Lucky you!

Doctor to 62 year old female patient: . . . And when did you go through menopause?

::Long silence::

62 year old patient: Oh, you mean the change of life? No, in my family we don't do that.

In the midst

of a particularly trying and uncomfortably full of dying children 30+ hour shift I decided to enjoy a 42 second dance party on the elevator ride down to the lobby. Turned around to leave and you guessed it. . . security cameras in the elevator.

peds and poopsicles

I went through a phase, circa age 9, when anything remotely involving the concept of poop was fall-over-laughing hysterical. For a good month I responded "pooperoni and cheese" when asked what I wanted for dinner then howled with glee for about twenty minutes.

Last night would have been a singularly joyful experience for nine year old me.

Case number 1:

Teenage-ish male took it into his head to eat oh three large bags of sunflower seeds, shells included, last weekend. Presented like clockwork yesterday with a sore bottom and constipation. After failing manual disimpaction in the ER, and finding a large mass on x-ray much like the following, he was sent to gastro.


Gastro stuck up a scope and found a 6+ cm bezoar which took him nearly an hour and a half to remove. Our patient is currently in the ward where he continues to poo out shell fragments and be generally remorseful.



Research shows that these guys have been caused by all kinds of my favorite foods: sesame seeds, pomegranate seeds, prickly pear flesh, watermelon seeds, human hair. I'll add this to my list of things I didn't know I should be afraid of but really should be.

Patient two: And the inappropriate parental comments commence

Another preteenish age boy, very sweet, recovering from surgery and having pain-medicine related slowing of the digestive system. We gave him a mild laxative to help get things moving and the previously unconcerned teen became suddenly apprehensive. With some prying he whispered that he was scared he would go in his pants or the bed.

Dad overheard the conversation and chimed in: "Don't worry about it son, you'd be just like grandma. Happens to her all the time."

Thanks, pop.


Be afraid.

faith in humanity. . . restored

We had a family of evacuees from Texas in the peds ER yesterday. They were placed in a homeless shelter temporarily, their medicaid paperwork hadn't gone through yet, parents managed to find temporary work but still haven't received their first paycheck, and all four daughters managed to pick up nasty cases of head lice. Dad spent over $200 of Rid and Nix and managed to treat three of the four girls, but the youngest daughter's lice just kept coming back. He's now out of money, scared to put any more toxic chemicals on his 3 year old's head, and the shelter won't let them back in until she's cured.

So he comes to us broke and at his wit's end. We quickly realize that the best treatment option, malathion, costs $112 per bottle. We called social work and financial advisers and they couldn't figure out a way to get the cost covered by medicaid and our pharmacy doesn't have an adequate dose on hand to treat her here. It was recommended that we give them another dose of Rid and a "good luck."

Instead, the entire medical team sat down and through genius manipulation of every possible billing code loopholes managed to arrange two free treatments here and two free follow up appointments for additional treatment if needed. Amazing.

Impossible patient of the month

A simple-sounding case came in. Middle aged woman with advanced ovarian cancer that's metastasized to the abdomen. Underwent a major abdominal surgery (small bowel resection) just about a month ago. Decided two days ago to stop taking her pain medication (because pain medicine just masks the problem and she knows there's something wrong with her and refuses to be on pain medication until her real problem is addressed). So she presents with (surprise!) abdominal pain. We've done a workup. All her labs are essentially normal and an abdominal CT shows nothing other than expected post-surgical changes.

Easy, I think to myself, and walk in to the room prepared to have a conversation about how recovering from surgery takes time and how she has a good reason to have abdominal pain and how very logical it is that she may be dependent on pain medication for a little while.

I'm not even in the door when she starts:

"You all walk in here with your glib remarks and your know-it-all answers. But I know my body and I know when something's wrong with it and telling me that the cancer or the surgery is responsible for my pain is simply unacceptable."

(Which of course is the cause of her pain, and is what I was just about to tell her). She kept going:

"Five years ago, the doctors told me I had three months to live, if I'd listened to doctors (pronounced in the same tone of voice most patients use to describe things like poop or intestinal parasites) I would have been dead four years ago."

(I resist the urge to point out that a prognosis is not exactly a direct order to die immediately when the time is up.)

She continued for a good 20 minutes, calling me glib about three more times (I still hadn't spoken), and informing me that she did research on the internet and he presentation is classic for pancreatitis. I finally timidly interject, pointing out that we looked at her pancreatic enzymes and performed a CT and that she doesn't have any indicators of pancreatitis. She gives me a look that vaguely resembles the way people look at a puppy who keeps running into a glass window. Speaking very slowly: "People are not textbooks, dear. I have never presented typically."

I finally gave up and called her surgeon who agreed to talk to her. Long story short? A terminal cancer patient with abdominal pain following abdominal surgery who refused to take pain medication for her thoroughly expected pain was admitted to the hospital for a thoroughly unnecessary workup of her aforementioned pain.

The kicker. As I walked out I peeked at her chart. She'd been requesting Dilaudid (the strongest pain medicine we have in the ED) every 30 minutes since arriving.

spread your wings

Spent yesterday morning doing weapons of mass destruction decontamination drills with the local urban search and rescue team. I left with an extraordinary increase in my level of trust in our government. The resources committed to saving lives in the event of any kind of disaster- the thought, planning, training, equipment: just unbelievable. We really have a warehouse filled with enough medical and rescue equipment to save thousands of lives. And it can be deployed within hours. It was really awe-inspiring. And it's always fun to dress up in a uniform and play with heavy equipment in the company of local firefighters.

Then last night was my first Lifeflight shift. We ride fixed wing flights and effect hospital transports for patients too sick to be treated out in the community hospitals who wouldn't tolerate an ambulance ride to the capital. Neither of my patients were really sick or exciting but they definitely wouldn't have done well on a three hour car ride. It was absolutely beautiful flying over New Mexico as the sun came up. And again, got to wear a jumpsuit which is always a bonus. The EMS crews have taken to calling us me a "baby doc." (Code for med student) Very cute, although I do worry that some of the patients may have gotten the false impression that I'm a neonatologist.

This week has been a crazy one in the hospital. Insane trauma after insane trauma, the capstone of which came in last night while the trauma bay was already completely filled. A young yard worker came in with a tree branch through his heart. We wandered through the trauma bay on our way back from delivering a patient upstairs and the ED looked like a full on war zone.

Something in the water? Full moon spillover? Well, wish me luck on my shift tonight. . .

Case of the day

An urban legend comes to life!

A paramedic was at home eating a peanut butter cup when he accidentally inhaled a bit of it. He tried to do the Heimlech maneuver on himself, his wife tried as well, no luck.

So what does he do?

He grabs a kitchen knife and performs a cricotracheotomy on himself. (For the non-medical, he cut a hole into the front of his neck, and then stuck his finger through it and into his trachea below the obstructing peanut butter cup.)

Yeah. Pretty hard-core.

The beeper message when he came in was my favorite part: "Criked himself."



Careful this Halloween!

overheard in disaster medicine course lecture

"Bottom line is no one's going to want to go shopping in a supermarket where a bunch of radioactive cesium's been dispersed. I'm pretty sure."

Jerk

Stick with this story, it gets better and better.

1. 30ish year old dood with girlfriend and young son in tow drinks 12 beers, gets in car, crashes car into a parked truck.

2. When Mr. D hears police coming, he gets out of his car and begins running, leaving injured girlfriend and child in car.

3. When caught by police, acts remarkably appropriately, cooperates, expresses concern for his family in the car, states that he had some beers, and that he is not injured.

4. Police mention that he is not a first-offender, is going to be charged with a felony, and will probably do jail time. All of a sudden Mr. D's "entire body hurts" and he falls to the ground "unresponsive."

5. Mr. D is brought to the ER and continues to play possum for. . . 9 hours. We stuck a catheter in him, performed sternum rub after sternum rub, multiple IVs, no response. Yet he miraculously was seen looking around, scratching his head, and readjusting his blankets every time he though he was alone. When caught, right back to playing dead.

Now our ED was absolutely packed this night and there were people literally sitting in the hallway with crushed limbs waiting for a bed. And Mr. D? Lying there taking a nap while his family, who are actual injured patients, are being scanned and sutured and splinted, and while other actually sick patients are out in the waiting room because he's tying up a bed in some incomprehensibly selfish (and short-sighted) bid to avoid a felony charge.

6. Mr. D ends up being scanned and x-rayed to the tune of several thousand dollars, since he's now been persistently "unresponsive" with no discernible cause for six hours.

7. Finally, at 6:30 am, the attending had enough. A rather vigorous finger pinch with a pair of trauma shears miraculously raises our patient from the dead. Hallelujah! He has no idea where he is, no idea what's happened for the past ten hours, he hurts all over, he's so so concerned about his family. He knows he messed up, it's never going to happen again, he's going to get into treatment today, he just wants to know his kid is okay.

8. I halfway fall for it, give the guy the benefit of doubt, sneak him in to see his girlfriend, check the various body parts he claims are injured (essentially his entire body), and arrange for a few more x-rays to be safe.

9. 8am. Mr. D leaves the hospital, abandoning his girlfriend, his injured child, the team that spent the past ten hours treating his uninjured, smelly, drunk, lying self. I spend close to an hour (after my overnight shift) looking for him, thinking maybe, in spite of everything, he was legitimately injured and is hurt or lost. I call security. I walk through all the bathrooms. I call the police in case he's hurt out on the streets. No luck.

10. 9:10am I go in to tell the girlfriend that I can't find Mr. D, ask if she knows where he might be. "That bastard left us in the hospital again!"

Yup, this is not the first time.

Scary!

Ms. M was a very sweet 23 year old woman who was involved in a minor car accident this morning. She went over to Other Major Emergency Department complaining of some minor neck and abdominal pain. They examined her, took x-rays of her neck and sent her home with some ibuprofen, end of story.

She comes back to our ED about six hours later complaining of continued abdominal cramping and a gush of vaginal bleeding when she went to the bathroom earlier. She states that her last period was about five weeks ago and that it's been pretty much regular every month until then. I order a quick pregnancy test, thinking maybe she's 5-6 weeks pregnant and having a spontaneous abortion, draw some labs, and go back to examine her.

So her exam is essentially normal except for some stretch marks on her stomach and a fullness in her lower abdomen that feel remarkably like uterus full of baby. Strange for someone who's last period was only five weeks ago.

Well, I set up for a pelvic exam, sit down at the foot of the bed, lift the sheet. . . and there is fully formed loop of umbilical cord protruding from her entirely open cervix. . . which has a head pushed up against it. This young lady was not having a spontaneous abortion, she was in full-on labor. The bleeding she felt earlier was apparently her water breaking.

I rushed out, trying my very best to look like a calm and competent professional and not like the scared medical student I was, and called ob-gyn. End of the story, this young woman was more than six months pregnant. She had no idea. The baby, by now, had no heartbeat, and she ended up being rushed to OR to deliver the dead fetus.

It's impossible to say when the pregnancy terminated, but I can't help but wonder if the other hospital had caught the pregnancy this morning if she might have been able to successfully deliver. I don't know.

Moral of the story: Every single woman who could conceivably, remotely be pregnant must must must must have a pregnancy test no matter what they come in complaining of.

(The triage nurse apparently took this lesson to heart, my next patient was a 71 year old woman with abdominal pain. The triage sheet helpfully stated "urine pregnancy test negative.")

Overheard on rounds

Resident: "Mr. Z is an 77 year old alcoholic homeless gentleman who was hospitalized for three months. He was released yesterday to a Motel 6, immediately drank a fifth of vodka, and was brought in by ambulance after being seen falling down multiple times."

Attending: "Well there's your problem, he should've stayed at a Holiday Inn."

Balloons!

Pretty right? Unfortunately, last night's shift brought not one but two balloon related patients to my domain. I knew it was just a matter of time, I'd heard this happens every year. The first case was a sad, though not too terribly surprising, case of balloon meets electric wire, catches on fire, and people jump out. I feel somewhat responsible too, I was just thinking to myself as I entered my shift how lucky we were that there hadn't been any balloon accidents this year. Totally jinxed us.

The second event involved this famous balloon:

A young father, PC, brought his son to the fiesta to collect pins (all the balloon owners make small pin representations of their balloons and lots of locals collect them over the years). Now PC was lucky enough to get the last darth vader balloon pin. A group of young men noticed this, and not-so-politely asked that he hand the pin over. PC declined, saying he was starting a collection for his son. The young men were not so satisfied with this response, followed PC to the parking lot, and beat him up. He came in with a tremendously dislocated finger, I mean almost not attached to his hand anymore, and cuts all over his face and neck from where they had kicked him. While he was down. For a balloon fiesta pin.

He was one of the sweetest, most delightful patients I've had, even after I and three orthopedic surgeons literally pulled on his dislocated thumb with all our might for just about twenty minutes.

The happy ending? He still has the darth vader pin. He turned to me as he was leaving for surgery, "It was totally, totally worth it doc."

Mean people suck

My night was filled with sewing up person after person who drank too much and did something stupid ("play-fighting with butcher knives" "drunk cactus-trimming with a machete" "falling out of moving vehicle" "riding bike down main road the wrong way wearing all black with no helmet on").

The running excitement through the shift was provided by my first patient, a twenty-something young man with pretty severe stomach pain, constipation, and vomiting for a day. The twist? He is a 450 pound twenty-something young man with pretty severe stomach pain, constipation, and vomiting for a day. We pretty desperately needed to do a CT scan and he. . . can't fit into the scanner. The surgery team actually called the zoo in the morning to find out if they had a veterinary scanner we could use. I know it should be kind of funny but the guy was just so sweet and I wanted so much to be able to treat him and it was really sad. I was so embarrassed for him and frustrated that we weren't able to give him the care he should have received. We had similar trouble with x-rays, he couldn't fit on the radiology table and his abdomen shape prevented us from getting a good view of the intestines.

Finally, the morning was capped off with an oh so emergent "back pain for two months and peeing a lot," (Yeah, she ended up waiting 15 hours in the waiting room. Yes, literally.) This turned out to be an oh so awkward case of I-may-be-pregnant-but-I'm-in-denial-so-I'm-going-to-ignore-three-months-of-not-having-my-period-and-throwing-up-every-morning-and-my-swollen-breasts-and -rapidly-enlarging-lower-abdomen-and-just-hope-it-all-goes-away-on-its-own-itis.

And of course she came in with her mother. And of course she didn't want her mother to find out. Now she has a new pregnancy and pain so we have to do an ultrasound to make sure the baby is in the uterus. So I had to keep weirdly think up legitimate reasons to ask the mom to leave the room so we could do all these exams for what the mother thinks is just some back pain. Well good luck to her.

Grey's Anatomy moment of the day

Informing a deaf boy that his previously healthy 55 year old grandfather had died using a ballpoint pen and a piece of printer paper. Something about having that conversation in writing made it so much more sad and real.

Tough stuff.

Trauma bay quote of the day

Young man comes in after being stabbed with a butcher knife in the buttocks, both arms, and lower abdomen. Doctor begins a head to toe exam, pushing on his spine, stomach, neck, head etc. to assess for injuries.

Doctor: Tell me where it hurts.
Patient: Ummm, mostly where there are holes in me.


Logical.

Poignant triage note of the month

Patient presents for third time in two days with hornet stings, open sores on foot, and bruise. Needs money to get belongings off Greyhound bus. Also needs help finding an apartment. Also needs someone.

Aww, don't we all.

Back in the game

So after two fly-by dreamy months in big east coast inner city ED, I've moved out westward and am currently in Overcrowded Understaffed University ED. The patients are sicker, the waits are longer, the traumas more traumatic. The waiting room looks like the aftermath of a war zone. Dozens of moaning, bleeding, vomiting, figures strewn about the chairs and the floor, crouching under airplane-sized white blankets in various states of misery. The wait can be eight hours or more.

One of the doctors reassured me that "if they survive the waiting room, they can't be that sick."

Oh, and students are allowed to write orders, meaning that I'm am actually treating my patients essentially on my own. The theoretical one-to-one student to attending ratio flies out the window when seven trauma/resuscitation cases come in the door at once, every single doctor runs off to the trauma room, and I'm left alone managing literally the entire team's patients for four hours. I do my best to make absolutely no decisions of any importance during those times. Although doing nothing is a bold decision as well when one of the patients is an active GI bleeder, and six different nurses implore me to write orders for pain medications I've never heard of for patients I haven't seen.

Once in a while my attending will pop by and rattle off a list of about 20 things to do that I've never done before. It goes much like this: "Order pain meds for the patients in 43, and 47, whatever you want to give them. Change 41's antibiotic to something more broad-spectrum and then discharge her with a laxative. Order procedural sedation and find the sedation cart for 53, look up how to reduce luxatio erecta shoulder dislocations and be ready to do it, put an NG tube down 37 and lavage him to clear once now and once in twenty minutes, look at 39's x-rays, call ortho, and describe her fracture to them." Then he zooms off down the hall and disappears to trauma-land for another three hours.

I imagine this will be a fantastic place to learn once I get my sea-legs. Right now I feel like I've played a simulator game a few times and suddenly find myself piloting a commercial airline with no backup. I theoretically know what to do but. . .

The good news is zero people died under my watch, I did successfully reduce the shoulder dislocation, my GI bleeder stayed stable, and I actually sent three of my patients home feeling better.

Working overnight tonight, I have to go study my pain medication dosages.

As you can tell

from the lack of recent posts, I'm finding family medicine less than inspiring. 72% of the patients have what amounts to the sniffles or a pulled muscle but will not leave until prescribed entirely unnecessary painkillers and/or antibiotics. 3% are undertreated psychiatric patients. A good 21% are lonely or depressed and just come by to have someone to talk to/something to do. The remaining 4% that are actually in need of a doctor are immediately referred away to the emergency room or to a specialist.

By far the most interesting thing that happens at the clinic is that the receptionist's bra always, and I mean always, perfectly matches her shoes. And they're different colors every day. Impressive.


The one part I have enjoyed is the walk from my house to the clinic. It's about an hour walk, the clinic is located on the outskirts of the city almost in the desert, and on the way I pass through the Bedouin market, which is always a neat reminder that I am definitely not in Maryland anymore. Yesterday, I passed a boy grazing his cows in the community park, and this morning two old women rode by me, side-saddle, on mules. The patients sometimes stop by the market on the way to the clinic so we get gifts of herbs or tapestries or, occasionally, a chicken or two.

To make the culture shock as dramatic as humanly possible my first fourth-year elective is smack in the center of New York. I start one 12 hour flight and four days from now. I am beyond excited to be able to speak English with my patients, to use needles with safety caps, and to be back in the ER again.

It's going to be tough though to be back in NY and not be doing theater. I have a constant inner impulse telling me to tear off my gloves, walk out of the hospital, get some new headshots, and start going out to open calls.

Well, someone needs to save the world I guess. Are you ready for me New York?

Socialized healthcare strikes again

I entered my clinic the other day to find my supervising doctor furtively folding a New England Journal of Medicine article and sliding it into unmarked envelopes.

I should explain that this is the doctor who snuck into his own clinic and tore down all the ceiling fans overnight in order to get them to install air-conditioning. A year later, he actually tore down all the internal walls in order to convince the government to pay for renovation. So I was, let's say, concerned. I enjoy working in a clinic with walls.

He didn't explain himself but throughout the rest of the day he muttered to himself and made multiple threatening and vague-sounding phone calls in between patients.

In the afternoon, the story came out. In Israel, the outpatient clinics are funded by the government, doctors are paid a steady salary. To assure quality, doctors are reviewed every year and receive either a financial "punishment" or "reward" based on their performance.

Now how are they reviewed? The blood sugar level (HbA1C) and blood lipid levels (cholesterol, etc.) as well as a few other measurements of all their patients are averaged and the doctor is assigned a quality score based on the health of their patients.

A flawed system? Obviously. I mean, obviously. The system basically encourages doctors to refer away their sick or difficult patients. It also pushes towards treating numbers, to overmedicaton possibly.

So my attending refused to do this, he's been refusing to play the numbers game for years, and as one of the most respected and experienced doctors in the area, he receives the most difficult and elderly patients, pushing his score down even more.

So this year, not only has he been financially penalized again, but they want to bring him before a review board. Meanwhile, two new studies have shown that overly controlling diabetes actually increases mortality. So my doctor is refusing to go to his hearing until he receives a written apology from the committee for penalizing him and an admission that he's actually been the only one, according to this new study, who has been appropriately and safely treating his diabetic patients. He's also been anonymously mailing copies of the article and making threatening phone calls.

I really hope this turns out his way, though I'm pretty sure it won't. This man has 40 years of experience, built his clinic from the ground up, works 60+ hours a week, treats the kinds of cases most family physicians wouldn't touch with a 50 foot pole wrapped in liability waivers, and is loved, I mean loved, by his patients. And he may lose his practice precisely because he chooses to treat sick people instead of healthy ones and to treat patients instead of blood tests.

So it goes.

Who says drug companies don't spend their money wisely?

Patient(bursting in without an appointment): I saw a commercial for a drug! I need you to give it to me.
Doctor: Do you know the name of the drug?
Patient: It was on tv! With the people! It's supposed to work good. I need it.
Doctor: Well, do you know what the drug is for?
Patient: It's. A. Pill. The one with the commercial on tv!! It was on the tv! Last night! For people. To feel better. They said it works really really good. I need a pill that works good! Give it to me.



Later in the conversation. . .
Doctor: ::gives up:: Okay, we can talk about medication in a minute. Is there anything else I can help you with.
Patient: My shoes have anxiety.

not to be read at the dinner table

Warning, I'm going to touch on both religion and politics. So polite company, this is not for you!

I've been asked a few times about the involvement of religion in the Israeli healthcare system. This is a topic that's difficult to confine to a blog post, and one that I'm by no means an expert in, but I'm happy to offer a few anecdotes.

Israel is a strange bird. Its a tremendously modern country that prides itself on being cutting-edge and technologically relevant, and especially in healthcare, practices tend towards the liberal side. The level of service we provide is not too disimilar from what I experienced in America. The doctors are up to date on the literature, we have all the technology you would expect in a major hospital, and the socialized system covers basic needs very nicely (prescriptions, diagnostic tests, necessary surgeries, checkups and prenatal care, and visits to specialists are all compensated).

But by nature of living in a country that holds some very large and deeply conservative communities (who wield significant political sway), we're confronted with religious issues on a daily basis.

Some examples:

-The abortion policy here is liberal to an extreme. Abortions are covered by health insurance if "medically indicated" (presence of birth defect such as Down Syndrome, cardiac defects, etc., risk to the health of the mother, unmarried mother (!))and can even be performed legally through the third trimester (although many doctors refuse to do this). I personally witnessed a mid-second trimester abortion that was performed for strictly social reasons, a teenage mother, and as liberal as I am that pushed the boundaries of my tolerance, for sure.

The hospital is very permissive (appropriately, I believe) of doctors who feel uncomfortable performing abortions for religious or personal reasons. However, doctors are required to provide prenatal counseling including genetic screening and to educate about birth control methods (which are covered by insurance).

On the flip side, many of our patients (and a percentage of physicians)are deeply conservative. The Bedouin population our hospital serves have a long history of consanguinity and a birth defects prevalence to prove it. They also tend to marry young and have as many children as possible. It's not uncommon for these patients to risk their lives, and that of their unborn child, by refusing c-sections or life-saving medical procedures because it is so important to them to preserve their fertility.

We also see quite a few patients who have refused any prenatal care or genetic testing, despite their significant risk factors, because they believe that their health is simply in god's hands. It's impossible for me to argue with their belief system, but it's difficult when complications do occur, they change their minds about healthcare, and arrive to the hospital expecting us to pick up the pieces (and to take responsibility for the outcome.)

- A small subset of the ultra-orthodox in Jerusalem have stopped vaccinating their children according to the order of their Rabbi (the health-is-in-the-hands-of-god-until-someone-actually-gets-sick argument). Within my six weeks of pediatrics, I saw four cases of measles, one of which resulted in major neurologic complications, and one which proved fatal. Again, I try to be respectful of their decision, but it's very difficult when I see children suffering for the choices of their parents. In addition, when these children come into the small emergency room with measles, they put all the immunocompromised children in the waiting room and the ward at risk.

-I completed my pediatrics rotation at a private religious hospital. This hospital remained open on Shabbat (Friday night and Saturday) BUT- no lab tests, no diagnostic imaging, and no writing. That's correct. The already understaffed ER is allowed only to provide immediately life-save services without the benefit of basic diagnostic information. In addition, they rely on volunteers to do any writing that needs to be done which slows down the already vastly backed up ER to such an extent that children with real emergency sometimes had to wait up to four hours to see a physician (who won't actually be able to diagnose or treat them fully).

In my mind, it would be better to simply close the ER and let the patients with emergencies go to a public ER where they can be treated appropriately. I volunteered one Friday evening and was so horrified I ended up leaving early. I have no problem with doctors choosing not to work on Shabbat or on closing the hospital entirely. But to provide half-healthcare in my mind is almost worse than providing nothing at all.

On the positive side, government run hospitals and clinics are fully functional through the holidays with one major exception that I wrote about in the fall.

So it's really a mixed bag here. The contrasts can be quite shocking. I don't see religion interfering too much in hospital policy. To the contrary, actually. But by the very nature of this country, it's still a daily issue, and a constant consideration.

I love neurology

"Good morning, I am Dr. Honest. This morning you will do a neurologic exam. You will do it all wrong. I will be mean. Let's go."

And that's pretty much how it went down.

Giardia

is creepy, right?

Overheard in neurology

"I tapped her knee, attempting to elicit a reflex, and accidentally shocked her into another personality."

<-- it's a good idea to read your charts.

Welcome to neurology

"It's going to be a long and terrible day." - Chief resident upon seeing us.

Apparently the neurology department is not super happy about having students.

Back to the psych ward

I'm back from a way too short six day jaunt to the states. My oh-so-typical suburban neighborhood took on a new magical shine through the eyes of my fresh off the plane husband. (It looks just like the movies!)

Today's patient of the day: In his late 40s with syphilis inspired dementia, the only way they were able to convince him to stay in the dementia ward was to tell him that he works there. He takes his work very seriously, assisting the cleaning crews, helping the nurses wheel their carts, and moving the other patients around the ward when he isn't happy with where they're sitting. Today he assigned himself the job of watching the tea pitcher and "assisting" the other patients in pouring themselves the right amount of tea. If they pour what he perceives to be the wrong amount of tea? He chastises them, takes the cup, spills it over their head, and guides them back to their seat.

The nurse seemed to feel this was benign enough not to merit intervention so we got to watch him do this about six times during our fifteen minute tour of the ward.

In other news, I managed to get hopelessly behind my training schedule for the triathlon despite my very best intentions. Luckily there are three weeks to go so I'm going to try my very best to un-jet-lag fast, make up for the lost time over the next two weeks, and then hope for the best.

article time!

The article.

You've probably already encountered it. It's about the anti-anorexia legislation passed in France.

I have mixed feelings. I do have the feeling that it's effectively impossible to be a healthy-sized female in this western universe that we inhabit and not have a hidden suspicion that life would be just a wee bit better if we were just a wee bit smaller. So I support, 100%, the idea of legislation that attempts to change pro-anorexia/pro-skinny thinking on a large-scale basis. It's amazing really. Two years in jail! I love that it's taking a stand, a bold stand. And yes, yes, yes, a change must be made. A big one.

But on the other hand I do believe in free speech. And if we're going to prosecute websites for promoting unhealthy-and-possibly-lethal lifestyle choices, we might as well shut down half the internet.

I'm on my way out to go on a bike trip in the desert with the adolescent psychiatric ward. I love this rotation. . .

On-call in the peds ER

(details changed for confidentiality of course)

A few evenings ago I spent my on-call night in the pediatric ER, one of my very favorite places of the hospital. The majority of the night was your usual mix of earaches, coughs, diarrhea, minor head trauma, an endless stream of parents who wanted antibiotics for their children's clearly viral minor illnesses, and an adorable three year old with a toy truck in his esophagus who prompted an irritating argument with the ear-nose-throat resident who didn't feel this was an emergency and wanted the child to sit in the ER with a truck in his throat until morning surgery hours. (While we agreed that the child was technically stable it's pretty tough to explain to parents that yes, we're just going to just leave the toy there until the morning because the ENT is hoping it passes on its own).

There was also a two year old with a painless limp who'd just learned how to drink from a cup and was very excited to show this off. "Cup!!" he shouted, and there went his urine sample. He was so delighted by our shocked response that he spent much of the rest of the night running up and down the hallway screaming "pee-pee!" and looking for other sample cups to drink. (Luckily the limp slowed him down enough that we were generally able to catch him before he got anything into his mouth).

And then, around 1am there was a case that stopped me in my tracks. It started out unassumingly: a really sweet young woman in high school with a few days of high fever and muscle aches. We didn't suspect anything specific but she looked really miserable so we took x-rays, drew some blood, and did a pretty thorough exam looking for a source of fever.

Everything came back negative except her blood tests: which came back abysmal, awful, worst-case-scenario. And it was like time stopped. We're thinking we'll see something consistent with a virus, with a bacteria, maybe a normal blood count- and what we get back could be a lot of things but the only thing that really explains it well (I don't even want to write it) well, it's cancer.

There was before, when we were joking with her and the parents, and after, when we ask her questions we hadn't thought relevant before: weight loss, night sweats- and she answers yes to all them, and we now need to tell her and her family that they're not going home tonight with antibiotics like they'd imagined.

I feel mildly responsible since I'm the one who took the-blood-sample-that-changed-a-life.

I've been checking on her every day and so far there are no conclusive results. We're still ruling out viruses and gallstones and she had a CT late last night that I'm going to go over and check. So it could all turn out to be nothing. I'm endlessly optimistic.

There's just something strange about the fates that led me to be there at that *moment* when the flu turned into maybe-cancer. As a student and an EMT I've been present at so many of these turning points, before-grandpa-died to after-grandpa-died, before-my-leg-was-amputated to after.

It's strange to be a witness to these seconds that turn worlds around.

To be involved and to care and to take these stories home with me at the end of the day and yet also to be completely uninvolved, really irrelevant to what they're going through- just another face in a white coat that they'll maybe remember and maybe not.

Excerpts from psychiatric interviews

-Why are you here? "I Bit off the ear of a cat." Why? "Why not?"

- How are you feeling today? "I'd like to make hamburgers from everyone's penis."

-Reason for admission: "Killed wife with a squeegee."

-Do you speak English?
"I speak every language in the world."
Great! Do you mind if I ask you some questions?
"All the words I say are bullshit. Music is the only truth. I can only talk to you if you have a guitar."
::proceeds to sing the entire rest of the interview::

-"Hasn't slept in three days. Presented to surgery department requesting general anesthesia so he could take a nap. Refused to speak to any psychiatrist other than Freud himself."


I adore psychiatry. I've always found normal people in all their normal craziness fascinating. I love that my actual job these days is to sit and just talk and get to hear all their stories. We also get to go to morning activities with the patients. Yesterday was karaoke. The picture you have in your head of psychiatric patients singing karaoke- pretty much exactly what it was like.

A surprising number of patients stop me in the hallway and tell me that they can see my soul. One told me that he can tell I have a good soul. That's always nice to hear. Another told me that he's the manager of the world and he's going to take care of everything for me. Yay!

Of course there's a difficult side: the depression and the suicides and the medical-student-syndrome of daily diagnosing myself with every psychiatric illness I've seen that given day. There are also these absolute moments of sanity and clarity from the patients, these moments that I really connect with them and enjoy them and understand them, and all of a sudden their psychosis, hospitalization, the things they've done without understanding what they've done, the things they lost. . . it's tragic really. And hard to wrap my head around.

So I keep talking to them and enjoying them and trying to find those little moments of connection. And hey, I'm getting school credit for singing karaoke.

Joy!

Overseen at lunch today (in the psychiatric hospital quad):

A dignified looking middle-aged man strolled out onto the grass where we were eating, performed a perfect back somersault, stood up, and walked away.

Welcome to psychiatry!

Head doctor: It's a good idea to keep your name tags on you at all times. This allows the staff to know they can let you out.

Journal club: Empathy as Emotional Labor

The article.

Now this article is old news, it was published in JAMA in 2005. But our psychiatry tutor brought it up this morning and I just had to look it up.

For those of you who don't feel like reading, it's basically an article that examined the "work" involved in displaying empathy for your patients when you may or may not actually feel it and whether practicing your ability to act empathetic is a valuable component of medical education and training.

The conclusion they came to:

Although deep acting is preferred, physicians may rely on surface acting when immediate emotional and cognitive understanding of patients is impossible. Overall, we contend that physicians are more effective healers—and enjoy more professional satisfaction—when they engage in the process of empathy. We urge physicians first to recognize that their work has an element of emotional labor and, second, to consciously practice deep and surface acting to empathize with their patients.

My favorite part of the article is the flowchart demonstrating the effect of actually caring about your patients. Okay, I'm being cynical. But seriously, we now need a flowchart to show us that actually caring about patients is better than pretending to care about patients? (And that pretending to care about patients is better than nothing at all)?

The article then goes on to detail methods of acting empathetic when you're not particularly inspired to feel empathy.

I had two instant and absolutely contradictory reactions to the article.

My first reaction:
Really? We need an article teaching us how to pretend to care about patients? Really?

Because isn't this, theoretically, the entire reason most of us go into medicine? And isn't there something very very wrong that we need an article teaching us how to fake compassion for our patients?

My second reaction:
Wait a minute. Actually, we desperately need this article.

Maybe what this article means, maybe it isn't about acting, pretending, faking. Maybe this is about professionalism.

When I worked at Starbucks I smiled at every single customer no matter what. And I recommended our drink of the day with enthusiasm and cheer regardless of what I actually felt inside for said beverage. (Egg-nog latte. ::shudder::)

And isn't medicine, in its own way, customer service. We're here to make people feel better. And a hand on the shoulder, an understanding look, a sympathetic nod, is undoubtedly as important a part of healing as the medicines we prescribe (to my mind anyway).

So perhaps, who cares what you're feeling inside? Maybe it's 100% right to practice your best understanding head-tilt in the mirror. If you make the patient feel understood and cared for and that facilitates their healing and well-being, woo-hoo!

So I'm ambivalent. As much as I agree that this is the most essential, integral component of what we do, it just rubs me the wrong way that we need an article of "tips" for tricking patients into thinking we care when we don't.

What do you think?

Overseen everywhere

This is my all-time favorite hospital safety poster. (Okay, second to the one featuring a young child walking into a bonfire with a big red "no" x across it).

The title of this gem is "Earthquake Safety." It's especially dear to my heart because I have actually experienced an earthquake in Israel. Tragically, I had not yet seen this poster.

Now, having seen it, I know the right thing to do (in any situation!):

1. Am I alone? Kneel. Pray. Sit under a table and cry.
2. Alone in a hospital bed? Launch a tiny UFO.
3. In a room with a patient? Kill my patient (or balance a tiny UFO on their face? Debatable). Pray for forgiveness. Sit under the bed and cry.



I see this poster every day. I love it even more every time. (And welcome any other interpretations).

Triathlon training in the desert: the aftermath.

A photo essay.



p.s. This was with sunblock.
p.p.s. Spf 30.
p.p.p.s. At 7am.

strange fact of the day

Most schizophrenics are born in the winter.

Hmmm.

overseen in a class email

Welcome to psychiatry!

"At 0830 the group will move off to the classroom where the majority of activities will be held Which is located in the bomb shelter of ward 20. Late-comers will have to find their way alone."

Babies babies babies babies babies!

It's awfully presumptious to say that I "delivered" someone's baby. I mean really, really, really, she did all the work. So I will say that I caught a baby yesterday. All by myself for the first time!

She was 5cm dilated and her water had just broken when the midwife handed me the delivery package and told me to take over. Since she had 5cm more to go, I figured I had a fair amount of time to prepare. It took me about three minutes to find a gown that fit me: the ER had large, extra large, and extra extra large gowns placed on the shelves labeled large, medium, and small, respectively. I finally settled on large, and hurried back into the delivery cubicle (our delivery center is a teeny bit overcrowded).


Then the gloves. Now these are sterile gloves. The point of them is to open the package and put them on while touching only the insides so that the outer glove doesn't become contaminated by the amusement park for bacteria that is my hands. This is not a difficult thing to do. I however, get all shaky and weird whenever I'm being watched, and cannot seem to put the things on without contaminating them, tearing them, ending up with three fingers in the pinky hole, or all of the above at once.

So of course now, with the midwife, the nurse, the patient, and the top of the baby's head all staring at me, I had no chance. I misaligned the fingers and spent at least three minutes awkwardly squinching my fingers against each other trying to inch the glove onto my index finger as, to my horror, the baby's entire head suddenly appeared on the bed.

The nurse strongly suggested that perhaps I should stop playing with my gloves and consider delivering the baby in question.

I did as instructed, clamped and cut the cord, drew cord blood, massaged the uterus, and delivered the placenta without dropping or breaking anything (or anyone).

And it was a boy!

While I have no desire to be an obstetrician, and despite my feelings about our delivery ward (I would prefer to give birth to quadruplet porcupines alone in a rice paddy in a snowstorm than spend even part of my delivery at this hospital - another story for another time) this is definitely the most joyful thing that happens in a hospital. It's neat to have been a part of it. Today was a day that made me start feeling like maybe just meeeeeebeeeee I might be able to do this whole doctor thing.

That feeling will instantaneously dissolve the next time I have to put an IV in or take arterial blood gasses or do a pelvic exam. But it's a nice feeling.

Even better, today was free HIV test day. Negative, baby!

Chief complaint of the day

"I think my cervix is falling out."

An open letter to my golden retriever puppy

Dear Luka,

You are not tied up because I don't love you. You are not tied up because you were a bad puppy or because you poop all over the rugs every month or so.

You are tied up because you have eaten, in the past six months, five pairs of underwear, three pens, two name tags, seven socks, an entire Princess Barbie plastic medical kit, and a plastic bag.

Now I don't mind that I am currently wearing emergency back-up underwear that I bought at the drug store; and while it's not my all-time favorite pastime, I don't even mind observing your. . . outputs to make sure that everything that goes in come out the other side.

But despite the fact that I have no randomized double-blind studies to confirm this, I have a strong clinical suspicion that not pooing out household objects is much better for your digestive system than pooing out household objects.

So you are tied up for your own good. Because I love you and your intestines. Please stop looking at me like that.

Love,
mommy

Superstition

I consider myself to be about averagely superstitious. I'll walk under ladders, I've broken more mirrors than I can remember (stress makes me clumsy- not a stellar character trait for a future doctor), Friday the 13th is just a day.

But I have my little things. Like when I was a competitive kayaker, I had to do exactly the same warm-up before every race. And when I did theater, I had a very precise sequence of vocal exercises before every show/audition. I also had a lucky belly-button ring for extra-important auditions only.

I find myself playing little mind games now in the hospital. If I'm standing in a complicated surgery, I force myself to breathe evenly and slowly and pay very close attention to what's going on. This started as a little joke with myself when I got bored during operations. One of my classmates is really big on Reiki and energy healing. Inspired by him, I would amuse myself while I was standing and holding retractors for eight hours by trying to focus all my positive energy on the patient and see if I could, for example, slow down their heart rate or bring up their blood pressure. I was variably successful, as you might imagine.

But now, once in a while, we'll be operation a patient I particularly like, and I find myself playing that little game, but for real. Like if I focus hard enough on the monitors and I think positive thoughts into their room, maybe it will make a difference.

So this weekend, one of our high risk pregnancy patients lost her baby. Which obviously comes with the territory of high risk pregnancy. Now I know I had absolutely nothing to do with it. But a little part of me feels uncomfortable, because it was a surprise. She was in the ward only for observation because she'd lost a baby before at the same week; and for the week she was there everything looked fine with her pregnancy. The doctors weren't worried about her. I wasn't worried about her. And part of me feels like we let our guard down. Like we weren't sending enough mental energy her way.

Which is silliness. Stuff and nonsense. I know! You can't save someone by worrying about them or thinking about them. If that was the case, we wouldn't need doctors at all, just parents.

But I see the power that a smile has, that holding someone's hand has. A lot happens in the hospital that has a lot to do with healing and very little to do with medicine. And vice versa as well.

So I imagine I'll keep playing my little mind games as long as it makes me feel like I'm doing something when there's really nothing to be done.

Behind the curtains: gynecology

I had three patients in the same room in the gyn ward who were so thematically similar it was like a Grey's Anatomy episode.

Patient 1:

-Mrs. Fertile was in the ward for bilateral tubal ligation. The reason? She's had two children while on the pill, followed by two children with an IUD. Supereggs!! On a more serious note, she suffers from pretty major depression which she relates partially to the four "unwanted" children. We joked a lot about how we could remove all her reproductive organs and she'd probably still find a way to have three more kids. I actually do believe her tubal ligation won't even slow her down. Her fetuses find a way.

Her case was such a strange contrast to the 90% of women in the ward who were there for miscarriages, ectopic pregnancies, endometrial cancer. We're used to women who are absolutely desperate to have babies and can't. We joked about it so much because it was such a welcome relief from all the bad news, but it was also a big reminder that there's only so much we can do with medicine, sometimes the fates will just have their way.

Patient 2:

Mrs. B is a middle aged woman who's had continuous very light vaginal bleeding since menopause. All tests showed that this was just benign overgrowth of the uterine walls, and there was no need for invasive treatment. We explained that we could prescribe medication that would cut back the amount of bleeding. She did a trial of the medication and it worked, she had spotting only occasionally, no intolerable side effects.

Then, she came back with a letter from her Rabbi ordaining that she must have a hysterectomy. The reason: Religious Jews practice "T'harat habayit," literally purity of the house. The couple must refrain from contact for the entire duration of the woman's period and seven additional days after that. So every time a woman bleeds, she effectively cannot touch her husband for 12-14 days. In Mrs. B's case, because she didn't know when she was going to have spotting, she was risking "impurity" every time she was with her husband because she might have bleeding during the act.

It's actually very logical, from a religious perspective, for her to have the operation. From a medical perspective, I see a woman going through a major and unnecessary surgery for an, in my opinion, antiquated religious practice. The surgery turned out to be rather unpleasant and complicated and it felt so. . . just unnecessary to me. On the other hand, it will probably improve the quality of her life dramatically.

Summary: I'm ambiguous on this one. I suppose I have to come down in favor of treating the entire patient, so in this case, the surgical option was the one that improves her life the most and therefore the best treatment. As you, darling readers, will come to realize, I'm just generally strongly in favor of the least invasive treatment possible, so it's hard for me to endorse surgery for no real medical indication. Moving on. ..

Patient 3:

Ms. H, a 41 year old Bedouin unmarried virgin with major uterine tumors that were causing her life-threatening bleeding. The absolute best option for her was a complete hysterectomy. The complication? She still hopes to be married and an infertile woman has no chance of securing a husband. Even though she has very little hope of securing a husband, or having a healthy child if she does, at the age of 41.

Another interesting complication to her care is that it is very very important that her virginity be maintained, which means absolutely no vaginal exams of any type, including transvaginal ultrasound.

In the end we did a fertility-sparing myectomy, just removing as much of the tumors as possible without damaging the uterus. Again, a complicated surgery. Again, I feel that we did the best we could given her circumstance, but I don't know that I can say it was the best possible care from a medical perspective.


These things come up all the time, I'll write more about the prenatal diagnosis stuff we encounter later this week. The one thing this always highlights for me is the difference between a competent doctor, one who would offer the best possible medical care, and an excellent doctor, who realizes that sometimes the best medical care isn't the best patient care. It's a fine line.

Panic! In the ER

The avian flu incident:

First I need to explain the way our ER "functions." After triage, the patients wander/are wheeled over to the nurses' desk, wait for an overworked nurse to notice them standing there, inform the nurse that they are indeed patients and would like to, I don't know, lie down and be treated. The nurse then takes a glance around the ER trying to find an empty bed, gets interrupted by a dozen or so other wandering patients, disgruntled physicians, couriers on bicycles (they drive around the hospital on three-wheeled bikes), and then eventually remembers the patient and directs him or her to a bed.

So I was not surprised, as I awkwardly hovered around the desk waiting to be asked to stick needles in people, when a young man sauntered up to me, tapped me on the shoulder, and asked where he was supposed to go. A nurse intercepted when it became clear that he was a patient, and began to try to find him a bed. She casually asked him what his complaint was.

"I work with chickens and I think I have avian flu."

And then. . . chaos and despair! Three nurses converge trying to get a mask on the guy, trying to figure out if he needs to be isolated, where he should be isolated, how much isolation is necessary, whether the whole ER should be quarantined, whether we all needed to put on HAZMAT suits. The doctor I was following began frantically flipping through the avian flu protocol binder (the avian flu protocol is about 50 pages long). Then ::whoof:: all the doctors and nurses effectively disappeared for about 45 minutes leaving one resident and I alone to basically run the ER.

I actually never found out what happened in the end, I'll have to check on Sunday. I overheard the chief attending telling someone he was sure this wasn't avian flu and thought all the precautions were silliness- but who knows?

I of course, like any good medical student, have been obsessively monitoring myself for signs/symptoms of fever since I got home last night.

So far so good.

Emergency rooms. . . not just for emergencies

Our first patient's chief complaint (after her initial complaint that it had taken us too long to see her):

"Two years of painful intercourse."

Oh rrrrrrly?

Overheard on rounds:

"Mrs. F has had two live births and seven elective abortions. She uses no method of birth control."

Perks of the profession

The doctor I've been following this week, a high risk obstetrician, received a sack of just-picked tomatoes from a very satisfied Bedouin couple the other day.

He's also received, in addition to lots of yummy produce, more than fifteen chickens and ducks. (And a goat, which he politely declined). His kids are raising them in the backyard.

Yay for rural health care!

People are special

A middle aged woman with three children came in for pre-op rounds one afternoon last week. These rounds are pretty simple: we talk to the patient about why we feel they need surgery, explain the procedure to them, answer any questions, and then they sign the release forms.

This case was clear: she had had an operation a few months ago for an ovarian mass that was suspicious for cancer. During the operation they removed most of the tumor (which did turn out to be cancerous). But the lab reports showed that the surgical margins were not clear, some tumor had been left in her body.

They called her in immediately to schedule a second operation. When she arrived, her doctor explained everything to her, and told her that he wanted her to have surgery the next day.

"Oh, no." She replied, "tomorrow doesn't work for me."

We asked if the next week was better for her.

Nope, next week didn't work for her either. Couldn't we wait until April?

Her doctor explained to her beautifully how important this surgery was. That ovarian cancer can be aggressive, can spread quickly, that putting off her surgery could be really dangerous for her.

She was unmoved. This month just really wasn't convenient for her.

It took about twenty minutes of cajoling to get the reason out of her. And the reason?

She wants to lose weight and look amazing for her nephew's bar mitzva next month. And she gained weight and didn't look good after her last operation. So, long story short, there is absolutely no way to convince her to have the surgery before the bar mitzva.

Now because Israel is socialized, it's nearly impossible to schedule elective surgeries in a timely manner. This means that if she doesn't have the urgent surgery now, we might not be able to schedule it again until June.

She understood all this and still left without scheduling the surgery.

And I feel like we failed. And I feel that she let down her family, let down her body, let down the team of doctors that put a lot of thought and energy into her well-being.

It was disappointing.

But there you go.

On a side note. . .

I may or may not have just been exposed to avian flu.

Overseen in the ER

"More money is spent on breast enlargements and Viagra than on Alzheimer's research. This means that in the year 2020, much of the population will have huge breast and huge erections and be entirely unable to remember what to do with them."

I am ashamed. . .

Embarrassed. (<-- curse you extraneous consonants.) Abashed. Chagrined.
Humbled even.
I have become that which I scorned.
I have become an American who lives abroad.
And drinks. . . americanos.

What's an americano? Basically a shot of espresso diluted in a cup of hot water.

Wikipedia elaborates: One popular explanation for the name is that it was originally intended as an insult to Americans, who wanted their espresso diluted. During the Second World War, American occupational forces in Italy searched for the "cup of joe" they were accustomed to at home, which local baristas tried to emulate for them.[1] If this is the case, many American coffee drinkers are either unaware of or unfazed by the derogatory nature of the name, even in some cases going so far as to misinterpret americano as being a uniquely American way to drink espresso

Except that Wikipedia errs. I am fazed by the derogatory nature of the name. When I worked at Starbucks, I was horrified to discover that the drink named after our country was in fact basically espresso tea. I almost spit it out the first time I had a sip. It's everything that's bitter and harsh about espresso combined with everything that's boring and pointless about hot water. It nowhere near approaches the happiness that is a cup of actual coffee.

I quickly put two and two together and figured that the name probably arose from some European hotel barrista trying to approximate drip coffee for picky American tourists. And I swore that I would not perpetuate this slander, this myth that an americano bears even a passing resemblance to actual coffee. And, even worse, that my weak American taste buds can't handle real coffee unless it's diluted tenfold. And it just seems so lame, so typical to be an American ordering an americano.


And then it happened. I had been on-call the night before, delivering babies, saving lives, the usual. Okay, actually just delivering babies. I was too tired for tea. Couldn't handle the thought of another capuccino or nescafe (Israeli instant coffee) and my friend in line in front of me ordered an Americano. And against all better judgment, when it was my turn I found myself saying, "I'll have the same."

And I put a teeny bit of milk in, pretending it was normal coffee. And then, to my shock and horror. It actually kind of did taste a little bit like actual coffee. Bear in mind that I have not had actual coffee in about ten months, so my sense memory may be moderately distorted at this point. But it was kind of yummy. Not too milky, not too strong.

And this has become my drink of choice. And I cringe a bit inside every time I order it and try to use my best Israeli accent which doesn't fool anybody.

My name is T. I am an American. I am an americano drinker.
Sad.

Today was. . .

chock full of fetuses.

Which is to be expected from my obstetrics/gynecology rotation, I suppose.

We are currently 30 students rotating in two gynecology wards, two high-risk pregnancy wards, post-delivery care, multiple outpatient clinics, one emergency room, surgical day care, and labor and delivery. Each of those venues can accommodate between one and six students on a given day. We are paired with different students every day. We are also each on-call in labor and delivery or the women's ER 3-5 nights during the rotation. Our schedule approaches the complexity of most moderately sized military operation.

Today I accidentally ended up in the outpatient OR dedicated to abortions when I was scheduled to be in the gynecology ward. This led to a different kind of day than I had first anticipated.

Israel has relatively liberal abortion policies and extensive prenatal screening programs so this OR is a busy one. To be honest, I don't find it all that upsetting. Well, that's not true. I find all surgery vaguely upsetting and violent and unnatural. Especially the ones where we take internal organs out and throw them away and/or place foreign objects, such as giant plastic intestine snaps, in. I appreciate the results, ie survival, but something about it feels so wrong to me. And I didn't go through all of our clinical days, communication skills afternoons, and empathetic body language role-play weekends to poke sleeping people all day.

Moral of the story, I don't find the abortions disturbing. But it was a downer of a day anyway. Our population here is largely Bedouin, and the entire focus of their culture is children. And they're very quiet and stoic. But you can feel the desperation for a healthy pregnancy. There was a women there today, exactly my age, with six children. (What have I been doing with my life?!) This was her first pregnancy loss. She wasn't visibly upset, but right before the procedure she looked so scared, and my Arabic isn't remotely good enough to say anything comforting. Meh, it was one of those days.

I obsessively watch Scrubs to cheer myself up. I vaguely consider this time educational. Sadly, like all medical students, I tend towards the obsessive and refuse to just watch my favorite episodes. I have to watch them in order. From season 1 episode 1. This means sitting through the annoying "extra special" Scrubs(es?) where they get all serious for no justifiable reason.

So that's today. Tomorrow promises a long night of vaginal bleeding in the women's ER. Till then. . .

Overheard in the women's ER

Chief Attending to a group of students on a hospital tour: "This ER serves as the gynecologic trash can of Southern Israel."

Overseen in the gynecologic ER

The doctor pointed out the word "Virgo" written in bold across the top of an 18 year old patient's chart and asked me why it was important. I should have realized that we probably had a translation/spelling error at play, but it was the middle of the night and I wasn't thinking at my brightest, so I sat for a good ten minutes trying to figure what a zodiac sign could possibly have to do with women's health.

The answer of course is that the doctor just doesn't know how to spell virgin and he guessed. (They write it in English on the charts in order to not embarrass the patients. Despite all the other equally if not more embarrassing personal medical information also written in the chart). And the clinical significance is that we don't do transvaginal ultrasound on virgins because we'd have to break the hymen.

This is not as exciting as finding out that Virgos are more susceptible to, I don't know, ruptured ovarian cysts when the moon is in Capricorn. But reassuring to find out that my sign is not, in fact, of medical significance.

Highlights of my Israeli wedding- a cautionary tale

After explicit and vaguely violent assertions that yes he absolutely, positively had years and years of experience with American wedding cakes and he understood exactly what I wanted and I definitely, assuredly did not need to bring him pictures or check on the cake myself because he is the world expert on wedding cakes, this is what our Israeli wedding planner came up with:



My guess is that he googled "American wedding cake" about two hours before the wedding, pasted together four cakes he happened to have back in the kitchen, tried to hide the icing mistakes with ribbons, put it on the giant roll-y thing in an effort to disguise the fact that it's about 1/16th the size a wedding cake is actually supposed to be, then remembered as he was rolling it out that I had requested flowers, so he grabbed a giant pink plastic flower most likely left over from a bar mitzah the previous day and threw it on top. Very creative, actually.
(Note: this is actually the way the cake looked when it was first wheeled out. This is our wedding cake at it's very best. This is not, as it may appear, our wedding cake after a long night of drinking tequila, making out with strippers, and dancing on bars.)

And then, the ceremony itself. . .
Our actual conversation with the DJ:
DJ: When do you want the sparklers?
Husband and I: No. No sparklers. We do not want sparklers.
DJ: They're included in the price.
Husband and I: We don't want sparklers at our wedding.
DJ: I was thinking just when the bride walks in.
Me: ::As emphatically no as possible:: No no no no no no no. (I even had my husband repeat this is better Hebrew for emphasis)
DJ: Oh, so you don't want sparklers?
Us: Correct, no sparklers.

life in Israel

My Israeli husband: I'm taking you on a new bike trail tomorrow.
Me: Will it be crowded?
MIH: No, it was supposed to be a lot of people, but everyone else backed out because they're scared of the kazaam rockets.
Me: Are you worried about the kazaam rockets?
MIH: No.

Okay then.

Overseen on the ward (ob-gyn)

On a box of hospital gloves:

"Shield gloves from sunlight, fluorescent lights, x-rays, moisture, excessive warmth, and ozone."

So these medical gloves cannot be used outside, inside, in hospitals, in human orifices, or at high altitudes.

Useful.

overheard in the ward

Ornery older gentleman as a fellow student struggled with an IV insertion:

"First the holocaust, now this."

things change

(Warning: I'm going to describe some surgery stuff and some real life stuff that might be on the icky/disturbing side.)

For some paradoxical reason, this surgery rotation, rather than desensitizing me, has started to make me more sensitive than I've ever been before. I've never been one to be disturbed by tv violence, by the news, even by the actual trauma I've seen in the ER or working on ambulances.

But despite my rather extensive exposure to blood and guts and pain, recently I find myself haunted by a few scenes. Just more upset than I should have been. For longer than I really should have been.

I've been living in Israel for long enough to have vaguely adjusted to things exploding near me. And car crash after car crash. And shockingly substandard (or different-standard) medical care.
But it's been a weird month for me.
It started with a trauma surgery two weeks ago. We passed a nasty-looking car crash on the way in to the hospital. The driver was being wheeled in to surgery just as we arrived. He was clearly not going to make it- it took nearly 40 minutes to get him to the hospital and into surgery, his heart was not beating upon admission (but revived with CPR), and the medics who brought him in had not made any significant efforts to stop bleeding or provide patient care at all that I could tell. I'll spare boring details, but his blood tests showed levels of lactic acid and carbon dioxide incompatible with life, his pupils were unresponsive, his blood pressure was around 30.

Since his heart was still beating though, we had to go through the motions of doing everything we could. What ensued was a five hour mess of a surgery during which we removed both his legs and cut open both his abdomen and chest (twice). He finally died on the way from the OR to the recovery room.

The surgery itself was punctuated by frequent arguments between the anesthesiologists and surgeons, between the general surgeons and the orthopedist, between everyone and the nurses. For the first 15 minutes the patient's leg was spurting blood, but the orthopedist was unconvinced that this was a problem worthy of his attention- and the general surgeons refused to control the bleeding until the orthopedist had decided whether or not he wanted to amputate. This argument was punctuated by the anesthesiologist pointing out every three minutes that the patient's blood pressure had not risen about 30 this entire time, so they needed to do something. As nothing was decided about the leg, it continued to bleed while the general surgeons went ahead with exploratory abdominal surgery. (I asked the anesthesiologist if we should do something, he said it really didn't matter and went back to arguing with the blood bank on the telephone.)

I can't figure out what was so upsetting to me about all this. For one thing, it was a dramatically violent surgery on a dramatically injured young person. But also, it just felt to me like we were throwing money, supplies, time, blood, energy into this hopeless case. And it felt so deeply disrespectful to me. If he's already dead, and you're treating him as though he's not going to survive, then let him die with his legs intact and organs on the inside. And then of course I had the feeling I always do when patients die where it feels to me like we could have done so much better or more than we did.

But I've seen all that before, I can't figure out why this has been bothering me so much.

Then to follow that up there was our entirely unnecessary and disastrous two-day whipple procedure (another story for another time).

And the recent Israel drama. They've been showing footage on the news of the second Dimona suicide bomber being shot. While he's already down on the ground. And I can't argue that he shouldn't have been shot- it was certainly justified. But after all the trauma of the week, the last thing I want to see while I'm on the treadmill at the gym is a man being shot while he's down. Regardless of the situation. Don't want to see it.

And that's something that wouldn't have bothered me a few months ago. And really bothers me now.

Or maybe it's all just wildly misplaced wedding jitters :-)

preop rounds

I believed after my first day of surgery, that nothing could be more awkward, inefficient, or generally unproductive and uncomfortable for everyone that morning rounds.

Day 1 involved a team of literally, I exaggerate not, 27 doctors, students, and nurses. We trooped from bed to bed- well actually we kind of just collectively turned in the direction of the beds because there isn't actually room to move during morning rounds. The doctor of the day looks at the patient, looks confused, looks at the chart, looks again at the patient, checks the name on the bed to confirm that the patient in the bed is at all related to the chart he's holding, and then reads the admission from the chart. Bonus points if they make no eye contact with the patient whatsoever. Double bonus points if they accidentally refer to the patient as the opposite gender than they are during the entire report. (And of course all time high score if they refer to the patient as obese at least three times during the presentation.)

Then about half the doctors poke the relevant body parts, then force all the students to poke said body parts again. Especially if they hurt. Most of the surgeons are Russian, so we get the added benefit of Russians translating Hebrew to English. It's an extraordinary learning environment really. And fun for the sick people!

So I believed I was relatively inured to insensitivity and dehumanization. I had not yet experienced pre-op rounds.

Background: Patients at our hospital are not allowed to know who their surgeon is before surgery. I'm not 100% sure why, but something with socialized health care and being a community hospital. To ensure that this anonymity is maintained, each surgical patient must be examined and interviewed by every single surgeon.

At the same time.

Let's set the scene. You are a person. Probably not feeling your all time best. Perhaps a little bit apprehensive about your upcoming surgery. Possibly your medical condition involves a private or sensitive body part.

You show up to the basement of the hospital and are led into a bomb shelter like room (which is actually a bomb shelter) containing an examining table behind a curtain in the corner, a desk, and a circle of 20 - 30 doctors and students with a chair in the middle.

You sit in the middle of the circle while these 20+ strangers discuss your possibly embarrassing medical condition and fire questions at you from all directions.

You then go over to the examination table behind the curtain, take of the necessary amount of clothing, and squeezing into the tiny examining corner 5-7 at a time, every single doctor examines you.

We students felt a bit odd about it and tried at first to get lost in the crowd and not subject the poor patient to, for example, 27 intimate examinations of their rectal fistula. But the doctors always seem to notice and insist upon every single one of us palpating the testicle until we've all felt the hernias to his satisfaction.

It's absurd. Even more so in practice, I can't seem to describe it right, but the general atmosphere of the whole thing is pretty much what I imagine aliens would do to the first human being they discover.

The strange, and good part I suppose, is that the patients don't seem to mind at all. Or even to find it unusual.

And healthcare goes on. . .

moment of the day

Context: Discussing the one-complication-after-the-next Whipple procedure we performed yesterday.

Student: I'm not exactly sure, but I thought I saw a spleen in the trash at one point during the operation.
Doctor: Ah yes. Another complication of surgery.

Not amusing in the sense that Mr. yellow lost his spleen due to a surgeon's hand slip. Amusing in the sense that I immediately pictured informing patients that a rare but disturbing side effect of their coming surgery is spleens spontaneously appearing in trash cans.


On a related note, after surgeries of this ilk, patients often have to be fed initially through a tube directly into their small intestine. Our head surgeon absolutely insists that when this was first done in France the meal of choice was eggs, cheese, and wine. We of course were dubious as to the legitimacy of this, but he insisted that it was not only true, but actually logical. Eggs and cheese for calories and protein. And the wine? "It goes well with breakfast. And helps with depression." Exact quote.

today . . .

I scrubbed into a Whipple procedure.

A gallbladder exploded on me.

I got a bikini wax.

How was your day?

Our hospital has magic tubes! Every room has a pipe with a small opening that travels up through the ceiling. You stick blood vials/lab orders in glass capsules, pop them in the tube, punch in a room number and the capsule magically zooms through the walls of the hospital and is plopped down in the room you sent it to.

I adore the magic tubes.

Or I did until 1:44 am Tuesday night.

Let's go back. . . I had been in the hospital since 7:50am, awake since 5am. It was my first night in the surgical side of the ER. (Israeli hospitals have multiple emergency rooms: surgical, internal, gynecologic/obstetric, and pediatric). And the ER was jumping.

The on-call surgeon has a teeny little office in the middle of the ER. Israelis are tougher than Americans, so instead of being wheeled in, or waiting in beds, they walk themselves on in to the office and then the surgeon decides if they're sick enough to need a bed.

Now- the little tiny surgery office closet is also home to the ER's only magic tunnel. Which means that about 7 times per interview the machine makes various groaning and clunking sounds and then loudly gives birth to a tube filled with lab results. And about three times per interview a nurse or doctor will run in, throw some tubes in a capsule and send them on their way, a process which makes about the amount of suctioning noise I imagine is necessary to vacuum seven to nine 747s up the tube.

This was fascinating and delightful to me for about the first hour.

Some of my favorite calls of the night:

Mr. M, a 30something Ethiopian immigrant who drank two liters (yes, two liters) of all-purpose kitchen cleaner. "The lemon flavored one," the nurse made sure to inform us. He entered the ER yelling and flailing and making as much of a scene as possible. This disturbed the surgeon, who clearly prefers anesthetized patients, so I was given the job of getting him to calm down and finding out exactly why he drank two liters of kitchen cleaner.

The calming down part I never really succeeded, but he readily volunteered that he drank the kitchen cleaner because he wants to die. "Why?" I asked. "No happy in tummy."

The orthopedist who happened to be walking by quipped: "well at least it's clean now."

Heh.

My favorite patient of the night was a 19 year old girl who'd been bitten on the lip by her Pekinese. She was unvaccinated. Her dog, all vaccinations up to date.

The facial surgeon took a look and advised that she get a few stitches to align her lower lip. She asked if needles were involved, we explained that it's difficult to insert stitches into skin without something sharp and pointy being involved but that we would numb her and she'd only feel one prick. She panicked, refused the stitches, and tried to get discharged. Her father literally dragged her back and said that she had to have the stitches because she was way too pretty to mess it up with a scarred lip.

After about 15 minutes of arguing she reluctantly agreed, and cried and screamed and squirmed through the entire procedure. Halfway through her father goes: "you didn't make this much of a scene with your breasts." Turns out, little miss terrified of needles has had two elective breast enhancements (they didn't turn out big enough the first time).

The thing that's the strangest to me about all this is that daddy payed for two breast enhancements, and vaccinated his dog, but she has received zero of her scheduled vaccines.

People are special.