My Pal Al

I'll give you something to puke about

2011-01-07T19:03:00.000-08:00

Time for a Blahg. I started counting the number of times people told me I hadn't posted, and they added up to enough that I decided to post something.

On my mind this evening is the fact that I have to go back to work tomorrow and take care of a big fat faker. a PHONY!!

He claims to have cyclic vomiting syndrome. Look it up, it involves repeated bouts of vomiting. It has a psychiatric component, but the people (and here's the rub) do actually vomit.

Reasons I had a problem admitting this patient.

1. My senior resident foisted it off on me for no other reason than the fact that he could. Bastard.

2. Reading the note, something stank. This guy was referred here to see a particular GI doctor. At 3am, he had woken up with abdominal pain, then started vomiting, yada yada. His mother (uh, yeah, he's 36 years old) brought him to the ED, where he got a $2000 workup which was totally normal, was given IV fluids, and sent to his GI appointment. According to the ED note, he never actually threw up. When he was told he wasn't going to be given the dilaudid his primary care provider did not feel comfortable writing for anymore and instead sent to his clinic appointment, he "spit up" (from the note) in the trashcan.

3. After that episode, he proceeded to put on such a show in the GI clinic that the specialist called US and said he was too sick to go home. So we had to admit him.

4. Nobody wanted to re-admit him to the ED because they had already worked him up for nothing, so I took the senior medical student down to the triage area they'd put him in, showed them into the ECG room where we could examine him in private, and told the med student: "I don't trust my filter right now, so I'm going to introduce myself, introduce you, then let you do the talking. I'll interject when I have more questions and I won't let you miss anything, but I'm going to mostly keep my mouth shut and keep us out of trouble."

5. This guy was wrapped in a blankie hunched over like a two year-old in a wheelchair (which he had very recently been peacefully napping in according to the nurses), then as soon as we got him, Mom, and sis in a room he began rocking back and forth banging his hands and making unintelligible grunts. Luckily, Sis and Mom were all over it.

"Do you need water?"
"Do you need something to throw up in?"
"TRASH CAN RIGHT NOW"
"Do you want me to rub your back?"
"Do you need a drink of water right now?"

For the love of Zofran, this was some sick s@#$ going down. I would have thought the guy was autistic or developmentally delayed, but according to Sissy and Mommy, who also provided all the history down to the fact that he'd eaten about half a meal of pasta at 8pm last night--oh, no, you had some crackers and milk at 11--he used to be an engineer, prior to this vomiting and needing to go on disability and moving into his parent's basement apartment.

All of this would be pitiable, sad, yeah, a little weird with the drama-loving duo hovering so intensely I expected them to do a poop check any minute (something parents do to babies if you're not in the know), except for the very very important number:

6. That was a fake vomit.

I know my way around a vomit people. That was a fake. A crappy, unconvincing, F-U for effort fake. He basically coughed a few times, went "HUuuuhhHH", and spit clear just-outta-the-mouth spit in a trash can. Once.

Here's the thing about vomiting-if you're really committed, you can make yourself puke. It's called bulimia if you're really good at it. If you're not even that committed , don't try to pull one over on a pregnant lady. Not only do I know every which way to vomit, the fact that you're trying to fake me out after I've been eating saltines and Sprite for 8 weeks is going to piss me off.

He wanted dilaudid, he wanted IV ativan, and he wanted attention. And the fact that he was caught by nursing doing oh just fine (I can just picture him soft shoeing while eating a pudding snack) until Mommy walked in the room (at which point, more fake vomiting), and I can't go back tomorrow and say, "You have to leave." is one of the reasons I don't belong in patient care.

Hopefully I have a medical student to keep me professional.

"I'm not gonna lie Doc."

2010-11-11T19:02:00.000-08:00

Sometimes first impressions are....absurdly funny.

I walked in to a patients room this morning with this history: 50-something male who blacked out while driving Sunday, losing control of bodily functions, crashed his car into a pole, woke up and decided to drive himself home, then spent the next few days occasionally blacking out while continuing to drive himself around town. That is, until he decided to drive himself to the emergency room.

He had a history of cancer, drinking, and has enjoyed more drugs than there are ways to "just say no".

I'm real excited to meet this dude.

I head into the room, and he looks like he's been rode hard, dragged through some cacti, and put away wet. He has multiple scratches and thick blood-crusted scabs and bruises on him. His hair is thin all over. He is painfully thin. He looks a little wild-eyed. Then there's the trach that he cleans with his hand (imagine you could reach into the back of your throat and pull out all the snot and spit with a swipe of your hand, only to wipe it on the front of your gown before offering your hand to shake with the doctor).

"How are you doing today?" I lead with. Pretty benign, usually. He grunted something and grabbed his belly just around his stomach under his ribs--you can't talk and use both hands at one time with a trach, you need one to push your speaking button.

"Does your stomach hurt?" I asked next. He responded by clutching his stomach, holding up one finger in a "just one moment please ma'am" gesture, then, jeez this deserves a new paragraph:

He then took that one finger, pushed his trach button, and without a word, turned to his left, and projectile vomited coffee ground looking emesis, managing to arc it from his bed into a trash can.

This was not that man's first time around a vomit.

I am positive my head left a dent in the wall behind me because my first and only instinct was to back up so fast I flattened myself against the first surface I hit. Seriously, I moved so fast my arms flew up; it's probably more like a snow angel impressioned in the paint.

The guy had just had coffee, otherwise as you know if you're in the medical field seeing actual coffee colored emesis means the dude is BLEEDING in his throat or stomach, both of which could happen in a man with his history.

When he was done, he turned back to me, pushed the speak button in his trach and said, "SORRY. BEING AROUND PEOPLE MAKES ME NERVOUS."

"That's ok. I might throw up myself," I said.

Probably not the most doctorly thing to say, but come on, I'd just about given myself a concussion and two weeks ago I wouldn't have even been able to get words out before I yakked on his hospital bed. But it actually worked out; this guy started to laugh, and I could tell he was visibly more comfortable with me after.

The title of the blog comes from other events in this guy's day. A few conversations passed to me:

Neurology: "How much do you drink?"
Mr Bad Decisions: "I don't drink."
Nurse: "Your blood alcohol is still 0.05%"
MBD: "I only drink to take the pain away."

My attending: "So, you're having a hard time without alcohol? (the patient is in florid withdrawal by this point).
MBD: "Doc, I'm not gonna lie to you. I ran out of my Vicodin two days ago and I hit the vodka instead. It's the only thing that works for the pain. So I been drinking a lot."

Ladies and gentlemen, my favorite patient of the day.

I have work to do.

2010-11-10T16:10:00.001-08:00

Right now. But I'm putting it off to dash off a blog.

I worked 91 hours last week. It is getting old. Some days I look at radiology attending positions just to remind myself that it won't be like this forever.

A patient I got really close to is probably going to die tonight. I've gotten in the habit of checking on her several times and day and again one more time before i go home. It's especially hard to leave oncology patients for some reason. I guess because most of them were going about their business when they got a crappy cancer diagnosis. It's a little different than the ones who seem to come in and out of the hospital playing the Poor Me card for painkillers or attention.

I think I actually like the Palliative Care patients the most right now. Since I'm not the final decision maker on treatment, something I can do really well is explain things to families and offer comfort.

Harassment

2010-11-05T19:55:00.000-07:00

Sometimes nurses do not know when to leave me alone. I'm sure that today it was because a very angry patient would not leave them alone, but for craps sake when I'm taking care of 16 patients, sometimes I can't answer a page for five minutes!

Anyway, the point is, if you hear me use my slow, measured, somewhat quiet voice, you do not want me to have to come to the nurses station.

After being paged repeatedly and having my attending called despite asking for a few minutes to figure out what was going on with the patient, I stomped down the hall ready to rage to Death Star, a cute little nickname one particular unit in our hospital earned for having spazzy, constantly-paging nurses who somehow manage to miss things like, a blood pressure of 80/40. What do they page about? I spent two weeks and several nights on call and I still can't tell you.

"You paged me repeatedly on this issue. I have a patient with a systolic blood pressure >200, asked for five minutes to figure out what's going on, and every time you page me all patient care gets put off until I can answer the page."

I lead in with that for drama, then since I can never trust my hormones' next move, the urge to really mess with them came over me. "I have had use the bathroom for two hours but can't because I'm getting paged. I have to pee so bad my belly looks like THIS!" I then opened my white coat and gestured wildly at my newly bumped preggo belly. These nurses didn't know I'm pregnant, so the looks on their faces when they thought of how long I must have had to go before I looked like someone stretched a dress over a watermelon was PRICELESS.

"Oh my gosh I'm so sorry there's a bathroom right there I'll leave you alone!"

"Nah, I'm kidding. I'm pregnant. But seriously, I still have to go."

I am very concerned that unless I find ways to deal with the frustrations of intern life, I will have a rage baby who does nothing but cry until he learns how to yell obscenities. So I have to find ways to bring a little funny to the workday. I actually don't feel stressed the majority of the time despite working 70-80 hours a week. Of course, I say that this minute...

Pain and suffering

2010-10-20T19:11:00.001-07:00

I started oncology today.

It's been difficult to write lately for various reasons:
1. I work all the freaking time
2. When I am home, I don't really want to think about the hospital. I've actually spent 4 years honing the Dr. Kelso skill of dropping my cares off when I leave the hospital. That clip is in Spanish, but it's really the faces that count.
3. Looking at a computer for a long time makes me want to vomit. Really.
4. Because I'm pregnant.

It's added an extra spice to my usual demeanor at the hospital. When I was on night float I was about 7-8 weeks along. Not eating at the normal times, sleeping about 5 hours a day and dealing with the massive stupidity that passes for RN's at night time (not all were terrible, let me clarify) meant I spent my free time eating the two things that sounded good--all fruit popsicles and English muffins, both of which I can't look at now--and popping Zofran to keep myself from throwing up too many times.

When someone woke me up for a blood pressure of 150/80, I wanted to burn the whole unit down. I am not kidding. I am seriously afraid my baby will have rage problems because of the time I spent on the night shift.

Starting Oncology has depressed me for various reasons. Like everybody is dying. And, I have to be at work at 6am 6 days a week until April. I shouldn't be awake.

Today I saw a young guy with a son who looked like he was around 5 years old. This kid was CUTE. And his dad was going home on hospice. I started to feel the crush of sadness settle over me, then I thought about the tiny baby who was at the mercy of my moods. Part of me worried about whether this would ever happen to me. Then a better part of me said, "Just flood that baby with love. That's the best thing you can do now."

I certainly wish I'd thought to do that the other day when I cried for ten minutes over an episode of Battlestar Galactica just because of a scene where a somewhat nerdy character was eating alone and looking sad and lonely. Yeah.

In the end, I really don't give a crap about this year. I am being forced to do a year of internal medicine do to an archaic system that is slow to change due to money and IM departments reluctant to give up their cheap smart labor (anyone who gets into a competetive residency that requires a prelim year is usually pretty darn competent. I don't know how I got in.) It was always going to be difficult, whether or not I was especially hormonal or occasionally throwing up. I had the thought this morning that it would be a year I'd look back on and wonder how I survived. Usually I don't realize that until after I've had the year. :-)

And now, after that round of wallowing in self-pity, you can see why I don't always blog! I'll have a funny story next.

Dryer than a Popcorn Fart

2010-10-17T15:05:00.000-07:00

My elderly patients crack me up. Sometimes they are whiners, but sometimes they are the funniest things this side of an emergency room.

That title was one of my favorite quotes from one of my favorite patients. This guy got up like every other day of his life, gave his neck a pop, and broke it.

Yes. He broke his own neck.

I’ve known this could happen for years. By known, I mean the grotesque image has run through my mind whenever I see someone crack their neck, and I try to stifle my shudder and use my doctor voice to convince them of something I’m sure of, namely, that they are going to break their own necks right in front of me.

Blech.

Anyway, though I believe I was proven right, I guess I should add something else to the story. He had cancer he didn’t know about, and it had grown metastases in his spine, weakening it. So he still broke his own neck, but his neck did have a few fragile spots.

Unfortunately, the cancer/contrast from the scans that found the cancer also shot his kidneys. The man has been in a halo (he has screws coming out of his skull, yes, through his skin that attach to a halo with a fabric-covered harness down over his shoulders midway to his belly button. He can’t sit up for dialysis in an outpatient clinic, so he can’t go to a nursing home. None of the Long-Term Acute Care facilities (kind hospital-lite) will take him to chemotherapy, so he can’t go to an LTACH. He’s been stuck here for over a month for no reason other than administrative policies. Plus at first they gave him a crappy renal diet, then by the time we figured out to give him whatever he wanted, the chemo had already made him lose his appetite.

You’d figure the guy has every reason to be a grump. But he’s not. He’s always upbeat. He always says, “Oh, I’m doing pretty good!” when you ask him how his day is. Every now and then he says something like, “I need you to blow me out again.” (the first time he said he was constipated, I told him I was going to “blow him out because that was one thing I know how to do well.”).

With the dialysis we realized we might have been pulling a little too much fluid off of him. My attending asked, “Do you feel like you’re thirsty?” to which he replied, “Doc, my mouth’s dryer than a popcorn fart!” I don’t even know what that means, but it was awesome to see my attending try to keep a straight face.

Pooh continued

2010-09-16T05:28:00.001-07:00

A lot of my phone calls involve bowel movements. I don't know if patients just don't get up the nerve to talk about them before 8pm, or if the night nurses just want something to do, but I end up dealing with other people's crap every night.

One nurse called just to tell me that a patient w/ a partial small bowel obstruction (who had orders for enemas q 2 hours until she had a bowel movement, no need to call the on-call doctor), that Mrs. Pooz had a "large bowel movement that was very green. I didn't know if you wanted to look at it or do anything about it..." Wha? Yes, she really did call to see if I wanted to hike my butt up two flights of stairs and go look at poop. One of my many talents is sarcasm, which I felt I restrained by only saying, "Thank you for that very useful piece of information regarding the patient's care. Although I am very interested in bowel movements, I will not change her care plan at this time." Nurse Literal, not getting the sarcasm, responds seriously: "Oh, I can call you if she has any more like that, I think it's interesting too!" I decided to be direct. "If you call me again for a bowel movement that has anything other than frank blood, I will make you do enemas for the rest of your shift." The funny thing is, that is the comment she didn't take seriously, and then she had a great chuckle and said how funny I was and never called me again that night. And no, she wasn't mad at me, those nurses call you for blood sugars of 90 (normal) at 3 o'clock in the morning.

This morning I had a bullshit admission (Kari, I know you're an ED resident, but sometimes I could just take a hose to the place) for a lady who has been admitted once a month for CONSTIPATION, nausea, vomiting, and abdominal pain. Ladies and gentlemen, this lady is why people whine and moan about the ED being misused by people who don't pay. If this lady had any intention of paying a hospital bill, I'll tell nursing that I want to see pooh all night tonight. But she said the magic word, "chest pain" that bought her a 23 hour obs stay courtesy of Medicaid. Funny thing is, her "chest pain" resolved with an enema, leaving her only with abdominal pain. Her troponins were negative x3 (she'd been in the ED long enough to have 3 troponins, which are drawn 6 hours apart), ECG was normal, basically I was more likely to be having a heart attack at that moment. But due to attendings who were off site and an ED doc who didn't want to reverse the previous shift's decision to admit, we had to admit the lady.

Ok. You want to fix your constipation? That is something I do well.

That lady is on Miralax, Senekot, Colace, GOLYTELY, and enemas q2. She is going to be crapping food she hasn't even eaten yet. My hope is to clean her out so well no stool will stay in her body for at least another month. You're welcome.

And no, I don't want to see it.

You don't know the meaning of "constipation".

2010-09-09T13:27:00.001-07:00

A few highlights from my first night on night float. Most of these are dumb pages from nursing. You'll have to wait til tomorrow to see the dumb things I did myself when I was tired.

Twenty minutes in, while getting report from one of the day teams, I get not one but TWO pages from a nurse on a specific unit (I will find this to be the troublesome unit all night). While I was answering the first the second one came across (they are not supposed to page during checkout), the nurse worriedly says, "Mr. Toots hasn't had a bowel movement in four days and he doesn't have a bowel regimen AT ALL."

"Is that what both of these pages were about?" I asked. "I'm doing checkout. If he hasn't had a bowel movement in 4 days (which is a daytime issue anyway), waiting 20 minutes while I do checkout isn't going to change his situation. Just put him on Colace 100mg BID."

I didn't get any more calls about his BM's, but I did get a call on an AIDS patient who had liquid bowel movements. I went up to see him (because it's just common courtesy before you agree to put a tube in someone's rectum) and the nurse says, "It's still here (the BM) if you want to see it." "Really?" I wanted to say. "I'm going to trust you on this one." But I wanted to check out his possible peri-rectal erosion to make sure I wasn't going to hurt him with the tube, so I met my first patient of the night ass-first covered in narsty. This nurse was great though, and she'd taken care of him for a few nights so I relied on her to let me know what his baseline was.

I also got paged at 10:30 because Mr. Gaggles "is nauseated and doesn't have any IV meds" I looked at my patient check out sheet, which lists the medications the patients are on (because I don't know these patients well enough and there are too many to try to remember safely without looking in the chart.)

Dr. Al: "He has compazine and Zofran PO written. Have you tried those?"
Nurse Incompetent: "Well, I gave him the compazine and it didn't help."
DA: "Ok, did you give him the Zofran?"
NI: "Well, I ordered it but it hasn't come up from pharmacy."
DA: "Sooooo that's a no. He has two anti-nausea meds written. Give him those two anti-nausea meds and then see how it works."
NI: "But he doesn't have any IV nausea meds."
DA: "Is he throwing up?"
NI: "Well, no. But he's dry heaving."
DA: "It's the same med. He doesn't need IV if he's keeping PO down. You already have Zofran ordered, plus there is a dissolve-able form. Give him that and if it doesn't work at max dose call me."

At 10:30 I am much more open to having that conversation. Besides, this has apparently happened before, as it was specifically in my checkout to ask this nurse if she'd given the ordered meds before prescribing new ones.

At 1:30, when I was woken up from my nap (I probably won't nap anymore, but it was my first night and I had trouble switching over) for this call.

DA: "This is Dr. Al, I was paged."
NI2: "Ms. Nightowl in 3219 wants an Ambien to help her sleep."
This is my fault for not going into her chart and seeing that she already had orders for a damn Ambien. But rule of thumb is to try simple tactics first.
DA: "Are her lights and TV on?"
NI2: "What?"
DA: "Is she in there "trying" to sleep with the lights and TV on?"
NI2: "I don't know, I haven't been in there. "
DA (thinking groggily at 1:30am): What? How the hell do you know she wants an Ambien?

Right there I should have known a nurse who was too lazy to go see the patient would also be too lazy to check her medical order sheet and see that this particular question had already been answered. But I ordered Ambien anyway.

By now, this s#$@ was getting old.

Another nurse had to call me after a patient requested IV fluids because she was going to be NPO (nothing by mouth-no food or water) for 8 hours (while sleeping, mind you) before a procedure. Otherwise she'd been tolerating a normal diet. The patient wouldn't leave the nurse alone until she called me. The nurse and I had a good chuckle, and I said no, if we all needed IV fluids during sleep we would have died out as a species a long time ago.

I came to really REALLY appreciate nurses who wrote notes that included, "this is a daytime issue and will bring it up with the primary team." Nurses who think on their feet are the best thing in the world. As a night float, I just don't know these patients as well as their primary team. I covered four teams' worth of patients last night, each team having two interns. So I had 8 interns worth of patients to cover. I didn't admit these patients, I don't see them day to day, it's really not in their best interest to have me messing in their medical care.

I did get to admit two patients. By get, I mean was slapping myself in the face in the elevator to stay awake. One poor lady was in her 40's but looked 80. She had a chronic disease, and her nursing home had snowed her on pain medications. She perked up with some Narcan, but she said all the lines and tubes in her hurt and she just wanted to go back home. I felt so bad for her.

Another came in because she's God and God doesn't need to take her anti-psychotics. When I introduced myself she said, "I remember you. You're absolutely beautiful." (though we'd never met.) "This lady isn't crazy at all!" I thought to myself.

You can lead a horse to water, but you can't make him accept the fact that he's dying.

2010-09-06T07:05:00.000-07:00

I don't think that's the original saying, but who cares. It's very true.

I got dismissed by a patient while on Palliative Care. We disagreed on a major point in her care plan: the PC (and her Oncology team, who asked us to come), thought her uncurable metastatic stomach cancer that had spread everywhere in her body, leaving her unable to eat or even absorb nutrition through her G-tube, put her in constant pain from bony mets, and had caused a small stroke meant that she was going to die. She thought that God had told her he wasn't through with her, so we were a) all wrong. b) Were faithless, Godless unbelievers and c) were going to be sorry about it when we realized we were wrong. (HA! Doctors are never sorry about anything.)

She wasn't always like that. This is a theme that came up time and time again in PC: A patient could sense his or her body was already sending messages (like, "I've had enough of this). With the help of PC, the patient thought about what kind of life they wanted, especially if it were only going to be months or weeks. Then the family comes in. It's usually really one family member, who lives far away, who maybe feels guilty that he's been in prison/Texas/his own selfish world to see Mom, who doesn't realize how sick she is, that comes in late in the game and goes completely apeshit.

This lady's son was no exception. "You got to eat Mom, you just have to make yourself. It's mind over matter!" No, really it's mind over obstructed intestines that make everything she eats come out her nose. But I'm sure she likes the 3-a-day enemas we're giving her to try to relieve that. "I don't believe you doctors. You all don't have any faith You all are always negative. I know a guy who was told he had to weeks to live, and he's still alive!" Hmmm, has it been two weeks? "He had cancer all over and Vitamin C cured it. We need to give her Vitamin C so her immune system will cure this!" All of a sudden, Vitamin freaking C has become the wonder drug that doctors don't know about. There's probably some preacher, former ThighMaster hawker or a Reader's Digest article ("10 things your doctor is deliberately keeping from you because she is an evil knowledge-hoarding killer!") talking about Vitamin C and your immune system because many people have mentioned this to us. I'm all for trying Vitamin C. We're talking high dose IV therapy, not taking extra Flinstone's. Fine. But say your goodbyes and write your will.

"Oh NO Cancer!"

One part about PC concerning cancer patients that drove me bazonkers is that one particular oncologist would not say flat out, "This will not cure you." I would come in to see the patient, and she would say, "Dr. Tumor told me there's a new chemo to try if I just get my strength up." Then I read the note, talk to Dr. Tumor, and what he really meant was, "If you can get your strength up to 50% of your Activities of Daily Living, which probably won't happen, we could try this experimental chemo that might shrink your cancers for palliative (comfort) goal only. This will not prolong your life or cure you."

I thought maybe this woman was just hearing what she wanted to hear. That could have been part of it. But then I actually listened to this particular doc talk to patients. All he said was "get your strength up and we have another chemo we could try." I couldn't believe it. He was hanging the rest of us out to dry, and in my mind leading this lady on, because he didn't have the stomach to say nothing was going to cure her and she was going to die. My attending practically had to beat him with an oxygen tank until he admitted that the chemo would only be for comfort.

No wonder she didn't trust my happy little ray of sunshine and death talk.

This was early in the month. So this lady, who would both say, "Well, when it's my time it's my time. God will save me if he wants" and "Do everything you can if my heart stops" (Chest compressions on a 66 y/o w/ metastatic cancer is just stupid, I could write a whole other post about Code status). Eventually got coded, intubated, and sent to the ICU. Which sucks. She then self-extubated and was sent back to the floor weaker than ever for her trouble. Last time I checked she was being visited by PC again and was DNR.

Why did it bother me that she and her family couldn't accept it? Really it was mostly a selfish hurt that they thought we were idiots and were "giving up on her." Yeah, I went to four years of medical school so I could march around a hospital giving people crappy news for no reason.

I also enjoy kicking puppies.

I guess no one wants to believe they'll die. As far as I can tell, we all do though, and the ones who accept it seem to have a much better time with what they have left. I sure know I wouldn't want to spend it in a hospital.

You are all going to die.

2010-08-31T20:10:00.000-07:00

That's the gist of my last month's work. I am finally done with helping patients die. From now on, I will be no help whatsoever in the dying process.

Ok, maybe that's a little dramatic.

It has been a very long time since I last posted. That is because my job sucked. Sure, there were moments where I felt like I'd helped a family. Or even a nurse, like when the S(urgical) ICU nurse asked me, "If we disconnect the monitors (which is something we do when people are dying so their families can hug them or get close to them or actually look at them without the monitors constantly reminding them that their loved one is circling the drain), how are we going to know when the patient is dead?"

Are you flipping kidding me? "Well, people have been dying since before we had monitors. Surely we'll find a way to figure it out. By the way, I'd like to introduce you to something I call the "Physical Exam."

I think he learned something that day.

To be more grotesque, you may not know the second someone has died. Their breathing is usually apneic (meaning long irregular pauses between breaths). I saw a guy go a minute and a half without breathing. I thought he was gone and stepped up to pronounce him, but then all of a sudden he took a huge gaspy breath. Geez. Now I wait outside until a nurse (who doesn't need monitors) comes to get me. I can't take the suspense.

Anyway, you may not know which is the exact last breath, but you know as soon as you walk back into the room. People change color. They look different. Not "oh he's on death's door" different, they're there already. I mean it is unmistakable and indescribable.

And on that note, I'm going to bed.

I'm currently on Radiology, which is AMAZING, then night float, which will probably give me some great stories about the batshit crazy. I still have some up my sleeve for this month; I just tried to forget work as soon as I got home. I got tired of having nightmares every night.

Dear Chiefs

2010-08-03T17:33:00.000-07:00

Dear Chief Residents,

I'd like to take time out of my hectic life to thank you for this F#$% of a schedule.

I can tell you really put a lot of thought into what I might want to learn during this year. For example, how little you care about anyone who isn't going to do Internal Medicine for the rest of her life.

The ICU was a great place to start for someone who didn't go to medical school at this institution. Especially when she's the only intern on the service due to a little scheduling oversight (Oh, she'll be fine covering the work of two interns! )I got to spend several FANTASTIC hours those first three days learning both the computer system and how to manage 5 patients who were on the brink of crashing. Nothing like learning how to write an order when every order you make could tip a patient over the edge. What a thrill! I'm soooo looking forward to the next ICU month you scheduled me for (and I am so grateful for the chance to do TWO ICU months, when the other interns are only supposed to do one!)

Man, just when I thought things couldn't get any better, I switched to Palliative Care. Nothing like watching people die for 9 hours a day six days a week. It was such an intuitive place to put an intern who neither requested the experience, nor ever hinted that she liked patients in the first place! I'm sure you saw the fact that I was going into Radiology and just knew I was a lady who wanted to get in touch with her feelings. It's tons of fun for the attendings on the service too! I think they enjoy watching me cry several times a day--so much that they sent me home early for not handling things well! This really gives them a chance to focus on doing their job taking care of interns...I mean patients.

Well, I guess I better go get some sleep. The nightmares I've been having since all my patients started dying keep me pretty busy at night! I sure as heck don't want to be so tired I miss anything tomorrow, like the ability to control my emotions!

Thanks again for not following the ACGME recommendations for a pre-radiology clinical year! I'm sure I'm going to look back on all of this and think about how great of a time I had learning how much a real Medicine residency blows.

Hugs,
Your Pal Al

Oh Beverly.

2010-08-02T09:05:00.000-07:00

It's my one day off out of the week, and a patient that I have taken care of from my very first day is leaving.

This lady was a doozy. None of my co-residents could understand why I was attached to her. I don't really understand it either I guess, but she was another patient who started out with one illness that snowballed until months later she was three weeks in an ICU stay that never should have happened. At one point she was my only patient who wasn't dying. She had a husband who visited every single day for the entire day, even after he found out she may have cleaned out their bank account in a manic spending spree.

Yet in an ICU full of patients who were either going to get better or get worse, she was the for whom I might make a difference.

Beverly was the same age as Peggy. She didn't use to run marathons, I'm pretty sure she used to eat too much and boss her husband around. You don't get to eat on a ventilator (so you basically get Ensure shakes down a tube in your throat, but on her clear days she could definitely boss her husband around.

She didn't have a lot of clear days. She had a bad case of ICU delirium, complicated by the fact that when she first came to the hospital, her home psychiatric medications (anxiety, depression, etc) were held. By the time I took over her care, she'd been without them for a week. We would NEVER recommend stopping psych meds cold turkey to a patient in the clinic. Or on a psych ward. All of a sudden, just when you're super stressed by being in a hospital, we've held the medications helping to keep your brain chemistry regular . Why patient's psych meds get routinely held when they come to a hospital is beyond me. After having seen what she went through, I'll never forget it.

I didn't figure out that she was supposed to be on these meds for another week. I was not informed by the team leaving the service, and the records were buried in a paper transfer from her previous hospital. Once we got Psychiatry on board, things started to improve, but it took another week to really get enough clear days to move her out. She couldn't go home anymore. I know it bewildered her husband. Before the surgery, she was fine. Then all of a sudden she can't get off a ventilator, she can't eat on her own and needs a tube coming out of her stomach, doctors are throwing around the words "Long Term Acute Care Hospital", and the wife he thought was healthy might not ever be home again. And I couldn't deny it. After we lost Peggy I couldn't tell him she'd ever be herself again.

Anyway, the nurses didn't see the story like I saw it. I think instead of feeling responsibility for holding her psych meds and possibly triggering the delirium, they saw a patient who could wave her arms for HOURS and a frustrated husband who constantly asked questions they couldn't answer. They really did have to deal with the brunt of her behaviors.

We were all set to send her to that care facility on a Friday (where it was less expensive, it was closer to home, and they were much better at handling ICU delirium), when she had a little problem with her feeding tube. Friday turned into a weekend when she didn't get physical therapy (they don't work weekends in this hospital), which was also the weekend that a particularly dumb shit of a psychiatry resident was on call. In the five minutes he saw her he managed to ask her every offensive psych question possible (so where do you get treated for your psychosis when not here?) and write a note that I would have spit on as a first year medical student ("Patient is going through a lot of medical stuff"). That agitation gave her another round of delirium, setting her back another WEEK.

So Thursday, when her PEG tube clogged, I knew the LTACH wouldn't take her if that tube weren't working. I felt like if she didn't get out Friday she wouldn't get out. Probably dramatic, but I didn't know who was on call for Psychiatry that weekend. "You have to get this done." my attending said, meaning I had to browbeat the interventional radiology team into taking her. "Yeah, wear your ovaries on the outside today," the fellow added.

It took hours of pleading and phone calls, some of which were spent convincing a male tech down in the department that I was the patient's DOCTOR, not nurse, before I finally told them my attending was going to yell at me if I didn't get it done and I just didn't know what to do. The lady on the other end was silent, then asked who my attending was. "Sampson." I said. "Oh. He will probably yell at you. Let me call you back."

Long story short, her feeding tube was fixed, and she went out. I have no idea if that will be the last time I see her, but I do know that she and her family were the first people I really felt like I made a difference for. In a month where most things are out of my control, I actually felt like a doctor.

You can't make this S#$% up.

2010-07-31T09:39:00.000-07:00

I don't even know where to start with this next patient.

First of all, he was never supposed to end up in my ICU. He had end-stage scleroderma that had hardened and was failing every organ system in his body. He didn't want to be intubated, but when he dropped a lung during an endoscopy to investigate a bleeding Peg tube (dysphagia had robbed him of the ability to eat on his own by this point), his wife said to "do everything you have to! Yes I want him intubated!"

I had heard that he didn't actually want it, but we didn't have any legal papers and he was completely unable to make legal decisions, or even say previously made ones out loud for that matter. Those kinds of decisions aren't ones we just take on good faith, "Oh, his cousin Cooter said he told him he was ready to die a few weeks ago over some beers? Welp, that settles it for me, let's make him DNR folks!" You can't exactly take it back.

Anyway. He got intubated. What's funny is, when you learn to intubate, you learn on dummies. Stiff dummies. And non-alive ones, in case a few of you smart-asses thought we practiced on the slow learners. It's very hard to recreate human skin, at least on a level that you'd be able to pay for. The guys at MythBusters seem to get ahold of good stuff. When you get to real people they are very much more pliable. Except this guy. Put the blade in his throat and instead of lifting his jaw you lift his whole dang body. Needless to say, it was neither an easy or enjoyable intubation, and required us calling Anesthesia for backup. Unfortunately, during the intubation, he aspirated a frick-ton of gut chunks. Sorry. It was gross for me too. There was really no way to prevent it, he was a very difficult emergency intubation. But it gave him a nasty case of aspiration pneumonitis and pneumonia (one's a chemical burn, one's an infection).

Fast forward one miserable week later, and this guy doesn't look like he's ever going to come off intubation. Not that it makes him reasonable. At first he was heavily sedated, but for a few days he perked up enough to spell "Eucerin cream scrotum" to let the nurses know....well, I pretended I didn't know what Eucerin was to make sure they'd take care of it. Not. My. Job.

The problem with this patient was he had nowhere to go. Every organ system he had was crapping out. And now he had a pacemaker and was on a vent and had a feeding tube, and the way his kidneys were working he'd probably need dialysis eventually. In short, the words "long-term" weren't anything we used with the family because there was no other intervention to do for him. He was just waiting for an infection to get him. Meanwhile he wouldn't be able to get off the ventilator for any kind of meaningful time period. It wasn't a bridge to improved health. It was a last resort to keep his body working. In my opinion, it probably shouldn't have been used, and that apparently was his opinion too. But when push came to shove his wife didn't want to let him go. So he laid in our ICU suffering.

That brings me to the meat of my story: the craziest s#$ goes down in hospitals. The lady I thought was his wife? Not actually his wife, but his live-in-ish girlfriend of 27 years. He'd never wanted to marry her, his family told me. Repeatedly.

I had noticed something was weird with the family a few days into the saga. For one thing, there were tons of them. For another, several family members, especially adult women, got thisclose to his face, repeatedly asking questions and trying to get him to write on a little clipboard. They were so close to his face I thougt they were sharing an endotracheal tube. They just hovered constantly. His "wife"/girlfriend/Creepy McCreeperson was especially attentive, fawning over him, fussing over him, accidentally unhooking monitor wires and IV's as she repositioned him. I actually walked in on her putting makeup on his face one day because, "he doesn't like his spots (vitiligo) to show." "Something is just off" I told my co-intern.

One thing that was indisputable was that every morning I'd look at his vitals and they would be perfect. They were something I could take to my attending and show how I had his BP and heart rate under control. Then by 11:00 nurses would be running to find me and tell me his BP was in the 190's and what was I going to do about it?!?!

I tell you what I did about it. I kicked everyone out of his room. It took some huevos, but after I realized I actually had the authority to do it (still can't remember I'm an for real doctor now), I walked into the room, re-introduced myself emphasizing the doctor part, and said, "I know you all want to be with him now, but my job is his vital signs. And they're going to Hell in an emesis basin." LOL I said the last part more like, "All the extra company and crowding in the room seems to agitate him. His blood pressure is up 30 points from when I first see him in the morning. I can't have this for my patient. We have a 2-visitor policy and we're sticking to it." The women clucked and agreed and kissed his hands 30 more times before I realized that they weren't leaving until I said "NOW." Which I actually did as I physically ushered them out. Later his daughter said, "They would not leave him alone! When you came in there and said you weren't having it in your ICU I was like "Oh good, she's MAD now!"

Things got weirder at night. I started making it a habit to go by the cafeteria and pick up my second breakfast (one to get me out the door, one to keep me from jumping out the window) and sit down to read the night nurses notes. One morning I just about spit out my oatmeal when I read the "wife" and her sister (who I didn't actually know was her sister, but whatever) came out of the patient's room and told the nurse that Terrence had asked her to marry him. Huh? The man is on a VENTILATOR. Have you ever tried to propose with a tube down your throat? Oh, he wrote it out they said. "Note showed to nursing staff did not seem to match patient's handwriting," the nurses' documentation read.

I thought it would be dropped, but nope nope nope. By now we were starting to talk extubation and "comfort care only". Things got a little more urgent. The patient also had a plastic sheet with the alphabet on it, thought being you could spell out simple words, not make life decisions or write legal documents. Wouldn't you know, the patient "spelled out "will you marry me?" on his tablet!" the girlfriend insisted.

The macrabre spectacle started becoming a part of our patient care. "Don't let patient get married." was in my checkout sheet to the night resident. "Wha..?" "I'm serious. Crazy things happen here at night. Don't let that be one of them." She brought in a chaplain one night (I was starting to wonder if the fact that I repeatedly put the kibosh on proposal-writing and man-hounding during the day is what made this a nightly occurance) and had to be told for the 10th time that we did not believe the patient was capable of making complex decisions. No, not just because of the ventilator. The powerful narcotics were also something to consider.

As she grew more insistent, so did we. I started to document in my notes that I specifically did not believe he was capable of making legal decisions. It's not something I said lightly, seeing as he knew he was dying and if he did know what he was saying I'd hate for him to not get the chance to cut that mean-looking sister out of his will. But I also saw myself getting lead down a road to one of those fake weddings you see in a movie where the heroine is bound and gagged and the deaf old minister says, ""LemmegoIdon'twantthissssshhhh? Was that a yes? Ok, very well, I now pronounce you..."

Each night she'd insist they were getting married the next day. I started hearing things like, "she told the nurse something about her name not being on their stuff. He has a car and a camp trailer I think." God knows he couldn't have had much else. The patient's mom told the medical student not to let them get married because she gave him crabs in the 1990's. She started asking what kind of doctor can declare a person legally competent to get married. One time, after clearing the room, it was just me and the medical student with him. "Ok Terrence. It's just you and me. Tell me, do you want to get married?" I asked. "I...want...to...breathe...." he said. "Well, I don't know if that's a metaphor, but I'll check your vent settings and try to keep you single." I replied.

One of his sisters came in with papers folded up in her back pocket that I saw her waving under his face with a pencil. His nurse told me they were papers she wanted him to sign leaving her that damn camper and car. "He promised me this stuff a long time ago" she said. "OUT." I said.

His adult children, who I now realized were the only sane ones in the bunch, told me the patient's sisters and brothers were in the waiting room dividing up his stuff. The daughter was in tears over how her family was cracking and spilling their greedy craziness all over what should have been their time to say goodbye to their dad. This is the daughter that thanked me for kicking everyone out. At the time I honestly didn't know if they'd listen or gang up on me, but I guess it's what she was waiting for so she'd get some alone time with her dad.

We got the Palliative Care team involved. They specialize in helping patients and families make tough decisions and transitions. Their attending asked me to PLEASE make sure I was documenting the patient's condition. But the woman wouldn't leave it alone.

The weird thing was, to look at her, she looked like a sweet middle-aged school teacher with little glasses and curly hair pulled back in a low ponytail. If I only saw her during the day, I would have thought it was sweet. But every other piece of evidence pointed to batshit crazy. Why would you stick with a man for 27 years who, when asked if he wanted to marry you, would have actually answered "Over my dead body" and meant it?

On the day we were going to extubate him, she showed up in all in white. Down to her new tennis shoes. "Craaaappp. This is going to be a fight." I thought. She had already bought herself an engagement ring. She had her chaplain. "I just know Terrence's last wish was to get married," she said. The Palliative attending and I got him alone again. "Do you want to get married today?" She asked. "Msmdhhmimme". He said. "Well I don't know if that was a yes or a no. Do you want to get married?" "It's time." He said. Hmm...again not really a yes or no answer. We tried again. "Yes or no, do you want to get married?" He nodded. "I'll be damned." I thought. "It's time." he said. "Romantic," I thought.

After a little ingenuity, the Palliative Care doc came up with the idea of a "spiritual wedding." One where we very clearly stated the patient would not be signing any legal document or marriage license, but if it meant a lot to the woman, they could have a marriage ceremony in the room. I thought it was freaking brilliant, but after the PC attending said of all the weddings she's held in the ICU (really?) this was the only one that made her want to throw up.

So after the patient talked to the kids and they felt satisifed that he really meant it, a "spiritual wedding" was held. It was bizzare, but it shut the lady up. "Huh, maybe all she wanted was to be married in Jesus' eyes after all," I thought.

What a dope. That night his mother called and said that Abigail had told her she and Terrence were married, they signed papers, and it was all legal.

He died the next day while Abigail was reading to him from Psalms. His kids cried and prayed over him for an hour. His sisters and brothers didn't show up. As for me, I won't be surprised if my documentation doesn't earn me a subpeona when this fight over his trailer goes to probate court.

Emotions take time...

2010-07-18T18:20:00.000-07:00

And I don't have it. I've started two more blog posts, but just don't have the emotional capacity or the hour of consciousness it take to finish them. So I'll pacify you with a little story.

I declared my first death the other day. Lucky for me I had a.) Expected it and b.)Not caused it. The senior residents gave us a little booklet with various how-to's they don't have time to teach you in medical school, such as how to declare a death, so when the nurse asked me to pronounce it I trudged to the room, thumbing through the booklet.

Step one is introduce yourself. These people knew me, because before it was imminent (to me) that the man was going to die, I'd kicked the majority of them out of the ICU for hovering around him asking him which of his possessions they could have. I didn't care who got his boat, I cared that his blood pressure spiked 70 points when they were in the room. How do you ask a man on a ventilator to sign a will? ("because he promised me these things before he was on a ventilator" was the answer)

Next up explain that you have to do a physical, see if they want to leave (they still didn't), and then spend an awkward five minutes assuring the person is dead without upsetting the family. How would YOU make sure a person is dead? No, really dead, not just "Oh, I think he's dead but we should call the authorities." You ARE the authority, and if you say he's dead and he isn't, well, I don't want that skeleton in my closet.

Suffice to say, I check his wrist like I'm feeling for a pulse and squeeze the bejeezus out of a fingernail.

You also have to do things like check the wristband to make sure it's the right patient (wonder what happened to get that rule put in place), say his name out loud, listen for heart sounds for FIVE WHOLE MINUTES, which quite frankly is five whole minutes longer than I care to spend in the company of the deceased, and check for pulses in several places.

There are a few things the guide did not mention.

After I'd done each of the steps, I have to admit I was afraid that being freaked out by touching a corpse so repeatedly for the first time since anatomy had made me possibly miss a heartbeat or pulse. I didn't want to just phone this one in, so for good measure, med student by my side, I put my fingers where his radial pulse should have been one more time.

That's when his arm jerked.

Just poop yourself? Because I practically jumped out of my white coat when it happened. I actually physically jumped back and flung my arm up. The slow-reflexed medical student was still frozen beside me when it dawned on us. "I think that's his pacemaker," his spiritual wife (another story) said. Thank God Thank GOD she was focused so much on his body when he jerked she didn't see me swallow my tongue.

So, moral of the story, if someone is going to die, FOR THE LOVE OF GOD CALL MEDTRONIC AND HAVE THEM TURN OFF HIS PACEMAKER! If I didn't know the patient well enough to remember he had it, I may have tried to shoot him in the head.

I hope you all know that's how you kill zombies.

And today was his birthday

2010-07-07T18:37:00.000-07:00

We had husbands crying all around the ICU today.

I wish I could find humor in it, but today was so stinking sad that I just can't. Today wasn't about finding humor in life, it was about making hard decisions and offering comfort.

One patient has been in the hospital for months. Before that she lost her legs in previous hospitalization, and before that she was a marathon runner. She's in her late 50's, and I don't need magic glasses to see what she was like, I can just look at her daughter who can barely stand to come by the hospital now.

I have been taking care of her for a week, and every morning I'd go in to see her, and every morning she wouldn't respond. She might open her eyes, she might even follow me around, but she didn't answer questions or even reveal any understanding of what I was saying to her. Her skin is puffy and weeping from edema, her face is encircled and squished by the ventilator straps (yes, you can be conscious and on a ventilator-I was not really aware of that). I couldn't tell if she were in pain or not. As a doctor that seemed like the one thing I could really do for her, but I was really just standing there by her bed stupidly repeating the same questions and wondering if she was screaming at me inside her head. Her husband was broken up over this change in his wife. In a lot of people's minds, you're either going to get better or you die. Three months in and we didn't know. That's very hard to understand.

This morning she nodded. She nodded! "Are you in pain?" I asked. She shook her head. "Are you having trouble breathing?" She shook her head. Can you nod your head for me? She nodded. I was elated. I bounced around telling the nurses and other residents that Peggy had cleared up and answered questions for me. This is what I'd been waiting for! We could extubate her! She would breath on her own and then slowly but surely get better and then go home to her sweet husband who brought bags of chocolate for all the nurses!

Then her CT scan came back. She had both persistent and new areas of abscess in her pancreas. You can't get rid of abscesses with antibiotics. You have to drain them or cut them out. Interventional radiology could reposition or replace the drain, but the attendings knew from their previous visits with her that every other time her drain had been repositioned or replaced, she went septic, getting sicker and taking longer to recover each time.

We had a family meeting with her husband today. He was alone in the room with her, dapper in a cowboy hat and boots with a yellow button down shirt. We explained the CT and what it meant, and asked him what he wanted to do.

He said, "She was fine until all this started. Then she got sick the first time. Then it killed her when she lost her legs (during her septic shock her legs infarcted from too little blood, becoming gangrenous) but she said she wanted to be fitted for her prosthetics. Now each time she goes down she comes back worse. She looks like a corpse. It's tearing the kids up to see her. I don't know if I can get my wife back. I know her face; I know the furrow in her brow. I can't see her in agony all the time like this." At this point her nurse started to cry. It took everything I had not to let the tears leave my own eyes. We asked her what she wanted, but she couldn't talk and couldn't answer complex questions. You could tell she recognized her husband. When we asked if she knew what she wanted she didn't answer. When we asked if she was scared her eyes grew big and a tear dropped down her face.

He asked the attending point blank what he would do. The attending thought and said that if it were his mother, he would consider how it would take months of everything going perfectly to get her to her best possible level. And that we didn't even know if that level was going to be where Peggy would want to live at.

In the end the husband decided to pull her ventilator. She is breathing on her own, and we are still giving her antibiotics, but it's only a matter of time before she gets septic again.

Today was her husbands birthday. I hope she makes it a few more days so he doesn't have to remember every birthday like this.

I don't know how the nurses can handle it. They are with these patients for months, get their hopes up, and then sit with the families when there isn't hope left. One nurse drove two hours home to see her parents after a patient suddenly died this week. I made sure to hug my own sweet husband extra tight when I got home today.

I wish

2010-07-07T03:18:00.000-07:00

I wish I had a pair of magic glasses. That way I'd see child hugging his mother, instead of an elderly man leaning over a shell. That way I'd see a little boy holding his mother's hand, instead of a stubborn old fool trying to keep a corpse alive. That way I'd see how they used to play together instead of how he tries to manipulate the system for her. I'd understand how he didn't want to leave her the first day of school, then maybe I'd see why he's willing to put tubes and lines in her 90 year-old body so she won't leave him now. To him it doesn't seem to matter that her memories are gone, her consciousness addeled, her speech stopped. As long as her heart doesn't stop beating he still has a mother.

I hope I remember that when we pull her ventilator tube today. Because right now I feel relief for her and pity for him.

Tomorrow, Life Is Over...

2010-06-30T20:10:00.000-07:00

Or it begins. I suppose that's how I should look at it.

A short list of things I know or assume:

1. I'm telling myself someone will die tomorrow. I start in the ICU; it's a fair guess and maybe this way I won't freak out if it happens.

2. I'll probably feel like I'm drowning all day.

3. I'm pretty sure I'll see someone's ass. That's just the way it happens.

4. It's cruel that the department didn't think to give me access to patient charts until MIDNIGHT tonight....meaning I'll have to go in around 6 (or earlier depending on when I wake up) to get started.

5. Thank God I get to wear scrubs. I don't intend to look good this entire month.

6. I have a long coat!!! Finally, after years of that dorky short coat that made the word "Eager" come to mind whenever I saw someone wearing it. And I hate the word "Eager".

7. Even after a tour I STILL don't know where I'm supposed to go tomorrow.

8. I think I'm going to throw up.

Another One Bites the Dust

2010-06-24T05:33:00.000-07:00

I'm about to start residency. It is a mix of joy and nausea to be honest. Nice that I can finally answer the phone with "This is Doctor...." when telemarketers call ("I'm sorry, I can't talk about new siding, I need to go back to SAVE SOMEONE'S LIFE! ). Really nice that I'll finally FINALLY get paid. As one of my friends said, "It's your first real paycheck of your whole life!" I'm 26 years old. How sad is that?

I start out in the ICU however. I'm mentally preparing myself for the idea that someone's going to die every day. Then when it happens, maybe I'll remember that they were in the ICU because they were very sick, and 30 years ago they probably wouldn't have made it anyway.

Of course, if any of you are my patient, you should know that's not a treatment goal, that's a consolation so I don't go crazy when people smoke their last cigar on my watch.

I have to brush up on ACLS. It's the algorithm and protocol you follow when running a Code Blue. It involved drugs and electricity. On the surface, it is awesome. In practice, I should probably avoid caffeine and/or wear a diaper. Btw, some things that I find hilarious:

I kid you not, I am authorized to shoot you with this.

1. The advice old hands give to interns regarding Code Blue: "If they're in Code Blue, they're already dead anyway. All you can do is help; you certainly can't kill them twice."

(btw, far fewer people survive Code Blue than Grey's Anatomy let's on. It's not a 2-for-3 thing, it's more like a 1-in-4 thing. And even then they ain't always right. Could YOU go 30 minutes without a heartbeat or proper blood flow to your brain without being a little "off" when you came back? It's rare.)

"If this were Grey's, I'd be using my tongue."

2. Chest compressions are one hell of a workout. Especially triceps. And again, what you saw on that episode of Saved By the Bell where Zach and Slater do CPR on a homeless man that happens to be the father of Zach's new (also homeless) love interest who only eats apples for lunch is crap-ola. You don't just shrug your shoulders up and down while your hands happen to be on someone's sternum. It's as if Death himself were stuck under that ribcage and your hands are the only thing than can unlodge him.

3. In order to help the people doing the compressions to keep a correctly timed rhythm (ie a regular heart rate), there is a song you're told to sing in your head: Stayin' Alive by the BeeGees.

"Aren't we worth coming back for?"

4. Unfortunately, there is another song with the same rhythm: Another One Bites the Dust.

"Give it up and you could look like thissss YEAHHHHH!!!!"

Did you say, "Caulk Gun?"

2010-06-17T13:57:00.000-07:00

More adventures at Home Depot.

I needed to buy caulk and a gun to seal our screened-in porch so I of course went down the street to HD. The very friendly hippie behind the paint counter showed me to the section, and then helped me pick out caulk and a gun.

"It doesn't really matter which one you pick. They're all pretty much the same," he said. "You have no idea", I thought, as I picked up one resembled the Crap-o-matic we had to use last year for defecography. "Just write 'Surgical Grade' on the label and you got yourself...well, disgusted is what you got yourself."

He went on to describe how to use it, and as he mock squeezed the trigger I couldn't help but flashback to the poor lady who was up in the air with a bowel full of putty just as the x-ray camera went on the fritz.

"Oh, I know how to use it." Then my face turned very red and I snort/laughed while simultaneously trying to decide if I further explain why I knew it. I decided that it was a little too much for a Sunday evening, thanked him, and walked away with a huge grin on my face hoping he didn't think I was laughing at him.

Unfortunately, though I thought I knew what I was doing, caulking a seal requires a lot more finesse than caulking a...wow. And there's the line.

All Bats Have Rabies.

2010-06-14T07:31:00.000-07:00

I am a new homeowner.

It's pretty great, actually, especially considering that I've moved 12 times in the past 9 years. I no longer qualify as "transient/homeless" at free clinics (good thing since I'm the doctor), and I think for the first time in my life my checks, driver's license, billing and mailing address will all be the same...and current. Also, my parents took the opportunity to get rid of all evidence that I once lived in their house. If anybody wants a Ginger Spice barbie doll (New in the package!) or a collection of floppy disks, let me know.

Of course there are downsides to being a new homeowner. Well, let me put it this way. There are downsides, especially if the homeowners are a doctor and an engineer. One is a "can't see anything but the repairs necessary to make the house the most efficient structurally sound environmentally healthy protected against any future wear or problems "Preventative Maintenance" is my middle name" kinda guy, and the other is a "Maybe you need protective eyewear for this and full coveralls for that don't cut yourself and I will absolutely not go into the attic because it probably has bats and all bats have rabies" kinda gal.

There are many reasons I believe medical school has scarred me, but when it comes to bats, I am absolutely certain it has. Our house is old. It has a comical amount of insulation. We would save at least half the cost of insulation if we put it in ourselves, but I will not WILL NOT go into that attic.

During the first year of medical school the Infectious Disease docs get an open mic during a series of lectures on viruses, bacteria, and general pathogens. They use it to scare the bejeezus out of us. For one thing, I don't know if I've mentioned it before, but something is wrong with those ID folks. I don't suppose I could volunteer in an STD clinic every Tuesday night without coming out a little "off" either. One of them has made it his mission to mention the how the HPV test should be used on men as well, the punchline being "I'd call it a "Crap smear!" He then pauses for effect and looks at the students to make sure they aren't total idiots and understand his humor. After that he goes and takes a smoke break.

Another colleague gave a speech at our senior banquet last month. He took the opportunity to get buzzed and click through a powerpoint presentation made up entirely of drunken facebook pictures he'd apparently found by befriending the one person who takes all the stupid pictures in our class. While providing a running commentary ("Hello ladies!"). My husband, who I don't think really understood me when I'd tried to explain these people before, alternately laughed his ass off and asked me, "What does this guy do again?"

Anyway, I digress.

I don't remember which one it was, but one doc gave a speech on viruses that included the rabies virus. I still remember him saying "All bats have rabies," probably because he repeated it OVER AND OVER and finished the lecture (which had moved beyond the rabies virus) by repeating, "Get checked for STD's, and all bats have rabies." There might have even been audience participation: "What do all bats have?" "Rabies." "What do you do if someone has been in close proximity with a bat?" "Treat them like they have rabies."

In case you aren't familiar with the details of rabies, it travels up your nerves until it gets to your spinal cord, after which it travels everywhere your CNS goes. So everywhere. It then makes you bat-shit crazy and afraid of water. You are delirious and in pain. And then you die. The treatment is to get shot, but you have to have it before the virus reaches your spinal cord. If you get bitten on the toe you have a little longer than if you get bitten on the neck. Once you have symptoms, it is almost always fatal. 3 people survived in the 1970's, and one 15 year-old has "partially recovered" (their words, not mine) from a case in 2004.

These guys generally work at the Veteran's Hospital. They actually tell a story about an old veteran who DIED of rabies after being bitten by his "pet" bat. His family did not bring him to the hospital immediately because it was his "pet" bat.

I hope by now you understand why I asked my friends at Home Depot if they sell bat-proof coveralls. And I call them friends because by now the guys in Paint recognize my voice on the phone. As I explained to anybody willing to listen, I am not necessarily afraid of bats. I am afraid of the rabies virus. With good reason!

"I repeat, we are ready to move in; let's insulate this attic!"

Point being, I'm taking bids to insulate that attic.

Another thing you should know: Raccoons actually have the highest incidence of rabies. Yet another reason to hate those rat/bear trash-eaters.

And How Many Drugs Have You Taken Today?

2010-06-06T07:51:00.000-07:00

I try to leave work at work when I can. Though I fail miserably in inopportune places (I'm pretty sure I haven't gone an entire family dinner without saying something disgusting in 4 years), I don't go around shopping malls diagnosing people under my breath, "Parkinson's. Neurofibromatosis. Chronic alcoholic. Teenager."

Unfortunately, when I turn off my medical mind, I generally revert to the naive small-town idiot I am. Whereas in the hospital or office I don't trust anything, if someone I meet in a coffee shop tells me he's the prince of Nigeria, I won't give him any money, but I will probably go home and tell my husband about the nice man I met. This baffles him. "Al, our kid could smoke pot in the room next to you and you'd have no idea." How can you play "name that drug" in the hospital and not be able to smell the weed in a snowboard shop?

I do not know. Apparently it's an all or nothing switch. If I turn it on, I'll know that the shifty-eyed loon in the corner is on PCP, but I'll also tell the donut shop lady to have that mole on her neck checked out. Which, unless you then follow up by saying "I'm a doctor" (which will either make you look like a pompous ass or the Prince of Nigeria) is not socially acceptable. I'm finding out.

When I was on Family Medicine this April, we got some strange ducks. It was in an older low-income part of town, so even the attendings saw a lot of new faces (as opposed to the usual way clinics in teaching hospitals run, with the residents getting the patients with lackluster follow-up and the attendings having a relatively cush patient roster). I was always sent in first to scope out the situation and listen to the wandering complaint list. My job was to find 3 specific things the patient wanted out of that clinic visit.

One time I had a patient who looked like Diana Ross. Just as the 80's would have left her. I actually thought maybe I had found a rip in the universe and had time traveled back to the 80's by walking through the door. She had enormous hair, false eyelashes, gold eyeshadow, and a spandex/sequin outfit that would have made Freddie Mercury cry with Jealousy. Her eyes bugged out of her head. Not in a thyroid-problem way (I checked anyway), but like someone kept simultaneously pinching her and yelling "BOO". She would gaze off in the distance, but every once in a while decide to pay attention and freak out. Even once the attending got in there, anything we said what greeted with a "WHAT?" and that spooked expression. I couldn't figure out what drug she was on, or if she was mentally ill. I guess she had paranoia with a severe case of disco fever.

I don't know how else to describe it. Imagine if you had a Solid Gold dancer in your examining room and every time you said something as innoculous as, "sinus drainage" she acted like you'd just told her disco had been murdered. She was just bizzare.

I think if I'd seen her on the street, I would know something was not right. That's pretty hard to ignore.
"What do you mean, colonoscopy!?"

A small story

2010-04-30T20:42:00.000-07:00

One poor guy was sent in with his three kids for well child checks while Mom went to work. I actually don't think they were all his kids. I don't know if any were his kids. I asked if he was Dad and his reply was, "Yeah. Well, stepdad. Or something...yeah" I would have been like, "Hey you perv, why are you here with these kids, diligently checking on their health?" but he produced a document signed by the mom in the kids medical records (all the kids had different last names, but their first names started with the same letter. That's how I knew they were related.) that read, "To whom it may concern, I authorize my boyfriend, Mr. Nice Guy Doormat, to bring my children in for medical care and authorize shots."

Three kids under 5 with one "Dad" to corral them is a lot. He actually did pretty well, he was really attentive and knew where they all were at one time! In seriousness, he really did stay on top of their behavior. When the little guy (I think about 3) started to act up and try to escape, the man asked him to come back. Undeterred, little man kept trying to escape. "Excuse me, last time I checked my name is "Daddy." I don't think the kid quite understood what was happening. He replied, "Well my name is Junior!"

There really is nowhere to go from there. The kid was right. I've tried that in my home life now, but since I'm no longer an adorable three year old and my name actually isn't Junior, it hasn't had the same effect.

Fair enough.

2010-04-22T18:45:00.000-07:00

Two days ago I was getting my morning coffee from the clinic cafe and thought "I don't really need this. I should just stop drinking coffee." Then I looked down and realized in my morning fog I'd just put iced tea into my coffee cup. "Fair enough," I thought.

Later that day a 16 year old came in to get rechecked for a surprise chlamydia attack (she had no symptoms, the clinic just has a policy to screen all teens and early 20 somethings during their annual exam). "Did you tell your boyfriend about the chlamydia?" I asked. "Oh he's NOT my boyfriend anymore." "Ok...Did you tell that jerk who gave you chlamydia that he needs antibiotics?" "Yeah I did that." "Have you had any new partners since then?" "No no no, I'm kind of afraid to have sex now." Fair enough.

How do you answer that?

Ok, really, you keep your preachin' to yourself and say something like, "The only sure way to prevent STD's is total abstinence, but condoms are also a fairly effective method. If you do choose to have sex again, definitely use a condom." And a ten-foot pole. And another form of birth control. And maybe go talk to the other 16-year old I just saw with a baby. As I told my little sister when giving her one of my awesomely informative "Life Talks", you should always use a belt and suspenders unless you want to be caught with your pants down.

I'm no lady, I'm a doctor.

2010-04-14T19:01:00.001-07:00

Sometimes when we have gentlemen patients over a certain age, they get embarrassed in front of the "lady doctor" and don't want to talk about what's bothering them. Usually they get over it pretty quickly.

We had a string of those patients today. One wanted to talk about sexual problems, another needed a digital rectal exam (not by me, I'm going into radiology!) another had absolutely enormous testicles. Which had not previously been enormous. Oh wait, excuse me, he said they'd always been big, just not the size of softballs.

Obviously, they get over their shyness.

I remember riding in the car one day and my sister (or was it cousin?) going, "Hey Al, tell me a story about the balls you've seen." I would have been offended if I hadn't worked several summers at a nursing home in preparation for medical school.

Anyway, when the gentleman who probably had bilateral hernias saw that the attending was also female, he said to the (male) resident, "I don't know why you keep bringing in ladies. I don't really want to show this to any more ladies." "She's not a lady, she's a doctor," I said, before thinking about how that came across. Luckily the attending concurred. "Parts are parts, and I've seen them all," she reassured him before giving him the hernia what-for.

I'm trying to think of examples that would make my sister puke, but I can't even come up with any right now. I think they have a shelf life of about 5 hours in my brain, less than that if I happen to have had a margarita at dinner.

Seen it.

Point being, you may think you have something weird going on, but most likely we have seen weirder. And we really don't care or even notice so much, unless it's testicles the size of basketballs. Then we just feel terrible for you because you seem like a nice man and it's not fair to add insult to old age. Or if you have legs hairier than a yeti up in the stirrups. I don't mean you didn't find time to shave in the last week or five. I mean if it's so bad we think ALF decided it was time for his annual, that is something we will notice. Or old man toenails. Yeech.

Oh that was gross. I am no lady.

Can I keep him?

2010-04-12T19:08:00.000-07:00

I started the clinic part of my rotation today. I'm at the hospital an hour and a half later than when I had to start for inpatient. It's quite awesome.

A few highlights of the day:

Cutting a sebaceous cyst (a sweat gland that has lost its connection to the surface of the skin--so imagine one sweat gland saving all it's output for two years) out of a lady's back. "Yep, there's the locker room smell," the doctor said as he squeezed thick yellow-green crud out of the incision. "I've been mouth-breathing for the last ten minutes, I can't smell anything," I replied. I do love a good excision.

We had a twenty year-old with a sprained ankle. I was in the room alone, doing a prelim exam, and decided to do a drawer test for stability. As I've mentioned before I am not good with grotesque jointsNot only did her ankle move way too far, it also popped grotesquely in my hands--I was not expecting it. I shot backwards across the room on my rolly-stool shrieking, "HhOOohhhhhHH I'm gonna throw up!" Then I took a few deep breaths with my head in my hands and we had a talk about what not to say when my attending came to the room.

Most of the patients just didn't show up, but the last patient who did was a mother with a history of abuse and neglect bringing in her latest victim for his one-year exam. The doctor I was with told me the woman had been hotlined several times for neglect, so I went in ready to think the worst. "Mean face," I thought immediately. Then I saw the baby. I expected to see Sally Struthers crouching behind the exam table. This kid wasn't the worst I've ever seen, but in my humble opinion he was one of the worst I've ever seen in person. I can't put my finger on exactly what was wrong, but overall he just looked shell-shocked and gaunt. His hair seemed too thin. His face looked sunken. He wasn't as active as the one year old we'd just seen in the previous visit. He didn't cling to his mom when we poked and prodded. And his eyes. His big brown eyes looked too big for his face and just stared at me. "I'll take you home baby," I thought to myself. "I know where to buy diapers. I have friends with kids this age--I could figure it out." I didn't actually say it out loud of course, with his mother being batshit crazy and all. But if she had offered, I think my husband would have been surprised when he came home tonight.

"You are getting very sleepy....Now take me home feed me sweet potatoes...."

It's hard enough to not want the well-cared for adorable kids. When you see babies and wonder what kind of life they have ahead of them, it stays with you long after they go home.

Do You Understand Why You're Here?

2010-04-11T17:57:00.001-07:00

During my first week on this rotation, I was reminded once again that our best medical opinion isn't worth a bowel movement if it doesn't work for the patient. It is so hard to accept that, especially when you think what you're telling the patient is going to save her life.

While I was on call the first week of this rotation I got a patient I knew was going to be interesting. For starters, we were told her name was something like "Gerthard". The nurse spelled it out. And then I noticed it said "Male" on the patient ID stickers in her chart (I don't think the nurse had referred to her as a "he" or "she", but I thought it was a lady patient). It wouldn't have been the first time I'd had a transsexual patient, but these are just things I'd like to know before I go make an ass out of myself in a patient's room.

When we walked in, I still wasn't sure. I said, "Gerthard?" "NO! My name is Gertrude! I don't know why my name tag says that!" Ok, question no. 1 answered. I wasn't about to come right out and ask about the other one, so I tried to observe. No clear answer. It could really go either way. The surgical history saved me--no one with a hysterectomy could be a male. And she was carrying quite a frou-frou purse.

Anyway, that is not the point of the story. The point is, she was one of those, "I haven't needed to go to the doctor in 30 years!" patients. When a patient says that, you might think, "Oh, they must be really healthy." No. Definitely no. I suppose the rare patient might be like that, but usually that phrase means: "I've been smoking and eating sugar-coated fried crapsticks for 30 years and didn't want to spend the money to have a doctor tell me to stop."

What brought her in today? "Well, I've just been having a little trouble catching my breath." Uh. Oh. This could be something easy or something like when my dad said he was "having a little trouble moving around" and ended up having bypass surgery three days later. Then she said, "I went to the clinic"--GOOD for her! She went to a clinic first in case it was something easy to fix!--"and they said my oxygen was really low so they sent me here."

Not only were her O2 sats in the 80s resting (should be around 95-100), I heard an honest-to-God S3 when I listened to her chest. Medical students get very excited about this because it's something we have to memorize out of a book but spend half of third year not understanding what we're hearing when we listen to a heart. Instead of the usual "lub-DUB" heartbeat with lub being S1 and DUB being S2, hers sounded more like "lub-DUB-dub...lub-DUB-dub..." with the last "dub" being and S3 beat. It sounds like "Kentucky", vs a "Tennessee" "lub-lub-DUB....lub-lub-DUB". That's an S4. Neither S3 or S4 should be there, and if I were at a hospital with medical students, they would have announced that clear S3 over the intercom and lined up the short white coats and shiny stethoscopes outside her room to take turns listening for it.

S3 usually means heart failure, S4 makes you think it's a stiff left ventricle (usually due to years of high blood pressure). SOB + S3 and 2+ pitting edema in her legs probably equaled heart failure. She was a really heavy lady, so her chest x-ray was kinda crap, but it clearly showed fluid in her lungs.

The lady had a neck like a tree stump. She told us how she liked to play solitaire at her computer, but lately would just "fall asleep" sitting upright during a game. I assume she has obstructive sleep apnea due to that bullneck and the extra weight on her chest, but I don't know if she was falling asleep due to OSA or passing out due to too much CO2 in her system.

So we know she's a lifelong smoker. We know she's in heart failure. We pretty much know she has sleep apnea. Thanks to the multiple BP readings in the 170s/100s, we know she has high blood pressure. She had a remote history of "asthma" that she only used a rescue inhaler for--4 times a day. After I listened to her lungs I added COPD to that list. Do you have diabetes ma'am? "Oh, no." Yeah whatever. If you don't have diabetes I'll take my pants off and do a lap around the STD clinic's waiting room.

We put her on the standard regimen for heart failure and suspected COPD exacerbation, as well as HTN, and diabetes (yeah, her HgA1c was nearly 9%), and admitted her to the hospital.

The next day her arterial blood gas (usually we take blood out of the veins because it hurts like watching a 5'1 girl date a 6'5 guy (That's for you, Beth) showed a Co2 level twice what's normal, and it was rising from yesterday. The intern who admitted her and I were really worried about this lady. She was a nice woman who liked to talk about her grandkids and did not understand that she was literally dying. I think some people know their decisions will catch up to them (she frankly admitted she needed to quit smoking and that she was way overweight and ate too much), but they think it will happen "when they're older". She knew she should take care of herself, but was in denial that she could actually be in end-stage disease in her early 60's.

Our biggest battle came when we wanted her to wear a bi-pap machine. It would force her lungs to stay open as she exhaled, helping her to get rid of that trapped CO2. She was headed for respiratory failure. As her CO2 level rose, she was going to get stuporous, then comatose, and require intubation. Intubation on her was going to be ugly, and getting her off the ventilator would be just as hard for a patient with her problems. At least, that's the worst case scenario as we saw it.

The Bipap machine is attached to a mask that the patient has to wear. It's pretty loud, and some patients feel like they're trapped when they wear it. This lady flipped s#$ when the respiratory tech put it on her. She absolutely would not wear it.
The intern and I played good cop, bad cop (I was good cop because she was on her last week of a long month in inpatient medicine. She told the patient how serious her condition was in, how it could kill her, and how she if she could just wear that machine for two hours today it would help her. After the lady freaked out on the intern, I gave her an hour and went in.

I tried to understand where she was coming from. She had not been to a doctor in years, then she goes to one and a day later she has COPD, congestive heart failure, high blood pressure, diabetes, and sleep apnea. Each of those diseases could kill her. In our minds, she's had all these for a long time and needs the most aggressive treatment right now. In our mind it was clearly the best treatment and clearly necessary. In her mind, she was healthy until a few days ago. Now with the oxygen and Lasix (diuretic) she's gotten some fluid off her lungs and feels much better. So she doesn't really believe us when we say that even though her O2 level has improved, she's trapping so much CO2 she might crash at any time. What the heck does that even mean? Oxygen is the important one, not carbon dioxide!

She looked at me in tears, absolutely terrified of the machine. "Have you ever been so afraid of something you just couldn't do it?" I couldn't think of anything I would rather die than do (which is how I saw it even if she didn't) so I said so. "I just don't know what to do! You are sitting here telling me I'm dying and I feel fine!" She's probably been living at an O2 sat of 90% for years, so I bet she does feel like normal. You could hear the fear in her voice, she was nearly hysterical. I figured it was a good time to shut up and sat down on the bed by her and gave her a hug. After another day of refusal (we even tried Ativan, which just snowed her and still didn't convince her to wear the bipap) I decided to treat her as if she were dying. We had told her everything we knew. She could make the decision. If she'd rather die than wear the machine I couldn't hold her down and strap it to her face. It's her life and death.

I think that was harder for the intern to take, maybe because it was her admission and would be her M&M conference if the lady died after not getting the full gamut of available medical treatment. But I think it's an important distinction to make--our recommendations are not always going to be a patient's decision. If you get exasperated or offended by a patient's refusal, often you don't understand what exactly is behind it. I think I knew what was behind hers, and still didn't agree. However treating a patient as non-compliant vs. recognizing a patient's right to make medical decisions makes a huge difference in how everyone else down the chain of command acts toward the patient. If a doctor thinks a patient is an idiot and gripes about it to a nurse, how do you think the nurse will look at the patient when he or she goes in that room? If it's her last few days on Earth, I would like to think people were nice to her instead of angrily complaining about her.

In the end, she never wore the machine. She was moved to a unit that could intubate her, but did not end up needing it. She spent several more days in the hospital than she probably would have if she'd worn the machine. She will have a large hospital bill. She will have to have O2 at home. She will probably not live 10 years. But I'd like to think she came out of the hospital thinking that people cared about her instead of shoving invasive treatments she didn't want at her. I don't care if that's hokey. People want to be treated kindly more than just about anything. Sometimes that means not getting the latest treatment.

Crack Makes Baby Jesus Cry

2010-04-07T06:54:00.000-07:00

Pretty much every day we get a frequent flier back on our service. They're all new to me, but there is an exponential correlation between number of times the patient has been in the hospital and how loud the residents yell in the rounding room when they see the patient's name on the list.

We got a doozy today. Sometimes when I'm in the hospital I think, "If I tell people what really happens here, nobody will believe me." or "This is the strangest #$% I have never imagined."

This lady was apparently in because she'd done crack and had chest pain. Not that she admitted the crack part at first, but since that combo had brought her in every other time, and her urine drug screen was positive I feel comfortable in saying that was an accurate estimation of events. Last hospitalization? I think she got out just under two weeks ago. Pretty sure that this lady spends more time in the hospital than I do. Though I'm a matched fourth year, what the hell do I care?

Oh man I knew exactly which patient she was as I went walking through the ER. The one that looked like Don King. Hallucinating. (really, a lot of people in the ER look like one or the other, but both? Probably Crack Lady).

I couldn't understand what she was talking about at first, but I got the impression she was very excited about it. And it involved a suitcase. But as she calmed down and got up onto the hospital floor she started to tell us all about how ready she was to go to rehab and how she couldn't live like this anymore.

I will tell you something personal. When I was a little kid, a few of my best friends were assholes. To me. I never knew when or why they'd decide to be jerks, just that when they were done and were nice to me again, I never said, "No, you're a terrible person. Why don't you just march off to your future filled with Daddy-issues and ass-centric weight gain." I totally forgot about anything they'd done and took their word hook line and sinker that they would be nice for realsies this time. I don't know if it's my good heart or my ADD, but the point is I am still that person. If a person tells me a sob story and I sense genuine remorse (or maybe just hear what I want to I suppose), I forget about all the other times they told me they were "really done with smoking" or would "schedule a follow-up appointment for their meds".

Chief Resident wasn't having it. "When did you last smoke crack?" "Uh, a week ago." "You didn't smoke it yesterday? Or Sunday? Or Saturday?" "No, no. I haven't done that in over a week." "What did you do for Easter?"

--Another interjection--I know he asked that because a previous hospital visit was right around Christmas, and when the nurse asked her if she'd celebrated Christmas with crack, she said adamantly, "I'd never do crack on Baby Jesus' Birthday!"

Anyway, back to the story. "Why did you smoke crack?" Fair question. "Because I'm weak." Fair answer. "Where did you get it?" "Somebody brought it to me." "How did you pay for it?" Ah crap. This lady obviously doesn't have any money or job. I really hope she isn't prostituting or selling her meds for crack. "They gave it to me." Who the heck is running around the city giving out crack? "They just gave it to you? Why would someone give away drugs?" "People don't want to do it alone. Sometimes people get spooked." You learn something every day. Though I suppose I don't drink alone....

By the way, this patient made me understand why the Chief says every time he's on call, he tries to put up "Free Crack at Mercy" (another hospital in town) signs in the hospital parking lots.

"Oh my chest is starting to hurt."
"Quit moaning and hurry up, we gots to get to Mercy!"

Chief Resident treated her like she knew which end was up. He talked to her as if stern talking was what she needed to stop smoking crack. Then he left, frustrated because the work he'd done last time was for nothing and because this lady was in worse shape each time she came in. And who knows, maybe because she requires expensive medical care every time that of course she doesn't pay for. I wish I could say that the concern was purely for the patient's health. In a perfect world, it would be. I may whine and groan about these patients who abuse the system, but I really do believe that it's my job to treat each individual patient without bias or judgement. Even when they look like Don King on crazy juice.

Softer gentler resident took over after Chief walked out. He said to me "You can't let other people's biases affect how you think about a patient. If they keep coming back, something we're doing isn't working." I thought he was talking about compassion, but he said, "Oh no, this has nothing to do with that. I probably have the least compassion out of anyone. But if something's not working, we have to see if we're part of the problem." I didn't know what to say to that.

So SGR starts talking to her. She had of course done crack more recently than she'd fessed up to earlier, but she had been feeling bad for days before she came in. "Why did you wait so long to come in this time?" SGR asked. Her voice got quiet and she teared up when she said, "I was embarrassed to come back because I come so often." then "I don't want to be here, but I can't stop. I have to get out of where I live."

Sitting behind SGR, looking at her face I feel like I got punched. The way she talked (and her bug eyes) reminded me of my sister when she was a kid. Not that my sister did crack at 8 years old, more like that was probably where this woman's emotional maturity stopped. Being angry with her was like being angry with a child. And obviously, by releasing her from the hospital to the street was a terrible idea.

She hadn't been taking her medication as prescribe either. Why not? "I can't remember to take 2 pills at one hour and 3 pills at the other. I have 13 pills. When one runs out, they don't all run out so I got to wait so I can get them all together at the drugstore. I tried to take the three that the doctor told me were really important last time."

I'll be damned. Chief had angrily talked about how he'd gone over all her meds, stressing the important ones, and how it was wasted on her. But it really wasn't. She actually remembered and tried. Maybe she wasn't so non-compliant after all.

She had a good point about the pharmacy too. Chief had told SGR that he would have to personally call her pharmacy and repeat "Put all meds on the same refill schedule" in a variety of volumes and tones until they agreed to do it. Otherwise the store would refill each a few days apart, which for a lady with poor memory dependent on public transportation and angel dust to get her from place to place was really a hassle.

And why was she sent home? I guess she insisted on it last time, but now that she's willing to go to treatment I sure hope there is a place to send her. She needs intensive inpatient rehab. And she needs it paid for. You can say all you want about paying other people's medical bills, but it's just the right thing to do. Even die-hard John Gault-ers have to admit you can't hold her to the "pull yourself up by your bootstraps" logic.

I asked her if she had any family. She shook her head no. The a few minutes later she said, "I have a daughter, but my Momma has custody of her."

There is a clear cause-and-effect to her problems that could be avoided if she just stayed off drugs. You get it, I get it, deep down maybe even she gets it. But we can't settle for just repeating that over and over. Maybe now that it's April, and the service isn't flooded with flu patients, we can take a better look at the repetitive assumptions we are making when handling her care plan.

That's it. Off my soapbox. For all my snark, truly sick needy patients like her just make me grateful for the easy road I've had in life.

Sign of a High IQ

2010-04-06T18:08:00.001-07:00

This morning in rounds one of the uppity attendings had a settle to score. I suspect it had to do with him sleeping through his alarm clock and completely missing 7am night shift checkout, then having to testify in court against one of the hospital's disgruntled (or more likely, dumb money-grubbing) former patients.

During one of the resident's patient presentations, the resident (who is prone to nervy spazzes) said something like "number of walled-off fluid collections in the abscess", for which he just as easily could have said "loculations". "Loculations." the attending said. "Well, they are fluid pockets but they are walled off from each other, " the resident replied. "Yes, that would be the definition of loculations," the attending insisted. The resident, now twitching, goes, "Yeah, loculations. That's what I said, wasn't it?" "No, you used 15 words instead of one." Ok, the attending had a point, we were all saying loculations in our heads, and that was probably why this resident's presentations always took twice as long as the other residents. I think the resident knew what a loculation was. Hmm...where did he go to med school...But then Dr. PressnBadger had to cross the line. "We're all doctors here. You can talk like a doctor. There have been studies about differences in IQ, and it's a sign of high IQ that you substitute one appropriate word for multiple words." "Well, mine's not very high," the resident mumbled into his lap. "No, no, you are intelligent. Now use the doctor words."

Meanwhile I'm at the end of the table, thinking that instead of saying, "Persistent attending who prefers to teach using methods last seen at the Inquisition" I could show my high IQ and just say "Jerk". But I didn't know the attending well enough to get away with saying that out loud so I just shuffled my papers until it didn't seem so hilarious. Honestly I can't think of any boss I'd know well enough to say that out loud. Herd dynamics are very important in the rounding room, and my nose is behind a lot of asses.

"If anyone so much as steps a toe out of this chain of command,
I will straight up choke you with my "Badass surgeon's only" scrub hat."

Yes, it's that bad.

2010-03-31T21:31:00.000-07:00

My schedule + personal items requiring a lot of attention=very short blog post.

Today, as it is early in the block and I am well-fed and rested, I actually talked to a nurse about showing compassion.

Picture it: Two patients in the ED. Both are going to be admitted. Both probably should have been at a clinic (but I can't go into ER misuse right now). Both probably contributed to their illness by ignorance/non-compliance.

There is one nurse to take care of those two patients. One stopped taking his medications b/c they "cost too much and weren't working". I'm not really sure why the other one was there except I'm sure it had something to do with his morbid obesity.

On a related note, why is it that when my hunger is at a fever pitch do I get a train wreck patient who is Obese with a capital "Oh."?

Patient #1 was one of those that answered "Well, yeah, I think I have that" to every question. And obviously had different ideas about how medical care worked. Patient #2 was just obnoxious. Now, I might have mentioned before that I don't care to be whistled at, hooted at, or called "NURSE". This guy did all three to me because his actual nurse (who was wearing pink scrubs compared to my professional dress) was too busy taking care of a stroke patient to attend to all 650 lbs of need.

Nurse Bitterface had had it up to her angry forehead lines by then. She started making under-the-breath comments that so loud she had to be a. deaf or b. close to retirement. When patient #1's family accidentally used the word "thyroid" instead of "fibroid" (totally wrong part of the body), she rudely corrected them, saying, "You said thyroid! That's wrong! It's a totally different thing!" I could hear patient #1's family member say, "You're right, I'm sorry. I messed up the words again," with clear embarrassment in her voice. I know it was a difficult patient, and I know that nurse is probably tired of dealing with people who misuse the system. But I know deep down that the patient's family meant the best for her. And a good doctor or nurse will dig deep down enough to pull out some compassion. Besides, at that point it's not our jobs to judge (if at all possible. It's hard sometimes.)

Soooooo...how to approach that without making her feel like an asshole...

I decided to take a tactic from my usually very well-spoken husband. When she came back to the desk after harassing patient #2 (who quite frankly could stand to wait around a little bit. Maybe he'll learn the ER isn't a 4 star hotel) I said, "you have some tough cases today." "Sure do" she replied. "The hard part for me is making sure that I don't get so frustrated with one patient's rudeness that I punish another patient's ignorance. I know they mean well, they just don't seem to know any better," I offered. "Yeah, I think they really do want to take care of her, but why would you go off meds?" "I don't know," I said, "but I assume I won't know everything about a situation."

After that she at least toned her 'tude down with the patients a little. I would not want her job, but knowing I was coming home to my husband, who didn't deserve a bad attitude (yet), made me want to work a little harder at controlling my thoughts concerning difficult patients.

The Animal Continued.

2010-03-24T05:19:00.001-07:00

As we went along in anatomy, we worked our way from the neck down (you didn't do the head until you'd been properly desensitized). We did everything except for the leg. The embittered anatomy department had an ongoing feud with the Office of Medical Education. The OME thought traditional anatomy shouldn't take up so much of our time considering we didn't have any strictly anatomy questions on our boards. The anatomy department wasn't having it. In my first year, they got so mad they told the OME they just weren't going to teach us the lower limb. "They were just not given enough time." So we didn't learn the leg. Way to put the students over politics, anatomy department. Not that I expected you to particularly care about students who aren't going into your field and snicker when you insist on being called, "Dr."

For three years, any time an attending asked me an anatomy question about the nerves in the lower limb, I just said, "We didn't learn that." Kind of a cop-out considering I actually still had to learn it on my own.

I could tell you about the things you'd expect to hear in an anatomy blog, like how you had to squeeze all the stool into one spot in the colon, then tie it off above and below so you didn't get it all over yourself when you remove the colon. Ugh. I'd forgotten about that.

When it came time to do the pelvis, we'd join groups so we had one male and one female cadaver. Then we had to cut. Of course none of the guys wanted to cut one of their own, so I said, "scalpel please."

Yes, we found a penis pump or two. My favorite quote of the day was when we were on the female cadaver. As we were going down our checklist, we hit "clitoris." A male student working with my group leaned over and said quietly, "I don't actually know where the clitoris is." "I'm about to change your life" I said.

Monday I start my last real rotation. Internal Medicine. I expect to have many more stories.

The Animal, Part Two

2010-03-14T09:23:00.000-07:00

As promised, I have more to tell about anatomy lab. Ready?

I believe I left off after describing some unsavory realities of the actual lab. Now I'll talk about what we actually had to do in there.

I was not particularly looking forward to this. I had never seen a dead body before and I was about to see a bunch of them. They were all under sheets but it was an unmistakable form, one you see all the time in movies and TV but these were real and I was going to have to touch one. My group and I gathered around our cadaver, an elderly lady, and pulled back the sheet. The head of the cadaver is covered by a bag so you don't see the face at first. It helped a little. We had to flip her over because we were learning about the muscles of the back and the upper limb. In a word, awkward. I remember the moment I made my first cut so clearly. It was one of those "Take a deep breath and just do it" moments. "Now you're real medical students." the instructor boomed.

Once that was finished, so was the short list of things we knew how to do. As I mentioned last time, our "instructor" didn't really give us any clue about what we were doing in his pre-lab lecture. I assumed the long list of ridges and bumps he was rattling off were meant to point us in the general direction. So there we were, a bunch of mouth-breathers with scalpels, one group member reading from the dedicated anatomy and dissection book, trying to take apart skin and muscles we didn't know the names of.

The revered anatomist marched around the room, not really answering questions (or even being visible when you had one), but always managing to show up just as you cut too deep and ruined what you were looking for the whole time. "Ahhh you totally messed this up! You're going to have to walk around and find someone who didn't butcher their cadaver." "You just bluntly probe around until you--Ah well you already mutilated the ligament." "Jeez, don't you people know how to do this?" I think his one pleasure in life was to walk around observing all of us who hadn't and couldn't dissect a cadaver as well as he could (after his many lonely years in the lab) and make sure we knew it. It was almost as if none of us scrubs were worthy of his knowledge.

We were specifically lectured on what not to do in the lab--for example, move a cadaver's mouth to "make it talk" or generally disrespect the cadaver in any way other than cutting it's flesh of its bones, gutting it, and sawing off limbs as the instructor saw fit. He, however, had the bizarre habit of, when he got around to teaching, coming over to your table, leaning an arm on the cadaver's shrouded face (and we're talking leaning on it), and referring to it (the cadaver) as "The Animal". As in "The Animal's trapezius should be dissected away to reveal the small muscles of the upper back." or "The Animal's heart has been surrounded by blood trapped in the pericardial sac." or "The Animal needs to be flipped over now to allow access to its thorax."

That never failed to bother me.

"Who you calling an animal?"

On that note, I will leave again. More to come; this is turning out to be a series!

The Animal

2010-03-12T17:06:00.000-08:00

Since I'm once again on vacation (I DO love fourth year), I think it's time to talk a little about the first two years of medical school.

One of the things that truly distinguishes your transition from hopeful pre-med to "why-am-I-doing this?" medical student is anatomy. Shudder.

I know some freaks like anatomy lab. I liked anatomy as much as I'd like being drowned in a bucket of vomit.

Did that gross you out? Good, because that's how I feel every time I think about anatomy class and it's fearsome fearless leader, a man who wore shorts to every single anatomy session, a man who'd spent his life studying what had already been taken apart and put back together. And documented. Really, I don't see what there is left to do regarding anatomy. But there he was, crusty old weirdo, happily hoarding his knowledge while leaving us utterly adrift in a sea of skin and muscles.

He gave a lecture right before each anatomy lab session, but honest to God I have no idea if he ever actually intended those lectures to help us. To start with, they were early. It feels like they started at 7am, though that would have been weird. Probably they started at eight, but I as a first year student I was blissfully unaware of what 5:30 looked like and thought 8am was painfully early. Also, they were as boring as watching a bitter old man mumble aimlessly in front of a projector. Because that's what we were doing.

At the start of the 8 week academic block we were given a multiple page list of anatomy we were to have learned by the end of the block. This list ranged from the doable "humerus" to the ridiculous "coracobrachialis". We were supposed to know every bump on every bone. From what I gather we were supposed to know a certain amount of them before each lecture too. I think I tried really hard the first week, but still ended up banging my head on the desk after his "lecture", so after that I just flew by the seat of my pants. Excuse me, by the gluteus maximus of my pants.

Next up was actual anatomy lab. We trudged back to our classrooms and changed into our dedicated anatomy scrubs. I say dedicated because once you stepped into the anatomy lab wearing something, it would never be the same. So we wore the same set of scrubs, shoes, and for me, lab coat, undershirt, shorts, and old sports bra (you could never have too many layers) for the first 3/4 of our M1 year. Some groups rotated every week on who would take everyone's scrubs home to wash them. Some people washed their scrubs after every block. Some reasoned that they wouldn't want to put whatever had splashed onto their scrubs into their home washing machine and just sent the lab coat, scrubs, undershirt, shorts and old sports bra to the incinerator at the end of anatomy.

Oh Lord. They smelled. The whole hallway with the lockers where we kept our scrubs smelled. Any hallway we walked through to get to and from the lab smelled. And the lab itself? Shudder. One friend wore a surgical mask that she either sprayed perfume onto or stapled a dryer sheet into it to mask the smell of formaldehyde. Brilliant.

You may ask, if the chemicals smelled so bad, how was it safe to be in the room? Actually, that is a great question. Our anatomy lab was usually kept ice cold (for good reason), and was in the lowest level of the building. The windows were occasionally cracked open, but not at any degree as to actually give us fresh air. There's a group that goes around monitoring the air quality in medical school anatomy labs. A few years before I started, one M1 class just didn't have anatomy because the lab had failed the standards. So they were off the hook while the lab was fixed. If ours was that rank after it was refurbished, I don't even want to imagine the headaches the class before it had.

After a few months of anatomy, certain areas of the lab started to take on a slightly different even more terrible smell. Inevitably, some of the cadavers are not as well preserved as the others. We rotated cadavers every eight weeks, and you just prayed that you wouldn't transfer to a rotting one.

Another fun-killer in anatomy was the obese cadaver. We had a set amount of things to dissect and see per session, and I felt terrible for the groups who would spend the first hour or two dissecting down layer after layer of adipose tissue before they could even start to see muscle.

I have so much more to say on this topic (more than I thought when I started this!) that I'm going to post this now and finish later. And my title will make more sense. I feel bad because posts have been slow since I got off vagina-detail.

But don't worry. Next month I'm on Internal Medicine again.

Here's Your One Chance...

2010-03-10T14:26:00.001-08:00

I continue to be fascinated by babies having babies.

As I've said before, some are whiners, some are idiots, some were trying, some just got caught. Some though, you just can't figure out.

One 17-year old having her first baby was completely calm and collected. She was doing her Lamaze breathing through the contractions, with a mom-aged lady on either side of her. I couldn't figure out which one was the mom. One of the women seemed to be much more helpful and generally pulled-together. The kid was listening to her more than the other, but you can never assume. Sure enough, that lady was a friend of the family; the real mom was the not-so-pulled together one in sweatpants sneaking out to smoke. Her name was the title to a country song. I've never actually met a real person with that name before.

That girl ended up with a C-section. "She's always been so grown-up" the real mom said after I commented on how well her daughter was handling everything. "Agree to disagree," I thought.

Now, every time the parent of a teenager about to birth said something like that (and I kid you not, it happened more than once), a little part of me started seizing. I have to concentrate so hard on keeping a straight face that I'm surprised my nose doesn't start bleeding. How grown up is it to have sex without birth control? How grown up is it to intentionally get knocked up at 15 because you think you really love him! I grew up in a small town, so I thought I'd understand it. But I don't. While I was thinking about getting my act together in high school so I could go to medical school (no, I didn't date much), some of those girls don't have anything to think about after high school.

What about adoption? Oh no. OH no. You don't understand. Out of that entire month, every day of which at least two unmarried teenagers gave birth, only 1 woman gave her baby up for adoption. The other patients and their families were all excited about the new arrival.

It's a difficult situation. On the one hand, at this point the baby will be born so you might as well be excited about it. It's not like I think everyone should wear black to the birth and sit around talking about how the girl is probably never going to finish school or make more than minimum wage. But these patient's mothers, many of whom were teenage parents themselves, act as if she's going to bring home a new doll for everyone in the family to play with. As if things will magically be better, despite the fact that they already can't afford health care or rent for a big enough apartment to house the expanding family.

There has been a little research showing that a religion-free abstinence education program might delay teen sex better than religion-based abstinence only (might as well rent the kids hotel rooms for how successful that is) and comprehensive sex-ed. Honestly, at this point, after that month, I don't care if you send in fire-breathing nuns that do balloon animals out of condoms. If it would convince these women that there are more possibilities in life, I'd blow them up myself.

Cancer! CANCER!!!

2010-03-05T05:16:00.000-08:00

One day while hanging around with the on-call OB (I lived away from my husband during the week, what did I have to go home to?) we got a call from the ER. Actually, every day we got calls from the ER, but this one was about a post-menopausal (early 70's) lady who had massive amounts of vaginal bleeding.

That's never good. Besides being unexpected and pain to clean up, post-menopausal bleeding is cancer until proven otherwise.

Not that it's always cancer-actually, only about 10% of that post-menopausal bleeding will be diagnosed as cancer. There are several other reasons it could happen, fibroids being one common harmless example. But you have to prove it isn't cancer. And with the amount of blood the patient described that was our first suspicion. Not to mention the patient had a pelvic ultrasound that showed a 17cm uterus (normal for a post-menopausal lady is around 8x5 cm) with a thick shaggy endometrial strip measured in centimeters--the endometrium should be no bigger than 4-5millimeters, and her was in centimeters.

Well that was bad news. We saw all this before we went to go see the patient. She was a very pleasant lady who brought her daughter along. It's very odd to interview patients in the ER because they are often laid out in a bed scrunched in a tiny room. So you are standing at the foot of the bed and they are laying down straining to see you. Sounds weird that this would matter, but people just look different like that. And you have to remember that until they got to the ER, they were perfectly upright and mostly-normal looking (i.e., not sick and in a hospital gown).

Anyway, this lady knew she'd bled a lot, but I don't think it sank in how bad that was. The attending asked her the whole gamut of normal questions like family history and previous symptoms and allergies because she knew the patient would be admitted to our service that night. The lady just talked and talked, telling us about her aunt's history of diabetes or her father's father's heart attack and not really getting that we're trying to find out if there's anything other than cancer that could be happening. I could barely concentrate on her answers because my mind was screaming "CANCER! YOU PROBABLY HAVE CANCER! I DON'T WANT TO KNOW THAT YOU'RE ALLERGIC TO STRAWBERRIES--CANCERCANCERCANCER!!" Her daughter looked a little more worried--I tried to see if she understood what was probably happening. Maybe that's why the doctor wrote things down; otherwise she'd be like me unable to remember anything but how the lady looked and wondering how long she had left. The attending told her how vaginal bleeding, especially her amount, was abnormal and that it could be fibroids but we needed to get a tissue sample. "What else could it be?" She knew and we knew what else it could be. "Well, I'm concerned about cancer." "Oh."

Endometrial adenocarcinoma is usually found early, at stage I the 5-year survival rate is 85-95%. But something about the size of her uterus and endometrium made us think it was more serious. And even if you know that statistic, it's still cancer. It's still scary.

We scheduled this lady for a D&C (dilation and curettage-basically a cleaning out of the uterus) so we could send tissue to pathology. "When would we go to surgery?" she asked. "Tonight" my surgeon replied. "Oh."

Once back in the OR, we started cleaning out bloody necrotic material with black and yellow blobs. "This makes me lean toward cancer unfortunately," the attending said.

After we were done we went out to see the patient's daughter (husband still wasn't there for some reason). "We should have pathology results by Wednesday. Make sure someone is here with her." Meaning, "It's probably bad news."

Later that week the doctor relayed what had happened. The path report came back as cancer, specifically a type of sarcoma, which has a much lower 5-year survival rate than adenocarcinoma. She said the patient's daughter was with her again, and the patient said she couldn't rely on her husband for support; she did everything for him and he couldn't handle the idea of cancer. So he wouldn't come to the doctor's with her.

It seemed like the lady and her daughter handled the news well, and she was sent to the city where a gyn oncologist could do her hysterectomy and look for cancer elsewhere in the pelvis. I hope this lady's husband comes around and decides to be with her as all of this is happening.

Hysterectomies all around!!

2010-03-03T00:35:00.000-08:00

Apparently, in that small town, uteri were no longer cool.

Women not much older than me were having them yanked right and left for things like "menorrhagia" and "dysmenorrhea" (heavy bleeding and difficult periods, respectively). Even when they were offered endometrial ablation, which is totally awesome and involves knocking the patient out, sticking a tube up in the uterus, and to grossly simplify it, push a button so that the end of it shoots out and opens up like an uterine cavity-shaped umbrella. Then you press another button and it sizzles the endometrium. Sure, it eventually grows back, but not for a while. And it sure as hell beats losing an organ.

I don't think I can impress upon you enough how much I dislike surgery. Not just because of those bowel-goblins who tortured me for four weeks last year either. It is not natural. Having seen what I have seen now, I would not do it unless it were impressed upon me that I would die without it. Appendix? Yeah that'll kill you, take it. Gall Bladder? Hmm...that can still be fatal, and any idiot can take out a gall bladder. But hysterectomy? I better have cancer, or fibroids the size of fists. And not just one fibroid. I better have enough that if I cough my uterus falls out on its own. Then the surgery will be more like a wart removal I imagine.

Picture it: 325lb, 5'3" woman who thinks her uterus is what she needs to lose. The preferred way for someone to let go of her uterus is through her "natural orifice". Women who have it out like that usually get to go home the next day. Unfortunately, things are so padded down there that despite the fact that you have the lady in "dorsal lithotomy position" aka. "The Baby Maker" (sorry if you clicked the link already) the 5 inch long deep weighted speculum couldn't hold its ground.

I thought you needed a picture.

Soooo if you can't spelunk the lady-cave, there are other options. One is a laparoscopic-assisted vaginal hysterectomy, where you go in with a camera through her abdomen and loosen things up. Then you finish the job through the vagina.

With this lady though, we elected to do an open hysterectomy. These are the old-school surgeries everyone used to get. For this one we cut a Pfannenstiel incision and went right for it. This particular patient had a few pieces of fantastic that made the surgery something to look forward to:

A. Morbid obesity. Like, Tim Burton morbid.
B. Panic attacks at the thought of anesthesia-specifically the Happy Mask going over her mouth and nose.
C. How did we find this out? Because she flipped s#$@ ON THE TABLE at her last surgery and canceled. Do you know how frustrated an OR team gets when a patient does that (besides the fact that you're all dressed up for a party that just got canceled, another customer could have had the spot. And you knew she'd come back when she calmed down.)
D. She has a coagulation disorder. So now you have 4 inches of fat to cut through, which loves to ooze, and the lady has a bleeding problem (due to meds that she has to take to prevent clotting all around her body). That's before you start the real cutting.
E. She smokes. Grrrrr.

In short, this was a very difficult surgery. Before we even went in I noticed several circular bruises on her abdomen from heparin shots in the days leading to the surgery. My job, per usual, was to keep the tidal-pannus from lapping over the surgery site. It took a long time because the attending was fastidious about stopping any and all bleeders. After it was done and the uterus was in the bucket, I actually thought things had gone well.

Unfortunately, the next day, her hemoglobin dropped. Several points. CCRRRrraaaaaappp. She had to get transfusions and stay in the hospital several days because after each transfusion (sometimes 2 units), her hemoglobin would keep drifting down. She had a bleeder somewhere, probably something arterial with how fast things dropped that first day. I was really surprised. My attending had been so careful; nothing, I mean NOTHING, was bleeding when we got out of that abdomen. Did a stitch slip? Did we not notice something? Did something else rip when she sat up, coughed, went to the bathroom? I don't want to blame her, but her obesity and coagulation problem did not help.

We were left with several decisions: Should we restart anticoagulation? It seems like a no-brainer NOT to start anti-coagulation when a woman is actively bleeding, but during this time she also developed a DVT in her arm at her IV site, probably due to poor IV care by the nursing staff. So now what?

Do we go back in and try to stop whatever is bleeding? Then we run the risk of making something else bleed.

We started with an ultrasound to look for blood, which is usually a crap study on someone so heavy-sound does not penetrate obesity. We finally had a CT scan done, and in a disappointing show from the radiology department, two different doctors were told two somewhat different results. The hematologist got a phone call that there was an abdominal wall hematoma. That is something that does not require surgery, as the pressure in an enclosed space will likely cause hemostasis.

My attending was not called, and instead read the dictated report, which mentioned "some free fluid in the abdomen" (at least attempt to quantify, please), and had absolutely nothing about the hematoma.

Those are two vastly different interpretations with vastly different treatments. A patient can bleed out into her abdomen. Luckily the hematologist talked to the gyn surgeon and they eventually cleared things up. Not before the surgeon talked to the patient and looked like an ass, unfortunately, but she covered very well.

So we didn't have to go back and do surgery. Thank GOODNESS. But I do wonder-when we inspected her abdomen, there was new bruising. My pannus-retraction, while definitely not anything you could call "eager", probably did that to her. Her hematoma could have been caused by several parts of the surgery, but what if the big one was my fault? What if this lady had 4 blood transfusions and a week in the hospital because I was focused on wrangling her wayward belly and forgot that she bruised so easily? Could I have been gentler? Was there another way to fat-smash without actually smashing? During the surgery, all I thought about was clearing the way so we could see and reach what needed to be done. I guess I have some things to learn about holding each patient's special circumstances in my head instead of approaching each like they are the same problem with the same rote solution.

Follow Up

2010-03-02T06:13:00.001-08:00

I still have stories to tell about last month, so don't worry. My blog won't get boring just yet.

Before I forget though, remember the strung out woman who didn't know that the kicking lump in her abdomen was a baby?

The baby tested positive for HIV. Mom tested positive for opiates (heroin?) among other things. I hope she never gets that baby back.

I gotta warn you, I'm a puker.

2010-02-25T19:55:00.000-08:00

So many things happen in a day in the hospital, but I usually only have time to write about one. So here's the one that stuck out today:

After a relatively unremarkable surgery day, we were called to consult on a patient upstairs. An 84 year-old patient. "Sooo she's not pregnant?" Nope. Which means it isn't the usual, pretty harmless, "she has a slight cough, but she's pregnant and I've forgotten how to look up the pregnancy classes for antibiotics myself." It was most likely something narsty.

The story we got: She had pneumonia, then had C.diff diarrhea from the antibiotic, and now has copious clear discharge "from we don't know where". The stuff coated her from waist to knees and soaked her bed. But they didn't think it was urine because she has a foley in. And diarrhea wouldn't be clear. Are you seriously asking us to go poke around an 84 year-old's Dirty South and to find out where your leak is? UUUuuuggghhh it's a bad day to be on Vagina Patrol.

We trudged up to the floor and sought out the nurse to have her describe it to us. Before she started, I decided to give up on looking dignified and just told my attending, "I've thrown up twice in medical school, and they've both had to do with smells. One was directly vagina related. This is just a warning." When the nurse used the words, "Just keeps coming", "Thick sticky"-- I can't type this anymore. Let's just say I started to gag and the attending turned to me and said, "Stick to the wall and mouth breathe."

When the internist who called for the consult said the lady was "Mostly with it", he was mostly delusional. This poor lady was drawn up, limbs barely able to move, and she didn't really respond to our questions. With a patient like this it's even more important to examine her, because she probably can't vocalize if she's in pain or uncomfortable. Which still sucks because I'm sure she was confused as to why two strangers came in with gowns and gloves (did I mention she's on contact isolation precaution due to a positive MRSA swab?) and started prying her legs apart.

It was everywhere. I Darth Vader-breathed in the background until I pulled myself together enough to go comfort the patient. That's probably what did it for me; I used to work in a nursing home and really do like to take care of the elderly. They can't fend for themselves in the healthcare system, and no one ever looks like their best version in a hospital bed. It's not her fault she has ice cream all over her chin; someone should have cleaned that up.

It was evident we would need to do a speculum exam. We had to do it in the hospital bed because we didn't want to take her to Labor and Delivery with MRSA. Unfortunately that's not the ideal place to do a Fire in the Hole. "Wish I had my headlamp" I muttered. "That really would be useful," my attending agreed.

"If I'm not back out in 15 minutes, call Search and Rescue. And the Ghostbusters"

While going back to Labor and Delivery we talked about possibilities. What could cause a clear, non-odorous vaginal discharge like that? "Well, she might have a plugged Skeine's gland". "I didn't feel any plug or mucocele." "When women get aroused, plasma seeps out of their vaginal walls for lubrication." "That would be a lot of arousal." "I mean maybe she has a clot that's causing a weepy vaginal edema." "Or a cervical stenosis could do that." "You know, it reminds me of that opening scene in Ghostbusters where the librarian gets totally lubed." "Wasn't that green though?" "No, I thought it was clear and pink." "We should go back in there with boxes strapped to our backs and laser-lassos." We gathered the goods, tried to arrange the patient, and my attending did the exam while I held the flashlight. This time the patient had a few things to say, mainly that it hurt to move her legs. I felt so bad doing this to her.

In the end, I think it's either cervical stenosis or a mucous-y urine leaking around her Foley. I'm pretty excited to see the lab report tomorrow. And hope it does NOT mean that we have to go in there again.

"Train Wreck" doesn't even begin to cover it.

2010-02-24T19:41:00.000-08:00

What do you call a 37 y/o woman with looks like she's been rode hard and put away wet, with congestive heart failure, COPD, diabetes, new-onset chest pain, 7 miscarriages, 2 stillborns, 3 live children (none of whom live with her I was told), and a 5-week old embryo cooking in her well-used oven?

My patient.

She was also belligerent, insistent on repeating how horribly she was being treated, and seemingly unaware that pregnancy could very well kill her. And no, she didn't want to hear about it. Even saying, "This pregnancy is considered high-risk" got her hopping mad--not that she should hop in her condition. "YOU'RE SAYING I SHOULD HAVE AN ABORTION AND I WON'T!"

Actually we weren't. Not to her face definitely. Yes, she has a good chance of dying with this pregnancy. Yes, she has three living children. No, we would not have ever recommended pregnancy to a patient like this. Draw your own conclusions. Honestly, she'll probably miscarry again due to her poor health.

Nobody in the practice wants to touch her. When I went in with the doctor I was working with for the day, I stood in the back with my arms folded and a serious face so that maybe she'd get a bad feeling about that doctor and not ask to see her when she left the hospital.

"I want morphine! And 13 more pregnancies! And a pony to ride out of here on!"

Denial really won't help you right now.

2010-02-23T16:57:00.000-08:00

Friday as snow started to fall wet and heavy I eyeballed the parking lots wondering how long I could safely stay there without destroying my weekend going-home-to-hubby plans. Of course, that's when one of the wildest patients I've seen yet decided to come to Labor and Delivery.

By decided, I mean felt like it was the optimum place to go after feeling strong continuous contractions while in labor with a child she didn't know she was pregnant with. Contractions strong enough to dilate her to 7cm and 100% cervical effacement. Yeah.

She didn't know she was pregnant Al? For realsies? Well, that is what she said. Also, she told me her last menstrual period was 3 weeks ago.

Before you say "OH she was LYING!", she might not have been. Several women who didn't know they were pregnant say they had periods all along. They aren't really periods (there are a lot of reasons women bleed during pregnancy), but if you had irregular periods all along, or if you didn't think you were pregnant and tended to see life as if you couldn't possibly be, you could probably take any sign of bleeding as your "period".

Sometimes pregnancy tests can be negative as well. I have a friend whose doctor told her she wasn't pregnant, put her on a medicine to make her have a period, and then she found out she actually WAS pregnant.

The next question people ask usually is, "Was she really fat?" Nope. She was the degree of skinny only methamphetamines can get you. Which, after looking at her mouth, I'm pretty sure she'd sampled once or 500 times. So I don't know what she thought the squirming mass beneath her belly button was, but I after seeing the needle marks on her arm I wouldn't have been surprised if she told me Barney had taken up residence in there and was inviting all of his pink elephant friends over for tea and crumpets. Oh yeah, she told me she didn't use any illegal drugs either. When I asked how much she smoked (No need to ask "if", she smelled like a truck stop) she said, "A lot." As in 2-3 packs a day.

She didn't have any STD's two years ago when she spawned her other child, but who knew what happened after that. Since she didn't have prenatal care we didn't know if she had Group B strep (some women have it in their vaginal canals, it can give babies meningitis, sepsis, and horribleness). We also didn't know how far along she was.

After mid-pregnancy, you can use a tape measure to estimate fetal age. you start at the pubic bone and go up and over the fundus. Cm=weeks gestation. She measured 29 weeks which put all of us on high alert. At 29 weeks, it was very likely that the baby was going to have problems breathing. We couldn't give steroids to speed up baby's lung delivery because that baby was coming out before they would have had enough time to take effectShe was dilated to 7cm, so she was too close to delivery to send her to the city and it's specialists.

We got an ultrasound, which is accurate + or - a few weeks in the third trimester. Radiology said just over 33 weeks, which was an improvement. It's very possible the fetus was growth restricted due to all the chemical insults Mom was slinging at it. As an aside, when you read about preterm labor, one of the reasons theorized for it is that the fetus recognizes a "hostile environment" and in layman's terms decides to get the heck out. Of course this is not the reason for every pre-term labor, and sometimes hostile environment can mean something happened to the placenta or umbilical cord. I'm definitely not saying it's always Mom's fault. But let's be honest--this time, if I could bet my imaginary month's salary, my money would be on blaming the crack addict in the stirrups.

We called the on-call pediatrician and alerted the Children's Hospital down in the city. Did I mention it had already snowed a fresh three inches in the last two hours with no sign of stopping? It would take them at least an hour to get here in good weather.

All in all, it was a crap situation. It was interesting to me how the nurses, who I would have expected to be taking turns cutting each other with needles out of frustration, treated this patient like she was a child, coddling her and comforting her and absolutely NOT letting it show that she might have done a few stupid things. Which was totally perfect. And inspiring. Here are some of the snarkiest of snarks, but after seeing someone truly needing support, they were just awesome with her.

That may seem like a departure from the somewhat ranting tone I took early in the post. Don't misunderstand; I still think she couldn't identify a healthy decision if it walked up and pierced her nipples. But what would the use be in bringing that up now? That horse left the barn...and got pregnant. We have no idea what she went through leading up to this. People who abuse drugs stop developing emotionally at the age which they start abusing. In my mind she was a child. And as much as I rant, when I see someone suffering, even if it's as a consequence of their own choices, my heart hurts. Yes, I have one. How can you make a woman feel bad when she's in pain and confused and scared? Yeah, dumb as a sandbox, but is that not even more of a reason to show compassion?

They were unwavering in their support, even when she cursed and screamed and her head spun around her neck. Ok that didn't happen. But she did yell, "I'm gonna SSHHHHHIIIITTTT" and did. The nurse said, "It's ok honey, everyone does it." Another said, "It's just part of life honey" It is, they all do, and none of the 30 other deliveries I've seen have bothered me, but while they were saying comforting things I was gagging behind my mask and wondering how I could excuse myself if I actually did throw up (you know how sensitive I am to smells and this was the WORST).

When that baby was born, amid her cursing strong enough for the doctor to actually say, "You have a problem.", it was the first time I had seen a birth and didn't think of it as a miracle. Watching that happen, in those circumstances, I felt like I was watching an unfortunate consequence of biology. There was no thought of baby's future, or a family welcoming it. It was purely a byproduct of nature, unexepected and unprepared for. You have an action, sometimes this happens after it. The baby might as well have been vaginal discharge after an STD. I understand that sounds crass, especially to those black-and-white types (who probably have never seen a situation as gray as a meth addict's teeth). I'm just explaining how it felt.

The baby actually had APGAR's of 8 and 9. But then she (we were glad she was a girl--they are tougher and have higher survival rates after preterm birth) started to have retractions (trouble breathing). And she was a peanut, weighing in under 5 pounds.

The nurses started calling her "Chloe", but then the Mom said some name I've never heard of combing the top three most popular syllables and consonants (K's are very in fashion right now, by the way). I can't believe we were just going to give her back to that woman. I guess that is pending the urine drug screen results.

"God, why did you give me THIS woman as my mother?"

Sometimes when I leave the hospital I'm just sad. I feel like I have a weight on me when I think about some of the situations I've seen during the day. I passed the ambulance going towards the hospital as I drove out of town. The mom left at 6:00pm that night. I'll just have to rely on word of mouth to hear how they are doing.

Except for one thing: The Children's Hospital called on Monday to let us know the Mom had tested positive for HIV. I guess our hospital lab didn't think it was important enough to call us directly. The patient hadn't known and hadn't gotten any anti-retrovirals, so the baby has a 25% chance of having acquired the virus during the vaginal delivery. I'm very fastidious about personal protective equipment, but it certainly would have been nice to know what I was dealing with when I was standing in a puddle of blood and amiotic fluid. What a way to end such a fantastic case.

Shots! Shots! Shots!

2010-02-21T06:00:00.000-08:00

While on call the other day we were paged to the ER for a confirmed ectopic pregnancy. She was fifteen years old.

She had known for two weeks that she was pregnant. Her mom was in the room with her, and they both knew at the time that she had forgotten to put in a new Nuva Ring around Christmas. Folks, this is why teenagers should never be put on the pill. The Nuva Ring is something you only have to remember twice a month. Once to put it in, once to take it out. If she couldn't remember THAT, how do you think she'd ever manage something you have to take every single day? Remember, teenagers are generally idiots. I recommend the Depo shot. Sure, some people say it makes them fat and crazy, but I think that's a great side effect when you want to stop teens from getting pregnant.

Not the point of the story. The point is that she was 15 and had a large extrauterine pregnancy that had to be dealt with. She was too far along for methotrexate (a chemotherapy drug that stops rapidly dividing cells, such as a fetal cells), so we had to go to surgery. Now we had to talk to her and her mother about how she was going to lose a fallopian tube and possibly an ovary at 16. She would still be able to have children, but it would probably drop down to an every other month chance. I hate it when dumb decisions affect young people for the rest of their lives. Someday (hopefully!) she was going to be in a happy stable relationship, maybe with one of them working a real job (I can dream), and she was going to want to have a baby. I feel the same way about STD's. Kids don't realize you can get them without having "real sex"--vaginal sex--a lot of teens don't count oral or anal sex as "real sex"--and don't think about STD's either. It is so sad when a patient got chlamydia from her high school boyfriend, and didn't realize it could make her infertile later. Or that HPV, which you can get even when using condoms, could give her cancer or warts for the rest of her life.

Mom and daughter were both in tears, nearly hysterical, but there was no other choice. So we got an OR spot, and the staff took them back to the holding room. The patient asked us to wait until her boyfriend got there before we took her back. This kid showed up looking like he'd walked out of a Calvin and Hobbes comic. Spiky hair, oddly short legs (or just really low pants), kid sneakers, and the dumb bewildered look on his face that I've come to expect from teenagers who found out that even blind squirrels find acorns once in a while. If I were her mom the only way I'd let this kid come to the hospital was through his own trip to the ER.

She told us when she'd gone to the bathroom before coming back to the hold room, all of a sudden she'd felt very sharp pain that continued to get worse. As far as we were concerned, that meant she'd ruptured her tube.

Sure enough, once we got the laparoscope in she had a pelvis full of blood (500ccs). The crazy thing about her ectopic though was that it actually wasn't in her tube. It was ON her ovary. It looked like a swollen purple sac of blood sticking out of white ovary--it was bigger than the actual ovary. And the placenta had begun to attach itself to her abdominal wall. Ovarian ectopics make up 3.2% of all ectopics. I never thought I'd see one. Her placenta attaching to the wall was very dangerous. Placentas invade by nature; that's how they wrangle blood supply from Mom's uterus to feed the parasite, I mean, baby. If the placenta had invaded her abdominal wall, it could have put its sticky fingers into a number of blood vessels. We needed to remove all the pregnancy-related tissue, but had to be extremely careful we didn't open up a blood vessel by removing placenta.

Lucky for all involved, the placenta had not yet invaded. It pretty much peeled off the peritoneum. And since the gestational sac was on one end of the ovary and didn't touch the tube, we actually just removed the sac and were able to leave the tube and remaining part of ovary intact. She still has two tubes and two ovaries to try to get pregnant with. Which I was excited about until her nurse told me that she had actually been trying to get pregnant at fifteen by Little Boy Wonder.

I always wondered if I'd be able to see a little fetus in what we brought out. I didn't try. I thought it would be creepy and upsetting to see it. My attending said one time a lady came in so far along, and the fetus was actually still alive, that you could see it's heartbeat and hand waving on ultrasound. There's nothing you can do; you have to save the Mom and you have to take out the pregnancy to do it. But if it's a desired pregnancy I think that would just be a heartbreaking surgery.

Why?

2010-02-19T18:19:00.000-08:00

Another long day. But here are a few highlights:

One lady scheduled for a c-section had not been told to remove a piercing she had in her..ahem. Nope, not the belly button. You aren't supposed to have any piercings in you during surgery because we use electricity to cauterize just about anything that bleeds.

A nurse came out of the room exasperated, "We can't get that piercing out! I tried to turn the ball around and around and it didn't come off!"

I had the choice of watching yet ANOTHER vaginal deliver (my sixth today), or trying my hand at the thing. "I'll catch up to you later Dr. H. I've seen a delivery, I've never seen a clit ring." "OH Thank you!" the nurse said.

I go into the room, introduce myself confidently (you can't f#$^ around if you're going to go after someone's clitoral ring), kick out the 14 family members who are there to witness the birth (hah, imagine explaining that to your in-laws...or the unmarried equivalent), get the needle driver and hemostat, put on my gloves, and take a look.

What the what? I had not expected this style of ring. After some detective Googling (and a lot of firewall-blockage by the hospital's internet), I discovered this was a captive-ball style. The ball is just for kicks. Ooookkay. Next search: "How to remove captive-ball piercing" (I found that leaving the "clitoral" part out sidesteps a lot of the more offensive listings out there). The answer "Go to your jeweler. Attempts to remove the piercing yourself often result in infection and tearing of the pierced tissue."

Oh hell no. I was not about to go yanking around a woman's genitals if that's what I had to look forward to. "Call surgery and get a metal cutter," I asked the nurse. Done.

I expected a straightforward cutter like the metal cutters my dad had in his shop. What came was a bizarre circle and lever contraption. I couldn't even find a picture from the internet to post. "I have never seen this cutter. I'm not comfortable using this--I'm going to go find someone who is." As I explained to the nurse later, if she were pierced in her ear or nose, I'd go have a crack at it. What's a few tugs here and there? But I did not think it was going to advance my medical knowledge to go willy-nilly around her non-expendable parts. Especially with the 15 members of her family so close outside the door you can see the shadows of their feet outlined below it.

I asked the hippie anesthesiologist I'd done several surgeries with if he knew how to use the thing, saying I wasn't comfortable doing it myself. He'd apparently been waiting three weeks to talk down to me, as he basically ignored my question and started his reply with, "I know it's all cool to be a medical student and go take care of things, and you feel like you know some stuff, and next year you'll have to pretend while you learn Man, but I'd ask someone who knew how to do this to help you." Thank you for your astute observations and your help. If I see you wearing Birkenstocks in the OR again I swear to God I'm calling OSHA.

Just then someone was delivering, and I never turn down a change to get my hands on a fresh baby. By the time we were finished, the ring had "just fallen out" in the woman's hands. Oh yeah, that's after the nurse picked up the cutter and took a stab at things herself (it didn't work, by the way. And the patient wasn't too happy about it). I think after getting man-handled, the ring just gave up the ghost. Thank goodness. Proceed with C-section!

The other piece of fantastic for the day? Over in Antenatal it's almost like an ER for pregnant ladies. It's supposed to be for labor or directly pregnancy-related issues only, but since every time the ER physicians see a positive pregnancy test they assume it's pregnancy related (diarrhea? Oh the fetus probably has Crohn's disease. Sore throat and runny nose? Well, you're pregnant, so it's probably amniotic fluid leaking up around your Eustachian tubes while you sleep. Better call OB) the OB's end up having to see everyone who even might be pregnant.

This time it was a lady who was 30 something weeks along with twins. Her complaint? I can't even keep a straight face while I type this. She'd had some cramping in the morning, then she and her boyfriend had sex and now she's "leaking something". Who wants to go down that rabbit hole? One of the older nurses said, "It's been a long time since I've had sex, but if I'd had it this afternoon, I'd be leaking something too."

My job is so gross.

Room Full of Class

2010-02-17T19:45:00.000-08:00

I'd like to take you on a walk in my shoes today. I will be narrating a few of the day's events, with my thoughts in italics.

One of the C-sections today was a 309 lb woman. I knew what my job would be. Another hour of vagina curtain retraction. Oh wait, I think I said that out loud to a nurse.

If you've never seen a C-section from the surgeon side of the drapes (and I'm assuming more people haven't than have), there comes a moment as you are cutting through the uterus, gently and lightly slicing through thin layer after thin layer (so you don't cut anything you aren't supposed to), when the amniotic sac bulges out. Everyone takes a deep breath before the surgeon ruptures it: Alright, where's she going to pop? I gotta aim the suction wand right place so it doesn'tAAAUUUGGGHH it splashed all over me it's a fountain of ICK!! AAAUUGH IT KEEPS COMING!! Since there was an extra amount of pressure from her fatness, the stuff came out like a fire hose.

After surgeries were done for the day, we had a delightful delivery. I don't really mean delightful of course, I'm being snarky. It's just as delightful as you'd expect a 17 year-old's second baby by her second baby-daddy to be. The nurses had to keep switching around to take care of her. As soon as one was about to strangle the teen, she'd press the call light and another nurse would show up to gently pull Nurse 1's fingers from around Baby Factory's neck and send her off to the patient kitchen to pull herself together and maybe chug a Puddin' Cup.

I've seen several deliveries that made me want to cry, but not because they situation was so freakin' sad that I wanted to take the baby myself. For the love of vernix they were DDDUUUUMMMBBBB. This girl just laid on the bed saying things like, "I just want to put my clothes back on and go home." You should have said that nine months ago "I can't do it" I don't know who else is going to give birth for you. And you should have said that nine months ago. "Is it going to hurt?" How the hell should I know kid? You're the one on your second baby. But I sure hope so.

Did I mention that her biggest question before the delivery was whether her boyfriend and the father of the baby could both be in the room with her? Ehhhhhh you really suck at life. During the pushing and delivery, FOB and BOGHB (Boyfriend of Girl Having Baby--maybe I'll just say SOB) were both present, along with the girl's excited picture-taking mother (Ma'am, may I talk to you outside? Ok, so I'm going to slap you around for a little bit. Still, we should take a walk). FOB sat kind of shell-shocked in a corner, absolutely quiet, probably wondering how he got himself in this (I know) and thanking God he was just the baby daddy. New Boyfriend (SOB), was by the girl's side, holding her hand and chewing a plastic spoon like it was the last dip of Skoal at a demolition derby. (What are you, a kindergartner? Do you know how stupid you look with that spoon all flat and tooth-marked hanging out of your mouth? Would you like a pacifier from the nursery instead? I can't even look at you right now. As soon as I see something disgusting, I'm going to trick you into looking-If I'm lucky you'll pass out, if I'm luckier you'll never want to reproduce.)

I should mention that I was hungry during these thoughts.

"You know, on second thought, you are gonna be crap parents. I think I'll keep her myself."

She finally gave birth and I got the heck out of there, tripping on the 10 family members(ish) outside. I'm pretty sure I heard that the new baby had two older sisters, though Mom only had one other child. So Dad must have another baby too. There was another teenager with a 2 year-old mini-me on her hip outside the door. Mini-me was screaming, demanding to see her new sister. Would the mother of the dad's OTHER child really come to see the birth of the new baby? DO THESE PEOPLE EVER WORK?? I don't know. All I know is that they kept trying to come into the damn room while the mother's legs were up in stirrups, bleeding like, well, a woman who just gave birth. That is a disgusting enough simile, no need to be creative. Someone's sandwich isn't getting made at Burger King because you all called in sick to be here.

That is all.

Posts coming!

2010-02-16T15:35:00.000-08:00

Last night was a 12-hour day followed by a phone call at 9:30 asking if I wanted to come back to help out with a surgery. I got home around 12:45 last night and went in at 6:30.

I have posts coming; it just takes me a while to write sometimes. Especially when I'm comatose.

Meanwhile, I fixed some of my pictures. Let me know if they still aren't coming up.

Toodles,
Your Pal Al

I'm sorry, you no longer have a life.

2010-02-11T15:44:00.000-08:00

I don't know how long this post will be; I have to go back to work in two hours.

Several of the doctors are back from their various tropical vacations, which means s#$ got real at the hospital. The attending who is in charge of me thinks its a great idea for students to see "what it's like to practice medicine after an entire day and night on call." I like my husband's description for it: "F#$@ing stupid." The only thing that might save me from having to sleep there tonight is that there is no bed for me to sleep in. That might save me. Another med student slept on a couch when she got assigned to this doc.

I can't go into how little I ate today. So I'll just say breakfast never happened (Doc wanted surgery to start early today unbeknownst to me), lunch didn't really either. When I asked (hinted) if the Doc wanted me to go get lunch for her, she replied, "It's call day. The adrenaline really keeps me from being hungry. Now let's go do another 2-hour hysterectomy." AAAuuuGGGHHH.

At the end of the day, I had planned to go snowboarding with my roommates. It was the light at the end of the tunnel. Unfortunately, there was an avalanche. "Well, surgery is over for the day," (4:30pm from a 7:00am start-the only break we took was to see an ER patient for a suspected ectopic pregnancy). "It doesn't look like anyone's going to give birth for a few hours. I'd come back at 8 tonight and give the night shift your phone number." Oh I did that yesterday. "I'd still come in again tonight at eight. Now go relax for a few hours." At least I get the few hours--if I didn't eat soon, I was going to beat somebody. Like that new mom who wasn't in her room during rounds because she was out smoking.

"I find that I operate best when I've neither eaten or slept for 48 hours. Also, I never have to go to the bathroom. But yeah, sure, I'm safe."

Tomorrow is going to be awesome. If you think I'm a loudmouth now...go back and read my night shift blogs.

Nugget

2010-02-10T17:01:00.000-08:00

Those who have ever heard of Chelsea Handler should know that's her name for midgets. Which is the name for Little People for the rest of us without our own cable show.

Who cares? I care. Because yesterday a dwarf was born.

When I hit the floor Tuesday morning after surgery, I went over to antepartum to see if anything wild was happening. Antepartum is always an interesting mix of sick and crazy. When pregnant women get to the end of their "confinement", they are completely unpredictable. Sane women are nuts, nutty women are flinging poo; you just never know who's going to walk in and demand two fingers in their cervix. Which is what you do when you check to see if they are in labor you Sicko.

Yesterday my curiosity was rewarded. "There's a dwarf baby?" "Excuse me?" "We've got a lady in there, 5'9", and her husband is a dwarf, and so is the baby!" Well I gotta see this.

They were very friendly, and I legitimately had a reason to introduce myself (I generally try to make my first patient contact before they are actually pooping and popping in the stirrups--meet the face first, I always say). So I went in and chatted for a while. Mom was tall and thin thin thin. Laying on her back, she looked like she was 6 months pregnant at the most (she was actually 38 weeks). Dad had achondroplasia, the most common type of dwarfism. During the conversation, Dad, who clearly wore the shants in the family, casually referenced her as "Chubby". At 5'9" and 38 weeks pregnant, she weighed 120lbs.

"What did you say?" I couldn't quite see the funny in calling a pregnant woman weighing nearly 30 lbs less than me "Chubby", especially since I think someone that thin and nervous might have an eating problem. "Oh, I have the kids in on it too. They say "put down that sandwich Mom, you're so fat!" I paused, contemplating how serious I was about threatening a man half my size. Never having engaged in dwarf-slapping, I figured this wasn't the time or place. Plus, after a quick glance at Dad's hypertrophied arms, I'm not sure I would have won. Instead I said, "I'm amazed that you'd dare to call a laboring woman chubby! Try saying that when she has another contraction."

Determined to see the occasion, I gave the OB on-call and all nurses my phone number with explicit instructions to call me if it looked like she was going to deliver. No call came; they had sent her home because she wasn't technically in labor. I guess overnight she'd had enough, because later that afternoon she was back and we were scheduling her for a C-section.

They remembered me, because Dad (who some nurse said was a stripper) starting trading cracks with me as soon as I walked into the prep area for C-sections. "You're in on this? I hope you're not the first thing she sees!" he said, "I hope she doesn't look like you" I retorted, followed quickly by the thought "Damn it, that's not something you say to a dwarf who's about to have a dwarf baby."

I've seen women rocket out 9 lb babies au naturel with less fuss than this lady. She had a 5 lb-er cut out of her numb pelvis. I know it was numb because I pinched her with an Allis clamp before the surgery started and she didn't feel it.

Finally the moment I'd waited for: BABY!! She was pretty little, with shortened arms and legs and the facial features of dwarfism, even as a newborn. Oh but she was darling. She opened her eyes and looked around before letting loose. She couldn't keep her O2 sat up however, and had to get oxygen by mask. I don't really know if babies with achondroplasia routinely have problems right after birth, especially if they're a few weeks early, but this little one was headed to the NICU.

As I walked home, I looked up into the sky to see if there was a new or particularly bright star in the sky. "Surely a new star comes out when a dwarf is born" I thought. But alas, it was cloudy.

This morning she was out of the NICU and doing well. Of course I went to the nursery to check on her. I've fallen into my old Peds habit of starting the morning by greeting every baby I saw being born. I try to say comforting things, since the last time they saw me their heads were getting squeezed as hard as the butts at Hooters. I don't know how they feel about seeing me, but since I delivered two of the babies in there currently, I really love to see them!

"Shut your big gob and get out of my face; I haven't forgotten you."

Welcome to the World, You Adorable Screaming Little Monster.

2010-02-09T17:52:00.000-08:00

I delivered a baby today!! I actually did the pulling and everything!

That is why I came to this rural hospital again. At my university, I delivered a few placentas. One kind resident let me put my hands over his while he delivered a baby. But this time I was the one delivering with my attending coaching me encouragingly behind me. It was awesome.

A lot of credit goes to the lady actually giving birth. This was number two, 13 months after number one btw. Crap she had skinny legs. I can't believe she had two babies in a year and looked that good. She made it look easy too.

Last week a physician gave birth. I think I mentioned her--I was excited to see someone older than me married and giving birth to her first child. Then she mentioned she was a doctor. I should have known.

She was the biggest whiner I've ever seen in stirrups. Actually she wasn't even in those yet. She knew it too. She apologized for being a whiner right before screaming bloody murder and cursing everyone in the room. "We need Anesthesia and a Priest" I thought as I crawled out of the room, trying to stay underneath her line of vision. She was in Labor for a good 20 hours.

Her baby was born a little small, under seven pounds, and on inspection had a two-vessel cord. That was a surprise, he had a 3-vessel one at an earlier ultrasound. That may have been why he wasn't growing like expected at the end. Now, being a doctor, she naturally heard "2-vessel cord" and flipped her sh#%. She wasn't a pediatrician or an OB, so she had my level of understanding--2-vessel cord=bad. We know just enough to list the bad outcomes, without the experience to recognize the (overwhelmingly) good outcomes. The doctor and I had to go in several times to talk to her about possible reasons for it, meaning we repeated the same "it probably just atrophied for idiopathic reasons". We did an in-house cardiac and renal ultrasound, which were normal, and still she couldn't get the skeptical/worried/anxious look off her face. When we told her about another baby born perfectly normal who weighed less than hers, she turned to her newborn and said, "Well we beat somebody kiddo!" "Look," my doctor said, "If you don't want him, I'll take him!" "I want him, I just want him to be perfect!" she whined. My God, if this is how the kid's life starts out...he's going to have a nervous tic by preschool.

So the lady I helped today was the opposite. She probably could have done it without me. I saw her and her family roll in around 9:30 that morning, looking for all the world like they were walking in to a shopping mall rather than L&D. She didn't even look like she was in labor. Two hours later we went in and broke her water-she was dilated to 4cm. She did seem a little uncomfortable then, but I don't even know if she had an epidural. An hour later she was completely dilated at 10cm and ready to push. I think the woman pushed 4, FOUR times and that baby was born. I had my hands on his head as he started to come out; he had so much hair under my fingers! Then I gently pushed down and up to deliver the anterior and posterior shoulders. He felt warm and soft, and slimy :-). I had to grip him around the back of the neck and help pull the rest of him out. I looked down at him as he took his first shuddering breath. I was in awe. Then I snapped back and put him on his mom's belly as she, her husband, and her sister all cried and welcomed him into the world.

After that I still had work to do. I clamped and cut the umbilical cord, drained the placental cord blood into a test tube, then clamped and held the remaining cord until the placenta separated. Then I delivered the placenta, holding pressure on the fundus (placing a hand on Mom's abdomen to make sure the uterus was shrinking and firming up, and not inverting!) and checked it to make sure it was complete-no chunks left in the uterus to become septic! Next we inspected the vaginal vault to make sure she hadn't torn anywhere--of course she hadn't, I already told you she was amazing at this. Then we got out of our gowns, congratulated the family, peeked at the baby again, and chatted for a bit before I could tear myself away from it.

It was such an amazing thing to be a part of. I don't want to be an OB forever, seeing as they a. stay up late at night, b. deal with dumb fertile people and c. sometimes lose babies, which would just kill me. But how awesome to get to do this a few times before I move on. I was the first person to ever touch that living breathing human being. I was the first person to look at his face and say hi. He only opened his eyes for a second, but I was his first glimpse of the world.

Maybe I should try to look prettier for the next couple of weeks.

Don't Make Me Pull this Surgery Over!

2010-02-08T12:37:00.000-08:00

Today was one of the most difficult C-sections I've been a part of. There weren't technically any complications, the problem was that the lady was in her forties, and so was her BMI. She had also had a previous C-section, and plenty of scar tissue to prove it.

Apparently her thyroid had been on the fritz. When her doctor so helpfully set it to rights, she ovulated. And got knocked up (by her husband. My hubby says I can't use the words "knocked up" now that we're married). So here she was, with two teenage kids in the waiting room, about to become a parent again. The Insensitive Ass of the Day prize goes to the anesthesiologist, who contributed "I'm about your age, and I can't imagine how awful it would be to go through this again. Yuck. But good for you!" to the pre-surgery conversation.

Lately the scrub tech has been training new scrub techs (Crap, I think you're supposed to call them "Surgical technicians". I probably sound like those old coots who still say "stewardess". Though I do NOT indulge in any ass-grabbing. Woof. Anyway, this sometimes means there isn't room for me to scrub in. Today's trainee was especially panicky and hard of hearing, but they still needed me to scrub in for my favorite job: pannus-retracting.

I've talked before about how much I love a good pannus. And how it always falls to the medical student to deal with it, as if there is no other reason for us to be in the OR except to grab huge hunks of obesity and wrestle it until our arms shake. I try to think about how I'll never let the cafeteria lady talk me into the fried pickles again. I try to think of all the skinny suburban housewives in my gym, and how maybe this will help me reach my goal of wearing leopard print in child sizes. But the truth is when you have to retract anything for someone else in surgery, your comfort and structural stability is not what matters. You find yourself in the weirdest positions, squeezed between the patient's arm, the surgeon's hip, an elbow up your nose and head hitting the lamps if you try to straighten out, trying to hold 25 years worth of Big Macs at a 45 degree angle with your arms outstretched. Nothing is right with that.
"If I can just hold this position, nobody will know I have an enormous pannus!"

Methinks the patient was a bit thinner the last time she had a C-section, because the surgeon's now faced a dilemma: If they made the incision around the old scar, it would lay right in the pannal fold (I made that term up). It would hold the meat and cheese in the pannal taco (that one too). It would be subject to sweats that don't evaporate. Air that doesn't circulate. Not something you want an incision to sit in.

So they cut, and cut, and cut. The woman has a lot of scar tissue. Not her fault, just a pain in the ass. The fact that she had so much adipose tissue (I don't know if that's actually nicer to say than "fat globlets", but I tried) meant there were many more small vessels oozing and making a mess of the field. Plus, the attending had to keep cauterizing them, so the event smelled more like a barbecue than a birthing. Which I don't know if I minded; birthing isn't exactly a pleasant smell. Still, it held up the procedure because we had to keep stopping to burn the fat. During the surgery I shifted my grip and accidentally flung one of those little fat globs off of her and onto the surgical towel. "You're welcome" I thought to myself.

Once they finally got down to the baby, I thought my luck was going to change. The doctor assisting was going to take a turn holding the pannus while I pushed on the baby (I had the better angle). Unfortunately, because the woman's abdomen was obese, that little squirt was deep in there relative to where I thought, and quite frankly I don't have the experience to find a butt the size of a baseball in a belly the size of a featherbed. So I switched places and went back to retracting the ol' vagina-curtain while they worked to get baby out.

During this whole time, FOB (father of the baby) was nervously running his mouth. He had the video camera in hand, and it took 3 nurses to convince him that he couldn't videotape the actual delivery (too much liability involved). Sir, you can't take video or pictures until after the baby is born. No sir, you can't tape the baby coming out. No sir, not until the baby is born and with the pediatric nurse. No sir. No. NO. Every few minutes I'd hear him behind the drape, "Is he out yet?" Or "I don't hear him crying yet." "Is he almost here" "Does it usually take this long?" Or I'd see the video camera come peeking up over the drape as the guy tried to stand up and see the baby the very second after he came out. "We haven't even started yet." "We're still working on getting to the baby" (you don't want to say "we have to cut through 5 inches of fat, then the scar tissue before we get there). "It won't be long sir" "PUT THE #$@$ING CAMERA DOWN!" It was like being in a car with a child; I almost said, "Don't make me pull this C-section over"...or asked that he be seat-belted to his stool.

After we finally got the kid out, the anesthesiologist made a few "You'll never sleep again!" comments, and Dad took the baby out to see family. Mom was apparently so relaxed, she fell asleep. P.S. You don't get ANY sedation during a routine C-section. All she had was a spinal block. I knew she was asleep because I could hear her snoring on the other side of the drape. "I think our lady has a little sleep apnea" the anesthesiologist said. "While she's been snoozing here her sats have routinely gone down to the 80's, and twice they've been down to 60%." Holy Snap! Her brain is taking a hit. When she woke up he asked her if she experienced any daytime sleepiness (a common symptom of sleep apnea). "No, not really," she said. Well, you know, except that she fell asleep at 9:30 in the morning while three people were wiggling their hands in her pelvis and oh yeah, she had a baby too.

I can't imagine having a suprise baby at 44. And it makes me sad that she already has some scary health problems. I think since her O2 sats were so low the OB attending was going to have a pulmonary consult on her while she's in the hospital. I see daily reminders of why it's important to stay at a healthy weight. It affects so many things you don't realize, from how well you sleep at night to how well you tolerate medical procedures.

Now, if you'll excuse me, my Lean Cuisine is calling. Sigh.

Pregnant or fat?

2010-02-07T17:39:00.000-08:00

If you've never found yourself wondering this question in public, you probably don't live in the Midwest. Most people know better than to actually ask it to anyone other than themselves or a very quiet friend (it helps if they have bat-like hearing so that you can mumble the question under your breath. If you don't even have to say the question out loud for them to know what you're thinking, you should marry that friend.) If they're pregnant you're probably safe (but with those hormones a-ragin' you don't really want to point out that they are ballooning around the mid-section-just a tip). If they aren't pregnant, well you've just pissed off someone bigger than you, you idiot.

In the labor and delivery ward, you would think it would be a pretty safe place to assume people are knocked up. But even in the medical field, even in the OB profession, you never assume a woman is pregnant unless you are actually seeing a fetus come out of her va-gingo. New moms' uteri have not yet recovered from the indignity of 1. Being occupied and 2. Getting pummeled day and night by the little squatter. Even the skinny moms leave looking 7 months pregnant. You only know they aren't by the fact that they're awkwardly carrying a angry little human with them.

"What do you mean pregnant? There was birthday cake in the breakroom!"

You can't assume any parent with a child over six weeks couldn't possibly be pregnant either. One of our patients gave birth to her second child in less than a year. I bet that was an awkward conversation at the doctor's office. "Ok, now that you're six weeks post-partum you can have sex again. So what birth control were you thinking? Not the pill because you're throwing up every morning? Uhhhh yeah....we should talk."

Sometimes one has to take advantage of these sorts of social oddities. On a recent outing that involved birthday dinner at a Mexican restaurant, I knew things could get ugly. There was queso dip involved after all. So I sweet talked my hubby into wearing his thrift-store "Daddy to Be" shirt (he was actually wearing it the day we met-it wasn't true then either Thank God). As long as I kept my drinking surreptitious, I could eat as much as I wanted that night, and NO ONE would be wiggling their eyebrows behind my back. Hah.

In short, this is a situation that often requires finesse and professionalism. So sometimes I just back out of the room quietly and go get a nurse who knows who is the patient, who is the father(-ish) du jour, and whether any of the other people in the room happen to be pregnant.

Alien!!

2010-02-03T16:43:00.000-08:00

Gyn surgeries include C-sections. Which I love! Despite the "Will I puke/Will I cry?" questions in the back of my mind, I love seeing babies borned.

We did a C-section today on a woman who might possibly be missing her rectus abdominus sheath. I don't really mean that, but from what I could see, she had nothing but a layer of skin separating that baby from the outside world.

The doctor doing the surgery tried to warn me as we were heading to the OR. But I thought she was just making conversation, not giving me a heads up so I didn't yell "WHOA WHOA WHOA" when I saw the baby's facial features clearly through a stretch mark. Which would be totally unprofessional of course. And hopefully something the mom wouldn't remember it once she got the anesthesia.

I have never seen anything like it. When the nurse undraped her abdomen, it was like seeing a baby laying on the woman's stomach with a layer of brown silly putty stretched over it. A baby pushing on the walls to get the heck out of there! I didn't know if she was pregnant or had unhinged her jaw and swallowed a baby.

Once we started cutting, I actually saw her rectus sheath. It did exist. But holy schlamoley did she had some work ahead of her. I bet when she stands up she can grab her colon and squeeze out a fart.

I'm sorry, that is a disgusting thought. Maybe I should just stop typing.

Back in the Saddle

2010-02-01T18:31:00.000-08:00

Day One of my gyn surgery rotation.

I saw a lot of vagina today. I was expecting to see the isolated surgical species, but the attending I was with also happened to be on call. Which meant more vagina than you could shake a...I just went to the gutter. Fill in your own joke.

As usual in the town where I am working, most of the patients were either some flavor of crazy or unmarried, 20 years old, and G3+ (meaning they've been pregnant at least three times). Some of these women are having tubal ligations before mine even get broken in.

There was also the inevitable teenager. This one was particularly great as she was one of the most outta-control diabetics I've ever seen. We're talking a hemoglobin A1c of 13.7%!! That means she had so much glucose swimming in her insulin deprived bloodstream that a certain type of hemoglobin in her blood was glycosolated (glucose-ated) at an obscene level--normal is below 6%, diabetic control is 7%, hers sucks.

It's pretty common to have poor control in teenagers. They are generally idiots. And I include myself in that assessment, as a teenager I sprained my ankle twice, then when it got better I sprained it again by purposefully cleating a 3rd baseman in the mitt (while not wearing my ankle brace--to be fair, she deserved it). Then 6 weeks after the surgery on it, I sprained my other ankle playing "one-footed basketball" because I was so stir-crazy. Luckily my boyfriend at the time could carry me back to my dorm.

Anyway, teens think they're invincible. Teens don't want to do what someone else tells them. Teens don't want to stick out by being diabetic. Teens are morons. Lots of reasons for them not to follow their regimen. But when teens get pregnant and are diabetic and possibly morons, it is a bad deal all around. I guess it's not intuitive to some people that pregnancy and diabetes are not pals. At least, not to anyone who hasn't seen STEEL MAGNOLIAS! I bet doctors in the 80's didn't have to deal with this shit. Not after Julia Roberts so classically portrayed what can happen if you're uncontrolled and pregnant (in case you didn't see the movie--unfortunate haircut, coma, and death). Long story short, we now have a teen mom whose baby is got shipped to a Children's Hospital weighing in at a whopping 4lbs. The risk of congenital birth defects in a patient like that are as high as 18%. This was a lucky baby, all things considered.

Oh, and now for the funny part. I usually assume the bewildered looking guy in the room is the father...ish. Teen Mom's besties were going to the cafeteria for Mountain Dew and bags of fried crap (DANG your teen metabolisms!), and when they came by they helpfully said, "Um, a nurse said she needed to sign some kind of afa-didi? They're ready". "You mean an affadavit?" "Uh, yeah, she can do it now." After they left, the nurse said, "Weeeellll, we're ready for them to sign, but she's not sure of the paternity." "Hmmm...does he know that?", I asked, now understanding a bit more about why that guy in the room looked confused. "Yeah, he knows and she knows (that's good), but no one else does."

Perhaps not the best way to determine the father of your child.

My doctor said she has more and more teenage patients unsure about the paternity of their babies. They want to know exactly when they would have conceived, or how soon they can have paternity tests done. Yikes. Tell me again why sex education is a bad thing?

Falling off a cliff-the fun way.

2010-01-30T16:00:00.000-08:00

As part of the Disaster Medicine course, we also got to haul ourselves up and down a nearly sheer rock face. You know, in case someone's life depended on it.

I say that only half-jokingly, because we actually trained with Albuquerque Mountain Rescue (they even had the shirts!), who, several times a year, actually do have to go get someone off the mountains surrounding the city. My personal favorite: A man and his girlfriend were hiking together when they were separated. Why? That was left out of the story but I imagine it's a good one. Man hikes off, leaves Girlfriend, who was probably only out there because Man dragged her out with promises of outbacky-togetherness and desert-bonding. At least, that's my guess because while Man made it safely to the car, Girlfriend got herself lost and panicked. I'm guessing he made it out with the map. And I'm guessing that's the last time she got herself talked into an innocent dayhike.

So yes, sometimes you have to clip in and climb. I hadn't rappelled since high school, several injuries ago and before my frontal cortex was fully developed. Now that I understood consequences a wee bit better, I was less the "fearless" Al and more the "You go ahead and do it first so I know it will support my weight" Al. Sometimes starting is the hardest. You have to back over a cliff, and with one setup, you had to do that clipped to a fixed rope before you got to the rappelling one. I'm not really afraid of heights, but I have a good healthy fear of scratching my pretty face on the cliff wall that is one misstep away. Yeah I'm married, but still.

Anyway, we practiced going up and down for a bit, which was fun. Then we had to practice putting a patient in a basket and lowering him down. Quite honestly, I was really over it by then, and I sure as hell wasn't going in the basket. Luckily, two guys on the squad and a very hardcore girl/woman were all about going over the edge. Unfortunately for everyone involved, the heaviest guy there that day volunteered to be the dummy in the basket. I have made my feelings on hanging out with people who can't carry me very clear. I guess this guy wasn't so discerning.

They finally get him over the edge with no small amount of scary near-tipping (yes, he's strapped in, but seriously. He was totally helpless in that basket, and they had crazy looks in their eyes). They were about halfway down when I hear, "Ashley wants to practice putting an IV in the patient". WHAT? Having recently had an IV myself, I knew that hanging off the side of a bluff was the last place I would want someone to attempt an IV. Then I heard someone else say she was a second year medical student. What a dumbass. Both her and the guy who agreed to let her try.

In a surprise turn of events, she failed miserably at her three attempts. This wouldn't have drawn so much ire from my colleagues and I at the top of the bluff if we hadn't been left to hold the belay ropes the whole time. We'd been on them for a good twenty minutes supporting four people's weight. We started to yell about how Evan's arms were turning purple and how we'd all had to wrap the ropes several times around ourselves, but Miss Action Adventure wanted "just one more try!" to do what she was going to learn next year with all the other medical students. Gunner.

In the end, the fact that we didn't have enough people to properly do the drill and it had gone so frustratingly off course is pretty typical for training...and I suspect sometimes rescues. Not to mention some of the people who are drawn to that field are the same ones who don't think twice about attempting to stick an unnecessary blood-drawing needle into a perfectly healthy someone's veins while swinging 25 feet off the ground. Which is maybe why I belong in the radiology department.

Elbow deep in Pelvii

2010-01-28T15:19:00.000-08:00

The party is about to stop.

Monday I start a gynecological surgery rotation. I have no idea how things are going to go down, but what I do know is that I have no intention of being in the OR when the nurses and techs prep the patient. At this point, I don't care if I whether or not I can put in a Foley catheter on the first try. And I'm not going to let the nurses goad me into either. Let the people getting paid wrestle their way down to an obese woman's urethra. I'll send them a nice card.

The good thing about the particular flavor of surgery I'm doing is that it's the only one that I can do off my medical school's main campus, and therefore away from the University Hospital and it's coven of evil lady surgeons. Now that I don't give two toots about grades and am *cross your fingers* almost matched to an entirely unrelated specialty in a city where I won't have to see them again, I don't think it would be quite the anxiety inducing experience it was a mere 12 months ago. But who wants to take chances this late in medical school? I was just at the dentist the other day, and we reminisced about how at the end of that rotations my gums bled at the slightest provocation. Like, opening my mouth. Fortunately for me, I didn't open my mouth much near then end of those two months for fear of getting "Work on professional demeanor" on my review again.

So anyway, what I really want out of this rotation is a. To remember internal female anatomy (I think I have the external stuff figured out) and b. To sew some crap together. I've been substituting my sewing machine, Fancy, for my love of all things suturing, but sewing placemats and tea towels ain't no substitute for making the edges of an incision come together as if they were never scalpeled and stretched so you could get at someone's innards. Ahhhhh.

Well on that note, gotta finish dinner.

Disco Thursday

2010-01-21T20:32:00.000-08:00

I've told some embarrassing stories that make patients look like idiots. It's probably time to tell one where I'm the a$$hole.

The other day I was in my doctor's office for my own annual women's exam. Which already put me in a great mood. Then the nurse mentioned one of my least favorite phrases, "There's a student with Dr. Poke'n'Prod today, do you mind if he comes in?" Yes, yes I do. I understand that I was in his position, waiting outside the door trying to make the time pass more quickly by reading all the STD posters in the office. But I also understand that the reason I go to another town to have this done is so that I don't meet one of my future co-residents business end first. I don't even want them in the clinic the day I'm there. Even if they don't see me, they read the name and reason for visit. And probably talk about it with the doctor after she's done. That's how I know a student in the class above me had an inguinal hernia. Just saying.

I used to be more open to the idea. When I was in college and knew I'd never meet those people again. My very first women's exam, for example. I had to go to the student health center just down the street from my dorm. I had taken a couple of Vicodin that I had leftover from a surgery. What the hell? I wasn't driving a vehicle, and I figured it was the best use for the stuff.

There was a female medical student with the doctor that day, and like I said I'd taken painkillers, so when the nurse asked I said "Sure." Then came the exam. It was my first time so I didn't know what was really supposed to happen. I figured they were quiet because she was pointing things out. Which is still weird to think about. Then the doctor asked in a puzzled voice, "Did you know you have sparkles on your...?"

I should interject with a backstory. My idiot friends and I were into themed days. We'd declare a catchy name ("Topless Tuesday"), wear or do something related to the theme, and giggle together over our hilariousity. That day happened to be Disco Thursday. And I happened to have a sequined pair of underthings for the occasion.

In retrospect, I should have thought about my wardrobe choices. It's not as if I expected that pair to be especially well-made. I should have known they could possibly shed their sequins, making me look like a fish in drag from waist down. Which, when that's all you see, would be pretty weird.

If that happened to me now, I'd say some smart-ass comment like, "Yeah, my crotch was the 100 customer at the new Price Chopper; she's also won a year's supply of pet food." But since I was 18, shy(ish), and on heavy pain medication, I just giggled a little a mumbled "Disco Thursday" without any other comment or explanation.

I'm sure that if that medical student has a blog; I'm a post in it. Which I totally deserve.

Rank-List

2010-01-19T10:33:00.000-08:00

My interviews are finally over. I ended the streak in a place that, when I told people where I was going, they unanimously said, "Why on earth would you go there?" I didn't want to say, "Because findyourspot.com said it was a good place to live" which underneath a lot of other reasons is why I first considered it.

I got in from my next-to-last interview at 3am Friday, slept for as long as I could, then packed the car for the trip. I picked up a girlfriend along the way, and we didn't roll into town until midnight-not a good start for an 8am interview.

I wouldn't say any radiology interview has been malignant (do people outside of the medical field describe things as "malignant"?). It's not like surgery. These people like their lives. But sometimes you get some bonehead questions from interviewers. I count "Why did you choose radiology?" as a bonehead question because:
A. I already have an entire personal statement which explained it when I applied. Do they just want to see how much I remember?
B. Seriously, did you get that question out of Interviewing for Dummies? In my estimation, there are only so many answers to that question and when you interview 30 in a day, you are not going to want to listen to the same answer over and over. So the third time an unoriginal interviewer asked me, I said I was doing it for the hookers and blow.

As I mentioned before, what I really hate is when a program asks, "So where are you going to rank us?" Basically, they want to look the best, and everyone looks the best when the people they rank highly rank them highly. They don't want to put you as number one if you're going to put them in the "I'd rather sleep on a park bench for a year and try again than to go to this program" category. But to me, asking me that question, especially in a pointed, "You have to show your cards sometime Al" (actually said to me by one department chair) way is like asking, "So, I think you want better than this. Are you just pulling our....?" you know what I mean.

One interviewer last week was supposedly a "hard interview". As the attending who followed him said, he tries to get under each candidates skin and pick apart their ideas about how life works. I could tell he was watching me for a reaction, but I generally agreed with his assessment that I know about as much about life as Rush Limbaugh knows about moderation. Plus, as I so desperately wanted to point out, I've worked in a truck stop and I've been pooped on by a human. More than once, if you want to know the truth. It would take a little more to rattle me.

Like maybe making a big fat deal about my name change. One interviewer at the last place told me, "Don't you know you should never change your name in this profession?" Another, "I know a woman who didn't match because she changed her name." My match ID is the same under both names. If this department can't handle something as simple as a name change without lecturing me on the duality of my application and the future difficulty I will have in all areas of life because of it, it makes me wonder how they handle something really important. Like my vacation time.

Now it's rank list time. I will rank the programs in order of which one I'd like to spend the next five years at. They in turn rank their candidates. A computer will match us together. Kind of like e-harmony for THE FUTURE OF YOUR CAREER. And it doesn't even have a spot to check "Likes backrubs and wine". So I make sure to mention that in every interview.

If you don't match? I can't think about that right now. I'll write about that after I'm safely matched.

I can't believe four years of college and four years of medical school come down to a few minutes in a computer program.

Knot my fault.

2010-01-09T06:34:00.000-08:00

Since I've been on vacation now for a bit, I have a story from one of my classmates.

Another classmate of ours was on OB during a pretty busy night. I think I mentioned before that in our university hospital, the medical student's main job is to deal with the placenta. Which is totally gross. And smells like warm squishy bait. Sorry. I get upset every time I think about what they make us do.

Anyway, after you deliver it (which involves gently GENTLY tugging on non-baby half of the cord and mashing the heck out of Mom's lower abdomen), it gets thrown in a blue tub with a clear plastic lid. Why the emphasis on gently? Because our OB textbook specifically says that medical students pulling too hard have inverted uteri. Who wants that on their record?

Your job is to measure it, record that in the mother's medical chart, and if there is something particularly weird about it, or if the doctor says to, you send it to pathology. Some reasons include maternal disease (diabetes, preeclampsia), or baby pathology (two vessel cord, malformations, etc.) Otherwise it gets incinerated, unless of course the parents want it for eating or burying or...gross. I know it can be a cultural consideration, but part of me says that's just what a society came up with so that people saw afterbirth as a special sacred part of the process instead of a quivering, steaming nasty-sack. I gagged more than a few times dealing with that little part of the birth miracle. As for the hippies who want to make a necklace out of it...you must be first time parents. When I used to think of placenta I pictured something like the natural sea sponges you buy in Florida, only reddish-colored. You know, dry and inoffensive. Add a lot more hydration and a little more poop surrounded by a membrane and now you know why I can't get over it. I tried to think of something like that stalactite pic I came up with for HPV, but even that would be too gross to post.

I digress. So our buddy gets a placenta to take back to the measuring room, a small closet with a refrigerator and disposable measuring tape. You're supposed to get it out, but honestly I just poked it around the tub a bit to make sure it was intact. He starts to measure the cord, and what's this? A knot! I'm a little fuzzy on how the next part happened, but I guess he thought somehow during the acrobatics AFTER the birth one of the staff accidentally twisted the cord into a knot. So he untied it and went about his measuring.

It was only later when a resident was talking about the birth and said, "Oh yeah! That baby's cord was knotted; we need to send the placenta to pathology!" that the student realized he had in fact grossly misunderstood. Not one to panic, he went back to the room, retrieved said placenta, and re-tied the knot. Then I imagine he slipped it back in the fridge, dusted off his hands, and went back and acted like nothing happened.

Seriously, this could be a side-story in an episode of Scrubs.

A Tale of Two Toenails.

2010-01-07T12:59:00.000-08:00

I've been sitting on this story for a while, but I need a break from trying to quilt (sounded like something good to do with my free time, but apparently I'm a F#$#%ing terrible seamstress).

We just got back from a week of snowboarding in Colorado. My main goals were:
1. Have fun
2. Not get left behind by the boys
3. Not bonk my head into stupidity. After all, I'm not really skilled in anything...my brain is all I have, and it's currently in hock.
4. Come back with two normal toenails.

Last year, while trying to follow rules one and two, I got talked into a run I really didn't want to do. My boots weren't tied quite right, and my left foot REALLY hurt somewhere in the big toe area. The rest was numb, so I couldn't be more specific. I didn't want to hold up the party, so I did the run. At the bottom I could nearly stand up my foot hurt so bad. When we got back to the condo I took of the stupid boot to find this:

I know the pic is blurry; I can't find any others--this is probably for the best.

Anyway, you get the picture-black toenail. What I surmised was that since my foot was crammed into the toe of my boot, the force of snowboarding had lifted the nail from the bed, bursting a blood vessel until it filled the space and the pressure stopped the bleeding. Gah-ross.

The reason I'm talking about it is because had I known that's what was happening, I could have done something! When I was on family medicine I got to use the coolest clinic tool ever: The portable cordless bovie.

All you have to do is push that little white button on the top--then the filament tip glows red-hot and you can burn the crap out of whatever pinpoint sized thing you want to. You can order these online, but after seeing how excited I was, the doctor let me take it home. Score!

In the clinic I used it to burn through a guy's smashed finger--he had a pool of blood similar to mine. You get the filament hot-hot-hot, then tell the patient to take a deep breath (actually, that's what I did), and hold the filament straight down on the nail until you feel it "pop" through the nail and sizzle the blood. You shouldn't look too closely while you do this; if the blood is still liquid it could shoot out from the pressure. Which is a shame; my first instinct is to get up close and see the action.

This guy's blood had partially coagulated so the Bovie didn't do too much for him. By the time I saw my toenail nothing would have helped. (Otherwise I totally would have Bovie'd myself. I feel like I was too gentle with it in the clinic that day). I didn't have my Bovie at the time either, but you can do the same with a paper clip and a lighter. Not that I recommend that of course.

So, since I had no way to remedy it, I went through this past year, including my August open-toe-shoe wedding with one funky toe. As it grew out blood clumps came out from under it. The ladies at the bridal shop nearly fainted when I went to try on shoes.

I made it safely through this trip, though a girlfriend of mine started her Derm rotation with a black eye from a particularly nasty snow smash in the face. But you know what? I think it looked good. Tough. Definitely a good start for Dermatology :-)

CrichothyroDundee

2009-12-22T06:12:00.000-08:00

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.

(from Surgery Encyclopedia)

But apparently, the risks associated with it are enough that the people who really know how and when to do it don't want the people who kinda know how and when to do it to be running around sticking ink pens in people's throats. There is a little friction between docs and paramedics when it comes to field procedures. By nature, people who ride around in ambulances like the action, and in my experience doctors get very angry when procedures are done in the field without proper justification. Probably because if the patient has a bad outcome, it will essentially hang on the doctor before anyone else.

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.

Intubation Obstacle Course

2009-12-17T06:32:00.001-08:00

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.

The Interview Trail

2009-12-13T14:44:00.000-08:00

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.

Da Boards

2009-12-07T04:47:00.000-08:00

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.

Everybody's a Comedian

2009-12-03T06:04:00.000-08:00

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.

The Second Time I Soiled My Pants

2009-12-01T06:52:00.001-08:00

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.

Next Up: What the Hell Happened to Me?

2009-11-04T11:33:00.001-08:00

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.

Radiology Means Never Having to Say "Rectal Exam"

2009-10-31T17:09:00.000-07:00

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.

Now THAT's constipation!

2009-10-30T16:40:00.000-07:00

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.

The Spirit is Willing...

2009-10-25T08:02:00.000-07:00

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.

Maybe Flying Ain't For Me.

2009-10-21T14:12:00.000-07:00

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.

Wilder-nasty

2009-10-16T17:58:00.001-07:00

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.

My 100th Post

2009-10-14T19:22:00.000-07:00

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!

There's a Sucker Born Every Day

2009-10-12T21:48:00.000-07:00

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.

No Really, Those Poppyseeds Aren't Mine!

2009-10-06T15:55:00.000-07:00

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.

My mother the Hothead.

2009-10-01T09:14:00.000-07:00

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.

Idiots in Public

2009-09-20T09:36:00.000-07:00

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.

Stub or Nubbin'

2009-09-11T21:16:00.001-07:00

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.

So I got married

2009-09-09T17:33:00.001-07:00

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

but I will write more.

40 Lashes

2009-08-18T20:36:00.001-07:00

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!

The Fine Art of Making a Good Impresssion

2009-08-08T06:18:00.000-07:00

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.

Happy Birthday!

2009-08-03T15:00:00.000-07:00

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?

Fourth Year Is....

2009-07-28T07:00:00.000-07:00

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.

Candy Gram! Updated

2009-07-23T05:06:00.000-07:00

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.

Apology

2009-07-22T05:10:00.000-07:00

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.

Beware the Google Search

2009-06-23T17:09:00.000-07:00

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.

Why I haven't blogged lately.

2009-06-22T21:06:00.000-07:00

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.

He-Man Woman Haters Club

2009-06-17T20:24:00.000-07:00

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.

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

2009-06-12T05:34:00.000-07:00

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.

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

2009-06-08T19:42:00.000-07:00

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.

What have I done?

2009-06-05T20:04:00.000-07:00

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.

The $3,000 Case of Strep Throat

2009-06-03T19:05:00.000-07:00

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.

I am not a night person.

2009-06-02T19:32:00.000-07:00

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.

Why Are You Here If You're Not Going to Listen?

2009-05-29T05:46:00.000-07:00

I'm really not sure why people come to the ER sometimes. They aren't going to listen to what we say. Stop smoking to help my COPD/shortness of breath/asthma/habit of getting pneumonia? No thank you. Quit drugs so I'm not found wandering in Walgreens in my boxers mumbling about how Barack Obama is the Antichrist come to get us all? I don't think that's what's wrong with me. Lose weight so my knees don't hurt? Well that can't be the cause of it!
One of the attendings told me a story about when he was a resident. A 300lb lady came in complaining of chronic back pain. And not just complaining. She spent most of their time talking together saying, "Well WHY do you think this happened to me? Why has God put this affliction on me? Why? WHY does my back hurt? What can I do?"

Now, how I would have handled that question is why I probably shouldn't work with the public. This doctor tried a little tact. "Well ma'am, as we age and start to gain a little weight..." "ARE YOU CALLING ME FAT?" Welp, there goes that. He tried to tell her he wasn't calling her fat per say (which she was--and how she didn't know it I have no idea), but she was done with him. She left with a harrumph! and wrote a letter to the hospital. When he explained himself to his ER director, the director said, "Well, you have a chance to respond." So he did. To the tune of "I didn't call you fat, but now that the cat's out of the bag, you're OBESE! And that's probably why your back hurts!"

Yesterday we had a gentleman in his 60's transferred here from another hospital. He went there complaining of odd chest pain. When I went in to see him, I saw a ruddy, solid looking guy in a hospital gown and cowboy boots already fussing and complaining about all the things we'd done to him, how he shouldn't have come in, how he was fine now and the pain didn't feel like a heart attack. Here's the funny thing: he had a scar along the entire length of his sternum. What was that from? Oh, just his quadruple bypass a few years ago. Yeah, you're not having a heart attack sir. I tried to explain how this probably wouldn't feel the same because his surgery cut through nerves and altered his pain sensation. We tried to explain how the fact that he did manual labor everyday doesn't replace a stress test, especially because his chest started to hurt while he was doing said manual labor...you don't have to have a medical education to put that together. We tried to talk to him about how we only wanted him to stay one night so they could check his enzymes and have him see a cardiologist.

But it was no use. Two hours later we got called to his room because he was ripping out his IV lines and preparing to leave Against Medical Advice. I can't think of any other word to describe what I felt when I looked at him stubbornly refuting everything we tried to tell him except revulsion. "Well what's all this bullshit! I don't see why I have to be here! I've already sat here for an hour and a half! (btw you have to wait to take serial cardiac enzyme assays-we weren't just holding him) I don't think anything's wrong with me! I'm just gonna go back to work." I wanted to light into him for being so stupid. I resented every word out of his mouth. My attending pulled out every reason and logical explanation for why we wanted him to stay. He seemed like he was going to agree, then he just said, "Well, I think I'm just going to go. I'll take my chances." I wanted to say, "fine, get the hell out of my ER, you old fool. Next time it's gonna kill you."

You might say, "Al, it's his choice, why are you so mad?" If he were to leave and never come back, that's one thing. But what "take my chances" really means is "I'll go back to my habits, do the same thing, and then when this happens again I'll either get scared and come back or I'll be dead before I have a chance to get here." People come into the ER scared to death and desperate for help, but they leave exactly the same person they were before. Talking to people about changing the very things that are killing them is a frustrating effort in futility most of the time. The Mom-Dad-daughter combo in room 11 who each have their own oxygen tanks will probably still populate the smoking section of Denny's. The woman with a wall of mesh surgically placed in her stomach will still work at her heavy-lifting job, smoke, and weigh too much. My attending says it means job security, but I think it means a lot of emergency medicine is hand-holding and stabilizing for people who are intent on eventually killing themselves.

When I coughed, my bottom exploded!

2009-05-23T12:03:00.000-07:00

More tales from a male doc:

One day a lady is nearly two hours late for her clinic appointment. She had driven a long way, so my attending decided to squeeze her in the schedule.

The first thing you ask a patient is, "Why are you here?" (It's called the Chief Complaint on every form we have to fill out later).

"I coughed at work and something popped down there." What? You coughed and your butt exploded. Hmm....what in the name of episiotomy is the differential diagnosis for that?

Welp, time to take a look. I think maybe there was a little more history of swelling or discomfort, but in the end you're going to have to check it out anyway so you might as well get to it. Plus I'm sure his curiosity was running rampant by this point.

When he gets a look, a wrinkly discolored mass is pushing out where her perineum (there are a few other names for it, go to Urban Dictionary and poke around a bit.) used to be. It was a shock. Imagine going in thinking you'd see just normal skin and you see this.

To make a long story interesting, she had vulvar cancer. This cancer had been growing for a while, probably helping itself to her tissue, making a bulge and hurting and making look very ungracefull when she sat down. Then one day, she coughed, and her old episiotomy scar just gave up. KER-PLOP!

Ladies, please go to the doctor before this happens to you.