Random

**Tuesday as I was leaving work, I told my coworker, with whom I worked to call me in the morning if things were hectic and I'd come in early and help her catch up before the day person was to arrive. I went out to dinner that night, was totally wrecked, and ended up being out later that I had planned. Got home, had a lot on my mind, and couldn't sleep. Finally went to bed at 2 am. God knows who I heard the text message, but at 5:30 am it was my coworker. The message "Haven't sat down all night, not even a chance to eat." Which seems typical for calls, regardless where in the world one is. She didn't specifically ask me to come in. But knowing the hour of the morning, and knowing I would be in bed, to me there was an implied message. Please help. I think back to when almost exactly a year ago I was having a horrible night in the CCU and was so far behind I called in the morning person early. (That's not the exact story, but we'll leave it at that). So, I got up, showered, ate, made coffee (well made coffee then showered and ate) and headed in, arriving slightly before 6:30. I'm hesitant to describe what I saw, in full.

-one resident doing CPR/bagging one newborn.

-2 nurses bagging and doing CPR on another newborn

-one resident doing a spinal tap on a newborn who had been seizing

-one resident trying to get an IV on a kid who needed a bolus, urgently.

-4, or 5 (maybe even 6) other kids in cots (meaning all 8 usual beds/heaters were full).

-a pair of 650g twins, under the same head box of oxygen, unable to tell if they were still breathing.

 

**I rounded in NICU today. NICU is really only 12 beds. (The step down NICU is about 30 beds). They didn't want to overload me since I'm just an MO/SHO, so they had me round on 2 kids. 2 kids. Phew, was I swamped. Silliness. This hierarchal shit is really getting old.

 

**After work tomorrow, my friend David and I are headed to the Drakensberg, the Central Berg for some hiking. It'll be great to be in the mountains tomorrow.

 

**My car alarm went off last night. Twice. I grabbed my new headlamp and headed out to look around. Of course, all I had to defend myself with were keys and a headlamp. I was annoyed, and embarrassed that it went off a second time. So I just left it off last night. And then when I got into bed, the power went out. And of course I wondered in that means that somebody had cut the power line to disarm the alarm to the house so they could come in. And then I realize that really, they would have seen my just walking out to look at the car with a flashlight and keys to protect me.

 

**My car alarm went off sometime during the day when I was at work.

 

**

Brief quotes

As promised, quotes from call.

 

"Doctor, would you please see the sick babies last, it slows things down when they are seen first."

-kid you not. The "nurse" asked me to stop seeing the sick babies as they came in and instead make it a priority to see the well babies that I have to review first, so that they can be triaged out, and room made for more babies. That would be possible, if it meant that the "nurses" placed sats monitors on the babies and made sure the oxygen was actually flowing to the babies so that I didn't have to hover over the sick kids...

"I've had 8 admissions so far, and have only seen 5 of them."

-the very, very cool resident covering the transitional NICU (who is my back up) at about midnight, explaining how hectic her night had been, and kind of justifying why she hadn't been able to come over and help out a bit, not that I had really expected it, as I was holding down fort, barely. By holding down the fort, what I really mean was that all of the babies were oxygenated, hydrated, had normal blood sugars, and were warm. Plus (BIG PLUS) I didn't need bailing out to get IVs and bloods. Oh, by the way, of course I knew that she had 8 admission, I had admitted all 8 of those babies to the T-NICU.

 

"You have bad luck."

-Stating the obvious. The previous Sunday, the doc on that night got 6 hours of sleep! At one point I was 5 babies behind.

 

"FD in Theatre"

-Nothing like being in the middle of bagging a blue baby and knowing that I'm due in theatre in 5 minutes to be present at a delivery for "fetal distress." Most of the FDs that I've attended have been perfectly well babies. Thankfully, with some aggressive bagging, the blue babies usually pink up, and then there is a minor leap of faith as I hook up the O2 and sats monitor as I run to theatre.

 

"Doctor, ward 66 called and need you down there urgently"

Ward 66 is the equivalent of our transitional NICU. Of course, they don't tell me why I am needed down there "urgently" and I'm kind of pissed. If the nurses back home asked me to come urgently, I'd likely run. But I could be called down "urgently" because there isn't an order for something stupid. So I walk down. Of course, the moment I arrive, I get called by theatre for a FD. And the urgent call was for a baby who "stopped breathing while feeding" which is because being a "baby friendly" hospital these kids don't get bottles, but rather cup fed. Which seems so un-natural to me.. And the kid who turned blue, was being fed by NG. And even though there is no rational reason for me to do it as far as I am concerned, I do a -FULL- septic work up on the kid, and start him on antibiotics and make him NPO and start IV fluids. Is it likely that the kid suddenly became septic. No. Is it likely that I'll be humiliated in the morning for not making the kid NPO, doing a septic work up and starting Abx. Yes. So, do I treat the kid, or treat because of the expectations of the Bara way. Sadly, I do all this ridiculous stuff to avoid having to defend what would be my decision: to not treat and make sure the feeding tube is in the stomach . And quite frankly, I'm tired of defending my decisions, which are not the Bara Way.

 

"There are no students today"

-My post-call assignment is to cover the lying-in wards. Essentially, any kids that we are following who is "rooming in" with moms will be evaluated by a peds resident, and the students in the mornings. There are 4 wards to cover. I had no idea yesterday morning who many kids that would be, but figure that it was manageable, given that it would be me, and one or two students to round on the essentially well kids. These are kids who may have high bilirburins, or small babies who we just check up on etc. But sadly, Monday morning, at hour number 24 of work, I find out that this week there are no students. So, post-call, smelly and irritable, I get to see almost 40 FORTY, F-O-R-T-Y newborns.

 

But, as I leave Bara around 1pm, I had a tiny sense of victory. 3 calls done. No major fuck ups. One more to go.

 

Will I be a better doctor after this month. Doubt it. I've certainly resuscitated more newborn in this week and a half that I have in 3 previous months of NICU back home, but I don't think I've learned anything I didn't know before. What I've learned is that as long as patients aren't blue, as long as there is glucose in the blood, and as long as that blood is moving well enough, then really all is well.

 

 

Pushing Through

Gosh, I haven't done this in a while. Up for 30 hours, it's gorgeous outside, and taking a nap now would kill the moment! I figure might as well push through and stay up until bed time. I feel like I've become an old man, planning a schedule around sleep!

 

So, headed off to town, going to pack up a book and hit my fav coffee shop, then home this evening.

 

Last night was a doozey for a while. Kind of unpleasant, there are a few memorable quotes, and I'll jot them down another time.

 

The good news: One ONE more call left! Gracias a Dios!

 

30 Hours

I was in the LW for all 30 hours of my call.

 

Feast and Famine.

 

It was actually kind of pleasant during the day, but there were periods during the night and then this morning when things got hectic.

 

What I am kind of dreading is the weekly Morbidity and Mortality meeting, which occurs tomorrow. I have 2 kids from yesterday, who may be presented. One will not be too interesting, a straight forward resuscitation of a newborn who essentially was dead upon delivery, and whom we resuscitated per protocol for 30 minutes. I'll mention that it was essentially 2 of us coding the kids, bagging, doing chest compressions, drawing up meds (which means diluting out of the vial the epinephrine, which is trickier to do when your gloves are coated in slime etc-god how I was wishing for the prepared syringes that we have back home). The other was a twin who was looking great, but then cashed out of the blue and had to get fully resuscitated. Still not too sure what happened there, the kids was looking great, was about to send him to the ward to be with mom. Not too sure if it was sepsis, congenital heart lesion, or pulmonary hypertension. Needless to say it was pretty un-nerving, and kind of shattered my confidence for a while, and felt like I couldn't trust my clinical skills, and every kid should go to the NICU for observation...

 

Anyway, that's about it.

 

 

 

 

No Humor

I am working in a humorless environment.

Not much joking around.

Not much humor.

Not much smiling.

 

21 shifts left. 3 more calls.

 

I had a serious debate with myself today about this month.

 

Am I learning? Not really.

Am I improving technical skills. Yeah, kind of.

 

Am I gaining some kind of experience that will someday make me a better doctor when I'm back in Massachusetts, Colorado, Lesotho, or god knows where I end up? Maybe.

 

Because this week, for 4-6 hour every morning, and for 30 hours on wednesday-thursday and 24 hours on Sunday, I get to do newborn triage.

 

This morning resuscitating one newborn, on the newborn resuscitation bed, which doesn't have a working radiant warmer, I was slightly dismayed when a pair of twins were brought into the room while I was bagging and doing chest compressions on the one kid, and then within a matter of minutes, two MORE kids were brought in. Granted, those 4 other kids were fine-ish, but still...

 

So, I quickly had 7 kids in my triage room. And the benefit was that I get to be right there with these kids for a few hours and watch them progress (or crump). And that to me is the learning point. Someday when I'm trying to arrange evacuation/transport for a sick newborn, I'll look back to the experience this month and realize then, that I'm getting some valuable experience.

 

 

Neonates

I had a blog post partially written out, but decided to delete it.

Friday was the second most miserable experience thus far in residency. Admitting 20 newborns to NICU-Transition NICU & newborn wards, attending 10 deliveries, getting called about other newborns on other wards... (all between 5pm and 7:30am).

Did I make it through the night. Of Course.
Do I think I made any bad judgments. No
Did I get the IVs. Almost all
Did I get the blood draws. Some of them (poor average, disappointing)
Was I as thorough as I would have been back home. No way.

I suspect this will be a quiet month for blogging about my experiences. I'm hesitant in that I want to be fair in my posting, and that right now I'm a bit critical of this rotation.

And now I understand

And I think I agree, horrible is likely to be the correct description...

 

I had a mini-orientation to being on call tonight. Call will be covering the LW. The Labor Ward. Solely responsible for assessing sick newborns, covering the c-section calls, and any infants who get sick in the outlying wards.

 

It's like newborn M*A*S*H. The babies just kept coming in... The LW is essentially a triage unit and an observation unit, and holds babies until the level 2 NICU can get beds open to take kids, or until the level 1 NICU has beds.

 

I think there is space for 8 kids. Well, beds for 8 kids. we had 7 kids, 2 of whom hadn't really been assessed when they brought in a premature baby who needed some minor resuscitation (just needed to be bagged). He went onto the last open bed, which was conveniently, the resuscitation bed. The glorious moment, or surprise, was when they brought in his TWIN SISTER (which they neglected to mention) who likewise needed some bagging. It's really all manageable, except  that the person covering LW also does all the bloods and IVs. That to me pushes me a wee bit closer to insanity. I was sorely out of practice today, and am hoping for a small miracle in reviving IV and phlebotomy skills before my first call in Saturday.

 

And again, I had flashbacks to being an intern, when a very wise colleague mentioned a saying: "they can hurt you, but they can't make the clock stop."

 

I mulled that saying over as I drove home. How the fuck would I manage if I were on call the rest of the night, tonight. I would count down until 8 am. I would literally see that there was an end point to this shift. That all I would have to do is keep kids alive until I get them sorted and into their respective units for further care. And so I thought a bit about the level of medical care, and came to think that when working in extremis, it is not feasibly possible to be the thorough type of practitioner that I expect of myself. That it is not going to be possible to really examine these kids in the level of detail I want to, nor to really review the maternal history and write the detailed notes that I come to expect as being standard.

 

If I had to guess, I would say that in the 5 hours I was there for orientation tonight, we probably had 12 kids filter though, plus getting called about problems on outlying wards, and reviewing 2 stillbirths. I'm not really sure how one person is suppose to do all of that work, but I guess I'll figure it out on Friday night.