Weekend to rejuvenate

We were short one staff this week, and only 3 people to cover 45 patients, some more active than others, we had to take on twice as many. At about around Wednesday I started getting a sore throat, fatigue and weakness.

I’m on week 5 of 6 of my internal medicine rotation. We usually take on a max of 2 or 3 “active patients”, and however many patients who don’t have as many critical issues. Being as enthusiastic a learner as I wanted to be, I never said “no” to my attending. I took on as much as I could, worked as hard as I could, because I knew that I had to take advantage of every learning opportunity I could. As much as I impressed my attending, it seemed to come at a price. I showed up Thursday morning, sharp stabbing pains down my throat, dizziness, fatigue despite a full night’s sleep – and I just did not feel right. I spent 3 hours trying really hard to work through the day, but I had been assigned 11 patients, 8 were active and 3 were not – and I had only 4 hours to get through them all as opposed to 8 due to a half academic day. I kept telling myself “5 hours left, 5 hours left”. But when the NP I worked with came and asked how I was doing, my first response, “I don’t feel so hot“. My attending checked my throat, and temperature (so my supervisor apparently was a GP before becoming an internist) and told me to go home.

To be honest, a sore throat would be something I would have stayed at work at anyway. I was going the entire week 2-3 times harder than my usual norm, maybe it was burn out too. I felt so emotionally depleted, and I felt guilty about going home. As SM told me, “If you’re sick and continue working, this will impact your health, and the health of your patients!”. I was finally convinced.

I had hot teas, soups, plenty of rest. Unfortunately I had to cancel on a friend’s birthday on Saturday. I spent Friday completely away from work and with SM. Today, I slept, a LOT, I read leisurely, and I also spent some quality time with SM. The throat is still sore, but I am feeling much better emotionally, and feel as if I have the strength to take on as many responsibilities as I need to. I’m lucky to have someone as nice as SM to look out for me.

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Forgiveness

“To forgive is to set a prisoner free and discover that the prisoner was you.”
– Lewis B. Smedes

I’m week 4 into my internal medicine rotation, and was speaking with one of my patients. He’d told me a lot about his life, and his experiences. A retired corporate lawyer, now working on his deteriorating health. Since he was just waiting in hospital for placement in the community, he doesn’t have any acute issues, so he was one of the last patients I saw for the day. I usually sit with him for an hour or so because we have pretty unique conversations.

We were discussing some of his experiences in law school, and practise. He told me some of the reasons why he was averse to family-practice and divorce-law, and he replied “I never want to be in the middle of two people that hate each other immensely.” So I told him how I couldn’t believe that two people that vowed for undying love would turn to hatred. I asked him whether it had to do with communication or trust. “No, its about forgiveness. People hold on to the smallest things of lttle significance, and its like a spur under a saddle. It builds resentment over time. If you can’t let go of the little things, the resentment builds and turns to hate, and when something big happens – everything falls apart. It happens because people can’t forgive. Some are just incapable of it, and hold on to things simply because they don’t know how to let go.

Forgiveness is a lot harder for me than trust. It means not bringing up someone’s past and using it against them. It means taking a step back and appreciating why someone may have betrayed your trust. To me, that is hard to fathom. But I realize that forgiving someone is acknowledging the fact that friends and loved ones are human, and make mistakes.  I think more importantly, without being able to forgive, we shut out people in our lives that could have made a world of difference, and we limit our ability to grow and expand.

However, if someone truly hurt us, in the most deepest, intimate and unimaginable of ways – is forgiveness appropriate in that situation? Because even if forgiveness takes place, betrayal changes a relationship (of any kind whether with family, friends, a partner – it changes trust. So how does true forgiveness occur in that circumstance?

A Good Teacher

Today I am week 3 into my internal medicine rotation. Our clinical teaching team just switched attending physicians. The internal medicine physician I worked with today called me over, and told me he had a good Emergency Consultation. My case:

78 year old male with history of hypertension, diabetes, renal transplant after 15 years of dialysis, severe peripheral vascular disease and gangrene of the toes, past coronary artery disease presented with 3 second periods of light-headedness which started this morning at 8:30 AM when he sat down to read the paper. This occurred six times. The paramedics found atrial fibrillation on ECG at 10:30 AM while on route to hospital. Pt has had no other symptoms other than the lightheadedness. Patient denies chest pain, shortness of breath, altered level of consciousness or mental state. Physical findings were unremarkable, however cardio exam revealed a 4th heart sound. All investigations came back normal (bloodwork, Troponin T, CK, glucose, etc.).

He told me, “this would be a good case for you, I have lots of clinical pearls to teach.”. I saw the patient on my own, wrote up my consultation note, and reviewed the case once I was ready. He listened to me as I listed what I gathered from the history and physical, investigations, as well as my assessment of the situation and plan.

“Talk me through the common causes of Atrial Fibrillation”

“What do we worry about for management of New-Onset Atrial Fibrillation?”

“What drugs would we use?”

After each point, he gave me feedback.  He wasn’t condescending towards me as I expressed that I didn’t know the answer to some of his questions. He even sat down and walked me through how to read this gentleman’s ECG. Afterwards, he thanked me and acknowledged my contributions for this patient’s care at the hospital under the Internal Medicine unit.

I walked away, feeling like I had learned so much. I appreciated his patience, his time, and acknowledged the fact that medicine is not something I can learn entirely on my own.

What an end to a great day.

Sleep

Ehh… I’ve been working on this project on wordpress (shhh… Its still secret and unfinished! But you can check out how its doing by clicking here). I stayed up a little late last night to work on it, then woke up extremely early. Seems like I am the kind of person that requires AMPLE sleep in order to function. So guess what? Bad day.

I felt I had very little to run off on today, and a pretty hefty workload, so I got overwhelmed pretty early in the day. Instead of powering through and being on top of all of my patient’s issues, I felt I was chasing my tail. It made me realize if you aren’t on top of your game, Internal Medicine can become overwhelming. If I have a lot of gusto and good sleep, I’m good and enjoy it so much. If I don’t, even staying awake is really difficult, and the job is less fun.

Gonna take tonight to re-energize and ensure I can tackle work so is fun again.

Finding Home

How exhausting. I just moved from a lucrative (for me) $840 a month apartment to a $285 room in a student house closer to the university I study at. I managed to move the majority of things within 4 hours – and the help of 3 burly young men (my two cousins and friend Alvin). With 2 cars, and shuttling back and fourth, as well as up and down 31 floors. Everything is moved.

When I arrived at the new room I was supposed to move in – a single desk, room light and lots of dust I had to sweep up. The first thing I set up was my bed. Put domo and my other plushies into one corner, plugged in the light, and set the boxes down.

A room is a lot like a sanctuary. Somewhere I may come home to be comfortable, relaxed, where I study, and spend time with my special someone. Except what usually ends up happening is that mess inevitably starts to accumulate, and without constantly cleaning – I end up with a mess by the end of the week. Its funny though, for the past 6 years, every year I have moved once – or even twice from a student residence on campus, to many rooms in student houses, to a 3 bedroom apartment, to my own apartment.

My hope is that my next “home” will be a condo or upscale apartment. Where I am not paying for it with  student loans like I am right now, but my own income once I start working.


Looking Out for Number One

Let me explain the hierarchy of medical learners within an academic hospital, to give you a context for my rant:

    1. Staff Physician – the know all be all who probably has more years of experience working than you have had living
    2. Fellow – A Physician who has finished their medical training as a resident
    3. Chief Resident: Resident in their last year of training. Basically walking textbooks, knowing not only general medical knowledge, but minute details of obscure diseases you’ve never heard of. They’re on their final year, and are in charge of other residents of their program (whether it be general surgery, plastics, ophthamology, urology, etc.).
    4. R3: 3rd year resident, again more training exclusively in their field of interest.
    5. R2: 2nd year resident, usually start training exclusively in their field of interest
    6. R1: 1st year resident. Freshly minted and completed medical school. Most R1’s from all specialties (e.g. Family Medicine, Obstetrics/Gynecology, etc.) complete the same first year. They rotate through different services within the hospital for several weeks/months. Know the least amount of information compared to their upperclassman.
    7. Clinical Clerk: 3rd or 4th Year Medical Student who spends 4-6 weeks rotating through different medical specialties. Knowledge is minimal in comparison.
    8. Physician Assistant Clerk: Me. I’ve finished one year of medical foundations, and am half way through my clerkship. I’ve done rotations in Family Medicine, Pediatrics, NICU, Emergency, Psychiatry and now am doing General Surgery. Pretty much comparable to a clinical clerk in terms of experience and medical knowledge.

A clinical clerk gave me enlightment about the residents managing our team today in the hospital cafeteria for lunch. He told me this particular facility calls themselves an “academic centre”, but staff are not concerned with student education or learning. “Residents don’t care unless it gets them more OR time. The fellows are concerned about getting OR time, and the physicians don’t care about the clinical clerks.” So us clerks have to look out for ourselves, arrange our own learning sessions, and teach each other – which is the essence of problem based learning.

However, I was at a famous teaching hospital just a few months ago. The one-on-one time I got with physicians and residents was phenonemenal. I got challenged, had docs making me working through my thought process about how to get through a differential. And they had me justifying why I should do certain tests, or what lab work reveals about a patient’s disposition.

Nope, not really any of that here. Rounds consist of scribing for the residents, while they completely manage. Since we are competing with so many learners (fellows, residents and other clinical clerks), we can’t be surgical first assist, or even have the priviledge to “retract” during surgeries.

“Residents look out for number one.” At least at this facility. I hope this experience makes me appreciate teaching that I got, and to be able to hand off learning to medical / physician assistant students in the future. My next rotation is Internal Medicine, from which I hear that the learning experience isn’t that great. Here’s hoping for the best.

Me and My Surgery On-Call Adventures

Today, I helped put a nice man’s bowels back into his abdomen.

I’m sitting in the operating room lounge, its 10:42 PM, we just finished one appendectomy for an acute appendicitis, which was perforated (leaking purulent material into the peritoneal cavity), and an evisceration of an abdominal wound. So, a gentleman had a not-so-closed wound from a previous procedure, and now his bowels were pushing through gaping holes in the wound.

The surgical fellow (and chief resident) asked me to scrub in, which I did. The scrub nurse yelled at me to not touch anything on her table where she hands the surgeon on all the tools. The chief resident leaned over and reassured me that all of them had been yelled at for doing so before. She did a great job explaining different parts of the procedure, and answered all of my questions. 

My resident, a Plastics Resident Year 1, seems to take more time teaching me at night than he does during the day. This is still more exciting than my psychiatry rotation / on-call nights – where we had decompensated schizophrenics high on some kind of drug.

Still, I love clerkship, and everything I’m learning. I don’t think surgery is a career I would want to get into as a PA, but I’m learning a lot of useful things I can use if I end up in Family Medicine or Emergency. I’m trying my  best to get into a urology for my surgery selective (2 weeks of a surgical specialty of our choice during our 6 week surgical rotation). I figure that there will be plenty of patients who come in with urinary symptoms and emergencies, it’d be useful to know.

This entry doesn’t make much sense, but I started my day at 5 am this morning.

The night is quiet now, so I’m going to head to my call room to hopefully get some shut eye before we get another consult, and that oh-so-unpleasant pager goes off.