Running in the rain

Another afternoon thunderstorm rained on the city today. Traffic crawled down the expressway on my way home, but fortunately I knew a little shortcut that bypassed a good 3/4 mile of traffic! And even though I'm post-call, I wasn't that tired, so I decided a quick afternoon run would be just the thing. Although it was nice not being drenched in sweat, being drenched in rain still leaves me drenched...

I had quite a few cross-cover calls during the night. One of the first one caught me in the dead of sleep, around 1:00 in the morning. "Doctor," the intense nurse began, speaking quickly, "the patient's Calcium Gluconate was written for 50 mg/hour, and the dilution leaves it at 1 mg/cc, but the fluid has been running in all day at 4.5 cc/hour, so should I run it as ordered at 45 cc/hour, or continue as it's been at 4.5 mg, could you please clarify?!?" I felt like I'd been awakened by a story problem: If a train leaves Chicago heading due east at 80 km/hour and 2 hours later another train leaves Pittsburg heading due west...

An hour later, another page came. This time, the ICU was calling. The nurse taking care of my intubated patient began explaining that his O2 saturation had been dropping and they were having trouble keeping it up. I was a little confused what his question was, until I asked, "Would it be helpful if I came down?" and he answered, "Yes!! Please do!" Even though this took nearly 45 minutes in the middle of the night, it was one of my first opportunities to work through a good differential diagnosis for shortness of breath in the acute setting. I ended up diuresing the patient for a volume overload state, but the lower extremity dopplers in the morning showed bilateral DVT's (deep venous thromboses), even though the patient is on prophylactic blood thinners. Even with my lack of experience and still young sense of intuition, it was satisfying to be able to take care of a patient simply by virtue of being there.

A little Beethoven...

Today was a much needed day off! (My last one was Thursday, July 21.) I enjoyed the luxury of sleeping in until 8:30 and even toyed with taking a morning nap. I'm still plowing through the Hawking book, but it's a little denser than I'd anticipated. Space-time, quarks, and anti-matter fill the pages. It's a little surprising, however, to read about the revolutionary ideas of Maxwell, Dalton, and Bohr in the 19th and 20th Centuries, and to recognize these names from various facts I'd learned for freshman Chemistry in college, eight years ago. This book sets the "Pauli Exclusion Principle" and the "Heisenberg Uncertainty Principle" in the context of the developing understanding of the world around us. Some things we now take for granted (like an atom's being composed of electrons orbiting around a nucleus made up of protons and neutrons) weren't always known. These discoveries were made little by little as speculative theories, experiment, and observation led to accepted fact.

This afternoon David, Dawn, Erin, and I got together at Erin's for round two of "Us verses Beethoven Razumovsky Quartet No. 1." We did a little better this time around! And I hate to admit it, but I'm enjoying the "middle part" nuances that I can create with the viola. While we rehearsed, a wonderful Texas summer thunderstorm rolled through which added greatly to the ambiance!

Another call day tomorrow. We'll see what it brings!

A "capped" call day

Another day admitting patients...since there are two interns on my team, there's a limit of 10 patients (five per intern) that can be admitted per call cycle. We reached that limit, or cap, at approximately 11:00 PM. My last patient is gone to ultrasound, so I'm killing a little time before she comes back so I can interview her. The attending physician has already seen her, so I've discussed the case with him and pretty much have her admit orders together.

Seems like a good mix of cases today. I've picked up:

1. Rule-out myocardial infarcation in an elderly Hispanic man.
2. Heat stroke verses infection in a white female (temp of 109.0), progressing to sepsis, shock, and disseminated intravascular coagulation
3. Acute arterial insufficiency in a middle-aged white female
4. Unilateral leg edema in a middle-aged white male
5. Acute on chronic lower back pain in a middle aged white female with fibromyalgia. Also with acute renal failure, elevated white blood cells, and elevated liver function tests.

It's now 1:30 AM and I've finally finished admitting and getting the patients "tucked in." If I'm fortunate I'll get four or five hours of sleep, and I hope to get few cross-cover calls during the night!!!

My reading list

As mentioned before, one of my little goals is to read a bit more. The last book I read for fun was back in June. Named The Curious Incident of the Dog in the Night by author Mark Haddon, this book provides an interesting glimpse into the mind of an autistic child. (More info here.) Having worked with autistic children himself, the author's insights and compassion are evident. Quirky illustrations and diagrams liberally sprinkle the pages, and prime--rather than sequential integral--numbers head each chapter. Amazon.com reviewers give strong marks to this book, and I too would recommend the book.

I picked up Stephen Hawking's ever-so-famous A Brief History of Time the other day. For those with the slightest bit of interest in reconciling the general theory of relativity with quantum mechanics, I'd recommend this book. And if you find anything with the word "quantum" daunting, I'd encourage you not to be intimidated by this book, because Hawking writes with laypeople in mind. Some say the true mark of genius is being able to explain complexities in a simple and straightforward manner. While I think that's silly, I still appreciate the author's ability to do just that. If you took physics in high school, that should be enough background.

Trivia time

After one month of residency, I've taken a little time to reassess. Today I sat down and made a list of things I'd like to do differently while in residency; e.g., do more anesthesia reading, exercise in the mornings more regularly, read daily about at least one of my patients, etc. That was one column. In the right-hand column, I listed how I might go about accomplishing each goal. And I think it all comes down to going to bed earlier! This will give me time in the mornings, as well as help me resist the temptation for a time-wasting afternoon nap.

A rather unpleasant experience awaited me in the ICU this morning. From across the nurse station, I heard an ICU attending make a demeaning comment about my TPN (Total Parenteral Nutrition) orders to another resident, not realizing I was at the nurse station. I walked over to him, and I think he felt embarrassed when he saw my name, but still was condescending and sarcastic when he questioned the electrolyte concentrations I'd ordered. Even though it was one of those situations where I felt he was acting inappropriately, I was pleased that I was able to respond calmly and professionally, and explain my rationale for ordering the TPN as I did. It turned out that my TPN orders would have made a lot of sense had not another MD changed some other orders after I'd rounded--orders I'd had no idea were changed. Anyway, I'm certain it won't be the last time that a superior is perhaps out of line, but at least it was good practice in keeping my cool in that type of situation.

I felt I redeemed myself in the ICU this afternoon when I successfully and essentially independently placed a subclavian central line with the supervision of my resident and a different ICU attending!

Here's the trivia question for the day: What was the largest thing killed by the first bomb the Allies dropped on Berlin in World War II? 10 points for the first correct response...