Tuesday, December 22, 2009

CrichothyroDundee


As part of Airway Day, we also go to practice doing cricothyroidotomies (you may know them as tracheotomies, though technically cricothyroidotomies are a subtype of tracheotomies). Trach generally refers to a surgical tracheotomy which take longer and are usually left in longer. In that a surgeon will cut between the Adam's Apple (if you have one) and breastbone, separate the muscles, split the thyroid, and cut through the tough cartilage of the windpipe. In the crich, I swear it felt like all I did was grab a scalpel, feel above, feel below, and oh so delicately jab that sucker in the soft spot of the crichothyroid membrane. (You can also do this with a needle and catheter instead of a scalpel.

We did this on dummies of course. Though I think if I were going into emergency med we'd have to practice on cadavers too. Shudder. The dummies have this jelly-ish plastic "skin" wrap that goes around their necks and velcros together in the back. You can see where other people cut, so you have to keep taking it off and rotating it after someone practices. When it's your turn, you feel for the thyroid cartilage (aka Adam's apple, and yes, even girls have it though it's harder to find), then you feel below for the cricoid cartilage. In between should be a soft spot the width of a finger--that would be the cricothyroid membrane. You can try this on yourself, but for some reason it really freaks me out. I think I'm scared my finger will go all the way through. Then you hold the cricoid cartilage steady, get your scalpel, and make a small vertical incision through the skin and membrane. Some surgical texts teach to cut horizontally then vertically, but the newer thinking is just to cut vertically and be done with it. If you wimp out your first go through, just keep going over it a little deeper until you're in the airway.

Next you have to have a clamp or your finger hold the incision or else it will clamp up. Then hopefully some helpful person will hand you the tube to slip in there and voila, an airway!

Here's a fun part of medical school: It's very easy to forget that step, and nearly all of us did. The first or second guy made the incision, then reached for the tube without holding it. He then looked around and, thinking no one saw him, saw the cut on the neck wrap and slipped his finger back in like he'd had it there the whole time. The kicker is that when I made my cut and forgot to do that, he's the kind of guy who would (and did) yell "OOOOHHH you didn't hold it! You're patient is dead!" I wanted to say "Look here jackass, killing a patient with no one watching is still killing a patient." but he's the type of guy who had already gotten a vanity license plate with "Dr. LastName" on it, and I figured his self-esteem was fragile.


Ok, so we did demonstrate a little on each other.

So that's what you see all the time on TV; someone is choking, has a bee sting, is talking to loudly at a restaurant, and some DIY-er takes a steak knife, straw, ballpoint pen, insert whatever other filthy rigid hollow instrument you want, and saves the guy by jamming it into his throat. Alright, now I'm trained, so I had to ask the question:

"Um, so when would I be able to do this in public without getting arrested or sued?"

Unfortunately for me the answer was, "Well, never really." Dang it. Real indications for it are
  • Major injuries to the face or jaw, such as multiple fractures of the jawbone or severe fractures of the patient's midface. In many cases of facial injury, the airway is blocked by broken teeth or fragments of bone from the jaw and cheekbones.
  • Burns in or around the mouth.
  • A neurological disorder or damage that has caused the patient's teeth to clamp shut.
  • Fractured larynx. Fractures of the larynx most commonly result from automobile or motorcycle accidents, but also occur in cases of strangulation or attempted suicide by hanging.
  • Larynx swollen shut by allergic reaction to bee or wasp venom.

So could I do this? Yeah, I feel completely comfortable with the procedure now. Would I do this? Hmmmmmmm. I'll take that on a case by case basis.

Thursday, December 17, 2009

Intubation Obstacle Course

When I was in New Mexico, the title of this blog was on the schedule for one afternoon. I had no idea what that would entail, but who doesn't love a good obstacle course?

It was more like the obstacles were getting to the patient in adverse but possible situations, not running around in red and blue uniforms hoping you don't have to look for a flag in giant plastic waffles.

It was still fun though.

Number one for me was under an ambulance. Luckily I'm fairly thin and wriggly, so once I maneuvered in the dirt around the hitch, it was no problem. It's actually quite roomy under an ambulance. Not that I recommend getting stuck under there--you never know who's doing the rescuing. Some of the guys had a hard time with that hitch.












Obstacle two was supposed to simulate an unconscious driver who you had to intubate through a windshield. There was no hood of the car simulation to go along with the windshield simulation, so the shorties in our group nearly asphyxiated themselves trying to reach over the wheel. Also, by this time the intubation kit (the yellow thing) had been in the sun for an hour. The laryngoscope could melt your skin.









Obstacle three was a tube meant to recreate a sewer pipe. No sewer part though. It was on a ramp with the dummy's head sloping down into the tube. I rested my own big bucket on the back of the tube to get this one. It actually wasn't that hard except for the spots flashing in front of my eyes after I'd been inverted for a bit. In real life I would have also had my headlamp, but I think a headlamp is pretty much the most useful thing ever invented. I was out at a pig roast with my husband and in-laws a few months ago, and it was getting dark. My hands were occupied with pig and alcohol, and I made a comment that I should have worn my headlamp. My mother-in-law looked at me for a moment and said, "Now that would be embarrassing." We were at a pig roast in the middle of nowhere, wearing matching shirts (reading "Miller's Annual Pig Party" in hot pink), trying not to trip over the tents strewn about the yard for those who overindulged, drinking out of a box of wine in my fold-up chair, listening to a band who got paid in pig, and THAT would have been embarrassing.





Obstacle four was an upside-down dummy strapped to the inside of a bike rack tube. There are two types of laryngoscopes (tubes used to hold all the soft stuff in your mouth up so you can look down the windpipe and put a tube in): Miller and Mactintosh. Miller has a straight blade, Mac has a curved blade. I actually like the Mac much better in this situation; the curved blade made the whole scope shorter, so I could fit it in between myself and the dummy easily.










I really do love to intubate. I have a great story about a "laryngeal tumor" that turned out to be a hot dog chunk in someone's windpipe, but I'm feeling lazy so I'll save that for another time.

Sunday, December 13, 2009

The Interview Trail

Things I've learned so far about interviewing for Radiology.

1. They really ARE the happiest people in the hospital.

2. It's about a 5:1 ratio of dudes to ladies in this process. And two memorable interviews actually had 7 guys and little ole me as the lone estrogen source in the process.

3. Each one of those guys, and all the girls too for that matter, will wear a black or nearly black pantsuit. Two guys even wore the same tie at one interview. I can only remember one person out of 35 who interviewed in a light gray pants suit, and she was going into Internal Medicine anyway.

4. They definitely do not interview in a red dress suit. Guys really can't help this, but ladies? Seriously. Hopefully, the cat is out of the bag that you are of the female persuasion. There is no need to shop in the men's section for interview day.

5. To answer another interviewee's question: If you do not have a black leather binder, you obviously did not get the memo that you would be needing to bring a useless empty piece of cowhide to hold pretentiously and zip and unzip several times throughout the process as if there were anything in there besides your self-esteem. I'm very sorry. If it makes you feel better, I ignored that memo myself. It wouldn't match my dress suit nearly as well as this purse.

6. Bring questions, even if they're not really questions in any sense except your voice goes up at the end. Sure, you feel like a jackass and spend the time they are answering you thinking about where you'd live if you came to that residency, but I am ok with that.

7. Get the residents alone. If a place is terrible, they will let you know. They don't exactly write "Help Me" on their bellies and flash you from behind an attending, but they let you know.

8. I don't know if guys get this, but people ask me what my husband does in the sense of "Will he come here? Because I'm sure you're picking the place purely based on what he wants." I am pretty certain they just assume wives will travel wherever their husbands go, but not so much if their first question (What does your husband do for a living?---not "Does your husband work?") is answered with any type of a real job. I answer the question by saying:

1. We didn't apply to any place we wouldn't want to go. (which is true, and useful)
2. I will make 4 times more money than him after residency is done, so why wouldn't we go where I get the best education? Usually they tilt their head and go, "Well, that's true" as if they haven't ever thought about that argument. I think about it all the time, as I make absolutely no money compared to him right now.

9. That brings me to: Always pretend you want to go to someplace. Are you saying to LIE Al? Weeeellll, I haven't figured this one out. I am pretty terrible at hiding my feelings (I am also terrible at talking about them according to my hubby--apparently I just stomp around with an angry face.) but am fantastic at lying truthfully. So, when one less than awesome program put the thumbscrews to me to say I wanted to go there, instead of giving a straight, "Yes", it came out like, "Well, I really like this and that about here, and my family is close, my husband could go to law school...this will definitely be one of our top choices." Notice I didn't say "top". It could be a top 20 choice. Always leave wiggle room; you never know how the other interviews are going to go.

10. Write thank-you cards after you're done. I don't know if anyone reads them, and my handwriting is like a fourth-grade serial killer's, but I think you should write them anyway.

11. Rank the programs as you go, but each interview so far has changed my mind. I will absolutely think I want to go one place after one interview, then I go to another one that doesn't look as good on paper and it blows me away. We're just going to sit down after they're all done and have a nice dinner to talk about it.

Monday, December 7, 2009

Da Boards

One of the crappiest parts of becoming a doctor is the constant testing we have to undergo. No, not pyschiatric testing, though you could certainly make a good argument for it. (Here's a little gem from med school Orientation Week: "By the end of these four years, 1 in 4 of you will be medicated for depression, and that's only the ones we catch."--our dean of students)

We take something called the United States Medical Licensing Exam-USMLE for short, "The Boards" for shorter. You don't take it all at once, where would the fun be in that? Nope, it gets dragged out in three expensive steps, four really because Step 2 has two exams, plus your specialty-specific boards.

Step 1 I took back before I had a blog. I was not a pleasant person around that time. Step 1 basically tells you if you can be a plastic surgeon or not, in varying degrees of "Not." I thought I wanted to be something far less competitive at the time, so I took it a week after our regular final exams and then went to Montana and got engaged. I think I chose well. That's not to say I didn't spend nearly every waking hour from the end of February to May 21 studying. I ate, slept, and breathed medicine. Literally. I studied while I ate (as the pancake syrup on my review book shows), I listened to board review podcasts while I exercised and in the car, and more than a few nights I would study in my sleep. I had actually memorized pages of my First Aid for the USMLE review book and would re-read them page-by-page in my dreams. I always woke up really pissed off when that happened; it was supposed to be my 7 hours of freedom from studying.

Anyway, that went well enough to make me competitive for radiology (though more on that when I blog about interviews), and I got a nice 15-month break before I had to take the next step.

It's a lot harder to study when you live in the same house as your favorite person in the world. During Step 1, we didn't live in the same city, so I could obsessively study without distraction. Step 2 was a bit harder, luckily I did well enough on Step 1 that no one asks about Step 2.

What really blows about Step 2 is that there are two costly parts: the multiple-choice Clinical Knowledge exam ($400 I think), and the real-life-ish practical Prove-You-Speak-English-and-Are-Not-A-Total-F$%^wit, excuse me, Clinical Skills Exam(which costs you $1,000 for the privilege of taking). Ouch. Plus, since CS involves 12 actors pretending to have various vague symptoms in a simulated clinical experience that is both timed and taped, you have to go to one of a very few places in the country to take it. In the midwest, you have Chicago or Houston. I think there are five total locations across the US. Every IMG (international medical graduate) as well as every graduating US medical student has to take this exam. In one of five spots. With a maximum capacity of 24-48 people a day, no weekends, no holidays, I don't feel like they even do Mondays or Fridays. I paid in February to take the exam, and I got a spot in November. Tell me how awesome this system is.

That part I did two weeks ago. My mommy and I drove up and stayed with relatives. We had a case review book and practiced scenarios. I'm not sure if it prepared me for taking the boards, but it was a good time. My mother likes to go off-script, for example:

Mom as Patient X: Doc, I'm also worried that this might be AIDS
Me as Dr. Z: Why do you ask that? Is there a reason you are concerned about AIDS?
Mom as PX: Well why do you think? I sleep with everything that walks! I probably do drugs too!
Me: Mom, I don't think that's in the case book.
Mom: So? You know that's what's going on!

That exam lasted from 3pm to 10pm. The testing center served us dinner (other testee: "I always wondered what a $1,000 dinner would taste like. I thought there would be more meat.") and told us we could talk to each other, as long as we didn't talk about anything related to the tests under penalty of death. Did I mention we were sitting in our assigned seats, which were set up classroom style so we were each facing the back of the person in front of us? Not very conducive to chatting, I helpfully pointed out to the proctor. Plus no one felt like talking at the beginning when we were dreading the next 8 hours and no one felt like talking during the exam because the life was being sucked out of us. The worse part was that the actors, I mean "patients", had a role to play, and they focused so hard on that role that you couldn't get them to talk like real people. The only thing I'm good at in clinical settings is to get people to open up by laughing or talking about themselves. These people were two script lines deep, and they were too busy concentrating on if I asked the right questions or not to relax and laugh. Blech.

Sometime in your first year of residency, you take Step 3, another multiple-choice exam. I heard this is the easiest of all three, though I was told Step 2 was easier than I thought it was. All I know is I had better take it quickly before I lose all semblance of clinical knowledge in my chosen specialty.

Thursday, December 3, 2009

Everybody's a Comedian

Just when you thought I couldn't fit anymore fun into a single night in the ER, I had one last bit of awesome before I left.

By this time of night the resident had grown to trust me (something about watching me get puked on with nary a curse word while still holding suction and prepping the intubation kit endeared me to him I suppose). So he said I could come help perform a paracentesis on the alcoholic in room 44 if I liked. Uh, YEAH! (Uptight attending: I don't think this is something for someone on her level; she shouldn't do that, humph harrumph. Resident: Oh, she'll only assist me *wink wink).

In a paracentesis, we stick a big hollow needle in someone's ascites (fluid)-filled belly and drain it out using either suction on the wall or vacuum cannisters. It looks like warm lager, which is why I drink brown ales.

So I go in to check out the victim and wowza he looks like he's eight months pregnant (I wouldn't say nine because his belly button hadn't popped out quite). "Is all this fluid because of my drinking doc?" he asks after I'd introduced myself. "Uh, YEAH. Most likely. Unless you also have hepatitis from IV drugs." I'm kidding. I didn't say that. Even if you're sure that's what did it, even if you've warned the patient for years that whatever nasty habit they had would do it, there's some sort of weird doctor's code stating you have to hem and haw a little bit and offer some other, less their-fault explanations. I think it's because doctors don't like to see people cry. Or because the patient might try to sue them if they don't tell them their lung cancer could be from the environment and not just the 30 years they've smoked (which, of course it could, just like the quarters under your pillow could have been left by the tooth fairy and not a creepy neighbor with a spare key). People are dodgy when it comes to accepting responsibility for their poor health decisions.

Anyway, he asked the question a few more times for good measure, and I was tickled to see the resident answer in the same way I did. The guy felt like talking I guess, because then we talked bout all the other things the cirrhosis did to him.

For starters, with your liver kaput, certain jobs it used to take on don't get done, such as breaking down estrogen. This man did not care for his new moobs. Also, blood doesn't flow through it as well as it used to, leading to huge veins popping out of your skin around your belly button (called caput medusae because your liver is kaput and it looks like medusa's hair. I made that first part up.) You also don't break down cortisol as well, which gives you all sorts of fun: thin skin, buffalo hump between your shoulder blades, skinny little arms and central obesity on top of your ascites.

As we talked about this, he decided to show me each characteristic. Thank goodness he didn't know it could also make your testicles shrink. My favorite comment of the encounter: "Look! My arms used to be as big as YOUR arms, now they're sticks!" Yes, he was talking to me. About my arms. The (male) resident made him repeat what he said and then had a good chuckle.

I am not some burly Amazon. I'm not even the tallest one in my family, though that would be hard with a 6-ft. sister (Sorry, it's the truth Sis). I just seem to inspire these kinds of comments in people. Especially the elderly and alcoholics. Those and comments about my purty teeth. Which I prefer, thank you very much.

Tuesday, December 1, 2009

The Second Time I Soiled My Pants

Neither of these times was my fault, by the way.

After I'd watched the orthopod massage bones back in place, I had no time to change my now-bloody pants (I was cursing the packing wisdom that told me to leave my plug ugly, wipe-clean ER shoes in Kansas because I'd only wear them once, but at least someone had put booties on me) before we had another guest in the trauma bay.

I swear no one listens to the EMS people when they come give report. Then they are gone and you don't know why the patient is semi-comatose with a tube down his throat and nothing to knock his gag reflex out.

I had actually heard bits and pieces of what they'd found out from his mom (apparently you can't give a good history if you yourself are lights out). He was 20 and had overdosed on "some pills". I don't know if it was intentional or not, but that isn't really our concern anyway. "Get the intubation kit ready for me" the resident said. Holy crap, something I actually knew how to do! I'd spent the last two afternoons intubating dummies (actual dummies, not just idiots) so I was ready, standing right beside the resident at the head of the bed, when the patient started blowing chunks. Son of a....

I thought I'd had an ugly night with LifeGuard. This guy's was worse. The problem with and LMA (laryngeal mask airway) is that they do not seal off the trachea to protect from gastric contents. They are actually not supposed to be used if the risk of aspirating is anything more than minimal. And as I mentioned before, this patient was not all the way out, so he still had a gag reflex. Though he may have been vomiting from something he ingested, any one of us would be hurling if someone stuck that tube down our throats without knocking us out.

Maybe he was unconscious when they first got there. I don't know why they chose an LMA vs. a tube. But now the question do we put him under and put a real tube in, or just suction and keep the airway that was working in. His O2 sat was actually pretty good, in the mid-90's for now. The resident and attending disagreed on what to do, meanwhile I was standing in vomitus trying to dodge each fresh assault while still keeping my torso and hands where I was told to. I accidentally forgot to mouth breathe once and thought I was going to add to the fray.

The attending won out, and we left the LMA in. When the chest X-ray came back, he had crap in his lungs. I personally agreed with the resident, who was pretty mad that we probably made the guy's situation worse by a. making him vomit and b. allowing him to aspirate it. Suction can't get everything coming up; I'm sure some slipped around that LMA. So he probably has pneumonia now, or chemical pneumonitis on top of his OD and whatever problems led to it in the first place. Awesome.

In situations like that you have to bow to the attending. It's a judgement call as to what treatment approach you take, and in the end he's the judge.

After he'd finally stopped throwing up and was on his way to ICU, I went to the locker room to find new pants. Damn it. A scrubs PYXUS. If you've never dealt with this, it is basically a vending machine that takes a code instead of money. I had neither. Usually used for medications so that no one gets handsy with the controlled substances (at least without being recorded as having taken them out), some frugal hospitals also put them in the locker rooms to retain scrubs from disappearing. This one also exchanged dirty scrubs for new scrubs, however since I was wearing scrubs I pilfered from my own institution, I couldn't exactly do that either.

My only option left was to hang around the ER, stinking the place up and looking pathetic until someone took pity on me and loaned me a pair of pants. Which happened thank goodness. Luckily I'd worn real pants to work that day, so I didn't have to change back into grossness after the shift.

Wednesday, November 4, 2009

Next Up: What the Hell Happened to Me?

Before I could do the aforementioned highly anticipated rectal exam, I heard the sound of the trauma pagers going off (perfect timing! They sounded like angel's wings).

A male motorcycle rider in his 60's and the drunk who crossed lanes to hit him were both being brought in. We staked claim on the more equipped private trauma room and therefore got to take care of the motorcyclist.

The first steps in assessment when someone comes in to the ER (or really anytime you're assessing an emergent situation) are to look at the ABC's: Airway, Breathing, Circulation. Well, he was mumbling and had a (Thank God) full helmet on, so he had an airway and was breathing.

While we had him talking, we asked if he had pain anywhere. Well, my leg's bothering me. Yeah no kidding, I can see your bones sticking out of it. Of course I didn't say that out loud. But they were.

Overall, he seemed like he was in pretty good shape and he no internal bleeding that we could find. The only thing that worried us, besides the aforementioned bones sticking out of his leg, was that he kept asking what happened to him. I personally explained 4 times, and I think each of the nurses took several turns doing the same. "OH. Ok. Well, my leg is kinda bothering me." That's it? This guy must have had the pain tolerance of Valentina Vassilyeva.

The EMS team had called it an open tib-fib fracture, and we referred it to that for quite a while, until we got the X-rays. It was weird; there was no tibula or fibula fracture that we could see, but something wasn't quite right. Then on a different angle we could see it. Yikes. He had popped off the whole distal end of his femur and relocated it up a little higher in his leg. OOOHHHH.

The orthopod was already in the ER, so he started prepping for what we had to do next: Irrigate the hell out of the wound and try to relocate the leg as best we could before he went into surgery. (The OR team was currently tied up cleaning out my earlier patient with the acute abdomen). Irrigation is never particularly pretty, and since we were in the trauma bay with a big nasty wound it took on an even more rushed tone than usual. We doped the patient (but not too much b/c we didn't want to intubate) and started putting chucks (large disposable absorbent pads with plastic backing. I saw plenty of these in my nursing home days) under him, with a half-assed plan to funnel all the wound juice into a trash can. My glamorous job was to hold his leg up. Nothing like old man toes in your face at midnight to put you in a happy place.

Next came the saline. If you're doing a small wound you can use a syringe. If you're doing a large wound, sometimes all the docs do is grab a bag of saline, get a tube for it, and squeeze the bag directly. Always wear a mask with a face shield during something like this. The expertly designed chuck funnel didn't work (surprise) but I couldn't drop the guy's leg...so I stood there and watched while a big puddle of bloody saline slowly eased toward the side edge of the chuck before plopping at my feet. That was the first time my scrubs were soiled that night.

A wound like that looks like raw meat; it's amazing how the orthopods put something like that back together. Unfortunately, we had to put his leg back in line. He kept saying things like, "Watch my leg, it's a bit tender" and "I think my leg is hurt" (he couldn't remember why, but he picked up on the fact that somethin' weren't right). Since I was the tallest in the room (at least of disposable medical people who didn't have an MD behind their names), the orthopod made me stay on the job of holding up his leg while he worked it over.

I've mentioned before how much I like orthopedic injuries and manipulations. I couldn't leave, and I was standing on a stool surrounded by a puddle of bloody saline so I didn't feel like fainting was an option either. All I could do was zone out and do this forced quick breathing technique I've developed for any time I feel like I'm going to pass out or throw up. It's kind of like Lamaze, which makes sense because the time I use it most is when I have to watch someone give birth. Meanwhile the orthopod is working the guy's leg, pulling and shaping it like it's putty. Which, without proper bone structure, it kind of was. Deep breath, breathe ooooouuuuuuuuttt.

Then we wrapped a new quick-dry soft cast on it (man what I would give for a medical supply catalogue) and went to talk to his wife who had just gotten there.

I am probably done collecting dangerous hobbies. The more I see things like this, the less I feel inclined to ride a motorcycle, or a bike down a mountain, or talk smack in the car to that big jerk who can't drive.

I don't even know what happened to the drunk who hit him; he was in another room and out before I could see him.

Saturday, October 31, 2009

Radiology Means Never Having to Say "Rectal Exam"

My next patient that night in the ER was a middle-aged man who had started to bleed during his bowel movements. That's always a good time to work up.

He had actually just been in the hospital in October for an upper GI bleed, after which he supposedly quit all the hard living (IV drugs, drinking, smoking) he was doing that caused the bleed in the first place. I don't know if I was just hyper-enthused and idealistic after my last train-wreck patient actually turned out to be legit, but I really believe that he had quit all that stuff and was taking his meds. Another reason I can't be an ER doc (besides the fact that when we practice running codes, after 35 minutes everyone else is still pumping away and I'm like: "Well, it's just his time to go") is that I still remember the look on that guy's face as he was telling me his story and my heart sinks wondering if he has anyone left to care about him.

Anyway, from his story about what was currently happening, it was hard to tell where the bleed was. Hemorrhoids can give you blood in the toilet (try this: put 2 drops of red food coloring in your toilet bowl and see how red it turns. It doesn't take a lot of blood in the water for people to completely flip out.) Bright red blood ON stool means hemorrhoids or anal fissure, blood IN stool means it's internal, dark blood or stool means it's been digested. But briskly bleeding from from an upper GI source (bleeding ulcer for example) can go through so fast that it's still red. Bet you didn't want to know this much about bloody poop.

The moral of the story was, we needed to put a nasogastric tube and probably do a rectal exam. I was in favor of the NG tube first--if we got blood out of it, well hell it's an upper source and we were done! Seems like good cost-saving medicine to me. The attending wasn't having it. "You are going to have to do thousands of rectal exams in your life, you might as well get used to--wait, you are going into ER aren't you?" "No sir, I'm going into Radiology." I'm pretty sure he wanted to hit me for an instant right then. But then he just shook his head and laughed. I couldn't help myself. "Sir, radiology means never having to say "rectal exam"."

Lucky for me (I was going to do it for crying out loud, I just wanted to use logic about it), we had several traumas and acute patients come in, and the nurses never moved him to a private room (yeah, with H1N1 the ER is so crowded I had to interview him about his pooh in a room crowded with other patients), so by the time we were done, my shift was over. Yes, 7 hours later.

I pray I never have cause to go to the ER during flu season.

Friday, October 30, 2009

Now THAT's constipation!

I spent another wild night in the ER Tuesday.

I had already put in a full day with more disaster lectures in the morning, then an afternoon crawling around in a confined space drill (more on that later), but at four pm I shook the rust and dirt out of my hair, changed into scrubs, and headed to the hospital.

The university has the only Level 1 trauma in the state, as well as being the catch-all hospital for everyone without insurance, including those without any documentation whatsoever.

My resident read a few charts and picked out out for me. Chief complaint: Abdominal pain. Which could be anything. There are so many organs in that area! Two patients could present with abdominal pain and one leave with pepto-bismol and the other leave with a baby.

I read over the lady's chart a little and in her words, she was here because, "Everything shut down on me." Alright, so that's not really helpful. When I went to talk to her, she was a TERRIBLE historian. And her story was so wild, I had no idea what to believe. She told me she hadn't had a bowel movement in eight weeks. ("Really ma'am? Eight weeks?") She told me she was mostly homeless. She had a miscarriage 10 years ago that was never "cleaned out" and now was the root of her problems. She was having difficulty urinating. She used to be a hhheeeavvvvy drinker (but of course, she wasn't anymore) She was full of pain and pressure. She had been kicked and beaten in the head while minding her own business in an area of town they call the War Zone (that one I believe, she had bruises all over her face--really made me look forward to the Fire Department Ride-Along I had scheduled the next night).

Basically, her story was wildly worthless. When you get something like that, from a person with altered mental status, you can try to take bits and pieces of the information and put it back together. Eight weeks without a bowel movement? Not hardly. Four days of abdominal pain, constipation, and difficulty urinating? Ok. The differential is huge: Does she have an ectopic pregnancy that burst? A ruptured appendix? Bowel obstruction from years of pelvic inflammatory disease? An STD? Did she get kicked in the abdomen during that beating and is she now bleeding? Or is she withdrawing from some drug? Or just being a whiner with indigestion?

I figured the best thing to do next would just be to put my hands on her abdomen and see if there was anything big going on. As soon as she lifted up her shirt I could see her abdomen looked distended. There is a difference between distended and fat. I don't know how exactly to describe it, partly I'd say it's the lack of a place to hide things. There is definitely a difference once you touch it. Her abdomen was hard and distended. And very painful. That's not a Chinese food baby. When I pressed down she hurt, but when I lifted my hand up quickly she nearly came up off the bed (rebound tenderness). I put my hands on both sides of her hips and rocked her back and forth. Ugly.

OH Crap. That was it for me in the physical exam part, I excused myself and got the resident. "So, whatcha got?" he asked, not really expecting much. "Eh, I don't want to be dramatic, but I think we have an acute abdomen." Acute abdomen means something terrible is going on in there. Blood, pus, gut juices, something has spilled out of its God-given container and into the peritoneal cavity. That equals an automatic trip to the OR.

But I'm just the medical student. And acute abdomens don't happen that often. So we went right back in there where he did a physical exam as well. When we came out of the room he said, "I don't mean to be dramatic, but I concur." The attending agreed and called surgery. We didn't scan her, and besides the basic labs (HIGH white blood cell count, slightly screwed up electryolytes, negative pregnancy test) we didn't need anything. No need for it; you can't medically treat an acute abdomen; nothing you give would clear the crap up anyway. She was going to the OR within half an hour.

"Well Allison, that's one hell of a case for your first patient here. Remember what she looked like; that's an acute abdomen and you won't see it often." The last I heard about the patient was from a general surgery resident who casually mentioned they had a complicated case going on with a woman whose belly was full of pus. That's a problem with the ER, especially just filling in shifts; you never really find out what happens.

My Mexican national patient died a few days after we brought him to the hospital. In some ways I'm surprised he lasted that long, but part of me still has the magical thought that if you make it through hell and arrive at the hospital alive, you're home free. It's still hard to understand that even if we know what's going on and have all the tools right there!, we can't always fix it.

Sunday, October 25, 2009

The Spirit is Willing...

Apparently I am a legend around LifeGuard. I'm pretty sure there isn't a flight nurse, pilot, or paramedic in the state who hasn't heard about the medical student completely losing it on the flight to the point that she had to be medicated.

Friday afternoon we went over rope safety for a rappelling trip we're going to do Monday off some mountain in the Sandias. We spent the afternoon in the courtyard learning knots and "rappelling" off a 4 foot high walkway. The LifeGuard guys were training in one of the rooms in the building, and a handul looked out to see what was going on, saw me, and within a few minutes they'd ALL come out of various doors to see which one I was (which Keith, the flight paramedic, gladly assisted by pointing and saying, HI ALLISON! in the middle of the demonstration).

In spite of this, I had such an amazing time that I still wanted to go back up. I called the director of LifeGuard to see if she had any advice for new motion sickness regimen (Dramamine not being the ideal choice anymore) for my next flight. "Well, you got to see an interesting patient, didn't you?" Oh yeah, it was great. "You know honey, I think you should just let this one go." Alright, you have a point.

So no more flying for this girl, much to the relief of patient's mothers and to the chagrin of flight crews looking for a little fun.

Wednesday, October 21, 2009

Maybe Flying Ain't For Me.

I have so much I could write about. But I'll start with the funniest first.

Last night, after a morning spent learning about bioterrorism (though apparently you don't have to leave New Mexico to get plague, hanta virus, tuleremia, and don't forget anthrax), and an afternoon crawling through a shaking, debris-filled semi in an Urban Search and Rescue earthquake recovery drill (definitely more about that later), I showed up to the fancy section of the ABQ airport where all the private flights, including the medical transport flights, take off.

Let me start off with the fact that these planes are awesome. It's like an ambulance in the air-ventilators, IV's, pharmacy cache, telemetry, all packaged with an ability to quickly load, secure, stabilize and monitor a patient through a flight. There were a lot of cool toys in that plane. The crew consists of pilot, flight paramedic, and flight nurse who all have a bit of a death wish if you ask me.

I had a 7p to 7a shift, which already made me a little nervous considering my swift detorioration after 10pm, but it was also a rare stormy night in Albuquerque (rare meaning the crap just hung around; it's still cloudy and rainy today!). I wasn't crazy about going up in a tiny airplane (it holds 5 people plus a patient) in dark stormy weather, but the flight nurse convinced me of the difference between helicopter rescues and planes which have ground support and fixed wings, plus the safety record of the pilot (he must have given that speech before). Alright, fine. I'm coming.

The first problem of the night was that I had been assured earlier that when I did my shift, I'd have enough lead time between getting a call and taking off to take my Dramamine. I used to pull whole caravans over on field trips when I was in elementary school. Anyway, the minute I got there they were already preparing to fly. The medicine makes me say crazy things, so I had really hoped for 30 minutes to drool quietly in a corner and come back to my senses in time to fly. No such luck. Plus, in the excitement of the weather and the rush to get off the ground I just forgot.

We flew to Truth or Consquences, NM to pick up a teenager who'd fallen off a moving car. She had a small subarachnoid bleed, and would probably just need observation, but we needed to move her to a facility with a neurosurgeon in house just in case. For some reason, El Paso was the closest place for her to go (guess they don't have a LifeGuard of their own). On the flight down there, we hit some storm-related turbulence. You don't know turbulence until you've been in a plane that small. That little thing shook like my old gifted education teacher when someone used the word "pregnant."

Anyway, I was not feeling awesome, but I really thought I could handle it. I haven't thrown up from motion sickness, well, ever that I can really remember. Maybe a few times, but it was long enough ago to give me a false sense of security. After we picked up the patient and her mom to head to El Paso though, we hit big time turbulence. I just wanted to die, but instead I turned to the flight nurse and simply said, "Basin time." I threw up and down. Repeatedly. For the whole rest of the hour flight. Fortunately, it was in a basin (if I feel a little sick and look at a toilet, I automatically throw up just by thinking of how dirty it probably is), but unfortunately, it was on a small plane. It was so pathetic that when we landed and loaded the teenager in the ambulance, her mom gave ME a comforting hug. The flight nurse said several times later that by looking that bad I actually took the mom's worry off her daughter and diffused the tension. She was much less worried about her comfortable medicated sleeping daughter after seeing me hurl repeatedly with tears streaming down my face (why does that happen when you throw up?) Thank you Drew, sure glad I could help.

While we were in El Paso (conversation excerpt--Pilot: We can fly over Mexican airspace, right? Paramedic: Who's going to shoot you, the imaginary Mexican Air Force? Pilot: You have a point. This will shave ten minutes off the trip!) the crew decided to go to Chico's Tacos on the border for some Mexican food. Having forgotten my ID at home, I didn't really want to go anywhere near the border, but it was my only chance to pick up some Dramamine. The restaurant was like a roller rink in smell and music selection; it was a little overwhelming. Especially since I was told to "Not act really white". Their idea to try some french fries was a spectacular failure, even thirty minutes after two Dramamine.

Once we got to the airport, they had joked about medicating me for the flight home. Then as we were walking across the tarmac, a call came to fly to another town, Demming, on our way home. A Mexican national who had spent two days wandering in the desert before a rancher found him and took him to border patrol (Really? Not a hospital? I'm sure that's in the Bible somewhere...). The man was in terrible shape. As soon as they agreed to take the flight, the nurse turned to me and said, "Zofran" (anti-nausea drug). Our choices were phenergan and Zofran. Phenergan can be given IM (intramuscularly--I was fine with getting shot at this point) but phenergan can give some people crazy reactions. We didn't need two people out of their mind on the plane, so Zofran was the logical choice. Unfortunately, you can't give Zofran IM, and you can't really give anything orally to someone who's puking....plus, by this time I was dehydrated. I really would have said yes to any idea they suggested.

So that's how I found myself in the back of a plane in the middle of the night flying to the edge of the US with an IV in my hand and a liter of saline hanging next to my head. I passed out pretty soon on the flight, whether it was from the meds or the hour I don't know, but I only woke up when we were on the ground and they were locking my IV.

The ER we went to was tiny, and packed. Mostly Hispanic patients; the signs were either bilingual or in Spanish. The room with out patient smelled horrible-if I hadn't already had two anti-emetics on board, things might have gotten uglier.

One look at that poor man and I knew he was in serious trouble. He was one of the worst patients I think I've ever seen. He was cachetic, with dried crusted sunburn on his face and ears, his lips were flaking off from dehydration, his eyes rolled around insensibly in his head unable to focus on anything. He had severe lactic acidosis--his muscles were breaking down because of the dehydration and exposure, his kidneys were failing, his liver enzymes were elevated. He was taking rapid, deep breaths, using all of his accessory muscles to try and clear some CO2 (a compensatory mechanism to rid the body of excess acid). He was out of it and moaning from pain. He had bag of O pos hanging and a positive fecal occult blood test, meaning he was losing blood out of his GI tract. Basically, everything in his body was going kaput. As he tried to move himself to our stretcher, his nose started to bleed.

Normal potassium in the blood is around 4 or 5. This man's was 8.3 Part was because of his acidosis, but a potassium this high in the blood, no matter the source, can cause fatal cardiac arrythmias. His CO2 level on arterial blood gas was 12 (normal is 40). As soon as he tired out (and he would), that was going to fail as a compensatory mechanism. I have never seen electrolytes as out of range as his.

Now that I'd been medicated, I rallied hard and was ready to go...at least while I was on my feet. We loaded him up and watched his breathing and O2 saturation. We gave him calcium gluconate to stabilize his heart and watched to see when we might have to intubate. It was a pretty uneventful flight, and it was around 3am by this time. I can't believe it, but I fell asleep sitting upright unsupported while leaning over the patient monitoring his vitals. Luckily the turbulence woke me up.

When we got back to Albuquerque, we loaded him up in the ambulance to take him to UNM hospital. When we got him out of the aircraft, I noticed blood flecked in his oxygen mask. That was new. In the ambulance he coughed and more blood came up. Crap.

He went straight to the MICU. I gave the patient report to the attending and we headed out to go back to LifeGuard headquarters. By this point I have dealt with two ambulance crews, an ER staff in Demming, MICU nurses and doctors at UNM and Border Patrol with an IV in my hand. One of the Abq crew said, "Hey, Erica needs to practice IVs, will you let her practice injections into it?" "Get your creepy eyes off me Erica, I've had enough for the night." (It got taken out in an elevator by the flight paramedic--don't know if that was much better than what she could have done.) You'd think we were done for the night, but I needed a flu shot, as did the flight nurse, so we said "What the hell?" and convinced a charge nurse to give us flu shots at 3:30am. By that time what was one more shot anyway? At least the IV was out.

On the drive back to HQ, they amused themselves by replaying the night. "You should have seen her give report Drew! She's all grown up!" "Oh Keith, she has just come so far. It seems like only yesterday she was throwing up in the back of the plane...oh wait, that WAS yesterday! HAHAHAHA!"

I went to sleep on a couch in the lounge around 4:30am after having a celebratory drumstick (celebratory because I could now hold food down).

I don't know if our patient made it or not. I'm pretty worried about his chances. I could write another blog on him. I also don't think I'll make another flight with LifeGuard. It was an amazing experience, but I can't fly with an IV every time. And I don't want to be another patient for the crew to deal with. This morning I've already received two emails from people who weren't there asking how I was doing. Lol word travels fast.

Friday, October 16, 2009

Wilder-nasty

The other day in my Disaster Medicine rotation we talked about wilderness medicine, which is just a fancy way of saying practicing medicine in austere conditions.

In the morning we listened to lectures on radiation and the consequences of accidental or intentional exposure. I'm not sure the lecturer really knew what level we were at because he asked, totally serious, if any of us had ever seen an X-ray before. So that was hard to get through.

The next lecture spoke about chemical exposure and warfare. My favorite line from the day: "When a person with cyanide poisoning vomits, their vomit is dangerous to you." I couldn't help but reply that I generally consider anybody else's vomit dangerous just as a general rule. "Well, their burps are dangerous to you too." he modified.

The afternoon was spent in the courtyard (it's 75 degrees and sunny most of the time) where the instructors recreated scenarios that might happen in unexpected places. For example, one of the docs just got back from lectures on wilderness medicine in Fiji. Several hours after he first got there another lecturer started bleeding profusely out of an unfortunate orifice. Yeah. So you can't just hold pressure until the bleeding stops. Another great story was a lady who slipped and fell on a walkway while running to get a picture. Her husband, an orthopedic surgeon, told everyone else gathered around concernedly that she was just prone to hysterics and that she really would stop screaming and get up. Well, she had a broken femur. Yeah. I wonder how they're doing now.

We did things like improvise cervical spine and back immobilizers, built a traction device for a femur fracture, and learned a few techniques for how to carry somebody back down the mountain if they can't walk.

Notice the Spanish Windlass below his foot. It's twisted in the straps to provide traction, pulling his theoretically broken femur and keeping it in alignment so the bones can't slide past each other and let a big hematoma sphere (basically a ball of blood in all the leg space-someone can bleed out internally from a femur fracture).




Cervical spine immobilization + handy leg-shoulder strap harness+ 2 dudes=one very uncomfortable ride down the mountain.






Two backpacks plus a walking pole and sleeping pad. I probably wouldn't try this with anyone over 60 pounds. Dang you Shook Ming.







Much less bulky femur traction device. Using a telescoping walking pole, a strap that originally held skis together, and the biggest carabiner I have ever seen.






Things I took away from this:
1. Don't hike with anyone you can't carry. Also, they need to be incredibly strong so they can carry you (you may remember my college rule of only dating those who could do a lap around a room with me in their arms. This is just good advice, mountain or no mountain). I'm thinking Chinese Acrobats are my best bet for future hiking partners.

2. It is very hard to improvise tape. All those people at the airport and on the mountain that had a strip of duct tape on their backpacks didn't just put it on there so they could find their bags at the baggage claim. Not that that's what I ever thought or anything.

3. I really should hike with hiking poles. Otherwise, if I ever break my femur I'm going to end up with a tree branch poking me the whole way down the mountain.

4. Also, a long rope. Crowd control during the hike, rope litter in case of emergency.

Those are all the lessons I can remember right now.

Wednesday, October 14, 2009

My 100th Post

In honor of this momentous occasion, I would like to open the floor to a reader with a good story.

Anyone who would like to guest post, possibly talking about how stupid you think doctors are to get back at my snarkiness, please comment or email me.

And now for my real post.

I'm in a disaster medicine rotation here in NM. You may wonder, why are you doing that when you want to be in Radiology? At least, that's what all the other medical students each asked me. They're going into emergency medicine of course.

Well, the long answer is, I wanted to check New Mexico out for residency, October has beautiful weather, when someone asks if there is a doctor in the house I'd still like to answer even if I'm only a picture doctor, I couldn't take another month of sitting behind three people trying to see a CT scan.

The short answer is, it's freakin cool.

Yesterday I listened to the head of NM's Urban Search and Rescue Team talk about going to New Orleans after Hurricane Katrina. She was one of the people on a boat floating around New Orleans cutting people out of their attics. She talked about why people might not have left before the storm, what was killing people in the first days after the hurricane..like it was blasted hot, and people were stuck in there attics. The US&R team had to stop rescue operations for 36 hours because people started shooting at the rescue boats. Really. The she showed pictures of the devastation, the flooding, and the four Porta-Potties that some firefighters with bolt cutters stole out of a construction site--the were the only ones there for 10 teams of 81 people.

By the way, did you know there's a regulation stating that you need to have a 20:1 person to toilet ratio in acute care settings like that? Who knew? But when the rest are under water, I guess there's nothing you can really do about that. We probably spent 20 minutes talking about the toilet situation (I did not know about the military field bucket system...something to read about).

I could have listened for hours. It's so fascinating to think about the different aspects of disaster preparedness and repsponse. I hope to have a lot more posts in the future as I learn more!

Monday, October 12, 2009

There's a Sucker Born Every Day

And I ain't one of them. I moved to New Mexico last night. But I moved again today.

It was a very long drive, even when spread over two days with my mommy to keep me company. Once we got to Albuquerque we stopped at a cousin's house to visit with her family. It was pretty late (in our time zone anyway) when we pulled into the place I was planning to stay for the month.

I had found the place on a list of housing options provided by UNM. It's pretty hard to move someplace sight unseen, but it sounded like a young grad student with a charming house very close to campus. For $400 (I had negotiated from $450--the listing said negotiable), I was told I would have a furnished room and bathroom, and if anyone else was interested in renting the other open room, she'd call me to let me know.

You should never stay very close to campus. It is just not a good idea. when I think of the houses withing walking distance next to my campus, I should have known exactly what I was walking into. The house at one time, before a crappy landlord and thirty years of renters, was probably great. It had wood beams, a fireplace, and a sunroom. It also had nasty cracked and faded linoleum, a carpet stained beyond recognition, bathrooms I would have to wear flip flops in, and oh by the way, you get the basement room with two completely lightless windows across from the open room with the dog door to the outside where you can see the washer. Not the dryer. Um, yeah, I said it had laundry. There's a clothesline outside. I'm all for eco-friendly, but that is some bullshit. And internet? Well, I get by stealing it from my neighbor. If you sit in the exact middle of the house, stack the computer on some books in the middle of the table and cock your head just right you can get signal. But sorry, my computer is already in that spot.

As soon as I walked in I had a bad feeling. I've lived in a basement before and it blew. I asked about the other room and she said, "Well another girl is moving in there." Oh really? Yeah. Did you make a deal with her to get that room? Well, yeah. Nice. I looked at the basement room again and decided I didn't care how big of a jerk I looked like, I was not staying there damnit. So I told her that. That's when I found out that my room came with the parking spot. Since she rents out her driveway to three other students (for $50/month), if I didn't have the spot I would need to be ok with my car being parked in from 9-5 everyday while her other suckers, I mean customers, were parked there.

This girl drives a brand new Highlander. I was getting hustled.

I figured I was just tired from the drive and that in the light of day things would look nicer. But I was so irritated with her that I couldn't sleep. Well, that and the pillows were composed of dust and human skin flakes (I started nose-whistling around 3am according to my mom) and the bare mattress under the sheet was composed of wood planks with old fabric wrapped around them. And the toilet was filthy. Ugh. I thought to myself, "this would have all been a lot easier to live with about 6 years ago when I was a poor college student who didn't know any better."

I talked to my sweet husband, who made me promise to call another lady who lived nine miles out of town but sounded really nice. "Just go check it out Al. Don't just try to survive this month. That's ridiculous. Stay in a hotel for four weeks if you need to."

So this morning at a coffee shop I finally got my email up and called Fran, a semi-retired lady with a house who had hosted medical students for 25 years. This afternoon Mom and I drove up to her house. Crap it was beautiful. And $100 cheaper. And I could park in a garage. "Do you have wireless internet? A washer AND dryer?" Yes, yes. "Fran, I think I'm your new roomie."

I didn't realize how bad my mom thought the old place was until she got on the phone to tell people I was moving. Lol she played it pretty cool the night before, but on that drive down it seemed like she told three people how awful the place was and how glad she was that she wouldn't have to worry that she was leaving me in a crime-filled dirt house. We got back to the house and packed like rats in the night. I told the girl things weren't going to work out, wrote her a check for the pro-rated amount, and got the heck out of Dodge. We weren't there ten minutes. If she hadn't been home, I would have just left the check and a note.

When it comes down to it, I am just too dang old to live in someone else's squallor. Find another sucker to make your car payment, Crazy Eyes.

Tuesday, October 6, 2009

No Really, Those Poppyseeds Aren't Mine!

My husband was informed today that as part of an outside client's business practices, all consultants must take a drug test.

Heh. My husband is an engineer. The craziest stuff they do is listen to techno music after drinking a redbull. He's going to love that commment.

But whatever. They have the inglorious duty of peeing in a cup while someone else is within earshot. I hate that. Anyway, they are providing donuts that morning, so at least the workers have something to look forward to.

My hilarious husband (yes, even though he's an engineer), requested that since everyone is health conscious these days, maybe bagels instead of donuts. Now, unlike the forwarded emails my new uncle-in-law sends about Obama trying to kill off the elderly, this rumor is actually true. For realsies. The part about inmates and those on furlough not being able to have poppyseed (because then any opiod-related discretion could be chalked up to those little boogers) made me remember one of the reasons I'm not going into ER.

On my overnight (most of my crazy stories happen between 10pm and 4am), this guy in his early twenties comes in with a grossly out of place shoulder. He had dislocated it a couple of times before; this time he "slammed the car door too hard." Yikes. If that's all it took to dislocate my shoulder I would never be able to make a point to my husband.

Standard procedure is to load the kid up on pain meds, get a couple of the meaner nurses and yank him around until his arm looked normal again (after which you take X-rays to make sure you did the job). Being the strong-stomached person I am, I promptly started sweating and left the exam room so I could faint in peace. I had a bad injury in high school...but try explaining that to those nurses.

Once I composed myself, I went back to see how he was feeling. Fine fine, pain meds had kicked in nicely. Oh by the way doc, I need a note, I have to take my drug test Tuesday and I don't want them to think I took anything illegal.

Naive idiot that I am, I actually thought he was genuinely concerned about being framed on a drug test. When the attending heard the request, he said, "If he keeps intentionally throwing his shoulder out, eventually it's not going to stay put." WHAT.

Next step in most ER diagnoses is a quick chart review. That little bastard had thrown his shoulder out every few months lately. Wonder when his drug tests are; it would certainly be convenient if he had a note explaining why he had enough opioids in his body to stun Chewbacca. Or shoot, maybe he gets his jollies by being man-handled in the ER.

After I saw that, I was ready to go back and dislocate both his shoulders. (which is why I can't be an ER doc). But I had no proof, and it wouldn't have changed how we treated him.

Thursday, October 1, 2009

My mother the Hothead.

My mom called me the other day, and the first words out of her mouth were: "Well, you got me in trouble."

My mom lives two hours away, so I didn't know exactly how that happened.

My mom is a dietician with her own consulting business. Part of her job is dietary consulting for patients at a local hospital. As part of her questioning, she asks the general stuff: diabetes, hypertension, eating habits, nothing too offensive.

While talking with one morbidly obese patient, as they frequently are around here, she asked if he had diabetes. He said no. High blood pressure? No. Now as she says this, I'm thinking, "either he's lying, doesn't know about it, or is an anomaly."

Apparently my mom thought the same thing. In the traditional blunt manner that women in my family can't seem to avoid, she said, "Well, you're lucky." That's it. Not too offensive by my standards.

The patient, apparently unaware that his massive fatness predisposed him to every kind of common health problem imaginable (except maybe spontaneous vampirism), FILED A COMPLAINT. He said my mom called him fat. No, she actually didn't. But crap, if I got a complaint like that filed on me I would have had a hard time not going back to the patient and correcting myself. "No sir, I did not call you fat, but while we're on the subject, if you complain about knee pain one more time I'm going to beat you with a turkey leg."

My husband, ever professional and tactful, told her she should have used the word "fortunate" because people take that in a positive connotation. They take "lucky" to mean they should have had something terrible happen to them.

I'll try it. "Sir, you are fortunate you're body hasn't completely crapped out on you yet due to your inability to take care of yourself."

Somehow, I don't think I quite have it.

Sunday, September 20, 2009

Idiots in Public

Some people have a problem leaving their work in the workplace. For the first two years of medical school, I couldn't walk in public without thinking to myself, "Neurofibromatosis. Alcoholic. Morbid obesity. OOOohhh that guy's a 60 year smoker!" Even now that I have a handle on that, sometimes it just finds me in ways I can't ignore.

Last week at a grocery store around 4:00 this child in front of me asks for cigarettes. "If he's 18 I'm Rush Limbaugh" I thought to myself. The astute cashier asked for his ID. Twitching slightly, he handed it over. She entered his birth date and it of course set off the alarm. "This won't work" she said. "Why not?" "It says you're not 18" "What do you mean?" "What year were you born?" "1993". "So you're not 18. You can't buy cigarettes." "Oh, ok." And then he took his ID and left.

Did he not know you have to be 18 to buy tobacco? Did he think he was 18? Was he just hoping the cashier wouldn't ask a 16 year-old who obviously came to the grocery store right after school? What the hell is wrong with him, buying cigarettes in 2009?

I seriously considered smacking him upside the head for being a dumbass.

Wednesday was even funnier, in a pathetic kind of way. I was minding my own business, eating out with a girlfriend for lunch, when our waiter (affectionately known as "Creepy Johnny") came up to chat and take our drink orders. An old man with a beer belly in the cubbyhole next to us (it's a subway station themed restaraunt, though not actually Subway) interrupted our waiter midsentence--wow, really rude, even for the elderly--and asked for his Bud Light. "Sir, I was on my way to talk to you; we are out of Bud Light. We have several other domestic light beers." "Whaddy mean you're out? Harrumph Harrrumph harrumph blustery bluster I take Miller Light I guess. I just need it now. I'm diabetic you see, and my sugar is getting low."

Excuse me, I think I just had a seizure. Did you just demand your beer extra quick because of your diabetes? I'm so sorry Wilbur, either modern medicine or God has failed you miserably.


If only it were this easy.


So no reader of mine ever sounds this stupid in public, here's what's real: Alcohol is not a treatment for diabetes. Actually, alcohol impedes your liver from producing glucose at times when your blood sugar is low...so Old Man Impatient stomping around until he got his Bud Light was actually being counterproductive. After discussing this with my girlfriend, who is a pharmacist, we also hypothesized that his choice of light beer, while possibly a help for his weight control, actually would have fewer carbs--which is what he was after if his sugar was really truly low. So bend over, Samhill, you've just screwed yourself twice.

Here's why I'm going to be a radiologist. A family doc would have probably rolled his eyes, sighed, thought a few bad things about this guy, but then would want to teach him about his disease very patiently. At least, a good one would. I, on the other hand, felt like ordering him a few more beers and REALLY treating that there diabeetles. Of course, this was before I actually ate. If he hadn't interuppted the process of me obtaining food I probably would have felt more charitable.

Friday, September 11, 2009

Stub or Nubbin'

One of the reasons I like radiology is that it seems like once a day you get something completely surprising.

I was looking at plain films with one of the residents two days ago when something nearly unrecognizable popped up on the screen. I thought the system had flipped out and scrambled an image, but no, it was a real x-ray.

"What is that?" I asked.
"It was supposed to be a foot," he said.
"Well why isn't it?" I replied.

This foot had no toes. And it didn't really have any meta tarsals (the bones in the middle) either. Or if it did, they were all smashed and grown together. It didn't look like an acute injury because the bones actually looked like they'd grown together. Have you ever seen a tree that's been cut and twisted (as if someone were half-heartedly trying to remove it because his wife told him to but he just kinda wrenched on it instead of actually pulling it out) and eventually grew together all gnarly and intertwined? No? Didn't you have a dad with a lawnmower?

Speaking of lawn-mowers, I think that's how this guy lost his toes. That could be totally wrong, the report just said "traumatic amputation in 1972" (this is where you wish those internal medicine guys were a little more forthcoming), but something in me says lawnmower. Must be the memory of that poor little oak tree.

Anyway, that brought up an interesting question: would I call this a Stub or a Nubbin'? After much thought and a few cups of coffee, I decided it was definitely a nubbin'. A stub clearly means the amputation was above the wrist or ankle line. A Nubbin'? Well, let me use it in a sentence to make my point. "If you try to touch my mashed potatoes you will pull back a nubbin'!" Ahh childhood.

My point is, a nubbin is a much smaller amputation than a stub.

Oh yeah, and guess what the patient was in for? Foot pain. No kidding.

Wednesday, September 9, 2009

So I got married

And then went on a honeymoon. And then applied to residencies. Life has been very busy lately.

but I will write more.

Tuesday, August 18, 2009

40 Lashes

My dad chastised me for not writing in my blog. "I check it every day Al, and you don't post!"

You'll have to excuse me. I'm getting married Saturday. I'm going to diverge from the usual topic to list a few reasons why I haven't posted.

See, despite the fact that I have a few mannish qualities (like my head and shoe size), when it comes to wedding planning, I still have the lady's role in it. Meaning, I have to do everything. Not that I don't have great support. My mom and future mother-in-law are on top of their games right now. My groom is understandably excited to get married to me, and is trying his bestest to help.

Something more learned women know, and that I am just figuring out, is that when it comes to details, especially wedding details, most men are as helpful as a three thumbs in a harmonica showdown. You don't need thumbs to play the harmonica Al. I know.

An example:
My groom, sampling truffles at another friend's wedding: Wow, these are really good! What a great idea!

Me, choking on my third truffle: You do know this is what I spent four hours making this week...right? I talked to you several times on the phone while I was doing it? These are our wedding favors. You know, the chocolate at each table like I described in excruciating detail?

Groomsy: Really? I didn't know what you meant when you said "favors".

Me, incredulously: Where do you GO when we talk?

Tonight I learned that this might be a gender specific trait. Here's another specific conversation from this very evening, 4 days from my wedding:

Me (while listening to strings and piano play Pachelbel's Canon in D): Wow, I am so glad that I'm going to have strings and piano playing this!

My Father: Where? At your wedding?

Me: No Dad, in the shower tomorrow morning. I thought it would add a little excitement to an otherwise boring routine.

Granted, I don't hold my dad responsible for knowing all the details of the wedding. And I've stopped hoping that my groom will know them either. I'm only griping because I wanted to sign up for the Today Show Throws a Wedding gig. Just give me a dress and tell me where to show up.

Wait, I think something else like that exists in nature. It's called being a guy.

I'm really excited about the wedding. I love to tease my fiance, but he is a wonderful guy and we're gonna have a big fun party to celebrate!

Saturday, August 8, 2009

The Fine Art of Making a Good Impresssion

I am currently doing a visiting medical student rotation at a school where I hope to do a residency. In your fourth year you can do up to 4 four-week rotations at outside institutions in the hopes that you'll make such a good impression that they will want to hire you for residency.

I was originally supposed to do radiology research at this school, and had arranged it six months prior to my supposed start date. Unfortunately, the doctor I was going to research with had a heart attack. So there went that.

One of the risks you take when doing an outside rotation is that you will at some point make an ass of yourself and they will see your true colors before they hire you. This is especially dangerous for me. Plus, every time you go to an outside institution, it has its own flavor and culture. I happen to be at a rival school where apparently no one is accepted into medical school until they can prove they are completely devoid of a sense of humor. At least the ones in radiology. Blech.

Yesterday I was sitting in a lecture given by a grandfatherly man whose voice and enunciation has long been reduced to a pleasantly low completely unintelligible rumble. I was pondering the mysteries of life, like how I moved across the state to live with my fiance a few weeks ago, my residency application, my wedding in two weeks, you know, minor stuff, when through the fog I made out a few words: "Does this make sense? You look perplexed. You, there in the front row."

Of course I was the only idiot who sat in the front row. I had every intention of paying rapt attention when I sat there. I just thought the lecture was going to be given by someone with teeth. I didn't want to say yes because then he'd talk more than the hour and fifteen minutes he'd gone already, and I couldn't even vaguely grasp at anything intelligent to say (I was that far in La-La Land), so as usual I said the first thing that came to my head.

"Nope...I think that's just my face."

Judging from the snorts and shoulder-shaking behind me, the rest of the class thought that was a fantastic reply. The lecturer just looked at me, then shrugged his shoulders. But he didn't ask me anything else the rest of the time, leaving me to my thoughts.

"Nice recovery" one of the family med students said as we left. "I don't know what happens to me sometimes." I replied. "Hey, you were off the hook the rest of the lecture; he didn't want to insult your face! I think I'm going to use that line myself!".

I'm glad we learned something in that lecture.

Monday, August 3, 2009

Happy Birthday!


My birthday was last Wednesday. I spent the morning looking at people's butts.

Not like the day where I watched people poo on camera. Nope, that morning I walked in to what was supposed to be the neuro room, minding my own business, and up on the screen was a KUB (old term for x-ray that evaluates the Kidneys, Ureters, and Bladder, though none of those things show up on a plain film) with a very strange addition to the normal anatomy.

"Guess what fruit that is?" the resident asked. Ummm, it's round...a peach? Nope, he said, a peach wouldn't survive that. Forgive me for being so ignorant. "It's an orange!!" another resident guessed. Yup. It sure was. The apple was a lot easier to pick out.

The whole morning was spent with each resident in the reading room pulling up their favorite hilarious cases of people inappropriately playing hide-and-seek with various orifices while the rest of us alternately ooo'ed and aaah'ed and tried to guess what we saw. It was like a game of shadow puppets. Except I felt kinda dirty.

This is starting to become a theme in Radiology. I really need to find a reading room with more ladies.

PS: I found this pic on a blog. It's an electric toothbrush. Whatever happened to a good old-fashioned vibrator?

Tuesday, July 28, 2009

Fourth Year Is....

I'd finish the sentence, but I don't have to. That's the beauty of fourth year. When you're a third year, as soon as someone asks you what year you're in, a wince comes over your face and you kind of mumble, "third year." It's a sad moment because now you both know it is now their duty to wipe the floor with you.

In your third year, sure, your job is to go through all the different rotations and learn medicine. But really, it's just as much a year where you have to learn you are Medicine's bitch. Just in case you think you could have a life outside of medicine, they put you through third year and slap you around until you wish you'd never gone to medical school. When I was a student rep for a medical school faculty committee, a girl wanted to take two years to do her third year because she wanted time off to have her baby. They said a resounding "NO"; for the reason, as one doc put it, that "third year is supposed to be 12 months of learning that Medicine is hard." She was already pregnant, so I don't know what she did. Probably dropped birth in the middle of a 9-hour urology surgery, handed the kid off to a nurse, and kept going with the very important job of holding the scrotum.

Fourth year is totally different. When you tell someone you're a fourth year, you're instantly buddies. I think this is because fourth year medical school, with the exception of a few months, is the best year you'll ever have again. Fourth year is the reason you go to medical school. Or at least it should be. Through policies and scheduling, it is made to be almost completely blown off.

My fiance, baffled by this change from third year to fourth year, observed the other morning, "You get to go to work in pajamas. Every day." It's true, and it is just glorious. That day it was especially true because I didn't feel like putting much effort into the day and just pulled scrubs on over what I had slept in the night before. So yeah, I technically went to work in pajamas.

Radiology is probably the most amazing rotation. Not just because its what I want to do, but because you are actively encouraged not to attend your own rotation. The first time a resident offers to let you go home, you have to ho hum and "well, I'm really interested in this" and somehow try to show that you give a crap and want good evals (especially if you want to go to that residency). The second and third time they tell you, you're probably in the way and should just give it up. After you cross that bridge its hard to go back. Yesterday I made the faux pas of coming back to the reading room after noon (I had a lecture later and had to be there anyway). As soon as the attending left, the resident twirled around in his chair and said, "so, has anyone told you how this rotation works?" "You mean, why am I here after noon?" I asked. "Well, basically, yeah." he said. "Welp, see ya later."

Hmm dee hum hum, I think I might go get ready now. Meaning I'll put my pajamas back on, waste time for an hour or so, and roll into work about 9. This is the best year ever.

Thursday, July 23, 2009

Candy Gram! Updated

I'm back. And boy do I have a story for you.

I watched someone poop yesterday. You know, now that I think about it, I've done that before. I did work in a nursing home after all. But this time felt a little different. Maybe that's because we took pictures. And she was sitting five feet up in the air. And we shot her full of radioopaque poo to do it.

I was sent to fluoroscopy (which as far as I can tell is where you stick contrast in one hole or the other and watch where it goes with x-rays.) because there are quite a few future radiologists vying for a spot here. The resident said, "Well, you picked a boring day. Nothing really going on except two defecographies." Defe-what?

Wait. I know what that root word means.

But there's already something called a barium enema, where Dr. Feelgood shoots your backdoor full of contrast and takes a picture. Why would we ever need to watch someone push it back out? "Really, no one does it anymore, we just have one doc who orders it. A lot." said the resident. Oh my. That's something that scares me about medicine. If you went to my home institution, you'd never hear of the crap-o-gram. But here some doc with a fetish has people going right and left.

As we were getting ready, I walked into the room where the tech was prepping the caulk gun. "So, is it go time?" I asked. Then I laughed really hard.

So this already sounds pretty terrible. But then he started to describe the procedure. I'll do my best to recreate it and my reactions.

First you make the person drink contrast (no, of course it doesn't taste good). This is so their bowel and bladder lights up a little and you can tell where they are on the film.

Next, if it's a lady patient, you have her go insert a contrast soaked Tampon so you know where all the parts are.

After that fun, the patient lays down on a table, business end skyward, while you (the unfortunate resident in this case) take a caulk gun basically from a hardware store --apparently, if you say "surgical grade" it covers all manner of sins--filled with a radio-opaque putty (it really looks like caulk-hence the equipment I suppose), and pump. You know where. I can barely type this, this is horrifying. To add injury to insult, it's very hard to pump the stuff, so you try to go as fast as you can without getting a debilitating cramp. You wouldn't want to try to switch to lefty in the middle of this.

I'm not even done. After that, the patient holds it in and goes to sit on a chamber pot in front of the x-ray machine. Here's something hilarious; the x-ray camera arm doesn't go low enough to capture the action on the chamber pot, so the patient+potty combo gets lifted in the air several feet while on the pot.

Then the real fun starts. First we just take a picture, I guess to see if there's any leakage while you're just minding your business. I would think that a patient wouldn't need defecography to figure out if that were happening (wouldn't you be able to tell if you were, ahem...you know?), but who am I to judge Medicine? "Ma'am, I want you to bear down as if you were having a bowel movement, but try not to actually go." I about lost it at this point. I already need two doors and an alibi, I would never be able to go through this. Then we took another picture, I think looking for angles and outpouchings and other things that won't probably affect the treatment. "Ok, now go." More pictures. I just spent ten minutes watching someone poop from the inside out. And there is no fan or springtime lemon air-freshener spray in the room-I discretely stepped out so I wouldn't reenact the scene from my surgery foley catheter disaster. I really need to figure out a way to dumb down my sense of smell. I used to be able to switch automatically and mouth breathe at the nursing home, but honestly that is just as gross.

This woman took it like a trooper. After she was in the bathroom the resident asked the nurse, "So, this is the room we're doing all these in now?" The guy replied, "Yeah, the equipment in the other room is really crappy." The snort was out of my mouth before I knew it was coming. Luckily the young female tech student caught the joke too. Apparently he wasn't kidding though; during the middle one of these procedures the x-ray quit and they had to LOWER THE PATIENT AND TAKE HER TO ANOTHER ROOM while she was holding a rectum full of putty!

When I was looking for images I noticed Rush University had a lot on their website about this. HA! Get it? RUSH!

If I didn't laugh, I'd probably throw up.

Wednesday, July 22, 2009

Apology

I was out of town for a few weeks. I should have posted a warning. I will be back with a post today. I've already started it, but feel it will take me a little longer to describe watching someone poop on camera.

Tuesday, June 23, 2009

Beware the Google Search

I'll begin today's blog with a definition. Didactics: the hour every day where every available radiology resident/medical student is required to go sit in a dimmed lecture hall while an attending is dragged in to talk about the first thing they can find a ready-made powerpoint presentation for. Meanwhile I hope it's not the doctor with monotonous voice and accent--not because I have to focus to understand, but because my mind just stops trying completely without even asking me. I totally space out for a good ten minutes before I even realize my mind wandered. It's like being in church. It also means I have to eat lunch crammed on a tiny tiny desk/chair combo that makes for a crappy desk and a crappy chair.

Today I was sitting innocently in didactics , minding my own business and trying to be happy with my pre-wedding lunch regimen, when one of the attendings, my advisor actually, walked in and said "So Al I was searching online for Dr. Howe's phone number today and found this picture of you..."

Oh Sweet Jesus. That is never something you want an attending to announce to you. I lock up my facebook account, and luckily I was 21 before it even came to my college, but still, you never know. Plus, I am not exactly photogenic. Well, maybe I would be, but in most pictures I'm too busy trying to look like I ain't got no sense. It really tones down my cuteness, to be honest.

"I just laughed and laughed!" Oh no. "I can't imagine what they story is behind that picture."

Now I really want to know what pic it was. "Where did you find it?" I asked. "It was on that website with the sarcastic med school newsletter." "Was it a picture of me dressed as Chuck Norris?" "Noooo, but I'd like to see that too." Well that was a miscalculation on my part. He couldn't describe it with any other words beside "hilarious" and "something he wished he had on everybody". so I had a little search project for the afternoon.

The rest of the day, if I passed him in the hall he laughed out loud. Or once he said, "There's the Wild Woman!" Good grief.

It wasn't that bad after all. At least, it's not that bad compared to other pictures I've taken. I suppose how someone used to Professional Soon-to-Be-Doctor Al and not Every Other Moment of Her Life Al could be a bit taken aback. Maybe I'll do a little cleanup of my facebook profile. Just in case.

Monday, June 22, 2009

Why I haven't blogged lately.

Wedding. Wedding, wedding wedding. Your wedding, that other guy's wedding, my wedding...lots of weddings.

But here's a story from a lady getting a cerebral angiogram. She used to work at a prison sorting the mail and opening it, for obvious reasons. One of the nurses asked, "What's the best thing you found in the mail?"

"Well, aside from the pictures around Valentine's Day--which usually had notes that read "Don't let anyone else see this!!"--I'd say it was the drugs." Apparently, people routinely mail their friends/significant others all sorts of contraband. The funny thing is, they almost always put their return addresses on the envelope full of drugs. Hmmm.... I guess people really take that second-grade envelope writing lesson seriously. It's a hard habit to break, even if the law isn't.

She said one lady mailed her man drugs, but didn't put enough postage on it, so it went back to her. She re-applied postage and mailed it back.

That's all I have for now. I'm moving on Saturday, so I can't promise too much more.