Heartbreaking and true

On the wall of the VA.

Drug rash

For anyone who hasn't seen an allergic drug rash, this is what it looks like. Yes, that's my leg and yes, that's me having the allergic reaction. No, it wasn't confined to my right leg. It was, in fact, over my entire body, including my face.

This photo was snapped while I was in the urgent care waiting for steroids. I tried Benedryl and hoped it would do the trick. Nope. So off to urgent care for a shot of solumedrol to the hip and a prednisone taper as well as two varieties of antihistamine.

36 hours post solumedrol it covers the same area, but a much lighter shade of pink. Yes, I will go to work tomorrow and yes, I will be wearing concealer, long pants and long sleeves.

Tenants of surgery

1. Don't stand when you can sit

2. Don't sit when you can lie

3. Eat when you can

4. Sleep when you can

5. Don't mess with the pancreas

kiddies say the darndest...

16-year old boy I'm playing scrabble with on inpatient psych ward: You look like a fish.

Me: That's not very nice.

Boy: It's the eyes.

Me: I have poppy-buggy fish eyes?

Boy: No. They're just... like... fluorescent!

Me: Fluorescent? How is that fish like?

Boy: They just remind me of the Caribbean, okay?

shelf exams

At the end of each rotation in your third year of medical school, you sit a national exam called the "shelf". It's made up of questions very similar to what will be on the USMLE step 2 (which you sit during your fourth year). Unlike USMLE step 1, the shelf exams and the step 2 are more clinically oriented; however, they are no less frustrating. Step 1 was a pain because of questions like "what arm of what chromosome is implicated in ridiculously rare disease X?" Answer: No idea, not relevant, don't care. The medicine shelf exam, it seems, will be a pain for an entirely different, but equally irritating reason: apparently I'm supposed to be psychic. For example, one question was about a 10-week pregnant woman with a swollen leg and shortness of breath. I was apparently supposed to deduce that her main problem was vomiting, despite the fact that pregnancy is known to place an increased risk for DVT (which the swollen leg would fit with). Another example? A woman with arthritis symptoms comes back for a follow up visit with gastric discomfort. I was supposed to infer that she was having methotrexate side effects, despite the question never describing any treatments being started. This all brings to mind another, perplexing question. I'm not a stupid person and I struggle with these exams. I know some stupid people who are doctors... how the hell did they pass them all?!

I feel used

Me: Sir, I would like to do a rectal exam on you to be sure you're not bleeding before I give you a blood thinning medication.

Paranoid schizophrenic patient: As long as it's you and not that guy-doc

Me: Yes sir, it will be me doing the exam.

Patient: Do what you gotta.

[rectal exam]

Me: All done sir, I'll let you clean up now.

Patient: That was the best sex I've had in years.

alternative treatment

Man walking in the VA hallway: Are you a doctor here?

Me: Sort of, I'm a medical student here.

Man: Well, I really like the care I get here.

Me: That's good to hear, I'm glad.

Man: I come all the way from [some town in Ohio] because this is a good VA.

Me: Well, I'm glad we can help you.

Man: You know, if this doctor thing doesn't work out for you, you could be a model.

Me: Thank you, that's very kind.

Man: You got it going on. I'm serious. You could be a model.

Me: Thanks, but, I think I'm going to stick with the doctor thing.

Man: Looking at you done cured my cataracts. Damn.

Me: Thank you. Have a good afternoon, sir.

Man: You too, gorgeous.

LOL

hat tip: geekinheels blog.

And now for something completely different

A little humour...

I find my white coat heavy and it contains: a pager, tiny notebook, pens, penlight, reflex hammer, pocket medicine book, alcohol swabs, my cellphone and a near card. That's light compared to.... The Mr. Always Prepared For Everything Guy. And yes, these students really do exist.

Sad for me

My cardiology month is over. Sad for me. I think the heart is the most interesting organ in the body - it's both mechanical and electrical and just keeps going without any rest. Your brain needs sleep, but your heart just keeps beating minute after minute, day after day, year after year.

Cardiology highlights:

1. Man who did "only" 8 lines of cocaine before presenting with a "mysterious" BP of 200+ and no urine for three days.

2. Placing an arterial line and doing ABGs

3. Spending literally hours pouring over one man's EKGs to determine his AV nodal arryhthmia, which turned out to be... all of them

4. A patient who had a dream my attending was a rapper in a music video

5. Correctly identifying SVT with aberrancy at 3am when the telemetry monitor thought it was v-tac

6. Watching a man de-compensate into heart failure from a heart attack in front of me

7. Listening to a patient tell my attending about the "hind-lick" maneuver

8. Being the only person on the team who could draw the anatomy of a {I, D, D} congenital heart patient

9. Listening to an aortic stenosis murmur so severe you could hear it on her back - louder than her breath sounds

10. Being told by patient's and their family that my being on the team had made their stay better.

Now it's general medicine at the VA. Stories to come...

Long call

Intern year is infamous for the amount and frequency of long call (overnight) that must be done. While on internal medicine during third year, I have had to work the same schedule as the interns; thus also q4 long call (overnight every 4th night). It's busy, it's tiring, it's frustrating, but it's also when you bond the most with your team and with your patients.

This photo is an example of the night float bonding with an M4 over a shared love of high level mathematics. I was busy bonding with one of my interns over bento boxes and having grown up out west. Later that night I went to visit a patient and his wife, who declared they would be my surrogate grandparents since my family is so far away.

Long call is also exciting as an M3 because it's when you get to do the most. You can get a complete history for your busy intern and then write up the admission paperwork for them. You can follow up on orders to make sure tests and labs are done and interpreted, call consults and be the contact point for the nurses so that you are in the loop on the evolving treatment plans. On cardiology you carry the code pager so when anyone in the hospital goes into cardiac or respiratory arrest you have to drop what you're doing and respond. First person on scene starts chest compressions and let me tell you, a real chest feels nothing like those dummies you learn on.

I really like long call - I like being in the middle of it all. But I can see how 8 months of it would get tiring. Still, 6.5 weeks into 12 weeks of this I'm mostly just pumped. I'm finally in the hospital. Finally working with patients. The last two years I've been impatient to become an M3. Now that I'm finally there, I'm even more impatient to be an intern.

RN vs MD

There is a lot of literature and there are many studies assessing the relationship between doctors and nurses. As a medical student you are told often and early, "don't piss of the nurses." This is sound advice because honestly, you learn a lot from your nurses and they can make your life very frustrating if they so choose. On the other hand, I can already understand some of the frustration that doctors feel. There are those nurses who, for some reason or another, think their accumulated wisdom is more valuable and correct than what goes into the education of an MD. Two recent examples:

1. I was reviewing a rhythm strip on a patient who has an AV nodal arrhythmia. We were concerned the patient was intermittantly having 3rd degree heart block - a rhythm in which the atria no longer communicate with the ventricles, who begin to generate their own "escape/junctional" rhythm. The nurse told me that he couldn't possibly be having an arrhythmia because the interval between the beats was constant. I tried to explain that a junctional rhythm would, in fact, be regular, but would still be an arrhythmia. She proceeded to tell me that after all these years here she knew that, but it still couldn't be an arrhythmia. Um, yes, it could. She insisted it couldn't. I gave up because she clearly wasn't going to change her mind. But honestly... what does she think I've been studying for these last few years? Proper bleaching technique for my white coat?

2. Another patient of mine has been on the floor for two solid weeks getting antibiotics. He's going a little stir crazy and I wanted to let him walk around the hospital courtyard for some fresh air and sunshine. My attending agreed that he was safe to be off telemetry for an hour or so and a walk would be good for him. The nurses overruled us. Apparently, they decided he was too sick to be off telemetry. Excuse me? Since when did nurses get the right to veto physician orders?

Many kinds of "call"

I didn't realise until now that there are many kinds of call. It turns out, the overnight kind we all think of when we hear "on call" is more precisely long call. If you are on long call, it means your service is admitting patients. On my current service, the interns cap out at 4 patients each and the senior resident doesn't stay all night.

While on long call you also cross-cover the patients on other services. If something happens to a patient admitted to another service over the night, you will get the page instead of them. Of course, this also means that your patient's problems will be handled by others when you are not on call.

The day after overnight call you are post call. Interns usually leave by noon because they were working all night. The senior resident will finish any remaining management on the patients for that day. Unlucky for the medical students: afternoon conferences are still required even if you're post-call.

The second day after long call you are on short call. You admit one patient early in the day.

The day before your long call, you are pre-call. Your service doesn't admit any new patients in anticipation of the new load during long call.

Another good question: what does it actually mean - "admitting" a patient? Well, it means the ED or another hospital has determined a patient needs care in your hospital. When your service accepts the patient you get a one-liner about their major symptom (chief complaint). Then you go and examine the patient, ask lots of questions and come up with several possible reasons for their illness (differential diagnosis). You also come up with a plan of how to manage each of the patient's problems. Usually the intern will see the patient first, then the senior resident, then the attending. The intern writes up an admission note and the attending co-signs it.

Each day in the hospital the intern (and med students) will pre-round on the patient, then the interns, resident and attending all round on all the patients together. They discuss progress and complications that occurred overnight and how to continue or change the management plan. The intern and the senior then spend the day organising that care and documenting it.

That's life on general medicine, inpatient. I'll post some stories about my first patients soon.

Skeezy old man

My friend and I were sitting outside enjoying some frozen yogurt after a sushi dinner when we were approached by an elderly gentleman. Well, my friend was approached... he interrupted our conversation and completely ignored me while having the following conversation with my friend:

Old man: Excuse the interruption but you look familiar. Are you on the volleyball team?

My friend: No I'm not.

Old man: I'm retired so I have the time to keep up with the sports, you know. Are you a student here?

My friend: Yes.

Old man: What do you have... two years left?

My friend: Yes.

Old man: What are you studying?

My friend: I'm actually a graduate student.

Old man: In what?

My friend: Medicine.

Old man: That's a long and difficult road. What do you think of this healthcare bill Obama just passed? Do you think it will be good or bad for doctors?

My friend: My friend and I were just discussing that. We agree it will be bad.

Old man: Yes, you won't make the big bucks anymore. Probably doesn't make it worthwhile. Maybe you'll change fields now. Medicine is a long road.

My friend: I think I'll stick with it.

Old man: [gives his name, sticks out his hand to shake hers]

My friend: [gives her first name only]

Old man: [first name] what?

My friend: [gives her last name]

Old man: [mispronounces her last name], is that English or German?

My friend: German. I was actually in the middle of a conversation with my friend so if you'll excuse us...

Old man: Do you have a boyfriend?

My friend: Sir, I ...

Old man: Well now I was hoping to ask if you would like to get together for lunch some time so we could get better acquainted in a proper manner?

My friend: I don't think so...

Old man: Well if you don't ask, you'll never know. Take it as a compliment and have a nice evening.

Ok, so despite the veneer of politeness it was a decidedly skeezy conversation of the part of this AARP member. Let's not forget that when he approached her, he thought she was an undergrad with two years to go... that would make her 20, max. He looked an easy 70. Did he really think he was getting a yes? Delusions of Hefner much?

Who knew?

The reservoir for leprosy in the USA is armadillos.

Scorpion stings can cause acute pancreatitis.

pls Reply: none

A grad student sent out an email request today asking other grad students to take a short survey for her biostat final project. She sent it to all the grad students at UofM. One person, who took her survey, was appalled by the gender choices: male or female. Appalled enough to spam the entire list of grad students with a paragraph on social justice and acceptance.

That was a poor choice. Even poorer decision making was displayed by the 20 other people that then continued the discussion CCing ALL the grad student list-servs. The discussion expanded somewhat and the most recent email contained not just statements on social justice, but on manners, the phylogeny of the mango tree and the racial classifications on the US Census.

We've passed 40 emails and they still trickling in.... seriously people, don't you have something BETTER to do? Like, write your thesis?

Another fun fact...

Once upon a time in France, children born with cretinism were thought to be so mentally retarded that they were incapable of sinning. Thus the name cretinism, meaning Christlike.

Cretinism, for those not studying for the USMLEs, is endemic fetal hypothyroidism.

Alphabet Soup

Flash of brilliance: Immunology should be taught Sesame Street style.

This episode is brought to you by the letter C...

Big Bird: Hey Elmo, what are you doing with those big letters?

Elmo: I'm building the classic pathway of the complement cascade!

Big Bird: Gee Elmo, that sounds hard. Can I help?

Elmo: Sure! Why don't you hold these IgGs and C1s for me?

Elmo hangs IgGs and C1 on big bird like ornaments on a christmas tree.

Elmo: With the power of IgG/C1 you can split the C2 and C4!

Big Bird karate chops a C2, the halves come apart as C2a and C2b. He then chops a C4, creating a C4a and C4b.

Elmo: Yay! Hey, these two stick together!

Elmo stick the C2a and C4b together like magnets. A C3 floats onto the screen.

Big Bird: What's that?

Elmo: I can take care of it with this!

Elmo uses the C2a4b like a sword and slices the C2 into C3a and C3b, but the C3b sticks to the sword. C5 floats onto the screen...

Elmo: More of them! There are almost as many proteins in complement as there are in coagulation!

Elmo slices at the C5 with his C2a4b3b, splitting it into C5a and C5b. After a moment, cookie monster walks in sniffing the air...

Cookie Monster: Me smell... me smell C5a! Mmmm... cookie monster like C5a... nom nom nom

Elmo: Cookie Monster, what's that on your tummy?

Cookie Monster: Those are my lobar nuclei! Me hungry... me want to phagocytose!

Big Bird: This was fun Elmo! Next time we should try the alternate pathway!

WTF?

I was looking up information on intelligence tests (they constitute testable material on USMLE step 1) and I found a page about high IQ societies and their entrance requirements. Apparently many of them will accept high scores on the GRE or the LSAT, but not the MCAT. I'm not nearly as surprised that the GMAT doesn't count...

High IQ societies

X vs Y

According to my pathology review book, if you have an extra copy of the Y chromosome (male) you are more likely to have severe acne and be a violent criminal. If you have an extra copy of the X chromosome you are likely to have menstrual abnormalities.

If you have two extra copies of the female chromosome you will have mental deficiencies, but if you have two extra copies of the Y chromosome you will be dead.

One day of freedom

I officially passed and completed my M2 year! Pre-clinical medical school is over! My reward is a single day off before 4.5 weeks of intense boards studying.

I decided this was insufficient and so allowed myself the following two additional indulgences:

1.) Oreo milkshake from Potbelly's. Amazing and delicious.

2.) A new pair of shoes. They are completely impractical but utterly fabulous. Who doesn't feel sexy in red peep-toe heels?

I drove this car (Mustang Bullitt) last night. It started raining and I spun it out (without hitting anything or hurting anyone). The owner was sitting next to me, totally nonplussed. He's going to let me drive it again.

It's good to be a girl.

Happy thoughts...

Dr. V on maternal mortality:

" That's about 6 jumbo jets per day that crash full of pregnant women and they all die."

Yesterday afternoon's class consisted of watching a video of a cesarean section and a second video of a vaginal birth (all the funnier because it was filmed in the '70s). You may be surprised to learn that I would still prefer a cesarean. Neither looks like fun so maybe .... no kids. But, accidents happen and in that case... I'll take the surgery.

The Good and the Bad... an update

Thumbs Up:

• I found a new apartment - a one bedroom - and will move in July
• M3 rotations are out, I got my first choice track
• No cavities at the dentist
• Passed my physical with flying colours
• My car is fixed and looks/smells new again
• Love my gym, really enjoying PT

Bummer:

• Grandma may need surgery
• A friend is sick (with something chronic)
• Research projects are lagging a bit
• Um... boards?

I will try to post something more substantial soon.

Evil Email

When you go to visit a medical school, especially one with pass/fail pre-clinical years, you inevitably hear a lot about how collaborative the students are. How they all want to help each other and work together because ultimately, medicine is a team discipline.

Reality check: Type A's don't change their spots overnight.

Exhibit 1: An email from A--- to our entire class:

Subject: I'm tired of people wearing jeans to MDC's

Text: [insert classmate's name]. Done.

Exhibit 2: 20 minutes later a second email from A--- to the whole class:

Subject: Re: I'm tired of people wearing jeans to MDC's

Text: And now sleeping during the MDC. Not cool. Way to be respectful.

You might think this kind of behavior is limited to students.

Reality check: Once a gunner, always a gunner.

Exhibit 3: Last night the entire class (!!) was accidently cc'd (do people really not notice when they hit reply all?) on this email from a pathology faculty member to a senior administrator:

Subject: GI handout

Text: Are you serious? A synopsis of Robbins textbook? Are medical students now incapable of reading, even reading stuff that may be wrong?

Exhibit 4: And then we were CC'd on the reply (apparently no one over the age of 30 can tell the difference between reply and reply-all):

Subject: Re: GI handout

Text: As a faculty member we/I cannot control what he does -that is why I sent the e-mail - he does it on his own - not a team player or collegial - he will be retired in August - just a heads up

Despite these outliers, most people are actually very friendly and collaborative. And drama-prone. Does high school ever really end?

Live from the OR

Once upon a time I did a post composed of live blogging from the ER. I thought I would replicate the concept tonight by giving you an idea of what a transplant case looks like for me.

11:07 - consent is obtained and I receive an email. I am now aware that a donor liver is expected to arrive for a patient and the surgery should occur sometime today.

17:48 - I find out the donor liver is not expected to arrive until after 10pm, that means an overnight surgery is likely.

21:11 - I call the main OR desk and they indicate a lines-in time of 11:30pm. That means the incision won't happen before 00:30am.

23:50 - I arrive at the hospital to change into clean scrubs, prep some dry ice for samples and start the paperwork.

00:18 - I head down to the OR to check on the progress. They are just finishing the echo and still have to place the radial line.

00:37 - Incision. I draw two purple tops and collect 10cc of urine. I leave the OR and head to the lab to centrifuge the samples and put them on dry ice.

01:26 - Back in the OR to observe

02:51 - Anhepatic phase begins. This is when the patient is no longer connected to his old liver and not yet connected to the new one. I draw samples and put them on ice to process later.

03:29 - Reperfusion. This is when the new liver is connected and circulation through the liver is restored. All the preservatives and biochemical waste from the new liver cause the patients heart to struggle briefly. When well-managed and with a little luck this can be short-lived and uneventful. Tonight, reperfusion goes smoothly.

03:59 - I draw samples and bring them and the pre-reperfusion samples up to the lab to process. Sometimes I stay in the OR until close, but tonight I'm hoping to catch a few hours sleep before class. If the close is within two hours of my shift ending, I will be able to draw the closing samples and leave. If not, I will have to stay until 2 hours post-op.

04:40 - The surgeons have closed, the operation is complete. This was a very short surgery, which is good for the patient, but bad for me. I now have to stay until 6:40 to do the 2 hour post-op samples.

04:50 - Follow the patient up to the SICU to get immediate post-op samples. Run back to the lab to finish processing samples already collected.

05:30 - Email an update about the surgery and schedule for post-operative draws through POD4 to the research group.

06:30 - Head over to the SICU to check in with the nurse and get the 2 hour draw.

06:45 - Head back to the lab to leave the samples on ice (the girl coming in at 7 will process it), head home to catch a three hour nap before class at 11.

Swing performance!

Last night was the performance of the swing dance we've been working on for the last few months. We all landed our big breakout moves, which was awesome! Proof that med students do something other than study ;)

Smartest or Nicest?

The NYT ran an article recently on using personality tests as part of the criteria for medical school entrance. Apparently they gave personality tests to 600 students to look for which traits correlated with future success. Big surprise, those who stressed easily did poorly and those who were extroverted did well.

The thing is - I don't agree with their proposition that doctors all need to be super-nice people. Sure, a physician should treat you with respect and courtesy, but you're not there to make friends. When did it become an expectation that your doctor also be your confident and therapist?

Let's put this another way. If you found out tomorrow that you had cancer or HIV or needed a triple bypass - do you want the nicest kid in the class or the smartest?

I know what you're thinking, can't I have both? Sometimes yes. There are some very smart people who are also very friendly. But the traits that get you through training are not the traits that win friends. In medical school and residency you sacrifice a lot of your personal time to your training; thus your relationships are neglected. The divorce rate for doctors is above the national average. You have to be willing to study for hours alone - be independent and driven. The decisions you make and their consequences are weighty; they require detachment and objectivity.

Everyone's job has stress, but not everyone will find themselves leaving their son's baseball game because their pager went off. Your patient is in respiratory failure because they developed graft vs host disease after their bone marrow transplant, which you recommended and without which they would have died. And it's not just cancer doctors - it's the primary care physician whose patient has a hypertensive crisis or a stroke. It's the ER doctor that has to call the organ donation team when a 24 year old comes in from a motorcycle crash. It's the pediatrician who pronounces the unlucky child who got meningitis or the ob/gyn that tells a first-time mom that her baby has hydrocephalus. Every doctor sees these cases in training and no practice is immune from tragedy.

Why is the system built this way? Why do we make it such a stressful process to become a physician? Are we turning good people into bitter ones? I say no. I think we're pushed because there is a lot of medicine to learn and not enough time to learn it in. We spend two years in lecture halls learning biochemistry, anatomy, pharmacology and histology - no patients in sight - a lot of which we won't use in everyday practice. But those years are the difference between a doctor and everyone else on the medical team. They are they difference between memorizing a standard protocol to treat a disease and understanding on a molecular and cellular level how the disease and it's treatments work. You can't reassemble an engine if you don't understand how the parts work.

I promise that when I graduate and begin practicing that I will make every effort to treat you with respect. I will explain my reasoning and answer your questions. I will be professional and courteous. But I will not be your therapist or your best friend. I will not hold your hand or cry with you. It will have to be enough that you had the smartest kid in the class, trained in one of the best schools, using all of their intellect to save you.

Autologous surgery

Apparently, in 1961 a Russian surgeon did an appendectomy on himself in Antarctica. It's written up in the BMJ, complete with two intra-operative photos.

Thanks Andrew, for the link.

Pre-clinical years

I thought it would be interesting to total the number of exams I will take prior to my first clerkship in medical school.

M1 year: 37 written exams + 8 anatomy exams

M2: 15 written exams + Clinical Competency Exam (9 parts) + USMLE step 1

I've also had to write 15 essays and create an interpretive art project on chronic illness.

Hilarious

Those of you who read other medical blogs have probably see this, I know White Coat has re-posted this as well, but on Tales from Serenity Now there is a great story (with pictures) about a guy trying to escape the ED.

I can't wait for my fourth year ED rotation... I had a great time working in a PA ED during post-bacc and that was only 8 hours a week.

Best moment: my hand in an open chest.

Second: being barricaded in the ED because the gang fight followed the ambulance.

Being a positive deviant

I just finished writing a couple of essays for school. One of the assigned topics was on Atul Gawande's book Better. In the book, he lists his five suggestions for being a positive deviant; basically how to be Better.

1. Ask an unscripted question

2. Don't complain

3. Count something

4. Write

5. Change

I find it an intriguing list because it bears some similarity to the ideas I try to use to not just be better at what I do, but be a better person.

1. Ask more questions than you answer. I, like many extroverts, like to talk. It doesn't have to be about me, I like explaining things, I like reading out loud, I like debating - it's a hunger to participate. The risk, of course, is that with all the talking I find I've spent two hours with someone and I don't know their name, what they do or whether they've ever been West of the Mississippi. People have interesting stories and I can't hear them if I'm the one talking.

2. Don't whine. This is essentially the same as don't complain, but he's right.

Whining is not attractive and let's face it, everyone could come up with something to whine about. Interesting people find things to be happy about. Really interesting people can radiate their optimism to others.

3. Move the goal posts. Having a purpose is important. It creates focus, creativity and energy. They key is to be flexible about goals and to have them in multiple spheres of life. For example, one of my goals is to graduate medical school, but another (more fun) goal is to get stamps from every continent on one passport. Goals are personal - it's about what you are passionate about and should reflect who you are and who you want to be.

4. Choose. It's easy to follow orders and do what's expected. It's far more fun to go out on a limb and find your own path. It's harder, to be sure, but you learn much more. That's not to say you can't go with convention, just make sure you choose it, rather than letting life or others choose it for you.

5. Try everything once. Okay, within reason. But experience is a great way to learn things and fear is a poor excuse for ending up 75 with a bucketload of regrets. Trust your ingenuity, your resourcefulness and your survival instinct - you'll live through it and you might even like it.

Why is it that I feel slightly foolish publishing my philosophy and Gawande confidently makes a fortune off of his? Oh yes, because I'm not yet an accomplished surgeon at a world-renowned hospital. Still, I don't think it's a bad list. Plus, I'm wearing two pagers and he's only wearing one...

Law of unintended consequences

From the New York Times:

Britain was planning on using full body scanners at airports to enhance security after the Christmas Day bombing attempt in Michigan. Apparently, these scanners create an image of the body being scanned, which includes the genitals and any *ahem* enhancements.

Clearly, someone didn't think this through because now they will need to pass laws to exempt security personnel from child pornography laws. Britain also has some of the world's most aggressive paparazzi - images created of celebrities as they enter the country would be worth a fortune. I can see the US Weekly now: which of your favorite actresses really has fake boobs? See page 15!

I'm in favour of making our airports actually safer (take your shoes off? 30z of liquid? please...), but I'm not sure turning everyone into a porn star is a good solution. First, why are the images saved? Second, couldn't they be auto-analysed and then only exceptions reviewed manually?And third, do we have any evidence (say, in the form of controlled trials) that shows full body scanners catch more than metal detectors and pat downs?

Prion power

I have never been allowed to donate blood in the United States. Having lived in England during the "mad cow years", I'm permanently banned from donating for fear of spreading prion disease. I've never really understood this because in order to get Creutzfeldt-Jacob disease you need to ingest contaminated brain matter (since that's where the prions are located).

A quick aside for those unfamiliar with infectious particles: there are bacteria (alive), viruses (not alive) and prions (also not alive). Bacteria are whole cells, viruses are essentially a little pod of either DNA or RNA and prions are naked proteins. These proteins are misfolded, however, and have a knack for causing normal proteins to also misfold and create aggregates in central nervous system neurons. Since prions live only in neurons, they cannot be transmitted by blood or air or droplets (coughing) like viruses and bacteria.

So basically, the US government is concerned that I am contaminated from prions but haven't shown disease yet and that somehow I will spread this via blood donation. Recent research is now showing - lucky me - that prions may actually be adaptive and develop drug resistance. This is alarming (for the obvious reasons) although currently Creutzfeldt-Jacob is a death sentence (within months) and to my knowledge we didn't think we had effective drugs.

There are several human prion diseases (no, CJD is not the only one) and all are fatal. Worse, standard sterilization procedures do not eliminate prions so it's a good thing they aren't easily transmitted. Adding drug resistance to their virulence is almost superfluous.

Please excuse the girl moment...

I bought myself a little christmas present in the post-holiday sale... the Kate Spade Opus bag. Now if only I could justify a BCBG dress...

I graduated high school a DECADE ago?!

This is a photo of me getting dressed for new years this year. It was a low-key affair with low expectations so it turned out to be an okay night. I wasn't quite back to myself -I'm still not- having just been traveling internationally. I always get a bit brooding when I return home. I don't like giving up the freedom of traveling - life is a bit too tied down and restricting for my taste. I wonder if I should have taken more time off - a whole year of traveling instead of just a few months? I also miss the person I am when I'm not here - I'm more confident, easygoing, in-the-present when I'm away.

I'm not usually very big on new year's resolutions, but this year I have a few. They are more reflections on self-improvement that stem from travel, but new years is as good an excuse as any.

1. I choose confidence. I choose to be okay with who I am. I will own it.

2. I will read more non-medical non-fiction.

3. I will stop using medical school as an excuse.

I'm going to head back to California for a couple of weeks in early April and then hopefully off to Turkey the first week of May. Hopefully that will sate the nomad in me until next December.

Victory!

As of May 2010, Michigan will go smoke-free. That means when I go out to restaurants, bars and clubs my hair and clothes will no longer reek of cigarettes! Even better, I won't be increasing my risk of practically every medical ailment for the sake of being social.

Joke's on me

I went on a date with a MBA student this weekend and during our conversation he asked how our classes work (since we don't really get electives or any control over our schedule at all). I honestly had never looked at how many credit hours we take because it never seemed relevant. So I looked it up. I also looked up the requirements for the MBAs for comparison.

Total credit hours in 2 years for b-school: 57
Total credit hours in 2 yrs (pre-clinical) for med school: 97

Years it takes an MBA to earn back the debt and lost salary: 5
Years it takes an MD to earn back the debt and lost salary: 20-40

The non-medicine side of medicine

The MI chapter of the American Academy of Pediatrics had an open forum meeting tonight, which I attended. It was interesting to attend a meeting of physicians that really had nothing to do with medicine or providing care. The two hours were spend discussing Medicaid reimbursement, disproportionate share payments and the requirements for re-certification; specifically the quality initiative requirement. I have strong opinions on all of these issues, but the one I will disucss now is re-certification.

Re-certification, which must be done every 10 years, requires four things:

1. Send in your license
2. Complete lifelong learning modules
3. Pass an exam
4. Complete an approved quality improvement project

An example of an improved quality improvement project is to plug data from 10 patients with asthma into some software which analyzes your management practices against accepted asthma guidelines. It will then suggest areas you could improve. You choose one, change your care appropriately and put the new data into the program. You can then look at how your patients are doing based on the change in your practice. The idea is to continually be evaluating your quality as a practitioner and actively identify and implement potential improvements.

My issue is this: it seems a lot like research without informed consent. The patient does not know they are part of this quality initiative. Their management is not being changed based on an individualized assessment by the physician, but by a national guideline or software program.

Apparently, if the intent is not publishing, it's not "research". I think this is an ethical gray area. Comparing your practices in a systematic way against the national guidelines is a good thing - it can help you identify ways to improve. But altering the treatment of your patients then merits thought about their individual case. I would like to believe that when my doctor makes a decision about my care, he has done so because he thinks it's best for me, not because he needs to meet his re-certification requirements. And as far as I'm concerned, if you run a systematic intervention with the intent of producing altered outcomes - that's research, published or not.

Lastly, patient outcomes are reliant on two (controllable) factors: the ability of the physician and the compliance of the patient. The physician can follow all the guidelines, run the right tests and prescribe the right meds, but if the patient doesn't take responsibility, the outcomes are still going to be poor. We should absolutely measure and track physicians performance, but we have to remember that the doctor cannot be there every day to put a pill in your mouth, put the ice cream away and get you out the door for a run.

For example, the pediatricians were discussing how they are held accountable for vaccination rates in their practices. Some parents simply don't make appointments and don't bring their kids in, so those kids hurt the physician's numbers (which hurts their reimbursement). The docs were seriously considering renting a van and going to the local school, rounding up the kids who hadn't shown for the vaccinations and vaccinating them. Are you kidding? In order to get paid for the services they provide the kids who do show up they have to track down all the rest and accost them at school? I'd rather fine the non-compliant parents. The money would help pay for child health insurance, incentivize care and remind the parents of a little thing called personal responsibility.

Wednesday night procrastination

My much-anticipated new shoes came - limited edition pinstripe Jack Purcells. I love them. Super preppy with a twist. So perfect. They took their inaugural walk to get me to IV clinic and back.

IV clinic is where the emergency department docs teach us how to place IVs and subsequently give us equipment to practice on each other. My friend J and I stuck each other three times. It turns out placing IVs in the hand is both more difficult and more painful than in the arm.

I watched the premiere of Scrubs season 9 and was disappointed. What the hell were all the first year medical students doing on rounds, in scrubs and working with patients? Your first two years (until you take and pass the boards) you are lucky if you shadow rounds - you are definitely not let loose in the hospital. Not to mention you would definitely not have a class called internal medicine before you've completed something as basic as anatomy. C'mon writers. Seriously.

Speaking of boards, I've turned in my registration for mine. I'm aiming for April 26... USMLE step 1 is officially on my radar.

I haven't been in the OR since Oct 14th, but I'm on call this Thurs-Sun. Here's hoping for a liver. Except maybe not Sat night (day is fine) because I have a date and I would kinda like to make it. Even if I have to show up with a pager and track marks (from IV clinic). Actually, Sat would be a good time to get my autopsy requirement out of the way. So here's hoping for a dead body and a life-saving liver, all in one weekend.

Sounds like...

One of the blogs I read recently had a patient come in with Flea-bitis. It reminded me of a mother who brought her son in to neurology clinic for a second opinion. Apparently he had been diagnosed with something that sounded like Gardenias. The neurologist and the NP threw out a series of potential neurologic conditions... Guillian-Barre, maybe? After a quiet moment, I volunteered, do you mean Myasthenia Gravis? Yes, she did.

Why I never call anymore

Recently, characters on tv have taken to enrolling in medical school. For example, the revamped Scrubs show will be set in medical school (the original started in residency). I'm actually quite curious to see what Scrubs does with this as the first few seasons were a fairly realistic portrayal of life as a resident.

On Brothers & Sisters, the youngest son and war vet, Justin, started medical school this season. His classes don't really seem anything like mine, but that could simply be a curricular difference. Medical schools all teach the same facts the first two years, but the approach to disseminating the information is quite varied. What was interesting though, it that they wrote him as a stressed out character that became removed from everyone else in his life. He lost track of much of the family gossip and was not there to support his girlfriend during his midterms; even telling her "there are going to be times when I'm not there for you."

I actually really appreciated this portrayal because honestly, that's how it happens. Like it or not, everything else comes second to medical school. Right before a final exam, your laundry, the dishes, phone calls to parents, gchat - everything is put on hold. If you're dating a medical student and you have bad news - hold on to it until the exams are done. Think of it as a preview for life to come: if you marry a doctor you will always come second to whatever patient is on the other end of that beeper. My 10 year anniversary? My daughter's first ballet recital? Your father's funeral? If I'm on call and that pager goes off... I have to go.

We joke about it sometimes, but I'm a little scared. In not too long I will be responsible for people's lives. I am leaning towards pediatric subspecialties; that could be your child. And if it was your child - consider - aren't you glad that I put everything else second to my education?

Body Surface Area

While gchatting (ostensibly studying neurology) a friend sent me a news story (from the science section?!) detailing how much skin a woman should show to maximize attractiveness to nearby men.

Methods: This was an observational study in which the authors used percentages of the body to determine the amount of exposed skin. Each arm was 10%, each leg 15% and the torso 50%. They they counted how many times each woman was approached. Neither the men or the women knew they were being studied.

Results: Women showing more or less than 40% exposed skin were approached less frequently.

Conclusion: Women showing less than 40% sent "prude" signals and women showing more sent "whore, adulteress" signals.

My immediate reaction was not "what a stupid thing to study" or "how can they claim to know what the men were thinking" or even "how does the methodology account for the possibility that the 40% women just happened to be the hottest regardless of clothing".

No, my reaction was: they got the body percentages wrong! Commonly used body surface area percentages for estimating burn injury are shown in the picture.

picture from UofM burn website: http://www.traumaburn.org/referring/fluid.shtml

Vocab lessons

Thanks to medical school I now know:

- The annoying twitching that my left deltoid has been doing all day is called a fasciculation.
- My myopia will likely mean a later onset of presbyopia (compared to non-myopes).
- When I was a child I had a form of parasomnia (I sleep-talked; c'mon, who's surprised?).

- Neurologists like disorders with either 1) long names or 2) eponyms 3) both for the same syndrome (ex. acute demylinating polyradiculoneuropathy aka Guillian-Barre)
- Ophthalmologists also like long names, but prefer they end in "-ia" (ex. internuclear opthalmoplegia)

- If you eat contaminated pork, you can get pork tapeworm (T. solium), but if you eat a carrot contaminated by someone with pork tapeworm you get neurocysticercosis so cook those carrots good (see picture above).

- Laser Assisted Subepithelial Keratomileusis (LASEK) surgery involves shearing a flap into your cornea, while you are awake (with analgesic eye drops, picture).

- Anesthesia is technically only central nervous system depression. When you are put under you also get neuromuscular blockade (paralysis), analgesia (pain control) and amnesia (no memories).

- A symptom of hepatic (liver) failure or renal (kidney) failure is asterixis (characteristic hand flapping). It is likely accompanied by encephalopathy (altered mental status). Oh, and you're in danger of dying, soon.

Pearls of wisdom

Recent quotes from lecture:

"Our country handles schizoid personalities very well. That's why we have software engineers, pathologists and Montana." -Dr. J

"Biopsying an aneurysm is not a successful procedure." -Dr. G

"If someone's head is cut completely off, that's not an emergency - that's a tragedy." - Dr. G

10 cent words

Medicine is full of big words with very specific meanings. Here is a fun paragraph from today:

Internuclear ophthalmoplegia (INO) is indicative of a particular opthalmoparesis. It is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When the partner eye is abducted, it diverges from the affected eye. This produces horizontal diplopia. During extreme abduction, compensatory nystagmus can be seen in the partner eye. Convergence is generally preserved.

You know you're a med student when...

You realise you washed suture with your white coat.

AND you're excited it's still in tact so you can practice.

Best. Decision. Ever.

Where I used to work:













Where I work now:

My competitive nature

I felt a certain pressure to match last year's pumpkin. I fear I did not manage it.

Last year:













This year:

Oops

I'm pretty sure I just heard Chase, on the show House, order Streptokinase and heparin. That would be a no-no. You can use tPa with heparin, but not streptokinase.

The environment of medicine is all wrong on the show, but usually the medicine (diagnostically) is accurate. Where was your physician-fact checker? Tsk tsk. I'm disappointed.

Pee

Time I got paged this morning: 5am
Hours of sleep I got: 3.25
Time I waited for my patient to pee: 8hr 37min
# 12oz coffees I drank in that time: 2
# times I peed in that time: 3

A week in the life

What school tells me my week looks like:























What my week actually becomes:

Breaking bad news

A recent assignment for school caused me to recollect a patient from my previous hospital. An excerpt (the original essay is several paragraphs longer) from my assignment summarizes the story...

The patient, an 8-year-old boy, was the elder of two sons of a recently immigrated family. He had been admitted for status epilepticus, which proved to be refractory. He was ultimately placed in a medically induced coma (which he continued to seize through for a month) and the parents were asked whom else they would like present for a discussion of his prognosis.

The family requested that a doctor from their home country be involved and so a teleconference was established. Various members of the care staff reported their opinions and summarized the boy’s course to date. There was almost as much silence as there was talking and each person was careful to solicit and answer questions. The questions themselves guided the discussion. The parents really needed to believe that every option had been exhausted. They believed that because we had been able to find an etiology, we should be able to find a cure.

From a physician’s perspective, after a month of seizing and coma there was likely to be little brain function left. A multitude of testing revealed a genetic defect in a sodium channel, which was blamed for the seizure activity. The boy was not a surgical candidate because the seizures were multi-focal and originated from both hemispheres. Everything had been tried and nothing would break the seizures, which were still occurring roughly every three minutes. There was nothing more that could be done.

Most of the conversation centered on the futility of our treatments. That we, as doctors, could not even promise he would wake up if we took away the sedatives. Eventually the parents chose to withdraw support. I think they knew their decision from the moment they sat down; they just couldn’t say it out loud. I didn’t get the sense we had persuaded them; more that we gave them a safe and justified way of letting go and not feeling as if they were bad parents, that they were simply giving up because it was hard.

It was then, when they stated their decision, that I was so thankful for the private room (not a patient room) the whole conversation took place in. The family had somewhere they could be where they wouldn’t be disturbed or overheard. Not by a nurse who needed to take vitals, not by a doctor checking on another patient. They couldn’t hear the business of medicine still working around them, healing some of the other children who would eventually be able to go home to their parents. But the room also allowed us, as the medical staff, to separate the conversation we just had from the rest of our work. When you walk out the door and back onto the ward, you leave the heaviness in that room and focus on health and healing on the floor. The spatial separation aids the mental and emotional one.

That separation is not learned with one conversation. Or maybe it’s always imperfect. But I do know that I was unusually quiet the rest of the day. When a friend needed sympathy later that night, I just couldn’t muster any. His problems seemed so petty. The boy was only eight and he was dead. Dead because of a sodium channel, which seems like such a insufficient and small reason. He had a little brother who clearly didn’t understand what had happened. He had a mom and dad that somehow had to keep going. And while I wasn’t consciously dwelling on it, something in me didn’t let it go immediately. Within the week though, the petty problems regained their gravity and the pressing concerns of work and medical school applications took over.

- * - * - * - * - * -

I have to admit that delivering bad news became easier. Maybe not in the moment, but my recovery got much faster.

With regard to the family in the story, the little brother had ongoing issues coping with his brother's death. I personally think some of this had to do with the fact that the parents never allowed the younger son to visit the older one (they didn't want him to see his brother sick or in pain). Then again, I am neither a parent nor a psychologist, so I am not at all qualified on the subject.

National Grand Rounds

Today at noon the National Physicians Alliance Foundation and the American Medical Students Association held a National Grand Rounds policy panel discussion on the current legislation on health care reform. There were three panelists: one from the House, one from the Senate and one from Health and Human Services. The questions were relatively predictable, centering on access to primary care, the public option, tort reform and quality of care. The answers were similarly predictable: sound bites encapsulating pretty much what we want to hear and how historic this whole endeavor is. Pleasantly vague and bland, with little actual substance.

I would really like to see some of the legislators being honest about some of the real, and short-term unsolvable problems we're facing. How do we increase the number of primary care physicians to what we need when there aren't enough doctors going through school? How are we going to decide what medications and procedures are covered under the new insurance? How are we going to reduce the paperwork burden? How are we going to pay to insure/care for all these new people - most of whom cannot pay themselves? Because let's be honest, there will be a physician shortage in the short term and ERs will get even more crowded. We won't be able to cover everything for everyone. All these new committees and program will produce bureaucracy and without some planning, that will fall on docs and hospitals. And we don't have the money to cover all this new healthcare - either taxes will need to go up or spending will need to be cut. Public hospitals will need cash from the government to cover the services they have to provide to the population. Those are just realities.

The panelists all indicated in their introductions that their comments were off the record for any press attending, so it would have been nice if they had actually said something.

Transplant facts

Interesting fact: Identical twin transplant recipients do not need immunosuppression.

Another interesting fact: The first dialysis machine was made out of sausage casings and a bathtub. (picture)

Health disparities fact: While ethnicity is not a match criteria for organ transplant, blood type is. Caucasians (who form the majority of donors) tend to be O & A blood types. African Americans, who have the highest need (for kidneys) have a much higher incidence of type B blood. (source: http://www.bloodbook.com/world-abo.html)

Words medical school taught me to spell:

abscess
arrhythmia
component
dilated
epididymis
etiology
exercise
fourchette
gynecomastia
immunoflorescence
staphylococcus
wenckebach

Deet for men

I made an appearance at a local bar's grad night last night. None of my friends would go, but I met up with some classmates and made an appearance anyway. I was hoping at least one of the two cute guys I notice would be there. Neither was. A friend introduced me to his friend, an attractive German who was doing two months of research here. The German and I chatted for 30 minutes or so. Today I find out the German thinks my classmate is the most beautiful thing he's seen and that I was supposed to introduce them.

This comes after last weekend's fantastic ego boost of being told that I don't seem to know how to have fun. Not only did I let that slide, I was supposed to meet up with that guy later in the evening. He never showed.

FML.

Acute hepatic congestion or nutmeg?

Liver or pumpkin pie?

Finally watching tv

Old woman to doc: Dr, When I arrived at the hospital I had one leg and now I have two!
Doc: Well, there is a war on, is it possible you miscounted?

-Dr. Who [episode 10 season 1]

No means no

I was in the hemodialysis unit recently, chatting with a patient about how his life had been affected by HD and how he generally feels. As corny as it may sound, I find these touchy-feely encounters with patients to be incredibly rewarding and informative. I think those of us who are healthy underestimate the impact of chronic disease, but simaltaneouly underestimate people's adaptive resiliance. This summer I have been fortunate to have several one-on-one opportunities, but group interactions of this kind are a regular part of our medical school curriculum.

Anway, this one was especially awkward because the patient proposed to me several times and repeatedly offered to have my children. He was neither demeted nor joking. He wanted to take me out to dinner that night and put a ring on my finger. He thought it was a genetic imperitive that I breed because I (apparently) am "drop-dead gorgeous and a genius." Just about every question I asked was answered with some variation on this theme (along with some genuine insight into renal failure) for almost two hours.

An example interaction:
Me: Do you have other health problems too?
Him: I'm healthy enough, if you know what I mean; no disrespect.
Me: How about high blood pressure or high cholesterol?
Him: Yes, I got both of those, lady.
Me: Are you on medications for them?
Him: Yes, but I don't take em. I don't believe in pills. I seen to many people die from pills.
Me: I suspect those were different kinds of pills. It's important that you take your medicines.
Him: I feel fine. I'll take them if you hand them out though.
Me: Your health could get a lot worse if you don't control your blood pressure and cholesterol. You want to make it to transplant don't you?
Him: I would take them if I had you to come home to, lady.
Me: Do you live with anyone now?
Him: No, you can move right in. I'll take you out to dinner tonight and put a ring on your finger.

Liver #2

I went to bed excited because we had consented another patient for our liver transplant study. The OR schedule said they would induce the anesthesia at 10:30am, so I hit the sack just before 2 with my alarm set for 9. At 4:46 my pager goes off. They are inducing now. I head straight to the OR where I find out that this is expected to be a tricky case. I have had 3 hours of sleep and haven't eaten since 8:30pm the previous night. I emerge from the OR at 10:30am, put the samples on ice and head straight to Einsteins for a large coffee and a honey wheat bagel with honey almond smear. Never tasted so amazing.
The surgery itself was longer than the last one I observed, but they didn't have to use any blood products and were able to extubate before sending the patient to the SICU. It speaks to the skills of the surgeons and anesthesiologists in managing the anatomy (surgeons, no blood) and physiology (anesthesiologists, not acidotic).
The patient was awake when I went up to the SICU for the 2 hour post-op samples; the family was there too. It's really kind of fun when you can say you were in there with the patient the whole surgery.
I left the hospital around 2:45pm and was kind of dragging this afternoon, but I just had some coffee and a chocolate chip cookie. Nothing like caffiene and glucose to keep yourself on point.
There's another harvest this afternoon. If they keep the liver in house there's a chance I'll have another surgery this evening, although it looks like the graft is of poor quality, so I may get some sleep instead.

Crystal ball

Before medical school I took a quiz to see which medical specialty I should be. Those answers are here. I retook it now (beginning of M2 year) to see if it's changed at all. Apparently, the new list is:

1. Thoracic surgery
2. Urology
3. Plastic surgery
4. Orthopaedic surgery
5. Ob/Gyn
6. Nephrology
7. Neurosurgery
8. Infectious disease
9. Cardiology
10. Nuclear Medicine

Apparently I am straying farther into surgery and surgical subspecialties. It is worth noting that the quiz does not separate pediatric specialties from adult. If I remember, we'll try again after third year and see if I'm any different then.

Don't tease me!

(18:21) I get the email that there is to be a liver transplant at 20:30.
(20:07) I get the page that says the transplant will begin 21:00.
(20:14) I get the page that says the transplant has been canceled.
(22:00) I go out dancing instead.

Turns out carrying a pager in a club makes you attractive. A law student asked for my phone number.

Cirrhotic liver. The kind you take out, not put in.

Big trauma

A class one rolled in with the survival flight paramedics; he had been broad-sided in a MVC. He looked to be in surprising good shape: unstable pelvis and dehydrated, but good vitals, responsive pupils and moving all four extremities. The CT scan, however, told a different story and he went up to the OR emergently: 3 perforations in his bowels, multiple pelvic fractures (with bleeding) and an aortic dissection. He went straight from OR to IR to BICU... we'll see how he does.

Yet more trauma

It started off well. I was studying in a coffeeshop when my trauma pager went off. It's silly, but I felt a little cool reading the page out to my friend and booking it out of there.

"Class 2 M, Go cart vs truck, blunt, 115/78, not intubated, unk GCS, ETA 8 min"

It turned out the patient was pretty much ok - just a closed tib/fib fracture. He had been transferred to our hospital mostly because of questionable change in mental status, which it became quickly clear was not the case.

On my way back to my car to drive home and contine studying (well, doing write-ups on clinic patients) the pager goes off again (in front of more people!).

"Class 1, M, ATV vs tree, blunt, 123/80, intubated, GCS 3, ETA 10 mins."

It turned out ATV vs tree was actually fell-off-the-back-of-moving-pickup-truck. For those non-medical folk, GCS of 3 is very bad. It's a scale of 3-15 based on eye opening, movement and vocalization. A 3 means you have none of the above. He displayed from priapism (look it up if you don't know), indicating decreased sympathetic tone. On CT he had an impressive skull fracture and significant uncal herniation.

While eating a delayed dinner, the pager again beeps.

"Class 2, M, dirt bike accident, GCS 15, not int, in ER"

Five minutes later...

"Adult, class 2, motorcycle accident, left ankle lac, 148/68, HR 118, GCS 15, ETA 5mins"

More trauma pages

The trauma pager has beeped a few more times and I've seen multiple bike vs. car and a falling off a 30 foot ladder. Think chest tubes, intubation, consults with a neurosurgeon and lot of leg fractures. Any thoughts I had of becoming a bicyclist are definitely out. Mostly I just watch the trauma team in action, but occasionally I get to do things like put a gown on the person, stabilize the neck while rolling him.. small things of that nature.

I've also had two more gen med clinics. Yesterday's was particularly cool because Dr. K went in and did the appointment (without me), then sent me in to try my hand (observed by Dr. P). I asked my questions, did a limited physical exam and then explained what I thought it was and attempted to address the patients concerns and questions. Upon debrief with Dr. K and Dr. P... I got it RIGHT! I successfully diagnosed a real patient based only on information I gathered myself in real time. I have to admit, that felt really really good.

There was a second ego boost later in the day when the M4 on trauma rotation was quizzing the M3s on surgery about thoracotomy and pneumothorax. M3s didn't have a clue (and I knew all the answers, but kept my mouth shut because no one likes a show off). The current M3 class has been running around patting themselves on the back for their record-breaking board scores (their average was the highest at UofM ever), but they are being outdone by lowly little M2s in the trauma bay.

Caught

Rounds just ended. I did fine on the first half where we are walking from room to room. Even saw a man with 27% of his body surface burned by a bbq. Also saw a compartment syndrome fasciotomy on the anteriolateral lower leg. THEN we went to the conference room and went through another hour of patients just talking.... talking in a dim room... sitting down... after I'd been up all night... I REALLY tried to hold it together.

The trauma surgeon who was in the trauma bay over the weekend walks out of the room with me.

"Looks like your coffee is wearing off. Fighting a losing battle there."

And now I'm completely ashamed. Ashamed and embarrassed. And still really sleepy.

My first overnight

It's the morning of my first overnight in the hospital. I was here from 10am-4pm on Sunday getting samples for anesthesia and working on charts for cardiology. When I checked my email on arrival at home, I found out there was going to be a liver transplant that evening. I took a quick nap, ate some food and headed back to the hospital. I spent the night in the OR, pestering the anesthesiologists with questions and asking for samples. Did you know that post liver transplant the person will have no gallbladder? I spent the wee hours of the morning processing the blood and urine. I just returned from putting it in the -20/-70 freezers. In less than two hours I have trauma/burn rounds, after which I will run home to shower/change into professional dress and return to the hospital for noon conference and trauma clinic. At about 6pm I will be able to go home and crash. And you know what? It's fantastic fun!

Hide and seek

I was getting some ice to prepare for the samples I am getting today when two doctors approached me. Keep in mind I am standing at an ice machine in an otherwise empty pre-op unit (non-emergent surgeries are not scheduled for weekends, especially not holiday weekends).

Doctor: Have you seen a big fat man?
Me: Excuse me?
Doctor: We're looking for a patient, Mr. L. He's ginormous, you couldn't miss him.
Me: I'm sorry, I haven't seen anyone like that.
Doctor: If someone was going to have surgery, where would they be pre-op?
Me: Here, but it's a weekend.
Doctor: Yes, I know, but we've lost him you see. He's missing.
Me: Sorry.

I'm not sure what's more concerning: that fact that they have managed to lose a huge fat patient or that the doctors had to ask the medical student where patients go pre-op.

First pages

This weekend brought the first liver transplant since I started taking anesthesia call and the first trauma page on my trauma block.

For anesthesia, my friend J was on call of the intra-op samples (I'm jealous) but I've been going in to the surgical ICU every day to take blood from the arterial line and urine from the Foley for processing. I'm sure there will eventually be a liver on my watch and I'll get to go into the OR.

For trauma, I booked it down to the trauma bays to watch the team take care of a young adult with an open tib-fib fracture from a motorcycle accident. I was hoping July 4th would be a heavy trauma weekend, but so far - not so much. Let's hope it gets busier over the next two weeks.

Ok, so I realise that my hoping for livers and trauma requires that people get sick and that it makes me a tad bit of a bad person. But really, these things are going to happen; I just want them to happen here (as opposed to in OH or some other place that I am not).

X-rays

Dr: A man came into clinic yesterday with pelvic pain. This was his x-ray. What do you think is wrong?

Me: There is a flashlight up his rectum.

Dr: Exactly.