My buddy the heroin addict

We're standing on rounds and the resident presents the following patient that was admitted to our team over-night:

John Doe is a 25 year old male presents with left sided facial/anterior neck swelling, left shoulder soreness and pain/parestheisas over the left buttock/thigh. He was skin popping heroin the night before last and woke up yesterday morning with these symptoms and presented to the ED…Febrile to 102 in the ED…cough, hoarse voice, a couple ulcers over his chest…CXR shows scattered infiltrate, cultures and some labs are cooking but he's got a white count and a CK>16,000. Yadda yadda yadda. This is a good case, why don't you cover him Bostonian??

I hate those words..."this is a good case" usually means that the patient will have a mildly interesting work-up but is such a pain in the ass that the residents didn't want to deal with him...

My prediction was right...he's cursed and swore through the H&P that morning. He kept telling us that he just woke up that way and was in alot of pain. He was even courteous enough to remind us that he has a tolerance to opiates. So my attending decided to throw me under the bus: "Alrighty, well we'll do our best to make your pain more tolerable and then Bostonian will be back in to talk a little later on". Thanks doc...I can't wait to work with this little ray of sunshine for the next 2 weeks.

So I come back later in the day and he's passed out, snoring away with a half finished breakfast tray in front of him...guess that extra dilaudid helped with the pain. I woke him up and got the whole story from his side of what happened. He ended up being a pretty nice guy underneath the gruff exterior and the pain was controlled. He had gone to a decent college was trying to keep his own business afloat, but he got mixed up with the wrong crowd and started using the hard stuff. I ended up having to do the patient education since I was covering him.

John: So this was pretty serious huh? I could have died from this, right?
Bostonian: Yep, if you had waited to come in, you might have been much worse off.
John: Hey, how old are you man??
Bostonian: 25
John: That sucks. We're the same age and you're here being a doctor and I could have died from heroin. That's scary man!
Bostonian: Yeah, we've had different lives. My parents were on my ass for the first 20 years of my life and your dad was an alcoholic who and won't even visit you 3 miles from home in the hospital. But the good thing is that you're young and still have your health and a business and a talent. You can change your life before the drugs kill you...alot of people don't get the wake-up call until it's too late.
John: You know I've been thinking about going back to school once I get clean. You've inspired me man, I want to do something with my life. I mean seeing you here making a difference, it's amazing. I don't want to waste my life any more.
Bostonian: I'm glad, I'll have the case manager give you some numbers for rehab programs.

Getting over your cynical preconceived notions of someone is a good thing sometimes. It gave me one of the more rewarding patient interactions in my career, but I'll always wonder how much of that was him blowing smoke up my ass to get his dilaudid and how much was genuine. I'm hoping that he's clean and back in school!

I guess you gotta wear the rose-colored glasses sometimes to hope for the best, because reality sucks sometimes.

EM in the Village

My school is affiliated with a hospital in New York's Grenwich Village and they saw fit to send me there for a few weeks of EM. For those of you unaware, the Village houses some of the more interesting people in the City living alternative lifestyles. I don't mean "alternative" in the GLBT alternative...I mean the homeless, the drug abusing, and the clueless. Here's a few of my favorite chief complaints and quotes:

29 yo F with chest pain-
Had a history of panic attacks with chest pain when riding the subway. She started having a panic attack when I was on the subway and had some chest pain...wanted to make sure it wasn't a heart attack. Her panic disorder remains untreated.

34 yo M with fever and L testicle pain/swelling-
Bostonian: Do you use any drugs?
Dude: Officially, no. This isn't going in my medical record is it?
Bostonian: I need to know because certain drugs can cause fevers and infections. Unofficially?
Dude: I dunno, just little bit of Meth.
Bostonian: What happened on your arms there? (Pointing to the relatively fresh track marks)
Dude: Ok, I use a little bit of heroin too. But only a couple times.

25 yo F with BRBPR-
Bostonian: Any change in bowel habits?
Chick: Well...not really. I just moved in with my boyfriend a few weeks ago and I can poop with him in the apartment. I hold it, sometimes all weekend.
Bostonian: Honestly, I didn't know that girls poop until medical school.
Preparing for DRE
Chick: I usually don't let guys get to this point unless there are dinner and drinks first...
Me: Um...does that mean I owe you a drink?

23 yo F- with classical migrane and possible seizure D/O
Her- OH MY GAWD...I THINK I'M GOING TO HAVE A SEIZURE!!!!!
Me- Do you always have seizures when you feel like this?
Her- No
Me- So why do you think you're going to have a seizure?
Her- Because I have a headache!!!
Me- How many seizures have you had?
Her- Like 15 since 2006. But no one believes me.
Me- Have you seen a doctor for them?
Her- I just started seeing one last month. He didn't believe me until my roomate yelled at him and made him order an MRI. He started me on Keppra a month ago which I didn't start until 3 days ago. And he gave me perscriptions for an MRI, EEG and CT scan, but I missed them all so they have to reschedule them.
Me- So you had 15 seizures and didn't see a doctor for 3 years and then you didn't follow up with your appointments or take your medication. Did you tell your neurologist about your headaches?
Her- No.

Cutting back on the drink...

A fairly put-together 30 year-old lady came in with some moderate epigastric pain and nausea for a few days. She said she over did it over the weekend before at a bachelorette party but no real other medical history besides some poorly controlled hypertension and a rapid tremor that she claimed had been there since birth. Oh...and by the way she drank about a bottle and a half of wine most nights. Labs showed elevated amylase and lipase, so we went with acute pancreatitis (alcoholic vs. gall stone). The enzymes came down after a few days of NPO and hydration and the GB U/S was clean, so we decided to send her home after she tolerated PO without pain or nausea and we were able to send her home with her tremor and hypertension. Well, the whole HTN and tremor history sounded pretty funny to me...but my attending brushed it off, so I did too...who am I to question the attending? I rotated onto the CCU team the following Monday thinking that she was doing well.

About a day after discharge, the poor girl has a seizure and spends 2 days in the ICU where she was suddenly hypotensive and dyspneic, placed on BIPAP. She got an ECHO that showed an EF around 20% due to alcoholic cardiomyopathy. Suddenly that hypertension and tremor looked a bit more noteworthy than before...I saw my attending rounding and all I could ask is "WHAT'D YOU DO???".

She ended up doing pretty well, fortunately. But missing a girl in alcohol withdrawl is kind of a big deal in my book and I hope the attending knew it. I felt aweful that I hadn't spoken up about my tingling spidey sense...not that my attending would have paid attention to me anyway.

Suck it third year

Sorry for the long lapse between posts...I was studying for my medicine exams, planning fourth year and moving, etc.

Finished my medicine shelf last friday and OSCE last Sunday...so I'm essentially onto 4th year of med school!!!!

Since then I've been couch-surfing down in Brooklyn while working in one of our affiliated ED's in Manhattan...more on that later though. For now I'm going for a nice long run in Prospect park, and I'm going to catch up on some of the non-medical parts of life...which involves a decent amount of driving around in circles up and down the east coast...I've got another week here in the ED then home for a few days next weekend, then down to see the GF down in DC for a few days. Then I've been conned into helping out with orientation for the rising third years...so it's back to NY for a few days and then my last few days of freedom before I spend the summer in some of the busier EDs in Massachusetts doing what I love to do!!! Oughtta be fun...

I'll try to get some of my better post ideas up before I'm stuck studying my face off for the summer and hanging out with my fam and the Boston crew. 

Finally LEARNING medicine

Up until this year, medical school has been a long series of arduous memorization tasks with the ultimate goal being passing an exam at the end of the course and moving onto the next exam and getting into the hospital. Then you get onto the wards and you're stuck trying to figure out how to write a note on one patient while your team has rounded on about 30 others. Slowly over a few days you figure out how to get things done and you get comfortable in that role...but then it's over and you're onto another service or specialty and essentially back to square one.

So much of third year of medical school has been an absolute waste of hours. It's incomprehensible to anyone that hasn't been through it that I could complete a total of 20 minutes of work in a day and do nothing else with the remainder. On surgery, I'd stand around in the OR holding a retractor for three hours staring at the back of someones shoulder because it was an interesting case just to spend 10 minutes writing an op note. I spent peds writing the same note on the same patient every day for a month straight. I've stood around for hours on rounds talking about the consistency of patient's stool, phlegm, nasal discharge and every other bodily fluid just because there's a teaching point burried beneath the pile of excrement. I've introduced myself to the same demented little old lady every day this week, and said goodbye as she begs me not to leave her...breaks my heart every time still. Today was the perfect example of medical educational inefficiency: 8AM-8PM Sunday call...I wrote 2 notes and one admission note, ate 2 meals, had 4 small cups of coffee and stood around watching my residents enter orders, answer pages and take admission histories for about 10 hours. Atleast my new team throws around some decent pimp questions that are clearly worded in English and logically extension from the discussion we were having on the patients...so I atleast feel less frustrated.

A funny thing is starting to happen though, something's starting to click. I'm able to answer a good portion of the pimp questions, I'm nailing down my treatment plans for alot of the more common ailments and I'm actually able to keep up with the majority of the discussions. Moreover, I feel like I can pick out and retain the pertinent parts of a history without forgetting anything too huge. I finally feel like I'm a part of the team rather than a lead weight dragging the whole process down. While I haven't really mastered my differentials, nor have I been allowed to see patients on my own, I feel like I'm getting to the point where I have a level of knowledge that allows me to eventually operate as a bumbling sub-intern.

Unfortunately, I'm going to be that bumbling sub-i running around the EDs of programs that I want to match in JULY...a mere 8 weeks away. Crap...this is all coming up waaaaay faster than I thought it would. Before you know it, I'm going to be Dr. Bostonian, PGY-1 EM resident...::gasp of horror::

Medicine...the last frontier (clerkship)

I've been in the hospital consistently since July 7th of last year...and now 5 weeks into my medicine rotation and I'm ready to gouge my eyes out with my stethoscope (I'll find a way). It seems that the more I grow as a medical student, the more I stay the same.

It's not that I'm disinterested in the material, I'm just burnt out. There's only so many months that I can go through the motions of writing patients' notes without actually synthesizing any of the decisions contained within them. Sure they let me throw in my 2 cents with regard to diet and how I think the patient is tolerating their treatment and what the lab results mean...but in the grand scheme of things, the residents do EVERYTHING. That includes saving the patients from horrible attendings who may be actively trying to kill patients (if it weren't for the Hippocratic Oath...sometimes I wonder whether they really knew what they were vowing).

Truth be told, I actually am enjoying medicine in terms of the breadth of patients that I'm seeing and the opportunity to finally flesh out my basic medical knowledge. But rounds are possibly the most painful exercise invented in the history of man. I mean really...why do I have to see the patient if we're all going to then go visit him a few minutes later and find the same findings that I did and repeat the same exact exam that I did and come to the same conclusion that I presented to you because it was what we said the plan was yesterday.

And to make things worse, why are you pimping me during hour 11 of my 12 hour weekend call day, in the middle of the emergency department on differentiating pre-renal and renal azotemia in the acute setting? No I haven't gone over the causes of acute renal failure yet because half of my patients chronically run a BUN in the 70's and a Creatinine in the 4's. Yes, this is the first healthy patient that with acute renal failure that I've ever seen that may have a slim hope of recovering function. no I still get mixed up calculating FENa ((Una/Sna)/(Ucr/Scr)???). Oh yeah, asking your indirect and vaguely worded question in broken English is not making life easier for me. Yes, I'm still going to say "I don't know" because I'm a third year medical student and I really haven't ever encountered alot of things in my clinical career because my clinical career has only been months long. And yes I still hate the kidney...despite my attendings insistance that all medical students love nephrology because it makes sense. I'm sorry, when you have 4 types of RTA numbered I thru IV where IV is not actually a tubular problem and type III is as common as a unicorn, I have already given up hope because so have most nephrologists. Sure I'll give a presentation on monday...it's not like I had other plans for my sunday like catching up on my write-ups.

Anyway, I have no idea how I'm doing thus far and I'm living for my one-week vacation before I start up with my Massachusetts-based EM electives this summer. Oh the little things in life that get me through the hours of standing there staring off into nothingness trying to look interested. ...:).

Fun with old ladies

I have a strange talent. Now I'm not going to pretend that I'm a sex symbol or anything, but old ladies seem to like me. We're talking the butt-pinching, candy-giving, giggle-inducing kind of old lady crush that I'm hoping other male medical students have induced. It must be my towering 5'8" physique with the 158 lb recreational distance runner/beer drinker buld...gets em every time. Generally these cougars are something around age > 65 and/or BMI > 40. Yeah...I'm a stud.

We had the crotchetiest old woman on our service who hated EVERYONE...my residents, my attending, the nursing staff, the food-delivery people...everyone! She kicked my resident out of the room the morning before when he went in to say good morning. The nurses put her on contact precautions so that everyone would leave her alone...I think she had C. diff in the 90's, but wasn't a really compelling case. Of course she was old and obese...s/p gastric bypass 2 years ago. Lo and behold, my married, male resident is talking to her about her medications while I'm in the room.

Old Lady: Well I'm not taking the plavix AND this blood thinner...they do the same thing!!
Resident: Well...not exactly, the lovenox is prevent you from getting another PE like last time you were here and the plavix is for the stents in your heart.
OL: I don't care I'm only taking one!!!
R: Ok then, but we need to put some other sort of DVT prevention...will you wear the thromboguards?
OL: FINE...
R: Ok, I'll go put in those orders in
::we both head towards the door and start pulling off the isolation gowns as quickly as possible to move on to the next patient::
OL: Dr. Bostonian...I didn't say that you had to go (with that creepy trying to be coy/seductive voice)
::shudder...swallow vomit...try not to laugh out loud...turn to face her::
Bostonian: Can I help you with anything Mrs. OL?
::I can hear my resident outside running down the hall to tell the rest of the team::
OL: I just wanted to talk to you for a bit...are you married?
B: Nope, but I have a girlfriend. She's a lawyer.
OL: That's nice...blah blah blah...stories about when she wasn't sick or morbidly obese...try to not look at the clock on the wall that says I have 15 minutes to see my other 2 patients before rounds...now isn't that a hoot?
::Smile politely...swallow vomit again because it really smells like C. diff in here::
B: Alrighty Mrs. OL, I have to get going to see my other patients, but I'll stop by later to say hi
::Move quickly towards door and hope to escape unscathed::
OL: Bye Dr. Bostonian...I can't wait to see you later...
::shudder::

Anyway, it happens time and time again on this service. Today I got some candy from a 73 year old who wanted to talk to me about my plans for having children in the future...uggggh. Atleast if I moonlight at a nursing home, I'll do alright...;)

Don't believe everything you read

Dictations tend to be rife with errors in the midst of the technical and precise language used to create a historical record of a patient's health care and to bill insurance companies for services rendered. I actually laughed out loud when I read this one today

Past Medical history:
"blah blah blah....and the patient is deceased. blah blah blah."

Um, no he's not. He's sitting here in the ED on a stretcher very much alive. I just talked to him like 2 minutes ago.


PS-and to drum up hits: Swine flu, Tamiflu, H1N1...that ought to get the hit counter spinning. More to come.

Why I dislike Psychiatry...

I started this post on last day of my psychology rotation. Let me start off by saying that I have IMMENSE respect for everyone that works with the mentally ill. They serve in some of the most thankless, poorly understood jobs in the world. While I'm sure I'll look back wistfully on the days where I got to sleep in until 8AM, psych has been one of the most tiring rotations of the year for me personally. I despise it and here's why:

Your patients are behind a locked door
There are some people who are just downright incapable of functioning
within society. They drive with their eyes closed, they hear voices
telling them that their neighbor is going to get them, they're bizarely dressed/unkempt/disorganized in their behavior, they're incapable of fitting into the "norm". I'm not talking about the Emo crowd that is sad because life
sucks (though their overly tight jeans do make me nervous at times). Pretty often, they're the kind of people that you'd see and cross the street to avoid because you don't feel safe. Basically your spidey-senses are telling you to stay away from them...but you still have to sit down across a table from them and try to understand where they are coming from.

Now it's not It's pretty hard to convince a patient to talk to you when you're behind locked doors. The therapeutic relationship is almost prisoner-jail keeper and I spent about 75% of my time in an adversarial role with my patients. Atleast medical patients know that they're sick, they know that they need your help and willingly accept it. Inpatient psych is kind of like trying to sell the iPhone to an isolated tribe in the amazon that has never had contact with modern man...some of them are in awe and accept willingly, while others would rather spear you and go back to their little world.

The need to fit everyone into a diagnostic box
There were some brilliant folks who sat around and thought about the way that people think. Freud had his Id, Ego and Super-Ego to explain every conscious act as the interaction between the competing forces of the unconscious world. While brilliant, it's not much more than a load of crap that he made up and wrote down while toking the ol' opium pipe. Nowadays we rely on those so-called "neurotransmitters" that become "imbalanced" and cause a person to act "crazy"...OK, that I can buy because it's scientifically based, peer reviewed research and corresponds to treatments that work.

But then we have the DSM-IV QS. It is the biggest piece of crap in the world created by psychiatrists for the express purpose of diagnosis and billing. While it is quite comprehensive, the Diagnostic and Statistical Manual makes diagnosis of patients a simple checkbox process. While it works for some people, it gives the absolute wrong impression of how we view individual psych patients and the agony that is individualizing their treatments.

The patients don't always get better
Granted, I was just doing in-patient psych, but these people have some scary things going on in their heads and we give them a couple pills and boot them out the door as soon as they're no longer a threat to themselves and others. It wasn't really satisfying to wonder "what did we actually do for this person" at the end of a 6 week stay or "what if I run into this guy on the street" or "what if her voices tell her to close her eyes while driving again and I happen to be in the other lane". Most people will stop their meds at some point and bounce back. Others just get stuck in a state institution somewhere. It's not like a STEMI or an appy or pneumonia where you can manage the acute problem and send the people on their way...they need extensive rehab to fit back into society, which they usually cant afford. It's sad.

The understanding of the diseases sucks
Sure you have Freud's theories and the neurotransmitter models, but be don't really understand the entirety of what's going on. That makes it tough to effectively design therapies and meds to fix the problem. And the side effect profiles are nasty too...


But on the bright side, I got pretty good at talking to crazy people, their families and other health care providers...

OB/GYN

I really thought I was going to despise OB/GYN. We're talking angsty, pit-of-the-stomach dread...not just the "oh man this is going to suck alot". I basically thought I was plunging back into the surgery-type dread of not wanting to get out of bed.

It turns out that it's really a lot of fun. It may have been a product of the wonderful people that I worked with in the lovely private facility with the largely private patient population, but it was a nice mixture of everything (Surgery, primary care and babies). Things that I will be taking with me for my future EM career:

1) Pelvic Exams- they're not fun for anyone, but they're not too bad once you've done a bunch of them...except with discharge, those are always bad.
2) SVD's are horrifying- Anyone who thinks that the act of birth is beautiful watches WAAAAY too much TLC or has never seen a birth. Then there's the smell...ohhh that smell of rending flesh, blood, poo and amniotic fluid...ugh.
3) Epidurals are good- You have not heard a blood curdling scream until you've heard a "natural birth." Oh good lord, every time one of those niave primips would walk through the door I would just roll my eyes and try to avoid that delivery room. I definitely learned how to sell the epidural though...something about 20+ hours of labor (aka the worst pain imaginable) without pain control made the case itself.
4) Some women just don't know when they're pregnant- it may be unfathomable to you, oh virgin teenager in the ED with your parents, but your 4 month amenorrhea and weight-gain in the uterus area kind of tipped me off.
5) Drugs and babies don't mix- Just because your first two kids were fine despite your eight-ball a day coke habit doesn't mean that this one will be. Or yes, your baby will be ok, he's just going through withdrawl from your vicodin habit...you can visit him in the NICU. And my favorite: You do realize that you'll probably want an epidural because your nasty pot-habit has caused your child to tip the scales at around 10 pounds...
6) Juno was the worst movie ever in terms of creating mis-conceptions about pregnancy
7) DIC (or disseminated intravascular coagulopathy) is scary shit...
8) intrapartum hypertension+proteinuria=magnesium
9) Don't rupture the cyst- or to quote my favorite attending "If you rupture this f---ing cyst I will literally kill you." For the record, I felt it when before she went to ultrasound.
10) Acute pelvic pain= rule out ectopic pregnancy, ovarian torsion, hemorrhagic cyst rupture, physiologic cyst rupture and PID.

I would have considered OB/Gyn as a career, but if I had to be surrounded by hormonal/pregnant/OCD women for the rest of my career I'd lose it. Never mind the patients...;)

I'm a bad blogger

So it turns out that I've been a very bad blogger over the past several months. I guess what it comes down to is spotty internet access at one clinical site and just straight up boredom on my psych rotation...and now that it's coming to a close I figure that I should probably write at least something down to show that I'm still alive.

I've just been feeling like there isn't much to write about on a day to day basis. I'm much less distressed in the clinical world and as my third year comes to a close over the next several weeks, I'll be looking back at what I've done, reflecting on how it's going to impact my near future and untimately my career/personal life.

But boy do I have stories when I get around to writing them down...these people are crazy.

Stay tuned

Hiatus

Sorry for the long Hiatus...I've been secluded away on OB/GYN away from my apartment. Between spotty interwebs access (leading to lost posts), sleep deprivation and about 30 other excuses, I haven't really had time or energy for writing much. But now the shelf exam is looming, so it's time to procrastinate.

Now when I say secluded, I mean I've been living a semi-monastic lifestyle for the past 5 weeks of the rotation. Considering that I quite litereally live in the hospital...I'm not at all suprised. But hey...it's free and I was able to sublet my apartment for a decent amount...can't complain too much. I also just got my first digtal camera (thank you Circuit City for closing), so it's time for a look inside of the monastic, semi-deprived life of the Bostonian in NY. Enjoy.

Here is the semi-anonymous hospital...if it weren't for the stupid banners touting how amazing the hospital is (and it is), you'd probably just think it was some ugly federal building.

Here is the tiny little dorm room that I've called home. Note the bottle of scotch sitting on the window sill, the lappy and general clutter everywhere. I'm in study mode...back off.

Here's the reverse view of the place...yeah I'm messy, so what. You try working my hours...;)

Anyway, I have a few posts in the chute and Psych coming up next so I'll have some decent content over the next 6 weeks or so...enjoy

Third year...

Being a third year is kind of like being a chameleon. You have to quickly adapt to your service and blend in seamlessly or risk being killed on your evals. You can never get too comfortable though; just as soon as you get used to catching babies, you have to go talk to crazy people in another hospital with a different group of people judging you on a completely different standard. Different ancillary services, different nurses, different charts, different abbreviations, different living conditions...very little carries over. But then again, you're a chameleon...you change your colors and fit in.

In the midst of this constant, whirlwind of change, you're forced to decide on where you'd like to direct your life and all you get is a short exposure to one service in one hospital. All it takes is a couple of miserable residents or a really bad day, and you've cut a career choice out of the picture permanently. Or maybe you have two options in front of you that you like equally in your experience, but you not enough information to choose between the two. Or maybe you liked nothing. Whatever the case, you have to make a career choice pretty soon.

I was fortunate. I had found my niche before third year began, and it still feels right after several months. I feel bad for all of those who have no idea at this point.

Home for the holidays

After working my butt off without a full week off since July, I'm looking forward to just hanging out with the fam and being a normal, non-medical student person for a little while.

I almost always enjoy my ride home...until I'm stuck driving on the "clear" day between two snowstorms (it snowed the entire way) on the same day when people from the southern states are all of a sudden trying to drive in the snow for the first time in who knows how many years. I only saw 4 accidents on the way and they only added 45 minutes to the ride, so it could have been alot worse...

I actually miss the Massachusetts winters. There's a routine that happens around a snowstorm, life slows down a little bit and there's a clear priority to the days affairs: get the snow out of the way and go about life. It's almost automatic, ingrained on my soul from my formative years. It could be 3 inches or 3 feet...life goes on as normal. In NY, life pretty much stops for a few inches of snow, everyone on the roads looses their mind. In DC, it takes about half an inch of the white stuff to cripple the nation's seat of power. I came home to about 6 inches on the ground and then we had about 10 more that fell on top of that...so it's a nice wintery change of pace up here. I've already hit the local ski resort up once which was great, though there's something that seems wrong about skiing corduroy the day after 10" of snow fell (but it's the east coast...I can count the number of days I've skiied powder on one hand).

I haven't really been in my usual holiday spirit this year. I think it's the all consuming nature of school coupled with the girlfriend and family being far away, my classmates being spread all over the tri-state area and my roomate being depressed because his girlfriend moved back home for the forseeable future. Despite my case of the Bah-Humbug's, I spent 6 hours of yesterday shopping for everyone with my youngest brother. I'm almost finished, just the girlfriend's mom and niece to shop for. I have to head up for their traditional Christmas Eve Party, which is always interesting since it's the only time that I interact with her massive extended family. Then it's back home for christmas day and then to upstate NY/Canada for a bachelor weekend including the world famous Dinosaur BBQ, a venture into Canada, the Pats-Bills game...and probably lots of heavy drinking in there too. I imagine we'll probably also end up in a canadian strip club at some point (which is always interesting). Then it's back home for new years in Boston with a few of the college buddies and the GF. Then I have 3 days to recover, ski and get ready for OB/GYN to destroy my sleep cycle/personal life.

Merry Christmas to you all! Until 2009...
~Bostonian

A little too close to home...

I had the lovely opportunity to spend 3 days in the NICU of my hospital. Being an ex-30 weeker with APGAR's below 5, I was a little hesitant to begin this rotation to say the least. It brought up a lot of personal feelings that I didn't know were there...like a deep appreciation for the docs and nurses that worked on me...I would have never known that I was such a giant pain in the ass for so long. There's also a sense that all of that is worth it.

It's also immensely sad to see young familes go through that kind of ordeal...I could never imagine the anguish that my parents went through over 25 years ago watching my pediatrician code me in the delivery room...I guess I turned out all right. I feel a deep attachment to the field and a fondness for everyone in the unit. It's truely a wonderful profession that they practice.

At the same time, I had this weird identity crisis thing going on every time that I would reach into an incubator to examine a baby with tubes coming out of everywhere. It was like looking back 25 years ago onto what my life was, and could have been. Rounds for the past three days have been a little too personal of an experience for me to even consider as a career option. I wouldn't be able to deal with it the first time I lost a kid...which happens. Having to code a kid in the delivery room would probably be just too much for me to handle.

But at the same time it has alot of the benefits of EM (proceedures, good lifestyle, portable practice) that I like. I just don't think I could hang through 3 years of gen peds only to have to deal while being emotionally invested in those kids for the rest of my life. It just hits a little too close to home for me.

The rest of the week the Peds ED

So I've nearly had just about every bodily substance pass by my general direction while torturing the kiddies for the past 6 days. I've seen everything from perfectly behaved children who don't even bat an eye while you poke them with needles to 4 year olds that require 5 full-sized adults to hold them down to look in the ears. I've seen parents who would do anything to make sure that their very sick children get healthy to some of the dumbest, drug addicted DNA donors that I've ever met.

What I've learned:
-A thorough H&P will pretty much give you the right diagnosis 9 times out of 10...be thorough and cautious.
-Parent's ideas of what constitutes an emergency and what is an actual medical emergency are two very different things
-Schools and daycares are germ factories. Wash your hands or you'll catch a stupid URI that will suck the life out of you.
-Kids puke for almost anything at all: Strep- puke, PNA-puke, Cold- puke, Flu- puke, AGE-puking alot, intusceception- puke, bad mood-puke, poor self image- puke,
-Not every
-Eyes are disgusting...conjunctivitis is gross, eye herpes is perhaps the scariest thing in the world.

Finally, I love the ED...undifferentiated patients, procedures, trauma, medicine, primary care, decent pace to keep me from slacking, a good lifestyle, near-instant access to resources, being the floodgates...it's awesome. Yeah, it's a shitty field in many other respects but I'll deflate that baloon full of niave optimism when the time comes.

NICU next week, with exams...should be a fun week.

Peds ED Night 1

First night in the Peds ED with my favorite attending and tolerable peds residents...it was great!

Favorite Chief Complaint of the night: "Pain in behind" with photographic evidence that I can't make this crap up. Second favorite was "congestion"...mom wanted her kid suctioned for a runny nose...discharged with reassurance.

Snow!

Being a native New Englander, the first snow is something that I've looked forward to every year since I can remember...it always makes me feel like a kid again.

I went out for my weekly long run yesterday on a quiet out-and-back route that takes me by a local pond. There was a decent chop on the pond and it wasn't even frozen over yet. I watched a few ducks diving below the surface and then popping back up into their ripples a few second later. It was a bit windy but overall a quiet December day with the occasional snowflake that would meander out of the sky and land in my eye...always in my freaking eye. I can just see myself now, running next to traffic with my face all contorted into some sort of demented wink to try and melt the snowflake on my cornea. I no longer wonder why passing motorists give me weird looks...though maybe it's the tights.

Anyway, I cruised through the first half of the run without much of a problem through the turn around point. I passed one other runner in too much pink and she let out a quick "hello" between breaths...I smiled and waved. Most runners are a friendly folks and will acknowledge you unless they're in the midst of a full-on tempo run or sprint. I stopped at the end of the path to check my watch and catch my breath for a moment before turning around. Being the friendly runner that I am, I said "good morning" to the lady crossing the street with her yellow lab. She gave me a look of disgust/"why-the-fuck-did-you-just-acknowledge-me" that is quite prevalent in the greater NY area and continued right by me as I tried to get the tightness out of my left calf and get enough oxygen into my brain to calculate my splits (8:29/mi).

All of a sudden I was hit by a C-O-L-D gust of wind and I looked up to see a wall of white absolutely flying down the hill in front of me. I thought to myself, I've never seen a snow squall come out of nowhere like this one.

The white wall enveloped me and I decided that I should get on my way. I felt like the care-free seven-year-old version of me again as I cruised along the path next to the pond, squinting my eyes to keep the snow out and leaving my footprints in the accumulating dust on the path. For those of you that have never experienced a snowfall, the sound of it is amazing. There's a background of white noise from innumerable snowflakes hitting anything in their path, and a muffled quality to the rest of the sounds that you'd normally expect. It's absolutely other-worldly.

I passed the lady with her lab in silence, as is my NY-bound cultural duty, and continued home in the snow with only the syncopated rhythm of my breathing and footfalls to keep me company.

When the hell did I get 16,000 viewings??

The combination of longer hours in the hospital, getting back into running, some peer-advisory stuff, the return of new TV (TopChef and How I Met Your Mother) and Netflix (TM) have conspired to knock the will to blog out of me lately. I've got a few ideas on the brain that might be interesting to share...but I also have my peds shelf coming up in a few weeks.

Apparently people have started to read by blog for some reason or another. I'm not quite sure why...but thank you for looking at the blog 16,000 times. I was playing around with the new gadgets so please note the addition of the followers gadget and my new countdown to the end of medical school...feel free to stick yourself on there and I'll reciprocate!

I've also started using an add-on for Firefox called Scribefire to write my posts and it's been great so far...just thought I'd share a free utility.

Normal Saline Analgesia

I've been working on the floors of a peds hospital for the past month and I finished up my last call the Saturday before Thanksgiving. I had to cover a new admit with the working diagnosis of "Chest Pain" just admitted last night. Seemed like a strange symptom in a tween, but I'm pretty much open to anything after a few months at the major referral center.

Generally, I like to approach these new patients with an open mind and go through my working differential a kind of slowly since I'm still not the brightest crayon in the box. Her symptoms were refractory to a week of antacids/PPI's and had NO identifiable triggers or patterns. Kid had a normal cardiac workup, normal pulmonary work up, clear films of the chest and abdomen, nothing out of the ordinary on labs. So I go out onto the floors to start the day and I hear what sounds like crying coming from her room...great.


Mom comes running out to ask for pain meds. So I eyeball her...and she looks like she's a little uncomfortable, but not in too much distress. She's able to answer my questions clearly through her distress and "8/10" pain. I get the story from mom and it seems like the kid has these paroxisms of stabbing, non-specifically localizable chest pain for about a week. Kid's not in any distress, so I walk away to see the other 10 patients I was covering. Motrin doesn't touch it. Tylenol #3 puts the kid in a comfortable place...problem solved.

So I sit down to write some notes about and about an hour later I hear screaming coming from the room again and mom comes out looking distressed. I stroll on over to check on the kid...10/10 pain, inconsolable, stabbing pain everywhere in her chest. But she still answers my questions and is distractable. Resident writes for some morphine and the nurse goes in a few seconds later to flush the IV and get some fluids running before she pulls the drugs out of the Pyxis.

On the way back over to the room, the nurse notices that it's unusually quiet on that side of the unit...so she palms the morphine while asking the kid how she's feeling. She feels great now, 2/10 pain. Much better!!! I'll file the normal saline analgesia trick away for the finicky attention seekers later in my career.

The difference between kids and adults when they fake:
Adults seek the rush they feel from morphine hitting their neurons,
Kids seek the rush of everyone's attention falling on them for a brief moment

Just an interesting case that I wanted to share.