Unexpected Simile

"Come look at this, it's so pretty!" she exclaimed from the kitchen.

I left my dark office to go have a look. Ru was slowly stirring a concoction of sugar and eggs on the stovetop. It had this opulent, creamy sheen to it.

"Hmph."

"Isn't it pretty?" she asked.

"Well, it kind of has that shine-- like pus draining from a shooter's abscess that I've cut into." With that remark, I went back to my study, after receiving a cutting glare.

Vocabulary Lesson

This past week I started a toxicology rotation at the poison control center. Unfortunately, (or fortunately, depending on whom you ask) there haven't been many overdoses lately, so business has been pretty slow. I was sitting around the table with a couple of the pharmacy students when one of them turned to me. (Keep in mind these women are six months away from becoming doctorate-level pharmacists.)

1st student: "Excuse me, can I ask you a question?"

Me: "Sure."

1st student: "Which word means country: rural or urban?"

Me: "Rural."

1st student: "Are you sure about that?"

Me: "Pretty sure."

2nd student: "The way I remember it is that the store, Urban Outfitters, is like, in the city."

1st student: "Oh, yeah." (Long pause here, then much scrunching of the face.) "But what about Keith Urban?"

Me: "What about him?"

1st student: "Isn't he a country singer?"

(I shake my head and walk out of the room to keep from laughing.)

2nd student: "I'm pretty sure she's right that rural means country."

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Am I wrong here, or aren't those 4th grade vocabulary words? Maybe these two have dedicated all of their brain power to chemical reactions, but I found this conversation kind of scary.

Crazy People Get Sick, Too

During medical school, several of us wrote down funny quotes from different speakers throughout the year, and then some of the best ones were printed on our class t-shirt. One of the better ones was, "Managing physicians is like trying to herd cats." Another favorite, "Crazy people get sick, too. Don't get distracted by all of the craziness."

The other day I almost missed a bread and butter diagnosis. This guy came in complaining of a headache for three months, chest pain for two days, and abdominal pain for twelve hours. He was really distractable, and the more I tried to get him to focus on one thing or another, the more symptoms he kept developing... like insomnia, and left ankle pain. Perhaps I was already annoyed by my ongoing cold and the opportunity to hone my mouth-breathing skills, but I just was losing all of my patience with this guy. It didn't help either when later he started having pseudoseizures... he would start twitching at random, but still was able to answer questions and follw commands, like from the nurse to "Stop twitching and hold still so I can start this IV."

Annoying, just annoying.

Somewhere along the history of present illness for his headache, he told me that the only thing that made his headache of three months better was, "Stabbing myself in the temple daily with a butter knife."

Review of his daily meds revealed two narcotics, and an asthma inhaler.

Review of his computer chart revealed a previous mention of schizoaffective disorder... for which he was not currently being treated. It was becoming clear to me that this guy hadn't just "slipped through the cracks" with regard to follow-up care, it was more like he had fallen down a gorge and the vultures were circling.

So I called the psychiatry resident on call, and told them that I was working on clearing him medically for his chest pain, headache, and abdominal pain. However, what he really needed was assessment and follow-up with a therapist and a psychiatrist.

Easy enough, right?

Things got a little busy in the trauma room, and the next thing I know my personal intercom is going off while I'm putting in a central line. It is his nurse. She tells me that his blood sugar is 690. (Normal is 70-110 fasting, or less than 200 after eating.)

Oops.

Not only is this guy an undiagnosed diabetic, but he is in DKA and as all of his bloodwork starts coming back, it is becoming apparent that he is actually quite sick. Fortunately, he had already been started with IV fluid replacement, but I could have been a lot faster with the insulin therapy had I not so been distracted by all of his psych stuff.

He actually ended up getting admitted to the ICU for monitoring, but should be discharged by now after having received diabetic teaching and started on new meds, and will be seen by the psychiatry service before discharge. Before he went upstairs, he thanked me for taking his complaints seriously. I felt like such a jerk. I guess that's why we do lab workups on our psych patients.

Queen Bee

Somewhere along the way, I am sure that I have mentioned Aunt Ruth. Aunt Ruth has been the head of my mother's side of the family for the past six years since my grandparents both passed away. She is the reason the family still gets together once a year in the summertime.

Aunt Ruth is 104 years old. She was driving and living in her own two-story brick home until she was 99. She knows exactly who is in charge, and she doesn't let you forget it.

This past weekend she fell in her apartment and broke a hip. We were afraid that given her age, no surgeon would want to touch her, and she'd be confined to her bed. However, my mother told me last night that they operated on her yesterday and expected her to be back on her feet TODAY. She must have just needed some minor pinning rather than actual joint replacement, but I still can't believe they operated on her.

Just a couple of weeks ago, she was giving her visiting nurse Hell because a state inspector came through the facility and insisted that she had to have someone dispense her medications for her because of her age. I think that this was a wise decision because last year she had some problems when she mis-dosed her meds... and then there was the episode of setting off all the smoke detectors on her floor when she forgot about some prunes that she left boiling on the stove.

Aunt Ruth is ticked off though, as "I don't want any govenment making decisions about my healthcare." So now there is a long recovery road ahead of her, and all I can say is good luck to her nurses!

Rat Wrangling

For my required research project I am going to be working with rats to see if we can find another indication for an already existing antidote. The positive aspect is that this research may help a lot of people. The negative aspect is the working with rats part.

Today I had a meeting at the animal lab with the other co-investigators in the project to learn how to handle the rats. No one told me that we would be using the ugly white rats with the creepy red eyes. There's just something sort of evil-looking about them.

The instructions were simple: Grab the rat by the tail with one hand and with the other hand, grab it just behind its front feet, high enough to cause the front paws to cross over each other. This helps to minimize struggling and at the same time, makes it relatively difficult for the little varmint to bite you.

You would think that for women with PhDs and medical degrees this would be a simple task. Well, you thought wrong.

The first of our group did well enough. She was hesitant at first, and with good reason as the rat sliced through her rubber gloves with one swift swoop of a paw. But she held on to him tightly, so tightly that when we were learning to place a tiny needle down the rat's throat to administer medication that his little tongue was purple and he looked kind of short of breath. A fine job overall, though.

The next woman was less hesitant, and reached with one hand to encircle the rat, but forgot to first grab on to its tail for stabilization. The animal deftly spun in her hand, and somehow she ended up with rat urine on her face! She was a good sport about it though, especially considering that the rest of us were giggling like schoolgirls.

Finally, it was my turn. I think my rat was just more docile, and other than flinching a bit, there were no problems. I have to admit that I have a slight advantage in the rodent-handling department because as a child, my brothers and I helped to raise mice for a bird rescue project of my father's. Of course a few select mice were kept as pets, but it's been almost 20 years since I've handled a mouse.

Next week we go back to the lab to learn how to test for normal reflex and behavioral reactions. I knew that this study was going to require a lot of commitment, but I didn't know that golden showers were going to be one of the exposure risks!

On Diplomacy...

I have been working overnights lately. It has been especially painful lately with the flow of waiting room traffic being steady ALL NIGHT LONG. Why, oh why, would you check in at 3 am with a complaint of foot pain FOR A YEAR?

To make things worse, I have been dealing with contractors lately... another particularly painful practice. My driveway is in horrible condition, and the "highly-recommended" person I called three weeks ago, finally bothered to show up the other day. Unfortunately, my driveway is too narrow for him to negotiate with his paving equipment. This has since sent me into a frenzy of phone calls, trying to get people to come out and give me an estimate because I would really like this taken care of before winter. So, to add to my already toasted Circadian rhythm, what sleep I do get during the day has been interrupted by random dudes calling me back or showing up at my door.

Having some experience in customer service in the past, I pride myself on being able to remain calm when dealing with your average jerk. The other night, this particularly difficult woman came in at 4 am, and I just wasn't going to deal with any nonsense. First off, she wouldn't narrow down her complaint. First it was nonspecific tremors, then the list expanded to include chest pain, left ring finger pain, and tongue pain. The "tremors" she was talking about involved her rhytmically flapping her hand on her chest. However, when she answered my questions, the flapping stopped, and only resumed when she remembered to start it back again.

Suddenly, she began demanding Valium. It turns out that someone has just been giving her this medication for over a year, without having diagnosed anything. Apparently she has now ran out. Oh, and prior to coming in by ambulance? She drank 2 inches of vodka.

I told her straight off that I couldn't see any reason to give her Valium, that I would like to workup her chest pain and other problems, but currently I had no reason to give her that medication. At this point, she refused any blood draws, stating that she was Jewish, and it was against her religion.

I went to enter her orders in the computer.

At that point, the nurse came in and told me that the patient was screaming and cursing. So, I went back to the room, where I was told that she was going to, "F***ing sue you so hard, you won't know what hit you." I again told her that I wouldn't be giving her any Valium, but that it was important that we make sure that her heart was ok.

At this point, the attending walks in, and the patient starts screaming at him that I am calling her a liar. I reiterate that I don't disbelieve that she had tremors, I just don't see any reason to give her that medication.

The attending and I talk privately, and he explains to her that the Jewish religion is opposed to autopsy (which sadly we will not be performing), but that blood draws are typically ok. So she agrees to the blood draw, and he compromises to 1 mg of Ativan, on the condition that she stays for evaluation.

Ten minutes later, she's screaming again at the staff, so I offer her another dose, and explain to her that she can just hit her call button rather than coming out and yelling obscenities.

Five minute later, she's demanding: a warm blanket, jello, and the "head doctor". The attending stalls on going back in there and thankfully she yanks out her IV and walks out. Everyone was silently rejoicing. I think she would have walked out much sooner if we hadn't caved to her demands in the first place. I just don't have any patience for people demanding medications without wanting to be evaluated. Even more annoying is that when people walk out, apparently social work has to contact them at home and ask them if they want to come back in. I'm pretty sure I know what her answer will be!

Creepy Beer

The other night after our midnight shift, we all went out for a drink. Everything was fine, until the attending bought me a second one. Look closely at the foam, there's clearly a skull in there! It actually was pretty anatomically correct with teeth and everything. It is slightly distorted here as unfortunately, I had turned the pint to show my buddy.

1, 2, 3

Found out today that I passed the last part of my medical licensing exam! Now I feel like I can finally focus on Emergency Medicine. Woohoo! No moonlighting (working for extra money on the side) until next summer, though.

Please, Leave YOUR Doctor at Home

This is something of a rant, so forgive me if there's a lot of jumping around.

"The other day" I walked into a room to find a 60's something female. She was brought in by ambulance, and the nurse was still finishing up reviewing her medications and getting her vital signs, so I walked into the room "cold". The only thing that I knew before walking in was that the word "Dizzy" was written on the whiteboard. Fine.

So, after walking into the room I begin interviewing the patient. I am a few questions in when a well-dressed woman in the room interrupts and asks me if the patient will be getting an EKG. I haven't decided this yet, but to get her off my back, I just say "Yes" because basically just about everyone over 40 gets an EKG... for just about anything.

So, I go back to the patient. The other woman then introduces herself as an internist and says that she works with my patient. She then proceeds to answer for my patient and gives me what details about the episode of dizzyness, only including what she thinks is important. She then adds that "I'm really anxious to see what my friend's 12-lead EKG looks like."

Finally, I get through my interview. As it turns out, the patient didn't just get light-headed, she has numbness and tingling in her left hand, foot, and although I don't observe any slurred speech, the patient is reporting that she just "isn't talking like her normal self."

So, I run through a quick physical exam, being sure to complete a full neuro exam. Now I'm thinking this isn't just a near-fainting dehydration/cardiac problem, it could be a stroke.

I duck out of the room. The attending is busy, so I quickly order an EKG and some meds to make the patient feel better. I give the attending a brief synopsis, and we decide to activate the stroke pager, which means that this patient basically gets pushed in front of everyone else in the hospital with respect to lab results, and imaging studies.

At this point, the internist grabs me in the hallway, and says, "Look, I don't mean to tell you how to do your job, but we still don't have an EKG." As she says this, the neuro resident is stepping into the room behind her back and the patient's nurse is putting her on a portable monitor to get her ready for the head CT.

I calmly tell the internist that the patient is not only getting an EKG, but she's getting evaluated for a possible stroke. Silly me, I had thought this would make her happy. She then asks me if I'm getting cardiac enzymes. I respond that they have already been ordered. At this point, I'm already daydreaming about punching this internist in the face.

I check up on one of my other patients, and see the internist pounce on my attending. By this point, the neuro resident is stepping out of the room, and she then proceeds to pounce on him, too. The patient is starting to improve, so it looks like more of a TIA or mini-stroke picture, rather than a full-blown stroke. Finally, to placade the internist, an EKG is done before the CT scan, and it is completely normal.

The CT scan doesn't show any hemorrhages and all of our labs come back normal. However, the neurology team is convinced enought that this is a neurological problem that they want to admit the patient and start her on a medication to help prevent any future events.

I walk into the room to make sure that the patient understands what is going on, and the internist is sitting there telling her who she'll need to see as an outpatient and blah, blah, blah. Finally, the internist leaves. At this point, the patient starts saying that she just wants to go home. Today, when I did my dictation I saw that she did actually get admitted.

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I have several issues with the way this patient was taken care of. First off, if someone wants to accompany a patient, fine, but this woman was nothing but a hindrance from interfering with me speaking with the patient directly all the way through her workup. If she wanted to be in control of how this patient's workup went, she could have easily admitted the patient directly to the hospital herself.

There's nothing more annoying than patients that show up in our department with prescriptions for MRI's and other studies. I'm not running a lab. I'm there to actually evaluate patients and do some of my own independent thinking. If bloodwork or imaging needs to be done, then just send your patients to a place that does that crap and sends the results back to you without ever looking at it.

My other least favorite thing is when patient show up expecting their doctor (who usually is not even the one on-call for their group) to meet them at the door. When your doctor tells you to go to the ER, that means check in, get evaluated, and if the ER finds something we'll let him/her know. If they really want you admitted, then they do it directly, and you can just bypass our infernal lobby of misery.

Zoology Crash Course

Up late tonight finishing up a computer training module on animal research.

Here are three things I learned:

1.-Pick the least sentient animal that's appropriate for your study... this makes more sense as it makes the work more acceptable to the public and all those involved.

2.-It's important that researchers get vaccinated so that they don't infect the monkeys with things that can crossover like tuberculosis.

3.-Rabbits and rodents have some sort of weird esophageal anatomy that make it impossible for them to vomit, therefore it is not necessary to make them fast before surgery to prevent aspiration.

Tug of War

Lately, I have felt pulled in too many directions. I often feel like by remaining neutral at work, I have somehow managed to become everyone's personal emotional dumping grounds. At the same time, I feel guilty about not keeping up with the list of old friends in my head that I need to call and catch up with. I'm trying to be better though, by simply not answering the phone and having some peace and quiet to myself.

Changes since my last post:

-I haven't gone for a run since, and yet I somehow have a 10K to do next weekend.

-I finished my SCUBA lessons and pool time. Now I just have to do my open water dives and I'll be certified.

-I have a new roommate... Ru's great, although I am afraid I haven't had too much free time with her.

-There's a new guy in my life. We've had three dates and I still like him.