The Gas Mask

Trust Me, I'm a Doctor

2008-06-03T09:58:00.000-05:00

It's actually true now.

AI

2008-04-18T20:00:00.002-05:00

In keeping with this month's tradition of posts entitled with abreviations (with a grand total of 2 now), I give you AI.

Not artificial intelligence. That might actually be useful in medicine. Like really awesome PDA's. No, AI in medicine means "Acting Intern". That's what I am this month. I think it should also stand for "Absolutely Inept". Because that's how you feel when the nurses page you for something. Not because you don't know what to do all the time (that's only like half to 3/4's of the time). It's because even if you do know what to do, your answer can only be, "We should probably do xxxxx, but I can't give you an order. Let me talk to the resident and they'll take care of it."

As an acting intern, I'm supposed to be doing all the work that interns do. Except there's billing and medicolegal implications involved, so everything I do has to be duplicated anyway by a resident. So it makes me redundant. And out-of-the-loop when things happen and people go to where they can get orders instead of to me.

The nice thing, however, is that since my upper level resident has to duplicate everything I do she tends to not give me a lot to do. I only take up to 2 patients on call and tend to be last in line every time to get patients. That means if the service doesn't cap, I get only 1 patient on call. This is glorious because it frees up all sorts of time to do other important things. Like watch every single episode of Arrested Development.

The third year medical students on my team are all taking their internal medicine shelf exam this week. And they are all blaming me for their decreased study time because I told them about Hulu.

AMA

2008-04-09T21:42:00.003-05:00

I've considering posting about this multiple times over the past two years. AMA. It stands for a lot of things. Like acquired member assets, or Academy of Model Aeronautics. It's actually also a word that means "metabolic waste products and toxins that have accumulated in body and mind and which obstruct the healthy functioning of mind and body". On a related topic, it also stands for the American Medical Association.

But even more importantly, it stands for against medical advice. It's a phrase that means you took off from the hospital without being discharged. It generally conotates that you absolutely don't agree with your doctor and would rather be billed for all services since no insurance company will pay for a hospital stay that ends in a patient going AMA.

I knew going AMA existed before coming to medical school, but have been interested in its multiple faces since being on the wards. My first encounter with it was with a patient who came in for an organ transplant. If all goes well, they spend a bit of time in the ICU followed by about a week in a regular floor room. One patient during my first month had one of these kind of transplants. Everything was great and he was getting close to being discharged. To encourage this, we encouraged him to get up and walk around, as doing so has been shown to decrease length of hospital stay for most patients. Well, this patient interpreted that "going for a walk" meant leaving the hospital and strolling around, IV pole in tow, down the park across the street. The nurses caught on after about 4 or 5 hours that the patient was gone and not in the hospital anymore, so they started filling out the AMA paperwork. When the patient finally returned to find an empty room, they were clearly angry that the hospital would do that when they were just trying to do what the doctors had asked.

While amusing, other times its less so. Like the patient that showed up with **automatic admission** complaint earlier this week. They knew all sorts of details and used medical jargon in a bit of a peculiar way, sometimes seeming to feign not really knowing the right word, but then in the end getting it out anyway. Lots of patients show up and say they're in pain and sometime in the past that one that starts with a "D" helped. They then look in the corner and go "hmmmm" and then say, "Oh yeah! Demerol. 100mg in my IV." This patient was one of those. They also are ALWAYS allergic to a lot of stuff. Because if you're allergic to ibuprofen, morphine, vicodin, etc, etc, etc (add pain meds here) then you know that they can't give it to you. If you're allergic to everything but *drug of choice* then that's the only one they can give you.

Anyway, so this patient shows up following this pattern, but to a new high. They supplied medical record type information saying they'd been in the hospital recently for the same thing. Except when we called said hospital, they'd never heard of this patient. The patient also wasn't just allergic to all the other medicines, they were also allergic to the workup for **automatic admission**. No iodine. Not even xenon.

Seeing through the ploy, the patient was given no narcotic pain meds. Period. They were restricted to their room in the ED, and not allowed to leave the unit. And within a few hours, the patient demanded the AMA form. By name.

I've previously witnessed such things as punitive exams (like DRE's) and procedures (like colonoscopies) that aren't exactly necessary, but justifiable. They're done to discourage frequent flying of that particular hospital's ER. If you do enough mean stuff to a patient, they won't come back.

But what's always bothered me is what if they really are in pain? What if? There was another patient who left AMA this week that I felt bad about. They genuinely appeared to me to be in pain. And had several good reasons to be in pain. But also knew the names of a few pain meds that worked for them. But didn't get any. And left really upset. And part of me feels like they were just there for the pain meds, and part feels like we just did a bad job helping them.

Baby Story

2008-02-25T21:57:00.003-06:00

Moved

Proud Daddy

2008-02-23T18:15:00.008-06:00

Moved

Second Best

2008-02-09T15:15:00.000-06:00

For those of you who know me, you know that I believe very strongly in my religion. That's why this post is called second best. Because if had to choose a back-up, this would be it. The Jedi Church. It's for real. The Jedi Church was officially estabilished in this, the year of our Lord 2008. It's no secret that they've been around for years - putting down "Jedi" as their religion on census bureau data for quite a while. But what's different now is that is officially recognized by the UK as a religion. Ned Flanders admitted in one episode of the Simpsons to "eating Kosher - just in case." Well, here's to the Force - just in case.

A quick survey of their site reveals that they "have no doctrine", and that their members are almost exclusively males between the age of 10 and 40 who live in the US and UK. Most are students, although quite a few work for the government. Which reveals a rather bleak future for the religion. How far could a religion go without women? Then again there's always this girl:

I guess it's like the Smurfs. They only needed one Smurfette to populate an entire village of mushrooms.

Not So Infrequent

2008-01-30T19:27:00.000-06:00

I was just reading through the day's "Odd News" and found an article that raised my interest, possibly because it relates directly to my current situation. The story talks about a woman who was 36 weeks pregnant and started having labor pains. She went to the hospital, was told that it was false labor, and went home. Waiting for the false labor to pass, she rested at home until she just couldn't bear the false labor pains anymore. So she tried to get to the hospital again. Except she didn't make it very far. Only to her driveway, in fact.

The thing that struck me about this article is that it isn't exactly a rare event for a woman to go to the hospital and be told it's false labor and get sent home only deliver shortly thereafter. I remember a few such cases in the 3 weeks of inpatient OB that I did last year. That's 1 a week. Late in the residency calendar year. At the end of the residency calendar year, in fact. One woman came in and the resident checked her. He told her that she was only 2 cm dilated and her contractions weren't regular enough. So after protesting that she had a history of short labor she left. And then nearly had her baby at IHOP over pancakes. She made it back to the hospital and was crowning within 5 minutes of getting to triage.

I'm glad I'm not going into OB. It's becoming more and more of a regimented profession in a process that is highly variable. But that's a whole different story for another post....

Triage

2008-01-24T08:37:00.000-06:00

One of the (many) perils of going to medical school is the whole concept of phone triage. That is, when someone calls you up and wants to know your medical advice for their current ailment.

The first time it happens it's almost universally so early into medical school that you have no idea what to actually say to the person. But you feel awesome that someone thought to call you. Medical school is interesting in that most people have little or no patient contact until the third year. So when you're a first year student, you can think of that one weird disease you just learned about in histo or micro, but really you don't even know what to ask next. Then you get to second year. Second year's classes are all about things that go wrong in the body. The "zebras". So when you get that call all you can think of is that rare African tribal disease that it "just might be." It never is. And of course along with second year comes the supressed hypocondria. Everytime you yourself have any symptom at all you think you have lupus or colon cancer or leishmaniasis. Never mind it's pretty unlikely. You probably have it.

Then you hit third year. Actual daily patient contact and real medicine. You start to learn the differential and actual effective history taking. That's also when "I don't know" becomes the only thing you can think of during that phone call. "Ummmm. I don't have Peds till next semester. Better call someone else." Then you finally get to fourth year. Blessed fourth year. You get to where you think you know everything. You've passed your step 1, 2, and 2CS. You've gotten boat loads of invitations to interview at residency programs. You've turned down interviews. And then you get that phone call. And all you can think is the absolute worst case scenario. "She says her neck hurts and she has a fever." "Oh my gosh - it's meningitis". "She says her stomach hurts when she eats fatty foods and now she's vomitting." "Oh man - I hope it's not cholangitis." And so your answer becomes the same for every single phone call. "Better take 'em to the ER. Just in case."

So if I've told you this year to go the ER and it turned out to be nothing, or if you called and all I could say was "Ummmm. I don't know", or if I told you that you have a rare African tribal disease that comes from eating human brains, I'm sorry. It's just the way of the med student.

EtAOK: Journal Impact

2007-12-11T19:52:00.000-06:00

So for you fans out there of my ramblings, you may have noticed I don't drink. I've actually blogged before about it. Multiple times.

Anyway, the other day I was driving to an interview somewhere and heard a radio ad that reminded me of the whole issue. They were selling a supplement that was "red wine extract pills with no alcohol." So it obviously peaked my interest as knowing what it is in red wine that isn't in vodka is obviously what gives red wine its FDA/AMA stamp of approval over, say, moonshine.

Now I call this update journal impact because I'm all too aware of what journal impact factor is and what it means. So if I were to, hypothethetically of course, cite a study published by FASEB (that's the Federation of American Societies for Experimental Biology) I already know that it doesn't carry the same weight as something in, for example, The New England Journal of Medicine.

That said, the FASEB came out just recently and talked about what exactly it is in red wine that makes the difference. Turns out it's "polyphenols". There's a decent summary you can read about it here. After being tortured through organic chemistry anything with the word "phenol" in it just sounds dangerous, but apparently there's an exception to every rule. You can now buy polyphenol supplements on eBay (not that I am in any way, shape, or form endorsing this product. I personally think most supplements are garbage even more overpriced than the proven pharmaceuticals they "replace" - all without that pesky FDA who is always trying to stamp out American ingenuity).

One thing that's helped me support the belief that alcohol is heart unhealthy is the fact that the mormon population overall has a lower rate of heart disease compared to non-mormon countparts. In the off chance you're reading this and aren't mormon and don't know anything about mormonism, mormons are pretty well known for their abstinence from, among other things, alcohol.

Well, it turns out that it's the abstinence from one of those other things that seems to play one of the biggest factors. While I know that Deseret News is also not exactly a high impact journal, the story actually was broken across the AP wire and showed up on most credible news sites today (i.e. MSNBC, CBC, The London Free Press, etc). The study showed that fasting may actually be more cardioprotective than all that other stuff. Traditionally the first Sunday of every month is "Fast Sunday" worldwide in the LDS church. On fast Sunday, those whose health permits abstain from a meal or two and are encouraged to donate the money saved from not eating those meals to the Church's Fast Offering fund, which is specifically used to to provide welfare to the poor. While the study certainl by no means proves that fasting is cardioprotective, it certainly is suggestive.

But I still think alcohol is not good for the heart.

Questions: The Interview Process Part 2

2007-12-06T00:25:00.000-06:00

If you know anything about me, you know I'm in the middle of interviewing all over the place for residency.

I'm not even half way done, but I don't think I can stand to hear one more person ask me, "Do you have any questions?" Because if I say no, then I look disinterested. And if I say yes and repeat the same question I just asked three other people at whatever place I am that day and then I look like a zombie totally zoned out as I hear the same answer repeated almost verbatim back to me.

Maybe I need to cancel some of these prelim/transitionals when most of the schools I applied to provide their own.

Watching Football with the Folks

2007-12-02T19:32:00.000-06:00

I've waited to post this to wait for the relative excitement to die down. I was back home for the Thanksgiving holiday and my parents' home was filled with relatives. Two in particular are complete and utter BYU football fanatics. Having attended BYU, I understand. I do think it's a little ironic considering the fact that neither went to BYU, and neither did any of their children. In fact, one graduated from the hated rivals - the University of Utah. I digress. Anyway, so Thanksgiving was nice. And then came the Saturday after. The TV had to be dibbed days in advance for this game and the DVR was set to record "The Mountain" - the crappy station that broadcasts nothing but Mountain West athletics. BYU was playing the University of Utah.

There is a long tradition of heated games between the two. For example, last year the game came down to the final play. BYU trailed by 4 with time enough for one final play. You can see the rest below.

So after taking it to them in their own house, the Utes were particularly set on taking the W this year. That and the winner of the game actually stood to take the conference title for the year. It was a big game this year. Like Kansas v. Mizzou big. And I was interested in the outcome so I had to watch, despite my better judgement.

It was a very defensive game with both teams struggling. The 4th quarter started at a score of 9-3 BYU. And in fits of passion, I can still hear one person yelling "Get 'im! GET 'IM" as we watched the Utah quaterback scramble away from poorly excecuted tackles. The other of this dynamic duo spent most of the time talking about how much BYU was going to miss their missed field goals and TD opportunities. All I could think was, "Duh". It was kind of like when John Madden says things like, "You know, the team that gets into the endzone the most is going to win." Real men of genius.

And then Utah scores a touchdown. 10-9. Less than 2 minutes to go. In comes another family member who starts trying to lead high-school-esque chearleader cheers. I'm practically boiling over to tell them all, "You know that they can't hear you, right?" or "You know I passed first grade math a long time ago, right?"

BYU has the ball and then after a bit of poor playing it's fourth and long. Like 20 something yards long. And the pull out a 40 yard pass to keep themselves in the game. And then it happens. What annoys me the most about the BYU uber-fan dynamic duo is the way they talk about the officiating. If their team loses, it was always the officials fault for making calls that weren't really there or missing crucial penalties that would have saved BYU. During this particular game, there were a few questionable no-calls for pass interference and personal fouls that went both ways actually. But on this particular drive all the flags came out. After completing the impossible on fourth and twenty, BYU went on to have a both a pass interference and personal foul call go their way. The thing is, on replay they both looked pretty identical to stuff BYU had gotten away with earlier. In fact the BYU no-calls in some ways looked worse. And after getting over 30 yards extra from questionable calls, BYU was able to ram home a rushing touchdown followed by a two point conversion to win the game. Despite their poor clock management. I digress again.

Anyway, it's pretty clear to me that Utah should've won the game, but didn't. And I'm a BYU fan. But if you bring up the questionable calls to the dynamic duo, they argue tooth and nail that the calls were fair throughout the game. Of course - the Lord's team won. (For those of you not immersed in Utah culture, some on the more extreme side of the religious scale feel that BYU is "the Lord's University" therefore making BYU football, "the Lord's team." See picture at top of page. And who's that kid tackling Jesus?)

So I guess the point of this post is two-fold. 1 - I hate watching football with certain family members because the endless stream of inane commentary. 2 - BYU should've lost the game but managed to win with lop-sided penalties in their favor. Sorry Emma G*.

Some People: The Interview Process

2007-11-16T15:42:00.000-06:00

I've been interviewing for residency positions over the past month all over my home state. I've met quite a few individuals on the trail, and all I can say is "Some People!"

Interviews for residency are interesting. You are there obviously bowing before the altar trying to get a job from these people - although they can't officially offer you anything outside "the match". And they are trying just as hard to sell themselves to you. I consider myself lucky in that this year anesthesia programs are doing quite a bit to woo their applicants. Most are paying for hotels the night before. Most are providing us with extravagant dinners or lunches at fancy restaraunts. Several hand out SWAG bags when you leave. I've gotten pens, t-shirts, coffee mugs (they did their research on that one, huh?), snacks, and the obligatory school folder.

Each morning there is an introductory power point slide show (if the chairman/director is tech savy enough to figure out how to power up the projector and computer) that shows off their program. One program, which notably lacked the fancy dinner/lunch and SWAG, spent most of their presentation talking about unbuilt hospitals that they are pouring money into and how great their program is going to be. Others go on and on about their benefits, which frankly is what I want out of them, while others spend the hour showing you pictures of the town and of their residents out partying together at "journal club". Then you go off to interview.

Interviews so far have ranged from 2 to 6 interviewers for about 30 minutes each. When there's just two, you pray that you get someone high up on the chain of command while with 6 you die just trying to come up with original questions to ask each interviewer and to continue to look interested as they sell their program to you by giving you the same information the last 5 have.

And the whole time you pray you don't have a situation like I had at the aforementioned school-who-sells-you-unbuilt-hospitals. I walk into the interviewers office which happens to be noticably bare of any decoration. That's a red flag that whoever this is is new to the faculty and can't tell you much or not very involved with the main faculty. Turns out this interviewer was the later. The interview starts and I notice right away that this interviewer also doesn't say much. And then the fun starts. They asked me about my step 1 score. It by no means is anything that would blow you out of the water, but it is one I'm proud of and feel like was an accomplishment. They specifically ask what I did to study for it. I tell them all about the 3 week course I took and how it helped and they start writing down details on a sticky note and then put it in their pocket. Weird. Finally they give me something to grasp at and tell me their daughter is about to take her step and they just wondered what kind of courses were available to help. Fine - I think. Then I made a big mistake. I asked what their daughter was going into. The answer was she wants to go into XX-non-anesthesia-program. Without any further interaction on my part I then get a story about how this interviewers spouse was a high up faculty for this speciality at a near by hospital and then died of cancer 4 months ago. And then the interviewers eyes started welling up with tears. Not exactly what I signed up for.

Anyway, usually while part of the interviewees are interviewing, the other half are off in a room trying to make stifled conversation. Some people are great and are people I wouldn't mind working with in the future. And some, especially those who come from big name schools, act very guarded. They ask probing questions of you and offer very little information in return. They like to hear all about every other school and even go as far to ask where you want to end up, but when you ask them in return you get a quiet, "I don't really want to talk about it." Cut throat gunners! One girl I interviewed with today was just that person. She tried very hard not to divulge any iformation even about where she had applied. What's worse is this was at her home institution so she knew all the residents and faculty well so was off gossiping with them and even had the gall to take over on part of the tour of the facilities. She was very snooty about this particular school and inferred that no other school in the state was good enough for her. I hate cut throat gunners. Fortunately none of the other residents in that program came off that way, but she seriously drove me up the wall. Some people!

"Ambulatory" "Medicine"

2007-11-10T23:23:00.000-06:00

This month I'm on a 4th year required core rotation - ambulatory medicine. Essentially what that means is I'm supposed to be at just a regular run of the mill internal medicine clinic. Not in the hospital.

So I entitled this post the way I did because of what I'm actually doing. "Medicine" because it's actually more like "interventional cardiology". The attending I'm working with is a cardiologist, and a pretty well respected one at that. My friends are all treating diabetes and hypertension and "chronic pain" and whatever else it is regular doctors do. I'm seeing people who have all sorts of crazy messed up heart disease. SVT of pregnancy, s/p quintuple CABG (coronary artery bypass graft, or "cabbage" as we lovingly call them for short), or nectrotic foot ulcer limb slavage (necrotic = dead tissue). It's also interesting considering the number of health care professionals we see and treat. Nothings stranger than doing a history and physical exam on a patient who also happens to be a doctor at the school you attend.

"Ambulatory" because >50% of this month we're actually in the hospital and not in clinic. We have clinic two mornings and two afternoons a week. The other 3 days worth of time is actually hospital time. We round on patients in the CVIMU, CCU, and CVICU. We do lots of endovascular procedures in the cardiac cath lab. I think I've been wearing lead in the cath lab more time this month than I've spent in the clinic. Procedures after all is where the money in medicine is.

Oh yeah, and I think on average I'm working 3 days a week for the whole month. 4th year is everything I dreamed and more.

Note to Self [update 1]

2007-11-07T22:51:00.000-06:00

No "disco dancing" while intubating. Or putting in lines or anything else. Especially if I ever have the opportunity to be using an extremely high powered drill that CUTS BONE while cutting bones in the face. Read more here: http://www.msnbc.msn.com/id/21599495.

The real issue here is what do/should doctors and other health professionals do if (read WHEN) they screw up. Clearly not do what this guy did. I'd write more about it, but it's late.

[update 1]: I fixed the broken link, in case any of the 3 people who read this actually wanted to read the stem article.

They're Watching You

2007-10-23T22:34:00.000-05:00

This month I've been working in the surgical ICU. One thing I've come to notice is that ICU delirium is a very real thing. One patient on our service developed quite florid delusions and delerium. He rants about nurses having sex near his room and hospital staff stealing his credit cards and perseverates on the idea that the hospital staff is trying to keep him from communicating with his son. His delusions are so strikingly paranoid that if they were in almost any other context I'd think schizophrenia. Or cocaine abuse.

Anyway, he reminded me of my stint at the county psychiatric hospital. While there I saw many patients who had all sorts of bizarre and non-bizarre delusions. People would confide to you such things like their mother is really satan, or that their bones are disintegrating or that their doctor is conspiring against them.

It's interesting dealing with these patients because you have to build their trust, but at the same time cannot foster their delusions. You have to reassure them that you believe them, but at the same time let them know what is actually real.

The reason I am re-blogging about this (you'd have to have access to the old blog to see the original post) is that I saw the below video at The Onion. I wasn't quite sure what to think of it. They bring up some of the most common delusions that schizophrenics have, but make a mockery of it in a Steven Colbert style comedy. While some of the delusions people have can certainly be entertaining is this video going too far?

Hijack a Phone Number

2007-10-18T14:35:00.000-05:00

Yesterday my wife called me. Instead of hearing her familiar sweet voice, I was greeted by Optimus Prime. He told me that the Decepticons are waging war in my own home state and that I was needed in the battle lines. He also warned me that one of my classmates may have joined the enemy as a Decepticon named Devastator. He then instructed me that I could help by purchasing the Transformers movie on DVD or HD-DVD.

What is super awesome about this call is that you can send it to anyone from this website. I'm sure it's totally against the terms of agreement, but you could potentially hijack anyone's cell phone number and send anyone else a message. You could even send it to two people's phones at the same time (if you have two windows open) and have them call each other at the exact same time.

P = MD

2007-10-11T22:16:00.000-05:00

Today we ate lunch with one of the pharmacy students and a pharmacist. While eating, the pharmacist said, "There are people who were in my class I just thought shouldn't be pharmacists. Do you see the same thing in medical school?"

Sadly you do. Medical education is interesting. The admissions criteria are difficult. There are lots of hoops to jump through. You have to look good on paper and in person. You have to weigh competing offers or pray that you are at the top of the wait list. But once you are in, you are in. Atrition from medical school, at least my medical school, is remarkably low. I can think of only one person who has actually been kicked out. I can think of at least 5-10 others who probably should be kicked out. But doing so is a death sentence to a career in medicine. After acquiring so much debt to get through school, it seems like the school bends over backwards to get you through to the end.

Some people pick fights with ancillary staff. Some people let their egos supercede their training. Some people just don't have what it takes to survive effectively in the system. Some people are just plain not mature enough to handle hearing the proper terms for certain anatomic regions without giggling. Somehow all of them become doctors.

Every now then urban legends crop up about so-and-so who did such-and-such on the wards. Hearing those things second hand through the grapevine make them hard to believe, but almost all gossip and rumor are seated in at least a little peice of truth. And what's even more incredible is the fact that almost universally everyone seems to have a story about one person they rotated with that did something so incredibly stupid that you wonder how that person ever got into medical school. What's funnier is that sometimes the entire class knows how that yahoo got into medical school. It's so prevalent it just leaves you wondering - was there ever a day that it was me who gave someone else something to talk about? I know when I hear stories about people, or witness it for myself, I don't really have the guts to bring it up to their face (i.e. coumadin anyone?). Am I the gunner that just makes people look bad without knowing it (you couldn't tell from my non-AOAness)? I'm that guy who left all the scut work for someone else to do? I'm I the class idiot who doesn't see what everyone else on the team sees?

I try to not be any of those things, but sometimes you just have to wonder. Am I?

Hugest Baby Ever

2007-09-26T21:03:00.000-05:00

So I'm in the middle of studying for my Step 2 right now. Not nearly as hugely important in deciding the course of the rest of your life quite like Step 1, but it's still pretty important. So, I wasn't intending on blogging until after the test, which begins in 35 hours from now, but when I saw this I couldn't resist. A 17 pound 1 ounce baby. That's a really big baby.

Surprsingly, this little bundle of joy was born via C-section. I've seen my fair share of those and it's usually a pretty tight fit for a regular size baby to come out. I would have to guess they didn't go with a fanninsteil on this one.

Anyway, on further reading of the article lots of read flags went up. That's how they train us, you know. This was baby #12. Cheaper by the dozen, right? Apparently none of the other 11 babies came in under 10 pounds. And mom couldn't afford any fancy diet, so she just went with potatos (carbs), noodles (carbs), and tomatos (not-carbs). I thought pregnant women were supposed to get unsatiable odd cravings. The point is that this sounds like classic gestational diabetes. Insulin is an anabolic substance. Anabolic kinda like anabolic steroids, but not quite. That means it helps build tissue up. Mom's with diabetes are resistant to insulin's effects, which is why they start making too much. Babies, however, are not insulin resistant. So babies become overtly huge if gestational diabetes goes untreated. There can be other complications, but this is classic "macrosomia" (litterally translates to "ginormous body" in latin) that really is a red flag to look for Friday on my test. So this really was studying.

Believe

2007-09-24T08:38:00.000-05:00

Imagine this. It's the year 2552 and the Earth is under assault by an alien race. It's a war on the human species, and we're definitely out-manned, out gunned, and on the verge of defeat. Except there's one man who manages to rally the troops and single handedly throw the war in our favor. Master Chief.

OK, so this isn't really going to happen and is based totally out of a video game. Perhaps the most hyped video game ever. So hyped that the makers, Bungie, have gone to the trouble of making quite the ad campaign out of it. They call it the "Believe" campaign, and through it have tried to make the Halo story more real by interposing live actors to talk about the war in a fictitiously created museum that honors "the Chief". I quite like the videos, but my wife thinks I'm a nerd for even being interested in them.

The first is a fly through of the center piece in this museum. It depicts the battle where the war was supposedly decided. I particularly like the piano music background and the dramatic details on the minatures' faces.

This second one is an account given by one of the soldiers who was in that battle talking about how they were able to stay in the fight and the hope that Master Chief brought them.

This third one made my wife laugh that someone would go to all the trouble of actually constructing this monument about a fake war that happens in a video game. And that they'd make a documentary about it like it really happened.

This one is an account given by another soldier that was there. He talks about some of the weapons and is asked a few questions about one the alien guns, the "Spiker", which is a new addition to Halo 3

This is the latest one of the commercials and is a soldier talking about hiding in the forest while the aliens were running around looking for humans. And all he could do was sit and wait for Master Chief.

So, yes, I am a nerd and I am excited for this game to come out tomorrow even though I know I won't be getting it for a while.

Et-AOK revisited [update 1]

2007-09-20T11:04:00.000-05:00

Those of you who have been reading my blog since its previous address may remember my EtAOK post. Without reposting it, a quick summary is that despite its many ill effects and the huge cost it creates within society, alcohol (a.k.a. EtOH) is consistently and preferentially ignored throughout medical education. I like to therefore call it Et-AOK because despite the huge medical burden it places on society, since most doctors seem to enjoy drinking more than the average individual it is passed off as being totally OK, or EtAOK.

We all know smoking is bad. It causes cancer of many kinds. It causes significant decrease in lung function. It causes birth defects. It even carries a surgeon general's warning that using the product will cause these problems.

Alcohol can cause cancer, specifically hepatocellular cancer and stomach cancer. Alcohol can cause you to die from just about any organ system failing. Alcohol is the #1 cause in America of birth defects. Nobody seems to care.

Not only does alcohol cause all these things, it also causes a lot of trauma. You might remember my ER rotation posts "Life Lessons" and "Chief Complaint". A lot of those people also came in with pretty notably elevated blood alcohol levels. Anyway, the whole reason for me revisiting this post is I spotted this article in the news today. You might notice a few things about this guy. Like his use of a mixture of "stupid stuff" right before inserting the snake in his mouth. A poisonous western diamond back rattlesnake. Into his mouth. Because it was a "nice snake". Not that this one case report among many would change the fact that in medical school you will hear more about "the beneficial effects of drinking one glass of red wine daily" than anything other consequence of drinking alcohol.

Oh yeah, and this case is double awesome because it's anesthesia related because his tongue was so swollen as to totally occlude his airway requiring an emegency trach.

[update 1]: Who could ask for such luck in a single day?! Not just one story of inibriated madness, but two. This one is the story of a 54 year old drunk man who got in trouble with the law for throwing an onion at his 27 year old wife. I'm sure there's more than one story of "night's I can't remember" in that family. Your first clue might be that when the man was his wife's age she was but an embryo.

Poor Choice of Words

2007-09-16T21:34:00.001-05:00

I like to read the weird news that comes across the AP wire. A great place to find it is at Yahoo's Oddly Enough. Tonight I noticed a rather poorly titled article ; "Cities Cracking Down on Sagging Pants". Very punny!

Combitube

2007-09-14T13:21:00.000-05:00

Today I was given the opportunity to attend a lecture given by the man who invented the combitube. You might ask, "What exactly is a combitube, and why would I care?" Well, the combitube is an airway device that is blindly inserted into the esophagus which then occludes the esophagus and also occludes just above the opening to the trachea. Between the two ballons that you blow up, there are a bunch of holes that allow for ventilation. It's pretty useful especially for EMT's in emergency situations because it's supposedly very user friendly. You just shove it down the patient's throat and 95% of the time you're in the exact right place. Just to give you an idea of where exactly that tube is sitting, here is a cut away view.

There are several upsides to its use, including the apparent lack of the need for pre-anesthetic to tolerate its placement in extreme emergency as seen in the video below.

I especially like the look of panic on his face when he realizes he forgot to deflate the second balloon. You gotta love YouTube.

Future in a Fortune Cookie

2007-09-04T18:47:00.000-05:00

Every now and then we go out to eat at Pei Wei. It's pretty reasonably priced, quick, and pretty good. Like many people, we always get a fortune cookie or two just for kicks. Last time we went was actually way back in May. Here's the fortunes we got (my wife's on top, mine on bottom).

The next new moon came and went. Nothing in particular amazing happened. Until two weeks later.

And then shortly there after this.

And then two months later this.

And finally at 4 months out this. Unfortunately, although you can't tell from this angle, the baby's legs are crossed and the baby is currently breech (you maybe could tell that if your name is Edwin or Fetzer).

So yes, Ashely J, I know you searched my blog for the word "pregnant" and the answer is yes.

Who'd have thought fortune cookies could be so accurate?

The Secret

2007-09-01T22:31:00.000-05:00

Recently we were visiting with a friend who was telling us about this Oprah phenomenon - "The Secret". I say Oprah phenomenon because no one would have cared about it if Oprah hadn't mentioned it on her show. But since she did, we all have to live with people who actually believe in it.

So in case you didn't know, "The Secret" is that if you think and focus long enough on things that you will become some sort of powerful psychic energy beacon to the universe. The more of this energy to the universe, the more the universe will do to give you the very thing you are obsessing over, whether it be good or bad. So if you obsess over, say, a necklace from Tiffany's, then eventually that's exactly what you'll get. Or if you obsess over having bad health, then bad health you will have. Because the universe will give it to you for thinking about it.

I have a few observations about this so called secret. First, and foremost, I plan to make an official un-official psychic energy wave transmitting beacon; which will strengthen and amplify the signal your psychic brain waves give off. Here is a picture of them being modeled by two children.

Pretty soon everyone's going to be wearing them so you might as well just buy one now. After all, you are going to get tons of free stuff from the universe if you wear it. I mean even way more free stuff than people who don't.

Second, this phenomenon reminds me of the mindset of people that just drives me crazy. Entitlement. Getting something for nothing. Of course being in medical school, that means that there is more than one person I encounter regularly that just rubs me the wrong way. I digress. So the whole root of this philosophy is that you get stuff for just thinking about it. And it is well spelled out that it is not because you make any sort of plans because you obsessively are thinking about. The universe just magically gives you stuff because you think about it. I must be broken because there's lots of stuff that I've thought about that never happens. And I would never want the universe to grant my every thought.

However, sometimes you just have to wonder if maybe there is something to it. For example: this article. You'll have to excuse my callousness, but her name was "Debree" (pronounced the same as the word "debris"??). A sad story, but ironic nonetheless.

Life Lessons

2007-08-27T09:05:00.000-05:00

So by popular demand*, or rather at least one person's demand, now at the end of my ER rotation I have more to blog about my actual ER rotation.

I'm sure everyone reading this has seen that awesomely cheesey poster that lists like a million things that you learn in kindergarten that make you a wonderful person. Well, this month in the ER I've compiled a similar list that will help make you a healthy person. At least as healthy as luck and/or stupidity will permit.

Don't wear flip flops while mowing the lawn. Don't put your hand under a stalled lawn mower that is still turned on. Don't try to take a riding lawn mower out of the back of a pick-up truck all by yourself. All are really good ways to lose body parts. If you know the neumonic - it's usually a body part that you wouldn't use lidocaine with epinephrine on that you lose. If you don't know the neumonic, well, I'm not going to post it here because while I do like the attention from random google searches, that's not the attention I want.
Don't cuss out homeless men with knives who ask you for money. They might stab you. A couple times.
Don't zip your pants up too fast without looking to see what's still in the zipper. I didn't think that this actually happened, but as I discovered this month, it does. And it looks very painful.
Don't lie to the doctor about what happened to you. For example, don't tell the doctors at 2 different hospitals that you fell off a swing if you actually were bitten by a cottonmouth snake. Some of them might believe you and your treatment might get delayed 6 hours and you might risk loosing body parts.
Don't punch glass windows. Don't jump through glass windows. Don't lean all your body weight on glass windows. Don't push really hard on glass windows. Glass breaks. Broken glass is sharp. It will cut you. Deep. There will be blood. Lots of it.
Don't insert objects PR. P stands for "per". R stands for a word that starts with R and sounds like "wrecked 'um". It might just disappear on you. And that's a really embarrassing story to have to tell the doctor.
Don't think that you are too good for eye protection. Especially if you are breaking up concrete (it might just end up inside your eye) or working with methyl chlorobenzene (it might just burn your corneas right off).
Don't think that vizine eye drops is all you need if you get methyl chlorobenzene in your eyes. And don't wait 2 days to go to the hospital.
Don't do drugs. Especially fry (marijuana dipped in embalming fluid). It will make you crazy. Irreversible-forever-for-the-rest-of-your-life crazy.
Don't think you no longer need your psychiatric anti-psychotic meds. You will go psychotic if you stop them.
Don't think you don't need a seatbelt. Unless you are curious what it's like to break a steering wheel in half with your chest or go through the windshield.
Don't put your feet over the passenger air bag. It will come out very fast and it will hurt you very badly.
Don't accept unscreened blood transfusions from Mexico.
Don't beat your child to death. The police are pretty good at figuring that one out.
Don't let your kid ride a broken bicycle outside after 11 PM. It might just be asking for disaster.
Don't come into an ER and ask for a pain medicine by name and dose. You won't get it, or much of anything else after that.
Don't stop coumadin all of a sudden because you think it's not doing anything. If you had a stroke before and they put you on coumadin, it's pretty likely that you'll have another if you stop the coumadin.
Don't get 20 tattoos and then be a cry baby about getting stitches. Or about getting shot by your father-in-law with a shotgun.
Don't change your tire on a too-narrow shoulder of a busy 6 lane freeway. Unless you want to get hit by a car.
Don't jaywalk and think you can beat any car. You can't. And cars weigh roughly 10 times what you do. And don't break as easily.
Don't shoot at the police. They shoot back.
Don't eat like an American.
Don't think that you don't need pre-natal care. You do.
Don't think that if the doctor told you to be on bedrest that this means don't go to work, but spend all day out and around town doing a million things.
Don't bring all your personal belongings to the ER with you in a cardboard box. And then drop it all over the trauma bay as they are taking you out to a bed.
Don't come to the ER and say you have a spider bite unless you saw an actual spider on you and saw and felt it actually bite you.
Don't eat batteries.
Don't come to the ER in a busy academic hospital unless you want some random medical student to anonymously blog about your stupidity.

So there you have it. Real convential wisdom for your bathroom wall.

*I say this is by popular demand, but I have no actual way of confirming this since apparently the popular demand all read this site previously via an RSS aggregator and never actually came and visited my site nor did they artificially inflate my self importance by raising my site visits counted by sitemeter.

McMarketing

2007-08-21T15:46:00.000-05:00

We've all seen those golden arches saying "Billions Served." I'd even venture to say that there is not one single person reading this that has never eaten at a McDonalds. Remember when you were a kid and your parents would strap you into the car and drive you to go play in the ball pit and eat a handful of chicken mcnuggets soaked through with McDonalds brand honey? Remember the TV ads with McBurgler and Grimace and Birdie and Mayor McCheese? Remember how often you begged to go to McDonalds?

Turns out McDonalds knew what they were doing, and now there is scientific proof. According to this study out of this month's Archive of Pediatric and Adolescent Medicine kids can taste a difference in food presented in McDonalds packaging. The authors had 63 kids from 5 different low SES day cares to whom they provided 5 different foods, including hamburgers, french fries, and carrots, which were identical in all aspects aside from their packaging. The results of the study are probably predictable to any parent. Four out of the 5 foods tested turned out to that kids thought the McDonalds branded food tasted better. The only one that came out being even was the hamburger. They did find some influencing factors. Kids who ate at McDonalds more frequently were more likely to prefer the McDonalds packaged food. Also, kids who live in homes with increasing number of television sets are increasingly more likely to prefer McDonalds wrapped foods.

So I guess the lessons learend here are that you should 1 - let your kids eat less at McDonalds 2 - get rid multiple television sets and 3 - if you want your kid to eat carrots, put them in a McDonalds french fry box.

Welcome 1st years!

2007-08-15T15:06:00.001-05:00

Although I doubt a single one of them will read this, here's a big fat welcome to all the new first years who I saw today at orientation. They looked so innocent, naive, and excited to be there. We'll see about that once their first block of tests rolls around.

I had a good time sitting with my born-a-radiologist friend labeling the newbies as they walked by. Like the nerdy, quiet looking foriegners - aka "pathologists". Or the guys overflowing with testerone as the pretended not to be flexing for the bleach blond barbie dolls - aka "orthopedics". Or the bleach blond barbie dolls - aka "OB/Gyn". Or the totally lost and clueless guys wandering around - aka "Medicine". Or the super white, never seen the sun before - aka "radiologists". Or the hardcore shaved headed giant - aka "emergency". Or the not so nerdy or quiet looking foreigners - aka "family practice". Ok, I'll quit being so, um, specialty-ist there before I alienate everyone. (TS, notice there's not a single psych joke there - just making up for that aggie dig earlier!)

Anyway, it reminded me of how far we've come and how different things seem now. It strange how 3 grueling years of med school can change the way you see things. It's also funny to think they've never experienced the joys of pimping, or scut work, or guaiac cards, or noon conference, or M&M, or grand rounds; yet here they all stood excited as ever to dive head first in.

Here's to those with the cleanest white coats in the school!

It's Broken

2007-08-10T10:45:00.000-05:00

American health care. It's an entirely broken system.

While I don't necessarily believe in socialized medicine, what we have doesn't work. And it will only get worse. A major problem in health care is non-payment. Hospitals and doctors have horrible collection rates. Some collect as low as in the neighborhood of 20%. What that does, however, is forces costs to climb in an attempt to cover the cost of those who don't pay. A single dose of aspirin, which costs cents over the counter, can cost several dollars if you get it in the hospital. The ramification of this is that as people don't pay, everything will cost more, which will create more non-payment. Simple economics says cost will climb until the supply and demand curves intersect, the problem is that the demand/usage doesn't change despite the increasing cost.

So as costs climb, so does cost to insurance companies, which in turn creates higher cost of health insurance. Health insurance, however, does experience normal economic pressure and demand does drop with increasing cost. So fewer people will be insured every year as fewer and fewer can afford it. Which will create more non-payment. Which will raise the cost of health care. Which will decrease the number of insureds. Lather, rinse, repeat. Fortunately, I don't think it'll get to the point that health care ceases to exist, because at that point even politicians would be affected.

Beyond that, there is a huge amount of waste in the system today. Administrative costs of health care in America are astronomically higher than they are in other countries. For example, in the billing department of hospitals there is a full time staff of many people to keep up with the paperwork of billing each seperate insurance company or private payor. Each company has their own forms and documentation that has to be filled out in their own particular manner in order for them to even consider paying the claim. Across the border to the north, it takes one person to do all the billing for an entire hospital. Because it is standardized. One form. One location. What if America were to mandate that all health insurance companies accept one single form, like the Medicaid form? It would certainly cut out some administrative cost.

What if health insurance were an industry that was mandatorily non-profit and could not be traded on the stock market - so that health insurance companies would be responsible towards patients instead of stock holders?

What if health insurance were a mandatory benefit all companies with >15 employees had to include (not just offer, but include) for all employees (not just full time, but ALL)?

What if congressman and senators had to get their own private insurance and were not given free care?

What if we find a solution before the system collapses?

Traumatic Brain Injury

2007-08-07T15:50:00.001-05:00

Once upon a time there was a man. His name started with "H" and ended in "omer Simpson". When he was a boy he was playing with his crayons. And then he lost one after shoving it up his nose. Years later he had a strange neurological complaint and went to Dr. Hebert, who discovered the crayon on X-ray. When asked why he never noticed it before despite Homer's numerous trips to the hospital with head trauma, Dr. Hebert showed the Simpsons how he always missed it by the way he routinely held X-rays up to the light to see them.

After succesful removal of the foreign body, Homer had a dramatic recovery and even became extremely intelligent. The problem was that he had built a life that centered around him being an imbicile and he quickly began alienating all those around him. In his intellectual nirvana, he realized he would never truly be happy this way and elected to re-insert a crayon into his nose to try to regain what he had lost. And in true Simpsons fashion, all came full circle nice and neatly in 22 minutes.

The reason I make note of this now, is that a German woman has had a quite similar experience, at least to the first part of that story. When she was 4 years old, she tripped and managed to lose a pencil into her cheek. It, unlike Homer's case, was actually quickly diagnosed but went untreated due to the lack of today's sophistocated medical technology. And then at age 59 she finally had surgery to remove almost all of the pencil - 55 years later. Thanks to the skilled ENT, she has reportedly stopped having headaches and nosebleeds. The question is, in a year will she feel so isolated by her own intellectual prowess that she elects to reinsert it?

Chief Complaint

2007-08-06T08:50:00.000-05:00

I just finished my first night shift this month and am having trouble sleeping so I thought I'd say a word or two about E.R. Really, E.R. boils down to those two words - Chief Complaint. You are responsible for finding out why the patient is at the hospital and then figuring out if said chief complaint is worthy of hospital admission or worthy of a trip back home.

One of the coolest features of the EMR (electronic medical records for you lay-people) software our ER uses is that you can pull up a list of all the people in rooms, in waiting, and inbound and it tells you their name, location, how long they've been waiting or roomed, and what their chief complaint is. This is the absolute funnest tool in the ER. By far. Because if you happen to have a short break in the action, you can log on and see who's coming and why. I guess the other super cool part about it is that the people in triage are instructed to list the chief complaint exactly in the patients' own words and not to translate it into medical terminology.

So, from two nights worth of working, here's a short sampling of what came through.

I broke a window and am bleeding - (Pretty accurate assessment I thought. I put 25 stitches in that person's arm. 24 beers + nagging spouse + glass = disaster waiting to happen)
My parts are huge - (to clarify, those were man parts he referred to, and indeed they were perhaps the largest man parts I have ever seen.)
bicycle in foot - (this was actually EMS's words since it was a small child who was crying. She really did have a bicycle impaled through her foot.)
I chainsawed my leg - (disappointed I didn't get to meet this one)
broken skull s/p jumping from moving vehicle - (this one was cheating too since the chief complaint actually came from doctors at another hospital. S/P means "status post" and is doctor-ese for "after".)
broke my arms - (Yup. We didn't do much diagnosing past that one)
woman problems - (enough said)
f%$# you - (this guy wasn't too happy with being at the ER. He also said that was his wife's name. And his name. And his address. I guess that makes it all easy to remember)

Anyway, on a totally seperate note, I just wanted to give a nod to a not so average family for mentioning me in their blog. Sitemeter tells me that in the past 3 days I've doubled in traffic from people linking in from their page. Despite one of their members leaving deceptive comments on one of my posts.

It Blends!!

2007-08-02T14:23:00.000-05:00

In my hunt for mindless activities to do this afternoon since I am home more days than at school this month(with the notable exception of being scheduled almost every Saturday and Sunday), I remembered vaguely having heard of the website Will It Blend? and decided to check it out. After all, one cannot study non-stop for their Step 2, unless of course your name is "First Aid".

Guess what! iPhones blend. And beyond that, blended iPhones sell for $901. As long as your ebay ad is explicitly clear that it is a blended iPhone and not a new iPhone.

Other exciting things that blend include:

and even Bic ligthers.

All in all, it was pretty productive day for me.

Crushing

2007-08-01T12:47:00.000-05:00

I suppose starting off with the title "crushing" on my first day of ER might imply some sort of intense physical trauma, but it's the only word that describes the horribleness I saw today.

It's more of an emotional horribleness.

So imagine this. You are a new 4th year medical student and your first rotation is an ER elective. You absolutely fall in love with it and decide, "This is IT! This is what I'm doing." You talk to lots of people and find out it's a really good idea to get at least one away rotation if that's what you're going into. Great. So you get on the ball trying to find one. Turns out the only ER program in a city you want to go to has a couple openings. You try as hard as you can to get it set up and are even told when and where orientation is the first day. So you DRIVE from Tennessee across the country to get there in time to start on August 1st.

So you get to orientation just as its starting. Some big burly guy at the front is counting people and says, "There's one more person here than there should be." You say that it's probably you because you've been trying to get all the paperwork ironed out still.

"I'm sorry, but you have to leave. We don't have you on our roll and so you can't be here for orientation."

What do you say? Well, how about, "All my stuff is at student affairs. They're getting it together so I can be here."

"No. I'm sorry. We don't have your stuff yet from them and so we can't enroll you, so you can't be here."

"Can I pick my shifts and do all this after I get it worked out."

"No. You can't be here. We don't have you on our rolls so you can't be in orientation and if you miss orientation you can't rotate this month."

"But I drove from Tennessee to be here...."

"Sorry, but no."

So, as it turns out, that's exactly what happened this morning. Some poor girl who came all the way from Tennesse got kicked out of orientation. Imagine lining things at home to live for a month in a different city and then getting there and the job you thought you were there for is still open, but since your paperwork wasn't finished before 7 am on day 1 you lose that whole month. And even though the administrative people beg and plea for the boss to let you stay, the boss says, "No. Rules are rules." And then you're totally screwed, because it turns out that the big, burly guy is actually the residency director for that school and you've now made a situation where you'll never get in to that school because you couldn't get your paperwork together in time.

The Good, The Bad, and The Ugly

2007-07-31T22:07:00.001-05:00

After a month long hiatus of updating this, I figured it was time seeing as I just completed my Anesthesia rotation and this blog is called "The Gas Mask".

The Good

So first the good. I really enjoyed a lot of things about this month. The schedule was pretty awesome. I mean, when an attending tells you, "You're a fourth year; you need to leave before noon," it's gotta be a good rotation. I also enjoyed getting to do lots of procedures everyday. Well most everyday. It's something I really like about medicine and it was nice to get to do it. I was proactive about it and even got to help do central lines and do my own spinals for c-sections. Part of me feels like it was kind of sneaky to stand back there while the first patient thought the resident was doing it, but who would say, "It's your first time? Go right ahead!" Needless to say my technical skills got a lot better this month. The residents were great, and one even let me start an IV on him when I blew one on the sleeping patient in front of the attending. Then he took a picture of it with his iPhone to show the attending that I actually could do it.

I also really liked the test at the end. Mostly because when I went to take it, the director told me I didn't have to. You gotta love having special exceptions made for you. Turns out it pays off to do a little hard work before hand.

The Bad

I learned that while most people graduate medical school and change their name to Dr. ____, people who go into anesthesia graduate medical school and change their name to "Anesthesia". Surgeons tend to be a little condescending to anesthesiologists. Maybe because anesthesiologists make just as much, but also get to see their families. And get to practice the ABC's. Airway Book Chair. Anyway, the biggest bad of it all is just not having control of your own time - you have to meet the surgeons' schedules.

One of my favorite residents from this month actually defected out of general surgery into anesthesia. He was always happy and never once complained, "It's four in the afternoon and I'm still here!" He was one of the most laid back, easy going residents and it was shocking to hear him talk about how he was as a surgeon.

The other bad is mouth noises. I'm not a fan of them and there is an awful lot of suctioning that goes on in anesthesia. At least it's suctioning there and not somewhere else.

The Ugly

Guys who wear those decorative surgical caps. With Hawaiin print. Or worse yet, A&M. Girls like to look pretty, and that's fine if they buy decorative head wear. But no self respecting man should don one of those. Ever. Ever ever.

Top 3rd Year Moments

2007-06-20T09:57:00.001-05:00

In commemeration of finishing what many consider the hardest year of medical school, I'd like to list out the most memorable moments of my third year.

Flying across the state with the transplant team to do a donor harvest surgery. In a private jet. And being the only medical student in the surgery
Being trusted to use the scalpel and bone saw during my CV surgery rotation
Sewing up an incision better (but not faster) than the chief
Being commended for being the only student on the team to turn in my required assignments on time
Being taken to eat at Fogo de Chao by a fellow student
Driving home from a far away clinic during peds during a horrible thunderstorm that actually flooded the highway making it impassable
Being in the group that scored the highest average on the surgery board
Trading to a different medicine month and team only to find out that I totally screwed myself over
Making a TB diagnosis missed by my upper level in the county hospital ER
Wearing a mask before talking to the above TB patient
Seeing first hand both patients experience seemingly miraculous cures as well as patients suddenly or quite protractedly pass away
The MR patient at the county hospital who, as I was examining another patient in the same room, shouted out, "Nurse, Nurse. Thank you for the underpants!!"
Fun month was actually fun. Because I didn't study hardly at all
Having the Director of Internal Medicine give me 100% on my eval and offering to write me a LoR
Driving 64 miles everyday to the furthest away FP clinic. With Cecil
Cecil somehow managing to get me out of lots of hours of FP clinic time
Getting a super buzz off my first and only energy drink. And being told I was a little hypomanic from it
My resident on neuro from Siberia. "Must to practice checkout sheet" and "Most of you (there was only 3 of us) very hard working"
The neuro resident who called her patient a "carpet muncher", and then for some reason was threatened by the patient that they'd call the TV news stations to come report on the (ie her) poor quality of care
The paraphilia lecture
The county psych hospital
Catching a baby for the first time
Delivering a placenta and accidently squirting cord blood all over the room, and resident, when I moved the hemostat up during said delivery
BV clinic

So that was my year in a nutshell. At least the most memorable parts of it. I am excited for fourth year. No call. No weekends. 2 months off. If you are still reading this and happen to also be ending your third year, I meme you!

Whiff Test

2007-06-19T12:25:00.000-05:00

So today was my last glorious day of OB/Gyn, and more importantly, of my 3rd year. And I had an extra special way of rounding out my 3rd year experience.

Today I got the opportunity of going to the county jail OB clinic to treat all the incarcerated women. They should really change the name of the clinic though. I suggest they rename it, BV clinic, because everyone who came in (with one exception) had really florid BV.

So, for all my non-medical fans, BV stands for bacterial vaginosis. It is essentially an infection caused by overgrowth of certain types of normal vaginal flora, much like a yeast infection except with bacteria and not yeast. What is extra special about BV is that the discharge has these cells in it (see picture) called "Clue Cells". I have yet to figure out why they call them clue cells. Mostly because the first clue you get that someone has BV is not the clue cell, but by the very distinct odor that wafts your way as you get up close and personal with an infected person's nether region. Who needs yet another clue as to what's going on? There's actually a test called the "whiff test" where one adds potassium hydroxide to the already foul smelling substance to see if you can make your sample smell even worse than it already does. While clue cells are rather inappropriately named, the whiff test (much like dumping syndrome) is quite an accurate description of the test.

BV is also associated with a discharge. Usually its white and somewhat thick. Sometimes its a little different. My favorite was asking the patients about it. "It's like boogers coming out my hoochie," was my personal favorite description. At least it painted a vivid image.

End Of Slavery

2007-06-13T08:20:00.000-05:00

You might have noticed a little clock counting down almost a year's worth of time there to the right. Actually it's really more like about 10 and a half months. It's the countdown to the end of slavery.

You may be thinking, "But slavery was abolished by Abraham Lincoln in the early 1860's". Wrong. Today in medical education medical students everywhere pay for the priveledge and honor to be able to take 30 hour shifts of doing work for people who are being paid to be there. Medical students everywhere are dumped on by residents, interns, nurses, LVNs, janitors, transport, and even volunteers. All for the low, low price of $10,000 / year. That's not a salary, that's "tuition". Multiply that by 220 students in a class and 4 classes in the school and that's like 10 million dollars of "tuition" that we pay.

And we still have to pay for parking, books, syllabuses, meals, etc, etc.

So keep an eye on that clock, because when it reaches zero, I no longer will be paying to work for the school.

On a side note, commencement was officially announced for exactly one month following the end of that countdown, on Saturday May 31st at 10 am.

Darwin Awards

2007-06-12T11:49:00.000-05:00

By the year 2007, I'm sure everyone has heard of the infamous Darwin Awards, awarded annually to people who unsanctimoniously remove themselves from the human gene pool.

I've always thought it a little silly when people with small cars insist on backing into parking places for a quicker get away, like they were robbing a bank everywhere they go. If you have a big truck and have a hard time backing out, that's one thing. But if you drive, say, a Ford Mustang, that should be plenty maneuverable to just park normally. There's a certain group of people who seem more likely to do so, but that's neither here nor there.

So here's my nomination for a Darwin Award this year. A man living in a high rise apartment complex said to have very narrow parking places was backing his Ford Mustang into a parking spot on the fifth floor of the parking garage. One would think that at normal parking velocities a solid cinderblock wall might be able to withstand impact with a car. Based on the fact that there are tire marks indicating he was backing up, one can only guess at what the driver was thinking about as they peeled out in reverse into a small tight parking space. Perhaps they thought, "Maybe this skinny pedal on the left is the brake". In any event, the driver managed to reach escape velocity and launched their car through the wall onto a building below. Upside down. Unfortunately, the driver did not survive his short flight, but such is the nature of natural selection.

Strange Day

2007-06-07T20:27:00.000-05:00

Today was perhaps one of the strangest day I've ever had on this rotation. It all started nice and early at 5 AM. I got to the hospital and rounded until 6 without ever seeing a resident. "That's weird," I thought.

At 630 at board checkout finally the residents showed up, a whole new set just because it was Thursday. Apparently the regularly scheduled residents all have clinic on Thursday and so the clinic residents come and take their place. We ran around the whole day with crosscover residents and a cross cover attending, on what was actually a pretty slow day, but somehow managed to not actually round on the patients at all. But back to my morning...

Then I went upstairs to see a baby born earlier. They told me I needed to see it for my education. So I get up there and the nurse says, "Oh, you want to see his malformations. Look here." And she takes off the diaper. I've seen ambigious genitalia before, but this was not ambiguous..definitely a boy. After trying to figure out what his problem was called, I found one single case report at pub med here. If the link is too medical mumbo jumbo for you, what it says is that this particular problem is where the scrotum is actually ABOVE the shaft. I didn't know what to think, and then the nurse says to look at his bottom. At which point I noticed his anus was way too high. It was posterior, just not low enough. The attending said he would never sit down to poo. Poor kid.

And then I met the mail-order bride. She was pregnant and not really having a problem but her husband was a complete nervous wreck. With way too much coffee. He kept checking the empty mug he brought in with himself in case magical coffee appeared in it again. And he never let her answer for herself. And asked a million and one irrelevant questions. "Why are you asking about that? Is something wrong? Is it bad that she is hurting like that? What should I do? Should she be taking her medicine more often? Is the baby a boy or girl? Is the cord wrapped around the neck? Is the baby too low? Where's her uterus?" 1) I can only answer 1 question at a time 2) I don't know the sex of a baby by asking about contraction pain 3) I don't have xray vision 4) I really wanted to find this guy some xanax just to shut him up so we could talk to his wife who actually knew what symptoms she was having.

At least it was interesting today.

SP Heaven

2007-06-01T19:34:00.001-05:00

Today I had my end-of-third-year clinical skills test, aka the CCCE, or as I like to call it the CCCCCCCCCCCCE. I don't know what any of the C's actually stand for. It's just it's name. Because doctor's like abbreviations. Especially OB/Gyn's.

It was an standardized patient's dream. 11 of us showed up at 0730, which was sleeping in for me this month, and went and talked to 11 different "patients". Some of them had just histories to take, and some of them had physical exams on top. And the pedi patient wasn't even there, just their parent. It was a long grueling day of taking histories and doing physicals on people who were just pretending to be sick. My favorite was the patient who was supposed to be homeless and somehow the testing center had let a fly into that exam room. I guess they were just going for realism.

Anyway, I have a special place in my heart for standardized patients. They have a job that honestly you couldn't pay me enough to do. Especially brave are the patients who taught us the urology (DRE and male genital exam) and the breast/pelvic SP. Can you imagine having your prostate checked and then having to turn your head and cough 10 times in a row for people who have no real experience doing said exam? How about having your well-woman done 6 times in a day by people who are highly likely to do it wrong? Somebody should call Mike Rowe.

Omega Beta Gamma Pt. 2

2007-05-31T19:04:00.000-05:00

I guess now I can give a more fair assessment of OB/Gyn rotation now that I've done almost a week of OB. OB isn't bad in and of itself. It's actually pretty easy considering most of the patients are generally pretty healthy.

My general day consists of doing morning rounds on post partum patients, going to checkout (worthless for students to be there), and then trying to stay on top of all the new patients coming in through triage and those who are delivering for the next 12 hours until evening board checkout (equally worthless for students to be there). After that I can go home. Lather, Rinse, Repeat x 10. It actually seems a lot like working in an ER with a very focused patient population.

There also is a lot of procedures to do. On gynecology, it was all procedures. On OB, it's less so, but still everyday there is stuff in the OR, deliveries, tubal ligations, etc. It keeps you on your toes and is active medicine. I hate passive management. For example, today was my first delivery. Probably because everyone in Houston delivered today and so we were a little shorthanded. I can't take all the credit though. The resident delivered the head (i.e. yelled "PUSH PUSH PUSH" at the patient until the head was out) and then had me jump in to pull out the rest. I probably would've delivered the head too, but the baby was DOP (direct occiput posterior). That means the baby came out looking up. It sounds good, but it's not because of the diameters involved. So this kid came out looking like a conehead (like most vaginal deliveries), but the cone was on his forehead.

Then, of course, I did the obligate medical student delivery of the placenta. They finally actually taught me what exactly I was doing, so now it makes more sense why you push on mom's belly while you pull it out.

Anyway, so that part hasn't been bad. What's been bad is that a lot of the female residents in this program are mean. They just don't like medical students. I thought that one I had on gyn was bad, but almost all of them on OB this month are that way.

For example, today when I got there at 0500 and began rounding on the patients I worked backwards from the direction the resident usually goes. Once I got to the resident, she got upset and told me "Work the other direction so we aren't just fighting over charts." She just assumed I had ignored what I'd been told the other day and had come late to rounds. I guess she figured out she had wrongfully yelled at me once she got to the other pods and saw notes on all the other patients.

Then after board checkout the residents (all girls on this OB team) just walked out of the room without saying a word to us. So we just went and tried to find stuff to do. I thought we were doing OK, but apparently one of the residents thought we weren't doing the right stuff and yelled at us. Usually the first step in getting people to do what you want is to ask them, not just assume they know and yell after it doesn't happen.

Then we have a bunch of stuff happen all at once with admitted patients. Cool stuff, like a velimentous implantation of the umbilical cord and stat c-sections. The problem was everytime something good happened, they would overhead page the other med student on the team (a girl) to come do them. The other problem was whenever something cool was about to happen suddenly there would be some kind of mind dumbing scut for me to suddenly have to do right then.

So, that's how the day goes almost all day long. I'm seeing all the patients in triage. I'm doing all the stupid paperwork. I'm spending all day trying to chase down the residents. The other (girl) medical student is spending all day doing procedures and scrubbing in cases (that I had been invited to scrub until they found out she wasn't doing anything). And then we get to board checkout at 5 pm. Finally the day was over. While doing checkout on a newly admited patient from triage (guess who the med student was who saw her) a question came up about her history. The attending asked and didn't get an answer, so finally I spoke up and answered the question. And got an evil eye death glare from one of the residents for having spoken during board checkout. Heaven forbid I attempt to make sure the patient gets good quality care instead of protecting the resident's ego. I mean it would be one thing if board checkout was 99% a ginormous gossip session about all the residents and attendings who are not currently present (note the sarcasm). So, once again put in my place for looking out for patient care. Like the time I mentioned chest pain and shortness of breath in a tachycardic women in triage, who had come with a different chief complaint, to the resident who went on to send the patient home at which point the patient called their clinic doctor who then had the patient direct admitted for chest pain. And then suddenly the residents threw a fit over how the patient had never complained of that to anyone and she shouldn't be being admitted.

I guess she didn't read very closely the MS3 note she copied almost verbatim.

8 Random Facts About Me

2007-05-28T14:23:00.000-05:00

Tipping my hat to one of the two blogs currently listed in my "Friends' Blogs" (yes I have no internet friends...maybe someday) and her meme'ing of me, here are 8 random facts about myself.

1) I play way too many video games. Here's proof. I have no idea how I find the time to do so during medical school, but somehow I do.

2) On a similar note, I recently completed Viva Pinata. Yes, I know it's a kids' game, but I don't care. It was fun.

3) My pet peeve is mouth noises. I don't like them. I don't like chewing noises. I don't like teeth brushing noises. I don't like spit noises. Good thing I'm not in dental school.

4) I lived in Brazil for two years on a mission for my church. I now speak fluent Portuguese which comes in handy with all the Brazilian patients I have.

5) I have never seen either the Atlantic nor Pacific Oceans. The closest I have come is the Gulf of Mexico. People tell me I don't know what I'm missing.

6) I hate fish, eggs, and hot dogs. If we were meant to eat fish, we'd have been born with gills.

7) I love reading the headlines from Yahoo's Oddly Enough and MSNBC's Peculiar Postings. Rarely do I read headlines about actual "important" world events or watch the evening news.

8) My wife says this post makes me sound like a 10 year old. Maybe I am. So what.

Omega Beta Gamma

2007-05-25T17:56:00.000-05:00

I was warned that when I started my OB/Gyn rotation that the residents were all gossipy and back biters. I heard that it was essentially like living through 6 weeks of some perverted sorority; the Omega Beta Gamma sorority, if you will.

I honestly can't say that's been my experience so far. I've worked with several residents, and while I have noticed that they are far more focused on their education than mine, I can't say it's been what I was expecting.

One resident, who is pregnant with twins, I have come to notice treats all encounters with medical students the same. She makes a few basic assumptions. 1) Each medical student encounter is the first time she has worked with that medical student. Today, after working with her sporadically over the past 2 weeks, she introduced herself to me and asked how long I'd been on the rotation. 2) All medical students are on their first rotation. Despite realizing that I had been to the OR with her before, I again got a lecture about how blue things are sterile and you sew in to out and then out to in. She also took my job everytime the chief resident asked me to do anything during the operation. I'm not helpless and can suture. The ones I did looked better than hers in the end anyway, despite her having to double check every aspect of how I had tied the knot. 3) Medical students do not understand medical theory. I may not know everything, especially about the eccentricites of gynecology, but I'm not stupid. If anything, my knowledge base is something that carries me through the other aspects of medical school.

The big down side is how little time we spend on each team. In order to get us out to clinic (which in my opinion is of little educational value) they pared down our time on gynecology and obstetrics to two weeks each. Now that I have the hang of the gynecology service and just what I need to do to stand out (in a good way of course), I am being shuffled off to the obstetrics team on Monday. Hopefully that one requires a little less scut, but I'm not keeping my hopes up too high.