Leaving Miami

This post has been a while in the writing – a lot has happened since the last one. Before I get into the details of my move to NYC, I just want to recapture some sentiments from the last Miami days.

I’ve said before that I think we spend entirely too much time in the ER – I added that as one of the negative points on my evaluation of this program. Since July was my ER month, it was inescapable. I’d rotated through with several of the docs in the ER, pulling 12 hour shifts at a time. There are some docs who don’t take students, and just a few I hadn’t worked with. I began my shift with one of the docs with whom I was unfamiliar at 6am, when I walked into a surprisingly quiet ER. There was perhaps one nurse at the nurse’s station, and two paramedics on the other side of the counter. I sat in the doc box (a little enclosure with its own lighting, to facilitate the reading of imaging reports), thumbing through my Washington Manual while I waited. The doc I was with came in, said something to the one nurse, and immediately turned and rushed into one of the patient rooms. I followed him in – and realized that it was so quiet, because everyone was in there, partaking in a code. An obese, 40’s-ish man had been brought in by fire and rescue, having a massive heart attack. That was about an hour before I arrived.

I walked in, and nurses were surrounding the table, paramedics switching off doing compressions, while the docs and PAs watched. I stood out of the way, until the doc I was assigned to turned around and saw me. The doc who was running the code turned as well, and asked me if I’d ever done CPR. I told her that I hadn’t, as I turned and grabbed some gloves. She asked if I knew how to, and I pulled on my gloves and told her that I did. The paramedic currently working on the man moved to the side, and I stepped up, and began compressions.

If ever you watch people doing compressions on TV, and they’re going less than twice a second, they’re doing it wrong. You can’t do it too fast. And so, mimicking the rhythm of the paramedics, I compressed and compressed and compressed, and was overcome with the overwhelming conviction that I was squeezing blood through the dead veins of a dead man. He was intubated, and the look of a tube going down someone’s throat is always disconcerting. Beyond that, though, was the fact that his unblinking eyes were wide open and bloodshot, glassy and staring at nothing. I stopped and checked for a pulse, and one of the other paramedics took over. One of the nurse’s pulled out a syringe filled with epinephrine, and the head doc told her to put it back – he’d already been given 12 amps of epi.

Another paramedic jumped in, and then the lead doc took over, checking the vital signs monitor. She got a better result (nicer QRS complexes) than the rest of us - a testament to her experience. Finally, though, someone brought in the ultrasound machine. Everything stopped, and we looked at the grainy, gray picture of a completely motionless heart – frozen muscle, unmoving valves, not even a flicker of bloodflow. There was still some electrical activity – pulseless electrical activity – but the docs chalked that up to all of the epinephrine and dopamine in his system…and they called it.

I remembered that, on the way in, I’d passed some folks who didn’t look too happy. They were, obviously, the family. We pulled the curtains, and a nurse went to speak with them.

It was perhaps this death that cast a foul tinge over the rest of the day – I didn’t like the doc I worked with at all. He was very helpful, suggesting that I organize my approach to the patients in a certain way (breaking down the Plan part of the SOAP note into labs, test, meds, and orders), but I found him frustratingly arrogant and condescending. Part of it could have been that I’d finished my previous shift at 9pm the day before, and had to be back at the ER to pick up Nicole at 2am. So I was sleep deprived and in a mildly foul mood, compounded by the doc’s foul mood. Another student commented that it was perhaps nothing more than the clashing of the two egos, but I’m sure it was more than that. Despite the fact that I feel like we spent too much time in the ER, this was the first and only time I hated it – and it had nothing to do with the patients.

My next ER stint was entirely different. I was with one of the other docs I’d worked with before, and was comfortable with. Since I’d been taking the other doc’s recommendations on organizing my patient notes and applying them to some practice cases I’d been working through, I felt more confident with my approach to the patients. That day went well – the highlight was another heart attack. Another gentleman, around the same age as the one who’d passed away, had come in complaining of some chest pain. He’d gotten the full cardiac workup – CBC with differential, complete metabolic panel (CMP), coags (PT/PTT/INR), cardiac enzymes, chest x-ray (CXR), ECG, etc – and it looked like he was having a very minor heart attack. The cut-off for ST elevation, the place where the change from normal becomes significant, is 1mm. This guy’s ST elevation was at 2mm. The doc I was with called a cardiac alert, and within moments the interventional cardiologist was on the floor, followed by his son who must have been about 14. He came in, talked to the doc, and looked at the ECG. He was unconvinced….until he learned that the troponin (one of the cardiac enzymes) was 1.5 (below 0.4 means that heart muscle isn’t dying) – and called up to the cath lab, and told them to set up. From then on, it was a rush – we headed upstairs with the guy. He sat there on his hospital bed, shirtless in the elevator, joking about how his cell phone wasn’t getting reception.

From there we followed everyone into the cath lab. The doc I was with stopped to talk with another interventional cardiologist, explaining the merits of the iPhone 4G, especially when it came to transmitting images – like ECGs . Then the interventional cardiologist was ready and headed into the cath lab. The ER doc I was with – since he knew that I’m interested in cardiology -said I could stay and watch. Of course, I jumped at the chance, and went to sit in the observation box with the nurse and the son, and watched as the cardiologist opened the guy’s blocked right coronary artery (RCA) and placed two stents. I left for the ER just after he explained the whole process to him.

So that was it for the ER, and almost it for my internal medicine experience – it only had to be capped by our shelf exam. Luckily, the ER doc I was with on Thursday gave me a half-day, and so I went in well-rested and ready. Well….perhaps not entirely ready. I’d read through Step up and some of Davidson, and kept up with articles and other information. The day before, I finished the hundred cases in the back of Step Up, and felt reasonably comfortable – but not as much as I would have been, had I spent the past 3 months doing practice questions in preparation.

To add insult to injury, another group of students who were taking their internal medicine shelf were in the same room as we were – the Cleveland Clinic group. I explained to some of them how the Mount Sinai rotation was mostly University of Miami Hospital, by way of Miami Beach Community Health Centers, and felt my ire begin to simmer as some of them told me how they’d been working closely with residents, getting up early every day to round on patients in the hospital, and that they’d had journal review and some lecture every day. This pissed me off – granted there was a lecture held at Mt. Sinai daily for the residents there, but attending when I was scheduled to be across town wasn’t feasible, and the parking fee was prohibitive. Moreover, I’d felt that that they knew they were having a shelf exam, meaning that, at the very least, Ross was working more closely with their program.

At the end of the day, though, it’s not one group against another, and the only thing that matters is how hard I worked, and how deeply I read. At the end of the exam, I felt that it went alright.

Since it was the last day, a group of us headed out to Outback Steakhouse for dinner, before an even smaller group of us went to see Salt. While the action was entertaining, the story didn’t blow me away, and I think I’d have done it differently.

And then we went home and packed like mad. We were up until 4 waiting for laundry to be done. The next day, the new tenants moved in – luckily, It was a girl I knew from the island. Then we zipped our way to the airport, hopped on the plane, and touched down at La Guardia in NYC. Once we’d collected our baggage and headed outside, the first thing that hit me was a wave of nostalgia – all of New England must smell the same, because I was reminded powerfully of Yale in New Haven. We hopped in a cab and headed to Astoria, where I sitting typing right now. The apartment is very small, but it’s clean, and after disassembling and reassembling some of the furniture, Nicole and I have made the space decently useful. We walked around Ditmars Boulevard, acquiring the necessities (how someone lives without an ironing board, I can’t imagine. On the other hand, how someone packs an ironing board for travel, I also can’t imagine.)

This morning, we bought unlimited ride metro cards, and rode out to see Flushing Hospital Medical Center. The Subway system isn’t terribly intuitive – rather than being laid out geographically, with lines running east and west, north and south, they seem to loop around NYC, giving preference to places of importance. I’d texted my brother and told him that NYC is like Rome – all roads seem to lead here – but, once you’re here, all subway lines seem to lead to Times Square. Anyway, we missed the final bus-stop because I thought that the doors would open automatically. It wasn’t until the next stop when a woman shoved right through that I slapped myself on the forehead and went hopped off.

So we found the hospital, headed back to the station, and wended our way home – where we straightaway went and joined the Rock. I’m not a meathead, but I enjoy working out, and a nearby gym is something I value when looking for housing. The Rock is about 2 blocks away, and after signing up, Nicole and I went for a workout. I didn’t want to go terribly hard and heavy today – for one thing, my blender is still en route from Miami Beach – but also because this is the first time I’ve been in an official gym since leaving Dominica at the end of April in 2009. I’ve worked out at home and the exercise room in condo complexes, but I hadn’t been under any serious weight in over a year. That being the case, I took it relatively easy, and was pleased to see that I hadn’t declined too much.