I Made Plants!

It was 81 degrees this afternoon here on the sunny Gulf Coast, and it's that time of year when a young girl's thoughts turn to... green things. Apparently, my maternal ancestors were farmers for generations (at least, according to my mother), and it's a fairly common occurrence for the women in my family to make random trips to the plant nursery in early spring to buy green things, tools, and dirt.

I used to have a "black thumb". The only plant I'd ever owned was a sad little jade I had in college. Jade plants are succulents, like cacti; they don't require much water. I still managed to water it so infrequently that it died. When my then-fiance moved in with me nearly two years ago, we went to Ikea to purchase furniture, and we ended up also taking home a small orchid. The poor plant would have been better off remaining in the store. I think it lingered on for a few painful months before it finally, mercifully died on my dining table.

Starting in college, however, I started noticing springtime's arrival because of the appearance of the plants at Home Depot and such. Then, I started noticing that I was staring at the plants. Ogling them, if you will. Each spring, this weird feeling got stronger and stronger, until I realized that I was itching to plant green things in the dirt, black thumb and all.

Last spring, I finally gave in to my urge to plant things. I took a friend with a lovely garden to the nursery with me, and we purchased a lovely variety of flowers and herbs. She even helped me plant them. My whole crop nearly died during my stint on surgery, which coincided with the hottest months of the year, July-August (which are truly ungodly months here, trust me; the average high temp is 92 degrees). They rallied, however, and my basil plants grew to tremendous size; each was at least 3' high (above the ground). I took to calling it my "basil hedge". My lantana came back and bloomed in November (this place is strange). I found something called balloon flower that is just about my favorite flower ever. My little second story patio was a green, happy place.

Then "winter" came, it actually froze twice, and all my plants died.

For about 4 weeks now, the plants have been set out in dazzling array at the stores, and I have been begging my hubby to let me buy plants. He kept saying "it will get too cold, it will get too cold, wait a little bit." "Too cold" for someone raised here means below 60, apparently.

Today, I had the afternoon off with NOTHING to do. It was a glorious day, sunny, 81 degrees with a good cool breeze. I bought plants. I planted plants.

In one box, I put bell peppers, marigolds, and a rosemary; in the other box, I put basil, peppermint, and a luscious purple velvet petunia. Another petunia went in a hanging pot (and we actually got a rope with which to hang it from the ceiling!!!), and a special lavender went in its own little pot. I repotted the yucca palm my hubby got me last year.

My favorite, though, is the gorgeous red hibiscus plant I got for $10. It already has a few blooms, with many buds and thick green foliage. I think we get just enough sun that it will do well. Visiting my maternal grandparents over the years, one of the most striking memories I have is my grandfather's hibiscus. Since the blooms only last about a day, every morning he'd go outside and pick a new one, set it in a glass, and put it on the end table next to my grandmother's favorite seat. His were usually red, also.

I have been in the best mood all day, ever since I decided to get plants. There's nothing like getting dirt under your fingernails and up to your shoulders to put you in a good mood.

Here's to turning that black thumb green!

Case of the Mondays

I am an irritable person. And it was Monday.

Point the first: Today was intro to "Family Medicine". It is no longer PC to call it "Family Practice". I wouldn't think anything of it, but after the lectures we had, it's almost like they're trying to remind the rest of us that FP is "real medicine".

Point the second: Our last lecture of the day was called "Family Medicine", and consisted of a doctor berating us for ever thinking that FP... I mean FM could be a) boring b) dull c) too easy d) too hard, or that family docs don't make any money, citing an example of a doc who works 8 months a year and makes $250k (I'm not sure what planet that doc practices on! The expected median in Houston is $158k).

I don't know why it is that so many family docs (certainly not all, but quite a few) get so freaking DEFENSIVE about family practice. "No, really, it's super awesome! Really! I swear!" I understand that primary care is necessary; I understand how some physicians find it fulfilling. I just find it extremely boring to manage "the same 20 diseases" over and over again. And just because you CAN perform an outpatient procedure, or deliver a baby, doesn't necessarily mean you SHOULD, Mr. "I do all my own procedures". Grrrr.

Point the third: It was an extremely useless day. We had 2 hours of lecture on "Behavioral Change", aka "why you should feel sorry for your patients who smoke." The first hour wasn't too bad: the lecturer was engaging, the topic was new, she made it interactive... The second hour was a rehash of the first, with a repeat of the exercise from the first hour. "Now, when you take a history, you should repeat what the patient says, to show you're listening! You can even repeat it back in DIFFERENT TERMS; it's called paraphrasing!"

I did Sudoku.

Point the fourth: These lectures were followed by a 2 hour lunch break. Why take a 2 hour lunch when you could take a 1 hour lunch and go home at 3 instead of 4? Inquiring minds want to know. We ate outside, and I got sunburned. Curses on my pastiness!

Point the fifth: I went to the gym tonight and hopped on the elliptical machine for a bit. The good ellipticals are hard to come by, so they limit your time to 30 minutes during busy times (like tonight). The machines are packed into a small space, and are therefore only about 1.5 feet apart.

A girl got on the one next to mine, which happened to be next to a close friend of hers (on her other side). He hopped off his machine and spent the next 30 minutes (of my workout) draped over the front end of her machine. Oh, did they have a great talk! I know this, because I could hear them over Nine Inch Nails and Christina Aguilera at top volume on my iPod.

During this time, he kept his leg draped over the elliptical he'd been using, so he was still "on" the machine, even though he was having such a fabulous conversation, effectively keeping everyone else off 1 of the 5 elliptical machines.

To make matters worse, he was all of 5 feet away from me, facing exactly my direction. I am not an attractive gym-goer. My face turns beet-red, I get visible sweat marks, my hair gets soaked, and my whole body jiggles (except what's inside my two sports bras). In other words, I look awful, and I'm extremely self-conscious about it. And I could not get over the fact that he was facing me, not looking politely in another direction, or better yet DOING HIS OWN GODDAMN WORKOUT.

Yes, I'm a cranky-pants, but is it too much to ask that everyone else get hot and sweaty, too, if they're at the gym? If you want social hour, and you're not going to work out while you do it, then go to a coffee shop for pete's sake and let me sweat in peace.

At least when I got home I had an ice cream sandwich waiting for me. Tasty!

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Does anyone else's dog or cat like to snuggle while you are on the toilet? J-dog came in with me after I got home from the gym and spent the time licking the sweat off my hand until I gave in and just petted him. What a dog.

It wasn't actually a terrible, horrible, no good, very bad day. I just love that book a lot, and sometimes I remind myself of Alexander. At least I didn't have gum in my hair.

Spoiled Dog

My dog, J-dog, has been running around in a black leather collar with diamond-shaped metal studs for a couple of years now. One of the studs fell off a while back, and the leather is starting to look frayed, and I started feeling guilty that my dog looked so neglected.

Yes, I know.

A couple of months ago, I went to the large chain pet store where J-dog's vet is located to try to replace his collar. It's where I bought the current one, and they have an entire aisle devoted to dog collars, so I didn't think this was a futile task. One black leather dog collar with silver studs (not spikes, studs; this dog shares my bed, after all) coming up!

Except not.

Apparently the one collar this store doesn't carry is a black leather collar with studs. They carry patent leather collars, collars with bling, nylon Harley Davidson collars, collars that say "Princess" and "King", nylon collars in every color under the rainbow, rolled leather collars, collars with every type of spike... it goes on and on and on.

I checked back at this store earlier this week, with no luck again. So I ventured into the scary online world of the "pampered pet", where you can easily spend $150 for an alligator-skin dog collar. I found a reversible collar that says "Rocker" on one side and "Badass" on the other; nylon collars that say "Stud" and "Bitch"; even a collar called "Rose and Swarovski Crystal". In other words, the sky is the limit.

We ended up getting J-dog a cute collar (and matching lead) from this company. It's the one with the blue stars. He looks super handsome in blue.

Oh, and the picture at the top? That's him curled up on top of the cushions of a couch. The cushions for your back, not your butt. He's easily lying upon 3 solid feet of cushion. I didn't pose him for this picture; this is honestly where he prefers to be. He's currently lying on "his" papasan chair, under two blankets.

My poor, neglected dog.

/crazy dog lady

For my seester

From Urban Dictionary:

scut work: Used frequently in teaching hospitals by junior residents and medical students to describe mindless and thankless errands, such as chasing down radiology reports, drawing blood, and staying on hold with public health -- anything which is heavy on the "service" and light on the "education."

Apparently derived from scutwork, meaning "the work of a useless person."

scutmonkey: A person who does scut work, especially a junior medical student or intern (aka, ME).

________________________________________________________

In the medical field, scut work is the paper work, the clean up, the daily grind to get patients in and out of the hospital quickly. It's the shit work that has to get done, but nobody wants to do it. For example, pulling Foley catheters out is a job no one wants to do, so it gets passed down the totem pole. Doing rectal exams, looking at feet, filling out discharge paperwork, writing stacks of prescriptions before a patient leaves... all of these are scut work.

And now you know.

Grossness

I briefly mentioned my fear of sputum in my last post. I would like to expand on this subject.

I dislike spit. I don't want to do anesthesia because there's a lot of spit-suctioning, which is nasty. I just don't like it.

Phlegm and sputum, however, are an entirely different story. This past month, I had three patients in a row with a chief complaint of "shortness of breath". When I went to see them, they were coughing, and all three proceeded to hack up HUGE loogies in my presence. And then show me the contents of the emesis basin.

That's three separate patients who were almost barfed on.

When someone starts producing phlegm, I look away. I started staring at the telemetry monitors on all of these patients, like "ooh, shiny and non-nauseous!"

I first realized I had a problem with sputum on pediatrics. I had an asthmatic kid who started hacking up nastiness, and I wasn't prepared for it, and I almost retched. My resident laughed at me. A nurse nearby agreed with me that it was a horrible thing.

I've realized that many medical students (and indeed, health professionals) tend to have at least one bodily secretion which they can't really seem to deal with. For me, it's phlegm/sputum. For my friend Barbie, it's pus. The very idea of pus offends her soul. Another friend, Latin Lover, can't stand feces, to the point where the DRE gives him trouble. I'm certainly not crazy about feces, especially when an adult human poops on themselves while cursing the nursing staff who are trying to help him get a bed pan, but the rectal exam doesn't cause me to vomit. For LL, it's another story, apparently (not that he vomited).

Why is it that we can handle some things, but not others? Why are some bodily fluids nastier than others? Why do doctors wear white coats, when we come in contact with human nastiness every day? Indeed, why is medicine considered such a "noble" profession, when it is necessary to dabble in bodily excreta every day in nearly every medical field?

I don't know, but I do know that I do not like sputum.

Recap

So at the end of internal medicine, I must say I had a much, much happier month this time around. There were some frustrating moments, and occasionally members of my team drove me crazy, but for the most part it wasn't bad. I feel like if I had to do this for a living, I could. I might not be too happy all the time, but I could probably do it.

Here's a little review of the high points of the rotation:

1. My resident, a third year who will soon be going off for fellowship in heme/onc, was super-obsessed with people coding. I had a patient having a massive asthma attack, and when we rounded on her, she wheezed for us. She was on only 2 liters of oxygen, her sats were fine, we had her on nebs... in other words, she was uncomfortable, but stable, and we were doing everything we could (in addition to treating the influenza A which was most likely causing her asthma attack).
   My resident went in to talk to her, and without introduction asked "If you were to stop breathing, do you want us to put a tube down your throat?" It's a good thing I've had 3 years of medical education under my belt, or I would have had no idea what he was talking about. This poor woman, not highly educated, didn't have a clue. She stuttered "no", and he left the room. She then turned to me and said "I'm gonna stop breathin'??" She was totally panicked, which was going a long way to help her breathing, let me tell you. I did my best to smooth the situation over.
2. We had a deal with our attending. For all the super-ridiculous pimp questions, the bet was that if he got more right, he'd take us out to eat, but if we won, we'd take him out. It didn't make much sense to me, either. My attending took us to eat at a buffet-style Indian restaurant to celebrate his winning the "Who's smarter?" contest. And picked up the tab. I ate so much curry, I almost couldn't work during my last call night--I was practically waddling. Damn, I love curry.
3. To celebrate our last call night, the ER set up a special President's Day surprise. We had zero admissions during the day, and then all the admissions happened from 5 pm until around 4 am! Special, huh?
4. Hours spent waiting for my attending: approximately 15.
5. Grade all 4 students got: Honors.
6. My attending said we were the best team he's had in three or four years. Thanks?
7. A random resident, on hematology consult, starting pimping me when I went to see my patient. Not only that, the things he pimped me on weren't entirely correct. He then told me "all of my students but 2 have decided to do medicine after rotating with me." Hmm. Would I have to work with you? Yes? Then no.
   

All in all, not a bad month. Sure, I haven't been off two days in a row since January, the weekend between neuro and medicine; sure, I had to sleep in the hospital every 4 days (at least I usually got some sleep!), but it wasn't so bad.

My resolve to do urology is the same, despite the month. I think a lot of internal medicine docs feel that people who super-specialize are kind of "selling-out", that we should all forge into the depths of primary care, with long hours and lower pay. They also tend to think that people don't do internal medicine because of the money.

I must say, the money never really occurred to me. Maybe it's because I grew up without a whole lot of it, but I kind of feel like, no matter what field I go into in medicine, I'll have plenty of money to have a house, eat, and pretty much do what I need to do. In other words, I don't see a whole lot of difference between making $95,000 as a pediatrician and $250,000 as an ob/gyn. Obviously, there is a difference, but I'll be able to take care of myself and my family at either level.

It's just funny. I guess it's the whole "hazing" mentality--I went through it, so you will too. If I work long-ass hours, and don't have much of a family life, then neither should you.

It's the thing I hate most about medicine, actually.

Addendum: After a comment posted earlier, I must add that a close second for "thing I hate most about medicine" is sputum. I have a sputum-phobia, if you will. Ugh.

Proof Hospitals Are Not Good For People

There are oh-so-many things about the hospital that prove to me that no one actually considered the patients who would stay there when the hospital was built:

• The temperature in this place fluctuates dramatically. The cafeteria is usually 20 degrees colder than the rest of the building; it's actually an immediately noticeable change. By the time I finish a meal, I'm usually shivering, and my fingernails are blue. Some rooms are 80 degrees or warmer, which makes me wonder how we're supposed to know if our patient is having a fever, or are just under too many blankets. I believe that these constant changes of climate contribute to the easy distribution of viral illness amongst the medical teams, which in one case last month led to a third year med student contracting viral meningitis.
• The cafeteria accepts cash and credit cards, but last month instituted a $4 minimum for credit card purchases. Since the average breakfast costs $3.50, this led to many people a) frequenting the conveniently-located ATM, which charges $2 per transaction or b) adding extra food to their tray to push their total over that magic number 4. It also led to me swearing while dumping all my change out of a tiny change purse so as to avoid receiving 86 cents in change, multiple times, while the line behind me sighed and cursed.
• The main parking garage for this particular hospital is connected to the building via a long walkway, which is nice. What is weird is that you enter the hospital through the second floor of the garage building, but the first floor of the hospital. The end result is that I encounter at least two arguing families per shift who try to head to the garage via the second floor of the hospital, which takes you through OR-land and is actually impossible anyway.
• Many hospitals were built in stages. We have a building from the 1920's (C), a building from the 1950's (B), one from the 1970's (A), and one from the 1990's (D), and a new building is going up outside. The problem here is that building codes were obviously dramatically different in 1920, so all these different buildings, which were connected to each other, have different ceiling heights. There is a hallway where you literally walk from the 5th floor of the newer A building into the 6th floor of the older B building without encountering any stairs. This also means that the 4th floor of the B building dead ends at an odd little stairwell which you must climb to reach the A building. It's very confusing.
• The really old C building from the 1920's has a room-numbering system that was obviously done by an imaginative 4-year old. You can walk from room 5.01 to room 5.33 then to 5.27, and they are contiguous rooms on one hallway. As a result, when I have patients in the C building, it takes me at least 20 minutes to locate their room, because I literally have to check every room to figure out where the right one is.
• The hospital is kind enough to have dispensers of hand sanitizers located outside every patient's room, down the hallways, in the cafeteria, and indeed anywhere the wall stayed still long enough to attach a dispenser. I continue to carry a small bottle on my white coat, looped through a button hole. Why? Because the handles of said dispensers are coated in brown gunk. Hello, people, hand sanitizer is for CLEAN HANDS, not for visibly dirty ones! I don't care how sanitary the brown gunk is, it frightens me.
• The cafeteria food continues to be greasy and overpriced. Baked Lays are the most difficult chips to find, but you can get pork rinds at any time. Astonishingly, my hospital is one of the few not to have a McDonald's or any other fast food chain located inside, but we do have two Starbucks kiosks (or we will, once they finish remodeling the bigger, nicer one). As much as I hate Mickey D's, at least they don't have a friggin' $4 minimum.

Thank god our cafeteria makes excellent iced tea in large quantities (unlike the cafeteria at [county hospital], where the tea was undrinkable sludge), or my time here would be totally wasted.

And with that, my last call for internal medicine ends, and my last day of this rotation also ends. Exam is on Friday, and then I'm on to family practice, aka "a whole month with actual weekends and no call."

Sunday Procrastination

Instead of studying, I have gone out to breakfast, gone to Super Target, cleaned the kitchen, updated my facebook account, searched through my sister's facebook account to find old friends, searched the internet to see if I could find out who writes a blog I read (I'm not a stalker, I swear!), watched "Man vs. Wild" on the Discovery Channel, and helped my hubby take out the trash. I didn't even clean the house, like I had planned, so I have successfully procrastinated from studying AND making our small apartment suitable for human (or canine) inhabitants.

I guess I should start MKSAP now. This is why it's so dangerous having these questions on my laptop, because there are so many other, far more enjoyable, things to do with my laptop.

My Long Walk to Jail

So if it weren't already terribly obvious that I'm going straight to hell, not collecting $200 or passing Go, last night made it even clearer. Last night, Animal Planet aired a show called "World's Ugliest Dog Competition". There is actually a dog show devoted to the ugliest dogs in the world.

Here is this year's winner, Archie:









This dog is a Chinese Crested, missing all but 4 teeth so his tongue hangs out to the side. He has no hair except the tuft on his head, and his skin is like a human's--this dog wears sunscreen.

Last year's winner, and the long-term reigning champion, Sam, passed away last year. I can't even post his picture here, because every time I see his picture, I recoil in horror. Apparently, he was a very sweet dog, but GODDAMN he was an ugly dog.

The point of the competition is to help promote the "unadoptable" dogs, the ones who get left in the shelters or euthanized because no one will adopt them. Dogs missing teeth, or deformed (one had hydrocephalus, so her head was crooked and her eyes bulged out). For some reason, Chinese Cresteds reign supreme, proving my theory that they are the ugliest dogs on the planet.

Despite the philanthropic aim of the competition, it still seems so fucking wrong to make fun of these poor dogs. It was probably even more wrong of me to cry out "DEAR GOD WHAT IS THAT THING??!" when I saw some of these dogs. I also laughed so hard that I nearly wet the bed, especially when one of the dogs shook his head and flung drool all over the judges, or when the emcee couldn't speak after introducing one of the dogs, because he was too busy laughing.

Insert "Little Boy/Hell Isn't Good" lyrics from the South Park movie here.

New Address

Glad you made it to the new, improved, (hopefully) more anonymous site! It may be premature of me to change the profile name to "Tiny Surgeon", but hey, let's think positively! Welcome in, make yourself at home!

Nephrology

I'm not sure why this is, but all the nephrologists I've met seem to have this attitude that they are SO FREEKIN SMART that they must share it with everyone. My current attending is a nephrologist, and all of our pimp questions have to do with the kidney. "What is the pathognomonic kidney lesion in scleroderma? What is Fanconi syndrome, and what cancer is it associated with? What is the kidney dysfunction in sickle cell anemia?"

My attending is consistently late. It's a good day if he's only an hour late. Just to keep us on our toes, he will show up on time about once a week. Last week on call, we were supposed to round at 5 pm; we didn't round until 10 pm. The next morning, post-call, he didn't show up at all, so we checked out to the float and left. Apparently, he came some time later and saw patients on his own (which was good, because we had several patients who were waiting to be staffed so that they could go home).

I know a resident's time is not worth much. If you work their salary out by hour, it comes out to somewhere around minimum wage; an attending, even on salary, makes over two times as much. I guess some economical principle might make it okay for an attending to waste a resident's time, because their time is worth less. My argument, however, is that since two interns and one resident all had their time wasted, the wasted money is roughly equivalent. I would further argue that I am PAYING to have my time wasted. I am paying (and the government is paying, through my loans) to wait for hours while my attending goes to movies (another resident saw him one night). Add in the SHEER RUDENESS of continuously running hours late every day, and perhaps one could understand my frustration.

Yesterday, on call, we were initially supposed to round on our old and new patients at 4 pm. Around 4:30, we were hanging out in an empty room studying, and our intern came in to tell us we were now going to round at 9 pm. At 11 pm, when the attending HAD STILL NOT SHOWN UP, I figured to hell with this, I'm hungry, I'm going to go get some fast food. My interns went to bed, we hadn't seen our upper-level resident in hours, and I said screw it. I went and picked up my keys and began the trek to the parking garage to my car.

In the hallway to the parking garage, I saw my attending walking towards me.

He saw my car keys in my hand and asked if I was going home. I said "No, I was going to go put some stuff in my car, but I guess I'm not now." I pulled a 180, peeled off at a closer elevator, and started frantically calling people. "Quick, he's here, get to the conference room!" One of the students had been keeping watch on the conference room, so she zoomed out to start the text-paging while I raced up to the room, still calling people. We text-paged the interns out of their call-room, the upper-level out of wherever the hell he was, the student from the girls' call-room, and the other student who went to sleep in the medical school building on a couch. People started showing up after a few minutes, to find that our attending brought us a cheesecake. Not in any kind of apology for being late, because I don't think he really knew he was late, but "for the hard-working team." Awww.

After presenting our new patients to him last night, he looked down at his list, looked up at us, and said "Why are all our patients so boring? We only get 1 or 2 good, interesting admissions a night! This is so boring!"

Maybe that's why people go into specialties, to see the "interesting", zebra-type cases. No one wants to treat diabetes, or hypertension, or obesity, because those are commonplace and "boring". People go into rheumatology to see the bizarre vasculitides; they go into nephrology to learn the ins and outs of acid-base disorders (and he thinks diabetes is boring??). But if you're in nephrology, and you're going to take internal medicine call, then you have to be prepared to see the bread and butter of internal medicine. If you are so intelligent that these diseases bore you to tears, then maybe you should go back to the dialysis unit!

It's a good thing I usually like my attending, when he's actually there with us.

Not Studying...

I've been reading medical blogs. I've updated my blogroll on the sidebar. And, I've come to a very sad realization. Until today, I had managed to delude myself into thinking that I was the only medical blogger to pick this particular template. Many people use the dark blue one that I used to use, so I switched to this one--it's more cheerful. And I talked myself into believing that I was the only one.

It was a dumb delusion, I knew that. After all, thousands of people use Blogger, and there are only a few templates available through Blogger itself, so obviously there are going to be thousands of people using this particular one, but it was still a shock to click a link and see a blog that looked almost exactly like mine, dealing with medical issues. The main differences are that the blogger in question is a Canadian family practice resident, and she has about 13,000 more hits than I do.

I am a beautiful unique snowflake, just like everyone else. *sigh*

Almost a Code

We have a very unfortunate patient on our service. She's a very pleasant lady with diffuse scleroderma, systemic, and many complications thereof. She keeps filling her lungs with fluid, which makes her desat and gives her tachycardia. She's on TPN because, as one intern put it, "her GI tract is like a garden hose." In medical terms, she's a real mess (and I don't mean to be insensitive, or mean any disrespect to this poor woman.)

Every day since assuming her care, my resident has said "she's really sick, she could code at any minute." My resident is OBSESSED with coding. He's always talking about "when you're the resident, it's just you and God, it's you and the patient and life or death." I understand his obsession, but it's scary enough picturing myself running a code without someone constantly hyping them to me.

On Friday, we were *finally* rounding, around 11:30 am, when our resident got a page. He made a phone call, grabbed his papers, muttered "Mrs. X is unresponsive" and dashed out the door. Since I'm apparently the only person on my team who actually listens to anyone else on the team (a topic for another post), I was the only person who heard this. I stood up and started to grab my stuff. My attending looked up, puzzled. "Where'd the resident go?" I think I said at least three times "Mrs. X is unresponsive, he went to see her" before he understood. The whole team packed up and headed out the door.

We eventually made it to her room, where my attending turned into a snarling bear. "Why doesn't she have a blood pressure yet?! That should have been the first thing you did! Where is anesthesia? Why haven't you intubated her yet?" Repeat ad nauseum, and you get the idea. Mrs. X was indeed sick, but alive, and not a "code", so we were able to eventually intubate and transfer her to the MICU, where a bed mysteriously opened up for her.

Worst parts of the whole experience?

• My attending bitching everyone out, then sitting in the corner pouting. An honest-to-god, actual POUT was on the man's face.
• Waiting 30 minutes for anesthesia to show up and actually intubate the patient. Respiratory therapy couldn't do it, as her mouth only opened about 1.5 cm due to her scleroderma.
• Listening to the rapid response team girl talking on the rapid response phone: "Yeah, I'm pretty hungry. I haven't eaten ALL DAY. I was down in the cafeteria, talking to some people, when I got the call." Blah, blah, blah, ON THE FUCKING RAPID RESPONSE PHONE. Thank god none of this lady's family was present.
• There were so many people in the room that confusion was rampant. "What's her name?" asked the anesthesia resident. "Mrs. Y" shouted one nurse. "Mrs. B" shouted another. "Mrs. X" shouted our team. Oh my god, people, if you don't know the patient's name perhaps you shouldn't volunteer the information!

Worst part of all? Standing by the wall, feeling helpless and hungry (I hadn't eaten ALL DAY either, bitch!), knowing there was nothing I could do to help, and praying she didn't actually code.

ARRRGGGGGHHHHH!!!!!!!!!

So I finally got my appointment this afternoon at student health, by which time I was mostly feeling okay. Occasional slight headaches, a stuffy nose on one side, but mostly okay. I actually felt a little silly sitting in the doctor's office. She was unimpressed by my story and only moved when she examined my nose--"wow, now I know why you can't breathe!" (At least my turbinates swelled nicely for the performance.) She gave me some amoxicillin and some decongestant/guiafenesin tablets, and sent me on my way.

Tonight, I'm sitting here with a completely clogged nose. I'm trying SO HARD not to use the Afrin, no matter how much I'm tempted to, because I've already used it several times and that stuff can be habit-forming, but OH MY GOD MY NOSE I CAN'T BREATHE AND MY EARS ARE POPPING AND MY THROAT IS SORE AND THIS IS PISSING ME OFF.

I'd be yelling all of that, but I sound like I'm talking through a rubber clown nose, which I find extremely annoying. All I wanted was some freaking Flonase or Nasacort, is that too much to ask???

Favorite Patients

I currently have 3 of my favorite patients ever:

#1: 75 year old Hispanic lady, advanced Alzheimer's dementia. She came in from a nursing home with no information, a raging UTI, and horrible decubitus ulcers on her feet (which made me angry). She doesn't speak, and can do nothing to care for herself.

What I like about her are her eyes. She has beautiful dark brown eyes, and they are very expressive. When I come in and speak to her in Spanish, she looks at me, and I can see her facial muscles twitching, as if she'd like to say hola. She can nod or shake her head in response to questions. Perhaps it's all my imagination, but I don't care. I call her "abuela" and try to take good care of her, and look forward to seeing her look a little better every day.

#2: 75 year old white lady, quadriplegic for over 20 years. She came in with a UTI and pneumonia. She gets around in a motorized wheelchair, as her right arm is about all she can move; she is otherwise dependent on a caretaker, but lives alone. She's also active in her church, takes her grandkids to Target on the weekends, and is a political activist for the disabled.

When I came to see her, she had a fever, and had so many blankets piled on top of herself that all I could see was a small black knitted hat sticking out. The whole pile was quivering (she had chills). Her fingernails and toenails were painted shiny pink, and she had eyeliner on (she'd been at a church meeting in the morning). Her daughter spent the night in the empty bed next to her mother's, and when she left in the morning to go to work, another family member took her place.

#3: 80 year old African American lady, PMH of diabetes, HTN, heart attack, coronary bypass, coronary stents, CHF, cholecystectomy, cataracts, dyslipidemia, and breast cancer 20+ years ago. Amazingly, she lives alone, cooking, cleaning, grocery shopping, even driving for herself. She'd taken her oral hypoglycemic agents faithfully for years, including last week when she had gastroenteritis and wasn't eating much. When her family went to see her Saturday morning, she had two black eyes and didn't know how she'd gotten them. They left, but returned quickly when they couldn't reach her by phone. They broke down the door to find her sleeping in bed, unarousable. EMS found a glucose of 21, so they shot her full of dextrose, she woke up, and they brought her to us.

She had two vivid black eyes, a cut on her nose, and a goose egg on her forehead. Her chief complaint? "I don't know." She was too cute. She kept touching her forehead, amazed at how tender it was. She just couldn't figure out how her sugar had gotten that low. Her fingernails and toenails were also painted pink.

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I've had other patients whom I've greatly enjoyed meeting. There was a little old lady at [county hospital] who had metastatic cancer to her lungs. Her doctors had quit chemotherapy a few weeks prior. She came in with pneumonia. We got to talking, and she was only a few weeks younger than my grandmother. We talked about her grandchildren, and her life. She told me she was ready to sign the DNR, because while she didn't want to die, if it was her time, it was time to go. She'd had a long, happy life, full of love. We fixed her pneumonia and sent her back home with her daughter. She was so peaceful and happy, even with all her pain, that it helped heal something in me.

I loved the newborn babies. I loved the 4 week old African American baby with fever whose proud papa dressed him in a black Nike onesie and matching cap. I loved the Hispanic baby who grinned toothlessly at us every time we approached.

It's so easy for me to get distracted by the sad stuff. In peds, the sad stuff outweighed the happiness. On neuro, it was almost all sad--neurological disease is devastating, and we can do so little to cure. In general, we do so little to cure in all of medicine, which is one reason I'm attracted to surgery. I like the idea of fixing things, not just tweaking long-term meds. I probably ruined myself for internal medicine by reading House of God before medical school, but so little has changed in the 30 years since it was written that it's amazing and depressing all at the same time.

At least there are high points.

What's Wrong With This Picture?

Case #1: 35 year old gentleman, athletic, rides his bike for a living as a messenger. Previously admitted to our hospital for chest pain, he was thoroughly worked up for cardiac causes, all were ruled out, he was diagnosed with GERD and sent home on Nexium. 3 days after discharge, he experienced the same kind of chest pain (in the middle of his chest, radiates to his mouth), after drinking a large quantity of juice on an empty stomach. He never filled his Nexium, since he couldn't afford it. He came to the ER, where he was given Maalox (pain relieved) and admitted for a cardiac stress test. WTF???!!!

We discharged him the same day with a new prescription for another PPI.

Case #2: 75 year old lady, past history of stroke and heart disease. She was at Walmart in a nearby county with her husband, standing in a long line, when she felt a little tired. She sat down, and when she stood back up, she felt dizzy, so she sat down again.

That's it, that's all that happened: presyncopal episode.

Some concerned citizen called a helicopter to bring her to my hospital. This flight easily cost $15,000, and she really didn't even need an ambulance, let alone a helicopter.

Once in our ER, they may not have had much of a choice about admitting her since she came by helicopter emergently. She came to our service last night, was dubbed "Walmart lady", diagnosed with slight hyponatremia (likely due to her MULTIPLE anti-hypertensive medications), corrected, and left this morning.

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What do these two cases have in common? WASTED RESOURCES. The unfortunate guy with GERD was a little anxious, I think, prompting an unnecessary visit to the ER. However, the ER should never have let him pass the threshold. Never. I know "chest pain" on a chart makes everyone sweat about lawsuits, but he'd seriously had the entire cardiac workup within like 2 weeks prior to this admission. All negative, all easily accessible by computer in his old chart. He had no risk factors, he was young and athletic, no problems riding his bike anywhere he needed to. AND his pain was relieved with Maalox. AND EKG AND CARDIAC ENZYMES WERE NORMAL IN THE ER.

Obviously, I don't know about all the cases that the ER refuses to admit, because I don't see them. I'm sure they do a great job on most occasions, even if we do make jokes about the "ER-bot", a machine that hits you with a head CT, chest x-ray, EKG, and shot of rocephin. Case #1, though, slipped through the cracks.

Case #2 is a weirder story. It would have taken a brave ER doc indeed not to admit someone emergently helicoptered in, I understand that. It may even be hospital policy, I have no idea. But who in God's name called the helicopter? Was it the podunk county hospital, fearing that the woman had had a stroke? Was it a concerned bystander, or the worried husband? One popular theory held that Walmart called the helicopter, fearful of a lawsuit from an injured customer.

She never lost consciousness, she had no shortness of breath or chest pain, no hemiparesis or slurred speech, she didn't have a seizure; she just felt dizzy. And she was certainly with it enough to thoroughly enjoy her helicopter ride.

As one intern said last night, "That $15,000 could have run a free clinic at [county hospital] for a month." I know the system isn't that simplistic, but still.

Another wasted resource in these cases is my team's time. Both of these patients had student H&P's, intern H&P's, orders to write, etc; then we had to round on them with the attending, so it wastes the attending's time, too. On both nights, our team capped on admissions, which means that we couldn't admit a patient in the ER because we admitted these patients.

Again, thank god for my attendings on this service, who have agreed with our plans to rapidly discharge these patients, so instead of seeing the lady with "pre-syncope" every morning for a week, I can see a patient who really needs to be seen. And the lady with "pre-syncope" can be at home, which is a much happier place than our hospital.

imanerd

I got an email this morning that I've been awaiting for a while now: Amazon.com announced the pre-order for Harry Potter 7!!!! Yes, Harry Potter and the Deathly Hallows is finally available to pre-order, and the release date is set for July 21, 2007. Amazon already has my $18.89!

A spot of light in the gathering gloom of internal medicine...