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).