Okay okay trying to keep up

Hey everyone,

Well this is better than before, only a couple of weeks since my last post. But its been an eventful couple of weeks! Another step in adulthood. We just bought our first new car! It's a 2007 Honda Accord 4-door, EX-L, V6, in metallic graphite. Its an amazing car - sporty and luxurious, and fast. 240 horsepower! Only thing we didnt get was the Navigation, a bit expensive. I can't believe I'm saying this, but we did have to consider having a car that would work when we have kids. Yup, we thought about something smaller and sportier, but we worried about a carseat. So our top choices were the Prius (hybrid, cool and different), Camry SE (sporty, but still has stigma of a "camry"), and '08 Accord (but expensive as its brand new). But we got a great deal on the 2007 model, and we love it.

In addition, our friends Amy and Nate just got engaged! Amy is one of Nicole's close friends, and they were in PA school at Emory together. Nate planned a big surprise, where he took Amy to the Bahamas and proposed to here there, without her ever knowing a single detail. He never even told her he got a ring until he proposed! Nate also surprised her by having us secretly going on the trip with them! We had a great time, and Amy was swept off her feet with the proposal.

Nate asked me to join him on this trip to the Bahamas, for the whole purpose of proposing to Amy, more than 8 months ago. I tried to keep it from Nicole as well, but she's too smart and figured out what we were doing. Nicole and I flew from Durham to a connecting flight in Atlanta, where we surprised Amy and Nate! Then we flew together to the Bahamas, and had an awesome time. The resort (Sheraton at Our Lucaya) was absolutely beautiful, and very quiet since it was the "slow" (aka Hurricane) season. Luckily, only a few showers, otherwise it was sunny and warm! We spent time poolside, on the beach, sailing Hobie Cats, and enjoying jerk chicken. Not to mention, the exciting engagement on the docks surrounded by a beautiful harbor and yachts!

Here are some more pics:

Well I just started a rotation in the MICU (medical intensive care unit). But this time, I'm a resident, not an intern. Overnight, its just me and my intern. I now have the responsibility of making decisions for these critically ill patients. I'll have to decide if they need to be intubated (have a tube inserted into their lungs and hooked up to a breathing machine), or if they have come to the point where we recommend withdrawing care. If a patient "codes" (or has a suddent serious event like a cardiac arrest, or can't breathe, or becomes unresponsive), they call the "code" over the entire hospital intercom, and we are the ones who have to respond immediately and decide what to do in the emergency setting. Whew, its quite anxiety-provoking to have to be this person to make the call! I guess I feel "slightly" prepared for these situations...whereas last year as an intern, I felt in no way prepared. Of course, we always have people above us where we can ask questions, but they are at home. We are the ones who are there, and we're the first call. Eek!

One more thing...HAPPY BIRTHDAY MOM! (Sep 29)

More later...and thanks those who are still reading!

Alan

"I'm growing up! Aren't I cute?" --Sofie Cheng

Well, I am guilty of procrastinating soooo much, that it seems I haven’t written in almost 6 months. If anyone is still reading this, I will be so shocked! I am sorry to have not written so long, especially since a lot of things have changed (and many things remain the same). I hope that some of you will pick this back up, as I am trying to renew my commitment to my blog as well.

So, here I am…back again.

So much has happened, that I guess I will just summarize.

I finished my last few months of my internship, and officially finished being an intern on June 24! It went by fast, but at the same time, I never thought it would end. What a long, tough, crazy, and educational year. In medicine, I think you grow more as an intern than any other year the rest of your career. I officially became an “upper level” or a “resident”. I now spend some time running the teams in the hospital, responsible for a set of interns and students, as well as a set of patients. I can look back and say it was a pretty good year, but often it didn’t feel that way. But, the last few months became much easier as I became more adept at being an intern.

Some of the boys - Mark, Bridger, me, Jason, Scott, and Andrew - chillin' at intern retreat 2007 in Wrightsville Beach, NC.

Our friends Jenny and Tem, at intern retreat.

More of our friends, Leslie, Mily, Karen, and Nicole at intern retreat.

We redid our lawn! It was filled with weeds and spotty grass, and we’ve always wanted a fenced, grassy lawn for Sofie to run around. We had a fence put up, then had the lawn killed and tilled, and had new sod put down. It’s looking much nicer now, but is still full of crabgrass that we will kill by next spring, and finally will have a nice lawn then.

Above, our lawn after it has been tilled bare.

1 day after the sod has been laid. Ahhhh....green.

After I finished my last days of internship, Nicole and I took a road trip down to Atlanta to see Keith Urban play at Phillips Arena. If you remember our first dance, our song was “Making Memories of Us” by Keith Urban (who sang this very song to Nicole Kidman on his wedding day…but we picked it first!). It was an awesome show! Michelle Branch opened for him…we caught one of her songs. Some of you remember that I had a crush on her too…

Above, the guitars for Keith Urban and the rest of his band, before they came on stage.

There was a catwalk from the main stage to the middle of the floor. We were sitting about 15 feet from the catwalk stage! Sweet!

Keith Urban...great show!

Sofie continues to grow…the last pictures on my blog of her were as a puppy. Now she is about 65 pounds! She’s training us to be good parents. She’s become such a sweet dog, excellent with kids, doesn’t beg for food, and makes a so-so guard dog. She acts like she growls when someone new shows up, but I doubt she’d ever attack even a burglar!

Jenny and Jeff had their second child, a baby girl named Kaelyn. She is absolutely adorable, and her big brother Tyler is taking care of her! They were just up here visiting, and we had a blast swimming in the neighborhood pool, visiting the museum of natural science in Raleigh, and going to play video games at Frankie’s! Interestingly, Nicole’s cousins are also Katelyn and Tyler…I’m not sure why my sister is choosing almost identical names for their kids!

Tyler giving his baby sister, Kaelyn, some love.

Don't we look like a happy family! Good thing they're not ours...I couldn't handle it!

I have decided on a career path for myself – after much deliberation over whether I do primary care (clinic) medicine, being a hospitalist (a “hospital doctor”), or pursuing a subspecialty (such as gastroenterology, cardiology, nephrology, etc), I have decided to pursue a career as a gastroenterologist (GI doctor). It’s a great field that involves a lot of interesting disease, involves a lot of different parts of the body, and has really cool procedures (which are much like toys or video games). As a specialist, you do get to spend more time with your patients on each visit, and don’t have to rush to see 35-40 patients a day just to pay the bills. I’ll be applying this year to be a GI “fellow” after I finish residency. A “fellow” is a step above being a resident, when you are training for a subspecialty. Once you finish your fellowship, you are finally an “attending”, or full-fledged doctor.

Nicole has continued working for the UNC GI program, and is really enjoying her job. She sees patients in her and her attendings’ clinics about 3 days a week, and helps out with research and patient follow-ups and procedures the other 2 days. Her bosses are excellent – they really teach her well, and really appreciate her work…hard to get that combination from a lot of people. She works with world-class GI doctors who specialize in esophageal and stomach problems, and specifically cancer and precancerous lesions of the esophagus. They are among the leaders in the world in treating a condition called Barrett’s esophagus, a precancerous lesion of the esophagus coming from excessive and chronic acid reflux from the stomach. I am very proud of her! (Plus she makes all the money for us)

Well, I think that’s enough for now. Now that I’m starting this blog back up, I can start my random journal entries and free associations. I am really going to try and keep this up!

Also, I’m trying to start up a MySpace page, to also keep in touch with everyone that way too…

Miss everyone,

Alan

The last 4 months...

Events from the last few months...

Nicole graduated from Emory physician assistant school December 2006. She was one of the 5 people in her class with a perfect 4.0 GPA! What a smarty!


Andre, Colleen, Nicole, and Amy at the awards banquet before their graduation. Sorry, they're all taken...

Nicole's parents (aka the in-laws)

Us at the banquet...

Jenny, Nicole, Tyler, and Jeff at Nicole's graduation day.

Amy (far left) is single!

Our house lit up for Christmas 2006!

We got only 2 days of snow this year. Sure is pretty though...

Ben and Jen came to visit! Sofie loves him.

The wife in her place!
Dinner at our house, with Alex, Sarah, Ben, Jen, and her friend.

Useful web sites

Hey, if you have useful or fun web sites, let us know!

Here's some I discovered today for travel:

www.farecast.com - predicts airfare routes

www.airefarewatchdog.com - finds hidden airfare delas

www.site59.com - unsold flights for last minute sales

www.luxurylink.com - luxury vacation packages, we actually bought our honeymoon through this.

Ben told me about this one:

www.singsong.com - record yourself singing karaoke, and post it, and listen to others!

Others I use:

www.slickdeals.net - really great deals on bunches of stuff

Fishy peanut butter...

Well this last month has been fabolous. I had a "regular" job for once - showing up at work from 8 to 5, and having my nights and weekends off! I was in the Same Day Clinic, kind of like an urgent care clinic but only for our established patients that we see at UNC Internal Medicine. You see the range of things, but most common being colds, sinus problems, musculoskeletal problems, and diarrhea. I got to perform "outpatient" procedures, such as injecting joints, incise and drain some abscesses (collections of pus), and did a spinal tap on a really fat guy.

It's funny what the news and media can really brew up in the community. You have maybe heard of the outbreak of salmonella in Peter Pan peanut butter. It's been all over the news, and the CDC (Centers for Disease Control) has confirmed it. Apparently a batch of Peter Pan had been contaminated with a bacteria called salmonella. This is usually found in raw chicken or poultry, sometimes in raw eggs, and can give you a pretty bad gastroenteritis - an infection/inflammation of the GI tract, often causing fever, abdominal pain, and bloody diarrhea.

Anything outbreak in the news inevitably makes it to the doctor's office...and they come in droves. I had a number of patients who stated that they ate Peter Pan, and then had an upset stomach and come to the doctor to ask if they got infected by the Peter Pan. Of course, no one I saw actually had the infection. But some of them even wanted to sue Peter Pan. I told them they were fine.

One person even brought their peanut butter in. Sure enough, it was from the batch that got contaminated. If the 1st 4 numbers on the top of the can start with "2111" then the CDC recommends you throw it away and if you're sick, see your doctor. She brings it in, sure enough its "2111". So, being the curious doc, I open the peanut butter and smell it. Smells like peanut butter to me. I even ask my attending if I can culture it and see if it grows salmonella. But we didn't, and it got thrown away. I advise the patient to throw away the rest of her Peter Pan at home. She'll be fine. She had no bloody diarrhea or fever. I reassure her. She says okay, but if she gets sick, she's gonna sue!

I have to say, being a doctor, I complain about being busy all the time. But, its never boring!

The enemy

As medical students, we are often idealistic, thinking of how many ways we can help a patient, and wanting to help or save every patient we ever see. I remember being somewhat appalled at how some of the fellow interns of residents treat patients. They were rushed, and didn't spend time with patients, always having one foot out the door, or cutting patients off while they spoke. I remember thinking, "I will never do that to a patient. I'll always give the patient my time and respect they deserve, because they are the one with the illness and need the sympathy, empathy, and healing..."

But as an intern or resident, we are often tired and overworked, and our patience can run thin. Yep, we are all guilty of it. Every one of us has come to the point where we view the patient as "the enemy." If you spend 20 minutes talking with the patient, you realize your to-do list expanded from 5 to 15 items. You were just paged something like 8 times and need to return these calls. And you always have too many patients...patients are the source of work, the ones who complain, the ones who bring you more paperwork and requests for laxatives at 3 am. And your patience is simply lost when a patient is narcotic-seeking and giving you attitude for not giving them their oxycodone.

You enter residency bright eyed and bushy tailed, ready to learn and save the world. Ready to be there for your patients 24-7. But we get tired and jaded, and we forget that naivete, that idealism and desire to do good and mean well. And the patient becomes the enemy.

I admit, I got that way myself. I think there were classmates of mine who were worse, and then some who always cared for the patient no matter how crappy their day went. I fell in the middle. I felt that overall, I wanted to care about and care for everyone, but some days it was a damn challenge. Some days I just wanted to forget that certain patients didn't exist and walk pass their room, so they couldn't pester me for more narcotics.

It is standard procedure to ask patients when they are admitted about their "code status" or "advance directives." This means, we ask patients that, if in the case that their heart stops or their lungs fail, would they wants us to perform CPR or place the patient on a breathing machine? Some, but a minority, of patients have already thought about this ahead of time. Most patients, however, have never thought about it. And at my most jaded or most frustrating of days, I remember asking this to patients bluntly, as if I'd be better off if they said "no, don't bring me back," and then I woulnd't have to worry about bringing them back. If they died, they died, and that was one less patient for me to "care for."

I now look back, and I can't believe that I thought these thoughts. These are human beings, and I can't believe I even had the thought run across my mind that if a patient died, I'd be better off. Have I forgotten what it means to be a physician? Or to be a person who cares? Or to put myself in the place of a patient and understand what it is to be in a thin, half-gown laying in a hospital, always being awoken, poked, sent off to tests and scans often without even advance notice, having catheters put in my urethra, and all the while sick with whatever disease they've got?

The funny part is, every one of us interns has likely had those thoughts. Thats how grueling this process is, and how low one can get. The good news is, once we become better at our job - better at being an intern - we are able to step back and start looking at our intern year with some perspective. And we realize we're in a dark place, where no one outside our profession could possibly understand. And when things start getting easier for us, we stop being jaded, and we start caring again. We remember that these patients are human beings, they have loved ones, and we need to do everything we can to care for and protect them. The meaning behind being a doctor in training returns. The thirst to learn returns. And the work is still there, but flows easier, and you realize that the nightmares of residency really are true; you've lost the naivete, but gained the perspective of the dark side and climbed out of it.

UNC 79, Duke 73

Since I now live in a college town with a real, major college sporting team, I can't help get caught up in the fever. The UNC-Duke basketball rivalry is by far the most talked-about sporting event in this area each year. Actually we play each other twice this year. Tonight, UNC beat Duke at Duke, 79-73! And on the news, people on Franklin Street, the main street through UNC's campus with all the bars and restaurants, were gathering in the streets. Apparently there is this tradition of creating bonfires in the streets, and then (perhaps foolishly) students jumping over the fire. I can see how that might be slightly unsafe...meanwhile I'm at home, bout to get ready for bed. Exciting.

Anyways, go Heels!!

Vacation time...

Ahh, I finally made it to my next vacation. I get a week off starting today, and its been a rough 4 months having had 2 of 4 be ICU months. But, all is good as Nicole, Sofie and I are heading through Atlanta and to Tampa! We wanted to do a vacation, but Sofie is too young for a kennel and not even spayed, so we decided to go home to Tampa so she could come with us. We definitely plan on relaxing, and spending time with the family, and seeing some of our friends while in the area (hi Danielle and Kristen!)

As a med student you are idealistic, thinking of all the ways you can help a patient overcome whatever problem it is. You have the opportunity to spend long amounts of time with a patient, really listen to them and get to know their story. Unfortunately, as an intern, you don't. On cardiology we worry about chest pain, and if the chest pain is caused by a cardiac problem, or not. If we find out its not the heart, or anything else serious, we discharge them. Thats great, except that they still have chest pain, and we don't know what its from. If they have other complaints that aren't serious, but are bothering them, doesn't matter...their regular doctor can see them. It's a bit unsatisfying for me, and for the patient, and for some folks they keep coming back to the hospital with the same pain...it hurts too much that they don't want to wait for their appointment with their doctor, but we never find a major cause for it. Half the time these people get admitted with the diagnosis of "rule out MI" (which means make sure its not a heart attack), rather than an actual condition. I'd love to be the med student again, sitting down with the patient and exploring other reasons that could be causing this patient their pain...how is their personal life at home? Their work? Stressors? What activities have they done lately that might have caused this? Rather, I have to work quick, and move on as 10 other patients will be needing my attention too. I sure hope its not like this when I "graduate" and become my own doctor.

Which is another sad part, that any "general doctor" often sees too many patients in one day in their clinic...often its 20-25 patients a day, but I've heard of even 35-40 patients! 40 patients divided by 8 hours, or 5 patients an hour, 12 minutes a patient, not including your lunch break, paperwork, phone calls, arguing with insurance to get them to pay for their patient's procedure. Maybe its down to 7-8 minutes a patient. Cann I really help that patient who is depressed and needs to talk about whats going on in their life in 8 minutes? Or just give them the script for an antidepresant...

Specialists, on the other hand, are the cardiologists, or GI docs, or the kidney docs. Their experts in their field, and they usually see patients when their general doc refers them. Their load may be 10-15 patients a day, and they can spend more time with their patients, work less hours, and often are paid more than generalists. Seems like a great gig. But a really good generalist is invaluable...they know the patient the best, and have a sense of perspective. Not sure which I want to do...

Wow its been a while...

Sorry, its been a while since I've written. A lot has happened, a number of milestones and new events, and it sure has been busy. But alas, I can sit and write, and realize that I've already had this blog for 1 year!

First of all, Nicole graduated from PA school, and moved up with me in North Carolina permanently about 2 weeks ago. It sure is nice to have my wife living with me finally! She graduated with her second Masters's degree (her first was her public health degree from Johns Hopkins) with a perfect 4.0 from Emory's physician assistant program, and was offered a great job at UNC Hospital (where I work!). She'll be working with the GI docs that specialize in esophageal disorders, working in clinic and doing procedures. No overnight call, no weekends!! She will surely be my sugar mama! It will be exciting to have her in the same hospital, so that we could occasionally meet for lunch, etc!

Second, as soon as Nicole got up here, we got a new puppy! Her name is Sofie, and she is a catahoula leopard dog (with a little bit of lab mixed), which is the American version of an Australian shephard. She looks a little like our dog at home in Tampa, Fozzy, which is partly why I loved her so much.

The face of an angel!

Sofie in the mountains. It's cold, let me in!

Third, work has gotten better and better for me. Yep, as you can tell from me not writing for a while, I have been really busy. Since the ICU, which was a really good month for learning, I did a month on the pulmonary service which was extremely busy. Lots of people with lung disease, and this included teens and adults with cystic fibrosis, people with bad COPD and pneumonias, lung cancer, and people who were on ventilators who are extubated (taken off the ventilator) and transferred out of the ICU to us. I always carried between 7-12 patients, and at one time had 15 patients!! But this was the month that really gain some confidence, because if I got through that month with that many patients, I could handle anything. And sure enough, it was about this time I started getting more comfortable at being an intern. I'd start doing procedures myself, start needing less help while cross-covering overnight, and felt more comfortable seeing patients on my own. You start knowing that a patient with chest pain "needs an EKG, cardiac enzymes x 3, fasting lipid panels, hemoglobin A1C, thyroid tests, telemetry, started on an aspirin, statin, nitroglycerin, meds for high blood pressure, a beta-blocker if is pressure is ok, and consider a heparin drip." It all rolls off your tongue, and you don't realize that, damn, over the past 6 months this has become second nature.

After my pulmonary month, I did a month of geriatrics, which was a really good month. These old people are so cute, and many of them pretty fascinating. They have been all over the world, or have had interesting jobs or positions, and many of them are still living the good life in their assisted living homes. But also, we had many of the more somber cases of nursing home residents, who often get the nursing home sicknesses (pneumonia, urinary tract infections, diarrhea, etc), come to the hospital, get better, and then are sent back to the nursing home to get their next infection. I remember specifically, we had one nursing home resident who comes to us with failure to thrive, decreased appetite, nonspecific abdominal pain. Turns out he was a prominent faculty member of the UNC medical school. He has no wife, no kids, no family around. He had a fall a few months ago, and had to be put in a nursing home as he had no one to take care of him. But since his placement, he seemed to be profoundly depressed, and his memory got worse and he just didn't want to eat, or do anything. Other things can cause this presentation, this wasting away and anorexia and weight loss and abdominal pain, mainly cancer. But we did a big workup, and eventually found that really this was all from depression. Even his memory loss was from big time depression, which is called "pseudo-dementia." All his former friends and colleagues are associated at UNC, and there was no where else he wanted to be than among them at UNC. But he had no other reason to be hospitalized. We let him stay about a week longer than he should have, but eventually had to force him back to his nursing home, where he would spend Christmas and New Year's alone. That's the other side of these elderly patients. I hope that none of my family and friends have to be alone when they're old.

Lastly, Nicole, Sofie, and I spent our first Christmas in our own home, which was really great. Nicole's mom Barbara came down and joined us for the holidays, and we set up lights, got a tree, they put up stockings, and we had a great time. I got 5 days off for the holidays which was badly needed. We spend 2 of those days after Christmas over in the mountains, visiting Margot, George, and Stefan, friends of ours who were at the wedding. Stefan and Nicole were born the exact same day in the same hospital in Dallas, and lived on the same street! They have been friends since Day 0, and its pretty cool to see them still keeping in touch.

I'm now starting on cardiology at UNC, and it will be another busy but good month! And after that, another week of vacation, followed by 2 "easier" months, one of which I'll have no call or weekends!! Half way done with intern year!!!!!!!!!!!!!!

There's a lot more to catch up on, and more pictures to post, so as one of my new year's resolutions I'll try to keep up on this blog again. I wonder if anyone is still reading this after my lastest lull though...oh well! Happy holidays and happy new year!

the ICU

The intensive care unit is a very different place. The environment is good, the staff and nurses supportive, and all the doctors and residents who are on the MICU (medical intensive care unit) work really well as a team.

But the patients...they are so sick. Academic hospitals tend to have sicker patients than community hospitals. And patients in the ICU are the sickest of the sick. Here are some examples:

- 21 year old male who was binge drinking, past out drunk, vomited and then aspirated his vomitus. Found a few hours later by his brothers, and may have suffered severe lung injury as well as decreased oxygen to his body for hours.

- 70 year old male who had shortness of breath. His heart function turned out to be 1/6 of normal person.

- 45 year old female with metastatic breast cancer who was moaning, low blood pressure and high heart rate and fever. Symptoms were consistent with bad infection, and complicated by blood clots in all extremities. Died 2 hours after we transferred her to the ICU, from a heart attack.

- 60 year old male with shortness of breath and cough for 6 weeks. He was found to have lung cancer that occupied 50% of his lungs. We treated him with chemotherapy and helped him breathe with a breathing machine...but watched him slowly die, first by lungs failing, then with fever and infection, then dropping blood pressure, until finally his family stopped the suffering.

What I've learned is that, as much as we try to treat and save these patients, most of them will do what they'll do. If they are dying, no matter what we do most of them will still die. Medicine can only work its magic so far, until nature overpowers us.

We have saved people, too, though. The biggest thing we do for people is aggresively give antibiotics and fluids, and support their breathing if their lungs fail temporarily. The people who come in with raging infection that threatens to shut down all organs, we give them TONS of fluids, antibiotics, and hope that their body makes it through. And some do, and it really is a miracle.

The last gentleman I described above, the one with lung cancer, was one of the saddest cases. The wife finally decided to call all the family in, so that everyone could say their goodbyes. And then she gave the decision to withdraw support. He died 2 hours later. But they are only pronounced dead when a doctor says so.

I have never seen someone pronounced dead, and never learned how to do it in medical school or residency. It wasn't part of the training...and you don't study or prepare for it. But I was on call, and the nurse told me I was to pronounce Mr. S. I don't know how to describe walking into their room (not knowing what I'm supposed to do), with all of the family surrounding the bed. When I approach, they step aside to let me walk to the patient. And I do what I think I'm supposed to...I listen for a heart beat, feel for a pulse and a breath, and open his eyes and shine a light to see if his pupils react. Its very surreal, eerie, to be doing this to an already dead person, with the family watching me. I do these motions, and then simply say, 'okay', and nod with closure to the wife. I walk out with the nurse, and pronounce him: "Time of death, 7:50 pm." And I tell the nurse to ask his wife if she wouldn't mind answering some questions for me, whenever she is ready.

Its crazy. Mr. S was happy, jolly, eating when we first saw him. We knew he had cancer, and we saw that he needed oxygen by a face mask, but he was still alive and still talking with us. His wife was always there at his side. And we saw him slip away over the course of 2 weeks.

Afterward, I talked with his wife and 2 brothers, and we talked about his funeral home, if an autopsy was desired, if he is an organ donor. And then we reflected a little bit about him, how he didn't want to suffer, how it was hard to let him go. And they were thankful, I think, even though I barely knew him...I was just the doctor on call. It feels strange that I should be the one to give the final declaration that this person is gone.

I felt sad for the family, and a little numb that I just pronounced someone dead. I didn't quite know what to say to the family, or if I should've said more, or less, shown more emotion, or less. I felt like I was intruding into a emotional, very personal family meeting, and that it wasn't my place to say too much. Maybe they thought a doctor was coming in, performing the routine and doing his job, but I'll tell you it felt like a young, afraid, unsure man who just graduated from school had just put closure onto a huge chapter of this family’s life, and it didn’t feel natural to do so.