Nobody wears a white coat any more...
...a tribute to becoming a doctor.
ayradyss
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We'll be heading out on Saturday for a month-long mission trip to Papua New Guinea.  Committed to trying to blog daily while there - will be sharing rental space with lakos  at http://png-09.blogspot.com (syndicated to LJ via mnpng if you want to follow that way).  Warning: I keep religion out of my entries here.  The PNG blog is a mission trip, and one I'm taking for spiritual growth as well as professional experience.  You have been notified.


And then I'm headed to $real_medical_practice...  We'll play it by ear from there, shall we, O Best Beloved?

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In case anyone is wondering what my daughter is up to these days, here she is!

In other news, today was an ER day from hell, and I'm going to bed before the temptation to complain about how the work I take on to get play money is so hard takes over and keeps me up.

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Sauntered in at 0730 with the intention of meeting fellowship director, who gives a lie to the old-dogs-new-tricks mantra, for a little chat about breast disease in pregnancy.  Nurses are buzzing - seems there's a patient going downhill on high-risk side.  Looks like my 0800 chat is going to become an 0800 section, if I let it, and I plan to.
Yesterday, she was an ordinary preeclamptic - blood pressures up, maybe some protein in the urine, labs looking okay.  This morning, she's in HELLP syndrome - her liver numbers are skyrocketing and her platelet count is plummeting.  We're down from 225,000 to 74,000 overnight already, and anesthesia refuses to stick a needle in her spine for fear she'll bleed.  The problem is that she's not even 30 weeks along yet, and while she may have gotten steroids that doesn't mean that everything will be all right.

This is the part of obstetrics that frightens me - the bit where I don't get to package up a 7- or 8-pound bundle of baby in a blanket and send it smiling home with happy parents.  It's why I'm glad there are obstetricians backing me up, and why I'm secretly glad I'll be sending scary sick mommies and babies to bigger hospitals if I have any concern at all.  But, as I'm constantly reminded, sometimes there isn't time to send them.

Walked into the OR with the attending OB, a somewhat quirky woman who was the very first to hand me a scalpel and has been my cheering squad for the last three and a half years.  We're gowning up and she looks at me.  "I don't know how you feel about this..."  It's an opening for me to let her take primary on the case, if I want.  Something inside me flares.  I can do it.  She gives me a startled look, but smiles and nods.  High Risk OB has me do them.  "She's all yours, then."  And we take our places.
Three, maybe four minutes later, we're handing over a struggling, crying infant to the NICU staff, and the attending is smiling behind her surgical mask.  "He taught you well.  Next time I see him, I'm going to have to tell him.  That was really good." 

The quads are doing well - they were in the paper the other day.  Those are my babies!  And the NICU staff just smiles.  I think my transparent enthusiasm for my work amuses them.  

Many fat and happy full-term babies have been delivered recently as well, bundled up and given to mothers.  My favorite kind are the women who deliver all-of-a-push, as if there were no pain and no effort to giving birth.  They make the rest of us poor mortals seem like struggling shadows of motherhood, but it is so glorious to be a part of it that I can't be angry with them.    That's simply the way of it. 
My clinic patients are beginning to complain to me that I am leaving them; they are threatening to follow me.  I wish that I could box some of them up and take them with me, really.  I am amazed at how attached we have become.  I thought it would be easier to leave, but even the ones who drive me a little crazy, the ones I think I have never really helped, I am sorry to see them go. 

This is somewhat stream-of-consciousness, and I apologize, O Best Beloved.  I want to tell you stories and catch your attention.  I want to rivet it.  I want you to hear about the C-section on the patient with the fantastic socks, and why she almost died, and what it was like to be in the operating room for three and a half hours, and what happened afterwards.  But I wanted to write it then, and I was too exhausted, and now it is late and if I do not sleep now I will not sleep at all.  Perhaps that will come later.  It is a good story, I think.  I will most definitely never forget her socks, or the baby, or the uterus we couldn't save.

But enough, or I'll ruin the story by talking about telling it.  We leave for Papua New Guinea on May 30th.  We'll likely have Internet access while we're there - we'll be taking a very tiny computer with us and blogging from the Highlands at  http://png-09.blogspot.com/.  You're welcome to follow along - I'd like to spend a little time in mental preparation, so there may be posts incoming eventually.  We're going as part of a medical missions trip (and my Angel has already been asked to do networking support while he's out there); I think it's a good time to do some spiritual soul searching - something I've kept out of this blog - and I'm hoping for Angel to contribute as well.  We'll see what happens.

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Angel is recovering from having his wisdom teeth out. Miricup doesn't want to get out of bed. And the board is full of FOUR scheduled sections. I make it in by 0705 and they're done prepping by the time I have my scrubs on.

I'm an assistant today, but a skilled one. Nobody has to give me instructions. He laughs, as he's putting in the stitches to close off a particularly noxious little bleeder. "You pulled the suture wrong, misled me."
A hubbub in the hallway, muted, as if trying not to draw attention. Afterward, I look for the scrub. "There's quads. 28 weeks. Doc's coming to evaluate, probably going to section." My heart jumps.

There's time for me to make my phone calls to patients and round on the postop folks before the 9 goes back. This OB stands on the surgeon's side if I'm going to assist, and usually tells me why. This time, it's the father's expensive camera. "He's going to take a lot of pictures."

I call clinic, make plans to come over if it happens while I'm seeing patients. And then the eleven becomes the one, and they wheel in three more baby warmers, and we're playing baby-go-round with the bandage scissors and the clamps and he let me cut...
I am in love with medicine all over again, standing in the NICU staring at four warmers, writing down weights. Smallest baby weighed a kilogram, all of them wriggling and crying as his big hands lifted them out of the uterus, tiny wrinkled naked creatures now connected to tubes and wires, oxygen support but no ventilators yet. The NICU nurses smile when I come in to see "my babies," the little ones I deliver with the perinatology service, and they let me stand and watch.
I carry the news back to the parents in recovery, reciting weights, accounting for forty fingers and forty toes. They glow, and smile at me - a stranger an hour previously.

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Program filled.  Got the page yesterday: 888.  Next year - it seems like tomorrow and forever at once - there will be no Match.  There will be nobody threatening to fail me if I stick them with a needle.  There will be no more of a lot of things. 

I am sitting on the couch in the staffing room in the library, all dressed nice and melting inside.  Residents come and sit next to me, ask me questions.  I talk a little loudly - as if to a partly-deaf aunt - so that the actual staff can hear me and maybe provide some input.  I think maybe I don't know anything at all.
Sometimes it is like this.  Sometimes, I submit and resubmit my charts to my faculty attending in between providing what I hope is sound and evidence-based medical advice - and he sends them back to me with notes that remind me of how little I know.  Sometimes, I think everyone knows more than I do.

I am in the adolescence of medical training.

Went into the OR with a new OB on my own patient - fourth baby, now with contractions at 37 weeks and a placenta previa on ultrasound suggestive of a possible vasa previa.  What's the difference? Placenta previa means mom is bleeding when the cervix dilates.  Vasa previa means baby is.  When you consider the blood volume of a newborn baby, you don't have much spare to lose.  So off we went to a C-section, with one anxious patient, one anxious fellow, and one attending obstetrician who was cool as a cucumber.  Tell me what you want me to do.  I want you to assist.  Then I'll assist. 
And then he smiled, and he assisted while I operated, and as I was scrabbling around inside an open uterus, shearing off the placenta trying to find a baby hidden somewhere under it, he leaned in.  Let me know if you want help.  "Now would be great."  And he did what I wasn't brave enough to do - reached through the placenta and pulled out a baby's head, and then he looked at me.  Go aheadThis isn't an easy surgery. 
The rest of it went smoothly, tidily.  As he looked across the table at me, stitching up the skin with slow careful movements (I love closing skin; it's artistry.  Soothing.  I love the look of a newly-closed incision, when I've done it well - smooth and well-approximated, as if I hadn't had my hands buried in the warm depths of humanity.  A C-section is brutal, O Best Beloved - there is tugging and cutting and sometimes I come out of them with my deltoids aching from the effort - but closing is beautiful.  And I close well, and I am proud of that beautiful approximation in the end) - he looked at me and said So what do you need, for paperwork?  Nothing, just tell me I did a good job and have a good night.
You did great.  Any time.

Saw a patient of my own postoperatively.  I assisted on her initial section; I performed her repeat, from the decision to section to the phone call to the attending obstetrician.  "Come in around five AM, we'll do it then."  And I wrote orders, did everything but sign the consent.  Halfway through, the attending looks up at me.  Did you give antibiotics?  I did, ma'am.  Preoperatively.  Oh, good. I guess I just assumed you'd done it all.  And that was that - and I knew I had.  And I closed, gently, smoothly - with the tiny needle that takes longer but makes it pretty, and we were still out in about an hour.
She came in for her 2 week check, showing off her flat belly.  Showing off her scar.  You did great.  Can't hardly see it.  And you couldn't, and it felt good.

I can operate.

Yesterday, I took over a case while the OB, scrubbed and with his arms folded, watched me operate and the resident whose patient it was assist.  Between him and the anesthesiologist giving me a hard time through the entire case, it was a fair trial.  And it went well - at least, we got the baby out without a problem and the uterus closed back up.  Afterward, he nodded.  "Your second layer on the uterus was worthless.  But otherwise, nice job."  And he was right, and we both knew it.

We are looking for housing in $new_city.  We have found nothing, and I am resigned to renting until we do - perhaps, until we build something.  My Angel is agitated about this.  He wants to be settled - and so do I, really, but I want to be settled right.  And we're talking about committing a positively ridiculous amount of money for a home, really, and we haven't even gotten our old one on the market.  We've gotten acres of boxes moved and piles of trash reorganized, but it still looks just awful inside, and I don't think it will ever be ready.
I want this to be over with.

It's mid-March.  At the end of May we're going to get on a plane - several sequential planes - and head to Papua New Guinea for a month of missions work.  [ Incidentally, there is currently a 5-10 day layover in Brisbane, Australia planned.  Can anyone give some advice on what MUST be done on the first trip to Australia, starting from Brisbane, with a 2 and a half year old? ]  And when I come back, I'm going to be a real doctor - with no residency director and no work hours restrictions and nobody to look over my charts and ask me probing questions.

And I'm scared.  I want to be a good doctor, and more than just compassion is required for that.  And as I move through this awkward adolescence I am reminded of how much I don't know yet.  It's definitely going to be an adventure.

Current Location: $hospital
now feeling:: thoughtful introspective

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ayradyss
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Nursing behind me is ranting about the woman who called her at 0740 to
complain that Home Care wasn't there to teach her how to give evening
meds.  They said they'd be there in the morning.  It's morning.  They're not here.  And the best part?  Not even our home care company.  Not even our city
"So you called our inpatient peds unit to complain about a problem at
$other_city_hospital home care?"   Perhaps, she suggested, you should
contact them.

"I'm going to make a blog.  I'm going to call it Don't be crazy unless you pay your bills."

Best medication refusal ever, she says.  We won't approve a three day course of this antibiotic.  You have to have a full two-week course or we won't pay.

And yesterday, apparently, the operator misheard "please page Anesthesia to PICU".  And overhead comes Any anesthesiologist to the deli, stat!



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I'm not OB proctor again, she tells me, brows furrowed.  I was just proctor Monday.  I shrug.  "I just need someone to talk to about these patients so I can send them home."  Phone calls are made, and she sighs.
He said "But they really like you!"  Like that makes it better.
"Think of it this way.  At least I'm your resident.  And we'll have lots of fun."  She laughs, shaking her head. What've you got?

I walk out of the call room to check on patients.   The board has changed - from dilation-station-effacement-special notes to "#105".  Delivered.  Without me again.  Second one tonight.  I stop him as he comes out into the nurses station.  "Sneaky delivering babies behind my back!"  News flash - I don't need a proctor.  He says it with a smile, but it reminds me what it must be like to be an obstetrician here.  You don't get to deliver your own patients - there's always someone hanging over your shoulder.  And tonight, he's in a do-it-yourself mood.  I haven't gotten to do much at all.  Interestingly enough, the words don't sting.  I think they would have, not long ago.
Later on, in the C-section, I bring it up.  "So, if you promise to let me know if you're doing something interesting, I promise not to proctor you."  He nods.  Sounds like a deal.  It means I don't do his vaginal deliveries, but I've done 63 since August already.  And it means nobody's waking me up to push at 3 AM for his patients, too.

I'm having a good day, even if I was running steady until noon-plus.  I've sent two people home and when I presented my patient to the proctor I did so with a plan already in mind, called her, made some followup plans.  I took a little nap and fixed a pregnant woman's migraine with Reglan and Benadryl and IV fluids.  And I keep thinking about the fact that tomorrow night is spa night, and Sunday I'm not working for anyone at all.

Postcall on Tuesday night, feeling like someone had run me over.  I'd spent the day staring into space, more or less, and just about to go to bed when my pager goes off.  It's my partner, on OB.  "Your patient, multip, ruptured, four cm."  Which means back to the hospital.  She delivered at 3 AM and I made an executive decision to go home instead of sleeping there for a second night in a row, slept in until ten since there were no scheduled sections, and I think I might have actually gotten enough sleep because I'm feeling better already instead of sick for weeks and weeks.

All in all, it's a good day.
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Tech-savvy med students fear life without EMRs

The gist of the article is that we are becoming technology-dependent physicians; it's accompanied by a slew of other articles about the usefulness of smartphones, the permanence of the pager, and the new trend toward texting your doctor. And as I look at my electronic medical record (which I hate), and my smartphone with Derm Meister, and ePocrates, and my OB Wheel, and I'm considering re-subscribing to UpToDate so I can install it there too...

I have to agree with them.

I'm going to be spending the month of June in the highlands of Papua New Guinea.  As a fourth-year medical student I went to Nicaragua.  I remember, then, the paper charts and the little slips of notes that served for records.  And I think I understand what they mean - that we are so wound up in our technology for every little extra thought that it's a frightening concept. 
But after it all, medicine is still an art.
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So many things have happened since I posted last.  And so many of them - I keep thinking "I need to write about that." 

And I don't know why I haven't.

Mom got me a book for Christmas.  It's a book of stories by an Internal Medicine resident.  I started it and then I put it down.  I like reading the stories.  But I wish I could put together something like that of my own.  It would mean something to me, to know someone cared enough to buy it. 

Doing some LJ-rearranging; I may be moving the meat of this journal elsewhere - somewhere that doesn't have quite the networked identity that this one has, somewhere where I'm not bombarded by service status changes every few weeks.  I don't quite know yet.  I made a new journal on blogspot with a pretty new name that I liked; I'm in the process of copying all 1200+ LJ entries over to a backup on blogspot (just a journal duplication, for now).  I stared at the blank new journal with its pretty new name, and I thought.
I should write something.

And I can't.  Instead, I've been reading journal entries from years back, and I'm amazed at how this has evolved.  Go back to the early-medical-school entries - in 2002 - and then come back to 2008 and read them.  It's a different voice.  Somewhere along the line I stopped talking to myself and started talking to someone else. 

I like it better that way.  It's certainly more interesting for me to read.  But I've hit a wall, suddenly, staring at the pretty new blank journal.  It reminds me of when everything was in notebooks, and I filled an old one, and I got out a new one (I have an extensive collection of blank notebooks) and stared at it, afraid that I would write something that wasn't worthy of being written down.
I have an extensive collection of notebooks which I have filled with things and probably many of them didn't need to be written down, but in the end it didn't matter, did it?

For New Years, O Best Beloved, I resolve to stop asking for someone else's approval for everything I do.
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This one's for you, Tony :D

$rural_er again today.  Medics listening to the radio - no hurry, no fuss, just back from a run.  And I didn't catch what happened exactly until they came back, in a huff, rolling their eyes.

$next_county signals.  Adult male, unresponsive, not breathing.  First responders (fire trucks and basic life support) calling, headed to the scene.  Closest EMS is already on a run.  And then nobody else calls in.  My medics pick up the mic.  "This is $county, did you notify $next_county EMS?"  
We're signalling them now.
Silence.
$county, $next_county has been advised.
"Does that mean we can disregard the call?"
$county, use your discretion.
So they went, because nobody knew if an ambulance was on the way with anyone who could do advanced support or not.  And it's a medic call.

"I get out there," he says, "and there's four ambulances, and guys standing around chatting.  And I said 'is there a medic with the patient?'  And they said yeah, so I was like 'shit, we're outta here'.  And we left.  And I picked up the mic and said 'you can tell anyone coming to the scene to signal-9.  And she says, '$county, all responders are at the scene'.  And I said 'I believe that, dispatch.'  And we came home."
And then came the signoff - patient refusing treatment, refuses transport.  Everyone go home. 
Turns out, the story goes, someone was smoking morphine patches.  Morphine suppresses respirations.  Once he got an oral airway, bag ventilated, reoxygenated and woke up, he chased them all out.  Price of stupidity, folks.

~~~~~
 
In other news, Miricup got her arm stuck in her pajamas the other day and said "Oh no! My arm is stuck!"  It was very cute.

now feeling:: blah blah

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User: ayradyss
Name: I whisper your name
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I'm almost two years out from medical school, here in Indiana where I was born and grew up. I used to write poetry - still do, sometimes - but now I've taken to spilling my heart out in prose. I'm balancing family, expecting a new baby, and working as a second-year family medicine resident. I'd like to take you along for the ride.

My updates are erratic, dependent on my mood, my current work schedule, and my ability to motivate myself. You are warned.

Expect a narrative of my days on shift. Anticipate good experiences and bad. Almost everything I write, personal or not, is a public entry, so be prepared for things that you don't quite understand.

There is a list of those who really do want to know more about me than the general public desires to see. Flip down to "spin a web" and click the link there to get in on that list.
. o O ( what's said is said ) O o .
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