July 1, and another new year. What's YOUR story?

[Ian Wong]

Hey all,

 

It's been a while since I've last posted. As of today, I'm now a PGY-4 radiology resident, with 2 years to go before finishing residency, and finally hitting that position of being an attending. I was on call this weekend for both Saturday, June 30, and Sunday, July 1st, and therefore was in the hospital from 8 am to 6 pm for both days.

 

As expected, the hospital was in a significant amount of chaos, as an entire cohort of residents graduated and left the premises, to be replaced by a new set of recently promoted residents. Many of my phone calls and questions today came from PGY-1 residents who hadn't managed to receive their logins to PACS (because of the weekend), and therefore couldn't access images or read my reports.

 

As I worked today, I fielded 5 phone calls from the same hapless PGY-1 resident, who told me: "this has been one of my worst days in medicine thus far."

 

She moved to this city earlier in June, didn't know a soul in the city, and now was expected to act as the first-line of defense for all of the new patients she'd just inherited earlier that day, in a totally unfamiliar hospital. This particular hospital is also a quaternary care hospital, specializing in transplant and oncology, and as a result, you can imagine that the inpatients, as a general rule, are extremely sick and very unstable.

 

Many of these patients are neutropenic, most are immunocompromised, and all have poor vascular access and are on kajillions of medications. All transplant patients are either end-stage awaiting transplant and therefore are sick as hell, or are post-op recovering from recent transplant now with new immunosuppressants on board, and therefore are sick as hell. Most cancer patients are inpatients post-op recovering from resection and therefore are sick as hell, or otherwise were admitted due to complications related to their neoplasm or chemotherapy, and therefore are sick as hell.

 

It got me thinking back to my first day of PGY-1 residency during my clinical year, or my first day as a Med 3 on the floors, where I started out on an Orthopedic Surgery rotation, and was paged that night by a nurse regarding a post-op patient who had a blood pressure of about 70/40, which was secondary to an active GI bleed... I had just figured out how to write the SOAP notes for rounding, still didn't know where the charts were kept, and here I was getting called for what was (both then, and still now), a very terrifying situation.

 

Anyway, this weekend was full of interesting cases, and it made me appreciate how far medical education can take you.

 

I overread a case that had been preliminarily interpreted by a fellow resident the night before. It was a patient with known metastatic uterine cancer, who had fallen 2 weeks ago, and presented to the ER with severe L hip pain. Plain films were normal, and a CT pelvis was ordered, to look for a possible subtle non-displaced fracture, or perhaps a bone metastasis. It was interpreted as "no fractures, normal bones", which was correct. However, at the corner of the study, there was a small amount of extraluminal gas around the sigmoid colon. We called the ER back, and had them rescan the patient, this time getting both a CT abdomen, and a CT pelvis, and were able to find the perforated colonic diverticulitis that was causing her left pelvic pain. The ER had actually sent the patient home after the first CT scan.

 

Earlier that day, I did a U/S guided thoracentesis on a patient with metastatic breast cancer, and recurrent malignant pleural effusions that gave her severe shortness of breath. A thoracentesis, sticking a big needle into the chest cavity of someone you've met just a few minutes before is one of the "basic" procedures that we do. On some big patients, it's not uncommon to have 5-10 cm of needle sticking perpendicularly into their chest before you start getting fluid back. I was frightened out of my mind the first time I did one on a patient. Now it's just a routine bread and butter case. After draining off about 1.3 litres of fluid out of her R chest, her respiratory status improved markedly, and she thanked me for being "the nicest Dr. she's had thus far..."

 

Later that day, I had the unfortunate task of reading a CT scan on a patient who'd had a thoracotomy and lobectomy for lung cancer 3 months earlier, for increased shortness of breath. It turns out that on this scan, he'd developed metastases to his pericardium, adrenal gland, spine, and pelvis, and the shortness of breath was likely due to the rather large malignant pericardial effusion that he'd developed. While I didn't have to break the news to this patient, ultimately I was responsible for the horrible information that made yesterday the worst day in that patient's life. He had just undergone a huge surgery with curative intent, only to discover yesterday that the cancer had metastasized widely throughout his body. It's now incurable, and he probably has months to live, at this point.

 

Over this weekend, I read a huge number of studies, including plain films of the chest, abdomen, pelvis, and every extremity part that you can imagine. I looked at numerous head CT's to exclude strokes, head bleeds, and tumours. I read a leg CT to exclude subcutaneous abscesses in a patient with florid cellulitis of the entire foot, calf, and thigh. I actually went over to the x-ray section to show the techs how I wanted them to image a patient's shoulder (she had marked scoliosis and severe skeletal deformities due to some sort of crazy congenital disorder). We were able to conclude after the new images that her shoulder was dislocated (this was uncertain on clinical exam by the ER). I excluded DVT's on ultrasound Doppler studies and confirmed perfusion in numerous transplanted kidneys and pancreas's (pancrei?). I read a ridiculous number of CT's of the chest, abdomen, and pelvis.

 

One of the morning chest x-rays that came through was on a neonate immediately post-intubation. The ET tube was in the esophagus. The fact that it happened on July 1 is no surprise. That got an immediate phone call to the floor.

 

Another chest x-ray was on a patient who'd swallowed a toothbrush (no freaking joke). You could see the bristles overlying the upper esophagus near the aortic arch. GI was able to remove it endoscopically, and confirmed that it was a regular size toothbrush. The patient was not psychiatrically all there (he was nuts). I guess if certain people can swallow swords as part of an act, getting a toothbrush to go length-wise down your esophagus is entirely possible.

 

In the 20 hours I was in house this weekend, I probably fielded in the neighborhood of about 125+ pages or phone calls from other residents, fellows, attendings, or radiology techs, all of whom needed one thing or another from me or my department.

 

I'm not going to lie. This weekend sucked, and I hate being on call. But looking back on it, it's amazing how far I've come, and how amazing it is to have to walk a PGY-1 resident through reading a chest x-ray to evaluate the position of a PICC line. Especially knowing that that was you, just a few years earlier...

 

Lest you think everything I did was great, my attending had to put in an addendum for a CT abdomen/pelvis dictation I'd done where I called a metal tubular structure in the liver a metallic biliary stent. It was, in fact, a TIPS shunt. Oops. Highly embarrassing. I clearly have a ways to go yet, but looking back and taking stock of things, it's really exciting to know that you are gradually gaining the competency you need to have once you exit residency.

 

For all of you guys starting, or within your clinical years of either med school or residency, I'd love to hear any July 1 stories you might have.

 

Ian

[Isosceles]

Thanks for that post, Ian

I don't really count yet but...

 

I been following your story for half a decade, and less than a month from now my own will finally begin.

July sees me struggling through the arduous final weeks of (non-medical)academia, so that on Aug.1 I can embark upon my own story in medicine.

 

Thanks Ian, I mean overall. What you've done for thousands of the doctors of the future (and today!) is absolutely mind-blowing.

Thank you for what you've done for just this one.

 

I

[leviathan]

I love the cath lab... it's pure adrenaline, and as fellows, we scrub in for every acute case. I've done about 230 diagnostic angiograms, and I'm starting to do angioplasty now... with lots of supervision, of course!

Cool...we had a guy come into the ER on Monday who was having a massive MI and he DROVE himself to the hospital, and came up to us in the waiting room. He was a classic presentation, too (crushing substernal chest pains, radiation to L arm, diaphoretic, Levine's sign, etc). Anyhow, they started fibrinolytics right in the trauma room before they sent him up to the cath lab. I didn't realize they could do BOTH, because I thought the former would be a contraindication for any invasive procedures?

[The Bunny]

My father had an MI on the golf course and finished all 18 holes before we could get him to leave

[Isosceles]

"Ha ha... It's common for patients to have MIs and finish harvesting their crops before driving themselves into the hospital!"

 

lol! totally what I was thinking - old farmer mentality

[leviathan]

"Ha ha... It's common for patients to have MIs and finish harvesting their crops before driving themselves into the hospital!"

 

lol! totally what I was thinking - old farmer mentality

 

I hear it's common in the more rural areas....but NOT in the city! When we have people calling an ambulance for sore back x 6 months, you are usually shocked to see someone stumble in to your ER after driving themselves with a deadly ACS. I was, anyhow!

[leviathan]

Ha ha... we see both ends of the spectrum. I have seen "week and dizzy for 2 years" decide that they absolutely HAVE to be seen in the ER at 2am on a Sunday... no particular reason. I've also seen people with 5 minutes of chest pain and no evidence of MI coming into the ER with a handful of stuff they have printed from the internet... trying to demand a particular kind of stent when they go for their angioplasty... even though their pain is obviously non-cardiac.

 

Around harvest-time, we always see the farmers, though... 2 days of crushing chest pain, but didn't get off the combine until the last of the crop was in. The worst thing I saw was as a med student on the ER rotation (in Alberta). A farmer sustained 2nd and 3rd degree burns to much of his arm in a combine accident. He wrapped a towel around the arm, and didn't present to emerg until the harvest was done, about 3 days later. We had to sedate him to peel the towel off... and much of his skin came with it. There were residual towel-bits intermingled with the primordial soup that was his arm. The sight and smell made me gag. We started broad-spectrum antibiotics and consulted plastics right away.

 

Eww....what is WITH farmers? They are so stoic! I heard a case from an EP in NJ of a farmer who fell off his tractor and landed on his head. Didn't come in for 2 days to get that splitting headache checked out, which was naturally a slowly developing subdural hematoma.