Ode to the Taxi Cab Driver

The hours are horrific,
His sense of direction uncanny.
His malodorous backseat
Has carried many a large fanny.

That guy on the corner--
"Where to?", no other question.
A good driver knows
There's more pay for discretion.

A gunshot or stab wound
Gets driven with haste.
When they prepay,
There's no time to waste!

Drop him at the ER,
Somewhere near the door.
At $2.80 per mile,
That is all he paid for.

The man in the lot,
His story, no one knows.
"Hey wait, Mr. Cab Driver!"
But silently he goes.

With a screech, he drives off
To the next airport or bar.
Wherever it is,
May the next fare go far!

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.

Sinking to New Depths

Recently, I enrolled in an Open Water SCUBA Diving Course. Fortunately, I am able to do all of the bookwork and quizzes online, needing only to visit a small dive shop for actual pool time and my dives. Today, I got into the pool for the first time. At first there was a little awkwardness, but once I was comfortable that I could in fact breathe under water, it all went pretty well. I have to return next week to finish up my pool skills, but I am lucky to have found a program that works around my schedule! Once you get certified, your card is good for life. The plan is to meet up with "The Phoenix" later this year for another awesome vacation adventure.

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Tonight I tried to make some brownies in honor of Ru coming in to town. They were just from a box, so it didn't require much effort on my part. My kitchen was smelling wonderful. The timer went off, and I expected to open the oven door to perfectly gooey brownies. Instead, I found a square pan of chocolate with a layer of oil boiling on top. Apparently, I forgot to mix in the eggs! Leave it to me to forget one of three required ingredients in a pre-mixed recipe and screw it up! The whole oil brownie brick went straight into the garbage.

Downsizing

Yesterday, I cleaned out my closets. Literal closets-- don't get all excited. Things I hadn't worn in the past year or two were thrown out. Things that were of questionable fit were thrown out. Gone were any shirts picked out by old boyfriends. Pants I could slide off over my hips without unbuttoning or unzipping were thrown out (When I started medical school, I weighed 125% of what I do now.). Oddly, things that had been tight that I would have thought would look good after losing another 10 lbs were still ill-fitting. And, things that were flattering when I was heavier, still hung on me with good shape. I guess there is some truth to clothes just being well made or not. By the time that I was done, I had SIX filled garbage bags of clothes to haul off to the Salvation Army. I think I got rid of about half my clothes (not counting workout and housework stuff).

Part of the motivator is that next weekend I am getting a roommate. My dear friend Ru will be here for an extended stay. She has whittled her material possessions down to what will fit into her compact car and has been heading my way over miles and miles of asphalt trails. She is braver than I am. Rather than moving out of employment obligations, she is just picking up and relocating for a while. It will be fun to have a friend in-house. I'm hoping we'll do some local trips and have many misadventures while she's here.

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This morning I ran a 5K with one of my friends. We banged it out pretty well, but our time was actually almost a minute slower than the last one we did in May! There's another 10K coming up in a few weeks' time, so I had better up my running schedule again.

The weather has been beautiful lately. A few days of rain have been followed by perfect skies. This afternoon I finally finished the second coat of paint on the deck, so gone are the ugly boards of pinkish-tinged primer that had been exposed for the past year. Unfortunately, the whole thing now needs a third coat to hide all of the brush strokes, but just being all one color now already makes it look much better! Suddenly, there is an almost air-conditioned cold to the breeze through the leaves. It's a warning of cold days ahead. There are so many projects I had put off last year until "the weather is nicer" and I am suddenly realizing the weather's now about to worsen. Argh.

Mystery Solved

Silk already solved the mystery about the psychiatry symbol for me. Based on my poor description, phonics and Greek language skills, she knew right what I was talking about! There's nothing quite like having a Mensan available to do one's homework... if only she had been around for those painful semesters of O-Chem in college!

Cashing Out

The other I day I picked up a chart in which the chief complaint read: ANGRY. The whiteboard wasn't much help, where under chief complaint, there was the shorthand symbol for psychiatry-- it looks like a pitchfork... sometime I need to look this symbol up, to see whether it's a reference to being tortured by demons or more likely, something far less creative.

Anyway, I sighed and started the long walk towards Room 15, our designated psychiatric room. There's nothing much different about it, other than that it is a physical room with a locking door (as opposed to a curtained off area, like most of our other bed spaces), absolutely no equipment in it, and covered, locked electrical outlets.

I asked my patient why had come in and he said that he was angry because his personal things were stolen from the shelter he lived at. He had filed multiple complaints with the police department and was getting no results. He said that he was here for someone to "write me a check to pay for all of my missing things."

After running through a long, exhausting social history and review of systems to make sure there was nothing wrong with him, we finally returned to his missing stuff. No, he wasn't angry enough to be homicidal. No, he wasn't going to hurt himself. I told him I didn't think we could write him a check, because we don't do that, but perhaps the social worker could see him and see if there was anything else that could be done.

Then I found my attending and told him the story. He said something along the lines of, "What do you mean he wants a check?" So, we walked down to Room 15 again, where my attending proceeded to tell the guy that we don't write checks, we take care of sick people. I know that we see a lot of people for routine stuff that should be covered by their regular doctor, but most of them at least come in with a medical complaint!

After waiting for over an hour for the social worker to arrive, the gentleman walked out. I don't know where he is going to get that check, but when he does, I hope that he gets one for me, too.

Doomsday

My laptop continues to drive me bonkers. In spite of spending $135 and painfully surrendering it for four days, it continues to charge intermittently and angrily flash the lightning bolt at me, threatening to go into hibernation mode at any given moment.

A smarter person would have backed up her photos and music a long time ago.

A more organized person would have already been shopping for the best deal.

Alas, I am not that smart or organized.

I just don't want to deal with it, in spite of the fact that every time I turn this blasted machine off, I have to question whether or not I am going to be able to coax it back on again. I have also tried just leaving it on continuously, which just seems to cause it to freeze up.

I am also thinking about making the switch to Macintosh as their customers seem to be happy, if not a little fanatical. At least for me, PCs tend to be trouble-free for about 2-3 years, and then they sort of self-implode in terms of efficiency. This laptop is going on 3 years now, and does it make any sense to spend any more money on this thing when a newer, faster model could be mine for approximately $700, although I think Macs start at $1000? And I am thinking of just getting a desktop computer as I am no longer homeless and relocating every 4 weeks.

Any recommendations?

In My Humble Opinion

Granted I am a wee bit short in the experience department, but in my opinion, if you manage to present with a broken neck, femur, and wrist, and still have the stamina to give me a "Come Hither" look after your sedation and dislocation reduction in the trauma bay, you are probably going to be just fine.

Although I suppose this was before the orthopods took a power drill to his tibia, shoved a rod through it, and left him with weights dangling off the bed... sometimes leeches and bloodletting don't sound like such crazy ideas.

A Sick Sense of Humor is Mandatory

So, "the other day" I saw this guy that had amputated his right ring finger. He had somehow crushed it at work and literally pulled the end off when he pulled it out from where it was smashed. He showed up accompanied by a leather glove in a Ziplock bag full of ice.

After I checked out his stumpy finger and saw the bone sticking out of the end of it, I wanted to look and see how the detached part looked. So, I took the glove over to the sink and proceeded to examine it... but not before plugging the drain as I have a bumbling co-worker who had the misfortune of dropping someone's tooth down the sink last year! Sure enough, I could feel something squishy at the fingertip end of the glove. I tried shaking the glove out, but the severed finger would not come out.

Here comes the punchline: At that point, I told the patient I wanted to cut off the end of the glove to get his finger out, but not before asking him if he cared, or was "attached to the glove!" Sometimes, I crack myself up!

Unfortunately, the detached skin was too soggy and devitalized to salvage (don't put things directly on ice) so I think we just threw it out. And, if you have seen Michael Moore's new flick, "Sicko" then you already know where unsalvaged fingers go...

Audited!

Do you know what makes for a fun day? How about checking your mailbox and getting a letter from the Department of Health? How about that letter being from that Narcotics Department?

Still not having fun?

I'm not in trouble. It was just a letter alerting me that one of my charming patients has been bouncing from hospital to hospital, and I was one of FIVE people who sent him home with a prescription for narcotics in a period of a few weeks. However, I do not appreciate having made the Narcotics Division's list.

Being in Emergency Medicine, there is no continuity of care. We have computerized records, so I am able to look up a particular patient's recent visits and hopefully someone documented what scripts they sent them home with. Unfortunately, there's no city-wide list, so other than reviewing our own records I don't have any way to prevent this from happening again. The best I can do is stick to supplying only a few days of meds at a time and referring people back to their regular doctor. Argh.

And You Thought You Were Having a Crappy Day

In that wild and crazy idealistic mind of mine, I would like to think that my job is about helping others. Sometimes though, it seems to take a drastic turn towards meeting someone's demands, rather than practicing any actual medicine.

Here's a story one of my co-workers told me about a horrific experience in which one of her patients workups suddenly went "crappy" the other night:

A male in his mid-forties presented to the ER with chest pain. He had several risk factors for heart disease, so he got the workup: chest x-ray, EKG, bloodwork, aspirin, nitroglycerin, oxygen, and maybe even some morphine for his pain. Midway through his workup, the patient decided that he wanted to leave, that there were better things that he could be doing with his time.

Unfortunately, the man had an IV site in his arm, so he had to be stopped before he hit the door as sending someone out with an IV site in place can lead to all sorts of headaches from providing them with easy access with which to deliver their "unprescribed meds" to infection, bleeding, or damage to the actual blood vessel. Not a good idea.

So the gentleman was stopped and escorted back to his room. In the meantime, another well-intending, but often clueless coworker of mine decided to have a heart-to-heart talk with the guy and convince him to stay. Getting him to stay consisted of fetching him a turkey sandwich . Fine. Whatever.

So the guy stays and waits for his labs to come back, all the while glaring at the nursing staff and demanding them to wait on him repeatedly. Finally, in spite of all the catering to his wants, he gets up and walks out the door... but not before defecating on the floor.

There's nothing that frustrates me more than dealing with rude people like that. Most people are fairly rational, and I think understanding when it takes time for their workup to get done or even when they get pushed back in the line a little bit when something more serious comes in. However, there's always those few demanding individuals that want everything done for their own convenience that cause the most problems.

Sometimes I think that the line between us and animals is very fine, if it exists at all. It's too bad he didn't make it out the door the first time, as a lot less time and effort would have been wasted.

Today's Headlines

Sorry I haven't posted in a while, thanks to those of you who have stuck around.

Lately I have been doing the overnight shift. The bad thing about the overnight shift is that you walk into a messy department. The good thing is that by sunrise, everything has pretty much calmed down.

I have been involved in no small amount of trouble over the past week. There have been shootings, stabbings, and the usual strokes and heart attacks. For the size of this city, we do pretty good. One of my attendings says that working on the pediatric side is pretty much like practicing veterinary medicine, because the infants can't tell you what is wrong with them. I think the same is pretty much true of trauma patients.

I generally don't get much of a story from them. It's usually something along the lines of, "I don't know what happened, I heard gunshots and then I realized I had been shot." Or the more classic, "I was walking to church when this guy just walked up and stabbed me in the chest."

It is generally the next afternoon when I wake up that I get the full story. There's nothing like hearing that the guy you spent 3 hours resuscitating was part of a string of retaliation while you sip your coffee. Or that the guy that died got stabbed because he called his girlfriend a "fatty". Hell hath no fury like a woman scorned, I guess. But then I guess it's better that we don't know what happened... easier not to develop a bias and all that.

Waterfalls

The walk was short, but what a great view:

Yawn

The PU's just left. Today was the one day during their visit during which I didn't have to work. I seem to be run down more now than usual. One would think that it would be no big deal to spend a few hours eating and squeezing in a quick activity or visit and then going off to work, but it's exhausting. I think I am very lucky in that I have low-maintenance parents. They are generally happy enough to just see me for a bit here and there, and entertain themselves the rest of the time.

Second Wind

Today I took the final part of my medical licensing exam. I was somewhat anxious about it as for Steps 1 and 2, I had blocks of vacation during which to study in 6-8 hour sessions. This time, I didn't want to use one of my precious vacation weeks for board studying, so I've been trying to cram in a hour or so of practice questions or reading here or there. The mantra in med school as to necessary study time is "Two months for Step 1, two weeks for Step 2, and for Step 3-- bring a #2 pencil." That is all fine and dandy, except I have a friend who actually failed Step 3 a few months ago, and at over $600, I don't want to make that mistake.

I think that it went well enough. The exam is actually computerized these days. By the end of it, I was kind of absent-minded, but I think I did alright. I won't find out now for over a month. Some of the cases were ridiculously easy, and other ones left me playing eenie, meenie, miney, mo between options of bizarre syndromes.*

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Yesterday I ran by the lake again. I don't know what the heck people are talking about when they talk about runner's highs and all that garbage. The best feeling I've ever had is getting to that point where I'm not painfully aware of my labored breathing while trying to find a semi-dry area of my hand with which to wipe away the sweat.

The humidity was a killer. The air was so moist, you could feel each oxygen with its two attached hydrogens hurling itself at you. The air was so moist that if you grabbed a handful of it, you could squeeze the water out of it like a sponge.

Mile 1 sucked. Mile 1 always sucks. I took my walk break, and knocked out Mile 2. Second walk break. I hit the hash mark on the path, but I wasn't ready to turn around and start running again, so I walked down to the water's edge. This run sucked-- even the squirrels were lined up along the path, laughing at me.

And then for once, the shuffle option on my iPod saved me. Instead of it's usual trickery of breaking my stride with something like Enya, AC/DC came on. It was a song I hadn't heard in quite some time-- the one I convinced the squad to choose for the halftime performance, much to the dismay of our coach. It was time to stop being a pansy, and run. Miles 3 coasted by, and by the time I hit Mile 4 it was over: bad mood abolished.

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I know I have mentioned this before, but days at work seem to almost have themes. The other day, it was nosebleed day. And, more recently it was "Bad News Day". I can understand that no one likes giving their patient bad news, but when I am at least the fourth or fifth person to speak to a cancer patient that week, I don't think it's fair that I am the one stuck telling them they aren't going to get better.

I had a handoff patient at signout. They had been seen by someone else. I was just supposed to wait for them to get back from radiology, and send them home. Simple. The woman comes back and starts puking all over the place. I get that under control, and then she asks me why she keeps going into renal failure. I tell her that I don't know. I ask her what's going on with her colon cancer. She says she doesn't know what is happening, but her surgeon said he wouldn't operate because the cancer had "exploded all over her abdomen".

Then I ask her what her oncologist said was the next step. She said she didn't know. So there I am, stuck telling her that while I don't know what is going on with her personally, sometimes when cancer starts spreading, different organs start shutting down, and they don't get better. She looked like I had slapped her. I told her that I could treat her urinary tract infection, and give her medicines for pain, but that she needed to talk with her oncologist about her options. They left shortly afterwards, but not before I saw it-- the recognition that she was losing her battle.

It's not fair. I have a hard enough time doing my job-- I don't want to clean up after somebody else. And I don't mean to crush anyone's hope. I do think that attitude is a big part of healing. However, if you are being turned down for surgery because your cancer has metastasized, someone should tell you that this is not only a bad thing, but a VERY bad thing. I went into emergency medicine partly to protect myself from becoming attached to patients. While helping to improve the quality of life of a terminal patient is important, it's also hard to watch them go.

Then there was the very anxious executive who came in after a car accident. He looked absolutely fine, and wouldn't you know it, there was an abnormality on his head CT. Some sort of "spot" that they couldn't determine whether or not it was a benign lesion, a dilated blood vessel, a chronic deformity... or MALIGNANCY. Great. As you can imagine, that little news bit didn't go over so well. "Uh sir, there's something unusual on your head CT..."

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Tomorrow the PU's (parental units) are back in town. It's not exactly the best time, as I am working every day but one of their visit, but I guess that leaves them plenty of time to explore on their own. They have a huge RV now, which somewhat complicates things as it won't fit in my driveway, but I guess it has been working well for them.

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*I know you don't want to actually think of your personal physician just randomly guessing at crap, but if you've been reading this blog for any length of time, you should know that by now, NOTHING IS SACRED.

All Work and No Play

Here's a few pictures from my recent "work" conference. This was the main part of the hotel. They were smart and put us in the back building.

We learned a new dice game. This was hours before security got called that first night.


Views from the kayak.




I think I would like to try sailing some day.

Oh, and I Forgot to Mention....

Some days at work are easy. The asthmatic comes in for a tune-up and goes home. The heart failure patient was a little too indulgent over the holiday and now needs to be admitted, diuresed, and discharged after an observation period. The sprained wrist that may actually have a hidden fracture that needs a splint.

"The other day" (From here on I will now be referring to encounters as having occurred "the other day" to further obscure identities.) my shift was filled with "Oh yeah, and another thing" cases.

#1- First there was the cop that came in with what he was sure was a kidney stone as he had one in the past and it felt similar. So, after getting his pain under control, we checked his urine and ran him through the CT. Sure enough, he had a kidney stone. However, he also had a BULLET fragment in his back. It was very superficial, there were no scars on his skin and it didn't need to be removed. However, it seems to me like having been shot would be something you could kindly remember to mention in your medical history.

#2- Then there was the prisoner that I think just didn't want to go back to jail. Everything was wrong with this guy. He'd had seizures, and although he admitted to not taking his seizure-prevention medication, his case wasn't that simple. He also claimed he was attacked and blacked out when he was arrested the day before (head CT), was vomiting blood, had blood in his stools, a fever, and difficulty urinating.

Our whole workup process is based on the idea of a chief complaint and ruling out life-threatening issues. When you give me a bunch of unrelated crap, it just slows everything down. This guy was young, so he learned first-hand that if you complain of blood in your stools, you're getting a rectal exam. If you complain of bloody vomiting too, and your rectal exam is unfortunately positive, you are definitely getting a tube down your nose.

Getting a tube down one's nose also involves flooding your stomach with saline, and sucking said saline back out into the vacuutainer to make sure that there isn't any active bleeding going on. Meanwhile this involves hawking up all sorts of mucus, and nose lubricant-- which is, by the way, the one thing that makes ME sick to witness. And, this is all very entertaining for the officers accompanying you to the emergency department. Here's a hint: next time, stick with the seizures.

#3- Then there was my uncooperative patient. He had a history of some baseline mental retardation and lived by himself. He called his sister up, and told her he just "didn't feel right" and she had him transported to the hospital. He was stubborn and extremely frustrating to examine as he refused to follow directions and wouldn't give me any description other than just "feeling blah". He did seem to have some more distractability than he should have though, so into the CT scanner he went, with having a plethora of labs pending. This was at the end of my shift. I was dictating his chart the next day, and guess what? The guy had evidence of a recent stroke on his scan. We had no idea when the onset was, and there wasn't much to do acutely, but 30 year-olds who just feel "blah" shouldn't be going around having strokes. Now I am a little paranoid about sending anyone home.

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Posting around here has been scant this past week for two reasons:

1. My laptop's power cord wasn't connecting well enough to charge the battery. It had gotten to the point where no amount of jiggling would do. $135 and four days later it is better, but I think this machine may be nearing hospice-time as the power button is now sticking and it doesn't like to shut down.

2. We had a state chapter conference thing that was four days long. I survived rooming with McNeedy and even went out kayaking for the first time ever. It was a fun time, but between all the lectures and hanging out, I ended up exhausted.

July 4th Memories

Somewhere in the linen closet at my parents' home, there is an old green and black flannel blanket. It has several holes in it, and I am sure the thing is quite musty. It is scratchy to the touch and I am sure there are still several burrs still clinging to its worn fibers. It is the last blanket on Earth that you would ever want to offer to a guest.

However, to me that blanket is special. I remember many a July 4th when our family would park along the street of a residential neighborhood and walk what must have been close to a quarter of a mile to find an empty spot on the grass of a local park. All of our arms would be full. Some of us would be carrying lawn chairs. Some of us would carry jackets for when the heat of the hot Texas sun finally dissipated and it got chilly. Someone would be dragging the old orange and white cooler along. Inside the cooler, there would be ice-cold lemonade, and cold fried chicken. My mother would always have brought along some salted popcorn (made on the stove, not the microwave back then), fruit, and some cookies.

That was our tradition. We'd lie on blankets, my brothers and I, straining our eyes against the dusky sky-- looking for the firemen setting up the fireworks. People around us would be waving sparklers.

Finally, you would hear it, the slight whistle of a rocket shooting up in the sky. You would try to guesstimate just how far up it would go, and then-- all of a sudden, bright lights filled the sky.

The green and black blanket was used to duck and cover when the loud cannon booms that rattled our young eardrums would go off. There were many holes poked through it by little fingers as we wanted to be under cover, but still able to see the night sky.

At the end of it all, the sky would be filled with smoke. There were several years when fireworks fell on a dried up cluster of trees and created quite an impressive blaze. After it all ended, we'd stagger back to the car, as suddenly the sleepiness and full-belly combo hit.

After we moved to Arizona, there still were firework shows, but it wasn't the same. By then, my older brother and I were well on our way to becoming miserable teens, and it just wasn't as magical.

Clearing My Head

I don't know what it is about being near water, but it is always very soothing for me. Yesterday I ran by the lake again... granted it is a polluted lake and when the wind blows just so, there it this odd, almost metallic smell to it.

Just the same though, I like running under an old signal bridge, and along the water. The slow, gentle ripples are the one thing moving slower than me as I doggedly jog along, being passed by roller bladers in their fluorescent shorts and bicyclists with their aerodynamic helmets and spandex.

Speedboats cruise back and forth, painting white lines in the glassy water.

The geese are gone today, but along the water are ducks lined up in a row, and every now and again I spot a robin in the grass.

As I plod along, a wee girl with pigtails paces me on her purple tricycle. For a minute, it is her and I-- neck and neck, until her mother calls her back.

Black-Eyed Pleas

I have nothing much to comment on.

The eye is much better, but is still distinct enough that I have now become a "familiar face" to even the surgeons.

I gave in and turned the air conditioner on because I was tired of waking up in a sweat from the stagnant summer air.

I turned it off again today after a cold front came through.

I am hardly running, but sweating like I have gone three times as far.

Even the grass thinks it is too hot to grow this week.

Death caught up with one of my patients this week, and there was nothing anyone could do about it.

Anniversary

Ok, so this entry is a little off. I arrived here with my friend, Ru, June 22nd last year. So much has happened here since that long, frantic drive. I remember closing on the house on the 23rd. On the 26th, I started orientation at the hospital.

Today the new interns are starting orientation, and they will be in the department next week. We are having a welcome party for them this evening. It has gone by in such a blur. If it weren't for this blog, I wouldn't be able to tell you what I was doing most of this past year. Names and faces of patients have long been forgotten. I am glad to be able to look back on bits and pieces of what I was experiencing here.

This coming year brings new responsibilities. Most of the time I will actually be in the Emergency Department, with helpful nurses and clerks that I already know. So much of last year was learning how each service did things, and I won't have to deal with that any more. Now it's time to buckle down and start carrying more patients. In our department, the second years see the bulk of the patients as the third years are busy precepting medical students and interns. While it will definitely be busy, at least I will be doing things that are relevant to my career.

The Shiner

My eye, sans makeup, in all of its glory:


Initially, there was a lot more swelling, but it does not hurt at all. It is really just an eyesore (ha ha).

Keep Your Eye on the Ball, NOT the Ball on Your Eye

Um, yeah... so we lost the softball game last night 13-20. I started off catching and managed to get injured before the end of the top half of the 1st inning.

It was all very stupid.

In our little intramural league, we don't have a lot of equipment, specifically masks for the catchers. The first time I played catcher I was intimidated by having some stranger swinging a bat with all their might just a few feet from my head. The second time I was a little bit more comfortable, and last night I hardly gave it a second thought.

And, while I stay nice and pretty far back from the plate, that doesn't give you any protection if a foul ball suddenly ricochet's off the bat and heads straight for your eye in a split second.

I didn't have time to move.

I didn't have time to think.

The softball clunked directly against the ridge of bone just above my left eye. I stood up from my crouched position, as the first thought that entered my mind was, If I fall down they're going to think I passed out and make me go into the emergency department.

The rest of the game was spent on the bench with an ice pack slapped over my eye. My vision was fine, and my head didn't really even hurt.

Today when I woke up the eye had swollen up even more and I could only open it with great effort. Dark purple and hot pink pooled blood had collected above and below my eye.

When I walked into the department this morning, everyone stared. Several of the nurses lectured me for not seeking treatment. One of my attendings was initially concerned about my vision, but once he saw that my actual eye looked fine, he switched to giggling every time he saw me the rest of the morning.

And wouldn't you know it, one of my first few patients this morning had a black eye... only hers wasn't even a quarter the size of mine, and she'd gotten it from being punched out last weekend! My attending asked me if I had any sympathy for her, and I just laughed as I had joked about immediately sending home anyone that looked better than me at the beginning of the shift.

The eye actually doesn't hurt at all. I took a good dose of ibuprofen during my shift, even though it wasn't bothering me, and by the end of the shift I was actually walking around with an open left eye as much of the swelling had gone down.

It certainly got me a lot of attention today, although none of my patients actually asked what happened. I got all sorts of nicknames today from "Lefty" to "Slugger". Not exactly how the girl who doesn't like to draw attention to herself wants her day to go. Part of me would have liked to have found an eye patch and a stuffed parrot to wear on my shoulder.

The funny thing is that tomorrow night is the big graduation dinner, and I have to get all dressed up. Too bad I don't have anything fuschia to match my eye.

I think part of my next paycheck will go to donating a catcher's mask to the team.

Wiped Out

The last two night shifts have left me wiped out. Emotionally-difficult patients, and always the less sick ones demanding more time than the really sick ones. Last night we seemed to be having a special on drunken lacerations that required a lot of time to repair. And for it being a week night, there just have been way too many patients coming in lately.

Right now, we're transitioning through the end of the year. The senior residents are done, so rather than running stuff by them, every one of us have to present to the attending directly. This wouldn't be so bad but we have been so busy lately that the attendings have been having to see patients on their own, so there ends up being a waiting line to talk to the attendings. So basically, my fastest, most-efficient coworkers are gone, so I'm feeling a little frustrated with all of the delays.

And on top of the working, there are numerous other activities going on this week, and morning meetings and simulation labs that have been keeping me busy. Fortunately, someone asked me to trade my shift tonight with them, so I can go to bed at a decent hour tonight after this evening's softball game.

Finally, the results of our national exam came back today. I am disappointed with my performance, but our program doesn't really place a whole lot of importance on the test. I didn't prepare for it at all, and that is pretty much obvious by my score. Basically, I just need to show improvement next year, and I managed to score low enough that I can pretty much guarantee that. Maybe this is the kick in the butt that I've been needing though to motivate me start seriously studying for my upcoming licensing exam next month.

In the Summer Time...

Much of this weekend was spent catching up on much-procrastinated on housework. Bleh.

On Saturday, I went down to the local farmer's market for the first time. I feasted on fresh strawberries, tomatoes, and peppers. There were plants everywhere, but I held back and only bought a rose bush to replace the one that died during the winter.

I thought I was showing pretty good restraint, and then I walked by the table of Amish baked goods, where I bought both a homemade pecan pie and a tray of coffee rolls. I have been living off the coffee rolls for the past two days. They were slathered in just enough cream cheese frosting and resting in the perfect proportion of cinnamon and sugar goo. Can you imagine more perfect food? I can't.

One of my friends dislikes the Amish. She says that they don't pay taxes, and feels it is hypocritical for them to come into the hospital as patients, particularly in the intensive care unit, given their shunning of current technology. Personally, I don't really see what the problem is. Just like any other community, I imagine that they have a hard time letting their loved ones go. And, while I don't exactly know what kind of financial resources they have, I just kind of lump them in with all of our other uninsured patients. At least they only show up for care when they absolutely need it, rather than coming in with imaginary aches and pains in order to get certain medications or a night's stay. One of our senior residents did a research project looking at return visits and costs of care for that special group of patients we call "frequent fliers". He found that 1% of the county healthcare budget went to covering costs for one of these patients alone. Now that's ridiculous!

I also went for a run along the lake, and saw several of this spring's goslings tagging along with their parents. Their feathers were still fuzzy. Although they were fairly large in size and learning to feed themselves, they still deferred to "mother goose". That's kind of what I feel like at work. Sometimes it does feel like I am just blindly following the leader, but slowly I am starting to think for myself. I had my second semi-annual evaluation this past week. Those things seem to turn out much briefer than I expect. I don't know what they are like for anyone else, but mine are just kind of "keep doing what you're doing" talks. I guess that's a good thing.

I called my father yesterday (Happy Father's Day if you celebrated!) and found out the PU's are in Montana currently. They're enjoying their RV and slowly meandering across the country to meet up with the family in July for a reunion and me at some later point.

Vegas, Baby

The rest of my vacation was pretty much spent recovering from our hike. I met up with an old college roommate and we flew to Las Vegas to see "Mamma Mia". It was a fun show, and after losing a few bucks quickly at the tables, we decided to spend the rest of our time there lounging by the pool and at the spa, which was good for my sore muscles.

I was in Phoenix long enough to witness a car accident in which someone plowed through a red light right smack into another vehicle. My friend and I left our names and numbers with the officer on scene, but as there were 2 other witnesses, I don't expect to be contacted to provide more details. Luckily, no one appeared seriously hurt.

I won't say that getting away fixed everything, but I do think that I have at least had a better attitude at work this past week. And, while the annoying people are still annoying, there's just nothing much that I can do about them, so there's not much point in worrying about stuff.

The Long Walk

Well, I finally did it: last weekend I hiked the Grand Canyon! "The Phoenix" and I stayed in a hotel a few miles from the South Rim and then awoke early the next morning to start our hike. We hiked down South Kaibab Trail, crossed the Colorado River, and hiked out along the Bright Angel Trail. We had been talking about doing this for over a year now, and this hike is the reason I had been pushing myself to run further and further.

We went all the way down and back up in one day, which is highly discouraged by the park service. Despite all of our planning and preparation, we still ended up exhausted and overheated. We hiked from 7:30 am until 9 pm, with the last mile up being in the dark. For the next two days, my legs were so sore that I was hobbling about. Fortunately, neither of us ended up seriously injured, but I don't think that I would attempt a one-day hike again.

This is the start of the South Kaibab Trail:




South Kaibab Trail is very steep and without water, but fortunately a good portion of it was in the shade at the start.




Finally, we reached the river:


This is my proof that I went all the way:


This is near Bright Angel Campground, where we stopped to take advantage of the water supply, working toilet (!), and grab a quick lunch:


Desert squirrels are a little more scruffy looking than the beasts back home:


Taken along the Bright Angel Trail on the way up:



A small group of deer crossed our path. I guess we must not have looked very threatening by that point.


Final shots during sunset:


Although I was concerned about hiking in the heat of the day, there wasn't much we could do about it besides taking frequent short breaks. I couldn't really get heat conditioned either as it was simply too cool outside back home. What I didn't account for was hiking though that big of an elevation change. We were so exhausted by the end that breathing was labored, and we had to stop every hundred yards or so to catch our breaths.

It took us 4.5 hours to get to the bottom, where we rested for 30 minutes before our 8.5 hour hike out. The hike down was about 6 miles, with a mile crossing at the river, and a more gradual 9 mile hike out. We definitely underestimated the hike though, as it was way above our fitness level. Believe it or not, on the way up, there were actually a small group of men running up the canyon!

Best of all, "The Phoenix" and I are still friends and on speaking terms after this adventure.

Dentist for a Day

My vacation started with "The Phoenix's" graduation. When you graduate from medical school, you get hooded at graduation. It's not really so much of a hood as it is a velvet sash that goes around the neck. The person doing the hooding has to have a doctorate degree. There are instructors available to hood graduates, or at our school you can be hooded by a family member. "The Phoenix" and I side-stepped this little requirement by telling our school that we were cousins.

As I was flying in the night before, "The Phoenix" picked up my gown and hood. She told me the hood was purple, which I thought was a little odd as it was green last year, but then I thought maybe it had to do with my specialty or something.

All was going well enough, until an elderly gentlemen came up from behind me and started straightening my hood. "All of us dentists have to look good," he said. So that's how I found out that purple is for dentists, whereas green is for medicine. Between me not being her cousin, and not being a dentist it was quite the misrepresentation.

Her ceremony was just as long and drawn out as mine was. Our CEO (Yes, I said CEO, not president) was there, wearing her blindingly large, gold University medallion, ala Flava Flav style.

Finally, we double-checked that the name on her diploma was correct, and booked it out of there! I remember the feeling of relief that came with having that piece of paper in my hand.