Good to Be Home

After five days in the desert, two at home, and four in Charleston; two flights on Southwest Airlines (one with peanuts, one with Oreo ChocoStix), two flights on American Eagle ($2 for nuts, $5 for a pillow/blanket), one flight on US Airways Express and one on Mesa Air/America West Regional/US Airways (which included George Foreman!); two rented cars (Chevy Impala and Ford Focus); and tons of restaurant food, most of it fantastic, I am finally home. I'm such a boring person, I really prefer to be at home, where I can sleep when I want, eat on my own schedule, and use my own bathroom. I really like using my own bathroom, especially since my stomach was upset the entire time I was in South Carolina and I was forced into some unsavory restroom facilities. For some unknown reason, my whole abdomen swelled up until I looked about six months pregnant. Fortunately, it has since deflated and I feel much better (thanks for asking).

And now, I'm ensconced on my couch, watching some crazy sci-fi show that my husband loves (and it is actually kinda cute). We took our dog to a big park today, then brought home some Boston Market. I doubt we'll even watch the ball drop.

And I'm happy as a little clam to be back in my little world.

Update

Travel, travel, travel. I just spent 5 days in West Texas with my dad's family and my grandmother (eating lots of Rosa's and Taco Villa, the world's greatest fast-food Tex-Mex). Back home Christmas Eve, spent Christmas with my wonderful hubby, then today I'm flying to Dallas and tomorrow to Charleston, SC for a short vacation with my aunt and my seester, a recent college grad with honors.

I really have nothing exciting to say, so Merry Christmas, Happy New Year, or Happy Whichever Holiday you celebrate!

PS- Best quote of the day: "I'm 100% genuine fortified!" (from the Dog the Bounty Hunter commercial on A&E). Pure brilliance.

Ambrosia

I don't remember when I started eating this soup, but I was very young. It's always been one of my favorites, even though most other people in my house thought I was nuts. It has a warm, rich broth and is FULL of salt, which to me is one of the best parts.

Today, I was post-call and sniffly. I've had a scratchy throat and post-nasal drip since Friday. I didn't feel awful, necessarily, but I didn't feel good, either, and I felt just bad enough to whine a little. Well, hopefully only a little. My intern let me come home at 7 this morning since we'd already presented my patient to the attending and, um, since I whined a little. (Actually, it was non-verbal whining. You know, the well-timed sniffle or cough, the oh-so-pathetic offer to stay and help out in that annoying scratchy voice.) I came home and slept for 5 hours in my own bed--much better than the sofa I slept on last night (although I was glad to get that sleep, sofa or not). When I woke up, I knew what I wanted to eat for lunch. Only one thing would coat my scratchy throat and go down easily, and I would accept no substitutes.

While my soup was heating, I was thinking to myself "you know, this stuff has absolutely ZERO nutritive value. It's basically salt with beans." So I decided to read the label on the can. I realized that in at least one aspect, I was definitely wrong: the label declared that one serving of this soup contains 8 grams of fiber, or 32% of the daily value. By comparison, one serving of oatmeal contains 4 grams of fiber. I was shocked. Then, looking further, I realized that there were 2.5 servings of soup in this can; therefore, there are 20 grams of fiber, or upwards of 75% of the daily recommended fiber allowance.

I concluded that I will spend a large part of my day tomorrow in the fourth floor student library bathroom at the hospital. It was sooooooooo worth it, though.


Speaking of fiber, if you're ever interested, go check out your local medical book store. There, you can find pocket laminated cards with various types of information: EKG's, Spanish, ACLS, and fiber. Yes, this company sells pocket cards with information about daily fiber intake and amounts of fiber in various foods. Just in case you ever wanted to know...

Interns

Interns come in many shapes and sizes, as well as all levels of skill. Some interns are FMG's, foreign medical graduates; some were even attending physicians in other countries before coming to America. Some FMG's really suck; some American-trained interns really suck. Interns are like a box of chocolates: you never know what you're going to get.

My half of the team currently has two interns: one from Chicago and one from Europe. I'll call them C and E respectively. I am drawing no conclusions about their abilities based on their places of origin; I am simply trying to identify them in an anonymous fashion.

Intern C is efficient but rather bitter. It's funny bitterness, and not directed toward students, so I don't mind so much. He's pretty good with patients, likes to teach, and doesn't mind when I ask a million questions of him or of the patients. It's easy to get into "complain" mode when I'm around him for a length of time, which is my only real complaint (and it's not a strong one).

Intern E is almost entirely the opposite. He's a nice enough guy, new to this country. Since he's a recent immigrant, I expect things to be difficult for him in some ways: just learning America is tough, let alone American medicine or Texas (an entirely different proposition). However, he seems to think that students are his personal assistants, like we exist to do his work. If we don't do his work, or don't take patients with him, his work doesn't get done. He also makes decisions about patient care, after the attending has made his plan, without consulting the upper-level resident or the attending. Case in point: attending (an oncologist) makes a plan to consult pulmonology on a cancer patient with possible respiratory stridor. After attending leaves, E decides the patient doesn't really have stridor and therefore doesn't need a pulmonary consult. He didn't discuss this with anyone, so today when the attending came, this patient with a potentially life-threatening condition (if she really has respiratory obstruction due to her tumor) did not receive the consult he'd discussed with the team.

My attending, a very soft-spoken, nice man, has a side that I had suspected when I first met him. He is the nicest guy possible unless you obstruct patient care, and then he gets very angry. Politely angry, but angry nonetheless. While I continue to feel that some of the tests we order are not terribly necessary, he makes the decisions, not me--I'm not the boss (although I'm definitely bossy). He's willing to go to bat for the consults and tests he orders, he's made himself available at all hours to his residents and interns, and he's willing to come to the hospital at any time. One reason he orders so many tests, also, is he has worked at many private hospitals and is highly offended that the county hospital would treat patients any differently--I understand that, too. I respect the man, and I've seen residents politely debate (for lack of a better word) ordering certain tests or consults with him--he listens closely, and if they have a good reason for their opinion he gives it consideration. There is NO REASON to go behind his back and just not do something because you suddenly disagree with the plan.

I feel kind of bad that I've quit taking patients with E, because stuff doesn't get done on his patients. He doesn't listen while the attending is giving the plan, and expects the student to know everything that's supposed to get done. Never mind the fact that the plan is written in the attending's very thorough notes (it's part of why we round for so damn long every day)--he can't seem to be bothered to listen or go back to the chart to copy down the plan. The other student on my half of the team agreed, saying she didn't want to babysit him all the time.

He also gave me a little "lecture" the other day on patient care: "It's not your job to get the social stuff done, it's your job to get the medical stuff done." This on a patient who remained in the hospital overnight simply because he couldn't be bothered to write "d/c home" on her chart--I had to get the other intern to write it for me the next day at noon when she was still there. He had gone to see the patient after I paged him to tell him the wheelchair would be delivered to her home, and that she would be able to borrow one until then, so she could go home right away--since he'd gone to see the patient to tell her she'd stay overnight, I know he was still at the hospital, and I know he wasn't just being lazy, so what the bloody hell was he doing??

I think I want to try to talk to him first, or perhaps Intern C, but I'm unsure of what to say. I've thought about talking to the upper level resident, or the attending, but I don't want to do that just yet. I also know that I'm a know-it-all, and it must be annoying to have some smart-ass student always thinking she knows better than you, an actual MD. I don't want to offend him further. I'm really concerned that I'm going to say something that will get me in trouble, though, if I continue to be this frustrated. How in God's name do you not check the vitals on a patient with bacteremia and suspected endocarditis??? I feel like I could help his patients if I took some of them, but at the same time I don't want to cover for his ass.

I'm much too grouchy lately to be a doctor. Sometimes I think the only people I'm nice to are my patients and occasionally my long-suffering husband, who has heard me bitch WAY TOO MUCH about this situation. I'd better go kiss him to try to make it up to him.

Favorite Time-Wasting Spots

Since I have nothing better to talk about, I'm going to briefly talk about my favorite blogs & places to waste time on the internet.

• The Underwear Drawer: My first blog, my first med student blog. Michelle is now an anesthesia resident with a toddler and an ophtho resident husband. I periodically go back and reread her student-era stuff because it reminds me that other people feel the same way I do during med school. That, and I am a huge stalker.
• Ah Yes, Medical School: One of the funniest and most bitter of the med school blogs. Posting under "the Fake Doctor", this California student has written some stuff that caused me to need to wipe off my monitor because I spit all over it while laughing my ass off.
  
• The Fat Doctor: "Famine-resistant doctor, pastor's wife, stroke survivor, singer in the church choir, mom of one toddler and two dogs, cynic and active daydreamer." Funny, poignant--an excellent account of life as a family practice doc.
• UroStream: A female urologist describes life as... a female urologist. Hilarity ensues.
• Medstudentitis: Inflammation of the med student, or the blog of a Canadian student in her second year.
• Fingers and Tubes in Every Orifice: An ER doc details life on the front lines of medicine: the drunks, the frequent fliers, the lawsuits, the lives saved and lost.
• The Berry Patch: A med student in Israel talks about her cat, buying kosher cat food, and the differences between living in America and living in Israel.

One reason I read so many student blogs is for solidarity--even across different countries, many of the experiences are the same. The frustrations, the huge piles of books, the pain of shoving information in your brain ("drinking from a fire hose"). I read "grown-up" blogs because it's nice to hear from those who survived, who walked through the fire and came out the other side. I read some others, but I'm too lazy to type about any more blogs.

Shorts

• Driving to work at 0630 sucks because it is dark and early, but traffic is nil. Driving to work after 0700 is nice because it's actually light out, but traffic is remarkably thicker.
• Homemade fudge is super tasty.
  
• Being on call sucks.
  
• When on call, it is entirely possible to sleep comfortably on a chair, in my white coat, with full pockets, under a thin hospital blanket, wearing a hat, in a room with multiple people walking in and out and a television on mute.
• Brushing your teeth at 0445 after a night in the hospital and 3 Cokes is only temporarily refreshing.
• Two packages of stale Saltines from the hospital "Nourishment" closet are wonderfully sustaining while on 5 hours of rounds.
• Hearing from an old friend first thing in the morning over AIM is the best part of waking up.
• I love my tiny Christmas tree.
• 40 degree weather here feels colder than 12 degree weather in the Rocky Mountains. I am also a huge wuss.

I am totally NOT creative while post-call, even after 4 hours' sleep in the hospital and a good nap this afternoon. Hopefully tomorrow will be a bit more inspiring.

Crabby

Sorry to be such a grouch. Today wasn't nearly as bad. I think the real thing about my attending is that he is inconsistent: he treats some patients fearfully (let's order everything under the sun) and some with confidence (I know what they have and I can treat it, and they're well enough to go home). I love it when patients go home, and I have less work to do. (Kidding!) But it is a good thing when patients go home. The county hospital is definitely aromatic, and with 4 patients per room, separated only by curtains, very noisy as well. I wouldn't wish a prolonged stay in the county hospital on my enemies, let alone my patients.

Currently watching: the AKC Dog Show, Part II. My hubby has a real soft spot for these shows. I will totally confess to loving to watch beautiful, happy dogs prance around for the audience. Speaking of dogs, our dog is located on the papasan chair, buried under a pile of thick blankets with only the tip of his nose poking out. I really ought to take more pictures of stuff like this, so then people will have no doubt that I'm a crazy dog lady.

New Attending

My new attending for the month started off well. Tall, soft-spoken, I'll call him Dr. C for "Castilian"--I think he may be Spanish. He didn't place a lot of demands on the students at our meeting--he even said we could choose to write H&P's. We're finally allowed to do long and short call--every other call, I get to go home in the afternoon. He made an arrangement with the residents to come to the hospital at 5 pm on call days, to round on the earliest-arriving newly admitted patients. It all sounded well and good. He's new to our school and this hospital, but has worked in our hospital district before.

Today, we were post-call. I woke up at 0430 so I could get to work by 0530 to round at 0630. At 0445, the other student paged me to say that the attending had changed his mind--we wouldn't round until 0730, and the other half of the team would go first. I got a wee bit more sleep, finished my H&P (I only had one new patient), and got to the hospital by 0700. Between vitals, seeing patients, and writing my note, I was ready to go by about 0800.

The rot set in by 0930 when we still hadn't begun to round--Dr. C was still with the other half of the team. We finally began around 1000. For some reason, Dr. C insisted on seeing the patients he'd already seen the evening before, as if he'd never seen them before. What, then, was the point of him spending so much time there the evening before? He also started ordering multiple tests on patients that were maybe not so necessary (like a D-dimer on a patient with chronic chest pain, most likely related to GERD). One of my patients had a cough and a fever, with sputum production and some hemoptysis. His CXR showed an upper lobe process. My diagnosis? Pneumonia. My attending, for some reason, started worrying about fungus balls, and ordered a stat CT of the chest. What did the CT show? "Ground-glass opacity in the upper lobe"--the radiology resident told me "if he clinically has pneumonia, then he has pneumonia, honey". This CT gave us absolutely nothing that would help us. The patient wasn't severely ill, he's responded well to antibiotics overnight, he's not requiring oxygen--did we really need to start chasing zebras? I was finally dismissed by one of the interns at 1400 (well past the 30 hour rule for the rest of the team--at least I'd gotten some sleep).

I'll make the "I'm lazy" argument--I don't like chasing tons of labs. I'll make the "primum non nocere" argument--every test has risks to the patient; nothing is totally benign. I'll make the statistics argument--every test could be falsely positive or negative. My old attending, Dr. H, railed at us about "pre-test probability"--clinically, how likely is it that the test will be +/-, and then order those tests which will change your therapy. Now, I know why he harped on us about this.

Another thing. If a residency group is going to enforce the 80 hour week/30 hour shift rules, the attending should take care not to round for so long that 30 hours comes and goes while the team is still rounding. If you get there at 0600 on call, then you *should* be leaving by noon the next day. We should not be rounding until 1400. This is how residency programs get in trouble (when this stuff happens all the time--let's hope this was a one-time thing).

Damn, now I miss Dr. H. Sure, I was terrified of him, but he used rounds to direct patient therapy and to teach. Rounds today had no purpose; we did a lot of sitting while the attending wrote lengthy notes on each patient, then asked every patient if they had any breast masses and when their last breast exam was (even the men). I realize his specialty is heme/onc, but still. Another Dr. H-ism holding true: "Pick your specialty and you'll pick your disease."

Between the agonizing long rounds (until 1400 on a post-call day) and my new, disorganized, slow intern, it's going to be a pitiful 2 weeks.

The Chameleon

Way back in high school, I had an English teacher my senior year whom I really loved. She was an excellent teacher, a truly Southern woman, yet totally liberated. After I'd received my acceptance to college, and gotten accepted into a pre-med program, I told her all about it. Her response? "You should be an English teacher." I thanked her politely, but I told her I had my heart set on being a doctor.

One of my high school band directors also played trumpet with me in our church orchestra on Sundays. I told him about my plans to go to medical school after college; he told me "I can see you going to a small liberal arts college, majoring in music, and becoming a band director." It really was too bad that I didn't see myself that way at ALL. I thanked him politely, and told him I really didn't think I wanted to be a band director. Although, there are times when that option seems more appealing than it did then...

One of my surgery chiefs got all into the idea of my being a surgeon; she offered to help me find an adviser, and help me write and publish a case review. Both of my pediatrics attendings asked me if I was going into pediatrics, and were visibly disappointed when I politely (but firmly!) told them I had no interest in pediatrics.

Last night, on call for internal medicine, was one of the worst nights ever. I made several screw-ups that got me (nicely, and rightfully) chewed out by my upper-level resident. I misunderstood an errand I'd been asked to run, and instead of heading upstairs to fetch the cards, I drove to the med school and back (an hour round-trip in 5 pm traffic). As I got progressively sleepier and more brain-dead, only 3 Cokes and intense, unholy fear of my attending kept me moving. As I prepared my notes, I kept filling in blanks I'd left: a finger-stick glucose here, a TSH there. I finished and signed my notes, transferred data around until my scut sheets had all the values I'd need (hopefully), and felt the pressure in my chest get heavier and heavier. 6 am: go time. My respiratory rate sped up. The onslaught began with chest x-rays: "what do you see?", "why do we have this CT?" (the answer was almost always, "the ER ordered it") "what other abnormalities are there?" (after we'd discussed the only abnormalities I could see). One of my fellow students, a studious but nervous guy, had a visible tremor as he fumbled his papers looking for lab values (this same student has Gilbert's syndrome, and was a distinct shade of yellow this morning from the stress). It went on, and on, and on, for 6 hours and 20 patients. Constant calm criticisms flowed: "this is unacceptable", "you guys' physical exam skills suck", "that's not the question I asked you", "I'm asking you guys to use some common sense," etc. It was brutal. I managed to escape the worst of it, and after my first patient to present, the shaking stopped, and all I could think about was the fact that I hadn't peed in 6, 8, 10, 12 hours (nor did I really need to, which was more worrisome). Finally, the last quick staff note hit the last chart, and Dr. H said "Students, come with me."

We entered his lair, I mean office, and settled in for a quick chat. "I only yell because I care", "don't be overwhelmed", "medicine is tough--a lifelong process" were only a few of the quick phrases that were tossed around. As this was our last (and only) call with him, he asked if we had any problems or questions. When no one spoke for 2 seconds, he said "Great. I want to talk to you [pointing at me] for a second--the rest of you can go." The other three filed out, relieved at having gotten off so lightly, and looking at me with pity. I collapsed in a chair and waited while he made a phone call. What had I done wrong? Did I kill a patient? Did I forget yet another lab value? My notes went on the chart at the correct time, I had all my vitals, and I'd escaped the most furious of the tongue-lashings. Then I wondered, did he want to talk about my intern or resident? My intern was convinced she was failing, although I didn't think she was the most yelled-at of the interns. My resident was definitely the better of the two on the team. WHAT THE HELL DID I DO WRONG OH GOD I SWEAR I DIDN'T MEAN IT JUST GET IT OVER WITH AND KILL ME NOW! He hung up the phone, turned his chair around to face me, and said...

"You were made to be an internist."

I don't know how I kept my mouth from dropping open. My heart had definitely stopped.

He proceeded to tell me that I asked the right questions (I didn't recall asking any), that I had a good knowledge base, that I was not only made to be an internist but also a subspecialist, because I needed to know everything, to be an expert. He discussed an article I'd given him (at his request), and how I was obviously thinking in the right way. He said he wanted me to seriously consider internal medicine as a career, that he didn't know if I already had plans but he wanted me to keep medicine in mind. He then asked if I had any plans and I politely said "I'm keeping my options open now". I thanked him and told him I'd never felt as stupid as I had during the past week and a half. He reiterated the don't get overwhelmed speech, I said "thank you, sir", and we walked out.

I didn't know whether to laugh or cry or tell him how much I'd hated the previous evening, how many times I'd picked up my purse to see the next patient and thought "I could just leave now". I didn't tell him I'd never considered internal medicine, or that I liked surgery or OB. I just said "thank you, sir".

Even now, after a refreshing post-call nap, I still think I was hallucinating.

I Talk A Lot

As I went through to edit the HTML of my blog layout and some of the posts that never quite worked right (like the Hangover post--I finally got it to work!), I noticed something. I make excessively long posts. In other words, I am exceedingly verbose (even when I'm saying that I talk too much). My apologies if the mega posts are annoying. Take some Ritalin--you'll make it through. (By "you" I'm referring to any of the 1,062 people who have visited my blog. Thanks! Fortunately, SiteMeter doesn't tell me how many of those visits are me, checking to make sure stuff worked.) I'll try to work harder at not rambling for hours through every single last detail of my boring, lame life that nobody wants to read, not even myself. I promise. I will stop talking. I swear.

More Mythbusters, then bed. I have my first call on internal medicine tomorrow, and I'm terrified. I only have 4 more days of Dr. Hardass! My goals: learn LOTS (the man is truly a walking library of evidence-based medical facts) while NOT receiving any ass chewings. We'll see.

Too Boring to Blog

Get up, go to work, quiver in face of attending, come home, watch TV (lots of CSI: Miami and Mythbusters), whine about cooking dinner, go to bed. Get up, repeat (insert a chewing-out by said attending). Get up, repeat. Get up extremely late, bake a gingerbread (I took it out of the oven a shade early, so it was too gooey in the middle), drive to the boonies, have Thanksgiving with hubby's grandmother, drive home, go to bed. Get up, watch football, go shopping to finish wedding registry, go out to dinner with father-in-law, come home, go to bed. Work Saturday, come home, watch lots of TV. Work Sunday, come home, watch even more TV. That brings us up to tonight, where I'm watching Mythbusters and reading other people's blogs.

It was a bit of a depressing week. I'm usually a "superstar" in medical things. My peds attending told me she wished all students were like me (I blushed). Fast forward a month, and I'm a gibbering idiot. Thanks to a miscalculation of my time and a misunderstanding, I failed to write any notes on my patients before rounds and failed to check DTR's on a patient with a TSH of 53, so I was told I obviously didn't want to learn and that my performance was "unacceptable". All this on the second day of the rotation. Ever since, when I have to speak to my attending, I've started shaking like a leaf--it's truly pitiful.

He's a hardass, this is true. He's also an unbelievably intelligent man, a very caring physician, and a demanding teacher. He won't be doing my eval, so I don't necessarily have to impress him; I just don't want to be a blithering idiot. It doesn't help when I have interactions like this:

Surgery intern: Hey, how's it going?
Me: Hey, I haven't seen you since trauma. I'm on medicine now.
Intern: Oh yeah? Who's your attending?
Me: [Dr. Hardass]
Intern: *Laughter*
Me: Gee, thanks.

If people didn't continue to say things like this to me, maybe my stomach wouldn't be tied in so many knots. Perhaps I'd be sleeping better, not constantly imagining my next interaction with the man.

Other than that, the only news I have to report is that one of my patients gave me a bracelet this morning. I tossed it in the trash (out of his view, of course), as it was constructed of the band from a latex glove and some sort of paper, and it wasn't entirely clean. He told me it had the power of the Bible in it. Who knew dressing a guy's decubitus ulcer could prompt such gratitude.

Scary

My new attending literally told a patient today that if he continued to do cocaine and drink alcohol, that not only would his bleeding ulcers get worse, but that he could possibly die. The attending then told him that he should find another hospital if he was going to continue these habits and quit wasting the county's money.

Last night my new team admitted patients; this morning was our first day, post call for the rest of the team. One of my interns wrote a little note on her papers and showed it to another while we were rounding (very middle school). It said "3/4 of my patients are cocaine positive".

As I read through the H&P my intern wrote, I noticed that she said the patient was "hyperthyroid" at least 4 times, yet her plan included "thyroid replacement hormone" for "hyperthyroidism". It's a good thing this patient is actually hypothyroid, or this plan could be really dangerous.

Ah, good times at ye olde county hospital. It's going to be an exciting month.

Ugh

I'm sure most people already know about this, but OJ Simpson has written a book entitled "If I Did It", detailing how he would have killed his wife (if he had, of course). This announcement comes very soon after the court ruling denying Ron Goldman the rights to Simpson's celebrity persona (which is probably a good decision, in my opinion, even if it is a hard one to swallow). This whole thing is disgusting and trashy, and to make it worse, Fox is going to air an interview where he will discuss these issues (NBC turned it down). My computer is freezing up, or I would post a link to the times of this airing.

It's entirely within Simpson's First Amendment rights to say these things, and the precedent of double jeopardy prevents any further prosecution in these matters. Therefore, my only recourse is to exercise my civil rights NOT TO WATCH THIS MAN'S SHOW and NOT TO READ THIS MAN'S TRASH.

Breaking Bad News

We had our first-ever class on how to break bad news to a patient this week. I say "first-ever" because I actually think I might have benefited from having such a class earlier in my training, followed by a refresher course now. The class didn't really contain any instruction; instead, a standardized patient (SP) sat in the front, and two student volunteers each attempted to break the news to her that a routine chest x-ray revealed a lung mass suspicious for cancer (confirmed by CT). The first student did an excellent job; the only thing I would have done differently is that I wouldn't have interrupted the patient's questions to read things like "pleural effusion and right pleural mass" off the CT findings. The second student didn't really have a chance. The SP changed her tactics: instead of being quietly shocked and tearful, this time she was fuming mad from the get-go. "Some idiot called me and said there was a mistake on the x-ray, and instead of repeating it I got some cat scan thing, and all I wanted is your signature so I can go get my new job!" The poor student, flustered from the beginning, struggled to do his best, but the SP wouldn't give him any ground. At one point, he looked at the audience and the instructor and said "Can I call a friend?" He was given no lifelines, however, and literally ran out of the "patient's room" at the end of the encounter (amongst much laughter, including his).

I, fortunately, was not chosen for this encounter, and studiously avoided the instructor's eyes when she asked for volunteers. During both students' attempts, I squirmed in my chair, especially during the second. All I could think was "Thank GOD that isn't me up there!" It's one thing to deliberately enter an encounter that is guaranteed to be uncomfortable; it's entirely another to do so in front of a room of your classmates. I do think it might have been nice to have a little more instruction, like "What NOT to do when breaking bad news", or "How to pass the SP interaction on Thursday".

My extreme discomfort showed me that I have an awful lot to learn about this topic. I was present when my senior resident confirmed that the "head mass" seen CT was indeed most likely cancer for the family of the fifteen-year-old patient, and it didn't feel so awkward, just sad. But I didn't really have to talk. I've never had to break that news myself. I'm really not looking forward to the "practice session" on Thursday, where I will get my own SP and I will have to tell them something bad. However, I think this is something, like the rectal exam, that I'd rather practice on someone who's getting paid before I have to do it for real.

I do have a fear about breaking bad news, and that is that I will cry. I don't know if a patient or their family would be offended if their doctor cried while delivering bad news. Would it be a sign that the doctor cared, or would it make the encounter more about the doctor than the patient? Is it a sign of weakness?

On a slightly related tangent, I expect to have to use my new-found knowledge during this year, because one of the oddities of being a third year medical student is becoming a "patient advocate". We really get the most time to be with each patient, since we have (far) fewer duties than any of the actual MD's or nurses: we generally only carry 3-4 patients at a time, and we are only marginally useful in doing actual work, AND we are inefficient at conducting H&P's, so the combination gives us the most time to spend with the patients. I've had patients tell me I'm the only person who answered their questions. Most residents and doctors I've worked with cared about the patients, answered questions, and tried to keep patients informed. Yet, the perception was one of confusion and lack of information on the part of the patients. As I'm getting ready to go back to the county hospital for internal medicine, I'm trying to get back into that mindset, to remind myself that it's so busy at this place that questions get lost and patient care may be cursory. We'll see how well I do.

Why I'm Still in Med School

As a third year student, I finally get to interact with patients. It's so strange, finally getting to do what I came here to do (except, of course, this month). I had occasion to give a tour to some interviewees last week, and it reminded me just how far I've come since I got here two and a half years ago. Ah, to be so naive, thinking medical school is all about gross anatomy and learning to be a doctor. All these kids wanted was to talk to a "real live med student" about what life is like on the inside. How busy will they be? What is gross anatomy like? What are the students like? How competitive is it here? Can we go to the gross anatomy lab? What does it feel like, to almost be a doctor?

I get that kind of question a lot. Other common questions I get when I tell people I'm in medical school: Is it like Grey's Anatomy? (Of course! I have sex in call rooms with my supervisors ALL THE TIME.) Medical school? So you're going to be a nurse? (Nurses work hard, but I'm paying an awful lot to go to school for that MD, dammit.) What is internship like? (Why are people so obsessed with interns? I guess that goes back to the first question.) What is it like, getting to see patients and treat them?

Two years ago, these questions were a little more painful for me. The first year of medical school (at my particular institution; it varies) is split in half. The first semester consists of gross anatomy, biochemistry, histology, developmental anatomy, and the first part of a course on learning how to take a history and physical (called ICM). The second semester contains physiology, immunology, neuroscience (blegh), microbiology, and the continuation of the "being a doctor" course. The first semester is physically and mentally gruelling. Lectures are held every morning from 8 to noon, gross lab MWF, histo lab T/Thur, ICM whenever they can fit it in. Week-long blocks of exams occur 3 times, with the last block running into 2 weeks of finals. The second semester has a little more free time in the afternoons, with the exception of neuro lab on Mondays, but there are 4 week-long blocks of exams plus two weeks of finals.

I did okay through the first semester of first year. I was living alone at the time, since my fiance was living in DC, so I was able to keep basically whatever hours I wanted. I made some close friends within the med school class, and we had marathon bitch sessions about the hardships of med school. I started going to the homeless clinic that December, seeing patients and trying to reconcile learning dense enzymatic pathways with "being a doctor". I did okay. I even started seeing a psychologist at the school, beginning to work out my years of depression, anxiety, and neuroses (I said "beginning", okay?? Geez!).

After Christmas, the semester started badly. I had traveled too much over the break, beginning the semester exhausted. The neuro professors emailed us over the break, giving us homework that I couldn't complete (along with a majority of the class) because I was out of town. I started thinking, why am I here in medical school? I didn't come here to learn 80 different cytokines, I didn't come here to learn every single neural pathway (especially when we don't *really* know how they work, anyway), and I didn't see how learning the delicate nuances of gas exchange across lung membranes was going to affect me as a doctor. I got more and more depressed, more and more avoidant. I quit going to school, relying instead on the school's streaming video system to race through lectures as quickly as possible. I only showed up for neuro lab, which was mandatory, and sometimes microbiology, which I inexplicably loved (and which most everyone else in my class HATED). I took spring break up to my mom's house in the mountains and slept nearly the whole week, watching CSI when I was awake; I actually took the following week off of school, renting CSI DVD's from Blockbuster one at a time (on one of those unlimited rental passes). I knew my behavior was destructive. I didn't like how I felt sitting on the couch for hours unshowered, eating frozen dinners, barely getting up to walk the dog. My whole life's direction seemed up in the air. Why was I in medical school? I wanted to be a doctor, not a biochemist, not a physiologist, not an immunologist, and certainly not a neuroscientist. I hated being in the school building. One of the few things that I did that semester that helped (aside from continuing to see my counselor) was that I continued to visit the homeless clinic. I don't remember how many times I went, perhaps 4 or 5 times, but those were the few times I felt like I was in the right place. This is why I'm here, I'd think, I just have to make it through this other bullshit.

Since I've wanted to be a doctor pretty much as long as I can remember, this existential crisis really threw me. If I weren't going to be a doctor, what would I be? There was no answer to this question. With only a few weeks left to go in the semester, I made myself a deal: if I couldn't hack it, I'd take a year off, do some research, work a part-time job, and come back in a year. That way, I allowed myself room to maneuver, so I didn't feel so trapped. I also signed up to do a couple of preceptorships over the upcoming summer, where I'd follow doctors, see patients, and try to rejuvenate.

I thought I hid all this pretty well from my classmates. I've always worked hard to hide my depression from people: the harder I've cried, the giddier I am when I see my friends later. The lower I am inside, the louder I laugh. And, to be honest, I didn't feel this bad every single minute of every single day. I may or may not have met the criteria for major depression, I'm not really sure. It was a close thing. Also, medical students are fairly notorious for "playing tough", since ego drives medicine.

Later, when I've mentioned to classmates that I had a rough semester, I've been told that I looked sad, but most people assumed it was because my fiance was so far away. Even my family assumed my unhappiness had more to do with my fiance than with depression or medical school.

After I made it through the final final, an enormous load lifted. My earlier bargain was rendered obsolete--why would I need to take a year off med school? That would just prolong the ordeal. I'd heard second year was oh so much better than first year, I had preceptorships to look forward to, and my fiance had finally been able to make plans to move to be with me.

Now, over a year later, things are much rosier. Second year was so much more clinically relevant that it passed very quickly. Even with the terror of the USMLE, and the agony of taking so many exams in so little time, I never had that crisis again. Now, my panic is thinking "how will I ever pick a specialty?" But that's for another post, since this one is already approaching War and Peace proportions. So, I feel uniquely suited to talk to interviewees, and to first and second year students about why it's rough to be a med student. I tutored many first years as a second year, and we discussed these issues over and over. I promised them it would get better, and that if they were truly in the right place it would get easier. I actually got a "referral" the other day, a first year student who was having a similar crisis. After a morning interviewing patients at the homeless clinic (using my Maxwell's), she said she felt better, like it worthwhile to be in medical school again. It gave me a warm fuzzy.

Where's Mine?

Man, I'm going to Burger King tonight!

What???

Many thanks to a friend for pointing me to this link on USA Today. Since the abstinence only message is oh so effective in the teenagers it's aimed at, apparently now states seeking federal funding for sex ed... I mean abstinence education are required to target "adolescents and/or adults within the 12- through 29-year-old age range". The reason for this change: "Childbearing by unmarried women reached a record high of almost 1.5 million births in 2004, up 4 percent from 2003", according to the National Center for Health Statistics. However, at the same time, "childbearing by women in their early twenties showed a decline" of 1%, so my highly uneducated interpretation is that fewer women 20-24 had children, but more of them were unmarried.

I was going to expound on this topic, but I really can't. So all I'm going to say is wow. >90% of the population over 20 has had sex at some time. I really think abstinence-only education, aimed at people my age, is going to be EXTREMELY effective. Cuz, you know, sex isn't so great, I'm sure we can all do without. Of course, my personal opinion is that this funding would be better spent educating people about proper birth control, RECOGNIZING that a) abstinence is the only way to avoid pregnancy and STD's and b) over 90% of the population are already having sex, so message a is already obsolete! But again, that's only my opinion. For more information on an excellent article reviewing both the federal abstinence-only policy, as well as the "evidence" behind it, go here.

Boy, I'm glad I'm married now. If I got pregnant now, I'm automatically qualified to handle it well. I mean, they give out "Entitled to Bear Children" cards when you get married. The magic switch was flipped in June: before, I was unfit to be a mother; since then, I'm fit to be a mother. Except I'm not.

Fun Month, or School of Ineptitude

It's 9:52 am, and I'm sitting in my school's computer lab, blogging. At noon, I'll give a talk to the future surgeon's club in exchange for free food; at 1:30, I'll give a tour to a visiting potential student. Then I'll go home, finish the last remnants of the laundry, beat my husband into helping me clean the apartment, and hopefully head to the gym.

Why am I telling you this? And what happened to medical school? Surely, a busy third year student shouldn't have time to do all these things. She should be running around the hospital, doing scut and "saving lives".

This year, my school enacted the "fundamentals month", aka "Fun Month", during internal medicine. The orientation power point described the objectives of fun month as follows:

• Acquire, record, organize and analyze patient data.
• Independently identify key problems of patients
• Application of this knowledge and formulation of an appropriate differential diagnosis
• Perform focused interviews and physical exams on standardized
• Reflect on the ethical and professional boundaries of patient care.
• Demonstrate understanding of ethical and professional issues in patient care.
• Identify basic EKG conditions.
• Understanding and application of therapeutic options for thee diseases including any related issues of pharmacology.
• Understand pathophysiology of all disease processes you encounter.

What this actually translates into:

• Attending 5 lectures on "clinical reasoning", where I wrote a brief paper on CHF, a briefer paper on treatment on high blood pressure and cholesterol in diabetics, and a rough draft of what questions I'd ask a patient with shortness of breath
• Attending 1 lecture on "Diabetes", where we "learned" how to prescribe insulin
• Taking an EKG baseline exam, on which I scored 62%
• Reading Dubin's "Rapid Interpretation of EKG's"--useful. Amazingly, I do actually feel that I understand some of the principles behind EKG interpretation now. It makes me feel so smrt.
• Attending 2 lectures on EKG's, which reiterated the reading materials
• Reading "Cecil Essentials of Medicine"--I've gotten through about 6 chapters
• Attending 3 ethics lectures, including discussions of HIV confidentiality, US healthcare system, Doctors Without Borders, and How to Break Bad News--somewhat useful
• Attending 4 standardized patient encounters, where I pretend that their complaint is valid in the face of their entirely normal physical exam. My grade on the first one, where the patient said I did "great": 77%. My grade on the second one, where I forgot more stuff, had to ask the patient to sit up and lie down 3 times (he had "abdominal pain"), and misdiagnosed his pancreatitis as a perforated gastric ulcer: 87.5%. I think I'm going to be a better doctor because of this.

Note that only the material I specifically marked as "useful" is actually useful.

What I've actually done with my "Fun Month", since all of the above amounts to less than 2 hours at school per day:

• Contacted a personal trainer at the gym, meeting once a week. More on this later.
• Worked out at least every other day
• Done mountains of laundry
• Taken up a new hobby: jewelry making. I'm being cheap for Christmas!
• Watched weeks of TV. I've probably watched 20 episodes of Mythbusters on my first two weeks of Fun Month.
• Donated blood
• Got a flu shot and a PPD (totally flat! No TB here!)
• Cuddled with my husband a lot
• Taken my dog to the dog park at least 3 times so far
• Getting my oil changed this week
• Went out to lunch and shopping with a friend and her baby
• Got a massage

Obviously, I'm using this time to my best advantage.

Why does Fun Month make me mad? After all, I'm basically on vacation this month. I get up at 7:30 or later, I'm working out a lot, I'm getting some basic stuff done that I can't really do when I'm on rotations. The reason it makes me mad is that I'm not supposed to be on vacation now. I'm supposed to be working my ass off. I was ready to work, not ready to vegetate. I'm a little worried that next month will hurt more because this month was so easy.

I'm also mad because they changed the format of third year for our class. They took 2 weeks off OB/Gyn and 2 weeks off Psychiatry to give us 1 month of Neurology during the third year. Ugh, I hate Neurology. Anyway, they took a month out of what might be useful rotations to add Neurology. Internal Medicine has traditionally been 3 months long, with 1 month at the county hospital, 1 month at the "nice" hospital, and 1 month spent in a subspecialty. This year, they took off the subspecialty to add Fun Month. So, they cut other rotations which might have been useful to add Neurology, but they took a whole month out of Medicine to allow me to vacuum my apartment more often. If the subspecialty month of medicine was so useless, why didn't they cut it to add neuro? One reason I heard they added neuro was that it's an early match, so people need to see it during third year. Well, now it's NOT an early match--it just joined ERAS. Most of the internal medicine subspecialties don't match until after residency, so there's no real trade-off here. My only concern about losing subspecialty month is that we're losing exposure to some of the variety of internal medicine. They might not get us a whole lot of test questions on the shelf exam, but the subspecialties provide us a break from "standard" internal medicine. Not to mention, many 4th years I talked to said the subspecialty month provided plenty of time to read Cecil's.

Giving me a whole month to read Cecil's has translated to my reading almost nothing. I work best under pressure. I also know that I won't be taking the shelf exam until the end of February. I don't even like to read too much 1.5 months in advance of the exam, because I forget it all and have to go reread it, let alone 4 months in advance.

But TS, isn't the point of third year to learn how to be a good doctor? Shouldn't you read Cecil's just because you should? Probably. If I were a better student, and more self-motivated right now, I probably would read Cecil's. But I'm not. I learn better when I'm faced with a patient and I have to go look up the appropriate therapy than when I'm reading about abstract concepts in a book. I would also like to point out that the book chosen is 1216 pages. This is both too long and too short. Too long is obvious. Too short because Cecil's is a little too concise. Harrison's Principles of Internal Medicine, or "the Bible", is 2607 pages. Of course, I'm not reading it, either, so it's a moot point.

The big point here is that I'm lazy, and this month is allowing me to feed my laziness. The only useful thing I'm getting out of this month is how to read EKG's, which didn't require a whole month with nothing else to do to learn.

How dare they give me time off. Which wasn't necessarily the school's intention, but it is the (predictable) result. Bastards.

Huh?

So if "sleep medicines can cause dependence", or in other words you can get addicted to them, and this manufacturer is giving away free samples of this sleep medicine, how is this different from a drug dealer giving you the first sample of crack so you'll become addicted and continue to need their product?

World's Best Chili

I'm a Texas girl at heart (though relocated). I grew up eating various forms of chili, and I love most of them. Sometimes, though, people attempt to pass something off as chili and it's just NOT. For example, this deplorable vegetarian product didn't actually contain enough chili powder to taste like anything but canned tomatoes with beans. Bleh. On the other hand, this turkey chili had a very hearty flavor, and was perfect on an organic beef hot dog. However, these canned varieties are only good in certain situations, like in a dip or on a hot dog. If you want a hearty bowl of chili, you have to make it yourself.

I love this recipe. I start with the basic ingredients from my Betty Crocker cookbook recipe, then tweak it. I'm a spoon-by-the-Crockpot kind of chef, tasting and spicing, tasting and spicing. Delicious! So, without further ado, my chili recipe (modified from Betty Crocker):

Ingredients:
1 lb meat: ground beef or turkey is okay, but I prefer stew beef (it's more like steak chunks)
1 large onion, chopped (yellow onions are good)
2 cloves garlic, crushed (I use the kind in a jar)
1 tablespoon chili powder (to start)
1/2 tsp salt
1 tsp cumin
1 tsp dried oregano
1 tsp cocoa powder (key!)
sprinkle cayenne pepper to taste
sprinkle Tabasco sauce to taste
1 can (16 oz) diced or chopped tomatoes (NO seasoning!)
1 can (16 oz) kidney beans (I prefer Ranch Style Beans)
1 chopped bell pepper (green or red)

Cook the meat, onions, and garlic in a skillet over medium heat until lightly browned. Throw in Crock Pot. Add the rest of the ingredients. Turn on Crock Pot to low/medium, cover, and cook all day. Taste periodically and add more chili powder, cayenne, or Tabasco to taste. If it's too hot or too thick, add a LITTLE water at a time. As water cooks out of the veggies, it will thin out, so don't add much. Serve in bowls with cheese (if you like), chopped onions (if you like), or over pasta if you're from Cincinnati and are totally weird. Serves around 4-5.

This recipe makes fantastic leftovers. The spiciness will dissipate, so when you microwave it, you may want to add Tabasco.

Note on spiciness/heat: I prefer my chili with a slow burn. I want to eat 2-3 bites before I start sweating. I do NOT want to cry when I put it on my tongue. Other people have different preferences. If you want no-heat, don't add any cayenne or Tabasco. The 1 tbsp chili powder gives it flavor, but shouldn't add much in the way of spiciness. Even my husband can eat this chili, and he's a weenie (sorry, sweetie!).

This recipe is easily modifiable to vegetarian (leave off the meat, and add zucchini and/or tofu) and is easy to double. You could use a stock pot on low/medium on the stove all day in the absence of a crockpot.

PS: Yes, I grew up in Texas (though I don't live there now). Yes, I put beans in my chili. You don't like it, don't eat it.

This Makes Me So Mad

How DARE Michael J. Fox exploit his illness in order to push support for stem cell research? I mean, after all, he should just LIE BACK AND SUFFER, since God has punished him with Parkinson's disease. Pro-life decisions only apply to embryos and fetuses, not 45-year-old men with four children to raise and support. I mean, he was OBVIOUSLY faking his tremors and mask-like facies in order to garner sympathy votes! The same with that Christopher Reeve--he should have just lain in bed and accepted God's disdain, instead of driving around in that unnatural wheelchair contraption campaigning for stem cell research. My man Rush Limbaugh has hit the nail on the head with this one: it's a huge liberal "deception" to push for "cures that don't exist", and "the idea that certain people because of their victim status are allowed to enter the fray with impunity is something [he is] not going to subscribe to". Just because we feel sorry for someone doesn't mean we should take what they're saying seriously! Just because Fox is up there shaking away doesn't mean that Parkinson's is so bad! There are perfectly good drugs for Parkinson's--give you a few good years, and then you should go meet your maker like a good boy. And all this talk about "adult stem cells" versus "embryonic stem cells", it's all baloney. A stem cell is a stem cell is a DEAD BABY. Period. End of discussion.

This senator wannabe McCaskill, for whom Fox made the FAKED ad, is all about killing babies to make stem cells. See? This Ballot Initiative, even though it forbids making an embryo just to destroy, and bans human cloning, is CLEARLY a threat to our nation's unborn. The current Senator Talent is CLEARLY in tune with what Americans want (he supports whole-heartedly Bush's recent decision to fence the Mexican border), and even though he never mentions it on his website, I'm certain that he wants what is best in the way of medical research in adult stem cells. I can sense it.

And just because the three candidates Fox has campaigned for are Democrats, don't be fooled. He'd campaign for a Democratic monkey because he hates Republicans. I mean, the guy running against Rep. Cardin in the Maryland Senate race, Lt. Governor Steele, has likened embryonic stem cell research to Nazi experiments--clearly this Steele is a candidate who is stable, in control of his emotions, and also in tune with the American people.

Damn that Michael J. Fox. He should go shake somewhere else so I don't have to see it and think about how horrible Parkinson's disease is. And this whole stem cell thing is probably a pipe dream anyway; it'll never work to cure Parkinson's.

Yay, I got reviewed!

The very kind Mark at Blogs of Medical Students has written a little blurb about my little blog here, and basically compares me to an unedited, X-rated Dr. Gregory House (with whom my aunt seems to wish I could procure her a date).

This brought something to my attention: I have a dirty potty mouth. I've known this for years. The problem came when I entered the pediatrics rotation and I suddenly had to clean it up. But why, you might say, did it take the peds rotation to make you clean up your mouth? Surely it is always unprofessional to curse at work, regardless of the rotation you're on! To this I reply, you are indeed correct; however, my first rotation was surgery. Surgeons are the most uncouth, foul-mouthed group in the whole hospital. One of my attendings would end a particularly difficult or nasty case by saying: "Well, y'all, this is about like that ol' fox, makin' love to that skunk. He said, 'I think I've had about all this good stuff I can handle.'" No curse word was too dirty for these dirty old men, especially the trauma surgeons.

Pediatricians, on the other hand, are a little nicer. Smoother around the edges when it comes to their language, perhaps. There were no F-bombs in morning report in pediatrics; no "oh, shit!" when the intern failed the 14th freaking time to enter the subarachnoid space during an LP; there wasn't even cursing when there were no patients around (of course, when there were no patients it tended to be "just us girls", but still, haven't these ladies ever seen Sex and the City??). It was a striking difference.

Here's a conundrum. If pediatricians don't curse, and surgeons curse a lot, then what about pediatric surgeons? I've been told that pediatric surgeons tend to be the foulest-mouthed of them all, or at least the ones at our hospital are. Apparently, all the jokes were sexual, to the point where a fellow female classmate felt sexually harrassed. I wonder if the pedi surg guys just need to relieve the tension, or if they're overcompensating for going into a less "manly" type of surgery than, say, ortho. (Whenever I think of orthopods, I think of The Todd and smile).

Woohoo!

I'm like, sort of, an author! My post was accepted for today's Grand Rounds at Health Care Law Blog. The post in question is located here. Hope you enjoy!

I'm Such a Tweaker

I found myself sneezing violently earlier (something in the air?) and my lightning-speed reflexive action was to immediately shut my nose down. Or, my nasal turbinates instantly swelled shut and I could no longer breathe out of my nose. Damn. Sniffling, blowing my nose, and speaking in my oh-so-sexy stuffy nose voice, I decided it was time to take some medicine. But gasp! We were out of pseudoephedrine. Loratadine alone would simply not do; I needed some real power to unblock these nares. I took myself to the local CVS and priced out the goods.

Here's where I get in trouble. Pseudoephedrine is not only an amazing vasoconstrictor and nasal decontgestant, but it is also an ingredient in home-made crystal meth. My great state has decided that the way to stop meth heads from buying this dangerous chemical is to limit its sales to a certain amount (6 grams or two boxes), put the stuff behind the pharmacy counter, and make law-abiding citizens show ID and sign for the drug. I'm torn about this legislation: meth is a nasty, nasty drug, with absolutely zero beneficial properties; but I hate feeling like a druggie when I go buy my allergy medicine. I'm also uncertain about how effective this legislation will be in cutting down on crystal meth (although the senator who pushed this law had very high hopes). This article on PBS.com makes it sound as though a large portion of our crystal meth comes across the border (although I'm sure the home-brewed variety is common as well.)

I'm a nervous talker and a nervous giggler. Therefore, when I go to get my CVS brand pseudoephedrine, I can't just be cool and say "yeah, I need that one, please." No, I have to start sneezing and sniffling like crazy, saying stuff like "man, I can't breathe out of my nose." Out of curiosity, I almost asked the checker how much I was allowed to buy, but I decided against it. In my Gap sweater over button-down shirt and corduroys, I'm sure I looked like your standard meth head, but I still got so damned nervous! This happens every single time, too. I start commenting on how lame it is to sign for the stuff, and how bad my allergies are. One of these days a paranoid clerk is going to call the cops on me and I'm going to have to sniffle on him to prove I don't use meth.

This is Truly Awesome

At this link, I found an article about an OB/Gyn department which switched to all shift work and not only survived, they thrived. It makes so much sense, instead of different teams rotating different days, Team A signing out A patients to Team C, who then has total care of them for the night in addition to Team C's own patients. I think continuity of care is FAR better preserved under this shift system than under the current rotating call system. Another fascinating fascet of this particular program is that they focused on efficiency to make it work. No more 9 am clinic starting at 10 because patients weren't in the room until 9:45. It's amazing! This website has some real horror stories, so I'm glad to see that someone, somewhere is actually working to try to make positive changes.

Inspiration

For the past week or so, I've been browsing medical blogs to avoid studying for my dreaded (but now completed) pediatrics exam. I've seen the occasional poorly written tome, but for the most part my fellow medical writers are very well-spoken. One thing some of my favorite bloggers have done is incorporate articles into their blogs, sort of an internet book report show-and-tell type of thing. Yes, I realize that makes all of us huge nerds. That fact didn't keep me from feeling totally inspired to do something similar myself, so from now on I will try to review articles on here that might be interesting to someone other than myself. No clinical trials of one ACE inhibitor compared to the new "pharmaceutical company's losing the patent so they changed a hydrogen group on the compound to get a new 7 year patent" drug on here, though. I'll try to keep it sort of not boring.

Like this article I used for my CAT during peds. At my school, a cat is not a feline, but a "critically appraised topic". I had to dissect this article to shreds, pointing out the study groups, the statistics, and... I'm even boring myself with this discussion. The article, however, was fairly interesting.

Apparently, the belief has long been held amongst pediatricians that breast milk will make a baby smarter than the average bear. The first study of breast vs. formula was done in 1929. Since pediatricians love boobies, many studies have been done on this topic, most showing an advantage to the breast milk. One thing none of these studies seemed to adequately account for was the intelligence of the mother compared to the intelligence of the kid. IQ is highly heritable, so it stands to reason that smart moms have smart babies. As it turns out, this study shows that smart moms tend to breast feed in addition to having smart babies. One arm of the study compared sibling pairs where one was breastfed and the other formula-fed and found no difference in intelligence. The milks alone did not make smart or dumb babies. The main reason I cared about this article is for the women who choose to feed formula or who cannot breastfeed. While breastmilk obviously offers many advantages to a baby, later intelligence is NOT one of them. Apparently, there are still pediatricians who will guilt-trip a mom over this issue.

(Der G, Batty GD, Deary IJ. Effect of breast feeding on intelligence in children: prospective
study, sibling pairs analysis, and meta-analysis. BMJ Der et al. doi: 10.1136/bmj.38978.699583.55)

Now that I've sufficiently bored all 3 of you who read this, I'm going to bed to enjoy my weekend with NO SICK KIDS. None. Not a single one. It's awesome.

Hangover: An Interpretive Blog

My eyeballs crack open this morning. The throbbing above my left eyeball makes me shut them again, and hide behind a pillow. Oh geez. How many drinks did I have last night? I had two beers. TWO. Thinking about beer makes me queasy, but I can't help but rail against my fate. TWO FUCKING BEERS. I even had a large bottle of water in between beers, and way too much pizza. Damn, that was good pizza. Ugh, pizza, I might throw up. Shit, my head really hurts. I roll onto my left side and discover the throbbing to be less. I get out of bed and stagger into the living room, gripping my forehead, to ask my husband to bring me some orange juice and to tell him that I need a big freaking hamburger and fries NOW. After gulping the orange juice, I lie back down, groaning every time the dog jumps on me or I mistakenly roll onto my right side. Oh, no. I'd always heard that orange juice was good for a hangover, but I forgot about my sensitive stomach. Now actively wishing for death, I crawl to the bathroom and lie on the cold tiles until, finally, the orange juice exits my body spectacularly. Instant relief. After crawling back to bed, still moaning every time I even THOUGHT about moving, my beloved hubby came through. He had already brought me orange juice, then walked the dog for me even though I'd said I would do it (I lied). He then drove across town to bring me Beck's Prime, handing me a glorious container of french fries right when I thought I would die right then and there. One fry went down easily, so I reached a pale shaking hand out for a second. Damn, that salt was so good. After a few sips of life-restoring iced tea, I inhaled my 1/2 lb burger and the rest of the large fries, gulped down the 2 3/4 lb tea (that's honestly how they label them), took my ibuprofen, and rejoined the human race.

I may still be wearing my pajamas, but at least I'm alive. Pediatrics is now OVER and at least I had fun last night before I died this morning and was resurrected by an enormous hamburger.

This is some funny stuff

I would have said "shit", instead of "stuff", but for obvious reasons "urine" would be more appropriate. It's a blog post by a female urologist on why some male patients prefer a female urologist to a male. This is the stuff of legend, boy.

What Am I Going to Do... The Sequel

So a lot has happened since I made this post in July. I've been splashed with urine, for example. I've stuck my fingers in butts. I've snuggled crying babies and then held them in a vice grip while an intern jabbed their backs with needles, praying for the "pop!" that would signal that we had (finally) reached the subarachnoid space. Babies don't like that. I've been slapped by sleeping children whom I must wake to auscultate. I fell asleep standing up in an OR. I witnessed open brain surgery (last week, and SO FREEKIN COOL). Missed a lot of meals (although you wouldn't know to look at me--I think my body's in survival mode, and is packing on the adipose for warmth), missed a lot of sleep, and generally smelled rank at times (in public).

So what have I learned from all this?

a) I don't wanna be an intern. All of the above complaints are NOTHING compared to what the interns suffer. One of my interns is 8 months pregnant and she cannot get any sleep on a call night. On post call days, the interns (and residents) routinely get out by 2 or 3 pm, having shown up at 5 or 6 am the day prior. That's a leetle bit longer than the 30 straight hours rule. Our interns were so nice to us, letting us eat, pee, and sleep. I think either they remembered what it was like to be a student and yearned for those days, or they wanted to soften our hides before we ourselves were subjected to the brutalities of internship.

b) I have a real problem with the sad stories. We already knew this. (When I have my classroom month in November or December, I'm going to go seek professional help yet again about all this, so someone other than my husband can watch me cry about the little ones).

and c, the moment you've all been waiting for, is my updated
Goals in Life:

I had a free moment in the school computer area the other day and started poking around on the school's 4th year scheduling options. I went through the electives and started looking at stuff I'd like to do or *might* be interested in. Here's what I've come up with:

Heavy-weight contenders:

Ob-Gyn is still high on the list, as is Infectious Disease (although I'm not sure what they do, besides running around saying "What a cool, multi-drug resistant bacteria you have! Here's a nice toxic antibiotic to treat that with."). Recently dropped from the list: Peds and Med/Peds (which, for some reason, is pronounced "Peeeds", not "ped" like "med" or "Mister Ed" or "Keds" the shoes). Goddamn surgery is still on the Heavy Weight List. Recently added to the heavy weight list: Urology, ENT, and Ophthalmology. I'm not sure if I'm extremely interested in any of them, but they do offer some aspects of surgery, specializing, lifestyle, and happy cases. We'll see--I'm going to examine each one to see how they fit.

No-No's:

Medicine, Psych, Neuro (I FUCKING HATE NEURO), Radiology, Pediatrics, Med/Peds, Cardiology (ugh).

Unknown entities:

Anesthesia--everyone tells me I should do anesthesia. I have no idea why. It seems kind of boring to me, honestly.

Gastroenterology--not as nasty as I'd initially thought, and colons look cool on the inside.

Derm--perhaps boring, but also immediately rewarding in some cases.

Pathology--man, those pathologists are the happiest, friendliest, smiliest group in the whole hospital. I'd love to have that little responsibility for a living patient's well-being (well, not really).

_______________________________________________________

And there you have it. I love procedures, love working with my hands, don't like rounding so much, enjoy some clinic time (but not all the time), LOVE the "fix it now" immediacy of surgery, and don't like really really sad stuff.

Does anyone else occasionally think I'm in the wrong profession? It's still not too late to be a bus driver again--Metro is hiring at $12/hour!

It's a Bad Idea

It's never wise to tell a pediatrician "Oh, really?" when she tells you your child has been hospitalized too many times for severe asthma attack (kid = 3, hospitalizations = 4). It's also not wise to tell that pediatrician, especially one who is PASSIONATE about asthma, that you continue to smoke 1.5 packs per day, but cannot afford your child's daily medication, which is partially how she ended up in the hospital in the first place. (Let's calculate this, shall we? If a pack of Newports cost around $4.00, then at $6.00 a day that's $42 a week, $168 a month. 30 containers (1 month supply) of Pulmicort nebulized corticosteroid, the drug this little girl really really needed, is $149 at an online pharmacy in cash.)

It's even worse to tell a pediatrician you couldn't even quit smoking while you were pregnant with this child.

Of course, maybe it's not such a bad idea, because most pediatricians (including this one) are too nice to up and KICK YOUR FUCKING ASS.

Whew!

I just spent the entire afternoon wrestling with this mighty, mighty blog. You may not see much in the way of changes, but believe me, they're there and they're proud. I was mostly trying to improve navigation around the site, but apparently that's nearly impossible in old Blogger. For example, I tried everything in my very meager HTML skills (and exhaustive searches of expert bloggers' blogs, AND the google group for blogger help) to get the archives page to show up when you click the (new!) link to a post's title, in case you want to read the next post or an archived post without having to go back to the Home page. I couldn't do it. Apparently, I'm going to have to switch to Blogger Beta to do such a relatively simple thing. Oh well.

Several hours of sweaty blogging later, I have achieved a few simple links, some sarcastic remarks, and listed my blog on Google sitemap. All of that just to avoid studying for the peds exam.

PS

And much to love to my college football team, who upset their opponent today in one of the best games I've ever seen. And thanks to the quirks of a call schedule that has 3 teams covering 4 call nights, I actually had time to watch all but the second quarter because a) it's a slow Saturday and b) there were 2 other teams to take patients. Now I will eat my Lean Cuisine Grilled Panini (chicken, spinach, and mushroom goodness) and read ESPN highlights of the game, because it beats the hell outta reading Case Files! Whoop! (ha, ha, ha)

EWWWWW Moment of the Day

*warning: disgustingness ahead*


Up here on the children's floors, there are an amazing number of bathrooms available. Bathrooms in every patient's room (which are all singles), staff bathrooms spaced abundantly throughout the halls, even bathrooms in the "Parent Sleep Rooms" which I would never, ever use, except for maybe once earlier today, but it was okay because I REALLY REALLY had to pee. Oh well, at least it was quiet and peaceful.

Anyways, I digress. The staff bathrooms are fairly clean, especially at the beginning of the day. However, as the day goes on, they begin to smell a little worse and a little worse. And by 7:30 pm, when I went in there, someone had left a small puddle of what looked like dried pee on the floor in front of the toilet.

If this were the first occurrence, I would have just said "ew!" and gotten over it. Unfortunately, this happens every single day. Every day, I have to watch out for my pants and shoes to make sure I'm not stepping in the pee puddle (especially since I'm short and tend to be stepping on my pants every day). This is the freaking staff bathroom. Have professional medical men (or women who stand up to pee?) not learned how to control their stream? It just seems to me (lacking the equipment to try this technique) that if you are a messy micturator, you should lean closer to the bowl to control the spray. Is this unreasonable? We already make men put the toilet seat up to pee, so they don't spray it; is it too much to ask that they not pee on the floor, either? Perhaps a diagram would work, with a little toilet bowl, and a peepee, and an arrow saing "pee goes in the potty", and a big X on the floor, saying "pee doesn't go here".

I'm just sayin'.

No Quiero Ser Pediatra

So I think we've already established that I don't handle sad things all that well. I'd like to present the following cases to prove that either I am a huge wuss, or you have to be a lot colder person to be a pediatrician than I am:

1) I had a 15 year old patient who cracked his neck in a car accident this summer. After awakening from the surgical repair of his fracture, he couldn't move the right side of his body. Neurology came to see him and, salivating, delivered a diagnosis of Brown-Sequard syndrome. Neurosurgery ran about a million diagnostic tests to try to figure out what happened. In the end, both services said "What a fascinating case" and referred the patient for PT/OT. As his only therapy. He has gone to long-term rehab to learn how to function without the right half of his body. He liked to play sports.

2) I saw a young woman about the same age as the previous patient walking around with PT, totally blank.She barely responded when the other walkers told her to "turn right here" or "slow down". Only weeks earlier, this young woman was perfectly healthy when she began having seizures of unknown origin. Now, she does not appear to even recognize her parents.

3) My service has had a total of 4 kids with liver and small bowel transplant issues (3 are awaiting; 1 has received both, and is rejecting the bowel and has ruined this new liver). A common theme to these children is that they were premature, had some injury to their guts which necessitated gut removal, leaving too little bowel to absorb nutrients. Thus, these children have had their nutrition pumped directly into their veins as TPN since birth or soon thereafter, which has caused their livers to fail. One child, toddler-age, has suffered at least 2 central line infections since he's been on the service (3 weeks); he has also suffered several strokes in his short life, and now basically lies in his crib and cries if anyone touches him. Another child, 5 years old, is the size of an infant, and can barely speak, due to spending most of her life ill and in a hospital. Another, perhaps the most poignant, is now a teenager, still awaiting transplant. She told her mother the other day that "she was thinking about escaping from the hospital" so she could go home and eat pizza, her favorite food (at least she knows how to eat). Sadly, she only has one open vein above her heart, so she's now on anticoagulation so that vein will remain patent and she can remain alive.

4) A 2 year old girl came to the ER in the middle of the night and was admitted to the floor with fever, leg pain, and limp. She'd received a diagnosis of "cat-scratch disease" at a well-known outside hospital (apparently without receiving any diagnostic tests) 2 weeks earlier and been treated with antibiotics with no resolution of her symptoms. When I saw her, I saw a beautiful little girl, very pale, who barely winced when I manipulated a very tender knee and palpated some very large lymph nodes in her groin (she was the stoic type). Upon the recommendations of infectious disease, who suspected osteomyelitis or a septic joint (as did I), an MRI was ordered, which clearly showed a large lytic lesion in her femur, HUGE lymphadenopathy in her groin and into her pelvis, retroperitoneal lymphadenopathy, and a large mass on her adrenal gland. Tissue biopsy confirmed the diagnosis of neuroblastoma, stage 4. That beautiful little girl is now a cancer patient.

5) And last night, I got called to see a 15 year old girl, who likes to play basketball and is learning to drive a car, who had had a severe headache for a week, to the point where she was throwing up. Her family history of migraines had kept her out of the ER for a week, but yesterday she went. Whether the ER doc was CT-happy or actually suspicious, I don't know, but a CT of her head was obtained, which showed a "5 cm calcified solid mass in the cerebellum, with hydrocephalus and generalized edema." Further workup shows that she might have distant metastases. She'd been told there was a mass, but I was in the room when her mother asked point blank "Is it cancer?", to which we replied "Most likely." In the span of 12 hours, she went from being a healthy kid with a headache to a cancer patient with severe disease. Her family wept last night with guilt: "I thought it was a migraine, everyone in her family gets them, I should have brought her sooner." In radiology report this morning, the radiologist looked at her MRI and said "this doesn't look good." The neurosurgeon said "ouch" when he saw her CT. She will never drive that stick shift car or play another game of pickup.

Yes, I'm a wuss. I don't know how you don't take this stuff home with you. I couldn't sleep last night for thinking about this girl, watching her cerebellar exam deteriorate. I don't know what to say in the face of such suffering. I don't know how to handle it. It hurts me, and I don't know how to make it stop without turning away and ignoring it, which isn't my goal either. I know life is short, and there are no guarantees, and it's a stupid cliche to say "life isn't fair", but it's fucking NOT.

Ophthalmology and dermatology are looking better and better.

Fat Kids Denied Soda at School

Go to CNN for the story. From what I can tell, President Clinton has met with some of the largest snack food makers to encourage them to make and sell healthier snacks at school. This follows the spring's decision amongst soft drink manufacturers to ban sales of full-calorie sodas at elementary and middle schools. Some critics have said that these measures aren't enough, but I think they're at least moving in the right direction.

That said, why not in hospitals or medical schools? The vending machines in the medical school offer pretzels as about their only healthy food option. Also, up until about 3 months ago, the healthiest thing I could find in the prepackaged section of the hospital cafeteria was Baked Lays, and that was only if you came in right after the Frito Lay guy had delivered them--they went quickly. The cafeteria has recently started selling the 100 calorie snack packs, which is how I became addicted to the Chip's Ahoy ones--100 calories of sheer goodness, let me tell you. But at 2 am, about all that's left are the Mrs. Baird's Cinnamon Rolls, which are approximately 1000 calories and 400 grams of fat apiece. Damn, they are tasty, though.

Many hospitals (although not the ones I work at) have actual McDonald's restaurants inside. Are the hospitals trying to create repeat business? I've always wondered.

I think I was trying to make a point, but I've derailed and all I can think about are Mrs. Baird's cinnamon rolls instead. Good thing I'm having homemade frosting with graham crackers (most important ingredient listed first) for dessert, to appease my ENORMOUS sweet tooth.

Banned Book Week

JK Rowling, author of the Harry Potter books, posted this to her website:

" Once again, the Harry Potter books feature on this year's list of most-banned books. As this puts me in the company of Harper Lee, Mark Twain, J. D. Salinger, William Golding, John Steinbeck and other writers I revere, I have always taken my annual inclusion on the list as a great honour. 'Every burned book enlightens the world.' - Ralph Waldo Emerson"

There you go. If a book is worth reading, some nut somewhere has banned it.

Woo girly fangirl gushy post

So guess who found out 30 Seconds to Mars is coming to town next month??? I've already purchased the tickets. Now to arrange my work schedule around the concert...

How to Vote in Texas

[Author's note: in 2006, Texas had an interesting gubernatorial election. I wrote about it, since I used to live there.]

So in all honesty I could care less who any of you vote for in November 2006. What is important to me is that you vote. As I was rooting around on the Internet, I came across some handy websites I'd like to share:

• Locate Your District By entering your address and/or zip code, you can find out what congressional districts you live in, as well as who the incumbent is for that district.
  
• Don't Vote Also a place to find your incumbent, as well as who they are running against.
• Wikipedia Article on United States House election in Texas
• CQ Politics, online (supposedly) objective political news source
• How to Register to Vote in Texas: note that the application (available online) must be postmarked 30 days prior to an election (October 10th officially) in order to be eligible to vote. You can also register at most county or state offices, including DPS.
  
• Early Voting in Harris County for those who won't make it on November 7. It shows you where and when you can vote early, including dates over the weekend of October 28-29. For an FAQ of early voting, go here. All registered voters in Texas are eligible to vote early in person.
• Wikipedia Article on Texas gubernatorial (I love that word) election. This ought to be a good one, guys, so pick a candidate (out of 6!) and go for it

Why is it important to vote in this election? There are a lot of national Senate and House seats up for grabs, so the balance of power in the country is really subject to change. In Texas, the governor's race is at least 6-way, with good ol' boy Perry, tough grandma Strayhorn, soft-spoken Bell, Jewish cowboy Friedman, a Libertarian and a write-in. You can also write in your favorite Green Party candidate or yourself if you want to. The balance of power in the nation's second largest state is up for grabs. Strayhorn's decision to run as an independent has split the Republicans and the Democrats, so the race could feasibly go any of 3 directions. If the major candidates are too divided, Friedman could pull off a surprise victory. Crazy!

As I once saw written on a bathroom stall: "If you didn't vote, don't bitch about the election." Just vote, for fuck's sake.

Tales From the Pedi Student Library

• A fellow student, who attended college with me, stated that she must be the only person in the world who disliked yoga. It turned out that we were in the same yoga kinesiology class in college. She said "oh yeah, you were up at the front. You were really good." I replied that I used to be a gymnast, so I have always been flexible, and I added "Even now that I weigh three times as much as a normal gymnast now, I'm still pretty flexible." She looks at me and says "well, yeah, I mean, most gymnasts are about 70 pounds." I nearly died laughing as she tried to apologize for accusing me of weighing 210 pounds (I'm overweight and curvy, but not morbidly obese, okay?) We decided that if I weighed that much, at least I carry it well. I said it must be my extraordinary slimming undergarments.
• Funny, yet sad. Another fellow student shared her morning in specialty clinic with us: "So after this family [mom, dad, and kiddo] had waited an hour to see the doctor, he made me present the patient to him IN THE ROOM. Including a differential diagnosis. This kid had cervical lymphadenopathy [swollen lymph nodes in the neck], so his differential included really scary things like HIV, TB, lymphoma, and leukemia, and I had to keep talking about them, watching the mom's eyes getting bigger and bigger. At the end of all that, the doctor turns to the family and says 'I think it's probably nothing, just a virus', but by then the mom was totally freaked and asked for tons of tests for the conditions we'd just mentioned. To make matters worse, he then told the parents 'Well, if you were a white family, I'd probably overlook the TB thing [the kid had zero risk factors for TB], but TB tends to be a little more prevalent in African American families. After all, TB chases poverty.' Both parents shared shocked looks while I tried to melt into the floor. This family had been referred to this doctor by their pediatrician, whom they see regularly. They're well-dressed, the kid is well taken care of, and this doctor has no idea what their social situation may be." Another student replied "Perhaps he should be wearing a white pointy hat with eyeholes on top of his white coat." A third student, black herself, began to flick imaginary TB on us all.
• Yesterday in a lecture on "Health and the Human Spirit", we were cautioned against complimenting a Hispanic baby without actually touching the baby. The doctor in question said she's had parents who were CONVINCED the student gave the baby the Evil Eye, when all the student had done was the say "Oh, what a cute baby!" Note to self: do not put the Evil Eye on any innocent babies. I think I will start complimenting people I don't like more often, however.
  

Oy vey. Just another day of saving the world.

New Layout

Hope you like it! It's all cheerful and green, like Kermit the Frog. Except here it's easy to be green.

The Carpet Makes All The Difference

So I'm on my third day of inpatient pediatrics, and the differences between this and my first rotation, surgery, are enormous. First and foremost being the CARPET. Yes, friends, the pedi floors at this hospital have carpet. And giant papier-mache trees. And the individual "wards" or nursing divisions on the floor are called "pods", and each pod has a corresponding shape, for example the 13th floor beige pod. The first time I came up here, I thought I'd left the hospital. The adult floors where I worked during trauma are actually in a different building, but it might as well be another world.

The reason the carpet matters is as follows. I had my first call night Monday night. On trauma, by about 11 pm, my legs would start to ache. Deep in my back, hips, and knees, the bones and joints would hurt so badly that I'd be doing yoga maneuvers in the corner to try to stretch my muscles or standing on one leg to rest the other. Up here, however, there is carpet to shield the joints. Ah, bliss. It was my first call night since my first call night where I didn't premedicate with ibuprofen so that I could remain standing. In addition to the carpet, peds residents don't seem to mind if you sit down to do your work. Talking to a parent? Have a seat! Writing a note? Typing a newborn into the computer? Go for it! One resident actually apologized to me because the room we were in didn't have enough chairs for all of us. Wow!

The differences go way beyond carpet. On the first day, the residents learned our names, asked what we want to do when we grow up, and even learned our nicknames. When the intern's father offered to bring dinner for the whole team, I was included! Not that surgery was totally hardcore rigid all the time, but there was definitely a stricter hierarchy in place that said "residents and students are not of the same species." Separate but equal, baby. At one point on surgery, due to some unknown infraction by a fellow student, the head of the department decreed that medical students were under no circumstances to be allowed to eat the free drug rep food should it be present. Don't feed the medical students! Bad!

There's also a prerequisite amount of oohing and aahing over the babies that is required of all peds residents. If you don't coo at the newborns or all walk in and say "you are so cute!" or bring stickers, you are not part of the club. Fortunately, I adore babies and most of our patients are pretty darn cute, so I can check that one off.

I think it'll be an okay month. I'm pretty sure I don't want to pursue peds as a career, however. That decision was cemented after holding a 1 day old infant still while the intern, then the resident both failed to obtain a lumbar puncture. I know it's necessary, but GEEZ. That baby screamed at the top of his tiny lungs, just screamed with pain and the injustice of it all, and the best I could do was try to free a hand and shove my (gloved) finger into his mouth for him to suck on. At least you can explain things to an adult (usually, and whether they understand you or care is another matter entirely), but there's no reasoning with a newborn baby. Good thing they are so dadgum CUTE. Even the one we had to grease up with Vaseline because her skin was so dry it cracked open and scabbed.

Irony

is getting your grade from 1st month of peds (finished 5 days ago) and your grade from 2nd month of surgery (finished 6 weeks ago) on the same day. Actually, I haven't officially received my trauma grade yet; I just have the composite grade for the entire course of surgery. Perhaps it is also ironic that the two grades are identical, yet I worked probably 1/3 as much for the peds grade.

Return to Innocence

or at least to childhood. One of our well child hand-outs that we give to parents says that 2-4 year old children like to be told "you're doing a good job" or "you're such a good helper." (It also says that children these ages like to do chores, so what do they know?)

Today, I was told to go home. "You did a good job today. You were a big help." Another lady thanked me "for all my good help." I basked in the glow, knowing that I hadn't been totally useless today. After all, I'd all but been petted on the head and tossed a puppy treat.

After only 13 years of basic education, 4 years of undergraduate work, >2 years of professional school, $50,000 for college and $90,000 (so far) for medical school, I've graduated to being a "good helper." Pretty soon, I'll be wearing my hair in pigtails and carrying crayons in my pocket.

ARRRGGGHH

According to the New York Times, a Canadian man arrested in 2002 for alleged terrorist links, deported to Syria, tortured, and released 10 months later has finally been cleared by a Canadian panel. I'm directing you to the Times because CNN.com strangely has no mention of this story. Curiouser and curiouser. Even the Houston Chronicle ran the story, albeit under the title "Judge: Man was tortured after US got faulty info", which implies that everything we did after getting this info was above board.

Wow. We deported a Canadian citizen to Syria for torture. Torture. An innocent Canadian citizen, no less.