Rachmoninov

So, friends both new and old have begun calling, E-mailing and texting to find out if I am still alive! I am -- no fears. However, I am currently working in the Medical Intensive Care Unit, which is occupying more than a significant portion of my life.

I was originally going to talk about my experiences there over the past few weeks -- especially last night when I was on 24-hour call. I shocked my first cardiac arrest (and brought him back!), watched the 3rd year medicine resident perform a procedure that currently takes me about 20 minutes in about 30 seconds flat in a crash situation... and much more. Crazy, amazing 24 hours of my life.

However, sitting here in my living room listening to Rachmoninov's 2nd Piano Concerto on my formidable and kickass stereo system, I realized that I have talked about many things on this blog, but am yet to mention a final HUGE aspect of my life -- music.

I grew up in a home where we didn't leave the TV on -- we left the CDs playing. Continuously. Beethoven would be blasting on the first floor, Mahler on the second and some version of whatever was popular at the time on the third (my room). Every day when I came home from school I had to do my homework (like every kid), clean my room (never did that) and practice both Flute and Piano. At my peak in high school, I was playing the flute at least 6 hours a day between rehearsals and practicing. Without enough time to practice at home, I would practice at school during lunch and my other free periods. I was in literally every musical group in my high school (except for Jazz Band) -- and there were quite a few! I also spent a full 10 years from the age of 12 to 22 first in local youth orchestras and then in the non-music-major orchestra during college.

Music brought me to lifelong friends, took me all over Europe, brought me skill and accomplishment -- brought me solace.

Medical School threatened to kill all that.

During the first months of medical school I left music. I thought I needed to focus -- work harder than ever. After a few months of wondering why I hated my life so much I called my parents -- could we get my keyboard from Grandma's in Florida? Something in my voice must have told them I was in dire straights. Without hesitation or questionning I had the keyboard in my dorm room within a week. My mood improved immensely with playing. I had learned something valuable -- music wasn't something I did. It was my sanity.

I resumed flute lessons with my long-time teacher of now over a decade -- Mr. Jones. Maybe even more so than the playing, Mr. Jones became a rock for me during medical school and now during residency. Having no connections to the medical world, I could go to him every weekly and vent my frustrations (a lot of "look what medicine DID to me this week!") and he would be outraged, threated to lock me in my apartment when I needed to study more and generally kick my butt my drilling the music for a hour so I couldn't think of my frustrations.

Now I practice on my off days (which are rare), struggle to go to the Philharmonic as much as possible and usually listen to my iPod in the hospital in the morning while reviewing the computer for overnight events on my patients. It is not the satisfaction I used to get from playing an orchestra, but it is a compromise for now.

Enjoying NYC

Announcement: I have *officially* completed my first month of residency!! (only 46 more to go, as my Residency Director likes to point out...).

Over the past month I have done some cool stuff (I pushed tPA on a patient!! my med peeps will know what that means. It was very anticlimactic, but cool nevertheless). I have had lots of lectures and educational time as the program eases us into reality. I have made mistakes but fortunately haven't harmed anyone. One huge thing is that I have been talked to a LOT about how HARD intern year is and how important it is that I make the most of my free time.

Being that I am more than a bit of a homebody, this could present a problem. When I am busy and working hard, I am much more inclined to just drop dead at home when I have a day off. My seniors and attendings, however, are telling me that such behavior will lead to a never-ending spiral that ends in hating life. Or something along those lines.

So, I decided to start out strong and have been really enjoying myself during my free days (of which I have had 4.) and Rob has been a tremendous help in working towards this goal.

First off, there 4th of July, when I showed for a shift I wasn't supposed to be working. My salvage: a day on a beach in the Hamptons with Ted (Rob's old roommate) and his family and, ofcourse, Rob. I even took the midnight train back to NYC and had that song "Just a small town girl, livin' in the lonely world... took the midnight train going aaaany-where..." stuck in my head for the two hour ride back. The day was, in a word, fabulous.

Then there was last Sunday, when I hung out with friends on Saturday night at a wine tasting, slept until 11:30, went to fancy-schmantzy brunch at Sarabeth's with friends, discovered that Rob and I in a Barnes and Noble is a recipie for spending WAY too much money and then ended up down at Battery Park looking out at NY Harbor and reading for the afternoon.

This weekend I actually had BOTH days off (amazing!) and I've met new people, gone to brunch x2, took Sashi and Deka to the park, spent the day at Coney Island and am now in the process of cooking some genuine russian dumplings from Brighton Beach. Again, so great!

I think I need to keep this up. (Here's hoping I can!)

Back into puppyness...

It's been a while since I wrote about the antics of my parents' new puppy, Deka. She is now 5 months old and is just barely starting to show some signs of calming down... sometimes.

My mother recently convinced me to go with her to Deka's dog training class. The puppy decided to buck and whine every time another dog was getting attention that she wasn't. She sits like an angel (my mother had taught her that when she was 10 weeks old). The "no jumping" training was a complete and utter failure. The best, however, was the "come" training.

For this exercise, the trainer stands on one end of the room attempting to hold the dog (usually an easy job... until you separate Deka from my mother, and then you have a bucking, whining, crazed 60lbs of muscle) and the owner stands at the other. When the dog is released, the owner calls the dog and tries to get the dog to come to them. The other dogs looked like this...

Deka, however, looked like this...(That's Deka a few weeks ago at the doggy park.)

She went careening across the room at a FULL SPRINT, crashed into my mother at full tilt, bounced off, shook herself off, spun around a few times and promptly sat to receive her treats. Not only that, but she did it three times! The whole thing was hillarious, but I think the funniest part was the absolutley careening into my mother each time rather than stopping BEFORE knocking her owner over.

I'll leave you with a few more Deka at the doggy park shots.

Yeah, this last one is Deka sniffing the butt of a Great Dane. So funny.

What makes a Trauma Center?

Numerous recent conversations with friends of mine have brought me to seek an answer to the question, "What makes a trauma center?" I run into this all the time because Columbia is a Level II Trauma center while Cornell is a Level I Trauma center. What do these different designations mean?

The concept of the "trauma center" began in the 1960's in either Baltimore, MD (Ever heard of the hospital called the Shock Trauma Center? yeah.) or Chicago, IL (Cook County, the hospital that the TV Show ER is about). These are facilities who are equipped to handle any form of trauma care or complication 24 hours a day without delay in care.

What do the levels mean?

Level I: 24-hour in-house trauma surgeons and anesthesiologists as well as rapidly available (at Cornell, that means <10 onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://www.myds.com.au/img/game/Trauma-Center--Under-the-Knife-1.jpg">es. In addition, Level I's must be conducting active scientific research into trauma care, be involved in trauma education (ie- have a trauma fellowship) and be able to and willing to act as a referral center for neighboring regions. You might be thinking this is extremely expensive. It's even more expensive than you are imagining, I promise you.

Level II: must have 24-hour availability of all the required specialties, but they do NOT have to have training programs in all the specialties. In addition, they are not required to be conducting ongoing research into trauma care.

Level III: does not have 24-hour access to all the required specialties. However, they DO have the facilities required for emergency management, critical care and general surgery for simple trauma patients. These are generally smaller community hospitals without all the specialties that may be required, such as neurosurgery or hand surgery.

Level IV: Their job is to asses, stabilize, and transfer to a higher level center. So, Columbia is a huge hospital with residencies in everything under the sun, so why is it level II? There are a number of resons. First, no super passionate trauma surgeon. Second, the ER is literally in a DIFFERENT BUILDING from the rest of the hospital. Little bit of logistical stupidity. It is just too far from the ER to transfer an unstable, hemmorrhaging trauma patient to the operating room. (lots of famous trauma centers, like Shock Trauma, have a Trauma operating room literally adjacent to the Emergency Room. The patient is moved about 20 feet to get into the OR). Third, lack of trauma research. Fourth, lack of a full cohort of trauma-specialized staff.

That is all going to change. Dr. Maruzio Miglietta is a recent addition to the Columbia Presbyterian surgical staff. He is a trauma surgeon who has trained at every big name in Trauma that exists. The guy's resume is mind-blowing. He is dedicated to increasing the level to Trauma care at Columbia by first building staff and then getting the funds to remedy the physical and logistical issues that prevent Columbia from becoming Level I. His vision for Columbia will require increased staff, development of a Trauma fellowship, resesarch (which he is already conducting) and construction to change the layout of the ER to make it more trauma-friendly. The construction is already planned -- the Columbia ER is embarking on a renovation project that will renew the facilities from top to bottom.

I, for one, am very excited about this prospect. Columbia is in a high-trauma neighborhood of New York City and yet, we don't see many traumas due to our Level II status. A recent fire on the Columbia hospital campus sent three injured trauma patients to Harlem Hospital!! How embarassing. Hopefully, under Dr. Miglietta's direction, all that will change.

Tale of the missing patient...

Rob is encouraging me to collect "Tales from the ER"... and felt that this one deserved to be told.

Recently, I had a lost patient. Columbia's ER, while one of the largest in NYC (second or third) is really not that big when it comes down to it. Four rectangular patient areas connected in a line with short hallways in-between.

I sent the patient to ER x-ray expecting him to be back in about 15 minutes. His admitting doctors show up and, no patient! I direct them to x-ray. No patient. Radiology claimed they had sent him back. His wife was standing at my area's nurses' station without her husband.

Radiology didn't have him (the patient was stretcher-bound). In fact, his stretcher was still in x-ray with no patient on it. Multiple loops through every area of the ER did not reveal my missing patient. Overhead announcing his name and asking him to return yielded nothing. The surgery residents admitting him were extremely kind in trying to help my search, however they had no idea what the patient looked like! It is triply hard to find a patient in an ER if you don't know what they look like without walking patient to patient and taking names. As a result I was running around the ER with a team of surgeons trailing after me for an hour.

It should be pointed out here that (said in a snooty voice), "doctors don't run." However, we do walk damn fast.

The search expanded into the main hospital hallways around the ER. Maybe my stretcher-bound patient had wandered out... somehow. Security was notified and everyone was radioed the patients description (he looked like 90% of the patients at Columbia).

Finally, when me and my entourage made our fifth run through the ER, the patient is miraculously sitting in his assigned slot, in a wheelchair, looking definitely worse for the wear. Where had he been? CT on the 6th floor of the main hospital! Someone had taken the wrong patient from x-ray OUT of the ER and across the street and up to the 6th floor. Who takes an emergency room patient out of the emergency room!?!?! (point #2: the ER has it's own CT scanner INSIDE the ER. There is no need to patients to go to main CT in the hospital.)

The lesson for budding young doctors out there? Tell your patient the plan! I had told my patient, in detail: "You're going to x-ray. When you come back, you are going to drink contrast liquid. 2 hours after that, you are going to get at CT scan." If I hadn't, he wouldn't have put up such a fight in the main hospital CT (apparently, he caused a bit of a scene). The patient himself knew that he was lost and got himself returned to the ER. I just ran (read: walked briskly) around like a chicken without a head trailing a team of Transplant surgeons.

Intubation workshop

I knew there was a reason I wanted to come to this program. They held an intubation workshop for the interns (formal advanced airway training is during second year, but they want us to at least have a clue). We walked into the room and rather than intubation supplies, the first thing we saw were splinting supplies.

(To catch my non-medical colleagues up, to intubate someone is to put a tube down their throat so that you can hook them up to a breathing machine. It is a definitive airway for patients who can't breathe on their own. No breathing = no life, so, it's important. Splinting is applying a strip of plaster cast to stabilize a part of the body and then wrapping in an ACE bandage.)

What the hell does applying a cast have to do with intubating a patient?
The pictures below illustrate what happens if you move your wrist to rock the blade back and forth... you knock out your patient's front teeth. Yet that doesn't stop most young doctors because the more natural thing to do when you can't see is to rock your wrist. BAD. You're supposed to pull UP towards the far corner of the ceiling as in the second picture.













So, how did we look while trying to do this?

Yeah EM interns!... No opportunity for wrist movement this way. (I am totally the shortest person in my class by far... Joyce, Edozie, Debbie, me, Rishi).

The thing is, this is BRILLIANT! I have been to many intubation workshops before. During Anesthesia as a third year medical student, Emergency Medicine three times (one on each rotation) as a fourth year medical student, ACLS this year, and yet I NEVER GOT IT RIGHT. This time it was easy as pie. Two seconds and I had a perfect view (you have to view the vocal cords and watch the tube pass between them, otherwise you're just going to end up ventilating the patient's esophagus, which lies right behind the airway) and in another 2 seconds, I had an airway. 5 previous intubation classes and all anyone had to do was put a cast on my wrist. So impressive.