(Don't tell me I didn't warn you.)
Mojo is usually the one to hack up nasty "hairballs" (really puke mixed with hair). Moxie, never. Just now, I hear a retching noise and look up, and there's Mojo near me, just chilling. Moxie is the one retching? This I have to see.
There she is, in the kitchen, near the food dishes. On the floor in front of her is a perfect tube-shaped conglomeration of cat food and lettuce (oh yeah, she's the weird cat who eats lettuce, too). It's almost completely solid, like she had just chewed it a few times and spit it out again. A perfect, 8-inch long cylinder of cat food and lettuce. That she begins to eat again.
Gross.
Monday, March 31, 2008
Wednesday, March 26, 2008
I've never had a patient who...
I've noticed that doctors like to use the phrase, "I've never seen [insert outcome here]" to try to convince their patients that something is OK (or not OK).
My mom had surgery on Monday (everything's OK, no big deal) and the physician was going through the consent form and came to nerve injury. The official risk is 1%, but "I've never seen it happen," he said.
Mountain Mama the same day posted this (really good) essay regarding the seemingly confusing decision parents face regarding vaccination, in which a physician is discussing the pros and cons of influenza vaccination during pregnancy with a patient. The physician tells the patient, "if you do get [the flu], you should know that pregnant women have a higher rate of complications than the general population," then continues, "But I've never, in all my years of practice, had to hospitalize a pregnant patient for the flu."
Here's my issue with that statement.
-On average, according to the CDC, every year more than 200,000 people are hospitalized in the United States for conditions due to or related to influenza. The average age-specific hospitalization number for people ages 5-49 is 47,745 people.
-According to the National Center for Health Statistics, the pregnancy rate in 1999 was 102 per 1,000 women ages 15-44 (with a total of 6.27 million pregnancies in 1999)
-According to census data, there were 270.5 million people in the U.S. in 1998, and 138.2 million or 51.2% of them were women. Of the women, 60.1 million were ages 15-44.
So assuming that the influenza attack rate does not favor men over women or vice versa (a fair assumption, I think, but let me know if you disagree), and acknowledging that the influenza hospitalization stat isn't perfect since it was for people ages 5-49 while the pregnancy data was for women ages 15-44, we can figure that in 1999 about 51.2% of people ages 5-49 who were hospitalized for influenza were female, for a total of 24,445, and 6 million women ages 15-44 were pregnant.
So 0.4% of pregnant women in 1999 were hospitalized for influenza, which is 4 of every 1,000 pregnant women. I couldn't tell you off the top of my head the pregnancy rate in an average Ob/Gyn office's patient census, but I'm going to presume there are fewer than 1,000 pregnant women in the average office during a flu season. Statistically, though, one of those 4 hospitalized women is going to end up in that doctor's practice at some point, and the only way to prevent it would be to get the flu shot. No solace regarding future potential influenza infection should be found in the phrase, "I've never had a patient who needed to be hospitalized" when the doctor has no control over what determines whether a patient needs to be hospitalized. Statistically, if I were planning on refusing the flu shot, I would feel better if one of her patients HAD needed to have been hospitalized already! Since none of her patients have been one of those four-per-thousand yet, I'd be clamoring for the vaccination so as to not become her one statistical patient.
And while I also found my mom's surgeon's use of the phrase, "I've never seen it happen" annoying and falsely reassuring, it's a little different, because he IS able to control, to a larger extent, whether the negative outcome occurs. A good surgeon is aware of the risk of nerve damage and knows how to avoid the nerve, and is able to control a lot of the factors that go into whether a surgical infection occurs. So a good question to ask a surgeon when you are told what the infection risk for your procedure is, is "What is your infection rate?"
One of the things we learned back in our pre-clinical years was that people like information conveyed to them in different ways. Some people like numbers and statistics, if broken down to simple, conversational terms. Others hate them and find solace in phrases like, "unlikely to happen." You can't really tell ahead of time which patients are going to be what kind of people, but I know what I like and how I like to communicate. Cold, hard facts.
So I vow not to use the phrase, "I've never seen it happen." Because there are already plenty of things that I HAVE seen happen that other med students havne't. Are my patients more or less likely to suffer the same outcomes just because I saw it happen before? I don't think so. That's why the statistics are tabulated, so that we do know what affects illnesses and outcomes. Unless it's something the physician is directly responsible for, personal experience shouldn't play a role in recommendations, in my opinion.
Thoughts?
My mom had surgery on Monday (everything's OK, no big deal) and the physician was going through the consent form and came to nerve injury. The official risk is 1%, but "I've never seen it happen," he said.
Mountain Mama the same day posted this (really good) essay regarding the seemingly confusing decision parents face regarding vaccination, in which a physician is discussing the pros and cons of influenza vaccination during pregnancy with a patient. The physician tells the patient, "if you do get [the flu], you should know that pregnant women have a higher rate of complications than the general population," then continues, "But I've never, in all my years of practice, had to hospitalize a pregnant patient for the flu."
Here's my issue with that statement.
-On average, according to the CDC, every year more than 200,000 people are hospitalized in the United States for conditions due to or related to influenza. The average age-specific hospitalization number for people ages 5-49 is 47,745 people.
-According to the National Center for Health Statistics, the pregnancy rate in 1999 was 102 per 1,000 women ages 15-44 (with a total of 6.27 million pregnancies in 1999)
-According to census data, there were 270.5 million people in the U.S. in 1998, and 138.2 million or 51.2% of them were women. Of the women, 60.1 million were ages 15-44.
So assuming that the influenza attack rate does not favor men over women or vice versa (a fair assumption, I think, but let me know if you disagree), and acknowledging that the influenza hospitalization stat isn't perfect since it was for people ages 5-49 while the pregnancy data was for women ages 15-44, we can figure that in 1999 about 51.2% of people ages 5-49 who were hospitalized for influenza were female, for a total of 24,445, and 6 million women ages 15-44 were pregnant.
So 0.4% of pregnant women in 1999 were hospitalized for influenza, which is 4 of every 1,000 pregnant women. I couldn't tell you off the top of my head the pregnancy rate in an average Ob/Gyn office's patient census, but I'm going to presume there are fewer than 1,000 pregnant women in the average office during a flu season. Statistically, though, one of those 4 hospitalized women is going to end up in that doctor's practice at some point, and the only way to prevent it would be to get the flu shot. No solace regarding future potential influenza infection should be found in the phrase, "I've never had a patient who needed to be hospitalized" when the doctor has no control over what determines whether a patient needs to be hospitalized. Statistically, if I were planning on refusing the flu shot, I would feel better if one of her patients HAD needed to have been hospitalized already! Since none of her patients have been one of those four-per-thousand yet, I'd be clamoring for the vaccination so as to not become her one statistical patient.
And while I also found my mom's surgeon's use of the phrase, "I've never seen it happen" annoying and falsely reassuring, it's a little different, because he IS able to control, to a larger extent, whether the negative outcome occurs. A good surgeon is aware of the risk of nerve damage and knows how to avoid the nerve, and is able to control a lot of the factors that go into whether a surgical infection occurs. So a good question to ask a surgeon when you are told what the infection risk for your procedure is, is "What is your infection rate?"
One of the things we learned back in our pre-clinical years was that people like information conveyed to them in different ways. Some people like numbers and statistics, if broken down to simple, conversational terms. Others hate them and find solace in phrases like, "unlikely to happen." You can't really tell ahead of time which patients are going to be what kind of people, but I know what I like and how I like to communicate. Cold, hard facts.
So I vow not to use the phrase, "I've never seen it happen." Because there are already plenty of things that I HAVE seen happen that other med students havne't. Are my patients more or less likely to suffer the same outcomes just because I saw it happen before? I don't think so. That's why the statistics are tabulated, so that we do know what affects illnesses and outcomes. Unless it's something the physician is directly responsible for, personal experience shouldn't play a role in recommendations, in my opinion.
Thoughts?
Tuesday, March 25, 2008
Articles, public health, medical and otherwise
When is sedation really euthanasia? -- Pretty interesting, especially considering my new understanding of end-of-life care and advance directives. From a medical ethics standpoint, it is completely OK, as a physician, to give a dying person a dose of morphine to ease his pain, if that dose might also depress his respiratory drive, and in so doing, hasten respiratory failure and death. If the goal is pain control (and if this is all done in conjunction with the patient's wishes of course), then respiratory depression is an acceptable outcome. Could doctors be overdoing it?
Guidelines for epidemics: Who gets a ventilator? In light of the (most likely) oncoming flu epidemic, as well as issues regarding intensive and end-of-life care and scarce resources, how will we allocate those resources? Health policy principles state that there are four possible goals in any situation: equity, efficiency, security, and liberty. Does everyone get a ventilator (equity)? Or do only the sickest patients who will benefit the most from one get one (efficiency)? Do we vaccinate everyone against infectious disease (security)? Or do we allow people to do what they want to do (liberty)? All four of these goals cannot be achieved in any one situation. I think it's good for people to have these discussions regarding emergency situations and healthcare resources.
TB patients chafe under lockdown in South Africa -- Speaking of security, TB is interesting because in the United States it is the only disease that we as a society have decided is severe enough to warrant DOT (directly observed therapy). That is, if you are diagnosed with active TB and there is reason to believe you will not take your medicines appropriately (see "Doctors without orders," below), public health officials can take you into temporary custody every time your dose is due and watch you swallow your pills. We have decided that security is more important than liberty when it comes to tuberculosis. What's happening in South Africa sounds horrible, though, and I hope that even if XDR-TB becomes more prevalent in the U.S., we have the resources to handle it in a way that still manages to preserve some aspects of liberty.
Doctors without orders -- Why don't patients take their prescriptions accurately? I think a lot of it has to do with patient education -- although the article points to other factors as well. A couple years ago, my mom was prescribed a prednisone taper, and messed up the regimen early on. I came home for spring break to find a mom-monster, crabby, bitchy, anxious, tearful, and I had no idea why. Finally, over the course of about 36 hours, the full story came out: she had left off at "5 pills a day" when she missed a dose, so she caught up on her extra dose, then didn't bother to read the directions again, and kept taking 5 pills at a time until she used up the whole bottle! I tried to explain what was wrong, but the steroids had made her so irrational and she just kept arguing with me. She didn't understand the mechanism by which the prednisone worked, so she assumed they were like antibiotics, and she should take a catch-up dose if she missed one. In the end it worked out, but I have seen first-hand the side effects of steroid withdrawal! I guess I can't point the finger too much, either; I know that ideally, OCPs should be taken exactly 24 hours apart every day, yet I almost never do that...
Get ready to step up, Dad -- I occasionally (OK, more than occasionally) ruminate about life after the wedding. AKA, marriage. And that frequently leads to ruminations about parenthood and career. The good news is that at least in medicine, it's not completely unheard of to negotiate less-than-full-time positions. The bad news is that I am a micro-manager when it comes to a lot of things, and I'm sure that will be true for parenting as well. The good news is that I'm apparently not alone. Also, I still have time to change my micro-managing ways (I'm working on it slowly).
Career or Family? Yes. -- Another article along the women-in-the-workplace theme. I didn't know there were headhunter services for part-time female workers; that's very cool and obviously providing a much-needed service. Hopefully I won't run into too much trouble if and when I need to negotiate a 75% contract -- that's the nice thing about having office hours; if you choose not to have them, then you choose not to have them!
The Mecca of the Mouse -- Ah, Disney World. This Slate author is spending a week there sans children, to explore what it's really about. First up, Epcot. Here's what got me: "Disney had purposefully designed [Epcot] to appeal more to young adults than to their offspring. It was bound to disappoint all but the nerdiest of children." Who loved Epcot at age 10? Yeah, that would be me...
The book of the undead -- Interesting piece from Slate about phone books and why they're still around. Ours keep piling up on the shelf in our coat closet... at least I've stopped taking them from the lobby when they get delivered. Watch all the YouTube clips; I've never seen the Tufts one, and it's a really good prank!
Getting to Europe is about to get easier -- One word: HOORAY!!! I just started reading one of our Scotland travel guides (honeymoon destination), and I've been getting nervous about the financial aspects of a honeymoon in the UK. But maybe airfares will come down?
Guidelines for epidemics: Who gets a ventilator? In light of the (most likely) oncoming flu epidemic, as well as issues regarding intensive and end-of-life care and scarce resources, how will we allocate those resources? Health policy principles state that there are four possible goals in any situation: equity, efficiency, security, and liberty. Does everyone get a ventilator (equity)? Or do only the sickest patients who will benefit the most from one get one (efficiency)? Do we vaccinate everyone against infectious disease (security)? Or do we allow people to do what they want to do (liberty)? All four of these goals cannot be achieved in any one situation. I think it's good for people to have these discussions regarding emergency situations and healthcare resources.
TB patients chafe under lockdown in South Africa -- Speaking of security, TB is interesting because in the United States it is the only disease that we as a society have decided is severe enough to warrant DOT (directly observed therapy). That is, if you are diagnosed with active TB and there is reason to believe you will not take your medicines appropriately (see "Doctors without orders," below), public health officials can take you into temporary custody every time your dose is due and watch you swallow your pills. We have decided that security is more important than liberty when it comes to tuberculosis. What's happening in South Africa sounds horrible, though, and I hope that even if XDR-TB becomes more prevalent in the U.S., we have the resources to handle it in a way that still manages to preserve some aspects of liberty.
Doctors without orders -- Why don't patients take their prescriptions accurately? I think a lot of it has to do with patient education -- although the article points to other factors as well. A couple years ago, my mom was prescribed a prednisone taper, and messed up the regimen early on. I came home for spring break to find a mom-monster, crabby, bitchy, anxious, tearful, and I had no idea why. Finally, over the course of about 36 hours, the full story came out: she had left off at "5 pills a day" when she missed a dose, so she caught up on her extra dose, then didn't bother to read the directions again, and kept taking 5 pills at a time until she used up the whole bottle! I tried to explain what was wrong, but the steroids had made her so irrational and she just kept arguing with me. She didn't understand the mechanism by which the prednisone worked, so she assumed they were like antibiotics, and she should take a catch-up dose if she missed one. In the end it worked out, but I have seen first-hand the side effects of steroid withdrawal! I guess I can't point the finger too much, either; I know that ideally, OCPs should be taken exactly 24 hours apart every day, yet I almost never do that...
Get ready to step up, Dad -- I occasionally (OK, more than occasionally) ruminate about life after the wedding. AKA, marriage. And that frequently leads to ruminations about parenthood and career. The good news is that at least in medicine, it's not completely unheard of to negotiate less-than-full-time positions. The bad news is that I am a micro-manager when it comes to a lot of things, and I'm sure that will be true for parenting as well. The good news is that I'm apparently not alone. Also, I still have time to change my micro-managing ways (I'm working on it slowly).
Career or Family? Yes. -- Another article along the women-in-the-workplace theme. I didn't know there were headhunter services for part-time female workers; that's very cool and obviously providing a much-needed service. Hopefully I won't run into too much trouble if and when I need to negotiate a 75% contract -- that's the nice thing about having office hours; if you choose not to have them, then you choose not to have them!
The Mecca of the Mouse -- Ah, Disney World. This Slate author is spending a week there sans children, to explore what it's really about. First up, Epcot. Here's what got me: "Disney had purposefully designed [Epcot] to appeal more to young adults than to their offspring. It was bound to disappoint all but the nerdiest of children." Who loved Epcot at age 10? Yeah, that would be me...
The book of the undead -- Interesting piece from Slate about phone books and why they're still around. Ours keep piling up on the shelf in our coat closet... at least I've stopped taking them from the lobby when they get delivered. Watch all the YouTube clips; I've never seen the Tufts one, and it's a really good prank!
Getting to Europe is about to get easier -- One word: HOORAY!!! I just started reading one of our Scotland travel guides (honeymoon destination), and I've been getting nervous about the financial aspects of a honeymoon in the UK. But maybe airfares will come down?
Monday, March 24, 2008
Clarification
So it occurred to me that maybe the point of my last post missed its mark.
By saying that "vaccines [are connected] with ... immunology," that woman is only stating the obvious.
For an SAT-style review:
vaccines :: immunology
algebra :: mathematics
So there's really nothing scary, ominous, or "secret researchers hiding things from the mass media" about vaccines being connected to immunology. Of COURSE they're connected to immunology -- they are a subset of the study of immunology, just as algebra is a subset of the study of mathematics!
Maybe she meant that vaccines are connected to immunological disorders? Well, I have to say that's still stupid. Because guess what? NOT vaccinating is ALSO connected to immunological disorders, and in a much more scary and obvious way.
By saying that "vaccines [are connected] with ... immunology," that woman is only stating the obvious.
For an SAT-style review:
vaccines :: immunology
algebra :: mathematics
So there's really nothing scary, ominous, or "secret researchers hiding things from the mass media" about vaccines being connected to immunology. Of COURSE they're connected to immunology -- they are a subset of the study of immunology, just as algebra is a subset of the study of mathematics!
Maybe she meant that vaccines are connected to immunological disorders? Well, I have to say that's still stupid. Because guess what? NOT vaccinating is ALSO connected to immunological disorders, and in a much more scary and obvious way.
Saturday, March 22, 2008
More anti-vaccine crap
Public health risk seen as parents reject vaccines
This is nothing new, I know, but I had to point out this woman's idiotic quote:
“When I began to read about vaccines and how they work,” she said, “I saw medical studies, not given to use by the mainstream media, connecting them with neurological disorders, asthma and immunology.”
Really? Vaccines connected to immunology? Thank goodness you read those studies, or that little fact might have been kept secret by the medical community!
Sigh. More stupid people doing stupid things.
This is nothing new, I know, but I had to point out this woman's idiotic quote:
“When I began to read about vaccines and how they work,” she said, “I saw medical studies, not given to use by the mainstream media, connecting them with neurological disorders, asthma and immunology.”
Really? Vaccines connected to immunology? Thank goodness you read those studies, or that little fact might have been kept secret by the medical community!
Sigh. More stupid people doing stupid things.
Wednesday, March 19, 2008
Match Week!
Yesterday (well, it's technically now Wednesday, so the day before yesterday, but I'm still awake from Tuesday with insomnia) all the 4th-year medical students around the country found out if they matched for residency. If they did, then they did not receive an email on Monday at 11:30 am. If they did not match, then they received an email. If they received the email, then Tuesday they started scrambling for open spots around the country. Most should still match somewhere, but maybe not in their chosen field.
On Thursday at noon, they will all be gathered in auditoriums at their medical schools holding envelopes that tell them where they matched.
In one year, that's going to be me. AAAAAAAHHHHHHH! I'm nervous thinking about it even now. I'm attending this year's Match Day event at UofL, to see how it all goes down, so I can start planning our own Match Day extravaganza for next year. I'll let you know how it goes.
In the meantime, the New York Times wrote their own piece on residency match, with a particular focus on the lifestyle fields. In case you didn't know, it is said (only slightly tongue-in-cheek) that the ROAD to happiness in medicine is paved by Radiology, Ophthamology, Anesthesiology, and Dermatology. As in, those are the "lifestyle" fields. Lots of money for not so much work (relatively). And that's why they're so competitive to get into. Only suckers like me work this hard for 25+ years only to choose a field that has pretty much the crappiest hours guaranteed once you're done. Stupid babies being born in the middle of the night.
Anyway, good luck on Thursday (tomorrow!) to all the 4th years at UofL, as well as Dora and Tam and Dan. I wrote this same good luck bit this time last year, and next year I'll be saying it to myself :)
Seriously, why am I not tired at 3 am?
On Thursday at noon, they will all be gathered in auditoriums at their medical schools holding envelopes that tell them where they matched.
In one year, that's going to be me. AAAAAAAHHHHHHH! I'm nervous thinking about it even now. I'm attending this year's Match Day event at UofL, to see how it all goes down, so I can start planning our own Match Day extravaganza for next year. I'll let you know how it goes.
In the meantime, the New York Times wrote their own piece on residency match, with a particular focus on the lifestyle fields. In case you didn't know, it is said (only slightly tongue-in-cheek) that the ROAD to happiness in medicine is paved by Radiology, Ophthamology, Anesthesiology, and Dermatology. As in, those are the "lifestyle" fields. Lots of money for not so much work (relatively). And that's why they're so competitive to get into. Only suckers like me work this hard for 25+ years only to choose a field that has pretty much the crappiest hours guaranteed once you're done. Stupid babies being born in the middle of the night.
Anyway, good luck on Thursday (tomorrow!) to all the 4th years at UofL, as well as Dora and Tam and Dan. I wrote this same good luck bit this time last year, and next year I'll be saying it to myself :)
Seriously, why am I not tired at 3 am?
Monday, March 17, 2008
Fun facts for the day
Semen analysis: $100
Artificial insemination -- husband: $400-500 (intrauterine insemination; they stick the sperm in the uterus where the uterus and tubes meet so they can swim on down to the egg)
Artificial insemination -- donor: $1000 (same procedure but you have to buy the sperm)
In vitro fertilization: $10-14,000 per cycle
I saw 3 women in the REI clinic for infertility today. The youngest was 25. The oldest was 35.
Thanks. I didn't already have enough worries about having babies. Really.
Artificial insemination -- husband: $400-500 (intrauterine insemination; they stick the sperm in the uterus where the uterus and tubes meet so they can swim on down to the egg)
Artificial insemination -- donor: $1000 (same procedure but you have to buy the sperm)
In vitro fertilization: $10-14,000 per cycle
I saw 3 women in the REI clinic for infertility today. The youngest was 25. The oldest was 35.
Thanks. I didn't already have enough worries about having babies. Really.
Health article roundup
Eliot Spitzer and the price-placebo effect -- So it turns out that there is evidence supporting the theory that when someone pays more for a purchase, they actually enjoy it more, based on brain activity. I guess that doesn't totally surprise me. But what COMPLETELY surprised me was the experiment where they gave people the "energy drink" and the ones who knew it had been purchased at a discount performed worse on the word puzzle, yet the knew it was the exact same drink! I am apparently completely different from all of these test subjects, because I get MUCH more pleasure out of purchases if they are bought at a discount, especially if they are the exact same as the full-price version. I love getting a deal. Oh, and best phrase of the whole article? Eliot Spitzer's "tragicomic downfall."
Training Daze: Why do doctors fixate on diagnosis, not treatment? -- This Slate article is pretty interesting. It kind of goes all over the place, touching on a few different issues. The first is, why do doctors fixate on diagnosis? The answer is pretty clear -- that's the fun of it. We all want to be Sherlock Holmes, figuring out the mystery. They're right that "any old doctor can write a prescription" -- in fact, I routinely get to write prescriptions, because that's how much of a low-level job it is (I just need the doctor to sign them). Of course, what they're really talking about is not actually the writing of the prescription, but the choosing of the prescription to write. And that is left up to the residents. In academic medicine, for the most part, the attending oversees what the resident is doing and double checks to make sure the diagnosis is right, but treatment options are varied and, for the most part, one is as good as another, so that part is left up to the resident. Some things have guidelines -- infectious disease, for instance, is full of guidelines for antimicrobial use. But otherwise, there's a lot of gestalt in choosing treatment regimens. "I like metoprolol," you might hear someone say. "I've had good results with it, I really like it." And in academic medicine, the physicians and residents are much more likely to know why they're prescribing what they're prescribing and can quote you the research studies. But we ALL read Up to Date all the time, no doubt about it. I love it. Up to Date and Wikipedia are pretty much my go-to sources for quick information. Find it disturbing that Wikipedia is educating medical students? Don't be -- it's pretty accurate stuff. In any case, the bottom-line of the article, that you should ask your doctor WHY he or she is recommending a certain treatment, is pretty good advice. Empower yourself to take charge of your own medical care.
Training Daze: Why do doctors fixate on diagnosis, not treatment? -- This Slate article is pretty interesting. It kind of goes all over the place, touching on a few different issues. The first is, why do doctors fixate on diagnosis? The answer is pretty clear -- that's the fun of it. We all want to be Sherlock Holmes, figuring out the mystery. They're right that "any old doctor can write a prescription" -- in fact, I routinely get to write prescriptions, because that's how much of a low-level job it is (I just need the doctor to sign them). Of course, what they're really talking about is not actually the writing of the prescription, but the choosing of the prescription to write. And that is left up to the residents. In academic medicine, for the most part, the attending oversees what the resident is doing and double checks to make sure the diagnosis is right, but treatment options are varied and, for the most part, one is as good as another, so that part is left up to the resident. Some things have guidelines -- infectious disease, for instance, is full of guidelines for antimicrobial use. But otherwise, there's a lot of gestalt in choosing treatment regimens. "I like metoprolol," you might hear someone say. "I've had good results with it, I really like it." And in academic medicine, the physicians and residents are much more likely to know why they're prescribing what they're prescribing and can quote you the research studies. But we ALL read Up to Date all the time, no doubt about it. I love it. Up to Date and Wikipedia are pretty much my go-to sources for quick information. Find it disturbing that Wikipedia is educating medical students? Don't be -- it's pretty accurate stuff. In any case, the bottom-line of the article, that you should ask your doctor WHY he or she is recommending a certain treatment, is pretty good advice. Empower yourself to take charge of your own medical care.
Sunday, March 16, 2008
Random Thoughts
A few weeks ago I saw this Nova on apes and humans, and it was absolutely amazing. I've always realized apes are very human-like (I used to watch this mommy gorilla at the ape house at the National Zoo, and when too many people gathered by the glass while she was breast feeding, she would give us all a withering look and turn away to (it seemed) protect her privacy), but watching people prove it is just cool. The best was that I made Eric watch it when he came to visit and everything that I found absolutely amazing, he found kind of disturbing. I fully believe we are not that different from apes, but I think maybe most people find that thought kind of creepy, in an existential sort of way. Anyway, I'm not deleting it from my DVR, so if you want to come watch it, please do.
Time reported this week that Hong Kong is experiencing a huge flu scare -- regular flu, not bird flu or SARS -- but it's got the city up in arms anyway. I can tell you from experience that the average Hong Kong citizen is highly excitable and easily thrown into a frenzy, and at the same time majorly over-reacts to things while responding actually completely appropriately. When I went over there in 2004, they were still recovering from the SARS scare, so at every major public place, like museums, they had these body heat sensors at the door, so they could scan to see if anyone had a fever. So having kids wear surgical masks seems a little ridiculous, but at the same time, isn't a bad idea at all. But overprescribing Tamiflu? Not such a hot idea at all.
Anyway, I had this idea that I was going to go back to Hong Kong next spring to do an international away rotation. It would accomplish a few things: 1) Experience a foreign healthcare system for myself (it's a mix of public- and private-pay); 2) Visit my grandmother while earning credit; 3) Take advantage of one of the last times I'm guaranteed to be able to travel for a while. Over the last few weeks I've been making up my schedule for next year, and I had all these grand thoughts of doing all these awesome rotations I'm never going to get the chance to do again. Neonatal ICU would have been cool, for instance, and relevant to OB. Anyway, none of it is going to happen. I have 12 weeks of elective time, and all 12 are going to be spent in OB. I get 8 weeks of vacation, and I'm going to take 4 in the summer and 4 next spring, right before I graduate. So next April would be a great time to go to Hong Kong, but now I don't need the credit and would pretty much have to work in the OB or surgery departments due to scheduling and my lack of fluent Cantonese skills, and if I want to go to HK for my vacation, I can just do that and visit my grandmother without worrying about actually working, so I don't think it's going to happen. I still might go for vacation, but that's totally different.
So here is the next year of my life, as it stands now:
This week: Last week of medicine, final exam on Friday
Next week: Spring break! Visit Eric, go home, host a bachelorette party in Pittsburgh for my friend Jamie
April: Psychiatry
May: Finish psych, start family medicine rural rotation
June: Finish family med, end third year (!), take 2 weeks off and do some hard-core wedding planning (1 of these weeks is one of my 8 for 4th year)
July: Away Ob/Gyn rotation at Drexel
August: Away Ob/Gyn rotation at UPenn, take Step 2 to get it out of the way (there are 3 weeks of vacation in here, as well, but I'll be studying)
September: Ob/Gyn AI at UofL
October: Surgery AI
November: Neurology (ugh)
December: finish neuro, get 3 weeks of winter break!
January 2009: Medicine AI
February: AHEC (rural rotation), probably in Ob/Gyn because if I have to be in the middle of nowhere, at least I'll be doing something I like
March: Ambulatory rotation, maybe in pediatrics. I had fun on peds this year. Match Day!
April: Vacation! Hopefully looking for a house in NJ/PA.
May: Graduate, take another 2 weeks off, get married!
June: Honeymoon, move, get readjusted to the real world after taking 10 straight weeks of vacation.
July: start intern year...
Once again, I've managed to create a projection 15 months into the future, but I am incapable of studying for this test I have on Friday. Pretty much par for the course, though.
Time reported this week that Hong Kong is experiencing a huge flu scare -- regular flu, not bird flu or SARS -- but it's got the city up in arms anyway. I can tell you from experience that the average Hong Kong citizen is highly excitable and easily thrown into a frenzy, and at the same time majorly over-reacts to things while responding actually completely appropriately. When I went over there in 2004, they were still recovering from the SARS scare, so at every major public place, like museums, they had these body heat sensors at the door, so they could scan to see if anyone had a fever. So having kids wear surgical masks seems a little ridiculous, but at the same time, isn't a bad idea at all. But overprescribing Tamiflu? Not such a hot idea at all.
Anyway, I had this idea that I was going to go back to Hong Kong next spring to do an international away rotation. It would accomplish a few things: 1) Experience a foreign healthcare system for myself (it's a mix of public- and private-pay); 2) Visit my grandmother while earning credit; 3) Take advantage of one of the last times I'm guaranteed to be able to travel for a while. Over the last few weeks I've been making up my schedule for next year, and I had all these grand thoughts of doing all these awesome rotations I'm never going to get the chance to do again. Neonatal ICU would have been cool, for instance, and relevant to OB. Anyway, none of it is going to happen. I have 12 weeks of elective time, and all 12 are going to be spent in OB. I get 8 weeks of vacation, and I'm going to take 4 in the summer and 4 next spring, right before I graduate. So next April would be a great time to go to Hong Kong, but now I don't need the credit and would pretty much have to work in the OB or surgery departments due to scheduling and my lack of fluent Cantonese skills, and if I want to go to HK for my vacation, I can just do that and visit my grandmother without worrying about actually working, so I don't think it's going to happen. I still might go for vacation, but that's totally different.
So here is the next year of my life, as it stands now:
This week: Last week of medicine, final exam on Friday
Next week: Spring break! Visit Eric, go home, host a bachelorette party in Pittsburgh for my friend Jamie
April: Psychiatry
May: Finish psych, start family medicine rural rotation
June: Finish family med, end third year (!), take 2 weeks off and do some hard-core wedding planning (1 of these weeks is one of my 8 for 4th year)
July: Away Ob/Gyn rotation at Drexel
August: Away Ob/Gyn rotation at UPenn, take Step 2 to get it out of the way (there are 3 weeks of vacation in here, as well, but I'll be studying)
September: Ob/Gyn AI at UofL
October: Surgery AI
November: Neurology (ugh)
December: finish neuro, get 3 weeks of winter break!
January 2009: Medicine AI
February: AHEC (rural rotation), probably in Ob/Gyn because if I have to be in the middle of nowhere, at least I'll be doing something I like
March: Ambulatory rotation, maybe in pediatrics. I had fun on peds this year. Match Day!
April: Vacation! Hopefully looking for a house in NJ/PA.
May: Graduate, take another 2 weeks off, get married!
June: Honeymoon, move, get readjusted to the real world after taking 10 straight weeks of vacation.
July: start intern year...
Once again, I've managed to create a projection 15 months into the future, but I am incapable of studying for this test I have on Friday. Pretty much par for the course, though.
Saturday, March 15, 2008
Gold digging
Pawnshops see rush of gold sellers -- Hmm, I might have to see if I have any broken chains lying around...
Thursday, March 13, 2008
Lost = sad
I always cry over babies and lost loves.
But did you notice that there were three dates on that tombstone? Sun's was on the left (born 1980, no died date) and Jin's was on the right (born 1974, died 9/22/2004). After some discussion with Eric, we determined it must have been put up by Sun after she got off the island, and they said Jin died in the crash to keep up with the story of only 8 survivors that Jack told in court.
So here's my dorky Ob/Gyn take on it:
According to Lostpedia (thank goodness someone is keeping a timeline!), the plane crashed on 9/22, and it is now 12/27 or 12/28. Sun and Jin were definitely not sleeping together the first few weeks, and it's pretty clear (from the online recaps) they reconciled on 11/4, before Jin leaves on the raft. On 11/20, Sun finds out she's pregnant. That fits pretty well with my ACOG pregnancy wheel -- a conception on 11/4 would make her at 4 weeks and 1 day on 11/20, and she would have missed a period, and that would make her in the middle of the 9th week on "today," 12/28. (If you're counting along, the embryo would be 7 weeks old, but pregnancies are tallied from the first day of the last menstrual period, not from the date of conception, because traditionally it was easier to identify the LMP than the date of conception. So a full-term pregnancy is 40 weeks, but the fetus is 38 weeks old.) So her true due date is July 28, 2005.
But, if Jin died in the crash, then Sun would had to have been pregnant on 9/22 already, before he died. Even if they had joined the mile-high club and conceived on the flight, her due date would have been June 15, so a July 28 delivery would make that baby a whopping 6 weeks late. That would be a huge red flag, and pretty much anyone who knew the story of the Oceanic Six would have been able to figure that out -- don't you think part of Sun's story would be that she was pregnant when the plane crashed? Don't you think the media would have been clamboring for some baby photos in mid-June? The other alternative is that Sun did deliver on June 15, with her physician thinking she was full-term but with Sun knowing that she's really only at 34 weeks. That's preemie, people. Which maybe would account for the fetal stress the physician was talking about, I guess. But the other problem with that is that pediatricians can date babies pretty darn accurately in the first 24 hours, and it's done routinely, so the pediatrician is going to take one look at the baby and realize it's a 34-weeker, not a full-term baby. So someone besides me is going to figure out there's a problem!
I guess the other scenario is that Jin died, and then Sun slept with someone else on 11/4, giving her a term delivery at the end of July. I seriously want to know -- I can't imagine that the Lost writers are going to let that detail slip through, when they were detail-oriented enough to make the date of conception (11/4) match the date of pregnancy discovery (11/20) and match "today's" date of being in the 9th week, coming up on her second trimester just like Juliet said. Argh!
I know, I know, I'm a big fat dork.
But did you notice that there were three dates on that tombstone? Sun's was on the left (born 1980, no died date) and Jin's was on the right (born 1974, died 9/22/2004). After some discussion with Eric, we determined it must have been put up by Sun after she got off the island, and they said Jin died in the crash to keep up with the story of only 8 survivors that Jack told in court.
So here's my dorky Ob/Gyn take on it:
According to Lostpedia (thank goodness someone is keeping a timeline!), the plane crashed on 9/22, and it is now 12/27 or 12/28. Sun and Jin were definitely not sleeping together the first few weeks, and it's pretty clear (from the online recaps) they reconciled on 11/4, before Jin leaves on the raft. On 11/20, Sun finds out she's pregnant. That fits pretty well with my ACOG pregnancy wheel -- a conception on 11/4 would make her at 4 weeks and 1 day on 11/20, and she would have missed a period, and that would make her in the middle of the 9th week on "today," 12/28. (If you're counting along, the embryo would be 7 weeks old, but pregnancies are tallied from the first day of the last menstrual period, not from the date of conception, because traditionally it was easier to identify the LMP than the date of conception. So a full-term pregnancy is 40 weeks, but the fetus is 38 weeks old.) So her true due date is July 28, 2005.
But, if Jin died in the crash, then Sun would had to have been pregnant on 9/22 already, before he died. Even if they had joined the mile-high club and conceived on the flight, her due date would have been June 15, so a July 28 delivery would make that baby a whopping 6 weeks late. That would be a huge red flag, and pretty much anyone who knew the story of the Oceanic Six would have been able to figure that out -- don't you think part of Sun's story would be that she was pregnant when the plane crashed? Don't you think the media would have been clamboring for some baby photos in mid-June? The other alternative is that Sun did deliver on June 15, with her physician thinking she was full-term but with Sun knowing that she's really only at 34 weeks. That's preemie, people. Which maybe would account for the fetal stress the physician was talking about, I guess. But the other problem with that is that pediatricians can date babies pretty darn accurately in the first 24 hours, and it's done routinely, so the pediatrician is going to take one look at the baby and realize it's a 34-weeker, not a full-term baby. So someone besides me is going to figure out there's a problem!
I guess the other scenario is that Jin died, and then Sun slept with someone else on 11/4, giving her a term delivery at the end of July. I seriously want to know -- I can't imagine that the Lost writers are going to let that detail slip through, when they were detail-oriented enough to make the date of conception (11/4) match the date of pregnancy discovery (11/20) and match "today's" date of being in the 9th week, coming up on her second trimester just like Juliet said. Argh!
I know, I know, I'm a big fat dork.
For your reading pleasure
800 chihuahuas, other dogs taken from Arizona home - Ew. 800?!?!? I can see why E gets so upset about me wanting a third cat. Then it will be 4...5.... but they're so gosh-darned cute! Like seriously, what's so wrong about wanting a clown car of kitties? Or mitosis bunnies? I'd stop before it got out of control, srsly!
Boyfriend: Phobia caused woman's 2-year bathroom stay - Now I KNOW you've heard this story already. I cannot even imagine. One thing E and I are wondering is whether she's overweight? We're guessing yes, because in order for your skin to grow around a toilet seat, there would probably have to be some overhang to begin with, right? Plus, if she wasn't mobile for two years, she probably wasn't getting enough exercise to keep the pounds off.
School clears kid in contraband candy caper - Political scandals on a small scale! How traumatizing! First Spitzer, and now this... what is going to disappoint us next? Don't worry, I promise not to disappoint MY constituency. (Except I've been eating lunch in the Norton doctor's lounge this week even though I'm not working at Norton... shhh!)
Some day my 9-to-5 job will come - I saw the premiere of this show, and it was pretty good. Yes, it was totally sad that the husband couldn't handle the kids, and kind of sad that the oldest daughter was a second mommy (reminds me of my own childhood), but it was a good show. Obviously she doesn't need the job for the money, or she would have gone back to work already, but is it really that bad for women to want to do something outside the home? I think people need to find other things to be upset about, rather than how other people's children are raised. Like global warming, sustainable energy, or Darfur. I'm really more upset that 'Wifeswap' is on the air than this one.
Final 'Harry Potter' book to be split into two movies - Yay! Of course, if you ask me, all of the books had elements that shouldn't have been removed that were removed anyway, to the detriment of future movies. I'm interested to see how this will turn out.
Tooth Fairy economics ain't nickel-and-dime - I got a quarter for each tooth. And toward the end there, the Tooth Fairy left me my teeth, too, so I used to have an empty tic-tac container with a good number of my baby teeth in it... I wonder where that went to? But even back then, I knew kids who got a dollar, and I think the maximum I ever heard was five. Craziness! And apparently I didn't take enough business classes, because I'm intrigued to hear the rest of the dad at the end's franchise lecture...
Boyfriend: Phobia caused woman's 2-year bathroom stay - Now I KNOW you've heard this story already. I cannot even imagine. One thing E and I are wondering is whether she's overweight? We're guessing yes, because in order for your skin to grow around a toilet seat, there would probably have to be some overhang to begin with, right? Plus, if she wasn't mobile for two years, she probably wasn't getting enough exercise to keep the pounds off.
School clears kid in contraband candy caper - Political scandals on a small scale! How traumatizing! First Spitzer, and now this... what is going to disappoint us next? Don't worry, I promise not to disappoint MY constituency. (Except I've been eating lunch in the Norton doctor's lounge this week even though I'm not working at Norton... shhh!)
Some day my 9-to-5 job will come - I saw the premiere of this show, and it was pretty good. Yes, it was totally sad that the husband couldn't handle the kids, and kind of sad that the oldest daughter was a second mommy (reminds me of my own childhood), but it was a good show. Obviously she doesn't need the job for the money, or she would have gone back to work already, but is it really that bad for women to want to do something outside the home? I think people need to find other things to be upset about, rather than how other people's children are raised. Like global warming, sustainable energy, or Darfur. I'm really more upset that 'Wifeswap' is on the air than this one.
Final 'Harry Potter' book to be split into two movies - Yay! Of course, if you ask me, all of the books had elements that shouldn't have been removed that were removed anyway, to the detriment of future movies. I'm interested to see how this will turn out.
Tooth Fairy economics ain't nickel-and-dime - I got a quarter for each tooth. And toward the end there, the Tooth Fairy left me my teeth, too, so I used to have an empty tic-tac container with a good number of my baby teeth in it... I wonder where that went to? But even back then, I knew kids who got a dollar, and I think the maximum I ever heard was five. Craziness! And apparently I didn't take enough business classes, because I'm intrigued to hear the rest of the dad at the end's franchise lecture...
Wednesday, March 12, 2008
REI
That would be reproductive endocrinology and infertility, not the outdoor store. It's the subspecialty of Ob/Gyn that fixes menstrual cycles that are out of whack, fixes hirsutism, and gives people babies who can't have babies. I'm working with them a few days over the next couple of weeks instead of taking two weeks of vacation (I'm saving that vacation for next year, and I fully intend to take the entire month of April 2009 off!).
So here's an interesting patient I saw today: a 38-year-old woman who had her tubes tied in 2001 in Honduras who now wants a reversal. We're waiting to see if we can get records from the hospital in Honduras that would tell us what kind of tubal ligation she had; if it's the kind that can't be reversed, then it's a no-go. If it's a kind that can be reversed, then it will cost $7,400 to reverse and there's an 80% chance she'll be able to conceive again.
Her husband doesn't know she's doing it.
She'll have to stay overnight in the hospital. She's going to tell her husband she's visiting someone. She won't be able to lift anything heavy (requiring two hands to lift) for at least two weeks, and she reportedly rearranges her furniture every other day. Um, think he's going to notice, much?
She plans on telling him when the baby arrives. OK, she's going to tell him before then, but not until after she's pregnant.
Shocked? There's no requirement that the husband be told. It's probably not that shocking that the physician doesn't have to tell the husband, but wouldn't you think it would be a good idea for the patient to tell her husband? Well, before you go get yourself in a tizzy over this sounds-like-a-board-question scenario, here's the full story: She and her husband were teenage sweethearts, and she got pregnant at 14. Oops! Her parents got pissed, she and he eventually broke up, and she eventually had 3 other children with another man. Now, many years later, she and her teenage guy are back together and married, and he definitely wants more kids but knows her tubes are tied. So this will actually be a nice surprise, not a crazy one.
Enter the ICHC online Poker Cats Contest!
So here's an interesting patient I saw today: a 38-year-old woman who had her tubes tied in 2001 in Honduras who now wants a reversal. We're waiting to see if we can get records from the hospital in Honduras that would tell us what kind of tubal ligation she had; if it's the kind that can't be reversed, then it's a no-go. If it's a kind that can be reversed, then it will cost $7,400 to reverse and there's an 80% chance she'll be able to conceive again.
Her husband doesn't know she's doing it.
She'll have to stay overnight in the hospital. She's going to tell her husband she's visiting someone. She won't be able to lift anything heavy (requiring two hands to lift) for at least two weeks, and she reportedly rearranges her furniture every other day. Um, think he's going to notice, much?
She plans on telling him when the baby arrives. OK, she's going to tell him before then, but not until after she's pregnant.
Shocked? There's no requirement that the husband be told. It's probably not that shocking that the physician doesn't have to tell the husband, but wouldn't you think it would be a good idea for the patient to tell her husband? Well, before you go get yourself in a tizzy over this sounds-like-a-board-question scenario, here's the full story: She and her husband were teenage sweethearts, and she got pregnant at 14. Oops! Her parents got pissed, she and he eventually broke up, and she eventually had 3 other children with another man. Now, many years later, she and her teenage guy are back together and married, and he definitely wants more kids but knows her tubes are tied. So this will actually be a nice surprise, not a crazy one.
Enter the ICHC online Poker Cats Contest!
Global warming
Eight inches of snow on Friday and 66 degrees and sunny tomorrow! It's kind of the best of both worlds. Tons of snow without all the crappy, cold days afterward, followed by full-blown spring.
I need my Ding!
Southwest had better get its act together quickly. They're my favorite airline and I fly them again in two weeks! Yes, yes, safety comes first, and no, I don't want to die in a plane crash. But still, let's just make sure those planes are safe and we can all go about our normal business again.
Friday, March 07, 2008
Done with MICU!
It was a long and intense two weeks, but I made it, and I finished by taking call last night and finishing post-call today, which has its own special feeling. Here's what's happened the last couple of days:
The musician guy who we were declaring brain dead, was declared brain dead. The intern taking care of him made a CD of some of his songs and played them in his room all day. That afternoon, the ventilator was turned off and, according to the intern, his heart just kept plugging along for a few minutes at about 90 bpm and then, all of a sudden, just stopped.
The car accident guy that surgery made a mess of died last night while I was on call. Since my last update, we discovered that he had a dead bowel, and things were not looking good. The family was insisting that he was still a full code, however, but I think they understood the gravity of the situation because they summoned his sister from Alabama yesterday afternoon. Yesterday evening, the intern I was on call with talked again with the family and they decided to make him DNR. In these situations, you really want to think about the life your loved one led: Were they fiercely independent, vowed to drive until the couldn't see, and hated asking for help? Or were they content being a little less active, a little more dependent on others, and wouldn't have minded needing someone else to take care of them fully? In any case, he was made DNR yesterday evening, and our goal was to keep him alive until his sister got here today. No care was withdrawn; he kept getting all the antibiotics and medicines he was getting anyway. He ended up dying at about 10 pm, so his sister didn't get to see him, which is unfortunate. But in hindsight, he was going to die no matter what at 10 pm, so by making him DNR, his family spared him getting useless CPR for 30 minutes, which is nice.
Last Wednesday, on my first call night, we admitted a woman who had been in status epilepticus for an unknown amount of time. She also had end-stage renal disease and had required dialysis for the last three years or so. We continued dialysis, neurology kept monitoring her EEG and was finally able to break her seizures, but she never woke up from her sedated state after we stopped her sedation medications. She was only requiring a little bit of supplementary oxygen and was breathing on her own, and didn't have any infections, so she was in better shape than most -- except for the fact that she was in a coma. The neurologists examined her and her EEG again, and finally concluded that she had a poor prognosis, with little chance of any mental status improvement. Unlike the musician, she was not brain dead, but her brain had been fried by the continuous seizure. She still had most of her brain stem functions, like corneal reflexes, although she did not withdraw to deep pain. Yesterday morning the neurologists told her daughters about her poor prognosis, and they took it very well, considering. There were lots of tears, but I think they themselves had already realized that their mother wasn't in very good shape. They told the doctor, "Thank you for being honest with us."
So what was keeping my patient alive at this point was dialysis, tube feeds, and a little bit of supplementary breathing support with CPAP. The dialysis was the biggest thing. After talking to the nephrologist, though, the daughters decided to stop dialysis. I overheard one of them say, "There are other people who could benefit more from that dialysis machine than my mother can." While that's not really necessarily how resource allocation works, it was still touching. Because it's true: If you are otherwise mobile and have something to live for, be it grandchildren or a job, dialysis is great. But if you are in a coma with very little chance of recovery, it doesn't really make sense to keep someone alive with it. She had actually just finished dialysis yesterday morning and wasn't due to get it again until tomorrow, so that wasn't going to imminently kill her; in fact, if you are otherwise OK, death by renal failure can take up to a week or so, and is actually pretty peaceful and not painful at all, which is a blessing.
So the daughters withdrew dialysis, and after talking with the palliative care team, decided to withdraw the feeding tube and extra breathing help (CPAP) as well, and provide comfort care only. I thought she would make it a few more days, but she was requiring more and more supplemental oxygen and was getting tired breathing. I checked in on her at 7 am today and she was not great, but OK. But by 8, she had passed. Heart heart rate had been pretty fast, in the 120s, then it slowed to the 80s, the 60s, the 40s, the 20s, and eventually just stopped. It was kind of bittersweet, in the sense that she was my first MICU patient, and she died on my last day. Not that all, or even any more, of my patients should follow me in and out of the hospital that way. But still.
In other news, we are in the middle of a big (by Louisville standards) snowstorm. It started snowing around 7 am today and there was about an inch on the ground by the time I left the hospital at 10. They were calling for anywhere from 2-8" by the time it's over. We definitely have at least 2 right now, but I don't think we'll get to 8. They closed the public schools preemptively this morning, and the university was closed at 1 pm today, and has already been closed for tomorrow as well. Not that it would affect me, since the hospitals never close. Plus, I'm off for the weekend!
One of the worst feelings in the world is having to go to sleep in a call room, followed by waking up in a call room. But one of the best feelings in the morning is getting home post-call, absolutely weary, taking a very hot shower, putting on a comfy robe, eating some breakfast (or lunch, depending on what time you get home), and crawling into bed for post-call sleep. You feel absolutely peaceful and rested when you wake up.
The musician guy who we were declaring brain dead, was declared brain dead. The intern taking care of him made a CD of some of his songs and played them in his room all day. That afternoon, the ventilator was turned off and, according to the intern, his heart just kept plugging along for a few minutes at about 90 bpm and then, all of a sudden, just stopped.
The car accident guy that surgery made a mess of died last night while I was on call. Since my last update, we discovered that he had a dead bowel, and things were not looking good. The family was insisting that he was still a full code, however, but I think they understood the gravity of the situation because they summoned his sister from Alabama yesterday afternoon. Yesterday evening, the intern I was on call with talked again with the family and they decided to make him DNR. In these situations, you really want to think about the life your loved one led: Were they fiercely independent, vowed to drive until the couldn't see, and hated asking for help? Or were they content being a little less active, a little more dependent on others, and wouldn't have minded needing someone else to take care of them fully? In any case, he was made DNR yesterday evening, and our goal was to keep him alive until his sister got here today. No care was withdrawn; he kept getting all the antibiotics and medicines he was getting anyway. He ended up dying at about 10 pm, so his sister didn't get to see him, which is unfortunate. But in hindsight, he was going to die no matter what at 10 pm, so by making him DNR, his family spared him getting useless CPR for 30 minutes, which is nice.
Last Wednesday, on my first call night, we admitted a woman who had been in status epilepticus for an unknown amount of time. She also had end-stage renal disease and had required dialysis for the last three years or so. We continued dialysis, neurology kept monitoring her EEG and was finally able to break her seizures, but she never woke up from her sedated state after we stopped her sedation medications. She was only requiring a little bit of supplementary oxygen and was breathing on her own, and didn't have any infections, so she was in better shape than most -- except for the fact that she was in a coma. The neurologists examined her and her EEG again, and finally concluded that she had a poor prognosis, with little chance of any mental status improvement. Unlike the musician, she was not brain dead, but her brain had been fried by the continuous seizure. She still had most of her brain stem functions, like corneal reflexes, although she did not withdraw to deep pain. Yesterday morning the neurologists told her daughters about her poor prognosis, and they took it very well, considering. There were lots of tears, but I think they themselves had already realized that their mother wasn't in very good shape. They told the doctor, "Thank you for being honest with us."
So what was keeping my patient alive at this point was dialysis, tube feeds, and a little bit of supplementary breathing support with CPAP. The dialysis was the biggest thing. After talking to the nephrologist, though, the daughters decided to stop dialysis. I overheard one of them say, "There are other people who could benefit more from that dialysis machine than my mother can." While that's not really necessarily how resource allocation works, it was still touching. Because it's true: If you are otherwise mobile and have something to live for, be it grandchildren or a job, dialysis is great. But if you are in a coma with very little chance of recovery, it doesn't really make sense to keep someone alive with it. She had actually just finished dialysis yesterday morning and wasn't due to get it again until tomorrow, so that wasn't going to imminently kill her; in fact, if you are otherwise OK, death by renal failure can take up to a week or so, and is actually pretty peaceful and not painful at all, which is a blessing.
So the daughters withdrew dialysis, and after talking with the palliative care team, decided to withdraw the feeding tube and extra breathing help (CPAP) as well, and provide comfort care only. I thought she would make it a few more days, but she was requiring more and more supplemental oxygen and was getting tired breathing. I checked in on her at 7 am today and she was not great, but OK. But by 8, she had passed. Heart heart rate had been pretty fast, in the 120s, then it slowed to the 80s, the 60s, the 40s, the 20s, and eventually just stopped. It was kind of bittersweet, in the sense that she was my first MICU patient, and she died on my last day. Not that all, or even any more, of my patients should follow me in and out of the hospital that way. But still.
In other news, we are in the middle of a big (by Louisville standards) snowstorm. It started snowing around 7 am today and there was about an inch on the ground by the time I left the hospital at 10. They were calling for anywhere from 2-8" by the time it's over. We definitely have at least 2 right now, but I don't think we'll get to 8. They closed the public schools preemptively this morning, and the university was closed at 1 pm today, and has already been closed for tomorrow as well. Not that it would affect me, since the hospitals never close. Plus, I'm off for the weekend!
One of the worst feelings in the world is having to go to sleep in a call room, followed by waking up in a call room. But one of the best feelings in the morning is getting home post-call, absolutely weary, taking a very hot shower, putting on a comfy robe, eating some breakfast (or lunch, depending on what time you get home), and crawling into bed for post-call sleep. You feel absolutely peaceful and rested when you wake up.
Wednesday, March 05, 2008
He said WHAT?!?!?!
Sorry John McCain, I didn't have any beef with you before, but now you are dead to me.
"Studies repeatedly have discounted any link between thimerosal and autism, but legal challenges continue. The issue even cropped up in the presidential campaign, with Republican John McCain asserting on Friday that "there's strong evidence" autism is connected to the preservative."
I'm glad I didn't hear about this on Friday, because I got to spend an extra five days of my life not pissed off about this. ARE YOU FREAKING KIDDING ME!?!?!?!?!?!!? This is worse than Mike Huckabee not believing in evolution.
By the way, I have no reaction to the story this quote came from except to roll my eyes. Thanks for the really informative article. No idea what kind of mitochondrial disorder the kid has, no idea what vaccines she got, no sort of information that would allow me to intelligently interpret the information given. Thanks.
By the way, just as a reminder, vaccines don't contain thimerosal anymore, autism rates are continuing to rise despite this, and there was just another measles outbreak due to a kid not getting vaccinated due to personal beliefs.
All I can do right now is scream in frustration.
"Studies repeatedly have discounted any link between thimerosal and autism, but legal challenges continue. The issue even cropped up in the presidential campaign, with Republican John McCain asserting on Friday that "there's strong evidence" autism is connected to the preservative."
I'm glad I didn't hear about this on Friday, because I got to spend an extra five days of my life not pissed off about this. ARE YOU FREAKING KIDDING ME!?!?!?!?!?!!? This is worse than Mike Huckabee not believing in evolution.
By the way, I have no reaction to the story this quote came from except to roll my eyes. Thanks for the really informative article. No idea what kind of mitochondrial disorder the kid has, no idea what vaccines she got, no sort of information that would allow me to intelligently interpret the information given. Thanks.
By the way, just as a reminder, vaccines don't contain thimerosal anymore, autism rates are continuing to rise despite this, and there was just another measles outbreak due to a kid not getting vaccinated due to personal beliefs.
All I can do right now is scream in frustration.
Tuesday, March 04, 2008
Happy National Grammar Day!
It's National Grammar Day: Why You Should Care
Because I said so! OK, because Martha Brockenbrough said so. But still, you should care. I would especially like to point out the atrocity that is Physicians Who Cannot Write or Spell. Seriously? We're considered among the most intelligent people in society (I'm not saying it's always true), but you write "vomitting"? Sigh...
Robert Irvine gets fired from Food Network
I really don't understand why people still lie on resumes. Especially considering Food Network already had a resume-falsifying issue with The Next Food Network Star's Josh Garcia last season. Tsk, tsk, Robert Irvine.
Because I said so! OK, because Martha Brockenbrough said so. But still, you should care. I would especially like to point out the atrocity that is Physicians Who Cannot Write or Spell. Seriously? We're considered among the most intelligent people in society (I'm not saying it's always true), but you write "vomitting"? Sigh...
Robert Irvine gets fired from Food Network
I really don't understand why people still lie on resumes. Especially considering Food Network already had a resume-falsifying issue with The Next Food Network Star's Josh Garcia last season. Tsk, tsk, Robert Irvine.
Depressing?
I was talking to a friend yesterday and mentioned I was on MICU. She asked if I had seen anything depressing, and I have. The thing is, I don't really get depressed by the MICU. The patients there are VERY sick, and many are not going to get better. But I'm learning and doing so much that it doesn't really sink in. One thing I had never really had a good grasp of was when it's appropriate to keep trying new interventions, and when it's best to just step back and hope the family will make the patient DNR (do not resuscitate). It's a little clearer now -- mostly because I look at a patient, realize they aren't going to get better, and declare to myself that I never want to be in that state, so therefore, they would be better off passing on. (Obviously, my opinion of what constitutes a fulfilling life is not the be-all and end-all of end-of-life decision making, but you get the point.)
I used to get really upset when a patient's condition was due to their own stupid actions, and it still does bother me a little bit (pregnant women who use drugs, people with alcoholic liver disease, etc), but I realized that it only bothers me the most when the patients are awake and defiant and (sometimes) mean, despite what we are trying to do to help them. When the patients are so sick they're in the ICU, they're usually intubated and sedated and they don't piss me off because they can't talk or complain. So I distance myself emotionally from the reason they're in liver failure and instead am just interested in treating it.
What DOES bother me, though, is when people get bad treatment from other services. Now, I know there is a long tradition of surgery mocking medicine and medicine mocking surgery, but the truth is, surgeons do not know how to handle infections very well at all. Everyone gets put on prophylactic antibiotics even when there is no reason for it; people with positive cultures get put on the wrong antibiotics; people with mounting signs of infection don't get worked up for them adequately. I'm really happy I rotated on infectious diseases last month and wish all surgeons had to.
Case in point: we have an elderly gentleman who just got transferred to us from the trauma service. He was in a car accident a few weeks ago and fractured his hand. They operated on the hand and fixed it, and he's been recuperating. Then he started spiking fevers, so they checked some cultures and found he had MRSA in his blood. So they treated it with what they thought was an appropriate antibiotic. But the thing about bloodstream infections is that they don't just appear out of nowhere -- they always have a source. The surgeons didn't change his central lines or get an echocardiogram to find or treat the source. After 10 days of MRSA treatment and persistently positive blood cultures, they called the MICU service. We got an echo. He has a huge-ass abscess on his mitral valve, and more vegetations (a nidus of bacterial growth) on his aortic valve. In other words, he has endocarditis. Now he needs surgery. The surgeons are apprehensive because he's a poor candidate for surgery (ah, the irony). Hopefully both the family and surgeons will agree with proceeding with surgery and there may be some chance of infection resolution, but the prognosis is poor, because with every beat of his heart, he is showering bacteria into his bloodstream and every corner of his body. If the family doesn't ask for surgery, then they should make him DNR, because he is not going to get any better (there are other issues going on as well that contribute to his poor prognosis).
But anyway, here's what I actually intended to blog about. We're in the process of declaring another one of our patients brain dead, which is a very serious, but also very interesting thing. This patient was found down initially and spent some time in the ICU with various infections and an altered mental status. He finally got better enough to be transferred to the regular floor while they were looking for long-term placement options. He was originally a British citizen, but has lived in the U.S. for over 30 years illegally. As such, he has no U.S. citizenship or claim to government healthcare, and the UK won't take him back either since he has been gone so long. He has a daughter who wants nothing to do with him and apparently doesn't care that he's this sick. He just has a friend from California who is legally not allowed to do anything because he's just a friend. Actually, this friend is his music partner -- the two of them are folk guitarist/singers and they have a few songs on YouTube that I've watched. I'd share, but I'd be violating HIPAA, sorry.
Anyway, while he was on the floor and they were trying to find a nursing home or rehab facility that would take him without any form of payment (haha, yeah right), he went into cardiopulmonary arrest. They were able to restart his heart, but the anoxic brain injury didn't do him any favors. He was put back on the ventilator and transferred back to the ICU, where he eventually developed ventilator-associated pneumonia. Eventually we realized that his mental status was very depressed despite being on no sedating medicines, so the process of evaluating brain function was initiated.
First, you check for deep pain reflexes, like the sternal rub (rub really hard on the sternum -- it hurts! -- to see if the patient withdraws from your hand) or supraorbital pressure (press really hard on the eyebrows to elicit a withdrawal reflex). You check to see if the pupils react to light (they should constrict when you shine a light in the eyes). You check for corneal reflexes (touch the tip of a q-tip to the eyeball, which should make you blink reflexively). You check for a gag reflex. You do the doll's eye maneuver. You do caloric stimulation, in which you squirt cold water in the ear, which should elicit eye movement called nystagmus. Finally, you turn off the ventilator and see if the patient has any spontaneous respiratory drive. Respiratory drive is the last of the brain stem reflexes to disappear.
On Saturday, this patient had abnormal versions of all of those tests (that is, no withdrawal to deep pain, fixed pupils, no corneal reflex, no gag reflex, no doll's eye movement, and no nystagmus with caloric stimulation) except he still would breathe spontaneously. So we put him back on the ventilator (even though he was breathing on his own, he wasn't taking good enough breaths to get good oxygenation) and checked again the next day. Yesterday was my day off, but I know he had an EEG (actually not necessary or useful in determining brain death), and sometime over the course of the day he failed his spontaneous breathing trial. So the final piece of declaring brain death is to do an apnea test.
I'm not going to describe all the little details of apnea testing, but here are the basics. You breathe in oxygen and you breathe out carbon dioxide (I know you know that, but I have to establish the basics, you know?). If you hold your breath, you will eventually succumb to the urge to take a breath again -- try it if you don't know what I'm talking about. This urge is not because your body senses that it doesn't have enough oxygen; it's because your body senses you have too much carbon dioxide building up in your blood and you need to get rid of it. Your body is very acutely tuned to carbon dioxide levels, and will regulate your breathing automatically to keep them at a normal level (normal for most people is a partial pressure, or paCO2, of 40 mm Hg).
*Side note: if you are submerged underwater, one of the reasons you actually drown is because your CO2 levels get so high that your brain kicks in and forces you to take a breath -- of water. Oops.
OK, so back to apnea testing. A non-brain dead person, even one who is unconscious, will respond to CO2 buildup by initiating a breath. So to determine brain death by apnea testing, you are looking for the patient to NOT take a breath. Of course, there are rules: the patient can't be hypothermic, or have any toxins in the body, or have any sedating medicines on board. First you get an ABG while the patient is on the ventilator and make sure the pH is normal (so there is neither excess acid nor base in the body) and the CO2 is normal (40). Then you turn off the ventilator, and give the patient 100% oxygen flow through the breathing tube (normal air is 21% oxygen) for 8 minutes. The cells in the body are still alive, so their mitochondria will use that oxygen and create CO2 as the byproduct, which is released back in the bloodstream. Because there is so much oxygen being given, there will be a lot of CO2 produced, which should trigger the breathing reflex in the brainstem. After 8 minutes (this isn't an arbitrary number, but the details are not necessary here), if the patient hasn't breathed, then you draw another ABG, and if the CO2 level is 60 or higher (meaning 20 mm Hg more CO2 in the blood than previously), then you have a positive apnea test and the patient is brain dead. There are also rules about who can determine brain death (obviously, not me!). In our hospital, you need two different services to do it, so in this case it's MICU and neurology. After brain death is determined, you keep the ventilator turned off, and the combination of hypoxia and hypercapnea will cause physiological death.
Anyway, the apnea testing is happening today. When I left, they were still trying to get the patient's blood pH normalized as the first step. I don't think he's going to be there tomorrow.
Don't worry, there are some patients who get better. Not everyone is this depressing. But what you, yourself, should do ASAP -- tonight! -- is write up your advance directives. A lot of these situations arise because the patient has never clearly expressed any wishes regarding end-of-life treatment, and family members are unavailable or unable to agree on decisions. So check out this website, which has lots of great information, and then click on the link on the right from the National Hospice and Palliative Care Organization to find an advance directive form for your state. Fill it out, make some copies, and give them to the appropriate people.
Another note: brain death is actually pretty clear-cut. If you're brain dead, there's no point in keeping you on a ventilator. The murkier issues are where you are still breathing on your own but your higher mental capacities are damaged, so it is a quality-of-life issue. So the things you need to discuss with your health-care proxy are what you think constitutes a good quality of life. If a good life is dependent on you being able to read a book and discuss it with someone, that is very different than if you think you would be happy lying in bed all day staring blankly and not knowing what is going on around you. I'm not saying either is better than the other, just that they are very different states of being.
I used to get really upset when a patient's condition was due to their own stupid actions, and it still does bother me a little bit (pregnant women who use drugs, people with alcoholic liver disease, etc), but I realized that it only bothers me the most when the patients are awake and defiant and (sometimes) mean, despite what we are trying to do to help them. When the patients are so sick they're in the ICU, they're usually intubated and sedated and they don't piss me off because they can't talk or complain. So I distance myself emotionally from the reason they're in liver failure and instead am just interested in treating it.
What DOES bother me, though, is when people get bad treatment from other services. Now, I know there is a long tradition of surgery mocking medicine and medicine mocking surgery, but the truth is, surgeons do not know how to handle infections very well at all. Everyone gets put on prophylactic antibiotics even when there is no reason for it; people with positive cultures get put on the wrong antibiotics; people with mounting signs of infection don't get worked up for them adequately. I'm really happy I rotated on infectious diseases last month and wish all surgeons had to.
Case in point: we have an elderly gentleman who just got transferred to us from the trauma service. He was in a car accident a few weeks ago and fractured his hand. They operated on the hand and fixed it, and he's been recuperating. Then he started spiking fevers, so they checked some cultures and found he had MRSA in his blood. So they treated it with what they thought was an appropriate antibiotic. But the thing about bloodstream infections is that they don't just appear out of nowhere -- they always have a source. The surgeons didn't change his central lines or get an echocardiogram to find or treat the source. After 10 days of MRSA treatment and persistently positive blood cultures, they called the MICU service. We got an echo. He has a huge-ass abscess on his mitral valve, and more vegetations (a nidus of bacterial growth) on his aortic valve. In other words, he has endocarditis. Now he needs surgery. The surgeons are apprehensive because he's a poor candidate for surgery (ah, the irony). Hopefully both the family and surgeons will agree with proceeding with surgery and there may be some chance of infection resolution, but the prognosis is poor, because with every beat of his heart, he is showering bacteria into his bloodstream and every corner of his body. If the family doesn't ask for surgery, then they should make him DNR, because he is not going to get any better (there are other issues going on as well that contribute to his poor prognosis).
But anyway, here's what I actually intended to blog about. We're in the process of declaring another one of our patients brain dead, which is a very serious, but also very interesting thing. This patient was found down initially and spent some time in the ICU with various infections and an altered mental status. He finally got better enough to be transferred to the regular floor while they were looking for long-term placement options. He was originally a British citizen, but has lived in the U.S. for over 30 years illegally. As such, he has no U.S. citizenship or claim to government healthcare, and the UK won't take him back either since he has been gone so long. He has a daughter who wants nothing to do with him and apparently doesn't care that he's this sick. He just has a friend from California who is legally not allowed to do anything because he's just a friend. Actually, this friend is his music partner -- the two of them are folk guitarist/singers and they have a few songs on YouTube that I've watched. I'd share, but I'd be violating HIPAA, sorry.
Anyway, while he was on the floor and they were trying to find a nursing home or rehab facility that would take him without any form of payment (haha, yeah right), he went into cardiopulmonary arrest. They were able to restart his heart, but the anoxic brain injury didn't do him any favors. He was put back on the ventilator and transferred back to the ICU, where he eventually developed ventilator-associated pneumonia. Eventually we realized that his mental status was very depressed despite being on no sedating medicines, so the process of evaluating brain function was initiated.
First, you check for deep pain reflexes, like the sternal rub (rub really hard on the sternum -- it hurts! -- to see if the patient withdraws from your hand) or supraorbital pressure (press really hard on the eyebrows to elicit a withdrawal reflex). You check to see if the pupils react to light (they should constrict when you shine a light in the eyes). You check for corneal reflexes (touch the tip of a q-tip to the eyeball, which should make you blink reflexively). You check for a gag reflex. You do the doll's eye maneuver. You do caloric stimulation, in which you squirt cold water in the ear, which should elicit eye movement called nystagmus. Finally, you turn off the ventilator and see if the patient has any spontaneous respiratory drive. Respiratory drive is the last of the brain stem reflexes to disappear.
On Saturday, this patient had abnormal versions of all of those tests (that is, no withdrawal to deep pain, fixed pupils, no corneal reflex, no gag reflex, no doll's eye movement, and no nystagmus with caloric stimulation) except he still would breathe spontaneously. So we put him back on the ventilator (even though he was breathing on his own, he wasn't taking good enough breaths to get good oxygenation) and checked again the next day. Yesterday was my day off, but I know he had an EEG (actually not necessary or useful in determining brain death), and sometime over the course of the day he failed his spontaneous breathing trial. So the final piece of declaring brain death is to do an apnea test.
I'm not going to describe all the little details of apnea testing, but here are the basics. You breathe in oxygen and you breathe out carbon dioxide (I know you know that, but I have to establish the basics, you know?). If you hold your breath, you will eventually succumb to the urge to take a breath again -- try it if you don't know what I'm talking about. This urge is not because your body senses that it doesn't have enough oxygen; it's because your body senses you have too much carbon dioxide building up in your blood and you need to get rid of it. Your body is very acutely tuned to carbon dioxide levels, and will regulate your breathing automatically to keep them at a normal level (normal for most people is a partial pressure, or paCO2, of 40 mm Hg).
*Side note: if you are submerged underwater, one of the reasons you actually drown is because your CO2 levels get so high that your brain kicks in and forces you to take a breath -- of water. Oops.
OK, so back to apnea testing. A non-brain dead person, even one who is unconscious, will respond to CO2 buildup by initiating a breath. So to determine brain death by apnea testing, you are looking for the patient to NOT take a breath. Of course, there are rules: the patient can't be hypothermic, or have any toxins in the body, or have any sedating medicines on board. First you get an ABG while the patient is on the ventilator and make sure the pH is normal (so there is neither excess acid nor base in the body) and the CO2 is normal (40). Then you turn off the ventilator, and give the patient 100% oxygen flow through the breathing tube (normal air is 21% oxygen) for 8 minutes. The cells in the body are still alive, so their mitochondria will use that oxygen and create CO2 as the byproduct, which is released back in the bloodstream. Because there is so much oxygen being given, there will be a lot of CO2 produced, which should trigger the breathing reflex in the brainstem. After 8 minutes (this isn't an arbitrary number, but the details are not necessary here), if the patient hasn't breathed, then you draw another ABG, and if the CO2 level is 60 or higher (meaning 20 mm Hg more CO2 in the blood than previously), then you have a positive apnea test and the patient is brain dead. There are also rules about who can determine brain death (obviously, not me!). In our hospital, you need two different services to do it, so in this case it's MICU and neurology. After brain death is determined, you keep the ventilator turned off, and the combination of hypoxia and hypercapnea will cause physiological death.
Anyway, the apnea testing is happening today. When I left, they were still trying to get the patient's blood pH normalized as the first step. I don't think he's going to be there tomorrow.
Don't worry, there are some patients who get better. Not everyone is this depressing. But what you, yourself, should do ASAP -- tonight! -- is write up your advance directives. A lot of these situations arise because the patient has never clearly expressed any wishes regarding end-of-life treatment, and family members are unavailable or unable to agree on decisions. So check out this website, which has lots of great information, and then click on the link on the right from the National Hospice and Palliative Care Organization to find an advance directive form for your state. Fill it out, make some copies, and give them to the appropriate people.
Another note: brain death is actually pretty clear-cut. If you're brain dead, there's no point in keeping you on a ventilator. The murkier issues are where you are still breathing on your own but your higher mental capacities are damaged, so it is a quality-of-life issue. So the things you need to discuss with your health-care proxy are what you think constitutes a good quality of life. If a good life is dependent on you being able to read a book and discuss it with someone, that is very different than if you think you would be happy lying in bed all day staring blankly and not knowing what is going on around you. I'm not saying either is better than the other, just that they are very different states of being.
Monday, March 03, 2008
Phone: ring ring
Phone: ring ring [phone number with 215 area code]
Me: Hello?
Guy: Hi, this is [garbled] from the Inquirer. [garble garble]
Me: I'm sorry?
Guy: Are your parents home?
Long pause.
Me: I'm an adult.
Guy: I'm sorry. You're the homeowner?
Me: Yes.
Guy: I'm sorry about that. [tries to get me to re-subscribe to the Inquirer]
Me: Cuts him off. I don't live in the Inquirer area any more.
Guy:About to tell me I can still get the Inquirer in Maryland or some BS like that. Oh, well where do you live?
Me: Kentucky
Guy: [not suppressing a chuckle very well] Oh, well you enjoy yourself there, then.
Me: click
Me: Hello?
Guy: Hi, this is [garbled] from the Inquirer. [garble garble]
Me: I'm sorry?
Guy: Are your parents home?
Me: I'm an adult.
Guy: I'm sorry. You're the homeowner?
Me: Yes.
Guy: I'm sorry about that. [tries to get me to re-subscribe to the Inquirer]
Me: Cuts him off.
Guy:
Me: Kentucky
Guy: [not suppressing a chuckle very well] Oh, well you enjoy yourself there, then.
Me: click
Sunday, March 02, 2008
Just added to my Google Reader
Stuff White People Like
This blog was just started on January 18, but it's apparently the hottest thing out there right now. Thanks to eukaryotic for alerting me to it!
I have to say, half of the things I laugh at are because I am white and identify with them (Kitchen Aid stand mixer definitely going on my registry), and half are because I am not white and identify with them (I did not understand extreme reading for quite a long time and even now can only stand to do it for short amounts of time; I would choose to eat at restaurants with ducks hanging in the window every meal of every day if possible, and an otherwise intelligent white person I knew in college once declared to me that India was not part of Asia).
I just finished reading the whole thing; I'm not really sure why I never took a nap as I said I was going to do earlier, but I guarantee I'm going to sleep for a long time tonight.
This blog was just started on January 18, but it's apparently the hottest thing out there right now. Thanks to eukaryotic for alerting me to it!
I have to say, half of the things I laugh at are because I am white and identify with them (Kitchen Aid stand mixer definitely going on my registry), and half are because I am not white and identify with them (I did not understand extreme reading for quite a long time and even now can only stand to do it for short amounts of time; I would choose to eat at restaurants with ducks hanging in the window every meal of every day if possible, and an otherwise intelligent white person I knew in college once declared to me that India was not part of Asia).
I just finished reading the whole thing; I'm not really sure why I never took a nap as I said I was going to do earlier, but I guarantee I'm going to sleep for a long time tonight.
Scrabulous is fabulous
Online Scrabble craze leaves game sellers at loss for words (haha, get it?) I love Scrabulous. And it's true; I don't have the time to invite people over and make the tea and biscuits anymore these days.
Spring!
I know Mother Nature is just toying with me, but that's OK for right now. I had a long call night last night, and got out post-call around noon. It was 60 degrees and bright and sunny. I ran some errands this afternoon, and it just got sunnier and warmer. Right now it's cooled down and weather.com still tells me it's 66. Beautiful!
As I pulled into a parking spot this afternoon, the opening strains of Journey's Don't Stop Believing came on the radio, and I pulled right back out of the parking spot and drove around the shopping center singing until the song was over. It was that kind of day :)
And guess what -- tomorrow's my day off for the week and the projected high is 65! I foresee studying at a sidewalk cafe in my future.
I don't think I've talked about MICU yet. I really, really like it. The patients are really sick and complex, but there are very clear things you need to do for them. It's fast-paced and decisive. In that way, it reminds me of ER medicine, but the good thing is that even when you do have to deal with drunks and drug addicts, they are for the most part intubated and can't berate you the way they do down in the ER. Oh yeah, and did I mention I put in a central line the other night? That was completely and totally awesome.
As for now, it's time for a post-call nap/sleep.
As I pulled into a parking spot this afternoon, the opening strains of Journey's Don't Stop Believing came on the radio, and I pulled right back out of the parking spot and drove around the shopping center singing until the song was over. It was that kind of day :)
And guess what -- tomorrow's my day off for the week and the projected high is 65! I foresee studying at a sidewalk cafe in my future.
I don't think I've talked about MICU yet. I really, really like it. The patients are really sick and complex, but there are very clear things you need to do for them. It's fast-paced and decisive. In that way, it reminds me of ER medicine, but the good thing is that even when you do have to deal with drunks and drug addicts, they are for the most part intubated and can't berate you the way they do down in the ER. Oh yeah, and did I mention I put in a central line the other night? That was completely and totally awesome.
As for now, it's time for a post-call nap/sleep.
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