Sunday, June 28, 2015

Week 31: I guess no more standing elbow deep in someone's abdomen for awhile for me. Surgery rotation completed.

Another week and another rotation over.

That was it for surgery and that was it for the ER for now. I'm a bit sad about it actually. My doctor and I were a pretty good team. 

Monday was spent in Milan with a UW-Madison college friend of mine. I showed him around Milan a bit and we visited the World Expo 2015 taking place there. One of the coolest stops of the day was checking out the Chiesa di San Bernardino alle Ossa. There is a room decorated with hundreds if not thousands of human bones from a former cemetarty. I, the med student thought it was so cool. My rocket scientist friend (he's an actual rocket scientist), thought it was gruesome but then again cool at the same time.
Il Duomo, Milano, Italia

Chiesa di San Bernardino Alle Ossa, Milano, Italia

I am excited to see how internal medicine will be starting Monday. I expect to learn a lot and this expectation scares me a bit too. I don't want to end up sitting around all day again. If that does happen, I'll be right back in the ER.

I examined a man with an abdominal aorta aneurysm this past week. That was nifty. You could really feel a softball sized tumor in this mans stomach pulsating.

Thursday was weird. We might admit 1 or 2 patients a day on average in trauma surgery. This day, out of the 10 patients we saw until the afternoon meeting, 2 were kids and the parents opted to take the home rather than have them admitted, 6 were already admitted and the last two were ones we were working on. It was absolutely crazy and most of the time was spent with paper work. 

I had one patient I was primarily working on. I really tried hard to take care of his case in a timely manner but it just wasn't possible. Either I was waiting for one of the doctors to see him, waiting for the x ray or the lab results. He had pain in the hip region about 4 months after a hip surgery. When I examined him, the pain didn't appear to be coming from the hip. My thought was that he might have a hernia. The physical examination wasn't very typical for one but it's usually the small ones that cause the most pain. 

The surgeon on duty (vascular surgeon) took a look. She called the general surgery attending to come take a look. He said he'd bet his mother-in-law that it isn't a hernia. So I threw that theory out. My main objective was to exclude all the bad things it could be. Even checked his foot pluse with Doppler sonography. All good. In the end, we agreed that he had a tendinose. Since he was doing so well after the operation and in recovery and only started experiencing pain a few weeks ago, it correlates with the time he started to use his new hip more. This caused muscles to work differently than before the operation and which created the soreness at the location he was experiencing it. I apologized multiple times that everything took so long and that I was always bound to waiting on someone or something. He was very sweet though and wished me all the best in my career. Very sweet and understanding man.

Friday was busy but not crazy. At least we had patients that twisted their ankle or cut their finger instead of hip fractures and pain patients we had to admit the day before. I conveniently forgot my key at home and couldn't access my locker. I ran around in only blue scrubs, a pen and my phone all day. I was called nurse a few times. Interestingly, a lot of the patients born in the 1920's/'30's often call the other female doctors and I nurses. In their heads, women aren't doctors. We just go along with it. Sometimes they will be seen by three female doctors during the week who have all introduced themselves as such and when a male attending does rounds and they'll exclaim they are so happy to see a doctor......mhmm ok. 

We had two older ladies that were rather entertaining. To say they had slight dementia would be an understatement. One was incredibly adorable, the other one called us stupid and told us to take down the cross from the wall because we were not worthy of it. While the one waited to be picked up from the ward and the other on the transporter back home, the lobby was filled with yelling from both ladies.

I left work on time because I still had to pick up some relatives and drive to Hamburg for my grandmas 85th birthday. We went out to the Reeperbahn Friday night with a huge gang of family members. It was hilarious to say the least. 
After getting up after just 3 hours of sleep to take care of the munchkins, I had my sweet revenge when I made them wake up "the monster" aka my dad.

On our way to the bakery!

Monday morning it's back to the hospital and diving into a new department. Hope my expectations get somewhat fulfilled. 

Stay healthy!


Saturday, June 20, 2015

Week 30: "Have you changed a nephrostomy tube before?" "No." "Well, you gon' learn today!"

Well, it's 6:30 on a Sunday morning.....thanks internal clock for not letting me have the experience of sleeping in on a Sunday. I'm awake and not tired but still....there is just something about waking up after 9AM on a Sunday that has a feel of luxury to it. Oh well, early bird know.

This past week flew by again! And once again I have a hard time trying to keep the days apart. So I can't really describes my individual days but rather my individual patients.

I was allowed to suture every case that came in and needed stitches. There was the guy at work that cut the back side of his finger with a saw, the old man that fell and rather deeply cut the side of his hand (it bled so much and his hands were drenched in blood and it looked like he had killed something with is bare hands), the old man that fell and hit his head and had a small wound and then there was the woman suffering from borderline disease who cut herself to relieve pressure.

Suturing in the ER is more fun for me than in the OR. I worked in plastic surgery for a month and learned the importance of aesthetics suturing. We weren't doing aesthetic surgery but rather reconstructive. Of course, if you are operating on a patient that needs reconstructive surgery, you will try really hard to make it look nice....its a big reason for why the operation is being done.  Most other departments don't see the closing of the patient as an aesthetic issue. Often times, patients will have staples placed instead of sutures because it's quicker. I think, if you had to go through a big abdominal operation, your scare isn't your biggest issue but the thing that constantly reminds you that you had to have surgery and might as well look nice. In the ER, the patients are wide awake and usually watching you as you suture (since the local anesthesia had time to work by then). A few do mention that we should try hard to make it look nice (especially when its in the face) but I also have expectations for myself to make it look good. So far, everyone has been really pleased with my work.

On my way up!

I was called up to the privately insured ward twice. Both times to place a line. You never know how a patient is until you meet him/her but I'm always more concerned about how a patient is when I'm on the privately insured ward. The privately insured often have higher expectations and straight up make you feel like you are a servant in a luxury hotel sometimes with the requests they have. I'm just not a fan of that mentality and sometimes have to refrain from commenting. The second day I was called up, it was the first thing I did that day. When I arrived, the nurses just smiled and said the patient was a rather complicated patient. Greeeeeeeeat. Just what I want to hear first thing in the morning and then having to place a line. In the end, this lady wasn't complicated at all. She was frustrated and exhausted. Her operation kept getting rescheduled due to her blood lab values. There is construction happening near her room and she is afraid to have another operation. All those factors together just made her exhausted and frustrated with the whole situation......but she wasn't complicated.

I definitely empathized with her. It bugged me a bit that she was described as complicated by the nurses. I've dealt with complicated patients before with absurd requests and expectations of the whole staff.  I'm sure even this patient rang for the nurses multiple times a day with questions about weather or not her operation is taking place. Keep in mind that the patient is not eating every day because there is a chance she might have her operation just to find out she isn't being operated in the afternoon. Please tell me you wouldn't be frustrated and exhausted if you were in the same situation.

Friday morning, trauma surgery was less than busy in the ER. Oddly enough, the urology department was receiving one patient after another. One of the first ones was a man from England. The nurse sitting at the reception desk just called over to the doctors room to inform me that I had a patient to see due to my English skills.

He was an urological patient which just made it all the much better for me. I stayed with the patient even after the urologist came. Once the urologist found out that I was planning on going into urology, his face lit up and for the next two hours, I was constantly by his side and doing procedures I hadn't done in the whole 16 weeks of my urology rotation. He would just ask me if I had changed a suprapubic catheter or nephrostomy tube before (my answer to both was no) and without further hesitation, I was changing the catheters with the help of his instructions.

Both things really aren't complicated but they were things I hadn't done before and that made it really exciting. We had a patient whos catheter was cut off by the nurse in the nursing home and the end part with the blocking-balloon was still in his bladder! We had to take him to the urology department because our plan was to perform a cystoscopy (looking into the bladder with an endoscope through the penis) and removing the catheter piece. The urologist again asked me if I had done that before and I again answered with no. He said I could do everything once we were in the bladder. This urologist was on a roll! Sadly, the passageway into the bladder was blocked due to a big prostate and adhesions that I didn't actually get to do anything. Nonetheless, the urologist explained how the endoscope worked (which was a question I had had for a while but people were always so stressed in the urology department I was in to take the time and explain it to me). This urologist was under stress too due to being responsible for the ER patients and the outpatient procedures but he made it work. He asked me when I would start working and that I should apply in their department. Very sweet but I had to break it to him that I am attempting to do residency in the States. After a few more things, I returned to my doctor in the ER. It was still rather empty.

That of course changed quickly. The second half of Friday was packed with patients. To top it all off, we also had a polytrauma. While my doctor had to work on the polytrauma, I did as much as I could to finish up the other 7 cases we had. I left an hour later than I had expected. I was so drained by the time I got home. I decided to take a 25 minute nap.....which I then repeated.....and once more. I made myself get up again to finish some errands before eventually dropping back into bed.

I have one week left in trauma surgery. It'll only be a three day week because I'm gone Monday and Tuesday. My doctor repeatedly told me that she was going to miss having me around when I leave for the internal medicine department. I'll miss her too and the work we do together. But I won't be far away considering I'm only two floors above her. So if I end up being bored can most likely find me in the ER suturing up a wound!

Stay healthy!


Monday, June 15, 2015

Week 29: Sir, your wife's knee pain she has had for 2 years....isn't an EMERGENCY. So shush!

I often can't decide if a week went by fast or if it seemed forever long. Usually working in the ER, I'd say the week went by really fast. Monday was especially stressful for my doctor and when she was telling a colleague about it on Thursday, I could have sworn it happened the week before.

So lets dive into Monday. The place was already crazy at around 8:30AM. The patients just kept coming in. At some point, I just started writing patient release notes as soon as I heard their story so that we could discharge them promptly after my doctor treated them. 

Trauma surgery was definitely the busiest that day but the other departments weren't sitting around sipping coffee and watching us run around like chickens with our head cut off....they were running around just like us. The chief of the ER was hyperventilating at one point (not literally but pretty dang close). He wanted us to see patients in the waiting room to decide if they can immediately be sent to radiology instead of being examined in an examination room.

In theory, this might be an elegant way of avoiding the transfer of the patient from the waiting room to the examination room but it also has the potential to create a lot of problems. And it definitely did. We walked out with the next three patient clipboards to see what could be sent to get x-rayed. The first patient had knee pain. We had to exam him properly to see if he even needed an x-ray. So he had to wait until a room was open. The next patient was described on her chart as having a problem with her finger. This really was her smallest problem though. When we asked her what had happened, she paused, looked a bit scared and asked if she really needed to talk about this in public. Of course she didn't have to and we were about to say that it can wait until we have a room (the doctor and I both have a heart and already didn't like the idea of talking in public to the patients), but the patient was quicker and proceeded to tell us that she was badly beaten up by her boyfriend. She proceeded to break down and cry. Understandably and the doctor and I stood there mad at the chief for having made us do what we did. The third patient fit the theory quite nicely, hurt his wrist while playing soccer. Quick examination of the wrist (which is possible without an examination room obviously) and immediately sent him to get it x-rayed. 

The load of patients just didn't stop. One patient, who came with her husband due to knee pain she has had for 2 years(!!!!!!!!!), was examined by us and we needed one of the attendings to lend us a hand with figuring out what she might have. (I remind you that we work in the Emergency Room, this was not an emergency and we aren't there to do lengthy investigations, we are there to treat acute problems.) 

After her examination, a poly-trauma came in and we were all busy with that. So this couple ended up having to wait a while. When we finally did get to telling them that they need to see an orthopedic surgeon for further evaluation, the husband was not pleased. He quite sternly and not nicely told my doctor that this was absurd and that its an abomination that we simply "petted" his wife's knee and made them wait three hours to be told they had to go see an orthopedic surgeon. At some point, it was too much for my doctor and she started to cry and excused herself. (For people who regularly read this blog might remember my similar situation in urology. Although I didn't cry in front of anyone I was very empathetic for my doctor). I was not as emotionally involved in the situation and still stood there with the couple. I tried to calmly explain to the man that due to the poly-trauma which was an actual emergency, we couldn't finish up his wife's case any quicker and that I understand that waiting is annoying but that it was an emergency room and his wife's issue was flat out not an emergency. I also mentioned that as doctors, we are trained to gather a lot of information from simply observing the patient and "petting" their knee. 

He kept going on about how his wife's heart is bad and how despicable it is that we made them wait. Honestly, would your wife be doing much else at home than sit if her heart is so bad? I realized there is no point in arguing with crazy so I asked him to wait a moment and had an attending step in. He didn't have any more luck than I did and he made the chief have a talk with the man. In the end, the man came and apologized to my doctor for having been harsh. It obviously wasn't only this man's actions that brought my doctor to tears but rather the whole day. 

Patients need to learn to realize which doctors truly care about them and do their best to treat them and which doctors really don't care if you wait three hours. The doctors that care (and I'll include myself) really put themselves under a lot of stress to help patients as best and as quickly and comfortably for the patient as we can. We aren't sitting at our desks twiddling our thumbs. 

I ended up sewing a finger that day of a lady who almost cut off the bottom side of her finger with a knife.

The rest of the week was better than Monday but still had times a patient congestion. The other doctors in the department were really supportive of my doctor. On Monday, two came down to help us and that gave her a chance to collect herself. The chief said that she should go eat something and that the other two could finish up the last hour of her shift. The attendings offered her to stay out of the ER the next two days. They were all really great but my doctor is a lot like I am when it comes to these episodes of frustration. It gets to a point, we break and then we move on. She didn't need the next days off from the ER, she just needed a few minutes to breathe. Nonetheless, I think its great that she had so much support from her colleagues. I think almost every doctor (that cares) has these moments. 

I sewed up a few more patient during the week. 

Thursday was definitely a little kids day. About 80% of the patients were kids. I ended up just carrying around Berni the Teddy Bear in my scrubs pocket all day. Each kid that comes into the ER and looks like they would enjoy having a teddy bear gets one to take home.

Friday was another fairly busy day. Since it was, I was allowed to take care of a patient almost all by myself. He had cut his lower arm while moving material at work. It was deep enough to sew up and that is what I did. I prepared everything, sewed up, bandaged and wrote the release note all by myself. The only thing I didn't do was the local anesthesia. (That is something I still would like to do the next two weeks.)

I also sewed up a wound on a older man's head after he fell. The options were staples or sutures. I was happy we collectively decided to suture. I personally think the wounds look better with fewer scares and I have something to do. 

The whole week, I was spending my time after work preparing my friends bridal shower. I had planned on a nice picnic by the lake. I had even picked out the tree the week before. The weather forecast predicted rain. Only on Saturday. Not on Friday or Sunday. Just on the one day in the year I plan a picnic. I ended up transforming my itsy-bitsy apartment into an indoor picnic. Everyone was happy and had a good time so I see it as a success! 

Sunday I spent my day at the flea market trying to make some money and reduce the size of my baggage. Always thinking prospectively. In a few months, I have to decide what goes back to the states with me!

Stay healthy!


Saturday, June 6, 2015

Week 28: "I've been looking for fractures, I've been looking so long!"

Well, David Hasselhoff and the reference to his song is quite fitting for the past week. No, we didn't single-handedly bring down the Berlin Wall with our angelic voices, but we did have a reason to feel like we accomplished an equally challenging task after Thursday's shift.  Secondly, there was once again no lack in the most-asked-question-of-my-life. And we did look for a lot of fractures on x-rays.

Each day of this past week was completely different from the next. I love that. I can't even keep the days and the cases straight anymore because for the most part we were working off one case after another. Sometimes more relaxing than others.

I got quite a bit of flesh sewing in this week. There was the glass-cut-open-my-hand case, the I-tripped-in-the-yard-and-busted-up-my-lip case, the I-was-moving-junk-and-slit-open-my-forearm case and I believe a few more that I can't remember.

We had another load of kids throughout the week as well as the numerous cases of elderly folks falling down.

One of the cases that falls into the age gap was a mid 40 year old that hurt her fingers while at the gym. Unfortunately, it happened the night before and she didn't remove her wedding ring. I tried as much as I could to massage the edema out of the finger in the hopes of saving the ring. Try as I may though, the swelling around the capsule was so strong that I couldn't get it over the joint. We had no other option but to cut it off. The patient was understanding and even joked that this would be a good excuse for her husband to buy her a new one. So as a good thing to remember, if you ever hurt your hand....REMOVE ANY JEWELERY ON YOUR ARM! We don't enjoy cutting off wedding rings but we will if it means saving your finger!

Many cases we had this week were not cases for the emergency room. Dear citizens of the world, if you have had back pain for 6 weeks, make an appointment with a practice (I am aware you can't get those quickly sometimes but make it very clear to the receptionist that you need an appointment) and get treated. An emergency room (and it baffles me that we have to tell people this) is for EMERGENCIES! It's not a free for all to get to see a doctor right away when you don't have a new acute problem! Just because your binge watching of TV shows can't continue because you have seen all the seasons and you happen to have a moment of time in your schedule, it is not the time to fill it with a visit to your local emergency room (preferably at 3:30AM) to complain about your shoulder that has been bugging you for the past week. (That specific case didn't happen in my current hospital, but people. it happens). Use common sense, us doctors (and soon to be doctors) don't want to (and can't) turn you away but our job in the emergency room is to treat emergencies. Rant end.

Thursday was crazy. We had enough cases to work on at 9:30 and the files in our slot just kept coming. The other departments started to fill up as well and by 11AM we had patients/nurses/EMTs/doctors packing the ER. I went from seeing people with the doctor to immediately writing the start of the release note and leaving to see the next patient again. The doctor would finish the release letter and I would get it in an envelope, to the patient and discharging them. At some point, while both our computers were being used by doctors, I took all their money cards, went to the cafeteria, called the doctors and told them what was available and carried multiple meals back to the ER so that we could eat in between writing letters and looking at x-rays. It was a crazy but absolutely fun day.

Friday was the COMPLETE opposite! We had 5 patients in the whole day I was there! We thought it might even get crazier than it was Thursday because the weather was absolutely beautiful and 30 degrees Fahrenheit out that we figured everyone was coming out of hibernation (I know it's June but it was still rather icky and cold until Friday) and since they haven't been out in the world, would fall on their face after the third step and show up in the ER. Surprisingly, that was not the case. The internal medicine department had a few more cases because people forgot to drink plenty of water. But all in all, it was a really calm day. It made the day drag on and on though. After work, I bought a container of really lovely looking yummy strawberries and dropped them off in the ER because they let me go an hour early!

My doctor has told me several times that she doesn't know what she'll do without me. She will be just fine without me, I can tell you that much. I do try really hard to make the lives of people around me easier though. I'm like the born personal assistant (although I could use my own). While in Urology, I made sure the doctors were eating and if they didn't stop to have breakfast, I'd make them something and make them eat it. If I heard a sniffle or saw a runny nose, I'd make them ginger-honey-lemon tea and even brought it back to the hospital after my work day if they had a night shift. I was usually one step ahead of them when it came to office work. I'm the same in the ER. I know when something is about to be printed and already have the letter in the envelope with a work release note filled out so that the doctor only has to sign it. I don't like sitting around doing nothing so I'd rather fill my time with those kinds of things or reading up in a book than just staring at the wall.

I'm excited to return to work on Monday. My body is pretty set on it too I guess. I forgot to set an alarm on Friday but woke up on my own only 7 minutes after what should have been my alarm. Today, although it's Saturday, I was up and started my day at 6:45. As long as I'm not tired I don't mind an early start to a day.

I shall see if my internal alarm clock takes off on Sundays ;-)

Stay healthy!

Monday, June 1, 2015

Week 27: Trauma surgery-- broken bones, sewn up wounds and death.

I finally got my hands dirty this week! My first of six weeks of trauma surgery and I'm in the emergency room. I plan on staying there too seeing that I have already observed enough knee and hip replacements to last me a life time.

I'm working with a fairly new doctor. There is almost always something going on which is great. The four days flew by.

I loved going to work with my dad in the emergency room and I still enjoy it now. I like that you don't know what is coming and what needs to be done that day from the get go. You take care of the patients and then move on to the next. It's just not predictable and I like that.

Most of the time I would follow the doctor around and see patients with her. I sewed up three patients during the week. We had a lot of people come in that fell on their way to work or at school. There were only small broken bones: fingers and toes, nothing big.

We did have an interesting case. An older lady comes in because she supposedly fell and hurt her knee. She couldn't really tell us when we asked her but mentioned pain while we examined her joints. Her son had said that she seemed to become more confused over time. We did multiple x-Rays of the areas she had pain but found no fractures. Due to some really high lab values, we had a CT scan of her head done. It showed us a big structure in her brain that was thought to be either a meningoma or a calcified aneurysm. She was transferred to the Neurologie department so I'm not quite sure what it ended up being.

I spent most of my Friday with one of the first patients to come into the ER. Again, an older lady fell. She had a big open wound on the side of her head from the fall. By the time she made it to us, she could hear what we were saying but wasn't reacting appropriately, we immediately had a Ct scan of her head done and it sadly showed a huge bleed. Even sadder was that it was a kind of bleed that can't be operated on. She was basically going to bleed to death while slowly becoming more and more unconscious of the world around her while her body reacts to the rising pressure in her head. Her son told us that she had contemplated attending college seminars the day before. She was just a few years shy of 100. It really made me sad that a person who was more or less absolutely fine the day before could so easily be given the prognosis of dying in the next few hours just because of a fall. Her son left the ER to take a walk. The nurses and doctors all moved on to work. I was the last one left in the room and sure wasn't going to leave this lady to die alone. I cleaned her up a bit and helped when the rising pressure in her head made her vomit. Other than that, I just sat there and held her hand. When she was transferred to the ward, I went along. I asked a nurse to help me clean the patient up a bit, put a new night gown on and I cleaned the blood out of her hair from the wound we stapled. I sat there for another 2 hours holding her hand waiting for the son to come back. At this point, I was pretty sure she wasn't registering the outside world consciously anymore and I had to get back to the ER. I asked the nurses to keep a close eye on her because I didn't want the relative returning to find her covered in vomit. I was disappointed that the son was gone for so long. I understand it being hard for a child to be with their parent in that situation as well but I would want to be there as a child. I'm sure she didn't have many more hours to live.

This weekend I'm spending some time in Paris. Monday is a national holiday in Germany so I don't have to go to work and I'm taking Tuesday off as my study day. So it'll be a short 3 day week but I'm hoping to learn some cool things and help some more people. 

Stay healthy!