterus. Out came handfuls and handfuls of clot. In less than 5 minutes, the uterus had been evacuated and the bleeding had stopped. I will always remember that moment in my intern year. It was one of awe – awe regarding my resident’s ability to keep her cool and bring order to a frantic clinical scenario. It was also one of terror – terror regarding the idea that in 1 year, I would be expected to handle that situation with the same level of calm and skill. It seemed a daunting task.
Fast forward to my first shift on OB nights. It was 2am. The high pitched squeal of my pager shot me out of my near slumber. “Postpartum hemorrhage, pt J.K. in room 5015.” I jumped from my seat and headed towards the elevator. On the ride up, I recalled the steps in the management of post-partum hemorrhage in my head. Before I knew it, I was running it. I was calling for vitals, calling for IV access, for Pitocin, Misoprostol. I was clearing out her uterus. I was calling for a stat hemoglobin. Before I knew it, the patient was stable and her bleeding had stopped.
It didn’t hit me until later, when I was recalling the experience in my head, that I had missed something. That feeling that had haunted me for months – the panic, the insecurity, the tachycardia – was not there. In its place was an excitement, a sense of pride, and a rush that shouted “yes! I did it!” Yes, folks, I am growing my doctor wings.
Monday, November 16, 2009
Becoming More Than a Resident.
Oh, medical students. Feels like just yesterday I was one of those chipper, eager-to-learn little students dressed up in my short white coat with a Maxwell’s in my pocket and stethoscope around my neck. The best rotations were with residents who:
a. Were enthusiastic about their job
b. Made your experience hands-on
c. Made an effort to teach
The worst rotations were with the residents who saw medical students as nuisances and spoke to them only to assign us non-educational busywork to do, a term known as “scut work”. For me, the most dehumanizing part was that these were usually the same residents who couldn’t be bothered to acknowledge our existence or learn our names. As I looked towards graduation, I swore I’d be the former type of resident.
In all honesty, to be that type of resident has been a challenge. As an intern, I am constantly working to get one of a thousand things crossed off my to-do list. The most basic of actions – stopping to say hello, introducing myself – requires effort. As the year goes by, and I get more comfortable and efficient with my work, I am becoming more able to be that resident I aspire to be. I try to teach. Engage in benign pimping. Review suturing, knot tying. But this is constantly a work-in-progress.
One thing I've noticed is that my ability to be the "good resident" is equally proportional to having a "good medical student". The proactive, eager medical students are by far the easiest to teach. L.W. was a perky, well-learned sub-intern on my Oncology rotation. She anticipated what needed to be done throughout the day and did it. She made my life easier. She had done her reading. As a result, I loved teaching her. The passive, uninterested medical student brings the "bad resident" out of me. Fast forward to our next Oncology sub-intern who clearly had not studied basic oncology, who hangs out in the background and waits to be told what to do, who showed up late. I am finding it much harder to be enthusiastic about taking time to teach her. Instead, she gets a lot of scut work in return...
a. Were enthusiastic about their job
b. Made your experience hands-on
c. Made an effort to teach
The worst rotations were with the residents who saw medical students as nuisances and spoke to them only to assign us non-educational busywork to do, a term known as “scut work”. For me, the most dehumanizing part was that these were usually the same residents who couldn’t be bothered to acknowledge our existence or learn our names. As I looked towards graduation, I swore I’d be the former type of resident.
In all honesty, to be that type of resident has been a challenge. As an intern, I am constantly working to get one of a thousand things crossed off my to-do list. The most basic of actions – stopping to say hello, introducing myself – requires effort. As the year goes by, and I get more comfortable and efficient with my work, I am becoming more able to be that resident I aspire to be. I try to teach. Engage in benign pimping. Review suturing, knot tying. But this is constantly a work-in-progress.
One thing I've noticed is that my ability to be the "good resident" is equally proportional to having a "good medical student". The proactive, eager medical students are by far the easiest to teach. L.W. was a perky, well-learned sub-intern on my Oncology rotation. She anticipated what needed to be done throughout the day and did it. She made my life easier. She had done her reading. As a result, I loved teaching her. The passive, uninterested medical student brings the "bad resident" out of me. Fast forward to our next Oncology sub-intern who clearly had not studied basic oncology, who hangs out in the background and waits to be told what to do, who showed up late. I am finding it much harder to be enthusiastic about taking time to teach her. Instead, she gets a lot of scut work in return...
Saturday, October 3, 2009
Escaping the Inevitable
Any OB/GYN will tell you it’s inevitable. Sometime, no, multiple times during your career, you will perforate the uterus. They all have a story in which an instrument they so gently insert into the uterine cavity goes a little too far… and into the abdomen. But it could never happen to me, right?
It was the last case of the week and I scrubbed in to do a D&C Hysteroscopy with an attending I had never worked with. I sit down to do the procedure while Dr. M supervises. I examine the patient and note the position of her uterus. I place the speculum and visualize the cervix. I place the tenaculum, a grasping instrument which allows the surgeon to manipulate cervix. I sound, or measure, the length of the uterus and then dilate the cervix. I look inside the uterine cavity with the hysteroscope (an intrauterine camera). Everything is going super smoothly and I am proud of my independence in the case. Then it came time for the curettage. I introduce the curett, a long instrument with a sharp metal loop at the end used to shave off the endometrial lining. It is entirely done by feel. Once I feel as though I am done, we re-introduce the hysteroscope to make sure the uterine cavity looks clean and intact.
This time, I am having a difficult time getting oriented in the uterus. I move the camera past what I believe is the cervix, but the uterine cavity just looks more lumpy than usual. I rotate the camera to try and get my bearings when I see something that makes my heart drop. My camera focuses in on two round bulging structures that look frighteningly familiar. “Dr. M, do you want to take a look and tell me what this is?” She takes control of the hysteroscope and is quiet as she examines these structures. Finally, I say it. “Is it BOWEL???” Everyone in the OR, the circulating nurse, the scrub tech, the anesthesiologist, rush over to the camera screen. To get bowel, aka intestine, into the uterus would not only require a perforation of the uterus, it would require a huge tear. How clumsy could I have been to do that without feeling it?
Then again, it really does look like bowel. Dr. M and the surgical staff don’t know what to say. They have never seen anything like this. We remove the hysteroscope and two other GYN surgeons are called in for a second opinion. The wait for them to appear was painful - you could taste the tension in the room. Meanwhile, thoughts race back and forth in my head. Will we have to cut her abdomen open? What if I perforated her bowel too? Will we have to do a bowel resection? How are we going to explain this to her and her family? I thought about my own fate as well. What will the program say? What if I get sued? No attending is ever going to want to work with me again. Maybe I picked the wrong field after all. I am just going to quit before I hurt anyone else. I even start seeking help from a higher power. Please God, please don’t let me have perfed the uterus. Please…
Finally the other surgeons show up. They replace the hysteroscope. Although it’s a bit bloody and messy inside the uterus, we can’t seem to find those structures again. The consult surgeons suggest using a resectoscope, which is bigger and can dilate the uterus much more to increase our visibility. What we find is shocking. We see a perfectly normal and intact uterus. Dr. M and I can’t believe it. We examine every wall of the uterus 5 times. One ostia, another ostia, anterior wall, posterior wall. All smooth. All intact. No perforation, no bowel. Nothing but normal uterus.
The consult surgeons laugh. “See! We told you everything would be fine! There’s nothing!” The rest of the OR and Dr. M. breathe a huge sigh of relief. As for me, it takes me a good ten minutes before I trust that everything is going to be okay. What. A. Scare.
We never did find out what it was that we originally laid our eyes on. On theory was that we saw clots. My theory is that it was a miracle. God really must not have wanted me to quit my residency program.
It was the last case of the week and I scrubbed in to do a D&C Hysteroscopy with an attending I had never worked with. I sit down to do the procedure while Dr. M supervises. I examine the patient and note the position of her uterus. I place the speculum and visualize the cervix. I place the tenaculum, a grasping instrument which allows the surgeon to manipulate cervix. I sound, or measure, the length of the uterus and then dilate the cervix. I look inside the uterine cavity with the hysteroscope (an intrauterine camera). Everything is going super smoothly and I am proud of my independence in the case. Then it came time for the curettage. I introduce the curett, a long instrument with a sharp metal loop at the end used to shave off the endometrial lining. It is entirely done by feel. Once I feel as though I am done, we re-introduce the hysteroscope to make sure the uterine cavity looks clean and intact.
This time, I am having a difficult time getting oriented in the uterus. I move the camera past what I believe is the cervix, but the uterine cavity just looks more lumpy than usual. I rotate the camera to try and get my bearings when I see something that makes my heart drop. My camera focuses in on two round bulging structures that look frighteningly familiar. “Dr. M, do you want to take a look and tell me what this is?” She takes control of the hysteroscope and is quiet as she examines these structures. Finally, I say it. “Is it BOWEL???” Everyone in the OR, the circulating nurse, the scrub tech, the anesthesiologist, rush over to the camera screen. To get bowel, aka intestine, into the uterus would not only require a perforation of the uterus, it would require a huge tear. How clumsy could I have been to do that without feeling it?
Then again, it really does look like bowel. Dr. M and the surgical staff don’t know what to say. They have never seen anything like this. We remove the hysteroscope and two other GYN surgeons are called in for a second opinion. The wait for them to appear was painful - you could taste the tension in the room. Meanwhile, thoughts race back and forth in my head. Will we have to cut her abdomen open? What if I perforated her bowel too? Will we have to do a bowel resection? How are we going to explain this to her and her family? I thought about my own fate as well. What will the program say? What if I get sued? No attending is ever going to want to work with me again. Maybe I picked the wrong field after all. I am just going to quit before I hurt anyone else. I even start seeking help from a higher power. Please God, please don’t let me have perfed the uterus. Please…
Finally the other surgeons show up. They replace the hysteroscope. Although it’s a bit bloody and messy inside the uterus, we can’t seem to find those structures again. The consult surgeons suggest using a resectoscope, which is bigger and can dilate the uterus much more to increase our visibility. What we find is shocking. We see a perfectly normal and intact uterus. Dr. M and I can’t believe it. We examine every wall of the uterus 5 times. One ostia, another ostia, anterior wall, posterior wall. All smooth. All intact. No perforation, no bowel. Nothing but normal uterus.
The consult surgeons laugh. “See! We told you everything would be fine! There’s nothing!” The rest of the OR and Dr. M. breathe a huge sigh of relief. As for me, it takes me a good ten minutes before I trust that everything is going to be okay. What. A. Scare.
We never did find out what it was that we originally laid our eyes on. On theory was that we saw clots. My theory is that it was a miracle. God really must not have wanted me to quit my residency program.
Friday, October 2, 2009
Breathless
It has been awhile since I have written.
In one's life, there often comes a time when they are let down by the person they rely on most. For me, I have been more than let down. I have been crushed and devastated. My plans for a future with my presumed best friend and soulmate - getting married, becoming a wife, a mother - have ended. And I don't know if they can ever be mended with him.
This last month has been felt like I have been cut off from the air I breathe. I can only now begin to type these words.
I won't say much more. I will simply continue my professional journey into the world of medicine. Because right now, it feels like it is all I've got.
In one's life, there often comes a time when they are let down by the person they rely on most. For me, I have been more than let down. I have been crushed and devastated. My plans for a future with my presumed best friend and soulmate - getting married, becoming a wife, a mother - have ended. And I don't know if they can ever be mended with him.
This last month has been felt like I have been cut off from the air I breathe. I can only now begin to type these words.
I won't say much more. I will simply continue my professional journey into the world of medicine. Because right now, it feels like it is all I've got.
Thursday, September 10, 2009
Drug Seekers
When I found J.M., he was wincing in pain on the ER stretcher. Attempting to get moderately comfortable, he shifted his position from side to side to no avail. I introduced myself. He was my age, clean cut and pleasant, resembling someone I might have been friends with under different circumstances. He explained his story. One year ago, he had fallen off a room and injured his lower back. With the help of his Orthopedic Surgeon, he was back to himself after a couple of months. Unfortunately, he recently re-injured his back and the pain was intolerable. I could see the discomfort on his face and tears welled up in his eyes as he told his story. “I can’t walk. I have to call the neighbor to help me to the bathroom. Do you know how embarrassing that is?” My heart broke for him. He was on an impressive regimen of Percocet and Oxycodone at home and it just wasn’t managing his pain. As I set out to examine him, no doubt a painful endeavor, I recalled something an ER Attending had said to me. “ER docs are notoriously bad at managing patient’s pain. So make sure you don’t forget to make a patient comfortable.” So, before I went any further, I said to J.M. “I’ll be right back with some pain medication for you and then we’ll finish the exam.” He looked at me with gratitude. “Thanks.” he said.
Four milligrams of Morphine later, I returned to his room. He was still writhing in pain. “Doctor, the medicine didn’t touch me. When I was in the hospital last time for this, they gave me Toradol and Dilaudid.” I gave him both. After examining him, I called the Orthopedic resident to come down to see him. Clearly this patient’s pain control issues and lack of mobility warranted his admission to the hospital. The Orthopedic resident did not agree. Our conversation went like this:
Ortho: “I know this guy. He’s had back problems forever. He just wants a prescription for pain killers and he will go home”.
Me: “You don’t understand. His pain medications are NOT working. He CANNOT WALK by himself.”
Ortho: “How did he get to the ER then?”
Me: “He told me his Dad carried him in!”
Ortho: “Allright fine. Get some X-Rays and I’ll come and see him”.
Long story short: Ortho came down. Saw that his X-Rays had not changed at all - meaning his back issues had not gotten, that we could see, any worse. Ortho found out he ran out of his Oxycodone last night. Offered to write him a prescription for new pain medications and send him home. The patient agreed. Ortho got him to demonstrate his ability to walk. Ortho also found out that he had been to 4 ERs in the span of 2 weeks asking for pain control. Needless to say, his story got fishier and fishier. And I got more and more embarrassed.
How could I have not seen this? Was it because he looked like someone I could relate to? Was it because he didn’t have a history of drug abuse, like so many of our other patients? As a physician, how do you balance being compassionate and being taken advantage of? How do you avoid enabling prescription drug abuse? Let me know if you have any ideas...
2QVRV5F3EPCJ
Four milligrams of Morphine later, I returned to his room. He was still writhing in pain. “Doctor, the medicine didn’t touch me. When I was in the hospital last time for this, they gave me Toradol and Dilaudid.” I gave him both. After examining him, I called the Orthopedic resident to come down to see him. Clearly this patient’s pain control issues and lack of mobility warranted his admission to the hospital. The Orthopedic resident did not agree. Our conversation went like this:
Ortho: “I know this guy. He’s had back problems forever. He just wants a prescription for pain killers and he will go home”.
Me: “You don’t understand. His pain medications are NOT working. He CANNOT WALK by himself.”
Ortho: “How did he get to the ER then?”
Me: “He told me his Dad carried him in!”
Ortho: “Allright fine. Get some X-Rays and I’ll come and see him”.
Long story short: Ortho came down. Saw that his X-Rays had not changed at all - meaning his back issues had not gotten, that we could see, any worse. Ortho found out he ran out of his Oxycodone last night. Offered to write him a prescription for new pain medications and send him home. The patient agreed. Ortho got him to demonstrate his ability to walk. Ortho also found out that he had been to 4 ERs in the span of 2 weeks asking for pain control. Needless to say, his story got fishier and fishier. And I got more and more embarrassed.
How could I have not seen this? Was it because he looked like someone I could relate to? Was it because he didn’t have a history of drug abuse, like so many of our other patients? As a physician, how do you balance being compassionate and being taken advantage of? How do you avoid enabling prescription drug abuse? Let me know if you have any ideas...
2QVRV5F3EPCJ
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