The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Friday, July 28, 2006

Time Flies When You’re Having Fun

And nowhere is this more true than when I’m working in the emergency room. Unfortunately, my time is half done and I’m already dreading the return to ward medicine. Particularly when my next rotation is pediatrics.

That’s certainly not to say that my rotation has been without it’s low points. One of the doctors I’ve been assigned to work with frequently is a huge advocate of the ABC’s… or at least insofar as they stand for Airway, Breathing and Consult. He’s so quick to hand patients over to other services that I actually feel like I lose out on learning about patient management. When I’m on with this staff I can guarantee that anyone requiring a pelvic exam will be referred to gyne, anyone over the age of 75 will be referred to medicine and anyone complaining of low mood will end up in the hands of the Emergency Psychiatric Team. It definitely gets frustrating.

This may be a direct result of the fact that the hospital where I work has it’s emerg docs billing fee-for-service. Most of the other teaching hospitals in the area are on salary, which is intended to encourage teaching but discourage efficiency. Studies have shown that fee-for-service emergency rooms result in shorter wait times, and I can attest that there is no shortage of teaching at my hospital. In fact, when multiple residents are on shift at once, many of the emerg docs simply make themselves comfortable in the back and don’t see patients—they just review the patients with the residents and make suggestions regarding their treatment plans. We get more done, they bill more patients, people don’t wait as long… in short, everyone wins.

The biggest limiting factor to that approach, however, is that you have to be working with residents that you trust. Not always a given. Not everyone has the insight to know when they’re in over their head, or the guts to admit that they don’t know how to approach a particularly sticky problem. Not that I’ll be naming any names…


Friday, July 21, 2006

So apparently my dogs listen when I talk about work. I got home from my ER shift today to learn that my puppy has an infected eye that had been angry-looking and swollen shut all day. My wonderful spouse had already made a vet appointment.

The verdict? Anterior uveitis. You have to be kidding me. See picture below (two posts ago). Only in a dog-eye. Now since we're pretty sure my dog doesn't have ankylosing spondylitis (and I don't know enough about uveitis in dogs OR humans to really know what else causes it) we have no idea how it happened. She might have an allergy that set it off, she might have been exposed to something while we were at the Conservation Area yesterday, she might have had blunt trauma to the eye (possibly in the form of older dog's tooth while they were wrestling this morning)... who knows? But she definitely had cells and pus in the anterior chamber, she was markedly photophobic and her pupil was fixed and constricted. Lovely.

So as was the case with my patient last week (minus the stat opthalmology consult)... atropine drops q4h for 24 hours, then q8h, then q12h, then daily to keep the pupil dilated. Steroid ointment on the same schedule, but then twice daily for a grand total of EIGHT weeks. And the puppy is NOT impressed. But at least she won't be going blind in her left eye anytime soon. We hope.

So here's what anterior uveitis looks like in a 7-month-old puppy.

If life continues to imitate work I expect to be extracting a quarter from my dog's nose next week.

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Thursday, July 20, 2006

Some Things I Learn the Hard Way

For example, when the emerg psych nurses offer you Vicks VapoRub for your nose before entering the room to interview a suicidal homeless crack addict, don't put it directly in your nose. In fact, don't even put it under your nose. It's probably a much better idea to don a mask, coat the inside of the mask with the VapoRub and tell the patient you have a cold.

My eyes are still watering.


Wednesday, July 19, 2006

Defying the Laws of Nature

When my friends are on call and I'm in emerg, I feel less hesitant about asking them my stupid questions. Which is lucky for me, since I have many of them. The other night a friend of mine from med school was on call for general surgery, and was hanging around the ER after a consult. So I decided to bounce a case off him-- a kind of unofficial consult, as it were.

Dr. Couz: What are the chances that my 46-year-old female patient presenting with right upper quadrant pain and nausea is suffering from cholecystitis?

Surgery Resident: Pretty Good.

If she's had it before?

Even better.

If she was previously treated with a cholecystectomy for recurrent cholecystitis?

Um... well, it's still possible that she retained a stone.

And if she had a follow-up ERCP 3 months later for removal of a retained stone?

Hm. Pretty much nil.

Are you sure?

Yup. It's gotta be something else.

So, as per Murphy's Law, an hour later my patient's bloodwork comes back with elevated liver enzymes, including the one that serves as a somewhat specific marker for gall bladder obstruction.


Consult surgery.

This month's career-related goal and personal growth experience? Becoming comfortable with uncertainty and discharging patients without having any clue what the hell is wrong with them.

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Monday, July 17, 2006

I Love my Job

And not just because the hospital is air conditioned while the rest of the world (including my house) is sweltering in the second straight week of temperatures in the mid-thirties coupled with smog and Humidex advisories. But that helps.

And as an aside, what is up with the freaking Humidex? If the Humidex makes it FEEL like it's 43 degrees, don't tell us that it's 34 degrees with a Humidex of 43... just tell us the bottom line. It's not like anyone walks around in a humidity-free bubble. It's like the windchill in the winter-- there's no point in reporting the temperature as -10 if the second you step outside a blast of icy wind makes it "feel like -20". If it FEELS like -20, it's -20! No?

Okay, I'm over it. But working 10 hour shifts nearly every day last week (they nicely gave me Wednesday off to attend my academic half day... and yes, I'm rolling my eyes as I say this) was much more tolerable when it was viewed as an escape from the heat. I need air conditioning in a big bad way.

Oddly enough, we haven't seen that many people come in with heat-related illness. In the past week, though, I've seen some interesting stuff. Although I have to admit, I feel somewhat sheepish posting about the 'interesting' stuff I've seen when I read Fingers and Tubes in Every Orifice, a kick-ass blog written by an emerg doc in the US. A regular shift for him sees more action than two weeks in this mid-sized Canadian town. On one hand, I'm envious-- I may go through an entire career without seeing a gunshot wound. But on the other hand, the constant adrenaline rush that comes from dealing with trauma must grow tiresome at best... lead to early burnout at worst. I don't know if I'd be able to cope.

So yes, I've managed one or two 'life or death' type situations. A woman came in with a ruptured thoracic aneurysm last week, just a few minutes before the end of my shift... I got to tube her, start her central line (my first one unassisted!) and more or less run the code under the watchful eye of the emerg attending. She died, but not before a daring vascular surgeon attempted an emergency thoracotomy in the middle of the ER, unwilling to wait the 10 minutes it would take to open up and staff another operating theater. She coded three times in the process before someone finally conceded defeat.

Most of the docs let me work pretty independently. Which is cool, because I'm gaining so much more confidence in my skills.With the exception of peds and neurology, both of which make me feel like a useless tit, I rarely feel like I'm in over my head. I've diagnosed a first-outbreak genital herpes in a middle-aged woman who had been treated (unsuccessfully) for a UTI and a yeast infection before she landed on our doorstep. I've seen an anterior uveitis in a young guy with ankylosing spondylitis, although it took quite a bit of fumbling with the slit lamp to do so. I've caught both a peritonsillar abscess and mono on nothing more than a hunch, and managed to catch a fractured shoulder that my staff missed on first pass. I'm not exactly saving lives, but I'm starting to feel like I might be able to eventually.

And on that note, the match website for the emergency medicine third year for family practice residents is up. Here we go again. My new match day is November 2nd. Wish me luck.


Wednesday, July 12, 2006


So after one year of residency, half of which was in Emergency Medicine, I am finally in an actual emergency room full time.

I'm LOVING the shift work. Granted, the hours would be much sweeter if I didn't still have my academic half day and my family medicine clinic half day in addition to my emerg shifts, but I'm loving it none the less. I have an impressive talent for being able to fall asleep any time, any where. So it didn't take long to adjust.

The upside? Well, it's emerg. Nuf said. The downside? The hospital I've ended up at isn't the trauma centre for the region. Nor is it the cardiac cath centre. Or the stroke centre. Sigh. You can see where this is going. Calling it a glorified walk-in clinic isn't all that far from the truth. But it is the regional centre for... ready for it? Emergency Psychiatric Services. Thank God for that month I spent in Emerg Psych last year. At least I'm not completely unprepared.

The patient of the day came in the form of a 19-year-old boy brought into the ER by his father, who was requesting the services of the emergency psychiatric team. He was claiming that his son was apathetic, lacked focus and wasn't able to concentrate. Fair enough... these can all be early signs of clinical depression. When I actually interviewed the kid, however, he turned out to be the most pleasant and normal person I had encountered all day. His mood was good, he denied any suicidal ideation, and he joked with me throughout our conversation. He did admit to having trouble finishing projects... he found he just lost interest in them easily. He had also gotten into university for the fall, but it wasn't to his first choice school and he was seriously thinking of taking a year off to reevaluate his career goals. No signs of depression that I could see.

So I called in the father to join us. The father was quite distraught. I asked him straight out why he thought that his son needed a psych assessment. The father, in English heavily accented with an accent that may have originated in India (I'm not great with identifying accents) told me that their family owned a store. The father had been trying to get his son to work at the store, but all he did was sit behind the counter and watch television. He didn't want to go to university. He didn't work hard at school like his sister. He wanted to hang out with his friends and play video games. He argued with his parents. Obviously, concluded the father, his son was mentally ill. He had asked the family's doctor to provide a referral to a psychiatrist, but they were told there was a three month wait. So here they were.

It was difficult to stifle a giggle. I explained that the purpose of the emergency psychiatric team was to identify people who were at immediate risk for harming themselves or others. I assured him that I saw no signs of mental illness in his son, and that if he continued to have concerns he could see his family doctor for family counselling.

Obviously there was a cultural component here, but what was I supposed to diagnose this kid with? Teenage boy syndrome? Sigh.


Wednesday, July 05, 2006

Bring in the new...

Yup. New look. Same whining.

I got tired of looking at the old template. This one has orange. I like orange.

Think I lost my counter, though.


For the past week I've been brewing a long, meaningful post about my transition from first year residency to second. A lot has happened in a year-- I've changed programs. I've shifted priorities. I've learned stuff.

But really? It doesn't feel any different. Maybe if I were in one of those programs where I go from being the 'intern' to the 'resident' (and thus become the in-house representative for my specialty during my nights on call) like obs/gyn, internal medicine or orthopaedic surgery, but I'm not. And other than trying to get used to ending my signature with "R2" rather than "R1" (the latter being so ingrained in my subconscious that I have often caught myself signing cheques with a flourishing "R1" after my name) I don't feel that anything has changed.

Welcome to Medical Postgraduate Year II. Please keep your hands and feet inside the vehicle at all times and enjoy the ride.