Too tired to be tired

Being on call can be a good or a bad experience. At it's best, it's like a big sleepover with good friends, food and a tidy room you don't have to keep clean. At it's worst, it's an unbroken 28 hour marathon of demeaning busy work in a discipline that will produce no positive impact for the people you care for or your education.

Sometimes it's easy to predict whether call will be good or bad.

Some call shifts I've enjoyed. Even when I get called I don't mind, as long as it's something I can help out with, something I can learn from, and if it's not going to interfere with my sleep too much. There have been a few times on call when all these things have happened and I go home the next day feeling pretty good about it. It sure doesn't hurt that I get the afternoon off after I've been on call. Getting 5 hours off work in exchange for having worked an extra 19 hours overtime doesn't seem like a great trade, but that just goes to show how good call can be. I prefer working 19 hours overtime sometimes if the call experience is good. It's even better if I'm skipping out on something I hate postcall, like GI clinics. God. What kind of doctors like making people squeeze their fingers with their anuses? Gastroenterologists, that's who.

The bad call shifts are pretty shitty. It's those times that make me question whether or not medicine was the right choice. It doesn't take much to make my call shift the reason why I hate a rotation.

I just finished 3 weeks of obstetrics, and I was on call 5 times over those 3 weeks. Twice I was on call on Saturday, which means you start work at 7am on Saturday, and stay in hospital working until 7am on Sunday. You get Sunday off, and on Monday you go right back to work like everybody else. The difference with obstetrics call versus the other call rotations I've had to do is that there is virtually no sleep. Over those 5 call shifts I've averaged 1.2 hours of sleep a night. The rest of the time I've been dealing with OCD doctors, superiority complexed nurses, and all kinds of women squirting out blood, feces, and baby juice on my shoes.

The bad nights are the ones where you're too tired to even sleep. It gets to the point where the grogginess associated with an abbreviated nap is worse than just staying up an extra hour or so to wait for that patient to get to the hospital.

Being chronically fatigued screws around with the internal chronometer too, so when you fall asleep you have no idea what time it is when you wake up. Going to bed at midnight and waking up at 1215 feels the same as waking up at 630. It sucks pretty hard when you go to bed dead tired at 4am and wake up thinking it's morning and time to go home when really it's been ten minutes since you went to bed and there's still a whole night of work left for the nurses to page you about.

It's like an office gift exchange. When you give in your gift, you put a fair bit of effort into picking something people might like, and do your best to please. You have no idea whether or not your gift will be properly compensated though. I put in craploads of energy trying to perform on call, but the effort I put in has no bearing on how much sleep I'm going to get.

Holy s*** I'm tired. I'm going to bed.

Ideas

I'm full of ideas! Here's one.

Medicine is full of tests. These tests can be useful, or not useful depending on what their "sensitivity" and "specificity" are. What does this mean? Let's use an example, say, complete blood counts (CBCs) and bleeding.

Sensitivity tells us how good positive CBCs are at picking up bleeding. Specificity tells us how good negative CBCs are at telling us there's no bleeding. When a test has lots of false positives, it means it's got great sensitivity, but crappy specificity. When a test has lots of false negatives, it means it's got crappy sensitivity but great specificity.

All of medicine loves these sensitivity/specificity/positive predictive value/negative predictive value garbage.

I'm here to talk about false false positives.

Say you use a CBC as a test for bleeding in a patient (all you doctors shut up; it's the best example I could come up with). The CBC shows anemia, and the patient is indeed bleeding. Yay, true positive. OR IS IT?????

What if the patient IS bleeding... what if the patient DOES have anemia... but what if the patient's bleeding isn't severe enough to cause anemia? What if the cause of the anemia is something else? This is what I mean by false false positive. A false false positive is a false positive in someone who just happens to have the illness you're testing for.

Someone should really study this. I mean, it won't really make a BIG change to the statistics out there already, but it's something that would impact the reliability of EVERY medical test. False negative rates would be adjusted upwards to reflect false negatives and false false positives.

Anyway. That's my brilliant idea. If you need a thesis, go right ahead. I didn't articulate it well, but I'm postcall so up yours, freeloading moochfaces.

Perseverance

Med school wannabes listen up.

You can get in.

You will get in.

Well. You'll probably get in. Provided you aren't a complete douche, you will get in if you stick to the only rule that matters in getting in and past medical school.

Don't give up (DGU).

If you really want to get into medical school, DGU will get you in. You may not believe me now, cause you're on the other side of the fence, and you're thinking "How the hell does DGU overcome my 60% average and my thousands of misdemeanours on my police record?" IT WILL WORK. All you have to do is keep trying.

Sooner or later, somebody somewhere is going to let you in. It might take a lot longer than you expected or wanted, but if you persist you will get in. After a second degree, your chances go up. After living in the community, your chances go up. Every year you spend after school doing things will improve your chances. DGU IS THE KEY.

DGU is the key to everything in medical school too. There is no trick to learning how to start intravenous lines, to learn how to intubate people, to how to go back to work after your attending staff has just told you you're going to fail. There have been too many times when some technique or set of facts has seemed just beyond my comprehension, but persisting will yield results. DGU my friend, and you will graduate.

Navy seals and medical school. What's the difference? In the seals, they feed you. DGU.

Call is bad for me but worse for you

I'm on call. It's 3 am and I haven't seen a bed in 27 hours. My supervising resident thinks I fouled up my previous two patients and it looks a lot like she's going to think the same about the next patient I'm seeing. My new patients are all dying. My old patients were all living until I ran out of time to take care of them and now they're dying too. I'm tired, my motivation is in the gutter, my confidence in my abilities as a clerk has been decimated.

The attending gave me money to order dinner with. I didn't really want any, but I ordered to shut up him up. The delivery man didn't bring a receipt. Turns out the attending wasn't really buying dinner, but using somebody else's money to buy dinner and he needs a receipt. My resident says now I need to pay for dinner.

On days like these my pager feels heavier than it should, the nursing requests grate just a little bit more and the headaches seem just a little bit stronger. Also, it's the weekend.

Somedays I wonder why these nights have to be so painful. I get so easily frustrated with patients, teachers, administration and policies it's easy to forget why I'm here getting berated for not being as anal as my sphincter clenching resident.

Everybody I'm treating is having a worse day than I am. It's hard to remember that sometimes, but it's the only thing worth remembering on call.

Report card

My vacation is coming up in a little less than 2 weeks from now, and I'm excited. I've wanted to get away from the hospital setting for a long time, and I think I'm overdue.

Everyday's been pretty stressful, but not the way I thought it would be. I thought the prospect of people getting hurt, people dying, of being the least competent person on the floor would be stress enough to make me dislike my job, and in some ways those prospects have been sources of some unease. Surprisingly, the biggest stressor I've had is the feeling of constantly being evaluated.

It's almost like going to visit the in-laws, except you do it every workday, sometimes on weekends, sometimes for 36 hours at a time. No matter how nice they may be, and no matter how accomodating they are, you never really feel like you can be yourself until you go home.

Also, your in-laws don't give you a report card that will influence your relationship, let alone your career prospects. Although they may give you the cluck of the tongue, the resigned sigh, and the why-am-I-letting-you-date-my-daughter raise of the eyebrow every now and then, you don't need them to write you reference letters so you can get a job later on. If you do, stop dating your preceptor. It's not good for anybody concerned.

It's nice to know somebody's watching me in case I make a mistake but I need a break from my significant other (the hospital)'s parents (the hospital staff). God dammit stop asking me what I'm doing with my life.

I'm leaving for 2 whole weeks, and during that time, the only thing that's going to be evaluated is the room service and my form from the diving board. Booya.

Welcome to the House of God

It is 1220 hrs on July 2 and I just got home 30 min ago.
I have been awake and working since July 1 at 0640 hrs.

This is day 1 (or is it day 2 now?) of my new career as a
resident physician on the general internal medicine service.
I use the term "physician" loosely. July 1st is a bad day to
be on-call. And maybe a worse day to be a patient.

I have peed exactly 4 times during that period. I drank exactly
1 bottle of water, 1 can of diet coke, and 1 cappucino from the
coffee stand in the lobby.  I did not have time to change into
scrubs... until after i got home today. I am eating crackers
to appease the nausea of being up for 30+ hrs.
I am nauseated and hungry at the same time.

Our team comprised of 1 senior resident and 2 juniors.
Each of us juniors carried 3 pagers: our personal pager and
2 other teams' pagers and. As a bonus, 1 lucky intern got
to carry the code blue pager. The team pagers are twice as big
as our own pagers. I need a stronger belt for call.

I wear a long lab coat now. No more of this short-coats-for-clerks
business. But the bottom pockets bunch up when i sit down and
everything spills out of them,
including the 3 pagers clipped on the pockets.

I was assigned 4-5 inpatients to start with.  While on-call,
I picked up 2 more that another resident had admitted during the daytime.
I also admitted 2 new consults in the ER. I covered the wards for a
busy team trying to manage patients whom I knew nothing about.

One of them passed away last night, although I was warned to expect it.
I pronounced a death for the first time. 0215 hrs. I called the family.
I didn't know what she died of.  I learned to introduce myself as "Doctor".

I helped my team to do a therapeutic procedure on an elderly sick man.
It didn't work. I felt his faint radial pulse disapear under my fingers.
Both patients were elderly and very sick.  I learned later that neither
was unexpected.

I did not cry.
Nor did I sleep.

Our attending physician came in at 8am to hear about the patients
that came in during the night.  He told funny stories about things
that happened in his day as an intern.  We rounded with him at 9am.
He was gone by 10am.  We should have been allowed to go home based
on the union guidelines, but we could not leave the patients'
loose strings unattached.  I stayed until 11:30am.

Now I sit here, finally changed into my scrubs, in front of my computer.
Maybe I'll shower then try to sleep.  I have post-call adrenaline
keeping me awake. And hunger, but only for bland foods.

Tomorrow is a new day.... at work.

Signed,
Scutterbug, MD,
PGY-1, House of God Hospital,
pager 4444

The jovial bovine human hybrid pho mascot

A lot of Viet restaurants seem to enjoy using this laughing cow as a logo. It bears a striking resemblance to the cow on those little cheese rounds. It also looks human, which is only distressing if you dwell on it.

I always wondered why these cows were laughing. Do cows find the prospect of having their sides and legs chopped off to be made into soup humourous? Maybe it's not a happy laugh, but an insane kind of cackle, one that a crazy cow would get. A MAD cow. Or maybe it's a picture of a cow about to sneeze. People look all kinds of weird when they're about to sneeze.

Whatever the reason, lately I've been finding myself relating to the cow who laughs. In fact, I look on the cow as something of a role model. That's right. A farm animal you can look up to.

Being on this psych rotation has made me realize how much I put into clerking. Before I came here, where people work civilized hours and and try to maintain some semblance of a functional subset of society, I had to give a lot to the hospital. Sacrificing free time, my nights, my dignity, my youth... Many times I'd felt like maybe I'd given up just a little more than I was getting back.

But there's no real alternative. I'm in too far to back out now. I'm far along enough to think I can see the light at the end of the tunnel. All I have to do now is endure.

That's how this cow must feel. "Jesus they're going after my rump roast. MY RUMP ROAST. For mooing out loud how much more can they take? You can't get blood from a stone you hungry bastards! YOU HUNGRY BASTARRRRRRRRRRRRRRRRDS! Oh wait, cud coming up .... gotta chew..."

And when I feel like I've given all I can, when I've been sucked dry of all the energy I was hoarding to take home, there's nothing I can do but laugh. Laugh laugh laugh. I don't laugh because it's funny. I laugh because there's no other way to deal with it. Ha ha ha! I have no life! Ha ha ha! A cow, being a ruminant, must have done a lot of thinking. I bet she came to the same conclusion. When someone's taking away every last piece of you and there's nothing you can do, might as well laugh.

Ah laughing cow. We're bred from the same stock. Sort of.

Cowboy MD

"I promise I'll never break your heart."
"Awww that's sweet."
"But I will sedate and paralyze you so you suffocate on your own saliva."
"What?"
"I love you."
"Awwww that's sweet."

I have a few rules which have served me well in the past. They've never let me down, and I don't expect them to let me down anytime soon. I shall share them with you in the hope that you too, may someday benefit from their wisdom.

1) The authenticity of a Chinese restaurant is directly proportional to the number of spelling mistakes in the menu.


2) The authenticity of an Italian restaurant run by Chinese people is inversely proportional to the number of spelling mistakes in the menu.

3) Put on a shirt before you fry bacon.

4) Don't get anesthesia from Dr. S.

We were providing anesthesia for a healthy young patient who had come in for some elective surgery. Dr. S. had left me alone for several periods lasting 15 minutes at a time, which in retrospect, really shouldn't have been allowed. What the hell do I know about resuscitating someone? Or maintaining a proper state of anesthesia?

Beans. That's what I know.

At the end of the surgery, the patient was breathing on her own, so I decided to take the tube out. After the patient was extubated, I checked to see if breathing was still going on. "Come on, let's move her over to recovery." Dr. S said. I didn't move, still checking to see if the patient was going to take a breath. The patient hadn't taken a breath since I'd taken the tube out.

"Is she breathing yet?"

I looked a little closer. Come on, breathe dammit. My boss is hassling me.

"I don't think she is."

"Come on let's go."

I was surprised, but hey. He's the anesthesiologist, what do I know? I helped slide her onto the gurney and off we went down the hall.

I wasn't thinking about it but the whole time we were sliding her onto the gurney, cleaning up the OR, pushing her down the hall to recovery, the patient wasn't breathing. This took maybe 5-6 minutes. Try holding your breath for 5-6 minutes. I bet it's hard. I bet it's not good for your brain too.

So when we got to recovery, Dr. S told me to hand over to the nurses, because he had to make some important business phone calls. He left before the brakes were even put on the gurney. I started handing over but in the middle, I heard the oxygen saturation drop. A good oxygen saturation should be above %94. Hers were now 47. A code blue was called and everybody came running. The nurses were managing the airway and everything was being taken care of. All I could do was stand there and wonder to myself whether or not this was my fault and whether or not this patient was going to a) die b) have impaired brain function c) have some other complication I'm sure I'm not aware of yet.

I wondered if all this could have been avoided if I'd spoken up a little louder to make sure Dr. S had known the patient was breathing when we left the OR, so that we could have stayed and managed her airway properly before she started desaturating. I wasn't feeling very good about myself.

Later on, I heard from a few other clerks that that's just the way Dr. S operated. He doesn't perform up to the standard of care, and certainly doesn't do what was in the patient's best interests. I felt a little better hearing that. He would have been cavalier with her airway regardless of what I'd said.

The point of the story?

There are good doctors and bad doctors. Get the good ones to do your surgeries and anesthesia. And look for typos in your menus.

In case you didn't hear the first time

I don't get smoking.

Well, maybe I do get smoking. I guess it's not hard to see how some misguided insecure teenagers in poor company could get started on something stupid. It's the people who are going to die who keep on smoking that I don't get.

Patients have lost their legs because they smoke. They lie wasted away on hospital beds because all their fat and muscles have been cannibalized for energy, except for their massive neck muscles that work overtime just to keep them breathing. They've lost their fingers because they smoke. They can't even hold onto their cigarettes anymore because all they have are either sutured stumps or black shriveled stumps.

And they still won't quit. They bitch about how none of the smoking cessation adjuncts worked, how they tried 300 times and still can't shake the habit. What kind of lame ass excuses are those? If I was in a steel cage slowly filling up with water, and I'd tried to pick the lock 300 times already, you could bet your last breath of air I'd be still trying to pick the lock until the end.

While these patients die, they suck up money. They need to be fed, oxygenated, watered, cleaned, drugged, monitored, fussed over by doctors, nurses, and surgeons. If these patients leave the hospital, the government will have spent thousands upon thousands of dollars on their care. Not only that, but those patients occupy valuable beds that could be used to treat other patients who have medical issues that don't result from smoking.

And it's my money. It's all of our money. Instead of buying myself a new park, a better school, a space program or whatever, I bought myself a dying patient who can't or won't stop smoking long enough to realize that it's not his health I really care about when he says he wants a smoke. It's already too late for this one. I care about everybody else's health. The money this patient uses on cigarettes helps get other insecure teenagers smoking someday down the road, and before long they'll be in here just like this guy.

God dammit. Stop smoking! You're pissing me off.

Work crisis

Am I cut out for this?

How do these psychos keep getting up at 5 something in the morning to get to their jobs? Do they really love it that much? I certainly don't. There isn't a lot I get up that early for, and after I graduate I certainly don't expect work to be one of those things.

I'm sure I'm not the only one who feels this way. Maybe everyone else denies that they're not sure. Maybe they don't talk about it out loud. Maybe it's embarrassing to admit that maybe after all the money, time, education and jumped hoops, medicine was the wrong choice.

Maybe everybody else is sure of what they're doing.

I'm just not that interested in these things. Other people seem to be excited when they talk about new meta analyses or how interesting they find SKIN or LUNGS or CANCER. I certainly don't feel the same passion about anything I've learned so far.

So maybe I'm weird. No, I'm definitely not weird. THEY'RE weird. Maybe I'm just not the right kind of weird to be a doctor.

Maybe I'm too normal for this job.

My co-worker

Hello, cranberry muffin.

Good to meet you. My name is cc3 and I can already tell we're going to get along juuuuuuuuust fine.

First off, let's lay down some ground rules. Today's gonna be crazy busy. I'm going to need all the help you can give me. Over the course of today, I'll have climbed 60 flights of stairs, some running. Every fifth nurse I run into is going to raise my blood pressure by 10 mmHg. I imagine there'll be at least 3 demented patients to deal with, and if we're lucky we won't have created any new demented patients before the day is out. There's going to be a cornucopia of new smells today. If things go well and we get a couple minutes break, we'll get some reinforcements in the form of hospital orange juice and an airline sized pack of peanut butter on a napkin. Until then though, you're going to be my sole source of energy for today.

So. I don't know how you baked goods do it. Deep inside that paper cup adorned oven baked abdomen of yours lies the energy I need to keep going all morning. Must be some form of cocaine. Or saturated fat. If it's cocaine, I don't want to know. If it's saturated fat... I don't want to know either.

Welp. Time to get to work. Chomp.

Could Nelson Muntz please report to the Hospital CEO's office...

It's definitely been a while for me: many thanks to the faithful readers who have put up with the "filler" posts from my colleagues! Just kidding - they're probably more entertaining than mine!

But what I have to talk about is no laughin matter. This is an issue that I never would expect in the hospital: bullying. Now I'm not talking about the kind of bullying where docs are ushering their patients out the clinic door while saying "uh huh" to the patient's concerns simultaneously dictating their management for the next 6-8 weeks. I'm talking about the worst kind: resident on med student. My personal experience is not of being bullied per say but moreso the psychological flogging that is a commonality between the two. I could talk about how this makes me FEEL but I think a better use of this space would be how to identify how awful a poisoned environment can be to learning: anxiety before the day begins, anxiety during the day, and frustration at the end of the day. It's a pattern that you can count on more faithfully than the rising sun. I can only imagine what kids have to deal with without the benefits of proper stress-reducing activities like lifting heavy objects in a large room with women wearing lulu lemon or watching funny movies like Happy Feet - well, they can but they won't get all the jokes. They'll just say "ooo penguins! Clickety-clack!" and laugh. I'm grateful that I never went through any experiences of bullying as a child and I don't wish it upon anyone...except the bullies. They'll get theirs. What goes around, comes around. Thanks JT.

The Falun Gong Show

Every time I switch over to another rotation, there's an adjustment period lasting about 1 week. Switching over to neurosurgery was no different.

I forgot that in the hospital there aren't any lockers for clerks, so I spent the whole day hauling around my tofu container of lunch in an old milk bag. I proceeded, lunch in hand, to orientation where I expected to find out where I was supposed to go and when I needed to be there.

"Neurosurgery? I don't know. You'd better find that out."

Thus concluded my orientation.

So me and my lunch wandered around the hospital, eventually making our way up to the right floor after an hour or so of shrugs and vacant expressions. The surgery for the day had already started so I waited for them to finish before I introduced myself and figured out what was supposed to happen. A few hours later, I got paged to scrub in.

In the surgical suite. I finished scrubbing and came out ready to be gowned, only to end up being told to leave because there were going to be too many people in the OR.

I returned for the next surgery and scrubbed. The nurse told me to scrub again because I didn't scrub long enough, although I scrubbed longer than the surgeon. I scrubbed again. The third scrub for my first surgery.

Gowned and gloved, the operation begun. I was told to "stand over there". I waited for something to happen. Everyone else was standing around the patient, working away steadily. Too far away to see anything, my mind began to wander. I began to get tired. My feet started hurting. Checking the clock, I realized I'd been standing for 2 hours without having seen or done anything. I was also having trouble standing up because I was falling asleep.

I rounded the rest of the day and forgot to sign my name to a bunch of patient charts.

I forgot to contact the resident to let him know I was on call with him that night.

I lost my tofu container somewhere. I hope it turns up.

Someone keeps paging me from all over the hospital but when I call nobody needs me. I think someone's handing out a fake pager number.

I got in a physical altercation with an old demented lady who wouldn't let me look at her surgical incision.

About the time the old lady started trying to gum me to death with her dentureless jaws, I started thinking about how much of a gong show this day was, and how there were so many times when I was really hoping Jaye P Morgan or Rip Taylor would show up and BWONGGGGGGG me out of the hospital.

Several times that day I felt like if somebody had said to me "Just go home." I would have done exactly that with no regrets. That night I was listening to the TV while looking for a new lunch container, and I realized that despite all the mistakes and stupid things that happened, I was pretty lucky. Nobody really cares if I screw up, cause it's my job. Even if somebody cares, there are probably no more than 4 people at any time who notice my particular screw up. It's not like pro sports or real game shows or being a public figure where every move and every fumble is scrutinized the world over by millions of people, videotaped, then shown again the next morning to the billions of people who didn't see it happening live by satellite feed.

The next day ended up being better. The next day always ends up being better.

Covered in secrecy

The first time I worked in the OR way back in first year, the biggest adjustment I had to make was to get used to the masks. They're not very comfortable things to wear, fogging up glasses and making you rebreathe the warm humid air you just exhaled, generally making an excellent nuisance. They also prevented me from hearing people properly. I didn't realize how much I relied on lip reading to help me when people aren't speaking loud enough to be heard above the sounds of bonesaws and suction. The surgeon I worked with was a big Nigerian man with an odd accent, and without the benefit of watching him speak, I couldn't make out a single word he said.

Of course, with time, I learned to understand his accent eventually arriving at the point where I wondered how I ever could have had trouble understanding him. After a little while, I also began to learn to understand the mask.

Doctors pride themselves on a lot of things, one of which I'm sure is being funny. This, however, is not the case (see Stitches, the medical "humor" magazine. Any sentence, any picture, any page, any issue EVER. I challenge you to find an iota of funny in there. Stop sending articles.) Lots of lame jokes are cracked, some of which I just don't feel like faking laughter at. Hiding behind a mask, I don't have to smile. All I have to do is squint my eyes like I'm smiling and everyone thinks I enjoyed hearing the one about cheetahs never winning races. In secret though, my squinting eyes really say "I loathe your joking. Stop contributing to Stitches."

God that magazine is terrible. It's like Family Circus for doctors.

Another important aspect of the mask is that you can stuff it full of tasty smelling things. That way, when that tireyard employee who vomited up feces mixed with his last meal of burnt hair shows up in the OR, you can smell Calvin Klein's Obsession, rosemary and thyme, or whatever. Me, I soak it in Cheetos crumbs. That way I can also have a snack without anyone knowing if I get hungry, in addition to smelling hydrogenated oil, natural and artifical flavors, and coloring additive #43 all day.

The most useful part of masks is the emotional one I don when I meet patients. I do listen a lot, and try to stay attentive to their issues and problems. At the end of the day though, I have to go home and deal with my own life. I don't know how I'd do it with all the baggage I'd accumulate if I didn't maintain some kind of barrier between me and the patient. Really, I'm surprised psychiatrists don't go home and almost kill themselves everyday. Whatever Patch Adams said was a wad of garbage. Staying emotionally detached isn't something I do because I'll make better decisions for the patient. I stay emotionally detached because I'll go crazy otherwise. Crazy enough to start submitting articles to Stitches.

I'm a real boy!

Every Friday during this emerg elective, I'm supposed to go to resuscitation rounds. Unfortunately, every Friday thus far I've been so eager to watch my new downloaded sepisode of "The Office" and "Scrubs" and "Andy Barker Private Investigator", I've forgotten to go to all of the rounds. This Friday though, I remembered.

Resuscitation rounds consist of going through different scenarios we might encounter in practice where the patient is in need of serious and timely medical care. The patient is a plastic mannequin who blinks, breathes, and has detectable pulses. Just like a real person! Also, he also has about 9-10 extra nipples made of brass to attach electrodes to. I think they're not made to be nipples though, just to look like them.

The best part about the mannequin is that he can talk. Everybody else seemed to think this was nothing out of the ordinary. I was amazed! It could hear your questions, interpret your words and respond appropriately! Just like a real person!

He even coughed and hacked when he had chest pain, and when he was defibrillated he screamed! Just like a real person!

I turned to one of my classmates and said "That mannequin is just like a real person!". Bemused, he said "Yeah... that guy controlling him behind the one way glass sure is good."

Oh.

So we spent the next couple of hours going through scenarios, each one of us rotating through the role of team leader. Because I'd missed all the previous sessions, I had no idea what to do as leader. Nuts to those NBC Thursday nights! Why do they have to be so distractingly entertaining!

It didn't help that the preceptor told us that the scenario was going to be really tough, to finish off the session. I was becoming more and more anxious as the start drew close. Suddenly, I remembed that it was only a drill. Stupid mannequin! He's not even alive! He should be glad he's getting any medical care at all!

Pulseless electrical activity. Ahhhh... I studied this several weeks ago, and of course I'd forgotten the list of things that could cause it. And I had never studied the proper intervention. My mind raced through possible treatments, or at least temporizers but nothing seemed to work. As soon as I'd tried one thing to correct problem A, problem B would surface while problem A was just getting worse. Wash, rinse, repeat.

So the patient died, and I was surprised at how crappy I felt. Nobody really died. Nobody's family has to listen to bad news. Strangely enough, I felt really guilty. I hadn't studied enough, and I hadn't been ready. I guess that mannequin's even more realistic than I thought. Just like a real person...

Run cc3

Ever since I was a kid, I can remember being told not to run. Don't run on the pool deck. Don't run in the library. Don't run when the building is on fire. In a society where running is forbidden even when your surroundings have exploded into flame, it becomes a pretty special occasion when you're supposed to run in a hospital.

So when there was a code on the psych floor and nobody was around to take care of the patient except for emerg, I ran faster than Forrest Gump on EPO. In a way, I was getting back at all the lifeguards, librarians, and old ladies with walkers I'd bowled over while escaping a burning building who have admonished me throughout my life for running.

I beat the crash cart to the elevator. I beat the gurney to the elevator. I even beat the trio of beefy/fatty security guards who were supposed to be there first to get the elevator down to the first floor. I don't think anybody else knew it was a race, but that didn't stop me from trying to beat them all.

The beating hearts were almost audible in the elevator. I could tell everybody was mentally going over what they were going to do when they got to the scene. Mouths moving silently, ticking lists off fingers, eyes towards the ceiling. Psh. That's such a loser mentality. I was stretching my quads and taking my mark for the next heat.

I lost in the final to the nurse with the teddy bears on her nametag. To her credit, she ran a good race, elbows askew to prevent any potential drafters from taking poll position on the inside lane. Maybe next time.

When I got there, and I'd had my fun, I felt a little out of place. There was a guy lying on the ground and everybody had crowded around him and the crash cart, leaving me out of the picture. I was now presented with a dilemma I'd run into a number of times thus far as a clerk; do I stand back and learn little, or do I squeeze in, try to get involved, learn more but possibly compromise patient care?

The phrase teaching hospital had always confused me, as everybody spoke of teaching hospitals as if they were excellent places to recieve care. But if I had the choice, I think I'd rather be treated in a community hospital. Not a tiny hospital, but definitely a place that isn't crawling with clerks eager to learn at my expense. On the other side of the fence, I need to learn how to deal with these kinds of situations.

So I propose the following. If you don't wish to have your care compromised by me trying to learn, send me an email with your name, social insurance number, and bank PIN and I promise I'll leave you alone. Otherwise...

Funny words

Some sound better with exclamation marks!

Incarcerated bowel.

Pea-picker's disease.

Explosive diarrhea.

Megacolon.

General Paresis of the Insane.

Monoclonal Gammopathy of Uncertain Significance.

Organizing Pneumonia.

Beer Drinker's Potomania.

Vaginal Vault.

Tired of tired

When I was too young to remember and fussy, my dad would put me in the car and drive around the block. He said it never failed to put me to sleep. To this day, I still have trouble staying awake in cars.

Later in Grade 1, my French teacher used to call on me all the time when we were learning vocabulary. One reason was because she said I used to know the answer all the time. The other reason was because I was asleep for the entire vocabulary session, and she was trying to embarrass me into staying awake.

In high school and undergrad I had endless trouble staying awake during classes, and during movies. None of this was due to sleep deprivation, sleep apnea, or any of the other usual suspects. It wasn't just the usual after lunch nodding off that everybody else gets. I fell asleep in almost every class, but more easily in those classes I found boring. I could tell the exact moment I fell asleep in class, as my notes would gradually get more illegible, wavering above and below the ruled lines, and to cap off le fait accompli, the perfectly curved penstroke right off the side of the page and onto my neighbor's notes as I completely lost consciousness.

I wasn't trying to sleep through class; I'd be fighting to stay awake all the way through the hour but I would invariably lose the battle and nod off. It would annoy me when I did nod off, because I was doing my best to stay awake but it clearly wasn't good enough. It frustrated me further when someone would comment on it. God dammit I was trying to stay awake.

I tried everything, from going to bed early and regularly, stimulants in the mornings and none in the afternoon... nothing was working. I started having trouble keeping my marks up, as I would invariably fall asleep during some crucial moment of the lecture. I got in trouble at work because I fell asleep at the company social outing planning meeting. I got in trouble for falling asleep during RA training.

I continued my somnolent ways right through med school. If it wasn't for some excellent notetaking from friends, I'd have been lost. I started wondering if I had something a little more serious than simple daytime fatigue. None of my symptoms seemed to fit with any syndrome in the literature, much less any syndrome that wasn't laughed at behind patients' backs.

Most recently I got ousted from resident rounds because I was nodding off. Being bitched out for falling asleep was nothing new to me, but what bothered me more this time was how the staff talked about it like I was too stupid not to know sleeping during rounds was wrong, and how I "needed more sleep" or should try "drinking coffee". What a bunch of asswipes. I wasn't about to explain to them my chronic problem with sleeping.

When they condescended the way they did, it hurt more than that time I fell in the cotton candy machine. It hurts to have a problem that people don't believe is real, or don't understand. It's even worse when they punish you for it.

So I have a little more sympathy now for people with weird conditions. Narcoleptics, you can crash at my place anytime. You my boys, chronic fatigue syndrome sufferers. Restless leg syndrome, let's go cut a rug sometime. And everyone else who's just bored easily by boring people and unengaging teaching, don't let the man get you down.

PS: Morgellon's? No sympathy. You guys are just plain crazy.

Foot in mouth disease

Requisition History: Hirsutism.

I remember writing a while back about how patients talk too much. I'd like to eat those words tonight please. No, the specials will not be necessary, thank you. A house salad will be fine, vinagrette on the side. And a bottle of your second cheapest wine, mon sewer.

So what happened? Did my patients read my post, huff indignantly and organize covertly to begin a health care system wide silent treatment? Fortunately, my readership is limited and this was not the case. No one's talking to me because right now I'm in radiology.

Whenever I wrote up a radiology requisition, I never bothered putting much information on it for the radiologist to read. I always figured that whatever the problem was, their well trained eyes would pick it up and find it anyway. Since I've started though, there have been no shortage of instances when I needed any kind of clinical information at all to help me figure out whether or not this patchy crap in the patient's lung was something to worry about, or whether there even was any patchy crap there to begin with. But those xrays won't tell you anything that you can't already figure out from the look on their faces.

I guess that's part of the reason why radiologists become radiologists; they don't have to deal with people. In radiology you'll never have those patients that can't answer a simple yes or no question without an A&E Biography style retelling of their life. At the same time, you'll never know anything important or interesting about the people under your care. Every person you see is going to be as informative as the unconscious drunk, the frontal lobe stroke, or the parentless 6 month old.

I realized that talking to people was a big part of the reason why I liked suturing so much. You get to sit down with someone for a good 10 minutes and chew the fat, find out who they are, where they're from. I met an Afghani refugee the other day with some pretty crazy stories about Afghanistan. I never would have known by looking at his CT scan.

So radiology's not for me. I like talking to people. I hope this rotation ends quickly. I don't envy that luminescent pearly white sheen everyone seems to acquire after their patients stop talking to them.

American I-bull sh**

I just finished up a month in emergency medicine, and while en route to another educational locale I got together with CLL and 888 and a few other friends for lunch. Naturally, all we talked about was medicine. One of my lunchmates is not a medical student, and as I listened to myself go on and on about the different things I've seen and done so far it suddenly dawned on me that I must sound incredibly boring.

To someone who's not a medical student, being privy to our mealtime exchange must be as stale as astronaut food. I imagine sitting at that table was something like judging a miniature painting contest, or making a Hinterland Who's Who funded documentary about muskoxen, or somehow poking yourself in the eyeball with your other eyeball.

Most of what I talk about is medicine. Most of what I think about is medicine. Pretty much everything I do is somehow medically related. People told me when I started that I would work non stop, take no vacations, and run away with the secretary, but nobody warned me that it would swallow my life to the extent that it has. Even when I make a conscious effort to try to talk about something else, invariably I find myself talking about another medical school related issue or anecdote. Is there no way out?

Well, I think I've started taking steps in the right direction. I've recognized that I need to shut up more about work/school, and do more that's not tied to medicine. I've been trained for many years to convert all my free time into more work time. It won't be easy to break free of my Pavlovian conditioning, but now that I've made my career choice, hopefully it won't be impossible. Here's to the work free weekend, and keeping it that way.

Learning the hard way

"Doctor I think there's something in my eye..."

I'd just put the finishing touches on my first 6-0 facial stitches. My preceptors had been harping on me for a long time about how hard it was to use 6-0 stitches (it's not), and how important it is to stitch properly on a face (it is). My job today was made slightly more difficult because my patient was a 19 year old girl who had previously had an injury to her face that had not healed well.

So when I'd closed up her forehead and sent her away with the right instructions I was feeling pretty good about myself. I'd done an impressive job in my opinion, I'd properly disposed of all my sharps and strode out of the surgery room a little more confident in my skills and a little less inept.

Five minutes later the ward clerk chased me down and gave me grief because I'd sent my patient home looking like she'd walked off an excerpt from the next Fox special "When Prison Riots Go Wrong". In my excitement over another suture technique to add to my arsenal, I'd forgotten to wipe off the excess blood off the patient's face. For some reason, foreheads bleed like stink and the nurse wasn't going to let me forget about this one.

Such is learning in clerkship, at least for me that's how learning is done. I don't know the answer to a question, or I don't know how to do a procedure, and I go look it up later. I get chided for doing something improperly or I nod sagely through a conversation that's completely over my head, and I go look it up later. The path to enlightenment appears to be littered with those times when you fall flat on your face with everybody watching. Shamed into learning! It's the best way to remember your lessons. It's embarrassing, but it works.

It's so easy to identify the people who are going to be star doctors someday, catering to Bill Clinton's quadruple bypass, Kirstie Alley's stomach stapling, and when the other shoe drops, Britney Spears' medically supervised methadone usage. Those clerks are the ones that know the answers before the questions are asked, the ones that never have to be bailed out of a jam, the ones that seem to never have to study. I don't know how those people learn, unless it's direct download into the USB port they have secretly installed in their rectums.

Learning. Digital, or humbling.

Playing the game

I was sitting with an acquaintance of mine in the anatomy lab when he asked me if I was playing "the game". I assumed that he was not a character from The Executioner series of adventure novels, and I also assumed he was not asking if I was participating in everybody-wins-musical-chairs. I'm pretty sure he was asking if I was trying to get into a competitive specialty by sucking up to doctors and program directors.

Looking at the other clerks around me in the emergency room who want to do get into an emergency specialty program, I can't imagine ever standing a chance. It's very similar to Olive's entry into the Little Miss Sunshine competition: wrong reasons for entering, late to the competition and nobody likes the way I dance.

I can't imagine standing a chance cause some of those people are insane. They start emergency medicine clubs, where they get together and talk about emergency medicine and how much they love it. Are they really that in love with emergency medicine, or are they doing it mostly to further their career? I really love my Nintendo Wii and I haven't started a Nintendo Wii club. And I really really love my Wii. Or these people will get together and do research projects for their supervisors, or maybe follow them around all day laughing at all their jokes, maybe wash their car, walk their dog...

I guess that's what it takes to climb the ladder in any job, and the people who need to do it should be doing it to get where they want to. Short term pain for long term gain, so they say. Good thing there's family medicine. The underachieving, misunderstood child of the medical specialty family. To end up in family medicine, they'll have to kiss my ass.

Verbal infancy

Doctors talk way too much.

I know. I've listened to them not shut up for two and half years, morning, most afternoons, and sometimes in my nightmares. Sometimes nightmares in the morning while they're talking too much and I'm sleeping too little. I don't know why doctors talk so much. I have a feeling it's a reflex retained from when they were children and were unable to communicate their need for attention in any form other than vocalizing loudly, painfully, and without regard for whoever may or may not be listening. Everybody needs attention, but as I've learned, doctors and babies especially.

One of the things that I've stopped doing is asking questions unless I've found something to sit on. Simple queries such as "Given this patient profile, should I do a CT head?" or "Where are the sutures?" invariably lead to 15 minute diatribes on each study completed in the last decade on the subject followed by a brief examination of the Socratic method versus problem based learning, and ultimately the failure to recall what the original question was.

So far the colleagues who've struck me as smart are the ones that say less. Also, the ones that struck me as idiots say more.

Bloggers included.

Have your pap smear uploaded to Youtube at no charge

Even before the days of the first yabba dabba doo powered automobile and the brontosaurus steam shovel, the ultimate goal of technology has always remained the same...

To build a ROBOT DOCTOR.

One day, maybe in my lifetime, I'll be conveyed into a clinic on a moving sidewalk. A friendly ferrous-alloyed physician will shake my hand with a just sterilized claw, steaming like a hot towellette, or maybe I'll grasp the disposable prosthetic hand shaker/quad orifice scope instead. "BEGINNING DIAGNOSTIC" flashes on the viewscreen, and after an uncomfortable but thorough four minutes of being probed in my all orifices simultaneously, the software comes to a conclusion.

"DIAGNOSIS: MEDICAL STUDENT. WELCOME TO YOUR MEDICINE ROTATION."

Ah, technology. Making life better for us all.

Mechanical medical personnel aside, there have been many techy advances for medical students which have come about in recent years. PDAs jump readily to mind. These secondary brains have saved many a clerk from looking foolish in front of an attending more times than their primary brains have. If somebody tells you they're not useful in medical school, they either haven't found the right programs, or the Mennonites have gotten to them.

Another happy byproduct of medical technology has been the introduction of computers as record keepers in the hospital. For the most part, I've found that records are easier to access, harder to lose, and much more organized than their paper counterparts. The benefits are almost infinite, but the drawbacks are in no short supply. Computer crashes, data backup failures and incompatible software are just a few of the issues EMRs face. Bad for health care. But good for students!

As long as you're tech savvy enough to have found and read this blog, you have a pretty decent
chance of being computer hero to many of the old-school pre-digital era dinosaur MDs out there. You know the ones I'm talking about. They're the ones that hold the mouse upside down, or the ones that somehow manage to activate the virtual aquarium screen saver and password lock themselves out. Once there's an EMR crap out, you can save the day and feel marginally useful, rather than marginally primate.

Lemonade from high tech lemons. End transmission.

Tales out of medical school

Just like the poisoned deposit enevelopes at the ATM, the cellphone that exploded a gas station, and the toilets that flush backwards in Australia, medicine is full of urban legends. I don't know how many of them are true, but I thought they'd be interesting to keep track of in case someone knows if they hold any water or whether they're just another Letters to Playboy Magazine that no one will ever be able to verify.

1) Anti-retroviral therapy for HIV positive patients is full of side effects. Nausea, constant vomiting, liver and kidney failure, life-threatening infection, cancer and death are just a few of the more notable complications an HIV positive patient can get if they undergo this treatment. Not only are the side effects bad, but the pill regimen is complex and the outcome of treatment is uncertain at best.

Legend: In order to communicate the extent to which these pills affect a patient's life, an attending physician in the infectious diseases department at an unnamed hospital made it mandatory for all the residents under him to undergo a week's worth of treatment, just so they could see how bad the side effects really were.

2) Hospitals have to be prepared to deal with anybody who might present at their door. While many hospitals are equipped to handle almost any medical condition a patient might have, not all of them are outfitted to handle any criminal tendencies a patient might have. Convicted felons are often in need of medical attention, and when in-prison visits aren't enough, prisoners are taken to the hospital.

Legend: A hospital employs 2 crash carts. One is a normal crash cart with an automated defibrillator, induction drugs and resuscitation paraphanalia. The other crash cart also carries induction drugs and resus equipment, but instead of a defibrillator it carries a taser. Of course, both crash carts are painted the exact same colour and are located right next to each other at the nursing station. An inmate at the hospital goes into cardiac arrest and the wrong crash cart is brought in. Somehow, the resident on the crash team fails to recognize the subtle differences between a taser and a defibrillator, and tasers the patient. Outcome? The inmate's rhythm returns to normal.

3) Legend: Premarin, a hormone replacement therapy for women is made from pregnant mare's urine.

Let the debunking begin.

The debits and credits of life...

25 y/o male presents to the ER, suicidal ideation - consult psychiatry

58 y/o male presents to the ER, suicidal ideation - consult psychiatry

38 y/o female on the psychiatry ward, admits suicidal ideation - you betcha, a consult.

And then there was this man in the cardio-resp ward. 77 years old, can't breathe from his COPD and can't keep his head upright because of a CVA. He's DNR now but when I asked him whether he wants die?

NO (as if I'm talking crazy)
I want to go home and live with my wife *breath*, my dogs, my kids *breath* and their kids.
*head slumps into pillows because his arm to too tired from hoisting it up*

I'm writing this tonight because I think I'm suffering from a mild case of TMS. Too Much Suicide. As much as I've tried to separate myself from the despondence that comes with the stories that I am hearing everyday it's hard not to feel a little sadness about the world when I come home. How could there be a 25 year-old who wants to die when there's a man more than triple his age struggling to hold on to his? To be fair I understand everyone I've met who wants to commit suicide has SOME reason to - not necessarily a good reason, but there is a reason. But I guess a guy can only take so many awful stories before he begins to lose that once-a-week 5 minutes of sunshine he gets on his walk to work on sleep-in day. (Note: once-a-week is a gross exaggeration - the reality is more like once a month)

Clearly I still haven't completely made sense of what I'm experiencing as you can tell from the disorganization of this piece but ultimately this is my reaction to my experiences in psychiatry so far. I have been told to expect some sort of reaction from psychiatry patients. Their weird and wonderful delusions will not sit well with you sometimes. Their awful stories will give you pause to take stock of how good you have it. And their racist, vulgarities that they spit in your face aren't personal - so don't take it personal.

More to come.

Courage

The other day one of my friends remarked how scary it must be to be at least partially responsible for people's lives in the hospital, and how medical students are either all crazy brave or crazy crazy to do it. While I can't say for certain I'm not crazy crazy, I don't think I have to be particularly brave to take care of patients. What you have to be crazy brave to do is to be a patient being cared for by me.

All the patients I've seen don't put up a fight. "Hi my name is X, I'm a clerk and I'm working with Dr. Y today. I'm here to do a bit of a workup before he comes in..." and they all acquiese with little more than a smile, a grunt, or in the case of that frontal lobe patient the other day "JESUS FUCK OFF JESUS FUCK OFF JESUS FUCK OFF". Since he was saying that to everybody, I didn't think he really minded me working on him.

If it was me on the other side of the clipboard though, I think I'd have some problems letting a clerk suture up my face, or do superficial surgery over my lungs. Sure there's a real doctor making sure everything's going well, and sure the clerk's probably a smart cookie... but it's me we're dealing with here.

So thanks, patients. Thanks for letting me learn.

Thanks to the man with the huge abscess who had pain while I drained it because I didn't anesthetize a large enough margin around the site. Because of your suffering, the next patient I had that needed to be drained didn't feel a thing because I froze her like a wrist shot from center ice freezes Andrew Raycroft.

Thanks to the guy who tore his hand open on a rusty nail. Because you let me put in the stitches, I learned how much of a pain it is to need more sutures after you've used up all the ones you have.

And thanks to the man who let me feel his prostate. Again. It's already unpleasant enough having it felt once, but you sucked it up and now I have a better idea of what a normal prostate feels like.

All of these things I've learned are lessons that I wouldn't have learned in lecture, or by taking notes while someone else did it. I don't think patients understand how helpful it is to be able to do some of the things they let me do on them, so to those people, I say, thank you.

Now turn your head and cough.

The Perks of a Clerk

It's been a few weeks into clerkship, and I'm finally starting to feel I can control that sheer terror I've got deep in my gut a little better now. I've also been pretty lucky, no one has really drilled me in my sandbox-sized field of knowledge too hard -- perhaps it's because I wear my incompetence on my sleeve, thus rendering proving my ineptitude similar to coping a cheap feel on a drunken sorority girl.

There are myths out there - ones about the almighty "doctors-to-be" and the kinky business that goes down in the call rooms; about patients moaning a little too loud for comfort during a breast exam (or the dreaded rectal exams - not that there's anything wrong with that). Thus far, I've slept in the call room for many silent nights, palpated multiple pairs of pecs, and had my finger up more rectums than I'd like to admit. Still, no dice. Until now.

Looking at my triceps flickering about as I jotted down her history in her charts, she asks "do you work out?". Noticing my boyish good looks as I stared intently at her face, looking for the slightest hint of discomfort while palpating her abdomen for peritoneal signs, she inquires "what nationality are you?". Oh man, the myths are true. It was happening to me. Then the clincher: "you know, you're very handsome... "

I knew it! I AM McDreamy!

"... just like my grandson". So much for those myths.

Alright, so nothing spectacular happened. The truth is, clerkship is not very sexy, or glamorous. But really, there are perks to the job. This lady received some terrible news that evening -- she has late stage pancreatic cancer, and it's not likely curable. During her stay in the hospital, I've seen her everyday, and everytime I see her, her face lights up just a little bit. It's really not me or anything I did special, but if by reminding her of her grandson can bring just a hint of familiarity of family to this cold hospital, then yes, there are definitely perks to being a clerk.

Too emergencied

I like the emergency room. I get to do a lot of stuff, like drain abscesses. I drained two yesterday, and one was the biggest zit you will ever hear about. There must have been enough there to fill a sleeping bag.

The emergency room's also interesting. There're always pretty good patients to see, who have things that you can set right pretty quickly. Dislocated limbs, coughs, colds, etc etc. And the people you can't fix right away, (or don't want to deal with) like the psychiatric patients, you can send off to someone else who can take care of them.

The one thing I don't like about emergency is how you don't get to hear the rest of the story. Oftentimes, I find that the people I meet and treat are people I'd like to see again so I can find out how they're doing. Especially after I heard about all the stories about stupid emergency doctors missing diagnoses. Sure, we all laugh at them. Dumb doctors! How could they be so moronic? HA HA HA!

But wait... I'M probably making those same mistakes! I'll never find out though. Or rather, the only time I'll find out is when someone's lawyer comes calling. It'd be nice to know how your patients turn out so you won't develop a habit of undertreating or overtreating or improperly treating them later.

The other reason why I'd like to hear the rest of the story sometimes is because there're some patients I root for. I saw the nicest guy the other day, joking and upbeat even though he'd been waiting for hours to get his headaches looked at. He was a middle-aged guy with a family, and was just checking in to make sure his new onset headaches weren't anything serious.

I worked him up and didn't find anything unusual. His story was textbook migraines too. I reassured him that it probably wasn't anything dangerous, but a CT was ordered anyway cause he'd waited so long.

Turns out he had a huge tumor in his temporal lobe. The news wasn't easy to give, and I'm sure it was harder to take. Here was this guy coming in to see if there was anything we could do for his migraines, and now he has cancer in his head. It looked like he was overwhelmed with the pace at which things happened after that. Requistions for more CTs, more referrals, more consults, more directions to more hospitals for more appointments... suddenly his whole life changed. I bet he'd been planning to go home and hang out with the kids before work the next day. Not so anymore. Now he's in a battle for his life.

So he was referred to a neurosurgeon and we gave him what little information we could. And that was that. I'd like to meet him again to find out how he's doing, but that won't happen in the emerg.

Dr. Cox's Winter Stash

Looking back on my life, I've noticed that people don't praise me as much as they used to.

Nobody claps when I successfully crap in a toilet, flush and wash my hands.

Nobody gives me a gold star for remembering to put my chair on top of my desk so the janitor can mop under it.

Nobody remarks positively on my vocal participation in high school sexual education classes. It's even frowned upon nowadays.

So far, this trend has held steady into clerkship. I rarely find myself getting praised for anything. This isn't because I haven't been able to adequately demonstrate a clerk appropriate mastery of the history, physical and treatment, rather I haven't been praised in spite of it. Shouldn't someone who's inept at even the most pedestrian maneuvers and evaluations be congratulated whenever they leave an interview without being served a subpoena?

The bright side to receiving scant words of encouragement is that when something does go right, it becomes the highlight of your week. Like last week, I found a 1/6 murmur and showed my preceptor how to do a McMurray test. He said "You're quite good with your physical findings." Like a woman with a broken bikini buckle, I clutched those words to my chest and didn't let go for the rest of the week.

And then today, after hitting my first 3 venipunctures, he said "You've turned pro pretty fast!". Again, clutching, savouring etc, etc.

So far, this strategy's served me well. The sheer number of dumbasseries I make everyday are enough to cause anybody to quit, especially medical students who positively thrive on achieving. If I focus on the few things I do correctly though, maybe it'll keep me going long enough for me to learn how to do everything properly.

PS - Needlestick history is negative for infectious disease. Clutching, savouring...

Needless needles

A guy came in today with a minor facial laceration. I was sent in to stitch him up and I thought my biggest worry would be if I could keep everything that needed to be sterile sterile.

I was in a little bit of a rush cause I'd been slowed down previously by another patient's overbearing wife, and I didn't want to keep my preceptor waiting. I hastily grabbed the suture to load it into the needle driver when I felt something sharp go deep into my thumb.

Fuck.

I yanked my hand back and looked at it intently. Luckily, my patient's head was covered with the surgical drape so he couldn't see what was going on. I didn't see any puncture on the glove so I kept on working, but the thought of a needlestick infection was niggling me until I sewed shut his injury. It felt like it went in pretty deep though... No blood from my thumb but it was a pretty fine blade to begin with.

The worst part about this was I didn't do anything about it. I didn't tell anyone cause I thought it wasn't a big deal and that nothing would come of it. The patient got his tetanus shot and left, and by then I'd started wondering if I shouldn't have taken a more thorough medical history. All these shortcuts I take in emergency seem to come back to haunt me...

He didn't seem like a high risk individual, but god dammit. Who knows who's really high risk and who isn't? The stupidest thing for me to do was wait and not do anything about it or tell anybody about it. I studied my thumb intently. Still no blood and still no sign of puncture. Does that mean I didn't get stuck? Couldn't a virus stil be transmitted subcutaneously? I was so terrified of having contracted something evil I filed it under F for Forget About It and saw some more patients. It's probably nothing, I thought.

But every second that ticked by made me feel stupider and stupider for not having said something a second ago, but I felt like if I said something now I'd seem even stupider for not having said something earlier. I knew I was being an idiot but I couldn't help myself. I should have stayed in bed today.

I googled needlesticks and looked at the stats. 1 out of 300 needlesticks with HIV positive patients will cause an infection. Good odds, I supposed. I didn't even know if this guy was HIV positive or not. Hep B I've been immunized for. Hep A, whatever. I can deal with Hep A. Hep C though...

I looked at my thumb again, and squeezed it, checking it under a bright light for any sign of trauma. I knew I wouldn't see anything, and even if I did what did I expect to find? It's not like the virus is going to let me know I'm there. Until my liver dies or I get AIDS.

Now I was starting to get worried. Partly cause I had been exposed, and partly cause I couldn't stop acting like an idiot and just tell someone I'd been stuck. Why couldn't I just suck it up, look like a moron and get some help?

I ended up talking to my preceptor about it in the end, and he said to call the patient and ask about risk factors and leave it at that. I called and nobody was home. While I was waiting, my preceptor told me about the time he got a needlestick while working on a guy who had recieved multiple transfusions. Nothing happened to my preceptor in the end, which is nice. But what about me?

Still waiting for the guy to get home. Good lord I hope I'm worrying about nothing.

Today, unruly children who have stupid parents. Tomorrow, the world!

I attended a problem based learning session a little while ago. It was my first one outside of medical school. I didn't know that doctors used PBL after they graduated, but hey. The ice caps are melting, Israel and Iran both have nuclear weapons, Scrubs looks like it's going into its last season... everything else is going down the tubes, why not education for doctors?

Anyway. This session's PBL was on sleep disturbances in kids and what family doctors need to do about it. One of the doctors who was completing the session with us commented on how there was no limit to the scope of family practice, and GPs nowadays are expected to be prepared to deal with all facets of the everyday life. I wasn't sure what she was getting at until I read what exactly the sleep disturbance we were to learn about was: resisting bedtime.

Resisting bedtime! It's exactly what it sounds like. Little kids who don't want to go to bed when their parents say it's bedtime. I'm sure I'm not the only one who thinks this is something that you DON'T have to make an appointment for. If a kid doesn't want to go to bed, then you MAKE them go to bed. HMOs and publically funded programs, you'll receive invoices for this doctor trip cash money saving 3 step consensus statement I've provided.

To make your kid go to bed

1. Take off your belt. Belts with rhinestones generally frowned upon. Generally.
2. Psh-snap!
3. Celebrate parental victory by indulging in primetime television complete with cursing and borderline softcore pornography.

Done and done. You get to watch your Heroes, and for the rest of your child's life, his ass will really start to tingle around 8pm and he'll never ever figure out why until he has a kid of his own.

You don't need to visit a doctor for "resisting bedtime". I think there're too many issues out there that have been medicalized way beyond the point of there being effective medical management for any of them. One of my teachers once told me that we should all be teaching our patients masturbation as part of sexual education. Now, is that really a medical issue or is it just something that nobody wants to deal with so they leave it to the doctors? If someone's masturbating or not, is it really anybody's business? For crying out loud, I already have to stick my finger up your ass. I don't know if there's a way I can make that relationship anymore awkward, but if there is, I'm sure it's talking about masturbation.

Quit making doctors do things that doctors aren't qualified to do, like disciplining your kids. That's Supernanny's job. If you need pills, I got pills. If your kid needs a belt, you need to start wearing some pants, my friend.

More people should know about... : Germ Killing Soap

This is the first in a series of public service bloggings about things the public should know about their health but generally don't. As a broad disclaimer, any information contained in the body of this post and any other post should not be taken verbatim or as a substitute for real medical opinion. If you have real questions, ask a doctor you know, not somebody who may be pretending to be a doctor in the media... I'm looking at YOU Sunjay.

While using soap that kills germs sounds like a good idea in the first place, here's why it isn't. All the germ killing soaps out there say they kill 99.999999% of all bacteria. Why does it kill only 99.999999% of bacteria? Because out of the millions and billions and trillions of little microbes that live on your hands, there's always one bastard that has to be "resistant", and can't be killed with the soap. Pretend this picture below is your hand (Figure 1). The smileys are bacteria. None of these bacteria can cause disease. The resistant bastard is represented by the green smiley. The yellow smileys are unresistant bacteria which are about to not be so smiley cause THEY'RE GONNA DIE!

Figure 1

So you wash your hands and after you're left with only the green resistant bastard on your hand. Of course, he's not hurting anyone. He's just a tough little cookie. So cute! So square! Well, wait till he reproduces a few times (Figure 2).

Figure 2

Now you have an assload of resistant bacteria on your hand that aren't going anywhere. But wait! There's more! Not only are they now resistant, but through some bad luck and some mutation, one of them has gone rogue. That's right, he's not a happy smiley anymore. He's become one that's gonna give you the runs all day and all night...(Figure 3)

Figure 3

And, little known fact, bacteria can talk with each other. And when they talk with each other they give each other all kinds of information. Like how to turn into a red triangle (Figure 4).

Figure 4

And before you know it, your hand is chock full of red triangles just itching to ruin your formerly non explosive watery diarrhea day (Figure 5).

Figure 5

And the worst part is when you go to the hospital to get it taken care of, the drugs don't work cause all the bacteria on your hands have become resistant to them. How's that for suck?

So why does regular soap work better?

Well, regular soap doesn't get rid of all bacteria either. The difference is regular soap leaves behind random bacteria, not necessarily the ones that are resistant to antibiotics. So instead of getting only the green bugs seen in Figure 2, usually only yellow bugs are left behind. And whenever green bugs are left behind, there're usually enough yellow ones around to take up enough real estate and eat enough food to stop the greens from growing up and taking over your hand. In this way, if any of the bugs on your hands becomes evil (red triangles) the chances of them being evil AND resistant are very low. And your friendly neighborhood doctor will be able to fix you with some medication (Figure 6).

Figure 6

Play ball!

No matter how many times I start an elective, I always goof the first patient. It's like not swinging for the first pitch. And then the first pitch beans you in the head. Except the not-swinging-beaning process repeats itself everytime you start a new game.

Starting clerkship was no different. Clerkship started in some small town in some rural area with some nervous little clerk in the emergency department. The first patient I saw was sweaty, short of breath and could only speak Italian. The first clerk he saw was also sweaty, short of breath and could only speak gibberish. The hundreds of lectures and hundreds of hours of clinical experience I've had since starting school might as well not have happened. It's as if I was starting all over again at the beginning of my education, and in many ways I suppose I was.

I didn't ask many pertinent questions, and did a limited but accurate physical assessment. I managed to put a couple of decent diagnoses on my differential and went to report back. As soon as I started to give my report to my attending physician, I realized I'd forgotten to write anything I'd learned in my history or physical on the chart.

Ahh crap.

We've been taught that people who suffer from mania may display a speech pattern known as a "word salad" (http://en.wikipedia.org/wiki/Word_salad_(mental_health). I think I could have managed to produce a pretty awesome word salad of a report but instead a sliced boiled word egg from the word salad caught in my throat and the only sound I could make was sort of like that sound you hear when you get static on your tv late at night.

khkhkkhkhkhkhhkhhkakaaaaaaaaaaaaaaaaaaaakhkhkhakaa.

It didn't go over well.

However, when the next few patients come along everything usually falls back into place. And today everything came rushing back as soon as I'd had time to think a little bit about what my job in the department was. I resolved to improve for the rest of the night, and improve I did.

For the remainder of the evening I was the future of medicine. Like baby Jesus, except without the miraculous healing powers. My medical knowledge base returned quicker than if someone had slapped me in the face with Harrison's. Everything clicked somehow after I got that first one out of the way. I think after I allowed myself some mistakes with patient number one, the pressure was off for the rest of the night. I managed to convince my preceptor that I wasn't an idiot, and everything was great. We had pizza. And breadsticks.

So next time I step up to the plate, make sure you head for the bleachers. Cause even though the first pitch is gonna get me right in the face, my big thick skull is gonna hit it so hard it'll clear the park.