This month has been a major shift in gears. In the ICU units we only had 3 to 5 patients and we were keeping up with every detail of their care. This month I was on the Ortho Trauma service. I was told that the "Rotators" (the interns who work on the service who are not orthopedic residents) see after the patients on 3 South. Well, guess what. There are usually somewhere between 12 to 16 patients on the Ortho Trauma service on 3 South. There is no way you can spend 30 - 45 minutes on each patient in the morning before the 6:30 conference the orthopedic service has each morning. So, I found out that the ortho service really has to have a focused approach to examining the patients and to doing the notes. Now, the only ortho rotation I had done before this was one week during my M3 year. So, I really felt like a fish-out-of-water. So, with the increase in the number of patients and being somewhat unfamiliar with the requirements of the ortho exam, I was trying to get to the hospital between 4:00 and 4:30 am.  The first day, I was asked if I had seen what kind of range of motion a patient had and I was like, "No, they just had surgery two days ago." But, that's why they put the plates and screws in during surgery. This allows the patient to get back on their feet quicker. Unlike 30 years ago when I broke my femur (thigh bone). I was in traction lying in a hospital bed from September to December.

Speaking of traction, that has changed a lot also. They used a manual drill to put my traction pin in. Today, they use a big, heavy-duty rechargeable drill. I got to help put several traction pins in and I must say, this is another example when it's better to give than to receive.

One of the things I try and get out of these different rotations is to learn what needs to be done before calling in a consultation. One of the things I learned on this rotation is that all fractures don't automatically become primary ortho patients. For example, one lady came in with a fractured hip. She obviously had an orthopedic problem but, she also had a history of cardiac problems, diabetes, and high blood pressure. Since she was having an irregular heart beat, she was admitted to the cardiac service who became the primary service.

Once again, UMC gets all of the difficult cases. We had two patients transferred in from other orthopedic surgeons after the patients had already had multiple surgical failures. At the beginning of the rotation, I saw the x-rays and CT scans of some of the patients and thought, "No Way." But, because of the expertise of the Attendings and the ample opportunities to operate, the really complex surgeries become commonplace.

Since I am a non-surgeon, I would try and take care of all of the problems that occurred on the floor and allow the surgeons to do surgery. Another one of my tasks was to collect all of the CT scans and x-rays done on the patients. This also helped me in knowing what kinds of x-rays to order in the future. I also got plenty of opportunities to put splints and casts on patients.

Once again, I was surrounded by awesome residents and nurses. It seems that the busier a service is, the more important that there is a "team" mentality. It was no different this month and the best personal example I had was on Christmas morning. I had only seen 2 or 3 of my patients when one of the nurses asked me to come to a patient's room. The patient was actually on another ortho service but, she had a drop in her mental status and was not oxygenating and I was the only MD on the floor at the time. Always go back to your basics and go through your ABCs. By the time we had her stabilized, ordered a STAT CT scan, and transfer papers done to transfer her to a monitored bed, I had spent about 45 minutes with her. I knew there was no way I was going to be able to see all of my patients before the morning conference. But, before I knew it, there were 3 other senior residents from other ortho services on 3 West helping me see my patients. All of the patients were seen before conference and I was really appreciative of the help they gave me since it allowed me to get out of the hospital sooner and spend as much of Christmas as possible with DGA, CC, and KT.

Well, I'm at the half-way point in my intern year. Six months down and only six months to go before I start my Emergency Medicine residency. I will spend January in the NeuroScience ICU (NSICU). I'll try and make some more up dates a bit more regular for the rest of the year.

Take Care, God Bless, and HAPPY NEW YEAR EVERYONE!

Well, I got my wish for wanting more "excitement." This month I'm in the SICU, which is the ICU for surgery patients. The same still holds true. Some really sick and injured patients come to UMC. About half of the patients in the SICU were transported to UMC by Air Care helicopter. I told DGA today that it's pretty bad that out of my five patients the one that is doing the best is the one the TREE FELL ON breaking all of his ribs on one side and collapsing his lung.

I'm glad that I had already done my MICU rotation. Since there are not as many residents working in the SICU, each resident has to take on more responsibility. Because of my MICU rotation, I felt like I was prepared for the tasks at hand. Once again, we had to track everything. The most time consuming part of this rotation is having to write down all of the information each morning. We usually averaged 3 to 5 patients each. Since I have a habit of wanting things to look "just right" (yes, I have been accused of being anal retentive before) I was getting to the unit between 5:30 and 6:00 each morning. The plus side of getting in early is that you also get to leave early if you are not on call.

Anyway, I got plenty of opportunities to continue to develop my skills. I got to put in 4 or 5 chest tubes, several arterial lines, and a chance to do some intubations

Once again, my first on call night was my worse. I had a patient that one of the other residents had been following who wasn't doing well. I spent all night adjusting IV medicines, fluid rates, changing ventilator settings, and following labs. I had also called the attending to give him updates and gather advice on what to do next throughout the night. Because of everything that had been done, I had to spend extra time doing her daily note so I would be prepared for morning rounds. However, when the family visited at 6:00 a.m., they finally accepted the futility of our efforts and accepted that we were only prolonging the inevitable. They made the most difficult and yet, the most humane decision a family has to make. They decided to withdraw all of the medicines we were using to artificially keep her blood pressure up. They decided to make her comfortable and let nature take its course.

Some of the patients admitted to the unit where there just for post-surgery observation. Some of them however, went out of the way to do something to get themselves admitted. For example, we had one guy, who I assume fell asleep, drove his 18-wheeler into a bridge and had multiple fractures and internal injuries. Speaking of internal injuries, we had two patients who were admitted at different times with a tear in their aorta (the big vessel that comes off of the heart) and their abdominal organs pushed up through their diaphragm and into their chest cavity. Once again, the skill and expertise of the doctors and staff at UMC proves to be life-saving. Both survived their initial injuries and were moved from the SICU to a room on the floor. Granted, neither one will ever be back to their pre-accident condition but, they didn't die from their injuries either.

Another aspect I enjoyed was working with the nurse practitioners (NP) in the SICU. I was able to learn a lot and appreciated all of the help they gave me during the rotation. The NPs are the stability factor. They are there in the unit and on the Trauma service every month. So, as new residents rotate in on the first of every month, the NPs can bring them up to speed on the problems and goals of all the patients already admitted to the unit. Also, they are trained to do a number of advanced invasive techniques like chest tubes, central lines, etc. They also help the residents out in other ways. For example, since I'm not a surgery resident, I do not get to work as closely with the surgery Attendings as some of the other residents. So, it was nice to be advised ahead of time that this particular Attending likes to use these antibiotics or this other Attending likes you to have already done this or checked that.

Once again, the nursing staff was tremendous. It was also such a contrast when compared to the autonomy of the nurses at the VA. While I was at the VA, the nurses couldn't do anything without an order. They may ask you to give the order but they wouldn't do anything without an order. In the different ICU units at UMC, you have a dedicated staff working day in and day out with the different Attendings and Residents. So, after working in this type of environment they know that if the patient does __________ then they are going to get an order to do __________. Because of this, they can easily predict what needs to be done and will go ahead and write a "verbal order" so they can do what needs to be done. Since you are constantly rounding on each patient in the unit, the next time they see you they tell you what was done and you just sign the orders. Initially, I was wondering about this. But, with 18 patients in the unit and you being the only resident in the unit at night, you would physically wear yourself out if you had to constantly run from one end of the unit to the other just to order a blood gas or to make a medication change or vent change. By the end of the month, I had learned to really appreciate the nursing staff and all that they do to care for the patients.

This was my month for Neurology, which got off to a really bad start. First of all, I had no communication with the department ahead of time giving me any kind of instructions on where to go or what to do on my first day of the rotation. Since we were so busy on the Cardiology service in September, I never called to find out what was going on. That was a big mistake. When I arrived on the Neurology floor on the first day of my rotation, I noticed several problems. 1) They did not have the current month posted with a schedule of who's on call. 2) When I found the correct on-call list, I'm not on the list. Initially I thought, "Cool! No call for the month." Then I noticed I wasn't assigned to anything. I go downstairs to talk to one of the other emergency medicine interns who had just gotten off the Neurology rotation. He tells me that everyone will be meeting at Methodist Rehab for morning rounds.

So, I make it to the meeting on time and I meet the Chief Resident who tells me that Im not on the schedule because I'm not suppose to be rotating with Neurology in October. I had already thought of this possibility and I had checked the master schedule I was given. On the master schedule, I was listed to do a Neurology rotation in October. When I mentioned this, I was told that I might have to do the rotation "next month." No, next month and every month after that, I'm already scheduled to do a rotation somewhere else. Then I was told that they would have to get with my program coordinator to see when I could make up the rotation since the schedule was already made up and everyone was already assigned and the call schedule for the month was basically finished. Needless to say, I was starting to feel a bit frustrated.

After Grand Rounds, I followed the Chief Resident back to the VA where she picked up her copy of the master schedule that was sent to her and she pointed and said, "See, we already have an intern from anesthesia rotating with us this month." I looked and said, "Oh, there's my name, right there." Not only was my name on the list, it was highlighted. I will say, from that point on, the Chief resident did go out of her way to accommodate me. I started at the VA taking care of neuro patients admitted to the hospital. Then, I went to the VA Neurology consult service. Then I went to the UMC Ward team that takes care of the neuro patients admitted to the hospital. I was hoping to be transferred to the UMC Consult service since I felt I would benefit from seeing and doing the initial neuro exam on patients as they initially presented to the service. Instead, I spent the rest of my rotation working with the team taking care of Neurology patients admitted to UMC.

Let me say this before I go any further. The Neurology service does a lot of really good things for patients with chronic disease. There are many patients whose quality of life has improved tremendously because of the advances in neuroscience. We had a patient come in who could barely walk and depended on a wheelchair to get around. By the end of the week, she was walking out into the hall with the help of a walker.

However, just as everyone doesn't like chocolate ice cream, it's only natural that there are some aspects of medicine that doesnt appeal to everyone. Neurology just didnt get me real excited. It's probably because of the lack of technical procedures. About the only procedure they do a lot of is a lumbar puncture. This lack of technical procedures became obvious one day when the nurses told me that they could not get an IV on a patient after two days of trying. I reverted back to my secret weapon and started another EJ (see cardiac arrest in September.) When I reported to the senior resident what I had done I was told I wasn't allowed to "start any lines." I was supposed to contact Surgery. I pointed out that I was not starting a central line but an IV. When she continued telling me I "couldn't do that" I got a bit frustrated and told her I was not going to consult surgery to start an IV for me.

Anyway, as usual I learned a lot while working on a focused rotation. Like I said before, it just wasn't my cup of tea.

Ah ha....Cardiology, one of my real interests points in medicine. I guess one of the reasons why I like trauma and cardiology so much is because of the way Paramedics are trained. When the first Paramedic course was put together, it was felt that Paramedics could save the most lives if they could stabilize trauma patients and treat cardiac arrest. Because of this philosophy, a large part of the Paramedic training curriculum deals with trauma and cardiology.

First of all, let me say its true. Mississippi is the center for out of control high blood pressure, heart disease, diabetes, smoking, and generally poor life style habits (Okay, how many of you reading this gets at least 30 minutes of aerobic exercise three times a week and follow a low-cholesterol, low-fat diet?) Needless to say, the cardiology service has been one of the busiest services I have worked on. Once again, I lucked out and was teamed up with some really great residents. (Josh may not feel the same way since this is the second rotation he's had me tugging on his coat trying to keep up) Billy, the Cardiology Fellow who headed up the team, was awesome and made a really busy service a pleasure to be on. Even though we were really busy, Billy always looked for opportunities to teach me the things I need to know when I start taking care of cardiac patients in the ER.

BTW, a "Fellow" can be a guy or girl. The term Fellow applies to someone who has already completed a residency program and is doing additional training in a certain specialty. For example, before someone becomes a heart doctor, lung doctor, kidney doctor, etc. they must first do an Internal Medicine residency that covers adult medicine problems.

Anyway, once again I was shown how the really sick patients get transferred to UMC. One of the cardiac markers we check to see if someone is having a heart attack is called Troponin which is usually less than 0.04 in someone who is NOT having a heart attack. Between 0.04 and 1.0 is a gray zone and you have to take other things into consideration. If the patients level is >1.0, it is likely that they are having a heart attack. Well, one of the patients transferred to us from another hospital had a Troponin of 783!! I felt pretty comfortable in telling the wife that he really did have a heart attack instead of waiting for the patient to come back from the heart cath lab.

I also got a chance to work with Dr. Bennett who someone referred to as a "Diagnostic Ninja" because he can arrive at a diagnosis before you can even think about ordering any kind of a test. I was reading the ECHO report (like an ultrasound of the heart) on one of my patients and mentioned that the ECHO had picked up and anterior wall aneurysm and he goes, "of course it did. It's pretty big. Didn't you feel it?" Then he takes my hand and places it on the patients chest and explains to me that what I'm feeling is part of the heart bulging out during contraction. On another patient, he takes a pen a places it on the patients chest and says, "See that split S2?" Well, no. A split S2 means two of the heart valves that are suppose to close at the same time are actually closing at different times. I have a really hard time hearing a split S2 much less seeing a split S2.

Once again, I got to work with a dedicated staff of nurses who focused on cardiac patients. They really helped me out a lot, especially my first night on call. Because of the way the month fell, I had to spend 11 nights at UMC while on my MICU rotation. So, I thought spending only 7 nights on call during my cardiology rotation would be a breeze......WRONG!!! Did I happen to mention how many cardiac patients are admitted to UMC? Also, the really bad sick cardiac patients are located in the new Critical Care Tower. The not as sick cardiac patients are on 2 West in the regular hospital. So, you are constantly running back and forth between the two buildings while on call.

On the morning of my first call night, I put my bags in my call room bed and pretty much didn't go back into my call room until the next AFTERNOON when I got my things to leave. It seems like everything went wrong, I had a heart transplant patient with a new onset of seizures, a patient being transferred in from an out of town hospital, and a patient decompensating who eventually went into cardiac arrest.

While I hate that a patient I was taking care of went into cardiac arrest (i.e., his heart stopped) I'm glad I had my Paramedic training. The way the hospital has it set up; there is a dedicated group to respond to a patient going into cardiac arrest anywhere in the hospital. They all have "code pagers" which go off and announce where they need to respond. Well, since my patient was already starting to have problems, I was already on the floor going through his chart at the nurses station. Suddenly, I heard a woman screaming, "He's dead! He's dead! She killed my baby!" Usually, this isn't a good sign. Especially when you hear it in a hospital around 1:00 in the morning. As I'm going toward the screaming woman, (who runs past me) the nurse comes out and says, "I just gave him a sip of water to help him take his medicine. I think he may have choked." So, we go in and roll the patient onto his side to clear his airway and while I'm holding him on his side I feel a very weak pulse. When we lose the pulse we roll him onto his back and called for the "Code Team." Now then, did I wait for the Code Team to arrive before we started doing something besides basic CPR? Of course not! The Code Cart (that is at every nurses station) was brought into the room. The Code Cart has everything needed to run a Code. BTW, running a "code" means doing everything possible to treat someone who has gone into cardiac arrest. Anyway, I was putting an ET tube down (a breathing tube to help get oxygen into the lungs and not the stomach) when the Code Team arrived. Then, the Chief Resident on the Code Team asked for a triple lumen set which is a really big IV that goes into a really big vein (remember what happened to me in the MICU?) For some reason, the medicine residents just love starting triple lumens during a code. I have wondered about this since it takes longer to do than a peripheral IV and since you can deliver more fluid faster with a large bore IV. Since I knew this situation might come up during my rotation, I had started carrying a 14 gauge IV cath in my lab coat pocket, just in case. So, while the resident was opening up his triple lumen kit, I was turning the patients head to the side to expose his external jugular vein (the big vein you see on the side of your neck.) I had the IV actually started before the nurses had the bag of IV fluid spiked with the tubing. The resident asked me if it was a good line and I briefly removed my finger from holding pressure to see the blood flow (and those of you who have done this know what kind of flow you get with a 14 gauge in an EJ.) Needless to say, he abandoned his attempt to start his triple lumen.

We worked the code aggressively and actually got a pulse back. We called transport to move him to the MICU. Unfortunately, before we could get him out of the room, he went into cardiac arrest again and we couldn't get a pulse back a second time.

While we did have a few patients die during this rotation, there were a large number of patients that did very well.

Without a doubt, this rotation has been AWESOME. Great Attendings, great Residents, and a great staff surrounded me. I learned a lot, which will hopefully payoff when I get into the ER. If there is anyway possible, I'm going to try and do another Cardiology rotation.