Priorities

Me: Good morning Mr. here-every-three-days-for-dialysis-because-you-commited-medicaid-fraud-and-can't-get-a-chair-without-coming-through-the-emergency-department. How can I help you today?

Him: "I need some chocolate ice cream with a fork."

::pause::

"And dialysis."

Good morning!

I walked in to my first patient's room this morning, a schizophrenic alcoholic brought in by ambulance to sleep it off, and was greeted by a giant boozy hug. It was a good minute and a half before I could disentangle.

"How are you doing today?"

"Well, doctor," (another hug), "I peed myself. Also, can you look at my rash, I think I got some of them bugs on me again."


Lesson of the day: Bring a change of scrubs. Always.

Chief complaint of the day

"Bugs in vagina."


(She was right).

AAAAH!

First patient of the morning: R eye gouged out in bar fight.

And I was right in the middle of breakfast. This is the one circumstance where I am so so glad (for the patient's sake) that he's completely sloshy. He will not be happy when he sobers up.

Not an auspicious way to start the night

"So, patient in 43 was out with some friends when a car pulled over with two men in it who offered her 2 adderall. For unknown reasons, she accepted and took them. . .

overheard at morning changeover

"Patient 3, is well, literally a crack ho, I guess there's not a better way to say it. So she was out working last night and one of her clients brought her in for agitation. . . this is probably attributable to the crack."

Overheard

Staff physician nextdoor to a very very frequent flier:

"Hello sir! I've seen you here a few times before. What brings you back?"

Patient: Wasn't me, I've never been here before.

SP: Actually you were here two weeks ago, and one week before that, only you were wearing an eye patch last time.

Patient: Wasn't me.

SP: Sir, it was you. All your other features are exactly the same.

Emergency of the night

A for-real triage note:

"23 female Pt complains of lower abdominal pain, crampy in nature, for two days. Pain has been accompanied by vaginal bleeding. She has had similar symptoms frequently in the past and thought she should get it checked out."

Actual chief complaint of the week

Circa 4am:

"Okay, so I'm a dancer and I found an amazing new move on Asianpoledancing.com or something like that and I practiced it a bunch of times at home but I don't have a pole at home so I just practiced in my living room. When I got into work tonight I thought I'd try it out but I swung out too far and hit my knee on the pole and cracked it. I was going to keep working cause I only made $8 so far and only one free drink but my manager said I had to come to the ER because he needs my booty on duty."

Later that evening I overheard her repeating the story to a friend on her phone only the last line became ". . .he needs my hole on the pole."

(Her manager apparently speaks entirely in dirty rhymes).

Her knee was fine so I'm sure all her body parts are back hard at work tonight.

Class.

with friends like these

We got a strange overhead page mid-shift this evening requesting all available staff immediately to the front sidewalk. We get there and find a young woman lying unconscious on the ground with a note on her stomach that reads "took heroin, not breathing."

We just caught a glimpse of the car that dropped her off driving away.

Happy holidays us.

a far too typical patient encounter, Monday edition

Me: Do you use any illicit drugs?

Patient: No way doc, I gave all that stuff up. I'm totally clean now. A new man. No drugs for me.

Me: Okay. So when was the last time you used any drugs?

Patient: Saturday.

Weird night.

On call last night I got not one, but four, unrelated calls from four different wards on four different patients with four entirely unique medical problems. Every single one of these gentlemen was experiencing. . .

A bleeding penis.

And of course each of the four different nurses prefaced their call with "Hey, doctor, you probably want to come take a look at this."

(For the records, whenever a call starts that way, it will almost indefinitely lead to something I really really don't, thanks for asking, want to take a look at).

Now they each turned out to have four different and perfectly valid excuses for having blood in their urine.

But still. Really weird.

And awkward for me when I received repeat calls that evening:

"Hey doc, it's me the nurse with the patient with the bleeding penis. . ."

Me: "I'm sorry. . . can you describe which bleeding penis you're with?"

Guess the medical condition

Middle age lay-d presents to the ED with the chief complaint: "I couldn't find the tv remote."

See if you can guess what actual medical-condition-mixed-with-a-dash-of-human-folly precipitated this emergency-department-at-one-am worthy disaster.

. . . .

. . . .

. . . .

I'll tell ya.

So lay-d has multiple medical problems including diabetes, heart failure, high blood pressure, previous heart attack etc. She was sitting on the couch a few weeks ago watching her stories when a television ad came on: "You may be able to control your diabetes with diet alone," proclaimed the ad.

Excited, the woman heaved herself off the couch, gleefully discarded her 12 daily medications and made herself lunch. "I eat a diet!" She thought. "That should control my diabetes." (And heart failure and blood pressure and coronary artery disease too? Well, why not).

As the weeks progressed, she started to notice her legs swelling. Then she became short of breath, developed a cough, her arms swelled up, her chest started hurting. . .

None of this concerned her too much, life went on. Until. . . the evening of admission. Lay-d woke up from her afternoon nap and her eyes were swollen shut.

She groped around for the tv remote. Unable to find it, in a (hehe) blind panic, she yelled for her neighbor to call an ambulance. Not to transport to the hospital, oh no, to "fix my eyes so I can find the g-d tv remote".

Wisely, EMS realized that her "diet" of whatever foods she feels like eating is not exactly the kind of diet that will cure diabetes, coronary artery disease, and congestive heart failure, and they brought her in to our ED. . . in florid heart failure with a blood glucose >400.

Once in a while, I'm proud I don't own a tv.

Phone call of the day

We're an underfunded, understaffed community hospital, so I've gotten quite used to labs not being drawn, medications being given hours to days after they were initially ordered, charts getting lost. (It's a running "joke" here that orders should really be called gentle suggestions).

Anyway . . . mix ups, omissions, oversights, I pretty much count on them.

But this morning's error of commission caught even me off guard (and this is word for word):

"Good morning Dr. S, it's Nurse Jack on 4E. Your patient in room 63 was having some pain this morning and I know she's written for tylenol but I accidentally put in an IV and gave her 2mg of IV morphine."

::confused silence::

"Can you write an order for IV placement and the morphine for me?"

I actually did write the order after checking on the patient, though I had to file an incident report as well. At least I can relax a little, now that IV morphine has been written for, I can be relatively assured that my patient will never get it again. :-)

Welcome to the Community Hospital

New intern, day 1, patient 1:

Hey S, can you help me out with one of my patients? He's already been cleared by psych twice and they're refusing to come see him again, but every time I go near him he hides under the bed and starts screaming that I'm killing him with my word bullets to his brain.

Yes please

Do wake me up at 2am 5 minutes into the only 17 minutes of sleep I'll get with the following phone call:

"Hi Dr.! It's that nursing student! Remember? You ordered some labs for me to draw a few hours ago? Well, I just drew the tube for her CBC (blood count, looking for anemia) and her blood looks so dark and thick, I don't think she could have anemia! Her blood just looks so good. Do you still want me to send it to the lab?"

Now as much as I want to believe that my nursing students are magical and can actually perform a complete blood count just by looking, I decided to yes, still send it to the lab just in case. The patient's hemoglobin level turned out to be just above the level you'd expect from an average cucumber, or starving vampire. She's receiving her second blood transfusion now.

I love the nursing staff her, and the students, and it was actually really cute. Just would have been cuter at 2 pm.

What goes around

Comes back around.

One of my patients got pissy a few days ago and decided to walk out of the hospital before discharge was complete barefoot, in his hospital gown, with his central line in place (like a giant IV that goes into a vein below his collarbone and is sewn into his skin).

Security couldn't find him and he was technically no longer a patient, his paperwork had gone through, so we just let it go and figured he'd come back for his clothes at some point.

He wandered back in around 9pm last night with the chief complaint "take this IV out of my nipple."

Turns out his plan had been to cover the line with tin foil and just leave it in forever. But he got really drunk on Sunday and his buddies were making fun of the line and pulling on it and he lost the piece of tinfoil and it was starting to hurt a little so he decided it was time to drop by and visit us.

Oh, and by the way, can he have his clothes back and a free ten day supply of his pain meds?

:-) Gotta love a community hospital.

Most PG-13 justification for prophylactic antibiotics . . .ever

We consulted on a 20something patient with multiple psychiatric problems (admitted for inserting multiple household implements into her intestines through every imaginable route. Yes, including her belly button. I know, gross.)

Anyway, we went to see her, she was doing fine. We went over her home medications: 5 psychiatric drugs and . . .an antibiotic.

How long had she been on the antibiotic?

About a year.

Why?

Why indeed.

So it turns out that about a year and a half ago one of her doctors came up with a novel suggestion for stress relief involving a certain plastic vibrating male body part (actually a sage and semi-safe alternative for someone with an uncontrollable proclivity for inserting objects into assorted orifices). Well, her hygiene, shockingly, was not setting any world records, her mechanical "assistant" was likely not being wiped down on a regular basis, and she quickly developed recurrent infections.

Instead of, I don't know, patient education on proper vibrator hygiene, the doctor opted to put her on lifelong prophylactic antibiotics.

:-) Whatever works.

birth control in the water anyone?

I discharged a patient this afternoon with a newly diagnosed feeding disorder. He has poor oral motor skills, gets most of his nutrition through his abdominal feeding tube, and can only eat pureed and soft foods like oatmeal and baby food by mouth.

I was warned ahead of time by social work that the mother is slightly "limited" so I sat down with her and spent a good 15-20 minutes explaining why her child had trouble chewing and going through lists of foods that would be good or bad for him. "His mouth works like a baby's mouth so he can only have very mushy foods like a baby would eat."

Mom seemed to get it. I sent our dietician and nurse practicioner to spend some more time, help her come up with a meal plan, and make sure she understood. I went to see another patient for a few minutes and then returned with the staff physician to complete the discharge.

"I hear you've been learning about the right kinds of foods for Chase to eat. What do you think you'll feed him when you get home?" Asked my staff.

Mom thought about it for a second. "Pizza."

::headdesk::

Sensing our mild disapproval she tried again, "Peanut butter and jelly sandwich?" . . . "Chicken?"

His discharge form now reads, in capital letters: CHASE MAY ONLY EAT PUDDING OR YOGURT. CHASE MAY NOT EAT ANY FOOD THAT IS NOT PUDDING OR YOGURT. NO PIZZA. NO CHICKEN. NO SANDWICHES. ONLY PUDDING OR YOGURT.

::Sigh:: Sometimes. . .

sounds valid to me

I got called down to a patient's room around 3pm. The nurse cornered me in the hallway. Mom was discharged hours ago but she's refusing to leave now.

I enter the room and am greeted by the healthiest looking three year old in the entire hospital. . . and mom.

"Hi mom. I've read through the chart and it looks like little Manhattan has been eating and drinking well for two days, hasn't had a fever in three days, has no new symptoms, and was cleared for discharge this morning. What's concerning you?"

"Well "doctor" (spoken in that way that makes it sound like there are quotes around it), I told the nurse and the doctors this morning that her poop smells different today than it ever has before. They seem to think it's okay to just send her home when something is clearly wrong with her poop. I mean, the doctors didn't even look at it!"

After an agonizing 35 minutes during which I, yes, examined the poop in question (it was poop)and offered mom multitudes of perfectly reasonable and not at all alarming explanations for poop changes (getting older, changes in diet, recent illness, new medications. . .) , well, little Manhattan ended up being readmitted for the night.

For smelly poop.

(Bonus points for taxpayers when the child picks up H1N1 during her extra overnight stay and ends up staying another week).

We all win.

Not quite clear on the whole "baby" concept yet?

Chief complaint of the day

"Good morning! Why did you bring your 4 day old in to be seen today?"

"Well, he sleeps all the time. Like even in the day. But then he wakes up in the night.
Oh. And he cries a lot."

Oh did I mention?

I carry two pagers at night.

One is good and one is evil.

Good pager pertains to my actual patients. This pager is for good phone calls:

"Hi Dr. S! Don't wake up. I'm so sorry to bother you again. Patient A has a fever, she looks fine, you don't have to come examine her. I've already given tylenol from your orders and was wondering if I can get a verbal order to give x mg of motrin in four hours so I don't have to bother you again. Yay thanks!"

Evil pager pertains to the 50 odd patients I possess only one sentence of information about: Ashley is a 4 year old here with acute renal failure, chronic lung disease, recent head trauma, a UTI, and the flu. She'll be fine overnight! They won't call about her!

These are my cross-cover patients, the patients on all the other teams that I do my best not to break overnight.

Occasionally evil pager will yield an actual medical problem with one of these cross-cover patients. Then I'll go see them, read through their chart, talk to the parents, and try to patch them together well enough that they'll make it to the morning. These are not the evil calls.

Unfortunately these are not the majority of calls evil pager produces.

Here are some typical evil-pager calls (always between 2:30 and 5:30 am)

"Hi Dr! I was bored and looking through the chart and I noticed that this patient you've never heard of has an old prescription for antibiotics that they're not getting anymore that wasn't cancelled. Can you come look at the chart and then call pharmacy and figure out why the order is still in there?"

"Heeeey, I'm taking care of random-completely-healthy-baby-who's-ready-to-be-discharged-tomorrow-and-who-you-know-nothing-about. I noticed that on his eating schedule he's supposed to get a feed at 4am and I was just thinking that it would be nice if mom could sleep a little later. Can you come down, calculate his calorie needs, and see if you can rearrange his feeding schedule?"

"Yeah, I was just looking through the orders from today on extremely-complicated-patient-you've-never-laid-eyes-on and I'm not quite sure why he's scheduled to get x treatment tomorrow night instead of y treatment. Can you talk me through the team's reasoning? And then can you come talk to the patient's mom about it? Also, he doesn't feel like eating right now, can you convert his list of 24 rare medications you've never heard of from oral to IV."

Or the very very very very worst:

"I have call orders to let you know about a heart rate over 150. It isn't 150, it's actually 134, I just thought I should let you know."

Thanks.

The call room we theoretically sleep in while on call is located at the end of a long long white hallway, which for some reason evokes The Shining and seems to lengthen exponentially as the night evolves. Around 1am, this hallway feels completely interminable and the call room starts to feel like some mirage of a desert oasis. Whenever, miraculously, I find that I'm caught up on my charting and I've seen all the patients on my list, I amble towards the 2 south side of the hospital (very casually, and by a different path every time, I don't want to alert the pager-gods to the fact that I am actually thinking about sleeping. This ires them). Once I reach the end of that hallway, I accelerate into a full-on power walk, and now it is simply a race to reach the room, kick of my clogs, and climb into bed for a glorious 5 - 15 minutes until the pager goes off again.

Sometimes, just to tease me, the page comes the second I turn the light off. 99% of the time I don't even make it past the doorway.

If the stars align and I actually have a 30 - 45 minute break, the pager gods watching over the other residents in the call-suite will make sure that every single other beeper in the suite is set to maximum volume, goes off every 5 minutes, and that the resident-owner of that pager will have the slowest beep-silencing reflexes of all time. As well as the loudest possible telephone voice. They also arrange it so that every single door of the suite slams when you go through it, no matter how gently.

Hmmm. . . .

I speak in love

You must understand that I was one of the most nervous third year medical students of all time. It's terrifying when you're suddenly thrust out of the warm, comfortable womb of classroom case studies into the harsh glaring lights of an actual hospital with actual real live patients who they are actually going to let you touch and possibly break.

But the boy student sets all new standards for not quite ready to cut the cord.

It turns out that his first day choice to awkwardly orbit within five feet of me at all times was actually the best case scenario as I was paged by not one, but three, charge nurses in the afternoon after I sent the boy one across the hall to get a chart(literally open the door, turn right, chart rack).

"Hi, I'm calling from PICU south/infant unit 3/2b (which are literally on completely different floors on opposite sides of the hospital), I have your medical student here, he's lost and he's not sure how to find you."

For some reason, once lost, he decided the best way to proceed would be to leave the unit and ascend stairs.

Poor lost duckie.

And I've arrived

So the day has come!

I showed up yesterday morning for more baby plumping fun and got the following 911 page:

"Scopes, go pick up your medical students from the lounge, they don't know where to go."

Yes, loves, I have my very own bright eyed nervous-as-all-get-out third year of medical school ducklings to do whatever I please with for the next three weeks.

No matter what project I assign them, they manage to do it while nervously fluttering around exactly three feet behind me and two feet to either side. Everywhere I go they're there, looking at me expectantly. "Teach me," plead their eyes, "And please please please assign me a project I can successfully accomplish without injuring anyone or passing out."

The girl one (I-have-a-phd-I'm-a-doctor-and-a-half!) is picking things up relatively well, and spends her down time at least pretending to research stuff or work on her notes. The boy one (it's-wildly-unclear-how-I-got-into-medical-school-to-start-with-and-please-don't-count-on-me-to-help-you-with-any-phone-calls-because-I-will-forget-my-name-panic-and-hand-the-phone-to-you) is having a tough time.

The following breathless page is not atypical (approximately 35 minutes after I sent him to another ward to check if a patient's surgical scar is healing well).

"Hi, Dr. S. I got to the patient's room. What should I do now?"

Well, try looking in the room and seeing if the patient is there or not.

"Um. ::agonizing 27 second pause:: The curtain is closed. I can't tell."

Love, you are now a student doctor. You may enter the room and look inside the curtain, then check the scar site for redness, tenderness, pus, and make sure it's well-aligned.

::50 minutes later, back at the work room.::

"Okay, she's there, I looked at her and she looks fine. Her pupils are equal and reactive to light, she has reflexes present in both kness, I can't tell if she has a murmur or not. . ."

::I interrupt:: Butterfly, sweetheart, what did the incision site look like?

"Oh. The incision?? The incision. Oh yeah! The incision. I didn't check."

Repeat times 80 times a day.

Feed the babies

I'm currently working on one of the developmental pediatrics wards. Most of our patients are teeny little "failure to thrive" babies (below 3rd percentile for weight). I spent most of the first week frantically ordering genetic testing, swallow studies, abdominal x-rays, examining poops (how much of my day is spent talking about poops? Oh, about 97.3% of it.) . Basically looking for any reason these little button bbs are remaining little tiny button bbs.

(Is there anything sadder than a skinny baby?).

So my staff put up with all my nonsense for about three days and then, in the middle of yet another description of various surgery consults I want to order to evaluate ye randome rare GI condition by biopsy, she stops me.

"Scopes."

I look up.

"If you feed them, they will grow."

Important

Presenter at morning conference: "I couldn't find a good visual representing appropriate post-drowning CPR, but I thought this was actually pretty close."

True EMS presentation

Winter.

"Two sisters, 13 and 15, were drinking in the backyard when one fell into their swimming pool. The other jumped in to rescue her sister, but was unable to get her out of the pool.

Their mother, also drunk, came outside to look for the girls and fell into the pool. EMS was involved when a neighbor called police to file a noise complaint against the family.

The good news is that the alcohol-induced vasodilation allowed them to cool so quickly, they were all able to be resuscitated when rewarmed."

Yay!

AwwS

A somewhat depressing sentence from my cardiology review book:

No waiting is necessary to have sex after [a heart attack]. Sex does not significantly increase the risk of [another heart attack], because neither the duration nor the intensity of exertion is sufficient to provoke ischemia in most cases.

Good news! But sad at the same time.

I know . . .

. . . this is supposed to be funny.

But my, how much trouble it would save us:




And we need all our energy to panic about swine flu.

In swine-flu-related news

At pediatrics clinic, we've come up with a cute little nickname for the H1N1 virus that's a little easier to say and less likely to panic people.

I think it's adorable.

But we've been causing a bit of concern with the patients when they hear us asking the nurse for a
"hiney" exam.









Heehee, hiney.

It's here!

I've spent the past six months with my head buried firmly in the sand, insisting that all this swine flu silliness was just going to blow over, that it's exactly like any flu, really not a big deal. Totally shrugged off any discussion of it. I figured it was going to be a total nothing. If we had to deal with anything at the hospital, I imagined it would just be a steady stream of worried well trying to stockpile antivirals.

But over the past week or so our hospital has been pretty firmly whomped with a steady trickle of very early and very severe flu cases, and a fair number of them are H1N1.

Now I do have an inexplicable passionate love affair with horror movies, and most especially those of the viral apocalypse variety. Nonetheless, I am not at all excited about the prospect of my first ever year as a doctor being the year we all die of the flu.

(Mostly because I'm just not sure my uterus is up to the task of repopulating the world).

I may have felt a tiny tingle of excitement as I snapped the elastic of my respirator behind my ears and headed down the hallway to see my first verified H1N1 patient. But as we tried to tease out who might have been exposed and how many high risk contacts he had and whether he needed to be admitted and whether he met the criteria for antiviral treatment and whether his one month old baby with a fever and runny nose needed treatment, I just thought oh no.

I may not be getting very much sleep on call this winter.

brand new pet peeve #1

Doctors (and it's always doctors) who push the blue handicapped wall button to open every single door in the hospital. Every single time.

Adult critical care vs. Pediatrics

Two not-so-exaggerated interactions.

Peds clinic (after 4 minutes with the patient):

Me:

"Patient Baby is a healthy one year old who presents with a birthmark on his head that has been previously diagnosed as a sebaceous nevus by two pediatric dermatologists who recommend removal between age 8-11.

My assessment is that this child has a sebaceous nevus that should be removed sometime before adolescence."

Staff pediatrician:

"Great job! Exactly right! I agree! Excellent presentation and clinical instincts! Woo-hoo! You've been working so hard, that's your second patient, right? Go take a coffee break."

Adult Critical Care: (after literally 12 overnight, sleepless hours of being in the patient's room every 10-15 minutes while juggling pages about literally, yes literally, 43 other critically ill patients)

Me:

"Good morning Dr. S! Patient W has significant history of every cardiac pathology imaginable (which I then listed in chronologic order including details such as systolic function, dates of hospital admissions, and cardiologists consulted) as well as end stage renal disease (presented in similar detail). He presented in vtach cardiac arrest and was found to be febrile.

I literally saved his life by performing three rounds of CPR including epinephrine, shocks, intubation, central line placement, aggressive fluid and electrolyte management, antibiotics, and blood transfusion. He proceeded to code two more times, requiring initiation of an antiarrhythmic drip, and subsequently developed pulmonary edema while remaining hypotensive, requiring a dialysis consult and initiation of pressors. I've arranged for dialysis this morning, cardiology consult, ordered all necessary labs and diagnostic testing for this morning and patient is currently clinically stable."

Staff:

"Well, doctor, (somehow impregnating a Colbert Report season's volume of sarcasm into that one word) I notice that his [random irrelevent electrolyte like manganese] was checked at oustide hospital and is slightly low. Did you miss that? Were you planning on fixing it anytime soon? And what supremely esoteric fungal infection observed only in a 1 mile subtropical region of latin America might you have considered and covered for? And what is his exact troponin level to the third decimal point. . . .? "

Me: [reflexes are slow at hour 29 awake] ::long pause::

Staff: I highly suggest, doctor, that you know your patients before presenting them. Now why don't you get to work at fixing this? ::walk away::


I'm currently on the peds side, by the way, and going through pretty significant negative reinforcement withdrawal. I keep waiting to get yelled at and it keeps not happening. Makes me nervous.

Oh and did I mention

Dr. S actually laughs with the sound "Mwa ha ha ha ha." (This laughter is usually occurring at the expense of someone else, most likely a patient). It bears a striking resemblance the count on sesame street mixed with the evil witch of west but with about 71% more evil. Bone chilling.

So appreciated

7:01am

Dr. S: Why is [other resident] not here yet?
Me: She's across the street at Starbucks, it was her birthday yesterday, she's probably a little tired.
Dr. S: She didn't mention her birthday yesterday. Why didn't she mention that to me??
Me: [pause] . . . . .
Umm, sir, she wasn't here yesterday. It was her day off.
Dr. S: Oh. I never really notice if my interns are here or not unless I end up
having to do extra work.

Code blues and parsnips

One of my favorite on-call joys is perking up my ears while we're in the middle of a code and listening to the random sideline conversations that take place at the moment of someone's passing.

I find it both amusing, the topics that come up! and kind of touching or poignant sometimes.

Occasionally there's radio playing 80s hits at one of the nursing desks. Last night two respiratory techs were talking about the best time of year to plant parsnips. There are always a handful of nervous interns and medical students milling about, chit chatting about other patients, and secretly hoping no one asks them to do anything important.

It's just such a striking reminder that life really really goes on.

I suppose it could be seen as irreverent or disrespectful to the moment, but I kind of appreciate it. And we can't just fall apart every time a code happens, that would do a great disservice to our living patients that we'll have to get back to in a few minutes. I mean, if I was dying I sure wouldn't want every doctor in the place standing around in reverential silence. Or crying. I think I wouldn't mind so much overhearing one final conversation about parsnips.

An actual lecture slide today

Strongyloides geographic distribution

-Developing countries
-Regions where fecal contamination of water is prevalent
-Kentucky


p.s. Hundreds of these buggers were found inside one of my patients! Neato!

Wishful thinking

Dr. S: "I've had a headache since you presented your first patient this morning."

Optimistic me: "Have you just realized how much you're going to miss me next week?"

Dr. S: "No." the look I really don't think that's it at all."


I tried.

not quite getting it

I just discharged a youngish man who had literally been without a heartbeat for about 20 minutes by the time he was admitted to me.

This was one week after his first heart attack. He had been down for 5 minutes without a pulse before his wife remembered how to dial a telephone. Down close to 10 minutes before EMS arrived and CPR commenced.

The first five days we didn't think he would survive the day.

The next five days we didn't believe he had any real chance of meaningful neurologic recovery.

Three days after that he seemed to have some brain function but developed acute respiratory distress and we doubted we'd ever be able to get him off the vent breathing on his own.

Four days after that? Breathing tube gone, sitting up in bed, talking, no neurologic deficits whatsoever, doing pushups and situps in the bed whenever the nurse was looking the other way.

I mean, a straight up miracle.

And through it all, his wife sat at his bedside 24 hours a day, slept sitting up in a hard-backed chair, woken every hour for his vital sign checks, not leaving to eat, keeping the tv on the channels he liked, rubbing his feet and arms when they got swollen, filling out piles of insurance forms for him. She did not leave his side.

This morning I walked in and, as usual, asked if he had had any problems overnight:

"Well, I'm thinking about leaving my wife, I'm just not sure about that woman. Something shady about her."


Sometimes I give up.

Now I of all people

should know that correlation does not imply causality.

And yet these past two days, Dr. S has been downright pleasant to work with. He has even lowered himself to, heaven forbid, teaching me on a few occasions. (And not his usual "teaching" tactic which involves stonily staring at me after I make a statement until I realize my mistake, apologize, and correct it. At which point he either continues staring for a good awkward moment longer, to drive it in I guess, or has already started rounding on some other floor and is less-than-patiently waiting for me.)

Anyway, two days of puppy dogs and bunny rabbits and frolicking in the petunias, and on these two days it just so happens that I did not have any clean professional looking socks and thus opted to wear. . . a skirt.

So now I have no idea if these two seemingly random happenings, Dr. Me in a skirt + Dr. S behaving like a human being, actually have anything to do with each other. But nonetheless I need to come up with four more skirts to wear for the rest of the rotation and fingers crossed that that will be enough to carry me through Sunday when I'm on call in scrubs.

Hey, every little thing helps.

Creating rapport with patients

A master class.

Dying (and not aware of it) patient: "Dr. Saul, I hope that next time I see you it's for a round of golf."

Dr. Saul: "I sure hope not, cause the only place you're playing golf in the near future will be in heaven."

Patient: What?

Dr. Saul: Well, remember those tests we did last week? You have cancer! One of the cancer docs will be around to talk to you about it later. Bye."


Yes, for real.

My first saul-pliment!

(Dr. Saul is my oh-so-lovable senior physican this month, described in this post.)

So a usual saulpliment goes something like this:

::peering over his glasses::

"Hmm . . . you seem to have quite a rapport with the family."

This is accompanied by a suspicious squint usually reserved for someone who's just drunk a gallon of milk and then thrown it back up. Kind of vaccilating between awe and disgust. You get that look for two seconds or so then he walks off.

(Yes, he leaves me behind just about every time I step into a patient's room or pause to have a conversation with a nurse. Occasionally he actually leaves for other wings of the hospital and then I get that look again when I find him againtwenty minutes later.)

So that's the closest to positive feedback that I've gotten so far this rotation. Then, this morning, it happened.

I showed up, late of course, as he'd told me to meet him on the third floor and then booked it to the sixth floor within the 50 seconds it took me to ascend on the elevator. When I arrived, as usual he looked me up and down, but instead of the usual extra-dissaproving version of the look, he actually smiled (yikes!) and choked out, "well don't you look professional today, Dr. Scopes," awkward pause, "and you have certainly performed adequately for an intern this rotation."

I was literally in shock. I was unaware that he knew my name as he has only referred to me as "the intern." (As in "well, the intern must have forgotten to write the vent settings this morning leading to patient F's respiratory alkalosis.)

After I managed to stutter out a 'thank you,' he turned to the NP:

"Laura, make sure you write down that I gave verbal feedback and commented on the intern's professionalism."

And off he went.

So I had the fortune of ending up with a rather *special* staff physician this rotation. His reputation far far preceded him. As in, when I approach nurses and introduce myself as Saul's new intern, they often spontaneously hug me. Patients in the morning pat my arm and ask me how I'm doing.

His name is Saul but he's more commonly referred to as "the assault," occasionally "salty bastard" and a few other less publishable monikers.

His one redeeming feature is that he's equally horrible to everyone: interns, nurses, patients. Maybe nurses especially, unfortunately, but that's just because he hates anyone who's good at their job.

Luckily he's generally amused by my incompetence so I seem to be spared the worst of it. Well, viva la education. . .

Snakes and ladders

I've noticed that hospital nights tend to bring out the superstitious in everyone. Some interns will never take the elevators, some will never enter the stairwells. Everyone has a strategy for making the night as smooth as possible: "if you walk three rounds of the two adult critical care units before you eat dinner, the nurses will let you sleep for a few hours." "Don't ever get midnight snack at the cafeteria, you always get called with a new admission the second you pick up a tray." Etc.

Intensive care south has a ghost named Thomas who's been known to change vent settings and discontinue IV drips overnight. Elderly patients get confused, weird patients get weirder, hallways seem to move and you have no idea how you ended up in the F building when you thought you were heading for the ER.

I've noticed myself fixating on seemingly random events as prognostic indicators on how my patients are going to do. But I do seem to see a clear trend emerging.

The elevator of hope: Once in a while, I'll get called for a patient that sounds terrible, like about-to-die terrible. I'll book it over to the elevators and, about four times a night, there will be an elevator there just waiting for me. Warm and light and open and empty, waiting just for me, and always with the arrow lit in the direction I need to go. This never happens during the day. It doesn't happen when I'm heading towards not-so-sick patients, it never happens when I'm with anyone else. I sort of see it as a sign that I'm going in the right direction. It's always good news.

The fishbowl of dispair: The hospital has a television channel, called "Mr. Fish," that's essentially a camera inside a dirty fish bowl with a few hungry looking goldfish swimming around. This is soundtracked by a continuous loop of three benign classical string quartet pieces and one new-age dolphin/synthesizer duet.
If my patient is watching Mr. Fish (usually the nurse or a family member leaves it on for them. Sometimes Thomas the ghost will do it), they're essentially going to die. It's the worst. When I hear the viola starting up from outside the room, I don't even want to go in.

This morning two of my patients were watching Mr. Fish. And I'm only covering four patients today. Disaster. You'll see.

This place is too weird

Actual stroll-by conversation while pre-rounding this morning.

Large angry pre-op small bowel obstruction patient: Hey doctor! Doctor!! Doctor!!!!!1!

Me ::poking my head in::: Umm, yes sir?

LAP: Are surgeons born or hatched?

Me: Well. . . as a general rule they tend to be human beings, so I'm going to go with born.

LAP: Then why won't those m***f*** chickens let me have a drink of water??!!!

Worst hand-off ever

Another nursing changeover (as she's walking towards the door):

"Okay, patient in room 21. You perhaps noticed that he's managed to dislodge his c-collar again despite the three sets of restraints and cross ties. Huh, looks like he's just pulled out his Foley catheter for the fourth time . . . and I'm guessing probably his IVs are out now as well. Havefunwiththatonegoodnight!"

actual nurse changeover

"Alright, bed 38, guy who tried to shoot himself through the mouth, missed all vital structures, had palate repair this morning.

Spends most of the day yelling, it's hard to understand what he's trying to say, aside from the cussing.

Don't know much about his history aside from three single car crashes and four intentional overdoses within the past three weeks. So I guess what we do know is that he absolutely sucks at killing himself."



Poor guy.

No no no no no no no no nooooooooooooo

An actual call I just got, 8:02pm:

"Hi, it's the nurse for (completely stable not sick) Mrs. R, I just wanted to let you know that her afternoon labs are normal. I'll call you back a little after midnight to tell you about her next set."

Awesome! can't wait.

altered mental status is fun!

One of my favorite patients is a 50something gentleman who's very slowly recovering from hepatic encephalopathy. He waxes and wanes, but 99 percent of the time he stares at the ceiling, talks nonsense words to himself, and ignores everyone in the room.

Imagine my surprise when I walk in this morning, he looks right at me, and starts singing "Ain't Love the Sweetest Thing."

'Mr. L! Are you singing to me?'

Right in my eyes. "Yes I am!"

'What are you singing L?'

"My ooooode to yoooouuuu. Doo doo doo doo doo." ::his voice drops down to a whisper:: "shh. . . we're in the locker room."

He spent the rest of our encounter parroting every sound he heard, including his IV pump beeping.

The saddest

22 year old soldier,
not a scratch on him,
after ten months of combat duty in Iraq.
Finally came home to his family yesterday morning.
'I love mom' tattooed on his left shoulder.
Went out with some friends last night,
to celebrate being home,
took an unknown mix of drugs,
never woke up this morning.

Admitted to me with only a hearbeat,
no brain activity,
and an 'I love mom' tattoo.

Ten months in combat in Iraq.
One day at home.

His family has put his Ipod buds in his ears, playing, of all things, Grateful Dead.
They'll be deciding whether or not to donate his organs tomorrow.

The end.

a moment

We slid the wedding set off the ring finger of a 71 year old woman in hospice care as she was being discontinued from mechanical respiratory support and handed them to her 16 year old granddaughter.

She hadn't taken those rings off that finger in 37 years.

what gets you through the night

1. Keeping track of how many patients point out to you that you're giving their grandmother the medicine that killed Michael Jackson. (7 last night)

2. Watching your sixth code of the night through the window next to a nurse's station and noticing Pandora's playing 'pour some sugar on me'. Bonus points for singing a little inside your head and then feeling bad.

3. Cataloguing the myriad pronunciations of "Au Bon Pain" (our new hospital coffee shop! Yay!)
The most common is "Ow Bone Pain" followed closely by "Oh bone pain." Then there's the French variation which comes out vaguely "Oh Bo Pah" and generally needs to be repeated three to six times before anyone figures out what you're saying. Not quite sure why this amuses me so.

4. These. Shoes.


5. 30 second elevator dance parties. Bonus points if someone catches you as the door opens.

6. Going the long way to the east building so that you can walk through the newborn ward filled with pictures of babies taking baths. Bonus points if your delivery pager goes off while you're there (new babies!).

7. Looking at your watch at 8am and you have not eaten, slept, drunk, peed, caffeinated, or sat down for over 17 hours and didn't even notice.

8. 3am check. 47 out of 53 patients still alive!

9. 5am: the pager operator starts apologizing when she calls you, "wow, you're getting slammed."

10. When the nurses call you with a question thusly: "Hello Dr. SS, I have a patient in room thirteen with "x" problem, usually in this situation the doctor would recommend "y" treatment at 5mg BID, would you like me to write that order that for you?" Yes, yes yes!!!

11. Lavishly detailed bed fantasies.

I wonder when doctors actually start to feel like doctors

Pager: ::beep! beep!::

I answer. "Hi, it's nicest-most-patient-nurse-in-the-universe from the floor. I was wondering if you were going to come up and pronounce Mr. N."

Me: "Like. . . pronounce him dead?"

NN: ::encouraging pause::

Me: "Like . . . 'time of death 1407' pronounce him dead?"

NN: . . . . . . .

Me: "Like. . . you need a doctor to come down and certify the death and you called me. . .?"

NN: ::sigh:: "Yeah, and now please, we actually kind of need the room for another patient. Thanks."

So I get down there and look kind of lost and nervous (theme of the day) until NN takes pity and comes over. "No worries, all you have to do is go in the room, make sure he's really dead and then fill out the paperwork."

So I stroll into the room trying to look terribly authoritative and appropriately grave. And I look at the gentleman. And he doesn't look all that dead. I look around to see if any of the nurses are watching. They are. Waiting. So I reach out and try to feel for a pulse in his neck. Then I have creepy feeling like he's going to jump up and say boo and snap at me so I quickly remove my hand as though satisfied with my thorough assessment of pulselessness.

But they're all still looking. So I pull out my stethoscope and find myself out of habit saying "I'm just going to take a listen to your heart now." The words kind of echo and hang there. I place the diaphragm to the left of his sternum and all I can hear is the echo of my own pulse rushing through my ears and I can't say for 100% that it isn't actually his heart. Maybe it was just so weak the monitor couldn't pick it up right? So I just stand there and listen and listen and listen. Probably for a full minute I listen. And I can't tell. I swear I hear a heartbeat. His hands are freezing and white. He's motionless, her tongue protruding a little, eyes closed, chest still. But I just can't tell for sure.

The nurses have lost interest and wandered off. I kind of pet his cold, dry hand a bit and excuse myself, looking back one more time before I leave, as though to catch him readjusting his head on the pillow.

Then I fill out the form: Respirations Have Ceased 14:07

trial by fire

True story

Nervous 1st day of ICU me: "Good morning Dr. Cranky-and-prone-to-pointless-yelling, I'm your new intern! Yay! So, I just finished orientation, and I was wondering where I should meet you?"

Dr. Crappy: "Actually nervous intern, I strongly suggest you go attend to your patients before worrying about me. I, more specifically, suggest you check on Mr. R as he's going to die."

Me (realizing I have no idea where 27W is; like I'd have any idea what to do when I got there): "Umm. . . ."

Dr. C: "Perhaps I stuttered? Your patient is literally dying right now. Go. Go."



P.S. Yeah, he was right.

Mmm. . . not so sure she got it

Thursday night; Emergency Department:

Me: Okay, mom, we got the x-ray results and it looks like L'k's'ha (name obviously changed, but it did have that many apostrophes in it in real life) did break her leg. She has a displaced spiral fracture involving both the tibia and fibula, which means that she broke both the bones of her lower leg and that the pieces of bone aren't lined up right anymore. I'm going to call orthopedics to come down and decide if she's going to get a cast or if they need to do an operation to line the bones up.

Mom: So, will she be cool to go to sports camp next week?

Me: Umm, I imagine it's actually going to take quite a bit longer than that to heal.

Mom: But it's not like she'd have to go Monday. . . camp doesn't start until Wednesday.

Chief complaint of the night

"7 year old male was practicing his AWESOME Undertaker wrestling moves when he fell forward onto carpet, hitting his forehead and twisting his neck."

Sure enough, I go into the room.

Me: Hey, Buddy, what kind of wrestling moves were you trying to do when you fell?
Buddy: Awesome ones.

surprise!

I walked in on a rather special family moment in room 29 last night. The young married couple had just returned from a family reunion and were discussing their various and sundry relatives, when they had the simultaneous realization that his Aunt Margie, oh yes, also her Aunt Margie.

They spent my entire physical exam (White-Castle-related-nonspecific-gastroenteritis) on the phone with their parents frantically trying to figure out exactly how related they were.

Though neither seemed terribly disturbed by the news.

After some observation, a dose of Mylanta, and a detailed discussion of why going back to White Castle for dinner might not be the all time best treatment for their nausea, vomiting, and diarrhea, they were discharged home to do some family bonding.

On my way out after the shift, I noticed they had taken my nutrition counseling to heart: There they were, hand in hand, walking out of McDonald's.

You know you're in residency when. . .

you're extremely excited about sleeping in tomorrow morning. . . and sleeping in = 6:15 am.

Apologies if you've seen this before

It's been on youtube for a while. If you've not seen this before humor me. Go over to a couch or pillow and perform CPR compressions on it, try to keep your form good, arms straight and push at about 100 times/minute (the rhythm of "staying alive").

Now keep compressing and push play. Follow the instructions on the video (just count the number of times the white team passes the ball). It's over when there's a pause in the video.























Neat, right? (Of course no-attention-span me was the first person in the history of the program to notice the first time around. I reallly need to work on focusing.)

Save the bunnies!

Today was wound repair day, the majority of which was spent lacerating and then repairing pig's feet, which I always enjoy more that one might imagine. Somehow, the topic of wound research was raised, and one of the physicians brought up the methodology behind one of the major studies on how the size of injury relates to the risk of infection.

So how was it done? Basically, the researchers dropped heavier and heavier weights onto bunny rabbits, exposed them to bacteria, and observed which bunnies got the most infected.

I would like you to keep in mind, next time you rub on some neosporin, or put on a bandaid, or get stitches, that partially responsible for the healing of your injury, is a squished bunny.

Thank you bunnies.

overheard in the ED part two

later that night:

Same resident: My patient in three says her last doctor told her that she had a condom stuck on her ovary once.

Staff physician: Man, I would really love to have a look at her boyfriend.

overheard in the ED

circa midnight.

Resident: Hey med student, I have a patient in 14 with watery, irritated eyes and copious malodorous vaginal discharge. What do you think's going on with her?

::long pause::

Student: umm. . . maybe she's crying about the copious vaginal discharge?

The trend continues. .

Tonight I sewed up the faces of three men who were all "just minding their own business" when they, respectively, were pistol whipped in the face, punched in the eye with brass knuckles, and had their throat slashed from behind.

Dangerous stuff.

did not see that coming

Chief complaint (direct quote): "Back hurts. Oh, and it feels like my butthole is crying."

History revealed nothing. Healthy young woman, a bit on the plus size of plus size, regular periods, no lady-part complaints of any kind, no urinary tract infection symptoms, no history of trauma or back strain, really no complaints at all except the above.

Well my oh-so-lucky male intern friend gamely helped the lass undress to discover what exactly she could mean by this (expecting some kind of sore, abscess maybe?) and discovered, I kid you not, a full term just-born infant. In her pants.

She was surprised, to say the least. As was her husband. And the nurse. And the intern. And all of us.

Both baby and mom are doing fine.

Weird stuff.

Ahhhhhhhh!

Most squirm-inducing patient of the week:

Medical student bursts into the call room, runs over to the attending looking super nervous: "excuse me, sir, my patient said her ear hurt and I looked in there with the ear light thing, and I'm pretty sure. . . she's got a bee in there."

A few seconds of silence, and then of course we all had to go take a look. And yes, indeed, full sized honeybee.

Then poor lady had to suffer through the medical student extra-nervously trying and failing to remove the bee in its entirety with a pair of forceps. Half the body ended up sticking to her tympanic membrane. Eventually we rinsed the thing out with about 30 minutes of flowing water.

Not fun.

And yet another addition to my life list of things-I-didn't-think-I-had-to-worry-about-but-really-really-should-be-worrying-about-constantly. Considering permanent skin grafts over my auditory canal.

Oh noes

I've discovered the most dangerous thing one can do in this city. Here are three true stories from last night:

-"I was on my front porch, minding my own business, when these three guys came up yelled a bunch of stuff at me and hit me up the back of the head with their gun."

-"I was sitting on the couch minding my own business when my family came in and tried to kill me and cut me and stabbed me in the neck."

"I was just minding my own business when the police started chasing me and sent their dogs after me. Once the dog took me down it bit through my arm; then the police kicked me in the head a bunch of times and arrested me."

Scary stuff! Remind me please to never ever mind my own business ever again.

(Disclosure, that second one was actually a hallucination, but I think even a hallucination of your grandma stabbing you in the neck is a fairly undesirable outcome of just minding your own business.)

chief complaint of the weekend

"25 year old male states he drank some beers last night, now complains of headache (10/10) and vomiting."

And yes, correct, I work in an emergency department.

Taxpayers, this is where the money goes.

Hello. :-)

Yum.

And apparently we're doctors

The results of a vote on the two pieces of information the current residents wished they had known as interns:

1. They sometimes shut down the ice cream machine in the 24 hour McDonald's at 1am so any "code white" should be called, at the latest, around 12:45 am.

2. The middle button on your pager makes the screen light up.


Yes, ladies and gentlemen, we hold the lives of your children literally in our hands, and as a collective group, we could not, over the course of an entire year, figure out how to make our pagers light up.

Thinking about calling a code white right now. ..

Real live doctor day 2: first existential crisis of orientation

Guy in ID tag office:

"Your name's not in the system. Is there anyone you know of who can verify your existence?"

Real live doctor day 1- orientation begins, any post-medical school self esteem remaining instantly quashed

Day 1 of internship began with protective mask fit-testing. It unfolds as follows:

1. The examiner stares intently at your chin, mutters disapprovingly, yells across the room to the other fit tester, what is up with all these tiny chinned people today?, then angrily digs through a bin and produces a comically child-sized bright pink mask shaped like a duck bill.

2. The mask is affixed to your head with a ceremonious, if unnecessary, snap of the rubber band around your neck.

3. Examiner stares at you for ten minutes straight as you breathe heavily, wiggle your head around, and read a passage entitled "the pot of gold at the end of the rainbow" from a late 1800s diction textbook two times.

4. A machine shoots tiny fake-bacteria particles into your air and a sensor detects how many of these sneak in under the mask, around your pitifully undersized chin, and into your respiratory system.

5. If you're the unfortunate young lady sitting next to me, the examiner writes on your form (which does indeed sit in your file for-ever): "failed fit testing due to unacceptable facial structure."

Really.

And this, lucky me, is my assigned mask for the next five years. Image courtesy google images "Kimberly clark Respirator mask."

And wash your hands too

I am so so so so so so so so so so so excited about the upcoming movie "Carriers." So excited.

Basically Avian flu kills everyone in the world (especially Germans) and then they all turn into zombies who join together to try to infect (eat? scare? it's unclear what motivates zombies) the only four survivors, who are of course 20-something attractive Americans with an SUV who make the sage decision to drive across the country to an abandoned motel where they'll be oh-so-"safe".

(On a side note, why are all horror-movie viruses zombie viruses? Isn't bleeding out your ears and dying scary enough?)

Now I luuuurve horror movies, especially with a pseudo-medical component, and double triple especially if that element is a communicable disease. (Giant poisonous mutated animal will also do).

But what's funny about this trailer is that it is nearly indistinguishable from the training video I just had to watch on controlling infectious diseases. I mean, holding the mask to your face instead of firmly securing it with both elastic straps? Classic rookie mistake. (In my training video, the girl who forgot to wear her mask got TB. You don't want to know what happened to the intern who recapped a needle).

Anyway, here's the trailer. . . enjoy:



Note the menacing histology slides flashed at the beginning. . . microbes are scary!

the tragic downside to graduation

I asked for my usual student discount at yoga this morning ($12 instead of $20!) and then realized mid-sentence that, oh no, I am no longer a student.

I don't imagine too many places offer doctor discounts.

Alas.

A change is going to come

As of today I:

-am an official, real live, MD

As of today I will no longer:

-drive past spray painted camels on my way to work (they're painted orange so cars can see them)
-be force fed endless cups of turkish coffee during morning report
-be greeted by my attendings with a kiss on each cheek
-have to clarify with my patients if their wife is a first or second cousin (or a first or second wife for that matter)
-have a majority of patient conversations translated from Arabic to Russian to Hebrew to English (or some variation thereof) and back
-be able to pretend I don't understand when attendings make uncomfortable comments about how my srubs fit
-be the cute chick with an accent
-live in a country where drive-through doesn't exist
-live in a town where 90% of restaurants daringly offer sandwiches, salads, quiches, pastas, pizzas, steak, fish, sushi, asian noodles, and hummus on a single menu
-be a medical student ever again


But I will try to continue:

-seeing each patient as an unkown, without prejudice or preconceptions
-to treat the patient in the way they would like to be treated, not the way I decide is best for them
-remembering that even someone who looks just like me comes with their own personal culture that I must try to discover, understand, and respect

Taking a two week moving vacation and then the new adventure begins. . .

Overheard in the trauma bay. . . oops, I mean dermatology clinic

My mistake.

Student (after noticing that the doctor examines all patients extremely intimately and without gloves, including three cases in a row of crabs):

"How do you avoid contracting contagious conditions, like pubic lice?"

Dr. derm (100% serious): "Well, I mostly try to avoid sleeping with my patients."

I see our translator comes with a side of agenda. . .

Today our fascinating and varied array of patients included 7 cases of warts, 10 psoriasis outbreaks, three dry skin emergencies, 2 cases of acne, and one 27 year old male who is starting to go bald. About half of these were signed in as "urgent."

Luckily there are always a few cross cultural occurrences to help keep me interested. Watching the doctor contend with the veritable parade of languages, religions, and cultural norms that walk through the door on a given day is far more educational than the actual medical content.

A completely typical day may include several Bedouin patients, several secular Israelis, a few orthodox Jews, a handful of recent immigrants from Russia, Romania, Ethiopia, and West Africa, and one or two European tourists. It's dizzying.

A few select moments from today:

1. The clinic is very sensitive to modesty/privacy issues. All the doors are locked during patient visits and there is an additional screen or curtain in the corner so that the religious and Bedouin patients don't have to remove their clothes out in the open. Today, we got to experience ultimate (like award winning) modesty. An orthodox Jewish woman in an ankle length skirt came in with a psoriasis eruption on her heel and insisted on going behind the modesty screen while removing. . . her sock. Not even removing, just rolling it down over her heel.

I'm with her, no good can come of women wantonly exposing their ankles.

2. We've seen multiple Bedouin women over the past few days with severe dry skin. Today, the doctor explained to us that a few of the desert tribes have a tradition of bathing for a few hours a few times a day. Sure enough, when I asked a patient today how long she usually showers for, she answered, "the normal, two or three hours."

3. The doctor was speaking to a twentysomething secular looking woman through a Greek translator. He was considering accutane for her acne (which can harm a fetus) so he needed to know if she was sexually active and if there was any chance she might get pregnant. He asked the translator to ask her if she was at any risk of getting pregnant. Without asking the patient, the translator immediately replied "no." The doctor repeated the question and asked the translator to please ask the patient. The translator refused, "It's not relevent, doctor. She's not married."

(A friend of mine had the exact same experience with her doctor. He was thinking of prescribing her an antibiotic that is harmful in pregnancy and asked her only "are you married or engaged?" before prescribing the drug).

4. A young Bedouin woman with severe warts on her hand came in to have the warts burned off. Her hands were hurting her after the procedure so the doctor asked her father if there was anyone who could help her around the house so that she wouldn't have to cook or wash dishes that evening. Her father responded "no, there is no one to help her. She has only five brothers at home."

(One of my classmates, a secular Arab-Israeli, stepped in and tried convince the father to make one of the brothers help out around the house, at least for that evening. The girl, who hadn't understood the (Hebrew) conversation up to that point, nearly fell off her chair laughing at the the thought of one of the men helping out with the housework. She honestly couldn't fathom.)

5. The camels are grazing!! There are camels strewn literally all over the city. And herds of sheep with sheperds following them on donkeys. It's like Israel is trying to be extra extra middle eastern for my last few weeks here.

Overheard in dermatology

A classmate: Ugh- this whole specialty makes me want to gouge my eyes out with a punch biopsy.


It is a rather anti-climactic way to end medical school. Nine days of fungus ridden toenails, age spots (excuse me, solar lentigo) thinning hair, and EMERGENCY!!!!!!!!!!!!!! pimples.

70% of the patients on the list had made an "urgent" appointment this morning. 100% of the patients had the least urgent medical conditions humanly possible. . . (in the vein of: "I've had this bump on my chin for seven years, it really bothers me!" Or: "My hands feel dry!! And they're peeling!!! Sometimes they itch!!!!!!!!!! What's happening to me??!!")



The highlight of the day for sure are the magical-derm-gnome consults. This guy is the dermatologist of the region. He's been practicing for about three of my lifetimes and is technically retired but hangs around the clinic to help out with tough cases (read: cases in which the doctor actually has to examine the patient and/or think). So every time our doctor encountered a patient who required him to move from the chair or :gasp: perform a physical exam, instead he would lift the phone and call a consult.

Within minutes and without a word, preceded by a giant magnifying glass, in trots this tiny squat little man, white hair flying in every direction (see above but without the hat). He silently examines the patient from head to toe with the magnifying glass glued to his eye and his face about 1/2 an inch from the patient's ulcerating rash. After thoroughly inspecting every inch of exposed skin (usually paying special attention to the armpits) while mumbling to himself, he proclaims his diagnosis in a thick Romanian accent, nods authoritatively, pushes up his glasses, and leaves, still nodding and mumbling, with the magnifying glass at the ready.

::I totally want one::

The doctor then of course prescribes steroid cream and a moisturizer (which is what he would have done regardless) and the patient goes on their way.

Typical medical school for international health conversation

Me: Hi 3rd year! How's your year been?

3rd year student: Not too bad. I mean, aside from the war. Which was a little stressful.

Welcome to geriatrics/off to a swinging start

Enthusiastic first-day-of-a-new-rotation me: Good morning Mrs. C! How are you feeling today?

Adorable 101 year old patient: "That's enough. I would like to die now, please."


Perhaps geriatrics is not for me. . .

Memories of Peru: Baby Special!

At those prices, I'll have both!

I'm home!

Overheard in cute Cambridge coffee shop:

"Hiiiiii. I'd like a chocolate chip cookie, only if they're made without nut ingredients. No, not that one, a rounder one please, the roundest one you have. And an espresso, in a ceramic cup. ::to companion:: Espresso only looks right in ceramic, it allows the crema to expand. Oh, and a skoche of whipped cream on top. Thanks!"

I wanted to just hug him it was so unmistakably American.

::soaking it up for 48 more hours::

Hebrew manages to make oncology adorable

Today was a whole lot of the usual: Four patients, four different languages. One woman refusing breast cancer treatment because her husband and her rabbi decided against it. One woman caught early by her first screening mammography. One caught very very late with an 8x8 cm mass.

The cute part.

A mass, or lump, in Hebrew, is: Goosh. (Already cute, right?)

It gets better.

A palpable mass, or lump, is: Goosh namoosh.

Best language ever.

Sensitivity

Big Fancy Orthopedic Surgeon presenting a patient (after sauntering into the room 20 minutes late in jeans and a leather jacket and and deigning to grace us with a consult):

"Mr D is a 19 year old Bedouin man who was injured when a rocket landed on his construction site." ::with exaggerated eye roll:: "For some reason he wants us to remove the shrapnel lodged in his pelvis, elbow, and face. He says it causes him pain and is uncomfortable. He is on anti-depressives (sic), I don't know why." (My emphasis. I mean, really??)

Student: Why don't you want to do the surgery?

BFOS:"I think is no big deal, some shrapnel."

I'm currently on oncology, which does not seem to predispose itself to providing me with pithy little anecdotes.

I find it fascinating. The patients usually start the meeting by telling me their diagnosis, but I'm much more interested in the story of the moment. The moment when they went from being someone with an unexplained symptom that was "probably nothing" (that phrase comes up about 17 times a day) to a cancer patient.

Especially meaningful right now when it feels like every third person I know is close to someone who has just crossed that line.

The other thing I like is how absolutely normal the clinic is. Most of the patients are feeling relatively well, look well, joke around with us as we discuss how many treatments they're going to receive in what is most likely the last months of their life.

I also play a little game with myself as I watch the conversations. I try to see the hidden agenda in the patient's eyes. There always is one. They politely sit through discussions of dosing and risks of surgery and statistics and all they want to know is if it's safe for them to play with their grandchild this weekend or if they're going to be receiving a chemo treatment during their brother's bar mitzva in two months. This is almost always the "doorway question" they ask as they're on their way out of the room and their whole body just sighs once they get an answer.

It seems to be these little things that matter way more than where or why the cancer has recurred and how many infusions they're going to need and when to take their pills and what their lab results are today. Which makes sense, because those are the things that make them people, not cancer patients.

So the summary is, I dig it here.

overheard at lunch

A sentence starter unlikely to be heard anywhere other than a medical school for international health:

"Every morning as I walked past the slaughtering of water buffalo on my way to clinic. . . . "

I am sad to say . . .

that no. . . still no special lady time for me.

And I so wanted to believe!

When you know your country is way too small. . .

So first year, in a moment of insanity, I auditioned for a community theater production of Anything Goes scheduled to tour Israel in the spring. I was cast as the lead and spent the rest of the year in a panic, frantically hiding pharmacology cards in my costumes to glance at backstage between scenes and rehearsing dance numbers in my head during microbiology class and generally being underslept, overstretched, and ruing my decision.

I had effectively put the whole experience out of my mind until this afternoon when, sitting in a coffeeshop downtown, out of the corner of my eye I noticed a familiar red dress on the large television screen behind the counter. Casually looking up, I was horrified to see. . . me, dancing in a red velvet dress with a feather boa. I then appeared, just about life-sized (which isn't very big but still), in a slip and my voice, singing "Blow, Gabriel, blow," assaulted me from what felt like ten million hidden loudspeakers.

This commercial for the theater group, featuring a good 90 seconds of garishly becostumed me, was repeated six times as I sat trying to have a very serious (very doctorly of course) group meeting.



Kind of fun. Kind of painful and embarrassing.

Miracles! A personal note

I just received my first email addressed to . . . . Dr. Me And on the residency website they list me as "me," MD. I wonder when this will stop being exciting.

In personal medical news, ever since leaving Israel last summer I have for all intents and purposes dispensed with menstruation (it's been about 10 months now). While I like to believe that my uterus has simply evolved beyond the need for such barbaric and messy practices, I realize that this is probably not indeed my ideal state of being.

I saw my ob/gyn in the states and we're trying out some meds, discussing fertility options. But my husband also insisted I see his Chinese doctor/acupuncturist, Larry. Since he also plays ocean sound music, shiatsus my shoulders, and the room smells like lavender, I have no problem acquiescing.

So Larry takes my pulse, shakes his head and clicks his teeth, asks to see my tongue, looks terribly disappointed in me, and tells me he wishes I had called him when I had my worm troubles because all I needed to do was warm my spleen either externally or with ginger tea, and I could have been symptom-free my entire trip. If only I had known it was my frigid spleen causing all the trouble!

So then, he focuses on my ovaries: massages my tummy for a while ("you have a lot of fire in your liver which is overheating your heart leading to obstruction in your thyroid- I've got to get things moving"), and then he sticks two needles in the webs between my first and second toes, and in both wrists.

About 7 minutes later, he holds his hands over my head for a few minutes and then says, "Okay, you're better now. You'll get your period tomorrow I imagine, and you shouldn't have any troubles with menstruation any more. I've retaught your nervous system how to regulate itself."

Amazing!

Hee. I'll let you know what happens tomorrow. . .

And for your viewing pleasure. . . a polycystic ovary:

depressing but true

Our ortho rounds finished muy early today, leaving me with a whole afternoon free to run, yoga, make salad, do laundry etc.

Having completed all those things I now have three glorious empty hours before bedtime in which to read a new novel, play catch with the dogs, paint my toenails, catch up on 30 rock or Grey's Anatomy, lie on the couch and look at the ceiling. . .

What am I doing?

Studying ahead for residency.

Oh medical school, look what you have wrought.

Squeegees in the storm

Would be a decent to excellent novel title, but I'm stuck after that.

Perhaps you can tell I have some free time these days?



Okay, I know I've ranted about this before but it continues to baffle me. Israelies are excellent at architecture, they're technological masterminds, they can irrigate anything into vibrant fertility (I trust that my husband could make the kitchen floor sprout tomatoes with a Nalgene full of water if the need arose). So I cannot cannot cannot wrap my head around the bathroom design here.

Essentially they take a room, put a hole in the floor, and then stick a shower head, a toilet, and a sink in said room. Perhaps an ornamental shower curtain separates the elements. Perhaps there's even a symbolic ridge on the floor loosely denoting the shower area. But the water in no way is funneled towards the drain and in no way is the shower head one of those yummy rain ones that pours straight down. No, it's generally one of those detachable shower hoses with a penchant for wildly ricocheting from wall to wall when you turn the faucet on. Which really doesn't make a difference since the bathroom is continuously soaked any way.

Now you have to admit it's thrifty, and I do take some pleasure in peeing, brushing my teeth, cleaning the bathroom, and showering simultaneously.

But here's what I hate. After the shower, you're expected, while cold and wet and freshly scrubbed, to grab a giant squeegie on a stick, and futilely attempt to shovel all the water into the drain. I tolerated this in my old apartments, but my new apartment takes things a step further.

So the floor here actually slopes down away from the drain, out of the bathroom, and bottoms out somewhere in front of the living room couch. And the water pours down this slope much faster than the meager little drain can collect it. The end result is that for literally the entire duration of my shower I have to continuously squeegee the water back towards me as I attempt to shampoo, shave, and soap one-handed, or I flood the entire apartment.

This ruins showering for me to such an extent that I chose option B. Flood the Entire Apartment for the first week and a half, until my husband gently informed me that this is not good roommate behavior.

cross cultural miscommunication of the day

Believe me, I am far too deeply familiar with the perils of navigating a second language, and am generally happy just to properly phrase a coffee order without offending anyone around me. So I do my best to be understanding and to not overtly giggle when our Hebrew speaking professors pronounce something wrong or have a spelling error on the board. But today's mistake was just too cute to handle.

The topic of the lecture? Child abuse

The header on the top of every single powerpoint slide?

"Buttered Babies."




Hee.

Oh yeah, that old conflict

In celebration of my almost-doctor status and impending midwesterly relocation, I registered for this year's Indianapolis marathon.

I decided to go out for my first base-building run this afternoon and casually asked my husband if there's a good trail to run on in the area (we're living in a suburb outside Beer Sheva surrounded by desert).

"Sure," he said, "there's a trail that starts right down the road."

I headed off to the bedroom to get changed. He stopped me on my way out the door.

"Wait. . . make sure when you get to the water tower that you don't turn right. That will lead you into an Arab village and they've been shooting towards bikers in that area. And if you get to a fence or a guard tower, you've gone too far and you're in the Palestinian territory."

I had a perfectly lovely sunset desert run (holding rocks in both hands in preparation for the frequent packs of wild desert dogs. [no, seriously]), though I did encounter the relatively anticlimactic fence half an hour in and had to turn back earlier than I planned.

I'll miss this crazy country.

Only in Israel or Ahh, home

Husband: "I know the perfect place to practice driving manual. No traffic, no hills, all you have to worry about is the rockets."

Oh!

And I can drink the tap water!!!!!!!!!!!!!!!!!!!!!!!

The nice thing about coming home from traveling is how impossibly luxurious my everyday life feels. Endless hot water, copious amounts of toilet paper, I almost teared up in the gynecologist's office when I saw the private exam room with it's shiny padded table, clean pink gown, stacks of paper towels on the shelf next to the green tea and lemongrass scented hand soap. It's like I;m living in a 5 star hotel.

I sat in ortho lecture this morning, giggling fondly at the screen (on which the professor had misspelled anesthetized as anestheseized), with a cup of coffee in my hand, the calming hum of the air conditioner in the backgroun, powerpoint slides projected onto a shiny white screen, and just thought wow, my every day life is so unimaginably cushy.

I'm back in Israel now after 4 straight days of flying, interrupted by a 15 hour layover in Lima and a 24 hour stop in MD to pack my bags and wave to my parents.

It's this terrible week of limbo. Tomorrow night I find out if I matched and Thursday tells me where I matched. There's nothing more to be done except wait and go to class and try to remember both basic anatomy and how to practice medicine with resources.

It's hard to know what to do with myself without any tests or interviews or application forms on my horizon. (Although I have a terribly embarrassing confession to make: I picked up a USMLE Step 3 book before I left, it's not till next year and I don't even know if I'll match but I just can't imagine my life without something I should be studying). Well, I've mostly been eating Ben and Jerry's cinnamon roll ice cream and watching every episode of 30 rock consecutively.

Not bad at all.