Wards: Internal Medicine

EDC. It’s been too long.

I’ve been doing ward medicine for 3+ weeks and have appx 1.5 weeks more to go. It’s been a rocky transition. I won’t go into details here, but just know that being a medical student vs. Intern is just completely a different world and that the team dynamic really makes or breaks the experience.

Otherwise, ward medicine has been something else. The learning curve is a beast, the hours are rough, and maintaining your sanity is a daily challenge. Right now, I’m on Medicine Red (one of the 4 resident teams) at the hospital. My team consists of one senior resident (R2), a c0-intern (R1), and a medical student (MS3). We alternate Attending Physicians every two weeks and right now are super lucky to have an excellent Attending to work with. The schedule is intense. We all, easily, average more than 80 hrs/week. If I leave the hospital by 4pm, it has been a successful day – but this has only happened once. Yesterday.

Here’s a quick run down of a typical day:

  • 6:15 am: arrive to the hospital, head to the team work room and print out patient lists
  • 6:30 am: head to the 4th floor, get sign out from the overnight team on my patients, grab the pagers, and code pagers if we’re on call
  • 6:45-8 am: pre-round on my patients. Currently have 5 pts (thank gravy!!!) and I know them all pretty well, so this doesn’t take too long.
  • 8 – noon: round with Attending and Sr. resident; which are regularly interrupted by other meetings:
    • 8:50 am: social work rounds
    • 10 – 11 am: Morning Report w/ the other Medicine/Neuro/Endo teams
    • noon – 1 pm: Case Report/Teaching/lecture, etc w/ lunch
  • 1 pm – 6:30 pm: discharge pts, consult other docs, put in orders, write notes, see pts again if needed
  • 6:30 pm: sign out pts to the overnight team; if we’re done early sign out to the on-call team.

If we’re on call, we accept patients from noon – midnight. The time is very strict, on my last call we got two new admits at 11:15pm and 11:30pm. This basically results in nobody sleeping. Regarding the call schedule, we’re on a Q4 system – so every 4th night we’re on call. The post-call day we have to round on our new admits, write notes, do orders, etc and sign them out to the day team and get out by 11 am. Then go home and sleep.

It’s overall been a great rotation and I’ve learned a lot but am regularly reminded of my knowledge gaps. I love having “my patients” and taking care of them. I’ve had a couple of really sick patients and being their point of contact and getting them better and out of the hospital is a really gratifying feeling.

I miss all of you and would love to hear what a break down of your days is like and how residency is going for everyone. 🙂

Dr. Nari, a tired Intern.

An Ode to EDC

Image result for calvin and hobbes quotes on life

In two weeks we will be reunited. I can so clearly recall sitting in BHH writing my very first blog post and being so excited for EDC to form and to start clinical rotations. We had no idea what the future had in store at that time and will soon be in that same spot of unfamiliarity.

I, for one, am freaked out about starting residency. Instead of the “struggle” being real, I think a more apt phrase would be “the anxiety is real.” We are going to be (limited) licensed physicians. Prescribing medications and ordering labs and imaging on someone else’s family members, complete strangers, and everyone in between. Thank gravy I won’t be doing this alone. I am also excited to get this doctor-ball rolling. But right now, starting at the bottom and climbing out feels a bit insurmountable. I’ve been listening to a lot of music to quell my anxiety.

I know it’s been hard for us to keep in close touch these past couple of years and each of us went on our own journeys throughout the past few years, but I always think of you guys as being constants in my life; like touchstones that are only a grouptext away. Thanks for humoring me and keeping the EDC blog alive, even though Kat without cats forgot her password. 🙂 Who knows, maybe we’ll be able to convert this into an “EDC goes off to Residency” blog. In any case, it would be nice for us to have one last night in Ellensburg together, play poker, and eat many desserts. Maybe after graduation.

I am really looking forward to seeing you guys very soon,

Nari

Japan & Taiwan: An Asian in Asia

Greetings EDC,

As you all know, I went on a splendid trip recently that required some time travel: past the international date line and into East Asia. I have not been before, aside from being born in Taiwan, and had been looking forward to this trip for basically my entire life. It was as strange and wonderful as I always imagined. Robert, the friend that I married, adventured with me and we both appreciated the fact that he was finally a racial minority. We began our trip in Tokyo, then stayed in the outskirts of Kyoto in Kurama before flying out to Taiwan and touring the entire island essentially. Our trip was only 2 weeks long, but we packed a lot (maybe too much) into it. Here are some of the highlights!

Tokyo: A feast for your eyes, ears, and tummy!

Tokyo delights the senses with overwhelming sounds and visual stimulation while bustling with orderly activity. Some favorite districts of ours were Akihabara, Harajuku, Shinjuku, Shibuya, and Ginza. Each offered their own distinct personality and flare keeping us pretty much in awe the entire time. The metro system is very precise and organized making it easy for any traveler to use, but there is a very specific etiquette for these trains. Before boarding you must stand in line, race each other to open seats and then sit noiselessly. Speaking at full volume is frowned upon on these train cars.

A cold, drizzly day in Akihabara.

 

 

 

 

 

 

 

View of Tokyo skyline from Observation deck at the Mori Art Museum.

 

 

 

Conveyor belt sushi in Harajuku. You submit your meal requests on the electronic device, and the conveyor belt zips it out directly to your counter station!

 

 

 

Takeshita street in Harajuku – known for all things cute and sweet: cat-petting cafes, cotton candy stands, creperies (on every corner), fashionable shopping, and many food items to select!

 

 

 

 

 

Owl-petting cafe: my personal favorite. While the owls were being fed live mice, we drank tea. Best to satiate their appetites prior to being petted by strangers. 

 

 

 

 

 

 

 

Pictured here is the extremely popular and often photographed Shibuya crossing. It’s maybe the busiest crosswalk in Tokyo but as all things Japanese, superbly organized. The second the light changes to red, there is a complete absence of pedestrians in the street. Amazing.

 

 

 

 

 

UNIQLO in Ginza. Happy happy me!

 

 

 

 

 

 

 

Onsen in Kurama: Bathing naked outside and eating traditional Japanese food

The bathhouse that we stayed at was up the street from the Kurama Mountain, a hike boasting stunning Buddhist Temples and a steep train-car to the top. Two days of wearing yukatas at every meal, sleeping on tatami mats, and bathing outside in the wilderness was very refreshing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TAIWAN: The Best Part

After enjoying eclectic and energetic Tokyo paired with quiet, drizzly Kurama, we made our way to the homeland. We flew from Tokyo to Taipei and made the most of our first day in Taiwan by doing laundry. Positioned right next to the street market and Dr. Sun Yat-Sen museum, we were able to wander around while the clothes spun.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Following a single evening in Taipei, we set off for the streets in which I was born – Taichung. A gritty, scooter-dominated city, Taichung represented a lot of what I imagine Taipei used to be. The skyline was dimly polluted, the night market was noisy and crowded, streets were narrow and without sidewalks, and nobody spoke English. The night market was probably the best part; imagine 3+ miles of food stalls, backpack and phone cases stores, and being packed in with a crowd of people while stinky tofu harasses your nostrils. I loved so much about this city, it really felt like home.

 

 

 

 

 

 

 

 

 

The courtyard of the orphanage in which I spent the first couple years of life. It no longer houses orphans, but instead is dedicated to caring for physically and mentally handicapped children. A wonderful place.

 

 

The rooftop garden of the orphanage.

 

 

 

 

 

After the emotional and wonderful time spent in Taichung, we ventured forth to Kaohsiung, a port city in the southwest region of Taiwan. This was a really fun city to visit and we were able to rent bikes, take a ferry to a local island, visit the British Consulate for Tea & Biscuits, and just wander around. We even got sunburns.

above: view from British Consulate

 

We took a river Gondola ride and were serenaded by the Gondola driver in Taiwanese songs. Very unexpected, a little cheesy, but much fun.

 

 

 

 

 

 

next: Lotus Lake temples and temples

 

 

 

 

 

 

 

 

The best cold noodles I’ve ever eaten.

 

 

 

 

 

 

To round out the trip, we returned to Taipei and enjoyed some Din Tai Fung (very busy), night markets (Raohe >>> Shilin), visited the Taipei 101 Starbucks, and spent our final day at the National Palace Museum. I loved visiting Taiwan and Japan, but as they say, there really is no place like home.



Thanks for reading. 🙂

It’s a Match!

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Guys.

We made it through two different Match Days. How do we not have stomach ulcers already? Because we are awesome. I am so proud of all of us. Through the marathon that was 4th year and frequent trips to the bathroom, we came out the other end and are one step closer to closing that gap on our dreams of becoming Physicians. We each have a tremendous amount to look forward to and can realize the weight of this. As women and first generation doctors, very little can stop us from being advocates for our patients, helping those in need, and progressing modern medicine.

I can’t wait to see all of you at graduation and celebrate the closure of this important life chapter.

Nari

Burn Injuries

HI EDC!

We are so close to being finished with medical school – I am finally feeling the weight of that thought and getting excited about graduation. 🙂

My final surgical elective was in the Burn Unit at a local hospital. It was a very busy rotation; from pre-rounding at 5am, rounding at 6am, a very full panel of patients, and surgery MWF, there was a lot going on. Overall, I really enjoyed this rotation. I am fairly non-surgical, but having the opportunity to observe application of various skin grafts to 50% total body surface areas (TBSA) burns was pretty cool. I will not miss the 90 deg temps in the OR though. Burn surgery ORs are kept at least 85 deg F for patients with large burns because of the tremendous loss of heat from the absence of skin. It gets gross under surgical gowns quite quickly.

Some highlights of this rotation:

  • Working with a large team of residents: 4 Interns (1 ortho, 2 gen surg, 1 EM), 1 gen surg pgy-3, and 2 fellows. Plus me, tagging along. We were a big group and everyone’s roles changed weekly.
  • Surgery on Monday, Wednesday, Friday: burn cases would take up to 4 hours depending on the extent of the burn injury
  • Clinical rehab psychologist on site. Many burn injuries result in PTSD from the injury or may be the consequence of behavioral issues (drug use, violence/abuse). Rehab psychologists are quite rare in hospital settings, but essential – especially in the burn unit. The majority of the cases were tragic and having a resource for patients coping with serious life changes was instrumental for their treatment and long-term prognosis. Patients that believe that life can get better, after severe tragedy, are ones that will do better with their burn/wound care and have the best outcomes.
  • Patient cases were complex and a many of them were the result of homes catching fire. When your home is destroyed… what do you do after? These are really unfortunate cases and many times patients live in transitional housing or if they’re lucky will live with friends/family until they can obtain stable housing.
  • Patients were very sick, and not necessarily because of their burns. So much of how well someone does is based on their health status prior to hospital admission. If someone has chronic peripheral vascular disease, poorly controlled diabetes or regular diabetes, meth use (this one’s huge), poor nutritional status (alcoholism, Crohn’s disease), or any autoimmune process then the ability for wounds to heal is significantly impaired.

I am really glad to have had the opportunity to participate on this service as I think this is a really unique surgical specialty and one in which more attention should be paid. But I’m biased now. 🙂

Until Match Day,

N

Interviewing for Psychiatry Residencies

Alright, all 2% of our readers that are seriously considering pursuing Psychiatry Residencies. Please sign in at the front door, make sure you haven’t lost your mind, and proceed to enter the world of neuroses, psychoses, and wandering thoughts. If you have been mindlessly paying attention, you will know that I am really into psych and am super excited about entering into this field. This is not a backup plan for me, this is THE plan. My goal as a psychiatrist is to work with chronically, severely mentally ill persons in a community behavioral medicine setting (hopefully with integrated care) and to work in psychiatric emergency services. I have completed the psych interview trail and recently put together my unofficial rank list. I come here to give you tips on how to best approach this messy year and am most helpful to you if you are interested in psych. But feel free to ask general residency application questions.

  • Psych Residencies in General:
    • Psych is one of the less competitive specialties. Poor reimbursement matched with the fact that mental illness is stigmatized and worsened by the belief that psychiatrists aren’t real doctors.
    • Psych is a 4-year residency with a lot of Fellowship opportunities:
      • Child & Adolescent
      • Psychosomatic
      • Forensic
      • Geriatric
      • Addiction medicine
  • Decide if you are going NRMP (MD) vs AOA (DO) Match. 
    • I applied to both initially because I wanted to take advantage of dually accredited psych programs. Unfortunately, there are not very many of these available and I only ended up applying to one and pulling out of the AOA match.
    • If you go NRMP: 
      • There are 204 psych residencies and they range in size. Some of the largest programs are 16 residents, smallest I’ve seen were 4 residents. Most are tied to large academic institutions and are centrally located in suburban or urban settings.
      • TAKE USMLE STEP 1. At the very least. I know programs accept COMLEX scores, but in my experience it really helps taking USMLE Step 1 to get one foot in the door. If you take USMLE Step 2, you may get both feet through. I took both USMLE Step 1 and 2 and think this really helped me get some solid interviews because it put me in the running with MD applicants.
      • *Dually accredited programs accept COMLEX scores, so no stress with these ones.
    • If you go AOA: 
      • There are 24 psych residencies and they are small. I am not sure about all of them, but the ones I looked into accepted 2-4 residents/year. Most are community-based which is really nice but in more isolated locations.
      • No need to take USMLE Step 1 or 2.
      • I’ve heard rumor on the interview trail that there are certain AOA programs that are more malignant than others, be on the lookout for these ones.
  • The Magic Number.
    • 9 if you go NRMP. I think people can typically match within their top 5 and most will match if they have at least 4 programs ranked.
    • No idea if you go AOA. I would guess 4.
  • Write a SOLID personal statement. NO Crap.
    • No joke, I got interview invitations off of my personal statement. The idea here is that if you meet a minimum requirement in your grades, clerkships, board scores, etc. you are seen as a decent applicant. But your personal statement is what will set you apart. No need to be a prolific writer, but have a story and be passionate. I had a lot of program directors directly ask me to talk about parts of my life based off of my personal statement. In psychiatry, this matters more than other specialties because programs want to see that you are truly interested in psych and why this field matters to you.
  • Doing Sub-I’s/Aways/Acting Internships:
    • I would recommend doing an elective rotation at a program that you are really interested in but don’t have regional ties to or for programs that are notoriously competitive. It also shows programs that you are legit interested in psych. I had a lot of faculty and program directors ask me about what type of psych rotations I’ve done and what I’ve learned from these experiences, etc. I think it makes for good conversation.
    • A lot of 4th year medical students don’t do away rotations in psych as they don’t see it as being necessary.
  • If you have RED FLAGS* on your application:
    • Still apply broadly. Be mindful of programs that require you to pass without any failure attempts and apply to the rest.
    •  *failed any board exams or clerkships or classes

I think I’ve exhausted my focus for the evening. If you have any questions please feel free to comment. I am happy to be a resource for all you.

How to ICU

Nearly 4 weeks into ICU and I am still uncertain as to what is going on. On a regular basis. It’s been a strange rotation. Partly because I have missed an inordinate amount of time on this rotation combined with having patients that are extremely complicated. Luckily, much of the ICU is managed by a team of  really good RNs, Respiratory therapy, social work, and solid pharmacists. And of course your Pulmonologists/Critical care doctor. It really takes a team to manage one patient.

Overall, I have enjoyed the freedom provided on this rotation as I am able to pre-round independently, write my own notes, and present my patients to the team. Being able to do your own thing is really nice. But fear not! – a Resident is always around in case I have lingering Q’s. Something that I found to be immensely useful is chatting with the nurses before ICU rounds. These nurses know their medicine and are some of your best allies when training and beyond.

Before I started ICU, I didn’t really know what to expect and relied on the google machine to help me out. I stumbled upon these resources and reviewed them throughout the rotation:

I guess that’s not too many. I also relied on good ol’ fashioned uptodate and Medscape app.

The majority of your time will be spent reviewing drips and vent settings. Having a good understanding of pharmacological sedatives and vasopressors will serve you well. Additionally, knowing how vent settings work is helpful; at the bare minimum you should know how to interpret them. Jenny did a great job detailing this in her ICU video, so give that a listen for more info.

Everyone that warns you that ICU will be depressing was right. I had a patient die each day. Not fun stuff. Plus your patients are either intubated on a ventilator or altered or sedated so you can’t interview them. You end up relying on their vitals, PE, labs, and imaging to communicate with you their progression. Some of the more interesting cases included:

  • Meth user with valvular vegetations and septic emboli to the pleura causing pneumothorax requiring multiple chest tubes.
  • Former meth user found down in his trailer found to be in DKA and septic shock with a necrotic right foot that underwent emergent guillotine below knee amputation (BKA).
  • Diffuse scleroderma in a young adult resulting in advanced interstitial lung disease complicated by pneumomediastinum.
  • Lung metastases secondary to advanced ovarian cancer, undetected until admission.

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Of course, we also had a lot of the bread & butter cases like COPD exacerbation, isolated DKA, toxic vs metabolic encephalopathy, acute respiratory failure, and septic shock. I also was able to get in a couple of procedures: intubation and placing chest tubes. Nothing too crazy. Oh, and in case you’re wondering, I only missed time because of residency interviews – those wait lists are no joke – if you pop off of one, you find out last minute!

By the way… anyone notice the fog after January 20th? I think the Dementors were let loose from Azkaban.

Nari