Adverse Effects

Love & medicine

2012-01-09T20:28:00.002-05:00

Mr. Inmabusiness: Are you married?
PGYx: No.
Mr. IMB: Why?
PGYx: [...]
Mr. IMB: Picky Picky!?

Ms. Freedom: Are you married?
PGYx: No.
Ms. Freedom: Good! Stay single!

Nurse Sweet: Have you seen that movie, No Strings Attached?
PGYx: No, but I heard it's good. What do you think?
Nurse Sweet: Yeah, it is, you should watch it!...The thing is, it's about residents and you remind me of Natalie Portman's character.
PGYx: [...]
Nurse Sweet: NOT that I'm trying to say that you have a lot of relationships with no strings attached or anything! I'm not!
PGYx: Thanks! I'll have to watch it. And for the record, I don't have a lot of relationships with no strings attached.

Dr. Andrew Weil is winning

2011-12-09T23:38:00.008-05:00

Combating Depression With Meditation, Diet : NPR

"In his book Spontaneous Happiness, Dr. Andrew Weil writes of an 'integrative' approach to mental health, warding off mild and moderate depression with an anti-inflammatory diet, exercise and activities such as yoga and meditation, rather than antidepressants."

You can listen to the audio or read the transcript. Dr. Weil makes some great points about drawbacks of our reflexive tendency to prescribe antidepressants. I think our society would benefit from realizing:

1) Depression isn't cured by a 15 minute office visit and daily pill. Coping skills & positive outlook develop with time and effort. For a minority, antidepressant medications may facilitate this process.
2) Antidepressants --and all medications -- carry risks
3) Life's ups & downs aren't necessarily pathologic

We have good data to suggest antidepressants are no more helpful than placebo for a majority of cases of mild-to-moderate depression. It is a sad sign of our broken health care system -- and one of my greatest sorrows in my work caring for patients prone to depression -- that antidepressants have become a first-line treatment for mood disturbances that fall far short of severe clinical depression.

The quick fix lives up to only the first half of its promise.

Thanksgiving vacation!

2011-11-22T12:25:00.007-05:00

Yesterday I bicycled up Mt. Local near my parents' house out West. I'm on vacation!

When I attempted the same ride a few years ago I'd never been on a road bike. I stopped at around the 1000 foot mark and nearly vomited from overexertion before getting hypothermia riding down the mountain. It was...fun.

Obviously I hoped for a better outcome this time now that I've earned the nickname, "Dr. Nature," from one of the custodians at work.

As it turns out, my n-of-one case study shows regular outdoor exercise leads to improved fitness: I made it 2200 feet straight up to the ranger station, where I met real cyclists before we headed back down.

Nose breathing & staying mindfully in the moment saved me on the way up.

Ate enough. Drank enough. No desire to vomit. Layered up/down appropriately and avoided over/underheating.

Used clipless pedals for the first time. I tipped over a few times, with ego & knee bruises to show for it, but wonder if I would have made it up the mountain without 'em.

Missed my comfy Jamis seat. Ouch.

Saw a group of quail, a hawk, a skydiver, plenty of pretty views, and regular installments of coyote poop precisely deposited on the side of the road.

On the way down, I accidentally ran over a tarantula(!). Avoided two more after that. Mildly questionable brakes + small hands equalled a swirling mix of exhilaration and crash fear.

Made it home. Plan to do it (or something similar) again soon.

Next up: Yosemite later this week!

I love my patients

2011-09-30T22:45:00.003-04:00

PGYx: Sir, are you right or left handed?
Mr. Literal (adorable old man w/history of schizophrenia): Left handed.
PGYx: Oh, so do you consider yourself to be a creative person?
Mr. Literal: No! I'm not creative, not artistic. Not one bit! Why do you ask?
PGYx: Well, I've met a lot of left-handed folks who "think outside the box."
Mr. Literal: [without missing a beat] Well, I am schizophrenic!

We both immediately burst into laughter, which sounds inappropriate on my part, but it totally wasn't.

Mr. Literal: I knew I could get a smile out of you!

I look 12 (flattery will get you everywhere)

2011-08-31T01:53:00.007-04:00

I made it through a long Hurricane Irene call shift with two nights of minimal sleep on a call-room bed that is more metal springs than fluffy mattress. When I returned [to my thankfully unscathed!] home, my elderly neighbor greeted me in the driveway for a little neighborly small talk.

Mrs. Cataract: So, you gonna start back at college soon?
PGYx: (in scrub pants & t-shirt) [laughing] I'm a doctor!
Mrs. C: Oh! Where you work?

In related news, not one but several patients and family members have commented specifically that I "look 12!" Not 14 or 16 or like a teenager, but that I specifically look 12 years old.

Now let me tell you, I don't think I look that young. I wish I looked younger. I've aged a lot since my early 20s, including gaining a few horribly wiry white hairs worthy of Alfalfa's cowlick.

I wear modest business-casual clothing -- not purchased from the children's section -- to work with sensible flats or Sanita clogs. I top off the ensemble with a long white coat.

I wear a little bit of natural-looking makeup and have eye creases from smiling and laughing a lot. I'm starting to get two vertical lines between my eyebrows from chronically furrowing my brow every time I think, have a question, or feel amazed (i.e., ~16 hours per day). I'm told I have a very expressive face, so more wrinkles can't be far behind.

I never really had a growth spurt, it's true, but have no clue how anyone could mistake me for a day under 26. I don't act young and from a very early age have frequently been told I am "mature for my age."

Plenty of patients ask me questions like, "So, doc, in your experience, how often do you see [insert adverse effect]?" And I always have to toe the line between inspiring confidence in my clinical judgment and acknowledging that I'm a new physician-in-training supervised by much more experienced attending physicians. So it's not as though people are questioning my competence when they muse about my age.

One particularly lovely and loving family surprised me when they shared their curiosity about my age. We spent a long night together in the intensive care unit as I directed care for their loved one, unexpectedly gravely ill with sepsis.

We had a frank goals of care discussion during which they opted against cardiac resuscitation for an arrhythmia I told them they could reasonably expect. They understood that compressions and defibrillation would not meaningfully prolong her life. They seemed satisfied by my explanations and no one asked for a second opinion from someone with greater expertise.

The next day, the arrhythmia came. My attending indicated that we could cardiovert her. It was both an academic statement and a chance for her family to feel as though they tried "everything." Her husband, clearly upset, motioned for me to come over. He questioned whether his decision to withhold aggressive care was mistaken. "Would it change anything?" he asked, his pain palpable. "No, it won't change anything. It won't save her," I told him as kindly as I could.

"Is he the big doctor?" he asked, referencing both my attending's expertise and alluding to his small stature. "Yes," I replied, "He knows what he's talking about, but only you know what your wife would want for herself."

"How about you, how old are you?" "Yeah, we've been wondering all night!" his daughter chimed in with a smile. I paused a fraction of a second before answering, but felt he deserved an answer: "Thirty-three." "You look twelve!" he exclaimed without skipping a beat.

To this day, he remains the only family member with whom I have exchanged goodbye kisses in my role as physican. I will never forget him, his wife of more than 50 years, their children & grandchildren, or the fact that I apparently look 12 came up in this most unlikely of circumstances. I hope they're doing ok now. And selfishly, I hope I get to look 12 for at least a little while longer.

This could explain my humility

2011-08-25T23:32:00.007-04:00

Texting with mom:

Me: [sends photo] My residency class!
Mom: Cool picture you r the best looking though
Me: You have to say that that because you're my mom.
Mom: All I know for sure Ur the best looking compared to the bald guy

And we're officially a PGY2! (life update)

2011-07-31T13:33:00.004-04:00

Okay, so I became a PGY2 (post-graduate year 2) resident on July 1, but my life has been super busy since then! I had just about the worst move of my life thanks to Lenora's of Philadelphia (they actually get great reviews elsewhere, but here are some poor ones -- if you are at all inclined to use these folks then e-mail me first!). Fortunately, my parents made it all better by putting their noses to the grindstone for most of the next 10 days to get me settled in my new place.

They left me with just a few things to do after they left (bookshelf, coffee table, curtains) and surprise surprise, I haven't made any further progress. I still need to post pictures of the transformation, I know! I hit the ground running during residency and haven't spent much time attending to life details beyond laundry & paying bills. I'm just grateful we managed to install a faucet that accommodates the Danby portable dishwasher, which has drastically changed my life for the better.

I may still be curtainless (relax, I do have shades!) and awaiting arrival of my wooden bed frame from somewhere in Appalachia, but I did get a new Jamis road bike! It's entry level but works very well for me and I have been riding in a park near my rotation site with a couple of fitness-minded attending physicians. My attending jokes that's I'm not really riding because I'm barely sore after 12-18 miles, but I swear I'm riding as hard as I can! All signs point to me being a lot more cardiovascularly and musculoskeletally fit today than I was three weeks ago! I admit I have a hard time pushing myself to ride harder/faster/stronger for very long stretches but I'm working on that.

I've also started hiking on some of my days off. My new home is close to a vast array of gorgeous trails just waiting to meet my feet! Since I don't know too many people in the area I joined several groups of outdoor adventurers through Meetup.com. So far, I have met several nice & fun folks on the hikes. The only fishyness so far came from a guy who e-mailed me the same day he joined the site with an offer to show me "more private" hikes starting with a waterfall/swimming hole. I'll stick with the group, thanks!

In medical training news, I just got my Step 3 scores back and now officially qualify for my very own medical (non-trainee) license! With great gifts come great responsibility. I have to thank my favorite mentor (again) for reminding me how dumb it is to postpone board exams. I studied intensively for a few days, trusted internship to prepare me for the rest, and was not disappointed.

Finally, I love my residency program! I'm learning so much and everyone associated with the program is truly awesome. I'm also SO grateful to have completed what amounted to a sometimes brutally hard intern year. As I learned on my very first PGY2 call shift, my program prepared me well to be the only in-house physician (with phone backup, whew!) covering ~150 beds. Overnight call aside, I am reminded many times daily how lucky I am to have gained solid internal medicine training.

That's all for now -- I'm headed out with a new acquaintance for another 15 miles on the bike! All this activity makes me feel almost athletic.

Rawrrr!

2011-06-10T10:25:00.005-04:00

Attending: Do you ever get jealous of all the guys looking at your wife?
[Adorable woman in her 80s sits nearby, smiling sweetly]

Mr. Lucky: No. [Pauses] She's a cougar.

[Stunned silence with wide-eyed looks and threatened giggle loop exchanged between the residents & attending]

Mrs. Lucky: It's true, I am a month older than he is, haha.

[Entire room erupts into extended laughter & guffaws]

My new home!

2011-06-05T12:24:00.015-04:00

After an agonizing search filled with long drives, dead ends, and abundant reminders that descriptive adjectives in apartment ads are open to WIDE interpretation, I'm thrilled to report I have found my next home!

My search wasn't all sunshine & roses -- I definitely grew demoralized as I plumbed the deepest recesses of sites like Craigslist, Rent.com, and Zillow into the wee hours of the night. I sent countless e-mails to check availability and introduce myself as a clean, quiet, smoke-free resident with excellent housing and professional references. Finally, I advertised myself on Craigslist -- through a housing wanted ad, what were you thinking? -- and described my ideal apartment. This yielded several really nice housing options as they were tailored to my want list.

I passed up a more conventional (though comfortable!) apartment with an actual waterfall & swimming hole on the premises in favor of a charming unit in a 4-unit home built in 1920. It boasts newly sanded and refinished hardwood floors and chestnut trim, great light, original stained glass windows in living and dining rooms, and antique fixtures in the bathroom. It includes laundry and storage in the basement plus garage parking to save me from having to scrape snow off of my car during the winter. Epic score!

The only downside is that it has no dishwasher, but I'm considering one of the portable/rolling units. The landlord and his daughter, who is around my age and lives in a neighboring unit, are truly wonderful people. My residency program coordinator made the excellent point that it will be good for me to live in a place where others will notice if my lights are on when I'm at work or if I go missing.

Anyway, the place is adorable and I will post photos after it is ready for move-in complete with finished floors and a few more finishing touches. I hope I can decorate it so that it feels like a real home. Since I failed to inherit the decorating gene from my mother (oh how she struggled to impart her ways!), she is going to fly out to help me get settled.

I remain moderately ashamed of my inability to choose things like area rugs, window treatments, and wall hangings. I view accessorizing as a mysterious black box -- much as a person with Asperger syndrome cannot fathom the nature of others' emotions and motivations.

The concept of creating a cohesive decorative theme with several items purchased from different stores on different days overwhelms and mystifies me. Is linen better than chiffon? Do I prefer piglet snout to dusty rose, or would I perhaps appreciate the tasteful elegance of simple wheat or Cream City brick? What about patterned fabrics? Add throw pillows and I turn into a lost lamb crying for my mommy.

At least I can accurately diagnose a decorating misstep, but only in hindsight. As they say, those who can, do, while those who can't, edit. I am perfectly capable of filling in gaps with one or two basic items and am quite proud to have purchased new towels and even an antique end table all by myself, thank you.

But as much as I want to be like Dr B. Culp, beautiful surgical resident by day (and, er, night) and decorator extraordinaire during times she has every right to be asleep(!), I cannot fathom putting something like this together. How does she do it? For goodness' sake, the flowers match the pillows! I quite love it, but it is not my fate to be able to create it.

I'll be over here, admiring her talent and waiting for my saint-like mother to bail me out. Again. Thanks, mom!

The best moments?

2011-05-18T20:39:00.010-04:00

I saw this on Healthy Librarian's wonderfully inspiring, informative, and fun-to-read blog. It sums up how I feel about my internship experience better than anything I could write:

“The best moments usually occur when a person’s body or mind is stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile.”

--Mihaly Csikszentmihalyi

I also ran across this similar sentiment in the Dalai Lama's book (on CD), How to Be Compassionate: A Handbook for Creating Inner Peace and a Happier World:

"In my own life the most difficult periods have been the times when I have gained the most knowledge and experience. If every thing is going well, you can maintain the pretense that life is a smooth ride. However, when you face really desperate situations, you have to face reality."

I have become intimately acquainted with reality over the past year or so. In retrospect, chronically pushing my physical and mental limits this year has been worth the sacrifice to gain some priceless experience. I'd change only a few small things if I could.

On the other hand, sometimes I all I really want is a nap followed by a nice cappuccino, a copy of the latest New Yorker magazine, and a sunny day to walk the dog I haven't adopted yet.

Time is flying by with just 29 more days before the next step, with moving, boards, and a little relaxation squeezed in for good measure! Soon, it'll be time to stand high on my toes again. How do people manage to do it all?

And the intern slept on

2011-05-14T17:20:00.007-04:00

I just finished my last EVER! Internal Medicine 30-hour call shift. Some of you are aware that I picked my internship program largely based on the number of 30-hour shifts because I correctly suspected these would be internship's most brutalizing feature. Of all my expectations regarding the past year, this one is the only one that was 100% fulfilled.

In a National Geographic article published last year about the science of sleep, Harvard sleep authority Dr. Charles Czeisler notes:

Going without sleep for 24 hours or getting only five hours of sleep a night for a week is the equivalent of a blood alcohol level of 0.1 percent. Yet modern business ethic celebrates such feats. "We would never say, 'This person is a great worker! He's drunk all the time!'"

[...]

"We know that one out of five first-year residents admits to making a fatigue-related mistake that resulted in injury to a patient'...'One in 20 admits to making a fatigue-related mistake that resulted in the death of a patient." When Czeisler came out with this information, he expected hospitals to thank him. Instead many "circled the wagons." He despairs of anything being done until U.S. employers get serious about insomnia and sleepiness. "My conviction is that one day people will look back on what will be viewed as a barbarous practice."

Amen! 30-hour shifts are the zenith of internship's inhumanity. While I spent many a late night and night float shift in the hospital to make up for fewer 30-hour shifts, I utterly cannot imagine having spent this year taking sleepless overnight call every 4th night. I'm just not made to stand up to that challenge.

I did, however, work 29 of 31 days until yesterday, which I'm not really made for, either. First, my body balked at my inability to come even close to a full night's sleep. It balked still more when I stopped making my 64 oz morning smoothies each day in favor of a few more minutes of sleep. Finally, my mood and will to continue gave in to the sheer ridiculousness of working 80+ hours each week with only two distantly separated days off in the last month. My normally good nature at work degenerated into an impatience for setbacks that promised to keep me in the hospital beyond the 80-hour weekly duty hour limit.

By the evening of my 30-hour shift, I felt so overwhelmed by the never ending work stream and competing demands of, well, everyone, that one of my co-interns gave me a spontaneous hug. A couple of attendings told me to hang in there. My PGY3 resident told me I had the face of someone who had been completely beaten down. I felt so close to giving up that I couldn't fake even a hint of optimism -- it was a new low for me.

The same resident later commented that he doesn't know what other programs are like, but he doesn't think it is possible for a resident to work any harder than we do in our program. We essentially work at the same frantic pace all day long every day with only the rarest brief lull in workload. In keeping with the adage that we're never given more than we can handle, this last shift was probably the easiest overnight shift of my entire internship despite a greater than usual number of cross coverage patients who required personal attention for urgent medical issues.

Around 4:30 a.m., my co-intern (who shares a schedule similar to mine with just a couple of days off in the last month) and I collapsed on the floor* of our conference room using bed linens meant for patients and blankets mashed into pillow substitutes. The cold, hard floor felt like heaven. I think our PGY2 resident must have seen how exhausted we were because he refrained from waking us around 5 am to do two late admissions. We slept nearly an hour, waking occasionally to field pages. "This is torture," my co-intern sleepily croaked when she had to get up to attend to a patient with chest pain.

My team rounded until after 12 and I ended my shift late to finish some discharge paperwork. I knew it would be impossible for my upper year resident to do it all, handle afternoon team issues, AND get out at a reasonable hour (and besides, he'd feel bitter as the paperwork was mainly for my patients). I drew the line at 31 hours and drove carefully home using loud radio and the wind in my hair to guard against dozing.

When I got home, I logged onto our hospital EMR system to do a little more work, had a snack, and passed out just as I was thinking about calling to make an appointment for a haircut. I could go no further. I comfortably awakened 18 hours later, which tells me I'd been a lot more worn out than my usual post-call self. Happily, I earned myself a Golden Weekend with this last shift. My recovery smoothie tastes even sweeter knowing I have just 6 more days of floor work before my last month of internship!

*My hospital lacks dedicated call rooms for overnight Internal Medicine residents not covering the ICU because we rarely, if ever, get even a few moments to rest between cross coverage responsibilities and hospital admissions.

Patrick Park -- Here We Are (mp3)

Wye Oak -- Civilian (mp3)

Narcan saves the day (again)

2011-05-08T22:11:00.006-04:00

Mr. Heroin: I swear I will NEVER do that again. NEVER again!
PGYx: You just almost died. You stopped breathing and if your sister hadn't brought help (after bringing you the heroin) you'd be dead.
[Sister looking on shifts uncomfortably]
Mr. Heroin: I'm never doing that again!
PGYx: Ok, so would you be interested in going to rehab?
Mr. Heroin: I think I'd do well with AA meetings and things like that.
PGYx: What about rehab?
Mr. Heroin: Well, I sort of just got out of rehab...
PGYx: Ok, but you just now shot up heroin, so clearly there's more work to do regarding your addiction.
Mr. Heroin: Well I had to do it because the IV pain meds you're giving me weren't working.
PGYx: Do you see that you're proving my point here?

(And if I haven't said it enough before, Thanks, Narcan!*)

*a.k.a. naloxone, which blocks and reverses the effects of heroin and prescription narcotic/opioid drugs.

Off!

2011-05-06T22:04:00.008-04:00

I have spent 23 of the last 24 days hard at work in the hospital. My last day off was 15 days ago but tomorrow I am FREE! I'm so excited to sleep in, look at apartments, finally fix my malfunctioning toilet, meditate, and tackle the massive accumulation of laundry that has left me with nothing to wear.

Ok, so looking at apartments may have to wait until my Golden Weekend (2 days off!) next weekend, but I can at least look at places online. I'd also really like to see this movie that supposedly explores the brighter side of human nature, what's wrong with the world, and what we can do to make it better.

My excitement about these fairly mundane activities reminds me of the "low level ecstasy" that Bill Bryson champions in A Walk in the Woods, his memoir about hiking the Appalachian Trail. Some of my most cherished free time during internship has consisted of enjoying small things that somehow amount to everything.

As much as the hazy lens of retrospect has made me nostalgic for internship before it's even over, I will be so happy to hand off my intern responsibilities to the next group of bright-eyed youngsters in just 48 short days!

Self-evident truths #2

2011-05-03T20:36:00.003-04:00

PGYx (admitting a very old, very spry woman to the hospital): It was truly a pleasure to meet you. Thanks for your book recommendations. I hope you feel better and get out of here soon!

Mrs. Wise: Oh, I enjoyed talking with you very much. Now be sure to get enough sleep tonight. Don't push yourself to overdo. Some people can handle it, but you don't have the physical constitution for that.

How's that for the art of diagnosis?

And suddenly...

2011-05-02T19:16:00.002-04:00

...I miss this more than I can say.

Maybe it's telling that I have never had my hair cut on the East Coast. After nearly 5 years ostensibly comfortably settled here, I've grown weary of the frantic pace and unhealthy lifestyle of nearly everyone I know. I wish I could go home.

In other news, I'm so grateful that my family in Tuscaloosa survived the tornado. Two of my cousins lost nearly everything they owned, but they and their families are unhurt.

Looks like long hours, lost sleep, and absent life balance are taking their toll. Day off Saturday after 15 days on!

Be here now

2011-04-20T02:04:00.007-04:00

My last sleepless and eventful overnight call left me feeling pretty drained -- to the tune of a 15-hour long sleep marathon followed by bedtime at 5:30(!) pm after an early day yesterday. Now I'm wide awake (for an intern, anyway) after a semi-disturbing work-inspired dream.

I've grown to accept that the only constant in life is change. Five minutes from now, anything I observe will have changed in at least some small way. I'm learning to observe things as they are.

But sometimes a moment stands in such stark contrast to the one that came before that it's hard to just meekly watch.

My work experiences constitute the bulk of my waking life and increasingly contribute to my core sense of self. Still, I try to avoid bringing details of my patients, their families, and my work day home with me. I gently correct myself when I find myself mentally tweaking patient care plans or musing about a patient's life circumstances during the ride home and as I fall into sleep each night.

I catch myself replaying what I told a worried family, wondering if I softened the blow of the severity of their loved one's condition a little too well. Always, I implore myself to do better -- to be better -- next time. I slip easily into these patterns, but am learning to slip out more easily. In a leap forward from my old habits, I almost never reconsider the day's small injustices. It's nice to let these things go without a second thought.

So I'm getting better at leaving work in the hospital, but sometimes I fail. These people to whom I dedicate nearly all my waking hours seep into my off-duty thoughts. They grace my prayers and haunt my dreams.

This is one of those times, a reminder that while everything changes from moment to moment, once in a great while, the events of a single moment can change everything. How many more major lessons can a year of internship bring?

It's a wonderful life

2011-04-16T07:57:00.009-04:00

Yesterday I was post-call on a 30-hour shift. It is standard humane practice for the team to round on the post-call intern's patients first so that s/he can leave somewhere around the 30-hour mark. When my attending arrived for rounds she asked,

"Who's post-call?" (Rests her gaze on me and hesitates) "PGYx, you're not post-call, are you?"

"I am!" I said, smiling.

"Wow, you look great! You look the same as you did when I left last night!"

(Picture the same pony tail I'd had since the day before and an unwashed face. It had been a busy night. I was still wearing mascara from the day before, but somehow it had not run or flaked. I had brushed my teeth, at least).

"I must have looked pretty bad last night," I joked.

"Look at her, she even looks happy to be here, too!"

And I was. I smiled as I thought about how content I am to be working in the unit despite the long hours of near-complete immersion in the ICU millieu.

I have so little time outside of work that I've had to discard all but the most essential aspects of daily life. I only just finished my taxes(!) and have hardly spoken to a soul outside of work in weeks. After spending most of my waking hours extensively communicating with patients, colleagues, and family members, I feel drawn to silence when the day is done.

These days the hospital is my home away from home (fortunately it's a really nice hospital). I bring a big bag of nourishing food, wear my pajamas to work, and get to work with a team of some of the brightest and most competent folks -- from nurses to residents to attending physicians -- I've had the pleasure of knowing. I feel a little sad to know that I won't be able to learn more from them next year.

Together, we help bring a few folks back from the brink of sometimes wildly unexpected critical illness, allowing them to return to function in time. Sometimes we keep people alive long after they would ask to die if they could speak for themselves. Other times, we help families to understand when their loved ones are at the end of life.

It's not perfect but satisfying overall and each night I leave work tired but happy to be giving my best effort to patients and their families. My thorough approach is well-suited to caring for very sick people with problems in multiple organ systems. Today one of my attendings told me that I'm "really good at Medicine" and that she hopes I will continue to use it extensively even after I specialize.

I've caught myself entertaining fleeting fantasies of pursuing a Pulmonary and Critical Care fellowship -- in an unrealistic alternate universe where I stay in Internal Medicine. This represents a near-tectonic shift in my perspective. After the initial months of intern despair, I feel so so grateful to have had the opportunity to train in my current program.

Sometimes I find happiness where I least expect it. I'll try to remember that for the next round.

Soundtrack of our lives

2011-04-10T22:07:00.003-04:00

And the hardest part was falling down the stairs gracefully...

Sounds a lot like life to me. :-) Check out this beautiful song from Ghosts I've Met posted by the discerning authors of Those Who Dig. The full album drops this Tuesday, April 12.

This post is mostly a test of whether my 5-minute effort to embed a music player worked. If I've failed then please pardon my construction efforts and know I'll get back to them some time this summer. Busy times here and ahead.

Ghosts I've Met - Blackwoods (mp3 link)

Amazing news

2011-04-06T22:46:00.008-04:00

My mother just learned her sister, missing for 38 years, is alive and well in West Africa. She was presumed murdered, along with her husband and daughter, by Liberian guerillas. In fact, they escaped. My mother searched for her for more than three decades. Their parents died thinking their eldest daughter died horrifically.

My aunt's life story isn't a particularly happy one, but we are so glad she is alive. She and my mother have already reunited by Skype. We hope for a real reunion in their homeland, yet another chronically war torn nation, later this year. I can hardly wait to meet her.

What brought this wonderful revelation?

Facebook.

Thank you, Mark Zuckerberg.

Ready, set, into the fire

2011-03-27T22:17:00.005-04:00

Today was day 1 of 57 grueling long days. I'll work 50 of the next 57 days on the floors and in the ICU. Yikes, this hurts.

Yeah, I know too well that the first days are the hardest. Not that today was anything close to the first days of internship, thank God. Looking forward to making it through tomorrow -- I wake in 6 hours for my first day back in the ICU and on overnight for good measure.

In times like these it's best not to look too far ahead of myself.

Self-evident truths

2011-03-23T14:27:00.010-04:00

PGY2: You drink coffee?
PGYx: [making coffee] Yeah!
PGY2: When did you start drinking coffee?
PGYx: I've always used coffee. I love coffee.
PGY2: [incredulously] Even during med school?!

Patient's son: Dr. Brain increased mom's Alzheimer's medication dose when he saw her last week.
Mrs. Mom: Who's Dr. Brain?
Son: I don't think I notice a difference, but it's probably too soon to tell.
Mrs. Mom:[insistently] WHO IS DR BRAIN?
Son: He helps you with your memory.
Mrs. Mom: Oh! I don't remember him! (Laughs almost as though she gets the joke)

Nurse: I'm going to test your hearing now.
Mrs. Mom: What?
Nurse: I want to check your hearing with this machine!
Mrs. Mom: I need you to repeat yourself because I can't hear you!

I left my heart in Buena Vista

2011-03-18T13:02:00.008-04:00

I've been blissfully immersed in the stunning beauty of Colorado's blue skies, mountains, & rivers for the past few days. I feel so refreshed that I've decided to remain here rather than return to the East Coast for the remainder of my residency training.

Kidding! But it's a nice fantasy to entertain, anyway. An old friend and I spent the first few days at a Buena Vista B&B with a woodburning stove and narrated by the rushing Arkansas river 20 feet from our door (pictured below). The photo above is the view from the front of the inn. After a day there I felt any baseline stress or worry float away. It was a helpful reminder that I feel renewed and sustained when I spend time in nature's quiet.

Now I'm learning a lot and enjoying reconnecting with my osteopathic friends, colleagues, and mentors in Colorado Springs. I'm a little sad to go home tomorrow but so grateful for the inspiration this trip has brought. I needed it more than I realized!

It depends how you define "medical problem"

2011-03-07T21:53:00.002-05:00

PGYx: What medical problems do you have?
Mrs. Tothepoint: Well you see, I was scheduled to go to a 5000-person meditation event...

***

PGYx: Do you ask your wife to check your skin regularly for new moles?
Mr. Earnest: Well, it's not one of our official activities...

***

Mr. Muscles: <Dramatically> It doesn't look good, does it, doc?
PGYx: Well the tests we just did show your strength is similar on both sides in both your arms and legs.
Mr. Muscles: I'm just so weak all over. I used to be strong enough to do pushups.
PGYx: When was the last time you did that?
Mr. Mucles: Last night.
PGYx: Oh, do you think you could do some here for me now?
Mr. Muscles: <Gets down on the floor and easily does several pushups>
PGYx: Ok, that's enough, you can get up now.
PGYx: <To Attending> I'm pretty sure this is not an acute stroke.

***

Attending:<To elderly patient> Wow, you've really gone through a lot of shit lately.
Mr. Spin: It's an opportunity for growth.

Is it bad that sleep is my all-time favorite?

2011-03-01T23:28:00.006-05:00

I just finished a fairly grueling rotation admitting patients to the hospital from the ED and foolishly decided to follow with 20 hours of extra weekend coursework "for fun." After too much fun, I've slept 27 hours in the past two days, winning the latest battle between PGYx vs sleep deprivation. I envy the people who say (and truly believe) they'll sleep when they're dead because I must have signed some kind of pre-birth deal that ensures I'll spend at least a third of my life in dreamland. While I felt hungover after waking from my two sleep mini-marathons, by mid-today I felt strangely human for the first time in a while.

When I got home at 7 after an hour in traffic, I didn't feel the post-work sleepiness I've come to accept as my standard(!) so I got to work in a fit of wonderful productivity. Is this what life could be like if I weren't jonesing for sleep all the freaking time? A med student who lives thousands of miles away helpfully reminded me via Twitter that I have a treadmill in my very own apartment (hint, hint) after I ate half a pack of Trader Joe's chocolate dipped oat cookies. I don't even like cookies. Or chocolate. Damned oats drew me in.

Sadly, it didn't even occur to me to exercise until jjoh jokingly suggested I could safely eat the cookies while on the treadmill. And just today I counseled two patients about how to fit exercise into their busy schedules. After a good bit of self-flagellation for my own hypocrisy I got off my proverbial ass and walked/ran on my heretofore ignored treadmill. I feel really good.

I also called my mom to wish her a happy birthday, paid all my bills, baked some yams, took a relaxing bath, drank a veggie smoothie to balance the cookies, and devoted 30 minutes to straightening my apartment. I have a semi-irrational fear that my landlord will have some reason to need to get into my apartment (e.g., a space heater fire or me getting hit by a car & needing friends to get into my apartment to bring me a few essentials from home) and see what a slob I have become. Hell, I already totaled my car in a blaze of glory that left me and others miraculously untouched, so is my worry so farfetched? Ok, it is, but I think we can all agree that I need to clean & organize in the name of feng shui, at least.

So yeah, it was a good day. Wish I could have done more but am really glad to have accomplished more than my usual weeknight regimen of zombified blah. I plan to wrap it up with some meditation before I rest my head on my pillow secure in the knowledge that even we interns can take good care of ourselves some of the time. Maybe even a little bit every day.

Quotes of the week

2011-02-23T23:37:00.004-05:00

Medicine PGY3: Hey, PGYx, I saw your consult on Mrs. Swollen Shoulder. It was really good! I read through the whole thing and thought it was done by a real rheumatologist until I saw your name at the bottom.

Me: Man, I'm going to miss Rheumatology.

***

Dr. Bones: I can't keep giving you a steroid if you don't really need it. The medicine has side effects. I'm worried about your bone density.

Mr. Arthritis: Just give it to me. I'm 85 -- I've only got 5 years left, max!

***

Me: So other than your inguinal hernia repair and lung biopsy have you had any other surgeries?

Mr. Details: Yeah, they did something to my balls.

Me: Do you remember what they did?

Mr. Details: No.

What's wrong with health care: Reason #506

2011-02-19T09:13:00.002-05:00

I recently called the mother of a 40-something year old patient to verify his version of events surrounding his tale of unexpectedly passing out. He told me he had essentially no symptoms beforehand, adamantly denied any drug use, and firmly stated that his mother could not arouse him for several minutes despite her frantic efforts to do so. I called mom because I wanted an eyewitness account, but there were also several things about the patient's tale that sounded fishy. His mother's version of events dramatically differed from his own.

Despite the fact that his mother's account suggested a benign issue at most, my attending noted that I was obligated to treat the patient as though I believed his story of what could have theoretically reflected serious illness. In other words, I was essentially forced to work up his presenting symptoms with a battery of expensive tests and continuous cardiac monitoring even though I am 99% certain these tests will reveal absolutely nothing. He has state-sponsored insurance.

Coincidentally, he also reported that he had run out of his pain medications the same day and emphasized that they hadn't been working all that well, anyway. He has metastatic cancer, so he has a good reason to have pain. He received a lot of powerful intravenous narcotic pain medication in the ED and repeatedly asked me for more.

On the whole, it seemed he had made up a story simply to get IV pain meds. Did a cancer patient really need to so elaborately dupe several doctors just to get a little pain medicine? Seriously, no. Having cancer is like having a season pass to a Dilaudid theme park. Doctors generally err on the side of making sure cancer pain is controlled, even when the patient has a history of major ongoing drug use, as this patient did.

This patient's ED visit and admission were a big waste of everyone's time and I shudder to think how much money taxpayers will pay and the hospital will lose by caring for this patient. Of course I dislike being duped, but I dislike it a lot more when it drains our already fragile resource net that too often inadequately serves those with real medical needs.

It's complicated

2011-02-10T22:36:00.005-05:00

Admission note selection of the day:

"The patient is visiting the Emerald City from Kansas, where he has a distant relationship with his girlfriend. He denies all sexual contact outside of relations with his wife."

Now that's a compliment!

2011-02-09T17:50:00.010-05:00

In my program, residents are anonymously evaluated by the nurses with whom we work. Our hospital is Magnet recognized for nursing and I can honestly report that this is reflected in the high quality of our nurses.

One of them wrote in my evaluation:

Dr. PGYx is highly dedicated to patient care and I would gladly have her care for my family members.

My program director told me that our nurses are often brutal in their resident evaluations and stingy with kind comments. Nurses also have special radar to detect quality in physicians & patient care, so this is an extra-nice compliment!

I'd like your opinions, please

2011-02-06T19:59:00.008-05:00

I recently opened my mouth to mention that I'm an occasional blogger, so a few people I know have understandably asked to see my blog. For some reason, it makes me nervous to show them all these years of posts that track my passage -- if with major gaps -- through medical school and now internship. What I see isn't always pretty, which makes me feel a little naked when I think about friends or family reading my words.

I started the blog as a place to talk about things I like or find intriguing, and also as a more personal way to keep track of other blogs and sites I follow. I named it after a song by a band I adore that has nothing to do with medicine. And, yes, it was also a play on words regarding this chronically cold girl's move from sunny California to the frozen East Coast.

In the beginning, I talked mostly about music, studying, and snippets from my personal life. Sometimes I discussed patient interactions that taught me key lessons, posted a favorite poem, or wrote about a recipe I liked. I've never posted more than sporadically, but somehow the posts added up over time.

As I came to accept that I reflect upon my profession, my posts took on a less irreverent tone. That made me want to blog less, because I really thrive when I can be both irreverent and sweet, which my patients & colleagues seem to appreciate. Life got busier with clinical rotations, busier still during residency interview season, and with internship reached a zenith of busyness I hadn't thought possible (but oh yes, it is). I posted when I could, but not as much as I wanted.

So here I am, a newly minted physician with an impossibly un-physician-like blog name and questions of whether I should keep this blog secret forever or let my friends and family in. A lot of folks find my blog through Google search (I get a remarkable number of hits by people looking for images of a Foley catheter, which is a question for another post), but it would be a lot harder for anyone looking for me to find my blog in the haystack of med-friendly blogs out there.

So here's where you, dear readers, come in. If you were me, would you let your family, friends, and/or casual acquaintances read my blog? Let me know in the comments or via coldgirlfeverblog at gmail dot com.

Thanks!

Dog days are over

2011-01-26T18:35:00.012-05:00

World's first bungee jump site at Kawarau Bridge, Queenstown, New Zealand, circa long before I knew enough to worry about retinal detachment risk

As usual, I haven't posted in a long while. I'm more than 7 months of the way through an internship that everyone and their mother swore would fly by. I blinked 3 times and now less than 5 months remain! Now that I've gotten the hang of this internship gig I'm starting to feel twinges of regret that I'll be leaving this job and the teammates I've grown to trust for yet another brand new start.

Wait, maybe regret isn't the right word. Maybe it's really that I'm getting comfortable again and sense that the start of residency represents another departure from a comfort zone I've worked damned hard to dig from gristle and stone.

But comfort zones are suspiciously synonymous with ruts, which is why one of my recent resolutions is to leave mine every chance I get. I've managed to take a proverbial breath and leap several times this year, and you know what? I feel more alive already.

Maya Angelou wrote that our routines lead us to forget that life is an ongoing adventure. I admit that lately my gut response to the thought of moving (again!) and starting over (again!) is more trepidation than excitement. But as I look back at some of the most fun & worthwhile things I've done, I see they all started unassumingly with plans and progress forged more through luck and serendipity than my own master planning skills.

I sometimes envy my colleagues who have worked their whole lives toward a single goal. They seem happy and, well...settled. I admire their ability to set their sights on and achieve exactly what they want from a young age. At the same time, I accept that my more tortuous path was exactly right for me and has heavily shaped my identity.

Now that I'm a grown-up, I'd like to put down some solid roots and say yes to new experiences. Other than my residency program & field of medicine, I can't say exactly where I'm headed. But I do know that at my core I have an adventurous spirit that could use some fresh air after a couple years spent in hibernation. Here's to letting it out.

Florence and the Machine - "Dog Days Are Over" (streaming)

Monsters of Folk - "Say Please" (streaming)

A joyful life

2010-12-27T13:35:00.019-05:00

I decided to give my backpack a good cleaning before filling it with my laptop, fresh scrubs for my first day back at work tomorrow, and rations for my next 36 hours away from home. I ran across several maps and notes from my amazing pre-internship trip to Costa Rica.

I also found a handwritten medication list (how did that get in there?) for a patient whose memory sticks with me more than any other. I admitted and cared for him last summer. His med list is written on personalized paper meant to spread holiday cheer. There's a smiling Rudolph in one corner and brightly wrapped gifts in the other. It's yours to keep, his son told me, his eyes nervous with worry for his father's health.

The patient was a warm and joking man, his smile extending widely across his round face. He asked me about where I went to school and explained that he retired from work in the health care profession, too. We're colleagues, he offered generously without hint of sarcasm. He seemed too healthy to be in the intensive care unit, and we all told him as much. However, his severe underlying lung disease warranted closer monitoring.

When I inquired about his code status, or preferences regarding how far I could go to resuscitate him in the event of cardiac or respiratory compromise, I carelessly told him that while I must obtain code status for every admitted patient, I did not really expect to have to apply his instructions. His physical exam suggested he was one of the healthiest patients I'd seen in weeks in spite of baseline lung disease. And he glowed with a rarely seen inner light of joy that made it hard to imagine him anything less than alive and functional.

So it surprised us all when I watched his heart rate dwindle to nothing and found myself on his bed crouched over his small trunk doing my first meaningful chest compressions (i.e., the patient still had a shot at survival) and barking the first instructions of a Code Blue. This guy is supposed to live! I thought as I compressed his chest wall with all the force I could muster.

He survived that day. I learned a powerful lesson to never tell a patient his code status is anything less than critical to his care. By sheer accident, weeks later I learned that he died several days after I left the ICU for another rotation.

I still have his medication list here, although I'm not quite sure why. Part of me knows I have no business keeping it instead of dumping it into the nearest HIPAA-sponsored hospital shredder. Maybe I'm just not quite ready to give it up yet.

All i need is everything

2010-12-15T22:10:00.011-05:00

I write this from the perspective of 80-95 hour work weeks, far too little sleep, limited opportunities to eat, and a sore throat I can't seem to shake. My personal life and body have been ravaged by my semi-forced but mostly chosen dedication to my early medical training. I've lost a lot this year.

I've also recently gotten a string of praise for my work from several attending physicians, nurses, and the resident I'd most like to emulate. I know I have a ton of room for growth but these compliments are hard won and paid for with things I once held dear.

I've finally settled into the profound fatigue of internship with only fleeting thoughts of the distant light at the end of the tunnel. Although I've grown used to most of the hardest parts and increasingly view my position as one of great privilege (Oh, how much I get to grow, learn, and DO for others this year!), internship has been a remarkably brutal hazing and initiation into the world of medicine.

The good news is that on each new day I'm a more resilient person and a more capable physician for facing the many challenges internship brings. I find myself hoping that the next 6 months will be at least as transformative even if the process hurts a whole lot at times.

My heart swells with the realization that this is as much as I could ask from my internship experience. I feel humbled and privileged to be responsible for doing the best I can do for my patients. There's plenty of grace to be had here. Today, at least, I know I'm exactly where I'm supposed to be.

"All I Need is Everything" - Over the Rhine (click play on site to stream)

Quotes of the week

2010-11-27T11:48:00.008-05:00

Mother of a malingering patient who pretended to be unable to walk:

I'm a nurse, too, you know. I worked in a hospital for a while...and if she falls, I WILL sue you!

Patient in heart failure with urine drug screen positive for cocaine: They use the table at my apartment to bag [the cocaine]. I was cleaning around the table so I was exposed -- I DIDN'T SMOKE IT!

Same patient in HF: I ran out of food so I was making soup with a chicken bone and salt.

Me: Did you run out of food because you didn't make it to the store [b/c you were high on crack] or because you didn't have the money?

PIH: Because I ran out of money! You gonna give me some?

Paranoid patient: You're just trying to drag this out to keep me from going home right now!

Me: Sir, that is absolutely not the case.

PP (yelling): Well I think it is!

Me: I have been awake for the past 34 hours -- believe me, I want this to be over as much as you do.

PP: Oh.

Top 10 must-ask pre-internship & residency questions for medical students

2010-10-30T14:40:00.018-04:00

Now that internship and residency interview season is upon 4th year medical students I'd like to share some 20/20 hindsight about the top 10 questions I'm glad I asked or wish I'd asked during my internship and residency interviews.

This is by no means a comprehensive list -- indeed, I've omitted some of the obvious important questions about call schedules and elective time -- and is skewed toward internship and Internal Medicine since that's my experience so far.

1. During floor and ICU months do you find that you can finish all your work within the 80 hour/week limit without sacrificing work quality or patient safety?

The 80 hour per week limit applies to the average time worked over the last 4 weeks, so it's ok to go over 80 hours some weeks. Sometimes it's essential to stay late to ensure that a sick patient gets the right care. Rushing out the door at quitting time without tucking in your patients will make you a less effective intern, promote bad outcomes, and invite the hatred of your co-interns who cover for you when you leave. However, if residents in your favorite program or specialty regularly work more than 80 hours then you'll have to decide whether you're a committed masochist or just like to dabble in pain.

2. What time do interns “like” to get in to pre-round on patients? Do you “like” to pre-write your notes the evening before?

If most interns feel compelled to arrive an hour or more before the standard intern start time then this will almost certainly lead to duty hour violations in the setting of a typical call schedule. You shouldn’t have to spend evenings pre-writing notes or arrive at 5 a.m. to get your job done -- most of the time, anyway. If you find yourself alone in the slow boat then you should ask your upper year residents to help identify ways to become more efficient. If the only way to get out on time is to do more work at home then the program has deeper issues.

3. Does chronic underreporting of duty hours really happen in some programs?

BTW, this is not an appropriate interview day question. Yep, it happens. More in some specialties than others. There’s a lot of work to be done by a set number of residents. Try to avoid programs with a pervasive culture of underreporting duty hours. See my masochist comment in #1. Residents often want to protect their program from being cited by the ACGME for violations. This failure to report gives the program a false sense of how much work is really required of residents. In programs where residents chronically underreport hours, individual residents may fear being singled out as the only resident who can't finish work in a timely manner or worse, as the resident who got the program into trouble.

4. How many interns/residents are on each floor team? What is the maximum number of patients per team? What is maximum number of patients for each intern?

Adequate exposure to a variety of patients and cases is essential to develop competence, but chronically handling too many patients at once makes it tough to develop a deeper understanding of medicine's complexities. How many patients is too many? The ACGME caps interns at 10 patients (down from 12 as of July 2009). The ACGME caps a single-intern team, which includes one resident, at 14 patients.

Realistically, it’s disheartening to care for 10 patients when you have no time to briefly review, say, the workup for hyponatremia in the new edition of your trusty Massachusetts General Hospital Handbook of Internal Medicine. It's fine to learn from attending physicians and residents, but it's also important to fine tune your patient care plans through your own research and study.

Note that you will help to care for your resident’s patients since nurses will automatically page you for all the patients on your team. You will also likely write full chart notes for up to 14 patients on a weekend when standard rounds are not held, so it's a good idea to keep any intern or team caps in mind when you select a program.

5. How do the floor teams split work between interns and residents?

In some programs a team's work is split close to evenly between interns and residents. At the opposite end of the spectrum, an intern may cover all patients on the team up to the 10-patient cap. For the purpose of maintaining intern sanity, an ideal approach is likely somewhere in between. Note that upper year residents take responsibility for the entire team of patients so it doesn't make sense for them to evenly split the progress note burden with an intern. The resident who does this is a saint (and likely a masochist). S/he will warmly hug you at the end of the rotation. Warning: this species of resident is rare.

6. How much do attending physicians teach in this program?

This is essential whether you're a Preliminary intern gaining a year of experience prior to residency or a Categorical intern in it for the long haul. As an intern you'll be a hospital employee with a contractual responsibility to care for patients, but you're also there to gain competence for when the time comes to practice without a residency safety net. Effective teaching that is relevant to your caseload increases the educational value of your hard work. Don't get stuck in a residency program where the work-education balance is anything but.

7. What proportion of the patients on each team belong to "private" attending physicians?

Rounding on a full census of patients takes time, but even brief discussions about a patient add more to both your education and patient care quality than merely carrying out the wishes of a private attending with whom you have little contact. For better or worse, I provide more attentive care to patients with teaching attending physicians since I have regular contact with them throughout the day. In my opinion, no more than 25% of a team’s census should consist of private attending patients, and the less the better.

8. Is lecture time protected, either entirely or from all but urgent/emergent pages?

Protected lecture time means you won't be paged during educational time because "Mr. Smith wants to know when he can go home" when the paging nurse knows perfectly well that Mr. Smith isn’t going anywhere until noon conference is over. Protected or even semi-protected lecture time suggests that the program will pay more than just lip service to educating you.

9. Do interns dictate discharge summaries?

Some programs do not require interns to dictate discharge summaries for patients but assign this important and time-consuming task to upper year residents. Dictating discharge summaries requires you to coherently and succinctly describe a patient’s clinical course and your team’s underlying clinical reasoning.

If you dictate from Day 1 you may be a better intern since you will gain a broad view of what could otherwise seem like a bunch of disjointed details. You’ll also have a chance to identify things that were missed to do better next time. However, it is a red flag if interns regularly must dictate discharge summaries from home because they can't find time during the 80 hour work week. Many (most?) of the big university programs do not require interns to dictate discharge summaries. If it's good enough for them, it's probably good enough for you. Go ahead, save yourself a little misery.

10. Can you access electronic medical records from home?

Convenience or a sign of extra obligation? Depending on the program, maybe a little of both.

Overall, you probably won't find the perfect combination of work, education, and leisure in a program but it's fair to seek the right fit for you. If something strikes you as a red flag in a program I urge you to dig deeper rather than just hope for the best.

Don't settle for just any program that will accept you. Unless you're a very weak candidate or interview at only a few programs, you will likely have choices regarding which program will be your constant companion for the next 1-5 years.

As many program directors shared with me last year, the residency match is a buyer's market. You, the candidate, are the buyer and have limited opportunity for returns or exchange. Spend wisely.

Damn you, sneaky patients

2010-10-17T08:52:00.016-04:00

A particularly sick patient was recently transferred from the Intensive Care Unit for care by my team on one of the medical floors. He was the prototypical extremely nice guy who had been blindsided by one terrible medical problem after another through no fault of his own. "Bad things happen to good people," is an adage often repeated by cynical residents because, well, that's just the way things seem to go for many of the nicest patients.

Late one evening as I was getting ready to leave, his nurse paged me to tell me his blood pressure was 76/48. I had briefly examined & interviewed the patient in the early morning and knew he had required large fluid boluses for hypotension that afternoon, but I wasn't entirely familiar with his case as my senior resident had cared for him while I attended a training session. When my resident left for the day he told me I should have a low threshold for transferring the patient back to the ICU.

His nurse told me that his blood pressure had only transiently risen after the fluid boluses. When I visited his bedside I was not reassured -- his blood pressure was still low, his breathing was labored, and his abnormal heart rhythm & rapid heart rate continued despite two days of anti-arrhythmic medication delivered by IV drip. To complicate matters, his only IV access was a small peripheral line in his hand. A surgical team had tried and failed to obtain central venous access in his internal jugular vein to allow rapid delivery of large amounts of fluid or medication earlier that day. They had opted to not place a "dirty line" in a groin vein because he had not seemed unstable enough to merit the infection risk.

My patient told me his systolic blood pressure (the top number that reflects blood pressure when the left ventricle of the heart squeezes blood into the body's arterial system) normally runs in the 140s. So, loosely speaking, his body was running on about half of his normal blood pressure. He complained of continued weakness but surprisingly denied any lightheadedness, shortness of breath, heart palpitations, chest pain, or nausea.

Did I need to send him back to the ICU? I considered why he might be hypotensive even after extensive IV fluid rehydration (and no kidney function to filter his blood and make urine). Was too much fluid removed in dialysis earlier that day? Was his heart rate too rapid to allow adequate filling of his heart? This would result in a lower cardiac output and thus a lower blood pressure. Or could it be that his lung infection had worsened despite broadened antibiotic therapy and was now overwhelming his system? Hypotension and rapid heart rate together can be hallmarks of systemic infection, and he had had a fever earlier that afternoon. Worsened infection may also have precipitated his arrhythmia.

Finally, I was concerned about his rapid and labored breathing. Was it caused by his low blood pressure, potentially worsened pneumonia, or possibly a blood clot that had broken off from one of the deep veins in his legs and traveled to blood vessels in his lungs? His current condition and medical history included no fewer than three risk factors for blood clot formation. At the very least, his respiratory muscles could become fatigued in the setting of such rapid and labored breathing, which would require artificial ventilation for respiratory failure. I explained my concerns to the patient and drew a sample of blood from his radial artery to check oxygenation and gas exchange by his lungs, which themselves sounded fairly clear.

His blood gas was fine. Truthfully, there wasn't much action left to take after considering the differential diagnosis and all that had been done before. He had already been given broad antibiotic coverage for infection and was on a powerful anti-arrhythmic drug. I awaited results of new blood cultures drawn earlier that day. With all this in mind, I ordered an ultrasound of the deep veins in his lower extremities to check for a blood clot and gave him another bolus of IV fluid. His arrhythmia remained but his blood pressure rose enough that I couldn't justify transfer to the ICU, a unit reserved for people who require closer observation than a nurse caring for up to six patients at a time can reasonably provide. I implored the patient to let his nurse know immediately if he felt any of the symptoms I had inquired about or worse in any way at all. He made an ok sign with his thumb and forefinger. I hoped the mild increase in his blood pressure would hold, and I discussed the plan with his nurse and signed out his case in detail to the covering team.

I saw him first thing on Saturday morning (the last day of my rotation on the floor!) when I returned to the hospital. He looked relatively great. His breathing was comfortable, his blood pressure closer to his baseline, and while his arrhythmia remained, his heart rate wasn't quite so rapid. I expressed relief that his condition had improved and we discussed the likely causes for his hypotension the night before. Then he surprised me by saying, "You know, a lot of doctors come in here and they're just doing their job. But it's obvious you really care about my well-being, and that means a lot to me."

As some of you know, my general thoughts about my job are conflicted at best. Health care delivery is fraught with so many frustrating issues that being a physician is often unpalatable. I also never wanted to be a doctor who mainly doles out prescription medication to chronically ill patients because I don't think a steady diet of pills alone is likely to result in health even if it can absolutely stave off some of the worst sequelae of chronic disease. I maintain a great attitude at work without any conscious effort, which probably means I like my job as much as any intern could. I also get to work with some truly wonderful people to balance the few patients who do things like disconnect the blood transfusion a kind person donated when I refuse to give them IV Dilaudid (a narcotic pain medication).

But when I reflect on my path during my invariably late evening drive home from the hospital, my thoughts drift to other job possibilities, other lives I could have chosen, and other lives I might still choose. I think about moving to the country, having a garden, preparing food from whole food ingredients, teaching little hands to cook, and having time to do all of this. I chose to attend medical school because I adore studying the human body's intricacies -- through both reading and experience -- and then finding practical implications of what I learn to help others maintain or regain their health and quality of life. I also love meeting new people and hearing their stories.

Somehow the practice of medicine doesn't deliver enough of either of these two things. My focus is necessarily more on appropriate documentation than on spending significant time with patients or even on learning. While I have certainly learned a great deal through my immersion in the practice of medicine, I rarely find time to read enough to make connections with what I learn in daily life. So in the end, my current job doesn't give me much of what I love most and I wonder if the career I've chosen, albeit in a different specialty, will ultimately leave me similarly dissatisfied.

Then when patients like this one tell me that my efforts make a difference in their lives and that my work is meaningful to them, it almost makes me want to stay. Damn you, sneaky patients.

Some dude strikes again

2010-09-08T09:38:00.005-04:00

Yesterday some dude rear-ended me on my way to my night float shift. I sat peacefully in a line of traffic on an off-ramp when he rudely awakened me from my hopeful reverie about the coming night of hospital admissions and cross-covering 70 patients I don't know well.

Me: I *just* bought this car!*
SD : Sorry...there's no damage...
Me: Yeah, ok. Yay for your rubber bumper.
SD (lopes back to his car)
Me: Wait -- What happened there?
SD: I don't know...I thought you would move and then the traffic in front of you stopped.
Me: The traffic had been stopped for 2 minutes. No one ever moved!
SD: Oh...
Me: Are you high?

After my bumper got slammed my team got slammed in the ED harder than I imagined possible. My back is jacked and I'm thrilled that I have an appointment with my DO for some OMM after work tomorrow. I'm not so thrilled that I have to spend another evening as part of a severely understaffed night float team serving an understaffed day team.

*After totaling my beloved car in a terrible but still incredibly lucky one-car highway accident while rushing to work one morning early during my internship.

Atul Gawande is on the right track (read this now)

2010-08-15T21:05:00.007-04:00

I'm running late for sleep the night before yet another 30+ hour shift in the ICU so for now I'll just post a link to this perfectly timed New Yorker Magazine article by Atul Gawande. In it, he eloquently addresses the important question of what medicine should do when it can't save a patient's life. It's a question that most of us will at some point have to answer for ourselves, or more likely for a loved one.

One of my caught-in-limbo patients prompted his internist to strongly recommend the article to me. Atul Gawande + the New Yorker + end-of-life care obviously means that this article is required reading for all. Please check it out and consider what you would want for yourself or your spouse, mom, or sibling. Then take the next step and share your thoughts with your loved ones . It is difficult to initiate this conversation -- as it was even for death-and-dying expert Dr. Susan Block when she had The Conversation with her father -- but it's better to consider and discuss this question with loved ones before a critical need to respond arises.

A Pulmonary & Critical Care attending physician recently explained that people don't want to die at home anymore. He said most people want to die in the hospital instead. I refrained from openly contradicting him given our quite formal relationship and because he seemed so satisfied by his conclusion, but I think his Critical Care perspective leaves him heavily biased. As far as I can tell, families bring their loved ones to the hospital at the end of their lives with hope that medicine will offer life-prolonging therapies. Thoughts about quality of life don't really enter their minds until later, when the acute emergency has passed and it becomes clear that medicine won't offer the fresh start they seek.

Gawande briefly addresses the subject of admitting people to the ICU near the end of life:

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions...Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”

Atul Gawande, in "Letting Go," New Yorker Magazine, August 2, 2010

His words sum up the experience of a sizable proportion of my patients in the Intensive Care Unit so far. At times it seems nearly criminal that our efforts to "save" clearly terminally ill patients manage only to extend their suffering.

What's more, we do a poor overall job of providing comfort care, despite having a certified Palliative Care Nurse Practitioner on staff in our ICU. There is even wide variation in how often different nurses decide to give the "as needed" medicines to address pain, anxiety, and shortness of breath. Some give every 2 hours on schedule and consider it a failure if the patient wakes up. Others give more judiciously but delay administration when they get bogged down in myriad other duties.

I've even seen a couple of nurses completely withhold pain medicine because they were concerned about an actively dying patient's low blood pressure. He spent several hours in distress and was relatively uncomfortable during most of the week before his death. Surely hospice-based care or even just an overall palliative care strategy to address goals of care would have been a more effective option than spending his last days in an intensive care unit not set up to provide true comfort care. I feel I failed him despite my efforts to provide ready access to comfort measures.

I'll post more about my ICU adventures when I can -- it's definitely the most interesting, educational, and thought-provoking time in my medical education and training so far.

The business of medicine is the least fun part

2010-08-14T21:35:00.004-04:00

The following comment caught my eye on Dr. Robert Centor's blog, DB's Medical Rants. I pruned for space considerations, but you can read Dr. Centor's thought-provoking full post "Is it Time to Reinvent Medicine?" and its spirited comment section here.

Hospitalists are similar to primary care doctors. The hospitals want hospitalists to see 25-30 patients/day to efficiently provide services and get the patients in and out...Salary and insurance is about the only overhead for hospitalists.

Outpatient primary care doctors have rent, insurance, salary, employees etc for the same $48-70 per encounter. Add on mountains of paperwork, prior auths, pharmacy refills, diabetic supplies, power chairs, PT/HH/specialty referrals, etc. I can't simply write for a CT/MRI without a 20 min prior auth or a refill on an ADHD med that is brand name and not covered by a patient who has tried 3 generics and has been on the same med for two years but the prior auth has to be done every 6-10 months. Try doing this between the 30 patients on the schedule and have 4 labs, 4 xray centers, HH, PT, specialist, and other places fax you 100-200 pages a day of orders and notes to review

...Most primary care docs do enjoy seeing patients, but the financial realities of overhead/salary/lifestyle etc. do weigh in over time...The current payment system encourages procedures for financial reasons and liability prevention.
--Solo Dr

I'm a mere medical intern going into a faraway specialty, but Solo Doc's comment still resonated with me in the sense that he echoed some of the reasons I eliminated primary care from my list of career choices. His comment makes me consider that outpatient medicine may be a losing battle for docs regardless of specialty. Why would any rational person voluntarily take on the degree of responsibility he describes?

Maybe it's the long hours of internship taking their toll (duty hour limits? Ha!), but I am increasingly dismayed that I have spent the last 4+ years of my life preparing to participate in this country's medical system. It's a real mess in too many ways and already I feel punished for spending extra time with the patient, even though it's by far the part of my job I enjoy most and is one of my primary reasons for choosing my career path.

I'm aware that as a hospital employee I'm protected from some of the ridiculousness of our system. I've adapted to the rigors of internship enough that I no longer want to quit my job on a daily basis, but my rational side wonders if finding a new career would be a smarter choice than spending another 3 years and 10 months on training to enter the often senseless and demoralizing U.S. healthcare system. That said, I feel it's a true privilege to care for people and can't think of anything else I'd rather do. Ideas welcome.

Maybe it's my fault you don't know what you want

2010-08-08T09:03:00.016-04:00

One of my first ICU patients went to the OR for her final surgery. The next day, I returned to her room to find an empty bed, crisply made with thin white bedclothes that emphasized the bed's right angles and hard edges. The bed looked so small without my patient's bulk, grossly swollen from head to toe. The room seemed bare without the many monitors and machines connected to tubes and sheaths inserted into her every major orifice, vein, and artery.

My patient was a middle-aged woman with multiple co-morbidities (i.e., several chronic diseases) who had suffered a major heart attack with nearly complete multi-organ system failure. We managed to keep her alive for 21 arduous days through multiple cardiothoracic surgeries and a rarely but increasingly used means of life and organ-system support. She was heavily sedated during this time, although continued to grimace when her endotracheal (airway) tube secretions were suctioned.

Her fate was a foregone conclusion before I met her, yet our team worked hard to keep her alive. I gently questioned those around me to gain insight into why this woman had been singled out for this particular rare and costly intervention, as well as whether my impressions of her poor prognosis were overly pessimistic. I learned that my impressions were realistic, but no one explained why this woman had met her machine-driven fate when most in her position simply die, with sudden, brief illness and stories left largely untold.

The day she left for her last surgery, my prodding revealed a new answer as to why she had found her way to this rare path. "Because her family wants it, and they have a right to have the care they want because they can afford it." If her family had truly understood the patient's grim prognosis, would they have asked for this care? Would they have chosen this path if they had realized how many invasive procedures and interventions their wife/mother/sister would bear over the next few weeks with severely limited chances for a reasonable recovery?

I'm dismayed that her family, like others with loved ones in hospitals across the nation, lacked understanding of the health care services they thought they wanted. Families tend to hope against all odds that their loved one will prevail in the face of long odds for recovery. Given this assumption, I think it's the job of health care providers to set reasonable therapy goals and to be honest with patients and families about what medicine & surgery can and cannot do. Overall, we do a poor job in this regard, both in critical care and more run-of-the-mill cases of disease. Barring a multitude of miracles, my patient never had much (any?) chance of survival. I can't estimate what she felt or perceived during those three weeks that machines kept her alive, yet it still seems less humane than the lower-tech alternative course.

I do admit that exploring new frontiers in medicine, however likely to fail, can lead to major discoveries that bring effective new therapies to the masses. At the same time, it seems shameful that we poured so many resources into one patient with virtually no chance of survival when we deny cost-effective care to poor children who have a virtually 100% chance of living for many more years. This dichotomy should unsettle us all, yet most who find themselves or a loved one hospitalized with the sequelae of decades of chronic disease usually agree to expensive heroic measures that aren't likely to work.

Surely there will be revolt if/when ObamaCare deprives us of what currently amounts to a right to extensive health care regardless of its expected efficacy. I think this revolt will be warranted since, as history suggests, the rule-makers likely will not have the clinical expertise to make sensible rules. Right now, however, it seems that a few limits wouldn't be such a bad thing. Wouldn't it be nice if health care providers could work with patients to set reasonable limits on our own?

37 days down, 328 to go

2010-07-30T20:52:00.009-04:00

Well folks, I made it through my first rotation on the floors and have completed 10% of my internship as of today! I got a little better each day and even shared many laughs with my wonderful nurses, resident, & medical students, but there nearly always seemed to be more work than I could finish in a timely manner. There is always more to do, and I did my best to not sign out anything to the night team if it should have been done during the day. The night team is plenty overwhelmed by covering half of the patients in the hospital while doing admissions in the Emergency Department.

I remember that one of the internship programs I considered emphasized that interns should be capped at covering no more than 8 patients each day for the sake of learning. The official ACGME cap is 10, which in hindsight feels like too many. That reminds me -- I'll publish a post with advice from the trenches for 4th year medical students choosing internship & residency programs.

The intern's role is mostly one of data gathering, communicating, and coordinating care dictated by the attending & consulting physicians. In theory, an intern should learn a lot about medicine through this process. In reality, covering 10 patients at a time (up to 14 on weekends!) makes it tough to spend much time learning. During my first month on the floors I rarely attended a full noon conference. Often, my resident and I would go just to sign our names to meet the ACGME attendance requirements yet still get our work done.

On my last day, a Sunday, I apologized for not being ready (i.e., finished seeing all the patients, writing notes & putting in orders) to round sooner with my attending physician. He said I should just keep doing what I'm doing and that his colleagues have told him what a good job I do. "Sure, some interns are faster, but they miss things, and then you know you can't trust them. Just keep doing what you're doing," he urged.

I don't mind coordinating care for patients and enjoy communicating with other team members, but I do mind the incessant pressure to go faster and get more done in less time. I'm a pretty deliberate & thorough person in general, but I found myself feeling rushed and late just about all the time once I started internship. As I know well, hurrying doesn't pay. I'm convinced it's the reason I totaled my beloved 16-year old car on the way to the hospital during my first week of internship (thankfully avoided other cars and have an awesome D.O.).

When I tried to cut corners last weekend in order to finish my team's work in time for my pending call, I missed a few things. The attending took it in stride and caught what I missed, but trading thoroughness for speed didn't sit well with me. Especially as a new intern, it takes time to ensure I really know a patient and her medical history well enough to provide adequate care. At some point, missing a piece of information will make an important difference. I'm responsible for what I miss, as one of my co-interns recently learned the hard way.

There are also times I am essentially expected to be in two or more places at once for important matters. And the nurse or resident in the place where I am not will duly note my absence in the computerized record. It is possible for an intern to get in trouble for this, which I have managed to avoid so far. There have certainly been times I didn't feel equipped with sufficient time and/or experience to safely handle urgent situations when I covered my team alone (with one upper year available to all interns by page) on weekends. They tell us we're never alone, but sometimes it feels as though we are. It can be overwhelming, which I mind a lot.

The good news is I made it through the first 32 days with just 3 days off and I'm still going strong. Well, I'm going, anyway. The morning veggie-fruit smoothies have surely played a pivotal role. I'm already gaining back some of the weight I lost power-walking the floors. It also helps tremendously that I find the vast majority of hospital staff to be friendly, patient, and helpful. I really do feel like an important & valued team member. This month I'm in the ICU, which in many ways is worlds better than the floors. In other ways it's less palatable, but I get to eat at least once a shift, which puts me in the lap of luxury for the next few weeks.

18 days down, 347 to go

2010-07-11T09:58:00.008-04:00

Me (with 60% voice loss & a frequent deep, hacking cough): I've been sick for the past three days and today have reached the point where I am too sick to work. My lungs burn from this cough, I can hardly swallow, and I feel pretty dizzy.

Chief Resident: Do you have a fever?

Me: Um, I don't know. I did sweat through my sheets last night.

CR: Well, to be honest, it will be difficult to get someone to come in your place, especially for the 30-hour shift you have today.

Me: I understand that. My resident called out sick yesterday with the same symptoms. I felt sick for the past few days and probably should have called out sick earlier to recover for today's shift, but we got that e-mail from one of the program directors chastising us for so many residents calling out sick.

CR: Do you think you could at least try to see your patients & write the progress notes and then see how you feel by the afternoon?

Me (still speaking with great difficulty): I don't think I can. I'm feeling dizzy & disoriented on top of my respiratory symptoms.

CR: Ok, well it would be good if you could try, but I don't want to pressure you because I wouldn't want you to have an accident from being dizzy.

Me: Well...I guess I could try.

CR: Ok, well as long as you know I'm not pressuring you!

Me: Ok...

I ended up working 32 hours straight. Patients didn't seem to notice I was ill -- they'd just continue to tell their story during my violent cough & sneeze attacks even when they literally drew tears. Technically I should have left at the 30-hour mark but was so mentally slow from being up all night that I couldn't finish my work in a timely manner. The drive home in moderate traffic was one of the five most terrifying drives of my life because my depth perception seemed shot.

Despite long hours & little time to eat, on most days my interactions with my patients make me feel a degree of fondness for my job. My satisfaction wears thin when I don't get enough sleep. This weekend I had my first two precious days off and am on my way to feeling close to human again. I have no idea how other interns manage to stay up all night but I'm keen to figure it out soon so that I can have a better experience next time. I'm still feeling pretty traumatized by my last shift and can only hope that it won't be quite so bad next time without the added burden of illness.

Internship update: Day 2

2010-06-25T22:00:00.005-04:00

It's past time for bed, but I just wanted to briefly share that Day 2 was better than my first day on the floors. I knew that adjusting to such long hours would be hard, but I didn't realize just how long they would be. By the end of my first day I questioned whether I could adhere to this ascetic wake-eat-commute-work-commute&eat-shower-sleep lifestyle. I considered it a mixed blessing that I didn't comprehend even the most basic challenges internship would bring.

If I had known more about this in advance I'm not sure I would have chosen to pursue medicine. This may sound hyperbolic, but many former interns have told me they wanted to quit every day during their first couple of months of internship. Then several current interns & residents assured me that I will adjust and the year will fly by. I take comfort in these bits of advice and try to recall that adjusting to medical school and the freezing East Coast winters must have been hard for me at one time.

Fortunately, I have a great resident to show me the ropes and expect to continually improve with time, practice, & guidance. Everyone I have encountered has been very welcoming and willing to answer my many questions or help me to find my way. I also enjoy seeing patients, although I feel so pressed for time each day. I'm torn between trying to be more efficient and my detail-oriented nature/fear of missing something important.

I want to add that I don't think I could do this without Mike's support. He has been amazing about getting up each morning with me to fix a hearty breakfast and send me off with plenty of food for the day. I'm pretty sure that today's VitaMix veggie smoothies at breakfast and lunch were pivotal in keeping my energy steady throughout the day.

Of course I'm not out of the woods yet, but I'll keep putting one foot in front of the other and hope to make it through this thing with my body & soul intact, along with a solid set of new skills I can use during residency and in my future practice.

Let the games begin

2010-06-23T17:59:00.002-04:00

Well folks, my program's seemingly endless orientation has come to an end. I start on the hospital floors tomorrow. I'll work for the next 15 days straight then take overnight call on the 15th day. Then I'll get a blissful 2-day weekend to recover before a 20 day run with one day off somewhere in the mix. So let's see, that's 3 days off over 45 days of floors and ICU rotations. So much for spending my free time kayaking. At least I get to wear scrubs on the ICU (yay, no ironing!).

It's probably safe to say that my rigorous schedule and semi-brutal commute mean I won't be posting much here for a little while. I have a feeling it's going to be a rough few weeks, so if I do post I'll try to cover something other than how tired I am or how much I crave a day off to sleep in & relax. On a positive note, I should have my sea legs in the hospital by the end of these next couple of months. And I'm headed to the Outer Banks of North Carolina with family at the end of August so there is a light at the end of the tunnel!

Sleep more, get smarter

2010-06-16T19:05:00.008-04:00

I slept an average of 10 hours each night during much of my first two years of medical school. I like my sleep. I wonder if this may partly explain how I was able to do so well academically during what could easily have been an overwhelming time.

I also slept a ton as a kid and think it's shameful that overfull academic & extracurricular schedules as well as technological innovations lead many teens to chronically subsist on just 5-7 hours of sleep.

During sleep, our brains process & consolidate new (short-term) memories for long-term storage. Sleep also allows our brains to make room for new knowledge. Researchers have noted this effect from naps, but deeper "slow-wave" sleep (aka sleep stages 3 & 4; not typically seen during naps) is also strongly associated with boosting memory power.

People who get less deep sleep are more likely to experience impaired memory. So I guess all those folks who claim we can sleep when we're dead are either delusional or -- less likely -- genetically gifted.

Beyond the learning & memory benefits, I think that being well-slept helped me to have a lot more fun learning during those first two years, which are typically considered the most stressful time in medical school.

Now I just need to commit to maximizing my sleep load during internship!

Kayak mini-adventure

2010-06-13T19:24:00.013-04:00

Lake Arenal with view of Volcan Arenal, Nuevo Arenal, Costa Rica. May 28, 2010.

In the spirit of fun activities that require little or no preparation, I'd like to recommend L.L. Bean's Outdoor Discovery School. We spent the morning kayaking for just $10 each (usual price is $20) in a local lake through Bean's Walk-On Adventures program. They transported us to the site and provided all equipment, including water shoes, plus plenty of basic instruction tailored to our individual skill level. The whole experience took 2.5 hours. I'd love to take advantage of one of their weekend adventures in Maine.

I've been thinking about getting my own kayak since kayaking in Costa Rica's scenic Lake Arenal but am still on the fence since at the moment I don't have a kayaking partner. I am also not sure how I would get a kayak loaded onto my car without help. For now, it probably makes sense to rent them on-site with the hope that I can figure out a way to get more involved over time. I hear there are plenty of places to paddle around here.

Speaking of adventures, orientation for my internship starts tomorrow. I'm doing a year of medicine before I move on to my residency field. Wish me luck!

Lake Arenal, Nuevo Arenal, Costa Rica, May 28, 2010

Milestone

2010-06-06T15:33:00.021-04:00

Wawona Tunnel, Yosemite National Park, May 2010

Well folks, I earned my D.O. degree (yay!), got my temporary state trainee license, and am excited although not quite ready to start my medicine internship later this month. I loved my time as a medical student and am grateful that the commonly referenced image of medical school as tunnel with a light at the end never really resonated with me. In the spirit of optimism, I expect to find internship and residency even more rewarding.

My school organized what some have deemed the most enjoyable graduation ceremony and reception they have ever attended. I had a ton of fun, learned that my mom is an awesome dancer(!), and am grateful to every one of my family members for coming to support me on a night that was so much more important than I imagined it would be. They helped me to recognize that my graduation is a key milestone in my educational journey even though I'll spend at least four more years in training.

I've been away from home for all but a few days during the past two months and am enjoying reacquainting myself with my wonderful little yellow-walled apartment. I'm ready to brush the old leaves from my neglected backyard trampoline so I can put it to good use. I'm also eager to start working my way through 60 Hikes Within 60 Miles of the hospital where I'll spend my internship.

I just returned from nine truly magical days in Costa Rica and will share more about our trip soon! Until then, check out any of 42 Medical Blogs Written Entirely by Medical Students, including mine, over at Medical Insurance Blog. I recognize some of the featured blogs and look forward to finding new favorites.

Score!

2010-04-23T11:51:00.004-04:00

Yesterday a doctor asked me to recite my differential diagnosis for a patient who complained of bilateral leg pain. This particular doctor has achieved a lot in his career and tends to stress his own accomplishments ad nauseam while minimizing those of others. His vocabulary also seems to lack the words "please" and "thank you," so my day with him felt long.

After sharing my short list of potential diagnoses, I got a little more history from the patient. The doctor remained uncharacteristically silent as our conversation led to a detailed discussion of the patient's lifestyle, his other health questions, and some relevant recent research to support my recommendations.

"So you must be nearly done with school," he said. "Yes," I replied. "I have about a week and a half of this rotation left before I graduate." "Ah," he said. "You know a lot more than the other students I've met."

I try to keep my ego grounded, but I'm going take the liberty of calling this one a win.

Aww, shucks!

2010-03-25T23:53:00.005-04:00

I'm just back from my school's class party. It was our next-to-last hurrah and I missed most of the official trips down memory lane but had a wonderful time reminiscing with classmates and catching up with others I haven't seen in a long while. I'm fighting a cold, but I'm really glad I went.

I got a class award! My class voted me Most Likely to Have Just Read an Article About That.

And that, my friends, pretty much describes me to a T. In fact, earlier today my classmate and I briefly discussed a family member recently diagnosed with diffuse large B-cell non-Hodgkins lymphoma. I serendipitously ran across an article about some recent preliminary results that suggest survival is higher in DLBCL patients with adequate vitamin D levels. (Just to clarify for the curious, the results don't guarantee that replacing vitamin D with supplements would yield the same results, but research is probably underway to find out!)

Did I send the article to my classmate? You bet!

The search is over!

2010-03-20T11:46:00.009-04:00

I'm living & learning it up in Colorado Springs but wanted to take time to share that I matched into both my top choice internship & residency! I feel so blessed & excited to take the next steps on my path.

I'd like to thank everyone who patiently listened to my at times extensive analysis of my interview & match process! Do-they-like-me, do-I-like-them, will-they-take-me, they-like-me-but-do-they-like-me-enough blah blah blah. Man, am I glad all that is over! After matching into a fantastic residency program, I had to admit that at times I can be a little hard on myself. Maybe I can work on that.

I partly regret pouring so much energy and money into pursuing one field only to end up in the field that first attracted me. In hindsight, I should have taken it as a bright red flag when I found one thing or another "wrong" with every program I visited.

I basically took a detour to end up right where I started. In comparison, being accepted to my field was no work at all. It was just so clearly right for me. I'm grateful that one of my deans had the courage to redirect me to the field he thought I would love and find most satisfying.

Part of me wishes I could have made my decision sooner, though I suppose I needed to find out for myself. I'm deeply relieved that I made the right decision in time to match to a program that is simply awesome! I know I have plenty of hard work ahead, but I'm confident I'll get what I put into my training over the next 4 years. I can hardly wait!

Today's news

2010-03-15T22:00:00.007-04:00

1) Yay, I matched! I have to wait a few more days until Match Day to find out where I'll go, but the pressure is OFF!

2) My mailman brought me a set of sweet glass straws from GlassDharma. They're a sturdy, plastic-free, environmentally-friendly way to enjoy coffee & tea without staining your teeth!

3) The folks at Glass Dharma also directed me to Sesen, maker of my next water bottle. Now I can finally live out my long-held dream of having a (non-used Pellegrino) glass water bottle!

Plea for Short-Term San Diego Housing

2010-03-14T15:44:00.003-04:00

I'm looking for a place to stay during a rotation in San Diego from April 3-30 (next month!). I know it's late notice, so I'd appreciate any leads any of you might share! Thanks in advance for e-mailing any hot housing tips to coldgirlfeverblog at gmail.com.

I’ll take a little more weekend, please

2010-03-14T14:52:00.002-04:00

Every 4th year medical student is eager to find out whether s/he matched tomorrow, and even more eager to find out later this week where s/he’ll be for the next few years.

I’m just as eager to know my fate as the next med student, but I’d happily take a few more hours of suspense as trade for a few more weekend hours!

Monday will come, people. Thursday will, too. As will our first day of internship, first day of residency, and every other imaginable major milestone. Time marches forward without our permission and the days we await inevitably grace us with their presence at the right time. Too soon, sometimes.

We suffered enough anxiety (7+ months worth!) during application and interview season, and for most of us, our fate is sealed. I hope we can all relax and enjoy the rest of this lovely, rainy weekend.

Procrastination deferred

2010-03-14T12:38:00.007-04:00

Okay, so the title is a little ambitious given my reality. I'm searching for motivation to finish, er, start some busywork for school. Instead, I find myself wanting to make another recipe from 101 Cookbooks, post about a couple of awesome dishes I recently made, & wade through my massive digital music collection to delete any duds.

But I'm headed to gorgeous Colorado Springs for my favorite conference early Wednesday morning and know I'll be happy to finish my work early. Besides, I need to get the apartment in sleepover shape for one of my favorite classmates and also want to treat her to some osteopathic manipulation tonight. At least interview season dramatically improved my ability to pack for a trip!

So in service of my work goals, I just downed a cup of oolong tea and a slice of church bake sale pumpkin bread. Coffee is made. Go!

Trader Joe's scores again

2010-03-12T14:40:00.003-05:00

Me: Mmmm, these blueberry pancakes are SO delicious!

Mr. MG: Well that's good, because I sort of cut corners this morning.

Me: How?

Mr. MG: Well I didn't add the egg.

Me: I see, so just soymilk?

Mr. MG: Not exactly.

Me: Well what makes them so good?

Mr. MG: I don't know, I just added water and the TJ's frozen wild blueberries to some TJ's multigrain pancake mix. I cooked them a little longer than usual.

Me: Works for me!

Staying on the path

2010-02-24T23:50:00.014-05:00

Yesterday, I submitted and certified my National Residency Match Program (NRMP) rank order list (ROL) of programs I'd be willing to call my own. Nearly a whole day early. And I even followed the NRMP's advice to avoid any impulse changes within 6 hours of the ROL deadline.

Now all there is to do is wait, hope I don't have to move past #5 on my list of programs, and enjoy life until Match Day.

I won't lie to you. Residency application and then interview season was the most stressful part of my medical school experience. I have my first few silver strands of hair to show for it. I applied to too many programs, accepted too many interviews, and traveled too far & too often with too little sleep. I held high hopes for some programs only to be sorely disappointed on interview day. I changed my specialty choice mid-way through the process, and had to interview for separate internships to boot. And since I didn't have any firm location requirements, my applications spanned a broad geographical area. If it isn't clear, I made the process about as complicated as it could possibly be.

More important, my efforts led me to honestly assess my life and accomplishments from the past few years. The process also forced me to consider what I really want out of my training, career, and life outside of medicine -- and what I need to do to get it. I'm more aware than ever that I have just one life and that choices I make today will determine my long-term satisfaction.

I'm the sort of person who prefers to leave doors open until the last possible moment. My high degree of openness to new opportunities has led me down so many interesting & enjoyable, though not always unified, paths in life. More than one of my interviewers complimented the breadth of my life experience, but I realize the inherent focus of residency training necessitates closing many doors. Given my open nature, this has been a long-standing concern about my career in medicine -- after choosing a field, the barriers to switching fields later are high.

Still, focusing my efforts is worthwhile if it enables me to gain expertise to help patients improve their lives. Besides, being an expert in one field doesn't preclude considering the whole person. Fortunately, I'm confident I'll be able to pursue my own uniquely satisfying practice path provided I keep an open mind. Here's to enjoying the rest of my 4th year before I start what promises to be a demanding internship!

Rule #1: Wear underwear.

2010-02-23T18:07:00.008-05:00

If you are scheduled to receive osteopathic manipulative treatment today, we will need to assess your low back and sacrum. We may ask you to don a long cloth gown. Accordingly, please observe the following guidelines:

1.) Wear underwear.

2.) Wear clean underwear.

3.) Avoid see-through, thong, & g-string underwear.

Optional: Wear underwear right side out.

Bonus points: Shave legs prior to visit.

Even normal people would like them

2010-02-10T18:17:00.012-05:00

Today was a wonderfully lazy snow day that gave me a chance to focus on my other great love: preparing & eating flavor-packed, healthy food!

Mr. MG & I use the freshest & highest quality ingredients we can find and more often than not achieve flavor nirvana. He tends to throw ingredients together seemingly haphazardly while my efforts are usually more orderly & research-based. Guess which one of us leaves vegetable matter on every kitchen surface? In any case I can't deny that he is a tasty food-making machine! We eat so well that most restaurants leave me dreaming of the food we make at home.

Versions of nutritionist George Mateljan's World's Healthiest Foods recipes for 15-Minute Black Bean Salad and 15-Minute Dark Chocolate Truffles (made with Trader Joe's organic, raw-processed cocoa!) were the big winners of the day. I modified the black bean salad with stovetop-cooked beans, avocado, lots of lime juice, and added extra garlic, cumin, & cilantro for more flavor. We also enjoyed some tamari-kissed vegetable potstickers with steamed broccoli and a simple but delicious papaya-mango-blueberry parfait.

Mr. MG enthused that we should bring the truffles to the next gathering we attend because "even normal people would like them!" I laughed as he continued, "Well, honey, we're not normal. You have to admit it! I mean that in a good way!"

Can't argue with him there.

Neurology: never a dull moment

2010-02-07T11:53:00.015-05:00

Neurologist: What brought you to the hospital?

Patient: [speaking loudly in stream of consciousness manner] I don't know why I have to be here I feel fine my head feels fine well I do have a little headache and I had a seizure and I have a metal plate in my head [points at head, smiles].

Neurologist: Did you experience any weakness on one side of your body?

Patient: I broke my wrist in two places a while back [motions to slightly misshapen forearm].

Neurologist: Did that heal well?

Patient: (enthusiastically) Sure did! [forcefully punches opposite palm with clenched fist] Put your face right there!

***

Neurologist (after performing neurologic exam): All right buddy, we're going to go look at the results of your tests and imaging studies then we'll see what we can do to get you out of here.

Patient (paranoid & with delusions after acute confusion stemming from a metabolic derangement): Wait, don't I get to give you my test?

Neurologist: What test is that?

Patient: [slowly, without emotion] Come over here. I'm going to close my eyes -- you guys can tape paper over my eyes to be sure. Then I will put my fist within an inch of your face without touching it.

Neurologist: Uh, I think I'm going to pass on that one.

***

Me: I'd like to examine you now if that's okay with you.

Patient: Sure!

Me: Follow my light with just your eyes.

Patient: [follows command, then points at my belly] Ohhh, you're having a BABY!!

Me: Nope, no baby.

Patient: [still firmly pointing] Yes, yes, you are! Right there!! [still pointing]

Me: No, no, I promise I'm not having a baby. But this shirt sort of makes it look that way, so I can understand why you might think that. Okay, now show me your teeth with a big smile!

Patient: Oh, I'm so sorry! I really thought you were having a baby...

(Reality check: Coincidentally, this exchange happened the day after I found out two of my sisters are pregnant. Fortunately, I don't actually look pregnant. Not even close. )

New year's resolution #2

2010-01-02T15:30:00.004-05:00

Have fun!

The new year is now

2010-01-01T11:57:00.010-05:00

It's a gorgeous first day of the decade with shining sun and the lightest dusting of snow outside. 2009 brought its share of inspiration & challenges and culminated in a wild ride of a holiday season. I'm ready for the calm after the storm and trust 2010 will bring many opportunities for grace, growth, & redemption.

I'm normally not one for once yearly resolutions, but now seems as good a time as any to resolve to live fully in and appreciate each moment rather than drown myself in past should-haves and future projections. As 2009 has reminded me, it's the kind of resolution I need to make again and again.

I wish you all a satisfying and productive year ahead.

Live from the interview trail

2009-12-06T00:05:00.006-05:00

So I'm between interviews for the weekend and rather than drive all the way home and back, I am staying at a lovely inn near a Vermont ski resort. I meant to explore the area or hole up inside my room to write overdue thank you notes to programs. Instead, I spent the day watching the snow fall (finally!), warming myself by the fire, chatting with my awesome innkeeper, playing cards with kids, and putting together a 300-piece puzzle with a 6-year old puzzle shark. We finished the puzzle! I also slept late and well to make up for some of the late night pre-interview dinners followed by 7:30 am interviews. It was really nice to spend a night away from home without having to check out before 7 a.m. dressed in my interview best.

I head down to Boston tomorrow evening after what I hope will be a fun visit to Brattleboro, Vermont. The mountain doesn't open 'til Monday so I'll have to save skiing for another time! I can hardly wait to visit the gorgeous upper northeast again soon and will definitely come back for the fall foliage season next year if I can sneak away on a weekend during internship!

Why I'm thankful: Reason #397

2009-11-26T04:53:00.004-05:00

Mr. MG, via phone: Did you get a haircut by your favorite stylist (a.k.a. the only woman who has touched my hair in the past 9 years)?

Me: Yep, she cut off about 6 months worth of length. It's pretty short.

Mr. MG: Wow, that's great! I'm excited about your short hair. Is it about the length in your license photo? That would be great!

Me: Well, it's not quite that short. But it's pretty short.

Mr. MG (sensing potential haircut remorse): Well, do you know the awesome thing about short hair?

Me: What's that? (expecting something along the lines of, "It always grows," or "It's low maintenance.")

Mr. MG: It makes it a lot easier for me to get to your neck to rub it. I'm excited!

And that, my friends, is just one of the many reasons Mr. MG has and fully deserves my heart. He also makes me feel good after even the worst experiences and makes a party-in-my-mouth weekday breakfast that keeps me going strong all morning long. I can hardly wait to get one of his famous neck rubs when I fly home tomorrow.

Happy Thanksgiving to you all!

I never learned this in medical school

2009-10-24T21:51:00.005-04:00

Cardiologist:

"If you want a heart transplant then why are you still smoking?"

Patient (in chronic heart failure with a left ventricular ejection fraction of just 5-10%):

"I can't quit! My doc told me that quitting cold turkey would be worse for my heart than smoking. He said it'll kill me!"

In loving memory

2009-10-17T21:11:00.006-04:00

Mr. MG's grandmother passed away tonight after an unexpected and brief struggle with right-sided colon cancer. She suddenly became ill less than two weeks ago, utterly surprised by the hand she had been dealt. She was a fiery and indefatigable woman who raised four strong daughters and helped to make Mr. MG the fine man he is today. We will miss her and remember her fondly as she reminds us to live fully in each moment.

Hear This: the Fox, the Crow and the Cookie

2009-09-29T20:05:00.006-04:00

The most creative song & video ever? Riveting & so stuck in our heads. Lyrics here.

Well, when you put it that way...

2009-09-04T13:51:00.010-04:00

Physician:

"There's a chance your memory could worsen faster without the medicine."

Vibrant but memory-impaired patient in her 80s who looks 20 years younger:

"I've been taking medicines since I was a little girl and now that I'm younger I don't want to do it anymore!

So I'll forget everything -- who cares? "[To mild-mannered physician, nearly shouting] "Do you care? I don't care. As long as I'm walking and talking I'm fine! You think it matters to remember what I did yesterday? Well guess what, that's not important to living a good life!"

[30 seconds pass]

[Serenely] "I don't believe in taking medicines." [Points to daughter] "Did she tell you?"

Goal of the day: Stay on the bridge

2009-08-15T14:17:00.005-04:00

I just found out that one of my good friends, a new intern, fell asleep and nearly drove off of a bridge. Exploded tires got caught on the curb, saving her life. She was unhurt and crawled back into her car to rest.

When a passing runner checked to see if she was ok, my friend burst into tears. Not from the stress of the accident or the major damage to her car, but because she was that much further from her bed.

I love the idea that I will probably look back on internship as one of the most pristine & sacred times of my life, but profound sleep deprivation is likely to be my least favorite part of the ride. Is it necessary? I don't know. I'm pretty sure that being "alone" in the hospital at night without immediately available superiors will be essential to my growth as a physician. But since I lack a mutant DEC2 gene, a few hours of sleep here and there would leave me better equipped to make sensible management decisions about sick patients.

I wonder if I'll be able to afford post-call cab rides home from the hospital.

Room for growth

2009-08-08T21:57:00.005-04:00

Last week I attended my school's White Coat ceremony, where the school's largest class ever was welcomed into the osteopathic medical family. I had one of the best seats in the house as I watched the huge group file onto the stage to don their short white coats for the first time. They looked young, earnest, and in some cases appropriately nervous.

As I listened to the keynote speaker dispense pearls of useful advice to these new Student Doctors, I mused that my classmates and I sat in their places not long ago. How we've grown & matured in just a few short years! It occurred to me that the future of medicine sat before me in the auditorium chairs.

Then today I participated in an outdoor manual-labor-heavy community service project with a few dozen of the Future-of-Medicine-protégés.

1st year medical student quote of the day:

"[Whining] This is the hardest community service I've ever done. I usually tutor!"

Thinking of his comment and woe-is-me tone makes me smile and reminds me to give the newest generation of medical students room to grow and realize their potential just as my classmates and I have (& will continue to do).

Misplaced: social skills, priorities

2009-08-08T17:09:00.020-04:00

Today I joined a few dozen incoming first year medical students for a community service project in a neighboring inner city. Together, we cleaned an abandoned lot, pulling weeds, hauling the remains of an ancient felled tree, and hanging colorful tiles for a decorative mural on the lot's concrete building.

At lunch, I met one of the new Problem-Based Learning (PBL) students. Seconds after I told her I had loved my PBL experience she asked me without hesitation, "Were you happy with your board scores?" We'd known each other less than a minute.

In a knee-jerk reaction, I nodded yes and smiled uncomfortably. Then I emphasized that her first two years will also prepare her for clinical rotations, which is really the main point of the pre-clinical years. "Yes, yes, of course," she hastily added, but it was clear that her enthusiasm was laser-focused on board scores she'll earn two years from now.

In hindsight, I should have told her that my board scores are none of her business and her board scores shouldn't even be on her radar right now. Great scores directly result from continued efforts to understand medicine & the workings of the human body. I get a ton of joy from learning for its own sake, and then am rewarded again when something I've learned is useful in a clinical (or yes, licensing exam) setting.

The principal goal of pursuing medical education is to learn as much as one can to become a competent -- and I daresay good & humane -- physician. These qualities, not board scores, should be the primary endpoints by which we measure educational success.

I'm disappointed that that this obviously driven, if rather lacking in certain social skills, young woman's priorities are more focused on studying for a distant exam than on gaining what it takes to become a great physician. I hope that her medical education & experience will encourage her and others like her to establish more meaningful priorities.

I like the way you think

2009-08-05T21:57:00.003-04:00

Top patient quotes of the day so far this week:

Monday

"Is this weight loss side effect going to taper off soon? Let's just say I've dropped two pants sizes, and as a black woman, I can't have that."

Tuesday

"I have to face the fact that I'm never going to be 60 years old again!"

Wednesday

"I love my wife 100%."

After more than 60 years of marriage and given the instruction, "Write any sentence you like here on this sheet of paper."

Say it with me: Awwww.

How sleepy is your airline pilot?

2009-05-17T14:02:00.008-04:00

This article in yesterday's NYT exposes what many working pilots must endure: loans from training combined with often pitifully low pay, untenably long work days flanked by long commutes, & desperate sleep deprivation.

Some of their challenges seem strikingly similar to those medical residents face, except that many residents will one day have some degree of control over their schedules. After residency (or at least after several years of practice) physicians may shun positions that will leave them chronically & severely sleep deprived. I understand that in some fields this is either difficult or may result in dramatically less pay, but it seems that even experienced pilots have little choice in the matter.

Caffeine or even prescription drugs like the probably addictive Provigil (seemingly marketed to airline pilots, even if in an off-label way), don't replace the need for sleep. Pilots' bodies will find a way to steal sleep eventually, and judgment quality typically declines well before the body crashes.

I hope the Federal Aviation Administration implements strict rules regarding sleep & time off before flights. These standards should be applied without docking the pilots' salaries, even if it means higher flight costs for consumers like me. Who doesn't want her pilot rested, alert, & content?

Spring break

2009-04-26T13:10:00.007-04:00

Since my last post was more than a month ago, I'd like to make it official:

I'm taking a brief break from blogging to focus my spare energy on the last responsibilities of my 3rd year of medical school and those that 4th year is sure to bring. Spring has brought me so many weekend opportunities to learn & serve others that I've taken little time for much else. I'll be applying to residency programs before I know it and have some extracurricular OMT course work planned for the spaces in between (Great Barrington, MA next weekend, yay!).

In recreational news, a recent birthday has made me the proud new owner of a training kite & kiteboarding instructional video I can't wait to use. Even if my feet don't quite grace a kiteboard this year I'm excited to spend some quality time on my favorite fishmonger's labor-of-love sailboat. In my quest for balance & good eats, I've also developed a taste for cooking with & for my sweetie. I'm on an Indian food kick but would appreciate hearing about your favorite flavorful vegetarian-friendly recipes!

Thanks for reading my blog & sharing your stories with me in the process. I still use my blog links list to keep up with other blogs I like and will post again once I start 4th year rotations. Then I'll be better equipped to share some of the stories I've witnessed without violating the date identifier component of HIPAA.

Wishing you all a happy & healthy Spring,

MG

Heard of hospice?

2009-03-22T13:19:00.006-04:00

Healthy Librarian at Happy Healthy Long Life has posted a beautiful story of her mother-in-law's end-of-life experience with hospice. It's well worth a read & an excellent way to spread the word about how hospice can improve end of life care & quality of life.

For those not familiar with hospice, it provides team-based palliative care to terminally ill patients. It also offers support for their loved ones. Hospice services are available to those who have less than 6 months to live, although average enrollment time in hospice before death is a mere three weeks (with 10% enrolling in the last 24 hours of life)(1).

Hospice neither hastens death nor prolongs life -- the aim is to manage symptoms & reduce pain to make the most of one's remaining days. It often helps patients to address unresolved issues or "loose ends" in a way that might not be possible in the context of extreme pain or aggressive & invasive medical measures taken to prolong life.

In addition to state of the art pain management & home (or inpatient) nursing care, hospice services are geared to help patients & their caregivers deal with any end-of-life issue that may arise. Examples include help with financial & estate planning, religious/spiritual counseling, help with end-of-life review, art/music/massage therapy, caregiver respite, & bereavement services for those left behind.

I became a hospice volunteer in college after a former co-worker, T., died way too young from pancreatic cancer. She was diagnosed at 39. When I kneaded her back muscles a little as we hugged goodbye one day she said, "Hey, that massage feels good!" We joked in all seriousness that she should take full advantage of any hospice-provided massage therapy. When my mother & I visited a short time later, T. was close to death. Her body was so wasted that she was nearly unrecognizable. I'd never seen anyone near death before. Yet the hospice nurse's angelic demeanor & gentle care of my friend helped me to overcome my initial shock.

Years later, I clearly recall getting more from volunteering with hospice than I gave. Being present for a person's last days can be an amazing gift. I just started volunteering again last Wednesday on an inpatient hospice unit to provide gentle osteopathic manipulation. The response from patients & their families was overwhelmingly positive. I'm glad to have returned to hospice even if I don't get to spend as much time with each patient as I once did.

Find out more about hospice at the Hospice Foundation of America. Locate a hospice here.

1. Casarett DJ, Quill TE. "I'm Not Ready for Hospice": Strategies for Timely and Effective Hospice Discussions. Ann Intern Med, March 20, 2007; 146(6): 443-449. [PMID: 17371889]

Now this is more like it

2009-03-02T15:57:00.003-05:00

Blood work is all clear.

I'm enjoying a beautiful snow day & even bundled up for a walk to the bank this morning. I wore snow pants & multiple layers from head to toe; my sweetheart eschewed gloves while his hands stayed warm even as it snowed! At least one of us is tough enough to withstand cold. Spent the rest of the morning with patients doing osteopathic manipulation (finally!). Heading into the city tonight with friends for satsang.

It's a wonderful day, indeed.

Nothing to worry about

2009-02-28T17:59:00.007-05:00

Still waiting for my Hepatitis C PCR needle stick bloodwork to come back. HIV antibody was negative, but as most of you know by now, the HCV is my primary concern since the source patient was HCV-positive.

I'm sure there are plenty of reasons it would take more than a week to get the bloodwork back. I recall waiting at least 8 days for results in mid-December. But since my first HCV PCR test took 3 days to come back (and my employee health contact has told me it typically takes about 5 days), my mind turns to possible problems. There's only so much delay caused by lab back-ups & faulty PCR runs before I start wondering about the lab having to re-test my blood to double check a positive result. Then again, it's a weekend and for all I know my negative HCV PCR results are back just waiting to be delivered to me on Monday (Day 9).

I'm not too nervous, since negative results at 2-, 4-, & 6-weeks indicate I'm probably in the clear. But I admit I'm looking forward to a phone call from my friendly employee health contact soon. I hope Monday isn't her day off.

Peter Bjorn & John - "Nothing to Worry About" (mp3)

My 1st needle stick update #2 & What to do if you get stuck

2009-02-22T22:03:00.013-05:00

Allergy Notes & Peter Gayed tweeted my post, "My first needle stick," making it one of the most read posts on my blog. You can read my first update here.

I just got my 3 month needle stick blood work (HCV PCR, HIV Ab) drawn on Friday. Everything was clear at the 6-week mark & I hope it stays that way!

For any concerned soon-to-be 3rd year medical students (a.k.a. the ultimate dilettantes) reading this, you're probably at greatest risk of sticking yourself during surgery or if a patient moves during a blood draw or IV start. Treat all blood as though it is infected -- with so-called universal precautions -- and know the needle stick protocol at all of your hospitals.

If you get stuck, immediately bleed the wound then wash with chlorhexidine. If it happens during surgery, do break scrub even if you're embarrassed to admit you stuck yourself. Most needle stick protocols involve an immediate visit to the ED regardless of what important tasks an ED visit will prevent you from completing. Do go to the ED even if your attending tells you you're most likely fine.

The bottom line is you want to get post-exposure labs drawn while the patient is still around. If the patient is discharged your chance of learning his infectious disease status is slim to none. Better to find out whether you've been exposed now than find out years later you're Hepatitis C positive and, "Gosh, it must have been that needle stick I never followed up on."

A 3rd year classmate, Carl, pulled me aside at the library during 2nd year to share the same advice in great detail. He also suggested glasses & long sleeves for extra protection from bodily fluids. I remember thinking that as a medical student my risk of getting stuck would probably be so low as to be negligible.

After my stick, several physicians shared tales of their own needle sticks during medical school & residency. One gave a sobering account of getting stuck during 3rd year with a large bore hollow needle during a paracentesis (needle drainage of accumulated abdominal fluid) on a Hep C positive patient. How's that for nerve-wracking? So while med student needle sticks may be rare, they do happen.

In retrospect, I should have followed Carl's expert advice to the letter. I regret* not doing so, even if I never seroconvert. I didn't anticipate "peer" pressure from & lack of knowledge of how to proceed on the part of my residents. I also never imagined an attending could stick me without a word of acknowledgment or instruction.

I hope none of you have to apply the above advice, but if you do get stuck, I hope you won't make the same mistakes I did.

*On the note of regrets & new beginnings, now is a good time to replace the needle stick hotline card that broke off from my ID card clip during 2nd year.

More adventures in geriatrics

2009-02-16T19:47:00.007-05:00

I'm midway through my Geriatrics rotation and just started at the nicest long term care facility in which I've ever set foot. Even the dementia unit was hopping with positive energy, bright light, a sing-a-long, seasonal decorations, & a hefty dose of good cheer. It was a far cry from my hospice volunteer days of visiting patients with Alzheimer's disease on far darker units with halls haunted by loud wails of misery & despair.

The facility is in an affluent town with massive well-kept homes & a quaint Main Street peppered with unique shops & police officers who will pounce on a parking violation in less than 5 minutes. Today after a much needed postprandial coffee run I learned that a law in my state prohibits parking within 25 feet of a crosswalk. Back in California I knew well enough to not park in front of fire hydrants, in a crosswalk, or in the red zones that color the ends of city blocks. Other than that, I relied on NO PARKING (ever; specified time range) signs to guide my parking. Leaving a sign-less, non-red, unmetered car-sized space empty was parking suicide that would lead only to driving-around-the-block purgatory on the streets of San Francisco. Not so in my new home state.

Fortunately I saw the police SUV as the officer sat inside writing a ticket for yours truly. I asked if he was writing a ticket for me. When he asked who I am I explained that I'm a medical student rotating at a nursing home down the street. I wondered if I had parked illegally but hadn't seen any signs. He explained the law to me and I admitted my ignorance. He could have continued to write the ticket (I know ignorance doesn't excuse a violation!), but instead he closed his ticket book & told me that Main St. has strictly metered parking and that I should spend my money elsewhere. I thanked him & promised I would park legally from now on.

It may be the only special treatment (if it was indeed special) that my med student status has ever garnered. Or maybe my elderly car suggested that I need to save my money. In any case, I just dropped $1095 on the COMLEX PE (performance evaluation) so I'm glad I didn't have to add a parking ticket to my recent spending history.

But let me get back to the Shangri-La of nursing homes, where I had an eventful first day. First patient of the day had new onset cardiac chest pain & a nearly new bare metal coronary artery stent. We administered some of the recommended medications (chewed aspirin, nitroglycerin for symptomatic relief, a beta-blocker to reduce risk of progression to frank myocardial infarction, & oxygen) and promptly called 911 so the patient could be worked up in a hospital setting.

Second patient of the day had a mental status change after being found face down on his bedroom floor. His family declined the physician's recommendation to send their loved one to the hospital for a head CT & additional workup. They said he loves it here in the nursing home and that it would be cruel to put him in a new environment (demented patients often find comfort in places they know, while new places bring confusion & agitation).

The decision to make him Comfort Care / Do Not Resuscitate / Do Not Intubate / Do Not Hospitalize (CC/DNR/DNI/DNH) was a tearful one. I was overwhelmed by the love his wife of 65 years demonstrated when she refused most additional medical treatment. I had to fight back my own tears in response to her selfless decision & open heartbreak. Later, as the patient returned to his usual laughing & friendly self, it was clear that he does indeed love his new home. How often do you hear that about a nursing home?

I also repeatedly caught sight of an elderly man nursing his beautiful but vacant-appearing wife. Just as the second patient's wife above, this man showed such love for his wife that it was both inspiring & heartbreaking at once. I somehow manage to deal appropriately with patient illness & disappointment even as I attempt to convey my sympathy & empathy, but seeing two loving & devoted spouses in the process of losing their loved ones to dementia really got to me today. At the same time, I hope that if I am ever on either end of a similar situation that my relationship will be marked by the same sort of deep love that I saw today.

When can I eat again?

2009-02-07T20:29:00.008-05:00

So much for recovering from this GI virus. Even after Zofran I still feel terribly nauseated & ineffectual. I did manage to keep down some soda crackers & babyfood-flavored butternut squash soup but for that I now have a club rave in my stomach.

Interestingly, after my IV fluid rehydration on Thursday my pants & ring were too tight: I could barely get the pants zipped & buttoned & couldn't begin to get the ring off. Today it's just the opposite. I can pull on the jeans without unbuttoning them while the ring very nearly falls off on its own.

Time to start drinking, you say? Just tried it and, well, let's just say that the soup & crackers never moved past my stomach. Remember that vomit scene from Poltergeist?

I'm so not digging being chronically worn down by an early-to-rise & late-to-bed-or-fall-behind schedule. I'm ready to be physically resilient again!

Welcome to geriatrics

2009-02-06T18:43:00.011-05:00

These days it seems like the only time I manage to post is when I'm sick. This post is no exception. Since starting my clinical rotations 7 months ago I've been sick more times than in the prior 13 years. I must confess I'd begun to think I'm invincible when it comes to viruses making their rounds.

I never returned to full health after my 2-week CAPU cold from hell and have lately felt exhausted much of the time. So perhaps it should come as no surprise that my body welcomed the GI virus du jour. Yep, 12-15 episodes of violent projectile vomiting in one night. My toilet now looks like it belongs in a frat house. My poor sleepless sweetheart deserves an award for getting up with me each time to offer comfort, fluids, & a helping hand when my weakened muscles could barely raise me from the bathroom floor.

I have some Phenergan lying around the house but some of you may recall how that stuff knocks me out for 12 hours minimum. The otherwise lovely (actually, yes) Geriatrics rotation administration folks have made it perfectly clear that to miss a day of the rotation is akin to selling one's firstborn son (and already I have jury duty this Monday), so I wasn't about to voluntarily knock myself out cold for a day.

Which brings me to how well those in the medical profession take care of themselves. Really, if a health care worker has infectious gastroenteritis then shouldn't s/he be encouraged to stay home rather than infect sick people & other health care workers? But nope, a day absent is points taken off my grade and/or days I must make up during 4th year vacation. I know that in the real world a day absent may mean lost pay, but seriously, if you're my doctor or nurse and have gastroenteritis then please DO stay home. No one wants what you've got goin' on.

Anyway, around violent vomiting episode #8 I made the not-so-rhetorical request to be put out of my misery. By the time the sun had risen fully I knew I needed to get to the ER stat. I had learned from my last ER visit and entered through the back door, where I was lucky to find both an intern & resident who knew me and told me straight up that I looked like s***. Eight sleep-filled hours, anti-emetic drugs, & 3-4 liters of IV fluid later a cab dropped me off at home where I proceeded to sleep for another 16 hours. When I woke this morning I'd 3rd-spaced enough of the extra fluid that I could barely close my newly sausage-fingered hands, but hey, at least I wasn't dehydrated.

This weekend I plan to finish my acceptably late Psych paper & work on a Geriatrics case presentation. Lately I've been so worn down & out that I'm also requiring myself to enjoy this weekend's sunshine-filled days with temps that are supposed to make it into the low 50s! Oh, and let me not forget (how could I?) to clean the food- & bile-covered toilet. Happy weekend to all, and here's hoping my next post is about something other than my recent illness!

Neko Case: Blog for charity!

2009-01-25T15:50:00.014-05:00

My musical interest has waned of late secondary to time constraints & nothing but a tape deck in my oldie-but-goodie car, but I've been eagerly awaiting Neko Case's upcoming record since I saw this video:

Case is an alt-country darling, a member of the prolific & excitement-inducing New Pornographers, ~~& married to NP frontman A.C. Newman~~. She more recently donated her spine chilling vocal talents to the rockin' Crooked Fingers tune, Your Control. Case's record label, ANTI- will make cash donations to Best Friends Animal Society when bloggers link to her new single and iLike users add the song to their profiles ($5 for blog posts & $1 for iLike adds).

Read part of the record label press release below. Check out a prettier & fuller version here at ANTI-'s label blog & please link to the single in your own blog.

Today, we are especially happy to bring you “People Got A Lotta Nerve,” the first single from Neko Case’s forthcoming album Middle Cyclone (out March 3), because for every blog that reposts the song and/or iLike user who adds it to their profile, Neko Case and ANTI- will make a cash donation to Best Friends Animal Society.

The promotion will run from January 13 to February 3, 2009. Five dollars will be donated for every blog post and one dollar for every user of iLike that adds the song to his/her profile.

Celebrating its 25th anniversary in 2009, Best Friends Animal Society is one of America’s foremost animal rescue organizations. Founded in 1984, Best Friends advances nationwide animal welfare initiatives by working with shelter and rescue groups around the country. On any given day Best Friends Animal Sanctuary, the nation’s largest facility for abused, abandoned and special needs companion animals located in southwestern Utah, is home to approximately 2,000 dogs, cats, horses, rabbits, birds, and other animals. The society also publishes Best Friends magazine, the nation’s largest general interest, pet-related magazine with approximately 300,000 subscribers. For more information, visit www.bestfriends.org.

Download "People Got a Lotta Nerve" (free mp3)

Pre-order Middle Cyclone (released March 3, 2009)

NYT: Least desirable e-card ever?

2009-01-23T17:24:00.008-05:00

For those too cowardly to face unpleasant phone or face-to-face conversations, there's now an anonymous e-card to deliver important but ugly news of possible STD infection. I guess e-notification is much better than no notification, but the e-card option sounds like yet another example of some individuals' unwillingness to take responsibility for their mistakes.

"Steve, a health care worker in his 30s, had been told more than once that he had been exposed to a sexually transmitted infection. So when it happened again, he was not upset — even though this time he learned about it through an anonymous online postcard, e-mailed by a man with whom he had had sex."

I'm concerned about health care worker Steve, so accustomed to STD exposure that news of a new exposure to syphilis left him "not upset." Is it so wrong for me to expect health care workers to know & even be better than the average Joe when it comes to STD prevention?

Coldgirlfever catches cold, whines

2009-01-09T01:19:00.015-05:00

In a staggering turn of events, I've caught the CAPU (child & adolescent psychiatry unit) cold & am officially down for the count. I may have a bit of cold-related hubris because ('til now) I haven't had one since 1998. I march bravely into the rooms of cold virus-infected patients & loved ones without the slightest fear of catching any bugs myself. Yes, I did get a terrible flu in early 2005 during an ill-fated Florida bus tour with an ex-boyfriend's band, but overall I have been remarkably free of upper respiratory infection since my teenage years. Besides, with my recent vertigo & antibiotic-induced GI distress I'd concluded that my illness datebook is too fully booked to accommodate a cold or bout of flu.

Fast forward to 2009, when a week & a half in the closed environment, sink-deficient CAPU (tho' sure, there's plenty of that hand sanitizer crap I hate) changed all that. Which brings me to Day 6 of MG's first cold of the decade. I signed up for a weekend OMM course & managed to tough it out yesterday (with its temperature high of a whopping 20 degrees). By the end of the day I was left with an empty tissue box and felt worse than ever.

In my imaginary world, I'm supposed to be completely better by Cold Day 3, not feel more miserable than ever on Cold Day 5. So I decided/was forced to stay in bed all day with my sweetheart's amazing hot lentil vegetable soup (with homemade vegetable broth!). I added regular boluses of chopped garlic, hydrating orange wedges, & Trader Joe's dark chocolate-covered raisins* for good measure. Finally, I resolved to sexy it up by donning my cozy men's plaid flannel nightgown that I got at the now defunct Emporium Capwell in 1991. More proof that quality items endure. I won't include a photo since I like to keep the site content clean, folks!

I spent most of the day alternately sleeping & blowing my nose (riveting, I know!). I felt too sick to read much or make the trek to my living room to watch TV (since I've only ever watched 3 shows, all of them on ABC, the only channel I know despite now having cable, and didn't have the stamina to make it through the Harry Potter movies I Netflixed while visiting my parents). Predictably, my thoughts turned to how awesome it is to be able to spend a wickedly cold day sleeping in bed. After I'd exhausted that satisfying but undeniably brief thought train, my mind turned to Things That Make My Winter Life Good:

In no particular order, they are:

1. Earbags bandless ear warmers - these don't squeeze/hurt my head
2. Helly Hansen women's HH Warm Prowool pant base layer
3. Wakeupland.com (try free for a week) - wake up calls to supplement my alarm clock
4. space heaters on timers - allow me to return to a warm home each night without roasting the guy who lives on the 2nd floor
5. glove liners
6. hot water-only baths
7. 9am rotation start with a <15 min commute
8. hot tea to warm my belly in the frozen a.m. (on my way to the hospital)
9. Trader Joe's frozen organic wild blueberries in hot oatmeal w/soymilk (often on my way to the hospital)
10. scarves
11. orange wedges, apple wedges, carrot stick snacks for the hospital
12. avocado toast with black beans/chickpeas & TJ's Salsa Authentica
13. dried plums (formerly known as prunes)
14. Larabars - Cherry Pie/Apple Pie/Coconut Cream Pie flavors
15. my sweetheart AND his made-with-love-&-creativity soups & salads

The more astute among you may see a couple of themes in my list: 1) Things that make me warm & 2) Things I buy at Trader Joe's. I am but a simple girl with simple needs & simple to please. And I very simply vow to learn to love that hand sanitizer crap & force my way into empty rooms with sinks any time I please.

*Yes, I realize sugar depresses immune system function, but TJ's dark chocolate covered raisins are delicious! Oops, too delicious -- I ate most of a tub today.

Winning combo: autism + slaughterhouse design

2009-01-09T00:29:00.012-05:00

I'm just back from a talk by Temple Grandin to promote her new book, Animals Make Us Human: Creating the Best Life for Animals.

Dr. Grandin is best known as a successful author & livestock handling equipment designer despite her autism. She designs & helps implement more humane animal feedlots & slaughterhouses. Accordingly, her fans hail from many special interest groups -- tonight's audience included vegetarians, animal lovers, psychiatrists, and of course parents with their autistic children in tow.

I'm keen to read more about her in the Oliver Sacks book, An Anthropologist on Mars, or in Sacks' much-praised 1993 New Yorker Magazine article if I can get my hands on it.

In case anyone wonders, she's no vegetarian:

Dr. Grandin is not apologetic about savoring her steak at the Lone Star Restaurant in Fort Collins.

"I believe that we can use animals ethically for food, but we've got to treat them right," she said. "None of these cattle would have existed, if we hadn't bred them. We owe them a decent life -- and a painless death. They're living, feeling things. They're not posts, or machines."

Which is exactly the spirit that endears her to so many animal welfare supporters regardless of their own dietary choices or restrictions.

See Grandin on her national book store tour this month & in early February.

I might as well have been naked

2008-12-12T22:02:00.004-05:00

Today I got locked out of the house wearing nothing but scrubs w/leggings & tank top beneath. A well meaning stranger activated a lock for which there is no key, and there I was, standing outside the front door with nothing but an empty recycle bin. No keys, no phone -- just a vague idea of my landlord's nearby home address.

I've been meaning to start exercising (treadmill finally restored last weekend!) but in the end it was necessity -- not my good intentions or even my slowly upward creeping weight -- that drove me to action. The threat of ~40 degree cold got my ass in gear. I got a few strange looks, but I'm sure I looked completely normal running through the streets in scrubs without a coat. Oddly enough, my landlord drove right by me and said he figured I was taking a walk.

Thankfully, I found my landlord's house before I got too cold to move. His wonderful wife greeted me at the door with a warm coat. I feel a little pathetic admitting that 40 degrees is well below what I require to sustain my life. I wear 4 upper body layers plus scarf & gloves in the Fall around here. Maybe this Winter, my 3rd on the east coast, will be the one when I figure out how to stay warm without holing up inside. It's definitely the one where I figure out how to never again leave my house sans keys & coat.

Routine screening for HIV recommended by American Academy of Physicians

2008-12-01T19:27:00.010-05:00

“Right now it’s estimated 1 million to 1.2 million Americans have H.I.V., but 24 to 27 percent are undiagnosed or unaware of their infection,” Dr. Qaseem said. “We’re recommending clinicians just adopt routine screening in their patients.”

Boy, the world sure has changed if we need to recommend regular HIV screening for everyone over 13 years old, as the NY Times reports today. Remember the days of going steady? All right, neither do I, but I've seen it in movies & I do remember the days when most 20-year olds could count their lifetime sex partners on one hand or less. Now I fantasize about locking my future profoundly socially-impaired daughter in an ivory tower until she's 25 & console myself that I can at least try to teach her how to best protect herself from life-threatening sexually transmitted disease & the herpes virus.

I'm glad to see the recent ACOP HIV-screening recommendation. It's impossible to fully know a patient's risk factors even when they don't actively lie about their behavior. What's more, people often don't realize their behavior is risky. I've encountered too many well-educated folks who have unprotected sex without knowing their partner's HIV status. Or one partner (usually the guy) gets tested to appease the other but doesn't ask for the same in return. "So you're telling me you've never asked any of your past partners to get tested for HIV? Great." Here's the thing: a professional degree & daily showers don't accurately reflect whether there are bad critters crawling in & around your potential partner's genitalia. Many clean-looking/-smelling people are dirty. There, I said it.

For these & other reasons, I always recommend dual HIV testing for couples planning to start a monogamous sexual relationship. Many people shy away from starting that conversation, but believe me, anyone who really wants to have sex with you (especially in a caring relationship) will get tested in a flash. There's nothing hotter than baseline HIV negative status all around.

Newsbits from MG's small & beautiful world

2008-11-26T11:26:00.008-05:00

In surgical news, yesterday I saw an atrioventricular valve redo & mitral valve repair. Open heart surgery almost makes abdominal surgery look like child's play. It was extra cool to see the vegetation on transesophageal echocardiogram & then see it in all its pus-sy* (purulent) glory when the surgeons removed it along with infected valve.

In Some People Never Learn news, Dr. Safety got shot in the eye with blood known to be contaminated with HCV. Within days of my stick. No eye protection, as usual.

In flattering news, one of my extra-funny residents told my classmate he thinks I'm hilarious and loves my fabulous one-liners. I may not be able to perform an appy on my own just yet, but I sure as hell can make surgeons laugh in the OR & during sign-in/out. My job here is done.

In holiday news, I got sent home early today in honor of an empty operating room schedule & the Thanksgiving holiday tomorrow. I'm sad to not see the inside of an OR today, but glad to get some much needed sleep even as workmen are banging away to replace my front door today.

Happy Thanksgiving weekend to all!

*Yes, that's a word. It normally contains no dash and is not pronounced as it is written. People say it, but damn if I'm ever going to write it in a chart or presentation. Purulent is a nice synonym, but sometimes you just want to emphasize the presence of lots & lots of wonderfully disgusting pus.

My first needle stick update

2008-11-22T12:38:00.019-05:00

A few people have asked about the details of my needle stick in hopes of preventing a similar accident for themselves. The stick resulted from a surgeon who failed to follow safety protocol several times on the day I worked with him. A few minutes before I got stuck the scrub nurse reprimanded him ("I could have stuck myself!") for leaving a needle on the sterile field without telling her it was "down."

When I got stuck, my hands were on the sterile field where we are typically instructed to keep our hands to avoid contaminating ourselves when not actively assisting with the surgery. The attending* placed the needle (in a holder) directly into the back of my resting hand. Oops. After removing the needle, he made brief eye contact then went on working. Never said a word about it. When I saw blood pooling under my glove a few minutes later I knew the needle had penetrated my glove & skin.

That said, most needle sticks in the OR are self-inflicted. Surgeons stick themselves relatively often. My classmate stuck herself 2 days after my stick trying to remove a needle from suture. She'd never done it before and her hand slipped. The surgeon (a different one) told her that if he were in her position he would not go to the ED to follow up. Despite an inherently low risk of HIV transmission via solid needle and the patient's lack of risk factors for the big 3 bloodborne diseases, my classmate opted to visit the ED to gain some peace of mind.

I now know that an ED visit is required (at least at this particular hospital) if you want postexposure labs drawn on the patient to determine infectious disease status. It's important that students feel free to break scrub immediately to go to the ED.

Needle stick aside, the aftermath was marked by poor communication and unnecessary confusion about how to proceed. HCV transmission risk (unlike that of HBV) is fairly low, but I'd like to see future needle stick accidents handled more expeditiously. I've certainly learned (as well as been told by several more advanced colleagues) that not everyone will have my best interests at heart and that I may be solely responsible for my own safety & well being.

*Not affiliated with my school. I'm pretty sure any surgeon affiliated with my school would have both followed protocol and apologized for an obviously accidental but still unfortunate needle stick.

My first needle stick

2008-11-19T22:12:00.011-05:00

Got my first needle stick in surgery yesterday. After being assured this morning that patient's postexposure labs were negative (no HIV, hepatitis B or C viruses), I learned that the hepatitis C result later came back positive. That means I may have been exposed to an infectious disease with no postexposure prophylaxis and no cure. I am especially disappointed since the stick was 100% preventable, in no way my own fault, and not handled particularly well by those who should know how to handle needle stick injuries.

Last night I had blood drawn to check my own infectious disease status. In two weeks, my blood will be tested for viral RNA with a nucleic acid amplification (PCR, or polymerase chain reaction) technique. Then I'll submit for further PCR testing at 6 weeks & 3 months. I'll also be tested for antibodies against the virus at 6 months & one year after exposure to be sure everything is clear. If at any point the results indicate HCV infection the plan will change in ways I'm too tired to write about now.

The average risk of needle stick HCV transmission as defined by clinical infection is estimated at 2%, while eMedicine cites a range of 1-10%. My risk is likely on the low end of the range since I was stuck with a non-hollow solid bore needle. Still, the risk exists & hepatitis C tops my admittedly long list of least desirable diseases so I'd appreciate any positive thoughts, vibes, & prayers anyone can send my way!

Beyond NEJM: Stephen Colbert on the JUPITER trial

2008-11-15T18:58:00.005-05:00

Thanks to the WSJ Health Blog for alerting me to the latest web sensation, “Cheating Death with Dr. Stephen T. Colbert, D.F.A.”

In this latest installment, Colbert comments on two recent studies published in the New England Journal of Medicine:
1) Testosterone supplementation's effect on women's libido
2) JUPITER trial (sponsored by AstraZeneca) findings that rosuvastatin (Crestor) reduced the incidence of major cardiovascular events* in individuals with high levels of the inflammatory marker high sensitivity C-reactive protein (CRP) but normal cholesterol levels

Colbert's piece has hit a nerve with cynics everywhere & those who have lost their rose-colored glasses for the pharmaceutical industry &/or healthcare itself. It even inspired Ivan Oransky at Scientific American to suggest Colbert as a candidate for the next U.S. FDA commissioner.

*This post does not represent an endorsement of Crestor by myself or this blog

You are getting very sleepy

2008-11-09T12:54:00.006-05:00

I struggled to keep my chin up at times last week. I admit I was sorry to leave Busy Inner City Hospital (a.k.a. Cool Surgery Central) for a weeklong Anesthesia rotation at a suburban inner city hospital. However, I tried to keep an open mind that I might enjoy Anesthesia, a highly competitive "lifestyle" field (to be fair, after-hours anesthesia call removes the "lifestyle" factor for many).

Over the course of the week (4 days, really, since I have lecture all day Monday) I never once saw two people perform a general anesthesia case the same way. I encountered a lot of "This is how you perform Procedure A" followed by another person imploring me to "Never ever perform Procedure A in that manner." As far as I can tell, safe & effective general anesthesia is more art form than algorithm, so it'll probably take a month-long anesthesia elective at a busier hospital to better understand what it's like to practice anesthesia.

I spent Day 1 of my Anesthesia rotation with a young anesthesiologist helping with nerve blocks & happily reviewing neuroanatomy. I also got to work with an experienced certified registered nurse anesthetist (CRNA) who taught me well & gave detailed instructions so that I might do things right on the first try. He was knowledgeable about recent anesthesia studies, which improved the day's educational value. As I learned some practical pearls about general anesthesia, I got to practice placing endotracheal tubes & laryngeal mask airways, a less invasive alternative to endotracheal tubes used in traditional intubation.

Midway through a general anesthesia case the CRNA asked with anticipation if this would be my first time voting in a Presidential election. I replied that I'm 30 years old, to which he responded, "Well I take it you don't smoke!" & asked a scrub nurse to guess my age. She told me I look 13, which proves that youth-obsessed America should consider wearing ill-fitting scrubs + scrub cap & mask for that fountain-of-youth look. Those who look bad in blue or green are out of luck.

The bulk of Days 2 & 4 of my Anesthesia rotation were spent with a grouchy youngish CNRA who, 5 minutes after meeting me, told a nurse he didn't feel like teaching anymore. He was "sick of giving the same lecture" and noted he isn't compensated for teaching. I was disappointed since I'd been specifically told to seek him out as someone who loves to teach students. What a load of crap that was. As he promised, he barely taught the first day I was with him. When I offered to help with even the easiest & most menial tasks he tersely noted he had it covered.

Of course he had it covered. I was with him to gain some idea of how I might someday "have it covered" myself. It's not that the things I offered to do were difficult, but as a student, it's good for me to see how the many steps taken pre-, during, & post-anesthesia come together. My requests to help in no way implied he was incompetent to strap an arm in place, place EKG leads, or take tape off the patient's face before removing an endotracheal tube.

Day 3 was much more educational than Day 2. I even got to do a couple of entire general anesthesia cases under the watchful eye & guidance of another experienced anesthetist. I left the hospital feeling encouraged.

On Day 4, thanks to the training others had given to me, grouchy CRNA from Day 2 let me help set the patient up in the operating room & allowed me to place a couple of airways, probably since others had let me do so many procedures earlier in the week. He also taught a bit & entertained my questions, but mostly he seemed to enjoy making me uncomfortable. I tried to grin & bear it but after a while I just wanted to make it to the end of the day with a passing evaluation from a guy who would no doubt be happier after my departure. I tried to stay relaxed but I walked on eggshells much of the time and was annoyed with myself for reacting to behavior I couldn't control. I wondered if the way he treated me reflected the way other doctors treated him during his training. Maybe he thought that his harsh training is what helped to get him to his highly experienced & knowledgeable level. At the very end of the Day 4 he surprisingly grew more pleasant and even gave me a decent evaluation.

All in all, my anesthesia mini-rotation was a pretty light week. Still, I felt more tired at the end of each day than I did during my exciting first week of surgery. The experience made me even more aware that my opinion of a given specialty is heavily influenced by the teachers I encounter. I'm fortunate to have teachers who actually enjoy teaching & don't live to make me feel bad about myself. I read about med students who are rarely encouraged or rewarded for good performance & who are virtually never told that they are doing a good job. I am so grateful to all the attending physicians, residents, & patients who have made it a point to make sure my medical education experience is the polar opposite.

Surgery update

2008-11-01T01:45:00.003-04:00

I just got home from scrubbing in on a kidney transplant & am over the moon! Winding down from a 21-hour day that flew by. I am glad to have the day off to sleep in tomorrow, but I'm having a blast on my surgery rotation.

Each day of surgery has been better than the last. I improve my skills a little with each new case so I'm gaining more confidence than I did with sporadic C-section procedures on OB.

And yeah, I'm as surprised as anyone to learn that my surgery rotation is my hands-down favorite so far. My compression socks are 100% rocked.

It is still a beautiful world, Part 3

2008-10-28T20:05:00.005-04:00

Med School Fool tipped me off to Edwin Leap's encouraging & thought-provoking reader take at Kevin MD's blog.

Did I mention it's still a beautiful world?

Highly recommended.

Meat market news

2008-10-18T17:04:00.008-04:00

Niman Ranch founder, Bill Niman, has re-entered the meat market with a herd of goats & his young vegetarian animal welfare lawyer wife. I'm a big fan of more humanely & healthfully-raised meat, so this article successfully distracted me from one of my other favorite subjects, Internal Medicine.

A branch of my family owns an award-winning steakhouse in our nation's heartland. As a kid I attended cattle auctions and frequented the meat locker where the butchers cut slabs of meat directly from the cow. I'm also a long-time vegetarian whose greatest beef with the meat industry is the way farm animals are treated (egg & dairy industries included, too). I have no problem with people eating reasonable amounts of meat. Although let's face it, I love animals & don't have the heart to slaughter my friend Bessie when I can't even kill a spider.

In related news, when I grow up I want to pull a Sheryl Crow & move to a farmhouse in the middle of nowhere. Lately I can't stop dreaming of pet goats, chickens, fruit trees/berry bushes, & a flower patch with sunflowers & zinnias taller than me. Hope I can make all that fit with what promises to be a demanding career in health care.

You're old. I love you. Here's why.

2008-10-11T10:37:00.015-04:00

Reason #10 Why I Love Old People: The older you get, the younger I look. You're 83 years old and just told me you & your 89-year old husband thought I must be a teenager. Aww, shucks. Thanks for letting such a young kid interview & examine you.

Reason #9: You are blind. "It's so NICE to see a pretty girl here in the hospital!" I blush. By the way, you are also female.

Reason #8: You are warm. Your husband warmly shakes my hand after the intern & I share the diagnosis & treatment plan for your upcoming hospital admission. You hold out your hands to me...and give me a huge bear hug. I wish I could have done more to help and hope you don't have to stay in the hospital too long.

Reason #7: You don't complain when I feel for enlarged cervical lymph nodes & thyromegaly with my ice cold hands. You're wise enough to realize that my feeble efforts to warm my hands are no match for the bitter cold stored within them. You merely enthuse that my heart must be very, very warm. I think we both know it's more like boiling hot if my hands are any indication, but you wouldn't want to make me feel bad by telling me that.

Reason #6: I get to hear about your adventures in the jungle while you served in the military during the war. I'm not sure which war, since you are nearly a century old, but surely one that happened a long time ago and took place in a jungle. Where else could I hear about this?

Reason #5: You have a strong sense of humor. Your (insert important organ(s) name here) is/are failing and you might even die during this hospitalization. But you live for today & somehow maintain good humor in the face of what could/should be a purely unpleasant (at best) experience. You make me & other team members laugh with your jokes & endearing personality. This warms our hearts & makes us even sadder that you're sick.

It also makes us realize our lot isn't unbearable, even when we feel nearly broken on hour 29 of our 30 hour sleepless call shift. Thank you for this rare & precious gift.

Reason #4: You're enthusiastic about contributing to my education & helping me to develop into a competent physician. You're sick and feel like s*#%, yet allow me to thoroughly explore your body in search of your problem even though I'm the 3rd person to do it and won't be the last. If I happen to have a 1st year student with me you happily let him listen to your heart, lungs, & belly, too.

Reason #3: You get a kick out of surprising me. "I'm just going to take a listen to your belly," I say. "I'll hold up your blanket as a drape while you lift your gown to expose your abdomen." My eyes scan slowly down from your rib cage, past where I would expect a navel to be, and down to the area where your underwear may or may not be.

Wait, I think to myself, I must have missed the umbilicus. Be cool, he doesn't have to know. Scan again, more slowly this time, being careful not to scan too far down for the sake of modesty (this is the abdominal -- not the genital -- portion of the exam). "I don't have a belly button," you casually mention, your eyes dancing with pleasure in showing me something you're sure I've never seen.

Reason #2: You've been married 67 years. And you're still in love.

Reason #1 Why I Love Old People: You inspire me to keep traveling my chosen path in medicine during the darkest times when I question whether I can sustain the toll it takes on my body & mind. You are the reason I considered a career in medicine & you're one of the most important things that keeps me here. To say thanks seems small & insignificant, but at times it's the most I can do. I'll do my best to pay forward the many gifts you've shared with me. Thank you.

Michael Franti & Spearhead - "Say Hey (I Love You)" (mp3)

Mgmt - "Kids" (mp3)

R.E.M. - "E-Bow the Letter (live w/Thom Yorke)" (mp3)

Get your nerd on

2008-10-05T15:07:00.011-04:00

A Medicine lecture plays in the background to set just the right mood. As I sew a split seam (from too many books & tools carried) in my white coat & happily tie surgical knots to finish the job, I'm filled with a sense of peace on this chilly but gorgeous Sunday afternoon.

If, like me, you're inclined to take the nerd way, check out the BBC's Interactive Human Body. There, you can build a skeleton, add some muscles, organize organs, & map out the nervous system in an interactive male or female body. It's a chance for the med students out there to feel really really brilliant.

You can also take a quiz to determine whether you your brain has a more male or female bent (or determine your Sex I.D., as they say on the site).

It's a fun time to be had by all.

Oh the pain (Reason #36 Why I love lemons)

2008-10-04T10:59:00.014-04:00

Warning: If you're squeamish about bodily functions then this post is not for you.

Well I finally folded & started an antibiotic on my 8th day of sore throat. I waited because I never spiked a fever (>100.4 degrees Fahrenheit) & know that 60% of sore throats (pharyngitis) have a viral cause. However, ongoing tender cervical lymphadenopathy (swollen lymph nodes), exudate (white pockets of pus) on my tonsillar buds, and an absence of cough or nasal congestive symptoms left room for a bacterial pharyngitis diagnosis. So when I developed airway narrowing & chest pain on the 8th night I took the antibiotic my doctor had urged me to take only if my symptoms worsened.

I'm not a fan of frivolous antibiotic usage. In addition to promoting bacterial resistance to antibiotics, they have side effects that range from unpleasant to serious (FDA black box warning on fluoroquinolones & tendon rupture, anyone?). Many (most?) women who take antibiotics develop some degree of vaginal yeast infection when antibiotics disrupt normal flora by killing lots of normally benign (or even helpful) bacteria along with bacteria that cause disease.

Another unpleasant potential side effect is diarrhea. It's a taboo enough topic that I rarely hear it discussed in an office setting. However, I've commonly seen people admitted to the hospital for Clostridium difficile-associated diarrhea, which can lead to pseudomembranous colitis. It can be life-threatening, especially in the elderly. When it's not associated with C. difficile, a bacterium that commonly colonizes the colon (& is ubiquitous in the environment), antibiotic-associated diarrhea is usually benign provided the patient stops the offending antibiotic. Adding a probiotic may help to prevent antibiotic-associated diarrhea or reduce its duration & severity.

But benign doesn't mean it's a walk in the park. I mean, on one hand I'm glad it's not life-threatening. On the other hand, there are moments I wish it were. I'm talking about the PAIN. My insides feel like they're on fire. Spending the day curled up in the fetal position with disabling abdominal cramps is something I wish to never again experience.

In related news, if you turn me sideways I nearly disappear because there's nothing left in my gut. I'd love to re-inflate my midriff but am afraid to eat lest it exacerbate my symptoms. So pardon me if I think the term "diarrhea," doesn't do justice to the experience. Believe me, the next time a patient complains of diarrhea I will overflow with empathy above & beyond my already high baseline level.

Update - 2 days later:
My desperate use of an Ayurvedic home remedy (water plus healthy portions of fresh lemon juice, ginger juice, black pepper, & salt) completely(!) cleared up the problem in less than an hour. It may sound disgusting, but at the time it tasted like heaven in a glass. I drank two glasses right off the bat and then another two glasses later that evening. I was able to take hospital call a few hours later & work a full post-call morning without any further sequelae.

I miss my Muxtape

2008-09-28T11:06:00.006-04:00

Read all about the effective demise of Muxtape on New Yorker pop-music critic Sasha Frere-Jones' blog. You can read the entire story at Muxtape's site.

Frere-Jones writes:

People took to the site and began sharing “muxtapes.” All these people! Loving and sharing music! The music was streaming, not downloadable, and it cost the Recording Industry Association of America (R.I.A.A.) and labels nothing. A free, promotional tool. Sounds like good news for an ailing industry, right? I mean, nobody using a muxtape was walking away with any digital assets. Muxtape was not a file-sharing service; in fact, playlists were eventually modified to include embedded links to Amazon, where you could buy the MP3 in question, if it was available.

Carrot for the med student

2008-09-21T23:51:00.005-04:00

I just learned I honored [or got an 'A' in] my Peds rotation. In addition to being excellent practice in delayed gratification -- I finished my Peds rotation 7 weeks ago! -- a good grade means I did well on both my clinical evaluations & on the comprehensive "shelf" exam given nationwide. Don't ask me why the undercover pessimist in me is always surprised when I perform well after at least a decade of straight 'A's, positive feedback, & even some awards sprinkled in for good measure. Maybe it's to minimize any disappointment if I fail.

In other news, I just finished my first week of Internal Medicine (IM). I traded schedules with a classmate. That means I'll do Surgery on my next rotation at a busy inner city hospital very close to home. I had been scheduled to spend the rotation at two suburban hospitals with lighter caseloads, so the faster pace should keep me from boredom. I'll be working 5am - 9pm but at least I can leave the house close to wake time to minimize my chance of being late, one of the seven deadly sins a rotating medical student can commit.

Tomorrow I start my second week of outpatient (office-based) IM. I'll be in an inner city clinic with a large Hispanic population. Time to break out my two weeks of medical Spanish education & remember that Spanish is just like French but with easier-to-pronounce words. I should be just fine, provided the patients speak slowly & have enough teeth to speak clearly.

Amy MacDonald - "Run" (mp3)

Jenny Lewis & the Watson Twins - "Handle With Care [Traveling Wilbury's cover]" (mp3)

Natalia Clavier - "Dormida" (mp3)

Charles M. Blow waited his whole life to say this

2008-09-06T20:31:00.011-04:00

Charles M. Blow addresses the U.S. failure to provide adequate sex education in his excellent New York Times Op-Ed piece today: Let's Talk About Sex.

Sarah Palin's daughter is the ostensible impetus for the piece. Here's a sample:

London’s Daily Telegraph reported last month on a June study that found that “one in three secondary schools in England now has a sexual health clinic to give condoms, pregnancy tests and even morning-after pills to children as young as 11.”

That may be extreme, but many Americans can’t even talk about sex without giggling, squirming or blushing. Let’s start there. Talk to your kids about sex tonight, with confidence and a straight face. “I’d prefer you waited to have sex. That said, whenever you choose to do it, make sure you use one of these condoms.” It works.

Damn, morning-after pills for children as young as 11. Don't get me wrong, I would absolutely want my possibly pregnant 11-year old to use Plan B contraception within 30 seconds of condom breakage (as I pray to God there was, in fact, a condom to be broken). However, I'd want to know about it so Baby Girl & I could have a[n other] conversation about love & lifelong gifts like babies & the herpes virus. I promise not to giggle during said conversation. I'm pro-abstinence for my [hypothetical] 11-year old, but I'm certainly not pro-abstinence only education.

Blow also cites a 2001 UNICEF report that Danish girls have more sex than U.S. girls yet have just 1/6 the U.S. teen birthrate & 1/2 the abortion rate. I predict U.S. teenage boys will soon saturate the American-Danish foreign exchange program market, praying they haven't come too late to the game.

Important research update: Who blogs?

2008-09-04T22:07:00.011-04:00

Do the Big Five personality traits predict blogging? If like me, you've allowed your Computers in Human Behavior subscription to lapse, recall that these traits are neuroticism, extraversion, agreeableness, openness to experience, and conscientiousness.

Even without Level I Evidence I think we can all agree that the Big Five traits are certainly Big. Psychologists must be some of the most clever people around if they can get funding for projects like this one & this one, too. I'm pretty there's a Cochrane systematic review (complete with meta-analysis) to prove that point, too. Not that I can mock psychologists (may God bless 'em), who have to put up with stuff I never could.

I'd greatly appreciate it if any psychologists/ genius grant writers reading this post would help me to get funding for my kite surfing & New Zealand adventure vacation research. I score high on Big Five traits 2-5 if that helps my case at all. I also have massive-yet-supersleek arm muscles.

Hat tip to the Clinical Cases & Images Blog.