Here comes the new blood!

People said February would be the worst, and it was. Even my CCU attending told me he remembers February of his intern year being a lowpoint in his life. Now that it's March, my spirits are magically improved. Is it because I was in the CCU in February pulling those fun 30-hour shifts? Is it because I am on my first vacation in eight months? Is it because spring is finally in sight? Or is it because yesterday was Match Day?

It seems that my Match Day was a lifetime ago, but alas, it was only last year! What a strange day! People were laughing and crying, but regardless of elation or misery, everyone wanted to drink as much alcohol as they could until their bodies said, "No more!" That's because they have spent the last nine months, the four years, or their entire lives waiting to find out what that envelope said.

What it means for me as an intern this year is that my replacements are on their way! They will shortly be signing contracts for the wild ride of intern year, and I will be moving on. Yes, the end of intern year is in sight! I know this means that I will be a resident in a few short months. It's a scary thought that I will try not to dwell on while soaking in the Caribbean sun.

ER vs everyone else: Where's the love?

I have to say that there is no love between the emergency room and the rest of the hospital. The main reason is because when the ER decides to admit patients, they are creating work for the residents on the wards and in the ICU. While sitting upstairs, it's easy to criticize the emergency room staff. We criticize them for admitting patients who look too well, and we criticize them for not doing more for the very sick. What I had not realized until working down in the ER was how difficult it can be to make judgment calls about a patient when they come in. Sure, the next morning when you know how the patient did, it's easy to say what should have been done. However, in the ER, sometimes there are so many patients in the waiting room, that you can't wait to see which way the patient is going to go. You make a clinical decision--you admit the patient to the hospital or you send them home with some good instructions on what should bring them back. And then you pray that you erred on the correct side.

Adventures in the emergency room

After working 30+ hour shifts in the CCU, I thought a 12-hour shift in the emergency room would be nothing. I was wrong.

First of all, I started with night shifts. There seems to be no easy way to switch your body over to being awake all night. I tried afternoon naps, but that didn't work. After three nights of work in the ER, I was finally able to sleep nine hours during the day. Too bad after four night shifts I now have to flip to doing day shifts!

The ER is an interesting place. I'm used to being upstairs where someone else has already decided that someone's problems are serious enough to be in the hospital. My biggest problem in the ER is adjusting my "bullshit meter". Who is in the ER for secondary gain? It's not the coziest place in the world, but it does offer a warm place to sleep and as many 4 oz containers of juice as you want. I've had people come in saying "I had a seizure" or "vomited up lots of bright red blood" or "I want to kill myself!" Individually any of these would be a serious complaint, and I quickly started to realize that they know if they say one or sometimes all of these things we can't kick them out the door for at least a few hours. Yes, the people who say these things are usually drunk and sleepy. However, they are also symptoms that are more likely in people who are drunk, and the fact that they're sleepy would normally be more concerning. Did they overdose? Try to kill themselves? Hit their head and lose consciousness? Probably not, but I worry and often rely on the judgment of those who have more experience.

The other thing I find interesting is that people come to the ER in the middle of the night for the most mundane things--sore throats, tooth pain, a cough that's been going on for a week. They know the wait is shorter if you come at 3 am. I know that this is a symptom of our broken healthcare system. I myself haven't seen my primary care doctor in two years because it's too darn hard to get an appointment. Sometimes the wait for a sick visit is a week. However, there are people who keep coming to the ER for the same complaint, and I ask them why they don't go see their primary care doctor in between visits. Usually, they say "I didn't think about going when I felt okay." It's probably silly of me to try to change the system one person at a time, but I sit down and tell them about the role of the primary care doctor. Despite the frustrations of the system, that person is the main coordinator of their health. If they continue to have complaints serious to them but not serious enough to be admitted to the hospital, they're not going to get fixed until something very bad happens. I might be imagining a light bulb going off in their head, but hopefully my pleas to go see their regular doctor are heard.

One more week until my first vacation in eight months! Can't wait!

Isn't it supposed to be a bad flu season?

People say February is when the interns hit rock bottom. Honestly, I'm so tired and burned out that I started wishing for the flu. Even if I had to stay home with rigors all day, I would get to see my husband and sleep more. I need a break! Despite my co-intern getting some terrible viral illness and my team treating two patients with influenza pneumonia, somehow I've escaped without a single sick day used this month. Oh well, a girl can dream.

an intern's worst nightmare ...

is falling asleep during rounds! I didn't even know it was my worst nightmare until it actually happened. To be fair, I was post-call without a wink of sleep and into the third hour of rounds. My attending called me out on it in front of everyone but was laughing. Whew!

A lifetime of learning, no kidding

I'm in the last week of my month-long outpatient rotation, and I had a long list of tasks to accomplish before entering the CCU next week. In addition to seeing friends and cleaning my apartment, I also wanted to slog through the tall pile of journals that has accumulated since last time I was on an outpatient month. Flipping through the January 17th issue of the New England Journal of Medicine, I was reminded how medicine is ever-changing. There is constant revision of therapies in addition to the social and political aspects of the medical field, and I need to keep up! Here are a few excerpts for those interested in what I've been reading.

I've had the opportunity to work with foreign medical graduates in the past, but this article really describes the sacrifices they make and the hoops they jump through in order to practice medicine in the Western world.

[Foreign medical graduates] must not only relearn the theory, which many of them first studied decades ago, but also master the social and behavioral nuances of being a doctor in the West. Some must do so while supporting themselves by driving taxis or picking fruit; others rely on meager personal savings or small government handouts. They are driven by the dream of becoming doctors again, but the reality can be a nightmare.

I need reminders like this so that I remember how lucky I am to do my crazy job everyday. I've heard about publication bias, but this article really lays the numbers out there.

Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published ... Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive.

I haven't had an ethics course since I was a first-year medical student, but there are still many unanswered questions. When I read this case about cell lines derived from a patient's splenectomy specimen, I couldn't believe that the law wasn't more clear.

Under ancient Roman law, when agricultural crops were in the ground, they were owned by the landowner, but picked fruits and vegetables were owned by the farmer who worked the land. Trees taken from the land, however, belonged to the landowner. Is a removed spleen more like an ear of corn or an oak tree? ... Since the cells in human tissue are living and reproduce, perhaps they are more analogous to farm animals than to fruits or vegetables. The progeny of animals are the property of the mother's other. Is the cell line equivalent to [the patient's] "progeny"? Similar, an owner wrongfully deprived of livestock is owed the value of the eggs from converted chickens and milk from converted cows. Are [the patient's] immortal cells like chickens, and the protein products derived from them like eggs? The need to resort to cases that involve the ownership of corn, trees, cows, and eggs demonstrates the need to create modern rules that deal directly with the ownership and use of human tissue.

I remember in my medical school application essay I stated I wanted to enter medicine due the ever-change challenges the field encountered requiring a lifetime dedicated to learning. Boy, I don't think I knew what I was getting myself into!

Health Care in an Election Year

Our health care system is broken. I see examples of it everyday. People who can't afford their medications in the emergency room, hospital wards, or ICU due to poor control of their chronic medical problems. I am going into primary care praying that there will be meaningful change in the system that will allow me to take better care for my patients, but how does that translate into who to vote for? Well, I've been pouring over this site comparing the candidates' plans today. There are flaws in each of these plans as I really do believe in a single payer system, but they are all a step in the right direction. The devil will be in the details of how these plans are implemented. I'm still struggling with which candidate understands the deficiencies of the current system the best. I want my candidate to know which of the many parts of their plans to push for and which will have to be sacrificed as the plans are made into law.

I'm excited that I will be able to make it to the voting booth for my state's primary on Super Tuesday. I'll be post-call from the CCU and will go directly from the hospital to my polling station. I just don't know yet who to vote for.