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.

Wednesday, June 17, 2009

He-Man Woman Haters Club

Apparently Radiology is a bit of a man-fest.

In the radiology department at my school, there are a whopping total of 2 female residents among the 25. And in the two weeks I've been there, I think I've seen one of them. Once. From a distance. They are a rare breed around here.

I really think in this day and age the only appropriate time to see such a gender bias is at a Promise Keeper's convention or NAMBLA neighborhood pool party.

One of the (male) residents warned me about an attending being something of a dirty old man. Um, yeah, I got that when he:

1. Saw me wearing pants (gasp!) on day two and said, "Well boys, she doesn't want to impress us anymore."
2. When asked how he was doing this morning, he did a full swivel around in his chair, looked me up and down, and said, "Well, Better! Now that I've seen you!"
3. The (male) residents sneak me down into the resident lounge for a caffeine break. When he saw me heading off with two guys he made some, "I'm worried about her virtue!" comment.

Hmph. I'm getting the vapors just thinking about it. What do you say to that?

I asked a few of the residents why they were so short on lady folk. After thinking a little bit, at least I assume that's what he was doing because honestly I'd moved on from the conversation, he out of the blue says, "I think traditionally women didn't go into it, now, I don't mean any offense (I love it when they say this), but I think its because women tend to want to go into more, uh, nurturing professions. At least, that's the stereotype." "I'm as nurturing as they come, you ass." Ok, I substituted the word "ass" for a very sarcastic tone of voice.

Luckily I have the movie tastes of a dude (according to my fiance), so we usually have things to talk about.

Friday, June 12, 2009

Is that a aneurysm in your stomach, or are you just happy to be here?

Occasionally in the ER, you see something that makes everyone stop and go: "Oh s@$#!"

One morning the ambulance guys brought in a skinny little old man. He was stretched out, shirtless, and man was he thin. He looked either malnourished or very very old. As an aside, I never understand putting restrictions on the elderly diet (unless it will choke them or otherwise immediately kill them I suppose). once I hit 70 or 75, I'm eating whatever the hell I want. If anyone seriously ever tells me to eat a low cholesterol diet when I'm old, I'll bring enough bacon to my next appointment to choke him. And here's the thing; I don't even think that's such a bad way to go.

Not that I would say I really limit my bacon intake now. I just won't have to hide it anymore.

Anyway. This guy was emaciated. Except for his belly. His belly was huge. He looked like our class snake after my biology teacher fed him a microwaved mouse. He looked like he'd swallowed a basketball on a bet. Except for one thing. It was pulsing. Oh s#@t.

There was only one reason I could think of for that man's stomach to have a pulse. He had a AAA. Abdominal Aortic Aneurysm. He fit the profile: old male smoker, poorly controlled hypertension, probably had atherosclerosis and coronary artery disease. His son gave this history: "Well, dad went to the bathroom, and came back all pale and shaky. His blood pressure is usually 150/90, but when I took it then it was 90/60. I figured something was wrong and I should call the ambulance." Crap crap crap that's probably because he's losing his blood volume into his abdomen. He went in for his morning Valsalva maneuver, blew his aneurysm, and halved his blood pressure.

He was lucky to have even made it to the hospital. He was one of the worst looking patients I'd ever seen. Just before he got through the doors he lost consciousness. After resuscitation fluids he wasn't much better. We had to get him to surgery immediately.

Once we'd done the necessary assessment and handed him off to cardiothoracic surgery, we went to sit down and talk with the family. My attending explained to them what had most likely happened, how they did the right thing to bring him in, and that most people didn't make it this far so at least he'd done that. In my mind, even if he made it through surgery, how low had the blood flow to his brain gotten? How long had his organs been deprived of enough oxygen? Sometimes just because you keep someone alive doesn't mean they'll come out just like they were before.

Then one of the sons asked, "What caused the aneurysm?" My attending said, "Sometimes people just get them." and then mentioned his gender, age, and reiterated that he was fortunate to get here in time. What a load of crap. I have never heard of a AAA patient who didn't smoke at some point. Even if there are some who didn't, the vast majority do. I weakens the structure of your blood vessels. It increases your blood pressure. It increases intra-thoracic pressure because your lungs are crap and you have an old man cough. And the doctor admitted all of this when I asked him about it later. I guess he just didn't want the family to feel like the old man contributed to it himself. Yeah, as they go out to the parking lot to have a relaxing smoke themselves, I'd hate for them to leave their comfortable ignorance.

I think the man survived the surgery. But I don't know what happened afterwards. It's hard to follow up with people in the ER. I just hope his sons don't have the same thing happen to them in twenty years.

Monday, June 8, 2009

You Could Be My Grandmother, Except You Haven't Called Me Fat.

Day two in the ER (this is one of those posts that I started, but didn't have the energy to finish).

Midway through my twelve hour shift, I wondered just how many crazy-eyed little old ladies could come in in one day. It felt like the entire female 80+ population of the tri-state area was thumbing a ride from the nearest passing ambulance and hightailing it to my emergency room.

Before medical school I worked in a nursing home. I always thought I would want the plug pulled if I got like that. I sometimes tend to view all old people as the same--clinging to life, or maybe that their children were clinging to their lives and they were just a helplessly being wheeled in and out of emergency rooms. "Yep, you're still old."

When my dad had bypass surgery, one of the first things I did when I got there (Unfortunately I was on a Colorado mountain when he called saying "he was having a little trouble moving around", so I was a little late to the party) was to comb his hair. One thing I have to remember, really one thing every doctor or nurse should remember, is that sick people do not look like themselves. They look crazy. They are stripped of their identifying clothing (funny, everyone looks puny in a hospital gown. No power suits in the hospital), depending on how they got there their hair is probably Einstein-worthy, they usually have a sick, wild-eyed shocked look...in short, they look terrible, and sometimes it's hard to remember that's not who they are. If I ever go to a hospital, I'm having someone fix my hair and makeup every day. And I don't even wear makeup at work. Or fix my hair.

Some of the elderly have an ENORMOUS list of medical problems and a stupid amount of medications to keep them in some semblance of life. Sometimes I wonder what's the point of bringing these people to the hospital? Oh, your mother is dying of COPD, gasping, wheezing, emaciated...but you brought her here for her runny nose and cough? So we have to work her up for pneumonia, a pulmonary embolism, etc etc etc all billed to Medicare that probably won't prolong her life by even a day?

I think the children feel that if they don't do everything possible for their parent, that they are not being a good child. Or that somehow it will be their fault when, not if, their parent dies. But that's so flawed. Death gets everyone, yet people have a God complex about delaying it. No matter what you do, you are only bargaining. And it's not always "if we get her over this hump, she'll live another 10 years". What sometimes people don't think about is how much pain and suffering going to the emergency room or hospital can entail. You start by waiting on harsh seats and fluorescent lighting, get your fragile veins poked, get prodded, moved around, catheterized, and have to spend at least three hours waiting for any word of what's going on. Then usually elderly people get admitted to the hospital because there is something wrong with them and the ER doc doesn't want to let them go only for them to die at home the next day and the family to come back yelling, "you didn't do enough for my mom's COPD/bladder cancer/heart disease/ every other problem that come with old age!"

Then you eventually take them home, only to repeat the process a week, a month, or two months later.

This was all on my sometimes quick-to-assume mind when I first started working in the ER. But like always, life can throw your assumptions in your face (this time in a good way). One particularly wild-looking lady was brought in on an ambulance. She was over ninety, and was brought in because she "wasn't acting quite normal". What the hell does that mean? Luckily I'd had enough sleep the night before so I phrased that question a little better when I spoke to the family. She's over 90! She's had two strokes!

When I started to talk to her (always talk to the patient first, no matter how old they are), I realized this lady was sharp. Forget the two strokes, she gave a better history than some of the 50 year olds who came through. And funny. I ran through the usual questions, as always asking, "Do you smoke?" "No, she said, but I do drink beer!" "Oh really?" "Yep, every now and then I like to have my beer. Just one! And not every day! But I do like the taste of it." Her daughter said, "We just give her one beer and put her bedrails up."

Alright, I get it, I was wrong to assume she was demented with no quality of life. But still, why was she here? Whatever, we were still going to run the usual litany of tests; there's even a protocol titled, "weak elderly patient". I asked my attending to make sure a certain test was in there; something that can affect elderly ladies and if positive could be easily treated.

To make a long lesson short, it was positive. She had a urinary tract infection. Something that could make her a little "off", could affect her quality of life, was easily treated, and absolutely should be taken care of.

I am very grateful to that lady. Even if she's the exception rather than the rule, every time I treated an elderly patient after that, I remembered how she surprised me and to never judge a patient by her age. Or her crazy-looking hair.

Friday, June 5, 2009

What have I done?

This morning we had a young guy, 30's or so, come in because the vision in his right eye was blurry. After I questioned him, I found out he also had his hands go numb a few days ago. Oh, and his dad has a history of multiple sclerosis. And an upgoing Babinski sign on his left foot.

I was very concerned that he might be showing early multiple sclerosis. I wanted to order an MRI. the problem was, he was self pay. My attending thought he should have an MRI too, enough so that he called the MRI center (we usually can't get MRI's out of the ER) and found out they had a spot open. I asked the guy if he would be willing to get an MRI. But I never talked with him about how much it was going to cost. Which is probably $2,000. He already had a financial aid packet in his hand; I guess I didn't want to bring it up because I was afraid he'd refuse and that we really needed to find out what was going on. What were the chances that he'd see a neurologist after we let him out? Or that a neurologist would see him, seeing as he has no insurance or even Medicaid?

He agreed to the MRI, and I felt a little flip in my stomach for doing it. Was it the right thing? How was this going to help? I know it would help to get him on medication, but what if he wouldn't be able to afford it anyway? What if there's nothing there, and I've just talked him into spending that much money? I felt like we had enough evidence to warrant it, and I didn't want a CT first because that would just cost more money (albeit less than an MRI) but I was really uncomfortable with how I used my pseudoposition of authority. He didn't know how likely it was that he had MS. He just knew that my attending and I told him he needed a test. I possibly just put this man out of a lot of money for a test that I wasn't sure of the result.

The MRI came back with a simple cyst. I thought I was home free for a little bit. I mean, here's this big hole in his brain on the MRI!

But then the radiology report came out. It was most likely just a simple cyst. The position where it was probably couldn't cause his symptoms. I just got lucky. We ordered an MRI and there just happened to be a remarkable but benign cyst in his brain. No multiple sclerosis, which I guess is good, maybe, unless you just spent 2 grand of someone else's money on a test for it.

Here's the worst part. He has to go back in 6 months for a follow-up MRI to make sure that it isn't a tumor. It probably isn't. It most likely isn't. So he's going to spend more money (maybe), on another useless MRI.

I can't stop wondering if I sank this guy financially. I rack my brain thinking about if there was any other way than that MRI. We are told to try to control costs, but what if he'd actually had MS? Then I would have done him a disservice. I still don't know what I should have done.

Wednesday, June 3, 2009

The $3,000 Case of Strep Throat

Yesterday evening we got an ambulance transfer from a town about 80 miles away. The patient was a 12 year old with a suspected case of appendicitis. The thing with transfers is that each hospital up the chain doesn't trust the hospital before it. I think the only evidence we usually accept is radiological evidence, and even then sometimes the doctors will run the scans again. I used to think that was a little ridiculous. But then this kid came in yesterday.

Appendicitis. Ok. It can be a problem when patients come in with a suspected diagnosis. It's easy to get caught up in their story, which makes it hard to do a thorough unbiased history and physical exam. This kid's dad gave me a patient presentation straight out of House, he even said, "His white count was 115,000". That's high. Like leukemia high. "115?" I said? "Oh, maybe it was 15. I might have exaggerated that part. But it was high." Thanks for the clarification. I'll probably run my own labs.

The first thing I did was ask them why they were in the ER. Always a good one to start with. From their story, it sounded like the first thing that happened to the kid was a fever. Flag #1: Fever, not abdominal pain. I'd usually expect abdominal pain to be the first complaint, and you usually don't get fever until the appendix ruptures.

Next, I poked the kids belly. He was sore around his belly button and in the left lower quadrant. Flag #2: The appendix is on the right side. Unless all your organs in your body are reversed, anyway.

Nausea and vomiting? Check. Ok, that's pretty nonspecific, but usually true in appendicitis.

Now that I was skeptical (I'd seen a crap ton of suspected appendicitis by that day) I said, "Are you hungry?" "Yeah. I tried to eat before but threw it up. But I'm hungry now." Flag 3: Kids with appendicitis aren't hungry.

Since fever was his first complaint, I went looking for reasons for him to have a fever. Starting with a full physical exam. I hunted down a portable otoscope and looked in his mouth. Except for when I do a neuro exam, this might have been the first time I looked in someone's mouth in the ER. Honestly I don't know what possessed me to do it.

Anyway, I told him to say ahhh, and his tonsils touched. They were enormous, with huge pus pockets. "Does your throat hurt kid?" "Yeah, it's hard to swallow." You are freakin' kidding me.

I asked a few more questions, finished the physical, then went out of the room and asked for a strep test. "We don't have the rapid strep test down here." Well what the hell do you do? "A regular swab, then we send it to the lab."

"They said cancer, but I'm thinking it's just a case of jungle rot."

The nice difference about being at a rural hospital rather than back at my university is that at the U it would be a bit of a faux paus for a lowly student to ask for a strep test on an appendicitis case. After all, the doctors at the other ER saw this kid and saw fit to transport him here (at $750 plus $12/mile). But here the nurse just said ok and showed me where the culture kits were.

I have maybe done one strep swab in my career. Now proving my hunch that this kid didn't need surgery relied on my questionable swabbing skills. In front of a worried parent. I guess I could have asked a nurse, but what pansy medical student can't do a strep swab? So I went in there, got the tongue depressor, and told the kid to open up. I just tried to swab around so I hit one of the pus pockets before he puked on me. I checked the tips, yep, yellowish stuff. Ok, here goes nothing.

I waited and waited, praying for the results to be positive. It just fit, the fever, the throat, the stomach pain. Surely my training hadn't failed me.

When the little lab icon came up, I clicked and saw "Group A Strep: Positive" in red letters.

WWWWAAAAAHHHHOOOO!!! I couldn't contain it. "Do you feel like a real doctor now?" my attending asked. Yeah. Holy snap, I actually did.

So we got to go in the exam room, tell the family the kid didn't need surgery, he just needed a shot of penicillin G in his hiny, and got the heck out before they got over their relief and started wondering how much that ambulance ride cost.

Tuesday, June 2, 2009

I am not a night person.

I did another overnight shift on Saturday. Since it was the ER, there was no chance of sleeping.

I put an overnight in my schedule because I thought it would be a good idea to see the differences between a day shift and a weekend night. Hmmm...

It was certainly different. I really think a lot of the patients would have been run of the mill patients, but the fact that they came in the middle of the night gave them a touch of crazy. Like the probably single dad with three kids who brought his kid in for pink eye. At midnight. He'd had a red eye all day. The other two kids were there with him, which is why I draw the conclusion that he was single. He mentioned something about putting milk in the kids eye to help it and I really hope my face didn't show what I was thinking. Which was, "What the @#$!?" Apparently it was a camp remedy. He really tried to take care of the kid I guess, I'd just never heard that one before.

Around 4:30am a lady in her sixties coded. Her hemoglobin was around 5, which is critically low. Her organs were failing, she was bleeding out of every hole she had, and we needed to get fluids, blood, and plasma in her as fast as possible. Faster than the rate gravity could go.

My job during this code was to hold a bag of warm saline in one hand, a bag of fresh frozen plasma in the other, and to squeeze the living be-jeezus out of them. In order to make sure the flow went through the thin IV lines well, they needed to be held as high as possible. At least, that's what they said, and who was I to argue at 4:30 in the morning? Did I mention that one bag was at the head of the bed and the other was off to the side? Yeah, I spent what felt like an eternity with my hands up in the air like one of the Village People squeezing the bags with everything I had in me. My hands cramped to the point of near uselessness. My back and triceps were screaming "This is not how we planned to work out!" But we turned her labs around. I have no idea if she survived the next day, or if the complications from being down so long will catch up to her eventually, but at least she made it out of the ER.

Whenever I pull an all-nighter, my schedule is jacked for days. I got home around 8am, took my scrubs off, and crashed for a few hours before I headed to the city to hang out with my fiance. I thought I was doing pretty well. The A/C was out at his place so we sought out a dark cool place and went to go see Pixar's UP. I cried three times. Sometime during the second episode (a full thirty minutes into the animated movie), my fiance, who already had a comforting arm around me, leaned over concernedly and asked, "Do we need to leave?"

"No" I hiccuped, "I think I'm just a little more tired than I thought". Then I wiped my face on his sleeve and wondered how I was going to make it through my 12 hour shift the next morning.