Thank you to the great attending and residents who trusted me, supervised me, and allowed me to do so much today!

• Intubated a sedated (but not paralyzed) septic patient having a STEMI (my 2nd intubation ever)
• Got an ABG on the first try
• Lac repair of a partially avulsed finger skin flap
• Lead a basic trauma resuscitation
• Put in a foley on a comatose patient
• Stapled a scalp lac

Done most of these before, but it was in such rapid succession–one procedure after another–that I totally felt in the zone. It was great!

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Sewed up several intraoral lacerations lately, one attending never mentioned antibiotics, the other was pimping me on which to give. Looks like there may be some benefit in compliant patients for reducing likelihood of abscess formation .

(Actively bleeding through and through lacs (ie: they go thru the skin and all the way thru the lip and gums into the mouth) are a pain in the ass to close and close well, especially when they don’t respond to lidocaine with epi! That being said, I think I did some pretty good vermillion border work, even with the crappy throwaway instruments and blood everywhere.)

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Resident: “My patient snorted 3 grams of cocaine today. That seems like a lot. Is that a lot?”
Attending: “I don’t know, it seems like a lot.”
Me: “Isn’t an 8-ball like an eighth of a gram or something? So that’s like 24 8 balls?”
Other Resident: “How much did Al Pacino snort before he killed that guy in Scarface?”
Clerk: “Oh, it was a lot, cause it was in a big pile, then he cut it into three lines.”
Resident: “You sure know a lot about Scarface.”
Clerk: “It was just on TV 2 days ago!”
Attending: “I guess it just depends on how wide your lines are.”
Me: “And how long they are.”
Resident: “So… 3 grams, is that a lot?”
Everyone: “No idea.”

An 8-ball is one eight of an ounce of cocaine, approximately 3.5 grams. This is a lot of cocaine for one person, enough to overdose on. So be careful.

So there you go. And much less than that is enough to give you a stroke or a heart attack, because cocaine causes spasm of your arteries and cuts off blood supply, so not only be careful, don’t use it.

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Dearest Mayor Newsom , could you please remove the crazy pills from the water?

The ED was like I’ve never seen it last night, just busy to the brim. And on the drive home, 7, yes, SEVEN people ran across the street in front of my car. They were just *asking* to get a PVA.

And to my patient who the deputies dropped charges on and you pulled out your IV and left, after I did all this work-up AND made the diagnosis of hyperthyroidism based on history alone, with a very low TSH and a very high free T4, you really should have stayed to at least get your diagnosis. I was proud of making it, and you’d probably feel better sooner rather than later if you had gotten hooked up with an outpatient provider. Sorry dear.

Random ED terminology I’ve made up (feel free to add your own):

Laction: The act of suturing/stapling/closing a laceration. “Man, I’ve had a lot of laction today.”
Awheezile: Like afebrile, but for wheezing. “Yeah, this patient with asthma was wheezing really bad, but after a neb, he’s awheezile.”

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May I plleeeease sit at the cool kids table at the ER now? I have conquered the MTFers, withstood the trials of the Neuro Lecture, and even ass-kissed preemptively .

Also, my scrubs do not taper.

Maraka and I’m a Dude ; we will *totally* go to a Bootie Mashup Party .

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The season finale of Lost was amazing, but could we get some wound eversion for Jack’s laceration repair, TV ER doctor? Hell, that little thing could be dermabonded. And while we’re at it, you might not want to use absorbable, practically transparent suture since those need to come out in 3 days to prevent scarring. Snark off.

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Shadowed/eavesdropped on calls today at the California Poison Control Center , which was pretty cool. The center here in SF shares the duties with 3 other centers in the state, operating the 24 hour, toll-free number to answer pretty much any question and either make sure people get the right treatment or some needed reassurance. Each state has its own poison control center and the people are incredibly helpful, knowledgeable and friendly–definitely call if you have any questions.

My one experience with it involved my mother making some sort of pasta or tuna salad, while also getting out some hydrocortisone cream for a rash or something, with a tiny bit of the steroid cream ending up in the bowl. Don’t ask me how this happened. I just remember my brother and I freaking out and SCREAMING for her to throw out the entire bowl of food, not wanting our mother to die. She called poison control and they said it would be fine (she’s a nurse so she knew this anyway) but I think we put up such a fit she tossed it anyway. (Or at least she told us she did.) So everyone does silly things, and children eat everything. No matter how silly, it’s no reason not to call. The call centers have heard everything.

• Dad: Hi, my child just ate some Play-Doh.
  Pharmacist: How much?
  Dad: Like half a can.
  Pharmacist: Okay, he or she should be fine–
  Dad: Oh, wait, nevermind, he just had it in his hand.
• Caller: I know this is a line for humans, but my puppy just ate some pills.
  Pharmacist: Okay, well, I’d recommend calling your vet. There is a Poison Control Number for Animals, but they charge $55 per call.
• Caller: I made some chicken chili last night, and left it out last night. Can I eat it?

Most calls dealt with toddlers eating pills. One “licked the coating off a bunch of Advil and Tylenol.” One important point: Tylenol is actually incredibly dangerous in overdoses–which is hard to do unintentionally in adults–but isn’t so difficult for small children, since overdoses are generally based on weight. Tylenol in overdose has been bad enough to cause patients to go into liver failure and require a liver transplant. Keep pills out of the reach of kids!

Oh, interesting fact: Those little freshness packets in shoe boxes that say “don’t ingest?” They’re just silica, and non-toxic. It’s like eating sand, apparently. (This is not medical advice!) Update from the comments:: Silica gel, the desiccant in “freshness packets,” isn’t always harmless. Sometimes it’s packaged with a moisture indicator and some of those are quite toxic.

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I’ve been watching Grey’s Anatomy to relax in my few hours of freedom per day, and I must say, nurses totally get the shaft on the show. Addison is always rooming patients in the ER, checking vitals, and hanging fluids, as if the physicians on the show are these solo practitioners who can do everything for everyone (surgical interns staffing a free clinic, ha!)

ER nurses can laugh with the best of them, and are incredibly fun to work with when the patients are stable. They’re even more amazing to watch when patients go bad. One patient went from looking mildly uncomfortable to coding (needing CPR) in the span of about 3 or 4 minutes, and just like a switch was flipped on, the nurses swooped in and knew exactly what to do. Two secured IVs, another started documenting, and a fourth was pulling meds. I’ve seen the phenomenon a number of times now, and it’s really, really impressive. The teamwork is fantastic. One of the reasons I love the ER.

I remember a patient once asking a Peds nurse why he went into nursing. His reply: “I wanted to help patients. Doctors diagnose patients, but it’s the nurses that actually treat them.”

My hat is off!

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4 hour “orientation” shift today.

Already learned how to put someone in restraints and tie them down, saw a patient from the county jail, and re-did an IV on an altered patient who had already ripped it out twice. I was also told to “fight for a suture room and grab it before someone else does.” Grabbed my patient, maneuvered her bed around the drunk man who had urinated in his bed and the onto the floor.

This month is going to be awesome. And crazy.

Possible theme for the month, advice given to me by an attending today: “Better to ask for forgiveness than permission.” (Did I mention I can write my own orders?)

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Another year, another reason not to get sick in July. That’s right, it’s the guide to clerkships/rotations/clinics/whatever you wanna call it. (If you’re not there yet, you should be reading Graham’s Guide to Boards .) Probably not worth reading if you’re not a med student.

Let’s begin at the beginning.

1. Get used to feeling stupid. I often forget this fact, but when I remind myself that I’m supposed to feel this way, it’s much less damaging to the ego. Every first week of a new clerkship, you will feel like the biggest dumbass in the world. You will make boneheaded mistakes, be totally overwhelmed and confused, and will often feel very alone, like you are the only person that has experienced this. It is not the case. In the pre-clinical classroom, you learn by memorizing. In the clinical classroom, you learn by experiencing (or at least, I sure do). And you learn much better and faster. I think part of the reason you pick up things so quickly is that there is so much to learn on each rotation that your brain doesn’t have any other choice. Back to my original point–it is okay to feel this way, so don’t let it get to you. You have residents who do this thing night and day, and attendings who’ve done this thing for 30 years, who argue about minutae for fun. You’re not going to be at their level any time soon, don’t sweat it! (Note: most of this is internalized stupidity or ignorance–in no way do I think anyone else should be belittling you or making you feel shitty. I had a jerk surgeon who humiliated me in front of the entire team my very first week, presenting my very first patient ever to an attending, but I felt much better when the entire team told me his behavior was uncalled for.)
2. “You gotta do your job.” I stole this quote from my surgery chief resident. Don’t half-ass your way through clerkships, do at least what is expected of you. If you don’t, you’re just making even more work for your already-overworked team.
3. Be enthusiastic. This goes ridiculously far, especially in your first 6 months of clinics. You may not know anything, but showing interest and trying counts for a lot.
4. Do. Not. Lie. Your attending or resident will ask you a question about a patient–because either you forgot to mention it in your presentation, or they’re curious, or they want to make sure you didn’t miss something, or I guess sometimes to pimp you–and you will be tempted to think “If I just say that there were no carotid bruits, then at least they won’t think I’m stupid for not checking them”–but just don’t. “There is nothing I hate more than liars,” quoth my Surgery clerkship director. “I can teach people that forget things, but I can’t ever trust liars.” Just be honest! Say “I forgot to check that, but I’ll make sure to right after we’re done” and jot it down. Or if you can’t remember what the patient said or what you found on exam, just say so. You’ll gain trust and credibility, because they are expecting you to miss stuff. You’re just beginning your training!
5. Be professional. What does that mean? Professionals put others’ interests (usually patients’) above their own. That means being on time–always–being appropriately dressed, being respectful of colleagues and patients. Figure out the team’s level of fun/sarcasm/joking/crudeness and don’t go past it, I’d say.
6. Ask questions. If you’re confused, or are lost, or need help, ask. It’s not a sign of weakness, it’s a sign that you’re thinking through things on your own. That being said, there is a time and a place for asking questions. “Which one is the superior mesenteric artery” is probably not best asked when your attending is screaming for suction ’cause he’s just hit said vessel.
7. Be aggressive, and ask for responsibility once you think you’re ready. Maybe I’m just a gunner here, but the clerkships I’ve enjoyed the most have been the ones where I’ve actually felt like I’ve contributed to the team. The worst ones have been me shadowing fellows or writing H&Ps that the intern or resident is going to basically write again him or herself. You’re paying a pile of money to work, you might as well get something from it and “help people” finally–isn’t that what you put on your med school application?
8. Clarify stuff up-front. If you don’t know if your attending likes long thorough presentations (medicine) or short’n’sweet ones (surgery), ask. You won’t waste their time, and you’ll need to learn how to present both types, anyway. (Presentation types to master: the one-liner, the consultation request, the 3-minute, and the 10-minute.)
9. It doesn’t matter what you take first. I know surgery residents who took surgery first and matched just fine, just as well as surgery residents who took surgery toward the end of their first year. It will not kill you. The earlier clerkships will expect you to have more pre-clinical knowledge, while the later ones will expect you to have more clinical knowledge. It all balances out.
10. Certainly not least: MAKE TIME FOR YOURSELF! While it’s great to go above and beyond, don’t stress yourself or drive yourself crazy. Clerkships are rough because you’re expected to learn clinical medicine, manage patients, and still be studying once you get home on both your patients’ conditions and the clerkships’ classic diseases, too. Do your best to find a balance. Make time for your significant other, if you’re lucky to still have one by this point (cynical much, Graham?), try to get together with friends once every week or two, go out, live. Appreciate the time you have outside of the hospital–clerkships really make you do this.

The transition to clerkships can be rough, and at times, very lonely. You go from spending every moment with your classmates as a preclinical student to being thrown around different rotations at different hospitals with different schedules. You often lose your support network, because they’re all busy, too. Lean on non-medical friends if you have them. They’ll enjoy hearing your gross stories about doing rectal exams and weird diseases you’ve seen, and you’ll get a chance to catch up with them.

Oh, and I found a nice physical exam review site tonight if you’re interested. Those skills tend to weaken while you’re studying all night and day for Boards.

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