New England Interviews

I had a direct flight that got me into Hartford, CT around 11pm on Sunday, December 17th. Luckily, I missed several days of snow from a major storm. Getting my rental car and driving to the hotel went smoothly. But I heard lots of stories of people stuck in traffic for hours after 13 inches fell in eight hours during the workday.

It was a little crazy getting the 2-3miles to UConn Monday morning due to the snow and icy conditions, plus I missed a turn-off. It was a little stressful but I made it to the interview exactly on time.

I started out not being too impressed with the UConn program for the initial didactic lecture we sat through the PD's program overview. But during the interviews and lunch the warm fuzzy feeling about the people returned. By the end of the day, they were right back at the top tier of my ROL and I was looking forward to driving Tuesday for dinner with some of the residents.

I spent the night in Springfield near the Baystate EM offices. The Baystate/Tufts also gave me the warm fuzzies about the people, but I just wasn't as impressed with the actual program. I was actually irritated that they made applicants get on the hotel shuttle at 7am and sit around the ED offices for an hour and a half while the PD drove in. The cooridinator, a nice lady, did the program no favors by mentioning how the facility was falling apart and one resident almost got by falling ceiling debri while snoozing in the oncall room. As I remembered from my previous visit, the place is packed and very efficient in an old school way. They put more patients through fewer beds than any other program I know of. By the end of the day, after mentally bouncing them up and down my ROL, they returned to the same I had them before starting the trip.

I headed back down to Hartford for the UConn resident dinner and had a chance to ask lots of questions that came up during the interview. I had a really good time and enjoyed the people and atmosphere a lot.

Then I drove an hour or so to Worcester, MA. It sure looked familiar having finished my month there only 6-7 weeks ago. I arrived on time for my UMass interview of the trip and immediately got the "wow" impression I had had from reading about the program and my initial visit. The offices, ED and hospital are all brand new and gorgeous. The new sim lab being built in the new building across the street will likely be just as impressive. Like the other applicants, I was on their leash through the PD's introduction and the resident slideshow. On paper, the place has everything going for it including a month in HI for a PGY-III hyperbaric elective. I even enjoyed the interviews. However some of the problems quickly came to the forefront. The Attendings don't do much teaching and you don't see them at conferences. Jeremy, whom I had rotated with, and I compared notes afterwards and came to the same conclusion. There is great training, but it isn't a warm place and do get very busy moving meat in the ED.

So the I started to question the value of the whole trip since all three programs ended exactly where they had started in my ROL. Of course I had to make the interviews in order to rank the programs, and I will rank all three. It just seemed like a lot of time and energy for not a lot of new information or gut feelings.

My drive back to Hartford, night at the hotel and flight back was uneventful. I shouldn't have scheduled a 5:30am flight because I had to get up at 2:30am East Coast time. But I managed to sleep a bit on the plane and start studying for my upcoming COMLEX Level 2 PE exam the following week.

Finished plastics

Get getting around to this rotation summary a week and a half late. My Emergency Medicine post-rotation exam and several interviews side-lined me for awhile. I passed the exam and will blog about the interviews next.

Well I am very impressed with Dr. Kotoske's practice. It's almost unique in medicine today to have a sole practice with its own operating room and over twenty employees (6-8 at any given time). But cosmetic surgery, as cash pay service, is one of the last truly lucrative fields in medicine.

More importantly, Dr. Kotoske has a great reputation for his Quicklift procedure, breast augmentation and tummy tucks. I also saw him do one nose job (rhinoplasty) on a gorgeous young lady that had had a life-long complex about a slight asymmetry. But who has a naturally symmetrical nose anyway?

Breast jobs are just fun. You take young, generally already attractive females and give them these large, shapely breasts that are incredibly attractive. But the best part is seeing their new self-confidence and huge smiles (many times with smiling significant others present as well) at the post-op visits a couple of days after surgery. I guess if I was a breast guy I would find the artistry more appealing. I'm just not a perfectionist like Dr. Kotoske when it comes to breasts.

The Quicklifts are a great invention. They are the perfect surgical treatment for the majority of women over 50 that want to look 10 years younger. I might be interested in one myself someday, except that I'd need something for my forehead wrinkles. I don't see myself doing botox anytime soon.

The tummy tucks were the most physically demanding procedures and the most "barbaric" on the patient. Lots of flank and abdomen liposuction followed by blunt dissection of the abdominal tissue from belly button to ribs. Then two big, generally several pound, flaps of flesh get removed. Finally, there's a multi-layer closure with multiple deep sutures and staples on the skin.

All the patients looked great at the post-op visits, were thrilled with the results and couldn't stop thanking Dr. K. for his work. Not a bad gig!

If it wasn't so competitive and cut throat to get into with a masochistic residency I would be tempted. However, Emergency Medicine is definitely a better fit for me and for the family. It was an easy rotation that convinced me cosmetic surgery isn't too vain and Dr. K. is one of the surgeons I would consider using for myself someday.

Maricopa

I'm starting feel like life is getting back to normal. However, I still have mail and magazines stacked around the house. And my diet and exercise routine aren't up to snuff. After all, it's not like things are "back to normal".

I started a new job on Monday. My plastic surgery rotation is going to be interesting, but I don't get to do anything since these are patients paying cash for a celebrity plastic surgeon to work on them. And there isn't a whole lot of wound care going on, it's all cosmetic procedures.

I've seen four "Quicklift" facelifts over two days. Very interesting procedures and a very lucrative business model. Dr. K. has patented the procedure with a partner, so they get royalties from othe surgeons around the country and can exclude the run-of-the-mill surgeons from messing up the procedure's reputation. A local news host had the procedure done and was back on TV in two days. Can't get better marketing than that! Anyway, I have enjoyed talking with Dr. K., his surg tech, the anesthetists and the circulating nurses, all of whom have been great. And the results are fantastic. Heck, I might have to get one of these in 10 or 15 years!

If plastics wasn't so darn competitive I would probably put up with the long, difficult residency/fellowship and go for it. I can see myself doing these procedures easily. The cosmetic operations make the mint and the reconstructive stuff makes you feel good (or at least removes the guilt). Plus you're working with a great patients (healthy, cash pay and frequently already very attractive), being creative and owning your own business. Dr. K. advertises the "eyes of an artist" while employing 21 people (most part-time) and operating his own private, JHACO approved, surgical suite. No surprise here I'm sure, but he drives a nice Porsche as well. Not bad!

Becky and I went to Maricopa's pre-interview dinner on Monday night with a big group of current residents and fellow applicants. Dave Levin from my class was there as well. He's been rotating there for two months, so I was the one asking all the questions. Becky was a bit bored, but we had an ok time. The dinner was just mediocre.

The interview on Tuesday went well. I really like the Program Director, whom I met in Seattle at the ACEP Residency Fair. The tour went fine. It's a county ED, but not a bad as I feared. They will be building a new one well after I'm done with Residency, but the current one, curtains and all, will suffice. I was pleasantly surprised by how well the department is funded and how strong the leadership throughout the county system. I feel confident I could get a great education there. The regional (southwest USA) burn center is a unique factor I like. They teach EM residents how to do fasciotomies and skin grafts! Finally, we would save a ton of time and expense because we could stay in our current home. The commute is much more doable than I thought and many residents live further away than we do now.

Maricopa will definately be in my top five, likely in my top three. The big decision comes down to whether we want to put Hopkins #1. Becky and I have been talking a lot about that lately.

Today I mostly relaxed. I could have gone in for office visits of patients following up on surgeries. But understandably Dr. K. doesn't want a student in the room when he's having potential patients baring their souls and skin as he makes his pitch. So I stayed home and finalized travel plans for the COMLEX PE test at the end of the month and my five remaining interviews, three in New England and two in Ohio. I still need to cancel MCG. But right now I'm torn between finishig Wired magazine or playing an Xbox 360 game...

Finished Christiana and the audition rotations

Today was my last shift at Christiana. It was a little short since I took off at 1pm to get errands done before I fly out tomorrow. One memorable case was a guy with a "surgical belly" from, we believe, his second bowel perforation. He had the first repaired last month, but it didn't have nearly as much free air, free fecal matter or perotinitis. These are happening because mets from his stage IV lung cancer are eating holes through his intestines. And he's a young guy.

Over the last week I've had several good cases at Christiana. Good traumas, some acute injuries and some interesting work-ups. Yesterday in Wilmington we had a homeless lady with Pyoderma Gangrenosum. She was a sad case that used alcohol and crack to self medicate on the street. The bandages we took off were at least two weeks old. They were black and the smell of rotting flesh lingered around the ED for hours after she was admitted. The ulcers were easily the worst I've ever seen. Her breasts, back and left hip were craters. If she would try to take care of herself and stay on her medications it wouldn't have gotten nearly this bad.

On Tuesday I had my Christiana interview. It went better than I expected. I really liked the answers to my questions. There's some great new changes like a $5M sim lab and one-on-one teaching rounds. And the EM department is very strong with the hospital organization. I really enjoyed meeting the Assistant Program Director as well. Right now, it feels like it will come down to whether we want a 4-year program with fellowship (i.e. Hopkins) or 3-year program that really takes care of its residents (i.e. Christiana).

Hopefully Becky and I can come back in January for a second look at the programs and areas (homes, schools, job opps for her).

Now though I have to pack. I'm getting up at 2:30am to turn in my rental and catch a shuttle to the Baltimore airport. My flight leaves at 7am and gets me into Phoenix around 2pm. Then we have a late Thanksgiving meal with Tucker and his family at our house. It's going to be a long, tiring day tomorrow.

Luckily I've managed to get 8-9 hours of sleep the last couple of nights. I'm starting to feel like myself again. If I had to use one word to describe the week it would be exhaustion. The lack of days off, numerous interviews, stress of setting up interviews and getting rejections all caught up to me. I've also done a terrible job of keeping shape.

I'm going to have to spend some serious hours in the pool and on the bike to shed a few pounds and get back into shape upon returning to Phoenix. But on the plus side, I'm halfway through my interviews!

Time to pack and try to get a little sleep.

Tough week with four interviews!

The Drexel interview went well last week. I'm still trying to schedule a second look at their CCU where they complete about seven months of training. It's a solid program with good people in downtown Philadelphia.

Over the weekend I had a couple really good shifts at Christiana. I finally got to see some of the trauma and procedures that I knew could be found here. I saw two motor vehicle deaths and was allowed to listen to one of the Attendings talk with the family. It was a good learning opportunity and I am glad I sat through it. Tough to explain to the adult children how family members died unexpectedly, but it's something that Emergency Physicians have to be able to do.

Then I had most of the week off to complete three interviews. I only worked on Thursday at the secondary hospital in Wilmington. It's a more urban location and patient population. I had a good time there as well. I also got a chance to talk ask one of the residents a lot of questions about Christiana. I'm looking forward to my interview on Tuesday so I can ask the leadership some questions.

Monday I drove to upstate New Jersey and had dinner with the Morristown residents. They were incredibly nice. During the interview, I got the feeling that it's a small residency with very nice people that has a family feel. You get lots of face time with Attendings. The residents and attendings are very close. Morristown is also a nice area for families. For trauma you go to Newark, NJ to see penetrating trauma.

Wednesday I interviewed at Cooper in lower New Jersey. It also impressed me more than I expected but for different reasons. The Program Director is very impressive and I like their unique track system where you use your RRC required scholarly project to concentrate on an area of interest that you can list on your CV. The trauma and pathology is more acute for the patient volume than most places. Camden, NJ is a very poor area with lots violent crime. It would also give us the option of living near Philadelphia so Becky's job opportunities would be great.

Friday, today, was the most surprising of all. But first, I had to get to Baltimore. I got off work in Wilmington at 4pm last night. The resident dinner was at 6:30pm. I thought that would be plenty of time to drive down about 65 miles with a quick stop at my hotel room to change out of scrubs and grab a bite to eat. Well, the Wilmington traffic was horrible. It took me over an hour to get 7 miles from the hospital to my hotel room! So I spent an hour chilling out and hoping rush hour traffic would die down a bit. After all, I was going into Baltimore so it should be against traffic. However, construction on the main freeway, I-95, turned a 57-mile drive into a three and half hour parking lot. I kept thinking it would speed up once we passed some fatality accident. But they just kept reducing lanes after miles and miles of more stop than go traffic. Six lanes reduced to one for no apparent reason! They didn't seem to be doing any work on the road at all!

I arrived at the hotel, Mt. Washington Conference Center, at 10pm. The bar where I was supposed to meet the residents was the closest place to get food so I walked thinking I was going to foot the bill for a very late dinner. After inquiring though, four residents were still there. All the other applicants had already headed home. We talked for two hours over a couple glasses of Guiness, which greatly helped me recover from the drive down. The appetizers filled me up at well. I got six and a half hours of good sleep.

Hopkins itself is incredible. Their are three cranes there right now building the largest hospital expansion in history. A two billion(!) dollar expansion including a new ED. However, it won't be ready until early 2011 according to the latest estimates. I really liked the residents, including the three D.O.'s there now. No overblown egos, just lots of nice friendly people, many of whom are world renowned for writing our textbooks are publishing prominent studies. The Mt. Washington offices are opulent and were effective at demonstrating how well funded the Emergency Department is. Friday is conference day at Hopkins, and the training seemed very good. Then we took a tour of the city even though most of the applicants knew the city as well as our guides. It's a nice place of about 650,000 that would offer a reasonable cost of living with lots of opportunities for Becky. The Hopkins ED was fairly plain, but seemed more than adequate for a place to get good training. And finally the interviews were, like everywhere else, low key and a friendly Q & A session with equal time for both parties to ask questions.

I left really impressed. They are now a four year program, so the decision really comes down to whether that fourth year will pay for itself either financially or in new opportunities. I think it would, especially with the Hopkins name backing it up. And they have 12 tracks to choose from, which I don't think could be offered at any other institution. Education, administration and ultrasound are the most interesting to me right now. In the end, I would put Hopkins at the top of my list of places I've interviewed so far. My top four will probably end up being UConn, UMass, Christiana and Hopkins but I have no idea what order they will ranked. Cooper and Maricopa may also make it in there.

Lots to think about. It's been a very stressful week nailing down four of the five interviews while I'm here in the MidAtlantic region. Plus I nailed down St. Vincent's and Case Western/Cleveland Clinic in January and Maricopa in two weeks back in Phoenix. I also got a number of rejections. The only one that is really disappointing is OHSU. MUSC was equally surprising, but not nearly as disappointing. Financially my current schedule will be much more doable with only two more trips. The amazing thing is that the numbers are working exactly like I was shooting for. Five interviews while I'm here at Christiana and ten total. I actually have eleven if I don't cancel MCG, plus I'm still on the waiting list at three programs and there's five or six I haven't heard from yet. But I'm pretty satisfied.

My Tuesday interview is just me for three half hour sessions with the Christiana leadership. I'm a little nervous about that one since it will be just me with no warm and fuzzy introduction to the program over lunch. At least I have one of my two days off this month the day before it. What a month!!

First Interview: tomorrow at Drexel

The first week at Christiana was good. Nothing about the program swept me off my feet, but everything has this unspoken confidence of doing things right. A resident would get a good education here, but the program has also shown me that I could get a good education at many programs. The only question mark in my mind is how they handle their volume with only two trauma bays. Their older design reminds me of UConn except I think UConn had four with two pairs back-to-back.

The attendings and residents have all been good to work with. I think I have been doing a good job based on the limited feedback offered thus far. I need to remember to ask for feedback directly at the end of each shift. Yesterday I had a chance to work with the Program Director. Since I had never met him I didn't even know who he was until a resident pointed him out. That was annoying. But it went well otherwise. His parting comments included mentioning that 80% of their interview invitations go out today. So I've pretty anxious all day.

I finally just started phoning up programs to ask what the status of my residency interview applications was. The only one I got through to anyone was Christiana. The Program Director wants to get some feedback from my attendings and residents before deciding whether to give me an interview. Not what I had hoped, but if I continue doing a good job I believe I'll get an interview while I'm here.

Dean's Letters went out on November 1st, last Thursday. I expected a rush of interview invitations and even rejections by now. But nothing until an hour or so ago when I received an invitation from Cooper in New Jersey. That's number seven. They are an inner city program across the river from Philadelphia, where I'd most likely live. Not a ton of volume, but lots of trauma and serious illness. I'm trying to get that scheduled while I'm here as well. However, the ones I really want to fit in, UMaryland and Hopkins, haven't responded yet :(.

Tonight I'm driving to Philadelphia for an informal social with Drexel residents. The interview is tomorrow at 11am. I'm trying to prepare my questions, review the program information online, etc. but it's been difficult with the anxiety of waiting to hear from all the other programs I applied to. Well, time to stop procrastinating with this blog and go back through all my first year research. I'm certain to get asked questions on it.

A little dreaming

Over the week of vacation, I've made a point to do very little medically related. I need to get mentally recharged for a month audition intermixed with a month and half of interviews.

To keep motivated I love National Geographic's Adventure Travel magazine as well as Wired magazine. Travel and gadgets keep me going. But here's a couple YouTube videos that are also motivational:





There's more great ones for giggles and spectacles at http://www.flixxy.com/.

Week of vacation

It's almost time to head to Delaware for my Christiana rotation. And while I'm getting excited to see the program, I'm going to miss playing with the family. I've spent a lot of time with the boys playing catch; mostly baseball and football. I feel a little guilty not having done a good job teaching the fundamentals of throwing a ball or catching a ball until now, but life has been crazy and soccer and swimming were all I could manage.

They are a little more confident with friends and in gym class now. Moreover, I'm still the cool dad :-).

All four of us swam together at the Arrowhead pool. The boys on their team and Becky and I on the Masters team. The coach had us doing hypoxia drills. Wow, I thought I was in decent shape, but 2000 yards of it wiped me out. The competitiveness of swimming with the other guys really pushed me.

I've also had a chance to work on a bunch of paperwork and small To Dos. I reviewed my Dean's Letter as recommended by the four EM PDs in Seattle a couple weeks ago. And I organized my four (so far) interviews. I scheduled my Morristown, NJ interview as early in the Christiana rotation as possible. It will be my work-up. Then I hope to take four or five more days off to interview at Christiana, UMaryland, Hopkins, Drexel, Georgetown and/or Cooper. It would save a ton of time and money.

I'm also enjoying hanging out, drinking wine with Becky and her sister in the evenings and playing a bit on the Xbox 360. Time to start printing all my logistical paperwork for the next month. And a couple more errands to try to squeeze in. Then it's off to Delaware.

Baystate and saying goodbye to UMass

The day after visiting UConn I went to Baystate not really knowing what to expect. I reviewed the web site for the residency program but it didn't really give me a good idea of what to expect.

First, the hospital is very suburban. No high rise parking lots here. And it's a mix of stages built over probably fifty years. The existing ED is an older section and not expected to be upgraded for a few more years. The didactics were held in the newer wing and fine. Nothing spectacular, but nothing to fault either. Residents and students all got along, seemed to be having a good time and were learning a lot.

The ED itself is cramped! They take care of more patients per year (~120k) in a smaller space than I ever seen. It's very efficient but also a little chaotic. The main physician/nursing area is small enough that everyone can see the gigantic whiteboard used to track patients. Every square inch of hallway space is used with carts, beds and even recliners for the asthma patients. I am sure I would get a good education there, but I didn't get the warm fuzzies that I did at UConn.

The last two days of shifts were pretty easy. Busy as usual, but I was able to get in some suturing and run a few patients on my own. Nothing too crazy. The night before I left the owner of the house I stayed at mentioned a bunch of great restaurants nearby. Unfortunately the other roomie and I chose one with poor service and mediocre service. Then we topped it off with a funny but amateur comedy show. I packed and got a few hours sleep before starting the day of travel.

The trip back was long, a full day, but got me into Phoenix around 3pm due to the time zone changes. Becky picked me up and then we headed home to see the kids. I'm really glad I took the two days to see UConn and Baystate. While UMass has everything going for it on paper including high patient volume, a new ED, airflight service and a Hawaii elective, I felt more at home at UConn. I think that was recognized by UConn as well. They already sent me an invitation for an interview!

UConn visit

The drive to University of Connecticut was beautiful. The trees are all changing to Fall colors and there were numerous ponds and creeks along the way with forests of Fall trees lining the banks. Plus it was a sunny brisk day.

I found the parking lot and department offices in plenty of time to get lunch and be assured that my business casual (Prna pants, Quicksilver button down and Keen loafers) attire was fine. The two hours of lecture from noon until two PM was fun. The material was fine, but I really appreciated the camaraderie the residents displayed. Their was joking and teasing and plenty of talk about after work get togethers. They had DO residents and one older than me!

We then proceeded to their very cool sim lab with dummies and set-ups for ICU, Trauma and more. We donned hazardous environment suits and entered two sim labs for training in running codes for patients with highly contagious or poisonous exposures. It was challenging and a blast. I actually felt part of the team and was able to contribute a bit. The PGY-2 residents certainly knew more than me, but I never felt patronized or looked down upon.

Finally I headed to the Emergency Department to work with one of the PGY-3 residents for a few hours. We had a trauma and several really sick patients. But I was able to get feel for the ED and ask a bunch of questions. Even though they have paper charts (with efficient electronic ordering software) and the ED is a bit dark, I liked the place and the people I met.

I certainly hope I get an interview at UConn.

What's so great about New England?

Today I really had to question what's is so great about New England. It's overpriced, overtaxed, overly Liberal and filled with gruff, even mean, people. Ok, I was a bit unlucky today, but maybe it's another sign.

I was running late to my 11am shift because I slept in late. Had to catch up on sleep after a very busy week of shifts that never stayed at the same times (morning, afternoon, overnight, afternoon and then morning again). I also had a down comforter so I was comfy warm for the first time.

As I walked out to the car at 10:40a, here's what I saw:Granted, it wasn't the sweetest ride to begin with, but WTF!?! How did my car get singled out when there were tons of other cars on the curb? How come I didn't hear anything (my window was only 20 feet away)?

Today just got worse and worse. After taking the pictures and talking to the police, I limp to the hospital. Luckily it was very close since the steering had play now measuring in feet! The mangled front hubcap was rubbing into the tire and brakes.

So I arrive late and can't find parking anywhere. I finally park in the spot the furthest away from the stairs thinking it's a safe spot. Par for the course, I found a parking ticket on my windshield when I returned later that night. However, on my way into Fast Track, 20 minutes late for my shift, VISA tells me that the car isn't covered by my credit card because the rental is over 15 days!!! Since I rented for one continuous month, they probably won't cover it. (I haven't decided whether to cancel it or just change next month's rental into two consecutive 14 day rentals.)

Becky talked to Geico and they inform us that they'll cover it after the $500 deductible. So I file the third stinking claim for the morning and proceed to work a slow, uninteresting shift. At the Attending was cool. He was a hospitalist moonlighting in the ER. Nice guy that was fun to talk to considering that he owns multiples of just about every toy I've ever dreamed of owning. Plus he travels at least once a month. Helps that his wife is a physician as well and they have no kids. I wouldn't trade the kids for anything, but puts it all in perspective.

Enterprise was across the street from the hospital so I headed over there. They upgraded my vehicle and were very nice about taking my credit card for $500. I can't complain about their service at all.

I can only hope that my trip to UConn in Hartford tomorrow is better. It's a bigger, nicer car (if you can call a Chevy Cobalt nicer). I'll get out of the big city. Maybe the sour taste for all of New England will melt away with the drive through the forests of fall trees.

Getting Comfortable At UMass

Only nine days and seven shifts left at UMass. The two days off I'm going to drive out to the UConn and the Baystate/Tufts EM programs in Hartford, CT and Springfield, MA, respectively. I'll get to meet some residents at their didactic conferences, then spend a couple hours in the ER shadowing a senior resident.

I am definitely getting more comfortable here. The residents have all been pretty cool. And the Attendings have been very good as well. The "systems" side of things (EMR, charting, admitting, protocols) still have kinks to work out. They may be long-term issues, but I get the feeling these issues have gotten more obvious since the new ED opened a year ago.

No super exciting cases. I've sutured lots of lacerations, seen a few traumas and learned how to treat many kinds of patients. The didactics continue to be one of this programs strong points. And the morning shifts we usually get a good 30 minute lecture in the ED from an Attending. The volume is high, and while there's not too much penetrating trauma, there's a ton of acute cases that need monitoring, airways and eventually ICU beds.

I spent the weekend in Seattle with the family which was terrific. Friday I arrived early and spent most of the day playing with the boys. You could just tell they needed some daddy time. Even at 9 and 11, they enjoyed the tickling, wrestling, hugs, etc. Becky did too; wink, wink. Saturday we met Becky's brother Paul and his family. It was a cold, gray Seattle day but the enjoyed playing at my old stomping ground, Greenlake. We even had some Spud's Fish & Chips for old time sakes.

Saturday night we went Becky's older brother's, Dave's, house. It was a huge family gathering mostly to send Paul and his family off to Zurich for the Microsoft job he just accepted there. The food was good. Everyone seemed to be doing well. And the kids (lots of cousins and second cousins) played great together. Only once or twice was there a scream followed by everyone looking at me "Dr. Grady" for some reaction. My mother seems to be well too, and I enjoyed driving her Prius around.

Sunday Becky drove me into Seattle for the American College of Emergency Physicians (ACEP) Scientific Assembly's Residency Fair (whew!). I spent in obvious reasons and made it to the 10am meeting. We had several good lectures until about 2pm on improving residency applications, being a good resident and interview tips. The rest of the afternoon was the "fair" part of the program where 100 EM residency programs hosted tables in a ballroom.

I was able to see most of the programs I've applied to and got a lot of positive feedback. Sure they hadn't seen my application, and they were selling there programs, but my confidence in getting more interviews was definitely increased. In case I didn't already mention it, St. Vincent's in Toledo, OH where I rotated at last year for Peds and Surgery has already invited me for an interview. Anyway, I met a lot of program directors and current residents while getting excited about seeing many of these programs I only know from a web site.

The day was worthwhile and I was happy to have attended, but I don't think it would be worth going if you don't family nearby or some other reason to make the trip. Becky, the kids and I had a nice dinner together and then I changed out of my suit and played a little flashlight tag with the boys. All too soon, Becky was back in the car driving me to the airport for my red eye flight back to Boston.

After the trip home, I'm ready for this rotation be over. However, there's still more to learn and more to prove. I don't know if I'll get a LOR from this rotation simply because I haven't gotten to know any one Attending very well. And I'm still trying to decide whether or not to ask the PD, Dr. Cukor, for an interview while I'm here.

Well one more rotation after this, Christiana in Delaware. The residents at the ACEP meeting were very nice. I'm excited about that program as well as several of the one's nearby; UMaryland, Hopkins, Georgetown and one in Phili I can't remember right now.

Off to an evenign shift now, then my only overnighter tomorrow. 237 days left in the short coat.

First week at UMass

Monday was an ok day. We had an excellent orientation of the ED software programs and the facility itself. However, I was the only student in scrubs. It made the program feel stuffy, especially when one of the Attendings pointed out that ties highly encouraged by the program's directors. First, who where's a tie in the ED!?! Kinda hard to jump in on a trauma in a friggin' suit! Second, I only brought my interview suit with two shirts!

After the students made our schedule for the first week, I decided to wear my new suit slacks and dress shirts only when I working with one of the PDs. I ended up getting the more conservative PD's only two shifts of the month, Monday and Friday. So I headed home after orientation and changed into my $1000 suit slacks vowing to send UMass a bill if I got blood and guts on them.

The facility is less than a year old. The $120M hospital included a new $50M ED and new offices for the ED department, some of which don't even have furniture yet. They did a nice job with the design. It's attractive and functional. The only problem I've seen so far is that the hospital beds are so full, the ED is becoming an Observation Unit.

The software is a little nicer than MUSC's, but has plenty of usability issues and glitches in its second version. Bottom line, they are still using paper charts for the foreseeable future. Unlike, MUSC however, the paper chart system is horrendous. It's a pain to find charts and make sure orders or being seen and acted on.

The residents are very nice. I've only met a handful of the 36, but they are helpful both on the job and in answering questions about UMass and EM. They seem very happy with the program. And they never wear ties in the ED! In fact, most of the attendings wear traditional "in the trenches" scrubs and casual clothes. I guess it's just the PDs and attendings involved in running the program that are stuffy.

Didactics have been pretty good. Wednesday conference involved five hours of lectures, case studies (M&M lectures), going over EM Board prep questions and small group break-outs sessions to work through case management together. Journal club Thursday night was well attended by residents and attendings, included dinner and had some great content on Pediatric Lumbar Puncture procedures. Today was my first morning shift, so I got to experience teaching rounds by one of the PDs on overdoses and found it very good.

The shifts have been very tiring. This is a very busy ED and I rarely get a chance to eat and take bathroom breaks. So far it's been a little too busy for optimal learning. The cool cases get snatched up and I never have time to peak in on them or procedures. My patients are either run-of-the-mill or very complicated. The former mean I don't get much attending attention and therefore don't learn much. The latter mean I have the patients all day and do a lot of babysitting between specialty consults and extensive tests. I'm hoping that as I take more morning and overnight shifts things will settle down a bit. I also think the 8 hour shifts make things more chaotic with a lot more turnovers and long stay after shifts to finish discharges. I usually stay 30-60 minutes after my shift tidying up paperwork.

Hopefully, when we finalize the schedule for the rest of the month on Tuesday, I can get some easier shifts.

As for cases, my luck seems to be hanging with me. I was able to help out on a paraplegic guy, probably homeless, who had his foot mangled by his girlfriend's chihuahua. They are both in wheelchairs, and probably sleeping on the street by their smell. He states that while sleeping their new puppy had a free meal of his left fore foot! The big toe was gone as was most of the next one and the flesh where bunions occur. I didn't stick around to see who won the debate about whether the patient should be admitted to Ortho or Plastics.

The other cases have been pretty standard. And while I'm out of practice working on adults, it coming back pretty quickly. Exhausted as I am, I'm enjoying the job which is very comforting this close to the Match.

Probably the highlight of the week had nothing to do with UMass. I received both my SLORs in the mail from the PDs at Arrowhead and MUSC. That was a relief. I immediately updated my ERAS applications to include them. A close second was winning an auction on Ebay for a new Phone/PDA since mine broke. Hate spending the money, but at least it's an upgraded model and I can have access to all my medical programs while on shifts.

Finally, the house I'm staying at is a nice old Victorian three story being remodeled by another 6th year student (MD, PhD). He and his wife, along with the two other renters are nice. It's a comfortable place with lots of room to study, store food, etc. My favorite thing is having a big room with a desk and wireless Internet access.

One week until I fly to Seattle to see the family and attend the ACEP Scientific Assembly Residency Fair!

Election Year Politics

Everyone talks about how healthcare reform is the issue in the upcoming Presidential election. However, the candidates and, especially, the media treat it like a distraction. A good editorial from the NYT today reminded me of where we're at in this mess.

The Battle Over Health Care

While the Democrats are least talking about the issue, they seem to be taking the easy road as much as the Republicans. No on either side mentions how generate competition between insurance companies, pharmaceutical companies (or at access their offshore pricing) and other Biotech companies. Equally detrimental to the country is that neither side mentions how we are going to cover health costs as a nation so that our biggest employers and exporters aren't burdened with costs that hurt their competitiveness internationally.

Recent articles and TV reports portrayed CEOs of multi-nationals as very interested in reform foremost because of the competitiveness issue internationally, but also because the liability of retirees is hurting stock prices and company values.

So why aren't there more substantial discussion going on? Are we Americans so naive that we can't face the truth - any solution with hit all of us in the pocketbook? Are we going to wait until this is a crisis and the babyboomers bankrupt the country between Social Security and Medicare?

It's very frustrating that elections now seem to direct their campaigns (and their terms in office in large part) towards the lowest common denominator of society: the uneducated or uninformed, those who vote on one emotional issue (gun rights, abortion, etc.) and the those naively think they can escape any pain or consequence of costly decisions.

How long can a Democracy last catering to clicks and Junior High mentalities?

Trip to Worcester

It's been a long day. One that reminds me travel isn't all bells and whistles.

First, Microsoft Outlook again messed me up, almost causing me to miss my flight. Because I entered the flights while on the West Coast, my 11:50am flight became 2:50pm. Luckily I remembered this issue around 10am and called Continental to check. Charleston is a small airport, so I was still able to make it to the gate in time.

However, the plane was late arriving. Then it had mechanical problems, and being such a small airport Continental couldn't be sure when the next flight would leave or how we could catch connecting flights. I got lucky and made it back to the ticket counter #2 in line since most people lined up back at the gate. They switched to US Airways, which gave me 40 minutes to fly out. Somehow my baggage made the switch as did I.

I arrived in Boston later than expected, and it was a long limo ride out to Worcester. But it could have been much worse. The house is pretty nice and walking distance to one of the hospitals I will be working at. It doesn't look like this is as nice an area as Charleston, but it's hard to tell at night.

I'm exhausted, but I got in some pleasure reading and am enjoying staying at a place wireless access so I check e-mail while watching Saturday Night Live.

EM for Immigrants?

The immigrant debate seems to have crashed into Emergency Medicine coverage for the uninsured. This NYT article got me thinking:

U.S. Rule Limits Emergency Care for Immigrants

With healthcare costs skyrocketing, why should we provide chemotherapy, expensive experimental medications, transplants, etc. that definitely aren't critical emergencies to foreigners without insurance? I think that it is a lot to ask Americans that are going broke trying pay for healthcare costs and medical insurance.

Equally troubling is what coverage we as taxpayers should shoulder for children born here from illegal immigrants. Tetralogy of Fallot is a life long condition that typically several heart surgeries. As a chronic condition, I don't think treatment should be automatically provided. However, withholding ongoing treatment can lead to more expensive and traumatic treatment for acute emergencies.

No easy answers, but heart chemotherapy for illegal alien may mean dozens of poor kids don't get regular care, including immunizations and other preventative measures.

Break Time: Onion Medical Humor

These have had me rolling with laughter. Great way to relax.

Millions Of Americans Succumbing To Sudden Elder Death Syndrome

My Baby Don't Want No Medicine

In The Know: Should We Be Shaming Obese Children More?

Report: Aspirin Taken Daily With Bottle Of Bourbon Reduces Awareness Of Heart Attacks

MUSC Rotation Ends

Finished my last shift at 8am this morning. Slept for a few hours and now am relaxing contemplating whether to catch a movie or now. Flight to UMass takes off tomorrow afternoon, so I don't have to pack quite yet.

The rotation ended well. I managed to meet up with Dr. Kini and get my SLOR completed by him, signed and deposited at the MUSC offices. I also met with one of the assistant program directors for coffee and had a nice conversation. Probably the best was the compliments I received from the Attendings and Residents over the last day or two. You know you're doing ok when the residents say that they keep forgetting you're only a student and not one of them. And when a first year EM resident hugs you goodbye, I think it's a good indication you have their confidence and trust.

The last two shifts were 12-hour night shifts in Peds. Nothing too wild, but I did get to see some interesting cases. A depressed young girl with ALL and a rash that turned about to be a bad case of mucositis from her chemo. At least it wasn't a fungal infection like we initially believed. Another girl had a simple UTI, but the parents were petrified about rhabdomyolysis since one of siblings died from it and all the children have a muscle enzyme deficiency making them susceptible to malignant hyperthermia and rhabdo.

I would be extremely surprised if I don't get invited back for an interview, D.O. package notwithstanding. Now it's time to get mentally prepared for UMass and a month of adult EM.

Two more weeks until I get to see Becky and the kids in Seattle!

Lakes aren't safe anymore either!

It was a tiring but very interesting weekend in the adult ED with the MUSC Program Director, Dr. Kini. I really like his teaching style. It's obvious he loves to teach students and that is what keeps him going at this point in his career. His 3-minute lectures are pretty classic and entertaining.

I believe I did a good job being thorough and efficient, his big concerns. So I hope he'll write a standardized letter of recommendation (SLOR) for me. I didn't get a chance to ask him at the end of my shift on Sunday because we had a couple very interesting cases come in.

First, a young mom got herself and her daughter into an accident. She couldn't remember how, but she drove her car into a tree resulting in a small transverse process fracture to her T-1 vertebrae (upper back) and pretty bad laceration on her lower lip. The EM resident wanted to repair it, but a Plastics Fellow finally showed up to do the job since it went all the way through to her mouth and had big cosmetic implications for a 20 year old. Everything went smoothly until we neared the end when we learned the next trauma case coming in was a 59 year old man that had his arm bitten off by an alligator! (Her daughter was fine, just a couple of scrapes and bruises.)

As you can imagine, there was a crowd waiting to see the guy arrive. I managed to get a good view since I working the ED and helping the young mom in an adjacent trauma bay. So the guy finally arrives conscious and in pretty good condition with the help of pain medication and tight bandages over the stump of his left shoulder. The EMS personnel told us that he was swimming in a local lake frequented by several of the ED staff. He was returning from a work-out when something tugged on his arm and presumably spun around to twist off his arm. He walked out of the water clutching his stump with his one arm. He was then airlifted to us while a large posse of active, retired and volunteer police officers went on a hunt for an alligator with a human arm in its mouth!


The alligator had to be killed and then cut open to retrieve the arm, which arrived on ice about a half hour after the patient. He was rushed up to surgery for an attempt to reattach his arm. Remarkably there wasn't much bleeding. Nurses that saw him walk out of the water probably saved his life by putting pressure and ice on the wound until EMS arrived. Even so, it was a pretty gruesome sight as the surgeon felt around for the brachial artery, clavicle and scapula/glenoid fossa. In typically clinical medical terminology, it was called a 'disarticulated' shoulder.

The story made front page news in town today. The article mentioned it was a 12 foot 550 pound alligator. I headed home a half hour later as he headed up to the OR for the attempt to reattach his arm. I kept thinking how weird it has been that I experienced shark and alligator bites on this rotation in little old Charleston.

Today Peds ER shift was pretty routine. I enjoyed working with the kids again though. Now it's time to finish my presentation for Dr. Upshaw on - treating shark bites of course!

Hassles and 12-shifts

It's been a long four days since my last post and the beaches. I normally don't mind 12-hour shifts, but this week has been exhausting. My allheart scrubs are falling apart; three out of four pants arrived with defects. Worse, my cell phone/PDA broke so I can't make or receive calls.

I tried to solve the problem by driving to the nearest T-mobile store (hoping it was just SIM card problem) on the first day I had a few hour break. So after two days of 12-hour shifts, I worked 8 to noon in the Peds ER then headed 2.5 hours to Hilton Head! The Walmart folks couldn't help, the they got T-Mobile customer service on the phone and we determined it was the phone. They got the HTC repair dept. on the see about warranties and it came to having no phone or PDA for a couple of weeks and hopefully having defect covered by the warranty ($20 vs. $280) or buying new one ($380). While considering the options I drove the 2.5 hours back to Charleston just in time to start my first shift in the adult ED from 6 to 11.

The shift went well I think, but I would have liked to have more opportunities to impress the attending, one of the assistant program directors. I did get a chance to talk Becky and we agreed she'd ship her PDA/phone to me now that my primary medical software, Epocrates, works on Smart Phones.

Early the WWednesday morning we had 8 to noon conference with some good classes on chest pain and syncope. I got some e-mail done then at 3p three other students and I met with a couple of the residents to discuss the residency program. Nothing earth shattering came from it, but the meeting reinforced my thoughts on the program.

Finally I worked a low key shift in the Peds ER from about 4:30 to 11. I enjoy the Peds ER and the autonomy I get here. I still to work more on clearly communicating my differential diagnoses, but at least I can now get into the online medical records to see lab values, etc. It has only taken 2.5 weeks for my ID card to work and my log-in and password to be functional!

Upon arriving phone I was able to use Becky's Dash phone to call home and talk to the boys for the first time in a few days. Better yet, we're going to meet in Seattle in a couple weeks so I can see them, wish Becky's brother & his family farewell as the expat it with Microsoft to Italy and, finally, I get to attend the ACEP residency fair in downtown Seattle.

Day at the beaches

Last Saturday (Sept 8th) I had recovered from a viral infection and decided to tour the area. It was a beautiful 85 degree day. I started by heading to Isle of Palms (IOP), a very ritzy $1+ million area with a nice beach frequented by families, tourists and locals. On the way I drove over the largest cable-suspension bridge in the US and the high point in the area, so the joggers and bicyclists were out in large numbers. The mansions on the beach were right out of postcards photos. My cell phone doesn't do them justice, but the photos below give you an idea of Charleston's version of "southern charm".


Then I headed to the nearby Sullivan Island. This is the beach were one of my patients was recently bitten by a shark, so I had to check it out. It was more residential than IOP and full of locals taking advantage of the local winds. There were so many kite surfers it looked they should be getting tangled up. My photos don't do it justice. I kept envisioning the family and I out there learning to kite surf. It looked more fun and easier to learn than sailboarding.

After snacking on a couple delicious fish tacos, I headed back to Folly Beach near my rental room. It was busy, not nearly as crowded as you'd expect a popular local beach to be on a spectacular day. After a long walk I went for an ocean swim. It was getting out past the breakers, but I tried to stay near kayakers and surfers. The memory of the shark bite kid was too fresh and I found myself looking at all the waves for dorsal fins.

It also was getting lonely by this time. Seeing all the families playing on the sand and in the water reminded me how far away my family was. Then it was time to head home and rest for four 12-hour days.

Where should I live?

Interesting site with a checklist of factors you consider important for lifestyle. After taking the "quiz" I think the site is pretty accurate. We moved from Portland to go to medical school in Phoenix. Unfortunately, Portland is the only I have a chance of going to for an Emergency Medicine residency and I'm not sure how good a chance it is.

American Cities That Best Fit You:

80% Portland 70% Honolulu 65% Denver 65% Seattle 60% Las Vegas

Which American Cities Best Fit You?

Updated ERAS Map

A link to my Google Map of programs I'm applying to, excluding Oregon (OHSU) and Phoenix (Maricopa).


View Larger Map

What weekend?

I must have caught a virus from one of my pediatric patients: dry, scratchy cough and general malaise. I'm trying to get extra sleep and still do some studying. Exploring the area has been the activity to suffer. Kind of feels like I'm wasting my three day weekend, but I know I need to rest up and be ready to work come Sunday.

I met with one of the Attendings yesterday. He gave me some good information on where I stand and the process of selecting interviewees at MUSC. No big surprises, but I sent a few e-mails today trying to set up shifts, or at least partial shifts, with the three assistant program directors. I want them to at least remember me as a good worker and someone they want to have back for an interview.

I think I'll go catch a movie tonight and get in some more reading. Tomorrow hopefully I'll get over to Mount Pleasant to check that area out. I would love to hit the beach as well.

ERAS and Shark Boy

Labor Day weekend was supposed to be my weekend to play and maybe explore the area. But September 1^st was also the first day the ERAS applications opened up. Naturally I agonized about selecting programs and even specialties. So it was a good thing that that it rained until Monday the 3^rd, Labor Day.

I spent a good part of the weekend at the rental house, holed up in the one corner where I can get wireless Internet access from a neighbor’s router. I messed around with my ERAS application until I was sick of reading my own resume. Then I worked on program selection with web sites, my anal retentive spreadsheet and the ERAS selection process. Becky and the kids went to visit my father in San Diego so he got pretty involved in rating residency locations on how they would benefit Becky’s career and how easily he could get ITT deanships at each one.

In the end I picked 29 programs that broke up as follows. 19 are on the East Coast, 8 are in the Midwest and two (Phoenix and Portland, OR) are in the West. I flagged all the locations on Google maps and was surprised how East Coast centric it ended up. After playing in the San Diego surf for an afternoon the boys voted for a coastal location with beaches nearby. Some of the East Coast locations have good beaches, but the 19 cover Jacksonville, FL all the way up to Portland, ME so there’s a lot of areas that might be a bit cold for playing in the surf.

I still have one more to add. And I am thinking of either Davis, CA or Georgetown in DC at the moment. However, I also wrote up another Personal Statement for Family Practice in one of my paranoid moments. I still might throw in my top three rural FP programs as fallbacks. However, after sleeping on it a night, I realized this would distract me from EM and interviews for the programs would just cost more money and time and further exhaust me, if I even got interviews. For now I’m going to focus on EM programs solely and see if I can get any interviews. If get only get half a dozen I’m going to start getting worried. I would really like 10-12 and have really good feelings about 6-10 afterwards.

I was going to work on Monday evening, but the stress tired me out, even with 9 hours of sleep every night. So I enjoyed Monday’s sunshine by heading to the beach after I hit SEND on ERAS and paid my $375. The nearest beach, Folly, is pretty nice and seen from the pictures I got on my cell phone. The water is warmer than the West Coast, and even though it was windy and choppy I had a very nice walk. One of these days I want to go for a long ocean swim. I have to build up my confidence that one of tonight’s cases wasn’t an omen first though.

We had a 15 year old surfer come in with shark bites! Luckily they weren’t too bad as you can see from the picture. The other leg had similar small bites marks with a couple of deep heal lacerations and a little toe with a large triangular flap of tissue attached on one side. I would have liked to suture the wounds, but I was allowed (told) to leave early since I had conference in the morning. Some of the lacerations were good sized, but none were too deep. The weird part was how you see the crescent bite pattern from the mouth. Reminded me how the beach isn’t perfectly safe, especially at dusk.

Colton seems to be having a tougher time with my absence than his brother on this trip. He was always the child who got upset when having to say goodbye to relatives, so I guess it isn't too much of a surprise. But he's a happy outgoing soul you'd think introspective Connor might have a tougher time, especially stating Junior High. It was fun to share the shark case with Colton and cheer him up a bit. He always asks me if I have had any interesting cases. And just as he likes to share stories in intimate detail, he wants to hear every detail fully described regarding my medical cases. It will be interesting to see what careers the boys decide on given their greater exposure to the professions than I had. I like to think that Becky and I are also more savvy and street smart as parents than either of us had growing up.

Step 2

Well this isn't where I had hoped to be. Ideally I wanted to get both COMLEX and USMLE Step 2 exams out of the way before audition rotations and have scores that improved on my Step 1 scores to show off at residency interviews.

COMLEX Step 2 came back at just about exactly the same as my Step 1 score (551 vs. 565). Statistically they are identical. No problem there, however it looks like I won't be applying to any Osteopathic programs.

The Allopathic programs are going to be much more interested in my Step 2 scores. And my USMLE Step 2 score came back at 210 versus 225 for Step 1. The for Step 1 was an average of about 217 (180 is passing) with a Standard Error of Measurement (SEM) of 7 or so. Step has an average of 221 with the same SEM and a Standard Deviation of 24. In other words both scores are ok, but Step 2 is at the trailing end of average scores so worst case is that some programs now don't offer me interviews.

The whole thing is very frustrating with 20/20 hindsight. I didn't have to take USMLE Step 2 at all, and certainly not before ERAS applications went out. So I spent $500 for the test which now may have done me a great disservice.

Looking back I should have probably dropped out of the test before I finished it. I just couldn't concentrate well with interruptions from other test takers, the staff and the frigid temperatures. I kept running out of time and having to guess at the last couple questions for each block. The block right after lunch I didn't even read the last 5-6, I just entered guesses in the last 20 seconds. I should have practiced a lot more timed tests on my Qbank account.

So, now what to do. I'm going to ask around for some advice. I could just enter my COMLEX in ERAS and then present Step 1 USMLE when asked, but that might come across as hiding something. Or I can just submit the scores and go for broke, hopefully that I have a chance to address any concerns about the score in person. This probably the best strategy, but I hoping out to see if there's any other options. I still want my application to be complete by early September so I'm at the front of applicant pool.

The whole thing kind of bums me out. Instead of being a confidence builder, I spent all this money on something I feel a bit embarrassed about. I know I could have done significantly better. Moreover, I don't think the score represents my knowledge or ability. Ironically, the ridiculous and even unprofessional COMLEX test seems like a better representation of my study efforts and knowledge. I would have rested a lot more easily with a 220 or above.

Charleston

The trip was pretty uneventful. Continental Airlines came through on-time without any hiccups. And I found the car and house easily. With a little bit of daylight remaining, I drove through the lush, green country crosses many bridges along the intercoastal waterway on my way to James Islan, about 7 miles from the hospital. The room I'm staying is fine, if not the epitome of southern comfort. Another student interested in EM, Joe from Indiana, takes the other second floor bedrrom and bathroom. We've had a good time comparing thoughts and impressions on programs, EM and the Match. My only regret was that he arrived so he got first choice on rooms. I have no desk and no Internet access from the neighbors unsecured router.

Monday was a bit crazy. For a still relatively small town, Charleston has a ton of construction and activity going on. Medical University of South Carolina (MUSC) is a huge but compact campus with the Roper and VA hospitals adjoining it. Parking is a nightmare of highrises, remote lots and shuttle buses. After a quick orientation with the Pediatric Department, Joe and I ended up meeting at the MUSC medical school offices to get out IDs. Once we negotiated our way through one of the worst administration clerks I've ever dealt with (and she seems to have the reputation everywhere), started hiking.

It was a long, hot adventure walking across campus several times lugging my laptop and books around. It felt like an obstacle course with multiple stops for both MUSC IDs and Parking passes to lots for days and, separately, evening lots. I was too exhausted to volunteer for a shift that evening. Nine hours of sleep in a comfortable bed was just what the doctor ordered.

Tuesday I worked my first shift from 3pm to 11pm. It started off slow but I ended up seeing quite a few pediatric ER patients. Nothing was too serious, lots of abdominal pain, coughs and sore throats. The people are all very nice. Lots of southern charm and southern belles. For a people person like me, it felt great to talk with warm, friendly folk. And the teaching wasn't too bad either. Lots of pimping, but fair and non-threatening. I had received a large packet of teaching material including many relevant medical articles and little handbook that all the Pediatric Residents get. It has some great material, so I put away my adult ER textbook for a bit and managed to get through a few chapters before the shift started. This helped a lot on the pimp questions thrown at me. I hope to finish the severla hundred page packet in the next week or so.

Wednesday was a long day that started with three hours of lecture with the EM residency program. Joe and one of the EM attendings helped to plug into it. The latter heard I might be interested in the program and offered to get me more adult ER shifts and take me to lunch to discuss the program next we week. The Program Director talked to us for an hour, then we had a chance to the residents. Somehow I had missed that the program is brand new. The PYG-1s that just started are the very first class of EM residents at MUSC. This a bit concerning but also might mean it's a little less competitive. The residents and attendings I met were all very nice and friendly. The lectures were pretty good, but I definitely got the feel that there are bugs to be worked out in the program. I can't think of better facility and medical system to start a residency program in though. This would have been a great place to go to medical school.

My second 3pm to 11pm started off the same and got a little crazy at one point. I tried to be helpful and took on three patients but got reminded that first and foremost I need to always be on top of the patients I have and not worry about new patients waiting to be seen. It was a good lesson for me.

Today I'm hoping to nail down housing for next month in Worcester, MA. But I've been spending some time working on loose ends. My ERAS (online residency application) Personal Statement is basically done. However, I got my Board scores back and they weren't where I had hoped. So I'm dealing with that too. I have two off starting tomorrow. I have to decide how time to dedicate to studying versus checking the area out versus visiting other programs in the area. Always more to do.

Quick Trip Home

I finished Arrowhead almost a week ago now. The last day was pretty interesting. I spent 4-5 hours sewing up a dozen or so lacerations on a guy who jumped out of second story window (a little Meth-induced paranoia). A couple of the lacs could have actually used skin grafts and one almost took off the end of his pinky. But perseverance and some reinforcing vertical mattress ties and his was closed up - if not pretty.

After I was done with his knee and arms (about 8 Prolene sutures later) a maxofacial surgical resident took over on his face. The resident also took some time on four big lacs across the patient's nose and forehead, but when he was done the result looked much nicer. Now my wounds were much dirtier, so I had leave them more open even after irrigation. But I have to remember that the knots should all be pulled to the same side so you have a nice clean looking finished product.

We also had a trauma where I successfully performed the CPR to get the gunshot victim resuscitated. He had two bullets in his chest and had been pulseless for about 25 minutes when we got him into our trauma bay. About 10 people including nurses, emergency docs and surgeons surrounded him but I squeezed my way in to relieve the paramedic from doing CPR. We were about to call the time of death when the ultrasound showed a weak heartbeat. I felt for the carotid pulse and it strong! His radial pulse was very weak but the surgeons immediately decided his only chance emergent surgery (he had already had 5 units of blood after we removed 2L from a hemothorax).

I learned later that they had removed one bullet in the OR, but his blood gases showed a pH of 6.6! Being that acidic is NOT compatible with life. So I'm sure if he's with us today. If he is, what brain function remains, not to mention kidneys, etc., is questionable.

The rest of the 12-hour shift went fast with small procedures and lots of patients to see. Then I loaded up on caffeine and drove a little over fours to get home in Phoenix around 11:30pm. The boys were pleasantly excited to see me even at 6am. We played for a bit, them Becky and I took long 3-hour naps. The four of us had a leisurely afternoon and went to a movie together. The evening was also relaxing. We just had a great time hanging out together. I made sure to touch, tickle and cuddle them as much as possible. After everyone went to bed, I spent 1-2 hours packing for the long 2-month trip.

While it was sad to hear, I was happy too that Connor told Becky, after she returned from the airport; "One day just isn't enough mom. You just end up missing him more when he's gone."

Big Bear and Lake Arrowhead

Becky and I had a great vacation from Saturday until this morning. She's picking up the boys right now, in Phoenix, while I'm trying to finish up some logistics for rotations.

On Saturday, we had a chance to visit with my father and his wife. It was nice to catch up since I haven't seen them in quite a while. My dad was also helpful regarding information about locations for different residency programs. Since Becky nor I know anything about some of the East Coast locations (e.g. the Carolinas) any information was helpful. He also seemed excited for us and not too disappointed that we didn't seem sold on Arrowhead.

Saturday night we drove the windy climb up to Lake Arrowhead on Hwy 18. Our Inn was a bit of a disappointment. It was a quaint place with some style, but our room was so small it only had room for one chair. And the internet connection was a joke, so I couldn't research things to do, residency stuff, etc. The boys said they were having a great time in Seattle with their cousins on a camping trip. They are at the age where the conversation is very short and they don't miss us too much since they are with family.

Sunday we had a great breakfast in Arrowhead and walked around the village. It was relaxing and really nice to spend some time alone. We realized the last time we'd spent more than one night with just the two of us was probably before Connor was born!

Monday we drove the 26 miles of cliff side curves to Big Bear Lake. It is bigger and the town is more residential than the private, resort-like Arrowhead. We had another incredible breakfast and then hiked up to Cougar Crest (2.6mi) where the Pacific Crest Trail overlooks Big Bear. The hike and the weather were perfect. The lake was a little green, but still beautiful. Dinner (surprisingly good Ahi Sashimi) and a movie in Arrowhead topped off a second great day. The only "downer" if you want to call it that, was a house tour of a new three story, 4k sf place on Big Bear with the lake on two sides. While the place was lovely, $2.2 million seemed crazy for a place destined to be a second home for some rich LA socialite.

The weirdest experience was during the drive over. Arrowhead is at about 5k elevation and Big Bear at 7,500'. The drive you're above the clouds, but you can see the smog and cloud layer hanging over LA. The thought of living in that brown air wasn't attractive.

Tuesday we weren't too sore and decided to drive back to Big Bear for more activities. By this time, Becky was used to my driving on the twisties. I had the minivan's wheel squealing quite a bit! We drove our Treks around the North side of the lake for a few scenic miles. After lunch, we rented a sea kayak and paddled around the South shore for an hour. Another relaxing evening in Arrowhead with our books ended the evening.

Wednesday we packed up and took our last drive to Big Bear. Breakfast at our favorite place, Grizzly Manor, included a skillet meal called "the Mess" that served at lunch as well. A local eating at the bar next to us (you know it's good when the locals wait 30+ minutes for seating!) filled us in on some of the activities we'd missed. For starters we headed to one of the two ski resorts and road the chair lift to the top. What a view! I wish we had left our bikes behind and rented some real mountain bikes the day before. You could hundreds of miles of National Forest with views of Big Bear and a handful of nearby mountains. You couldn't ride down the ski slopes (too many injuries) but that seemed crazy to us anyway. My idea of crazy would be to pack a week's worth of food and just start walking to the tallest peak in the area. The high alpine terrain didn't have too much undergrowth, but it would still be some good exercise.

Finally, we drove back down into the smog. We drove through the Redlands area just to see if we live there for three years, but it was pretty depressing after being in the clean mountains. Locals told us a few people commute from Arrowhead to Colton every day, but Hwy 18 can get really treacherous and icy in the winter. And Emergency Medicine residency wouldn't look too kindly to me calling in late because I'm was snowed in or stuck behind an accident.

Becky and I agreed that after residency a community like Big Bear would be perfect. It has all the services you could need, a hospital with an ED and an incredible setting for the family. However, we still have to get through residency before we start comparing Big Bear, Tahoe, Jackson Hole, Bend, Durango, etc. While agreeing to not write off Arrowhead yet, there are certainly good EM programs located in better areas for the family. Michigan, New England, the Carolinas, OHSU have possibilities. Unfortunately the only EM/Peds combined programs are in Indianapolis and Baltimore. I still might throw my hat in the ring for them just to see where it goes.

Didactics this morning was fine. It made me glad I got about 100 pages of my EM textbook read over the trip. Time to hit the books in between my upcoming seven 12-hour night shifts.

First week at Arrowhead

It's only Thursday afternoon, but I've completed three 12-hour shifts and four hours of didactic lectures. Now I'm off until I start two weeks of night shifts (seven 12-hour 7p - 7a) next Friday.

Arrowhead is definitely busier than Ft. Wayne and right up their with St. Vincent's in Toledo. I've been working in Pod D which is unmonitored, so the patients are typically abdominal pain, OB/Gyn, Peds, inmates, fractures and that sort of thing. I've seen a lot of very interesting cases and got to do a ton. I see all the patients first, write up the H&P on the charts and then present it to the Attending. The Attendings have been pretty good and had some time to teach Monday and Tuesday. Yesterday was just too crazy though with no time rest at all.

Monday I did an adult lumbar puncture (LP) with a little assistance and a reduced a dislocated toe. Tuesday I did an infant LP and had some good cases, but the day was slower so I also got in a little reading. Wednesday I did an I&D. We had 3+ appies, several kidney stones, a guy with face kicked bloody and an assortment of infections and fractures.

Overall there's been a good variety of pathology and I've been learning a lot. However, I don't think this program will be my first choice. One thing that irritated me was that the Nutrition Dept(?) decided to end the $9 per day food allowance without informing us, so I was embarrassed as the cashregister with food for my Attending and myself but no cash.

I am still considering the program because the Attendings seem good, there's of good learning cases and it looks like EM is getting very competitive. As a four year osteopathic program, Arrowhead should be easier to get into than the allopathic programs that I like better, at least on paper. Becky is driving over this weekend to spend a few days with me at Lake Arrowhead (and no kids!), then we'll spend a day looking at neighborhoods. My father would love to see us here as it would give me much more time and access to the kids.

Speaking of the kids, they seem to having a great time in Seattle with gandmothers, cousins and aunts/uncles. I've had a few minutes to talk with Gregor, Krintina, my neice Jane and nephews Cooper and Oliver. It's been nice, but brief given twelve hour days. I even spent one evening at an informal journal club with the residents and another swimming at an LA Fitness nearby.

This afternoon has been all about updating flight plans, tickets, rental cars and Outlook with the latest plans. Luckily Christiana has free housing to offset the cost of canceling the flight to Carolinas and buying a new ticket to Wilmington, DE. In case I didn't mention it earlier, I canceled Carolinas because of all the trouble (obstacles) UNC was giving me to confirm the rotation and the fact that they have never a DO resident. Christiana looks every bit as good, has DOs in the program now and it much easier to work with. Free housing doesn't hurt either!

Well, I plan to study my new EM books most of the day tomorrow and get in a swim. However, tonight I'm going to relax and maybe catch a movie. It's going to be an enjoyable week before I hit two long weeks of 12-hour night shifts. I'm not even sure that I will have time to drive back to Phoenix to see the boys :(. Speaking of which, I need to call them now and see how they are enjoying camping with their cousins.

Making Trouble

Last week I failed to mention an interesting series of events. On Tuesday, my one afternoon off early from Derm, I went to AZCOM to take care of a bunch of administrative stuff. One of my main goals was to look over my LORs and hopefully my Dean's Letter as well, seeing as how I wouldn't have much opportunity over the next few months when applications are due.

Well as I walk into the Dean's office, I get told that students can't look at LORs or Dean's Letters anymore! They asked; "Didn't you get the e-mail?" Ah, no. I had been working all morning and the e-mail had only gone out the previous night. I was pissed, but held my breath since chewing out the staff does no good. I read the e-mail at home at home and was further disgusted by the lack of explanation and "stick it to you" attitude. And then I waited 24 hours to cool off.

Wednesday night I wrote an e-mail to the Dean and our class officers explaining that the e-mail was incomplete and the decision to restrict our access was wrong. I outlined, without being too pissy, four good reasons including: poor timing due to our brand new Dean writing letters on students she doesn't know; forms we submitted for the Dean to consider were written under the old policy; the policy changed three times on a little over a year; and classmates that knew the previous Dean were able to look at and/or discuss their Letter's with him.

That set off a firestorm.

Tucker, the class Prez and I ended up meeting with the Dean on Friday after Dr. G., the university Pres and many others got involved. She made a good case for us to not look at the Letters (more impact on residency PDs) and agreed that the decision wasn't explained very well. She promised to consider Tucker's proposal that we be given the option to look at the Letters this year. She also agreed to send out an e-mail explaining the decision and how it benefited us. It was a friendly, positive meeting that included lots of sharing of ideas and thoughts.

As our new Dean, I think she appreciated hearing some of the preconceptions we had going into this process given our school's reputation of providing little support third and fourth year. She also appreciated hearing about how her office could be more helpful to us with guidance through the residency process and openness in communication.

I don't know what changes will come from the meeting but I had a chance to air my grievances. And I think meeting the Dean this may benefit my Dean's Letter (she knows I care) instead of blackballing me like I initially feared. She may accept all or part of Tucker's recommendations, but at least she will do a better looking at this decision from the students' perspective.