Quick Update...

Just so that no one thinks I've dropped off the face of the world, I'm in mid-move. After passing my CCFP exams (yay, me!) and finishing my family medicine residency, I've packed up Mr. Couz, Big Dog, Velcro Dog and The Bean (who, at 18 weeks gestation, is still very portable) and moved to a less "academic" region.

Stay tuned. More adventures of Dr. Couz are coming as I become a full-fledged emergency medicine resident (again) and muddle through various rotations across Canada (the downside of a less "academic" centre is that it's not big enough to support specialized rotations like trauma and peds emerg) while moonlighting my ass off (so much debt to pay off!), as I try to fit my rapidly-expanding waistline into Hazmat suits (makes the scrubs look positively stylish!).

But in the meantime, I'm just trying to get the internet hooked up at our new house. Trying to focus on one battle at a time.

Back soon.

Learning my Lines

... but not in the musical theater sense.

This month I've been in the ICU. A very intense rotation. I've been dealing with patients sicker than any I've ever seen before. I've seen medicine do things I didn't know were possible. I've seen countless people who were clinically dead brought back to life with electricity and drugs. I've seen people who should be dead kept alive for days, sometimes weeks, using medications, ventilators and a little luck. It's been a long month.

The reason I've chosen to do ICU (as a family medicine resident, it's not a required rotation) is for the procedures. Now I'll be doing another 2 months of it as an emergency medicine resident in the coming year, but I figured another month of it would be more helpful than my other choices (including palliative care, more internal medicine and more geriatrics). There are lots of procedures done on a daily basis in ICU that come in handy in the emergency room. Before this rotation I had superficial experience with most of them, but I figured this would be a good chance to hone my skills.

Not so much. I have had a horrible streak this month. If anything, I think I'm getting worse at the procedures I should be getting great at. Central lines have become the bane of my existence. Before this rotation, the only experience I had with central lines was one subclavian under close observation in a trauma situation. But technically, I was one for one. This month I've had two subclavian attempts. Although I got both, one gave the patient a pneumothorax (a known complication of subclavian lines, but I can't help but feel bad about it).

IJ's, the mainstay of central lines, should be routine for me by now. Instead, the only attempts I've gotten have been on patients who are awake. Now for those of you who have never attempted an IJ, imagine trying to perform a delicate procedure involving sticking long needles into people's necks in people who are combative, can't lie flat, won't stop touching the sterile drapes, keep turning their heads to see what you're doing and often don't understand enough English to follow simple instructions (Damn, I wish I spoke Italian!). In short, I am 0-for-three in IJ's, and frustrated to tears.

Femoral lines aren't often done in the ICU where I am currently working. I have seen one done, that's it. So according to the 'see one, do one, teach one' rule, I should be trying the next one. But there's not much chance of seeing another one in the two days I have left.

Chest tubes are another procedure that I've been eager to learn. In an entire month, I've done one. That's all. I was successful, but to put things in context it was a large pneumothorax in a small, thin, 40-ish woman. NOT the typical patient. I can only hope I'll be just as successful when I'm called on to do the same in people with much more tissue to cut through.

But the issue with the central lines has been really discouraging. Particularly for me, who apparently has placed far too much of my professional self-worth in my proficiency at various procedures-- after spending the first three years of medical school thinking I was going to be a plastic surgeon, I do tend to pick up things like this easily. And now I seem to have grown extra thumbs and some kind of gypsy curse, to boot.

Oh well, there's always intubations. Crap, now I've probably cursed those too.

On Being a Pregnant Medical Resident...

The Good:

• Limited maternity wardrobe required-- I went from yellow-string scrub pants to blue-string scrub pants around week 14 so that I could wear them over my expanding belly and not have to hike them up all day. Saves me a ton of money.
• My emergency medicine program has been amazingly accommodating regarding my pregnancy and impending maternity leave. I've basically re-written my schedule for the next year so that the rotations that have to be done out-of-town will be done by the time The Bean makes an appearance.
  
• It looks like I can take 5 months of leave and still manage to write my emergency medicine certification exams on schedule. That's 2 months more than I expected to be able to take.
• PAIRO (have I mentioned that I love my union?) tops up my mat leave to 75% of my take-home salary. Not too shabby.
• As a doctor, I seem to be subject to very little of the unsolicited advice that is often heaped on pregnant women. I guess people assume that my medical training makes me better prepared for managing pregnancy. With the exception of my mother-in-law, who believes, for example, that my intention to cloth diaper is something that should be met with eye-rolling and smirking.
  

The Bad:

• I'm torn between wanting to tell everyone I work with that I'm pregnant (since I'm definitely looking wider around the middle) and not wanting them to think that I expect special treatment.
• Due to some first trimester spotting, I had to stop running. I've been walking instead, but it's really not the same as far as stress reduction goes.
  
• I need to pee about 10 times a day. This is actually pretty disruptive to a busy workday.
• Eating is a challenge. I'm done with the nausea of the first trimester, but very few foods are appealing to me. And it's not like I can leave the ICU with the code pager to get myself some fresh watermelon and a McDonald's cheeseburger when the mood hits.
• I miss sushi. A lot. And wine. And my beloved aspartame (I long for a Diet Coke!). I am aware that not everyone believes that forgoing sushi and aspartame is necessary during pregnancy, but it's what I've chosen. That doesn't mean I can't complain.
  
• 10 hour days with 1-in-4 call is exhausting to the most hardy of individuals. Being pregnant doesn't help. Thank God I had easy rotations during the dreaded first trimester.
• My blood pressure has been problematically low. My systolic is hovering around 80. In the stuffy confines of the ICU, rounding (standing in front of a patient's bed for long periods of time) gives me pre-syncope. I think I'm going to have to tell my attending I'm pregnant, or he's going to think I'm just a lazy shit who drags a chair around the ICU with me.

The Ugly:

• Uncontrollable pregnancy gas. Nuf said.
  

Eye See You.

My last rotation of residency has begun, and it's been a hell of a rude awakening. After 7 straight months of family medicine (and before that, two months of babysitting a Level II nursery) it's been a long time since I've done any 'real' medicine. And now it's somehow become me and one staff covering a ward of a dozen people who spend much of their days actively trying to die.

It's funny, but that aspect of this rotation bothers me less than I thought it would. People die. It happens. More often than not, people die when their time has come. It's never easy to say goodbye, but it seems somehow less hard to swallow when an 86-year-old man dies after a lengthy illness surrounded by extended family. It's a good death.

Not that we let everyone have the 'good death' that (in my opinion) is the ideal way to end your time on earth. Whether it's due to the patient's wishes or the family's, many people are subject to endless lines, procedures and resuscitations before they finally pass on. Medical science is quite adept at prolonging life, even when life is not meant to be prolonged. And I'd be lying if I said that it wasn't disturbing to be doing chest compressions on an elderly man with multiple medical problems, or intubating an end-stage COPD patient for the 9th time in 2 years. Some people were just meant to die. Peacefully. Without cracked ribs and tubes down their throat.

Funny that death doesn't seem to bother me as much when I'm faced with it on a daily basis. But you can bet your ass I'm getting "NO CODE" tattooed across my sternum when I hit 75 or so. Assuming I last that long.

What To Expect From Your ER Doc

People bitch about doctors a lot. Not necessarily to me, but in my presence. I don't mind, most of the time. Many times these people have legitimate beefs. But more often than not, I think that the problem lies in poor communication. Doctors often assume a level of medical knowledge in the general public that simply isn't there. And patients, for one reason or another, don't ask questions. When this is the situation, the patient will leave the encounter upset, and the doctor will have no idea that the patient wasn't satisfied with the result.

A patient's expectations should be different depending on the physician and the circumstances. This view may reflect the fact that I am currently awkwardly straddling my roles as family physician and emergency physician, have have yet to become truly comfortable with either one. But I find that whereas a certain degree of bedside matter and handholding should be expected of a family physician, to expect the same from an emergency room physician is misguided. Not to say that ER docs have free reign to be assholes, but their role is different.

So here's a quick primer on what you should expect from your friendly emergency room physician:

1. To be appropriately triaged.

The first thing that happens to you in the emergency room is that your complaint is ranked on a scale of how likely it is to be life-threatening. This system may not seem fair, but it usually works very well. So if you're grumbling because the young girl in the corner with seemingly minor stomach pain is seen before you in spite of the fact that you're puking from your horrendous migraine, remember that you don't know the whole story. If there is a chance she's pregnant, the possibility that her pain is resulting from an ectopic pregnancy definitely outranks your migraine (which, although obviously unpleasant, isn't likely to kill you). See how this works?

2. To have life-threatening conditions ruled out.

Let's say you're the one with the belly pain. If you're not pregnant, not bleeding, have no signs of an acute (aka surgical) abdomen and aren't dehydrated, you'll likely be discharged. I can understand that people want answers, but sometimes we're not going to be able to give them. It might be gastro. It might be food poisoning. It might be muscular. It might be very early appendicitis that just hasn't 'declared' itself yet. If it's the latter, that will become clear soon enough. It it's any of the former, it won't kill you. So we're sorry that we can't tell you exactly why you woke up with belly pain and had some diarrhea, but we don't have all the answers.

3. To do what is medically indicated for your condition.

Not everyone walking into the ER warrants extensive investigation. The job of the EMERGENCY room is to rule out EMERGENCIES. See how this works? So once it has been established that your presenting complaint is unlikely to cause you significant morbidity or mortality any time soon, you may find yourself punted in the general direction of your primary care provider for further care.

4. To see the doctor (although the length of time you waited is not reflected in the amount of actual time you spend with him/her).

This may come as a shock to those of you who have waited 3-4 hours in the ER only to get less than 30 seconds of face time with the physician who breezes by to tell you that your wrist is not broken (and, if you're lucky, perhaps a script for some Tylenol #3's). But if you're looking for a longer discussion about how long you can expect to be in pain, what kind of limitations you should put on your activity, how you should ice it, what kind of exercises you can start doing and when to regain strength... well, you're best to see your family doc.

This may seem unnecessarily harsh, but it's reality. Not only is the ER doc usually the ONLY doctor in the emergency room (and therefore balancing the multiple needs of many patients, most of whom are far sicker than you) but it's often hard to muster up convincing sympathy for someones infected ingrown toenail when you've got people actively trying to die in 3 different resuscitation rooms. This is not usually the place for handholding and sympathy.

5. To be waiting longer if you abuse the nurses.

Wandering back and forth to the nurses station to complain about the wait and threaten the nursing staff will prove to the nurses (and, by proxy, the doctor) that you are well enough to ambulate and complain and therefore not sick enough to warrant immediate attention. So stay where you've been put and wait your turn. Besides, wandering around the emergency department compromises patient confidentiality-- would you want people wandering around overhearing the doctor ask you personal questions? I think not.

6. To be treated respectfully.

Although you might not get stickers and hugs, you should expect to be treated as a human being. That means that your dignity will be preserved as much as possible in an environment like the ED, you will be treated fairly, and you won't feel as though you are being judged for your problem (particularly if it involves mental illness, substance abuse, physical/sexual abuse or sexually transmitted infections). If this is NOT true of your emergency room visit, this warrants an official complaint.

No doubt I'll be adding to this list as time goes on. But for now, please excuse the disjointed blogging... there has been a lot going on in my real life, which hasn't left much time for blog updates. More to come soon.