I beg to differ

Trauma is the only way you can enjoy help save lives during a gory bloodbath?

The ICU begs to differ...

Buffalo Chicken Lasagna

Lasagna is an easy, filling, universally-loved firehouse meal. I mean really, what's better than lasagna? Lasagna with buffalo sauce and lots of cheese! Yummmmmm... I'm really embracing the idea of taking traditional pasta and mixing it up with totally different flavors. Multiple people emailed me later to ask for the recipe after I served it to the troops. It's cheesy and tangy. Easy as squad meals go too. This recipe's inspiration came from here. I did change it a wee bit though.

-lasagna shells
-2 lbs chicken breast
-1 jar of Frank's Buffalo Sauce
-3 jars of Alfredo sauce
-30oz ricotta cheese
-1 cup of egg substitute
-1 cup of shredded sharp cheddar

Preheat oven to 350*. Do all the prep things: cook chicken and noodles if needed. I poach my chicken. And I used no-cook lasagna, but cooked noodles would be fine. So cook them now. Once the chicken is cooked through, chop it up into bit-sized pieces.

Get two separate bowls. Mix Alfredo sauce and buffalo sauce in one bowl. In the other, mix together ricotta, egg substitute and chicken (chopped into small pieces). Start by spooning a thin layer of sauce across the bottom of a 9x13 pan. Place a layer of noodles, then more sauce, followed by a layer of the ricotta mixture. Continue layers until ending with a layer of sauce. Bake for an hour covered. Sprinkle cheese over the top and cook uncovered for about 15 more minutes.




Then inhale :)

Ambulate before carry

So once upon a time, there was a kid in our first due who, in the time I've known him, has weighed anywhere between 350 and almost 500 pounds. (By the way, I'm not exaggerating about his weight... he could only be weighed on one special scale in the hospital and I've seen those red numbers flashing and he doesn't fit on our "bariatric cot.") Back when he was closer to 500 pounds, he was a cardiac arrest at home. He was successfully resuscitated by some of my colleagues and walked out of the hospital like a month later. Did I mention he was only 17 at the time? I can't swear to you what caused him to code, but I'd wager that his extra 300+ pounds didn't really help the situation. We go to his house a lot, not always for him, but also for his mother and grandmother who have a variety of medical problems of their own. This kid had no chance... both Mom and Grandmom has BMIs > 40 or so.

I went there the other day for the kid. He's like 20 years old now and has lost a fair amount of weight. A trim 375lb or so? So now his BMI is only like 54...

His complaint was "shortness of breath." He clearly had a cold. Was telling me about his runny nose, his cough and never actually mentioned being short of breath. In fact, he denied dyspnea when I asked him point blank.

Because I knew his history (and really didn't want to code him again), I did my initial assessment in the house, including a 12-lead. Everything was stole cold normal, so I offered my hand to him and said, "Ok let's go to the truck." He stands up and we start walking out.

Mom and Grandmom start rushing waddling into the room.

Cue the screeching...


"What do you think you're doing?!"

"You're making him WALK?!"

"Sit down baby... you're too sick to walk!"

"Y'all better be carrying him out of here!"

"Go get that cot girl. After I call, you work for me and I say carry him out to that ambulance!"

Seriously? How do you even say that with a straight face to me? I'm literally a third of his size. And I'm supposed to pick him up?

I carry out people who physically can't walk or those whose condition could be exacerbated by exertion. Chest pain, dyspnea, bad trauma, seizing/post-ictal or unconscious patients. This does not include obesity. (By the way, at this point the kid has already made it halfway to the truck, with no adverse effects.)

The mother and grandmother continued to scream at us until finally I pointed out that the kid was in the ambulance and so it was a moot point.

And I wish I were kidding... but the mom and grandmom proceeded to sit back down on the couch, eating chips and watching TV while we took the kid to the ED. Not stereotypical at all.

I think a little more walking would do the whole family some good...

My new favorite

I wish I were as funny and satirically accurate as these guys...

http://www.gomerblog.com/

Happy Reading!

How to be a good resident, from a nurse's POV

I think being a resident, especially being an intern, is basically legalized torture. It's physically and emotionally draining. You have to learn a new unit/service/specialty/whatever every month. That lengthy month you're on that rotation, you better know nuances like that Attending 1 needs silence until after the first retractor is in in the OR, or that Attending 2 likes to round from the back of the unit forward, or Attending 3 prefers to review all the day's X-rays with his morning coffee before rounds start. If you call an upper level for something they think isn't worthy of their time, you get yelled at. Conversely, you get yelled at for not calling them if you didn't do what they would've done if you had called. You get paged constantly by nursing, pharmacy, the lab... You get up at the crack of dawn and work long hours. (Seriously, when do you guys sleep?) Not to mention, you literally make life and death decisions on a day to day basis.

But you want to be a good resident right? You want to provide the best care for your patients and get beaten down as little as possible in the meantime.

So without further ado, a nurse's tips on how to be a good resident:

• Assess your patients. At least lay eyes on them. (And preferably hands... And maybe a stethoscope...) This sounds pretty obvious, but it's amazing how many residents have not seen their patients with their own two eyes. Then you have a reference point when the grouchy fellow or hurried attending notices something amiss and asks you if it's new/old, better/worse. 

• Communicate with your upper levels before it's 0300 or they're in the OR. Ask them what they want to be notified about, get parameters to act on your own (ie: transfuse Mr. B for a HCT <30%) and know what decisions they're comfortable with you making on your own. 

• Don't try to do procedures that aren't emergent/urgent at shift change. Ok, re-intubation, sure probably needed. But you can wait 30 minutes to rewire the arterial line or pull the chest tube if you need help from the nurses. Prepare to get the evil eye from the day shift and the night shift nurse when you interrupt them to ask them to put the patient back to bed (who got up 10 minutes ago) so you can pull a chest tube. 

• Learn ACLS. (Or PALS for those of you who like the little humans.) It is just embarrassing if you're attempting to run a code while looking at your ACLS cheat sheet algorithm you just fished out of your pocket. It's really not hard to memorize... you learned way more complicated things in med school, I swear.  

•  For the love of everything, talk to the residents who were on your rotation the month before. Learn from them the culture of that rotation. What time do rounds start? What do the attendings expect to be included in your presentations? Do we give morphine or fentanyl for pain control? Are you supposed to be in scrubs or street clothes? Does your attending prefer to round with a computer or paper printouts? Do you share your workload with a PA or an NP? 

• Listen to the nurses. We stay in this unit or clinic while you guys rotate through month to month. We can help you out with attending quirks.  We know what the upper levels want you to wake them up for at 0200 and what they'd rather hear about in the am. And importantly, we know a lot about nuances in our patient population. I'd go ahead and listen to an experienced neuro nurse who's telling you his patient (who looks exactly the same as the last time you peeked your head in) is evolving his stroke. Nurses who have been doing cardiac critical care for awhile can probably teach you a thing or two about cardiovascular hemodynamics and invasive monitoring. 

• Also important however, is to learn which nurses (and other caregivers for that matter) you should be listening to. See which nurses always seem to have the heaviest load or the sickest patients... that means the other nurses trust them. You should trust them too. Know who the charge nurse is. Refer to him/her if you are skeptical. I realize this is a little contradictory to the above statement, but sadly there are nurses who are not so good or smart. You listen to them and then the patient suffers, your attending is probably not going to like, "well the nurse said so" as an excuse. 

•  Caffeine. Caffeine is always the answer.

• Learn a bit about the specialty you're rotating through that month. Everything is relative in medicine. A blood pressure of 136/78 is probably reasonable for a trauma patient. 136/78 is perhaps too low for your little lady with a new ischemic stroke. And 136/78 is likely dangerously high for your patient actively dissecting his aorta. So you want to be a neurologist? Great... but this month you're responsible for the lives of gyn-onc patients... learn about them.

• Don't sleep around too much. The hospital is not that big. We allllll talk. You slept with a three nurses on your MICU rotation? We'll know all about it before your rotation with us starts. You're an intern and are caught with your attending? We definitely know about that and all assume you're too dumb to make it though without your sideline sexual favors. You don't want to be that guy/girl. 

•  Don't be condescending. Or simply an ass. This goes along with "listen to the nurses." You treat me like an uneducated peon, and I will destroy you in front your superiors the next time I get the opportunity.

• And as opposite from above, don't be a doormat either. Show some backbone. You made it through med school. You're smart! Contribute to the discussion. Don't just order every thing I ask for carte blanche... think about it. I respect a resident who thinks things through and discusses it with me, but then denies my request much more than a resident who is simply an order-entering monkey.

• Try to understand that we're required to page you with every little thing. Critical lab values, abnormal vitals, whatever. I know you're not surprised that the lady who has been spiking fevers all weekend is now 38.5, but the order and the damn hospital attorney say I have to let you know.

• Be ready early. If round are at 0600 and you're finishing your notes at 0545, I promise you someone will code at 0530. 

• Don't sign out onerous things to the next shift. Poor form! I know you've done twelve smelly, hunting-for-STDs pelvics today in the ER, but knock out that last one before you leave. And if the patient died on your shift, you do the death packet.

• Ask questions. You are here to learn after all. 

Wow... that went on longer than I planned. I probably have more too. Will stop for now.