duh!

So, my conclusion from today's test was that I definitely need to read more. Parts of it were good, and I think I probably misinterpreted stuff, but I still think my score will be up from last year. Maybe this was the inspirational kick in the pants that I needed to get back on track.

I cleared 8" of fresh snow off the driveway before I went in to the test this morning.

Mock Me

Sometime tomorrow, emergency medicine residents all across the country will be sitting down with #2 pencils. It's that time of year again, mock EM boards. Bleh. Luckily, our program doesn't put too much weight on your scores, but I would like to at least improve on my performance from last year (which should be pretty doable, as I set the bar REALLY low).


Most of my time this year has been in the ED, so I think I am probably at least learning things more relevant to my profession. The last two days I have been taking practice tests, which range from "duh" answers to what-the-Hell-is-that syndrome-type questions. I generally find it's not good to hear of a condition for the first time ever during testing. Judging from the way the count of tests taken on the website has been going up rapidly over the past 3-4 days, at least I know I am in the company of fellow test-crammers.


Last year it took several months before we got results back as there was a program that was caught cheating. Some programs like to use their residents' scores as bragging rights for future applicants. At my program, we just take our applicants out to drink. This year, I think I will probably have to face the music a lot sooner.

Sadomasochism

I am sure I will get all sorts of bizarre hits for this entry, maybe even more than the one about hermaphrodites...


The other day I had a particularly cantankerous patient. I am just waiting to turn 70 because I figure this is the age when such behavior becomes somewhat tolerated. The guy was being a complete pest and doing everything in his power to agitate me. Finally all of his x-rays got shot, and I found a break in one of the bones of his hand. What should have been a simple x-ray, splint, and go home case turned into x-rays, patient stealing a banana from another patient, patient eating own dinner before allowing me to splint, patient attempting to sneak self into our hazmat shower, patient demanding earlier-refused breathing treatment, patient fighting with social work and getting escorted off the premises by security, case.


Somewhere in there, I did manage to slap some plaster together and get him splinted properly, but he did everything in his power to try and stall the process. As I was molding the splint and manipulating his hand into the proper position I was unfortunately stuck listening to endless complaints with no escape. There just was no pleasing this guy. He wanted us to admit him overnight so that he could have a good night's sleep and several meals. While I felt somewhat bad about sending him out, there was no need to admit him. Social work tried to placate him with a cab voucher to a shelter for the night, but he didn't go for it.


As security was escorting him out and he was screaming, I couldn't help but remember a line from the movie "Juno" which had all sorts of clever lines:

"Doctors are sadists who like to play God and watch lesser people scream."


Personally, I think doctors tend to be more masochistic than sadistic, but perhaps my view is a bit skewed from here.

The Poker Face

Never play poker with Emergency Medicine doctors. Our patients may show up in scary predicaments or with unusual piercings, but part of my job is to not participate in panic or react and make faces at gangrenous toes, etc.

The other day, I had a "surprise" while performing a pelvic exam. The story was typical: suprapubic pain in a 30's female, with her last menstrual period being in December. So we checked her urine for infection, and the tech got her all set up in the pelvic exam room.

Oh, did I mention she was from Somalia?

As I started to do the exam, I realized that she was missing all of her uh, external genitalia. Now, I had heard of this, but had never actually encountered it in person before. I think I kind of did a double-take, but didn't want to make her uncomfortable. The rest of the exam was unremarkable. In medical school, they told us to never say that everything "looks good" when doing pelvic/breast exams, so I usually say something about everything being "healthy and normal". I think this time I just settled on everything being healthy. In the end, she turned out to be pregnant, with no infection. After confirming that it wasn't an ectopic pregnancy, we sent her off on her way.

It has been interesting relocating here. Even though I am in a much smaller city, I am exposed to a much broader range of cultures and practices than I was back home. It's pretty cool.

Licensed to ill

On Saturday a cardboard envelope was wedged into my mailbox. The efforts of the past 5 and 1/2 years was contained on half a sheet of 8" x 11" paper. You guessed it... my very own medical license! Funny thing is, it says that I am licensed to practice medicine AND SURGERY in this state. I suppose if you count all of the little procedures I do as surgery, but it doesn't exactly list any restrictions. My attending tonight told me that she would gladly let me take out her appendix... except that some actually qualified surgeon did it last year. Ah well, incisions and drainages it is, then.

Date Night

So Army Guy blew me away again with surprises. The night started with greeting me with red roses at the door. Then we went out to a very nice restaurant downtown, and later we went to a local production of "Arabian Nights". The play was awesome, with several of the actors really hamming up their parts and quite a bit of acrobatics. We ended up being right in the front row with the stage literally ending 6 inches in front of our feet. It was great!

I countered with homemade sugar cookies, a card, and some warm mittens that fold back into gloves to keep his trigger fingers warm, but I think he clearly outdid me once again.

Valentine's Day

For Valentine's Day, I gave Army Guy laryngitis... just kidding. He's out "in the field", whatever that means. You would think the Army would let their people sleep indoors when it's below zero outside, but I guess they are literal believers in "what doesn't kill you, makes you stronger."

We have plans for a big date later this weekend. I have mixed feelings about Valentine's Day: while it's fun to do something extra special for your significant other, it's also annoying when you're single.

Partying Like a Rockstar

Last night I went to a rock concert with some friends. The weather was not so good, and I still had a hacking cough. Worse yet, I had been scheduled at the very last minute to present at trauma conference today. Trauma conference involves presenting not only in front of your peers and attendings, but the trauma surgeons, all the surgery residents, and burn unit and ICU staff. I HATE speaking in front of people... even small groups, but just shy of 100 people is definitely large enough to make me all sweaty and tachycardic.

So did I stay home like a sensible person and blow off the concert? No way. One of my teenage favorites was opening for the main group, and there was no way I was going to miss seeing that!

The case was easy enough: teenager shot in the chest, filmed, and given a therapeutic chest tube. Yesterday was spent scrambling to load x-rays and CT scan images into a Powerpoint presentation. I was fortunately able to also track down a rare video shot in the trauma bay of the procedure being performed on the patient.

The concert went much later than I had expected. It was also at this weird venue where you have to provide your own alcohol. Fortunately, one of my friends is a good planner. She brought a couple of bottles of wine as well as champagne that she had earned a few months back. (There is a longstanding tradition in medicine of rewarding residents who successfully perform a lumbar puncture without any RBC's on the lab results with a bottle of champagne.)

I finally got home at 2 am, slept for about 4 hours and got up early to run over my presentation. For once there wasn't any problem transfering my files onto the hospital's computer system. It went pretty smoothly, I was able to answer every question, despite not really having been all that involved in the case. My role was to essentially look at the kid, check his airway, breathing, and circulation. Maybe I should precede every presentation with a night of drinking and sleep deprivation-- it seemed to help my nerves anyway. More likely, I should just chalk it up to a fluke, and be more responsible next time.

The Dress

Last week I drove a couple of hours away from here to catch up with Ru. Her boyfriend proposed over the holiday and we were now on a mission, a mission to find her dress. She already had some ideas about what style she wanted, so that made things easier.

I enjoyed the drive out to meet her. It had been a while since I had driven anywhere far enough away to actually enjoy the drive. It was kind of foggy out, with a mist that was just slightly too warm for snowflakes. Bare trees lined the road, and snow still covered the ground. Between the poor visibility and the somberness of winter, it was almost like I was driving in a monochromatic world. The trees are in that completely state of dead right now, with no promises of spring. It's almost like looking at their roots, and if you could just flip them upside down, maybe you could find some leaves and life somewhere.

Dunkin' Donuts and Starbucks were in a neck-and-neck competition, alternating their wares at progressive rest stops along the toll road. The further east I drove, the more country music stations there were. The snow accumulation also started to grow, and I began to pass evergreens with branches so laden with snow that they stooped like old widows.

The dress shop turned out to be a perfect midway point, with Ru and I arriving within minutes of each other. We found her size, and begun the process of heaving plastic bundles containing precious volumes of lace, beads, and satin on a rack. (My shoulders are quite thankful that she wasn't interested in the full-skirted dresses.)

She stepped out of the dressing room with the first one and it was amazing. Gone was the girl with the rainbow t-shirt and sneakers I had walked in with. The first dress fit amazingly, so well that it blew the next several out of the water... but it wasn't quite right.

We went back for more, gleaning the rack of everything in her size that wasn't immediately offensive to the eye. A few more dresses, and then there it was. When she stepped out of the dressing room, she suddenly looked like a bride, instead of a pretty girl in a pretty dress. I was pretty sure that we were on to something because she kept that one on longer and endured more of the banal chatting from the saleswoman. Reluctantly, she took the dress off and tried a few more, but clearly we had a winner.

I couldn't believe that we had found her dress in one outing, and Ru was hesitant to make any rash decisions. So, we went out for an early dinner, scarfing obscenely potent garlic bread, spinach salad, gnocchi, and chocolate cake. Ru was back to her quirky self, asking the waiter to bottle up the quart of milk they brought her with the cake. We went back to the shop, made arrangements to pay for the dress, and because I had to work early the next morning, we parted ways. Mission accomplished.

----------

In other news, Army Guy came back early from Ranger School this past week. He was disappointed to return not having completed the training, but it boiled down to a whole lot of unfairness on the part of the instructors. While I'm disppointed for him, I am glad to have him back early, and have promptly responded to his returning by getting a nasty runny nose and cough, and being great fun to hang around with. Sigh.

A Feather in Your Cap

On overnight shifts, nursing homes are the bane of my existence. If you have been reading for a while, you probably have noticed that I actually tend to favor geriatric patients, particularly those with dementia. The problem with nursing home patients on an overnight is that we are on a strict time limit. In this city, while there are plenty of ambulance services to get patients to the hospital, once a bed-bound or even wheelchair dependent person gets here, if we are ready to send them home, there are no transport services available between the hours of 10 pm and 8 am.

This is appalling.

What it boils down to, is that if I can't get my geriatric patients dispositioned by about 9:30 pm, then they are stuck in the Emergency Department until the next morning as "Overnight Guests". Imagine being 80 years hold with dementia and being stuck on a plastic lined mattress for over 12 hours, with all sorts of screaming, bright lights, and not to mention bad smells surrounding you. A sleepless night certainly isn't going to help any, as a lot of dementia patients tend to decompensate at night. Sure, there's a call bell at their bedside, but for someone who can't remember their address or thinks that Harry Truman is the president, how do you expect them to remember to call for help? It's difficult on our staff too, to have to go in and reassure these patients every 15 minutes when they cry out for help.

So, when I see a nursing home patient in the rack on a night shift, there's always a ticking sound going off in my head to get the labs done, and get the x-rays back in time to arrange for a ride. On overnight shifts, the deadline has already passed, so any patients that come in are guaranteed to be stuck until morning. We have tried all sorts of creative options ranging from calling local family members for transportation to taxi cabs, if the patient is able to be transported sitting up and can fit in the backseat of a regular vehicle.

Unfortunately, some of the staff members at these facilities seem to be aware of our transportation problems and take advantage. If grandpa or grandma is being particularly cantankerous, one phone call gets them transported to the ED for "changes in mental status" and gets them off the hands of the night staff, sometimes even for a day or two. While some of these assisted living places are great about sending paperwork, too many times I walk into a room and meet a senior who not only can't tell me if anything hurts, they can't tell me anything about why they are in the department. This leads to what we call the Granny Grope-o-Gram, a workup including lots of tests that are probably unnecessary, but rule out major bad things... head bleeds, hip fractures, pneumonia, etc.

The other night, I walked into Room 4 to find a nursing home patient who was sent in for "purple, pulseless feet." She was very with it mentally, but when I asked her why she was there, she said, "Frankly, my dear, I haven't the foggiest idea." I examined her feet: they were not swollen, and were warm and pink. She had great pulses. Nothing hurt. After calling three different numbers and paging the provided "staff nurse" someone finally returned my page 3 hours later, to verify that my patient had just been sent for a foot evaluation. By this time, it was 4 am. So, I tucked my friend in, ordered her a breakfast tray, and sent her home in the morning.

The other night, I was amused to see a complaint of a rattlesnake bite listed on the board. There are no rattlesnakes here, and it is winter, so there should not be anyone getting bitten by anything other than a pet snake. As it turned out, the patient was from a nursing home. He was a creative guy, and had an old Stetson hat that he had decorated with several feathers and the head of a rattlesnake. This thing was at least 10 years old, but apparently during the day, he had scraped his finger on one of the fangs of the snake. No way he had been envenomated, but the facility had sent him in for evaluation after-hours. So he was an overnight guest too.

I guess these sort of transport issues are why some departments have opened observation units for people who don't have any active issues going on, but either they can't be set home (too intoxicated, no available psych beds, etc.) either. It's easy to see how having 3 or 4 patients stuck in rooms indefinitely causes waiting room overload, and eventual department closure to ambulances as we have no space for more patients. It's a frustrating thing. Hopefully, someone will eventually start up a transport service in the near future, but until then I don't know how to fix it.

Hot Boxing

I'm tired. I skipped going to the gym tonight. I'm two shifts into a six-day stretch. It takes me a half a pot of coffee to get going in the morning. Let me know if you have seen my motivation running around anywhere, because I can't seem to find it.


Outside, freezing rain pelts against the glass. I decide that a quiet night in is just what I need. I heat up a frozen pizza, sip a glass of red wine, start up the fireplace, and then a movie.

Just what I want.


Suddenly, the movie gets interrupted by loud beeping.

?

It is the downstairs smoke alarm.

I didn't burn the pizza, so I shut it off, and resume my movie.

Minutes later, the upstairs smoke alarm starts going off.

?

I wander upstairs and jump and swat at the thing to knock it down (Apparently, I could use a few chairs or stepladder upstairs.)


As I head back downstairs, I realize I'm walking into a hazy, smoke-filled room...

That's right...

You guessed it...

I forgot to open up the damper on the fireplace.

Pure genius.


I guess at least it doesn't smell like paint in my house anymore!