EM Month Winding Down and First Interview

I was very proud of myself recently. I saw a patient with a history of panic attacks and meth addiction. Supposedly the meth from her most recent relapse had worn off and she was solely under the influence of a panic attack when she got to the ER, but I have my doubts. In any case, what I'm proud of is that I was able to calm her down with with a reassuring tone, redirecting her attention, and having her do deep breathing. This was an ego boost not only because I was able to calm a distraught patient, but more so because the whole time I was thinking what a mess her life is and how I didn't want to be dealing with her. So, yes, I'm bragging about my hypocrisy in some ways. It's important, though, to be able to get over your own feelings, judgments, etc. about a patient and be able to provide appropriate treatment. I thought I was already cynical, but this month in the ER with at least a third of my patients being drug seekers has really been an eye-opener and tried my standpoints on the cutoff between providing for patients' needs and being an enabler of unhealthy habits.

Another interesting patient was a quite mature, almost precocious, teen with abdominal pain. I needed to examine the patient's abdomen, and decided it would be best to do so without pants in the way (US pants, not UK pants). I was reminded of the Scrubs episode in which Turk is reluctant to see his doctor because he has to take his pants off for all visits. "Oh, you have a sore throat? Ok, take off your pants and I'll be back in a moment." This ER patient is also a Scrubs fan and I was able to connect over the pop-culture reference. With this patient's maturity level, I had already been able to establish a good rapport, but it was good to see how that personal connection can further put a patient at ease. After the initial ER workup, the general surgeon admitted the patient for observation since the pain was reminiscent of appendicitis, but wasn't as severe as would be expected, plus the appendix was not assessable on CT.

It's worth while to highlight some differences between the two patients above. For the drug addict, I had to step up my interaction with her from my default of not wanting to deal with her. For the teen, I was drawn into conversation and had to rein in my desire to chat in too informal a manner. In both cases, it was important to form a personal connection with the person while maintaining objective professionalism.

I was invited for my first interview yesterday. I have applied to both Orthopedic Surgery residencies and Traditional Rotating internships in case I don't get into an ortho program. The traditional path of medical education was to finish med school, do a generic internship year rotating through all major specialties, then do residency. Some residency programs, ortho included, have wrapped an internship into the curriculum as the first year of the program, and therefore take one step out of the process. My interview offer is with one of the internship programs, and the most convenient available interview date is this coming Monday. So, I had a flurry of activity booking a flight and hotel today. Thankfully the airport, hotel, and hospital are within a 3-mile radius of each other, so transportation is easy. Unfortunately, booking a 36-hour trip only five days in advance is pricey, and all the numbers are starting to run through my head: several hundred per interview trip, times 23 programs applied to, subtracted from what remains of my student loan for this semester... ugh. I'll be panhandling by November.

Scott

EM Rotation and Setting Up Auditions

This month has been fairly low-key as far as my emergency med rotation goes. Somebody in some office not affiliated with the ER docs' group set up my schedule, each day with a different doc, and the docs don't know I'm supposed to be there until I show up at the beginning of their shift. The unfortunate thing is I have to take both parts of my level 2 boards this month, plus go to a doctor's appointment an hour away. I asked the "somebody" if he could alter the schedule, which he obligingly did. However, I was left with an awful 11-day stretch with no days off amongst being at the hospital, taking an all-day test, flying to take another all-day test.... I decided to add in my own days off to even things out. Every now and then, there are perquisites to being in a new program with no one knowing what the hell's going on. I don't want to take advantage of this loophole by being lazy, so I may switch around the end of the month so I can experience an overnight shift instead of strictly day shifts.

I took the computer-based portion of my board the 6th and will fly out the 13th to take the practical portion, only offered in PA. In addition to these tests complicating the month, I am trying to set up audition rotations at hospitals that have orthopedic residencies to which I want to apply. I have been more successful than I expected, as I applied for the rotations a bit late in the game. I'm finding that sites' rotation coordinators can take several months to get back to you regarding whether you can rotate. When they do, three in a row have responded with a large packet of information that I had to fill out quickly and remit along with information directly from my school since the rotation had apparently already been scheduled for me. Twice, I have had to tell the coordinator that I already set up a different rotation while waiting to hear back.

The really embarrassing event was when I mixed up a couple programs. I already have a rotation set up at HFHS for October, and someone emailed me from BGMC, only identifying the program by its initials. Well, all the initials ran together in my mind and I thought she was contacting me about the rotation I had already set up, asking for paperwork I thought was already completed. So, I faxed back the completed paperwork, most of which was thankfully for BGMC. In my panic and confusion, I faxed back a few pages from HFHS as well. Totally mortified, I had to email the BGMC rotation coordinator, apologize profusely, and explain the situation with as positive a spin as possible. Not much room for spinning, unfortunately. In my defense, though, her email said something like "we have you penciled in for October but don't have any paperwork on you, so fill it out and send it in." Realize that this is the first time I have ever heard from BGMC, and had no idea I had been "penciled in" there. In any case, this all happened late Friday, so I won't hear back on the issue until Monday at the very earliest.

If you were able to follow that whole story, then I could sure use a personal assistant. I sill feel like I'm in Vegas, and I've been in Pueblo, CO for two weeks already. All this trouble keeping track of rotation sites and dates has been a good experience. I only have a handful of potential audition rotation sites, whereas my list of residencies is over a dozen if you include traditional internship programs. Since the rotation arm and the residency arm of a program are somewhat separate, I'm hoping my little mix-up doesn't reflect poorly on my quality as a residency applicant at that location. In any case, I'm determined to be more organized as the residency interview and application process gets more involved. It just wouldn't do to be in an interview and answer the question "What sets our program apart from the others?" with a list of things I like about another residency.

Well, it's after midnight and I still can't sleep, but I should try since I have to be at the hospital tomorrow.

Scott

August Newsletter

August brought my first audition rotation, on which I was trying to show off to the program director and other VIPs of an orthopedic residency program. This particular program is in Las Vegas, and it will be brand new when I graduate med school next year (May 19th, 2012). It was an interesting feeling doing an audition rotation. The knowledge that I might spend the next five years there made the experience sink in a little deeper. All in all, it was a good month and it went faster than I expected. The four weeks in Vegas ended on a high note when, on my last day there after work, I saw a woman helping a collapsed man and got to help get an ambulance and provide emergency care for him. I've been analyzing my actions so I can improve next time something like that happens and I'm trying to get a hold of the 911 recording to remind myself what all happened. The city communications person is not getting back to me on the matter, though.

My parents pointed out that this collapsing man was a good segue to my current rotation. Since August 29th, I've been doing emergency med. I like the diversity of cases that come through. I've seen a couple of patients who needed intensive care: a drowning victim and a patient with a STEMI. Other patients just need a pat on the wrist and are sent home, like a kid who had mild RUQ pain and a completely normal workup, and a psych patient who basically wanted someone to talk to and a bite to eat. There have been many patients filling in the middle of the spectrum, either. My only problem with EM is there is entirely too much medicine and too little emergency. I prefer the lacerations, fractures, etc. that can be fixed by slicing, casting, jabbing, or suturing. All this abstract stuff with lab values, liver function, body temperature, heart rhythm is too much for my concrete mind to wrap around. I'm improving, though. Each time I start a new rotation, it's taking less time to get in the swing of things. I am also getting better at general medical tasks like doing a complete H&P, which was a bear when I first started.
In the coming months, I have two more audition rotations set up. Sadly, they are both scheduled for October, so I'm trying to move one. In personal news, I am still struggling with my 30-year-old motorcycle. It's back in the shop, and I don't even want to think about how much it's going to cost to fix up all the little things going on with it. I swear, I should have been a mechanic. You make practically as much as a physician, don't pay malpractice out the nose, and your worst disgruntled customers are biker gang members, who mercifully won't sue you, and will resort to much more minor forms of retaliation like arson, murder, and the like. Anyway, once it's out of the shop, I plan on using it as my main form of transportation this month since it gets roughly double the gas mileage of my car.

Scott

First Few Days of ER

Today an attending told me about a four-month-old he had seen in the ER. The mother's only concern was tachypnea, and on exam, the kid didn't show any other signs or symptoms. The doctor normally doesn't get lab work on kids that young, but he decided to and just happened to catch a case of DKA, which is very rare in this age group.

Patients I've seen include a drowning victim, a burn victim, a young adult with DKA, a depressed/psychotic patient who can only say three words, and an infected thumb laceration. There have been many others, and I appreciate the diversity of cases in the ER. One pregnant patient was exposed to low levels of carbon monoxide, and though she was fine, she had to stay a while as we figured out what to do about the fetus. Hemoglobin prefers binding CO over oxygen, and fetal hemoglobin binds both gases with higher affinity than adult hemoglobin. My attending had me call poison control, and they didn't have specific recommendations for a pregnant patient. We got in touch with a OB/GYN, and my feeling is they didn't know what exactly to do, either. I looked it up later on UpToDate, and for mild to moderate exposure, there seems to be no adverse affect on the fetus.

I plan on getting my newsletter posted today amongst reading, so I'm cutting this post short.

Scott