A Haunting Encounter

Today, I had a class on incorporating the humanities in medical education.  We were asked to write a short piece of prose or poetry on a patient encounter that haunts us.  Hearing what others wrote was way to much for my hormonal psyche.  I didn’t share mine because I was too busy trying not to let anyone see me cry about the ones that were shared.

I am not a poet, but it kind of has a poetic feel, I think… Here it is…

You did your best.  You knew something was wrong.  You were low risk, they said.  But, now, you are sit in clinic and don’t know how bad it really is.

You are angry and scared.  You cry when I review what is happening within your body.  I am gentle, but I am up front.  Medicine is so advanced, but so limited.  

Together, we bring you down off that ledge.  We have a plan.  You know what is likely to happen.  Then, I point out you need to meet my staff.  To keep in mind that a chance for second opinion isn’t gone.  

Gruff and curt, he approaches.  The plan changes and you are confused.  There is no explanation.  Just a closed door.

I try to help you understand.  I feel a sense of loss.  Like I am free falling in a place outside of my control.  It can’t compare to what you feel.

You don’t want another opinion.  You trust him.  Because you trust me.

In that moment, I don’t trust me.

I go home and review the literature.  I think and think.  I talk to another staff person.  I am right.  There may be more.  But, how does that get approached?  Who is willing to speak up?  

Everybody talks, but nobody deals.  That seems to be the way sometimes.  The questions are brought up, but I wonder if they were truly dealt with.  They get swept under rugs that some of us can’t help but look under.

This time, someone did say something.  This time, something did change.  Somehow, the suggestions were accepted.

I was relieved.  I want the best for you.  I want the best for all of you.  But still, the whole thing is unsettling.

In the long run, will it be enough?  Will you continue to get the care you deserve? 

If I hadn’t been there, if you didn’t trust me, would it be different?  Would you have made a different choice?

Maybe it is enough.  But, I wonder if we could do better.  I wonder if it is my fault.  That my being nice, that we “clicked” made you not question, not request that second opinion.

I won’t know.  I can’t help but wonder it is my fault.  And I’m not even sure what “it” is.

Teacher, teacher

I’m doing an education elective this month.

I have almost always wanted to be a teacher (and an author).  Well, after I got over the wanting to be a vet (my parents quashed that dream when I was about 4 when they informed me that if I was a vet, I would have to take a bath every day) and work at KFC (I was a chubby kid who really liked the way it smelled, despite the fact that I was informed I would no longer like KFC if I smelled it every day… I didn’t even have to smell it everyday to develop a dislike for KFC as an adult).  Honestly, medicine came much, much later in life.

I realized as a teenager that I hate kids in mass, so perhaps teaching elementary or middle school was out of the question.  I also realized science was very fun.

Once I hit medicine, though, I came to this crazy realization that maybe, just maybe I could “have it all.”  Who knew doctors teach?

Probably most people.

But, the fact that it could be my reality blew my mind a little.

So, I have always thought teaching was important.  I tutored in med school, mentored new students, all that stuff.  And now, I am doing an education elective and launching some new education related stuff in my department.  It has confirmed that I want to teach more.  I think I might even start working on my masters in the next year or two (depending on how this whole juggling residency and baby thing goes).

The funny thing is about the elective is that, for the first time in a long while, it is like being a student again.  Sure, there is no call and my hours are a bit more set, but I have assigned readings and projects and assignments.  Plus, the studying/prep for my usual program academics.  I forgot a bit what it was like to be a “real” student.  I have a love-hate relationship with being like a “real” student.

My focus is suboptimal.  Lectures from 8-12 and 1-4:30  That is a lot now.  Friday afternoon half-day is like torture and that is just 1-5 one day a week.  Plus, the degree of interaction is much more than I’m used to.  Group work?  Heck, usually my whole program is the size of a group they have me working with.  Non-clinical assigned readings are novelties.  Doing assignments and writing papers are things I do much more rarely now, but they are becoming regular occurrences.  Presentations and teaching practice prep is similar, but different.  And then there is switching focus completely to study for my usual departmental half-day stuff and exams.

That being said, it is neat to learn more about being a better teacher.  And knowing that it is something I can do.  And will do.

Seeing the enthusiasm of the Med 1s in tutorial and how everything is challenging and exciting is super cool.  Learning about what always seemed to be the top secret world of designing OSCE stations and training standardized patients makes me realize how much goes in to our learning.  Finding ways to make things better for newer trainees is encouraging.  Even figuring out how and why I learn the way I do and how to make that work for me is useful.

Most of my friends are teachers.  Heck, I’m married to a teacher.  And I am realizing that in more ways than I originally thought, I am a teacher too.

I know, I’m a huge geek.  But, I’m okay with that.  Just humour me.

Work in the midst of call

This weekend, amidst all of my call-y goodness, I am trying to get some work done on a few upcoming projects/presentations.

I have a journal club a week from Tuesday, so I picked some articles.  Head and neck cancer supportive care.  Look out world.  I’m about to critique the pulp out of an article on prophylactic versus reactive feeding tubes and hemoglobin levels and transfusions in head and neck folks.

And then, I spent a bunch of time looking into stuff for career day.  Every year, I help out with career day.  And every year, I say we will make it better next year.  You see, Rad Onc, much like me in high school, is kind of one of the nerdier, quiet and obscure specialties out there.  As a result, most people walk right past our booth.  Seriously.  You should see them all flock to the surgical simulators and fake airways at Gen Surg or Anesthesia.  And everyone wants to know how much the Radiologists make to sit in a dark room.  But, the Rad Onc folks.  They have creepy masks and a powerpoint.

Image from ebroc.com.

Not this year.  Okay, we will still have creepy masks and a powerpoint running.  That is who we are.  But this year, I am cracking out some YouTube videos of some of the “cooler” aspects (that’s right… big machines and computer animations).

They are cool to me.  And at least they give people something to ask questions about.

Plus, I think I have found an online application that we can use to make ourselves “interactive.”  A try your hand at contouring station, perhaps.

I know, not as cool as intubating a dummy.  But, maybe we’ll get to tell another couple people who we really are.

I just have to get approval from the powers that be (and acquire the technology to make it all happen).

Today I decided to clean out my email inbox instead of starting to actually work on the journal club.  Because that is just too much energy.

I got about 2 minutes in when I realized something.  I have something like 30+ One45 emails.

For those of you in the world who don’t use One45, it is an online evaluation system people in the medicine world love.  And we evaluate every single flipping session we ever attend.  And get evaluated almost as often.

Image from imerrill.umd.edu.

Usually, I’m on top of those things.  I hammer them out once a week or so.

The last two months or so, not so much.

I know what I’m doing this evening.  It involves a likert scale, good music and trying to reach back into the recesses of my memory.

The Happy In My Halloween

Today was a happy in my Halloween.

I managed to arrange for transfer for one of my patients.  It is always good to get people back to home hospital, but it is especially good when it also makes my day start off well.

I presented Morbidity and Mortality rounds today and people actually kind of participated.

It is Friday half day, which means an afternoon of lectures, which is tough at the best of times, but especially on Fridays.  This week, I was supposed to have Radiobiology from 4-5, which is the most potent form of educational torture there is.  Unfortunately, our instructor went home sick with the flu.  Fortunately, that meant we didn’t have that lecture and although it has to be rescheduled, I was glad to not sit through it at 4 on Friday.

Also in Friday half day, the radiologist who taught us an awesome head and neck lecture brought us Halloween candy.  And not just any Halloween candy… The good stuff with peanuts in it that can kill people but tastes soooooo good.

I realized in said head and neck lecture that I am finally beginning to figure out head and neck and knew things in the lecture.  It was an exciting “ah ha” moment for me.  And thank goodness it is starting to come together because I have a treatment planning exam this week and it is yet again on head and neck (the universe or at least my staff seem to hate me on this front).

Patrick and his class went on a field trip today and had a good party afterwards (complete with cookies he made last night).  I was impressed at his craftiness and ability to get through Halloween with a classroom full of third graders.

We went to a Mexican restaurant tonight for supper where I got to feed my most recent craving… Spicy chilli.  I love a good burrito.

It is Jeter’s “birthday.”  The anniversary of when we inherited him two years ago.  He threw up on the carpet for us when we got home from work and is now happily carrying around his new “birthday” replacement feather on a stick.

We are settling in for a night of watching Charlie Brown and other relevant specials while waiting for the kids that never come to our apartment. It is to bed early tonight for band and a day full of studying, house cleaning and a potential games night!

Happy Halloween!

How Did That Happen?: Surviving Call

I am way overdue for a How Did That Happen? post yet again.stethoscopes1

This week’s How Did That Happen? is all about surviving call. I did buddy call last weekend with our new first year resident (did I mention I love teaching?) and I have been briefing our other junior resident about what to do in certain situations and stuff like that. It had me thinking back to my first full weekend call as an R1 and my first gen surg call (shudder) and all that good stuff.

  • Like anything else, show up and do your job. Seriously. I have met some mighty lazy people who just want to slack off or get others to do the work. Other people notice. It makes you look bad. It puts patients at risk. And if the other staff get wind of it, they can make your life pretty much miserable.
  • Answer your pages. This goes along with doing your job. I mean answer your pages when you get them. Don’t make people wait if you can help it. Nurses notice if you’re being a jerk and not answering. They will also take pity on you when your pager stops receiving pages in the middle of the day and you failed to answer them the first two times they called (true story, my pager decided to konk out this weekend for about 4 hours… The fact that I am usually answer saved me from a ton of trouble).
  • Trust your nurses and allied health professionals. They are my superheroes. A good nurse can tell when things are going south and give you tips and suggestions when you are new and unsure.
  • If you are rounding on inpatients you don’t know, take the time to skim their chart and figure them and their current issues out, especially if they look unwell.   It can save a world of touble.
  • Before you leave after rounding, ask the floor staff if there is anything else you can do. Sometimes it creates work, but most of the time, it saves calls and it is the polite thing to do.
  • Get handover. I’m serious. It is a huge safety issue. Even if people aren’t seeking you out to give it, check with the regular team if you can. If someone is unwell, find out what the regular team would want you to do in the likely scenarios. Ask for that plan. If they don’t know suggest something. Going in knowing what to do about certain expected issues can make life easier.
  • Give handover. This is the safe and polite thing to do. Find the person coming on the next day and tell them either in writing or in person what happened to their patient, especially if it something that changes the plan.
  • Know who you are on call with. If you are a resident, you will always have at least a staff person on with you. Often, a senior resident too. Know their name and number in case it is asked of you or you need to get in touch with them.
  • Keep notes. Notes about the patients you need to give handover on, notes about things like outside calls. All that good stuff.
  • Ask for help. There are situations that you just can’t handle on your own. Or you aren’t sure of yourself. Do the best you can, but ask for help. Try to know what your plan might be, but admitting you don’t know or trying to figure something out is good learning and much safer.
  • If someone offers to lend a hand, take it. Sometimes, I had more senior residents tell me to text them if something weird came up that I just wanted to run by them. I was immensely grateful to just bounce a plan past someone without having to always run to the staff, especially when it was something simple that I was just new at.  
  • Sleep/eat when you can.  I feel like I say this often. But, I have been burned many times by staying up to wait for that last call or waiting to eat at a certain time. Just do it.
  • Some nights just suck. You can’t do anything about it. Just count down until it is over.
  • Bad stuff will happen on your watch. Someone will die (both expectedly and unexpectedly). Someone will get worse. Something crazy will happen (like a piece of suture hanging out of a drain that nobody can explain). Someone will hate you (because you told them they needed something they didn’t want). Someone may come at you with a weapon (people get creative sometimes).   Someone (including yourself) will make you look stupid (for instance, no matter how many times you tell a certain nurse not to do chest compressions because the person has a pulse and you need to manage their airway because they aren’t breathing, if the code team arrives and that nurse is still doing chest compressions despite your repeated attempts to tell her to stop while you are trying to ventilate because she just wouldn’t listen, they will still think you are the fool because you were “in charge” and it wasn’t even your patient, you just happened to be down the hall and arrived on the scene a minute before to help) know that. Learn from it.
  • Sometimes, you just have to go curl up in a ball and cry because the badness is just too much. Other times, you have to beat the pulp out of a pillow. And at times, you will need to leave a room to laugh your face off.
  • That paniced feeling of not having a clue what you are doing subsides. I don’t know when it goes away. I’m not there yet. It still comes in waves.
  • Have good references on hand. Don’t be afraid to look stuff up.
  • Prioritize your time. There are times where you are pulled in a million directions. Know what needs to get done. The sickest people are your priority. Computers and phones make good friends to help with reviewing results and doing quick orders.
  • Document stuff. Because, as above, bad stuff will happen on your watch. So does good stuff. The medical record is important, both for patient care and legal purposes. Plus, the day team will appreciate knowing what all went down.
  • If you are sick when you start call, odds are you will be sicker when it is over. One night, the nurses on a certain unit found it both sad and humorous that over the course of the night, my voice disappeared and my cough/breathing progressively got worse than half the patients I was managing. The whole illness being worse at night is amplified if you don’t sleep.
  • If you do home call, don’t forget things like your stethoscope. Nothing is worse than carrying your tired body back to the hospital at 3am only to realize you have to use one of the crummy “fisher-price” stethoscopes because yours is in your other bag.
  • If something can wait until morning for the regular team to take care of it, then let it wait. They might have a plan you weren’t aware of.
  • If you feel annoyed at that 2am call for Tylenol or a sleeping pill, just be glad it isn’t a new onset fever in a chemo patient or wound dehiscence.
  • Hospitals often have mice or rats. They come out when normal people are sleeping. Brace yourself.
  • There is a rule when it comes to call… If you have big plans the next day, stuff to get done, etc. it will be busy.  That being said, always bring something to do if you have down time.  But, know it will likely be interrupted.
  • Phone chargers and tooth brushes make the stay in hospital much better. So does take-out!

What are some of your surviving call tips?

Nacho breakfast, unicycles and cat. Some random updates.

We had friends visiting from that lovely island where we once lived this weekend.  It was great minus the fact that I was on call (minor detail).  Thus the absence yet again of blog updates.  So, here are some random updates…

Our cat is currently trying to chew his way into a giant Costco box of garbage bags.  We think (and hope) it is because he can smell his cat food on the box.

There are some people in your life that you can just pick up where you left off… Even if you haven’t seen them in two years.  The people visiting are precisely some of those people.  

We played a new game this weekend basically about swimming robots.  What more can you want?

Image from amazon.com.

I got hit in the face with a chunk of tree walking in our tail of a hurricane weather a few weeks ago.  Instead of being distressed or mad… I found it funny.  

I saw someone riding a unicycle down the street the other day.  That is something that always makes me smile.

My cat is out to kill our cilantro and our carpet.  He has knocked the whole pot over three times.  I think the cilantro is now dying. 

Some person or group in our city hung random red swings from trees in various places.  I really want to find one and swing on one.  There is one right by the hospital.  One day, I will do it.

When I see a hopscotch thing drawn on the sidewalk, I almost can’t resist hopping on it.  Almost.

My to do list at work is an expansile mass.  But, it is a colourful one.

I drew lungs on a piece of my patient list this weekend while teaching the new resident on call.  Patrick saw the drawing and asked why I had lungs on my paper.  I was super impressed that he identified the body part!

We went to a wildlife park last weekend and saw a ton of peacocks just wandering around.  They screech like mad, but are kind of entertaining to see.photo

Nachos can make a good breakfast.  Especially if you are on call.  At least I think so.

 

How Did That Happen?: How to overwhelm the pulp out of a new resident

I have been off my blogging game.

I blame starting core Rad Onc.  I keep staying late and studying at night and all of that stuff.  Funny how when you are doing something you actually love you tend to work more.

I also blame summer.  The nice weather nights have us out and about meeting up with friends.  Last night, we had a hymn sing at the nursing home we volunteer at with our small group and then went out for ice cream.  Tonight was coffee with a couple we know from back home who recently moved here.  So awesome.

I am a week overdue on a How Did That Happen? post.  So, that is what you shall receive.  stethoscopes1

I have been spending my last week orienting and mentoring our new, delightful R1.  My How Did That Happen? is how to overwhelm the pulp out of a new resident (in case you didn’t already know).

**Note: This is kind of sarcastic and based on things that really do happen.  There are some things I think administration and faculty can do better with.  There are some things that I can’t see solutions to… Just facts of starting new jobs.

  • First of all… DON’T OVERWHELM THEM.  This is my for real advice.  This will fail.  Starting residency at baseline is kind of overwhelming.  But, bits of information at a time and having someone available as help and back-up is better than just slamming it all in a book or presentation at once.
  • Have multiple giant orientation sessions for the incoming residents from the university, the hospital.  Fill them with tons of information that is both useful and useless intermixed with facts about failures, crying and patients dying.  Make sure that it is unclear what is useful or useless and make it seem like terrible things will happen.
  • Make sure to start them on call the first day or so of residency.  Nothing is better than really starting out with a bang.
  • Send out various passwords and user IDs to different email accounts and expect the person to sort them out themselves.
  • Have a very not user friendly computer system with a million different log-ons, passwords and variations.  Review these in orientations, but don’t do any practical training, that would be too helpful.
  • Use four digit paging in a hospital where you have to dial 7 numbers that can differ between sites.  Expect new person to call you back promptly.
  • Let new people loose in the hospital without giving a tour. 
  • Take the new person a tour on a hot day after a full day of orientation to show them everything.  Realize that they will remember very little of this.  Do it anyway.
  • Leave them to figure out everything on their own.
  • Tell them all of your call horror stories.
  • Take them to visit the ward.  Show them where everything is.  Show them the charts.  Talk about writing notes, finding computers and how the rooms are organized.  Introduce them to the all of the staff on the ward who promptly start asking who they are looking after. 
  • Go to a session about how to use an EMR only for the radiation oncology patients and for radiation planning.  Use technical terms just to really keep them on their toes.
  • Give them the sickest patients. 
  • Ask them to read around everything they saw that day.  The list of topics totals a page.  Oh, and review the clinic charts for tomorrow too.  Hope you can work the disconnected computer systems!
  • Talk to them about booking vacation.  That is months away.  On rotations that “you just need to take vacation from.”
  • Tell them you are so glad to be done intern year, it really does get better (this can be good… it can also instil fear of what is yet to come).
  • Try to tell them everything they need to know ever in one day.  Or at least make them think that is what is happening.

 

What things happened to you that overwhelmed you as a new resident or med student or employee in general?

 

Milestones

I was walking to work the other day when the thought struck me… I have met a milestone.

What milestone, might you ask?

I was wearing normal people shoes (not my fake Toms and not sandals).

This wouldn’t be such a big deal except that I have not worn normal shoes in a month and a half since I broke my toe.  It is very exciting stuff.  I was super sore last night as a result, but still, it is a gain.

I also thought of a few other milestones…

I finally figured out how to take the bus to a few key locations in the city without getting lost and knowing where to get on and off the bus.  Taking the bus used to be a huge adventure and I considered it a big inconvenience here.  But, now it is normal.

I passed junior physics.  Yes, I got an 86%, despite the question I knew I got wrong because I circled the wrong answer and despite me forgetting to put units on one of my long answer questions.  If I got those marks back, it would have been a 90.

I used the first of my herb garden this weekend… Chives on our pizza and a couple pieces of coriander in my “Asian noodle bowls.”  I decided to focus on the coriander and ditched the chives because they weren’t growing well anyway.

I am back to the gym.  Still not running, but getting some good rowing and cycling in.  On a related note, I can now walk to and from work without wanting to die (I really didn’t know how important toes were, but I also think a tarsal was involved, not just the toe).

Monday will be my last day of PGY2.  That is a big milestone.

It will also be the end of Patrick’s first adventure as a long-term substitute teacher.  Tonight was his first grade 6 graduation (well, his second if you count his own).

What milestones are you celebrating?

 

Being a Leisurely Commuter

It was a good morning.

I was seeing some consults at another hospital and I was told to show up at 9:45.  That is basically halfway through the day.

I got up around the same time and went downtown for coffee and some physics studying.  I love doing work with caffeine, food and the bustle of people heading out for the day.  Especially with a good view and Eddie Vedder playing in the background.IMG_0036 IMG_0037

I then commuted using the ferry.  Yes, the ferry.  I never get to travel by ferry.  It is more awesome than the subway, in case you are wondering.  IMG_0040

I then took a more scenic walking trail to the hospital.  Although, I did get a bit lost, it was worth it.IMG_0043

I concluded I could do this.  Be a ferry commuter, specifically.  If every day was as sunny and leisurely as this morning.  But when the weather sucks (or I just want to sleep as late as reasonably possible), I am glad I am close to the hospitals I usually work at.

Really, I am a commuter.  I take the bus or walk every day now that Patrick has a real job that sends him an hour out of town every morning (meaning he leaves at 7 in the morning every day).  That kind of commuting just isn’t as novel to me.  The having a husband with a REAL teaching job (at least until the end of the year) is, though, so I like it nonetheless.

Even finding out my physics exam was rescheduled AGAIN couldn’t ruin my morning.  Okay, it did have me agitated most of the day, but it is a growing experience.

Learning Style

Yesterday, the Daily Post had a prompt called “Learning Style” asking about your learning style.

I used to cringe when people would pass out those learning style inventories and such.

I have never been one to really fit into one of the boxes.

And I suppose that is a good thing.

It is easier for me to say what I don’t learn well doing…

Group work.

I have never been a fan of the group work.

Sometimes I like to joke it is because I’m an only child and don’t play well with others.

But seriously, I hate relying on other people to get work done.

Plus, I was always one of those kids who would have a bunch of work dumped on them.  And I like to teach and help people, but I want to get to do my own work too.

So, group work is a big no!

I am also not the best at learning by doing.  I like to learn by doing… Otherwise medicine would be a big issue.  That being said, practical skills learning by doing takes me a long time.  Manipulative skills are not my strong suit.

I like to read things in books.  Or hear them in lectures.

And yes, I prefer them in print.  Or tables.

I don’t get mneumonics.  Pictures don’t stick in my head particularly well (unless they are hilarious and not fully related).

I work things out in my own head through research and note taking… Then, I can apply it.

My books are highlighted.  I make post-its to piece together concepts.  Sometimes, I make entire sets of my own notes.  I like practice questions.

The more real-life applications and examples, the better.

But I need to know the basic concepts and build principles.

That is how I learn best.