Tetany

There has been a little bit of a theme this week. First, there were several adult patients in clinic that hadn't been immunized for years. (And, no, this isn't going to be a discussion on the need to immunize children... maybe later) Most people know that they should get their tetanus shot every ten years, but very few people actually remember when they are due. You would be surprised how quickly ten years can go.

It goes so quickly that even I let it slide. However, this afternoon my sleeve was rolled up, and my shoulder was in a nurse's pinching grasp. One second later I was good for another 10 years. One less thing on my to-do list. It feels good to not have that over my head.

Then, in our morning teaching session someone presented a case they saw from last month when they diagnosed a real life tetanus infection. And this isn't the first time this has happened in Omaha either. It is everywhere.

Moral of the story: get your vaccine!

Work Hours

Resident work hours is a hot topic in medical education lately, and is also a hot topic at our house. It isn't a secret that residents work a lot of hours, but living it is completely different than hearing about it. What surprises most people is that not too long ago the hours were even longer. The limits were only put into place around 2003 and in 2011 they are revamping them again. Our staff roll their eyes at us when we yawn or our heads bob during noon conference, and they will tell us stories about working for 120 hours per week when they were residents. With a smile they say, "The term 'resident' actually means something, you know."

Essentially, the current "recommended" work limits are:

• A total shift should not exceed 30 hours, but we cannot assume care of new patients after 24 hours. Practically speaking, we come in at 6am, admit patients all night, round with our staff the next morning, and then hopefully leave around noon.
• The work week should be limited to 80 hours/week averaged over 4 weeks.
• At least one 24-hour period per week should be free of duties averaged over 4 weeks (i.e. four days off per month, including weekends and holidays).
• Call cannot be more frequent than every third night. That mostly applies to surgery residents who are notorious for breaking work hours. In medicine, our most frequent call schedule is "q4" (every fourth night), and that only happens when we're working in the ICU.
• Any of these rules can be broken for the sake of patient care (i.e. one of your patients gets really sick and you want to stay to help take care of them).

It sounds like a lot of work. It is a lot of work. However, time actually goes pretty quickly. There is a lot to do and a lot to learn. Our patients tend to expect to see the same doctor every morning and in the middle of the night when they have questions. And, honestly, sometimes it is tough to hand off patients who you've been working hard to diagnose and treat to another resident who doesn't know nearly as much about them as you do. (Or maybe that is just me and the anal/controlling part of my personality).

Regardless of how difficult it is to trust another person with my patients, it is still always a relief to walk out of the hospital doors and into my living room where a little smiling face and a kiss from a handsome man are waiting.

Handwriting

There is one thing that doctor's are known for. I'm not talking about long hours or nice cars. Not white coats or stethoscopes. Doctors are known for terrible handwriting! We all know it, and unfortunately we generally live up to the stereotype. Honestly, this is one of my biggest pet peeves.

This week I consulted a few specialists in the hospital. I wanted their expert opinions on how to workup one patient's condition and how to treat another's. The specialists came around and saw the patients just as I had asked. Shortly after, my pager went off, and the nurse let me know they'd been around. I headed back to the hospital after I finishing up at the clinic. I opened the chart in anticipation of their recommendations. On top of the page "cardiology" was scribbled in black ink. There were about five more waving and dotted lines below, but I struggled to make out any other recognizable words. How helpful! I was aggravated but decided to just call them and clarify. I looked at the bottom of the page and there again is a scribbled signature. Not a big deal. After all, the hospital knows that 99.9% of doctor's signatures aren't legible (mine included) so there is a standing policy to write your ID number or pager next to your John Hancock. Sure enough,next to the sribbled signature were several numbers. Do you think I could read them? Nope. Is that a 4 or a 9 or an 8? Aahh!! They basically wasted their time doing the consult.

Now I take pride in having readable writing. And until we go to all electronic medical records, I'm sure I'll be frustrated by other doctor's lack of handwriting pride many more times. So I apologize on behalf of my profession for sometimes forgetting our first-grade lessons. :)

Awesome

Trust me, my job is not always overwhelming and depressing. Looking back on the past few stories I've shared, it would be natural to think that I'm crazy to keep doing what I'm doing. But really, my job is awesome! To prove it, here are a few things I love...

... hearing the nurses at my clinic refer patients to "Dr. Newman."

... seeing the bellies of my Ob patients grow at each visit.

... discharging a patient from the hospital happier and healthier than when they came.

... coming up with a treatment plan and then hearing my staff say "I like it!"

... when patients quit smoking.

... hearing a murmur that no one else heard.

... counseling patient's on their end of life wishes before it's necessary.

... post-call naps.

... educating someone that what they read on the internet isn't true.

... knowing what our pediatrician will say when Owen has an appointment.

... when patients say "Thank You."

... trying to answer friends and family's (mostly Jason's) weird medical questions.

... laughing at far-fetched medical dramas.

... free food and Diet Coke.

... every morning when Jason gives me a kiss and says "Save a life today!"

Totally Awesome!

Code

My first call night back at UNMC was... ? ...hard to describe. The afternoon had been excruciatingly busy, so I was gearing up to get slaughtered with new patients. However, we must have soaked up all of the sick people of Omaha during the day because we admitted less than the average number of new patients. As good as that was, cross-covering on other resident's patients was especially busy, and my code pager went off more than anyone would ever want. Once is too many times, and twice is painful. Trust me, I would much rather do an admission than go to a code.

Heading down the stairs after checking an EKG of a chest pain patient, I heard the dreaded and distinctive "beep!-beep!-beep!" of the code pager on my hip. My personal pager is set to vibrate, so I nearly fell down the stairs with this terrible sound. The pager gave the room number, and it happened to be on the opposite end of the hospital. When I say opposite end, I mean 0.25 miles away. As I changed my direction and headed to the room, I quickly scanned the list of our patients in my pocket and hoped that I wouldn't find a matching room number. No match. Whew! It wasn't one of our patients.

To my surprise I was the first one in a long white coat to arrive. My worst nightmare! How could I be the first one if I was nearly as far away as physically possible. In that split second I prepared myself to run the code. My worst worst nightmare!! Instead, one of the nurses that had gathered in the hall outside the room intercepted me and said, "I think he's already passed." (Hello! That's why you called the code blue!) "What's his code status?" I asked instead of sarcastic remark that first came to my mind. "He and his family decided to be DNR/DNI about 30 minutes ago." I prayed that this was documented somewhere. The patient's room was filled with family gathered respectfully around the bed. Who was I to charge in there, expose their family member, and begin pounding on his chest against all of their wishes simply to appease some malpractice lawyer? This quickly became my worst worst worst nightmare!!! Thankfully, before I had time to respond, my supervisor and the patient's primary doctor arrived. The primary doc took over (as they should), and the rest of us left out of respect for the patient and family. Big sigh of relief.

This was in contrast to the "beep!-beep!-beep!" that sounded a few hours later at 3:00AM. It first came across as an "RRT." This stands for "Rapid Response Team" and is intended to get help to a patient who is in trouble but isn't in a code situation... yet. As my supervisor and I arrived at the elevators the "beep!-beep!-beep!" sounded again. Same room. Now a code blue. The room was already filled with nurses, support staff, and all of the contents of the crash cart. This was the real deal. An hour later, it was over. All over. I walked away by myself so I could gather my thoughts of what that night had held. Thankfully, the other residents would be arriving shortly and this night would be done.

First Days

One of the difficult and frustrating things about residency, and even med school, is starting a new month. Imagine starting a new job with new co-workers, a new boss, a new schedule, a new system, and new expectations every single month. Going to sleep on the 30th or 31st of the month is always a little more difficult because my mind is racing with thoughts of what tomorrow will bring. Before I fall asleep, I say a little prayer that my alarm clock will go off at the new time for which it's set. It rings extra early on the first of the month, and I put in extra effort to get ready. The first day of rounds we walk around in silence as we feel out the new attending and their sense of humor. After rounds, I waste most of my time being inefficient because I haven't learned the shortcuts through the hospital, or where to find the medication lists, or how to call to find results, or this, or that. Everyone knows how "first days" go. A week or two into the month things settle in. I enjoy it for about a week. About then it's almost the end of the month, and I prepare to go through it all again.

August 31st was my last day at Children's hospital, and September 1st was my first day back at UNMC. I went from taking care of kids to adults. From infections of the ears to infections of the lungs. From diabetes type I to type II. From diapers to catheters. From one past medical problem to twenty. From no home medications to thirty (of which they actually only take ten, five as prescribed). From a two day hospital stay to a two week hospital stay. From CPS to APS. From tripping over toys in the morning to stubbing my toe on a walker. From hearing crystal clear heart and lungs, to struggling to hear anything through inches of "soft tissue".

It was more difficult to transition than I had anticipated. Even though I've done inpatient adult medicine several times before, as I sat down at the chart of my first patient early on Wednesday morning, I was suddenly overwhelmed. As much of a challenge as Children's was, in that moment I wanted to go back and find the confidence that I must have left there somewhere in the resident's lounge.

Thankfully, that moment passed, and after one night of call, my feet are back under me. There is still a lot of adjusting and learning left to do, but I'm ready for it now. I even think I can say: "I'm glad to be back."