nANIMOv

So I got what I wished for: a busy, hectic day running around between patients and responsibilities. At times it was stressful, but at the same time it felt like I was doing more or less what I was supposed to. I got to field some calls on the VoIP, I had to put in urgent orders, I was interacting with the nursing staff and pharmacy and others like a real member of the team, which feels kinda lame to say, but this is also never something I really experience as a medical student, at least to this level. It always felt like playing as a doctor. It still feels like that sometimes, but when I see my seniors, and the fellows, and the attendings who are really doing the damn thing, it’s pretty cool to watch. So being a part of the team, and being a productive and valuable part of the team makes me feel like I’m getting a little bit closer to that which is nice.

Today was especially difficult from an imposter syndrome standpoint. All my patients got transferred or discharged today. Which may be a good thing from a patient health standpoint, but it also made me feel like I wasn’t taking care of complex enough patient, or maybe I am not being trusted with the more complex patients. This makes no sense of course, because this whole time we’ve pretty much been picking our own patients. I took on an relatively straightforward one today with the plan of taking on the first new admit. It never came. Meanwhile, my co-interns are dealing with multiple complex patients, many of whom were moving towards goals of care discussions or required extensive work ups, and working closely with the seniors and talking to families just made me feel a little less like a doctor today. Again this is all my own problem, and I feel guilty about having these selfish feelings because on the other side of this all are real people with real lives. But I think that’s also where some of these feelings come from. I feel like I’m not doing enough. But instead of wallowing in these feelings for too long, I want to use them to push me to be better. Also while I so appreciate my seniors and the fellows and the attendings being so nice and patient, I feel like a little constructive criticism, communicated tactfully, would be similarly appreciated.

Today we talk about hyponatremia — a topic that I’ve learned and been lectured on more times than I could count, and yet still get confused by. Today though our attending went over it in a way that I thought was really helpful, while also using a real world example of one of our patients. Creating frameworks rooted in physiology and in real work examples has always been really helpful for me. I’ll come back and maybe put together my own version of what we talked about to solidify my understanding.

There’s so much to be learned in the ICU on a day to day basis that I feel like I don’t do a good enough job solidifying what I learn in my brain. I’ve learned a lot each day about both the process of doctoring and the medicine itself. Since I feel like I’ve been kinda getting repetitive or at least somewhat stale in this posts, I feel like I will try to use this space to help nail down the things I am learning while still having space to put my reflections.

Today we talked about a few things. Pressure-volume loops in individuals with different types of airway obstructions. First there are fixed airway obstructions in which the loop is flattened in both the inspiratory and expiratory phases. Which makes sense; if you have a small opening for air to go in and out and it doesn’t change, the flow will be inhibited in both directions. Then there are variable intrathoracic obstructions and variable extrathoracic obstructions. The terminology was confusing to me at first, I think because I didn’t quite understand that we where talking specifically about airway obstructions and not just any kind of inhibition of flow. Thinking about it now, this actually will help a lot in me thinking about airway obstructions vs restrictions. Anyway, for variable intrathoracic obstructions, there is negative pressure in the intrathoracic space during inhalation so when the person inhales, the soft tissues is able to move out of the airway to allow air to flow unobstructed. During exhalation when that negative intrathoracic pressure is gone, the obstruction is then present, inhibiting flow on exhalation, therefore only the exhalation phases is flattened. On the other hand for a variable extrathoracic obstruction, during inhalation the negative pressure is in the airway lumen causing the obstruction to worsen, and then during exhalation when that negative pressure is gone, the airway can open up again and you get the opposite effect on the pressure-volume loop. From a Med+Peds perspective, this also helps me better understand possible clinical findings related to airway obstruction such as stridor and wheezing (just because these are probably more common findings in the younger hospitalized population), and know when we would expect to hear those abnormal breath sounds. That’s all for now.

Even though today was probably more busy for our MICU team as a whole, it was a little slower of a day for me. All my patients were pretty stable with mostly minor interventions. One of them did have some activity toward the end of the day was kind of exciting, but both in a good and a bad way. It’s kinda hard to watch people come out of sedation, at least when they appear to be struggling and fighting, or if they are coming out of it agitated.

On another note, I haven’t had to talk to any family members about their loved one in the hospital which is good, but also having those conversations is part of what I like about the ICU, not in the sense that I like it when people are sick and having to break that news to people. There is just something that feels special about being in this place between life and death, dealing out what hope you can, fighting against death, but at the same time trying to do you best to manage expectations and guide patients and families gracefully to whatever may happen. It feels morbid to put it down in writing, and I am not sure if that is even a good way to think about my time here, but I guess it’s how I feel none the less.

I started in the medical ICU today. It felt good to be back in the hospital, and especially starting in a rotation I surprisingly enjoyed a lot during medical school. I definitely still feel behind and honestly still feel like a medical student, but I know that the more time I spend doing it the more comfortable I will become with this new responsibility. I still find myself waiting for approval to do really anything, which I think is probably expected to some extent, but also I feel like if I was more confident in my skills I would definitely trying to take more initiative. That is going to be my motivation going forward to really hone in on my clinical skills, develop my workflow, and expand my knowledge base.

I’m feeling excited right now I just hope I can sustain it.

My first day in clinic. I started the day in pediatric cardiology clinic which felt like another full circle moment because this was the first place I shadowed during medical school. It felt good to be back in a clinical setting and seeing patients, and in cards especially seeing some interesting conditions, getting to look at echoes, and only having to focus on one condition. I impressed my attending because after we went back in together to see a patient, the patient who normally is not cooperative with any type of exam, motioned for me to listen to her heart again (probably just ’cause she’s just getting older, but still was gratifying).

Then in the afternoon I had my first continuity clinic patient, a newborn. It’s always fun to work with the wee babes and (usually) the families. I did have to learn and do all the stuff real doctors have to do though beyond writing the note; doing the med rec, doing the visit charge, etc.

It’ll be a pretty stark transition when I start in the MICU next week which I’m actually looking forward to, but for now I’m just going to enjoy the coming weekend for my brothers wedding.

I couldn’t have asked for a better way to start my residency training. I was scheduled for community outreach all day which involved going to a local organization for “Questions for a Doctor” in the morning, and then in the afternoon we went to a local high school for an on-site “mobile” clinic to do sports physical for students. The opportunity to be out in the community and bring healthcare to people who may otherwise have limited access is a big reason why I wanted to be in this program. This morning I had some really great conversations with people in a setting that they feel comfortable and on their terms, answered some question, and got some advice on how to be a better doctor. This was my first time engaging with people and also doing clinical work as an MD, I even signed my first sports physical which was exactly as exciting as it sounds. While these kind of community-based activities are not going to be as frequent as I would like since I still need to become an expert at regular medicine, it was hugely motivating as I go into tomorrow to see my very first patients in clinic.

It’s been a while since last wrote anything on here despite this being probably the most eventful 3 months of my life. I matched into my first choice residency program, I finally went to Japan, I finally built a pizza oven with my dad, graduated medical school, and tomorrow is my first day official day as a resident loose in the world. Luckily for the world I’m on a weird +1 week this first week and in Med-Peds we can have a day of community engagement and so that is what I have tomorrow. It feels fitting though because involvement in the community is one of the big reasons I wanted to stay here at this program. And then Thursday I have my very first clinic patient. I am very excited to finally start after all this time since match day. Hopefully I can keep up this enthusiasm. But yes that is all for now.