Tuesday, December 23, 2008

All I Want For Christmas is My Sanity


I'm beginning to think that everyone is a little bit crazy. The only difference is, do you know how to blend in?

When I first started in the psych unit we had this patient who is practically paralyzed by anxiety. She wanders the halls and has fixed delusions that spell doom for her. She watches the windows afraid that a van is going to come up to take her away somewhere. Where the heck would we send her? She's already in the psych unit! I could not understand how she was letting her days pass by in this tortured state of anxiety. Surely, I thought, sooner or later she's going to just let it go or decide that even though she's afraid, she wants to leave.

I suppose I will never quite be able to let my own experience color my assessments. Just because I have a loving generous fiance and family to look forward to going home to doesn't mean she does. Or maybe she's so deep in delusion that she couldn't recognize it even if she did.

As days are growing shorter and I go to work and come home in the dark, I noticed I'm starting to feel more anxious too. I worry about the weather and whether my fiance is going to make it home safely. I worry about getting sick, or someone I love dying. Sometimes my mind is consumed, obsessively playing little movies about all the bad things that could happen. It's a horrible feeling. I try to think about something else or just remember sometimes there's nothing I can do about it. Sometimes it works and I can let go, sometimes it doesn't and instead my mind races through every aspect of a situation logically working through the odds of each scenario and the best actions to prevent or deal with it. Usually it's just time that takes care of it. What goes on in my patient's head? Is that where she is stuck? When do you tell if someone needs medication?

What a fragile balance between having a detailed mind and an obsessive one. I always wonder how much I can really affect my thoughts, or if it's just another way my ego thinks I am in control. You know doctors have such God complexes. :-) I used to have a prejudice in the back of my head that anxiety medication was the easy way out. That if you tried hard enough or trained your mind you could change it. I don't know anymore. Maybe it's just chemicals in your brain. Maybe it's a combination. Maybe the things that make me a good medical student are also things that could send me to the psych ward myself.

Wednesday, December 17, 2008

Prayers needed.

Please say a prayer for my cousin Kari, her family, and especially the little one on the way.

And maybe a little prayer of thanks to her doctors who took a lump in a young woman seriously the first time.

Monday, December 15, 2008

Who's the crazy one?

I just started Psychiatry last Monday. Woohoo! Nothing like the holidays to bring out the crazy in people. I really should have thought about that before I scheduled this.

A wise TV character once said "People are bastard-coated bastards with bastard filling" (it's a quote Mom, so don't judge me for that one.) I usually try not to take that approach with patients, and give them the benefit of the doubt when it comes to telling me what's going on. With psych patients, however, all bets are off. That doesn't just apply to the patients, either.

Yesterday we were getting a history on someone with suspected antisocial behaviors. He seemed perfectly pleasant and cooperative, except for a few legal troubles here, a minor for a girlfriend there (not legal), you know, the usual. We were trying to get a childhood history from Mom, who said "He was perfect! Blah Blah Blah blah his psychiatrist..." Jigga What? Why, pray tell, did he have a psychiatrist ma'am? "Because he burned the house down when he was 5".

After blinking a few times, I thought: Surely she didn't just say this. Nope, there she was looking at me with a straight face. Ok, maybe he was playing with matches out of curiosity and oops, the house caught on fire. So I asked. "Well, he took a lit candle and went around setting the curtains and the furniture on fire."

Are you kidding me? I never would have found out about this if I hadn't completely blanked on my next question and just let her talk. My psychiatrist is a pro at talking to people and getting the real dirty. I apparently am a mere amoeba when comparing interview skills.

Needless to say, after that particular conversation I am much more probing when talking to patients. And I always ask if a patient has ever burned a house down.

"So, Timmy, have you scalped any kitties lately?"

Thursday, December 11, 2008

Mental Health Needs Parity.

Since I started psychiatry, I've begun to hear stories that would break just about anybody. What an experience to go from 3 strictly medical rotations where mental health was a somewhat ignored side note to psychiatry where we actually have the time (and urgency) to explore people's lives and motivations.

As the practice of medicine improves with new technologies and medications, we routinely save patients who 30,15, sometimes even 10 years ago would have died. What I now realize is that we focus so much on keeping patients alive, but overwhelmingly neglect what happens to them after they leave the hospital. How many times do you hear of an accident on the news and wonder "Did he/she survive?" How many times do you think of what permanent injuries they will have if they do survive? Will they be able to work? Will their brains change?

One patient I spoke with this morning survived a horrible work injury. Among other sequelae, it left him blind. He went from a hard-working functioning man to someone completely dependent on others. He feels like he is no longer a complete person. He was unable to be the father he thought he should be. To make things worse, his caregivers are cheating him out of his injury settlement, tearing his family--the people he loves the most in the world--apart.

I especially wonder about patients with traumatic brain injury. A brain injury, especially to your frontal lobes, can completely change your personality. A son who was described as a "gentle, docile man" is now threatening to stab his dad over a glass of milk. What happens to a marriage when one partner's personality completely changes? Is he the same person you married? Do you stay and try to help even though he could be a danger? If you divorce, who takes care of him? Where will his anger go next? When a wife is now out of work and in a severe depression, how does a father of two young girls pay the bills? What happens to the kids when Mom and Dad are so far sunk in drugs and alcohol that they can't even think to put a coat on them when it's 18 degrees outside?

It is so easy to look at people in a mental health unit and think that their lives are different than mine. I came into this without any idea of the stressors some people live with, or that one really can make a difference in their (and their children's) lives. This unit provides an invaluable service to society. Here the social workers and doctors and nurses attempt to untangle the complicated mess of mental illness and societal stressors that precipitate psychotic breaks or suicide attempts or all the other manifestations of a mind in trouble. Here is often the refuge where these patients are actually listened to--the whole story, not just the runny nose or the risky sexual history or even the mild depression that leaves out the fact that the patient was abused as a child. We NEED more money in mental health care. Familes are often too stretched and unable to care for these people. Where are they supposed to go? Leave them on the streets?

It's unconsionable to me that as a society we abandon these people. I hate that Missouri had such a fight in the state capitol over mental health parity--as if it is something that if we ignore, it will just go away. We are fiercely on fighting over abortion as a "Pro-life, pro-family" issue but fail to take care of families that are breaking apart. It's inhumane.

Anyway. I am already learning so much on this rotation. I hope to take away more understanding and compassion, and maybe give a little help or at least comfort while I'm here.

Thursday, December 4, 2008

Do you think I'm cute too?

Nothing like an ego boost....from your friendly psych/neuro patients.

A few examples before I crash:

"You made my day though, you're CUTE!" --Younger alcoholic patient

"May I ask you a few questions?" --Me
"I'm already married, but you sure are cute." --Older alcoholic patient

"I gotta tell you doc, she's cuter than you" --Pretty hilarious elderly patient...with dementia.

I don't know what's more disturbing, the consistent independent use of the word "cute" to describe me (must be the new bangs) or the fact that the last time I got this much male attention I was on the wards at the Veteran's Hospital.

I suppose if the med school thing doesn't work out, I could easily entrance an alcoholic demented rich old man...provided I got to him first. And of course, that my fiance ok'd it.

Monday, December 1, 2008

Too Frickin Tired

I will post more later probably...but it's going to be a bit of a dry spell until I work fewer than 12 hours a day. I have to have some time to read so I don't look stupid the next day. And by some I mean a lot.

I will leave this one story, however: picture it, a young (younger than me) woman, pregnant with No. 2, refuses to take her multiple sclerosis meds even when she isn't in the family way because she "doesn't want to be dependent on her medications". I think underneath that statement were some problems with the side effects, but seriously. Half of patients diagnosed with MS are in a wheelchair in 15 years. How's that for dependent? I never understand when people say they don't want to be dependent on something but can't look a little farther down the line to see the consequences. Like the smoker who couldn't quit smoking but wouldn't take his Advair every day because he--you guessed it.

Why do they even come to the doctor?

Tuesday, November 25, 2008

BRAIN!


Yesterday morning I started Neurology. I'm only in it for two weeks, so I have to make it count. Unfortunately, Thanksgiving is in two days and then it's Christmas and then it's time for my annual SNOWBOARDING TRIP!!

So I'm having a little trouble concentrating.

Neurology is very interesting. It is so logical: lesion here? Oh, that will probably affect here, here, and here. It's so well mapped out--which, by the way, we mostly learned by watching what people with brain injuries acted like, then peeked into their brains once they died to see where the lesions were.

Take Phineas Gage. He was a mild-mannered church going railroad worker when one day an unfortunate explosion put an iron rod through his forehead. He calmly walked himself over to the doctor and had it removed. Miracle, right? Well, yeah, but that's not all. The formerly polite quiet-living man turned into a drinking, gambling, potty-mouthed man who ended dying early from impure-living anyway.

From poor Phineas we learned the role of the frontal lobes in forethought, planning, personality, and impulse control. By the way, they're not fully developed until you're about 25, which I try to keep in mind when I deal with teenagers.

Read more at Encyclopedia (it's also where the pic is from)

Tuesday, November 18, 2008

?Como Se Dice "Breast Pump"?

This morning was a wild one in the nursery. For starters, my doc, loopy from having been on call for three days, showed his fatigue by Nazi-marching around the nursery when the nurses got on his case about not re-wrapping the babies to their standards. More importantly, one of out little guys was born early; he barely weighs over 4 pounds. He is having some trouble keeping his body temperature up because he doesn't have enough subcutaenous fat, and he uses most of the calories he eats to keep his temp up.

This morning we had him under the warmer, but he was still having trouble. We needed to keep him in the nursery for a few more days and give him high calorie supplements (along with breast milk). Then Mom could take him home and breast feed him. Fine. The catch was that Mom only spoke Spanish. And today her translator friend wasn't here.

As I mentioned before, I speak enough Spanish to get by, but most of the Spanish I learned was daily life or tourist Spanish. And it's been years since I really studied verb conjugation. Unfortunately, I'm it. Waiting on a translator would have taken an hour of precious time that we could not have made up in the clinic that was waiting. Soooo that's how I found myself explaining "breast pump" in Spanish in front of nursing staff.

Usually I write down what the doc wants me to say, look up any words or phrases I'm fuzzy on, and hightail it out of there before someone asks me something complicated. This time, however, the nursing staff got wind of me translating in room and decided it was high time to get their questions answered and instructions given.

The trick to translation, at least for me, is being flexible. I didn't know how to say "isolette" in Spanish, so I said "caja de calimiento"--warming box. To be honest I didn't even know what an isolette was when I started the day, so warming box was probably a better way to say it anyway. When I forgot the word for shampoo I said "sopa por el pelo"--hair soap. The nurses got a huge kick when the lady said "Shampoo?" after I labored over the words. Apparently the reason I couldn't remember it is because it's the same dang word with a Spanish accent. Another good one--portabebe is "carseat".

Where we really ran into trouble was when I had to explain that we wanted her to breastpump when she went home, put it in the fridge, and bring it back so we could feed it to her baby. I used maquina, "machine" and extractar, "to extract" (I kinda guessed on that one, luckily the Spanglish worked), and already knew leche de pecho--breast milk (really, "milk of the chest"), but then, as usual when I need to explain a body process, things quickly devolved into hand guestures. Luckily, being of the lady persuasion myself I had the proper equipment for pantomiming. Observe:









Thank God my (male) doctor was not in there with me when I had to do that. The nurse nearly peed herself laughing.

My New Year's resolution is to memorize my medical Spanish book so I don't have to embarass myself like that anymore.

Friday, November 14, 2008

I torture children

At least, that's what you would think if you walked by some of the rooms in our clinic.

Usually I'm pretty cold-hearted about taking away binkies, giving shots and the other various little tortures we put kids through. I try to make the kid comfortable, and don't prolongue the torture, but I have to be pragmatic. There's no way to reason with a 2 year old about giving shots. 5 year olds don't understand logic. One 11 year old boy was the biggest baby I had ever heard about getting one little shot--he had to have two adults hold him down. Sometimes you're the adult and you just do what is best for the kid no matter how much they scream.

A young girl came in for a well check and I started to read her chart to prepare before I went into the room. Her ear was bothering her and we were probably going to have to scrape out a tube with the little metal currette. It's not usually a painful procedure (the tube is already out of the eardrum and sitting in the ear canal), but sometimes when you get the cerumen (wax) out, the underneath of it is a little irritated. A little irritated was an understatement for this kid. I had the job of holding her arms down while she begged us not to take it out. She was terrified, and what was in her chart made me feel absolutely horrible about doing it.

She had been sexually abused mulitple times by a teenager in her home. When I read through the chart my heart sank, then I just felt numb and overwhelmed. Such a bad situation.

What do you do when both abuser and victim are your children? Do you still love your child? Do you still feel like he is your child? I wondered what kind of a mother can let her child back in the house knowing he hurt the other children, but can you turn him out of your house when he has nowhere to go? Does love switch to hate easily, or do you waver back and forth feeling terrible and guilty on each side? Usually an abuser has been a victim himself at some point--did someone hurt him first? Does that make it easier to help him, or do you just feel helpless in breaking the cycle?

Sometimes we have to do things that cause kids pain. I knew it was for her own good but contributing to her fear and pain made me want to throw up.

Wednesday, November 12, 2008

Don't Make Me Get the Stick


Doing a physical exam on the little guys can be tough. They usually don't understand directions, and when they do they feel no obligation whatsoever to humor you (at least the 2-3 year olds). Sometimes I use their desire to imitate and do whatever it is I want them to do. I'd say 40% of the time it works all the time. It usually makes them laugh at least, but there are hazards. Demonstrating "AAaaahhhh!" is how that 6 month-old spit in my mouth last month.

Looking into their little mouths is particularly tricky. If they are fond of the binky, I tickle their bottom lip with it--I know, I'm such a tease. They either open their mouths or start licking their tongues in and out. I either see inside or get a good laugh out of how funny they look. Another favorite trick is to let them hold the otoscope. Within 5 seconds they open really wide so they can stick it in their mouths. Lastly, if they are already screaming at something else I've done to them, that's the best view. I don't like to use a tongue depressor. Honestly, if the kid is already irritable I usually don't bother trying to look. The "Real Doctor" is going to look at them anyway. No need to doubly torture them.

One kid today just looked different. He was only 11 months old, but had an odd red rash all over his body. I had never seen anything like it. Usually when that happens, I just say, "Well, I think it might be this, but Dr. So-and-so has had much more experience looking at these things" and hightail it out. After I've seen it, if I don't know immediately I'm not going to, so I get out asap and go try to google something like it before I have to present the patient and give my hypotheses. Google images really helps me save face with my preceptors.

This time though, I sucked it up and got out the tongue depressor. There it was--a red puss-pocket throat. Even though strep is rare in kids younger than 2, I asked the nurse to swab him. Sure enough, it was strep. I was happy we found it and could treat him, but it sure made me regret not waiting for the "Real Doctor"--when I used the tongue depressor the kid wet coughed spittle droplets all over me. I swear if my throat tickles tomorrow I'm going on antibiotics.

Tuesday, November 11, 2008

A Dino Visits the Clinic!



Halloween is a great day to be in a Peds clinic. My family has an enormous collection of costumes. One day I found this child's dino costume and discovered I could squeeze myself into it (my enormous head is the only part that gave me trouble). I've been waiting for an occasion to wear it--and what a perfect time! I sure as heck wouldn't have gotten away with this outfit in Surgery.

The 1-2 year old crowd weren't too sure of me. They already have a good healthy fear of strangers, and one dressed as a dinosaur with an otoscope certainly didn't endear herself to them. I tried to talk in a dino voice, but I don't really know what that would sound like so it came out as a weird, doofus Barney-like voice. I only tried it once. I let the little kids pet me; that seemed to warm them over a little bit. The costume was very soft, but I think one of the 3 year olds definitely tried to cop a feel.

The teenagers were mildly amused, but of course not overly excited because that would be showing too much interest in a relative grown-up. The costume was a HUGE hit with the 4-7 year olds. My last patient of the day, a 6 year old boy, nearly jumped off the table when I walked in. "She's a DINOSAUR!!!!!"

That night I ignored the fact that the armholes really didn't fit as well as I'd thought and pulled an enormous lacy circa 1980 wedding dress over the top for a costume party. Get it? I was Bridezilla!

Haahahaha. Seriously, that is way funnier that "Slut du joir".

The fact that the back of the dress didn't zip all the way up past the "athletic ribcage" that the David's Bridal saleslady so kindly pointed out last year only made the costume better--it meant my purple shiny spikes and little tail wagged out the back. It's almost reason enough to go into Pediatrics.

Monday, November 10, 2008

Addendum

Friday, after I wrote this blog, I had a patient come in complaining of "knee pain".

When I walked in the room I saw a 254 lb. 13 year-old girl. As callous as this sounds, I thought--"Well, there's your knee pain."

This girl was pleasant, polite, and honestly much nicer to work with than most of the other teenagers. She's just on the fast track to an early death. I sat there, trying not to reveal my thoughts, mind blown by the magnitude of the problem and all the pain and suffering she is setting herself up for. I asked if my doctor would mind if I stayed and talked to her after the visit, maybe counseling her a little on how her knee pain is probably related to her weight. "Go ahead" he said, "but you might want to know we've had two-hour counseling sessions, enrolled in Weight Watchers Youth, arranged for a dietician, and nothing has worked yet."

He then said if I wanted to I could take it on as a project and schedule her as my only patient to see one afternoon and just talk to her. I think I'm going to do it, but not because I have any hope of changing anything. I am hoping to get a little personal perspective from her. I know my side of the situation; in order to ever be of any help I need to understand hers.

Friday, November 7, 2008

The Fattest Baby I Ever Saw

I do love chubby babies.

They are so roly-poly and cute with their double chins and baby-boobs and round bellies. It cracked me up when this one baby's legs were so big I had to push back the fat to test his reflexes. And even though I hated it when great-Aunt Marjorie would do it, I always want to give their chubby wittle cheeks a pinch.

It's all fun and peekaboo until I see that Mom and/or Dad are overweight. How are you supposed to know when to start worrying about weight in a kid? I asked my preceptor and he said once they've been walking for six months, if they are still overweight (comparing weight %-ile to height), then he starts to address it.

Babies are born with a good sense of hunger. They will tell you when they are hungry (well, scream) and naturally stop eating when they are full. It's the grownups that train it out of them. When they are little drool-pots slobbering on themselves, sometimes parents push food on them because "it's been four hours; time to eat". Then as they grow parents introduce them to their own bad habits by giving them juice (one doctor calls it "Nature's Soda) which is generally crap, soda, and basically fat and sugar loaded food. Then they wonder why the kid won't eat vegetables. Here's a secret-no kid is going to starve herself. Don't try one spoon of carrots and then switch to ice cream "to make sure she gets her calories".

While we were in the clinic for a 15 month well check, one mom's "friend" (I don't really ask usually) opened her 20oz bottle of Dr. Pepper because the kid was mad and let her sip it so she would stop. I nearly croaked!

A week ago I walked in to a well child check and saw the fattest baby I've ever seen. He was 17 months old and weighed 37 lbs. When I held his hands, they squished like the Pillsbury Doughboy's. That wasn't even the worst part for this kid. It seems that Mom and Dad don't ever want to cut his hair, but Grandma babysits and wanted it to look nice--the poor kid spends his days ambling around with his hair in a slicked back pseudo-mullet.

Grandma was clearly concerned with his weight. She said she thought his parents were feeding him things like Hamburger Helper and Velveeta cheese because they couldn't afford better food. I don't believe it. I think people get sucked into that sort of food because they don't know how to cook, they don't follow sale prices, and they don't ever think outside the box (literally in this case). The parents live off of processed crap, and they force-feed it to their kids. You can buy lean hamburger and noodles and make a one-time spice investment and have the same meal but with less salt and less fat. When I was in AmeriCorps I lived off of food stamps and never once ate Hamburger Helper. I could still shop the perimeter of the grocery store and make good meals. Granted, I don't really remember what I ate, but I lost weight so it was probably good for me.

The reason I get so worked up is because these babies come back to us later as overweight children. They get picked on, they don't exercise as much, and they are even starting to complain about knee pain and back pain. One sixteen year old the other day was developing insulin resistance--enough that her blood sugar was starting to show it. By then the habits are ingrained and they are on their way to be obese adults.

Parents act like it is inevitable. They call it "genetic" because they are overweight. They don't act like parents and take away the soda or the candy bars (um, my mom would never have let me eat a regular sized candy bar, and sodas were a once a week occasion--and diet then!). It's not inevitable. It's calories and exercise. And it's something you need to do.

I could go on for a while, but I need to go talk to a kid about her BMI right now.

Wednesday, November 5, 2008

Nervy Spaz

I cried three times today in clinic.

My current attending likes to quiz me in front of patients in a "guess what I'm thinking" style. It's oh so fun. Don't get me wrong, he's a very detailed and enthustiastic teacher. I just might lose my mind before it's over.

Usually I can tolerate it, even appreciate it, but lately I've been getting less sleep due to studying (and of course, the election), so as we say during our behavioral talks, I have fewer tools in my toolbox to deal with my emotions. The last straw was this morning when I had to do an on the spot history and physical, complete with presentations of findings, in front of the patient and her dad, then answer a series of questions which devolved into mathematical parlor tricks to calculate her appropriate dose of amoxicillin (in liquid form because that's more difficult).

A snippet of the more ridiculous part of the conversation:
What do you think is going on with this patient? Strep throat or a virus
How would you treat it? I'll assume it's strep right now until we get the cultures, and treat it with amoxicillin
What is the dosing schedule? Twice daily for 10 days
What is the dosing amount for children? Umm...400 mg/kg/day? (Actually 40mg/kg/day)
She weighs 22 kg. How much would you give her? What is this, a math test? Ok,ok..880mg/day
Would she take that at one time? No, it's bid dosing, so it's actually 440mg/time
The liquid dosing is 250mg/5ml. How much liquid does she need? You have to be kidding me.
At this point I was starting to feel trapped in the tiny room with all eyes on me, so I just guessed 7.5 ml. I figured I was probably close (my mom is a math whiz after all).
Actually, that would only give her 775 mg. Wouldn't you say 8.5 ml is a better dose? Sure. (Why is he doing this to me? Crap I was so close!)

At this point he turned and typed the medicine into his computer, where the medical program took the patient's weight and liquid suspension and calculated the correct dose.

It's difficult to explain how nerve-wracking this is. Imagine every two months you are given a new area of expertise to learn at work. Then each day while you are attempting to learn you are forced to stand for 20 minutes at a time(no one offers a medical student a chair) 25-30 times a day in front of your new boss--who determines your evaluations and possibly future--and a few strangers, answering question after impossible question. It's enough to give a reasonably sane woman a nervy spaz.

It doesn't matter if you get 5 questions right, when you miss that 6th question you get a sympathetic/surprised look (Oh, you didn't know that? You really should), and then the next day you present on "Denny's Crease". Denny's Crease was another question today--according to him that's the name for the crease kids get in their nose from wiping it with allergies. When he pressed me about that (Just saying "crease from allergies" was not specific enough) I finally broke down and said, "How would I ever know that?" I came home and googled it; you know what I found it to be called? "Allergic Crease".

Why do doctors do that? Guess what? I could do the same thing to you with Saved By the Bell references. And I think it would accomplish about as much as those math questions.

After a day like today I would unwind with a beer...but I'm on call tonight and at any moment the pager could go off for another round.

Thursday, October 30, 2008

Cross-eyed babies


Yesterday morning I got pooped on, spit up on, and peed on by three different babies. All before noon.

But still, I looooooove babies.

Too be fair, my hands are usually freezing because I wash them so much. Every morning I start my day in the newborn nursery checking on the freshly born little goobers. I have to check their soft spots, their hips for dysplasia, their boy or girl parts, and their eyes. I check everything, of course, but those are part of the special baby exam. It's when I check their boy parts that I have to be on high alert. Cold hands plus fresh air minus diaper equals whiiiiizzzzz. I have to have reflexes like a cat if I don't want to smell like a diaper the rest of the day.

One little guy had perfect hair straight out of the womb. He could have been a Catholic choirboy with that hair: thick, blond, and long enough to have a perfect little boy side-part. So cute! His mouth an nose were bruised though; I didn't realize how common that was. Apparently birth is traumatic for everyone involved. He also had crossed eyes. That's completely normal, at least until about 4 months. One of the first signs of development is when a baby's eyes track together. It means both sides of baby's brain are working together now! Knowing that cool factoid didn't stop me from giggling a little when I saw it. It was so precious. Plus, I had to pry his eyes open to see them, stubborn little guy, so his face was all scrunched up with anger. No, prying his eyes open isn't child abuse. I asked. It's how you have to do it unless you want to get the lid retractors (which sound worse).

Before I leave the nursery I say hi to every baby there, whether or not they are my patient. It means a lot of hand-washing, but it's one of the best parts of my day. I do the same thing with well checks--I always sneak a little extra squeeze before I give them back to Mom or Dad. I consider it my little perk for getting up early. Besides, we had a baby born in a Ford Fiesta in the parking lot the other morning, so of course I had to check that kid out.

Monday, October 27, 2008

Hey! Don't Give Me 'Tude!

Normal "Man" sign

New "Teenage" Man Sign complete with skinny jeans

Teenagers crack me up.

I had been lucky in the past with teenage patients. They come in with their little attitudes and their punky outfits, sassing mom a little but meekly answering every question I ask. One 15 year old I talked to looked just like my alter ego on Rock Band, rainbow hair and everything. I would have told her that, but figured that wouldn't mean too much to a teen and besides, my alter ego on Rock Band doesn't have a very classy name (the game will actually tell you that, in case you have no taste). Instead I said her hair was amazing and I should have done way more crazy stuff when I was in high school and it didn't matter. Dang I'm still jealous of that Fun-dip colored hair.

Today I switched clinics to an older clinic, meaning I saw a lot more teenagers and older children. Probably a good cure for the baby fever I caught at my last clinic. There were several patients today for whom a better description of their illness might be "Demon possession" or "OMG-my-life-is-so-dramatic-ism" (yeah I made that up).

One patient with false eyelashes and a haircut stolen from Elvira steadfastly refused to fill out her intake form. In between yelling at her mom and tugging at her Juicy sweatpants (with the writing on the butt, while we're on the subject of classy), she whispered behind the nurses' back that she didn't have to do it, then when the nurse would turn around she'd lift the clipboard up and make scribbles as if she were. Apparently her dad owns a few small businesses in town, so she gets to act like an ass every time she comes to the clinic.

She wasn't the only one yelling at her mother either! Two other teen girls in clinic today told their mothers to shut up! Multiple times! Now, I don't know if all you readers have met my mother, but let me tell you this: if I said shut up to her face, she would wrestle me to the ground and teach me a lesson. And I'm 25 years old.

I will be the first to admit that when it comes to teenagers, I'm over the hill. I try to remember one rule when dealing with them: They are the oldest they've ever been, and they think that's the oldest they'll ever be. The world revolves around them and their friends. That's just how it is; they don't know any better. Their frontal lobes are not developed enough to engage in the sort of planning and forethought that most of ours are now able to accomplish.

Now, personally I don't think that excuses such phenomenon as boys wearing lady jeans (especially in a smaller size than I do-makes me want to kick their tiny little hinys), or man-scara, guyliner, crying in public, excessive touching, forming enormous giggling groups and parking themselves at the movie theater entrance so I have to walk through the cloud of AXE and sex hormones, but it's not like I run around Sonic parking lots with a broom yelling "Tarnation" either.

Part of being a good doctor is realizing you have a filter through which you view your patients. Most of us are perfectionists, a lot are a little egotistical. We spend a decade learning how to do things The Best Way, and can't understand why patients don't always see it like we do. In order to treat patients effectively, you have to learn to set aside that filter and see from their perspective. Even if you think they are drama-crazed hormone-mongers. I just hope I have more patients like Cool Hair Chick, and fewer like Tramp-ola. And crap I hope I didn't act like that in high school.

Wednesday, October 22, 2008

So much fun I nearly puked.

Last night I was in the OR for three hours. One of my preceptor's patients showed up at the ER with an MRSA abscess and a fever. She called a surgery consult, and in the OR that night we found out the pinky-sized hole the ER cut into the abscess was a gross underestimate for the nearly hand-sized abscess.

This might be a little graphic, so unless you're Uncle Kevin, you may not want to read. When you're dealing with an abscess, you can't pussy-foot around it. You have to cut a big enough incision to allow aallllll the puss to get out. In order to ensure that, once you incise with a scalpel, you poke around inside the wound with a blunt probe to find out how big it is and where its borders are. When we had examined the patient this morning, we saw a teeny hole surrounded by purple skin. She still had a fever after nearly half a day of IV antibiotics, so it didn't surprise us to find another hard, red, hot area two inches away from the ER's incision. She needed surgical drainage.

Once in the OR, we cooed and talked to her to keep her calm until the anesthesia took effect. Then they went to work. The surgeon found a large two-inch tract extending from the original abscess incision to a large pus pocket on her thigh. He found another smaller tract extending about one inch below. He made an incision in each of the new pockets, picked up an instrument that looked a lot like a turkey baster, and started squirting saline into the abscess one incision at a time. It was crazy to see the stuff coming out of the other incisions in her legs. I was grateful I still can't smell anything because necrotic fat and blood just gushed out of her wounds. Blech.

When we went out to talk to her parents, something was weird. I thought it was just a cultural difference, young separated parents and all, but then I put my finger on it. Dad was high. Not just high, but HI-IIIIGH. Now, I didn't formally test him or anything, but I would bet my student loans that was what was going on. We're taught to be observant. Oh yeah, and then the next day we heard that there was a shouting match over not "doing drug deals while your child is in the hospital. "

I see a lot of young, unprepared parents in this town. I don't have the prejudice that young and single= terrible parent. Buuuut when I know in two days I'm going to release a baby who gets 10 day stretches of quality time with a dad who can't seem stay clean for a single day, it takes a little longer to fall asleep that night. The weirdest part about it is that I can't find a fault in his chain of action for the baby. I read the reports and took histories. I think he did everything he could. I think he did everything I would have (if I weren't a hypochondriac medical student). Surely he can't be competent enough to take care of this kid. But if anything, it was a missed diagnosis at an urgent care center several days earlier that led to the abscess' impressive size. If you looked past the jumpiness and twitchiness and pressured speech you could see fear in his eyes. Now, I don't know if it was pure drug-induced paranoia, but I'd like to think it was genuine concern for his kid. Maybe that's why he got high; he couldn't take the stress.

Either way, I didn't want to give the kid back, but I had no reason not to. I just wonder what kind of life is she going to have. At what age is she first going to realize what Daddy does?

All the doctors involved in the case (including me) asked the same question at first: "How could the parents let it get this big?" Things get a lot squirmier when you can't blame something on the easy target of the addict dad or young ignorant mom. It wasn't their fault, and the fact that we all stubbornly assumed it was is keeping me up another night.

Monday, October 20, 2008

Did you just spit in my mouth?

A six-month old spit in my mouth this morning.

I was leaning over her innocently performing my well-child exam as she started blowing raspberries. "Oh how cute!" I thought, "It's a pre-speech skill!" Then she straight up spit in my mouth. Why was my mouth open? BECAUSE I'M STILL SICK AND MOUTH-BREATHING FROM THE LAST KID WHO PICKED HER NOSE AND PUT IT MY MOUTH WHEN I WAS DISTRACTED.

At least I know she's been vaccinated.

Later in the afternoon, after I had thoroughly rinsed my mouth, I walked in another room to see an orange baby. Yep, I checked twice and put in my eye drops. She was orange. Everywhere. Except for her eyes. That's the clue to what was going on with her. A jaundiced baby can turn orangey-yellow, but her eyes will be jaundiced too. This baby was nine months old, and loooooved her sweet potatoes, carrots, mac and cheese, basically any orange food. I guess sometimes you really are what you eat.

On that note, just so you know Mom, I bypassed the fresh-made onion rings the cafeteria ladies were shamelessly hawking tonight in favor of some tomatoes...balanced out by a nice green salad. I don't really remember the color wheel details, but I think if I eat both of those I should turn out a nice browny-tan color.

And I don't care how scary it makes me look, tomorrow I'm wearing a dang surgical mask.

Thursday, October 16, 2008

Shut your mouth!


I hope that as I go on in my medical career, I will learn to control my mouth. In the meantime, here are a few choice quotes from the clinic:

"Have you ever wondered if that's a third nipple?"

"She looks like you, but with more hair."

"Are you having sex talks with your child yet?"
The 10 year old boy: "I already know, don't do it when you're married!"

"My, your daughter certainly has sturdy legs"

"Ix-nay on the nipple thing when the real doctor comes in--that woman
is in charge of my grade."

"HOHHH! That is disgusting"

"That reflex was totally fake."

"Are you seriously whining about the ear exam? Want some tissues and
a sticker?" (That was to a 15 year old boy with quite the 'tude)

"I'm sure that nostril flaring trick gets all the ladies."

"Sure I've stitched before. Not on people, but they say pig skin
teaches the same thing."

Oh no Oh NO CRAP he peed all over me!"

"Well of course you gained weight when you went off your diet."

Tuesday, October 14, 2008

Vaccinations-LOOK OUT!


Today in clinic I had a particularly precious baby in for a well child check. She's six months old; so she's not afraid of me and will even giggle and interact--a big lift considering two kids screamed as soon as I walked in the room that morning. Anyway, she had blue eyes, pale skin and chubby chubby cheeks--if the Marshmallow Man had a baby girl, she would look like this kid.

Well child checks are when we typically give the 2, 4, 6, 12, and 15 or 18 month immunizations (they poor little guys get another round when they go into school too). Something I didn't know before this rotation is how many parents choose not to immunize their children.

It's never a good idea to call a parent crazy or ignorant to their face. But what does one do when someone tell me that they don't want to immunize their child because vaccinations are a "government conspiracy trying to brainwash parents" ? I'll tell you what I do. The first time I waited a few seconds for the parent to laugh so that I could too. When that didn't happen (yikes), I quickly dropped all emotion from my face. Blank slate. I just try to totally empty my mind for as long as it takes and sit there, glassy eyed, until I can continue like a professional. It's a trick I have worked hard to perfect. One day on Family Medicine a lady was telling me all about her guava juice and cayenne pepper "detoxifying cleanse" (and didn't mention the 1/2 pack she smoked a day) and I had to hold the face so long I felt a little drool coming out of the corner of my mouth.

Only when I am outside of the room do I let myself think: "Yeah, it's a conspiracy. Against HORRIBLY DEVSTATING CHILDHOOD DISEASE!" But sure lady, I think it's totally possible that the CDC, American Academy of Pediatrics, FDA, and American Academy of Family Physicians are all sitting together in a bunker giggling about how they got us to poke needles in children for the yell of it.

Here are some reasons I've heard for why parent's don't vaccinate their children:
--"We are waiting for her immune system to develop a little more."
Vaccines work by stimulating a child's natural immunity so that if it ever encounters the real thing, it is already prepared to fight. With the exception of MMR (measles, mumps, rubella) and Varicella Zoster Virus (chicken pox) which are live attenuated (weakened), vaccines are dead dead dead, either killed like the polio vaccine (IPV and the flu shot), toxoid like diptheria and tetanus, or made from a compenent like Hib, Hep A and B, and pneumococcal. You give MMR and VZV at one year of age when the little ones are stronger anyway.

--"I've done a lot of research, and we are worried about the link to autism"
Here's a little more research for you to read:
CDC's position on thimerosal and autism
American Academy of Pediatrics latest study on purported link to autism

--"I don't want my child to cry from shots"
Hmmmm....I'm sure they'll cry a lot more when they get MEASLES. Though I totally support your parenting style of making decisions about his health and well-being based on whether he cries or not.

Parents have the right to choose whether or not they immunize their child. I support those who have put a lot of effort into researching; I truly believe they are trying to make the right decision for their child. That is how I can discuss the options with the parents rather than sit silently and alienate them. I simply come to a different conclusion when I read the available evidence and couple it with the fact that children suffer and sometimes die from these diseases.

And why would doctors spend years of their lives and hundreds of thousands of dollars they don't have to hurt children? We want what we honestly believe is the best thing for your child.

Part of the success on vaccines depends on herd immunity. We are starting to see outbreaks of measles where an unvaccinated child was the original vector, but children whose immunizations didn't produce enough response, or children who were not able to be immunized, were sickened. The more parents do not vaccinate their own children, the higher the disease burden and the more other children will also be affected. This does not seem right.

We as a nation are fortunate in that we largely do not remember the suffering caused by vaccine-preventable diseases. Instead of seeing the morbidity and mortality of measles we can focus on the possible links, the shadowy conspiracy theories with the vaccines. In the end, I think what it will take is children dying from diseases we had previously nearly irradicated. Then the reality of these illnesses will shock parents into vaccinating their children.

Monday, October 13, 2008

Children Make Me Sick

Literally. This morning during clinic I felt my throat start to tingle, then tickle, then...ooooohhhhh so sore. Being stubborn and a little stupid at times, I ignored it and kept going. As the day went on, I felt progressively crappier. Here's a rundown:

9:30 am: Hmph. My throat hurts a little. Wonder if my mouth is dry or it's allergies. Though usually those get better as the day goes on...
10:30 am: Good gravy my neck is achy. I guess I slept on it wrong. Oh there's a 2 year old to exam; better keep moving,
11:30 am: Head hurts. Must keep going. Can't have my preceptor (doctor that determines my grade) thinking I'm lazy. Why do I have ear and jaw pain? Ear infections aren't contagious are they?
11:40 am: Crap, did she see me put my head down in her office? Quick, while she's busy with an adult I'll just check xkcd.com for a few funny comics to wake me up.
12:00 pm: Just. keep. moving. Oh the drug rep brought peppermint patties. I believe those are very therapeutic for sore throats. I think a good dose is 5 patties...
1:00 pm: Broke down to ask if there was any ibuprofen in the office. Ended up on the wrong end of a strep swab. Now is not the time to show off my impressive gag reflex. Hope I've always been nice to this particular nurse.
1:05 pm: Hmph. I guess not.
1:20 pm: "Allison, go home if you don't feel good." But wait! There's a kid with possible appendicitis. Dang it I've never seen that.
2:00 pm: I can't take it anymore.
3:00pm: ZZZZZzzzzzzzz
5:00 pm: Oh licks and giggles even my calves hurt. I hate children.


"Yes, that's it, breathe all over me dear."

Yes, as my doctor so helpfully mentioned during the day, I carefully wash my hands before and after each visit. But when you spend your days a stethoscope away from snotting spewing little darlings, eventually your immune system says, "What the crap you masochist?" I lasted longer than my roommate. I'm in my third week; he succumbed during week 2.

Something interesting: My ear/jaw pain (you can get both b/c they use the same nerve) is most likely not from an infected middle ear (aka acute otitis media), but from fluid pressure. The cycle usually starts from something (a virus? allergies?) inflaming your throat. This can close off the eustachian tubes which normally drain your ears. Fluid builds up and bothers the crap out of you. Sometimes it gets infected--then it's AOM. I took an antihistamine and an anti-inflammatory (decongestants work too) which presumably decreased the swelling in my throat. My ear could drain, and three hours later I felt like I could hold my head up straight again.

Saturday, October 11, 2008

You Can't Fix Stupid

Yesterday we admitted a 2 month old whose mother said turned purple
this morning. From the sound of the history, she had an apneic
episode, possibly a ALTE--acute life-threatening event. It used to be
called Near-miss SIDS, but ALTE is the term used now.

While I was taking the history I asked if there were any smokers in
the house. "Yes", the mother said. "How many?" "Four". Four
smokers around a precious two month old baby. A two month old who
turned purple yesterday from not breathing and might have died.

This morning when I went to round on her in the hospital the nurse's
report said the mom had screamed every time the baby "stopped
breathing". Babies' breathing can pause for several seconds, that is
perfectly normal. From the nurse's report, she was breathing normally and her oxygen saturation remained fine the whole times. Unfortunately, mom was already on edge and took the opportunity to scream obscenities at the nurses while yelling into her
cell phone that "They are not doing anything!! She's dying!!"

Things had calmed down by the time we went to the room. We explained
that her tests were normal so far, and that what may have happened was
that she had a viral illness and the FOUR SMOKERS around her probably
filled her little lungs up and irritated them so much that she
couldn't breathe. But in a tactful way of course. Actually, my
doctor handled that part because she has more tact in the face of
stupidity than I do. She said it takes years of practice. When we
explained that any smoke around a baby increases her risk of SIDS and
for the health of the baby they should stop, her reply was, "Well,
it's not our house so I don't feel comfortable telling other people
what to do."

I can understand that is a precarious situation. So we suggested that
people leave the house when they smoke. They are family after all,
and surely care about the baby's life. "Well, the thing is several of
them are disabled and can't move to go outside every time they have to
smoke." Ok. I have seen plenty of people who disregard their own
health, like the 52 year-old whose oxygen tube was brown from smoking
while she was on it. So the fact that people whose bad habits may
well have disabled them continuing to smoke doesn't a. Surprise me or
b. Make me pass judgement. I'm not in their situation and it is
their body. But this is a baby, and they are putting her health and
possible her life in danger. It is baffling to me that someone
couldn't put down a cigarette for such a sweet helpless being.

On our way out of the hospital we passed the mom. She was going
outside to smoke. I wanted to tackle her and stuff cigarettes in her mouth until she
saw the error of her ways! Buuuut, aside from being unprofessional,
her size, stubborness, and facial hair made me think it wasn't a fight
I was going to win. All I can do is hope the next time I see the baby, it's for a Well Child Check, and not for pneumonia.

Thursday, October 9, 2008

Torture Me Elmo

I torture children. At least, that's what you would think if you spent some time in my clinic.

Kids are usually pretty cooperative until around 9 months. Then stranger anxiety starts to kick in. I don't blame them. They shouldn't like me. I poke and prod and check their business in front of everyone in the room. Then I unleash the nurses to give s-h-o-t-s (you have to spell a lot when you're in pediatrics). I'm pretty much the gateway to evil in a kid's world. And I don't even give suckers.

I let them play with my stethoscope. I try to show them my otoscope won't hurt by putting their little fingers on the light so they could see it glow. I try to let them poke around so they give me the same courtesy. I even let a 15 month old put his finger up my nose. Not really let so much as "was distracted while the surprisingly quick little hand popped up".

I had a perfectly precious little guy in my clinic that screamed bloody murder every time I touched him. And only when I touched him. It was bizarre. I could be in the same position, right up in his face, stethoscope outstretched, but as soon as I actually touched it to his chest, WWWAAAAAAAHHHHH!! So I'd take the stethoscope off but otherwise didn't move a muscle and immediately--silence. Touch the stethoscope-SCREAM! Take it off--sucking his thumb. I tried it several times to make sure I wasn't making it up. His mom and I had a good laugh while I did it, but secretly I wonder if she didn't just bring a slightly larger Asian version of Tickle Me Elmo. Or Torture Me Elmo.

I think I'm slowly getting better at the ninja-peek. Or when all else fails, Mom or Dad holds the goober's arms and head for dear life, and I say a little prayer of thanks that I don't have to go home with the screamer.

But I really do love the cuties. :-)

Tuesday, October 7, 2008

Circumcision touches a nerve

It shouldn't have surprised me that people want to talk about circumcision. But I am surprised that people are reading this blog who aren't related to me (and therefore, under pressure to read it). Here are some more thoughts about circumcision I learned from my pediatrician and research:

1. Why is female circumcision "genital mutilation" but male circumcision is not only culturally acceptable but something that parents feel like they have to do to make their kids normal?

2. Out of the English-speaking countries that used to practice circumcision (US, England, Canada, Australia and New Zealand), the US is the only one who still circumcises the majority of its babies.

3. Male circumcision in the US was advocated in Victorian times as a cure for child masturbation. Yeah, from what I've heard that works really well.

4. Here's a little quote from Dr. John Harvey Kellog (same guy whose corn flakes I now look at a little differently)

"A remedy for masturbation which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement. "

(John Harvey Kellogg, M.D., "Treatment for Self-Abuse and its Effects," Plain Fact for Old and Young. Burlington, Iowa: F. Segner & Co. (1888). P. 295

Enjoy your breakfast. Did anyone else just about mess themselves when they read about the carbolic acid?

Soon I hope to tackle the thoughts I have about Medicaid and Medicare, but that's such a huge topic I'm sure it will turn into a series.

Saturday, October 4, 2008

Moobs!

I saw a baby lactate yesterday.

No, really. It happens. When both baby boys and baby girls are hanging out inside mommy, they are exposed to hormones galore. These hormones cause them to develop little breast buds: actual breast tissue fat pads. There is a difference between a fat chest and man boobs--moobs if you will. The real term, just so I use the knowledge I'm paying dearly for, is gynecomastia from "gyn"-woman and "mastos"-breasts. To truly call it breast, there has to be a palpable little bud of glandular fat right underneath the nipple. Fat is only fat, unless you have glandular proliferation.

Gynecomastia. Image courtesy of Robert Paulson. Actually, this is him in the flesh. Since this is a dude, this isn't obscene, right? What do you think Mom?

So what causes moobs in adults? Well, when the processes in your body that are designed to create or break down hormones (mainly estrogen and testosterone) are altered, it alters what God intended. Either estrogen increases or testosterone decreases. Either way, estrogen wins and Viola, moobs. Some examples of causes: Liver disease (the liver is supposed to clear estrogen in a healthy person), kidney disease, medications such as spironolactone (for high blood pressure) and several HIV treatments. That's only a sample! Technically, obesity can cause gynecomastia because fat actually creates one of the forms of estrogen. Crazy.

Anyway, when my attending and I were examing this new baby, we found breast buds. Eager to teach me, she said, "And sometimes, you can actually..." and pressed on the baby's buds. Wouldn't you know, a little serous fluid came out! (In another ultra-professional moment, my reaction was "Aack!")

Here's an emedicine article for further reading if you're interested.

Wednesday, October 1, 2008

Circumcision--Let's cut right down to it.



I saw a circumcision the other day. It was traumatizing.

First of all, the longer you wait, the bigger the foreskin and the bigger the blood vessels. Not good. This baby was a week, a few days older than my doctor preferred, but the problem is that a hospital circ would cost $1,000 (an estimate from my doc for my area) but in the family doc's office it's only $150. Medicaid doesn't pay for circumcision by the way, so no one on Medicaid wants to get it done in the hospital. Usually it's at least two days before the baby gets to the clinic.

For the not so squeamish, I'll give you a rundown. The parents go out of the room because they don't want to see what they've just signed their newborn up for. Next we strap the poor little unsuspecting goober to a white baby-shaped board. Naked. Screaming ensues, and that's all before we get out the Gomco (a metal clamp contraption with a hole in the middle for you-know-what).

This particular doctor didn't use general anesthesia because "there's no evidence that it does more good than harm. I'm sure that clamp hurts like hell. In my readings since, I've found that there are options for anesthesia, but honestly, after seeing that all I can think about it is "AAAAAAAaaaaHHHHHHhhhhh!" By the way, the parents are nowhere to be found at this point. Lucky jerks.

I hope that if I have a little boy, I have the guts not to circumcise him. In the US, 50% of boys aren't circ'd anymore (down from 80% in the 80's). The American Academy of Pediatrics doesn't recommend for or against it. Neither does American Academy of Family Physicians. I'm a little afraid of him looking weird in the locker room, but for peter's sake that procedure cuts off the most sensitive part with only a 1% absolute risk reduction for UTI and 0.1% reduction for penile cancer. Yes, there may be a reduction in STD transmission, but aren't we all supposed to be using condoms and good hygiene anyway?

I'll try to post a picture. But in the meantime I just hope I'm not asked to step in. I'm not ready to be entrusted with a little dude's future pride and joy (I assume he could care less right now. I am female however.)

Tuesday, September 23, 2008

NarcolepZZzzzzz

Occasionally, as a med student I am sleep deprived. By occasionally I mean ah-lot. I try to look on the bright side of it: I never have trouble falling asleep once I'm actually in bed, and I like to pretend that I'm training to be a Masai warrior instead of just a doctor. Some of my best naps are in lectures where I zonk out for a good 10 minutes, then have to snap back to full battle-ready attention when the mumbling neurologist points his arthritic finger at me and demands and answer to his unintelligible question.


There is one odd side effect of being sleep deprived--every night, between 10 and 10:30pm, I lose my God-fearin' mind. They are actually called hypnagogic hallucinations. At night, usually when trying to have a serious and meaningful conversation with my fancy-A, my mind is so determined to fall asleep that it leaves the rest of me behind, weaving in and out of dreams, mixing consciousness with the utterly bizarre. You know how you have crazy dreams where one minute you're climbing a fireman's ladder in a tutu and the next you're running from vampires? Now imagine having the things you would say in such situations actually come out of your mouth during a real conversation. That's what he has to put up with.
Most people have experienced this--it's the name for when you're about to fall asleep and dream of falling or having something thrown at you, then jerk yourself awake.
I swear he baits me sometimes just to hear the ludicrous crap I say. When we were very first dating we were having a great conversation about life when I interrupted him to ask if the "physics demonstration is outside". Awesome. Last month he woke up to find me laying on top of him with my face veryveryclose to his creepily saying "I just want you to know how much I love you" before dropping my head and snoring slightly (hey, I have allergies). He said he laid there quietly for a while wondering if I was planning to stab him before he could go back to sleep. Just this weekend I hallucinated that there were ants on his neck. I don't think there were, but I sure slapped the hell out of him just in case. I thought I was still dreaming when I did that, but the red marks backed his side of the story.
"This time, let's read him a story about the Loch Ness Monster and see what he does!"
Little did I know, these hallucinations can actually be a feature of narcolepsy. So can things like hearing your name called just as you drift off to sleep, or hearing a bell ringing (these are auditory only hallucinations, and could be pretty scary if you didn't know what was going on).

Even though we know what's going on, I think my future hubby prefers when I fall asleep first. Just so he can defend himself.

Saturday, September 20, 2008

A Good Day Starts With a Scalpel



Let me make this clear: I like to cut. Any day in the clinic that gets a scalpel or scissors or or a magic wand that either freezes or burns is a day that makes me think about actually going into Family Practice.

I've had to learn a lot about what NOT to say in a clinic procedure: Things like "Oh, well, I've stitched on a pig's leg, but this is my first human stitch," or "Oh--wow--that's the grossest/coolest thing I've ever seen" or simply "OOoohhhhhhhh". Not everyone shares my enthusiasm for pus. Especially when it's coming out of their own arm.

The other day I got to play with an entire styrofoam cup full of liquid nitrogen. Seriously! I was on a wart hunt. I dabbed a sort of giant Q-tip into the cup and then squashed it onto the wart, holding it there until it was good and frozen. My rule of thumb was, when the patient started squealing about the pain, it was down to the viable tissue. That's terrible. I don't really do it like that. But I did get too close to a guy whose head I was freezing. I pulled back and realized the cup had been up against his hair, giving it a nice frosted look. I didn't say anything until it melted and I was sure no permanent harm had been done. I already had a slightly frozen spot on my forehead from bending too closely over the cup, so I figured we were even.

A weird little fact that most people don't know is that if you have an abscess where you can see pus, incision and drainage is the cure. So you should be happy that I'm coming at you wielding a scalpel. Also, unfortunately, when I stick your abscess with a needle and inject anesthetic before I cut, all the pus in the abscess raises the pH of the anesthetic, rendering it somewhat useless. Sorry 'bout that. I've noticed men don't take that nearly as well as women. But that's a story for another day.

Friday, September 19, 2008

Test Post

We're trying out some new colors!

Thursday, September 18, 2008

Drug Reps-The Real Dirty

Today, as in most days this month, during lunch I head to the break room and get lunch. I never know what is going to be there or how terrible for me it will be, but what I do know is that it is provided by pharm reps, and in order to eat lunch, I have to leave the party of nurses and techs eating peacefully in the break room and go face the music in the conference room.

It's not that I think pharm reps are bad people. But why would I go through 12 years of science and medical training to listen about a drug from someone with a history degree and two weeks of "intense" training on his or her particular drug? One rep pointed this out and said, "I would be insulted if I were you. To think that we could come in and influence you; you're too smart for that." I said if it didn't work I'd have to ask why she was still coming and pandering to my ego.


Is this sub-sandwich worth my soul?

I feel a little like a lunch slut for eating. Most doctors use it as social time amongst themselves, making a game out of how they can thwart the sales pitches or poke holes in the studies presented by, funded by, and of course, favorably showing their company's product.

Blah Blah blah even writing about them is mind-numbingly annoying. But now I'm hungry. Thank goodness there's an "informational dinner" tonight.

Monday, September 15, 2008

M is for Muscle strain

Monday, September 15, 2008

So kickball is no place for sissies. Or has-beens. And last night, I think I proved myself both. The second play of our second kickball game found the red ball of death screaming off the way-too-serious former soccer great's electric blue cleat and right at me. I exploded in a blur of agile athletic movement, years of honing my cat-like reflexes about to pay off as I leaped toward the ball.

Or so it played out in my head the split second before I strained my right quadriceps.

The phrase "muscle strain" is too tame for what happened in my leg. Muscle fibers that had spent years working out 5 days a week in cardio, agility, and strength training literally tore themselves apart in my right thigh simply because I asked it to move a little faster than usual, please. Fast movement was no longer an option; I wasn't sure any movement was at the time. The damn thing is still killing me. I didn't hear a pop, and I could still move my leg, so I figured it wasn't a complete tear. But wow did I find out how often you use your quads without knowing.

Shame is a good way to describe my feelings last night. My fancy-A had to carry me back to the car after I stupidly refused the umpire's golf-cart offer. Luckily I've had this rule since college that I only date men who can pick me up and carry me. Just a lap around the bar or party will do, and we're not going for romantic. Utilitarian still gets the job done. It sorted out the bad sports and the L7 weenies. I'm now marrying a guy who can carry me a good 100 ft without a break. I can't believe my luck.

Aside from my patients laughing at my limp, a cross between shriveled old man and purpose-filled soccer mom (I needed arm-swinging momentum), it's nice to work at a doctor's office. This afternoon I got stimulation, heat, and some ultrasound action. AAahhhh. Tomorrow I think I get a pain relief patch to slap on it. I hope they don't make me drool.

I learned a little lesson: warm up Warm Up WARM UP and stretch before any athletic maneuver, even one so seemingly innocent as kickball. And if you strain a muscle (and can still walk, if not go to the ER): rest, ice (not on bare skin of course, and only for 20 minutes at a time), NSAIDS (ibuprofen), slight compression, elevation, and for heaven's sake don't keep trying to play in a hopeless game. By then you have nothing to prove.

Thursday, September 11, 2008

Bend over, por favor.


Once a week I volunteer at a free clinic here in town. We take the poorest of the poor, no copay required.


Though I usually feel a little in the way as I am only a medical student, I do have a talent which occasionally proves useful--I have a faint grasp of the Spanish language. Enough, anyway, to serve the purpose of explaining hypertension, understanding that instead of what I said in Ingles, the interpreter just told a patient I'd like to practice a gyn exam before the real doctor came in (NO is the same in both languages, by the way), and once, to explain a digital rectal exam. Though to be honest, that was more a matter of hand gestures. It's not really something one learns in Conversation Spanish class.

Senor, mi uno necessito ir en su....ahem....

Anyway, I was tasked to get more history from a man brought to town by the local meat processing plant. His address was a motel, the usual one the plant puts its workers up in before they start work. The problem? His blood pressure was so high I'm surprised his eyeballs hadn't started to bug out. Almost enough to put him in the hospital right there. (>200 systolic or >100 diastolic).

From talking to the nurses who had been there awhile, and to the interpreter who clearly cared more about the patients than the providers, I learned that's generally par for the course. The plant brings workers, often with no English, often with no Social Security number, to their plant. Once they have them there, THEN they do a health screen for a work release. Fail the health screen? Oh, well, you can't work. That's it. No job, no home, no bus ticket back to where you came from. This clinic could give the man medication, and I could interpret that he had been controlled on drugs before. But what if we weren't there, and supported by public funds? Imagine the drain on the town's resources. Workers with no jobs brought into a town and dropped there. What happens when the motel kicks them out? What happens when their English isn't good enough, or their immigration status isn't legal enough to get a job? What happens when they are hungry?

High blood pressure blows. I'm sure I'll preach more about that later. But high blood pressure in a foreign place with no money, no job, and no language skills is a teensy bit worse. I wish I knew more about the meat processing company to stop it. For now, I just hand out HCTZ and hope it makes enough of a difference to get the man a job. And then, maybe we can work on his health.

Tuesday, September 9, 2008

Melanoma-Holy Moley!


We have a lady in the hospital with melanoma in her chest. Melanoma is a nasty nasty cancer. It looks tiny and unassuming, but LOOK OUT! If it sneaks itself into your skin beyond 1mm, it invites itself to the rest of your organs. And it doesn't even bring a bottle of wine.

Seeing as I am myself covered in nevi (medicalese for mole), I always find myself eyeballing each freckle for the ABCD's (you know: Asymmetry, borders (irregular?), color (even? splotchy?) and diameter). Nothing exciting yet, but I just like to let them know I'm watching. Kind of a mole-standoff, if you will. But without the compounds and FBI involvement.


Is today the day Mole?

For those of you with a willing significant other, spice up your date night and check each other!

Monday, September 8, 2008

Kickin' it old school


Last night the fancy-A and I played in our first kickball game. A whole league of grown-ups playing kickball on a real field with a real umpire! Unfortunately, we lost. Big time. There's a rule about having to have equal numbers of men and women, and we were short on the lady side. And apparently I have a lot to learn about the subtle art of kicking the crap out of a big rubbery ball.

Things I learned:

1. Kickballs give a satisfying thwap when they tag a runner trying to make it to home plate.
2. You can't throw kickballs from center field to home, no matter how well you can throw a softball.
3. Most of the fun in adult kickball leagues is derived from watching grown men and women (esp. engineers) run around, arms in the air, faces lit up with apprehension and anticipation, right up until the ball bounces of their chest.


My pal Kristin sent me this from Mexico. I think it's the perfect addition to my kickball uniform. Nothing like a little intimidation to get the game going.