Back from the MICU

The medical intensive care unit is a very difficult place for interns to work. I'm glad my month is finished.

I'm back to being a regular New Haven Resident, which includes time for writing, for studying and for kitchen renovation in the midst of learning how to intubate patients and how to look at just about everything you can imagine using ultrasound.

Here are some other things I've been working on recently:

A little article about couple's matching for residency over at Medscape. The couple's match is how medical school graduates can be guaranteed placement in a city where their partner (who must also be a soon-to-be intern) will also match.

I'm also helping kick-start some conversations over at a discussion board within Medscape, called Med Student Connect. Check out my morning report posts if you want to work through some clinical brain-teasers. #1, #2, and #3. I'm trying to kick up some controversy in the ethics section, but haven't any takers yet.

You'll need a free log-in for Medscape to read each of these. Sorry.

So not very much news from me other than these. For now...

Intensive Care

As my wife and I completed some interventions on our New Haven home this weekend (namely finishing circuitry and hanging drywall), I prepared for my month in the intensive care unit. It begins tomorrow at 06:00.

See you in a month.

Voting en bloc

Yesterday I set foot in the concrete bunker of a behemoth called East Rock School to vote. It was the first time I've voted in Connecticut. It's the fourth state I've voted in. IL, PA, WA are the others. There were three positions and one ballot measure up for review. The most important race (for District 9 alderman) included an individual who ran unopposed. Roland Lemar's frequent neighborhood updates are useful to me, and he's replied to all of my emails. I enjoyed voting for him. The other race was for a mayor who easily won his 9th term, and for a city clerk. I didn't know I was voting for a clerk so decided to let the other New Haven residents pick that job.

One of the reasons I voted was that the polling place was right across the street (in a school slated to be torn down and rebuilt next summer). Likened to a prison in its current manifestation, the new design promises to be open, friendly and better integrated with the neighborhood.


Extra points go to the person who can ID which house on the architectural design is ours. My wife and I are excited about the new park and playground area across the street.

A second reason I voted is because I appreciate the opportunity to participate in government, even as a mere voter.

Finally, if I ever participate in government as more than a voter, I think it's important to show that, yes, I have voted in every election I was able.

Which brings me to another point. Sometimes, I'll not be able to vote, except by absentee ballot, simply because I'm working 30 hour shifts. CT doesn't make absentee balloting as easy as King County, Washington does. I'll have to figure that one out later. By this time next week, I'll be a MICU intern. Remember those work hours limitations? No more than 80 hours a week or 30 hours at a time... I've heard that it's pretty hard to observe them when you're a MICU intern. Either way, you won't be hearing much from me on this blog, by emails, or frankly, in any other medium, for the next month, as I will be in the midst of my MICU schedule block. Or said another way, en MICU block.

Immune!

Look at this scary beast!

Influenza H1N1 - striking fear into the hearts of mothers and 24-hour news networks alike. Except that it's not. On the pediatrics floor where I'm working this month, there are so many parents I've talked with who just aren't sure about the new H1N1 vaccine. They're happy giving the seasonal flu shot, but are leary of the other. "Is it safe?" they ask. "I don't know," they say. Or in one case, "This is all just a damn conspiracy cover-up for a bioterror experiment gone bad."

Right.

I can't make parents give a shot to their kids, but it is awfully frustrating to hear how someone out there (the media?) has confused so many people about this. Here is some of the information I know:

• The flu vaccine was produced by the SAME technique as the seasonal variety.
• Most (in my area 99%) cases of flu are H1N1, so the seasonal vaccine will not cover you.
• The best guesses out there are that younger patients may be at increased risk.
  

If you need more reasons, check out this list posted by an infectious disease doctor on the West Coast. As I see it, my job as a medical resident working on a pediatrics floor this month and in the ICU next month, I hardly have a choice in the matter of vaccination. I owe it to the patients and families I care for to build up my resistance. So when I learned that my hospital had made the vaccine available to staff from the women's and children's departments, I was among the first in line.

Plus, if I have a bad night tomorrow on call, I can blame it on all of those flu vaccine side effects!

Interior Walls

I'm about to finish my 4th month as a resident of/in New Haven.

Let's just say I'm undergoing some remodeling. This applies to the metaphor of individual change and literally to the state of our house. Our neighbors no doubt have recognized the debris in our back yard from our kitchen project. Hopefully all of the cognitive remodeling I am pursuing in my clinical training is moving along, too.

Unfortunately, there is not as much time as in medical school to take stock of the situation and reflect. Perhaps that will change next month on my pediatrics rotation. For now, I have two more overnight shifts...

Rarely do I encounter a statement from a professional organization that I agree with en total. The following myth-busting memo from the American College of Emergency Physicians (of which I am a resident member) is one I can put my support behind. President Obama mentioned emergency medicine in his joint session, but in doing so added fuel to the fire that emergency care is at the root of our current crisis. It is not. Take a few minutes to read this well crafted letter.

An Open Letter from America's Emergency Physicians

As the physicians on the front lines of emergency care, we see the tragic problems of a failing health care system. We care for people who are ravaged by untreated disease; help worried mothers on weekends with sick children, unable to access a system that's open 9 to 5, weekdays only; and treat the victims of heart attack, stroke and injuries whose very lives depend on our care.

The role of emergency medicine has been badly misrepresented during the health care reform debate. The American College of Emergency Physicians supports comprehensive reform, including universal coverage. But it is vitally important that reform legislation not be based on erroneous perceptions, but instead address the critical problems harming emergency patients. It is time to debunk the myths, focus on the real problems and outline solutions to ensure that health care reform will protect and enhance everyone's access to quality, timely emergency care.

Myth: Emergency medical care is expensive and inefficient. Reducing emergency care will "bend the cost curve" on our nation's rising health care costs.
Fact: The 120 million annual visits made to emergency departments account for only 3% of all health care spending. In addition, emergency departments are equipped with state-of- the-art diagnostic equipment and highly trained physicians who can draw on many hospital resources quickly, providing coordinated, efficient patient care. The fixed costs of being open 24/7 are high, but the variable costs for seeing patients in the emergency department are the same as anywhere else care is provided.

Myth: Emergency departments are crowded with patients seeking non-urgent care.
Fact: Only 12.1% of emergency patients have non-urgent conditions that could wait 2 to 24 hours for medical care, according to the Centers for Disease Control and Prevention (CDC). While this percentage may be slightly higher in some hospitals, the reality is that crowded conditions and longer wait times are primarily caused by patients being "boarded," or forced to stay in the emergency department - often on gurneys lining the hallways - long after they have been seen and admitted to the hospital.

Myth: Your local emergency department will always be there when you need it.
Fact: Hundreds of emergency departments have closed nationwide because of an overburdened emergency care system. Those remaining must accommodate an average increase of 3 million more patient visits each year. Every 60 seconds emergency care is delayed when an ambulance is diverted to a distant hospital because a nearer one is unable to accept more patients. In addition, 75% of emergency department directors report significant problems getting needed on-call specialists, such as neurosurgeons and orthopedists, to provide vital on-call services to emergency patients.

Myth: The need for emergency care will decrease when health care reform is enacted.
Fact: With a growing and aging population, our role in providing care to the sick and injured any time day or night, and our front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Since enacting its universal health care legislation, Massachusetts has experienced an increase in emergency department patients. Emergency medicine is an essential community service that is vitally important to our nation's health care system.

To help ensure our country has a strong emergency care system, the American College of Emergency Physicians supports comprehensive health care reform that includes:

• Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance. It should be means-tested, allowing those in need to receive coverage or financial support to buy insurance. A combination of private sector and governmental solutions may be needed to achieve universal coverage. America is experiencing a dramatically rising tide of uninsured and underinsured patients. Emergency physicians are the only doctors in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility we embrace proudly, but many emergency departments and physician groups are closing under the burden of uncompensated care.
• Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expensive tests known as "defensive medicine." Liability reform can also help increase the availability of critically needed on-call specialists. Widespread adoption of electronic health records could substantially cut costs and improve patient care if there were complete integration of data between the emergency department and other medical settings. Administrative and overhead costs must be reduced.
• Quality and patient safety must be improved by eliminating the practice of "boarding" admitted patients in emergency department hallways until they are transferred to an in-patient hospital bed. This can be achieved by establishing quality standards that define how quickly admitted patients are moved to their appropriate care settings, with such information reported and available to the public.
• A national surge capacity plan must be developed and resources provided to prepare our nation's hospital emergency departments for public health crises such as the H1N1 pandemic, a terrorist attack or other catastrophes.

With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make health reform decisions based on myths. Go to www.acep.org/realities for information on protecting your access to quality, timely emergency care.

We must act now.

Nick Jouriles, MD, FACEP
President
American College of Emergency Physicians

This Crazy Town

Everything's connected.

Earlier this month, I spent a week in the back of ambulances learning about pre-hospital medical care. As part of that, I was on the scene at two rather large fires in the city of New Haven. The first was well-reported by the New Haven Independent. I helped take care of guys that had been battling the blaze for hours. We monitored heart rates and blood pressure, gave oxygen, and transported guys with vital signs out of range to local hospitals just to be checked out. The second fire I was present for occurred early one morning and happened to be across the street from a neighborhood where both one of my senior residents and one of my professors live. The former took this photograph of me looking happy about the smoking building in the background. Really, I was just happy to be outside of the back of the ambulance cab...

The very next call that day was for a person who was feeling like she might hurt herself. She had a history of feeling suicidal and had been hospitalized before, so we took her to Yale, where she would presumably be connected with a psychiatrist who could help her. Hopefully it would not be the self-proclaimed "Savior of Death," who was arrested a few days ago about 2 blocks from my home. Evidently, a well-respected psychiatry resident was involved in an altercation in a local bar and found to have an unlicensed firearm on his person. Any person who is charged in the care of others who makes threatening gestures suggesting danger to those individuals or others in the public may be arrested and be searched without a warrant. A subsequent search of this individual's home revealed a stockpile of firearms and ammunition. He lived about a block from me. The instigating incident goes to show that everyone can be affected by alcohol or mental illness - even physicians.

The arrest was made at the same time that the news conference announcing the discovery of Annie Le, the unfortunate victim who has put Yale on the front page of the nation's newspapers and other news sources. The continued media presence around the police headquarters in New Haven has provided additional unlikely casualties in this story. No fewer than two people from the television news industry have presented to the Yale-New Haven Hospital for carbon monoxide poisoning. I treated a cameraman who was thinking slowly and just wanted to go to sleep. It's the time of year that we ER docs need to think more about that colorless, odorless gas that causes more people to wake up dead than any other poison. (Check your heaters for leaks and please don't burn kerosene or gasoline inside!) The cameraman (and his friend, a union representative) asked me what I knew about the occupational dangers of CO. I know that no significant studies have shown ambulance drivers (who often leave the rigs' engines running in closed spaces) to be at risk, but that smokers and firefighters tend to be chronically exposed and sometimes need to be monitored as such.

Which reminded me of the ambulance ride-alongs I did earlier this month.

Fireman Doctor

Have you ever wondered how a 9-1-1 call translates into a trip to the local emergency department? What determines if the fire department shows up, or a private company like AMR?

When I'm not in the ED, I live in New Haven. When residents of this city (and most others in Connecticut) call 9-1-1 for a medical emergency, there are a number of steps between the call and an ambulance showing up. I've been riding around on ambulances this week, so have learned a bit about the system. This knowledge will help me in the ED, but could also be interesting to you, the random reader of this site.

Step 1: The call. You'll speak with an operator who tries to gather as much info as possible from you. Generally the info they need is your address and what happened. If bad things are happening, this is when to say it. "I stubbed my toe" is not bad. "My dad collapsed and hasn't woken up yet" is bad. This is where the 9-1-1 charge on your phone bill goes.

Step 2: The relay. Medical calls get routed to a dispatch system that tells the fire department and the ambulance service of the problem. If the ambulance service is integrated into the municipal department, this dispatcher will send the nearest paramedic to the scene, with the nearest ambulance to follow. Sometimes the nearest medic is at a fire station with an engine. That's why a fire truck may show up for a heart attack.

Step 3: Ambulance Dispatch. In many locations, the fire department only responds to the call for help. Those medics do not transport sick patients to the hospital. A second dispatch occurs to tell the ambulance where to go and how fast. (Lights & Sirens?) The ambulance tells both dispatches where it is headed so everyone is on the same page.

Step 4: The Scene. Most of the time, the FD is already there by the time the ambulance arrives and tells the transporting medic the story. A story in the Washington Post this week draws attention to this new role of firefighters in America's urban centers. Most of the time, in CT, the fire department goes to the next call while the ambulance continues care. The medic gives a call to the emergency department preferred by the patient about 5-10 minutes out, and before you know it, the patient is rolling through the ambulance bay doors.


All along the way, critical information is repeated, either in person, on the radio or in print. The patient hand-off between the medics and the hospital team may be the first of many during the hospital stay. What I typically forget from my view in the ER is that a complicated game of telephone was acted out even before anyone saw the patient.

Swan Song

My last post over at the WebMD-sponsored medical student blog, The Differential went up on September 1. My thank-you to readers marks the end of my first honest attempt to tailor my writing for a general audience. But don't worry: I'm hooked! Look for other ways for me to participate in written media over the coming months and years. I'll keep you updated. I cannot stop writing about my journey. Here's a rough account of something that occurred tonight.

Barreling up State St. in the back of an ambulance at 50 mph, I was reminded this evening there is much to observe, experience and transcribe about medicine in an emergency setting. This week, I'm participating in "ride-alongs" with paramedic ambulance teams; I'm learning a lot about pre-hospital care that will help me in the ED. While en route to a code-100 (or presumed cardiac arrest), I was reviewing how I would do my initial assessment at the scene and what my likely first interventions would be. Bouncing around the captain's chair in the back of the cab, I noticed with a shiver the music on the radio up front: "December" by Collective Soul. It turned out the soul we were about to collect had found its way to another place, or soon would. We found the patient warm but lifeless. She would not notice the view of a world being left behind from the windows on the back of the truck. She probably wouldn't even notice her ribs cracking as I compressed her chest to pump blood through her body. Her work on this planet was finished even as ours had just begun. At the behest of her family, we applied all of Western medicine's best known methods of restoration. Mrs. Lazarus traveled from home to the Yale Emergency Department, all the while being maintained in an intermediate stage between life and death. There would be no miracle this evening, however. The accompanying family member was invited into the code room shortly before the attending pronounced death. But by then, we were responding to another call. Someone in West Haven was vomiting blood.

The Double Life

The other day my neighbor saw me biking home at 8:00 AM. It wasn't that I'd been up all night working a shift a the Yale emergency department. I'd actually forgotten my lunch. Wednesdays are when the formal teaching in my residency occurs. We have 5 hours of lectures starting at 8:30 AM. Sometimes they are all in the same cavernous lecture hall at the Yale Medical School. Last week, we split up into small groups and did some simulation cases before two hours of standard lectures. (In the sim session, I resuscitated an 83 year old woman who was toxic on her digoxin heart medicine and who also had a gastrointestinal bleed. My feedback consisted of, "You have the best bedside manner I've ever seen for a plastic mannequin.") But I digress.

My point is that residents' schedules are known to be strange. It was natural for my neighbor to ask me yesterday if I was coming off a shift when he saw me biking in spandex and toting a full backpack away from the hospital. He was on a morning walk with his wife and young son. In fact, Wednesday was the only day that had a semblance of 9-5 for me. The rest of the week, I worked 4PM to 2AM. The carrots and hummus on my kitchen counter would be no good staving off the hypoglycemia (low sugar) antecedent to nodding off during the lectures. I did worry I'd be late for the first session when I turned around. Fortunately (for me AND everyone else in the program), I had plenty of time to change out of my spandex for the first small group. Emergency physicians are intent on being on time at shift change, but organizing a large group of night-owls at 8:30 AM takes more than coffee...

The same neighbor was washing his car while I was turning up sod for a new garden. We chatted about work hours, the economy and generally of making lemonade out of lemons. (He gets to prepare for his classes and spend time with his son more than he did when business was booming; I always have interesting patients to see in the ED.) We've only lived in New Haven for two months, and have not met many people, but it's nice how often we see those who we have met. We see them when we work in the garden, or when they are walking dogs, or commuting, or on evening strolls... it's nice to live in a neighborhood. I'm not intent on figuring out how to reside in it during normal hours. But even an off-hours resident can connect without that much work.

On Being A Resident

All of my posts thus far have focused on the municipal understanding of the word resident, specifically in the City of New Haven. It's time for me to address the other side of the pun. I am a newly minted M.D. who works in the Yale hospitals in New Haven and Bridgeport. Therefore I am a New Haven Resident.

Most of my time occurs within the venue I've chosen to spend my career: the emergency department. I'll be rotating in other areas of the hospital as well, but for the next few months, I'll be an ER doc. The ED has a schedule not shared by other specialties. The emergency room is open 24 hours a day, therefore doctors must work around the clock. Few docs prefer to work nights all the time, so the shift schedule tends to cycle through the circadian cycle. This is why I am at my computer on a Tuesday morning typing away. And why you might see me jogging on the local high school track at 2:00 in the afternoon, and why I sometimes come home at 3:00 AM. The so-called "shift work" done by emergency physicians is often maligned by other specialties as making the field less serious. If those other specialties have a better idea about how to staff America's health care safety net, I'd love to hear them!

So far, I like having the flexibility of having free time during business hours, and so long as I have access to a little bit of caffeine, I think I'll be able to handle the schedule. The information however, is another story. If you can imagine a fire hose of information coming at you when you just want a sip from the drinking fountain, that's medical school. Residency is like a burst water main. Which brings me back around to the New Haven resident pun. Perhaps I need to report this hydraulic emergency to the City of New Haven. It's easy to find at the Northeast corner of York and Howard. Look for the sign that reads, "Emergency."

SeeClickFix New Haven

When we moved in to our new home in New Haven a few weeks ago, one of the first things we noticed was the preponderance of pot holes on our street. One was so big, my wife's car could fit in it. It was only a couple of inches deep, so was more like a specially recessed parking space, but other smaller craters were nearly 8 inches deep. With all the rain we've had this summer, the array of street defects created a veritable Chain of Lakes for the length of the small street. (A deliberate nod to my NE Illinois readers.) Whether I drove or biked, every time I was on Eagle street, I felt like the driver in Moon Patrol. Fortunately, there are no enemies shooting at me. I understand there are other regions of this city where that could be an issue.

Anyway, I found a thread of complaints about this very issue at a website called SeeClickFix. There are actually three posts about potholes on Eagle St.: here here and here. The third link has some juicy vitriol; potholes bring ou the worst in people. Anyway, I don't know if it's because of the website, or that I emailed my alderman to complain (and ask for voter registration cards!) a few weeks ago, but I incredulously watched a work crew of two fill in every last pothole on the street last Friday. And they only fixed the stretch that goes past my house. The next block - equally riddled with holes, but not as complained about - received no repairs.

So perhaps this SeeClickFix business works! It's a Web 2.0 (user created content) interface that uses GoogleMaps to start and maintain threads. The site's history is connected to Yale and started in New Haven, but has spread to such foreign lands as Seattle and France; it is less used in those places.

Here's a map of the region of New Haven I live in. East Rock is where many grad student and medical resident Yalies live. It's pretty close to the hospital, has great shuttle routes (to Yale), is a quiet but still dense area, has a few little groceries, delis and pizzarias, and is close to freeways if needed. There is plenty to complain about, too. Look at all of those orange conversation balloons!





According to my alderman, the City of New Haven uses this tool to track municipal complaints and requests. Perhaps your municipality can use it, too! The site is looking for what they call SideClicks to spread the use of their website. It seems like unpaid digital evangelism to me, but if other cites catch on and use the system, maybe it's worth it.

Worm Bin... Check!

This weekend, I finished constructing my vermiculture incubator. What is such a thing? Take away the academic language and you've got a worm bin. Vermicompost is an easy way to compost food scraps that doesn't throw off the balance of your outdoor yard waste compost. (If you are looking for a free outdoor compost set-up, look no farther than the City of New Haven Public Works at 34 Middletown Ave.) The best yard waste composts consist of 2/3 brown (carbon-rich) waste and 1/3 green (nitrogen-rich) waste. (What's brown and green? The EPA knows.) In the summer, most waste is green (trimmings, weeds, sod). Green waste includes kitchen waste like fruit scraps and coffee grounds.

If you still want to keep green kitchen waste out of the landfill, you can use worms. Worm bins are a fast and non-smelly way to generate a moderate amount of high quality compost from your kitchen scraps. The worms love to eat the bacteria that break down your (non-meat) food scraps. They burrow through watermelon rind like nobody's business and dig coffee grounds, corn husks, fruit scraps and even the occasional piece of produce gone bad. Since you bury the waste underneath the existing substrate, the smell that you've known escaping from your trash bin is not present. Sure, the bacteria are still there, but all you get is a musty fragrance of earth.

How do you keep worms happy? For one, not any old worm will do. You will need red wigglers, or the more difficult to find European earthworm. The worms in your back yard, while probably not native to North America, are neither of these. Those are probably of the variety known as dew worms or Canadian earthworms. What do the worms look like? They are characteristically red with yellow stripes. There's a good picture I took from the Yankee Worm website, which is actually a good place to get information about what you'll need to build a worm bin. All of the materials can be gathered from around the house. I recently ran out of duct tape, and didn't have hardware cloth, so had to buy thise items. So my grand total for this project was $7.91 and a couple hours of my time. And the worms? I joined my neighborhood's Freecycle community to find people who could give me a handful of their worms. I found two enthusiastic donors. Thanks Jean and Betsy! My do-it-yourself approach saved about $100 for the compost bin and $40-50 in worms. The make a bin .pdf at Yankee Worm is a pretty good guide, although I'm not sure how easy it will be to collect the worm castings at the end without spoiling the styrofoam peanuts. Since we have an abundance of peanuts from our move, I tried it anyway. Other guides use other ways to keep the worms from getting too soggy.

My worms are now hanging out in their cool dark corner of the basement munching on their first meal of kitchen scraps. I'll check in on them in a week to see if they need any more!

District 9

The other night, I visited a neighbor who volunteered to share with me some red wiggler worms to start my vermicompost (see this post), and found that her husband is actually an Alderman in the City of New Haven. We chatted a bit about the municipal structure and local politics. He represents a neighboring district though, so I looked up which I lived in. It turns out that I reside in District 9.

District 9 Trailer (HD) - The best video clips are here

Evidently, I've a lot of learning to do about where I live... I started by emailing my own Alderman to ask about how I could request a storm drain be unclogged. Need to know which district you live in? Check out the aldermanic map at the bottom of this web page. Note that while there are plenty of crazy trees in New Haven, this map does not indicate where they are located. Talk about false advertising...

Another Blog

Here we go again!

This little blog is a way for me to interact with my community. The title identifies the content. I'm a resident of New Haven and a resident physician at Yale-New Haven Hospital. The content here will be limited to each of these topics. Don't expect regular timing of posts; my schedule from month-to-month and day-to-day is highly variable. Expect the content to also be variable.

Writing about being a physician is less amenable to blogging. Among others, there are issues of patient confidentiality, technical accuracy and the small risk of litigation that make seat-of-the-pants writing a challenge. It will be much easier to write about something new I discovered about living in New Haven. Therefore, expect most of the initial posts to focus on living in my new environs. Topics will, of course be all over the place.

If you've read any of my other blogs, I'll be winding down writing there (for now). To you, and anyone else out there that found this place, welcome.