Days Four and Five

So Day Four is called a "regular work day" where you just monitor the patient, try new things to make them better, or send them home. No new patients. Day Five is "pre-call" and is much of the same. The best case scenario is that you've discharged all the patients you got on long and short call, and are ready to start long call the next morning with no patients left over! Yeah, right.

Changing gears:
Today marks an interesting day. 9/11 has for several years now been the epicenter of intense politics, but to me it carries a different meaning. Every year as 9/11 approaches, I groan inwardly, knowing that people will get all worked up about this day, but then completely forget about it the rest of the year save for the politicians who continue to evoke it to their benefit. If this day just passed every year without anyone noticing, I'd be okay with that. It's like Valentine's Day - you're not supposed to love your significant other only on Valentine's Day, you're supposed to every day. Yet the commercialization and superficiality that is synonymous with V-day is pretty nauseating. Inasmuch, those who sacrificed their lives to save others should be remembered privately all the time, not staged once a year into a political tool.

I woke up today like any other day. Of course, I was aware that it was 9/11, but it didn't compel me to do anything differently than I would any other day. However, I was driving along PCH to go study at my favorite Starbucks this afternoon, when all of a sudden, there were hundreds of firefighters on motorcycles driving north. As I continued south, there were local fire engines parked along PCH, waving at the motorcycles. It was a huge, noisy spectacle, as cars and motorcycles honked and firefighters stood atop their rigs with their emergency lights flashing, waving at the motorcyclists as they thudded by.

I suddenly became really "homesick" for my fire family back home up north. How many other professions do this? Can you imagine hundreds of CPAs rallying together on a giant motorcycle ride to remember their own who were killed in New York seven years ago? Firefighters are pretty unique, along with the few other professions where you must live together despite your differences and sometimes rely on each other with your lives. I never had any Backdraft moments of falling through the roof into a fire, but there are countless less sexy or dramatic times when my ass was saved by someone I worked with. I haven't forgotten what it is to be a firefighter. The job and the landscape where my firefighter self was born, trained, lived and worked, has changed me for good.

I wish everyone could experience such a tie to their brethren - known and unknown - sometime in their lives. The world would be a better place for it. And that would be the best way to pay respects on such a day like this for those who gave their lives, unarmed but for rescue tools, surely terrified, but still answering the call for help.

Short Call

This is Day Three. Short call means we take new patients from 7am-4pm, with a cap of four new patients. Sometimes you get all four first thing in the morning from the "night float" resident, who is there to admit any new patients who come after 7pm when the long call team stops taking admisssions, and to make sure the rest of the patients don't die in the middle of the night. Other days you get the four dribbling in throughout the day.

I was assigned one of the new patients today, a young lady whose skin is calcifying. It's a very sad disease. She can't open her mouth completely because the skin at the corners of her mouth are calcified, and she walks with a limp because she can't bend her leg due to the calcification. Patients with her variation of this disease supposedly have no reduction in life expectancy, although it's a restricted and not-so-fun life. However, patients with the diffuse form of this disease have a very poor prognosis owing to organ involvement in addition to the skin problems, and most often die because their lungs lose capacity to expand and contract. There's no cure for this disease, so we do all we can to give supportive care. I hope my patient doesn't go from her limited end of the disease spectrum to the diffuse end. She seems really nice and I hope she can leave soon. There was another patient we had recently who had the diffuse form. It came on suddenly a few months ago when she had her baby. She was otherwise healthy, but has since developed calcified skin and organs everywhere, and her skin turned nearly black everywhere too. Her baby isn't going to have a mommy soon.

Anyhow, after we finish rounds in the morning, we work up our new patients and treat and monitor our old patients. It's not as long a day as long call, because we only accept new patients until 4pm, then we are generally able to interview the new patients, admit them, order some labs and studies, and finish their paperwork by 8-9pm. We even got done early enough today for me to hang out with Darron and try out his neighborhood Japanese restaurant. He liked everything we ordered! I'm so proud of my newly Japanophilic baby!

Okay... off to study up on skin-calcifying disease.

Library Books Sarah Palin Supposedly Tried to Ban

A Clockwork Orange by Anthony Burgess
A Wrinkle in Time by Madeleine L'Engle
Annie on My Mind by Nancy Garden
As I Lay Dying by William Faulkner
Blubber by Judy Blume
Brave New World by Aldous Huxley
Bridge to Terabithia by Katherine Paterson
Canterbury Tales by Geoffrey Chaucer
Carrie by Stephen King
Catch-22 by Joseph Heller
Christine by Stephen King
Confessions by Jean-Jacques Rousseau
Cujo by Stephen King
Curses, Hexes, and Spells by Daniel Cohen
Daddy's Roommate by Michael Willhoite
Day No Pigs Would Die by Robert Peck
Death of a Salesman by Arthur Miller
Decameron by Boccaccio
East of Eden by John Steinbeck
Fallen Angels by Walter Myers
Fanny Hill (Memoirs of a Woman of Pleasure) by John Cleland
Flowers For Algernon by Daniel Keyes
Forever by Judy Blume
Grendel by John Champlin Gardner
Halloween ABC by Eve Merriam
Harry Potter and the Sorcerer's Stone by J.K. Rowling
Harry Potter and the Chamber of Secrets by J.K. Rowling
Harry Potter and the Prizoner of Azkaban by J.K. Rowling
Harry Potter and the Goblet of Fire by J.K. Rowling
Have to Go by Robert Munsch
Heather Has Two Mommies by Leslea Newman
How to Eat Fried Worms by Thomas Rockwell
Huckleberry Finn by Mark Twain
I Know Why the Caged Bird Sings by Maya Angelou
Impressions edited by Jack Booth
In the Night Kitchen by Maurice Sendak
It's Okay if You Don't Love Me by Norma Klein
James and the Giant Peach by Roald Dahl
Lady Chatterley's Lover by D.H. Lawrence
Leaves of Grass by Walt Whitman
Little Red Riding Hood by Jacob and Wilhelm Grimm
Lord of the Flies by William Golding
Love is One of the Choices by Norma Klein
Lysistrata by Aristophanes
More Scary Stories in the Dark by Alvin Schwartz
My Brother Sam Is Dead by James Lincoln Collier and Christopher Collier
My House by Nikki Giovanni
My Friend Flicka by Mary O'Hara
Night Chills by Dean Koontz
Of Mice and Men by John Steinbeck
On My Honor by Marion Dane Bauer
One Day in The Life of Ivan Denisovich by Alexander Solzhenitsyn
One Flew Over The Cuckoo's Nest by Ken Kesey
One Hundred Years of Solitude by Gabriel Garcia Marquez
Ordinary People by Judith Guest
Our Bodies, Ourselves by Boston Women's Health Collective
Prince of Tides by Pat Conroy
Revolting Rhymes by Roald Dahl
Scary Stories 3: More Tales to Chill Your Bones by Alvin Schwartz
Scary Stories in the Dark by Alvin Schwartz
Separate Peace by John Knowles
Silas Marner by George Eliot
Slaughterhouse-Five by Kurt Vonnegut, Jr.
Tarzan of the Apes by Edgar Rice Burroughs
The Adventures of Huckleberry Finn by Mark Twain
The Adventures of Tom Sawyer by Mark Twain
The Bastard by John Jakes
The Catcher in the Rye by J.D. Salinger
The Chocolate War by Robert Cormier
The Color Purple by Alice Walker
The Devil's Alternative by Frederick Forsyth
The Figure in the Shadows by John Bellairs
The Grapes of Wrath by John Steinbeck
The Great Gilly Hopkins by Katherine Paterson
The Handmaid's Tale by Margaret Atwood
The Headless Cupid by Zilpha Snyder
The Learning Tree by Gordon Parks
The Living Bible by William C. Bower
The Merchant of Venice by William Shakespeare
The New Teenage Body Book by Kathy McCoy and Charles Wibbelsman
The Pigman by Paul Zindel
The Seduction of Peter S. by Lawrence Sanders
The Shining by Stephen King
The Witches by Roald Dahl
The Witches of Worm by Zilpha Snyder
Then Again, Maybe I Won't by Judy Blume
To Kill A Mockingbird by Harper Lee
Twelfth Night by William Shakespeare
Webster's Ninth New Collegiate Dictionary by the Merriam-Webster Editorial Staff
Witches, Pumpkins, and Grinning Ghosts: The Story of the Halloween
Symbols by Edna Barth

Who's scared? I am.
Please Snopes at your convenience to verify.

Post Call

Day Two is the day after call, so it is appropriately named "post-call."  So I got there at 7am and left by 5pm.  Such a short day is hiiiiighly unusual!  Last cycle we were there at 6:15am until 10:30pm or so.  This is the day where you have done some initial workups of all your new patients the day before, so you finally get to present them to the attending (remember, he left at noon yesterday so he hasn't seen any of the patients who were admitted after he left).  Since he is such a scarce character but does the most of your block evaluation, you want to shine when delivering your report to this guy.  Additionally, the patient's been there overnight, so you get to see what effect your initial treatments had on your new patients... did they work?  Are the lab test values any better?  Any imaging studies that are done, with reports by radiology completed?  The answers to these questions get incorporated during morning rounds (keep up with the terminology here!) and help form your all-important Assessment & Plan.  Any Joe Schmoe can go find lab values and vital signs and report on them, but what they really want to see out of us is the ability to synthesize all this information and come up with a comprehensive "probable problem" vs. "possible other problems" list, explain how we can eliminate the possible problems, and how to effectively and safely treat the remaining most likely problem.

Usually this is a day of hard work but because we admitted so few patients yesterday, seeing that it was a Sunday, we had very little work to do.  Plus we were lucky in that a lot of our patients weren't sick enough to hang around for days and days, we were able to send a lot home after just one night in the hospital.

So next time you are hospitalized and hate the food and being woken at all hours of the day and night to have your blood drawn and are bored in your little room, just know that the medical team wants you to go home just as much as you do!  I, for one, came home, went for a short run and promptly fell asleep when I got back, since my body doesn't know what exercise or sleep is anymore.

Time to go scavenge for some food, then do some studying so I can be ready for Day Three!

A Typical Hospital Day

I'm currently doing my internal medicine rotation.  Internal medicine covers sick people who don't need surgery or aren't there on an emergency, and they can't ambulate in/out of their family doctor's office - they are the sickies.  Think congestive heart failure, heart attack, leukemia, those weird rare diseases that kill you... etc.

Whereas my work cycle in the fire dept. was a 3-day cycle, here at UCI Med Center Internal Medicine it is a five-day cycle.  The difference was, at OFD it was work-off-off.  Now it is work-work-work-work-work with a random day off here and there.  I used to have twenty days off per month.  Now I have four.  What the hell was I thinking?!?!  Well, I guess I might have been thinking that it's priceless to hear someone blame away their syphilis on a wet gym towel and know they are lying sack 'o bleeps.  Or that once someone develops a swollen belly from their boozing, you better say all your last thoughts because they aren't going to be around much longer.  Or that I know definitively how to end a life.  Although I won't use that knowledge, it's powerful stuff.  Those sirens that were Odysseus' temptation?  Sailors didn't throw themselves overboard to listen to them sing silly songs!  The sirens' "song" was actually knowledge - of the past, present, and future.  Knowledge is irresistable.  Many a brave Greek sailor went to their watery deaths trying to attain it.

In any case, this is Day 1 of my 5-day cycle, with an intro to my team:

1.  One attending.

He is the dude who makes the final call on treatments and plans for the patient.  He comes at 9am and leaves at noon, and makes a lot of money.  The 9-noon period is called "rounds" where first the whole team sits in a conference room and debriefs the attending on what new patients we have that day, or what the progress is on continuing patients since the day before.  Then we run around the hospital together, the whole team, so he can examine each patient, one by one.  On any given day in a teaching hospital, there are multiple teams flying in and out of all patient rooms.  It's hilarity to watch.

2.  One 2nd or 3rd year resident (aka "the senior").

She is the dutiful deputy.  She runs things before 9am and after noon, and makes sure everyone's verbal reports to the attending during rounds are delivered smartly, adding clarification or background as needed.  She is there at or before 6:30am and leaves after everyone else.  She coaches the interns on their treatment decisions, orders to nurses, consults with specialists, and teaches medical students in between. 

3.  Two 1st year residents (aka "the interns").

They also get there around 6:30 or before and start examining patients, checking lab values, etc.  They split the patient load in half and have the primary responsibility for the patients.  They consult with the senior throughout the day to keep her informed and bounce ideas off her.  They also babysit lost medical students who need help with menial things.

4.  One 4th year medical student ("the sub-I").

She has already rotated through internal medicine before as a 3rd year, but 4th years have to do a dry-run internship for a month or so (the sub-internship) before they graduate and actually become interns.  Optimally, she carries half the load of the interns, but is primarily responsible for patient treatment decisions just like the interns are.  Of course she consults extensively with the senior, but it's obviously nerve-wracking and hectic for her.  She's not responsible for anyone but herself, but she is the closest to us in experience, so she gives us good little tips and nuggets to help us navigate the behemoth medical system in the hospital.

5.  Finally, the two 3rd year med students.

We just wander around with perplexed looks on our faces.  We never know what we're doing, we just show up when told, and leave when told.  The saddest members of the team.  Don't know anything.  Nurses fart in our general direction, but it's a happy time in the day when unsuspecting family members address us or benevolent attendings introduce us as 'doctor.'  Of course the latter always clarifies that we are "student doctors," but it's still nice to hear!  We come in at 6:30 just like everyone else and write up our paperwork like everyone else, albeit a reduced load, since we're learning and slow at it still, but none of our work counts for anything.  The intern, senior, and attending will all repeat the work done, so we are actually useless on the team; rather we slow everyone else down.  However, we are the only members on the team (and the 4th year too) who are actually paying money to be present, so they have to tolerate us and teach us a thing or two.

Day 1 (long call)

Being "on call" means you admit patients up from the ER, down from the ICU, or from doctors' offices.  You can't just walk into internal medicine and say you want to stay in the hospital; someone has to determine you need to be admitted.  Admitting a patient takes a long time.  You have to go find the patient, spend roughly 30-60 minutes interviewing and examining and looking through the chart to see what's already been done to the patient.  The interview is basically detective work so you can start thinking, "what's wrong with my patient and how can I fix it?"  On long call days, we accept patients from 7am-7pm.  Each team can carry a maximum of 20 patients - eight per intern and four for the sub-I.  Med students generally get one to three patients, and our heads are spinning at that point.  We round with the attending at 9am-noon as usual for our existing patients, but throughout the day, whenever there's another that needs to be admitted, the interns take turns getting assigned.  At noon, there is "noon conference" which is just a fancy way to say "mandatory lecture on whatever and free food to guarantee your attendance."  At 1pm, we go back to work, ordering labs, consulting with specialists, sending patients to get MRIs, talking with family, coordinating with the case worker, calling the family or the convalescent home nurse for background info, etc.  It's an amazing amount of information synthesis that happens all day.  The last long call day I had, by the time I drove home it was midnight, just in time to change, eat, shower, sleep for a few hours, and get up to be back again by 6:30am.  Long call is aptly named!

Tomorrow... Day 2 (post-call)!