The Year in Review...

Good-bye, 2005. It's been interesting. Here's a look back at the highs and lows of the past 12 months.

January

The year started off with winter fun up north with my soon-to-be in-laws. From there, the CaRMS tour. I hit Sudbury, Montreal, Ottawa, Kingston, Hamilton, Toronto, Winnipeg, Edmonton and Vancouver in the space of 10 days. Craziness. It was a blast. I was snowed in three times (January is NOT the best month for air travel in Canada), spent an unscheduled second night in Winnipeg and narrowly missed having to sleep a night at the Edmonton airport. I was hosted in the 'Peg by a fantastic friend whom I was meeting face-to-face for the first time, and had a blast chatting over wine well into the evening. I met lots of great people, and realized that part of what drew me to emergency medicine to begin with is the amazing people. I also realized that Vancouver is an absolutely beautiful city, and I'm eager to return there soon to spend some time exploring.

Honestly. How could you NOT love this city? If it weren't for the exorbitant cost-of-living, I'd be there in a shot.

February

I had the first two weeks of this month off, and then dove into 4 weeks of Hematology clinics. Hardly taxing. I used the time to discover my inner Martha Stewart. My significant other got to come home to lovely meals and enjoy a clean apartment every day. A definite departure from my usual.

March

March 1st was Match Day. I'm not going to re-hash.

http://drcouz.blogspot.com/2005/09/match-day-results.html

That and three weeks of gastroenterology rounded out my month. Good times.

April

I got engaged. Hee hee. I'm sure other stuff happened that month, but it's kind of overshadowed by the engagement. I still think the boy is crazy to want to put up with me and my crazy job for the rest of his life but hey... HE asked ME. In fact, my response to his sweet, heartfelt proposal was to throw my arms around him and tell him he was crazy. I did, of course, eventually accept.

May

I finished medical school. Granted I finished with a hideous rotation on general internal medicine where I got a shitty review (I was told that my knowledge base was lacking and I wasn't 'engaged' with my patients) but I was redeemed by getting honours on my internal medicine exams. Screw you, Dr. W.

Then, I wrote the LMCC's-- a glorified day-long multiple choice exam that you need to practice medicine in Canada. Really, just an excuse to squeeze another $1200 out of the already-impovrished medical student. Thanks. I passed. Very anticlimactic.

Then I graduated. Eleven years of university education come to a close. I can feel the student loan collectors breathing down my neck already.

June

I don't even remember what I did for most of this month. Met equally bored friends for coffee, went for long walks with my dog in the bush, went to the gym, met other friends for patio drinks and generally enjoyed the last of my freedom.

Went north. Got bit by a mosquito. Got lymphadenopathy, flu-like symptoms and neck stiffness, followed by weakness of my right arm. Became convinced I had West Nile Virus. Serology proved me wrong. Apparently leaving medical school doesn't cure the med student hypochondria.

Moved to a new town on the first day of a brutal heat wave. Thank God for large, muscular male brothers-in-law. I didn't lift anything heavier than a houseplant. Which was DOA thanks to making the trip in the 40 degree heat. Next time, I'm going to try to move in January.

July

I was lucky to draw a pretty easy start to residency. I started off with a one month rotation in emergency psychiatry. It was slow, but kind of fun. Now, in retrospect, I really wish I had started blogging back then. So many stories...

August-December

At this point, the months just started blending into each other. I worked a lot, this month on obsetrics and gynecology. I started blogging. I started to think about changing programs. Anyone who has read my blog knows what happened for most of the rest of the year. I did two months of obs-gyn... loved it. I did a month of anaesthesia... hated it. Did two months of surgery... well, you know the story. Tried to keep my sanity and my non-medical life while surviving residency. Sometimes I managed to do this, sometimes I failed. Life is a learning process.

The intern year... six months down, six to go.

Thank God. It's back!

So I admitted a woman direct to the surgery floor today. Middle aged, with abdominal pain. Pretty run-of-the-mill. She was a transfer from a rural hospital from a doctor who was concerned about her high white count and tender belly, but didn't have a CT scanner to further investigate her pain. She had been in pain for two days... not too impressive, and although her abdomen was tender she didn't have any peritoneal signs (in english, that means she didn't have any of the physical signs that we look for when really bad things are happening in the belly). So I admitted her, started her on empiric antibiotics (again for the med newbies: antibiotics that cover pretty much most of the bugs that could possibly be making her sick, often used when you have no idea what you're dealing with) and arranged her CT scan.

A few hours later, mired in the day-to-day floor scut, I had all but forgotten about her. Then I got a page from the radiology resident, sounding excited. She had a ruptured appendix. And it had ruptured but good. She had an abscess that stretched from the caecum to the Pouch of Douglas, and then back up to within a few centimetres of the sigmoid colon. Trust me... that's a lot of pus.

So I found myself in the OR. Not altogether unusual on a surgery rotation, right? But here's what was unusual. With the patient prepped and draped and me, the chief resident and the staff surgeon standing around her, someone handed me the scalpel. And told me to cut. Oh... my... God. I opened the abdomen. And cut through the fascia. And, after copious amounts of pus were drained from her belly, I mobilized the appendix. And, after the base of it was secured by the chief, I removed the appendix.

So standing there, at an hour of the night when most of the sane world is asleep, holding this angry-looking appendix that looked like a bullet had passed through the end of it and smelled like pus, I found it. That feeling. That "holy-crap-I-can't-believe-they-let-me-do-this" feeling that was all but a distant memory after two soul-crushing months of surgery. So there I was, clutching this disgusting appendix and grinning like an idiot behind my surgical mask.

I found my enthusiasm for medicine. Welcome back. I've missed you.

The Light at the End of the Tunnel...

Apologies to those who have been waiting for a new installment. It's taken me a while. Partly because I've been busy, partly because I haven't had much to say. Truthfully, I'm tired of complaining about stuff. Unfortunately, I haven't had much positive to share. So in the vein of 'if you can't say anything nice', I haven't been saying anything at all.

So I took some vacation... my first since starting residency. Not a good move, waiting until I was half way through to take some mental health time. Possibly also not good to think that a week of family time would recharge me. I love my family, but half of them are crazy. And in order to spend time with the half that I like, I often have to spend time with the other half. Not making for a relaxing time. Actually, I'm exaggerating. Of the two that I expected to make my vacation hell before it started, only one of them actually did. The other was very pleasent. Which continues to baffle me, but the family member in question doesn't seem to want to discuss or work through old issues so I guess the situation will continue as it has. And now that I've lost every reader who doesn't know me well enough to know who the hell I'm talking about... sorry. Sometimes I forget that not all of you know me in person.

By the time I got back to work, I felt like I had nothing left to give. I was cranky, bitter and angry. It felt awful. I had no interest in being there, and I resented every minute. After a day or two, though, things started to turn around. I felt like I was finally getting the hang of it. I was no longer walking around in that state of constant panic. I actually got some sleep on a night of call.

Just in time to move on. Family medicine is my next stop. Four whole months of it. My first rotation as a family medicine resident. I admit I'm kind of sorry to not call myself an emergency medicine resident anymore, but I know that I'm doing the right thing. Besides, I'll be an emerg resident again in a year and a half after my family residency is over. And I'm going to be doing a horizontal elective in emergency medicine during my family rotation. In english, that means that I get to work in the ER one afternoon a week. Finally... some actual "Tales from the Emergency Room"!

Family medicine is looking interesting. The family doc I'm working with is in a small town (about a 45 minute commute for me, but worth it to be out of the academic centres!) and besides running an office practice, follows his own patients in the local hospital, does obstetrics (Yay! More baby-catching!) and works at a nursing home. I should be seeing a really good mix of stuff. He's been advertising me in his practice not as a student, but as a 'new doctor joining his practice'. I start seeing my own patients within a week. Crazy. I can't wait. :-)

Please Allow Me to Apologize on Behalf of the Entire Medical System...

It started as soon as I was accepted into medical school. People would feel inexplicably compelled, upon learning of my career path, to tell me their medical horror stories. It was never in relation to a bona fide medical error, but usually in reference to some asshat physician who was insensitive. I've heard stories about how someone's aunt was told that she had cancer by a physician over the phone while he was chewing loudly in her ear. I've heard about family doctors who have erroneously diagnosed people flippantly with everything from 'probably herpes' to 'possibly leukemia' until tests showed that they were fine.

In these cases I often expressed the appropriate amount of horror and sympathy, thinking that was likely the best I could do under the circumstances. Inside, of course, I was wondering if the doctor would have told a much different version of the story. But defense of the doctor was obviously not what these people were looking for. I'm not sure exactly what they WERE looking for (anyone feel free to enlighten me?) but they seemed satisfied with my response at the time.

Now it's a whole new ball game. Now I'm considered part of the giant enemy. I'm one of them. Now, apparently, my sympathies and apologies aren't going to cut it. Now I get all kinds of complaints-- my room is too cold, my nurse doesn't come fast enough, I want to see a real doctor... it never ends. In fact, I am often paged at odd hours because a patient, facing discharge, does not feel that he or she has had a chance to adequately air their grievances. So the nurse does what I'd certainly do in his or her situation... passes the buck. Page the intern.

I'm the first to admit that our medical system is far from perfect. That being said, it worries me when people talk as though our only alternative is a system modeled after our neighbours to the south. In my opinion, our system is the lesser of two evils (in spite of the fact that a nice cushy job in a private hospital is looking like heaven to me right now). But plenty of other countries have managed to do a better job at providing health care than any of the ones on our continent. In France, where I did a month-long elective in general surgery after my second year of medical school, the country has managed to make a two-tiered system both sustainable and satisfying to the people who use it. But I digress...

I find it ironic that the people who expect me to act instantly to fix what's bothering them are the same people who, just minutes after introducing myself as doctor Couz, ask when they're going to be seen by the doctor. So I'm medically impotent, but when it comes to making your nurse respond to your call bell immediately or the fact that your dinner was cold I'm expected to produce immediate results.

Just call me Couz: Medical Ombudsman.

A Perfect Example of Why I'm Getting the Hell Out Of Academic Centres

Warning: Gratuitous vent ahead.

When the December call schedule came out at the end of November, I was surprised to see myself put on call on December 28th. According to our union contract, every resident is entitled to 5 consecutive days of vacation, either over Christmas or over New Year's. Now, since I'm related to many people with crazy schedules I opted to apply for New Year's over Christmas... I figured I'd be more likely to get what I wanted and could arrange two different celebrations. One with my family the week before Christmas (this week) by taking a week of vacation, and one with my in-laws the week after Christmas (the New Year's block). Everyone would be happy.

So when I applied for my New Year's block and didn't get any response (all vacation requests need to be denied within two weeks, or they're considered approved), I made my holiday plans for that period... my five days were December 29th, 30th and 31st and January 1st and 2nd. Then the December schedule came out and I was on call the 28th. That means that I'm actually working until at least 10am on my first day of "vacation". Totally not allowed by union contract. So I'm only getting four days of vacation instead of the five I'm supposed to get.

I e-mailed the chief resident as soon as the schedule came out, thinking it was just a mistake. I was told that 'someone has to take that day', and told that I wasn't going to get an additional day elsewhere to make up for it. Basically, I was brushed off. I mentioned it to our program secretary who sent an e-mail stating in no uncertain terms that they had no right to take a day off my holiday, and to please change it. No response. I mentioned it at a recent union meeting, and another e-mail was sent. No response. Finally, the contract compliance guy got the big guns (i.e. union lawyer) to draft a letter threatening grievance if the contract was not honoured.

Finally, a response. I was pulled aside yesterday by the chief resident who expressed his anger at being contacted by the union lawyer in no uncertain terms. He said that I took him by surprise... apparently no one has EVER complained about having their vacation shortened after being previously approved before. Right. I'm sure.

He said that if I was 'determined' to follow our union contract 'to the letter', he'd start following other rules to the letter as well. He threatened, for starters, to make me work every day over holidays as though it were a normal day (due to OR shutdowns and cancelled clinics over holidays we usually just treat each day as a weekend day and the person on call covers both that day and night). I asked if he'd be expecting this of everybody, and he responded that this would be enforced on 'a case-by-case basis'. Meaning, obviously, that I'd be doing this alone. He then pointed out that I only have 5 call in December and therefore have no right to complain. I pointed out that 5 is the maximum number of call that anyone on the schedule is doing in December, and that I have the same number of call as everyone else in spite of having a week of vacation. His response was that he could legally (according to the contract) have given me more, particularly on the weekends flanking my week of vacation. Hint, hint, eh? Sigh.

So I'm being forced to suck it up. It's apparently not enough that I work my ass off for enough hours every week to be equivalent to two and a half NORMAL jobs, but now the minute I try to stick up for the time off that I'm entitled to by my contract, I get threatened by my senior. I can't freaking believe this shit.

An Hour in the Life of a Pager

I read an interesting fact the other day-- as many as 25% of all beeper pages were unimportant or unnecessary and actually interrupted patient care (citation below, if you care that much). That makes one heck of a lot of wasted time answering pages and trying to find a free phone.

What immediately came to mind was an incidence of pager-abuse not too long ago, when I was paged *1 (meaning STAT, or emergency) out of a patient assessment to the emergency room. As I had three patients in emergency at that time that were admitted and waiting for beds to become available upstairs, I rushed out of my assessment and ran to the nearest phone. The emergency? I had forgotten to sign a radiology requisition, and the patient was on their way to x-ray. Nice.

So I decided to conduct an experiment. Today I actually wrote down what I was being paged for every time my electronic leash went off. This lasted for little more than an hour before I couldn't keep up with it, but it was interesting while it lasted. Now keep in mind that during this hour I am trying to see three surgery consults in the emergency room with the help of two clinical clerks.

10:02am: The floor pages me to tell me that Mrs. W's urine output was low. I ordered a bolus of fluid over the phone.

10:04am: The emerg (two feet from where I was currently sitting) pages me to let me know my patient is waiting for me in emerg. Um, thanks. I know.

10:04am: Senior resident pages me to remind me that Mr. D's CT scan needs to be set up before lunch. Thanks, I know. I've done it already.

10:09am: Radiology pages me with results of an ultrasound on one of my patients.

10:12am: The floor pages me to tell me that Mr. P's PICC line fell out. I inform her that it didn't fall out, we ordered it removed last night because it was infected. She is satisfied with that.

10:12am: One of the clerks pages me from the other end of the emergency room to tell me he's finished assessing his patient.

10:12am: Who knows who this was? I tried to call it back three times and the line was busy. Don't page me and then get on the freaking phone!

10:19am: The floor pages me to ask if I'm sure that I want Mr. H's heparin stopped. Yes, I do. That's why I wrote the order "discontinue heparin".

10:21am: The floor pages me to tell me that Mr. Y has spiked a fever of 40.2. The nurse has given him Tylenol, but she just wanted to make me aware. Um, thanks.

10:34am: The floor pages me to tell me that Mr. L's nurse thinks that his abdomen is becoming more distended. I tell her I'll be up to look at it when I get a chance.

10:34am: Senior resident calls me from the OR to let me know that we'll be running the list with the staff (i.e. discussing the patients) after their next case. I agree to meet them. I wonder how the heck I'm going to get these consults done before then when my pager keeps going off.

10:40am: Hematology resident pages me to tell me about another consult on one of their patients. This day is not looking any better.

10:52am: Nurse from the floor pages me to ask me if Mrs. M's additional bloodwork can be done tomorrow morning when the tech comes back because she's a difficult stick. The bloodwork isn't urgent, so I tell her it's fine.

10:54am: Nurse from the floor pages me to tell me that Mrs. W's bloodwork showed that her INR (measure of how easily blood will clot) is too high. I change her dose of coumadin (drug that makes blood less clotty) for that evening.

10:57am: Another page from the ER (this time, 10 feet from where I am sitting) to ask if we're going to be sending one of our consults home. If I had time to deal with the consult between pages I'd be happy to answer the question.

That made 15 pages in the space of one hour. A page every four minutes, on average. Of these, maybe 6 were useful or necessary. This hour might not have been representative (I don't usually get THAT many useless pages in such a short period of time) but I'm now starting to understand why I can get through a 12-hour day without having time to eat or sit down and yet still feel like I've accomplished nothing.

There is good news, though. As of today at 6pm when I finally left the hospital, I am on vacation. For a whole week. Thank God.



Blum NJ, Lieu TA: The effects of paging on pediatric resident activities. American Journal of Diseases of Children 1992; 146(7):806-808.

In Praise of the Medical Spouse

Someone once told me that the purpose of dating in medical school is to find someone who likes you enough to commit to you before they find out what they're getting into. At the time, I thought that was a bit cynical. Now, I'm thanking God that I managed to find just such a person.

As those of you who know me in person are aware, I'm engaged to be married. He and I had known each other as 'friends of friends' for a few years, and started dating at the end of my third year. Well, it wasn't that abrupt. He gradually looked away from my breasts, and I gradually looked away from his ass. Then we realized that we actually liked each other. He passed my five rules of dating.

1. No guys who smoke
2. No guys who live with their parents
3. No guys who wear electronic equipment in holsters on their belts
4. No guys who wear jeans that I can't fit into
5. No guys in medicine

Some of these may sound odd, but they're all grounded in solid fact and past experience. Trust me on this one.

Now although not being medical himself, he was not a stranger to the medical profession. His family was full of nurses, and his ex was an aspiring medical student with a physican for a mother. That being said, when we moved in together about six months later I don't think he was entirely prepared for the life of a medical spouse.

At any get together where there is more than one medical student or doctor, the conversation invariably turns to medicine. It doesn't matter how much we try to stop it. It's the thread that binds us together, and even when we see ourselves falling into that trap it's nearly impossible to avoid. That often leaves various spouses milling around trying to find things in common with other medical spouses other than the fact that they have the misfortune of being committed to someone in medicine. It leads to a lot of awkward silences and some embarassing social situations. Like the one when one medical spouse (possibly mine, but I'm not telling) who was obviously dreading another evening of stilted conversation with complete strangers, managed to down half a bottle of Absolute by himself before the evening even started and proceded to spend the night wrapped around the toilet of a lovely spanish restaurant.

But at the risk of gushing, I have to give credit where credit is due. I could not have asked for a better partner when it comes to surviving residency. This boy has the patience of a saint. He does almost all of the cleaning around the house, including almost daily vacuuming thanks to our dog, the shedding machine. He does the dishes, since our current place doesn't have a dishwasher. He does the laundry, which thankfully isn't much of an issue since I rarely wear anything but hospital greens. Although I usually do the cooking, since starting surgery I'm rarely home early enough to consider doing that either. He's no chef, but he manages to pull together something edible more often than not. He walks the dog everyday, and on the days when I'm home and awake enough do it he comes along.

He never complains, either. Not about the hours, the amount of work I don't do around the house, or the fact that when I am home I'm often too tired to be any fun at all. He's recently gone back to school to become a paramedic. Even with a full courseload and studying to do at home, he still manages to keep my life going. My bills would never get paid if he didn't open my mail. He didn't start to do that until recently, when he got tired to looking at the ever-expanding pile of unopened mail on the table next to the front door.

I don't know what the heck I did in a past life to deserve such an amazing, supportive guy. But I'm very glad I did. And yes, I tell him how much I appreciate him on a daily basis.

So here's a word of advice to any medical students out there. Find a really good partner while you still have the time to show them what a friendly, fun, interesting person you are. Because once you start residency, it's a lot easier when you've got someone along for the ride.

Now if only I could find the time to plan my own damn wedding.

I am a Bonehead

Apologies to those of you who have been trying to post comments. I didn't realize that I had inadvertently set something to require administrator approval before publishing comments. I am a loser who can't figure out HTML. And thanks as well to the poster who directed me to the idiot-proof Site Meter website that allowed me to add a counter to the bottom of the page without managing to corrupt my entire blog. Whew.

And as an aside... a few people expressed confusion at the sudden mention of a program switch. I snuck in a post a while back. Apparently, when you publish a post it's filed based on the day you started to write it, not the day you published it. So it got lost in the shuffle. But for a full explanation, please refer to: http://drcouz.blogspot.com/2005/10/its-official.html

Yes folks, I'm the future of health care. And I can't figure out my own damn blog. Be afraid. Be very afraid.