Sometimes that's the way it ends

I am officially done with my month on the MICU. Intense would be an understatement for how I'd describe the month. I was on call yesterday (Superbowl Sunday) and realize that I watched not a wink of the game (which I hear was great with a great [to Giants' fans] end!) due to it being a crazy, crazy call day.

Perhaps I should have known what a day it would turn out to be when stuff started to go south just before morning rounds. Mr. C, a patient I'd admitted about 12 days prior, with very aggressive lymphoma, neutropenia, and sepsis from his biliary system, started to have a lot of irregular rhythms on the monitor as well as worsening mental status and respirations after being extubated the previous day. His devoted wife, who could always be found by his bedside, talking softly to him and stroking his hand, made the tough decision that it was time to withdraw care in terms of pressors and oxygen.

I completely lost it when I passed by to see her, calm and not crying, still at the beside as he lay there breathing, now without the endotracheal tube that had been in there for almost two weeks. While I knew he was very sick, I didn't expect to have things turn this way on my watch, on my last day on the service. Crisis worker was called to help comfort his daugther who was understandably emotional in contrast to Mr. C's wife's collected serenity; however, she ended up sitting me down for several minutes trying to validate the way I felt. I just hurt for the family. And if I, who'd only known him for two weeks and whom he probably didn't even recognize, could feel such grief, how could they even go on? I think, despite being his "doctor" as part of the medical treatment team, I had started (shockingly) to forget how to think of him as a person (husband and father) and, yesterday, as he passed his last hours, I remembered good and well.

Mr. C died yesterday evening at 8:17 p.m. and I was called to pronounce him. All I can say is, I hope that I pass my last hours surrounded by people that love me as much as his family loved and supported him.

Just before Mr. C passed, I had also admitted a 50-year-old woman who was in her normal state of health until about 3 p.m., when she complained of a headache. She was found less than an hour later, unrespsonsive, and brought to the ED where she was discovered to have a massive intracranial hemorrhage for which really nothing could be done. She was already showing signs of brain herniation and, although I admitted her to our service with treatment to lower intracranial pressure and her family wanted her to be full code, we feared that she, too, would also likly not survive the night. As Jacob, my senior, was initially tied up with other sick patients on the floor, I had to be the initial bearer of devastating bad news to her sons and fiance who then had to summon the rest of the family to the hospital rapidly to see their loved on in what would likely be her last hours.

She went into v-tach around 2 a.m. and we successfully resuscitated her; however, when she began to tank again on pressors, the sons decided that it was time to disconnect the ventilator, stop the pressors, and let her pass peacefully. Twelve hours after she was talking, walking and interacting with her family, she was no longer with us.

That's the ICU for you. After pronouncing her, I had to go work on another admission, a 39-year old woman admitted to our service after having a cardiopulmonary arrest on the floor. I wonder if she has survived the day.

Seeing people this young, this sick, makes you really value health... and life.

The call day did finally come to an end. In some ways, it was a very fitting way to end my last day in the ICU, with a lot of closure in the passing of Mr. C, Mrs. Y, and another patient on a different team. I definitely got the full ICU experience. Jacob, the awesome senior and all-around guy that he is, actually let me off today after my *work* was done, i.e. after dictations and notes were done, but before rounds, so I didn't have to be there until noon on my first day of vacation. This was a real gift. However, I'm still thinking about my patients. Despite now taking a little "break" from medicine (Florida, Virginia, here I come!), they are still with me and will be for a long time. I think it's a good thing.

Coastal Cali (and more bad bowling)

Some picture updates.... (okay, so I broke down and posted a pic :))

Bowling on Friday (in pictured above, from left, are: me, Shomir, Arash, Amy, Sonia, Alvin, Darina, Din Hai)

Amy with the "clown" shoes-- they must have been lucky, because she kicked our butts (or maybe it's just her supreme skill). Yes, I still suck at bowling. I think I broke 100 one round, though, which was a major accomplishment.
Tu cracked us up with her strikes with the ball rolling 3-4 mph (does anyone realize HOW SLOW this is?!).

I tried to capture the "record" speeds.
Saturday was an expedition to Sonoma county and the coast!

Shomir and I headed out from Sac to the wineries in Sonoma county (there are HUNDREDS!!), stopping at B.R. Cohn's, Martinelli's, and then Martin Ray for some tastings. Now, it's a good thing he was driving and that there's someone who has an ounce of tolerance around here, because even the little tastings they gave us got me loopy by about 1 p.m.! We had some great local wines, though, including a yummy Muscat dessert wine, good Zinfandels, and also some tasty olive oil.



We had some really good pie at a local place in Sebastopol, Mom's.

We then headed out to Point Reyes National Seashore, which you may recall I saw from the air with Mike back in October (see below). However, the weather stank (rainy, stormy) and we could hardly see past the little curvy road that headed out there, despite some glimpses of the surf!

In fact, the weather was so bad that the famous lighthouse could not even be reached via stairs (here's proof)!

I made Shomir post some in front of the surf.
For a good-looking guy, he sure takes some funny pictures....

here...

trying again...
...and here (this one cracks me up! I quit trying after this picture) :)We also, while out there, had amazing oysters at Drake's Bay Oyster Farm, a little family-run shack-on-the-roadside where they shuck fresh oysters right there in front of you to eat! I'm actually not sure I've had oysters before, but they were awesome!




The day concluded with a visit to Shomir's sister and brother-in-law's place south of San Fran, where I got to meet his three adorable nieces, Anne, Lily, and Emma, and rest for a bit before coming back to Sac-town.

CALIFORNIA IS SO FUN TO EXPLORE!!! :)

(Perhaps not so interesting) updates

• I realize that it has been over a week since I posted. I can't keep up with Kristen, though (props for all of the recent postings!)
• I guess my life is not that interesting.
• As for social outings: Amy, Shomir, Katherine, and I went to see "Bodies Revealed" (plastinated bodies) last week; not as good as "Body Worlds" which I saw at the St. Paul Science museum last year, but still good.
• "Tainted Love," an 80s band, played at Harlow's on Friday, where Amy, Kate, Shomir, and I jammed away. I wish I'd crimped my hair (some people went all out!). I love 80s music.
• I recently read House of God, which I wouldn't recommend. I hope to read some better books over break.
• I want to go see 'Kite Runner' but friends (ahem, Amy and Shomir [I realize that this is sounding a bit redundant, but no, we are not joined at the hip but do hang out a lot!!]) who said they would go w/ me want to "read the book first" but haven't been doing so much reading. I gave them a deadline of Saturday; otherwise, I'm going to go by myself or something on vacation!
• I realize I'm slacking w/ the pictures, but I've started to get made fun of...
• MICU (which, truthfully, has actually turned out to be pretty great with great attendings and fun other residents) continues. Three weeks down, one week left.
• I successfully, on one poke, placed a central (internal jugular) line last week and did not drop a lung or puncture the carotid (this may not be a big deal for some people, ahem anesthesiologists like Hansie, but it [placing it; don't worry, I haven't injured any structures on anyone before either] was really nerve-wracking for me b/c I'm not confident at all).
• Sadly, I learned (when checking up) that another one of my patients who we transferred to the floor died 2 days later. I have yet to learn the details but this shook me again. One thing I will NOT miss about the ICU is the frequent deaths. I don't think I will be transferring any more people to the floor.
• Luckily no one died my last night (Saturday) on call in comparison to one of the early ones when two did and when I had to pronounce one.
• I got called about 150 times to Tower 7 on my last night of overnight call. I kid you not.
• I started hanging out on Tower 7 so they wouldn't page me every 5 minutes.
• I slept near-continuously for about 19 (yes, that is nineteen!) hours after call.
• I don't think I'm made for q4 overnight call.
• I was a white cloud, though-- only 2 total (instead of 10!) admits.
• Today was my day off which I luckily got FREE from clinic (had to have clinic one of my days off on week 1) or testing responsibilities (had to take the CREOG, or ob/gyn inservice exam last Friday on my day off)
• I got a haircut today! No pics, though. You'll have to wonder what it looks like. Maybe I won't post any until I figure out the Kits' May baby's name (you realize, however, that they could significantly expedite this).
• This is the first haircut since May, before graduation!
• There are no costcutters or Haircutteries in Sacramento! (I went to SuperCuts).
• My fridge went on the fritz again. This time the temp was 56 degrees.
• My landlord is as frustrated as I am and... drumroll...now I have a new fridge!
• I can officially feel okay about grocery shopping for less risk of things going bad; however, I still hate grocery shopping and do not enjoy cooking.
• Shomir introduced me to gummy vites today. OH MY GOSH. If I had only known about gummy vites (chewable, gummy-bear-like vitamins!) when I was a child, I would have been much more vitamin-replete! Those Flinstones vitamins my parents forced on us were nasty (remind me to tell you about my sister's love and history with Flinstones vitamins sometime...). Maybe I will never have to go shopping... I could survive on these things...
• I promptly went to Target and bought gummy vites, among other miscellaneous things.
• I realize that I'm on call on Superbowl Sunday :(. Not that I'm a *real* football fan, anyway (Phi gives us a hard time about this), but I do like to watch the 'big game.' :)
• I love days off.
• I am very inefficient on days off.
• The hours in my day off are passing too quickly.
• I should go for a run.
• This post is nearly as random as Ebby Ray's.
• In one week, I will be post-call, DONE with the MICU and PACKING to prepare to head to Destin and then to McLean!! (Yay, vacation!!!)
• I like vacation.
• That's all I got.
  

q4 call, q7 posts

Sorry for the mini-absence. It's been kind of busy! I do have to say, however, that MICU time does pass quickly with the q4 call schedule! Two weeks (well, and one day) and I am OFF for vacation!!

Last Monday, the first call night where I had to carry the pager, was about as busy as a call night could be with 10 (!!!!) ICU admits, a near-record. Although it was quite tricky to answer all the cross-cover calls on what ballooned to a 46-patient or something service, I (on the "team that has it easy") was blessed to have both another intern to split them with (no, Hans, I, unlike you, am not superhuman and could not physically do that all!) as well as a great senior who took one of them himself. Some firsts for the night: anoscopy to evaluate for a source of GI bleeding (this little bedside funnel-thingie.... I'd never used one until then!) and pronouncing death in a patient who I had never seen before... very difficult and moving. Similarly sad was learning, this past Friday (our next call, where I again took the pager but which was just BORING in comparison), that one of the patients I'd recently transferred to the floor died the next day in the hallway in his second (this hospitalization) cardiac arrest. I was really shaken. Despite feeling more comfortable with the ICU setting, this is one of the many reasons I don't particularly enjoy ICU medicine. I cannot handle deaths.

On a lighter note, are some pics from some recent fun outings.

Shomir and me at Second Saturday last weekend

Bowling (which I still suck at):

Anika and Din Hai

Shomir, Alvin, me and Din Hai

Crocker Art Museum in Sac, where we went on Thursday-- I was trying very hard to take an arsty picture of this mirror exhibit

Then, today, as I had it off, Amy and I took off for a mini day trip to Berkeley (East Bay- around 75 min. from here) and a movie in SF. Berkeley was cool! I'd never been there, but it is home to CAL and has a very hippie feel... Amy and I walked around a bunch, visiting some quirky shops and then going to eat at Cafe Gratitude, a restaurant that specializes in Raw food which, from what I understand, proposes that the best food for you is that which has not been cooked over a certain temperature... The menu was interesting (all items had names like "I am triumphant" or "I am peaceful"-- very "granola,") but the food-- the sushi bowl I had and the enchilada Amy had (which I definitely tried)-- was great! I also tried some almond milk with my organic tea and we did break down and split some raw carrot cake, which was yummy and quite healthy, too!

The Spirit of Berkeley

"I am grateful"

I am grateful for dessert

Amy and I then headed just a bit further west to hit San Francisco to see The Business of Being Born, a documentary (only playing in select cities) recommended to me by my advisor, which discussed many aspects of the birth process and which really raised great points about doing it the "natural" way with midwives and home-births. Although that may put me out of a job, I really took many points home and think I'm going to try to seek out some exposure to labor in these settings, as I think we truly are too aggressive and interventionalistic in our hospital setting and in medicalizing something which is truly, most times, very uncomplicated.

In any case, we are back in Sac now (I still can't get over how close SF is!) but, as there is no MLK day off for me, I should head to bed. Good night! Until next time...

Why I am alive

I will be with thee: I will not fail thee, or forsake thee. - Joshua 1:5

I thought I was a big believer before. After this week, it is more evident that ever that God's presence abounds in my life.

These things I have spoken unto you, that in me ye might have peace. In the world ye shall have tribulation: but be of good cheer; I have overcome the world. - John 16:33.

Just in case it wasn't BLATANTLY evident from that last post, I was utterly terrified of this MICU business. Thank you all for your words of support- I think I kind of freaked a few people out. I was, truly, kind of in the dumps and depressed about this rotation. However, it has actually been tolerable.

The Lord shall be thy confidence, and shall keep thy foot from being taken. - Proverbs 3:26.

It is obvious that the Lord only gives you as much as you can handle. Some people might whine that I am having the "easiest" time ever on this rotation. First of all, I didn't have to take overnight call until the 4th day of the rotation (Thursday), whereas one lucky intern got to be on call the first night on, when the MICU is overwhelming enough.

Second of all, there are two interns on my team, meaning that we share the patients and so each have fewer than each of the other teams; in addition, we get to alternate having the cross-cover pager when on q4 call (Mika took it on Thursday-- I have it tomorrow).

Thirdly, we are somewhat of a white cloud and only admitted two patients our night on call (I don't believe there's a cap and the team on today already had 4 pts by 1 p.m.!), both of whom we wrapped up and transferred to the floor within 1-2 days post-admit. We may be having some "redistribution" going on tomorrow but, in any case, it has been a blessing to have it kind of slow to be able to "ease" in and get more familiar w/ the whole system, esp. data-gathering, which really is the hardest part (Other than OB, I haven't done an inpatient medicine rotation at UCDavis and didn't know where everything is reported or really how to get things done in the hospital).

Fourthly, we have an AWESOME attending this week and next, and another great one coming on after him. This can really make things go smoothly. Rounds are efficient, but also infused with teaching pearls which really enhances our experience.

Fifthly (is that a word??), q4 off is wonderful.

God is our refuge and strength, a very present help in times of trouble. - Ps. 46:1

Anyway, believe me, I needed to have it a bit easier than the others, for sanity's sake. I really think that God designed it this way because he knew how fearful and anxious I was and only gave me as much as I could take without sending me into a nervous breakdown. I have no problem admitting that I feel like the wimpiest, weakest intern on :) Today I started to feel a bit better and think I might be starting to get the hang of things. After rounds, I brought myself up to speed on the hospital course of one "rock" patient who may get transferred to a different floor if a bed opens up (I will be the lucky author of the transfer summary). Ventilators and arterial blood gases are also much less of a mystery to me and I might be better at doing math (i.e. anion gap calculations) on the fly, in my head, which is a blessing in itself.

When thou passest through the waters, I will be with thee; and through the rivers, they shall not overflow thee: when thou walkest through the fire, though shall not be burned; neither shall the flame kindle upon thee. Fear not: for I am with thee. - Isaiah 43:2,5.

So, in a nutshell, things are looking up (but, although things are better, I still ask that you pray for me on Monday the 14th when I will have the cross-cover MICU pager trying not to let down the 30 or something patients on the various teams!). God also let the sun come out yesterday and today, which does wonders for the mood (can you imagine if I lived in Portland?!!).

I also wanted to wish VERY HAPPY BIRTHDAYS to some very important people in my life as it's unlikely I'll post again until the end of this call-starting and -ending week.


First of all, MOM (without whom I definitely would not be alive!) :) - Jan 14th

Also on the 14th is AMY (far left; I don't have an excuse to ever forget her birthday now!)
On the 16th are the birthdays of my "other Mom" Inara...

...and my dear friend and California neighbor ERIN (here at her Bachelorette party last March!)And last, but certainly not least, is the birthday of my awesome mountain-climbing friend, Mindy (Friday the 18th).

Happy birthday to these wonderful women! I will be thinking of you and wishing I could celebrate with you rather than hanging out amidst the beeping ventilators on Tower 6 at UCD. Blessings and love to you all!

Slightly losing it

So to follow up my flat car tire Friday, I somehow punctured the front tire of my bike around 5:40 a.m. on the way to start the MICU rotation Monday. The metal prong-thing I found when I reached the bike cage behind the ER didn't get wedged in there was close to the hospital, so I made it there before the tire became fully flat, but I was not very pleased. A harbinger of the excitement to come this week/(month)?

Our team was post-call yesterday so I really had minimal duties at the MICU-- the leaving team took care of the couple of transfer summaries and presentations of new patients; however, I just walked around with this really ill feeling in my stomach. The ICU is very foreign to me, and while some people thrive in that environment (I remember Lesley telling me one time "I LOVE the ICU! You don't have to talk to those patients, you just do your exam and get out to write about the plan, which doesn't change much..."), it just makes me feel ill. I like taking care of mostly well, young, healthy people that can walk into my office (or pop out a baby). Anyway, I walked around all day feeling as though I was going to puke or burst into tears and I sort of feel the same way today (my "day off" even though I have clinic this afternoon), as I have to go back tomorrow. Ugh. Even the fact that it is technically q4 "off" doesn't make me feel better, as the terror of the "on" (q4 call) part wins. I am "ON" call on Thursday. I think I need to start both an antacid and an anti-anxiety medication. I hope this improves over the course of the month.

Anyway, I pretty much just slept all Monday night and then this morning. And I know that I'm really losing it because I thought I had clinic at 1:00. In fact, I don't. It's at 1:30. I really am usually on top of stuff like this. And I don't know what kind of a clock I was using at home, because I left my house in time to make it here.... by 12. Yes, a whole hour early. So much for that (half) day off which really should be a FULL day off (not coinciding with the clinic half- day), but the resident didn't have much sympathy for me when I brought this up.

As much as I tried, I could not get my bike tire back ON my bike, once the tube was replaced, when I tried last night. Anyone wanna lend a hand? :)
It is also raining a heck of a lot.

I wish things would change around here :).

I think I will go to grand rounds and try to learn a little something. I'm here, after all.

The good and bad of 2008 (so far)!

2008 started out wonderfully! I was lucky enough to get New Year's Day off b/c we worked out a "holiday-type" schedule w/ the other admitting medicine team at Mather, and so when work finally ended Monday night, I was freeeeeeeeee until Wednesday.

Shomir's friend Rachel has a house up in Tahoe so we, spontaneously, just went. It took us about an hour and a half to find the place... and rolled in around 11:56 p.m., just in time to get a glass of champagne handed to us to bring in the New Year! It was weird seeing snow up there, just less than 2 hours from (warm) Sacramento, but it was pretty! We joined Arash, his wife, and a friend and checked out a couple of the casinos in town-- no gambling for me, though.

Wednesday afternoon, we tried to go out to Sierra for some skiing, but, due to heavy traffic leaving the Tahoe area, ended up at Heavenly, another resort in town. Now, some of the day had me wondering why it is legal, much less a good idea, to let extremely klutzy/uncoordinated people like me get on two little planks and try to make it down mountains (I will stick to the greens only next time, I think)-- I was kind of paralyzed in fear as I got stuck falling multiple times on a Blue, but I suppose it was good to try. I've been skiing 2 times before, the last time about 4 years ago. I hope to make it up there more times this season to get better and some more confidence with it! I can see how skiing, if you're good, is awesome; the terror, however, is still too much for me.

This would be my level of skiing :)

But even when I was on my butt (Shomir was so patient with me!!), it was lovely because of the awesome views of Lake Tahoe from the hills.. They really took my breath away. What a gorgeous area! Here are some pics from the ski lift.

Well, it was back at work on Wednesday, with clinic in the afternoon. I had my first continuity patient come in for a 1-week OB check and, as she was uncomfortable and was worried about her baby's movement, I sent her over to triage to be checked out with a nonstress test. The admitting resident called me around 7:30 p.m. and said that she appeared to be ruptured and was contracting every 5 minutes! Wow! At the time I got the news, I was at an FP/OB applicant dinner, however, I could not concentrate worth a cent and had to take off for the hospital.

The patient wanted to VBAC (have a vag delivery after a prior C-section, which was in Mexico with an unknown incision), so it was a bit higher risk, but it was cool! I got to AROM her forebag, place an IUPC, and really manage the entire labor! I didn't start her on pitocin for augmentation until she stalled out a bit around 2 a.m. (I really wanted to be there for the delivery so had to be a bit more aggressive than ordinary), but everything went beautifully! I got about 2 hour-long naps in during the night, but I was just so nervous! She started pushing around 4:40 or so a.m., and by 5:11, we had ourselves a gorgeous little baby boy and an easy delivery without lacerations or anything!

Although I was exhausted and had to go straight back to work at the VA for my next day shift, it was really worth it to be there. That continuity is what I love about family medicine-- and the OB part is just plain fun. It was actually strange being back on L and D, as it's been a couple of months, as well as in this different "role" (I've been doing a whole lot of prostate exams on wheezy men this last month!), but it was great to see the nurses and residents again while I was hanging out all night:)

So the bad?

Work this week has been really rough. It's been a lot busier than last week, and the turnaround is getting me exhausted. We are admitting every day and so every morning we come in, there are overnight admits we pick up after having "capped" with other admits the previous day. Our attending is very good, but very aggressive with getting things done and people moving, so our hospital stays tend to be quite brief. I am churning out discharge summaries like there's no tomorrow. Honestly. And then, since we are constantly diuresing our census and have, on average, fewer people than the other team, the overnight admits and more of the transfers tend to come to us, which makes for hectic and quite stressful mornings.

Although I really do like internal medicine and am liking finally feeling comfortable and everything at the VA, all that, combined with extreme sleep deprivation, made me really crabby yesterday. That, and a really difficult patient with some sort of personality disorder that I had to discharge. And constantly being a little short-staffed due to clinic/days off/people showing up late/being sick/etc.

Today, we are having what appears to be a hurricane-equivalent in Sacramento (the mountains are probably getting TONS of snow!). The power went out at the VA, which was running on its emergency generator. I was supposed to give a case presentation over the noon hour today, on which I kind of slaved away last night despite being near comatose with fatigue, but it was so busy today that we didn't get to have lunch/noon conference. The only good? Today was my "half" day which meant that I could get out early, after my work was done (except that we had MORE discharges!! So exhausting!) I went over to the hospital to see my patient, but she had already been discharged!

I was going to go to the gym but it was closed secondary to the storm. Hmmph.

And then my "tire" light came on in my car. When I checked, my left rear tire was hissing and definitely going flat, and I found a piece of wood with a nail in the back groove of my tire space. Excellent way to end the (for normal people-- it's Friday!!!) week. Luckily, 2 blocks from the gas station where I initially stopped to rescue-inflate the tire, was a tire place where they helped me plug it up (I would be near-useless in tire-changing-situations). Also very luckily this was after I'd made it home on my half day and actually had time to take care of this.

I also have that sore throat and fatigue prodrome of a cold coming on. Grr.

At least I only have TWO MORE days of VA medicine to make it through.
Then a month to make it through MICU alive.

Oofda.